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Week 3: Mood Disorders - Coggle Diagram
Week 3: Mood Disorders
Understand the term "Mood disorder"
Definition of mood on a continuum
Ranging from low mood to euthymia to euphoria
What do you call individuals who experience both ends of the continuum
Bipolar disorder
Definition of Mood disorder
Encompasses
conditions in which individuals experience
an extreme in the mood continuum
From the low, sad unpleasant mood of unipolar depression to the elevated, energised mood of mania
What is the older term of mood disorder
Affective disorder
Fulfilment of certain diagnostic criteria: in order to meet the diagnosis of a mood disorder
Describe types of DSM-5 mood disorders and their presenting symptoms
DSM-5 Classification (Two diagnostic Groups)
Depressive disorders
Major Depressive Disorder
Persistent Depressive Disorder
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
Substance/Medication-induced Depressive Disorder
Depressive Disorder due to another medical condition
Bipolar disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Substance/Medication-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition
Identify different types of depressive disorders
1. Major Depressive Disorder (MDD)
Characteristics
Depressive disorder characterized by major depressive episodes in which person's behaviour is dominated by depressed or loss of interest or pleasure
DSM-5 Criteria of Major Depressive Disorder
[A] Five or more of following symptoms during same 2-week period, at least one being (1) depressed mood or (2) loss of interest or pleasure
(1) Depressed mood most of the day, nearly every day
(2) Diminished interest or pleasure in all or most activities, most of the day, nearly every day
(3) Significant unintentional weight loss or gain
(4) Insomnia or hypersomnia weight loss or gain
(5) Psychomotor agitation or retardation (observed by others) Nearly every day
(6) Fatigue or loss of energy nearly every day
(7) Feelings or worthlessness or inappropriate/excessive guilt, nearly every day
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day
(9) Recurrent thoughts of death , recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
[B] Symptoms cause significant impairment in social, occupational or other important areas of functioning
[C] Episode(s) not due to effects of substance, or another medical condition
[D] Episode(s) not better explained by a Schizophrenia Spectrum Disorder
[E] Absence of a manic or hypomanic episode
Criteria A-C constitute a major depressive episode. Major Depressive episode is a requirement of Bipolar II disorder
Specifiers of Major Depressive Episode
With Melancholic features
Three of the following:
early morning awakening
depression worse in the morning
marked psychomotor agitation or retardation, loss of appetite or weight
Excessive guilt
Qualitatively different depressed mood (adhedonia)
With psychotic features
Delusions or hallucinations (usually mood congruent); feelings of guilt and worthlessness common
With Atypical features
Mood reactivity - brightens to positive events
Two of the four following symptoms:
Weight gain or Increase in appetite
Hypersomnia
Leaden paralysis (arms and legs feel as heavy as lead)
Being acutely sensitive to interpersonal rejection
With Catatonic Features
A range of psychomotor symptoms from motoric immobility to extensive psychomotor activity, as well as mutism and rigidity
With Seasonal pattern
At least two or more episodes in past 2 years that have occurred at the same time (usually fall or winter)
And full remission at the same time (usually spring). No other non-seasonal episodes in the same 2 year period
Depression as a recurrent disorder
(Differences between Remission, Relapse and Recurrence )
Remission
Symptoms have largely been gone for at least 2 months
Relapse
The return of symptoms within a fairly short period of time
May commonly occur when
pharmacotherapy is terminated prematurely
: after symptoms have remitted but before underlying episode is over
Recurrence
Onset of a
new episode of depression
Occurs in about 40-50 percent of people who experience a depressive episode
Probability of recurrence increases with number of prior episodes and comorbid disorders
Those with
residual symptoms, or significant psychosocial impairment
, more likely to have recurrences than those whose symptoms remit completely
2. Persistent Depressive Disorder
Characteristics
Dysthymia: Characterized by persistently depressed mood for more than 2 years (1 year for children and adolescents)
Average duration is 4-5 years
DSM-5 Diagnosis of PDD represents a consolidation of DSM-4 Chronic Major Depressive Disorder and Dysthymic Disorder
Difference between PDD and MDD
Periods of normal mood may occur briefly (few days to a dew weeks): Distinguishing feature of MDD
What is the definition of double depression
A major depressive episode superimposed on a longer-standing dysthymia (PDD and MDD)
But still in general able to function (high functioning depression)
Chronic Course: Poorer outcomes and as much impairment as MDD
DSM-5 Criteria of Persistent Depressive Disorder
[A] Depressed mood for most of the day, more days than not, for more than 2 years
[B] More than 2 of the following symptoms
Poor appetite or overeating
Insomnia or hypersomnia
Fatigue or loss of energy
Low Self-esteem
Diminished ability to think or concentrate, or indecisiveness
Feelings of hopelessness
[C] Periods with no depressed mood (A) or symptoms (B) must be less than 2 months
[D] Criteria for MDD may be continuously present for 2 years (Double depression)
[E] Absence of a manic of hypomanic episode and cyclothymic disorder
[F] Not better explained by a Schizophrenia Spectrum Disorder
[G] Not attributable to affects of a substance or medical condition
[H] Significant distress or impairment in social occupational and other areas of functioning
PDD specifiers same as MDD except "with catatonia" and "with seasonal pattern"
Prevalence and Course of PDD
Prevalence
Lifetime prevalence 2.5%-6% general population
Singapore Mental Healthy Study 2016: 12-month prevalence: 0.2%
PDD more frequent in females
Development and course
Early and insidious onset with chronic course
Early onset (more than 21 years) associated with an increase comorbid personality disorders and substances use disorders
Comorbidity with anxiety disorders and personality disorder associated with decreased recovery rates
Associated with poorer self-rated health status
Significantly increases risk of suicide
Average duration is 4-5 years
Other Depressive Disorders
3. Disruptive Mood Dysregulation Disorders
Childhood condition characterized by severe and recurrent temper outbursts expressed verbally and/or behaviorally
DSM-5 Criteria for Disruptive Mood Dysregulation Disorder
[A] Severe recurrent temper outbursts (verbal or behavioral)
[B] Temper outbursts inconsistent with developmental level
[C] Outbursts occur average more than 3 times per week
[D] Mood in-between outbursts is irritable or angry most of the day, nearly every day
[F] A-D present in at least 2-3 settings (home, school, peers) and severe in at least 1 setting
[E] A-D present for more than 12 months, No 3 plus months period without all of the symptoms
[G] Diagnosis must not be made before age 6 or after age 18
[H] Age at onset of A-E before age 10
[I] Absence of manic or hypomanic episode
[J] Behaviour not attributable to another mental disorder (egg MDD, autism, PDD)
[K] Not attributable to affects of substance or medical condition
4. MDD with Peripartum
(The time shortly before, during, and after giving birth) Onset
DSM-IV-TR: Postpartum Depression onset specifier for MDD
DSM-5: Changed specifier to peripartum onset
50% of postpartum MDD episodes begin before delivery
Mood and anxiety symptoms during pregnancy increase
Often disturbances in appetite, sleep, low self-esteem, difficulties maintaining concentration or attention
Peripartum onset episodes can include
psychotic features
(e.g infanticide: hallucinations to kill infant/delusion or infant possessed)
Genetic factors, history of depression or anxiety can increase risk
Understand causes the theories of depressive disorders
Aetiology of Depressive Disorders
[Genetic-Environmental Interaction]
Biological
Sleep and biological rhythms
People who are depressed show variety of sleep problem (eg difficulty falling asleep, periodic awakening during night, early morning awakening)
Shorter time to enter into rapid eye movement (REM) sleep and reduced amount of deep sleep
Abnormalities in circadian rhythms (eg sleep wake cycle, locomotor activity cycle, hunger cues)
Genetic
Family studies:
Relatives of persons with MDD 2-3 times more likely to develop MDD
Monozygotic co-twins of a twin with MDD
about twice as likely to develop the disorder as are dizygotic co-twins
Moderate genetic contributions
to the causal patterns of MDD, although not as large as for bipolar disorder
Gene-mapping studies
: Some evidence two short alleles (s/s), of serotonin-transporter gene but results inconclusive
Depressive disorders polygenic
Indications for genotype-environment
Neurochemical
Altered neurotransmitter activity (norepinephrine/noradrenaline and serotonin) associated with MDD
Decrease dopaminergic activity linked with some forms of depression (such as depression with a typical features)
Current theories suggest interactive effects of neurotransmitters
Serotonin
Norepinephrine
Dopamine
Neuropeptides
Abnormalities of hormonal regulatory and immune systems
Elevated activity of hypothalamic-pituitary-adrenal (HPA) axis (partly controlled by norepinephrine and serotonin) may be involved in development/ Maintenance of clinical depression
HPA axis overactivity: well replicated finding in neurobiology of depression
Finding out the exact functions of hypothalamic-pituitary adrenal gland
Increased production of cortisol may lead to changes in brain structures and function
People with hypothyroidism often become depressed
Dysregulation of immune system
Increase
production of proinflammatory cytokines
*Group of proteins/peptides/glycoproteins secreted by specific cells of immune system)
Such as: Interleukin, Interferon
Neurophysiological and neuroanatomical
Depression is linked to
Decrease activity in left anterior prefrontal cortex
Decrease Hippocampal volume
Decrease volume, Decrease activation of anterior cingulate cortex
Increase activation of amygdala
Environmental
Stressful life events
Stressful life events (precipitating factors), contributing to 20-50% of cases
Loss of loved ones
Serious threat to important relationships or occupation
Serious health problems
Severe economic problems
Childhood trauma
(Physical, emotional, sexual abuse)
Family disruption
Parenting style (hostile, negative, withdrawn)
Parental psychopathology
Lack of social support
Psychological
Cognitive Vulnerability
Psychological contributions
Insecure attachment relationships
Personality
Neuroticism: temperamental sensitivity to negative stimuli
Low positive affectivity: unenergetic, dull, flat and bored (mixed evidence)
Psychodynamic theories of depression
Classic psychodynamic theory: depression represents anger turned inward (introjection)
Research: loss of significant others (real or symbolic) often associated with the development of depression
Evidence supports a self-focusing style (inward/self-absorbed focus attention associated with depression)
Beck's Cognitive Model of Depression
Process of the model
Certain early experiences can lead to formation of dysfunctional assumptions: increases vulnerability to depression
Critical incidents (stressors) activate those assumptions later in life
Once activated, dysfunctional assumptions trigger automatic thoughts
Produce depressive symptoms, which further fuels the depressive automatic thoughts
Process
Early experiences --> Formation of dysfunctional beliefs --> Critical incidents --> Beliefs activated --> Negative automatic thoughts --> <-- Symptoms of depression (behavioural, motivation, affective, cognitive and somatic)
Negative cognitive triad
These negative automatic thoughts centre on three themes
Examples of negative thoughts
Self (eg I'm Worthless)
World ("No one loves me")
Future (eg It's hopeless because things will always be this way)
Being maintained by a variety of
cognitive distortions
All or nothing:
expecting things to be perfect or not have them at all
Over-generalisation
: viewing a negative event as all-encompassing and/or never ending
Mental filter
: Ignoring the positive/functional aspects while dwelling on the negative/dysfunctional aspects
Discounting the positive:
Insisting that one's accomplishments or positive qualities do not count
Jumping to conclusions
Mind-reading: assuming that people are reacting negatively to oneself when there is no evidence
Fortune telling: Arbitrarily predict that things will turn out badly
Magnification or minimisation
: Blow things out of proportion of shrink their importance inappropriately
Emotional Reasoning
: Reason from how one feels (eg "I feel like an idiot, therefore I must be one", "I don't feel like doing this, so I will put it off"
Should statements:
Criticize oneself or others with "should", "shouldnt", "must", "have to", and other unreasonable rules
Labelling:
Identify with one's shortcoming. Eg instead of "I made a mistake", it becomes "I am a loser"
Personalization and blame
Personalization: Blame oneself for something that one was not entirely responsible for
Blame: blame other people and overlook ways that one's attitude or behavior could have contributed to the problem
Learned Helplessness
3 attribution for negative events increases vulnerability to depression
Internal factors (vs external)
: attributes negative outcomes to personal inadequacies rather than external causes eg "I suck"
Global factors (vs specific)
: attributes negative outcomes to overall personal flaws rather than specific weakness
eg "I cannot do anything right"
Stable factors (vs unstable)
: attributes negative outcomes to long term effects
eg "Things will always be bad for me"
Identify different types of bipolar disorders
Bipolar and related disorders
Describe the causal factors influencing the development and maintenance of bipolar disorders
Understand key interventions for mood disorders
Identify risk factors, key theoretical perspectives and interventions for suicidal behaviours
Statistical studies on Mood Disorders
Cases of depressive disorder (millions) by WHO region
(27%) South-East Asia Region
(21%) Western Pacific Region
(15%) Region of the Americas
(12%) European Region
(16%) Eastern Mediterranean Region
(9%) African Region
Singapore Mental Health Study (SMHS) 2016: Lifetime Prevalence of Mental Disorders
Mental disorder
Major Depressive Disorder
SMHS 2010: 5.8%
SMHS 2016: 6.3%
Bipolar Disorder
SMHS 2010: 1.2%
SMHS 2016: 1.6%
Generalised Anxiety Disorder
SMHS 2010: 0.9%
SMHS 2016: 1.6%
Obsessive Compulsive Disorder
SMHS 2010: 3.0%
SMHS 2016: 3.6%
Alcohol Abuse
SMHS 2010: 3.1%
SMHS 2016: 4.1%
Alcohol dependence
SMHS 2010: 0.5%
SMHS 2016: 0.5%
Any of the above mental disorders
SMHS 2010: 12%
SMHS 2016: 13.9%
Comorbidities (presence of two or more of the above mental disorders in the same period)
SMHS 2010: 2.5%
SMHS 2016: 3.5%