Chapter 12 Mood Disorders
Comorbidity
The simultaneous presence of two or more chronic diseases or conditions in a patient.
Mood Disorder Etiology
Biological Theories - major focus for understanding the cause of depression and bipolar disorder. Some research shows link between physiology, genetics, and mood disorders.
Flight of Ideas
A confused state in which thoughts and speech go in all directions with no unifying concept
Rapid Cycling
A pattern of bipolar disorder involving at least four manic or depressive episodes per year
Hyperprexia
Extreme body temp increase of over 106 F
Electroconvulsive therapy (ECT)
A treatment that involves inducing a mild seizure by delivering an electrical shock to the brain
Bipolar II Disorder
The patient has one or more hypomanic episodes alternating with major depressive disorder.
Epidemiology
-19.3% of general population -depression occurs in 21.3% of women and 12.7% of men -bipolar onset: Mid- to late 20s -depression onset: Mid 30s -depression frequency greater in Caucasians, Hispanics, and lower socioeconomic groups -bipolar frequency greater in higher socioeconomic groups
Carbamazepine (Tegretol), Valporic Acid (Depakene), Divalproex Sodium (Depakote)
-2nd generation anticonvulsant -require a therapeutic serum level of 50-100; greater than 100 is toxic -toxic reactions include blood dycrasias (disorder of the cellular elements of the blood) -do not eat grapefruit or drink grapefruit juice
Gabapentin (Neurontin)
-3rd generation anticonvulsant -found to be ineffective for bipolar -abrupt withdrawal can cause seizures
Medical Conditions and Mood Disorders
-A medical patient develops a mood disorder as a stress response to a serious medical condition. -A medical patient develops a mood disorder as a physiologic response to either medical pathology or medication. -A psychiatric patient with a persistent mood disorder develops common medical disorders. -A psychiatric patient with a persistent mood disorder has an exacerbation of symptoms as a result of medical pathology or treatment. -Health care providers identify previously unrecognized relationships between mood and medical disorders.
Assessment - Physiologic Disturbances
-Appetite -Vital signs -Hydration -Sleep pattern changes -Activity level -Fatigue -Constipation -Weight loss -Sex drive
Behavioral Symptoms of Dysthymic Disorder
-Chronic fatigue -decreased activity -decreased productivity
Adjustment Disorder Subtypes
-Depressed mood -Anxiety -Mixed anxiety and depressed mood -Disturbance of conduct -Mixed disturbance of emotions and conduct -Unspecified
Types of Mood Disorders
-Depressive Disorders -Bipolar Disorders
Perceptual Symptoms
-Distractibility -hallucinations
Psychosocial Factors
-Evolutionary Psychology/Biology -Psychodynamic Theory -Cognitive Theory -Learned -Helplessness/Hopelessness Theory -Live Events and Stress Theory
Mood Stabilizers
-Lithium -Carbamazepine -Valproate -Lamotrigine -Gabapentin
Additional Symptom Features of Mood Disorders
-Melancholic Depression -Atypical Depression -Seasonal Affective Disorder -Postpartum Mood Disorder
Biological Theories
-Neurotransmission -Neuroendocrine Dysregulation -Genetic Transmission
Early-Onset Bipolar Disorder (EOBD)
-Once thought to emerge around early adulthood, but has recently been made as early as 5 years old. -symptoms overlap other childhood psychiatric disorders -difficult to distinguish from ADHD with the exception of EOBD having cyclic patterns not evident in ADHD or other disorders
Adjustment Disorders
-Problematic responses to life events -Affecting otherwise mentally healthy people -Transient episodes of dysfunction in response to specific stressors -Acute duration: 6 months or less -Chronic duration: 6 months or more
Diagnosing Depression in Older Adults
-Requires three (instead of five) symptoms from the DSM-IV list -the list is expanded to include irritability, social isolation or withdrawal, assessing for decreased positive affect rather than loss of interest, no longer requiring symptoms to occur nearly every day but rather determining that they represent a change from previous behavior.
Social Symptoms of Dysthymic Disorder
-Social withdrawal -patient's mood and negativity make people not want to be around them
Atypical Depression
-mood reactivity -loss of ability to react to positive stimuli -significant weight gain or increase in appetite -hypersomnia -leaden paralysis or heavy feeling in arms and legs -long standing pattern of being sensitive to interpersonal rejection -associated with suicide more often than other depression types
Foods with Tyramin
-Strong or aged cheeses, - -Cured meats -Smoked or processed meats -Pickled or fermented foods -Sauces, such as soy sauce, shrimp sauce, fish sauce, miso and teriyaki sauce. -Soybeans and soybean products. -Snow peas, broad beans (fava beans) and their pods. -Dried or overripe fruits -Meat tenderizers or meat prepared with tenderizers. -Yeast-extract spreads, such as Marmite, brewer's yeast or sour dough bread. -Alcoholic beverages -Combination foods that contain any of the above ingredients. -Improperly stored foods or spoiled foods. While you're taking an MAOI, your doctor may recommend eating only fresh foods — not leftovers or foods past their freshness dates.
Seasonal Affective Disorder (SAD)
-a seasonal pattern occurs when a regular temporal relationship between onset and remission of episode of major depression (unipolar or bipolar) at particular time of year -must be evident for 2 consecutive years with no intervening nonseasonal episodes -seasonal episodes of altered mood must outnumber any nonseasonal episodes over a lifetime -mostly develop during October or November to March or April; some during summer -atypical features associated with SAD -increased light triggers manic or hypomanic episodes in bipolar II disorders
Melancholic Depression
-anhedonia and a lack of reactivity to any pleasurable stimuli -a distinct quality of mood in which the patient perceives the depression as different from the feeling after the death of a loved one -worse in the morning -sleep disturbances of waking at least 2 hours before normal -marked psychomotor retardation or agitation -Weight loss or loss of appetite -excessive guilt
Norepinephrine Dopamine Re-Uptake Inhibitors (NDRIs)
-bupropion (Wellbutrin) -2nd Line antidepressant that is resistant to SSRI or SSRIs -lowers seizure threshold; don't take with seizure disorders or eating disorders
Children and Adolescents
-can begin in early childhood and adolescence -less is known about the diagnosis and treatment than that of adults -Mood disorders at this age are significant: 1) they generate extraordinary pain and distress due to them not being prepared to understand or deal with the emotions and behaviors 2) initiate major difficulties during this period of time that is essential to psychosocial development 3) they produce tremendous stress and concern for the entire family unit 4) they affect the educational experience 5) they influence biologic processes and brain functioning to create changes that will have lifelong effects -may occur as early as infancy
Psychotherapeutic Intervention
-cognitive therapy -interpersonal therapy -psychodynamic therapy
Children and Adolescents Symptoms
-declining academic performance with no apparent reason -behavioral problems -aggression -difficulty with peer relationships -withdrawal -moodiness Boys: -acting out -external expression of symptoms Girls: -more internalization withdrawal, sadness and self-deprecation
Emotional Symptoms of Dysthymic Disorder
-depressed mood -reports feeling chronically down, gloomy, or sad -unable to remember a time when they felt good or their usual self -unlike major depression, anhedonia is not a major symptom -irritability or angry mood
Cognitive Symptoms of Major Depressive Episode
-diminished ability to think, concentrate, or make decisions -recurrent thoughts of death -excessive focus on self-worthlessness and guilt -negative thinking -sometimes delusional -fixed beliefs that cannot be changed by logic -Delusions focus on persecution, punishment, nihilism, or somatic concerns
Alternative and Complementary Therapy
-family intervention -group intervention -psychotherapeutic intervention -self-management intervention
Postpartum Mood Disorder
-includes manic or depression symptoms after birth of child -most common in childbirths with complications -15-20% of new mothers affected -usually within 3 months of the birth -severe forms include hearing voices and experiencing delusions
Social Symptoms
-increased sociability and sexuality -intrusive, interruptive, and disruptive during conversations or activities -fluctuations between euphoria and anger
Behavioral Symptoms
-increased talkativeness -decreased need for sleep -increased goal-directed behavior or agitation -excessive involvement in activities thought to be pleasurable, risky, or even dangerous
Vagal nerve stimulation
-induced with vagal nerve stimulator device implanted in the LCW -helps patients with treatment-resistant depression
Cognitive Symptoms of Dysthymic Disorder
-low self-esteem -inadequacy -guilt and brooding about the past -difficulty concentration, memory, and decision making -negative thinking such as pessimism, despair, and hopelessness -little regard for themselves -overwhelming sense of inadequacy -lack of self-confidence
Atypical New-Generation Antidepressants
-may cause fatal reaction if taken with MAOIs (serotonin syndrome, neuroleptic malignant syndrome, and autonomic instability) -Elderly more sensitive to anticholinergic, cardiovascular, and sedative effects
Nonadrenergic/Specific Serotonergic Antidepressants (NSSAs)
-mirtazapine (Remeron) -higer risk of seizures than tricyclic antidepressants -use with MAOIs may increase the risk of hyper pyretic crisis, hypertensive episodes, and severe seizures -self-harm and suicide more likely when younger than 18 years old
Prognosis for Dysthymia
-often continues for years before individuals seek assistance -most are unaware of chronic low-level symptoms are treatable -many with dysthymia go on to develop major depression -with proper treatment, the prognosis for maintaining functioning with mood disorders is favorable but most people don't seek treatment, comply with treatment regimen, lack proper diagnosis
Older Adults
-older adults less likely to report depressed mood -tend to describe somatic symptoms such as apathy, fatigue, difficulty sleeping, and loss of interest ion usual activities -Made worse by loss of SO and friends at this time of life -often have no support system -social and generational differences: sometimes depression is seen as a normal part of aging or some not accepting psychiatric treatment -depression could be a an early sign of dementia
Depressive Disorders not Otherwise Specified
-premenstrual dysphoric disorder -minor depressive disorder -recurrent brief depressive disorder -postpsychotic depression of schizophrenia
Lithium
-require therapeutic drug monitoring to prevent toxicity -0.6 to 1.2 is therapeutic -greater than 1.5 is toxic -1.5 to 2.0 results in vomiting, diarrhea, drowsiness, confusion, lack of coordination, coarse hand tremor, muscle twitching, and t-wave depression -Acute toxicity may have seizures, oliguria, circulatory failure, coma, and death -may not work or side effects are intolerable for half that have bipolar -monitor sodium intake, changes can alter lithium excretion
Behavioral Symptoms of Major Depressive Episode
-significant weight loss or gain -changes in appetite -insomnia or hypersomnia -psychomotor agitation or psychomotor retardation -fatigue
Cognitive Symptoms
-thoughts of inflated self-esteem and grandiosity -thought-flow disturbance with racing thought and flight of ideas
Serotonin-2 Antagonist/Re-Uptake Inhibitors (S2ARIs)
-trazadone (Desyrel), nefazodone (Serzone) -may increase risk for hypertensive crisis when taken with MAOIs -trazadone is used for insomnia; can contribute to dysrhythmias
Prognosis for Major Depression
-usually a lifetime disorder -most people who experience depression have recurrences -long term outcomes tend to be less than positive -less than a third of people who experience depression seek treatment -with proper treatment, the prognosis for maintaining functioning with mood disorders is favorable but most people don't seek treatment, comply with treatment regimen, lack proper diagnosis
Prognosis for Bipolar Disorder
-usually a lifetime disorder -perceived as recurrent with periods of depression and mania interspersed with periods of euthymia -some experience rapid cycling -high rate of recurrence and relapse -factors that contribute to relapse: number of and recovery from previous episodes, a family history, functional incapacity with episodes, past psychotic episodes, and past suicide attempts -with proper treatment, the prognosis for maintaining functioning with mood disorders is favorable but most people don't seek treatment, comply with treatment regimen, lack proper diagnosis
Social Symptoms of Major Depressive Episode
-withdraw from family and social interactions -problems at work as a result of the inability to organize, initiate or complete work -financial problems
Clonazepam (Klonopine)
1st generation anticonvulsant
Mood Disorders
A group of psychiatric illnesses in which the predominant symptom is the dysregulation of mood or emotion.
Cyclothymic Disorder
A chronic mood disturbance of at least 2 years duration with many periods of hypomanic symptoms, depressed mood, and anhedonia. Have not been without the symptoms for more than 2 months over a period of 2 years that are less severe or intense than those seen with major depressive or manic episodes.
Psychomotor Retardation
A condition in which a person has slowed mental or physical activities
Euthymia
A normal mood state
Major Depressive Episode, Single or Recurrent
A specific episode of major depression is indicative of a first episode or of a recurrent episode of major depression. Symptoms occur as a result of the disorder and not from the effects of a substance, a medical condition, or the loss of a loved one within the previous 2 months.
Nihilism
A total rejection of established laws
Manic Episode
Abnormally or persistently elevated, expansive, or irritable mood for at least 1 week. Must include at least three symptoms.
Neuroleptic Malignant Syndrome
Adverse reaction to antipsychotics with severe "lead pipe" rigidty, FEVER, and mental status changes
Interventions - Psycopharmacology
Antidepressants -SSRIs -Atypical new-generation Antidepressants -SSNRIs -NDRIs -S2ARIs -NSSAs -TCAs -MAOIs Mood stabilizers -Lithium -Carbamazepine -Valproate -Lamotrigine -Gabapentin Antipsychotics Anxiolytics Sedative-hypnotics
Dysthymic Disorder
Chronic instead of episodic. No manic or hypomanic episodes. Must have had a depressed mood and at least three of the symptoms for most of the day, nearly every day, for at least 2 years (1 year for children and adolescents): -poor appetite -insomnia or hypersomnia -low energy -low self-esteem -poor concentration -difficulty making decisions -feelings of hopelessness
Anticholinergic Side Effects
Dry Eyes, Dry Mouth, Urinary Retention, Constipation
Psychomotor Agitation
Excessive motor and cognitive activity, usually nonproductive and in response to inner tension
Emotional Symptoms
Excessively and persistently elevated, expansive, or irritable mood
Depressive Disorders
Experienced only episodes of depression with no manic or hypomanic episodes (unipolar depression). -Major Depressive Episode, Single or Recurrent -Dysthymic Disorder -Depressive Disorders Not Otherwise Specified
Assessment
Mood -key to mood disorders -the internal manifestation of subjective feeling state Affect -the external expression of manifestation of a feeling state -restricted, flat, blunted Temperament -observable differences in the intensity and duration of arousal and emotionality Emotion -the experience of a feeling state Emotional Reactivity -the tendency to respond to internal or external events with emotion Emotional Regulation -the ability to control or modify the occurrence and intensity of feelings Range of Affect -the span of emotional expression experienced and displayed by an individual.
Bipolar Disorder
Occurs when people experience periods of depression that alternate with periods elevated mood, impulsivity, and hyperactivity, which is known as mania.
Bipolar Disorders
Occurs when the patient experiences both episodes of depression and episodes of mania or hypomania over time. Diagnosed as either Bipolar I or II disorder
Bipolar I Disorder
One or more manic episodes, usually with history of depressive episodes (can have psychotic aspects)
Hospital/Outpatient Discharge Criteria
Realistic: -verbalize plan for future, seeking help, -demonstrate ability to manage basic self-care needs -Identify psychosocial or physical stressors that have negative influence on mood and thinking -State positive and helpful coping strategies for threats, concerns, and stressors -Identify s/s of mood disorders -Describe how to contact sources for validation or interventions -verbalize understanding of medication treatment and self-care strategies Ideal: -Describe mood state and demonstrate ability to identify changes from euthymic mood -verbalize realistic perceptions/expectations and positive and hopeful abilities for self -use learned techniques and strategies to prevent/minimize symptoms -engage family/S.O. for support -structure life to include appropriate activities that promote social support, minimize stress, facilitate healthy living
Unipolar Mood Disorder
Refers to patients who usually have only depressive episodes or, rarely, only manic periods.
Hypertensive Crisis
Severe hypertension, severe headache, chest pain, fever, sweating, nausea and vomiting
Hypomanic Episode
Shares symptom criteria with manic episodes. At least 4 days of elevated, euphoric, or irritable mood that is less severe than a manic episode. Not severe enough to cause significant impairment to social or occupational functioning or cause hospitalization.
Serotonin Syndrome
Similar to neuroleptic malignant syndrome but caused by serotonin medications, and has HYPERreflexive muscle activity
Mood
Subjective feeling state
Affect
The emotional state observed by others, whereas mood is the patient's report of his or her own emotional state.
Transcranial magnetic stimulation
The use of strong magnets to briefly interrupt normal brain activity as a way to study brain regions
Emotional Symptoms of Major Depressive Episode
Two primary symptoms, one of these must be present most of the day, nearly every day, for at least 2 weeks: -depressed mood -anhedonia (loss of interest and the capacity to experience pleasure) Other symptoms: -depressed, sad empty, or numb mood -difficulty experiencing pleasure or satisfaction from their usual activities -feelings of sadness -frequent crying -report disinterest, disconnection, or an inability to feel emotion -anxiety, irritability, or anger, loneliness, helplessness, or hopelessness -flat or constricted affect with minimal expression -can appear rather normal to the outside
Tricyclic Antidepressants (TCAs)
amitriptyline (Elavil), clomipramine (Anafranil), imipramine (Tofranil), desipramine (Norpramin), doxepin (Sinequan), nortriptyline (Aventyl), protiptyline (Vivactil), amoxapine (Asendin), trimipramine (Surmontil) -use with MAOIs may increased risk of neuroleptic malignant syndrome, seizures, hypertensive crisis, and hyperprexia -use with anticoagulants can lead to bleeding -use with clonidine can cause severe hypertension
Antidepressants (SSRIs)
citalopram (Celexa), fluoxetine (Prozac), paroxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), fluvoxamine (Luvox), escitalopram (Lexapro) -first-line -fatal reactions with MAOIs by causing serotonin syndrome, hypertensive crisis, rigidity, and neuroleptic malignant syndrome -self-harm and suicide more likely when younger than 18 years old -avoid caffeine (agitation), smoking (decreased effectiveness), and alcohol (increases sedation) -Do not take with Lithium -St. John's Wort may cause serotonin syndrome
Phototherapy
exposure to bright lights, often used to treat SAD (seasonal affective disorder)
Monoamine Oxidase Inhibitor Agents (MAOIs)
phenelzineu (Nardil), tranylcypromine (Parnate), isocarboxazid (Marplan), moclobemide (Manerix), selegiline transdermal patch (Emsam) -3rd line agent after SSRIs and TCAs have been tried -signs of toxicity are increased headaches and palpitations -MAOIs should not be used within 14 days of SSRIs -(PANAMA = parnate, nardil, marplan) (foods with tyramin contraindicated)
Oliguria
production of an abnormally small amount of urine