Mood Disorders

Adjustment Disorder

Diagnosis

Adjustment disorder includes behavioral/emotional symptoms following a stressful life event such as a divorce, death of a family member or friend, or changes in one's school or work situation. Four key differential diagnoses to rule out before diagnosing are:

• Acute stress disorder

• PTSD

• Bereavement

• Major depressive disorder (MDD)

In adjustment disorder, the life event is not life threatening, a key feature that differentiates it from post-traumatic stress disorder (PTSD).

Symptoms of anhedonia, weight loss, or other symptoms of major depressive disorder trump dysthymic symptoms of adjustment disorder. Diagnose MDD in the presence of these.

If the patient fits normal characteristics of bereavement, adjustment disorder cannot be diagnosed. This can be a very difficult distinction to make. Rule out symptoms directly related to the loved one in order to diagnose adjustment disorder. For example:

• Adjustment disorder after death of loved one: Patient exhibits anxiety/depressed mood over the added stress of funeral costs, moving, and continued care of relatives.

• Bereavement after death of loved one: Patient exhibits anxiety/depressed mood over the absence of their loved one and the associated loss of quality of life. Their symptoms are temporally and circumstantially tied to reminders of their loved one.

As in most aspects of psychiatry, the line between physiological and pathological adjustment to a life stressor is defined by functional impairment. Adjustment disorder differs from a normal stress reaction by the presence of social/occupational dysfunction.

Symptoms

Symptoms in adjustment disorder can range from mood disorder symptoms (e.g. depressed mood) to anxiety symptoms, and are sub-classified as such. The symptoms begin within 3 months after the stressful life event has occurred.

Symptoms of adjustment disorder classically end within 6 months after the event is over. This is key in the differential diagnosis of adjustment disorder and other similar disorders.

While unlikely to be tested, adjustment disorder can be chronic in the face of a chronic, continuous stressor.

Treatment

The best treatment for adjustment disorder is supportive psychotherapy. Medications may be used to help improve associated symptoms, such as pharmacotherapy for insomnia.

Bereavement

Bereavement, or grief, is the emotional reaction to a major event in one's life, such as the death of a family member or friend. Bereavement is a normal experience (non-pathological). Symptoms of bereavement or normal grief include crying, insomnia, and difficulty concentrating, though the symptoms may be unique to the individual.

VS MDD

Bereavement can be pathological in severity. Major depressive disorder can be considered soon after the grief inciting event if the patient's symptoms are beyond that of normal bereavement (e.g. anhedonia, suicidality, grossly impaired social/occupational functioning). There is no longer a 2 month time period that must pass before normal bereavement can be excluded in favor of major depressive disorder if a patient's symptoms warrant that diagnosis.

Note: Bereavement complicated by major depressive disorder does not necessarily last longer than normal bereavement.

Bereavement can be pathological in duration. Persistent complex bereavement disorder occurs when normal bereavement lasts >12 months.

Note: Persistent complex bereavement disorder is not necessarily more severe than normal bereavement.

Both bereavement and persistent complex bereavement disorder exhibit a focus on the loss of the loved one, distinguishing them from major depressive disorder. Patients' symptoms are temporally and circumstantially related to the loved one; the symptoms arise when exposed to objects, locations, or other reminders of the loved one. Waves of grief.

5 stages of grief

The Kubler-Ross model, or the five stages of grief, describes how individuals cope with grief or tragedy. The 5 stages of grief according to the Kubler-Ross model include:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

It is important to note that individuals may not experience all 5 stages of grief described in the model, nor is there a particular order or time period for the progression through the stages.

Mania

Diagnosis

A manic episode is defined as a period of abnormally and persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy. Symptoms must last for a minimum of 1 week.

Note: No time requirement applies if hospitalization is necessary.

In addition to mood disturbance and additional energy or activity, manic patients must demonstrate three or more of the following symptoms. A commonly used mnemonic is "DIG FAST":

• Distractibility

• Indiscretion (buying sprees, sexual indiscretion)

• Grandiosity (e.g. "I have been chosen to end world hunger!")

• Flight of ideas (racing thoughts)

• Activity is increased and goal directed (e.g. "I was up all night working on my TV pilot!") OR increased and non-goal-directed (psychomotor agitation)

• Sleep deficit (feels rested after less than three hours of sleep)

• Talkativeness (pressure speech)

Cause

Can be secondary to an organic pathology. Some medical conditions to consider include:

• Hyperthyroidism (and some other endocrinopathies)

• Multiple sclerosis

• Epilepsy

• Stroke

Can be precipitated from medication or substance use. Some pharmacological include:

• Antidepressants

• Alcohol (disinhibition of intoxication)

• Illicit stimulants (cocaine, amphetamine, etc.). Marijuana does not cause mania.

• L-dopa

• Corticosteroids.,

Use a combination of medical history (history of medication use or drug use) and physical exam (pupillary findings, ataxia, nystagmus, tremor) to delineate the possibility of a pharmacological cause.

Hypomania

A hypomanic episode is a period of elevated, expansive, or irritable mood with the same symptoms as mania (3 or more DIGFAST criteria). The main two differences in diagnosis are that in hypomanic episodes:

• Symptoms need only be present for ≥4 days (as opposed to ≥1 week in mania)

• Patient is not hospitalized, with no significant impairment in psychosocial functioning

If a patient displaying symptoms of hypomania has psychotic features, the episode is considered manic, not hypomanic.

Similar to mania, be wary of possible organic or pharmacological causes of secondary hypomania.

Bipolar

Bipolar I vs II

Bipolar disorder is a psychiatric illness that involves episodes of mania and/or hypomania as well as major depression. A diagnosis of bipolar I disorder requires only one episode of mania. However, most bipolar I patients experience periods of hypomania and depression as well.

Bipolar II disorder is characterized by at least one hypomanic episode and at least one episode of major depression.

Occurrence (in the past or present) of mania or psychosis warrants a diagnosis of bipolar I over bipolar II disorder. Always include bipolar I on your differential for a psychotic patient, as psychotic features can be present in both manic and depressive poles of bipolar I disorder.

Bipolar I Genetics

Has a significant genetic component. The risk of a patient developing this disorder is as follows:

• 10% risk if a 1st-degree relative has it

• 70% risk if a monozygotic twin has it.,

Treatment

Treatment for both classes of bipolar is similar. First-line medications for maintenance therapy include:

• Lithium

• Valproate

• Lamotrigine

• Quetiapine

Note: Carbamazepine is not a first-line treatment for bipolar disorder.

Patients with bipolar disorder that inadequately respond to maintenance monotherapy can be treated with combination therapy. Lithium or valproate plus a second-generation antipsychotic (e.g. quetiapine) is recommended in these patients.

Atypical antipsychotics (e.g. olanzapine, quetiapine) are first-line monotherapy for an episode of mild to moderate acute mania.

Lithium or valproate plus an antipsychotic is recommended for severe manic episodes. Combination therapy should be tried before using electroconvulsive therapy (ECT).

Choice of medication used for maintenance therapy should be guided by the patient's tolerance in side effect profile, as well as comorbidities. Lithium should not be used in patients with decreased renal function, and valproic acid should be avoided in patients with elevated liver enzymes.

Pregnancy Treatment

Bipolar disorder in pregnancy warrants special consideration, as the medications used in its therapy are some of the most teratogenic in psychiatry. Carbamazepine and valproic acid are contraindicated in pregnancy, and use of lithium is generally discouraged when possible.

First-generation antipsychotics (e.g. haloperidol) are first-line medications for the treatment of manic and hypomanic pregnant patients.

Vs postpartum psychosis

Postpartum psychosis is not a distinct condition, but rather a manifestation of disorders with psychotic features. Bipolar disorder is one of the most common underlying disorders, and postpartum psychosis may be its initial presentation. In a patient with no prior psychiatric history and new-onset postpartum psychosis, a diagnosis of bipolar disorder should be considered.

Cyclothymic disorder

Cyclothymic disorder is marked by alternating periods of hypomanic symptoms and periods of depressive symptoms.

Notably, neither true hypomania nor true depression exists in cyclothymic disorder; the symptoms the patient experiences merely resemble these conditions.

Cyclothymic disorder may resemble the bipolar disorders, borderline personality disorder, or substance abuse among other differential diagnoses. Rule these pathologies out before diagnosis of cyclothymic disorder.

Note that borderline personality disorder can be diagnosed concurrently with cyclothymic disorder; they are not mutually exclusive diagnoses and frequently coexist with one another.

Symptoms resembling hypomania and depression must persist for >2 years for diagnosis of cyclothymic disorder.

Treatment for cyclothymic disorder involves psychotherapy (e.g. cognitive behavioral therapy) and supportive pharmacotherapy (e.g. lithium, anticonvulsants) in some patients.

Major Depressive Disorder

Symptoms and Diagnosis

Major depressive disorder (MDD) is a mood disorder characterized by recurrent episodes of sadness, anhedonia, and other symptoms. Patients often struggle with adverse factors in their life in social, occupational, economical, and other realms. At least 1 major depressive episode is necessary for diagnosis, and symptoms must be present for >2 weeks for diagnosis of an episode.

A major depressive episode is characterized by at least 5 of the following, with either depressed mood or anhedonia required for diagnosis. Depression symptoms can be remembered by the mnemonic "SIG E CAPS":

• Sleep Disturbance (insomnia in typical depression; hypersomnia in atypical depression)

• Interest (decreased, also called anhedonia)

• Guilt (or thoughts of worthlessness)

• Energy (fatigue or low energy)

• Concentration (decreased)

• Appetite (increased or decreased, also notable weight gain or loss)

• Psychomotor (retardation or agitation)

• Suicidal (recurrent ideation or attempt)

Patients with depression often present to a primary care physician with headaches or other physical complaints (eg, fatigue, insomnia, nonspecific aches and pains).

Causes

Major depressive disorder (MDD) must be differentiated from MDD secondary to a medical cause. This diagnosis is fitting when an organic medical illness causes the mood disorder (the illness cannot simply cause life stress that precipitates the mood disorder). Some medical causes of MDD include:

• Hypothyroidism

• Parkinson disease

• Cushing syndrome

• Stroke

• Cancer (oropharyngeal, pancreatic, breast and lung)

There are other medical causes of depression, but the above 5 are the most high-yield.

Major depressive disorder (MDD) must be differentiated from substance-induced MDD. Some pharmaceutical and illicit substances that can cause depression include:

• Alcohol (suspect in a patient who "drinks their problems away")

• β-blockers (esp. propranolol)

• Corticosteroids

• Levodopa

The major complication of major depression is higher mortality rates. Depression is associated with increased all-cause mortality, completed suicide, homicidal death, and accidental death.

Major depressive disorder is episodic, not a constant malady. Patients have a 50% recurrence rate within 2 years of their first episode of MDD.

Children

Major depression can manifest as irritability and anger in children and adolescents. Be suspicious of major depression in an adolescent with such personality changes concurrent with other symptoms of depression (insomnia, anhedonia, etc.) Another notable differential of behavioral change in adolescence is drug abuse.

Treatment

• The 1st line pharmacological therapy for major depression is SSRIs. If failed, switch to another SSRI. If failed again, switch to a different class.

• Mirtazapine is a good choice for patients with poor sleep and appetite as it can cause drowsiness and increased appetite.

• Single episode of MDD: maintain dose for 6 months after reponse

• Multiple episodes/chronic/strong family history/suicide attempt: maintain dose for 1-3 years

• Severe/highly recurrent (>3 episodes): maintain indefinite

• Refractory/very severe(acute psychosis)/actively suicidal: ECT

  • marked weight loss, minimal fluid intake, and refusal to eat require urgent treatment.

• Catatonic patients: ECT 1st line

The US Food and Drug Administration (FDA) issued a warning in 2007 that patients 18 to 24 years of age should be informed about a small risk of becoming suicidal during initial treatment with an antidepressant agent.

Patients 18 to 24 years of age that are candidates for antidepressant pharmacotherapy should be warned about the small increased risk of suicide, but this should not preclude pharmacological treatment of depression since the small increased risk of suicide needs to be balanced against the risk of suicide associated with moderate or severe depression.

Physicians should closely monitor patients during initial pharmacologic antidepressant treatment and follow up at short intervals.

Dysthymic

Persistent depressive disorder, (formerly dysthymic disorder) involves a chronic depressed mood that occurs almost continuously for >2 years. Symptoms include:

• Sleep disturbance: either insomnia or hypersomnia

• Appetite disturbance: poor appetite or eating too much

• Fatigue, decreased energy

• Low self-esteem ("The truth is that I never feel good and have always had low self-esteem. Ever since I started college 5 years ago, my energy is low and I always feel run down.")

• Cognitive difficulties: poor concentration, problems making decisions

• Feelings of hopelessness or pessimism

The classic description of a patient with persistent depressive disorder is one who feels sad for as long as they can remember, possibly due to negative circumstances in their life (e.g. chronic medical conditions, social ineptitude, joblessness). The patients have activities that they enjoy despite their persistent "baseline" sadness.

Patients may meet diagnostic requirements for major depressive disorder during dysthymic periods (termed "double depression"). Consider this in a patient with persistent sadness or depressed mood, with episodic suicidality, anhedonia, or significantly exacerbated depression.

A patient with persistent depressive disorder will never have symptoms of mania or psychosis. The presence of these features mandates an alternate diagnosis, such as major depression w/ psychosis, schizoaffective disorder, cyclothymic disorder, etc.

The most effective treatment of persistent depressive disorder is psychotherapy. If pharmacotherapy is desired, antidepressants such as SSRI's may be used.

Catatonia

This patient's history of severe bipolar disorder and current immobility and mutism are suggestive of catatonia. Catatonia is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with mood disorders with psychotic features, psychotic disorders, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic). Common features include decreased motor activity, lack of responsiveness during interview, and posturing. Catatonia can range from stupor to marked agitation (catatonic excitement), which contributes to difficulties in recognition.

Treatment of catatonia includes benzodiazepines and/or electroconvulsive therapy (ECT) (1st line). A lorazepam challenge test (lorazepam 1-2 mg IV) resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis. Catatonia generally responds to benzodiazepines within a week; ECT is the treatment of choice in patients who do not improve.

Avoid antipsychotics (can worsen symptoms).

Premenstrual Dysphoric Disorder

This patient's presentation is suggestive of premenstrual syndrome (PMS). The most common physical manifestations of PMS are bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include mood swings, anxiety, difficulty concentrating, decreased libido, and irritability. Symptoms usually begin a week prior to menses and resolve within a few days after menses start. Patients are symptom free during the follicular phase. Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, with prominent irritability, hopelessness, depressed mood, self-critical thoughts, anger, and greater psychosocial impairment.

Prior to recommending a treatment approach, a clear diagnosis of PMS/PMDD must be established. This requires ruling out an underlying psychiatric disorder that may be exacerbated during the premenstrual phase but is still present at other times (eg, dysthymia, cyclothymia, personality disorder). A detailed menstrual history (diary) with prospective charting of daily mood and physical symptoms over the course of 2 or 3 menstrual cycles is commonly used. Demonstration that symptoms occur repeatedly and predictably prior to menstruation and resolve with menses confirms the diagnosis. If symptoms occur irregularly or throughout the menstrual cycle, a primary mood or personality disorder is more likely.

Mild PMS can be managed with exercise and stress reduction. Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine) are first-line treatment for moderate to severe PMS/PMDD.

Suicide

Suicide is the act of intentionally ending one's own life. Risk factors in patients associated with an increased risk to commit suicide can be remembered with the mnemonic: “SAD PERSONS”:

• Sex (male)

• Age (elderly >65 and teenagers 15-24)

• Depression

• Previous attempt

• Ethanol or drug use

• Rational thinking lost

• Sickness (medical illness, 3 or more prescription medications)

• Organized plan

• No spouse (divorced, widowed, or single, especially if childless)

• Social support lacking

The #1 risk factor for suicide is previous attempt.

Men successfully commit suicide more often than women, although women attempt suicide more often than men.

Suicide rates are high among patients with mental illness such as depression, bipolar disorder, schizophrenia, borderline personality disorder, and substance abuse issues. Suicide risk screening and assessment is essential for suicide prevention.

Assessment

Evaluate ideation

• Wish to die, not wake up (passive)

• Thoughts of killing self (active)

• Frequency, duration, intensity, controllability

Evaluate intent

• Strength of intent to attempt suicide; ability to control impulsivity

• Determine how close patient has come to acting on a plan (rehearsal, aborted attempts)

Evaluate plan

• Specific details: Method, time, place, access to means (eg, weapons, pills), preparations (eg, gathering pills, changing will)

• Lethality of method

• Likelihood of rescue

Hospitalization to maintain safety is indicated for patients with active suicidal ideation that includes a plan and intent to act. Patients with suicidal ideation but no specific plan or intent need intensive outpatient treatment, but not necessarily hospitalization (eg, treat the underlying disorder with medication and/or psychotherapy, increase the frequency of clinical contact, mobilize supports).

The most common method of suicide in children and adolescents is drug overdose. Therefore, consider a suicide attempt in a pediatric patient who presents with medication or drug overdose.

Prevention of suicide involves careful risk assessment and a high index of suspicion. If you see an answer choice such as "screen for suicide risk" in a question, carefully evaluate the question and consider it as an option. It is most likely the right answer in a patient with depressed mood or anhedonia.

Management of an actively suicidal patient usually requires hospitalization for stabilization and mental recovery. An actively suicidal patient expresses suicidal ideation (e.g. "I just want to end it all"), often with a plan.

Management of a patient who is not actively suicidal but who has multiple risk factors for suicide involves close follow-up (e.g. within a few days).

Homicide

• access to firearms most concerning risks