MOOD

DISORDER
S
CORPUZ, RACHELLA NICOLE P.
SPUP JUNIOR INTERN
TREATMENT
 02 02 21

EPIDEMIOL
OGY
Epidemiology
❖ SEX
➢ Major depressive disorder- women>> men
➢ Bipolar I disorder - men=women
➢ Manic episodes are more common in men, and depressive episodes are more
common in women
❖ AGE
➢ Bipolar I disorder- childhood (as early as age 5 or 6 years) to 50 years or even
older in rare cases, with a mean age of 30 years.
➢ Major depressive disorder- mean is about 40 years, with 50 percent of all patients
having an onset between the ages of 20 and 50 years.
Epidemiology
❖ MARITAL STATUS
➢ Major depressive disorder- most often in persons without close interpersonal
relationships and in those who are divorced or separated.
➢ Bipolar I disorder- divorced and single persons>married persons.
❖ SOCIOECONOMIC AND CULTURAL FACTORS
➢ Bipolar I disorder- persons who did not graduate from college>>college
graduates.
➢ Depression- rural areas>urban areas.
❖ COMORBIDITY
➢ The most frequent disorders are alcohol abuse or dependence, panic disorder,
obsessive-compulsive disorder (OCD), and social anxiety disorder.
 02 02 21

ETIOLOGY
ETIOLOGY

BIOLOGIC FACTORS GENETIC FACTORS PSYCHOSOCIAL

BP>UP FACTORS

BIOGENIC AMINES LIFE EVENTS AND

HPA AXIS- ENVIRONMENTAL
HYPERCORTISOLEMIA STRESS
INFLAMMATION/NEURO PERSONALITY FACTORS
TOXICITY
 MAJOR
DEPRESSIVE
EPISODE
Major depressive disorder or unipolar
depression
- patients with only major depressive episodes.
- occurs without a history of a manic, mixed, or hypomanic episode.
- must last at least 2 weeks, and typically a person with a diagnosis of a major
depressive episode also experiences at least four symptoms:
■ changes in appetite and weight
■ changes in sleep and activity
■ lack of energy
■ feelings of guilt
■ problems thinking and making decisions
■ recurring thoughts of death or suicide.
TREATMENT
DSM-5 Diagnostic Criteria for MDD
[Link] (or more) of the following symptoms have been present during the same 2- week period
and present a change from previous functioning; at least one of the symptoms 15 is either
01 (1)21
depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to a medical
condition
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report
( e.g., feels sad, empty, or hopeless) or observation made by others ( e.g., appears tearful).
( Note: In children 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).
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 gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day ( observable by others; not merely
subjective feelings or restlessness or being slowed down).
DSM-5 Diagnostic Criteria for MDD 04 01 21

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 (either by
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 cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another
medical condition.
DSM-5 Diagnostic Criteria for MDD 04 01 21

Note: Criteria A-C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a
natural disaster, a serious medical illness or disability) may include the feelings of
intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss
noted in Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the loss, the presence
of a major depressive episode in addition to the normal response to a significant loss
should also be carefully considered. This decision inevitably requires the exercise of
clinical judgment based on the individual’s history and the cultural norms for the
expression of distress in the contest of loss.
BIPOLAR
DISORDER
Mania
❖ Manic episode- period of an abnormally and persistently elevated, expansive, or
irritable mood lasting for at least 1 week or less if a patient must be hospitalized.
❖ Hypomanic episode- at least 4 days and is similar to a manic episode except that
it is not sufficiently severe to cause impairment in social or occupational
functioning, and no psychotic features are present.

**Both are associated with inflated self-esteem, a decreased need for sleep,
distractibility, great physical and mental activity, and overinvolvement in
pleasurable behavior.
TREATMENT
Mania

❖ Bipolar I disorder- one or more manic episodes and, sometimes,

major depressive episodes. A mixed episode is a period of at least 1
week in which both a manic episode and a major depressive episode
occur almost daily.
❖ Bipolar II disorder- variant of bipolar disorder characterized by
episodes of major depression and hypomania rather than mania.
For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode
may have been preceded by and may be followed by hypomanic or major depressive episodes.
15 01 21
Manic Episode
A.A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly
every day (or any duration if hospitalization is necessary).
[Link] the period of mood disturbance and increased energy or activity, three (or more) of the following
symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change
from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., purposeless non-goal directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
 15 01 21

C. The mood disturbance is sufficiently severe to cause marked impairment in social or

occupational functioning or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, or there are psychotic features.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological
effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I
disorder.
Note: Criteria A to D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder
Hypomanic Episode
A.A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 4
consecutive days and present most of the day, nearly everyday.
B. During the period of mood disturbance, three (or more) of the following symptoms
have persisted (four if the mood is only irritable) and have been present to a
significant degree
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g. feels rested after only three hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g.
engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Hypomanic Episode
C. The episode is associated with an equivocal change in functioning that is uncharacteristic of an
individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication)

Note: A full hypomanic episode that emerges during anti-depressant treatment (e.g. medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect
of that treatment is sufficient evidence for a hypomanic episode diagnosis.
TREATMENT
 15 01 21

❖ ›Treatment of patients with mood disorders should be

directed toward several goals.
➢ ›patient's safety must be guaranteed.
➢ ›a complete diagnostic evaluation of the patient is necessary
➢ ›a treatment plan that addresses not only the immediate
symptoms but also the patient's perspective well­ being should
be initiated.
TREATMENTS 11 01 21

PSYCHOSOCIAL
HOSPITALIZATION
THERAPIES

❖ Clear indications for ❖ ›Threetypes of short-term

hospitalization are the risk of psychotherapies
suicide or homicide, a patient's ➢ Cognitive Therapy
grossly reduced ability to get food ➢ Interpersonal
and shelter, and the need for Therapy.
➢ Behavior Therapy
diagnostic procedures
Pharmacotherapy
❖ Mood stabilizers
❖ Typical antipsychotics
➢ Lithium
➢ Haloperidol
➢ Carbamazepine
➢ Chlorpromazine
➢ Na Valproate/ Divalproex
Na
❖ Atypical antipsychotics ➢ Lamotrigine
➢ Clozapine
➢ Risperidone
➢ Olanzapine
➢ Quetiapine
Pharmacotherapy

❖ Antidepressant
➢ Fluoxetine
➢ Sertraline
➢ Paroxetine
➢ Fluvoxamine
➢ Escitalopram
➢ High-potency benzodiazepine
➢ Clonazepam
 DYSTHYMIA
AND
CYCLOTHYMIA
Dysthymia and Cyclothymia

❖ Dysthymic disorder and cyclothymic disorder are characterized by the

presence of symptoms that are less severe than those of major depressive
disorder and bipolar I disorder, respectively.
❖ Dysthymic disorder- at least 2 years of depressed mood that is not
sufficiently severe to fit the diagnosis of major depressive episode.
❖ Cyclothymic disorder- at least 2 years of frequently occurring hypomanic
symptoms that cannot fit the diagnosis of manic episode and of depressive
symptoms that cannot fit the diagnosis of major depressive episode.
DYSTHYMIA
❖ Dysthymia, which means “ill humored,” was introduced in 1980 15 01 21
❖ Most patients now classified as having dysthymic disorder were classified as having depressive neurosis
(Neurotic depression).
❖ Most typical features : presence of a depressed mood that lasts most of the day and is present almost
continuously.
❖ Associated feelings of inadequacy, guilt, irritability, and anger; withdrawal from society; loss of interest;
and inactivity and lack of productivity.
❖ Distinguished from major depressive disorder: patients complain that they have always been depressed.
❖ —Core concept of dysthymic disorder refers to a sub affective or subclinical depressive disorder with:
➢ (1) low-grade chronicity for at least 2 years;
➢ (2) insidious onset, with origin often in childhood or adolescence; and
➢ (3) persistent or intermittent course
—**Late-onset subtype, much less prevalent and not well characterized clinically, has been identified
among middle-aged and geriatric populations.
—Epidemiology 15 01 21

◦Common among the general population (5-6%)

◦No gender differences
◦More common among unmarried and young persons and in those with low
incomes.
◦Coexists with other mental disorders, particularly major depressive disorder, and
in persons with major depressive disorder there is less likelihood of full remission
between episodes
◦May also have coexisting anxiety disorders (especially panic disorder), substance
abuse, and borderline personality disorder
◦More common among those with first-degree relatives with major depressive
disorder
 15 01 21

—Etiology
◦Biological Factors
❖ –Sleep Studies
➢ Decreased REM latency and increased REM density are two state markers of depression in
MDD that also occur in a significant proportion of patients with dysthymic disorder
❖ –Neuroendocrine Studies
➢ Adrenal axis and the Thyroid axis, which have been tested by using the dexamethasone-
suppression test (DST) and the thyrotropin-releasing hormone (TRH)-stimulation test,
respectively.
❖ **Patients with dysthymic disorder are less likely to have abnormal results on a DST than
are patients with MDD
—
 15 01 21
◦Psychosocial Factors
❖ Karl Abraham: the conflicts of depression center on oral- and anal-
sadistic traits.
❖ Anal traits : excessive orderliness, guilt, and concern for others; they are
postulated to be a defense against preoccupation with anal matter and with
disorganization, hostility, and self-preoccupation.
❖ Major defense mechanism: reaction formation.
❖ Low self-esteem, anhedonia, and introversion are often associated with the
depressive character.
 15 01 21
—Freud
◦Asserted that an interpersonal disappointment early in life can cause a
vulnerability to depression that leads to ambivalent love relationships as
an adult; real or threatened losses in adult life then trigger depression
◦Persons susceptible to depression are orally dependent and require
constant narcissistic gratification
—
 15 01 21

—Cognitive Theory
◦It holds that a disparity between actual and fantasized
situations leads to diminished self-esteem and a sense of
helplessness
DSM-5 Diagnostic Criteria for Dysthymic 15 01 21
Disorder
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account
or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
◦poor appetite or overeating
◦insomnia or hypersomnia
◦low energy or fatigue
◦low self-esteem
◦poor concentration or difficulty making decisions
◦feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been
without the symptoms in Criteria A and B for more than 2 months at a time.
D. No major depressive episode has been present during the first 2 years of the disturbance (1 year for children
and adolescents); i.e., the disturbance is not better accounted for by chronic major depressive disorder, or major
depressive disorder, in partial remission.
DSM-5 Diagnostic Criteria for Dysthymic 15 01 21
Disorder
Note: There may have been a previous major depressive episode provided there was a full remission (no significant
signs or symptoms for 2 months) before development of the dysthymic disorder. In addition, after the initial 2 years (1
year in children or adolescents) of dysthymic disorder, there may be superimposed episodes of major depressive
disorder, in which case both diagnoses may be given when the criteria are met for a major depressive episode.
E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met
for cyclothymic disorder.
F. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or
delusional G. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
—Specify if:
Early onset: if onset is before age 21 years
Late onset: if onset is age 21 years or older
Specify (for most recent 2 years of dysthymic disorder) if
With atypical features
Dysthymic variants 16 01 21

◦Dysthymia is not uncommon in patients with chronically disabling physical

disorders, particularly among elderly adults.
◦Dysthymia-like, clinically significant, subthreshold depression lasting 6 or
more months has also been described in neurological conditions, including
stroke.
◦Prospective studies on children have revealed an episodic course of
dysthymia with remissions, exacerbations, and eventual complications by
MDD.
Course and Prognosis 16 01 21

◦Onset of symptoms before age 25

◦Early onset of symptoms are at risk for either MDD or bipolar I disorder
◦Patients with the diagnosis of dysthymic disorder indicate that about 20% progressed
to MDD, 15% to bipolar II disorder, and less than 5% to bipolar I disorder
◦10-15%: remission 1 year after the initial diagnosis
◦25% of all patients with dysthymic disorder never attain a complete recovery.
◦Prognosis is good with treatment
Treatment 16 01 21

◦Cognitive Therapy
–-patients are taught new ways of thinking and behaving to replace faulty negative
attitudes about themselves, the world, and the future. It is a short-term therapy
program oriented toward current problems and their resolution.
◦Behavior Therapy
–-focus on specific goals to increase activity, to provide pleasant experiences, and
to teach patients how to relax
Treatment 16 01 21

◦Insight-Oriented (Psychoanalytic) Psychotherapy

– - treatment of choice
-attempts to relate the development and maintenance of depressive symptoms and maladaptive
personality features to unresolved conflicts from early childhood.
◦Interpersonal Therapy
-a patient's current interpersonal experiences and ways of coping with stress are examined to
reduce depressive symptoms and to improve self-esteem.
-lasts for about 12 to 16 weekly sessions and can be combined with antidepressant medication
◦Family and Group Therapies
-may help both the patient and the patient's family deal with the symptoms of the disorder.
—
Treatment 16 01 21

—Pharmacotherapy
◦therapeutic success with antidepressants
◦SSRIs and bupropion are an effective treatment
—Hospitalization
◦Hospitalization is usually not indicated for patients with dysthymic disorder,
but particularly severe symptoms, marked social or professional
incapacitation, the need for extensive diagnostic procedures, and suicidal
ideation are all indications for hospitalization
CYCLOTHYMIA
Cyclothymia 16 01 21

● Symptomatically a mild form of bipolar II disorder, characterized by episodes of

hypomania and mild depression
● A chronic, fluctuating disturbance with many periods of hypomania and of
depression
● Emil Kraepelin and Kurt Schneider: one third to two thirds of patients with mood
disorders exhibit personality disorders
● Kraepelin described four types of personality disorders: depressive (gloomy), manic
(cheerful and uninhibited), irritable (labile and explosive), and cyclothymic
Epidemiology 16 01 21

◦3-5% of all psychiatric outpatients

◦Lifetime prevalence- estimated to be about 1%
◦Frequently coexists with borderline personality disorder
◦Female-to-male ratio: 3 to 2
◦50-75%: onset between ages 15 and 25
◦Families of persons with cyclothymic disorder often contain members with
substance-related disorder
—
Biological Factors 16 01 21

◦30% have positive family histories for bipolar I disorder;

◦1/3 of patients with cyclothymic disorder subsequently have major mood
disorders, that they are particularly sensitive to antidepressant-induced
hypomania, and that about 60 % respond to lithium
—
Psychosocial Factors 16 01 21

◦Lies in traumas and fixations during the oral stage of infant development
◦Freud: the cyclothymic state is the ego's attempt to overcome a harsh and
punitive superego.
◦Major defense mechanism in hypomania is denial
◦Patients defend themselves against underlying depressive themes with their
euphoric or hypomanic periods
—
DSM-5 Diagnostic Criteria for Cyclothymic Disorder
16 01 21

A. For at least 2 years, the presence of numerous periods with hypomanic symptoms and
numerous periods with depressive symptoms that do not meet criteria for a major depressive
episode. Note: In children and adolescents, the duration must be at least 1 year.
B. During the above 2-year period (1 year in children and adolescents), the person has not been
without the symptoms in Criterion A for more than 2 months at a time.
C. 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 (in which case both bipolar I disorder and
cyclothymic disorder may be diagnosed) or major depressive episodes (in which case both bipolar II
disorder and cyclothymic disorder may be diagnosed).
DSM-5 Diagnostic Criteria for Cyclothymic Disorder
16 01 21

D. The symptoms in Criterion A are not better accounted for by

schizoaffective disorder and are not superimposed on schizophrenia,
schizophreniform disorder, delusional disorder, or psychotic disorder not
otherwise specified.
E. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Course and Prognosis 16 01 21

◦Having been sensitive, hyperactive, or moody as young children.

◦Occurs insidiously in the teens or early 20s
◦1/3 of all patients with cyclothymic disorder develop a major mood
disorder, most often bipolar II disorder
Treatment 16 01 21

◦Biological Therapy
– -The mood stabilizers and antimanic drugs are the first line of treatment.
◦Psychosocial Therapy
-best directed toward increasing patients' awareness of their condition and helping them
develop coping mechanisms for their mood swings

**Family and group therapies may be supportive, educational, and therapeutic for
patients and for those involved in their lives
 SUMMARY
MAJOR BIPOLAR 1
DYSTHYMIC
DEPRESSIVE DISORDER
DISORDER
DISORDER
Mood is down and other At least one lifetime
Sad mood or loss of pleasure for 2
symptoms are present at least 50 manic or mixed episode.
weeks, along with at least 4 other
percent of the time for at least 2
symptoms
years

BIPOLAR 11 CYCLOTHYMIC
DISORDER DISORDER
Recurrent mood changes
At least one lifetime episode from high to low, without
of hypomania and episodes hypomanic or manic
of major depression. episodes for at least 2
years.
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