MOOD

DISORDERS
EMOTIONS CAN BE DESCRIBED
AS TWO MAIN TYPES
 MOOD
A sustained and pervasive emotional attitude which colours the whole
psychic life
 AFFECT
A short-lived emotional response to an idea or an event
(what people observe)
Mood: internal amp
Affect: speaker
 Classification of mood disorders:
1. Manic episode
2. Depressive episode
3. Bipolar mood (affective) disorder
4. Recurrent depressive disorder
5. Persistent mood disorder
6. Other mood disorders
MANIC EPISODE
• Life-time risk: 0.8-1.0%
• Tends to occur in episodes
lasting usually 3-4 months
followed by complete
clinical recovery future
episodes
(manic/depressive/mixed)
Characterised by the following features :

❑ Elevated, expansive or irritable mood

❑ Psychomotor activity
❑ Speech and thought
❑ Goal-directed activity
❑ Other features
❑ Absence of underlying organic cause

(which should last for at least 1 week and cause

disruption in occupational & social activities)
The elevated mood can
Ecstasy
pass through 4 stages: (very sev elevation of mood)
Exaltation
(sev elevation of mood) Intense sense of rapture or blistfullness
Elation
(mod elevation of mood) Intense elation with Stupurous mania (stage III)
Euphoria A feeling of confidence
delusion of grandeur

(mild elevation of mood) and enjoyment, increase Severe mania (stage III)
in psychomotor activity
an increased sense of
psychological well-being Mania (stage II)
and happiness

Hypomania (stage I)
Speech and thought
Since these psychotic
• More talkative than usual symptoms are in keeping with
the elevated mood state, these
• Describes thoughts racing in mind are called mood-congruent
• Develops pressure of speech psychotic features

• Uses playful language

(joking/teasing)
• Speaks loudly
•Flight of ideas
•Delusion of grandeur
• Delusion of persecution
•Hallucinations, often with
religious content
Goal-directed activity
Unusually alert, trying to
do many things at one time
•Hypomania
•the ability to function
becomes much better &
marked increase in
productivity and
creativity
Mania
• Marked increase in activity
with excessive planning
• Marked increase in sociability
even with previously unknown
people
• Poor judgement. Often involve
in high risk activities such as
reckless driving, distributing
money to strangers
• Usually dressed up in gaudy
and flamboyant clothes
Other features:
• Decreased need of sleep
• Increased appetite later
decreased food intake d/t
overactivity
• Absent insight into illness
• Psychotic features delusions,
hallucinations (mood
incongruent psychotic features)
DEPRESSIVE EPISODE
• Life time risk of common depression:
• 8-12% (in males)
• 20-26% (in females)

• Life time risk of major depression/

depressive episode is about 8%
Characterised by the following features :

❑ Depressed mood
❑ Depressive ideation / cognition
❑ Psychomotor activity
❑ Physical symptoms
❑ Biological functions
❑ Psychotic features
❑ Suicide
❑ Absence of underlying organic cause
(which should last for at least 2 weeks for a diagnosis to be made)
Depressed mood
• Sadness of mood and loss of interest/pleasure in
almost all activities (pervasive sadness)
• Present throughout the day (persistent sadness)
• Varies from day to day and often unresponsive to
the environmental stimuli
• Results in social w/drawal, decreased ability to
function in occupational and interpersonal areas
and decreased involvement in previously
pleasurable activities
• Severe depression complete anhedonia (inability
to experience pleasure)
Depressive ideation/cognition

Sadness of mood usually associated with

pessimism, which can result in
3 common types of depressive ideas:

• Hopelessness (no hope in future)

• Helplessness (no help is possible now)
• Worthlessness (feeling of
inadequacy/inferiority)
Depressive ideation/cognition

• Other features:
• Difficulty in thinking/concentrating
• Indecisiveness
• Slowed thinking
• Poor memory
• Lack of initiative and energy
• Thoughts of death
• Suicidal ideas
• Delusion of nihilism

“My world is coming to an end”

“My intestines have rotted away”
Psychomotor activity
• Young patient (<40 years) retardation is common
• Slowed thinking and activity, decreased energy, monotonous
voice.
• Severe stuporous (depressive stupor)

• Older patients agitation is common

• Marked anxiety, restlessness (inability to sit still, hand-wriggling)
• Subjective feeling of unease

• Anxiety is a frequent accompaniment of depression

• Irritability (easy annoyance and frustration in day to day activities)
Physical symptoms
• Multiple physical symptoms (general
aches and pain)
• Complain of reduced energy and easy
fatigability
• Consult a physician instead of
psychiatrist
Biological functions
• Insomnia (or sometimes increased sleep)
• Loss of appetite and weight (or sometimes
hyperphagia and weight gain)
• Loss of sexual drive
• Melancholia (somatic syndrome in ICD-10-DCR)
signifies higher severity and more biological
nature of disturbance
Psychotic features
• 15-20% of depressed patients have psychotic
features such as delusions, hallucinations, grossly
inappropriate behavior or stupor
• Mood-congruent psychotic features nihilistic
delusions, delusion of guilt, delusions of poverty,
stupor
• Mood-incongruent psychotic features delusions
of control
Suicide
• Should always be taken seriously
• Factors increase the risk of suicide
• Presence of marked hopelessness
• Males; age>40; unmarried; divorced/widowed
• Written/verbal communication of suicidal
intention/plan
• Early stages of depression
• Recovering of depression
• Period of 3 months from recovery
BIPOLAR MOOD (OR
AFFECTIVE) DISORDER
Characterized by recurrent episodes of mania and depression
in the same patient at different times
• Earlier known as manic depressive psychosis (MDP)
• This episode can occur in any sequence.
• The current episode in bipolar mood disorder is specified as one of the following (ICD-10):
• Hypomanic
• Manic without psychotic symptoms
• Manic with psychotic symptoms
• Mild/mod depression
• Severe depression, without psychotic symptoms
• Severe depression, with psychotic symptoms
• Mixed
• In remission
• Further divided into bipolar I & bipolar II disorders
• Bipolar I: Charact. by episodes of severe mania and severe depression
• Bipolar II: Charact. by episodes of hypomania and severe depression
RECURRENT DEPRESSIVE
DISORDER
• Characterized by recurrent (at least 2) depressive episodes (unipolar
depression)
• The current episode in recurrent depressive disorder is specified as
one of the following:
• Mild
• Moderate
• Severe, without psychotic symptoms
• Severe, with psychotic symptoms
• In remission
PERSISTENT MOOD
DISORDER
Characterized by persistent mood symptoms
which last for >2 years (1 year in children)
But not severe enough to be labelled as even
hypomanic or mild depressive episode

• Persistent mild depression dysthymia

• Persistent instability of mood between mild
depression and mild elation cyclothymia
OTHER MOOD
DISORDER
• Includes the diagnosis of
mixed affective episode
• Frequently missed diagnosis
clinically
• Full clinical picture of
depression and mania is
present either at the same
time intermixed or alternates
rapidly with each other (rapid
cycling), without a normal
intervening period of euthymia
COURSE AND
PROGNOSIS
• Bipolar mood disorder has an earlier age of onset (3rd decade) than
recurrent depressive (unipolar) disorder.
• Unipolar depression is common in two age groups: late third decade
& 5th – 6th decade
• An average manic episode lasts for 3-4 months while a depressive
episode lasts from 4-6 months
• Unipolar depression usually lasts longer than bipolar depression
• With rapid institution of treatment , the major symptoms of mania
are controlled within 2 weeks and of depression within 6-8 weeks
• Rapid cyclers patients with bipolar mood disorder of more than 4
episodes/year

• Ultra-rapid cycling condition when phase of mania and depression

alternate very rapidly (in matter of hours/days)
Prognosis is better than schizophrenia

Good prognostic factor Poor prognostic factor

Acute/abrupt in onset Co-morbid medical disorder, personality disorder or
alcohol dependance
Typical and clinical features Double depression (acute superimposed on chronic or
dysthmia)
Severe depression Catastrophic stress or chronic ongoing stress

Well-adjusted premorbid personality Unfavourable early environment

Good response to treatment Marked hypochondriacal features, or mood
incongruent psychotic features
Poor drug compliance
ETIOLOGY
• Biological theories • Psychosocial theories
• Genetic hypothesis • Psychoanalytic theories
• Biochemical theories • Cognitive and behavioral theories
• Neuroendocrine theories • Stress (stressful life events)
• Sleep studies
• Brain imaging
DIAGNOSIS
• 1st step: exclude a disorder with known organic cause, e.g. organic
(especially-drug induced) mood disorders and dementia
• 2nd step: to rule out a possibility of acute and transient psychotic disorders,
schizo-affective disorder and schizophrenia
• 3rd step: exclude possibility of other non-organic psychoses such as
delusional disorders
• 4th step: exclude possibility of adjustment disorder with depressed mood,
gen.anxiety disorder, normal grief reaction, obsessive compulsive disorder
(with or without secondary reaction)
• Important to look for comorbid medical and/or psychiatric disorders
(anxiety, alcohol or drug misuse, personality disorder)
MANAGEMENT
Somatic treatment
Antidepressants
• Tx of choice for a vast majority of
depressive episodes
• It may take upto 3 weeks before
any appreciable response may be
noticed
• Before stopping/changing a drug,
the particular drug should be given
in a therapeutically adequate dose
for at least 6 weeks
• Tricyclic antidepressants (TCAs) : Imipramine (75-150mg upto 300mg)
• Amitryptyline is NOT USED due to dry mouth, blurry vision, post. HTN
• Newer antidepressants
• Selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline,
citalopram
• Serotonin NE reuptake inhibitors (SNRIs) venlafaxine, duloxetine
• Mirtazapine
Electroconvulsive therapy
• Indications
• Severe depression with suicidal risk
• Severe depression with stupor, severe
psychomotor retardation, or somatic
syndrome
• Severe treatment refractory depression
• Delusional depression
• Significant antidepressant side effects
• In most clinical conditions, usually, 6-8
times ECTs are needed, given 3 times a
week
Lithium
• Drug of choice for tx of manic episode
(acute phase) as well as for prevention of
further episodes in BPD
• 900-1500mg of lithium carbonate/day
• Need to be closely monitored by repeated
blood levels, as the difference between the
therapeutic and lethal blood levels is not
very wide (narrow therapeutic index)
• Therapeutic blood lithium = 0.8-1.2mEq/L
• Prophylactic blood lithium = 0.6-1.2mEq/L
• Blood lithium level of >2.0mEq/L is often asst. with toxicity
• A level >2.5-3.0 mEq/L may be lethal
• The common acute toxic symptoms are neurological
• The common chronic side effects are nephrological and endocrinal
(usually hypothuroidism)
• Most important investigations before starting lithium include
complete GPE, CBC, ECG, urine R/E, RFT, TFT
Antipsychotics
• Important adjunct in the tx of mood disorder
• Commonly used drugs:
• Risperidone
• Olanzapine
agranulocytosis
• Clonazepine
• Quetiapine*
• Haloperidol
• Aripiprazole*
*safe from metabolic syndrome
Other Mood Stabilizers
• Sodium valproate (1000-3000mg/day)
• Carbamazepine (600-1600mg/day)
• Benzodiazepines (Lorazepam/clonazepam) as adjuvants
• Lamotrigine
• T3 and T4 as adjuncts
Psychosocial treatment
• Cognitive behavior therapy
• Interpersonal therapy
• Psychoanalytic psychotherapy
• Behaviour therapy
• Group therapy
• Family & marital therapy
“And do not
kill yourselves.
Surely, Allah is
Most Merciful
to you”
[An-Nisa:29]