MOOD DISORDERS

BY. Abdurehman. K(MSc in Mental health)

Course objectives
At the end of this course students will be able to:
 understand and discuss the diagnostic features,
classification, etiology, epidemiology, treatment
and prophylaxis of mood disorders.
 students will acquire latest information on
characteristic of pathological elevated or
depressed mood that exist in continuum with
normal mood.
 They will also be expected to use holistic
approach to manage different types of mood
disorders.

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Outline
 What is a mood disorder?
 Criteria for specific mood episodes and
disorders
 Epidemiology
 Etiology
 Differential diagnosis
 Case examples
 Questions

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General points
definition
 Mood can be defined as a pervasive and
sustained emotion or feeling tone that
influences a person’s behavior and colors his
or her perception of being in the world.
 Disorders of mood—sometimes called
affective disorders

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General points cont’d…
 make up an important category of psychiatric
illness consisting of depressive disorder,
bipolar disorder and other disorders
 A variety of adjectives are used to describe
mood:- depressed, sad, empty, melancholic,
distressed, irritable, disconsolate, elated,
euphoric, manic, gleeful, and many others, all
descriptive in nature.
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DSM-V-Classification of Mood Disorders
 It is tempting to consider disorders of mood
on a continuum with normal variations in
mood.
 Majorly classified as unipolar and bipolar
 Unipolar refers to the presence of onily
depressive episode, no manic or mixed
episode occur during the course of the illness
 Bipolar refers to the presence of manic or
mixed episode with or without depressive
episode

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DSM-V-Classification of Mood Disorders cont’d
 Depresive disorders include:
1. disruptive mood dysregulation disorder
2. Major depressive disorder
3. persistent depressive disorder (dysthymia)
4. premenstrual dysphoric disorder
5. substance/medication-induced depressive
disorder
6. depressive disorder due to another medical
condition
7. other specified depressive disorder and
8. unspecified depressive disorder.
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DSM-V-Classification of Mood Disorders cont’d
 The common feature of all of these disorders
is the presence of sad,empty, or irritable
mood, 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

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DSM-V-Classification of Mood Disorders cont’d
Disruptive Mood Dysregulation Disorder
 referring to the presentation of children with
persistent irritability and frequent episodes of
extreme behavioral dyscontrol,
 depressive disorders for children up to12
years of age
 children with this symptom pattern typically
develop unipolar depressive disorders or
anxiety disorders rather than bipolar
disorders, as they mature into adolescence
and adulthood.

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DSM-V-Classification of Mood Disorders cont’d
major depressive disorder
 occurs without a history of a manic, mixed, or
hypomanic episode
 A major depressive episode must last at least 2
weeks and also experiences at least 4 symptoms
from a list that includes in addition to either
depressed mood or loss of interest.
 changes in appetite and weight
 changes in sleep and activity
 lack of energy
 feelings of guilt
 problems thinking and making decisions and
 Recurring thoughts of death or suicide.
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DSM-V-Classification of Mood Disorders cont’d
persistent depressive disorder (dysthymic
disorder)
 A more chronic form of depression,
 can be diagnosed when the mood disturbance
continues for at least 2 years in adults or 1 year
inchildren.
 the presence of symptoms that are less severe than
that of major depressive disorder
premenstrual dysphoric disorder:
 a specific and treatment-responsive form of
depressive disorder that begins sometime following
ovulation and remits within a few days of menses
 has a marked impact on functioning
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DSM-V-Classification of Mood Disorders cont’d
 Bipolar and Related Disorders

1. Bipolar I Disorder

2. Bipolar II Disorder

3. Cyclothymic Disorder

4. Substance/Medication-Induced Bipolar Disorder

5. Bipolar Disorder Due to Another Medical Condition

6. Other Specified Bipolar Disorder

7. Unspecified Bipolar Disorder

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DSM-V-Classification of Mood Disorders cont’d
 manic episode: is a distinct period of an abnormally and
persistently elevated, expansive, or irritable mood lasting for
at least 1 week
 hypomanic episode: lasts 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 mania and hypomania are associated with
 inflated self-esteem
 decreased need for sleep
 distractibility
 Great physical and mental activity and
 Over involvement in pleasurable behavior

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DSM-V-Classification of Mood Disorders cont’d
 Bipolar I disorder: is defined as having a clinical
course of 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
 Cyclothymic disorder: is characterized by 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
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episode
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Mood states

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EPIDEMIOLOGY
Incidence and Prevalence
 Mood disorders are common
 In the most recent surveys, major depressive
disorder has the highest lifetime prevalence (almost
17 percent) of any psychiatric disorder
 The annual incidence of bipolar illness is considered
generally to be less than 1%, but it is difficult to
estimate because milder forms of bipolar disorder
are often missed.
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EPIDEMIOLOG…
Life time prevalence

Bipolar I 0-2.4

Bipolar II 0.3-4.8

Cyclothymia 0.5-6.3

Hypomania 0.6-7.8

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EPIDEMIOLOG…
Life time prevalence
Range Average
Major depressive episode 5-17 12

Dysthymic disorder 3-6 5

Minor depressive disorder 10 -

Recurrent brief depressive 16 -

disorder

Disruptive mood 2-5 -

dysregulation disorder
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EPIDEMIOLOG…
Sex
 An almost universal observation, independent of
country or culture, is the twofold greater prevalence of
major depressive disorder in women than in men.
 The reasons for the difference are hypothesized to
involve
 hormonal differences
 the effects of child birth
 differing psychosocial stressors for women and for men and
 behavioral models of learned helplessness.
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EPIDEMIOLOG…
 bipolar I disorder has 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
 Women also have a higher rate of being rapid cyclers,
defined as having four or more manic episodes in a 1-
year period.
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EPIDEMIOLOG…
Age
 The onset of bipolar I disorder is earlier than that of
major depressive disorder.
 bipolar I disorder ranges from 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.
 The mean age of onset for MDD is about 40 years, with
50 % of all patients having an onset between the ages
of 20 and 50 years.
 MDD can also begin in childhood or in old age
 Recent data suggest that the incidence of MDD may be
increasing among people younger than 20 years of age
 This may be related to the increased use of alcohol and
drugs of abuse in this age group
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EPIDEMIOLOG…
Marital Status
 MDD occurs most often in persons without close
interpersonal relationships and in those who are
divorced or separated
 Bipolar I disorder is more common in divorced
and single persons than among married persons,
but this difference may reflect the early onset
and the resulting marital discord characteristic of
the disorder.
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EPIDEMIOLOG…
Socioeconomic and Cultural Factors
 No correlation has been found between
socioeconomic status and major depressive disorder
 A higher than average incidence of bipolar I disorder
is found among the upper socioeconomic groups
 Bipolar I disorder is more common in persons who
did not graduate from college than in college
graduates, however, which may also reflect the
relatively early age of onset for the disorder
 Depression is more common in rural areas than in
urban areas
 The prevalence of mood disorder does not differ
among races
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COMORBIDITY
 Individuals with major mood disorders are at an
increased risk of having one or more additional
comorbid disorders
 The most frequent disorders are alcohol abuse or
dependence, panic disorder, obsessive-compulsive
disorder (OCD), and social anxiety disorder.
 Conversely, individuals with substance use disorders
and anxiety disorders also have an elevated risk of
lifetime or current comorbid mood disorder.
 In both unipolar and bipolar disorder, men more
frequently present with substance use disorders,
women more frequently present with comorbid
anxiety and eating disorders.
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COMORBIDITY CONT’D
 In general, patients who are bipolar more frequently
show comorbidity of substance use and anxiety
disorders than do patients with unipolar major
depression.
 In the (ECA) study, the lifetime history of substance
use disorders, panic disorder, and OCD was
approximately twice as high among patients with
bipolar I disorder (61%, 21%, and 21%, respectively)
than in patients with unipolar major depression (27%,
10%, and 12% , respectively).
 Comorbid substance use disorders and anxiety
disorders worsen the prognosis of the illness and
markedly increase the risk of suicide among patients
who are unipolar major depressive and bipolar.
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ETIOLOGY OF MOOD DISORDERS
A. Biological Factors
 studies have reported biological abnormalities in patients
with mood disorders.
 Until recently, the monoamine neurotransmitters
norepinephrine, dopamine, serotonin, and histamine were
the main focus of theories and research about the etiology
of these disorders.
 A progressive shift has occurred from focusing on
disturbances of single neurotransmitter systems in favor of
studying neurobehavioral systems, neural circuits, and
more intricate neuro-regulatory mechanisms.

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ETIOLOGY OF MOOD DISORDERS
CONT’D

1. Biogenic Amines
 norepinephrine and serotonin are the two neurotransmitters
most implicated in the pathophysiology of mood disorders.
NOREPINEPHRINE.
 The correlation suggested by basic science studies between
the down regulation or decreased sensitivity of β-adrenergic
receptors and clinical antidepressant responses is probably the
single most compelling piece of data indicating a direct role for
the noradrenergic system in depression.
 Other evidence has also implicated the presynaptic β2-
receptors in depression because activation of these receptors
results in a decrease of the amount of norepinephrine released.

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Etiology Of Mood Disorders Cont’d
 Presynaptic β2-receptors are also located on
serotonergic neurons and regulate the amount
of serotonin released
 The clinical effectiveness of antidepressant
drugs with noradrenergic effects for example,
venlafaxine (Effexor) further supports a role
for norepinephrine in the pathophysiology of
at least some of the symptoms of depression.
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Drug Action on Synaptic Activity

© 2012 John Wiley & Sons, Inc. All ri

ghts reserved.
Etiology Of Mood Disorders Cont’d
SEROTONIN.
 the selective serotonin reuptake inhibitors (SSRIs)
for example, fluoxetine (Prozac) have made on the
treatment of depression,
 The identification of multiple serotonin receptor
subtypes has also increased the development of
even more specific treatments for depression.
 In addition to this evidence depletion of serotonin
may precipitate depression
 some patients with suicidal impulses have low
cerebrospinal fluid (CSF) concentrations of
serotonin metabolites and serotonin uptake sites
on platelets.
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Etiology Of Mood Disorders Cont’d
DOPAMINE.
 has also been theorized to play a role suggest that
dopamine activity may be reduced in depression and
increased in mania.
 Drugs that reduce dopamine concentrations for example,
reserpine (Serpasil) and diseases that reduce dopamine
concentrations (e.g., Parkinson’s disease) are associated
with depressive symptoms
 In contrast, drugs that increase dopamine concentrations,
such as tyrosine, amphetamine and bupropion (Wellbutrin),
reduce the symptoms of depression.
 Two recent theories about dopamine and depression are that
the:
1. mesolimbic dopamine pathway may be dysfunctional
2. dopamine D1 receptor may be hypoactive

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Serotonin and Dopamine Pathways

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Etiology Of Mood Disorders Cont’d
Other Neurotransmitter Disturbances.
 Acetylcholine (ACh): found increased in
depression and decreased in mania.
 γ-Aminobutyric acid (GABA)
 Reductions of GABA have been observed in
plasma, CSF, and brain GABA levels in
depression.

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Etiology Of Mood Disorders Cont’d
Alterations of Hormonal Regulation.
 Lasting alterations in neuroendocrine and behavioral
responses can result from severe early stress.
 Recent studies indicate that a history of early
trauma is associated with increased HPA activity
accompanied by structural changes (i.e., atrophy or
decreased volume) in the cerebral cortex.
 Hypercortisolemia in depression suggests one or
more of the following central disturbances:
 Decreased inhibitory serotonin tone;
 increased drive from norepinephrine, ACh or corticotropin
releasing hormone (CRH); or
 decreased feedback inhibition from the hippocampus.

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Etiology Of Mood Disorders Cont’d
 THYROID AXIS ACTIVITY: decreased in depression and increased in
mania
 GROWTH HORMONE: Decreased CSF somatostatin levels have been
reported in depression, and increased levels have been observed in
mania.
2. Alterations of Sleep Neurophysiology
 Depression is associated with a premature loss of deep (slow-wave)
sleep and an increase in nocturnal arousal.
 The latter is reflected by four types of disturbance:
 (1) an increase in nocturnal awakenings,
 (2) a reduction in total sleep time,
 (3) increased phasic rapid eye movement (REM) sleep, and
 (4) increased core body temperature.
 The combination of increased REM drive and decreased slow-wave
sleep results in a significant reduction in the first period of non-REM
(NREM) sleep, a phenomenon referred to as reduced REM latency
 this event is seen in depressed patients

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Structural and functional brain imaging
 Some depressed patients also may have reduced
hippocampal or caudate nucleus volumes, or both
 greater left hemisphere reductions are seen in
depression compared with greater right hemisphere
reductions in mania
Etiology Of Mood Disorders Cont’d

Neuro anatomical abnormalities

 Prefrontal cortex (PFC):goal directed activities
 Anterior cingulate: integration of attentional
and emotional inputs
 Hippocampus: involved in various forms of
learning and memory
 Amygdala: processing novel stimuli of
emotional significance and coordinating or
organizing cortical responses
Key Brain Structures Involved in Mood
Disorders

Serotonin and Dopamine Pathways

© 2012 John Wiley & Sons, Inc. All ri

ghts reserved.
Etiology Of Mood Disorders Cont’d
Genetic Factors
 Family study: Family data indicate that if one
parent has a mood disorder, a child will have a risk
of between 10 and 25 % for mood disorder.
 If both parents are affected, this risk roughly
doubles.
 The risk is greater if the affected family members
are first-degree relatives rather than more distant
relatives.
 A family history of bipolar disorder conveys a
greater risk for mood disorders in general and,
specifically, a much greater risk for bipolar
disorder.
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Etiology Of Mood Disorders Cont’d
 Twin Studies: studies find a concordance
rate for mood disorder in the monozygotic
(MZ) twins of 70 to 90 % compared with the
same-sex dizygotic (DZ) twins of 16 to 35 %
 Adoption Studies
 provide an alternative approach to separating genetic and
environmental factors in familial transmission.
 One large study found a threefold increase in the rate of bipolar
disorder and a twofold increase in unipolar disorder in the
biological relatives of bipolar probands.
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Etiology Of Mood Disorders Cont’d
B. Psychosocial Factors
i. Life Events and Environmental Stress:
 A long-standing clinical observation is that
stressful life events more often precede first,
 losing a parent before age 11 years
 the loss of a spouse
 unemployment; three times more likely to report
symptoms of an episode of major depression
 Guilt may also play a role
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
Cognitive theory
 Aaron Beck postulated a cognitive triad of
depression that consists of

(1) views about the self, i.e., a negative self-

precept;

(2) about the environment, i.e., a tendency to

experience the world as hostile and demanding,
and

(3) about the future, i.e, the expectation of

suffering and failure
Etiology Of Mood Disorders Cont’d
 Psychodynamic Factors in Mania
 Most theories of mania view manic episodes as a defense against
underlying depression.
 The manic state may also result from a tyrannical superego, which
produces intolerable self-criticism that is then replaced by euphoric
self-satisfaction.
 Klein also viewed mania as a defensive reaction to
depression, using manic defenses such as
omnipotence(having great power), in which the person
develops delusions of grandeur.
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
 they showed behaviors that differentiated
them from dogs that had not been exposed
to such uncontrollable events.
 The dogs exposed to the shocks would not
cross a barrier to stop the flow of electric
shock when put in a new learning situation.
 In the reformulated view of learned helplessness as
applied to human depression, internal causal
explanations are thought to produce a loss of self-
esteem after adverse external events.
 Behaviorists who subscribe to the theory stress that
improvement of depression is contingent on the
patient's learning a sense of control and mastery of the
environment
 n k
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