MOOD DISORDERS: DEPRESSIVE MOOD DISORDERS AND BIPOLAR DISORDERS
Mood disorders depression, mania, & bipolar disorder
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Transcript of Mood disorders depression, mania, & bipolar disorder
Mood Disorders: Depression, Mania, &
Bipolar Disorder
By:- firoz qureshiDept. psychiatric nursing
What is Mood?
“Mood is a a conscious state of mind or predominant emotion”
Webster’s Dictionary
What is a Mood Disorder?
Involves disabling disturbances in emotions that are markedly different from normal functioning
Can also include cognitive & behavioral disturbances
Generally occurs in discrete episodes– Depression – extreme sadness – Mania – extreme elation and irritability
Types of Mood Disorders
Main Distinction: unipolar or bipolar– Unipolar: only one end of the emotion spectrum
Major Depressive Episode Manic Episode
– Bipolar: cycling between both ends of the emotion spectrum
Bipolar Disorder
Other Disorders– Dysthymia: mild, chronic form of depression – Cyclothymia: similar to bipolar, but a more mild
form of mania (hypomania)
Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder
Manic Episode: DSM Criteria
A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:(1) inflated self-esteem or grandiosity(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)(3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing(5) distractibility (i.e., attention too easily drawn to unimportant stimuli)(6) increase in goal-directed activity or psychomotor agitation(7) excessive involvement in pleasurable activities that have a high potential for painful consequences
Manic Episode Rule-Outs
do not meet criteria for a Mixed Episode – Mixed episode = both manic and depressed nearly everyday for
at least one week
marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features
not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism)
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder
Bipolar I 1 or more manic episodes; may have
had past depressive episodes or not Lifetime Prevalence: about 1%; equal in
men and women Course and Prognosis: poorer prognosis
than MDD– 45% have one more episode – only 50-60% achieve control over Sx with lithium– 40% develop a chronic disorder
Bipolar II recurrent major depressive episodes
with hypomanic episodes– Hypomania - All the criteria of a Manic
episode except criterion C (marked impairment)
– NOT full-blown manic episodes, if an individual does experience a manic episode, they are then diagnosed with Bipolar I Disorder
matter of differential diagnosis
Bipolar Disorder
Bipolar I Alternation of
full manic and depressive episodes
Average onset is 18 years
Tends to be chronic
High risk for suicide
Bipolar II Alternation of
Major Depression with hypomania
Average onset is 22 years
Tends to be chronic
10% progess to full biploar I disorder
CyclothymiaA. For at least two years (one year for children
and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression
B. During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time
C. No evidence of MDD or Manic episode during the first two years of disturbance
D. No psychotic disorderE. No organic cause
Mania Etiology better-suited for the biological model
– not normally distributed in the population – Symptoms are very marked and severe
not necessarily precipitated by a positive life event & can override negative events– further evidence in favor of diathesis
Familial Pattern seen
Twin and adoption studies
What Does Mania Look Like?
Client 1: Mary
Depressive Disorders Major Depressive Disorder (single,
recurrent) [Major Depressive Disorder:
Postpartum onset]** Dysthymic Disorder Double Depression Postpartum depression as a
specifier
What Does Depression Look Like?
– Sadness– Suicidal Thoughts– Tiredness– Boredom– Unwilling to get out – Insomnia
Depressive Episode/Disorder:
DSM Criteria Five or more of the following during the same 2-week
period that represent a change from usual functioning including either (1) depressed mood or (2) loss of interest.
Sad, depressed mood, most of the day, nearly every day for two weeks
Loss of interest and pleasure in usual activities Difficulties sleeping Shift in activity level Changes in appetite and weight loss/gain Loss of energy, fatigue Negative self-concept, self-blame, guilt,
worthlessness Difficulty concentrating Recurrent thoughts of death or suicide
Depression Diagnosis Rule-Outs
The symptoms do not meet criteria for a Mixed Episode
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Major Depression
MDD, Single episode
Absence of mania or hypomania
MDD, Recurrent
2 major depression episodes, separated by at least a 2 month period with more or less normal functioning/mood
Dysthymic Disorder: SymptomsA. Depressed/irritable moodB. Presence of two of the following: Appetite disturbance Sleep disturbance Low energy/fatigue Poor concentration of difficulties making decision Feelings of hopelessnessC. Present for two year period (one year in children and
adolescents)D. No evidence of a Major Depressive Epidsode during
the first two years (one year for children)E. No manic or hypomanic episodeF. No chronic psychotic disorderG. Not related to organic factors
“Double Depression” Not a diagnosis Meet diagnostic criteria for both
MDD and Dysthymic Disorder
Prevalence Point prevalence is the
percentage of the population who have the disorder at a particular time or over a given period of time.
Lifetime prevalence is the percentage of individuals who have ever had a specific disorder at any time.
Facts About Depression
Major depression is the single most common psychiatric disorder in the U.S.
The point prevalence rate over a 1-year period is 8% for men and 13% for women.
Lifetime prevalence rate is 12.7% for men and 21.3% for women.
In addition, depression is the most common factor leading to suicide.
What Does Depression Look Like?
Client 1: Mary Client 2: Barbara Client 3: Evelyn
Video Reactions? What symptoms of depression did
you notice in these clients?
Any evidence of suicidal thoughts?
Which patient might be more likely to commit suicide? Why?
Etiology: Biological
Genetic Factors– Family, twin, and adoption studies suggest
that depression in hereditary – More severe the depression in an
individual, more likely that relative have depression as well
– MDD concordance: 40% MZ, 10% DZ– Mania concordance: 75% MZ, 25% DZ– Severity of disorder is due to strength of
genetic loading
Etiology: Biological cont. Adoption studies
– More mood disorders occur in the biological relatives of those with mood disorders
– both unipolar and bipolar disorders– severity linked to the strength of the
genetic loading
Etiology: Biological Con’t
Neurochemical Factors– Neurotransmitters
Norepinephrine Serotonin Dopamine
– Not clear what processes are dysfunctional (production, reuptake, chemical breakdown, etc.)
– Neuroendocrine changes Hypothyroidisim
Research on Neurotransmitters
norepinephrine & serotonin– Implicated in mania and depression
effectiveness of antidepressants – most drugs in psychiatry discovered by
accident Not as simple a relationship as
previously thought– E.g. TCA and MAOI drugs
Permissive hypothesis
Beck’s Cognitive Theory of Depression
distortions of reality & depressogenic cognitions result in depression
schema filters and organizes experiences to store beliefs and knowledge about ourselves
cognitive triad of negative schemas– negative view of the self, the world, and
the future
Cognitive Theory Con’t negative automatic thoughts
– further bias that individuals’ view of himself, the world, and the future
– e.g., arbitrary inference, selective abstraction, overgeneralization, magnification, etc.
thoughts focused on experiences of loss and failure
research supports the presence of distorted, automatic cognitions – the causal relationship of these factors not
established
Helplessness/Hopelessness Model
Seligman’s learned helplessness model started as a conditioning model with dogs
those who were exposed to uncontrollable aversive situations would develop depression that was rooted in feelings of helplessness
Attributional Model Abramson - Attribution of lack of control over
stress leads to anxiety and depression
Cognitive distortions affect the interpretation of causes of events in people’s lives.
biased attributional style (i.e., a cognitive style regarding beliefs about the causes of events) characterized by internal, stable, and global attributions.
Seligman and BeckSeligmanAttributions are: Internal Stable Global
I am inadequate (internal) at everything (global) and I always will be (stable).
“Dark glasses about why things are bad”
Interpretation (theory)
BeckNegative interpretations
about: Themselves Immediate world (their
place) Future (their place)
I am not good at school (self). I hate this campus (world). Things are not going to go well in college (future).
“Dark glasses about what is going on”
Description
Attributional Model Con’t
Internal - attribute negative events to own failings
Stable - belief that causes of negative events remain constant
Global - assume causes of negative events have broad and general effects
research supports the hopelessness model – but cannot establish causal relationship
Major Depression: Social and Cultural Factors Stressful life events Social support (marital
relationship) (see chart) Gender Culture (see chart)
Marital Status and MDDPercentage w/MDD
2.1 2.12.8
6.3
0
1
2
3
4
5
6
7
Married Widowed Never M. M/D/W
MarriedWidowedNever M. M/D/W
Ethnicity and Prevalence of MDDPercentage by Ethnicity
3.1
4.45.1 4.9
0
1
2
3
4
5
6
Af. Am Latina White Average
Af. AmLatinaWhiteAverage
Gender Differences in Depression
Dr. Susan Nolen-Hoeksema Women diagnosed twice as often as
men difference not evident in childhood
– boys and girls are just as likely to experience depression
– Changes in preteen years What factors may be involved in the
development of these differences?
Diathesis-Stress Model
Neither biological nor environmental and personal factors alone can produce depression
a biological vulnerability (or diathesis) interacts with life stressors to produce depression – For example, a neurotransmitter
dysfunction may interact with life stressors (e.g., death of a loved one) to produce depression
Diathesis-Stress Example
No Life Event Life Event
Depr
essio
n
Low NE
Normal NE
Comorbidity with Anxiety distinguishing depression from anxiety difficult Watson & Clark: tripartite model
– Negative affectivity (NA) - pervasive individual differences in negative emotionality and self-concept
Common to anxiety & depression
– Anhedonia - lack of experiencing pleasure specific to depression
– Anxious arousal - physiological symptoms of anxiety specific to anxiety disorders
Psychological Treatments for Depression
Psychodynamic Therapies
Cognitive-Behavioral Therapies– Beck Cognitive Therapy– Social Skills Training– Behavioral Activation
Interpersonal Therapy
Cognitive Therapy
Procedures16 weeks of treatmentExtensive Assessment:
Placebo & Clinical Management
Depression Collaborative Research ProgramInterpersonal
Psychotherapy
T
Treatment Groups
Outcome MeasuresDepressive SymptomsOverall symptomotology and life functioningFunctioning in treatment specific domains
Results:Post-Treatment
• Equivalent success in three active treatments over placebo
• Medication was faster • IPT better than CBT for
more severely depressed patients
• Particular treatments effected change in expected domains
ResultsFollow-up-18 months
• Equivalent success in three active treatments• Only 20 to 30% of recovered patients were still
well• Patients in IPT report more satisfaction with
treatment• IPT and CBT patients more likely to report that
treatment affected capacity to establish and maintain relationships and to understand source of their depression
MedicationImiprimine
Many Controversial Issues
Biological Therapies for Depression
Drug Therapies– Tricyclics– Selective serotonin reuptake
inhibitors– Monoamine oxidase inhibitors
Electroconvulsive Therapy
Mood Disorders: PrevalenceDisordersMajor
DepressionDysthymiaBipolar IBipolar II
MDD (Postpartum)
Prevalence4.9%3.2%0.8%0.5
13%
Suicide 8th leading cause of death in the
U.S. Overwhelmingly white
phenomena Suicide rates also quite high in
Native American Rate of suicide is increasing in
adolescents and elderly Males are more likely to commit
suicide Females are more likely to
attempt suicide (except China)
5 Myths and Facts About SuicideMyth #1: People who
talk about killing themselves rarely commit suicide.
Fact: Most people
who commit suicide have given some verbal clues or warnings of their intentions
5 Myths and Facts About SuicideMyth #2: The suicidal
person wants to die and feels there is no turning back.
Fact: Suicidal people
are usually ambivalent about dying; they may desperately want to live but can not see alternatives to problems.
5 Myths and Facts About SuicideMyth # 3: If you ask
someone about their suicidal intentions, you will only encourage them to kill themselves.
Fact: The opposite is
true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for accurate risk assessment.
5 Myths and Facts About SuicideMyth # 4: All suicidal
people are deeply depressed.
Fact: Although depression
is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.
5 Myths and Facts About SuicideMyths # 5: Suicidal people
rarely seek medical attention.
Fact: 75% of suicidal
individuals will visit a physician within the month before they kill themselves.
Sociodemographic Risk Factors Male > 60 years Widowed or Divorced White or Native American Living alone (social isolation) Unemployed (financial difficulties) Recent adverse life events Chronic Illness
Clinical Risk Factors Previous Attempts Clinical depression or schizophrenia Substance Abuse Feelings of hopelessness Severe anxiety, particularly with
depression Severe loss of interest in usual
activities Impaired thought process Impulsivity
Assessing Risk and Planning InterventionRiskLevel
Specific
Plan
Risk Factors
Severity
Intent
Interven.
Low No Few None Safety Plan
Mod. VaguePlan/low
lethal
Increased None Safety Plan
Severe Specificlethal plan
Increased None Safety PlanRemove
Lethal ItemsExtreme Specific
lethal planIncreased Intent to die Safety Plan
Remove Lethal ItemsHospitalize
Commonalities of Suicide
(Schneiderman, 1985)1. purpose is to seek a solution. 2. goal is the cessation of consciousness (not
death). 3. stimulus is intolerable psychological pain. 4. stressor is frustrated psychological needs. 5. emotion is hopelessness-helplessness. 6. cognitive state is ambivalence. 7. perceptual state is constriction. 8. action is egression. 9. interpersonal act is communication of intention. 10. consistency is with lifelong coping patterns.
Clinical Considerations of Suicide AssessmentFor those who are reluctant to
assess suicide:
Asking questions may feel intrusive but not asking has dangerous consequences
A calm and genuinely concerned approach is effective
Suicide:Treatment Problem-solving Cognitive behavioral therapy Coping skills Stress reduction
Postpartum Depression
Burden In the United States, depression is the
leading cause of non-obstetric hospitalizations among women aged 18-44.
In the year 2000, 205,000 women aged 18-44 were discharged with a diagnosis of depression.
Seven percent of all hospitalizations among young women were for depression.
Perinatal Depression: Prevalence
Pregnancy PostpartumKumar & Robeson 1984
13.4% 14.9%
Watson & Elliott 1984
9.4% 12.0%
O’Hara et al., 1984 9.0% 12.0%
Cooper et al. 1988 6.0% 8.7%
O’Hara et al., 1990 7.7% 10.4%
Evans et al., 2001 13.6% 9.2%
Postpartum Blues Most common, 50-
80% Relatively brief
– Few hours to several days
Onset usually in first week to 10 days PP
Typically remit spontaneously– May represent the
initial stages of PPD/PPP
Typical Blues Symptoms Low Mood Mood Lability Insomnia
Anxiety Crying Irritability
Postpartum Psychosis
Rare: 1/1000 postpartum women
Hallucinations and/or Delusions
Risk Factors: History Bipolar
Affective Disorder/Psychosis
Family history of psychosis
Having first child
Aggressive intervention absolutely necessary
Postpartum Psychosis
Usually Begins Within 90 Days Postpartum
Length is Quite Variable Prevalence: 1/500 to 1/1000 Family history of bipolar disorder
33/1000 Family history of postpartum psychosis
22/1000 Personal history bipolar disorder: 1/2 Sequelae: Future Postpartum Psychosis
Postpartum Depression Not as mild or
transient as the blues
Not as severely disorienting as psychosis
Range of severity Often undetected
Postpartum Depression: Risk Factors Lower SES/unemployment Past depression or anxiety disorder Past history of alcohol abuse Stressful life-events Poor marital relationship Inadequate social support Child-care related stressors African American ethnicity
Effects of Perinatal Depression:An Overview Depression negatively effects:
Mother’s ability to mother Mother—infant relationship Emotional and cognitive
development of the child
Postpartum Depression:Maternal Attitudes– Infants perceived to be more
bothersome
– Make harsh judgments of their infants
– Feelings of guilt, resentment, and ambivalence toward child
– Loss of affection toward child
Postpartum Depression:Maternal Behaviors
Gaze less at their infants Take longer to respond to infant’s utterances Show fewer positive facial expressions Lack awareness of their infants Increased risk for abusing children
Postpartum Depression:Maternal Interactions
Flat affect, low activity level, and lack of contingent responding
OR
Alternating disengagement and intrusiveness
Effects of Maternal Depression Infants- lowered Brazelton scores,
frequent looking away, fussiness
Toddlers- poorer cognitive development, insecure attachment
Children- cognitive development of low ses boys
Adolescents-higher cortisol levels
What Can Be Done?
ROUTINE SCREENING
REFERRAL TO TREATMENT
Why Screen for Perinatal Depression?
Screening is associated with increased detection
Georgiopoulos et al., 1999, 2001– EPDS screening resulted in increased
chart-based diagnosis of PPD from 3.7% to 10.7% after one year of universal screening – Rochester, MN
Barriers to Detection Women will present themselves
as well as they are ashamed and embarrassed to admit that they are not feeling happy
Media images contribute to this phenomena
Barriers to Detection Women will present themselves
as well as they are ashamed and embarrassed to admit that they are not feeling happy– Tom Cruise: Snap out of it mentality
Media images contribute to this phenomena
Barriers to Detection (cont) Lack of knowledge about range of
postpartum disorders
They don’t want to be identified with Andrea Yeats
May genuinely feel better when you see them (they got dressed, out of house, lots of attention, not isolated)
“I Was Depressed But Didn’t Know It.”
Commonalities in the Experience of Non-depressed and Depressed Pregnant and Postpartum Women
Changes in appetite Changes in weight Sleep disruption/insomnia Fatigue/low energy Changes in libido
What is Required for Effective Screening?What to do with a positive screen?
1. Implement or refer for diagnostic assessment
Arrange for treatment2. Antidepressant medication3. Psychotherapy (individual or group)
Arrange for follow-up
THANK YOU