Definition :-
Affective disorders are a group of functional psychiatric disorders , with a primary disorder of mood , which can either be depression or mania , and accompanied by a disturbance in the daily functioning of the individual (1) .
classification :-
Affective disorders are classified into :
1. Unipoler affective disorder :-
This usually presents in the from of recurrent depressive episodes .
2. Bipolar Affective disorder : -
T his usually presents in at least two episodes , one of them is a depressive episode , while the other is an episode of . ــــــــــــــــــ
* PROF. DIAA E .Elgaili, M.D. Professor of Psychiatry , Head of the Dept . of Mental Health , Faculty of Medicine University OF Gezira .
mania . recurrent manic episodes are considered to be bipolar .
There are no observable sex differences in the incidence of bipolar affective disorder .
Manic and depressive episodes are usually sudden in onset . A manic episode is usually of a shorter duration compared to a depressive episode , and lasts on average 4 months , while a depressive episode usually lasts , on average 6 months .
The onset of an affective disorder is usually preceded by stressful life events , and can occur at any age .
3. Mixed affective state : -
This is a form of affective disorders , presenting with a mixture of depressive and manic symptoms in one episode . Depressive symptoms may appear first , and last for days or weeks , to be followed by manic symptoms , within the same episode of affective disorder . In other cases , depressive and manic symptoms may present simultaneously , within the same day , days , or weeks , in one episode of affective disorder .
The main characteristics of affective disorders include : -
1. A primary disorder of affect .
2. Episodes lasting on average 4- 6 months .
3. Possibility of spontaneous remission .
Epidemiology : -
Depressive symptoms are fairly common , and occur in (13-20%) of the individuals in a given society , and are more common in females , and in low socio - economic classes . The incidence of bipolar affective disorder is almost 1% , while The incidence of unipolar disorder is 3% in males and (5- 10%) in females (1) .
Why depression is commoner in females ? : -
The exact reason is unknown , however many factors are likely to be responsible : -
1. Females are better than males in expressing depressive symptoms .
2. Many depressed males abuse alcohol and other drugs and are likely to be diagnosed as suffering from drug abuse and not from depression .
3. Depression is likely to be one of the x- linked inherited disorders .
4. Depression is likely to be related to hormonal changes in females .
clinical Presentations :-
A . Mania : -
The primary symptoms of mania include : -
1. A high , elated mood .
2. A quantitative increase in physical and psychic activites
This includes : - pressure of talk , hyper activity , ect .
Secondary symptoms of mania include : -
disturbance of sleep and appetite , aggression , disinhibition , disturbance of attention and concentration , and psychotic symptoms in the from of delusions and / or hallucinations .
Manic episode is classified into :-
1. Mild manic episode ( Hypo mania ) :-
This is the mildest form of mania , presenting with some of the primary and secondary symptoms of mania , but usually no psychotic features (4) .
2. Manic episode with out psychotic symptoms :-
Symptoms are more , severe compared to mild manic episode . The patient is likely to be aggressive , with a remarkable increase in activity , a disturbance of sleep , social disinhibition , and grandiose ideation .
The first manic episode usually occurs at the age of 15- 30 years , but can occur at any age .
To diagnose this type of mania , the symptoms must continue for at least one week , and must be severe enough to disturb the normal daily functioning of the individual (4) .
Manic episode with Psychotic symptoms :-
The symptoms are more severe compared to the previous types of mania . The patient may present with grandiose and persecutory delusions , and / or with second person auditory hallucinations .
Excessive physical actively . may be associated with aggression and violence .The neglect of feeding and drinking may lead to a deterioration is the physical state of the individual. B - Depression :-
Definition : - A number of researchers attempted to define depression . The following represent some of the definitions of depression : -
1. It is a state of persistently low mood , sense of fatigue , with a tendency to be inactive , and mentally slow (2) .
2. It is a state of low mood , low energy , pessimistic thoughts , accompanied by other psychological symptoms (2) .
The world Health Organization (W . H . O .) defined depression in the (I.C.D- 10) as : -
A mood disorder , presenting with low mood , loss of interest in daily activities , and sense of low energy and fatigue (4) .
Epidemiology : -
Depression is more frequent in females compared to males. The incidence of depression in females is twice that in males (5) . The first episode of depression usually occur between the age of (25-44) years .
The incidence of depression is lower in the married individuals compared to the divorced (6) .
Although previous studies showed that the diagnosis of cases depression is higher in the high social class , recent studies showed an increase in the number of cases of depression diagnosed among members of low social class (7) .
Clinical features : -
Symptoms of depression may appear suddenly , or show a slow progression over several months . The symptoms show individual differences .
The primary symptoms of depression include : -
1. A low mood .
2. Loss of interest and pleasure .
3. A sense of low energy and fatigue .
Secondary symptoms of depression include : -
1. Disturbance of sleep .
2. Disturbance of appetite .
3. Weight loss .
4. Poor libido .
5. Loss of self – confidence .
6. Guilt feelings and sense of worthlessness .
7. Pessimistic thoughts , about the future .
8. Suicidal ideas and attempts .
classification of depression :-
There are many systems of classification of depression : -
1. Classification based on etiology : -
A) Endogenous and reactive depression : -
Endogenous depression refers to a typce of depression , the onset of which is not related to obvious precipitating environ-
mental factors . While reactive depression refers to depression with an onset clearly related to obvious precipitating environmental factors .
B) Primary and secondary depression : -
Primary depression refers to a depressive disorder the onset of which is not related to any other mental disorder .While the onset of secondary depression is related to the presence of other mental disorders .
2. Classification based on symptomatology : -
Depression can be Classified into : -
a) Neurotic depression: -
This refers to a mild depressive episode with prominent anxiety features .
b) Psychotic depression : - refers to a severe depressive episode with Psychotic features in the form of delusions and / or hallucinations.
Some researches insist on the presence of the Neurotic - Psychotic dichotomy in the Classification of depression , while other researchers consider depression as a unified disorder with varying degrees of severity (10) .
3- Classification based on the course of the disorder : -
depressive disorder is classified into : -
a) Unipolar disorder : - referring to a disorder with recurrent episodes of depression .
b) Bipolar disorder : - refers to depressive episodes occurring within a bipolar affective disorder (10) .
4. Classification of depression in the (I.C.D. 10) : -
Depression is classified into : -
a) Mild depressive disorder : -
The diagnostic criteria :-
1. The presence of at least two of the primary symptoms of depression in a mild degree .
2. The presence of at least three of the secondary symptoms of depression in a mild degree .
3. Symptoms must continue for at least two weeks (4) .
b) moderate depressive disorder : -
The diagnostic criteria : -
1. The presence of at least two of the primary symptoms of depression in a moderate degree.
2. The presence of at least three of the secondary symptoms of depression in a moderate degree.
3. Symptoms must continue for at least two weeks (4) .
c) Severe depressive disorder : - The diagnostic criteria :
1. The presence of all (3) primary symptoms of depression in a severe degree .
2. The presence of at least four of the secondary symptoms of depression in a severe degree .
4. Symptoms must continue for at least two weeks (4) .
severe depressive disorder is further classified into :
a) Severe depressive disorder with psychotic symptoms.
b) Severe depressive disorder without psychotic symptoms .
The psychotic symptoms include :
1-Delusions : usually of guilt , worthlessness , poverty , or nihilistic delusions .
2-Hallucinations : usually auditory in the form of second person auditory hallucinations , usually abusive in nature , but can be olfactory .
Depressive stupor is considered to be a feature of severe depressive disorder with psychotic symptoms (4) .
The Aetiology of affective disorders : -
A. Predisposing factors :
1. Heredity : -
1-Family studies showed that first degree relatives of patients with an affective disorder are more likely to be affected with the disorder compared to other members of the population , (10-15%) compared to (1-2%) .
2-Twin studies : - showed that the incidence of the occurrence of bipolar affective disorder is higher in mono zygotic twins compared to di-zygotic twins , if one of the twins is suffering from a bipolar affective disorder .
3-Adoption studies : - showed that the incidence of bipolar affective disorder is higher in mono-zygotic twins compared to di- zygotic twins , if one of the twins is already suffering from a bipolar affective disorder , despite the fact that the twins were separated and living in different environments(1).
2-The personality :
Krapelin (1921) mentioned that individuals with a cyclothymic personality are at risk of developing a bipolar affective disorder .
No specific personality type is clearly associated with the predisposition to unipolar affective disorder , but it seems that certain personality traits (anxiety and obessional traits) , can be linked with the predisposition to depression (1) .
B-The precipitating factors : -
1-Stressful life events are usually apparent in the weeks or months preceding the onset of affective disorder .
2-Organic factors play a role in precipitating an affective disorder , and include : surgical operations , febrile illnesses , head injuries , ect . (1) .
3- Beck’s cognitive theory views depression as a disorder resulting from a primary disorder of thinking , presenting with negative thoughts towards self , the surroundings , and the future. These negative thoughts lead to the appearance of a depressed mood .
4-The Biochemical theory views depression as being the result of a deficiency in mono- a mine neurotransmitters (serotonin , adrenaline , and noradrenalin) , while mania as resulting from an excess of these neurotransmitters .
Differential Diagnosis :
1. Anxiety disorder : mild depressive disorder with an admixture of anxiety features has to be differentiated from Anxiety disorder .
2. Schizophrenia : severe depressive disorder with psychotic features has to be differentiated from schizophrenia –
3. Drug abuse and dependence : -
Depressive features are common in association with drug abuse and dependence and must be differentiated from a typical depressive episode .
4. Organic brain disorder : - may present with depressive features that must be differentiated from a typical depressive disorder .
Prognosis : -
Without psychiatric intervention , an episode of affective disorder usually lasts for weeks or months . However the episode may last for a year or even more .
A depressive episode is usually longer than a manic episode .
Management : -
A) Treatment of depression : -
1-Drug treatment : in the form of anti depressant drugs : -
a-Tricyclic anti depressants .
b-Mono – amine oxidase inhipitors (M.A.O.I) .
c-Selectivs Serotonin Re - uptake ininhiptors .
2-Electro - Convulsive therapy (E.C.T) : Represents a first line form of therapy in severe depressive disorder , especially in the presence of psychotic symptoms , the biological features of depression , and suicidal ideas and / or attempts .
3-Cognitive therapy : -
Beck’s approach to cognitive therapy in depression includes the following steps : -
1. Identiving negative thoughts .
2. Linking the negative thoughts with the patient’s suffering and difficulties in achieving a normal level of daily functioning .
3. Replacing the negative thoughts with positive thoughts that will enable the individual to achive a normal level of daily functioning .
4. Training on methods of self- evaluation , that will empower the individual to find the best means of adjustment with the environment .
B) Treatment of mania :-
1. Drug treatment in the form of :
a) Anti - psychotic drugs .
b) Lithium .
2. Electro - convulsive therapy may be needed in cases of acute excitement or in manic stupor .
Prophylaxis :-
In cases of bipolar affective disorder with frequent relapses prophylaxis treatment can be used .
Use can be made of lithium , carbamzepine and other forms of drugs (10) .
Complications of affective disorder :-
1-physical complications :
include : weight loss , dehydration , low immunity , and physical exhaustion that can lead to sudden death .
2- Social Complications :- include : family problems that can lead to divorce and problems at work that can lead to loss of job , restricted social relation , and confrontation with law procedures .
3- Psychiatric complications :
a)In the case of depression :-
2. Suicide : Around 11-17 of the patients diagnosed to be suffering from a severe depressive disorder attempt suicide .
3. Depressive stupor .
b)In the case of mania :-
1. Aggression and violence .
2. Manic stupor.
Depressive and manic stupor :-
These are cases of psychogenic stupor , in which the patient is immobile , mute , refuses to have his meals or to drink , with diminished responses to external stimuli .
Differentiation between depressive and manic stupor depends basically on meticulous
Affective disorders are a group of functional psychiatric disorders , with a primary disorder of mood , which can either be depression or mania , and accompanied by a disturbance in the daily functioning of the individual (1) .
classification :-
Affective disorders are classified into :
1. Unipoler affective disorder :-
This usually presents in the from of recurrent depressive episodes .
2. Bipolar Affective disorder : -
T his usually presents in at least two episodes , one of them is a depressive episode , while the other is an episode of . ــــــــــــــــــ
* PROF. DIAA E .Elgaili, M.D. Professor of Psychiatry , Head of the Dept . of Mental Health , Faculty of Medicine University OF Gezira .
mania . recurrent manic episodes are considered to be bipolar .
There are no observable sex differences in the incidence of bipolar affective disorder .
Manic and depressive episodes are usually sudden in onset . A manic episode is usually of a shorter duration compared to a depressive episode , and lasts on average 4 months , while a depressive episode usually lasts , on average 6 months .
The onset of an affective disorder is usually preceded by stressful life events , and can occur at any age .
3. Mixed affective state : -
This is a form of affective disorders , presenting with a mixture of depressive and manic symptoms in one episode . Depressive symptoms may appear first , and last for days or weeks , to be followed by manic symptoms , within the same episode of affective disorder . In other cases , depressive and manic symptoms may present simultaneously , within the same day , days , or weeks , in one episode of affective disorder .
The main characteristics of affective disorders include : -
1. A primary disorder of affect .
2. Episodes lasting on average 4- 6 months .
3. Possibility of spontaneous remission .
Epidemiology : -
Depressive symptoms are fairly common , and occur in (13-20%) of the individuals in a given society , and are more common in females , and in low socio - economic classes . The incidence of bipolar affective disorder is almost 1% , while The incidence of unipolar disorder is 3% in males and (5- 10%) in females (1) .
Why depression is commoner in females ? : -
The exact reason is unknown , however many factors are likely to be responsible : -
1. Females are better than males in expressing depressive symptoms .
2. Many depressed males abuse alcohol and other drugs and are likely to be diagnosed as suffering from drug abuse and not from depression .
3. Depression is likely to be one of the x- linked inherited disorders .
4. Depression is likely to be related to hormonal changes in females .
clinical Presentations :-
A . Mania : -
The primary symptoms of mania include : -
1. A high , elated mood .
2. A quantitative increase in physical and psychic activites
This includes : - pressure of talk , hyper activity , ect .
Secondary symptoms of mania include : -
disturbance of sleep and appetite , aggression , disinhibition , disturbance of attention and concentration , and psychotic symptoms in the from of delusions and / or hallucinations .
Manic episode is classified into :-
1. Mild manic episode ( Hypo mania ) :-
This is the mildest form of mania , presenting with some of the primary and secondary symptoms of mania , but usually no psychotic features (4) .
2. Manic episode with out psychotic symptoms :-
Symptoms are more , severe compared to mild manic episode . The patient is likely to be aggressive , with a remarkable increase in activity , a disturbance of sleep , social disinhibition , and grandiose ideation .
The first manic episode usually occurs at the age of 15- 30 years , but can occur at any age .
To diagnose this type of mania , the symptoms must continue for at least one week , and must be severe enough to disturb the normal daily functioning of the individual (4) .
Manic episode with Psychotic symptoms :-
The symptoms are more severe compared to the previous types of mania . The patient may present with grandiose and persecutory delusions , and / or with second person auditory hallucinations .
Excessive physical actively . may be associated with aggression and violence .The neglect of feeding and drinking may lead to a deterioration is the physical state of the individual. B - Depression :-
Definition : - A number of researchers attempted to define depression . The following represent some of the definitions of depression : -
1. It is a state of persistently low mood , sense of fatigue , with a tendency to be inactive , and mentally slow (2) .
2. It is a state of low mood , low energy , pessimistic thoughts , accompanied by other psychological symptoms (2) .
The world Health Organization (W . H . O .) defined depression in the (I.C.D- 10) as : -
A mood disorder , presenting with low mood , loss of interest in daily activities , and sense of low energy and fatigue (4) .
Epidemiology : -
Depression is more frequent in females compared to males. The incidence of depression in females is twice that in males (5) . The first episode of depression usually occur between the age of (25-44) years .
The incidence of depression is lower in the married individuals compared to the divorced (6) .
Although previous studies showed that the diagnosis of cases depression is higher in the high social class , recent studies showed an increase in the number of cases of depression diagnosed among members of low social class (7) .
Clinical features : -
Symptoms of depression may appear suddenly , or show a slow progression over several months . The symptoms show individual differences .
The primary symptoms of depression include : -
1. A low mood .
2. Loss of interest and pleasure .
3. A sense of low energy and fatigue .
Secondary symptoms of depression include : -
1. Disturbance of sleep .
2. Disturbance of appetite .
3. Weight loss .
4. Poor libido .
5. Loss of self – confidence .
6. Guilt feelings and sense of worthlessness .
7. Pessimistic thoughts , about the future .
8. Suicidal ideas and attempts .
classification of depression :-
There are many systems of classification of depression : -
1. Classification based on etiology : -
A) Endogenous and reactive depression : -
Endogenous depression refers to a typce of depression , the onset of which is not related to obvious precipitating environ-
mental factors . While reactive depression refers to depression with an onset clearly related to obvious precipitating environmental factors .
B) Primary and secondary depression : -
Primary depression refers to a depressive disorder the onset of which is not related to any other mental disorder .While the onset of secondary depression is related to the presence of other mental disorders .
2. Classification based on symptomatology : -
Depression can be Classified into : -
a) Neurotic depression: -
This refers to a mild depressive episode with prominent anxiety features .
b) Psychotic depression : - refers to a severe depressive episode with Psychotic features in the form of delusions and / or hallucinations.
Some researches insist on the presence of the Neurotic - Psychotic dichotomy in the Classification of depression , while other researchers consider depression as a unified disorder with varying degrees of severity (10) .
3- Classification based on the course of the disorder : -
depressive disorder is classified into : -
a) Unipolar disorder : - referring to a disorder with recurrent episodes of depression .
b) Bipolar disorder : - refers to depressive episodes occurring within a bipolar affective disorder (10) .
4. Classification of depression in the (I.C.D. 10) : -
Depression is classified into : -
a) Mild depressive disorder : -
The diagnostic criteria :-
1. The presence of at least two of the primary symptoms of depression in a mild degree .
2. The presence of at least three of the secondary symptoms of depression in a mild degree .
3. Symptoms must continue for at least two weeks (4) .
b) moderate depressive disorder : -
The diagnostic criteria : -
1. The presence of at least two of the primary symptoms of depression in a moderate degree.
2. The presence of at least three of the secondary symptoms of depression in a moderate degree.
3. Symptoms must continue for at least two weeks (4) .
c) Severe depressive disorder : - The diagnostic criteria :
1. The presence of all (3) primary symptoms of depression in a severe degree .
2. The presence of at least four of the secondary symptoms of depression in a severe degree .
4. Symptoms must continue for at least two weeks (4) .
severe depressive disorder is further classified into :
a) Severe depressive disorder with psychotic symptoms.
b) Severe depressive disorder without psychotic symptoms .
The psychotic symptoms include :
1-Delusions : usually of guilt , worthlessness , poverty , or nihilistic delusions .
2-Hallucinations : usually auditory in the form of second person auditory hallucinations , usually abusive in nature , but can be olfactory .
Depressive stupor is considered to be a feature of severe depressive disorder with psychotic symptoms (4) .
The Aetiology of affective disorders : -
A. Predisposing factors :
1. Heredity : -
1-Family studies showed that first degree relatives of patients with an affective disorder are more likely to be affected with the disorder compared to other members of the population , (10-15%) compared to (1-2%) .
2-Twin studies : - showed that the incidence of the occurrence of bipolar affective disorder is higher in mono zygotic twins compared to di-zygotic twins , if one of the twins is suffering from a bipolar affective disorder .
3-Adoption studies : - showed that the incidence of bipolar affective disorder is higher in mono-zygotic twins compared to di- zygotic twins , if one of the twins is already suffering from a bipolar affective disorder , despite the fact that the twins were separated and living in different environments(1).
2-The personality :
Krapelin (1921) mentioned that individuals with a cyclothymic personality are at risk of developing a bipolar affective disorder .
No specific personality type is clearly associated with the predisposition to unipolar affective disorder , but it seems that certain personality traits (anxiety and obessional traits) , can be linked with the predisposition to depression (1) .
B-The precipitating factors : -
1-Stressful life events are usually apparent in the weeks or months preceding the onset of affective disorder .
2-Organic factors play a role in precipitating an affective disorder , and include : surgical operations , febrile illnesses , head injuries , ect . (1) .
3- Beck’s cognitive theory views depression as a disorder resulting from a primary disorder of thinking , presenting with negative thoughts towards self , the surroundings , and the future. These negative thoughts lead to the appearance of a depressed mood .
4-The Biochemical theory views depression as being the result of a deficiency in mono- a mine neurotransmitters (serotonin , adrenaline , and noradrenalin) , while mania as resulting from an excess of these neurotransmitters .
Differential Diagnosis :
1. Anxiety disorder : mild depressive disorder with an admixture of anxiety features has to be differentiated from Anxiety disorder .
2. Schizophrenia : severe depressive disorder with psychotic features has to be differentiated from schizophrenia –
3. Drug abuse and dependence : -
Depressive features are common in association with drug abuse and dependence and must be differentiated from a typical depressive episode .
4. Organic brain disorder : - may present with depressive features that must be differentiated from a typical depressive disorder .
Prognosis : -
Without psychiatric intervention , an episode of affective disorder usually lasts for weeks or months . However the episode may last for a year or even more .
A depressive episode is usually longer than a manic episode .
Management : -
A) Treatment of depression : -
1-Drug treatment : in the form of anti depressant drugs : -
a-Tricyclic anti depressants .
b-Mono – amine oxidase inhipitors (M.A.O.I) .
c-Selectivs Serotonin Re - uptake ininhiptors .
2-Electro - Convulsive therapy (E.C.T) : Represents a first line form of therapy in severe depressive disorder , especially in the presence of psychotic symptoms , the biological features of depression , and suicidal ideas and / or attempts .
3-Cognitive therapy : -
Beck’s approach to cognitive therapy in depression includes the following steps : -
1. Identiving negative thoughts .
2. Linking the negative thoughts with the patient’s suffering and difficulties in achieving a normal level of daily functioning .
3. Replacing the negative thoughts with positive thoughts that will enable the individual to achive a normal level of daily functioning .
4. Training on methods of self- evaluation , that will empower the individual to find the best means of adjustment with the environment .
B) Treatment of mania :-
1. Drug treatment in the form of :
a) Anti - psychotic drugs .
b) Lithium .
2. Electro - convulsive therapy may be needed in cases of acute excitement or in manic stupor .
Prophylaxis :-
In cases of bipolar affective disorder with frequent relapses prophylaxis treatment can be used .
Use can be made of lithium , carbamzepine and other forms of drugs (10) .
Complications of affective disorder :-
1-physical complications :
include : weight loss , dehydration , low immunity , and physical exhaustion that can lead to sudden death .
2- Social Complications :- include : family problems that can lead to divorce and problems at work that can lead to loss of job , restricted social relation , and confrontation with law procedures .
3- Psychiatric complications :
a)In the case of depression :-
2. Suicide : Around 11-17 of the patients diagnosed to be suffering from a severe depressive disorder attempt suicide .
3. Depressive stupor .
b)In the case of mania :-
1. Aggression and violence .
2. Manic stupor.
Depressive and manic stupor :-
These are cases of psychogenic stupor , in which the patient is immobile , mute , refuses to have his meals or to drink , with diminished responses to external stimuli .
Differentiation between depressive and manic stupor depends basically on meticulous