Lyudmyla T. Snovyda

1. Affect disorders. Mask depression. Epilepsy. Etiology and pathogeny. Classification. Epileptic psychoses. Patients with changes of personality on epileptic type. Lyudmyla T. Snovyda

2. SADNESS AND DEPRESSION • Sadness • All of us have experienced sadness, the undesired emotion which accompaniesundesired events, such as loss of a valued object or individual, or failure to achieve adesired goal. While healthy people report days when they are “a bit down” for no • apparent reason, in healthy people, significant sadness occurs only as a reaction to events. • In the mood disorders, the mood shifts excessively in response to minor events, or autonomously, that is, in the absence of stimulating events, and once shifted the pathological mood position is sustained

3. SADNESS AND DEPRESSION • Grief • Grief is the term applied to the unpleasant experience of having lost a significant other person. While this experience can result from the loss of inanimate objects, such as a valuable art works collected over a lifetime, grief most commonly occurs with the loss of an individual who has been important in our lives. Grief is emotional pain, accompanied by a longing for the return of the lost object, and a feeling of loss, emptiness and incompletenes s. In Western cultures there may be crying, insomnia and loss of appetite. There may be a sense of guilt at being alive in the absence of the important other, and auditory and visual hallucinations of the lost individual.

4. SADNESS AND DEPRESSION • Grief • Culture influences the expression and experience of grief. Some cultures prescribe the behaviour and dress of the bereaved, and even the precise length of the grieving/mourning process. The details vary depending on the nature of the relationship (universally, spouses grieve longer than siblings). There are advantages of an established grieving protocol. The bereaved individua l, who is distressed and • finds making decisions difficult, has a clear scrip t/ritual to follow. Adhering to the ritual ensures no one is offended during this emotiona l time. Also, once all steps/obligations have been fulfilled there is a sanctioned end to the grieving, and the bereaved are to return to their usual life .

5. SADNESS AND DEPRESSION • Grief • The grief reaction is considered to have become “pathological” when it persists longer than usual or has unusual features (Nakamura, 1999). There is concern when the grief is not abating some months after the death. It is generally believed the grieving • process takes 6 to 12 months. • Unusual features which identify pathological grief include distress to a much greater degree than is culturally sanctioned. The bereaved individual who has not eaten or slept and is inconsolable one week after the event is suffering excessively

6. SADNESS AND DEPRESSION

7. SADNESS AND DEPRESSION • When pathological guilt is suspected, it is im portant to exclude other diagnosable conditions (major depressive disorder or anxiety disorder s) which may have been triggered by the loss. Along with grief counselling and support, any co -morbid disorders should be treated in the standard manner. • Grief and pathological grief are yet to be fully elucidated. For example, what does “recovery” mean following the loss of a spouse of 50 years? Pathological grief is not • listed in the DSM-IV.

8. Depression • We all suffer sadness in response to undesired events such as loss. In this section, those psychiatric disorders will be outlined, in which the mood is changed in the direction of sadness/depression . It is important to be aware that in these disorders, mood change is not the only symptom; others include vegetative symptoms such as sleep and appetite change. Thus, these d isorders are diagnosed using batches or • patterns of symptoms. • The main disorders include major depressive disorder, bipolar depression and dysthymia. Until recent times it was considered that the depressed episode in major depressive disorder and bipolar depression were much the same.

9. Depression • This is now in doubt; certainly bipolar depression presents a greater challenge to the clinician. Dysthymia is distressing condition, but the depth or the sadness and impairment of function is less • severe than major depressive disorder and bipolar depression.

10. Major depressive episode • A major depressive episode is a batch or pattern of symptoms, which is the same for • depressive disorder and bipolar depression. The final diagnosis of major depressive • disorder as opposed to bipolar depression depends on whether ther e has been an • episode of mania (pathologi cal mood elevation) in the past..

11. Major depressive episode • Criteria for major depressive episode: • 1. At least one of the following for at least two weeks: • persistent depressed mood • loss of interest and pleasure. • 2. At least four of the following: • significant weight loss or gain,insomnia or increased sleep, agitation (worrying and physical restlessness) or retardation (slowed thinking and moving),fatigue or loss of energy • feelings of worthlessness or inappropriate guilt • diminished ability to concentrate or indecisiveness • thoughts of death or suicide.

12. Major depressive episode • Major depressive disorder • Major depressive disorder is diagnosed when there is/has been one or more major depressive episodes and no history of mania or hypomania • This serious disorder causes great suffering and may end in suicide. The prevalence in Western societies is 5.4 to 8.9 % (Narrow et al, 2002). A recent modelling study found that close to half the population can expect one or more episodes of depression • in their lifetime (Andrews et al, 2005). The prevalence of depressive disorder is twice as common in females. The average age of onset is in the mid -20s.

13. Major depressive episode • 80% of people who suffer a major depressive episode will have recurrent episodes. The clinical course of depression is not as favourable as was once believed. In fact, at one year follow up, only 40% of patients are symptom free, 20% have some residual • symptoms, and the final 40% still have depressive disorder. About 15% of people with either depressive disorder or bipolar disorder die by suicide. • Abnormalities in a range of neurotransmi tter have been proposed, including serotonin, • norepinephrine, dopamine, GABA, brain derived neurotrophic factor, somatostatin, • acetylcholine, corticotropin releasing factor, and substance P.

14. Major depressive episode • Aetiology • Heritability of depression is estimated to be in the range 31-42% . No single gene for major effect have been identified. A multitude of genes • with small effect are likely to be involved, which interact with environmental factors. In addition to genetic factors, other risk factors i nclude neurotic personality traits, low self-esteem, early onset anxiety, a history of conduct disorder, substance misuse, adversity, interpersonal difficulties, low parental warmth, childhood sexual abuse, low eduction, lifetime trauma, low social support , divorce and stressful life events

15. Major depressive episode • Aetiology • Heritability of depression is estimated to be in the range 31-42% . No single gene for major effect have been identified. A multitude of genes • with small effect are likely to be involved, which interact with environmental factors. In addition to genetic factors, other risk factors i nclude neurotic personality traits, low self-esteem, early onset anxiety, a history of conduct disorder, substance misuse, adversity, interpersonal difficulties, low parental warmth, childhood sexual abuse, low eduction, lifetime trauma, low social support , divorce and stressful life events

16. Bipolar depression • In the mid 1960’s the conclusion w as drawn that bipolar disorder (formerly manic • depressive psychosis) and major depressive disorder (also termed unipolar • depression) are different disorders

17. Bipolar depression • The depressive episodes seen in bipolar disorder, in contrast to those typically seen in a major depression, tend to come on fairly acutely, over perhaps a few weeks, and often occur without any significant precipitating factors. They tend to be characterized by psychomotor retardation, hyperphagia, and hypersomnolence and are not uncommonly accompanied by delusions or hallucinations. On the average, untreated, these bipolar depressions tend to last about a half year. • Mood is depressed and often irritable. The patients are discontented and fault-finding and may even come to loathe not only themselves but also everyone around them.

18. Bipolar depression • Patients may lose interest in life; things appear dull and heavy and have no attraction.Many patients feel a greatly increased need for sleep. Some may succumb and sleep 10, 14, or 18 hours a day. Yet no matter how much sleep they get, they awake exhausted, as if they had not slept at all. Appetite may also be increased and weight gain may occur, occasionally to an amazing degree. Conversely, some patients may experience insomnia or loss of appetite.Psychomotor retardation is the rule, although some patients may show agitation. In psychomotor retardation the patient may lie in bed or sit in the chair for hours, perhaps all day, profoundly apathetic and scarcely moving at all. Speech is rare; if a sentence is begun, it may die in the speaking of it, as if the patient had not the energy to bring it to conclusion. At times the facial expression may become tense and pained, as if the patient were under some great inner constraint.

19. Bipolar depression • Pessimism and bleak despair permeate these patients' outlooks. Guilt abounds, and on surveying their lives patients find themselves the worst of failures, the greatest of sinners. Effort appears futile, and enterprises begun in the past may be abandoned. They may have recurrent thoughts of suicide, and impulsive suicide attempts may occur. • Delusions of guilt and of well-deserved punishment and persecution are common. Patients may believe that they have let children starve, murdered their spouses, poisoned the wells. Unspeakable punishments are carried out: their eyes are gouged out; they are slowly hung from the gallows; they have contracted syphilis or AIDS, and these are a just punishment for their sins.

20. Bipolar depression • Hallucinations may also appear and may be quite fantastic. Heads float through the air; the soup boils black with blood. Auditory hallucinations are more common, and patients may hear the heavenly court pronounce judgment. Foul odors may be smelled, and poison may be tasted in the food. • In general a depressive episode in bipolar disorder subsides gradually. Occasionally, however, it may come to an abrupt termination. A patient may arise one morning, after months of suffering, and announce a complete return to fitness and vitality. In such cases, a manic episode is likely to soon follow.

21. Dysthymia • In dysthymia, patients present with extremely chronic yet low-level depressive symptoms that seem to pervade their entire existence— past, present, and probably future. • Dysthymia is in3 times more frequent among females than males, and appears to be a common condition, with a lifetime prevalence of about 6%. • The fact that the vast majority of patients with dysthymia also at some point experience a full depressive episode argues for an identity between the two disorders; however, a small percentage of patients with dysthymia never experience a full depressive episode throughout their lives.

22. Dysthymia • Mood is typically depressed and sorrowful; at times some querulousness or irritability may occur. The outlook is pessimistic, even somber. Everything is taken too seriously, and life is seen as an opportunity only for toil. Though joyous occasions, such as a promotion, graduation, or the birth of a child, may temporarily lift these patients to some warmth and appreciation, they typically sink again quickly back into misery. • Self-confidence is lacking. New tasks or stresses seem hopelessly difficult, and although patients may shoulder their burdens with grim determination, in their hearts they expect only failure.Thinking is difficult. Patients may complain of feeling heavy-headed and slow and of not being able to concentrate. Irresolution is common, and decisions may be postponed, again and again.Fatigue is common, and patients may complain of feeling exhausted much of the time.Hypochondriacal concerns may appear. Patients may worry over minor headaches or gastrointestinal upset, and this may occasion numerous trips to the physician. Appetite may suffer, and some patients may lose weight. Difficulty falling asleep is common, and some patients complain of restless, broken sleep.

23. MOOD ELEVATION DISORDERS • Pathological mood elevation is conceptualized as two levels: mania (the highe r level), and hypomania (under or less than mania). Hypomanic symptoms may occur in both bipolar disorder and the eleva ted phase of cyclothymia. As these are matters of degree and judgement, in a particular case, clinicians may disagree on the most appropriate designation. This is of little importance. The important issue it to identify when treatment is indicated, and to pro vide that treatment. • Mood elevation often presents with euphoria, disinhibition and friendliness

24. MOOD ELEVATION DISORDERS

25. MOOD ELEVATION DISORDERS • Manic episode • The DSM-IV diagnostic criteria for a manic episo de: • A. A distinct period of abnormally and persistently elevate d, expansive, or • irritable mood, lasting at least one week (or any duration if hospitalization is necessary). • B. During the period of mood disturbance, at least 3 of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree. • 1. Inflated self-esteem and grandiosity • 2. Decreased need for sleep • 3. More talkative than usual or pressure to keep talking • 4. Flight of ideas or subjective experience that thoughts are racing • 5. Distractibility

26. MOOD ELEVATION DISORDERS • Manic episode • 6. Increase in goal-directed activity or psychomotor agitation • 7. Excessive involvement in pleasurable activities which have a high • potential for painful consequences (unrestrained buying sprees, sexual • indiscretions, foolish business investments) • C. Mood disturbance sufficiently severe to cause marked impairment in • occupational functioning or in usual social activities or relationships with • others, or to necessitate hospitalization to prevent harm to self or others.

27. MOOD ELEVATION DISORDERS • Hypomanic episode • By definition, the hypomanic episode is less severe than the full manic episode. DSM - • IV has attempted to quantify this difference. It is unclear whether this distinction is • helpful. • Rather than being present for 1 week, the diagnostic criteria state that hypomania need • be present for only 4 days. The need for 3 or 4 of 7 listed symptoms remains • unchanged. The main difference is that: “ The episode is not severe enough to cause • marked impairment in social or occupational functioning, or to necessitate • hospitalization, and there are no psychotic symptoms ”.

28. MOOD ELEVATION DISORDERS • Cyclothymic disorder • The DSM-IV diagnostic criteria are that over a period of 2 years there have been numerous episodes of hypomanic symptoms and numerous episodes of depressive • symptoms. Further, during this time it is not been possible to make a diagnosis of major depressive episode, manic episode or mixed mood state.