Download 8-AFFECTIVE DISORDERS

AFFECTIVE DISORDERS
DR. Rabie A. Hawari
Consultant Psychiatrist
AFFECTIVE DISORDERS
Epidemiology
•
•
•
female: male = 2:1 (dep.)
= 1:1 ( mania)
age = dep. – 20-50. mean 40yr.
= mania – earlier mean 30yr
Etiology
various theories
•
Genetics :- evidence is stronger for BAD,
- 50% of pts.---> one parent have M.D,
- BAD. pt. ----> 27% any child have M.D,
- Both parents ----> 50-75% any child,
- MZ twins ----> 75% concordance.
•
Biochemical :- Norepinephrine & Serotonin reduced at receptor
sites in the brain ---- > dep.
- NE & 5HT increased at receptor sites ---> mania.
.
Psychological Factors :- Life Events. – P.M.P. – Psychoanalytic.
- Cognitive. – learned helplessness.
DEPRESSION
Signs & Symptoms
• A. Mental:• Mood:- Depressed, Diurnal Variation, Pessimism,
Suicidal ideas, Loss of Interest, Anhedonia.
• Thinking:- Poverty of thoughts, poor concentration,
Poor cognition, poor judgment & insight,
Delusions (paranoid, guilt, nihilistic,
hypochondriases)
• Perception: - Auditory Hallucination,(2nd. Person).
Signs & Symptoms(cont)
• B. Physical:-
.
Insomnia or Hypersomnia,
Loss of Appetite, Loss of Wt. or Gain,
Psychomotor Retardation or Agitation,
Loss of Libido, Loss Energy, Tiredness,
stupor.
Somatic c/o:headache, constipation,drymouth,abnormal
menses, etc.
Types of depression
1. Major Depression: - unipolar – s/s. 2/52, 40ys.
2. Dysthymia: - Neurotic depression. Chronic. 20 s.
3. Seasonal Affective disorder (SAD): - Major dep., in winter & fall (short daylight)
- s/s: hypersomnia, hyperphagia & psychomotor
slowing
- due to abn.Melatonin metabolism,
- Rx. Exposure to light 3-6 hr. /day.
4. Post Partum Depression: - after birth. 30 days.
s/s .insomnia, fatigue, suicide, homicide & delusions.
Types of depression(cont.)
5. Myxedema Madness: -HypothyroidismS/s.fatigability, Dep.
suicidal impulse, delusions, hallucination & Paranoia.
6. Organic Mood Disorder-- Depression type: - secondary to
organic cause e.g. Cushing’s Synd., Propranlol med.,
Infections (flu, Aids,).
•
7. Pseudo Dementia: - Dementia Synd. Of depression in the
elderly. Dep. Is primary than the cognitive dysfunction
8. Adjustment Diso. with Depressed Mood: - response to a
clear identifiable stress.
Types of depression(cont.)
9. Grief: - sadness secondary to major loss.—not Dep.,
remits with time, no suicide or helplessness.
10. Depression in children: - not uncommon, same s/s.
Masked dep. = running away from home, school
Phobia, substance abuse & suicide.
11. Double Dep.: - Major dep. On top of dysthymia.
12. Atypical Dep.: - s/s. do not meet criteria of depression
- intermittent dysthymic episodes,
- Wt. gain & hypersomnia.
Treatment of Depression
•
*
Pharmacological:a. TCA: - Imipramine, Amitriptyline,Clomipramine,
(3/52 to start to act).
b. MAOI: - Phenelzine, Parnate
(Tyramine dietary restrictions).
c. SSRIs: - Fluvoxamine, fluoxetine,
“Rx. For 6/12. if recurrent lithium as an adjunct
appears to be affective “
Physical :- ElecrtoConvulsiveTherapy (ECT).
Treatment of Depression(cont)
•
Psychological:a). Cognitive: corrections of chronic distortions in
thinking which led to depression.
b). Behaviour: aimed at specific behaviour.
c). Interpersonal: emphasis on ongoing current issues.
d). Psychoanalytic: to understand the unconscious
conflicts & motivations that might sustain
depression.
e). Group Rx.
f). Family Rx.
g). Supportive Rx.
MANIA
Signs & Symptoms
A. Mental:-
- Mood:- Elevated (Elated) mood over days or weeks.
- may be interrupted by episode of depression,
- Irritability with Angry outbursts.
- Impulsiveness.
-Thinking:- - Low concentration, Distractibility,
- Over talkative, Laud, Rapid,
- Pressure of thoughts,
- Flight of Ideas,
- Memory & Orientation = intact,
- Judgment & Insight = impaired,
- Delusions = Grandiose, Paranoid,
- Inflated self-esteem.
- Perception: - Hallucination may be present.
Signs & Symptoms(cont)
B. Physical:
- Insomnia,
- Increase activities & energy,
- Increase Libido, Disinhibtion,
- Psychomotor agitation,
- Wt. loss due exhaustion.
TYPES OF MANIA
Organic Mood Disorder: - Manic Type.
Secondary to organic disorder e.g. – Tertiary
Syphilis, Influenza, Corticosteroids, TLE,
Amphetamine, Hyperthyroidism, Head Trauma,
Vit. Def. (B12, Folate, Thiamine), MS
•
•
•
•
Cyclothymia: - 2yrs. Symptoms, recurrent mood
swings
Rapid Cycling Bipolar Disorder: - Mania/Depression Episodes
with intervals 48-72 hrs.
Bipolar Disorder not otherwise specified (NOS):1 Depression episode & 1 manic episode.
•
•
•
Treatment of Bipolar Disorder:• A. Pharmacological:: Lithium = effective in 80%,-- takes 7-10 days,-- full
trail at least for 4 wks.,-- blood level 0.6 – 1.2 mEq/L,-starting dose 300mg tid,- usual dose range 900-2000mg
per day,-- toxicity more than 1.2mEq/L.
: Carbamazepine = dose 200mg bid / day,-- increase by
200mg. every wk. until plasma level 6 -12 mg/L.
: Valporic acid = ½ life 8 hrs.,-- peak 1- 4 hrs.,-- starting
dose 500 mg, -- range 750 – 3000 mg,-- therapeutic
level 40 – 100 ug/mL, -- toxic 200 ug/Ml.
: Clonazepam = dose in acute mania 2 – 16 mg/day.
Treatment of Bipolar Disorders(con)
: Typical Antipsychotic =
-Haloperidol – oral, I.M., I.V., dose 5 – 60 mg.
- Clopixol – oral10-60 mg., I.M.Aquaphase 50-100mg
- Chlorpromazine – oral, dose 100 – 2000 mg/day.
: Atypical Antipsychotic =
- Risperidone – oral, dose 2 – 8 mg./day
Risperidal Consta-i.m.(25-37.5-50mg)X2/52
- Zyprexa – oral, I.M., dose 5 – 20 mg./day.
B. Psychological: - when Pt. is controlled with
medications.
COURSE & PROGNOSIS
• Depression: - 15% commit suicide.
- Untreated – episode last for 10 months.
- 75% have secondary episode after 6/12
- Average No. of episodes in lifetime = 5.
PROGNOSIS: – 50% recover. – 30% partially recover.
– 20% have chronic course.
– 20-30% of Dysthymic or cyclothymic
develop major Dep., or mania.
COURSE & PROGNOSIS(cont)
• Mania; - 45 % recur.
- Untreated – episode last 3-6 months.
High rate of recurrence average 10.
-80-90 % experience a full Dep., episode.
• PROGNOSIS: – fair.
– 15 % recover. – 50 – 60 % partially recover
– 1/3 have some evidence of chronic symptoms
& social deterioration.