Bipolar And Related Disorder

Question 1

Characteristics of bipolar and related disorder

Answer 1

1. Classified as mood disorder in DSM-5 to distinguish them from brief sadness or joy.
2. Emotions are amplified beyond normal ups and down.
   - goes extreme negative or positive directions for long periods of time.
3. Strong feelings of despair or emptiness, other instances feel anger or euphoria
4. Significantly impairs individual daily function.

Question 2

Affective disorders

Answer 2

1. Psychological disorders characterised by emotional extremes which caused impaired cognitive, behavioural and physical functioning.
2. Different from normal moods, based on duration, intensity and absence of cause.

Question 3

Two types of affective disorders

Answer 3

1. Unipolar disorders
   - depression only
   - major depression lasts on average 6 months
   - a mood disorder in which a person experiences two or more weeks of depressed mood, feelings of worthlessness, and diminished interest of pleasure in most activities
   - must meet 5 out of 9 criteria for DSM-5
   > depressed mood most of the day nearly everyday
   » sadness and hopelessness experiences by the individual for most of the day, on most days
   > diminished interest of pleasure in most activities (anhedonia)
   » no longer enjoy activities they used to find pleasurable
   > significant weight loss (>5%) or significant increase or decrease in appetite
   > insomnia or hypersomnia nearly everyday
   > noticeable psychomotor agitation or retardation
   » mood may or may not be noticeable to those around them
   » may appear angry, withdrawn or tearful
   > fatigue, loss of energy nearly everyday
   > diminished ability to think, concentrate, or make decisions nearly everyday
   » make normal functioning difficult
   > recurring thoughts of death or suicidal ideation
   - other unipolar disorders
   > dysthymic disorder
   » similar to Major Depressive Disorder, yet less severe and with periods of normal moods intertwined with the depression
   > seasonal affective disorder (SAD)
   » similar to Major Depressive Disorder with a seasonal (winter) pattern
2. Bipolar disorders
   - manic depression
   - depression followed by episodes of mania (manic depressive) last an average 4 months
   - mood disorder in which the person alternates between the hopelessness and lethargy of depression and the overexcited state of mania
   » this shift state is involuntary (can occur quickly or over an extended period of time)
   - due to a rush of exhilaration, creativity, purpose and euphoria, they cannot conceive that anything is wrong with them
   » close friends and family can recognise the change
   - criteria for mania
   > a distinct period of abnormality and persistently elevated, expansive, or irritable mood lasting at least one week and present nearly every day
   > three or more of the following symptoms are present:
   » inflated self-esteem or grandiosity
   » decreased need for sleep
   » more talkative
   » flight of ideas
   » distractibility
   » increase in goal directed activity
   » excessive involvement in risky behaviour (spending money, using drugs or engaging in risky sex)
   - differential diagnosis
   > bipolar I
   » more serious
   » at least one manic or mixed episode often with a Major Depressive Episode
   » must meet the criteria for mania for at least one week
   > bipolar II
   » at least one more Major Depressive Episode with at least one hypomanic episode
   » the person is hypomanic in that they only meet the criteria for four days

Question 4

Manic symptoms in bipolar disorder

Answer 4

1. Changes in mood
   - long period of feeling euphoric or ‘high’
   - rage, irritability
2. Changes in behaviour
   - becoming easily distracted, having racing thoughts
   - sudden interest in new activities or projects
   - overconfidence in one’s abilities
   - speaking quickly
   - sleeping less or appearing not to need sleep
   - engaging in risky behaviours such as gambling, sexual promiscuity

Question 5

Depressive symptoms for bipolar disorders

Answer 5

1. Changes in mood
   - long period of feeling sadness and despair
   - loss of interest in enjoyable activities
2. Changes in behaviour
   - struggling to concentrate or remover easily
   - withdrawing from activities or friends
   - fatigue or lethargy
   - finding it difficult to make decisions
   - change to appetite or sleeping patterns
   - considering or attempting suicide

Question 6

Comparing unipolar and bipolar

Answer 6

1. Long periods of
   Unipolar (depression)
   - sadness and despair
   Bipolar (mania/ depression)
   - euphoria and ‘high’
2. Mood
   Unipolar
   - loss of interest in enjoyable activities
   Bipolar
   - rage, irritability
3. Concentration
   Unipolar
   - struggle to concentrate
   Bipolar
   - easily distracted or racing thoughts
4. Activities
   Unipolar
   - withdraw from activities or friends
   Bipolar
   - sudden interests in new activities or projects
5. Behaviour
   Unipolar
   - fatigue
   - difficult to make decisions
   Bipolar
   - overconfidence in abilities
   - speaking quickly
6. Sleep + Appetite
   Unipolar
   - appetite and or sleeping
   Bipolar
   - sleeping less or no need to sleep
7. Thoughts
   Unipolar
   - suicide
   Bipolar
   - risky behaviours

Question 7

Beck’s Depression Inventory

Answer 7

1. Psychometric testing
2. 21-item self-report measure
3. Assess attitudes and symptoms of depression
   - widely used tool for detecting depression
4. Each item consists of four statements
   - the person taking the test must choose the one that best fits how they have been feeling during a recent period of time
   - each item has a related point value from 0 to 3
5. Score range to determine the severity of the disorder
   - 0 to 63
   - 1-10
   > these ups and downs considered normal
   - 11-16
   > mild mood disturbance
   - 17-20
   > borderline clinical depression
   - 21-30
   > moderate depression
   - 31-40
   > severe depression
   - 40+
   > extreme depression

Question 8

Evaluation for Beck’s Depression Inventory

Answer 8

1. A robust instrument
   - numerous studies have demonstrated that it has high levels of reliability and validity
   - fairly accurate and consistent in measuring the severity of an individual’s level of depression
2. Quantitative measurement
   - provides numerical score for each person
   - gives a level of objectivity which could not be achieved through an unstructured interview
   - cannot capture detain and richness that a less structured approach would offer
   - allow clinicians treating those with depression to measure improvement or deterioration of their condition over time or with treatments
3. Self-report
   - a risk that validity may be reduced as the person taking the test may either exaggerate or play down their symptoms

Question 9

Issues and debates for Beck’s Depression Inventory

Answer 9

1. Application in everyday life
   - important diagnostic tool
   - can be used in clinical settings to aid in the diagnosis and treatment of depression
   - inclusion of items around suicide an death can aid healthcare professionals in identifying those individuals who may be most at risk to themselves
   - adapted for use with children below the age of 13 who may suffer from depression

Question 10

First cause of depression

Answer 10

Biological: genetic and neurochemical (Oruc et al.)

1. Genetic argument follows the idea that depression may well run in families and be encoded in genetics
2. First degree relatives such as parents and siblings share 50% of their DNA
   > just like physical illnesses, some mental disorders are thought to have a genetic basis, meaning they can be transmitted from one generation to the next
   > current evidence for bipolar depression suggests that there is at least some genetic explanation for why some individuals are most at risk of developing such disorders
3. Researcher has shown that serotonin plays a vital role and exists in low levels for both depression and mania
4. Oruc et al. (1997)
   A. Aim
   - examining the genetic basis for these disorders
   B. Participants
   - aged between 31 and 70 years of age with a diagnosis of bipolar disorders
   - 42 participants with 25 females and 17 males
   - drawn from two psychiatric hospitals in Croatia
   - a control group of 40 participants with no personal or family history of mental health disorders matched for sex and age
   - 16 of the bipolar group had at least one first degree relative who had been diagnosed with a Major Depressive Disorder such as bipolar
   > this information was collected form participants and their family members, with diagnosis confirmed through medical records
   C. Procedure
5. DNA testing was carried out with participants to test for polymorphisms in serotonin receptor 2c(5-HTR2c) and the serotonin transporter (5-HTT) genes.
   > these genes were chosen since alterations in them can lead to disturbances in specific biochemical pathways with known links to depressive disorders
   > polymorphisms is a variation in a gene or genes
   - rather than ‘mutation’ which suggests a unique change, polymorphisms refers to different expressions that may be present in a normal population, even if that expression occurs infrequently
   D. Results
   - no significant associations in the sample
   - serotonin as a neurotransmitter is understood to be sexually dimorphic
   > sexually dimorphic is any differences between males and females of any species which are not just differences in organs or genitalia
   > these differences are caused by inheriting either male or female patterns of genetic material
   - when participants were analysed separately by gender, trends for association with both polymorphisms in female participants were observed
   > this analysis suggested that polymorphisms in these genes could be responsible for an increased risk of developing bipolar disorder in females only

Question 11

Evaluation for biological cause for bipolar disorder: genetic and neurochemical by Oruc et al.

Answer 11

1. Limited in sample sizes (42 participants and 40 in control groups)
   - difficult to generalise from the results
   - typically, genetic studies require fairly large samples for accurate and valid analysis to take place
   - establishing the importance of the serotonin-related genes in increasing risk of depressive illness in females would require a larger sample
   - some participants in the study were still within range for detecting onset for bipolar disorder
   > this means the findings might have changed if the researchers had used an older population and so age is an extraneous variable
2. Laboratory setting
   - study collected DNA samples were analysed in a laboratory setting with automated equipment
   - increases the validity of the measurement and removes researcher bias

Question 12

Second cause of bipolar disorders

Answer 12

Beck’s Cognitive Theory

1. Beck believe that cognitive symptoms of depression might actually be the most important.
   - negative views of someone with depression form a reality for that person, even if they seem far-fetched to others
   > If someone believes they are unworthy of love, they might become depressed
2. The reason for the individual’s low mood and physiological symptoms is an underlying process of incorrect information processing.
   > focuses on the way we think about or dwell on, or jump to conclusions of our negatives
3. Another term for this irrational thinking is ‘cognitive distortion’.
   > according to Beck, cognitive distortion is an automatic process which develops as a result of earlier life experiences, through developing schemas.
   > adverse events activate the potential underlying assumptions, creating a negative bias towards new events
   > the result of cognitive distortion is the emotional, cognitive and behavioural symptoms typical of depression
4. Cognitive processes involved in depression can be understood to form a triad.
   - first component of this model: individual’s view of themselves
   > unpleasant experiences are attributed internally
   > the individual thinks that they are worthless and not capable of being happy
   > eg, I am ugly, I am worthless
   - second component: the individual perceives the world as presenting them with insurmountable obstacles to happiness and well-being
   > they misinterpret external forces as being against them
   > eg, no one loves me
   - third: negative view of the future
   > when considering undertaking a specific task in future, the person anticipates failure or rejection
   > eg, things will never change

Question 13

Evaluation of Beck’s Cognitive Theory for bipolar disorders

Answer 13

1. Useful
   - it creates a very efficacious form of therapy through the cognitive approach
   - addressing one’s negative thoughts in hopes of changing their outlook and thus depression
2. Reliable and valid when compared to other assessments

Question 14

Third cause of bipolar disorders

Answer 14

Learned helplessness (Seligman et al.)

1. Seligman and Groves work with dogs not being able to escape a shock, sitting and taking the shock, and still not trying to escape even when opportunity was given.
   - sparked research into learned helplessness
2. Similarities between learned helplessness in animals and depression in people.
   - both show lowered initiation of voluntary responses (sometimes known as ‘paralysis of will’)
   - both show cognitive deficits
   - both show a lack of aggression and a loss of appetite
   > this is based on life experiences teaching us to develop trust or mistrust of our surroundings, leading us to develop patterns of thinking about ourselves and the world
3. Learned helplessness is behaviour that occurs as a result of a person having to endure an unpleasant situation, when they perceive the unpleasantness to be inescapable.
4. In theory, individual learns that they are unable to control the situation and prevent suffering, so they eventually cease to resist it.
   - Seligman and his colleagues’s view were that depression was a direct result of a real or perceived lack of control over the outcome of one’s situation.
   - this theory is the basis of ‘attributional style’ or ‘explanatory style’
   - consistently view things that happen in the future as internal, stable and global
   > if something bad happens, they might think it is their fault (internal)
   > it will stay this bad forever (stable)
   > it means more things are likely to go wrong now (global)
5. Seligman et al. (1988)
   A. Aim
   > to investigate how well attributional style could predict depressive symptoms
   B. Participants
   > 39 patients with unipolar depression and 12 patients with bipolar disorder participated in the study during a depressive episode
   > all the participants came from the same outpatient clinic, included a mix of genders and had a mean age of 36 years
   > they were compared with a non-clinical control group of 10 participants
   C. Procedure
6. At the start of the study, participants completed a short form of the BDI to assess severity of symptoms.
7. They then completed an Attributional Style Questionnaire consisting of 12 hypothetical good and bad events.
   > participants had to make causal attributions for each one and then rate each cause on a seven-point scale for internality, stability and globality
   D. Results
   - the more severe the depression score on the BDI, the worse the pessimism on the Attributional Style Questionnaire
   - for those with unipolar depression undergoing cognitive therapy, an improvement in Attributional style correlated with an improvement in BDI scores
   > this suggests that the way we make attributions is an important mechanism underlying the experience of depression

Question 15

Evaluation for Seligman et al. for bipolar disorder

Answer 15

1. Used standardised questionnaires to assess participants
   - the Attributional Style Questionnaire and BDI are considered to be valid and reliable measurement tools
2. Correlational questionnaires
   - link between BDI and positivity of attribution was correlational, meaning it is impossible to determine cause and effect in this research
   - it could be, that as one’s symptoms of depression improves, this causes attributional style to also become more positive
   - it is not clear that the link between the two is actually causal

Question 16

Issues and debates for learned helplessness in bipolar disorders

Answer 16

1. Nature
   - biological explanation for depression reflects the influence of nature
   - as particular genes and neurochemicals are implicated in developing these illnesses, biology is seen as the primary cause
   - example: Oruc et al - showed a possible genetic cause for bipolar in the female population
2. Nurture
   - there are other complementary explanations which might explain why depression is ‘triggered’, such as adverse life events
   - learned helplessness: life experiences teaches us to develop trust or mistrust of our surroundings, leading us to develop patterns of thinking about ourselves and the world
   - individual learns that they are unable to control the situation and prevent suffering, so they eventually cease to resist it
3. Individual
   - learned helplessness and a negative attributions style develop as a result of an individual’s interaction with their environment
   - the cognitive account also assumes that the depression results from an individual’s dysfunctional thinking, rather than explaining the symptoms as a result of situational variables such as a difficult childhood
4. Reductionist
   - genetic explanation for depression is reductionist as it focuses on a very narrow set of genes, such as those relating to serotonin, that may be responsible for the disorder
   - despite this, it cannot account for all instances of depression, or why not all first degree relatives develop the same disorder
5. Deterministic
   - as we cannot change our DNA, this explanation is somewhat deterministic as it demonstrates that individuals with a family history of depression or bipolar are at much higher risk of developing a similar disorder
   - however, in this case, the findings of Oruc et al. suggests only a small genetic susceptibility for females
   > this indicates that there must be other causes of the disorder, which may or may not be genetic in origin
6. Use of psychometric testing
   - the Beck’s Depression Inventory for example is popular because it is easy to administer and score
   > useful tool for clinicians
   - however, as a self-report measure, it is subject to bias
   > individuals may downplay symptoms to appear more socially desirable which reduces its validity
7. Practical application
   - these approaches are useful as therapy has been created to improve the lives of patients with depression based on the approach
   > example, CBT, drug therapy
   > if the explanation is valid, then the application will be effective
   > however, if the explanation is not valid or reductionist, the treatment which is based on the explanation may not work, may not fully work or may not work for everyone
   » for example, SSRIs (selective serotonin reputable inhibitor) do not work for everyone
   »> some feel much better, whereas others feel worse
   - this could be because the biochemical explanation is limited and therefore medication on its own will never be 100% effective without treating the other causes of depression

Question 17

First treatment for depression

Answer 17

Biochemical treatment

1. Most used treatment options for many as it can be a ‘fast fix’
   - for moderate to severe depression cases
2. Commonly known as antidepressant drugs
   A. Monoamine oxidase inhibitor (MAOIs)
   > introduced in 1950s, they were the first round of drugs to target depression and anxiety disorders
   > work by inhibiting monoamine oxidase from breaking down serotonin, norepinephrine and dopamine, allowing them to remain at high levels in the brain
   » one’s mood is alleviated as these neurotransmitters stay at higher levels
   > severe side effects of one stays on MAOIs drugs for an extended time
   » it interacts with other food, drinks, other drugs, even serotonin syndrome (super elevated levels)
   » dry mouth
   » nausea
   » weight gain
   » headaches
   » involuntary muscle jerks
   » drowsiness
   » low blood pressure
   » cause patients issues with withdrawal, and may interact with other medication
   > for this reason, current MAOIs use tends to be a course of action reserved only for atypical depression, when other antidepressants or treatments have been unsuccessful
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   B. Selective serotonin reuptake inhibitors
   > well-known brands such as Prozac
   > SSRIs act on the neurotransmitter serotonin to stop it being reabsorbed and broken down once it has crossed a synapse in the brain
   > most commonly prescribed antidepressant drug in most countries
   > have fewer and less severe side effects than MAOIs, though different individuals may respond better to particular drugs

Question 18

Evaluation for biochemical treatment for bipolar

Answer 18

1. Both MAOIs and SSRIs are agreed to be more effective treatment for depression than placebos, as evidenced by a multitude of large clinical studies.
2. However, growing evidence to suggest that the impact of these drugs on individuals is far more noticeable in patients with moderate to severe symptoms, and less so in patients diagnosed with mild depression (Fournier et al.)

Question 19

Second treatment for bipolar

Answer 19

Electro-convulsive therapy (ECT)

1. Sedated patients will have electrodes placed on the head and then one second low voltage electric current passed through the electrodes
   > results in a seizure last about one minute and patients will be conscious within 15 minutes
2. Effective on patients
   > severely depressed and imminent of suicide
   > cannot or do not want to take medications
   > other medications or treatments do not work
3. Dierckx et al. (2012)
   > included over 1000 patients with either unipolar depression or bipolar disorder
   > found that ECT had similar levels of effectiveness, both resulting in around 50% remission rate
4. Often followed by SSRIs as a maintenance procedure as ECT is short-term
   > benefits of treatment can be quite short term
   > this means that relapse rates are just as high as in individuals who cease antidepressant use
   > it is likely that an individual will experience a recurrence of symptoms which necessitate further treatment

Question 20

Third treatment for bipolar

Answer 20

Cognitive restructuring (Beck, 1979)

1. Therapists aim to gain ‘entry into the patient’s cognitive organisation’
   > to understand the patients’ illogical beliefs, monitor them and challenge these beliefs and negative thoughts
2. Essentially a talking therapy
   > based on one-to-one interactions between the patient with depression and their therapist
3. Six-stage process
   Phase 1 - explain how the treatment works
   > therapist tries to find the theory of depression within the patient (root cause of their depression) and then explains the negative, self-fulfilling cycle of the cognitive triad
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   Phase 2 - taught to monitor negative thoughts and self-schema
   > patient must then be trained to observe and record their thoughts
   > this allows them to recognise irrational, inaccurate beliefs
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   Phase 3 - taught to use behavioural techniques to challenge these thoughts
   > therapist explains the link between the patient’s thoughts, emotions and behaviour
   > patients must try to ‘catch’ automatic, negative thoughts, record them and refute them
   > this sort of ‘automatic thought catch practice’ should happen outside the therapy, in a real-world context, to maximise patent outcomes
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   Phase 4 - explore how the client responds to negative thoughts
   > these negative thoughts can be discussed and challenged in therapy, to make it clear to the patient their reflections may not be accurate (reality testing)
   > if their perspective is too negative, that could be worsening their depression
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   Phase 5 - dysfunctional beliefs are identified and challenged
   > patient is meant to investigate and notice when their thinking is distorted
   > therapist can help the patient reattribute the emotion by seeing if the cause of problems/failures is internal or external
   > patients can reframe their thinking, understand their level of responsibility, and grow from the experience
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   Phase 6 - clients have the tools to use the process along in the future
   > therapy concludes when the patient can independently practise cognitive restructuring on their own, essentially conducting self-maintenance
4. Wiles et al. showed that it can reduce symptoms of depression in people who fail to respond to antidepressants
   > a group of 469 individuals with depression were randomly allocated either continuing usual care (including on-going antidepressants) or care with cognitive behavioural therapy
   > results: those who received the therapy were three times more likely to respond to treatment and experience a reduction in symptoms

Question 21

Fourth treatment for bipolar

Answer 21

Rational emotive behavioural therapy (REBT) (Ellis, 1962)

1. A psychological approach to treatment based on the principle of Stoicism
   > stoicism is a philosophy, one of the principles of which is that in the majority of cases, the individual is not directly affected by outside things but rather by their own perception of external things
   > a person becomes depressed as a result of internal constructions because of their perceptions and attitudes towards things that happen to them in their lives
2. In REBT, therapist helps the individuals to understand the process known as the ABC model.
   A - activating event
   > event that took place and is out of your control
   > eg: unsuccessful at a job interview
   > activating event or adversity in one’s life (not directly the cause of emotional upset or negative thinking)
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   B - beliefs about event
   > this is the key as we distort event to a negative of us
   > eg: I’ll never get anywhere; I’m just not good enough
   > beliefs about the activating event which lead to emotional and behavioural problems
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   C - consequences, emotional and behavioural responses
   > eg: feeling sad, tearful or angry; withdrawal from friends and family; refusal to apply for other work
3. The most important element of the model is ‘B’, one’s beliefs about the event .
   > this is because, while we all experience adversity and setbacks to some degree, Ellis argue that it is how we think about those experiences that have the greatest impact on our emotional well-being and behavioural outcomes
   > people who consistently develop negative, fixed or irrational beliefs are at greater risk of depression
4. Goal of therapy: help individuals create and maintain constructive, rational patterns of thinking about their lives
   > this means identifying and changing thoughts which lead to guilt, self-defeat and self-pity, or negative behaviour such as avoidance, withdrawal and addiction
5. Main way this is achieved is through a process known as ‘disputing’
   > the REBT therapist forcefully questions irrational beliefs using a variety of different methods in order to reformulate dysfunctional beliefs
   > thus, therapist enables the individual to recognise that whatever setbacks befall them, they can choose how they think and feel about it
   > individuals must begin to see that the consequences (C) they experience are only partly a result of an activating event (A)
   > they then must accept that holding on to negative and self-defeating beliefs (B) is a destructive tendency, but one that can be changed by disputing them and replacing them with healthier thought
   > Ellis argue that the tendency to hold on to irrational and unhealthy beliefs is ingrained in people over time, and thus REBT has a great focus on the present, with little concern for exploring past experiences as would psychoanalysis.
6. Lyons and Woods (1991)
   - background
   > conduct a meta-analysis of 70 REBT outcome studies
   - method
   > a total of 236 comparisons of REBT to baseline, control groups or other psychotherapies are examined
   - results
   > they found that individuals receiving REBT demonstrated significant improvement over baseline measures and control groups
7. Recent research comparing the effectiveness of REBT to antidepressants suggests that both methods of treatment are equally effective in relieving symptoms of depression (Iftene et al., 2015)

Question 22

Evaluation for bipolar treatment

Answer 22

1. High replicability
   > studies in this section investigating the effectiveness of antidepressants such as MAOIs and SSRIs consist of generally well-controlled experimental research using large samples which are highly replicable
   > research considering the use of cognitive therapy and REBT such as Wiles et al, Lyons and Woods and Iftene et al also include the use of control groups
   » this allows the experimenters to draw valid conclusions about cause and effect
   » eg: Lyons and Woods assessed results between those receiving REBT and the control group who did not receive the therapy
2. Ethical issues
   > the use of antidepressants and ECT have serious ethical considerations because they involve the potential for physical and psychological harm
   > MAOIs and SSRIs can have mild, temporary side effects such as causing headaches, or more severe ones such as increase in suicidal thoughts
   > the risks of ECT include memory loss
   > so healthcare professionals and patients must balance the risks and benefits of each treatment

Question 23

Issues and debates for bipolar

Answer 23

1. Individual
   > All the forms of treatment outlined in this section focus on the individual’s requirements.
   > For example, the individual is considered to have problematic levels of neurotransmitters which require correction through antidepressant usage, or irrational thinking which needs to be challenged.
   > Little consideration is given to changing situational factors which may contribute to depression, such as trying to alleviate social isolation.
2. Nature
   > Biochemical treatments such as MAOIs, SSRIs and ECT consider biological factors (nature) as most important in reducing symptoms of depression.
3. Nurture explanations
   > Cognitive therapy and REBT regard dysfunctional patterns of behaviour and thinking as learned from our experiences with the world.
   > For example, Ellis argued that adverse or activating events in one’s life can trigger irrational beliefs, meaning depression can be treated only when we consider how we react to situational variables.