191 -10 Common Errors in the Diagnosis of Mood Disorders and PTSD – Addiction Counselor Training Series
Counselor Toolbox

 
 
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Mood Disorders and PTSD
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Objectives
~ Bipolar 1 & 2
~ Cyclothymic Disorder
~ Depressive Disorder
~ Persistent Depressive Disorder
~ Premenstrual Dysphoric Disorder
~ Circadian Rhythm Sleep Disorder
~ Generalized Anxiety
~ Social Anxiety
~ Panic Disorder
~ Agoraphobia
~ Acute Stress Disorder
~ PTSD
Manic
~ A. (Often ego-syntonic) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased activity or energy, lasting at least one week (or any duration if hospitalized).
~ Often the mood is irritable if due to the use of a substance or if the person’s wishes are denied
~ High mood liability is possible
~ In children, happiness, silliness inappropriate to context and developmental age
~ Depressive symptoms can occur during a manic episode lasting hours or a couple of days
Manic
~ B. During the period of mood disturbance and increased energy or activity, 3+ of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
~ 1) Inflated self-esteem (uncritical self-confidence) or grandiosity.
~ Despite no prior experience, person may undertake a grandiose task like writing a novel
~ Delusions of grandeur are possible
~ Children overestimate abilities and may think themselves better at things than they are
~ 2) Decreased need for sleep (eg, feels rested after only three hours of sleep).

Manic
~ 3) More talkative than usual or pressure to keep talking.
~ 4) Flight of ideas or subjective experience that thoughts are racing.
~ 5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
~ Heightened sense of smell hearing or vision may be reported
~ 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (ie, purposeless non-goal-directed activity).
~ Marked increase in sociability including talking to strangers is common
~ Dress may become markedly more seductive or flambouyant
~ Person may become aggressive or hostile
Manic
~ 7) Excessive involvement in activities that have a high potential for painful consequences (eg, unrestrained buying sprees, sexual indiscretions, or foolish investments).
~ In children, developmentally inappropriate sexual preoccupations or taking on many tasks simultaneously
~ C. Causes marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
~ D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other treatment) or to another medical condition.
~ Cocaine, amphetamines; Medications: steroids, L-Dopa, antidepressants, stimulants (ADHD, weight, decongestants); Light therapy, ECT, MS, Stroke, lupus, AIDS, encephalitis
Manic/Hypomania
~ Hypomania:
~ A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood increased activity or energy, lasting at least four consecutive days (4 days vs. 1 week)
~ The episode is not severe enough to cause marked impairment in social or occupational functioning
~ Do not confuse with euthymia —elevated mood that occurs for a couple days following remission of major depression
Major Depressive Disorder
~ A. 5 (or more) (2 or more for PDD) of the following symptoms have been present during the same 2-week period (2 years for PDD (1 in children) and represent a change from previous functioning; at least one of the symptoms is either
~ (1) Depressed mood most of the day, nearly every day. Note: In children and adolescents, can be irritable mood.
OR
~ (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
~ Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. In children, consider failure to make expected weight gains.
~ Insomnia or Hypersomnia nearly every day
~ Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
Major Depressive Disorder
~ A. Five (or more) of the following symptoms cont…
~ Fatigue or loss of energy nearly every day
~ Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
~ Diminished ability to think or concentrate, or indecisiveness, nearly every day
~ Recurrent thoughts of death (not just fear of dying), suicidal ideation or attempt.
~ B. Does not meet criteria for a Mixed Episode
~ C. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
~ D. Not due to the direct physiological effects of a substance or a general medical condition (e.g., hypothyroidism).
~ No bereavement exclusion
~ Consider individual’s history, cultural norms for expression of distress, PMDD

Persistent Depressive Disorder
~ The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years (at least 1 year for children and adolescents).
~ Major depression may
~ Precede persistent depressive disorder
~ Occur during persistent depressive disorder.
~ Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.
~ Never been a manic episode, a mixed episode, cyclothymic disorder.
~ No hypomanic episode in the first 2 years

Bipolar Disorders Overview
~ Many children and some adolescents may experience bipolar-like phenomena, especially short duration hypomania, that do not meet the criteria for bipolar disorder
~ 1/3 of persons with bipolar may attempt suicide
~ 6 fold increase in suicide risk among first degree relatives of someone with bipolar disorder
~ 14% of those with bipolar have at least one eating disorder esp. binge eating.
~ Anxiety and eating disorders are commonly associated with depressive episodes
~ Substance use disorders and addictive behaviors (gambling, sex) are more associated with manic episodes.
Bipolar Disorder Comorbidity
~ Anxiety Disorders (75%)
~ ADHD and other impulse control disorders including intermittent explosive disorder (50%)
~ Substance Use Disorders (50%)
~ Bipolar + AUD = increased risk for suicide
~ Metabolic Syndrome
~ Migraines

Bipolar 1
~ Neither psychosis nor major depression is required
~ At least 1 manic episode is required
~ May be preceded by or followed by a hypomanic or depressive episode
~ Equally common in males and females
~ Females more likely to be rapid cycling and have multiple comorbidities including higher rates of eating disorders and alcohol use disorder
~ Prevalence rate for both bipolar 1 and 2 combined is ~3% (CDC/NIMH)
~ Mean age of onset 18-years old for BP1 and mid 20s for BP2
~ 20% of adolescents with major depression develop bipolar disorder within five years of the onset of depression
~ Onset of manic symptoms in mid or late life should prompt consideration of neurocognitive disorders or substance use
~ 60% of manic episodes occur before a major depressive episode
~ 4 or more mood episodes within a year = rapid cycling

Bipolar 2
~ Often begins with MDD and is more chronic than Bipolar 1
~ Requires lifetime experience of at least 1 episode of major depressive disorder
~ At least 1 hypomanic episode and no manic episodes
~ Not better explained by
~ Schizoaffective
~ Schizophrenia
~ Schizophreniform
~ Delusional or other psychotic disorders
Bipolar 2
~ Symptoms of depression or unpredictability of alterations between depression and hypomania cause clinically significant distress
~ Clients often present during a depressive episode. Hypomanic episodes rarely cause distress. Fluctuations between the 2 cause unpredictability in interpersonal and occupational functioning
~ Intervals between episodes tend to decrease with age and depressive episodes are more enduring with time
~ Depression + hypomania may present as irritable depression or depression with increased energy
~ Childbirth can trigger a hypomanic episode and may foreshadow impending depression (50%)
Bipolar Risk and Prognostic Factors
~ Separated, divorced or widowed have a higher risk than those who are married or never have been married
~ Family history is one of the strongest predictors
~ Degree of kinship increases magnitude of risk
~ One an individual experiences psychotic features, further episodes will likely include psychosis
~ Suicide risk for persons with bipolar is 15x higher than the general population
~ Past hx of suicide attempt and %days depressed during the past year are predictive of suicide
~ Functional recovery lags behind symptom recovery
~ Vocational
~ Interpersonal
~ Cognitive

Bipolar Differential Diagnosis
~ Bipolar 1 = at least one manic episode.
~ Bipolar 2 = at least one MDD and no mania
~ Cyclothymia= for 2 years numerous periods (with no remission of >2months)with hypomanic and depressive symptoms that do not meet criteria for hypomanic or depressive episode
~ Major Depressive Disorder
~ May also have manic or hypomanic symptoms—fewer and shorter in duration than required for Bipolar
~ Irritability can be present in both depression and bipolar disorder

Bipolar Differential Diagnosis
~ Anxiety Disorders
~ May be comorbid
~ Differentiate from bipolar
~ Anxious ruminations from racing thoughts
~ Efforts to minimize anxiety from impulsive behavior
~ ADHD
~ Especially common to misdiagnose in children and adolescents
~ Clarify if the symptoms such as rapid speech, racing thoughts and distractibility are part of a distinct episode or ongoing
Bipolar Differential Diagnosis
~ Personality Disorders
~ Borderline also has impulsivity and mood lability
~ Symptoms must represent a distinct episode and marked increase over baseline
~ A PD Dx should not be made until bipolar symptoms are stabilized
~ Disruptive Mood Dysregulation Disorder (Children)
~ When irritable mood is persistent and severe

PMDD
~ PMDD Criteria
~ Mood swings, sudden sadness, increased sensitivity to rejection
~ Anger, irritability, increased interpersonal conflict
~ Problems concentrating
~ Having a depressed mood, negative/critical thoughts about the self or sense of hopelessness
~ Tension, anxiety, being “on edge”
~ Appetite changes, over eating (including bingeing), specific food craving
~ Sleeping too much or not sleeping
~ Feeling overwhelmed or not in control
~ Tender breasts, pain, bloating, swelling, weight increase
~ Fatigue, lethargy, lack or energy
~ Reduced interest in usual activities such as school, work, friends, hobbies

PMDD
~ Between 3 and 8 per cent of women
~ Symptoms last on average 6 days, are most intense just before and after the start of menstrual flow, absent in post-menstrual weeks
~ Not due to any other mental illness, cause significant distress for the individual, and experienced several months over the course of a year.
~ The current consensus is that normal hormonal fluctuations trigger pain, anxiety and depressive symptoms through interaction with serotonin systems
~ Alterations in serotonin, GABA, adrenaline and opioid pathways have all been implicated
~ Commonly co-occurs with depression and anxiety disorders

Circadian Rhythm Sleep Disorder
~ A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep-wake schedule required by a person’s environment
~ Others may exhibit a variable sleep pattern (e.g., take multiple naps instead of sleeping an extended block of time) throughout the regular 24 hr period leading to similar sleepiness or trouble concentrating during the socially conventional awake period.
~ The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
~ The disturbance does not occur exclusively during the course of another sleep disorder or other mental disorder (depression, anxiety, bipolar).
~ The disturbance is not due to the direct physiological effects of a substance or a general medical condition (chronic fatigue, fibromyalgia, lyme disease).
Anxiety Disorders Overview
~ 4 to 6% of people will experience GAD
~ 7% will experience social anxiety
~ 2x as frequent in women
~ Age of onset
~ GAD is 45-59 years
~ Social Anxiety 8-15 years
Generalized Anxiety
~ 1. The presence of excessive anxiety and worry about a variety of topics, events, or activities more often than not for at least 6 months and is clearly excessive. May be accompanied by reassurance-seeking from others.
~ 2. The worry is experienced as very challenging to control, and may shift from one topic to another.
~ 3. The anxiety and worry are associated with at least three of the following (In children, only one symptom is necessary):
~ Edginess or restlessness
~ Tiring easily; more fatigued than usual
~ Impaired concentration or feeling as though the mind goes blank
~ Irritability (which may or may not be observable to others)
~ Increased muscle aches or soreness
~ Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)
Generalized Anxiety
~ Many individuals with GAD also experience symptoms such as sweating, nausea, or diarrhea.
~ The anxiety, worry, or associated symptoms cause difficulty in one or more life functioning areas
~ Unrelated to any other medical conditions and cannot be explained by the effect of substances including a prescription medication, alcohol, or recreational drugs.
~ Not better explained by a different mental disorder.
Social Anxiety
~ Fear or anxiety specific to social settings, in which a person feels noticed, observed, or scrutinized. In children, it must occur in settings with peers, rather than adult interactions
~ The individual will fear that they will display their anxiety and experience social rejection
~ Social interaction will consistently provoke distress
~ Social interactions are either avoided, or painfully and reluctantly endured,
~ The fear and anxiety will be grossly disproportionate to the actual situation,
~ The fear, anxiety or other distress around social situations will persist for six months or longer
~ Cause personal distress and impairment of functioning in one or more life domains

Social Anxiety
~ The fear or anxiety cannot be attributed to a
~ Medical disorder
~ Substance use
~ Adverse medication effects
~ Rule out shyness, introversion, agoraphobia, panic, GAD, body dysmorphic disorder, avoidant personality disorder
~ Social anxiety can lead to depression, due to loneliness, isolation, and inability to make social contacts
~ Treatment:
~ CBT
~ Exposure therapy/systematic desensitization
~ SSRIs
Panic Disorder
~ Four or more of the following symptoms:
~ Palpitations, pounding heart, or accelerated heart rate
~ Sweating
~ Trembling or shaking
~ Sensations of shortness of breath or smothering
~ A feeling of choking
~ Chest pain or discomfort
~ Nausea or abdominal distress
~ Feeling dizzy, unsteady, lightheaded, or faint
~ Feelings of unreality (derealization) or being detached from oneself (depersonalization)
~ Fear of losing control or going crazy
~ Fear of dying
~ Numbness or tingling sensations (paresthesias)
~ Chills or hot flushes

Agoraphobia
~ Now an independent diagnosis, not a modifier of panic disorder
~ Diagnostic Criteria
~ Experience intense fear or anxiety in a minimum of two situations including being out in public, open spaces, and in crowds.
~ Avoidance behaviors must be exhibited.
~ Symptoms are a result of the fear of being in situations that may induce panic attacks or anxiety

ASD and PTSD Overview
~ Prevalence
~ Acute Stress
~ PTSD ~8%
~ Risk factors
~ History of a pretrauma psychiatric disorder
~ History of traumatic exposures prior to recent exposure
~ Female gender
~ Trauma severity
~ Neuroticism
~ Avoidant coping

Acute Stress Disorder/PTSD
~ A. Exposure to…
~ Actual or threatened death, serious injury, or sexual violation (natural death (even sudden) not included)
~ By direct experience
~ Witnessing, in person, the events(s) as it/they occurred to others
~ Learning that the events(s) occurred to a significant other;
~ Repeated or extreme exposure to aversive details of the event(s) This does not apply to exposure through electronic media, television, movies, or pictures unless this exposure is work related.

Note feelings of helplessness, horror are no longer included
Acute Stress Disorder/PTSD
~ B. Intrusion symptoms (1+)
~ Intrusive distressing memories of the traumatic event(s).
~ Note: In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
~ Nightmares where content and/or affect of the dream are related to the events(s).
~ Note: In children older than 6, frightening dreams without recognizable content.
~ Flashbacks and dissociative reactions
~ Intense or prolonged psychological or physiological distress in response to internal or external reminders of the traumatic events.
Acute Stress Disorder/PTSD
~ C. Avoidance symptoms (one or both)
~ Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
~ Efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about the traumatic event(s).
~ D. Negative Mood: Persistent inability to experience positive emotions
~ Negative thoughts or beliefs about one’s self or the world
~ Distorted sense of blame for one’s self or others, related to the event
~ Being stuck in severe emotions related to the trauma (e.g. horror, shame, sadness)
~ Severely reduced interest in pre-trauma activities
~ Feeling detached, isolated or disconnected from other people

Acute Stress Disorder/PTSD
~ E. Arousal symptoms
~ Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)
~ Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression
~ Hypervigilance
~ Problems with concentration
~ Exaggerated startle response
~ F. The duration of the disturbance is 3 days to 1 month (1+ months for PTSD) after trauma exposure.
~ Note: Symptoms typically begin immediately after the trauma
Acute Stress Disorder/PTSD
~ G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
~ H. The disturbance is not attributable to
~ Physiological effects of a substance (e.g., medication or alcohol)
~ Medical condition (e.g., mild traumatic brain injury)
~ Brief psychotic disorder
Summary
~ Anxiety, Depression, Mania and Acute Stress all have overlapping symptoms.
~ Effective treatment requires
~ Effective diagnosis of all conditions mental health and addictive
~ Ruling out of substance and medication effects
~ Evaluation of medical issues including pain, hormone related issues, stroke, fibromyalgia, chronic fatigue, and autoimmune disorders including lupus, multiple sclerosis, and rheumatoid arthritis