Depression And Anxiety Flashcards
Depression
Core symptoms
- Absence of positive affect, diminished interest or pleasure
- depressed/Low mood
Emotional, cognitive, physical & behavioural symptoms
Significant unintentional weigh loss or gain
Sleep disturbance (too much or less)
Agitation or psychomotor retardation noticed by others
Reduce concentration
Recurrent thought of death
Fatigue or loss of energy
Depression and anxiety
Syndrome which is a combination of symptoms that occur at the same time
Cognitive theory of vicious cycle
Thoughts-it’s not worth trying
Emotion -sad, hopeless
Physical- agitation, poor sleep
Behaviour - avoid social interaction
Suicide and self harm risk
Depressed people have 4 times more risk of suicide than general population
Deliberate self-harm (DSH)
Separate suicidal behaviour
Chronic disorder
Intentionally injuring of one’s own body without apparent intent to die
–>separate from suicide ideation
Due to impulsive compulsive to harm themselves without feeling capable of resisting these
Anxiety disorder
Where anxiety is out of proportion to the actual risk and is constant or intrusive enough to cause significant disability
Symptoms share similarity with depression but more physical symptom
Fight or flight response ( autonomic system) adrenaline and cortisol
Types of anxiety disorder
Panic disorder General anxiety disorder Specific phobia Obsessive compulsive disorder Post traumatic stress disorder
Specific phobia
Anxiety restricted to phobia Autonomic system(physical) Avoidance
Agoraphobia
Fear of market place/crowded place
Fear of leaving the house, taking tube, entering the shop/crowd, public place
Avoidance of crowd
Social phobia
Fear of judgement by others
Avoidance of social contact
Low self-esteem
Avoidance of social contact
Obsessive compulsive disorder
Recurrent obsessional thoughts and/or compulsive acts
Obsessive and intrusive thoughts are distressing and unwanted idea/image
The more they try to get rid of this thoughts, the more it occurs in their mind –> anxiety
Compulsive acts are for reducing the anxiety and it repeated so many times that become rituals
Intrusive thoughts-anxiety- compulsive acts- feel better- reduce anxiety- compulsive acts ritualized
Post traumatic stress disorder
Delayed response to stressful events
- reliving/re-experiencing the event (can smell, hear, see the event)
- responding to trigger (avoid trigger) -flashback
- anxiety over recurrence (constantly on alert)
- emotional numbing (to avoid/protect the emotional reaction)
Difference from PTSD
Acute stress response (last only hours up to a day) / agitation, confusion etc
Chronic stress response (stress hormone keep releasing and affect emotion and physical)
Epidemiology of depression
Most common in 45-64y.o
Women are twice more likely to have depression than men in same age
1 in 10 women experience symptoms of depression after having baby (postpartum depression)
Gender difference emerge after puberty (age 12y.o)
Risk factor of depression
Women (2:1)
Most common is 32/45-64
Black, minority ethnic group
Previous history /family history of depression
Significant physical lines - pain and disability
Other mental health problem (dementia, schizophrenia)
Epidemiology of anxiety disorder
Phobia (agoraphobia +social phobia) is the most common one
GAD is second most common one
Risk factor for anxiety disorder
Female (simple phobia, agoraphobia, GAD)
No gender difference in social phobia, panic disorder , OCD
Divorced/widow Highest in 25-44yo lowest in more than 65 yo People with disability Unemployment Black, minority ethnic group
Mixed Depression and anxiety
66%of those with depressive disorder also have anxiety, worry or panic
Prognosis of depression
Episode =6-8 months
Under 20 or over 65 has higher risk of relapse
Biological risk factor
HPA axis Nicotine , cannabis Lack of Physical activity Genetic predisposition biochemical imbalance
Psychological risk factor
Entrenched negative thinking style
Negative memory bias
Decreased perceived coping (less self esteem)
Other mental health problems
Social risk factor
Negative Life events Social network and support Financial difficulties/ unemployment Childhood environment (abuse, neglect, bullying) War
Cause of depression and anxiety - bio psychosocial model
Stress- life events, chronic difficulty
Interpretation- ability to cope with difficulty
Biological - activated HPA axis (hypothalamic-pituitary-adrenal)
Types of depressive disorders
Major depression: severe symptoms that interfere social functioning
Persistent depressive disorder: depressed mood that last at least 2 years. They can have episode of major depression along with period of less severe symptoms that last 2 years
Psychotic depression: severe/major depression + some psychosis
Postpartum depression:10-15% of women experience
Seasonal affective disorder:onset of depression during the winter
Bipolar disorder/manic -depressive disorder: less common than major depression or persistent depressive disorder
Popular antidepressants
SSRI and SNRI(serotonin and norepinephrine reuptake inhibitor)
- Fluoxetine (Prozac)
- Sertraline (Zoloft)
Tricyclics - older antidepressant
Serious side effect of heart condition
MAOIs (monoamine oxidase inhibitor)oldest antidepressant– shouldn’t be taken with SSRI, food restriction,
Psychotherapy for depression
CBT Interpersonal therapy (IPT)
Electro convulsive therapy (ECT)
Side effect of confusing, memory loss, disorientation that usually last short term.
Usually 6-12 treatments
Newer treatment
-Transcranial magnetic stimulation -stimulation to left dorsalateral prefrontal cortex
-Deep brain stimulation -brain peacemaker stimulating subcallosal area
Behavioural therapy for anxiety disorder
CBT
Exposure therapy
What to include when taking history ?
Presenting problem -nature of the problem -recent example Development of problem -onset -course Early life experience/predisposing factor Recent trigger Risk Maintaining factor -biological, social, psychological, environmental, systematic Goal Previous treatment Engagement in current treatment plan Resource and strength ( when they were coping with stress)
How to take history
Principle of funnelling
-start from open question and the narrow down to closed question
Formulation of -4 “P”s model
- Predisposing factor (what makes the person vulnerable)
- precipitants (trigger)
- Perpetuating factor (what keeps the symptom)
- Protective factor
CBT
Focus on present issues Structures and active Time limited Interacting system Important of empiricism
Focus on 5 interacting system
- cognition
- behaviour
- emotion
- physiological
- environmental
Cognition of CBT
- Core belief: deeply held unconditional belief about self, world and others ( I’m weak, I’m unlovable)
- dysfunctional assumptions, rules, conditional belief (if I cannot pass the exam, I’m a loser, I must always pass the exams)
- negative automatic thoughts
Cognitive model
Early life experience Core belief Assumption and rule Critical incident Belief/rule activated Negative automatic thoughts -emotion, physiology, behaviour
2 neural pathway for anxiety
Subcortical pathway
Cortical pathway
Subcortical fear pathway
Include sensory cortices, dorsal thalamus, amygdala, and physical response system
- fast, sensitive without significant conscious evaluation
- lead to immediate arousal and avoidance response
Cortical fear pathway
Include significant cortical networks involved in
- executive working memory
- affective appraisal system
Heavy involvement of the prefrontal cortex in addition to subcortical structure
Slower, evaluative, subjective to more conscious control
Neurotransmitter for anxiety
GABA : main inhibitory neurotransmitter reducing anxiety, arousal, muscle tone, alertness, cognitive function
- -benzodiazepines (vallium); bind GABA to receptors
- –alcohol does it too
Serotonin
Beck cognitive model -depression
Provides both;
developmental account
>interaction between life-events and vulnerability in terms of developing a depresogenic cognitive structure
And cognitive account
>that explains how low mood is maintained by interpretation of ongoing experience
Cause of depression & anxiety - biopsychosocial model
Stress; life events, chronic difficulty
Interpretation; ability to cope with difficulties
Biological; activates HPA axis
Anxiety
An emotional prediction of danger Normal reaction Not just an arousal Anxiety involves the activation of the fight or flight system Mainly learnt
Anxiety and arousal are same ?
Anxiety involves increased physiological arousal and activation of the fight or flight system
Increased heart rate, blood pressure, adrenaline, muscle tone
Arousal =excitement or pleasure
Anxiety= unpleasant
Anxiety includes arousal but not just arousal
Classic conditioning
Anxiety becomes associated with an originally non-threatening stimuli due to co-occurrence with anxiety-inducing situation
- ie you experience violence when ur partner is drunk
- smell of alcohol = anxiety
Operant conditioning
After a behaviour, the outcome can encourage or discourage the future use of the behaviour
Anxiety can act as “punishment” to decrease doing something
Or a “reinforcer” if the behaviour leads to an escape from anxiety to increase
Ie, checking the light switch to reduce anxiety about house burning
Extinction
The association between stimuli and anxiety fade over time as;
The newly anxiety-provoking stimuli appears enough times without original anxiety-provoking event (ie smell of alcohol is no longer accompanied by violence)
Or behaviour is no longer reinforce
Cognitive for anxiety
Anxiety can be triggered by our understanding of the situation even if it’s completely new
Psychological treatment for anxiety
Anxiety is maintained because people use coping strategies that are effective for short term at the expense of maintaining the problem in the long term
- general treatment principle
- -adjustment of unhelpful belief and appraisal
- -extinction of anxiety through exposure
- -breaking down maladaptive coping
Adjustment of belief and appraisal
This can involve teaching (psychoeducation)
And testing out (behavioural experiments, data gathering)
Extinction through exposure
Anxiety will fade through sustained exposure to feared situation when danger does not occur
Graded exposure: the person draws up a hierarchy of situations and how much anxiety they cause
Is exposed to each and stays long enough for anxiety to fade before moving on to the next step
Can start with imagination, cues and then the actual situation
Breaking down maladaptive coping
Maladaptive coping strategies are those that prevent sufficient exposure to feared situation or updating of appraisals
Ie dog phobia-avoid park
Two main neural pathways to fear
Subcortical pathway
Cortical pathway
Both pass through the amygdala
Subcortical fear pathway
Include sensory cortices, dorsal thalamus, amygdala and physical response systems
Fast, sensitive, without significant conscious evaluation
Leads to immediate arousal and avoidance response
Cortical fear pathway
Includes significant cortical networks involved in
>executive working memory
>affective appraisal system
Heavy involvement of the prefrontal cortex in addition to subcortical structures
Slower, evaluative, subjective to more conscious control
Neurotransmitter system
As anxiety is so complex, many neurotransmitter system have been implicated
Research has focus on two
>GABA
>serotonin
GABA
Main inhibitory neurotransmitter, important in reducing neural excitability
Increase in GABA function tends to reduce»_space;anxiety, arousal, muscle tone,alertness, cognitive function
Fast acting system, effects felt in minutes to hours
Direct GABA modulating drugs
Typically bind to GABA or GABA receptor
- benzodiazepines
- barbituates
- alcohol
- GHB
Serotonin
Released by the raphe nuclei in brainstorm but affect virtually whole of brain
Gradual level changes leads to slower modulation of other brain circuits, particularly those involved in emotion
14 different serotonergic receptors
Serotonergic drugs in anxiety
Most antidepressants affect serotonin system and have anxiolytic (anti-anxiety) effects
Selective serotonin reuptake inhibitors (SSRIs) tend to prevent serotonin from being re-absorbed and so increase its level
Most well known fluoxetine or Prozac
Depression: some key concept
Cognitive theory of depression aim to explain
»development of depressive thinking style
»immediate cognition -how thinking style biases judgments to maintain poor mood
Serotonin and HPA -axis among the most studied biological aspects of depression
Depression: Beck Cognitive Model
> > thoughts- moment to moment interpretation
> > cognitive bias -ways of processing information that focus us on negative aspects and conclusion
> > dysfunctional schemas-core network of attitudes and beliefs about the self that can be activated by negative events
Beck mode : developmental aspect
Adverse developmental experience
Dysfunctional attitudes (schema); cognitive vulnerability
Activation by stressful events
Pervasive negative cognitive bias: depression
Beck model: cognitive aspect
When the dysfunctional schema are activated by negative daily events it leads to negative interpretation bias and a drop in mood
If this repeatedly happens, there is a shift into a depressive mode which affects, emotion, cognitive and behaviour (depressive episode)
As this happens more often, smaller negative events are needed to re-start an episode
Behavioural Activation Therapy
Attempts to address the negative cycle whereby:
Depressed people reduced short-term distress by avoiding activities that promote long-term well-being
Behavioural activation approach
Graded approach to initiating activities based on perceived effort
- monitor activity and mood
- identify positive behaviour
- ranking from the least to most difficult
- set weekly goals and monitor progress
Effective but trial quality low
Mindfulness-based CBT
Based on practicing and applying techniques from mindfulness meditation to disengage with negative thoughts and emotions
Initial trials have found it reduces relapse in people who have had three or more episodes of depression
Does low serotonin cause depression ?
No, but changes to the serotonin system likely play a role in maintaining depressive state
Imaging has shown no consistent difference in serotonin receptor
Tryptophan depletion does not induce depression
But evidence that serotonin transport gene (5-HTTLPR) moderates the relationship between stress and depression
Newer theories
Reduced production of new neurones (neuro genesis) in the hippocampus
Role of body’s response to inflammation (cytokines) as a trigger
Depression syndrome
Seasonal affective disorder
Psychotic depression
Major depressive disorder
Postpartum depression
Negative automatic thoughts (NAT)
Streak of thinking/commentary
Common to all of us
Often barely aware of NATs
With training can bring these thoughts into consciousness
Can learn to challenge NAT and thereby reduce distress
Assumption/rule in CBT
Conditional beliefs/rules that guide action
“If…..then….”
-If I get lower than 60%, I’m a failure
“Should” and “must”
-I should always work hard
Core belief
Deeply held unconditional beliefs about self, world and others
Usually arising from early life experience
May be reinforced by later experience
Emotional symptoms of anxiety
Apprehension or dread Trouble concentrating Feeling tense and jumpy Anticipating the worst Irritability Restlessness Watching for signs of danger Feeling like your mine's gone blank
Physical symptoms of anxiety
Pounding heart Sweating Stomach upset or dizziness Frequent urination or diarrhea Shortness of breath Tremors and twitches Muscle tension Headache Fatigue Insomnia
Self-help for anxiety attack and anxiety disorder
Write down your worries Creat an anxiety worry period Accept uncertainty Practice relaxation technique Reduce alcohol and nicotine Exercise Sleep
DSM IV
Depressed mood and/ or loss of interest or pleasure in life activity for at least 2 weeks and at least 5 of the following
Core symptoms :
Depressed mood most of the day
Diminished interest or pleasure in all or most activity
Significant unintentional weight loss or gain
Insomnia / sleep too much
Agitation or psychomotor retardation noticed by others
Fatigue or loss of energy
Feeling of worthlessness or excessive guilt
Diminished ability to think or concentrate or decide
Recurrent thought of death
