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Female Mood Disorders Jeanne Watson Driscoll, PhD, APRN, BC October 5, 2007 Women’s Health: Addiction, Trauma and HOPE Objectives The participants will: Discuss the key variables in women’s mental health and disease Discuss the importance of women’s hormones and reproductive transitions Describe common mental disorders in women Discuss signs and symptoms of the disorders and care strategies Women’s mental health Female aspects are invisible Limited research pertaining to the menstrual cycle and women’s mental health Context and culture The Female Brain Different metabolism of medications 15% greater blood flow in brain: serotonin system more reactive Differences across the menstrual cycle Drug interactions Exclusion from drug studies Structure/Function Differences Corpus Callosum: 23% larger (Gorsky & Allen) Language area 30% larger (Harasty) Paralimbic Cortex more active (Gur & Gur) Facial recognition easier (Gur & Gur) Neuroanatomy Limbic Brain Amygdala Locus ceruleus Hippocampus Paralimbic Cortex Amygdala Connected with hypothalamus Regulates sexual and aggressive behavior Promotes emotional learning, survival behavior and fear Dense estrogen receptors Locus Ceruleus Located in brain stem Main depot for Norepinephrine, “fight or flight” mechanism Hippocampus Learning and memory Key determinant in the brain’s ability to regulate stress response, if it cannot switch off the secretion of cortisol it can lead to depression and memory problems Dense estrogen receptors Hypothalamus Critical to the endocrine system Affects thyroid and adrenal glands, ovaries, testes and the secretion of reproductive hormones Neurochemical pathways feed this gland: serotonin, dopamine, and norepinehprine Paralimbic Brain Emotional coloring Buffer between external reality and internal urges Learning and memory Stress Response Cortex Higher cortical functions Right brain Left brain Hypothalamic-pituitary-adrenal Axis (HPA) Hypothalamus secretes corticotropin releasing hormone (CRH) Pituitary secretes adrenocorticotropic hormone (ACTH) Adrenal glands secrete cortisol Reproductive Hormones Estrogen Progesterone Testosterone Estrogen Maintains orderly firing of serotonin, dopamine, acetylcholine, and norepinephrine nerve cells Enhances glutamate activity (neurotransmitter that accelerates nerve communication in the brain) May promote growth of nerve cells containing acetylcholine, especially in the hippocampus. (mental acuity) When it rises, overall effect is to elevate 5HT levels----mood stability: when it drops may alter mood stability Progesterone Decreases the number of available estrogen receptors Evidence that at the end of the menstrual cycle progesterone may dismantle nerve connections that estrogen established at the beginning of the cycle (potential problems with progesterone component of birth control pills) Testosterone In women produced in small amounts in the synthesis of estrogen Affects the limbic brain, stimulating libido and aggressive behavior Key vulnerable times in a woman’s life Menarche Premenstrual Pregnancy Infertility Postpartum Perimenopause Menopause How does this all interact? “Brain Strain” Allostatic Loading (McEwen) Allostasis: stability through change. When the body is placed underincreased demand, it adjusts to the demand. Allostatic loading: wear and tear on the brain and the body, especially the hippocampus Allostatic Loading Wear and tear: Situations associated with allostatic load Frequent stress Adaptation to repeated stressors of the same type, resulting in the prolonged exposure of the body to the stress hormones Inability to shut allostatic responses after the stress is terminated Inadequate responses from some allostatic systems trigger compensation in others The brain in distress Does not feel pain Distress is interpreted through signs and symptoms Mood, anxiety, and physical symptoms are demonstrated The following are mental disorders that can occur or be exacerbated by the reproductive events of a woman's life: menarche, infertility, pregnancy, postpartum, perimenopause, and menopause. Depressive Disorders (DSM-IV, 1994) Major depressive episode (296.2x) Dysthymic disorder (300.4) Depressive disorder not otherwise specified (311) Depressive Disorders Lifetime rates 10-25 % (Kessler, et al, 1994) Onset peaks between ages of 25 and 44 years Women living with depression have longer duration of illness, recurrences linked to reproductive events, atypical symptoms, more somatic symptoms, delayed treatment response, seasonal susceptibility and comorbidity (Burt, 2002) Major Depressive Disorders Five or more of following present during the past two week period: Depressed mood most of the day Marked diminished interest or pleasure in all or most activities of the day Decrease or increase in appetite Insomnia/hypersomnia Psychomotor agitation or retardation Major Depressive Episode con’t Fatigue or loss of energy Feeling worthless, excessive guilt Diminished ability to think, concentrate or indecisiveness Recurrent thoughts of death Dysthymic Disorder (DSM-IV, 1994) Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years Presence, while depressed, of two (or more)of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Dysthymic Disorder, continued Symptoms continued Low self esteem Poor concentration or difficulty making decisions Feelings of hopelessness Premenstrual Dysphoric Disorder Premenstrual mood changes that interfere with functional living Careful evaluation: are the symptoms related to menstruation or are they exacerbations of other psychiatric illnesses? Chart/document for a few cycles Bipolar Spectrum Disorders Bipolar 1: Bipolar II (soft): Bipolar III: Cyclothymic Disorders: It is critical to do a complete history to rule out the biochemical sensitivity/vulnerability of the women to these disorders Bipolar I Disorder (DSM-IV,1994) Presence of only one manic episode and no past major depressive episodes Manic episode Distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week Bipolar I Disorder, continued During the period of mood disturbance, three of more of the following symptoms have persisted and have been present in a significant degree Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Mood disturbance sufficiently severe to cause marked impairment in occupational functioning or usual social activities and interpersonal relationships, may require hospitalization to prevent harm to self or others. Bipolar II Disorder (DSM-IV, 1994) Presence of one or more major depressive episodes Presence of at least one hypomanic episode Symptoms cause distress Hypomanic Episode (DSM-IV, 1994) Distinct period of persistently elevated, expansive, or irritable mood, lasting for at least 4 days, that is clearly different from the usual nondepressed mood 3 or more of the following present: Inflated self esteem or grandiosity Decreased need for sleep More talkative, pressure to talk Cyclothymic Disorder (DSM-IV, 1994) For at least 2 years, presence of numerous periods of hypomanic symptoms and numerous periods of depressive symptoms that do not meet criteria for major depressive disorder Anxiety Disorders 1 year prevalence rate in the general population 17.2%; lifetime prevalence is 24.9% Lifetime rate of any anxiety disorder in women in 34.4% Anxiety Disorders (DSM-IV, 1994) Panic disorder without agoraphobia (300.01) Panic disorder without agoraphobia (300.21) Obsessive compulsive disorder (300.3) Posttraumatic Stress disorder (309.81) Acute stress disorder (308.3) Generalized anxiety disorder (300.02) Panic Attack (DSM-IV, 1994) Discrete period of intense fear or discomfort, four or more of the following develop abruptly and reach a peak within 10 minutes: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Panic attack, continued Chest pain or discomfort Nausea or abdominal distress Derealization (feelings of unreality) or depersonalization (being detached from oneself) Feeling dizzy, unsteady, lightheaded, or faint Fear of losing control or going crazy Fear of dying Paresthesias (numbing or tingling sensations) Chills or hot flashes Panic attack, continued With agoraphobia: anxiety about being in places or situations where escape might be difficult or embarrassing, or in which help may not be available in the event of having a panic attack Situations are avoided or endured with marked distress Obsessive-Compulsive Disorder (DSM-IV) Either obsessions or compulsions Obsessions: Recurrent or persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress The thoughts, impulses, or images are not simple excessive worries about real-life problems OCD, continued Obsessions,con’t. Person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action Person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind(not imposed from without as in thought insertion) OCD, continued Compulsions: Repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly OCD, continued Compulsion, continued The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. OCD, continued At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive and unreasonable The obsessions or compulsions cause marked distress, are time consuming,and significantly interfere with normal routine Other obsessions Trichotillomania: hair pulling Other obsessions may be do to another primary disorders: eating disorder, body dysmorphic disorder, substance use disorder, hypochondriasis, etc. Posttraumatic Stress Disorder (DSM-IV, 1994) The person has been exposed to a traumatic event in which both of the following were present: Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to physical integrity of self or others PTSD, continued Person’s response involved intense fear, helplessness, or horror Traumatic event re-experienced in one or more of the following: Recurrent or intrusive distressing recollections of the event, including images, thoughts, or perceptions PTSD, continued Recurrent distressing dreams of the event Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated PTSD, continued Intense physiological distress at exposure to internal or external cues Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. PTSD, continued Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, as indicated by three or more of the following: Efforts to avoid thoughts, feelings, or conversations associated with the trauma Efforts to avoid activities, places, or people that arouse recollections PTSD, continued Unable to recall important aspects of trauma Marked diminished interest or participation in significant activities Feeling of detachment or estrangement from other Restricted range of affect Sense of a foreshortened future PTSD Women have a higher propensity to develop PTSD after exposure to traume than men (Kessler, et al, 1995) Rate of PTSD secondary to birth trauma ranges from 1.5% to 5.6% (Beck, 2004) Generalized Anxiety Disorder (DSM-IV, 1994) Excessive anxiety and worry, occurring more days than not for at least 6 months. Person finds it difficult to control worry Anxiety and worry associated with: Restlessness or feeling keyed up or on edge Being easily fatigued GAD, continued Difficulty in concentrating or mind going blank Irritability Muscle tension Treatment and management issues Case finding: Estimated that 20% of patients see their PCP for symptoms of depression, yet this common condition continues to remain undiagnosed and undertreated (Marrow, et al, 1993; Zung, et al, 1993) Identification of risk factors Family history Where to send for help? Who are your resources? Care plan development Physical examination R/o Thyroid disorders Treatments: Psychotherapy Insight based Cognitive behavioral Supportive Interpersonal Psychopharmacology Neuroleptics, antidepressants, anti-anxiety medications, mood stabilizing medications Treatments continued Treatment based on the context of the woman’s life Support systems Family involvement Pregnant Postpartum/breastfeeding Depressive Disorders: suggested treatment modalities Pharmacological methods SSRI agents SSNI agents Others Psychotherapy Interpersonal Cognitive Behavioral Relational-Cultural Mood Swing Disorders Pharmacological aspects Mood stabilizer agents Atypical neuroleptics Psychotherapy Interpersonal Cognitive behavioral Relational-cultural Anxiety Disorders Psychopharmacological agents Benzodiazepines Antidepressant agents Psychotherapy Cognitive Behavioral Interpersonal Supportive Relational-cultural The NURSE Plan© Sichel & Driscoll, 1999 Nutrition and Needs Understanding Rest and Relaxation Spirituality Exercise Nutrition and Needs Nourishment and needs Eliminate alcohol Vitamins Medications: food for the brain Emotional needs Understanding Engage the intellect/cortical skills Feelings, thoughts, concerns Psychotherapy Education Journal keeping Rest and Relaxation Sleep is critical! patterns and rituals Meditation, visualization, and mindfulness Stress reduction strategies Spirituality Uplifting and meaningful experiences Relationships, solitude Appreciation of nature Belief in a higher power Soul food Doing good deeds “mitzvot” Exercise Find an exercise that you enjoy and do it! Three times per week for thirty minutes “break a sweat” www.womensmentalhealth.org: Web site for Massachusetts General Perinatal Psychiatry Department www.motherisk.org: Canadian agency www.iBreastfeeding.com: Dr. Hale’s web site www.MedEdPPD.org www.postpartum.net www.pregnancyanddepression.com www.psycom.net/depression.central.pos t-partum.html www.4woman.gov/faq/postpartum.htm www.postpartumdads.org Select Bibliography McEwen, B. (2002). The end of stress as we know it. Washington,DC: Joseph Henry Press. Sichel, D. & Driscoll, JW (2000) Women’s moods. New York: Quill. Beck, CT & Driscoll, JW (2006) Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury,MA:Jones & Bartlett Publishers Driscoll, JW (2005). Recognizing Women’s Common Mental Health Problems: The Earthquake Assessment Model. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 246-254. McEwen, B (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171-179 McEwen, B (2000). Allostasis and allostatic load: Implications for neuropsychopharmacology. Neuropsychopharmacology, 22, 108-124. McEwen, B (2005). Stressed or stressed out: What is the difference? Journal of Psychiatry and Neuroscience, 30, 315-318. McEwen, B.S. (2000). The neurobiology of stress: from serendipity to clinical relevance. Brain Research, 886,172-189. McEwen, B.S. (2002), Sex, stress and the hippocampus: Allostasis, allostatic load and the aging process. Neurobiology of aging, 23:921-939. McEwen, B.S. (2003) Interacting mediators of allostasis and allostatic load: towards an understanding of resilience in aging Metabolism, 52, 10-16. McEwen, BS & Wingfield, JC (2003). The concept of allostasis in biology and biomedicine. Hormones and Behavior, 43, 2-15. Hendrick, V & Gitlin, M (2004) Drugs and women: fast facts. NY:W.W. Norton & Company. Steiner, M & Yonkers, KA & Ericksson, E. (Eds.)(2000) Mood disorders in women. Martin Dunitz Ltd. Brizendine, L. (2006). The female brain. NY: Morgan Road Books.