Lecture 4 -2 Bipolar Disorders and suicide

Bipolar disorder Symptoms

Unlike those experiencing depression, people in a state of mania typically experience dramatic and inappropriate rises in mood

Emotional symptoms in bipolar disorder

Heightened, expansive, or irritable mood

Motivational symptoms in bipolar disorder

Increased energy or "feeling on top of the world"

Behavioral symptoms in bipolar disorder

Disinhibition, increased speech and movement

Cognitive symptoms in bipolar disorder

Racing thoughts, grandiosity, distractibility

Physical symptoms in bipolar disorder

Decreased need for sleep

Diagnosing bipolar disorders

• Two kinds of bipolar disorder (DSM-5)

  • Bipolar I disorder

  • Bipolar II disorder

• Worldwide, 1 to 2.6 percent of all adults have bipolar disorder at any given time: 4 percent have it at some point in life

• No gender differences, but higher rates in low-income populations

Manic episode

For 1 week or more, person displays a continually abnormal, inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day

Person also experiences at least three of the following symptoms for Manic episode

• Grandiosity or overblown self-esteem

• Reduced sleep need

• Rapidly shifting ideas or the sense that one’s thoughts are moving very fast

• Attention pulled in many directions

• Heightened activity or agitated movements

• Excessive pursuit of risky and potentially problematic activities

Bipolar I disorder

• Occurrence of a manic episode

• Hypomanic or major depressive episodes may precede or follow the manic episode

Bipolar II disorder

• Presence or history of major depressive episode(s)

• Presence or history of hypomanic episode(s)

• No history of a manic episode

Cyclothymic disorder (DSM-5)

• Numerous periods of hypomanic symptoms and mild depression symptoms

• Symptoms continue for two or more years, with normal moods for days or weeks in between

• No gender differences

• May evolve into bipolar I or bipolar II

What Causes Bipolar Disorders?

• Throughout the first half of the twentieth century, the search for the cause of bipolar disorders made little progress.

• More recently, biological research has produced some promising clues

  • These insights have come from research into neurotransmitter activity, ion activity, brain structure, and genetic factors

Biological research and perspectives - Neurotransmitter activity

Mania may be related to high norepinephrine activity along with a low level of serotonin activity (“permissive theory”)

Biological research and perspectives - Ion activity

Improper transport of ions back and forth between the outside and the inside of a neuron’s membrane

Biological research and perspectives -Brain structure

• Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorder —in particular, the basal ganglia and cerebellum

• Not clear what role such structural abnormalities play

Genetic factors

• Many theorists believe that people inherit a biological predisposition to develop bipolar disorders

• Family pedigree studies

• Molecular biology techniques

Treatments for Bipolar Disorders

• Before 1970, treatments for people with bipolar disorders were largely ineffective

• In 1970, FDA approved the use of lithium

• Mood-stabilizing (antibipolar) drugs were later developed

Lithium

• Very effective in treating bipolar disorders and mania

• Determining the correct dosage for a given patient is a delicate process

  • Too low = no effect

  • Too high = lithium intoxication (poisoning)

Other mood stabilizers

Some patients respond better to other drugs or to combinations of drugs

Effectiveness of lithium and other mood stabilizers

• More than 60 percent of patients with mania improve on these medications

• Most individuals experience fewer new episodes while on the drugs

• These drugs may help prevent symptoms from developing

• Mood stabilizers also help those with bipolar disorder overcome their depressive episodes, albeit to a lesser degree

Adjunctive psychotherapy

• Psychotherapy or mood stabilizing alone is rarely helpful for persons with bipolar disorder

• Individual, group, or family therapy is often used as an adjunct to lithium (or other medication-based) therapy

• Adjunctive therapy improves a variety of client behaviors, especially in those persons with a cyclothymic disorder

Unipolar depression factors

• Biological abnormalities

• Positive reinforcement reduction • Negative thinking

• Perception of helplessness

• Life stress

• Sociocultural influences

Bipolar depression factors

• Biological abnormalities

• Inherited

• Stress triggered

What are

1. the one-year prevalence

2. female-to-male ratio

3. typical age at onset

4. prevalence among first-degree relatives

5. percentage receiving treatment for Major Depressive Disorder?

• Prevalence: 8.0%

• Female-to-Male Ratio: 2:1

• Typical Age at Onset: 18−29 years

• Prevalence Among First-Degree Relatives: Elevated

• Percentage Receiving Treatment: 50%

What are

1. the one-year prevalence

2. female-to-male ratio

3. typical age at onset

4. prevalence among first-degree relatives

5. percentage receiving treatment for Persistent Depressive Disorder (with dysthymic syndrome)?

• Prevalence: 1.5−5.0%

• Female-to-Male Ratio: Between 3:2 and 2:1

• Typical Age at Onset: 10−25 years

• Prevalence Among First-Degree Relatives: Elevated,

• Percentage Receiving Treatment: 62%

What are

1. the one-year prevalence

2. female-to-male ratio

3. typical age at onset

4. prevalence among first-degree relatives

5. percentage receiving treatment for Bipolar I Disorder?

• Prevalence: 1.6%

• Female-to-Male Ratio: 1:1

• Typical Age at Onset: 15−44 years

• Prevalence Among First-Degree Relatives: Elevated

• Percentage Receiving Treatment: 49%

What are

1. the one-year prevalence

2. female-to-male ratio

3. typical age at onset

4. prevalence among first-degree relatives

5. percentage receiving treatment for Bipolar II Disorder?

• Prevalence: 1.0%

• Female-to-Male Ratio: 1:1

• Typical Age at Onset: 15−44 years

• Prevalence Among First-Degree Relatives: Elevated

• Percentage Receiving Treatment: 49%

What are

1. the one-year prevalence

2. female-to-male ratio

3. typical age at onset

4. prevalence among first-degree relatives

5. percentage receiving treatment for Cyclothymic Disorder?

• Prevalence: 0.4%

• Female-to-Male Ratio: 1:1

• Typical Age at Onset: 15−25 years

• Prevalence Among First-Degree Relatives: Elevated

• Percentage Receiving Treatment: Unknown

Suicide

• Suicide is one of the leading causes of death in the world

  • Approximately 1 million people die by suicide each year worldwide, including more than 42,000 in the United States

• Classification

  • Not officially classified as a mental disorder in DSM-5

  • Suicidal behavior disorder has been proposed for the next revision

Definition of Suicide

Self-inflicted death in which one makes intentional, direct, and conscious effort to end one’s life

Intentional death

• Death seeker

• Death initiator

• Death ignorer

• Death darer

Non-suicidal self-injury

• The deliberate, self-directed damage to body tissue without suicidal intent and for purposes not socially or culturally sanctioned.

• Increases capability for suicide, which increases the risk later in life

Suicide rates vary

• Country to country

• Gender and marital status

• Race and ethnicity

• Social environment

• Religious devoutness (not exclusively affiliation)

• Underreporting may exist

Common triggers

• Stressful events

• Mood and thought changes

• Alcohol and other drug use

• Mental disorders

• Modeling

Stressful events and situations for suicide = Immediate stressors

• Loss of loved one through death, divorce, or rejection

• Loss of job or significant financial loss

• Natural disasters

Stressful events and situations for suicide = Long-term stressors

• Social isolation

• Serious illness

• Abusive or repressive environment

• Occupational stress

Mood and thought changes

Many suicide attempts are preceded by changes in mood and shifts in thinking patterns

• Hopelessness

• Sadness, anxiety, tension, frustration, shame

• Psychache

• Dichotomous thinking

Alcohol and other drug use

• 70 percent of suicide at tempters drink alcohol just before the act

• One-fourth of these people are legally intoxicated

• Use of other kinds of drugs may have similar ties to suicide, particularly in teens and young adults

Mental disorders

The majority of suicide attempters have a psychological disorder

• Unipolar or bipolar depression (70 percent)

• Chronic alcoholism (20 percent)

• Schizophrenia (10 percent)

• Risk increases with multiple disorders

Other psychological disorders to triggers a suicide

• Posttraumatic stress disorder (PTSD)

• Panic disorder

• Substance use disorder

• Often in conjunction with schizophrenia or borderline personality disorder

Modeling: Contagion of suicide

A suicidal act appears to serve as a model for other such acts, especially among teens

Common models

• Family members and friend

• Celebrities

• Highly publicized cases

• Coworkers and colleagues

Interpersonal-psychological theory (Joiner et al.)

Perceptions related to desire for suicide

• Perceived burdensomeness

• Thwarted belongingness

• Psychological ability to carry out suicide (capability for suicide)

  Important to examine variables collectively

Biological view of Suicide

Genetics

• Early twin studies port to genetic links to suicide

Brain development

• Low serotonin activity and abnormalities in depression-related brain circuits contribute to suicide

• Both aid in the production of aggressive feelings and impulsive behavior

Is Suicide Linked to Age?

Children - Suicide

• Suicide is infrequent among children

• Suicide by very young is often preceded by behavioral struggles

• Many child suicides appear to be based on a clear understanding of death and a clear wish to die

Adolescents - Suicide

Suicidal actions become much more common after the age of 13

• About 8 of every 100,000 U.S. teenagers commit suicide yearly

• 12 percent have persistent suicidal thoughts

• 4 to 8 percent make suicide attempts

Teenage suicide links

• Developmental stress of adolescence

• Long- and short-term stressors, especially among LGBTQ teens

• Clinical depression, low self-esteem, hopelessness

• Anger, impulsiveness, alcohol or drug problems

• Internet and in-person modeling

Factors linked to suicide attempts for Adolescents

• Competition for jobs, college position, academic and athletic honors

• Weakening family ties

• Availability of alcohol/drugs

• Mass media

Far more teens attempt suicide than succeed

Ratio may be as high as 200:1

The Elderly - suicide

U.S. elderly are most likely to commit suicide and most successful

Contributory factors of suicide in Elderly

• Illness

• Loss of close friends and relatives

• Loss of control over one's life

• Loss of social status

Treatments after suicide attempts

• Medical care

• Appropriate follow-up with psychotherapy or drug therapy

Therapies for Suicide.

1. Psychodynamic

2. Drug therapy

3. Group and family therapies

4. Cognitive - behavioural therapy

   • Mindfulness - based

   • Dialectical Behaviour

Therapy goals after suicide attempts

• Keep the patient alive

• Reduce psychological pain

• Achievement of nonsuicidal state of mind and a sense of hope

• Development of better ways of stress management

Suicide prevention

• Prevention programs and crisis hotlines

  • Staffed by professionals or paraprofessionals

  • Offered through various modalities

Suicide prevention goals for initial contact

• Establishing a positive relationship

• Understanding and clarifying the problem

• Assessing suicide potential

• Assessing and mobilizing the caller's resources

• Formulating a plan

Longer-term prevention of Surcide

• Referral

• Therapy

• Reduction of access to common suicide means

Do suicide prevention programs work?

• Assessment of program effectiveness is difficult

  • Variety of program types, variables, and confounds

  • Mixed results

• Accurate suicide risk assessment is elusive

Newer assessment approaches for suicide prevention programs

• Nonverbal behaviors

• Psychophysiological measures

• Brain scans

• Self-Injury Implicit Association Test

Following the break-up with his girlfriend, Eduard (27) has been feeling down for the past week, complaining that he has difficulties concentrating, is unable to sleep but feels nonetheless tired, feels agitated, and has been gaining some weight. He does not, however, have a history of mania. According to the DSM-5, Eduard would classify for the following diagnosis:

No disorder