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Abnormal Psychology

LaGuardia Community College


Mood Disorders Cont.
DSM-5 Bipolar and Related Disorders

 Bipolar I
 Bipolar II
 Cyclothymic Disorder
 Substance/Medication-Induced Bipolar and Related Disorder
 Bipolar and Related Disorder due to another medical condition
 Other specified Bipolar and Related Disorders
 Unspecified Bipolar and Related Disorder
Bipolar and Related Disorders

 Bipolar disorders are distinguished from unipolar disorders by the presence of


manic or hypomanic symptoms
 Manic Episode-markedly elevated, euphoric, and expansive mood, often
interrupted by occasional outbursts of intense irritability or violence.
Bipolar Disorder I and II

 “Bipolar” replaces the term “manic-depressive”


 If a person only shows Manic Symptoms, it is nevertheless assumed
that Bipolar Disorder exists
 Bipolar I disorder includes at least one manic or mixed episode
 Mixed episode includes both depressive and manic symptoms for at least one week
 Even if periods of depression do not reach threshold for a major depressive episode, diagnosis
of Bipolar I still given.
 Bipolar II disorder does not include full-blown manic or mixed
episodes, but does include hypomanic episodes
 Symptoms are the same for manic and hypomanic episodes, but less
impairment in hypomania, and hospitalization is generally not required.
 Pt experiences depressed mood that meet the criteria for major depression.
DSM-5 Manic Episode
 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 (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
 7. 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 medical condition.
 Note: A full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a manic episode and bipolar I diagnosis.
DSM-5 Hypomanic Episode
 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 and have been
present to a significant degree
 1. Inflated self-esteem or grandiosity
 2. Decreased need for sleep (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 or psychomotor agitation
 7. 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 episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not
symptomatic
 D. The disturbance in mood and the change in functioning are observable by others.
 E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate
hospitalization. If there are psychotic features, the episode by definition is manic
 F. 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 medical condition.
 Note: A full manic episode that emerges during antidepressant treatment but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a manic episode and bipolar I diagnosis.
Bipolar Disorder I and II

 Occur equally in males and females


 Usually start in adolescence or young adulthood. Average age of onset is 22
years
 Approximately three times as many days are depressed as manic/hypomanic
 Some experience Rapid Cycling (at least four episodes (either manic or
depressive) every year.
 In 5-15 percent of cases, Bipolar II evolves into Bipolar I Disorder, distinct
disorders?
Cyclothymic Disorder

 Cyclical mood swings less severe than those of bipolar disorder


 Symptoms similar to Dysthymia and Hypomania
 Symptoms must be present for at least 2 year duration
 Lacking the severe symptoms and psychotic features of Bipolar Disorder
 There may be significant periods between episodes in which the person with
Cyclothymia functions in a relatively adaptive manner.
The Manic Depressive Spectrum
Depressive Episodes: Bipolar vs. Unipolar

 Bipolar
 More Mood lability, Psychotic Features, Psychomotor Retardation, Substance Abuse
 On average more severe than Unipolar
 Unipolar
 More Anxiety, Agitation, Insomnia, Physical Complaints, Weight Loss
Causal Factors

 Biological causal factors


 Psychological causal factors
Biological Causal Factors

 There is a greater genetic contribution to bipolar disorder than to unipolar


disorder
 Norepinephrine, serotonin, and dopamine all appear to be involved in
regulating our mood states
 Disturbances in hormonal regulatory systems
 Neurophysiologic and Neuroanatomical Influences
 Disturbances in Biological Rhythms
 Cyclical Nature perhaps related to Circadian Rhythms-Sleep Difficulties, core
feature during and between manic/depressive episodes.
Lithium Carbonate Therapy

 Historically the drug of choice for Bipolar Disorder


 1-2 weeks of Lithium use eliminates or reduces symptoms in 60-80% of
manic episodes without causing depression.
 Less effective in treating depression, may be administered with an anti-
depressant.
 Reduces the occurrence of future episodes of mania and depression
 Treatment with mood stabilizers may be a lifelong necessity for some pts.
Lithium Carbonate Therapy

 Serotonin key neurotransmitter


 Side Effects-Lethargy, cognitive slowing, weight gain, decreased motor
coordination, GI upset.
 Specific mechanism not well understood
 Hypothesis-Modifies second messenger systems.
Lithium Adherence

 Patients may discontinue use for many reasons


 Side Effects
 Failure to experience normal mood changes, diminishing the richness of life
 Loss of manic phase which may be perceived as a period of heightened creativity
and productiveness.
Psychological Causal Factors

 Psychological causal factors include:


 Precipitating Stressful life events
 Hypothesis-Destabilization due to stress

 Personality variables (such as neuroticism and high levels of achievement striving)


 Low social support
 Pessimistic attributional style
Comorbity

 Bipolar I: Anxiety Disorders including Panic Disorder, Social Anxiety Disorder,


Specific Phobia occur in approximately 75% of individuals. More than half of
individuals whose symptoms meet criteria have an Alcohol Use Disorder and
those with both disorders are at greater risk for suicide attempts.
 Bipolar II: Approximately 60% of individuals with Bipolar II disorder have
three or more co-occurring mental disorders: 75% have an Anxiety Disorder
and 37% have a substance use disorder. Approximately 14% of individuals with
Bipolar II Disorder have at least one lifetime Eating Disorder, with BED being
the most common. Anxiety and Eating Disorders tend to associate most with
depressive symptoms, and substance use disorders are moderately associated
with manic symptoms.
Suicide
Sometimes people die from their disease…
Suicidality in Clinical Practice

 Treating the Acute and Chronically Suicidal


 Suicide Assessment-Increased risk: family hx, previous attempts, alcohol and other
drug use, lack of protective factors-what stops you?, access to realistic method
 Treating the Survivors of Suicide
 Loss of a loved one through suicide is “one of the greatest burdens individual and
families may endure” (Dunne, 1992, p. 222)
 Guilt, Anger, Loss, Yearning to know why
 Impact on the Therapist/Patient Dynamic
 Assessment with Uncertainty
 Restoring Trust
 Processing Loss
 Individually and Systemically
 Hospitalization
Suicide Attempts and Fatality

 Suicide attempts are most common in people between 18 and 24 years old
 Highest rate of completed suicides are most common in the elderly (65 and
older)
 In the U.S., women are more likely to attempt suicide, but men are more
likely to complete suicide
 In 2011, in the U.S., suicide was the seventh leading cause of death for men and the 15th
leading cause of death for women. Method may be a factor
 Exception in Bipolar pts., as many or more women as men complete suicide.

 Elevated rates also in fairly severe and recurrent mood disorders,


schizophrenia, ETOH dependence, BPD, History of Conduct Disorder, Isolated
individuals, highly creative or successful scientists, health professionals,
business people, composers, writers, artists.
Adolescent Suicide

 Rates of suicides for people 15-24 tripled between the mid-1950s and mid-
1980s
 Suicide is now the 3rd leading cause of death in the US for 15-19 year olds,
after accidents and homicide
 Risk factors for adolescent suicide include mood disorders, conduct
disorder, and substance abuse
 Very slight increase in suicidal ideation in children and adolescents with
anti-depressants
Biological Causal Factors

 Genetic factors may play a role in risk for suicide


 Reduced serotonergic activity appears to be associated with increased risk
Suicidal Ambivalence

 Of those who have made an suicide attempt 7 to 10 percent will eventually die by
suicide.
 Distinct Groups
 Those who do not really wish to die but instead want to communicate a dramatic
message concerning their distress
 Nonlethal methods
 Arrange their action so that intervention by others is likely
 Those Intent on dying
 Little or no warning of intent
 Rely on certain means
 Those Ambivalent about dying
 Methods are often dangerous but moderately slow acting, such as drug ingestion.
 “If I die, the conflict is settled, but if I am rescued that is what was meant to be.”
Communication of Suicidal Intent

 People who threaten to take their lives often do so


 Interviews with family and friends indicate that 40% of
people who committed suicide specifically indicated
suicidal intent
 Another 30% had talked about death or dying in preceding weeks or months
 Communication is most often to a friends and family members.
 50% of people who die from suicide have never seen a mental health professional, and only
20% under the care of a mental health professional at the time of their death
Suicide Notes

 Only 15-25% of completed suicides left notes


 Some notes include statement of love and concern; others include very
hostile content
 Many short and straightforward, “I could not bear it any longer.”
Suicide Notes

 Three main thrusts to preventive efforts:


 Treatment of the person’s current mental disorder(s)
 Crisis intervention
 Coping with an immediate life crisis
 Do you want to die, or escape?
 Maintain support and contact

 Recognize acute distress

 Instill hope, distress will not be endless

 Working with high-risk groups


 Ex. Groups for older men and adolescents
Something to Think About….

Is suicidal intent categorically pathological?