Mood Disorders Flashcards
Key Points
- depression is a systemic disorder of mind, brain and body
- mood disorders shorten life thru excessive metabolic loads
- comorbidity is the rule
- effective treatment requires multiple approaches
- remission and relapse prevention are essential
Definition of a Mood Disorder
- biological, psychological, and social disturbances of mood and functioning associated with an episode of depression or mania
- mood: pervasive and sustained emotion that colors the perception of the world
(Has an impact on our cognition and judgement of the world around us)
DSM 5 Mood Disorders
- Major Depressive Disorder: single or recurrent
- Persistent Depressive Disorder (dysthymia): depression that lasts for a couple of years, very chronic
- Substance-induced Depressive Disorder: quite common
- depressive disorder due to another medical condition
- premenstrual dysphoric disorder: timing of periods (at least 3)
- Bipolar I Disorder: current or most recent episode (manic, hypomanic, depressed)—if you have a manic episode (you’re automatically I)
- Bipolar II Disorder: difference from one is that it’s much more mood instability, fewer intervals free of hypomanic or depressive episodes, more frequent episodes
- cyclothymic disorder: smaller amplitude for both highs and lows of bipolar I. Bipolar I light.
Major Depressive Disorder
- the most common mood disorder: 15 million adults (US), 5-6% of population
- leading cause of disability worldwide (accounts for the bulk of Horus and days lost to work)
- median age of onset 25-30 (wide variation)
- females:males (2:1), worldwide
- avg. duration of untreated episode: 4 months (doesn’t spontaneously remit)
Criteria: 5 or more of 9 sx's lasting 2 weeks -anhedonia* -depressed mood* -appetite loss or increase -insomnia or hypersomnia -agitation or psychomotor retardation -low energy or fatigue -low self esteem, sense of worthlessness -poor concentration -thoughts of death or suicide *need to have one or the other (can have both) B: significant distress or impairment C: not attributable to substance use or another medical condition
Signs and Symptoms of MDD
Signs:
-poor eye contact, slow speech, voice changes, dyscoordination, altered gait (reflects changes in muscle tone in trunk, limbs, face), loss of muscle tone in face and trunk, poor appetite, negative thinking, social avoidance
Symptoms:
- apathy (just as important as sadness. There are a number of people with severe major depressive who won’t tell you they’re sad, rather they feel flat or numb), hopelessness, self-blame, shame, feeling unattractive, preoccupations with dearth, feeling nothing or numb
- more self blame and guilt rather than grief
Recovery, Relapse, Recurrence:
- episode begins with appearance of a few symptoms, get to 5 then continue on to severe zone. Beginning of acute phase of treatment starts at beginning of red. Better is not good enough. Really aiming for remission, not just response. Getting to zero or one or 2 symptoms.
- to actually call this a full recovery, need to be free of symptoms for 2 months. If you get worse again before achieving recovery, it’s called a relapse. If you go a couple months and then have an episode, it’s called a recurrence
-think of it as beginning in the cortex with perception of stress leading to changes at the hypothalamus level, corticotrophin releasing hormone, leading to pituitary release in ACTH and cortisol, then secretion that hopefully feeds back to hypothalamus and closed loop. in depression, the looped doesn’t close well. Increased cortisol, increased risk for arrhythmias, excessive bone resorption due to cortisol, beer belly abdominal fat, dysregulation of the immune system leading to increased circulation of inflammatory cytokines and decreased resilience
Etiologies of Depression
Helen Mayberg Model
-dysregulation of Cortico-limbic circuits that regulate mood:
Pre-frontal cortex
Amygdala
Hippocampus
Hypothalamus
-dysregulation of appetite, libido, sleep, mood stability, memory and stress response
Problem according to model: the problem according to the model is that the prefrontal cortex (regulate limbic structure of amygdala, hypothalamus and hippocampus) is not inhibiting and regulating these as efficiently as usual. Circadian rhythms get of out of whack, food appetite and sexual rhythms get out of whack. Not operating efficiently
Etiologies of Depression (HPA Axis)
HPA Axis dysregulation of stress response
- CRF is the “black bile” of depression
- Excessive cortisol secretion
- impaired feedback at the paraventricular nucleus of the hypothalamus
-Important to recognize that CRF by itself is inherently depressing
-CRF: gets secreted from hypothalamus to pituitary which triggers ACTH release which goes to adrenal glands to increase release of cortisol. One thing that can trigger increased release of CRF is stress in general. Some can be generated by ENV, some just self-thoughts
-There is genetics involved. Genes do contribute to our vulnerability to mood disorders in general. Various forms of depression. Some ct directly. Some respond to stress (epigenetic phenomenon). Family histories point to a 40-50% genetic contribution
-another school of thought: some forms of depression are learned/behavioral. Some therapy can focus on unlearning these behaviors
-genetics and stress (gene-ENV interactions)
-learned helplessness
-anger turned inward
In this HPA axis for adaptive behavior: need a good feedback loop. Something needs to turn off CRF secretion or it goes a from an acute response to a chronic response
Depressive patients: more likely to die after a heart attack in a few months due to increased catecholamine’s
Etiologies of Depression (N.T.’s, genes, behavior)
-dysregulation of NT’s involved in mood regulation:
Serotonin
NE
DA
GABA
Glutamate
-role of antidepressants in reregulating
-genes, stress, and epigenetic activation of vulnerability genes: life events may trigger episodes early in the course of mood disorders
Applies to epilepsy and other recurrent conditions. Stressful events have a greater impact on the vulnerability of the stress-response system in the beginning. Once the vulnerability has been set up, it takes a life of its own and it can perpetuate itself
-another reason why it’s important to get full remission of symptoms early on in the course and treatment mood disorders before it becomes a chronic thing
- —-learned helpless: behavioral model for depression. Animal research models of depression
- —-loss; anger turned inward: Freud’s theory of depression
Persistent Depressive Disorder
(Formerly “dysthymia” for mild symptoms)
A: depressed mood x 2 yrs
B: at least 2 other depressive symptoms
C: no period of more than 2 months free of A and B sx’s
D: MDD x 2 yrs = mod or severe PDD
E: clinically significant distress or impairment
Mood disorders hit much earlier on in life and last throughout the course of life for many people. Takes a real hit on duration and disability of life
Bipolar Disorder
- affects about 6 million, 2.5% of population
- mean age of onset 18-20
- female:male (1:1)
- about a third as many people have Bipolar Disorder as have MDD
- different meant age of onset and ratio
Criteria for Manic Episode
A: a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B: during the period of mood disturbance, three (or more) of the following symptoms have persistence (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
3: more talkative than usual or pressure to keep talking
4: flight of ideas or subjective experience that thoughts are racing
5: distractibility
6: increase in goal-directed activity of psychomotor agitation
7: excessive involvement in pleasurable activities that have a high potential for painful consequences
Criteria for Hypomanic Episode
A: a distinct period of persistently elevated, expansive, or irritable mood lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood
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
3: more talkative than usual or pressure to keep talKING
4: flight of ideas or subjective experience that thoughts are racing
5: distractibility
6: increase in goal-directed activity or psychomotor agitations
7: excessive involvement in pleasurable activities that have a high potential for painful consequences
-difference between manic and hypomanic is fuzzy
Key differences on this slide is duration of 4 days. Criteria included having 3 or more symptoms but think of them as less severe or less obvious but still impair functioning to some degree
Types and Symptoms of Mania
Classic (euphoric)
Hypomania
Irritable Mania: gets people into fights, jail, trouble. Judgement on other people’s response to them is terrible
Mixed Mania: it is possible to be both depressed and manic at the same time. most noxious and stressful states: have suicide and grandeur thoughts
Sx:
- beings with euphoria, elation, heightened pleasure
- may turn into irritability, anger, psychosis
- impulsivity, poor judgment, poor concentration, decreased need for sleep, cognitive impairment
Stages of Mania
I: Hypomania
-energetic, extroverted, assertive
DDx: idealized norm, substance abuse, borderline
-People often start out in a really pleasant stage of hypomania. Party type. This energetic state of mind often leads to being assertive, irritable and at this stage it can often be associated with substance abuse. Can be dismissed as borderline behavior
II: Mania -euphoric: grandiose -paranoid: irritable -hyperactive DDx: schizophrenia, substance abuse, metabolic
III: Psychosis
-paranoid
-delusional
-confused
DDx: schizophrenia, substance abuse, metabolic
-delusional thinking. They can get delirious, paranoid, schizophrenia is often misdiagnosed at this stage
Criteria for Mixed Episode
A: the criteria are met for both a Manic and Major Depressive Episode (except for duration) nearly every day during at least a 1 week period
B: the mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
C: the symptoms are not due to the direct physiological effects of a substance or a general medical condition
