What is Affective Disorder?
Affective Disorder (Mood Disorder) is a mental disorder associated with disorders in the emotional sphere. Combines several diagnoses in the classification of DSM IV TR, when the main symptom is a violation of the emotional state.
The most widely recognized are two types of disorders, the difference between which is based on whether a person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, among which the most well-known and studied is a major depressive disorder, which is also called clinical depression, and bipolar affective disorder, previously known as manic-depressive psychosis and described by intermittent manic periods (lasting from 2 weeks to 4 -5 months.) And depressive (average duration of 6 months) episodes.
Causes of Affective Disorders
The causes of affective disorders are unknown, but biological and psychosocial hypotheses have been proposed.
Biological aspects. Norepinephrine and serotonin are the two neurotransmitters that are most responsible for the pathophysiological manifestations of mood disorders. In animal models, it has been shown that effective biological treatment with antidepressants (BP) is always associated with inhibition of the sensitivity of postsynaptic β-adrenergic and 5HT2 receptors after a long course of therapy. This probably corresponds to a decrease in the functions of serotonin receptors after chronic exposure of blood pressure to them, which reduce the number of serotonin reuptake zones and the increase in serotonin concentration detected in the brain of suicide sufferers. There is evidence that dopaminergic activity is reduced in a state of depression and increases with mania. Recent studies have shown that the number of muscarinic receptors increases on tissue culture of fibrinogen, urine, blood and cerebrospinal fluid in patients with mood disorders. Apparently, mood disorders are associated with heterogeneous dysregulation of the biogenic amines system.
It is assumed that secondary regulation systems, such as adenylate cyclase, calcium, phosphatidyl inositol, can also be etiological factors.
It is believed that neuroendocrine disorders reflect dysregulation of the entry of biogenic amines into the hypothalamus. Deviations along the limbic-hypothalamic-pituitary-adrenal axis are described. In some patients, hypersecretion of cortisol, thyroxin, a decrease in melatonin nocturnal secretion, a decrease in the basic level of FSH and LH are present.
Sleep disturbances are one of the most powerful markers of depression. The main disorders are a decrease in the latent period of REM sleep, an increase in the duration of the first REM sleep, and an increase in REM sleep in the first phase. It was suggested that depression is a violation of chronobiological regulation.
Decreases in the cerebral blood flow, especially in the basal ganglia, decreased metabolism, impaired late components of visual evoked potential were found.
It is assumed that the basis of sleep disorders, gait, mood, appetite, sexual behavior – is a violation of the functions of the limbic-hypothalamic system and the basal ganglia.
Genetic aspects. Approximately 50% of bipolar patients have at least one parent suffering from mood disorders. The level of concurrency is 0.67 for bipolar disorders in monozygous twins and 0.2 for bipolar disorders in dizygotic twins. It was found that the dominant gene, localized on the short arm of chromosome 11, gives a strong predisposition to bipolar disorders in the same family. This gene is probably involved in the regulation of tyrosine hydroxylase, an enzyme that is needed for catecholamine synthesis.
Psychosocial aspects. Life events and stress, premorbid personality factors (suggested personalities), psychoanalytic factors, cognitive theories (depression due to a misunderstanding of events in life).
Symptoms of Affective Disorders
Depressive disorders
A major depressive disorder, often called clinical depression, when a person has experienced at least one depressive episode. Depression without periods of mania is often called unipolar depression, because the mood remains in one emotional state or “pole”. When diagnosing, there are several subtypes or specifications for the course of treatment:
Atypical depression is characterized by mood reactivity and positivity (paradoxical anhedonia [paradoxical anhedonia]), significant weight gain or increased appetite (“eat to relieve anxiety”), excessive sleep or drowsiness (hypersomnia), a feeling of heaviness in the limbs and a significant lack of socialization, as a consequence of hypersensitivity to apparent social rejection. Difficulties in the assessment of this subtype led to the question of its validity and its distribution.
Melancholic depression (acute depression) is characterized by loss of pleasure (anhedonia) from most or all cases, inability to respond to pleasurable stimuli, low mood, more pronounced than regret or loss, worsening of symptoms in the morning, waking up early in the morning, psychomotor inhibition , excessive weight loss (not to be confused with anorexia nervosa), or a strong sense of guilt.
Psychotic depression is a term for a long depressive period, particularly in a melancholic nature, when the patient experiences psychotic symptoms such as delusions, or less likely hallucinations. These symptoms almost always correspond to mood (the content coincides with depressive themes).
Freezing depression – involutional – a rare and severe form of clinical depression, including movement disorder and other symptoms. In this case, the person is silent and almost in a state of stupor, and either is immovable or makes aimless or even abnormal movements. Similar catatonic symptoms also occur in schizophrenia, manic episodes, or are the result of a neuroleptic malignant syndrome.
Postpartum depression is noted as a qualifying term in DSM-IV-TR; it refers to excessive, sustained and sometimes resulting in the loss of capacity of depression experienced by women after the birth of a child. Postpartum depression, the probability of which is estimated at 10-15%, usually manifests itself within three working months and lasts no longer than three months.
Seasonal affective disorder is a clarifying term. Depression in some people is seasonal, with an episode of depression in the fall or winter, and a return to normal in spring. A diagnosis is made if depression manifested itself at least twice during the cold months and never at a different time of the year for two years or more.
Dysthymia is a chronic, moderate mood disorder, when a person complains of an almost daily bad mood for at least two years. Symptoms are not as severe as those of clinical depression, although people with dysthymia are simultaneously prone to periodic episodes of clinical depression (sometimes called “double depression”).
Other depressive disorders (DD-NOS) are identified by the code 311 and include depressive disorders that cause damage, but do not fit the officially defined diagnoses. According to DSM-IV, DD-NOS covers “all depressive disorders that do not meet the criteria for any specified disorder.” They include a study of the diagnoses of Recurrent brief depression [Recurrent brief depression], and Minor Depression, listed below:
Recurrent brief depression (RBD) is distinguished from major depressive disorder mainly due to the difference in duration. People with RBD experience depressive episodes once a month, with individual episodes lasting less than two weeks, and usually less than 2-3 days. Diagnosing RBD requires episodes to occur for at least one year and, if the patient is female, regardless of the menstrual cycle. People with clinical depression can develop RBD, as well as vice versa.
Minor depression, which does not meet all the criteria for clinical depression, but in which at least two symptoms are present within two weeks.
Bipolar disorder
Bipolar affective disorder, formerly known as “manic-depressive psychosis,” is described as intermittent periods of manic and depressive states (sometimes alternating very quickly or mixing together in one state in which the patient has symptoms of depression and mania at the same time).
Subtypes include:
Bipolar I disorder [Bipolar I] is determined if one or more manic episodes with or without episodes of clinical depression are present or present. Diagnosis by DSM-IV-TR requires at least one manic or mixed episode. For the diagnosis of bipolar disorder I, depressive episodes, though not necessary, occur quite often.
Bipolar II disorder [Bipolar II] consists of repeated hypomanic and depressive episodes alternating with each other.
Cyclothymia is a milder form of bipolar disorder, which manifests itself in occasional hypomania and dysthymic episodes, without any more severe forms of mania or depression.
The main violation is a change in affect or mood, level of motor activity, activity of social functioning. Other symptoms, such as a change in the pace of thinking, psychosensory disorders, self-incrimination or overestimation, are secondary to these changes. The clinic appears as episodes (manic, depressive) of bipolar (two-phase) and recurrent disorders, as well as in the form of chronic mood disorders. Between psychosis intermissions are noted without psychopathological symptoms. Affective disorders are almost always reflected in the somatic sphere (physiological functions, weight, skin turgor, etc.).
The range of affective disorders includes seasonal weight changes (usually the increase in weight in winter and its decrease in summer within 10%), evening craving for carbohydrates, in particular for sweets at bedtime, premenstrual syndromes, expressed in a decrease in mood and anxiety before menstruation, as well as ” North Depression ”, which migrants to the northern latitudes are exposed to, is observed more often during the polar night and is due to a lack of photons.
Diagnosis of Affective Disorders
The main signs are changes in affect or mood, the remaining symptoms are deducible from these changes and are secondary.
Affective disorders are observed in many endocrine diseases (thyrotoxicosis and hypothyroidism), Parkinson’s disease, and vascular pathology of the brain. In organic affective disorders, symptoms of cognitive deficit or disorders of consciousness are present, which is not characteristic of endogenous affective disorders. They should also be differentiated in schizophrenia, but with this disease there are other characteristic productive or negative symptoms, in addition, manic and depressive states are usually atypical and closer to manic-hebephrenic or apathetic depressions. The greatest difficulties and disputes arise in the differential diagnosis with schizoaffective disorder, if the structure of affective disorders arise secondary ideas of revaluation or self-incrimination. However, with true affective disorders, they disappear as soon as it is possible to normalize the affect, and do not define the clinical picture.
Treatment of Affective Disorders
Therapy of affective disorders consists of the treatment of depression and mania itself, as well as preventive therapy. Depression therapy includes, depending on the depth, a wide range of drugs from fluoxetine, lerivon, zoloft, mianserin to tricyclic antidepressants and ECT. Sleep deprivation therapy and photon therapy are also used. Mania therapy consists of therapy with increasing doses of lithium while controlling them in the blood, using neuroleptics or carbamazepine, sometimes beta-blockers. Maintenance treatment is carried out with lithium carbonate, carbamazepine or sodium valprat.
Treatment of psychogenic depression begins with the appointment of antidepressants. Depression, as mentioned above, can be with the anxiety component or, conversely, asthenic syndrome can be the leading one. Depending on this, treatment will be built. Doses are titrated as necessary.
In the presence of asthenic syndrome prescribe SIOZS such as fluoxetine, fevarin, paksil.
If there is an alarm, they are prescribed SSRIs such as: tsipramil, zoloft. Additionally prescribed alprazolam (xanax) or mild neuroleptics – chlorprotixen, sonapax.
The patient as a cure can go into a hypomania state, in this case it is necessary to prescribe mood stabilizers, for example finlepsin from 200 mg and more. Psychotherapy is also prescribed (cognitive therapy, behavioral, interpersonal therapy, group and family therapy).
From the moment of improvement, continue treatment with antidepressants for at least 6 weeks, then reduce the dose of the drug, if necessary, maintenance therapy is prescribed.
Treatment of endogenous depression begins with the appointment of antidepressants. The most effective selective and non-selective serotonin reuptake inhibitors and norepinephrine.
In the presence of anxiety, amitriptyline is prescribed, and other sedative antidepressants are prescribed. Selective inhibitors include ludiomil, desipramine, and Remeron (central alpha-2 adrenergic blocker), moclobemide, may be an additional purpose of anxiolytics or neuroleptics. If ineffective, non-selective MAOIs, but necessarily in combination with anxiolytics, or neuroleptics, since MAOI have a pronounced only activating effect.
With the prevalence of anguish, the absence of anxiety is prescribed and anafranil, protriptyline, nortriptyline – activating antidepressants. In case of ineffectiveness, it is also possible to prescribe IMAO – tranziltsipril (non-hydrosized) – a positive effect in 2-3 days. When using hydrated – nialamide – after 2-3 weeks.
From the moment of improvement, treatment is continued for 6 months (as recommended by WHO). 2-3 weeks before dose reduction prescribed mood stabilizers (finlepsin 1000 mg). Reduce amitriptyline 25 mg per week, and after discontinuation, continue treatment with mood stabilizers for 1-2 weeks. If necessary, supportive therapy.
In the event that the patient gives an allergic reaction to all antidepressants or treatment is ineffective – ECT (electroconvulsive therapy) is prescribed. It is possible to conduct up to 15 sessions in elderly patients with endogenous depression.
Treatment of mania comes down to the prescription of neuroleptics of the buterophenone or phenothiazine series, mood stabilizers, and psychotherapy. ECT – 10-15 sessions.
Treatment of cyclothymia is reduced to the appointment of antidepressants (with small doses, because of the possibility of reversal of the phases), mood stabilizers, psychotherapy – see endogenous depression.