Overview of Affective Disroders

1. Androu Waheeb

2. To be Discussed
 Affect
 Abnormalities
 Episodes
 Disorders
 Episodes secondary to Medical Illness
 Substance-Induced Episodes
 Other Disorders of Note

3. Affect
 Affect = mood = internal emotional state
 Can be triggered by internal and external stimuli
 Variation: range and control
 Normal: wide range, can control
 Abnormal: abnormal range, can’t control

4. Abnormalities
Mood Episodes Mood Disorders
(distinct time) (pattern of episodes)
Major Depressive Major Depressive
Manic Bipolar
Mixed Dysthymic
Hypomanic Cyclothymic

5. Episodes 1
Mood Episodes
(distinct time)
Major Depressive
Manic
Mixed
Hypomanic

6. Episodes 2
• 2+ weeks • Sleep • 1+ weeks • Distractability
increase/decrease • Expansile/ irritable/ • Insomnia
• Anhednoia and/or
• Appetite/weight elevated mood • Greandiosity
depressed mood change • 3+ of DIG FAST • Flight of ideas
• 4+ of other SAME • Mood depressed symptoms (4+ if
CIGS symptoms • Energy decreased
• Activity
irritable mood) increased
• No medical or • Concentration • No medical or
decreased • Speech
substance abuse substance abuse cause pressured
cause • Interest decreased
(Anhedonia) • Significant social and • Thoughtless-
• Significant social occupational ness
• Guilt/
and occupational worthlessness impairment • 75% have
impairment • Suicide thoughts • Psychiatric emergency psychotic
symptoms
Major
Manic
Depressive

7. Episodes 3
• Same as mania except for • 1+ weeks
• 4+ days • Meets criteria for major
• No psychotic symptoms depressive AND manic
• No significant episodes
impairment of function
• Not an emergency
Hypomanic Mixed

8. Disorders 1
Mood Disorders
(pattern of episodes)
Major Depressive
Bipolar
Dysthymic
Cyclothymic

9. MDD - General
 DSM-IV TR
 At least one MDE
 No previous manic or hypomanic episodes
 Epidemiology
 15% (USA)
 12% (SE KSA)1
 M:F=1:2
 Average onset 40 y

10. MDD - Subtypes
Melancholic Psychotic Catatonic Atypical
Anhedonia Immobility Hyperphagia
Early morning Delusions Purposeless
Hypersomnia
awakening motor activity
Psychomotor
Negativism Reactive mood
disturbances
Guilt Bizarre posture Laeden paralysis
Hallucinations
Hypersensitive to
Anorexia Echolalia
rejection

11. Seasonal Affective Disorder
 Type of Depression
 Diagnostic Triad: Irritability, Carbohydrate
Drawing, Hypersomnia
 Only present in winter
 Due to lack of sunlight
 Rx: Light therapy

12. MDD - Etiology
Biological Genetic Psychosocial
1. Serotonin decreased 50% mono- 1. Loss of parent
2. Abnormal b- zygotic before 11 years
adronergic receptor concordance
regulation 2. Poor stability of
3. High cortisol (HPA family structure
hyperactivity)
3. Poor social
4. Thyroid disorder functioning
(TSH response to TRH
blunted)

13. MDD - Course
 Natural history
 Self-limiting (6-13/12)
 Disorders increase in frequency temporally
 15% commit suicide (USA)
 50% receive treatment
 75% treated successfully

14. MDD - Treatment
• Suicide
• Homicide
Hospitalization • Cant care for self
• Anti-depressants
• Adjuvant medication
Pharmacotherapy
• CBT
• Family Therapy
Psychotherapy
• Non-responding
Electro-convulsive • Non-tolerating
• Rapid recovery required
Rx

15. MDD – Anti-depressant
Pharmacotherapy
Anti-depressants
all equally effective and need 4-8/52 to work
SSRI TCA MAOI
(safer. Better tolerated) (Lethal in Overdose) (Refractory Depression)
• Sedation • Orthostatic
• Headache hypotension
• Weight gain
• GI disturbance • Orthostatic • Serotonin syndrome* if
hypotension + SSRI
• Sexual • Hypertensive crisis if +
• Anti-cholinergic effects
dysfunction sympathetomimetics or
• Aggravates long QT
• Rebound anxiety tyramine-rich food
syndrome

16. MDD – Anti-depressant
Pharmacotherapy 2
 *Serotonin Syndrome
 SSRI + MAOI
 Diagnostic triad
 Autonomic instability
 Hyperthermia
 Seizures
 May result in coma or death

17. MDD – Adjuvant Pharmacotherapy
Conversion of non-
Stimulants
Antipsychotics responders to
(methylphenidate)
responders
• Indications • Psychotic MDD • Liothyronine
• Terminally ill • Levothyroxine
• Refractory • Lithium
symptoms • L-tryptophan
• Cause
dependence

18. MDD - ECT
 Safe
 May be used alone
 8 treatments over 2-3/52
 Process
1. Atropine
2. General anesthesia
3. Muscle relaxants
4. Induce generalized seizure
 S/E: Temporary retrograde amnesia for 6/12

19. MDD - DDx
Dysthymia
Adjustment Disorder
Bipolar II in depressed state
Parkinson’s Disease
Brain Tumor
Cocaine Abuse
B-Blocker Side Effect
Hyperthyroidism
Hypothyroidism
Syphilis

20. CASE 1
 65 y o Widow
 Not taking care of self
 Put in geriatric home
 Wakes up early
 Does no particular activity
 Stopped going to Bingo meetings
 Claims there is nothing for her life

21. Disorders 2
Mood Disorders
(pattern of episodes)
Major Depressive
Bipolar
Dysthymic
Cyclothymic

22. Dysthymic Disorder – DSM
 Law of 2’s
 Depressed mood most of time most of days for 2+ years
without MDE
 Never without symptoms > 2/12
 2+ of CHASES symptoms
1. Concentration reduced
2. Hopelessness
3. Appetite reduced or overeating
4. Sleep increased or decreased
5. Energy reduced
6. Self-esteem reduced
 Never manic or hypomanic episode

23. Dysthymic Disorder – General
 Epidemiology
 < 1%
 F:M = 3:1
 Onset before 25
 Course (Rule of 20’s)
 Chronic disorder (MDD is episodic)
 Never get psychotic symptoms
 20%  MDD
 Double Depression: MDD+DD in between MDE’s
 20%  BPD
 20%  Lifelong symptoms

24. Dysthymic Disorder – Therapy
 Psychotherapy
 Cognitive Therapy
 Insight-Oriented Therapy
 Concurrent Anti-depressants
 SSRI + MAOI + TCA

25. Case 2
 28 yo Female
 Sad since adolescnce
 Does not remember last fun activity
 Denis suicidal thought
 Denies hopelessness
 Denies sleep impairment

26. Disorders 3
Mood Disorders
(pattern of episodes)
Major Depressive
Bipolar
Dysthymic
Cyclothymic

28. Bipolar Disorder
Bipolar I Bipolar II
• 1+ manic or mixed • 1+ MDE
episode • 1+ hypomanic episode
• Interspersed with • Never a manic episode
• MDE (most
common)
• Dysthymia
• Hypomanic episode
• Euthymia

29. Bipolar I - General
 Epidemiology
 1%
 Onset before 30
 Course
 Untreated episode lasts 3/12
 Chronic with relapses
 7% do not recur
 Increased frequency of episodes with progression
 50% of treated patients improve

30. Bipolar II – General
 Epidemiology
 0.5%
 Women more common
 Onset before 30
 Course
 Chronic and requires long term treatment

31. Bipolar I & II - Etiology
Biological 75% mono- Psychosocial Environmental
zygotic
concordance

32. Bipolar I & II - Therapy
• Lithium (Mood stabilizer)
• Carbamezipine or Valproic Acid*
(Anticonvulsant used as mood stabilizer)
Pharmacotherapy • Olanzapine (atypical antipsychotic)
• Supportive Psychotherapy
• Family Therapy
Psychotherapy • Group Therapy
• More treatments than MDD
• Works well
Electro-convulsive Rx

33. Bipolar I & II – Therapy 2
 Lithium Side Effects (GGD.FAWLT.UC.SAM)
1. GI Disturbances
2. Gotire or Hypothyroidism
3. PolyDipsia
4. Fatigue
5. Arrhythmia
6. Weight Gain
7. Leukocytosis
8. Tremor
9. PolyUria
10. Coma
11. Seizures
12. Allopecia
13. Metallic Taste

34. Bipolar I & II – Rapid Cycling
 4+ episodes in 1 year
 Especially responsive to anti-convulsants
 Carbamezipine
 Valproic acid

35. CASE 3
 35 yo Male
 Brought by wife
 Takes out loans to start business
 3 hours of sleep
 Compares himself to Bill Gates
 Previous suicide attempt
 Previously felt hopeless

36. Disorders 4
Mood Disorders
(pattern of episodes)
Major Depressive
Bipolar
Dysthymic
Cyclothymic

37. Cyclothymic Disorder – DSM
 DSM - IV – TR
 Many alternating periods with hypomanic and
depressive symptoms for 2+ years
 Never symptom free for > 2/12
 Never MDE or Manic Episode
 Epidemiology
 < 1%
 Coexist with Borderline Personality Disorder
 Onset 15-25

38. Cyclothymic Disorder – Therapy
 Course
 Chronic
 33%  BPD
 Anti-manic agents used for BPD

39. CASE 4
 28 yo student Female
 Feels moody
 Admits episodes of extreme happiness in last 2 years
 Every day for a period
 Admits lapse of judgment
 a/w increased energy
 Irrational depression of mood

40. Other Causes of MDE
Substance – Induced
2o General Medical
Condition
• CVD • Sedative-Hypnotics
• Endocrinopathies • Psychostimulant
• Parkinson’s Dx withdrawal
• Mononucleosis • Anti-convulsants
• Carcinoid Syndrome • Anti-psychotics
• Lymphoma • Alcohol
• Pancreatic CA • Anti-hypertensives
• SLE • Barbituates
• Corticosteroids
• Diuretics

41. Other Causes of Manic Episode
Substance – Induced
2o General Medical
Condition
• Hyperthyroidism • Antidepressants
• Temporal Lobe • Levodopa
Seizure • Dopamine
• MS Agonists
• Neoplasms • Sympatomimetics
• HIV • Bronchodilators
• Corticosteroids

42. Other Disorders of Note
 Minor Depressive Disorder
 Not meet criteria for MDD (symptoms)
 Not meet criteria for DD (euthymic periods)
 Recurrent Brief Depressive Disorder
 Premenstrual Dysphoric Disorder
 Mood Disorder Not Otherwise Specified (NOS)

43. References
1. Abdelwahid HA, Al-Shahrani SI. Screening of
depression among patients in Family Medicine in
Southeastern Saudi Arabia. Saudi medical journal.
Sep;32(9):948-52.
2. First Aid for the Psychiatry Clerkship