1. MOOD
DISORDERS

2. EMOTIONS
AFFECT: MOOD:
Short-lived, emotional Sustained and pervasive
Response to an event

3.  Healthy persons experience a wide range of
moods and have a large repertoire of emotional
expressions, feel in control
 Mood disorders are a group of clinical conditions
which are characterized a by sense of loss of
control over one’s mood and subjective sense of
distress, impaired interpersonal, social and
occupational functioning

4. History
 Hippocrates (400 B.C.) used the terms mania
and melancholia to describe mental
disturbances
 Roman physician (30 A.D.) described
melancholia as depression caused by black bile

5.  In 1854, Jules Farlet described a condition
called folie circulaire: alternating moods of
depression and mania
 In 1899, Emil Kraepelin described manic-
depressive psychosis using most of the criteria
that psychiatrists use now

6. CLASSIFICATION
 Manic Episode
 Depressive Episode
 Bipolar Affective Disorder
 Recurrent Depressive Disorder
 Persistent Mood Disorder (cyclothymia
and dysthymia)

7. Mania: Clinical Features
 Core features
 Elevated/irritable mood
 Increased speech
 Decreased need for sleep
 Increased psychomotor activity
 Psychotic features
 Delusions
 Hallucinations
 Others
7

8. 1. Elevated/ irritable mood:
o Euphoria/ Grade 1: mild elevation of mood, increased
sense of psychological well being and happiness, not in
keeping with ongoing events
o Elation/ Grade 2: moderate elevation of mood, feeling of
confidence and enjoyment, along with increased
psychomotor activity
o Exaltation/ Grade 3: severe elevation of mood, intense
elation with delusions of grandiosity
o Ecstasy/ Grade 4: very severe elevation of mood,
intense sense of rapture or blissfulness
8

9. 2. Increased speech
o Volubility
o Acceleration
o Pressured speech- difficult to interrupt
o Flight of ideas- shift from topic to topic with
cues
o Prolixity- ordered flight of ideas
3. Increased psychomotor activity
o Over activity/ restlessness
o Excitement
o Stupor
9

10. 4. Psychotic symptoms
 Delusions: grandiose, love, persecutory
 Hallucinations

11. 5. Other symptoms
o Over religiosity
o Over spending/ expansive ideas
o Over familiarity/ disinhibition
o Appearance
o Appetite may be increased, but decreased
food intake due to over-activity
o Decreased need for sleep

12. Psychiatric Interview
 http://www.youtube.com/watch?v
=zA-fqvC02oM&feature=relmfu

13. DEPRESSIVE EPISODE: Clinical
Features
1. Depressed Mood:
 Pervasive and persistent sadness
 Quantitatively and qualitatively different from
sadness encountered in normal depression or
grief
 Varies little from day to day and is often
unresponsive to environmental stimuli

14. 2. Anhedonia:
 Loss of interest or pleasure in almost all
activities/ earlier pleasurable activities
 Results in social withdrawal
 Decreased ability to function in occupational and
interpersonal areas

15. 3. Anergia:
 Easy fatigability
 Increased effort to perform simple tasks

16. 4. Depressive ideation:
 Hopelessness
 Helplessness
 Worthlessness
 Feelings of guilt
 Death wishes
 Suicidal ideas

17. 5. Psychomotor Activity:
 Younger patients (less than 40): slowed thinking and
activity, decreased energy, monotonous voice
 Older patients: agitation, marked anxiety, restlessness
 Severe depression: stupor

18. 6. Biological functions/ somatic syndrome:
 Insomnia
 Loss of appetite and weight
 Loss of sexual drive
 Early morning awakening (atleast 2 hrs)
 Diurnal variation

19. 7. Psychotic Symptoms:
 Delusions of guilt, nihilism, poverty
 Hallucinations

20. Other symptoms
 Difficulty in concentration
 Forgetfulness
 Low self-esteem
 Decreased self-confidence

21. Psychiatric Interview
 http://www.youtube.com/watch?v
=4YhpWZCdiZc

22. Bipolar affective disorder
 Characterized by repeated episodes of disturbed
mood and activity levels
 Disturbance consisting of elevation of mood,
increased energy and activity on some occasion
and on others of low mood, decreased energy
and activity
 Recovery is usually complete in between the
episodes
22

23. Recurrent Depressive Disorder
 Recurrent (at least 2 depressive episodes) of
unipolar depression
 First episode occurs later than in bipolar, usually
in the 5th decade
 Episodes last between 3 to 12 months
 Recovery is usually complete
 Often precipitated by stressful life events

24. Persistent Mood Disorders
 Persistent mood symptoms lasting for more than 2 years
 Not severe enough to be labeled as even hypomanic or
mild depressive
 Persistent mild depression: dysthymia
 Persistent instability of mood between depression and
mania: cyclotymia

25. Next Class
 Course and Prognosis
 Epidemiology
 Treatment
 Differential Diagnosis
 Co-morbidities
 Other syndromes of depression and mania

26. Psychiatric Interviews
 http://www.youtube.com/watch?v
=4YhpWZCdiZc
 http://www.youtube.com/watch?v
=zA-fqvC02oM&feature=relmfu

27. Course and Prognosis
 Average manic episode lasts for 3-4 months
 Average depressive episode lasts for 4-6
months
 Unipolar depression is usually longer than
bipolar depression
 As age advances, intervals between 2 episodes
shorten; duration and frequency increases

28. Epidemiology
Prevalence
Annual incidence is <1%, milder forms often
missed
Sex ratio
Equal prevalence among men and women
Manic episodes more common in men and
depressive episodes more common in women
28

29. Age of onset
Onsetearlier than depressive episode
Ranges from 5-50yrs; mean age 30yrs
Marital status
More common in divorced and single persons
Socioeconomic status
Higher than average incidence among upper
socioeconomic status
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30. Classification
 Bipolar type 1- having clinical course of
one or more manic episodes and major
depressive episodes
 Bipolar type 2 – characterized by episodes
of major depression and hypomania
30

31. Diagnosis- ICD 10 criteria
 Hypomania- lesser degree of mania
o Persistent mild elevation of mood- euphoria
o Marked feelings of well being and efficiency
o Increased energy and activity
o Decreased need for sleep
o Increased sociability and talkativeness
o Not leading to severe disruption of work or
social rejection
o Present for several days on end (4 days)
31

32.  Mania without psychotic symptoms
o Last for at least 1wk
o Severe enough to disrupt ordinary work and
social activities
o Elated mood
o Increased energy with over activity
o Pressured speech
o Decreased need for sleep
o Marked distractibility
o Disinhibited, overspending
o Expansive ideas
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33.  Mania with psychotic symptoms
o More severe form
o Delusions- grandiose and/or persecutory
o Perceptual abnormalities
o Severe and sustained physical activity,
excitement
o Flight of ideas, incoherence
o Impaired personal care
33

34. Etiology
Biological theories
2.Genetic factors
3.Neurotransmitter theories- inconsistent
o Dopamine- raised in mania and vice versa
4.Neuroendocrine theories
o CSF somatostatin- raised in mania and vice
versa
5.Neuroimaging and anatomy
o Regions involved in regulation of normal
emotions- PFC, antr cingulate, hippocampus,
amygdala 34

35. Contd-
Psychosocial theories
2.Life events and stress
o Play a formative role in depression;
precipitating in mania
o More often precede first rather than the
subsequent episodes
35

36. Course
 Most often first episode is depression
 Average manic episode lasts 3-4mnths
and depressive episodes 4-6mnths
 Long term follow up- 15% are well, 45%
are well with multiple relapses, 30% in
partial remission, 10% are chronically ill
36

37. Treatment
 Pharmacological- Acute- Mood stabilizers
Antipsychotics
Benzodiazapines
Antidepressants
ECTs
Prophylaxis- Mood
stabilizers
 Non pharmacological- Psycho education
CBT
Interpersonal 37

38. Contd-
Mood stabilizers
Lithium- exact mechanism of action
unknown
Indications- acute mania
prophylaxis of unipolar
and
bipolar disorder
adjuvant to
antidepressant
impulsive/ aggressive
behavior 38

39. Contd-
Precautions- RFT, TFT, ECG
Adverse effects- CNS- tremors,
seizures,
cognitive impairment,
delerium
Renal- DI, polyurea, dypsia
CVS- hypokalemia- T wave
Abnormal thyroid function
GI- nausea, diarrhoea
Skin- acne, psoriasis
39

40. Contd-
 Sodium valproate- acute mania,
prophylaxis
750-2500mg/day
rapid onset of
response
 Carbamazepine
 Oxcarbazepine
 Lamotrigine- depression, prophylaxis; skin
 Topiramate
40

41. 41

42. Summary
 Clinical features- 4 core features
psychotic features
others
 Management- pharmacological- acute
prophylaxis
non-pharmacological
42

43. Poor prognostic factors
 Young onset
 Longer duration of episodes
 Presence of psychotic features
 Inter episode depressive features
 Premorbid poor occupational status
 Comorbid medical and psychiatric
problems
43

44. Etiology
Biological theories
2.Genetic factors
o 3 fold increase in biological relative
o Increased concordance rate for monozygotic
twins
o Chromosome 18, 21, 22
4.Neurotransmitter theories- inconsistent
o Serotonin and norepinephrine- depression
o Dopamine- reduced in depression and
increased in mania 44

45. Contd-
1. Neuroendocrine theories
o Elevated HPA activity, hypothyroidism-
depression
o CSF somatostatin- raised in mania and vice
versa
3. Neuroimaging and anatomy
o Regions involved in regulation of normal
emotions- PFC, antr cingulate, hippocampus,
amygdala
o Ventricular enlargement 45

46. Contd-
Psychosocial theories
•Psychoanalytic theory- mania as defense
against underlying depression
•Life events and stress
o Play a formative role in depression;
precipitating in mania
o More often precede first rather than the
subsequent episodes
6.Cognitive theory- depression
46

47. Course
 Most often first episode is depression
 10-20% experience only manic episodes
 Manic episodes typically have rapid onset
 Average manic episode lasts 3-4mnths
and depressive episodes 4-6mnths
 Long term follow up- 15% are well, 45%
are well with multiple relapses, 30% in
partial remission, 10% are chronically ill
47