Definition

Mood disorders represent a heterogeneous group of mental disorders that are characterized by extreme exaggeration and disturbance of mood and affect. These disorders are associated with physiologic, cognitive, and psychomotor dysfunction. Mood disorders, which tend to be cyclic, include depression and bipolar disorder.

Epidemiology

About 5% of the adults in the United States have a significant mood disorder. Mood disorders are more common among women ( Table 29.1 ). Major depression may begin at any age, but the prevalence is highest among older adults followed by those 30 to 40 years of age and, in recent years, an increased number of 15- to 19-year-old adolescents and young adults. Lifetime prevalence rates for major depressive disorders are 15% to 20%. Point prevalence rates for major depression in urban U.S. populations are 2% to 4% for men and 4% to 6% for women. After the age of 55 years, depression starts to occur more commonly in men. About one third of depressed persons require hospitalization; 30% follow a chronic course with residual symptoms and social impairment.

Etiology

Several theories have been presented to explain the origin of mood disorders. Reduced brain concentrations of norepinephrine and serotonin (neurotransmitters) are believed to cause depression. Increased levels of these neurotransmitters have contributed to the onset of mania. The causes of depression and mania now appear to be complex. Current research focuses on the interactions of norepinephrine and serotonin with a variety of other brain systems and on abnormalities in the function or quantity of receptors for these transmitters. The interactions between thyrotropin and thyroid-stimulating hormone as well as cortisol release by corticotropin-releasing factor and adrenocorticotropin over a long period may be associated with the development of depression. This model suggests that depression is the result of a stress reaction that is prolonged.

Clinical Presentation and Medical Management

Depressive Disorders

The DSM-IV lists three types of depressive disorders: major depression, dysthymic disorder, and depression not otherwise specified (NOS). Major depression (unipolar) is one of the primary mood disorders. Patients with major depression are depressed most of the day, show a marked decrease in interest or pleasure in most activities, exhibit a marked gain or loss in weight, and have insomnia or hypersomnia ( Box 29.1 ). These symptoms must be present for at least 2 weeks before a diagnosis of major depression can be made. About 50% to 80% of persons who have had a major depressive episode will have at least one more depressive episode; 20% of these people will have a subsequent manic episode and should be reclassified as bipolar. A major depression usually will last about 8 to 9 months if the patient is not treated (see Box 29.1 ).

Bipolar Disorder

The DSM-IV lists four types of bipolar disorders: bipolar I, bipolar II, cyclothymic, and bipolar disorder NOS ( Fig. 29.1 ). Fig. 29.2, A , shows the normal variation in moods. Bipolar I disorder consists of recurrences of mania and major depression or mixed states that occur at different times in the patient or a mixture of symptoms that occur at the same time (see Fig. 29.2, B ). The essential feature of a manic episode is a distinct period during which the affected person’s mood is elevated and expansive or irritable ( Table 29.2 ). Associated symptoms of the manic syndrome include inflated self-esteem, grandiosity, a decreased need for sleep, excessive speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities. During a manic episode, the mood often is described as euphoric, cheerful, or “high.” The expansive quality of the mood is characterized by unceasing and unselective enthusiasm for interacting with people. However, the predominant mood disturbance may be irritability and anger. Speech often is loud, rapid, and difficult to interpret, and behavior may be intrusive and demanding. Style of dress often is colorful and strange, and long periods without sleep are common. Poor judgment may lead to financial and legal problems. Drug and alcohol abuse also are common in this patient population.

Mood disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). Patients with bipolar disorder have had at least one episode of mania or hypomania. Cyclothymic disorder consists of recurrent brief episodes of hypomania and mild depression. Major depression usually is recurrent but sometimes happens as a single lifetime episode. Dysthymic disorder is mild depression that lasts at least 2 years. NOS, Not otherwise specified.

A, Normal mood cycles. B, Bipolar type I disorder. C, Bipolar type II disorder.

(From Khalife S: Bipolar disorder. In Carey WD, editor: Current clinical medicine 2009—Cleveland Clinic, ed 2, Philadelphia, 2010, Saunders.)

Bipolar II disorder (see Fig. 29.2, C ) consists of recurrences of major depression and hypomania (mild mania). Cyclothymic disorder manifests as recurrent brief episodes of hypomania (see Table 29.2 ) and mild depression. Bipolar disorder NOS refers to partial syndromes, such as recurrent hypomania without depression. Patients with bipolar disorder have at least one episode of mania or hypomania.

The diagnosis of bipolar disorder is made as soon as the patient has one manic episode, even if the person has never had a depressive episode. Most patients who become manic eventually experience depression. However, about 10% of patients in whom bipolar disorder is diagnosed appear to have only manic episodes.

Men tend to have a greater number of manic episodes and more numerous depressive episodes than women. Untreated patients with bipolar disorder will experience a mean of nine affective episodes during their lifetime. The length of each cycle tends to decrease, although the number of cycles increases with age ( Fig. 29.3 ). Each affective episode lasts about 8 to 9 months. Bipolar patients have a greater number of episodes, hospitalizations, divorces, and suicides compared with unipolar patients.

Natural history of recurrent mood disorders: an integrated model. Genetic factors and early environmental stress may predispose to development of a mood disorder. Early episodes are likely to be precipitated by environmental stress; later episodes are more likely to occur closer together and spontaneously, without precipitants.

Medical Management

Table 29.3 shows commonly used antidepressants. The first-line medication for major depression is a selective serotonin reuptake inhibitor (SSRI) such as citalopram. Sertraline, venlafaxine, and bupropion are second-line drugs that may be used in patients who fail to achieve remission with citalopram. These agents are used primarily to treat major depression, dysthymic disorder, and depression NOS and have a limited role in depression associated with bipolar disorder that responds to an antipsychotic medication and the standard antidepressant medication fluoxetine.

The mainstays of drug therapy for bipolar disorders are the mood-stabilizing drugs, which generally act on both mania and depression ( Table 29.4 ). Drugs used are lithium, valproic acid or divalproex (valproate semisodium), lamotrigine, and carbamazepine. The most widely used mood stabilizer is lithium carbonate. Lithium is most helpful in patients with euphoric mania. When lithium is ineffective or when medical problems prevent its use, one of the anticonvulsants (valproic acid or divalproex, lamotrigine, or carbamazepine) with mood-stabilizing effects can be used.

Electroconvulsive therapy is an effective antimanic treatment. It may be used in cases of manic violence, delirium, or exhaustion. It also is appropriate for use with patients who do not respond to medication taken for many weeks. When antidepressant drugs are given for bipolar depression, they may cause a switch to mania or a mixed state, or they may induce rapid cycling. The most common treatment for bipolar depression is an antidepressant combined with a mood stabilizer to prevent a manic switch or rapid cycling.

It takes about 7 to 10 days for lithium to reach full therapeutic effectiveness. With most antidepressant drugs, a delay (10–21 days) is noted before full therapeutic benefits are achieved.

An estimated 30,000 suicides occur each year in the United States. About 70% of them involve persons with major depression. The physician must consider suicidal lethality in the management of patients with depression. In general, the risk for suicide is increased in association with the following factors: alcoholism, drug abuse, social isolation, elderly male status, terminal illness, and undiagnosed or untreated mental disorders. Patients at greatest risk are those with a history of previous suicide attempts, drug or alcohol abuse, recent diagnosis of a serious condition, loss of a loved one, or recent retirement and those who live alone or lack adequate social support. Persons with a suicide plan and the means to carry out that plan are at greatest risk for suicide. After medical control is attained in a patient with a mood disorder, insight-oriented psychotherapy often is initiated as an adjunct for management of the patient’s condition.

An interesting potential is the role of celebrity suicides triggering others on an international basis. For example, after the railway suicide of the German national goalkeeper Robert Enke in 2009, a significant increase of railway suicides was observed nationally. Enke’s suicide in 2009 was also followed by increasing train suicide numbers in Europe. An international copycat effect or an increased overall awareness about this particular suicide method appears to be one likely explanation for the changes.

Definition

Persons with somatoform disorders have physical complaints for which no general medical cause is present. Associated unconscious psychological factors contribute to the onset, exacerbation, or maintenance of physical symptoms. The following conditions are regarded as somatoform disorders: somatization, conversion disorder, pain disorder, and hypochondriasis ( Table 29.5 ). Patients with a somatization disorder experience multiple, unexplained somatic symptoms that may last for years.

Epidemiology

The prevalence of somatoform disorders is 5%. Most of these occur in women. Patients with symptoms that do not meet the full criteria for somatization disorder are much more common. Conversion disorder, pain disorder, and hypochondriasis appear to be more common than somatization disorder.

Etiology

In this group of disorders, physical symptoms suggest a physical disorder for which no underlying physical basis can be found. Symptoms are linked to psychological factors. Somatization therefore is defined as the manifestation of psychological stress in somatic symptoms.

A conversion reaction results when a psychological conflict or need is expressed as an alteration or loss of physical function, suggesting a physical disorder. A person who views a traumatic event, for example, but has a conflict about acknowledging that event may develop a conversion disorder of blindness. In this instance, the symptom of blindness has symbolic value and is a representation of, and a partial solution to, the underlying psychological conflict.

Clinical Presentation and Medical Management

Somatization Disorder

Somatization consists of multiple signs and symptoms and usually begins before the age of 30 years. Patients experience multiple, unexplained physical manifestations of illness or disease, which may include pain, diarrhea, bloating, vomiting, sexual dysfunction, blindness, deafness, weakness, paralysis, or coordination problems. Somatization disorder is a serious psychiatric illness. Many patients have concurrent anxiety, depression, or personality disorder.

Conversion Disorder

Conversion disorder is a monosymptomatic somatoform disorder that affects the voluntary motor system or sensory functions. The patient may experience blindness, deafness, paralysis, or an inability to speak or to walk. Symptoms suggest a physical condition, but the cause is psychological. The somatic manifestation, which is not intentionally produced, typically is a symbolic representation that relieves an underlying emotional conflict.

Pain Disorder

Pain disorder causes the patient significant distress in important areas of functioning such as social and occupational activities. In patients with pain disorder, no organic disease can be identified. Often, a stressful event precedes the onset of pain. Pain often results in secondary gain in the form of increased attention and sympathy from others.

Hypochondriasis

Patients with hypochondriasis are preoccupied with the fear or belief that they have a serious disease. Their misinterpretations of normal bodily functions generally are to blame.

Factitious Disorder

Factitious disorder consists of intentional self-harm that is produced by infliction of physical, chemical, or thermal injury. It involves the voluntary production of signs and symptoms (physical injury or psychological symptoms) without external incentives such as avoidance of responsibility or financial gain. Many affected persons also have other mental disorders. Factitious disorder is more common among men and occurs more often in health care workers. The skin is the most common site for injury.

Treatment

Treatment of patients with somatoform disorders often requires multiple therapeutic modalities, including psychotherapy for their interpersonal and psychological problems. Medication for the treatment of underlying depressive disorder also may be needed. Group therapy is beneficial in some cases.