General model Mood disorders - manchesterpsychiatry.net

8/27/2009

Introduction to Mood and Overview
Anxiety Disorders
• Introduction to mood disorders
Dr Carlos Gonzalez
Specialist Registrar, MRI – Depression
– Bipolar affective disorder

• Introduction to anxiety disorders

– Phobias, panic disorder and generalised
anxiety disorder

– OCD
– PTSD and adjustment to stress disorders
– Dissociative and somatoform disorders

General model Mood disorders

Thinking,
Cognition

Behaviour Feeling,
Emotion

Biological
functions

Behaviour Manic Episode Depressive Episode

Speech Overactivity, restlessness Psychomotor retardation or agitation
Mood Increased sociability, overfamiliarity Avoids social interaction
Biological Self neglect
functions Disinhibition Suicidal behaviour or acts
Thought Impulsivity, recklessness behaviour
Overspending, aggressive behaviour Slow speech
Perception Reduced quantity of speech
Duration Over talkative
Pressure of speech Low mood most of the time
Anhedonia (=lack of enjoyment)
Elation or Can present with comorbid anxiety
irritability
Anergia, reduce energy
Diminished sleep but no fatigue Disturbed sleep - Early morning wakening
Increased libido
Increased energy Decreased appetite/weight loss
Reduced libido
Flight of ideas
Increase self-esteem, grandiosity Poverty of thought, slow thinking
Distractibility, poor concentration Reduce self-esteem and confidence

Full of unrealistic plans Pessimistic, hopeless
May develop mood congruent Inappropriate guilt
delusions (i.e. of grandiose)
Suicidal ideas and/or intent
May develop hallucinations if severe May develop mood congruent delusions

At least 1 week (i.e. of poverty or guilt)

May develop hallucinations if severe

At least 2 weeks

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Special features Severity

• Psychotic symptoms - Hallucinations and delusions • Severity: The severity of a depressive episode
can occur in severe depression and mania. Delusions depends upon the number of individual key
are usually mood congruent. Hallucinations are usually symptoms, the intensity of these symptoms and
auditory and in the second person. the effect upon the person's level of functioning.

• "Neurotic" Symptoms - Most commonly anxiety • Hypomania: Abnormally elevated or irritable
symptoms but prominent obsessive compulsive or mood + 3 or more symptoms of mild intensity.
hypochondriacal symptoms may occur, particularly in the Duration required is only 4 days.
elderly.
• Mania: Abnormally elevated or irritable mood +
• “Melancholia” or “somatic syndrome” -This refers to 3 or more symptoms of more severe intensity.
a severe depression where biological symptoms are Duration required is one week.
prominent: i.e. weight loss or marked anorexia, early
morning wakening, diurnal variation (with mood worse in
the morning), psychomotor retardation or agitation.

Severity Course

• Mild depressive episode: At least 2 typical • Single episode
symptoms (depressed mood, anhedonia, • Recurrent depressive disorder (or unipolar affective
fatiguability) and at least 2 other symptoms.
disorder) - At least 2 episodes reaching the criteria for
• Moderate depressive episode: At least 2 mild, moderate or severe depression.
typical symptoms (see above) plus at least 3 • Bipolar affective disorder (manic depression) - At least
(and preferably 4) other symptoms. 2 episodes reaching the criteria for a mood disorder, one
of which must have been mania (bipolar I) or hypomania
• Severe depressive episode: All 3 typical (bipolar II)
symptoms plus at least 4 other symptoms, • Mixed affective episode: An affective episode lasting
usually of severe intensity. for at least 2 weeks and is characterised by either a
Psychotic symptoms may be present. mixture or a rapid alteration (usually within a few hours)
of hypomanic/manic, and depressive symptoms.

Other diagnostic categories Epidemiology

• Dysthymia is a form of mild depression which Depressive Disorder Bipolar Affective Disorder
has a chronic course and does not meet the
criteria for a recurrent depressive disorder. It Sex ratio (F:M) 2:1 1:1
usually begins early in adult life and last for few Social class no social class differences
years (at least two). Prevalence greater in lower socio-economic
Lifetime risk class less than 0.3%
• Cyclothymia is a milder form of bipolar disorder Age 1%
with persistent instability of mood, involving male = 2-3%; female = 2-9%
numerous periods of mild depression and Other factors Mean age of onset is 21
elation. It may be a personality variant. Episodes male = 10%; female = 20% Both onset and peak age is in

• Schizoaffective disorder: criteria for both Mean age of onset is 27 the 20's to early 30's
schizophrenia and a mood disorder occur during Peak age is 25-40
the same episode. 10-20% have only manic
Older people and very young men episodes
are more likely to commit
suicide Compared to Depressive Dis.:
- Episodes are shorter
urban population > rural
- More number of episodes
Compared to bipolar: In the majority the first episode
- Episodes have longer duration
is depressive
- Less number of episodes

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Aetiology Aetiology - Genetics

• The aetiology is probably multi-factorial, • Twin studies show higher monozygotic
• Interaction between individual vulnerability concordance rates in bipolar disorder

and precipitating factors. This is known as • Higher hereditability in bipolar than depressive
the stress-vulnerability model disorder
• Biological factors: genetics, endocrine,
neurotransmitters • It is likely that mood disorders result from a
• Psychological factors: Psychodynamic, combined action of several genes of modest or
cognitive and behavioural models small effect (polygenic inheritance)
• Social factors
• Candidate genes are linked to polymorphism in
MAO-A, COMT, 5HT-T, DAOA/G72, and BDNF.

Aetiology - Endocrine Aetiology - Neurotransmitters

• Increased acitivity in the Hypothalamic-pituitary • The monoamine theory implies a
adrenal (HPA) axis dysregulation of catecholamine systems,
mainly serotonin (5-HT), but also
• Elevated levels of cortisol in plasma, CSF and noradrenaline and dopamine to a lesser
urine in about 50% of depressed patients. extend.

• Thyroid function - The TSH response to TRH is • The disorders are not simply due to low
impaired in some patients and in some with levels of transmitters, but alterations in the
treatment resistant depression functioning of specific receptors

• Hypo and hyperthyroidism are recognised to
cause alteration in mood.

Aetiology - Psychological. Aetiology - Social

• Psychodynamic: This emphasises the • Predisposing:
importance of loss, as in bereavement or
separation, and also self-esteem and self-image. – Maternal loss is a risk factor for Bipolar Disorder
(Mortensen Arch Gen Psych 2003).
• Cognitive: Depressed patients have a number
of cognitive errors or “distortions” when – Risk factors for depression are: lack of a confiding
appraising the world, themselves and the future. relationship; unemployment; having 3 or more
Examples of this errors are overgeneralising, children (Brown & Harris 1978)
personalisation (taking things personally),
selective abstraction (focusing on the negative • Precipitating: In the 6 months after a life event
and ignoring the positive) and dichotomous (bereavement, job loss, etc.) the chance of an
thinking (black/white thinking). episode of depression is increased 5 to 6 times.

• Behavioural: In animal models chronic stress
can result in loss of ability to act and avoid the
stress (“learned helplessness”).

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Prognosis Treatment - Mania

• Duration of episodes: An untreated depressive episode Treatment of Short term Long term
usually last 6 to 13 months; this is reduced to 3 to 6 Mania
months with medical treatment. A manic episode usually Neuroleptic medication Mood stabilisers: lithium,
last ~3 months. Physical consider lithium carbamazepine or
sodium valproate as
• Number of episodes: Over a period of 20 years the Psychological Rule out organic causes prophylaxis
mean number of relapses is around 5 or 6 for a recurrent
depressive disorder. In Bipolar Affective Disorder, a Social Support for patient and CBT - cognitive behavioural
patient can have between 2 and 30 episodes in a
lifetime, with a mean of 9. family, forging a therapy.

• 15% of patients with depressive illness will die by therapeutic relationship Supportive therapy
suicide. A quarter of patients with a manic episode will
suffer an episode of depression immediately afterwards Admission to hospital A minority need rehabilitation
should be considered and supervised care,
to minimise risk to most need advice
patient and others. regarding return to
normal life and spotting
future relapses

Treatment - Depression Anxiety disorders

Treatment of depression Short term Long term • The total point prevalence for anxiety
Physical Antidepressant medication: disorders is 4.5% (GAD 2.5%; OCD
- If no response change to 0.05%).
Psychological delay onset of 2-4 another antidepressant.
Social weeks • Anxiety problems account for about 27%
- If treatment resistance of GP consultations for emotional
Neuroleptics can be given consider alternative difficulties.
when there are antidepressant, lithium
psychotic features augmentation, • The overall sex ratio (M:F) for anxiety
combination or ECT. disorders is between 1:2 and 2:3 with a
E.C.T. when indicated peak age of onset between the ages of 25
- Antidepressants should be and 44.
Supportive therapy taken for at least 6
(C.B.T.), months after recovery to
Bereavement counselling decrease risk of relapse
Interpersonal therapy
support for carers More emphasis on specific
Admission if risk to patient psychotherapies such
as C.B.T., dynamic,
or others family therapy etc.
Specific social interventions
Specific social interventions
e.g. housing, finance

In some cases social and/or
occupational
rehabilitation

Generalised Anxiety Disorder

• Pervasive anxiety symptoms that are not
restricted to specific situations.

• A period of least 6 months when the
individual experiences tension, worry and
feelings of apprehension about everyday
events and problems.

• He/she should also experience at least 4
symptoms of anxiety

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Generalised Anxiety Disorder

• Co-morbidity is common
• Have some genetic, biological and

psychological components
• Is commoner in females
• Some physical illness present with

anxiety, like overactive thyroid or
phaeochromocytoma
• Treatment: CBT, antidepressants

Panic Disorder Phobic Anxiety Disorders

• Recurrent attacks of panic that occur • A fear that is disproportionate to the
unpredictably and without obvious specific situation that triggers it.
precipitants. At least 4 symptoms of
anxiety during the attacks. • Avoidance of the feared stimulus (negative
reinforcement).
• Treatment: Anxiety management and
CBT. Where hyperventilation is present • Simple phobias: animal phobias, blood
behavioural approaches to deal with this and injury phobias and vertigo
are appropriate. Role for antidepressants
• Agoraphobia
• Social phobia

Agoraphobia Social Phobia

• Symptoms consist of intense fear or • Fear of being the focus of attention with
avoidance of at least two of the following avoidance of situations that can cause
situations: leaving the home, being in humiliation or public embarrassment.
crowded spaces, travelling on public
transport or travelling alone. • These situations are typically eating, drinking
and speaking in public, or meeting people in
• The individual will experience at least 4 small groups.
anxiety symptoms when exposed to those
situations • Symptoms of anxiety plus blushing/shaking,
fear of vomiting, urgency and fear of
• 75% of sufferers are women with a defecating or urinating.
prevalence of 6.3 per 1000 population.
• Equal sex ratio

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Treatment of phobias Obsessive Compulsive Disorder

• Behaviour therapy involving graded • OCD has a lifetime prevalence of 1.9-3.3%
exposure or desensitisation to the feared
stimulus. • Obsessional thoughts: repetitive and
unpleasant thoughts, that are recognised
• A hierarchy of stages is worked out with as being the subjects own, resisted by the
the person, from least to most anxiety subject. Examples: contamination,
provoking. doubting

• The patient gradually exposes him/herself • Compulsive acts: Repetitive actions based
to the feared situation with avoidance on the obsessional thoughts which provide
prevention through anxiety management temporary relief of anxiety. Examples:
like controlled breathing. checking, cleaning...

OCD

• Aetiology: Strong evidence for a
biological aetiology and link with Gilles de
la Tourette syndrome. Neuroimaging
studies show abnormality in the basal
ganglia, anterior cingulate cortex and
orbitofrontal cortex.

• Treatment: CBT: Thought blocking and
response prevention. Also Clomipramine
and SSRIs. Most severe: neurosurgery.

Stress Related Disorders Somatoform Disorders

• Acute stress reaction. Onset is almost • Somatisation disorder. There is at least a 2
immediate and resolves rapidly. years history of multiple physical complaints, with
preoccupation and distress from the patient who
• Adjustment disorder. Onset is usually within 1 seeks medical help and refuses to accept medical
month of the stressful event resolves by 6 reassurance (i.e. negative investigations).
months: symptoms include depression, anxiety.
• Hypochondriacal disorder. The patient has a
• PTSD. Onset is delayed weeks to months from a persistent belief (at least for 6 months) that
stressor that is of an exceptionally threatening or he/she suffers at least one serious physical
catastrophic nature. Symptoms include illness despite negative physical findings and
flashbacks, nightmares, avoidance, autonomic reassurance. Alternatively may have a persistent
hyperarousal with hypervigilance, anxiety, preoccupation with a presumed deformity or
depression, guilt, emotional blunting, and partial disfigurement
recollection of the traumatic event

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Conversion Disorders

• The main feature is a restriction of the field
of consciousness or a disturbance of a
motor or sensory function for which there
is no demonstrable organic findings.
Symptoms are linked to unresolved
internal conflicts,

• Examples are: dissociative amnesia,
dissociative fugue, dissociative stupor,
dissociative motor disorder, dissociative
convulsions, dissociative anaesthesia and
sensory loss.

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