Bipolar and Depressive Disorder Comprehensive Study Notes

Introduction to Mood Disorders

• Mood disorders are a group of psychological conditions defined by disturbances in a person's emotional state or mood.
• These disorders involve experiencing extreme sadness, excessive happiness, or fluctuations between both states.
• Central features of mood disorders include:
  • Persistent emotional disturbance (prolonged sadness or excessive happiness).
  • Changes in energy levels, ranging from fatigue to excessive activity.
  • Disturbances in sleep patterns, such as insomnia or hypersomnia.
  • Changes in appetite or body weight.
  • Impairment in concentration or the ability to make decisions.
  • Anhedonia, or the loss of interest in previously enjoyable activities.
  • Significant impairment in social, academic, or occupational functioning.
• These mood changes are more intense and last longer than typical emotional reactions, interfering with daily activities and performance.

Causes of Mood Disorders

• Mood disorders result from the interaction of several complex factors:
  • Biological Factors: Imbalances of neurotransmitters including serotonin, dopamine, and norepinephrine.
  • Genetic Factors: Mood disorders tend to run in families, suggesting a strong hereditary component.
  • Psychological Factors: High risk is associated with negative thinking patterns, personality traits, and poor coping skills.
  • Environmental Factors: Stressful life events, such as the loss of a loved one, trauma, financial difficulties, or relationship conflicts can trigger the onset of a disorder.

Bipolar I Disorder

• Bipolar I Disorder is characterized by the presence of at least one manic episode.
• The disorder involves shifts between extreme emotional highs (mania) and extreme lows (depression).
• The manic phase is often severe enough to cause major problems in daily functioning and may require hospitalization to prevent harm.
• Core Feature: A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least $1$ week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

Diagnostic Criteria for a Manic Episode (DSM-5-TR)

• Criterion A: Persistent elevated, expansive, or irritable mood and increased energy/activity lasting at least $1$ week.
• Criterion B: During the mood disturbance, three (or more) of the following symptoms (four if the mood is only irritable) must be present to a significant degree:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep (e.g., feels rested after only $3$ hours of sleep).
  3. More talkative than usual or pressure to keep talking.
  4. Flight of ideas or subjective experience that thoughts are racing.
  5. Distractibility (attention easily drawn to irrelevant external stimuli).
  6. Increase in goal-directed activity (socially, at work/school, or sexually) or psychomotor agitation (purposeless activity).
  7. Excessive involvement in risky activities with potential for painful consequences (e.g., buying sprees, sexual indiscretions, or foolish investments).
• Criterion C: The disturbance is severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.
• Criterion D: The episode is not attributable to the physiological effects of a substance or another medical condition.
• Special Note: A full manic episode emerging during antidepressant treatment (medication or ECT) that persists beyond the physiological effect of that treatment is sufficient evidence for a Bipolar I diagnosis.

Characteristics and Symptoms of Mania

• Irritable Mood: Irritability often occurs when the individual's wishes are denied or they are frustrated. This can lead to anger, hostility, or argumentativeness.
• Mood Lability: Rapid changes in mood within a short timeframe (minutes or hours), shifting between euphoria, sadness, and irritability.
• Increased Energy and Goal-Directed Activity: Individuals starting multiple projects (work, social, religious, or sexual) with little planning, often believing nothing is impossible. Activity may continue throughout the night.
• Pressured Speech: Talking excessively, loudly, and rapidly, making it difficult for others to interrupt. Speech may include dramatic expressions, jokes, or singing.
• Racing Thoughts and Flight of Ideas: Thoughts move faster than they can be spoken, leading to jumping quickly between unrelated topics.
• Distractibility: Inability to focus due to shifting attention toward unimportant background noises or objects.
• Inflated Self-Esteem: Exaggerated confidence or grandiose delusions, such as believing one has special powers or a unique relationship with a celebrity.
• Decreased Need for Sleep: Different from insomnia, the person feels energetic and rested despite sleeping very little or not at all for several days.

Major Depressive Episode Criteria in Bipolar I

• While not mandatory for a Bipolar I diagnosis, depressive episodes are common.
• Criteria (A-C) for a Major Depressive Episode require five or more symptoms during a $2$-week period, with at least one being (1) depressed mood or (2) loss of interest or pleasure:
  1. Depressed mood most of the day, nearly every day.
  2. Markedly diminished interest or pleasure in almost all activities.
  3. Significant weight change ($> 5\%$ in a month) or change in appetite.
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation observed by others.
  6. Fatigue or loss of energy.
  7. Feelings of worthlessness or excessive/inappropriate guilt.
  8. Diminished ability to think, concentrate, or indecisiveness.
  9. Recurrent thoughts of death or suicidal ideation.

Features of Hypomanic Episodes

• A hypomanic episode is less severe than a manic episode.
• Duration: At least $4$ consecutive days, present most of the day, nearly every day.
• Severity: Not severe enough to cause marked impairment or necessitate hospitalization.
• Psychotic features are by definition absent in hypomania (their presence classifies the episode as manic).
• The individual exhibits an unequivocal change in functioning that is observable by others but uncharacteristic of their non-symptomatic state.

Comparison: Manic Episode vs. Hypomanic Episode

• Defined by Duration: Mania is $\ge 7$ days (unless hospitalized); Hypomania is $\ge 4$ days.
• Functional Impairment: Mania causes marked impairment; Hypomania does not cause marked impairment and may even temporarily improve functioning.
• Hospitalization: Often required for Mania; Not required for Hypomania.
• Psychotic Features: May be present in Mania; Must be absent in Hypomania.
• Insight: Often poor in Mania; Usually better in Hypomania.
• Associated Disorder: Mania is required for Bipolar I; Hypomania is required for Bipolar II.

Associated Features and Risks of Bipolar I disorder

• Lack of Insight: Individuals often do not recognize they are ill and resist treatment.
• Change in Appearance: Wearing flashy, colorful, or sexually suggestive clothing and excessive makeup.
• Heightened Sensory Perceptions: Sharper hearing, smell, or vision.
• Mixed Features: Depressive symptoms appearing during approximately $35\%$ of manic episodes, associated with higher suicide risk.
• Creativity: Linked to higher levels of creativity and high reward sensitivity (strong pursuit of pleasurable experiences).
• Consequences: Loss of employment, financial loss, legal problems, and relationship conflicts.

Development and Course of Bipolar I

• Age of Onset: Typically between $20$ and $30$ years.
  • United States average: $22$ years.
  • Mean onset in women: $21.5$ years.
  • Mean onset in men: $23$ years.
  • International median: $24.3$ years.
• Recurrence: More than $90\%$ of individuals with one manic episode will experience additional episodes.
• Cycling: Around $60\%$ of manic episodes are followed by depression.
• Rapid Cycling: Defined as $4$ or more mood episodes within one year; associated with a more severe course.
• Predominant Polarity: Most individuals have episodes that occur mostly as mania or mostly as depression.

Risk and Prognostic Factors for Bipolar I

• Environmental Factors:
  • Childhood adversity (emotional trauma, neglect, abuse) increases risk and may lead to earlier onset.
  • Stressful life events can trigger depressive relapse.
  • Goal-attainment events (e.g., marriage, achievements) are linked to manic relapse.
  • Substance use, particularly cannabis, can trigger mania.
• Genetic and Physiological Factors:
  • Heritability estimates are around $90\%$.
  • Risk in general population: $1\%$.
  • Risk with a first-degree relative: $5\text{--}10\%$.
  • Monozygotic twin concordance rates: $40\text{--}70\%$.
  • Shared genetic origins with Schizophrenia have been suggested.
• Gender Differences:
  • Women are more likely to experience rapid cycling, mixed episodes, and depressive symptoms.
  • Pregnancy typically does not increase episodes unless medication is ceased, but the postpartum period carries a high risk for manic/depressive episodes and postpartum psychosis.

Treatment of Bipolar I Disorder

• Mood Stabilizers (First-Line): The foundation of treatment.
  • Lithium: The Gold Standard; reduces suicide risk and controls mania.
  • Valproate (Valproic Acid).
  • Lamotrigine: Effective for maintenance and bipolar depression.
  • Carbamazepine.
• Antipsychotics: Used for acute mania and maintenance (e.g., Olanzapine, Quetiapine, Risperidone, Aripiprazole).
• Psychotherapy: Cognitive Behavior Therapy (CBT) identifies negative thoughts and encourages medication adherence.
• Lifestyle Modifications: Consistent daily routine, regular sleep schedule, balanced diet, exercise, and avoiding alcohol/drugs.

Bipolar II Disorder

• Bipolar II is characterized by recurrent major depressive episodes and at least one hypomanic episode.
• A history of a full manic episode precludes a Bipolar II diagnosis; if mania occurs, the diagnosis shifts to Bipolar I.
• Core diagnostic features (DSM-5-TR):
  • At least one hypomanic episode.
  • At least one major depressive episode.
  • Never have experienced a manic episode.
  • Distress or impairment is significant, often caused by depression or mood unpredictability.

Clinical Course and Features of Bipolar II

• Chronicity: Bipolar II often shows greater chronicity than Bipolar I, with more time spent in severe depressive episodes.
• Treatment Seeking: Most individuals seek help during depressive phases; hypomania is often not recognized by patients as problematic.
• Informants: Family and friends are often essential for identifying hypomanic behavioral changes.
• Creativity: Milder bipolar forms are often linked with higher creative achievements, though the relationship is not linear.
• Impulsivity: Increases the risk of suicide attempts and substance misuse.

Development and Risk Factors for Bipolar II

• Age of Onset: Mid-$20s$.
• Initial Presentation: Usually begins with a depressive episode and is often misdiagnosed as Major Depressive Disorder (MDD) for over $10$ years until a hypomanic episode occurs.
• Recurrence: Over $50\%$ experience another episode within $1$ year.
• Cycling patterns:
  • Rapid Cycling ($4+$ episodes/year) occurs in $5\text{--}15\%$ of individuals, primarily women.
  • Displacement to Bipolar I: $5\text{--}15\%$ eventually experience a manic episode.
• Genetic Factors: Risk is significantly higher in first-degree relatives. Bipolar II may have a different genetic structure than Bipolar I.
• Prognosis: Poorer prognosis with rapid cycling and long duration of illness. Better outcomes are linked to higher education and being married.

Major Depressive Disorder (MDD)

• MDD is characterized by persistent sadness and loss of interest in daily activities lasting at least $2$ weeks.
• The diagnosis requires no history of manic or hypomanic episodes.
• Main Symptoms:
  • Depressed Mood: Feelings of hopelessness, discouragement, or emptiness.
  • Anhedonia: Reduced interest in hobbies, social activities, and sex.
  • Weight/Appetite Change: Increase or decrease, or failure to make expected weight gain in children.
  • Sleep Disturbances: Initial insomnia (difficulty falling asleep), Middle insomnia (waking during the night), or Terminal insomnia (waking too early).
  • Psychomotor Changes: Agitation (restlessness) or retardation (slowed movements/speech).
  • Cognitive Impairment: Indecisiveness and memory problems (pseudodementia in elderly).
  • Suicidal Ideation: Ranges from passive wishes to die to active planning.

Development, Course, and Risk for MDD

• Onset: Most common in the $20s$, but can occur at any age. Early onset is linked to stronger family history and personality disturbances.
• Recovery: $40\%$ recover within $3$ months; $80\%$ recover within $1$ year. Poorer recovery is linked to psychotic features, anxiety, and personality disorders.
• Mortality: High mortality risk due to suicide.
• Risk Factors:
  • Temperamental: High neuroticism (negative affectivity).
  • Environmental: Adverse childhood experiences (abuse, neglect), low income, racism, and stressful life events.
  • Genetic: Heritability is approximately $40\%$. First-degree relatives have a $2\text{--}4$ times higher risk.
• Gender-Related Issues: Women are more likely to show atypical symptoms (hyperphagia, hypersomnia) and interpersonal sensitivity. Men may mask symptoms with substance misuse and risk-taking.

Treatment Options for MDD

• Cognitive Behavior Therapy (CBT): Challenges cognitive distortions and automatic negative thoughts.
• Interpersonal Therapy (IPT): Addresses grief, interpersonal conflicts, and role transitions.
• Behavioral Activation (BA): Schedules enjoyable activities to increase positive reinforcement.
• Medications:
  • SSRIs: Sertraline, Fluoxetine, Escitalopram.
  • SNRIs: Venlafaxine, Duloxetine.
• Biological Findings: Overactivity of the hypothalamic-pituitary-adrenal (HPA) axis is found in severe or melancholic depression.

Persistent Depressive Disorder (PDD)

• PDD is a chronic depressed mood present for most of the day, for more days than not, for at least $2$ years in adults (at least $1$ year in children/adolescents).
• Diagnostic Criteria:
  • Mood is never absent for more than $2$ months during the $2$-year period.
  • Presence of at least two symptoms: poor appetite/overeating, sleep problems, low energy, low self-esteem, poor concentration, feelings of hopelessness.
  • No history of manic or hypomanic episodes.
• Double Depression: When a Major Depressive Episode occurs during the course of PDD, leading to greater impairment.
• Course: Often begins early (childhood/adolescence) and has a gradual onset.
• Treatment: Includes CBT, IPT, BA, and Mindfulness-Based Cognitive Therapy (MBCT), which reduces rumination and lowers relapse risk.

Premenstrual Dysphoric Disorder (PMDD)

• PMDD is a severe form of PMS characterized by significant emotional and physical symptoms during the late luteal phase of the menstrual cycle.
• Diagnostic Timing: Symptoms occur in the week before menstruation, improve shortly after menses begins, and are minimal/absent in the week post-menses.
• Symptoms (at least five total):
  • Core Emotional (at least one): Mood swings (lability), irritability/anger, depressed mood/hopelessness, or anxiety/tension.
  • Behavioral/Physical: Decreased interest, concentration difficulty, lethargy, appetite changes/cravings, sleep issues, feeling overwhelmed, and physical symptoms (bloating, breast tenderness, joint pain).
• Confirmation: Diagnosis requires prospective daily ratings for at least two symptomatic cycles.
• Development: Starts anytime after menarche and ends after menopause.
• Environmental Risks: Stress and history of interpersonal trauma.
• Genetics: Research suggests $30\text{--}80\%$ of premenstrual symptoms may have a genetic component.
• Treatment:
  • First-line Medication: SSRIs (Fluoxetine, Sertraline, Paroxetine, Escitalopram).
  • Therapy: CBT for stress management and emotional regulation.
  • Lifestyle: Aerobic exercise, reduced caffeine/alcohol/sugar, and relaxation techniques like Progressive Muscle Relaxation (PMR).