Week 8 Lecture 8 - Depressive disorders, bipolar and related disorders - Jo Fielding (DN) Flashcards

Question

What are the **defining features** of Disruptive Mood Dysregulation Disorder?

Answer 1

* **Chronic**, severe & persistent irritability * negative mood * in at least 2 settings, 12 months * no mania Behaviour * extreme recurrent temper outbursts * inconsistent with developmental level * present most of the time * must be differentiated from other disorders 14:45

Answer 2

its the **level of chronicity** that distinguishes this disorder from others with similar symptoms 16:05

Answer 3

Dysthymia 17:20

Answer 4

* Anxiety Disorder * 60% Depressives also have anxiety * Substance-related disorders * Sexual dysfunction * Personality disorders * Cardiovascular disease

Answer 5

**Prevalence** * may vary due to different environmental stressors e.g., Beirut 19%, Taiwan 1.5% **Symptoms** * may reflect differences in acceptable expression * e.g., Latino - nerves, headaches * e.g., Asian - fatigue & weakness Cultural differences - bound to be more complex relationship 17:45 approx

Answer 6

Symptoms **change** over lifespan * children → somatic complaints * older adults → distractibility & memory loss

Answer 7

* MDD one of most prevalent psychiatric disorders (~16%) * Dysthymia rarer (~2.5%) * Twice as common in women? * Reported more often? * Three times more common in low SES individuals * Prevalence varies across cultures * e.g 1.5% in Taiwan, 19% in Beirut * Symptoms also vary across cultures * Nerves & headaches common in Latino cultures * Fatigue & weakness in Asian cultures * But may be a complex relationship: * Distance from equator? * Fish consumption? * Wealth disparity & family cohesion important

Answer 8

* In most countries prevalence of MDD increased steadily until late 20th century * Median age of onset now late teens to early 20s * support structures like extended family non-existent * marital stability often absent * Symptoms appear to change over lifespan: * children → somatic complaints * older adults → distractibility & memory loss * Often comorbid with other psychiatric problems: * 60% also meet criteria for anxiety disorder * Other comorbidities: * substance-related disorders * sexual dysfunction * personality disorders * cardiovascular disease

Answer 9

Presence of **Mania** * Manic episode * Hypomanic episode 21:30

Answer 10

**Manic** * **Significant impairment** * **psychotic** symptoms * Symptoms - 1 week or **hospitailisation** * cause distress/functional impairment **Hypomanic** * **Impairment not marked ** * but observable to others * **no psychotic** symptoms * at least 4 days * **no hospitalisation**

Answer 11

**extreme** dysfunction/impairment * elevated, expansive mood * psychotic episodes * odd behaviour * no insight * 1 week/ possible hospitalisation

Answer 12

* elevated, expansive or irritable mood * goal-directed activity * 4 days, most of time * no significant impairment * no hospitilisation

Answer 13

the highs of mania are quite pleasurable they are really enjoying their disorder! will rarely seek treatment for the mania normally seek treatment for the depression 25:45

Answer 14

Manic episode: Distinctly elevated, expansive or irritable mood, and abnormally increased goal-directed activity for 1 week, most of the day, nearly every day. At least 3 symptoms noticeably changed from baseline (4 if mood is only irritable): * Inflated self-esteem * Decreased need for sleep * Unusual talkativeness * Flight of ideas or subjective impression that thoughts are racing * Distractibility * Increased goal-directed activity * Excessive involvement in activities that are likely to have undesirable consequences * Symptoms last for 1 week or require hospitalisation * Symptoms cause significant distress or functional impairment

Answer 15

**For a hypomanic episode:** * Symptoms last at least 4 days * Clear changes in functioning that are observable to others, but impairment is not marked * Does not require hospitalisation * No psychotic symptoms are present

Answer 16

**Bipolar I** - diagnosis requires Criteria met for **one** single **manic** episode **Bipolar II** - diagnosis** **requires Criteria met for at least **one hypomanic** episode **AND** Criteria met for at least **one major depressive** episode 28:30 \>

Answer 17

**one** single **manic episode** other symptoms exist, but not required for diagnosis * hypomania * depressive episodes 28:30

Answer 18

**Criteria met for at least one manic episode** * If mood is irritable rather than elevated – requires 4 , not 3 ,other symptoms * Hypomanic and depressive episodes common (not necessary) * Diagnostic code based on: * type of current/most recent episode (e.g. manic, hypomanic, depressed) * Severity (mild, moderate, severe) * Presence of psychotic features * In remission/not * May or may not be experiencing current symptoms of mania * Episodes tend to reoccur

Answer 19

Criteria met for at least **one hypomanic episode** AND Criteria met for at least **one major depressive episode** * Diagnostic code as for BP I * Characterised by recurring mood episodes – usually more frequent and lengthier than BPI * Usually present with MD episode - unlikely to complain of hypomania

Answer 20

recurring mood

Answer 21

* the **depressive** component * the hypomania is quite enjoyable, very rare they would seek help for it 30: 40

Answer 22

**For at least 2 years (1 in children/adolescents)**: * Numerous periods of hypomanic symptoms that do not meet criteria for a manic episode * Numerous periods with depressive symptoms that do not meet criteria for a MDD * Symptoms do not clear for \>2 mths * cause significant distress/impairment

Answer 23

* **chronic** fluctuating mood disturbance * distinct periods of **hypomania** & **depressive** symptoms * \> 2 months * significant distress/impairment 31:15

Answer 24

Cylothymic Disorder resembles Bipolar II Although in Cyclothymic Disorder, the: * **hypomanic** symptoms **DO NOT** meet 'manic' criteria * **depressive** symptoms **DO NOT** meet major depressive disorder criteria * \> 2 months * must have never previously met criteria for either mania or major depressive disorder * as this would be Bipolar I (even just one episode of mania) 31:30

Answer 25

**Prevalence**: * Bipolar I disorder much rarer than MDD * Bipolar I ~ 0.6% * Bipolar II more difficult to gauge ~ 0.4 – 2% * Cyclothymia ~4% of mood disorders * Cultural variation may reflect differences in labelling behaviours as manic symptoms **Onset**: * \> half before 25, increasing frequency in children * Equally in men & women, women more episodes of depression **Comorbidities:** * 2/3 meet diagnostic criteria for comorbid anxiety disorder * 1/3 report history of substance abuse

Answer 26

* **Anxiety** Disorders * 2/3 have anxiety * **Substance Abuse** * 1/3 have history 35:30

Answer 27

Bipolar I * 1/3 remain unemployed 1 year after hospitalisation for mania * Unable to work ~25% of the time 36:30

Answer 28

50% risk of going on to develop episodes of * mania * major depression

Answer 29

Bipolar I disorder amongst most severe forms of mental illness * 1/3 remain unemployed 1 year after hospitalisation for mania * Unable to work ~25% of the time Suicide attempts: * Bipolar I ~1 in 4 * Bipolar II ~1 in 5 High risk for other medical condition: * Cardiovascular disease * Diabetes * Obesity * Thyroid disease * Often severe Cyclothymia = high risk for developing episodes of mania & major depression ~ 50%

Answer 30

Seasonal Pattern & Rapid Cycling subtypes * refer to the **overall pattern** of the **episodes over time** Other subtypes * refer to **current episode** 47: 30

Answer 31

* Unique to Bipolar Disorders * Move quickly in & out of depressive or manic episodes * \>3 manic or depressive episodes * increased suicide attempts & episodes of depression * 20-40% (60-90% female) * people on anti-depressant medication tend to have more cycling * increase in frequency over time * Can transform to ‘rapid switching pattern’ without breaks * most people stop cycling within 2 years 49: 30

Answer 32

Depressed episodes that occur **only** during **certain seasons** Applies to MDD & bipolar disorders * **Depressive Disorders** * late autumn \> early spring * **Biplolar Disorder ** * depressed in winter, manic in summer **Most involve winter depression** * Excessive sleep & increased appetite * Evidence links melatonin produced by pineal gland * Suppressed by light * Increases in winter * More prevalent in extreme latitudes * Trigger in vulnerable people? 50:30

Answer 33

**Rapid cycling subtype** * only applies to Bipolar * not applicable to MDD **Melancholic subtype** * only applies to depressive component of BP * not applicable to mania component of BP 47:50

Answer 34

'With anxiety' 'Suicide risk severity'

Answer 35

enables them to build up a heterogeneous (individual) picture of how an individual may be presenting 48:10

Answer 36

* Psychotic features * Mixed * Catatonic * Melancholic * Atypical * Postpartum

Answer 37

**Psychotic features**: * Mood congruent - hallucinations, delusions consistent with mood state * Mood incongruent (serious sub-type) * thought broadcasting * thought insertion * continuum - may progress to schizophrenia? * Rare: 5-20% * poor treatment response * greater impairment

Answer 38

**Mixed**: • At least 3 manic symptoms present during depressive episode, or • At least 3 depressive symptoms present during a manic episode

Answer 39

**Catatonic:** * Marked by motor disturbance * Stuporous state or catalepsy * thought to reflect end state reaction to imminent doom? may include * echolalia - immitate speach * echopraxia - immitating movements 1:00

Answer 40

**Melancholic**: * less rare than Psychotic & Catatonic * Full criteria met for MDD * More severe somatic symptoms * **Complete loss** of interest in just about every activity * e.g. loss of libido, anhedonia, guilt * early morning awakenings (2am) * whether its actually a subtype or exists on a continuum is difficult to determine (sounds like a continuum to me, DN!!!) 1:01:20

Answer 41

**Atypical:** * Applies to depressive episodes & dysthymia * Oversleep, overeat * Can still find pleasure * More common in women, early age of onset * More: symptoms, severe, suicide, * comorbidity (**DN question**: Table 5.2 on slide 24 shows 'Atypical' applying to both MDD & BP, but Jo & slide 29 say it applies to depressive episodes & dysthymia. Slide 24, Table 5.2 doesn't specify its only applicable to the depressive component of bipolar.........just sayin.......)

Answer 42

**Postpartum:** • Onset within first 4 weeks of childbirth • 13% post-childbirth, hormonal? • NOT “baby blues” – 80% for few days, normal stress response

Answer 43

**Duration** & **intensity** of **symptoms** distinguish them **Baby blues** * most women (80%) experience * about 3 days after birth **Postpartum** * some women (13%) develop major depression within first 4 weeks after birth **Cause unclear** but may be * decline in reproductive hormones after delivery * elevated corticotropin producing hormone has been proposed 102:40

Answer 44

Apparently not * Evidence that babies can become depressed * Genetics, environment, both? Depression fundamentally **similar across lifespan** Its presentation differs though * **Babies/Toddlers**: sad faces, irritability, fatigue, fussiness, tantrums, eating, sleeping problems * **Children**: loss of enjoyment, loss of sleep, social withdrawal * **Adults**: more exaggerated, severe with age * i.e., life experience? 103:35

Answer 45

Children under 9 - present with more **irritability** & **emotional swings** rather than classic manic states Children experience “Swings” less distinct than adults Children: only brief manic states, come in & out throughout a day, not full blown as in adults

Answer 46

* **Adults** - anxiety disorder * **Children** - ADHD & CD * Up to 90% meet criteria for ADHD * raises diagnosis issues 105:30

Answer 47

* **Neurobiological factors, including:** * Genetic factors * Neurotransmitters * Neuroimaging * Neuroendocrine system * **Social factors** * **Psychological factors** * Personality factors * **Cognitive theories** * Learned helplessness

Answer 48

**Genetic factors:** * Probability of having a mood disorder 2-3 x greater if relative has a mood disorder * Severity, recurrence, age at onset predict rate * Twin studies support relationship with depression ~37% * Bipolar - 90% inc. risk of any mood * \>160 loci linked – few well studied or replicated * “disconfirmation appears to be the rule rather than the exception” * Polymorphism of Serotonin transporter gene inc. vulnerability * DRD4.2 gene * Likely a set of genes that **confers vulnerability**

Answer 49

* they don't cause disorders * they confer a **vulnerability** * sets stage for disorder in context of other factors 1:08:00

Answer 50

**Neurotransmitters:** * Norepinephrine, dopamine, serotonin most studied * Serotonin thought to regulate emotional reaction * decreased serotonin dysregulates others? * balance rather than absolute levels? * dysfunction = **altered sensitivity** of **postsynaptic receptors?** * increased dopamine = hypomania * receptors oversensitive? * decreased dopamine = depressive b/h * G Protein high in mania, low in depression 108:45

Answer 51

**BALANCE** of neurotransmitterrs is important Serotonin's primary function - regulate emotional reaction * lower levels seen in mood disorders * decreased serotonin thought to lead to dysregulation in other neurotransmitters when serotonin is low it allows other neurotransmitters are able to range more widely \> **imbalance** 1:08:40

Answer 52

**Dopamine agonist (L Dopa)** **Hypomania ** * Increased Dopamine levels \> oversensitive receptors? **Depression (atypical & with psychotic features)** * Decreased Dopamine levels **Possible Triggers to imbalanced Neurotransmitters:** * **Chronic Stress** has been linked to reduced Dopamine levels & depression

Answer 53

**Neuroimaging:** * Amygdala, prefrontal cortex, hippocampus, sub-genual anterior cingulate * Functional imaging * elevated activity of amygdala \> vulnerability? * dimished activation / volume of other regions * Theory \> react with increased emotion but decreased ability to plan * Mania similar to depression * basal ganglia more active? * changes to neuronal membranes? * Kinase C abnormally high? 1:11:25

Answer 54

**Amygdala** * increased activity * hyper-reactivity to emotional stimuli **Other regions** * diminished activation * decreased volume in other regions * less activity in these regions involved in planning etc **Outcome** * react with increased emotion * less ability to plan 1:11:50

Answer 55

**Manic Episode** * **basal ganglia** particularly **active** * involved in reward reactions * differentiates from MDD **Bipolar Disorder** * Changes in **neuronal membranes ** * influencing how readily they can be activated * not seen in MDD 1:12:50

Answer 56

**Neuroendocrine system:** * **Hypothalamic-pituitary-adrenocortical axis overly active** * Triggers release of cortisol * **Known link between depression & high cortisol levels** * e.g. Cushing’s syndrome, animal studies * **Dexamethasone suppression test** * Cortisol not suppressed in MDD – esp psychotic features * Normalises when depressive episode ends * Poor regulation of HPA axis? * **Reduced hippocampal volumes** * Consequence of high cortisol levels? * Precedes/contributes to onset of depression? 1:13:35

Answer 57

poorly regulated **cortisol system** 1:15:00

Answer 58

**Stressful life events** *(key take home message)* * Role well established * 42-67% report serious life event prior to depression * Loss, humiliation, chronic stressors particularly likely triggers **Lack of social support** * Sparse social networks, regarded as unsupportive * Having a confidante reduces risk from 40% to 4% **Interpersonal problems** * Expressed emotion predicts relapse * Poor IP problem solving predicts onset * But depression, constant reassurance-seeking can also create IP problems? 1:16:00

Answer 59

the propensity to experience negative & positive affect 1:18:25

Answer 60

Neuroticism

Answer 61

* Negative affect * Positive affect * Somatic Arousal **Depressive Disorders** * Negative affect - high * Positive affect - low * Somatic Arousal - moderate **Anxiety Disorders** * Negative affect - high * Positive affect - moderate * Somatic arousal - high **Comorbid** * Negative affect - high * Positive affect - low * Somatic arousal - moderate 1:19:10

Answer 62

**Negative thinking** led to depression **Beck's Negative triad**: Negative views of * **SELF - WORLD - FUTURE** proposed to be caused by * Negative schemata acquired thru experience * Schemata lead to negative biases (i.e., cognitive errors) * which lead to negative views * viscious cycle 121:00

Answer 63

**Becks negative triad** * **Learned helplessness** * (Martin Seligman) * later revised to incorporate 'attributional style" * Internal * Stable * Global * revised again to highlight sense of **hopelessness** * sttributions only impt if contribute to hopelessness 123:30

Answer 64

**Depression:** * Triggers similar to MDD * Negative events important precipitator * Predicted by neuroticism, negative cognitions, expressed emotion, lack of support **Mania**: * One psychosocial model – reflects disturbance in brains reward system * Events involving attaining goals predict increases in manic symptoms * Getting married, graduating * Proposed that life events involving success may trigger cognitive changes in confidence * Spiraling into excessive goal pursuit 124:50

Answer 65

* Depression & anxiety share a common genetic vulnerability explaining between 20% and 40% of the variance in mood disorders * Environmental & psychological vulnerabilities explain the rest * Often experienced as an inability to cope with life’s stressors (i.e. lack of resilience) leading to learned helplessness and a sense of hopelessness * Causes of psychological vulnerabilities can be traced back to childhood adversity * Stressful life events act as triggers * Interpersonal relationships can act as either protective or risk factors 126: 50

Answer 66

Cognitive therapy * Alter maladaptive thoughts * Behavioural activation therapy * Mindfulness-based Cognitive Therapy

Answer 67

**Psychological** **Psycho-educational approaches** * educate about disorder management Cognitive Therapy Family-focussed treatment 131:00

Answer 68

**Antidepressant medications:** **75% show improvement** * 1. Selective serotonin re-uptake inhibitors * 2. Mono-amine oxidase (MAO) inhibitors * 3. Tri-cyclic antidepressants Combining psychotherapy with medication bolsters odds of recovery by up to 20% above either alone

Answer 69

Selective serotonin re-uptake inhibitors (SSRI's) e.g., prozac, sertraline blocks presynaptic reuptake of Serotonin - leaving higher quantities available in the synapse Side effects: may inc suicidal ideation in first few weeks physical agitation, sexual dysfunction, insomnia, gastrointestinal upset

Answer 70

Mono-amine oxidase (MAO) inhibitors: * Block the enzyme MAO * MAO breaks down nor-epinephrine, dopamine & serotonin * Increasing availability Last line because * Potentially **serious consequences:** * Consuming tyramine (red wine, cheese, beer) \> hypertension * Some everyday medications (cold medications) \> **dangerous interaction** More effective with ‘atypical’ 'melancholia' features

Answer 71

**Tricyclic antidepressants:** * Named after chemical structure * Mode unclear, initial block re-uptake of norepinephrine & serotonin * Complex effect on pre- & post-synaptic regulation **Not widely used now** * Side effects: blurred vision, dry mouth, drowsiness, weigh gain * Consequence: ~40% discontinue * Lethal if taken in excessive doses * increases chance of suicidal behaviour 136: 30

Answer 72

Mood stabilisers reduce manic symptoms: * Lithium remains gold standard * Up to 80% experience some benefit * 70% relapse in 5 years * effects wear off **Side effects** = blurred vision \> coma, death! If Lithium is not tolerated: * Anticonvulsants (e.g. Valproate) * Antipsychotics (e.g. Olanzapine)

Answer 73

Flattened affect Feel nothing, when used to experiencing enjoyable highs

Answer 74

**When patient is treatment resistant** * Most dramatic & controversial treatment for MDD * 70-130 volt current through brain **How/why it works?** * Massive functional/structural changes? * Increases serotonin levels * Blocks stress hormones * Neurogenesis in the hippocampus? **Side effects** * Short-term memory loss * Decline in cognitive function 6 months

Week 8 Lecture 8 - Depressive disorders, bipolar and related disorders - Jo Fielding (DN) Flashcards

 Lecture content *Mood disorders: Depressive disorders Bipolar and related disorders *Prevalence & life span development of mood disorders *Aetiology of mood disorders *Treatment of mood disorders

 Lecture content Mood disorders: Depressive disorders Bipolar and related disorders Prevalence & life span development of mood disorders Aetiology of mood disorders Treatment of mood disorders