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Konstantine Zakzanis

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GENERAL CHARACTERISTICS OF MOOD DISORDERS o Mood disorders – disabling disturbances in emotion from the sadness of depression to the elation and irritability of mania o Associated with other psychological problems i.e. panic attacks. The presence of other disorders can increase severity and result in poorer prognosis DEPRESSION SIGNS & SYMPTOMS o Depression – emotional state marked by great sadness and feelings of worthlessness and guilt o Symptoms include withdrawal from others and loss of sleep, appetite, sexual desire, and interest & pleasure in usual activities  Paying attention is exhausting  When confronted with a problem, no ideas for a solution occur to them  Dejected and completely without hope and initiative , may be apprehensive, anxious and despondent much of the time o Symptoms and signs vary somewhat across the lifespan o In children often results in somatic complaints i.e. head/stomach-aches o In older adults often characterized by distractibility and complaints of memory loss o Symptoms exhibit some cross-cultural variation, probably resulting from differences in cultural standards of acceptable behaviour  i.e. less prevalent in China than in North America, due partly to cultural mores that make it less appropriate for Chinese people to display emotional symptoms  people from non-western cultures emphasize somatic symptoms of depression, Western cultures emphasize emotional symptoms o Lawrence Kirmayer  only 15% of depressed primary care patients in Canada are psychologizers (people who emphasize the psychological aspects of depression) o Most depression tends to dissipate with time; untreated can go for months of longer o Cases where depression becomes chronic, person does not completely “snap back” to earlier levels of functioning between bouts MANIA SIGNS & SYMPTOMS o Mania – emotional state or mood of intense but unfounded elation accompanied by irritability, hyperactivity, talkativeness, flight of ideas, distractibility, and impractical, grandiose plans o Lasts several days to months o Speech is difficult to interrupt and reveals the manic person’s flight of ideas o Individual shifts rapidly from topic to topic; the need for activity may cause annoyingly sociable and intrusive o Any attempt to curb this momentum can bring quick anger and even range; mania usually comes on suddenly over a period of a day or two FORMAL DIAGNOSTIC LISTINGS OF MOOD DISORDERS o Two major mood disorders are listed in the DSM4: major depression (unipolar depression) and bipolar disorder o DIAGNOSIS OF DEPRESSION – the formal DSM4 diagnosis of a major depressive disorder (MDD) requires the presence of 5 of the following symptoms for at least 2 weeks; depressed mood or lost of interest and pleasure must be one of the 5 symptoms: - Sad, depressed mood, most of the day, nearly every day - Loss of interest and pleasure in usual activities - Difficulties in sleeping (insomnia); not falling asleep initially, not returning to sleep after awakening; or a desire to sleep a great deal of the time - Shift in activity level, becoming lethargic (psychomotor retardation) or agitated - Poor appetite and weight loss, or the opposite - Loss of energy, great fatigue - Negative self-concept, self=reproach and self-blame, feelings of worthlessness, and guilt - Complaints or evidence of difficulty in concentrating, such as slowed thinking and indecisiveness - Recurrent thoughts of deaths or suicide 1  Controversial, whether a person with 5 symptoms and a 2-week duration is distinctly different from one who has only three symptoms for 10 days  Fewer than 5 symptoms and a duration of less than two weeks, co-twins were likely to be diagnosed with depression and were likely to have recurrences  DSM MDD diagnostic criteria were developed on the basis of clinical experience  Zimmerman  conducted psychometric evaluation of the symptom criteria and found that all of them were significantly associated with the diagnosis; symptoms that are also criteria for other disorders performed as well as criteria unique to depression i.e. worthlessness - In analysis that controlled for symptom co variation, 5 symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis - This study has implications for the possible revision of the diagnostic criteria for MDD  Issue for DSM5 Andrew noted that few psychiatry or primary care trainees can remember the 9 symptoms and proposed simplifying the diagnosis by employing a restricted symptom set  MDD is very prevalent, lifetime ranges from 5.2 – 17.1% ; 12 month prevalence of MDD in the National Comorbidity Survey – Replication (NCS-R) study was 6.7%  Scott Patten  2008, defined by DSM4 criteria, the lifetime prevalence of major depression exceeds 20% and may be as high as 50%  MDD 2x more common in women than in men; Canada’s 1994-96 National Population Health Survey show that the gender gap emerges at age 14 and is maintained across the lifespan  Grilo  people with MDD who had certain coexisting personality disorders had a significantly longer time to remission of symptom than did MDD participants without personality disorders  First episodes have a stronger link with major life events stress than do later episodes – kindling hypothesis – once a depression has already been experienced, it takes relatively less stress to induce a recurrence  Not clear whether the apparent reduced role of life event stress in following depressions is because depression has become autonomous and no longer requires stress (autonomy hypothesis) or whether the person has become sensitized to stress FOCUS ON DISCOVERY 8.1 – girls are more likely to have certain risk factors for depression even before adolescents, but it s only when these risk factors interact with the challenges of adolescents that the gender differences in depression emerge; several explanations: 1. Females are more likely than males to engage in ruminative coping, while males are more likely to engage in distracting activities i.e. watching a hockey game. Ruminators focus their attention on their depressive symptoms, ruminative coping style predicts the onset of depression episodes and is associated with more severe depressive symptoms; gender differences emerge in adolescence 2. Treynor  differentiated between a more adaptive form of reflective pondering VS a maladaptive rumination component – brooding (moody pondering). The relationship between gender and depression could be due to the brooding component; may be a non-specific vulnerability for different forms of emotional distress including anxiety, worry, anger, and dysphoria 3. Interpersonal form; co-rumination- friends, typically female friends discuss and brood over each other’s problems as part of their friendship – linked with depression in adolescent girls 4. Dana Jack  females are more likely to engage in silencing the self – passive style of keeping upsets and concerns to oneself in order to maintain important relationships 5. Objectification theory – based on the premise that the tendency to be viewed as an object, scrutinized and appraised by others has a greater negative influence on the self-esteem of girls and boys A Toronto study found 50% of women receiving inpatient treatment for depression had been sexually victimized in childhood and adulthood. Women had higher levels of depression and were more likely to have a history of child sexual abuse (CSA) and report higher levels of victimization as adults; girls and women are more likely to take a more active role in generating stress for themselves 2 o DIAGNOSIS OF BIPOLAR DISORDER – bipolar I disorder involves episodes of mania or mixed episodes that include symptoms of both mania and depression  Also experience episodes of depression; a formal diagnosis of a manic episode requires the presence of elevated or irritable mood plus three additional symptoms (4 if the mood is irritable) - Increase in activity level - Unusual talkativeness; rapid speech - Flight of ideas or subjective impression that thoughts are racing - Less than usual amount of sleep needed - Inflated self-esteem; belief that one has special talents, powers, and abilities - Distractibility; attention easily diverted - Excessive involvement in pleasurable activities that are likely to have undesirable consequences, such as reckless spending  BD occurs less often than MDD, lifetime prevalence rate for both bipolar I and II of ~4.4% of the population in the NCS-R  Average age of onset, 20s and occurs equally often in men and women  Among women, episodes of depression are more common and episodes of mania less common than among men CANADIAN PREFERENCES 8.1 – Canadian Community Health Survey: Mental Health and Well-Being  Lifetime prevalence of MDD was 12.2%; one-yr prevalence was 4.8% and past month episode was 1.8%  Lifetime prevalence of a manic episode was 2.4% and one-year prevalence was 1%  MDD prevalence doubles between late adolescents and adulthood; 90% of people who met the one-yr criteria for either MDD or bipolar disorder reported that the condition interfered with their lives  40% of youth (15-24) with a depressive disorder presented with an anxiety disorder; more prevalent in the western provinces  Lifetime prevalence of MDD with chronic symptoms was 2.7% RISK FACTORS – One-yr prevalence of MDD in people with a substance use disorder were 6.9% for harmful alcohol use, 8.8% for alcohol dependence, and 16.1% for drug dependence. Presence of a comorbid chronic medical disorder in people with at least one manic episode was associated with employment dysfunction, not being n school, high among smokers who were young; TREATMENT – Long-term medical conditions, suicide attempts and severe role interference were more likely to have used conventional services HETEROGENEITY WITHIN THE CATEGORIES o People with the same diagnosis can vary greatly from one another; i.e. some bipolar people experience both mania and depression – mixed episode o Bipolar II disorder – individuals have episodes of major depression accompanied by hypomania a change in behaviour and mood that is less extreme than full-blown mania o Depressed people with delusions do not generally respond well to the usual drug therapies; but they do respond when they are combined with the drugs commonly used to treat other psychotic disorders i.e. schizophrenia o Some people with depression may have melancholic features – specific patterns of depressive symptoms; find no pleasure in any activity (anhedonia) and are unable to feel better even temporarily when something good happens , mood is worst in the morning, they awaken 2hrs too early, lose appetite and weight and are lethargic or extremely agitated o Melancholic features had more Comorbidity, frequent episodes and impairment, suggesting it may be a more severe type of depression o Manic and depressive, characterized as having catatonic features i.e. motor immobility; may also occur within 4weeks of childbirth, they are noted to have a postpartum onset  Postpartum depression (PD) – new mothers often complain of temporary baby blues or experience profound depression  Onset predicted by levels of depression in the pregnancy period as well as by a reported lack of warmth and care from one’s own parents while growing up 3  Predicted by depression during pregnancy, negative life events, and lower socio-economic status; newcomer mothers relative to Canadian-born mothers have an increased risk for PD, report receiving less prenatal care and social support o Both bipolar and unipolar disorders are sub diagnosed as seasonal if there is a regular relationship between an episode and a particular time of the year; linked to a decrease in the number of daylight hours o Seasonal affective disorder (SAD) – symptoms varied n response to changes in climate and latitude n a manner that suggested that reduced exposure to sunlight was causing their depression. Most had been diagnosed with bipolar depression o in Canada, seasonal subtype of major depression was detected in 11% of the people diagnosed with depression; the prevalence of SAD was 2.9% o reduced light causes a decrease in the activity of serotonin neurons of the hypothalamus, and these neurons regulate some behaviours such as sleep, that are part of the syndrome of SAD CHRONIC MOOD DISORDERS o long-lasting, or chronic disorders, in which mood disturbances are predominant o cyclothymic disorder – the person has frequent periods of depressed mood and hypomania, may be mixed with/alternate with/separated by periods of normal mood lasting as long as two months; people have paired sets of symptoms  depression they feel inadequate, during hypomania their self-esteem is inflated; they withdraw from people, then seek them out; they sleep too much and then too little; cyclothymics have trouble concentrating and verbal productivity decreases; during hypomania thinking becomes sharp and creative and their productivity increases; lifetime prevalence for cyclothymia is 2.5%, may also experience full blown episodes of mania and depression o dysthymic disorder – chronically depressed more than half the time for at least 2yrs  feeling blue, losing pleasure in usual activities and pastimes, insomnia or sleeping too much; feelings of inadequacy, ineffectiveness, and lack of energy; pessimism; an inability to concentrate and to think clearly; desire to avoid the company of others  women are 2-3 x more likely to be diagnosed with dysthymia and the chronicity of dysthymia can cause severe impairment  lifetime prevalence is 2.5%, many people with dysthymia have episodes of major depression, was well – a condition known as double depression o only two disorders were recommended to have no changes in diagnostic criteria from DSM4 (cyclothymic disorder and mood disorder not otherwise specified) and one disorder was proposed for possible removal from DSM5 (bipolar I disorder), consistent with the proposal to add “dimensional assessments” to diagnostic evaluations o the work group proposed or was considering (1) an anxiety dimension across all mood disorder categories, (2) a suicide assessment dimensions, and (3) a substance abuse severity dimension o the work group proposed one new disorder  mixed anxiety depression, the client have 3 or 4 symptoms of major depression accompanied by 2 or more symptoms of anxious distress that last at least 2weeks o the validity of the concept is based on shared genetic risk factors for depression and anxiety, the high Comorbidity between MDD and GAD, and a shared temperamental factor, negative affect o “premenstrual dysphoric disorder” (PMDD) – occurs a week or so before menstruation and is marked by depression, anxiety, anger, mood swings, and decreased interest in activities usually engaged in with pleasure and the symptoms are severe enough to interfere with social or occupational functioning o Proposed by both the Mood Disorders and Childhood work groups that “non-suicidal self injury” be included as a mood disorder  the individual engages in intentional self-inflicted damage to the surface of the body by i.e. cutting PSYCHOLOGICAL THEORIES OF MOOD DISORDERS PSYCHOANALYTIC THEORY OF DEPRESSION o Freud theorized depression is created early in childhood; during the oral period, a child’s needs may be over/insufficiently gratified, person to become fixated in this stage and dependent on the instinctual 4 gratifications particular to it; arrest n psychosexual maturation, person may develop a tendency to be excessively dependent on other people for the maintenance of self-esteem o Freud hypothesized that after the loss of a loved one, the mourner first introjects, or incorporates the lost person; identifies with the lost person, in a fruitless attempt to undo the loss o Freud asserted we unconsciously harbour negative feelings toward those we love, the mourner then becomes the object of their own hate and anger, the mourner resents being deserted and feels guilt for real or imagined sins against the lost person o Period of introjections is followed by a period of mourning work, the mourning work can go astray and develop into an ongoing process of self-abuse; The mourner’s anger toward the lost one continues to be directed inward COGNITIVE THEORIES OF DEPRESSION o BECK’S THEORY OF DEPRESSION – Aaron Beck central thesis is that depressed individuals feel as they do because their thinking is biased toward negative interpretations  In childhood and adolescence, depressed individuals acquired a negative schema – a tendency to see the world negatively – through loss of a parent, an unrelenting succession of tragedies, the social rejection of peers etc.  The negative schemata acquired by depressed persons are activated whenever they encounter new situations that resemble the conditions in which the schemata were learned  An ineptness schema can make depressed individuals expect to fail most of the time, a self-blame schema burdens them with responsibility for all misfortunes and a negative self-evaluation schema constantly reminds them of their worthlessness  Negative schemata with cognitive biases or distortions maintain the negative triad: negative views of the self, the world, and the future. The world part of the triad refers to the person’s judgment that they cannot cope with the demands of the environment  Negatively biased cognitive schemas function as efficient but maladaptive automatic information processors - Arbitrary inference – conclusion drawn in the absence of sufficient evidence or of any evidence at all - Selective abstraction – conclusion drawn on the basis of only one of many elements in a situation - Overgeneralization – an overall sweeping conclusion drawn on the basis of a single, trivial event - Magnification and minimization – exaggerations in evaluating performance  Emotional reactions are a function of how we construe our world  Kuiper  used a self-referent encoding task involved presenting participants with positive and negative word adjectives i.e. stupid and asking them to indicate whether the adjectives applied to them by stating yes or no 1. Depressed individuals endorse more negative words and fewer positive words as self- descriptive 2. Exhibit a cognitive bias: they have greater recall of adjectives with depressive content, especially if the adjectives were rated as self-descriptive  Depressed people pay great attention to negative stimuli and can more readily access negative than positive information  Differences in cognitive processing are assessed with the Stroop task – participants are provided with a series of words in different colours and are asked to identify the colour of each word and ignore the actual word itself; assesses the length of time it takes to respond  Gotlib  examined response patterns, non-depressed students did not differ in their response latencies across the word types, but depressed students took longer to colour-name  EVALUATION – two key issues 1. Whether depressed people actually think in the negative ways enumerated by Beck 2. Greatest challenge for cognitive theories of depression: whether it could be that the negative beliefs of depressed people do not follow the depression, but in fact cause the depressed mood - Depression can make thinking more negative, and negative thinking can probably cause and can certainly worsen depression 5 - Focus on personality styles known as sociotropy and autonomy o HELPLESSNESS/HOPELESSNESS THEORIES  LEARNED HELPLESSNESS – an individual’s passivity and sense of being unable to act and control their own life is acquired through unpleasant experiences and traumas that the individual tried to unsuccessfully to control; one of the neurotransmitter chemicals implicated in depression, Norepinephrine, was depleted  ATTRIBUTION and LEARNED HELPLESSNESS – helplessness inductions sometimes led to subsequent improvement of performance - Characteristic of feeling helpless yet blaming oneself is depressive paradox - Essence of the revised theory is the concept of attribution – the explanation a person has for their behaviour; when a person has experiences failure they will try to attribute it to a cause - Attributional revision of the helplessness theory suggests the way in which a person cognitively explains failure will determine its subsequent effects: Global attributions increase the generality of the effects of failure; Attributions to stable factors make them long term; Attributions to internal characteristics are more likely to diminish self-esteem, particularly if the personal fault is also global and persistent - People become depressed when they attribute negative life events to stable and global causes  HOPELESSNESS THEORY – some forms of depression (hopelessness depressions) are more regarded as caused by a state of hopelessness, an expectation that desirable outcomes will not occur or that undesirable ones will occur and that the person has no responses available to change this situation - Advantage is that it can deal directly with the Comorbidity of depression and anxiety disorders - If the perceived probability of the future occurrence of negative events becomes certain (a phenomenon called depressive predictive certainty) hopelessness depression develops  ISSUES IN THE HELPLESSNESS/HOPELESSNESS THEORIES: 1. Which type of depression is being modelled? 2. Are the findings specific to depression? B/c of the high correlation between anxiety and depression it is important for theories to document that they are truly about depression and not about negative effect in general 3. Are attributions relevant? Some research states that making attributions is not a process that everyone engages and that people are frequently unaware of the causes of their behaviour 4. The depressive attributional style is a persistent part of the makeup of depressed people; it must already be in place when the person encounters some stressor; some research shows that the depressive attributional style disappears following a depressive episode PSYCHOLOGICAL THEORIES o The manic phase of the disorder is seen as a defence against a debilitating psychological state CANADIAN PERSPECTIVES 8.3 – Aaron Beck – depression is associated with two personality styles: 1. Sociotropy – individuals are dependent on others, especially concerned with pleasing others, avoiding disapproval and avoiding separation 2. Autonomy – achievement-related construct that focuses on self-critical goal striving, a desire for solitude, and freedom from control  Revised Sociotropy-Autonomy Scale (SAS-R) assesses Sociotropy and two aspects of autonomy: a preference for solitude and independence  Blatt psychoanalytic perspective, suggested that introjective and anaclitic personality styles are associated with vulnerability to depression. The anaclitic orientation involves excessive levels of dependency on others. The introjective orientation involves excessive levels of self-criticism. Blatt developed the Depression Experiences Questionnaire (DEQ) to assess dependency and self-criticism  Strong association between self-criticism and depression and a weaker but still significant link between dependency and depression  Hewitt and Flett found that depressed people had elevated levels of self-oriented(high personal standards) and socially prescribed (expectations imposed on the self by others) perfectionism  Substantive research approaches: 6 1. Congruency hypothesis – reflects the diathesis-stress approach; if a non-depressed person with a personality style that makes them vulnerable to depression also experiences a negative life event that is congruent with their vulnerability in some way then this person will becomes depressed; highlights the distinction between interpersonal and achievement-based vulnerabilities 2. the Self-Critical Perfectionism Scale (SCPS) that incorporates items from measures of self- criticism, autonomy and perfectionism; among clients with MDD and various anxiety disorders, depressed and social anxiety disorder groups reported the highest levels of self-critical perfectionism, relative to other clinical groups and a control group FOCUS ON DISCOVERY 8.2 – The measurement of stress generation involves making the distinction between independent events (i.e. not due to oneself) and dependent events (i.e. stemming from personal choices or actions dependent on the self) BIOLOGICAL THEORIES OF MOOD DISORDERS GENETIC VULNERABILITY o bipolar disorder is one of the most heritable of disorders, the concordance rate is 85%; the genes account for ~85% of the variance in whether a person becomes manic o Genetic factors do not determine when manic symptoms will occur. The risk for mania is apparently also related to a higher risk for depression o relatives of unipolar probands are at increased risk for unipolar depression; however, this risk is less than the risk among relatives of bipolar probands o within bipolar disorder, variation in the brain-derived neurotrophic factors (BDNF) gene appears to predict risk for developing rapid cycling o some people seem to be genetically predisposed to the onset of MDD when confronted with a series of adverse life events o Caspi  people who possess one or two copies of the short variant of the 5-HTTLPR (serotonin transporter) gene, which is involved in modulating serotonin levels, experienced higher levels of depression and suicidality following a recent stressful event o In abused children, depression severity was predicted by an interaction of the 5-HTTPLR (short allele) with the brain-derived neurotrophic factor (Val/Met) genotype, especially in children receiving low social support (a gene-gene interaction) NEUROCHEMISTRY, NEUROIMAGING & MOOD DISORDERS o Most studied neurotransmitters are Norepinephrine, serotonin, and dopamine o Original theory – low levels of Norepinephrine and dopamine lead to depression and high levels to mania. The serotonin theory suggests that serotonin, a neurotransmitter presumed to play a role n the regulation of Norepinephrine, also produces depression and mania o 1950s two groups of drugs, were found effective in relieving depression 1. Tricyclic drugs (i.e. Tofranil) are a group of antidepressant medications so names b/c their molecular structure is characterized by three fused rings. They prevent some of the reuptake of Norepinephrine, serotonin, and/or dopamine by the presynaptic neuron after it has fired, leaving more of the neurotransmitter in the synapse so that transmission of the nerve impulse is made easier 2. Monoamine oxidase (MAO) inhibitors (i.e. Parnate) are antidepressants that keep enzymes monoamine oxidase from deactivating neurotransmitters, thus increasing the levels of serotonin, Norepinephrine, and/or dopamine in the synapse; compensating for the abnormally low levels of these neurotransmitters in depressed people o Newer antidepressant drug – selective serotonin reuptake inhibitors (Prozac) act more selectively; inhibiting the reuptake of serotonin o The therapeutic effects of tricyclics and MAO inhibitors do no depend solely on an increase in levels of neurotransmitters – earlier findings were correct – tricyclics and MAO inhibitors do indeed increase levels of Norepinephrine, serotonin, and/or dopamine when they are first taken, but after several days the neurotransmitters return to their elicit levels o Both tricyclics and MAO inhibitors taken from 7-14 days to relieve depression, but by the time, the neurotransmitter levels has already returned to its previous stage 7 o Lithium, the most widely used and effective treatment
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