Humour Disorders · 11:53am Sep 21st, 2013

Only Comma-Kazie (and Owlor, when I first showed that to him) expressed his real delight, interest and willingness to actually use this (and maybe research further) when I talked about psychotic syndromes. That is good; if at least one person was interested, my mission was accomplished.

If you want to know more, try getting Kaplan and Sadock's Synopsis of Psychiatry.

Psychotic Syndromes
Humour Disorders
Anxiety, Dissociative and Somatoform Disorders
Personality Disorders
Eating Disorders
The concept of normality: A psychopathological approach
Organic Mental Disorders

Note: I will refrain from calling it "mood", since mood can be easily confused with affection and that is definitely not what I want here. So, instead, I'll use the older word used to describe mood: humour.

The humour can be understood as the "affective tonus" of the individual, the basal emotional state that "colors" their perception of the world. This is intimately connected with the affection and can be described in several ways: anxious, depressed, euphoric, amongst many other. Affection is defined as the emotional quality that accompanies an idea; the external expression of the emotional state, and it can be congruent or incongruent with the humour.

The humour disorders, once called manic-depressive psychosis, constitute a group of clinical conditions characterized by the sense of loss of control of the affective expressions and by the subjective experience of great suffering. The fundamental disturbance is a humour alteration, in the sense of a depression (with or without associated anxiety) or exaltation. This alteration is generally followed by a global change in the person's activity and the majority of the other symptoms is secondary or easily understood in the context of such alterations.

The main mood disorders are the bipolar and depressive ones. Although there are a few differences between the classifications adopted by the ICD-10 and the DSM-IV, the nosological systems are correspondent, with similar diagnostic criteria.

The ICD-10 uses, basically, five categories: manic episode; affective bipolar disorder; depressive episode; recurrent depressive disorder and persistent humour disorders (cyclothymia and dysthymia).

The DSM-IV divides the humour disorders in: major depressive disorder; type 1 bipolar disorder; type 2 bipolar disorder; dysthymia; cyclothymia and other humour disorders.

We will first approach the depressive disorders, their categories and the bipolar disorder. Afterwards, we will study other humour disorders, particularly dysthymia and cyclothymia.

Epidemiology
The depressive disorder is the most common humour disorder, with a prevalence in life of about 15% in the female population (twice as much as it is on the male population; independent from country or culture). The incidence is also high and sits around 10% of the entire world population and 15% of all hospitalized patients. The bipolar disorder is less common, with a prevalence of 1% (similar to schizophrenia's). The age that it first manifests itself is around 30 years of age, while the average for depressive disorder is around 40 years old. There is no variation of prevalence of humour disorders when comparing race or socioeconomical level. The depression happens more frequently in people that have no intimate inter-pessoal relationships or that are divorced. The bipolar disorder can be more common in divorced and single individuals, but this difference may reflect the presence of precocious matrimonial discord in these patients.

Etiology
The causal base for humour disorders is unknown, but the causal factors can be divided into biological, genetical and psychosocial. This division is merely didactic due to the fact that all three factors probably work in synergy.

Genetic factors
Genetic data indicate that a strong, significant factor in the developing of these disorders is the genes, being stronger the "transmission" of the bipolar disorder when compared to the depressive disorder. It has been demonstrated that the incidence in families is bigger than in the general population and the concordance between monozygotic twins is bigger than that of dizygotic twins. Adopted children remain with a higher risk of developing a humour disorder, even if away from the biological parents that have said disorder.

Biological factors
Noradrenaline and serotonin are the two neurotransmitters most associated with the physiopathology of the humour disorders. With the ample effect that the serotonin-selective reuptake inhibitors (SSRI)--for instance, fluoxetine--had over the treatment of depression, serotonin became the highest associated neurotransmitter linked to depression. Although noradrenaline and serotonin are both the most frequent ones associated with depression, dopanine, the gamma-aminobutyric acid (GABA) system, neuroactive peptides (particularly vasopressin and endogenous opioids) also seem linked with the disorders.

Neuroendocrine factors may be related with the surfacing of depressive symptoms as well. Alterations on the thyroid hormones can cause either depression or mania. It is for this reason that, in every patient with mood disorders, one should always test the thyroid function, even if one makes no claims of typical damage towards this gland. Alterations in the growth hormone (GH) and on the adrenal functions (mainly the ones linked with cortisol) can alter the immunologic state of the patient.

Neuroimaging, electrophysiology and neuropathological studies are done, but they show no consistent results, making them worthless to the clinical practice. There is some evidence pointing towards the involvement of the limbic system, the basal ganglia and the hipocampus.

Psychosocial factors
The vital and stressful happenings more frequently precede the first humour episodes, be them depressive or manic, than happen afterwards. The presence of permanent stress agents can precipitate and influence the clinical course of the humour disorders, interfering with the symptomatology and the recuperation, independently of the therapeutical approach.

The most associated factor with the development of depression is the loss of one of the parents before eleven years of age. The depressive syndromes and reactions often happen after significant losses: of a loved person, of a job, of a place of residence, of a socioeconomical status or of something purely simbolic. There is no trace or personality archetype that is said to predispose to depression or the bipolar disorder.

I - Depressive Syndromes
The depressive syndromes have, as the central element, the saddened humour, although other symptoms can be present (with varying gravities and frequencies).

Affective symptoms
Sadness; melancholia; easy to start to cry and (or frequently) apathy (affective indifference); feeling a loss of feelings; incapacity of feeling pleasure; boredom and chronic crankiness; higher irritability; anguish or anxiety; despair.

Physical alterations
Fatigue; easy and constant tiredness; sleep disorders (terminal insomnia or hipersonia); loss of appetite/weight; constipation; indigestion; sexual disorders (lower libido, erectile dysfunction); paleness; menstruation alterations; migraines.

Thought alterations
Negative ideation; pessimism; ideas of regret or guilt; ideas of being abandoned; self-punishing ideas; death-related ideas; wishing to disappear; suicidal plans/attempts/ideations. Alterations in the self-valor: feeling of low self-esteem and worthlessness; feeling of shame; self-depreciation and self-accusation.

Psychomotor and volition alterations
Higher latency between questions and answers; psychomotor lentification; diminished discourse; lower tone of voice; mutism (verbal negativism); negativism (refuses to eat; refuses social interaction); absence of plans and perspectives towards life.

Cognitive alterations
Difficulty to maintain focus; forgetting; difficulty to make decisions; depressive pseudodementia.

Psychotic symptoms
Delusional ideas with negative content; ruin or misery delusions; hallucinations (usually auditive, with depressive contents); other psychotic symptoms that are incongruent with the humour.

At the psychic exam: The depressed patient can show him/herself tired and worried, showing a lack of visual contact. The care with one's own appearance is minimal and the patient has a tendency to cry. The humour can be sad or irritable. Situations that once brought pleasure or joy lose these effects. In less accentuated depressions, the humour can oscillate during the day, with noon or morning worsening and the patient can take hour to come back to normality. The speech is monosyllabic, without spontaneity, monotone and with long pauses. The predominant thoughts are depressive, hypochondriac, less-value, inferiority and guilt. The suicidal ideas must always be investigated! The patient can merely wish death or he/she can think about it constantly and even plan suicide. The patient shows himself with hypotenacity (unable to keep the mental focus on something) and hypovigil (unable to notice things around him) . Along with this comes the disinterest and inability to retain information. One of the main alterations is the lack of energy, with tendencies to social isolation. The capacity to exert critical thought is also jeopardized, since the happenings are less interpreted in this depressive state.

II - Manic Syndromes
Euphoria (or pathological happiness) constitutes the main aspect of the manic syndrome. Besides this, it is fundamental (and almost always present) the acceleration of all psychic functions (tachypsychism). In a general way, we can observe the following signs and symptoms:

- Higher self-esteem; the patient feels superior, better, more potent.
- Intense personal satisfaction and exaggerated wellbeing
- Elation; a feeling of expansion and grandeur of the "self"
- Vegetative symptoms; higher libido, loss of weight, anorexia and insomnia (usually associated with the idea of lower need to sleep)
- Logorrhea; rapid verbal production, fluent and persistent.
- The need to speak unimpeded.
- Distractability; the patient is hypervigil (aware of everything around him), but with hypotenacity (unable to focus on a single thing)
- Irritability and arrogance.
- Sexual and social dysinhibition; making the patient perform inadequate acts.
- Psychomotor agitation and heteroagressivity (against others; not against heterosexuals!).
- Hypersensuality and promiscuity.
- Tendency to excessive spendings and lack of control of the impulses.
- Grandeur or power delusions, which may or may not be associated with auditive hallucinations.

At the psychic exam: Extravagant appearance, with colorful clothes, excessive makeup, bizarre accessories and a lack of attention to the personal appearance. The patient can display impatience, self-confident and a seductive attitude. The affection is unstable and the humour euphoric, exalted or irritable. There can be abrupt humour swings. The contents of their thoughts are egocentric, grandiose, with a very, very high self-esteem. Grandeur, paranoid or mystical delusions can happen (with or without auditive hallucinations). The thought process becomes accelerated and there is the subjective feeling of a higher speed/influx of ideas; the patient is very talkative and filled with new plans and ideas. The extreme of this acceleration is the "idea drain", an alteration wherein the speech and the thought are controlled less by the meaning of the words and more by assonance associations, leading to a difficulty in comprehending the speech. The patient can't focus his attention (hypotenacity), losing the focus whenever new stimuli happen (hypervigil). Euphoria leads to the jeopardy of the critical thought capacity, usually leading to complete negation of the disorder and incapacity to make any decision. The patient can show him/herself as unrested, agitated, with physical or verbal aggression.

Diagnosis and classification
Both the manic and depressive syndromes are diagnoses phenomenologically. But they can all be classified as follows:

Depressive disorders
Depressive Episode
Evident depressive symptoms must be present for, at least, two weeks. The episodes, in general, last from three to twelve months. The episodes can be classified as weak, medium or severe depending on their number, intensity and the clinical importance of the symptoms. When the patient has, along his life, various depressive episodes that are never intercalated with manic episodes, the diagnosis of recurrent depressive disorder is made.

Endogenous depression (a.k.a. Melancholy)
Considered from "coming from withing"-"unhappy conscience"-it is more independent of psychogenic factors. The typical symptoms are anedonia, excessive guilt, worse during the morning, terminal insomnia and psychomotor lentification.

Atypical depression
Characterized by the gain of weight, hyperfagia, higher appetite (especially towards sweets and chocolate), hypersonia and feeling of a heavy body. Classically, it responds better to treatment with antidepressants that inhibit the monoaminooxidase (IMAO) when compared with the tryciclical antidepressants.

Seasonal depression
Depression that happens during the period of less daylight (winter and autumn) and disappears during spring and summer.

Postpartum depression
It starts within four weeks after the birth. The symptoms vary from accentuated insomnia, instability, fatigue and suicide. Delusional beliefs and homicidal tendencies towards the baby can happen. It happens with more frequency in women that already have a humour disorder or other psychiatric disorder. It can become a psychiatric emergency towards both mother and baby. The same applies to a manic episode or a short psychotic episode.

Psychotic depression
Grave depression, in which, along with the depressive symptoms, one or more psychotic symptom (such as ruin, guilt or hypochondriac delusions; hallucinations with depressive content). If the psychotic symptoms are depressive, it is classified as humour-congruent. If not, they are classified as humour-incongruent.

Depressive stupor
What prevails is the negativism, with absence of answer/response towards environmental solicitations, mutism, refuse to eat and immobile behavior. It is also called catatonic depressive episode.

Pseudodementia
A depressive episode that shows itself with cognitive dysfunction similar to that of dementia. It happens more frequently in the elderly with a previous history of humour disorders. The depression happens before the cognitive dysfunctions.

Double depression
Patients with dysthymia that develop a major depressive disorder on top of it.

Manic disorders
Grave manic episode
The most intense form of mania, with tachypsychism, psychomotor agitation, heteroaggressivity, idea drain and grandeur delusions.

Irritated manic episode (a.k.a. Dysphoria)
What is most prominent is the irritability, crankiness, hostility towards others which can lead to heteroaggressivity and the destruction of objects.

Mixed episode
There are both manic and depressive symptoms happening at the same time, with no intercalation between them.

Manic stupor
Like with the depressive stupor, the most prominent features are the catatonic ones.

Hypomania
It is an attenuated form of a manic episode which, many times, can pass by unnoticed and usually doesn't get medical attention.

Bipolar disorders
Type 1 bipolar disorder
Light to grave depressive episodes, intercalated with a normal phase or a manic episode that are very well characterized.

Type 2 bipolar disorder
Light to grave depressive episodes, intercalated with a normal phase or a hypomania episode. There are no manic episodes.

Fast-cycling bipolar disorder
Manic and depressive episodes alternating themselves quickly (intervals last from 48-72 hours)

III - Other Humour Disorders
Dysthymic Disorder
Light depression that can last for long periods of time. It is more common in women. It happens frequently in people with a history of prolonged stress or sudden losses. It can coexist with other psychiatric disorders, such as substance abuse and personality disorders. It first manifests itself at the start of adult life and the symptoms must be present for, at least, two years. The most common symptoms include: lower self-esteem; trouble with sleep; chronic crankiness; irritability; lack of concentration; difficulty to make decisions. It isn't incapacitating, but it affects the performance and social relationship of the patient and causes a considerable suffering.

Cyclothymic Disorder
Characterized by persistent mood instability which alternate between numerous dysthymical periods or lack of interest or pleasure with hypomanic episodes. Such episodes aren't grave nor lasting enough to be considered bipolar disorders. This condition is a chronic one and can affect both men and women alike. The first episode usually manifests itself during the end-teen years and the start of the adult age. The recurrent humour swings can cause professional and social difficulties.

Well, what you are willing to see next? Personality disorders? Eating disorders? Organic mental pathologies (dementia and delirium)?

Also: Don't do this... people get scared. If you do, however, film it!