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Essay questions on mood disorders



A mood disorder is a medical illness that manifests itself as extremely depressed or elevated mood as well as disruption of the major appetites (for food, sex, sleep, new experiences, social interaction, and life itself).

The major mood disorders are major depression, also known as unipolar Depression, and bipolar disorder, also known as manic Depression. Other variants include cyclothymia and, dysthymia, and adjustment disorder.

Question: What is major depression and how is it different from sadness? Don't we all get depressed?

Major depression is a serious, potentially life threatening illness. We may all get sad, but only 15% develop full-blown major depression. The most common symptoms of depression can be summarized using the mnemonic SIGECAPS :

    • Decreased S leep (especially with early morning awakening );
    • Decreased I nterest in things and people (anhedonia = (literally) absence of joy, decreased capacity for pleasure);
    • G uilt feelings;
    • Decreased E nergy (note that some depressed patients can have an increase in nervous energy);
    • Decreased C oncentration (often with decreased memory that can even mimic dementia);
    • Decreased A ppetite (for food and for sex);
    • P sychomotor agitation or slowing (translation: patient is either markedly slowed down in their movements or can't sit still - either condition can be seen in major depression);
    • S uicidal thoughts (note that these can be passive - "I'd be better of dead; I'm no good to anyone" - to active - "I want to kill myself").

Score: one point for each symptom that has lasted for at least 2 weeks.

Question: what percentage of the American population gets major depression?

Estimates vary from a low of about 5% (Epidemiological Catchment Area) to a high of about 24% (National Comborbidity Study). In any given year, it is estimated that 13 % of women and 8 % of men will suffer a major depressive episode. Women are twice as likely as men to suffer from depression.

The evidence is overwhelming that major depression has a strong genetic component. In one study, the biggest predictor of the development of depression in adopted-away women was the presence of depression in their biological mothers whom they had never met. The presence of depression in the adoptive family or of major life stressors was not as great a predictor of the development of depression as family history. 50% of identical twins will develop depression if the other twin developed depression; this rate is 25% for fraternal twins. A family history of depression makes you 2-5 times more likely to develop depression yourself.

Question: at what point in life do most people develop depression?

The first depressive episode most frequently occurs during late teens or early 20s. However, depression can occur in children and for the first time in middle-aged or elderly people, particularly following a major loss such as the death of the spouse.

Question: is major depression a normal part of the grieving process?

No. Most people who suffer a major loss do not go on to develop a full-blown major depression. Some sadness, sleep loss, decreased appetite is common, but suicidal ideation, pervasive and persistent symptoms, and profound social withdrawal is not. About 15 percent of those who suffer a major loss will develop major depression (meaning of course that 85 percent will not).

Question: who is particularly at risk of developing major depression?

Women, those with a family history of depression, those who are widowed, separated, or divorced, and those who have suffered a prior depressive episode are at particularly high risk. Major losses, especially the death of the spouse or diagnosis with a serious illness, may predispose to depression. Note that diagnosis with a severe mental illness, such as schizophrenia, frequently leads to depression, especially following the first episode.

In most cases, depression is thought of as a lifelong disorder. However, this does not mean that one is constantly depressed. The natural history of untreated major depression is that most (65%) resolves within six months, and 75% resolves within one year. However, 20 percent remain depressed for two years and 10 percent remain depressed at five years. In the vast majority of cases, depression is considered an episodic illness with intermittent periods of complete normalcy punctuated by several major depressive episodes spread over a person's life.

Question: about how many episodes does the average person with major depression suffer?

In one long-term study, the median number of episodes was estimated to be 6.

Absolutely. The good news is the depression is one of the most treatable illnesses. Seventy percent of patients will improve on their first antidepressant. Up to 90 percent will improve after three or more medication trials. Combining medication and psychotherapy, and using adjunctive treatment in some cases such as ECT, leads to almost universal response. The most common reason for failure to respond to conventional antidepressant treatment is concurrent use of alcohol or other drugs, set abstinence or moderation is critical during treatment of a depressive episode.

Question: is depression a result of weakness of character?

No. The evidence is overwhelming that depression is a genetic illness. It is not possible to will oneself out of a major depressive episode. Many highly functional, brilliant leaders suffered from severe mood disorders, including Abraham Lincoln, Winston Churchill, and Ted Turner. In fact, the rate of mood disorders is probably positively not negatively correlated with those character traits that we traditionally think of as desirable or "strong". It is noteworthy that Meriwether Lewis, a member of the Lewis & Clark expedition, arguably one of the bravest Americans of all time, suffered terrible depression following his return, and ended his life by suicide[1 ].

No. Most depression is not properly recognized or treated. Most that is treated is treated by family physicians and internists.

Question: is depression accompanied by physical symptoms?

Yes. Decreased energy, lack of motivation, constipation, loss of libido, headache, and a lowered pain threshold can all be symptoms of depression. The person may not recognize the symptoms as part of depression. It is important to rule out any medical causes of the symptoms, such as hypothyroidism or to anemia.

Question: can those who suffer from depression becomes psychotic?

Yes. Delusions and hallucinations can occur as part of a major depressive episode. Usually these symptoms are mood congruent, meaning they make sense given the mood.

Bipolar disorder is the current name for the illness once known as "manic depression." Someone suffering from bipolar disorder has periods of mania or hypomania alternating with periods of depression.

Mania is persistently elevated, expansive or irritable mood. To be diagnosed with bipolar disorder, this mood either must last one week or the person must be hospitalized with over three of the following symptoms:

  • inflated self-esteem or grandiosity
  • decreased need for sleep
  • more talkative or pressure to keep talking
  • flight of ideas or racing thoughts
  • distractibility
  • increased goal-directed activity or agitation
  • pleasurable activities leading to painful consequences.

A: Hypomania can be thought of as a "little mania" (hypo- means "beneath or below"). Hypomania can be a period of extreme productivity for artists, entrepreneurs, and workers. The elevated and expansive mood coupled with a decreased need for sleep and increase in goal-oriented activities can lead to terrific output. Hypomanic people can make great sales-people. Unfortunately, hypomania often develops into full-blown mania if untreated.

About .5-2% of the population suffers from bipolar disorder. Men and women are equally affected (unlike unipolar depression, which affects women twice as much). First degree relatives of bipolar patients are 24 times more likely to develop bipolar disorder and depression. 80% of monozygotic twins will develop bipolar disorder if the other twin does; this rate is 20% for fraternal twins.

The exact cause is unknown, but it appears to be a dysregulation of our normal circadian rhythm, as well as an extreme oscillation of the normal variation in our appetites for new experiences, sex, or sleep. It tends to run in families.

QUESTION: What is the treatment for bipolar disorder?

Mood stabilizing medications (also called thymoleptics) are the rule. There are 3 medications with FDA approval for the treatment of mania: lithium; Depakote; and Zyprexa. Other medications may be helpful, such as Tegretol, but they do not have the specific FDA indication. Antidepressants also may help, once the mood has been stabilized, but they may also increase the risk of mania and convert someone into rapid-cycling.

QUESTION: Is bipolar disorder related to schizophrenia?

No, it's thought to be a mood disorder; schizophrenia is thought to be a thought disorder. Having a family history of schizophrenia (assuming the diagnosis has been well-made) means you are LESS likely to have bipolar disorder (and vice versa). The two can be roughly distinguished as follows:

Note that many people with bipolar disorder can be very charismatic and engaging. This is in contrast to many who suffer from schizophrenia, who often are withdrawn and "autistic."

QUESTION: What is the biggest risk for someone with bipolar disorder?

Besides the consequences of behavior while manic (increased spending, reckless sexual behavior, substance abuse), suicide is a major concern. The suicide rate for clients suffering from bipolar disorder is higher than for any other major psychiatric illness. This is why close observation and/or hospitalization is often necessary, especially following the first episode.

QUESTION: Are there other illnesses that can look like bipolar disorder?

Absolutely. Perhaps the most common is substance abuse, especially of a stimulating substance like cocaine or amphetamines. The grandiosity, irritability, increase in goal-oriented activities, hypersexuality, and pressured, rapid, loud speech seen in these clients is sometimes indistinguishable clinically from mania. Other illnesses include schizoaffective disorder, schizophrenia, and a variety of organic disorders (head injury, stroke, medication side effect).

Question: is it uncommon for someone with bipolar disorder to deny that they have the illness?

Yes, this is the rule. Most people suffering from mania do not recognize that they are ill and will view the idea of treatment as ridiculous. They may feel euphoric and grandiose, and completely incapable of grasping why you do not share their worldview. They may spend a great deal of money, engage in high risk behaviors such as taking on multiple sexual partners, or travel impulsively to other cities. Their judgment is as a rule impaired; they may disregard ethical concerns. Often as the mania progresses, the person may be common irritable and even violent. Suicidal risk is highest immediately following the manic episode. Bipolar disorder has one of the highest suicide rates of any mental illness.

Question: is it possible to trigger a manic episode?

Yes. Unfortunately, antidepressant medications, such as Prozac or Zoloft or Paxil, can trigger a manic episode in those who are predisposed. Also, sleep deprivation, abuse of stimulant medication, and extreme stress can trigger a manic episode. Studies at Heathrow airport in England demonstrate that travelers who lose sleep (travel East) have much higher subsequent rates of hospitalization for mania than travelers who travel west.

Rapid cycling bipolar disorder is characterized by at least four episodes per year. 10 - 15% of bipolar patients have rapid cycling. Females are more likely than males to have this.

Question: is the treatment of bipolar disorder different from the treatment of unipolar depression?

Yes. The critical difference is that bipolar disorder should first be treated with a mood stabilizing medication. Since antidepressants can trigger a manic episode, they should generally be avoided until a mood stabilizer has been started. Only 3 mood stabilizers are currently approved by the food and drug administration for the treatment of mania: lithium; valproic acid (Depakote); and olanzapine (Zyprexa). Other medications that have been shown in clinical trials to be effective in the treatment of mania include carbamazepine (Tegretol) and adjunctive antipsychotic medication. Trials are ongoing with several other agents that show promise in treating this disorder. Benzodiazepines in the short-term may help normalize sleep and reduce agitation.

Question: can people suffering from mood disorders lead normal lives?

Absolutely. As a general rule, people who suffer from mood disorders tend to have more or less complete remission between episodes. With successful treatment, future episodes can be prevented or greatly ameliorated. However, it is absolutely critical that treatment be continued between episodes. Often when a person feels better, they discontinue their medication. Long term clinical trials indicate that the time to relapse disorder, the number of relapses is greater, the severity of the relapse is greater, and the response to treatment is less when medication is frequently started and stopped.

[1] "In September 1809, after much difficulty in trying to mediate between the Natives and commercial interests, Lewis fled St. Louis for Washington to plead his case before the new administration. He caught a riverboat to Memphis, during which his feelings of melancholy were enhanced by his continued drinking, and he twice attempted to take his own life. Later, while staying in a roadhouse along the Natchez Trace, Lewis took his own life by shooting himself first in the forehead then in the breast. He was buried next to the tavern, and today the site is marked by a monument that was erected in his honor in 1846." - pbs(http://www.pbslewisandclark/inside/idx_corp).

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