Mood Disorder

1. Mood Disorder Parco, Matthew Tan, Jaesser

2. RC Villanueva • Age: 27 • Female • Birthday: Aug 16, 1984 (Makati) • Religion: Roman Catholic • Nationality: Filipino • Marital Status: Single • Informant: Mother and Patient

3. Chief Complaint • According to patient “I am too happy” • According to the mother- behavioral change

4. History of Present Illness • 5 years PTA • Fresh graduate • inherited appliance company no had no idea how to run the business. • No help or guidance from the parents. • 3 years PTA • step dad died whom she was close to • Went to graduate school to study business. • Still stressed with her current work and does not see herself working in an office • Became more outgoing with friends and party all night especially during the weekends • Her mother noticed that she had been spending a lot of her money buying things • Patient claimed that she had so much energy • active in church and doing charity works and travelled a lot.

5. History of Present Illness • 10 months PTA • depressed and felt something was missing • broke up with her long term boyfriend • 7 months PTA • she went to US to escape the stress of work • claimed had trouble sleeping • change in appetite

6. History of Present Illness • 2 months PTA • went back to the Philippines and worked again on the same company • Started taking bangkok pills 7 capsules a day • 1 day PTA • Mother and friends notices change in behavior • Patient claimed was very happy • Said “knows everything and what to do with the business” • texted friends inappropriately and one of her friends replied “Naka drugs kaba?” • Persistence of symptoms prompted patient to sought consult at the medical city.

7. Review of Systems • Weight loss of 30lbs in 2 months • Sleep problems • Occasional visual hallucination • Disoriented but claimed that she was too busy working. • Use of bangkok pills

8. Past Medical History • No known medical illness • No previous surgeries • Allergic to shrimp

9. Family History • One of her uncle has a psychiatric illness (depression) • Hypertension and diabetes on the maternal side

10. Anamnesis • Patient was the eldest of four kids born via NSD in MMC • Only child on her mother’s first marriage.

11. Anamnesis • During School-age • very shy and smart • top 5 of her class consistently • likes math and participated in the math olympian • good relationship with the family • Parents got separated at age 12 • Depressed but was able to cope up.

12. Anamnesis • In College • BS economics at ADMU • active in school and was a very happy and cheerful person • occasional hyperactive episodes • small circle of friends • very good at handling her finances • mother remarried and had 3 other siblings • close to his step father but not so much with the other siblings but had no troubles with them

13. Anamnesis • Adulthood • managed their appliances business 8-14 hours/day • first boyfriend and claimed to have a good relationship • loved to shop and travel to destress • several events were she would be too happy that she had to leave work for awhile • currently started to live alone in a condo at Taguig City.

14. Physical Examination General Survey: Conscious, coherent, not in cardio-respiratory distress Vital Signs • 110/70, 108bpm, 18cpm, 37.1C, 61kg, 157cm, BMI 25

15. Mental Status Exam • Appearance • Well kempt, wearing white shirt and blue jogging pants, no mannerisms, good eye contact, cooperative • Speech • Pressured, with pleading tone • Mood • “extremely happy” • Affect • Intense w/ appropriate content • Thought Process • Thoughts are logical and goal-directed

16. Mental Status Examination • Thought Content • No delusions, phobias, obsessions and compulsions, suicidal /homicidal thoughts • Perception • No hallucination or illusions • Insight • Good; “aware and understands the illness” • Judgment • good

17. 5 5 3 5 3 2 1 3 1 1 1 30

18. Salient Features GENERAL DATA: 21/F Cc: “I am too happy” HPI: (+) Depression, ↓ sleep, ↓ eating Several episodes of manic attack ROS: Weight loss, use of bangkokpills, sleep problems • Personal & Social Hx: • -Broken family • Worked in a family company where she is unprepared for • - Excessive spending of money for shopping Physical Examination: Stable vital signs, unremarkable PE MSE -extremely happy mood MMSE 30/30 PMHx: Unremarkable Family Hx: Maternal side – pychiatric illness (depression), diabetes and hypertension

19. Psychodynamic Formulation Separation of parents Death of step father Stressed out with work Few friends Separation with her boyfriend Depression Manic Episodes Psychotic symptoms

20. Multi-Axial Diagnosis • Axis I: Substance Induced T/C Bipolar I disorder MRE • Axis II: Defer • Axis III: None • Axis IV: Work and family stressor • Axis V: 31-40

21. Initial Plan • CBC, UA, Serum Electrolyte, Urine Drug Screening, Liver function test

22. Depression

23. SYMPTOMS • Depressed mood. • Markedly diminished interest or pleasure in activities. • Significant weight loss when not dieting or weight gain, or decrease or increase in appetite. • Insomnia or hypersomnia. • Psychomotor agitation or retardation. • Fatigue or loss of energy. • Feelings of worthlessness. • Diminished ability to think or concentrate.

24. EPIDEMIOLOGY • Demographics • About 5 out of 100 suffer from major depression. • A further 5 out of 100 suffer from milder forms of depression at some time in their lives. • Gender • Females (8-10% probability) are more prone to depression than males. (3-5% probability) • Race • In DALYs, Caucasians tend to have more depressive episodes, followed by East Asians, and then Africans. • Philippines is 93rd country • Social Status • More common among divorced or separated people. • No correlation between socioeconomic status and depression.

25. CAUSES • For many, there is an obvious cause for depression, such as: • Physical illness • Illness of death of relative • Stress, overwork, or unemployment. • However, somebody can get depression withoutany apparent cause. • When someone gets depressed, their reaction to events like these is much more intense and lasting than it is to be expected.

26. BIOLOGICAL CAUSE • Biological: Monoamine hypothesis • Primarily happens in the limbic areas. • One of the function of serotonin is to regulate other neurotransmitter systems – decreased serotonin activity in the post-synaptic cleft allows the NT system to act in erratic ways. • Depression arises when low serotonin levels promote low levels of Norepinephrine. • Some antidepressants enhance NE levels, while others raise dopamine levels.

27. BIOLOGICAL CAUSE • Biological: Neuroanatomic incongruence • Increased volume of lateral ventricles, with smaller volumes of basal ganglia, thalamus, hippocampus, and frontal lobe. • Neurogenesis is impaired due to decreased Brain-derived neurotrophic factor (BDNF). • Biological: Hormonal • Increased cortisol levels and enlarged pituitary and adrenal glands are suggested to play a role in depression. • This is caused by oversecretion of corticotropin-releasing hormone from the hypothalamus.

28. BIOLOGICAL CAUSE • Biological: Cytokines • Symptoms of depression are similar to general illness, and may result from abnormalities in cytokines (esp. IL-6 and TNF-a).. • Genetic Concordance • Among monozygotic twins, 40-71% chance that the other twin will have depression if one twin is depressed. • Among dizygotic twins it is 3-13%.

29. PSYCHOLOGICAL CAUSE Negative emotionality is a common precursor. Adverse events and a person’s way of coping or reacting to them determines resilience which may help prevent depression. Low self-esteem and self-defeating or distorted thinking are also related to depression. Depression is less likely to occur among people who have a sense of religiosity

30. PSYCHOLOGICAL CAUSE • Psychological: Psychodynamic • Depression is a result of a person’s early experiences in life (Sigmund Freud). • Attachment Theory predicts relationship between depression and quality of earlier bond between infant and their adult caregiver. • Psychological: Humanistic • Depression arises when people are unable to attain their needs or to self-actualize (Abraham Maslow).

31. PSYCHOLOGICAL CAUSE • Psychological: Cognitive -Behavioral • According to Aaron Beck, three concepts underlie depression: • Triad of negative thoughts composed of cognitive errors about oneself, one’s world, and one’s future; • Recurrent patterns of depressive thinking; • Distorted information processing. • Learned Helplessness (Martin Seligman). • Humans remain in unpleasant situations even when they are able to escape because they initially had no control.

32. PSYCHOLOGICAL CAUSE • Psychological: Cognitive -Behavioral • Depressed individuals have negative beliefs about themselves which is based on initial experiences of loss, failure, and even on their emotional and physical states – all these result to a negative self concept and lack of self-efficacy (Albert Bandura).

33. SOCIAL CAUSE Certain social situations such as poverty, social isolation, and child abuse are associated with increased risk of developing depressive disorders. Among children, disturbances in family functioning serve as risk factors for depression; among adults, stressful life events are strongly associated with onset of depression

34. SUBTYPES OF DEPRESSION Melancholic Depression Loss of pleasure in most or all activities, a failure of reactivity to pleasurable stimuli, worsening of symptoms during morning hours, psychomotor retardation, and excessive weight loss. Atypical Depression Mood reactivity, significant weight gain or increased appetite, excessive sleep or sleepiness, sensation of heaviness in limbs, and significant social impairment due to perceived interpersonal rejection.

35. SUBTYPES OF DEPRESSION Catatonic Depression Severe form of Depression involving disturbances of motor behavior. Patient may be mute, stuporous, immobile, or exhibit purposeless movements. Postpartum Depression Intense and sustained depression experienced by women after giving birth, with an incidence rate of 10-15%.

36. SUBTYPES OF DEPRESSION Seasonal Affective Disorder Form of depression in which symptoms come during winter or autumn. And disappear during spring. Diagnosis is made if at least two episodes occurred in colder months with none at other months, over a two year period.

37. TREATMENT ANTI-DEPRESSANTS Selective Serotonin Reuptake Inhibitors Mechanism: SSRIs inhibit reuptake of serotonin, and make it stay in the synaptic cleft longer than usual, hence repeatedly stimulating the receptors of recipient cell. Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Escitalopram Serotonin-Norepinephrine Reuptake Inhibitors Mechanism: SNRIs have the same mechanism as SSRI. Examples: Venlafaxine, Desvenlafaxine, Duloxetine

38. TREATMENT • ANTI-DEPRESSANTS • Tricyclic Antidepressants (“pramines”) • Mechanism: Similar to SNRis, with affinity as antagonists to 5-HT2, 5-HT7, a1 adrenergic, and NMDA receptors. • Examples: Amitryptyline, Clomipramine • Monoamine Oxidase Inhibitors • Mechanism: Inhibit monoamine oxidase, hence preventing breakdown of serotonin, norepinephrine, and dopamine. • Examples: Hydralazine, Iproniazid

39. TREATMENT • PSYCHOLOGICAL TREATMENTS • Psychoanalysis • Uncover childhood trauma and awareness of self-directed rage. • Cognitive-Behavioral Therapy • Make patient aware of distorted cognition or overgeneralizations. Replace these with realistic adaptive ones. Focus on the person’s strength. • Interpersonal Therapy • Make patients more socially adept through uncovering of personal resources and strengths. • Logotherapy • Addresses existential vaccum associated with feelings of futility and meaninglessness.

40. TREATMENT Electroconvulsive Therapy Electricity is seen through brain via two electrodes to induce seizure while patient is under anesthesia. It is the treatment of choice in catatonic depression or when a person has severe anorexia or is suicidal. Relapse rate is around 50%-84%, but is reduced with use of psychiatric medications or with further ECT.

41. COURSE AND PROGNOSIS Course Can occur anytime, but usually before age 40. Untreated Depression usually lasts 6-13 months, while treated cases last 3 months. Prognosis 50% recover within first year. 25% recover within first six months. 50-75% relapse within next five years. Good Prognostic Indicators Mild episodes (lasting around month or two) Absence of psychotic or other comorbid psychiatric symptoms. Short hospital stay. Solid family function, friends, and sociality. Advanced age of onset.

42. OTHER CULTURE-BOUND MOOD DISORDERS Ataque de Nervios: uncontrollable shouting, attacks of crying, trembling, heat rising in chest, aggression. Piblokto: hysteria, depression, coprophagia, insensitivity to cold, echolalia Hikikomori: withdrawal from society, seeking isolation; sometimes can be violent. Hwabyeong: depression, sleeplessness, anxiety, obsessive-compulsiveness, anorexia, paranoia, sleeplessness, irritability. Shenjingshuairuo: elements of depression and anxiety disorder, such as fatigue, dizziness, sleepiness, irritability, and memory loss.

43. Bipolar I Disorder • Also known as manic depression • only requirement for this diagnosis is the occurrence of one manic or mixed episode • “MoodSwings” • Moodalternatesbetweenmania(highs) anddepression (lows)

45. Bipolar I Disorder • EPIDEMIOLOGY • Lifetime prevalence: 1% • Women and men equally affected • No ethnic differences seen • Onset usually before age 30

46. Bipolar I Disorder • ETIOLOGY • Biological, environmental, psychosocial, and genetic factors are all important. • First-degree relatives of patients with bipolar disorder are 8 to 18 times more • likely to develop the illness. Concordance rates for monozygotic twins are approximately • 75%, and rates for dizygotic twins are 5 to 25%.

47. Bipolar I Disorder, Single Manic Episode • Must be experiencing their first manic episode to meet the diagnostic criteria for bipolar I disorder, single manic

49. Bipolar I Disorder, Recurrent • Bipolar I Disorder, Recurrent • Manic episodes are considered distinct when they are separated by at least 2 months without significant symptoms of mania or hypomania.