Mood and Somatic Disorders

What is the difference between affect and mood, and how are mood disorders classified in DSM-IV-TR versus DSM-5?

Affect is communicated through facial expression, vocal inflection, gestures, and posture, and tends to be short-lived, reflecting momentary emotional states.

Mood is a pervasive, sustained feeling tone endured internally that impacts nearly all aspects of a person's perception of the external world.

Mood disorders (MD) are psychiatric disorders involving disturbed mood ranging from elation to depression, characterized by an episodic, remitting/relapsing course, sometimes with psychotic features.

DSM-IV-TR (2000) used the term "Mood Disorders," dividing them into Bipolar Disorders (BD) and Depressive Disorders (DD);

DSM-5 (2013) removed the "MD" term and replaced it with two separate entities: (1) BD and related disorders, and (2) Depressive Disorders.

What biological theories (neurostructural, neurochemical/monoamine) explain the etiology of mood disorders?

No single theory explains mood disorders; multiple theories exist.

Neurostructural/neurocircuitry: studies implicate networks formed by the orbital and medial prefrontal cortex (OMPFC) and related areas of the striatum, thalamus, temporal cortex, and limbic system, showing altered gray matter volume, cellular elements, neurophysiological activity, receptor pharmacology, and gene expression.

Neurochemical (Monoamine theory): mood disorders are linked to abnormalities in serotonergic, dopaminergic, noradrenergic, cholinergic, glutamatergic, GABAergic, glucocorticoid, and peptidergic function; the monoamine theory holds that altered serotonin, noradrenaline, and dopamine levels/function cause MD.

Antidepressants act via primary mechanisms (blocking presynaptic monoamine transporters, inhibiting monoamine oxidase, or modulating pre/postsynaptic receptors) and secondary mechanisms (delayed effects involving gene expression/synaptic plasticity changes, such as increased BDNF expression, enhanced 5-HT1A receptor function, and attenuated NMDA-glutamatergic transmission with enhanced GABA transmission).

What neuroendocrine, genetic, and psychosocial factors contribute to mood disorders, and what does the biopsychological theory propose?

Neuroendocrine: mood disorders are linked to hypothalamic-pituitary-adrenal (HPA) axis abnormalities, as well as thyroid and gonadotrophin dysfunction.

Genetic: twin, family, and adoption studies show significant heritability; a strong family history (especially parental mood disorder) is a vital and constant risk factor for developing mood disorders in children.

Psychosocial: exposure to stress and trauma — stressful life changes (death of a loved one), chronic stress, traumatic events, and childhood abuse — are major risk factors, especially for depression.

The biopsychological theory proposes that perinatal complications or adverse environmental exposure sensitize stress-responsive systems during development, so that subsequent trauma exposure can precipitate disease expression in genetically vulnerable individuals, with resulting abnormalities in post-receptor signaling and neuroplasticity producing the neurostructural changes seen in MD.

What are the DSM-5 diagnostic criteria for a major depressive episode?

Five or more of the following symptoms present during the same 2-week period, representing a change from previous functioning, with at least one being depressed mood or loss of interest/pleasure (excluding symptoms clearly due to another medical condition):
1) depressed mood most of the day nearly every day;
2) markedly diminished interest/pleasure in almost all activities;
3) significant weight loss/gain (>5% body weight change in a month) or appetite change;
4) insomnia or hypersomnia nearly every day;
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/concentrate or indecisiveness;
9) recurrent thoughts of death, suicidal ideation, or a suicide attempt/plan.

Symptoms must cause clinically significant distress/impairment, not be attributable to a substance or medical condition, not be better explained by a psychotic spectrum disorder, and there must never have been a manic or hypomanic episode.

What are the DSM-5 diagnostic criteria for a manic episode?

A period of abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed behavior/energy lasting one week or more, during which 3 or more (4 if mood is only irritable) of the following are present:
inflated self-esteem/grandiosity, decreased need for sleep, hyper-talkativeness/pressured speech, flight of ideas/racing thoughts, distractibility, increase in goal-directed or non-goal-directed activity (agitation), and increased involvement in risky activities (buying sprees, sexual indiscretions, foolish investments).

The disturbance causes social/occupational dysfunction and necessitates hospitalization to prevent self-harm or harm to others, and is not due to another medical condition or substance.

What are the DSM-5 diagnostic criteria for a hypomanic episode, and how does it differ from a manic episode?

A period of abnormally and persistently elevated, expansive, or irritable mood with increased goal-directed behavior/energy lasting 4 days or more, with the same 3+ (or 4+ if irritable) symptoms as mania (grandiosity, decreased sleep need, pressured speech, flight of ideas, distractibility, increased goal-directed/non-goal-directed activity, risky behavior).

Unlike mania, the episode is associated with an unequivocal change in functioning observable by others, but is NOT severe enough to cause social/occupational dysfunction or require hospitalization, and is not due to another medical condition or substance.

What are the specifiers that can be applied to mood episodes?

Mixed specifier:
alternating distinct manic/hypomanic and depressive symptoms in one period — e.g., full manic symptoms plus 3+ depressive features, or full depressive criteria plus 3+ manic/hypomanic features.

Psychotic specifier: delusions/hallucinations during depressive or manic episodes — mood-congruent (delusions of guilt/punishment in depression, grandeur in mania) or mood-incongruent (delusions of control/influence).

Melancholic specifier: diurnal mood variation or non-reactivity, guilt, and middle/late insomnia or early morning awakening (in depression).

Anxious distress specifier: anxiety symptoms during a depressive episode.

Atypical specifier: mood reactivity, hypersomnia, hyperphagia (in depression).

Catatonic specifier: excitement, stupor, and negativism, occurring during any mood episode.

What are the five main mood disorder diagnoses, and how are they distinguished?

Bipolar I Disorder: requires at least one manic episode (may also have depressive/hypomanic episodes).

Bipolar II Disorder: requires only hypomanic symptoms plus depressive episodes, but never a manic episode.

Major Depressive Disorder: only depressive episodes (called Recurrent Major Depressive Disorder if episodes recur).

Persistent Depressive Disorder (Dysthymia): depressive symptoms not severe enough for major depression, persisting for 2+ years (1+ year in children/adolescents).

Adjustment Disorder-Depressive Type: a stress-related reactionary disorder with depressive symptoms but full insight and no psychotic features (distinguished here from true depressive disorders).

How is a mood disorder evaluated, and what rating scales are used?

Evaluation requires a detailed longitudinal and family history plus a thorough mental status exam for early diagnosis; substance-induced MD requires a urine drug test, and MD due to another medical disease needs disease-specific investigations/imaging. Rating scales: Beck Depression Inventory, Hamilton Rating Scale for Depression (HAM-D — a 17-item clinician-administered scale rating mood, sleep, concentration, guilt, suicidality, anxiety, and somatic symptoms; 0-7 is normal, >20 needs intervention), and Montgomery-Åsberg Depression Rating Scale (MADRS — assesses sadness, tension, appetite, sleep, self-harm thoughts on a 0-60 scale; 0-6 normal, 7-19 mild, 20-34 moderate, >34 severe) are used for depression; the Young Mania Rating Scale (YMRS) is an 11-item clinician scale for mania (4 items scored 0-8, remaining items 0-4; ≤12 = remission, 13-25 = moderate, 38-60 = severe mania).

When is hospitalization or ECT indicated for mood disorders?

Hospitalization indications: diagnostic workup needed, lack of social support, refusal of food/medication or non-compliance, and suicide/homicide/self-harm risk. ECT (electroconvulsive therapy) indications: suicide/violence risk, psychomotor retardation or agitation, psychotic or catatonic features, multiple drug interactions or first-trimester pregnancy, and treatment-resistant depression.

How are bipolar disorder and major depressive disorder treated pharmacologically and with psychotherapy?

Bipolar disorder acute phase: initiate a mood stabilizer; for mania/hypomania add major tranquilizers; for depressive phases, titrate up mood stabilizers, consider ECT, use atypical antipsychotics with antidepressant effect (e.g., quetiapine), or antidepressants with the least manic-switch risk (e.g., bupropion, a noradrenergic-dopaminergic reuptake inhibitor). Maintenance phase: continue mood stabilizers, sometimes combined with an antipsychotic ("bipolar combos") for maximum relapse protection. Major depressive disorder: first episode treated with antidepressants for 6-12 months; recurrent episodes treated with antidepressants plus mood stabilizers. Psychotherapy is added based on disorder type: supportive psychotherapy for adjustment disorder-depressive type, cognitive-behavioral therapy for major depressive disorder, and compliance enhancement therapy for bipolar disorders.

What are somatic symptom and related disorders, and what are the six DSM-5 clinical types?

These are clinical states featuring symptoms without demonstrable physical abnormality, where psychological factors initiate/maintain symptoms that are not under the patient's conscious control; medically unexplained symptoms account for up to 50% of new outpatient visits, and diagnosis is by exclusion. The six DSM-5 types: Somatic Symptom Disorder, Factitious Disorder, Illness Anxiety Disorder, Conversion Disorder, Psychological Factors Affecting Other Medical Conditions, and Other Specified Somatic Symptom and Related Disorder.

What are the diagnostic criteria and management strategies for Somatic Symptom Disorder?

Criteria: one or more distressing/disruptive somatic symptoms; excessive thoughts, feelings, or behaviors about the symptoms (disproportionate concern about seriousness, persistently high health anxiety, or excessive time/energy devoted to symptoms); and persistent symptomatic state, typically over 6 months. It's characterized by multiple somatic complaints requiring medical attention without an associated physical disorder, more common in women, typically unmarried, of lower socioeconomic status, from rural areas, with symptoms appearing during emotional distress. Management: handled by a primary care practitioner with regularly scheduled short visits every 4-6 weeks, a partial physical exam each visit, avoiding unnecessary diagnostic tests/procedures, looking for signs of disease rather than focusing on symptoms, and understanding symptoms as emotional communication rather than disease.

What are the diagnostic criteria and clinical features of Illness Anxiety Disorder?

Criteria: preoccupation with having/acquiring a serious illness; somatic symptoms absent or only mild (preoccupation is excessive/disproportionate even if a medical condition or strong family risk exists); high health anxiety with easy alarm; excessive health-related behaviors (repeated body checking) or maladaptive avoidance (avoiding doctors/hospitals); preoccupation present for 6+ months (though the specific feared illness may change); and not better explained by another mental disorder. Prevalence is 4-6% in medical settings, more common in late adolescence/adulthood (peak onset 20-30), affecting higher socioeconomic status, with common OCD comorbidity. Unlike somatization disorder (which focuses on symptoms), these patients focus on the feared disease itself; the condition is chronic with waxing/waning symptoms and is treated by a primary care practitioner.

What is Conversion Disorder, and what clinical tests help distinguish it from true neurological disease?

Criteria: one or more symptoms of altered voluntary motor or sensory function; clinical findings show incompatibility with recognized neurological/medical conditions; not better explained by another disorder; and causes significant distress/impairment or warrants medical evaluation. Differentiating tests: the rising-up test differentiates conversion paraparesis from true paraparesis; astasia-abasia is a staggering ataxic gait with thrashing upper limbs and inability to stand unsupported, yet the patient may be able to dance; pseudoseizures are paroxysmal seizure-like episodes of long duration with secondary gain but no true epileptic features on EEG, no self-harm, and no urinary incontinence; conversion sensory symptoms follow non-physiologic distributions (e.g., anesthesia of an entire limb); and hysterical blindness shows pupils that still react normally to light. Prognosis is good — about 90% recover function by hospital discharge — and treatment includes various psychotherapies, hypnosis, and anxiolytics.

What characterizes Psychological Factors Affecting Other Medical Conditions and Factitious Disorder (both types)?

Psychological Factors Affecting Other Medical Conditions: a genuine medical condition is present, and psychological/behavioral factors adversely affect it by influencing its course (temporally linked to onset/exacerbation/delayed recovery), interfering with treatment (poor adherence), constituting additional health risks, or influencing underlying pathophysiology — not better explained by another mental disorder. Factitious Disorder Imposed on Self: falsification of physical/psychological signs or symptoms, or self-induced injury/disease, with identified deception, presenting oneself as ill/impaired/injured even without obvious external reward. Factitious Disorder Imposed on Another (formerly "by proxy"): the same falsification/deception but directed at another person (the victim), with the perpetrator (not the victim) receiving the diagnosis.

What is "Other Specified Somatic Symptom and Related Disorder," and how are somatic symptom disorders differentiated from other conditions and treated?

This category applies to presentations with characteristic but subthreshold symptoms (1-8 unexplained symptoms, 30-100 times more prevalent than full-blown disorders), including brief somatic symptom disorder (<6 months), brief illness anxiety disorder (<6 months), illness anxiety disorder without excessive health behaviors, and pseudocyesis (false belief of pregnancy with objective signs); comorbidity with depression, anxiety, or personality disorder occurs in about 50% of patients, and treatment mirrors that of the full-blown disorders. Differential diagnosis must exclude: general medical conditions (somatoform disorders can mimic conditions like temporal lobe epilepsy, MS, myasthenia gravis, periodic paralysis, endocrine disorders, polymyositis, fibromyalgia — with true and functional disease coexisting in up to 50% of cases, e.g., seizures plus pseudoseizures); other psychiatric disorders (depression/anxiety commonly present with somatic complaints, differentiated by predominant mood symptoms); and malingering (consciously simulated symptoms for a clear external goal like financial compensation or avoiding duty). Treatment uses an integrated medical-psychiatric approach with cognitive-behavioral techniques and family therapy, and clinicians should convey empathic understanding since these patients genuinely suffer and are not "faking" their sympto