MOOD DISORDERS

ANXIETY DISORDERS

LAMPU KOSULWIT, M.D.

PSYCHIATRIC DISORDERS

Definition of mental disorder

* Mental disorder
* Psychosis
* Neurosis
* Functional
* Organic
* Primary
* Secondary

Mental disorder : illness with psychological or

behavioral manifestations associated with significant
distress and impaired functioning caused by a biologic,
social, psychological, genetic, physical, or chemical
disturbance
---------------------------------------------------------------Psychotic : loss of reality testing with delusions and
hallucination
Neurosis : intact reality testing , mainly intrapsychic
conflicts or life events , major symptom = anxiety

e.g.,obsession, compulsion , phobia

Functional : no known structure damage or

clear-cut biologic cause to account impairment
Organic : illness caused by a specific agent
producing structural associated with cognitive
impairment , delirium , or dementia

Primary : no known cause ; also called

idiopathic (similar to functional )
Secondary : known to be a symptomatic
manifestation of systemic, medical or cerebral
disorder
e.g., Delirium from meningitis,
encephalitis, brain abscess
Dementia from hypothyroidism or
vitamin B12 deficiency, neurosyphilis,
AIDS dementia complex

* DSM-5
* DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 5th EDITION
* AMERICAN PSYCHIATRIC ASSOCIATION

MOOD DISORDER

Mood States

Elevated

Mania
Hypomania

Normal range

Dysthymia

Depressed

Depression

Mood disorders
Severe/ Acute Less severe /
Chronic
Unipolar
No history of
mania,
hypoamnia

Bipolar

Major
depressive
disorder

Dysthymia

Bipolar I
Bipolar II

Cyclothymia

Prevalence

Mood disorders
Unipolar:
Major depressive disorder*
Dysthymic disorder
Bipolar:
Bipolar I disorder*: Manic & depressive episodes
Bipolar II disorder: Hypomanic + major depress
Cyclothymic disorder : Hypomania+minor depress
Mood disorder due to GMC
Substance induced mood disorder
* psychotic features

Major depressive episode

5 or more of following symptoms for 2 weeks:

1.Depressed mood * 2. Diminished interest or pleasure

--------------------------------------------------------------3. Fatigue or loss of energy
4. Feelings of worthlessness or inappropriate guilt
5. Difficulties concentrating or indecisiveness
6. Recurrent thoughts of death
7. Weight loss or gain (>5% in a month)
8. Insomnia or hypersomnia
9. Psychomotor retardation or agitation
Symptoms

must cause sig. distress or impairment

Exclusions: Substance, Medical, Bereavement

Manic episode

1 week of abnormally elevated, expansive or

irritable mood with 3+ of following symptoms:

1. Grandiosity
2. Decreased need for
sleep
3. Talkativeness
4. Flight of ideas or
racing thoughts
5. Distractibility
Symptoms

6.Increase in goaldirected activity or

psychomotor
agitation
7.Buying sprees, sexual
indescretions, foolish
investments.

must cause sig. distress or impairment

Exclusions:

Substance, Medical condition

Hypomania
Similar symptoms to manic episode except:
n Minimum of 4 days
n Episode not severe enough to cause marked
impairment in social or occupational functioning
mania
n
n
n
n

Dysthymic disorder

2
B. 2
1.
2.
3.
4. self esteem
5.
6.
C. 2 A. B.
2
A.

D.
E.
F.
G.
H.

major depressive 2
manic / hypomanic episodes
schizophrenia/ delusional
disorder
// hypothyroidism
Significant distress or impairment

Cyclothymic disorder
A. hypomania MDD 2
B. 2 A 2
C. major depressive / manic / mixed episodes 2
D. schizoaffective d/o,
schizophrenia, schizophreniform d/o, delusional d/o,
psychotic d/o nos
E.
hyperthyroidism
F. Significant distress or impairment

Overview of Etiological factors

Biological
Neurotransmitters

Endocrine system
Family and
genetics

Mood
Disorder

Psychological
Stressful life events
Behavioural factors
Cognitive factors
Psychodynamic

Social
Support system
Woman & mood disorders

Biological: Neurotransmitters
n

Low levels of serotonin depression

Dopamine levels:
High Mania
Low Depression

Low level of norepinephrine

Depression

Threshold model
Threshold for mood disorder

Stress
Vulnerability

Low Vulnerability High Vulnerability

Treatment :
BIO :
MEDICATIONS
ECT
PSYCHO :
PSYCHOTHERAPY

SOCIAL :
PSYCHOEDUCATION

Treatment of bipolar I & II

n
n
n
n

CBT
Interpersonal psychotherapy
Psychoeducation about disorder
Chart the precipitants, nature, duration,
frequency, and seasonality of dysfunctional mood
to avoid future episodes.
Medication
Lithium
Anticonvulsants (Depakote, Tegretol, Lamictal)
Atypical Antipsychotics (Risperdal, Seroquel)

25

Treatment: Mania
Mood stabilizers:
Lithium
Anticonvulsants
* valproate
* carbamazepine
* lamotrigine
* topiramate
- Atypical antipsychotics
* olanzapine (zyprexa)
* risperidone (risperdal)
* quatiapine (seroquel)

Electroconvulsive therapy (ECT)

Antimanic drugs
n

Lithium 300-900 mg/d

(therapeutic blood level o.8-1.2 mEq/l)

Valproate 400-1200 mg/d

(50-125 g/ml)
Carbamazepine 600-1200 mg/d
(6-12 g/ml)

Treatment: Mania
Electroconvulsive therapy (ECT)
- severe mania
-

Treatment of Depression

Treatment: Medication
n
n

Used to treat and also prevent relapse.

Antidepressants:
Effective in 50-65% of depressive cases
* Selective Serotonin reuptake inhibitors (SSRIs)
* Serotonin noradrenaline reuptake
inhibitors(SNRI) : venlafaxine
* Tricyclics: Effective but can overdose
* Monoamine oxidase inhibitors (MAOs)
* ect.

Treatment
n

2-3

anxiolytic drugs
benzodiazepines : Clonazepam ,Diazepam,
Lorazepam
1st episode 6-9

 SSRIs
Fluoxetine(20) 1 tab PO OD pc

Diazepam 2-5mg PO hs
Sertraline (Zoloft) (50) 1 tab PO pc
, , ,
Venlafaxine (Efexor-XR) (75)
1 tab PO pc
, ,
,

 tricyclic
Amitriptyline (25) 1 tab PO hs

75-150mg/d
Nortriptyline (25) 1 tab PO hs
75-150mg/d

n anticholinergic side effects :

, postural hypotension
n Antihistamine side effects : , , .
n suicide

off
depress
mania

mania , hypomania

Treatment : depression
Electroconvulsive therapy
n - psychotic
n -
n -
n

Psychotherapy

Psychotherapy
Treatment : depression
Cognitive therapy
n Aim : correcting chronic distortions in thinking
that lead to depression
n in particular the cognitive triad of feeling of
hopelessness, helplessness about one s self,
one s future, one s past
Psychotherapy
Group therapy
Family therapy

Treatment: Which is best?

n
n
n

Vegetative symptoms and severe symptoms

medication important
Medication: quicker symptom alleviation than
psychotherapy
Psychotherapy more effective then
medication for prevention of relapse
Combined treatment most effective for
relapse prevention.

Case Study Jessica

n
n

n
n

n
n
n

Jessica is a 28 year-old married female. She has a very demanding, high

stress job as a second year medical resident in a large hospital.
Jessica has always been a high achiever. She graduated with top honors in
both college and medical school. She has very high standards for herself and
can be very self-critical when she fails to meet them.

Lately, she has struggled with significant feelings of worthlessness and shame
due to her inability to perform as well as she always has in the past.
For the past few weeks Jessica has felt unusually fatigued and found it
increasingly difficult to concentrate at work.
Her coworkers have noticed that she is often irritable and withdrawn, which is
quite different from her typically cheerful and friendly disposition.
She has called in sick on several occasions, which is completely unlike her.
On those days she stays in bed all day, watching TV or sleeping.

Case Study Jessica

n
n
n
n
n
n

At home, Jessicas husband has noticed changes as well.

Shes shown little interest in sex and has had difficulties falling
asleep at night.
Hes overheard her having frequent tearful phone conversations
with her closest friend.
When he tries to get her to open up about whats bothering
her, she pushes him away with an abrupt everythings fine.
Although she hasnt ever considered suicide, Jessica has found
herself increasingly dissatisfied with her life.
Shes been having frequent thoughts of wishing she was dead.
She gets frustrated with herself because she feels like she has
every reason to be happy, but the sense of that situation is bad
and is not likely to improve.

Jessica

n
n
n

Case study 2
29 8 .

3

Anxiety disorder

Anxiety disorder
Anxiety disorders are common
psychiatric disorders

Anxiety disorder
Many patients : experience
physical symptoms related to anxiety
visit to primary care physicians
high prevalence rates of these anxiety disorders
often are underrecognized and
undertreated clinical problems

 anxiety disorders
DSM-V anxiety disorders

1. Panic Attack (Specifier)
2. Panic disorder
3. Agoraphobia
4. Generalized anxiety disorder(GAD)
5. Social Anxiety Disorder (Social Phobia)
6. Specific phobia

Anxiety disorders
Lifetime prevalence : 1.5%-29%
(depending on subtype or severity)
Major depressive disorder comorbidity (50%)
Anxiety can precede or be coincident with depression
onset

Anxiety disorder
Race:
* no difference in rates of panic disorder
Sex:
female : male = 3 : 2

Anxiety disorder
Age :
* Most

: begin in childhood
adolescence
early adulthood

Sex:
female : male = 3 : 2

Anxiety disorder
New-onset anxiety symptoms in older adults
should search for
- unrecognized general medical condition
- substance abuse disorder
- major depression with secondary anxiety
symptoms

Normal anxiety Anxiety disorder

1.

2.
3.

Anxiety disorder
Pathophysiology :
caused by an
interaction of bio-psycho-social factors
including
- genetic vulnerability
- situations : stress, or traumatic experience

Anxiety disorder
Pathophysiology :
In

CNS

major mediators - norepinephrine and

- serotonin
other neurotransmitters and peptides, such as
- corticotropin-releasing factor
Peripherally, the ANS
esp. sympathetic nervous system, mediates many of the symptoms

Panic disorder

Panic disorder
is characterized by recurrent panic attacks
periods of intense fear of abrupt onset
peaking in intensity within minutes

Four of the following must be present for a panic attack:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Shaking
4. Sensation of shortness of breath or dyspnea
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization or depersonalization
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensation)
13. Chills or hot flashes

# Panic attack mental disorder

# code
#
PTSD SUNBSTANCE USE
DISORDERS
# cardiac,
respiratory , vestibular, gastrointestinal)

Panic disorder

Four of the following must be present for a panic attack:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Shaking
4. Shortness of breath or dyspnea
5. Sensation of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Derealization or depersonalization
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesias
13. Chills or hot flashes

1 month 1
1. Persistent concern or worry about panic attacks or their
consequences (losing control, havig a heart attack, going crazy)
2. A significant maladaptive change in behavior related to attack
( panic attacks
)

Agoraphobia
A. marked fear or anxiety about 2(or more) of the following 5
situations:
1.using public transportation (e.g. buses, trains, ships, planes).
2.being in open spaces (e.g. marketplaces, bridges).
3.being in enclosed places (e.g.,shops,theaters,cinemas).
4.Standing in line or being in a crowd.
5.Being outside of the home alone.
B. Avoid these situations because of thoughts that escape might be
difficult or help might be available in the event of developing panic-like
symptoms or other incapacitating or embarrassing symptoms (

)
C. A
D. A

Agoraphobia
E. out of proportion to the actual danger
F. 6
G. clinically significant
distress or impairmnet in social , occupational, or other
important areas of functioning
H.
specific phobia, OCD, PTSD

Generalized anxiety disorder

Generalized anxiety disorder

is characterized by
unrealistic excessive anxiety and worry
** free floating anxiety **
Worrying is difficult to control

DSM-V

: GAD

A. ()
6
( )
B.
C. 6 3 (
6 )
1.
2.
3.
4.
5.
6. ( )
D.

E. /

F. ( )
Mood disorder,
Psychotic disorder Pervasive developmental disorder

Generalized anxiety disorder screening

mnemonic

Social anxiety disorder

Social phobia
Marked and persistent fear or anxiety about
one or more social situation 6




impairment in social, occupational, or other
important areas of functioning

Specific Phobias

Specific Phobias
Marked persistent fear of situation or object
6
Examples : heights, animals or seeing blood, flying,
receiving an injection
Exposure causes intense anxiety and avoidance causing
interference

Anxiety disorder
MEDICATION
Antidepressant : drugs of choice
- SSRIs
- TCA
- SNRI
Benzodiazepines

Pharmacotherapy : anxiety disorder

Antidepressant : SSRIs
antianxiety
DZP, CLORAZEPATE, ALPRAZOLAM(prn panic)
Propanolol(10) 1*3 or 1* prn

Anxiety disorder
MEDICATION
Antidepressant : drugs of choice

- SSRIs : fluoxetine, sertraline,

fluvoxamine, paroxetine, escitalopram
- TCA : clomipramine
- SNRI : venlafexine

Anxiety disorder
* All SSRIs :
- equal in the treatment of anxiety disorders;
BUT select it by side effect and drug
interaction consideration.

Case Study : Kristen

Kristen is a 38 year-old divorced mother of two teenagers.
She has had a successful, well-paying career for the past several years in upperlevel management.

Shes found herself worrying constantly about losing her job and being unable to
provide for her children. This worry has been troubling her for the past 8
months. Despite her best efforts, she hasnt been able to shake the negative
thoughts.
Ever since the worry started, Kristen has found herself feeling restless, tired, and
tense. She often paces in her office when shes there alone.
Shes had several embarrassing moments in meetings where she has lost track of
what she was trying to say.

When she goes to bed at night, its as if her brain wont shut off.
She finds herself mentally rehearsing all the worse-case scenarios regarding
losing her job, including ending up homeless.

Kristen