Mood disorders are a group of disorders characterized by significant and persistent changes in emotion or state of mind. The main clinical manifestations are high or low affect, accompanied by responsive cognitive and behavioral changes, and may have psychotic symptoms, such as hallucinations and delusions. Most patients have a tendency to have recurrent episodes, and some may have residual symptoms or turn chronic.
Mood disorders include several types such as bipolar disorder, mania and depression. Bipolar disorder has the clinical characteristics of alternating episodes of mania and depression, and was previously called manic-depressive psychotic disorder. Mania and depression refers to only manic or depressive episodes, and is customarily called monophasic mania or monophasic depression.
I. Prevalence
The lifetime prevalence of mood disorders is 0.083%. The point-in-time prevalence is 0.95%, and the total prevalence is 1.15%.
Etiology and pathogenesis
The etiology of this disease is still unclear, and a large number of research data suggest that genetic factors, neurobiochemical factors and psychosocial factors have a significant impact on the occurrence of this disease.
(A) Genetic factors
The family history of patients with mood disorders is 30%-41.8%. The probability of relatives of patients with pre-existing mood disorders having the disease is 10-30 times higher than that of the general population, and there is an early genetic phenomenon, i.e., the age of onset is earlier from generation to generation, and the severity of the disease increases from generation to generation.
(B) Neurobiochemical changes
1, 5-hydroxytryptamine (5-HT) hypothesis 5-HT functional activity is reduced and depressed mood, loss of appetite, insomnia, circadian rhythm disorders, endocrine dysfunction, sexual dysfunction, anxiety, inability to deal with stress, and reduced activity in patients with depression are closely related.
2, norepinephrine (NE) hypothesis Clinical studies have found that the urinary NE metabolite 3-methoxy-4-hydroxy-phenylethylene glycol (MHPG) in patients with bipolar depression is significantly lower than that in the control group, and the MHPG content increases when it turns into mania.
3, dopamine (DA) hypothesis Neurochemical and pharmacological studies have found that DA function in the brain is reduced in depression, and DA function is increased in mania.
4, γaminobutyric acid (GABA) hypothesis GABA is the main inhibitory neurotransmitter in the central nervous system, clinical research found that many antiepileptic drugs such as carbamazepine and sodium valproate have antidepressant effects, and their pharmacological effects are related to the regulation of GA-BA content in the brain.
(C) Abnormal neuroendocrine function
Many studies have found that patients with mood disorders have functional abnormalities of hypothalamic-pituitary-adrenal axis, hypothalamic-pituitary-thyroid axis, and hypothalamic-pituitary-growth hormone axis.
(iv) Electrophysiological changes in the brain
Sleep EEG study found that depressed patients have the following changes in sleep: the total sleep time is reduced, the number of awakenings is increased; the fast eye movement sleep (REM) latency is shortened, the more severe the depression, the shorter the REM latency, and it can predict the treatment reflection. 30% or so of patients with mood disorders have computerized graph (EEG) abnormalities, depressive episodes tend to be low alpha frequency, while manic episodes tend to be high alpha frequency or High-amplitude slow waves appear.
(V) Neuroimaging changes
1. Structural imaging studies Most CT studies found that the ventricles in patients with mood disorders were larger than those in normal controls. The incidence of ventricular enlargement was 12.5%-42%. There was no significant difference in the rate of CT abnormalities between monophasic and biphasic depression.
2. Functional imaging studies have been found to have reduced local cerebral blood flow (rCBF) in the left frontal lobe in depressed patients.
(VI) Psychosocial factors
Stressful life events are more closely related to mood disorders, especially to depression. Life events play a contributing role in the occurrence of depression, and it is believed that negative life events, such as widowhood, divorce, marital discord, unemployment, serious physical illness, serious illness or sudden death of a family member, can lead to depression, and it is pointed out that widowhood is the stressor most closely related to depression. People with poor economic status and lower social class are also prone to the disease. Women are less able to cope with stress than men and are more likely to suffer from this disease.
Three clinical manifestations
(A) Manic episode
The typical clinical symptoms of manic episode are high emotion, running thinking and increased activities.
1, emotional high patients subjective experience is particularly pleasant, feel good about themselves, all day long, giddy, smiling, overflowing with joyful fun and attitude, and even feel that the sky is extraordinarily clear, the color of the surrounding things is extraordinarily gorgeous they also feel incomparable joy and happiness. This high state of mind of the patient is infectious and often resonates with the people around, causing laughter. Some patients are unstable and unpredictable, sometimes joyful and happy, sometimes excited and angry, despite their high emotions. Some patients are clinically characterized by anger, irritability, and hostility, and do not show high emotion, so they can easily jump like thunder, anger and even vandalism and aggressive behavior, but often quickly turn anger into joy or apologize.
When the patient’s emotions are high, the self-esteem is too high, manifesting as arrogance, arrogance, arrogance, arrogance, arrogance and arrogance. Exaggerated notions of being the greatest, the most capable, and the richest in the world may appear. It may even reach the level of exaggerated or rich delusions, but the content is not absurd. Sometimes there can also be relationship delusions, delusions of victimization, etc., which are mostly secondary to emotional highs and usually do not last long.
2.Thinking is faster and faster, and the content of thinking is rich and changeable, and the concepts in the mind come one after another. However, the content of the speech is superficial and messy and impractical, often giving people the impression that they are talking out of thin air. As the patient’s attention shifts with the situation, the thinking activity is often influenced by the change of the surrounding environment, so that the topic suddenly changes, and the content of the speech is often quickly changed from one topic to another, i.e., it is manifested as a drifting idea, and some patients can appear phonetic and intentional association.
3, increased activity Performance of high energy, a wide range of interests, fast and agile movements, significantly increased activity, and endurance, busy all day long, often do anything is a tiger’s head and snake’s tail, there is no end, nothing is achieved. The person is nosy and lacks proper judgment of his own behavior, often doing whatever he wants without considering the consequences, such as squandering money at will, being very generous, giving gifts to colleagues or passers-by at will. Focus on dressing and decorating, but not decent, to attract the attention of the surrounding people, and even perform in public, joking around. At work, he thinks he has superior intelligence and can solve all problems, and he commands others, reprimands colleagues, is domineering and arrogant, but gets nowhere. He is socially active, treats people casually, often goes to entertainment places, behaves frivolously, and is close to the opposite sex. He feels energetic, has inexhaustible energy, does not know how to get tired, and sleep is significantly reduced. When the disease is serious, the ability of self-control decreases, rude behavior, and even impulsive destruction behavior.
4.Somatic symptoms Since the patient feels good about himself and has abundant energy, he rarely complains of physical discomfort, and often shows a rosy complexion, eyes with energy, mildly dilated pupils, accelerated new rate, and symptoms of sympathetic hyperactivity such as constipation. Due to the patient’s extreme excitement and excessive physical exertion, it is easy to cause water loss and weight loss. Patients have increased appetite, hypersexuality and reduced need for sleep.
5.Other symptoms The active and passive attention of the patient is enhanced during the manic episode, but it cannot be sustained and is easily attracted by the surrounding things. This symptom of shifting with the situation is most obvious in the acute attack period. Some patients have enhanced memory, and diffuse uninhibited, changeable, often full of many details and trivialities, and often lose the correct demarcation of the time of memory, so that it is confused with the past memory without coherence. When the attack is extremely serious, the patient is in a state of extreme excitement and agitation, there may be brief, fragmentary hallucinations, disorderly behavior without purpose, accompanied by impulsive behavior; there may also be a disorder of consciousness, with delusions, hallucinations and incoherent thinking and other symptoms, called delirium mania. Most patients lose self-awareness at the early stage of the disease and do not think they have problems.
Manic episodes with milder clinical manifestations are called mania. Patients may have elevated emotions, high energy, increased activity lasting at least several days, a significant sense of self-importance, inattention and also lack of persistence, mild profligacy, increased social activity, increased sexual desire, and reduced need for sleep. It sometimes manifests as irritability, conceit and pride, and more reckless behavior, but is not accompanied by psychotic symptoms such as hallucinations and delusions. There is a mild impact on social functioning. Some patients sometimes do not reach the degree of affecting social function, and the general public often do not easily notice.
Patients with manic episodes in old age are clinically less likely to be in a high state of mind, mainly showing irritability, arrogance, exaggerated concepts and delusions, increased speech, but often more verbose, and may have aggressive behavior. Symptoms such as drifting thoughts and hypersexuality are also less common. The course of the disease is more prolonged.
(B) Depressive episodes
Depressive episodes are clinically characterized by depressed mood, slowed thinking, reduced volitional activity and physical symptoms.
1, depressed mood is mainly manifested as significant and persistent depressed mood, depression and pessimism. Patients spend their days worried, depressed, sad, long and short sighs. Patients with milder degree of depression feel sullen and unhappy, lack of interest in everything, usually very hobby activities such as watching soccer games, playing cards, planting flowers, etc., do not feel boring, can not get excited about anything; heavy degree of depression can be painful, pessimistic and desperate, with a sense of life as a year, life is worse than death, patients often complain that “there is no point in living”, “psychologically uncomfortable”, etc.. Some patients may have anxiety and agitation symptoms, especially in menopausal and elderly depressed patients. In typical cases, the depressive state of mind is characterized by a diurnal rhythm, i.e., depressed mood is more severe in the morning or during the day, and can be reduced in the evening.
Under the influence of low emotion, the patient’s self-evaluation is low, feeling that everything is inferior, blaming all the faults on himself, often generating a sense of uselessness, hopelessness, helplessness and worthlessness, feeling that he is incapable and incompetent, feeling that he has dragged down his family and society; looking back on the past, he has achieved nothing, and has a sense of guilt for his unimportant and dishonest behavior in the past; thinking about the future, he feels that the future is bleak, foreseeing Their own work to fail, financial collapse, family to appear misfortune, their health will certainly deteriorate. On the basis of pessimism and disappointment, there is a feeling of isolation, accompanied by self-blame and self-guilt, and in severe cases, delusions of guilt; on the basis of physical discomfort, there is also a suspicion of illness, suspicion that they are terminally ill, etc.; there may also be a relationship, delusions of victimization, etc. Some patients may also experience hallucinations.
2, slow thinking Patients think slowly, slow reaction, closed thinking, and feel that “the brain is like a rusty machine, the brain is like a layer of paste coated can not turn”. The clinical manifestation is a decrease in active speech, a significant slowdown in speech speed, a low voice, a feeling that the patient’s brain is not working, difficulty in thinking, and a decrease in the ability to work and study.
3.Decreased volitional activity The patient’s volitional activity is significantly and persistently inhibited. Clinical behavior is slow, life is passive, lazy, do not want to do anything, do not want to contact and interact with people around, often sit alone, or lie in bed all day, do not want to go to work, do not want to go out, do not want to participate in activities and hobbies that they usually like, often closed door and live alone, alienate friends and relatives, avoid social interaction. In severe cases, the patient may not even care about eating, drinking, or personal hygiene, or even develop into a state of silence, immobility, or inappetence, which may be called “depressive rigidity,” but on careful mental examination, the patient still shows painful depression. Patients with anxiety may have symptoms such as fidgeting, finger grasping, rubbing hands and feet or pacing around. Patients with severe depressive episodes are often accompanied by negative suicidal ideation or behavior.
Negative pessimistic thoughts and self-blame can lead to desperate thoughts, thinking that “ending one’s life is a relief” and “one is redundant in the world”, and can promote suicide planning and development of suicidal behavior. This is the most dangerous symptom of depression and should be alerted. Long-term follow-up has found that about 15% of depressed patients eventually die by suicide. Suicidal ideation is increasingly strong, and attempts are made to end oneself by any means possible.
4. Somatic symptoms are very common and include sleep disturbance, loss of appetite, weight loss, loss of libido, constipation, pain in any part of the body, impotence, amenorrhea, and fatigue. The complaints of somatic discomfort can involve all organs. Symptoms of autonomic dysfunction are also more common. Sleep disorders are mainly manifested by early awakening, usually earlier than usual, and inability to fall back to sleep after waking, which is characteristic for the diagnosis of depressive episodes. Some patients have difficulty falling asleep and do not sleep deeply; a few patients show excessive sleep. Weight loss is not necessarily proportional to appetite loss, but a few patients may have increased appetite and weight gain.
5.Other depressive episodes can also appear depersonalization, reality dissociation and obsessive-compulsive symptoms. Depressive episodes with mild clinical manifestations are called mild depression. The main manifestations are depressed emotion, loss of interest and pleasure, easy fatigue, reduced self-awareness of daily work and social skills, and psychotic symptoms such as hallucinations and delusions, but the clinical symptoms are more than those of cyclothymic disorder and bad mood. Depression in elderly patients is light, and most patients have prominent anxiety and irritability, which can sometimes be manifested as irritability and hostility.
Psychomotor retardation and somatic complaints are more pronounced than in younger patients. The symptoms of cognitive impairment may be more pronounced due to significant delays in thought association and memory loss, and may resemble dementia, such as decreased ability to calculate, remember, understand, and judge. Somatic complaints are more common in the gastrointestinal tract, such as loss of appetite, bloating, constipation, etc., and are often entangled with a physical complaint, and are prone to hypochondriasis, which can develop into suspicion, vapidity and delusions of guilt. The course of the disease is lengthy and can easily develop into chronic.
(C) Bipolar disorder
Bipolar disorder is characterized by repeated (at least two) episodes of markedly disturbed mood and activity levels, sometimes characterized by high mood, high energy and increased activity (mania or hypomania), and sometimes characterized by low mood, low energy and decreased activity (depression). The interictal period is usually characterized by complete remission.
Mixed episodes are a subtype of bipolar disorder in which manic and depressive symptoms occur together in a single episode and are less common in clinical practice. It usually occurs when mania and depression are rapidly phased, for example, a patient with a manic episode suddenly turns to depression and then mania again a few hours later, giving the impression of a “mixed” episode. Patients have both manic and depressive manifestations, such as a patient with significantly increased activity and incessant speech, while having serious negative thoughts; another example is a patient with depressive state of mind may have increased speech and action. However, this mixed state generally lasts for a short time, and most of them turn into manic phase or depressive phase more quickly. In mixed episodes, both manic symptoms and depressive symptoms are clinically atypical and can be easily misdiagnosed as schizoaffective disorder or schizophrenia. Rapid cyclic episodes are defined as the past 12 months
In the past 12 months, there are at least 4 episodes of mood disorder, regardless of the form of the episodes, but meet the criteria of light manic or manic episodes, depressive episodes, or mixed episodes.
(iv) Cyclothymic disorder
Cyclic mood disorder refers to the repeated alternation of emotional highs and lows, but to a lesser extent, and none of them meet the diagnostic criteria in manic or depressive episodes. In mild manic episodes, the person is very happy, active and positive, and makes some commitments in social life; however, when he/she turns to depression, he/she is no longer optimistic and confident, but becomes a painful “loser”. Subsequently, there may be a return to a period of relatively normal mood, or a change to mildly elevated mood. The interval between relatively normal moods can last for several months and is characterized by persistent mood instability. The fluctuation of this state of mind is not obviously related to life stress, but is closely related to the personality characteristics of the patient, which used to be called “cyclothymic personality”.
(E) Bad mood
Bad mood refers to a mild depression dominated by a persistent state of low mood, never mania. It is often accompanied by anxiety, somatic discomfort and sleep disturbance. Patients have a demand for treatment, but there is no significant psychomotor depression or psychotic symptoms, and their lives are not seriously affected. Patients feel heavy and depressed most of the time, look at things as if wearing a pair of sunglasses, the surrounding area is dark; no interest in work, no enthusiasm, lack of confidence, pessimistic and disappointed about the future, often feel mentally weak, fatigue, reduced ability, etc.. When the degree of depression worsens, there are also thoughts of lightness of life. Despite this, the patient’s work, study and social functions are not significantly impaired, he or she knows that the mood is bad and often has the desire to seek treatment.
The depression often lasts for more than 2 years, during which there is no prolonged complete remission, and if there is remission, it usually does not last more than 2 months. Such depressive episodes are more related to both life events and personality. Anxiety is a frequent concomitant symptom, and obsessive-compulsive symptoms may also be present. Somatic complaints are also more common. Sleep disturbances are characterized by difficulty falling asleep, nightmares, and shallow sleep, often accompanied by chronic pain symptoms such as headache, back pain, and extremity pain, as well as autonomic dysfunction symptoms such as stomach upset, diarrhea, or constipation. However, there are no obvious symptoms of early awakening, circadian rhythm changes and weight loss and other biological changes.
Course of disease and prognosis
(A) Manic episode
Whether it is a single manic episode or recurrent mania, most of them are acute or subacute onset, and the good season is late spring and early summer. The natural course of manic episodes is generally considered to last from several weeks to 6 months, with an average of about 3 months, with some cases lasting only a few days and individual cases lasting up to 10 years or more. Some people think that recurrent mania, each episode lasts almost similarly, and can become chronic after many episodes, and a few patients have residual mild affective symptoms, and social function is not fully restored to the pre-morbid level.
(B) Depressive episodes
Most depressive episodes are acute or subacute in onset, with a preference for autumn and winter. The age of onset of monophasic depression is later than that of bipolar disorder, and the duration of each episode is longer than that of mania, but there are also short ones, only a few days. The duration of the disease is related to age, severity of the disease and the number of episodes. It is generally believed that the more the number of episodes, the more serious the disease, with psychotic symptoms, the older the age, the longer the duration of the disease, and the correspondingly shorter the remission period. The main factors that influence relapse are.
① Inadequate dose and duration of antidepressants for maintenance treatment, it is believed that a significant proportion of relapsed patients are due to not receiving appropriate maintenance treatment;
(ii) Life events and stress, relapse in depressed patients is often associated with an increase in stressful life events, especially interpersonal tension and loss of relationships;
(iii) Social maladjustment.
④Chronic physical illness ;
⑤ Lack of social and family support.
⑥Family history of positive mood disorders.
The presence of residual symptoms often leads to relapse.
The prognosis of mood disorders is generally good, but those with recurrent, chronic, elderly, family history of mood disorders, maladaptive personality, chronic physical illness, lack of social support system, untreated or inadequate treatment tend to have a poor prognosis.
(C) Bipolar disorder
Manic episodes of bipolar disorder usually start suddenly. The duration varies from 2 weeks to 4 or 5 months; depressive episodes last longer, about 6 months, except in old age, rarely more than 1 year. Both types of episodes are usually followed by stressful life events or other psychological trauma. First onset can occur at any age, but most onset occurs before age 50. The frequency of episodes and the form of recurrence and remission are highly variable, but there is a tendency for the duration of remission to decrease over time. After middle age, depression becomes more common and lasts longer
V. Diagnosis
The diagnosis of mood disorders should be mainly based on medical history, clinical symptoms, and course of the disease.
Differential diagnosis
1. Secondary mood disorder Organic brain diseases, physical diseases, certain drugs and psychoactive substances can cause secondary mood disorder, and the main points of differentiation from primary mood disorder.
(1) The former has a clear organic disease, or a history of taking certain drugs or using psychoactive substances, positive physical examination signs, and changes in laboratory and other auxiliary tests with corresponding indicators.
②The former may have disorders of consciousness, amnesia syndrome and intellectual impairment, while the latter has no disorders of consciousness, memory impairment and intellectual impairment except for delirium manic episode.
③The symptoms of organic and pharmacogenic mood disorders fluctuate according to the duration of the primary disease, and the emotional symptoms improve or disappear accordingly after the primary disease improves or the relevant drugs are discontinued.
④The symptoms of manic episodes caused by certain organic diseases are not obvious, but are manifested as irritability, anxiety and nervousness, such as hyperthyroidism; or manifested as euphoria, irritability and emotional instability.
⑤ The former has no previous history of episodes of mood disorders, while the latter may have a history of similar episodes.
2. Schizophrenia Psychomotor excitement is often present in the early stages of schizophrenia, or depressive symptoms may appear, or depression may appear during the recovery period of schizophrenia.
3. Psychogenic psychiatric disorders Post-traumatic stress disorder in psychogenic disorders is often accompanied by depression, which should be differentiated from depression.
VI. Treatment and prevention
(A) Treatment of bipolar disorder
Bipolar disorder should follow the principle of long-term treatment.
Commonly used mood stabilizers Mood stabilizers are drugs that have therapeutic and relapse prevention effects on manic or depressive episodes, and do not cause manic and depressive transitions, or cause episodes to become more frequent.
(B) Treatment of depression
Antidepressants are the main drugs for the current treatment of various depressive disorders, which can effectively relieve depressed state of mind and the accompanying anxiety, tension and somatic symptoms.
(iii) Small doses of second-generation antipsychotic treatment
Relapse prevention
For patients who are clinically cured from their first depressive episode, most scholars believe that the duration of maintenance treatment should be 6 months to 1 year; for the second episode, maintenance treatment is recommended for 3-5 years; for the third episode, long-term maintenance treatment should be provided; the dose of maintenance treatment is considered by most scholars to be the same as the therapeutic dose, while some scholars believe that it can be slightly lower than the therapeutic dose. However, patients should be asked to follow up regularly.
The relapse rate of bipolar disorder is significantly higher than that of monophasic depressive disorder, and if a bipolar patient has had more than one episode per year in the past two years, long-term prophylactic treatment with lithium is recommended.
Psychotherapy and social support system also play a very important role in preventing relapse of mood disorders. Patients should be relieved or relieved of excessive psychological burden and pressure as much as possible, to help patients solve practical difficulties and problems in life and work, to improve their coping ability, and to actively create a good environment for them to prevent relapse.