Week 20: Psychopathology II Flashcards
Learning Objectives:
Describe the diagnostic criteria for mood disorders.
Understand age, gender, and ethnic differences in prevalence rates of mood disorders.
Identify common risk factors for mood disorders.
Know effective treatments of mood disorders.
___ in 20 women experience depression after the birth of a baby
one in 20
5% of all mothers
“perinatal depression”
World Health Organization on depression and bipolar
World Health Organization ranks both major depressive disorder (MDD) and bipolar disorder (BD) among the top 10 leading causes of disability worldwide. Further, MDD and BD carry a high risk of suicide. It is estimated that 25%–50% of people diagnosed with BD will attempt suicide at least once in their lifetimes
Mood Episodes
Everyone experiences brief periods of sadness, irritability, or euphoria. This is different than having a mood disorder, such as MDD or BD, which are characterized by a constellation of symptoms that causes people significant distress or impairs their everyday functioning.
Major Depressive Episodes (MDE)
refers to symptoms that co-occur for at least two weeks and cause significant distress or impairment in functioning, such as interfering with work, school, or relationships. Core symptoms include feeling down or depressed or experiencing anhedonia
Anhedonia
Loss of interest or pleasure in activities one previously found enjoyable or rewarding.
You need 5 of these 9 symptoms to be diagnosed with depressive mood disorder
- depressed mood
- diminished interest or pleasure in almost all activities
- significant weight loss or gain or an increase or decrease in appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feeling worthless or excessive or inappropriate guilt
- diminished ability to concentrate or indecisiveness
- recurrent thoughts of death, suicidal ideation, or a suicide attempt
These symptoms cannot be caused by the physiological effects of a substance or a general medical condition (e.g., hypothyroidism).
hypersomnia
Excessive daytime sleepiness, including difficulty staying awake or napping, or prolonged sleep episodes.
psychomotor agitation
Increased motor activity associated with restlessness, including physical actions (e.g., fidgeting, pacing, feet tapping, handwringing).
retardation
A slowing of physical activities in which routine activities (e.g., eating, brushing teeth) are performed in an unusually slow manner.
suicidal ideation
Recurring thoughts about suicide, including considering or planning for suicide, or preoccupation with suicide.
manic or hypomanic episode
Period of abnormally and persistently euphoric, expansive, or irritable mood and persistently increased goal-directed activity or energy. The mood disturbance must be present for one week or longer in mania (unless hospitalization is required) or four days or longer in hypomania.
*Manic episodes are distinguished from hypomanic episodes by their duration and associated impairment; whereas manic episodes must last one week and are defined by a significant impairment in functioning, hypomanic episodes are shorter and not necessarily accompanied by impairment in functioning.
You need 3 of these 7 symptoms to be diagnosed with manic or hypomanic mood disorder in the context of euphoric mood (or at least four in the context of irritable mood):
- inflated self-esteem or grandiosity
- increased goal-directed activity or psychomotor agitation
- reduced need for sleep
- racing thoughts or flight of ideas
- distractibility
- increased talkativeness
- excessive involvement in risky behaviours
grandiosity
Inflated self-esteem or an exaggerated sense of self-importance and self-worth (e.g., believing one has special powers or superior abilities).
Unipolar Mood Disorders
Two Major Types
- Major depressive disorder
- Persistent depressive disorder (PDD; dysthymia)
MDD is defined by one or more MDEs, but no history of manic or hypomanic episodes. Criteria for PDD are feeling depressed most of the day for more days than not, for at least two years. At least 2 of the following 6 symptoms are also required to meet criteria for PDD:
- poor appetite or overeating
- insomnia or hypersomnia
- low energy or fatigue
- low self-esteem
- poor concentration or difficulty making decisions
- feelings of hopelessness
Like MDD, these symptoms need to cause significant distress or impairment and cannot be due to the effects of a substance or a general medical condition. To meet criteria for PDD, a person cannot be without symptoms for more than two months at a time. PDD has overlapping symptoms with MDD. If someone meets criteria for an MDE during a PDD episode, the person will receive diagnoses of PDD and MDD.
Bipolar Mood Disorders
Three major types of BDs
- Bipolar I Disorder (BD I), which was previously known as manic-depression, is characterized by a single (or recurrent) manic episode. A depressive episode is not necessary but commonly present for the diagnosis of BD I.
- Bipolar II Disorder is characterized by single (or recurrent) hypomanic episodes and depressive episodes.
- Another type of BD is cyclothymic disorder, characterized by numerous and alternating periods of hypomania and depression, lasting at least two years. To qualify for cyclothymic disorder, the periods of depression cannot meet full diagnostic criteria for an MDE; the person must experience symptoms at least half the time with no more than two consecutive symptom-free months; and the symptoms must cause significant distress or impairment.
lifetime prevalence rate for MDD
16.6%
nearly one in five Americans will meet the criteria for MDD during their lifetime. The 12-month prevalence—the proportion of people who meet criteria for a disorder during a 12-month period—for PDD is approximately 0.5%
Although the onset of MDD can occur at any time throughout the lifespan, the average age of onset is mid-20s, with the age of onset decreasing with people born more recently. Prevalence of MDD among older adults is much lower than it is for younger cohorts. The duration of MDEs varies widely. Recovery begins within three months for 40% of people with MDD and within 12 months for 80%. MDD tends to be a recurrent disorder with about 40%–50% of those who experience one MDE experiencing a second MDE. An earlier age of onset predicts a worse course. About 5%–10% of people who experience an MDE will later experience a manic episode, thus no longer meeting criteria for MDD but instead meeting them for BD I. Diagnoses of other disorders across the lifetime are common for people with MDD: 59% experience an anxiety disorder; 32% experience an impulse control disorder, and 24% experience a substance use disorder.
Women experience two to three times higher rates of MDD than do men. This gender difference emerges during puberty. Before puberty, boys exhibit similar or higher prevalence rates of MDD than do girls.
MDD is inversely correlated with socioeconomic status (SES), a person’s economic and social position based on income, education, and occupation. Higher prevalence rates of MDD are associated with lower SES
Bipolar Disorders
The lifetime prevalence rate of bipolar spectrum disorders in the general U.S. population is estimated at approximately 4.4%, with BD I constituting about 1% of this rate
Adolescents experience a higher incidence of bipolar spectrum disorders than do adults. Making matters worse, those who are diagnosed with BD at a younger age seem to suffer symptoms more intensely than those with adult onset.
Prevalence estimates, however, are highly dependent on the diagnostic procedures used (e.g., interviews vs. self-report) and whether or not sub-threshold forms of the disorder are included in the estimate. BD often co-occurs with other psychiatric disorders. Approximately 65% of people with BD meet diagnostic criteria for at least one additional psychiatric disorder, most commonly anxiety disorders and substance use disorders.
A recent cross-national study sample of more than 60,000 adults from 11 countries, estimated the worldwide prevalence of BD at 2.4%, with BD I constituting 0.6% of this rate (Merikangas et al., 2011). In this study, the prevalence of BD varied somewhat by country. Whereas the United States had the highest lifetime prevalence (4.4%), India had the lowest (0.1%). Variation in prevalence rates was not necessarily related to SES, as in the case of Japan, a high-income country with a very low prevalence rate of BD (0.7%).
As with MDD, adolescence is known to be a significant risk period for BD; mood symptoms start by adolescence in roughly half of BD cases. Longitudinal studies show that those diagnosed with BD prior to adulthood experience a more pernicious course of illness relative to those with adult onset, including more episode recurrence, higher rates of suicidality, and profound social, occupational, and economic repercussions. The prevalence of BD is substantially lower in older adults compared with younger adults (1% vs. 4%).
Depressive Disorders
Factors in development
- genetic factors are implicated in the development of MDD
- Twin studies suggest that familial influence on MDD is mostly due to genetic effects and that individual-specific environmental effects (e.g., romantic relationships) play an important role, too. By contrast, the contribution of shared environmental effect by siblings is negligible
- Several genetic variants and environmental factors most likely contribute to the risk for MDD
- Romantic relationships can affect mood as in the case of divorce or the death of a spouse.
- stressful life events. In particular, severe stressful life events—those that have long-term consequences and involve loss of a significant relationship (e.g., divorce) or economic stability (e.g., unemployment) are strongly related to depression. Stressful life events are more likely to predict the first MDE than subsequent episodes. In contrast, minor events may play a larger role in subsequent episodes than the initial episodes.
- A meta-analysis of neuroimaging studies showed that when viewing negative stimuli (e.g., picture of an angry face, picture of a car accident), compared with healthy control participants, participants with MDD have greater activation in brain regions involved in stress response and reduced activation of brain regions involved in positively motivated behaviors
early adversity | Factors in development for MDD
Single or multiple acute or chronic stressful events, which may be biological or psychological in nature (e.g., poverty, abuse, childhood illness or injury), occurring during childhood and resulting in a biological and/or psychological stress response.
Chronic Stress |Factors in development for MDD
Discrete or related problematic events and conditions which persist over time and result in prolonged activation of the biological and/or psychological stress response (e.g., unemployment, ongoing health difficulties, marital discord).
interpersonal factors |Factors in development for MDD
marital dissatisfaction predicts increases in depressive symptoms in both men and women. On the other hand, depressive symptoms also predict increases in marital dissatisfaction.
*People with MDD whose relatives or spouses can be described as critical and emotionally overinvolved have higher relapse rates than do those living with people who are less critical and emotionally overinvolved
attributional styles
The tendency by which a person infers the cause or meaning of behaviors or events.
*People with a pessimistic attributional style tend to make internal (versus external), global (versus specific), and stable (versus unstable) attributions to negative events, serving as a vulnerability to developing MDD. For example, someone who when he fails an exam thinks that it was his fault (internal), that he is stupid (global), and that he will always do poorly (stable) has a pessimistic attribution style. Several influential theories of depression incorporate attributional styles
Bipolar Disorders
factors in development
Genetic
- There is compelling evidence for biological causes of BD, which is known to be highly heritable. It may be argued that a high rate of heritability demonstrates that BD is fundamentally a biological phenomenon.
- The triggers that determine how and when this genetic vulnerability is expressed are not yet understood; however, there is evidence to suggest that psychosocial triggers may play an important role in BD risk
Biological | Brain
- brain function. Many of the studies using fMRI techniques to characterize BD have focused on the processing of emotional stimuli based on the idea that BD is fundamentally a disorder of emotion. Findings show that regions of the brain thought to be involved in emotional processing and regulation are activated differently in people with BD relative to healthy controls
- Mixed findings are in part due to samples consisting of participants who are at various phases of illness at the time of testing (manic, depressed, inter-episode). Sample sizes tend to be relatively small, making comparisons between subgroups difficult. Additionally, the use of a standardized stimulus (e.g., facial expression of anger) may not elicit a sufficiently strong response. Personally engaging stimuli, such as recalling a memory, may be more effective in inducing strong emotions
Psychosocial
- environmental contributors to BD. A series of studies show that environmental stressors, particularly severe stressors (e.g., loss of a significant relationship), can adversely impact the course of BD. People with BD have substantially increased risk of relapse and suffer more depressive symptoms following a severe life stressor. Interestingly, positive life events can also adversely impact the course of BD. People with BD suffer more manic symptoms after life events involving attainment of a desired goal. Such findings suggest that people with BD may have a hypersensitivity to rewards.
Social Zeitgeber Theory
Zeitgeber is German for “time giver.” Social zeitgebers are environmental cues, such as meal times and interactions with other people, that entrain biological rhythms and thus sleep-wake cycle regularity.
*stressors that disrupt sleep, or that disrupt the daily routines that entrain the biological clock (e.g., meal times) can trigger episode relapse. Consistent with this theory, studies have shown that life events that involve a disruption in sleep and daily routines, such as overnight travel, can increase bipolar symptoms in people with BD.
Depressive Disorders
Treatment
A number of medications are effective in treating mood disorders. Meditation, exercise, counseling and other therapies also show effectiveness for some disorders.
- a number of antidepressant medications are available, all of which target one or more of the neurotransmitters implicated in depression.The earliest antidepressant medications were monoamine oxidase inhibitors (MAOIs). MAOIs inhibit monoamine oxidase, an enzyme involved in deactivating dopamine, norepinephrine, and serotonin. Although effective in treating depression, MAOIs can have serious side effects. Patients taking MAOIs may develop dangerously high blood pressure if they take certain drugs (e.g., antihistamines) or eat foods containing tyramine, an amino acid commonly found in foods such as aged cheeses, wine, and soy sauce.
- Tricyclics, the second-oldest class of antidepressant medications, block the reabsorption of norepinephrine, serotonin, or dopamine at synapses, resulting in their increased availability. Tricyclics are most effective for treating vegetative and somatic symptoms of depression. Like MAOIs, they have serious side effects, the most concerning of which is being cardiotoxic. Selective serotonin reuptake inhibitors (SSRIs; e.g., Fluoxetine) and serotonin and norepinephrine reuptake inhibitors (SNRIs; e.g., Duloxetine) are the most recently introduced antidepressant medications.
- SSRIs, the most commonly prescribed antidepressant medication, block the reabsorption of serotonin, whereas SNRIs block the reabsorption of serotonin and norepinephrine. SSRIs and SNRIs have fewer serious side effects than do MAOIs and tricyclics. In particular, they are less cardiotoxic, less lethal in overdose, and produce fewer cognitive impairments. They are not, however, without their own side effects, which include but are not limited to difficulty having orgasms, gastrointestinal issues, and insomnia. It should be noted that anti-depressant medication may not work equally for all people. This approach to treatment often involves experimentation with several medications and dosages, and may be more effective when paired with physical exercise and psychotherapy.
Depressive Disorders
biological treatments
Other biological treatments for people with depression include electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and deep brain stimulation. ECT involves inducing a seizure after a patient takes muscle relaxants and is under general anesthesia. ECT is viable treatment for patients with severe depression or who show resistance to antidepressants although the mechanisms through which it works remain unknown. A common side effect is confusion and memory loss, usually short-term
-Repetitive TMS is a noninvasive technique administered while a patient is awake. Brief pulsating magnetic fields are delivered to the cortex, inducing electrical activity. TMS has fewer side effects than ECT, and while outcome studies are mixed, there is evidence that TMS is a promising treatment for patients with MDD who have shown resistance to other treatments.
Most recently, deep brain stimulation has been examined as a treatment option for patients who did not respond to more traditional treatments like those already described. Deep brain stimulation involves implanting an electrode in the brain. The electrode is connected to an implanted neurostimulator, which electrically stimulates that particular brain region. Although there is some evidence of its effectiveness, additional research is needed.
Depressive Disorders
psychosocial treatments
These treatments include but are not limited to behavior therapy, cognitive therapy, and interpersonal therapy. Behavior therapies focus on increasing the frequency and quality of experiences that are pleasant or help the patient achieve mastery. Cognitive therapies primarily focus on helping patients identify and change distorted automatic thoughts and assumptions. Cognitive-behavioral therapies are based on the rationale that thoughts, behaviors, and emotions affect and are affected by each other. Interpersonal Therapy for Depression focuses largely on improving interpersonal relationships by targeting problem areas, specifically unresolved grief, interpersonal role disputes, role transitions, and interpersonal deficits. Finally, there is also some support for the effectiveness of Short-Term Psychodynamic Therapy for Depression. The short-term treatment focuses on a limited number of important issues, and the therapist tends to be more actively involved than in more traditional psychodynamic therapy.
Bipolar Disorders
treatment
pharmacotherapy
- Antidepressants such as SSRIs and SNRIs are the primary choice of treatment for depression, whereas for BD, lithium is the first line treatment choice. This is because SSRIs and SNRIs have the potential to induce mania or hypomania in patients with BD. Lithium acts on several neurotransmitter systems in the brain through complex mechanisms, including reduction of excitatory (dopamine and glutamate) neurotransmission, and increase of inhibitory (GABA) neurotransmission
- Lithium has strong efficacy for the treatment of BD. However, a number of side effects can make lithium treatment difficult for patients to tolerate. Side effects include impaired cognitive function, as well as physical symptoms such as nausea, tremor, weight gain, and fatigue. Some of these side effects can improve with continued use; however, medication noncompliance remains an ongoing concern in the treatment of patients with BD. Anticonvulsant medications are also commonly used to treat patients with BD, either alone or in conjunction with lithium.
Alternatives
- Interpersonal and social rhythm therapy is a psychosocial intervention focused on addressing the mechanism of action posited in social zeitgeber theory to predispose patients who have BD to relapse, namely sleep disruption. A growing body of literature provides support for the central role of sleep dysregulation in BD. Consistent with this literature, IPSRT aims to increase rhythmicity of patients’ lives and encourage vigilance in maintaining a stable rhythm. The therapist and patient work to develop and maintain a healthy balance of activity and stimulation such that the patient does not become overly active (e.g., by taking on too many projects) or inactive (e.g., by avoiding social contact). The efficacy of IPSRT has been demonstrated in that patients who received this treatment show reduced risk of episode recurrence and are more likely to remain well.
Recently, Zeb has lost his passion for sports. Invitations to play with his friends just don’t excite him. This loss of interest is an example of which symptom of a major depressive episode?
anhedonia
Psychomotor ______refers to an increase in activity that is marked by restlessness and fidgeting, pacing, or tapping of the feet.
agitation
