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Chapter 7

Abnormal Psych Chapter 7.docx

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York University
PSYC 3140
Kendra Thomson

1 Abnormal Psych Chapter 7- Mood disorders - For most people, their moods pass after a few days - Case of Katie: o had social anxiety, didn’t interact with people at school, became depressed. Later in life- she learned that on days when she feels really bad, she knows didn’t feel that way yesterday and probably wont the next day- its like the changing weather; it will pass. o Began drinking wine at dinner with permission of parents to calm her, then began drinking herself to sleep, thoughts of suicide so began severing relationships. o She attempted suicide and promised her parents that she would not do it again even though the thoughts remained with her - Katie’s depression is outside realm of normal experience bc of intensity and duration o Her severe/ “clinical” depression interfered with functioning o Experienced several psychological and physical symptoms that accompany clinical depression o AN OVERVIEW OF DEPRESSION AND MANIA: - in DSM-III- disorders were categorized under different general labels: “depressive disorders”, “affective disorders”, “depressive neuroses”- grouped under mood disorders bc characterized by gross deviations in mood - depression and mania either singly or together contribute to all mood disorders - most commonly diagnosed/most severe depression = a major depressive episode o DSM-IV-TR: an extremely depressed mood state that lasts at least 2 weeks and includes cognitive symptoms (feeling worthlessness and indecisive) and disturbed physical functions (altered sleeping patterns, changes in weight/appetite, notable loss of energy) to the point where slightest activity or movement requires overwhelming effort o General loss of interest and ability to experience any pleasure from life, including interactions with family/friends ad accomplishments at work/school o Loss of ability to experience pleasure = anhedonia o Physical changes (called somatic or vegetative symptoms) are central to this disorder bc strongly indicate full major depressive episode o If untreated- avg duration = 9 months - Second fundamental state in mood disorders is abnormally exaggerated elation, joy euphoria. - Mania: individuals find extreme pleasure in every activity; some describe it as a continuous sexual orgasm………… 2 o Become extraordinarily active (hyperactive), require little sleep, may develop grandiose plans, believing they can accomplish anything they desire o Proposed change in DSM-V: highlight this feature by adding “persistently increased ctivity or energy” to “A” criteria. o Speech typically very rapid and may be incoherent- indiv trying to explain so many exciting ideas at once – flight of ideas o DSM-IV-TR criteria for manic episode:  duration- of only once a week, less if episodes are severe enough to require hospitalization. This can occur for ex. if indiv engages in self-destructive buying sprees, charging thousands of dollars in expectation of making millions of dollars the same day.  Irritability often part of manic episode, usually near the end  Being anxious/depressed commonly part of mania  Avg duration of untreated manic episode = 2-6 months  DSM-IV-TR defines hypomanic episode: less severe version of manic episode that does not cause marked impairments in social or occupational functioning (hypo = below episode is below the level of manic episode) THE STRUCTURE OF MOOD DISORDERS: - indivs experiencing either depression or mania have unipolar mood disorder- mood remains at one “pole” of usual depression- mania continuum - mania by itself = extremely rare; most people with unipolar mood disorder has depression - if alternate btw depression and mood disorder- have bipolar mood disorder- traveling from one “pole” to the other and back again o label is somewhat misleading because depression and elation may not be at opposite ends of same mood state; though related, they are often relatively independent. o Indivs can experience manic symptoms but feel somewhat depressed or anxious at the same time- this combo = dysphoric manic or a mixed episode: the indiv usually experience such symptoms of mania as being out of control or dangerous and become anxious or depressed about them. o Manic episodes are characterized by dysphoric (anxious or depressive) features more commonly than was thought and dysphoria can be severe o Study: two-thirds of patients with bipolar depressed episodes also had manic symptoms, most often racing thoughts (flight of ideas) distractibility and agitation. Patients also severely impaired than those without concurrent depression and manic symptoms. The rare indiv who suffers from manic episodes alone also meets criteria for bipolar mood disorder bc experience shows that most of these indivs can be expected to become depressed at a later time. 3 o DSM-5: term “mixed episode” will be eliminated in favour of specifying whether a predominately manic or predominantly depressive episode is present, and then noting “with mixed features” to be more precise DEPRESSIVE DISORDERS: Clinical Descriptions: - most easily recognized mood disorder is major depressive disorder, single episode: defined by absence of manic or hypomanic episode before or during the episode. An occurrence of just one isolated depressive episode in lifetime is rare - if two or more depressive episodes occurred and were separated by at least 2 months during which individual was not depressed, major depressive disorder, recurrent is diagnosed. - Otherwise, criteria are same for major depressive disorder, single episode. - Recurrence is important for predicting future course of disorder and for choosing treatments. o Usually associated with family history of depression; unlike people experiencing single episodes o As many as 85%of single episode cases experience a second episode and meet criteria for major depressive disorder, recurrent o Study: in first year following an episode, risk of recurrence is 20%, but rises as high as 40% in second year. Therefore, scientists discovered that unipolar depression is often a chronic condition that waxes and wanes over time but seldom disappears. Median lifetime number of major depressive episodes is four to seven. Median duration of recurrent major depressive episodes is four to five months, somewhat shorter than the avg length of the first episode. - Dysthymic disorder: shares many symptoms of major depressive disorder but differs in its course. Symptoms: milder but remain relatively unchanged over long periods of time- sometimes 20-30 years or more. o Defined as persistently depressed mood that continues for at least 2 yrs during which patient cannot be symptom-free for more than 2 months at a time  Differs from major depressive episode in severity, chronicity and number of its symptoms, which are milder and fewer but last longer.  Study: 22% of ppl suffering from dysthymia eventually experience a major depressive episode  Dual depression: - double depression: people who experience both major depression episodes and dysthymic disorder o dysthymic disoder usually develops first (maybe at early age) and then one or more majore depressive episodes occur later- this pattern 4 is important bc associated with severe psychopaholgy and a problematic future course  study: found that 61% of patients with double depression have not recovered from underlying dysthumic disorder 2 years after follow up. Also found that patients who had recovered from superimposed moajor depressive episodes experienced very high rates of relapse and recurrence  ie case of jack: depressed for most of his adult life. In past 20 yrs- longest period he felt normal- or less depressed- was 4-5 days. Was told he had bright future, didn’t beilieve it, always pessimistic and his wife got fed up and divorced him. Later on, Lost all confidence, felt like he couldn’t move, extremely indecisive, hopeless, so started to consider suicide, and then he got fired. After 6 months, major depressive episode resolved and he had returned to chronic but milder state of depressions but realized that his depression would continue if he didn’t get help – he had double depression Onset and duration: - mean age of onset for major depression: 25 yrs for patients who are not in treatment and 29 for people who are in treatment. Avg age of onset is decreasing - prevalence of major depression increases dramatically during adolescent years- especially in girls - incidence of drepression and sonsequent suicide seem to be steadily increasing - greatly increased risk of developing depression in younger people (this is a trend occurring world wide) - length of depressive episodes is variable- some lasting as little as 2 weeks, and in more severe cases, an episode may last for several years with avg duration of first episode being 6-9 months if untreated. - Even in most severe cases, the probability of remission of the episode within one year approaches 90% - Even in cases where episodes last for 5 yrs or longer, 38% can be expected to eventually recover. BUT episodes may not entirely clear up and likelihood of subswquent episode with another incomplete recovery = much higher. This is important for treatment planning bc in these cases, treatments should last longer - Adolescent onset of depression is associated with: o 1) greater chronicity (it lasts longer) o 2) relatively poor prognosis (response to treatment) o 3) stronger likelihood of disorder running in the family - greater prevalence of current personality disorders has been found in patients with early-onset dysthymia than in patients with major depressive disorders or other nonmood disorders 5 - study: rather high rates of dysthymic disorder in children- and 76% later developed major depressive disorder - patients with dysthymic disorder most likely to attempt suicide than comparison group with episodes of major depressive disorder during the 5 year period - other studies prove that almost all children with dysthymia eventually recovered - common for major depressive episodes and dysthymic disorder to co-occur From Grief to Depression: - if someone’s family members dies, people start to experience same symptoms of major depressive episode: anxiety, emotional numbness, and denial. Frequency of severe depression is so high (62%) that mental health professionals (MHP) do not consider it disorder unless symptoms = severe (psychotic features/suicidal ideation or less alarming symptoms that last longer than 2 months) - some indivs require immediate treatment bc incapacitated by symptoms (severe weight loss/no energy) that they cant function - natural grieving processes usually resolved within first several months, maybe a year or longer. Grief often occurs at anniversaries, birthdays etc. - MHP concerned when someone doesn’t grieve after death - When greif lasts longer than normal time, chance of recovering from severe greif after a year without treatment considerably reduces for approx 10-20% of bereaved individuals, normal processes becomes disorder. Here suicidal thoughts increase - Psychological and social factors (history of past depressive episodes) also predict development of normal grief response into a pathological grief reaction or impacted grief reaction - Study: pre-loss dependency was predictive of patholgocial grief reaction following loss of spouse. - Pathological grief symptoms: intrusive memories and distressingly strong yearnings for loved one, and avoiding people aand places that are reminders of loved ones - Cases of long lasting grief: rituals intended to help face/accept death = ineffective - Victims with PTSD: theraputic approach is to help grieving indiv re- experience he trauma under close supervision. Person encouraged to talk about loved one and death, the meaning of loss while experiencing all of the associated emotions until they come to terms with reality (finding meaning in traumatic loss, incorporating positive emotions associated with memories of relationship into negative emotions connected with loss, and arriving at position that person can cope with pain and life will go on) - Research: some say shouldn’t treat pathological grief reaction and depression in same manner- study: dimensions of patholgocial grief could be distinguished from dimension of depression among ppl who experienced loss. Grief dimension showed most improvement in group therapy designed 6 to tract pathological grief reaction. Authors say that clinicians should not assume absense of pathological grief reaction in someone who has lost a loved one, even if person is not displaying depressive symptoms BIPOLAR DISORDERS: - key feature: tendency of manic episodes to alternate with major depressive episodes in an unending roller coaster ride from peaks of elation to depths of despair. - Bipolar disorders are parallel in many ways to depressive disorders- ex. Manic episode may occur only once, or repeatedly. - Case of Jane: o Jane and hypomanic episode, evident in her unbridled enthusiasm, grandiose perceptions, “uninterruptible” speech, and report that she needed bery little sleep, easily distracted, quickly switches from talking about children to talking about book on table. She said she has bipolar disorder. Depressive episodes- in bed for 3 weeks, unable to move for days, children take care of her, later discovered that she killed herself. Then hypomania- could last for months o Jane has bipolar II disorder- major depressive episodes alternate with hypomanic episodes rather than full manic episodes. Hypo= less severe- jane functions well in this mood state o Bipolar I disorder- same but indiv experiences full manic episode. As in criteria set for depressive disorder, for manic episode to be considered separate, they must have symptom-free period of at least 2 months in between them. Otherwise one episode is considered continuation of the last. - Case of billy: o Full manic episode: o Before reached the ward, hear him laughing, carrying deep voice, having wonderful time, saw ping pong table and said “ping pong, I love ping pong, only played twice but fave game, table is gorgeous blah blah blah…”. Then talks about something else that totally absorbs his attention. Previous week, emptied bank account taken his and parents credit cards and bought tons of things. Thought he would make millions renting it out. This episode had precipitated admission to hospital - during manic/hypomanic phase, patient denies problem. In manic episode, so wrapped up in enthusiasm and in expansiveness that their behaviour seems perfectly reasonable to them. - High during manic state is so pleasurable, people stop taking meds during periods of distress or discouragement in attempts to bring on manic state again- SERIOUS CHALLENGE FOR PROFESSIONALS - Like dysthymic disorder, cyclothymic disorder: chronic alteration of mood elevation and depression that does not reach the severity of manic or major depressive episodes. 7 o Tend to be in one mood state or the other for many years with relatively few periods of neutral (or euthymic) mood. o Pattern must last for at least 2 years (1 yr for children/adolescents). Indivs with cyclothymic disorder alternate btw the kids of mild depressive symptoms jack experienced during dysthymic states and the sorts of hypomanic episodes jane experienced. o Behaviour wasn’t severe enough in neither case to require hospitalization or immediate intervention. o Most indivs are just considered moody but chronically fluctuating mood states are substantial enough to interfere with functioning. o People with cyclthymia should be treated bc increased risk to develop more severe bipolar I or II disorders Onset and Duration - avg age of onset for bipolar I disorder = 18 - for bipolar II disorder = 22 - cases of both begin in childhood - somewhat younger than avg age of onset for major depressive disorder and bipolar disorders begin more acutely (more suddenly) - one third of cases begin at adolescents and onset often preceded by minor oscillations in mood or mild cychothymic mood swings. - Only 10-13% of bipolar I becomes bipolar II - Only 5.2% of large group of 381 patietns with unipolar depression experienced a manic episode during 10-yr follow up- other studies say 25%. In any case, if disorders were more closely related, we would expect to see more individs moving from one to the other - Rare for someone to develop bipolar disorder at 40 - When it appears, course is chronic; mania and depression alternate indefinitely - Therapy involves managing disorder with onoing drug regimens that prevent recurrence of episodes - Suicide is all-too-common consequence usually occurring during depressive episodes- estimates of suicide range from 12-48% over a lifetime and rate is approx 20 times higher than for indivs without bipolar disorder - Rates of completed suicide = 4 times higher in people with bipolar disorder than for people with recurrent major depression - Even with treatment, biopolar patients do poorly - In study: only 16% recovered, 52% suffered from recurrent episodes, 16% had become chronically disabled and in one study, 8% committed suicide - In typical cases, cyclothymia is chronic and lifelong o 1/3- ½ of patients cyclothymic mood sings develop into full-blown bipolar disorder o in one study: 60% were females and age of onset was often during teenage years or before (most common = 12-14 yrs) o disorder is often not recognized and sufferers are thought to be high- strung, explosive, moody or hyperactive 8 o one subtype of cyclothymia is based on predominance of mild depressive symptoms, one on predominance of hypomanic symptoms and another on an equal distribution of both Postpartum Depression: - lots of diversity in symptoms of mood disorders - postpartum onset specifier can apply to both major depressive and manic episodes. - Characterized by severe manic or depressive episode that first occur during postpartum period (4 weeks immediately following childbirth) typically 2-3 days after delivery - Postpartum incidence is quite low- 1/1000 deliveries- chance are if new mother experiences severe postpartum episode, approx 50% chance that she will experience another episode with subsequent births - Postpartum depression does not seem to require separate category in DSM- IV-TR o Study: having infant with difficult temperament is an important type of stressor that can contribute to postpartum depression o Study: low SES also related to persistence of postpartum depression after birth o Tragic cases: mother kills newborn child Specifiers Describing Course of Mood Disorders: - 3 specifiers may accompany recurrent mania or depression: o 1) Longitudinal course specifiers:  whether indiv has had major episodes of depression or mania in past is important, as is whether indiv fully recovered btw past episodes  whether patient with major depressive episode had dysthymia before the episode (double depression) and whether the patient with bipolar experienced a previous cyclothymic disorder.  Antecedent dysthymia or cyclothymia predicts decreasing chance of full interepisode recovery, mostly likely, patient will require long/intense course of treatment to maintain normal mood state for as long as possible after recovering from current episode o 2) rapid-cycling specifier:  temporal specifier applies only to bipolar I and II disorders.  Some people move very wuicly in and out of depressive or manic episoes  In indiv with bipolar who experiences at least 4 manic or depressive episodes within a year is considered to have a rapid-cycling pattern- severe variety of bipolar disorder that does not respond well to standard treatments- associated with higher suicide attempts 9  Alternative drug treatments such as anticonvulsants and mood stabilizers may be more effective with this group of patients  Approx 20% of bipolar patients experience rapid cycling. 90% female  unlike bipolar patients in general, most people with rapid cycling begin with depressive episode rather than manic episode.  In most cases, rapid cycling does not seem to be permanent, bc fewer than 3% of patients continue with rapid cycling across 5yr period, with 80% returning to non-rapid cycling pattern within 2 yrs o 3) Seasonal pattern specifier:  Temporal specifer applies to boh bipolar disorders and to recurrent major depressive disorder  Accompanies episodes that occur during certain seasons (winter depression)  Some mood disorders are tied to season of the year- most usual pattern is depressive episode beginning in late fall and ending with beginning of spring.  Seasonal affective disorder (SAD): depressed during winter and manic during summer - Although some studies have reported seasonal cycling of manic episodes, the overwhelming majority of seasonal mood disorders involve depression o Study: prevalence of the seasonal subtype of major depression (ie. Winter depression SAD) was about 3% - People with winter depression tend toward excessive sleep, increased appetite, symptoms shared with atypical depressive episodes- where the opposite occurs. SAD is different from other depressive episodes o Study: differences btw SAD and nonseasonal depressive patients include:  SAD patients scored higher on personality factor called openness which may be why they are prone to experiencing amplified reactions to reduced light level during winter months. o Study: this study did not reveal differential aggregation that would suggest winter depressions are really a separate type of depression - Biological explanations for SAD are beginning to appear o SAD may be related to daily seasonal changes in production of melatonin, hormone secreted by pineal gland. Exposure to light suppresses melatonin production, it is produced only at night. Melatonin production also increases in winter when there is less sunlight.  Theory- increased production of melatonin might trigger depression in vulnerable people o Cardiac rhythms, which are thought to have some relationship to mood are delayed in winter 10 - Prevalence of SAD higher in extreme northern and southern latitudes because there is less winter sunlight. o Study: SAD occurred in 11% of those with depression o Other Study: occurred in 20% of those with depression o Study: inuit community showed markedly elevated rates of SAD o Study: you can genetically adapt to reduced number of daylight hours in their environment, which provides some protection from development of SAD - SAD is quite stable o Study: 86% of people experienced depressive episodes each winter during 9yr period of observation, with only 14% recovery. In more severe cases- depressive episodes occurred during other seasons as well o Study: rates in children- 1.7-5.5%- higher rates in postpubrtal girls PREVALENCE OF MOOD DISORDERS: - prev rates in Canada are quite variable- ranging from 4.1% in Ontario Health Survey to 10.3% and 11% in surveys in Toronto and Calgary respectively - differences in prev rate: o different research methods may account for differing rates of prev o prev rates for depression in Canada appear to be decreasing, suggesting progress in public health efforts towards combating depression in our country - major depressive disorder of 16% lifetime and 6.5% in preceding ten months have been confirmed - women are twice as likely to have mood disorders than men In children and adolescents: - it is not true that depression requires some experience with life- ie. Accumulating negative events or disappointments leading to pessimism. - Evidence that 3 month old babies can be depressed- infants of depressed mothers display marked depressive behaviours (sad faces, slow movements, lack of responsiveness), even when interacting with nondepressive adults. Whether the behaviour or temperament is due to genetic tendency inherited form mother, the result of early interaction patterns with a depressed mother, or a combo is not clear - Mood disorders fundamentally similar in children and in adults- no “childhood” mood disorders in DSM-IV-TR are specific to developmental stages, unlike anxiety disorders. - The look of depression changes with age: o Ie. Children under 3 yrs of age might manifest depression by facial expressions and eating, sleeping and play behaviour quite differently from children btw 9-12 o Study: adolescents who are forced to limit activities bc of illness or injury are at high risk for depression 11 o Depressive disorders occur less frequently in children than in adults but rise dramatically in adolescence when, if anything, depression is more frequent than in adults. o Study: peak annual prev was in group aged 15-25 yrs (5% prev) with lower rates in adult ranges o Evidence shows that in young children, dysthymia is more prevalent than major depressive disorder, but this ratio reverses in adolescence. Like adults, adolescents experience major depressive disorder more frequently than dysthymia. o Major depressive disorder in adults is largely a female disorder as it is in adults, although this is not true for more mild depression. o Only among the adolescents referred to treatment does the gender imbalance exist, though why more girls reach a more severe state requiring referral to treatment is not clear. - In mania: o children below age of 9 seem to present with more irritability and emotional swings rather than classic manic states- often mistaken as being hyperactive o symptoms are more chronic- always present rather than episodic as in adults- this presentation seems to continue through adolescence, although adolescents may appear more typically manic. o Bipolar disorder rare in childhood- although case studies of children as young as 4 have been reported and diagnosis may be mistaken for conduct disorder ot ADHD o Prevalence of bipolar disorder rises substantially in adolescence, which is not surprising in that many adults with bipolar disorder report a first onset during teen years o One developmental diff btw children and adolescents on the one hand and adults on the other is that children, especially boys tend to become aggressive and even destructive during depressive episodes. Thus, childhood depression and mania often misdiagnosed as hyperactivity or conduct disorder where aggression and destructive behaviour are more common. o Conduct disorder and depression co-occur o Successful treatment of underlying depression (or spontaneous recovery) also resolves the associated problems in these specific cases o Adolescents with bipolar may become aggressive, impulsive, sexually provocative and accident-prone o Risk factors of experiencing additional depressive risk factors as adults: conflicts with parents, being female, higher propotions of family members experiencing depressive episodes o Exhibit patters of psychosocial impairments in areas such as: interpersonal functioning, QOL, and occupational performance o Seriousness of adolescent depression in terms of negative consequences continuing in adulthood 12 In the Elderly: - depression = problem in elderly - study: predicted that 18-20% of nursing home residents may experience major depressive episodes - late onset depression associated with: sleep difficulties, hypochondriasis, and agitation. - Difficult to diagnose bc presence of mood disorders complicated by medical illness or symptoms of dementia. (elderly ppl who get physically ill or diagnosed with dementia might become depressed, but signs of depression would be attributed to the illness or dementia and therefore missed) - Prev of major depressive disorder is same or slightly lower in elderly as in general population bc stressful life events that trigger major depressive episodes decrease with age. - Milder symptoms that do not meet criteria for major depressive disorder (MDD) is more common among elderly, maybe bc of illness and infirmity rd - Anxiety disorders frequently accompany depression in elderly (1/3 of cases)- usually GAD and panic disorder, and when they do, patients are more severely depressed - Depression can also contribute to physical disease in elderly- being depressed doubles risk of death in elderly patients who suffered heart attack or stroke. - Symptoms of depression are increasing substantially in growing population of elderly people - Study: As we become frailer and more alone, the psychological result is depression, which increases probability that we will become even frailer and have less social support- vicious cycle is deadly - Gender imbalance in depression disappears after age of 65 - In early childhood boys are more likely to be depressed than girls, but surge of depression in adolescent firls produces imbalance in sex ratio that is maintained until older age Across Cultures: - anxiety takes very physical or somatic forms in some cultures- instead of fear/anxiety, people report stomach aches, heart distress etc. - same tendencies across cultures for mood disorders - feelings of weakness or tiredness particularly characterize depression that is accompanied by mental or physical slowing/retardation - somatic symptoms of depression equivalent across cultures, but difficult to compare subjective feelings. Ways indivs think of depression may be influenced by cultural view of individual and the role of indiv in society. - Individualistic vs. collective cultures- “I feel depressed” vs. “our life has lost its meaning” - Use semistructured interviews where same questions are asked with allowances for different words that might be specific to culture or subculture. 13 - Study: look at figure 7.2- use same structured interview and diagnostic criteria in 10 countries. Highest rates of MD episodes were observed in the U.S. sample, and the lowest in Japanese cultures - Study: structured interview to determine % of adult members of first nations reserves who meet criteria for mood disorders. o Lifetime prev for any mood disorder was 19.4% in men and 36.7% in women and 28% overall- 4 times higher than general pop. - Study: indicates depression is most common psychiatric illness, occurring in 16.5% of 242 Cree people who were receiving treatment by nursing and other MHP. - Social and economic conditions faced by many groups of aboriginal people in NA, and their long history of cultural oppression and marginalization, fulfill all requirements for chronic major life stress- strongly related to onset of mood disorders- particularly MDD. Among the Creative: - genius is allied with madness? - Table 7.2- list of poets who won Pulitzer Prize- all of whom had bipolar and some committed suicide - Many composers, artists and writers speak of periods of inspiration when thought processes quicken, moods lift, and new associations are generated- it is one thing to have lots of energy during manic episode, but another to channel it into direction that creates new works and accomplishes effective tasks - Genetic vulnerability to mood disorders is independently accompanied by a predisposition to creativity. Genetic patterns associated with bipolar disorder may also carry the spark of creativity - Yet another possibility: moderately ill patients were significantly more creative than severely ill patients- creativity may peak at stage of illness where symptoms are moderate but creativity may decline as symptoms are progressive worse ANXIETY AND DEPRESSION: - overlap of anxiety and depression - we know that almost everyone who is depressed, particularly to the extent of having a disorder, is also anxious, but not everyone who is anxious is depressed - certain core symptoms of depression are not found in anxiety, and therefore, reflect what is “pure” about depression. - Core symptoms are inability to experience pleasure (anhedonia) and a depressive “slowing” of both motor and cognitive functions until they are extremely laboured and effortful - Cognitive content usually more negative in depressed indivs than anxious ones - Symptoms that seem central to panic and anxiety- in panic: symptoms reflect primarily autonomic activation (excessive physiological symptoms such as 14 hearth palpitations and dizziness); muscle tension and apprehension (excessive worrying about the future) seem to reflect essence of anxiety - People with depression have symptoms of anxiety or panic. - A large number of symptoms are not specific to either kind of disorder, they are called symptoms of negative affect - Symptoms may be common in both mood states- while worry is broadly associated with both anxiety and depression, rumination is uniquely associated with depression in uni students in Singapore - Table 7.3- symptoms specific to anxiety, to depression, and common in both - Thoughts of maybe combining anxiety and mood disorders into larger category - Symptoms are on a continuum with major depression and anxiety disorders - Example of Katie- severe anxiety often leads to to depression- combo of both - Major depression usually follows anxiety and may be a consequence of it - Individuals with co-morbid depression and borderline personality disorder report greater levels of depressive symptoms than people with depression alone- this is at least partly due to comorbid indivs greater cognitive vulnerability to depression - Like co-occurring anxiety and depression, personality disorders (which are long-standing in nature) tend to develop before depression in people with both disorders. CAUSES OF MOOD DISORDERS: - equifinality: same end product resulting from possibly different causes. o Depressive disorder that arises in winter has a different precipitant than a severe depression following a death, even though episodes might look similar - There are biologifical, psychological, and social factors that seem strongly implicated in the etiology of mood disorders- an integrative theory of etiology of mood disorder considers these 3 factors and notes the very strong relationship between anxiety and depression Biological Dimensions:  familial and genetic influence: - 3 types of strategies help estimate genetic contribution: o 1) family studies: look at prev of given disorder in first-degree relatives of indivdual known to have disorder (the proband)  studies show that both unipolar and bipolar disorder runs in families  despite variability, rate in relatives of probands with mood disorders is consistently about 2-3 times greater than in relatives of controls who don’t have mood disorders.  Increasing severity and recurrence of major depression in proband associated with higher rates of depression in relatives 15  Difficulties with family studies: we cannot separate from true genetic contributions the effects of a common psychosocial environment. This problem is solved with a second study- adoption studies. o 2) adoption studies: look at biological relatives of an individual with a given disorder who was adopted at early age. If genetic contribution exists, adopted probands with the disorder should have more biological relatives with the same disorder than the adopted probands without the disorder  data here is mixed- ex. Some studies report a greater risk of mood disorder among biological relatives of adoptees with a mood disorder  other studies- no greater risk of having mood disorder was found in biological relatives of adopted probands o 3) twin studies: examine frequency with which identical twins have disorder, compared with fraternal twins (sharing only 50% of genes- like all first relatives)  if genetic contribution exists- disorder present in identical twins to much greater extent than fraternal twins  figure 7.3- study showing identical twins is 2-3 times more likely than fraternal twin to present with mood disorder if first twin has mood disorder (66.7% of identical twins/ 18.9% of fraternal twins if first twin has bipolar disorder; 45.6% and 20.2% if first twin has unipolar disorder)  if one twin has unipolar disorder-chances of co-twin having bipolar disorder are slim to none.  Severity related to amount of concordance (degree to which something is shared)  Ie. If one twin had severe depression (3/+ depressive episodes)- 59% of identical twins and 30% of fraternal twins also presented with mood disorder  If less than 3 episodes- concordance rate dropped to 33% (ident) 14% (frat)  Severe mood disorders may have stronger genetic contribution than less severe disorders- this holds true to most psychological disorders  Sex differences in genetic vulnerability to depression  Characteristically higher rate of depressive disorders in women o Women range from 36-44% o Men range form 18-24% o Environmental events play larger role in causing depression in men than in women o In twin studies bipolar disorder confers an increased risk of developing some mood 16 disorders but not necessarily bipolar disorder- if 1 ident twin is unipolar, the other twin has an 80% chance of being unipolar but the disorders are inherited separately and may be separate disorders after all - Evidence suggests disorders are familial and almost certainly reflect at least a small underlying genetic vulnerability- especially for woman - With other psych disorders, unlikely that we will find single dominant gene responsible - Best estimates of genetic contributions to depression fall in rane of approx 40% for women- scientifically less for men - Genetic contributions for bipolar = higher  so 60-80% of causes of depression can be attributed to environmental factors - Behavioural geneticists brake down environ factors into events shared by twins (same upbringing in same house, same stressful events) and events not shared, - Part of our experience causing depression unique non-shared events rather than what is shared, that interact with biological vulnerability  Joint Heritability of Anxiety and Depression: - growing trend to examine heritability of related groups of disorders - close relationship among depression, anxiety and panic o eg. Family studies indicate that more the signs/symptoms of anxiety and depression patient has, the greater the rate of anxiety or deprssion or both in first-degree relatives and children o eg. Study: determined that same genetic factors contribute to both anxiety and depression. Social and psych explanations seemed to account for factors that differentiate anxiety from depression.  Findings suggest that the biological vulnerability for mood disorders may not be specific to that disorder but may reflect a more general predisopostion to anxiety or mood disorders. Specific form of disorder determined by unique psychological, social or additional biological factors  Neurotransmitter Systems: - new findings describing relationship of specific neurotransmitters to mood disorders appear almost monthly and are punctuated by occasional reports of so-called breakthroughs. - Neurotransmitters systems have many subtypes and interact in many complex ways, with one another and with neurmodulators (products of endocrine system) - Low levels of serotonin in etiology of mood disorders , but only in relation to other neurotransmitters, including norepinephrine and dopamine. – apparent primary function of serotonin is to regulate emotional reactions o Ex. More impulsive- our moods swing more widely, when levels of serotonin are low, possibly bc systems involving norepinephrine and 17 dopamine. one of the functions of serotonin is to regulate systems involving norepinephrine and dopamine o “Permissive hypothesis”- when serotonin levels are lose, other neurotransmitters range more widely, become dysregulated and contribute to mood irregularities ie depression (one consequence = drop in norepiephrine)  relationship btw impaired serotonergic transmission in patient with depression only true for more severe patients with suicidal tendencies. o Current thinking: balance of various neurotransmitters and their subtypes is more important than absolute level of any one neurotransmitter - Interest in role of dopamine – its relationship to manic episodes, atypical depression or depression with physical features. o Ex. Dopamine agonist L-dopa produces hypomania in bipolar patients with other dopamine agonists. o Chronic stress reduces dopamine levels- producing depressive-like behaviour  Endocrine System: - noticed patients with diseases affecting this system sometimes become depressed o ex. Hypothyroidism or Cushing’s disease affects adrenal cortex- disease leads to excessive secretion of cortisol and often depression/anxiety - HPA axis: o Axis begins in hypothalamus and runs through pituitary gland which coordinates endocrine system o One of glands influenced by pituitary is cortical section of adrenal gland (adrenal gland produces stress hormone cortisol, which is elevated during stressful life events) o cortisol elevated in depressed patients- makes us consider relationship btw depression and severe life stress - this finding led to development of biological test for depression, the dexamethasone suppression test (DST). Dexamethasone suppresses cortisol secretion in normal subjects but when given to depressed patient, much less suppression noticed and what did occur didn’t last long o in depressed patients, adrenal cortex secreted too much cortisol. Oversecretion thought to overwhelm suppressive effects of dexamethasone in depressed people  important bc promised the first biological lab test for a psychological disorder. But later research demonstrated that indivs with other disorders, particularly anxiety disorders, also demonstrate this nonsuppression effect 18  therefore hard for test to diagnose depression – understanding of role of cortisol in producing depression is overly simplistic o lots of research on this topic- new evidence: neurotransmitter activity in hypothalamus regulates release of hormones that affect the HPA axis. o Neurohormones increasingly important focus of study in psychopathology  Sleep and Circadian Rhythms: - sleep disturbances are hallmark of most mood disorders. - Ppl who are depressed have sig shorter peroiod after falling asleep before rapid eye movement (REM) sleep begins. - Depressed indivs have diminished slow-wave sleep, which is the deepest, most restful part of sleep. - Entering REM sleepmuch more quickly, depressed patience experience REM activity that is much more intense, and stages of deepest sleep don’t occur until later and sometimes not at all. - Not clear whether sleep disturbances also characterize bipolar patients although preliminary evidence suggests patterns of increased rather than decreased sleep - Depriving depressive patients of sleep, particularly in second half of night, causes temporary improvement in their condition, although depression returns when patients start sleeping normally again. o Lit review: sleep deprivation appears helpful for some bipolar disorder patients during depressed phase with no accompanying switches into mania observed. - Bc sleep patterns reflect biological rhythm, relationship may exist among seasonal affective disorder, sleep disturbances in depressed patients and a more general disturbance in biological rhythms. o Surprising if true- bc most mammals are exquisitely sensitive to day length at latitudes at which they live, and this “biological clock” controls eating, sleeping, and weight changes. Thus, substantial disruption in circadian rhythm might be particularly problematic for some vulnerable individuals. - Patients with bipolar disorder and their children(who are at risk for the disorder) show increased sensitivity to light- show greater suppression of melatonin when exposed to light at night - Extended bouts of insomnia trigger manic episodes - Findings suggest that mood disorders may be related to disruptions in our circadian (daily) rhythm o Ex. sleep deprivation may temporarily readjust biological rhythms of depressed patients o Light therapy for SAD may have similar effect o Specific genetic vulnerability to mood disorders related to low levels of serotonin which affects regulation of daily biological rhythms 19 Psychological Dimensions:  stressful life events: - noted that 60-80% of causes of depression could be attributed to psychological experiences - most experiences unique to indiv - stress and trauma are most striking unique contributions to etiology of all psycho disorders o reflected throughout psychopathology and is evident in wide adoption of diathesis-stress model of psychology vulnerabilities - significance of major event is not easily discovered- need to look at context of event and meaning it has for indiv o eg. Losing job = stressful but more difficult for some than others. If can be supported by spouse, not so bad. If aspiring writer who has no time for writing, losing job may be helpful. BUT if single mother of 2… bad o BOTH context of life event and meaning are important- George W. Brown came up with this o Difficult to carry out- methodology is still evolving o Issue- bias inherent in remembering events. Diff answers at diff point of depression- current moods distort to memories, so the only useful way to study stressful life events is to follow ppl prospectively to determine precise nature of events and relation to subsequent psychopatholgy. - Clear that stressful life events strongly related to onset of mood disorders - Severe events precede nearly all types of depression- major life stress is somewhat stronger predictor for initial episodes of depression compared with recurrent episodes. - For people with recurrent depression, clear occurrence of severe life stress before or early in lates episode predicts a much poorer response to treatment and a longer time before remission, and a greater likelihood of recurrence - Context and meaning are probably more important than exact ature of event itself, although breakup of relationship is particularly likely to lead to depression in adolescents o Study: romantic relationships play key role in vulnerability to depression in adolescent girls (LOLZZZZZ) - But not all stressful events are totally independent of the depression o Genetic endowment may increase probability that we will experience stressful life events. This is reciprocal gene- environment model  Ex. Ppl who tend to seek out difficult relationships bc of genetically based personality characteristic that the leads to depression  Ex. Ppl who display problematic social behaviours like complaining too often about personal difficulties to others which results in interpersonal rejection 20  Rejection in turn, serves as trigger for depressive episode (1/3 of association btw stressful life events and depression is not usual arrangement of stress triggering depressio- rather, individuals vulnerable to depression who are placing themselves in high-risk evironments o Relationship of stressful events to onset of episodes in bipolar disorder strong- but several issues may be relevant to etiology of bipolar disorders  1) stressful life events trigger early mania and depression, but as disorder progresses these episodes seem to develop lives of their own. Once cycle begins, psychological or pathophysiological process takes over and ensures disorder continues  2) some precipitants of manic episodes seem to be related to loss of sleep, as in postpartum period, or as result of jet lag, that is, disturbed circadian rhythms.  Most cases of bipolar disorder- stressful life events substantially indicate not only provoking relapse, but also preventing recovery o Although almost everyone who becomes depressed has experienced significant stressful event, most people experiencing such events do not become depressed.  Somewhere btw 20 -50% of indivs who experience severe events become depressed  Thus, 50-80% of indivs do not develop depression or other psych disorders  Strong support in data for interaction of stressful life events with some kind of vulnerability- genetic, psychological or combo - Case of Katie: transition from elementary school to junior high- experien
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