BEHAVIORAL MEDICINE

CASE STUDY: MOOD

DISORDERS
Gia Pauline S. Castillo-Mojica, MD, DSBPP, DPCAM, FPPA, FPSMSI, MHA
Raymond Joseph S. Valdez, MD, DSBPP
OBJECTIVES:
General Objectives:
1. To present cases in relation to the Mood Disorders.
2. To review some important topics on Mood Disorders.

Specific Objectives:
1. To define terms related to Mood Disorders.
2. To diagnose using the DSM5 diagnostic criteria.
3. To provide proper management of the cases.
CASE 1
Alvin, a 15-year-old boy is brought to the emergency room after
being found in the attic of his home by his parents during the middle
of a school day. The parents came home after receiving a call from
the school reporting that their son had not attended school for 6 days.
The boy was furiously working on a project he claimed would solve the
fuel crisis. He had started returning home from school after his parents
left for work because his science teacher would no longer let him use
the school laboratory after school hours. The patient was involved in
an altercation with the school janitor after being asked to leave the
school because it was so late. The boy claimed that the janitor was a
foreign spy trying to stop his progress.
CASE 1
The parents are very proud of their son’s interest in science but admit
that he has been more difficult to manage lately. He can’t stop talking
about his project, and others cannot get a word in edgewise. His
enthusiasm is now undeniable. For the past few months, he reads late
into the night and gets minimal sleep. Despite this, he seems to have
plenty of energy and amazes his parents’ friends with detailed plans
of how he is going to save the world. His friends have not been able
to tolerate his increased interest in his project. His train of thought is
difficult to follow. He paces around the examination room, saying “I
want to get back to my project before it is too late.” Although he has
no suspects in mind, he is concerned that his life may be in danger
because of the importance of his work.
QUESTIONS
What is the most likely diagnosis?
ANSWERS
Bipolar I disorder, single manic episode, with psychotic features.
QUESTION
What is the best treatment?
ANSWER
According to American Academy of Child and Adolescent Psychiatry
(AACAP) guidelines, monotherapy with the traditional mood stabilizers
or the atypical antipsychotics is the first-line treatment if no psychosis
is reported.
ANSWER
Lithium is the only mood stabilizer with FDA approval for management
of bipolar disorder in children aged 12 years or older.
Divalproex/Valproic Acid/Valporate has been used for seizure
disorder treatment for years in younger children and has a well-
established safety and risk profile, so it may be a better choice in kids
aged less than 12 years.
DEFINITIONS
BIPOLAR TYPE I DISORDER: A syndrome with complete manic
symptoms occurring during the course of the disorder
BIPOLAR TYPE II DISORDER: Hypomania; characterized by
depression and episodes of mania that don’t meet the full criteria for
manic syndrome
DEFINITIONS
HYPOMANIA: Symptoms are similar to those of mania, although they
do not reach the same level of severity or cause the same degree of
social impairment. Although hypomania is often associated with an
elated mood and very little insight into it, patients do not usually
exhibit psychotic symptoms, racing thoughts, or marked psychomotor
agitation
DEFINITIONS
RAPID-CYCLING BIPOLAR DISORDER: Occurrence of at least four
episodes—both retarded depression and hypomania/mania—in a
year.
LABILE: A mood and/or affect that switches rapidly from one extreme
to another. For example, a patient can be laughing and euphoric one
minute, followed by a display of intense anger and then extreme
sadness in the following minutes of an interview. An example is when
you encounter patients who are crying now and later on laughing and
then crying again.
DIAGNOSTIC CRITERIA FOR BIPOLAR
DISORDER (MANIC EPISODE) IN CHILDREN
A distinct period of abnormally and persistently elevated, expansive,
or irritable mood lasting at least 1 week (or any duration if
hospitalization is required).
Three or more of the following symptoms during this period:
 inflated self-esteem or grandiosity
 decreased need for sleep
 greater talkativeness than usual or pressure to keep talking
 flight of ideas or subjective experience that thoughts are racing
 distractibility
 increase in goal-directed activity or psychomotor agitation
 excessive involvement in pleasurable activities with a high potential for painful
consequences
DIAGNOSTIC CRITERIA FOR BIPOLAR
DISORDER (MANIC EPISODE) IN CHILDREN
Criteria for a mixed episode are not met.
Disturbance is severe enough to cause impairment in normal
functioning.
Symptoms are not caused by the effect of a substance or a medical
condition.
MNEMONICS FOR MANIA
D – distractibility
I – insomnia
G – grandiosity
F – flight of ideas
A – activities/psychomotor agitation
S – sexual indiscretions
T – talkativeness/pressured speech
CASE 2
Alvin, 45-year-old man comes to his outpatient psychiatrist with
complaints of a depressed mood, which he states is identical to
depressions he has experienced previously. He was diagnosed with
major depression for the first time 21 years ago. At that time, he was
treated with imipramine, up to 150 mg/d, with good results. During a
second episode, which occurred 15 years ago, he was treated with
imipramine, and once again his symptoms remitted after 4 to 6 weeks.
He denies substance drug. The man states that although he is sure he is
experiencing another major depression, he would like to avoid
imipramine this time because it produced undesirable side effects such
as dry eyes, dry mouth, and constipation.
QUESTION
What is the best therapy?
ANSWER
A selective serotonin reuptake inhibitor (SSRI) such as sertraline,
paroxetine, citalopram or escitalopram, fluoxetine, or fluvoxamine is
one of the first-line choices of medication for this patient
Selective serotonin-norepinephrine reuptake inhibitors (SSNRI) such as
venlafaxine and duloxetine are also first-line treatment options
QUESTION
What are the common side effects?
ANSWER
Gastrointestinal symptoms—nausea, stomach pain, and diarrhea—
occur in early stages of the treatment
Minor sleep disturbances—either sedation or insomnia—can occur
ANSWER
Other common side effects include tremor, dizziness, increased
perspiration, and male and female sexual dysfunction (most
commonly delayed ejaculation in men and decreased libido in
women). These are common reason for noncompliance.
DIAGNOSTIC CRITERIA FOR MAJOR
DEPRESSIVE DISORDER
Two or more episodes of major depression diagnosed by the
following: Five or more of the following symptoms have been present
most of the time for at least 2 weeks:
 Depressed mood
 Anhedonia
 Significant weight change or change in appetite
 Insomnia or hypersomnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness or excessive guilt
 Decreased ability to concentrate or indecisiveness
 Thoughts of death or suicidal ideation
DIAGNOSTIC CRITERIA FOR MAJOR
DEPRESSIVE DISORDER
There has never been a manic, hypomanic, or mixed episode.
Symptoms cause significant distress or impairment in functioning.
Symptoms are not caused by a substance of abuse, medication, or a
medical condition.
DIAGNOSTIC CRITERIA FOR MAJOR
DEPRESSIVE DISORDER
Symptoms are not better accounted for by schizophrenia,
schizoaffective disorder,
delusional disorder, or a psychotic disorder not otherwise specified.
Symptoms are not better accounted for by bereavement (ie, symptoms
last longer than 2 months; marked functional impairment, suicidal
ideation, and/or psychotic symptoms are noted).
MNEMONICS FOR DEPRESSION
S—sleep changes
I—(decreased) interest
G—(excessive) guilt
E—(decreased) energy
C—(decreased) concentration
A—appetite changes
P—psychomotor agitation or retardation
S—suicidal ideation
DEFINITIONS
ANHEDONIA: Loss of interest or pleasure in activities that were
previously pleasurable.
DEFINITIONS
SELECTIVE SEROTONIN REUPTAKE INHIBITOR: An agent that blocks
the reuptake of serotonin from presynaptic neurons without affecting
norepinephrine or dopamine reuptake. These agents are used as
antidepressants, antianxiety and in treating eating disorders, panic,
obsessive-compulsive disorder, and borderline personality disorder
(for symptom-targeted pharmacotherapy).
DEFINITIONS
SELECTIVE SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITOR:
An agent that blocks reuptake of serotonin and norepinephrine. These
agents are used as antidepressants, and for generalized anxiety
disorder. Duloxetine may also be used for painful neuropathy.
CLINICAL PEARLS
It is important to rule out an underlying substance (eg, alcohol and
cocaine withdrawal), medication (eg, antihypertensives, steroids), or
medical condition causing depression (eg, hypothyroidism, multiple
sclerosis), especially if the patient does not have a prior history of
depression.
CLINICAL PEARLS
More than 50% of patients who have had one episode of major
depression will have recurrent episodes.
CLINICAL PEARLS
The risk of future episodes of major depression increases with the
number of prior episodes, the occurrence of residual symptoms of
depression between episodes, and any comorbid psychiatric or
chronic medical illnesses.
CLINICAL PEARLS
The treatment that was successful for prior episodes of major
depression has a higher likelihood of achieving remission in future
episodes.
SSRIs & SNRIs, are all first-line treatment options for major depressive
disorder.
WATCH THESE VIDEOS:
DSM Major Depressive Disorder
https://www.youtube.com/watch?v=WyEhU5p-ud0

Clinical depression - major, post-partum, atypical, melancholic,

persistent
https://www.youtube.com/watch?v=QhukM33VLgo

Major Depressive Disorder | DSM-5 Diagnosis, Symptoms and

Treatment
https://www.youtube.com/watch?v=2dSQV6ZMbl0
REFERENCE
1. Kaplan & Sadock’s Synopsis of Psychiatry 11 th Edition
2. DSM Major Depressive Disorder
https://www.youtube.com/watch?v=WyEhU5p-ud0
3. Clinical depression - major, post-partum, atypical, melancholic,
persistent
https://www.youtube.com/watch?v=QhukM33VLgo
4. Major Depressive Disorder | DSM-5 Diagnosis, Symptoms and
Treatment
https://www.youtube.com/watch?v=2dSQV6ZMbl0
THANK YOU!