Mood/affective disorders

Dr Mndeme Erasmus

08/22/21
 Introduction
• Mood is a pervasive and sustained feeling tone that
is experienced internally and that influences a
person’s behavior and perceptions of the world.

• Affect is the external expression of mood. Mood can

be normal elevated or depressed.
 Defining mood (disorder)

Mood:
– Internally felt (symptom)
– Has a circadian rhythm; tends to normally fluctuate between two
extremes of happiness and sadness.
– We vary in the extent to which we express our mood (affect);
Variation is influenced by personality and culture
– Disordered mood is defined based on:
• The duration of the altered mood state
• The intensity of the altered mood state

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DSM-1V-TR CLASSIFICATION OF MOOD DISORDERS
• Major Depression disorder one or more depressed episodes
and occurs without a history of a manic
• Bipolar 1 defined as having a clinical course of one or more
manic episodes and sometimes a major depressive episode.
• Bipolar 11 is characterized by episodes of major depression
and hypomania rather than mania
• Bipolar mixed episode is a period of at least one week in
which a manic episode and major depressive episode occur
almost daily.
The partial but persistent mood syndromes
• Cyclothymia
• Dysthymia`
 Depressive Disorder
• Depressive episode can occur alone (MDD) or
as part of bipolar disorder. When it occurs
alone it is also known as major depressive
disorder or unipolar depression.

– Major depressive disorder single episode or

recurrent.
 Depression Natural Hx
Natural history
• Variable
• Mean age 40 years, the earlier the onset the greater risk
of recurrence
• Onset insidious, loss/stress, adverse life events common
precipitants in the vulnerable individuals
• Spontaneous remission may occur / or unchanged for
years
• 50% on treatment complete recovery in a year
• 25% relapse within 12 weeks
• 20-30% with no h/o mania develop episodes in the future:

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 Neurovegetive symptoms of depression

1. Sleep: decreased or increased nearly every day

2. Interest: interest in all or nearly all activities is lost nearly
everyday
3. Guilt: one feels excessively guilty about things done or not done
4. Energy: Marked loss of energy is noted nearly every day
5. Concentration: is decreased
6. Appetite: is either increased or decreased nearly every day
7. Psychomotor Changes: Psychomotor retardation represents
moving or thinking more slowly than usual and psychomotor
agitation represents physical restlessness
8. Suicide: Suicide ideation may be present
 Major depressive episode:Information obtained from
history
a. Depressed mood: subjective sense of sadness
feeling "blue" or "down in the dumps" for a
prolonged period of time. .
b. Anhedonia: inability to experience pleasure.
c. Social withdrawal.
d. Lack of motivation, little tolerance of frustration.
e. Vegetative signs.
1) Loss of libido.
2) Weight loss and anorexia.
3) Weight gain .
4) Low energy level; fatigability.
 Information obtained from history

5) Abnormal menses.
6) Early morning awakening (terminal insomnia);
approximately 75% of depressed patients have sleep
difficulties, either insomnia hypersomnia.
7) Diurnal variation (symptoms worse in morning).
8) Constipation
9) Dry mouth
10) Headache
 Information obtained from the mental status
• A. General Appearance And Behavior: Psychomotor Retardation Or Agitation,
Poor Eye Contact, Tearful, Downcast, Inattentive To Personal Appearance:
• b. Affect: constricted or labile.
• c. Mood: depressed, irritable, frustrated, sad.
• d. Speech: little or no spontaneity; monosyllabic; long pauses; soft, low monotone.

• e. Thought content: suicidal ideation affects 60% of depressed patients, and 15%
commit suicide; pervasive feelings of hopelessness, worthlessness, and guilt;; inde­
cisiveness; poverty of thought content and paucity of speech; mood congruent
hallucinations and delusions.

• f. Cognition: distractible, difficulty concentrating, complaints 'of poor memory,

apparent disorientation; abstract thought may be impaired.

• g. Insight and judgment: impaired because of cognitive distortions of personal

worthlessness
 Associated features
 Somatic complaints may mask depression: in particular, cardiac,
gastrointestinal genitourinary symptoms; low back pain, other
orthopedic complaints.

 Content of delusions and hallucinations, when present, tends to be

congruent with depressed mood; most common are delusions of
poverty, and deserved persecution

 Mood- incongruent delusions are those with content not apparently

related to the predominant mood (e.g., thoughts of thought insertion,
broadcasting, and control, or persecutory delusions unrelated to
depressive themes). .
 Age-specific features.

Depression can present differently at different ages

• Prepubertal: somatic complaints, agitation, single-
voice auditory halucinations, anxiety disorders, and
phobias.
• Adolescence: substance abuse, truancy, school
difficulties, increased sensitivity to rejection, poor
hygiene.
• Elderly: cognitive deficits (memory loss,
disorientation, confusion pseudodementia or the
dementia syndrome of depression, apathy and
distractibility.
 DSM-IV-TR Diagnostic Criteria Mjor depressive episode

A. Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning: at
least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure
Note: Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day as indicated by either
subjective report (e.g..feels sad or empty) or observation made by others
(e.g.. appears fearful), Note: In children
n and adolescents, can be irritable
mood
2) markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every
day (as indicated by either subjective account or observation made by
others)
(3) significant weight loss when not dieting or weight gain (e.g.. a change of
more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. Note: in children, consider failure to make
expected weight gains
(4) insomnia or hypersomnia nearly every day
 Cont #3
(5) psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of rest1essness or being slowed
down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every
day (by their subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide
B.The symptoms do not meet criteria for a mixed episode.
C. The symptoms cause clinically significant distress or impairment in social.
occupational. or other important areas of functioning.
 Cont #5
D. The symptoms are not due to the direct physiologic effects of
a substance (e.g.. a drug at abuse, a medication) or a
general'medical condition (e.g.. hypothyroidism).

E. The symptoms are not better accounted for by bereavement

(i.e.. after the loss of a loved one).
 Bipolar 1 Manic episode.
• Information obtained from history
• Mania
– Persistent elevated expansive mood.
– Erratic and disinhibited behavior.
– (1) Excessive spending or gambling
– (2) Impulsive travel.
– (3) Hypersexuality, promiscuity.
– Overextended in activities and responsibilities.
– Low frustration tolerance with irritability, outbursts of anger.
• Vegetative signs.
– (1) Increased libido.
– (2) Weight loss, anorexia.
– (3) Insomnia (expressed as decreased need for sleep).
– (4) Excessive energy
 Seven Cardinal symptoms of mania are:

 Distractibility-being unable to focus on tasks for an

extended period of time
 Insomnia-decreased need for sleep-despite little sleep
energy level is average or above on next day
 Grandiosity-reflects inflated self esteem
 Flight of ideas-racing thoughts….
 Increased goal oriented activities
 Speech: Pressured speech or increased talkativeness
 Thoughtlessness: pleasure seeking activities that do not
display usual judgment …reckless driving, spending
sprees
 Information obtained from mental status examination
a. General appearance and behavior
a. -psychomotor agitation; colorful clothing; excessive makeup;
inattention to personal appearance or bizarre combinations
of clothes; intrusive; entertaining; threatening; hyperexcited.
b. Affect-l
a. labile, intense (may have rapid depressive shifts).
c. Mood
a. -euphoric, expansive, irritable, demanding
d. Speech
a. pressured, loud, dramatic, exaggerated; may become
incoherent.
 Information obtained from mental status
examination
e. Thought content
-highly elevated self-esteem, grandiose, extremely
egocentric; delusions and less frequently hallucinations
(mood­congruent themes of inflated self-worth and power,
most often grandiose and paranoid).
f. Thought process-
flight of ideas (if severe, can lead to incoherence); racing
thoughts
 MSE cont
. Insight and judgment
-extremely impaired; often total denial of
illness and inability to 'make any organized or
rational decisions.
 Other types of bipolar disorders

1. Rapid-cycling bipolar disorder.

Four or more depressive, manic, or mixed
episodes within 12 months. Bipolar disorder with
mixed or rapid cycling episodes appears to be more
chronic than bipolar disorder without alternating
episodes. ,
2. Hypomania. Elevated mood associated with
decreased need for sleep, hypoactivity, and hedonic
pursuits. Less severe than mania with no psychotic
features
 Mania
Natural history:
• Variable in course
• Onset usually acute, early symptoms:
– Insomnia, elevated mood, increased energy and activity
• May be self limiting
– Average duration untreated ~ 7 months
– 15-20% poor response to drug treatment
• BPD with first episode depression
– 20% chance of remaining depressed after a year
• Rapidly alternating mania and depression poorer prognosis
• Peak age 20-25 years

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 Mania
Epidemiology and etiological hypothesis
• 1-2% life time risk
• 0.4-1.6% lifetime prevalence
• 6th leading cause of disability world-wide among
young adults
• Genetic loading
• Associated with high co-morbidity, mortality and
health care costs
• Early diagnosis and treatment – better outcomes

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 Mania
Prognosis
• Determined by frequency, duration and response to
treatment of episodes – drug compliance important.
• Psychological coping, social support, SES influence
outcome as much as drugs
• 45% single episode
• 15% poor response with chronic/recurrent symptoms
• Best predictor response to treatment current episode is
the previous episode
• Rapid cycling – poorer response to mood stabilizers –
Lithium salts
• Cycles often become shorter over time

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 Depression
Prognosis
• Worse if
– high severity of symptoms at onset
– less acute onset
– acute on chronic depression (double depression)
– recurrent suicidal ideation
– With profound delusional content
– family h/o depressive disorder or depressive equivalents
• Most only one episode in lifetime
– likelihood of recurrence increases dramatically with
second episode and slightly with each subsequent episode

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 The partial but
persistent mood
syndromes

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 Cyclothymic disorder
• Mild form of bipolar 11.-episodes of
hypomania and mild depression. Described as
a chronic fluctuating disturbance
with many periods of hypomania and mild
depression.
 Cyclothymic disorder
Symptoms and signs
• Mood changes that come and go
• Irritability with extreme sensitivity to
rejection/loss
• Persistent:
– 2 years in adults & a year in adolescents for
diagnosis
• Exacerbation may warrant diagnosis mania

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 Cyclothymic disorder
• Premorbid personality
– extroverts, sociable, self assured, energetic, and
impulsive
– substantial success and social status where these
traits are valued
– “stimulus seeking” characteristics - promiscuous or
substance abuse behaviours
• Usually no psychotic component

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 Natural history
• Onset late adolescence
– Intensification of symptoms first two years
• may meet criteria for major depressive disorder
or hypomania.
• 40-50% may present with pharmacologically
induced mania if depressive phase is treated
with tricyclic antidepressants
• higher risk of the natural development of
depression as opposed to mania.

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 Natural history
• Long term effects - important maintaining factors
– interpersonal conflicts
– consequent generalized anger
• character and presentation of conflict is often
subtle and may escape the awareness of
clinicians and sympathy of friends
• Recurrent unpredictable/intense mood
changes -development of major themes of loss
and low self-esteem

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 Epidemiology and pathos
Epidemiology
• More common than thought; exact figures not available
• > females than males
• family history of mood disorder or “mood spectrum” problems
(e.g. alcohol and other substance abuse)
Differential diagnosis
– Major mood syndrome
– Boarder line personality disorder - life history would indicate
chaotic life style with poor interpersonal relationships

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 Dysthymic disorder
– Chronic feelings of inadequacy
– DSM 1V TR
• the most typical features presence of a depressed mood that last
most of the day and is present almost continuously.
– Differentiated from major depression in that patient
complain that they were always depressed.
– Most cases of early onset in childhood or adolescence and
certainly occurring by the time they reach 20s
– A late onset subtype has been identified among middle
age and older patients

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 Dysthymic disorder
• Signs and Symptoms
– Loss of interest/pleasure in most activities of daily life
– Depressive symptoms that do not meet criteria for MDD
– Depressed mood either unremitting or episodic, with
normal mood states lasting a few weeks
– Over react with depression to normal daily stresses of
living
– Self-esteem/confidence low but tends to be demanding,
blame themselves and others for their failures
– Obsessional personality traits common
– Abuse of alcohol and other substances also common

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 Natural history
• Specific onset difficult to define; have always felt
depressed
• Onset in early adolescence/late childhood
– - several therapeutic interventions in the past frequent
consultations
• Double depression- underlying dysthymia
superimposed by recurrent episodes of MDD
• Suicide not common perhaps due to the lower severity
of symptoms

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 Epidemiology & pathos
• Lifetime prevalence about 6%, common in general
practice than psychiatry services.
• More prevalent amongst women.
• No genetic studies, though few with dysthymia may
have attenuated forms of a biologically based MDD.
• Less severe but more chronic illness Vs MDD with
similar etiological hypothesis.

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