From Wikipedia, the free encyclopedia
Mood disorder |
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Other names | mental disorder |
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A depressive man standing by a country pond in the pouring rain |
Specialty | Psychiatry |
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Types | Bipolar disorder, cyclothymia, disruptive mood dysregulation disorder, dysthymia, major depressive disorder, premenstrual dysphoric disorder, seasonal affective disorder |
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Causes | Family
history, previous diagnosis of a mood disorder, trauma, stress or major
life changes in the case of depression, physical illness or use of
certain medications. Depression has been linked to major diseases such
as cancer, diabetes, Parkinson’s disease and heart disease, Brain
structure and function in the case of bipolar disorder. |
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Medication | Antidepressants, mood stabilizers, antipsychotics |
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A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).
Mood disorders fall into seven groups, including; abnormally elevated mood, such as mania or hypomania; depressed mood, of which the best-known and most researched is major depressive disorder
(MDD) (alternatively known as clinical depression, unipolar depression,
or major depression); and moods which cycle between mania and
depression, known as bipolar disorder
(BD) (formerly known as manic depression). There are several sub-types
of depressive disorders or psychiatric syndromes featuring less severe
symptoms such as dysthymic disorder (similar to MDD, but longer lasting and more persistent, though often milder) and cyclothymic disorder (similar to but milder than BD).
In some cases, more than one mood disorder can be present in an
individual, like bipolar disorder and depressive disorder. If a mood
disorder and schizophrenia are both present in an individual, this is known as schizoaffective disorder. Mood disorders may also be substance induced, or occur in response to a medical condition.
English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.
Classification
Depressive disorders
- Major depressive disorder (MDD), commonly called major depression, unipolar depression, or clinical depression, wherein a person has one or more major depressive episodes.
After a single episode, Major Depressive Disorder (single episode)
would be diagnosed. After more than one episode, the diagnosis becomes
Major Depressive Disorder (Recurrent). Depression without periods of
mania is sometimes referred to as unipolar depression because the mood remains at the bottom "pole" and does not climb to the higher, manic "pole" as in bipolar disorder.
- Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide. Seeking help
and treatment from a health professional dramatically reduces the
individual's risk for suicide. Studies have demonstrated that asking if a
depressed friend or family member has thought of committing suicide is
an effective way of identifying those at risk, and it does not "plant"
the idea or increase an individual's risk for suicide in any way.
Epidemiological studies carried out in Europe suggest that, at this
moment, roughly 8.5 percent of the world's population have a depressive
disorder. No age group seems to be exempt from depression, and studies
have found that depression appears in infants as young as 6 months old
who have been separated from their mothers.
- Depressive disorder is frequent in primary care and general
hospital practice but is often undetected. Unrecognized depressive
disorder may slow recovery and worsen prognosis in physical illness,
therefore it is important that all doctors be able to recognize the
condition, treat the less severe cases, and identify those requiring
specialist care.
- Diagnosticians recognize several subtypes or course specifiers:
- Atypical depression (AD) is characterized by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite ("comfort eating"), excessive sleep or somnolence (hypersomnia),
a sensation of heaviness in limbs known as leaden paralysis, and
significant social impairment as a consequence of hypersensitivity to
perceived interpersonal rejection. Difficulties in measuring this subtype have led to questions of its validity and prevalence.
- Psychotic major depression (PMD),
or simply psychotic depression, is the term for a major depressive
episode, in particular of melancholic nature, wherein the patient
experiences psychotic symptoms such as delusions or, less commonly, hallucinations. These are most commonly mood-congruent (content coincident with depressive themes).
- Postpartum depression (PPD)
is listed as a course specifier in DSM-IV-TR; it refers to the intense,
sustained and sometimes disabling depression experienced by women after
giving birth. Postpartum depression, which affects 10–15% of women,
typically sets in within three months of labor, and lasts as long as three months.
It is quite common for women to experience a short-term feeling of
tiredness and sadness in the first few weeks after giving birth;
however, postpartum depression is different because it can cause
significant hardship and impaired functioning at home, work, or school
as well as, possibly, difficulty in relationships with family members,
spouses, or friends, or even problems bonding with the newborn. In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications. Women with personal or family histories of mood disorders are at particularly high risk of developing postpartum depression.
- Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome affecting 3–8% of menstruating women. The disorder consists of a "cluster of affective, behavioral and somatic symptoms" that recur monthly during the luteal phase of the menstrual cycle. PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders
in 2013. The exact pathogenesis of the disorder is still unclear and is
an active research topic. Treatment of PMDD relies largely on
antidepressants that modulate serotonin levels in the brain via
serotonin reuptake inhibitors as well as ovulation suppression using
contraception.
- Seasonal affective disorder (SAD),
also known as "winter depression" or "winter blues", is a specifier.
Some people have a seasonal pattern, with depressive episodes coming on
in the autumn or winter, and resolving in spring. The diagnosis is made
if at least two episodes have occurred in colder months with none at
other times over a two-year period or longer.
It is commonly hypothesised that people who live at higher latitudes
tend to have less sunlight exposure in the winter and therefore
experience higher rates of SAD, but the epidemiological support for this
proposition is not strong (and latitude is not the only determinant of
the amount of sunlight reaching the eyes in winter). It is said that
this disorder can be treated by light therapy. SAD is also more prevalent in people who are younger and typically affects more females than males.
- Dysthymia
is a condition related to unipolar depression, where the same physical
and cognitive problems are evident, but they are not as severe and tend
to last longer (usually at least 2 years). The treatment of dysthymia is largely the same as for major depression, including antidepressant medications and psychotherapy.
- Double depression
can be defined as a fairly depressed mood (dysthymia) that lasts for at
least two years and is punctuated by periods of major depression.
- Unspecified Depressive Disorder is designated by the code 311
for depressive disorders. In the DSM-5, Unspecified Depressive Disorder
encompasses symptoms that are characteristic of depressive disorders
and cause significant impairment in functioning, but do not meet the
criteria for the diagnosis of any specified depressive disorders. In the
DSM-IV, this was called Depressive Disorder Not Otherwise Specified.
- Depressive personality disorder
(DPD) is a controversial psychiatric diagnosis that denotes a
personality disorder with depressive features. Originally included in
the DSM-II, depressive personality disorder was removed from the DSM-III
and DSM-III-R.
Recently, it has been reconsidered for reinstatement as a diagnosis.
Depressive personality disorder is currently described in Appendix B in
the DSM-IV-TR as worthy of further study.
- Recurrent brief depression (RBD),
distinguished from major depressive disorder primarily by differences
in duration. People with RBD have depressive episodes about once per
month, with individual episodes lasting less than two weeks and
typically less than 2–3 days. Diagnosis of RBD requires that the
episodes occur over the span of at least one year and, in female
patients, independently of the menstrual cycle. People with clinical depression can develop RBD, and vice versa and both illnesses have similar risks.
- Minor depressive disorder,
or simply minor depression, which refers to a depression that does not
meet full criteria for major depression but in which at least two
symptoms are present for two weeks.
Bipolar disorders
- Bipolar disorder
(BD) (also called "manic depression" or "manic-depressive disorder"),
an unstable emotional condition characterized by cycles of abnormal,
persistent high mood (mania) and low mood (depression), which was formerly known as "manic depression" (and in some cases rapid cycling, mixed states, and psychotic symptoms). Subtypes include:
- Bipolar I is distinguished by the presence or history of one or more manic episodes or mixed episodes
with or without major depressive episodes. A depressive episode is not
required for the diagnosis of Bipolar I Disorder, but depressive
episodes are usually part of the course of the illness.
- Bipolar II consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes.
- Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
- Bipolar disorder not otherwise specified (BD-NOS),
sometimes called "sub-threshold" bipolar, indicates that the patient
has some symptoms in the bipolar spectrum (e.g., manic and depressive
symptoms) but does not fully qualify for any of the three formal bipolar
DSM-IV diagnoses mentioned above.
- It is estimated that roughly 1% of the adult population has bipolar
I, a further 1% has bipolar II or cyclothymia, and somewhere between 2%
and 5% percent have "sub-threshold" forms of bipolar disorder.
Furthermore, the possibility of getting bipolar disorder when one parent
is diagnosed with it is 15–30%. Risk, when both parents have it, is
50–75%. Also, while with bipolar siblings the risk is 15–25%, with
identical twins it is about 70%.
Substance-induced
A mood disorder can be classified as substance-induced if its etiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Also, an individual may have a mood disorder coexisting with a substance abuse
disorder. Substance-induced mood disorders can have features of a
manic, hypomanic, mixed, or depressive episode. Most substances can
induce a variety of mood disorders. For example, stimulants such as amphetamine, methamphetamine, and cocaine can cause manic, hypomanic, mixed, and depressive episodes.
Alcohol-induced
High rates of major depressive disorder occur in heavy drinkers and those with alcoholism.
Controversy has previously surrounded whether those who abused alcohol
and developed depression were self-medicating their pre-existing
depression. Recent research has concluded that, while this may be true
in some cases, alcohol misuse directly causes the development of
depression in a significant number of heavy drinkers. Participants
studied were also assessed during stressful events in their lives and
measured on a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviant peers, unemployment, and their partner's substance use and criminal offending. High rates of suicide also occur in those who have alcohol-related problems.
It is usually possible to differentiate between alcohol-related
depression and depression that is not related to alcohol intake by
taking a careful history of the patient.
Depression and other mental health problems associated with alcohol
misuse may be due to distortion of brain chemistry, as they tend to
improve on their own after a period of abstinence.
Benzodiazepine-induced
Benzodiazepines, such as alprazolam, clonazepam, lorazepam and diazepam, can cause both depression and mania.
Benzodiazepines are a class of medication commonly used to treat anxiety, panic attacks and insomnia, and are also commonly misused and abused.
Those with anxiety, panic and sleep problems commonly have negative
emotions and thoughts, depression, suicidal ideations, and often have
comorbid depressive disorders. While the anxiolytic and hypnotic effects of benzodiazepines may disappear as tolerance develops, depression and impulsivity with high suicidal risk commonly persist.
These symptoms are "often interpreted as an exacerbation or as a
natural evolution of previous disorders and the chronic use of sedatives
is overlooked".
Benzodiazepines do not prevent the development of depression, can
exacerbate preexisting depression, can cause depression in those with no
history of it, and can lead to suicide attempts.
Risk factors for suicide and suicide attempts while using
benzodiazepines include high dose prescriptions (even in those not
misusing the medications), benzodiazepine intoxication, and underlying
depression.
The long-term use of benzodiazepines may have a similar effect on the brain as alcohol, and are also implicated in depression. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression.
Additionally, benzodiazepines can indirectly worsen mood by worsening
sleep (i.e., benzodiazepine-induced sleep disorder). Like alcohol,
benzodiazepines can put people to sleep but, while asleep, they disrupt
sleep architecture: decreasing sleep time, delaying time to REM sleep, and decreasing deep sleep (the most restorative part of sleep for both energy and mood).
Just as some antidepressants can cause or worsen anxiety in some
patients due to being activating, benzodiazepines can cause or worsen
depression due to being a central nervous system depressant—worsening thinking, concentration and problem solving (i.e., benzodiazepine-induced neurocognitive disorder).
However, unlike antidepressants, in which the activating effects
usually improve with continued treatment, benzodiazepine-induced
depression is unlikely to improve until after stopping the medication.
In a long-term follow-up study of patients dependent on
benzodiazepines, it was found that 10 people (20%) had taken drug
overdoses while on chronic benzodiazepine medication despite only two
people ever having had any pre-existing depressive disorder. A year
after a gradual withdrawal program, no patients had taken any further
overdoses.
Just as with intoxication and chronic use, benzodiazepine withdrawal can also cause depression.
While benzodiazepine-induced depressive disorder may be exacerbated
immediately after discontinuation of benzodiazepines, evidence suggests
that mood significantly improves after the acute withdrawal period to
levels better than during use.
Depression resulting from withdrawal from benzodiazepines usually
subsides after a few months but in some cases may persist for 6–12
months.
Due to another medical condition
"Mood
disorder due to a general medical condition" is used to describe manic
or depressive episodes which occur secondary to a medical condition. There are many medical conditions that can trigger mood episodes, including neurological disorders (e.g. dementias), hearing loss and associated disorders (e.g. tinnitus or hyperacusis), metabolic disorders (e.g. electrolyte disturbances), gastrointestinal diseases (e.g. cirrhosis), endocrine disease (e.g. thyroid abnormalities), cardiovascular disease (e.g. heart attack), pulmonary disease (e.g. chronic obstructive pulmonary disease), cancer, and autoimmune diseases (e.g. multiple sclerosis).
Pregnancy
Not otherwise specified
Mood disorder not otherwise specified (MD-NOS) is a mood disorder
that is impairing but does not fit in with any of the other officially
specified diagnoses. In the DSM-IV MD-NOS is described as "any mood disorder that does not meet the criteria for a specific disorder." MD-NOS is not used as a clinical description but as a statistical concept for filing purposes.
The diagnosis of MD-NOS does not exist in the DSM-5, however the
diagnoses of unspecified depressive disorder and unspecified bipolar
disorder are in the DSM-5.
Most cases of MD-NOS represent hybrids between mood and anxiety disorders, such as mixed anxiety-depressive disorder or atypical depression.
An example of an instance of MD-NOS is being in minor depression
frequently during various intervals, such as once every month or once in
three days. There is a risk for MD-NOS not to get noticed, and for that reason not to get treated.
Causes
Meta-analyses show that high scores on the personality domain neuroticism are a strong predictor for the development of mood disorders. A number of authors have also suggested that mood disorders are an evolutionary adaptation (see also evolutionary psychiatry).
A low or depressed mood can increase an individual's ability to cope
with situations in which the effort to pursue a major goal could result
in danger, loss, or wasted effort.
In such situations, low motivation may give an advantage by inhibiting
certain actions. This theory helps to explain why negative life
incidents precede depression in around 80 percent of cases,
and why they so often strike people during their peak reproductive
years. These characteristics would be difficult to understand if
depression were a dysfunction.
A depressed mood is a predictable response to certain types of
life occurrences, such as loss of status, divorce, or death of a child
or spouse. These are events that signal a loss of reproductive ability
or potential, or that did so in humans' ancestral environment. A
depressed mood can be seen as an adaptive response, in the sense that it
causes an individual to turn away from the earlier (and reproductively
unsuccessful) modes of behavior.
A depressed mood is common during illnesses, such as influenza.
It has been argued that this is an evolved mechanism that assists the
individual in recovering by limiting their physical activity. The occurrence of low-level depression during the winter months, or seasonal affective disorder, may have been adaptive in the past, by limiting physical activity at times when food was scarce.
It is argued that humans have retained the instinct to experience low
mood during the winter months, even if the availability of food is no
longer determined by the weather.
Much of what is known about the genetic influence of clinical
depression is based upon research that has been done with identical
twins. Identical twins have exactly the same genetic code. It has been
found that when one identical twin becomes depressed the other will also
develop clinical depression approximately 76% of the time. When
identical twins are raised apart from each other, they will both become
depressed about 67% of the time. Because both twins become depressed at
such a high rate, the implication is that there is a strong genetic
influence. If it happened that when one twin becomes clinically
depressed the other always develops depression, then clinical depression
would likely be entirely genetic.
Bipolar disorder is also considered a mood disorder and it is hypothesized that it might be caused by mitochondrial dysfunction.
Sex differences
Mood
disorders, specifically stress-related mood disorders such as anxiety
and depression, have been shown to have differing rates of diagnosis
based on sex. In the United States, women are two times more likely than
men to be diagnosed with a stress-related mood disorder.
Underlying these sex differences, studies have shown a dysregulation of
stress-responsive neuroendocrine function causing an increase in the
likelihood of developing these affective disorders.
Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis could
provide potential insight into how these sex differences arise.
Neuropeptide corticotropin-releasing factor (CRF) is released from the
paraventricular nucleus (PVN) of the hypothalamus, stimulating
adrenocorticotropic hormone (ACTH) release into the blood stream. From
here ACTH triggers the release of glucocorticoids such as cortisol from
the adrenal cortex. Cortisol, known as the main stress hormone, creates a
negative feedback loop back to the hypothalamus to deactivate the
stress response.
When a constant stressor is present, the HPA axis remains overactivated
and cortisol is constantly produced. This chronic stress is associated
with sustained CRF release, resulting in the increased production of
anxiety- and depressive-like behaviors and serving as a potential
mechanism for differences in prevalence between men and women.
Diagnosis
DSM-5
The DSM-5, released in May 2013, separates the mood disorder chapter from the DSM-TR-IV
into two sections: Depressive and related disorders and bipolar and
related disorders. Bipolar disorders fall in between depressive
disorders and schizophrenia spectrum and related disorders "in
recognition of their place as a bridge between the two diagnostic
classes in terms of symptomatology, family history and genetics" (Ref.
1, p 123). Bipolar disorders underwent a few changes in the DSM-5,
most notably the addition of more specific symptomology related to
hypomanic and mixed manic states. Depressive disorders underwent the
most changes, the addition of three new disorders: disruptive mood
dysregulation disorder, persistent depressive disorder (previously
dysthymia), and premenstrual dysphoric disorder (previously in appendix
B, the section for disorders needing further research). Disruptive mood
dysregulation disorder is meant as a diagnosis for children and
adolescents who would normally be diagnosed with bipolar disorder as a
way to limit the bipolar diagnosis in this age cohort. Major depressive
disorder (MDD) also underwent a notable change, in that the bereavement
clause has been removed. Those previously exempt from a diagnosis of MDD
due to bereavement are now candidates for the MDD diagnosis.
Treatment
There are different types of treatments available for mood disorders, such as therapy and medications. Behaviour therapy, cognitive behaviour therapy and interpersonal therapy have all shown to be potentially beneficial in depression. Major depressive disorder medications usually include antidepressants; a combination of antidepressants and cognitive behavioral therapy has shown to be more effective than one treatment alone. Bipolar disorder medications can consist of antipsychotics, mood stabilizers, anticonvulsants and/or lithium. Lithium specifically has been proven to reduce suicide and all causes of mortality in people with mood disorders. If mitochondrial dysfunction or mitochondrial diseases are the cause of mood disorders like bipolar disorder,
then it has been hypothesized that N-acetyl-cysteine (NAC),
acetyl-L-carnitine (ALCAR), S-adenosylmethionine (SAMe), coenzyme Q10
(CoQ10), alpha-lipoic acid (ALA), creatine monohydrate (CM), and
melatonin could be potential treatment options.
In determining treatment, there are many types of depression scales
that are used. One of the depression scales is a self-report scale
called Beck Depression Inventory (BDI). Another scale is the Hamilton
Depression Rating Scale (HAMD). HAMD is a clinical rating scale in which
the patient is rated based on clinician observation.
The Center for Epidemiologic Studies Depression Scale (CES-D) is a
scale for depression symptoms that applies to the general population.
This scale is typically used in research and not for self-reports. The
PHQ-9 which stands for Patient-Health Questionnaire-9 questions, is a
self-report as well. Finally, the Mood Disorder Questionnaire (MDQ)
evaluates bipolar disorder.
Epidemiology
According
to a substantial number of epidemiology studies conducted, women are
twice as likely to develop certain mood disorders, such as major
depression. Although there is an equal number of men and women
diagnosed with bipolar II disorder, women have a slightly higher
frequency of the disorder.
In 2011, mood disorders were the most common reason for
hospitalization among children aged 1–17 years in the United States,
with approximately 112,000 stays. Mood disorders were top principal diagnosis for Medicaid super-utilizers in the United States in 2012.
Further, a study of 18 states found that mood disorders accounted for
the highest number of hospital readmissions among Medicaid patients and
the uninsured, with 41,600 Medicaid patients and 12,200 uninsured
patients being readmitted within 30 days of their index stay—a
readmission rate of 19.8 per 100 admissions and 12.7 per 100 admissions,
respectively.
In 2012, mood and other behavioral health disorders were the most
common diagnoses for Medicaid-covered and uninsured hospital stays in
the United States (6.1% of Medicaid stays and 5.2% of uninsured stays).
A study conducted in 1988 to 1994 amongst young American adults
involved a selection of demographic and health characteristics. A
population-based sample of 8,602 men and women ages 17–39 years
participated. Lifetime prevalence were estimated based on six mood
measures:
- major depressive episode (MDE) 8.6%,
- major depressive disorder with severity (MDE-s) 7.7%,
- dysthymia 6.2%,
- MDE-s with dysthymia 3.4%,
- any bipolar disorder 1.6%, and
- any mood disorder 11.5%.
Research
Kay Redfield Jamison and others have explored the possible links between mood disorders – especially bipolar disorder – and creativity. It has been proposed that a "ruminating personality type may contribute to both [mood disorders] and art."
Jane Collingwood notes an Oregon State University study that:
looked
at the occupational status of a large group of typical patients and
found that 'those with bipolar illness appear to be disproportionately
concentrated in the most creative occupational category.' They also
found that the likelihood of 'engaging in creative activities on the
job' is significantly higher for bipolar than nonbipolar workers.
In Liz Paterek's article "Bipolar Disorder and the Creative Mind" she wrote:
Memory
and creativity are related to mania. Clinical studies have shown that
those in a manic state will rhyme, find synonyms, and use alliteration
more than controls. This mental fluidity could contribute to an
increase in creativity. Moreover, mania creates increases in
productivity and energy. Those in a manic state are more emotionally
sensitive and show less inhibition about attitudes, which could create
greater expression. Studies performed at Harvard looked into the amount
of original thinking in solving creative tasks. Bipolar individuals,
whose disorder was not severe, tended to show greater degrees of
creativity.
The relationship between depression and creativity appears to be especially strong among poets.