Affective Disorders Clinical Aspects

Question 1

What is mood?

Answer 1

• moods characterise the state of mind or inner disposition of a person; a mood is a result of prolonged feelings and colour the whole mental life while it lasts (Karl Jaspers, 1913)

Question 2

How to assess mood?

Answer 2

• Descriptive psychopathology: phenomenological (emphatic) assessment of subjective experience. It describes and categorizes the abnormal experiences reported by the patients - and observed in behaviours

Question 3

Diagnostic test for mood disorder?

Answer 3

• There no diagnostic tests for mood disorders
• Diagnosis is based on identification of symptoms which clusters into “syndromes”

Question 4

Mood disorders - classification

• There no diagnostic tests for mood disorders
• Diagnosis is based on identification of symptoms which clusters into “syndromes”
  
  • …-5 and …-10 - standard sets of criteria used to classify all psychiatric disorders

Answer 4

• There no diagnostic tests for mood disorders
• Diagnosis is based on identification of symptoms which clusters into “syndromes”
  
  • DSM-5 and ICD-10 - standard sets of criteria used to classify all psychiatric disorders
    
    • the Diagnostic and Statistical Manual for Mental Disorders (DSM)
    • the International Classification of Diseases (ICD

Question 5

Mood Disorders: the episodes (4)

Answer 5

• Major Depressive Episode
• Manic Episode
• Hypomanic Episode
• Mixed affective episode

Question 6

Classification of Mood Disorders

• … depression
• … disorder

Answer 6

• Unipolar depression
• Bipolar disorder

Question 7

Major Depressive Disorder

Answer 7

• Free from symptom period, then periods of major depressive episode

Question 8

Symptoms of depression - list

Answer 8

• Depression of mood
• Anhedonia
• Psychomotor retardation
• Diurnal variation of mood
• Thoughts of
• guilt , self-reproach, self-blame, worthlessness, depersonalization
• Agitation / restlessness
• Anxiety / preoccupation
• Somatic symptoms
• Hypochondriasis
• Weight loss
• Insomnia
• Suicidal thoughts

Question 9

What is anhedonia?

Answer 9

Anhedonia is the inability to feel pleasure. It’s a common symptom of depression as well as other mental health disorders.

Question 10

MDD diagnostic criteria (DSM V) - Depression

• … of more symptoms during … weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or …
  • 5.Psychomotor … or retardation
  • 6…. or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or .., or indecisiveness
  • 9… suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Answer 10

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Question 11

MDD diagnostic criteria (DSM V) - Depression

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished … or …
  • 3.Weight loss / weight gain or … decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of … or excessive or inappropriate …
  • 8.Diminished ability to … or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically … distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Answer 11

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Question 12

MDD diagnostic criteria (DSM V) - Depression

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4…. or hypersomnia
  • 5.Psychomotor agitation or …
  • 6.Fatigue or loss of …
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent … ideation or a … attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Answer 12

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Question 13

MDD diagnostic criteria (DSM V) - Depression

• … of more symptoms during … weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Answer 13

• Five of more symptoms during 2 weeks period:
  
  • 1.Depressed mood most of the day, nearly every day
  • 2.Diminished interest or pleasure
  • 3.Weight loss / weight gain or appetite decrease / increase
  • 4.Insomnia or hypersomnia
  • 5.Psychomotor agitation or retardation
  • 6.Fatigue or loss of energy
  • 7.Feelings of worthlessness or excessive or inappropriate guilt
  • 8.Diminished ability to think or concentrate, or indecisiveness
  • 9.Recurrent suicidal ideation or a suicide attempt/plan
    
    • The symptoms must cause clinically significant distress or functional impairment and are not attributable to the physiological effects of a substance or to another medical condition

Question 14

depression with melancholic features

• Loss of … in all, or almost all, activities
• Lack of reactivity to usually … stimuli
• Profound despondency, despair, … mood
• Depression regularly worse in the …
• …-… awakening
• Marked psychomotor agitation or retardation
• Significant … or weight …
• Excessive or inappropriate …

Answer 14

• Loss of pleasure in all, or almost all, activities
• Lack of reactivity to usually pleasurable stimuli
• Profound despondency, despair, empty mood
• Depression regularly worse in the morning
• Early-morning awakening
• Marked psychomotor agitation or retardation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt

Question 15

Atypical depression

• Mood …
• and
  
  • Significant weight … or … in appetite
  • …somnia
  • … paralysis (i.e., heavy, leaden feelings in arms or legs)
  • interpersonal … sensitivity

Answer 15

• Mood reactivity
• and
  
  • Significant weight gain or increase in appetite
  • Hypersomnia
  • Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
  • interpersonal rejection sensitivity

Question 16

Atypical depression

• Mood reactivity
• and
  
  • Significant weight gain or increase in …
  • Hypersomnia
  • Leaden … (i.e., heavy, leaden feelings in arms or legs)
  • … rejection …

Answer 16

• Mood reactivity
• and
  
  • Significant weight gain or increase in appetite
  • Hypersomnia
  • Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
  • interpersonal rejection sensitivity

Question 17

MDD - Epidemiology

• Most common mental disorder in primary care
• Higher rates of depressed patients in … care office
• age of onset …-… years (but can be at any age)
• … more than …
• 1 in 5 lifetime prevalence (…); …:10%
• Variation in 12-months prevalence, av. 7%
• Variable course
• 8 -19% die by suicide

Answer 17

• Most common mental disorder in primary care
• Higher rates of depressed patients in primary care office
• age of onset 25-35 years (but can be at any age)
• Females more than males
• 1 in 5 lifetime prevalence (females); males:10%
• Variation in 12-months prevalence, av. 7%
• Variable course
• 8 -19% die by suicide

Question 18

MDD - Epidemiology

• Most common mental disorder in primary care
• Higher rates of depressed patients in primary care office
• age of onset 25-35 years (but can be at any age)
• Females more than males
• 1 in 5 lifetime prevalence (females); males:…%
• Variation in 12-months prevalence, av. ..%
• … course
• ..-…% die by suicide

Answer 18

• Most common mental disorder in primary care
• Higher rates of depressed patients in primary care office
• age of onset 25-35 years (but can be at any age)
• Females more than males
• 1 in 5 lifetime prevalence (females); males:10%
• Variation in 12-months prevalence, av. 7%
• Variable course
• 8 -19% die by suicide

Question 19

Impact of MDD

• Greater than most … medical diseases
• … morbidity/mortality from co-existing medical conditions
• Decreased work …
• Suicide … leading cause among 15-29 years old
• Immense costs to society

Answer 19

• Greater than most chronic medical diseases
• Increased morbidity/mortality from co-existing medical conditions
• Decreased work productivity
• Suicide 2nd leading cause among 15-29 years old
• Immense costs to society

Question 20

Impact of MDD

• Greater than most chronic medical diseases
• Increased morbidity/mortality from co-existing medical conditions
• Decreased work productivity
• Suicide 2nd leading cause among ..-… years old
• Immense costs to …

Answer 20

• Greater than most chronic medical diseases
• Increased morbidity/mortality from co-existing medical conditions
• Decreased work productivity
• Suicide 2nd leading cause among 15-29 years old
• Immense costs to society

Question 21

Bipolar Disorder

• EPISODES
  
  • … / …
  • Subthreshold … and major …
  • Neither = euthymia (no mood disturbances)

Answer 21

• EPISODES
  
  • Mania / Hypomania
  • Subthreshold Depression and major depression
  • Can be euthymia (no mood disturbances)

Question 22

Bipolar Disorder

• EPISODES
  
  • Mania / Hypomania
  • … Depression and … depression
  • Neither = … (no mood disturbances)

Answer 22

• EPISODES
  
  • Mania / Hypomania
  • Subthreshold Depression and major depression
  • Can be euthymia (no mood disturbances)

Question 23

The manic episode - DSM V diagnosis

• The mood disturbance is sufficiently severe to cause marked functional … or to necessitate … to prevent harm to self or others, or there are … features.
• The episode is not attributable to the … effects of a … or to another … condition.
• Can be associated to psychotic symptoms such as … and …

Answer 23

• The mood disturbance is sufficiently severe to cause marked functional impairment or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
• The episode is not attributable to the physiological effects of a substance or to another medical condition.
• Can be associated to psychotic symptoms such as delusions and hallucinations

Question 24

The manic episode - DSM V diagnosis

• Abnormally and persistently elevated, expansive, or … mood
• For a period lasting at least … … and present most of the day, nearly every day:
• abnormally and persistently … activity or …
• … or more of the the following symptoms
  
  • 1.Inflated self-esteem or grandiosity
  • 2.Decreased need for …
  • 3.More t… than usual or pressure to keep talking
  • 4.Flight of ideas or r… thoughts
  • 5.d…
  • 6.Increase in goal-directed activity or psychomotor agitation
  • 7.Excessive involvement in high risk activities

Answer 24

• Abnormally and persistently elevated, expansive, or irritable mood
• For a period lasting at least one week and present most of the day, nearly every day:
• abnormally and persistently increased activity or energy
• 3 or more of the the following symptoms
  
  • 1.Inflated self-esteem or grandiosity
  • 2.Decreased need for sleep
  • 3.More talkative than usual or pressure to keep talking
  • 4.Flight of ideas or racing thoughts
  • 5.Distractibility
  • 6.Increase in goal-directed activity or psychomotor agitation
  • 7.Excessive involvement in high risk activities

Question 25

The manic episode - DSM V diagnosis

• Abnormally and persistently elevated, expansive, or irritable mood
• For a period lasting at least one week and present most of the day, nearly every day:
• abnormally and persistently increased activity or energy
• 3 or more of the the following symptoms
  
  • 1.Inflated …-… or g…
  • 2…. need for sleep
  • 3.More talkative than usual or … to keep talking
  • 4.Flight of … or racing thoughts
  • 5.Distractibility
  • 6.Increase in goal-directed activity or … agitation
  • 7.Excessive involvement in … … activities

Answer 25

• Abnormally and persistently elevated, expansive, or irritable mood
• For a period lasting at least one week and present most of the day, nearly every day:
• abnormally and persistently increased activity or energy
• 3 or more of the the following symptoms
  
  • 1.Inflated self-esteem or grandiosity
  • 2.Decreased need for sleep
  • 3.More talkative than usual or pressure to keep talking
  • 4.Flight of ideas or racing thoughts
  • 5.Distractibility
  • 6.Increase in goal-directed activity or psychomotor agitation
  • 7.Excessive involvement in high risk activities

Question 26

The hypomanic episode - DSM V diagnosis

• Same as Mania except
• lasting at least … days …
  
  • The episode is not severe enough to cause marked functional impairment or to necessitate …
  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not …
  • The disturbance in mood and the change in functioning are … by others.

Answer 26

• Same as Mania except
• lasting at least 4 days …
  
  • The episode is not severe enough to cause marked functional impairment or to necessitate hospitalization
  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
  • The disturbance in mood and the change in functioning are observable by others.

Question 27

Bipolar Disorder(s) – DSM V definitions

• Acute episodes:
  
  • … -> elevated mood & increased energy + marked functional impairment
  • … -> elevated mood & increased energy + no marked functional impairment
  • … -> depressed mood or …
• Bipolar Disorder Type I
  
  • at least 1 Manic episode
• Bipolar Disorder Type II :
  
  • 1 Hypomanic episode +
  • 1 Depressive episode

Answer 27

• Acute episodes:
  
  • Mania -> elevated mood & increased energy + marked functional impairment
  • Hypomania -> elevated mood & increased energy + no marked functional impairment
  • Depression -> depressed mood or anhedonia
• Bipolar Disorder Type I
  
  • at least 1 Manic episode
• Bipolar Disorder Type II :
  
  • 1 Hypomanic episode +
  • 1 Depressive episode

Question 28

Bipolar Disorder(s) – DSM V definitions

• Acute episodes:
  
  • Mania -> elevated mood & increased energy + marked functional impairment
  • Hypomania -> elevated mood & increased energy + no marked functional impairment
  • Depression -> depressed mood or anhedonia
• Bipolar Disorder Type I
  
  • at least … … episode
• Bipolar Disorder Type II :
  
  • .. … episode +
  • … … episode

Answer 28

• Acute episodes:
  
  • Mania -> elevated mood & increased energy + marked functional impairment
  • Hypomania -> elevated mood & increased energy + no marked functional impairment
  • Depression -> depressed mood or anhedonia
• Bipolar Disorder Type I
  
  • at least 1 Manic episode
• Bipolar Disorder Type II :
  
  • 1 Hypomanic episode +
  • 1 Depressive episode

Question 29

Bipolar Disorder(s)

• Clinical Specifiers
  
  • … distress
  • … features
  • … features
  • rapid …
  • melancholic, atypical,
  • mood …/incongruent psychotic features
  • … pattern
  • others

Answer 29

• Clinical Specifiers
  
  • anxious distress
  • psychotic features
  • mixed features
  • rapid cycling
  • melancholic, atypical,
  • mood congruent/incongruent psychotic features
  • seasonal pattern
  • others

Question 30

Bipolar Disorder(s)

• Clinical Specifiers
  
  • anxious …
  • psychotic features
  • mixed features
  • … cycling
  • …, atypical,
  • mood congruent/incongruent … features
  • seasonal pattern
  • others

Answer 30

• Clinical Specifiers
  
  • anxious distress
  • psychotic features
  • mixed features
  • rapid cycling
  • melancholic, atypical,
  • mood congruent/incongruent psychotic features
  • seasonal pattern
  • others

Question 31

Mixed affective episodes

• Full criteria met for either … or … episode, and
• at least … symptoms of the opposite … are present

Answer 31

• Full criteria met for either (hypo)manic or depressive episode, and
• at least 3 symptoms of the opposite polarity are present

Question 32

Features that may be associated to both depression and mania

• …
  
  • Restlessness, tension, worry, anticipatory anxiety, fear of losing control
• … symptoms
  
  • Delusions and hallucinations, mood congruent or incongruent
• C…

Answer 32

• Anxiety
  
  • Restlessness, tension, worry, anticipatory anxiety, fear of losing control
• Psychotic symptoms
  
  • Delusions and hallucinations, mood congruent or incongruent
• Catatonia

Question 33

Features that may be associated to both depression and mania

• Anxiety
  
  • Restlessness, T…, worry, … anxiety, fear of … …
• Psychotic symptoms
  
  • Delusions and …, mood … or …
• Catatonia

Answer 33

• Anxiety
  
  • Restlessness, tension, worry, anticipatory anxiety, fear of losing control
• Psychotic symptoms
  
  • Delusions and hallucinations, mood congruent or incongruent
• Catatonia

Question 34

The problem for early detection of Bipolar Disorder

• … usually early onset
• Full episode of …
• Then … symptoms
• Full episode of … later
• Diagnosis usually later - age ….

Answer 34

• Depression usually early onset
• Full episode of depression
• Then mania symptoms
• Full episode of mania later
• Diagnosis usually later - age 30 roughly

Question 35

Recognition of Bipolar Depression - A probabilistic approach
(from Mitchell et al., 2008)

• Probable Bipolarity:
  
  • …somnia
  • Hyper…
  • … sx (leaden paralysis)
  • Psychomotor retardation
  • … features
  • Mood …; irritability
  • … onset
  • Multiple …
  • … family hx of BPAD

Answer 35

• Probable Bipolarity:
  
  • Hypersomnia
  • Hyperphagia
  • Atypical sx (leaden paralysis)
  • Psychomotor retardation
  • Psychotic features
  • Mood lability; irritability
  • Early onset
  • Multiple episodes
  • Positive family hx of BPAD

Question 36

Recognition of Bipolar Depression - A probabilistic approach
(from Mitchell et al., 2008)

• Probable Unipolarity:
  
  • Initial …/reduced …
  • Appetite/weight loss
  • Increased … levels
  • … complaints
  • … onset
  • … episode duration
  • … family hx of BPAD

Answer 36

• Probable Unipolarity:
  
  • Initial insomnia/reduced sleep
  • Appetite/weight loss
  • Increased activity levels
  • Somatic complaints
  • Late onset
  • Long episode duration
  • Negative family hx of BPAD

Question 37

Bipolar Disorder

• Familial aggregation (… times higher risk in 1st degree relatives)
• Men & women affected … (BP-I)
• Lifelong risk of …

Answer 37

• Familial aggregation (10 times higher risk in 1st degree relatives)
• Men & women affected equally (BP-I)
• Lifelong risk of recurrence

Question 38

Bipolar Disorder - Natural History

• Highly …
• May have … course
• High rates of …
• Low rates of fully … recovery
• High rates of … remission
• Rate of suicide up to … times higher than general population
  
  • 30%-50% of patients attempt suicide

Answer 38

• Highly recurrent
• May have progressive course
• High rates of depression
• Low rates of fully sustained recovery
• High rates of incomplete remission
• Rate of suicide up to 20 times higher than general population
  
  • 30%-50% of patients attempt suicide

Question 39

Bipolar Disorder - Natural History

• … recurrent
• May have progressive course
• … rates of depression
• … rates of fully sustained recovery
• High rates of incomplete …
• Rate of suicide up to 20 times higher than general population
  
  • ..-..% of patients attempt suicide

Answer 39

• Highly recurrent
• May have progressive course
• High rates of depression
• Low rates of fully sustained recovery
• High rates of incomplete remission
• Rate of suicide up to 20 times higher than general population
  
  • 30%-50% of patients attempt suicide

Question 40

Bipolar patients are symptomatic almost … their lives

Answer 40

Bipolar patients are symptomatic almost half their lives

Question 41

Prevalence - all bipolar disorders

• all BPADs: …%
• sub-threshold: 1.4%
• Type I: …%
• Type II: …%
• Age of onset
  
  • Early onset group - 17 yrs (3 SD): 42%
  • Middle onset group - … yrs (5 SD) : 25%
  • Late onset group – 32 yrs (12 SD) : 33%
• Familial aggregation (10 times higher risk in 1st degree relatives)
• 70-80% Monozygotic concordance rate
• Men & women affected … (BP-I)

Answer 41

• all BPADs: 2.4%
• sub-threshold: 1.4%
• Type I: 0.6%
• Type II: 0.4%
• Age of onset
  
  • Early onset group - 17 yrs (3 SD): 42%
  • Middle onset group - 24 yrs (5 SD) : 25%
  • Late onset group – 32 yrs (12 SD) : 33%
• Familial aggregation (10 times higher risk in 1st degree relatives)
• 70-80% Monozygotic concordance rate
• Men & women affected equally (BP-I)

Question 42

Prevalence - all bipolar disorders

• all BPADs: 2.4%
• sub-threshold: …%
• Type I: 0.6%
• Type II: 0.4%
• Age of onset
  
  • Early onset group - … yrs (3 SD): 42%
  • Middle onset group - … yrs (5 SD) : 25%
  • Late onset group – 32 yrs (12 SD) : …%
• Familial aggregation (… times higher risk in 1st degree relatives)
• …-..% Monozygotic concordance rate
• Men & women affected equally (BP-I)

Answer 42

• all BPADs: 2.4%
• sub-threshold: 1.4%
• Type I: 0.6%
• Type II: 0.4%
• Age of onset
  
  • Early onset group - 17 yrs (3 SD): 42%
  • Middle onset group - 24 yrs (5 SD) : 25%
  • Late onset group – 32 yrs (12 SD) : 33%
• Familial aggregation (10 times higher risk in 1st degree relatives)
• 70-80% Monozygotic concordance rate
• Men & women affected equally (BP-I)

Question 43

Progressive nature of Bipolar disorder

• the risk of … increases with the number of … and that current standard treatment regimens do not stop this …

Answer 43

• the risk of recurrence increases with the number of episodes and that current standard treatment regimens do not stop this progression

Question 44

Staging model of Bipolar Disorder

Answer 44

Question 45

Link between dementia and bipolar?

Answer 45

Question 46

Link between depressive episodes and dementia/mild cognitive impairment?

Answer 46