Bipolar and Related Disorders and Depressive Disorders Flashcards
Bipolar I Disorder
requires at least one manic episode which is a “distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy;” must last at least one week, be present most of the day nearly every day, and include at least three characteristic symptoms (inflated self-esteem or grandiosity, decreased need for sleep, excessive talkativeness; flight of ideas)
most common comorbid conditions: anxiety and substance abuse
Prevalence of Bipolar Disorder
.6% prevalence; male to female ratio is 1.1:1
age for first episode is 18 years and 90% will have more episodes
Etiology of Bipolar Disorder
of all psychiatric disorders, genetic factors have been most consistently linked to bipolar disorders
.67-1 for monozygotic twins and .20 for dizygotic twins
first degree relatives of individuals with Bipolar disorder are at elevated risk for both Bipolar Disorder and depression
Treatment for Bipolar Disorder
usually includes pharmacotherapy; lithium has been effective in 60-90% of classic Bipolar 1 Disorder; people give up lithium because they are unwilling to give up the highs of mania or do not like drug’s side effects
anti-seizure drugs like carbamazepine or divalproex sodium can be effective for people who have rapid cycling or dysphoric mania
olanzapine, resperidone, or other antipsychotic medication can be helpful for those experiencing acute mania
some risk of antidepressant will trigger a manic episode when combined with a mood stabilizer, with the risk being greater for the TCAs than the SSRIs
compliance with drug treatment and overall treatment effectiveness are enhanced when phamacotherapy is combined with a psychosocial intervnetion
effective interventions include CBT, family-focused treatment, and interpersonal and social rhythm therapy (IPSRT)
Bipolar II Disorder
requires at least one hypomanic episode and one major depressive episode
hypomanic episode is a “distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy that lasts for at least four consecutive days and is pesent most of the day nearly every day
manic symptoms not severe enough to cause marked impairment in social or occupational functioning or require hospitalization
Cyclothymic Disorder
characterized by “numerous periods of hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode and that cause significant distress or impaired functioning
symptoms last for at least two years in adults or one year in children and adolescents and are present for at least half the time with the individual not being symptom-free for more than 2 months at a time
Distruptive Mood Dysregulation Disorder
diangosed in the presence of
a. “severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation
b. chronic, persistently irritable or angry mood between temper outbursts on most days. Symptoms have persisted for at least 12 months and are exhibited in at least 2 of 3 settings and temper outbursts are inconsistent with the individual’s development level and occur, on average, at least three times each week
Diagnosis cannot be assigned for the first time before the individual is six years of age or after he/she is 18 years of age, and the age of onset must be before age 10
Major Depressive Disorder
requires the presence of at least five symptoms of a major depressive episode nearly every day for at least two weeks, with at least one symptom being depressed mood or a loss of interest or pleasure.
The symptoms are:
- depressed mood (or in children and adolescents, a depressed or irritable mood)
- markedly diminished interest or pleasure in most or all activities
- significant weight loss when not dieting, weight gain or a decrease or increase of appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue, or loss of energy
- feelings of worthlessness or excessive guilt
- diminished ability to think or concentrate
- recurrent thoughts of recurrent SI, or a suicide attempt
Associated Features of MDD
Sleep abnormalities (early morning awakening), reduced stage 3 and stage 4 (slow wave) sleep; decreased REM latency (earlier onset of REM sleep), and an increased duration of REM sleep early in the night
60% of people with MDD experience anxiety during their lifespan
Comorbid anxiety and depression has been linked to more severe symptoms of depression and less favorable outcomes, including a higher risk for suicide and poorer response to treatment
Prevalence of MDD
12 month prevalence rate is about 7% with 18-29 years olds being 3X more prevalent than 60+ year olds
rates before puberty are same for males and females; rate for females is 1.5-3 times the rate for males
peak age of onset of MDD is the mid 20s
initial episode may be precipitated by a severe psychosocial stressor
Peripartum Onset
applied to MDD, Bipolar I Disorder and Bipolar II Disorder when the onset of symptoms of during pregnancy or within 4 weeks postpartum; symptoms often include anxiety and a preoccupation with the infant’s well-being or, in extreme cases, delusional thoughts about the infant
10-20% of women experience depression either during pregnancy or the first several months after giving birth
baby blues involve midl transitory mood symptoms and affects up to 80% of women during the first two weeks following delivery
Seasonal Affective Disorder
linked to several factors including the season-related change in the dark-light cycle that increases melatonin levels; a phase delay in circadian rhythms; and serotonergic dysfunction
Phototherapy involves exposure to artificial bright light and has been found to be an effective treatment for this disorder
Age of MDD
Children- somantic complaints, irritability, and social withdrawal
Preadolescents (especially boys)- aggressiveness, memory loss, distractibility, disorientation, and other cognitive symptoms may be present, making it difficult to distinguish depression from a Major and Mild Neurocognitive Disorder
Psuedocognitive disorder- cognitive deficits usually have a gradual onset and progressive course and the person denies or is unaware of his/her impairments
Pseudodementia- onset of cognitive symptoms is likely to be abrupt and the person is concerned (sometimes overly concerned) about his/her impairments
Cultural Depression
sometimes manifested as somatic symptoms
Latinos complain of nerves and headaches
Asians experience depression as weakness, tiredness, or an “imbalance”
Etiology of Depression
strong genetic component; unipolar depression is .50 for monozygotic twins and .20 for dizygotic twins
1.5-3 times more common among first-degree biological relatives of individuals with the disorder than among individuals in the general population
correlated with neuroticism
Biochemical Theories of MDD
Catecholamine hypothesis- some forms of depression are due to a deficiency in norepinephrine
Indolamine hypothesis- describes depression as the result of low levels of serotonin, especially serotonin receptors
Also linked to elevated levels of cortisol, one of the “Stress hormones” secreted by the adrenal cortex, which causes atrophy of neurons in the hippocampus; and there is evidence that the total duration of untreated depression correlates with the amount of shrinkage in the hippocampus
Lewinsohn’s (1974) behavioral theory of depression
based on the principles of operant conditioning; attributes the disorder to a low rate of response-contingent reinforcement for social and other behaviors, which results in the extinction of those behaviors as well as in pessimism, low self-esteem, social isolation, and other features of depression that tend to reduce the likelihood of positive reinforcement in the future
Learned helplessness model- Seligman
describes depression as the result of prior exposure to uncontrollable negative events coupled with a tendency to attribute those events to internal, stable, and global factors
Rehm’s self-control model
dperession is the result of a combination of problems related to self-monitoring, self-evaluation, and self-reinforcement
people who are depressed attend most to negative events and immediate outcomes; fail to make accurate internal attributions and set stringent criteria for self-evaluation; and have low rates of self-reinforcement and high rates of self-punishment
Depressive cognitive triad– Beck
depression is related to negative, illogical, self-statements about oneself, the world, and the future
some research opposes. Lewinsohn found that “low self-evaluations by depressed individuals about their social skills were more accurate than the self-evaluations of non-depressed individuals who tended to overestimate their abilities
Treatment for MDD
combo of antidepressants and psychotherapy
Three classes of antidepressants:
- Tricyclics (TCAs)- appear to be most effective for “classic” depressions that involve vegetative (bodily) symptoms, a worsening of symptoms in the morning, an acute onset and short duration of symptoms, and symptoms of moderate severity
- SSRIs- considered the first-line drug treatment for moderate to severe depression and have fewer side effects and a lower risk for a fatal overdose than the TSAs
- Monamine oxidase inhibitors (MAOIs)- may be beneficial for individuals who do not respond to TCAs or SSRIs and or who have atypical symptoms (anxiety, hypersomnia, hyperphagia, interpersonal sensitivity
- newer- Serotonin norepeinhephine reuptake inhibitors (SNRIs)- increase levels of norepinephrine and serotonin; comparable to TCAs and SSRIs in terms of effectiveness but differ in terms of side effects
ECT
not often used but has been found effective for very severe endogenous forms of depression that involve delusions or suicidal ideation or that have not responded to antidepressants
primary undesirable effects of ECT are temporary anterograde and retrograde amnesia, confusion, and disorientation, but these effects may be reduced by administering ECT unilaterally to the right hemisphere
Persistent Depressive Disorder (Dysthymia)
characterized by a depressed mood (or in children and adolescents, a depressed or irritable mood) on most days for at least two years in adults or at least one year in children and adolescents as indicated by the presence of at least two of the following symptoms: poor appetite or overeating, insomnia or hypersomnia; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; feelings of hopelessness
during two or one-year period, individual has not been symptom free for more than two months and the symptoms cause clinically significant distress or impaired functioning
Treatment for PDD often includes a combo if an SSRI and CBT or IPT
Premenstrual Dysphoric Disorder
the presence of at least five characteristic symptoms during the week before the onset of menses with an improvement in symptoms within a few days after the onset of menses and the absence or presence of minimal symptoms during the week postmenses
At least one of the five symptoms must be marked affective lability, irritability or anger, depressed mood or self-deprecating thoughts, or anxiety or tension, and at least one symptom must be decreased interest in usual activities, impaired concentration, lethargy, marked change in appetite, hypersomnia or insomnia, a sense of being overwhelmed or out of control, or physical symptoms
Must cause clinically significant distress or interfere with usual activities or relationships with others and must not be an exacerbation of another disorder
Suicide risk Factors
approximately 60% of people who commit suicide have a diagnosis of a mood disorder at the time of their death
Risk Factors:
- Age= in 2010- the highest rate for males+females was ages 45-54; when separate: females= 45-54; male: 75+
- gender- 4X as many males as females commit suicide, but females attempt suicide 2-3 times more often than males
- Race/Ethnicity- for most age groups- highest suicide rates are Whites; exception is American Indian/Alaskan Natives ages 15-34 who have a suicide rate 2.5X higher than the national average for that age group
- Marital status- divorced, separated, and widowed people have the highest rates of suicide, followed by those who are single. The lowest rates are found among those who are married
- Suicidal thoughts/behaviors- as many as 60-80% of people who commit suicide have made at least one previous attempt, and about 80% give a definite warning of their intention
- Early warning signs- threatening self-harm or suicide, writing or talking about death or suicide, seeking a means to commit suicide, and making preparations for dying such as preparing a will, giving away possessions, or saying goodbye to loved ones
- Life stress- failure at work or school, rejection by a loved one, living alone, and an absence of social support and social ties are associated with an increased risk for suicide; among adolescents, completed suicide is often immediately preceded by an interpersonal conflict such as rejection by a boyfriend or girlfriend or an argument with a parent
- Psychiatric disorders- most suicide victims have a mental disorder (MDD and bipolar most common); individuals with a mood disorder being 15-20% more likely than individuals in the general population to commit suicide; when associated with depression, most likely to occur within three months after depressive symptoms begin to improve
- Personality correlates- hopelessness has been found to be more predictive of suicide than the intensity of depressive symptoms; perfectionism has been linked to an elevated risk for depression and suicide, although self-oriented perfectionism may be associated with an elevated risk only when it is combined with high levels of life stress
- Biological correlates- low levels of serotonin and 5-HIAA have been linked to an increased risk for suicide and violent suicide attempts
CBT, DBT, IPT, and problem-solving therapy helpful for suicidal clients
