Chapter 6 Mood Disorders and

Transcription

1 Chapter 6 Mood Disorders and Suicide id Rick Grieve, Ph.D. Psy 440: Abnormal Psychology Western Kentucky University Mood Disorders - Overview Characterized by gross deviations in mood Mood enduring states of feeling; pervasive quality of an individual s experience Depression and mania, either singly or together, contribute Mood disturbances are severe or prolonged and impair ability to function Mood Disorders DSM-IV Depressive Disorders (Unipolar) Major depressive disorder Dysthymic disorder Double depression Seasonal Affective Disorder (SAD) Postpartum Onset Depression Types of DSM-IV Bipolar Disorders Bipolar I disorder Bipolar II disorder Cyclothymic disorder

2 Major Depression: An Overview Major Depressive Episode: Overview and Defining Features Extremely depressed mood state lasting at least 2 weeks Cognitive symptoms (e.g., feeling worthless, indecisiveness) Vegetative or somatic symptoms Central to the disorder. Anhedonia Loss of pleasure/interest in usual activities Major Depressive Disorder Single episode Highly unusual Recurrent episodes More common DSM-IV Diagnostic Criteria for Major Depression Five or more of the vegetative symptoms present during the same two-week period and represents a change from previous functioning Cannot meet criteria for a Mixed Episode Symptoms cause clinically significant distress or impairment in social, occupational, or educational functioning not due to the direct physiological effects of a substance not better accounted for by Bereavement Differential Diagnosis Dysthymia: An Overview Overview and Defining Features Defined by persistently depressed mood that continues for at least 2 years Symptoms of depression are milder than major depression Symptoms can persist unchanged over long periods (e.g., 20 years or more) Facts and Statistics Late onset Typically in the early 20s Early onset Before age 20, greater chronicity, poorer prognosis

3 Double Depression: An Overview Overview and Defining Features Person experiences major depressive episodes and dysthymic disorder Dysthymic disorder d often develops first Facts and Statistics Quite common Associated with severe psychopathology Associated with a problematic future course Seasonal Affective Disorder Mostly winter-linked form of depression Symptoms Prevalence Rate Treatment Bipolar I Disorder: Overview Famous People with Bipolar Disorder Winston Churchill Lord Byron Virginia Woolf Edgar Allen Poe Napoleon Bonaparte Vincent van Gogh Robin Williams Patty Duke Jane Pauley

4 Bipolar I Disorder: Overview Overview and Defining Features Alternations between full manic episodes and depressive episodes -Manic episode: distinct period of time (1 wk. min.), abnormal & persistently elevated, expansive or irritable mood Facts and Statistics Average age on onset is 18 years, but can begin in childhood Tends to be chronic Suicide is a common consequence Bipolar I Disorder DSM-IV Diagnosis currently meets criteria for manic, hypomanic, mixed or depressive episode previously had at least one manic episode or mixed episode symptoms s cause clinically ca significant distress or impairment in social, occupational, or other important areas of functioning not better accounted for by Schizoaffective D/O, Delusional D/O, or Psychotic D/O NOS not due to the direct physiological effects of a substance Bipolar II Disorder: Overview Overview and Defining Features Alternations between major depressive episodes and hypomanic episodes Hypomanic same as mania but less severe (4 days vs 1 wk; doesn t impair functioning) Facts and Statistics Average age of onset is 18 years, but can begin in childhood Only 10 to 13% of cases progress to full bipolar I disorder Tends to be chronic

5 Bipolar Disorder Prevalence rates Country Age Dx Lifetime 12-month China Bipolar I/II 0.1 Germany Any Bipolar Bipolar I Bipolar II Japan >19 Bipolar I/II 0.1 Lebanon >17 Bipolar 2.4 Mexico Bipolar I/II 1.9 New Zealand Bipolar 1.8 Nigeria >17 Bipolar I/II Switzerland Bipolar I/II 1.7 United States >11 Bipolar I >54 Bipolar I/II >17 Bipolar I >17 Bipolar II >17 Subthreshold 2.4 Bipolar Disorder Associated features Course Causes Childhood Bipolar Disorder Different from adult presentation of symptoms Cyclothymic Disorder: Overview Overview and Defining Features More chronic version of bipolar disorder Manic and major depressive episodes are less severe Manic or depressive mood states persist for long periods Pattern must last for at least 2 years (1 year for children and adolescents) Facts and Statistics Average age of onset is about 12 or 14 years Cyclothymia tends to be chronic and lifelong Most are female High risk for developing bipolar I or II disorder

6 Mood Disorders: Additional Facts and Statistics Lifetime Prevalence About 7.8% of United States population at any one time 19 million people per year 20% lifetime prevalence Likelihood of subsequent depression increases with each episode Sex Differences Females to males - 2:1 up to age 65 then gender imbalance disappears Bipolar disorders are distributed equally between males and females Mood Disorders: Additional Facts and Statistics Mood Disorders are similar in children and adults but symptoms are developmentally linked Prevalence similar across subcultures Most persons w/depression are anxious, not all people w/anxiety are Depressed Mood Disorders: Familial and Genetic Influences Family Studies Mood disorder rates high in first degree relatives Relatives of persons with bipolar are more likely to have unipolar depression Twin Studies Concordance rates for mood disorders high in identical (MZ) twins Severe mood disorders have a stronger genetic contribution Heritability rates are higher for females compared to males Vulnerability for unipolar or bipolar disorder appear to be inherited separately

7 Figure 7.3 Mood disorders among twins Mood Disorders: Neurobiological Influences Neurotransmitters Biogenic amine hypothesis Low levels of serotonin relative to other neurotransmitters Mood disorders are related to low levels of serotonin The permissive hypothesis and the regulation of neurotransmitters Mood Disorders: Neurobiological Influences Endocrine System Elevated cortisol levels (stress hormone) Sleep Disturbance Hallmark of most mood disorders Relation between depression and sleep uncertain

8 Mood Disorders: Psychological Influences (Stress) The Role of Stress in Mood Disorders Stress is strongly related to mood disorders Frequent precipitator Return of diathesis-stress and reciprocal-gene environment models Mood Disorders: Psychological Influences Learned Helplessness - Seligman Lack of perceived control over life events contributes to viewing self as helpless to control Learned Helplessness and a Depressive Attributional Style Internal attributions Negative outcomes are one s own fault Stable attributions Believing future negative outcomes will be one s fault Global attribution Believing negative events will disrupt many life activities All three domains contribute to a sense of hopelessness TYPES OF ATTRIBUTIONS Stable Global INTERNAL I am so incompetent that I will never get hired. EXTERNAL The job interview is such an unfair way to assess the competence of prospective employees. I never interview well when I That interviewer likes to ask Stable do not have enough time to impossible questions so that Specific prepare. she can reject candidates. Unstable Global Unstable Specific I never do well at interviews. I was caught off guard by the focus of this interview and therefore made a bad impression. They probably rejected me because they had another candidate in mind all along. I think the interviewer woke up on the wrong side of the bed today, because he was simply nasty in the interview.

9 Mood Disorders: Psychological Influences Rumination Aaron Beck s Cognitive Theory of Depression Cognitive Triad: Think negatively about oneself Think negatively about the world Think negatively about the future Cognitive Errors/Distortions All or Nothing Thinking,Overgeneralization, Mental Filter, Disqualifying the Positive, Jumping to Conclusions, Magnification & Minimization, Emotional Reasoning, Should Statements, Labeling & Mislabeling, Personalization Figure 7.5 Beck s cognitive triad for depression Mood Disorders: Psychological Influences Other influences Sociotropy vs. autonomy Attentional Focus Loneliness Bereavement

10 Mood Disorders: Social and Cultural Dimensions Marriage and Interpersonal Relationships Marital dissatisfaction is strongly related to depression strongest for males Gender Imbalances Females > Males - except bipolar disorders Gender imbalance likely due to socialization (i.e., perceived uncontrollability) Social Support Lack of social support predicts late onset depression High expressed emotion and/or family conflict predicts relapse Substantial social support predicts recovery Integrative Model Mood Disorders Shared Biological Vulnerability Overactive neurobiological response to stress Exposure to Stress Activates hormones that affect neurotransmitter systems Turns on certain genes Affects circadian rhythms Activates dormant psychological vulnerabilities (i.e., negative thinking) Contributes to sense of uncontrollability Fosters a sense of helplessness & hopelessness Integrative Model Mood Disorders Social/Interpersonal Relationships/Support are Moderators Perfectionism Self-oriented Other-oriented Socially prescribed Bereavement

11 Treatment The number of people being treated for depression is on the rise Now for the bad news Treatment of Mood Disorders: MAO Inhibitors Monoamine Oxidase (MAO) Enzyme that breaks down serotonin/norepinephrine MAO Inhibitors Block Monoamine Oxidase MAO Inhibitors Are Slightly More Effective Than Tricyclics Must Avoid Foods Containing Tyramine (e.g., beer, red wine, cheese) Treatment of Mood Disorders: Tricyclic Medications Widely Used (e.g., Tofranil/Imipramine, Elavil/amitriptyline) Block Reuptake of Norepinephrine and Other Neurotransmitters Takes 2 to 8 Weeks for the Effects to be Known Negative Side Effects Are Common May be Lethal in Excessive Doses

12 Treatment of Mood Disorders: (SSRIs) Specifically Block Reuptake of Serotonin Fluoxetine (Prozac) is the most popular SSRI SSRIs Pose No Unique Risk of Suicide or Violence Negative Side Effects Are Common Especially with children Atypical SSRI Discontinuation Syndrome Table 7.7 Efficacy of various antidepressant drugs for major depressive disorder Treatment of Mood Disorders: Lithium Lithium Is a Common Salt Primary drug of choice for bipolar disorders Side Effects May Be Severe Dosage must be carefully monitored Why Lithium Works Remains Unclear

13 Treatment of Bipolar Disorders: Antipsychotic Meds Geodon Approved in August 2004 to treat Bipolar Disorder Still too recent to tell anything, but preliminary evidence suggests that it eliminates symptoms without side effects like weight gain Seroquel AstroZeneca seeking approval Figure 7.10 Percentage of patients with bipolar disorder recovered after standard drug treatment or drug treatment plus family therapy Treatment of Bipolar Disorders: Other Treatments Maintaining practical lifestyle habits New research Sleep Maintain routine Omega 3

14 Treatment of Mood Disorders: Electroconvulsive Therapy (ECT) ECT Involves applying brief electrical current to the brain Results in temporary seizures Usually 6 to 10 treatments (3 per wk) are required ECT Is Effective for Cases of Severe Depression Side Effects Are Few and Include Short- Term Memory Loss, Confusion Uncertain Why ECT works and Relapse Is Common Psychological Treatment of Mood Disorders Cognitive Therapy Addresses cognitive errors in thinking Also includes behavioral components Behavioral Activation Involves helping depressed persons make increased contact with reinforcing events Interpersonal Psychotherapy Focuses on problematic interpersonal relationships Family Therapy Combined Treatment TADS Psychological Treatment of Mood Disorders Outcomes with Psychological Treatments Are Comparable to Medications Lower rates of relapse

15 Figure 7.9 Data from Teasdale 2000 study on patients treated with severe depression Suicide Suicide is man s way of telling God, You can t fire me, I quit. Bill Maher

16 Suicide statistics the 11th leading cause of death in the United States. the 8th leading cause of death for males, 19th for females. 31,655 deaths by suicide in 2002 Bridges across America are being inspected following five deaths 4 per hour die from suicide Suicide Statistics 2 nd leading cause of death for college students nation wide Asian American women 30% of young women, 20% of young men (high school) seriously considered suicide last year. Suicide statistics Elderly adults have rates of suicide 50% higher than that of U.S. as a whole. Men over 75 account for 20% of all suicide. The largest total number of suicide comes from men and women in the middle years

17 The Nature of Suicide: Facts and Statistics Gender Differences Males are more successful at committing suicide than females Females attempt t suicide id more often than males Suicide in adolescents Suicide in the elderly Suicide in Kentucky Suicide is the second leading cause of death among year olds in KY. ( data) State has a suicide rate of 12.8 per 100,000 which is higher than the national average of per 100,000 Associated Press, 2002 Suicide: Risk Factors Recent Loss Past History Psychological Disorders Impulsivity A&D Use Social/Cultural Risk Factors Suicide Exposure Stressful Life Events Hopelessness Suicide is viewed as the only solution there is no other way out

18 Suicide as Escape from the Self a severe experience that current outcomes (or circumstances) fall far below standards is produced either by unrealistically high expectations or by recent problems or setbacks or both internal attributions are made during the experience such that the disappointing outcomes are blamed on the self and create negative implications about the self an aversive state of high self-awareness comes from comparing the self with relevant standards Suicide as Escape from the Self negative affect arises from this unfavorable comparison person responds by trying to escape from meaningful thought into a numb state of cognitive deconstruction the consequences of the deconstructed mental state include a reduction of inhibitions, which includes an increase in the likelihood that the person will commit suicide Suicide: Warning Signs A person may be suicidal if her or she: talks of death or committing suicide loses interest in hobbies, work, or school loses interest in hobbies, work, or school withdraws from family or friends takes unnecessary risks or increases alcohol or drug use makes final arrangements or gives away prized possessions

19 How You Can Help Be Direct Be willing to listen Offer hope Don t dare the person to do it Take action Don t be sworn to secrecy Refer the person to a trained professional SUICIDE AS A FUNCTION OF SEX AND AGE Suicides (in millions) Males 500 Females to to to to to to to to Age Range References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Ed.). Washington, D. C.: Author. Associated Press. (2002, September 16). State suicide rate higher than national average. The Paducah Sun, 5A. Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97, Clay, R. A. (2005). On the practice horizon: Economic and demographic trends are among those changing the professional landscape. APA Monitor on Psychology, 36 (2), Cox, B. J., & Enns, M. W. (2003). Relative stability of dimensions of perfectionism in depression. Canadian Journal of Behavioural Science, 35, DeAngelis, T. (2006). Promising new treatments for SAD: Light therapy improves symptoms in about half of seasonal affective disorder patients. Emerging research suggests that other modalities may help too. APA Monitor on Psychology, 37 (2), Fields, B. W., & Fristad, M. A. (2009). Assessment of childhood bipolar disorder. Clinical Psychology: Science and Practice, 16, Finger, S., & Zaromb, F. (2006). Benjamin Franklin and shock-induced amnesia. American Psychologist, 61, Friedman, M. A., Detweiler-Bedell, J. B., Leventhal, H. E., Horne, R., Keitner, G. I., & Miller, I. W. (2004). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Research and Practice, 11,

20 References Heisel, M. J., & Duberstein, P. R. (2005). Suicide prevention in older adults. Clinical Psychology: Research and Practice, 12, Hewett, P. L., Flett, G. L., & Endler, N. S. (1995). Perfectionism, coping and depression symptomatology in a clinical sample. Clinical Psychology and Psychotherapy, 2, Hewitt, P. L., Flett, G. L., Sherry, S. B., Habke, M., Parkin, M., Lam, R. W., McMurtry, B., Ediger, E., Fairlie, P., & Stein, M. B. (2003). The interpersonal expression of perfection: Perfectionistic self-presentation and psychological distress. Journal of Personality and Social Psychology, 84, Jak, A. J., Shear, P. K., Rosenberg, H. L., DelBello, M. P., & Strakowski, S. M. (2002, August). Intellectual functioning in children with bipolar disorder. Poster presented at the annual convention of the American Psychological Association, Chicago, IL. Kersting, K. (2003). Teen depression can affect adult happiness. APA Monitor on Psychology, 34(8), 11. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. R., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, Koplewicz, H. S. (2002). More than moody: Recognizing and treating adolescent depression. Brown University Child and Adolescent Behavior Letter, 18(12), 6-7. References Merikangas, K. R., & Pato, M. (2009). Recent developments in the epidemiology of bipolar disorder in adults and children: Magnitude, correlates, and future directions. Clinical Psychology: Science and Practice, 16, 133. Merrill, K. A., & Strauman, T. J. (2004). The role of personality in cognitivebehavioral therapies. Behavior Therapist, 35, Nairne, J. S. (1999). Psychology: The adaptive mind (2nd Ed.). Albany, NY: Brooks/Cole Publishing Company. O Connor, R. C., & O Connor, D. B. (2003). Predicting hopelessness and psychological distress: The role of perfectionism and coping. Journal of Counseling Psychology, 50, Oordt, M. S., Jobes, J. A., Rudd, M. D., Fonseca, V. P., Runyan, C. N., Stea, J. B., Campise, R. L., & Talcott, G. W. (2005). Development of a clinical guide to enhance care for suicidal patients. Professional Psychology: Research and Practice, 36, Raulin, M. L. (2003). Abnormal psychology. Boston, MA: Allyn & Bacon. Seligman, M. E. P. (1990). Learned optimism: How to change your mind and your life. New York: Pocket Books. Sherry, S. B., Hewitt, P. L., Flett, G. L., & Harvey, M. (2003). Perfectionism dimensions, perfectionistic attitudes, dependent attitudes, and depression in psychiatric patients and university students. Journal of Counseling Psychology, 50, References Shiltz, T. (2004). Suicide prevention: Knowing what to do. Rogers Memorial Hospital Update 2004, 5. Waters, M. (1999). Men and women handle negative situations differently, study says. APA Monitor, 30(9), 8. Watkins, C. E. (2004). Seasonal affective disorder: Winter depression. Retrieved from the World Wide Web, October 12, 2006: Youngstrom, E. A. (2009). Definitional issues in bipolar disorder across the life cycle. Clinical Psychology: Science and Practice, 16,