Differential 4

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Differential 4
Here we go. Thought I would share my professors comments from the last paper – he still has not graded it well He states exactly what he is looking

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â€ÂÂI just read your Differential 3 and wanted to explain your grade. It is lacking specificity. The diagnosis was not

specific. Perhaps there was a miscommunication that I wanted you to give me a disorder rather than just the classification of disorders. For the next case, please include specifics of the disorder, your rule-outs, and why your diagnosis seems best.
This PAPER: There is only ONE disorder to be diagnosed, and it’s definitely a mood disorder. The symptoms should lead you in the right direction. Let’s add something new… On this one, make sure to include the appropriate specifier for the disorder.
Definitions: Differentials. Students will complete differentials. Differentials will actually be case studies provided by the instructor. Cases will be relevant to the disorder category of the week. Students will read the case materials, consider the symptoms, and make a “best-guess” of what diagnosis the case describes using a series of questions provided by the instructor. The diagnosis is not intended to be perfect using all possible specifiers, etc., but rather to allow students to begin thinking through the complexities and inter-relatedness of many disorders, and recognizing symptoms and the disorders they represent.
Tips: This is your LAST differential! So, make it count. There is only ONE disorder to be diagnosed, and it’s definitely a mood disorder. The symptoms should lead you in the right direction. Let’s add something new… On this one, make sure to include the appropriate specifier for the disorder. See your text for more…

GENERAL: Read the case materials, consider the symptoms, and make a “best-guess” of what diagnosis the case describes. The diagnosis is not intended to be perfect using all possible specifiers, etc., but rather to allow students to begin thinking through the complexities and inter-relatedness of many disorders, and recognizing symptoms and the disorders they represent.

FORMAT: Use 12-point font, 1-inch margins, single-spaced, Times New Roman font. This shoud take NO MORE than one page. You can use more of an outline form if you like instead of a narrative. As long as you convey what you are thinking to lead you to your diagnosis, you should be alright. These are the things you should address: 1) What are the symptoms presented in the case? 2) Which disorders do these symptoms seem to match? Here you will note your differentials (rule-outs) of disorders whose DSM criteria presented in the text seem to match – there will be only one disorder. . 3) What is your diagnosis? This should be the disorder whose diagnostic criteria best matches the symptoms. 4) Why is this the best match?



There are two moods involved in mood disorders:

Mania – intense and unrealistic feeling of excitement and euphoria

Depression – involves feelings of extraordinary sadness and dejection

Some people with mood disorder experience each of these at different times and some only experience depression. Some may experience a MIXED EPISODE in which they have some manic symptoms and some depression symptoms such as feeling sad, euphoric, and irritable.

Unipolar disorders – the person experiences only depressive episodes

Bipolar disorders – person experiences at least manic episodes, and usually depressive episodes as well.


Lifetime prevalence rates of unipolar major depression – about 17 percent – higher in women than in men

Lifetime prevalence rate of bipolar disorder – .4 to 1.6 percent – no difference between the sexes

The gender differences, or lack thereof, may indicate that like schizophrenia, bipolar disorder is very biologically determined compared to many other disorders.


Most people experience some feelings of discouragement, pessimism, and hopelessness. Some mild depression is “normal†and may even be good for us – it slows us down and forces us to deal with some painful things that we may otherwise avoid dealing with.


I. Grief – seems to be more difficult for men than for women.

Major Depressive disorder is not diagnosed for the first 2 months after a loss. Some have even suggested that it take a year to get out of the grieving state.

Some people are truly resilient and have very symptoms and bounce back quickly. It doesn’t mean they were not attached, but they just move on faster.

II. Postpartum “blues†– emotional lability, crying easily, and irritability. About 50-70 percent of women may have postpartum symptoms most likely due to hormonal readjustments. More likely to occur if she doesn’t have a strong social support system.


Must have a persistently depressed mood most of the day, for more days than not, for at last 2 years (1 year for children and adolescents).

Must have at least 2 of 6 additional symptoms from the criteria list on page 230.

May have a normal mood for a few days, but not more than 2 months.

Dysthymia lasts on the average about 5 years, but can last more than 20 years.

Usually worse with chronic stress

Usually begins during adolescence

Dysthymia is essentially a low-grade, yet more chronic depression.


Must experience a markedly depressed mood or loss of interest in pleasurable activities most of every day, nearly every day, for at least 2 consecutive weeks.

Must have five or more of the symptoms noted in textbook.

These include cognitive symptoms, behavioral symptoms, and physical symptoms.

They have NEVER had a manic or mixed episode.

People also often experience anxiety. There is a very high comorbidity rate.

Depression can begin at any time in the life cycle – from early childhood (even infants) to old age.

With psychotic features – loss of contact with reality and delusions (false beliefs) or hallucinations; also feel worthless and guilty

-Have a poorer long-term prognosis

-Often given antipsychotic medication as well as antidepressants

With a diagnosis of major depression, it is specified whether this is a first and single episode or a recurrent episode. The average duration of untreated depression is usually 6 months.

If the depression does not remit for over 2 years, it is chronic major depressive disorder.

Depression usually remits (no symptoms for 2 months). But it usually comes back.

Relapse – often occurs when medication is stopped.



Genetic influences –

Family studies show that the prevalence of mood disorders is about 3 times higher in blood relatives of persons with clinical unipolar depression.

Overall, there is a moderate genetic contribution for major depression. For dysthymia, there doesn’t seem to be much evidence of a genetic contribution.

3 neurotransmitters involved in depression:

Norepinephrine, dopamine, and serotonin

Only some depressed patients have lowered serotonin activity – often those who are suicidal.

Some have elevated cortisol levels (human stress hormone released by the adrenal glands) – depressed patients with elevated cortisol have memory impairments which can cause cell death in the hippocampus (involved in making new memories).

Another possibility is that people with low thyroid levels (hypothyroidism) often become depressed.

Stroke damage to the left prefrontal cortex often leads to depression. Or if they haven’t had a stroke, they may still have lower levels of brain activity in that region.

Sleep. Depressed patients typically have some type of sleep difficulty. They go into REM sleep 15-20 minutes sooner and have more intense REM sleep.


Stressful events can precipitate depression – loss of a loved one, threats to close relationships, or occupation, economic troubles, or health problems. The depression is worse is there is a sense of humiliation.

Chronic stress can be as important as major life events.

If the individual already has a genetic predisposition to depression and they experience stressful life events, they are even more likely to experience depression.

Personality vulnerability factors:

Neuroticism (especially in conjunction with being sensitive to negative stimuli)

High levels of introversion

Beck’s Cognitive Theory:

Underlying dysfunctional beliefs – rigid, extreme, and counterproductive – “If everyone doesn’t love me, then my life is worthless.â€ÂÂ

Negative automatic thoughts:

Beck’s Cognitive Triad for Depression:

Negative thoughts about the self: “I’m a failure.â€ÂÂ

Negative thoughts about the world in general: “People treat me badly.â€ÂÂ

Negative thoughts about one’s future: “things will always be this way.â€ÂÂ

Ways of thinking:

Dichotomous or all-or-none thinking – “I have to make a 100 on all my tests or I am a failure.â€ÂÂ

Selective abstraction – focusing on only the negative

Arbitrary inference – jumping to conclusion based on no evidence. “Therapy will never work for me†after just one session.

Beck’s cognitive therapy – helps them change their way of thinking by testing and disproving these negative assumptions.

Learned helplessness – Martin Seligman – dogs who had control over being shocked and those who did not. People can develop learned helplessness.

Effects of Depression on Others:

Depressed people elicit negative feelings from others including rejection, especially if they need a lot of reassurance. It’s tiring and produces more depression and anxiety listening to a depressed person.

When someone in a marriage is depressed, they are more likely to have problems. For one thing, they’re preoccupied with themselves and they bring the other people down.


Bipolar disorders – presence of manic or hypomanic episodes.

Manic episode – markedly elevated, euphoric, and expansive mood; may have intense irritability or even violence; must last for at least a week; must be impairment of occupational and social functioning; hospitalization is often necessary.

Hypomanic episode – milder form; person experiences abnormally elevated, expansive, or irritable mood for at least 4 days.

Special note: Bipolar is often thought of as manic-depression; one has manic and depressive episodes (not necessarily at the same time). However, for Bipolar I disorder, one need not have ever had a depressive episode. Someone can be diagnosed with Bipolar I simply by having a manic episode. It is likely, though, that someone with Bipolar I will have depressive episodes as well.


Bipolar disorder I:

At least one episode of mania or a mixed episode (for one week, they have both depressive and manic symptoms all at once or rapidly alternate every few days). They may be in a manic state, but still feel anxious and suicidal.

Bipolar II:

Does not experience full-blown manic episodes, but has hypomanic episodes and major depression. More common than bipolar I. About 3% of U.S. population will suffer from one or the other (I orII). Bipolar II does NOT usually become bipolar I.

Both occur equally in males and females and usually starts in adolescence or young adulthood, and usually is recurrent. A single episode is rare.

Some (about 1/3) have normal functioning in between mania and depression.

Can be seasonal in nature just like depression.


Depressive episodes look like a major depressive episode though they may be more likely to overeat and oversleep (atypical depression) than not. Many with bipolar disorder are misdiagnosed with depression – maybe even never be recognized as bipolar. Important to ask about creative achievement, multiple marriages, unstable work patterns, etc.

Rapid cycling – experience at least 4 episodes every year – probably more. (5-10% of bipolars). May be caused by taking antidepressants.

Full-recovery from bipolar disorder is unlikely.


This is the less intense version of bipolar disorder. It is akin to dysthymia for the unipolar depressions.

One gets somewhat hypomanic, at which times they may become especially creative, and productive; suddenly have lots of energy (physical and mental). In the down-periods, they are low on energy, but not major depressed. Basically, they’re moody.

Cyclothymia must go on for at least 2 years (1 year in children and adolescents) for diagnosis.

It’s usually clinically significant but not to the point of being hospitalized.

It can develop into full-blown bipolar disorder so they should be treated, or at least monitored.



Genes account for about 80 – 90% of the variance in the tendency to develop bipolar depression. Highest of all the adult psychiatric disorders. This is higher than even the heritability estimates for schizophrenia.

There is some evidence for increased norepinephrine activity during manic episodes and lowered norepinephrine activity during depressed episodes.

Too much Dopamine can produce hyperactivity and euphoria.

Bipolar patients are very sensitive to and disturbed by any changes in their daily cycles – they need to eat and sleep on a schedule.


Stressful life events often precipitate a manic episode.

Neuroticism predicts more depressive symptoms.


Many do not seek treatment and still get better within less than a year.


4 kinds of medications for mood disorders:

1. Monoamine oxidase inhibitors (MAOIs) – inhibit the breakdown of norepinephrine and serotonin. Potentially fatal side effects. Can not consume red wine, beer, aged cheese, salami and some others)

2. Tricyclic antidepressants – increase norepinephrine and serotonin. Can cause dry mouth, constipation, sexual dysfunction, and weight gain. Many stop taking them before they can work. When taken in large doses can be legal, so probably should not be given to suicidal patients.

3. Selective serotonin reuptake inhibitors (SSRIs) – fewer side-effects and not as toxic in large doses – some problems with sexual activity, insomnia, and physical agitation.

Most common ones: fluoxetine (prozac), sertraline (zoloft), and paroxetine (paxil). Effexor is also not bad. Cymbalta is kinda a re-birthed Effexor that seems to work well, often without the sexual side effects (lack of interest, lack of functioning).

Antidepressant drugs usually take 3 to 5 weeks to take effect. If it doesn’t work in about 6 weeks, a new one is usually tried. Some of the side effects can be felt within a few days (i.e., skaky hands, dry mouth) so folks assume the treatment is working. However, they may get discouraged after one or two weeks when they don’t feel better… often some will stop at that time.

If they stop taking the medication, they are likely to relapse unless the depression has run its course. Stopping antidepressants “cold-turkey†is a bad idea. You get all the glorious withdrawal symptoms that can come with other drugs.

Bipolar disorder:

Lithium – mood stabilizer is oldest line of defense (it’s a metallic chemical related to sodium). Prescribing regular antidepressants (i.e., SSRI) may precipitate a manic state. This is somewhat controversial.

Lithium has unpleasant side-effects: lethargy and some toxic effects are possible. Also, some patients don’t comply with medication because they miss the “highs†and the energy.

Somehow (no, we don’t know exactly how) lithium (stabilizes people with manic episodes. Some anticonvulsants also work well too without the “nasty†side effect of lithium. These include Depakote and Tegratol. These are becoming preferred among many psychiatrists.


Electroconvulsive therapy (ECT) – severely depressed patients with suicide risk; and/or psychotic features;

Take 6-12 daily treatments

With general anesthesia and muscle relaxants

Causes confusion

Also treats manic episodes

PSYCHOTHERAPY (Best for Unipolar Depression)

Cognitive-behavioral therapy – 10-20 sessions focusing on the here and now to treat unipolar depression. Evaluate their beliefs and negative automatic thoughts.

Behavioral activation treatment – focuses on getting patients more involved in activities. Schedule activities and work toward goals.

Interpersonal therapy – focuses on current relationship issues; help them understand and change maladaptive interaction patterns.

What does the research say? Overall, a combination of cognitive-behavioral and SSRIs seems to be most effective for unipolar depression.

For Bipolar: medication again is the first step. Some extra supportive therapies and education may be thrown in with the meds as well.


Suicide risk is a significant factor in all types of depression and bipolar. Often, the risk of suicide is greatest when the person is emerging from the deepest phase of the depression. At that time they have more energy to carry through their suicide.


Suicide attempts are highest in those from 18-24.

Women are 3 times more likely to attempt; whereas men are 4 times more likely to succeed. Men use more lethal methods seems to explain this.

Divorced and separated people are 3-4 times higher than married or single.

Children: ages 5-14, suicide is rare, but is the 7th leading cause of death.

Risk factors: losing a parent or abuse, depression, antisocial behavior, high impulsivity.

Adolescents and young adults: 15-24: 3rd most common cause of death

Antidepressant medication may increase suicidal ideation and behavior in children and adolescents.

Between 1 and 13 percent of adolescent suicides occur as an attempt to cope with stress or problems.

Factors that seem to lead to suicide:

Hopelessness (#1 predictor outside of previous attempts and having a plan).


Panic attacks

Severe anhedonia



Alcohol abuse

Being married and having children seems to “protect†people from suicide.


Some people who attempt suicide don’t want to die, but want to communicate a message to others (a cry for help). They arrange to be found in time.

There are others who give no warning and rely on lethal means.

Some don’t care one way or the other and leave it up to the fates as to whether they live or die.

After someone attempts suicide, they experience a reduction in emotional turmoil. They feel much better. However, they are likely to make another attempt within the year.

Most people communicate their intent before attempting suicide. But many deny suicidal ideation before committing suicide. Often once someone makes the decision they are going to kill themselves, they seem to feel better; as if a weight has been lifted. They may seem happier and begin giving away prized possessions.


Suicide is difficult to prevent.

Crisis intervention focuses on:

-Maintaining supportive and highly directive contact with the person

-Helping them see that the distress is impairing their ability to solve the problem

-Helping them see that they will feel better again

The thinking pattern of a suicidal person is rigid, dichotomous (all or nothing), and hopeless. You must break through this somehow to help.
* Melancholia

* Major Depressive Episode

* Manic Episode

* Mixed Episode

* Hypomanic Episode

* Unipolar Depression

* Major Depression Disorder

* Dysthymic Disorder

* Depressive Disorder

* Genetic Factors

* Biochemical Factors

* Monoamine Hypothesis

* Hormonal Dyregulation

* Sleep Dysregulation

* Neuroanatomy

* Psychoanaltic View

* Infant-Mother attachment

* Learned Helplessness

* Attribution Model of Depression

* Bipolar Disorder

* Suicideapy

* Phototherpy
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