Mood-Related Conditions
Mood related disorders or affective disorders include depression and bipolar disorder (manic depression). They are the most common psychiatric problems. The terms mood and affect refer to the state of one’s emotions. A mood disorder is marked by periods of extreme sadness (depression) or excitement (mania) or both (bipolar disorder). If untreated, these episodes tend to recur or persist throughout life. Even when treated, there may be repeated episodes.
It has been shown that depression increases symptom burden and
functional impairment and worsens prognosis for heart
disease, stroke, diabetes mellitus, HIV/ AIDS, cancer and other chronic
illnesses (Evans and Charney, 2003; Stein et al., 2006; Katon et al., 2007). Very
far from Zambia, in a nationally representative survey of over 130,000 Canadian
adults, it was demonstrated that depression independently increased role
impairment by 21% compared to healthy controls. However, when depression
occurred along with chronic lung disease, diabetes mellitus or heart disease,
the rate of disability increased by over 50% (Stein et al., 2006). A more
complete understanding of the adverse effect of depression on biological and
self-care (e.g., adherence to diet, smoking cessation, exercise, medications)
has demonstrated a compelling picture of the importance of depression in
medical illness (Lin et al., 2004; Judd et al., 2005; de Jonge, et al.,
2006; Frasure-Smith and Lespérance, 2006).
Major Depression
Depression has been generally described as a decline
in mood that persists for an extended period, represents a decrease from a
previous level of function, and causes some impairment in function. Depression is projected to become the leading cause of disability and
the second leading contributor to the global burden of disease by the year
2020. Depression occurs in persons of all genders, ages, and backgrounds. Depression in some degree will affect between 10%
and 20% of the population at some time during their lives. Severe, recurrent
depression will affect between 3% and 5%, some as often as once or twice a
year, with episodes which may last longer than six months each. In many cultures depression is expressed
commonly as somatic or physical complaints (e.g. fatigue, generalized pain,
digestive problems, and headache). These problems can become chronic or
recurrent and lead to substantial impairments in an individual's ability to
take care of his or her everyday responsibilities. At its worst, depression can
lead to suicide, a tragic fatality associated with the loss of lives every
year. Depression is thought to be the cause of as many
as 75% of suicides. Probably more than with any other illness, people with
depression are blamed for their problems and told to “snap out of it,” “pull
themselves together,” etc. Often others will say a person “has no right” to be
depressed. It is critical for family and friends to understand that depression
is a serious illness; the person with this illness can no more snap out of it
than a person with diabetes can will away that illness.
People with the most severe depression find they cannot work or
participate in daily activities, and often feel that death would be preferable
to a life of such pain.
Aetiology
There are numerous causes of depression. Below is a
schema that shows the possible causes of the disorder.
It
has been found that depression may be:
- Genetic since
depression and bipolar illness often run in families.
- Recent loss through death, divorce, separation
or a broken relationship; also loss of a job, money, status,
self-confidence or self-esteem.
- Chronic illness (e.g; chronic lung disease, diabetes mellitus, functional gastrointestinal
disorders, asthma, heart disease, cancer and chronic pain, low levels of
physical health-related quality of life, and physical disability).
Signs and symptoms of
depression and warning signals include:
·
Change in
personality: usually sad, withdrawn, irritable, anxious, tired, indecisive,
apathetic or moody.
·
Change in
behaviour; difficulty concentrating on school, work or routine tasks;
·
loss of
appetite; crying
·
Change in
sleep patterns: oversleeping or insomnia, sometimes with early waking
·
Loss of
interest in friends, sex, hobbies or other activities previously enjoyed
·
Fear of
losing control, “going crazy,” or harming oneself or others
·
Worries
about money or illness, either real or imagined
·
Feelings
of helplessness and worthlessness
·
Sense of
hopelessness about the future
·
Drug or
alcohol abuse
·
Loss of
religious faith
·
Giving
away favourite possessions or revealing a desire to die.
·
Agitation, hyperactivity and restlessness
Beyond persistent depressed mood, the symptoms of depression include:
·
Loss of
interest in daily activities; loss of energy and excessive tiredness
·
Poor
appetite and weight loss, or the opposite: increased appetite and weight gain.
·
Energy
loss
·
Sleep
disturbance: sleeping too little (insomnia) or sleeping too much (hypersomnia )in an irregular pattern
·
Feelings
of worthlessness, or guilt that may reach unreasonable (delusional) proportions
·
Recurrent
thoughts of death or self-harm; wishing to be dead or attempting suicide or with specific plans made
·
Poor
concentration or memory
Symptoms of hypomania[1],
or the more severe state of mania, include:
·
Euphoric,
expansive mood; or irritable mood
·
Boundless
energy, enthusiasm, and activity
·
Decreased
need for sleep
·
Rapid,
loud, disorganized speech
·
Short
temper, argumentativeness
·
Delusional
thinking
·
Activities
which have painful consequences, i.e. spending sprees or reckless driving.
Other Mood disorders
Anxiety disorders include
the phobias, panic disorder, obsessive-compulsive disorder (OCD), and
posttraumatic stress disorder. Symptoms may be so severe as to be disabling,
but these illnesses seldom involve psychosis. Panic attacks come “out of the
blue” when there is no reason to be afraid. Symptoms include sweating,
shortness of breath, heart palpitations, choking and faintness. With OCD, the
individual may have only obsessions or only compulsions, but most have both.
Obsessions are repeated, intrusive, unwanted thoughts that cause extreme
anxiety. Compulsions are ritual behaviours that a person uses to diminish
anxiety. Examples are hand washing, counting, repeated checking, and repeating
a word or action.
10.3 Treatment of Mood disorders
Counseling Interventions for Depression
Educate
the patient and family that depression is a common condition. Depression is not
weakness or laziness; effective treatments are available and compliance with
treatment is important for a positive effect.
Techniques for coping with specific
symptoms of depression
The
following interventions may be useful in helping patients cope with specific
symptoms of depression.
1. Managing
decreased motivation, interest, or activity.
(*The
relevance of the examples listed will vary among different cultures and ethnic
groups).
Instruct
the patient to try the following in order to regain motivation, interests, and
activities:
a.
Identify activities that were done
routinely (i.e. daily or weekly) and activities that were done for pleasure
prior to the depression.
a. Increase
the routine and pleasurable activities gradually. At the beginning of each
week, choose activities from your routine ‘list and pleasurable’ list and build
them back into your day.
b. If
a task seems too difficult, try breaking it into a series of small steps. After
breaking the task down, set the goal of completing one step at a time. For
example, making a flowerbed can be broken down into a number of smaller tasks:
·
Choose a few new plants;
·
Pull out the old plants ;
·
Prepare the soil;
·
Put in the new plants.
d. Use
the support and encouragement of others as a reward. Ask others around you to
encourage and praise you for each small step you take.
1. Managing
loss of appetite
Make an effort to eat at least
small portions of food. Eat at your own pace; choose foods that you enjoy but
also be sure to incorporate a balance of nutritious foods and fluids.
2. Managing
sleep disturbance
·
Set a regular bedtime and make efforts
to adhere to it even if not tired;
·
Make efforts to arise at the same time
each morning;
·
Avoid napping during the day;
·
Exercise during the day;
·
Practice relaxation exercises in the
evening (e.g. meditation, yoga);
·
Ensure a comfortable sleep space;
·
Limit activating substances (e.g.
caffeine, alcohol, nicotine).
3. Managing
poor self-esteem or negative feelings about you. Depression can cause some
individuals to focus on or amplify their negative traits or experiences. When
one is depressed he/she may not only concentrate on the negative features and experiences,
but also underestimate his/her positive characteristics and ability to solve
problems. The following strategy may help the individual maintain a positive
sense of self and a positive outlook in challenging situations. Instruct the
patient to try the following:
a. Make
a list of your three best features. Carry the list with you and read it
whenever you find yourself focusing on negative thoughts.
b. Keep
a daily record of all the small pleasant things that happen and discuss these
events with your friends, family or your healthcare provider.
c. Recall
pleasant occasions in the past and plan pleasant occasions for the future.
d. Identify
those areas of your life that are positive. When you are de-pressed it is easy
to lose sight of the things that you value in life. Think about life before
depression. What did you value and what was special? Make a list (e.g. family,
children, work, sport, music, etc…).
e. Avoid
constant discussions about bad events. In particular, do not fall into a
pattern of expressing unreasonable, negative thoughts about your-self.
f. Consider
alternative explanations for unpleasant events or thoughts. Although your
initial explanation may be that you are at fault, rethink these conclusions and
write down all other possible explanations for these events or thoughts.
g. Keep
yourself busy doing useful activities. Avoid sitting or lying about doing
nothing.
4. Managing
worries and problems/problem-solving. Choose one or two problems that are
particularly bothersome and make a decision to make an effort at resolving them
as best as possible.
a. On
a sheet of paper, list the specific problem(s).
b. List
five or six possible solutions to the problem. Write down any ideas that occur
to you, not merely the good ideas.
c. Evaluate
the positive and negative points of each idea.
d. Choose
the solution that best fits your needs.
e. Plan
exactly the steps you will take to put the solution into action.
f. Review
your efforts after attempting to carry out the plan. Praise all efforts. If
unsuccessful, start again.
5. Managing
negative, distorted thinking. Negative thinking is common in depression.
Identifying the negative, distorted thoughts and balancing them with more
realistic ideas is an important skill that can help reduce depressive symptoms.
Examples of common negative, distorted thoughts:
(*The
relevance of the examples listed will vary among different cultures and ethnic
groups).
a.
Thinking the worst (e.g. your beloved
one doesn't contact you. You assume he/she does not like you any more).
b.
Over-generalizing - Thinking that
everything has gone wrong when only one thing has gone wrong (e.g. you make one
mistake at work and think ―I'll never succeed. I‘ll never make it in this job).
c.
Ignoring the positive and only seeing
the negative (e.g. ―I received an honours ranking on the exam but I did not
answer every question correctly).
d.
Arguing away anything positive (e.g.
―He said he liked what I did be-cause he is sorry for me.).
e.
Making negative predictions (e.g. ―It's
no good my doing that, I'm bound to fail. It will be a disaster).
f.
Taking things personally and blaming you
for what others have done (e.g. ―My son failed that exam. I should have helped
him more. I am a bad parent; or ―My partner has left me. I am no good).
g.
Exaggerating the negative (e.g. ―The
poor grade on my exam is a complete disaster and will lead to total failure).
One
may also hold distorted, unrealistic beliefs about the world that can interfere
with the ability to deal with common problems. Examples of distorted beliefs:
·
I should be happy all the time.
·
To be a good person, I have to be nice
to everyone.
·
If someone is hurt by something I say
or do, I am a bad person.
·
If I show emotion, it means that I am
weak.
·
It is shameful for me to show any sign
of weakness.
·
If someone does not like me, it means
there is something wrong with me.
·
If I argue or disagree, people won't
like me.
·
If I am criticized, it means I am
wrong.
·
If I don't succeed, I am worthless.
·
I cannot handle it when things go
wrong.
Medication
Therapy
Depression is a very treatable illness. Approximately 70% to 75% of
people properly diagnosed respond to treatment.
Use
of Antidepressant Medications
Varied classes of antidepressant medication have been shown to be effective for symptoms of depression. Antidepressant medications commonly used include:
· Address any
specific psychosocial stressors with the patient and the family
· Other
medications such as carbamazepine 100-200mg twelve hourly or eight hourly and
sodium valproate 100-200mg twelve hourly
or eight hourly can be used for mood stabilization over a prolonged period,
especially if relapses are frequent or patient is refractory to treatment with
a single anti-psychotic drug over a period of six weeks.
Bipolar Disorder (Also called manic-depression)
A
major mood disorder characterized by two distinct phases of
sustained dysphoria (depression) and/or euphoria (excitement) 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).
There are periods of recovery generally separating
the mood swings. Characteristically, recovery is
usually complete between episodes, and the incidence in the two sexes is more
nearly equal than in other mood disorders. As patients who suffer only from
repeated episodes of mania are comparatively rare, and resemble (in their
family history, premorbid personality, age of onset, and long-term prognosis)
those who also have at least occasional episodes of depression, such patients
are classified as bipolar. Psychosis may be present
during manic episodes in either phase.
Aetiology
Most scientists believe that
mental illnesses are caused by a combination of several factors working
together. In bipolar disorder, these factors are usually divided into
biological, psychological cause
and environmental. When talking about biological causes, the first issue is whether in the
patient’s family there are others with bipolar disorder; first-degree relatives
(parents, children, siblings) are more likely to have a mood disorder than the relatives of those who do
not have bipolar disorder. Studies of twins indicate that if one twin has a mood disorder, an
identical twin is about three times more likely than a fraternal twin to have a
mood disorder as
well.
Neurotransmitters
The
neurotransmitter system has received a great deal of attention as a possible
cause of bipolar disorder. Researchers have known for decades that a link
exists between neurotransmitters and mood disorders,
because drugs which alter these transmitters also relieve mood disorders.
- Some studies suggest that a low or high level of
a specific neurotransmitter such as serotonin, norepinephrine or dopamine
is the cause.
- Other studies indicate that an imbalance of these
substances is the problem, i.e., that a specific level of a
neurotransmitter is not as important as its amount in relation to the
other neurotransmitters.
- Still other studies have found evidence that a
change in the sensitivity of the receptors on nerve cells may be the
issue.
In short, researchers are quite certain
that the neurotransmitter system is at least part of the cause of bipolar
disorder, but further research is still needed to define its exact role.
Stress Triggers
For mental, emotional and environmental issues, stressful life events are
thought to be the main element in the development of bipolar disorder. These
can range from a death in the family to the loss of a job, from the birth of a
child to a move. It can be pretty much anything, but it cannot be precisely
defined, since one person's stress may be another person's piece of cake.
With
that in mind, research has found that stressful life events can lead to the
onset of symptoms in bipolar disorder. However, once the disorder is triggered
and progresses, "it seems to develop a life of its own." Once the
cycle begins, psychological and/or biological processes take over and keep the
illness active.
Putting
it all together
When
we look for the cause of bipolar disorder, the best explanation according to
the research available at this time is what is termed the
"Diathesis-Stress Model." The word diathesis means, in
simplified terms, a physical condition that makes a person more than usually
susceptible to certain diseases. Thus the Diathesis-Stress Model says that each
person inherits certain physical vulnerabilities to problems that may or may
not appear depending on what stresses occur in his or her life. Durand and
Barlow define this model as a theory "that both an inherited tendency and
specific stressful conditions are required to produce a disorder."
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. Episodes of both kinds often follow stressful life events or other
mental trauma, but the presence of such stress is not essential for the
diagnosis. The first episode may occur at any age from childhood to old age.
The frequency of episodes and the pattern of remissions and relapses are both
very variable, though remissions tend to get shorter as time goes on and
depressions to become commoner and longer lasting after middle age. Although
the original concept of "manic-depressive psychosis" also included
patients who suffered only from depression, the term "manic-depressive
disorder or psychosis" is now used mainly as a synonym for
bipolar disorder.
Essentials of diagnosis
- The
current episode must fulfil the criteria for hypomania and
- There must have been at least one other affective episode
(hypomanic, manic, depressive, or mixed) in the past.
Other Types of Bipolar Disorders
Bipolar
II – presence of at least one major depressive episode and one hypomanic
episode. No manic episode has occurred. The criteria for a hypomanic episode
are the same as for a manic episode except that in a hypomanic episode the
symptoms do not cause significant impairment in social or occupational function.
Psychosis may occur with this condition. If
required, delusions or hallucinations may be specified as congruent or
incongruent with mood
Mixed or ―rapid-cycling – the manic and depressive episodes
alternate every few days (2-3 days) rather than weeks, months, or years apart.
Psychosis may occur as a part of this condition as well. Although the most typical form of bipolar disorder
consists of alternating manic and depressive episodes separated by periods of
normal mood, it is not uncommon for depressive mood to be accompanied for days
or weeks on end by over activity and pressure of speech, or for a manic mood
and grandiosity to be accompanied by agitation and loss of energy and libido.
Depressive symptoms and symptoms of hypomania or mania may also alternate
rapidly, from day to day or even from hour to hour. A diagnosis of mixed
bipolar affective disorder should be made only if the two sets of symptoms are
both prominent for the greater part of the current episode of illness, and if
that episode has lasted for at least 2 weeks.
Management of for Bipolar Disorder
Counselling interventions for
Mania/Bipolar Disorder
1.
There is need to educate the
family/caretakers. Educate the family and patient that agitation, mood
fluctuation, and impulsivity are common symptoms of bipolar disorder and are
not intentional. Relapse is possible and should be anticipated. Review with
them the signs and symptoms of bipolar disorder. Emphasize the importance of
medication compliance.
2.
There is need to emphasize medication
compliance. Discuss with the doctor medication options and regimens that will
make taking pills easy (e.g. use of pill organizer boxes; explore whether once
a day dosing is appropriate and possible).
3.
There is need to reward constructive actions.
Determine the items or situations that the patient values and reward him/her
with them when appropriate behaviour is displayed (e.g. offer a valued reward
for having contained impulsive behaviours).
4.
There is need to encourage a routine
schedule. Outline a weekly schedule with the patient. A structured routine
helps one to know what to do and expect - this can reduce the stress and
anxiety that can precipitate symptoms. Clearly list the core activities of
daily living (ADLs) so that basic self-care skills are fostered and maintained
(showering, shaving, dressing, supply shop-ping, food preparation, cleaning).
Include chores so that a sense of responsibility is maintained. Have the
patient decide on pleasure activities to be included. Be sure there is a good
balance between indoors and out-door activities. Also be sure to incorporate
activities that involve social interaction.
5.
There is need to help the patient
identify situations that cause stress or anxiety as these can be triggers for a
relapse of illness. Help the patient limit involvement in these situations. If
a stressful situation is unavoidable, help the patient think in advance about
what may occur and how he/she will respond. Breathing and relaxation exercises
can be incorporated to help reduce anxiety felt in these situations (see
chapter on ―Anxiety Disorders‖ for breathing
and relaxation exercises).
6.
There is need to emphasize keeping
track of appointments. Missed appointments can lead to the patient‘s running
out of medication. Missing doses of medicine can put the patient at risk for a
return of symptoms and a relapse of illness.
Medication Therapy for Bipolar Disorder
Lithium,
carbamezapine, lamotrigine and sodium valproate could be used to manage manic
symptoms. Usually a combination of an antidepressant (to stabilize depressive
symptoms) and an anti-manic medication (to stabilize manic symptoms) is used
concomitantly for bipolar disorder. An anti-psychotic medication is added if
psychotic symptoms are present.
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