Download Psychopathology II: Common Psychiatric Disorders

Psychopathology II: Common
Mood Disorders
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine
A clinical vignette…
A 24 year-old male is brought to the hospital by his family.
He has only slept 3 hours a night for the last 3 days.
The family tells you that he has recently withdrawn
large sums of money from his savings account and
gone on wild spending sprees. During the interview, he
is very talkative and easily distracted. He tells you that
he feels “on top of the world.” This patient is most likely
to be suffering from:
A.
B.
C.
D.
E.
dysthymic disorder
major depressive disorder
bipolar disorder
hypochondriasis
cyclothymic disorder
Outline
•
•
•
•
•
What are unipolar mood disorders?
What are bipolar mood disorders?
Epidemiology of mood disorders
Biology of mood disorders
Risk of suicide
Mood disorders
• Everyone’s mood tends to rise & fall
– sadness is a normal part of the human
condition
• very happy self-confident end = mania
• very sad worthless end = depression
– abnormal if people experience extremes,
especially if not consistent with events
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present or absent
Chart: Unipolar Mood Disorder
Major depressive disorder
major depressive
symptoms
week
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present or absent
Chart: Bipolar Mood Disorder
Bipolar mood disorder
major depressive
symptoms
manic syptoms
week
Depressed Mood versus
Major Depressive Disorder (MDD)
• Feeling depressed is different from
major depressive disorder!!
• Major depressive disorder is more than
just feeling depressed!!
– Just feeling sad, even very sad, not sufficient
for dx of major depressive disorder
• Feeling sad is not even necessary for diagnosis of
major depressive disorder
• Severity, intensity, duration matter
Signs and Symptoms of a
Major Depressive Episode
•
•
•
•
•
•
•
•
•
Sad or empty feelings
Anhedonia – loss of interest or pleasure
Weight loss/gain or appetite increase/decrease
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to concentrate or indecisiveness
Suicidal ideation, plan or attempt
Best known by the mnemonic: SIG E CAPS
Criteria for Unipolar Mood Disorders
Major depressive
disorder
At least 1 major
depressive episode
(lasting at least 2
weeks)
Dysthymia
No manic or
hypomanic episodes
No manic or
hypomanic episodes
Depressive symptoms
for at least 2 years
Symptoms of Dysthymia
• Depressed mood for most of the day on more
days than not
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making
decisions
• Feelings of hopelessness
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ay
Ju 02
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p0
2- 2
N
Ja ov
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ay
Ju 03
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Se -03
p0
3- 3
N
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present or absent
Chart: Dysthymia
Dysthymia
depressive
symptoms
week
Clinical Impairment in MDD and
Dysthymia
Clinical impairment
• Occupationally
• Socially
• Other important areas
Exclusion Criteria
• Not due to a general medical condition
(e.g., thyroid condition)
• Not due to substance use (e.g., alcohol)
• Not bereavement (it is considered normal
to have some symptoms of depression
after someone dies)
Types of Mood Disorders
Unipolar mood
disorders
person experiences
only episodes of
depression
Major depressive
disorder
Dysthymia
Bipolar mood
disorders (previously
manic-depression)
person experiences
episodes of mania and in
most cases episodes of
depression
Bipolar I disorder
Bipolar II disorder
Cyclothymia
Symptoms of a Manic Episode
•
•
•
•
•
•
•
•
•
Elevated mood
Irritable/angry mood
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep
talking
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor
agitation
Excessive involvement in pleasurable activities
that have a high potential for painful
consequences
The Difference Between a Manic and a
Hypomanic Episode
Manic episode Hypomanic episode
Symptoms
Same
Same
Duration
1 week
4 days
Severity
Must interfere
with
occupational or
social
functioning
Must be noticeable
to others, but not
severe enough to
impair functioning or
to require
hospitalization
Chart: Bipolar I Disorder
present or absent
Bipolar I disorder with major depressive episodes
manic episode
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12
major depressive
episode
week
Chart: Bipolar I Disorder
present or absent
Bipolar I disorder without major depressive episodes
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manic episode
week
Additional Criteria
• As with unipolar mood disorders, must be
clinical impairment or distress
• The symptoms cannot be:
– Due to a medical condition
– Due to substance use
Epidemiology of Mood Disorders by
Gender: Lifetime Prevalence
25
20
15
10
female
male
5
0
major
depressive
episode
manic
episode
dysthymia any mood
disorder
Gender & Depression
• Why do almost twice as many women
develop depression?
– women experience more trauma
• particularly sexual abuse
– women have more chronic strains
• poverty, harassment, etc.
– with equal stressors, women still more likely
to develop depression
• biology, coping style
Prevalence of Major Depressive
Disorder by Employment
7
6
currently employed
5
percentage
currently unemployed
4
3
unemployed less than 6
months
2
1
unemployed more than
6 months
0
major depressive disorder
Prevalence of Major Depressive
Disorder by Income
3
under $15,000
2
percentage
1
higher than $15,000
0
major depressive disorder
Course and Outcome:
Major Depressive Disorder
• Average age of onset is 23 for males and 25 for females
• Minimum duration of at least 2 weeks but episodes could last
much longer
• Most people who have major depression will have at least 2
depressive episodes
• MDD is frequently a chronic and recurrent condition
• Half recover from their episode of major depression within 6
months. 40% of recovered people relapse within a year
Course and Outcome: Bipolar Disorders
• Onset is usually between ages 18-20
• Average manic episode 2-3 months, bipolar II patients
(have hypomania) tend to have shorter and less severe
episodes
• Long-term course
– Most will have more than one episode
– Length of intervals between episodes varies and is difficult to
predict
– 40-50% of patients are able to achieve a sustained recovery; rapid
cycling patients have a worse prognosis
Etiology: Social Factors and
Depression
• Loss (of significant others, of social role, selfesteem, etc.) plays an important role in onset
of depression
• Social support or lack of social support is a
risk factor for depression
– and suicide
Neurotransmitters & Depression
• Neurotransmitters
– Early theories about lack of serotonin probably overly
simplistic
– Multiple transmitters involved
• including serotonin, NE, lesser extent dopamine
– Interaction between neurotransmitters, genes, social
stresses is important
More neurotransmitters
• Serotonin
– converted from tryptophan in CNS
– elevation causes improved mood, sleep, but
decreased sexual function
– decrease causes poor sleep, poor impulse
control, depression
More neurotransmitters
• Norepinephrine
– synthesized by noradrenergic neurons, mostly
located in locus ceruleus
– elevation causes increased mood, anxiety,
arousal, learning
More neurotransmitters
• Dopamine
– synthesized from tyrosine
– involved in schizophrenia, psychosis,
Parkinson’s, reward system
– to a lesser extent mood disorders
Antidepressants
• Serotonin is a particularly important neurotransmitter
for mood
– Selective serotonoin reuptake inhhibitors (SSRIs) are
effective
– Stop reuptake of serotonin at synapses
• TCAs are older drugs
–
–
–
–
mostly block NE and serotonin
also have anticholinergic effects
lots of side effects
fatal in overdose
• MAOs
– block dopamine reuptake
– lots of side effects!
Depression & Genetics
• Unipolar depression concordance rates:
MZ = .54, DZ = .24
• Bipolar disorder concordance rates
MZ = .43, DZ = .06
• No strong evidence of a single gene
responsible for mood disorders
Suicide
• Depression is a risk factor for suicide
– 7.5-20 times more likely to commit suicide
when have MDD
– In 1 study*, 2.5 times more likely to commit
suicide when in remission
Suicide
• Increased risk
– previous suicidal behavior, family history,
severe depression, substance use, poor
physical health/perception of poor health, lack
of social support
• Reduced risk
– suicidal gesture, no family history, mild
depression, no substance use, good health,
married, strong social support
A clinical vignette…
A 24 year-old male is brought to the hospital by his family.
He has only slept 3 hours a night for the last 3 days.
The family tells you that he has recently withdrawn
large sums of money from his savings account and
gone on wild spending sprees. During the interview, he
is very talkative and easily distracted. He tells you that
he feels “on top of the world.” This patient is most likely
to be suffering from:
A.
B.
C.
D.
E.
dysthymic disorder
major depressive disorder
bipolar disorder
hypochondriasis
cyclothymic disorder