2. EMOTIONS
AFFECT: MOOD:
Short-lived, emotional Sustained and pervasive
Response to an event
3. Healthy persons experience a wide range of
moods and have a large repertoire of emotional
expressions, feel in control
Mood disorders are a group of clinical conditions
which are characterized a by sense of loss of
control over one’s mood and subjective sense of
distress, impaired interpersonal, social and
occupational functioning
4. History
Hippocrates (400 B.C.) used the terms mania
and melancholia to describe mental
disturbances
Roman physician (30 A.D.) described
melancholia as depression caused by black bile
5. In 1854, Jules Farlet described a condition
called folie circulaire: alternating moods of
depression and mania
In 1899, Emil Kraepelin described manic-
depressive psychosis using most of the criteria
that psychiatrists use now
7. Mania: Clinical Features
Core features
Elevated/irritable mood
Increased speech
Decreased need for sleep
Increased psychomotor activity
Psychotic features
Delusions
Hallucinations
Others
7
8. 1. Elevated/ irritable mood:
o Euphoria/ Grade 1: mild elevation of mood, increased
sense of psychological well being and happiness, not in
keeping with ongoing events
o Elation/ Grade 2: moderate elevation of mood, feeling of
confidence and enjoyment, along with increased
psychomotor activity
o Exaltation/ Grade 3: severe elevation of mood, intense
elation with delusions of grandiosity
o Ecstasy/ Grade 4: very severe elevation of mood,
intense sense of rapture or blissfulness
8
9. 2. Increased speech
o Volubility
o Acceleration
o Pressured speech- difficult to interrupt
o Flight of ideas- shift from topic to topic with
cues
o Prolixity- ordered flight of ideas
3. Increased psychomotor activity
o Over activity/ restlessness
o Excitement
o Stupor
9
11. 5. Other symptoms
o Over religiosity
o Over spending/ expansive ideas
o Over familiarity/ disinhibition
o Appearance
o Appetite may be increased, but decreased
food intake due to over-activity
o Decreased need for sleep
13. DEPRESSIVE EPISODE: Clinical
Features
1. Depressed Mood:
Pervasive and persistent sadness
Quantitatively and qualitatively different from
sadness encountered in normal depression or
grief
Varies little from day to day and is often
unresponsive to environmental stimuli
14. 2. Anhedonia:
Loss of interest or pleasure in almost all
activities/ earlier pleasurable activities
Results in social withdrawal
Decreased ability to function in occupational and
interpersonal areas
16. 4. Depressive ideation:
Hopelessness
Helplessness
Worthlessness
Feelings of guilt
Death wishes
Suicidal ideas
17. 5. Psychomotor Activity:
Younger patients (less than 40): slowed thinking and
activity, decreased energy, monotonous voice
Older patients: agitation, marked anxiety, restlessness
Severe depression: stupor
18. 6. Biological functions/ somatic syndrome:
Insomnia
Loss of appetite and weight
Loss of sexual drive
Early morning awakening (atleast 2 hrs)
Diurnal variation
22. Bipolar affective disorder
Characterized by repeated episodes of disturbed
mood and activity levels
Disturbance consisting of elevation of mood,
increased energy and activity on some occasion
and on others of low mood, decreased energy
and activity
Recovery is usually complete in between the
episodes
22
23. Recurrent Depressive Disorder
Recurrent (at least 2 depressive episodes) of
unipolar depression
First episode occurs later than in bipolar, usually
in the 5th decade
Episodes last between 3 to 12 months
Recovery is usually complete
Often precipitated by stressful life events
24. Persistent Mood Disorders
Persistent mood symptoms lasting for more than 2 years
Not severe enough to be labeled as even hypomanic or
mild depressive
Persistent mild depression: dysthymia
Persistent instability of mood between depression and
mania: cyclotymia
25. Next Class
Course and Prognosis
Epidemiology
Treatment
Differential Diagnosis
Co-morbidities
Other syndromes of depression and mania
27. Course and Prognosis
Average manic episode lasts for 3-4 months
Average depressive episode lasts for 4-6
months
Unipolar depression is usually longer than
bipolar depression
As age advances, intervals between 2 episodes
shorten; duration and frequency increases
28. Epidemiology
Prevalence
Annual incidence is <1%, milder forms often
missed
Sex ratio
Equal prevalence among men and women
Manic episodes more common in men and
depressive episodes more common in women
28
29. Age of onset
Onsetearlier than depressive episode
Ranges from 5-50yrs; mean age 30yrs
Marital status
More common in divorced and single persons
Socioeconomic status
Higher than average incidence among upper
socioeconomic status
29
30. Classification
Bipolar type 1- having clinical course of
one or more manic episodes and major
depressive episodes
Bipolar type 2 – characterized by episodes
of major depression and hypomania
30
31. Diagnosis- ICD 10 criteria
Hypomania- lesser degree of mania
o Persistent mild elevation of mood- euphoria
o Marked feelings of well being and efficiency
o Increased energy and activity
o Decreased need for sleep
o Increased sociability and talkativeness
o Not leading to severe disruption of work or
social rejection
o Present for several days on end (4 days)
31
32. Mania without psychotic symptoms
o Last for at least 1wk
o Severe enough to disrupt ordinary work and
social activities
o Elated mood
o Increased energy with over activity
o Pressured speech
o Decreased need for sleep
o Marked distractibility
o Disinhibited, overspending
o Expansive ideas
32
33. Mania with psychotic symptoms
o More severe form
o Delusions- grandiose and/or persecutory
o Perceptual abnormalities
o Severe and sustained physical activity,
excitement
o Flight of ideas, incoherence
o Impaired personal care
33
34. Etiology
Biological theories
2.Genetic factors
3.Neurotransmitter theories- inconsistent
o Dopamine- raised in mania and vice versa
4.Neuroendocrine theories
o CSF somatostatin- raised in mania and vice
versa
5.Neuroimaging and anatomy
o Regions involved in regulation of normal
emotions- PFC, antr cingulate, hippocampus,
amygdala 34
35. Contd-
Psychosocial theories
2.Life events and stress
o Play a formative role in depression;
precipitating in mania
o More often precede first rather than the
subsequent episodes
35
36. Course
Most often first episode is depression
Average manic episode lasts 3-4mnths
and depressive episodes 4-6mnths
Long term follow up- 15% are well, 45%
are well with multiple relapses, 30% in
partial remission, 10% are chronically ill
36
42. Summary
Clinical features- 4 core features
psychotic features
others
Management- pharmacological- acute
prophylaxis
non-pharmacological
42
43. Poor prognostic factors
Young onset
Longer duration of episodes
Presence of psychotic features
Inter episode depressive features
Premorbid poor occupational status
Comorbid medical and psychiatric
problems
43
44. Etiology
Biological theories
2.Genetic factors
o 3 fold increase in biological relative
o Increased concordance rate for monozygotic
twins
o Chromosome 18, 21, 22
4.Neurotransmitter theories- inconsistent
o Serotonin and norepinephrine- depression
o Dopamine- reduced in depression and
increased in mania 44
45. Contd-
1. Neuroendocrine theories
o Elevated HPA activity, hypothyroidism-
depression
o CSF somatostatin- raised in mania and vice
versa
3. Neuroimaging and anatomy
o Regions involved in regulation of normal
emotions- PFC, antr cingulate, hippocampus,
amygdala
o Ventricular enlargement 45
46. Contd-
Psychosocial theories
•Psychoanalytic theory- mania as defense
against underlying depression
•Life events and stress
o Play a formative role in depression;
precipitating in mania
o More often precede first rather than the
subsequent episodes
6.Cognitive theory- depression
46
47. Course
Most often first episode is depression
10-20% experience only manic episodes
Manic episodes typically have rapid onset
Average manic episode lasts 3-4mnths
and depressive episodes 4-6mnths
Long term follow up- 15% are well, 45%
are well with multiple relapses, 30% in
partial remission, 10% are chronically ill
47