MOOD DISORDERS. Mood Disorders. Major Depressive Disorder (MDD) Bipolar Disorder Dysthymic Disorder Cyclothymic Disorder

MOOD DISORDERS Mood Disorders Major Depressive Disorder (MDD) Bipolar Disorder Dysthymic Disorder Cyclothymic Disorder Major Depressive Episode (MDE...
Author: Sheena Norton
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MOOD DISORDERS

Mood Disorders Major Depressive Disorder (MDD) Bipolar Disorder Dysthymic Disorder Cyclothymic Disorder

Major Depressive Episode (MDE) One of the following for at least a two-week period: 1) depressed mood most of the day nearly every day 2) diminished interest or pleasure in most activities (anhedonia) Plus 4 or more of the following for a two-week period: 3) weight change 4) sleep changes 5) psychomotor retardation or agitation 6) loss of energy 7) feelings of worthlessness or excessive guilt 8) can’t concentrate or make decisions 9) suicidal thoughts

Major Depressive Disorder (MDD) • presence of one (Single Episode) or more (Recurrent Episodes) depressive episodes • no history of mania or hypomania • lifetime risk for women 10-25% • lifetime risk for men 5-12% • before puberty, risk is same for boys and girls • individuals born between 1940-50 at greater risk than those born before 1940 • risk for depression appears to be growing

Development of Clinical Rates of Depression by Gender and Age

Hankin, et al. (1998) Journal of Abnormal Psychology

MOOD positive

The Depressive Spectrum of Disorders

negative

normal

Depression on a continuum: (differences in duration and severity of symptoms) Dysthymic Disorder Major Depressive Disorder Double Depression

Are There Different Types of Depression? • reactive (aka exogenous) vs. biological (aka melancholic, vegetative, endogenous) • DSM IV Specifiers (may indicate different biological processes or different etiologies) • with catatonic features • with melancholic features • with atypical features • with postpartum onset • with seasonal pattern

Specifiers With Catatonic Features • motoric immobility or stupor • excessive purposeless motor activity • extreme negativism or mutism • posturing or stereotypical movements • echolalia or echopraxia

With Melancholic Features • loss of pleasure in all or almost all activities • lack of reactivity to pleasurable activities • depression worse in the morning • early morning wakening • extreme weight loss • excessive or inappropriate guilt

Specifiers With Atypical Features • mood reactivity (mood brightens with positive events) • weight gain or increase in appetite • hypersomnia • leaden paralysis (heavy feeling in arms or legs) • long-standing pattern of interpersonal rejection sensitivity

With Postpartum Onset • onset of depression within four weeks postpartum • may include psychotic features (delusions/hallucinations) • may include anxiety and panic attacks • risk is 1 in 500 - 1 in 1,000 births • risk of psychotic postpartum depression increases to 30-50% if previous episode

Specifiers With Seasonal Pattern • depressive episodes are temporally tied to season of year • full remission occurs at certain season of year • no non-seasonal episodes have occurred within past 2 years

Depression as a Reaction to Life Events Life events may act as both diathesis and stress Diathesis/Stress Model

Abnormal Str

Normal

ess

Underlying predisposition

• single event (usually 4-6 mo. in past) may be stressor • accumulation of negative events (or negative events early in life) may act as underlying predisposition

Examples of Life Events that are Stressors:

loss of loved one job loss divorce severe accident (auto accident) unanticipated natural disaster

Examples of Life Events that are Predispositions to Depression:

loss of parent in childhood childhood abuse loss of social support or intimate relationship

Life Conditions that May Be Predispositions to Depression: • 3 or more children living at home • low SES • neighborhood problems • marital problems • chronic health problems • living with alcoholic • living with depressed spouse • cognitive impairments • social isolation

Exciting New Genetic Research Combines Life Events Research with Biological Diathesis • Serotonin transporter gene (fine-tunes transmission of serotonin comes in two alleles: long (l) and short (s) • short allele may be associated with predisposition to depression

• Multidisciplinary Health and Development Study (Caspi

et al, 2003)

What Else Can Act as a Predisposition to Depression?* Social Social skills deficit model of depression Negative interaction model of depression Psychological Beck’s cognitive theory Helplessness/Hopelessness theory Biological Neurotransmitter dysregulation hypothesis HPA Axis dysregulation hypothesis

LEVELS OF ANALYSIS Cellular Anatomical

Biological

Biochemical

WITHIN THE PERSON

Functional

Cognitive Emotional

Psychological

Experiential

AT THE LEVEL OF THE PERSON

Individual Differences

Dyadic Social Cultural

Social

BETWEEN PERSONS

Social Theories and Treatment of Depression

Social Skills Deficit Theory of Depression (Lewinsohn, 1974)

depression

social deficits

negative life events

• depressed persons are rated as less socially competent both by themselves and others • gaze • communication skills

• paralinguistics

• content

Negative interaction model of depression (Coyne, 1976)

• depressed persons induce negative mood in their interactional partners • partners end up acting in hostile, rejecting manner • hostile reaction from others increased depressed mood • evidence • Joiner et al (1989) • Hooley & Teasdale (1989) • Joiner (2002)

Treatment - Social Interpersonal Therapy (IPT) • short (16 sessions) • addresses current rather than past problems • addresses following interpersonal difficulties: • role loss (grief and mourning) • role disputes (incompatible expectations of partner) • role transition (change of role) • interpersonal deficits (skills education and training) • one of most effective therapies for depression, especially mild-moderate symptoms (non-melancholic)

Psychological Theories and Treatment of Depression

Cognitive Theory of Depression (Beck, 1967.1979)

Negative Triad (Pessimistic view of self, world, future) Negative Schemata (core beliefs) (e.g. “I have to please everybody to be loved”) Cognitive Biases Depression

Helplessness/Hopelessness Theory (Seligman,1974; Abramson et al,1989)

Learned Helplessness uncontrollable adverse event

Attribution Theory Reformulation uncontrollable adverse event

+ sense of helplessness

negative attribution

depression

sense of helplessness

(global, stable, internal)

depression

Hopelessness Theory uncontrollable adverse event

+ negative attribution or other cog factor (e.g. low self esteem) sense of hopelessness depression

Depressive Attributional Style global, stable, internal Reason I failed my GRE math test

Specific Global

Internal (personal) Stable Unstable

External (environmental) Stable Unstable

I was

I’m stupid exhausted I’m not good at math

I was just fed up with math

These tests are all unfair

It was too hot to concentrate

The math test was unfair

My test was numbered 13

Davison, Neale, & Kring (2004)

Treatment- Psychological Cognitive Behavioral Treatment (CBT) • behavioral activation (make pleasurable behavioral changes) (running, going out with friends) • recognize automatic thoughts and negative self-talk use hypothesis testing • work on changing negative cognitive distortions • develop positive coping styles

Biological Theories and Treatment of Depression

Neurotransmitter Dysregulation Theory of Depression • one or more neurotransmitter systems is impaired in one or more regulatory or homeostatic brain mechanisms • basal output of neurotransmitter is erratic (too low/too high) • normal circadian fluctuations are disrupted • dysregulated system is less responsive to environmental input • drugs restore efficient regulation • most studied neurotransmitter in depression is serotonin • norepinephrine and dopamine also implicated Notice that biological theory does not explain how system might become disrupted in the first place

HPA Axis Dysregulation Theory of Depression •stress can cause increase in HPA activity/increase in cortisol • depressed persons show abnormalities in the HPA axis (especially melancholic depressives) • increased cortisol can affect norepinephrine system • increased cortisol can damage hippocampus • increased cortisol can affect levels of serotonin receptors • thus, abnormalities in processing stress

dysregulation

HPA axis more abnormalities + depression

Antidepressants Tricyclics • block reuptake of serotonin, norepinephrine, dopamine • probably also downregulate sensitivity of receptors • especially effective on melancholic depression • side effects: drowsiness, blurred vision, tachycardia, weight gain, dry mouth, orthostatic hypotension • examples: imipramine (Tofranil) and amitriiptyline (Elavil)

MAOIs

• inhibit MAO (the enzyme that breaks down , SE, NE, DA • more effective with atypical depression • usually NOT first line of defense because of side effects (must eliminate tyramine from diet) • side effects: chance of hypertension, heart problems • examples: phenylzine (Nardil)

Antidepressants SSRIs • inhibit reuptake of serotonin • usually first drug of choice • may have beneficial effects on comorbid disorders including OCD, eating disorders, anxiety disorders, panic disorder • fewer side effects: drowsiness or insomnia, maybe weight loss or weight gain, sexual dysfunction • less chance of overdose • examples: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil)

Other Biological Treatments

ECT rTMS (Transcranial Magnetic Stimulation) 10,000 lux light therapy

Conclusions • depression appears to adhere to the diathesis/stress model, negative life events can trigger the disorder or act as underlying predisposition • social, psychological, biological, and genetic factors can predispose a person to depression (causes may work in tandem and are not mutually exclusive) • different types of depression may have different causes and respond to different treatments • unlike anxiety disorders, combining pharmaceuticals and

psychotherapy may enhance effectiveness in treating depression

Question of the Week: There is evidence that depression is associated with biological changes in the brain, for instance dysregulation of neurochemicals. Do you think that depressed individuals who have committed violent crimes against others (case in point: Andrea Yates, the mother who drowned all five of her children while suffering from depression) should be held morally accountable for their actions? (Note that we will discuss their legal accountability in a future lecture)

Recommended of the Week: The Hours starring Nicole Kidman Julianne Moore Meryl Streep

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