Mood Disorders Flashcards
What is a mood?
A description of one’s internal emotional state
Both external & internal stimuli can trigger moods, which may be labeled as sad, happy, angry, irritable, etc.
It is normal to have wide range of moods & to have a sense of control over one’s moods
What is a mood disorder?
Aka affective disorders
Patients w/ mood disorders experience an abnormal range of moods & lose some level of control over them
- Distress may be caused by severity of their moods & resulting impairment in social & occupational functioning
Defined by patterns of mood episodes
Include major depressive disorder (MDD), bipolar I disorder, bipolar II disorder, persistent depressive disorder, & cyclothymic disorder
Some may have psychotic features (delusions / hallucinations)
- When patients have delusions / hallucinations due to underlying mood disorders, they are usually mood congruent
With what disorders can major depressive episodes present in?
Major depressive disorder
Persistent depressive disorder (dysthymia)
Bipolar I / II disorder
What are mood episodes?
Distinct periods of time in which some abnormal mood is present
Include depression, mania, & hypomania
DSM-V criteria of major depressive episode
Must have at least 5 of the following symptoms (must include number 1 or 2), for at least 2 weeks: 1. Depressed mood most of the time 2. Anhedonia (loss of interest in pleasurable activities) SIG E CAPS 3. Sleep (insomnia / hypersomnia) 4. Interest (anhedonia) 5. Guilt or feelings of worthlessness 6. Energy (loss) or fatigue 7. Concentration (diminished) 8. Appetite (increased/decreased) 9. Psychomotor agitation or retardation 10. Suicidal ideation (recurrent thoughts of death / suicide)
Symptoms are not attributable to the effects of substance (drug / medication) or another medical condition
Must cause clinically significant distress or social / occupational impairment
DSM-V criteria of manic episode
Distinct period of:
- Abnormally & persistently elevated, expansive, or irritable mood
- Abnormally & persistently increased goal-directed activity or energy lasting at least 1 week (or any duration if hospitalization is necessary)
- Including at least 3 of the following (4 if mood is only irritable):
DIG FAST
1. Distractibility
2. Insomnia / impulsive behavior / decreased need for sleep
3. Grandiosity or inflated self-esteem
4. Flight of ideas / racing thoughts
5. Activity / `agitation (increase in goal-directed activity or psychomotor agitation)
6. Speech (pressured [rapid & uninterruptible] or more talkative than usual)
7. Thoughtlessness (excessive involvement in pleasurable activities that have a high risk of negative consequences - e.g. shopping sprees, sexual indiscretions)
Symptoms are not attributable to effects of substance (drug / medication) or another medical condition
Must cause clinically significant distress or social/occupational impairment
> 50% of manic patients have psychotic symptoms
Manic episode is a psychiatric emergency
What is a hypomanic episode?
Distinct period of abnormally & persistently elevated, expansive, or irritable mood
Abnormally & persistently increased goal-directed activity or energy
Lasting at least 4 consecutive days
Includes at least 3 of the symptoms listed for manic episode criteria (4 if mood is only irritable): DIG FAST
Differences between manic & hypomanic episodes
Time frame:
- Mania: lasts at least 7 days
- Hypomania: lasts at least 4 days
Impairment in social or occupational functioning
- Mania: severe impairment
- Hypomania: no marked impairment
Hospitalization:
- Mania: may necessitate hospitalization to prevent harm to self/others
- Hypomania: does not require hospitalization
Psychotic features:
- Mania: have psychotic features
- Hypomania: no psychotic features
Mixed features of mood episodes
Criteria are met for a manic or hypomanic episode & at least 3 symptoms of a major depressive episode are present for majority of the time
Criteria must be present nearly every day for at least 1 week
Diagnosis of mood disorders
Often have chronic courses that are marked by relapses w/ relatively normal functioning between episodes
Like most psychiatric diagnoses, mood episodes may be caused by another medical condition or drug (prescribed or illicit)
Always investigate medical / substance-induced causes before making primary psychiatric diagnosis
Differential diagnosis of mood disorders (depressive & manic episodes) due to other medical conditions
Medical causes of depressive episode:
- Cerebrovascular disease (stroke, MI) - stroke patients are at significant risk for developing depression & associated w/ poorer outcome overall
- Endocrinopathies (DM, Cushing syndrome, Addison disease, hypoglycemia, hyper/hypothyroidism, hyper/hypocalcemia)
- Parkinson’s disease
- Viral illnesses (e.g. mono)
- Carcinoid syndrome
- Cancer (lymphoma, pancreatic carcinoma)
- Collagen vascular disease (e.g. SLE)
Medical causes of manic episode:
- Metabolic (hyperthyroidism)
- Neurological disorders (temporal lobe seizures, MS)
- Neoplasms
- HIV infection
Substance / medication-induced mood disorders (depressive & bipolar disorder)
Substance/medication-induced depressive disorder:
- EtOH
- Antihypertensives
- Barbiturates
- Corticosteroids
- Levodopa
- Sedative-hypnotics
- Anticonvulsants
- Antipsychotics
- Diuretics
- Sulfonamides
- Withdrawal form stimulants (e.g. cocaine, amphetamines)
Substance/medication-induced bipolar disorder:
- Antidepressants
- Sympathomimetics
- Dopamine
- Corticosteroids
- Levodopa
- Bronchodilators
- Cocaine
- Amphetamines
What is major depressive disorder (MDD)?
Marked by episodes of depressed mood associated w/ loss of interest in daily activities
Patients may not acknowledge their depressed mood or may express vague, somatic complaints (fatigue, headache, abdominal pain, muscle tension, etc.)
Most common disorder among those who complete suicide
Most adults w/ depression do not see mental health professional, but they often present to primary care physician for other reasons
Diagnosis & DSM-V criteria of MDD
At least 1 major depressive episode
No history of manic / hypomanic episode
Epidemiology of MDD
Lifetime prevalence: 12% worldwide
Onset at any age, but age of onset peaks in 20s
1.5.-2 times as prevalent in women than men during reproductive years
No ethnic or socioeconomic differences
Lifetime prevalence in elderly: <10%
Depression can increase mortality for patients w/ other comorbidities (e.g. DM, stroke, cardiovascular disease )
Sleep problems associated w/ MDD
Multiple awakenings
Initial & terminal insomnia (hard to fall asleep, early morning awakenings)
- 2 most common types of sleep disturbances
Hypersomnia (excessive sleepiness) is less common
Rapid eye movement (REM) sleep shifted earlier in night & for greater duration, w/ reduced stages 3 & 4 (slow wave) sleep
Etiology of MDD
Precise cause is unknown, but it is believed to be a heterogeneous disease, w/ biological, genetic, environmental, & psychosocial factors contributing
Likely caused by neurotransmitter abnormalities in brain
- Antidepressants exert their therapeutic effect by increasing catecholamines
- Decreased CSF levels of 5-HIAA (main metabolite of serotonin)
Increased sensitivity of beta-adrenergic receptors in brain has also been postulated in pathogenesis of MDD
High cortisol: hyperactivity of hypothalamic-pituitary-adrenal axis
- Shown by failure to suppress cortical levels in dexamethasone suppression test
Abnormal thyroid axis: thyroid disorders are associated w/ depressive symptoms
GABA, glutamate, & endogenous opiates may additionally have role
Psychosocial / life events: multiple adverse childhood experiences are risk factor for later developing MDD
Genetics: first-degree relatives are 2 to 4 times more likely to have MDD
- Concordance rate for monozygotic twins is <40%, & 10-20% for dizygotic twins
What is used to screen for MDD?
Hamilton Depression Rating Scale: measures severity of depression & is used in research to assess effectiveness of therapies
PHQ-9: depression screening form often used in primary care setting
Course & prognosis of MDD
Untreated, depressive episodes are self-limiting, but last from 6-12 months
- Episodes occur more frequently as disorder progresses
- Risk of subsequent major depressive episode is 50-60% within first 2 years after first episode
Loss of parent before age 11 is associated w/ later development of major depression
Depression is common in patients w/ pancreatic cancer
2-12% of patients w/ MDD eventually commit suicide
Approx. 60% of patients show significant response to antidepressants
- Combined treatment w/ both antidepressant & psychotherapy produce significantly increased response for MDD
Treatment of MDD
Only 1/2 of patients w/ MDD receive treatment
HOSPITALIZATION
Indicated if patient is at risk for suicide, homicide, or is unable to care for him/herself
PHARMACOTHERAPY Antidepressant meds (all are equally effective, but differ in side effect profiles; usually take 4-6 weeks to fully work): - SSRIs - TCAs - MAOIs
Adjunct meds;
- Atypical (second-generation) antipsychotics
- T3, levothyroxine (T4), & lithium
- Stimulants
PSYCHOTHERAPY
Cognitive behavioral therapy (CBT), interpersonal psychotherapy, supportive therapy, psychodynamic psychotherapy, problem-solving therapy, family/couples therapy
- May be used alone or in conjunction w/ pharmacotherapy
ELECTROCONVULSIVE THERAPY (ECT)
ECT treatment & its side effects for MDD
Indicated if patient is unresponsive to pharmacotherapy, if patient can’t tolerate meds (pregnancy, etc.), or if rapid reduction of symptoms is desired (e.g. immediate suicide risk, refusal to eat/drink, catatonia)
Extremely safe & may be used alone or in combination w/ pharmacotherapy
Often performed by premedication w/ atropine, followed by general anesthesia (usually w/ methohexital) & administration of muscle relaxant (typically succinylcholine)
Generalized seizure is induced by passing current of electricity across the brain (generally bilateral)
- Seizure should last between 30-60 seconds, & no longer than 90 seconds
6-12 (average of 7) treatments are administered over 2- to 3-week period, but significant improvement is sometimes noted after first treatment
Side effects:
- Retrograde & anterograde amnesia are common side effects, which usually resolve within 6 months
- Headache
- Nausea
- Muscle soreness
SSRI treatment & its side effects for MDD
Safer & better tolerated than other classes of antidepressants
Side effects are mild:
- Headache
- GI disturbance
- Sexual dysfunction
- Rebound anxiety
Medications for MDD that activate neurotransmitters
SSRIs
SNRIs: venlafaxine (Effexor), duloxetine (Cymbalta)
Alpha2-adrenergic receptor antagonists: mirtazapine (Remeron)
Buproprion (Wellbutrin) - dopamine-norepinephrine reuptake inhibitor
TCA treatment & its side effects for MDD
Most lethal in overdose due to cardiac arrhythmias
Side effect:
- Sedation
- Weight gain
- Orthostatic hypotension
- Anticholinergic effects
- Can aggravate prolonged QTc syndrome
MAOI treatment & its side effects for MDD
Considered particularly useful in treatment of “atypical” depression, but SSRIs remain first-line treatment for major depressive episodes w/ atypical features
Older meds occasionally used for refractory depression
Risk of hypertensive crisis when used w/ sympathomimetics or ingestion of tyramine-rich foods (e.g. wine, beer, aged cheeses, liver, & smoked meats)
Risk of serotonin syndrome when used in combo w/ SSRIs:
- Autonomic instability
- Hyperthermia
- Hyperreflexia (including myoclonus)
- Seizures
- Coma or death may result
Most common side effect is orthostatic hypotension
When is adjunctive treatment done in MDD? What are they?
Usually performed after multiple first-line treatment failures
Atypical (second-generation) antipsychotics w/ antidepressants
- First-line treatment in patients w/ MDD w/ psychotic features
- May be prescribed in patients w/ treatment resistant / refractory MDD without psychotic features
Triiodothyronine (T3), levothyroxine (T4), & lithium have demonstrated some benefit when augmenting antidepressants in treatment refractory MED
While stimulants (e.g. methylphenidate) may be used in certain patients (e.g. terminally ill), the efficacy is limited & trials are small
Specifiers for depressive disorders of patients w/ MDE
- More likely in severely ill patients
- Characterized by anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, & anorexia
Atypical features:
- Characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, & hypersensitivity to interpersonal rejection
Mixed features:
- Manic/hypomanic symptoms present during majority of days during MDE: elevated mood, grandiosity, talkativeness/pressured speech, flight of ideas/racing
Melancholic features
Atypical features
Mixed features
Catatonia
Psychotic features
Anxious distress
Peripartum onset
Seasonal pattern
Melancholic features of depressive disorders
Present in 25-30% of patients w/ MDE
More likely in severely ill patients
Characterized by anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, & anorexia
Atypical features of depressive disorders
Characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, & hypersensitivity to interpersonal rejection
Mixed features of depressive disorders
Manic/hypomanic symptoms present during majority of days during MDE:
- Elevated mood
- Grandiosity
- Talkativeness/pressured speech
- Flight of ideas/racing
- Increased energy / goal-directed activity
- Excessive involvement in dangerous activities
- Decreased need for sleep
Catatonia of depressive disorders
Features include:
- Catalepsy (immobility)
- Purposeless motor activity
- Extreme negativism or mutism
- Bizarre postures
- Echolalia
Especially responsive to ECT
Psychotic features of depressive disorders
Characterized by presence of delusions and/or hallucinations
Present in 24-53% of older, hospitalized patients w/ MDD
Anxious distress of depressive disorders
Defined by feeling keyed up/tense, restless, difficulty concentrating, fears of something bad happening, & feelings of loss of control
Peripartum onset of depressive disorders
Onset of MDD symptoms occurs during pregnancy or 4 weeks following delivery
Seasonal pattern of depressive disorders
Temporal relationship between onset of MDD & particular time of the year (most commonly winter)
Patients w/ fall-onset SAD (seasonal affective disorder or “winter depression”) often respond to light therapy
Triad of seasonal affective disorder
Irritability
Carbohydrate craving
Hypersomnia
What is bereavement?
Aka simple grief
Is a reaction to major loss, usually of a loved one, & it is not a mental illness
While symptoms are usually self-limited & only last for several months, if an individual meets criteria for depressive episode, he/she would be diagnosed w/ MDD
Normal bereavement should not include gross psychotic symptoms, disorganization, or active suicidality
This is NOT DSM-V diagnosis
- If patient meets criteria for major depression following the loss of a loved one, the diagnosis is major depression
What is bipolar I disorder?
Involves episodes of mania & of major depression
Episodes of major depression are NOT required for diagnosis
Aka manic-depression
May have psychotic features (delusions / hallucinations)
- These can occur during major depressive or manic episodes
- Remember to always include bipolar disorder in differential diagnoses of psychotic patient
Diagnosis & DSM-V criteria of bipolar I disorder
Only requirement for this diagnosis is occurrence of manic episode (5% of patients experience only manic episodes)
Between manic episodes, there may be interspersed euthymia, MDE, or hypomanic episodes
- None of these are required for diagnosis
Epidemiology of bipolar I disorder
Lifetime prevalence: 1-2%
Women & men are equally affected
No ethnic differences seen
- High income countries have twice the rate of low-income countries (1.4% vs. 0.7%)
Onset usually before age 30
- Mean age of first episode is 18
Frequently misdiagnosed & thereby inappropriately or inadequately treated
Etiology of bipolar I disorder
Biological, environmental, psychosocial, & genetic factors are all important
First-degree relatives of patients w/ bipolar disorder are 10 times more likely to develop the illness
Concordance rates for monozygotic twins are 40-70% & rates for dizygotic twins range from 5-25%
Bipolar I has highest genetic link of all major psychiatric disorders
Course & prognosis of bipolar I disorder
Untreated manic episodes generally last several months
Course usually chronic w/ relapses
- As disease progresses, episodes may occur more frequently
- Rapid cycling = occurrence of 4 or more mood episodes in 1 year (major depressive, hypomanic, or manic)
90% of individuals after 1 manic episode will have repeat mood episode within 5 years
Bipolar disorder has poorer prognosis than MDD
Maintenance treatment w/ mood stabilizing meds between episodes helps to decrease risk of relapse
25-50% of people w/ bipolar disorder attempt suicide
10-15% die by suicide
Treatment of bipolar I disorder
PHARMACOTHERAPY Lithium Anticonvulsants Atypical antipsychotics Antidepressants
Treatment includes lithium, valproic acid, & carbamazepine (for rapid cyclers), or second-generation antipsychotics. Lithium remains gold standard, particularly due to demonstrated reduction in suicide risk
Patient w/ history of postpartum mania has high risk of relapse w/ future deliveries & should be treated w/ mood stabilizing agents as prophylaxis, but some of these meds may be contraindicated in breastfeeding
PSYCHOTHERAPY
Supportive psychotherapy, family therapy, group therapy (may prolong remission once acute manic episode has been controlled)
ECT
Lithium treatment & side effects of bipolar I disorder
Mood stabilizer
50-70% treated w/ lithium show partial reduction of mania
Long-term use reduces suicide risk
Acute overdose can be fatal due to its therapeutic index
Side effects:
- Weight gain
- Tremor
- GI disturbances
- Fatigue
- Cardiac arrhythmias
- Seizures
- Goiter / hypothyroidism
- Leukocytosis (benign)
- Coma (in toxic doses)
- Polyuria (nephrogenic diabetes insipidus)
- Polydipsia
- Alopecia
- Metallic taste
Anticonvulsant treatment of bipolar I disorder
Carbamazepine, valproic acid
Mood stabilizer
Particularly useful for rapid cycling bipolar disorder & those w/ mixed features
Atypical antipsychotic treatment of bipolar I disorder
Risperidone, olanzpine, quetiapine, ziprasidone
Effective as both monotherapy & adjunct therapy for acute mania
Many patients (especially w/ severe mania and/or w/ psychotic features) are treated w/ combo of mood stabilizer & antipsychotic - Studies have shown greater & faster response w/ combo therapy
Antidepressant treatment of bipolar I disorder
Discouraged as monotherapy due to concerns of activating mania or hypomania
Occasionally used to treat depressive episodes when patients concurrently take mood stabilizers
ECT treatment of bipolar I disorder
Works well in treatment of manic episodes
Some patients require more treatments (up to 20) than for depression
Especially effective for refractory or life-threatening acute mania or depression
Best treatment for pregnant women who is having manic episode
- Provides good alternative to antipsychotics & can be used w/ relative safety in all trimesters
What is bipolar II disorder?
Aka recurrent major depressive episodes w/ hypomania
Diagnosis & DSM-V criteria of bipolar II disorder
History of 1 or more major depressive episodes & at least 1 hypomanic episode
If there has been a full manic episode (even in the past), then the diagnosis is bipolar I, not bipolar II disorder
Epidemiology of bipolar II disorder
Prevalence is unclear, w/ some studies > and others < than bipolar I
May be slightly more common in women
Onset usually before age 30
No ethnic differences seen
Frequently misdiagnosed as unipolar depression & thereby inappropriately treated
Etiology of bipolar II disorder
Same as bipolar I:
Biological, environmental, psychosocial, & genetic factors are all important
First-degree relatives of patients w/ bipolar disorder are 10 times more likely to develop the illness
Concordance rates for monozygotic twins are 40-70% & rates for dizygotic twins range from 5-25%
Bipolar II has highest genetic link of all major psychiatric disorders
Course & prognosis of bipolar II disorder
Tends to be chronic, requiring long-term treatment
Likely better prognosis than bipolar I
Treatment of bipolar II disorder
Fewer studies focus on treatment
Currently, treatment is same as bipolar I:
PHARMACOTHERAPY Lithium Anticonvulsants Atypical antipsychotics Antidepressants
PSYCHOTHERAPY
Supportive psychotherapy, family therapy, group therapy (may prolong remission once acute manic episode has been controlled)
ECT
Specifiers for bipolar disorders
Anxious distress
Mixed features
Rapid cycling
Melancholic features (during depressed episode)
Atypical features (during depressed episode)
Psychotic features
Catatonia
Peripartum onset
Seasonal pattern
Anxious distress of bipolar disorders
Defined by feeling keyed up/tense, restless, difficulty concentrating, fears of something bad happening, & feelings of loss of control
Mixed features of bipolar disorders
Depressive symptoms present during majority of days during mania/hypomania:
- Dysphoria / depressed mood
- Anhedonia
- Psychomotor retardation
- Fatigue / loss of energy
- Feelings of worthlessness or inappropriate guilt
- Thoughts of death or suicidal ideation
Rapid cycling of bipolar disorders
At least 4 mood episodes (manic, hypomanic, depressed) within 12 months
Melancholic features (during depressed episode) of bipolar disorders
Characterized by:
- Anhedonia
- Early morning awakenings
- Depression worse in the morning
- Psychomotor disturbance
- Excessive guilt
- Anorexia
Atypical features (during depressed episode) of bipolar disorders
Characterized by:
- Hypersomnia
- Hyperphagia
- Reactive mood
- Leaden paralysis
- Hypersensitivity to interpersonal rejection
Psychotic features of bipolar disorders
Characterized by:
- Presence of delusions and/or hallucinations
Catatonia of bipolar disorders
Catalepsy
Purposeless motor activity
Extreme negativism or mutism
Bizarre postures
Echolalia
Especially responsive to ECT
Peripartum onset of bipolar disorders
Onset of manic or hypomanic symptoms occurs during pregnancy or 4 weeks following delivery
Seasonal pattern of bipolar disorders
Temporal relationship between onset of mania / hypomania & particular time of the year
What is persistent depressive disorder (dysthymia)?
Chronic depression most of the time
May have discrete major depressive episodes
Diagnosis & DSM-V criteria of persistent depressive disorder (dysthymia)
Depressive Disorder = 2 D’s
- 2 years of depression
- 2 listed criteria
- Never asymptomatic for > 2 months
Depressed mood for majority of time most days for at least 2 years (in children or adolescents for at least 1 year)
At least 2 of the following: CHASES
- Concentration (poor) or difficulty making decisions
- Hopelessness
- Appetite (poor or overeating)
- Sleep (insomnia / hypersomnia)
- Energy (low) or fatigue
- Self-esteem (low)
During 2 year period:
- Person has not been without symptoms for >2 months at a time
- May have MDE or meet criteria for MDD continuously
- Patient must never have had a manic or hypomanic episode (this would make the diagnosis bipolar or cyclohtymic disorder)
Epidemiology of persistent depressive disorder (dysthymia)
12-month prevalence: 2%
More common in women
Onset often in children, adolescence, & early adulthood
Course & prognosis of persistent depressive disorder (dysthymia)
Early & insidious onset w/ chronic course
Depressive symptoms much less likely to resolve than in MDD
Treatment of persistent depressive disorder (dysthymia)
Combo treatment w/ psychotherapy & pharmacotherapy is more efficacious than either alone
Cognitive therapy, interpersonal therapy, & insight-oriented psychotherapy are most effective
Antidepressants found to be beneficial:
- SSRIs
- TCAs
- MAOIs
What is cyclothymic disorder?
Alternating periods of hypomania & periods w/ mild-to-moderate depressive symptoms
Diagnosis & DSM-V criteria of cyclothymic disorder
Numerous periods w/ hypomanic symptoms (but not full hypomanic episode) & periods w/ depressive symptoms (but not full MDE) for at least 2 years
Person must never have been symptom free for >2 months during those 2 years
No history of major depressive episode, hypomania, or manic episode
Epidemiology of cyclothymic disorder
Lifetime prevalence: <1%
May coexist w/ borderline personality disorder
Onset usually age 15-25
Occurs equally in males & females
Course & prognosis of cyclothymic disorder
Chronic course
Approx. 1/3 of patients eventually develop bipolar I/II disorder
Treatment of cyclothymic disorder
Antimanic agents:
- Mood stabilizers
- Second-generation antipsychotics
Same as used to treat bipolar disorder
What is premenstrual dysphoric disorder?
Mood lability, irritability, dysphoria, & anxiety that occur repeatedly during premenstrual phase of cycle
Diagnosis & DSM-V criteria of premenstrual dysphoric disorder
In most menstrual cycles, at least 5 symptoms are present:
- In final week before menses
- Improve within few days after menses
- Minimal/absent in week postmenses (should be confirmed by daily ratings for at least 2 menstrual cycles)
At least 1 of the following symptoms is present:
- Affective lability
- Irritability / anger
- Depressed mood
- Anxiety / tension
At least 1 of the following symptoms is present (for total of at least 5 symptoms when combined w/ above):
- Anhedonia
- Problems concentrating
- Anergia
- Appetite changes / food cravings
- Hypersomnia / insomnia
- Feeling overwhelmed / out of control
- Physical symptoms (e.g. breast tenderness /s welling, joint / muscle pain, bloating, weight gain)
Symptoms cause clinically significant distress or impairment in functioning
Symptoms are not only exacerbation of another disorder (e.g. MDD, panic disorder, persistent depressive disorder)
Symptoms are not due to a substance (meds / drug) or another medical condition
Epidemiology / etioology of premenstrual dysphoric disorder
Prevalence: 1.8%
Onset can occur at any time after menarche
Has been observed worldwide
Environmental & genetic factors contribute
Course & prognosis of premenstrual dysphoric disorder
Symptoms may worsen prior to menopause but cease after menopause
Treatment of premenstrual dysphoric disorder
SSRIs:
- First-line treatment
- Either as daily therapy or luteal phase-only treatment (start on cycle 14 & stop upon menses or shortly thereafter)
Oral contraceptives
- May reduce symptoms
GnRH agonists
Bilateral oophorectomy w/ hysterectomy will resolve symptoms
What is disruptive mood dysregulation disorder (DMDD)?
Chronic, severe, persistent irritability occurring in childhood & adolescence
Diagnosis & DSM-V criteria of DMDD
Severe recurrent verbal and/or physical outbursts out of proportion to situation
Outbursts >=3 per week & inconsistent w/ developmental level
Mood between outbursts is persistently angry/irritable most of the day nearly every day & is observed by others
Symptoms for at least 1 year & no more than 3 months without symptoms
Symptoms in at least 2 settings (e.g. home, school, peers)
Symptoms must have started before age 10, but diagnosis can be made from age 6-18 years
No episodes meeting full criteria for manic/hypomanic episode lasting longer than 1 day
Behaviors do not occur during MDD & not better explained by another mental disorder (can’t coexist w/ oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder)
Symptoms not due to substance (meds / drug) or another medical condition
Epidemiology / etiology of DMDD
Prevalence is unclear as this is new diagnosis
6-12-month prevalence rates of chronic / severe persistent irritability in children: 2-5%
Rates likely greater in males than females
Course & prognosis of DMDD
Must occur prior to 10 years
Approx. 50% of those w/ DMDD continue to meet criteria after 1 year
Rates of conversion to bipolar disorder are very low
Very high rates of comorbidity, especially w/ ODD, ADHD, mood disorders, & anxiety disorders
Treatment of DMDD
Given new nature of this disorder, there are no consensus evidenced-based treatments
Psychotherapy (e.g. parent management training) for patient & family is first-line
Meds:
- Should be used to treat comorbid disorders
- Stimulants
- SSRIs
- Mood stabilizers
- Second-generation antipsychotics
Mood disorders in DSM-V
Major depressive disorder (MDD)
Bipolar I/II disorder
Persistent depressive disorder (dysthymia)
Cyclothymic disorder
Premenstual dysphoric disorder
Disruptive mood dysregulation disorder (DMDD)
Mood disorder due to another medical condition
Substance / medication-induced mood disorder
Specified depressive / bipolar disorder (meets criteria for MDE or bipolar except shorter duration or too few symptoms)
Unspecified depressive / bipolar disorder
