3. Mood disorders Flashcards
Emotion
states of arousal defined by subjective feelings, such as sadness or anger; usually short lived and marked by physiological features
affect
pattern of observable behaviours that are associated with subjective feelings
mood
a pervasive and sustained emotional response
depression
pervasive and sustained low mood and related behaviours and sumptoms
Dysthymia
experience of low mood
Dysphoria
Experience of mixed unpleasant emotions
Euphoria
Intense feelings of well-being, excitement, over-confidence and over optimism
mania
elevated mood, inflated self-esteem and associated symptoms
hypomania
increased energy but symptoms are less severe than mania
emotional symptoms
dysphoria/euphoria
cognitive symptoms
- Disturbed concentration
- Grandiosity and inflated self-esteem
- Depressive triad: themselves, environment, future
somatic symptoms
Fatigue, pains, appetite and sleep patterns
behavioural/affective symptoms
Affect, psychomotor slowing versus pursuit of
goals indiscriminately/agitation
difference between depression and normal sadness
Mood change is pervasive and persistent; does not improve, even temporarily, when engaging in pleasurable activities. Mood change may occur without precipitating events or may be out of proportion to the person’s circumstances
Impaired ability to function in social and occupational roles.
Mood change with additional cognitive, somatic behavioural signs.
Nature or quality of mood change may be different than what’s experienced with normal stress
Common features of depressive disorders
- Involve presence of “sad, empty or irritable mood, accompanied by somatic and cognitive changes”
depressive disorders distinguished from others
What distinguishes the different mood disorders is their duration, timing, and presumed aetiology
DSM-5 depressive disorder definition
Primary impairment involving sad, empty or irritable mood, accompanied by somatic and cognitive changes
DSM-5 forms of depressive disorders
- disruptive mood dysregulation disorder
- Premenstrual dysphoric disorder
- major depressive disorder
- persistent depressive disorder
- other depressive disorders due to other medical condition or substance or medication induced
major depressive episode/major depressive disorder criteria
• 1 major episode in the absence of any history of manic episodes
A. An episode is ≥5 of 9 symptoms indicative of change over 2-week period; including either (1): depressed mood, or (2): loss of interest or pleasure.
PLUS
B. Cause significant distress or impairment
C. Not attributable to other disorders/substances
DSM-5 beravement
Bereavement may induce great suffering, but it does not typically result in MDE/MDD. When they do co-occur, it may be more severe, prognosis may be worse, and it may occur in people with “other vulnerabilities” in which case “recovery may be facilitated by anti-depressant treatment”
Mild MDD
: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
moderate MDD
The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
severe MDD
The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
specifiers of MDD
- Anxious distress
- Mixed features
- Melancholic features
- Atypical features
- Psychotic features (Mood-congruent or Moodincongruent)
- Catatonic features
- Peripartum onset
- Seasonal pattern
- Rapid cycling
Persistent Depressive Disorder (previous dysthymia)
• A more chronic, milder presentation
• Over a period of >2 years, exhibit a depressed
mood for most of the day, more days than not
possible symptoms of PDD
Two or more of 6 possible symptoms • Poor appetite or overeating • Insomnia/hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration/decision making • Feelings of hopelessness
Would NOT diagnose PDD if …
- Symptoms absent for more than 2 months at a time during 2-year period
- If at any time during first 2 years meets criteria for MDE/MDD, then given MDD diagnosis
- Presence of manic episode
Disruptive mood dysregulation disorder
Controversial addition to DSM 5
• Children 6-18 yo
• Chronic, severe, persistent irritability and frequent episodes of extremely out-of-control behaviour
Premenstrual Dysphoric Disorder (PMDD)
Controversial addition to DSM 5
• Moved from DSM IV ‘further study criteria’ to the main body in the DSM 5
• Severe form of PMS, characterized by mood lability, irritability, dysphoria, anxiety, difficulty concentrating, changes in appetite and sleep, pain, etc.
• Mood disturbance is temporally linked to menses
Why is Disruptive Mood Dysregulation Disorder a bad change in DSM5?
DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. …. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.
why is excluding beravement a bad change in the DSM-5
Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations
of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.
DSM-5 Bipolar disorders
Primary impairment involving mood but with a manic/hypomanic component
DSM-5 categories of bipolar disorders
- Bipolar I
- Bipolar II
- Cyclothymia
- Bipolar disorder due to medical condition or substance or medicaiton induced
Bipolar I
At least one manic eopisode
Bipolar II
- Hypomania: episodes of increased energy, not severe enough to qualify manic episodes
- At least 1 hypomanic episode, 1 depressive episode and no manic episodes
Cyclothumia
- Chronic, but less severe form of bipolar
* Symptoms of mania and depression rather than ‘episodes’
Manic episodecriteria
A. At least a week of (or any period of time if
hospitalisation results) abnormally & persistently
elevated, expansive, or irritable mood and
persistently increased goal-directed activity/energy:
feature is present for most of the day, nearly every
day of this period
B. ≥3 of 7 symptoms (≥ 4 if mood is irritable)
C. Sufficiently severe to cause marked impairment in
functioning, OR to necessitate hospitalisation, OR
with psychotic features
D. Not attributable to effects of a substance or due to
another medical condition (can be complicated)
Manic episode symptoms
3 or more of these symptoms (or 4 if mood is ‘irritable’):
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Increased talkativeness or pressure of speech
- Flight of ideas or racing thoughts
- Distractibility
- Increased goal-directed activity / psychomotor agitation
- Excessive involvement in activities with high potential for painful consequences
Psychiatric emergency
- Risk can be high
- Decreased sense of threat
- Poor judgment
- Participation in high risk behaviours
- Presence of psychosis
- Persistence and recurrence are markers of potentially poorer response to treatment
Hypomanic Episode
Same symptoms as manic episode (3 or more) except:
• Lasts at least 4 consecutive days
• Unequivocal change in function but not severe enough to cause ‘marked impairment’ in function or trigger hospitalization
• Still necessitates treatment
Cyclothymic disorder
- Chronic, fluctuating mood disturbance for 2 years or more
- Numerous periods of hypomanic & depressive symptoms (not enough to meet criteria for episodes)
- Never symptom free for more than 2 months
- No history of major depressive episodes or mania during first 2 years
- Onset usually in adolescence or early adulthood
mean age of onset of depressive disorders
32
typically 5-6 lifetime episodes
risk of recurrence of depressive disorder and remission
- Risk of recurrence increases with each episode
- 1 episode = 50%
- 2 episodes = 70%
- 3 episodes = 90%
- The longer the remission, the less chance there is of relapse
recovery from depressive disorder
50% recover within 6 months of beginning of an episode
comorbidities of depressive disorder
anxiety, substance abuse
Mean age of onset of bipolar disorder
18-22 years
what may preceded bipolar disorder
manic or depressive episode
• Manic episode average = 2 to 3 months
• Difficult to predict intervals/course
• > 90% of individuals who have a single manic episode will have further mood episodes
number of bipolar episodes compared to depressive disorder
There are usually more episodes over the lifetime than with depressive disorders
prognosis of bipolar disorder
mixed long-term
prevalence of depression in australia
- 1 million adults experience depression each year
- 1 in 6 people will be depressed in their lifetime (16%)
- 1 in 5 for women (20%)
- 1 in 8 for men (12%)
- $12.6 billion in costs per year
- 6 million working days of lost productivity
- 80% of suicides preceded by a mood disorder
ABS 2008 National Survey of Mental Health and Wellbeing (SMHWB) - prevalence, incidence and risk of mental disorders
- 45% had a lifetime mental disorder
- 20% had a 12-month mental disorder
- 14.4% Anxiety Disorders
- 6.2% Affective Disorders
- 4.1% Depressive Episode
- 1.3% Dysthymia
- 1.8% Bipolar I / II
- For anxiety and affective disorders
- Females > Males
- Younger adults > Older adults
differences in sexes in depression
2-3 times more vulnerable to depression
differences in sexes in bipolaw
no sex difernce observed
cultural factors of MDD
MDD differences in prevalence, risk factors, and greater somatic symptoms in some cultures
cultural factors BPD
BPD little research indicating cultural differences in presentation
Chinese culture and depressive symptoms
boredom, discomfort, feelings of inner pressure, pain, dizziness, fatigue
western culture and depressive symptoms
crying, feeling sad or down, fatigue/decreased energy, change in appetite and sleep, loss of pleasure, guilt
depression accountability for disabilities
Depression accounts for approximately 10% ofall disability
expected growth of depression in society
Expectation that depression will only continue to grow as a public health issue
• Younger age at onset
• Higher rates within young people
factors of depressive disorders
• Negative life events:
• Interpersonal loss
• Loss of “social roles”
• Feelings of entrapment, humiliation, defeat
• Stress generation: increased prevalence of stressful life
events among depressed persons
For specific groups, such as Indigenous peoples, there may be additional significant social and intergenerational influences such as dispossession, cultural genocide, displacement, segregation, stolen generation
Psychological factors in depression
Cognitive vulnerability - thinking errors, distortions, attentional biases
- Assign global, personal meaning to failures
- Overgeneralise conclusions about self from events
- Drawing arbitrary inferences about self without supporting evidence
- Selective recall of events with consequences
causal attributions to depression
- Depressogenic attribution style: internal, stable, global
* Perceived lack of control and efficacy
Response styles to depression
- Ruminative style
* Distracting style
goal attainment in depression
- Generalized goals
* pessimistic attitude
developmental model of depression
- Integration of factors
- Cognitive and interpersonal patterns arises out of life experience
- Schemas
Schemas
– enduring representations of prior experience that serve to guide perception and interpretation of future events
formation of schemas
Schemas are formed in response to early life experiences – particularly patterns of experience
What do schemas shape?
Schemas shape the relationships people enter, the approach to managing difficulties/stress and interpretation of events, expectation of positive resolution
Biological factos in depression
- Family studies and twin studies suggest a mild genetic influence for unipolar depression
- Higher rates of concordance in monozygotic twins than dizygotic but not 100% concordant
Kelder’s research on interaction of severe life stress and genetics
- Severe life events increase the probability of depression even among those at low genetic risk.
- The magnitude of the effect of stress is much greater for the genetically predisposed.
Biological effect of the NEUROENDOCRONE SYSTEM on depression
—dysfunction in the hypothalamicpituitary-adrenal (HPA) axis may also play a role in the development and maintenance of depression
Biological effect of differing brain structures on depression
Brain imaging studies suggest differences in structure and activity in people with depression, noting some areas of the pre-frontal cortex (PFC) becoming less active than normal, while other areas of the PFC show abnormally elevated activity
Biological affect of NEUROTRANSMITTERS on depression
serotonin appears particularly important, as levels are related to mood, hopefulness, sleep, and appetite. However, many neurotransmitters are likely to be involved
Precipitating factors in mania
- Schedule-disrupting event - Reduced sleep – night shift, travel, change in light
- Goal attainment events
- Antidepressant medications
Social factors that influence recover/relapse of mania
- Emotional climate within families – high expressed emotion associated with relapse
- Social support – lower social support associated with relapse
Genetic components in Bipolar and depression
Stronger genetic component in Bipolar mood disorders than in depression
• Concordance rates in MZ twins is .69 compared to .19 in DZ twins
• Heritability estimate is 80%
Psychological approaches to depression
Cognitive therapy
Interpersonal therapy
Cognitive behavioural/behavioral therapy
cognitive therapy for depression
addressing cognitive distortions, maladaptive schemas
interpersonal therapy for depression
focuses on interpersonal factors in current relationships that cause and maintain depression; treatment focuses on building communication and problem-solving skills
cognitive behavioural therapy/behavioural therapy for depression
learning new responses/changing the contingencies, behavoural activation
• Changing biology: antidepressant medications
- SSRIs
- Tricyclics (TCAs)
- MAOIs
Medication or psychotherapy for depression?
- Both are effective; neither clearly more than the other
- In practice, medication and psychotherapy are often combined; recent evidence suggests that quicker remission of symptoms is likely when medication and therapy are combined.
Electroconvulsive therapy for unipolar or bipolar disorder
- Most patients receive two or three treatments/week, totaling 6–8 sessions.
- The mechanism of action is unknown, but ECT is effective for those with severe depression.
- Also an appropriate treatment for those with rapid cycling bipolar disorder and depression with psychotic features
light therapy for seasonal mood disorder
exposure to broad-spectrum bright light used for one-two hours per day
• Improvement is often found within two-five days; light therapy plus cognitive therapy may be particularly helpful.
• Unclear what the mechanism is that explains improvement, but may be tied to hormonal secretion
types of Mood stabilisers for bipolar disorders
lithium carbonate
Anticonvulsant medications
Lithium carbonate
- Very effective for treating bipolar patients in a manic or depressive phase
- Reduces relapse in patients who continue taking lithium between episodes
- 40 percent do not respond to lithium
- Negative side effects (e.g., nausea, weight gain, memory problems) contribute to a poor compliance rate ; approximately 50 percent do not take as prescribed
Anticonvulsant medications
- 50 percent of bipolar patients respond positively to the anticonvulsants
- Side effects include GI distress and sedation.
Types of psychotherapy treatments for bipolar disorder
cognitive therapy
interpersonal and social rhythm therapy
medications
interpersonal and social rhythm therapy
- focus on stress, disruption and the onset of symptoms
- the regulation of sleep/wake cycles
- Relationships
- work patterns
Medications as treatment for bipolar disorder
medications are primary but current evidence suggests combination of psychotherapy and medication is more effective
suicide statistics
- 1 million people suicide worldwide each year
- In general adult population, the ratio of attempts to completion approx 10:1, but it is much higher (100:1) in adolescents
- Male to female Australian ratio of completions is 3.9:1;
- Attempts are more frequent in females than males
- Suicide is the most common form of ‘injury’ death in Australia (29% of all injury-based death)
rates of suicide
- In Australia, suicide is the leading cause of death for males and females aged between 15 and 44.
- In a typical year, about 3,000 people in Australia die by suicide. That’s an average of 8 people every day.
following suicide attempt
- About 50 per cent of those who attempt suicide don’t attend any treatment post-discharge.
- Of those who attend treatment, 38 per cent stop within 3 months.
- 15–25 per cent re-attempt and 5–10 per cent die by suicide.
- This highest risk period is 3 months after a suicide attempt
age and suicide in Australia
- Suicide rates in older Australians are higher than for any other age group (De Leo, 2001)
- Absolute number of suicides in older adults is not as high as in younger adults, the rate is higher because the proportional number of older people is lower in the overall population
Indigenous suicide
- Suicide rate for young Aboriginal and Torres Strait Islander men is about 40% higher than that for the young men in the general population
- Tends to manifest in a “cluster” pattern (Hanssens & Hanssens, 2007)
Risk factors of suicide
- Presence of an Axis I disorder, particularly depression & substance dependence
- Recent life events (e.g., ill health, relationship breakdown, death of loved one, other significant losses, social isolation)
- Previous suicide attempts
- Communication of intent
- Restriction of options
- Substance misuse
- Access to lethal means
- Impulsivity
- Agitation
depression as a risk factor if suicide
Depression is strongest single risk factor for attempted or completed suicides (Beautrais, Joyce, & Mulder, 1996)
lifetime risk of suicide in people with mood disorders is 19%
non-suicidal self injury
- Deliberate self harm not accompanied by intent to end life
* Typically cutting, burning or scratching the skin
self harm as a mental disorder?
Self harm alone is not a mental disorder but it can be associated with various mental disorders (depression, substance use, eating disorders and PTSD)
self harm association with suicidal ideation or intent?
Not necessarily associated with suicidal ideation or intent (but can be)
explanations for self harm
Explanations for self harm vary
• Can be a punishment – a reflection of anger and frustration
• A response to dissociation or numbing
• Regulation of intense negative emotional states
Durkheim’s classifications for causes of suicide
egoistic suicide
Altruistic suicide
Anomic suicide
Fatalistic suicide
When is suicide increased?
Suicides will increased in societies or groups where levels of social integration and regulation are either relatively low or excessively high
Egoistic suicide
(diminished integration)
Person becomes relatively detached from society and feels existence is meaningless
Altruistic suicide
(excessive integration)
Rules of the social group dictate that the person sacrifices own life for other’s sake
Anomic suicide
(diminished regulation)
Sudden breakdown in social order
Fatalistic suicide
(excessive regulation)
Living under unbearable circumstances
individual factors that cause suicide
- Psychological: “an attempt to escape from unbearable psychological pain”
- Hopelessness and helplessness
- The means/ability to enact lethal self-injury
Hopelessness and helplessness as a cause of suicide
- Associated with prolonged frustration of psychological needs for affiliation and competence,
- Low belongingness
- High burdensomeness
means/ability to enact lethal self-injury as a cause of suicide
- Numbing
- Past attempts
- Habituation to pain and fear of death
biological causes of suicide
- Reduced serotonin levels– associated with reduced impulse control
- Genetic factors – increased risk of mood disorders
- Unknown if there is a direct contribution of genes to suicide
Psychotherapy as an Intervention/prevention of suicide at the individual level
Psychotherapy aimed at changing ideation (tunnel vision); progressing to identification, and alleviation (if possible) of contributing factors; engaging social supports/connections
There are also pharmacological treatmerns
Physical / means as an intervention/prevention of suicide at the individual level
Involuntary treatment; removing access to means; reduce lethality; increase supervision
Suicide prevention in older adults
- Supporting carers of spouses with ill health
- Supporting bereaved elderly
- Encouraging people to plan for retirement
- Building social support networks among elderly people and between them and others
- Increasing public awareness about positive ageing and how to achieve it
- Reducing known risk factors: Living alone; living in a hostel or nursing home; social isolation and disadvantage; poverty
Suicide prevention in younger adults
- Traditional suicide education in schools may be unhelpful
- Better to promote emotional well-being, resilience, self-esteem, coping skills & life skills, & create supportive environments (school & home)
- Enhance connection and communication
- Identify young people at risk & target them with early interventions
Education of suicide as a prevention strategy
Suggested to increase depression, anxiety & preoccupation, by fostering view that youth suicide is more common than it really is
