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Mood Disorders

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Mean onset at age 17 with peaks at 14 and 18. Gender distribution 90% of those with eating disorders are female. ANOREXIA NERVOSA ... Binge-Eating/Purging Type ... – PowerPoint PPT presentation

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Title: Mood Disorders


1
Mood Disorders
  • Theodore M. Godlaski
  • College of Social Work
  • University of Kentucky

2
Clients by Primary and Secondary Diagnoses, NASW
PRN III Surveyn1836
www.socialworkers.org/PRN
3
NASW Practice Research Network, 2000 Survey, n
2000
4
http//www.socialworkers.org/naswprn/surveyTwo/Dat
agram4.pdf
5
Mood Disorders
  • Major Depressive Episode
  • Manic Episode
  • Mixed Episode
  • Hypomanic Episode
  • Major Depressive Disorder
  • Dysthymic Disorder
  • Bipolar I Disorder
  • Bipolar II Disorder
  • Cyclothymic Disorder
  • Bipolar NOS
  • Mood Disorder Due to General Medical Condition
  • Substance-Induced Mood Disorder
  • Mood Disorder NOS

6
Major Depressive Episode
  • A. Five or more of the following SX present
    during the same 2 week period represent a
    change from previous functioning. AND at least
    one of the SX is either 1) depressed mood or 2)
    loss of interest or pleasure.
  • 1.  depressed mood most of the day, nearly every
    day
  • 2.   markedly diminished interest or pleasure in
    all or almost all activities nearly every day
  • 3. significant weight loss when not dieting
  • 4. insomnia or hypersomnia

7
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8
Major Depressive Episode
  • 5. psychomotor agitation or retardation
  • 6. fatigue or loss of energy
  • 7. feelings of worthlessness or excessive or
    inappropriate guilt
  • 8. diminished ability to think, to concentrate,
    to make decisions
  • 9. recurrent thoughts about death
  • B. The SX do not meet criteria for a Mixed
    Episode
  • C. The SX cause clinically significant distress
    or impairment in social, occupational, or other
    areas of functioning. 
  • D. The SX are not due to physiological effects
    of a substance or general medical condition. 
  • E. The SX are not better accounted for by
    Bereavement (SX continue longer than 2 months,
    etc)

9
Major Depressive Disorder
  • Characterized by one or more major depressive
    episodes without a manic or hypomanic episode.
  • With multiple episodes, must be at least 2 months
    between.
  • Can be mild, moderate, severe without psychotic
    features, severe with psychotic features (either
    mood congruent or mood incongruent).
  • The actual diagnosis for an episode is Major
    Depressive Disorder, Single Episode. For two or
    more episodes it is Major Depressive Disorder,
    Multiple Episodes.

10
Major Depressive Disorder
  • 15 of those with HX of MDD die by suicide.
  • Lifetime risk in women is 25
  • Lifetime risk for men is 12
  • 60 of those with MDD may experience complete end
    of the disorder after TX. Other data suggests
    that among those who do not meet MDD criteria,
    20 have depressive SX, just not the full
    disorder.
  • Untreated episodes last 6 to 13 months.

11
Major Depressive Disorder
  • 40 still have SX one year later. Other studies
    suggest that 50 60 have a recurrence of MDD
    within two years (even with aggressive TX).
  • Individuals with one episode have a 50 chance of
    a second, after the second, chances for a third
    increase to 70, a third episode increases the
    chances of subsequent episodes to 90.
  • There is a high degree of co-occurrence with
    alcohol abuse and dependence.

12
Major Depressive Disorder
  • Men are more likely than women to experience a
    chronically impaired course.
  • The course is often chronic with multiple
    relapses
  • Cessation of medication in 3 months or less
    almost always leads to reemergence of symptoms.

13
Dysthymic Disorder
  • A. Depressed mood for most of the day, for more
    days than not as indicated by subjective account
    or observation by others for at least 2 years.
  • B. Presence, while depressed of 2 or more of the
    following
  • 1. Poor appetite or overeating
  • 2. Insomnia or hypersomnia
  • 3. Low energy or fatigue
  • 4. Low self-esteem
  • 5. Poor concentration or difficulty making
    decisions
  • 6. Feelings of hopelessness

14
Dysthymic Disorder
  • C. During the 2-year period (1 year for children
    or adolescents) of the disturbance, the person
    has never been without the SXs above for more
    than 2 months at a time.
  • D. No MDE has been present during the first 2
    years of the disturbance (1 year for children and
    adolescents) i.e., it is not better accounted
    for by chronic MDD
  • E. No Manic, Mixed, or Hypomanic episodes ever
    (has not met criteria for Cyclothymic Disorder

15
Dysthymic Disorder
  • F. The disturbance does not occur exclusively
    during a chronic Psychotic Disorder.
  • G. Not due to substance use, medication, or
    medical disorder.
  • H. Symptoms are clinically significant and cause
    significant impairment or distress.
  • You can specify Early Onset if onset before age
    21, or Late Onset if after 21.

16
Dysthymic Disorder
  • Effects 5 to 6 overall and 30 to 50 of
    samples from psychiatric clinics.
  • Often comorbid with MDD, anxiety disorder, BPD,
    and substance use disorders.
  • 15 to 20 symptom free after 1 year of Dx.
  • Only 25 do not obtain complete recovery over
    time.

17
Manic Episode
  • A. A distinct period of abnormally and
    persistently elevated, expansive, or irritable
    mood, lasting at least 1 week.
  • B. During the period of mood disturbance, 3 or
    more of the following have persisted (4 if the
    mood is only irritable) and have been present to
    a significant degree

18
Manic Episode
  • 1. Inflated self-esteem or grandiosity
  • 2. Decreased need for sleep (e.g., 3 hours)
  • 3. More talkative than usual pressure of speech
  • 4. Flight of ideas or subjective belief that
    ideas are racing
  • 5. Distractibility
  • 6. Increase in goal-directed activity
  • 7. Excessive involvement in pleasurable
    activities that have high likelihood of negative
    consequences

19
Manic Episode
  • C. The SX do not meet criteria for Mixed Episode
  • D. The mood disturbance is severe enough to cause
    marked impairment, risk of harm, or requires
    hospitalization
  • E. The SX are not due to a general medical
    condition or use of a substance

20
Mixed Episode
  • A. The criteria are met both for a Manic Episode
    and MDE (except for duration) nearly every day
    during at least a 1-week period.
  • B. The mood disturbance is sufficiently severe
    to cause marked impairment in occupational or
    usual social activities or relationships or to
    necessitate hospitalization to prevent harm to
    self or there are psychotic features.
  • C. The symptoms are not due to the direct
    physiological effects of a substance or general
    medical condition.

21
Hypomanic Episode
  • A. A distinct period of persistently elevated,
    expansive, or irritable mood, lasting at least 4
    days that is clearly different from the
    non-depressed mood.
  • B. During the period of mood disturbance, 3 or
    more of the following SXs have persisted (4 if
    the mood is irritable) and have been present to a
    significant degree

22
Hypomanic Episode
  • 1. Inflated self-esteem or grandiosity
  • 2. Decreased need for sleep (3 hours)
  • 3. More talkative than usual pressure of speech
  • 4. Flight of ideas
  • 5. Distractibility
  • 6. Increase in goal-directed activity
  • 7. Excessive pursuit of pleasurable activities

23
Hypomanic Episode
  • C. The episode is associated with an unequivocal
    change in functioning that is uncharacteristic of
    the person when not symptomatic.
  • D. The disturbance in mood and the change in
    functioning are observable by others.
  • E. The episode is Not severe enough to cause
    marked impairment in social or occupational
    functioning or to necessitate hospitalization and
    there are not psychotic features.
  • F. The SXs are not due to the effects of a
    substance or a general medical condition.

24
Bipolar Disorder I
  • Presence of Manic Episodes (can alternate with
    Hypomanic Episodes) and MDE.
  • Most often begins with depressive episode 67
    for men, 75 for women.
  • About 10 - 20 of individuals experience only
    manic episodes.
  • Untreated, manic episodes last about 3 months.
  • Eventual interval between manic episodes is 6 9
    months, some experience 4 to 6 per year and are
    termed rapid cycling.

25
Bipolar Disorder I
  • Can be single episode or recurrent
  • Recurrent comes in 5 types
  • Most recent episode hypomanic
  • Most recent episode manic
  • Most recent episode mixed
  • Most recent episode depressed
  • Most recent episode unspecified
  • About 10 to 15 of individuals with recurrent
    depressive episodes will eventually have a manic
    episode.

26
Bipolar Disorder II
  • A. Presence of one or more MDEs.
  • B. Presence of at least one Hypomanic Episode.
  • C. There has never been a Manic Episode.
  • D. The mood disorder in A and B above are not
    better accounted for by Schizoaffective Disorder
    and are not superimposed on any psychotic
    disorder.
  • E. The Sx,s cause clinically significant distress
    or impairment in social, occupational, or other
    areas.

27
Seasonal Fluctuation
  • As with Light Sensitive Seasonal Affective
    Disorder, Bipolar Disorder appears to be seasonal
    in a significant number of cases.
  • Recent research has indicated that it may show
    more seasonal fluctuation that other mood
    disorders.

Shin, K., et al. (2005) Journal of Affective
Disorder. 86 19-25
28
Cyclothymic Disorder
  • A. For at least 2 years (1 year in children and
    adolescents), the presence of numerous periods
    with hypomanic SXs and depressive SXs that do
    not meet the criteria for MDE.
  • B. During the 2-year period, the person has not
    been without SXs for more than 2 months at a
    time.
  • C. No MDE, Manic or Mixed Episodes during the
    first 2 years of the disturbance.

29
Cyclothymic Disorder
  • D. The SXs in A and B above are not better
    accounted for by Schizoaffective Disorder and are
    not superimposed on a psychotic disorder.
  • E. The SXs are not due to the direct
    physiological effects of a substance or a general
    medical condition.
  • F. The SXs cause clinically significant distress
    or impairment in social, occupational, or other
    areas.

30
Cyclothymic Disorder
  • If there are only hypomanic episodes without any
    symptoms of depression, the diagnosis should be
    Bipolar Disorder Not Otherwise Specified.
  • There has been very little study of this
    disorder.
  • Some clinicians maintain that Borderline
    Personality Disorder is actually a species of
    Cyclothymic Disorder.
  • 10 of outpatients and 20 of inpatients with BPD
    have coexisting Cyclothymic Disorder.
  • Female to male ratio is 3 to 2
  • In 50 to 75 of cases onset is between 15 and 25
    years of age.

31
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33
Mood Disorders in Children
  • Most frequent symptoms of depression common to
    children and adolescents
  • Suicidal ideation, depressed or irritable mood,
    insomnia, difficulty concentrating
  • Symptoms most common in children
  • Mood-congruent auditory hallucinations, somatic
    complaints, withdrawal and sad appearance, poor
    self-esteem
  • Symptoms most common in adolescents
  • Pervasive anhedonia, severe psychomotor
    retardation, delusions, sense of hopelessness

34
Mood Disorders in Children
  • Suicide in children and adolescents
  • Increased since 1950 from 2.5 to 11.2/100K
  • Among 15 to 19 year olds 13.6/100K for males,
    3.6/100K for females.
  • lt14 yrs. 50 attempts per 1 completion
  • gt14 yrs. 15 attempts per 1 completion
  • Most often involve Mood Disorder
  • Often, but not always, related to chaotic and
    stressful family situations.

35
Mood Disorders of Specific Etiology
  • Mood Disorder Due to a General Medical Condition
  • Degenerative Neurological Illness
  • Parkinsons Disease, Huntingtons Disease
  • Cerebrovascular Disease
  • Stroke
  • Endocrine Conditions
  • Hypo- and Hyperthyroidism
  • Hypo- and Hyperadrenocorticism
  • Autoimmune Conditions
  • Lupus erythematosus
  • Viral and Other Infections
  • Hepatitis, mononucleosis, HIV
  • Certain Cancers
  • Carcinoma of the pancreas

36
Mood Disorder Due to a General Medical Condition
  • A prominent and persistent disturbance in mood
    predominates, characterized by
  • 1. Depressed mood or diminished pleasure
  • 2. elevated, expansive, or irritable mood
  • There is evidence from history, PE, or labs that
    the disturbance is a direct consequence of a
    general medical condition

37
Mood Disorder Due to a General Medical Condition
  • The disturbance is not better accounted for by
    another mental disorder
  • Adjustment Disorder with Depressed Mood in
    response to having a general medical condition
  • The disturbance does not occur exlusively during
    delirium
  • The symptoms cause clinically significant
    impairment or distress

38
Mood Disorders of Specific Etiology
  • Substance Induced Mood Disorders
  • Can be caused by intoxication, withdrawal, side
    effects of medication, or toxic effects of a
    variety of substances
  • Is reserved for situations in which the mood
    symptoms are especially noteworthy.

39
Substance Induced Mood Disorders
  • A prominent and persistent disturbance in mood
    predominates, characterized by
  • 1. Depressed mood or diminished pleasure
  • 2. elevated, expansive, or irritable mood
  • There is evidence from history, PE, or labs that
    either
  • 1. The symptoms above developed within a month
    after substance intoxication or withdrawal
  • 2. Medication use is etiologically related to the
    disturbance

40
Substance Induced Mood Disorders
  • The disturbance is not better accounted for by a
    mood disorder that is not substance induced.
  • The disturbance precedes substance use
  • The disturbance continue long after substance
    cessation
  • The disturbance is in excess of what could be
    expected given the quantity and duration of
    substance use.
  • The disturbance does not occur exclusively during
    delirium
  • Cause clinically significant impairment or
    distress

41
Eating Disorders
42
Eating Disorders
  • The hallmark of these disorders is a distorted
    perception of body image and an extreme fear of
    weight gain.
  • These disorders are specific to the developed
    world, most specifically the US.
  • They effect females far more often than males.

43
ANOREXIA NERVOSA
  • Prevalence conservatively estimated at .5 to
    1.0 for Anorexia Nervosa - some place as high as
    4 for eating disorders as a whole
  • Mean onset at age 17 with peaks at 14 and 18
  • Gender distribution 90 of those with eating
    disorders are female

44
ANOREXIA NERVOSA
  • Familial/genetic factors shows heritability,
    also associated in family histories with
    depression, OCD, ETOH abuse/dependence
  • Endogenous opioids may play a role in denial and
    in the reported mental states associated with
    anorexia
  • Mortality is 5 to 18 during the condition
  • Even among those who recover, the path is not
    clear
  • Damage to cognitive systems can result from
    malnutrition and malnourishment
  • Susceptibility to other psychiatric conditions is
    increased

45
ANOREXIA NERVOSA CRITERIA
  • A. Refusal to maintain body weight at or above
    a minimally normal weight for age height a
    weight less than 85 of that expected or
    failure to make weight gain during period of
    growth resulting in less than 85 of that
    expected.
  • (wt. in kg/height in m2 lt17.5 kg/m2)
  • B. Intense fear of gaining weight or becoming
    fat even though under weight.

46
  • C. Disturbance in the way in which ones body
    weight or shape is experienced, undue influence
    of body weight or shape on self-evaluation, or
    denial of the seriousness of the current low body
    weight.
  • D. In postmenarcheal females, amenorrhea for 3
    consecutive cycles

47
  • Restricting Type has not done binge eating or
    purging
  • Controls weight through strict dieting or fasting
    and exercise
  • Tends to have compulsive personality
    characteristic, is rigid, inflexible, and adheres
    strictly to rules and is morally scrupulous.
  • Binge-Eating/Purging Type
  • during the episode of Anorexia, regularly binged
    or purged or both, or used laxatives, diuretics,
    or enemas.
  • More likely to engage in impulsive behaviors and
    substance abuse

48
BULIMIA NERVOSA
  • Prevalence is 1-3 among adolescent females,
    .1-.3 among adolescent males
  • Familial pattern same as anorexia some
    indication of association with obesity, but not
    definitively known yet.

49
BULIMIA NERVOSA CRITERIA
  • A. Recurrent episodes of binge eating
    characterized by both of the following
  • (1) eating, in a discrete period of time (e.g., 2
    hours) an amount of food that is definitely
    larger than most people would eat during a
    similar period under same circumstances.
  • (2) a sense of lack of control over eating during
    the episode (e.g., a feeling that one cannot stop
    eating or control what or how much one is eating.

50
  • B. Recurrent inappropriate compensatory behavior
    in order to prevent weight gain, such as
    self-induced vomiting, misuse of laxatives,
    diuretics enemas or other medications, fasting or
    exercise.
  • C. The binge eating and inappropriate
    compensatory behaviors both occur, on average, at
    least twice a week for 3 months.

51
  • D. Self-evaluation is unduly influenced by body
    weight and shape.
  • E. The disturbance does not occur exclusively
    during and episode of anorexia.
  • PURGING TYPE during the current episode, has
    regularly engaged in self-induced vomiting or
    misuse of laxatives, diuretics or enemas.
  • NONPURGING TYPE during the episode has used
    other inappropriate compensatory behaviors such
    as fasting, excessive exercise, but has not
    purged.

52
Sub Typing of Bulimia
  • Based on 178 bulimic women with comorbid
    psychopathology (depression, anxiety, substance
    use, impulsivity, self-destructive behavior, and
    perfectionism).
  • Affective-Perfectionistic Cluster
  • Most severe level of symptoms and preoccupation
    with body shape and weight.
  • Impulsive Cluster
  • Highest level of dissocial behavior and lowest
    levels of compulsivity.
  • Low Comorbid Cluster
  • Most numerous, lowest levels of all pathologies.

Wonderlich, S., et al. (2005) Psychological
Medicine, 25 649-657
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