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Disorders of Mood (Depressive disorders (Persistent depressive disorder…
Disorders of Mood
Depressive disorders
Major depressive disorders
Clinical description
single episode: rare (many as 85%of cases have the 2nd episode)
recurrent episodes: 2 or more separated by 2 consecutive months
Has never been a manic or hypomanic episode
disruptive mood dysregulation disorder
new diagnosis in DSM-5 (children and adolescents)
Clinical descriptions
Severe recurrent temper outbursts that are out of proportion in intensity & duration
The outbursts are inconsistent with developmental level
Present in at least 2 of 3 settings and are severe in at least 1 of them
Present for at least 12 months (has not experienced no
symptoms for 3 or more consecutive months)
Age of onset is before age 10
Diagnosis should not be made for the first time before age
6 or after age 18
Persistent depressive disorder (dysthymia)
Milder symptoms
Symptoms persist for at least 2 years
(at least 2 of the following)
Insomnia or hypersomnia
Fatigue
Poor appetite or overeating
Low self-esteem
Poor concentration
Feelings of hopelessness
cannot be symptom-free for more than 2 months during
the 2-year period
(1 year period for children & adolescents)
premenstrual dysphoric disorder
New diagnosis in DSM-5
Clinical descriptions
At least 5 symptoms in the final week before the onset of menses
improve within few days after onset, & become minimal or absent in the week postmenses
1 or more of the following
Affective liability
Irritability or anger or increased interpersonal conflicts
Depressed mood
Anxiety or tension
double depression
onset & duration of depressive disorder
"Bereavement” and “Post-partum Depression"
not person-centred? [no, but trying to eliminate the potential risk]
rusk management spproach
"post-partum"
irritable, cannot coop with the low mood
easily be neglected
Overview
Major Depressive Episode
Core Clinical descriptions (at least 1)
Extremely depressed mood (subjective/ observed)
Anhedonia: loss of pleasure or interest in usual activities /anything
At least five of the following during the same two weeks
Disturbance of appetite or significant changes in weight :arrow_up_down:
Sleep disturbance (sleeping quality-intense sleep assessment/ insomnia/ hypersomnia) (early-morning awakening) :arrow_up_down:
Psychomotor retardation or agitation (slowing-down of thought and a reduction of physical movements)
Loss of energy or fatigue
Feelings of worthlessness or guilt
Diminished ability to think & concentrate
Recurrent thoughts of death or suicide :star: [manic patients too]
Manic Episode
exaggerated elation, euphoria or irritable mood
abnormally increased goal-directed behaviour or energy ; eg, gambling for money earning
for at least one week(4 days) with >3 of the following
Inflated self-esteem
Decreased need for sleep (one-way only)
Talkativeness (but not getting to the point) or pressure to keep talking
Flight of ideas (disorganized speech)
Distractibility (~ADHD)
Increase in goal-directed activity or psychomotor agitation
Reckless/ dangerous behavior (bc of inflated self-esteem)
Hypomanic Episode
Persistently elevated, expansive, or irritable mood
at least 4 days with At least 3 of the following
Inflated self-esteem
Sleeplessness
Talkativeness or pressure to keep talking
Flight of ideas
Distractibility
Increase in goal-directed activities
Reckless/ dangerous behavior
The structure of mood disorders
unipolar disorders
depression or mania alone
typical depression
bipolar :star:
both manic & depressive
distinguished from unipolar disorders by the presence of manic or hypomanic symptoms
sth about mood instead of thoughts
medical base/ drug treatment
disturbances in emotions that cause SUBJECTIVE discomfort
alternatives for counselling
Mood episodes
cannot be diagnosed as separate entities
not only depression, also other episodes
see the patient at least twice to have a wider concept of their condition (always trace back a bit)
current generation of the elderly usually somatize their symptoms
Treatments
Medications: Antidepressants
Selective Serotonin Reuptake Inhibitors
(SSRIs)
Fluoxetine (Prozac)
First and common treatment choice
Block
presynaptic reuptake of
5-HT
[help the SSRI to stay longer between cells]
Concerns about suicidality among adolescents, especially in early stages of treatment
Side effects:
Headaches, physical agitation, sexual dysfunction or low desire, insomnia, & gastrointestinal upset
Tricyclics antidepressants (TCAs)
Block reuptake / down-regulate
[Norepinephrine (NE) & Serotonin (5-HT)]
Efficacy [2 to 8 weeks to work]
Alleviate depression in 50% of cases to as high as 65% to
70% of cases
Many side effects
e.g. heart attack, stroke, anxiety, dry mouth, blurred vision, constipation, urinating problems, drowsiness, weight gain, & sexual dysfunction,Lethality
Monoamine Oxidase Inhibitors (MAOIs)
Block Monoamine Oxidase (MAO): Enzyme that breaks down 5-HT & NE
Fewer side effects (e.g. hypertension, dry mouth, dizziness, & headaches)
Ingestion of tyramine foods (e.g., cheese, red wine, & beer) or cold medications with the drug can lead to severe hypertensive episodes & occasionally death
usually prescribed only when tricyclics were ineffective
EARLY “PSYCHOLOGICAL” MODELS OF TREATMENT
Freud
compared the experience of mourning with the pathological state of depression
With loss, energies that flowed out of the ego and into the object are displaced into alternative objects, resulting in anger turning inwards towards the self
Victor Frankl
finding meaning in life and suffering, elevating oneself from hopelessness
anguish by realizing the purpose of one's existence on earth
medication for bipolar disorders
Lithium
Primary treatment for bipolar disorders
Mechanisms of action are not well-understood
may work on DA, NE, and/or the endocrine system, & electrolytes
Side effects
Tremors, gastric distress, lack of coordination, cardiac
arrhythmia, blurred vision & fatigue
Narrow therapeutic window
Too little: ineffective; too much: toxic, lethal
Electroconvulsive Therapy (ECT)
For severe depression
Applies brief moderate electrical voltage to brain; temporary
seizures
Efficacy: 50% of patients not responding to medications will get better
Side effects: transient short term memory loss & confusion
Relapse is common
Transcranial magnetic stimulation (TMS)
Localized electromagnetic pulse
Fewer side effects
Efficacy is likely good but more studies are needed
Psychological Treatments for depression
Cognitive-Behavioral Therapy (CBT)
Identify negative, self-critical thoughts, & cognitive errors
See their connection with depression, & replace them with
realistic interpretations
Increased positive events, & practice (e.g. monitor & log)
Lewinsohn’s Behavioral Activation model stresses the planning implementation of activities to increase positive reinforcement from the external environment
Interpersonal Psychotherapy (IPT)
Short-term, psychodynamic-eclectic treatment
Geared toward present, not past, relationships
Efficacy (See PDF on article of CBT versus IPT**)
CBT & IPT are both effective for treating depression
Long-term cognitive therapy have shown effects in brain changes
Combination of psychotherapy & medication is also effective
Psychological Treatments for bipolar disorder
Increase medication compliance
Psychotherapy & family therapy have also proven helpful
Interpersonal & Social Rhythm Therapy
creation of day-to-day routines: regulates circadian rhythms, e.g. sleep & eating cycles
Family-focused, interpersonal, & cognitive-behavioral therapy reduce symptom severity & relapse, & enhance psychosocial functioning
Bipolar disorders (Manic + Hypomanic)
Bipolar I Disorder
at lest 1 manic episode
preceded by & may be followed by hypomanic or major depressive episodes
most terrible type
Bipolar II Disorder
At least 1 hypomanic episode & at least 1 major depressive episode
Never been a manic episode
not so horrible
Cyclothymic Disorder
For at least 2 years (1 year for children & adolescents)
mild and not severe
During the period the hypomanic & & depressive symptoms have been present for at least half the time & the individual has not been without the symptoms for more than 2 months
onset & suicidal attempts
the earlier the onset, the poorer
Bipolar I disorder: age 15-18
Bipolar II disorder: age 19-22
Cyclothymic disorder: age 12-14
Suicidal attempts
Unipolar depression: 12%
Bipolar I disorder: 17%; Bipolar II disorder: 24%
Completed suicide rate of Bipolar disorders is four times higher than that of recurrent major depression
more common when a patient is recovering and "thinking about their future"
Etiology of mood disorders
Biological Causes
Neurotransmitters
Depressed mood are associated with deficit and/or dysfunction of specific neurotransmitters
The “permissive” hypothesis: :arrow_down: 5-HT :arrow_right: deregulations of other neurotransmitters (e.g. DA)
Serotonin (5-HT), dopamine (DA), & norepinephrine (NE)
Endocrine system
“Stress hypothesis”: overactive HPA axis
(The hypothalamic-pituitary-adrenocortical axis produces stress hormones) (saliva)
Elevated cortisol level
Consequences of these elevations::
Decreased ability to form neurons in hippocampus
Shrinkage or underdevelopment of hippocampus
Sleep & Circadian Rhythms
Sleep disturbance is one of the hallmarks of mood disorders
:arrow_down:latency & :arrow_up: in rapid eye movement (REM)
:arrow_down:slow wave sleep (SWS)
Neurophysiological causes
Decreased activities in
Prefrontal cortex
Anterior cingulate
Hippocampus
Increased activities in
Amygdala
Familial & Genetic influences
Family Studies
2 to 3 times higher in relatives of probands
Twin Studies
The rate for identical twins are 2 to 3 times higher than that of fraternal twins
Bipolar: identical 66.7%, fraternal 18.9%
Unipolar: identical 45.6%, fraternal 20.2%
Higher heritability for females: 40% (F) vs. 20% (M)
Psychological Causes
Stressful Life events
Diathesis-Stress Model
Stress may activate a genetic predisposition for depression
relationships among life events & bipolar disorder seem to be more complex (vs. depression
Goal-achieving life events are associated with
mania onsets
May also be triggered by lack of sleep or jetlag
Cognitive dimensions
learned helplessness (seligman)
lack of perceived control
Depressive Attributional Style: Internal (vs. external), Stable (vs. unstable), & Global (vs. specific)
Cognitive Theory of Depression (Beck)
Depressive cognitive triad
Self, world, & future
Cognitive errors in depression
cognitive errors
Arbitrary inference
The individual tends to draw conclusions that are not supported by evidence
Selected abstraction
The individual takes a minor incident or detail out of context & focuses on it
Overgeneralization
tends to draw a sweeping conclusion about his or her ability, performance, or worth from one single experience or incident
Magnification/ minimization
The individual tends to exaggerate limitations & difficulties & play down accomplishments, achievements, and capabilities
Social Causes
Marital Relationships
Relationship disruption precedes depression, & it has stronger effects on males
Gender differences in causal direction: depression causes men to withdraw or otherwise disrupt the relationship, for women relationship problems cause depression
Social Relationships
Lack of support predicts late onset depression
Substantial support predicts recovery for depression (not mania)
Additional Defining Criteria for mood disorders
specifiers for depressive and bipolar
Severity of disorder
Mild, Moderate, & Severe
Specify when
Full remission-"seems better" (during the past two months, no significant signs or symptoms were present) & Partial remission
Presence of mixed features
With anxious distress (called as pre-depression)
With melancholic (feeling very sad bc of lost) features
somatic (physical) symptoms
e.g. early morning awakening, psychomotor
agitation/retardation, anorexia/ weight loss
With psychotic features
Mood congruent hallucinations or delusions
Mood incongruent features are possible, but rare
With seasonal pattern
During certain seasons, usually wintertime
Related to circadian & seasonal changes in the increased melatonin production
Phototherapy is one of the effective treatments
Atypical
hypersomnia, weight gain, & leaden paralysis
Peripartum onset
symptoms occur during pregnancy or in the 4 weeks following delivery
With catatonia
Marked psychomotor disturbance (e.g.
immobility, excessive motor activity)
specifiers for bipolar
Rapid-cycling pattern
Applies to bipolar I & II disorders
At least 4 episodes of mood disturbance within 1 year
More severe form of bipolar disorder: does not respond well to treatment; higher suicidal rates
Prevalence
Depressive Disorders
Children
Less often in children than in adults
Different manifestation (e.g. < age 3: irritability, fatigue, & changes in sleeping & eating)
Equal gender ratio
Adolescents
The prevalence difference closes during adolescence, where depression becomes more frequent as compared to adults
Major depressive disorders are more common in females (vs.
mild depression)
Adults
Top ten causes of world-wide disability and immense cost to public health
Associated with other disorders (e.g. panic & generalized anxiety disorders (GAD), substance dependence, & personality disorders)
Increased risk for women, middle-aged, widowed, separated, divorced, & people with low SES
Elders
Prevalence major depressive disorders is the same or slightly lower as in the general population
Comorbidities (e.g. GAD , panic disorder, & alcohol- related problems)
Manifestation: sleep problems, hypochondriasis, & agitation
Gender imbalance disappears after age 65 (F: M = 1:1)
Biopolar
Prevalence rates are similar among children, adolescents, & adults
Less prevalent than major depression
the costs of bipolar disorder are higher than that of
unipolar depression
Onset
Age of onset is earlier as compared to that of depressive disorders
Children of age less than 9 years show more irritability
& emotional swings rather than classic manic states, & are often misdiagnosed (e.g. AD/ HD & conduct disorder (CD))
Those with bipolar disorder have greater tendency to
attempt suicide than depressed individuals
Unlike depression, there is no major gender differences
Cultures
Most studies showed similarity across cultures
Some differences
Manifestation: Physical or somatic symptoms
Constructs, statements, wording