Depression Flashcards
Genetics - heritability (depression)
Sulivan et al 00: heritability rate 30-40% shown by adoption studies
GTKDSHHHC
- Depression
Genetics, Twins (Sullivan et al 00), Karg, Davidson et al (02), Stress, HPA, Hippocampus, Heusch, Cortisol
Stress response (depression)
- HPA releases cortisol in response to chronic stress, ANS responsible for fight/flight/freeze
- Hippocampus responsible for HPA regulation
- 80% those hospitalised for depression show poor HPA regulation (Heusch)
- Cortisol: enlargement of adrenal glands reducing frequency of serotonin receptors
Ingram et al 1994 (depression)
- conducted a dichotic listening task with 35 formerly depressed individuals and 38 not formerly depressed.
- Form. depressed found it harder to ignore negative distractor words than controls
- However, small and limited sample (young, well educated, early onset of dep)
Cognitive biases in CBT (depression)
Mind reading - Am i assuming what others are thinking? Notice that they are my thoughts not theirs
Catastrophising - Yes that is the worst likely scenario, but what is the most realistic one?
Mental filter - have i got my gloomy specs on?
Black and white thinking - what are the grey areas?
NICE (09), Kupfer & Frank (01) (depression)
NICE (09): CBT as effect as a-d in treating depressive symptoms
Kupfer & Frank (01): CBT + A-D more effective than each treatment alone
Psychoanalytic theory (Freud 17) for depression
- Depression response to loss
Introjection:
1. Loss in adulthood - regress to oral stage
2. Integrate lost object with own identity
3. Direct feelings to lost object at self
4. Leads to self hatred and low mood
Unmet needs during oral stage = vulnerable to develop depression
Evidence of psychoanalytic theory: Kim et al, Goodman, Harris et al (depression)
Kim et al: self directed anger is strongly associated with depression
Goodman: unmet needs as a child = more likely to become depressed after experiencing a loss
Harris et al: women whose mothers died/abandoned them more likely to develop depress
Evidence of psychoanalytic therapy: APA, Dreissen, Lemma (depression)
APA: no support for long term efficacy
Dreissen: Meta analysis of 23 studies involving 1300 patients: short term psychodynamic psychotherapy effective treatment for depression in outpatient context
Lemma: DIT as effective as cut in reducing symptoms
Personality Disorder- DSM-5
An enduring pattern of inner experience that deviates markedly from the expectations of an individual’s culture. Manifest in 2+: impulsivity, affectivity, cognitions and interpersonal functioning
- Lead to social and occupational impairment
- Discusses dimensional approach to PDs which it hopes to use in the future
BPD
- Part of cluster b (erratic, dramatic and emotional)
- Emotional instability, impulsivity, disturbed pattern of thinking and intense but unstable relations with others
Acronyms for BPD: PDMBIDRTTSLNCW
LVIGD4M,SRBSICAPD
personality, deviates, markedly/manifests, (cluster) B, issues, diathesis stress, risk factors, torgesson, genetics, short allele variant, lis, nts/nora, comorbid, walker (CAILHOL et al 14)
Linehan, Vulnerability, innate/infer/intense/ISSUES, Gilbert, 4(stages), multimodal/McMain, soller/stoffer, (object) relations (theory), Bartholomew, suvak, insight, Clarkin, Aarts, Padesky, Davidson, (McMain)
Cailhol et al (14) - BPD
- investigated rTMS on right DLPFC on individuals with BPD
- 5 experimental, 4 sham
- 4 participants improvements in anger, affective, instability, planning
- However, might be able to feel stimulation on scalp in exp and also tiny sample size as well as self-report method
Diathesis stress - BPD
Risk factors: CA/neglect/rejectful/inconsistent/loveless parenting, prenatal adversity, 20% no abuse - torgesen et al also stated not married/widow/divorced in adulthood but could be c/e
BPD: Genetics - Torgeson et al 00, Smith et al 04
- Does appear to run in families, 35% MZ, 7% DZ (T)
- 44% comorbid with bipolar disorder - could account for unpredictable mood swings (Smith et al 04)
- Short allele variant of 5-HTTLPR polymorphism (regulates expression of serotonin transporter gene) - risk factor but common to many
Neurobiology - BPD, Lis et al (07)
- Limbic system (emotion and learning)
- Amygdala (threat perception and coordinates and initiates fear response)
- Hippocampus - involved in spatial learning and contextualising memory
- Lis et al (07) noted excessive activation of limbic system and amygdala
- But could be c/e, cmbd/substance misuse
BPD: NTS
- Dopamine (mood, reward, motivation)
- Serotonin (mood and impulsivity)
- GABA (anxiety)
In BPD, low levels of serotonin (nora) and some evidence for dysfunction in DA but evidence circumstantial
Biological treatments for BPD - Walker et al (03), Cailhol et al (14)
- Generally used to treat comorbid e.g. a-d for depression and lithium chloride for bipolar
- Walker et al (03): investigated quatiapine (atypical antipsychotic) in a case study of 4 participants suffering from severe ASPD, severest case seen. Effective in reducing anger, irritability and impulsivity - due to expenses prisons have discontinued it resulting in increased anger (only 4 patients and treatment short term)
- Very few RCTs examined medication and those that have are poorly controlled, small sample size and equivocal
BPD: biosocial theory - Lineman (87)
- main theory currently used
- innate vulnerability that compromises capacity for emotion regulation is chronically exposed to invalidating environments
- Individual communicates about inner challenges but is consistently invalidated (mild-extreme) and so becomes more self invalidating
- Mod. displays of emotion regul punished
- Severe displays - fam. concerns for medic. care
- Ind. may have on going emotional inhibition with periodic intense emotions
- Thus biological disposition + invalidating environment - person has trouble regulating thoughts, feelings and behaviours and emotions experienced more intensely than average person
BPD: Dialectical behaviour therapy
- Dialectics: trying to balance
- A1) accept who you are
- A2) change - make positive changes in life, reduce suicidal behaviour, behaviour that interferes with therapy and also that reduces quality of life, engage in behavioural skills for emotion regulation and enhance self respect
A3) aware of maladaptive behaviours and consequences of them
4 stages: distress tolerance/interpersonal functioning/ emotion regulation/mindfulness
Multimodal programme
BPD: DBT support
- Effective therapy for BPD
- McMain et al (12): long lasting positive effects on suicidal and non suicidal self harm behaviours, depression, interpersonal functioning, anger control and re-hospitalisation
Soler et al 05: effective when combined with app. medication
Stoffer et al 12: cochraine review of BPD: DBT decreases inappropriate anger, self harm and improves general functioning
BPD: object relations theory
- children learn about others through relationships with mothers/caregivers
- Initially child does not distinguish between representations of self and mother and views things as either all good or all bad
- During development, child realises they are separate from mother and begins to integrate all good/all bad object relations
Thus, neglectful/abusing/loveless/inappropriate parental behaviour - child fails to develop mature object relations - personality fails to develop correctly
- Develops insecure ego, low self esteem and fears separation and rejection (Bartholomew et al)
- Use defines mechanism - Splitting! evaluates people in black and white, difficulties in relationships when people don’t meet high standards
BPD: evidence for object relations theory
- Suvak et al: individuals with BPD judge things on valence, no intensity control
BPD: Object relations psychotherapy
- insight is mechanism to change
1) show client how normal ways of behaving defensive
2) normal ways of thinking too simplistic causing swing between +/- emotions
3) provide more adaptive ways of dealing with important life issues - Therapist active role
1) clarification: asks p to elaborate on thoughts/emo on self/other in problemat. situ.
2) confrontation: point out inconsistencies between differing accounts of self/other
3) interpretation: offer explanation for inconsistencies by suggesting links between defence mechanisms and anxiety associated with trying to link all good/bad OR
Outcome:
1) capacity to reflect on own and other’s roles in emotionally intense interaction increases
2) better able to tolerate painful emotions without resorting to all good/all bad thinking and stop them from acting out emotions in destructive ways
3) series of trials supporting effectiveness in functioning for BPD (Yeoman’s and diamond 10)
