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Mood disorders

Mood disorders

This chapter discusses disorders characterized by abnormalities of mood: namely, depression, mania, or both. Included here are descriptions of a wide variety of mood disorders that occur over a broad clinical spectrum. Also included in this chapter is an analysis of how monoamine neurotransmitter systems are hypothetically linked to the biological basis of mood disorders. The three principal monoamine neurotransmitters are norepinephrine (NE; also called noradrenaline or NA), discussed in this chapter, dopamine (DA), discussed in , and serotonin (also calledChapter 4 5-hydroxytryptamine or 5HT), discussed in .Chapter 5

The approach taken here is to deconstruct each mood disorder into its component symptoms, followed by matching each symptom to hypothetically malfunctioning brain circuits, each regulated by one or more of the monoamine neurotransmitters. Genetic regulation and neuroimaging of these hypothetically malfunctioning brain circuits are also discussed. Coverage of symptoms and circuits of mood disorders in this chapter is intended to set the stage for understanding the pharmacological concepts underlying the mechanisms of action and use of antidepressants and mood stabilizing drugs, which will be reviewed in the following two chapters ( and ).Chapters 7 8

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Clinical descriptions and criteria for how to diagnose disorders of mood will only be mentioned in passing. The reader should consult standard reference sources for this material.

Description of mood disorders

Disorders of mood are often called affective disorders, since affect is the external display of mood, an emotion that is felt internally. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Classically, mania and depression are “poles” apart, thus generating the terms depression (i.e., patients who just experience the or depressed pole) and unipolar down

(i.e., patients who at different times experience either the [i.e., manic] pole or the bipolar up down [i.e., depressed] pole). Depression and mania may even occur simultaneously, which is called a

mood state. Mania may also occur in lesser degrees, known as , or switch somixed hypomania

Figure 6-1. . Bipolar disorder is generally characterized by four types of illness episodes: manic,Mood episodes major depressive, hypomanic, and mixed. A patient may have any combination of these episodes over the course of illness; subsyndromal manic or depressive episodes also occur during the course of illness, in which case there are not enough symptoms or the symptoms are not severe enough to meet the diagnostic criteria for one of these episodes. Thus the presentation of mood disorders can vary widely.

fast between mania and depression that it is called .rapid cycling

Mood disorders can be usefully visualized not only to contrast different mood disorders from one another, but also to summarize the course of illness for individual patients by showing them mapped onto a mood chart. Thus, mood ranges from hypomania to mania at the top, to euthymia (or normal mood) in the middle, to dysthymia and depression at the bottom ( ). The most common andFigure 6-1 readily recognized mood disorder is major depressive disorder ( ), with single or recurrentFigure 6-2

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

episodes. Dysthymia is a less severe but long-lasting form of depression ( ). Patients with aFigure 6-3 major depressive episode who have poor inter-episode recovery, only to the level of dysthymia, followed by another episode of major depression are sometimes said to have “double depression,” alternating between major depression and dysthymia, but not remitting ( ).Figure 6-4

Patients with bipolar I disorder have full-blown manic episodes or mixed episodes of mania plus depression, often followed by a depressive episode ( ). When mania recurs at least fourFigure 6-5 times a year, it is called rapid cycling ( ). Patients with bipolar I disorder can also haveFigure 6-6A rapid switches from mania to depression and back ( ). By definition, this occurs at leastFigure 6-6B four times a year, but can occur much more frequently than that.

Bipolar II disorder is characterized by at least one hypomanic episode that follows a depressive episode ( ). Cyclothymic disorder is characterized by mood swings that are not as severeFigure 6-7 as full mania and full depression, but still wax and wane above and below the boundaries of normal mood ( ). There may be lesser degrees of variation from normal mood that are stable andFigure 6-8 persistent, including both depressive temperament (below normal mood but not a mood disorder) and hyperthymic temperament (above normal mood but also not a mood disorder) ( ).Figure 6-9 Temperaments are personality styles of responding to environmental stimuli that can be heritable patterns present early in life and persisting throughout a lifetime; temperaments include such independent personality dimensions as novelty seeking, harm avoidance, and conscientiousness. Some patients may have mood-related temperaments, and these may render them vulnerable to mood disorders, especially bipolar spectrum disorders, later in life.

Figure 6-2. . Major depression is the most common mood disorder and is defined by theMajor depression occurrence of at least a single major depressive episode, although most patients will experience recurrent episodes.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-3. . Dysthymia is a less severe form of depression than major depression, but long-lastingDysthymia (over 2 years in duration) and often unremitting.

Figure 6-4. . Patients with unremitting dysthymia who also experience the superimpositionDouble depression of one or more major depressive episodes are described as having double depression. This is also a form of recurrent major depressive episodes with poor inter-episode recovery.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-5. . Bipolar I disorder is defined as the occurrence of at least one manic or mixedBipolar I disorder (full mania and full depression simultaneously) episode. Patients with bipolar I disorder typically experience major depressive episodes as well, although this is not necessary for the bipolar I diagnosis.

Figure 6-6

A. . The course of bipolar disorder can be rapid cycling, which means that at least fourRapid cycling mania episodes occur within a 1-year period. This can manifest itself as four distinct manic episodes, as shown here. Many patients with this form of mood disorder experience switches much more frequently than four times a year.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

B. . A rapid cycling course (at least four distinct mood episodes within 1 year) can alsoRapid cycling switches manifest as rapid switches between manic and depressive episodes.

Figure 6-7. . Bipolar II disorder is defined as an illness course consisting of one or moreBipolar II disorder major depressive episodes and at least one hypomanic episode.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-8. . Cyclothymic disorder is characterized by mood swings between hypomaniaCyclothymic disorder and dysthymia but without any full manic or major depressive episodes.

Figure 6-9. . Not all mood variations are pathological. Individuals with depressive temperamentTemperaments may be consistently sad or apathetic but do not meet the criteria for dysthymia and do not necessarily experience any functional impairment. However, individuals with depressive temperament may be at greater risk for the development of a mood disorder later in life. Hyperthymic temperament, in which mood is above normal but not pathological, includes stable characteristics such as extroversion, optimism, exuberance, impulsiveness, overconfidence, grandiosity, and lack of inhibition. Individuals with hyperthymic temperament may be at greater risk for the development of a mood disorder later in life.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

This chapter discusses disorders characterized by abnormalities of mood: namely, depression, mania, or both. Included here are descriptions of a wide variety of mood disorders that occur over a broad clinical spectrum. Also included in this chapter is an analysis of how monoamine neurotransmitter systems are hypothetically linked to the biological basis of mood disorders. The three principal monoamine neurotransmitters are norepinephrine (NE; also called noradrenaline or NA), discussed in this chapter, dopamine (DA), discussed in , and serotonin (also calledChapter 4 5-hydroxytryptamine or 5HT), discussed in .Chapter 5

The approach taken here is to deconstruct each mood disorder into its component symptoms, followed by matching each symptom to hypothetically malfunctioning brain circuits, each regulated by one or more of the monoamine neurotransmitters. Genetic regulation and neuroimaging of these hypothetically malfunctioning brain circuits are also discussed. Coverage of symptoms and circuits of mood disorders in this chapter is intended to set the stage for understanding the pharmacological concepts underlying the mechanisms of action and use of antidepressants and mood stabilizing drugs, which will be reviewed in the following two chapters ( and ).Chapters 7 8

Clinical descriptions and criteria for how to diagnose disorders of mood will only be mentioned in passing. The reader should consult standard reference sources for this material.

Description of mood disorders

Disorders of mood are often called affective disorders, since affect is the external display of mood, an emotion that is felt internally. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Classically, mania and depression are “poles” apart, thus generating the terms depression (i.e., patients who just experience the or depressed pole) and unipolar down

(i.e., patients who at different times experience either the [i.e., manic] pole or the bipolar up down [i.e., depressed] pole). Depression and mania may even occur simultaneously, which is called a

mood state. Mania may also occur in lesser degrees, known as , or switch somixed hypomania

Figure 6-1. . Bipolar disorder is generally characterized by four types of illness episodes: manic,Mood episodes major depressive, hypomanic, and mixed. A patient may have any combination of these episodes over the course of illness; subsyndromal manic or depressive episodes also occur during the course of illness, in which case there are not enough symptoms or the symptoms are not severe enough to meet the diagnostic criteria for one of these episodes. Thus the presentation of mood disorders can vary widely.

fast between mania and depression that it is called .rapid cycling

Mood disorders can be usefully visualized not only to contrast different mood disorders from one another, but also to summarize the course of illness for individual patients by showing them mapped onto a mood chart. Thus, mood ranges from hypomania to mania at the top, to euthymia (or normal mood) in the middle, to dysthymia and depression at the bottom ( ). The most common andFigure 6-1 readily recognized mood disorder is major depressive disorder ( ), with single or recurrentFigure 6-2

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

episodes. Dysthymia is a less severe but long-lasting form of depression ( ). Patients with aFigure 6-3 major depressive episode who have poor inter-episode recovery, only to the level of dysthymia, followed by another episode of major depression are sometimes said to have “double depression,” alternating between major depression and dysthymia, but not remitting ( ).Figure 6-4

Patients with bipolar I disorder have full-blown manic episodes or mixed episodes of mania plus depression, often followed by a depressive episode ( ). When mania recurs at least fourFigure 6-5 times a year, it is called rapid cycling ( ). Patients with bipolar I disorder can also haveFigure 6-6A rapid switches from mania to depression and back ( ). By definition, this occurs at leastFigure 6-6B four times a year, but can occur much more frequently than that.

Bipolar II disorder is characterized by at least one hypomanic episode that follows a depressive episode ( ). Cyclothymic disorder is characterized by mood swings that are not as severeFigure 6-7 as full mania and full depression, but still wax and wane above and below the boundaries of normal mood ( ). There may be lesser degrees of variation from normal mood that are stable andFigure 6-8 persistent, including both depressive temperament (below normal mood but not a mood disorder) and hyperthymic temperament (above normal mood but also not a mood disorder) ( ).Figure 6-9 Temperaments are personality styles of responding to environmental stimuli that can be heritable patterns present early in life and persisting throughout a lifetime; temperaments include such independent personality dimensions as novelty seeking, harm avoidance, and conscientiousness. Some patients may have mood-related temperaments, and these may render them vulnerable to mood disorders, especially bipolar spectrum disorders, later in life.

Figure 6-2. . Major depression is the most common mood disorder and is defined by theMajor depression occurrence of at least a single major depressive episode, although most patients will experience recurrent episodes.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-3. . Dysthymia is a less severe form of depression than major depression, but long-lastingDysthymia (over 2 years in duration) and often unremitting.

Figure 6-4. . Patients with unremitting dysthymia who also experience the superimpositionDouble depression of one or more major depressive episodes are described as having double depression. This is also a form of recurrent major depressive episodes with poor inter-episode recovery.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-5. . Bipolar I disorder is defined as the occurrence of at least one manic or mixedBipolar I disorder (full mania and full depression simultaneously) episode. Patients with bipolar I disorder typically experience major depressive episodes as well, although this is not necessary for the bipolar I diagnosis.

Figure 6-6

A. . The course of bipolar disorder can be rapid cycling, which means that at least fourRapid cycling mania episodes occur within a 1-year period. This can manifest itself as four distinct manic episodes, as shown here. Many patients with this form of mood disorder experience switches much more frequently than four times a year.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

B. . A rapid cycling course (at least four distinct mood episodes within 1 year) can alsoRapid cycling switches manifest as rapid switches between manic and depressive episodes.

Figure 6-7. . Bipolar II disorder is defined as an illness course consisting of one or moreBipolar II disorder major depressive episodes and at least one hypomanic episode.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-8. . Cyclothymic disorder is characterized by mood swings between hypomaniaCyclothymic disorder and dysthymia but without any full manic or major depressive episodes.

Figure 6-9. . Not all mood variations are pathological. Individuals with depressive temperamentTemperaments may be consistently sad or apathetic but do not meet the criteria for dysthymia and do not necessarily experience any functional impairment. However, individuals with depressive temperament may be at greater risk for the development of a mood disorder later in life. Hyperthymic temperament, in which mood is above normal but not pathological, includes stable characteristics such as extroversion, optimism, exuberance, impulsiveness, overconfidence, grandiosity, and lack of inhibition. Individuals with hyperthymic temperament may be at greater risk for the development of a mood disorder later in life.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

This chapter discusses disorders characterized by abnormalities of mood: namely, depression, mania, or both. Included here are descriptions of a wide variety of mood disorders that occur over a broad clinical spectrum. Also included in this chapter is an analysis of how monoamine neurotransmitter systems are hypothetically linked to the biological basis of mood disorders. The three principal monoamine neurotransmitters are norepinephrine (NE; also called noradrenaline or NA), discussed in this chapter, dopamine (DA), discussed in , and serotonin (also calledChapter 4 5-hydroxytryptamine or 5HT), discussed in .Chapter 5

The approach taken here is to deconstruct each mood disorder into its component symptoms, followed by matching each symptom to hypothetically malfunctioning brain circuits, each regulated by one or more of the monoamine neurotransmitters. Genetic regulation and neuroimaging of these hypothetically malfunctioning brain circuits are also discussed. Coverage of symptoms and circuits of mood disorders in this chapter is intended to set the stage for understanding the pharmacological concepts underlying the mechanisms of action and use of antidepressants and mood stabilizing drugs, which will be reviewed in the following two chapters ( and ).Chapters 7 8

Clinical descriptions and criteria for how to diagnose disorders of mood will only be mentioned in passing. The reader should consult standard reference sources for this material.

Description of mood disorders

Disorders of mood are often called affective disorders, since affect is the external display of mood, an emotion that is felt internally. Depression and mania are often seen as opposite ends of an affective or mood spectrum. Classically, mania and depression are “poles” apart, thus generating the terms depression (i.e., patients who just experience the or depressed pole) and unipolar down

(i.e., patients who at different times experience either the [i.e., manic] pole or the bipolar up down [i.e., depressed] pole). Depression and mania may even occur simultaneously, which is called a

mood state. Mania may also occur in lesser degrees, known as , or switch somixed hypomania

Figure 6-1. . Bipolar disorder is generally characterized by four types of illness episodes: manic,Mood episodes major depressive, hypomanic, and mixed. A patient may have any combination of these episodes over the course of illness; subsyndromal manic or depressive episodes also occur during the course of illness, in which case there are not enough symptoms or the symptoms are not severe enough to meet the diagnostic criteria for one of these episodes. Thus the presentation of mood disorders can vary widely.

fast between mania and depression that it is called .rapid cycling

Mood disorders can be usefully visualized not only to contrast different mood disorders from one another, but also to summarize the course of illness for individual patients by showing them mapped onto a mood chart. Thus, mood ranges from hypomania to mania at the top, to euthymia (or normal mood) in the middle, to dysthymia and depression at the bottom ( ). The most common andFigure 6-1 readily recognized mood disorder is major depressive disorder ( ), with single or recurrentFigure 6-2

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

episodes. Dysthymia is a less severe but long-lasting form of depression ( ). Patients with aFigure 6-3 major depressive episode who have poor inter-episode recovery, only to the level of dysthymia, followed by another episode of major depression are sometimes said to have “double depression,” alternating between major depression and dysthymia, but not remitting ( ).Figure 6-4

Patients with bipolar I disorder have full-blown manic episodes or mixed episodes of mania plus depression, often followed by a depressive episode ( ). When mania recurs at least fourFigure 6-5 times a year, it is called rapid cycling ( ). Patients with bipolar I disorder can also haveFigure 6-6A rapid switches from mania to depression and back ( ). By definition, this occurs at leastFigure 6-6B four times a year, but can occur much more frequently than that.

Bipolar II disorder is characterized by at least one hypomanic episode that follows a depressive episode ( ). Cyclothymic disorder is characterized by mood swings that are not as severeFigure 6-7 as full mania and full depression, but still wax and wane above and below the boundaries of normal mood ( ). There may be lesser degrees of variation from normal mood that are stable andFigure 6-8 persistent, including both depressive temperament (below normal mood but not a mood disorder) and hyperthymic temperament (above normal mood but also not a mood disorder) ( ).Figure 6-9 Temperaments are personality styles of responding to environmental stimuli that can be heritable patterns present early in life and persisting throughout a lifetime; temperaments include such independent personality dimensions as novelty seeking, harm avoidance, and conscientiousness. Some patients may have mood-related temperaments, and these may render them vulnerable to mood disorders, especially bipolar spectrum disorders, later in life.

Figure 6-2. . Major depression is the most common mood disorder and is defined by theMajor depression occurrence of at least a single major depressive episode, although most patients will experience recurrent episodes.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-3. . Dysthymia is a less severe form of depression than major depression, but long-lastingDysthymia (over 2 years in duration) and often unremitting.

Figure 6-4. . Patients with unremitting dysthymia who also experience the superimpositionDouble depression of one or more major depressive episodes are described as having double depression. This is also a form of recurrent major depressive episodes with poor inter-episode recovery.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-5. . Bipolar I disorder is defined as the occurrence of at least one manic or mixedBipolar I disorder (full mania and full depression simultaneously) episode. Patients with bipolar I disorder typically experience major depressive episodes as well, although this is not necessary for the bipolar I diagnosis.

Figure 6-6

A. . The course of bipolar disorder can be rapid cycling, which means that at least fourRapid cycling mania episodes occur within a 1-year period. This can manifest itself as four distinct manic episodes, as shown here. Many patients with this form of mood disorder experience switches much more frequently than four times a year.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

B. . A rapid cycling course (at least four distinct mood episodes within 1 year) can alsoRapid cycling switches manifest as rapid switches between manic and depressive episodes.

Figure 6-7. . Bipolar II disorder is defined as an illness course consisting of one or moreBipolar II disorder major depressive episodes and at least one hypomanic episode.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

 

 

Figure 6-8. . Cyclothymic disorder is characterized by mood swings between hypomaniaCyclothymic disorder and dysthymia but without any full manic or major depressive episodes.

Figure 6-9. . Not all mood variations are pathological. Individuals with depressive temperamentTemperaments may be consistently sad or apathetic but do not meet the criteria for dysthymia and do not necessarily experience any functional impairment. However, individuals with depressive temperament may be at greater risk for the development of a mood disorder later in life. Hyperthymic temperament, in which mood is above normal but not pathological, includes stable characteristics such as extroversion, optimism, exuberance, impulsiveness, overconfidence, grandiosity, and lack of inhibition. Individuals with hyperthymic temperament may be at greater risk for the development of a mood disorder later in life.

Downloaded from http://stahlonline.cambridge.org by IP 100.122.180.231 on Fri Mar 22 00:39:37 UTC 2019 Stahl Online © 2019 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution.

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