Bipolar and Related Disorders and Depressive Disorders

Question 1

Bipolar I Disorder

Answer 1

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

Question 2

Prevalence of Bipolar Disorder

Answer 2

.6% prevalence; male to female ratio is 1.1:1

age for first episode is 18 years and 90% will have more episodes

Question 3

Etiology of Bipolar Disorder

Answer 3

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

Question 4

Treatment for Bipolar Disorder

Answer 4

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)

Question 5

Bipolar II Disorder

Answer 5

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

Question 6

Cyclothymic Disorder

Answer 6

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

Question 7

Distruptive Mood Dysregulation Disorder

Answer 7

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

Question 8

Major Depressive Disorder

Answer 8

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

Question 9

Associated Features of MDD

Answer 9

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

Question 10

Prevalence of MDD

Answer 10

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

Question 11

Peripartum Onset

Answer 11

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

Question 12

Seasonal Affective Disorder

Answer 12

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

Question 13

Age of MDD

Answer 13

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

Question 14

Cultural Depression

Answer 14

sometimes manifested as somatic symptoms
Latinos complain of nerves and headaches
Asians experience depression as weakness, tiredness, or an “imbalance”

Question 15

Etiology of Depression

Answer 15

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

Question 16

Biochemical Theories of MDD

Answer 16

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

Question 17

Lewinsohn’s (1974) behavioral theory of depression

Answer 17

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

Question 18

Learned helplessness model- Seligman

Answer 18

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

Question 19

Rehm’s self-control model

Answer 19

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

Question 20

Depressive cognitive triad– Beck

Answer 20

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

Question 21

Treatment for MDD

Answer 21

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

Question 22

ECT

Answer 22

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

Question 23

Persistent Depressive Disorder (Dysthymia)

Answer 23

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

Question 24

Premenstrual Dysphoric Disorder

Answer 24

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

Question 25

Suicide risk Factors

Answer 25

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