Psychopathology of mood disorders

It contains the psychosocial theories of Bipolar affective disorder, mania and depression.

1. PSYCHOPATHOLOGY OF MOOD DISORDERS Mr. Varun Muthuchamy Mrs. Rashi Midha Dr. Nitin Anand

2. ICD-10 (Overview of Affective disorders) STEP 1 Manic Episode Bipolar affective disorder Depressive Disorder Recurrent depressive disorder Persistent mood disorder

3. ICD-10 Criteria of Depressive Disorder In typical depressive episodes of all three varieties described below (mild (F32.0), moderate (F32.1), and severe (F32.2 and F32.3)), the individual usually suffers from depressed mood , loss of interest and enjoyment , and reduced energy leading to increased fatiguability and diminished activity . Marked tiredness after only slight effort is common. Other common symptoms are: (a) Reduced concentration and attention; ( b) Reduced self-esteem and self-confidence; ( c) Ideas of guilt and unworthiness (even in a mild type of episode); (d ) Bleak and pessimistic views of the future ; ( e ) Ideas or acts of self-harm or suicide; (f ) Disturbed sleep (g ) Diminished appetite.

4. ICD-10 Criteria of Recurrent Depressive Disorder The disorder is characterized by repeated episodes of depression as specified in depressive episode (mild (F32.0), moderate (F32.1), or severe (F32.2 and F32.3)), without any history of independent episodes of mood elevation and over-activity that fulfil the criteria of mania (F30.1 and F30.2). However, the category should still be used if there is evidence of brief episodes of mild mood elevation and over-activity which fulfil the criteria of hypomania (F30.0) immediately after a depressive episode (sometimes apparently precipitated by treatment of a depression).

5. ICD-10 Criteria of Persistent Mood Disorder The essential feature is a persistent instability of mood, involving numerous periods of mild depression and mild elation, none of which has been sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder (F31.-) or recurrent depressive disorder (F33.-). This implies that individual episodes of mood swings do not fulfil the criteria for any of the categories described under manic episode (F30.-) or depressive episode (F32 .-). The essential feature is a very long-standing depression of mood which is never, or only very rarely, severe enough to fulfil the criteria for recurrent depressive disorder, mild or moderate severity (F33.0 or F33.1). It usually begins early in adult life and lasts for at least several years, sometimes indefinitely. When the onset is later in life, the disorder is often the aftermath of a discrete depressive episode (F32.-) and associated with bereavement or other obvious stress.

6. Theories of Depression Biological Perspective Psychodynamic Diathesis-Stress Model Behavioural Theories Cognitive Behavioural

7. Biological Perspective HPA axis Hypothalamic-Pituitary-Adrenal axis To regulate stress response. Neurotransmitter [Monoamine NT (serotonin, Dopamine, Norepinephrine) ] Decreased activity of serotonergic receptors Family study Relatives of patients with bipolar disorder are more likely to have unipolar depression. Twin study Rate was high on identical twins when comparing with fraternal twins. Heritability rates are higher for females than males.

8. Psychodynamic Freud (Mourning and Melancholia) Loss of an object (love) Ambivalent feelings toward that object Displacement of that feeling toward oneself when a loved one dies, the mourner regresses to the oral stage of development and incorporates the lost person, feeling all the same feelings toward the self as toward the lost person. Depression also occur in response to imagined or symbolic losses.

9. Psychodynamic Bibring (1953 ) Depression rooted from the tension between ideal and reality. Three highly invested narcissistic aspirations: T o be worthy and loved To be strong and superior To be good and loving- are held as standards of conduct.

10. Psychodynamic: 2 types of depression (Blatt , Quinlan and Chevron ) Anaclitic Depression Introjective Depression - Anaclitic depression involves a person who feels dependent upon relationships with others and who essentially grieves over the threatened or actual loss of those relationships. - It is characterized by feelings of helplessness and weakness. - A person with anaclitic depression experiences intense fears of abandonment and desperately struggles to maintain direct physical contact with the need-gratifying object Introjective depression occurs when a person feels that they have failed to meet their own standards and that therefore they are failures. Introjective depression arises from a harsh, unrelenting, highly critical superego that creates feelings of worthlessness, guilt and a sense of having failure. A person with introjective depression experiences intense fears of losing approval, recognition, and love from a desired object.

11. Diathesis-Stress Model Diathesis: Vulnerability factors to develop a disorder. Stress: Perceived severely threatening event. The basic premise is that stress activates a diathesis, transforming the potential of a predisposition into a presence of a psychopathology.

12. Behavioural Theories Learned Helplessness (Martin Seligman) An individual’s passivity and sense of being unable to control their life is acquired through repeated unpleasant experiences and traumas that the individual tried to control unsuccessfully leading to depression. Three deficits are noted in this condition: Motivational Cognitive Emotional Paralysis of will: where individual shows no initiative Learning that one has no control interferes with one’s future ability to learn that one does, in fact have control Learning that one has no control produces passivity and perhaps depression

13. Behavioural Theories Response Contingent Positive Reinforcement ( Lewinsohn , 1974 ) When a behaviour receives low rate of positive reinforcement then the possibility of that behavior getting extinguish is higher. Subsequent loss of reinforcement leads to feeling of dysphoria , low self-esteem and hopelessness. Simultaneously when the depressive symptoms are reinforced by social envi . through sympathy, interest and concern Possibility of repetition of these kind responses will be increased.

14. Cognitive Behavioural Approach Cognitive Distortion (Aaron Beck) Beck hypothesized that cog Sx of D often precede mood Sx Features of Beck’s THEORY: Depressed people have underlying dysfunctional beliefs- acquired early in life through major life events such as death, loss. When dysfunctional beliefs are activated by current stressors in the environment, the negative cognitive triad of an individual becomes activated Fuelled by underlying cognitive errors/distortions that lead depressed person to misperceive reality (Negative Automatic Thoughts )

15. Cognitive Behavioural Approach Negative automatic thoughts (Characteristics) AUTOMATIC : They just seem to come into your mind without any effort. DISTORTED: They are not always supported by the things you know to be true. UNHELPFUL: They keep you feeling depressed, and make it difficult to change. PLAUSIBLE : You accept them as facts and do not question them . INVOLUNTARY: You do not choose to have them and they are very difficult to stop.

16. Cognitive Behavioural Approach Negative automatic thoughts (Types) Overgeneralisation Filtering (Selective Abstraction ) All or Nothing Thinking Personalising Catastrophising Emotional Reasoning Mind Reading Fortune Telling Error Should Statements Magnification/Minimisation

17. Cognitive Behavioural Approach Cognitive Triads

18. Cognitive Behavioural Approach Early Maladaptive Schemas (Young, 2003) This model speaks beyond cognition and explains about the schema (mental structure) Schemas are considered to be trait like cognition which is enduring. It consists of one’s view of oneself and others. It includes memories, bodily sensations, and emotions, which once activated, intense emotions are experienced Origin: Early childhood experiences Temperament Cultural influences

19. Cognitive Behavioural Approach EMSs are thought to be stable and perpetuated later in life even if the circumstances have changed. EMSs have become a part of the individual’s identity, and the individual behaves and interprets situations in a way that confirms the schema Cognitive biases and self-defeating life-patterns maintain and strengthen EMSs, making the individual vulnerable to depression, (Young, 1999 ) The EMS are categorized in 5 domains: Disconnection and rejection, Impaired autonomy, Impaired limit, Other-directedness and Over-vigilance and inhibition

20. ICD-10 Criteria of Mania Three degrees of severity are specified here, sharing the common underlying characteristics of elevated mood , and an increase in the quantity and speed of physical and mental activity . All the subdivisions of this category should be used only for a single manic episode. If previous or subsequent affective episodes (depressive, manic, or hypomanic), the disorder should be coded under bipolar affective disorder. There is a persistent mild elevation of mood (for at least several days on end), increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or result in social rejection.

21. Bipolar Affective Disorder and Mania

22. ICD-10 Criteria of Mania Three degrees of severity are specified here, sharing the common underlying characteristics of elevated mood , and an increase in the quantity and speed of physical and mental activity . All the subdivisions of this category should be used only for a single manic episode. If previous or subsequent affective episodes (depressive, manic, or hypomanic), the disorder should be coded under bipolar affective disorder There is a persistent elevation of mood (for at least several days on end), increased energy and activity, and usually marked feelings of well-being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a decreased need for sleep that lead to mild/severe disruption of socio-occupational functioning.

23. ICD-10 Criteria of Bipolar affective disorder This disorder is characterized by repeated (i.e. at least two) episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression). Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months (median duration about 4 months). Depressions tend to last longer (median length about 6 months), though rarely for more than a year, except in the elderly .

24. Theories of Bipolar Affective Disorder Social Zeitgeber hypothesis Behavioral approach system dysregulation theory Integrated model

25. Social Zeitgeber hypothesis The social Z eitgeber hypothesis is based on two assumptions 1. Disturbances in circadian rhythms shown by many physiological processes are important in the pathophysiology of mood disorders 2. In human circadian rhythms, physical and social cues are relevant.

26. Social Zeitgeber hypothesis Although bipolar disorder is biochemically based, circadian rhythm dysregulation plays a crucial role in determining when episodes of mania or depression occur. Frank suggests that just as the rising and setting of the sun is important for establishing the circadian rhythm, social routines such as work, meal times, and synchronizing with the rhythms of one's spouse or family are also critical to maintaining biological routines or rhythms. When social rhythms are disrupted, biological rhythms such as sleep are disturbed, and the body is out of sync.

27. Social Zeitgeber hypothesis Although non-vulnerable individuals may only experience temporary and quickly reversible somatic changes in such situations, those who are genetically at risk for mood disorders become stuck in a desynchronized state, and this prolonged state may precipitate a manic episode. Such conditions might include flights across time zones, shift work, domestic discord that disrupts sleep and daily routines, and having a new born. So the primary physiological disturbance in mood disorders is thought to be a chronobiological one.

28. Social Zeitgeber hypothesis Interpersonal and social role stress leads to changes in the body's biological clock and that these circadian rhythm changes lead to mood episodes in vulnerable individuals. Instability is the hallmark of bipolar disorder, and social rhythm stability may be one protective factor . Therefore, an intervention that could help vulnerable patients to eliminate or better control challenges to their biological rhythms, help them to construct more accommodating and stable social relationships, and prevent upsetting life events that are dependent on their own behaviour could restructure the course of their recurrent biological mood disorders.

29. Behavioral approach system dysregulation theory Alloy and Abramson, 2010. According to the BAS-dysregulation model, vulnerability to bipolar disorder is reflected in an overly sensitive BAS that is hyper-reactive to relevant cues. When vulnerable individuals experience events involving rewards or goal striving and attainment, their hypersensitive BAS becomes excessively activated. This leads to (hypo)manic symptoms, such as excessive goal-directed behaviour, increased energy, decreased need for sleep, optimism, and euphoria. Alternatively, in response to events involving definite failures, losses, or non-attainment of goals, a hypersensitive BAS becomes excessively deactivated, leading to a shutdown of behavioural approach. Consequently, depressive symptoms result.

30. Behavioral approach system dysregulation theory

31. Integrated model for BPAD Jones and Lam,2012 Stressors (Life events, family conflicts ) Residual symptoms, stigma Acute mood episode Disrupted social rhythms, abnormal goal pursuits Maladaptive coping and cognitions (e.g., depressive inactivity spiral; manic hyperactive spiral) Dysregulation of reward system and biological systems Episode of P rodome

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