MOOD DISORDERS

ANGELLENE FIRMALINO – NEW ERA UNIVERSITY

 Mood disorders virtually always result in impairment
of:

INTERPERSONAL FUNCTIONS SOCIAL FUNCTIONS OCCUPATIONAL FUNCTIONS

 Mood | Affect
Description of one’s internal External display of one’s mood - Objective
state of being - Subjective
 MOOD
• Can be defined as a pervasive and sustained emotion or feeling tone that
influences a person's behavior and colors his or her perception of being in the
world
• Mood can be labile, fluctuating or alternating rapidly between extremes
 MOOD DISORDERS
SIGNS + SYMPTOMS:
Changes in activity level
Cognitive abilities
Speech
Vegetative functions (e.g., Sleep, appetite, sexual activity, and other biological
rhythms)
EPIDEMIOLOGY
 Major depressive disorder Bipolar I disorder Manic episodes

20 and 50 years, with a Childhood (5 or 6 years) to 50 years or

mean age of 40 years older, with a mean age of 30 years

***Mood disorders can begin in childhood or in old age ***

without close
interpersonal
relationships

divorced or separated divorced and single persons

no correlation has been found the upper socioeconomic groups

between socioeconomic status
rural areas did not graduate from college
 x Anxiety disorders
Coexisting x Alcohol Dependence
x Other Substance-Related Disorders
Disorders
x Medical Conditions
BIOLOGIC, GENETIC & PSYCHOSOCIAL FACTORS
BIOLOGICAL
FACTORS
1. Biogenic amines - NOREPINEPHRINE, SEROTONIN, DOPAMINE
2. Other Neurotransmitters - Ach, GABA, AA glutamate and glycine
3. Alteration in hormonal regulation
Elevated HPA activity - hallmark of mammalian stress responses and one of the clearest links
between depression and the biology of chronic stress
4. Structural and functional brain imaging - MRI, CT scan, PET scan
5. Alterations in sleep neurophysiology
• Depression is associated with a premature loss of deep (slow-wave) sleep and an increase in nocturnal arousal
• Reflected by four types of disturbance:
 increase in nocturnal awakenings
 reduction in total sleep time
 increased phasic rapid eye movement (REM) sleep
 increased core body temperature

• Reduced REM latency- is a combination of increased REM drive and decreased slow-wave sleep results in a
significant reduction in the first period of non-REM (NREM) sleep
 G E N E T I C FAC T
ORS

1. Family studies (1 parent – 10-25%, both – 50%)

2. Twin studies -monozygotic (MZ) twins of 70 to 90%, same-sex dizygotic (DZ) twins of 16 t
o 35%
3. Linkage studies
PSYCHOSOCIAL FACTORS
1. Life events and Environmental stress
2. Personality Factors
3. Psychodynamic Factors in depression
4. Psychodynamic Factors in mania
 Psychodynamic factors in depression
CLASSIC VIEW OF DEPRESSION (4 KEY POINTS):

1. Disturbances in the infant- mother relationship

during the oral phase (10-18 mo of life)
predispose to subsequent vulnerability to
depression 1. Introjection of the departed objects is a defense
mechanism involved to deal with the distress
2. depression can be linked to real or imagined connected with the objects loss
object loss
2. because the lost object is regarded with a
mixture of love and hate, feelings of anger are
directed inward at the self.
Psychodynamic Factors in mania

x Manic episodes may reflect an inability to tolerate a

developmental tragedy, such as the loss of a parent.

x The manic state may also result from a tyrannical superego,

which produces intolerable self-criticism that is then replaced by
euphoric self-satisfaction
 DIAGNOSIS

Major depressive disorder BP I Disorder BP II Disorder

1) Single episode 1) Single manic The diagnostic criteria for

bipolar II disorder specify the
2) Recurrent episode episode
particular severity, frequency,
• Patients who are 2) Recurrent and duration of the hypomanic
experiencing at least a
second episode of
symptoms
depression

*Single – A cc to DSM -5, pati e nt s must b e experiencing their first *Recurrent - Episodes are considered distinct when they are separated by at
depressive/manic episode to meet the diagnostic criteria for major depressive least 2 months without significant symptoms of depression / mania or
disorder or bipolar I disorder, single manic episode hypomania
Specifiers (Symptom features)
 Psychotic features:  Melancholic feature:  Atypical features:
• congruent psychoses- • depression characterized by severe • patients with atypi-cal features
psychotic type of mood have specific, predictable
anhedonia, early morning
disorder characteristics: overeating and
• incongruent psychoses- awakening, weight loss, and
oversleeping
schizoaffective disorder profound feelings of guilt (often over
or schizophrenia trivial events)

 Catatonic features:  Postpartum onset  Rapid cycling (4  Seasonal pattern (winter)

• Hallmark Sx of catatonia: episodes within 12
stuporousness, blunted mos.)
affect, extreme
withdrawal, negativism,
marked psychomotor
retardation
C LI N I CAL F EAT U R E
S
Depressive episodes Manic episodes
In Children and Adolescent An elevated, expansive, or irritable
mood is the hallmark of a manic episode
School phobia and excessive clinging to parents
may be symptoms of depression in children.

Poor academic performance, substance abuse,

antisocial behavior, sexual promiscuity, truancy,
and running away may be symptoms of depression in
adolescents

In Older people

feel blue, hopeless, in the dumps, or worthless

Manic episodes

Depressive episodes
• Excited, talkative, amusing, frequently
• hyperactive
• Social withdrawal, decreased activity, deny
• Euphoric, can also be irritable; low frustration depressive feelings
tolerance
• Decreased rate and volume of speech
• Mood congruent delusions
• Mood congruent delusions and hallucinations
• Self confidence
• Negative views of the world and themselves
• Accelerated flow of ideas
• Oriented but insufficient energy to answer questions
• Assaultive and threatening
• Cognitive impairment
• Little insight about their disorder
• Depressive thoughts
• Unreliable with information
• Overemphasizing the bad, minimizing the good
  during conversations
 Mental Status Examination

1. Depression

• Generalized psychomotor retardation is the most common symptom of

depression
• Psychomotor agitation, especially in older patients
Hand wringing and hair pull­ing are the most common symptoms of
agitation
 Classically, a depressed
patient has a stooped posture; no
spontaneous movements; and a
downcast, averted gaze
 Mental Status Examination

x Mood affect and feelings x Judgement and insight

x Speech x Reliability
x Perceptual disturbances x Objective rating scales for depression
x Thoughts -Zung Depression Scale
x Sensorium and cognition -Raskin Depression Scale
-orientation -Hamilton Rating Scale For Depression
-memory
x Impulse control
**paradoxical suicide
Mental Status Examination

2. Manic Episode

• Many patients are: excited, talkative,

sometimes amusing, and frequently
hyperactive
• At times, they are grossly psychotic and
disorganised and require physical restrains
and the intramascular injection of sedating
drugs.
 Mental Status Examination
Mood, affect and feelings

X Euphoric- classic
x Irritable
x Low frustration tolerance
x Emotionally labile- switching from laughter-irritability-
depression in minutes to hours
 Mental Status Examination
SPEECH

 Manic patients cannot be interrupted while they are speaking, and they are
often intrusive nuisances to those around them

 As the mania gets more intense, speech becomes louder, more rapid, and
difficult to interpret

 At a still greater activity level, associations become loosened, the ability to

concentrate fades, and flight of ideas, clanging, and neologisms appear
CAT E G O RY
Disorders of Mood/Affective Disorders

Make up an important category of psychiatric illness consisting of:

1) depressive disorder, 2) bipolar disorder, and 3) other disorders
hypomania, cyclothymia, and dysthymia
 Major depressive disorder
or Unipolar depression
Patients with only major depressive episodes
DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER
CRITERIA

A. Five or more of the ff. symptoms have been present during the same 2 week period and represent a
change from previous functioning: at least 1 of the symptoms is either: (a) depressed mood or (b) loss of
interest or pleasure
B. The symptoms cause clinically significant distressor impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to other medical conditions.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode

+ SIGECAPS

Note: Criteria A to C represent a major depressive episode

 five or more symptoms for at least 2 weeks

DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER

CRITERIA
  ONSET - Before age 40 yrs (50%)

 DURATION - Untreated: 6-13 mos

Treated: about 3 mos over 20yrs (5-6 episodes)
COURSE
 DEV’T OF MANIC EPISODES
- Initial diagnosis of major depressive disorder have a
manic episode 6 to 10 years after the first depressive episode (5-
10%)
-Mean age for this switch is 32 years
 + PROGNOSIS
• Major depressive disorder is not a benign disorder. It tends to be chronic,
and patients tend to relapse
• Hospitalized for a first episode- 50% chance of recovering in the first year
25% of patients experience a recurrence of MDD in the first 6 months
after release from a hospital
30 to 50% in the following 2 years
50 to 75 % in 5 years
DIFFERENTIAL DIAGNOSIS
 MEDICAL DISORDERS
-adrenal and thyroid dysfunctions
-acquired immune deficiency syndrome (AIDS)
-neurological conditions
Parkinson's disease, dementing illnesses (including dementia of the Alzheimer's type),
epilepsy, cerebrovascular diseases, and tumors
-pseudodementia
 MENTAL DISORDERS
 OTHER MOOD DISORDERS
 BIPOLAR

Patients with both manic and depressive

episodes or patients with manic episodes alone

“unipolar mania” or “pure mania” are

sometimes used for patients who are bipolar
but do not have depressive episodes
 M A N I A

A manic episode is a distinct period of an abnormally and persistently elevated,

expansive, or irritable mood lasting for at least 1 week or less
**Additional Categories of Mood Disorder

1) Hypomania - an episode of manic symptoms that does not meet the

criteria for manic episode

A hypomanic episode lasts at least 4 days and is similar to a manic episode except
that it is not sufficiently severe to cause impairment in social or occupational
functioning, and no psychotic features are present
 MANIA
Bipolar I disorder -is defined as having a clinical course of one or more
manic episodes and, sometimes, major depressive episodes

Bipolar II disorder -A variant of bipolar disorder characterized by episodes of

major depression and hypomania rather than mania
DSM-5 Diagnostic Criteria for Bipolar I Disorder

- Necessary to meet the ff. criteria for a manic episode

- May have preceded by and may be followed by a hypomanic or major depressive episodes

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, increased goal-
directed activity or energy lasting at least 1 week and present most of the day, nearly everyday

B. During the period of mood disturbance and increased energy or activity, 3 or more of the ff. are present

+ DIG FAST

HYPOMANIC EPISODE
DSM-5 Diagnostic Criteria for Bipolar I Disorder
MANIC EPISODE

C. The mood disturbance is sufficiently severe to necessitate hospitalization to prevent harm to self or to others, or there are psychotic symptoms
D. The episode is not attributable to the physiological
effects of a substance (e.g. a drug of abuse, a medication, other treatment) or to another medical
condition

HYPOMANIC EPISODE

C. The episode is associated with unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
D. The disturbance in mood and change in functioning are observable by others
E. The episode is not severe enough to cause marked impairment in social or occupational functioning
F. The episode is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication, other treatment) or to another medical
condition
Hypomanic episodes are common in Bipolar I, but are
not required for the diagnosis of Bipolar II.
MAJOR DEPRESSIVE EPISODE
MAJOR DEPRESSIVE EPISODE

A. 5 or more of the ff. symptoms present during the same 2 week period and represent a change from previous functioning; at least 1 of the symptoms is either:
(a) depressed mood or (b) loss of interest or pleasure

S: Suicide I: Interest G: Guilt

E: Energy
C: Concentration A: Appetite P: Psychomotor S: Sleep

DSM-5 Diagnostic Criteria for Bipolar I Disorder

COURSE + PROGNOSIS
BP I DISORDER - COURSE

 Bipolar I disorder most often starts with  The manic episodes typically have a rapid
depression (75% women, 67% men) and is onset (hours or days) but may evolve over a
a recurring disorder few weeks.

-Untreated - lasts about 3 months;

 Most patients experience both therefore, clinicians should not discontinue
depressive and manic episodes, although giving drugs before that time
10 to 20 percent experience only manic
episodes
 Persons who have a single manic
episode, 90 percent are likely to have
another
 x Incidence- about 1 percent
x Onset- 8 years
x Common misdiagnoses are schizophrenia and oppositional defiant
disorder
BIPOLAR I DISORDER IN
CHILDREN &OLDER Bipolar I disorder with such an early onset is associated with
PERSONS a poor prognosis
Manic symptoms are common in older persons
Range of causes is broad and include: non- psychiatric
medical conditions, dementia, delirium, and bipolar I disorder
The onset of true bipolar I disorder in older persons is
relatively uncommon
 BP I DISORDER -
PROGNOSIS
 Patients
with bipolar I disorder have a poorer  Poor Prognosis:
prognosis than do patients with major
depressive disorder  premorbid
 About 40 to 50 percent of patients with bipolar I  poor
disorder may have a second manic episode within 2  occupational status
years of the first episode
 alcohol dependence
 Although lithium prophylaxis improves the course  psychotic features
and prognosis of bipolar I disorder, probably only
 depressive features
50-60% of patients achieve significant control of
their symptoms with lithium  interepisode depressive features
 male gender
BP II DISORDER  Diagnosis is stable because there is a high likelihood that
patients with bipolar II disorder
will have the same diagnosis up to 5 years later
COURSE &
PROGNOSIS  BipolarII disorder is a chronic disease that warrants long-
term treatment strategies
 DIFFERENTIAL DIGNOSIS

BP I DISORDER BP II DISORDER
Bipolar II disorder Psychotic disorders
Cyclothymic disorder Borderline disorder
Mood disorder caused by a
general medical condition
Substance-induced mood
disorder
T R EAT M E N T
TREATMENT GOALS:
1. Patient’s safety must be guaranteed
2. Complete diagnostic evaluation of the patient should be
done
3. Treatment plan that addresses not only the immediate
symptoms but also the patient’s prospective well-being
should be initiated
4. Address the number and severity of stressors in patient’s
lives
TREATMENT PLAN:
 Hospitalization
 Psychosocial
 Transcranial magnetic stimulation
 Sleep deprivation
 Phototherapy
 Pharmacotherapy
Hospitalization

x The first and most critical decision a physician must make is

whether to hospitalize a patient or attempt outpatient treatment

Clear indications for hospitalization :

 risk of suicide or homicide
 grossly reduced ability to get food and shelter need for diagnostic
procedures
 A history of rap­idly progressing symptoms rupture of a patient's
usual support systems
Psychosocial Therapy

Three types of short-term psychotherapies:

1. Cognitive therapy
2. Interpersonal therapy
3. Behavior therapy
Cognitive Therapy
x Focuses on the cognitive distortions postulated to be present in major
depressive disorder
x Such distortions include selective attention to the negative aspects of
circumstances and unrealistically morbid inferences about
consequences

• GOAL: to alleviate depressive episodes and prevent their recurrence by

helping patients identify and test negative cognitions; develop
alternative, flexible, and positive ways of thinking; and rehearse new
cognitive and behavioral responses
Interpersonal Therapy
x Focuses on one or two of a patient's current
interpersonal problems

x Interpersonal therapy may be the most effective method

for severe major depressive episodes when the treatment
choice is psychotherapy alone
Behavior Therapy
x Behavior therapy is based on the hypothesis that maladaptive
behavioral patterns result in a per­son's receiving little positive
feedback and perhaps outright rejection from society

By addressing maladaptive behaviors in therapy, patients learn to function in

the world in such a way that they receive positive reinforcement
ANSCRANIAL MAGNETIC STIMULATION
x It involves the use of very short pulses of magnetic energy to
stimulate nerve cells in the brain

specifically indicated for the treatment of depression in adult

patients who have failed to achieve satisfactory improvement from
one prior antidepressant medication at or above the minimal
effective dose and duration in the current episode
Sleep deprivation

x Mood disorders are characterized by sleep disturbance

x Mania tends to be characterized by a decreased need for sleep

x Depression can be associated with either hypersomnia or insomnia

Sleep deprivation may precipitate mania in patients with bipolar I disorder and temporarily
relieve depression in those who have unipolar depression
 Phototherapy

Phototherapy typically involves exposing the affected patient to

bright light in the range of 1 ,500 to 1 0,000 lux or more, typically
with a light box that sits on a table or desk.

Patients sit in front of the box for approximately 1 to 2 hours

before dawn each day, although some patients may also benefit
from exposure after dusk

Phototherapy has been used to decrease the irritability and

diminished functioning associated with shift work
Pharmacotherapy
The objective of pharmacologic
treatment is symptom remission, not
just symptom reduction
 PHARMACOTHERAPY -
MDD
 All currently available anti­depressants may take up to 3 to 4 weeks to exert significant
therapeutic effects, although they may begin to show their effects earlier

 Choice of antidepressants is determined by the side effect profile least objectionable to a

given patient's physi­cal status, temperament, and lifestyle
 Dosage of an antidepressant should be raised to the maximum recommended level and
maintained at that level for at least 4 or 5 weeks before a drug trial is con­sidered
unsuccessful
• When a patient does not begin to respond to appropriate dosages of a drug
after 2 or 3 weeks, clinicians may decide to obtain a plasma concentration of
the drug if the test is available for the particular drug being used

• Antidepressant treatment should be maintained for at least 6 months or

the length of a pre­vious episode, whichever is greater

• When antidepressant treatment is stopped, the drug dose should be tapered

gradually over 1 to 2 weeks, depending on the half-life of the particular com­
pound

PHARMACOTHERAPY -
MDD
ACUTE TREATMENT FAILURE trials should last 4
to 6 weeks to determine if mean­ingful symptom reduction is attained

Patients may not respond to a medication, because:

( 1 ) they cannot tolerate the side effects, even in the face of a good
clinical response

(2) anidiosyncratic adverse event may occur

(3) the clinical response is not ade­quate

(4) the wrong diagnosis has been made

PHARMACOTHERAPY -
MDD
 SELECTING SECOND TREATMENT
OPTIONS
• The choice between switching from the initial single treatment to a new
single treatment (as opposed to adding a second treatment to the first one)
rests on the patient's prior treatment history, the degree of benefit
achieved with the initial treatment, and patient preference

As a rule, switching rather than augment­ing is preferred after an initial

medication failure

PHARMACOTHERAPY -
MDD
SELECTING SECOND TREATMENT
OPTIONS
 The best-documented augmentation strate­gies involve lithium (Eskalith) or
thyroid hormone

 A combina­tion of an SSRI and bupropion (Wellbutrin) is also widely used

 Electroconvulsive therapy (ETC) is effective in psychotic and nonpsychotic forms

of depression but is recommended generally only for repeatedly nonresponsive
cases or in patients with very severe disorders

PHARMACOTHERAPY -
MDD
PHARMACOTHERAPY -
BP
The pharmacological treatment of bipolar disorders is
divided into both acute and maintenance phases
ACUTE BIPOLAR
DEPRESSION

- Antidepressant drugs are often enhanced by a mood stabilizer in the first-line treatment
for a first or isolated episode of bipolar depression

-A fixed combination of olanzapine and fluoxetine (Symbyax) has been shown to be

effective in treating acute bipolar depres­sion for an 8-week period without inducing a switch
to mania or hypomania

PHARMACOTHERAPY - BP
MAINTENANCE TREATMENT FOR BIPOLAR
DISORDER

X Pri­mary goal- sustained euthymia - normal, tranquil mental state or mood

-but the medications should not produce unwanted side effects that affect functioning
Seda­tion, cognitive impairment, tremor, weight gain, and rash are some
side effects that lead to treatment discontinuation

x Lithium, carbamazepine, and valproic acid, alone or in combination, are the

most widely used agents in the long- term treatment of patients with bipolar
disorder

PHARMACOTHERAPY - BP
**Additional Categories of Mood Disorder

2) Cyclothymia and 3) Dysthymia- disorders that represent less severe forms of

bipolar disorders and major depression
Differentiation

Dysthymic disorder is characterized by at least 2 years of depressed

mood that is not sufficiently severe to fit the diagnosis of major
depressive episode

Cyclothymic disorder is characterized by at least 2 years of frequently

occurring hypomanic symptoms that cannot fit the diagnosis of
manic episode and of depressive symptoms that cannot fit the
diagnosis of major depressive episode
DYSTHYMIA aka persistent depressive
disorder
Most typical feature: presence of a depressed mood that lasts
most of the day and is present almost continuously

Associated feelings of :
 guilt
 irritability
 anger
 withdrawal from society
 loss of interest
 inactivity
 lack of productivity
 DYSTHYMIA
Core concept of dysthymia refers to a subaffective or
• Means "ill humored," was subclinical depressive disorder with:
introduced in 1980
(1) Low-grade chronicity for at least 2 years
• Before that time, most patients
(2) Insidious onset, with origin often in childhood or
now classified as having dysthymia
were classified as having depressive adolescence
neurosis (also called neurotic (3) A persistent or intermittent course
depression)
  Most cases are of early onset, beginning in childhood or
adolescence and certainly occurring by the time patients reach
ONSET their 20s

 Late-onset subtype has been identified among middle- aged

and ger i atri c populations
It is much less prevalent and not well characterized clinically
 EPIDEMIOLOGY
x General population - 5 to 6% x Coexists: major depressive disorder, anxi­ety
disorders (especially panic disorder), substance
abuse, and borderline personality disorder
x General psychiatric clinics - between half and
one-third of all patients
x More common among those with first- degree
x Women younger than 64 yo > men of any age relatives with major depressive disorder
x More common among unmarried and young
persons and in those with low incomes x Patients with dysthymia are likely to be taking a wide
range of psychiatric medications, including
antidepressants, anti-manic agents such as lithium
(Eskalith) and carbamazepine (Tegretol), and
sedative-hypnotics
BIOLOGIC & PSYCHOSOCIAL FACTORS
 (1) BIOLOGICAL FACTORS

 Sleep Studies
 Neuroendocrine Studies
Decreased REM latency and increased
REM density are 2 state markers of of
depression in MDD that also occur in a Patients with Dysthimia are less likely
significant proportion of patients with to have abnormal results on a
dysthymia Dexamethasone- suppression test
(DST) than are patients with MDD
 (2) PSYCHOSOCIAL FACTORS
FREUD COGNITIVE THEORY

 Persons susceptible to depression are orally  It holds that a disparity between actual and
dependent and require constant narcissistic fantasized situations leads to diminished self-
gratification
esteem and a sense of helplessness
 When deprived of love, affection, and care, they
become clini­cally depressed; when they experience a
real loss, they internal­ize or introject the lost object
and turn their anger on it and thus on themselves

 S i g m u n d F r e u d a s s e r t e d t h a t an
interpersonal disappointment early in life can cause
a vulnerability to depression that leads to
ambivalent love relationships as an adult

 Real or threatened losses in adult life then trigger

depression
 COURSE + PROGNOSIS

 Despite the early onset, patients often suffer with the symptoms for a
decade before seeking psychiatric help and may consider early-onset
dysthymia simply part of life

 Patients with an early onset of symptoms are at risk for either major
depressive disorder or bipolar I disorder in the course of their disorder
- 20% progressed to major depressive disorder
- 15% to bipolar II disorder
- <5% to bipolar I disorder
Anti­depressive agents and specific types of psychotherapies (e.g., cognitive
and behavior therapies) have positive effects on the course and prognosis of
dysthymia

- 1 0 to 1 5% of patients are in remission 1 year after the initial

diagnosis
- 25% of all patients with dysthymia never attain a complete recovery
- Overall the prognosis is good with treatment

COURSE AND
PROGNOSIS
 TREATMENT
 Cognitive therapy

 Behavior therapy  Family and group

therapies
 Insight oritented
(Psychoanlytic)  Pharmacotherapy
Psychotherapy
 Hospitalization
 Interpersonal therapy
 Cognitive Therapy
 A technique in which patients are taught new ways of thinking and
behaving to replace faulty negative attitudes about themselves, the
world, and the future

 It is a short-term therapy program oriented toward current

problems and their resolution
 Behavior therapy
 The various treatment methods focus on specific goals to increase activity, to
provide pleasant experiences, and to teach patients how to relax

 Altering per­sonal behavior in depressed patients is believed to be the most effective

way to change the associated depressed thoughts and feelings

 Behavior therapy is often used to treat the learned helplessness of some patients who
seem to meet every life chal­lenge with a sense of impotence
 Insight-oriented Psychotherapy
The most common treatment method for
dysthymia, and many clinicians consider
IMPORTANT GOAL OF THIS it the treatment of choice
THERAPY:
The psychotherapeutic approach attempts
Patients' understanding of how they try to relate the development and
to gratify an excessive need for outside maintenance of depressive symptoms and
approval to counter low self-esteem and maladaptive personality features to
a harsh superego unresolved conflicts from early
childhood
 Interpersonal therapy

x Patient's current interpersonal experi­ences and ways of coping with

stress are examined to reduce depressive symptoms and to
improve self-esteem

x Lasts for about 12 to 16 weekly sessions and can be com­bined

with antidepressant medication
 FAMILY AND GROUP
THERAPY
 Family therapy may help both the patient and the patient's family deal with
the symptoms of the disorder, especially when a biologically based subaffec­
tive syndrome seems to be present

 Group therapy may help withdrawn patients learn new ways to overcome
their interper­sonal problems in social situations
 PHARMACOTHER
APY
 Because of long-standing and com­monly held theoretical beliefs that
dysthymia is primarily a psychologically determined disorder, many
clinicians avoid prescribing antidepressants for patients

 Many studies have shown therapeutic success with antidepressants:

Selective serotonin reuptake inhibitors (SSRis)
- venlafaxine
- bupropion
Monoamine oxidase inhibitors (MAOis)
Hospitalization
Indications:
x severe symptoms

x marked social or professional

incapacitation
x need forexten­s ive diagnostic
procedures
x suicidal ideation
CYCLOTHYMIC
DISORDER
 Symptomatically a mild form of bipolar II disorder,
characterized by episodes of hypomania and mild depression

 Defined as a "chronic, fluctuating mood disturbance" with

many periods of hypomania and of depression

Differentiated from bipolar II disorder, which is characterized by

the presence of major (not minor) depressive and hypomanic
episodes

CYCLOTHYMIC
DISORDER
Emil Kraepelin described four types of
personality disorders:
1. Depressive (gloomy)
2. Manic (cheerful and uninhibited)
3. Irritable (labile and explosive)
4. Cyclothymic

Cyclothymic personality as the alternation of the depressive and manic

personalities
 x Cyclothymic disorder frequently coexists with borderline
personality disorder
x An estimated 10% of outpatients and 20% of inpatients with
borderline personality disorder have a coexisting diagnosis
Epidemiology of cyclothymic disorder
x Female-to-male ratio 3:2
x 50-75%of all patients have an onset between ages
15 and 25 years
x Families of persons with cyclothymic disorder often contain
members with substance-related disorder
 ETIOLOG
Y
BIOLOGICAL FACTORS
x 30% of all patients with cyclothymic
disorder
have positive family histories for bipolar
disorder
I
x Prevalence of cyclothymic disorder in the
relatives of patients with bipolar I disorder is much
higher than the prevalence of cyclothymic disorder
either in the relatives of patients with other mental
disorders or in persons who are mentally healthy
 PSYCHOSOCIAL FACTORS
x Theories postulate that the development of
cyclothymic disorder lies in traumas and
fixations during the oral stage of infant

ETIOLOG
development

x Freud hypothesized that the cyclothymic state is

Y the ego's attempt to overcome a harsh and
punitive superego

x Hypomania is explained psychodynamically as

the lack of self-criticism and an absence of
inhibitions occurring when a depressed person
throws off the burden of an overly harsh
superego
Dx & Clinical Features
x Marital difficulties and instability in relationships are common complaints
because patients with cyclothymic disorder are often promiscuous and irritable
while in manic and mixed states

x The DSM-5 diagnostic criteria for cyclothymic disorder stipulate that a patient has
never met the criteria for a major depressive episode and did not meet the criteria
for a manic epi­sode during the first 2 years of the disturbance

x The criteria also require the more or less constant presence of symptoms for 2 years
(or 1 year for children and adolescents)
 SIGNS + SYMPTOMS
 The symptoms of cyclothymic disorder are  Almost all patients with cyclothymic disorder
identical to the symptoms of bipolar II disorder have periods of mixed symptoms with marked
except that they are generally less severe irritability

 The cycles of the disorder tend to be much shorter

 About half of all patients with cyclothymic than those in bipolar I disorder
disorder have depression as their major
symptom, and these patients are most likely to  The changes in mood are irregular and abrupt
seek psychiatric help while depressed and sometimes occur within hours
 SUBSTANCE ABUSE

 Alcohol abuse and other substance  About 5 to 10 percent of all patients with
abuse are common in patients with cyclothymic disorder have substance
cyclothymic disorder dependence
 Persons with this disorder often have a
 Use substances either to self- history of multiple geographi­cal moves,
medicate (with alcohol, involvements in religious cults, and
benzodiazepines, and marijuana) dilettantism

 To achieve even further stimulation

(with cocaine, amphetamines, and
hallucinogens) when they are manic
DDx
 All the possible medical and substance-related causes of
depression and mania, such as seizures and particular substances
(cocaine, amphetamine, and steroids)

 Borderline, antisocial, histrionic, and narcissistic personality dis­

orders should also be considered

 Attention-deficit/hyperactivity disorder (ADHD) can be difficult

to differentiate from cyclothymic disorder in children and
adolescents
COURS
E
x Some patients with cyclothymic disorder are characterized as
having been sensitive, hyperactive, or moody as young
children

x The onset of frank symptoms of cyclothymic disorder often

occurs insidiously in the teens or early 20s

The emergence of symptoms at this time hinders a person's

performance in school and the abil­ity to establish friendships
with peers
 • The reactions of patients to such a disorder
vary; patients with adaptive coping strategies
PROGNOSI or ego defenses have better outcomes than
patients with poor coping strategies

S • 1/3 of all patients with cyclothymic disor­der

develop a major mood disorder, most often
bipolar II disorder
T R EAT M E N T
BIOLOGICAL THERAPY PSCHOSOCIAL THERAPY

x The mood stabilizers and antimanic drugs- first line x Psychotherapy for patients with cyclothymic disorder is best
directed toward increasing patients' awareness of their
condition and helping them develop coping mechanisms for
x Experimental drugs: lithium, other antimanic agents their mood swings
carbamazepine and valproate (Depakene)- are reported to be
effective
x Therapists usually need to help patients repair any damage,
x Antidepressant treatment of depressed patients with both work and family related, done during episodes of
cyclothymic disorder should be done with caution hypomania
because these patients have 40-50% susceptibility to
antidepressant-induced hypomanic or manic
episodes x Patients often require lifelong treatment

x Family and group therapies may be supportive, educa­tional,

and therapeutic for patients and for those involved in their lives
SUMMARY
Textbook Reference:
11th edition of Kaplan and Sadock's Synopsis of Psychiatry