Mood disorders Flashcards
What are mood disorders?
• Fundamental disturbance in mood
• Depression (often with anxiety) or elation
• Mood change often accompanied by changes in activity
• Similar to normal variation in mood (we all feel ‘low) BUT
o More persistent
o Significant impairment in functioning
• Most episodes recur
• Onset of individual episodes tends to relate to loss events/stressors BUT not necessarily
What are the symptoms of depression?
- Pervasive low mood
- Suicidal thoughts
- Poor concentration
- Functional impairment
- Anxiety/panic
- Poor sleep
- Diurnal variation of mood
- Hopelessness
- Helplessness (can’t be helped)
Diagnostic criteria for mood disorders?
• Primary feature(s) → low mood, reduced energy
• Secondary feature(s) → physical / psychological / sleep
• Impairment → causing impairment in functioning
• Duration → >= 2 weeks
• Exclusions → not due to
- Substance misuse or
- Physical disorder or
- Another mental disorder
Depressive episode - biopsychosocial model - Psychological aspect
- Future – Hopelessness (N.B. hopelessness is a strong predictor of another psychological symptom: Ideas & acts of self-harm/suicide)
- Present – Low self-esteem
- Past –Guilt
Beck’s cognitive triad: -ve thoughts about:
- Self
- World
- Future
i.e. pervasive negative cognitive bias.
→ cognitive-therapeutic view of the three key elements of a person’s belief system present in depression.
Depressive episode - biopsychosocial model - physical aspect
- Reduced appetite
- Reduced weight
- Constipation
- Reduced libido
- Reduced energy
- Amenorrhoea
Depressive episode - biopsychosocial model - social aspect
- Social withdrawal
- Absence from work
- Reduced performance at work
- Reduced interest in hobbies/other interests
- Relationship dysfunction e.g. marital problems
Depressive episode - sleep symptoms
- Delayed sleep onset
- Early morning waking (EMW)
- Unrefreshing sleep/daytime fatigue
- Diurnal variation of mood (DVM) – wake early feeling especially distressed and depressed; gradually improve through the day, and then sleep, …
(N.B. this leads to the concept of sleep as a depressant in people with mood disorder; or of concept of sleep deprivation as an antidepressant in people with mood disorder)
What can depression be subcategorised into?
Depressive episode: - mild, moderate, severe - with or without psychotic symptoms - with or without biological symptoms Recurrent depressive disorder: - Current episode a) mild, b) moderate, or c) severe; or - currently in remission Persistent mood disorder: - dysthymia - persistent mild depression
Give example of how depression is a real biological illness
Ito et al, 1996 – showed that in depression, there is hypoperfusion in the limbic system and PFC
Incidence and prevalence of mood disorders
Lifetime prevalence rate 10-20%
12 month prevalence rate 7%
Point prevalence rate 2-5%
5% of disability worldwide (WHO); 9% of disability in developed nations: more than IHD / DM / CVD / DAT (Dementia of the Alzheimer’s type) / OA (osteoarthritis)
Risk factors for mood disorders
- Genes/FH: heritability 40-70% (Kendler et al, 1993); genetic overlap with anxiety and neuroticism
- Gender: 2 female: 1 male
- Cumulative childhood disadvantage (vs childhood resilience factors e.g. high IQ child, single good adult relationship)
- Personality: probably anxious/obsessional
- Adverse life events / disadvantage: especially loss events; N.B. G x E (genes and environment) interaction – genes increase vulnerability to stressors
- Physical illness: chronic or severe
- Previous depressive episode is a powerful predictor of future depressive episode
What percentage of suicides have depressive disorder?
> 40% of suicides
Describe depression treatment
For years, the mainstay of treatment of depression was pharmacological, using the MAOIs, then the TCAs (such as amitriptyline), then the SSRIs, and more recently a wave of other AD classes. In the last 20 years, though, a new psychological treatment for depression, supported by high quality RCTs, has emerged: • ‘Cognitive behaviour therapy’ or just ‘CBT’ is now the dominant psychological treatment for depression in the UK NHS This is due to the many RCTs (randomised controlled trials) that demonstrate it is more effective than usual care alone
Describe formal CBT
weekly x individual x 1 hour x 10-15 + homework
What specific elements can be incorportated into OP care?
- Collaborative
- Goal-oriented
- Structured
- Focused on the here and now
- Scientific empiricism
- Guided discovery – therapist and patient are experts
Two aspects of CBT
- ‘behavioural activation’ by ‘activity scheduling’
2. identify and challenge negative automatic thoughts
How may behavioural activation by activity scheduling occur?
Use an activity diary:
- Identify previous activities that gave pleasure/satisfaction – Pts with depression have sig. fewer of these activities in a typical week than pts who are non-depressed. Multiple mechanisms are likely, including reduced social isolation, which is both a cause and an effect of depression.
- Diarise these activities, in a realistic way; troubleshoot difficulties implementing them; can use them as behavioural experiments (e.g. ‘I won’t enjoy going to the gym’). (If in doubt, test it out!)
- Aim for a stepwise increase, week by week
Describe identification and challenging negative automatic thoughts
Use a dysfunctional thought record to identify NATs and their triggers, and then to challenge them systematically – how realistic is that??
Negative thinking:
- NATs are common in depression and in recovered depressives – may be a risk factor for relapse
- Follow common patterns
- Irritatingly plausible
- Congruent with our mood
- And reinforce our mood
- But not necessarily true!
- The fortunate among us have PATs (+ve automatic thoughts!)
- Cognitive therapy aims to turn NATs into PATs (or at least into RATs – realistic automatic thoughts!)
Bad thinking habits – cognitive errors:
- All or nothing thinking – “I won’t be able to do this perfectly so I might as well not bother”
- Over-generalisation – “I never do anything right”
- Mind reading – “He thinks I’m boring”
- Disqualifying the positive – “She was only being nice to me”
- Emotional reasoning – “I feel afraid, therefore there must be something to be afraid of”
- Magnification – thinking the problem/challenge is bigger than it is
Problem with CBT in depression
- the syndrome - helplessness, poor motivation
- non-cognitive maintaining factors - e.g. social isolation, alcohol use
- poor compliance
- practicalities - convenience
- psychological mindedness
- deconstruction - BT alone? as effective as CBT
- length treatment
- lack of therapists
- long waiting lists
future of CBT for depression
- Efficient, scalable interventions – IAPT (Improving Access to Psychological Therapies)
- Personalised treatment – focused, but how predict for individuals?
- Third wave treatment – incorporating e.g. mindfulness
- Early intervention / preventing relapse – ‘booster’ sessions / EWS
- Use as prevention in high risk groups – attentional bias modification as a ‘cognitive vaccine’
Mania diagnostic criteria
Core feature(s) → Elated or irritable mood
Secondary feature(s) → Inflated self-esteem, reduced need for sleep, more talkative (‘pressure of speech’), flight of ideas or subjective racing thoughts, distractibility, increased goal-directed activity (socially, work, school, sexually), excessive involvement in pleasurable activities that have a high potential for painful consequences (unrestrained buying, sexual indiscretions, foolish investments) (DSM calls this ‘heedless pleasure’)
Impairment → Causing marked (for mania) impairment in functioning
Duration → >= 1 week, unless hospitalised, when less is OK ; (4 days for hypomania)
Exclusions → Not due to substance misuse/physical disorder/schizophrenia (key differentials)
Different types of mania - WHO classification
Manic episode - Hypomania - Mania without psychotic Sx - Mania with psychotic Sx Bipolar affective disorder - current episode a) mania (as above), b) depressed (as above), c mixed - currently in remission Cyclothymia (mild)
Describe bipolar spectrum according to DSM-IV
Bipolar I
o Mania
o Depression
o Mixed states (of M and D symptoms)
Bipolar II o Hypomania (‘below mania’) + depression
Bipolar NOS
o Hypomania without major depression; sub-syndromal hypomania
What dominates symptom load in bipolar?
Depressive symptoms
Prevalence of bipolar
> 1 in 25 of the population has bipolar disorder.
Prevalence of…
Any bipolar – lifetime prevalence = 4.4%
o Bipolar I 1.0%
o Bipolar II 1.1%
o Bipolar NOS 2.4%
Predisposing factors of bipolar
Predisposing factors – genes First Degree Relatives of those with BPD – elevated rates: o Bipolar I 4%-24% o Bipolar II 1% - 5% o Major Depressive Disorder 4% - 24%
Twin studies
Concordance rates
Monozygotic 60-70%
Dizygotic 20%
You cant change a persons genes, so what is essential in for treatment of bipolar?
Managing precipitating and maintaining factors
What are maintaining factirs?
• Disturbed daily routine
• Sleep more/less
• Poor compliance with medication
• Use of alcohol/substances
• Impact of environment on mood
(N.B. these factors lead directly to clues about management)
High mood states (and low mood states) are self-reinforcing.
Treatment of bipolar
Mania
• atypical antipsychotic/lithum/valproate
Depression (in Bipolar disorder – NOT NORMAL DEPRESSION!)
• quetiapine / lamotrigine /
Mood stabilisation
What are long term treatments of bipolar?
Long-term treatment – psychosocial
- Psycho-education – about symptoms, medications, side-effects
- Use mood charts to monitor & spot “early warning signs” of relapse
- Regularisation of daily routine – sleep and wake times; appropriate stimulation, relaxation etc.
- Addressing adherence to medicines
