CPch5 - Mood disorders Flashcards
Mood disorders
Involve profound disturbances in emotion - from the deep sadness and disengagement of depression to the extreme elation and irritability of mania
What is affect?
Feeling
Mood and emotion fall under this umbrella
What is mood?
Long duration, not directed at an/one object
Mostly bias cognition - think differently depending on the mood
e.g. angry, sad, happy, anxious
What is emotion
Short-lived, directed at an object
Bias cognition and (immediate) action
Basic: fear, anger, sadness, happiness, disgust, suprise, etc
What are the two approaches to mood?
- Feeling theory of moods
- Dispositional theory of moods
Feeling theory of moods
Moods are raw feelings (i.e. objectless)
Feeling sad, feeling angry
These also make up the core of emotions, which are more complex
Dispositional theory of moods
Mood generates cognitions and mood-congruent appraisals
Being in a sad mood = appraising situations as uncontrollable
Being in an angry mood = appraising situations as threatening
When does mood become a problem - pathology? Why is depression/mania dysfunctional?
Symptoms must cause the individual clinically significant distress and impairment in social, occupational, or other important areas of functioning
The symptoms must also not be a result of substance abuse or another medical condition
What are the 2 poles of mood disorders
Mania > hypomania > normal elation > neutral/balanced mood > normal sadness > mild - moderate depression > major depressive disorder
Two types of mood disorders
- Depressive symptoms (unipolar depressive symptoms)
- Manic symptoms (bipolar disorders)
What is the difference between unipolar and bipolar mood disorder?
Bipolar - switch between mania and depression
Unipolar - stay on one side of the pole (e.g. Major Depressive Disorder (MDD))
DSM-5 Major unipolar depressive disorders
- Major depressive disorder
- Persistent depressive disorder
- Premenstrual dysphoric disorder - mood symptoms in the week before menstruation
- Disruptive mood dysregulation disorder - severe recurrent temper outbursts and persistent negative mood for at least 1 year beginning before age 10
What are the major bipolar disorders according to the DSM-5?
- Bipoler I disorder
- Bipolar II disorder
- Cyclothymia - recurrent mood changes from high to low for at least 2 years, without hypomanic or depressive episodes; the symptoms present at least 1/2 the time for more than 2 months at a time
Why is prevalence important to know in psychological disorders?
We can decide how likely it is that a patient coming in has or has not a disorder and maybe start the tests for the most prevalent disorders that match the presented symptoms
What is the prevalence of mood disorders?
Lifetime - MDD 18.7% (one of the most prevalent of psych. dis.), Dysthymia (PDD) 1.3%, Bipolar 1.3%
↪ More prevalent in females (more likely to experience sexual violence or cultural stress, cost of caring, hormones, more inclined to externelize and verbalise feelings)
Chronicity - MDD 27.8% (turns into PDD), Dysthymia 65.9%, Bipolar 63.5%
How is the chronicity after treatment? And what are the % of people who return to treatement later in life?
80% recovers within 12 months
Relapse/return to clinic:
* 25-40% within 2 yrs
* 60% within 5 yrs
* 91% within 20 yrs
Treatements effective but high relapse - treating symptoms not the disorder
MDD DSM-5 criteria
5 or more symptoms nearly every day, most of the day, at least 2 weeks:
Affect
1. Sad mood OR
2. Loss of interest or pleasure (anhedonia)
↪ one of these must be present
Physical
Plus 3 or 4 of the following:
3. Poor appetite and weight loss, or increased appetite and weight gain
4. Loss of energy
5. Psychomotor retardation (slow thoughts and movements) or agitation (pacing, fidgeting, wringing hands)
6. Sleeping too much or too little
Cognitive
7. Feelings of worthlessness or excessive guilt
8. Difficulty concentrating, thinking, or making decisions
9. Recurrent thoughts of death or suicide
What is the criticism of the criteria in DSM-5 to diagnose MDD?
It requires 5 symptoms to be present but little evidence present to support this threshold
↪ depressive severity - increases in functional imparememt and suicidality as the number of symptoms increases
Persistent Depressive Disorder + DSM - 5 criteria
Depressed mood for at least 2 years (>1/2 of days)
↪ or 1 year with children and adolescents
Combines DSM-IV Dysthymia & MDD, chronic subtype
PLUS 2 other symptoms
1. Feelings of hopelessness
2. Sleeping too much or too little
3. Poor appetite or overeating
4. Trouble concentrating or making decisions
5. Poor self-esteem
Biological etiology of depression
Part of bio-psycho-social model of depression
- Heritability 37% (more severe, higher)
- Serotonin/dopamine (dopamine system disrupted - less responsive to drugs increasing dopamine levels)
- Several brain regions
- Cortisol dysregulation
- Pro-inflammatory cytokines - prolonged inflammation > sickness behaviour seen in depression: decreased motor activity, reduced food consumption, social withdrawal, disturbed sleep patterns…
Biological etiology
Brain regions involved in depression
- Amygdala - overreactivity to emotion-relevant stimuli; vulnerability to depression not just aftermath of depression
- ↑activation in anterior cingulate and ↓activation of hippocampus and regions of PFC when viewing negative stimuli
↪ interfere with effective emotion regulation - overactivity in the amygdala = oversensitivity to emotionally relevant stimuli + systems regulating emotion compromised
-
striatum underactive to reward stimuli
↪ nucleus accumbens (dopamine release center) - key in motivation to pursue rewards
↪ explains why less motivated by the positive events
Biological etiology
Cortisol dysregulation in depression
- HPA axis - overly active in MDD (stress reactivity hightened)
↪ Heigtened cortisol awakening response - amygdala sends signals to HPA, HPA releases cortisol
- cortisol injected in animals - decreased interest in sex, food and sleep disturbances
Psychological etiology of depression
Part of Bio-psycho-social model of depression
- Neuroticism - tendency to experience frequent and intense negative affect
Cognitive theories: - Beck’s negative triad
- Hopelessness theory
- Rumination theory - dwelling on negative experiences and views about the self which increases negative mood
↪ women ruminate more
Psychological etiology
Beck’s negative triad
- Negative views of the self, the world, and the future
- Negative schemas acquired in childhood through experiences
↪ Activated when similar situations encountered - cause negative information-processing biases - Tested with:
1. Self-report scale called Dysfunctional Attitudes Scale - hard to interpret whether negative thoughts cause or a symptom
2. Studies of information processing - bias in the way they attend to (attention) and recall info (memory - remember negatives more, look at negative facial expressions more) - Recall biases related to some symptoms (sadness, self-dislike…) but not physical ones (e.g. low energy)
Psychological etiology
Hopelessness Theory
- Depends on person’s attributional style:
1. Stable (permanent) vs unstable (temporary) causes
2. Global (relevant to many life domains) vs specific (limited to one area) causes - Stable and global AS = become hopeless
Social etiology of depression
Part of bio-psycho-social model of depression
- Childhood adversity - parental death, physical or sexual abuse
-
Stressful life events (not caused by early mild depressive symptoms - losing a job because of demotivation)
↪ vulnaribilities: lack of social support - Expressed emotions - critical or hostile comments from people around you = lower social competence
- Interpersonal problems - interpersonal loss, isolation or concern can trigger depression but can also be triggered by depression
How can we integrate social and biological influences on depression?
- Social stressors (major life events, childhood abuse) → changes in sensitivity of serotonin receptors + increase in pro-inflammatory cytokines + function of dopamine system
- Short alleles of serotonin transporter gene only with combination of childhood maltreatment = depression
↪ More severe stressful events, the number of short alleles related to greater risk of developing depression
What is the overlap in anxiety and depression? How does it reflect in DSM-5?
- 60% of people with anxiety have depression and vice versa (also 60%)
- overlap in etiology - neuroticism and childhood adversity
- DSM-5 specifier (subtype): with anxious distress
↪ depressive episodes accompanied with at least two anxiety symptoms
↪ poor response to anti-depressant treatement
Biological treatment
- Based on biological theories of serotonin/dopamine
- Antidepressants and ECT
Work very well - quicker relief than psychotherapy - rTMS for treatment-resistant depression - coil with magnetic pulses to increase activity in the left dorsolateral prefrontal cortex
What antidepressants are there? Are they effective? Side effects?
- Monoamine oxidase inhibitors (MAOIs)
- Tricyclic antidepressants
- SSRIs (e.g. prozac)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
- Mostly best for severe MDD; placebo for mild or moderate
- 60% of people experience at least one side effect
↪ Under 25 yrs taking SSRIs: increased suicidality - Mostly positive findings are published = higher perceived effectiveness
↪ Large sample study: only 43% recovered (even with combinations of treatments and different meds)
Electroconvulsive Therapy
What is it? How does it work? What are the risks?
- Used to treat MDD unresponsive to meds
- Inducing momentary seizure by placing an electrode on the nondominant side of the forehead
- Also muscle relaxant and the patient sleeps
- 6-12 treatments, spaced several days apart
- Risks: short-term confusion or memory loss
Treatment
Psychological treatments
- Psychodynamic theory - problem: grief over loss > intervention: acceptance & mourning (evidence: +/-)
- Behaviourism/learning - anhedonia > e.g. behavioural activation, activity scheduling (evid. ++)
- Cognitive theory - negative triad, hopelessnes, rumination > Cognitive therapy, mindfulness based CT, interpersonal therapy (evid: +++)
- CBT - Various problems > various interventions (evid: +++)
- Behavioural Couples Therapy - experiencing marital distress increases depressive symptoms
Interpersonal Psychotherapy
- Examine major interpersonal problems, e.g. role transitions, interpersonal conflicts, grief…
- Identify one’s feelings about those issues, make important decisions and resolve problems related to those issues
Cognitive therapy & Behavioural Activation
Situation > Automatic neg. thoughts > Neg. feelings > Behaviour: doing nothing (results in neg. feelings)
Putting apart feelings and beliefs (I am worthless - I feel worthless - is it a feeling or do you actually believe it)
Cognitive therapy
Situation > Automatic thought > feeling
Tries to identify, challenge negative thoughts of a person and make them aware of them = cognitive reconstructing
↪ Help increase awarness of connection between thoughts and mood
↪ Then, change self-beliefs
E.g. I am worthless - therapist challenges that: what does a worthless person look like, do your children think you’re worthless
Behavioural activation
Focuses on the behavioural part of the model: on the feeling and behaviour
E.g. I’m staying in bed
Encourages to enagage in pleasant and rewarding activities
Start with something the person likes and start small and build up so that there is positive reinforcement
Positive reinforcement can change the feeling, then the automatic thought and then the situation
Mindfulness-based cognitive therapy
-To prevent relapse after successful treatement
- History of MDD, sadness is more likely to escalate
- Focused on developing a detached relationship to depression-related thoughts and feelings (I am not my thougths)
Which therapy?
Stepped care
Starting with the least costly, intensive and have the least amount of side effects
Which therapy to choose? Based on stepped care
- Psychoeducation
- Meta-analyses: most psychotherapies equally effective (CBT, MBCT…)
- Anti-depressants
↪ only in severe depression, then just as effective as psychotherapy
↪ overprescription - Intemsification or Electroconvulsive therapy
Suicide numbers with depression
- Untreated depression: 20% risk for suicide
- 50% of those who attempt suicide have MDD
- Men are four times more successful
Symptoms of (hypo)mania DSM-5
Criterion A.
Affect
A distinct period of abnormally and persistently elevated or irritable mood:
- at least 1 week or hospitalization > mania
- at least 4 days > hypomania
Criterion B.
During this period, at least 3 (4, if only irritable) are noticeably changed from baseline
Cognitive
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g. feels rested after 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
Physical
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in pleasurable, risky activities
What is the difference between mania and hypomania?
Duration: 1 week vs 4 days
Severity:
- Functioning impared for mania not for hypo.
- Hospitalization in mania
- Psychotic symptoms in mania
- Behaviour different from normal: both yes but mania more
- Difference clear to others: both but more for mania (but for hypomania to be diagnosed this has to be present because functioning is high)
Diagram of differential diagnoses of mood disorders with very elated mood
Very elated mood (VEM) > complete mania = Bipolar I (depression might not be there)
VEM > complete hypomania + major depressive episode > Bipolar II
VEM > some hypomanic symptoms + some depressive symptoms = Cyclothymic disorder
Does it mean that when someone has mania = Bipolar I?
No, mania can be present in schizoaffective disorders spectrum disorders
Always have to look whether there are other disorders that might explain the symptoms better
Explanatory models bipolar
Bio + psycho
Biological - heritability very high 93% (SNPs and CNVs identified as a genetic base - mixed evidence though), serotonin/dopamine (reward system - increase in dopamine triggers manic episode; unclear evidence from PET)
↪ Brain regions: elevated activity in amygdala, anterior cingulate, and striatum(MDD - diminished); diminished activity in regions of PFC and hippocampus
Psychological - reward sensitivity (success in life may trigger cognitive changes in confidence > excessive goal pursuit)
Other - major life event > sleep deprivation
Treatments of bipolar mood disorders
Meds + psychological
-
Medications
- chronic so take it for majority of life
- Mood-stabilizer (Lithum)
- If not tolerable: anticonvulsant (antiseizure) or antipsychotic
- Antidepressants also prescribed if depressive episodes present
↪ risk of increase of mania if taken without mood-stabilizer - Psycho-education and Family-Focused therapy
- Cognitive therapy - mainly for depressive part, problem-solving, recognizing symptoms
