Mood Disorders



Mood Disorders





I. Introduction

Mood is a pervasive and sustained feeling tone that is experienced internally and that influences a person’s behavior and perception of the world. Affect is the external expression of mood. Mood can be normal, elevated, or depressed. Healthy persons experience a wide range of moods and have an equally large repertoire of affective expressions; they feel in control of their moods and affects.

Mood disorders encompass a large spectrum of disorders in which pathological mood disturbances dominate the clinical picture. They include the following 7 disorders:



  • Major depressive disorders


  • Bipolar disorders (types I and II)


  • Dysthymic disorder


  • Cyclothymic disorder


  • Mood disorders due to a general medical condition


  • Substance-induced mood disorder


  • The general category of depressive and bipolar disorders not otherwise specified.


II. Epidemiology


A. Incidence and prevalence.

Mood disorders are common. In the most recent surveys, major depressive disorder has the highest lifetime prevalence (almost 17%) of any psychiatric disorder. The annual incidence (number of new cases) of a major depressive episode is 1.59% (women, 1.89%; men, 1.10%). The annual incidence of bipolar illness is less than 1%, but it is difficult to estimate because milder forms of bipolar disorder are often missed (Table 14-1).


B. Sex.

Major depression is more common in women; bipolar I disorder is equal in women and men. Manic episodes are more common in women, and depressive episodes are more common in men.


C. Age.

The age of onset for bipolar I disorder is usually about age 30. However, the disorder also occurs in young children, as well as older adults.


D. Sociocultural.

Depressive disorders are more common among single and divorced persons compared to married persons. No correlation with socioeconomic status. No difference between races or religious groups.


III. Etiology


A. Neurotransmitters



  • Serotonin. Serotonin has become the biogenic amine neurotransmitter most commonly associated with depression. Serotonin depletion
    occurs in depression; thus, serotonergic agents are effective treatments. The identification of multiple serotonin receptor subtypes may lead to even more specific treatments for depression. Some patients with suicidal impulses have low cerebrospinal fluid (CSF) concentrations of serotonin metabolites (5-hydroxyindole acetic acid [5-HIAA]) and low concentrations of serotonin uptake sites on platelets. This may prove to be a marker for depression with a high risk of suicide.








    Table 14-1 Lifetime Prevalence of Some DSM-IV-TR Mood Disorders





































    Mood Disorder Lifetime Prevalence
    Depressive disorders  
       Major depressive disorder (MDD) 10%–25% for women; 5%–12% for men
          Recurrent, with full interepisode recovery, superimposed on dysthymic disorder Approximately 3% of persons with MDD
          Recurrent, without full interepisode recovery, superimposed on dysthymic disorder (double depression) Approximately 25% of persons with MDD
       Dysthymic disorder Approximately 6%
    Bipolar disorders  
       Bipolar I disorder 0.4%–1.6%
       Bipolar II disorder Approximately 0.5%
          Bipolar I disorder or bipolar II disorder, with rapid cycling 5%–15% of persons with bipolar disorder
    Cyclothymic disorder 0.4%–1.0%
    Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.


  • Norepinephrine. Abnormal levels (usually low) of norepinephrine metabolites (3-methoxy-4-hydroxyphenylglycol [MHPG]) are found in blood, urine, and CSF of depressed patients. Venlafaxine (Effexor) increases both serotonin and norepinephrine levels and is used in depression for that reason.


  • Dopamine. Dopamine activity may be reduced in depression and increased in mania. Drugs that reduce dopamine concentrations (e.g., reserpine [Serpasil]) and diseases that reduce dopamine concentrations (e.g., Parkinson’s disease) are associated with depressive symptoms. Drugs that increase dopamine concentrations, such as tyrosine, amphetamine, and bupropion (Wellbutrin), reduce the symptoms of depression. Two recent theories about dopamine and depression are that the mesolimbic dopamine pathway may be dysfunctional in depression and that the dopamine D1 receptor may be hypoactive in depression.


B. Psychosocial



  • Psychoanalytic. Freud described internalized ambivalence toward a love object (person), which can produce a pathological form of mourning if the object is lost or perceived as lost. This mourning takes the form of severe depression with feelings of guilt, worthlessness, and suicidal ideation. Symbolic or real loss of love object is perceived as rejection. Mania and elation are viewed as defense against underlying
    depression. Rigid superego serves to punish a person with feelings of guilt about unconscious sexual or aggressive impulses. Suicide has been called “inverted homicide.”


  • Psychodynamics. In depression, introjection of ambivalently viewed lost objects leads to an inner sense of conflict, guilt, rage, pain, and loathing; a pathological mourning becomes depression as ambivalent feelings meant for the introjected object are directed at the self. In mania, feelings of inadequacy and worthlessness are converted by means of denial, reaction formation, and projection to grandiose delusions.


  • Cognitive. Cognitive triad of Aaron Beck: (1) negative self-view (“things are bad because I’m bad”), (2) negative interpretation of experience (“everything has always been bad”), and (3) negative view of future (anticipation of failure). Challenging these cognitive schemas can improve mood.


  • Learned helplessness. A theory that attributes depression to a person’s inability to control events. Theory is derived from observed behavior of animals experimentally given unexpected random shocks from which they cannot escape.


  • Stressful life events. Often precede first episodes of mood disorders. Such events may cause permanent neuronal changes that predispose a person to subsequent episodes of a mood disorder. Losing a parent before age 11 is the life event most associated with later development of depression.


IV. Laboratory, Brain Imaging, and Psychological Tests


A. Dexamethasone suppression test.

Nonsuppression (positive test result) represents hypersecretion of cortisol secondary to hyperactivity of hypothalamic–pituitary–adrenal axis. Abnormal in 50% of patients with major depression. Of limited clinical usefulness owing to frequency of false-positive and false-negative results. Diminished release of TSH in response to thyrotropin-releasing hormone (TRH) reported in both depression and mania. Prolactin release decreased in response to tryptophan. Tests are not definitive.


B. Brain imaging.

No gross brain changes. Enlarged cerebral ventricles on computed tomography (CT) in some patients with mania or psychotic depression; diminished basal ganglia blood flow in some depressive patients. Magnetic resonance imaging (MRI) studies have also indicated that patients with major depressive disorder have smaller caudate nuclei and smaller frontal lobes than do control subjects. Magnetic resonance spectroscopy (MRS) studies of patients with bipolar I disorder have produced data consistent with the hypothesis that the pathophysiology of the disorder may involve an abnormal regulation of membrane phospholipid metabolism.


C. Psychological tests



  • Rating scales. Can be used to assist in diagnosis and assessment of treatment efficacy. The Beck Depression Inventory (BDI) and Zung
    Self-rating Scale are scored by patients. The Hamilton Rating Scale for Depression (HAM-D), Montgomery Asberg Depression Rating Scale (MADRS), and Young Manic Rating Scale are scored by the examiner.


  • Rorschach test. Standardized set of ten inkblots scored by examiner—few associations, slow response time in depression.


  • Thematic apperception test (TAT). Series of 30 pictures depicting ambiguous situations and interpersonal events. Patient creates a story about each scene. Depressives will create depressed stories, manics more grandiose and dramatic ones.


V. Bipolar Disorder

There are two types of bipolar disorder: bipolar I characterized by the occurrence of manic episodes with or without a major depressive episode and bipolar II characterized by at least one depressive episode with or without a hypomanic episode.



Clinical Hint

If there is a history of a single full-blown manic episode, the diagnosis will always be bipolar I; a history of a major depressive episode is always present in bipolar II.


A. Depression (major depressive episode).

See Table 14-2.



  • Information obtained from history



    • Depressed mood: subjective sense of sadness, feeling “blue” or “down in the dumps” for a prolonged period of time.


    • Anhedonia: inability to experience pleasure.


    • Social withdrawal.


    • Lack of motivation, little tolerance of frustration.


    • Vegetative signs.



      • Loss of libido.


      • Weight loss and anorexia.


      • Weight gain and hyperphagia.


      • Low energy level; fatigability.


      • Abnormal menses.


      • Early morning awakening (terminal insomnia); approximately 75% of depressed patients have sleep difficulties, either insomnia or hypersomnia.


      • Diurnal variation (symptoms worse in morning).


    • Constipation.


    • Dry mouth.


    • Headache.


  • Information obtained from mental status examination



    • General appearance and behavior: psychomotor retardation or agitation, poor eye contact, tearful, downcast, inattentive to personal appearance.









      Table 14-2 DSM-IV-TR Diagnostic Criteria for Major Depressive Episode








      1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
           Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.


        1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears fearful).
             Note: in children and adolescents, can be irritable mood
        2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
        3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
             Note: in children, consider failure to make expected weight gains
        4. insomnia or hypersomnia nearly every day
        5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
        6. fatigue or loss of energy nearly every day
        7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
        8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
        9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

      2. The symptoms do not meet criteria for a mixed episode.
      3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      4. The symptoms are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
      5. The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one), or the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
      From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.


    • Affect: constricted or labile.


    • Mood: depressed, irritable, frustrated, or sad.


    • Speech: little or no spontaneity; monosyllabic; long pauses; soft, low monotone.


    • Thought content: suicidal ideation affects 60% of depressed patients, and 15% commit suicide; obsessive rumination; pervasive feelings of hopelessness, worthlessness, and guilt; somatic preoccupation; indecisiveness; poverty of thought content and paucity of speech; mood-congruent hallucinations and delusions.


    • Cognition: distractible, difficulty concentrating, complaints of poor memory, apparent disorientation; abstract thought may be impaired.


    • Insight and judgment: impaired because of cognitive distortions of personal worthlessness.


  • Associated features



    • Somatic complaints may mask depression: in particular, cardiac, gastrointestinal, and genitourinary symptoms; low back pain and other orthopedic complaints.



    • Content of delusions and hallucinations, when present, tends to be congruent with depressed mood; most common are delusions of guilt, poverty, and deserved persecution, in addition to somatic and nihilistic (end of the world) delusions. Mood-incongruent delusions are those with content not apparently related to the predominant mood (e.g., delusions of thought insertion, broadcasting, and control, or persecutory delusions unrelated to depressive themes).


  • Age-specific features. Depression can present differently at different ages.



    • Prepubertal: somatic complaints, agitation, single-voice auditory hallucinations, anxiety disorders, and phobias.


    • Adolescence: substance abuse, antisocial behavior, restlessness, truancy, school difficulties, promiscuity, increased sensitivity to rejection, and poor hygiene.


    • Elderly: cognitive deficits (memory loss, disorientation, confusion); pseudodementia or the dementia syndrome of depression, apathy, and distractibility.


B. Mania (manic episode).

Persistent elevated expansive mood. See Table 14-3.



  • Information obtained from history



    • Erratic and disinhibited behavior.



      • Excessive spending or gambling.








        Table 14-3 DSM-IV-TR Diagnostic Criteria for Manic Episode










        1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
        2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:


          1. inflated self-esteem or grandiosity
          2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
          3. more talkative than usual or pressure to keep talking
          4. flight of ideas or subjective experience that thoughts are racing
          5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
          6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
          7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

        3. The symptoms do not meet criteria for a mixed episode.
        4. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
        5. The symptoms are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
        Note: Maniclike episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of bipolar I disorder.
        From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.



      • Impulsive travel.


      • Hypersexuality, promiscuity.


    • Overextended in activities and responsibilities.


    • Low frustration tolerance with irritability and outbursts of anger.


    • Vegetative signs.



      • Increased libido.


      • Weight loss, anorexia.


      • Insomnia (expressed as no need to sleep).


      • Excessive energy.


  • Information obtained from mental status examination



    • General appearance and behavior: psychomotor agitation; seductive, colorful clothing; excessive makeup; inattention to personal appearance or bizarre combinations of clothes; intrusive; entertaining; threatening; and hyperexcited.


    • Affect: labile, intense (may have rapid depressive shifts).


    • Mood: euphoric, expansive, irritable, demanding, and flirtatious.


    • Speech: pressured, loud, dramatic, exaggerated; may become incoherent.


    • Thought content: highly elevated self-esteem, grandiose, extremely egocentric; delusions and less frequently hallucinations (mood-congruent themes of inflated self-worth and power, most often grandiose and paranoid).


    • Thought process: flight of ideas (if severe, can lead to incoherence); racing thoughts, neologisms, clang associations, circumstantiality, tangentially.


    • Sensorium: highly distractible, difficulty concentrating; memory, if not too distracted, generally intact; abstract thinking generally intact.


    • Insight and judgment: extremely impaired; often total denial of illness and inability to make any organized or rational decisions.


C. Other types of bipolar disorders



  • Rapid-cycling bipolar disorder. Four or more depressive, manic, or mixed episodes within 12 months. Bipolar disorder with mixed or rapid-cycling episodes appears to be more chronic than bipolar disorder without alternating episodes.


  • Hypomania. Elevated mood associated with decreased need for sleep, hypoactivity, and hedonic pursuits. Less severe than mania with no psychotic features (see Table 14-4).


D. Depressive disorders



  • Major depressive disorder. Can occur alone or as part of bipolar disorder. When it occurs alone, it is also known as unipolar depression. Symptoms must be present for at least 2 weeks and represent a change from previous functioning. More common in women than in men by 2:1. Precipitating event occurs in at least 25% of patients. Diurnal variation, with symptoms worse early in the morning. Psychomotor retardation or agitation is present. Associated with vegetative signs. Mood-congruent
    delusions and hallucinations may be present. Median age of onset is 40 years, but can occur at any time. Genetic factor is present. Major depressive disorder may occur as a single episode in a person’s life or may be recurrent.








    Table 14-4 DSM-IV-TR Criteria for Hypomanic Episode








    1. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout 4 days, that is clearly different from the usual nondepressed mood.
    2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:


      1. inflated self-esteem or grandiosity
      2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
      3. more talkative than usual or pressure to keep talking
      4. flight of ideas or subjective experience that thoughts are racing
      5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
      6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
      7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

    3. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
    4. The disturbance in mood and the change in functioning are observable by others.
    5. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
    6. The symptoms are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
    From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.


  • Other types of major depressive disorder



    • Melancholic: severe and responsive to biological intervention. See Table 14-5.








      Table 14-5 DSM-IV-TR Diagnostic Criteria for Melancholic Features Specified










      Specify if:
         With melancholic features (can be applied to the current or most recent major depressive episode in major depressive disorder and to a major depressive episode in bipolar I or bipolar II disorder only if it is the most recent type of mood episode)


      1. Either of the following, occurring during the most severe period of the current episode:


        1. loss of pleasure in all, or almost all, activities
        2. lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens)

      2. Three (or more) of the following:


        1. distinct quality of depressed mood (i.e., the depressed mood is experienced as distinctly different from the kind of feeling experienced after the death of a loved one)
        2. depression regularly worse in the morning
        3. early morning awakening (at least 2 hours before usual time of awakening)
        4. marked psychomotor retardation or agitation
        5. significant anorexia or weight loss
        6. excessive or inappropriate guilt
      From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.



    • Chronic: present for at least 2 years; more common in elderly men, especially alcohol and substance abusers, and responds poorly to medications. Accounts for the condition of 10% to 15% of those with major depressive disorder. Can also occur as part of depression in bipolar I and II disorders.


    • Seasonal pattern: depression that develops with shortened daylight in winter and fall and disappears during spring and summer; also known as seasonal affective disorder. Characterized by hypersomnia, hyperphagia, and psychomotor slowing. Related to abnormal melatonin metabolism. Treated with exposure to bright, artificial light for 2 to 6 hours each day. May also occur as part of bipolar I and II disorders.


    • Postpartum onset: severe depression beginning within 4 weeks of giving birth. Most often occurs in women with underlying or pre-existing mood or other psychiatric disorder. Symptoms range from marked insomnia, lability, and fatigue to suicide. Homicidal and delusional beliefs about the baby may be present. Can be psychiatric emergency, with both mother and baby at risk. Also applies to manic or mixed episodes or to brief psychotic disorder (Chapter 13).


    • Atypical features: sometimes called hysterical dysphoria. Major depressive episode characterized by weight gain and hypersomnia, rather than weight loss and insomnia. More common in women than in men by 2:1 to 3:1. Common in major depressive disorder with seasonal pattern. May also occur as part of depression in bipolar I or II disorder and dysthymic disorder. (See Table 14-6.)


    • Catatonic: stuporous, blunted affect, extreme withdrawal, negativism, and psychomotor retardation with posturing and waxy flexibility. Responds to electroconvulsive therapy (ECT).

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on Mood Disorders

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