Approach to mood disorders: Clinical sciences

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Introduction 0:00–0:26

Mood refers to a long-lasting emotional state that influences how a person views the world and behaves. So, mood disorders are characterized by persistent and excessive experience of emotions such as happiness, sadness, and irritation to a degree that affects an individual's overall functioning.
Now, if a patient presents with chief concerns suggesting a mood disorder, first, perform a safety assessment. Assess for features of psychosis, like agitation, paranoia, aggression, signs of auditory or visual hallucinations, and other forms of severely disorganized thoughts, speech, or behavior.

Safety assessment 0:26–1:25

Additionally, look for signs of mania, such as rapid speech, a decreased need for sleep, and an increase in goal-directed activity.
Finally, ask specifically about homicidal and suicidal ideation. Patients experiencing psychosis, mania, and active homicidality or suicidality, are considered high risk to themselves and others, so proceed with acute management, which often requires psychiatric hospitalization, pharmacologic stabilization, and a one-to-one sitter, if appropriate.
On the other hand, if the patient is not experiencing these features, they are considered low risk to themselves and others, so your next step is to obtain a focused history and physical exam.

H&P 1:25–2:49

History will typically reveal a persistently euphoric, irritable, or depressed mood that is significantly different from their baseline.
Next, on the exam, you will notice psychomotor changes, such as slowed or agitated movements; changes in the rate of speech, which can be increased or decreased; and extremes of affect, ranging from flat to exaggerated facial expressions.
Finally, you might notice changes in appearance, such as being unusually unkempt. With these findings, you should consider mood disorder.
Now, here’s a clinical pearl to keep in mind! When assessing patients with mood disorders, be sure to rule out other medical conditions as potential causes of mood changes.
For example, hypothyroidism can contribute to depression, while encephalitis can result in manic and psychotic symptoms.
Additionally, intoxication or withdrawal from substances, such as alcohol, cocaine, amphetamines, opioids, and benzodiazepines, can also lead to mood disturbances.
Next, assess for a current or past manic episode using the DSM-5 criteria. Manic episodes are characterized by a persistently euphoric or irritable mood with increased energy.

Bipolar 1 disorder 2:49–5:11

In addition, there must be at least 3 of the following symptoms, which can be remembered using the mnemonic DIG-FAST. DIG refers to Distractibility; Irresponsibility, including high-risk behaviors such as reckless driving, expensive shopping sprees, and sexual indiscretion; and Grandiosity and unrealistic self-confidence.
Next, F stands for Flight of ideas; while A refers to psychomotor Agitation, but also increased goal-oriented Activities, involving excessive planning, multitasking, increased sociability, and sexual drive.
Finally, S stands for Sleep deficiency but still feeling rested and energetic; and T for excessive Talkativeness that is rapid and hard to interrupt.
Sometimes, the patient might present with psychotic features, such as hallucinations, delusions, or severely disorganized thought, speech, and behavior.
Next, the manic episode must be at least one week or any duration of time if symptoms are severe enough to require hospitalization.
Finally, symptoms must cause clinically significant impairment. If the patient meets the criteria for a current or past manic episode, diagnose bipolar 1 disorder.
Here’s another clinical pearl! To diagnose bipolar 1 disorder, the patient must meet the criteria for a manic episode.
However, manic episodes in bipolar 1 disorder, can often be followed or preceded by hypomanic and major depressive episodes.
Hypomania is a less severe, less impairing form of mania, and typically lasts for a few days, although some episodes can last weeks or even months.
These episodes are often interspersed with periods of stable mood, but a person may switch directly from one pole, mania, to the other pole, depression.
On the other hand, if there is no history of a manic episode, assess for a current or past hypomanic episode using the DSM-5 criteria.

Bipolar 2 disorder 5:11–6:39

Like mania, hypomania is characterized by a persistently euphoric or irritable mood with increased energy and the presence of 3 or more DIG-FAST symptoms.
But, in contrast to manic episodes, hypomanic episodes are not associated with psychotic features. Next, the hypomanic episode must last at least 4 days and should not require hospitalization.
Finally, symptoms must cause clinically significant changes in function, but they cannot be severe enough to cause impairment.
If the patient meets all the criteria for a current or past hypomanic episode, the likely diagnosis is bipolar 2 disorder.
Here’s a high-yield fact! In order to make the diagnosis of bipolar 2 disorder, the patient must experience at least 1 hypomanic episode, 1 major depressive episode, and no manic episodes.
Similar to bipolar 1 disorder, mood episodes in bipolar 2 disorder also recur, with major depressive episodes being more frequent, longer lasting, and more severe compared to bipolar 1 disorder.
On the flip side, if there is no history of a hypomanic episode, assess for a current or past major depressive episode using the DSM-5 criteria.

MDD 6:39–9:11

To diagnose a major depressive episode, the patient must have at least 5 of the following 9 symptoms. These include consistently depressed mood; too much or too little Sleep; lack of Interest and pleasure in previously enjoyed activities, social withdrawal and decreased sexual drive; Guilt and feelings of worthlessness; decreased Energy; poor Concentration; changes in Appetite; Psychomotor slowing or agitation; and finally, Suicidality with recurrent thoughts of death, including passive thinking, active planning, as well as suicide attempts.
Keep in mind that at least one of these symptoms must be a consistently depressed mood or lack of interest and pleasure in previously enjoyed activities.
In addition to the consistently depressed mood, you can easily remember the last 8 symptoms using the mnemonic SIG-E-CAPS.
Additionally, the patient might present with psychotic features like hallucinations or delusions. Finally, symptoms must last at least 2 weeks and cause clinically significant distress or impairment.
If the patient meets the criteria for a major depressive episode, think of major depressive disorder. Keep in mind that in order to diagnose major depressive disorder, your patient must experience at least 1 major depressive episode and have no history of manic or hypomanic episodes.
Here’s another clinical pearl! Individuals with bipolar mood disorders often present during a major depressive episode, making it crucial to assess all depressed patients for any history of mania or hypomania.
This is important because starting antidepressant monotherapy might trigger or unmask manic or hypomanic symptoms. Additionally, after diagnosing major depressive disorder and initiating antidepressant therapy, monitor the patient for new manic or hypomanic symptoms and, if needed, update their diagnosis to bipolar 1 or bipolar 2 disorder.
Now, let’s go back and look at individuals with no current or past major depressive episodes. In this case, your next step is to assess for key features of the patient mood disorder.

PDD 9:11–10:42

If a patient reports persistent sadness, consider persistent depressive disorder or PDD. Next, use the DSM-5 criteria to assess for PDD, which is characterized by a persistently depressed mood lasting at least two years in adults and at least one year in children and adolescents.
During this period, the patient must experience two or more of the following six symptoms. These include poor Concentration; feeling Hopeless; changes in Eating habits, like overeating or poor appetite; low self-Esteem; Sleep disturbances, such as insomnia or hypersomnia; and low Energy.
Moreover, use the mnemonic CHEESE to remember these six symptoms. Next, during these two years in adults and one year in children and adolescents, the patient has never been without symptoms for more than 2 months.
Finally, symptoms that the patient is experiencing must cause clinically significant distress or impairment. If the patient meets the criteria, diagnose persistent depressive disorder.
Next, if a patient presents with frequent mood swings, consider cyclothymic disorder, so proceed with the DSM-5 cyclothymic disorder criteria.

Cyclothymic disorder 10:42–11:45

Cyclothymic disorder is characterized by a persistent pattern of unpredictable mood changes lasting over two years in adults or over one year in children and adolescents.
During this period, the patient must experience periods of hypomanic symptoms alternating with periods of depressive symptoms.
But keep in mind that your patient should not meet the criteria for hypomanic- and major depressive episodes. Next, during these two years in adults and one year in children and adolescents, there should be no symptom-free intervals lasting more than two months.
Finally, these mood changes must cause clinically significant distress or impairment. If all criteria are met, diagnose cyclothymic disorder.
On the other hand, if mood symptoms are closely associated with the patient’s menstrual cycle, consider premenstrual dysphoric disorder, or PMDD, so assess for the DSM-5 PMDD criteria.

PMDD 11:45–12:48

PMDD is a severe form of premenstrual syndrome characterized by significant mood changes, which start during the week before menstruation and begin to resolve a few days after the onset of menstruation.
These include severe mood swings, intense irritability or anger, depression, anxiety, or feelings of being overwhelmed, as well as physical symptoms like bloating, breast swelling or tenderness, and joint or muscle pain.
These symptoms should be present in most menstrual cycles. Also, the symptoms should cause clinically significant distress or impairment in everyday activities.
If all criteria are met, diagnose premenstrual dysphoric disorder. Finally, if your patient developed mood symptoms after a major life situation, consider adjustment disorder.

Adjustment disorder 12:48–14:16

Again, assess for the DSM-5 criteria for adjustment disorder, which is characterized by mood symptoms and distress disproportionate to a known stressor, like job loss, divorce, or natural disaster.
Symptoms appear within 3 months of the event and resolve within 6 months after it ends. Mood symptoms may manifest as depression or anxiety and lead to behavioral issues like aggression, refusal to follow rules, or risky behaviors such as substance use.
Symptoms must cause clinically significant distress or impairment. If your patient meets the criteria, diagnose adjustment disorder.
Here’s one last clinical pearl to keep in mind! Disruptive mood dysregulation disorder, or DMDD, occurs only in children.
It is characterized by a severe and persistently irritable or angry mood, along with frequent temper outbursts that are developmentally inappropriate and have persisted for at least a year.
Children with DMDD are at an increased risk of developing depressive or anxiety disorders in adulthood, but they are unlikely to develop bipolar disorder.
Alright, as a quick recap… When assessing a patient with mood disorder, first, perform the safety assessment, then obtain a focused history and physical exam.

Review 14:16–15:21

Use the DSM-5 criteria to assess for manic, hypomanic, and major depressive episodes. A current or past manic episode suggests bipolar 1 disorder; a current or past hypomanic episode combined with a major depressive episode indicate bipolar 2 disorder; while a major depressive episode without mania or hypomania is suggestive of major depressive disorder.
Finally, assess for key features, where persistent sadness may indicate persistent depressive disorder, frequent mood swings may suggest cyclothymic disorder, and mood symptoms linked to menstrual cycles likely represent premenstrual dysphoric disorder.
If mood symptoms develop after a major life stressor, think of adjustment disorder.
Approach to mood disorders: Video, Steps, and Uses | Osmosis