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15
Mood Disorders

Mood is defined as a pervasive and sustained feeling that is content and cognitive, speech, and social functioning. Unfortu-
experienced internally and that, in the extreme, can markedly nately, many people with depressive disorders go untreated be-
influence all aspects of a person’s behavior and his or her per- cause their symptoms are minimized or misinterpreted. People
ception of the world. Affect is the external expression of mood. with bipolar disorders are more often treated because their symp-
Mood disorders, formally known as affective disorders, include toms more frequently are bizarre or disruptive enough to bring
a group of psychological disorders that are mainly characterized them to medical and psychiatric attention.
by pathological moods and related vegetative and psychomotor Mood disorders are caused by a complex interplay of bio-
disturbances. The term mood disorder is preferred over affec- logical and psychological factors. Biologic theories involve the
tive disorder because it refers not only to the external (affective) role of the biogenic amines, particularly dysfunction in the nore-
expression of the present emotional state but also to sustained pinephrine, serotonin, dopamine, and GABA (γ -aminobutyric
emotional states. Mood disorders are syndromes (not diseases) acid) neurotransmitter systems. Most antidepressant medications
that consist of signs and symptoms that present a deviation from involve complex manipulations of these systems. There appears
a person’s normal functioning and are sustained over a period of to be dysregulation as well in the adrenal, thyroid, and growth
weeks to months. These signs and symptoms tend to recur, often hormone axes, all of which have been implicated in the etiol-
in periodic or cyclical fashion. ogy of mood disorders. Abnormalities in the sleep cycle and in
The most common mood disorder is major depressive disor- regulation of circadian rhythms have also been studied.
der (unipolar depression). Major depressive disorder is charac- Genetics always play an important role in the etiology of
terized by one or more episodes of major depression without a mental disorders, but genetic input is especially relevant in mood
manic episode. Patients with both manic and depressive episodes disorders. Bipolar I disorder is one of the most genetically de-
or with manic episodes alone are diagnosed with bipolar disor- termined disorders in psychiatry. However, as with any mental
der. Dysthymia and cyclothymia are less severe forms of major disorder, psychosocial factors play a crucial role in the devel-
depression and bipolar disorder, respectively. Hypomania is an opment, presentation, course, and prognosis of mood disorders.
episode of manic symptoms but does not meet the criteria for a Issues of real and symbolic loss, family relationships and dynam-
manic episode. ics, environmental stress, and unconscious conflicts all strongly
Mood disorders can sometimes be difficult to diagnose, given contribute to and determine mood symptoms. Some clinicians
the subjective nature of the symptoms. All people have nor- believe that these factors are particularly important in the first
mal periods of feeling either blue or elated, and most of these episodes of mood disorders, but in one form or another, they play
obviously are not diagnosable as disorders. A mood disorder a role in all episodes.
is characterized by the intensity, duration, and severity of the Students should study the questions and answers below for a
symptoms. Symptoms interfere with normal thought process and useful review of these disorders.

HELPFUL HINTS

Students should know the following terms that relate to mood disorders.

adrenal axis cognitive theories GH melancholic features

▲ ▲

▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲

anxiety-blissfulness cyclothymic disorder 5-HT melatonin

psychosis depression rating scales hypomania mild depressive disorder
atypical features depressive equivalent kindling mixed episode
▲ ▲ ▲ ▲ ▲ ▲

biogenic amines double depression learned helplessness mood-congruent and

bipolar I disorder dysthymia LH, FSH -incongruent
bipolar II disorder ECT lithium psychotic fear
carbamazepine euthymic major depressive neurological, medical,
▲

cognitive, behavioral, folieà double forme disorder and pharmacological

family, and psycho- folie circulaire mania causes of mood
▲ ▲

analytic therapies GABA MAOIs disorders

142
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15. Mood Disorders 143

norepinephrine premorbid factors seasonal pattern TSH, TRH

▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲

▲ ▲ ▲
phototherapy pseudodementia SSRI vegetative functions
postpartum onset rapid cycling suicide Zeitgeber
premenstrual dysphoric REM latency, density T3
disorder RFLP thymoleptics

QUESTIONS E. Thyroid function tests, complete blood count, preg-

nancy test
Directions
Each of the questions or incomplete statements below is followed 15.5. Which of the following statements regarding mood dis-
by five suggested responses or completions. Select the one that orders is false?
is best in each case. A. One of four patients with an acute depressive episode
will have recurrences throughout life.
15.1. Mild, nonpsychotic depression with predominant anxiety B. Approximately 15 percent of depressed patients even-
is called tually commit suicide.
A. Endogenomorphic depression C. Incidence of depression in younger age groups is in-
B. Bipolar disorder creasing.
C. Chronic depression D. Manic forms of mood disorders predominate in
D. Dysthymia men.
E. Anxiety disorder E. Depressive disorders are more common in women.

15.2. The most consistent computer tomography (CT) and 15.6. All of the following are vegetative disturbances of de-
magnetic resonance imaging (MRI) abnormality ob- pression except
served in depressive disorders is A. Hypersexuality
A. cortical atrophy B. Anorexia
B. sulcal widening C. Hypersomnia
C. ventricular enlargement D. Insomnia
D. increased frequency of hyperintensities in subcortical E. Circadian dysregulation
regions
E. none of the above 15.7. Serotonin
A. helps to regulate circadian rhythms
15.3. The following situations call for a break in doctor–patient B. is an important regulator of sleep, appetite, and libido
confidentiality except C. stores are increased by transient stress and depleted
A. A patient with a delusional disorder thinks his boss is by chronic stress
out to get him and threatens to kill her. D. permits or facilitates goal-directed motor and con-
B. A patient with major depressive disorder who is sex- summatory behavior in conjunction with nore-
ually promiscuous contracts syphilis. pinephrine and dopamine
C. A patient with bipolar I disorder admits he is homo- E. all of the above
sexual.
15.8. Which graph in Figure 15.1 depicts the pattern with the
D. A patient with conduct disorder thrives on the sexual
best future prognosis?
abuse of young children.
E. A patient with schizoaffective disorder hallucinates A. A
that he can fly. B. B
C. C
15.4. A 27-year-old patient has been diagnosed with bipo- D. D
lar disorder. Before starting this patient on lithium for E. None of the above
mood stabilization, which of the following laboratory
tests should be obtained? 15.9. Which of the graphs in Figure 15.1 depicts the prototyp-
ical course of double depression?
A. Thyroid function tests, creatinine, pregnancy test
B. Thyroid function tests, creatinine, liver function tests A. A
C. Thyroid function tests, creatinine, complete blood B. B
count C. C
D. Thyroid function tests, liver function tests, pregnancy D. D
test E. None of the above
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144 15. Mood Disorders

15.14. The defense mechanism most commonly used in depres-

sion is
A. undoing
B. sublimation
C. projection
D. introjection
E. altruism

15.15. Which of the following is not part of the text revision

of the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR) criteria for
diagnosing atypical depression?
A. Hypersomnia
B. Leaden paralysis
C. Shortening of REM latency
FIGURE 15.1 D. Mood reactivity
E. Significant weight gain

15.16. l-Tryptophan
15.10. Double depression is characterized by
A. has been used as an adjuvant to both antidepressants
A. two family members with major depressive disorder and lithium
concurrently B. has not been associated with any serious side effects
B. recurrent major depressive disorder with current C. is the amino acid precursor to dopamine
symptoms twice as disabling as usual D. has been used as a stimulant
C. two episodes of major depressive disorder per month E. all of the above
consistently
D. superimposed bipolar II disorder and atypical depres- 15.17. Which of the following is not an indicator of a good
sion prognosis for major depressive disorder?
E. recurrent major depressive disorder superimposed
A. Stable family functioning
with dysthymic disorder
B. No more than one previous hospitalization
C. A history of more than one previous depressive
15.11. Depression and mania share which of the following
episode
symptoms?
D. Advanced age of onset
A. Psychomotor acceleration E. The absence of psychotic symptoms
B. Low-self esteem
C. Grandiosity 15.18. Reactive depression can best be compared to
D. Anger A. Adjustment disorder
E. Pessimism B. Atypical depression
C. Conduct disorder
15.12. The person least likely to develop major depressive dis- D. Oppositional defiant disorder
order in his or her lifetime is E. Schizoaffective disorder
A. a 60-year-old man with pancreatic cancer
B. a 19-year-old woman who was raped 3 weeks ago 15.19. Which of the following statements regarding rapid
C. a 12-year-old girl mourning the death of her mother cycling bipolar disorder is true?
D. a 10-year-old boy diagnosed with dysthymia A. Alcohol, stimulants, and caffeine use are risk factors.
E. an identical twin of a patient with major depressive B. It is defined as at least four episodes per month.
disorder who committed suicide C. Hospitalization of these patients is rare.
D. It is more common in men than women.
15.13. A hypomanic episode differs from a manic episode in E. It often responds to tricyclic antidepressants.
that a hypomanic episode
15.20. All of the following are common causes of misdiagnosis
A. lasts at least 1 week
of mood disorder as schizophrenia except
B. lacks psychotic features
C. is severe A. reliance on the longitudinal rather than cross-
D. causes greater social impairment sectional picture
E. all of the above B. flight of ideas perceived as loose associations
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15. Mood Disorders 145

C. ascribing irritable mood to paranoid delusions 15.27. In the differential diagnosis, the diagnosis of schizoaf-
D. mistaking depressive depersonalization for schizo- fective disorder should be restricted to
phrenic emotional blunting
A. mixed episodes of bipolar disorder
E. incomplete interepisodic recovery equated with
B. affective psychosis with concurrent brain disease
schizophrenic defect
C. full affective and schizophrenic symptoms simulta-
neously
15.21. All of the following statements regarding cyclothymic D. affective psychosis superimposed on mental retarda-
disorder are true except tion
A. Symptoms must be present for at least 2 years. E. a contagious expansive and elated affect
B. It occurs at the same rate in men and women.
C. Symptoms may satisfy criteria for major depression. 15.28. Drugs that may precipitate mania include all of the
D. It consists of hypomania alternating with depressed following except
mood.
A. Bromocriptine
E. Its lifetime prevalence rate is about 0.4 to 1 percent.
B. Disulfiram
C. Isoniazid
15.22. Dysthymic disorder differs from major depressive disor- D. Propranolol
der because in dysthymic disorder, E. All of the above
A. depression is episodic
B. the symptoms outnumber the signs 15.29. Which of the following antidepressants would not be
C. the onset is usually late in life the best choice for a patient with a history of suicidal
D. manic episodes are common ideation?
E. has a high-grade chronicity
A. Bupropion (Wellbutrin)
B. A monoamine oxidase inhibitor
15.23. Psychomotor retardation is characterized by all of the C. A selective serotonin reuptake inhibitor
following except D. A tricyclic antidepressant
A. indecisiveness E. Venlafaxine (Effexor)
B. paucity of spontaneous movements
C. poor concentration 15.30. Which of the following statements regarding electrocon-
D. reduced speech amplitude and flow vulsive therapy (ECT) is false?
E. restlessness
A. ECT should be used in cases of psychotic depression
only.
15.24. Features of anhedonia may include all of the following B. Bilateral ECT is somewhat more effective than uni-
except lateral ECT.
A. derealization C. Retrograde memory impairment is a common side
B. difficulty describing or being aware of emotions effect.
C. inability to experience normal emotions D. ECT is often used for refractory mood disorders.
D. loss of pleasure E. Eight to 12 treatments are usually needed for symp-
E. withdrawal from interests tomatic remission.

15.25. The highest suicide rates are in which of the following 15.31. Mr. M is an 87-year-old man who, 6 weeks after a coro-
age groups? nary artery bypass graft that was complicated by pneumo-
nia and renal insufficiency, was admitted to an inpatient
A. Younger than age 15 years
rehabilitation service for management of physical de-
B. 15 to 24 year olds
conditioning. A psychiatrist was consulted 10 days after
C. 25 to 44 year olds
admission to rule out depression in the context of persis-
D. 45 to 64 year olds
tent low appetite and energy associated with suboptimal
E. Older than age 65 years
participation in rehabilitation. Mr. M reported no prior
psychiatric history. He had worked as a chemist until
15.26. Which of the following is the best predictor of the likeli-
retirement nearly 2 decades earlier. Laboratory exami-
hood of attempting suicide in the future?
nation revealed a low hematocrit of 21 and moderately
A. Alcohol abuse elevated blood urea nitrogen of 65. On interview, Mr.
B. Gender M demonstrated psychomotor slowing and bland affect.
C. Prior suicide attempt He denied depression, hopelessness, worthlessness, and
D. Recent divorce suicidal ideation. He expressed a desire to recover from
E. Unemployment his debilitated state but acknowledged uncertainty that he
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146 15. Mood Disorders

was capable of doing so. He also complained of extreme and loss of interest in previously enjoyed activities. Al-
weakness. He stated, “I just don’t seem to have an ap- though she never attempted suicide, she acknowledges
petite anymore.” Cognition largely was intact; there was that she thought she would probably jump off a local
mild short-term memory deficit. bridge if she ever had the chance. She denies any history
The most likely diagnosis in this patient is: of excessively elevated moods. You decide to start her on
antidepressant therapy. Two weeks later, this patient is at
A. Anxiety disorder with depressed mood
greatest risk for
B. Delirium
C. Dementia A. extrapyramidal symptoms
D. Major depressive disorder B. hypomanic episode
E. Mood disorder secondary to a general medical con- C. manic episode
dition D. medication noncompliance
E. suicide completion
15.32. A 19-year-old single woman presented with the chief
complaint that “all men are bastards.” Since her early 15.34. A 57-year-old woman presents to you after being diag-
teens, with the onset of her menses, she had complained nosed with major depressive disorder. She has been de-
of extreme variability in her moods on a nearly daily pressed ever since the death of her husband 2 years earlier.
basis; irritability with hostile outbursts was her main af- She has been taking the same antidepressant since her di-
fect, although more protracted hypersomnic depressions agnosis 1 year ago, with no relief of her symptoms. She
with multiple overdoses and wrist slashings had led to states that she would like your help in ending her life.
at least three hospitalizations. She also had migrainous The best option for your next step is:
headaches that, according to her mother, had motivated A. respect the patient’s wishes because she is of sound
at least one of those overdoses. Despite her tempestu- mind
ous and suicidal moods that led to these hospitalizations, B. seek to more adequately treat her depression
she complained of “inner emptiness and a bottomless C. seek family members to make a more informed deci-
void.” She had used heroin, alcohol, and stimulants to sion
overcome this troubling symptom. She said that she was D. contact the hospital ethics committee
mentally disturbed because of a series of stepfathers who E. obtain information from the state regarding
had all forced “oral rape” on her when she was between physician-assisted suicide laws
11 and 15 years of age. She subsequently became sex-
ually involved with any man that she met in bars, no
15.35. Ms. S, a 24-year-old woman, is brought for a psychiatric
longer knowing whether she was a “prostitute” or a “nice
consultation by her mother who complains of bizarre be-
little girl.” On two occasions, she had inflicted cigarette
havior. One month ago, Ms. S was fired from her job at
burns inside her vagina “to feel something.” She had also
a local bookstore because of frequently arriving late and
engaged in a “brief lesbian relationship” that ultimately
not performing her duties adequately. She states that she
left her “emptier” and guilt ridden; nonetheless, she now
fell in love with another employee and tried to get his at-
believed that she should burn in hell because she could
tention and spend time with him even though he seemed
not get rid of “obsessing” about the excitement of mutual
uninterested. Over the past 3 months, she increased her
cunnilingus with her much older female partner. The pa-
use of alcohol and marijuana to three beers and two to
tient was given phenelzine (Nardil), eventually increased
three joints per day. Her mother reports a 2-week history
to 75 mg per day, at which point the mother described
of increased energy, eating little, talking a great deal,
her as “the sweet daughter she was before age 13.” At
and interrupting others frequently. A week ago, Ms. S
her next premenstrual phase, the patient developed in-
reported that her former work colleagues were plotting
somnia, ran away from home at night, started “dancing
against her and attempting to control her by broadcasting
like a go-go girl, met an incredibly handsome man” of
thoughts into her brain. She did not sleep the previous 2
45 years of age (a pornography shop owner), and had a
nights. Ms. S has no significant psychiatric or medical
clandestine marriage to him.
history. She takes no medications.
Other than a mood disorder, this patient also shows
Physical examination reveals a blood pressure of
signs of
135/75 mm Hg, heart rate of 84 beats/min, and temper-
A. an anxiety disorder ature of 37◦ C. Her conjunctivae are pink, and her pupils
B. schizophrenia are equal, 3 mm, and reactive to light. Deep tendon re-
C. borderline personality disorder flexes are normal throughout. Urine toxicology reveals
D. schizoaffective disorder the presence of cannabinoids. On mental status testing,
E. none of the above her mood is euphoric, her speech is pressured, and she is
emotionally labile and irritable. Her thinking is illogical
15.33. A 35-year-old woman has just been diagnosed with major and disorganized. She denies hallucinations. She is alert
depressive disorder. For the past 8 months, she has had and oriented to person, place, and time. Immediate recall
a depressed mood, decreased energy and concentration, and recent and remote memory are intact. Throughout the
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15. Mood Disorders 147

interview, she is preoccupied by thoughts of the coworker 15.39. A 64-year-old woman with an extensive smoking history
with whom she has fallen in love. has recently been diagnosed with small cell lung cancer.
Ms. S is admitted to a psychiatric unit, and treatment is She develops a depressed mood, decreased interests, and
initiated with haloperidol, 10 mg/day, which is increased difficulty concentrating soon thereafter because she re-
to 20 mg/day on day 5 because of continued agitation. ports she cannot stop thinking about how worthless her
On day 6, she becomes withdrawn and uncommunica- life has been. She eats incessantly and has gained 10 lb in
tive. She is diffusely rigid with a temperature of 39◦ C. the last 5 weeks; she also reports increased sleep. You de-
Her white blood count is 14,300 and her creatinine phos- cide to prescribe phenelzine for her symptoms of atypical
phokinase is 2,100. Several blood cultures are negative. depression. Which of the following is contraindicated in
Which of the following is the most likely diagnosis at those patients taking phenelzine?
the time of admission?
A. Valproic acid
A. Bipolar disorder B. Trazodone
B. Delusional disorder, erotomanic type C. Lithium
C. Marijuana-induced psychotic disorder D. Fluoxetine
D. Schizoaffective disorder, bipolar type E. Clomipramine
E. Schizophrenia
15.40. A 28-year-old woman presents to a clinic with a chief
15.36. Which of the following is the most likely explanation for complaint of fatigue. She states that this feeling of “being
her behavior on day 6? tired” has persisted for the past 4 years. She has lost 12 lb
over the past 2 years and admits to overeating. The patient
A. Anticholinergic delirium
states that she sleeps at least 11 hours per night. She
B. Neuroleptic malignant syndrome
denies suicidal ideation but complains about not being
C. Marijuana-induced delirium
able to concentrate. What is the likely diagnosis?
D. Occult infection
E. Worsening psychosis A. Generalized anxiety disorder
B. Dysthymia
15.37. Which of the following pharmacologic approaches is C. Major depressive disorder
most appropriate on day 6? D. Substance abuse
E. None of the above
A. Increase dose of haloperidol.
B. Stop haloperidol and add risperidone.
C. Stop haloperidol, add bromocriptine, and seek medi-
cal consultation. Directions
D. Continue the same dose of haloperidol and add Each set of lettered headings below is followed by a list of
risperidone. phrases or statements. For each numbered phrase or statement,
E. Continue the same dose of haloperidol and add ben- select:
ztropine.
A. if the item is associated with A only
B. if the item is associated with B only
15.38. A suicidal patient with chronic depressive disorder
C. if the item is associated with both A and B
presents to your office very frustrated and in tears. He
D. if the item is associated with neither A nor B
tells you he cannot stop thinking about ending his life
because he is so depressed. You ask him if he has a
Questions 15.41–15.45
plan, and he details where he could buy a handgun and
where he would go to shoot himself. You fear the patient A. Bereavement
will carry out this plan because he has not had adequate B. Depression
control of his symptoms since his last antidepressant
change 1 month ago. You discuss inpatient hospitaliza- 15.41. Is perceived as normal
tion for medication stabilization, but the patient refuses. 15.42. Active suicidal ideation is common
You’re next step in management of this patient would 15.43. Persons often experience guilt
best be: 15.44. Persons react to the environment
15.45. Delusions of worthlessness
A. Admit the patient to the hospital anyway.
B. Give the latest antidepressant more time to take
Questions 15.46–15.49
affect.
C. Change to another class of antidepressant. A. Clozapine
D. Try to persuade the patient to admit himself to the B. Imipramine
hospital.
E. Initiate psychotherapy to discuss the reasons behind 15.46. Cardiotoxic
the suicidal thoughts. 15.47. Causes weight gain
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148 15. Mood Disorders

15.48. Acts as an NE partial agonist for a manic episode require the presence of a distinct period of
15.49. Teratogenic abnormal mood lasting at least 1 week. Typically beginning in
the teenage years, the 20s, or the 30s, the first episode of bipolar
Questions 15.50–15.53 I disorder could be manic, depressive, or mixed. On average,
manic episodes predominate in youth, and depressive episodes
A. Unipolar depression predominate in later years. Although the overall sex ratio is 1:1,
B. Bipolar II depression men, on average, undergo more manic episodes, and women
experience more mixed and depressive episodes.
15.50. Never any history of acute mania Endogenomorphic depression is a term used to describe in-
15.51. Typically has psychotic features present hibition of the pleasure or reward system to such an extent that
15.52. Symptoms of hypomania are present the patient no longer has the capacity for enjoyment. There may
or may not be an apparent environmental precipitant or stress. In
15.53. Can present with atypical features
most cases, patients show dramatic abnormalities in psychomo-
tor activity and somatic rhythms (i.e., sleep, appetite, libido).
Such patients may also be delusional. The symptom profile in
Directions
chronic depression usually displays low-grade intensity. Full
Each group of questions below consists of lettered headings fol- criteria for a major depressive episode must have been met con-
lowed by a list of numbered phrases or statements. For each tinuously for at least the past 2 years. Instead of the customary
numbered phrase or statement, select the one lettered heading remission within 1 year, patients are ill for years.
Anxiety disorders are disorders in which anxiety is the most
that is most associated with it. Each lettered heading may be
prominent disturbance or in which patients experience anxiety if
selected once, more than once, or not at all.
they resist giving in to their symptoms. They are among the most
prevalent mental disorders in the general population. Women are
Questions 15.54–15.59 affected nearly twice as frequently as men. They are associated
A. Dysthymic disorder with significant morbidity and often are chronic and resistant
to treatment. They include (1) panic disorder with or without
B. Neurasthenia
agoraphobia, (2) agoraphobia with or without panic disorder,
C. Bipolar I disorder
(3) specific phobia, (4) social phobia, (5) obsessive-compulsive
D. Cyclothymic disorder disorder (OCD), (6) posttraumatic stress disorder (PTSD), (7)
E. Bipolar II disorder acute stress disorder, and (8) generalized anxiety disorder.
F. Hypomania
15.2. The answer is D
15.54. Is diagnosed more in China than the rest of the world
Computed tomography (CT) and magnetic resonance imaging
15.55. Subsyndromal depression and hypomania
(MRI) scans provide sensitive, noninvasive methods to assess the
15.56. Rarely progresses to manic psychosis
brain, including cortical and subcortical tracts, as well as white
15.57. Insidious onset of depression dating back to child-
matter lesions. The most consistent abnormality observed in the
hood
depressive disorders is increased frequency of abnormal hyper-
15.58. Manic-like symptoms do not meet full manic syndrome
intensities in subcortical regions, especially the periventricular
criteria
area, basal ganglia, and thalamus (Figure 15.2). More common
15.59. Includes a full set of mania symptoms
in bipolar I disorder and among the elderly, these hyperinten-
sities appear to reflect the deleterious neurodegenerative effects
ANSWERS of recurrent mood episodes. Ventricular enlargement, cortical
atrophy, and sulcal widening have also been reported in patients
15.1. The answer is D with mood disorders compared with normal control subjects.
Dysthymia is defined as a reactive nonpsychotic depression of In addition to age and illness duration, structural abnormali-
mild to moderate intensity with predominant anxiety. It is char- ties are associated with increased illness severity, bipolar status,
acterized by the presence of a depressed mood that lasts most and increased cortisol levels. Some depressed patients also may
of the day and is present almost continuously. Patients complain have reduced caudate nucleus volumes, suggesting a defect in
that they have always been depressed. It is not a sequela to a the mesocorticolimbic system. Cerebrovascular factors often in-
major depressive episode as with chronic depression. There are volve subcortical frontal and basal ganglia structures and appear
associated feelings of inadequacy, guilt, irritability, and anger; particularly relevant to late-life depression.
withdrawal from society; loss of interest; and inactivity and lack
of productivity. Most cases are of early onset, beginning in child-
15.3. The answer is C
hood or adolescence and certainly by the time patients reach their
Confidentiality refers to the therapist’s responsibility to not re-
20s. The overall prognosis for dysthymia is good with treatment;
lease information learned in the course of treatment to third par-
however, 25 percent of dysthymic patients never attain complete
ties. Confidentiality is an essential ingredient of psychiatric care
recovery.
because it is a prerequisite for patients to be willing to speak
Bipolar disorder is defined as a mood disorder in which the freely to therapists. People would be less likely to go for help
patient exhibits both manic and depressive episodes. The criteria and would tend to withhold crucial information if confidentiality
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15. Mood Disorders 149

are more common in women, more men than women die of sui-
cide because of more lethal methods chosen.

15.6. The answer is A

Hypersexuality is cardinal sign of mania and usually indicates
a mixed episode of bipolar disorder in depressed patients. The
small subgroup of depressed persons with increased sexual drive
usually exhibit other atypical features; hence, increased sex-
ual drive is considered the fifth reverse vegetative sign (after
even worsening mood, initial insomnia, hypersomnia, and weight
gain).
The biological concomitants of melancholia include pro-
found reductions in appetite (i.e., anorexia or weight loss), sleep
(i.e., insomnia), and sexual functioning, as well as alterations
in other circadian rhythms, especially worsening of mood and
psychomotor performance. An equally prominent subgroup of
depressed persons exhibits a reversal of the vegetative and circa-
dian functions, with increases in appetite and sleep—and some-
times in sexual functioning—and an evening worsening of mood;
in this atypical pattern, patients characteristically exhibit mood
reactivity and sensitivity to rejection.

15.7. The answer is E (all)

FIGURE 15.2 Serotoninergic neurons project from the brainstem dorsal raphe
Magnetic resonance imaging scan of a patient with late-onset ma- nuclei to the cerebral cortex, hypothalamus, thalamus, basal gan-
jor depressive disorder illustrating extensive periventricular hyper- glia, septum, and hippocampus. Serotonin (5-HT) pathways have
intensities associated with diffuse cerebrovascular disease.
both inhibitory and facilitatory functions in the brain. For exam-
ple, much evidence suggests that 5-HT is an important regulator
of sleep, appetite, and libido. Serotonergic neurons projecting to
was not assured. There is no reason to break doctor–patient con- the suprachiasmatic nucleus of the hypothalamus help to regu-
fidentiality in situations involving a patient’s sexual preference late circadian rhythms (e.g., sleep–wake cycles, body temper-
(e.g., homosexuality) unless there is some threat to the patient’s ature, and hypothalamic-pituitary-adrenocortical axis function).
safety. Confidentiality must give way to the responsibility to Serotonin also permits or facilitates goal-directed motor and
protect others when a patient makes a credible threat to harm consummatory behaviors in conjunction with norepinephrine
someone (e.g, a patient threatening to kill his boss) or acts in a and dopamine. Moreover, serotonin inhibits aggressive behavior
way that could harm him- or herself (e.g., a patient who thinks he across mammalian and reptilian species.
can fly). Reportable diseases (e.g., syphilis) must also be reported There is some evidence that serotonin neurotransmission is
to the proper authorities despite the bond of patient confidential- partly under genetic control. Nevertheless, whereas acute stress
ity. Any suspicion of child abuse must also be reported to the increases serotonin release transiently, chronic stress eventually
authorities. depletes serotonin stores. Chronic stress may also increase syn-
thesis of 5-HT1A autoreceptors in the dorsal raphe nucleus, which
15.4. The answer is A further decrease serotonin transmission. Elevated glucocorticoid
Lithium (Eskalith), used for mood stabilization in patients with levels tend to enhance serotonergic functioning and thus may
bipolar disorder, is known for its low margin of safety, mak- have significant compensatory effects on chronic stress.
ing frequent monitoring necessary. Common side effects include
gastrointestinal disturbances, nephrotoxicity, hypothyroidism, 15.8. The answer is A
tremors, leukocytosis, acne, psoriasis flares, hair loss, and edema. The course of major depressive disorder, recurrent, with no an-
Because of these effects, it is important to get thyroid function tecedent dysthymic disorder and a period of full remission be-
tests and renal function tests (creatinine) before starting any pa- tween the episodes predicts the best future prognosis. This is
tient on this medication. Lithium is also teratogenic and has been depicted in graph A.
associated with cardiac defects, so a pregnancy test is necessary
before lithium therapy. 15.9. The answer is D
Graph D depicts double depression, which is character-
15.5. The answer is A ized by recurrent major depressive disorder and antecedent
Three (not one) out of four patients with acute depression will dysthymic disorder with no period of full remission in between
experience recurrences, with varying degrees of residual symp- the two most recent episodes. Graph A is the course of ma-
toms between episodes. Of note, although depressive disorders jor depressive disorder, recurrent, with no antecedent dysthymic
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150 15. Mood Disorders

disorder and full remission between episodes. Graph B is the the patient; the experience is often pleasant, and the subject may
course of major depressive disorder, recurrent, with no an- be unaware of it or may tend to deny it. Both mania and hypo-
tecedent dysthymic disorder but with prominent symptoms per- mania are associated with inflated self-esteem, decreased need
sisting between episodes (partial remission is attained). Graph for sleep, distractibility, great physical and mental activity, and
C is the rare pattern major depressive disorder, recurrent, overinvolvement in pleasurable behavior.
with antecedent dysthymic disorder but with full interepisodic
recovery. 15.14. The answer is D
In Sigmund Freud’s structural theory, introjection of the lost
15.10. The answer is E object into the ego leads to the typical depressive symptoms of
Double depression is characterized by recurrent major depres- a lack of energy available to the ego. The superego, which is
sive disorder with antecedent dysthymic disorder and no period unable to retaliate against the lost object externally, flails out at
of full remission between the two most recent episodes. This the psychic representation of the lost object, now internalized
pattern is seen in approximately 20 to 25 percent of the persons in the ego as an introject. When the ego overcomes or merges
with major depressive disorder. with the superego, energy previously bound in the depressive
symptoms is released, and mania supervenes with the typical
15.11. The answer is D symptoms of excess.
Despite their contrasts, depression and mania share such symp- Projection is the unconscious defense mechanism in which a
toms as irritability, anger, insomnia, and agitation. Mania is person attributes to another person those generally unconscious
defined as a mood disorder characterized by elation, agitation, ideas, thoughts, feelings, and impulses that are personally unde-
hyperactivity, and hyperexcitability. The clinical features of ma- sirable or unacceptable. Sublimation is an unconscious defense
nia are generally the opposite of those of depression. Depres- mechanism in which the energy associated with unacceptable
sion is defined as a mental state characterized by feelings of impulses or drives is diverted into personally and socially ac-
sadness, loneliness, despair, low self-esteem, and self-reproach. ceptable channels.
Depression is commonly associated with cases of lowered mood, Undoing is an unconscious defense mechanism by which a
thinking, self-esteem, and activity. Mania, on the other hand, person symbolically acts out to reverse something unacceptable
is commonly associated with elevated mood, a rush of ideas, that has already been done or against which the ego must defend
psychomotor acceleration, and grandiosity. An excess of the itself. Altruism is regard for and dedication to the welfare of
shared symptoms of escalating intensity suggests a mixed phase others.
of mixed episode of mania and depression occurring simultane-
ously, commonly called bipolar I disorder. 15.15. The answer is C
Nearly two-thirds of patients with depressive disorders, whether
15.12. The answer is B experiencing typical or atypical symptoms, exhibit marked short-
The 19-year-old rape victim is more likely to develop a variation ening of rapid eye movement (REM) latency, the period from
of posttraumatic stress disorder, which is highest among vic- sleep onset to the first REM period. This fact is not specific to
tims of rape, military combat veterans, and survivors of torture. atypical depression as are the other choices listed. Mood reactiv-
Childhood onset of dysthymia similarly presages extremely high ity is characterized by mood elevation in response to something
rates of depression and bipolar disorder in adulthood. Monozy- good happening. Leaden paralysis (a heavy, leaden feelings in
gotic twins have been shown to have a two- to fourfold in- one’s arms and legs), hypersomnia, increased appetite, and sig-
crease in concordance rates for mood disorders over dizygotic nificant weight gain are also among the features of atypical de-
twins, compelling data for the role of genetic factors in mood pression.
disorders.
Parental loss before adolescence is also a well-documented 15.16. The answer is A
risk factor for adult-onset depression. Medical problems of many l-Tryptophan, the amino acid precursor to serotonin, has been
types, such as cancer of the pancreas, multiple sclerosis, and used as an adjuvant to both antidepressants and lithium in the
space-occupying lesions of the brain, can produce depression. treatment of bipolar I disorder. Tyrosine is the amino acid precur-
sor to dopamine. l-Tryptophan has also been used alone as a hyp-
15.13. The answer is B notic and an antidepressant. l-Tryptophan and l-tryptophan–
A hypomanic episode lacks psychotic features, which can some- containing products have been recalled in the United States
times be associated with mania. A manic episode is a distinct because l-tryptophan has been associated with eosinophilia-
period of an abnormally and persistent elevated, expansive, or myalgia syndrome. The symptoms include fatigue, myalgia,
irritable mood lasting for at least 1 week or less if a patient must shortness of breath, rashes, and swelling of the extremities. Con-
be hospitalized. A hypomanic episode lasts at least 4 days and gestive heart failure and death can also occur.
is similar to a manic episode except that it is not sufficiently se- Although several studies have shown that l-tryptophan is an
vere to cause impairment in social or occupational functioning. efficacious adjuvant in the treatment of mood disorders, it should
Patients often believe that they benefit from the energy and con- not be used for any purpose until the problem with eosinophilia-
fidence of hypomania. Diagnostically, history of hypomania is myalgia syndrome is resolved. Current evidence points to a con-
preferably obtained from significant others who have observed taminant in the manufacturing process.
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15. Mood Disorders 151

15.17. The answer is C Table 15.1

A history of more than one previous depressive episode is not Common Causes of Misdiagnosis of Mood Disorder
an indicator of a good prognosis for major depressive disorder. as Schizophrenia
Rather, it increases the possibility for a poor prognosis. Other
indicators of a poor prognosis include coexisting dysthymic dis- Reliance on cross-sectional rather than longitudinal picture
order, abuse of alcohol and other substances, and anxiety disor- Incomplete interepisodic recovery equated with schizophrenic
defect
der symptoms. Men are more likely than women to experience Equation of bizarreness with schizophrenic thought disorder
a chronically impaired course. Ascribing irritable and cantankerous mood to paranoid delusions
Mild episodes, the absence of psychotic symptoms, and a Mistaking depressive anhedonia and depersonalization for
short hospital stay are good prognostic indicators. Psychosocial schizophrenic emotional blunting
indicators of a good course include a history of solid friend- Flight of ideas perceived as loose associations
Lack of familiarity with the phenomenological approach in
ships during adolescence, stable family functioning, and gener- assessing affective delusions and hallucinations
ally sound social functioning for the 5 years preceding the illness. Heavy weight given to incidental schneiderian symptoms
Additional good prognostic signs are the absence of a comorbid
psychiatric disorder and of a personality disorder, no more than Adapted from Akiskal HS, Puzantian VR. Psychotic forms of depression and
mania. Psychiatr Clin North Am. 1979;2:419
one previous hospitalization for major depressive disorder, and
an advanced age of onset. display an expansive and elated affect, which is often conta-
gious. By contrast, a severely retarded bipolar depressive person,
15.18. The answer is A whose affect may superficially seem flat, almost never exhibits
Reactive depression is defined as depression that results from a major fragmentation of thought. The clinician should therefore
specific life event. It continues as long as the event is present, place greater emphasis on the pattern of symptoms than on in-
and it terminates with the reversal of the event (e.g., return of a dividual symptoms in the differential diagnosis of mood and
lover after a breakup). With interpersonal support, most people schizophrenic psychosis. Table 15.1 lists the most common pit-
can face life’s reversals, which explains why reactive depression falls in diagnosis.
tends to be self-limiting. Hence, adjustment disorder is the more
appropriate diagnosis for many cases of reactive depression. Op- 15.21. The answer is C
positional defiant disorder is a recurring pattern of negative, hos- Cyclothymia is characterized by at least 2 years of numerous
tile, disobedient, and defiant behavior in a child or adolescent, periods with hypomanic symptoms and numerous periods with
lasting for at least 6 months without serious violation of the basic depressive symptoms that do not meet criteria for a major de-
rights of others. Conduct disorder is a childhood behavioral con- pressive episode. This disorder apparently occurs at the same rate
dition involving a pattern of repetitive and persistent conduct that in both men and women, but women seek treatment more often
infringes on the basic rights of others or does not conform to es- than men. The lifetime prevalence rate of cyclothymic disorder
tablished societal norms or rules that are appropriate for a child of is 0.4 to 1 percent.
that age. Atypical depression is characterized by “reversed vege-
tative symptoms,” which include oversleeping, overeating, rejec- 15.22. The answer is B
tion sensitivity, and temporary brightening of mood in response The profile of dysthymic disorder overlaps with that of major
to positive events. Schizoaffective disorder is a disorder with depressive disorder but differs from it in that symptoms tend to
symptoms of both schizophrenia and manic-depressive disorder. outnumber signs (more subjective than objective depression).
This means that disturbances in appetite and libido are unchar-
15.19. The answer is A acteristic, and psychomotor agitation or retardation is not ob-
Among the factors favoring the occurrence of rapid cycling bipo- served. This all translates into a depression with attenuated symp-
lar disorder are alcohol, stimulant, and caffeine use. Other fac- tomatology. Subtle endogenous features are observed, however,
tors include female gender because this subtype is much more including inertia, lethargy, and anhedonia that are characteristi-
common in women than men. Most antidepressants readily in- cally worse in the morning.
duce excited episodes and thus aggravate the rapid cycling pat- Dysthymic disorder is distinguished from major depressive
tern. Rapid cycling is defined as the occurrence of at least four disorder by the fact that patients complain that they have always
episodes of depression and hypomania or mania per year (not been depressed. Most cases are of early onset beginning in child-
per month). Hospitalization of these patients is often frequent to hood or adolescence and certainly occurring by the time patients
stabilize medication and achieve compliance. reach their 20s. A late-onset subtype, which is much less preva-
lent and not well characterized clinically, has been identified
15.20. The answer is A among middle-aged and geriatric populations, largely through
Reliance on the cross-sectional rather than longitudinal picture epidemiological studies in the community. Diagnostic criteria
(not vice versa) may cause a misdiagnosis of mood disorder stipulate the presence of depressed mood most of the time for at
as schizophrenia. Cross-sectionally, young patients with bipo- least 2 years (not episodic) or 1 year for children or adolescents.
lar disorder might seem psychotic and disorganized and thus Patients should not have symptoms that are better accounted for
schizophrenic. Their thought processes are so rapid that they as major depressive disorder and should never have had a manic
may seem loose, but unlike patients with schizophrenia, they or hypomaniac episode. The DSM-IV-TR allows clinicians to
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152 15. Mood Disorders

specify whether the onset was early (before age 21 years) or late women make more suicidal gestures, but men are more likely to
(age 21 years or older). choose lethal methods and thus are more likely to successfully
Dysthymic disorder refers to a subaffective or subclinical de- commit suicide. Therefore, male gender is considered more a
pressive disorder with (1) low-grade (not high-grade) chronicity risk factor for suicide completion. Alcohol or substance abuse,
for at least 2 years; (2) insidious onset, with the origin often in unemployment, and recent divorce are all additional risk fac-
childhood or adolescence; and (3) a persistent or intermittent tors but are less significant than a history of previous suicide
course. attempts.

15.23. The answer is E 15.27. The answer is C

Features such as restlessness, agitation, and pressured speech The concept of schizoaffective (or cycloid) psychosis should
are characteristic of psychomotor agitation, not retardation. be restricted to recurrent psychoses, with full affective and
Psychomotor retardation, which is often present in depressed schizophrenic symptoms occurring nearly simultaneously during
patients, manifests as paucity of spontaneous movements, re- each episode. This diagnosis should not be considered for a mood
duced speech amplitude and flow, increased latency of responses, psychosis in which mood-incongruent psychotic features (e.g.,
indecisiveness, poor concentration and forgetfulness, and over- Schneiderian and Bleulerian symptoms) can be explained on the
whelming fatigue. Brain imaging research that has revealed sub- basis of one of the following: (1) affective psychosis superim-
cortical (extrapyramidal system) disturbances in mood disorders posed by mental retardation, giving rise to extremely hyperactive
tends to support the centrality of psychomotor dysfunction in and bizarre manic behavior; (2) affective psychosis complicated
these disorders. by concurrent brain disease, substance abuse, or substantial with-
drawal, known to give rise to numerous schneiderian symptoms;
15.24. The answer is B
or (3) mixed episodes of bipolar disorder (which are notorious
Anhedonia is one of the DSM IV-TR criteria for major depres-
for signs and symptoms of psychotic disorganization). Official
sion. Patients with severe depression and anhedonia may com-
diagnostic systems use the category of schizoaffective disorder
plain of being emotionally cut off from others and experience
broadly. Thus, patients with clear-cut manic episodes receive a
depersonalization in a world that seems strange to them (dereal-
schizoaffective diagnosis if delusions or hallucinations occur in
ization). Loss of pleasure and withdrawal from previously enjoy-
the interepisodic period in the absence of prominent affective
able activities is typical of anhedonia. The impact of the loss of
symptoms. Many psychotic symptoms in mood disorders are of-
emotional resonance can be so pervasive that patients may de-
ten explanatory, whereby the patient tries to make sense of the
nounce values and beliefs that had previously given meaning to
core experiences of the affective illness.
their lives (e.g., members of the clergy complain they no longer
believe in the Church and have lost God). The inability of a
15.28. The answer is D
person with depressive disorder to experience normal emotions
Propranolol (Inderal), a β-blocker, is an antihypertensive and
(commonly observed among young depressed patients) differs
may actually cause depressive symptoms. Many pharmacolog-
from a schizophrenic person’s flat affect in that the loss of emo-
ical agents, such as bromocriptine (Parlodel), isoniazid (Ny-
tions is itself experienced as painful; that is, the patient suffers
drazid), cimetidine (Tagamet), and disulfiram (Antabuse), may
immensely from the inability to experience emotions. Anhedo-
precipitate mania, as can antidepressant treatment or withdrawal.
nia does not typically include alexithymia, which is defined as a
person’s inability to describe or be aware of one’s emotions or
15.29. The answer is D
mood.
In considering antidepressant use in suicidal or impulsive pa-
15.25. The answer is E tients, caution should be taken in using medications that may
Suicide is almost twice as frequent in older adults as in the be lethal in overdose (e.g., tricyclic antidepressants [TCA]) or
general population. The suicide rate for white men older than that may exacerbate disinhibition or cognitive deficits (e.g., ben-
65 years of age is five times higher than that of the general zodiazepines). Therefore, it is not the best idea to prescribe
population. Aging reduces suicide attempts but increases their a TCA to this patient. Selective serotonin reuptake inhibitors
lethality. Depression is the most common psychiatric diagnosis (SSRIs) and monoamine oxidase inhibitors (MAOIs) are better
in elderly suicide victims, unlike younger adults, in whom sub- choices. Care should be taken to avoid precipitating a hyperten-
stance abuse alone or with comorbid mood disorders is the most sive crisis in patients taking MAOIs. Bupropion and venlafaxine
frequent diagnosis. Older patients with major medical illnesses are other antidepressants that can be used alone or in combination
or a recent loss should be evaluated for depressive symptomatol- with another medication.
ogy and suicidal ideation or plans, and aggressive treatment can
help prevent their acting on suicidal thoughts. Suicide rates are 15.30. The answer is A
rising most rapidly in young adults, but the greatest risk remains Electroconvulsive therapy (ECT) is effective in psychotic and
in those people older than the age of 65 years. nonpsychotic forms of depression. Usually, 8 to 12 ECT treat-
ments are required to achieve symptomatic remission, and this
15.26. The answer is C form of therapy has been shown to be effective even in patients
The strongest indicator of the likelihood of attempting suicide who are refractory to several different medications. Bilateral
is a history of previous suicide attempts. It has been shown that ECT is somewhat more effective than unilateral therapy, but
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15. Mood Disorders 153

bilateral ECT also appears to have more cognitive side effects, Table 15.2
such as retrograde memory loss. Overlap of Borderline Personality Disorder and
Mood Disorders
15.31. The answer is E
After an extended hospital course, many patients, like this one, Familial
demonstrate withdrawn behavior, anorexia, and fatigue, occa- High rates of mood disorder
Phenomenology
sionally associated with mild cognitive loss, that do not meet Dysthymic disorder
criteria for cognitive or mood disorder but are a direct prod- Cyclothymic disorder
uct of resolving medical illness and associated debilitation. The Bipolar II disorder
likelihood that a mood disorder is due to a general medical con- Mixed state
dition is increased if a temporal relationship exists between the Pharmacological response
Worsening on most antidepressants
onset, exacerbation, or remission of the medical condition and Stabilization on anticonvulsants
the mood disorder. Atypical features (e.g., unusual age of on- Prospective course
set, lack of family history, and lack of prior episodes of mood Major mood episodes
disorder) also raise the likelihood of a medical basis for mood Suicide
symptoms. Mild short-term memory deficits can be normal with Adapted from Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M.
aging and do not necessarily indicate that Mr. M has dementia. Borderline: An adjective in search of a noun. Clin Psychiatry. 1985;46:41.
He also demonstrated largely intact cognition, making delirium
an unlikely diagnosis. Patients with a diagnosis of anxiety disor- noncompliance is a possibility with any patient, it is not the best
der with depressed mood primarily exhibit symptoms of anxiety choice listed. This patient has nothing in her history to indicate
states, such as marked tension, phobias, and panic attacks, all bipolar disorder as a more appropriate diagnosis; therefore, there
of which predate any depressive symptoms. In addition, anxiety is no reason to believe manic or hypomanic episodes will be pre-
disorders rarely appear for the first time after 40 years of age. cipitated by antidepressant use. Extrapyramidal symptoms are
a consequence of typical antipsychotic use, not antidepressant
15.32. The answer is C use.
This case illustrates the intimate relationship among atypical de-
pression, borderline personality disorder, and bipolar II disorder. 15.34. The answer is B
These three conditions, listed as distinct nosological entities in Much political and theological heat has been generated in recent
the DSM-IV-TR, may nonetheless share an underlying psychobi- years by the debate on physician-assisted suicide. Many of the
ological or genetic diathesis. The complaint is often heard that patients requesting death are depressed and would be likely to re-
even when a mood disorder is diagnosed in a “borderline” pa- spond to psychotherapy, pharmacotherapy, or both. Frequently,
tient, response to antidepressants is disappointing. The problem they have been inadequately diagnosed or treated. Active depres-
is that affective disorders in these patients usually conform to sion can be considered a state of incompetence, making such pa-
bipolar II disorder—often complicated by ultrarapid cycling— tients unable to make informed decisions for themselves. Family
and many clinicians trained in an earlier era, including some with members or a living will should be consulted only in cases of
a biological orientation, may lack sufficient experience in the art medical emergencies in which decisions must be made imme-
of pharmacologically managing patients who markedly deviate diately. In this case, treating the patient’s depression is the best
from classic bipolar I disorder. Recently, lamotrigine has shown option. It is not necessary to involve the hospital ethics commit-
promise for such patients. tee in this decision. Currently, Oregon is the only state that has
Table 15.2 shows that the overlap between borderline per- passed enabling laws regarding physician-assisted suicide.
sonality and mood disorders is extensive, so giving a borderline
diagnosis to a person with mood disorder is redundant. Use of 15.35. The answer is A
personality disorder diagnoses may lead to a neglect of the mood The diagnosis of bipolar disorder best fits the history and symp-
disorder or, perhaps, half-hearted treatment of the mood disor- toms, but it is by no means certain. She presents with a 1-month
der; failure to respond would then be blamed on the patient’s history of impaired judgment and erratic behavior followed by
“self-defeating character” or “resistance to getting well,” thus increased energy, pressured speech, mood lability, and decreased
exculpating the clinician. need for sleep, all of which indicate a manic episode. The emer-
gence of paranoid delusions is also consistent with mania, and a
15.33. The answer is E single manic episode, with or without major depressive episodes,
When antidepressant medications first begin to work, patients qualifies for a diagnosis of bipolar disorder. That diagnosis can
tend to report an increase in energy levels before significant only be made, however, if it is believed that the symptoms are not
improvement in mood symptoms. For this reason, carrying out the result of a general medical condition or substance use. We
suicide plans is more of a risk during this period. Medication non- know that she has been using increased amounts of marijuana
compliance with effective psychopharmacological treatments and alcohol and that she is probably intoxicated with marijuana at
during both acute and maintenance therapy is a major cause the time of admission. Heavy marijuana use in some individuals
of morbidity among patients with schizophrenia and disorders can cause a psychotic state with paranoid delusions and halluci-
with poor insight, not among patients with depression. Although nations. There are some features, however, that are inconsistent
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154 15. Mood Disorders

with a purely marijuana-induced state, which more typically 15.39. The answer is D
presents with decreased talkativeness and long response latency MAOIs have been shown to be particularly effective in the treat-
than with the pressured speech seen here. In addition, increased ment of patients with atypical depression. Important side effects
energy and activity and decreased need for sleep are much more of MAOI therapy include hypertensive crisis and serotonin syn-
likely in bipolar disorder than in a marijuana psychosis. The drome. Hypertensive crisis can be precipitated when foods rich
delusional belief of her thoughts being controlled by an outside in tyramine (e.g., wine, cheese) are ingested by someone who is
force is strikingly similar to delusions of control that are so often taking an MAOI. Serotonin syndrome is caused by the interaction
seen in schizophrenia, but the prominent mood symptoms and of an MAOI with a SSRI, pseudoephedrine, or meperidine. Sero-
time course (1 month) preclude that diagnosis. The diagnosis of tonin syndrome is characterized by hyperthermia, muscle rigid-
schizoaffective disorder would require a 2-week period of psy- ity, and altered mental status. Therefore, fluoxetine, an SSRI, is
chotic symptoms without prominent mood symptoms, which is contraindicated in this patient.
not the case here. An erotomanic delusional belief is that the
patient is loved by another (often famous) person, not as is the 15.40. The answer is B
case here, which the patient herself is preoccupied with being in Given the chronological course and degree of severity of the pa-
love with someone else. tient’s symptoms, the most likely diagnosis is dysthymia. Dys-
thymia is diagnosed when a patient experiences depressed mood
15.36. The answer is B for most of the day for a minimum of 2 years plus at least two
The events of days 5 and 6 almost certainly represent the of the following: insomnia or hypersomnia, poor concentration,
emergence of a neuroleptic malignant syndrome, an idiosyn- low energy, change in appetite, or lack of self-worth. Unlike
cratic response to antipsychotics (especially high-potency, typ- dysthymia, in major depressive disorder, patients must have five
ical agents) characterized by fever, rigidity, and obtundation. or more symptoms for most of the day over 2 weeks. General-
The clinical diagnosis is confirmed, with the typical findings ized anxiety disorder is characterized by sleep disturbance, ir-
of leukocytosis and greatly increased creatinine phosphokinase ritability, inability to concentrate, uncontrollable worrying, and
(CPK). Anticholinergic delirium includes fever but not the rigid- fatigue. Substance abuse is a possible, although it is a less likely
ity or laboratory findings. In addition, patients with an anticholin- diagnosis given the duration of symptoms.
ergic delirium are more likely to be agitated than withdrawn.
Answers 15.41–15.45
15.37. The answer is C
Neuroleptic malignant syndrome (NMS) is a life-threatening 15.41. The answer is A
medical emergency. All medications must be stopped; switching
to an atypical agent such as risperidone will not help her. Ap- 15.42. The answer is B
propriate treatment includes life support, maintaining fluid and
electrolyte balance, and decreasing her fever. Bromocriptine is a
15.43. The answer is C
centrally acting dopamine agonist that presumably works by re-
versing the effects of the antipsychotic-caused dopamine block-
15.44. The answer is A
ade. The treatment of NMS commonly combines bromocrip-
tine with dantrolene, a peripheral muscle relaxant. Consultation
with the medical service is crucial because the treatment may be 15.45. The answer is B
complex. Bereaved persons exhibit many depressive symptoms during the
first 1 to 2 years after their loss. However, there is a distinction
15.38. The answer is A between depression and bereavement. Whereas grieving persons
Suicidal patients with intent and specific plans should always be and their relatives perceive bereavement as a normal reaction to
taken seriously. For patients believed to be too much at risk for the loss, those with depressive disorder often view themselves as
outpatient therapy or partial hospital programs, inpatient treat- sick and may actually believe they are losing their minds. Active
ment is required. Such hospitalization is preferably on a vol- suicidal ideation is rare in grief but common in major depressive
untary basis, but if the patient refuses, involuntary admission disorder. Unlike a melancholic person, a grieving person reacts
is required. The options of changing antidepressants and giv- to the environment and tends to show a range of positive effects.
ing more time for the medication to take effect are not the best Delusions of worthlessness or sin and psychotic experiences in
options in this circumstance, although they may be in patients general point toward a mood disorder. Guilt is experienced in
when suicide is less of an acute risk. Psychotherapy is also not both bereavement and depression. Bereaved persons often feel
an option when immediate intervention is needed with actively guilty about not having done certain things that they believe
suicidal patients. Contact with the family and friends of suicidal might have saved the life of the deceased loved one.
patients is essential, and maintaining patient confidentiality is
not mandatory if divulged material is believed to be necessary Answers 15.46–15.49
to protect the patient’s life. Some patients appear so imminently
and acutely suicidal that the clinician is afraid to let them out of 15.46. The answer is B
the office. Patients can be admitted to the hospital against their
will if they are a danger to themselves or to other people. 15.47. The answer is C
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15. Mood Disorders 155

15.48. The answer is D erated by overstimulation is so excessive that it is replaced by a

chronic disposition to irritability, fatigue (especially mental fa-
15.49. The answer is D tigue), lethargy, and exhaustion. It seems as if the patient’s mind
Tricyclic antidepressants such as imipramine (Tofranil) are refuses to take on new stresses. Anxious manifestations include
known for their cardiotoxicity because they prolong cardiac con- headache, backache, heavy limbs, vague neuralgias, yawning,
duction time and can cause a variety of arrhythmias. Also among dyspepsia, palpitations, sweating of the hands and feet, chills,
the substantial side effects of tricyclic antidepressants are weight flushing, sensitivity to weather changes, insomnia, nightmares,
gain, sedation, anticholinergic effects, and orthostatic hypoten- pantophobia, asthenopia, and tinnitus.
sion. Weight gain is also a common adverse effect of clozapine Cyclothymic disorder is characterized by frequent short cy-
(Clozaril), as well as agranulocytosis; therefore, weekly blood cles of subsyndromal mild depression and hypomania. The
monitoring is necessary. Neither clozapine nor imipramine acts course of cyclothymia is continuous or intermittent, with infre-
as norepinephrine partial agonists; instead, clozapine acts by quent periods of euthymia. Shifts in mood often lack adequate
blockade of serotonin-2a and D2 receptors, and imipramine acts precipitants. Persons with cyclothymic disorder are dilettantes;
by reducing the reuptake of norepinephrine and serotonin. There they show great promise in many areas but rarely bring any of
are no known teratogenic effects of clozapine or imipramine. their efforts to fruition.
Hypomania occurring as part of bipolar II disorder rarely pro-
Answers 15.50–15.53 gresses to manic psychosis, and insight is relatively preserved.
Hypomania refers to a distinct period of at least a few days of
15.50. The answer is C mild elevation of mood, sharpened and positive thinking, and in-
creased energy and activity levels, typically without the impair-
15.51. The answer is D ment characteristic of manic episodes. It is not merely a milder
form of mania. Hypomania is distinguished from mere happi-
15.52. The answer is B ness in that it tends to recur and can sometimes be mobilized by
antidepressants.
15.53. The answer is C
The most typical developmental background of dysthymic
Between the extremes of manic-depressive illness defined by at
disorder is an insidious onset of depression dating back to late
least one acute manic episode, which could be mood-congruent
childhood or the teens, preceding any superimposed major de-
or -incongruent (bipolar I disorder), and strictly defined major
pressive episodes by years or even decades. The typical features
depressive disorder without any personal or family history of ma-
of dysthymic disorder are the presence of a depressed mood that
nia (pure unipolar disorder), there exists an overlapping group of
lasts most of the day and is present almost continuously. There
intermediary forms characterized by recurrent major depressive
are associated feeling of inadequacy, guilt, irritability, and anger;
episodes and hypomania (bipolar II disorder). There is never any
withdrawal from society; loss of interest; and inactivity and lack
history of acute mania in either unipolar depression or bipolar
of productivity. It differs from major depression in that patients
II disorder. Psychotic features are typically not present in either
complain that they have always been depressed.
form of depression. There can be recurrent episodes of major de-
The designation bipolar I disorder is synonymous with what
pressive symptoms, as well as atypical features in both unipolar
was formally known as bipolar disorder—a syndrome in which a
and bipolar II forms. Symptoms of hypomania are characteristic
complete set of mania symptoms occurs during the course of the
only of bipolar II disorder.
disorder. Typically beginning in the teenage years, the 20s, or the
30s, the first episode could be manic, depressive, or mixed. Bipo-
Answers 15.54–15.59
lar I disorder, single manic episode, describes patients having a
first episode of mania (most such patients eventually develop
15.54. The answer is B
depressive episodes). Bipolar I disorder, recurrent, is diagnosed
15.55. The answer is D on the basis of the symptoms of the most recent episode (i.e.,
bipolar I disorder, most recent episode manic; bipolar disorder I
15.56. The answer is F disorder, most recent episode depressed).
Bipolar II disorder is characterized by depressive episodes
15.57. The answer is A and hypomanic episodes, but the episodes of manic-like symp-
toms do not quite meet the diagnostic criteria for a full manic
15.58. The answer is E syndrome. A few studies indicate that bipolar II disorder is asso-
ciated with more marital disruption and with an onset at an earlier
15.59. The answer is C age than bipolar I disorder. Evidence also indicates that patients
The diagnosis of neurasthenia is currently used more in China with bipolar II disorder are at greater risk of both attempting and
than the rest of the world. It is a condition characterized by completing suicide than patients with bipolar I disorder or major
vague functional physical and mental fatigue. The anxiety gen- depressive disorder.