two ladies without a moment's delay, and when his convictions were tested by direct dismissal, he appeared to quickly abandon them. Concerning Ellis and Mellsop's (1985) indicative standards for unadulterated/essential erotomania, this case fits every one of the rules with the exception of basis f) - the article doesn't stay unaltered, model h) – the course is intermittent and not constant, and we don't know about the beginning, which should be abrupt to satisfy measure e). When taking a gander at Seeman's (1978) endeavour to partition Erotomania in two gatherings, we can see that our patient presents qualities from both the fixed and the repetitive gathering – there are cycles with various love objects, with the adoration object being subbed after rehashed dismissal like in the intermittent gathering, and like in the fixed gathering, Mr. X is single, explicitly unpractised, he has never had a significant relationship, he is tentative, with low confidence, he is incredibly reliant and near his mom, he never had a requesting position and as of now has no expert occupation and, except for Mrs. B, his affection objects are fairly standard figures with whom he had past little contact. Table 5.4: The Timeline of This Case Unlike the patients described by this author, Mr. X has no psychiatric diagnosis. In regard to Taylor et al.’s (1983) criteria, our patient seems to fulfil all of them except the sudden onset, which we are not sure about. This author reports four cases of male Erotomania, and the general profile of the described patients is similar to Mr. X’s case, with the exception that these men all had mood disturbances. These were lonely men who had solitary lives for many years prior to the onset of the delusions. Three of them never had a satisfactory relationship and had no sexual experience. All men had extremely close and dependent relationships with their parents, especially with their mothers. Three of the men had multiple love objects and a recurrent course of illness, and all of them showed aggressive behaviour, three of them committing and one of them threatening to commit offenses against people in the context of their disorder, which is in line with the higher prevalence of male patients with Erotomania in forensic samples, as male sex is a risk factor for aggressive behaviour. Mr. X also exhibited violent behaviour, stalking Mrs. A and Mrs. C and threatening Mrs. C with a knife, and only came in contact with mental health care services as a result of this offense, which is not uncommon for patients with Erotomania. Mr. X presents two other risk factors for violence, namely the presence of multiple love objects and the low socio-economic status. Mr. X had to 151 CU IDOL SELF LEARNING MATERIAL (SLM)
be separated from Mrs. C by means of hospitalization and responded well to first line treatment and is stable, presenting with adequate behaviour and with much less intense delusional beliefs. Mr. X’s case fits the Clérambault description of Erotomania, and the most important components of the syndrome, the paradoxical behaviour of the object and the grudge phase, are present in both Mrs. A and Mrs. C’s case. However, and also regarding Ellis and Mellsop’s (1985) criteria for pure/primary Erotomania, although the disorder is not secondary to other illnesses, Mr. X’s case lacks the chronic course with the presence of only one love object, and we are unsure about the sudden onset. Although presenting a course of illness typical of Seeman’s (1978) recurrent group, he presents a profile more typical of the fixed group. Mr. X. finds himself unattractive and is sexually inexperienced, never had a serious relationship and leads a rather isolated life, much like most descriptions of patients with Erotomania. Also, he is incredibly close and dependent of his mother, which is also typical according to some authors. Much alike other Erotomania reports, this case, fits the different criteria and classifications in a heterogeneous way. Interestingly, this case resembles other reports of male Erotomania, where a recurrent course and the presence of multiple love objects is common, also resembling a male case reported by de Clérambault himself. Since these cases tend to be similar, and since male patients are more commonly violent, being more frequently a part of forensic samples, it would be interesting to understand if the syndrome of male Erotomania differs from female Erotomania in other important ways, perhaps configuring a somewhat separate subtype of Erotomania. However, there are still not enough reports for us to be able to say that with any certainty. We can conclude that it seems reasonable to retain the operative concept of Erotomania as a subtype of Persistent Delusional Disorder/Delusional Disorder, since cases fitting the classical descriptions of the syndrome have been reported, and the diagnosis of Erotomania has particular implications in case management, treatment and prognosis – risperidone under 6 mg/day is the first line treatment, to diminish the intensity of the delusions and for behavioural control but, sometimes, the only effective treatment is separation from the love object and risk management, since the patient may become really bothersome and intrusive in the object’s life. Also, missing this diagnosis may culminate in violent situations that may have legal implications, since these patients, especially if male, can present for the first time with violent behaviour. We can also conclude that the developed diagnostic criteria and classifications retain use and should be kept in mind, in the sense that they help make clinicians aware of the heterogeneity of the syndrome, and this could facilitate making an important diagnosis that could have serious implications if missed. Increasing awareness of this illness may also lead to future developments in management and treatment. ● Somatic Delusional Disorder A late 19th century diagnosis Paranoia was originated with Kahlbaum and was refined by Kraepelin. Paranoia was considered distinct from schizophrenia. For most of the 20th century, however, cases of paranoid illness were usually diagnosed as forms of schizophrenia, and the term paranoia fell into disuse. In 1987, the revision of the DSM-III 152 CU IDOL SELF LEARNING MATERIAL (SLM)
(that is, the DSM-III-R) reintroduced the concept of paranoia, calling it “delusional disorder,” which was similar to the concept. Kraepelin had used it earlier. The condition was renamed delusional disorder because of concerns that the common clinical term paranoid was vague in meaning and often applied inappropriately. This condition is no longer regarded as rare, but systematic study of delusional disorder and the development of effective treatment remain unfinished tasks. Indeed, in the history of medicine, discovery of successful treatment often precedes basic understanding of a disorder. Riding and Munro reported on the use of the antipsychotic agent pimozide to treat several cases of what was termed “monosymptomatic hypochondriacal psychosis” (4). They replicated their work for additional publications, indicating that a form of delusional disorder (the somatic subtype) was treatable with this medication. They further found that, in unimproved cases, nonadherence to medication regimens was an important and frequent factor affecting outcome. Despite such reports, the impression of most practitioners has been that antipsychotic medications are of marginal value and that this condition is treatment-resistant. Munro and Mok reviewed clinicians’ published experience with antipsychotic treatment of delusional disorder from the 1960s to 1994 (5). They critically analysed approximately 1000 articles on delusional disorder dating from 1961, with most published between 1980 and 1994. Noting that case descriptions were often incomplete, they only selected cases where the patients’ presentation conformed to DSM-IV criteria. Of the 257 cases finally accumulated, only 209 cases were sufficiently detailed to report meaningfully on treatment. The authors concluded that even this refined body of data was disparate and confusing and that only the “broadest conclusions” could be drawn. Nevertheless, they asserted that delusional disorder was an illness with a reasonably good prognosis when adequately treated. They also observed that treatment response was positive regardless of the specific delusional content (the subtype) of the disorder. Interestingly, they proposed that pimozide appeared to show the strongest evidence of good results in clinical reports. This report extends those observations and reviews the current status of the treatment of delusional disorder, paying special attention to recent experience with second-generation antipsychotic agents. Methods: Our underlying aim was to catch all reports of whimsical issues distributed since 1994. We looked for instances of the issue through Medline questions of diary articles, including letters to editors, and furthermore analysed the Cochrane data set and book sections. In addition, we contacted drug companies that were developing significant antipsychotic drugs in response to case reports of capricious problem treatment. This pursuit technique yielded 153 articles on hallucinating problems, which we at that point surveyed for lucidity and culmination, treatment, and result depictions. Articles were distributed somewhere in the range between 1994 and 2004. Of the 153 articles, 68 had sufficient indicative thoroughness (models and strategy for analysis were recognized). Less still (n = 35) contained adequate data to portray treatment. Of 34 articles revealing clear result information, just 9 evaluated treatment results deliberately with target measures, while the excess 25 depended on clinician judgment for result gauges. Subsequent to barring instances 153 CU IDOL SELF LEARNING MATERIAL (SLM)
of natural preposterous issue, our determination interaction recognized 224 instances of capricious issue. Notwithstanding, adequate treatment data was accessible for just 136 cases, with the reports giving result information and follow-up data for 134. As Munro and Mok remarked in their past survey, the treatment regimens depicted were only sometimes express worry, for instance, the request for prescription application when numerous meds had been attempted. Results Demographics Consistent with Munro and Mok's 1995 audit, ladies dwarfed men in a proportion of almost 4 to 3 (57% contrasted and 43%) in the more current arrangement of cases (Table 5.5). In any case, this example of ongoing cases additionally showed a few contrasts. Despite the fact that patients with preposterous turmoil were comparable in mean age (48.8 years for men; 44.9 years for ladies) to their partners 10 years previously (44.3 years for men; 51.2 years for ladies), ladies were not significantly more established than men at the time of case identification. Age ranged from 29 to 78 years for women and 17 to 72 years for men; these ranges correspond to previous perceptions. Notwithstanding, most patients in our example were in their late 30s.The average follow-up period (10 months; range, 1 to 36 months) for this newer group was shorter than for the earlier sample (22 months; range, 0 to 36 months). Most subjects had delusions with a persecutory theme (n = 85) (Table 5.6). Somatic delusions was the delusion subtype with the greatest recorded detail about course, treatment, and follow-up (n = 80). Twelve patients experienced a mixture of delusions. Table 5.5: Demographic data (n=224) 154 CU IDOL SELF LEARNING MATERIAL (SLM)
Table 5.6: Delusion Types (n=224) ● Comorbid Conditions Recent cases of delusional disorder differed from those reviewed in 1995 in the occurrence of medical and psychiatric comorbid disorders (Table 5.7). Among Munro and Mok’s cases, the most prevalent comorbid conditions were also known risk factors for delusional disorder. For example, head injury or trauma and history of substance abuse were common. Table 5.7: Psychiatric Comorbid Conditions In our sample, depression or depressive symptoms were most commonly mentioned as comorbid conditions (n = 51, 23%). Only 5 patients (2.2%) were identified as having organic brain disorder or head trauma, and 2 patients (1%) had a known history of 155 CU IDOL SELF LEARNING MATERIAL (SLM)
substance abuse. It seems highly likely that more patients in our current sample would have such comorbid disorders, but they may not have been recorded. Strikingly, there was no mention in the newer articles of family history of mental illness. We classified outcomes in 3 categories: • Recovered • Improved • No improvement These were determined by symptomatology at follow-up. Thus, a patient who was symptom- free at the time of follow-up was identified as recovered, whereas one whose symptoms had not changed was considered as showing no improvement. A caveat here is that the description of recovery in many cases relied on clinical judgment rather than on objective measures. However, where actual numbers were presented, recovery was defined as a clinically significant reduction in scores on the assessment tool used. Outcomes are summarized in Table 5.8. Adherence Only one article discussed adherence issues (9); the authors noted that 12 (5.4%) of their patients might not have taken their medications exactly as prescribed. This finding likely underestimates actual nonadherence. In several articles, sporadic comments suggested that nonadherence was a problem in an infrequent number of cases. Again, these observations probably underestimate actual nonadherence. Use of Medications: The introduction of second-generation (atypical) antipsychotic medications may have appreciably changed the treatment of delusional disorder. Munro and Mok focused much attention on the efficacy differences found between pimozide and other neuroleptic medications (the typical antipsychotics), but trends in medication therapy have changed. First, polypharmacy regimens have emerged in the treatment of delusional disorder. Many of these patients also report depressive symptoms, and most patients now are treated with both an antipsychotic and an antidepressant medication. Second, patients commonly receive more than one antipsychotic medication over the course of their illness. This is important to note because, although the symptoms may ultimately resolve, the exact source of success is not always clear. Third, treatment regimens often mention cognitive behavioural therapy or even electroconvulsive therapy with concomitant antipsychotic medication. Most reports emphasize medication treatment, primarily with antipsychotic agents. Treatment actually encompasses various approaches, including medication, although evidence of such mixed strategies is meagre. In the current sample, nearly 45% of the patients with delusional disorders received pimozide. Using the Wilcoxon rank sum test, we found a difference in recovery rates that approached statistical significance (P = 0.055) between those who were treated with pimozide and those who were not, independent of delusion type, yet the raw data suggested that the trend from the earlier review was reversed. Among the group treated with pimozide, 77.9% were either fully recovered or improved at follow-up (Table 3c). Among patients receiving all other antipsychotic agents (including clozapine), 93.9% showed full recovery or improvement. In this newer sample, no particular method of medication treatment 156 CU IDOL SELF LEARNING MATERIAL (SLM)
produced a more favourable outcome. Most patients, regardless of which medication they used, had a favourable outcome after treatment. Table 5.8: Summarized Outcomes ● Comparison of Conventional With Second-Generation Antipsychotic Treatment When we examined the available outcome data for our patient sample, we found no significant differences in outcome by type of medication used. Using the Wilcoxon rank sum test for differences between groups, we noted no significant difference in outcome between the treatment types (that is, pimozide, other typical antipsychotics, and second-generation antipsychotics). Our follow-up analysis using the Yates-corrected chi-square test confirmed that the differences in outcome were not statistically significant. Although the data initially suggested the advantages of the newer medications, further analysis revealed a lack of statistical significance (P value only approached significance at the 0.05 level). Clozapine Use Four articles reported the use of clozapine (10–13) in the treatment of delusional 157 CU IDOL SELF LEARNING MATERIAL (SLM)
disorder, with mixed results (Table 5.9). The sample was small (n = 5). Clozapine is reserved for use in cases of intractable side effects and treatment-resistant delusions. Its use here resulted from the failure of previous antipsychotic drug trials. Clozapine appeared to have little effect on the central delusional theme. That is, although each author noted a reduction in the associated symptoms of delusional disorder, the delusion often persisted. Interestingly, the articles suggested that the patients’ quality of life improved when their treatment was switched to clozapine, despite the persistence of the delusions. Outcome in Somatic Delusions Compared with Other Subtypes Thirty-six percent of the reported cases (n = 80) experienced somatic delusions, in contrast with the 38% who experienced delusions of persecution (Table 5.8b). Unfortunately, little treatment information was recorded for most of the patients with persecutory delusions. In this updated review, we noted that 47/64 patients (73.4%) with somatic delusions were treated with pimozide. Using the Wilcoxon rank sum test, we found a significant difference in outcomes between delusion subtype groups (that is, somatic compared with other), based on the treatment received (P = 0.0004). That is, among patients treated with pimozide, there was a significant difference in outcome between those with somatic delusions and those with other types of delusions. As well, those treated with other types of medication showed a similar difference in outcome, despite the delusional theme. A follow-up, Yates-corrected chi-square test confirmed a significant difference in outcome between patients with somatic-themed delusions and those with other delusion types. Table 5.9: Treatment of Delusional Disorder - With Mixed Results Discussion Despite certain limitations, the last decade’s literature on delusional disorder treatment suggests optimism about the potential for treatment effectiveness. Of 131 reported cases, 50%. Of a positive response was noted .This observation contrasts with pessimism about treatment of delusional disorder. However, some caveats exist. 1. First, the clinicians may be reluctant to prepare reports on negative outcomes. Since case reports are the usual source of data, rather than controlled trials, they constitute our major source of evidence on this disorder. Thus, the actual rate of successful treatment may be lower. 158 CU IDOL SELF LEARNING MATERIAL (SLM)
2. Second, the lack of double-blind, randomized controlled studies raises concerns about the strength of the evidence for a positive response. 3. Third, the frequent use of combination treatments suggests that monotherapy with antipsychotic medication may be insufficient in many cases. 4. Fourth, the introduction of second-generation antipsychotics may have contributed to a reduced reliance on pimozide (68% and 44%, respectively), or it may reflect concern about pimozide’s potential for QTc prolongation. Perhaps the more reliable outcome from these atypical antipsychotics, coupled with their reduced side effects, has resulted in reduced reliance on pimozide for treatment. Conversely, claims about treatment effectiveness may be sound because factors such as nonadherence have not been adequately considered. In the earlier review, Munro commented that adherence to medication regimens was a central factor in treatment success. The fact that, in case descriptions, so few studies in our review indicated the level of such adherence raises the possibility that this factor, when not specifically addressed, is critical to treatment success. Whether it might also be responsible for the difference in treatment response between patients with somatic delusions and those with other delusion types is a question for further investigation. One reasonable explanation for the differential success is adherence to medication regimens. Unfortunately, we do not have data to support this assertion. However, recognizing nonadherence to treatment among patients with delusional disorder is clearly relevant to understanding this phenomenon. Indeed, the occurrence of any treatment success is noteworthy. The recovery rates we reported would be welcome in any clinic for any of the major psychotic disorders. Further, the general concordance of our review’s observations with those of Munro and Mok’s earlier review. Strengthen the idea that delusional disorder should not be considered a treatment-resistant condition; medication can be effective if the patient adheres to the treatment regimen. In the cases we reviewed, clinicians possibly overlooked or did not detect adherence problems and, in so doing, reinforced the perception that delusional disorder is difficult to treat, perhaps even treatment-resistant. The newer, possibly more acceptable, second-generation antipsychotic agents had sporadic, yet positive reports of treatment effectiveness associated with their use; the experience is thus far limited, but it parallels that of the older agents. All this holds promise. That continues to produce greater rates of improvement in patients with somatic delusions raises a question about the uniqueness of this intervention and also about a potential boundary between somatic and other forms of delusional disorder. Nonetheless, the observations from our review underscore the need for more focused research. Sample sizes were small, and controlled studies were almost non-existent. There is a need to move beyond case reports to collaborative efforts in this area so that researchers can examine delusional disorder systematically in sufficient numbers to generate meaningful clinical conclusions. 159 CU IDOL SELF LEARNING MATERIAL (SLM)
5.4 SUMMARY • Paranoia is a clinical sickness, which can influence the cerebrum, and causes changes in reasoning and feeling. • Paranoid people are energetic eyewitnesses. They think they are in harm's way and search for signs and dangers of that threat, dismissing any realities. They will in general be watched and dubious and have very contracted passionate lives. • Without delusion of oppression an individual may be analysed as a suspicious schizophrenic, just in light of the fact that their fancies allude for the most part to themselves. Their dread, and the dangers they see in the guiltless proclamations and activities of others, regularly adds to visit grumbling or threatening withdrawal or lack of approachability. • The principle side effect of suspicion is perpetual hallucination. It ought to be remembered that there is daydream in schizophrenia likewise yet around there, it isn't lasting or coordinated. • In distrustfulness the manifestations are noticeable bit by bit, and the patient is wistful, dubious, bad tempered, contemplative, discouraged, resolute, envious, narrow minded, unsocial and severe. Along these lines his alluring, the exertion that he is set up to consume is pretty much nothing. • The \"Symptomatic and Statistical Manual of Mental Disorders\", fourth release (DSM IV), has recorded the manifestations of suspicious behavioural condition: • The various types of neurosis are the persecutory, strict, reformatory, sexual, belligerent and so on • Delusions are frequently seen in people with other crazy issues like schizophrenia and schizoaffective problems. As well as happening in the maniacal issues, dreams likewise might be clear as a feature of a reaction to physical ailments, (for example, cerebrum injury or mind tumours), or responses to ingestion of a medication. • Delusions likewise happen in the dementias, which are conditions wherein mental indications and cognitive decline result from decay of cerebrum tissue. • Because dreams can appear as a feature of numerous illnesses, the finding of silly problems is somewhat directed by interaction of disposal. • The greater part of psychotherapy strategies utilized in hallucinating issues come from manifestation centred (rather than analysis centred) scientist experts. • A fix of distrustfulness is extremely troublesome, and it is fundamental that treatment ought to be begun promptly the infection comes to be known. When it develops on an individual there is no restoring to it. • The boss technique for restoring distrustfulness is as follows: Compared to other mental illnesses, this infection doesn't react quickly to psychoanalytic therapy on the grounds that, being dubious, the patient doesn't help out the specialist. That being 160 CU IDOL SELF LEARNING MATERIAL (SLM)
said, with due safety measures, certain outcomes can be accomplished by utilizing this technique. • CBT or different types of psychotherapy might be useful for specific individuals who have suspicion. CBT endeavors to make an individual more mindful of their activities and inspirations and attempts to assist the person with learning decipher signs all the more precisely around the person in question, with an end goal to help the individual change broken practices. Trouble can go into a remedial relationship with a neurotic individual, because of the degree of doubt and doubt that is probably going to meddle with their capacity to partake in this type of treatment. • Delusional issue treatment frequently includes a common (additionally called novel or more up to date age) antipsychotic meds, which can be viable in certain patients. • Risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa) are generally instancing of ordinary or novel antipsychotic meds. • Predicting the visualization of an individual experiencing Paranoia is very troublesome. • Paranoia for the most part turns into an entire life or deep-rooted condition if there exists any fundamental mental problem, for example, schizophrenia or neurotic behavioural condition. • People who have side effects of neurosis as a feature of another ailment may likewise have a coming and going mental course. 5.5 KEYWORDS • Grandiose: Individuals encountering grandiose delusions frequently portray overwhelming sensations of prevalence and safety. So, grandiosity is a misrepresented feeling of one's significance, force, information, or personality, regardless of whether there is little proof to help the convictions. • Genetics: Emerged from the gene qualities, the crucial units liable for heredity. Hereditary qualities might be characterized as the investigation of qualities at all levels, remembering the ways for which they act in the phone and the manners by which they are communicated from guardians to posterity. • Huntington's Disease(HD):It is a growing brain disorder issue brought about by an imperfect quality. This illness causes changes in the focal space of the cerebrum, which influence development, temperament and thinking abilities. • Parkinson's Disease: A brain disorder prompts shaking, solidness, and trouble with strolling, equilibrium, and coordination. Parkinson's side effects ordinarily start steadily and deteriorate over the long haul. As the infection advances, individuals may experience issues strolling and talking. • Wilson's Disease: A hereditary problem wherein abundance copper develops in the body. indications are commonly identified with the mind and liver. liver-related 161 CU IDOL SELF LEARNING MATERIAL (SLM)
indications incorporate spewing, shortcoming, liquid development in the mid-region, growing of the legs, yellowish skin and irritation. 5.6 LEARNING ACTIVITY 1. Conduct a session in a locality with different individuals and figure out if any is struggling with any delusional disorder. ………………………………………………………………………………………………… …………………………………………………………………………………………………. 2. Conduct a session with a person affected with delusions and, list down the session points, and measure the outcome. and provide the solutions for the same. ………………………………………………………………………………………………… …………………………………………………………………………………………………. 5.7 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are the causes of delusional disorder? 2. Write a short note on causes of erotomanic. 3. Write a short note on causes of grandiose. 4. What is persecutory delusion prognosis? 5. Write a short note grandiose prognosis. Long Questions 1. What are the causes of delusional disorder? 2. Illustrate the prognosis and treatment on persecutory delusion. 3. Illustrate the prognosis and treatment on delusion of grandeur 4. Illustrate the prognosis and treatment on delusional jealousy. 5. Describe the any one prognosis treatment from own study of delusion. B. Multiple Choice Questions 1. _________ may be a symptom of a psychiatric illness. a. Grandiose b. Erotomanic c. Persecutory d. None of these 162 CU IDOL SELF LEARNING MATERIAL (SLM)
2. ________ delusions usually occur in patients with syndromes associated with secondary mania, such as Huntington's disease. a. Grandiose b. Erotomanic c. Hallucinogens d. None of these 3. A diagnosis of delusional disorder_____type requires that “an individual experiences persistent, unrelenting content-specific delusions of a partner’s infidelity that cannot be explained by a conjoint history of schizophrenia, drugs, or physical illness. a. Grandoise b. Persecutory c. Jealous d. Somatic 4. ______are fixed beliefs that are not amenable to change in light of conflicting evidence. a. Erotomania or delusion of love b. Somatic c. Persecutory d. None of these 5. People with delusional disorder experience _______, which involve situations that could occur in real life, such as being followed, poisoned, deceived, conspired against, or loved from a distance? a. Somatic delusional disorders b. Bizarre delusion c. Non-bizarre delusions d. All of these Answers 1.b) 2. a) 3. c) 4.d) 5.c) 5.8 REFERENCES Textbooks • Advisory Council on the Misuse of Drugs (ACMD). Hidden Harm: Responding to the Needs of Children of Problem Drug Users. London: Home Office; 2003. • Garfield, S.L. and Bergin, A.E. (Eds.) (1986) Handbook of Psychotherapy and Behaviour Change. New York: John Wiley. 163 CU IDOL SELF LEARNING MATERIAL (SLM)
• Wolman, B.B. (1965). Handbook of Clinical Psychology. New York: McGraw Hill. Reference Books • Moore DP, Jefferson JW. Paranoid personality disorder. In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier; 2004: chap 134. • Satterfield JM, Feldman MD. Paranoid personality disorder. In: Ferri FF, ed. Ferri’s Clinical Advisor 2008: Instant Diagnosis and Treatment. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008. • Freeman, D. & Garety, P. A. (2004). Paranoia: The Psychology of Persecutory Delusions. Hove: Psychology Press. Websites • https://en.wikipedia.org • https://www.verywellmind.com • https://www.emedicinehealth.com 164 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 6: MOOD DISORDERS 165 STRUCTURE 6.0 Learning Objectives 6.1 Introduction 6.2 Types of Mood Disorder 6.2.1 Major Depressive Disorder 6.2.2 Bipolar I Disorder 6.2.3 Bipolar II Disorder 6.2.4 Cyclothymic Disorder 6.2.5 Other 6.2.6 New Mood Disorders 6.3 DSM Criteria 6.4 Incidence 6.5 Prevalence 6.6 Co-morbidity 6.7 Causes of Mood Disorder 6.8 Prognosis and Treatment 6.9 Summary 6.10 Keywords 6.11 Learning Activity 6.12 Unit End Questions 6.13 References 6.0 LEARNING OBJECTIVES After studying this unit, student will be able to: ● Define mood and mood disorders. CU IDOL SELF LEARNING MATERIAL (SLM)
● State the common mood disorders. ● Describe the identification and diagnosis of mood disorders. ● Explain the causes of mood disorders. ● Describe the prognosis. 6.1 INTRODUCTION The term 'mind-set' is ordinarily utilized in the English language to signify 'mood', 'temper', and so on. In any case, the term mind-set with regards to a mental ailment is utilized in an alternate manner. 'Disposition' and a connected term 'influence' are utilized to portray feelings and sentiments. Temperament is a supported inclination to express what is capable inside and impacts an individual's conduct and attention to the world. Influence is the outward appearance of a mind-set and is recognized by appearances. can be typical, merry, discouraged, bad tempered, restless and so forth. In disposition issues, the major unsettling influence is change in mind-set or influence, typically to gloom or to liveliness. The mind-set change is joined by the adjustment of the general movement of an individual. These progressions are determined (keep going for delayed timeframes, normally for quite a long time), inescapable (influence all parts of an individual's life) and affect individual, natural and socio-word related working of an individual. As per the Diagnostic and Statistical Manual (DSM-IV-TR) of Mental Disorders, disposition problems allude to a gathering of determination where an unsettling influence on the individual's mind-set is speculated to be the principle fundamental element. Mind-set issues are passionate unsettling influences comprising of delayed times of exorbitant bitterness, unreasonable cheerfulness or both. Along these lines, there might be serious bitterness, called discouragement or extraordinary delight, named madness, or it tends to be a mix of both sadness and craziness, called bipolar turmoil. Misery can also be classified as mild (dysthymia), moderate (dysthymia), or severe (dysthymia) depending on the number of grumbles and the degree of resulting brokenness. Checklist for identifying mood disorders ● Depressed state or feeling blue/down throughout the day or for most part of the day for the last two weeks. ● Unable to enjoy the things used to enjoy earlier for the last two weeks. ● Loss of interest in most of the things during the last two weeks. ● Feeling of sadness or depressed state for the last two years. ● A very high level of energy, excitement, and a feeling of ‘High’ as ‘Very Good’ – which is not the usual self of the person. 166 CU IDOL SELF LEARNING MATERIAL (SLM)
Mood disorders are described by an aggravation in the guideline of temperament, conduct, and influence. Mood disorders are partitioned into: (1) Depressive disorders, (2) Bipolar disorders, and (3) Depression in reference to clinical sickness or liquor and substance misuse. All disorders are separated from bipolar disorders by the absence of a manic or hypomanic episode. The World Health Organisation, (WHO) specified that unipolar major depression positioned fourth among all sicknesses as far as inability changed life years and was projected to rank second by 2020. Mood disorders, also called affective disorders, are a gathering of diseases that as their distinctive trademark, an encounter of temperament that is surprising for the conditions. Most mood disorders issues are at any rate to some degree treatable with medications and psychotherapy. At larger times, the major reason for such disorder to occur is due to the fluctuating chemicals in the body influencing the working of thyroid or affecting the brain leading to the ineffective brain function producing incorrect levels of various neurotransmitters. Mood disorders with this genealogy can be rectified with the aid of medication along with nutritional supplements. In this unit we will be dealing with mood disorders, their definition, their types, symptoms and causes along with solutions described for every variety. 6.2 TYPES OF MOOD DISORDERS As you have already studied in Unit 1, in India, Chapter V (F) of tenth revision of International Classification of Diseases (ICD -10) is used for making diagnosis of psychiatric disorders. Mood disorders present as episodes (with identifiable beginning and ending). They may present as a single episode only or may be recurrent (two or more episodes). There are two types of episodes: manic and depressive episodes. In manic episodes, the central feature is elevated mood accompanied by increase in physical and mental activity. Hypomania is a less severe form of mania. A depressive episode causes reduced physical and mental activity due to depressed mood. In view of the seriousness, in terms of state of mind, issues are grouped into different scenes. Each may have unique burdensome as well as hyper types of scenes, in addition to the seriousness and terms of the manifestations. In this way, when a patient presents to you, the initial step is to lead a clinical meeting to gather itemized data on history and direct mental assessment. On the off chance that natural sicknesses/psychoactive substances are not the 167 CU IDOL SELF LEARNING MATERIAL (SLM)
situation of introducing issues, the presence of run of the mill signs and side effects help in making an analysis of insanity or sadness as per demonstrative rules. With the information on the kind of the scene of madness or wretchedness and its seriousness, the last finding is made by the sort of mind-set issue as given in ICD-10. In ICD-10, disposition problems are characterized under segment F30-39 as follows: F30 Manic episode: There is only a single episode of mania and the level of severity of symptoms can be from hypomania to severe mania. F31 Bipolar affective disorder: This is characterised by repeated episodes (at least two) of either mania or hypomania only or episodes of both depression and hypomania/ mania. These are of two types: bipolar I and bipolar II. In bipolar I, patients may have only episodes of mania or of both depression and mania. In bipolar II, patients may have episodes of hypomania only or of both depression and hypomania. F32 Depressive episode: There is only a single episode of depression and the level of severity of symptoms can be mild to severe. F33 Recurrent depressive disorder: This is characterised by repeated (at least two) episodes of depression. F34 Persistent mood disorder: In these types of disorders, persistent, longstanding fluctuating mood is present. The symptoms are rarely, if ever, sufficiently severe to be diagnosed as mild depression or hypomania. Dysthymia is characterised by persistent, long standing low grade depressive symptoms and in cyclothymia patients may have persistent, long standing frequent mood swings of mild depression and mild cheerfulness. F38 Other mood disorder: Mixed affective episode and recurrent brief depressive disorder are classified here. In mixed affective episodes, the patient may experience either a mixture or a rapid alternation (usually within a few hours) of hypomanic, manic, and depressive symptoms. In recurrent brief depressive disorder, patients may experience recurrent (every month) depressive episodes of shorter duration (< 2 weeks). F39 Unspecified mood disorder is diagnosed when diagnostic guidelines of any of the categories mentioned above are not met with. 6.2.1 Major Depressive Disorder Indications in history from witnesses/patients The changes in behaviour are initially noticed by people who have close contact with the patients, for example, relatives, companions, or instructors, and are minor, for example, 168 CU IDOL SELF LEARNING MATERIAL (SLM)
difficulty sleeping or waking up early, missing appointments/dinners, and being unaware of daily errands. They begin feeling tragic and the trouble doesn't improve because of progress in conditions and might be more awful in the first part of the day. Once in a while, patients might be restless or crabby. They stress over trivial issues and have negative reasoning. They express that they are unequipped to be busy, useless and no good thing will occur in the future. They may communicate blame for their past acts/choices. They lose interest in everyday exercises and despise already pleasurable exercises like staring at the TV, understanding papers, and so forth. They feel tired even without doing a lot of movement and experience issues in completing everyday undertakings. They grumble of cognitive decline which is because of helpless fixation. Their discourse, walking and different activities become moderate. They additionally begin pulling out of social connections and like to remain alone. They express questions in regard to their capacities to complete an errand. They have intermittent contemplations of death and are distracted by death and passing on. They grumble about actual grumblings like body throbs, cerebral pain, impression of sickness, tipsiness, issues of acid reflux like obstruction and burping. It has been seen in different examinations that individuals from Asian nations will in general report more actual indications as opposed to low mind-set when they are experiencing burdensome turmoil. In addition to sleeping problems, they suffer from a loss of appetite and weight. They regularly gripe about clogging. Their advantage in sexual movement diminishes. As the disease advances, previously mentioned manifestations get exasperated, and they get nearly kept in bed. They may begin effectively thinking about taking their lives as they accept that they can't be restored or helped in any capacity and may design/endeavour self- destruction. Around 66% of all discouraged patients have self-destructive thoughts, and around 10-15% may end it all. They may likewise begin communicating deceptions that they have been answerable for the difficulties looking without help from anyone else, family and, surprisingly, the world, have turned poor, their body parts have rotted, or they have kicked the bucket. They may likewise report hearing voices blaming them. In serious cases, the patient may not talk or move by any stretch of the imagination, that is, there is extreme psychomotor impediment. In kids, school refusal, diminished interest in playing and over the top, sticking to guardians might be reminiscent of misery. In teenagers, notwithstanding common indications of discouragement, side effects like helpless academic execution, crabbiness, sexual indiscrimination, and delinquency might be reminiscent of melancholy. In older people, actual grumblings might be the main manifestation of depression. Signs On Psychiatric Examination 169 CU IDOL SELF LEARNING MATERIAL (SLM)
They have diminished psychomotor movement. They may set aside a long effort to respond to the inquiries posed; their discourse might be of low volume, moderate and repetitive. They portray their state of mind as discouraged with an unmistakable quality, may feel numb and without all emotions. At times, temperament might be restless or touchy. They may seem sad and begin crying. They have anhedonia (decreased/loss of interest or joy in beforehand charming exercises). They have anergia (decreased or no energy, stamped sluggishness even on slight exertion). They express thoughts of sadness, defencelessness and uselessness; this set of three is known as burdensome discernments. They may have thoughts of blame. They may also express death wishes and self-destructive thoughts. In serious cases, various kinds of dreams harmonious with the topic of discouraged state of mind might be available. The thoughts of blame might be held with conviction and satisfy measures of fancy. They may have dreams of neediness that they have gotten poor, of scepticism that they don't exist or of medical affliction. They may likewise have persecutory and referential daydreams. They may also have audible and visual visualizations. A few patients may show mental highlights like mutism and trance. In extreme cases, their judgment might be debilitated and may deny any requirement for treatment as they may accept that nothing can help them. 6.2.2 Bipolar I Disorder Bipolar Disorder or hyper burdensome problem is likewise known as bipolar emotional issue or hyper discouragement. It is a mental conclusion that depicts an order of manner issues portrayed by the presence of at least one scene of abnormally elevated energy levels, cognizance, and perspective with or without, at the very least, one burdensome scene. Madness or, if milder, hypomania is a term utilized clinically to mean increased states of mind. People experience hyper scenes alongside burdensome scenes, or manifestations, or blended scenes in which highlights of both madness and sorrow are available all the while. These conditions are regularly alluded to as times of \"typical\" disposition. However, special cases are people who rapidly experience both gloom and insanity. This speedy change in an individual is called fast cycling. Conclusion depends on the individual's self-detailed encounters, just as noticed conduct, which incorporates misery, disturbance and hazard of self-destruction. The expression \"bipolar confusion\" starts and alludes to the cycling among high and low scenes (posts). The connection between lunacy and sadness had for some time been observed, albeit the reason for the current conceptualisation can be followed back to French experts during the 1850s. Emil Kraepelin, a German expert, coined the term \"hyper burdensome sickness\" or psychosis in the late nineteenth century, initially implying a wide range of outlook issues. 170 CU IDOL SELF LEARNING MATERIAL (SLM)
German therapist Karl Leonhard split the characterization again in 1957, utilizing the terms unipolar turmoil (significant burdensome issue) and bipolar problem. Symptoms of Bipolar Disorder I ● Feeling unusually “high” and optimistic or irritability. ● Unrealistic, grandiose beliefs about one’s abilities or powers. ● Sleeping very little, but feeling extremely energetic. ● Talking so rapidly that others can’t keep up. ● Racing thoughts; jumping quickly from one idea to the next. ● Highly distractible, unable to concentrate. ● Impaired judgment and impulsiveness. Causes of Bipolar Disorder I Genetic Factors When talking about biological causes, the first issue is whether bipolar disorder can be inherited. This question has been researched through multiple family, adoption and twin studies. In families of persons 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 (3). 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 . Neurochemical Factors in Bipolar Disorder Bipolar disorder is primarily a biological disorder that occurs in a specific area of the brain and is due to the dysfunction of certain neurotransmitters, or chemical messengers, in the brain. Environmental Factors in Bipolar Disorder A life event can trigger a mood episode in individuals with a genetic disposition for this kind of disorder. Bipolar disorder appears at an increasingly early age. A life event may trigger a mood episode in a person with a genetic disposition for bipolar disorder. Treatment of Bipolar Disorder I Medications There is a wide variety of medications that are used in treatment. Each group of medications treats a particular set of symptoms. Side effects are common: some may cause a patient to discontinue the medication, others may go away with time or be tolerable or treatable. Psychological Therapy 171 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychiatrists, psychologists, therapists and counsellors. Primary physicians, psychiatric nurses, social workers and psych pharmacologists. Psychiatric Hospitalisation Sometimes it is necessary to get 24-hour monitoring and treatment. The hospital can only provide control and proper care. 6.2.3 Bipolar II Disorder According to the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), bipolar II disorder is characterised by one or more major depressive episodes accompanied by at least one hypomanic episode. The critical contrast between bipolar 1 and bipolar 2 is that bipolar 2 has hypomanic yet not hyper episodes. Notwithstanding, in bipolar II problem, the \"up\" temperaments never arrive at full during the fundamental scenes. The less exceptional raised temperaments in bipolar II issue are called hypomanic episodes, or hypomania. An individual influenced by bipolar II problem has had at any rate one hypomanic scene throughout everyday life. The vast majority with bipolar II problems likewise experience the ill effects of scenes of despondency. This is the place where the expression \"hyper despondency\" comes from. In the middle of scenes of hypomania and wretchedness, numerous individuals with bipolar II problems carry on with ordinary lives. Symptoms of Bipolar Disorder II • Decreased energy • Weight loss or gain • Despair • Irritability • Uncontrollable crying Symptoms And Characteristics Of Hypomania Include • Grandiosity • Decreased need for sleep • Pressured speech • Racing thoughts • Distractibility • Behaviours that affect severely like becoming a spendthrift and improper sexual experiences • Excess energy 172 CU IDOL SELF LEARNING MATERIAL (SLM)
Causes of Bipolar Disorder II Genetic Factors The major consequence of bipolar disorder is of inheritance. In groups of people with bipolar confusion, first degree family members (guardians, kids, kin) are bound to have a state of mind disorders than the family members of the individuals who don't have bipolar turmoil. Investigations of twins show that on the off chance that one twin has a temperament issue, an indistinguishable twin is around multiple times almost certain than an intimate twin to have a disposition problem too. Neurotransmitters The neurotransmitter system has received a great deal of attention as a cause of bipolar disorder. Some studies suggest that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause. Stress Triggers For mental, emotional and environmental issues, distressing life occasions are believed to be the primary component in the improvement of bipolar problems. These can go from a passing in the family to the departure of a task, from the introduction of a youngster to a move. Neurotransmitters The neurotransmitter system has received a great deal of attention as a cause of bipolar disorder. Some studies suggest that a low or high level of a specific neurotransmitter such as serotonin, norepinephrine or dopamine is the cause. 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. Treatment of Bipolar Disorder II Mood Stabilising Medications These are generally the best option to treat bipolar confusion. By and large, individuals with bipolar turmoil proceed with treatment with state of mind stabilizers for quite a long time. Aside from lithium, a significant number of these drugs are anticonvulsants. Anticonvulsant prescriptions are generally used to treat seizures, yet they likewise help control states of mind. These meds are usually utilized as disposition stabilizers in bipolar confusion: Antidepressant Medications These medicines are also used to diagnose symptoms of depression in bipolar disorder. People with bipolar disorder also intake mood stabilisers . The following are few psychotherapy treatments to diagnose bipolar disorder. Cognitive Behavioural Therapy (CBT) This helps people with bipolar disorder to overcome risky or negative thought patterns and behaviours. Family Focused Therapy 173 CU IDOL SELF LEARNING MATERIAL (SLM)
This therapy involves family coping strategies, like making them revisit new episodes early and helping their loved one. This therapy also enhances communication and to solve problems. Interpersonal And Social Rhythm Therapy This therapy enhances the bond with people and organises daily activities. Regulating daily routines and sleep schedules help to overcome manic episodes. Psychoeducation This method focuses on diagnosing illness as a result of bipolar disorder. This treatment seeks to identify the indications of relapse so they can look for treatment ahead of schedule, before an out and out scene happens. Generally done in a gathering, psychoeducation may likewise be useful for relatives and guardians. 6.2.4 Cyclothymic Disorder Cyclothymia is a temperament issue that causes hypomanic and delicate troublesome scenes. A singular scene of hypomania is satisfactory to break down cyclothymic disarray. In any case, the vast majority of people experience dysthymic episodes. When there is a foundation set apart by craziness, critical difficult scene, or mixed scene, the determination of a cyclothymic issue is not made. The lifetime regularity of cyclothymic issues is 0.4 to 1%. The rate appears to be comparable in individuals. Women even more routinely search for treatment. Cyclothymia resembles bipolar II issue in that it presents itself in conventional hypomanic scenes. Because hypomania is frequently associated with phenomenally innovative, dynamic, and advanced direct, the two conditions go unnoticed. Similarly, with such a large number of issues in the bipolar range, it is the difficult stage that drives the majority of casualties to seek help. Symptoms Dysthymic Phase Symptoms in this phase are poor decision making, lack in concentration, memory loss, feeling negative, guilt, self-criticism, low self-esteem, self-destructive thinking, melancholic, apathy etc. Euphoric Phase Symptoms in this phase are feeling elated and being positive along with inflated self-esteem, poor judgment, speedy conversation, rapid thoughts, ,forceful or unfriendly conduct, being rude of others, tumult, expanded active work, dangerous conduct, spending binges. Hypomanic Phase of Cyclothymic Disorder 174 1) Unusually good mood or cheerfulness (euphoria) 2) Extreme optimism CU IDOL SELF LEARNING MATERIAL (SLM)
3) Inflated self-esteem 4) Poor judgment 5) Rapid speech Depressive Phase of Cyclothymic Disorder 1) Sadness 2) Hopelessness 3) Suicidal thoughts or behaviour 4) Anxiety 5) Guilt 6) Sleep problems The reason for cyclothymic confusion is obscure. Although the progressions in mind-set are sporadic and unexpected, the seriousness of the emotional episodes is definitely less limit than that seen with bipolar confusion (manic depressive illness). Dissimilar to in bipolar confusion, times of hypomania in cyclothymia turmoil don't advance into real mania. Treatment of Cyclothymic Disorder Antidepressant Medication for Cyclothymia A preliminary of lithium carbonate is frequently attempted, particularly if the emotional episodes appear to be like those found in bipolar turmoil. Solution of such a medicine however ought to be reliant upon a careful clinical assessment and history of the patient. Psychotherapy for Cyclothymia Mental treatment typically focuses on the presence of change caused by Cyclothymia, as well as assisting the individual in recognizing the onset of a Cyclothymia and taking corrective action. Treatment routinely shows up as individual psychotherapy, in spite of the way that bundle treatment can similarly be valuable for this issue. Self Help for Cyclothymia Lifestyle changes almost always have a positive outcome, but they can take more effort to implement as the plunge becomes more genuine. Personal development methods for the treatment of this issue are routinely ignored by clinical bringing because there aren't many specialists associated with them. 6.2.5 Other There are various classes of demeanor that consolidate substance/solution and restoratively instigated disposition issues. There are moreover \"other indicated\" and \"undefined\" demeanor that don't all around fulfil guidelines for the other perspective issues. Premenstrual Dysphoric Disorder - This sort of mood disorder happens seven to 10 days before feminine cycle and disappears inside a couple of days of the beginning of the feminine time frame. Analysts accept this problem is achieved by the hormonal changes identified with 175 CU IDOL SELF LEARNING MATERIAL (SLM)
the feminine cycle. Indications may incorporate displeasure, crabbiness, pressure, diminished revenue in common exercises, and rest issues. Intermittent Explosive Disorder - This is a lesser-realized temperament issue set apart by scenes of unjustifiable indignation. It is usually alluded to as \"flying into a rage for no reason\" In a person with an irregular unstable problem, the conduct upheavals are messed up with regards to the circumstance. 6.2.6 New Mood Disorders (At least five) of the accompanying side effects have been available during a similar 2-week time frame and address a change from past working; at any rate one of the manifestations is either (1) discouraged disposition or (2) loss of premium or joy. Note: Try not to incorporate indications that are unmistakably owing to another ailment. Discouraged temperament a large portion of the day, practically consistently, as shown by either abstract report (e.g., feels tragic, unfilled, sad) or perception made by others (e.g., seems sorrowful). (Note: In youngsters and youths, can be crabby mind-set.). 1. Extraordinarily reduced interest or delight taking all things together, or practically all, exercises the vast majority of the day, virtually consistently (as shown by either abstract record or perception). 2. Critical weight reduction when not abstaining from excessive food intake or weight acquisition (e.g., a difference in over 5% of body weight in a month) or lessening or expansion in hunger practically consistently. (Note: In children, consider failure to make expected weight gain.). 3. Sleep deprivation or hypersomnia practically consistently. 4. Psychomotor fomentation or hindrance virtually consistently (detectable by others, not simply abstract sensations of anxiety or being eased back down). 5. Exhaustion or loss of energy essentially consistently. 6. Sensations of uselessness or exorbitant or unseemly blame (which might be capricious) practically consistently (remorse or blame about being wiped out). 7. Lessened capacity to think or focus, or uncertainty, virtually consistently (either by abstract record or as seen by others). 8. Repetitive contemplations of death (not simply dread of passing on), intermittent self- destructive ideation with-out a particular arrangement, or a self-destruction endeavour or a particular arrangement for ending it all. B. The manifestations cause clinically critical pain or weakness in friendly, word related, or other significant spaces of working. C. The scene isn't owing to the physiological impacts of a substance or to another ailment. Note: Criteria A–C represent a major depressive episode. 176 CU IDOL SELF LEARNING MATERIAL (SLM)
Note: Responses to a huge misfortune (e.g., deprivation, monetary ruin, misfortunes from a catastrophic event, a genuine clinical disease or handicap) may incorporate the sensations of exceptional trouble, rumination about the misfortune, a sleeping disorder, helpless craving, and weight reduction noted in Criterion A, which may look like a burdensome scene. Albeit such indications might be justifiable or thought about suitable to the misfortune, the presence of a significant burdensome scene notwithstanding the typical reaction to a huge misfortune ought to likewise be painstakingly thought of. This choice definitely requires the activity of clinical judgment dependent on the person's set of experiences and the social standards for the statement of pain with regards to loss. D. The event of the significant burdensome scene isn't better clarified by schizoaffective confusion, schizophrenia, schizophreniform jumble, whimsical turmoil, or other determined and undefined schizophrenia range and other crazy problems. E. There has never been a hyper scene or a hypomanic scene. Note: This prohibition doesn't make a difference if the entirety of the hyper like or hypomanic-like scenes are substance-initiated or are owing to the physiological impacts of another ailment. 6.3 DSM CRITERIA Depressive disorders include disruptive mood dysregulation disorder, major depressive disorder (including major depressive episode), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorder, and unspecified depressive disorder. Unlike in DSM-IV, this chapter. “Depressive Disorders” has been separated from the previous chapter “Bipolar and Related Disorders.” The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. What differs among them are issues of duration, timing, or presumed etiology. In order to address concerns about the potential for the overdiagnosis of and treatment for bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, referring to the presentation of children with persistent irritability and frequent episodes of extreme behavioural dyscontrol, is added to the depressive disorders for children up to 12 years of age. Its placement in this chapter reflects the finding that children with this symptom pattern typically develop unipolar depressive disorders or anxiety disorders, rather than bipolar disorders, as they mature into adolescence and adulthood. Major depressive disorder represents the classic condition in this group of disorders. It is characterized by discrete episodes of at least 2 weeks’ duration (although most episodes last considerably longer) 177 CU IDOL SELF LEARNING MATERIAL (SLM)
involving clear-cut changes in affect, cognition, and neurovegetative functions and inter- episode remissions. A diagnosis based on a single episode is possible, although the disorder is a recurrent one in the majority of cases. Careful consideration is given to the delineation of normal sadness and grief from a major depressive episode. Bereavement may induce great suffering, but it does not typically induce an episode of major depressive disorder. When they do occur together, the depressive symptoms and functional impairment tend to be more severe, and the prognosis is worse compared with bereavement that is not accompanied by major depressive disorder. Bereavement-related depression tends to occur in persons with other vulnerabilities to depressive disorders, and recovery may be facilitated by antidepressant treatment. A more chronic form of depression, persistent depressive disorder (dysthymia), can be diagnosed when the mood disturbance continues for at least 2 years in adults or 1 year in children. This diagnosis, new in DSM-5, includes both the DSM-IV diagnostic categories of chronic major depression and dysthymia. After careful scientific review of the evidence, premenstrual dysphoric disorder has been moved from an appendix of DSM-IV (“Criteria Sets and Axes Provided for Further Study”) to Section II of DSM-5. Almost 20 years of additional research on this condition has confirmed a specific and treatment-responsive form of depressive disorder that begins sometime following ovulation and remits within a few days of menses and has a marked impact on functioning. A large number of substances of abuse, some prescribed medications, and several medical conditions can be associated with depression-like phenomena. This fact is recognized in the diagnoses of substance/medication-induced depressive disorder and depressive disorder due to another medical condition. 6.4 INCIDENCE In 1999, more women than men were hospitalized for major depressive disorder in every age group except 90+ years (Figure 6.1). Young women aged 15-19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women between the ages of 40 and 44 years and men between the ages of 85 and 89 years had the highest rates of hospitalization for their sex. 178 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 6.1 Incidence Study In 1999, in all except the 5–9-year age group, women were hospitalized for bipolar disorder at significantly higher rates than men (Figure 6.2). This contrasts with the generally accepted equal ratio of prevalence of the disorder among men and women. Further research is needed to explain this distribution. Women were most frequently hospitalized for bipolar disorder between the ages of 40 and 44 years. 179 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 6.2 Incidence Survey 6.5 PREVALENCE Disruptive mood dysregulation disorder is common among children presenting to paediatric mental health clinics. Prevalence estimates of the disorder in the community are unclear. Based on rates of chronic and severe persistent irritability, which is the core feature of the disorder, the overall 6-month to 1-year period-prevalence of disruptive mood dysregulation disorder among children and adolescents probably falls in the 2%–5% range. However, rates are expected to be higher in males and school-age children than in females and adolescents. 6.6 CO-MORBIDITY Speeds of comorbidity in dangerous perspective dysregulation issues are incredibly high. It is extraordinary to find individuals whose results satisfy guidelines for dangerous perspective dysregulation alone. Comorbidity between dangerous perspective dysregulation issues and other DSM-described conditions appears to be higher than for some other paediatric useless practices; the most grounded cover is with oppositional insubordinate disarray. Not solely is the overall speed of comorbidity high in hazardous outlook dysregulation issues, yet furthermore the extent of comorbid illnesses appears particularly various. These children normally present to the middle with a wide extent of irksome direct, perspective, pressure, and surprisingly mental awkwardness range signs and decisions. In any case, kids with dangerous outlook dysregulation issues should not have results that meet models for bipolar 180 CU IDOL SELF LEARNING MATERIAL (SLM)
disarray, as around there, simply the bipolar issue assurance should be made. If youths have signs that meet measures for oppositional defiant strife or spasmodic insecure issue and inconvenient air dysregulation issue, simply the finding of risky disposition dysregulation issue should be consigned. Similarly, as verified earlier, the assurance of tricky perspective dysregulation issue should not be allowed if the appearances happen simply in an anxiety inducing setting, when the timetables of an adolescent with substance awkwardness range issue or obsessive pressing issue are vexed or concerning a critical oppressive scene. 6.7 CAUSES OF MOOD DISORDERS The affliction of major depressive disorder is amalgamation of anxiety, medical illness, brain chemistry, family history, and psychosocial environment. It is unsure to determine what dominates among them, but abnormal levels of the neurotransmitters norepinephrine, serotonin, and dopamine are closely linked with depression. The major reason for depression being “chemical imbalance” These neurotransmitters are crucial in determining the working of pleasure and moods in an individual. Genetic Risk Factors for Depression Analysis reflects that offspring of guardians who experience depression are bound to build up the actual turmoil. An individual has a 27% possibility of acquiring a disposition issue from one parent, and this possibility duplicates if the two guardians are influenced. Investigations of the event of sadness in twins show a 70% possibility for both indistinguishable twins to experience the ill effects of gloom, which is double the pace of the event in friendly twins. Psychosocial and Environmental Risk Factors for Depression Depression is prevalent who have experienced trauma, sexual misuse, actual maltreatment, actual handicap, mourning at a youthful age, liquor abuse, and inadequate family structure. In grown-ups, the departure of a life partner is the most widely recognized reason for a depression . Ladies are at expanded danger for despondency during and inside the initial not many months after pregnancy (called postpartum anxiety). Persistent despondency might be more normal in regions burdened with war, catastrophic events, destitution, or disregard. The following cognitive factors (which affect judgment and perception) are associated with depression: • Chronic low self-esteem 181 • Distorted perception of others’ views • Distorted sense of life experience • Inability to acknowledge personal accomplishment CU IDOL SELF LEARNING MATERIAL (SLM)
• Negative idea of self • Pessimistic outlook • Quick and exaggerated temper. Age and Depression Risk It is known that depression can occur at any age, its onset is typically between the ages 24 and 44. Later onset may correlate with the absence of a family history of depression. Fifty percent of people with major depressive disorder experience their first episode of depression at about age 40, but this may be shifting to the 30s. Studies find that the rate of incidence is higher among middle aged people. Teenagers are more at risk for depression. The evidence is in teen suicide rates, which are increasing yearly. Problems with self-esteem may result from failure or disinterest in meeting these expectations. Low self-esteem can lead to a negative perspective of life and depression. Gender and Depression Risk In terms of Gender, it is observed 10% of male and 20% of female are affected. Hormonal differences may put women at a higher risk for depression. Hormone levels are influenced by pregnancy, and many women experience depression after delivery. The shift in the levels of depression in men and women may reflect behaviours based on learned gender roles. Learned helplessness and socioeconomic stressors may result in depression in women. Race and Class and Depression Risk The race and class of the individuals are also affected by depression. The socioeconomic background is the major factor for predisposing the depressive behaviour. Anxiety Tension in an individual with significant depression prompts a more unfortunate reaction to therapy, less fortunate social and work, more noteworthy probability of chronicity and an expanded danger of self-destructive conduct. 80 to 90% of people with burdensome confusion perpetually likewise have nervousness indications. Medical Illness It has been tracked down that about 5% of people at first analysed as having Major Depressive Disorder therefore are found to have another clinical sickness which was the reason for their downturn. 25% of people with serious, persistent clinical ailment (e.g., diabetes, myocardial localized necrosis, carcinomas, stroke and so on) create gloom. 182 CU IDOL SELF LEARNING MATERIAL (SLM)
Ailments frequently causing sadness are: Endocrine problems like hypothyroidism, hyperparathyroidism, Cushing's infection, and diabetes mellitus. 6.8 PROGNOSIS AND TREATMENT Psychotherapy is a strategy that can be received by both individuals and at many levels, led by emotional wellness experts, including psychotherapists, specialists, therapists, clinical social laborers, advisors, and appropriately prepared mental medical caretakers. Prescriptions should just be offered in combination with mental treatment, like CBT, relational treatment, or family treatment. Psychotherapy works at a more prominent level among old individuals. has been demonstrated to be successful in more seasoned individuals. The most read type of psychotherapy for discouragement is CBT, which instructs customers to challenge pointless, suffering perspectives (comprehensions) and change counterproductive practices. Antidepressants are given in more modest measurement to those with gentle or moderate discouragement, yet a substantial dose is given to those with extreme sadness. The effects of antidepressants are somewhat better than those of psychotherapy, particularly in cases of ongoing significant discouragement; however, in preliminary studies, more patients, particularly those with fewer genuine types of sadness, discontinue medication than discontinue psychotherapy, undoubtedly due to unfavorable effects from the prescription and to patients' proclivity for mental illness. Stimulant medicine treatment and, surprisingly, as long as one year of continuation is suggested. Pharmacological and psychosocial interventions are used by executives of patients with temperament issues. The objective of the treatment of patients with mind-set problems is to diminish the manifestations, achieve early recuperation, reduce the brokenness, and to forestall events of future scenes. The treatment is arranged by the particular requirements of the patients and their families. Pharmacological Treatment Mind-set stabilizer drugs are the backbone of treatment for disposition problems and are treatment of decision for remedial (treatment of an individual scene) and for prophylactic (avoidance of future scenes) treatment of temperament issues. Nonetheless, for a scene of discouragement, energizer drugs are utilized, and antipsychotic drugs are utilized for quick control of insanity. The vast majority of patients with temperament issues can remain at home and be treated on an outpatient premise. Patients with severe disease who refuse to eat or take medications, are at increased self-destructive risk, exhibit horribly disordered or unseemly behaviour, and are 183 CU IDOL SELF LEARNING MATERIAL (SLM)
unmanageable and vicious are recommended for brief hospitalization (two and a half months). The treatment of mental health issues should begin as soon as possible because, in the event of craziness, the presence of erroneous thinking, impulsivity, and forcefulness may endanger the patient and others, and if there is an occurrence of gloom, the delay prompts the prolongation of wretchedness. A portion of the patients with temperament problems might not have any desire to be dealt with due to misguided thinking, e.g., in madness because of thrilled state of mind and vainglorious thoughts, the patient may not feel the requirement for treatment; and in sorrow, the patient may not need treatment as a result of thoughts of misery. Huge quantities of medications are accessible for use and ought to be endorsed by a certified doctor. There is a delay in the beginning of impact of upper and disposition stabilizer drugs; it might require 2-3 weeks before their impact develops completely. Be that as it may, antipsychotic drugs for treatment of lunacy show fast impact and the improvement begins inside seven days. The improvement happens progressively. First rest, craving and individual consideration improve, followed by perking up and mutilated reasoning. A medication ought to be gone after for at least a month and a half in sufficient measurement prior to evolving it. Substance abuse, such as the use of cannabis, interferes with the efficacy of treatment and may result in the discontinuation of medications. It ought to be guaranteed that patients don't burn-through these substances. In patients with the primary scene of insanity or sadness, just remedial utilization of the medications is suggested. After progression, the medications should not be stopped, but should be continued for at least 6-a year or more after the manifestations have vanished. In any case, if there is no repeat, the medications ought to be progressively diminished and halted. In patients with numerous scenes, and fragmented improvement, long haul prophylactic treatment is shown. Because the chances of recurrence are high in patients with bipolar disorder, prophylactic treatment is advised following the subsequent scene. In any case, in patients with first scene craziness, with positive family background of mind-set problems and exceptionally extreme sickness, prophylactic therapy is suggested. In patients with numerous scenes of gloom or fragmented improvement, prophylactic treatment is suggested. The blood levels of temperament stabilizer drugs in the blood ought to be checked occasionally as the low portion has little impact on manifestations and the high portion brings about more results. Issues of consistence with drug treatment, explanations behind helpless medication consistence and how to improve it, have been examined in detail in the section on schizophrenia and other crazy issues. 184 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychosocial Treatment The research indicates that a combination of pharmacotherapy with psychosocial interventions work best for patients with mood disorders. Many types of psychological interventions are available. Psychoeducation The objective of psychoeducation is to engage the patients and their families by giving pertinent data about mind-set problems in straightforward and clear language and assist them with applying this data to their own circumstances. They are taught about the idea of sickness and therapy choices accessible. They are additionally urged to create support instruments to manage issues experienced. Psycho education is simple and can be provided by qualified well-being workers. Relatives have fantasies about the disposition problems and their treatment. Consequently, they are taught about the side effects of disposition problems. The basic fantasy about sorrow is that it is because of character shortcomings of the individual or he/she is imagining. It is additionally accepted that patients need resolve to play out their errands and are not difficult enough to turn out to be okay. Normal legends encompassing medications are that they are compelling and control the brain. These ought to be dissipated by underlining that it is an ailment like other notable sicknesses and are treatable. Accessible treatment alternatives and reasoning of their utilization, results and dose of medications is additionally educated to the patient and relatives. They are informed about the two benefits and symptoms of treatment with the goal of reaching a group decision on the mode and duration of treatment. It is clarified that in spite of the fact that drugs do have some results, their valuable impacts far exceed the unfriendly impacts. Relatives and patients should be told about guaranteeing drug consistence. Management of meds is needed as there is a danger that they may not consume medications because of negative reasoning. They may accept that treatment may not assistance them or may assume control over measurement of drugs as a method of self-destructive endeavour. They are instructed to keep a record concerning the name of meds, results and viability of the meds. Relatives are urged to consider the advancement routinely after patients become okay, when they return to work or concentrate to forestall an abrupt and sudden backslide. People with bipolar problems ought to have a normal day by day and rest routine and ought to stay away from illegal substances. The role of family members in encouraging and supporting patients is also discussed. Relatives are told about the course and result of sickness with and without therapy. 185 CU IDOL SELF LEARNING MATERIAL (SLM)
Relatives should make a rundown of manifestations as these aides in distinguishing early indications of backslide. If these signs are observed, the patient should be taken to a therapist as soon as possible so that the medication can be changed, and a relapse can be avoided. Patients should also learn how to recognize early emotional signs of relapse. They should also have a plan in place for what to do if such abstract manifestations are observed. The patient ought to be instructed to defer any significant choices about connections, occupations, or cash until he/she is well once more. Because of erroneous thinking, they may sell or give properties, request separate, and so on during a disposition scene, especially during a hyper scene. Counselling Counselling is directed at a specific problem, identified to be a trigger/reason for poor improvement of the mood episode, or making it worse e.g., marital problems, sexual problems, problems at the workplace, etc. Supportive Psychotherapy Supportive psychotherapy aims at extending rapport to the patents and their family during and also after the course of illness. Guidance and report is offered at each and every step aimed at improving the condition of the patient as well as to prevent relapse after recovery. Supportive psychotherapy is very important as it conveys to the patient and family that help and support is available whenever there is a need for it. It offers guidance and reassurance which is important for preventing relapse. Interpersonal and Social Rhythm therapy for Bipolar Disorder Interpersonal and social rhythm therapy helps the patients with bipolar disorder to regularize their daily routines and sleep-wake cycles. It also helps them to understand the relationship between mood and interpersonal events. Sleep deprivation has been recognised as a trigger for an episode of mania. Patients should be advised to modify their lifestyles and stick to new lifestyles. They should have regular social and sleep routines; should avoid illicit substances. Also, the focus is on resolving interpersonal issues and problems that may directly impact a person’s routines and the patients are encouraged to build better and healthier interpersonal relationships and skills. Cognitive-behaviour therapy (CBT) for Depression Cognitive behaviour therapy is short term, problem focused, and goal directed therapy. It is based on the premise that faulty ways of thinking can trigger depression. It helps people to achieve changes in the way they think, feel and behave. It focuses on the here and now difficulties. It is carried over weekly sessions for 15-25 weeks. The cognitive techniques involve eliciting automatic thoughts, testing them, identifying maladaptive assumptions and 186 CU IDOL SELF LEARNING MATERIAL (SLM)
testing the validity of maladaptive assumptions. The behavioural techniques help the patients understand the inaccuracy of their cognitive assumptions and learn new ways of dealing with it. ‘Homework’ is given between sessions. Patients are asked to follow a structured daily routine. Once these techniques are taught, the persons have to use these whenever symptoms occur. For mild to moderate depression, cognitive behaviour therapy works well. Physical Exercise for Depression Regular exercise helps to improve symptoms of mild depression. A typical exercise plan for depression with a less severity is recommended with three sessions per week of moderate duration (45- 60 minutes) for 10-12 weeks. Exercises like jogging, brisk walking, swimming, etc are useful. Prognosis In patients with bipolar disorder, most have both depressive and manic episodes, although 10 -20 % experience only manic episodes. In 60-75% of cases, it starts with depression and after the first manic episode, 90% of the patients are likely to have another episode. An untreated manic episode lasts for about 3 months; therefore, drugs should not be stopped before that. Patients may have 2 – 30 numbers of manic episodes, the mean number is about nine and about 5- 15% are rapid cyclers. One third of all patients with bipolar disorder have chronic symptoms. Patients with bipolar disorder have a poorer prognosis than do patients with major depressive disorder. Factors related to good prognosis of bipolar disorders are short duration of manic episodes, late age of onset and few coexisting psychiatric or medical problems. Factors related to poor prognosis are an early age of onset, presence of substance/alcohol abuse and poor psychosocial support. Depressive disorder tends to be chronic, and about 50-75 % of patients have another episode of depression within the first 5 years. Over a 20-year period, the mean number of episodes is five or six. Some of the patients with depressive disorder may have manic episodes and turn into bipolar disorder after several years. An untreated depressive episode lasts for about 6-13 months, lasts for longer duration in elderly people. The withdrawal of antidepressants before this period almost always results in the return of the symptoms. Factors related to good prognosis are mild episodes, absence of psychotic symptoms, late age of onset, short hospital stay, history of stable family and social functioning for the 5 years preceding the illness. Factors related to poor prognosis are presence of coexisting dysthymic disorder, abuse of alcohol/illicit substances, anxiety disorder, history of more than one previous depressive episode, and men are more likely to experience a chronically impaired course. If a mood disorder is left untreated, a patient experiences a greater number of episodes, the time between the episodes decreases, and the severity and duration of each episode increases. However, with prophylactic treatment, number, duration and severity of individual episode decrease and interval between the episodes increases. 187 CU IDOL SELF LEARNING MATERIAL (SLM)
6.9 SUMMARY ● Mood is a sustained feeling state that is experienced internally and influences a person’s behaviour and awareness of the world. Affect is a related term which is an external expression of mood and is known by the facial expressions. ● Mood disorders are characterised by persistent and pervasive change in mood or affect accompanied by the change in the overall activity of a person and affect personal, biological and socio-occupational functioning of a person. ● The lifetime risk for bipolar disorder is 0.3-1.5% and for depressive disorders is 8- 20%. There is twofold greater prevalence of depressive disorders in women than in men. ● The clinical interview is the best method to elicit symptoms in history from the informants/patients and the signs on psychiatric examination. The information from history is corroborated with findings on psychiatric examination to make diagnosis. ● Manic episode is characterised by sustained mood elation, increased energy, increased activity, increased talkativeness, subjective experience of thoughts racing, decreased need for sleep, and inflated self-esteem, loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances and disruption of functioning. These symptoms should last for at least 1 week. Hypomania is less severe form of mania. ● Depressive episode is characterised by sustained mood of depression, anhedonia, anergia, depressive cognitions, ideas of guilt, suicidal ideas, poor sleep and weight. These symptoms should be there for at least 2 weeks. ● Bipolar affective disorder characterised by repeated episodes (at least two) of either mania or hypomania only or episodes of both depression and hypomania/ mania. Recurrent depressive disorder is characterised by repeated (at least two) episodes of depression. ● It is considered a biological disease which results from interplay of multiple factors like genetic and environmental factors. ● The goal of the treatment of patients with mood disorders is to reduce the symptoms, attain early recovery, decrease the dysfunction, and to prevent occurrence of future episodes. ● Management of patients with mood disorder involves use of pharmacological and psychosocial interventions. ● Mood stabilizer drugs are the mainstay of treatment for mood disorders. However, for an episode of depression, antidepressant drugs are used, and antipsychotic drugs are used for rapid control of mania. The mood stabilizer drugs are used for therapeutic treatment and are treatment of choice for prophylactic treatment of mood disorders. ● Psychoeducation is simple and can be imparted by trained health workers. It consists of providing relevant information about mood disorders in simple and clear language 188 CU IDOL SELF LEARNING MATERIAL (SLM)
and help family members apply this information to their own situation. Cognitive behaviour therapy has also been found helpful. ● Patients with bipolar disorder have poorer prognosis than do patients with major depressive disorder. About 90% of the patients with bipolar disorder are likely to have another episode. An untreated manic episode and depressive episode last for about 3 months and 6-13 months, respectively. 6.10 KEYWORDS • Anxiety Disorder A chronic condition that causes anxiety so severe it interferes with your life. There are few people who have both depression along with anxiety disorders. • Bipolar Disorder is a variety of depression causing extreme mood swings between depression and mania (or hypomania.) This condition used to be called manic depression. • Depression is an illness robs the body, mood, and thoughts afflicting the daily routine of a person such as eating, sleeping, and being too conscious of self. • Mania Mania s A period of bipolar problem, insanity is a time of exceptional energy, rapture or fractiousness, restlessness, or wildness. It is outrageous to such an extent that it meddles with an individual's life and can include deceptions (delusions) or discernments (hallucination). • Panic Attack An unexpected sensation of exceptional dread or tension, joined by actual manifestations, that isn't set off by genuine risk. Fits of anxiety are basic in numerous tension problems. 6.11 LEARNING ACTIVITY 1.Mood disorders result from an interplay of genetic as well as environmental factors. Genetic factors underline the role of inheritance and neurotransmitters. Environmental factors include stressful events coupled with negative attitudes towards self, environment and the future. ................................................................................................................................................... ………………………................................................................................................................. 2. An untreated manic episode lasts about 3 months, and an untreated depressive episode lasts for about 6-13 months, lasting for longer duration in elderly people. .................................................................................................................................................... ……………………..... ............................................................................................................... 189 CU IDOL SELF LEARNING MATERIAL (SLM)
6.12 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Describe the identification and diagnosis of mood disorders. 2. Explain a short note on aetiology and treatment for mood disorders. 3. Discuss the characteristic features of bipolar disorder. 4. What are different types of mood disorders? 5. How do we diagnose manic episodes? Long Questions 1. Discuss the three types of depressive episodes. 2. Explain the signs observed on psychiatric examination of a patient with manic episodes. 3. Describe the symptoms and characteristic features of Mania. 4. Describe the symptoms and characteristic features of depression. 5. Illustrate the increased prevalence of mood disorders among women? B. Multiple Choice Questions 190 1. The most common cause of mood congruent delusion is _________. a. Obsessive-compulsive neurosis b. Schizophrenia c. Dementia d. Mania 2. Features of depression include all, except ___________. a. Depressed mood b. Loss of appetite c. Hyperactivity d. Suicidal ideas 3. Mood disorder is seen in: a. Hysterical state b. Borderline personality state c. Paranoid state d. Schizoid state CU IDOL SELF LEARNING MATERIAL (SLM)
4. Acute mania with mood disturbance is ___________. a. Feature of the following b. Borderline disorder c. Cyclothymia’s disorder d. Paranoid disorder 5. Depression is not caused by _____________ a. Metronome b. Methyldopa c. Reserpine d. Oral contraceptives Answers 1(d) 2(c) 3(b) 4(c) 5(a) 6.13 REFERENCES Textbooks ● Hickey, Eric, W. (2005). Sex Crimes and Paraphilia Sage Publication, NY. ● Holmes, R.M. (2007). Sex Crimes and Paraphilia. Prentice Hall, London. Reference Books ● Carson, R.C. , Butcher, J. N. &Mineka Susan (2000). Abnormal Psychology and Modern Life.Allyn and Bacon. ● Carson, Robert C., Butcher, James N., Mineka Susan & Hooley Jill M. (2007). Abnormal Psychology (13th Ed.), Pearson Education Inc. & Dorling Kindersley Publishing Inc. India. ● Davison, Gerald C. & Neale, J.M. (2004).Abnormal Psychology (8th Ed.), John Wiley & Sons Inc, USA. ● Sadock BJ, Sadock VA (2007): Kaplan & Sadock’s Synopsis of Psychiatry: Behavioural Sciences/Clinical Psychiatry, 10th Edition. Lippincott Williams & Wilkins. ● Sarason Irwin G. &Sarason Barbara R. (2002). Abnormal Psychology: The Problem of Maladaptive Behaviour, Prentice Hall. Websites ● https://manhattanmentalhealthcounseling.com/ ● https://www.webmd.com/mental-health/mood-disorders ● https://www.health.harvard.edu/mind-and-mood/types-of-moods 191 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 7: DEMENTIA PART I STRUCTURE 7.0 Learning Objectives 7.1 Introduction 7.2 Types of Dementia 7.2.1 Alzheimer's Disease 7.2.2 Vascular Dementia 7.2.3 Lewy Body Disease 7.2.4 Frontotemporal Dementia 7.2.5 Alcohol Related Dementia 7.2.6 Down Syndrome and Alzheimer's Disease 7.2.7 HIV Associated Dementia 7.3 DSM Criteria 7.4 Incidence 7.5 Prevalence 7.6 Co-morbidity 7.7 Summary 7.8 Keywords 7.9 Learning Activity 7.10 Unit End Questions 7.11 References 7.0 LEARNING OBJECTIVES After studying this unit, student will be able to: • Evaluate a case of cognitive impairment and dementia including Alzheimer's disease. • Diagnose and differentiate it from related disorders. 192 CU IDOL SELF LEARNING MATERIAL (SLM)
• Provide relevant treatment plan. • Establish linkage with other disciplines, as comorbidity in old age is quite common. 7.1 INTRODUCTION Dementia is the most common mental disorder due to neurologic disease and affects 1-2% of 60-year-olds and becomes increasingly common among over age of 80. Dementing disorders are a category of brain ailment whose starting point is the deterioration of mental functions such as memory and other intellectual and functional abilities over time. More than 70 different conditions can cause dementia, where victims suffer impairment of memory and other intellectual abilities that leave them confused, disoriented and incapable of communicating normally. They show personality changes, various emotional reactions to their illness and behavioural traits, viz tendency to wander overtime. They experience increasingly difficult in carrying out simple activities of daily life, may lose bladder and bowel control and ultimately become totally dependent on others to provide for their personal need and safety. Primary cognitive dysfunction may occur because of illnesses, accidents, or insults to the brain. Possibly, secondary, as in systemic diseases and disorders that act on the brain, one of the body's many organs or systems. In normal aging, there occurs reduction in the speed of mental processes and difficulty in learning new tasks. Recall is also affected. But such changes do not interfere with the person’s personal, social or occupational life, as happens in dementia. Recent studies suggest that cognitive decline is not a normal consequence of aging. It has been observed on longitudinal study that subjects who eventually develop dementia of Alzheimer’s type show quite normal cognitive performance on the test battery over a period of years but then show a sharp downturn in performance. Secondly in cognitive functions, memory is the key to the self, providing us with our sense of who we are, when that has gone, where is the self and the person’s personality is totally lost. The pathophysiology of dementia’s is complex and as there are multiple causes, which include the social, biological and psychological factors besides neurochemical and viral factors have been attributed. Basically, any brain pathology (which is insidious in nature) can cause dementia. Alzheimer’s disease is the commonest cause of dementia. Here two important risks factors have been attributed, first the increasing age and second risk factor is genetic predisposition specially defect in chromosome 14, 19 and 25. Besides other factors have been implicated like aluminium poisoning and viral causes. Dementia is a condition characterised by loss of cognitive function (i.e., the ability to interpret thoughts) that is more severe than what would be associated with normal ageing. Memory, cognition, orientation, understanding, estimation, learning ability, vocabulary, and judgement are all affected. The state of consciousness is unaffected. Deterioration of emotional regulation, social behaviour, or motivation is most often synonymous with, and sometimes followed by, cognitive impairment. Dementia is caused by a number of illnesses and accidents that affect the brain directly or indirectly, such as Alzheimer's disease or stroke. Dementia is a leading cause of disability and dependency among the elderly around the world. 193 CU IDOL SELF LEARNING MATERIAL (SLM)
Not only for the people who have it, but even for their jobs and families, it can be daunting. Dementia is often misunderstood and stigmatised, resulting in delays in diagnosis and treatment. Dementia may have a physical, psychological, social, and economic effect on caregivers, families, and society as a whole. 7.2 TYPES OF DEMENTIA Dementia has been classified into 3 groups as per DSM IV classification. These groups are as • Dementia, associated with primary dementing illness, trauma, infections, intoxication etc., • Amnestic disorder and • Unspecified I. Primary Dementia • Dementia of the Alzheimer’s Type, With Early Onset • Dementia of the Alzheimer’s Type, With Late Onset • Vascular Dementia • Dementia Due to HIV Disease • Dementia Due to Head Trauma • Dementia Due to Parkinson’s Disease • Dementia Due to Huntington’s Disease • Dementia Due to Pick’s Disease • Dementia Due to Creutzfeldt-Jakob Disease • Dementia Due to the General Medical Conditions II. Amnestic Disorders • Amnestic Disorder Due to the General Medical Conditions • Substance-Induced Persisting Amnestic Disorder III. Unspecified Dementia’s Although the spectrum of psychopathological manifestations of dementia described above are broad. However, they can be granted into two main categories. • Dementia’s of Alzheimer’s Type • Dementia’s due to other causes 7.2.1 Alzheimer's Disease Definition: This is a primary degenerative cerebral disease of unknown etiology, with characteristic neuropathological and neurochemical features. It is usually insidious in onset to develop, slowly but steadily over a length of time The length of time can be short or 194 CU IDOL SELF LEARNING MATERIAL (SLM)
considerably long. The onset can be in any age group, but the incidence is higher in later life. In cases with early onset of disease there is likelihood of a family history of similar dementia, a more rapid course and prominence of features of parietal or temporal lobe damage, including aphasia or dyspraxia. In cases with a late onset, the course tends to be slower and cognitive impairment is more marked. Epidemiology It is more common with increasing age. It is very rare in the age group of 40-45, although it can occur, increases in the age group 60-65, and in the age group over 80 it is very common. Based on specific studies, almost half of people over the age of 80 will develop Alzheimer's disease. Only two risk factors have been discovered, first is increasing age and the second is genetic predisposition. Genetic transmission has been reported 10-30% of cases. Three genetic anomalies have been recorded, one on chromosome 14, one on chromosome 19, and one on chromosome 21. Many other causes have been suggested, including viral infection, aluminium poisoning, the patient's elderly mother at birth, and a family history of genetic defects. There has been no evidence that any of them raise the risk of Alzheimer's disease. Early Detection and Screening At the inception, the disease is insidious, slow and progressive, and the early detection of the disease is important. Screening is described as the rapid application of tests, observations, or other procedures to the presumptive identification of an unexplained disease or defect. A screening test distinguishes between people who appear to be healthy but possibly have a disease and those who do not. It is not meant to be used as a diagnostic tool. Hence the first step is to administer a simple test, which can measure cognitive impairment by a Mental Status Questionnaire and the short portable Mental Status Questionnaire. The second stage case identification includes, diagnostic procedures, which includes numerous standardized psychogeriatric interviews which are based on clinical diagnostic concepts but also make use of scores derived from rating scales. The dearth of detailed diagnostic criteria is specially significant in early case identification, since without a clear definition there can be no reliable case identification. The third stage of screening include assessment of associated impairments and disabilities. A comprehensive screening and diagnosis cannot be confined to psychiatric diagnosis and treatment alone As a result, a multidimensional approach is recommended in both evaluation and treatment. The techniques of multi-level assessment developed in recent years appear to provide the most suitable working tools for screening and diagnosis. Clinical Picture Onset is insidious, usually after 65, though sporadic cases can occur earlier. The disease runs a gradual course. At the start, the symptoms are impairment of memory and subtle personality changes, usually described by the family members, the patient often being unaware of these symptoms. Mild anxiety and depressive symptoms are frequently present initially. 195 CU IDOL SELF LEARNING MATERIAL (SLM)
Alzheimer’s disease causes progressively increasing impairment of memory and other intellectual abilities. Although the problems may initially be manifested in such ways as forgetfulness, poor judgement or difficulty making calculations and handling money, the cognitive losses ultimately leave the person confused, disoriented and incapable of communicating Normally common personality changes are there, which may range from apathy and social withdrawal to quarrelsomeness, agitation and frequently display various emotional reactions to their illness, such as apprehension, depression or suspiciousness. Additional symptoms are disturbed sleep, hallucinations and delusional ideas or likely to roam aimlessly. Overtime even customary daily activities are lost. Eventually they may lose elementary physical abilities such as bladder and bowel control and become totally rely on others to provide for their personal needs and safety. Urinary and faecal incontinence may occur at later stages. Seizures, coma and death are the final outcome. At the outset suspiciousness, obsessiveness, irritability and outbursts of anger may appear . These are followed by disturbances in orientation and judgement and incite purposeless wandering. The patient perhaps be found distant from home in a dazed condition. Neurological defects, such as gait disturbances, aphasia, apraxia and agnosia may occur. The peculiar tragedy of Alzheimer’s disease and other related dementia’s is that they dissolve the mind and steal the humanity of the victim, leaving a body from which the individual has largely been removed. Simultaneously dementia devastates lives of spouses and family members, who must endure their deterioration of their loved ones and the loss of the person and relationship that is implied. Caregivers face the agony of seeing their loved ones minds and personalities disappear from bodies that may frequently remain otherwise healthy and shoulder heaving physical, social and emotional burdens over a long duration. The effects on the afflicted families are personally profound and financially devastating. Differential Diagnosis Diagnosis in an established case of dementia is not difficult, nevertheless requires considerable skill to recognize it in early stages. Easily be muddled with pseudodementia (depression mimicking dementia) at early stages, dementia also needs to be differentiated from normal ageing. Third important differential diagnosis is delirium. Let us see three different diagnosis one by one. Depressive Pseudodementia In this type, depression presents itself like dementia. As already mentioned, depressive features may be present at the early stages of dementia. Delirium Delirium is another common ailment in elderly and needs to be differentiated. Delirium is an acute organic mental disorder which can usually be identified from dementia by presence of rapid onset, brief duration, fluctuation of cognitive impairment throughout the day, marked 196 CU IDOL SELF LEARNING MATERIAL (SLM)
disturbance in sleep-wake cycle, impaired orientation, clouding of consciousness and visual hallucinations. Treatment Guidelines There is no specific drug treatment. However, treatment guidelines include the following principles: First step in management is to find out the cause, if any. An out-and-out medical history should be taken, together with a detailed physical examination. In unique cases such as space occupying lesions a CT scan is helpful in confirming the diagnosis and also in finding the cause. Other relevant investigations must be carried out, for example, thyroid function tests, if hypothyroidism is suspected. If a treatable cause is found, specific treatment is started, e.g., thyroid replacement therapy for hypothyroidism, and neurosurgical treatment for subdural haematoma and normal pressure hydrocephalus. General treatment consists of good nutritious diet, nursing care, family support and consciousness to visual and auditory deficits, if any. If any other physical ailments, such as urinary tract problems, cardiac or pulmonary disorders are present, specific treatment should be given. It is vital to counsel the family regarding nature of illness for its effective management. Family has a very important role to play in management of dementia. Considering the breaking of joint families in India and increase in the elder generation living alone due to their children moving away, institutions for the elderly such as old age homes, day care centres, etc., are needed chiefly for the elderly ill, where they can be taken care of. Family members should be given a chance to receive a clear diagnosis and explanation of the issue. They also need assistance in assessing their changing care need as the disease progresses and the demand for care on the family increase. Care should start at home and then progress towards the community. Challenge arises in determining when to choose homecare or when nursing home care is necessary. Both forms of care are essential and mutually supportive components of long-term care, neither can substitute for the other. Medical care involves symptomatic management of treating both psychological and physical symptoms and treatment of medical comorbidity when present. Antianxiety and antidepressant drugs if anxiety and depressive symptoms are present. Risperidone or thioridazine are effective in controlling agitation, if present. Useful vitamins like B and E have been found in neutralizing toxic elements present in the body. Tacrine a cholinesterase inhibitor has been found to produce significant improvement in 20 to 25 % of patients with Alzheimer’s disease. Similarly, RIVASTIGMINE can slow down the advancement of Alzheimer disease. 197 CU IDOL SELF LEARNING MATERIAL (SLM)
Paramount for the treatment is a balanced diet and appropriate fluid management. Treatment of behavioural manifestations of Alzheimer’s is helpful. Another aspect of caring for Alzheimer patient which forms an integral part of management is personal hygiene and toilet habits. 7.2.2 Vascular Dementia Vascular Dementia contributions to cognitive impairment and dementia (VCID) are conditions arising from stroke and other vascular brain injuries that cause significant changes to memory, thinking, and behaviour. The size, place, and number of brain injuries may all have an impact on cognition and brain function. Two forms of VCID—vascular dementia and vascular cognitive impairment (VCI)—arise as a result of risk factors that similarly increase the risk for cerebrovascular disease (stroke), including atrial fibrillation (a problem with the rhythm of the heartbeat), high blood pressure, diabetes, and high cholesterol. Vascular dementia is a progressive decrease of memory and other cognitive functions in the brain caused by a vascular injury or disease. Alzheimer's disease and vascular dementia have almost similar symptoms which may sometimes be difficult to distinguish. Major factors differentiating Alzheimer and VCID is, memory loss, which is more prominent in Alzheimer's, while problems with organization, attention, slowed thinking, and problem solving are all more prominent in VCID. Changes in vocabulary, focus, and the ability to think, reason, and recall are all signs of vascular cognitive impairment, but they aren't severe enough to have a major effect on everyday life. These modifications, which are caused by vascular damage or disease in the brain, take time to manifest. After a major stroke, post- stroke dementia will develop months later. While not everyone who has had a major stroke develops vascular dementia, those who have had a stroke are at a much higher risk of developing dementia. Multi-infarct dementia is caused by a series of small strokes (infarcts) and mini-strokes. Depending on the affected part of the brain, dialect or other functions can be affected. People Any person who has had a stroke is at a far greater risk of developing dementia. When both sides of the brain are affected by a stroke, dementia is more likely. Also strokes that don't cause any obvious signs can put you at risk for dementia. CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a very rare hereditary condition in which the walls of small and medium-sized blood vessels thicken, reducing blood flow to the brain. CADASIL has been linked to multi-infarct dementia, stroke, and other neurological conditions. Between the ages of 20 and 40, the first signs can appear. Symptoms of CADASIL can be mistaken for those of multiple sclerosis. CADASIL affects a large number of people who are undiagnosed. Subcortical vascular dementia, also known as Binswanger's disease, is characterised by significant microscopic damage to the white matter of the brain's small blood vessels and nerve fibres. Short-term memory, organisation, concentration, decision-making, and behaviour are all affected by cognitive changes. Symptoms usually appear after the age of 60, and they develop in a stepwise fashion. High blood pressure, a history of stroke, or signs of 198 CU IDOL SELF LEARNING MATERIAL (SLM)
disease of the large blood vessels in the neck or heart valves are common in people with subcortical vascular disease. The build-up of amyloid plaques in the walls of blood vessels in the brain is known as cerebral amyloid angiopathy. When several small bleeds in the brain are detected using magnetic resonance imaging, it is usually diagnosed. How is VCID Treated? Drugs to avoid strokes or minimise the risk of further brain injury are often used to treat vascular contributors to cognitive dysfunction and dementia. According to some research, medications that enhance memory in Alzheimer's patients can also help people with early vascular dementia. Modifiable risk factors, such as elevated blood pressure, may be treated to help avoid more strokes. Inside The Brain The term vascular refers to blood vessels, and vascular dementia is caused by problems with the brain's blood supply. To live, nerve cells need oxygen and nutrients from the blood. These nerve cells will die if there isn't enough blood. Vascular dementia comes in a variety of forms. One form is brought about by a stroke (called stroke-related dementia). Another reason is a lack of blood flow to the brain's deeper regions (called subcortical vascular dementia). Strokes occur when a blood clot prevents blood flow to a part of the brain or when a blood vessel in the brain bursts. Vascular dementia sometimes follows a large stroke (called post-stroke dementia). It usually occurs after a series of small strokes. (called multi-infarct dementia). Subcortical vascular dementia – when there is poor blood flow to the deep parts of the brain – is often due to narrowing of the small arteries that supply the brain with blood. Early Changes The changes you go through can be determined by which part of your brain has been injured. Planning, thinking fast, and focusing are all common early changes. There may also be brief moments where you are completely perplexed. You may become depressed or nervous as a result of this. Memory loss isn't necessarily present in the early stages of Alzheimer's disease. Symptoms of vascular dementia may appear unexpectedly after a large stroke. They will then stay stable, or in the early stages, they can even improve slightly over time. If you have another stroke, the symptoms can worsen once more. If you have a series of small strokes, your symptoms may remain stable for a while and then get worse in stages, rather than experiencing a gradual decline. 199 CU IDOL SELF LEARNING MATERIAL (SLM)
If you have subcortical vascular dementia, your symptoms may get worse gradually or, less often, in stages. 7.2.3 Lewy Body Disease Lewy body dementia (LBD) is a brain condition caused by irregular deposits of the protein alpha-synuclein The deposits are called as Lewy bodies, affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behaviour, and mood. One of the most common causes of dementia is this disease. LBD can be difficult to diagnose. Symptoms of early Lewy body dementia are quite often mistaken with those of other brain diseases such as Alzheimer's or mental disorders such as schizophrenia. Lewy body dementia could also indicate the presence of other brain disorders. Dementia with Lewy bodies (DLB) and Parkinson's disease dementia are the two types of dementia associated with Lewy bodies. The first symptoms vary, but they all represent biological changes in the brain. Dementia with Lewy bodies or dementia caused by Parkinson's disease may experience similar symptoms over time. Lewy body dementia is a chronic condition, which means that symptoms appear gradually and progressively worsen over time. The disease lasts on average 5 to 8 years from diagnosis to death, but it can last anywhere from 2 to 20 years. The speed at which symptoms develop and change varies greatly from person to person, depending on general health, age, and the severity of symptoms. Symptoms of Lewy body dementia can be mild in the early stages, and people can function normally. Owing to a loss in thought and coordination skills, people with LBD need more assistance as the disease progresses. They also depend entirely on others for assistance and treatment as the disease progresses. For a short time, some symptoms of Lewy body dementia can respond to treatment. The disorder currently has no cure. Advances in science can one day lead to better diagnosis, improved care, and new therapies for this difficult condition, thanks to research. Inside the Brain Lewy bodies, small clumps of protein that form within nerve cells, give this type of dementia its name. They affect brain activity in the same way that plaques and tangles in Alzheimer's disease do. They trigger nerve cells to die by lowering chemical messenger levels. 200 CU IDOL SELF LEARNING MATERIAL (SLM)
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