L12 - Mood instability in the context of Bipolar spectrum disorders Flashcards
Learning objectives
- Describe some everyday examples of mood instability, including its triggers and associated behaviours [paraphrase]
- Describe examples of how mood instability may interfere with everyday life, in particular in the context of bipolar spectrum disorders [paraphrase]
- Describe distinct and overlapping features of mood instability across different disorders, for example affective and personality disorders [paraphrase] and apply them to a case [analyse].
- Describe methods for investigating mood instability [paraphrase], and elaborate on the pros and cons of each method [analyse].
- Describe mechanistic accounts of mood instability, particularly the role of mental imagery [paraphrase], and apply them to a case [analyse].
- Describe other cognitive processes that may play a role in mood instability [paraphrase], and apply them to a case [analyse].
In these flashcards…
- lecture
- Mood instability: significance, definition and measurement (Broome)
- Positive moods are all alike? Differential affect amplification effects of “elated” versus “calm” mental imagery in young adults reporting hypomanic-like experiences (Vannucci)
Mood Instability - some introductory statistics
(article Broome)
- population rate of 13.9%
- more common in women
- peak in 16-24 y.o., with decline in old age
- comorbid with depression, anxiety, PTSD and OCD
- associated to increased health service and suicidal ideation
- involved in origins and affects prognosis (bipolar, depression, ADHD)
what are the problems with the definition of Mood Instability?
→ comprehensive definition
(article Broome)
- mood instability is defined and measured differently across different fields
- different definitions make references to the valence, intensity, frequency of shift, rapidity of rise-times and return to baseline, reactivity to psychosocial cues, extent to which there is overdramatic expression
→ “rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioral consequences”
what developments can help the progress to define and measure mood instability?
(article Broome)
- Retrospective questionnaires
> still valuable approach to study mood instability
> many limitations (e.g. recall bias)
> hard to recall mood, vairation and intensity - Momentary assessment and remote monitoring
> greater insight and more detailed quantitative characterization of the nature of mood instability in daily life
> high-frequency prospective automated mood monitoring, remote sensors and other devices to capture the behavioral, physiological and environmental correlates of mood instability
what is the origin of mood instability?
+ Research Domain Criteria
- shares genetic and environmental risk factors of the disorders it is a feature of
- can also have its own causal factors
> we need more research on the topic - fits well with the Research Domain Criteria
> likely to reflect problems in a core behavioural function of the brain
> likely to be related to a dysfunction in neural circuits
> is dimensional
What are the cognitive and neural correlates?
- cognitive functions are impaired in diagnoses where mood instability is prominent
- amygdala and functional connectivity may be altered, but we don’t know yet what are the circuits underlying mood instability
> e.g. there could be link between neural stability and stability at cognitive or emotional level
→ should be studied through participants with different degrees of mood instability via brain imaging methods
What are the implications for treatment?
- Stabilisation of mood as treatment
> could serve as a predictor as to whether treatment for mood disorders would be effective
> if reliable predictor, it could be used to develop experimental models for studying mood disorders (both psychological and pharmacological) - Stabilisation of mood as added value to therapy
> crucial for early interventions in many conditions
what will the development of advanced remote monitors lead to?
- delineation of subgroups based on mood instability (not based on specific syndromes), that can be tested for prognosis and therapy
- monitoring of prone people remotely, so that if they are at risk they can be advised to act / take medication to prevent intense episodes
what are bipolar disorders characterized by?
- acute episodes of mania and depression (euthymic), with strong mood instability and anxiety in between
- mood is euthymic only 36.5% of time
Depression within bipolar disorder
- low mood, loss of enjoyment, loss of interest and motivation, poor sleep, …
- oversleeping and eating more are more prevalent in bipolar depression (compared to unipolar one)
- other symptoms are pretty much the same
mania - what are the symptoms?
- distinction: severity and functional impairment (mania vs hypomanic)
- mood can be elated and euphoric, but also irritable
- not just about mood, but also about hyperactivity (increased activation)
- increased desires, hypersexual behavior, …
! everything is so fast, but after a certain points it becomes overwhelming and too fast to keep up with, and becomes a jumble of confusion and irritation - acceleration of thoughts, speech (salad of thoughts)
- insomnia with no need of sleep (then followed by crush)
- goal directive behavior, doing more things, …
> hypomania: increase is in productivity
> mania: not goal directed anymore
(switch from elated to irritated often happens when individuals feel like other people cannot keep up, do not understand them, …) - also a bit paranoid (world is against me if no one can keep up and understands)
time course
- clear cut episode of depression and (hypo)mania
+ subthreshold symptoms in between
+ mixed state→ states where there is mix of symptoms from both polarities
→ mixed states are quite dangerous, because you might be suicidal + impulsive (higher suicide risk) - anxiety is comorbid over half the cases
> when does it fuel symptoms? can be early signs before episodes - 50-60 relapse within year from mood episode
other symptoms & comorbidities
- 50% comorbidity with anxiety (93% anxiety disorder lifetime comorbidity)
- psychotic symptoms (75% of BP patients) [both during manic and depressive episodes]
differential diagnosis
- unipolar MDD
- schizoaffective disorder and other psychotic disorder
- anxiety disorder
- SUD
- personality d.
- ADHD
there are many BDs
look at picture
- there are so many different presentations of BDs
! there is a lot of eterogeneity
epidemiology
- around 3% of population
- bipolar I → men=women
- bipolar II → «women
- strong genetic component
- bipolar disorder spectrum: BD NOS, cyclothymia
- BD NOS: maybe you don’t completely match the criteria, maybe you have family history or comorbid anxiety, so your illness must be part of this spectrum
- highest risk of suicide among disorders (40% attempts, of which 15-20% complete)
developmental trajectory of BD
- it onsets in adolescence/young adulthood
- adolescence maybe with a single depression episode, or hypomanic-like symptoms, or you feel grandiose and full of energy without clear-cut diagnostic criteria
- 80% of BD people it starts with depressive episode, and manic episode can come much later
- correct diagnosis after ten years (young adulthood)
- BD spectrum:
> crossectionally + longitudinal tragectory
onset - data
- 60% of cases before 21 y.o.
- 90% of those developing BD by age 20 had a depressive episode age 13, no more new cases after age 28
- first manic episode around age 18
- 12% developed BD and 36% MDD
treatment
1- in acute phase, medication
> mostly mood stabilisers and anti-psychotics
! works to prevent relapses
> lithium is gold standard
> antidepressants NEVER without mood stabilisers
! if given without mood stabilizers, mood switch into mania, or don’t work and mood becomes more unstable
! if keeps not working, then maybe indication for BD
2- psychosocial interventions: limited efficacy but in euthymia can decrease the risk of relapse and help recovery from depressive symptoms (CBT, IPSRT, family therapy)
> not clear how it works for BD, more complexity on how anxiety fuels symptoms, …
3- psychosocial interventions: need for more research and innovation
> maybe doesn’t help in acute episodes, but helps in everyday functioning, how people are, feel and what they do in life
4- challenge of treating anxiety (!)
> SSRIs make things worse in BD
> ssris + antipsychotic (not jsut in manic phase, but they reduce manic relapses as well)
Lithium
- we don’t know much about it
- take lithium and you’re good for 20 years (for some people)
- we don’t know why or how, or for who
- needs to be managed quite carefully (blood range)
- could have heavy side effects
- monitor thyroid and kidney
- kidney function after 20-30 years can suffer and if you stop lithium, you might relapse
> hard trade-off
! not pattented, and not prescribed enough
> there’s lot of fear and care around it (blood tests, …)
> it’s really worth trying!
creativity?
- what’s the relationship between BD and creativity?
- people who had parents with BD tend to be in more high-achieving and creative professions
- correlational evidence on the link between creativity and psychopathology
- strongest evidence for a link between creativity and BD
- scandinavian population registry study: first-degree relatives of BD more likely to have creative/high achieving professions
- higher IQ at baseline
! not to say that they are more creative than average population
Questions by audience - notes
1- attention is impaired and it has an impact on memory
> do not remember manic episodes (shame)
> memory bias and flashforwards
2- hypomania is egosyntonic (you feel like yourself), but manic symptoms on irritable and paranoid sides, then they feel ego-dystonic
> to what point is it ok for me? am I starting to be manic?
> psychoeducation is important! (sometimes better than doctors, you can find your own signals and predictions)
> why let go hypomania? hard trade-off (why should I get rid of this?)
3- mixed states have for example self-criticism and hopelessness, but together with agitation, anxiety, or maybe very elated but very fatugued
4- in psychosis of mania, sometimes hard to see the mania behind it
Mood instability - definition
“rapid oscillations of intense effect, with a difficulty in regulating these oscillations or their behavioral consequences”
- often comes with disregulating behavior
mood instability and clinical presentation
- mood instability part of diagnostic symptoms
> in borderline personality disorder: short-lasting reactivity of mood to interpersonal stressors
> in ADHD, PTSD: not well characterised - recent epidemiological studies
> 50% in depression and anxiety disorders
> …
mood instability - general notes
- very transdiagnostic !
- more prevalent with anyone with psychiatric illness
- not much research on adolescence mood swings
> adolescents have greater daily variability and more extremes that progressively reduce in young adults
> part of prodromal symptoms of depression and bipolar disorder in young people
→ not yet able to differentiate normal adolescence mood swings and predictors of BD
clinical relevance (this just in slides)
- wide range of mental disorders associated with poor clinical outcomes, including suicidal thinking and healthcare service use
- associated with self-harm and addiction
- associated with trauma in BPD, BD
- worse functional outcomes in BD
- predictor of outcome from psychological interventions in BD
> step-BD trial: depressive instability predicted lower likelihood and longer time until recovery
→ poor prognosis!
> more use of services, more risky behaviors, worse functional outcomes, worse response to psychological treatments (she said this!!!)
summary of mood instability
- transdiagnostic
- predicts outcomes
- could be early manifestation of psychopathology
- normative in adolescence to some degree
- for now, not much understanding on treatment considering mood instability
! we must understand it better
neurocognitive reseach
- Biases in processing emotional information
- studies looked at cognitive processes of depression (affective memories, faces recognition…) → can they predict in BP emotional instability?
> looked at rMSSD (sd; variance and mean of weekly measures of depression and mania)
> more negative memories biases were predictive of greater instability in depressive and manic episodes
! negative memory biases = prospective greater instability in depressive symptoms and manic symptoms - Attentional dysfunction
- studies looked at executive functions using attention test
> worse performance on test related to different indirect indeces of mood instability
> affective lability subscales, scores on mood disorders questionnaires, …
Neurocognitive models of mood instability
- our phenomenological understanding of mood instability is still quite imperfect, so there are inherent limitations in building models on an incomplete understanding
- not a lot of research
- research on memory biases, emotional processing recognition, … showed that all these cognitive processes underpin anxiety or low mood
> not same extent of research on what underpins switches in affect in BP
Neuroimaging
- assumption: if I image individuals with BD, I am imaging mood instability
> not true→ patients have more mood instability compared to controls, but among patients there is much variability (more or less m.i. in different BD)
= not telling us much about underpinning correlates to neural instability - there are however neural differences in areas of dysfunction of mood regulation
Brain areas
Emotional dysregulation areas (dysfunctional in BP):
- increased connectivity between ventromedial PFC and amygdala
- reduced connectivity between ACC and amygdala
During emotion regulation task:
- increased ACC activity
- reduced activity in ventrolateral PFC
> difficulty in regulating emotions may underpin mood instability (hypothesis, we need much more research)
Measurement
- so far we have not made progress, but from now on we might → why?
- originally, to measure m.i. we would ask people “do you usually experience lots of mood swings?”
> this is a self report, which has many limitations
on slides:
! self-report scales on trait constructs
! weekly retrospective ratings of symptoms (memory biases)
! mean, maximum and SD don’t describe variation over time
! diagnosis assumes the presence of mood instability
what would you do to improve how we capture mood instability?
- maths and digital tools
> mood zoom app (rate every single day how mood is)
→ growing number of simplified digital self-report mood monitoring = good association with standard questionnaires in mood disorders
→ mobile phone mood ratings correlated with clinician-rated depressive symptom severity vs paper-and-pencil ratings, but not for mania
are digital tools reliable?
yes!
- more reliable in depression (not as much awareness in mania)
Now we can have DIGITAL PHENOTYPING
> more sophisticated mathematical models
~ differentiates BD and emotionally unstable personality disorder
~ Eupd>bs on overall variability and irritability
> passive tracking features / machine learning
~ decrease in ohone call and sms communications associated with depression in BD, but not EUPD
~ call logs, sleep data, step count data and heart rate
→ also able to differentiate at 75-80% accuracy between a stable state and a mood swing state
! they can capture arrival of depressive episode
→ are they helpful to find prodromal symptoms?
are they useful? if so, for what?
- they are useful, need to be implemented by cilnician
- more research is needed to see whether they can add onto the diagnostic side, but more so for looking out for prodromal symptom patterns
- higher risk index, behavioral and digital phenotyping, more risk?
→ some of these method might help to accellerate pathways
imagery-based cognition and mood instability
- (holmes) idea that mood instability is connected to vivid, highly emotional mental imagery
- thinking through images, think in the form of visualizing in multi-sensory way
Mental imagery in psychiatry: conceptual and clinical implications (article in lecture)
1st study
- bipolar patients vs controls
- what about mental imagery in bd people with more or less stable patterns?
- access to app used in clinic by bd patients
= those with higher instability time course of bipolar disorder also reported higher levels of future images, related to anxiety
2nd study
- try to unpact content of imagery
- suicide vs positive imagery
- more qualitative study (interviews where patients were asked how images are, how preoccupying, compelling, vivid, …)
> compelling: i am visualizing this thing and it makes me want to do it, or do something about it
- in bipolar group, images are more preoccupying
evidence from lab experiments
- mental imagery has impact on emotion, motivation, cognition and behavior (stronger or different than mental thoughts
- imagery can shape perception, attention, action etc via shared pathways in the brain
- frequency, content and quality of imagery can modulate affect (and behavior) in clinical samples and impact symptoms
results of studies - mental imagery
Bipolar vs control
- higher levels of intrusive prospective imagery and more vivid imagery of future negative events
- unstable in BD group: higher levels of intrusive future imagery correlated with levels of anxiety and depression
Bipolar vs unipolar depression
- suicidal flashforwards more preoccupying and compelling in BD
- positive flashforwards more vivid, exciting, pleasurable in BD
clinical example
- images feel real, they are not hallucinations but the images are very real and powerful
- images make patients freeze, stay in bed, …
> interviews on asking patients on mental images
mental imagery as an emotional amplifier
- phenomenology in BD
Content analysis:
- imagery congruent with affect
- (hypo)mania: ego-inflation, acceleration (psychological and motor), idealised projects, state of fulfilment (pleasure, relazation, freedom), stunning landscapes and objectification of others
- depression: death, self-depreciation, overall restriction, violence, darkness, worry and social isolation
- euthymia: realistic project planning, carrying out daily activities, state of well-being (calm, security, relaxation), contemplation of natural landscapes, personal development and interactions with others
study
Imagery tasks (is there something about basic imagery functions that is different? or more subjective experience of imagery?)
- study comparing BD depressed vs BD euthymic vs MDD depressed vs anxiery disorders vs healthy controls
- all patients vs controls
- e.g. questionnaires on experience of future imagery, or picture-word tasks where show picture and word and ask to combine it in image
- ask for vividness and affect of imagery
> stronger subjective imagery characteristics (vividness)
> in particular future imagery (impact of intrusive future mental images scale, prospective imagery task and picture-word task)
- imagery associated with affective lability
! difference between all individuals with diagnosis and control in terms of having heightened imagery
! association of higher, more vivid future images and again more vivid images in task, associated with levels of anxiety and affective lability scale
! suggests that vivid intrusive images is not specific to specific diagnoses, but is associated to mood instability and anxiety across diagnoses
modelling affect amplification by imagery
- experimental studies in young individuals with BD vulnerability (MDQ questionnaire)
- positive imagery generation task (picture)
- outcome: rating affect on the panas before and after task
> individuals high in spectrum of hypomanic-like state - pictures/words with positive content, with goal-directed behavior, achievement content and positive social response content
- individuals had to generate images with this task and rate how vivid images are
- then rate affect on panas scale (before and after)
(often these are themes that have to do with mania)
what are the results?
- positive imagery generation task:
> greater mixed affect following positive imagery generation
> greater positive affect moderated by imagery vividness (the more vivid image generation, the more amplification of positive affect)
second study
- now added to panas scale more maniac like items (e.g. excited)
- elated vs calm positive affect (same picture, different words to cue what to visualize)
- compared people with high hypomanic like experiences and low hypomanic like experiences (MDQ score)
- panas measured at different times
> slope of the change over time was dependent on content of imagery and the group
results
- group with high MDQ score with elated imagery condition, there is an exponential increase in positive affect
- young adults with low MDQ show a flattening of positive affect over time
! elated positive imagery might play a role in mood amplification as cognitive mechanism of affect escalation in mania
future simulation in BD spectrum
Study
- imagine daily life negative future scenarios
- rate affect
- rate simulation (how real they felt)
> change image so it doesn’t feel so real
- imagine image black and white
- control condition to imagine image again
results
- realness was significantly higher in BD than controls
> even when repeated again
> still a bit higher in BD when black and white, but less than before - affect
> increase in sadness in BD when imagining negative scenarios (then decreases again)
! imagery might be playing role in amplyfying emotions
! seemed to be associated to caveates of imaging studies
imaging studies
- significant differences in activation in areas including inferior frontal gyrus, middle frontal gyrus and insula
- all areas that have to do with how the attentional control network modulates where you put your attention to, compared to other networks in the brain, partly with emotional regulation in BD
- imagery might play a role in driving, contributing or maintaning affect amplyfication in BD, both negative and positive side
summary
look at picture
does manipulating imagery reduce mood instability?
- clinical studies
- developed imagery based cognitive therapy
- individual manipulate images and control them, and how they describe impact on mood instability, depression, anxiety etc
- this therapy reduces mood instability (weekly and daily measured)
> as good as psychoeducation for BD
picture
Mega summary
picture
