Task 6 Mood disorders Flashcards
DSM-5 MDD
• 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
MDD single episode
People who experience only one depressive episode
MDD recurrent episode
Two or more episodes separated by at least 2 consecutive months without symptoms
Sub types of MDD
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
Prevalence
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
Genetic factors
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
Neurotransmitter theories
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
Structural and functional brain abnormalities
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
Hypothalamic-pituitary-adrenal axis
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
Teen age in women (factor)
for women changes in hormones as in the teens might trigger depression
Behavioural theories of depression
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
Learned helplessness theory
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
Negative cognitive triad
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
Ruminative response style theory
Suggests that rumination predicts onset of depressive episodes, as well as relapses
Reformulated learned helplessness theory/attribution theory
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
Interpersonal theories of depression
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
Rejection sensitivity
greater perception of rejection
• Countered by assuring seeking, which can get on the nerves of friends which can lead to social withdraw
Cohort effect
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
Gender difference
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
Ethnicity/race differences
minorities which suffer from discrimination are more prone to MDD
Might be caused by high rates of unemployment, poverty, alcoholism and helplessness
Selective serotonin reuptake inhibitors (SSRI)
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
Selective serotonin-Norepinephrine reuptake inhibitor (SSNRI)
Due to two neurotransmitters slight advantage in preventing a relapse of depression compared to SSRIs
Slightly broader side effects because of same reason
Norepinephrine-dopamine reuptake inhibitor
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
Tricyclic Antidepressants
Reuptake inhibitors
Less frequent used these days, bc. of side effects
High risk of overdosing only 3-4 times the prescribed dose
Monoamine oxidase inhibitors (MAOI)
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
Lithium
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
Electroconvulsive therapy
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
Repetitive transcranial magnetic stimulation (rTMS)
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
Vagus nerve stimulation (VNS)
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
Deep brain stimulation
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
light therapy
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
Behavioural therapy
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
Cognitive-behavioural therapies
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
Skill use article
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
Bipolar I
MDD can occur but is not necessary
Mania has to be fulfilled
Hypomanic episodes are not necessary but can occur
Bipolar II
MDD is necessary for diagnose
Full Mania cannot be present
Hypomanic (at least 4 days) (less severe than manic) episodes are necessary for diagnose
Cyclothymic disorder
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
Persistent depressive disorder
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
Seasonal affective disorder
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
Premenstrual dysphoric disorder
women experience increase in distress during premenstrual phase of their menstrual cycle
o Mood swings
o Only 2 percent meet criteria
Preception and attention and emotions
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
Interpretation (bias)
o Negative interpretation bias
o Still mixed results
Memory bias
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
Cognitive control
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
Lifestyle factors influencing MDD
diet sleep exercise
