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Affective (Mood) Disorders. Basal characteristics -Mood disorders are very common -Life prevalence is up to 20 %, and they have a high level of morbidity.

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Presentation on theme: "Affective (Mood) Disorders. Basal characteristics -Mood disorders are very common -Life prevalence is up to 20 %, and they have a high level of morbidity."— Presentation transcript:

1 Affective (Mood) Disorders

2 Basal characteristics -Mood disorders are very common -Life prevalence is up to 20 %, and they have a high level of morbidity and mortality as well as an immense impact on disabilities worldwide -The fundamental disturbance is a change in mood or affect, usually to depression (with or without associated anxiety) or to elation (mania or hypomania). -The mood change is usually accompanied by a change in the overall level of activity. -Most of these disorders tend to be recurrent, and the onset of individual episodes is often related to stressful events or situations.

3 Classification of Mood Disorders (ICD X) F30 Manic Episode F31 Bipolar Affective Disorder F32 Depressive Episode F33 Recurrent Depressive Disorder F34 Persistent Mood Disorders Cyklothymia Dysthymia

4 Unipolar vs. Bipolar Disorder Bipolar Unipolar Elevated Mood Elevated Mood Depressed Mood Depressed Mood

5 Classification of Depression ICD 10 F32 Depressive Episode –Mild (without vs. with somatic symptoms) –Moderate (without vs. with somatic symptoms) –Severe without psychotic symptoms –Severe with psychotic symptoms F33 Recurrent Depressive Disorder –Current episode mild (without vs. with somatic symptoms) –Current episode moderate (without vs. with somatic symptoms) –Current episode severe without psychotic symptoms –Current episode severe with psychotic symptoms –Currently in remission

6 Depressive disorder - epidemiology Prevalence (the total number of cases in the population, divided by the number of individuals in the population ) 5-10% in females, 2-3% in males Lifetime risk (The risk of developing a disease during ones lifetime ) in females 10–25%, in males 5–20% 15% of depressed patients commit suicide; generally increased mortality rate

7 Depressive episode ICD X basal (typical) symptoms: depressed mood, loss of interest and low level of energy ≥ 2 weeks (a) reduced concentration and attention; (b) reduced self-esteem and self-confidence; (c) ideas of guilt and unworthiness (even in a mild type of episode); (d) bleak and pessimistic views of the future; (e) ideas or acts of self-harm or suicide; (f) disturbed sleep; (g) diminished appetite.

8 Somatic symptoms (Somatic Syndrome) Some of the above symptoms may be marked and develop characteristic features that are widely regarded as having special clinical significance. loss of interest or pleasure in activities that are normally enjoyable; lack of emotional reactivity to normally pleasurable surroundings and events waking in the morning 2 hours or more before the usual time depression worse in the morning; objective evidence of definite psychomotor retardation or agitation marked loss of appetite weight loss (5%or more of body weight in the past month) marked loss of libido.

9 Mild, moderate, severe episode of depression mild – 2 and more symptoms from basal 3 + at least 2 additional symptoms moderate - 2 symptoms from basal 3 + at least 3 additional symptoms severe - all symptoms from basal 3 + at least 4 additional symptoms in in severe form severe with psychotic symptoms - a severe depressive episode in which delusions, hallucinations, or depressive stupor are present. The delusions usually involve ideas of sin, poverty, or imminent disasters, responsibility. Auditory or olfactory hallucinations are usually of defamatory or accusatory voices or of rotting filth or decomposing flesh. Severe psychomotor retardation may progress to stupor. If required, delusions or hallucinations may be specified as mood-congruent or mood-incongruent

10 F 33 Recurrent Depressive Disorder Repeated depressive episodes without history of separate episodes of mania (previously there was at least one episode of depression lasting minimally 2 weeks and was separated from the current one by the period of 2 months without symptoms) Current episode: mild, moderate, severe with or without psychotic symptoms, in remission

11 Cognitive behavioral model of depression Early childhood experiences ( conditional acceptance, conditional self-acceptance ) Creation of dysfunctional cognitive schemes (” I must succeed in everything “, “ If not perfect, it’s worthless“, etc.) Critical events (failures and increased expectations and demands 6 – 12 months prior onset of depression) Negative automatic thoughts (cognitive negative triad: negative self-assessment, negative assessment of external events, negative expectations of the future ) Symptoms of depression physical cognitive behavioral affective Možný a Praško, 1999

12 Other psychiatric dg.: anxiety disorders, schizophrenia, eating disorders, somatoform dis, personality dis., etc. Alcohol (30%), other psychoactive substances Neurological disorders: epilepsy (30-70%), Parkinson’s dis. (4-70%), Huntington’s dis. (37-43%), ictus (40-65%), multiple sclerosis (37-54%), dementia – Alzheimer’s d. (30- 40%), tics, Tourette’s, tumors, traumas, migrains, Wilson’s dis., muscular dystrophy, etc. Cardiovascular disorders (myocardial infarct 40- 65%); surgery, transplantation Endocrinological disorders, metabolic disorders (diabetes, deficit B12, thyreod., parathyr., kidney dis....) Others: tumors, infections, fatigue sy... Differential diagnosis

13 Drugs potentially inducing depression Psychotropics and substancesAlcohol (30%); reserpine (5-20%); cocain; marihuana; psychostimulants Hormonal drugsAnabolics (12%); estrogene contraception (5-20%); corticosteroids (5%); antagonists of gonadoliberine; ACTH (5%); progesterone, tamoxifene Cardiovascular drugsPropranolol (1-20%); alpha-methyldopa (10%); clonidine (1,5%); inhibitors of angiotenzine converting enzyme, Ca channel blockers; cinarizine AntipsychoticsTypical antidopaminergic antipsychotics in long-term treatment (10%) AntiepilepticsPhenobarbital; phenytoin; topiramate; vigabatrine Antimigrain drugsFlunarizin; sumatriptan Antagonists of H2 receptorsCimetidine Antagonists H3 receptorsOndansetrone BenzodiazepinesDiazepam Sedating hypnoticsTriazolam AntihistaminicsOlder drugs Hypolipidemics Antiparkinsonics Nonsteroid antirevmatics Chemoterapeutics of tumors Interferones+ Retinoides Other common drugsmetoclopramid; tramadol; ofloxacin; baclofen Anders, 2005

14 Course and prognosis Typical onset around age of 30´, earlier and late onset= increased risk of recurrence Development during days to weeks, prodromes (anxiety, mild signs of depression) can last longer (weeks to months) Untreated episode – 6-24 months, modern antidepressants have response rates in the 65% range and response to treatment typically requires 2–6 weeks or more and about one-third of patients will become resistant Unfavorable prognosis: more severe symptoms at onset (?), comorbidity of personality and organic disorders

15 Course and prognosis (cont. I) High risk of relapse during first 12 weeks of remission (25 % of total relapses) Risk of subsequent episode is increased with number of past episodes and with persistent sublinical symptoms With older age intervals between episode could be shorter

16 Likelihood of having another depressive episode if you’ve had… Major Depressive Episode Major Depressive Episode Major Depressive Episode Major Depressive Episode Major Depressive Episode Major Depressive Episode 1 episode 50% 2 episodes 70% 3 episodes 90% Maintenance treatment is fully indicated

17 Bipolar Disorder Also known as manic depression, a mental illness that causes a person’s moods to swing from extremely happy and energized (mania) to extremely sad (depression) Chronic illness; can be life-threatening Most often diagnosed in adolescence

18 Epidemiology of Bipolar Disorder Prevalence: 1% of population Adults = Adolescents Males = Females The first attack occurs most commonly between the ages of 15 and 30 years Tends to be recurrent 22% of adolescents with completed suicides had bipolar disorder

19 Classification of bipolar disorder ICD X F30 Manic episode –Hypomania –Mania without psychotic symptoms –Mania with psychotic symptoms F31 Bipolar affective disorder –Current episode hypomanic –Current episode manic without psychotic symptoms –Current episode manic with psychotic symptoms –Current episode mild or moderate depression (w/wo somatic symptoms) –Current episode severe depression (w/wo psychotic symptoms) –Current episode mixed –Currently in remission

20 F 30 Manic episode Hypomania = persistent mildly elevated mood, increased energy level, feelings of satisfaction and high efficiency. (Increased sociability, talkative, easiness, sexual energy, decreased need for sleep – but still without severe impairment of social or working functioning); hallucinations or delusions are absent, ≥ 4 days Mania = elevated mood not corresponding to the circumstances increased energy level (hyperactivity, talkative, decreased sleep, food, event. dehydration, lack of hygiene, distractibility, attention deficit), increased self-esteem, self-evaluation, overconfidence, lack of social inhibition, racing thoughts, word salad, aggressivity, sometimes delusions of grandeur, hallucinations The episode should last for at least 1 week and should be severe enough to disrupt ordinary work and social activities more or less completely. The mood change should be accompanied by increased energy and several of the symptoms referred to above (particularly pressure of speech, decreased need for sleep, grandiosity, and excessive optimism).

21 Manic episode with psychotic symptoms The clinical picture is that of a more severe form of mania. Inflated self-esteem and grandiose ideas may develop into delusions, and irritability and suspiciousness into delusions of persecution. In severe cases, grandiose or religious delusions of identity or role may be prominent, and flight of ideas and pressure of speech may result in the individual becoming incomprehensible. Severe and sustained physical activity and excitement may result in aggression or violence, and neglect of eating, drinking, and personal hygiene may result in dangerous states of dehydration and self-neglect. If required, delusions or hallucinations can be specified as congruent or incongruent with the mood.

22 Manic episode – differential diagnosis Diff. dg.: physical illness (multiple sclerosis, brain tumor, Cushing) psychoactive substance hyperkinetic disorder in children euthymia in chronic depression hyperthyroidism and anorexia nervosa early states of "agitated depression„ Schizophrenia vs mania with psychotic symptoms incongruent with mood

23 Bipolar Depression (Depressive episode of Bipolar disorder) 80% of patients exhibit significant suicidality Depressive episodes dominate course of bipolar disorder (twice the amount of time as in mania) 25-30% of patients initially diagnosed with unipolar depression subsequently have a manic or hypomanic episode

24 Bipolar disorder This disorder is characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression). Characteristically, recovery is usually complete between episodes. Patients who suffer only from repeated episodes of mania are rare, and resemble (in their family history, premorbid personality, age of onset, and long-term prognosis) those who also have at least occasional episodes of depression, such patients are classified as bipolar.

25 COMORBID DISORDERS Substance Abuse – Alcohol, Cocaine, THC Narcissistic PD, Borderline PD 20-30% OCD, Panic Disorder More mixed and rapid cycling, poorer response to lithium, slower time to recovery and higher number hospitalizations

26 Bipolar I Disorder (DSM-IV) Major Depressive Episode Manic or Mixed Episode Manic or Mixed Episode One or more manic episode OR Depressed and manic episodes OR

27 Bipolar II Disorder (DSM-IV) Major Depressive Episode Hypomanic Episode Hypomanic Episode One or more hypomanic episode OR Depressed and hypomanic episodes OR

28 Rapid cycling (≥ 4 episodes per year)

29 Long-term course: Zurich study 406 patients from 1959 -1991 Median of evaluation age: 68 Remission Recurence Chronicity Suicidium Jules Angst

30 F 34 Persistent mood disorder Cyclothymia and Dysthymia Last 2 and more years, fluctuating severity, episodes are not so striking to be diagnosed under previously mentioned (closer to so called “neurotic depression”) Sometimes superimpose recurrent disorder, or single episode (i.e.double depression) In DSM-IV dysthymia is among depressive disorders and cyclothymia among bipolar disorders

31 F 34.0 Cyclothymia 2 years of instable mood, several episodes of insignificant depression or hypomania If onset is between age of 30 to 50, then mostly follows affective episode Lifetime prevalence 0.4–1%, more frequent in females, family history of mood disorders, alcohol, personality disorders (associal) Etiopatogenesis – similarly to bipolar significant contribution of biological and genetic factors is presumed Course and prognosis: onset in adolescence, frequent hyperactivity in childhood, insidious, chronic course, 15-50% develop into bipolar; 60% stabilizes with lithium

32 F 34.1 Dysthymia 2 years of persistent or recurrent mild depressive symptomatology (normal mood maximum several weeks) Lifetime prevalence: 3-6%, higher in females Etiopatogenesis: similar to depression – biological factors (polysomnograph, genetics), psychosocial Course and prognosis: onset in childhood or adolescence, insidious, very likely develop into severe depressive episode


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