Mood Disorders

1
Mood Disorders

• Theodore M. Godlaski
• College of Social Work
• University of Kentucky

2
Clients by Primary and Secondary Diagnoses, NASW
PRN III Surveyn1836
www.socialworkers.org/PRN
3
NASW Practice Research Network, 2000 Survey, n
2000
4
http//www.socialworkers.org/naswprn/surveyTwo/Dat
agram4.pdf
5
Mood Disorders

• Major Depressive Episode
• Manic Episode
• Mixed Episode
• Hypomanic Episode
• Major Depressive Disorder
• Dysthymic Disorder
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Bipolar NOS
• Mood Disorder Due to General Medical Condition
• Substance-Induced Mood Disorder
• Mood Disorder NOS

6
Major Depressive Episode

• A. Five or more of the following SX present
  during the same 2 week period represent a
  change from previous functioning. AND at least
  one of the SX is either 1) depressed mood or 2)
  loss of interest or pleasure.
• 1.  depressed mood most of the day, nearly every
  day
• 2.   markedly diminished interest or pleasure in
  all or almost all activities nearly every day
• 3. significant weight loss when not dieting
• 4. insomnia or hypersomnia

7
(No Transcript)
8
Major Depressive Episode

• 5. psychomotor agitation or retardation
• 6. fatigue or loss of energy
• 7. feelings of worthlessness or excessive or
  inappropriate guilt
• 8. diminished ability to think, to concentrate,
  to make decisions
• 9. recurrent thoughts about death
• B. The SX do not meet criteria for a Mixed
  Episode
• C. The SX cause clinically significant distress
  or impairment in social, occupational, or other
  areas of functioning. 
• D. The SX are not due to physiological effects
  of a substance or general medical condition. 
• E. The SX are not better accounted for by
  Bereavement (SX continue longer than 2 months,
  etc)

9
Major Depressive Disorder

• Characterized by one or more major depressive
  episodes without a manic or hypomanic episode.
• With multiple episodes, must be at least 2 months
  between.
• Can be mild, moderate, severe without psychotic
  features, severe with psychotic features (either
  mood congruent or mood incongruent).
• The actual diagnosis for an episode is Major
  Depressive Disorder, Single Episode. For two or
  more episodes it is Major Depressive Disorder,
  Multiple Episodes.

10
Major Depressive Disorder

• 15 of those with HX of MDD die by suicide.
• Lifetime risk in women is 25
• Lifetime risk for men is 12
• 60 of those with MDD may experience complete end
  of the disorder after TX. Other data suggests
  that among those who do not meet MDD criteria,
  20 have depressive SX, just not the full
  disorder.
• Untreated episodes last 6 to 13 months.

11
Major Depressive Disorder

• 40 still have SX one year later. Other studies
  suggest that 50 60 have a recurrence of MDD
  within two years (even with aggressive TX).
• Individuals with one episode have a 50 chance of
  a second, after the second, chances for a third
  increase to 70, a third episode increases the
  chances of subsequent episodes to 90.
• There is a high degree of co-occurrence with
  alcohol abuse and dependence.

12
Major Depressive Disorder

• Men are more likely than women to experience a
  chronically impaired course.
• The course is often chronic with multiple
  relapses
• Cessation of medication in 3 months or less
  almost always leads to reemergence of symptoms.

13
Dysthymic Disorder

• A. Depressed mood for most of the day, for more
  days than not as indicated by subjective account
  or observation by others for at least 2 years.
• B. Presence, while depressed of 2 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

14
Dysthymic Disorder

• C. During the 2-year period (1 year for children
  or adolescents) of the disturbance, the person
  has never been without the SXs above for more
  than 2 months at a time.
• D. No MDE has been present during the first 2
  years of the disturbance (1 year for children and
  adolescents) i.e., it is not better accounted
  for by chronic MDD
• E. No Manic, Mixed, or Hypomanic episodes ever
  (has not met criteria for Cyclothymic Disorder

15
Dysthymic Disorder

• F. The disturbance does not occur exclusively
  during a chronic Psychotic Disorder.
• G. Not due to substance use, medication, or
  medical disorder.
• H. Symptoms are clinically significant and cause
  significant impairment or distress.
• You can specify Early Onset if onset before age
  21, or Late Onset if after 21.

16
Dysthymic Disorder

• Effects 5 to 6 overall and 30 to 50 of
  samples from psychiatric clinics.
• Often comorbid with MDD, anxiety disorder, BPD,
  and substance use disorders.
• 15 to 20 symptom free after 1 year of Dx.
• Only 25 do not obtain complete recovery over
  time.

17
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, 3 or
  more of the following have persisted (4 if the
  mood is only irritable) and have been present to
  a significant degree

18
Manic Episode

• 1. Inflated self-esteem or grandiosity
• 2. Decreased need for sleep (e.g., 3 hours)
• 3. More talkative than usual pressure of speech
  
• 4. Flight of ideas or subjective belief that
  ideas are racing
• 5. Distractibility
• 6. Increase in goal-directed activity
• 7. Excessive involvement in pleasurable
  activities that have high likelihood of negative
  consequences

19
Manic Episode

• C. The SX do not meet criteria for Mixed Episode
• D. The mood disturbance is severe enough to cause
  marked impairment, risk of harm, or requires
  hospitalization
• E. The SX are not due to a general medical
  condition or use of a substance

20
Mixed Episode

• A. The criteria are met both for a Manic Episode
  and MDE (except for duration) nearly every day
  during at least a 1-week period.
• B. The mood disturbance is sufficiently severe
  to cause marked impairment in occupational or
  usual social activities or relationships or to
  necessitate hospitalization to prevent harm to
  self or there are psychotic features.
• C. The symptoms are not due to the direct
  physiological effects of a substance or general
  medical condition.

21
Hypomanic Episode

• A. A distinct period of persistently elevated,
  expansive, or irritable mood, lasting at least 4
  days that is clearly different from the
  non-depressed mood.
• B. During the period of mood disturbance, 3 or
  more of the following SXs have persisted (4 if
  the mood is irritable) and have been present to a
  significant degree

22
Hypomanic Episode

• 1. Inflated self-esteem or grandiosity
• 2. Decreased need for sleep (3 hours)
• 3. More talkative than usual pressure of speech
• 4. Flight of ideas
• 5. Distractibility
• 6. Increase in goal-directed activity
• 7. Excessive pursuit of pleasurable activities

23
Hypomanic Episode

• C. The episode is associated with an unequivocal
  change in functioning that is uncharacteristic of
  the person when not symptomatic.
• D. The disturbance in mood and the change in
  functioning are observable by others.
• E. The episode is Not severe enough to cause
  marked impairment in social or occupational
  functioning or to necessitate hospitalization and
  there are not psychotic features.
• F. The SXs are not due to the effects of a
  substance or a general medical condition.

24
Bipolar Disorder I

• Presence of Manic Episodes (can alternate with
  Hypomanic Episodes) and MDE.
• Most often begins with depressive episode 67
  for men, 75 for women.
• About 10 - 20 of individuals experience only
  manic episodes.
• Untreated, manic episodes last about 3 months.
• Eventual interval between manic episodes is 6 9
  months, some experience 4 to 6 per year and are
  termed rapid cycling.

25
Bipolar Disorder I

• Can be single episode or recurrent
• Recurrent comes in 5 types
• Most recent episode hypomanic
• Most recent episode manic
• Most recent episode mixed
• Most recent episode depressed
• Most recent episode unspecified
• About 10 to 15 of individuals with recurrent
  depressive episodes will eventually have a manic
  episode.

26
Bipolar Disorder II

• A. Presence of one or more MDEs.
• B. Presence of at least one Hypomanic Episode.
• C. There has never been a Manic Episode.
• D. The mood disorder in A and B above are not
  better accounted for by Schizoaffective Disorder
  and are not superimposed on any psychotic
  disorder.
• E. The Sx,s cause clinically significant distress
  or impairment in social, occupational, or other
  areas.

27
Seasonal Fluctuation

• As with Light Sensitive Seasonal Affective
  Disorder, Bipolar Disorder appears to be seasonal
  in a significant number of cases.
• Recent research has indicated that it may show
  more seasonal fluctuation that other mood
  disorders.

Shin, K., et al. (2005) Journal of Affective
Disorder. 86 19-25
28
Cyclothymic Disorder

• A. For at least 2 years (1 year in children and
  adolescents), the presence of numerous periods
  with hypomanic SXs and depressive SXs that do
  not meet the criteria for MDE.
• B. During the 2-year period, the person has not
  been without SXs for more than 2 months at a
  time.
• C. No MDE, Manic or Mixed Episodes during the
  first 2 years of the disturbance.

29
Cyclothymic Disorder

• D. The SXs in A and B above are not better
  accounted for by Schizoaffective Disorder and are
  not superimposed on a psychotic disorder.
• E. The SXs are not due to the direct
  physiological effects of a substance or a general
  medical condition.
• F. The SXs cause clinically significant distress
  or impairment in social, occupational, or other
  areas.

30
Cyclothymic Disorder

• If there are only hypomanic episodes without any
  symptoms of depression, the diagnosis should be
  Bipolar Disorder Not Otherwise Specified.
• There has been very little study of this
  disorder.
• Some clinicians maintain that Borderline
  Personality Disorder is actually a species of
  Cyclothymic Disorder.
• 10 of outpatients and 20 of inpatients with BPD
  have coexisting Cyclothymic Disorder.
• Female to male ratio is 3 to 2
• In 50 to 75 of cases onset is between 15 and 25
  years of age.

31
(No Transcript)
32
(No Transcript)
33
Mood Disorders in Children

• Most frequent symptoms of depression common to
  children and adolescents
• Suicidal ideation, depressed or irritable mood,
  insomnia, difficulty concentrating
• Symptoms most common in children
• Mood-congruent auditory hallucinations, somatic
  complaints, withdrawal and sad appearance, poor
  self-esteem
• Symptoms most common in adolescents
• Pervasive anhedonia, severe psychomotor
  retardation, delusions, sense of hopelessness

34
Mood Disorders in Children

• Suicide in children and adolescents
• Increased since 1950 from 2.5 to 11.2/100K
• Among 15 to 19 year olds 13.6/100K for males,
  3.6/100K for females.
• lt14 yrs. 50 attempts per 1 completion
• gt14 yrs. 15 attempts per 1 completion
• Most often involve Mood Disorder
• Often, but not always, related to chaotic and
  stressful family situations.

35
Mood Disorders of Specific Etiology

• Mood Disorder Due to a General Medical Condition
• Degenerative Neurological Illness
• Parkinsons Disease, Huntingtons Disease
• Cerebrovascular Disease
• Stroke
• Endocrine Conditions
• Hypo- and Hyperthyroidism
• Hypo- and Hyperadrenocorticism
• Autoimmune Conditions
• Lupus erythematosus
• Viral and Other Infections
• Hepatitis, mononucleosis, HIV
• Certain Cancers
• Carcinoma of the pancreas

36
Mood Disorder Due to a General Medical Condition

• A prominent and persistent disturbance in mood
  predominates, characterized by
• 1. Depressed mood or diminished pleasure
• 2. elevated, expansive, or irritable mood
• There is evidence from history, PE, or labs that
  the disturbance is a direct consequence of a
  general medical condition

37
Mood Disorder Due to a General Medical Condition

• The disturbance is not better accounted for by
  another mental disorder
• Adjustment Disorder with Depressed Mood in
  response to having a general medical condition
• The disturbance does not occur exlusively during
  delirium
• The symptoms cause clinically significant
  impairment or distress

38
Mood Disorders of Specific Etiology

• Substance Induced Mood Disorders
• Can be caused by intoxication, withdrawal, side
  effects of medication, or toxic effects of a
  variety of substances
• Is reserved for situations in which the mood
  symptoms are especially noteworthy.

39
Substance Induced Mood Disorders

• A prominent and persistent disturbance in mood
  predominates, characterized by
• 1. Depressed mood or diminished pleasure
• 2. elevated, expansive, or irritable mood
• There is evidence from history, PE, or labs that
  either
• 1. The symptoms above developed within a month
  after substance intoxication or withdrawal
• 2. Medication use is etiologically related to the
  disturbance

40
Substance Induced Mood Disorders

• The disturbance is not better accounted for by a
  mood disorder that is not substance induced.
• The disturbance precedes substance use
• The disturbance continue long after substance
  cessation
• The disturbance is in excess of what could be
  expected given the quantity and duration of
  substance use.
• The disturbance does not occur exclusively during
  delirium
• Cause clinically significant impairment or
  distress

41
Eating Disorders
42
Eating Disorders

• The hallmark of these disorders is a distorted
  perception of body image and an extreme fear of
  weight gain.
• These disorders are specific to the developed
  world, most specifically the US.
• They effect females far more often than males.

43
ANOREXIA NERVOSA

• Prevalence conservatively estimated at .5 to
  1.0 for Anorexia Nervosa - some place as high as
  4 for eating disorders as a whole
• Mean onset at age 17 with peaks at 14 and 18
• Gender distribution 90 of those with eating
  disorders are female

44
ANOREXIA NERVOSA

• Familial/genetic factors shows heritability,
  also associated in family histories with
  depression, OCD, ETOH abuse/dependence
• Endogenous opioids may play a role in denial and
  in the reported mental states associated with
  anorexia
• Mortality is 5 to 18 during the condition
• Even among those who recover, the path is not
  clear
• Damage to cognitive systems can result from
  malnutrition and malnourishment
• Susceptibility to other psychiatric conditions is
  increased

45
ANOREXIA NERVOSA CRITERIA

• A. Refusal to maintain body weight at or above
  a minimally normal weight for age height a
  weight less than 85 of that expected or
  failure to make weight gain during period of
  growth resulting in less than 85 of that
  expected.
• (wt. in kg/height in m2 lt17.5 kg/m2)
• B. Intense fear of gaining weight or becoming
  fat even though under weight.

46

• C. Disturbance in the way in which ones body
  weight or shape is experienced, undue influence
  of body weight or shape on self-evaluation, or
  denial of the seriousness of the current low body
  weight.
• D. In postmenarcheal females, amenorrhea for 3
  consecutive cycles

47

• Restricting Type has not done binge eating or
  purging
• Controls weight through strict dieting or fasting
  and exercise
• Tends to have compulsive personality
  characteristic, is rigid, inflexible, and adheres
  strictly to rules and is morally scrupulous.
• Binge-Eating/Purging Type
• during the episode of Anorexia, regularly binged
  or purged or both, or used laxatives, diuretics,
  or enemas.
• More likely to engage in impulsive behaviors and
  substance abuse

48
BULIMIA NERVOSA

• Prevalence is 1-3 among adolescent females,
  .1-.3 among adolescent males
• Familial pattern same as anorexia some
  indication of association with obesity, but not
  definitively known yet.

49
BULIMIA NERVOSA CRITERIA

• A. Recurrent episodes of binge eating
  characterized by both of the following
• (1) eating, in a discrete period of time (e.g., 2
  hours) an amount of food that is definitely
  larger than most people would eat during a
  similar period under same circumstances.
• (2) a sense of lack of control over eating during
  the episode (e.g., a feeling that one cannot stop
  eating or control what or how much one is eating.

50

• B. Recurrent inappropriate compensatory behavior
  in order to prevent weight gain, such as
  self-induced vomiting, misuse of laxatives,
  diuretics enemas or other medications, fasting or
  exercise.
• C. The binge eating and inappropriate
  compensatory behaviors both occur, on average, at
  least twice a week for 3 months.

51

• D. Self-evaluation is unduly influenced by body
  weight and shape.
• E. The disturbance does not occur exclusively
  during and episode of anorexia.
• PURGING TYPE during the current episode, has
  regularly engaged in self-induced vomiting or
  misuse of laxatives, diuretics or enemas.
• NONPURGING TYPE during the episode has used
  other inappropriate compensatory behaviors such
  as fasting, excessive exercise, but has not
  purged.

52
Sub Typing of Bulimia

• Based on 178 bulimic women with comorbid
  psychopathology (depression, anxiety, substance
  use, impulsivity, self-destructive behavior, and
  perfectionism).
• Affective-Perfectionistic Cluster
• Most severe level of symptoms and preoccupation
  with body shape and weight.
• Impulsive Cluster
• Highest level of dissocial behavior and lowest
  levels of compulsivity.
• Low Comorbid Cluster
• Most numerous, lowest levels of all pathologies.

Wonderlich, S., et al. (2005) Psychological
Medicine, 25 649-657