Lecture 4: Chapter 5: Mood Disorders and Suicidality Flashcards
What are the 2 types of mood disorders in the DSM?
- Unipolar depressive disorders
- Bipolar disorders (include manic symptoms)
What is anhedonia?
The inability to experience pleasure and/or profound sadness
What are 3 types of physical symptoms for depressive disorders?
- Fatigue
- Low energy
- Physical aches/pains
What are 7 symptoms of Major Depressive disorder and how many criteria do you have to meet in order to get this diagnosis?
Meet at least 5 symptoms:
1. Sleeping too much/too little
2. Psychomotor retardation/agitation
3. Weight loss/gain
4. Loss of energy
5. Feelings of worthlessness or guilt
6. Difficult concentrating, thinking, decision making
7. Recurrent thoughts of death or suicide
Symptoms present nearly every day, most of the day for at least 2 weeks
What does it mean that major depressive disorder (MDD) is an episodic disorder?
Symptoms tend to be present for a period and then clear out
Major depressive episodes often recur
What are 6 symptoms of Persistent Depressive disorder? When do you get this diagnosis?
- Sleeping too much/too little
- Poor appetite/overeating
- Low energy
- Poor self-esteem
- Trouble concentrating/ decision making
- Feelings of hopelessness
At least 2 of the symptoms + depressed mood for most of the day more than half of the time for 2 years
What is a different name of persistent depressive disorder?
Dysthymia
What is the epidemiology of MDD?
MDD is very common and appears more often in women than in men and trice as often in poor people than wealthy people
How can you explain differences in prevalence of MDD in different countries?
It’s complex. It can be cultural, but it can also have to do with other factors, such as distance from the equator
How does the distance to the equator matter for mood disorders? Which disorder is more prevalent in more northern countries (Europe)?
Further away from equator means more seasonal changes. In the winter, humans have lower metabolism, which leads to higher rates of depression during winter
Seasonal affective disorder
How did the age of onset for MDD evolve over the last few years?
The age of onset becomes lower for each generation of people.
60 years ago: <5% experienced episode of MDD before age 20
Now: 10% experienced episod MDD before age 20
What can you say about the comorbidity of MDD and persistent depressive disorder?
15-30% of people diagnosed with MDD will have symptoms for over 2 years and then qualify for diagnosis of persistent depressive disorder
What are common comorbid disorders with MDD and persistent depressive disorders?
Anxiety disorders, substance-related disorders, sexual dysfunctions, personality disorders
When do gender differences in depression arise and what are 3 possible factors contributing to it?
Arises in adolescence
Factors:
1. Biological: fluctuations in hormones might increase stress reactivity in women
2. Social: girls more frequently exposed to sexual abuse and chronic stressors
3. Stress reactivity: self-critical attitudes about appearance, focus on gaining approval
How many people will approximately experience MDD during their lifetime?
Around 16%
MDD and persistent depressive disorder are both … as common among women as among men
Twice
What is the difference between mood and emotion? (4)
Mood:
1. Long duration
2. Not directed at smth
3. Mostly bias cognition
4. Angry, sad, happy etc.
Emotions:
1. Short
2. Directed toward smth
3. Bias cognition + immediate action
4. Basci: fear, anger, disgust, happiness
What are the 3 forms of bipolar disorders according to the DSM? How are they differentiated?
- Bipolar I
- Bipolar II
- Cyclothymic disorder
Differentiated by how severe and long-lasting the manic symptoms are
What is mania? Give at least 3 examples of symptoms. How long do they last?
A state of intense elation or irritability, along with abnormally increased activity and other symptoms.
E.g. people get louder, take more risks, have flight of ideas, anger outbursts, extreme self-confidence, no sleep, risky sexual activity
Symptoms last at least a week, require hospitalization or include psychosis
What is hypomania? What are symptoms of it? How long does it take?
A less extreme form of mania, often less damaging to the person and its surroundings
Clear changes in functioning, but no impairment of function. No psychotic symptoms
Last at least 4 days
What are symptoms for mania/hypomania? (8)
- Increased goal-directed activity
- Unusual talkativeness
- Flight of ideas, racing thoughts
- Decreased need for sleep
- Increased self esteem
- Distractibility
- Excessive involvement in risky activities
- Presen most of the day nearly every day
When is bipolar II disorder diagnosed?
When a person had at least one depressive episode and one hypomanic episode during their life
When is bipolar I disorder diagnosed?
When a person had at least one depressive and one manic episode in a lifetime
What is cyclothymia/cyclothymic disorder?
Chronic mood disorder, where the person has frequent but mild symptoms of depression, alternating with mild symptoms of mania
The symptoms aren’t as severe as bipolar I/II, but people close to clients typically notice ups and downs
What are 2 symptoms of cyclothymic disorders and how long does it have to be there to get that diagnosis?
- Numerous periods with hypomanic symptoms that don’t meet criteria for hypomanic episodes
- Numerous periods with depressive symptoms that don’t meet criteria for depressive episode
Symptoms for at least 2 years, present at least half the time and not clearing for more than 2 months at a time
What does it mean that mood disorders are very heterogenous?
People with the same diagnosis show very different symptoms
What is more common, MDD or bipolar disorders?
MDD
What is the prevalence of bipolar I, bipolar II and cyclothymia?
I: 1%
II: 0,4-2%
Cyclo: 4% (less known)
What is often the age of onset for people with bipolar disorders?
Half of the people report age ofonset before age 25. The age of onset of bipolar disorders are increasing in frequency for children and adolescents
What is the prevalence of suicide attempts among people with bipolar I disorder?
1 out of 4 –> bipolar disorder was the psychiatric condition with the highest rate of suicide
Which medication is most often used for people with bipolar disorder?
Lithium
How many episodes do people with bipolar I disorder experience on average?
4 or more episodes
What is the influence of genetics on mood disorders (depression)? What is the heritability number for depression and for bipolar disorders?
Depression: H=0,37
Bipolar: H = 0,93
What is a genetic explanation of the variation in symptoms in mood disorders?
It shows that mood disorders are probably caused by a whole set of varying genes and not just a single gene
What can you say about the activation of the striatum in response to rewards in depression and bipolar disorders?
Depression: diminished activation
Bipolar: elevated activation
What can you say about the genetic contribution in MDD and bipolar disorders?
MDD: moderate
Bipolar: high
What can you say about the cortisol awakening response in MDD and bipolar disorders?
MDD: elevated response
Bipolar: elevated among those in depressive episodes
What is the function of dopamine in the reward system?
More dopamine guides pleasure, motivation and energy in the context of opportunities to obtain rewards
This is lower in depression and high in mania
Which 3 neurotransmitters are thought to play a role in mood disorders?
- Norepinephrine
- Dopamine
- Serotonin
Mood improvements don’t immediately happen after intake of neurotransmitters in the form of antidepressants. To what hypothesis did that lead?
It lead to the idea that mood disorders are related to the sensitivity of postsynaptic receptors that respond to the presence of neurotransmitters in the synaptic cleft
What is the consequence of administering dopamine to people with bipolar disorder?
It can evoke a manic episode
How do tricyclic antidepressants work?
It prevents the reuptake of neurotransmitters from presynaptic neuron, so that the postsynaptic neuron gets more neurotransmitters
What can you say about the activity of the amygdala in people with MDD? Is it a consequence of depression?
More active in MDD clients: it helps people to grasp how great the emotional importance of a stimuli is
It’s not a consequence of MDD, it’s more like a vulnerability to get depression
What can you say about the activation of the anterior cingulate, the prefrontal cortex and the hippocampus in depression and in mania when viewing negative stimuli? What are these regions involved in?
Both:
- Anterior cingulate: elevated
- PFC: diminished
- Hippocampus: diminished
Regions are involved in emotion regulation
How can you explain the lack of activation of the striatum (nucleus accumbens) in people with depression?
It’s essential for reward system. Lack of activity can explain why people feel less motivated by the positive events in their lives
What does the HPA axis (hypothalamic-pituitary-adrenocortical axis) do in MDD? What is the neurological cause of it?
HPA regulates stress reactivity. It’s overactive during MDD episodes
The amygdala sends signals that activates HPA, which triggers the release of cortisol. Too much cortisol causes depressive symptoms
What is the Cushing syndrome?
Overly high levels of cortisol, frequently experiencing depressive symptoms
What is the cortisol awakening response (CAR)? How does it relate to MDD?
Cortisol levels increase sharply as people wake and then in the 30-40 minutes after wakening
It can predict the onset of a first episode of MDD. High CAR levels also predict recurrence
What is the role of pro-inflammatory cytokines in the body?
It’s an immune response that play a vital role in wound healing and fighting off infection by triggering inflammation
What is the role of pro-inflammatory cytokines in depression?
People vary in how well and quickly they recover from inflammation and prolonged response might be tied to depression
What percentage of people said they experienced a serious stressful event the year before their depression started?
42-67%
Why do people with depression often struggle to deal with stressful life events?
Due to lack of social support
What is high expressed emotion (EE) and how does it relate to depression? What does this imply?
It’s a family member’s critical or hostile comments or emotional involvement with the person with depression
This leads to higher risk of relapse in depressive person.
So interpersonal problems can trigger depressive symptoms, but these depressive symptoms could also create interpersonal problems
Which of the big 5 personality traits is involved in depression?
High neuroticism: it explains the link of genetic vulnerability with depression. It predicts the onset of depression and anxiety
Which 3 cognitive theories try to explain that negative thoughts and beliefs are major causes of depression?
- Aaron Beck’s theory
- Hopelessness theory
- Rumination theory
What is the information processing bias?
The tendencies to process information in certain negative ways because of negative schemas
Explain Beck’s theory of depression. Give 4 steps on how it works
Depression is associated with negative triad: negative views of the self, world and future
- Childhood: acquire negative schemas
- Schema is activated when person encounters situations like those that originally caused the schema to form
- Negative schemas cause information processing biases
- Leads to drawing conclusions that are consistent with their underlying schema which maintain the schema
What does the dysfunctional attitudes scale (DAS) measure? What theory has been tested with it?
It includes items concerning whether people consider themselves worthwilde or lovable. People with depression endorse patterns of negative thinking
Why are just results from the DAS (dysfunctional attitudes scale) not enough to say depression is caused by negative thoughts? How can you establish it is a cause?
Negative thought could be interpreted as either a symptom or a cause of the depression
With longitudinal studies: negative cognitive styles can predict the onset of a first episode of MDD and a relapse
What is the hopelessness theory of depression? What are its 2 dimensions of attributions?
It states that hopelessness is the most important trigger for depression
Dimensions of attributions (explanation why stressor occurred)
1. Stable (permanent) vs unstable (temporary) causes
2. Global (many life domains) vs. specific (limit to one area) causes
According to the hopelessness theory, which attribution styles lead to a higher likelihood of becoming hopeless?
When the causes are stable and global
What is some evidence on the hopelessness theory?
People who are depressed tend to endorse making stable, global attributions for negative events.
For people who aren’t depressed, tendencies to make stable, global attributions predict increases in depressive symptoms
Give an example of global/specific in combination with stable/unstable attributions in the hopelessness theory (total answers: 4)
- Stable-global: I lack intelligence
- Stable-specific: I lack math ability
- Unstable-global: I’m exhausted
- Unstable-specific: I’m fed up with math right now
What is the rumination theory of depression? What is rumination?
Ruminating (worrying) can increase the risk of depression.
Rumination = tendency to repeatedly think about negative events/thoughts. It interferes with problem solving and increases negative mood
How does the rumination theory differ from Beck’s theory and the hopelessness theory?
Beck/hopelessness: focus on the nature of negative thoughts
Rumination: focus on way of thinking
Give a global discription of the hopelessness model (summary p. 42)
Negative life event –> stable global attributions of event
Stable/global attributions + other risk factors –> hopelessness –> depression
How can social factors shape biological factors? Give an example
Major life events can lead to changes in neurotransmitters, receptors, cytokines and differences in brain structure
E.g. child abuse is tied to altered activity in brain regions involved in depression and changes in function of dopamine system. Major life events trigger inflammatory cytokines
What version of the serotonin transporter gene has been linked to a higher risk for depression in child abuse (Caspi)?
If the alleles are both short, higher risk in combination with child abuse
Give 3 examples what can trigger depressive episodes in bipolar disorder
- Negative life events
- Neuroticism
- Negative cognitive styles
- Family criticism
- Lack of social support
etc
Which 2 factors increase manic symptoms over time?
- Reward sensitivity
- Sleep deprivation
How can reward sensitivity increase mania symptoms?
Mania reflects disturbance in reward system of the brain. People with bipolar disorder describe themselves as highly responsive to rewards
How can sleep deprivation increase manic symptoms?
Problems with sleep and circadian rhythms can trigger manic episodes
What is interpersonal psychotherapy and what idea is it based on? How long does the treatment take?
It’s based on the idea that depression is strongly associated with interpersonal problems. It works for MDD and persistent depressive disorder and reduces relapse
16 sessions: short-term treatment
What are techniques used in interpersonal psychotherapy? Name at least 4
Discuss interpersonal problems, discover negative feelings, encourage expression, improve communication, problem solving, suggest new modes of behavior
What is the goal of cognitive therapy (CT)? What idea is it based on?
Goal = cognitive restructuring: change negative thought patterns
Based on idea that depression is caused by negative schema and information-processing biases
How does the therapist operate in cognitive therapy (CT)?
Help the client to challenge negative thoughts and learn strategies that encourage making realistic and positive assumptions
What is mindfulness-based cognitive therapy (MBCT)? What idea is it based on?
It focuses on preventing relapse after successful treatment for recurrent episodes of major depression
Based on the idea that a person is vulnerable to relapse because of repeated associations between sad mood and patterns of self-devaluing
What is behavioral activation (BA) therapy? What idea is it based on?
People are encouraged to participate in enjoyable activities that bolster positive thoughts about one’s self and life
Based on the idea that many risk factors for depression interfere with receiving positive reinforcement
Why is behavioral couples therapy sometimes effective for treating depression? How does this therapy work?
Effective, because depression is often tied to relationship problems
Therapy for both members of a couple to improve communication and relationship satisfaction
What is psychoeducation?
A component of treatment designed to help people learn about the disorder (symptoms, course, triggers, treatment strategies)
Which 2 types of treatment work well for bipolar disorder?
- Cognitive therapy
- Family-focused therapy (FFT)
What is electroconvulsive therapy (ECT) and when is it used?
Temporary attack is triggered in the non-dominant hemisphere by the application of an electric current in the brain of a patient.
Also a muscle release is given before the power is administered to prevent bone damage
Only used to treat MDD if there is no response to medication
How many treatments does one get with ECT?
between 6-12 treatments
Why would we induce a seizure with ECT for treating depression?
ECT is more powerful than antidepressants, especially when psychotic or the patient is elderly
What are 2 side effects of ECT?
Short term confusion and memory loss
What are 2 types of mood stabilizers? What is the generic name?
- Anticonvulsants (anti seizure)
- Antipsychotics
Generic name = lithium
What are 4 types of antidepressants?
- MAO inhibitors
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors (SSRIs)
- Serotonin-norepinephrine reuptake inhibitors (SNRIs)
Which category of antidepressant is most prescribed and why?
SSRIs (selective serotonin reuptake inhibitors): least side effects
How long do you have to take antidepressants after the last depressive episode and why?
Continue for 6 months after end of episode. This is because there is a high chance of relapse after stopping medication
How does combining psychotherapy and antidepressants increase chance of recovery?
Increase by 10/20%
What are 2 advantages of cognitive therapy over medication?
- Less expensive
- Prevents relapse in the long term
What are 2 issues with adding antidepressant medication to bipolar disorder treatment?
- It’s not clear if adding these is good when people also take mood stabilizers
- They can lead to slight increase in risk of manic episodes if not combined with mood stabilizers
How long do people with bipolar disorder have to take lithium/mood stabilizers?
For a lifetime
What is suicidal ideation?
Thoughts of killing oneself
What is nonsuicidal self-injury (NSSI)?
Involves behaviors that are meant to cause immediate bodily harm but aren’t intended to cause death
What percentage of people report suicidalideation at least once in their lives? What percentage of people have made at least one attempt?
9%: suicidal thoughts
2,5%: attempt
What is the difference in prevalence of suicide among men and women?
Men are 1,7 times more likely than women to kill themselves, varying from country to country
But: women are more likely than men to make suicide attempts that don’t result in death
What is the most common way of suicide?
Guns –> people who live in homes with guns have more than twice the general risk of death by suicide
Why do women have a lower rate of completed suicide?
Women often use pills, which is a less lethal method. Men usually use a more heavy method (hanging, shooting)
When do suicides most often occur in the year? Provide 2 reasons why
In spring
1. Broken promise effect: feel bad in winter, think it will be better in spring, but it isn’t
2. Effect of sunshine: get more agitated and energetic, but no improvement of mood
Why are attempts for suicide hard to measure?
Because of poor registration: mental health institutes aren’t obliged to register suicide attempts
Why is suicide a taboo topic?
It reminds us of our own vulnerability and it’s not in the societal norm that suicide is okay. It will remain controversial in the future
If people are reminded of own vulnerability, people become more conservative and have a natural distant reaction
What are 5 risk factors related to suicide?
- Presence of psychological disorder
- Neurobiological factors/genes
- Social factors
- Psychological factors
- Differentiating ideation from action
What is the role of heritability in suicide?
H = 0,5 –> half of the variance in who will attempt suicide is explained with genes
Which social factors can influence suicide? Give 2 examples
Celebrity suicide in media, economic recession
What are psychological factors related to suicide?
Escape from pain and problems. It’s tied to the sense that one has been defeated and that defeat is inescapable
What does differentiating ideation from action mean?
It’s harder to predict suicidal behavior than it is to predict suicidal ideation
Name 5 ways of preventing suicide
- Engage in open talk about suicide
- Treat disorder (CT/meds etc.)
- Treat suicidality by engaging in strategies to prevent suicide (improve problem solving and social support)
- Prevention programs that target high-risk individuals
- Provide immediate delay/barrier to completion of suicide (restriction)
What were Durkheim’s 2 dimensions of suicide (1897)?
- Social integration level
- Social regulation level
According to the interpersonal theory of suicidal behavior, which 3 elements are needed to have the highest risk of lethal suicide attempts? Which 2 lead to a desire for suicide?
- Twarted belongingness (alone)
- Perceived burdensomness
- Capability for suicide
Desire: 1 + 2
What is the difference between the pre-motivational phase, the motivational phase and the volitional phase?
Pre-motivation: background factors + triggering events
Motivation: ideation + intention formation
Volitional: behavioral enaction
