CHAPTER 7 MOOD DISORDERS (PP )

Transcription

1 CHAPTER 7 MOOD DISORDERS (PP ) 1 Overview MDE Clin. Descr. Introduction ME Depressive Disorders Grief Onset & Duration Structure Onset & Duration Bipolar Postpartum Child & Adol Mood Disorders Specifiers Elderly Other Facts Prevalence Culture & Anx Creative Suicide Treatment Bio Med Causes Psyc ECT & TMS Stats Soc Cult Last Treatment Photo. Risks Relapse Integr. Causes Comb 2 PsySoc OVERVIEW OF MOOD DISORDERS (PP ) 3 4 Extremes in Normal Mood Two basic emotional Episodes Major Depressive Episode (T7.1 +1) Depressed mood Cognitive symptoms: e.g., feel worthless Vegetative / Somatic symptoms: central Anhedonia: loss of pleasure / interest CES-Depression Inventory (+2) Manic Episode (T7.2 +3) Extreme pleasure in every activity Hyperactive Grandiose plans Rapid speech and ideation: flight of ideas Hypomanic Episode (hypo = below): milder version Hypomania/Mania Checklist (+2 +3) 5 6 1

2 7 8 OVERVIEW OF MOOD DISORDERS (+1 +2 PP ) 9 10 Depressive Disorders Major Depressive Disorder Dysthymic Disorder Double Depression Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder MDD BD I CD DysD BD II ADDITIONAL DEFINING CRITERIA FOR MOOD DISORDERS (P. 229) 11 DEPRESSIVE DISORDERS: AN OVERVIEW (PP ) Major Depressive Disorder Major Depressive Episode Extremely depressed mood state lasts at least 2 weeks Cognitive symptoms: e.g., feel worthless, indecisive Vegetative or somatic symptoms: central Anhedonia: loss of pleasure/interest in usual activities Absent manic or hypomanic episodes Single episode: rare, 85% single case have later episodes Recurrent episodes: more common; median lifetime number of MDE is 4; median duration 5 months 12 2

3 DEPRESSIVE DISORDERS: AN OVERVIEW (PP ) Dysthymic Disorder (+1) Persistent depressed mood for at least 2 years Symptoms milder than Major Depression Symptoms can persist over long periods (e.g., 20 years or more) Facts and Statistics Late onset: typically in the early 20s Early onset: before 20, greater chronicity, poorer prognosis Double Depression Person experiences MDEs and DD DD often develops first, then MDE Later cycles between moderate and deep lows Facts and Statistics Common Problematic future course: more negative outcome than Major Depression alone Normal Sadness (Grief) vs. Clinical Depression All of us feel sad sometimes, but sadness varies in: Intensity, Frequency, Duration, For some people, like 16-year old Katie in text, sadness becomes all-consuming like falling into a deep, dark hole that you cannot climb out of often cried for hours at the end of the day began drinking herself to sleep got out a sharp knife that I had been saving and slashed my wrist deeply thoughts of suicide became more frequent and much more real Winston Churchill referred to depression as the black dog ; Queen Victoria unable to perform duties for several years & mourned loss of Albert 50 years Normal grief can become Pathological or Impacted Grief Reaction 15 BIPOLAR DISORDERS (PP ) 16 Bipolar I Disorder Alternate between full manic and depressive episodes: like switch is turned on and off (+1) Facts and Statistics Average onset 18 years, or childhood; rare after 40 yrs Tends to be chronic Suicide common Bipolar II Disorder (+2) Alternate major depressive and hypomanic episodes Facts and Statistics Average age onset 22 years, can begin in childhood 10 to 13% of cases progress to full Bipolar I Disorder Tends to be chronic

4 CYCLOTHYMIC DISORDER (P. 227) 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 12 to 14 years Tends to be chronic and lifelong Most female High risk (1/3) to develop bipolar I or II disorder 19 Symptom Specifiers Atypical: oversleep, overeat, gain weight, and are anxious Melancholic: severe somatic symptoms, more severe depression Chronic: major depression only, lasting 2 years Catatonic: Very serious, absence of movement Psychotic: mood congruent / incongruent hallucinations / delusions Postpartum: severe manic or depressive episodes post childbirth ADDITIONAL DEFINING CRITERIA FOR MOOD DISORDERS (P ) 20 Course Specifiers Longitudinal course: Past history and recovery from depression and / or mania Rapid cycling pattern: Bipolar I and II only Seasonal pattern (+1): Episodes more likely during certain seasons 21 MOOD DISORDERS: ADDITIONAL FACTS AND STATISTICS (PP ) Lifetime Prevalence Rates in Canadian studies range from 4.1% in Ontario Health Survey to 11% in surveys in Toronto and Calgary. Statistics vary somewhat: methods, samples, Summary of Worldwide estimates (+1 +2) Median % (Range) Disorder 6-12mths Lifetime Major Depress 6.5 ( ) 16.1 ( ) Dysthymia 3.3 ( ) 3.6 ( ) Bipolar 1.1 ( ) 1.3 ( )

5 PREVALENCE Gender Females twice as likely to have mood disorder (right, -1, +1) Gender imbalance disappears after age 65 Bipolar equal for M and F Age and Depression Peak risk at young age (+1) Age of onset has decreased over generations (+2) Prevalence decreases in elderly (+1), but milder levels of depression perhaps higher: high levels of associated depression (vs. primary diagnosis) in hospitalized elderly (+3) PREVALENCE Culture Rate varies by nation (F7.2 F7.3, & later slides on suicide) Aboriginals: high rates of Depression, Suicide (later) 19.4% for M and 36.7% for W in one study Stress: may account for some cultural differences Depression and Creativity Bipolar disorder associated with creativity: Intense productivity alternating with despair (+1) Art: Van Gogh Poetry: Sylvia Plath Author: Dickens Musician: Beethoven Science: Newton

6 ANXIETY AND DEPRESSION Co-morbidity of Anxiety and Depression high (graph left, earlier data in Anxiety Disorders) Most depressed people anxious, not all anxious people depressed Many shared features (e.g., crying, irritability) and fewer unique to Depression (e.g., loss of interest, suicide) or Anxiety (e.g., tension, apprehension) (T7.3 +1) CAUSES: INTEGRATIVE THEORY (+1) (PP ) Shared Biological Vulnerability Overactive neurobiological response to stress Psychological Vulnerability 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 sense of helplessness and hopelessness Social & interpersonal relationships/support Moderate consequences of above factors 33 INTEGRATIVE MODEL OF 34 MOOD DISORDERS (P. 247) FAMILIAL AND GENETIC INFLUENCES (PP ) Family Studies Rate of mood disorders high in relatives of probands Relatives of bipolar probands more likely to have unipolar depression Adoption Studies Data mixed: some studies higher prevalence for biological relatives who were adopted Twin Studies Concordance rates high in identical twins (+1 +2) Severe mood disorders stronger genetic contribution Heritability rates higher for females: 40-45% Vulnerability for unipolar or bipolar disorder appear to be inherited separately MOOD DISORDERS IN TWINS 6

7 37 38 NEUROBIOLOGICAL INFLUENCES (PP ) Endocrine System Elevated cortisol and dexamethasone suppression test (DST) Dexamethason depresses cortisol secretion Persons with mood disorders show less suppression Sleep Disturbance Hallmark of most mood disorders Relation between depression and sleep Neurotransmitters Serotonin and its relation to other neurotransmitters Mood disorders related to low levels of serotonin Permissive hypothesis and regulation of neurotransmitters Brain imaging studies: less activation with depression, more with mania ( ) 39 PET SCAN OF DEPRESSED(LEFT) AND NONDEPRESSED(RIGHT) Side view of normal (top) and depressed (bottom) brain Lower activation particularly notable in frontal lobes (left side of image) 41 Image shows Increased brain activity associated with Mania / Hypomania Frontal lobes (left) and Amygdala (right) 42 7

8 PSYCHOLOGICAL DIMENSIONS (PP ) Stressful Life Events Stress strongly related to mood disorders: e.g., exposure to trauma (right) Poorer response to treatment, longer time before remission Diathesis-Stress and Reciprocal-Gene Environment models Low Income at risk (+1) Greater stress? Learned Helplessness Theory Lack of perceived control Origins: Animals initially punished without escape later fail when escape possible (right) Depressive Attributional Style Internal: negative outcomes own fault Stable: future negative outcomes own fault Global: negative events will disrupt many life activities Style leads to sense of hopelessness PSYCHOLOGICAL DIMENSIONS (PP ) 45 NEGATIVE COGNITIVE STYLES (PP ) 46 Aaron T. Beck s Cognitive Theory of Depression Depression: interpret life events negatively Depressed people engage in cognitive errors Arbitrary inference: overemphasize negative OvergeneralizationÈ generalize negatives to all aspects of situation Depressive Cognitive Triad Think negatively about Self, World, Future SOCIAL AND CULTURAL DIMENSIONS (PP ) Marriage and Interpersonal Relationships Marital dissatisfaction strongly related to depression Link particularly strong in males Gender Imbalance Occurs across all mood disorders, except bipolar disorders Socialization: i.e., perceived uncontrollability Greater exposure to certain stressors e.g., Abuse and violence (USA Statistics +1) Rumination (+2) Chronic, passive focus on one s negative emotions Women tend to ruminate more than men Rumination reinforces: Greater access to unhappy memories, Enhanced sensitivity to negative information about one s current situation, and Probability of making negative interpretations

9 RUMINATION EXPERIMENT Two Groups Rumination Condition Think about list of written items focused on self, feelings and physical symptoms for 8 minutes, e.g. Think about the physical sensations you feel in your body Distraction Condition Imagine written list of non-self-related scenes for 8 min. e.g. fire darting round log in a fire-place Results No difference in not sad undergraduates In sad undergrads, rumination had negative consequences: Increased sad mood (Nolen-Hoeksema & Morrow, 1993) Increased negative thinking Increased recall of negative memories (Lyubomirsky et al, 1998) Impaired problem solving (Lyubomirsky & Nolen-Hoeksema, 1995). 49 SOCIAL AND CULTURAL DIMENSIONS 50 Social Support Extent of social support related to depression Lack of social support late onset depression High Expressed Emotion and / or family conflict predicts relapse Substantial social support recovery Marriage (Gallup Poll left), Religion (+1) SOCIAL DIMENSIONS: RELIGION & SOCIAL SUPPORT TREATMENT OF MOOD DISORDERS Medication Electroconvulsive Therapy (ECT) Phototherapy for Seasonal Affective Disorder (SAD) Psychosocial Treatments Cognitive Interpersonal Combined Treatments Preventing Relapse Psychosocial Treatments for Bipolar Disorder TREATMENT: MEDICATION Tricyclic Medications (Pp ) Widely Used (e.g., Tofranil, Elavil) Block Reuptake of Norepinephrine and Other Neurotransmitters Takes 2 to 8 Weeks for Effects to be Known Negative Side Effects Common Lethal in Excessive Doses Monoamine Oxidase (MAO) Inhibitors (Pp MAO breaks down serotonin / norepinephrine MAO inhibitors block Monoamine Oxidase Slightly more effective than tricyclics Must avoid foods with tyramine (e.g., beer, red wine, cheese) TREATMENT: MEDICATION Selective Serotonergic Re-uptake Inhibitors (SSRIs) Specifically block reuptake of serotonin Fluoxetine (Prozac) is most popular SSRI SSRIs pose no unique risk of suicide or violence Negative side effects common Medications Effectiveness (+1) Side Effects (+2): Generally less for SSRIs (Fluoxetine) than Tricyclics (Imipramine, Amitriptyline) 9

10 55 56 Lithium (p. 250) A common salt Primary drug for bipolar disorders Mechanism unclear Side effects may be severe Dosage must be carefully monitored Symptoms return if discontinued, especially if ended rapidly (right) TREATMENT: MEDICATION 57 TREATMENT: BIOLOGICAL (P ) Electroconvulsive Therapy (ECT) Apply brief electrical current to brain Results in temporary seizures Usually 6 to 10 treatments required Effective for cases of severe depression Side effects few and include short-term memory loss Uncertain why ECT works and relapse is common Attitudes about ECT more positive among those receiving ECT than controls (+1) Phototherapy Light therapy for Seasonal Affective Disorder: Morning especially effective (+1)

11 PSYCHOLOGICAL TREATMENT (PP ) Cognitive Therapy Addresses cognitive errors in thinking Also includes behavioural components Behavioural Activation Involves helping depressed persons make increased contact with reinforcing events Interpersonal Psychotherapy Focuses on problematic interpersonal relationships Family therapy Work on family dynamics Effectiveness Psychological treatments comparable to or better than meds, and help prevent relapse ( ) TREATMENT: PREVENTING RELAPSE Preventing Relapse Recurrence of mood disorders (relapse) high Psychological treatments can reduce relapse versus medications alone Relapse rates Drug No continuation 50% Drug Continuation 1 year 32% Cognitive Therapy 21% Cognitive + Medication 15% Mindfulness-based Cognitive Therapy Reduced risk of relapse (+1) TREATMENT: RELAPSE AND FAMILY Expressed Emotion and Relapse High Expressed Emotion "I always say, 'Why don't you pick up a book, do a crossword or something like that to keep your mind off it.' That's even too much trouble." "I've tried to jolly him out of it and pestered him into doing things." "He went round the garden 90 times, in the door, back out the door. I said 'Have a chair, sit out in the sun.' Well he nearly bit my head off." Low Expressed Emotion "I know it's better for her to be on her own, to get away from me and try to do things on her own." "Whatever she does suits me." "I just tend to let it go because I know that when she wants to speak she will speak. Over-involvement of family and friends NOT good (+1)

12 SUICIDE:STATISTICS (PP ) Statistics Much variation across nations (+1) Gender Differences Females attempt suicide more often Males more successful, producing higher rate for Men (+1) Suicide rates increasing, particularly in young Geographic and Cultural variation within Nations Canada: suicide rates highest in Alberta, Quebec, and Northwest Territories and lowest in Newfoundland and Labrador (Sakinofsky, 1998). Suicide rate of Aboriginal people extremely high, especially for young males (+2) Great variability across groups: e.g., almost half BC bands 0 suicides in one study CANADASUICIDERATES: SUICIDE: RISK FACTORS (PP ) Risk Factors Increase risk with Suicide in family Low serotonin levels Psychological disorder Personality Traits: Impulsivity Alcohol use and abuse Past suicidal behaviour Experience of shameful / humiliating stressor Publicity about suicide and media coverage Threshold Model (+1) Availability of method: Guns (+2)