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Female Mood Disorders
Jeanne Watson Driscoll, PhD, APRN, BC
October 5, 2007
Women’s Health: Addiction, Trauma and HOPE
Objectives
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The participants will:
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Discuss the key variables in women’s
mental health and disease
Discuss the importance of women’s
hormones and reproductive transitions
Describe common mental disorders in
women
Discuss signs and symptoms of the
disorders and care strategies
Women’s mental health
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Female aspects are invisible
Limited research pertaining to the
menstrual cycle and women’s mental
health
Context and culture
The Female Brain
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Different metabolism of medications
15% greater blood flow in brain:
serotonin system more reactive
Differences across the menstrual cycle
Drug interactions
Exclusion from drug studies
Structure/Function Differences
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Corpus Callosum: 23% larger
(Gorsky &
Allen)
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Language area 30% larger (Harasty)
Paralimbic Cortex more active (Gur & Gur)
Facial recognition easier (Gur & Gur)
Neuroanatomy
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Limbic Brain
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Amygdala
Locus ceruleus
Hippocampus
Paralimbic Cortex
Amygdala
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Connected with hypothalamus
Regulates sexual and aggressive
behavior
Promotes emotional learning, survival
behavior and fear
Dense estrogen receptors
Locus Ceruleus
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Located in brain stem
Main depot for Norepinephrine, “fight or
flight” mechanism
Hippocampus
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Learning and memory
Key determinant in the brain’s ability to
regulate stress response, if it cannot
switch off the secretion of cortisol it can
lead to depression and memory
problems
Dense estrogen receptors
Hypothalamus
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Critical to the endocrine system
Affects thyroid and adrenal glands,
ovaries, testes and the secretion of
reproductive hormones
Neurochemical pathways feed this
gland: serotonin, dopamine, and
norepinehprine
Paralimbic Brain
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Emotional coloring
Buffer between external reality and
internal urges
Learning and memory
Stress Response
Cortex
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Higher cortical functions
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Right brain
Left brain
Hypothalamic-pituitary-adrenal
Axis (HPA)
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Hypothalamus secretes corticotropin
releasing hormone (CRH)
Pituitary secretes adrenocorticotropic
hormone (ACTH)
Adrenal glands secrete cortisol
Reproductive Hormones
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Estrogen
Progesterone
Testosterone
Estrogen
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Maintains orderly firing of serotonin,
dopamine, acetylcholine, and norepinephrine
nerve cells
Enhances glutamate activity
(neurotransmitter that accelerates nerve
communication in the brain)
May promote growth of nerve cells containing
acetylcholine, especially in the hippocampus.
(mental acuity)
When it rises, overall effect is to elevate 5HT
levels----mood stability: when it drops may
alter mood stability
Progesterone
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Decreases the number of available estrogen
receptors
Evidence that at the end of the menstrual
cycle progesterone may dismantle nerve
connections that estrogen established at the
beginning of the cycle (potential problems
with progesterone component of birth control
pills)
Testosterone
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In women produced in small amounts in
the synthesis of estrogen
Affects the limbic brain, stimulating
libido and aggressive behavior
Key vulnerable
times in a woman’s life
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Menarche
Premenstrual
Pregnancy
Infertility
Postpartum
Perimenopause
Menopause
How does this all interact?
“Brain Strain”
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Allostatic Loading (McEwen)
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Allostasis: stability through change. When
the body is placed underincreased
demand, it adjusts to the demand.
Allostatic loading: wear and tear on the
brain and the body, especially the
hippocampus
Allostatic Loading
Wear and tear:
Situations associated with
allostatic load
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Frequent stress
Adaptation to
repeated stressors
of the same type,
resulting in the
prolonged exposure
of the body to the
stress hormones
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Inability to shut
allostatic responses
after the stress is
terminated
Inadequate
responses from
some allostatic
systems trigger
compensation in
others
The brain in distress
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Does not feel pain
Distress is interpreted through signs
and symptoms
Mood, anxiety, and physical symptoms
are demonstrated
The following are mental disorders that
can occur or be exacerbated by the
reproductive events of a woman's life:
menarche, infertility, pregnancy,
postpartum, perimenopause, and
menopause.
Depressive Disorders
(DSM-IV, 1994)
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Major depressive episode (296.2x)
Dysthymic disorder (300.4)
Depressive disorder not otherwise
specified (311)
Depressive Disorders
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Lifetime rates 10-25 % (Kessler, et al, 1994)
Onset peaks between ages of 25 and 44
years
Women living with depression have longer
duration of illness, recurrences linked to
reproductive events, atypical symptoms, more
somatic symptoms, delayed treatment
response, seasonal susceptibility and
comorbidity (Burt, 2002)
Major Depressive Disorders
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Five or more of following present during
the past two week period:
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Depressed mood most of the day
Marked diminished interest or pleasure in
all or most activities of the day
Decrease or increase in appetite
Insomnia/hypersomnia
Psychomotor agitation or retardation
Major Depressive Episode
con’t
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Fatigue or loss of energy
Feeling worthless, excessive guilt
Diminished ability to think, concentrate or
indecisiveness
Recurrent thoughts of death
Dysthymic Disorder
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(DSM-IV, 1994)
Depressed mood for most of the day, for
more days than not, as indicated by
subjective account or observation by others,
for at least 2 years
Presence, while depressed, of two (or
more)of the following:
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Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Dysthymic Disorder, continued
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Symptoms continued
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Low self esteem
Poor concentration or difficulty making
decisions
Feelings of hopelessness
Premenstrual Dysphoric Disorder
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Premenstrual mood changes that
interfere with functional living
Careful evaluation: are the symptoms
related to menstruation or are they
exacerbations of other psychiatric
illnesses?
Chart/document for a few cycles
Bipolar Spectrum Disorders
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Bipolar 1:
Bipolar II (soft):
Bipolar III:
Cyclothymic Disorders:
It is critical to do a complete history to
rule out the biochemical
sensitivity/vulnerability of the women to
these disorders
Bipolar I Disorder
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(DSM-IV,1994)
Presence of only one manic episode and
no past major depressive episodes
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Manic episode
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Distinct period of abnormally and persistently
elevated, expansive, or irritable mood, lasting
at least one week
Bipolar I Disorder, continued
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During the period of mood disturbance, three of more of
the following symptoms have persisted and have been
present in a significant degree
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Mood disturbance sufficiently severe to cause marked
impairment in occupational functioning or usual social
activities and interpersonal relationships, may require
hospitalization to prevent harm to self or others.
Bipolar II Disorder
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(DSM-IV, 1994)
Presence of one or more major
depressive episodes
Presence of at least one hypomanic
episode
Symptoms cause distress
Hypomanic Episode
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(DSM-IV, 1994)
Distinct period of persistently elevated,
expansive, or irritable mood, lasting for
at least 4 days, that is clearly different
from the usual nondepressed mood
3 or more of the following present:
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Inflated self esteem or grandiosity
Decreased need for sleep
More talkative, pressure to talk
Cyclothymic Disorder
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(DSM-IV, 1994)
For at least 2 years, presence of
numerous periods of hypomanic
symptoms and numerous periods of
depressive symptoms that do not meet
criteria for major depressive disorder
Anxiety Disorders
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1 year prevalence rate in the general
population 17.2%; lifetime prevalence is
24.9%
Lifetime rate of any anxiety disorder in
women in 34.4%
Anxiety Disorders (DSM-IV, 1994)
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Panic disorder without agoraphobia
(300.01)
Panic disorder without agoraphobia
(300.21)
Obsessive compulsive disorder (300.3)
Posttraumatic Stress disorder (309.81)
Acute stress disorder (308.3)
Generalized anxiety disorder (300.02)
Panic Attack
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(DSM-IV, 1994)
Discrete period of intense fear or discomfort,
four or more of the following develop
abruptly and reach a peak within 10 minutes:
 Palpitations, pounding heart, or accelerated
heart rate
 Sweating
 Trembling or shaking
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Sensations of shortness of breath or smothering
Feeling of choking
Panic attack, continued
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Chest pain or
discomfort
Nausea or
abdominal distress
Derealization
(feelings of
unreality) or
depersonalization
(being detached
from oneself)
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Feeling dizzy, unsteady,
lightheaded, or faint
Fear of losing control or
going crazy
Fear of dying
Paresthesias (numbing
or tingling sensations)
Chills or hot flashes
Panic attack, continued
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With agoraphobia: anxiety about being
in places or situations where escape
might be difficult or embarrassing, or in
which help may not be available in the
event of having a panic attack
Situations are avoided or endured with
marked distress
Obsessive-Compulsive
Disorder (DSM-IV)
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Either obsessions or compulsions
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Obsessions:
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Recurrent or persistent thoughts, impulses, or
images that are experienced, at some time
during the disturbance, as intrusive and
inappropriate and that cause marked anxiety or
distress
The thoughts, impulses, or images are not
simple excessive worries about real-life
problems
OCD, continued
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Obsessions,con’t.
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Person attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize
them with some other thought or action
Person recognizes that the obsessional thoughts,
impulses, or images are a product of his or her
own mind(not imposed from without as in thought
insertion)
OCD, continued
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Compulsions:
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Repetitive behaviors (e.g. hand washing,
ordering, checking) or mental acts (e.g.
praying, counting, repeating words silently)
that the person feels driven to perform in
response to an obsession, or according to
the rules that must be applied rigidly
OCD, continued
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Compulsion, continued
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The behaviors or mental acts are aimed at
preventing or reducing distress or
preventing some dreaded event or
situation; however, these behaviors or
mental acts either are not connected in a
realistic way with what they are designed
to neutralize or prevent or are clearly
excessive.
OCD, continued
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At some point during the course of the
disorder, the person has recognized that
the obsessions or compulsions are
excessive and unreasonable
The obsessions or compulsions cause
marked distress, are time
consuming,and significantly interfere
with normal routine
Other obsessions
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Trichotillomania: hair pulling
Other obsessions may be do to another
primary disorders: eating disorder, body
dysmorphic disorder, substance use
disorder, hypochondriasis, etc.
Posttraumatic Stress Disorder
(DSM-IV, 1994)
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The person has been exposed to a
traumatic event in which both of the
following were present:
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Person experienced, witnessed, or was
confronted with an event or events that
involved actual or threatened death or
serious injury, or a threat to physical
integrity of self or others
PTSD, continued
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Person’s response involved intense fear,
helplessness, or horror
Traumatic event re-experienced in one
or more of the following:
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Recurrent or intrusive distressing
recollections of the event, including
images, thoughts, or perceptions
PTSD, continued
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Recurrent distressing dreams of the event
Acting or feeling as if the traumatic event
were recurring (includes a sense of reliving
the experience, illusions, hallucinations,
and dissociative flashback episodes,
including those that occur on awakening or
when intoxicated
PTSD, continued
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Intense physiological distress at exposure
to internal or external cues
Physiological reactivity on exposure to
internal or external cues that symbolize or
resemble an aspect of the traumatic event.
PTSD, continued
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Persistent avoidance of stimuli
associated with the trauma or numbing
of general responsiveness, as indicated
by three or more of the following:
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Efforts to avoid thoughts, feelings, or
conversations associated with the trauma
Efforts to avoid activities, places, or people
that arouse recollections
PTSD, continued
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Unable to recall important aspects of
trauma
Marked diminished interest or participation
in significant activities
Feeling of detachment or estrangement
from other
Restricted range of affect
Sense of a foreshortened future
PTSD
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Women have a higher propensity to
develop PTSD after exposure to traume
than men (Kessler, et al, 1995)
Rate of PTSD secondary to birth trauma
ranges from 1.5% to 5.6% (Beck,
2004)
Generalized Anxiety Disorder
(DSM-IV, 1994)
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Excessive anxiety and worry, occurring
more days than not for at least 6
months.
Person finds it difficult to control worry
Anxiety and worry associated with:
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Restlessness or feeling keyed up or on
edge
Being easily fatigued
GAD, continued
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Difficulty in concentrating or mind going
blank
Irritability
Muscle tension
Treatment and management
issues
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Case finding:
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Estimated that 20% of patients see their
PCP for symptoms of depression, yet this
common condition continues to remain
undiagnosed and undertreated (Marrow, et al,
1993; Zung, et al, 1993)
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Identification of risk factors
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Family history
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Where to send for help?
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Who are your resources?
Care plan development
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Physical examination
R/o Thyroid disorders
Treatments:
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Psychotherapy
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Insight based
Cognitive behavioral
Supportive
Interpersonal
Psychopharmacology
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Neuroleptics, antidepressants, anti-anxiety
medications, mood stabilizing medications
Treatments continued
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Treatment based on the context of the
woman’s life
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Support systems
Family involvement
Pregnant
Postpartum/breastfeeding
Depressive Disorders: suggested
treatment modalities
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Pharmacological methods
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SSRI agents
SSNI agents
Others
Psychotherapy
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Interpersonal
Cognitive Behavioral
Relational-Cultural
Mood Swing Disorders
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Pharmacological aspects
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Mood stabilizer agents
Atypical neuroleptics
Psychotherapy
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Interpersonal
Cognitive behavioral
Relational-cultural
Anxiety Disorders
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Psychopharmacological agents
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Benzodiazepines
Antidepressant agents
Psychotherapy
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Cognitive Behavioral
Interpersonal
Supportive
Relational-cultural
The NURSE Plan© Sichel & Driscoll, 1999
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Nutrition and Needs
Understanding
Rest and Relaxation
Spirituality
Exercise
Nutrition and Needs
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Nourishment and needs
Eliminate alcohol
Vitamins
Medications: food for the brain
Emotional needs
Understanding
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Engage the intellect/cortical skills
Feelings, thoughts, concerns
Psychotherapy
Education
Journal keeping
Rest and Relaxation
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Sleep is critical!
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patterns and rituals
Meditation, visualization, and
mindfulness
Stress reduction strategies
Spirituality
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Uplifting and meaningful experiences
Relationships, solitude
Appreciation of nature
Belief in a higher power
Soul food
Doing good deeds “mitzvot”
Exercise
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Find an exercise that you enjoy and do
it!
Three times per week for thirty minutes
“break a sweat”
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www.womensmentalhealth.org: Web
site for Massachusetts General Perinatal
Psychiatry Department
www.motherisk.org: Canadian agency
www.iBreastfeeding.com: Dr. Hale’s web
site
www.MedEdPPD.org
www.postpartum.net
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www.pregnancyanddepression.com
www.psycom.net/depression.central.pos
t-partum.html
www.4woman.gov/faq/postpartum.htm
www.postpartumdads.org
Select Bibliography
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McEwen, B. (2002). The end of stress as we know it.
Washington,DC: Joseph Henry Press.
Sichel, D. & Driscoll, JW (2000) Women’s moods.
New York: Quill.
Beck, CT & Driscoll, JW (2006) Postpartum mood and
anxiety disorders: A clinician’s guide.
Sudbury,MA:Jones & Bartlett Publishers
Driscoll, JW (2005). Recognizing Women’s Common
Mental Health Problems: The Earthquake Assessment
Model. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 34, 246-254.
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McEwen, B (1998). Protective and damaging
effects of stress mediators. New England
Journal of Medicine, 338, 171-179
McEwen, B (2000). Allostasis and allostatic
load: Implications for
neuropsychopharmacology.
Neuropsychopharmacology, 22, 108-124.
McEwen, B (2005). Stressed or stressed out:
What is the difference? Journal of Psychiatry
and Neuroscience, 30, 315-318.
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McEwen, B.S. (2000). The neurobiology of
stress: from serendipity to clinical relevance.
Brain Research, 886,172-189.
McEwen, B.S. (2002), Sex, stress and the
hippocampus: Allostasis, allostatic load and
the aging process. Neurobiology of aging,
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McEwen, B.S. (2003) Interacting mediators of
allostasis and allostatic load: towards an
understanding of resilience in aging
Metabolism, 52, 10-16.
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McEwen, BS & Wingfield, JC (2003). The concept of
allostasis in biology and biomedicine. Hormones and
Behavior, 43, 2-15.
Hendrick, V & Gitlin, M (2004) Drugs and women:
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Mood disorders in women. Martin Dunitz Ltd.
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