Mood Disorders PDF

Mood disorders  An Overview of Depression and Mania The most commonly diagnosed and most severe depression is called a major depressive episode. extremely depressed mood state that lasts at least 2 weeks includes cognitive symptoms (such as feelings of worthlessness and indec...

Mood disorders  An Overview of Depression and Mania The most commonly diagnosed and most severe depression is called a major depressive episode. extremely depressed mood state that lasts at least 2 weeks includes cognitive symptoms (such as feelings of worthlessness and indecisiveness) disturbed physical functions (such as altered sleeping patterns, signi cant changes in appetite and weight, or a notable loss of energy) to the point that even the slightest activity or movement requires an overwhelming e ort. general loss of interest in things and an inability to experience any pleasure from life, including interactions with family or friends or accomplishments at work or at school. Although all symptoms are important, evidence suggests that the most central indicators of a full major depressive episode are the physical changes (sometimes called somatic or vegetative symptoms), along with the behavioral and emotional “shutdown,” as re ected by low scores on behavioral activation scales Anhedonia (loss of energy and inability to engage in pleasurable activities or have any “fun”) - re ects that these episodes represent a state of low positive a ect and not just high negative a ect The duration of a major depressive episode, if untreated, is approximately 4 to 9 months ff fl fi ff fl ff  An Overview of Depression and Mania The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or euphoria. In mania, individuals nd extreme pleasure in every activity; They become extraordinarily active (hyperactive), require little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. DSM-5 highlights this feature by adding “persistently increased goal-directed activity or energy” Speech is typically rapid and may become incoherent, because the individual is attempting to express so many exciting ideas at once; this feature is typically referred to as ight of ideas. DSM-5 criteria for a manic episode require a duration of only 1 week, less if the episode is severe enough to require hospitalization. Hospitalization could occur, for example, if the individual was engaging in a self-destructive buying spree, charging thousands of dollars in the expectation of making a million dollars the next day. Irritability is often part of a manic episode, usually near the end. The duration of an untreated manic episode is typically 3 to 4 months DSM-5 also de nes a hypomanic episode, a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and need last only 4 days rather than a full week. fi fi fl  The Structure of Mood Disorders Individuals who experience either depression or mania are said to su er from a unipolar mood disorder, because their mood remains at one “pole” of the usual depression-mania continuum. Mania by itself (unipolar mania) does occur but seems to be rare, because most people with a unipolar mood disorder eventually develop depression. On the other hand, manic episodes alone may be somewhat more frequent in adolescents Someone who alternates between depression and mania is said to have a bipolar mood disorder traveling from one “pole” of the depression-elation continuum to the other and back again. An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time; or be depressed with a few symptoms of mania. This episode is characterized as having “mixed features” Research suggests that manic episodes are characterized by dysphoric (anxious or depressive) features more commonly than was thought, and dysphoria can be severe. In one study, 30% of 1,090 patients hospitalized for acute mania had mixed episodes (Hantouche et al., 2006). In another carefully constructed study of more than 4,000 patients, as many as two-thirds of patients with bipolar depressed episodes also had manic symptoms, most often racing thoughts ( ight of ideas), distractibility, and agitation. In DSM-5 the term “mixed features” requires specifying whether a predominantly manic or predominantly depressive episode is present, and then noting if enough symptoms of the opposite polarity are present to meet the mixed features criteria. ff fl  Depressive Disorders-Clinical Descriptions Major depressive disorder - de ned by the absence of manic, or hypomanic episodes before or during the disorder. An occurrence of just one isolated depressive episode in a lifetime is now known to be relatively rare If two or more major depressive episodes occurred and were separated by at least 2 months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Recurrence is important in predicting the future course of the disorder, as well as in choosing appropriate treatments. Unipolar depression is often a chronic condition that waxes and wanes over time but seldom disappears The median lifetime number of major depressive episodes is 4 to 7 The median duration of recurrent major depressive episodes is 4 to 5 months, somewhat shorter than the average length of the rst episode. fi fi  Depressive Disorders-Clinical Descriptions Persistent depressive disorder (dysthymia) shares many of the symptoms of major depressive disorder but di ers in its course. There may be fewer symptoms but depression remains relatively unchanged over long periods, sometimes 20 or 30 years or more Persistent depressive disorder (dysthymia) is de ned as depressed mood that continues at least 2 years, during which the patient cannot be symptom free for more than 2 months at a time even though they may not experience all of the symptoms of a major depressive episode. This disorder di ers from a major depressive disorder in the number of symptoms required, but mostly in the chronicity. ff ff fi  Depressive Disorders-Clinical Descriptions 22% of people su ering from persistent depression with fewer symptoms (called dysthymia) eventually experienced a major depressive episode. These individuals who su er from both major depressive episodes and persistent depression with fewer symptoms are said to have double depression. Typically, a few depressive symptoms develop rst, perhaps at an early age, and then one or more major depressive episodes occur later only to revert to the underlying pattern of depression once the major depressive episode has run its course Persistent depressive disorder is further speci ed depending on whether a major depressive episode is part of the picture or not. Thus, one might meet criteria for the disorder “with pure dysthymic syndrome,” meaning one has not met criteria for a major depressive episode in at least the preceding two years, “with persistent major depressive episode,” indicating the presence of a major depressive episode over at least a two-year period, or “with intermittent major depressive episodes,” which is double depression. fi ff ff fi  Additional De ining Criteria for Depressive Disorders 1. Psychotic features speci ers. Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms, speci cally hallucinations (seeing or hearing things that aren’t there) and delusions (strongly held but inaccurate beliefs) Patients may also have somatic (physical) delusions, believing, for example, that their bodies are rotting internally and deteriorating into nothingness. Some may hear voices telling them how evil and sinful they are (auditory hallucinations). Such hallucinations and delusions are called mood congruent, because they seem directly related to the depression. On rare occasions, depressed individuals might have other types of hallucinations or delusions such as delusions of grandeur (believing, for example, they are supernatural or supremely gifted) that do not seem consistent with the depressed mood. This is a mood-incongruent hallucination or delusion. Although quite rare, this condition signi es a serious type of depressive episode that may progress to schizophrenia Psychotic features in general are associated with a poor response to treatment, greater impairment, and fewer weeks with minimal symptoms, compared with nonpsychotic depressed patients over a 10-year period fi fi f fi  Additional De ining Criteria for Depressive Disorders 2. Anxious distress speci er. The presence and severity of accompanying anxiety, whether in the form of comorbid anxiety disorders or anxiety symptoms that do not meet all the criteria for disorders For all depressive and bipolar disorders, the presence of anxiety indicates a more severe condition, makes suicidal thoughts and completed suicide more likely, and predicts a poorer outcome from treatment. 3. Mixed features speci er. Predominantly depressive episodes that have several (at least three) symptoms of mania would meet this speci er, which applies to major depressive episodes both within major depressive disorder and persistent depressive disorder. 4. Melancholic features speci er. Melancholic speci ers include some of the more severe somatic (physical) symptoms, such as early-morning awakenings, weight loss, loss of libido (sex drive), excessive or inappropriate guilt, and anhedonia (diminished interest or pleasure in activities). fi fi fi fi f fi Additional De ining Criteria for Depressive Disorders 5. Catatonic features speci er. This serious condition involves an absence of movement (a stuporous state) or catalepsy, in which the muscles are waxy and semirigid, so a patient’s arms or legs remain in any position in which they are placed. Catatonic symptoms may also involve excessive but random or purposeless movement. In recent theorizing, this response may be a common “end state” reaction to feelings of imminent doom and is found in many animals about to be attacked by a predator 6. Atypical features speci er. While most people with depression sleep less and lose their appetite, individuals with this speci er consistently oversleep and overeat during their depression and therefore gain weight, leading to a higher incidence of diabetes Although they also have considerable anxiety, they can react with interest or pleasure to some things, unlike most depressed individuals. greater percentage of women and an earlier age of onset. The atypical group also has more symptoms, more severe symptoms, more suicide attempts, and higher rate of comorbid disorders including alcohol abuse fi fi f fi Additional De ining Criteria for Depressive Disorders 7. Peripartum onset speci er. Peri means “surrounding”, in this case the period of time just before and just after the birth. This speci er can apply to both major depressive and manic episodes. Between 13% and 19% of all women giving birth (one in eight) meet criteria for a diagnosis of depression, referred to as peripartum depression. In one study 7.2% met criteria for a full major depressive episode (Gavin et al., 2005). Typically a somewhat higher incidence of depression is found postpartum (after the birth) than during the period of pregnancy itself (Viguera et al., 2011). In another recent important study, 14% of 10,000 women who gave birth screened positively for depression and fully 19.3% of those depressed new mothers had serious thoughts of harming themselves (Wisner et al., 2013). During the peripartum period (pregnancy and the 6 month period immediately following childbirth), early recognition of possible psychotic depressive (or manic) episodes is important, because in a few tragic cases a mother in the midst of an episode has killed her newborn child Fathers don’t entirely escape the emotional consequences of birth. Ramchandani and colleagues (2005) followed 11,833 mothers and 8,431 fathers for 8 weeks after the birth of their child. Of the mothers, 10% showed a marked increase in depressive symptoms on a rating scale, but so did 4% of the fathers. And depression in fathers was associated with adverse emotional and behavioral outcomes in children 3.5 years later fi f fi Additional De ining Criteria for Depressive Disorders 7. Peripartum onset speci er. More minor reactions in adjustment to childbirth— called the “baby blues”—typically last a few days and occur in 40% to 80% of women between 1 and 5 days after delivery. During this period, new mothers may be tearful and have some temporary mood swings, but these are normal responses to the stresses of childbirth and disappear quickly; the peripartum onset speci er does not apply to them However, in peripartum depression, most people, including the new mother herself, have di culty understanding why she is depressed, because they assume this is a joyous time. Many people forget that extreme stress can be brought on by physical exhaustion, new schedules, adjusting to nursing, and other changes that follow the birth. There is also some evidence that women with a history of peripartum depression meeting full criteria for an episode of major depression may be a ected di erently by the rapid decline in reproductive hormones that occurs after delivery or may have elevated corticotrophin-releasing hormone in the placenta and that these factors may contribute to peripartum depression. But these ndings need replication because all women experience very substantial shifts in hormone levels after delivery, but only a few develop a depressive disorder. Nor is there strong evidence that hormonal levels are signi cantly di erent in peripartum depressed and nondepressed women fi ff fi ff f fi ffi fi ff Additional De ining Criteria for Depressive Disorders 8. Seasonal pattern speci er. It accompanies episodes that occur during certain seasons (for example, winter depression). The most usual pattern is a depressive episode that begins in the late fall and ends with the beginning of spring. (In bipolar disorder, individuals may become depressed during the winter and manic during the summer.) These episodes must have occurred for at least two years with no evidence of non- seasonal major depressive episodes occurring during that period of time. This condition is called seasonal a ective disorder (SAD). Unlike more severe melancholic types of depression, people with winter depressions tend toward excessive sleep (rather than decreased sleep) and increased appetite and weight gain (rather than decreased appetite and weight loss), symptoms shared with atypical depressive episodes Emerging evidence suggests that SAD may be related to daily and seasonal changes in the production of melatonin, a hormone secreted by the pineal gland. Because exposure to light suppresses melatonin production, it is produced only at night. Melatonin production also tends to increase in winter, when there is less sunlight. One theory is that increased production of melatonin might trigger depression in vulnerable people Another possibility is that circadian rhythms, which occur in approximately 24-hour periods, or cycles, and are thought to have some relationship to mood, are delayed in winter fi f ff Additional De ining Criteria for Depressive Disorders 8. Seasonal pattern speci er. Cognitive and behavioral factors are also associated with SAD Women with SAD, compared with well-matched nondepressed women, reported more autonomous negative thoughts throughout the year and greater emotional reactivity to light in the laboratory, with low light associated with lower mood. Severity of worrying, or rumination, in the fall predicted symptom severity in the winter. As you might expect, the prevalence of SAD is higher in extreme northern and southern latitudes because there is less winter sunlight. Some clinicians reasoned that exposure to bright light might slow melatonin production in individuals with SAD. In phototherapy, a current treatment, most patients are exposed to 2 hours of bright light (2,500 lux) immediately on awakening. If the light exposure is e ective, the patient begins to notice a lifting of mood within 3 to 4 days and a remission of winter depression in 1 to 2 weeks. Patients are also asked to avoid bright lights in the evening (from shopping malls and the like), so as not to interfere with the e ects of the morning treatments. But this treatment is not without side e ects. Approximately 19% of patients experience headaches, 7% have eyestrain, and 14% just feel “wired” ff fi f ff ff  From Grief to Depression Sometimes individuals experience very severe symptoms requiring immediate treatment, such as a full major depressive episode, perhaps with psychotic features, suicidal ideation, or severe weight loss and so little energy that the individual cannot function We must confront death and process it emotionally. All religions and cultures have rituals, such as funerals and burial ceremonies, to help us work through our losses with the support and love of our relatives and friends Usually the natural grieving process has peaked within the rst 6 months, although some people grieve for a year or longer The acute grief most of us would feel eventually evolves into what is called integrated grief, in which the nality of death and its consequences are acknowledged and the individual adjusts to the loss. New, bittersweet, but mostly positive memories of the deceased person that are no longer dominating or interfering with functioning are then incorporated into memory Integrated grief often recurs at signi cant anniversaries, such as the birthday of the loved one, holidays, and other meaningful occasions, including the anniversary of the death. This is all a very normal and positive reaction. In fact mental health professionals are concerned when someone does not grieve after a death, because grieving is our natural way of confronting and handling loss. When grief lasts beyond typical time, men- tal health professionals again become concerned After 6 months to a year or so, the chance of recovering from severe grief without treatment is considerably reduced, and for approximately 7% of bereaved individuals), a normal process becomes a disorder (Kersting, Brahler, Glaesmer, & Wagner, 2011; Shear et al., 2011). At this stage, suicidal thoughts increase substantially and focus mostly on joining the beloved deceased (Stroebe, Stroebe, & Abakoumkin, 2005). The ability to imagine events in the future is generally impaired, since it is di cult to think of a future without the deceased (MacCallum & Bryant, 2011; Robinaugh, & McNally, 2013). Individu- als also have di culty regulating their own emotions, which tend to become rigid and in exible (Gupta & Bonanno, 2011). Many of the psychological and social factors related to mood disorders in general, including a history of past depressive epi- sodes, also predict the development of what is called the syn- drome of complicated grief, although this reaction can develop without a preexisting depressed state (Bonanno, Wortman, & Nesse, 2004). ffi fi fi fl fi ffi  From Grief to Depression When grief lasts beyond typical time, mental health professionals again become concerned After 6 months to a year or so, the chance of recovering from severe grief without treatment is considerably reduced, and for approximately 7% of bereaved individuals), a normal process becomes a disorder At this stage, suicidal thoughts increase substantially and focus mostly on joining the beloved deceased. The ability to imagine events in the future is generally impaired, since it is di cult to think of a future without the deceased Individuals also have di culty regulating their own emotions, which tend to become rigid and in exible Many of the psychological and social factors related to mood disorders in general, including a history of past depressive episodes, also predict the development of what is called the syndrome of complicated grief, although this reaction can develop without a preexisting depressed state fl ffi ffi  Normal and Complicated Grief is encouraged to talk about the loved one, the death, and the Common symptoms of acute grief that are within normal meaning of the loss while experiencing all the associated emo- limits within the first 6-12 months after: tions, until that person can come to terms with reality. This Recurrent, strong feelings of yearning, wanting very much would include incorporating positive emotions associated with to be reunited with the person who died; possibly even a memories of the relationship into the intense negative emo- wish to die in order to be with deceased loved one tions connected with the loss, and arriving at the position that it is possible to cope with the pain and life will go on, there- Pangs of deep sadness or remorse, episodes of crying or sobbing, typically interspersed with periods of respite and by achieving a state of integrated grief (Currier et al., 2008). even positive emotions Several studies have demonstrated that this approach is suc- cessful compared to alternative psychological treatments that Steady stream of thoughts or images of deceased, may be also focus on grief and loss (Neimeyer & Currier, 2009); Shear, vivid or even entail hallucinatory experiences of seeing or hearing deceased person Frank, Houck, & Reynolds, 2005). Struggle to accept the reality of the death, wishing to Other Depressive Disorders protest against it; there may be some feelings of bitterness or anger about the death Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder, both depressive disorders, were Somatic distress, e.g. uncontrollable sighing, digestive added to DSM-5. symptoms, loss of appetite, dry mouth, feelings of hollow- ness, sleep disturbance, fatigue, exhaustion or weakness, restlessness, aimless activity, difficulty initiating or Premenstrual Dysphoric Disorder (PMDD) maintaining organized activities, and altered sensorium The history of the development of PMDD over the last several Feeling disconnected from the world or other people, decades as a diagnosis was described in some detail in Chapter indifferent, not interested, or irritable with others 3 (see pp. 96–97). Basically clinicians identified a small group of women, from 2% to 5%, who suffered from severe and sometimes Symptoms of integrated grief that are within normal limits: incapacitating emotional reactions during the premenstrual Sense of having adjusted to the loss period (Epperson et al., 2012). But strong objections to making this condition an official diagnosis were based on concerns that Interest and sense of purpose, ability to function, and women who were experiencing a very normal monthly physio- capacity for joy and satisfaction are restored logical cycle, as part of being female, would now be classified as Feelings of emotional loneliness may persist having a disorder, which would be very stigmatizing. As noted above, the history of this controversy is described in Chapter Feelings of sadness and longing tend to be in the back- 3. It has now been clearly established that this small group of ground but still present women differs in a number of ways from the 20% to 40% of Thoughts and memories of the deceased person accessible women who experience uncomfortable premenstrual symptoms and bittersweet but no longer dominate the mind (PMS) that, nevertheless, are not associated with impairment of functioning. Criteria defining PMDD are presented in DSM-5 Occasional hallucinatory experiences of the deceased may occur Table 7.5. As one can see a combination of physical symptoms, severe mood swings and anxiety are associated with incapaci- Surges of grief in response to calendar days or other tation during this period of time (Hartlage, Freels, Gotman & periodic reminders of the loss may occur Yonkers, 2012). All of the evidence indicates that PMDD is best Complicated grief considered a disorder of mood as opposed to a physical disorder (such as an endocrine disorder), and, as pointed out in Chapter 3, Persistent intense symptoms of acute grief the creation of this diagnostic category should greatly assist the thousands of women suffering from this disorder to receive the The presence of thoughts, feelings, or behaviors reflecting excessive or distracting concerns about the circumstances treatment they need to relieve their suffering and improve their or consequences of the death functioning. Other Depressive Disorders DSM 5 TABLE 7.5 Diagnostic Criteria for Premenstrual Dysphoric Disorder A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. B. One (or more) of the following symptoms must be present: 1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection). 2. Marked irritability or anger or increased interpersonal conflicts 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge. C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies). 2. Subjective difficulty in concentration. 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked change in appetite; overeating; or specific food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating”, or weight gain. Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year. D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. Note: The diagnosis may be made provisionally prior to this confirmation. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism). H. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism). From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.  but during one long ride turned to her father and said “Daddy, DSM please help me feel better because if I keep feeling like this I just 5 TABLE 7.6 Diagnostic Criteria for Disruptive want to die.” Mood Dysregulation Disorder A very important objective for the immediate future will be developing and evaluating treatments for this difficult A. Severe recurrent temper outburst manifested verbally condition both psychological and drug. For example, it is (e.g., verbal rages) and/or behaviorally (e.g., physical very possible that new psychological treatments under devel- aggression toward people or property) that are grossly opment for severe emotional dysregulation in children may be out of proportion in intensity or duration to the situation useful with this condition (Ehrenreich, Goldstein, Wright, & or provocation. Barlow, 2009). B. The temper outbursts are inconsistent with develop- mental level. Bipolar Disorders C. The temper outbursts occur, on average, three or more times per week. The key identifying feature of bipolar disorders is the tendency D. The mood between temper outbursts is persistently of manic episodes to alternate with major depressive episodes irritable or angry most of the day, nearly every day, and in an unending roller-coaster ride from the peaks of elation to is observable by others (e.g., parents, teachers, peers). the depths of despair. Beyond that, bipolar disorders are paral- E. Criteria A-D have been present for 12 or more months. lel in many ways to depressive disorders. For example, a manic Throughout that time, the individual has not had a episode might occur only once or repeatedly. Consider the case period lasting 3 or more consecutive months without all of Jane. of the symptoms in Criteria A-D. F. Criteria A and D are present in at least two of three set- tings (i.e., at home, at school, with peers) and are severe in at least one of these. JANE Funny, Smart, and G. The diagnosis should not be made for the first time Desperate before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. J ane was the wife of a well-known surgeon and the lov- ing mother of three children. The family lived in an old country house on the edge of town with plenty of room for I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except dura- family members and pets. Jane was nearly 50; the older chil- tion, for a manic or hypomanic episode have been met. dren had moved out; the youngest son, 16-year-old Mike, Note: Developmentally appropriate mood elevation, such as was having substantial academic difficulties in school and occurs in the context of a highly positive event or its antici- seemed anxious. Jane brought Mike to the clinic to find out pation, should not be considered as a symptom of mania or why he was having problems. hypomania. As they entered the office, I observed that Jane was well J. The behaviors do not occur exclusively during an episode dressed, neat, vivacious, and personable; she had a bounce of major depressive disorder and are not better explained to her step. She began talking about her wonderful and by another mental disorder (e.g., autism spectrum dis- successful family before she and Mike even reached their order, posttraumatic stress disorder, separation anxiety seats. Mike, by contrast, was quiet and reserved. He seemed disorder, persistent depressive disorder [dysthymia]). resigned and perhaps relieved that he would have to say little K. The symptoms are not attributable to the physiological during the session. By the time Jane sat down, she had men- effects of a substance or to another medical or neuro- tioned the personal virtues and material achievement of her logical condition. husband, and the brilliance and beauty of one of her older children, and she was proceeding to describe the second From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. (Continued next page)