Gangguan

Mood

dr. Anita E. Dundu, SpKJ

 Objectives
Mampu mengenali psikopatologi
Mampu membuat penilaian
(assessment) : menegakkan
diagnosis dan
mempertimbangkan diagnosis
banding
Mampu menyusun rencana
penatalaksanaan sederhana
 Ruang Lingkup
MDD :
Episode depresi
gangguan depresi berulang

Gangguan afektif bipolar

Episode manik/hipomanik
Bipolar 1
Bipolar 2

Gangguan Mood menetap : Distimia dan siklotimia

Gangguan mood lainnya

 Mood and Mood disorder
Mood : a pervasive and sustained feeling tone
that is experienced internally and that
influences a person's behavior and perception
of the world.
Affect : external expression of mood.
Mood disorders : a group of clinical conditions
characterized by a loss of that sense of control
and a subjective experience of great distress.
 Epidemiology (1)
Tipe Lifetime prevalence (%)
(Range/average)
Major depressive episode 5-17 / 12
Dysthymic Disorder 3-6 / 5
Minor Depressive Disorder 10 / -
Reccurrent Brief Depressive Disorder 16 / -
Full Unipolar Spectrum 20 - 25
Bipolar I disorder 0 - 2,4
Bipolar II disorder 0,3 4,8
Cyclothymia 0,5 6,3
Hypomania 2,6 7,8
Full Bipolar Spectrum 2,6 7,8
 Epidemiology (2)
Sex
Depresi : Lk = 2 : 1
Bipolar Pr= Lk (Pr > depresi, Lk manik.
Mixed : Pr
Age
The onset of bipolar I disorder 5 -50 tahun
(mean 30). Single/ divorced.
Depresi : onset 20 50 tahun ( Mean 40
tahun). Usia 20-an meningkat krn pengaruh
zat. Unmarried/ divorced/ separated..
 Socioeconomic and Cultural Factors
socioeconomic status :
Depression, no correlation. Rural areas. Bipoar,
upper class. Bipolar I disorder is more education :
Bip, under college grad.
Races : if differ th examiner, more skz, less mood
 Comorbidity
increased risk comorbid Axis I disorders. :
alcohol abuse or dependence (LK), panic
disorder, OCD and social anxiety and eating
disorder (Pr). Vice versa. Comorbid 2x> pd
bipolar, worsen the prognosis and markedly
increase risk of suicide.
Neurobiology (1)

Biogenic Amine :
NE, 5-HT, DA
Ach, GABA, Glutamat
Second Messenger & Intra
cellular Cascade
 Neurobiology (2)
Alteration of Hormonal Regulation
HPA-axis in chronis stress; TSH, Prolactin, GH,
FSH, and testosterone release; nocturnal
melatonin; immune functions
Alteration of Sleep Neurophysiology : delayed
onset, shortened REM latency, length 1st
REM period
 Neurobiology (3)
Immunological Disturbance
lymphocyte proliferation in response to mitogens
neuromodulators (CRF, cytokines, interleukins)
immune dysfunction.

Neuroanatomi dan neurofisiologi Otak

abnormal hyperintensities in subcortical regions
Ventricular enlargement, cortical atrophy, and sulcal
widening

Faktor Genetik
 Faktor psikososial
Life Events and Environmental Stress
Personality Factors : OCD, histrionik,
borderline greater risk
Learned Helplessness : internal causal
explanations are thought to produce a loss
of self-esteem after adverse external events
 Cognitive Theory : depressogenic schemata
Cognitive triad (Aaron Beck):
(1) negative self-view;
(2) negative interpretation of experience;
(3) negative view of future
 Psychodynamics : Depression

Freud (& Karl Abraham) :

(1) disturbances in the mother relationship
during the oral phase (the first 10 to 18 months
of life) predispose to subsequent vulnerability to
depression;
(2) depression can be linked to real or imagined
object loss;
(3) introjection of the departed objects is a
defense mechanism invoked to deal with the
distress connected with the object's loss; and
(4) because the lost object is regarded with a
mixture of love and hate, feelings of anger
are directed inward at the self.
Silvano Arieti depressed people lived their
lives for someone else rather than for
themselves. He referred to the person for
whom depressed patients live as the dominant
other, which may be a principle, an ideal, or an
institution, as well as an individual. Depression
sets in when patients realize that the person
or ideal for which they have been living is
never going to respond in a manner that will
meet their expectations.
 Edith Jacobson depression is the state of
powerless, helpless child victimized by a
tormenting parent.
Melanie Klein : expression of aggression toward
loved ones.
Edward Bibring : discrepancy between
extraordinarily high ideals and the inability to
meet those goals.
 Heinz Kohuts : the developing self has specific needs
that must be met by parents to give the child a
positive sense of self-esteem and self-cohesion. When
others do not meet these needs, there is a massive
loss of self-esteem that presents as depression.
John Bowlby believed that damaged early
attachments and traumatic separation in childhood
predispose to depression. Adult losses are said to
revive the traumatic childhood loss and so precipitate
adult depressive episodes.
 Psychodynamics : Mania
defense against underlying depression.
Abraham : inability to tolerate a
developmental tragedy, such as the loss of a
parent. The manic state may also result from a
tyrannical superego, which produces
intolerable self-criticism that is then replaced
by euphoric self-satisfaction.
 Bertram Lewin : manic patient's ego as overwhelmed
by pleasurable impulses, such as sex, or by feared
impulses, such as aggression.
Klein : defensive reaction to depression, using manic
defenses such as omnipotence, in which the person
develops delusions of grandeur.
 DIAGNOSIS : ICD - 10
F32 Episode Depresif
.0 ringan (.00 tanpa gejala somatik/.01 dengan)
.1 sedang (.10 tanpa gejala somatik/.11 dengan)
.2 berat tanpa gejala psikotik
.3 berat dengan gejala psikotik
F33 Gangguan Depresi Berulang
.0 ep.kini ringan (tanpa/dengan gej.psikotik)
.dst
F34 Gangguan Mood menetap
.0 siklotimia
.1 distimia
F38 Gangguan Mood lainnya
.0 tunggal (.00 ep.afektif campuran)
.1 berulang lainnya (.10 gangguan depresif
singkat berulang)
F39 Gangguan Mood YTT
 DIAGNOSIS : ICD - 10

F 30 Episode Manik
.0 Hipomania
.1 Mania tanpa gejala psikotik
.2 Mania dengan gejala psikotik
F 31 Gangguan Afektif Bipolar
.0 ep. Kini hipomania
.1 ep kini manik tanpa gejala psikotik
.2 ep kini manik dengan gejala psikotik
.3 ep kini depresi ringan atau sedang (tanpa/dengan
g.somatik)
.4 ep kini berat tanpa gejala psikotik
.5 ep kini berat dengan gejala psikotik
.6 ep. Kini campuran
.7 kini dalam remisi
A. Major Depressive Episode
Depressed mood most of the day, nearly
every day. In children and adolescents, can be
irritable mood
Markedly diminished interest of pleasure in
all, or almost all, activities most of the day
Significant weight loss when not dieting or
weighting gain, or decrease or increase in
appetite
Insomnia or hypersomnia
 Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or
inappropriate guilt
Diminished abillity to think or concentrate, or
in decisiveness
Recurrent thoughts of death (not just fear of
dying), recurent suicidal ideation without a
spesific plan, or a suicide attempt or a spesific
plan for committing suicide.
B. Manic Episode

inflated self-esteem or grandiosity

decreased need for sleep (e,g., feels rested
after 3 hours of sleep)
more talkative then usual or pressure to
keep talking
flight of ideas or subjective experience that
thoughts are racing
- distractibility (i.e., attention too easily drawn
to unimportant or irrelevant external stimuli)
- increased in goal-goal directed of activity
(either socially, at work or school, or sexually)
or psychomotor agitation
- excessive involvement in pleasurable
activities that have a high potential or painful
consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, or foolish
business investments)
 Gejala utama:
Afek depresi
Kehilangan minat
Berkurangnya energi, mudah lelah
Gejala lain :
Konsentrasi dan perhatian berkurang
Harga diri dan percaya diri berkurang
Merasa bersalah, tidak berguna
Pesimis akan masa depan
Suicidal thoughts
Gangguan tidur
Gangguan nafsu makan
Kriteria waktu minimal 2 minggu
 Peningkatan afek
Peningkatan jumlah dan kecepatan aktivitas
fisik dan mental (banyak bicara, kebutuhan
tidur berkurang, ide2 kebesaran, terlalu
optimis)
Kriteria waktu minimal 1 minggu
 GANGGUAN
BIPOLAR

Gangguan bipolar gangguan

tipe I bipolar tipe-
terdapat riwayat dari episode II.
manik depresif mayor terdapat riwayat
epi.depresif - hipomania
 DEPRESI (episode major depresi)

Informasi yang didapat dari anamnesis

Mood depresi
Anhedonia
Sosial withdrawal
Tiada motivasi
Gampang frustasi
Tanda vegetatif
 Informasi yang didapat dari pemeriksaan
status mental

keadaan umum dan perilaku : agitasi yang

berlebihan, kontak mata buruk, menangis,
putus asa, tidak memperhatikan
penampilan diri sendiri
Afek : menyempit,tidak stabil
Mood : tertekan, mudah marah, frustasi
 Berbicara : sedikit atau tidak secara spontan,
retarded, soft-low
Isi pikiran : ide bunuh diri,hopeless
kognisi : bingung, susah konsentrasi, memori
jelek, disorientasi, pikiran abstrak tertanggu
Pengetahuan dan pendapat terganggu
 Ciri yang berhubungan
Keluhan somatik yang mungkin
menutupi depresi ; gangguan
jantung, gastrointestinal, dan
gejala genitourinaria ; sakit
tulang belakang, keluhan sistem
skeletal dan persendian.
Waham dan Halusinasi ; waham
rasa bersalah, waham somatik
dan nihilistik.
 Ciri khas pada usia tertentu
Depresi akan memberikan gambaran berbeda pada
usia tertentu
a. Pubertas : keluhan somatik, agitasi, halusinasi, gelisah,
fobia
b. Remaja : penyalahgunaan obat, antisosial, kegelisahan,
bolos sekolah, ingkar janji, sensitif pada penolakan,
higiene yang buruk
c. Lansia : kekurangan fungsi kognisi,
pseudodemensia/demensia, apatis, ketidakmampuan
memusatkan atensi
 MANIA (episode manic)
Informasi yang didapat dari
riwayat pasien
a. Perilaku yang tidak tertahan dan
tak menentu
- Pengeluaran yang berlebihan
atau berjudi
- Perjalanan impulsif.
- Hiperseksualitas, promiskuasitas
b. Berlebihan dalam aktivitas dan
tanggungjawab.
c. Toleransi frustasi yang rendah
d. Tanda-tanda vegetatif.
- Libido yang meningkat.
- Penurunan berat badan atau
anoreksia.
- Insomnia
- Energi yang berlebihan.
 Pemeriksaan dari status mental
Keadaan umum dari perilaku : agitasi psikomotor,
seduktif, memakai baju dengan warna-warni yang
mencolok, make up yang berlebihan, tidak peduli
pada penampilan pribadi, suka mengancam, gairah
yang berlebihan
Afek : labil, intens
Mood : euforik, ekspansif, iritabel, suka meminta,
genit
Berbicara : meledak2, nyaring, dramatis, dilebih-
lebihkan, dapat menjadi inkoheren
 pemeriksaan status mental (lanjutan)

Isi pikiran : percaya diri yang tinggi, grandiosa,

egosentris
Proses pikir : pikiran yang melocat, pikiran yang
berlomba-lomba, neologisme, asosiasi clang,
sirkumstansialitas, tangensialitas
Sensorium : perhatian yang mudah dialihkan
Tilikan : penyangkalan total dari penyakit,
ketidakmampuan membuat pernyataan-
pernyataan yang terorganisir dan rasional
 Rapid cycling

Patients with rapid cycling bipolar I disorder are

likely to be female and to have had depressive
and hypomanic episodes. No data indicate that
rapid cycling has a familial pattern of inheritance
and, thus, an external factor such as stress or
drug treatment may be involved in the
pathogenesis of rapid cycling.
The DSM-IV-TR criteria specify that the patient
must have at least four episodes within a 12-
month period
 Distimia
DSM-IV-TR: the presence of a depressed mood
that lasts most of the day and is present almost
continuously. There are associated feelings of
inadequacy, guilt, irritability, and anger;
withdrawal from society; loss of interest; and
inactivity and lack of productivity. The term
dysthymia, which means 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).
 subaffective or subclinical depressive disorder
with (1) low-grade chronicity for at least 2 years;
(2) insidious onset, with origin often in childhood
or adolescence; and (3) persistent or
intermittent course. The family history of
patients with dysthymia is typically replete with
both depressive and bipolar disorders, which is
one of the more robust findings supporting its
link to primary mood disorder
 Siklotimia

Cyclothymic disorder is symptomatically a mild

form of bipolar II disorder, characterized by
episodes of hypomania and minor depression.
DSM-IV-TR, : a chronic, fluctuating

disturbance with many periods of hypomania
and of depression. The disorder is
differentiated from bipolar II disorder, which is
characterized by the presence of major (not
minor) depressive and hypomanic episodes.
 Gangguan mood lainnya
Tidak memenuhi kriteria distimia, gangguan penyesuaian
dengan mood depresi atau campuran. Atau termasuk
Anksietas ytt.
Include :
Premenstrual dysphoric disorder: in most menstrual cycles during the past year,
symptoms (e.g., markedly depressed mood, marked anxiety, marked affective
lability, decreased interest in activities) regularly occurred during the last week of
the luteal phase (and remitted within a few days of the onset of menses). These
symptoms must be severe enough to markedly interfere with work, school, or
usual activities and be entirely absent for at least 1 week postmenses.
Minor depressive disorder: episodes of at least 2 weeks of depressive symptoms
but with fewer than the five items required for major depressive disorder.
Recurrent brief depressive disorder: depressive episodes lasting from 2 days up
to 2 weeks, occurring at least once a month for 12 months (not associated with
the menstrual cycle).
Postpsychotic depressive disorder of schizophrenia: a
major depressive episode that occurs during the
residual phase of schizophrenia.
A major depressive episode superimposed on
delusional disorder, psychotic disorder not otherwise
specified, or the active phase of schizophrenia.
Situations in which the clinician has concluded that a
depressive disorder is present but is unable to
determine whether it is primary, due to a general
medical condition, or substance induced.
VI. DIFFERENTIAL DIAGNOSIS

1. Mood disorder resulting from general medical

condition secondary to medical illness
(e.g., brain tumor, metabolic illness, HIV, etc.)
2. Substance-induced mood disorder caused
by drugs or toxin
3. Schizophrenia
4. Grief
5. Personality disorders
6. Schizoaffective disorders
7. Adjustment disorder with depressed mood
maladaptive response
Primary sleep disorders
8. Other mental disorders eating disorders,
somatoform disorders, anxiety/disorders
 VIII. TREATMENT
Antimanic Medications
Antidepresant Medication
 PENGOBATAN

Psikoterapi
Kognitif: perawatan jangka pendek dengan
terapis yang interaktif
Behavior
Interpersonal
Berorientasi psikoanalitis
Keluarga
Kelompok
 Prognosis (depresi)
Cenderung kronis dan relaps. 50% pasien yang
dirawat inap pada ep. I dapat sembuh sempurna.
Angka ini berkurang pada perawatan berulang.
Yang tidak sembuh tetap menderita distimia.
Rekurensi MDD 25% dalam 6 bulan setelah
pulang perawatan, 30-50% dalam 2 thn, 50-75 %
dalam 5thn. Psikofarmaka profilaksis dan 1-2
episode depresi memperbaiki prognosis. Makin
sering kambuh, masa interepisode makin pendek,
keparahan sakin meningkat.
 Prognosis (bipolar)
poorer prognosis than mdd. 40-50 % mengalami manik ke-2 dalam
2 tahun. Profilaksis litium memperbaiki prognosis (bermakna pada
50-60% pasien).
Poor prognostic factor : a premorbid poor occupational status,
alcohol dependence, psychotic features, depressive features,
interepisode depressive features, and male gender.
Good prognostid factor : Short duration of manic episodes,
advanced age of onset, few suicidal thoughts, and few coexisting
psychiatric or medical problems predict a better outcome.
7% tidak rekurens; 45% menderita lebih dari 1 ep. 40% menjadi
kronis. Patients may have from 2 -30 manic episodes (mean 9). 40%
have more than 10eps. On long-term follow-up, 15% are well, 45 %
are well but have multiple relapses, 30% are in partial remission,
and 10% are chronically ill. One third of all patients with bipolar I
disorder have chronic symptoms and evidence of significant social
decline.
 Prognostic Indicators :
Mild episodes, the absence of psychotic symptoms, a short
hospital stay.
Psychosocial indicators, a history of solid friendships during
adolescence, stable family functioning, and generally sound
social functioning for the 5 years preceding the illness.
absence of a comorbid psychiatric disorder and of a personality
disorder, no more than one previous hospitalization for mdd,
and an advanced age of onset.
poor prognosis : coexisting dysthymic disorder, abuse of alcohol
and other substances, anxiety disorder symptoms, and a history
of more than one previous depressive episode. Men poorer
than women.
Case Illustration