Mood disorders - Clinical Features & Diagnosis
mood:
normal moods:
sadness & joy
elation
mood disorders:
see also:
NB. the following are mainly derived from DSM IV criteria.
affect is communicated through facial expression, vocal inflection, gestures, and posture and (according to current ethological research) is intended to move human beings and other primates to appraise whether a person is satisfied, distressed, disgusted, or in danger. Thus joy, sadness, anger, and fear are basic affects that serve a communicative function in primates as well as many other mammalian species.
Affects tend to be short-lived expressions, reflecting momentary emotional contingencies.
moods convey sustained emotions; their more-enduring nature means that they are experienced long enough to be felt inwardly.
moods are also manifested in subtle ways, and their accurate assessment often requires empathic understanding by the interviewer.
the words that subjects use to describe their inner emotions may or may not coincide with the technical terms used by researchers or clinicians and often vary from one culture to another.
furthermore, the inward emotion and the prevailing affective tone may be discordant. This conflict could be due to deliberate simulation (i.e., the subject does not wish to reveal his or her inner emotion) or it could result from a pathological lesion or process that has altered the emotions and their neural substrates. Thus, evaluating moods and affective expression requires considerable clinical experience.
normal moods:
Sadness and Joy:
the normal emotions of sadness and joy are part of everyday life and should be differentiated from major depressive disorder and mania.
sadness, or normal depression, is a universal human response to defeat, disappointment, or other adversities. The response may be adaptive, in an evolutionary sense, by permitting withdrawal to conserve inner resources, or it might signal the need for support from significant others.
transient depressive periods also occur as reactions to certain holidays or anniversaries, as well as during the premenstrual phase and the first week postpartum. Termed, respectively, “holiday blues,” “anniversary reactions,” “premenstrual tension disorder” and “maternity blues,” they are not psychopathological per se, but those predisposed to mood disorder may develop clinical depression during such times.
normal bereavement or grief, considered the prototype of reactive depression, occurs in response to significant separations and losses such as death, divorce, romantic disappointment, leaving familiar environments, forced emigration, or civilian catastrophes.
in addition to depressed affect appropriate to the loss, bereavement reactions are characterized by the prominence of sympathetic arousal and restlessness, believed to represent (from an evolutionary perspective) physiological and behavioural mechanisms to facilitate the search for the lost object.
like other adversities, bereavement and loss do not generally seem to cause depressive disorder, except in those predisposed to mood disorder.
Elation:
the positive emotion of elation is popularly linked to success and achievement.
however, paradoxical depressions may also follow such positive events, possibly because of the increased responsibilities that often have to be faced alone.
elation is conceptualized psychodynamically as a defense against depression or as a denial of the pain of loss, as exemplified by the so-called maniacal grief, a rare form of bereavement reaction in which elated hyperactivity may replace the expected grief.
introduction:
a mediating factor between normal and pathological moods is temperament.
most persons have a characteristic pattern of basal affective oscillations that defines their temperament. For instance, some are easily moved to tears by sad or happy circumstances, whereas others tend to remain placid.
normally oscillations in affective tone are relatively minor, tend to resonate with day-to-day events, and do not interfere with functioning.
some exhibit greater variability of emotional responses whereby, with no obvious provocation, the person alternates between normal mood and sadness or elation, or both.
an examination of the traits associated with these temperaments can provide the rationale for Ernst Kretschmer's hypothesis about the social functions they served.
the danger with such temperaments is that they could swing too far in one or the other direction, or in both directions (i.e., major depressive, manic, or mixed episodes). Use of such substances as alcohol, caffeine, and other stimulants might further destabilize affective regulation in persons with those attributes.
temperaments tend to cluster into basic types, four of which are of the greatest relevance to mood disorders.
the person easily swings into the sad direction
occurs in 3 to 6 percent of the general population
gloomy, incapable of fun, complaining
humourless
pessimistic & given to brooding
guilt-prone, low self-esteem & preoccupied with inadequacy or failure
introverted with restricted social life
sluggish, living a life out of action
few but constant interests
passive
reliable, dependable & devoted
hard working, dependable, and suitable for jobs that require long periods of devotion to meticulous detail
shoulder the burdens of existence without experiencing its pleasures
the person is naturally inclined toward cheerful moods
reported in 4 to 8 percent of population
cheerful & exuberant
articulate & jocular
over-optimistic & carefree
over-confident, self-assured, boastful & grandiose
extroverted & people-seeking
high energy level, full of plans
versatile with broad interests
over-involved & meddlesome
uninhibited & stimulus seeking
may assume leadership positions in society or excel in the performing arts or entertainment
swinging between cheerful and sad moods
characterizes 4 to 6 percent of young adults
in talented persons, could provide the inspiration and the intensity needed for composing music, painting, or writing poetry
irritable-explosive temperament:
occurs in 2 to 3 percent of young subjects and tends to attenuate by middle age
might be best suited for a military career or even revolutionary action
some adolescent girls with the irritable temperament might develop the extreme emotional disequilibrium that in contemporary psychiatry is considered borderline personality disorder.
5 or more of the following symptoms present during same 2 week period & represent a change from previous functioning. At least 1 is either depressed mood or loss of interest or pleasure. Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
depressed mood most of the day, nearly every day (eg. feels sad or empty or appears tearful or in adolescents irritable mood)
markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
significant weight loss when not dieting or weight gain (eg. 5% change in body weight in 1 month)
insomnia or hypersomnia nearly every day
psychomotor agitation or retardation nearly every day that is observable by others
fatigue or loss of energy nearly every day
feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
diminished ability to think or concentrate, or indecisiveness, nearly every day
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
symptoms do not meet criteria for mixed episode
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
symptoms are not better accounted for by bereavement, such that if after the loss of a loved one, symptoms either:
persist for longer than 2 months
are characterised by either:
marked functional impairment
morbid preoccupation with worthlessness
suicidal ideation
psychotic symptoms
psychomotor retardation
possible disorders causing this type of episode:
no PH of manic episode, a mixed episode, or a hypomanic episode then:
full criteria met => major depressive disorder
only 2-4 symptoms in criteria met => minor depressive disorder
duration only 2 - 13 days, but occurring at least monthly for 1yr & not menstrual-related => recurrent brief depressive disorder
generally depressed mood most days for > 2yrs & no symptom-free interval > 2 months => dysthymic disorder
PH of manic episode => bipolar I disorder
no PH of manic episode, but PH of hypomanic episode:
full criteria met for major depressive episode => bipolar II disorder
> 2yrs of intermittent hypomania & depressive phases & no no symptom-free interval > 2 months => cyclothymic disorder
a distinct period of abnormally & persistently elevated, expansive, or irritable mood, lasting at least 1 wk (or any duration if hospitalisation necessary)
during the period of mood disturbance, 3 or more of the following symptoms have persisted (4 if mood is only irritable) & have been present to a significant degree:
inflated self-esteem or grandiosity
decreased need for sleep (eg. feels rested after only 3hrs sleep)
more talkative than usual or pressure to keep talking
flight of ideas or subjective experience that thoughts are racing
distractability (ie. attention drawn to easily to unimportant or irrelevant external stimuli)
increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
excessive involvement in pleasurable activities that have a high potential for painful consequences (eg. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
symptoms do not meet criteria for mixed episode
the mood disturbance is sufficiently severe to either:
cause marked impairment in social, occupational, or other important areas of functioning
necessitate hospitalisation to prevent harm to self or others
cause psychotic features
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
NB. manic-like episodes that are clearly caused by somatic antidepressant Rx (eg. drugs, ECT) should not count toward a diagnosis of bipolar I disorder
possible disorders causing this type of episode:
full criteria met for manic episode => bipolar I disorder
too brief:
very rapid alternation with major depressive episode over days => bipolar disorder NEC
criteria met for both manic & major depressive nearly every day for at least 1wk => mixed episode => bipolar I with mixed
a distinct period of abnormally & persistently elevated, expansive, or irritable mood, lasting at least 4 days, that is clearly different from the usual non-depressed mood
symptoms as for manic episode
episode is associated with unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
disturbance in mood & change in functioning are observable by others
episode is NOT severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, and there are no psychotic features
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
NB. hypomanic-like episodes that are clearly caused by somatic antidepressant Rx (eg. drugs, ECT) should not count toward a diagnosis of bipolar I disorder
possible disorders causing this type of episode:
no PH of manic episode:
PH full criteria met for major depressive episode => bipolar II disorder
> 2yrs of intermittent hypomania & depressive phases & no no symptom-free interval > 2 months => cyclothymic disorder
no PH of depressive episodes but recurrent hypomania => bipolar disorder NEC
PH of manic episode => bipolar I disorder
criteria are met for both a manic episode & for a major depressive episode (except for duration) nearly every day during at least a 1 week period
the mood disturbance is sufficiently severe to either:
cause marked impairment in social, occupational, or other important areas of functioning
necessitate hospitalisation to prevent harm to self or others
cause psychotic features
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
NB. mixed-like episodes that are clearly caused by somatic antidepressant Rx (eg. drugs, ECT) should not count toward a diagnosis of bipolar I disorder
possible disorders causing this type of episode:
bipolar I disorder with mixed specifier
subtypes:
single major depression episode disorder
recurrent disorder:
presence of 2 or more major depression episodes with at least 2 months interval between them where criteria are not met for major depression episode
major depression episodes are:
not better accounted for by schizoaffective disorder
not superimposed on either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
there has never been a manic episode, a mixed episode, or a hypomanic episode
can further specify:
severity/psychotic/remission specifiers
chronic
with catatonic features
with melancholic features
with atypical features
with postpartum onset
longitudinal course specifiers
with seasonal pattern
a mood disturbance with only 2-4 symptoms in same 2 week period as for major depression episode
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
symptoms are not better accounted for by bereavement
there has never been a major depression episode, and criteria is not met for dysthymic disorder
there has never been a manic episode, a mixed episode, or a hypomanic episode and criteria is not met for cyclothymic disorder (this exclusion does not apply if such episodes are substance or Rx induced)
mood disturbance does not occur exclusively during either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
schizoaffective disorder
Recurrent brief depressive disorder:
criteria, except for duration, are met for a major depression episode
the depressive periods last at least 2 days but less than 2wks
the depressive periods occur at least once a month for 12 consecutive months & are not associated with the menstrual cycle
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
there has never been a manic episode, a mixed episode, or a hypomanic episode and criteria is not met for cyclothymic disorder (this exclusion does not apply if such episodes are substance or Rx induced)
mood disturbance does not occur exclusively during either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
schizoaffective disorder
dysthymic disorder is distinguished from chronic depressive disorder by the fact that it is not a sequel to well-defined major depressive episodes. Instead, in the most typical cases, patients complain that they have always been depressed. Thus, most cases are of early onset, beginning in childhood or adolescence and certainly by the time patients reach their 20s.
depressed mood for most of day, for more days than not, as indicated by subjective or observation for at least 2 years (in children or adolescents mood can be irritable & duration must be at least 1yr)
presence while depressed of at least 2:
poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficulty making decisions
feelings of hopelessness
during the symptom duration period, the person has never been without symptoms for more than 2mths at a time
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
no major depression episode during the initial symptom duration period (2yrs for adults, 1 yr for younger) and if one did occur prior, then at least 2 months in full remission must separate them
there has never been a manic episode, a mixed episode, or a hypomanic episode and criteria is not met for cyclothymic disorder (this exclusion does not apply if such episodes are substance or Rx induced)
mood disturbance does not occur exclusively during either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
schizoaffective disorder
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hypothyroidism)
for at 2 yrs (1yr for children, adolescents), the presence of numerous periods of hypomanic symptoms & numerous episodes of depressive symptoms that do not meet criteria for a major depression episode
during this symptom interval, person has not been without symptoms for more than 2 months at a time
there has never been a manic episode, a mixed episode, or a major depression episode in the initial symptom interval although these can occur after this interval in which case a bipolar I and cyclothymic disorder may be diagnosed
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
mood disturbance does not occur exclusively during either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
schizoaffective disorder
symptoms are not due to direct physiological effects of a substance or a general medical condition (eg. hyperthyroidism)
history of a manic episode with or without a major depression episode
manic episode:
not better accounted for by schizoaffective disorder
not superimposed on either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
specify:
mixed (see mixed episode)
severity/psychotic/remission specifiers
with catatonic features
with portpartum onset
history of at least 1 hypomanic episode and at least 1 major depression episode BUT never has been a manic episode
mood symptoms:
not better accounted for by schizoaffective disorder
not superimposed on either:
schizophrenia
schizophreniform disorder
delusional disorder
psychotic disorder NEC
symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
specify:
most recent episode: hypomanic/depressed
severity/psychotic/remission specifiers
chronic
with catatonic features
with melancholic features
with atypical features
with postpartum onset
longitudinal course specifiers
seasonal pattern (applies to pattern of major depressive episodes only)
with rapid cycling:
at least 4 episodes of mood disturbance in 12 mths where each episode is demarcated by partial or full remission for at least 2 months or switch to episode of opposite polarity
examples include:
very rapid alternation (over days) b/n manic symptoms & depressive symptoms that do not meet minimal duration criteria for a manic episode or major depressive episode
recurrent hypomanic episodes without intercurrent depressive symptoms
a manic or mixed episode superimposed on delusional disorder, residual schizophrenia or psychotic disorder NEC
situations in which the clinician has concluded that a bipolar disorder is present but is unable to determine whether it is primary, due to a general medical condition or substance induced