Mood Disorders – Causes, Signs and symptoms

Mood Disorders

Also called: Affective Disorders

Summary

A mood disorder is a mental illness characterized primarily by mood swings or an abnormally high or low mood. Most mood disorders are defined and diagnosed by the occurrence of one or more mood episodes, or periods of abnormal happiness or sadness. Such episodes are not mood disorders in themselves.

Mood disorders include major depression, dysthymia and bipolar disorder, among others. Major depression and dysthymia involve periods of sadness and lack of pleasure or interest in normal activities as well as fatigue. Bipolar disorder includes episodes of both depression and mania, which is an elevated mood of (euphoria), combined with increased self-esteem, racing thoughts and reckless behavior or impulsive activity. If severe, episodes of high and low mood can involve psychotic symptoms, such as hallucinations and delusions.

The causes of mood disorders are not completely understood. However, a chemical imbalance in the brain seems to play a major role in their development. Brain chemicals called neurotransmitters convey messages between the nerves. Abnormalities in the regulation of these neurotransmitters are believed to cause alterations in mood. Mood disorders also appear to be linked to genetics. Individuals who have relatives with a history of a mood disorder have a greater risk of developing a mood disorder.

The diagnosis of a mood disorder involves a physical examination by a physician and a mental health evaluation by a physician or a mental health professional. Mood episodes or mood disorders can be triggered or imitated by other illnesses, substance abuse or side effects of medications, so a physician must rule out these potential causes first. The mental health evaluation includes a complete history of symptoms, including when they began, how long they have lasted and how severe they are. It is also noted whether the patient has experienced these symptoms before and, if so, whether and how they were treated.

Depressive mood disorders are typically treated with antidepressants. Mood stabilizing drugs, particularly lithium, are the primary medications for bipolar disorder. Patients with mood disorders may also benefit from different types of therapy, including psychotherapy and cognitive behavior therapy (CBT), in addition to medications. Electroconvulsive therapy (ECT) may be used in severe cases or in cases where medications are not effective or are not safe to use (e.g., pregnancy)

About mood disorders

A mood disorder is a mental health disorder with an abnormal mood as its primary feature. “Mood” refers to the sustained feelings and emotions through which a person interprets life. Most mood disorders are defined and diagnosed by the occurrence of one or more mood episodes, or periods of abnormal happiness or sadness. Such episodes do not constitute a mood disorder in themselves.

Episodes of abnormal happiness often indicate the presence of mania, which may be accompanied by elevated feelings and self-esteem and abnormal and sometimes reckless behavior. Episodes of abnormal sadness indicate a depressive disorder (e.g., major depression, dysthymia, seasonal affective disorder) and involve lengthy periods of time where a patient is sad, fatigued and has little interest in usual activities.

Mood disorders affect people of all ages, races and genders. Children with mood disorders often display similar symptoms as adults, but they may not meet the full criteria for diagnosis. Once believed to be rare in children, mood disorders, particularly depression, are now known to be common even under the age of 12 years. Mood disorders seem to be occurring earlier in life today than in previous years.

Suicide is a serious risk involved in mood disorders, especially among children and adolescents. According to the National Alliance on Mental Illness (NAMI), about two-thirds of all children and adolescents who commit suicide have a mood disorder.

Many mood disorders are associated with anxiety disorders and other mental illnesses. This often results in misdiagnosis or underdiagnosis, particularly among children with attention deficit hyperactivity disorder (ADHD).

According to the National Institute of Mental Health (NIMH), in any given year, about 9.5 percent of American adults, or about 18.8 million people, have a mood disorder. Mood disorders can occur in any race or social class. They generally affect women more often than men.

Types and differences of mood disorders

There are many different types of mood disorders, most of which involve some episodes of depression.  To meet established criteria for a depressive mood disorder, episodes must not be related to a general health condition or the use of a substance. Depressive mood disorders include:

  • Major depression. One or more major depressive episodes occur in a patient with no history of any type of manic episodes.

  • Dysthymia. Depression that is not severe enough to fulfill the criteria for a major depressive episode and lasts for at least two years. The patient must not have a history of manic episodes.

  • Seasonal affective disorder(SAD). Occurs when people become depressed during a particular season (most often the winter).  

  • Postpartum depression(PPD). Type of depression that follows childbirth. Historically, PPD has been diagnosed solely in women, but researchers now believe that men may be affected by the condition as well.  
  • Depressive disorder, not otherwise specified (NOS). A patient with depressive symptoms that do not meet the criteria for any specific depressive disorder may receive this diagnosis.

Bipolar disorder is a mood disorder that includes at least one episode of abnormally high mood, which cannot be attributed to a general medical condition or the use of a substance. Types of bipolar disorder include:

  • Bipolar I disorder. The occurrence of at least one manic or mixed episode (includes both manic and depressive elements at the same time), with or without episodes of major depression.

  • Bipolar II disorder. The occurrence of at least one episode of major depression and one episode of hypomania (a milder form of mania). The patient must have never experienced a manic or mixed episode. This disorder may develop into bipolar I disorder if a manic episode occurs.

  • Cyclothymia. Repeated mood swings with hypomania and lows in mood that do not meet the criteria for major depressive episodes. This disorder is chronic and lasts for at least two years. It may develop into bipolar I disorder if a manic episode occurs or into bipolar II disorder if a major depressive episode occurs.

  • Bipolar disorder, NOS. Symptoms of bipolar disorder that do not meet the criteria for any other bipolar diagnosis. These may be more common in early onset bipolar disorder.

Other mood disorders include:

  • Mood disorder due to a general medical condition. Abnormal highs or lows in mood caused by a physical illness. Conditions that can lead to a mood disorder include endocrine disorders (e.g., thyroid disorders), neurological conditions (e.g., Alzheimer’s disease, epilepsy, stroke), brain tumors and viral infections.

  • Substance-induced mood disorder. Abnormal highs or lows in mood caused by the use of a substance, such as alcohol, illegal drugs or prescription medications (e.g., anti-anxiety drugs, corticosteroids).

  • Mood disorder, NOS. Any alteration in mood that does not meet the criteria for the diagnosis of any other mood disorder.

Risk factors and causes of mood disorders

The cause of mood disorders cannot be narrowed down to a single factor. However, it appears that brain chemistry plays a major role. Brain chemicals called neurotransmitters convey messages between the nerves.  Abnormalities in the regulation of these neurotransmitters, particularly norepinephrine, serotonin and dopamine, are believed to cause alterations in mood.

Mood disorders also appear to be linked to genetics, and researchers are making great strides in identifying the genetic links involved. Individuals who have relatives with a history of a mood disorder are at a higher risk of developing either the same or a different mood disorder. This is especially true for first-degree relatives (e.g., parents, children, siblings). Some researchers believe that some people inherit a tendency to develop mood disorders, which may then be triggered by environmental factors (e.g., stressful life events, disturbances in seasonal or circadian rhythm).

Gender is another major risk factor for mood disorders, particularly depressive disorders. According to the National Institute of Mental Health (NIMH), women have nearly twice as much risk of developing major depression as men. Many mental health professionals believe that hormones involved in pregnancy and miscarriage and hormone changes during the menstrual cycle, postpartum period, premenopause and menopause may lead to a major depressive episode.

Signs and symptoms of mood disorders

Mood disorders are characterized by mood swings or episodes of abnormal highs or lows of mood. Major depressive episodes are the most common mood episodes. Nearly all patients with a mood disorder will have one at some point during their lifetime. The symptoms of major depressive episodes include:

  • Altered mood. Patients may experience sadness, anxiety, anger, irritability or apathy (lack of emotion). They may be pessimistic (feel that everything in life will turn out badly) or discouraged and may experience crying spells or excessive emotional sensitivity.

  • Anhedonia. Patients may experience a reduction or loss of interest in activities they once found pleasurable, such as food, sex, work, friends, hobbies and entertainment.

  • Significant change in appetite or weight. Patients may experience reduced or increased appetite or significant weight loss or gain.

  • Changes in sleep patterns. Patients may sleep too much (hypersomnia) or not enough (insomnia). Often, patients will wake up early in the morning and cannot go back to sleep.

  • Changes in physical or verbal activity. Patients may be agitated and anxious, may wring their hands, or may pace or not be able to sit still. Conversely, patients may have sluggish movements or speech. They may pause before answering questions or starting actions. Patients may speak quietly or not be able to be heard. They may not speak except in response to a direct question or may become completely mute (not talking at all).

  • Fatigue and loss of energy.

  • Diminished self-worth. Patients may have feelings of worthlessness, self-reproach or excessive or inappropriate guilt.

  • Impaired concentration. Patients may have a diminished ability to think or concentrate.

  • Death thoughts. Patients may have recurrent thoughts of death and death wishes. They may think about committing suicide (suicidal ideation) or have suicidal actions. Patients may even attempt or complete suicide.

Symptoms of manic episodes include:

  • Euphoria and elevated, “high” feelings or irritability. Patients remain in a good mood, even when events occur that would normally dampen the mood.

  • Uncharacteristically elevated self-esteem, feelings of grandiosity or unrealistic confidence. Patients often feel very good about themselves or feel like they can take on the world.

  • Decreased need for sleep. Patients may wake up feeling rested after only a few hours of sleep.

  • Rapid talking, talking more than usual or feeling a need to keep talking. Patients may be excessively talkative. They may be loud or talk too fast.

  • “Flight of ideas,” feeling as though thoughts are racing, distraction or agitation. Patients may be easily distracted or restless. They may have rapidly shifting thoughts that may be revealed in conversation as constantly changing subjects.

  • Increased goal-directed activity. Productivity may be increased.

  • Intrusive or aggressive behavior. Patients may seem nosy or aggressive, sometimes with destructive outbursts.

  • Denial that anything is wrong. Because patients feel good and are often more productive, they may deny that there is a problem.

  • Seeking pleasure without regard to consequences, reckless behavior or poor judgment. Patients may engage in spending sprees, sexual promiscuity, substance abuse or other behavior when they would normally exercise better judgment.

In children and adolescents, manic episodes are more likely to be characterized by irritability and destructive outbursts than by elation or euphoria.

Sometimes, symptoms of depression may occur during a manic episode, resulting in a mixed episode. These may be more frequent in early onset bipolar disorder.

Hypomanic episodes are similar to manic episodes, but are less severe or have a shorter duration. They may not cause actual impairment. In fact, hypomania often results in increased productivity.

In severe cases, these mood episodes can involve psychotic symptoms, such as hallucinations or delusions. Such psychotic features tend to be mood congruent. For example, during manic episodes, patients may believe they are invulnerable to physical harm and, during major depressive episodes, patients may believe they are guilty of a great crime or sin. Obsessions and compulsions may also occur.

Diagnosis methods for mood disordersDiagnosis methods for mood disorders

The evaluation of a patient with a suspected mood disorder begins with a physical examination by a physician. Medical conditions and side effects of medications must be ruled out as potential causes of symptoms.

A physical examination is followed by a mental health evaluation by a physician or a mental health professional. This evaluation includes a complete history of symptoms, including when they started, how long they have lasted and how severe they are. It is also noted whether the patient has experienced these symptoms before and, if so, whether and how they were treated. The physician or mental health professional will also ask about alcohol and drug use, whether the patient has thought about death or suicide and whether other family members have had a mood disorder. If there is a history of a mood disorder in any family members, their treatment and its effectiveness will be discussed.  

Despite being serious and common disorders, mood disorders are highly underdiagnosed for many reasons. Some people believe there is a stigma attached to seeking help for any potential mental health condition. Mood disorders may be overlooked in pregnancy and medical conditions with similar symptoms. Diagnosis in adolescents may be difficult because many adults may expect moodiness in teens. Children may be difficult to diagnose because of confusion with attention deficit hyperactivity disorder (ADHD), which may also exist alongside mood disorders. ADHD and mood disorders must be identified separately because they require different treatment.

Mood disorders are not diagnosed if certain other mental illnesses, particularly ongoing substance abuse or psychotic disorders (e.g., schizophrenia, schizoaffective disorder), are present.

When major depressive episodes occur in patients with no history of manic, hypomanic or mixed episodes, major depression may be diagnosed. The diagnosis of an episode of major depression requires that symptoms must be severe enough to cause distress or impairment in function and last for two weeks or longer. The patient must experience at least five key symptoms. One of these five symptoms must be altered mood or loss of interest in pleasurable activities (anhedonia). The other key symptoms include:

  • Substantial change in appetite or weight
  • Too little or too much sleep
  • Observable agitation or sluggishness in activity
  • Fatigue
  • Reduced feelings of self-worth
  • Problems with concentration
  • Thoughts about death or suicide

If a manic or mixed episode ever occurs, bipolar I disorder is diagnosed. The diagnosis of a manic episode requires symptoms that are severe enough to impair function in occupational performance or social relationships. If the mood is elevated, three or more key symptoms must be present. If the mood is irritable, four or more symptoms must occur. All symptoms must last for one week or longer. The key symptoms of mania include:

  • Uncharacteristically elevated self-esteem or feelings of grandiosity

  • Decreased need for sleep

  • Talking more than usual or feeling a need to keep talking

  • “Flight of ideas” or feeling as though thoughts are racing

  • Distractibility

  • Increased goal-directed activity

  • Seeking pleasure without regard to consequences, reckless behavior or poor judgment (e.g., spending sprees, sexual promiscuity, substance abuse)

Mixed episodes fulfill the symptom-based criteria for both manic and depressive episodes, but must last a minimum of only one week. During these episodes, the patient often cycles rapidly between manic and depressive symptoms.

When hypomanic episodes occur in patients with a history of at least one major depressive episode but no history of manic or mixed episodes, bipolar II disorder is diagnosed. The criteria for a diagnosis of a hypomanic episode are the same as for a manic episode, except that they symptoms need only occur for a minimum of four days and a change in function, not necessarily an impairment, must be present. The symptoms must be observable to others, not necessarily the patient.

If depression that lasts for two or more years and does not meet the criteria for a major depressive episode occurs in a patient with no history of manic, mixed or hypomanic episode, dysthymia is diagnosed. When rapid mood swings and hypomania occur along with a similar low-grade, chronic depression, cyclothymia is diagnosed.

For postpartum depression (PPD), the symptoms of depression must begin within four weeks of childbirth. For seasonal affective disorder (SAD), the symptoms must begin during the same season each year (frequently, the onset of winter) and must not be attributable to another cause. For example, a worker who is unemployed each winter may be stressed by unemployment, not seasonal affective disorder.

Treatment and prevention of mood disorders

Although there are no known cures for mood disorders, they are treatable. There is no known way to prevent a mood disorder itself, but individual episodes may be prevented with the use of medications and therapy. Hospitalization may be necessary during severe episodes.

Medications are often the first line of treatment for mood disorders. They are used to rapidly establish control of dangerous or disabling symptoms, alleviate the symptoms and prevent further episodes. If thyroid dysfunction is present, it needs to be treated with thyroid medications for the treatment of a mood disorder to be effective.

The primary medications for the depressive mood disorders are antidepressants. These are not habit-forming, but need to be carefully monitored to ensure that the correct dosage is given. Antidepressants typically take several weeks to be effective and are generally taken for at least four to nine months, or even indefinitely, to prevent recurrence. It is important to never stop taking an antidepressant without consulting a physician because some types must be reduced gradually to allow the body time to adjust.  Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects.

In addition,  the U.S. Food and Drug Administration (FDA) has advised that antidepressants may increase the risk of suicidal thinking in some patients and all people being treated with them should be monitored closely for unusual changes in behavior.

Mood stabilizing drugs are the primary medications for bipolar disorders. Different types of mood stabilizers may be more effective in different patients and a second mood stabilizer may be added if a single medication is not effective. Lithium is the most common mood stabilizer and generally the first medication used. Anticonvulsant mood stabilizing drugs may be used for difficult-to-treat bipolar disorder or if there is a concern about lithium side effects. Lifelong maintenance with mood stabilizers is generally required to prevent new episodes and reduce the likelihood that subsequent episodes will be more severe.

Patients should be aware that not all medications are appropriate for every individual. Certain medical conditions (e.g., pregnancy) may preclude the use of some medications.

Psychotherapy is effective for many patients with major depression, especially when combined with medications. Psychotherapy encourages patients to take medication properly, assists patients and families in establishing and maintaining appropriate behavioral boundaries, provides counseling and support and addresses substance abuse when appropriate. Some therapies commonly used to treat mood disorders include:

  • Cognitive behavior therapy(CBT). Patients learn to change and control inappropriate thought patterns and behaviors that contribute to or result from their disorder.

  • Psychoeducation. Teaches patients about their mood disorder, its treatment and how to recognize early signs of new episodes so that early intervention can take place. This is often helpful for family members of patients with a mood disorder, as well.

  • Family therapy. Reduces the levels of distress within the family that may contribute to or result from the symptoms of a mood disorder.

  • Interpersonal and social rhythm therapy. Improve the interpersonal relationships of bipolar patients and regularize their daily routines and sleep schedules to give them more control of their lives and their condition.

  • Group therapy. Focuses on acceptance of the mental health condition and the need for long-term medication. This may include families.

  • Psychodynamic therapy. Focuses on resolving the conflict in a patient’s feelings, such as the desire for praise coupled with feelings of worthlessness. This therapy is often reserved until symptoms are significantly improved.

Light therapy is often useful in mood disorders with seasonal onset (e.g., seasonal affective disorder [SAD]). This involves the use of a box that emits bright, white light. The box is set at eye level and the patient looks into the light for a prescribed amount of time each day. Some patients find it more useful to participate in this therapy at a particular time of day that varies from patient to patient.

When a mood disorder is life threatening or severe in patients who cannot take medications or medications do not provide sufficient relief, electroconvulsive therapy (ECT) may help significantly. ECT is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication. ECT has been much improved in recent years with modern techniques, and problems such as long-lasting memory loss have been greatly reduced. ECT is administered using brief anesthesia and muscle relaxants. Electrodes are precisely placed to deliver electrical impulses to the brain. Several sessions are typically needed, usually at a rate of three sessions per week, to achieve the full therapeutic effect.

Questions for your doctor on mood disorders

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following mood disorder-related questions:

  1. Is it possible that my mood disorder is caused by my other medical disorders?
  2. What type of mood disorder do I have?
  3. How severe is my mood disorder?
  4. What medications are right for me?
  5. Should I use medications, therapy or both to treat my mood disorder?
  6. What type of therapy should I consider?
  7. How long will I have to take the medication? How will I know when to stop?
  8. How long will I have to have psychotherapy if I do not take medication?
  9. When will I start to notice the effects of the medication?
  10. What is the likelihood that my children will develop a mood disorder?
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