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Mood disorder

Mood disorder. Shaohua Hu, MD Associate Director Department of Mental Health First Affiliated Hospital, Zhejiang Univeristy School of Medicien dorhushaohua@zju.edu.cn. Overview. What is mood disorder? Criteria for specific mood episodes and disorders

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Mood disorder

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  1. Mood disorder Shaohua Hu, MD Associate Director Department of Mental Health First Affiliated Hospital, Zhejiang Univeristy School of Medicien dorhushaohua@zju.edu.cn

  2. Overview • What is mood disorder? • Criteria for specific mood episodes and disorders • Epidemiology and aetiology of mood disorder • Acute and long-term treatment of mood disorder

  3. What is a mood disorder? • Mood is a person’s subjective emotional state • Affect is the objective appearance of mood • Mood disorders (according to DSM-IV) involve a depression or elevation of mood as the primary disturbance. • Can have other abnormalities (psychosis, anxiety, etc.)

  4. Introduction • Mania elevated or irritable mood over-activity self-important ideas • Depression depressed mood negative thinking lack of enjoyment reduced energy slowness

  5. Depressed mood Anhedonia Decrease or increase in appetite OR significant weight loss or gain Persistently increased or decreased sleep Psychomotor agitation or retardation Fatigue or low energy Feelings of worthlessness or inappropriate guilt Decreased concentration or indecisiveness Recurrent thoughts of death, suicidal ideation, or suicide attempt Major Depressive Episode Five or more symptoms present for ≥ 2 weeks

  6. Moderate Depressive Episode • Appearance • Depressive cognition worthlessness, pessimism, guilt • Goal-directed behavior • Psychomotor retardation or agitation • Biological symptoms sleep disturbance, weight loss, physical symptoms • Other features

  7. Severe Depression and Psychotic Depression • Greater intensity of symptoms • Complete loss of function in social and occupational sphere • Inattention to basic hygiene and nutrition • Delusions and hallucinations Cotard’s syndrome

  8. Other Clinical Features of Moderate and Severe Depression • Agitated depression • Retarded depression • Depressive stupor • Atypical depression variably depressed mood overeating and oversleeping extreme fatigue and heaviness in the limbs pronounced anxiety

  9. Depressive Stupor Emile Kraepelin Manic-Depressive Insanity 1928 (English Edition)

  10. Mild Depressive States • Additional symptoms (neurotic) anxiety phobias obsessional symptoms dissociative symptoms

  11. Mania • Central features: Elevation of mood increased activity self-important ideas

  12. Mania Emile Kraepelin Manic-Depressive Insanity 1928 (English Edition)

  13. Clinical Features • Mood infectious gaiety • Appearance and behavior untidy and dishevelled, physical exhaustion • Speech and thought rapid and copious, flight of ideas, expansive ideas, extravagant, grandiose delusion • Perceptual disturbances hallucination • Other features impaired insight

  14. Manic Episode • A. Elevated (or irritable) mood for ≥1 week • B. Three or more of following (four if mood irritable): • Grandiosity • Decreased need for sleep • Pressured speech • Flight of ideas, racing thoughts • Distractibility • Increased goal-directed activity • Excessive involvement in pleasurable activities with high risk

  15. Specific Clinical Type • Mixed Mood (Affective) Disorder • Rapid Cycling Disorder • Manic Stupor

  16. Classification of Mood Disorder Classification of Depression • Based on presumed aetiology • Based on symptomatic picture • Based on course

  17. Classification by presumed aetiology • Endogenous depression • Reactive depression

  18. Classification by symptomatic picture • Melancholic depression More severe symptomatology Poor response to placebo medication Good response to ECT More evidence of neurobiological abnormalities • Psychotic depression • Non-melancholic depression

  19. Classification by course • Unipolar and bipolar disorder • Seasonal affective disorder hypersomnia increased appetite with craving for carbohydrate afternoon slump in energy

  20. Classification in ICD and DSM

  21. Classification of bipolar disorder • ICD-10 DSM-IV Manic episode Hypomanic episode Hypomania Manic episode Mania (Mild, Moderate, Severe, Severe with psychosis) Mania with psychosis Bipolar affective disorder Bipolar I and bipolar II disorder Currently hypomanic Current (or most recent episode) Hypomanic Currently manic Manic Currently depressed Depressed Currently mixed Mixed In remisson Cyclothymic disorder Cyclothymia

  22. Classification of Depressive Disorder(1) • ICD-10 DSM-IV Depressive episode Major depressive episode Mild Mild Moderate Moderate Severe Severe Severe with psychosis Severe with psychosis Other depressive disorder Atypical depression Recurrent depressive disorder Major depressive disorder Recurrent Currently mild Currently moderate Currently severe Currently severe with psychosis In remission

  23. Classification of Depressive Disorder(2) • ICD-10 DSM-IV Persistent mood disorder Dysthymic disorder Cyclothymia Dysthymia Other mood disorder Depressive disorder not otherwise specified Recurrent brief depression Recurrent brief depression

  24. A systematic scheme for the clinical description of mood disorders • Severity Mild, moderate, or severe • Type Depressive, manic, mixed • Special features With melancholic symptoms With atypical symptoms With prominent anxiety With psychosis symptoms With agitation With retardation or stupor • The coures Unipolar or bipolar • Aetiological factors Organic Family history of mood disorder Personal history of mood disorder Childhood experience Personality Social support Life events

  25. Differential diagnosis Depressive disorder • Normal sadness • Anxiety disorders • Schizophrenia • Organic brain syndromes Mania • Schizophrenia • Organic brain disease involving the frontal lobes • States of brief excitement induced by amphetamines and other illicit drugs.

  26. The Epidemiology of Mood disorder Bipolar disorder • the lifer time risk for bipolar disorder lies between 0.3 and 1.5 per cent • The 6-month prevalence of bipolar disorder is not much less than the lifetime prevalence, indicating the chronic nature of the disorder. • The prevalence in men and women is the same. • The mean age of onset is about 17 years of age in community studies. • Bipolar disorder is highly comorbid with other disorders, particularly anxiety disorders and substance misuse.

  27. The Epidemiology of Mood disorder Depression • The 12-month prevalence of major depression in the community is between 2 and 5 per cent. • The lifetime rates in different studies vary cosiderably (4-30 per cent). The true figure probably lies between 10 and 20 per cent. • The mean age of onset is about 27 years. • Rates of major depression are about twice as great in woman as men, across different cultures. • There may be increased rates of depression in people born since 1945. • Rates of depression are higher in the unemployed and divorced. • Major depression has a high comorbidity with other disorders, particularly anxiety disorder and substance misuse.

  28. The aetiology of mood disorder Area of investigation relevant studies • Genetic Genetic epidemiology Molecular genetics • Personality Temperament Cognitive style • Early environment Parental deprivation • Social environment Life events • Psychological Psychodynamic • Biological Monoamines HPA axis Neuropsychology

  29. Genetic causes Family and twin studies • Familial aggregation • Twin studies • Genetic evidence on classification of mood disorder Molecular genetics • Linkage studies • Association studies

  30. Personality • Cyclothymic personality were more prone to develop manic-depressive disorder • Some personality features may influence the way that people respond to adverse circumstance and thus make depressive disorder. • Certain kinds of personality development and psychiatric disorder may share common genes, such as neuroticism.

  31. Early Environment • Parental deprivation Psychoanalysts have suggested that childhood deprivation of maternal affection through separation or loss predisposes to depressive disorders in adult life. • Relationships with parents physical and sexual abuse, parental style, non-caring, overprotective parenting

  32. Precipitating Factors • Recent life events Studies suggest that events lead to feelings of entrapment and humiliation may be particularly relevant to the onset of depression. Clinical experience suggests that a proportion of manic cases are precipitated, sometimes by events that might have been expected to induce depression, for example, bereavement.

  33. Precipitating Factors • Vulnerability factors and life difficulties long-term difficulties vulnerability factor: have the care of young children, not working outside the home, having no one to confide in. poor social support • The effects of physical illness

  34. Psychological approaches to aetiology • Psychoanalytical theory Freud 1911 • Cognitive theory negative thoughts (automatic thoughts): cognitive distortions arbitrary inference selective abstraction overgeneralization personalization

  35. Neurobiological approaches to aetiology • The monoamine hypothesis: Depressive disorder is due to an abnormality in a monoamine neurotransmitter system at one or more sites in the brain. serotonin (5-HT) noradrenaline (NE) dopamine (DA)

  36. 5-HT Abnormalities in depression • Decreased plasma tryptophan • Decreased brain 5-HT1A receptor binding (PET) • Decreased brain 5-HT re-uptake sites (SPET) • Blunted 5-HT neuroendocrine responses • Clinical relapse after tryptophan depletion

  37. Noradrenaline Abnormalities in depression • Blunted noradrenaline-mediated growth hormone release • Clinical relapse after AMPT

  38. Dopamine Abnormalities in depression • Decreased homovanillic acid (HVA) levels in CSF • Increased dopamine D2 receptor binding (PET/SPET) • Clinical relapse after AMPT

  39. Role of monoamines • The studies that shows a key role for monoamines in the pathophysiology of depression are the 5-HT and catecholamine depletion paradigms. • It is now established that in vulnerable individuals, lowering of 5-HT and noradrenaline and dopamine function is sufficient to cause clinical depression.

  40. Two major question? • How does altered monoamine function impact on the cortical circuitry involved in mood regulation? • How does altered monoamine function contribute to the clinical symptomatology of depression.

  41. Endocrine abnormalities • Some disorder of endocrine function are followed by mood disorders more often than would be expected by chance, suggesting a causative relationship. • Endocrine abnormalities found in depressive disorder indicate that there may be a disorder of the hypothalamic centres controlling the endocrine system.

  42. Endocrine pathology and depression • Plasma cortisol • Dexamethasone Suppression Test (DST) Dexamethasone non-suppression is more common in depressed patients with melancholia • Glucocorticoid Receptor Hypothesis • Hypersecretion of CRH .

  43. Cortisol, monoamine function, and neuronal toxicity • Expression of post-synaptic 5-HT1A receptors in the hippocampus • Excessive cortisol secretion to damage to neurons in the hippocampus

  44. Thyroid function • Level of free triidothyronine may be decreased in depressed patients. • Blunted thyrotropin-stimulating hormone(TSH)

  45. Depression and the immune system • Lowered proliferative response of lymphocytes to mitogens • Lowered natural killer cell activity • Increase in positive acute phase proteins • Increase in cytokine levels (e.g. IL-1, IL-6)

  46. Sleep changes in depression • Impaired sleep continuity and duration • Decreased deep sleep (stage 3 and 4) • Decreased latency to the onset of rapid eye movement (REM) sleep • Increase in the proportion of REM sleep in the early part of the night

  47. Brian imaging in mood disorder • change in brain volume: enlarge lateral ventricle; decreased hippocampal volume decreased volume of basal ganglia structures; decreased grey matter volume of sub genual prefrontal cortex; increased amygdala volume

  48. Brian imaging in mood disorder • White matter hyperintensities In major depression, hyperintense MRI signals are associated with: late onset of depressive disorder; greater illness severity and poorer treatment response; apathy, psychomotor slowness, and retardation; presence of vascular risk factors

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