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Mood Disorders

Mood Disorders. Bruce Shapiro, M.D. April 6, 2001. Do psychiatrists have mood swings?. What Determines Mood?. Harlow and Spitz. Gross Anatomy. Neuroimaging. Regionalization questions. Synapse. Intracellular activities. Brain mediated environment. History. Mood Disorders.

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Mood Disorders

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  1. Mood Disorders Bruce Shapiro, M.D. April 6, 2001

  2. Do psychiatrists have mood swings?

  3. What Determines Mood?

  4. Harlow and Spitz

  5. Gross Anatomy

  6. Neuroimaging

  7. Regionalization questions

  8. Synapse

  9. Intracellular activities

  10. Brain mediated environment

  11. History... Mood Disorders

  12. History • The Bible (King Saul, Job) • Hippocrates - Humoral theory • Arateus - Psychological theory • 1800’s - Physical diagnosis • 1900’s - Psychological diagnosis • 1930’s - Somatic interventions • 1940’s - Psychoanalysis • 1950’s - Psychopharmacology • 1980’s - Biological markers • 1990’s - Neuroimaging • 2000’s - Herbals and magnetism ...

  13. Hippocrates

  14. Mood Disorders Famous Sufferers ...

  15. Abraham Lincoln

  16. Winston Churchill

  17. Churchill'sBlack Dog • "Black Dog”: Churchill's name for his depression • Lord Moran: inborn melancholia • Periods of solitude • Periods of high energy • Highly functional

  18. Ernest Hemingway

  19. Suicide - Familial Aspects

  20. A Quote “In my last severe depression, I took coca again and a small dose lifted me to the heights in a wonderful fashion”

  21. Sigmund Freud

  22. Freud and Mom or Mom and Freud?

  23. Famous Living Bipolars • Robert Boorstin, writer, special assistant to President Clinton • Rosemary Clooney, singer • Dick Cavett, writer, media personality • Kitty Dukakis, former First Lady of Massachusetts • Patty Duke (Anna Pearce), actor, writer • Connie Francis, actor, musician • Shecky Greene, comedian • Kristy McNichols, actress • Kate Millett, writer • Charley Pride, musician • Axl Rose, musician • Ted Turner, entrepreneur, media giant • Jonathon Winters, comedian, actor, writer, artist

  24. Famous Living Unipolars • Buzz Aldrin, astronaut • Rona Barrett, entertainment reporter, author • Art Buchwald, writer • Barbara Bush, former U.S. First Lady • Ray Charles, musician • Eric Clapton, musician • Dick Clark, television personality • Leonard Cohen, musician, writer • Francis Ford Coppola, director • Michael Crichton, writer • Kathy Conkrite, writer • Sheryl Crow, musician • Mike Douglas, media personality • Tony Dow, actor, director >>

  25. Famous Living Unipolars • James Farmer, civil rights activist • John Kenneth Galbraith, economist, educator, author • Mariette Hartley, actor • Anthony Hopkins, actor • Robert McFarlane, former US National Security Advisor • Joan Rivers, comedienne, talk show host • Roseanne, actor, writer, comedienne • Rod Steiger, actor • William Styron, writer • James Taylor, musician • Livingston Taylor, musician • Mike Wallace, news anchor • Marie Osmond, entertainer

  26. Mood Disorders Classification and Demographics ...

  27. Mood Disorders (DSM-IV) • Depressive Disorders • Major Depressive Disorder (single/recurrent) • Dythymic Disorder • Depressive Disorder, NOS • Bipolar Disorders • Bipolar I • Bipolar II • Cyclothymic Disorder • Bipolar Disorder, NOS • Mood Disorder due to: • Medical condition • Substance induced

  28. Mood Disorders - DSM IV

  29. Unipolar vs Bipolar Unipolar Bipolar Prev 5% 1% Gender F>M F=M Onset 30’s 20’s Suicide 15% 20% Sleep insom hyper Rx unipolar bipolar III Genetics lower higher

  30. Epidemiology • Lifetime risks: • Major Depression: 6 % • All mood disorders: 8 % • Prevalence • Major Depression: (point prevalence approx 5 -6 %) • Males: 2.6 - 5.5% • Females: 6.0 - 11.8 % • Dysthymia: 3 - 4 % • In primary care practice: • Major Depression: 4.8 - 9.2 % • All depressive disorders: 9 - 20 % • Bipolar Disorder: 1.0 - 2.5 % • 5 - 15 % of adult depressions are bipolar

  31. Prevalence of Mood Disorders • 20% of the U.S. population reports at least one depressive symptom in a given month • 12% report two or more depressive symptoms in a year • Major Depression: 5% in the previous 30 days, • Bipolar Disorder - approximately 1 % of the population • Increase in cohort post 1940 • Younger age of onset

  32. Genetics • Unipolar • Dizygotic: 30% • Monozygotic: 50% • Family history: 25% • Bipolar • Dizygotic: 30% • Monozygotic: 80% • Family history: 50%

  33. Gender differences • Bipolar - no difference • Unipolar - Female > Male • ?genetic • sociocultural • alcoholism/substance abuse

  34. Mood Disorders: Across the Lifespan • Infancy - Spitz and Harlow • Childhood - depressive equivalents • Adolescence - major onset; substance abuse • Adulthood - major onset • Geriatric - multiple symptoms; pseudodementia; differential medical diagnoses

  35. Predisposing factors • Prior mood disorder or moodswings • Positive family history • Female gender • Severe prolonged stress • Recent loss • Postpartum period • Medical co-morbidity • Current alcohol/substance abuse

  36. Prognosis • Major Depression recurrence rates: 1 episode: 50 - 60% 2 episodes: 70% 3 episodes: 90% • Untreated episode: 6-12 months • 20-30 % chronicity • Episode length and frequency: shorter episodes with increasing frequency • Treatment yields good results

  37. Mood Disorders Clinical Syndromes ...

  38. Hypomania:What does it feel like? “At first when I'm high, it's tremendous...ideas are fast...like shooting stars you follow until brighter ones appear...all shyness disappears, the right words and gestures are suddenly there...uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria...you can do anything...but, somewhere this changes”.

  39. Mania:What does it feel like? “The fast ideas become too fast and there are far too many...overwhelming confusion replaces clarity...you stop keeping up with it--memory goes. Infectious humor ceases to amuse. Your friends become frightened...everything is now against the grain...you are irritable, angry, frightened, uncontrollable, and trapped”.

  40. Clinical Mania • A sustained period of behavior that is different from usual • Increased energy, activity, restlessness, • Racing thoughts and rapid talking • Excessive "high" or euphoric feelings • Extreme irritability and distractibility • Decreased need for sleep • Unrealistic beliefs in one's abilities and powers • Uncharacteristically poor judgment >>

  41. Clinical Mania • Reckless behavior • Increased suspiciousness/paranoid ideation • Increased sexual drive • Abuse of drugs, particularly cocaine, alcohol, and sleeping medications • Flight of ideas • Provocative, intrusive, or aggressive behavior • Possibly delusions (paranoid/grandiose/religious) • Possibly hallucinations • Denial that anything is wrong

  42. Cycle Length

  43. Bipolar: Frequency of Recurrence

  44. Hypomania • Inflated self-esteem • Decreased need for sleep • More talkative than usual • Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments) • Increased activity • No major life disruption • No need for hospitalization • No psychotic symptoms

  45. Cyclothymia • Alternating hypomania and non-major depression • At least 2 years in duration

  46. Depression:What does it feel like? “I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless....[I am] haunt[ed]...with the total, the desperate hopelessness of it all... Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think, or care, then what on earth is the point?”

  47. Sadness vs Clinical Depression • Intensity • Duration • Neurovegetative changes • Self esteem changes • Normal Grief vs. Depressive Illness

  48. Depressive Disorders - DSM - IV • Major Depressive Disorder (296.xx) • Dysthymic Disorder (300.4) • Depressive Disorder NOS (311) • Mood Disorder due to general medical condition (293.83) • Substance-Induced mood disorder (293.83)

  49. Clinical Depression • Loss of the ability to experience pleasure • Unexplained or prolonged sadness or crying spells • Significant changes in appetite and sleep patterns • Diurnal variation of mood • Irritability, anger, worry, agitation, anxiety • Pessimism, indifference • A sense of hoplessness/helplessness

  50. Clinical Depression • Loss of energy, persistent lethargy, pathological fatigue • Feelings of guilt, worthlessness • Inability to concentrate, indecisiveness • Social withdrawal • Difficulty with personal hygiene • Unexplained aches and pains • May have delusions or hallucinations • Recurring thoughts of death or suicide

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