PSY388 Lecture 2: Emotional Disorders 1: Depressive Disorders; Bipolar Disorders

Features of being unwell

• Difference/Distance/Disturbance

• Functional Impact

• Distress

• Duration

What is an Emotional Disorder?

• Strong intense, frequent emotions

• Interpret as “bad”

• Avoid or control

(All 3 interact with each other)

12-month mental disorders, by disorder group and sex

Any 12-month Affective disorder, by age and sex 1

12-month Affective disorders, by type of disorder and sex 2

Depressive Disorders

Major Depressive Disorder (MDD)

Persistent Depressive Disorder (PDD)

Disruptive Mood Dysregulation Dx

Premenstrual Dysphoric Disorder

Substance-Induced, Other Med Condition, Other Specified, Unspecified

Unipolar Depression: Major Depressive Episodes alone

Major Depressive Disorder (MDD)

1. Depressed mood

2. Anhedonia

3. Appetite/weight disturbance

4. Sleep disturbance

5. Psychomotor disturbance

6. Fatigue/energy loss

7. Worthlessness/guilt

8. Impaired concentration

9. Suicidal ideation

Persistent Depressive Disorder (PDD)

1. Depressed mood

2. Appetite disturbance

3. Sleep disturbance

4. Low energy/fatigue

5. Low self-esteem

6. Impaired concentration

7. Hopelessness

Royal Aus and NZ Collefe of Psychiatrist clinical practice guidelines for mood disorders: Goal

The main objective of treatment is the complete remission of depression with full functional recovery and the development of resilience.

Royal Aus and NZ Collefe of Psychiatrist clinical practice guidelines for mood disorders: Step 0

• Taper and cease any agents that can potentially lower mood

• Institute sleep hygiene

• Implement appropriate lifestyle changes e.g. smoking cessation, adopt regular exercise and achieve a healthy diet

• Address substance misuse if relevant

Royal Aus and NZ Collefe of Psychiatrist clinical practice guidelines for mood disorders: Step 1

GENERIC PSYCHOSOCIAL INTERVENTIONS:

• Psychoeducation (family, friends, caregivers)

• Low intensity interventions (e.g. internet based education)

• Formal support groups, community groups

• Employment, housing

FORMULATION-BASED INTERVENTION

PSYCHOLOGICAL THERAPY

• Cognitive Behavioural Therapy (CBВТ)

• Interpersonal therapy

• Acceptance and Commitment therapy

• Mindfulness-Based Cognitive Therapy

PHARMACOTHERAPY

• First line: SSRIs. NaSSAs, NDRIs. SNRIs, NARIs, melatonin agonist, serotonin modulator

• Second line: Tricyclic antidepressants, MAOls

Royal Aus and NZ Collefe of Psychiatrist clinical practice guidelines for mood disorders: Step 2

• Combine pharmacotherapy and psychological therapy

• Increase dose of antidepressant medication

• Augment antidepressant medication with lithium and / or antipsychotic medication

• Combine antidepressants

• rTMS (if available)

Royal Aus and NZ Collefe of Psychiatrist clinical practice guidelines for mood disorders: Step 3

ECT

Downward Spiral of Depression

1. Trigger/Stressor - a difficult event, stress, or life circumstance + negative thoughts begin

2. Negative thinking - worry, self-criticism, and pessimism increase + mood drops, hope decreases

3. Emotional decline - feelings of sadness, emptiness, irritability or guilt intensity + energy and motivation decrease

4. Behavioural withdrawal - avoiding activities, withdrawing from people, procrastination + reinforces isolation and disconnection

5. Loss of positive reinforcement - fewer rewarding experiences, more negative thoughts + deepens hopelessness and despair

6. Deepening depression - overwhelming sadness, helplessness, worthlessness, possible thoughts of death + feels like there is no way out

Leads to hopelessness, isolation, suffering, impaired functioning

CBT for MDD

Behavioural Components

• Mood monitoring

• Pleasant event scheduling (joy)

• Mastery development

THEN start to shift unhelpful thinking styles

Cognitive Components

• Identifying and challenging (reappraising) automatic negative thoughts (“ANTS”) about the self, world, and future

Other treatment for MDD

• Anti-inflammatory diet/changes in diet

• Yoga/physical activity

Some evidence, can be useful but still growing in research

Bipolar & Related Disorders

Bipolar Disorder I

Bipolar Disorder II

Cyclothymic Disorder

Substance-Induced, Other Med Condition, Other Specified, Unspecified

Bipolar Disorders: Types with mood variations

BP I VS BP II: Manic & Hypomanic Episodes

1. Inflated self-esteem/grandiosity

2. Decreased need for sleep

3. More talkative/pressured speech

4. Flight of ideas/racing thoughts

5. Distractibility

6. Increased goal-directed activity

7. Engagement in high-risk activities

Bipolar Disorder I

• Must have manic ep

• MDE not necessary

• 15x higher rate of death by suicide than gen pop

• 80% of attempts and deaths occur during MDE

• ~75% have co-occurring anx dx

• >50% have co-occurring SUD

Bipolar Disorder II

• Must never reach manic

• Must have MDE

• 2x higher rate of death by suicide than MDD

• ~75% have co-occurring anx dx

• ~37% have co-occurring SUD

Cyclothymia

• Never meet manic or hypomanic ep or MDE

• Less severe, more chronic

• ~1 in 3 → BP I or II

Bipolar Treatments

CBT for Bipolar

Mood monitoring:

Examples:

• over the next week, monitor the fluctuations in your daily mood by filling in the mood graph below

• what am I like when I am mildly depressed?

• what am I like when I am moderately depressed?

• what am I like when my wood is mildly elevated?

• what am I like when my mood is moderately elevated?