Task 6 Mood disorders

Question 1

DSM-5 MDD

Answer 1

• A Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly attributable to another medical condition.)
o Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
o Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
o Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
o Insomnia or hypersomnia nearly every day
o Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
o Fatigue or loss of energy nearly every day
o Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
o Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
o Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
• B The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
• C The episode is not attributable to the physiological effects of a substance or to another medical condition
o Note: criteria A-C represent a major depressive disorder
• Note: Responses to losses, financial ruin, natural disaster) have to be diagnosed with caution and only If atypical symptoms are present
• D The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders
• E There has never been a manic episode or a hypomanic episode
o Note: This exclusion does not apply if all the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition

Question 2

MDD single episode

Answer 2

People who experience only one depressive episode

Question 3

MDD recurrent episode

Answer 3

Two or more episodes separated by at least 2 consecutive months without symptoms

Question 4

Sub types of MDD

Answer 4

o Anxious distress: Prominent anxiety symptoms
o Mixed features: Presence of at least three manic/hypomanic symptoms but does not meet criteria for manic episode
o Melancholic features: Inability to experience pleasure, distinct depressed mood, depression regularly worse in morning, early morning awakening, marked psychomotor retardation or agitation, significant anorexia or weight loss, excessive guilt
 Physiological features are particularly prominent
o Psychotic features: Presence of mood-congruent or mood incongruent delusions or hallucinations
o Catatonic features: Catatonic behaviours: not actively relating to environment, mutism, posturing, agitation, mimicking anothers speech or movements
o Atypical features: Positive mood reactions to some events, significant weight gain or increase in appetite, hypersomnia, heavy or leaden feelings in arms or legs, long-standing pattern of sensitivity to interpersonal rejection
o Seasonal pattern: History of at least two years in which major depressive episodes occur during one season of the year (usually the winter) and remit when the season is over
o Peripartum onset: Onset of major depressive episode during pregnancy or in the 4 weeks following delivery
o Cyclothymic: Basically Bi-polar 2 subthreshold, has to be present for 2 years

Question 5

Prevalence

Answer 5

o After drug use disorder the highest prevalence of all disorders
o 3-15% experience an episode of MDD in their lives
o Mostly between 18-29 years with older age it is less likely but when it occurs it tends to be severe, chronic, debilitating
o 2.5% in children
o 8.3 percent in adolescent
o Women are twice as likely
o 75% who experience one episode will experience subsequent episodes

Question 6

Genetic factors

Answer 6

people with a first degree relative with MDD are 2-3 times more likely to develop MDD
 Greater genetic base when early onset
 Dysfunctional neurotransmitter systems esp. Serotonin increase risk

Question 7

Neurotransmitter theories

Answer 7

 Monoamine are involved in limbic system which governs processes which seem dysfunctional in some MDD patients
 Not really a low concentration more an imbalance
 Norepinephrine, serotonin, and to a lesser degree dopamine
 Abnormalities in synthesis process may contribute to depression
 Abnormalities in transporter genes of presynaptic cell
 Less sensitive receptors

Question 8

Structural and functional brain abnormalities

Answer 8

 PFC: esp. left PFC which is associated with motivation and goal orientation
 anterior cingulate: Bodies response to stress, emotional expression and social behaviour
• decreased activation
 hippocampus: memory and fear related learning, heightened levels of cortisol inhibit development of hippocampal cells
 amygdala: helps direct attention to stimuli that are emotionally salient an have major importance for the individual
• heightened activation in depression

Question 9

Hypothalamic-pituitary-adrenal axis

Answer 9

systems which is involved in fight or flight response, activates when you waking up
• Chronic hyperactivity caused by higher levels of Corticotropin releasing hormone and Cortisol
• Decreases hypothalamus and pituitary activation
o Caused difficulties to recover base state
• Causes inhibition of monoamine neurotransmitter effects
• High cortisol levels cause inhibition of neurogenesis epc. In hippocampus (hippocampus problems are seen in MDD)
• Dysfunction of glucocorticoid receptors
• Causes: separation from parents in young age an increase cortisol release

Question 10

Teen age in women (factor)

Answer 10

for women changes in hormones as in the teens might trigger depression

Question 11

Behavioural theories of depression

Answer 11

suggest that life stress leads to depression because it reduces the positive reinforcers in a person’s life. The person begins to withdraw which results in further reduction of reinforcers, which leads to more withdraw, creating a vicious circle
• Esp. likely for people with low social skills

Question 12

Learned helplessness theory

Answer 12

suggests that the type of stressful stimuli most likely to lead to depression is an unconscious negative event
• Creates feeling of helplessness which leads to decreased motivation of control

Question 13

Negative cognitive triad

Answer 13

negative views of themselves, the world and the future
• Negative schemas
• Engage in exaggerating negative events and ignoring positive ones
• Can be treated by CBT

Question 14

Ruminative response style theory

Answer 14

Suggests that rumination predicts onset of depressive episodes, as well as relapses

Question 15

Reformulated learned helplessness theory/attribution theory

Answer 15

People learn to become helpless because they have attributional styles that generate pessimistic thinking. They become depressed when they attribute negative life events to factors that cannot be controlled or are unlikely to change. They attribute negative events to internal, stable and global factors

Question 16

Interpersonal theories of depression

Answer 16

focus on relationships
 Interpersonal difficulties and losses frequently precede depression and are the stressors most commonly reported as triggering depression
 Higher likelihood of interpersonal problems in MDD
 Close and high quality relationships can protect against maladaptive coping patterns and depressive symptoms

Question 17

Rejection sensitivity

Answer 17

greater perception of rejection

• Countered by assuring seeking, which can get on the nerves of friends which can lead to social withdraw

Question 18

Cohort effect

Answer 18

more recent generation are at higher risk for depression
 Might be caused by:
• Rapid changes in social values beginning in 1960
• Disintegration of family unit
• Younger generations might have unrealistic expectations for themselves that older generations did not have

Question 19

Gender difference

Answer 19

women are around twice as likely
 Women are more likely to ruminate about feelings and problems
 Due to gender socialization women tend to be more interpersonally oriented than men
 Base their self-worth more on health of their relationships
 Factors such as prejudice discrimination and sexual abuse in younger years can facilitate depression

Question 20

Ethnicity/race differences

Answer 20

minorities which suffer from discrimination are more prone to MDD
 Might be caused by high rates of unemployment, poverty, alcoholism and helplessness

Question 21

Selective serotonin reuptake inhibitors (SSRI)

Answer 21

 As effective as other anti-depressants but have less side effects (5-10% have to stop bc of side effects)
 Less risk for overdosing
 Positive effects on side effect of depression such as, anxiety, eating disorder, and impulsiveness
 Increase suicidal thought in children

Question 22

Selective serotonin-Norepinephrine reuptake inhibitor (SSNRI)

Answer 22

 Due to two neurotransmitters slight advantage in preventing a relapse of depression compared to SSRIs
 Slightly broader side effects because of same reason

Question 23

Norepinephrine-dopamine reuptake inhibitor

Answer 23

 Useful in treating people suffering from psychomotor retardation, anhedonia, hypersomnia, cognitive slowing, inattention and craving
 Appears to overcome sexual dysfunction caused by SSRIs and so is sometimes used in conjunction

Question 24

Tricyclic Antidepressants

Answer 24

 Reuptake inhibitors
 Less frequent used these days, bc. of side effects
 High risk of overdosing only 3-4 times the prescribed dose

Question 25

Monoamine oxidase inhibitors (MAOI)

Answer 25

 no longer frequently used
 MAO breaks down neurotransmitter, leads to more neurotransmitter on synaptic cleft, which is inhibited by MAOI
 Causes many physiological side effects, esp. in combination with cheese, alcohol

Question 26

Lithium

Answer 26

mood stabilizer:
 Improving the functioning of the intracellular processes that appear to be abnormal in the mood disorders
• Increases serotonin and decreases norepinephrine
 BP patients take it always to prevent relapses of mania and depression
 Reduces suicide risk
 Small effective toxic dose difference
 Resistance to it after 3 years
 Only 33 percent stay symptom free on Lithium

Question 27

Electroconvulsive therapy

Answer 27

o Passing electrical current through patients head
o Decreases in metabolic activity in several regions of the brain
o Mechanisms of relieving depression are not known
o Side effects: can lead to memory loss and difficulties in learning new information, esp. in the days after treatment
o 85% relapse rate

Question 28

Repetitive transcranial magnetic stimulation (rTMS)

Answer 28

o Exposure to repeated, high-intensity magnetic pulses focused on partciluar brain structures
 In depression left PFC
o Few side effects, only minor headache treatable by over the counter pain killers

Question 29

Vagus nerve stimulation (VNS)

Answer 29

o Vagus nerve carries information from head, neck, thorax and abdomen to several areas of the brain, hypothalamus and amygdala which are involved in depression
o Vagus nerve is stimulated by small electronic devise, which is implanted under the skin in the left chest wall
o Increases activity in the hypothalamus and amygdala which may have antidepressant effects
 Mechanism not really clear

Question 30

Deep brain stimulation

Answer 30

o Electrodes are implanted in specific parts of the brain, which is connected to a pulse generator which is placed under the skin
o Not really known why it works

Question 31

light therapy

Answer 31

SAD patients are exposed to bright light for a few hours of the day
o 57% general effectiveness and 79% in combination with CT
o Regulates circadian rhythm
o Reduces hormone melatonin, which rises levels of serotonin and norepinephrine
o Exposure to light might increase serotonin by its own

Question 32

Behavioural therapy

Answer 32

o Increasing positive reinforcers and decreasing aversive experiences by changing the interaction with the environment and with other people
o Lasting about 12 weeks
o First: finding out connections between circumstances and symptoms severity
o Second: teaching clients skills for changing their negative circumstances, esp. negative social interactions
 E.g. relaxion techniques

Question 33

Cognitive-behavioural therapies

Answer 33

o Two general goals:
 Change the negative, hopeless patterns of thinking described by the cognitive models of depression
 Help to solve concrete problems in their lives and develop skills for being more effective in their world
o 6-12 weeks

Question 34

Skill use article

Answer 34

 Use of skills increased over therapy time
 Use of more skills causes stronger decrease of depression
 Only total skill (behavioural activation and cognitive skills) predicted outcome
 Patients who report infrequent use of skills may be at risk for treatment non-response

Question 35

Bipolar I

Answer 35

 MDD can occur but is not necessary
 Mania has to be fulfilled
 Hypomanic episodes are not necessary but can occur

Question 36

Bipolar II

Answer 36

 MDD is necessary for diagnose
 Full Mania cannot be present
 Hypomanic (at least 4 days) (less severe than manic) episodes are necessary for diagnose

Question 37

Cyclothymic disorder

Answer 37

alternates between hypomanic symptoms and periods of depressive symptoms, over at least 2 year period
 Symptoms are insufficient to meet full criteria for hypermania and depression

Question 38

Persistent depressive disorder

Answer 38

depressed mood for most of the day, for more days than not, for at least 2 years (for children and adolescents 1 year)
o In addition two or more of these symptoms
 Poor appetite
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem poor concentration
 Hopelessness
o No longer without symptoms than 2 months
o People with PSD show higher comorbidity compared to only MDD
o Prevalence: 1.7% children, 8% adolescents

Question 39

Seasonal affective disorder

Answer 39

E.g. getting depressed when days get shorter and recover in summer over 2 years and without any other cause
o Higher prevalence in northern territory

Question 40

Premenstrual dysphoric disorder

Answer 40

women experience increase in distress during premenstrual phase of their menstrual cycle
o Mood swings
o Only 2 percent meet criteria

Question 41

Preception and attention and emotions

Answer 41

 No difference in negative words used in stroop task (only when long exposure)
 Attentional biases in later stages of processing
 Depresses people look more at pictures featuring sadness and loss (not more likely to look but stay there longer)
• Problems with disengaging

Question 42

Interpretation (bias)

Answer 42

o Negative interpretation bias

o Still mixed results

Question 43

Memory bias

Answer 43

o MDD leads to 10% more recall of negative than positive words
o Negative cues increase recall of autobiographical memories
 Do not display positive memory bias like normal
o General rather than specific memories are memorised

Question 44

Cognitive control

Answer 44

o Inhibition, disengaging and updating working memory
o Deficits in the inhibition of mood congruent material
 Difficulties in inhibition of entering and removing of previous negative stimuli from working memory
o More prone to rumination
 Associated with reduced ability to update working memory
o Difficulties in cognitive control may interfere with the ability to override biased attention and interpretation

Question 45

Lifestyle factors influencing MDD

Answer 45

diet sleep exercise