Download Mood Disorders - Psychology for you and me

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Mood
Disorders
Major Depression
And
Bipolar Disorder
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Prevalence of Mood Disorders
About 7.8% of the North American population
report some type of mood disorder during their
lifetime, and 3.7% over the
Family studies indicate that the rate of mood
disorders in relatives of probands (i.e., the person
known to have the disorder) with mood disorders is
generally two to three times greater than the rate in
relatives of normal probands.
Twin studies reveal that if one identical twin
presents with a mood disorder, the other twin is 3
times more likely than a fraternal twin to have a
mood disorder, particularly for bipolar disorder.
Severe mood disorders may have a stronger
genetic contribution than less severe disorders.
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Biological dimensions: Neurobiological
influences
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Research indicates low levels of serotonin in the
etiology of mood disorders but only in relation to
other neurotransmitters, including norepinephrine
and dopamine.
One of the functions of serotonin is to regulate
systems involving norepinephrine and dopamine.
The permissive hypothesis stipulates that when
serotonin levels are low, other neurotransmitters
are permitted to range more widely, become
dysregulated, and contribute to mood
irregularities.
Another theory of depression has implicated the
endocrine system, particularly elevated levels of
cortisol.
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The study of the effects of
various antidepressant drugsincluding MAO inhibitors,
tricyclics, and selective
serotonin reuptake (SSRIs)-has
led to hypothesis about the role
of the neurotransmitters in
producing behaviors associated
with depression.
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Sleep disturbances are a hallmark of most
mood disorders. Depressed persons move into
the period of rapid eye movement sleep
(REM) more quickly than nondepressed
persons and also show diminished slow wave
sleep (i.e., the deepest and most restful part of
sleep).
This REM effect is reduced for persons who
have depression related to recent life stress.
REM activity is intense in depressed persons.
Depriving depressed persons of sleep improves
their depression.
• Persons with bipolar disorder and their children
show increased sensitivity to light (i.e., greater
suppression of melatonin when exposed to light at
night). A relationship between seasonal affective
disorder, sleep disturbance, and disturbance in
biological rhythms has thus been proposed.
• Different alpha electroencephalogram (EEG)
values have been reported in the two
hemispheres of brains of depressed persons.
Depressed persons show greater right-side
anterior activation of the cerebral hemispheres
(i.e., left-side activation) than nondepressed
persons. This type of brain function may be an
indicator of a biological vulnerability for
depression.
Depression
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Depression can refer to a symptom or a disorder.
The symptom of depressed mood does not
necessarily mean a person has a depressive
disorder.
 Although some symptoms of depression occur
frequently in people who “have the blues” but
are nor clinically depressed,
Depressive disorders are sometime referred to as
unipolar disorder to differentiate these types of
depression from that found in bipolar disorder.
There are several categories of depressive
disorder.
Patients often describe the symptom of
depression as one agonizing emotional pain and
sometimes complain about unable to cry, a
symptom that resolves as they improve.
About two thirds of all depressed patients
contemplate suicide, and 10 to 15 percent commit
suicide.
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According to the learned helplessness
theory of depression, people develop
depression and anxiety when they assume
they have no control over life stress. A
depressive attributional style has the
following three characteristics.
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First, the attribution is internal in that one
believes negative events are one's fault.
Second, the attribution is stable in that one
believes that future negative events will be
one's fault.
Third, the attribution is global in that the
person believes negative events will
influence many life activities.
Evidence is mixed as to whether learned
helplessness is a cause or side effect of
depression.
•
These beliefs may comprise a negative
schema, or an automatic and enduring
cognitive bias/errors about aspects of
life. :
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Arbitrary inference refers to the tendency of
depressed persons to emphasize the
negative rather than positive aspects of a
situation.
Overgeneralization refers to the tendency
to take one negative consequence of some
event and generalize to all related aspects of
the situation.
Bipolar Disorder I
& II
Cyclothymia
MDD –Severe with
Psychotic features
MDD- severe
MDD-Moderate
MDD Mild
Dysthymia
Adjustment d/o with
Depressed Mood
Depressed Mood
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In every language, we often use the term
depression to refer to normal feelings
experiences after significant loss, such as the
breakup of a relationship or the failure to attain
a significant goal. Theses feelings are not
classified as a depressive disorder by DSM-VI.
Symptoms of grief over the death of a loved
one also are not classified as a depression
unless they continue for an unusually long
period.
Mood Disorders
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Facts about Mood Disorders
Depressive disorder is relatively
common.
Bipolar disorders are much less
common than depressive disorder.
The overall rates of both depressive
and bipolar disorders, but not their
typical symptoms, seem to be affected
by a variety of cultural, economic, and
environmental factors.
Vulnerability factors for
depression
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Genetic makeup, or heredity, is an important
risk factor for both major depression and
bipolar disorder.
Age is also a risk factor. Women are particularly
a risk during young adulthood, while for men
the risk is highest in early middle age.
Gender is also a related risk. Twice as many
women as men in the general population report
a depressive disorder.
Other risk factor are experiencing negative life
events and lack of social support, particularly
from close relationships. This support may be
especially valuable if stressful life events have
recently occurred.
Cont. Depression
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Almost all depressed patients (97 percent0
complain about reduced energy; they have
difficulty finishing tasks, are impaired at school
and work, and have less motivation to
undertake new projects).
About 80 percent of patients complain of
trouble sleeping, especially, especially early
awakening (I.e. terminal insomnia) and
multiple awakenings at night, during which they
ruminate about their problems.
Many patients have decrease appetite and
weight gain and sleep longer than usual.
Types of mood disorder
Depressive Disorder or Unipolar
1.
Dysthymic disorder:
1.
2.
History of depressed mood a majority
of the time.
Major depressive disorder:
1.
One or more major depressive
episodes.
Bipolar Disorders
1.
Bipolar I disorder: One or more manic
episodes, and usually
one or more major depressive episodes.
2.
Bipolar II disorder: At least one hypomanic
episode and one or more major depressive
episodes but no manic episode or
cyclothymia.
3.
Cyclothymic disorder: Numerous hypomanic
episodes and numerous periods of
depressive symptoms that do not meet
criteria for major depressive episode.
Dysthymic Disorder
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Dysthymic disorder shares many of the
symptoms of major depressive, but unlike major
depression, the symptoms in dysthymia tend to
be milder and remain relatively unchanged over
long periods of time, as much as 20 or 30 years.
Dysthymic disorder is defined by persistently
depressed mood that continues for at least 2
years. During this time, the person cannot be
symptom free for more than 2 months at a time.
Many eventually experience a major depressive
episode at some point.
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a.
The mean age of onset for dysthymia is
typically in the early 20s (i.e., late onset). The
onset of dysthymia before age 21 (i.e., early
onset) is associated with (a) greater chronicity,
(b) relatively poor prognosis (i.e., response to
treatment), and (c) stronger likelihood of the
disorder running in the family.
b.
The median duration of dysthymic disorder
is approximately 5 years in adults and 4 years in
children.
c.
Patients suffering from dysthymia have a
higher likelihood of attempting suicide than those
suffering from major depressive disorder.
DSM-IV-TR Diagnostic Criteria for
Dysthymic Disorder
A.depressed mood for mood for most of the day, for more
days than not, as indicated either by subjective
account or observation by other, for at least 2 years.
Note: In adolescents, mood can be irritable and
duration must be at least 1 year.
B. Presence, while depressed, of two (or more0 of the
following:
(1)
Poor appetite or over eating
(2)
Insomnia or hypersomnia
(3)
Low energy or fatigue
(4)
Low self-esteem
(5)
Poor concentration or difficulty making decisions
(6)
Feelings of hopelessness
C. During the 2-year period (1 yr. For children or
adolescents) of the disturbance, the person has never
been without symptoms in criteria A and criteria B for
more than 2 months at a time.
Cont.DSM-IV-TR Diagnostic Criteria
for Dysthymic d/o
D. No major depressive episode has been present during the
first 2 years of the disturbance (1 year for children and
adolescent_ I.e. the disturbance is not better accounted for
by chronic major depressive disorder, in partial remission.
Note: there may have been previous major depressive
episode provided there was full remission (no significant
signs or symptoms for 2 months) before development of the
dysthymic disorder.
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.
Cont.DSM-IV-TR Diagnostic
Criteria for Dysthymic d/o
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Age of onset is typically in the early 20s
(i.e., late onset).
Onset of dysthymia before age 21 (i.e.,
early onset) is associated with:
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Greater chronicity.
Relatively poor prognosis (i.e., response to
treatment).
Stronger likelihood of the disorder running in
the family.
Greater prevalence of personality disorders.
Criteria for Major Depressive Episode
Five (or more) of the following symptoms have
been present during the same 2-week period and
represent a change from previous functioning; at
least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to
a general medical condition, or mood-incongruent
delusions or hallucinations.
(1)
Depressed mood most of the day, nearly every day, as
indicated by either subjective report (e.g. feels sad
or empty) or observation made by other (e.g.
appears tearful) Note: in children and adolescent
can irritable mood.
(2) Markedly dimishid interest or pleasure in all, or
almost all, activities most of the day, nearly every
day (as indicated by either subjective account or
observation made by others).
A.
Cont.
criteria for major depressive
episode
(3) Significant weight loss when not dieting or weight gain
(e.g. a change of more than 5% of body weight in a month),
or decrease or increase appetite nearly everyday. Note: in
children, consider failure to make expected weight gains.
(4) Insomnia or hypersomnia nearly every day.
(5) Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of
restlessness or being slowed down)
(6) Fatigue or loss of energy nearly everyday
(7) Feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day (not
merely self-approach or guilt about being sick)
(8) Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others)
((9) recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
Recurrent Major depressive disorder
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When a person who has experience
one major depressive episode
develops the symptoms again at a
later time, the diagnosis is changed
to recurrent major depressive
disorder.
DSM-IV-TR-Diagnostic criteria, p.
376
A.
As many as 85% of single-episode
cases later have a second
episode of major depression.
Dysthymia + MDD =
A.
B.
C.
Double depression refers to both major
depressive episodes and dysthymic
disorder.
Dysthymic disorder often develops first,
and this condition is associated with
severe psychopathology and a problematic
future course.
Double depression is quite common, with
as many as 79% of persons with
dysthymia reporting a major depressive
episode at some point in their lives.
Indeed, many do not recover after two
years, and relapse rates are very high.
The bipolar disorders
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Is an illness involving episodes of mania and
depression. Tends to be chronic.
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Suicide is a common consequence.
Bipolar I – will experience episodes of mania
and usually major depressive episodes as well.
bipolar d/o has been found to occur with a
higher frequency of creative people such as
artist and poets than in the general population.
Episodes of bipolar d/o tend to recur. The
number of recurrence is greater in those who
have a family history that include bipolar
disorder.
Bipolar disorder
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Bipolar II Disorder is variant of bipolar disorder in
which there has been no manic episode but at least
one hypomanic period as well as a major depressive
episode.
A hypomanic episode refers to a period of manic
behavior that is not extreme enough to greatly
impair function.
People who experience a hypomanic episode may
not see it as pathological, although those around
them may be concerned about the erratic behavior
they see.
For the person affected, the feelings of elation and
creativity and the driving energy characteristic of the
hypomanic state can be positive forces.
DSM-IV-TR Diagnostic criteria, p.397
Manic/hypomanic& mixed
episodes
A manic episode is a distinct period of abnormality
and persistently elevated, expansive, o irritable
mood lasting for at least 1 week, or less if a patient
must be hospitalized.
A hypomanic episode lasts at least 4 days and is
similar to a manic episode except that is not severe
enough to cause impairment in social or occupational
functioning, and no psychotic features are present.
Both mania and hypomania are associated with
inflated self-esteem, decrease need for sleep,
distractibility, great physical and mental activity, and
over involvement in pleasurable behavior
Cyclothymic disorder
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is a more chronic version of bipolar disorder where
manic and major depressive episodes are less
severe. Such persons tend to remain in either a
manic or depressive mood state for several years
with very few periods of neutral (or euthymic) mood.
For the diagnosis, the pattern must last for at least
2 years (1 year for children and adolescents). Such
persons are also at increased risk for developing
Bipolar I or II disorder.
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Average age on onset is about 12 or 14 years.
Cyclothymia tends to be chronic and lifelong.
Most are female.
Suicide
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Suicide is the eighth leading cause of death in the
United States, although many unreported suicides
occur. Suicidal ideation refers to serious
contemplation about committing suicide, whereas
suicidal attempt refers to surviving an attempted
suicide. The rate of suicide is increasing, especially
among adolescents and the elderly. Males are 4-5
times more likely to commit suicide than females,
although females are three times more likely to
attempt suicide than men. This is explained by the
fact that men choose more lethal methods of suicide
than women.
Risk factors for suicide include the following:
If a family member commits suicide, there is an increased
risk that someone else in the family will also do so.
Existence of a psychological disorder is related to suicide,
as over 90% of people who kill themselves suffer from a
psychological disorder. As many as 60% of suicides occur
in persons suffering from a mood disorder.
• Depression and suicide are still
considered independent as suicide can
occur without a mood disorder and not all
persons with mood disorders try to kill
themselves.
• Alcohol use and abuse are associated
with 25% to 50% of suicides.
• Past suicide attempts is another strong
risk factor in predicting subsequent
suicide attempts.
• Most important risk factor for suicide is a
severe, stressful event that is
experienced as shameful or humiliating.
A Mnemonic Device for
Remembering all the different
sections of Psychological Disorders
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Depressed Patients Seem Anxious, So Claim Psychiatrists"
may be useful, as follows:
 Depression and other mood disorders (major
depression, bipolar disorder, dysthymia).
 Personality disorders (primarily borderline personality
disorder).
 Substance abuse disorders.
 Anxiety disorders (panic disorder with agoraphobia,
obssessive-compulsive disorder).
 Somatization disorder, eating disorders (these two
disorders are combined because both involve disorders
of bodily perception).
 Cognitive disorders (dementia, delirium).
 Psychotic disorders (schizophrenia, delusional disorder
and psychosis accompanying depression, substance
abuse or dementia).
SIGECAPS': A Mnemonic for
Symptoms of Major Depression
and Dysthymia
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SIGECAPS=SIG + Energy + CAPSules
Sleep disorder (either increased or decreased
sleep)*
Interest deficit (anhedonia)
Guilt (worthlessness,* hopelessness,* regret)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or
increased)*
Psychomotor retardation or agitation
Suicidality
SIGECAPS': A Mnemonic for
Symptoms of Major Depression
and Dysthymia
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NOTE: To meet the diagnosis of major
depression, a patient must have four
of the symptoms plus depressed
mood or anhedonia, for at least two
weeks. To meet the diagnosis of
dysthymic disorder, a patient must
have two of the six symptoms marked
with an asterisk, plus depression, for
at least two years
DIGFAST': Mnemonic for the Cardinal
Symptoms of a Manic Episode
Distractibility
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Indiscretion (DSM-IV's "excessive involvement in
pleasurable activities . . . ")
Grandiosity
Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)
NOTE: A manic episode requires at least one week of
elevated or irritable mood plus three of the seven
symptoms described above
DSM-IV=Diagnostic and Statistical Manual of Mental
Disorders, 4th ed