Psychopathology Exam 3

Depresive Disorders

Major Depressive Disorder, Persistent Depressive Disorder, Depressive Disorder Related to Reproductive Events

Major Depressive Disorder (MDD)

Persistent sad or low mood that impairs a person’s interest in, or ability to engage in, normally enjoyable activities; in adults depressed mood is essential to a major depressive episode; depressed mood OR loss of interest or pleasure; In children, mood disturbance may manifest as irritability or hostility; Symptoms must last for two weeks and interfere with functioning; Feelings of complete worthlessness or extreme guilt; May be at risk to harm self; Disruption in sleep, appetite, and sex drive; Symptoms cannot be a response to physical illness or the reaction to a loss of a loved one; Episodic: can be single (single episode of depression that lasts at least 2 weeks) or recurrent; Must have at least one depressive episode and no episodes of mania

Atypical Depression

Between 18-36% of people are diagnosed with this form of depression which includes too much sleep or eating

Prolonged Grief Disorder

symptoms of grief persist for more than a year, plus other psychological symptoms that are present every day (or most days) for at least the last month

Persistent Depressive Disorder (Dysthymia)

Chronic state of depression; Milder symptoms of major depressive disorder, but more chronic; Symptoms last two or more years – person is never without symptoms for more than two months; Can lead to social isolation and higher risk for suicide; not episodic like MDD; often goes undiagnosed

Double Depression

dysthymia (Persistent Depressive Disorder) with major depressive episodes; A combination of episodic major depressions superimposed on chronic low mood

Depressive Disorder Related to Reproductive Events

disorder unique to women associated with significant hormonal fluctuations and impact mood; at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses

Premenstrual Dysphoric Disorder (PMDD)

more severe forms of premenstrual mood symptoms occur with the menstrual cycle; Symptoms include deep sadness, anxiety and tension, anger or irritability, and panic attacks; Changes in sleep, appetite, and libido may also occur; Prevalence: 1% to 8% of women of reproductive age

MDD with Peripartum Onset

Symptoms are similar to MDD; Mothers can feel overwhelmed, empty, disconnected from their child, or guilty for not feeling the joy of motherhood; Prevalence: 6.5% to 12.9% within the first 6 months after birth; 80% of women develop the baby blues, heightened emotions, subside after 2 weeks postpartum; Risk is increased with birth complications

Epidemiology of Depression

most common psychiatric disorder in the U.S.; rates twice as high in women; lifetime prevalence of 20.6%; mean age of onset is 29.1 years; Non-Hispanic White people have higher rates of this than non-Hispanic Black people and Hispanic populations

Mania

high or euphoric mood that is clearly excessive and is often accompanied by inappropriate and potentially dangerous behavior, irritability, pressured or rapid speech, and a false sense of well-being

Bipolar Disorder

individual experiences a manic episode with or without preceding or subsequent depressive episodes; typically consists of extreme shifts in mood, energy, and ability to function. It is a long-term episodic disorder in which mood shifts between the two poles of mania and depression.

Mixed Features

individual experiences symptoms of mania and depression at the same time

Bipolar 1

full-blown mania alternates with episodes of major depression, Includes at least one manic episode; includes Unipolar mania: a single manic episode without periods of depression; There has never been a manic episode

Bipolar 2

hypomanic episodes or “mild mania” alternates with major depressive episodes; At least one major depressive episode and at least one hypomanic episode; Less severe than Bipolar I

Hypomania

clearly abnormal mood deviation but not to the point of full mania, may be overly talkative, excitable, or irritable, but there are no impulsive acts or gross lapses of judgment; lasts at least four days, but does not significantly interfere with functioning;

Rapid Cycling Bipolar Disorder

 four or more severe mood disturbances within a single year

Epidemiology of Bipolar Disorder

Lifetime prevalence of Bipolar I is 0.6% and Bipolar II is 0.4%; Occurs up to two times more in North and South America compared to rates in Africa and Asia; Average age of onset is 17 years; Commonly comorbid with substance use disorders, anxiety disorders, and impulse control disorder; Fairly equal across sexes; Fairly equal across racial/ethnic groups

Disruptive Mood Dysregulation Disorder

a new diagnosis that has been controversial; Reserved for children aged 6 to 18 with severe recurrent temper outbursts that are grossly out of proportion in intensity or duration in the situation; hopes to slow the rate of diagnoses of childhood bipolar disorder, which was being overdiagnosed

Suicide

10th leading cause of death in the United States; 2nd leading cause of death between ages 10 and 34; Rates decreasing in the world, Rates increasing in the US;  rates are 3.7 times higher in men and occur more often in urban settings; Previous attempts increase risk 30 to 40 times; Highest rates among American Indian/Alaska Native, non-Hispanic White, and Black males; 8X higher risk for individuals diagnosed with psychological disorders

Suicidal Ideation

thoughts of death; thoughts and plans

Passive Suicidal Ideation

type of suicidal ideation; wish to be dead without active planning

Active Suicidal Ideation

type of suicidal ideation; includes details on how to commit the act

Parasuicides

acts such as superficial cutting or overdoses of nonlethal amounts of medication; less likely to result in heath

Psychological Autopsy

Putting together the events leading to suicide, Accomplished by structured interviews with family, friends, coworkers, and health-care providers; identifying causes, motives, circumstances, potential stressors, intent, lethality; About 30% to 50% of people who die by suicide leave a suicide note; More likely to be single females, in financial or partnership crisis, and have a medical illness; Also more likely among Non-Hispanic White people, followed by Asian/Pacific Islanders

Etiology of Depression: Biological

Heritability rate is 40%; ⅓ of the risk of depression is due to genetic factors, the rest is environmental; Scientists have not been able to identify individual genes

Etiology of Bipolar Disorder: Biological

Heritability estimates of 60% to 80%; One of the most heritable psychological disorders; Studies suggest overlap in genes for bipolar, depression, and schizophrenia; Important brain regions are involved with emotional reactivity/regulation and parallel findings for depression; Brains have less volume and thickness

Etiology of Depression and Bipolar Disorder: Psychological

Psychodynamic theory (Freud): explains depression as “anger turned inward”

• Anger arises after a real or unconscious loss

• Melancholia

• View depression and mania are interlinked – mania is a defense against unwanted depression

Behavioral theories (Skinner): proposes that depression results from the withdrawal of reinforcement for healthy behaviors.

• A lack of social skills may impact the development of depression

Learning and modeling (Seligman)

• Learned helplessness: External uncontrollable environments (abuse) and internal uncontrollable environments (pervasive low mood) are inescapable stimuli that can lead to depression; depends on if the person thinks the situation is inescapable; but if negative events are seen as external (I lost my job because my boss is mean) helplessness can be averted 

Cognitive theory (Beck): (thoughts cause behaviors) proposes that negative thinking causes depression

• Negative cognitive schemas

  • Can be identified by automatic thoughts (I’m a failure, I will never fall in love, extreme and become fixes, self fulfilling prophecy) 

  • Negative cognitive triad: negative thoughts about the self, the world, and the future 

Learned Helplessness

Part of the learning and modeling theory of depression and bipolar disorder by Seligman; External uncontrollable environments (abuse) and internal uncontrollable environments (pervasive low mood) are inescapable stimuli that can lead to depression; depends on if the person thinks the situation is inescapable; but if negative events are seen as external (I lost my job because my boss is mean) helplessness can be averted 

Negative Cognitive Triad

Part of the Cognitive theory of depression and bipolar disorder by Beck; negative thoughts about the self, the world, and the future

Treatment of Depressive Disorders: Biological

First they need a comprehensive medical examine to rule out a medical reason such as illness or medication; Medications are the primary treatment

• First-generation antidepressants (Tricyclics and MAOIs) effective (mostly in adults) but they have a lot of side effects so they are no longer the first choice 

• Second-generation antidepressants (SSRIs and SNRIs); Prozac is the most common; effective, fewer and milder side effects 

• Psychedelics (LSD and ketamine); supervised use; improvement within hours, very fast acting; concern about safety and addiction

Light therapy (used for seasonal affective disorder); ECT for resistant and very severe cases; Trans-cranial magnetic stimulation for treatment resistant cases; Deep brain stimulation, one of the last resorts

Treatment of Depressive Disorders: Psychological

focus on understanding how thoughts, perceptions, and behaviors influence depression

• CBT: improve mood by changing thoughts/ behaviors; individual can learn how to think and behave differently  (GOLD STANDARD-FIRST CHOICE TREATMENT)

• Interpersonal psychotherapy (IPT): interpersonal problems can trigger depression and depression can influence interpersonal functioning

• Behavioral activation: focus on increased contact with positive reinforcement for healthy behaviors which results in positive moods

Treatment of Bipolar Disorder: Biological

medications are primary treatment; psychotherapy alone is not sufficient 

• Lithium - most commonly prescribed medication; intended to be taken long term, needs to be used consistently; Bipolar is lifelong and there is no cure 

• Anticonvulsant medications (Lamotrigine)

• Second-generation antipsychotics (risperidone, quetiapine, and ariprprazole)

• ECT

• Deep brain stimulation, transcranial magnetic stimulation and transcranial direct current stimulation

Adjunctive treatments (work when combined with medications, combination treatments)

• CBT

• Interpersonal and Social Rhythm Therapy (IPSRT): focuses on sticking to daily routines and sleep patterns (social rhythms)

  • SRT promotes adherence to regular routines

  • SRT by itself is shorter and more manageable than when combined with IPT

Nutraceuticals (food or part of a food with health benefits, amino acids( are used to target inflammation, oxidative stress, and mitochondrial dysfunction

Anorexia Nervosa

condition marked by a restriction of energy intake relative to needed requirements; results in significantly low body weight in the context of age, sex, developmental trajectory, and physical health; intense fear of becoming fat, even though severely underweight; Perceptual Distortion: perceive weight or shape as large even when emaciated; to an extreme degree; Place undue importance on body weight and shape as measures of self-evaluation; can lead to very low self-esteem; Deny the seriousnessness of low body weight; do not think its an issue that they could even lose more weight; very hard to get treatment; Highest mortality rate of any psychological disorder; Two Subtypes: Restricting: reduced caloric intake and increased physical activity; Binge eating/purging: eating a large amount of food in a short period and then purging it from the body (can show up as excessive exercise)

Weight Suppression

difference between the highest past weight and the current weight, shows severity

Amenorrhea

the absence of menstruation for at least three consecutive months; used to be a factor of diagnosis for AN, but removed now because people can have AN without having lost their period

Restricting

Subtype of AN: reduced caloric intake and increased physical activity

Binge Eating/Purging

Subtype of AN: eating a large amount of food in a short period and then purging it from the body (can show up as excessive exercise)

Epidemiology of AN

Lifetime prevalence: about 1%; Many more individuals may have subclinical symptoms; More common in females than males; Adolescence is the typical time period for the onset ; Incidence rate is increasing over time; At risk are those in the entertainment industry and athletes; Comorbidity: Major Depression (80%) Anxiety (75%)

Bulimia Nervosa

 Recurrent episodes of binge eating with recurrent inappropriate compensatory behaviors (help stop weight gain, throwing up, laxatives); Can occur at any body weight; includes Binge Eating: Consumption of an amount of food in a discrete period of time that is larger than most would consume, hallmark feature is a sense of lack of control; Pattern varies (once per week for 3 months is required for diagnosis); Inappropriate Compensatory Behaviors: any actions used to counteract the binge or prevent weight gain

Inappropriate Compensatory Behaviors

any actions used to counteract the binge or prevent weight gain; E.g. self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, and excessive exercise

Epidemiology of BN

Lifetime prevalence: 2-3% ; Many more individuals may have subclinical symptoms ; Many keep their behavior a secret due to stigma and shame; More common in females than males; Onset is middle or late adolescence to early adulthood; Physical complications associated with bulimia nervosa: fatigue, lethargy, cardiac arrhythmia, and gastrointestinal problems (bloating, constipation, abdominal pain, etc.); Disorder is hard on the body (issues from vomiting and use of laxatives); 2X more likely to die

Binge Eating Disorder

Characterized by recurrent binge eating, but without compensatory behaviors; Most common eating disorder; 3-6 times more likely to be obese

Other Specified Feeding and Eating Disorders (OSFED)

Must cause significant distress and functional disorder; 5 categories: Atypical anorexia nervosa; Bulimia Nervosa (of low frequency and/or limited duration); Binge Eating Disorder (of low frequency and/or limited duration); Purging Disorder; Night Eating Syndrome

Unspecified Feeding or or Eating Disorder (residual Category)

feeding disorder that does not fit in OSFED; includes Orthorexia Nervosa: obsession with healthy eating 

Pica

Persistent eating of nonnutritive, nonfood substances (e.g., earth, charcoal, paper, chalk, etc.) over a period of at least a month; Children with developmental disabilities make up the largest group; Prevalence is 5% in school-aged children; Occurs in all SES groups, sexes, ages, and racial/ethnic groups; Can result in serious health consequences; Cultural pica exists in India, Africa, and the U.S.; Potential Causes: Iron and zinc deficiencies; Environmental factors (stress, poverty); Developmental disorders

Rumination Disorder

recently eaten food is regurgitated, then rechewed, reswallowed, or spit out; Occurs in both sexes and may begin in infancy, childhood, or adolescence; Episodes may occur several times per day, last for more than an hour, and often occur within 2 hours of eating a meal; Overall prevalence is unknown, but common among adults with intellectual disabilities; Cannot be diagnosed with another DSM-5 feeding or eating disorder; Can include Medical complications

ARFID

restricted or inadequate eating, sometimes to regulate emotions, an emotional crisis, or an unpleasant experience; a lot of the time it is due to the sensory experience, leading to a small range of foods that are eaten; Most common in children and adolescents and can persist into adulthood; Prevalence not well-studied; Comorbid conditions include anxiety, pervasive developmental disorder, and learning disorder

Etiology of Eating Disorders: Biological

Animal Models: help us develop models of behavioral components, such as food restriction and binge eating 

Role of hypothalamus: regulates metabolic processes and is influential in appetite and weight control 

• Ventromedial hypothalamus: regulates overeating 

• Lateral hypothalamus: regulates appetite 

Addiction model of binge eating: neurological systems associated with addiction may play a role in development of binge eating

• More dopamine is released after exposure to a food stimulus among people with BED 

Brain structure and functioning studies

• Structural 

  • AN has less gray matter in cerebellum, temporal, frontal, and occipital cortices when compared to BN 

  • People with BN have increased gray matter in frontal and ventral striatal areas 

• Functional 

  • Disturbance in information flows across brain networks in the corticolimbic circuity with AN 

  • Abnormal neurological responses to food cues and anticipated food receipt with BN and BED 

• Family and Genetic Studies 

  • Eating disorders do run in families 

  • Individual chromosomes have been targeted for AN and BN

Etiology of Eating Disorders: Psychological

• Psychodynamic perspectives 

  • Focus on early life experiences 

  • AN is an attempt to defend against anxiety associated with emerging adult sexuality 

  • More contemporary models focus on interpersonal relationships and deficiencies in the sense of self 

• Cognitive Behavioral Theories 

  • Distorted cognitions about body shape, weight, eating, and personal control 

  • CBT treatment takes a transdiagnostic approach 

• Sociocultural Theories 

  • Emphasize Western preoccupation with thinness as beauty

  • Follows a path starting with thin ideal and ending in restriction

Treatment of Eating Disorders: Biological

• Pharmacological treatments

  • For AN: no medication has been identified as effective

  • For BN: Fluoxetine, an antidepressant, is the only FDA-approved medication

  • For BED: evidence exists for efficacy of second-generation antidepressants, the anticonvulsant (Topamax), and the amphetamine (Vyvanse)

• Nutritional counseling needed for eating disorder, not effective as a stand alone 

  • Individualized nutrition plans integral for all eating disorders

  • For AN: normalization of eating, set appropriate goal weights, and calculate caloric intake for weight gain

  • For BN: relearning appropriate portion sizes, relearn how to eat meals normally, calculate caloric intake for weight maintenance or weight loss, and find new ways to deal with urges for bingeing

  • For BED: centered around appropriate portion sizes and normalizing eating

Treatment of Eating Disorders: Psychological

(MORE RECOMMENDED)

• Cognitive behavioral therapy (CBT) BEST

  • Helps patients change patterns in thinking

  • Addresses cognitive distortions, automatic thoughts, and core beliefs

  • Enhanced CBT (CBT-E) consists of 20 sessions over a course of 5 months where patients are taught about eating disorders and taught to monitor their behaviors-very effective 

  • Dialectical behavioral therapy (DBT) focuses on emotional dysregulation 

• Interpersonal psychotherapy (IPT)

  • Brief, time-limited psychotherapy

  • Focuses primarily on decreasing eating disorder symptoms by enhancing social skills in relationships

  • Based on the principle that one’s disordered eating behaviors and symptoms are intertwined with interpersonal relationships

  • Goals are to decrease eating disorder symptoms and to improve interpersonal functioning by enhancing communication skills in significant relationships interpersonal disputes, role transitions, abnormal grief, or interpersonal deficits

• Family-based interventions  FAMILY INVOLVEMENT IN THE TREATMENT OF AN IS CRITICAL

  • Conjoint family therapy

  • Separated family therapy

  • Parent training

  • The Maudsley method (MOST EFFECTIVE) it involves the parent to empower them to take an active role in the treatment and its success/ EMPOWERS PARENTS

Maudsley Method

most effective family-based therapy intervention for eating disorders; it involves the parent to empower them to take an active role in the treatment and its success/ EMPOWERS PARENTS

Treatment of Feeding Disorders in Children

• Behavioral interventions such as overcorrection may be effective for pica

• Medications are not efficacious

• Behavioral interventions such as habit reversal, relaxation training, and CBT are efficacious for rumination disorder

• CBT and family-based treatment are effective for ARFID

The Treatment of Eating Disorders

• Normalization and stabilization of eating behavior and weight are central goals in treating all eating disorders 

• Anorexia Nervosa – goal is to increase caloric intake and gain weight

• Bulimia Nervosa and BED – goals are to eliminate use of binge eating (and purging) and to improve psychological aspects

• BED – Controversy exists over whether weight loss should be a therapeutic outcome for patients who are overweight or obese

  • Health at Every Size Movement

Inpatient Treatment for Eating Disorders

• Comprehensive approach with multidisciplinary team for AN

• Decision to do inpatient treatment

  • Individuals who are 85% or less of their expected body weight and who have medical complications; highly unlikely to be successful without inpatient treatment 

  • Other factors include those who have attempted suicide, who have comorbid disorders

• Stages of treatment

  • Restore weight

  • Psychotherapy

  • Earn privileges based on weight gain

  • Collaboration between patient and staff

• Involuntary treatment by means of legal commitment occurs for a minority of patients with eating disorders, especially for those who are suicidal

  • Legally, self-starvation is considered a behavior that endangers life

  • Last resort