Lecture 6

Question 1

what is the ICD-10 criteria for depression

Answer 1

severities: mild-moderate-severe
depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. marked tiredness

other common symptoms:
reduced concentration and attention

reduced self-esteem and confidence

ideas of guilt and unworthiness

pessimistic view of future

ideas or acts of self-harm/suicide

disturbed sleep

diminished appetite

Question 2

what is ICD-10 criteria for hypomania

Answer 2

persistent mild elevation of mood (or irritability)

increased energy and activity, usually marked feelings of well-being and both physical and mental efficiency

increased sociability, talkativeness, over-familiarity

increased sexual energy

decreased need for sleep

doesn’t cause a lot of problems, not psychotic

goes on for several days/weeks

Question 3

what is ICD-10 criteria for mania (without psychotic symptoms)

Answer 3

mood is elevated out of keeping with their normal situation and varies from carefree joviality to almost uncontrollable excitement (can be irritable/suspicious rather than related)

elation is accompanied by increased energy, resulting in overactivity, pressure of speech, and a decreased need for sleep

attention cannot be sustained, and there is often marked distractibility

self-esteem is often inflated with grandiose ideas and overconfidence, over-optimistic ideas

loss of normal social inhibitions (reckless/inappropriate behaviour)

perceptual disorders may occur ie appreciation of colours as especially vivid, preoccupation with fine details of surfaces and textures

extravagant and impractical schemes, spend money recklessly

Question 4

what is ICD-10 criteria for mania (with psychotic symptoms)

Answer 4

delusions (usually grandiose) or hallucinations (usually of voices speaking to patient)

inflated self-esteem and grandiose ideas that may develop into delusions, irritability/suspiciousness into delusions of persecution

severe cases, grandiose/religious delusions of identity/role

can be incomprehensible

severe and sustained physical activity and excitement = aggression/violence, neglect of eating/drinking/personal hygiene may result in dangerous states of dehydration and self-neglect

delusions can be specified as congruent/incongruent with mood

Question 5

what is bipolar I disorder

Answer 5

at least one manic episode

major depressive episodes are typical but not needed for diagnosis

Question 6

what is bipolar II disorder

Answer 6

at least one hypomanic episode and one major depressive episode

Question 7

what is cyclothymic disorder

Answer 7

hypomanic and depressive periods that don’t fulfill I criteria for hypomania or major depression for at least 2 years

Question 8

how is bipolar disorder diagnosed

Answer 8

by a psychiatrist

being diagnosed in childhood is controversial in UK, usually age 16 or above unless full mania

Question 9

what is prevalence of bipolar disorder in UK

Answer 9

McManus et al 2016

2% bipolar disorder

similar rates for men and women

no differences on ethnicity

higher rates in younger (3.4% 16-24 year olds versus 0.4% aged 65-74)

higher rates in unemployed

40% receive mental health care

most first episodes occur age 15-30 (WHO)

Question 10

what is the average time to diagnose with bipolar disorder like

Answer 10

from first contact with mental health services: 9.5 years

first high modo to diagnosis: 9.8 years

first depressed mood to diagnosis: 14.8 years

time to diagnose is not improving in recent years

average age of first diagnosis: 33.7 years

Question 11

do people find the diagnosis of bipolar disorder helpful

Answer 11

vast majority find it helpful

because it gave an explanation

helps feel understood

better medication and support

BUT some felt the treatment didn’t relate to them/they felt stigmatised etc

Question 12

what are the effects of bipolar disorder

Answer 12

WHO= one of the biggest burdens globally in terms of healthy years lost

significant impact on quality of life, employment etc

suicide rate 10-30X the general population, 20-60% attempt suicide (Dome et al., 2019)

reduced life expectancy (Kessing et al., 2015)

Question 13

what are some potential causes for bipolar disorder

Answer 13

genetic: Craddock and Sklar, 2013= genetic overlap between bipolar disorder and psychosis

lots of genes, no single gene

identical twins 40-70% risk

environmental risk factors: Marangoni et al 2016= substance use, issues during pregnancy, fetal development ie flu, parental loss, abuse, brain injury

abuse: Palmier-Claus et al., 2016= those with bipolar disorder 2.6X more likely to have childhood adversity than those without mental health problems (4X more likely for emotional abuse)

Question 14

what did chen et al., 2011 find about the brain of those with bipolar disorder

Answer 14

underactive in inferior frontal cortex (links to cog control, ability to suppress impulses/actions) - during cog and emotional processing tasks, and during mania

over-active limbic system, including hippocampus (learning and mem) and amygdala (emotion and mem), especially in emotional processing tasks

Question 15

what is the relationship between life events and bipolar disorder

Answer 15

Johnson et al., 2008:
goal attainment life events precede mania (strong relationship)

neg life events precede depression

Question 16

what are the most common self-reported triggers for relapse for bipolar disorder from most to least influential

Answer 16

losing sleep

taking anti-depressants

self-neglect

bereavement

starting/leaving a job

Question 17

what role does dysfunctional assumptions play in bipolar disorder

Answer 17

bipolar individuals score higher on dysfunctional attitude scale

goal attainment score is higher for bipolar than depression (if i try hard enough i should be able to excell at anything)

high goal attainment correlated with more hospitalisations

higher achievement beliefs (i need to set high standards)

dependency on others opinions predicts depression increase 4 months later

dysfunctional beliefs increase when mood goes up or down

greater dysfunctional attitudes predict relapse up to 3 years later

Question 18

how do the seasons affect bipolar disorder

Answer 18

25% have seasonal variation: mostly Bipolar II and linked to history of more depression episodes(Goikolea et al., 2007)

seasonal patterns linked more to depression in men, rapid cycling for women (Geoffrey et al., 2013)

summary and autumn linked to mania, depression during winter (Fellinger et al., 2019)

sunlight and higher temp increases risk of mania and hospitalisation (Montes et al., 2021)

Question 19

what are examples of dysfunctional attitudes

Answer 19

catastrophic cognitions about failure

perfectionism linked to more severe symptoms

Question 20

what role does the family play in dysfunctional assumptions

Answer 20

family emphasis on achievement and highly ambitious extrinsic goals associated with mania-relevant cognitions (Chen & Johnson, 2012)

Question 21

what is the link between self-compassion/perfectionism and bipolar disorder

Answer 21

lower self-compassion in bipolar individuals (Yang et al., 2020)

high levels of perfectionism and low levels of self-compassion in bipolar linked to greater anxiety and depression (Fletcher et al., 2019)

Question 22

what did Palmer-Cooper, Woods and Richardson (2023) find about self-compassion/meta-cognition in bipolar

Answer 22

331 people with BD followed up over 3 months

dysfunctional meta cognitive beliefs significantly predicted depression over time - more than dysfunctional assumptions & self-compassion

self-compassion mediates link between dysfunctional assumptions, meta-cognition and depression

greater self-compassion INCREASES manic symptoms

Question 23

what is the role of self-esteem in bipolar disorder

Answer 23

low self-esteem (Nilsson et al., 2010)

self-criticism when depressed, grandiosity when high suggests fluctuates

low self-esteem predicts increase in depression over four months (Atuk & Richardson, 2021)

Question 24

what is the role of shame and past trauma in bipolar disorder

Answer 24

those with more childhood trauma and high levels of current internalised shame (Fowke et al., 2012)

parental loss = risk factor (Marangoni et al., 2016)

bipolar people = 2.6X more likely to have childhood adversity than those without mental health problems (4X for emotional abuse)

Question 25

what is the role of impulsivity in bipolar disorder

Answer 25

specific impulsive behaviours linked to mania/hypomania (Fletcher et al., 2023) hypersexuality impulsive spending dangerous driving risk-taking = higher in Bipolar I (Ramirez-Martin et al., 2020)

Question 26

what is the positive bias in bipolar disorder

Answer 26

high risk for depression = overgeneralising from failures high risk for mania = overgeneralising from successes (Eisner et al., 2008) hypomanic personality = overestimate likelihood of unlikely events happening to them , AND overly pos predictions of the future (Schonfelder et al., 2017) bipolar ppl have more ambitious goals and this correlates with manic symptoms (tharp et al., 2016)

Question 27

what role does imagery play in bipolar disorder

Answer 27

pos imagery about the future when high in mood - more intense when ppl also have depression imagery amplifies emotions and goal-directed behaviour linked to mania (Ivins et al., 2014) more vivid imagery about the future - this increases mood in experimental tasks (O'Donnell et al., 2018) intrusive imagery (Holmes et al., 2011) M'Bailara et al., 2023: hypomania = acceleration, idealised projects, omnipotence, stunning landscapes depression = death, self-deprecation, powerless, violence

Question 28

what study shows the cultural influences on bipolar disorder

Answer 28

Johnson & Johnson, 2014: Bipolar I prevalence in 17 counties cultural traits of individualism and performance orientation related to bipolar I prevalence

Question 29

is advice helpful for bipolar

Answer 29

when high in mood, not really- less likely to take advice on-board (Mansell & Lam, 2006)

Question 30

what is the role of fame and fortune in bipolar disorder

Answer 30

greater ambitions for fame ambitions for fame and finances success predicts increase in manic symptoms three months later (Johnson et al., 2012) hypomanic personality set more ambitious achievement related to life goals for fame, wealth and political influence (Johnson & Carver, 2006)

Question 31

what is the role of sleep in bipolar

Answer 31

lack of sleep = most common self-reported trigger for relapse (80% Goodwin et al., 2002) relapsing in depression and mania/hypomania is associated with sleep problems but 40% of those with euthymia (patients stable in mood) meet criteria for insomnia and 29% for hypersomnia (Steinan et al., 2016)

Question 32

what is the role of reward sensitivity in bipolar

Answer 32

prone to depression = less response to reward hypomania = increased regards sensitivity and processing (alloy et al., 2016) diff patterns of learning and changing behaviour from reward and punishment in bipolar (Duek et al., 2014) those prone to hypomania make choices for immediate rather than delayed rewards (Mason et al., 2012)

Question 33

what is the role of emotional experience and regulation in bipolar

Answer 33

emotional instability is a risk factor for bipolar (Hayes et al., 2017) emotional dysregulation is NOT higher when mood is stable, but it is during depression and hypomania (DePrisco et al., 2022) more unhelpful emotional regulation strategies in particular rumination, neg focus and risk-taking behaviour (De Prisco et al., 2022) stronger emotional reactions (& physiological response) (Gruber, 2011) those with bipolar try to increase pos emotions and struggle to down-regulate them (Gruber, 2011)

Question 34

what is the role of creativity in bipolar

Answer 34

higher scores for inspiration (Jones et al., 2014) higher than depression for creative personality and art appreciation (Santosa et al., 2007) 62% more likely to be hospitalised for bipolar if they have artistic degree vs gen pop (MacCabe et al., 2018) KYAGA ET AL 2015: 300K ppl - siblings, one with bipolar one without = overrepresented inc reative professions JOHNSON ET AL 2012: milder forms of BD and risk for mania = greater lifetime creative accomplishments

Question 35

what is the role of leadership in BD

Answer 35

leadership qualities typical (Kyaga et al., 2015) entrepreneurship typical (Johnson et al., 2018)

Question 36

what did Folstad and Mansell 2019 investigate (BD)

Answer 36

asked those with bipolar if they wanted to keep it 1/4 didnt want to permanently remove more likely to want to keep it if they see it as part of their identity under half want complete control over mood enhanced abilities and fun of mania = why ppl don't want to permanently switch it off Richardson and Mansell, 2024 = those who believed being 'high' was a natural part of their personality had more manic symptoms 4 months later Lee et al., 2010 = correlation between sense of hyper-positive self (ie im dynamic) when manic, correlates with manic symptoms

Question 37

what are the models of bipolar disorder

Answer 37

behavioural activation system (BAS) dysregulation model integrative cognitive model of mood swings

Question 38

what is the behavioural activation system (BAS) dysregulation model

Answer 38

BAS regulates approach behaviour in response to signals of reward and goal attainment BAS is involved in bipolar; in mania BAS activation reflected by increase goal directed activity and elevated mood hypersensitive to reward and discount punishment (pos evaluation bias - Mason, 2012) dysregulated BAS in bipolar, over-activity leads to symptoms of mania (more energy/pressured speech/goal directed behaviour/high confidence etc) - under-activity leads to symptoms of depression

Question 39

what is the integrative cognitive model of mood swings (Mansell et al., 2007)

Answer 39

attempts at affect regulation are disturbed through multiple and conflicting extreme personal meanings that are given to internal states prompt exaggerated efforts to enhance or exert control over internal states - paradoxically provoke further internal state changes, feeding into a vicious cycle extreme appraisals fuel ascent and descent behaviours leading to mood swings trigger event -> change in internal state -> appraisal as having one of several extreme personal meanings leads to ascent and descent behaviours AND beliefs about self/world/others influence appraisal, that are equally influenced by life experiences

Question 40

what are potential changes in internal state

Answer 40

mood physiology cognition

Question 41

what is the role of appraisals in integrative cog model of mood swings

Answer 41

misinterpret as signifying extreme personal meanings appraisals extreme, but also multiple and contradictory interpretations of the internal state as a sign of an imminent catastrophe, a personal success, or a personal weakness

Question 42

what are ascent behaviours in the integrative cog model of mood swings

Answer 42

behaviours aimed at enhancing/controlling internal states that have the effect of increasing the state of activation internal = recurrent goal setting/worry physical = ingest stimulating substances, extended wakefulness behaviour = do things quicker, act on spur of the moment social = seek out people to influence, ignore advice

Question 43

what are descent behaviours in integrative cog model of mood swings

Answer 43

behaviours aimed at enhancing or controlling internal states that have effect of decreasing activation state internal = rumination/self-critical thinking/suppression behaviour = reduce activity social = withdraw from other people, increased dependence

Question 44

what are examples of poor beliefs about the self/world/others in the integrative cog model of mood swings

Answer 44

affects regulation "I cannot copy with feeling sad" self = "when im energised, i know im important" others = "when i feel good, other ppl don't understand me"

Question 45

what are life experiences in integrative cog model of mood swings

Answer 45

trauma failure experiences experiences of "hyping self up" to overcome adversity ongoing = other ppl's responses to changes in behaviour ie encouragement/worry etc

Question 46

what did Chiang et al 2017 find about CBT for bipolar

Answer 46

meta-analysis CBT reduces relapse and symptoms of depression/mania/psychosocial functioning 90min+ sessions have better outcomes and lower relapse for bipolar I miklowitz et al., 2021 meta-analysis: psychological therapies (+ medication) half risk of relapse compared to medication alone group or family based psychoeducation better than one to one at reducing relapse rates briefer and involving family in psychoeducation reduces dropout improves depression symptoms

Question 47

what are NICE guidelines 2014 for bipolar

Answer 47

psychological treatments recommended as primary modality of treatment in primary care in secondary care, this is medication

Question 48

what is an overview of the therapy for bipolar therapy

Answer 48

psychoeducation identify triggers and early warning signs behavioural strategies mood monitoring thought identifying and challenging challenge cog vulnerability can use life charts (link condition to life events)

Question 49

how to identify early warning signs in therapy for relapse prevention

Answer 49

identify prodromal symptoms (changes in cog, emo, behav) identify relapse signature differentiate normal mood fluctuations from relapse

Question 50

what are common prodromal symptoms for mania

Answer 50

sleeping less more goal-directed behaviour increased sociability racing thoughts irritability optimism/self-esteem increases impulsivity increases increased sex drive easily distracted

Question 51

what are common prodromal symptoms for depression

Answer 51

loss of interest in activities increased worrying or anxiety hard to sleep/sleeping more feel sad low motivation reduced sex drive hopelessness/self-critical thoughts tired

Question 52

what did lam et al., 2005 find about BD, therapy and relapse

Answer 52

those seeing bipolar with positives benefit less from therapy and more likely to relapse

Question 53

what are coping strategies for relapse prevention in bipolar disorder

Answer 53

breakdown early warning signs into early, middle, late make action plan/coping strategies for each focus on stability (use diary to identify problems): sleep routine, diet, exercise, alcohol, work/life balance, plan ahead for changes

Question 54

how to monitor mood for relapse prevention in BD

Answer 54

mood diary/app link thoughts to mood identify triggers for changes in mood identify normal fluctuations in mood vs signs of relapse - can show that mood does change linked to activities make sure this doesn't lead to over-vigilance

Question 55

what are behavioural coping strategies for mania

Answer 55

reduce activity involvement reduce stimulation avoid drugs/excessive alcohol avoid where overexcitable don't act impulsively (plan/prioritise) slow down don't take risks sleep well

Question 56

what are behavioural coping strategies for depression

Answer 56

activity scheduling (structure for the day, get outside) friends and family sleep and eat well exercise avoid alcohol and drugs

Question 57

what are typical thinking patterns for mania

Answer 57

selective abstraction/mental filter = focus on positives over-estimate abilities = self better than others over-estimate likelihood of things going well over-personalisation of behaviours (ambiguous look = sexual interest)

Question 58

what are typical thinking patterns for depression

Answer 58

self-critical thoughts compare self to others catastrophising predict things going wrong in future

Question 59

how to challenge thoughts for BD

Answer 59

balanced thinking alternative explanations evidence for and against for manic thoughts, challenge gently or clients feel criticised when fully manic, unlikely to change thoughts balanced thoughts reduces relapse risk reframe thoughts as early warning signs identify how optimistic ideas can escalate into grandiose ideas identify themes in manic thinking

Question 60

how to challenge manic thoughts

Answer 60

ask client if impulsive thoughts are similar to past thinking pros and cons of waiting on an idea sleep on it distancing and delaying technique 'reality test' is difficult when hypomanic so better to delay restraint excessive activity by getting clients to devise questions to ask themselves ie why do i need this NOW?

Question 61

what is an example layout of a psychoeducation group's 12 sessions for BD

Answer 61

1. group rules, what is BD, psychological and biological influences 2. mood diaries, stress vulnerability model, lifetime course and life charts 3, symptoms/triggers/early warning signs 4. medication 5. intro to CBT (hot cross bun, thoughts and mood, role of thought in relapse) 6. thoughts (unhelpful thinking patterns and challenging them) 7. mindfulness 8. stress/anxiety management 9. behaviour/habits 10. self-esteem 11. interpersonal issues (how to tell people) 12. relapse prevention plan putting everything together

Question 62

how many have had therapy at some point in life, and how many for BD specifically

Answer 62

76% offered or received therapy at some point in life 69^ referred for therapy on NHS 1 in 5 offered group-based psychoeducation for BD 29% never been offered psychological therapy on NHS 26% specifically told they couldn't get therapy on NHS and would have to pay themselves nearly half had to pay for their own therapy at some point postcode lottery??