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MAPD 2 > Lecture 11: Mood instability and Bipolar disorders > Flashcards

Lecture 11: Mood instability and Bipolar disorders Flashcards

1
Q

bipolar omschrijving

A

classified as a severe mental illness, clear distinction between low mood and mania. in the inbetween periods there is often anxiety. vaak weekly episodes (maar dit verschilt echt per persoon)

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2
Q

time between periods =

A

Bipolar Disorder patients weekly mood ratings: time between episodes only 36.5% euthymic mood

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3
Q

depressive phase symptoms

A

Low mood
Loss of enjoyment (anhedonia)
Loss of interest and motivation for everyday
activities
Poor sleep (early morning waking) / but also
the opposite!
Scarce appetite / but also the opposite!
Loss of concentration
Poor energies, mental and physical slowing
Feeling of emptiness or worthlessness
Self-doubt/self-blame
Suicidal thoughts

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4
Q

(hypo)manic phase symptoms

A

Constant elation or euphoria
Irritable mood, getting into arguments easily
Observable hyperactivity
Increased energies
Inappropriate optimism
Overestimating personal ability
Poor judgement, grandiose plans
Speeding up of thought and speech, flights
of ideas
Need for little sleep

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5
Q

The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty.
There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria pervade one’s marrow.
But, somewhere this changes. The fast ideas are too fast, and there are far too many, overwhelming confusion replaces clarity. Memory goes. Humour and absorption on friend’s faces are replaced by fear and concern.
Everything previously moving with the grain is now against…. you are irritable, angry, frightened, uncontrollable, and emerged totally in the blackest caves of the mind.”

A

oke

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6
Q

how many people relapse

A

Around 50-60% relapsing within a year of recovery from a mood episode

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7
Q

wat is vaak co-morbid met bipolar disorder

A
  1. anxiety!!!
    over 50% of people, ofwel 30-70%
    93% of the people have an anxiety disorder in their life
  2. psychotic symptoms
    75% of BD patients, can occur during both depressive and manic episodes
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8
Q

differential diagnoses for BD

A
  • Major Depressive Disorder (unipolar)
  • Schizoaffective disorder and psychotic disorder (continuum?)
  • Anxiety disorder
  • Substance use disorder
  • Personality disorder
  • ADHD (in children)
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9
Q

there are many BDs, there is a lot of heterogeneity!!

A

oke

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10
Q

epidemiology of BD

A
  • 2-4% of population
  • bipolar 1: men and women equally
  • bipolar 2: more women
  • genetics!
  • high risk of suicide: 30-50% attempts, of which 15-20% complete
  • 60% of cases start before 21
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11
Q

wat is de trajectory of BD

A
  • start in adolescence: minor/single depressive episode + family history of BD
  • dan tussen adolescence en young adulthood: recurrent depression en BD prodromes (including hypomanic like features)
  • na young adulthood: BD type 1 or 2 or “other” (sub threshold hypomania)
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12
Q

dutch bipolar offspring study:

A
  • 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
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13
Q

dus bipolar disorder begint vaak vroeg bij mensen! de meeste mensen merken het al rond 18 de manische episode, en eerder al een depressieve episode

A

oke

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14
Q

wat voor treatment in de acute fase

A
  • medication: mood stabilisers and anti-psychotics (lithium), antidepressants never without mood stabiliser!
  • psychosocial interventions (CBT, IPSRT, family therapy): limited efficacy, but in euthymia can decrease risk of relapse and recovery depressive symptoms
  • psychosocial interventions: need for more research and innovation
  • challenge of treating anxiety
  • lifestyle bijhouden
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15
Q

wat is er met creativity

A
  • er is een link met creativity and psychopathology, strongest link for creativity & BD.
  • scandanavian population study: first degree relatives of BD are more likely to have creative/high achieving professions
  • maar… opppassen dat er geen glorification of mental disorders komt.
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16
Q

waarom is medicatie zo lastig

A

tijdens een manische episode stoppen mensen vaak met het innemen, want dan voelen ze zich goed en willen ze dat gevoel behouden.

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17
Q

some of the key challenges in understanding and supporting people with BD

A
  • you might miss mania (usually retrospective assessment)
  • affect biases (difference mania and depression -> dus in welke mood ze dan zitten heeft een effect
  • the anxiety in between the episodes
  • the shame in between episodes (what have i done when i was manic…)
  • relapses
  • verschillende doelen van therapie tijdens mania & depression
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18
Q

most people with bipolar are put under regular checkups within the healthcare system

A

okee

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19
Q

mood instability =

A

Rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences

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20
Q

wat voor effecten heeft affect liability

A

affect liability -> mood swings -> emotional dysregulation -> substance misuse, binge eating, self harm

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21
Q

mood instability in other syndromes

A
  • borderlne personality disorder: short-lasting reactivity of mood to interpersonal stressors
  • adhd
  • ptsd
  • depression & anxiety (40-60%)
22
Q

hoe zit het met affect liability in de gehele populatie van mensen met een mental disorder

A
  • Comparing individuals with mental disorders from a general adult psychiatry clinic to primary care patients without a mental disorder
  • Three measures: affect lability, affect intensity, affect control
  • Mental disorders: higher levels of affective lability and lower affect control than those without mental disorder.
  • No differences in affective intensity
  • Independent of type of diagnosis, affect lability adversely impacts day-to-day functioning.
23
Q

developmental specificity of mood instability =

A
  • Adults survey in UK: 13.9%, peak aged 16–24, decline over time
  • Adolescents: greater daily variability and more extremes of mood that progressively
    reduce in young adults (dus “gewone” jongeren hebben meer dagelijkse moodswings)
  • Part of prodromal symptoms of depression and bipolar disorder in young people
24
Q

clinical relevance of mood instability =

A
  • poor clinical outcomes: suicidal thinking, healthcare service use, self harm and addiction
  • trauma in bipolar disorder and borderline personality disorder
  • worse outcomes in BD
  • STEP-PD trial: depressive instability predicted lower likelihood and longer time until recovery
25
Q

are there abnormalities or specific characteristics in any cognitive function that are associated with mood instability?

A

yes, in BD there are negative memory bias, that are associated with greater instability in depressive and manic symptoms. but we dont know how specific this is to mood in BD. because attentional dysfunction seems to also play a role; people with ADHD and BPD (attentional dysfunction) also showed mood instability. therefore attentional control may be implicated in BD

26
Q

emotion dysregulation areas dysfunctional in BP and BPD:

A
  • more connectivity between ventromedial PFC & amygdala
  • reduced connectivity between ACC & amygdala
  • more ACC activity during emotion processing task: compensatory mechanism?
  • reduced ventrolateral PFC activity during emotion regulation task
27
Q

wat liet een longitudinal study in 9-17 years old at risk zien

A

worsening affective lability (scale) = increased amygdala and ventrolateral PFC activity over time

28
Q

wat zijn difficulties in measuring mood instability

A
  • we zijn veel afhankelijk van self-report (lastig in te schatten)
  • daardoor recall bias aanwezig
  • mean, maximum and sd dont describe variation over time
  • diagnosis assumes the presence of mood instability
29
Q

hoe kunnen we nu beter mood tracken

A

via apps, veel gemakkelijker om mood door te geven, dus meer data en minder recall biases

30
Q

Mobile phone mood ratings correlated
with clinician-rated depressive symptom
severity vs. paper-and-pencil ratings
(Depp, et al., 2012) but not for mania

why?

A

dus depression severity is rated somewhat like clinical data, but not mania: because then they have less insight and fill in their symptoms less well

31
Q

hoe kan je differentieren tussen BD en BPD

A

borderline is more related to interpersonal interactions. also more variability and irritability in borderline.

32
Q

additional passive tracking features/machine learning

A
  • decrease in phone calls and sms communication in depression in BD, but not borderline
  • call logs, sleep data, step count data, heart rate (rond de 80% accuracy between stable state and mood swing state in patients with depression
33
Q

wat vonden BD group van mood tracking via apps

A

BD group with self-reported higher variability of symptoms: feasibility of using MoodZoom with twice daily autogenerated monitoring: more convenient, preferable and user friendly than questionnaires. (maar… het moet wel een voordeel hebben voor ze, anders is de engagement laag)

Personalization, adjustability, privacy, an
adjustable graphic report, and a direct link
to early intervention strategies are
necessary requirements for a successful
design.

34
Q

wat is er met mental imagery

A

mental imagery versterkt gevoelens die je hebt, meer dan verbale gedachtes!!!

mental imagery is an emotional amplifier

35
Q

evidence for mental imagery

A
  • imagery has a direct impact on emotion, motivation, cognition and behaviour (stronger or different than verbal thoughts)
  • imagery can shape perception, attention, action etc. via shared pathways in the brain
  • frequency and quality of imagery can modulate affect (and behaviour) in clinical samples
36
Q

imagery-related abnormalities in BD vs controls:

A
  • higher levels of intrusive prospective imagery & more vivid imagery of future negative events
  • unstable BD group: higher levels of intrusive future imagery correlated with levels of
    anxiety and depression
37
Q

prospective imagery in BP vs unipolar depression

A
  • suicidal “flashforwards” more preoccupying and compelling and intrusive in BD
  • positive “flashforwards” more vivid, exciting, pleasurable in BD
38
Q

prospective imagery in BD: clinical example

A

bv when studying for exam: very vividly seeing the picture of them failing

39
Q

content analysis of thesse mental images

A
  • Imagery congruent with affect
  • (Hypo)mania: ego-inflation, acceleration (i.e. psychological, motor), idealised projects, state of fulfilment (i.e. pleasure, relaxation, 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 (i.e. calm, security, relaxation), contemplation of natural landscapes, personal development and interactions with others
40
Q

misschien door die mental imagery ook meer creatief??? denk van gogh -> landscapes etc.

A

oke

41
Q

hoe transdiagnostisch is de mental imagery

A

Study comparing: BD depressed vs BD euthymic vs MDD depressed vs Anxiety disorders vs HC

  • All patients vs. controls:
  • Stronger subjective imagery characteristics (vividness)
  • In particular future imagery (impact of intrusive future mental images
    scale, Prospective Imagery Task & Picture-Word Task)
  • Imagery associated with affective lability

-> dus imagery is related to instability, not BD per se

42
Q

wat voor therapy kan je dus bedenken bij die mental imagery

A

positive imagery generation taks: bv inbeelden dat je je beste achievements haalt.

experiment: library inbeelden. sommige mensen dachten hun beste achievements the halen, anderen iets kalms zoals een boek lezen. high mdq scores (jongeren met hypomanic like experiences) leidden tot exponential positive affect amplification (stijgende lijn). combine words and pictures, rate the vividness and positivity after the task. het is een stijgende lijn.

43
Q

dus conclusie van positive imagery generation task:

A
  • greater mixed affect following positive imagery generation
  • greater positive affect moderated by imagery vividness

dus een hele steile lijn tussen vividness en mood positivity bij mensen met high MDQ, een minder steile lijn bij mensen met een laag MDQ

44
Q

wat was dan het verschil tussen young adults met high MDQ en low MDQ

A

Adults with High MDQ in the elated imagery condition show an ‘exponential’ positive affect amplification vs young adults with low MDQ shows a flattening of positive affect over time. dit zien we ook in BD: geen flattening en geen controle of this affect

dus high MDQ = stijgende lijn omhoog
low MDQ = soort curve/bolletje, gaat na een tijdje weer omlaag

45
Q

if you manipulate the imagery, does that change the effect?

A

yes, participants received future images of negative events. then they rated how emotional they felt and how real they felt. in the next condition: black and white images. this felt less real and shrinked the feeling. not changing the content but changing how it feels -> voelt meer als een simulatie in plaats van echt.

46
Q

wat voor verschillen zag je in het brein van healthy control vs BD spectrum

A

Significant differences in activation in areas including inferior frontal gyrus, middle
frontal gyrus and insula

47
Q

dus evidence for cognitive model of future imagery as driver of mood instability:

A
  • Future simulation more emotional and vivid in individuals with greater mood instability
    even when mood is euthymic
  • Perceptual manipulation of imagery is able to revert the emotional bias in imagery
  • Manipulating imagery is associated with activity in emotion regulation
  • Neural abnormalities during future simulation appear to be present in BD spectrum in
    the default network, frontoparietal and frontoinsular networks:
    ➢ areas that play a role in regulating social/emotional/planning aspects of future
    simulation
    ➢ PFC areas involved in key dysfunctional emotion regulation networks in BD
48
Q

Elated imagery generation:
Affect linear increase only in YP
with BD vulnerability

A

oke

49
Q

wat liet de studie met euthymic young people with BD spectrum dus zien

A
  • Future negative imagery more emotional and vivid in YP with BD spectrum and generates change in affect
  • Associated with greater activity in a network of areas including the frontal pole (BA9), inferior frontal gyrus (BA8, BA46), middle frontal gyrus and insula previously involved in emotion dysregulation in BD.
50
Q

Clinical studies (case series, 2 small RCTs) testing efficacy of an Imagery-based intervention in Bipolar Disorder:

A
  • promising effects at reducing mood instability measured weekly/daily
  • initial evidence of comparable or superior effects to standard psychological interventions (psychoeducation)
    on mood instability, anxiety, depression
  • Imagery techniques include: imagery rescripting and ‘meta-cognitive’ imagery manipulation
51
Q

summary of lecture

A
  • Mood instability is an under-researched transdiagnostic phenomenon, associated with poor clinical outcomes
  • A better understanding of underlying mechanisms including cognitive models is needed
  • More detailed, accurate and reliable measurement of mood instability can be achieved via novel mathematical and digital approaches
  • Initial evidence suggests that dysfunctional mental imagery (simulation) may be a cognitive characteristic of individuals experiencing mood instability
52
Q
A

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