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MOOD DISORDERS
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Toronto Notes
First Aid for the Psychiatry Clerkship
First Aid for the USLME step 1
MOOD

Description of one’s internal emotional state, Can be
triggered by both external and internal stimuli.
Labeled as sad, happy, angry, irritable…

Normal:



Wide range of moods
Sense of control over one’s moods
In Mood Disorders [Affective disorders]:



Abnormal range of moods
Lose some level of control over them
Some patients may have psychotic features (delusions or
hallucinations)
maybe sever enough to cause impairment in social and
occupational function
MOOD EPISODES VS MOOD
DISORDERS

Mood episodes: distinct periods of time in which some
abnormal mood is present





Depression
Mania
Mixed-state
Hypomania
Mood disorders: defined by their patterns of mood
episodes




Major depressive disorder (MDD)
Bipolar disorders (BD)
Dysthymic disorder (DD)
Cyclothymic disorder (CD)
MOOD EPISODES
A-1) Major Depressive Episode
A-2) Manic Episode
A-3) Mixed Episode
A-4) Hypomanic Episode
A-1) MAJOR DEPRESSIVE EPISODE
When an individual experiences a discrete
episode of persistent and pervasive
emotional depression
 May present in a Major Depressive
Disorder or a Bipolar Disorder

persons who hospitalize due to depression
episodes, increase risk for suicide later in
live by 15%
A-1) MAJOR DEPRESSIVE EPISODE
DSM-IV Criteria
 (A) must have at least five of the following symptoms (must
include either 1 or 2) For at least a 2-week period
1.
2.
3.
4.
5.
6.
7.
8.
9.



Depressed mood
Anhedonia (loss of interest in pleasurable activities)
Change in appetite or body weight (increased or decreased)
Feelings of worthlessness or excessive guilt
Insomnia or hypersomnia
Diminished concentration
Psychomotor agitation or retardation (i.e., restlessness or slowness)
Fatigue or loss of energy
Recurrent thoughts of death or suicide (15% risk if previously
hospitalized due to major depressive episode)
(B) symptom don’t meet criteria for mixed episodes
(C) Must cause social or occupational impairment
(D) Not due to substance use or medical conditions
DSM-V

clinically significant distress or impairment in social,
occupational, or other important areas of life, although
this is now listed as Criterion B rather than Criterion C.

The presence of mixed features in an episode of major
depressive disorder increases the likelihood that the
illness exists in a bipolar spectrum

The coexistence within a major depressive episode of at
least three manic symptoms (insufficient to satisfy
criteria for a manic episode) is now acknowledged by the
specifier “with mixed features.”
A-2) MANIC EPISODE
DSM-IV Criteria:
 A period of abnormally and persistently elevated, expansive, or irritable
mood
 Lasting at least 1 week
 Including at least three of the following (four if mood is irritable):
1.
2.
3.
4.
5.
6.
7.




Distractibility
Inflated self-esteem or grandiosity
Increase in goal-directed activity (socially, at work, or sexually)
Decreased need for sleep
Flight of ideas or racing thoughts
More talkative or pressured speech (rapid and uninterruptible)
Excessive involvement in pleasurable activities that have a high risk of
negative consequences (e.g., buying sprees, sexual indiscretions)
symptom don’t meet criteria for mixed episods
Not due to substance use or medical conditions
Must cause social or occupational impairment
Psychotic symptoms in 75% of manic patients
HIGHLIGHTS OF CHANGES FROM DSM-IVTR TO DSM-5 BIPOLAR AND RELATED
DISORDERS
Criterion A for manic and hypomanic episodes
now includes an emphasis on changes in
activity and energy as well as mood.
 mixed episode, requiring that the individual
simultaneously meet full criteria for both mania
and major depressive episode, has been
removed.
 a new specifier, “with mixed features,” has
been added that can be applied to episodes of
mania or hypomania when depressive features
are present

A-2) MANIC EPISODE

Mnemonic: DIG FAST









Distractability
Insomnia
Grandiosity
Flight of ideas
Activity/agitation
Speech (pressured)
Thoughtlessness
It is a psychiatric emergency!
Severely impaired judgment makes patient
dangerous to self and others
A-3) MIXED EPISODES
Defined by meeting the diagnostic criteria for
both Manic Episode and Major Depressive
Episode
 Must be present nearly every day for at least
full week
 The individual experiences rapidly alternating
moods (sadness, irritability , euphoria)
 It is a psychiatric emergency also!

A-4) HYPOMANIC EPISODE
Criterion of Mania except
1. at least 4 days
2. No marked impairment in social or
occupational function.
3. don't require hospitalization
4.no psychotic feature
A-4) HYPOMANIC EPISODE
Mania
Hypomania
Lasts at least 7 days
Lasts at least 4 days
Causes severe impairment in social
or occupational functioning
No marked impairment in social or
occupational functioning
May necessitate hospitalization to
prevent harm to self or others
Does not require hospitalization
May have psychotic features
No psychotic features
B) MOOD DISORDERS
B-1) Major Depressive Disorder
B-2) Bipolar Disorder (I and II)
B-3) Dysthymic Disorder
B-4) Cyclothymic Disorder
B) MOOD DISORDERS

Often have chronic courses ,Marked by
relapses, with relatively normal function
between episodes

May be triggered by a medical condition or drug
 Always
investigate for medical or substanceinduced causes before making a diagnosis
B) MOOD DISORDERS
Differential Diagnosis of Mood Disorders Secondary to General Medical Conditions
Depressive Episodes
Manic Episodes
Cerebrovascular disease
Metabolic (hyperthyroidism)
Endocrinopathies (Cushing’s syndrome,
Addison’s disease, hypoglycemia,
hyper/hypothyroidism,
hyper/hypocalcemia
Neurological disorders (temporal lobe
seizures, multiple sclerosis)
Parkinson’s disease
Viral illnesses (e.g., mononucleosis)
Carcinoid syndrome
lymphoma and pancreatic carcinoma
SLE
Neoplasms
HIV infection
B) MOOD DISORDERS
Differential Diagnosis of Mood Disorders Secondary to Medication
Substance Use
Depressive Episodes
alcohol
Antihypertensives
Barbiturates
Corticosteroids
Levodopa
Sedative–hypnotics
Anticonvulsants
Antipsychotics
Diuretics
Sulfonamides
Withdrawal from psychostimulants
(e.g., cocaine, amphetamines)
Manic Episodes
Corticosteroids
Sympathomimetics
Dopamine
Agonists
or
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Marked by episodes of depressed mood
associated with loss of interest in daily
activities
 Patients may be unaware of their depressed
mood or may express vague, somatic
complaints
 DSM-IV criteria:

1.
2.
At least one Major Depressive Episode
No history of manic or hypomanic episode
DSM V
The coexistence within a major depressive episode
of at least three manic symptoms (insufficient to
satisfy criteria for a manic episode) is now
acknowledged by the specifier “with mixed
features.” The presence of mixed features in an
episode of major depressive disorder
 creases the likelihood that the illness exists in a
bipolar spectrum; however, if the individual
concerned has never met criteria for a manic or
hypomanic episode, the diagnosis of major
depressive disorder is retained.

DSM V

DSM-5 contains several new depressive
disorders
1.disruptive mood dysregulation disorder :
included for children up to age 18 years who exhibit persistent
irritability and frequent episodes of extreme behavioral dyscontrol.

2. premenstrual dysphoric disorder

3. What was referred to as dysthymia in DSM-IV now falls under the
category of persistent depressive disorder, which includes both
chronic major depressive disorder and the previous dysthymic
disorder.
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Epidemiology:
 Onset: at any age [average = 30-40]
 No ethnic or socioeconomic differences
 F:M = 2:1 [but equal before menses and
after menopauses]
 Depression can increase the mortality for
patients with other comorbidities [DM, CVD]
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Etiology:
 Exact cause is unknown, but biological,
genetic, environmental, and psychosocial
factors each contribute
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Etiology:
1. Abnormalities of
Serotonin/Catecholamines:



Decreased brain and (CSF) levels of serotonin
and its main metabolite; 5 hydroxyindolacetic
acid (5-HIAA)
Abnormal regulation of beta adrenergic
receptors
Drugs that increase availability of serotonin,
norepinephrine, and dopamine often alleviate
symptoms of depression
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Etiology:
2. Other Neuroendocrine Abnormalities:


High cortisol: Hyperactivity of hypothalamicpituitary-adrenal axis
Abnormal thyroid axis:
 One
third of patients with MDD who have
otherwise normal thyroid hormone levels show
blunted response of TSH to infusion of TRH
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Etiology:
3. Psychosocial/Life events:


4.
Loss of a parent before age 11 > associated with
the later development of MDD
Stable family and social functioning > good
prognostic indicators in the course of major
depression
Genetic predisposition:



2-3X times more likely to happen in first-degree
relatives
monozygotic 50-70%
10-25% for dizygotic twins
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Sleep problems associated with MDD:
 Decrease slow wave sleep.
 Decrease REM latency
 Increase REM early in sleep cycle
 Increase total REM
 Initial and terminal insomnia (hard to fall asleep
and early morning awakenings)
 Hypersomnia
 Rapid eye movement (REM) sleep shifted to earlier
in night with stages 3 and 4 decreased
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Course and Prognosis:
 If left untreated, depressive episodes are selflimiting but usually last from 6 to 13 months
 Generally, episodes occur more frequently as
the disorder progresses
 The risk of a subsequent major depressive
episode is 50% within the first 2 years after the
first episode
 About 2/3 of all depressed patients
contemplate suicide, and 10 to 15% commit
suicide!!
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Treatment:
 Hospitalization: when there is a risk of suicide,
homocide or unable to care
 Medications:
Antidepressent’s: SSRIs, TCA, MAOIs
 Adjuvent therapy: stimulant (methylphenidate),
antipsychotic, T3, T4 or L-tryptophan

Psychotherapy: behavioral, cognitive supportive,
dynamic and family
 Electroconvulsive therapy [ECT]

B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Treatment:
 Medications significantly reduce the length
and severity of symptoms
 They may be used prophylactically between
episodes to reduce the risk of subsequent
episodes
 Approximately 50-60% of patients are
treated successfully with medical therapy
 Only half of patients with MDD ever receive
treatment
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Seasonal affective disorder:
 It is a subtype of MDD
 Episodes occur only during winter months
(fewer daylight hours)
 Patients respond to treatment with light
therapy
B-1) MAJOR DEPRESSIVE DISORDER [MDD]
Unique types and features:
 Melancholic:






40-60% of hospitalized pt’s with major depression
Characterized by Anhedonia, early morning awakening, psychomotor
disturbance, excessive guilt and anorexia
you can Dx those patients as “major depression with melancholic
features”
Atypical: Hypersomnia, hyperphagia, reactive mood, leaded
paralysis & hypersensitivity to interpersonal rejection
Catatonic: Catalepsy, purposeless motor activity, extreme
negativism or mutism, bizarre posture & echolalia
Psychotic: 10-25% of hospitalized depressions, presence of
delusions or hallucinations
B-1) MAJOR DEPRESSIVE DISORDER [MDD]

How it differs from Bereavement [Simple Grief]:


Grief comes as a reaction to a major loss, usually of a
person, and include crying spells, problem in sleeping, &
trouble concentrating at work
5 stages: Denile, Anger, Bargaining, Depression, Acceptence
Grief
Depression
suicidal thoughts are rare
suicidal thoughts may be present
Symptoms last <2 months
Symptoms lasts >2 months
Cognitive disorder lasts <1 y
Cognitive disorder lasts >1 y
Tt: benzodiazepine for sleep
Tt: Antidepressants, mood stabalizers, & ECT
DSM-V
1. The duration is more commonly 1–2 years
 2. bereavement-related major depression is
most likely to occur in individuals with past
personal and family histories of major
depressive episodes. It is genetically
influenced.

Bipolar
19/9/2012
34
BIPOLAR DISORDERS

Two types of Bipolar disorders:
1. Bipolar I Disorder
2. Bipolar II Disorder
BIPOLAR I DISORDER
(MANIC DEPRESSION)
 Disorder characterized by occurrence of manic episodes with or
without major depression.

Bipolar I disorder may have psychotic features (delusions or
hallucinations); these can occur during major depressive or
manic episodes. Always remember to include bipolar disorder
in your differential of psychotic patient.
36
MANIC EPISODE



DSM-IV Criteria:
A period of abnormally and persistently elevated, expansive, or
irritable mood
Lasting at least 1 week
Including at least three of the following (four if mood is irritable):
1.
2.
3.
4.
5.
6.
7.



Distractibility
Inflated self-esteem or grandiosity
Increase in goal-directed activity (socially, at work, or sexually)
Decreased need for sleep
Flight of ideas or racing thoughts
More talkative or pressured speech (rapid and uninterruptible)
Excessive involvement in pleasurable activities that have a high risk of
negative consequences (e.g., buying sprees, sexual indiscretions)
Not due to substance use or medical conditions
Must cause social or occupational impairment
Psychotic symptoms in 75% of manic patients
37
MIXED EPISODES
Defined by meeting the diagnostic criteria for
both Manic Episode and Major Depressive
Episode
 Must be present nearly every day for at least
full week
 The individual experiences rapidly alternating
moods (sadness, irritability , euphoria)
 It is a psychiatric emergency also!

38
BIPOLAR I DISORDER
DSM-IV criteria:
 The patient mainly presents with mania and
sometimes mixed episodes
 10-20% of patient experience only manic
episodes
 There may interspersed euthymia, major
depressive episodes, dysthymia or hypomanic
episodes, but none of these are required for
diagnosis
39
HIGHLIGHTS OF CHANGES FROM DSM-IV-TR TO DSM-5
BIPOLAR AND RELATED DISORDERS
Highlights of Changes from DSM-IV-TR to DSM-5 Bipolar and
Related Disorders
 Bipolar Disorders
 To enhance the accuracy of diagnosis and facilitate earlier
detection in clinical settings, Criterion A for manic and
hypomanic episodes now includes an emphasis on changes in
activity and energy as well as mood. The DSM-IV diagnosis of
bipolar I disorder, mixed episode, requiring that the individual
simultaneously meet full criteria for both mania and major
depressive episode, has been removed. Instead, a new specifier,
“with mixed features,” has been added that can be applied to
episodes of mania or hypomania when depressive features are
present, and to episodes of depression in the context of major
depressive disorder or bipolar disorder when features of
mania/hypomania are present.
40
EPIDEMIOLOGY
Lifetime prevalence : 1%.
Women and men equally
affected.
No Ethnic difference seen.
Onset usually before age 30
years.
Frequently misdiagnosed &
therapy mistreated.
Etiology
Biological, Environmental,
psychosocial, & Genetics
factors are all important.
1st degree relative with bipolar
are 8-18X more likely to
develop the illness.
The concordance rate of
monozygotic twins 40-70%.
The concordance rate of
dizygotic twins ≈ 5-25%.
““ Bipolar I has the highest
genetic link of all major
psychiatric disorders ””
41
COURSE & PROGNOSIS

Generally last about 3 months without treatment.

The course is usually chronic with relapses.

90% of pt’s after one manic episode will have repeat episode within 5
years.

Bipolar has a wors prognosis than MDD

Lithium prophylaxis between episode can decrease the risk of relapse.

25-50% of pt’s attempt suicide, 15% die by suicide, which is higher rate
than MDD.
42
TREATMENT
Pharmacotherapy:




Lithium—mood stabilizer
Anticonvulsants (carbamazepine or valproic acid)—also mood
stabilizers,
especially useful for rapid cycling bipolar disorder and mixed episodes
Olanzapine—a typical antipsychotic
Psychotherapy
Supportive psychotherapy, family therapy, group therapy
ECT (best tt for manic woman in pregnancy; safe in all
trimesters)
Pt’s with a history of postpartum mania should be treated with AD & lithium
in subsequent pregnancies as prophylaxis, but these are relative CI for
breast feeding.
43
BIPOLAR II DISORDER

Disorder characterized alternatively occurrence of recurrent
major depression episodes with Hypomania
Mania
Hypomania
Lasts at least 7 days
Lasts at least 4 days
Causes severe impairment in social
or occupational functioning
No marked impairment in social or
occupational functioning
May necessitate hospitalization to
prevent harm to self or others
Does not require hospitalization
May have psychotic features
No psychotic features
44
BIPOLAR II DISORDER




DSM-IV criteria:
 History of one or more major depressive episodes
and at least one hypomanic episode
Bipolar II Disorder = Depression + Hypomania
Remember: If there has been a full manic episode
even in the past, then the diagnosis is not bipolar II
disorder, but bipolar I
Frequently misdiagnosed as unipolar depression
19/9/2012
45
BIPOLAR II DISORDER

DSM-5 allows the specification of particular conditions for
other specified bipolar and related disorder, including
categorization for individuals with a past history of a major
depressive disorder who meet all criteria for hypomania except
the duration criterion (i.e., at least 4 consecutive days). A
second condition constituting an other specified bipolar and
related disorder is that too few symptoms of hypomania are
present to meet criteria for the full bipolar II syndrome,
although the duration is sufficient at 4 or more days.
46
DYSTHYMIC DISORDER (DD)
 Persistent Depressive Disorder, formerly known as
Dysthymic Disorder (also known as dysthymia)
 In which the patient have chronic, mild depression most of
the time with no discrete episodes.
 They rarely need hospitalization.
 Dysthymic tends to be persistent while MDD is episodic.
 DD can never have psychotic features; if delusion or
hallucination are present with “depresseion,” consider
another Dx.
 DD = 1. 2 D’s
2. 2 years of depression
3. 2 listed criteria
4. never asymptomatic for >2 months
47
DX & DSM-5 CRITERIA
1. Depressed mood for the majority of time of most days for at
least 2 years (in children & adolescence at least 1 years).
2. At least two of the following :
• Poor concentration or difficulty making decision.
• Feeling of hopelessness
• Poor appetite or over eating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
48
3. During the 2 years period :
• The person hasn’t been without
the above symptoms for >2
months at a time.
• No major depressive episodes.
• The patient must never had a
manic or hypomanic episodes
(the Dx will be bipolar or
cyclothymic, respectively).

Double depression : Patient with
MDD with DD during residual
periods.
49
EPIDEMIOLOGY



Lifetime prevalence is 6%.
2-3 X more common in women.
Onset before age 25 years in 50% of patient.
50
COURSE & PROGNOSIS



20% of patients develop major depression
20% of patients develop bipolar disorder
>25% of patients will have lifelong symptoms
Treatment


cognitive therapy & insight-oriented psychotherapy are
most effective.
Antidepressants (SSRIs, TCAs, or MAOIs) are useful when
used concurently with psychotherapy.
51
Cyclothymic disorder (CD)
 Patient have alternating periods of dysthymia and hypomania .
 Diagnosis and DSM- 5 Criteria :
• Numerous periods with hypomanic symptoms and periods with
depressive symptom for at least 2 years.
the presence of numerous periods with hypomanic symptoms that do not
meet criteria for a hypomanic episode and numerous periods with
depressive symptoms that do not meet criteria for a Major Depressive
Episode.
Cyclothymic disorder usually begins in adolescence or early adult life and is
sometimes considered to reflect a temperamental predisposition to other
bipolar-and-related disorders.During the above 2-year period (1 year in
children and adolescents), the person has not been without the
symptoms above for more than 2 months at a time.No Major Depressive
Episode, Manic Episode, or Mixed Episode has been present during the
first 2 years of the disturbance.Note: After the initial 2 years (1 year in
children and adolescents) of Cyclothymic Disorder, there may be
superimposed Manic or Mixed Episodes
• The person must never have been free of symptoms for > 2 months
during those 2 years.
• No Hx of major depressive episodes or manic episodes
52
EPIDEMIOLOGY




Lifetime prevalence < 1%.
May coexist with borderline personality.
Onset usually age 15-25 years.
Occurs equally in males & females.
53
19/9/2012
COURSE & PROGNOSIS

Chronic course.

1/3 of patient eventually diagnosed with bipolar disorder.
Treatment

Antimanic agents as used to treat bipolar disorder.
54
OTHER DISORDERS OF MOOD IN DSM-5
1. Minor Depressive Disorder:
-Episodes of 2-4 depressive symptoms that don’t met full five criteria for MDD.
-Euthymic periods are also seen unlike dysthymic.
-Associated with significant functional impairments.
-18% fit the criteria for MDD within 1 year.
2.Recurrent brief depressive disorder
3.Premenstrual dysphoric disorder
4.Mood disorder due to a general medical condition
5.Substance-induced mood disorder
6.Mood disorder not otherwise specified (NOS)
55
SPECIFIERS OF MOOD DISORDERS IN
DSM-IV
Specifiers are not considered a separate mood but rather a
subtype within any MDD.
•
Seasonal affective disorder (SAD):
-At least 2 consecutive years of two major depressive
episodes during the same season.
-Pt’s with fall-onset SAD (winter depression) often respond
to light therapy.
-Triad of: Irritability, Carbohydrate craving, hypersomnia
•
Postpartum major depression (PMD): the onset within 4
weeks of delivery.
56
ADJUSTMENT DISORDERS
•
Occurs when maladaptive behavioral or emotional
symptoms develop after a stressful life event.
•
Symptoms begin within 3 months after the event, end
within 6 months & cause significant impairment in daily
functioning or interpersonal relationships.
•
The stressful event is not life threatening (divorce, loss of a
job) in adjustment disorder BUT in Posttraumatic stress
disorders, it is.
57
DX & DSM-5 CRITERIA
1.
2.
3.
Development of emotional or behavioral symptoms within 3
months after stressful life event, these symptoms produce
either:
a. sever distress in excess of what would be expected after
such an event.
b. significant impairment in daily functioning.
The symptoms are not those of bereavement.
Symptoms resolve within 6 months after stressor has
terminated.
58
EPIDEMIOLOGY



Adjustment disorders are very common.
They occur twice as often in females.
They are most frequently diagnosed in adolescents but may
occur at any age.
Etiology

Triggered by psycosocial factors.
59
PROGNOSIS

May be chronic if the stressor is recurrent.
Treatment
Supportive psychotherapy (most effective).
 Group therapy.
 Pharmacotherapy for associated symptoms (insomnia,
anxiety or depression).

60
B-3) DYSTHYMIC DISORDER
Case
A 28-year-old accountant has felt sad since her
adolescence. She does not remember the last
time she “did something fun.” She denies any
suicidal thoughts or having any episodes of
hopelessness or impaired sleep pattern
From: First Aid for the Psychiatry Clerckship
THE END