week 10 - mood disorders Flashcards
The Episodes
The Episodes Manic Episode Major Depressive Episode Mixed Episode Hypomanic Episode
The Disorders
Bipolar I disorder
Major Depressive Disorder
–Description, Diagnosis (and DDx), Case Examples, Statistics, Formulation Models, Treatments
Dysthymic Disorder
Bipolar II disorder
Manic Episode
A distinct period of abnormal, persistently elevated, expansive or irritable mood, lasting at least one week.
During the mood disturbance, three or more of the following are present.
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative or pressure of speech
Flight of ideas or subjective experience of racing thoughts
Distractibility
Increased goal-directed activity
Excessive involvement in pleasant activities with potential for negative consequences.
Manic Episode
course/onset
Mean age of onset for first Manic Episode is in early 20s, although cases in adolescence and old-age are observed.
Manic episodes typically begin suddenly, with rapid escalation of symptoms over only a few days.
Episodes tend to last weeks to months
- –Onset and end are more abrupt than Major Depressive Episodes
- –Episodes tend to be more brief than Major Depressive Episodes
Onset of Manic Episode follows a Major Depressive
Episode in 50-60% of cases.
Major Depressive Episode
Five or more of the following over at least two weeks, representing a change from previous functioning
At least one of the symptoms present must be depressed mood or anhedonia.
Depressed mood Diminished interest or pleasure Significant weight loss Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or anergia Feelings of worthlessness or excessive guilt Diminished ability to think or concentrate Recurrent thoughts of death or suicide.
MDE - course
Course
Symptoms typically develop over days to weeks and when untreated Major Depressive Episodes tend to last around four months or longer.
Mixed Episode
Criteria for both Major Depressive Episode and Manic Episode are met nearly every day during a one week period
One week time-period for Manic Episode is not required.
Course:
May evolve from MDE or Manic Episode, or arise on own.
May last weeks to several months
Far less common for Mixed Episodes to evolve into Manic Episodes.
Bipolar I Disorder
Diagnosis
Occurrence of one or more Manic Episodes or Mixed Episodes
Additional episodes may be present (e.g. Major Depressive Episode)
The disorder is not better accounted for by other psychological conditions, medical conditions, or substance use.
Significant distress or impact on functioning
Differential Diagnosis
Other mood disorders and Psychotic Disorders
Bipolar I disorder - specifiers
Specifiers (Continued)
“With Rapid Cycling”
Four or more episodes occur within the previous 12 months
Episodes are demarcated by either full or partial remission for at least two months, or a switch to an episode of opposite polarity.
NOTE: Patients who describe rapid mood swings in which they are “happy one minute and deeply depressed the next” are usually not Bipolar, but are more accurately described as having ‘labile mood’.
bipolar 1 - stats
Statistics
Gender Differences
Epidemiological data from USA indicates no difference in prevalence between males and females.
Prevalence
Lifetime prevalence rates range from 0.4% to 1.6%
Elevated Suicide Risk
Completed suicide occurs in 10-15% of Bipolar I Disorders
More likely when patient is in Mixed or Depressed state
Bipolar I Disorder - course & onset
Average age of onset for males and females is 20 years.
Typical course is chronic, lifelong.
More than 90% of those who experience a single Manic Episode will experience future episodes.
60-70% of Manic Episodes occur immediately following a MDE.
—A specific pattern of episode may be evident
Untreated Bipolar I Disorder patients experience an average of four episodes per decade.
5-15% meet criteria for Rapid Cycling specifier
Around 20-30% suffer residual interepisode mood symptoms
10-15% of adolescents diagnosed with Major Depressive Disorder will go on to develop Bipolar I Disorder
Bipolar Disorders:
Etiology / Formulation – Biological
Genetic factors
Stronger genetic component in Bipolar than in Unipolar mood disorders.
Some studies identifying specific genes (e.g. Chromosome II, X Chromosome) need further investigation.
MZ Twin concordance is 33 to 90 percent.
Bipolar disorders:
Etiology/Formulation – Biological
Neurotransmitter Dysregulation
The usual suspects
5HT, NE, DA
Brain Imaging Studies
A significant group of male Bipolar patients show enlarged cerebral ventricles.
Ventricular enlargement is much less common in unipolar depression than in bipolar disorder.
bipolar disorders model
other life stress > family stress
|||
rhythm dysregulartion(sleep)»<
Bipolar Disorders
Etiology/Formulation – Biopsychosocial
Expressed Emotion
Critical comments, Hostility, and Emotional overinvolvement.
Several studies link high-EE families with greater relapse risk in depression.
The relationship between EE and Bipolar is complex and not simply reflective of an underlying vulnerability to interpersonal stress.
bipolar disorders -= Treatment, Pharmacological
Lithium Carbonate
Anticonvulsants
Antipsychotics
generally not Antidepressants as they may push client over edge
Bipolar Disorders treatment, psychosocial
Treatment, Psychosocial
Why bother with psychosocial interventions?
Cochran (1984)
Investigated 28 patients treated with Lithium
–Lithium Carbonate alone
—Lithium Carbonate with 6wks Cognitive Therapy aimed at restructuring cognitions associated with medication nonadherance.
A 6m follow-up, those receiving CBT showed
- -Better medication compliance
- –Fewer hospitalisations
- -Fewer mood episodes from non-compliance
bipolar disorders & misdiagnosis
69 percent of patients with bipolar disorder are misdiagnosed initially
40 percent are initially diagnosed with unipolar depression
Many others with Borderline Personality Disorder, Histrionic Personality Disorder or Adult ADHD.
misdiagnosis may be because:
- Lack of insight
E.g., It was not Mania It was great! - Lack of available information
E.g., I do not remember anyone telling me that I was manic - Lack of appropriate assessment tools used
E.g., 13-item Mood Disorder Questionnaire is good…typical depression inventories are not - The overlap in apparent signs with other disorders
E.g., many health workers are confused about what Borderline vs Bipolar is - The high percentage of comorbidity with other disorders
E.g., You could have Bipolar with comorbid personality disorder and unipolar depression…that is confusing to diagnose!
Major Depressive Disorder
Major Depressive Disorder, Single Episode
Presence of a single Major Depressive Episode (MDE)
The MDE is not better accounted for by Schizoaffective Disorder, and is not superimposed on another psychotic disorder.
There has never been a Manic Episode, Mixed Episode, or Hypomanic Episode.
Major Depressive Disorder - recurrent
Presence of two or more Major Depressive Episodes (MDEs)
The MDEs are not better accounted for by a psychotic disorder.
There has never been a Manic Episode, Mixed Episode or Hypomanic Episode.
Major Depressive Disorder
Severity Specifiers (Continued)
Severe, with psychotic features
-Delusions or hallucinations are present. Where -possible, specify whether or not the delusions are mood-congruent.
In Partial Remission
-Symptoms of a MDE are present, but full criteria are not met.
In Full Remission
-No significant symptoms of MDE over the past two months
Major Depressive Disorder
differential Diagnosis
Differential Diagnosis
Bipolar Disorder
—Have there been mixed, manic or hypomanic episodes?
General Medical Conditions
–Numerous medical conditions present with depression symptoms
Dysthymic Disorder (Now called Persistent Depressive Disorder) Severity, chronicity, persistence
Schizoaffective Disorder
Have there been >2wks of delusions/hallucinations in the absence of mood symptoms
Dementia
Major Depressive Disorder - stats, gender differences , family patterm
Age Differences
Younger people may be at greater risk for “atypical features”
Older adults may be more at risk for “melancholic features”
Gender Differences
In adults and adolescents, females present twice as often with Major Depressive Disorder (WHY?)
In childhood, males and females appear equally affected.
Family Pattern
1.5 to 3.0 times more common in 1st degree relatives
Increased risk of alcohol dependence in 1st degree relatives
Increased risk of anxiety disorder in 1st degree relatives
MDD stats - prevalence
Prevalence
Different studies have presented varying data on prevalence
Lifetime risk in community samples: 10% to 25% for women
Lifetime risk in community samples: 5% to 12% for men
Point-prevalence in adult community sample
—5% to 9% of females, 2% to 3% for males
Prevalence appears unrelated to ethnicity, income, education or marital status.
Major Depressive Disorder - Course: /Onset
May have onset at any age, mean onset in 20s
–Some evidence that age of onset is decreasing
Course of Recurrent MDD is variable and idiosyncratic
Naturalistic Course - One Year Post-Diagnosis Follow-Up
- –40% have symptoms that still meet MDE criteria
- –20% have residual symptoms, but do not meet MDE criteria
