Developmental Psychology (part 2)

Depressive disorders

• Pervasive

• Diverse

• Debilitating

Depression: A Continuum

⬇ “Normal” state

⬇ Feeling sad/”depressed”/gloomy

⬇ Depression

⬇ Depressive Disorder (diagnosable)

Depression: Diagnosis (DSM-5)

At least 2 core symptoms (2 weeks)

• Anhedonia: No interest or pleasure in all or almost all activities

• Depressed mood: most of the day, nearly every day

+ 4 other symptoms

• Weight loss or gain, or decrease or increase in appetite

• Sleep problems

• Agitation or retardation, observable by others.

• Fatigue or loss of energy

• Feelings of worthlessness, guilt

• Loss of focus, indecisiveness

• Thoughts about death

+ Significant suffering / impairment in social or professional functioning

Symptoms of Depression

• Cognition 

  • Poor focus, indecisiveness, low self-esteem, hopelessness, suicidal thoughts, delusions

• Neurovegitative

  • Disrupted sleep and appetite, psychomotor problems, catatonia, fatigue, amnesia

• Emotion 

  • Sadness, depressed mood, loss of interests, irritability

Clinical symptoms of MDD are usually accompanied by functional impairment

The greater the number and severity of symptoms (as opposed to particular symptoms), the greater the probability of the functional impairment.

Relevant Mood Disorders

Depressive Disorder Subtypes

Depression, Suicidality, Suicide

• Depression is the most important predictor of suicide

• … but most people with depression are not suicidal!

• Suicidality is associated with most mental disorders

• Suicidality can best be seen as a separate problem that often co-occurs with depression

• Suicidality is an important urgent indicator for treatment

Epidemiology: Prevalence Rates of MDD

• In any given year, 4.4-5% of the world population has MDD

→ Increase of 41% from 1990 to 2023

• Lifetime prevalence: approx. 10%

Epidemiology: Depressive Episodes

• Average duration of episode is 6 months (but: wide variation)

• Most acute episodes remit within a year, but 12-34% have chronic depression

• High recurrence rates: 27-45% over 20 years in community samples, much higher in clinical samples

• Recurrence risk increases with every additional episode

Epidemiology: Correlates & Comorbidity

• Prevalence about twice as high in women as in men

• High comorbidity: especially anxiety disorders, substance use disorders, personality disorders

• Help-seeking is low (7-28%), even in countries with broadly available and free healthcare

Epidemiology: Children & Adolescents

• Toddlers: 1 %

• Primary school age: 1-2 %

• Adolescents: ~5%

• Young adults: 7.2%

Median age of onset: 26 (17-37) in high-income countries and 24 (17-35) in low- and middle income countries

Disease Burden Compared to Other Mental Disorders

Depression: An Urgent Public Health Problem

• High prevalence (30.3 million Europeans), 322 million worldwide and huge burden of disease

• 2.5 – 8.5 trillion USD in economic losses

• Existing treatments can reduce burden of disease by no more than 35% (currently 15%)

Risk factors for MDD

• Genetic risk

  • 30-40% heritability, along with other internalising disorders

  • no specific/singular gene loci identified

• Prenatal factors (brain damage, infections, complications)

• Alcohol/substance abuse

• Obesity

• Childhood trauma

• Cognitive style

• Stressful live events, chronic stress, “daily hassles”

Biopsychosocial Model of Depression

Beck’s Cognitive Model of Depression

Treatment Options MDD

Antidepressants: Effects & Controversies

• Types of antidepressants:

  • SSRIs (selective serotonin reuptake inhibitors; first-line in most cases)

  • SNRIs (serotonin-norepinephrine reuptake inhibitors)

  • Tricyclic Antidepressants (older; affect other receptors as well, more side effects)

  • MAOIs (monoamine oxidase inhibitors; inhibits enzymes metabolizing serotonin, some irreversible)

• Effects & Controversies

  • Antidepressants are effective for depression, but effects are small-to-moderate

  • None is substantially more effective than the other

  • Long-standing debate in the 90’s and early 2000’s about the efficacy of antidepressants

  • For patients with milder symptoms, benefits may be very small

  • Consider side effects: irritability, sleep problems, weight gain, sexual side effects

  • Some patients have trouble stopping antidepressants (rebound effects)

Psychological Treatment for MDD

• Various “families” of therapies, e.g.:

  • Cognitive behavior therapy (CBT)

  • Interpersonal therapy (IPT)

  • Psychodynamic therapy

• Effects are moderate-to-large

• No clear evidence that one is substantially more effective than the others

• But some therapies (especially CBT) much better studied than others

Psychological Treatment & Pharmacotherapy

• Patients prefer psychotherapy by wide margins (75%)

• Effects of monotherapy are comparable short-term

• Combined treatment is more effective than either psychotherapy and pharmacotherapy alone

  • First-line treatment from moderate symptoms upwards!

• At the longer term, psychotherapy is probably more effective

Anxiety

• Adaptive → Problematic → Pathological

  • Intensity, duration and pervasiveness

  • 4 Ds: Dysfunction, Distress, Deviance, Danger

• Adaptive / nonclinical: most children have one or two fears appropriate to their age

• Problematic: interference with daily life and development

Risk Factors for development of anxiety disorders

• Child factors:

  • Genetic predisposition

  • Temperament

  • Cognition

• Environmental factors:

  • Insecure attachment

  • Education and parental style

  • Negative life events

Anxiety disorders – shared characteristics

• Excessive fear and anxiety

• Related behavioural disturbances

  • Fear: emotional response to real/perceived imminent threat

  • Anxiety: anticipation of future threat

• Not attributable to physiological effects of:

  • Medication/substance

  • Medical condition

Anxiety disorders facts and figures

• The most prevalent mental disorder worldwide*

  • About 5.7% of global population

  • 40% of people with a mental disorder have an AD

  • 47% increase from 2019-2023

• Often early onset

• Women are 1.66x more likely to develop an AD

• Wax and wain over time

• High comorbidity

• High individual impairment

DSM-5: Anxiety Disorders

• Separation Anxiety Disorder (e.g., parents leaving)

• Selective Mutism

• Specific Phobia

• Generalized Anxiety Disorders (GAD)

• Social Anxiety Disorder (SAD)

• Panic Disorder

• Agoraphobia

No longer considered anxiety disorders:

• OCD

• Acute stress disorder

• PTSD 

Anxiety: Average age of onset 

• Pre-school:

  • Selective mutism

• Elementary school:

  • Separation anxiety

  • Specific phobia

• Adolescence:

  • SAD (early)

  • OCD (early or late)

• (Early) Adulthood:

  • Panic Disorder

  • Agoraphobia

  • GAD

Separation Anxiety Disorder

• Non age-appropriate and excessive anxiety (or anticipation) of going away from home or leaving attachment figures

  • Excessive worry that caregivers may be harmed

  • Persistent refusal to go anywhere which may cause separation

  • Frequent nightmares about separation

  • Recurrent physical complaints when not in close proximity to attachment figures

Selective Mutism

• A child shows consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.

• Interferes with educational achievement and social interaction

• Duration: at least 1 month (not limited to the first month of school)

• Not attributable to a lack of knowledge of, or comfort with, speaking

• The disturbance is not better explained by other disorders

• Often co-exist with social anxiety disorder

• Early onset, later diagnosis 

Specific phobia: DSM-5

• A marked, intense fear / anxiety of a specific object or situation that substantially interferes with the person’s ability to function

• Phobic object almost always evokes immediate and persistent fear / anxiety

• Phobic object is actively avoided or endured with intense fear/anxiety

• Fear / anxiety is out of proportion (irrational)

• Persistent: >6months

• Not better explained by another disorder

5 main categories

• Animals, Natural environments, Blood-Injection-injury, Situational, Other

• 75% > 1 phobia present

Often difficult to recall specific reason for onset

• Following a traumatic event

• Informational transmission

• Observational learning

Generalized Anxiety Disorder: DSM-5

• Excessive anxiety and worry, occurring more days than not for at least 6 months about a number of events or activities

• Difficulty controlling the worry

• Associated with 3 or more other symptoms:

  • Clinically significant distress or impairment

  • Not attributable to medication, substance or other medical or mental disorder

  • Physically impairing

Social Anxiety Disorder: DSM-5

• Marked fear/anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others:

  • Social interactions

  • Being observed

  • Performing in front of others

• Individual fears he/she will act in a way or show anxiety symptoms that will be negatively evaluated

  • humiliating or embarrassing

  • leading to rejection or offending others

• Social situations (and behaviours) are avoided or endured with intense fear/anxiety 

• Social situations almost always provoke fear or anxiety

• Fear/anxiety is out of proportion

• Persistent: > 6 months

• Clinically significant distress or impairment

• Not attributable to substance, medication, or other disorder/condition

• Panic attacks may occur

Panic Disorder: DSM-5

• Recurrent unexpected panic attacks

• Attacks are followed by one month period or more of (either/or):

  • Persistent worry about having additional attacks or their consequences

  • Significant change in behaviour because of the attacks

• Not attributable to substance, medicine or other disorder

A panic attack ≠ panic disorder

• Great variety in severity and frequency of attacks

• Possible episodic outbreaks with years of remission in between

Agoraphobia: DSM-5

• Marked fear or anxiety for more than 6 months about two or more of the following 5 situations:

  • Using public transportation

  • Being in open spaces

  • Being in enclosed spaces

  • Standing in line or being in a crowd

  • Being outside of the home alone

• Situations are avoided or endured with intense fear

  • Interferes with routine or functioning

Obsessive Compulsive Disorder (OCD): DSM-5

• Obsessions or compulsions (most often both)

  • Time-consuming (min. 1 hour per day)

  • Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Varying degree of insight

  • Avoidance

• Obsessions: persistent and recurrent intrusive thoughts, ideas, images or impulses

  • Content; Disturbing, offensive or irrational themes

  • Related to uncertainty about frightening prospects

  • Causes severe distress and anxiety

• Compulsions: repetitive behaviours, urges, rituals or mental acts

  • Regarded as excessive or exaggerated (especially in calmer moments)

  • Examples: Checking, Washing, Counting, Repeating routine activities, Reassurance seeking

  • Mental rituals: Excessive prayer, Repeating special phrases or numbers, Mental reassurance

Traumatic events

Exposure to one or more event(s) that involved death or threatened death, actual or threatened serious injury, or threatened sexual violation

• According to DSM-5:

  • Direct exposure

  • Witnessing the trauma

  • Learning that a relative or close friend was exposed to a trauma

  • Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g., first responders, medics)

• Lifetime prevalence of common mental disorders in conflict settings:

  • Posttraumatic stress disorder (PTSD): 30.6%

  • Depression: 30.8%

Posttraumatic stress disorder

• History:

  • “Soldiers Heart”, “Shell Shock”

  • Vietnam, KZ-syndrome

  • 1980 diagnosis PTSD in DSMIII

• Criterion B (one required): The traumatic event is persistently re-experienced, in the following way(s):

  • Unwanted upsetting memories, Nightmares, Flashbacks, Emotional distress after exposure to traumatic reminders, Physical reactivity after exposure to traumatic reminders

• Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the following way(s):

  • Trauma-related thoughts or feelings, Trauma-related reminders

• Criterion D (two required): Negative thoughts or feelings that began or worsened after the trauma, in the following way(s):

  • Inability to recall key features of the trauma, Overly negative thoughts and assumptions about oneself or the world, Exaggerated blame of self or others for causing the trauma, Negative affect, Decreased interest in activities, Feeling isolated, Difficulty experiencing positive affect

• Criterion E (two required): Trauma-related arousal and reactivity that began or worsened after the trauma, in the following way(s):

  • Irritability or aggression, Risky or destructive behavior, Hypervigilance, Heightened startle reaction, Difficulty concentrating, Difficulty sleeping

Risk factors for PTSD

• Pretrauma

  • genetic vulnerability

  • being female

  • low age

  • intelligence

  • low SES

  • prior trauma

  • prior psychiatric symptoms

• Peritrauma

  • perceived threat

  • negative interpretation of event

  • physiological arousal

  • anger and shame

  • dissociation during event

• Posttrauma

  • social support

  • coping

  • negative interpretation of consequences of the event

  • new life events

Spectrum of psychotic disorders

Psychosis symptoms

Positive symptoms

Present in a disorder and are not normally experienced by most individuals. Reflect an excess or distortion of normal functions.

• Hallucinations

• Delusions

Hallucinations

Experience involving the apparent perception of something not present

• Auditory

• Visual

• Tactile

• Olfactory

Delusions

A delusion is a fixed belief in something that’s untrue (despite evidence of the contrary).

• Persecutory – Paranoia

• Grandiose

• Reference

• Erotomanic

Disorganisation

• Speech: incoherent, Q&A don’t match

• Thought: loose, weird associations

• Behaviour: unpredictable, clumsy behaviour, catatonia (rigid)

Experiential negative symptoms

• Avolition – reduced motivation to engage in meaningful activities

• Anhedonia – reduced pleasure experience

• Asociality – preference to be alone, not initiating social contact 

Expressive negative symptoms

• Alogia – poor speech due to thought problems

• Blunted affect – reduced ability to express emotions (facial expression, intonation voice, movement)

DSM 5 Criteria diagnosis schizophrenia

B: Social / professional disfunctioning

C: Duration: at least 6 months disturbed functioning, with 1 month symptoms

Excluding…

D. Schizoaffective or mood disorder

E. Use of medication, drugs or somatic disorder

F. Pervasive developmental disorder (ASD)

Psychosis vs. Schizophrenia

Schizophrenia as a heterogeneous disorder

Other symptoms of schizophrenia: cognitive problems

• Neurocognitive problems

• Social cognitive problems

Social cognition deficits

• Emotion recognition

  • more sensitive to negative emotions

  • neutral is negatively interpreted

• Theory of Mind

  • problems interpreting situations

• Social perception

• Attribution style

  • externalising positive events

  • internalising negative events

• Data gathering bias

  • jumping to conclusions: overconfidence

  • in the decision

Prevalence & Definition of Schizophrenia

“Schizophrenia is a severe, chronic mental disorder characterized by disturbances in thought, perception and behavior.” - DSM-5.

• Prevalence: 0.3 – 1 % of the population

  • 1.5–3.5% will experience during lifetime

  • 0.2% new cases per year (incidence)

• Typical age of onset: 16 – 30 adolescence/ early adulthood!

  • Important development is disrupted

• More common in males than females, but depending on age group

Schizophrenia and age & sex

Adolescence is the phase of risk

Comorbidity of schizophrenia

Important! Many schizophrenia symptoms overlap with other disorders (e.g., depression, bipolar disorder) and comorbidity is high.

• Substance abuse (47%)

• Anxiety & Depression (50%)

• Panic disorder (15%)

• PTSD (29%)

• OCD (23%)

Costs of schizophrenia 

• Unemployment: more than in non-schizophrenia persons (70% vs. 28%)

• Productivity loss: about 1/3 less productivity/income

• Health care services: 10-20 years shorter life

• Adolescent development interrupted → deficits

Developmental course of schizophrenia

Phases:

• Premorbid phase – impairments in language, cognition, social functioning.

• Prodromal phase – attenuated or milder symptoms of psychosis (high risk state).

• Transition to (first episode of) psychosis - approx. 1/3 of at-risk individuals transition after 3 years

Psychosis outcome

10 years after diagnosis of schizophrenia (NL) …

25% are completely recovered

25% are strongly improved, relatively independent

• 25% are improved, but needs extensive network of help

• 15% are hospitalised, not improved

• 10% are deceased (mainly suicide) 

Neurodevelopmental disorder

• Pre- and perinatal risk factors: linked to aberrant synaptic pruning during adolescence

• Developmental problems: Minor physical abnormalities and/or neurological soft signs 

  • (Motor, social, cognitive)

• Structural brain abnormalities 

  • (Ventricular enlargement, grey matter reductions, white matter disruption)

Heritability of schizophrenia

Genes are necessary, but not sufficient for the development of schizophrenia.

• Heritability 80-90%

Environmental factors in schizophrenia

• Childhood:

  • Rearing (attachment/ communication styles): paranoia

  • Brain injury

  • Abuse (trauma) - hallucinations

• Adolescence – adulthood:

  • Substance abuse - cannabis (initiate or aggravate)

  • Migration / ethnicity - paranoia

  • Urbanicity

  • Social adversity

  • Life events, trauma

Developmental mechanisms: Cognitive models of hallucinations

Internal voice seems externally generated →

• Source attribution

• Self monitoring

• Forward prediction model

Psychological models of schizophrenia

• Aberrant salience (dopamine)

  • Giving importance / attention to “unimportant” stimuli

  • Also in ToM

• Prediction error (N-Methyl-D-aspartic acid (NMDA) receptors) - delusions

  • Wrong predictions, explained “differently” to make sense

• Abnormal attributions - paranoia

• Source monitoring (grey matter reductions in mPFC) – hallucinations

→ Connected to each other!

Salience hypothesese

• DA secretion can lead to irrelevant stimulus-reward associations

→ unimportant things become important

• Hallucinations – giving importance to internal representations,

→ seem to be external stimuli

• Delusions – a ‘top-down’ cognitive explanation of increased importance or of insecurity (need for closure)

→ trying to explain the event

Dopamine and symptoms

• Important in reward learning

• Important for salience, motivation and attention

  • Excessive dopamine levels increase salience

  • → Leading to positive symptoms like delusions

• Medication almost exclusively on DA

  • 1/3 of patients is treatment resistant

  • → then Clozapine is prescribed

Dopamine sensitisation

• No tolerance (getting used to it), but hyper-sensitive

  • (c.f. stress, but unlike drugs)

• Environment impacts on several neurotransmitter systems, but the dopaminergic system is prone to sensitisation

Treatment of schizophrenia

• Antipsychotic medication

  • Dopamine: risperidone, olanzapine, quetiapine, aripiprazole

  • Treatment resistant: clozapine

    • D2 & D4 receptors; Serotonine; Histamine, acetylcholine,

    • Indirect effect on glutamate (not on NMDA receptors)

• Cognitive behaviour therapy (CBT)

• Cognitive remediation

• “Newer” approaches

  • In the social environment rather than in an institution (FACT teams)

  • Integrating first, then other treatment:

    • Individual placement and support (IPS)

Feeding and Eating Disorders

Disturbance of eating or eating-related behaviour that results in

• (1) the altered consumption of food

• (2) significantly impaired health and / or functioning

DSM-5 Feeding and Eating Disorders

Feeding Disorders

• Pica

• Rumination Disorder

• Avoidant / Restrictive Food Intake Disorder (ARFID)

Eating Disorders

• Anorexia Nervosa (AN)

• Bulimia Nervosa (BN)

• Binge-Eating Disorder (BED)

Feeding and eating disorders are largely mutually exclusive

Obesity is considered a medical problem, not an eating disorder

Pica

• Persistent (1+ month) eating of non-nutritious, non-food substances

• Prevalence is unknown

• Can occur in typically developing children, but most often comorbid with ASD / IDD

• Can result in medical complications and emergencies

Rumination Disorder

• Persistent (1+ month) and repeated regurgitation of food

• Spontaneous

• Food may be re-chewed, re-swallowed, or spit out

• Prevalence is unknown

• Associated with malnutrition, especially in infancy

Avoidant / Restrictive Food Intake Disorder (ARFID)

• Lack of interest in food

• May be based on appearance, smell, taste, texture, brand, presentation, or a past negative experience with the food

• 1+ of the following symptoms:

  • Substantial weight loss or failure of expected weight gain

  • Nutritional deficiency

  • Dependence on a feeding tube or dietary supplements

  • Significant psychosocial interference

• Prevalence unknown

Major Features of Eating Disorders

• Weight Concerns

  • Feeling overweight much of the time

  • Viewing one’s weight negatively

• Body Dissatisfaction

  • Distress with one’s appearance

• Eating Problems

  • Restricted eating or dieting

  • Lack of control over eating

Anorexia Nervosa: Symptoms

• Restriction of energy intake relative to requirements leading to a significantly low body weight

• Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight

• Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Anorexia Nervosa: Types

• Restricting Type: The person does not regularly engage in binge eating.

  • This is a subtype that is typically associated with the stereotypical view of anorexia nervosa.

• Binge-Eating/Purging Type: The person regularly engages in binge eating and purging behaviours, such as self-induced vomiting and/or the misuse of laxatives or diuretics.

  • The binge eating/purging subtype is similar to bulimia nervosa; however, there is no weight-loss criterion for bulimia nervosa

Anorexia Nervosa: Severity

Based on BMI

• Mild: >17

• Moderate: 16-16.99

• Severe: 15-15.99

• Extreme: < 15

Prevalence, Development, and Course of AN

• 12-month prevalence among females is ~0.4%

• Onset typically during adolescence/puberty

  • Often begins after stressful event or life transition

• Course and outcome are highly variable

  • But most experience remission within 5 years

Risk Factors for AN

• Temperament

  • Perfectionism

• Environmental

  • Cultures that value thinness

• Genetic and physiological

  • Heritable

  • Brain abnormalities

Functional Consequences of AN

Death from medical complications

• Leukopenia

• Anemia

• Dehydration

• Low hormone levels

• Heart problems

• Kidney problems

• Osteoporosis

• Electrolyte imbalance

• Hypotension

• Hypothermia

• Dental enamel erosion

Increased suicide risk

Treatment of AN

• Treatment for anorexia nervosa tries to address three main areas:

  • Restoring the person to a healthy weight

  • Reducing or eliminating behaviours or thoughts that originally led to the disordered eating

  • Treating the psychological disorders related to the illness

Binge episode

• Eating a large amount of food in a short period of time, AND

  • 2000+ calories in <2 hours

• A sense of lack of control over the eating

Compensatory behaviour

• Inappropriate behaviour that is done in order to prevent weight gain

• Classified as "purging" or "non-purging"

Bulimia Nervosa

• Recurrent episodes of binge eating

• Recurrent inappropriate compensatory behaviour

• Self-evaluation is unduly influenced by body shape and weight

• The binge eating and inappropriate compensatory behaviours both occur at least once a week for 3 months

• The disturbance does not occur exclusively during episodes of anorexia nervosa

Bulimia Nervosa: Prevalence, Development, and Course

• Prevalence in females is 1-1.5%

• Onset in adolescence / young adulthood

• Binging may onset after dysfunctional dieting

• Course is chronic

• Diagnostic crossover with AN and BED

• High comorbidity

Bulimia Nervosa: Risk factors

• Temperamental

  • Impulsivity

• Environmental

  • Childhood abuse

• Genetic and physiological

  • Heritable

  • Childhood obesity

  • Early pubertal maturation

Bulimia Nervosa: Functional Consequences

• Dental Problems

• Swelling of salivary glands

• Esophageal problems

• Chronic diarrhea

• Bowel problems

• Suicidal ideation

Binge Eating Disorder

• Recurrent episodes of binge eating

• Binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa

• Marked distress regarding binge eating

• The binge eating occurs at least once a week for 3 months

• Binge eating does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

BED: Prevalence, Development, and Course

• Prevalence in females is 3.5% and 2.0% in males

• Onset largely unknown

• Dysfunctional dieting may onset after binging

• Remission rates are high(er)

• Crossover is uncommon

• High comorbidity

BED: Risk factors

• Temperamental

  • Impulsivity

• Genetic and physiological

  • Heritable

BED: Functional Consequences

• Obesity and associated health risks

  • High blood pressure

  • Diabetes

  • Heart disease

  • Sleep apnea

BN vs. BED Severity

Treatment for BN & BED

• Cognitive Behavioural Therapy

  • Break the binge-purge cycle

  • Reduce binging and purging behaviours

  • Challenge automatic negative thoughts

  • Learn adaptive coping strategies

• Nutritionists may also help with structured meal plans and exercise regimens

• Medication (SSRIs) can help ease impulse control problems and reduce binge eating