Peculiarities of affective disorders in women – modern research findings
Affective disorders, i.e. mental disorders that influence the way you think and feel, are one of the most common mental disorders in the world. According to the WHO, around 100 million of people all over the world suffer from various depressive states and this number grows yearly from the mid 1970s.
Short information about affective disorders (mood disorders)
Worth noting that the increase in numbers is not due to “classic” major depressions but due to the widespread of reduced, atypical, disharmonious, altered depressive states, which in turn are caused by sociopsychological stressors, the number of which is steadily increasing in connection with the complex processes taking place in the modern world and public consciousness.
As of today, there is no single common concept of affective pathology. Modern affective disorders poorly fit the traditional classification – depressive states have blurred symptoms but still bear a great danger of suicide risk. This indicates the need for the search of new approaches to the treatment of affective pathology implying the assessment not only of the symptoms but also the set of interrelated social, personally significant issues and problems, the general state of the patient's body, its adaptive resources and the possibilities of their implementation.
Of no less importance are the study of the structure and specificity of affective pathology in modern conditions, the identification of personal characteristics of patients, their relationship and mutual influence.
In this article, we discuss the results of affective disorders studies from the new perspectives, particularly, study of the personality traits, clinical and psychological patterns of bipolar affective disorders in women. The referred study included 76 patients with bipolar disorder and cyclothymia (mild form of bipolar disorder). 33 of them had personality disorders. The patients were between 19 and 48 years old. Patients older than this age were not included because of the possibility of organic (vascular) pathology. Among the patients, persons engaged in mental work predominated. The clinical examination included the study of complaints, anamnesis of life and illness, premorbid personality traits, psychological, somatic and neurological state of patients. The personality was studied from the perspective of the most accepted concepts of activity in psychology.
Patients were divided into two groups based on the diagnostic criteria DSM-IV and ICD-10 (mental diseases classification systems).
The first group included 43 (56.6%) women with bipolar affective disorder without personality disorders, the second - 33 women (43.4%) who were diagnosed with certain personality disorders. In each group, subgroups were identified based on the presence or absence of personality disorders encoded along the II axis, since the multi-axis DSM-IV system was used in the work. Personality disorders were of a mixed nature and belonged to the same cluster (antisocial and borderline, borderline and histrionic) - cluster B (67%), or had signs of personality disorders from different clusters (borderline and schizoid) - clusters B and A (33%).
All patients had repeated (more than two) episodes of affective disorders, during which mood and activity level were significantly impaired. These changes in different periods of the disease were either mania (hypomania, i.e. mild manias) or depression. Almost complete recovery was noted between attacks. Manic episodes lasted on average about 4 months, episodes of depression - 6 months or more. Both episodes often, though not necessarily, occurred after stressful situations or mental trauma.
Bipolar disorder without personality disorder
Clinical examination of the patients under the supervision revealed the following picture of the course of the disease. The condition of the patients of the first group, who were diagnosed with bipolar affective disorder and cyclothymia along the I axis, during the period of mania was determined by excitement, more precisely, by excitability, which grew in situations in which there were many stimuli, and was characterized by multiple words, increased sociability, frivolity, the desire to joke, have fun, attract attention, stand out and lack of self-control.
- Manic affect was expressed in a heightened mood and a characteristic vital feeling of strength, energy, cheerfulness, clarity of thinking; depending on the severity of mania, it manifested ranging from mild mood enhancement to an ecstatic feeling of happiness. In some patients, manic affect was combined with anger, irritability, which were quite labile - they easily arose, but relatively quickly weakened. Such patients also had a low tolerance for frustration, which led to outbursts of rage and hostility.
- Cognitive function in the manic state was characterized by an unlimited and accelerated flow of ideas, speech was often impaired. In most cases, manic affect, accelerated thinking, and distraction were similarly expressed. As the mania intensified, the formal and logical rules of speech were rejected, it became loud, fast, full of puns, jokes, rhymes. With further activation of the process, associations became inadequate, the ability to concentrate decreased, giving way to flight of thought and neologisms.
- Ideas of self-praise and self-confidence became the content of the thought process. Perceptual disorders were observed in 62.5% of patients in the first group. The manic delirium concerned the high qualities, abilities or strength that the patient allegedly possessed.
- The motor disorders characteristic of mania manifested in the form of motor excitement. In general, with moderately pronounced mania, the activity of the patients was of a purposeful and productive nature, and only with a rather severe condition it lost these qualities. A typical sign of motor arousal was the absence of fatigue or its insignificance in comparison with the expenditure of physical energy that accompanied the patient's activity.
- Somatic and vegetative disorders were manifested in the form of sympathicotonia (increased heart rate, respiration, etc.). Sleep disturbances up to insomnia, which, however, did not cause feelings of weakness, fatigue, and foggy brain in the morning, were characteristic.
- The clinical manifestations of manic states were also distinguished by a sharp increase in sexual function: in most patients there was hyperlibidemia (abnormally high libido), sexual hyperesthesia (excessive physical sensitivity), multiorgasmia, and in all - increased sexual activity and sexual disinhibition, leading to the oblivion of moral and ethical standards of conduct.
The examination revealed a predominance of obsession traits in 1/3 of the patients.
General condition of patients of the first group in the period of depression was determined by depressive mood underlying the "depressive attitude", which determined thinking and the behavior of patients. Loss of interests and motives created a sense of meaninglessness existence, decreased energy, and difficulties in decision-making, caused feelings of powerlessness and hopelessness.
- The emotional state of women was determined by their depressed mood. Dominated by a melancholy affect that stained all in gloomy tones; its range was great – from slight depression, sadness, deprivation to deep melancholy, in which the patients experienced a heavy feeling of hopelessness, worthlessness of existence, permeated with a dark, painful vital feeling of general ill-being.
- The cognitive function of patients during the period of depression was characterized by a slowdown in the rate and a decrease in productivity. There was a simplification of the structure of associations, some narrowing of the volume of free associations. The content of thoughts was usually non-delusional reflections about losses, one's own guilt, suicide and death. One could note a kind of inertia of thinking: any intellectual effort, tension seemed to the patient an insurmountable difficulty, and they felt stupid.
- Significant changes took place in the motivational sphere - a decrease in the level of motivation, a loss of interest in almost everything that was previously significant for them.
- Perceptual disorders occurred in half of the patients, manifested in the form of delirium congruent (corresponding to) the mood - it was delirium of guilt, sinfulness, and one's own worthlessness.
- Motor retardation manifested itself in a slowdown in the tempo of speech, movements, a sluggish reaction to stimuli, in the absence of spontaneous movements, and meager facial expressions. Patients complained of lethargy, weakness; lay or sat most of the time.
- Somato-vegetative disorders characteristic of depression were observed in all the subjects. There was a decrease in appetite and body weight, menstrual irregularities, as well as a violation (weakening) of all components of sexuality: hypo- or alibidemia (low or lack of libido), sexual hypoesthesia (numbness of genitalia), hypo- or anorgasmia, most often (in 73% cases) combined with each other. Besides, a decrease in sexual activity and refusal of sexual intercourse were characteristic, and in some women, during an exacerbation of the disease, sexual aversion (negative attitude to intercourse) arose. There were also sleep disturbances in the form of early morning waking up (the so-called terminal insomnia) and frequent awakenings at night, during which patients were busy “experiencing” their problems.
Patients with affective disorder and personality disorder
In the second group, all patients noted the onset of the disease, which proceeded in the form of frequent and sharp changes in mood, from adolescence.
The general condition of patients in this group was determined by the presence of personality disorders - they had deep-rooted, inflexible, maladaptive patterns both in relation to the environment and in the perception of it and themselves. Against this background, there were sharp mood swings with a feeling of loss of control and extreme impulsivity. All patients have repeatedly attempted suicide.
The emotional state of women was characterized by instability, frequent, sometimes for several hours, unpredictable mood swings. Symptoms were revealed that were characteristic of both depressive and manic episodes, which patients referred to as "good and bad days."
- “Good” days were characterized by a sense of inspiration, overconfidence, and overestimation of their social significance, indiscriminate interpersonal contacts, and heightened thinking.
- On "bad" days, drowsiness, lack of energy, drop in self-confidence, painful thoughts about their role and place in life occurred. In almost all patients, it was possible to note periods of mixed symptoms with pronounced irritability, hostility and aggressiveness, which were often harbingers of a return to "bad days.” Although the symptoms of such periods very close to meeting the criteria for manic and depressive episodes, they were not sufficiently pronounced to be diagnosed as bipolar disorder.
Abuse of alcohol, prescription and illicit drugs was typical for the group of patients under consideration. The life history was replete with frequent changes in social status, marital status, social circle, religious beliefs.
The results of the studies carried out confirm the opinion about the comorbidity of affective disorders with personality disorders.
Clinical analysis revealed that patients with personality disorders had less severe and prolonged depression, but their prognosis in terms of clinical recovery and social adaptation was less favorable compared to patients without personality disorders. When examined 2 years after the course of treatment, they showed a tendency to re-admission to the clinic, a high suicide risk, and deterioration in the quality of life.
In general, the data obtained in the study allow us to conclude that the clinical picture of affective disorders depends on the patient's personality characteristics and is expressed to the greater extent, the lower the depth of depression.
Affective disorders develop in individuals with mixed and histrionic personality disorders, i.e. personality disorders characterized by self-drama, theatricality, egocentrism, emotional lability, exaggerated expression of emotions, a desire to be in the center of attention, and an excessive preoccupation with physical attractiveness.
The revealed patterns open up the opportunity to expand and clarify the diagnosis of affective disorders and to develop a system for their differentiated psychotherapeutic correction.
What can be advised for the therapy of people with affective disorders?
Although a share of the patients from the discussed study were not fitting the criteria for the diagnosis of bipolar disorder, it is obvious that the symptoms of their affective disorders significantly interfere with their lives. This means that even if you are not diagnosed with bipolar disorder, do not hesitate to seek medical assistance. It is highly advisable to find a psychotherapist with whom you would be comfortable working with. For acute episodes of mania, medications such as antipsychotics (Olanzapine) can be prescribed. And for depression, if psychotherapy doesn’t help or helps but cannot completely mitigate the negative symptoms, do not hesitate to take antidepressants.
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Post by: John De Vries, clinical pshychiatrist, Amsterdam, Netherlands
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