Psych Exam 3 CH 16

affect

external, observable emotional reaction associated with an experience

severe depression

significant distress that interferes with social, occupational, cognitive, and emotional functioning

depression

alteration in mood that is expressed by feelings of sadness, despair, and pessimism

• clinically involves loss of interest in usual activities, or evident somatic symptoms

• may have change in appetite, sleep patterns, or cognition

• if severe, may be accompanied by suicide ideation and/or attempts

melancholia

• historically thought to be caused by excess of black bile (heavily toxic substance produced in the spleen or intestine) which affected the brain

• currently describes severe form of MDD where symptoms are exaggerated and interest or pleasure in anything is lost

mood

pervasive and sustained emotion that may have major influence on one’s perception of the world (depression, joy, elation, anger, and anxiety)

persistent depressive disorder (moderate depression)

• similar, but milder symptoms than MDD

• mood = sad, downcast, or “down in the dumps”

• no psychotic symptoms

• chronically depressed mood for most of the day, more days than not, at least 2 years (1 year for children and adolescents)

• early onset = <21 y/o; late onset >/=21 y/o

major depressive disorder (severe depression)

• depressed mood or loss of interest or pleasure in usual activities

• impaired social and occupational functioning

• lasted for at least 2 weeks

• not r/t use of substances or a general medical condition

• no history of manic behavior

• will be specified into categories of:

  • single episode or recurring

  • symptoms are mild, moderate, or severe

  • is there evidence of psychotic, catatonic, or melancholic features

depressive disorder due to another medical condition

symptoms associated with a major depressive episode that are a direct physiological consequence of another medical condition = distress or impairment in social, occupational, or other important areas of functioning

• conditions may include:

  • stroke

  • MI

  • TBI

  • thyroid disorders

  • Cushing’s

  • Huntington’s

  • Parkinson’s

  • MS

postpartum depression

depressed mood varying from day to day, with more bad days than good, tending to be worse toward evening; onset later than those w/baby blues and takes weeks-months to abate

• fatigue

• irritability

• loss of appetite

• sleep disturbances

• loss of libido

• fear of being unable to care for baby

premenstrual dysphoric disorder

• markedly depressed mood

• excessive anxiety

• mood swings

• ↓ interest in activities during the week prior to menses, ↑ shortly after onset of menstruation, and becoming minimal or absent in the week postmenses

what is the difference between PMDD and regular premenstrual symptoms?

• intensity of symptoms- severe enough to interfere w/ability to function socially, at work, or at school

• frequency of symptoms- recurrent for majority of menstrual cycles over one year

psychomotor retardation

slowing down of thoughts and physical movement

transient depression

not dysfunctional, but part of every day human emotional responses, and subsides quickly; person can refocus on goals/achievements

assessment for transient depression

• Affective: Sadness, dejection, feeling downhearted, having the blues

• Behavioral: Some crying

• Cognitive: Some difficulty getting mind off one’s disappointment

• Physiological: Feeling tired and listless

mild depression

similar to uncomplicated grieving; less intense than at moderate or severe levels

assessment of mild depression

• Affective: Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency

• Behavioral: Tearfulness, regression, restlessness, agitation, withdrawal

• Cognitive: Preoccupation with the loss, self-blame, ambivalence, blaming others

• Physiological: Anorexia/overeating, insomnia/hypersomnia, headache, backache, chest pain, etc.

assessment of PDD (moderate depression)

• Affective: sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities

• Behavioral: Psychomotor retardation; slumped posture; slowed speech; limited verbalizations, ruminations about failures/regrets; social isolation w/focus on self; substance use possible; self-destructive behavior possible; lack of personal hygiene/grooming

• Cognitive: Slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive pessimistic/negativistic thoughts; suicidal ideation

• Physiological: Anorexia/overeating; insomnia/hypersomnia; sleep disturbances; amenorrhea; ↓ libido; headaches; backaches; chest pain; abdominal pain; ↓ energy; fatigue and listlessness; feeling best early in the morning and ↓ as the day progresses (may be r/t diurnal variation in the level of neurotransmitters that affect mood and level of activity)

assessment for MDD (severe depression)

• Affective: total despair, hopelessness, and worthlessness; flat (unchanging) affect, devoid of emotional tone; nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure

• Behavioral: Psychomotor retardation = physical movement may literally come to a standstill, or psychomotor behavior = rapid, agitated, purposeless movements; slumped posture; curled-up position; walking slowly and rigidly; no communication (if there is any, may be delusional); no personal hygiene/grooming; social isolation w/no inclination to interact w/others

• Cognitive: delusional thinking (persecutory/somatic most common); confusion, indecisiveness, inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide

NOTE: d/t ↓ energy & thought processes, person may not follow through w/suicide, even tho desire is strong

• Physiological: A general slowdown of the entire body - sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia/weight loss; difficulty falling asleep and waking very early; feeling worse early in the morning and somewhat better as the day progresses (as with moderate depression, this may reflect the diurnal variation in the level of neurotransmitters that affect mood and activity); pain syndromes.

Renaissance perspective of depression

result of obstructed air circulation, excessive brooding, or helpless situations beyond the individual’s control

True or false? MDD is linked to higher risk of coronary artery disease

true; especially in women under 65

true or false? bipolar illness has nothing to do with depression disorders

false; data shows that up to 50% of all depressions may actually be bipolar illness

why are meds given pre ECT

to decrease secretions (to prevent aspiration) & counteract effects of induced vagal stimulation (bradycardia)

• atropine sulfate or glycopyrrolate - IM 30 mins before

to prevent severe muscle contractions during the seizure to ↓ risk of fractures/dislocation

• succinylcholine chloride (oxygenate person b/c it paralyzes resp muscles)

true or false? rates of depression have plummeted in the last two decades

false; it nearly doubled from 2009-2019, particularly in young adults and adolescent girls

true or false? Older adults and adolescents have been identified as high-risk groups

true; but any age group can be diagnosed, including young children

theories as to why women have a higher prevalence of depression than men by almost two to one

• they have higher concentrations of monoamine oxidase (a neurotransmitter associated with depression)

• they are more susceptible to thyroid dysfunctions

• they are influenced by hormonal changes that occur during menstrual cycle, postpartum, and at menopause

• unequal power and status (and associated self-esteem issues), work overload, and history of sexual or physical abuse

relationship between socioeconomic status and mental illness

• mental illness may present economic burdens culminating in poverty

• economic hardship can contribute to mental illness

• depression is 3x as prevalent among those who are unemployed

relationship between race/culture and depression

factors may be matters of public policy rather than biological factors associated w/race, but racial and ethnic differences are hard to measure b/c they depend on methods/approaches used

true or false? all married people are happier and less likely to be diagnosed with depression

false; marital stress may be associated w/↑ risk for depression, but it is lack of social connectedness rather than marital status that’s associated w/↑ depression rate

seasonal affective disorder

• not a real diagnosis in the DSM

• studies vary; some see a small surge in depression symptoms during fall/winter months, and sometimes episodes in the summer, but no consistent data

genetic predisposing factors for depressive disorders

• monozygotic twins = 2-4x ↑ incidence of depression

• monozygotic twins = 70% - 80% chance of both twins having the illness

• 7x more common among first-degree biological relatives of people w/depression than among the general population

• biological children of parents w/mood disorders are ↑ risk of developing mood disorder, even if reared by adoptive parents who don’t have it

• effects of being reared by an adoptive parent with depression (particularly maternal) = ↑ risk of depression, oppositional defiant disorder, and conduct disorder

biochemical predisposing factors for depressive disorders

related to a deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine at functionally important receptor sites in the brain

true or false? cortisol levels are higher in people with depression

true

neurons that contain serotonin regulate:

• mood

• anxiety

• arousal

• vigilance

• irritability

• thinking

• cognition

• appetite

• aggression

• sleep–wake cycles

• eating

• intestinal motility

why can tryptophan be useful as an antidepressant?

it’s the amino acid precursor of serotonin, and low levels of serotonin = depression/suicidal impulses

how to determine if someone with depression is somatically treatable

↑ serum cortisol = basis for dexamethasone suppression test

in depression, normal system of hormonal inhibition fails = in ↑ cortisol

difference in treating depression vs depression r/t thyroid disorder

one must be treated with antidepressants and the other must be treated with hormone replacement therapy

learned helplessness

(seligman 1973) helplessness in people who have experienced numerous failures (either real or perceived) and results in no further attempt to succeed = predisposition to depression by imposing a feeling of lack of control over life situation

object loss theory

depressive illness occurs as a result of having been abandoned by/separated from a significant other during the first 6 months of life

cognitive theory

when cognitive distortions = negative/defeated attitudes

• Negative expectations of the environment

• Negative expectations of the self

• Negative expectations of the future

the distortions come from defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others

transactional model of stress and adaptation

recognizes that combined effects of genetic, biochemical, and psychosocial influences determines susceptibility to depression

secondary depression

when depression symptoms are r/t medication side effects, neurological disorders, electrolyte or hormonal disturbances, nutritional deficiencies, and other physiological or psychological conditions

where do brain tumors cause depression symptoms in the brain?

areas of the temporal lobe

electrolyte imbalances that induce depression symptoms

• ↑ levels of NaHCO3 or CA

• ↓ in MG and Na

• ↑ or ↓ levels of K+

hormonal disturbances r/t depression

• dysfunction of adrenal cortex; addison’s disease or cushing’s syndrome are associated

• also hypoparathyroidism, hyperparathyroidism, hypothyroidism, and hyperthyroidism

• estrogen and progesterone imbalance = predisposition to PMDD

nutritional deficiencies associated w/depression

• proteins

• carbohydrates

• vitamin D

• vitamin B1 (thiamine)

• vitamin B2 (riboflavin)

• vitamin B6 (pyridoxine)

• vitamin B9 (folate)

• vitamin B12

• iron

• zinc

• calcium

• chromium

• iodine

• lithium

• selenium

• potassium

true or false? anorexia nervosa = comorbid depression

true, d/t the nutrient deficiencies

true or false? vitamin D deficiency is linked to depression, so supplementation is a reliable treatment

false, vit D3 supplementation did not change incidence or recurrence of symptoms

true or false? research has shown that inflammation is present in all patients with depression

false; not all w/depression have signs of inflammation, but those w/treatment-resistant depression have ↑ C-reactive protein levels (CRP) and tumor necrosis factor (TNF)

how does chronic stress effect depression in the brain

it dysregulates astrocyte metabolism, and that this is a major hallmark of depression

depression symptoms in children

• irritable mood (more often than dysphoria)

• excessive self-reproach

• excessive clinging to parents

• changes in grades

• getting into trouble at school/delinquency

• refusal to go to school

• school phobias

• hyperactivity

• psychosomatic complaints,

• sleeping/eating disturbances

• social isolation

• delusional thinking

• suicidal thoughts/actions

disruptive mood dysregulation disorder

characterized by frequent temper outbursts (averaging >/=3x/ week) that are inconsistent w/developmental level

why may children/adolescents become depressed?

• genetic predisposition, then precipitated by a stressful situation

  • physical/emotional detachment by primary caregiver

  • parental separation

  • death of a loved one (person or pet)

  • a move

  • academic failure

  • physical illness

what additional reason do adolescents have for becoming depressed that is not the same as children?

stress and independence conflicts associated with the typical maturation process

also a breakup with a bf/gf

goal of therapy in children with depression

to alleviate child’s symptoms & strengthen their coping/adaptive skills

why might a depressed child/adolescent be hospitalized?

• actively suicidal

• when home environment precludes adherence to treatment regimen

• if they should be separated from the home d/t psychosocial deprivation

• if physical condition precludes self care of biological needs

• if they indicate harm to self or others in the house

what form of therapy is most commonly used to treat the younger depressed child?

Parental/family therapy

• individual therapy in older children

common symptoms of depression in adolescents

• inappropriately expressed anger

• aggressiveness

• running away

• delinquency

• social withdrawal

• sexual acting out

• substance misuse

• restlessness

• apathy

• loss of self-esteem

• sleeping/eating disturbances

• psychosomatic complaints

difference between a mood disorder and normal emotional stress in adolescents?

a visible manifestation of behavioral change that lasts for several weeks

FDA approved drugs for children/adolescents

• fluoxetine (prozac) (for depression)

• escitalopram (Lexapro) (for MDD ages 12 to 17)

bereavement overload

when one experience so many losses in that they can’t resolve one grief response before another one begins

stressors that influence an older adult’s coping strategies

• financial problems

• physical illness

• changes in bodily functioning

• ↑ awareness of approaching death

pseudodementia

when memory loss, confused thinking, or apathy symptomatic of NCD is actually the result of depression

why do antidepressants need to be carefully dosed in older adults?

plasma concentrations meds ↑ despite moderate oral doses

• tricyclics can cause anticholinergic side effects

• SSRIs may induce hyponatremia

electroconvulsive therapy in older adults

effective, safe, and well tolerated depression treatment alternative to medications

• response to treatment may be slower with age

• duration of therapeutic effects are limited

• Confusion usually more pronounced in older adults, but only lasts a few minutes to hours

depression treatments for older adults

• interpersonal therapy

• behavioral therapy

• CBT

• group therapy

• family psychotherapy

• ECT

meds commonly used by older adults that cause depression symptoms

• antihypertensives

• corticosteroids

• analgesics

prevalence of depression among older adult residents in long-term care facilities

15%-48%

Hippocrates, Celsus, and Galen (5th century BC-3rd century AD)

philosophers who rejected the idea of divine origin of depression; they considered the brain to be the root of emotional states

substance/medication induced depressive disorder

direct result of physiological effects of a substance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; can be from intoxication or withdrawal

• classes of drugs that may cause mood disorders:

  • anesthetics

  • analgesics

  • anticholinergics

  • anticonvulsants

  • antihypertensives

  • antiparkinsonian agents

  • antiulcer agents

  • cardiac medications

  • oral contraceptives

  • psychotropic medications

  • muscle relaxants

  • steroids

  • sulfonamides

symptoms from the hippocampus when affected by depression:

Memory impairments, feelings of worthlessness, hopelessness, and guilt

symptoms from the amygdala when affected by depression:

Anhedonia, anxiety, reduced motivation

symptoms from the hypothalamus when affected by depression:

Increased or decreased sleep and appetite; decreased energy and libido

symptoms from the frontal cortex when affected by depression:

Depressed mood; problems concentrating

symptoms from the cerebellum when affected by depression:

Psychomotor retardation/agitation

symptoms from other limbic structures when affected by depression:

Emotional alterations

side effects of drugs that block norepinephrine reuptake results in side effects of

tremors, cardiac arrhythmias, sexual dysfunction, and hypertension

side effects of drugs that block serotonin reuptake

gastrointestinal disturbances, increased agitation, and sexual dysfunction

side effects of drugs that block dopamine reuptake

psychomotor activation

side effects of drugs that block acetylcholine reuptake

dry mouth, blurred vision, constipation, and urinary retention

statistic r/t PPD

• psychotic features occurs in about 1 or 2 out of 1,000 cases

• 50% of PPD episodes actually begin prior to delivery

• depression onset prior to delivery ↑ risk for major depression in postpartum period

• w/PP psychosis, 30-50% chance of recurrence in subsequent pregnancies

baby blues

worry, sadness, and fatigue after having a baby but subside within a week or two

PPD w/psychotic features

• depressed mood

• agitation

• indecision

• lack of concentration

• guilt

• irrational focus on bodily functions

• lack of interest/rejection of baby

• morbid fear that baby may be harmed

• delusions and hallucinations

• risk of suicide/infanticide

etiology of PPD

unknown but

• Family history

• combo of hormonal, metabolic, and psychosocial

  • Baby blues = hormonal changes, tryptophan metabolism, or alterations in membrane transport during early PP

  • moderate-severe symptoms = ↑ risk for depression r/t heredity, upbringing, early life experiences, personality, or social circumstances

treatment for PPD

• reassurance from dr that mood swings are normal

• support from spouse

• antidepressants

• supportive psychotherapy

• group therapy

• family therapy

brexanolone (zulresso)

formulation of allopregnanolone, a major metabolite of progesterone (u/k mechanism of action)

• IV transfusion over 2.5 days; available thru restricted distribution program in a certified health agency

• severe side effects = sedation and sudden LOC

• requires a Risk Evaluation and Mitigation Strategy (REMS)

• Pulse ox continuously monitored

• patients must be accompanied during interactions w/children while receiving infusion

side effects of drugs that block histamine reuptake

sedation, weight gain, and hypotension

interpersonal psychotherapy phase 1

client is assessed to determine the extent of the illness, education about depression is provided, and a therapeutic contract is negotiated

interpersonal psychotherapy stage 2

• help resolve maladaptive bereavement reactions (resolving ambivalence over a lost relationship, assistance with establishing new relationships)

• focus on interpersonal disputes between client and a significant other

• difficult role transitions at various developmental life cycles

• development of interpersonal skills to assist w/initiating and sustaining interpersonal relationships

interpersonal therapy stage 3

therapeutic alliance is terminated

• expected outcome = through reassurance, clarification of emotional states, improvement of interpersonal communication, testing of perceptions, and performance in interpersonal settings, pt has improved relationship skills and social functioning