Disorders of Mood - Lecture notes 21-25 PDF

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notes from classes week 5 part 2...

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Disorders of Mood: Depression and Bipolar Unipolar Depression-Major Depressive Disorder:  Unipolar depression is defined as depression with no history of mania  Dejection vs depression  Major Depressive Episode: o Five or more of the following symptoms have been present during the same 2-week period and represent a change from the previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure  Depressed mood most of the day nearly every day (children it presents as irritability)  Diminished interest/pleasure in activities  Significant weight loss/gain  Insomnia/hypersomnia  Psychomotor agitation (restlessness) or retardation observable by others  Fatigue or loss of energy nearly daily  Feelings of worthlessness or excessive/inappropriate guilt  Decreased ability to think/concentrate or indecisiveness  Recurrent thoughts of death, suicidal ideation o Not part of bipolar disorder o Clinically significant distress/impairment o Not due to substances or medical condition o Not accounted for by bereavement  People who experience a major depressive episode without having any history of mania will receive a diagnosis of major depressive disorder  Depression: associated features o Sadness, irritability, brooding, rumination, anxiety, phobias, worry over health, pain, social disturbances, martial problems, sexual dysfunction, occupational/academic dysfunction, substance abuse and more o Absence of happiness or hopelessness is a more reliable symptom than sadness  Symptoms are categorized into 5 areas of functioning: o Emotional: lose humor, ability to take pleasure in activities they used to (anhedonia) o Motivational: lack of drive, initiative, spontaneity o Behavioral: less active, less productive, move/speak slowly o Cognitive: negative cognitive distortions, hopelessness and helplessness, depressed intellectual functioning o Physical: pain- muscles, headaches, bowel issues, appetite changes  About 8-10% of adults in US suffer from severe unipolar depressions in any given year and an additional 5% suffer from milder forms  About 20% of all adults experience an episode of severe unipolar depression at some point of their lives

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Can occur at any point, but people in their 40s are most likely to be diagnosed. This age is decreasing with new generations, median age in US is now 26 Women: men is about 2:1 o in children before puberty, it is equal approx.. 2/3 recover without treatment. The average untreated duration is 4 months o 40-60% of those will have at least one more episode o Most people with MDD have periods of normal mood o At least 2 months must separate one depressive episode from another for “recurrent” diagnosis The severity of the initial episode appears to predict persistence o First episode of MDD often follows a severe psychological stress, subsequent episodes are less dependent on stressors o The more often one experiences MDD episode, the easier to slip into another Genetics: o 1.5-3 times more common among first-degree relatives of people diagnosed with MDD vs general population o 22% life time risk for women x about 2 with 1 st degree relative o 13% for men x about 2 with 1st degree relative o No specific gene identified-likely multiple o People with MDD have a high probability or relatives with depression as well as anxiety, ADHD, OCD, eating disorders, headaches, irritable bowel syndrome o Proband has MDD, 20% of 1st degree relatives also have MDD o If monozygotic twin has MDD, you have a 46% chance of having it o If you are adopted and have severe MDD, your biological parents have a higher chance of severe MDD o Abnormality in some people with MDD for a serotonin transport protein, causing low serotonin activity in the brain Biology: o Up to 15% die of suicide o Large % with co-morbid medical illness (increased rate or premature death from medical conditions) lack of self-care o Large % with co-occurring mental disorders- substance abuse, panic d/o, OCD, anorexia, bulimia, borderline PD Sleep: o Sleep EEG abnormalities in 40-60% of outpatients and 90% inpatients o Sleepy continuity disturbances: intermittent waking, early morning waking, reduced deep sleep o Evidence that in some patients this may precede the onset of MDD or persist after remission Hormones: o Women are at a greater risk, because estrogen and progesterone have been shown to affect brain regions associated with mood

o Research in humans and animals shows the fluctuations in sex hormones marking female reproductive events influence neurological pathways linked to depression Premenstrual Dysphoric Disorder (PMDD):  Occurs during times of progesterone and estrogen instability, last 7-10 days of menstrual cycle  Symptoms = mood lability, depressed mood, irritability  Data supporting hormone treatments have been inconsistent, recent studies have found some hormone stability from oral contraceptives  3-9% prevalence  Dysthymia and depression are commonly co-morbid with PDD (about 40%)  Premenstrual exacerbation of an underlying mood or anxiety disorder? Post-Partum Depression:  Abrupt decrease in estrogen and progesterone may trigger a depressive episode in women  4.4-9% with the highest risk in women with a history of depression pre- or midpregnancy  Usually begins within 4 weeks of birth- extreme sadness, tearfulness, anxiety, intrusive thoughts, insomnia, feelings of inability  25-50% recurrence rate with other births  Increased risk in women with a family history of mood disorders Post-menopausal Depression:  Just as with menstrual cycles and pregnancy, most women go through menopause without experiencing depressive symptoms  Increased risk of depression even in women who have never experienced depressive symptoms prior to menopause Causes of Unipolar Depression:  Biological View: o Clear that there is a genetic predisposition as risk doubles with first degree relative affected with disorder o Low levels of serotonin and/or norepinephrine linked to MDD o Believed now that a complex interaction between 5HT and NE and likely many other neurotransmitters is responsible for MDD o Prefrontal cortex, hippocampus, amygdala, Brodmann Area 25 (all have abundant 5HT receptors)  Prefrontal cortex: changes in blood flow patterns, appears to be underactive in MDD patients  Hippocampus: neurogenesis (production of new neurons in adulthood) appears to decrease dramatically, decrease in size  Amygdala: greater blood flow in MDD patients  Brodmann Area 25: smaller in MDD patients, increased activity  Psychodynamic View:

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o People whose childhood needs were improperly met are particularly likely to become depressed after experiencing a loss Behavioral View: o Results from a change in # of rewards/punishments people receive o Strong relationship between positive life events and feelings of happiness Cognitive View: o View events in negative ways and that such perceptions lead to MDD o Two most influential cognitive explanations:  Negative thinking  Learned helplessness

Negative Thinking – Aaron Beck:  Maladaptive thinking is key to depression  Believes that children develop maladaptive attitudes that would later be triggered by upsetting situations  Cognitive Triad: interpret these 3 in negative ways and feel depressed o Their experience o Themselves o Their futures  Errors in thinking such as drawing negative conclusions based on little evidence  They minimize positive experiences and maximize negative ones  Depressed people experience automatic thoughts (steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and their situation is hopeless) Learned Helplessness – Martin Seligman:  Believe they no longer have control over reinforcements in their lives  Believe they themselves are responsible for their helpless state  Shocking dog experiment: dogs learned they had no control over the unpleasant events in their lives  Uncontrollable negative events lead to decreases in serotonin and norepinephrine in rats  “Attribution – Helplessness Theory” o People attribute their present lack of control to some internal cause that is global and stable, leads to sense of helplessness

Persistent Depressive Disorder aka Dysthymic Disorder:  Chronic but less severe and less disabling form of depression  Can lead to MDD  Diagnostics: o Depressed mood for most of the day, for more days than not, for at least two years o During two-year period, symptoms not absent for more than two months at a time o Same as depression for symptoms Treatment of Depressive Disorders:  Unipolar depression is among the most successfully treated of all disorders  Psychotherapy: o Bring underlying issues to consciousness and work through them o Use free association to gain awareness of losses and cope more effectively o Long-term therapy  Behavioral Therapy: o Mood is tied to rewards in person’s life, so therapists  Reintroduce clients to pleasurable activities (behavioral activation)  Reinforce non-depressed behaviors and do not reinforce depressed behaviors  Help them improve their social skills o Adding pleasurable activities is called behavioral activation o Needs at least 2/3 techniques to show any improvement, most effective for mild depression  Cognitive-Behavioral Therapy: o Help clients recognize and change their negative cognitive processes o 4 Phases:  Increasing activities: make a schedule  Challenging automatic thoughts  Identify negative thinking and biases: discuss how the illogical cognitions contribute to the automatic thoughts  Changing primary attitudes o 50-60% show a near-total elimination of depressive symptoms  Acceptance and Commitment Therapy: o Clients are guided to recognize and accept their negative thoughts as streams of cognitions that flow through the mind rather than as guides for behavior and decisions  Tricyclic antidepressants: o Primarily serotonin-NE reuptake inhibitors, but interact with many other receptors and have many side effects, still used for treatment-resistant depression  SSRI’s: o Most commonly used antidepressants

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o Far more selective = far less side effects Serotonin-NE reuptake inhibitors (SNRI’s): o Increase both 5HT and NE in the brain NE-DA Reuptake Inhibitor: o Wellbutrin: antidepressant on its own but often used in addition to an SSRI o Also blocks nicotinic receptors and helps stop smoking Atypical antipsychotics: o Works on various receptors (5HT, DA) o Often used as an antipsychotic for schizophrenia and bipolar disorder o Used for treatment-resistant depression Antidepressants: o Don’t work for anyone o Failure rate likely highest in the mild-moderate depression group Electroconvulsive Therapy: o Two electrodes attached to the head, 65-140 volts pass through brain for half a sec or less, results in a seizure that lasts 25 secs to a few mins o 6-12 treatments spaced over 2-4 weeks o Most patients feel less depressed o Still some memory loss, most regain within a few months, some never do o 60-80% improve o Particularly effective in severe depression and delusions o Use has declined since 1950s due to memory loss, and better drugs being made, and patient fear of procedure Transcranial Magnetic Stimulation: o Electromagnetic coil on or above patient’s head, sends a current into prefrontal cortex o Increases neuron firing in the area under the magnet o Administered daily for 2-4 weeks o New studies showing effectiveness comparable to ECT in patients with severe depression without the trauma...