AFFECTIVE DISORDERS DR Rabie A Hawari Consultant Psychiatrist

AFFECTIVE DISORDERS DR. Rabie A. Hawari Consultant Psychiatrist

AFFECTIVE DISORDERS

Epidemiology • • • female: male = 2: 1 (dep. ) = 1: 1 ( mania) age = dep. – 20 -50. mean 40 yr. = mania – earlier mean 30 yr

Etiology various theories • Genetics : - evidence is stronger for BAD, - 50% of pts. ---> one parent have M. D, - BAD. pt. ----> 27% any child have M. D, - Both parents ----> 50 -75% any child, - MZ twins ----> 75% concordance. • Biochemical : - Norepinephrine & Serotonin reduced at receptor sites in the brain ---- > dep. - NE & 5 HT increased at receptor sites ---> mania. . Psychological Factors : - Life Events. – P. M. P. – Psychoanalytic. - Cognitive. – learned helplessness.

DEPRESSION

Signs & Symptoms • A. Mental: • Mood: - Depressed, Diurnal Variation, Pessimism, Suicidal ideas, Loss of Interest, Anhedonia. • Thinking: - Poverty of thoughts, poor concentration, Poor cognition, poor judgment & insight, Delusions (paranoid, guilt, nihilistic, hypochondriases) • Perception: - Auditory Hallucination, (2 nd. Person).

Signs & Symptoms(cont) • B. Physical: - . Insomnia or Hypersomnia, Loss of Appetite, Loss of Wt. or Gain, Psychomotor Retardation or Agitation, Loss of Libido, Loss Energy, Tiredness, stupor. Somatic c/o: headache, constipation, drymouth, abnormal menses, etc.

Types of depression 1. Major Depression: - unipolar – s/s. 2/52, 40 ys. 2. Dysthymia: - Neurotic depression. Chronic. 20 s. 3. Seasonal Affective disorder (SAD): - Major dep. , in winter & fall (short daylight) - s/s: hypersomnia, hyperphagia & psychomotor slowing - due to abn. Melatonin metabolism, - Rx. Exposure to light 3 -6 hr. /day. 4. Post Partum Depression: - after birth. 30 days. s/s. insomnia, fatigue, suicide, homicide & delusions.

Types of depression(cont. ) 5. Myxedema Madness: -Hypothyroidism. S/s. fatigability, Dep. suicidal impulse, delusions, hallucination & Paranoia. 6. Organic Mood Disorder-- Depression type: - secondary to organic cause e. g. Cushing’s Synd. , Propranlol med. , Infections (flu, Aids, ). • 7. Pseudo Dementia: - Dementia Synd. Of depression in the elderly. Dep. Is primary than the cognitive dysfunction 8. Adjustment Diso. with Depressed Mood: - response to a clear identifiable stress.

Types of depression(cont. ) 9. Grief: - sadness secondary to major loss. —not Dep. , remits with time, no suicide or helplessness. 10. Depression in children: - not uncommon, same s/s. Masked dep. = running away from home, school Phobia, substance abuse & suicide. 11. Double Dep. : - Major dep. On top of dysthymia. 12. Atypical Dep. : - s/s. do not meet criteria of depression - intermittent dysthymic episodes, - Wt. gain & hypersomnia.

Treatment of Depression • * Pharmacological: a. TCA: - Imipramine, Amitriptyline, Clomipramine, (3/52 to start to act). b. MAOI: - Phenelzine, Parnate (Tyramine dietary restrictions). c. SSRIs: - Fluvoxamine, fluoxetine, “Rx. For 6/12. if recurrent lithium as an adjunct appears to be affective “ Physical : - Elecrto. Convulsive. Therapy (ECT).

Treatment of Depression(cont) • Psychological: a). Cognitive: corrections of chronic distortions in thinking which led to depression. b). Behaviour: aimed at specific behaviour. c). Interpersonal: emphasis on ongoing current issues. d). Psychoanalytic: to understand the unconscious conflicts & motivations that might sustain depression. e). Group Rx. f). Family Rx. g). Supportive Rx.

MANIA

Signs & Symptoms A. Mental: - - Mood: - Elevated (Elated) mood over days or weeks. - may be interrupted by episode of depression, - Irritability with Angry outbursts. - Impulsiveness. -Thinking: - - Low concentration, Distractibility, - Over talkative, Laud, Rapid, - Pressure of thoughts, - Flight of Ideas, - Memory & Orientation = intact, - Judgment & Insight = impaired, - Delusions = Grandiose, Paranoid, - Inflated self-esteem. - Perception: - Hallucination may be present.

Signs & Symptoms(cont) B. Physical: - Insomnia, - Increase activities & energy, - Increase Libido, Disinhibtion, - Psychomotor agitation, - Wt. loss due exhaustion.

TYPES OF MANIA Organic Mood Disorder: - Manic Type. Secondary to organic disorder e. g. – Tertiary Syphilis, Influenza, Corticosteroids, TLE, Amphetamine, Hyperthyroidism, Head Trauma, Vit. Def. (B 12, Folate, Thiamine), MS • • ood swings Rapid Cycling Bipolar Disorder: - Mania/Depression Episodes with intervals 48 -72 hrs. Bipolar Disorder not otherwise specified (NOS): 1 Depression episode & 1 manic episode. • • •

Treatment of Bipolar Disorder: • A. Pharmacological: : Lithium = effective in 80%, -- takes 7 -10 days, -- full trail at least for 4 wks. , -- blood level 0. 6 – 1. 2 m. Eq/L, -starting dose 300 mg tid, - usual dose range 900 -2000 mg per day, -- toxicity more than 1. 2 m. Eq/L. : Carbamazepine = dose 200 mg bid / day, -- increase by 200 mg. every wk. until plasma level 6 -12 mg/L. : Valporic acid = ½ life 8 hrs. , -- peak 1 - 4 hrs. , -- starting dose 500 mg, -- range 750 – 3000 mg, -- therapeutic level 40 – 100 ug/m. L, -- toxic 200 ug/Ml. : Clonazepam = dose in acute mania 2 – 16 mg/day.

Treatment of Bipolar Disorders(con) : Typical Antipsychotic = -Haloperidol – oral, I. M. , I. V. , dose 5 – 60 mg. - Clopixol – oral 10 -60 mg. , I. M. Aquaphase 50 -100 mg - Chlorpromazine – oral, dose 100 – 2000 mg/day. : Atypical Antipsychotic = - Risperidone – oral, dose 2 – 8 mg. /day Risperidal Consta-i. m. (25 -37. 5 -50 mg)X 2/52 - Zyprexa – oral, I. M. , dose 5 – 20 mg. /day. B. Psychological: - when Pt. is controlled with medications.

COURSE & PROGNOSIS • Depression: - 15% commit suicide. - Untreated – episode last for 10 months. - 75% have secondary episode after 6/12 - Average No. of episodes in lifetime = 5. PROGNOSIS: – 50% recover. – 30% partially recover. – 20% have chronic course. – 20 -30% of Dysthymic or cyclothymic develop major Dep. , or mania.

COURSE & PROGNOSIS(cont) • Mania; - 45 % recur. - Untreated – episode last 3 -6 months. High rate of recurrence average 10. -80 -90 % experience a full Dep. , episode. • PROGNOSIS: – fair. – 15 % recover. – 50 – 60 % partially recover – 1/3 have some evidence of chronic symptoms & social deterioration.