Mood Disorders

Table Of Contents
  1. General Principles
  2. Major Depressive Disorder (MDD)
  3. Bipolar Disorder
  4. Cyclothymic Disorder
  5. Persistent Depressive Disorder (Dysthymia)
  6. Seasonal Affective Disorder (SAD)
  7. Bereavement
  8. Postpartum Mood Disorders
  9. Disruptive mood dysregulation disorder
  10. Premenstrual Dysphoric Disorder

General Principles

Wide ranges of moods are normal, and mood can fluctuate from day to day. Very few people will be the same on a day-to-day basis. Mood and affect can be congruent or incongruent. Mood disorders (as defined by the pattern of mood episodes) happen when the patient’s mood becomes uncontrollable and causes impairment in daily life. Some mood disorders can present with psychotic features (delusions, hallucinations)

  • Mood
    • A description of one’s internal emotional state
    • What the patient feels
    • Can ask the patient how they feel on a scale of 1-10
  • Affect
    • The external display of one’s mood
    • How you perceive the patient
  • Mood episode
    • A distinct period of time in which an abnormal mood is present (depression, mania, hypomania)
  • Mood disorders
    • Major Depressive Disorder (MDD)
    • Bipolar I Disorder
    • Bipolar II Disorder
    • Persistent Depressive Disorder
    • Cyclothymic Disorders
  • Why do mood disorders seem to affect women more than men?
    • Cultural bias
      • In most cultures women tend to be more open about their feelings
      • Clinicians tend to be more attentive to feelings in women than in men
      • Men are more likely to complain about things that surround their mood (”I can’t sleep at night”) than about the mood itself (“I’m feeling down”)

Major Depressive Disorder (MDD)

Depression is a very common condition associated with significant dysfunction. It is usually underdiagnosed. Often chronic or recurrent. It commonly presents in patients with other General medical conditions and is highly treatable. Multiple safe and effective treatments are available.

More common in women. The average age of onset 40yo. The theory is due to abnormalities of 5-HT, NE, and DA. The patient presents with subjective feelings of “sadness”. The mental state exam is usually normal but some patients show poor eye contact and flat affect. The rationale behind using antidepressants is to decrease depressive symptoms (insomnia and appetite first) to enable the patient to undergo psychotherapy and social therapies. Patients with depression should continue meds for 4-12 months (acute phase 3 months, continuation phase 9 months) after Sx clear/remit. If relapse occurs, treatment may be continued for at least 2 years.

  • Investigation
    • R/o depression d/t medical condition or drug/substance
      • TFTs: hypothyroidism (should r/o in Hx and PE)
      • Adrenal function tests: Cushing dz,
      • HIV testing: HIV
      • Viral serologies: Chronic mononucleosis, Influenza
      • BS for MPS: malaria
      • CBC: chronic anaemia
      • Urine tox screen: drug use (EtOH, Benzos, Amphetamines)
      • Head CT: tumour, CVA
      • Neurological diseases: Parkinson’s, Alzheimer’s, Epilepsy
      • **Medications: anti-hypertensives (**inedral BB, methyldopa, clonidine), sedatives/hypnotics (long acting benzos and barbiturates), steroids (prednisone, OCPs), antipsychotics (phenothiazines), anti-neoplastics, ARVs
      • Metabolites of neurotransmitters in urine, serum, CSF
    • R/o other psychiatric ilnesses
      • BPD
      • SCZ spectrum
      • NCDs
      • ADHD
    • Psychological tests
      • Personality
      • Intelligence
      • ADHD
      • Psychometics for Depression (PHQ, Hamilton depression scale, becks depression rating scale)
    • Social test
      • Corroborative Hx
      • Home visits
  • Specifiers for Diagnosing Depression
    • Severity
      • MDD: ≥ 5
      • Moderate depression: 3-4 Sx
      • Mild depression: 1-2 Sx
    • Other specifiiers
      • Depression w/anxious distress
      • Depression w/mixed features
      • Depression w/melancholic features
      • Depression w/mood congruent psychotic features
      • Depression w/incongruent psychotic features
      • Depression w/atypical features
      • Depression w/catatonia
      • Depression w/seasonal pattern
      • Depression w/peripartum onset
  • Differentials
    • Hypothyroidism: presents w/symptoms of depression + weight gain. Early undiagnosed Hypothyroidism.
    • Hyperadrenalism: presents w/symptoms of depression + weight gain + buffallo hymp
  • Treatment
    • Admit: suicidal, not eating, Insight I, no social support, severe depression with severe comorbid medical condition
    • Biological
      • **SSRIs (**Sertraline, Citalopram, Paroxetinie, Escitalopram, Fluoxetine, Fluvoxamine): first-line therapy. Readily available, fairly available
      • TCAs (imipramine, amitriptyline): readily available and affordable. More side effects. Preferred for patients with insomnia (one SE is hypersomnia)
      • Buproprion: alternative for patients on SSRIs who c/o sexual dysfunction
      • Esketamine: reserved for severe resistant depression
      • Atypical antipsychotic (clozapine, risperidone, olanzapinie, quietapine): adjuvants, potentiate antidepressant effect and treat psychotic Sx
      • Thyroid hormones (levothyroxine, liothyronine): adjuvant,
      • Lithium, lamotrigine, pindolol
      • Benzodiazepine: if agitated, anxious, insomnia for a few days.
      • Rehydration: IVF, Multivitamins, aminoacids
      • Electroconvulsive therapy: rarely used; last resort in severe refractory cases (after SSRIs and Psychotherapy have failed). Can be started in patients in stupor, not eating, or can’t tolerate side-effects
      • Transcranial magnetic stimulation, vagus nerve stimulation, deep brain stimulation: not commonly done, very expensive
      • Phototherapy: Depression w/seasonal pattern
    • Psychotherapy
      • CBT: cognitive restructuring (combines cognitive and behavioral therapy)
      • Supportive psychotherapy
      • Patient psychoeducation
      • Caretaker education: illness nature, Tx modality, course and prognosis, signs of suicidal tendencies
      • Family/marital therapy
      • Psychoanalytical oriented psychotherapy
    • Social
      • Social support: based on precipitating and perpetuating
      • Follow up on clinics
    • Others
      • Herbal therapy/Chinese
      • Spiritual
      • Music therapy
      • Relaxation/yoga
      • Nutritional supplements
      • Exercise
  • Good prognosis
    • Mild depression
    • No psychotic features
    • Short hospital stay
    • Stable family
    • Strong social function 5 years preceding illness
    • Solid friends during adolescence
    • No comorbid psychiatric condition
    • Late age of onset (40s or 50s in women)
  • Poor prognosis
    • Presence of dysthymia
    • Substance abuse
    • More than 1 previous episode
    • Anxiety Sx
    • Relapse
    • Family Hx
    • Psychotic features
    • Early age of onset
  • SSRI side effects
    • GI distress
    • Weight gain
    • Sexual dysfunction (ED, Anorgasmia, Issue with ejaculation) in men
  • Why is sexual dysfunction more of an issue in men on SSRIs
    • Differences in how men need to function sexually
      • Men need to obtain an erection to perform sexual function
      • Visible orgasm in men
      • Men are more likely to have anxiety surrounding their sexual performance

Etiology

  • Biological
    • Genetics: 2-10X risk if first degree relative has depression; 50% monozygotic concordance, 20% dizygotic concordance
    • Biochemical: decreased 5-HT (markedly reduced), NE, DA in the brain and spinal cord
    • Neuroendocrine axis dysfunction: depressed patients have may have comorbid hypothyroidism (5-10%), elevated cortisol (50%), decreased growth hormone and somatostatin
    • Neuro-immunological regulation dysfunction: increased levels of cortisol (50%)
    • Neuro-anatomical changes: reduced movement, posture problems, and emotions d/t dysunction of the basal ganglia and limbic syste.
      • Reduced blood flow to the cortex (frontal lobe, anterior cingulate, caudate nucleus)
      • Arophy in the RAS, diencephalon
      • Increased ventricle:brain ratio (BPID and psychotic depression > MDD)
  • Psychosocial
    • Personality: Cluster C personality (OCPD, Avoidant, Dependent) and Cluster B personality (BPD, Histrionic) are at increased risk
    • Losses: Bereavement, job, failed exams, conflicts in relationships, failed relationships, business/financial, serious acute/chronic physical illness; early loss of parents; early separation of parents
    • Attachment, Psychosocial and Psychodynamic theories (Freud, Klein, Bibring, Jacobson, Arieti, Kohut, Bowlby)
      • Adverse early childhood experiences increase risk: parental loss before adolescence, deprived and disrupted home environment, divorce/separation. The brain is very sensitive in childhood (changes in cortical levels, neurotransmitter sensitivity and myelination) If social support is given
      • Learnt helplessness: from operant learning theory. Pt learns to give up completely (explains depressive Sx in some cultures/tribes)
      • Cognitive theory: depressed persons have problems in cognition. Important in CBT (cognitive restructuring)
        • Cognitive triad: negative pessimistic feelings about themselves, the world and the future
        • Conitive distortions: minimization, magnification, abstracting
        • Cognitie schemas:
  • Risk factors for depression
    • Sex: Females at higher risk (2:1)
    • Age: Depression starts earlier in women (25y-35y) than men (45y -55y)
    • Marital status: singles (not by choice) are at a higher risk than married (reinforced with children)
    • Race: more in whites than blacks
    • Socioeconomic status: rates higher in low SES than high SES (unlike bipolar disorders)
    • Religion: religion can predispose and precipitate. Christians at higher risk than Muslism, Hindus, Budhists. Amongs Christians Evangelicals > Protestans > Catholics.
    • Jobless

Depression

Dx of severe depression requires ≥ 5 of SIG E CAPS Sx for at least 2 weeks with at least one from the big 2. No drug/substance abuse, medical condition, manic or Schizophrenia spectrum disorder, bereavement (Sx < 2 months)

  • SIG E CAPS
    • Sleep changes (Hypersomnia or insomnia)
    • Interest (Loss thereof; Anhedonia = loss of pleasure )
    • Guilt (feelings of worthlessness rather than guilt in the elderly)
    • Energy (Lack of energy; can be related to sleep changes)
    • Concentration (Lack of concentration; distractibility)
    • Appetite (Change in appetite – can be eating less or more)
    • Psychomotor (Agitation or retardation)
    • Suicidality (Passive or active suicidation. Passive suicidal ideation is more common. Active suicidal ideation the patient has a plan and needs to be hospitalized. Pre-occupation with death)
  • Cardinal Symptoms (The big 2)
    • Depressed Mood
    • Anhedonia
  • Classic Symptoms
    • Insomnia
    • Anorexia
    • Weight loss
    • Easy fatiguability
  • Reversed Symptoms
    • Hypersomnia
    • Overeating
    • Weight gain
    ***More prevalent in men than women
  • Auxiliary Symptoms (Somatic)
    • General: Frequent headaches, pains/aches, pressure/fullness in head, coldness, heavy limbs
    • GI: fullness/bloating, nausea, constipation
    • CVS,: palpitations, sweating, burning sensation
    • Genitourinary: Amenorrhea, low libido
  • Psychotic Symptoms Are mood congruent
    • Delusions: sin, poverty, imminent disaster (nihilistic delusions)
    • Hallucinations
      • Auditory hallucinations: defamatory, accusatory
      • Olfactory hallucinations: rotting filth/decomposing flesh
  • MSE findings in depression
    • Appearance and Behavior
      • Stooped posture
      • No spontaneous movements
      • Poor eye contact (reduced, downward gaze, averted gaze)
      • Psychomotor agiation (Hand wringing, pulling/rubbing on skin, inability to sit still, pacing around)
      • Socially withdrawn
      • Disorganised behavior (if psychotic – mue, soiled, not bathing, catatonia)
      • Steretypies
    • Mood and affect
      • Feeling low
      • Flat affect
    • Speech
      • decreased in rate, tone, volume,
      • slow to answer,
      • single word answers
    • Thought
      • Pessimistic (negative view of the world, themselves, the future)
      • Delusions (if psychotic, mood congruent, nihilistic)
      • Overvalued ideas
      • Obsessions
      • Ruminations
      • Suicidal ideation
      • Thought block
      • Slow process
      • Ove epmphasizes the bad and minimizes the good
    • Perception
      • Mood congruent hallucination (if psychotic)
      • Few cases may have mood incongruent hallucinations
    • Sensorium and Cognition
      • Orientation: intact but may not have energy to answer questions
      • Attention and concentration: poor
      • Memory: poor/depressive pseudodementia
    • Insight
      • Partial (II, III, IV)
      • Completely unlikely to find insight I
      • Full insight (V) unlikely
  • Elderly patient who is depressed
    • More likely to have Somatic complaints (to the point of hypochondriasis). Manifests as easy fatiguability.
    • More likely to describe the Guilt part of SIG E CAPS as Worthlessness (Worthlessness vs Fullfilment stage – Erik Erickson)
    • More likely to exhibit psychomotor agitation or retardation
    • More likely to exhibit psychotic delusions with their MDD
    • More likely to commit suicide (patient > 55y make up 12% of MDD pts but represent 25% of MDD suicide)
  • Risk factors for suicide in elderly patients with MDD
    • Living alone
    • Alcoholism
    • Male sex
    • Comorbid physical conditions

Bipolar Disorder

Recurrent mood disturbance mixed with mania/hypomania + depression. Thought to be a bridge between unipolar depression and Schizophrenia spectrum disorders. The genetic link in Bipolar disorder is stronger than in Unipolar depression but less than that of Schizophrenia.

BPID: 0.6%. BPIID: 0.3%. M:F 1:1. 3-4 manic episodes per year in our setting. Mania is more common in men than women. Mixed episodes are more common in women (w/ rapid cycling). Rapid cycling is more common in women (≥ 4 episodes per year). High risk of relapse post-delivery in women of childbearing age. More common in High SES.

  • Classes
    • Bipolar I Disorder: At least one manic episode; may be accompanied by MDD
    • Bipolar II Disorder: MDD accompanied by hypomanic episode
    • Cyclothymic Disorder: ≥ 2 years of alternating hypomania and dysthymia; ≥ 1 year in children and adolescents
    • Bipolar Disorder d/t substance or medication: chronic benzodiazepines, cannabis
    • Bipolar disorder d/t other medical condition: Neurosyphyllis, HIV
    • Bipolar disorder NOS
  • Patients with Bipolar are at an increased risk of
    • Suicide and self-harm
    • Financial risk
    • Physical health risk: DM, CVS, STDs, pregnancy
    • Alcohol and drug abuse
    • Driving and accidents
  • Investigations
    • R/o general medical causes or substance use
      • Urine tox screen
      • TFTs (Hyperthyroidism, Hypothyroidism)
      • Adrenal function tests (Pheochromocytoma Hyperadrenalism)
      • HIV/AIDS
      • Viral (Rabies)
      • RPR/VDRL (Syphillis)
      • ANA (SLE)
      • CBC (Acute blood loss)
      • BS for MPS (cerebral malaria; watch out for false positives in endemic areas)
      • Head CT (Non-dominant hemisphere stroke or tumor)
      • EEG (Epilepsy)
      • Metabolites of neurotransmitters in urine, serum or CSF (Homovanillic acid, 5-IAA)
    • R/o psychiatric illnesses
      • Schizophrenia spectrum
    • Social investigation
      • House visit (to fill gaps in Hx)
    • Psychological tests
      • Personality disorder: Cluster B
      • ADHD espin hyperactive state
      • IQ test
  • Treatment
    • Biological
      • Mood stabilizers
        • Lithium: preferred in acute mania
        • Valproic acid: preferred in acute mania and mixed phase
        • Carbamazepine: preferred in rapid cycling and mixed phase
        • Lamotrigine: preferred in depressive phase
        • Topiramate
        • Gabapentin
      • Antipsychotics (Olanzapine, Quietapine, Risperidone): Psychotic features, and as Mood Stabilizers, as depot (slow-acting injections)
      • SSRIs (Fluoxetine): add if no response to mood stabilizers. Isolated use can push depressed patients to mania in both BPID and BPIID or precipitate rapid cycling.
      • Benzodiazepines (Lorazepam, clonazepam, diazepam): for acute manic epidose
      • Typical antipsychoics (haloperidol, ziprasidone): for agitated patients
    • Physical therapy
      • ECT: refractory to therapy
    • Psychotherapy
      • CBT
      • Family therapy
      • Interpersonal and Social Rhythm therapy (IPSRT)
      • Psychoeducation
    • Social intervention
      • Social worker depending on stressor
  • Differentials
    • Drugs (Cannabis, Benzos, Cocaine causing mania, Captopril for BPID)
    • Hypethyroidism:
    • Personality d/o: Mania will be a single episode while in personality disorders it will be persisitent.
    • Psychotic d/o: ****Bizzare delusions will be protracted
    • Non-dominant hemisphere stroke or tumors
  • Specifiers for diagnosing bipolar disorder
    1. Severity
      1. Mild BPID/BPIID
      2. Moderate BPID/BPIID
      3. Severe BPID/BPIID
    2. Current or Recent episode:
      1. BPID, Manic phase
      2. BPIID, Hypomanic phase,
      3. BPID/BPIID Depressive phase,
      4. BPID/BPIID Mixed phase
    3. Other features
      • BPD w/Psychotic features
      • BPD w/Rapid cycling
      • BPD w.Peripartum onset
      • BPD w/Seaonal pattern
      • BPD w/Anxious distress
      • BPD w/Catatonia
  • Good prognosis
    • Short duration of episodes
    • Acute
    • Late onset
  • Poor prognosis
    • Poor pre-morbid function
    • Psychotic features
    • Depressive
    • Male sex
    • Family History
    • Comorbidities
    • Suicidal
  • Treatment of Bipolar in teenagers
    • Lithium
    • Aripiprazole (Aripitas)
  • Controlling Bipolar Disorder
    • Meds daily
    • Exercise daily
    • Balanced diet at regular times
    • Routine sleep/wake
    • Avoid alcohol/drugs
    • Counselling (to reduce stress at work/home)
    • Limit caffeine/nicotine during mania
    • Avoid travelling to different time zones
    • Seek treatment immediately you notice Sx of relapse
    • Support groups
Bipolar I DisorderBipolar II Disorder
PresentationManic episode that causes a problem or dangerDepression with a history of hypomania
FrequencyLess commonMore common
Men:Women1:11:1
Genetic linkageVery highVery high

Etiology

  • Biological
    • Genetics: Strong genetic linkage (50-70% predisposition)BPIID > BPID > Unipolar depression
    • Endocrine: Increased hormones (Testosterone) in manic highs
  • Psychosocial
    • Personality: Cluster B personality (Dramatic and Erratic)
    • Attachment/psychosocial theories: 90% develop in childhood but manifest in adulthood)
    • Psychodynamic theory (Abraham, m.kleine): mania is an unconscious defense against underlying depression
    • Bad events (losses, trauma, childhood abuse, failed exam etc.) can precipitate depressive episodes
    • Good events (winning the lottery, promotion, passed exam etc.) can precipitate manic episodes
    • Higher incidence in single (not by choice) than married
    • Higher incidence in high SES than Low SES

Depression in Bipolar Disorder

25-50% of patients attempt suicide in the depressive phase. 15% complete suicide.

  • Depression in Bipolar Disorder
    • Early age of onset (18yo in BPID, Mid 20s in BPIID)
    • High chance of reversed vegetative symptoms (hypersomnia, increased appetite)
    • Increaed risk of relapse
    • Higher familial genetic link
    • More reactive to mood stabilizers and SSRIs

Mania

Diagnosis for Mania is DIG FAST (at least 3) for 1 week or more.

  • DIG FAST for Mania
    • Distractability (easily distracted)
    • Insomnia
    • Grandeur (Arrogance)
    • Flight of ideas (tangiental, can’t stay focused)
    • Activity (increase in activity, increase in activity)
    • Sleep (decrease in sleep. Does not cause fatigue)
    • Talkativity
  • Signs and symptoms of mania
    • Racing thoughts (Manifests as Flight of ideas in speech)
    • More talkative (Manifests as Pressured speech)
    • Extremely “high” (Manifests as Euphoric mood/affect)
    • Easily irritated
    • Easily distracted
    • Decreased need for sleep (sleep 2-3hours, wake up energized)
    • Inflated self-esteem (Grandiosity – unrealistic beliefs in one’s ability and power)
    • Excessive energy with increased activity (goal-directed or purposeless)
    • Poor judgement
    • Excessive pleasurable activity (Libido, Drugs, Deals, Spenging)
    • Delusions or Hallucinations (in severe cases. Insight I/II – never VI; mood congruent, usually auditory hallucinations)
  • Clues pointing to mania
    • Clothing may reflect mood (Colouful and excessive – pt may have a lot of accessories, colourful hair)
    • Self-neglect in severe cases (untidy/dishveled)
    • Exhausted
    • Unfinished tasks
    • Increased appetitie
    • Increased sexual drive

Hypomania

A mild form of mania ( at least 3 DIG FAST) that DOES NOT cause disturbance in the patient’s life. No psychosis. Mild impairment of performance or judgement.

  • Why do patients with hypomania ( or BPIID) have a worse prognosis than BPID
    • Rarely seek treatment and relapse frequently into MDD
ManiaHypomania
SevereMild
Marked impairment in social functionMild impairment in social function
BPIDBPIID, Cyclothymia
Lasts at least 7 daysLasts at least 4 day
HospitalizedTreated as outpatient
Psychosis (delusions and hallucinations)No psychosis
ECT plays a roleECT does not play a role
May need antipsychotic + Mood stabilizersMood stabilizers enough

Cyclothymic Disorder

Chronic disorder lasting for more than 2 years. Periods of mild depression (< 5 SIGE CAPS) + hypomania which come and go over at least two years

Think of it as a mild form of BPIID. Bouts of depression are not as bad and do not meet criteria for MDD.

33% risk of developing BPID and BPIID. 0.4-1% prevalence. M:F 1:1

  • Differentials (same as BPIID)
    • Drugs (Cannabis, Benzos, Cocaine causing mania)
    • Hypethyroidism:
    • Personality d/o: Mania will be a single episode while in personality disorders it will be persisitent.
  • Management
    • r/o Thyroid and drugs
    • Patients usually respond to mood stabilizers/antiepileptics
  • Differentiate BPIID/Cycothymia from ADHD in adults

Persistent Depressive Disorder (Dysthymia)

Chronic disorder lasting for more than 2 years. Period of mild depression (< 5 SIG E CAPS) lasting more than two years. Lingering, less severe depression (remember cut off for MDD was 2 weeks)

  • Differentials (same as MDD + dementia)
    • Hypothyrodism
    • Hyperadrenalism
    • Dementia: consider if the patient is older
  • Management
    • r/o hypothyroidism
    • Cognitive Behavioral Therapy (CBT)
    • SSRIs: can use.

Seasonal Affective Disorder (SAD)

Periods of mild depression come on in the fall and winter months. (Northern and Southern Hemisphere. Repetitive Hx is common (patients getting these symptoms in the winter).

  • Theory
    • Decreased UV exposure → Decreased MSH which is implicated in mood
  • Differentials
    • MDD
    • Cyclothymia
    • Persisitent Depressive Disorder (Dysthymia)
  • Management
    • Phototherapy

Bereavement

  • Changes in the bereavement exclusion in DSM-V
    • Cut-off no longer than two months (Patients can have protracted bereavement)
    • Patients can have MDD superimposed on bereavement (Use clinical judgement based on Hx and cultural norms to differentiate)
      • Patients who have a past medical history of MDD are at higher risk of relapsing from bereavement
      • If bereavement is severe enough (suicidality etc.) can give SSRIs
Prepatory GriefDepression
Mood fluctuatesThe patient feels sad or low most of the time. Tearfulness
Self-esteem is generally intact (comes and goes as in Kubler-ross stages of grief -self-blaming and guilt which affects esteem)Protracted feelings of worthlessness and guilt
The patient is able to enjoy seeing and interacting with friends and familyThe patient withdraws from friends and family. Less talkative
The patient is able to experience pleasure in various activities.Anhedonia. The patient experiences a loss of interest in activities.
The patient is able to look forward to special occasions.Thought of early death or suicide. May frequently ask physicians to hasten death.
Decreased ability to focus and concentrate
Inability to make decisions

Postpartum Mood Disorders

Postpartum Blues

50-85% of mothers in the first 2 weeks postpartum. d/t fluctuating hormone levels. Normal and is not considered a psychiatric condition. Mild and spontaneously remits. In the obstetrics and paediatric wards, it is important to ask the mother how she is feeling (especially in the first 2 weeks postpartum)

  • Symptoms
    • Irritability
    • Anxiety
    • Fluctating mood
    • Increased emotional reactivity.

Postpartum Depression

13% of mothers in the first year postpartum. Mothers usually feel unworthy to raise their children. Moderate to severe symptoms with a protracted course. May treat these women. Risk factors for depression

  • Signs and symptoms
    • Excessive guilt
    • Anxiety
    • Anhedonia
    • Depressed mood
    • Insomnia/hypersomnia
    • Suicidal ideation
    • Fatigue

Postpartum Psychosis

0.01% of mothers in the first 3 months postpartum. These women are a danger to themselves and their children and need to be hospitalized (psychiatric emergency)

  • Signs and symptoms
    • Mixed or rapid cycling
    • Agitation
    • Delusions
    • Hallucination
    • Disorganized behavior
    • Cognitive impairment
    • Low insight

Disruptive mood dysregulation disorder

Diagnosis reserved for children who exhibit persistent irritability (>12 mos) particularly temper outbursts and anger more than 3x/wk in more than two settings

Premenstrual Dysphoric Disorder

Depressive or other mood sx (consistent with SIG E CAPS criteria) in the majority of menstrual cycles that come on within one week prior to menses and improve in the days after.