Mood (affective)
disorders
Jana Hořínková
Dept. of Psychiatry
Masaryk University Brno
MOOD DISORDERS
Main feature: mood change in sense of
decrease (depression) or elevation (mania)
Definition of mood: long-termed tendency
to emotional reaction of certain polarity
CHARACTERISTIC FEATURES OF
PATHIC MOODS
Intensity – significantly higher intensity than the
variation of normal mood
Duration – it lasts mostly for weeks, months, even
years
The mood is not influenced by exogenous stimuli.
Influence on other psychic function – e.g. thinking,
behaviour
ETHIOPATOGENESIS
There is impaired signal transmission in the
brain especially on the level of chemical
synapses – changes of serotoninergic and
noradrenergic systems; maybe also cholinergic,
GABA-ergic and dopamine systems.
ETHIOPATOGENESIS
Hypothesis Approaches Findings
Hereditary theory Genetics Heredity and vulnerability to mood
disorders
Dysregulatory theory Stress
Chronobiology
Increased biological sensitivity after
repeating of certain events.
Desynchronization biological rhytms.
Neurochemical theory Neuromediators
Receptors
Postreceptor processes
Availability, metabolism.
Number, afinity, sensitivity.
G-proteins, systems of second
messengers, phosphorylation and
dephosphorylation, transcription.
Imunoneuroendocrine
theory
Axis hypothalamus-
hypophysis-adrenal
cortex
Immune function
Increased activity in depression
Different changes in depression.
THE MOST IMPORTANT UNITS
Fundamental units Subtypes
Depressive episode Mild
Moderate
Severe without psychotic symptoms
Severe with psychotic symptoms
Recurrent depressive disorder Current episode mild
Current episode moderate
Current episode severe
Current epis. severe with psychot.sympt.
Manic episode Hypomania
Mania without psychotic symptomps
Mania with psychotic symptoms
Bipolar affective disorder Current episode manic
Current episode depressive
Current episode mixed
Persistent mood disorders Cyclothymia
Dysthymia
DEPRESSIVE EPISODE
It should last for at least 2 weeks
There have been no hypomanic or manic
symptoms sufficient to meet the criteria for
hypomanic or manic episode at any time in the
individual's life.
Most commonly used exclusion clause: the episode
is not attributable to psychoactive substance use or
to any organic mental disorder (in the sense of
F00-F09).
DEPRESSIVE EPISODE
Diagnostic criteria according to ICD-10
A) At least two of the following three symptoms
must be present:
1) depressed mood to a degree that is definitely
abnormal for the individual, present for most of the
day and almost every day, largely uninfluenced by
circumstances, and sustained for at least 2 weeks.
2) loss of interest or pleasure in activities that are
normally pleasant
3) decreased energy or increased fatigability.
DEPRESSIVE EPISODE
 B) An additional symptom or symptoms from the following list should be present,
to give a total of at least four:
1) loss of confidence and self-esteem;
2) unreasonable feelings of self-reproach or excessive and
inappropriate guilt;
3) recurrent thoughts of death or suicide, or any suicidal behaviour;
4) complaints or evidence of diminished ability to think or concentrate,
such as indecisiveness or vacillation;
5) change in psychomotor activity - agitation or retardation (either
subjective or objective);
6) sleep disturbance of any type;
7) change in appetite (decrease or increase with corresponding weight
change).
DEPRESSIVE EPISODE
 Classification of intensity
Mild Moderate Severe Severe with psychotic
symptoms
Number of
symptoms A
At least 2 At least 2 3 3
Number of
symptoms B
+
additional
+
additional
+additio
nal
+ additional
Total number of
symptoms
4 6 8 8
Other features + delusions or hallucinations
(mostly mood congruent )
or depressive stupor
- At least 1/3
DEPRESSION – PSYCHOTIC SYMPTOMS
 Delusions or hallucinations
 Other than those listed as typically schizophrenic (i.e.
delusions other than those that completely impossible or
culturally inappropriate and hallucinations that are not in
the third person or giving a running commentary).
 The most common examples are those with depressive,
guilty, hypochondriacal, nihilistic, self-referential, or
persecutory content..
PSYCHOTIC FORMS OF DEPRESSION
With mood-congruent psychotic symptoms:
i.e. delusions of guilt, worthlessness, bodily disease, or
impending disaster, derisive or condemnatory auditory
hallucinations.
With mood-incongruent psychotic symptoms:
i.e. persecutory or self-referential delusions and
hallucinations without an affective content.
RECURRENT DEPRESSIVE
DISORDER
Dg. criteria according to ICD-10:
1) There has been at least one previous depressive
episode, lasting a minimum of 2 weeks and separated
from the current episode by at least 2 months free
from any significant mood symptoms.
2) In the past there has not been hypomanic or manic
episode.
The episode is not attributable to psychoactive
substance use or any organic mental disorder.
RECURRENT DEPRESSIVE
DISORDER
Classification
Current
episode
Mild Moderate Severe without
psychotic
symptoms
Severe with
psychotic
symptoms
Diagnostics See mild
depressive
episode
See moderate
depressive episode
See severe
depressive episode
without psychotic
symptoms
See severe
depressive
episode with
psychotic
symptoms
RECURRENT DEPRESSIVE
DISORDER
Epidemiology:
Lifetime prevalence: 9-26% in women
5-12% in men
In women it occurs 2-3 times more frequently than
men.
The most frequent onset: between 25-35 years
Clinical psychiatry,
Praško, 2011
RECURRENT DEPRESSIVE
DISORDER
Course:
Mostly – periods of remission with a good functioning
12% chronic course of depression
After the first episode risk of further episode is 50%.
Increased risk of suicidal behaviour
Clinical psychiatry
Praško, 2011
RECURRENT DEPRESSIVE
DISORDER
Treatment:
Antidepressants (1.choice – SSRI)
Combination of antidepressants; augmentation with
antipsychotics
Other biological therapy: ECT (a brief electrical
stimulus is used to induce an artificial epileptiform
seizure under controlled condition )
Psychotherapy
MANIC EPISODE
Dg. criteria according to ICD-10:
A)
The mood is elevated or irritable to a degree
that is definitely abnormal for the individual
concerned and sustained for at least:
 four consecutive days in hypomania
 a week in mania
MANIC EPISODE
 B) At least three of the following must be present, leading to some (hypomania) to
severe interference (mania) with personal functioning in daily living:
1) increased activity or physical restlessness;
2) increased talkativeness („pressure of speech“);
3) difficulty in concentration or distractibility; (in mania constant changes
in activity or plans);
4) decreased need for sleep;
5) increased sexual energy;
 6) mild spending sprees, or other types of reckless or irresponsible
behaviour - markedly foolhardy or reckless behaviour ;
7) increased sociability - loss of normal social inhibitions;
8) flight of ideas or the subjective experience of thoughts racing;
9) inflated self-esteem or grandiosity
MANIC EPISODE
 Classification of intensity
Hypomania Mania Mania with psychotic
symptoms
Symptom A must be present must be present must be present
Number of
symptoms B
At least 3 (items 1-
7) - some
interference with
personal functioning
in daily living
At least 3 (items 1-
9) - severe
interference with
personal functioning
in daily living
At least 3 (items 1-9)
- severe interference with
personal functioning in daily
living
Duration At least 4 days At least a week At least a week
Other features + delusions or hallucinations
(mostly mood congruent )
MANIA - PSYCHOTIC SYMPTOMS
Delusions and hallucinations
other than those listed as typical schizophrenic, i.e.
delusions other than those that are completely
impossible or culturally inappropriate and
hallucinations, that are not in the third person or
giving a running commentary.
The most common examples are those with
grandiose, erotic or persecutory content.
PSYCHOTIC FORMS OF MANIA
Mania with mood congruent psychotic
symptoms: such as grandiose delusions or voices
telling the subject that he has superhuman powers.
Mania with mood incongruent psychotic
symptoms: such as voices speaking to the subject
about affectively neutral topics, or delusions of
reference or persecution.
MANIC EPISODE
Epidemiology
Lifetime prevalence is about 1 %.
Course:
The most frequent onset: between 20.-35. years.
MANIC EPISODE
Treatment
Mood stabilizers (antimanic effect )
Antipsychotics (atypical)
Hypomania can be treated in outpatient
setting, patients with mania and psychotic
mania should be hospitalized.
BIPOLAR AFFECTIVE DISORDER (BAD)
Episodes are demarcated by a switch to an episode of
opposite or mixed polarity or by a remission.
In the past there was presented at least two episodes of
opposite polarity (depressive and manic or 2 manic
episodes).
Mood disorder, in which patient has had at least one
hypomanic, manic or mixed episode and any number of
other hypomanic, manic, depressive or mixed episodes.
Episodes are separated by different long remissions.
BIPOLAR AFFECTIVE DISORDER
BAD, current episode hypomanic
BAD, current episode manic
- without psychotic symptoms
- with psychotic symptoms
BAD, current episode mild or moderate depression
BAD, current episode severe depression
- without psychotic symptoms
- with psychotic symptoms
BAP, current episode mixed
BIPOLAR AFFECTIVE DISORDER
Mixed episode:
 A mixture of hypomanic, manic and
depressive symptoms …
 … or a rapid alternation of these symptoms
(i.e. within a few hours)
BIPOLAR AFFECTIVE DISORDER
Epidemiology:
Lifetime prevalence: 4 %
The most frequent onset: mostly 15-30 years
Clinical psychiatry
Praško, 2011
BIPOLAR AFFECTIVE DISORDER
Course:
Lifelong disorder with recurrent episodes.
1-2 depressive episodes often come before
the first manic episode.
Clinical psychiatry,
Praško, 2011
BIPOLAR AFFECTIVE DISORDER
Treatment:
Acute phase of treatment:
- treatment of acute episode symptoms,
therapy with mood stabilizers.
Maintenance (prophylactic) phase of treatment:
- prevention of relapses; mood stabilizers
Other treatment option:
- ECT, psychotherapy
PERSISTENT MOOD DISORDERS
Definition:
Persistent and usually fluctuating disorders of mood in
which the majority of the individual episodes are not
sufficiently severe to warrant being described as manic
or mild depressive episodes
Duration: at least two years of mood change
Dysthymia
Cyklothymia
DYSTHYMIA
A period of at least two years of constant or constantly
recurring depressed mood.
Intervening periods of normal mood rarely last for longer
than a few weeks and there are no episodes of hypomania.
None of the individual episodes of depression within such a
two-year period are severe enough or last long enough to
meet the criteria for recurrent mild depressive disorder.
Chronic „subliminal“ depression
DYSTHYMIA
Epidemiology
Lifetime prevalence: 3-5%
In women: 2-3x higher risk of disease development
Onset: slow, inconspicuous development,
usually in early adulthood between 20-30 years
Higher risk of depressive episode
Clinical psychiatry
Praško, 2011
DYSTHYMIA
Treatment:
Antidepressants + psychotherapy
CYKLOTHYMIA
Mood instability, an alternation of sad and
elevated mood
None of the manifestations of depression or
hypomania during a two- year period should
be sufficiently severe or long lasting to meet
criteria for manic or depressive episode
(moderate or severe).
CYKLOTHYMIA
Epidemiology
Lifetime prevalence: about 1%
Course
slow, inconspicuous development, usually in early
adulthood.
Higher risk of BAD development
Clinical psychiatry,
Praško, 2011
CYKLOTHYMIA
Treatment:
Mood stabilizers + psychotherapy