Mood Disorders
Patients with disorders of mood are common (3% to 5% of the population at any one time) and are seen by all medical specialists. It is essential to identify them and either treat or refer appropriately.
Two basic abnormalities of mood are recognized: depression and mania. Both occur on a continuum from normal to the clearly pathologic; symptoms in a few patients reach psychotic proportions. Although minor symptoms may be an extension of normal sadness or elation, more severe symptoms are associated with discrete syndromes (mood disorders), which appear to differ qualitatively from normal processes and which require specific therapies.
CLASSIFICATION
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has defined several different mood disorders that differ, among other things, in their clinical presentation, course, genetics, and treatment response. These conditions are distinguished from one another by (a) the presence or absence of mania (bipolar vs. unipolar), (b) the severity of the illness (major vs. minor), and (c) the role of medical or other psychiatric conditions in causing the disorder (1% vs. 2%).
MAJOR MOOD DISORDERS: Major depressive or manic signs and symptoms or both.
Bipolar I Disorder (Manic-Depression): Mania in past or present (with or without presence or history of depression). Major depression usually occurs sometime.
Bipolar II Disorder: Hypomania and major depression must be present or have been present sometime.
Major Depressive Disorder: Serious depression alone (unipolar).
OTHER SPECIFIC MOOD DISORDER: Minor depressive and/or manic signs and symptoms.
Dysthymic Disorder: Depression alone.
Cyclothymic Disorder: Depressive and hypomanic symptoms in the present or recent past (consistently over the past 2 years).
MOOD DISORDER DUE TO A GENERAL MEDICAL CONDITION and SUBSTANCE-INDUCED MOOD DISORDER: May be depressed, manic, or mixed; these are the second-degree mood disorders.
ADJUSTMENT DISORDER WITH DEPRESSED MOOD: Depression caused by stress.
The DSM-IV classification also requires the examiner to specify whether the current bipolar episode is manic, depressed, or mixed; whether the unipolar or bipolar disorder is a single episode or recurrent and/or shows psychotic features, catatonia, rapid cycling, complete clearing between episodes, a seasonal pattern, or a postpartum onset; and whether a major depressive episode is chronic (present at least 2 years), meets the criteria for melancholia [profound vegetative and cognitive symptoms including psychomotor retardation or agitation, sleep disturbance, anorexia or weight loss, and/or excessive guilt (see DSM-IV-TR, p. 419)], or is atypical [increased appetite, weight gain, hypersomnia, interpersonal rejection sensitivity, “leaden” feeling in limbs (see DSM-IV-TR, p. 420) (1)]. These characteristics “may” be important in determining treatment and prognosis.
CLINICAL PRESENTATION OF MOOD DISORDERS
Of the core clinical features common to affective disturbances, the Major Mood Disorders have the greater number and severity of symptoms and signs, whereas dysthymia and cyclothymia have fewer. The most common symptoms and signs of mood disorders are listed in Tables 4.1 and 4.2. A sufficient combination of these symptoms often clinches the diagnosis. However, particularly when the symptoms are mild, disorders of mood are frequently missed.
Although many depressed patients complain of depression, some do not. Moreover, other problems may obscure the diagnosis. Some patients have alcohol or drug abuse or acting-out behavior. Others, particularly early on, primarily demonstrate anxiety or agitation. Still others, instead of feeling sad, complain of fatigue, irritability, insomnia, dyspnea, tachycardia, and vague or chronic pains or both [usually gastrointestinal (GI), cardiac, headaches, or backaches, all unrelieved by analgesics] (2). People with such presentations (known as masked depressions) often have a personal or family history of depression and frequently respond to antidepressants.
Suspect depression in the unimproved patient who has atypical medical symptoms.
Suspect depression in the unimproved patient who has atypical medical symptoms.
Table 4.1 ▪ Symptoms of Depression | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Patients with mania often do not complain of their symptoms. A few feel too good and elated to complain; others feel agitated and unpleasant but fail to notice that their behavior is outrageous. Hypomanic patients can be irritable, or “full of life,” or both.
Patient rating scales can help determine the severity of a depression and can be used to measure change over time [e.g., the Beck Depression Inventory (21 questions, patient self-rates) and the Hamilton Rating Scale for Depression (17-21 questions, therapist rates)].
Table 4.2 ▪ Symptoms of Mania (When Nonpsychotic and Not Severe Enough to Impair Social or Occupational Functioning = Hypomania) | ||||||||||||||||||||||||||||||||||||||||||||
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NORMAL MOOD PROCESSES
Sadness or simple unhappiness affect us all from time to time. The cause is often obvious, the reaction understandable, and improvement follows the disappearance of the cause. However, prolonged unhappiness in response to a chronic stress may be indistinguishable from a minor affective disorder and require treatment. Support and improved life circumstances are the keys to recovery.
Grief or BEREAVEMENT (p. 740, V62.82) is a more profound sense of dysphoria that follows a severe loss or trauma and that may produce a full depressive syndrome, but, as time distances the precipitating event, the symptoms disappear. This process often takes weeks or months and requires a “working through,” which often includes disbelief, anger, intense mourning, and eventual resolution (see Chapter 10). Some bereavement grades into and, with time (e.g., longer than 2 months), becomes a major depressive disorder.
No generally accepted equivalent nonpathologic manic process is known, although some people do react to stress with hypomania.
MINOR MOOD DISORDERS
Depression
The common chronic nonpsychotic disorder of lowered mood or anhedonia or both is DYSTHYMIC DISORDER (p. 376, 300.4) (3). These patients feel depressed, have difficulty falling asleep, characteristically feel best in the morning and despondent in the afternoon and evening, and can display any of the nonpsychotic symptoms and signs of depression. Symptoms must have been present, at least intermittently, for 2 or more years. It is more common in women (W/M ratio, 2-3:1), often develops for the first time in the late 20s or 30s, has a lifetime prevalence of 6%, and begins insidiously, frequently in a person predisposed to depression by
major loss in childhood [e.g., of parent (maybe)]
recent loss (e.g., health, job, spouse).
chronic stress (e.g., medical disorder).
psychiatric susceptibility (e.g., personality disorders of histrionic, compulsive, and dependent types; alcohol and drug abuse; major depression in partial remission; obsessive-compulsive disorder).
It frequently coexists with these conditions.
It is similar to but less severe than a Major Depressive Disorder; however, 20%+ of patients who experience major depression will clear incompletely and have a chronic residue of Dysthymic Disorder (“double depression”). It tends to last for many years.
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