Mood and Affective Disorders - Some of my own notes

Mood / Affective Disorders

Classification:

A. Major - 1.Bipolar Disorder

                   2. Unipolor Disorder (Major Depression)

                        Types: Single episode or recurrent

                                    With or without vegetative Sx

                                     With or without psychotic Sx

Criteria: 4 out of 8 of the following SX for at least 2 weeks: Appetite, sleep, energy, interest, sex, suicide, concentration, cognition, guilt, and anhedonia.

A distinction b/t A. & B. is based on the number and severity of Sx.

B. Minor - Two Types: 1.Dysthymia - Prolonged unhappiness in response to chronic stress. This is the common chronic nonpsychotic disorder of lowered mood/ and or anhedonia.  Previously called neurotic depression or depressive personality.  Sx must be present for at least two years, at least intermittently. The difference between Dysthmia and Major Depression is the degree of Sx. and that there is not the discrete episodic nature as in Major Depression. Depressive features are common in psychotic disorders and should not be dx if only occurs during the psychotic episode. Personality Disorders frequently coexist with Dysthymic Disorder. Sx are not of sufficient severity or duration to meet the criteria for a major depression. May simply give histories of chronic feelings of inadequacy, low self-esteem, emptiness, or boredom.

                   2. Cyclothymia - depression and hypomania SX in the past or present, separate or mixed, continuous or intermittently. Resembles Bipolar disorder but less severe Sx.

In both of these two minor types of Mood D/O, psychotic symptoms are not present.

C. Organic Mood disorder - Maybe depressed/ manic mixed; these are the secondary mood D/O.

D. Adjustment Disorder with Depressed Mood - depression caused by stress / causal reason. Occurs in an adequately functioning person after a readily identifiable, causative stress and resolves as the stress disappears. A syndrome midway between normal sadness and a major depression. If social withdraw is the main feature then the term Adjustment D/O with Withdraw maybe used.

E. Atypical Depression – Residual category for persons with depressive Sx who cannot be D/X as having any specific affective syndrome or adjustment D/O.

F. Uncomplicated Bereavement – a normal grief response with no psychotic Sx

Exam includes whether current episode is manic/depressed/or mixed; whether the unipolar D/O is a single or recurrent episode; whether there are psychotic features

Clinical Presentation of Mood D/O can be described as Emotional/Cognitive/ Physiological see Pg. 34 Psychiatry 4^th Ed Ch. 4 Mood D/O

The term Major Depressive Disorder is used only when there is a history of one or more Major Depressive Episode.   A   Mood Episode can be anyone of the following- 1.Major Depressive 2. Manic 3. Mixed 4 Hypomanic.  These then can turn into a Major Mood Disorder of Unipolar, Bipolar or other Mood Disorders

Classification of Major Depressive Disorders:

1.      With Psychotic Features - Maybe mood congruent (the content of the delusions/hallucinations are consistent with a low mood - depressive themes) or it can be mood incongruent - no typical depressive themes.

2.      Chronic - A depressive D/O for greater then 2 years.

3.      Catatonic Features

4.      Melancholic Features

5.      Atypical Features - accompanied by mood reactivity and at least two of the following - wt. Gain, hypersomnia,

Differential:

1. Bereavement

2. Adjustment Disorder with Depressed Mood

3. Anxiety Disorder

4. Schizophrenia and Schizoaffective Disorder - A subjective depression may accompany acute psychosis.

6.      Dementia

7.      Mood Disorder due to Medical Condition

8.      Substance Induced Mood Disorder

Terms:

Dysphoria – Sometimes used instead of depressed mood particularly with the pt presents with irritability, fearfulness, worried, frustrated.

Functional D/O means not organic causes.

Reactive Depression is that which seems to be attributable to a particular stressor and that remits in response to resolution of that stress is termed adjustment D/O with depressed mood.

Melancholia - profound vegetative and cognitive symptoms incl. psychomotor retardation

Or agitation, sleep disturbances, anorexia or wt. Loss, and/or excessive guilt

Masked Depression- Instead of feeling sad complains of Fatigue, insomnia, tachycardia and vague and / or chronic pains 9 usually GI, back, headaches all unrelieved by medical interventions. Always suspect depression in the unimproved patient who has atypical medical symptoms.

Uncomplicated Bereavement or Grief - a more profound sense of dysphoria, which follows a severe loss or trauma and may cause a full depressive syndrome

Double Depression- A major Depression on top of a dysthymia. The major depression clears incompletely and there is a residue of Dysthymia

Anhedonia is the lose of interest of previous areas of interest.

Secondary Mania -These is the reversible causes such as medical disorders, brain injury, infection, substance abuse and metabolic and endocrine d/o. need to assess comorbidity. Hypothyroidism is particularly seen in women with rapid-cycling Bipolar D/O

Notes on Depression Alone

A diurnal variation is common with the most severe SX early in the day. A thought d/o is usually present. Delusions are usually affect laden and mood congruent, but may not be.

Depression is the world leader in disease/disability

Chronic/current

Phases of treatment: Active/Continued? Maintenance

Celexa/Citalopram- One of the leading Antidepressents in Europe.

Side effects: 20% of all pt will have S>E> in the first week, then this will decrease to 8% in the long-term. The body will build up a tolerance

Difference between relapse/and reoccurrence

Considerations in choosing an antidepressant: 1. Long-term efficacy 2. Pt. tolerance 3. Side effect profile 4.Safety in Overdose 5. Drug interaction

Length of treatment long term is indefinite it is to suppress Sx. much like Diabetes.

It is not necessary to "tail - off SSRI when being D? C or changed.

Notes on Bipolar D/O            Previously called Manic –Depressive D/O.
By convention all persons with mania receive the Dx of Bipolar D/O even if they haven’t had a depressive episode.

3 Categories:     Bipolar 1 – One true manic episode with or without a previous major depressive episode. Hx of Depression or hypomania maybe present.

                          Bipolar 2 - A depression interspersed with episodes of hypomania but no episodes of mania.

                          Cyclothymia - Hypomania cycling with less severe periods of depressive Sx. A less severe form of Bipolar D/O

Mixed Type – Present with both Mania and Depressive symptoms.

Manic Episodes: Defined - elevated, expansive or irritable mood for a least 1 week, accompanied by at least 3 of the following: inflated self-esteem, or grandiosity, pressured speech, hyperactivity, decreased sleep, talkativeness, flight of ideas, distractibility, inc. in goal directed activity, or excessive involvement in pleasurable activities. Bipolar 1 is as common as Bipolar 2.

40% of all manic episodes have mixed features of mania, hypomania and depression

Notes on Dual Diagnosis: It is estimated that about 35% of people with bipolar d/o also have Dx of ETOH, compared to 8% of the general population

Aggression turned against the self or the ego's reaction to failures to live up to one's ideals or moral standards. Often shows up in ambivalence towards the parents, often both devaluing and envy (resentfulness and idealization)

"Thoughts are not coming to my mind" is an indicator of high repression, similar to thought blocking. "I have lost my feelings"

Often they are a masochistic attachment to someone.

Obsession worrying is heightened by her depression.

Often a pt. will mirror the parent as "memorial to them" if the parent was a Depressive as well.

Melancholia’s self-criticism is usually present.

Such concepts underlie depression: object loss, ego ideal, and aggression.

Depression is commonly a repressive defense against the unconscious murderous rage towards those who abandoned the patient, commoningly seen in an emotionally neglected child, emotional abandoned by their detached, emotional cold parents.

An acute period of depression in adults is thought to be return to their earlier childhood experiences of total dependency on their parents, accompanied by the fear of wishes not being met and the sense of overwhelming helplessness and hopelessness.

With the fall of self-esteem, depression will follow and hostility begins. As to whether it is directed at others or at oneself, the direction is mediated by the superego. If they have a punitive Super-Ego the rage is directed towards the individual themselves.  Impulses of aggression must be given permission by the super ego before their expression. Without permission the aggression is held inside and is turned towards the self and the self suffers. Aggression becomes under the control of the superego after 2 years of age. 

By W Howe - 2015