EXAM 2 - Mood Disorders

Question 1

Unipolar Depression

Answer 1

Major Depressive Disorder

Persistent Depressive Disorder

Disruptive Mood Dysregulation Disorder

Premenstrual Dysphoric Disorder

Same“poles” of mood (NO depression to mania)

Question 2

Bipolar Disorders (mania or hypomania is present typically alternating with periods of depression)

Answer 2

Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder

Different “poles” of mood (depression to mania)

Question 3

Incidence of Depression

Answer 3

16 % suffered from Major Depressive Disorder at some point in their lives
3 % suffered from Dysthymic Disorder

Question 4

Incidence of Bipolar Disorder

Answer 4

Lifetime Incidence Rate for Bipolar I and II combined according to the National Comorbidity Survey Replication is close to 4%.

Question 5

Most Common Age of Onset - Major Depressive Episodes

Answer 5

Onset is typically 25 to 44 years old
Some MDD begin in childhood, but more often in adolescence
Rates in the elderly are high

Question 6

Most Common Age of Onset - Bipolar Disorder

Answer 6

Typical onset is in early 20’s (18 to 22)

However, some cases start in childhood or adolescence and others after age 50

Question 7

Gender Differences - Major Depression

Answer 7

Women are 2 to 3 times as likely as men to develop depression

Question 8

Gender Differences - Bipolar Disorder

Answer 8

Equally common in men and women
First episode in men tends to manic
First episode in women tends to be depressive

Question 9

DSM-5 Criteria: Major Depressive Episode

Answer 9

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g.,
appears tearful). Note: in children and adolescents can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly
every day. Note: in children, consider failure to make expected weight gains
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC

Question 10

Persistent Depressive Disorder

Answer 10

Depressed mood most of the day on more than 50% of days
No more than two months symptom free
Symptoms can persist unchanged over long periods (≥ 20 years)
May include periods of more severe major depressive symptoms
Major depressive symptoms may be intermittent or last for the majority or entirety of the time period

Question 11

Types of Persistent Depressive Disorder

Answer 11

Mild depressive symptoms without any major depressive episodes (“with pure dysthymic syndrome”)
Mild depressive symptoms with additional major depressive episodes occurring intermittently (previously called “double depression”)
Major depressive episode lasting 2+ years (“with persistent major depressive episode”)

Question 12

DSM-5 Criteria: Persistent Depressive Disorder

Answer 12

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.
D. Criteria for major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
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 cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Current severity: Mild, moderate, severe; With anxious distress; With mixed features; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With peripartum onset; Early onset: If onset is before age 21 years;
Late onset: If onset is at age 21 years or older; Specify (for most recent 2 years of dysthymic disorder):
With pure dysthymic syndrome: if full criteria for a major depressive episode have not been met in at least the preceding 2 years.
With persistent major depressive episode: if full criteria for a major depressive episode have been met throughout the preceding 2-year period.
With intermittent major depressive episodes, with current episode: if full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode.
With intermittent major depressive episodes, without current episode: if full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years.
In full remission, in partial remission
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Question 13

DSM-5 Criteria for Depressive Disorders: Persistent Depressive Disorder (2 years)

Answer 13

Persistent Depressive Disorder with pure dysthymic syndrome

Question 14

Persistent Depressive Disorder:Double Depression

Answer 14

Persistent Depressive Disorder with persistent major depressive episode
Both criteria have been met for at least the past 2 years

Question 15

Persistent Depressive Disorder with intermittent major depressive episodes with current episode

Answer 15

Persistent Depression AND major depressive episode, however, there was at least 8 weeks without a major depressive episode during the past 2 years

Question 16

Persistent Depressive Disorder with intermittent major depressive episodes without current major depressive episode

Answer 16

Persistent Depression AND 1 or more major depressive episodes in at least the past 2 years

Question 17

Diagnostic Specifiers for Depressive Disorders - Major depressive episodes which also include some psychotic features

Answer 17

Hallucinations: Sensory experience in the absence of sensory input
Delusions: Strongly held inaccurate and bizarre beliefs

Question 18

Diagnostic Specifiers for Depressive Disorders - Anxious distress specifier

Answer 18

Depression is accompanied by several significant symptoms of anxiety
Predicts poorer outcome

Question 19

agnostic Specifiers for Depressive Disorders - Peripartum onset specifier:

Answer 19

Depression occurring around the time of giving birth

Question 20

Diagnostic Specifiers for Depressive Disorders - Seasonal pattern specifier:

Answer 20

Depression occurring primarily in certain seasons (usually winter)
Sometimes called seasonal affective disorder.
May be related to seasonal changes in melatonin
May be treated effectively with light therapy

Question 21

Premenstrual Dysphoric Disorder

Answer 21

Significant depressive symptoms occurring prior to menses during the majority of cycles, leading to distress or impairment

Question 22

DSM 5 DISORDER CRITERIA SUMMARY Premenstrual Dysphoric Disorder

Answer 22

Features of premenstrual dysphoric disorder include the following:

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

One (or more) of the following symptoms must be present:

(1) Marked affective lability (e.g., mood swings),
(2) marked irritability or anger,
(3) marked depressed mood, or
(4) marked anxiety and tension

One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms above:
(1) Decreased interest in usual activities;
(2) difficulty in concentration;
(3) lethargy, fatigability, lack of energy;
(4) marked change in appetite, overeating, or specific food cravings; (5) hypersomnia or insomnia;
(5) a sense of being overwhelmed or out of control; or
(7) physical symptoms such as breast tenderness or weight gain.
Clinically significant distress or interference with work, school, usual social activities, or relationships Symptoms are not attributable to the effects of a substance (e.g., drug abuse) or another medical condition
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washing DC.

Question 23

Disruptive Mood Dysregulation Disorder

Answer 23

Severe temper outbursts occurring frequently, against a backdrop of angry or irritable mood
Diagnosed only in children 6-18; Criterion A-E have to be met before 10 years old
Criteria for manic/hypomanic episode are not met
Designed in part to combat over diagnosis of bipolar disorder in youth who essentially have a temperamental-type mood disorder (however, recent research doesn’t support that this diagnosis has fulfilled this goal)
Unfortunately, recent research indicates that this disorder is likely not a valid mood disorder.
Research indicates that children diagnosed with this disorder meet the primary criteria for Oppositional Defiant Disorder

Question 24

DSM 5 DISORDER CRITERIA SUMMARY Disruptive Mood Dysregulation Disorder

Answer 24

Features of disruptive mood dysregulation disorder include the following.
Severe temper outbursts occurring three or more times per week for at least one year, manifested verbally and/or behav-iorally that are out of proportion in intensity or duration to the situation and are inconsistent with developmental level

The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, is observable by others in at least two of three settings (i.e., at home, at school, with peers), and is severe in at least one of these settings

The diagnosis should not be made for the first time before age 6 years or after age 18 years

There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met

The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition

Question 25

Behavioral and Interpersonal Theory for Depression

Answer 25

Depression as extinction of positive reinforcement (Lewinsohn)
Depressed people behave in ways that alienate themselves from friends/family
Depressed people have smaller support networks
Interactions are more negative and argumentative

Question 26

Cognitive Theories

for Depression

Answer 26

Analogue Studies
Depressed people make attributions that are:
Internal versus External
Stable versus Unstable
Global versus specific
1989 Revision of Learned Helplessness Theory focuses on Hopelessness (Abrahmson)
Negative expectations about future events
The belief that the outcome of these events cannot be controlled

Question 27

Depression:Psychosocial Factors

Answer 27

Stressful events often precipitate the onset of depressive and manic episodes
Social support is a buffer for recurrence
Life events such as death of a close relative, assault, divorce may precipitate the onset of mood disorders.

Question 28

Biochemical Theories of Depression

Answer 28

disruptions in the balance of monoamine neurotransmitters

Catecholamines
Norepinephrine and dopamine

Indolamines
Serotonin

Lower levels of Serotonin may dysregulate norepinephrine and dopamine, triggering depression

A dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis may play a role in the development or maintenance of clinical depression for some people

When a person is threatened/stressed, the hypothalamus signals the pituitary gland to secrete the hormone, ACTH.

ACTH modulates the secretion of other neurohormones from the adrenal glands into the bloodstream (cortisol)

Question 29

Depression related Brain Imaging Studies

Answer 29

The Prefrontal Cortex
Decreased activity in some regions of the prefrontal cortex is associated with decreased motivation
Increased activity in other regions of the prefrontal cortex is associated with prolonged experience of negative emotion

Patients with major depression and bipolar disorders can have elevated levels of resting blood flow and glucose metabolism in the amygdala. Higher metabolism is associated with more severe depression. (Once depression abates metabolism normalizes).

Question 30

Depression: Biopsychosocial Models

Answer 30

Genetic vulnerability
Stress triggers genetic vulnerability
Produces changes neurologically
Psychological and/or Medication treatment can change neurological functioning

Question 31

Evidenced-Based Treatment of Depression: Psychotherapies

Answer 31

Integrative Approaches
Psychodynamic Therapy
Interpersonal Therapy
Cognitive and Behavior Therapy
Humanistic Therapy
Group Therapy

Question 32

Medication Treatment of Depression

Answer 32

Tricyclics (rarely used anymore; easy to overdose on)
MAO Inhibitors (rarely used)
Selective Serotonin Reuptake Inhibitors (the most popular)
Mixed reuptake inhibitors (e.g., Effexor, a serotonin/norepinephrine reuptake inhibitors; Wellbutrin)
Sometimes Atypical Antipsychotic medications are used in conjunction with antidepressants (e.g., Abilify)
Lithium is used with medication resistant depression

Question 33

ffectiveness of Drug Treatment, CBT, or Drug Treatment plus CBT

Answer 33

This can vary among individual patients
Overall, multiple studies have shown that including CBT in treatment prevents recurrence of major depressive episodes, even when patients continue to take medication.
Without CBT, relapse rates are high for patients who just take medication without CBT

Question 34

Treatment of Medication-Resistant and Therapy-Resistant Depression

Answer 34

Electroconvulsive Therapy (ECT)
Transcranial Magnetic Stimulation
Ketamine Infusion
Vagus Nerve Stimulation (difficult to access)

Question 35

Electroconvulsive Therapy (ECT)

Answer 35

Patients are given anesthesia and a series of controlled seizures are induced by passing electricity through the brain
It usually involves 6 to 12 sessions
Can be bilateral or unilateral, but bilateral tends to be more effective
Side effects tend to involve long-term memory loss, but it may be temporary

Question 36

Treatment of Mood Disorders: Transcranial Magnetic Stimulation

Answer 36

Uses magnets to generate a precise localized electromagnetic pulse
Few side effects; occasional headaches
Less effective than ECT for medication-resistant depression
May be combined with medication

Question 37

Ketamine Infusion Therapy

Answer 37

An anesthetic that is administered intravenously
Usually treatment effectiveness is determined after 2 treatments. Average course is 6 doses in 1 to 2 weeks with boosters every 5 weeks.
Typically, ketamine has to be re-administered periodically
FDA has granted two of the medications breakthrough therapy status and is fast tracking it to market (2017)

Question 38

Vagus Nerve Stimulation

Answer 38

First used to treat medication resistant epilepsy in 1988
First used to treat medication resistant depression in 1998
Involves implantation of a generator that stimulates the vagus nerve
Sensory connections of the vagus nerve provide direct projections to many of the brain regions implicated in neuropsychiatric disorders
The left cervical vagus nerve is stimulated via an implant
Structures in the Limbic system are affected
The amygdala, cingulate gyrus, stria terminalis
Neurochemicals are affected
GABA, glutamate, serotonin, and neurepinephrine
Several 2 year studies have been conducted
Rates of remission from MDD range from 42% to 54% after 2 years of treatment
Rates of reduced symptoms (at least 50% from baseline) range from 22% to 50%
Very difficult to access this treatment

Question 39

Criteria for Bipolar

Answer 39

Elevated, expansive mood for at least one week
Examples of symptoms:
Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors
Impairment in normal functioning

Question 40

DSM-5 Criteria: Manic Episode

Answer 40

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
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 (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (e.g., purposeless non-goal-directed activity).
Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another general medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence of a manic episode and, therefore, a bipolar I diagnosis.

Question 41

Types of Mood Episodes - Hypomanic episode

Answer 41

Shorter, less severe version of manic episodes
Last at least four days
Have fewer and milder symptoms
Associated with less impairment than a manic episode (e.g., less risky behavior)
May not be problematic in and of itself, but usually occurs in the context of a more problematic mood disorder

Question 42

Types of Mood Episodes - Mixed features

Answer 42

“Mixed features” = term for a mood episode with some elements reflecting the opposite valence of mood
Example: Depressive episode with some manic features
Example: Manic episode with some depressed/anxious features

Question 43

Bipolar I disorder

Answer 43

Alternations between major depressive episodes and manic episodes

Question 44

Bipolar II disorder

Answer 44

Alternations between major depressive episodes and hypomanic episodes

Question 45

Cyclothymic disorder

Answer 45

Alternations between less severe depressive and hypomanic symptoms

Question 46

Cyclothymic Disorder: Overview

Answer 46

Chronic version of bipolar disorder
Alternating between periods of mild depressive symptoms and mild hypomanic symptoms
Episodes do not meet criteria for full major depressive episode, full hypomanic episode or full manic episode
Hypomanic or depressive mood states may persist for long periods
Must last for at least two years (one year for children and adolescents)
Least common form of bipolar disorder

Question 47

Diagnostic Specifiers for Bipolar Disorders

Answer 47

All of the specifiers for depressive disorders may also apply to bipolar disorders
Additional specifer unique to bipolar disorders: Rapid cycling specifier
Moving quickly in and out of mania and depression
Individual experiences at least four manic or depressive episodes within a year
Occurs in between 20-50% of cases
Associated with greater severity

Question 48

Treatment for Bipolar

Answer 48

Medication
Lithium is the “gold standard”
20 to 30% of people don’t tolerate it well or are unresponsive
Monthly blood tests to maintain therapeutic (versus toxic) levels are inconvenient

Question 49

Treatment of Bipolar Disorders - medication

Answer 49

Anticonvulsants
Depakote (valproic acid); Lamictal; Trileptal
Depakote is especially effective for rapid cyclers (helps 60% vs. lithium helping only 10 to 35%) (ECT too)
Safer for the elderly
More specifically depakote seems to interfere with the enzyme that breaks down GABA, thus increasing GABA levels in the brain
GABA modulates mood/energy stabilizing neurotransmitters, such as neurepinephrine, serotonin, and dopamine.

Mood Stabilizers (atypical antipsychotic medications)
(act on dopamine primarily)
Abilify
Geodon
Risperidal
Zyprexa
Latuda