Transcript depression - DAV College For Girls, Yamunanagar

MOOD
DISORDERS :
DEPRESSION
> Depression is an emotional state marked by great sadness and
apprehension, feelings of worthlessness, and guilt, withdrawal from others,
loss of sleep, appetite and sexual desire, or loss of interest and pleasure in
usual activities.
> Often it is associated with other psychological problems and with medical
conditions.
> Seligman (1973) refers to depression as the “common-cold” of psychological
problems - i.e.- its’ the most common of all the psychological problems.
According to DSM-IV 1994 and DSM-IV TR 2000, Mood Disorders are
classified into two main categories:
A. Unipolar Disorder( Unipolar / Major Depression)
B. Bipolar Disorder
CLASSIFICATION OF MOOD DISORDERS
BIPOLAR DISORDER
UNIPOLAR DISORDER
MAJOR DEPRESSIVE DISORDER
BIPOLAR-I DISORDER
DYSTHYMIC DISORDER
BIPOLAR-II DISORDER
DEPRESSION NOS
CYCLOTHYMIC DISORDER
BIPOLAR DISORDER NOS
MAJOR DEPRESSION
Major Depression is a severe depressive disorder, in which a person may show
a loss of appetite, psychomotor symptoms, and an impaired ability testing.
CRITERIA FOR MAJOR DEPRESSIVE DIORDER
According to DSM-IV TR 2000,following is the criteria for Major Depressive
disorder :
I. The individual must show in his behavior, atleast five of the following
symptoms, for atleast two weeks, and these symptoms must interfere with
his day-to day functioning. Prominent mood should be a depressed one, and
the person must show a loss of interest or pleasure in day-to-day activities.
Symptoms are as follows:
(a) In adults, the depressed mood should continue for almost the whole day
and in children and adolescents, irritable mood is present for the entire
day.
(b) The individual may show a lack of interest in almost all the activities and
this lack of interest continues for days.
(c) Loss of weight and appetite.
(d) Person may suffer from insomnia or hypersomnia.
(e) Person may show lack of psychomotor activities, agitation & retardation.
(f) Feeling of fatigue or loss of energy for almost the entire day.
(g) Feeling of worthlessness, and excessive or inappropriate guilt almost
daily.
(h) Lack of concentration, diminished ability in various activities, and
indecisiveness.
(i) Recurrent ideas and thoughts related to suicide or suicide attempt.
II. Such a person does not show any of the Mixed or Manic episode
symptoms.
III. Due to the symptoms, the person undergoes distress and shows an
impairment in social, occupational, personal or school functioning.
IV. Symptoms should not be due to any general medical condition or
substance-use.
V. If depressive mood appears after some loss, such as death of a loved one,
then it may last for two months and is known as “ Bereavement ”. Thus, it
should not be considered a Major Depression, because the symptoms would
gradually disappear after two months. However, in case the symptoms
persist and the person continues to show functional impairment,
worthlessness, suicidal attempt, retardation in psychomotor abilities, then he
should be considered for the treatment of Major Depression.
>> Blatt et al.,1976, on the basis of the researches done on young adults /
college students, has cited three major reasons for depressive disorder in
males, as well as females:
1. Desire for dependency
2. Self-criticism
3. Feeling of inefficiency
Later on, in 1982 ,he mentioned two types of depression:
(a) Dependence depression
(b) Self-criticism depression
CLINICAL PICTURE OR MAIN SYMPTOMS OF
UNIPOLAR DEPRESSION
Symptoms of Unipolar Depression can be classified into six main categories:
I. EMOTIONAL SYMPTOMS
(i) Depressed mood (sadness, hopelessness, discouraged attitude)
(ii) Irritable mood
II. COGNITIVE SYMPTOMS
(i) Feeling of worthlessness and low self-esteem
(ii) Memory deterioration and defects
(iii) Lack of concentration
(iv) Guilt-feeling
(v) Pessimistic thinking
(vi) Lack of problem-solving ability
(vii) Suicidal thoughts
(viii) Attribution to others for ones’ own negative thinking and perception.
III. MOTIVATIONAL SYMPTOMS
(i)
(ii)
Loss of interest in surroundings, biological needs, etc.
Lack of initiativeness
IV. OVERT BEHAVIORAL SYMPTOMS
(i) Psychomotor disturbances
(ii) Speech disturbances
(iii) Suicidal attempts
V. SOMATIC SYMPTOMS
(i)
(ii)
(iii)
(iv)
Sleep disturbances
Hunger
Loss of weight, and in rare cases, an increase in weight.
Too much of fatigue
VI. SOCIAL AND OCCUPATIONAL SYMPTOMS
(i) Impairment in social relationships.
(ii) Lack of occupational efficiency.
(iii) Impairment of functioning in other areas.
>> DYSTHYMIC DISORDER
Its’ also known by other names- Chronic depression, depressive neurosis and
sub effective depression. According to DSM-IV-TR 2000, a person suffering
from this disorder shows the following symptoms :
1. Depressive mood almost daily for atleast two years and for children and
adolescents, this duration can be of one year only.
2. While showing the depressive mood, the person should reflect atleast two of
the following symptoms:
(a) Poor appetite
(b) Insomnia / hypersomnia
(c) Low energy or fatigue
(d) Low self-esteem
(e) Poor concentration or difficulty in decision-making
(f) Feeling of hopelessness
3. During the duration of two years ( one year for children and adolescents ),
there are not even two such months when the symptoms are not reflected in
the persons’ behavior.
4. Treatment for this disorder is given only when the patient is not showing the
symptoms of major depression. Sometimes, individuals suffer from
dysthymic disorder for two years and lateron, the person may start showing
the symptoms of major depression also. This means that the symptoms of
major depression are superimposed on the symptoms of dysthymic disorder,
and the person is said to suffer from double depression i.e. both- major
depression and dysthymic disorder. However, its’ also possible that after
getting the treatment, symptoms of major depression improve and the
person again becomes a patient of dysthymic disorder.
5. Individuals who have dysthymic disorder donot show any of the
characteristics of manic episode, mixed episode or hypomania. They donot
show any of the characteristics of cyclothymic disorder.
6. Disturbances in mood should not be due to any other psychotic disorder.
7. Symptoms should not be due to any general medical condition or the direct
physiological effect of a substance.
8. Symptoms should have some clinical significance, should cause significant
distress and impairment in social, occupational and personal functioning.
According to DSM-IV-TR 2000, in order to distinguish dysthymic disorder
from major depression, its’ essential to look for the following three indicators :
1. Severity of symptoms
2. Duration of symptoms
3. Persistence of symptoms
On the basis of the above indicators, we can distinguish dysthymic disorder
from major depression. However, sometimes its’ possible that the patients of
dysthymic and major depression – both – show similar kind of intense
symptoms, but in case of dysthymic disorder, we can observe normal mood of
the person for a few weeks, and on this basis, a clinician is able to identify the
patients of major depression and dysthymic disorder.
CAUSES OF UNIPOLAR DEPRESSION
CAUSES OF UNIPOLAR
DEPRESSION
BIOLOGICAL
PSYCHOSOCIAL
COGNITIVE
FACTORS
FACTORS
VIEWPOINT
HUMANISTIC
EXISTENTIAL
VIEWPOINT
HEREDITY
PREDISPOSITION
BECKS’ THEORY OF
DEPRESSION
BIOCHEMICAL FACTORS
LEARNED
HELPLESSNESS
NEUROENDROCRINE
SYSTEM
ATTRIBUTIONAL
THEORY
NEUROANATOMICAL
FACTORS
HOPELESSNESS
THEORY
REINFORCEMENT
MODEL
INTERPERSONAL
THEORY
SOCIOCULTURAL
FACTORS
I. BIOLOGICAL CAUSAL FACTORS
1. HEREDITY PREDISPOSITION
Heredity predisposition for this disorder can be studied on the
basis of twin study, family study and adoptee study. All the
three studies have shown a hereditary predisposition for
depression.
RESEARCHER
FINDINGS
ALLEN ,1976
FOR IDENTICAL TWINS,CONCORDANCE RATE FOR
DEPRESSION IS 40%,AND FOR FRATERNAL
TWINS,ITS’ 11%.
PLOMIN ET
AL.,1977
ON THE BASIS OF TWIN STUDIES,IT HAS BEEN
PROVED THAT HEREDITY PLAYS AN IPORTANT
ROLE IN CAUSING DEPRESSION.
WINOKUR,1979
ON THE BASIS OF FAMILY STUDIES, GENETIC
FACTORS HAVE BEEN PROVED TO PLAY AN
IMPORTANT ROLE IN CAUSING DEPRESSION.
WENDER ET
AL.,1986
ON THE BASIS OF ADOPTEE STUDIES,IT WAS
FOUND THAT HEREDITY PLAYS AN IMPORTANT
ROLE IN CAUSING DEPRESION
2. BIOCHEMICAL FACTORS
(a) Deficiency of certain neurotransmitters cause
depression.
Joseph et al.,1967,”Depression is caused due to deficiency of
Monoamine neurotransmitter”.
(b) Catecholamine Hypothesis: This hypothesis
states that the deficiency of norepinephrine, dopamine and
epinephrine can cause depression.
(c) Golden and Gilmore,1990 –”Deficiency of Serotonin and
histamine can cause depression”.
(d) GABA inhibits neurotransmitter activities and causes
depression.
(e) Role of acetylecholine has been proved in causing depression.
3. NEUROENDOCRINE SYSTEM
(a) Blood plasma levels of ‘ cortisol ’ are known to be elevated, in about 5060% of the seriously depressed patients.
(b) Role of hypothalamic-pituitary-adrenal axis is evident in depression.
(c) Thyroid gland is also considered to play an important role in depression.For
eg. People with low thyroid levels often become depressed.
4. NEUROPHYSIOLOGICAL FACTORS
(a) Research has shown that lesions of the left anterior or prefrontal cortex
often lead to depression (eg. Robinson & Downhill,1995)
(b) High level of limbic activity is related with depression.
(c) Abnormal role of hypothalamus is one of the important factors in
depression. Damage to hypothalamus creates a functional shift, which
occurs due to old age ,and thus, depression is developed.
(d) Deficient blood flow to the left frontal lobe causes depression
( Bench et al.,1995 )
II.PSYCHOLOGICAL FACTORS
>> PSYCHOANALYTIC VIEWPOINT
(a) According to Freud(1917),”Depression has its’ roots in childhood”.
(b) People who show overindulgence or deprivation may suffer from
depression. The individuals who show dependence on others and are
fixated to the oral stage of psychosexual development and who incorporate
the image of a lost person, may suffer from depression.
(c) Those who suffer from guilt feeling or feelings of real or imagined sins,are
more prone to suffer from depression.
(d) Persons who involve themselves in an imagined or symbolic loss , suffer
from depression.
(e) People with a low self-esteem and high self-critical tendency, suffer from
depression.
(f) According to Bibring,” Situations, rather than the internal conflicts, are
important in causing depression.”
(g) According to Alnaes & Torgersen,1993, ”Combination of traumatic childhood
experiences and acute external stressful events in adulthood, are important
in causing depression.
III. COGNITIVE VIEWPOINT
1. BECKS’ THEORY OF DEPRESSION
Beck has shown the interrelationship among the three
levels of cognition as an important cause of depression.
NEGATIVE SCHEMAS
OR
BELIEFS
SELFCOGNITION
DEPRESSION
TRIAD
NEGATIVE / BIASED /
DISTORTED COGNITION
FUTURE
FIG. BECKS’ COGNITIVE THEORY
LIST OF DISTORTED COGNITIONS
(i)
Overgeneralisation
(ii) Selective Abstraction
(iii) Excessive Responsibility
(iv) Temporal Casualty
(v) Self-References
(vi) Catastrophizing
(vii) Dichotomous Thinking
(viii) Minimisation and Magnification
Such kind of distorted cognition may lead to depression.
2. LEARNED HELPLESSNESS
Martin Seligman (1974,1975) first proposed that learned helplessness can
cause depression.
UNCONTROLLED
AVERSIVE EVENTS
SENSE OF
HOPELESSNESS
MOTIVATIONAL
D
DEFICITS
E
( Lack of / lowered
P
initiativeness )
R
COGNITIVE
E
DEFICITS
S
(Negative Cognitions)
S
EMOTIONAL
I
O
DEFICITS
(Passivity and low mood )
FIG. LEARNED HELPLESSNESS
N
3. ATTRIBUTIONAL THEORY
Abramson et al., 1978 have emphasized that the style of attribution is important
in causing depression. According to him, it is our own perceptions which are
responsible for making us depressed. For eg. If a person fails in an exam, then
the way he attributes is failure becomes important - i.e. - whether he gives
Personal / Universal, Stable / Unstable, Global / Specific reasons for his failure.
A typical depression attributional style includes attribution towards
oneself, the global and stable reasons for failure. Such an individual would
perhaps give the reasoning like – ”I lack intelligence”. This reasoning is of the
nature ‘ global , stable and personal ’ and may lead to depression.
4. HOPELESSNESS THEORY
This theory is given by Abramson et al.,1989.
AVERSIVE
EVENTS
ATRIBUTION TO GLOBAL
AND STABLE FACTORS
OR OTHER NEGATIVE
COGNITIVE FACTORS
SENSE OF
HOPELESNESS
DEPRESSION
( Not able to alter the situation)
+
(Hopelessness expectancy )
5. REINFORCEMENT MODEL
Ferster,1973,”Positive reinforcers have an important role in the upliftment of our
mood, but, if in any environment there is:
(i) A lack of positive reinforcers, or
(ii) High level of exposure to aversive situations, or
(iii) Drastic changes in life (e.g. Loss of a dear one ) and limited reinforcements,
then all these factors would lead to depression.
6. INTERPERSONAL THEORY
This theory is given by Coyne,1976.According to him, ”Those who are prone
to depression , have an aversive interpersonal style, and other persons have
negative reaction towards this style. Such individuals lack social skills, donot
have social support and are unable to cope with negative life events. They
always try to find reassurance for their acts from others in order to get shortterm satisfaction, and often show inconsistent behavior.
IV. HUMANISTIC – EXISTENTIAL VIEWPOINT
Its’ given by Carl Rogers,1980.According to him, the more the discrepancy
between the ideal and the real self , more is the chance that the person
would face depression. Other important factors are – loss of self-esteem ,
loss of some loved object, and a faulty self - assessment. All these factors
may lead to depression.
PERSONALITY “TYPE” AND DEPRESSION
Some of the personality traits make an individual vulnerable to depresson.
There are specifically two types of personalities, which have an important
relationship with depression:
(a) Sociotropic Type: Such individuals show interpersonal dependency and they
are sensitive towards loses and rejection.
(b) Autonomic Type: Such individuals give importance to achievement issues.
They are self-critical and sensitive towards achievements and failures.
V. SOCIOCULTURAL FACTORS
Depression has been found to be closely associated with social and cultural
trends. Kleinman, in 1986, found that depression is found to be less prevalent in
China. Carothers, in 1956, found that its’ less found in Africa as compared to
America. The reason could be that, in Africa, people are not held responsible
for their failures. Besides this, it has been found that depression is more
common in urban, than in rural areas. It is found in all types of socio-economic
classes, but the reasons vary, as illustrated:
LEVELS
High socioeconomic class
REASONS FOR DEPRESSION
Lack of interest in life.
Middle socioeconomic class
Loneliness, sorrow, guilt-feeling.
Low socioeconomic class
Meaninglessness and self-hatred
> Depression is more common in highly educated and
professional people.
> Depression is more common in women than men.
TREATMENT FOR DEPRESSION
I. BIOLOGICAL APPROACH
A. DRUG THERAPY
(i) Antidepressant drugs are useful to deal with negative symptoms and stress.
(ii) Heterocyclic drugs have been found to be useful in both-depression and
bipolar disorder.
(iii) Second-generation drugs are also very useful to deal with
depression. eg. Fluoxetine.
(iv) Monoamine Oxidase Inhibitors (MAOs) also help in dealing with depression.
(v) Sometimes, in the old age, its’ important to give certain stimulants to the
patient ( eg. Dextroamphetamine & Pemoline ), along with antidepressants.
B. ECT ( ELECTROCONVULSIVE SHOCK THERAPY )
(i) As far as depression is concerned, this therapy has also proved to be useful
for those who suffer from acute, major or psychotic-like depression.
(ii) This treatment is also useful for those who are not able to tolerate the sideeffects of antidepressants.
(iii) Success rate with ECT is quite encouraging. Almost 70-80% of the patients
benefit.
But even ECT could not control the relapse rate, and thats’ why antidepressant
drugs are followed, once the ECT treatment is over.
C. NON – PHARMACOLOGICAL APPROACH
After 1980, many such treatments came into existence which donot have the
side- effects like the drug therapy and the ECT. Although these treatments are
not as effective as the standardized ones, but still, these are useful for those
who are not able to bear the side-effects of the other available treatments.
(i) BRIGHT LIGHT THERAPY
Wehr & Goodwin, 1987 introduced this therapy. In this therapy, an intense light
of 2500 lux is being presented and the patient has to look at that light for almost
min. and he’s allowed to blink his eyes only once during he treatment.
Individuals who suffer from ‘ winter depression ’ or ‘ Seasonal Affective Disorder
’ (SAD), get benefit from this therapy.
(ii) SLEEP DEPRIVATION
When depressed patients are not allowed to sleep for one night, they get relief
from their symptoms of depression. But, if they get more sleep the next day,
they may experience symptoms of depression once again. The main purpose is
to deprive them of the REM phase of the sleep. That is why the patients are
advised not to sleep, after they have taken half of the sleep. According to
different researchers, its’ believed that if the patients are deprived of their sleep
during the second-half of the night (i.e. when REM phase of sleep is going on ),
they get relief from the symptoms of depression.
(iii) SLEEP PHASE CHANGES
According to Wehr & Goodwin,1987, sometimes the patients of depression get
benefit only by changing the phase of their sleep (i.e. phase-shifting) .For e.g. if
a person gets too early in the morning and feels depressed, then some
changes might be introduced in his pattern of sleep. He may be advised to go
to bed late at night. This helps in the improvement of their condition.
II. PSYCHOLOGICAL APPROACH
In mild and moderate depression, drug therapy is not much useful. So, in such
cases, the patients are provided different psychological therapies :
>> PSYCHOANALYTIC THERAPY
This therapy focusses on developing the insight of the patient towards his
inner conflicts, and an attempt is made to integrate the frustration and conflicts
into ones’ self. Patients are also taught not to internalize any aggressive,
hostile, negative objects and projection of mistakes towards self. Rather, they
are made to look at the external actors which are responsible for their worries,
tensions and failures. Its’ very important to unreveal the unconscious motives,
desires, and needs of an individual in order to deal with the symptoms of
depression.
III. COGNITIVE THERAPY
According to Beck,” Its’ very important to convert the maladaptive patterns into
adaptive ones“ and he has suggested four stages in his therapy to improve
the negative evaluation towards self, world and future.
FIRST STAGE emphasizes on increasing activities and alleviating negative
mood.
SECOND STAGE focusses on examining and invalidating automatic thoughts.
THIRD STAGE helps in identifying the distorted thinking and negative biases.
FOURTH STAGE aims at altering the primary attitudes.
IV. BEHAVIORAL THERAPY
There are different behavioral therapies for the treatment of depression, as
mentioned by Lazardus, 1968.
(i) POSITIVE REINFORCERS AND TIME PROJECTION
In this therapy, the patient is asked to imagine positive future activities. For
each positive imagination, some positive reinforcement is provided.
(ii) INHIBITION THERAPY
In this therapy, the patient is encouraged to express verbally,the opposite mood
to depression i.e. he’s encouraged to explain the positive aspects of life,
verbally, and lateron, integrate the same in his life.
(iii) DEPRIVATION TECHNIQUE
In this technique, the patient is deprived of any kind of stimulation for some
period, so that he could understand the importance of positive reinforcers.
>> Wilkoxen et al., 1976 and Lewinsohn, 1989 emphasized three techniques in
the treatment of depression:
(i) Reintroducing pleasurable events in the life of the patient.
(ii) Reintroducing non-depressive behavior.
(iii) teaching social skills to the patient.
OTHER THERAPIES
In the treatment of depression, many other therapies are also useful. These
therapies are termed as crisis-intervention therapies, as these are considered
to deal with crisis.
>> EXISTENTIAL THERAPY
It emphasizes on living life with some purpose.
>> PARADOXICAL INTENTION
In this therapy, the patient is intentionally made to indulge in his own
symptoms. For e.g. if the patient is not leaving his bed till late afternoon, he is
made to stand near his bed throughout the day. Exaggeration of the
symptoms leads to conscious awareness of the maladaptive behavior i.e.
excessive sleep.
>> COMPREHENSIVE GROUP TREATMENT PROGRAMME
This approach was put forward by Lewinsohn et al. 1999. Family members,
friends and colleagues are advised to give encouragement and support to the
depressed individual, so that he can manage to cope up with his lifes’
problems. With the support of these individuals, the patient is encouraged and
motivated to involve himself in various life activities.
>> INTERPERSONAL THERAPY
It focusses on interpersonal relationships by emphasizing :
(i) Controlled grief reactions
(ii) Solving interpersonal role dispute
(iii) Interpersonal role transition
(iv) Avoidance of interpersonal deficit
>> YOGA THERAPY AND MEDITATION have also proved to be effective in
alleviating mood. However, the most effective is the combination of all these
therapies.
BIPOLAR DISORDERS : BIPOLAR-I , BIPOLAR-II AND
CYCLOTHYMIC DISORDERS
Bipolar disorders were first known as manic depressive disorders or insanity.
This term was introduced by Kraeplin, 1899 and lateron, this was also known
by the name “manic depressive psychosis”. But according to DSM-IV-TR 2000,
the disorders in which we find both- an elated mood as well as depressive
mood, are known as bipolar disorders. In these disorders, a person can
experience Manic episode, Mixed episode, as well as Hypomanic episode,
along with Major Depressive episode.
BIPOLAR-I DISORDER: Characterised by one or more manic or mixed
episodes, and its’ usually accompanied by Major Depressive episodes.
According to DSM-IV-TR 2000,Bipolar disorder is further categorised as
follows:
(i) Single Manic episode
(ii) Most recent episode Hypomanic
(iii) Most recent episode Manic
(iv) Most recent episode Mixed
(v) Most recent episode Depressed
(vi) Most recent episode Unspecified
FEATURES / CRITERIA OF MANIC EPISODE
According to DSM-IV-TR 2000, the following criterias must be satisfied if a
person is suffering from mania :
1. The individual must show, in his behavior, for atleast one week, an elevated,
expansive and irritable mood.
2. Mood disturbance, if includes only irritable mood, then atleast four
symptoms, otherwise three symptoms must be reflected in the persons’
behavior.
Symptoms are:
(a) Inflated self-esteem
(b) Less need of sleep
(c) Talkative
(d) Flight of ideas
(e) Distractability
(f) Psychomotor agitation
(g) Inclination to involve oneself in pleasurable activities, which have a high
potential of painful after-effects.
3. Person must not reflect in his behavior the features of Mixed episode.
4. Mood disturbance is so severe that it interferes in occupational, social and
other functional areas. Sometimes it becomes necessary to hospitalize the
patient so that he doesnot cause any harm to himself or others. The
person does show psychotic features in his behavior.
5. Such symptoms should not be the after-effects of any general medical
condition or substance-abuse.
CRITERIA / FEATURES OF MIXED EPISODE
According to DSM-IV-TR 2000, following are the criterias for a mixed episode :
1. In this type of episode, person must show in his behavior ( almost daily ),
manic as well as depressed episode. Person rapidly changes his mood from
sadness and irritation to euphoria and a feeling of elevation.
2. Mood disturbance must interfere in the occupational , social and other
activities and relationships. Sometimes the features are so intense that they
seem to be psychotic features, and the person needs to be hospitalised.
3. These symptoms should not be due to any general medical condition or the
direct effect of any substance.
CRITERIA / FEATURES OF HYPOMANIC EPISODE
According to DSM-IV-TR 2000, the diagnostic criteria for this mood is as
follows:
1. Hypomanic episode is distinguished on the basis of time duration of the
mood. In this, an individual shows (atleast for four days) persistently
elevated, expansive and irritable mood.
2. Mood disturbance is accompanied by atleast three of the following symptoms
( four symptoms when the patient is showing only the irritable mood ).
Symptoms are as follows:
(a) Inflated self–esteem, grandiosity…
{ Other symptoms are the same as in Manic episode}
3. Due to mood disturbance, changes in the day-to-day functioning are
observable.
4. This episode affects the social and occupational functioning
in a low or a moderate manner.
5. Psychotic features are either absent or minimal in this
episode.
6. Symptoms are not due to any general medical condition or
the direct physiological effects of a substance.
BIPOLAR - II DISORDER
According to DSM-IV-TR 2000, Bipolar-II disorder is
characterised by one or more major Depressive episodes,
accompanied by atleast one hypomanic episode.
CRITERIA FOR BIPOLAR - II DISORDER
1. Patient must show atleast one or more than one depressive episodes.
2. Patient must also show atleast one Hypomanic episode.
3. Patient must not have ever shown Manic or Mixed episodes.
4. Mood symptoms of the patient should not be like the symptoms of
schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, psychotic disorder etc.
5. Symptoms must cause clinically significant distress and disturbances in dayto-day functioning.
In this particular disorder, the patient doesnot consider his hypomanic mood
to be a problem, but other individuals are affected by it as the mood
disturbance causes distress to others. When a person is going through his
Major Depressive episode, he is not able to recall his behavior during a
hypomanic episode. However, if he is made to recall that behavior, he does
show some kind of recognition of the symptoms.
CYCLOTHYMIC DISORDER
According to DSM-IV-TR 2000, cyclothymic disorder is characterised by
atleast two years of numerous periods of hypomanic symptoms that donot
meet the criteria for a Manic episode, and numerous periods of depressive
symptoms that donot meet the criteria for a Major Depressive disorder.
CRITERIA FOR CYCLOTHYMIC DISORDER
1. Individual must show, atleast for two years, the disturbances regarding
mood and the mood should be either hypomanic or a mild depressive
mood. For children, this duration is 1 year.
2. There should be a symptom-free interval for more than two months.
3. During this time, the individual should not show any of the Major
Depressive episode, Manic episode or Mixed episode.
4. Symptoms should not match the symptoms of other disorders, such as
schizoaffective disorder, schizophrenia, schizophreniform , delusional
disorder etc.
5. Symptoms should not be due to any general medical condition or the
physiological effect of any substance.
6. Individual must show clinically significant distress and impairment in
various areas of functioning.
BIPOLAR SPECTRUM
M : Mania ; m : hypomania ; N : Normal mood variation ; d : Mild depression ;
D : Major depression
M
m
N
d
D
NORMAL MOOD
CYCLOTHYMIC
DISORDER
BIPOLAR – II
DISORDER
BIPOLAR – I
DISORDER
ETIOLOGY OF BIPOLAR – II DISORDER
1.HEREDITY PREDISPOSITION
Heredity predisposition for Bipolar-II disorder is even more than unipolar
disorder. As far as studies related to identical twins and fraternal twins are
concerned, the concordance rate is far more for identical twins (72%) than
for fraternal twins (14%).
Same has been found to be true for adopted children.
2. BIOCHEMICAL FACTORS
Abnormalities in neurotransmitters is one of the major factor causing bipolar
disorders. It includes abnormalities in the following neurotransmitters :
(i) Norepinephrine
(ii) Serotonin
(iii) Dopamine
3. CONSTITUTIONAL FACTORS
Studies related to constitutional factors are quite old and have also been
criticized a lot. But they still deserve a mention.
According to Kretschmer, 1936, the individuals who are Pyknic type, are
more prone to manic depressive disorders.
According to Sheldon, Individuals who belong to endomorphic category,
have more probability for mood disturbances.
4. NEUROPHYSIOLOGICAL FACTORS
According to Flor & Henry et al.,1983, “ The psychosis and mod disorders are
the two ends of a continuum.” The individuals who have disturbances in their
left hemisphere of cerebrum, suffer from psychosis and those who have
disturbances in their right hemisphere of cerebrum show Bipolar disorders.
>> ENDOCRINE GLANDS : Secretions of various glands play an
important role in mood disturbances.
Important sequences are as follows :
1. HYPOTHALAMIC – PITUTARY – ADRENAL AXIS
2. HYPOTHALAMIC – PITUTARY – THYROID AXIS
3. HYPOTHALAMIC – PITUTARY – ADRENOCORTICAL AXIS
OTHER BIOLOGICAL FACTORS
1. Abnormal sleep rhythms play an important role in both – Unipolar and
Bipolar disorders. In bipolar disorders, the biological rhythms regarding
sleep are disturbed and the person experiences less need for sleep. This,
inturn, further causes abnormalities in the rhythms, resulting in Bipolar
disorders (Goodwin & Jamison, 1990; Whybrow, 1997)
2. ABNORMAL BRAIN GLUCOSE METABOLIC RATES
With the modern technology of Positron Emission Tomography (PET), its’
possible to visualize the variations in brain glucose metabolism rate during
depressed and manic states. According to Whybrow, 1997, the blood flow to
the left hemisphere and prefrontal cortex is reduced during depression;
whereas, during mania, this blood flow is reduced in the right frontal and the
temporal region. During normal mood, blood flow across the two brains
hemispheres is approximately equal.
II. PSYCHOSOCIAL FACTORS
1. PSYCHODYNAMIC VIEWPOINT : According to this view, manic and
depressive disorders may be viewed as two different but related defense
oriented strategies for dealing with severe stress. Manic patients try to
escape their problems by a ‘flight into reality’. They try to avoid the pain of
their inner lives through outer world distractions. Such people may involve
themselves in countless number of activities, but not necessarily with true
enjoyment. They try to deny the feelings of helplessness and hopelessness
and play their role with competency. Once a person adopts this mode of
coping with life’s problems, it is maintained until the person has spent all of
his energy and is emotionally exhausted. The shift from mania to depression
tends to occur when the defensive function the manic reaction breaks down.
Similarly, a shift from depression to mania tends to occur when an individual
devaluates himself and feels guilt-ridden by inactivity and an inability to cope.
Such a person feels compelled to attempt some counter measure, no matter
how much desperate that may be.
> Psychoanalysts have also pointed out that people who have weak
superego and those who have a self-punishing superego suffer from
mood disturbances.
OTHER PSYCHOSOCIAL FACTORS
1. STRESSFUL LIFE EVENTS
> Studies have found a significant association between the occurrence of
high levels of stress and the experience of manic, hypomanic or depressive
episodes.
> One of the studies found that patients with more prior episodes were likely
to have more episodes after the occurrence of major stressors, than the
patients with fewer prior episodes. (Hammen & Gitbin, 1997 )
> Patients who experienced negative events took, on an average, three times
longer to recover from an episode, than those without negative events
(Johnson & Miller,1997). This is because stressful events seem to disturb
the critical, biological rhythms, which play an important role in mood
disturbances.
2. PERSONALITY CHARACTERISTICS
Personality and cognitive variables may interact with stress and determine the
likelihood of relapse. For e.g. highly introverted and obssessional individuals
are more responsive to stress and mood disturbances; individuals with a
pessimistic attribution style and who also face negative life events show an
increase in depressive symptoms.
3. FAMILY
> If a person has lost one or both the parents before the age of five, or if one
has lost his father between the age of 10-14 years, then that person is
predisposed for depression.
> Feelings of inferiority in the family, an antisocial model in the family, and
excessive parental demands, also predispose a person towards mood
disturbances.
III. SOCIOCULTURAL FACTORS
In one of the earlier studies by Carothers ( 1947, 1951, 1959 ), he found
manic disorder to be fairly common among East Africans but depressive
disorder was rare. Incidence rate found in the U.S. was opposite to this
trend. The reason for this was that in Africa, individuals were not held
responsible for their failures and misfortunes. However, much has
changed in Africa since Carothers made these observations. Recent data
suggests that as the societies take on the ways of western culture, they
become more prone to developing Western style mood disorder
(Marsella, 1980)
> Mood disorders are found to be more in urban than rural areas; and more
in high than the low socio-economic class.
TREATMENT FOR BIPOLAR DISORDERS
1. BIOLOGICAL TREATMENT
> DRUG THERAPY
* Trycyclic drugs
* Second-generation drugs
* Third generation drugs
* Monoamine oxidase inhibitors (MAOs)
* Lithium Therapy : It focusses on the two phases of the mood – i.e. it acts
as a mood stabilizer and it has both -- anti-manic and
anti-depressive effects. But this therapy has many sideeffects and should be given when the patient has been
hospitalised.
* Antipsychotic drugs : These drugs are able to control the symptoms quickly
and cause less dysphoria ( uneasiness feeling ) than
the Lithium therapy.
> ECT / EST
> HYPNOSIS
> PSYCHOANALYSIS
> INTERPERSONAL THERAPY
> FAMILY THERAPY
> COUPLE THERAPY
> OCCUPATIONAL THERAPY