JERRY B.

SAGABAEN JR MD
MEDICAL OFFICER III
Cagayan Valley Medical Center

MOOD DISORDERS II

Sample Cases
You see Jill (age 24) in the emergency room of a
hospital where her parents have brought her for
evaluation. They are worried because she is giving
away all of her possessions and says she is planning
to move to Seattle so she can "save the world." Her
parents say that she has hardly been sleeping at all,
but she seems very energetic. They say she has
appeared to be "in a frenzy" lately. When you
interview Jill you notice that she speaks very rapidly.
It is hard to get her to be quiet long enough for you
to ask questions. She seems agitated, and has
difficulty sitting still.

 Morris has been referred to you for psychotherapy

following a suicide attempt. When you interview him
he is very teary. He speaks slowly and looks down at
the ground as he speaks. He reports difficulty in falling
asleep and staying asleep for the past month. Morris
states that he hasn't had much of an appetite and has
lost 15 pounds. He reports that things he used to like
just don't seem enjoyable anymore, and he thinks that
life is not worth living. Morris doesn't expect things to
improve in the future, which is why he tried to kill
himself.

 Lenore has been feeling very sad since her husband died 12
days ago. She has eaten very little, and has difficulty sleeping.
She is weepy most of the time. Lenore is preoccupied with
thoughts of her dead husband and does not want to do much
other than thinking about him. She has declined all invitations
by friends and spends most of her time alone

 Elise is a 35 year old architect. She comes to you in great

distress, feeling that she is unable to work, and generally
unable to function. She says that she feels tired all the time, to
the point of feeling completely exhausted. She says that she
cries easily, and almost every day. She is having difficulty
sleeping, and has lost 20 pounds in the last 2 months without
trying. She says that things have been "real bad" for the last 2
months; she doesn't enjoy doing anything and thinks
frequently of suicide.

Dysthymic Disorder

The term dysthymia, which means ill humored,was introduced

in 1980. Before that time, most patients now classified as
having dysthymic disorder were classified as having depressive
neurosis (also called neurotic depression).
is common among the general population and affects 5 to 6
percent of all persons. It is seen among patients in general
psychiatric clinics, where it affects between one half and one
third of all patients

ETIOLOGY
1. Biological Factors
2. Psychosocial Factors
Psychodynamic theories about the development of dysthymic
disorder posit that the disorder results from personality and
ego development and culminates in difficulty adapting to
adolescence and young adulthood
3. Freud asserted that an interpersonal disappointment early in
life can cause a vulnerability to depression that leads to
ambivalent love relationships as an adult; real or threatened
losses in adult life then trigger depression.

4. Cognitive Theory
The cognitive theory of depression also applies to dysthymic
disorder. It holds that a disparity between actual and fantasized
situations leads to diminished self-esteem and a sense of
helplessness. The success of cognitive therapy in the treatment
of some patients with dysthymic disorder may provide some
support for the theoretical model.

Diagnostic Criteria for Dysthymic Disorder

A. Depressed mood for most of the day, for more days than not,
as indicated either by subjective account or observation by
others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and
duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:

poor appetite or overeating

insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficulty making decisions
feelings of hopelessness

C. During the 2-year period (1 year for children or adolescents)

of the disturbance, the person has never been without the
symptoms in Criteria A and B for more than 2 months at a time.

D. No major depressive episode has been present during the first 2

years of the disturbance (1 year for children and adolescents); i.e.,
the disturbance is not better accounted for by chronic major
depressive disorder, or major depressive disorder, in partial
remission.
Note: There may have been a previous major depressive episode
provided there was a full remission (no significant signs or
symptoms for 2 months) before development of the dysthymic
disorder. In addition, after the initial 2 years (1 year in children or
adolescents) of dysthymic disorder, there may be superimposed
episodes of major depressive disorder, in which case both diagnoses
may be given when the criteria are met for a major depressive
episode.
E. There has never been a manic episode, a mixed episode, or a
hypomanic episode, and criteria have never been met for
cyclothymic disorder.

F. The disturbance does not occur exclusively during the

course of a chronic psychotic disorder, such as schizophrenia
or delusional disorder.
G. The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
Specify if: Early onset: if onset is before age 21 years Late
onset: if onset is age 21 years or older Specify (for most
recent 2 years of dysthymic disorder) if
With atypical features

Alternative Research Criterion B for

Dysthymic Disorder
A. Presence, while depressed, of three (or more) of the
following:
1. low self-esteem or self-confidence, or feelings of
inadequacy
2. feelings of pessimism, despair, or hopelessness
3. generalized loss of interest or pleasure
4. social withdrawal
5. chronic fatigue or tiredness
6. feelings of guilt, brooding about the past
7. subjective feelings of irritability or excessive anger
8. decreased activity, effectiveness, or productivity
9. difficulty in thinking, reflected by poor concentration, poor
memory, or indecisiveness

Double Depression
An estimated 40 percent of patients with major depressive
disorder also meet the criteria for dysthymic disorder, a
combination often referred to as double depression. Available
data support the conclusion that patients with double
depression have a poorer prognosis than patients with only
major depressive disorder.
The treatment of patients with double depression should be
directed toward both disorders, because the resolution of the
symptoms of major depressive episode still leaves these
patients with significant psychiatric impairment.

Treatment
1.
2.
3.
4.
5.

Cognitive Therapy
Behavior Therapy
Insight-Oriented (Psychoanalytic) Psychotherapy
Family and Group Therapies
Pharmacotherapy

Cyclothymic Disorder
Cyclothymic disorder is symptomatically a mild form of bipolar
II disorder, characterized by episodes of hypomania and mild
depression.
Patients with cyclothymic disorder may constitute from 3 to 5
percent of all psychiatric outpatients, perhaps particularly
those with significant complaints about marital and
interpersonal difficulties.
Families of persons with cyclothymic disorder often contain
members with substance-related disorder.

Etiology
1. Biological Factors
- About 30 percent of all patients with cyclothymic disorder
have positive family histories for bipolar I disorder; this rate is
similar to the rate for patients with bipolar I disorder
2. Psychosocial Factors
- Most psychodynamic theories postulate that the
development of cyclothymic disorder lies in traumas and
fixations during the oral stage of infant development
- The major defense mechanism in hypomania is denial, by
which the patient avoids external problems and internal
feelings of depression

Diagnostic Criteria for Cyclothymic Disorder

A. For at least 2 years, the presence of numerous periods
with hypomanic symptoms and numerous periods with
depressive symptoms that do not meet criteria for a major
depressive episode. Note: In children and adolescents, the
duration must be at least 1 year.
B. During the above 2-year period (1 year in children and
adolescents), the person has not been without the
symptoms in Criterion A for more than 2 months at a time.
C. No major depressive episode, manic episode, or mixed
episode has been present during the first 2 years of the
disturbance

Note: After the initial 2 years (1 year in children and

adolescents) of cyclothymic disorder, there may be
superimposed manic or mixed episodes (in which case both
bipolar I disorder and cyclothymic disorder may be diagnosed)
or major depressive episodes (in which case both bipolar II
disorder and cyclothymic disorder may be diagnosed).
D. The symptoms in Criterion A are not better accounted for by
schizoaffective disorder and are not superimposed on
schizophrenia, schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified.
E. The symptoms are not due to the direct physiological effects
of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.

A 29-year-old car salesman was referred by his girlfriend, a

psychiatric nurse, who suspected he had a mood disorder, even
though the patient was reluctant to admit that he might be a
moodyperson. According to him, since age 14 he has
experienced repeated alternating cycles that he terms good
times and bad times.During a badperiod, usually lasting 4 to 7
days, he oversleeps 10 to 14 hours daily, lacks energy,
confidence, and motivation just vegetating,as he puts it. Often
he abruptly shifts, characteristically upon waking up in the
morning, to a 3-day to 4-day stretch of overconfidence,
heightened social awareness, promiscuity, and sharpened
thinking (Things would flash in my mind
). At such times he
indulges in alcohol to enhance the experience, but also to help
him sleep. Occasionally the goodperiods last 7 to 10 days, but
culminate in irritable and hostile outbursts, which often herald
the transition back to another period of baddays. He admits to
frequent use of marijuana, which he claims helps him adjustto
daily routines.

Substance Abuse

Alcohol abuse and other substance abuse are common in

patients with cyclothymic disorder, who use substances either
to self-medicate (with alcohol, benzodiazepines, and
marijuana) or to achieve even further stimulation (with
cocaine, amphetamines, and hallucinogens) when they are
manic. About 5 to 10 percent of all patients with cyclothymic
disorder have substance dependence. Persons with this
disorder often have a history of multiple geographical moves,
involvements in religious cults, and dilettantism.

Minor Depressive Disorder

The literature in the United States on minor depressive disorder
is limited, in part, because the term is used to describe a wide
range of disorders, including dysthymic disorder,
Minor depressive disorder may be as common as major
depressive disorder that is, about 5 percent prevalence in the
general population. The disorder is more common in women
than in men and affects people of virtually any age, from
childhood onward.

Recurrent Brief Depressive Disorder

Recurrent brief depressive disorder is characterized by

multiple, relatively brief episodes (less than 2 weeks) of
depressive symptoms that, except for their brief duration, meet
the diagnostic criteria for major depressive disorder
The 10-year prevalence rate for the disorder is estimated to be
10 percent for people in their 20s; the 1-year prevalence rate
for the general population is estimated to be 5 percent. These
numbers indicate that recurrent brief depressive disorder is
most common among young adults.

Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder is also called late luteal phase
dysphoric disorder. The syndrome involves mood symptoms
(e.g., lability), behavior symptoms (e.g., changes in eating
patterns), and physical symptoms (e.g., breast tenderness,
edema, and headaches).
This pattern of symptoms occurs at a specific time during the
menstrual cycle, and the symptoms resolve for some period of
time between menstrual cycles.

Mixed Anxiety-Depressive Disorder

Mixed anxiety-depressive disorder is characterized by a
persistent or recurrent depressed mood lasting at least 1
month and by symptoms of anxiety, such as sleep
disturbance, fatigue or low energy, irritability, and worry.
The symptoms must cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.