W3: Depressive & Bipolar Disorders Flashcards
What are the mood disorders in the DSM
Unipolar depressive disorders and bipolar disorders
What are the depressive disorders in the DSM
Major depressive disorder
Persistent depressive disorder (dysthymia)
Disruptive mood dysregulation disorder
Premenstrual dysphoric disorder
What is major depressive disorder (MDD)? 
Clinically significant sadness with associated cognitive and somatic changes
It’s an episodic disorder with periods of normal mood in between periods of the depressed mood
What is the DSM criteria for major depressive disorder
Need to have five or more of the following within the same two week period
Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day (anhedonia)
Significant weight loss or gain or increase/decrease in appetite
insomnia or hypersomnia nearly every day
Psycho motor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think, concentrate, or indecisiveness nearly every day
Recurrent thoughts of death, suicidal ideation, suicide attempt or plan

Causes clinically significant distress, not attributable to substances or other medical conditions or mental disorder
There has never been a manic or hypomanic episode!!!!!!

What is the prevalence of MDD
14.4%
What is the mean onset of MDD
The main age of onset is 30.5 but this age seems to be decreasing this could be because people are becoming more aware and are willing to seek help earlier
Are there any gender differences in MDD
There are higher rights in women but is this a genuine reflection of prevalence or are women socialised to get help
Explain relapse in MDD
The risk of relapse is high but it is lowered went successfully completing CBT compared with medication
What is suicide ideation
Thoughts about ending your life this is common in depression
What is suicide attempt
An attempt was made to end your life but it is not completed
Women attempt suicide more than men
What is suicide
Successful death from a suicide attempt
Completed suicides are more likely in men
What is nonsuicidal self injury
The aim is to cause harm for not to die there may be a range of reasons for this but the main one seen is a release of pain
Differential diagnosis between bipolar and major depressive disorder
When you have someone with a major depressive episode it is important to always assess for a history of mania and or hypo mania - if the patient has had a manic or hypomanic episode it will exclude them from a diagnosis of MDD
What does the DSM say about persistent depressive disorder (dysthymia)?
Depressed mood for most of the day, for more days the not, as indicated by subjective account or observation by others, for at least two years
Two or more of the following: Poor appetite or over eating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness
During the two year period the individual has not been without symptoms for more than two months at a time
There has never been a manic or hypomanic episode
The disturbance is not better explained by schizoaffective disorder, schizophrenia, delusional disorder, other psychotic disorder
Not due to substances or medical conditions and cause clinically significant distress or impairment
What is Persistent depressive disorder (dysthymia)?
A mild but long-term form of depression.
Dysthymia is defined as a low mood occurring for at least two years, along with at least two other symptoms of depression.
Individuals with MDD and PDD often experience comorbidity disorders such as
Anxiety disorders
Substance use disorders
Personality disorders (borderline & dependent)
Explain the specifier of MDD and PDD of anxious distress
2 of the following;
Feeling keyed up or tense
Feeling unusually restless
Difficulty concentrating because of worry
Fear that something awful might happen
Feeling that the individual might lose control of himself or herself
Explain the specifier of MDD and PDD of mixed features
3 manic/hypomanic symptoms:
Elevated, expansive mood
Inflated self-esteem or grandiosity
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Increase in energy or goal directed energy
Increased or excessive involvement in activities that have a high potential for painful consequences
Decreased need for sleep 
Explain the specifier of MDD and PDD of melancholic features
1 of the following when episode is most severe
- loss of pleasure in all, or almost all, activities
- loss of reactivity to usually pleasurable stimuli
3+:
– Depressed mood characterised by profound despondency, despair, and or empty mood
– Depression that is regularly worse in the morning
– Early-morning awakening
– Marked psychomotor agitation or retardation
- Significant anorexia or weight gain
– Excessive or inappropriate guilt
Explain the specifier of MDD and PDD of atypical features
Mood reactivity (mood brightens in response to actual or potential positive events)
2 or more:
Significant weight gain or increasing appetite
Hypersomnia
Leaden paralysis (heavy feelings in arms and legs)
A long-standing pattern of interpersonal rejection sensitivity that results in significant social occupational impairment
Criteria is not met with melancholic features or with catatonia
Explain the specifier of MDD and PDD of psychotic features
Delusions and hallucinations are present
With mood congruent psychotic features, content is consistent with depressive themes
- inadequacy
- guilt
- disease
- death
- deserved punishment
With mood incongruent psychotic features, content is not consistent with depressive themes
Explain the specifier of MDD (only) of Catalonia?
Catatonic features
dominated by 3 or more:
- stupor (no psychomotor activity, not actively relating to the environment)
- catalepsy (passive induction of a posture held against gravity)
- waxy flexibility (slight, even resistance to positioning by the examiner)
- mutism (no, or little verbal message)
- negativism (opposition or no response to instructions or external stimuli)
- posturing (spontaneous and active maintenance of a posture against gravity)
- mannerism (odd, circumstantial caricature of normal actions)
- stereotypy (repetitive, abnormally frequent, non-goal directed movements)
- agitation (not influenced by external stimuli)
- grimacing (pulling unusual faces)
- echolalia (mimicking others speech)
- echopraxia (mimicking others movement)
Explain the specifier of MDD and PDD of peripartum onset
Onset of symptoms occurs during pregnancy or in the 4 weeks following delivery
Explain the specifier of MDD (only) of seasonal pattern
There has been a regular temporal relationship between the onset of major depressive episodes and a particular time of the year
- usually autumn and winter 
See full remission occur at characteristic times of the year usually spring and summer
This pattern needs to be seen for at least two years and seasonal episodes need to outnumber non-seasonal episodes
Are there any criticisms to these PDD and MDD specifiers
Not well validated
- seasonal pattern is probably the most well researched and validated
What is the paediatric diagnosis of depression
Disruptive mood dysregulation disorder – diagnosed in children from 6 to 18 years
What is disruptive mood dysregulation disorder
Characterised by persistent irritability and frequent episodes of extreme out of control behaviour – included to address concerns about over diagnosis of bipolar disorder in kids
What does the DSM say about disruptive mood dysregulation disorder
Severe recurrent temper outburst manifested verbally and or behaviourally but are grossly out of proportion in intensity or duration to the situation or provocation
The temple outbursts are inconsistent with their developmental level (out this characteristic of a three-year-old would be concerning seen in a 17-year-old)
The temper outbursts occur on average three or more times per week
 The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others
Present for more than 12 months and throughout this time the individual has not had a period lasting three or more months without symptoms
Severe outbursts and irritable or angry mood in between are present in at least two settings for example at home and at school and are severe in at least one of these
What are the bipolar disorders in the DSM
Bipolar I
Bipolar II
Cyclothymic disorder 
What are bipolar disorders
The bipolar disorders are characterised by the presence of a manic or hypomanic episode
What are manic or hypomanic episodes
There are periods of intense elation and/or irritation
What is the difference between bipolar I and bipolar II
The main difference between bipolar 1 and bipolar 2 disorders lies in the severity of the manic episodes caused by each type. A person with bipolar 1 will experience a full manic episode, while a person with bipolar 2 will experience only a hypomanic episode (a period that’s less severe than a full manic episode).
What is the DSM criteria for manic episode
Period of abnormal and persistent elevated, expansive, irritable mood and increase goal directed activities or energy, lasting at least one week (or any duration of hospitalisation is required)
3+ of following noticeable change from usuals behaviour:
-Inflated self-esteem or grandiosity
– Decreased need for sleep
– More talkative than usual or pressure to keep talking
– Flight of ideas or subjective experience that thoughts are racing usually evident in speech
-Distractibility
– An increase in goal directed behaviour or psychomotor agitation
-Excessive involvement in activities that have a high potential for painful consequences
Severe enough to cause marked impairment in functioning or to necessitate hospitalisation to prevent harm to self or others – symptoms not due to substance or other medical condition

What is the DSM criteria for bipolar II
This is a more mild version of bipolar I
The DSM criteria states that criteria have been met for at least one hypomanic episode and at least one major depressive episode
There has never been a manic episode
What does the DSM say for a hypomanic episode
abnormally and persistently elevated, expansive or irritable mood and increased goal directed activity or energy lasting at least four consecutive days
three of the following are present to a significant degree
-Inflated self-esteem or grandiosity
-Decreased need for sleep
– More talkative than usual or pressure to keep talking
– Flight of ideas or subjective experience that thoughts are racing
-Distractibility
-Increased in goal directed behaviour or psychomotor agitation
-Excessive involvement in activities that have a high potential for painful consequences
equitable change in functioning that is uncharacteristic of the individual were not symptomatic
The disturbance in mood and the change in functioning is observable to others
The episode is NOT severe enough to cause marked impairment in social or occupational functioning or two necessitate hospitalisation
Not attributable to the Physiological effects of a drug
What does the DSM say about cyclothymic disorder
Akin to persistent depressive disorder in the depressive disorders is a chronic disorder
For at least two years or one year in children or adolescence, there has been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode in numerous periods with depressive symptoms that do not meet criteria for major depressive episode
During this time the hypomanic or depressive episodes have been present for at least half the time and the individual has not been without symptoms for more than two months at a time
When is the typical onset of bipolar spectrum disorders
Most people develop symptoms before the age of 25
why are suicide rates so high in the bipolar spectrum disorders
They may do things in manic episodes that are then reflected on episodes of depression
Why are individuals with bipolar spectrum disorders often reluctant to take medication
They may receive a sense of achievement due to the mania productivity and feel this is a loss if they take medication but they are happy that depressive symptoms ease
Explain the specifier rapid cycling
Can be applied to bipolar I or II
Presence of at least 4 mood episodes in the previous 12 months that meet criteria for manic, hypomanic or major depressive episode – basically faster turnaround between the episodes
Are there any genetic links in depression
Twin studies demonstrate that about 30 to 40% of the variance in depression is accounted for by genetics
Is bipolar heritable
Twin studies demonstrate that bipolar is highly heritable up to 90%
Explain the role of dopamine in depressive disorders
Dopamine is involved in the reward system of the brain this is involved in pleasure, motivation and energy there is evidence that people with depression have reduced dopamine
Explain the role of serotonin in depressive disorders
Serotonin is involved in the regulation of emotional reactions it is hypothesised that people with a vulnerability to depression have serotonin receptors that are less sensitive than others without such a vulnerability
Explain dopamine in bipolar
Increasing dopamine levels leads to manic symptoms
It is hypothesised that in bipolar disorder dopamine receptors are too sensitive and you can be genetically predisposed to this as well which may point more towards the genetic link of bipolar 
Explain brain functioning in depressive disorders
Brain imaging studies show that people with depressive symptoms demonstrate changes in brain functioning
Such as elevated amygdala which is for emotional responses as well as elevated anterior cingulate 
May also see diminished hippocampus activity for memory and dorsolateral pre-frontal cortex activity for higher order thinking such as decision-making planning and motivation
Explain brain functioning in bipolar
Similar to depression but in mania the striatum aka basal ganglia is also implicated
Explain endocrine models for depressive disorders
The amygdala regulates the HPA axis and the HPA axis triggers cortisol - there is a link between depression and high levels of cortisol
What is the triple vulnerability theory of bipolar and depressive disorders
Biological vulnerability such as genes, psychological vulnerability such as coping skills, and stressful life events such as trauma all combine and lead to ….
physiological effects such as the release of stress hormones, cognitive effects such as depression negative thoughts hopelessness etc and mania such as inflated self belief and impulsivity
and social effects such as increased difficulty in relationships and reduce support
all of these lead to bipolar or depressive disorder
What medications are there for depressive disorders
SSRIs - is the most common and stop serotonin from being reabsorbed so that it can be used for longer
However it does take 4 to 6 weeks to work and symptoms can return when medication is withdrawn
What are the medical treatments for depression
ECT or electroconvulsive therapy
It involves inducing a mild seizure by sending an electric current through the brain.
The aim is to disrupt the circuitry of the brain and is only used in extreme cases for medication resistant depression
– Often short-term confusion and memory loss associated
TMS
Involves a magnet over the brain that provides a pulse to the dorsolateral pre-frontal cortex it is less invasive than ECT and has emerging evidence in the treatment of depression
What medication is there for bipolar disorders
Medication is the first line of treatment for bipolar
Mood stabilisers are the most common
E.g. Lithium
toxic and requires ongoing monitoring of blood levels - not an easy medication to take and may be problems with compliance
There will also still be residual symptoms that often persist despite the adequate use of medication
What is the cognitive model of depression
Maintained by distorted thinking - automatic thoughts, assumptions and core beliefs
This model states if you change distorted thinking you improve mood and reduce depressive behaviours
Core beliefs, assumptions and automatic thoughts lead to a reaction whether emotional behavioural and physiological
Give an example of the cognitive model of depression
The situation is a friend doesn’t return your call
Your core belief is that you’re worthless
Your assumption is that if you are not popular then you’re nothing
And your automatic thought to your friend not returning your call is that she hates you
Your reaction to this may be:
Emotional-anxious and sad
Behavioural – delete friend off of Facebook
Physiological – tense
So what is cognitive behavioural treatment for depression
Getting the client to look at evidence for and against the belief - aim is to develop a more adaptive way of thinking (not positive thinking, rational thinking)
Behavioural activation is the main behavioural treatment for depression this involves getting the client to gradually engage in more and more activities over time

What is CBT for bipolar disorders
Treatment interventions differ according to the current mood state
- depressed: CBT treatment for depression with behavioural activation and thought challenging
- manic: usually hospitalisation is required
Psychologist = enhance compliance with medications by psycho education and helping them to understand benefits
They also may be able to help prevent relapse through circadian rhythm management, sleep, exercise, diet, stress management
