The Clinical Presentation of Mood Disorders. Bob Boland MD Slide 1 The Clinical Presentation of Mood Disorders Slide 2 For the mood disorders, we’re going to have to Concentrating On cover both depression AND mania. • Depression – Major Depression •Mania – Bipolar Disorder (Manic-Depression) Slide 3 Phenomenology: Once again, we’ll use the mental status exam to The Mental Status Exam consider the phenomenology of the mood • General Appearance disorders. • Emotional • Thought • Cognition • Judgment and Insight • Reliability Clinical Presentation of Mood Disorders Slide 4 In both cases, people may look “normal” with General Appearance mood disorders. However, as the disorder • Depression worsens, often appearance is affected. Though •Mania one can imagine a variety of appearances, typically we see depressed patients taking less care of their appearance, whereas manic patients may be more flamboyant. Slide 5 I prefer the word “dysphoric” (i.e., “feeling Emotions: Depression bad”) to “depressed” in describing the typical •Mood sad mood of the depressed patient. However – Dysphoric – Irritable, angry patients may not be simply sad. They may be – Apathetic more irritable, angry, or feel like they have no •Affect – Blunted, sad, constricted emotion at all. Their affect may be sad, but it could also be blunted, or show less emotion altogether. Slide 6 The typical manic mood is euphoria. However, Emotions: Mania again, patients may instead be irritable. •Mood Typically, manic patients are animated with –Euphoric – Irritable exaggerated emotional styles. •Affect – Heightened, dramatic, labile Page 2 of 14 Clinical Presentation of Mood Disorders Slide 7 Depressed people often describe problems with Thought: Depression their thoughts—thinking more slowly, having • Process trouble organizing their thoughts. In the – Slowed processing • Thought blocking extreme, they describe feeling as if they are • Content demented. Typically, they see thinks as worse • Everything’s awful • Guilty, self-deprecating that it really is, and in the extreme, they may • Delusional become delusional. Slide 8 Manic people tend to think more quickly. In Thought: Mania the right amounts, the combination of this quick • Process thought, and the somewhat broader associations – Rapid – Pressured speech can make them seem quite clever, but as it – Loosening of Associations worsens, their thinking becomes more • Content –Grandiose incomprehensible. The speech is pressured— – Delusions not only rapid, but continuous, in the sense that they seem as if they will continue talking incessantly unless interrupted. The content of thought is typically grandiose—ex. Thinking one is more important than they are, richer, more attractive, etc. In the extreme they can be delusional. Slide 9 As already noted, depression can affect thought, Cognition to the point where patients cannot concentrate •Depression as well. As a result, they may find it harder to – Poor attention – Registration learn or remember things. The term –Effort – “Pseudodementia” “pseudodementia” has been applied to this, but •Mania it is probably best not used, as depression can –Distractible – Concentration affect cognition in a variety of ways, both in – May seem brighter, more clever terms of actual thought processing, and in the effort applied to answering questions. In the right amount, a manic patient can be very clever and certainly some of the brighter people around have had bipolar disorder. However, with worsening of the disorder, this worsens as well. Page 3 of 14 Clinical Presentation of Mood Disorders Slide One can imagine that as thought worsens, so 10 Insight and Judgment does insight and judgment. For example, if one • Depression thinks they are hopeless and worthless, it will – Unrealistically negative •Mania certainly affect their decisions about future – Unrealistically positive plans. Similarly, a manic person can be – Or just plain bad unrealistically optimistic and make poor decisions: ex. Buying things they cannot really afford. Slide Depression is very common—5-7% lifetime 11 Epidemiology risk in the Epidemiological Catchment Area •Depression (ECA) Study. Later follow ups suggest it may –5-7% –2:1 ♀:♂ be even more common than that. It is more – $53 billion/year in US – World: most costly common in woman than men—this seems to be (developed) true worldwide, and most believe this reflects some biological predisposition, though social causes remain possible and plausible. It is one of the most costly diseases known to man, and certainly the most costly in developed countries. This is due to the fact that it often strikes persons during the most productive years of their lives. Though many famous people have suffered from it, this probably has more to do with the fact that this disorder is common, rather than any particular association with creativity. Page 4 of 14 Clinical Presentation of Mood Disorders Slide Bipolar disorder is somewhat less common. 12 Epidemiology The gender difference is closer to parity. •Bipolar Disorders Though many very productive and creative –1% – ~1:1 ♀:♂ people have had the disorder, they usually have not been productive during highs and lows of the disorder. Slide In diagnosing the mood disorders, one should 13 Diagnosis and Criteria be aware that DSM describes first episodes, • Episodes Versus Disorders which are syndromes, or collections of symptoms, which then become the building blocks for the actual disorders. Slide There are the episodes. Once again, remember, 14 Episodes these are not diagnoses, merely descriptions of • Major depressive syndromes. •Manic •Mixed •Hypomanic Page 5 of 14 Clinical Presentation of Mood Disorders Slide All the episodes are described in terms of time 15 Major Depressive Episode course, a collection of symptoms with a •Time minimum required number, and the “global –2 weeks • Change criteria” (see the first lecture for more on that). – From previous functioning In the case of a major episode, the criteria are •Symptoms –5 or more listed here. – 1 has to be depressed mood or anhedonia • Global Criteria Slide Symptoms of Major Depressive These are the symptoms of a major depressive 16 Episode episode. In addition to these, one MUST have • “Sig E Caps” –Sleep either dysphoria or anhedonia (taking no – Interest –Guilt pleasure in anything). SIG E CAPS is a useful –Energy – Concentration mnemonic (like a prescription for “energy – Appetite – Psychomotor retardation – Suicide capsules”) for remembering these symptoms. •5 or more Slide Similarly, these are the criteria for a manic 17 Manic Episode episode. The actual symptoms list is on the •Time next slide. –1 week •Symptom list –3 or more • Global Criteria Page 6 of 14 Clinical Presentation of Mood Disorders Slide 18 Symptoms of Manic Episode –Grandiosity – Decreased need for sleep –Pressured Speech – Flight of Ideas – Distractibility – Increased Activity/Agitation – Risky Activities •3 or more Slide In addition to those (which I want to 19 Other Episodes concentrate on) there are 2 other types of •Mixed episodes: a mixed episode and a hypomanic •Hypomanic episode. More on these later. Anyhow, the episodes become the building blocks for the actual disorders. Slide 20 The Disorders Page 7 of 14 Clinical Presentation of Mood Disorders Slide These are the criteria for the Major Depressive 21 Major Depressive Disorder Disorder. Note that it doesn’t list symptoms— • “Classic Depression” these were covered by the episode criteria. • Major Depressive Episode Here, a patient has to have had a major • Rule outs – Some other disorder depressive episode (and the accompanying –History of mania/hypomania symptoms of that), and, essentially nothing else. Slide Similarly, here are the bipolar criteria. A 22 Bipolar Disorder I person has to have had at least 1 manic or • Classic “Manic-Depression” mixed episode. In practice, most (@90%) • At least one –Manic or, patients usually have had a depressive episode – Mixed episode as well (hence the synonym of manic- depression) however that is not required. Slide See the syllabus for a description of these 23 Other Mood Disorders episodes. It will be primarily important to • Dysthymic Disorder understand these as they differ from a major • Cyclothymic Disorder depressive disorder and bipolar I. •Bipolar II • Due to a generalized medical condition • Substance Induced •NOS Page 8 of 14 Clinical Presentation of Mood Disorders Slide 24 Differential Diagnosis Slide There is a long list of other disorders that can 25 Differential Diagnosis cause depressive symptoms without actually • Psychiatric Disorders causing major depression. Among the • Medical Disorders psychiatric disorders, some of the anxiety • Substance Induced • Reactive disorders disorders can, for example, have overlapping – Adjustment disorders symptoms. –Normal reactions Most difficult to judge are the reactive disorders: both normal reactions to severe stress (ex. Grief, loss) or abnormal reactions (ex. In the adjustment disorders). In practice, the differences are usually judged on the basis of how the disorder affects functioning, however in the acute setting, it can be difficult to judge. Slide One should not become too keen on 26 distinguishing between “physiological depression” and whatever the opposite of that might be. For example, the above scan demonstrates brain changes in the setting of normal transient sadness. No emotion, no thought is possible without some physiological effect or change. Page 9 of 14 Clinical Presentation of Mood Disorders Slide A number of other disorders are