Mood Disorders

Getasew L. (Assistant professor in ICCMH)

 Overview
What is a mood disorder?
Etiology
Criteria for specific mood episodes and
disorders
Differential diagnosis
Treatment of mood disorder
 What is a mood disorder?
 Mood is a person’s subjective emotional state

 Affect is the objective appearance of mood

 Mood disorders (according to DSM-IV) involve a

depression or elevation of mood as the primary
disturbance

 Can have other abnormalities (psychosis, anxiety,

etc.)
Major Depressive Disorder
 Depression …
 The common feature of all of these disorders is
the presence of sad, empty, or irritable mood
which;
 Accompanied by somatic and cognitive changes
that significantly affect the individual's capacity to
function.
 What differs among them are issues of duration,
timing, or presumed etiology.
 A new diagnosis, disruptive mood dysregulation
disorder, referring to the presentation of children
with persistent irritability and frequent episodes
of extreme behavioral dyscontrol, for children up
to 12 years.
10/27/2024 5
 Major Depressive Disorder (MDD)
• A depressed mood and a loss of interest or
pleasure are the key symptoms of depression.
• They feel blue, hopeless, worthless.
• The depressed mood often has a distinct quality
that differentiates it from the normal
emotion of sadness or grief
About two-thirds of all depressed patients
contemplate suicide but;
 10 to 15 percent commit suicide.
 MDD…
Those recently hospitalized with a suicide
attempt or suicidal ideation have a higher
lifetime risk of successful suicide than
those never hospitalized for suicidal
ideation
Almost all depressed patients (97 %)
complain about reduced energy; they have
difficulty finishing tasks, less motivation to
do new task.
About 50 to 75 percent of all depressed
patients have a cognitive impairment,
sometimes referred to as depressive pseudo
dementia.
Such patients commonly complain of impaired
concentration and forgetfulness.
 MDD
• About 80 percent of patients complain of trouble
sleeping, especially early morning awakening
(i.e., terminal insomnia) and
 Multiple awakenings at night, which they
ruminate about their problems.
 Many of them have decreased appetite and
weight loss, but others experience increased
appetite and weight gain and sleep longer than
usual.
o These patients are classified as having atypical
features.
 MDD
• Anxiety, a common symptom of depression,
affects as many as 90 percent of all depressed
patients.
• vegetative symptoms include abnormal menses
and decreased interest and performance in
sexual activities
• About 50 % of all patients describe a diurnal
variation in their symptoms;
• With increased severity in the morning and
lessening of symptoms by evening.
 MDD…
 Cognitive symptoms like inability to concentrate
and impairments in thinking.
Depression in Children and Adolescents may
present in the form of;
o School phobia and excessive clinging to parents.
o Poor academic performance,
o substance abuse,
o antisocial behavior,
o running away may be symptoms of depression in
adolescents.
 MDD…
Depression in older people is more common
than in the general population.
 in this group prevalence rates ranging from
25 to 50 %.
Depression in older persons correlated with;
low socioeconomic status,
the loss of a spouse,
a concurrent physical illness, and
 social isolation
 MDD…
• It is under-recognition in older persons.
• Because of depression disorder appears more
often with somatic complaints in older, than in
younger.
psychomotor retardation is more common in
younger depressed patients.
 psychomotor agitation is more common in
elderly patients.
 Prevalence of MDD
• MDD has the highest lifetime
prevalence(almost 17%) of any psychiatric d/o
• The yearly incidence of a major depression is
1.59%(women,1.89%;men,1.10%)
• In Ethiopia its prevalence is 5%-17%
• Twofold greater prevalence of major
depressive d/o in women than in men
• The mean age of onset for MDD is about 40
years, with 50% of all pts having an onset b/n
the ages of 20 & 50 years
 Prevalence of MDD
No correlation has been found between
socioeconomic status and major depressive
disorder
Depression is more common in rural areas
than in urban areas
The most frequent comorbid d/os are alcohol
abuse or dependence, panic d/o, OCD,&
social anxiety d/o
Etiology
A) Biological factors
i) Biogenic amines
• Norepinephrine and serotonin are the two
neurotransmitters most implicated in the
pathophysiology of mood disorders
• Dopamine has also been theorized to play a role
• Data suggest that dopamine activity may be
reduced in depression and increased in mania
ii) Alterations of hormone regulation
• can result from severe early stress
• Recent studies in depressed humans indicate
that a history of early trauma is associated
with increased HPA activity(hypothalamus-
pitutary axis) accompanied by structural
changes (i.e., atrophy or decreased volume) in
the cerebral cortex
• Elevated HPA activity is a hallmark of
mammalian stress responses and one of the
clearest links between depression and the
biology of chronic stress
• Evidence of increased HPA activity is apparent
in 20 to 40 percent of depressed outpatients
and 40 to 60 percent of depressed inpatients
• A disturbance of feedback inhibition is tested
by administration of dexamethasone
(Decadron) (0.5 to 2.0 mg), a potent synthetic
glucocorticoid, which normally suppresses
HPA axis activity for 24 hours
• 5 to 10 percent of people evaluated for
depression have previously undetected
thyroid dysfunction, as reflected by an
elevated basal thyroid-stimulating hormone
(TSH) level
• An even larger subgroup of depressed patients
(e.g., 20 to 30 percent) shows a blunted TSH
response to TRH challenge
iii. Structural and functional brain imaging
• Some depressed patients also may have
reduced hippocampal or caudate nucleus
volumes, or both
• The most widely replicated positron emission
tomography (PET) finding in depression is
decreased anterior brain metabolism, which
is generally more pronounced on the left side
• greater left hemisphere reductions are seen
in depression compared with greater right
hemisphere reductions in mania
iv. Genetic factors
• Numerous family, adoption, and twin studies
have long documented the heritability of
mood disorders
• Family data indicate that if one parent has a
mood disorder, a child will have a risk of
between 10 and 25 percent for mood
disorder. If both parents are affected, this
risk roughly doubles
A family history of bipolar disorder conveys a
greater risk for mood disorders in general

genes explain only 50 to 70 percent of the

etiology of mood disorders
B. Psychosocial factors
i) Life events and environmental stress
• life events more often precede first, rather
than subsequent, episodes of mood
disorders
 the stress accompanying the first episode
results in long-lasting changes in the brain's
biology
• the life event most often associated with
development of depression is losing a parent
before age 11
• The environmental stressor most often
associated with the onset of an episode of
depression is the loss of a spouse
• Another risk factor is unemployment: persons out
of work are three times more likely to report
symptoms of an episode of major depression
than those who are employed.
ii) Personality factors
Persons with certain personality disorder like
OCPD, histrionic, and borderline may be at
greater risk for depression than persons with
antisocial or paranoid personality disorder

The latter can use projection and other

externalizing defense mechanisms to protect
themselves from their inner rage
Psychodynamic factors in depression
psychodynamic understanding of depression
defined by Sigmund Freud and expanded by
Karl Abraham is known as the classic view of
depression
That theory involves four key points:
(1) Disturbance in the infant-mother relationship
during the oral phase (the first 10 to 18
months of life) predispose to subsequent
vulnerability to depression;

(2) depression can be linked to real or imagined

object loss;
3. introjection of the departed objects is a
defense mechanism invoked to deal with the
distress connected with the object's loss; and
• because the lost object is regarded with a
mixture of love and hate, feelings of anger are
directed inward at the self
• John Bowlby believed that damaged early attachments
and traumatic separation in childhood predispose to
depression.
• Adult losses are said to revive the traumatic childhood
loss and so precipitate adult depressive episodes
iv) Cognitive theory
• Aaron Beck postulated a cognitive triad of
depression that consists of
(1) views about the self,ie,a negative self-precept;
(2) about the environment,ie,a tendency to
experience the world as hostile and demanding,
and
(3) about the future,ie,the expectation of suffering
and failure
v) Learned helplessness
• This theory connects depressive phenomena
to the experience of uncontrollable events
• For example, when dogs in a laboratory were
exposed to electrical shocks from which they
could not escape
 Diagnostic Criteria of MDD
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.
1. Depressed mood most of the day, nearly every day (
feels sad, empty, hopeless) ( In children and
adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all,
activities most of the day, nearly every day.
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 every day.
 Diagnostic Criteria of MDD…
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every
day
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
8. Diminished ability to think or concentrate, or
indecisiveness, nearly every day .
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.
 Diagnostic Criteria of MDD…
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.
D. The occurrence of the major depressive episode is not
better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional
disorder, schizophrenia spectrum and other psychotic
disorders.
E. There has never been a manic episode or a hypomania
episode
Major Depressive Episode
 MDD…
• major depressive disorder can be recurrent
episode, presence of psychotic features, and on
remission status
• For an episode to be considered recurrent, there
must be an interval of at least 2 consecutive
months between separate episodes.
Severity :
– Mild
– Moderate
– Severe
– With psychotic features
– In partial remission
– In full remission
– Unspecified
 MDD…
 Delusions and hallucinations that are consistent with a
depressed mood are said to be mood congruent.
 include those of guilt, sinfulness, worthlessness, poverty,
failure, persecution, and terminal somatic illnesses (such
as cancer and a “rotting” brain).
 Delusions and hallucinations that are not consistent
with a depressed mood are said to be mood
incongruent.
 For example, a mood incongruent delusion in a
depressed person might involve grandiose themes of
exaggerated power, knowledge, and worth.
 A schizophrenic disorder should be considered in this
case.
 MDD…
Specifiers:
o With anxious distress
o With mixed features
o With melancholic features
o With atypical features
o With mood-congruent psychotic features
o With mood-incongruent psychotic features
o With catatonia
o With peripartum onset
o With seasonal pattern
Severity specifiers
• Mild: few, if any symptoms in excess of those
required to make the Dx; only minor
impairment in functioning.
• Moderate: symptoms or functional
impairment b/n “mild”& “severe”
• Severe without psychotic features: several
sms in excess of those required to make the
Dx symptoms markedly interfere with
functioning.
• Severe with psychotic features: delusions
&/or hallucinations are present.
 With melancholic features:
A. One of the following is present during the most
severe period of the current episode;
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli
(does not feel much better, even temporarily,
when something good happens).
B. Three (or more) of the following:
1. A distinct quality of depressed mood
characterized by profound despondency,
despair, and/or moroseness or by so-called
empty mood.
 Melancholic…
2. Depression that is regularly worse in the
morning.
3. Early-morning awakening (i.e., at least 2
hours before usual awakening).
4.Marked psychomotor agitation or
retardation.
5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
 With atypical features
 This specifier can be applied when these features
predominate during the majority of days of the current
or most recent major depressive episode.
A. Mood reactivity (i.e., mood brightens in response to
actual or potential positive events).
B. Two (or more) of the following features:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis ( heavy, leaden feelings in arms or
legs).
4. A long-standing pattern of interpersonal rejection
sensitivity (not limited to episodes of mood
disturbance) that results in significant social or
occupational impairment
 Atypical…
C. Criteria are not met for “with melancholic
features” or “with catatonia” during the same
episode
o Mood reactivity; is the capacity to be cheered up
when presented with positive events (e.g., a visit
from children, compliments from others).
o Hypersomnia; an extended period nighttime
sleep or daytime napping that totals at least 10
hours of sleep per day (or at least 2 hours more
than when not depressed).
 Risk and Prognostic Factors
• Temperamental; Neuroticism (negative
affectivity) is a well-established risk factor for the
onset of major depressive disorder,
• Environmental. Adverse childhood experiences
• Stressful life events ; are well recognized as
precipitants of major depressive episodes
• Genetic ; First-degree family members of
individuals with major depressive disorder have a
risk for major depressive disorder two- to four
fold higher.
 Risk…
• Major depressive disorder is not a benign
disorder and it tends to be chronic, and patients
tend to relapse.
• Patients who have been hospitalized for a first
episode of major depressive disorder have about
a 50 percent chance of recovering in the first
year.
• About 25 % of patients experience a recurrence
of major depressive disorder;
– In the first 6 months after release from a hospital,
– About 30 to 50 % in the following 2 years, and
– About 50 to 75 % in 5 years
 Suicide Risk
 The possibility of suicidal behavior exists at all
times during major depressive episodes.
 The most risk factor is a past history of suicide
attempts or threats.
 Other features associated with an increased risk
for completed suicide include;
male sex,
 being single or living alone, and
 having prominent feelings of hopelessness.
 The presence of borderline personality disorder
markedly increases risk for future suicide
attempts.
 5-HT reuptake inhibitors
Name usual daily dose(mg)
Citalopram 20-60
Escitalopram 10-20
Fluoxetine 10-40
Fluvoxamine 100-300
Paroxetine 20-50
Sertraline 50-150
 SSRI Side effects
• Reduced appetite
• Weight loss
• Headache
• Insomnia
• Sexual dysfunction
Tricyclic Antidepressant (TCA)
Name usual daily dose(mg)
 Amitriptyline 75-300
 Doxepin 75-300
 Imipramine 75-300
 Trimipramine 75-300
 Venlafaxine 150-375
 Duloxetine 30-60
 Side Effects

• Dry mouth, urinary retention, constipation,

tachycardia, & blurred vision (anticholinergic)
• Sedation & weight gain (antihistaminic)
• Can cause cardiac conduction delays, particularly
first-degree atrioventricular and bundle branch
block.
• Orthostatic hypotension attributed to blockade of
(alpha adrenergic receptors)
• Less common side effects are sexual dysfunction
Other treatment
• Psychosocial treatment
CBT
IPT( inter personal therapy)
Behavior therapy
• Physical therapy
ECT
Dysthymia
 Persistent Depressive Disorder
(Dysthymia)
• The most typical features of dysthymia is the
presence of a depressed mood that lasts most
of the day and is present almost continuously.
• There are associated feelings of inadequacy,
guilt, irritability, and anger; withdrawal from
society; loss of interest; and inactivity and lack
of productivity.
• The term dysthymia, which means “ill
humored”
 Dysthymic…
 Dysthymic 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) a persistent or intermittent course.
 Epidemiology
• Dysthymia is common and affects 5 to 6 %of
all persons.
It affects between half and one-third of all
patients in general psychiatric clinics.
 No gender differences for incidence rates.
more common in women younger than 64
years of age than in men of any age and
 Is more common among unmarried and
young persons and in those with low incomes.
 Epidemiology …
• The patients have coexisting anxiety disorders
(especially panic disorder),substance abuse,
and borderline personality disorder.
Etiology
• Biological Factors
• Psychosocial Factors
 Diagnostic Criteria
A. Depressed mood for most of the day, for more days,
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:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness
 Diagnostic Criteria…
C. During the 2-year period (1 year for children or
adolescents) of the disturbance, the individual
has never been without the symptoms in Criteria
A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be
continuously present for 2 years.
E. There has never been a manic episode or a
hypomania episode, and criteria have never been
met for cyclothymic disorder.
F. The disturbance is not better explained by other
mental illnesses.
.
 Diagnostic Criteria…
G. The symptoms are not attributable to the
physiological effects of a substance (e.g., a
drug of abuse, a medication) or another
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 at age 21 years or older
 Risk and Prognostic Factors…
• About 50 % of patients with dysthymia
experience an insidious onset of symptoms
before age 25 years
• Patients with an early onset of symptoms are at
risk for either major depressive disorder or
bipolar I disorder in the course of their disorder.
• Patients with the diagnosis of dysthymia indicate
that;
– about 20 % progressed to major depressive
disorder,
– 15 %to bipolar II disorder, and
– fewer than 5 % to bipolar I disorder.
 Differential Diagnosis
 Major depressive disorder.
 Psychotic disorders.
 Depressive or bipolar and related disorder
due to another medical condition
 Substance/medication-induced depressive or
bipolar disorder
 Personality disorders.
 Double Depression: An estimated 40 % of patients
with major depressive disorder also meet the criteria
for dysthymia, a combination often referred to as
double depression
 Treatment
Treatments indicate that only 10 to 15 percent
of patients are in remission 1 year after the
initial diagnosis.
• About 25 percent of all patients with
dysthymia never attain a complete recovery.
• Overall, the prognosis is good with treatment.
• Hospitalization is usually not indicated for
patients with dysthymia but;
 Particularly severe symptoms, marked social
or professional incapacitation, and suicidal
ideation are all indications for hospitalization.
Treatment…
• Contemporary data offer the most objective
support for cognitive therapy, behavior
therapy, and pharmacotherapy
• Data generally indicate that SSRIs, venlafaxine
and bupropion are an effective treatment for
patients with dysthymic disorder.
• MAOIs are effective in a subgroup of patients
with dysthymic disorder
Bipolar and related disorders
 Epidemiology

 The life-time prevalence of bipolar I disorder is 0-

2.4%
 an equal prevalence among men and women
 Manic episodes are more common in men, and
depressive episodes are more common in women
 When manic episodes occur in women, they are
more likely than men to present a mixed picture
 The mean age of onset for the first manic,
hypomanic or major depressive episode is
approximately 18yrs
 Women also have a higher rate of being rapid
cyclers (≥4 episodes in a year)
• 90% of individuals who have a single manic
episode go on to have recurrent mood episodes
• Bipolar I disorder is more common in divorced
and single persons than among married persons
• higher than average incidence of bipolar I
disorder is found among the upper
socioeconomic groups
• more common in persons who did not graduate
from college than in college graduates
Lifetime risk of suicide in individuals with
bipolar disorder is estimated to be 15 times
that of the general population
• the lifetime history of substance use disorders,
panic disorder, and OCD was approximately
twice as high among patients with bipolar I
disorder (61 percent, 21 percent, and 21
percent, respectively) than in patients with
unipolar major depression (27 percent, 10
percent, and 12 percent, respectively)
Bipolar I disorder
• defined as having a clinical course of one or more
manic, or mixed episodes and, sometimes, major
depressive episodes
A manic episode is a distinct 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
Additional symptoms of mania:
 Distractibility,
 over involvement in pleasurable activity
 inflated self-esteem
 flight of ideas, racing thoughts
 ↑ed goal-directed activity,
 decreased need for sleep,&
 talkativeness
 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).
B. During 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)
• 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)
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, other
treatment) or to another medical condition.
 Hypomanic Episode
• Elevated, expansive, or irritable mood lasting > 4
days – clearly different from baseline
• Three or more of the following (four if mood
irritable):
• Grandiosity
• Decreased need for sleep
• Pressured speech
• Flight of ideas, racing thoughts
Distractibility
Increased goal-directed activity
Excessive involvement in pleasurable
activities with high risk
Clear change in functioning but no marked
impairment in social or occupational
functioning
 Bipolar I Disorder
A. Criteria have been met for at least one manic
episode (Criteria A-D under “Manic Episode”
above).
B. The occurrence of the manic and major
depressive episode(s) is not better explained by
schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder,
or other specified or unspecified schizophrenia
spectrum and other psychotic disorder.
 Bipolar II disorder:

Criteria have been met for at least one

hypomanic episode and at least one major
depressive episode
• Clinically significant distress or functional
impairment (mainly for depressive episode)
• There has never been a manic episode
• Symptoms not better explained by other mental
disorder
• Symptoms shouldn’t be caused by
substance/medication or by another medical
condition
• a few studies indicate that bipolar II disorder is
associated with more marital disruption and with
onset at an earlier age than bipolar I disorder
• Patients with bipolar II disorder are at greater
risk of both attempting and completing suicide
than patients with bipolar I disorder and major
depressive disorder
• Patients typically present to a clinician during a
major depressive disorder and are unlikely to
complain initially of hypomania
• Typically the hypomanic episodes themselves do not
cause impairment

• Bipolar II disorder is not a milder form of bipolar I

disorder

• They have greater chronicity of illness and spend,

on average, more time in the depressive phase of
their illness, which can be severe and disabling
• Average age at onset is the mid-20’s,which is
slightly later than bipolar I and earlier than
MDD
• A rapid-cycling pattern is associated with a
poorer prognosis
• More education, fewer years of illness, and
being married are independently associated
with functional recovery in general
• Suicide risk is high in bipolar II disorder

• The prevalence rate of attempted suicides is

similar with bipolar I disorder (32.4% for II vs
36.3% for I) but the lethality of attempts is higher
for bipolar II disorder
 Specifiers for Bipolar and Related
Disorders
• With anxious distress: The presence of at least
two of the following symptoms during the majority of
days of the current or most recent episode of mania,
hypomania, or depression:
1. Feeling keyed up or tense.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of
himself or herself
• With rapid cycling (can be applied to
bipolar I or bipolar II disorder): Presence of
at least four mood episodes in the previous
12 months that meet the criteria for manic,
hypomanic, or major depressive episode.
• With psychotic features: Delusions or
hallucinations are present at any time
in the episode. If psychotic features are
present.
• With mood-congruent psychotic
features: During manic episodes, the
content of all delusions and
hallucinations is consistent with the
typical manic themes of grandiosity
• With mood-incongruent psychotic features:
The content of delusions and hallucinations is
inconsistent with mood episode
With catatonia
Clinical picture dominated by at least 3 of :
 Stupor ( no psychomotor activity, not actively relating
to environment)
 Catalepsy( passive induction of a posture held against
gravity)
 Waxy flexibility (slight resistance to positioning by
examiner)
 Mutism ( no, or very little,verbal response)
 Negativism ( opposition or no response to instructions
or external stimuli)
 Posturing (spontaneous and active maintenance
of a posture against gravity)
 Mannerism
 Stereotypy (repetitive, abnormally frequent non-
goal-directed mov’ts)
 Agitation (not influenced by external stimuli)
 Grimacing
 Echolalia (mimicking another’s speech)
 Echopraxia (mimicking another’s movements)
 Cyclothymic disorder:

• Symptomatically a mild form of bipolar II disorder

• Characterized by episodes of hypomania and

mild depression
• For at least 2 yrs. (at least 1 yr. in children and
adolescents), there have been 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
• During the above specified period, the
hypomanic and depressive periods have been
present for at least half the time and the pt
has not been without sms for >2 months at a
time
• 3 to 5 percent of all psychiatric outpatients
• Cyclothymic disorder usually has an insidiuos
onset and a persistent course
• About 5 to 10 percent of all patients with
cyclothymic disorder have substance
dependence
• The female-to-male ratio in cyclothymic
disorder is about 3 to 2
 Treatment
Most common choices include:
o Lithium (may be preferable in euphoric episode)
o Valproate (may be preferable in mixed episode)
o carbamazepine
o Olanzapine
o If psychosis is present, mood stabilizer often
combined with antipsychotic
o Use adjunctive treatments as necessary:
o Benzodiazepines, seclusion and restraint, sleep
aids
 Mood stabilizers

1. Lithium
Requires 10-14days to show effect
Medical workup including CBC, comprehensive
metabolic chem. (lytes, kidney function, TFTs),
pregnancy test
Start with 300 mg po tid and check the level
after 24 hrs.
Rx:900-2400mg/d(0.8-1.2mmol/l)
 Use in pregnancy
• Avoid in pregnancy(esp 1st TMP)
• Overall risk of fetal malformations is 4-12%
• CVS malformations(0.05-0.1% risk of Ebstein’s
anomaly)
• Use during lactation:
• Conc. in breast milk at 30-100% of mother’s
serum
• Avoid until infant is at least 5month of age due to
low renal clearance
• The American Academy of Pediatrics considers
lithium contraindicated during lactation
 Side effects

• Gastrointestinal: nausea/vomiting, diarrhea

• Neuromuscular: tremors of the hand, lethargy
and muscle weakness
• Renal: impaired concentrating capacity caused
by reduced renal response to ADH, manifested
as polyuria, polydipsia, or both.
• Hyperparathyroidism
 Lithium toxicity

• Signs and symptoms of early intoxication

(with levels above 1.5 meq/liter) include
marked tremor, nausea and diarrhea,
blurred vision, vertigo, confusion, and
increased deep tendon reflexes
• With levels above 2.5 meq/liter, patients
may experience more severe neurological
complications and eventually experience
seizures, coma, cardiac dysrhythmia, and
permanent neurological impairment
 2. Carbamazepine
• Start with 200 mg po bid as patient tolerates
and increase up to maximum 1200mg /day.
• Use in pregnancy & lactation:
• Teratogenic effect:1% risk of spina bifida
• The American Academy of Pediatrics considers
carbamazepine compatible with breastfeeding
 side effects
Hepatic failure
 Exfoliative dermatitis (Steven-Johnson
syndrome)
Agranulocytosis, &
Aplastic anemia. (stop Rx if
WBC<3000/mm³,platelet<100,000/mm³,
Hgb<11g/dl
 3. Sodium Valproate
o The only anticonvulsant approved for use in
acute mania by the FDA

o The mechanism of action of valproate as a mood

stabilizer is not fully understood

o Begin at 250mg tid & ↑progressively

o Usual dose 750-3000mg/d

 Precautions:

• Valproate may inhibit the metabolism of a

number of drugs metabolized by CYP
• Prior to Rx do LFT & CBC;repeat tests qmo for
1st 6mo,then q6mo
• Stop drug if hepatic transaminases are ↑ed 2-
3x the upper limit of normal
• Contraindicated in liver dysfunction
• Overdose can result in coma & death
o Use in pregnancy & lactation:

o Avoid use in pregnancy(1.2% risk of spina bifida

& up to 5% risk of neural tube defects)

o Valproate is considered compatible with

breastfeeding
 Side effects
o sedation,

o GI distress,

o benign hepatic transaminase elevation,

o weight gain, hair loss, and rarely it can cause

acute pancreatitis (especially in children), &

o polycystic ovary disease.

o Both the high-potency typical antipsychotics and
the second-generation antipsychotics
olanzapine and risperidone have demonstrated
efficacy in the treatment of mania and safe to
Use in pregnancy and lactation
 Premenstrual Dysphoric Disorder
(PMDD)
• The essential features of premenstrual
dysphoric disorder are;
– the expression of mood lability,
– irritability,
– dysphoria, and
– anxiety symptoms that occur repeatedly during
the premenstrual phase of the cycle and remit
around the onset of menses or shortly thereafter.
 PMDD
• Typically, symptoms peak around the time of the
onset of menses
• the core symptoms include mood and anxiety
symptoms, behavioral and somatic symptoms
commonly also occur.
• However, the presence of physical and/or
behavioral symptoms in the absence of mood
and/or anxious symptoms is not sufficient for a
diagnosis.
• Symptoms are of comparable severity (but not
duration) to those of another mental disorder,
such as a MDD or generalized anxiety disorder.
 Prevalence
• Twelve-month prevalence of premenstrual
dysphoric disorder is between 1.8% and 5.8% of
menstruating women
• Symptoms cease after menopause, although
cyclical hormone replacement can trigger the re-
expression of symptoms
• Environmental factors associated with the
expression of premenstrual dysphoric disorder
include stress and history of interpersonal trauma
 Diagnostic Criteria of PMDD
A. In the majority of menstrual cycles, at least five symptoms
must be present in the final week before the onset of
menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week
postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings: feeling
suddenly sad or tearful, or increased sensitivity to
rejection).
2. Marked irritability or anger or increased interpersonal
conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-
deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up
or on edge.
 DX Criteria of PMDD…
C. One (or more) of the following symptoms must
additionally be present, to reach a total of five symptoms
when combined with symptoms from Criterion B above.
1. Decreased interest in usual activities (e.g., work, school,
friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food
cravings.
5. Hypersomnia or insomnia.
6. A sense of being ovenwhelmed or out of control.
7. Physical symptoms such as breast tenderness or swelling,
joint or muscle pain, a sensation of “bloating,” or weight
gain.
 DX Criteria of PMDD…
D. Symptoms are associated with clinically significant distress or
interference with work, school, usual social activities
E. The disturbance is not merely an exacerbation of the
symptoms of another disorder, such as major depressive
disorder, panic disorder, persistent depressive disorder
(dysthymia), or a personality disorder
F. Criterion A should be confirmed by prospective daily ratings
during at least two symptomatic cycles.
G. The symptoms are not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication, other
treatment) or another medical condition (e.g.,
hyperthyroidism).
 Differential Diagnosis
 Premenstrual syndrome
 Differs from premenstrual dysphoric disorder in that a
minimum of five symptoms is not required, and there is
no stipulation of affective symptoms for Individuals who
have premenstrual syndrome
 Dysmenorrhea
 Dysmenorrhea is a syndrome of painful menses, but this is
distinct from a syndrome characterized by affective
changes.
 Moreover, symptoms of dysmenorrhea begin with the
onset of menses,
 whereas symptoms of premenstrual dysphoric disorder, by
definition, begin before the onset of menses.
 DDX…
 Bipolar disorder,
 major depressive disorder, and
 persistent depressive disorder (dysthymia)
 Use of hormonal treatments(hormonal
contraceptives)
Comorbidity:
– A major depressive episode is the most frequently
reported previous disorder in individuals
presenting with premenstrual dysphoric disorder.
– A wide range of medical (e.g., migraine, asthma,
allergies, seizure disorders) or other mental
disorders
 Managements
Treatment is symptomatic and includes
analgesics for pain and sedatives for anxiety
and insomnia
Some patients respond to short courses of
SSRIs
Fluid retention is relieved with diuretics