Thursday, September 18, 2008

Mood Disorders 101


In yesterday's post, I talked about how Ron Pies questioned the difference between depression and "proper sorrows of the soul"-- ah, Dr. Pies was quoting some dead monk-- and Lily mentioned that she was just diagnosed with Bipolar II. It got me thinking that we should say something about how a psychiatrist thinks about mood disorders. If you're a psychiatrist, you can go home now, today's blog post is not for you.

I'm going to start by saying that I'm typing this off the top of my head, I'm purposely not pulling out the DSM (Diagnostic Statistical Manual), I'm just rambling. I'm very good at rambling. So this is how I think about mood disorders and how I go about reaching a diagnosis.

In the course of the day, a person without a mood disorder generally feels "fine." People go through life with a fairly steady mood, not too good, not too bad. Sure, stuff effects mood, and it may vary some-- people feel transiently ecstatic about wonderful things happening, people feel sad about distressing things happen, and there's the unexplained 'bad hair day' also known as 'waking up on the wrong side of the bed.' Let's take it as a given that people have moods, they vary some, sometimes the reason is obvious, and they aren't generally extreme.

Mood itself is a good place to start. Mood variation alone is not enough to make a diagnosis of a mood disorder (weird, huh?) and someone who feels very sad, even a lot, who has no other symptoms of depression, isn't called depressed. So someone is trekking along just fine and then suddenly they start feeling down/sad/miserable and at the same time other symptoms emerge. These symptoms may include: changes in sleep, appetite, a decrease in the ability to feel pleasure, loss of energy, loss of interest, decreased sex drive, irritability, guilt, a feeling of being physically unwell, hopelessness, helplessness, thoughts that death might be welcome, or thoughts of suicide. People who have pain syndromes will have worse pain, people with Parkinson's Disease may have worsening of their movement disorder, people with dementia may have more trouble with their memories, food may seem tasteless, colors may look less bright. People's thoughts change-- these are the cognitive symptoms of depression-- with a tendency to see oneself in negative ways, to take on blame, to block or discount all positive feedback the world might give. You can't have just one symptom to be diagnosed with
Major Depression, you have to have a few symptoms and they have to occur together, because mood disorders are 'syndromic' illnesses: they are defined by the co-occurring constellation of symptoms. The same person may have different symptoms during different episodes of depression, but generally episodes are discrete, and with or without treatment, they usually abate eventually.

There are some people who don't see their depressions as discrete episodes but feel they've been depressed for a very long time. Maybe they have Major Depression, but there is also a condition known as
Dysthymia which is a chronic, low grade depression which lasts for years (--at least part of the day, most days, for at least 2 years, I think). This version of depression is not as striking as an episode of Major Depression-- the symptoms aren't as severe, abrupt, or debilitating and other people are often not as tuned in to the sufferer's distress.

That's the down side of mood.

Then there's the Up side of mood. Mania is the extreme up state, and the associated mood state is either elated/ecstatic or extremely irritable. Again, a simple shift in mood is not enough to diagnose an illness, there need to be some associated symptoms which occur at the same time as the mood elevation/extreme irritability.
Manias include an increase in energy and a decrease in the need for sleep. The issue of Need for Sleep is important here: it's not normal to be awake and active for days at a time and not feel tired, this is much different than insomnia. People may have more ideas, they may have completely irrational ideas, judgment becomes impaired, thoughts may flow much faster, sometimes racing so fast that the patient can't keep up with them. Activity increases, speech may become fast and pressured. The person may feel very very good about themselves, very optimistic and positive, or believe they have special powers. There may be an increased interest in sex or religion, and people may spend lots of money on things they wouldn't normally spend on. Behavior may become impulsive and insight is often very impaired. The manic patient often resists the idea that they have an illness, and doesn't see how outrageous their behavior has become. They may hallucinate (see or hear or feel things that aren't there) or have delusions, particularly of grandeur, but sometimes of paranoia. Full blown mania is not subtle and often results in psychiatric hospitalization.

Anyone who has had even a single episode of
Mania, ever, is diagnosed as having Bipolar Disorder, Type I, what used to be called Manic Depressive disorder. Do note that a person can be diagnoses as having Bipolar Disorder even if they've never (or Not Yet) had an episode of Major Depression. The fact is that it's extremely rare for someone to suffer an episode of mania and then live out life without ever having an episode of depression, that manias tend to recur (sometime after decades) and that it's not unusual for a person to have an episode of mania and then 'crash' into an episode of depression. Anti-depressants and steroids can precipitate an episode of mania and we still don't know if those manias have the same implication for lifelong diagnosis.

So mania isn't subtle, but there are people who have episodes of elevated mood states without the extreme symptoms. Maybe they have periods of time where their mood is better than the norm of fine/okay/good, and their energy is increased, and they are more productive or impulsive, and revved up than the usual even-keel. They may look good, feel good, live life a little more grandly. This may be subtle, and it's this state of elevation that is called
Hypomania. This mood state may be hard to differentiate from a high-energy person, an anxious person, someone with Attention Deficit Disorder, or just the way that everyone wishes they could feel all the time. Hypomanias do not result in psychiatric hospitalizations and are not accompanied by extremes in behavior, hallucinations, or flagrant delusions. Hypomanias alone do not generally result in someone coming to psychiatric attention and patients present during episodes of Depression. This is Bipolar Disorder, Type II.

People with Bipolar Disorder, type II, generally spend much more time depressed than hypomanic, their depressions may be harder to stablize, and they often do better if a mood stabilizer is added to the treatment regimen.

If this isn't all confusing enough, there is a diagnosis called
Cyclothymia, which means that a person's moods vary from hypomanic to mildly depressed, but none of the episodes of depression is severe enough to warrant a diagnosis of Major Depression. Psychiatrists don't use this diagnosis very much.

Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.