Lecture 2 - Mood Disorders Flashcards
How can you differentiate clinical from normal depression?
- intensity (given the cause)
- pervasiveness (impaired functioning)
- duration
- qualitative difference: can feel it in the room (heavy, blunt affect, slow/heavy speech)
- suicidality
- physical/vegetative symptoms
What is the DSM-5 criteria for Major Depressive Disorder?
- 2 weeks
- depressed mood (irritability in children)
- diminished interest/pleasure in activities
- weight change/appetite change
- insomnia/hypersomnia
- fatigue/loss of energy
- feelings of worthlessness or guilt
- psychomotor agitation/retardation
- decreased concentration/indecisiveness
- thoughts of death/suicide
- distress and impairment
What is the 12mth, lifetime and childhood prevalence of MDD?
- 12mth: 5.8% (7.4%F, 4.2%M)
- lifetime: 15.3%
- childhood: 0.92% (no gender diffs, diagnosis difficult; depression may present as irritability)
What is the course and comorbidity of depression?
- 74% MDD recurrent
- 69% PDD recurrent
Over 25 years:
- average 3 episodes
- 12% recovered
- 84% recurring
- 2% unremitting
- 2% suicided
78% comorbid MDD; 69% in PDD
Depression usually second
No. or prior disorder predicts depression more than specific disorders
How many people with depression seek treatment?
60%
What is the comorbidity of MDD?
57% F, 66% M
anxiety
substance use
psychotic disorders
medical conditions (epilepsy, Parkinson’s, cancer, hepatitis, cancer, the pill, chemo etc.)
What are the overlapping features of anxiety and depression?
fatigue can't sleep can't cope tense nervous
> > anxiety may occur first, limit functioning and thus lead to depression
What is the interaction between mood disorders and suicide?
60% of suicides are associated with a mood disorder
75% of adolescent
> > key factors: hopelessness and helplessness
What are the 4 causes of depression?
GENETICS
- 40-70% heritable
- risk in 1st degree relative: 5-25%
NEUROBIOLOGY
- neurotransmitters: 5HT, DA, NA
- stress hormones: cortisol, ACTH
STRESSFUL EVENTS
- 2.5x more likely in depressed patients
- role of the individual in contributing towards stress outcome (eg. woman leaves abusive relationship but now has no money)
- associated w poor decision-making
PERSONALITY
- neuroticism
- introversion
- negative self-esteem/self schema
What are the protective factors of depression?
exercise car ownership normal weight physically attractive/tall genetics positive social support old age
Explain Beck’s Cognitive Model of Depression
antecedent > beliefs > consequences
NATS
- automatic, unprompted, immediate, unchallenged
- triad: self, world, future
SYSTEMATIC LOGICAL ERRORS
- conclusions about self/world/future reached by errors
- eg. all-or-nothing, “should”, fortune telling, mental filtering
DEPRESSOGENIC SCHEMAS
- enduring assumptions (represent organisation of past/current experience)
- develop over many years
- inform cog processsing about events
- may be unconscious
- activated by stress
- eg. fear losing control, incompetent
What is the support for Beck’s model?
- depressed people have more NATS and make more logical errors
BUT… are they precipitants, vulnerability markers or products of depression??
Chicken vs. Egg??
What is the DSM-5 criteria for Persistent Depressive Disorder?
- depressed mood for most of the day, more days than not
- 2 years
2+ of….
- appetite change
- insomnia/hypersomnia
- low energy/fatigue
- low SE
- poor concentration/decision-making
- feelings of hopelessness
What are the prevalence, course and consequences of PDD?
- 12mth prev: 0.5%
- course: MDD may occur before, during or after
»> often precedes MDD though (may be a risk factor for MDD) - consequences: functional impairment as great, if not greater, than MDD
What is the prevalence of postnatal depression?
1/7 (13%)
50-80% experience ‘baby blues’
What are the risk factors of postnatal depression?
- hx of anx/dep (fam hx)
- stressful pregnancy
- moving house
- single parent
- hx abuse
- problems with baby’s health/breastfeeding
- lack of practical, financial or emotional support
- unrealistic expectations
What is a manic episode?
- abnormally and persistently expansive, elevated or irritable mood + increased energy and goal-directed activities
- 1 week
- sever enough to cause marked impairment or need hospitalisation
3+ of
- inflated SE/grandiosity
- decreased need for sleep
- talkative/pressured speech
- distractibility
- increase in goal-directed behaviour or psychomotor agitation
- involvement in activities with painful consequences
What is a hypomanic episode?
- same criteria as mania
- only 4 days
- disturbances observable by others
- episode not severe enough for marked impairment or hospitalisation
What is Bipolar I?
1+ manic episode
- may be mild, moderate or severe
- not better explained by some form of SZ
What is Bipolar II?
1+ hypomanic episode; 1+ major depressive episode
- NEVER had a manic episode
- not better explained by some form of SZ
- mild, moderate, severe
What is the onset and prev rate of BP-I and BP-II?
Onset: 18 BP-I, 2- BP-II
Lifetime Prev: 0.6% BP-I, 0.4% BP-II
12mth Prev: 0.4% BP-I, 0.3% BP-II
» sub-threshold more common
What is the course of BP-I?
- may have delusions/hallucinations
- may have distinct manic and depressive episodes, or may be mixed
- may have clear recovering b/w episodes or may have rapid cycles (more difficult to treat)
What happens if BP-I is not treated?
- length of ‘normal’ b/w eps decreases
- length of eps increases
- depressed phase more likely
- suicide more likley
When can mania occur as a secondary phenomena? (5)
- cocaine
- other stimulants
- anti-depressants (SSRIs can trigger)
- CNS disorders
- L-dopa
What is Cyclothymic Disorder?
- 2 years
- number of subthreshold hypomanic episodes and a number of subthreshold depressive symptoms
- episodes present at least 50% of the time; no more than 2mths symptom free at a time
- MDD, manic or hypomanic criteria have never been met
What is the risk of suicide in bipolar? What are the 3 predictors?
15% lifetime risk
1/4 BP-I
1/5 BP-II
predictors: comorbid PD, previous attempt, more depression
What is the comorbidity in bipolar?
75% have 1 other lifetime disorder
>50% have >3
anxiety (63%)
behaviour (45%)
substance use (37%)
What are the outcomes of bipolar?
- up to 60% in employment over long-term
- downward drift in occupational status over time
- Kraepelin: full recovery b/w episodes; favourable outcome relative to SCZ
- 24% failed to return to work up to 30yrs after first manic episode
- disjunction b/w symptom and functional recovery
- 80% symptom remission, but only 43% return to work and 20% working at premorbid competence
YOUNG PEOPLE
- 80% syndromal remission
- only 60% not symptom remission (due to anx/dep sx still there)
- 66% failed to return to previous functioning level at 6mths (61% at 12mths)
Explain the treatment delays in bipolar?
up to 9-10 years
WHY?
- diagnosed with MDD (depressive episode often first)
- atypical clinical presentation of mania
- hypomanic often pleasant
- substance use comorbidity (deflect diagnostic attention)
- reluctance to seek help
What are the consequences of delayed treatment in bipolar? (6)
- poorer social adjustment
- more hospitalisations
- increased risk of suicide
- comorbidities develop
- global impairment of capacity to face development tasks
- forensic complications
- shortening of frequency of cycle
What are the causes of bipolar? (8)
GENETICS
- risk of 1st degree relative 6%
- MZ twins 58%, DZ twins 17%
MOLECULAR GENETICS
- chromosome 11 (but more likely to be a number of genes involved)
NEUROCHEMICAL
- changing levels of neurotransmitters (5HT, NA - too high in mania, too low in dep)
- changing balance of Na-K at cellular level (lithium restores this balance)
- changing post-synaptic sensitivity in receptos
- issues with cerebral glucose metabolism
- HPA axis (cortisol in MDD)
MANIC DEFENCE
- predisposing BP factors: unstable SE + unrealistic standards for success
- grandiose ideas precipitated by intensification of low SE»_space; mood elevation and mania
- grandiose ideas keep distressing cogs out of consciousness
- insecure attachment
CIRCADIAN RHYTHM DISRUPTION
- sleep dep with onset of mania
- melatonin, cortisol, 5HT
- sleep-wake regulation/light therapy as proposed treatment
- sleep critical for mood regulation
DYSREGULATED BAS SYSTEM:
- behavioural approach system
- BAS drives approach behaviour + motivation to attain rewards
- goal-attainment events increase vulnerability to mania; rewarding nature triggers BAS
STRESS
- stressful events precede mania (and dep)
- predict relapse
- trigger more early episodes than later ones
PERSONALITY
- Cluster B (histrionic, narcissistic)
What is the relationship between mania and creativity?
- 50-60% describe +ve consequences of the disorder
- empathy, sensitivity, self-awareness, alertness, enhanced social rships + sexuality, increased appreciation of life, increased creativity
- poets, writers, visual artists, comedians
