Mood Disorders: Specialists and Information

Mood disorders are characterized by mood disturbances at the core of the problem. This means that the person’s mood is either depressed and withdrawn or manic and agitated.

Mood disorders typically occur in phases: Before and after a depressive or manic episode, the person’s mood returns to the normal range. In many cases, depressive and/or manic episodes occur multiple times throughout a person’s life. These are also referred to as recurrent or “relapsing” disorders.

In addition to depression and mania, persistent affective disorders such as

• dysthymia (a persistent mildly depressed mood) and
• cyclothymia (a mood that fluctuates persistently between mildly depressed and mildly elevated)

are classified as affective disorders.

Depression is classified according to its severity into mild, moderate, and severe depressive episodes. In cases of severe depression, a distinction can also be made between depression with and without psychotic symptoms (loss of touch with reality).

Manic episodes are classified as hypomanic (milder) and manic (more severe). Manic episodes may occur with or without psychotic symptoms.

In addition to purely depressive or manic episodes, so-called mixed affective disorders can also occur. In these cases, manic and depressive states alternate in rapid succession. This is also referred to as bipolar disorder.

Mood disorders can follow a unipolar or bipolar course. In a unipolar course, only manic or depressive phases occur; in the vast majority of cases, only depression occurs, while repeated episodes of pure mania are very rare.

In a bipolar course, manic and depressive episodes alternate, though the alternation is not regular. Unipolar disorders are much more common than bipolar disorders.

Most affective disorders are recurrent, meaning they occur in multiple phases. In only about 15 percent of all cases does depression occur just once.

Mood disorders are caused by various factors. These may include

• a genetic predisposition,
• adverse childhood experiences,
• physical illnesses,
• current stressful situations or conflicts, as well as
• hormonal or other biological changes

are among them.

It is believed that genetic factors contribute to an increased predisposition to affective disorders.

However, other factors—such as stressful situations or hormonal changes—are what trigger the episodes of the disorder.

• Evidence supporting a genetic predisposition includes findings that mood disorders occur more frequently among close family members. This clustering is also evident even when, for example, children did not grow up in the same household as the affected individual. However, the specific genes responsible are not yet precisely known.
• Early experiences of loss and separation during childhood are also more common among patients with depression.
• Physical illnesses or the use of certain medications can trigger a mood disorder.
• Current stressful situations play a role as triggers of affective episodes, as they frequently occur in the run-up to depressive disorders.
• The mechanism of action of antidepressants, among other things, supports the influence of biological factors, as these drugs interfere with neurotransmitter transmission in the brain.

About one to two percent of all people develop a bipolar disorder at some point in their lives. In this condition, depressive episodes alternate with manic, hypomanic, or mixed phases. On average, bipolar disorders begin earlier than major depression: the average age of onset is 16 to 18 years. Women and men are affected equally often.

Bipolar disorders more often begin with mania than with depression. They are usually more severe than major (“unipolar”) depression, meaning that more episodes occur.

When depressive episodes alternate with pronounced manic episodes, the condition is also referred to as bipolar I disorder. If only mild hypomanic episodes occur alongside depressive phases, the disorder is classified as bipolar II disorder.

As with major depression, the episodes in bipolar disorder usually resolve completely. Nevertheless, 20 to 30 percent of those affected may be severely impaired even during symptom-free phases due to increased mood lability.

The overall prognosis for bipolar disorders is worse than that for unipolar depression. The rate of comorbid mental disorders is higher, and the suicide rate is also higher, ranging from 15 to 30 percent.

Dysthymia refers to chronic (lasting at least two years) mild depressive disorders. They never reach the severity of a full-blown depression. However, additional depressive episodes often occur over the long term.

Approximately 6 to 10 percent of all people are affected. In the past, these forms were also referred to as neurotic depression.

Cyclothymia is characterized by alternating depressive and elevated moods over a period of at least two years, without meeting the criteria for bipolar disorder. It occurs in 0.5 to 1 percent of the population and progresses to bipolar disorder in 15 to 30 percent of cases.

Manic episodes are, symptomatically, the opposite of depression. The key diagnostic criteria are:

• Elevated, infectious, and at times irritable mood,
• increased drive,
• rambling thought (i.e., patients jump from one topic to another),
• a lack of awareness of illness and impaired critical judgment,
• an extreme, almost unstoppable flow of speech,
• overconfidence bordering on delusions of grandeur,
• severe distractibility,
• reduced need for sleep and increased libido.

The elevated mood of manic patients manifests as an extremely good mood, exuberance, and cheerfulness. However, they are easily irritated. This means that their mood can easily shift to irritability with a distinctly aggressive undertone. Self-esteem is elevated during mania, while self-reflection—and, in particular, insight into the illness—is correspondingly severely impaired.

The vegetative symptoms also form the opposite of those seen in depression: Patients

• hardly need any sleep,
• have an increased appetite,
• feel particularly healthy and energetic, and
• often have an increased libido as well.

For this reason, some manic patients engage in rapidly changing sexual relationships.

“Flight of ideas” refers to the fact that manic patients think in an inconsistent, fleeting, and imaginative manner. The content of their thoughts changes constantly, and outsiders often can no longer keep up. However, in contrast to schizophrenic symptoms, the connections between their trains of thought are still understandable—that is, they are not disjointed.

During manic episodes, delusions of grandeur with rapidly changing content frequently occur: for example, patients may successively believe themselves to be a gifted singer and a highly sophisticated entrepreneur. These delusions can escalate into delusions of grandeur.

The increased drive manifests as heightened activity and movement, along with a strong urge to talk. Many spontaneous thoughts and decisions may be acted upon without critical reflection. This can lead to serious social problems if, for example, patients

• ruin themselves financially by acting on a spontaneous business idea,
• behave in a completely uninhibited manner sexually, or
• do things for which they feel bitter shame once the mania has subsided.