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Chapter 8

PS280 Chapter 8 - Mood Disorders and Suicide.docx

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Wilfrid Laurier University
Camie Condon

C HAPTER 8– M OOD D ISORDERS AND S UICIDE H ISTORICAL PERSPECTIVE  Ancient times: all mental disorders were explained as possession by supernatural forces.  Greek era: mental disorders were explained using scientific approaches o Hippocrates lived at the time of Hellenic enlightenment, when great advances were made in all areas of knowledge o He applied Empedocles’ humoral theory to mental disorders proposed that:  “exaltation” (mania) was caused by an excess of warmth and dampness in the brain  “melancholia” (depression) was caused by an excess of black bile, which could be seen as a heavy residue in the blood or discolorations on the skin th  17 century: clinicians attempted to cure melancholia by draining blood from patients in attempt to rebalance the body’s humours (i.e. “bloodletting”)  Roman times: philosophers came to recognize the importance of emotional factors in causing depression. o Cicero stated that “perburtations of the mind may proceed from a neglect of reason” o Cicero was also the first to suggest psychotherapy as a treatment for melancholia th  4 century: Christian church predominated Western thinking, and supernatural explanations for mental disturbance (e.g. possession by the devil) o Natural theories of mental illness did not re-emerge in any serious way until the 17 century o Robert Burton’s Anatomy of Melancholy provided a detailed and scholarly account of the psychological (e.g. fear, solitude) and social (e.g. poverty) causes of depression that is still read today.  Modern Age: Emil Kraeplin began the modern age of theories about the etiology of depression. o Emil defined the word manic-depression and described both depressive and manic forms of this disorder o His description formed the basis for the definition of the mood disorders contained in DSM-IV- TR D IAGNOSTIC ISSUES  Mood disorder: an altered mood state severe enough to interfere with a person’s social and occupational functioning, and whose range of symptoms is not limited to the person’s feelings, but affects other bodily and behavioural systems as well.  Common symptoms of depression and mania: o Feeling sad, depressed, or “down” o Feel less interested in the things you usually enjoy o Feeling exhausted or fatigue o Opposite feelings: excited, “high”, more energy to do activities than usual, etc.  These symptoms demonstrate that almost everyone goes through transient periods of feeling down and “depressed” as well as through periods of feeling high and “on top of the world”  What distinguishes these feelings from the mood changes seen in clinical mood disorders are: duration and their severity, and to be diagnosed with mood disorder, several symptoms must co-occur. Example: o The DSM-IV-TR for major depressive disorder symptoms of depression:  Duration – must be present for most of the day, more days than not, for at least two weeks.  Severity – require more than an hour to fall asleep every night or nearly every night.  Co-occur – Include nine symptoms of which five must be present to achieve a diagnosis.  Note: DSM-IV-TR criteria represent arbitrary categorical conventions; there is nothing magical about five symptoms or the duration criteria.  Dr. Kenneth Kendler  depression, by its nature, is a continuous phenomenon, and that individuals with four (or three) symptoms may still suffer considerably.  Mood disorders are classified into two broad categories: unipolar and bipolar. 1. UNIPOLAR M OOD D ISORDERS  Unipolar mood disorders: involve a change in mood in the directions of depression, exclusively in the negative direction.  Unipolar mania is rarely seen. The two unipolar mood disorders are major depressive disorder and dysthymic disorder. A) Major Depressive Disorder Definition  Major depressive disorder (MDD): characterized by persistent feelings of sadness, loss of interest or ability to feel pleasure, unexplained weight loss, difficulty sleeping, fatigue, difficulty concentrating, feelings of worthlessness or guilt, suicidal thoughts, and either agitation or slowing down. o often referred to as the “common cold” of mental disorders because it’s so prevalent  It’s the leading cause of disability worldwide and is the second-leading contributor to the global burden of disease.  The use of the word depression when most of us describe feeling “depressed” is referred to very mild and transient states.  People with MDD may be accused of “faking it” to get attention and may be labelled as “weak” or even morally inferior.  MDD is a very real and serious disorder that involves abnormalities in all systems (biological, emotional, cognitive, and behavioural) and can impair functioning in all areas of a person’s life (physical, occupational, educational, and relational).  To be diagnosed with MDD, the person must show a persistent sad mood and/or a lack of pleasure or enjoyment in activities for at least two weeks. o Must be accompanied by at least four additional symptoms, including disturbances in sleeping or eating (either too little or too much), lack of energy, psychomotor retardation or agitation, difficulty concentrating or making decisions, feelings of worthlessness or guilt, and thoughts of death or suicide. Diagnostic Specifiers  Major depression is a heterogeneous syndrome that has wide individual variability in the symptoms that are expressed during episodes.  Subtypes include: 1. Melancholic  Has symptoms of extreme anhedonia (i.e. lack of interest or pleasure in people and activities)  These patients’ moods do not brighten in response to positive stimuli (e.g. jokes, good news)  They display at least three additional symptoms including:  Loss of appetite or significant weight loss  Insomnia  Marked psychomotor retardation or agitation  Diurnal variation (mood is experienced as qualitatively different than loneliness or grief)  Controversial topic: some research simply say it represents the severe end of the continuum of depression and isn’t a qualitatively distinct subtype, but recent research says it is distinct from other forms of depression  Patients with melancholic depression are more likely than those with non-melancholic to have a family history of a mood disorder and a history of trauma in childhood.  Melancholic is also less likely to be triggered by severe stress. 2. Atypical (most common subtype)  Involves “reverse vegetative features” – symptoms seen in atypical depression are opposite to what has historically been seen as “typical” in MDD.  These patients show mood reactivity, such that their mood brightens in response to positive events  They also display:  Increased appetite and weight gain  Hypersomnia (instead of the more typical insomnia)  Leaden paralysis (a heavy, leaden feeling in their arms and legs)  Interpersonal rejection sensitivity  They respond preferentially to the monoamine oxidase inhibitor (MAOI) class of antidepressant medications.  The depressive episodes of individuals with seasonal affective disorder (SAD) also involve atypical symptoms. 3. Psychotic  Patients who experience psychotic symptoms are limited to his or her episode(s) of MDD.  Symptoms typically involve:  Delusions and/or hallucinations with depressive themes o E.g. auditory hallucinations that comment negatively or command the person to kill themselves.  Persecutory delusional beliefs o E.g. they are the source of all that is bad in the world o Helped by low doses of antipsychotic medication in addition to standard antidepressant therapies 4. Catatonic (very rare)  Patients who are characterized by symptoms such as those seen in catatonic schizophrenia  These symptoms must be limited to the patients’ depressive episode(s) to qualify for a diagnosis of MDD  They display:  Motionless for hours at a time  Vigorous, random, or strange movements (e.g. bizarre facial contortions)  Seen most often in the depressive phase of bipolar I disorder  Treatment involves hospitalization and standard pharmacological treatments for mood disorders. Electroconvulsive therapy is also often used. Prevalence and Course  MDD affects 5% of the population and often suffer from comorbid mental disorders such as anxiety disorders. o Patients with comorbid disorders experience a more severe and chronic depression, and they show a slower and less complete response to treatment  Major depression is associated with significant occupational and interpersonal impairments, physical illness, disability, and death.  Main factor that accounts for the impact of MDD is the disorder’s recurrent course.  Periods of wellness between episodes become shorter and shorter as the disorder progresses; the episode themselves last between 6-9 months, on average (can last for years).  More and more sufferers are having their first onset at childhood and adolescence.  Adolescence is also the time when sex differences in major depression incidence emerge. o Dr. Ronald Kessler  rates of depression grow steadily and equally for both sexes throughout childhood but then begin to diverge at about age 10. o Rates of depression increases for girls throughout adolescence, but drops for boys. B) Dysthymic Disorder  Dysthymic disorder: chronic low mood, lasting for at least two years, along with at least three associated symptoms.  Prevalence in the population is about 3% and experience recurrent episodes of MDD superimposed on their chronic low mood.  Other presentations of chronic low mood are seen clinically: o Chronic major depression o Major depression with poor inter-episode recovery  Involves episodes of major depression that fail to remit successfully, thus leading to a chronic dysthymia- like state between episodes.  Dr. Daniel Klein  proposed that chronic depression has: o higher levels of impairment, o a younger age of onset, o higher rates of comorbidity, o a stronger family history or psychiatric disorder, o lower levels of social support, o higher levels of stress, and o higher levels of dysfunctional personality traits than does episodic major depression  individuals with chronic depression are less likely to respond to standard depression treatment than are those with episodic major depression  Dr. James McCullough  developed the Cognitive-Behavioural Analysis System of Psychotherapy( CBASP) for chronic depression 2. BIPOLAR M OOD DISORDERS Definition: Mania and Hypomania  Mania: distinct period of elevated, expansive, or irritable mood that lasts at least one week and is accompanied by at least three associated symptoms. o Symptoms include:  Increased energy  Decreased need for sleep  Racing thoughts  Pressured speech  Problems with attention and concentration o Judgment is impaired and these patients may go on spending sprees, engage in substance abuse, or risky sexual behaviour. o They may feel special in some way, or they have been “chosen” to fulfill a special mission. o At first, the symptoms they experience may be enjoyable and intoxicating, feel that they are energized to get a lot of things done, focused, and these positive side of mania may prevent them from seeking treatment, or delay medication if they are in treatment. o As the episode progresses, symptoms may become more severe and start to experience them as disturbing and frightening; can experience a break with reality or, psychosis.  Hypomania: less severe form of mania that involves a similar number of symptoms to mania, but those symptoms need to be present for only four days. o symptoms include high successful productivity o people with bipolar II are reluctant to take mood-stabilizing medication because they experience hypomania as enjoyable  For both disorders, the episodes typically last between two weeks and 4 months, while the depressive episodes last between 6-9 months, as in unipolar depression.  Rates of suicide range between 10-15%, similar to unipolar depression. Bipolar I and Bipolar II  Bipolar I: o An individual has a history of one or more manic episodes with or without one or more major depressive episodes. o Lifetime prevalence rate is about 0.8% (don’t differ between men and women)  Bipolar II: o A history or one or more hypomanic episodes with one or more major depressive disorders. o More difficult diagnose than bipolar I because hypomanic episodes are not as severe as manic o Lifetime prevalence rate is about 0.5% (don’t differ between men and women)  For both: o DSM-IV-TR states that the mean age of onset is 20 years o Now, more people are reporting their onset in childhood, and current estimates place prevalence of 0.5% in children, however, children tend to have a rapid-cycling or mixed-cycling pattern, and are underdiagnosed due to a lack of understanding about paediatric bipolar disorder. Cyclothymia  Cyclothymia: chronic, but less severe form of bipolar disorder – involves a history of at least two years of alternating hypomanic episodes and episodes of depression that do not need the full criteria for major depression.  Lifetime prevalence is 0.4-1%, and the rate is equal in men and women, but women more often seek treatment.  Individuals with Cyclothymia don’t often seek treatment as the mood swings are relatively mild and hypomanic episodes are enjoyable.  They are at risk for developing full-blown bipolar disorder Rapid Cycling Bipolar Disorder  Rapid-cycling bipolar disorder: defined as the presence of four or more manic and/or major depressive episodes in a 12-month period.  the episodes must be separated from each other by at least 2 months of full or partial remission, or by switch to the opposite mood state (i.e. mania  depression, or vice versa)  patients have higher rates of disability and lower rates of response to treatment with this disorder  rapid-cycling can be induced, or made worse, by antidepressant medications  it’s important for patients who are receiving antidepressant treatment to also receive a mood stabilizer (e.g. lithium)  types of cycles: o ultrarapid – cycling every few days o ultradian – cycling that occurs daily  ^These additional specifiers (descriptors of a patient’s condition) aren’t present in the DSM-IV-TR. SEASONAL AFFECTIVE D ISORDER  Seasonal affective disorder (SAD): can occur in both unipolar and bipolar disorder and is characterized by recurrent depressive episodes that are tied to the changing seasons. o In northern latitudes, episodes generally occur in the winter months o In southern latitudes, episodes tend to occur in the summer months  11% of patients with major depression have SAD  Prevalence in Canadian population is 2-3% compared with Europe of 1.3-3%.  Early research says the seasonal pattern of SAD focused on melatonin, a hormone that is secreted at night by the pineal gland o As the sun provides increased light in the morning, melatonin release is lowered o This causes body temperature to rise, triggering body processes to move to their awake state o Patients with SAD may need more light to trigger decreased melatonin secretion o In winter, nights grow longer and melatonin levels remain high, making patients with SAD continue to sleep or feel drowsy when awake (phenomenon known as “phase-delayed circadian rhythm”)  Lam-Levitan  argued that medications that suppress melatonin weren’t defective in relieving symptoms of SAD. o The 24-hour winter melatonin rhythm doesn’t differ between individuals with and without SAD M OOD D ISORDER WITH P OSTPARTUM O NSET  70% of women experience mood swings and feelings of depression up to two weeks after child birth.  In most new mothers these symptoms resolve themselves over time and don’t impair functioning  For some mothers, the mood swings are chronic and severe to meet the criteria for a major depressive or manic episode  Common symptoms of mood disorder with postpartum onset include: o Panic attacks o Sleep disruption o Intrusive thoughts about harming themselves or their babies  In rare cases, postpartum mood episodes can include psychotic symptoms such as hallucinations to kill the infant  Postpartum depression affects women similarly across cultures and socio-economic levels  Risk factors include: o A family history of depression o A history or previous depressive episodes o A poor marital relationship and low social support o Stressful life events concurrent with, or immediately following, childbirth  Progesterone is also a causative factor: o The waste product of progesterone acts like a barbiturate drug in the brain, and the very rapid withdrawal of progesterone occur with the delivery of the placenta.  This disorder not only affects the mother, but the current and future children as well.  Postpartum depression also changed women’s future child-bearing plans significantly, choosing adoption, abortion, or even sterilization. ETIOLOGY  There is no single cause for the mood disorders, and they’re likely caused by an interaction of a number of risk factors at a number of levels of analysis. PSYCHOLOGICAL AND ENVIRONMENTAL C AUSAL F ACTORS Examines how variables such as temperament and personality, dysfunctional thinking, and maladaptive interpersonal behaviour patterns contribute to the causes of mood disorders. Psychodynamic Theories  First developed by Sigmund Freud and Karl Abraham  their model drew a parallel between depression and grief  Freud noted that mourners regress to the oral stage of development, which allows them to regain the lost loved one symbolically by merging their identities with that of the lost person. If not, then they develop depression. o Symptoms that are similar in both acute grief and depression include: weeping, loss of appetite, difficulty sleeping, loss of pleasure in life, and withdrawal.  Individuals most likely become depressed following a loss are those whose needs either were not met or were excessively met, during the oral stage.  Imagined loss: the individual unconsciously interprets other types of events as severe loss events. o Even a failure at work could be interpreted as a loss (e.g. loss of esteem) o These events serve as catalysts for the development of depression  Relationships between parents and children are important in shaping a child’s temperament, and that neglectful parenting confers a strong risk for later depression.  Individuals with a temperamental vulnerability to depression do interpret life events as having a greater impact, and these events are more strongly related to depression than they are in individuals who don’t have this pre-existing vulnerability.  John-Bowlby  studied how disruptions in early parent-child attachment could affect personality development and confer vulnerability to depression. He proposed three styles: 1. Secure attachment: exhibit minimal distress when separated from their moms 2. Avoidant attachment: avoids parents, and when offered a choice, will show no preference between a caregiver and a complete stranger 3. Anxious/ambivalent attachment: become very distressed when parents leave and cling desperately to them when they return  These lead to “internal working models”, which guide the individual’s feelings, thoughts, and expectations in their relationships throughout life. Cognitive Theories  Aaron T. Beck  one’s emotional response to a situation is determined by the manner in which that situation is appraised or evaluated.  People with depression and people prone to depression, are more likely to appraise situations negatively than those not prone to depression, and will be more likely to experience negative mood in response to such situations.  Cognitive distortions to situations include: o All-or-nothing thinking: you see things in black-or-white categories. If your performance falls short of perfect, you see yourself as a total failure. o Overgeneralization: you see a single negative event as a never-ending pattern of defeat by using words such as “always” or “never” when you think about it. o Magnification (catastrophizing): you exaggerate the importance of your errors or problems o Jumping to conclusions: you interpret things negatively when there are no definite facts to support your conclusion.  According to Beck’s model, depressed person’s negative cognitive style is the depressive schema – the cognitive triad. o Schemas develop from our early experiences with the world and represent stored memories, images, and thoughts from these experiences. o Depressed individuals’ schemas consist of tightly interrelated negative core beliefs about the self, world, and future that are readily activated by events in the environment and impermeable to change.  Beck’s cognitive model of Diathesis-stress Model proposes that the negative cognitive schemas of the depression-prone person remain inactive in the mind, and thus serve as silent vulnerability factors that don’t express themselves until activated by a stressful life event that matches the theme of the schema. Interpersonal Models  Social signs of depressed people: o Have deficient social skills in relation to non-depressed people. o Interactions with others are often negative, involving the exchange of anger and depressed feelings. o Engage less in frequent eye contact, have less animated facial expressions, and show less modulation in their tone of voice.  A particular type of impaired social skill – negative feedback seeking – may serve as a risk factor for depression. o Negative feedback seeking: tendency to actively seek out criticism and other negative interpersonal feedback from others o This theory states that the need to obtain this info, which is consistent with the depressed person’s own self-schemas, overrides the pain of receiving negative feedback.  Excessive interpersonal dependency, excessive need for interpersonal attachment, support, and acceptance leads to behaviours that cause and maintain depression.  Excessive reassurance seeking: tendency to repeatedly seek assurance about one’s worth and lovability from others, regardless of whether such assurances have already been provided. o Coyne’s interpersonal model of depression: the depression-prone person may excessively seek reassurance after a negative event, such as an argument. o Even when given reassurance, the depressed person doubts its sincerity and continues to demand more reassurance.  Stress generation hypothesis: depressed individuals have been found to generate and contribute to the occurrence of stressful life events in the interpersonal domain, including fights, arguments, and interpersonal rejection. Life Stress Perspective  Stressful life events tax our psychological and physical resources and can cause significant increases in sadness, anxiety and irritability.  Stressful life events for some people can trigger a downward spiral into major depression focusing on three questions:  What characteristics of life events are most strongly associated with major depressions?  What characteristics of individuals place them at risk for developing major depression in the face of life events?  What characteristics of individuals confer resilience in the face of life events?  Individuals with depression were nearly 3x more likely than those without depression to have experienced a stressful life event prior to onset  Nearly 75% of major depressed people have suffered at least one severe loss event in the 3-6 months prior to onset of their depression.  Certain individuals possess characteristics that predispose them to be more sensitive to the effects of stressful life events  A study of monozygotic and dizygotic twin pairs found that individuals at the highest genetic risk for depression were more than twice as likely to develop depression in the face of a severe life event; the genetic risk sensitized these high-risk individuals B IOLOGICAL C AUSAL FACTORS Genetics  Both unipolar major depression and bipolar disorder run in families and this is evident by interviewing family members of people who have the disorder  It is estimated that first degree relatives of people with unipolar depression are 2-5 times more likely to develop depression than are individuals from the general population  For bipolar disorder, the link is even stronger – first degree relatives of people with bipolar have a 7-15 times greater risk of developing any mood disorder than the general population  However, these studies don’t prove that this link is genetic; family members also share the same environment, and environmental influences are very strong in promoting risk for mood disorders o Environmental vs. genetic contributions to mood disorders:  Adoption study – higher rates for bipolar disorder in biological parents of affectively ill adoptees compared to the adoptive parents  Twin study – identical twins share 100% of their genetic material, whereas fraternal twins share 50% just like regular siblings. MZ twins have higher rates than DZ twins for bipolar disorder and unipolar major depression  Hereditary estimates are an indication of the relative contributions of differences in genetic and non-genetic factors to the total variance in the disorder in a population.  There is no single “mood disorder gene”, but the alleles, located
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