Chapter 5 - Depressive and Bipolar Related Disorders

Mood Disorder

a group of disorders involving severe and enduring disturbances in emotionality ranging from elation to severe depression

Prevalence of mood disorders

12% worldwide lifetime prevalence

• 6% have experienced in past years

• females 2x more likely to have major depression

• bipolar equal across sexes

• more common in high income countries

• diagnosis disparities in marginalized communities

• misdiagnosis of bipolar in black patients

Types of mood disorders

• MDD

• PDD

• seasonal Affective Disorder

• bipolar

• PMDD

• substance/medication induced depressive disorder

• disruptive mood dysregulation disorder

• depression related to medical condition

Affect

mood

Cognitive aspects of depression

inability to concentrate, suicidal ideation

Behavioral aspects of depression

low energy, psychomotor agitation, crying, hypersomnia/insomnia, anhedonia

Anhedonia

loss of interest in doing things

Psychophysiological aspects of depression

appetite, weight change

Major Depressive disorder

Episodic disorder – Symptoms present for a period then clear

A. Five or more of the following symptoms have been present during the same 2-week

period and represent a change in previous functioning; at least one of the symptoms is

either (1) depressed mood or (2) loss of interest or pleasure

1. Depressed mood (may be irritable mood in children) most of the day nearly every day as indicated by subjective report or observation made by others

2. Markedly diminished interest or pleasure in all, or almost all, activities

3. Significant weight loss when not dieting or weight gain or decrease/increase in appetite

4. Insomnia or hypersomnia

5. Psychomotor agitation or retardation (observable by others)

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive/inappropriate guilt

8. Diminished ability to think or concentrate or indecisiveness

9. Recurrent thoughts of death, suicidal ideation, or suicide attempt/specific plan

B. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning. (Will always be

considered)

Rule Outs

C. The episode is not attributable to the physiological effects of a substance or

another medical condition

D. At least one major depressive episode is not better explained by a psychotic

disorder

E. There has never been a manic episode or a hypomanic episode.

Clinical features of major depression

one or more major depressive episodes separated by periods of remission

• single episode unlikely, recurrent episodes common

Previously could not be diagnosed during grief, now explained by complicated grief

Persistent Depressive disorder

Persistent Depressive Disorder

A. Depressed mood for most of the day, for more days than not, as indicated by

either subjective account or observation by others, for at least 2 years.

B. Presence, while depressed, of two (or more) of the following:

1. Poor appetite or overeating.

2. Insomnia or hypersomnia.

3. Low energy or fatigue.

4. Low self-esteem.

5. Poor concentration or difficulty making decisions.

6. Feelings of hopelessness

C. Rule Out: During the 2-year period (1 year for children or adolescents) of the disturbance, the

individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

Other Rule Outs

E. There has never been a manic episode or a hypomanic episode.

F. The disturbance is not better explained by a psychotic disorder

G. The symptoms are not attributable to the physiological effects of a substance or medical

condition

Distress & Impairment

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Dysthymia

PDD

Types of PDD

• mild depressive symptoms without any major depressive episodes - pure dysthymic syndrome

• mild depressive symptoms with additional depressive episodes occurring intermittently

• major depressive episode lasting 2+ years

Provisional Disorder

someone meets most of criteria, can’t officially diagnose

PMDD (premenstrual dysphoric disorder)

A. In the majority of menstrual cycles, at least five symptoms must be present

in the final week before the onset of menses, start to improve within a few

days after the onset of menses, and become minimal or absent in the

week post-menses

B. One (or more) of the following symptoms must be present:

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased

sensitivity to rejection).

2. Marked irritability or anger or increased interpersonal conflicts.

3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.

4. Marked anxiety, tension, and/or feelings of being keyed up or on edge

C. One (or more) of the following symptoms must additionally be present, to reach

a total of five symptoms when combined with symptoms from Criterion B.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).

2. Subjective difficulty in concentration.

3. Lethargy, easy fatigability, or marked lack of energy.

4. Marked change in appetite; overeating; or specific food cravings.

5. Hypersomnia or insomnia.

6. A sense of being overwhelmed or out of control.

7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of

“bloating,” or weight gain

D. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

E. Rule Out: The disturbance is not merely an exacerbation of the symptoms of

another disorder (e.g., MDD, PDD)

F. Criterion A should be confirmed by prospective daily ratings during at least two

symptomatic cycles.

G. Rule Out: The symptoms are not attributable to the physiological effects of a

substance or another medical condition

Bipolar

both extremes of moods

• depressive and manic/hypomanic episodes

Mania

state of intense elation or irritability and abnormally increased acitvity

Flight of ideas

symptom of mania involving rapid conversation shifts

Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or

irritable mood lasting at least 1 week

B. During the period of mood disturbance there is a significant degree of

at least three of the following (four if mood is only irritable)

1. Inflated self-esteem or grandiosity

2. decreased need for sleep (e.g., feeling rested after 3 hours of sleep)

3. Excessive talkativeness

4. Flight of ideas or racing thoughts

5. Distractibility

6. Increased goal-directed activity or psychomotor agitation

7. Excessive involvement in high-risk behaviors

C. Mood disturbance is severe enough to cause impairment in normal

functioning or requires hospitalization, or there are psychotic features

Hypomanic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or

irritable mood lasting at least 4 days, that is clearly different from typical

mood

B. During the period of mood disturbance there is a significant degree of at

least three of the following (four if mood is only irritable)

1. Inflated self-esteem or grandiosity

2. decreased need for sleep

3. Excessive talkativeness

4. Flight of ideas or racing thoughts

5. Distractibility

6. Increased goal-directed activity or psychomotor agitation

7. Excessive involvement in high-risk behaviors

C. Episode is not severe enough to cause marked impairment in social or

occupational functioning or to necessitate hospitalization. If there are

psychotic features, the episode is, by definition, manic

Mixed Episode

Mixed features: mood episode with some features reflecting opposite valence of mood

• depressive episode with manic features

• manic episode with depressive features