1. MOOD DISORDERS : DEPRESSION

2. > Depression is an emotional state marked by great sadness and apprehension, feelings of worthlessness, and guilt, withdrawal from others, loss of sleep, appetite and sexual desire, or loss of interest and pleasure in usual activities. > Often it is associated with other psychological problems and with medical conditions. > Seligman (1973) refers to depression as the “common-cold” of psychological problems - i.e.- its’ the most common of all the psychological problems. According to DSM-IV 1994 and DSM-IV TR 2000, Mood Disorders are classified into two main categories: A. Unipolar Disorder( Unipolar / Major Depression) B. Bipolar Disorder

3. CLASSIFICATION OF MOOD DISORDERS UNIPOLAR DISORDER BIPOLAR DISORDER MAJOR DEPRESSIVE DISORDER DYSTHYMIC DISORDER DEPRESSION NOS BIPOLAR-I DISORDER BIPOLAR-II DISORDER CYCLOTHYMIC DISORDER BIPOLAR DISORDER NOS MAJOR DEPRESSION Major Depression is a severe depressive disorder, in which a person may show a loss of appetite, psychomotor symptoms, and an impaired ability testing.

4. CRITERIA FOR MAJOR DEPRESSIVE DIORDER According to DSM-IV TR 2000,following is the criteria for Major Depressive disorder : I. The individual must show in his behavior, atleast five of the following symptoms, for atleast two weeks, and these symptoms must interfere with his day-to day functioning. Prominent mood should be a depressed one, and the person must show a loss of interest or pleasure in day-to-day activities. Symptoms are as follows: (a) In adults, the depressed mood should continue for almost the whole day and in children and adolescents, irritable mood is present for the entire day. (b) The individual may show a lack of interest in almost all the activities and this lack of interest continues for days.

5. (c) Loss of weight and appetite. (d) Person may suffer from insomnia or hypersomnia. (e) Person may show lack of psychomotor activities, agitation & retardation. (f) Feeling of fatigue or loss of energy for almost the entire day. (g) Feeling of worthlessness, and excessive or inappropriate guilt almost daily. (h) Lack of concentration, diminished ability in various activities, and indecisiveness. (i) Recurrent ideas and thoughts related to suicide or suicide attempt. II.Such a person does not show any of the Mixed or Manic episode symptoms.

6. III. Due to the symptoms, the person undergoes distress and shows an impairment in social, occupational, personal or school functioning. IV. Symptoms should not be due to any general medical condition or substance-use. V. If depressive mood appears after some loss, such as death of a loved one, then it may last for two months and is known as “ Bereavement ”. Thus, it should not be considered a Major Depression, because the symptoms would gradually disappear after two months. However, in case the symptoms persist and the person continues to show functional impairment, worthlessness, suicidal attempt, retardation in psychomotor abilities, then he should be considered for the treatment of Major Depression.

7. >>Blatt et al.,1976, on the basis of the researches done on young adults / college students, has cited three major reasons for depressive disorder in males, as well as females: 1. Desire for dependency 2. Self-criticism 3. Feeling of inefficiency Later on, in 1982,he mentioned two types of depression: (a) Dependence depression (b) Self-criticism depression CLINICAL PICTURE OR MAIN SYMPTOMS OF UNIPOLAR DEPRESSION Symptoms of Unipolar Depression can be classified into six main categories:

8. I. EMOTIONAL SYMPTOMS (i) Depressed mood (sadness, hopelessness, discouraged attitude) (ii) Irritable mood II. COGNITIVE SYMPTOMS (i) Feeling of worthlessness and low self-esteem (ii) Memory deterioration and defects (iii) Lack of concentration (iv) Guilt-feeling (v) Pessimistic thinking (vi) Lack of problem-solving ability (vii) Suicidal thoughts (viii) Attribution to others for ones’ own negative thinking and perception. III. MOTIVATIONAL SYMPTOMS (i)Loss of interest in surroundings, biological needs, etc. (ii)Lack of initiativeness

9. IV. OVERT BEHAVIORAL SYMPTOMS (i) Psychomotor disturbances (ii) Speech disturbances (iii) Suicidal attempts V. SOMATIC SYMPTOMS (i) Sleep disturbances (ii) Hunger (iii) Loss of weight, and in rare cases, an increase in weight. (iv) Too much of fatigue VI. SOCIAL AND OCCUPATIONAL SYMPTOMS (i) Impairment in social relationships. (ii) Lack of occupational efficiency. (iii) Impairment of functioning in other areas.

10. >> DYSTHYMIC DISORDER Its’ also known by other names- Chronic depression, depressive neurosis and sub effective depression. According to DSM-IV-TR 2000, a person suffering from this disorder shows the following symptoms : 1. Depressive mood almost daily for atleast two years and for children and adolescents, this duration can be of one year only. 2. While showing the depressive mood, the person should reflect atleast two of the following symptoms: (a) Poor appetite (b) Insomnia / hypersomnia (c) Low energy or fatigue (d) Low self-esteem (e) Poor concentration or difficulty in decision-making (f) Feeling of hopelessness

11. 3. During the duration of two years ( one year for children and adolescents ), there are not even two such months when the symptoms are not reflected in the persons’ behavior. 4. Treatment for this disorder is given only when the patient is not showing the symptoms of major depression. Sometimes, individuals suffer from dysthymic disorder for two years and lateron, the person may start showing the symptoms of major depression also. This means that the symptoms of major depression are superimposed on the symptoms of dysthymic disorder, and the person is said to suffer from double depression i.e. both- major depression and dysthymic disorder. However, its’ also possible that after getting the treatment, symptoms of major depression improve and the person again becomes a patient of dysthymic disorder. 5. Individuals who have dysthymic disorder donot show any of the characteristics of manic episode, mixed episode or hypomania. They donot show any of the characteristics of cyclothymic disorder. 6. Disturbances in mood should not be due to any other psychotic disorder. 7. Symptoms should not be due to any general medical condition or the direct physiological effect of a substance.

12. 8. Symptoms should have some clinical significance, should cause significant distress and impairment in social, occupational and personal functioning. According to DSM-IV-TR 2000, in order to distinguish dysthymic disorder from major depression, its’ essential to look for the following three indicators : 1. Severity of symptoms 2. Duration of symptoms 3. Persistence of symptoms On the basis of the above indicators, we can distinguish dysthymic disorder from major depression. However, sometimes its’ possible that the patients of dysthymic and major depression – both – show similar kind of intense symptoms, but in case of dysthymic disorder, we can observe normal mood of the person for a few weeks, and on this basis, a clinician is able to identify the patients of major depression and dysthymic disorder. CAUSES OF UNIPOLAR DEPRESSION

13. CAUSES OF UNIPOLAR DEPRESSION BIOLOGICAL FACTORS HEREDITY PREDISPOSITION BIOCHEMICAL FACTORS NEUROENDROCRINE SYSTEM NEUROANATOMICAL FACTORS PSYCHOSOCIAL FACTORS COGNITIVE VIEWPOINT BECKS’ THEORY OF DEPRESSION LEARNED HELPLESSNESS ATTRIBUTIONAL THEORY HOPELESSNESS THEORY REINFORCEMENT MODEL INTERPERSONAL THEORY HUMANISTIC EXISTENTIAL VIEWPOINT SOCIOCULTURAL FACTORS

14. I. BIOLOGICAL CAUSAL FACTORS 1. HEREDITY PREDISPOSITION Heredity predisposition for this disorder can be studied on the basis of twin study, family study and adoptee study. All the three studies have shown a hereditary predisposition for depression.

15. RESEARCHER FINDINGS ALLEN,1976FOR IDENTICAL TWINS,CONCORDANCE RATE FOR DEPRESSION IS 40%,AND FOR FRATERNAL TWINS,ITS’ 11%. PLOMIN ET AL.,1977 ON THE BASIS OF TWIN STUDIES,IT HAS BEEN PROVED THAT HEREDITY PLAYS AN IPORTANT ROLE IN CAUSING DEPRESSION. WINOKUR,1979ON THE BASIS OF FAMILY STUDIES, GENETIC FACTORS HAVE BEEN PROVED TO PLAY AN IMPORTANT ROLE IN CAUSING DEPRESSION. WENDER ET AL.,1986 ON THE BASIS OF ADOPTEE STUDIES,IT WAS FOUND THAT HEREDITY PLAYS AN IMPORTANT ROLE IN CAUSING DEPRESION

16. 2. BIOCHEMICAL FACTORS (a) Deficiency of certain neurotransmitters cause depression. Joseph et al.,1967,”Depression is caused due to deficiency of Monoamine neurotransmitter”. (b) Catecholamine Hypothesis: This hypothesis states that the deficiency of norepinephrine, dopamine and epinephrine can cause depression. (c) Golden and Gilmore,1990 –”Deficiency of Serotonin and histamine can cause depression”. (d) GABA inhibits neurotransmitter activities and causes depression. (e) Role of acetylecholine has been proved in causing depression.

17. 3. NEUROENDOCRINE SYSTEM (a) Blood plasma levels of ‘ cortisol ’ are known to be elevated, in about 50- 60% of the seriously depressed patients. (b) Role of hypothalamic-pituitary-adrenal axis is evident in depression. (c) Thyroid gland is also considered to play an important role in depression.For eg. People with low thyroid levels often become depressed. 4. NEUROPHYSIOLOGICAL FACTORS (a) Research has shown that lesions of the left anterior or prefrontal cortex often lead to depression (eg. Robinson & Downhill,1995)

18. (b) High level of limbic activity is related with depression. (c) Abnormal role of hypothalamus is one of the important factors in depression. Damage to hypothalamus creates a functional shift, which occurs due to old age,and thus, depression is developed. (d) Deficient blood flow to the left frontal lobe causes depression ( Bench et al.,1995 ) II.PSYCHOLOGICAL FACTORS >> PSYCHOANALYTIC VIEWPOINT (a) According to Freud(1917),”Depression has its’ roots in childhood”. (b) People who show overindulgence or deprivation may suffer from depression. The individuals who show dependence on others and are fixated to the oral stage of psychosexual development and who incorporate

19. the image of a lost person, may suffer from depression. (c) Those who suffer from guilt feeling or feelings of real or imagined sins,are more prone to suffer from depression. (d) Persons who involve themselves in an imagined or symbolic loss, suffer from depression. (e) People with a low self-esteem and high self-critical tendency, suffer from depression. (f) According to Bibring,” Situations, rather than the internal conflicts, are important in causing depression.” (g) According to Alnaes & Torgersen,1993, ”Combination of traumatic childhood experiences and acute external stressful events in adulthood, are important in causing depression. III. COGNITIVE VIEWPOINT 1. BECKS’ THEORY OF DEPRESSION

20. Beck has shown the interrelationship among the three levels of cognition as an important cause of depression. NEGATIVE SCHEMAS OR BELIEFS NEGATIVE / BIASED / DISTORTED COGNITION FUTURE SELF- COGNITION TRIAD DEPRESSION FIG. BECKS’ COGNITIVE THEORY WORLD

21. LIST OF DISTORTED COGNITIONS (i) Overgeneralisation (ii) Selective Abstraction (iii) Excessive Responsibility (iv) Temporal Casualty (v) Self-References (vi) Catastrophizing (vii) Dichotomous Thinking (viii) Minimisation and Magnification Such kind of distorted cognition may lead to depression. 2. LEARNED HELPLESSNESS Martin Seligman (1974,1975) first proposed that learned helplessness can cause depression.

22. UNCONTROLLED AVERSIVE EVENTS SENSE OF HOPELESSNESS MOTIVATIONAL DEFICITS COGNITIVE DEFICITS (Negative Cognitions) EMOTIONAL DEFICITS (Passivity and low mood ) ( Lack of / lowered initiativeness ) DEPRESSIONDEPRESSION FIG. LEARNED HELPLESSNESS

23. 3. ATTRIBUTIONAL THEORY Abramson et al., 1978 have emphasized that the style of attribution is important in causing depression. According to him, it is our own perceptions which are responsible for making us depressed. For eg. If a person fails in an exam, then the way he attributes is failure becomes important - i.e. - whether he gives Personal / Universal, Stable / Unstable, Global / Specific reasons for his failure. A typical depression attributional style includes attribution towards oneself, the global and stable reasons for failure. Such an individual would perhaps give the reasoning like – ”I lack intelligence”. This reasoning is of the nature ‘ global, stable and personal ’ and may lead to depression. 4. HOPELESSNESS THEORY This theory is given by Abramson et al.,1989.

24. ATRIBUTION TO GLOBAL AND STABLE FACTORS OR OTHER NEGATIVE COGNITIVE FACTORS SENSE OF HOPELESNESS DEPRESSION AVERSIVE EVENTS ( Not able to alter the situation) + (Hopelessness expectancy ) 5. REINFORCEMENT MODEL Ferster,1973,”Positive reinforcers have an important role in the upliftment of our mood, but, if in any environment there is: (i) A lack of positive reinforcers, or (ii) High level of exposure to aversive situations, or (iii) Drastic changes in life (e.g. Loss of a dear one ) and limited reinforcements, then all these factors would lead to depression.

25. 6. INTERPERSONAL THEORY This theory is given by Coyne,1976.According to him, ”Those who are prone to depression, have an aversive interpersonal style, and other persons have negative reaction towards this style. Such individuals lack social skills, donot have social support and are unable to cope with negative life events. They always try to find reassurance for their acts from others in order to get short- term satisfaction, and often show inconsistent behavior. IV. HUMANISTIC – EXISTENTIAL VIEWPOINT Its’ given by Carl Rogers,1980.According to him, the more the discrepancy between the ideal and the real self, more is the chance that the person would face depression. Other important factors are – loss of self-esteem, loss of some loved object, and a faulty self - assessment. All these factors may lead to depression.

26. PERSONALITY “TYPE” AND DEPRESSION Some of the personality traits make an individual vulnerable to depresson. There are specifically two types of personalities, which have an important relationship with depression: (a) Sociotropic Type: Such individuals show interpersonal dependency and they are sensitive towards loses and rejection. (b) Autonomic Type: Such individuals give importance to achievement issues. They are self-critical and sensitive towards achievements and failures. V. SOCIOCULTURAL FACTORS Depression has been found to be closely associated with social and cultural trends. Kleinman, in 1986, found that depression is found to be less prevalent in China. Carothers, in 1956, found that its’ less found in Africa as compared to America. The reason could be that, in Africa, people are not held responsible for their failures. Besides this, it has been found that depression is more common in urban, than in rural areas. It is found in all types of socio-economic classes, but the reasons vary, as illustrated:

27. LEVELSREASONS FOR DEPRESSION High socio- economic class Lack of interest in life. Middle socio- economic class Loneliness, sorrow, guilt-feeling. Low socio- economic class Meaninglessness and self-hatred > Depression is more common in highly educated and professional people. > Depression is more common in women than men.

28. TREATMENT FOR DEPRESSION I. BIOLOGICAL APPROACH A. DRUG THERAPY (i) Antidepressant drugs are useful to deal with negative symptoms and stress. (ii) Heterocyclic drugs have been found to be useful in both-depression and bipolar disorder. (iii) Second-generation drugs are also very useful to deal with depression. eg. Fluoxetine. (iv) Monoamine Oxidase Inhibitors (MAOs) also help in dealing with depression. (v) Sometimes, in the old age, its’ important to give certain stimulants to the patient ( eg. Dextroamphetamine & Pemoline ), along with antidepressants.

29. B. ECT ( ELECTROCONVULSIVE SHOCK THERAPY ) (i) As far as depression is concerned, this therapy has also proved to be useful for those who suffer from acute, major or psychotic-like depression. (ii) This treatment is also useful for those who are not able to tolerate the side- effects of antidepressants. (iii) Success rate with ECT is quite encouraging. Almost 70-80% of the patients benefit. But even ECT could not control the relapse rate, and thats’ why antidepressant drugs are followed, once the ECT treatment is over. C. NON – PHARMACOLOGICAL APPROACH After 1980, many such treatments came into existence which donot have the side- effects like the drug therapy and the ECT. Although these treatments are

30. not as effective as the standardized ones, but still, these are useful for those who are not able to bear the side-effects of the other available treatments. (i) BRIGHT LIGHT THERAPY Wehr & Goodwin, 1987 introduced this therapy. In this therapy, an intense light of 2500 lux is being presented and the patient has to look at that light for almost min. and he’s allowed to blink his eyes only once during he treatment. Individuals who suffer from ‘ winter depression ’ or ‘ Seasonal Affective Disorder ’ (SAD), get benefit from this therapy. (ii) SLEEP DEPRIVATION When depressed patients are not allowed to sleep for one night, they get relief from their symptoms of depression. But, if they get more sleep the next day, they may experience symptoms of depression once again. The main purpose is to deprive them of the REM phase of the sleep. That is why the patients are advised not to sleep, after they have taken half of the sleep. According to

31. different researchers, its’ believed that if the patients are deprived of their sleep during the second-half of the night (i.e. when REM phase of sleep is going on ), they get relief from the symptoms of depression. (iii) SLEEP PHASE CHANGES According to Wehr & Goodwin,1987, sometimes the patients of depression get benefit only by changing the phase of their sleep (i.e. phase-shifting).For e.g. if a person gets too early in the morning and feels depressed, then some changes might be introduced in his pattern of sleep. He may be advised to go to bed late at night. This helps in the improvement of their condition. II. PSYCHOLOGICAL APPROACH In mild and moderate depression, drug therapy is not much useful. So, in such cases, the patients are provided different psychological therapies : >> PSYCHOANALYTIC THERAPY

32. This therapy focusses on developing the insight of the patient towards his inner conflicts, and an attempt is made to integrate the frustration and conflicts into ones’ self. Patients are also taught not to internalize any aggressive, hostile, negative objects and projection of mistakes towards self. Rather, they are made to look at the external actors which are responsible for their worries, tensions and failures. Its’ very important to unreveal the unconscious motives, desires, and needs of an individual in order to deal with the symptoms of depression. III. COGNITIVE THERAPY According to Beck,” Its’ very important to convert the maladaptive patterns into adaptive ones“ and he has suggested four stages in his therapy to improve the negative evaluation towards self, world and future. FIRST STAGE emphasizes on increasing activities and alleviating negative mood.

33. SECOND STAGE focusses on examining and invalidating automatic thoughts. THIRD STAGE helps in identifying the distorted thinking and negative biases. FOURTH STAGE aims at altering the primary attitudes. IV. BEHAVIORAL THERAPY There are different behavioral therapies for the treatment of depression, as mentioned by Lazardus, 1968. (i) POSITIVE REINFORCERS AND TIME PROJECTION In this therapy, the patient is asked to imagine positive future activities. For each positive imagination, some positive reinforcement is provided.

34. (ii) INHIBITION THERAPY In this therapy, the patient is encouraged to express verbally,the opposite mood to depression i.e. he’s encouraged to explain the positive aspects of life, verbally, and lateron, integrate the same in his life. (iii) DEPRIVATION TECHNIQUE In this technique, the patient is deprived of any kind of stimulation for some period, so that he could understand the importance of positive reinforcers. >> Wilkoxen et al., 1976 and Lewinsohn, 1989 emphasized three techniques in the treatment of depression: (i) Reintroducing pleasurable events in the life of the patient. (ii) Reintroducing non-depressive behavior. (iii) teaching social skills to the patient.

35. OTHER THERAPIES In the treatment of depression, many other therapies are also useful. These therapies are termed as crisis-intervention therapies, as these are considered to deal with crisis. >> EXISTENTIAL THERAPY It emphasizes on living life with some purpose. >> PARADOXICAL INTENTION In this therapy, the patient is intentionally made to indulge in his own symptoms. For e.g. if the patient is not leaving his bed till late afternoon, he is made to stand near his bed throughout the day. Exaggeration of the symptoms leads to conscious awareness of the maladaptive behavior i.e. excessive sleep.

36. >> COMPREHENSIVE GROUP TREATMENT PROGRAMME This approach was put forward by Lewinsohn et al. 1999. Family members, friends and colleagues are advised to give encouragement and support to the depressed individual, so that he can manage to cope up with his lifes’ problems. With the support of these individuals, the patient is encouraged and motivated to involve himself in various life activities. >> INTERPERSONAL THERAPY It focusses on interpersonal relationships by emphasizing : (i) Controlled grief reactions (ii) Solving interpersonal role dispute (iii) Interpersonal role transition (iv) Avoidance of interpersonal deficit

37. >> YOGA THERAPY AND MEDITATION have also proved to be effective in alleviating mood. However, the most effective is the combination of all these therapies. BIPOLAR DISORDERS : BIPOLAR-I, BIPOLAR-II AND CYCLOTHYMIC DISORDERS Bipolar disorders were first known as manic depressive disorders or insanity. This term was introduced by Kraeplin, 1899 and lateron, this was also known by the name “manic depressive psychosis”. But according to DSM-IV-TR 2000, the disorders in which we find both- an elated mood as well as depressive mood, are known as bipolar disorders. In these disorders, a person can experience Manic episode, Mixed episode, as well as Hypomanic episode, along with Major Depressive episode.

38. BIPOLAR-I DISORDER: Characterised by one or more manic or mixed episodes, and its’ usually accompanied by Major Depressive episodes. According to DSM-IV-TR 2000,Bipolar disorder is further categorised as follows: (i) Single Manic episode (ii) Most recent episode Hypomanic (iii) Most recent episode Manic (iv) Most recent episode Mixed (v) Most recent episode Depressed (vi) Most recent episode Unspecified

39. FEATURES / CRITERIA OF MANIC EPISODE According to DSM-IV-TR 2000, the following criterias must be satisfied if a person is suffering from mania : 1. The individual must show, in his behavior, for atleast one week, an elevated, expansive and irritable mood. 2. Mood disturbance, if includes only irritable mood, then atleast four symptoms, otherwise three symptoms must be reflected in the persons’ behavior. Symptoms are: (a) Inflated self-esteem (b) Less need of sleep (c) Talkative (d) Flight of ideas

40. (e) Distractability (f) Psychomotor agitation (g) Inclination to involve oneself in pleasurable activities, which have a high potential of painful after-effects. 3. Person must not reflect in his behavior the features of Mixed episode. 4. Mood disturbance is so severe that it interferes in occupational, social and other functional areas. Sometimes it becomes necessary to hospitalize the patient so that he doesnot cause any harm to himself or others. The person does show psychotic features in his behavior. 5. Such symptoms should not be the after-effects of any general medical condition or substance-abuse.

41. CRITERIA / FEATURES OF MIXED EPISODE According to DSM-IV-TR 2000, following are the criterias for a mixed episode : 1. In this type of episode, person must show in his behavior ( almost daily ), manic as well as depressed episode. Person rapidly changes his mood from sadness and irritation to euphoria and a feeling of elevation. 2. Mood disturbance must interfere in the occupational, social and other activities and relationships. Sometimes the features are so intense that they seem to be psychotic features, and the person needs to be hospitalised. 3. These symptoms should not be due to any general medical condition or the direct effect of any substance.

42. CRITERIA / FEATURES OF HYPOMANIC EPISODE According to DSM-IV-TR 2000, the diagnostic criteria for this mood is as follows: 1. Hypomanic episode is distinguished on the basis of time duration of the mood. In this, an individual shows (atleast for four days) persistently elevated, expansive and irritable mood. 2. Mood disturbance is accompanied by atleast three of the following symptoms ( four symptoms when the patient is showing only the irritable mood ). Symptoms are as follows: (a) Inflated self–esteem, grandiosity… { Other symptoms are the same as in Manic episode} 3. Due to mood disturbance, changes in the day-to-day functioning are observable.

43. 4. This episode affects the social and occupational functioning in a low or a moderate manner. 5. Psychotic features are either absent or minimal in this episode. 6. Symptoms are not due to any general medical condition or the direct physiological effects of a substance. BIPOLAR - II DISORDER According to DSM-IV-TR 2000, Bipolar-II disorder is characterised by one or more major Depressive episodes, accompanied by atleast one hypomanic episode.

44. CRITERIA FOR BIPOLAR - II DISORDER 1. Patient must show atleast one or more than one depressive episodes. 2. Patient must also show atleast one Hypomanic episode. 3. Patient must not have ever shown Manic or Mixed episodes. 4. Mood symptoms of the patient should not be like the symptoms of schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, psychotic disorder etc. 5. Symptoms must cause clinically significant distress and disturbances in day- to-day functioning. In this particular disorder, the patient doesnot consider his hypomanic mood to be a problem, but other individuals are affected by it as the mood disturbance causes distress to others. When a person is going through his

45. Major Depressive episode, he is not able to recall his behavior during a hypomanic episode. However, if he is made to recall that behavior, he does show some kind of recognition of the symptoms. CYCLOTHYMIC DISORDER According to DSM-IV-TR 2000, cyclothymic disorder is characterised by atleast two years of numerous periods of hypomanic symptoms that donot meet the criteria for a Manic episode, and numerous periods of depressive symptoms that donot meet the criteria for a Major Depressive disorder. CRITERIA FOR CYCLOTHYMIC DISORDER 1. Individual must show, atleast for two years, the disturbances regarding mood and the mood should be either hypomanic or a mild depressive mood. For children, this duration is 1 year.

46. 2. There should be a symptom-free interval for more than two months. 3. During this time, the individual should not show any of the Major Depressive episode, Manic episode or Mixed episode. 4. Symptoms should not match the symptoms of other disorders, such as schizoaffective disorder, schizophrenia, schizophreniform, delusional disorder etc. 5. Symptoms should not be due to any general medical condition or the physiological effect of any substance. 6. Individual must show clinically significant distress and impairment in various areas of functioning.

47. BIPOLAR SPECTRUM M m N d D NORMAL MOOD CYCLOTHYMIC DISORDER BIPOLAR – II DISORDER BIPOLAR – I DISORDER M : Mania ; m : hypomania ; N : Normal mood variation ; d : Mild depression ; D : Major depression

48. ETIOLOGY OF BIPOLAR – II DISORDER 1.HEREDITY PREDISPOSITION Heredity predisposition for Bipolar-II disorder is even more than unipolar disorder. As far as studies related to identical twins and fraternal twins are concerned, the concordance rate is far more for identical twins (72%) than for fraternal twins (14%). Same has been found to be true for adopted children. 2. BIOCHEMICAL FACTORS Abnormalities in neurotransmitters is one of the major factor causing bipolar disorders. It includes abnormalities in the following neurotransmitters : (i) Norepinephrine (ii) Serotonin (iii) Dopamine

49. 3. CONSTITUTIONAL FACTORS Studies related to constitutional factors are quite old and have also been criticized a lot. But they still deserve a mention. According to Kretschmer, 1936, the individuals who are Pyknic type, are more prone to manic depressive disorders. According to Sheldon, Individuals who belong to endomorphic category, have more probability for mood disturbances. 4. NEUROPHYSIOLOGICAL FACTORS According to Flor & Henry et al.,1983, “ The psychosis and mod disorders are the two ends of a continuum.” The individuals who have disturbances in their left hemisphere of cerebrum, suffer from psychosis and those who have disturbances in their right hemisphere of cerebrum show Bipolar disorders.

50. >> ENDOCRINE GLANDS : Secretions of various glands play an important role in mood disturbances. Important sequences are as follows : 1. HYPOTHALAMIC – PITUTARY – ADRENAL AXIS 2. HYPOTHALAMIC – PITUTARY – THYROID AXIS 3. HYPOTHALAMIC – PITUTARY – ADRENOCORTICAL AXIS OTHER BIOLOGICAL FACTORS 1. Abnormal sleep rhythms play an important role in both – Unipolar and Bipolar disorders. In bipolar disorders, the biological rhythms regarding sleep are disturbed and the person experiences less need for sleep. This, inturn, further causes abnormalities in the rhythms, resulting in Bipolar disorders (Goodwin & Jamison, 1990; Whybrow, 1997)

51. 2. ABNORMAL BRAIN GLUCOSE METABOLIC RATES With the modern technology of Positron Emission Tomography (PET), its’ possible to visualize the variations in brain glucose metabolism rate during depressed and manic states. According to Whybrow, 1997, the blood flow to the left hemisphere and prefrontal cortex is reduced during depression; whereas, during mania, this blood flow is reduced in the right frontal and the temporal region. During normal mood, blood flow across the two brains hemispheres is approximately equal. II. PSYCHOSOCIAL FACTORS 1. PSYCHODYNAMIC VIEWPOINT : According to this view, manic and depressive disorders may be viewed as two different but related defense oriented strategies for dealing with severe stress. Manic patients try to escape their problems by a ‘flight into reality’. They try to avoid the pain of their inner lives through outer world distractions. Such people may involve

52. themselves in countless number of activities, but not necessarily with true enjoyment. They try to deny the feelings of helplessness and hopelessness and play their role with competency. Once a person adopts this mode of coping with life’s problems, it is maintained until the person has spent all of his energy and is emotionally exhausted. The shift from mania to depression tends to occur when the defensive function the manic reaction breaks down. Similarly, a shift from depression to mania tends to occur when an individual devaluates himself and feels guilt-ridden by inactivity and an inability to cope. Such a person feels compelled to attempt some counter measure, no matter how much desperate that may be. > Psychoanalysts have also pointed out that people who have weak superego and those who have a self-punishing superego suffer from mood disturbances.

53. OTHER PSYCHOSOCIAL FACTORS 1. STRESSFUL LIFE EVENTS > Studies have found a significant association between the occurrence of high levels of stress and the experience of manic, hypomanic or depressive episodes. > One of the studies found that patients with more prior episodes were likely to have more episodes after the occurrence of major stressors, than the patients with fewer prior episodes. (Hammen & Gitbin, 1997 ) > Patients who experienced negative events took, on an average, three times longer to recover from an episode, than those without negative events (Johnson & Miller,1997). This is because stressful events seem to disturb the critical, biological rhythms, which play an important role in mood disturbances. 2. PERSONALITY CHARACTERISTICS

54. Personality and cognitive variables may interact with stress and determine the likelihood of relapse. For e.g. highly introverted and obssessional individuals are more responsive to stress and mood disturbances; individuals with a pessimistic attribution style and who also face negative life events show an increase in depressive symptoms. 3. FAMILY > If a person has lost one or both the parents before the age of five, or if one has lost his father between the age of 10-14 years, then that person is predisposed for depression. > Feelings of inferiority in the family, an antisocial model in the family, and excessive parental demands, also predispose a person towards mood disturbances. III. SOCIOCULTURAL FACTORS

55. In one of the earlier studies by Carothers ( 1947, 1951, 1959 ), he found manic disorder to be fairly common among East Africans but depressive disorder was rare. Incidence rate found in the U.S. was opposite to this trend. The reason for this was that in Africa, individuals were not held responsible for their failures and misfortunes. However, much has changed in Africa since Carothers made these observations. Recent data suggests that as the societies take on the ways of western culture, they become more prone to developing Western style mood disorder (Marsella, 1980) > Mood disorders are found to be more in urban than rural areas; and more in high than the low socio-economic class.

56. TREATMENT FOR BIPOLAR DISORDERS 1. BIOLOGICAL TREATMENT > DRUG THERAPY * Trycyclic drugs * Second-generation drugs * Third generation drugs * Monoamine oxidase inhibitors (MAOs) * Lithium Therapy : It focusses on the two phases of the mood – i.e. it acts as a mood stabilizer and it has both -- anti-manic and anti-depressive effects. But this therapy has many side- effects and should be given when the patient has been hospitalised.

57. * Antipsychotic drugs : These drugs are able to control the symptoms quickly and cause less dysphoria ( uneasiness feeling ) than the Lithium therapy. > ECT / EST > HYPNOSIS > PSYCHOANALYSIS > INTERPERSONAL THERAPY > FAMILY THERAPY > COUPLE THERAPY > OCCUPATIONAL THERAPY