Mood Disorders

• Differ from temporary emotional reactions
• Often occurs for no apparent reason
• Involves extreme reaction not easily explained by what is happening in life
  • Being depressed after loss of family is normal
  • incongruence between complaints and level of function
• Avoid diagnosis MDD in people who just had major event -- usually for no apparent reason someone has MDD.

Diagnosis

• Brief depressive and hypomanic symptoms can occur in individuals without a mood disorder
• Depression occurs both in depressive and bipolar disorders
• Symptoms may vary considerably
• Irritability occurs in both bipolar and depressive disorders
• Time is a big factor in diagnosing depression
  • many hate it because it takes so much time, but it is important to see how it plays out
  • rule out a lot of things
  • Hold off if there is stressor

Symptom Categories

Cognitive

Emotional

Behavioral

Physiological

Depression

• Intense sadness and loss of interest in things found normally enjoy

Cognitive

• Hopelessness, pessimism
• guilt about things they shouldn't feel guilty fore
• rumination
• impaired concentration
• Suicidal Thoughts

Emotional

• Feelings of sadness
• feeling overwhelmed, empty, worthless
• low self-esteem
• what they actual feel
• apathy
• (dont feel anything)
• Feel numb

Behavioral

• Fatigue
  • Sleeping too much or too little
• Social withdrawal, isolation, disconnection previously apart of
• reduced motivation
• crying
• lowered productivity
• poor hygiene

Physiological

• Appetite and weight changes
  • Can go both ways, eating a lot or not enough.
• Sleep disturbance
• unexplained aches and pains
• aversion to sexual activity

Depressive Disorders

Major Depressive Disorder

Persistent Depressive Disorder

Premenstrual Dysphoric Disorder

Diagnosis and classification of depressive disorders

• Ensure patient has never experienced an episode of hypomania or mania
  • Do not have depressive, have bipolar disorder
    Consider severity and chronic nature of symptoms
• come up with appropriate diagnosis

Major Depressive Episodes

• What is it? Impairment in functioning for most of the day, and nearly every day, for 2 weeks or more
  • gotta be all day everyday
• Depressed mood, sadness, or emptiness
• Loss of pleasure in previously enjoyed activities
  • Impacting functioning
• At least four additional changes in functioning:
  • Alteration in weight, atypical sleep patterns, restlessness, low energy, feelings of worthlessness, difficulty concentrating, or suicidal behaviors or thoughts

Major Depressive Disorder (MDD) with a seasonal pattern

• must have had at least one episode
• Also known as seasonal affective disorder
• Some individuals with MDD and bipolar report seasonal pattern to depressive episodes
• Associated with changes in daylight as the seasons change
• Occurs more often in Northern latitudes
  • Rates in Alaska very high cus in winter, very little sunlight
    Symptoms
• Low energy
• Increased sleep
• Social withdrawal
• Carbohydrate craving

Persistent Depressive Disorder (Dysthymia)

• Symptoms are present most of the day for more days than not for a two-year period
• Must have two or more of the following:
  • Feelings of hopelessness
  • Low self-esteem
  • Poor appetite or overeating
  • Low energy or fatigue
  • Difficulty concentrating or making decisions
  • Sleeping too little or too much
• Chronic, low grade depression
• Most prob fall here

Premenstrual Dysphoric Disorder

• Serious symptoms of depression, irritability, and tension appearing the week before menstruation and remit soon after the onset of menses
• Controversial
  At least five symptoms must be present:
• Significant depressed mood or mood swings
• Anger/irritability
• Anxiety/tension
• Difficulty concentrating
• Social withdrawal
• Food cravings
• Insomnia or excessive sleeping
• Feeling overwhelmed
• Lack of energy

Depressive Reactions to Grief

Normal related reactions

• Important to distinguish from MDD
• Grief often involves feelings of emptiness associated with the loss
• May last for several years
• Frequency and intensity diminishes over time

Persistent Complex Bereavement Disorder

• Condition undergoing study as a diagnostic category in the DSM-5
• Must have a significant effect on the person’s interpersonal relationships or sense of identity
• Need to carefully consider cultural, religious, and age-appropriate norms
  • Someones reaction should very across lifespan

Prevalence of Depressive Disorders

• One of the disorders most common psychiatric
  • Second in world
• Women at significantly greater risk
• Depressive external stressors symptoms are also subject to
• Chronic disorder for many people
• About 15 percent fail to show significant symptom reduction when treated for depressive disorders
  • Hypothesized to be undiagnosed bipolar disorder
• 20% have at least one depressive episode in the life span
• 10% in 12 month period
• only around 1% for bipolar disorders
• 0.6-0.85 in 12 month

Etiology of Depressive Disorders; Bio Dimension

Neurotransmitters and depressive disorders

• Low levels of neurotransmitters
• Norepinephrine, serotonin, and dopamine
• Treatment-resistant depression

Depression tends to run in families

• Same types of depressive disorder
• genetic influence becomes most evident after puberty

Genes interact with environmental factors to produce depression

Short allele of the serotonin transporter gene

Cortisol, Stress, and Depression

Increased production of cortisol in formative years of brain make it diff for regulating stress later in life

• changes brain structure, eating away at important years
• high exposure to stress as kid, raised in poverty or violence, can struggle to cope with stress
• Dysregulation and overactivity of the hypothalamic-pituitary- adrenal (HPA) axis
• Overproduction of stress-related hormones appear to play an important role in depression

Circadian Rhythm Disturbances in Depression

Play a role in depression, particularly seasonal depression

• Sleep disturbances, including irregularities in REM sleep, strongly linked to depression
• Insomnia doubles the risk of developing depression
• Sleeping for more than 10 hours per night also increases risk
• Irregularities in rapid eye movement

Psychological Dimension of Depression

Behavioral explanations

• Depression occurs when people receive insufficient social reinforcement
• Lack of relationships, support, outlets outside of selfs
  Variables that enhance or hinder positive reinforcement
• Participating in few potentially reinforcing activities
• Few reinforcements available in the environment
  • Living paycheck to paycheck, each month decide which bills not pay to eat
  • very few reinforcements in environment
• The individual’s social skills and behavior

Cognitive Explanations in Depression

• what cbt looks at
• Depression is a disturbance in thinking rather than a disturbance in mood
  • Negative self-schema
    • Pessimism
    • Damaging self-views
    • Feelings of helplessness
      • CBT feels hard for those w/ depress
• Co-rumination
  • Constantly talking of problems or negative experiences with others
  • Increases depression risk, especially in girls

Social Dimension

• Maltreatment with later depression during early childhood is strongly associated
• Parental depression influences intergenerational transmission of depression
  • Pessimistic view of world
• Failure to develop secure attachments and trusting relationships early in life
• Stressful interpersonal events increase risk of depression
• Social rejection

Sociocultural Dimension

• Sociocultural factors found to be associated with depression include culture, race and ethnicity, sexual orientation, and gender
• Individuals experiencing the lack of security and self-sufficiency associated with poverty often find it difficult to escape the “cycle of poverty.”
• Discouragement over the systemic stressors associated with chronic poverty can lead to depression

treatment for depression - Biomedical

• Tricyclics, monoamine oxidase inhibitors, and serotonin norepinephrine reuptake inhibitors
  • SSRIs or SNRIs
• One-third to one half discontinue the use of the meds due to side effects
  • Lack of sex drive (if any at all)
    • Maybe not capable of orgasm
  • Weight gain
  • impact sleep
  • GI issues
• Publication bias in research and methodological design flaws involving antidepressant medication is a significant concern
• Adjunctive treatments are commonly used to supplement antidepressant use
• Omega-3 fatty depressive symptoms acid supplements have been found to reduce
  • Been talked about a littlebit, not yet treatment for clinical
• Therapy + Drugs is best treatment
• many stop drugs cus they take 6 weeks to work, people impatient

Nontraditional Treatments for Depression

• Some treatments for depression involve efforts to reset the circadian clock
• Use of specially designed lights is an effective and well-tolerated treatment for those with MDD with a Seasonal Pattern
• The use of probiotics to treat depression has also gained attention in recent years

Brain Stimulaiton Therapies

Types

• Electroconvulsive therapy (ECT)
  • can be helpul
• Vagus nerve stimulation
• Transcranial magnetic stimulation

Used for severe or chronic depression

• Specifically for depression not responding to more traditional treatments
• constant trying to die
• lots of si
• last result
• multiple sessions
• inducing brain to have siezures
• side effects: memory loss
  • dont know long term effectd

Psychological and Behaviorial treatments

Behavioral activation therapy

• Focus on increasing exposure to and social interactions
• Steps
• Identifying and rating activities in terms of pleasure and self-confidence
• Performing some of the selected activities
• Identifying day-to-day problems and using behavior techniques to solve
• Improving social and assertiveness skills

interpersonal psychotherapy

• Improving Communinication
• Identifying role conflicts
• increasing social skills

CBT

• Altering negative thought patterns associated with depression
  • Identify negative, self-critical thinking
  • Examine the connection between negative thoughts and negative feelings
  • Learn to replace inaccurate beliefs with realistic interpretations
• Individuals treated with CBT less likely to relapse than those treated with antidepressants
  • Need to fix thoughts, drugs dont fix those
  • thoughts arent helpful, without addressing them, depress will stay
• Computerized skill-building and cognitive retraining sessions has broadened the reach of CBT skills

Mindfulness-based Cognitive Therapy (MBCT)

• Calm awareness of one’s present experience, thoughts, and feelings
• Attitude of acceptance instead of judgmental, evaluative, or ruminative
• Disrupt the cycle of negative thinking by focusing on present
• Positive emotions and focus on appreciation of pleasant daily activities appear to have a protective effect
• Use of a web-based MBCT app in a group of adults with residual depressive symptoms was found to be effective
• Acceptance and commitment therapy (ACT)

Bipolar Disorders

• Involve episodes of hypomania and/or mania
• Very strong genetic component
• People with bipolar disorders respond to medications that have little effect with depressive disorders
  • those with depress wont respond to mood stabalizer
• Peak age of onset is teens and early twenties
  • Not considering substance use
  • meth everyday in 30s could develop bipolar
• Bipolar disorders occur much less frequently than depressive disorders

Hypomania/Mania

Cognitive

• Disorientation (time of day, where at)
  • Not nessesarly psychotic, but could be
• Racing thoughts
  • bouncing around between diff topics in difficult way to follow
• Flight of ideas
  • similar
• Decreased focus and attention
  • often report feeling creative
  • demonstrate poor judgement
  • saying or doing not socially appropriate things
    • also not consistent with usual behavior
    • Unaware of the inappropriateness

Emotional

• Elevated mood (Angry, Aggressive, Euphoric)
  • Hard to get them to take meds cus they feel up
• Extreme Confidence (grandiosity)
  • feeling responsible for great things (not accurate prob)
  • Not quite delusional, butthere
• Emotional mobility
  • gets confused with Multi personality disorder
  • Still at same high level, but shifts exact emotions (Euphoric to Angry)
  • Similar to like being on crack cocaine and meth
  • Stimulants replicate mania

Behavioral

• Overactivity (on the go, very energized n goal directed)
  • take on bunch of projects (all of the sudden)
• Rapid or incoherent speech
• impulsitivity, risky behavior
• cant delay gratification

Physiological

• Decreased sleep
  • several days w/o sleep but not tired
• react to everything
• increased sex drive
• weight loss
  • do a ton while not eating

Diagnosis and Classification of Bipolar Disorder

Bipolar I

• At least one weeklong manic episode
• Mixed features or depressive episodes are common, but not required, for diagnosis
• Possible psychotic features

Bipolar II

• At least one major depressive episode
• At least one hypomanic episode
• No history of mania

Cyclothymic Disorder

• Periods involving milder hypo-disorder manic symptoms alternating with milder depression for at least 2 years (with no more than 2 months symptom-free)^a
• Symptoms have never met the criteria for a hypomanic, manic, or major depressive episode

Manic vs Hypomanic Episode

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood AND persistently increased goal-directed activity or energy (present every day, most of day)
• Manic episodes: for a week and three symptoms unless irritable mood, than 4
• Hypomania: 4 consecutive days with three symptoms unless irritable mood, than 4
• During mood disturbance:
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in activities that have high potential for painful consequences

Examples

– https://www.youtube.com/watch?v=RNjo0ejSH8A
- Kanye west has bipolar disorder
- thoughts were just changing
- he was very up in mood
– https://www.youtube.com/watch?v=egGUqv8LTkw
– https://www.youtube.com/watch?v=tJeEVVYV8xE

Features and Conditions Associated with Bipolar Disorder

• Mixed features
  • Three or more symptoms of hypomania/mania or depression occurring during an episode from the opposite pole
• Rapid cycling
  • Four or more mood episodes per year
  • Increases chances that disorder will be chronic and symptoms more severe
  • bad indication: means its gonna be severe condition
• Anxiety and substance-use disorders commonly co- occur with bipolar disorder
• Suicide risk for people living with bipolar disorders is up to 20 times greater than found in the general population
  • energy to act on suicidal ideation

Etiology of Bipolar Disorders: Biological

• Complex genetic basis involving interactions among multiple genes
  • Including several genes influenced by lithium
  • Genes influencing circadian cycle
• Neurological abnormalities
  • Brain dysregulation after reaching a goal, or in response to obstructed goals
  • Mania can develop due to overly ambitious pursuit of goals and the brain dysregulation
• Individuals with bipolar disorders have functional and anatomical brain irregularities

Psychological Influences

• Individuals with bipolar disorder tend to cope with stress by disengagement and tend to have limited adaptive coping or problem-solving skills
• Personality trait of impulsivity is also strongly associated with bipolar disorder
• Inability to inhibit irrelevant information when trying to achieve a goal
• Difficulty in holding and manipulating information in the mind
• Problems in psychological flexibility in response to feedback
  • More cognitive rigidity
  • More psych flexible, the more healthy u r
• Use maladaptive forms of emotional regulation
• Prone to ruminating about events that occur just prior to or during depressive and hypomanic/manic episodes

Social and Sociocultural Influences

• Stressors during critical periods of brain development may lead to alterations in neurological functioning that increase vulnerability
• Loss of social support or strained social relationships can trigger the onset of either hypomanic/manic or depressive symptoms
• Women are more likely to experience depressive episodes, severe mood symptoms, and sleep difficulties
  • higher of mixed mania, comorbid eating, other shit
• Men are more likely to experience episodes of mania
  • comorbid substance disorder more likely

Psychosocial treatments for Bipolar Disorder

Family-focused therapy

• Educating families reduces risk of relapse and hospitalization
  Therapists teach clients to
• Avoid stress and overly ambitious goal setting
• Practice emotional regulation techniques
• Identify signs of an impending mood episode
• Understand the dangers of substance use and abuse
  Interventions focused on regulating sleep patterns
  Mindfulness interventions