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MED-SURG
Mood Disorders
| Term | Definition | Definition 2 | Definition 3 | Definition 4 |
|---|---|---|---|---|
| Mood: | pervasive and sustained feeling and tone that is experienced internally and that influences a person’s behavior and reception of the world | |||
| Affect: | external expression of mood | |||
| MOOD AND AFFECT | ● Normally, we have control of our mood and affect ● Normal in the middle, as you go up the patient can experience hypomania or an expansive elevate mood, they can experience severe mania. | ● The bottom of the line they can experience mild to moderate depression, and if there is extremes in low mood or interest, or extreme feelings of sadness, they can experience severe depression. | ||
| AFFECT | ● Constricted affect ● Blunt affect ● Flat affect ● Labile affect | |||
| Constricted affect | - clear reduction in the expressive range and intensity of affects | |||
| Blunt affect | - severe reduction in the intensity of affective expression | |||
| Flat affect | - lack of signs of affective expression (apathy); patient’s voice may be monotonous and the face may be immobile | |||
| Labile affect | - repeated, rapid, and abrupt shifts | |||
| MOOD DISORDERS | ● Group of clinical conditions characterized by a loss of emotional control and subjective experience of great distress or social and occupational dysfunctions | |||
| Bipolar and related disorders | ■ Bipolar I disorder ■ Bipolar II disorder ■ Cyclothymic disorder | |||
| Depressive disorders | ■ Major depressive disorder ■ Persistent depressive disorder | |||
| Majority of mental illnesses worldwide and the Philippines would be coming from, respectively: ○ anxiety | (5.7%), (3.2%) | |||
| Majority of mental illnesses worldwide and the Philippines would be coming from, respectively: ○ depressive disorders | (3.8%), (2.8%) | |||
| Majority of mental illnesses worldwide and the Philippines would be coming from, respectively: ○ Bipolar disorder | (0.4%), (0.3%) | |||
| Majority of mental illnesses worldwide and the Philippines would be coming from, respectively: ○ Schizophrenia | (0.3%), (0.3%) | |||
| Majority of mental illnesses worldwide and the Philippines would be coming from, respectively: ○ Eating disorders | (0.2%), (0.1%) | |||
| Proportion of males versus females in mental disorders (2021) | ○ Majority of mental disorders are more common in women ■ In bipolar disorders, they are somewhat equal | |||
| people died by suicide in 2021: | ● According to WHO, more than 720,000 | |||
| 3 Major forms of bipolar disorder | ● Bipolar I ● Bipolar II ● Cyclothmia | |||
| Mood States: ● Severe Depression | At least 2 weeks of hopelessness, apathy, decreased appetite, insomnia | |||
| Mood States: ● Mild/Moderate Depression | Similar to severe depression but not as long lasting or debilitating | |||
| Mood States: ● Normal | Moods may change from day to day but not in a way that interferes with life | |||
| Mood States: ● Hypomania | 4 days of unusually elevated mood, less need for sleep, distractibility, inflated self-esteem | |||
| Mood States: ● Mania or Mixed Mania | At least a week of even greater mania; mixed states show signs of both mania and depression | |||
| Unipolar depression | - no episodes of hypomania or mania | |||
| Black line | is the normal or euthymic mood, and the blue part is the depression. | |||
| Bipolar II | - There can be episodes of hypomani, 4 days of unusually elevated mood, less need for sleep, distractibility, inflated self-esteem, but it doesn’t lead to a marked or significant impairment in functioning | |||
| Bipolar I | - at least a week of even greater mania; mixed states show signs of both mania and depression | |||
| Bipolar disorder ○ Lifetime prevalence | ■ Bipolar I: 0.4-1.6% ■ Bipolar II: ~0.5% | |||
| Bipolar disorder ○ Annual incidence: | <1% | |||
| MDD ○ Highest lifetime prevalence: | 5-17% (average: 12%) | |||
| MDD ○ Annual incidence: | 1.59% ■ Female: 1.89% ■ Male: 1.10% | |||
| GENDER ● Bipolar disorder | ○ M= F ■ Manic episodes more common in men ■ Depressive episodes more common in women | |||
| GENDER ● MDD | ○ 2x in women than in men ■ Hormonal changes, effects of childbirth, differing psychosocial stressors, learned helplessness | |||
| AGE ● Bipolar disorder | ○ Onset: childhood to 50 years ■ Mean age - 30 vears | |||
| AGE ● MDD | ○ Onset: 20 to 50 years ■ Mean age - 40 years ■ Increasing incidence in <20 years due to alcohol and substance use | |||
| MARITAL STATUS ● MDD and bipolar disorder | ○ No close interpersonal relationships, divorced or separated | |||
| Individuals with mood disorders | are at an increased risk of having comorbid psychiatric illnesses | |||
| Individuals with substance use disorders and anxiety disorders | also have an increased risk of comorbid mood disorder | |||
| Between 50-70% of eating disorder patients | have a lifetime history of major depressive disorder. | |||
| Concurrent depression | is present in 13% of patient with panic disorder. | |||
| Substance abuse disorder | are present in 32% of patients with depressive disorders. | |||
| Depression | arises as a consequence of a disturbance of one or more of the biogenic amine neurotransmitters. | |||
| A relative deficit in norepinephrine, serotonin and dopamine | is responsible for the symptoms of depression | |||
| The biogenic amine hypothesis | postulates that the changes in mood (possibly linked to a deficit in 5-HT), deficit in drive and motivation (possibly linked to DA and NE) are the results of hypoactivity of these neurotransmitters. | |||
| Alterations of Hormonal Regulation | ○ Lasting alterations in neuroendocrine and behavioral responses can result from severe early stress ○ Damage to hippocampal neurons | |||
| Hypercortisolemia | Increased HPA activity | |||
| NOREPINEPHRINE | ● Correlation between the downregulation of p-adrenergic receptors and clinical antidepressant responses. ● There is accumulating evidence that the NE system modulates drive and motivation. ● Effectiveness of SNRIs | |||
| SEROTONIN | ● The serotonergic system modulates impulsiveness and mood ● Effectiveness of SSRis in the treatment of depression ● Depletion of serotonin may precipitate depression | |||
| DOPAMINE | ● Dopamine activity may be reduced in depression and increased in mania. ● Mesolimbic pathway may be dysfunctional in depression. ● Patients with Parkinson's disease develop depressive symptoms. | |||
| Four regions in the regulation of normal emotions | ○ Prefrontal cortex ● Anterior cingulate cortex ● Hippocampus ● Amygdala | |||
| Prefrontal cortex | representation of goals and appropriate responses to obtain these goals | |||
| Left PFC: | goal-directed or appetitive behaviors | |||
| Right PFC: | avoidance behaviors and inhibition of appetitive pursuits | |||
| Anterior cingulate cortex | point of integration of attentional and emotional inputs | |||
| Hippocampus | learning and memory including fear conditioning | |||
| Amygdala | processing novel stimuli of emotional significance and coordinating or organizing cortical response | |||
| FUNCTIONAL BRAIN IMAGING | ● Positron emission topography (PET) findings | |||
| Mania | ○ Decreased right anterior brain metabolism and relative increase in dominant hemispheric activity | |||
| Depression | ○ Decreased left anterior brain metabolism and relative increase in nondominant hemispheric activity | |||
| MOOD DISORDERS GENETIC FACTORS ● Family Studies | ○ 1 parent has a mood disorder: 10- ○ 25% risk ○ Both parents are affected: 2x the risk ○ The more family members are affected, especially 15t degree relatives, the greater the risk | |||
| MOOD DISORDERS GENETIC FACTORS ● Twin Studies | ○ Concordance rate: ■ Monozygotic twins: 70-90% ■ Dizygotic twins: 16-35% | |||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Life Events and Environmental Stress | ○ Stressful life events precede first, rather than subsequent, episodes of mood disorders ○ Stress accompanying the first episode results in long-lasting changes in brain's biology | ● Loss of a parent before age 11, loss of a spouse, unemployment, guilt | ||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Personality factors | ○ Persons with obsessive-compulsive, borderline and histrionic personality disorders: Higher risk for depression | ○ Patients with dysthymic and cyclothymic disorders: At risk of later developing MDD or bipolar I disorder | ||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Psychodynamic Factors in Depression | ○ Disturbance in the infant-mother relationship during the oral phase predispose to subsequent depression ○ Depression can be linked to real or imagined object loss | ○ Introjection of the departed objects as a defense mechanism to deal with the distress connected with the object's loss ○ Because the lost object is regarded with a mixture of love and hate, feelings of anger are directed towards self | ||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Psychodynamic Factors in Mania | ○ Defense against omnipotence | ○ Results from a tyrannical superego, which produces intolerable self-criticism that is then replaced by euphoric self-satisfaction | ||
| omnipotence | ■ Responds to conflict or stressors by acting superior to others, as if one possessed special powers or abilities | |||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Learned Helplessness | ○ Loss of self-esteem after adverse external events | |||
| MOOD DISORDERS PSYCHOSOCIAL FACTORS ● Cognitive Theory | ○ Depressogenic schemata | |||
| Depressogenic schemata | altered cognitive perception altered by early experiences | |||
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (1) | A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. | |||
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (2) | B. During the period of mood disturbance and increased energy and activity, 3 (or more) of ff symptoms (4 if the mood if only irritable) have persisted, represent a noticeable change from usual behavior, 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, as reported or observed. | 6. Increase in goal-directed activity or psychomotor agitation. 7. Excessive involvement in activities that have a high potential for painful consequences | |
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (3) | C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. | |||
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (4) | D. The disturbance in mood and the change in functioning are observable by others. | |||
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (5) | E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. | |||
| DSM-5 CRITERIA FOR HYPOMANIC EPISODE (6) | F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). | |||
| hypomanic episode diagnosis | A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a ____ ____ ____. | |||
| Hypomanic episodes | are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE EPISODE (1) | A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. | 1. Depressed mood most of the day, as indicated in subjective report or observation made by others. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day. 3. Significant weight loss/weight gain. | 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (obese) able by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. | 7. Worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death, suicidal ideation w/o a specific plan, or a suicide attempt or a specific plan for committing suicide. |
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE EPISODE (2) | B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE EPISODE (3) | C. The episode is not attributable to the physiological effects of a substance or another medical condition. | |||
| Major depressive episodes | are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. | |||
| MAJOR DEPRESSIVE EPISODE ● A Guide to Rapid Assessment | ○ S- Sleep ○ P- Psychomotor retardation / agitation ○ A - Appetite ○ C- Concentration ○ E- Energy ○ D- Depressed mood ○ I - Interest ○ G- Guilt ○ S- Suicidality | |||
| Common Symptoms of Depression ● Mood | ● Prolonged unhappiness ● Loss of interest or pleasure ● Hopeless ● Helpless | |||
| Common Symptoms of Depression ● Psychological | ● Guilt/Negative attitude to self ● Unable to think clearly/quickly ● Poor concentration/memory ●Thoughts of death or suicide | |||
| Common Symptoms of Depression ● Physical | ● Agitation or slowing down ● Tiredness/Lack of energy ● Sleep problems ● Weight loss or increased ● Disturbed appetite | |||
| DSM-5 CRITERIA FOR MANIC EPISODE (1) | A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day. | |||
| DSM-5 CRITERIA FOR MANIC EPISODE (2) | B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: | 1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. | ||
| DSM-5 CRITERIA FOR MANIC EPISODE (3) | C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. | |||
| DSM-5 CRITERIA FOR MANIC EPISODE (4) | D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. | |||
| bipolar I disorder | A full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a ____ ____ ____. | |||
| Bipolar I disorder | ○ Manic-depressive ○ Pure mania or unipolar mania | |||
| Bipolar Il disorder | - hypomania and major depression | |||
| Cyclothymic disorder | - less severe and chronic form of bipolar disorder | |||
| Major depressive disorder | - unipolar depression | |||
| Dysthymia | - chronic form of major depression | |||
| DSM-5 CRITERIA FOR BIPOLAR I DISORDER (1) | A. Criteria have been met for at least one manic episode (Criteria A-D under "Manic Episode" above). | |||
| DSM-5 CRITERIA FOR BIPOLAR I DISORDER (2) | B. Occurrence of manic and major depressive episode(s) isn't better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified/unspecified schizophrenia spectrum and other psychotic disorder. | ● One or more manic episodes and, sometimes, hypomanic or major depressive episodes ● Bipolar I disorder, most recent episode manic ● Bipolar I disorder, most recent episode hypomanic ● Bipolar I disorder, most recent episode depressed | ||
| DSM-5 CRITERIA FOR BIPOLAR I DISORDER (3) | ANXIOUS DISTRESS | The presence of at least two of the following symptoms during the majority of days of the current or most recent episode of mania, hypomania, or depression: | 1. Feeling keyed up or tense. 2. Feeling unusually restless. 3. Difficulty concentrating because of worry. 4. Fear that something awful may happen. 5. Feeling that the individual might lose control of himself or herself. | |
| Anxious distress | has been noted as a prominent feature of both bipolar and major depressive disorder in both primary care and specialty mental health settings | |||
| higher suicide risk, longer duration of illness, and greater likelihood of treatment nonresponse | High levels of anxiety have been associated with ____________________________ | |||
| MIXED FEATURES | The mixed features specifier can apply to the current manic, hypomanic, or depressive episode in bipolar I or bipolar Il disorder | |||
| Manic or hypomanic episode, with mixed features: (1) | A. Full criteria are met for a manic episode or hypomanic episode, and at least three of the following symptoms are present during the majority of days of the current or most recent episode of mania or hypomania: | 1. Prominent dysphoria or depressed mood as indicated by either subjective report or observation made by others. 2. Diminished interest or pleasure in all, or almost all, activities. 3. Psychomotor retardation nearly every day. | 4. Fatigue or loss of energy. 5. Feelings of worthlessness or excessive or inappropriate guilt. 6. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. | |
| Manic or hypomanic episode, with mixed features: (2) | B. Mixed symptoms are observable by others and represent a change from the person's usual behavior. | |||
| Manic or hypomanic episode, with mixed features: (3) | C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked impairment and clinical severity of full mania. | |||
| Manic or hypomanic episode, with mixed features: (4) | D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). | |||
| DSM-5 CRITERIA FOR BIPOLAR II DISORDER (1) | A. Criteria have been met for at least one hypomanic episode (Criteria A-F under "Hypomanic Episode" above) and at least one major depressive episode (Criteria A-C under "Major Depressive Episode" above). | |||
| DSM-5 CRITERIA FOR BIPOLAR II DISORDER (2) | B. There has never been a manic episode. | |||
| DSM-5 CRITERIA FOR BIPOLAR II DISORDER (3) | C. Occurrence of hypomania episode(S) and major depressive episode(s) explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other schizophrenia spectrum and other psychotic disorder of depression | |||
| DSM-5 CRITERIA FOR BIPOLAR II DISORDER (4) | D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational and other important areas of functioning | |||
| MAJOR DEPRESSIVE DISORDER | ● No prior history of a manic or hypomanic episode ○ Major depressive disorder, single episode ○ Major depressive disorder, recurrent | |||
| Major depressive disorder, recurrent | ■ 2 or more major depressive episodes ■ Interval of at least 2 months between episodes | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER (1) | A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure | 1. Depressed mood most of the day, as indicated in subjective report or observation made by others. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day. 3. Significant weight loss/weight gain. | 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (obese) able by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. | 7. Worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death, suicidal ideation w/o a specific plan, or a suicide attempt or a specific plan for committing suicide. |
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER (2) | B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER (3) | C. The episode is not attributable to the physiological effects of a substance or another medical condition. | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER (4) | D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other (un)/specified schizophrenia spectrum and other psychotic disorders. | |||
| DSM-5 CRITERIA FOR MAJOR DEPRESSIVE DISORDER (5) | E. There has never been a manic episode or a hypomanic episode. | |||
| DEPRESSIVE EPISODE WITH MIXED FEATURES (1) | A. Full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic symptoms are present during the majority of days of the current or most recent episode of depression: | 1. Elevated, expansive mood. 2. Inflated self-esteem or grandiosity. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. | 5. Increase in energy or goal-directed activity. 6. Increased or excessive involvement in activities that have a high potential for painful consequences. 7. Decreased need for sleep. | |
| DEPRESSIVE EPISODE WITH MIXED FEATURES (2) | B. Mixed symptoms are observable by others and represent a change from the person's usual behavior. | |||
| DEPRESSIVE EPISODE WITH MIXED FEATURES (3) | C. For individuals whose symptoms meet full episode criteria for both mania and depression simultaneously, the diagnosis should be manic episode, with mixed features. | |||
| DEPRESSIVE EPISODE WITH MIXED FEATURES (4) | D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment). | |||
| COURSE: BIPOLAR I DISORDER | ● More often starts with depression (75% in women, 67% in men) ● 10-20% experience only manic episodes ● Untreated manic episode lasts about 3 months | ● As the disorder progresses, the interval between episodes often decreases ● After about 5 episodes, interepisode interval stabilizes at 6-9 months ● 5-15% are rapid cyclers ● 4 or more episodes per year | ||
| PROGNOSIS: BIPOLAR I DISORDER | ● Poorer prognosis than MDD ● 2 to 30 manic episodes (mean: 9) | |||
| PROGNOSIS: BIPOLAR I DISORDER ● Recurrence rate | ○ 40-50% of patients will have a second manic episode in 2 years ○ 7% do not have a recurrence ○ 45% have more than one episode ○ 40% have a chronic disorder | |||
| PROGNOSIS: BIPOLAR I DISORDER ● Long-term follow-up study | ○ 15% asymptomatic ○ 45% asymptomatic but have multiple relapses ○ 30% in partial remission ○ 10% chronically ill | |||
| GOOD PROGNOSTIC FACTORS | ● Short duration of manic episodes ● Advanced age of onset ● Few suicidal thoughts ● Few coexisting psychiatric or medical problems | |||
| POOR PROGNOSTIC FACTORS | ● Poor pre-morbid occupational status ● Alcohol dependence ● Psychotic features ● Depressive features ● Poor pre-morbid occupational status ● Alcohol dependence ● Psychotic features ● Depressive features | |||
| COURSE & PROGNOSIS: BIPOLAR II DISORDER | ● Course and prognosis have just begun to be studied ● Preliminary data | |||
| COURSE: MAJOR DEPRESSIVE DISORDER | ● 1st episode occurs <40 years of age ● Untreated depressive episode lasts 6 to 13 months |
Created by:
avemaria