Transcript Chapter 8 - People Server at UNCW

The Mood Disorders
Dr. Kayj Nash Okine
The Mood Disorders
Unipolar Disorders:
 Major Depressive Disorder
 Dysthymic Disorder
Bipolar Disorders:
 Bipolar I Disorder
 Bipolar II Disorder
 Cyclothymic Disorder
Major Depression
Emotional Symptoms:
 Sadness, depressed mood
 Anhedonia – lack of interest or pleasure
 Irritability
 Excessive or inappropriate guilt
 Hopelessness
 Feelings of worthlessness
 Low self-esteem
Major Depression
Vegetative Symptoms:
 Lack of motivation
 Insomnia or hypersomnia
 Increased or decreased appetite
 Weight loss or gain
 Fatigue, loss of energy
 Psychomotor retardation or agitation
Major Depression
Cognitive Symptoms:
 Impaired concentration & attention
 Indecisiveness
 Suicidal ideation
 Delusions
 Hallucinations
Major Depression
Social Symptoms:
 Social withdrawal & isolation
 Lack of communication
 Lack of social initiation
 Relationship problems & conflict
 Dependency – clinginess, neediness
Diagnostic Criteria for a Major
Depressive Episode
5+ symptoms are present for at least 2 weeks:
Depressed mood*
Loss of interest or pleasure in most activities*
Significant increase or decrease in appetite or weight
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate
guilt
Diminished ability to think or concentrate or indecisiveness
Suicidal ideation
Diagnostic Criteria for a Major
Depressive Episode
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At lease one of the symptoms is either
depressed mood or loss of interest or
pleasure in most activities.
Symptoms represent a change from
previous functioning.
Symptoms cause significant distress
or impairment.
Symptoms aren’t better accounted for
by bereavement (2 month mourning
period after loss of a loved one).
Specifiers for Major Depression
Mild, Moderate, and Severe
Single Episode or Recurrent
Chronic
With Melancholic Features
With Psychotic Features
With Catatonic Features
With Atypical Features
With Postpartum Onset
With Seasonal Patterns
Longitudinal Course Specifiers
Criteria for Specifiers
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Severity: Mild, Moderate, or Severe level
of functional impairment
Single Episode: single episode of major
depression
Recurrent: 2 or more episodes of major
depression
Chronic: full criteria for a major
depressive episode have been met
continually for at least the past 2 years
Criteria for Specifiers

Psychotic Features: delusions or
hallucinations
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Mood Congruent: depressive themes
of personal inadequacy, guilt, disease,
death, nihilism, or deserved punishment
Mood Incongruent: content doesn’t
involve depressive themes, e.g. thought
insertion, thought broadcasting,
delusions of control, delusions of
grandeur, persecutory delusions
Criteria for Specifiers:
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Catatonic Features: at least 2 of the
following:
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Motoric immobility – catalepsy or stupor
Excessive motor activity
Extreme negativism (resistance to
instructions or attempts to be moved) or
mutism
Posturing, stereotyped movements,
prominent mannerisms or grimacing
Echolalia or echopraxia
Criteria for Specifiers
Melancholic Features:
4 or more of the following
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Loss of pleasure in activities and/or*
Lack of reactivity to pleasurable stimuli*
Quality of mood is distinct
Depression regularly worse in the morning
Early morning wakening (2+ hrs)
Marked psychomotor retardation or agitation
Significant anorexia or weight loss
Excessive or inappropriate guilt
Criteria for Specifiers
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Atypical Features: 3 or more of the
following:
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Mood reactivity*
Significant weight gain or increase in
appetite
Hypersomnia
Heavy, leaden feeling in arms or
legs
Interpersonal rejection sensitivity
Criteria for Specifiers
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Longitudinal Course Specifiers:
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With Full Interepisode Recovery – full
remission is attained between 2 most
recent mood episodes
Without Full Interepisode Recovery –
full remission is not attained between
mood episodes
Postpartum Onset: Onset of episode
within 4 weeks postpartum
Criteria for Specifiers
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Seasonal Pattern:
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Depressive episodes have developed at a
particular time of the year for past 2 years
Depression remits or switches to mania or
hypomania at a characteristic time of year
No nonseasonal major depressive episodes
have occurred during the 2 year period
Seasonal major depressive episodes
substantially outnumber nonseasonal
depressive episodes over the course of
person’s lifetime
Prevalence Rates For
Major Depressive Disorder
Lifetime prevalence: 10-25% for women; 5-12% for
men
Point prevalence: 5-9% for women; 2-3% for men
Gender: women have 2x the rates as men
Age: highest rates among 15-24 year olds
Onset: early 20’s
Other variables: no consistent differences in rates
across levels of ethnicity, education, income, or
marital status
Diagnostic Criteria For Dysthymia
A. Depressed mood for at least 2 years. For
children & adolescents, mood may be irritable
and duration may be 1 year.
B. Presence of 2 or more of the following:
-Poor appetite or over-eating
-Insomnia or hypersomnia
-Low energy or fatigue
-Low self esteem
-Poor concentration or difficulty making
decisions
-Feelings of hopelessness
Diagnostic Criteria For Dysthymia
C. During the 2 yr period, the person has not
been without symptoms for more than 2
months at a time.
D. No major depressive episode has been
present during the 1st 2 yrs of the
disturbance. After the initial 2 yrs, there
may be superimposed episodes of Major
Depressive Disorder, in which case both
diagnoses are given.
Dysthymic Disorder
Specifiers:
 Early Onset - onset before 21 yrs old
 Late Onset - onset at age 21 yrs old or older
 With Atypical Features
Prevalence:
 Lifetime prevalence: 6%
 Point prevalence: 3%
Gender Differences:
 2-3x more likely for women than men
Major Depression vs. Dysthymia
Major Depression:
 5 or more
symptoms
including
depressed mood or
loss of interest or
pleasure
 At least 2 weeks in
duration
Dysthymia:
 3 or more
symptoms
including
depressed mood
 At least 2 years in
duration
Manic Features
Changes in Mood:
 Irritability
 Excitability, exhilaration
 Hostility
 Anxious
 Hyper, wound-up
Manic Features
Increased Energy:
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Little fatigue, despite decreased sleep;
insomnia, and difficulty sleeping
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Increase in activities; increased productivity
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Doing several things at once
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Making lots of plans
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Taking on too many responsibilities
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Others seem slow
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Restlessness, difficulty staying still
Manic Features
Changes in speech
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Rapid, pressured speech
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Incoherent speech, clang associations
Impaired judgment
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Lack of insight
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Inappropriate humor and behaviors
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Impulsive or thrill-seeking behaviors:
increased alcohol consumption; financial
extravagance, spending too much money;
dangerous driving; sexual promiscuity
Manic Features
Changes in Thought Patterns
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Distractibility, inability to concentrate
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Creative thinking
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Flight of ideas
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Racing thoughts
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Disorientation
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Disjointed thinking
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Grandiose thinking
Manic Features
Changes in Perceptions
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Inflated self esteem, feeling superior
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More sensitive than usual: noises seem
louder & lights seem brighter than usual
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Hallucinations
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Paranoia
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Increased appetite
Increased Social Behavior
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Unnecessary phone calls
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Increased sexual activity
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Talkative & sociable
Criteria for Mania & Hypomania
4+ of the following symptoms have persisted to a
significant degree for at least a week:
 Elevated, expansive, irritable mood*
 Inflated self-esteem, grandiosity
 Decreased need for sleep
 Flight of ideas, racing thoughts
 More talkative than usual, pressured speech
 Distractibility
 Increase in goal-directed activity, psychomotor agitation
 Excessive involvement in pleasurable but dangerous
activities, e.g. unrestrained shopping sprees, sexual
indiscretions, reckless driving
Differential Diagnosis
MANIC EPISODE
HYPOMANIC EPISODE
(Bipolar I)
(Bipolar II & Cyclothymia)
 Mood disturbance is
 Mood disturbance is less
severe
severe
 Causes marked
impairment in social or  Does not cause marked
impairment in functioning
occupational
functioning
 The person’s behavior
 Necessitates
and mood significantly &
hospitalization
noticeably change
 Has psychotic
 The person no longer
features
seems like him/herself
Mixed Episode
 The criteria are met (except for duration)
for both Mania & Major Depression nearly
every day for at least a week
 Mood disturbance is severe enough to:
 cause marked impairment in functioning
 necessitate hospitalization
 contain psychotic features
Bipolar I Disorder
Characterized by the occurrence of:
 1 or more Manic or Mixed Episodes
 (usually) 1 or more Major Depressive
Episodes
Bipolar II Disorder
Characterized by the occurrence of:
 1 or more Major Depressive Episodes
 At least 1 Hypomanic Episode
 There has never been a Manic or
Mixed Episode
Cyclothymic Disorder
Characterized by:
 Chronically fluctuating mood states – numerous
periods of hypomania and depression
 Duration of at least 2 years in adults & 1 year in
adolescents and children
 Person is not without symptoms for more than 2
months at a time
 There are no Major Depressive, Manic, or Mixed
Episodes during the initial 2 years. After the
initial 2 years, there may be superimposed
Manic, Mixed, or Depressive episodes
Bipolar Specifiers
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Current or Most Recent Episode
Longitudinal Course Specifiers
With Rapid Cycling (at least 4 episodes of mood
disturbances in the past 12 months)
Mild, Moderate, Severe
With Psychotic Features
With Postpartum Onset
With Catatonic Features (very rare in manic
episodes)
With Seasonal Pattern
Prevalence Rates
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Lifetime Prevalence Rates:
 Bipolar I: 0.4%-1.6%
 Bipolar II: 0.5%
 Cyclothymia: 0.4%-1.0%
Course
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Average age of onset: 18 for Bipolar I, 22 for
Bipolar II, midteens for Cyclothymia
1/3 of bipolar cases begin in adolescence
1/3 of cyclothymics develop full-blown bipolar
Chronic & lifelong course
Suicide attempts: 17% for Bipolar I & 24% for
Bipolar II
Rapid cycling responds poorly to treatment
Gender Features
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Bipolar I and Cyclothymia are equally
common in men and women
Bipolar II is more common in women.
Men tend to have more Manic
Episodes
Women tend to have more Major
Depressive Episodes
Women are more likely to be rapid
cyclers
Biological Theories for Mood Disorders
Genetic Theories:
If an individual has a mood disorder, the rates of
mood disorders in his/her relatives is 2-3x greater
If one twin has a mood disorder, an identical twin is
2-3x more likely than a fraternal twin to have a mood
disorder
Severe mood disorders have a stronger genetic
contribution
Bipolar disorder has a stronger genetic loading
Women have a stronger genetic contribution for
depression than men do
Biological Theories for Mood Disorders
Neurotransmitter Theories:
 Low levels of serotonin (5HT)
 Permissive hypothesis: when 5HT levels are low,
other neurotransmitters, such as norepinephrine
and dopamine, range more widely & become
dysregulated, contributing to mood irregularities
 Kindling-sensitization model: neurotransmitter
systems become more easily dysregulated with
each episode of depression or mania
 Dopamine may play a role in manic episodes
Biological Theories for Mood Disorders
Neurophysiological Abnormalities
Sleep EEG abnormalities:
 Sleep continuity disturbances – the person
takes longer to fall asleep, wakes more
throughout the night, & wakes much earlier
than usual in the morning
 Reduced slow wave sleep
 Earlier onset of REM sleep
 Increased duration & intensity of REM sleep
Biological Theories for Mood Disorders
Neurophysiological Abnormalities
Alterations in cerebral blood flow & metabolism:
 Increased blood flow to limbic system
 Decreased blood flow to prefrontal cortex
 Overactivation of nondominant side of brain
Biological Theories for Mood Disorders
Hormonal Factors (“The Stress Hypothesis”)
 Chronic hyperactivity in the hypothalamicpituitary-adrenal (HPA) axis
 Inability of HPA axis to return to normal following
a stressor
 Heightened HPA activity produces excess of the
stress hormone cortisol, which may inhibit
monoamine receptors
 Chronic stress  poorly regulated
neuroendocrine systems
Drug Treatments for Mood Disorders
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Drug Treatments for Major Depression –
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Monoamine Oxidase Inhibitors (MAOI’s)
Tricyclic Antidepressants (TCA’s)
Selective Serotonin Reuptake Inhibitors (SSRI’s)
SNRI’s
Dopamine Agonists
Drug Treatments for Bipolar Disorder Lithium, anticonvulsants, calcium channel
blockers, antipsychotics
Electroconvulsive Therapy (ECT)
Light Therapy (for SAD)
Biological Treatments
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Electroconvulsive Therapy (ECT):
person is anesthetized & given muscle
relaxant drugs & then electric shock is
administered directly to the brain,
producing a seizure and convulsions
Transcranial Magnetic Stimulation
(TMS): magnetic coil is placed over the
indiviuals head to generate a precisely
localized electromagnetic pulse
Behavioral Theories of Mood Disorders
Lewinsohn’s Behavioral Model
Depression is due to:
A lack of rewarding, pleasurable experiences or
reinforcement.
Stressful, negative life events or aversive
consequences.
Behavioral deficits and excesses, such as a lack of
social skills, continued complaining, & selfpreoccupation.
Passive, repetitious, unrewarding behavior.
Behavioral Theories of Mood Disorders
Stressor leads to reduction in reinforcers
Person withdraws
Reinforcers further reduced
More withdrawal and depression
Lewinsohn’s Behavioral Theory of Depression
Behavioral Theories of Mood Disorders
Learned Helplessness Theory
Exposure to Frequent, Chronic,
Negative Uncontrollable Events
↓
Sense of Helplessness
↓
Learned Helplessness Deficits:
Lack of motivation
Passivity – the person stops trying
Indecisiveness
Inability to effect change or establish control,
even in controllable situations
Behavioral Therapy for Mood Disorders
Increase positive reinforcers & decrease
aversive events
Change aspects of the environment related to
depression
Teach person skills for addressing negative
circumstances and social interactions more
effectively
Teach person skills for managing their
emotions and moods.
Cognitive Theories
Aaron Beck’s Theory
The Negative Cognitive Triad: Depressed people tend to
have negative views of: (1) themselves; (2) the world; (3)
the future.
Cognitive distortions cause or maintain depression:
Distorted Automatic Thoughts – pervasive, negative
thoughts regarding oneself, one’s experience, and one’s
future, e.g. “Nothing I do works out.”
Maladaptive Assumptions – rigid, punitive, unreasonable
rules or guiding principles, e.g. “I don’t deserve to be
happy.”
Negative Schemas – core beliefs about oneself and
others, e.g. “I’m such a loser.”
Cognitive Theories
Seligman’s Theory of the Depressive
Attributional Style
Self-critical depression and helplessness stem from
certain patterns of causal attributions for negative
events or failure:
 Internal (vs. external) – blame self, e.g. lack of
effort
 Global (vs. specific) – touches many areas of
one’s life
 Stable – e.g. lack of ability or aptitude
Cognitive-Behavioral Therapy
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Help person identify and challenge
negative, distorted thinking and
maladaptive beliefs
Help the person learn more
adaptive ways of thinking
Help clients learn new behavioral
skills
Psychodynamic Theory
Early childhood experiences 
 unhealthy relationship patterns
 dependence on the approval of others
 anxiety about separation and
abandonment
Introjected hostility – person perceives
rejection or abandonment and turns
anger in on self, e.g. by blaming or
punishing him/herself
Psychodynamic Therapy
Insight Oriented Approach:
Help the person gain insight into “old
wounds” and unconscious conflicts
and themes, such as introjected
hostility and fears of abandonment
stemming from childhood, in order to
facilitate change
Interpersonal Theory of Depression
(Klerman, Weissman, Rounsaville, & Chevron)
Depression is precipitated or maintained by
problematic childhood relationships and current
interpersonal difficulties or patterns.
Depression occurs in the interpersonal context of:
Grief over loss of significant relationships
Interpersonal role disputes & conflict
Role transitions
Interpersonal deficits – e.g. lack of social
support or intimacy
Interpersonal Therapy
Focuses on four types of interpersonal problems:
Grief & loss
Role disputes & conflict
Role transitions
Deficits in interpersonal skills
Helps the person to establish more social support
and more positive, healthy relationships
Treatments for Bipolar Disorder
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Psychotherapy: supportive,
psychoeducational, self-care, family
involvement
Drug Treatments:
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Lithium Carbonate
Anticonvulsants – Depakote, Lamictal
Calcium Channel Blockers
Antipsychotics