Affective Disorder

Definition
Mood disorder encompass a large group of disorders in which
pathological mood and related disturbances dominate the clinical
picture
Known in Diagnostic and Statistical Manual of Mental Disorders
(DSM) as affective disorders, the term mood disorders is preferred
because it refers to sustained emotional states, not merely to the
external (affective) expressions
Mood disorders are best considered syndromes (rather than
disease) consisting of a cluster of signs and symptoms sustained
over weeks to months, tend to recur, often in periodic or cyclic
fashion
 Manifestations
Mood may be normal, elevated or depressed
Normal persons has a wide range of moods and are in
control of their moods and affects
In mood disorders the sense of control is loss
Patients with an elevated mood demonstrates
expansiveness, flight of ideas, decreased sleep,
heightened self-esteem and grandiose ideas
Patients with depressed mood show loss of energy and
interest, feelings of guilt, difficulty in concentrating, loss
of appetite, and thoughts of death and suicide
These disorders virtually always results in impaired
interpersonal, social and occupational functioning
 Patients who have major depressive
episode is said to have major depressive
disorder or unipolar depression
Patients with both manic and depressive
episodes or patients with manic episode
alone are said to have bipolar disorder
Hypomania is an episode of manic
symptoms that does not meet all the DSM-
IV criteria for manic episode
 Types of mood episodes
Major depressive episode
Manic episode
Mixed episode hypomanic episode

The main mood disorders

Major depressive disorder
Bipolar type I
Bipolar type II
Dysthymic disorder
Cyclothymic disorder
 Epidemiology
Incidence and prevalence
Major depressive disorder has a lifetime prevalence
of 15 % in medical patients
Bipolar I is less common with a lifetime prevalence of
1%

Sex
Manic episodes are more common in men
Depressive episodes are more common in women
 Age
Onset of bipolar I is earlier that MDD
Age of onset in bipolar I ranges from
childhood to 50 years, with mean age of 30
Mean age of MDD is about 40 years

Marital status
MDD occurs most often in persons without
close interpersonal relationships or in those
who are divorced or seperated
 Course and Prognosis
Untreated manic episodes generally last
about 3 months
The course is usually chronic with
relapses; as the disease progresses,
episodes may occur more frequently
Bipolar disorder has a worse prognosis
than MDD, as only 50-60% of patients
treated with lithium experience significant
improvement in symptoms
 Treatment
Pharmacotherapy
Lithium mood stabilizer
Anticonvulsants (eg. Carbamazepine or valproic acid)

Psychotherapy
Supportive therapy, family therapy

ECT
Works well in treatment of manic episodes
 Schizophrenia
A psychiatric disorder characterized by a
constellation of abnormalities in thinking,
emotion and behavior
In general the symptoms of schizophrenia
are broken up in 2 categories:
Positive symptoms: hallucinations,
delusions, bizarre behavior or thought
disorder
Negative symptoms: blunted affect,
anhedonia, apathy and inattentiveness
According to Eugen Bleuler, symptoms include
associational disturbances, affective disturbance,
autism and ambivalence

According to Emil Kraeplin described patients having a long

term deteriorating course and the common clinical
symptoms of hallucinations and delusions

Langfedlt classified patients with major psychotic

symptoms into 2 groups, those with true schizophrenia
and those with schizophrenialike psychosis.
 Etilogy
A. Stress-diathesis Model
A person may have a specific vulnerability
(diathesis) that, when acted on by a stressful
influence, allows the symptoms of
schizophrenia to develop

B. Dopamine Hypothesis
This theory posits that schizophrenia results
from too much dopaminergic activity
 C. Neuropathology
neuropathological and neurochemical abnormalities in
the cerebral cortex, the thalamus and the brainstem
Loss of brain volume in schizophrenic patients appear to
result from reduced density of the axons,dendrites and
synapses

D. Genetic Factors
A person is likely to have schizophrenia when other
members of the family have the disorder
Long arm of chr 5, 11 and 18, the short arm of chr 19,
and X chromosomes
 E. Psychosocial Factor
Freud postulated that schizophrenia results from
developmental fixations that occurred early in the
development of neuroses.
Ego disintegration in schizophrenia represents a return
to the time when ego was not yet developed. Thus
intrapsychic conflict arising from the early fixations and
the ego defect, which may have resulted from poor early
object relations, fuel the psychotic symptoms.
The ego defect affects the interpretation of reality and
the control of inner drives. The disturbance results from
distortions in the relationship between infant and the
mother
To Henry Sullivan, schizophrenia is an adaptive method
to avoid panic, terror and disintegration of the sense of
self
 Diagnosis (DSM-IV)
A. Characteristic symptoms: 2 or more of the
following each present for a significant portion
of time during a 1 month period
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, ie.,affective flattening, alogia,
or avolition
B. Social/ Occupational dysfunction
C. Duration
continuous signs for at least 6 months
This 6 month period must include at least 1
month of symptoms and may include periods of
prodromal or residual symptoms
D. Schizoaffective and mood disorder exclusion
E. Substance/ general medical condition exclusion
F. Relationship to a pervasive developmental
disorder
 Subtypes
Paranoid Type
Disorganized Type
Catatonic Type
Undifferentiated Type
Residual Type
 Treatment
Hospitalization
Pharmacotherapy
Dopamine receptor antagonist
Serotonin-dopamine antagonist
Other drugs: lithium, anticonvulsants
Psychosocial therapies
Social skills training
Family-oriented therapy
Group therapy
Cognitive behavioral therapy
Shcizoaffective Disorder
 Definition

1933- Jacob Kasanin introduced the term

schizoaffective disorder to refer to a
disorder with symptoms of both
schizophrenia and mood disorders
 Epidemiology

Lifetime prevalence is less than 1%

Lower in men than women
Age of onset for women is later than that of men

Etiology
The cause is unknown
Similar to etiology of schizophrenia, mood
disorders
 DSM-IV Diagnostic Criteria for
Schizoaffective Diorder
A. An uninterrupted period of illness during which, at some time,
there is either a major depressive episode, or a mixed episode
concurrent with symptoms that meet criterion A for schizophrenia
B. During that same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent
mood symptoms
C. Symptoms that meet the criteria for a mood episode are present
for a substantial portion of the total duration of the active and
residual periods of the illness
D. The disturbance is not due to the direct physiological effects of a
substance or a general medical condition
 Course and Prognosis
Considering the uncertainty and evolving
diagnosis of schizoaffective disorder,
determining the long-term course and
prognosis is difficult
An increasing presence of schizophrenic
symptoms predicted worse outcome
 Treatment
Mood stabilizers mainstay of treatment
Carbamazepine
Binds to voltage-dependent Na channels in
inactive stage prolonging inactivation
reduces Ca channel activation

reduce synaptic transmission

Adverse effect: rash, leukopenia
 Lithium
Therapeutic mechanism of action for lithium
remains uncertain
Used alone, in combination with each
other
In manic episodes, schizoaffective patients
should be treated aggressively with
dosage in the middle to high. As patient
enters maintenance phase, dosage can be
reduced to low to middle range to avoid
adverse effects