MOOD DISORDERS

Mood disorders are characterized by a disturbance of mood, accompanied by a full or partial manic or
depressive syndrome, which is not due to any other physical or mental disorder.

Broadly speaking, the emotions can be described as two main types:

1. Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world.
Examples of mood include depression, joy, elation, anger, and anxiety.
2. Affect is described as the emotional reaction associated with an experience (
So according to these definitions, depression and mania are mood disorders and not ‘ affective
disorders’ as they have been called so frequently in the past.

CLASSIFICATION
The classification of mood disorders is an area which is fraught with multiple controversies. According to the
ICD-10, the mood disorders are classified as follows:
1. Manic episode
2. Depressive episode
3. Bipolar mood (affective) disorder
4. Recurrent depressive disorder
5. Persistent mood disorder (including cyclothymia and dysthymia)
6. Other mood disorders (including mixed affective episode and recurrent brief depressive disorder).
Manic Episode
Mania refers to a syndrome in which the central features are over-activity, mood change (which may be towards
elation or irritability) and self important ideas.
.
Classification of Mania (ICD10)
• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms
• Manic episode unspecified

The life-time risk of manic episode is about 0.8- 1%. This disorder tends to occur in episodes lasting usually 3-4
months, followed by complete clinical recovery. The future episodes can be manic, depressive or mixed. A manic
episode is typically characterised by the following features (which should last for at least one week and cause
disruption in occupational and social activities).

Elevated, Expansive or Irritable Mood

The elevated mood can pass through following four stages, depending on the severity of manic episode:
a. Euphoria (mild elevation of mood): An increased sense of psychological well-being and happiness,
not in keeping with ongoing events. This is usually seen in hypomania (Stage I).
b. Elation (moderate elevation of mood): A feeling of confidence and enjoyment, along with an increased
psychomotor activity. Elation is classically seen in mania (Stage II).
c. Exaltation (severe elevation of mood): Intense elation with delusions of grandeur; seen in severe mania (Stage
III).
d. Ecstasy (very severe elevation of mood): Intense sense of rapture or blissfulness; typically seen in delirious or
stuporous mania (Stage IV).

Along with these variations in elevation of mood, expansive mood may also be present, which is an
unceasing and unselective enthusiasm for interacting with people and surrounding environment. At times,
elevated mood may not be apparent and instead an irritable mood may be predominant, especially when the person
is stopped from doing what he wants. There may be rapid, short lasting shifts from euphoria to
depression or irritability.
Psychomotor Activity
There is an increased psychomotor activity, ranging from overactiveness and restlessness, to manic excitement
where the person is ‘on-the-toe-on-the-go’, (i.e. involved in ceaseless activity). The activity is usually goal-oriented
and is based on external environmental cues. Rarely, a manic patient can go in to a stuporous state (manic stupor).

Speech and Thought

The person is more talkative than usual; describes thoughts racing in his mind; develops pressure of speech; uses
playful language with punning, rhyming, joking and teasing; and speaks loudly.
Later, there is ‘ flight of ideas’ (rapidly produced speech with abrupt shifts from topic to topic, using external
environmental cues. Typically the connections between the shifts are apparent). When the ‘flight’ becomes severe,
incoherence may occur. A less severe and a more ordered ‘flight’, in the absence of pressure of speech, is called
‘prolixity’.
There can be delusions (or ideas) of grandeur (grandiosity), with markedly inflated self-esteem.
Delusions of persecution may sometimes develop secondary to the delusions of grandeur (e.g. I am so great that
people are against me).
Hallucinations (both auditory and visual), often with religious content, can occur (e.g. God appeared before me and
spoke to me). Since these psychotic symptoms are in keeping with the elevated mood state, these are called mood
congruent psychotic features.
Distractibility is a common feature and results in rapid changes in speech and activity, in response to
even irrelevant external stimuli.

Goal-directed Activity
The person is unusually alert, trying to do many things at one time.
In hypomania, the ability to function becomes much better and there is a marked increase in productivity and
creativity. Many artists and writers have contributed significantly in such periods. As past history of hypomania and
mild forms of mania is often difficult to elicit, it is really important to take additional historical information from
reliable informants (e.g. family members).
In mania, there is marked increase in activity with excessive planning and, at times, execution of multiple activities.
Due to being involved in so many activities and distractibility, there is often a decrease in the functioning ability in
later stage. There is marked increase in sociability even with previously unknown people. Gradually this sociability
leads to an interfering behaviour though the person does not recognise it as abnormal at that time. The person
becomes impulsive and disinhibited, with sexual indiscretions, and can later become hypersexual and promiscuous.

Due to grandiose ideation, increased sociability, overactivity and poor judgement, the manic person is often
involved in the high-risk activities such as buying sprees, reckless driving, foolish business investments, and
distributing money and/or personal articles to unknown persons. He is usually dressed up in gaudy and flamboyant
clothes, although in severe mania there may be poor self-care.
Other Features
Sleep is usually reduced with a decreased need for sleep. Appetite may be increased but later there is usually
decreased food intake, due to marked overactivity.
Insight into the illness is absent, especially in severe mania.
Psychotic features such as delusions, hallucinations which are not understandable in the context of
mood disorder (called mood incongruent psy chotic features), e.g. delusions of control, may be present in
some cases.

Etiology
The etiology of mood disorders is currently unknown. However, several theories have been propounded which
include:
Biological Theories
Genetic hypothesis Genetic factors are very important in predisposing an individual to mood disorders. The lifetime
risk for the first-degree relatives of patients with bipolar mood disorder is 25%and of normal controls is 7%.The
lifetime risk for the children of one parent with mood disorder is 27%and of both parents with mood
disorder is 74%. The concordance rate for monozygotic twins is65%and for dizygotic twins is 15%.
Biochemical theories
A deficiency of norepinephrine and serotonin has been found in depressed patients and they are elevated in mania.
Dopamine, GABA and acetylcholine are also presumably involved.
Psychosocial Theories
Psychoanalytic theory According to Freud (1957) depression results due to loss of a "loved object",
and fixation in the oral sadistic phase of development. In this model, mania is viewed as a denial of depression.
Behavioral theory
This theory of depression Connects depressive phenomena to the experience of uncontrollable events. According to
this model, depression is conditioned by repeated losses in the past.

Cognitive theory According to this theory depression is due to negative cognitions which includes:
Negative expectations of the environment
Negative expectations of the self
Negative expectations of the future
These cognitive distortions arise out of a defect in cognitive development and cause the individual to feel
inadequate, worthless and rejected by others.
Sociological theory
Stressful life events, e.g. death, marriage, financial loss before the onset of the disease or a relapse probably have a
formative effect.

Background Assessment Data

Symptoms of manic states can be described according to
three stages: hypomania, acute mania, and delirious
mania. Symptoms of mood, cognition and perception,
and activity and behavior are presented for each stage.
Stage I: Hypomania
At this stage the disturbance is not sufficiently severe to
cause marked impairment in social or occupational functioning
or to require hospitalization (APA, 2000).
Mood. The mood of a hypomanic person is cheerful
and expansive. There is an underlying irritability that
surfaces rapidly when the person’s wishes and desires go
unfulfilled, however. The nature of the hypomanic person
is very volatile and fluctuating.
Cognition and Perception. Perceptions of the self are
exalted—ideas of great worth and ability. Thinking is
flighty, with a rapid flow of ideas. Perception of the environment
is heightened, but the individual is so easily
distracted by irrelevant stimuli that goal-directed activities
are difficult.
Activity and Behavior. Hypomanic individuals exhibit
increased motor activity. They are perceived as being very
extroverted and sociable, and because of this they attract
numerous acquaintances. They lack the depth of personality
and warmth to formulate close friendships, however.
They talk and laugh a great deal, usually very loudly and
often inappropriately. Increased libido is common. Some
individuals experience anorexia and weight loss. The
exalted self-perception leads some hypomanic individuals
to engage in inappropriate behaviors, such as phoning the
President of the United States, or buying huge amounts
on a credit card without having the resources to pay.
Stage II: Acute Mania
Symptoms of acute mania may be a progression in intensification
of those experienced in hypomania, or they may be
manifested directly. Most individuals experience marked
impairment in functioning and require hospitalization.
Mood. Acute mania is characterized by euphoria and
elation. The person appears to be on a continuous
“high.” However, the mood is always subject to frequent
variation, easily changing to irritability and anger or even
to sadness and crying.