Affective Disorders: Dr. Zeina Adnan Family Medicine Specialist

AFFECTIVE
DISORDERS
Dr. Zeina Adnan
Family Medicine Specialist
Affective disorders
Are those mental illnesses which predominantly affect mood and also
they have effect on thoughts, behaviors, and emotions… they are also
called mood disorders and are among the most common diagnosis in
psychiatry.
 Mood: is a persistent emotional state.
 Affect: is the external display of feelings

classification
mood disorders are classified in to 3 major groups:
 Unipolar disorders
Major depressive disorders(MDD)

Dysthemia disorders
 Bipolar disorders
Bipolar 1 disorder
Bipolar 2 disorder
Cyclothymic disorder
 Mood disorders that have known etiology

Substance induced mood disorders
Mood disorders due to general medical condition
MOOD RANGES IN MOOD DISORDERS
Mania--------------------------------------------------------------------------------------------------
Hypomania--------------------------------------------------------------------------------------------

Normal mood (euthymia) -------------------------------------------------------------------------------
Dysthemia--------------------------------------------------------------------------------------------

Depression--------------------------------------------------------------------------------------------
MDD dysthemia bipolar 1 bipolar2 cyclothemia
Major depressive disorders (MDD)
Epidemiology:
The lifetime prevalence of depression is 17%, with
approximately 8 million cases of major depression being
diagnosed per year,
the point prevalence is 5%- 9%
in adults
race distribution appear equal,

socioeconomic status do not
appear to be a factor.
:Risk factors
 Age: with a peak incidence at 20 to 40 years of age and decreases after the age of 65 years.
 Sex: Females are twice as likely to have depression as males.
 Family history: those with family history of depressive

disorders are up to 3 time more likely to be affected.
 Marital status: include those who are

divorced, separated, and widowed.
 Genetic factors: the risk is two to five times greater

if a first-degree relative (e.g., a parent) had major depression.
The risk of depression doubles again if both parents
were affected.
Studies of monozygotic twins have shown
a 65% concordance, which is more than four times
as great as the 14% for dizygotic twins.
 Hormonal : neuro endocrine disturbances in the hypothalamic- pituitary- adrenal axis is often
found in depression, e.g. women around the time of menstrual cycles, pregnancy, miscarriage, and
the postpartum period.
Diagnosis
The criteria of major depressive episode require 5 or more of the

specific following symptoms to be present for at least two weeks,
one of the symptoms should be depressed mood or loss of interest or
.pleasure
:symptoms fall in two main categories

emotional changes (mood, guilt, irritability) .1
2. vegetative (alteration in sleep, appetite, energy).
These symptoms must be a change from prior functioning and

cannot be due to medical condition or substance induced or
bereavement, also the symptoms must cause distress or impairment.
:Criteria in MDD
Include the SIGEM CAPS
 Sleep: insomnia or hypersomnia.
 Interest: marked decrease in interest & pleasure in most activities.
 Guilt: feeling of worthlessness or inappropriate guilt.
 Energy: fatigue or low energy nearly every day.
 Mood: depressed mood most of the day, nearly every day.
 Concentration: decreased concentration increased indecisiveness.
 Appetite: increased or decreased, weight loss or gain.
 Psychomotor: agitation or retardation.
 Suicide: recurrent thoughts of death, suicidal ideation, suicide plan or
attempt.
The diagnosis of MDD is made when the
patent has at least one episode and does not
meet the criteria of bipolar or etiologic mood
disorder.
MDD is usually recurrent; the usual duration

of untreated episode is 6- 12 months, 15% of
diagnosed patients die by suicide at some
point of their life.
Treatment
It include pharmacotherapy and

psychotherapy
 Pharmacotherapy is the mainstay of treatment.
 Antidepressants with psychotherapy together are more
effective.
 Antidepressants need 3- 4 weeks before they are effective.
 When patient with depression responds to treatment, it
should be continued for 9- 12 months.

Classes of antidepressants
 Tricyclic antidepressants: Imepramine, amitryptyline, nortryptyline,
doxepin.
 Selective serotonin reuptake inhibitors (SSRIs): fluoxitine,

sertraline(Zoloft), paroxetine (paxil), citalopam, escitalopram.
 Monoamine oxidase inhibitors (MAOIs): phenelzine, tranylcypromine,

moclobemide.
 Noradrenergic re-uptake inhibitors: Venlafaxine
 Selective noradrenaline (norepinephrine)re-uptake inhibitor: Reboxetine
 Noradrenergic and specific serotonergic inhibitor: Mirtazapine

Electroconvulsive therapy (ECT)
is used in psychotic, severe conditions,
treatment refractory cases, or when
medications are contra indicated.
phototherapy can be used for seasonal

mood disorders.
??When should we refer the patient
Failure of medical treatment.
Suicidal attempt.
Severe depression.
For diagnosis clarification or
treatment recommendations.
Co- morbidities that decrease
the response to treatment.
When patient requests referral.
Dysthemia
It is a mild, chronic form of major

depression, the life time prevalence is
6%
Clinical manifestations
:
 The diagnosis of dysthemia requires a minimum of 2 years
of chronically depressed mood most of the time.
 Associated symptoms include change in appetite and sleep,

fatigue, decreased concentration, and hopelessness.
 Dysthemia can be chronic and difficult to treat, sometimes

major depressive episodes may co-occur giving raise to the
term double depression
Management
:
The management is the same as major
depression but psychotherapy may play a
larger role and the course of treatment may
be more protracted.

Bipolar disorders (BPD)
etiology
 genetic and familial studies reveal that having bipolar disorder

in first degree relative increases the chance of having bipolar 1,
2, and MDD, x linkage has been demonstrated in some studies.
 Mania can be precipitated by

psychosocial stressors,
 otherevidence show that sleep/

wake cycle disturbance may
predispose to mania.
Bipolar 1 disorder
the diagnosis is made after at least one

episode of mania. These patients typically
have also major depressive episode in the
course of their life
the prevalence is 0.4%- 1.6%, male to

female ratio is equal, no racial variation in
the incidence.

Clinical manifestations
 the occurrence of mania (or mixed episode), single manic episode is
sufficient to meet the diagnosis.
 Most patients have recurrent episodes of mania typically intermixed with

depressive episodes.
 The first episode of mania usually occurs in the early 20s. In 2 of 3 patients,
 the transition between mania

and depression is without an
intervening period of euthymia
(normal mood), suicide ranges
from 10%- 15%.
Criteria for manic episode
Three of the following are required:
 Self-esteem: highly inflated, grandiosity.
 Sleep: decreased need to sleep, resting only for few
hours.
 Speech: pressured.
 Thoughts: racing thoughts & flight of ideas.
 Attention: easy distractibility.
 Activity: increased goal directed activity.
 Hedonism: high excess involvement in pleasurable
activities (sex, spending, travel)
The diagnosis requires a clear period of
persistently elevated, expansive, or irritable
mood lasting for 1 week; or severe enough
to require hospitalization.
These changes should not be caused by

substance use or by medical condition, and
also must cause distress or impairment.
Management
antipsychotics and benzodiazepines (for rapid
tranqualization)and then the initiation of mood stabilizer
medication ( lithium is widely used mood stabilizer, also
valproic acid is effective).
If the 1st line treatment fails, we use another drugs like

carbamazipine, lamotriagin, gapapentin, long acting
benzodiazepines.
The patient should continue on maintenance treatment

to prevent the recurrence of mania.
ECT is used in patients who don't tolerate
medication or when we need immediate
response.
Psychotherapy is used to encourage

compliance to treatment and to help the
patient to come to terms in their illness.
Bipolar 2 disorder
 It'ssimilar to bipolar 1 except mania is absent in type 2, and
the essential diagnostic finding is hypomania (milder form
of elevated mood than mania).
 Manic episode more than 4 days but less than 7 days is

classified as hypo manic episode.
 Epidemiology: the prevalence is 0.5%, it's more common in

females.
:Clinical manifestations
the presence of hypomania and major depression in
individuals who has never met the criteria for mania
or a mixed state
Hypomania is determined by the same symptoms

of mania but they are less severe, cause less
impairment, and usually not need admition to hospital
it's cyclic and the suicidal attempt is about 10%-

15%.

:Management
Is the same as bipolar 1 but hypomania
episode does not require as aggressive
treatment as mania;
 care should be taken when giving

antidepressants because they may cause
more frequent hypo manic episodes.
Cyclothymic disorder
Is a recurrent, chronic, mild form of bipolar
disorder in which mood typically oscillates
between hypomania and dysthemia, its not
diagnosed if the patient has mania or major
depressive episode.
Epidemiology: the life time prevalence is 0.4%- 1%,

equal in male & female, but women are more
seeking for treatment.
:Clinical manifestations
It'sa mild form of bipolar disorder, consist of recurrent mood
disturbances between hypomania and dysthemia mood.
 A single episode of hypomania is enough for diagnosis , yet
most patients Have dysthemic periods.
 The diagnosis is never made when there is history of manic
or major depressive episode.
Management:
Psychotherapy, mood stabilizers, and antidepressants are
used.

Mood disorders with known etiology
Substance induced mood disorders: like

medications (cardiovascular drugs, hormones, anti
inflammatory)
Mood disorder due to general medical condition:

endocrine disorders (thyroid and adrenal
dysfunction), AIDS, coronary heart disease & MI,
D.M, cancer, multiple sclerosis.
Subtypes
Melancholic depression
Postpartum depression
Seasonal mood disorders
Atypical
Rapid cycling
Thank
Thank you
you

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AFFECTIVE

 Mood: is a persistent emotional state.

 Affect: is the external display of feelings

Major depressive disorders(MDD)

 Mood disorders that have known etiology

race distribution appear equal,

 Sex: Females are twice as likely to have depression as males.

 Family history: those with family history of depressive

 Marital status: include those who are

 Genetic factors: the risk is two to five times greater

The criteria of major depressive episode require 5 or more of the

:symptoms fall in two main categories

These symptoms must be a change from prior functioning and

MDD is usually recurrent; the usual duration

It include pharmacotherapy and

should be continued for 9- 12 months.

 Selective serotonin reuptake inhibitors (SSRIs): fluoxitine,

 Monoamine oxidase inhibitors (MAOIs): phenelzine, tranylcypromine,

 Noradrenergic re-uptake inhibitors: Venlafaxine

 Selective noradrenaline (norepinephrine)re-uptake inhibitor: Reboxetine

 Noradrenergic and specific serotonergic inhibitor: Mirtazapine

phototherapy can be used for seasonal

It is a mild, chronic form of major

 Associated symptoms include change in appetite and sleep,

 Dysthemia can be chronic and difficult to treat, sometimes

 genetic and familial studies reveal that having bipolar disorder

 Mania can be precipitated by

 otherevidence show that sleep/

the diagnosis is made after at least one

the prevalence is 0.4%- 1.6%, male to

 Most patients have recurrent episodes of mania typically intermixed with

 the transition between mania

These changes should not be caused by

If the 1st line treatment fails, we use another drugs like

The patient should continue on maintenance treatment

Psychotherapy is used to encourage

 Manic episode more than 4 days but less than 7 days is

 Epidemiology: the prevalence is 0.5%, it's more common in

Hypomania is determined by the same symptoms

it's cyclic and the suicidal attempt is about 10%-

 care should be taken when giving

Epidemiology: the life time prevalence is 0.4%- 1%,

Substance induced mood disorders: like

Mood disorder due to general medical condition:

Seasonal mood disorders

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