The Clinical Presentation of Mood Disorders. Bob Boland MD Slide 1 - PDF document

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 Once again, we’ll use the mental status exam to Phenomenology: consider the phenomenology of the mood The Mental Status Exam disorders. • General Appearance • 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 worsens, often appearance is affected. Though • Depression • 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 sad mood of the depressed patient. However • Mood – Dysphoric patients may not be simply sad. They may be – Irritable, angry more irritable, angry, or feel like they have no – Apathetic • Affect emotion at all. Their affect may be sad, but it – Blunted, sad, constricted 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. Typically, manic patients are animated with • Mood – Euphoric exaggerated emotional styles. – Irritable • 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 trouble organizing their thoughts. In the • Process – Slowed processing extreme, they describe feeling as if they are • Thought blocking demented. Typically, they see thinks as worse • Content • Everything’s awful that it really is, and in the extreme, they may • Guilty, self-deprecating • Delusional become delusional. Slide 8 Manic people tend to think more quickly. In Thought: Mania the right amounts, the combination of this quick thought, and the somewhat broader associations • Process – Rapid can make them seem quite clever, but as it – Pressured speech worsens, their thinking becomes more – Loosening of Associations • Content incomprehensible. The speech is pressured— – Grandiose not only rapid, but continuous, in the sense that – Delusions 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 as well. As a result, they may find it harder to • Depression – Poor attention learn or remember things. The term – Registration – Effort “pseudodementia” has been applied to this, but – “Pseudodementia” it is probably best not used, as depression can • Mania – Distractible affect cognition in a variety of ways, both in – Concentration – 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 Insight and Judgment 10 does insight and judgment. For example, if one thinks they are hopeless and worthless, it will • Depression – Unrealistically negative certainly affect their decisions about future • Mania plans. Similarly, a manic person can be – Unrealistically positive unrealistically optimistic and make poor – Or just plain bad decisions: ex. Buying things they cannot really afford. Slide Depression is very common—5-7% lifetime Epidemiology 11 risk in the Epidemiological Catchment Area (ECA) Study. Later follow ups suggest it may • Depression – 5-7% be even more common than that. It is more – 2:1 ♀ : ♂ – $53 billion/year in US common in woman than men—this seems to be – World: most costly (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. Epidemiology 12 The gender difference is closer to parity. Though many very productive and creative • Bipolar Disorders – 1% people have had the disorder, they usually have – ~1:1 ♀ : ♂ not been productive during highs and lows of the disorder. Slide In diagnosing the mood disorders, one should Diagnosis and Criteria 13 be aware that DSM describes first episodes, which are syndromes, or collections of • Episodes Versus Disorders symptoms, which then become the building blocks for the actual disorders. Slide There are the episodes. Once again, remember, Episodes 14 these are not diagnoses, merely descriptions of syndromes. • Major depressive • Manic • Mixed • Hypomanic Page 5 of 14

Clinical Presentation of Mood Disorders Slide All the episodes are described in terms of time Major Depressive Episode 15 course, a collection of symptoms with a minimum required number, and the “global • Time – 2 weeks criteria” (see the first lecture for more on that). • Change In the case of a major episode, the criteria are – From previous functioning • Symptoms listed here. – 5 or more – 1 has to be depressed mood or anhedonia • Global Criteria Slide These are the symptoms of a major depressive Symptoms of Major Depressive 16 episode. In addition to these, one MUST have Episode either dysphoria or anhedonia (taking no • “Sig E Caps” – Sleep pleasure in anything). SIG E CAPS is a useful – Interest – Guilt – Energy mnemonic (like a prescription for “energy – Concentration – Appetite capsules”) for remembering these symptoms. – Psychomotor retardation – Suicide • 5 or more Slide Similarly, these are the criteria for a manic Manic Episode 17 episode. The actual symptoms list is on the next slide. • Time – 1 week • Symptom list – 3 or more • Global Criteria Page 6 of 14

Clinical Presentation of Mood Disorders Slide Symptoms of Manic Episode 18 – 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 Other Episodes 19 concentrate on) there are 2 other types of episodes: a mixed episode and a hypomanic • Mixed • Hypomanic episode. More on these later. Anyhow, the episodes become the building blocks for the actual disorders. Slide The Disorders 20 Page 7 of 14

Clinical Presentation of Mood Disorders Slide These are the criteria for the Major Depressive Major Depressive Disorder 21 Disorder. Note that it doesn’t list symptoms— these were covered by the episode criteria. • “Classic Depression” • Major Depressive Here, a patient has to have had a major Episode depressive episode (and the accompanying • Rule outs – Some other disorder symptoms of that), and, essentially nothing else. – History of mania/hypomania Slide Similarly, here are the bipolar criteria. A Bipolar Disorder I 22 person has to have had at least 1 manic or mixed episode. In practice, most (@90%) • Classic “Manic-Depression” • At least one patients usually have had a depressive episode – Manic or, as well (hence the synonym of manic- – Mixed episode depression) however that is not required. Slide See the syllabus for a description of these Other Mood Disorders 23 episodes. It will be primarily important to understand these as they differ from a major • Dysthymic Disorder • Cyclothymic Disorder depressive disorder and bipolar I. • Bipolar II • Due to a generalized medical condition • Substance Induced • NOS Page 8 of 14