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PSYB32 - Lecture 06 Notes.docx

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University of Toronto Scarborough
Konstantine Zakzanis

PSYB32 – Lecture 06 WebOption – Summer 2013  The first 82 minutes of this lecture consisted of stories from 2 guests who spoke of their battles with major depression  It’s not testable content, but it’s very eye-opening and emotional – I recommend watching it  The actual lecture begins with how to diagnose major depression and other Mood Disorders (Chapter 8 slides) Slide 6 – Formal Diagnostic Listings of Mood Disorders Major Depressive Disorder  There is no difference between MDD, Major Depression, or Unipolar Depression  To meet diagnostic criteria: one has to have at least five of the symptoms listed on slides 6 and 7, and these symptoms must persist for at least two weeks o If you wake up feeling one or more of these symptoms, then wake up the next day and they’re gone then you don’t fall under the diagnostic criteria for Major Depression  *Also, one of the five symptoms MUST be either depressed mood or a loss of interest and pleasure in usual activities o *So if you suffer from 5 symptoms of depression, but none of the 5 are a) depressed mood or b) loss of interest/pleasure, then you don’t qualify as having Major Depression Slide 8 – The Clinical Assessment of Depression  Diagnosing depression can be tricky however  For ex, what if someone only had 4 symptoms (for 10 weeks) but not 5? Should they be treated for depression? What if someone had 2 symptoms (suicide and depressed moods?)  *Even if they suffer from less symptoms than the DSM suggests, if the few symptoms they do have cause distress and disability, then it’s the clinician’s job to look beyond the DSM and treat the patient for Major Depression o It’s in situations like these where the more dimensional DSM-V improves on the more rigid, categorical approach of the DSM-IV  Important facts about Major Depression:  The prevalence of Depression is growing rapidly due to a reduction in stigma o People, especially men, are becoming much more willing to admit to having depression because there’s less shame in doing so  Depression is 2x more likely to occur in women than in men o This may be in part due to men and women’s differing ideas in emotional expression o Men are raised to control their emotions more than women o Women on the other hand engage in Ruminative Coping, where they talk about their depression  Thus, they’re more likely to seek treatment, which makes them more likely to be in these studies of prevalence o So technically it may not be more prevalent in women. Women are just more likely to come forward and admit their depression o Since men don’t engage in Ruminative Coping (discussing their depression), what do they do when they’re depressed? – Alcohol, physical/verbal abuse (often towards a woman in their life)  So they express their symptoms in very different ways  80% of those with depression will experience a second episode o In other words, relapse is very common in depressed people  The mean # of episodes a patient may have is 4, and they could last 3-5 months  The first episode typically follows a major stressful event in the person’s life  ***Over time, a kindling hypothesis comes into play o *In other words, following the first episode, it doesn’t take as traumatic an event for the person to experience another bout of depression  This is because their coping mechanisms begin to deplete, since a person can only handle so much  Shows clip on Slide 9 of a patient with MDD before and after treatment Slide 10 – Formal Diagnostic Listings of Mood Disorders (continued) Bipolar Disorder  Complete opposite of depression  DSM states that a diagnosis of Bipolar Disorder may be made if: o The presence of elevated mood or irritability is the dominant symptom, followed by 3 additional symptoms listed on slide  In Bipolar I Disorder, the patient will experience the full array of depression symptoms AND manic symptoms  **One of the symptoms to note is the patient’s improbable beliefs in their abilities o ie they’ll say that they can do things that are unlikely to happen, such as “once I leave treatment I’ll become an astronaut, then a Lawyer, and then I’ll learn 8 different languages so I can travel to various parts of the world” o *What’s important is that while these beliefs may seem improbable, they aren’t impossible. In other words, their thoughts are still based in reality o *Patients suffering from Delusions express thoughts which aren’t grounded in reality; completely unrealistic – Characteristic of patients with Schizophrenia  An important distinction to know Slide 11  Video of an individual who displays many of the symptoms  Notice how her beliefs may sound crazy, but are still technically realistic  Important facts about Bipolar Disorder:  4.4% lifetime prevalence – not uncommon  Average onset: early 20s  Equal gender incidence o However, in men the manic episodes are more common. In women, the depressive episodes are more common o This doesn’t mean that men don’t experience depressive episodes and vice versa, just that each gender experiences one episode more than the other  One of the reasons why Bipolar Disorder can last a lifetime is because patients have poor insight, especially in the manic state o People in manic states don’t believe anything is wrong with them o If you tell them they need help, they’ll wonder why because they feel like they can conquer the world, that they’re rich, etc o Many problems with those in a manic state – just imagine if you think you can do anything (spend all your money, treat people in a hospital because you think you’re a psychiatrist, etc) Slide 13 – Heterogeneity Within the Categories  Great deal of differences in the way in which patients with Bipolar Disorder and Depression can present: Mixed episodes  Someone with mixed episodes feels the complete array of manic symptoms (the highest of the high) as well as depressive symptoms (the lowest of the lows) within the same day o Rapidly shifts in emotion, whereas someone with regular Bipolar Disorder may be manic for a couple weeks and then depressed for a couple months and then swing back Hypomania (Bipolar II)  Less severe version of Bipolar Disorder  Patient experiences the full major depressed state, but their symptoms of mania never get to the extent that they would if they had Bipolar I Disorder Mood Specifiers  When we diagnose a patient, sometimes we wanna add some terms that clearly specify the kind of symptoms that may accompany the main disorder  Ex in depressed patient video on slide 9 where patient thought she was the devil. What kind of symptom is that? A Delusion o A Delusion is a psychotic feature not based in reality  So she would be diagnosed with Bipolar I Disorder with the qualifier of Psychotic Features o By including such specifiers, it indicates specific treatment implications o Ex not only would this patient receive mood stabilizers (ie Lithium), as well as antipsychotics  Melancholic is another specifier where the presentation of the depressed state will have four characteristic symptoms that, when present, cluster together to form a syndrome known as a Melancholic state o These symptoms include:  Loss of pleasure in previously enjoyable activities  Depression most severe in the mornings, but decapitates throughout the day  Sleep difficulties characterized by waking early, loss of appetite and weight  Lethargic (lack of energy) o When these symptoms cluster together, it’s considered a Melancholic mood specifier  Patients with a Melancholic mood specifier added to their Bipolar Disorder have worse outcomes than those with just Bipolar Disorder o This is because patients with a melancholic specifier often have more comorbidity  Another mood specifier is Catatonic features where you see slow motor movement in the patient o ie if you ask a Bipolar patient with catatonic features to pick up a pen, they’ll just look at it o They lack the volition, or motivation to engage in the movement required to grab the pen o The opposite of this which some patients experience is Excessiveness in movement, but this excessive movement serves no purpose  ie the patient paces back and forth for no reason  The fourth mood specifier is Seasonal Affective Disorder: when the onset of symptoms are specific to a particular time of year (typically fall/winter when there’s less sunlight) Slide 14 – Postpartum Depression in Canadian Women  Postpartum Depression: when the onset of major depression symptoms are within 4 weeks of childbirth  Slide 15 has video of patients who suffer from it Slide 16 – Chronic Mood Disorders  The patient will have symptoms which persist for two years, hence chronic  *The symptoms are never as severe as they are in a Major Mood Disorder  Two kinds of Chronic Mood Disorders: Cyclothymic Disorder  Can be thought of as a less severe Bipolar I Disorder  Person will experience periods of depressed mood and hypomania which are always there for 2 years  These symptoms however never get to the extent that they’re disabling. They cause distress, but it’s not as disabling as a Bipolar I Disorder  2.5% prevalence Dysthymic Disorder  Can be thought of as a less severe form of Major Depressive Disorder  Patient suffers from chronic depression  Must be chronically depressed more than half the time in the two year period  Symptoms: Loss of pleasure (Anhedonia), sadness, sleep disturbance, feelings of inadequacy, loss of motivation and concentration, withdrawal  Also a 2.5% prevalence Double Depression  When a person who has Dysthymia also experiences full episodes of depression  So within that two year span of the more subtle depression that characterizes Dysthimic Disorder, they also have two-week periods of full blown Major Depressive episodes (recall the 5 symptoms)  These individuals are more treatment resistant than individuals who suffer from only one of the disorders Slide 17 – Therapies for Mood Disorders  * The following is a therapy which he believes is very important for understanding depression and how to treat it  Aaron Beck is one of the major theorists on anxiety and depression; created his own form of therapy known as Beck’s Cognitive Therapy  Highly influential due to his theory of depression: depressed persons feel as they do because their thinking is biased towards negative interpretations o So people are depressed because the way in which they see themselves and the world is always filtered through a negative interpretation  ***How does this happen? Because of the Negative schemata which we create as we go through our developmental years o As negative life events happen to us, we put them into little categories, or schemas within our brain o As we age, we use these schemas to help us interpret all of the information we come across on a day-to-day basis o Those who are prone to depression will have these negative schemas activated when they’re trying to process event o Thus the filter they use prevents them from putting a positive spin on a negative event they experience. o Instead, they focus on how negative it is and they use different kinds of Cognitive Biases in their interpretation which reinforces why they see themselves and the world in such a negative way o Beck calls this the negative triad: when we have negative schemata activated and engage in cognitive biases as we interpret our reality  They key in these cognitive biases is they cause us to misinterpret our reality  What are these cognitive biases (filters) that we use which make us think negatively of ourselves and the world?: Arbitrary Inference  A patient with depression will come to a conclusion about something in the absence of suffic
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