Clinical Pysch test 2 (mood and anxiety disorder)

Epidemiology

The scientific study of how diseases and other health conditions are distributed (who, when, where) and determined (causes, risk factors) within populations, and then applying that knowledge to control health problems

Prevalence, gender, culture

Etiology

the study of the causes, origins, or reasons behind a disease, symptom, or medical condition

Evidence-based Treatment

• Medication and psychotherapy

• First line approaches, and in some cases, second line approaches when those fail

Clinical description

Symptoms, syndromes, diagnostic criteria, case studies

Test fromat

Clinical description

Epidemiology

Etiology

Evidence-based treatment

Mood disorders

Disorders, such as depressive disorders or bipolar disorders, in which there are disabling disturbances in emotion.

Two Broad types of mood disorders

Unipolar depressive disorders

Bipolar disorders

Unipolar depressive disorders

a mental health condition characterized by persistent, intense feelings of sadness, low mood, and a lack of interest in activities (anhedonia) without any manic or hypomanic episodes

Bipolar disorder

a chronic mental health condition characterized by intense mood swings, ranging from extreme highs (mania/hypomania) to severe lows (depression)

How many Unipolar depressive disorder

Major depressive disorder (MDD)

Persistent depressive disorder (PDD)

Premenstrual dysphoric disorder (PDSD)

Disruptive mood dysregulation disorder (DMDD)

4

How many Bipolar disorders

Bipolar I disorder

Bipolar II disorder

Cyclothymia

3

Major depressive disorder (MDD) Criteria

5+ Symptoms

• o Sleeping too much or too little

• o Psychomotor retardation or agitation

• o Poor appetite and weight loss, or increased appetite and

• weight gain

• o Loss of energy

• o Feelings of worthlessness or excessive guilt

• o Difficulty concentrating, thinking, or making decisions

• o Recurrent thoughts of death or suicide

(Including sad mood or anhedonia) (must have one)

For 2 weeks (nearly all or most days)

anhedonia

the reduced ability to experience pleasure or a total loss of interest in activities once enjoyed

Major depressive disorder Symptom list (5)

• o Sleeping too much or too little

• o Psychomotor retardation or agitation (Slow movement vs fidgeting)

• o Poor appetite and weight loss, or increased appetite and

• weight gain

• o Loss of energy

• o Feelings of worthlessness or excessive guilt

• o Difficulty concentrating, thinking, or making decisions

• o Recurrent thoughts of death or suicide

Psychomotor retardation

Thoughts and movements may slow

Psychomotor agitation

Cannot stand still (Fidget, pace etc)

Episodic disorder (Which disorder)

MDD because symptoms present for a period then clear. Once one episode finishes it can appear in a couple months or years etc.

Among people with a first depressive episode

15% state symptoms persists for about 10 years

50% who recover from first MDD episode experience at least one more across 10 years

Persistent Depressive Disorder (PDD) Criteria

• Depressed mood for at least 2 years

  • o 1 year for children/adolescents

• At least two of the following during that time (2):

  Sleeping too much or too little

  Poor appetite or overeating

  Low energy

  Poor self-esteem

  Trouble concentrating or making decisions

  Feelings of hopelessness

Persistent depressive disorder

chronically depressed—more than half of the time for at least 2 years, they feel blue or obtain little pleasure from activities and pastimes.

Premenstrual dysphoric disorder

Mood symptoms in the week before menses

Disruptive mood dysregulation disorder

Severe recurrent temper outbursts and persistent negative mood for at least 1 year beginning before age 10

Epidemiology and Consequences of Depression (1 of 2)

• Depression is common

  • o Lifetime prevalence:

  • • 16.2% MDD (FOR US in some point in their life)

  • • 5% Depression more than 2 years (US)

• • Twice as common in women as in men

  • o Three times as common among people in poverty

• • Prevalence varies across cultures

• o MDD

  • • 6.5% in China

  • • 21% in France

• o Cultural factors play an important role in depression rates

(4 things to remember)

MDD and PDD comorbidity %

45

Approximately _______ % of people will experience MDD during their lifetime.

16.2

Epidemiology and Consequences of Depression (2 of 2)

• Symptoms vary across cultures

  • o Focus on somatic symptoms (e.g., pain, fatigue)

• • Ethnic minorities in the US

• • People from Latin America and some Asian countries

• • Age of onset

  • o Early 20s

  • o Decreased over past 50 years

• • Co-morbidity

  • o 5-30% with MDD experience PDD

  • o 60% of those with MDD will also meet criteria for anxiety disorder at some point

• With each generation, age of onset gets lower for MDD

Manic and hypomanic Episode criteria (Ask in class)

4 (3) symptoms (5 (4) if mood is not elevated)

• Distinctly elevated or irritable mood

• Abnormally increased activity and energy

• PLUS other symptoms:

o Increased goal-directed activity or psychomotor agitation

o Talkativeness or rapid speech

o Flight of ideas or racing thoughts

o Decreased need for sleep

o Increased self-esteem or grandiosity

o Distractibility

o Excessive involvement in activities that are likely to have undesirable

consequences (e.g., reckless spending/sexual behavior/driving)

Manic episode criteria presentation

• Symptoms last at least 1 week, require hospitalization, or include psychosis

• o Symptoms cause significant distress or functional impairment

hypomanic episode criteria presentation

• o Symptoms last at least 4 days

• o Clear changes in functioning that are observable to others, but impairment is not marked

• o No psychotic symptoms are present

(Less intense and does not disrupt life)

Bipolar I Criteria

 1.At least one episode or mania during the lifetime

2.May or may not have a depressive episode during the lifetime

In fact, even someone who experienced only 1 week of manic symptoms years ago is still diagnosed with bipolar I disorder.

mania

Intense elation or irritability, accompanied by symptoms such as excessive talkativeness, rapid thoughts, distractibility, grandiose plans, heightened activity, and insensitivity to the negative consequences of actions.

Bipolar II Criteria

o At least one major depressive episode

o At least one episode of hypomania

o No episodes of mania

hypomania

a change in functioning that does not cause serious problems.

Cyclothymic disorder criteria

o Milder, chronic form of bipolar disorder

o Symptoms lasts at least 2 years in adults

• 1 year in children/adolescents

o Numerous periods with hypomanic and depressive symptoms

• Does not meet criteria for hypomania or major depressive Episode

• Symptoms do not clear for more than 2 months at a time

• Symptoms cause significant distress or impairment

Prevalence of Bipolar disorders

1% in U S; 0.6% worldwide for Bipolar I

0.4% – 2% for Bipolar II

4% for Cyclothymia

age of onset in Bipolar disorders

Average age of onset in 20s

No gender differences in rates of bipolar disorders

Consequences of Bipolar disorder

o 15% unemployed full-time in past year

o Suicide rates high

o One in four report suicide attempt

• More than half report suicidal ideation in past 12 months

Heritability Mood disorders Estimates

o 37% MDD

o 93% Bipolar Disorder

• Unlikely one gene explains these illnesses

o More likely Gene x Environment Interaction

Gene for MDD

• Serotonin transporter gene (5-HTT) polymorphism

o Short allele combination of the 5-HTT gene and childhood maltreatment or adulthood stressful life events increases risk of MDD

Etiology of Mood Disorders: Neurotransmitters (NTs)

Norepinephrine, dopamine, and serotonin effect mood disorders

New models focus on sensitivity of postsynaptic receptors

o Stress may lead to changes in sensitivity of serotonin receptors

o Dopamine plays a major role in the reward system

o Dopamine dysfunction may be connected to specific symptoms

(e.g., changes in energy and motivation)

o Dopamine receptors may lack sensitivity in MDD

o High receptor sensitivity in mania– fluctuating?

Etiology of Mood Disorders

• o Genetic factors

• o Neurotransmitters

• o Brain regions

• o Neuroendocrine System

• o Social factors

• o Psychological factors

Etiology of Mood Disorders: Brain Function

• Oversensitivity to emotional stimuli (elevated amygdala)

•  • Interference with emotion regulation (elevated anterior cingulate, diminished prefrontal cortex and hippocampus) 

• • Motivation to pursue rewards (striatum, dopamine activity) • Disruptions in the connectivity of these regions

Etiology of Mood Disorders: Neuroendocrine System

Overactivity of HPA axis (Releases cortisol)

High cortisol damages hippocampus

effects in MDD and BD

Etiology of Mood Disorders: Social Factors in Depression

o 42-67% report a stressful life event in year prior to depression

o 40% risk of developing depression when experiencing stressful

life event without support (4% risk with support)

• Interpersonal difficulties

o High levels of expressed emotion predict relapse

o Marital conflict also predicts depression

o Lack of social support

o Reassurance-seeking

Etiology of Mood Disorders: Psychological Factors in Depression (1 of 4)

Neuroticism

o Tendency to experience frequent and intense negative affect

o Also predicts onset of anxiety, which is highly comorbid withdepression

• Cognitive Theories

o Negative thoughts and beliefs cause depression

o Beck’s Theory, Hopelessness Theory, Rumination Theory

Beck’s theory

Consists of Negative triad, negative Schema, Cognitive biases

3 negative thinking patterns

Negative triad: negative view of self

Negative schema: Negative view of world

Cognitive biases: process info negative

Negative triad

negative view of self

Negative schema

Negative view of world

Cognitive biases

process info negative

Hopelessness Theory

People become depressed when they start to feel hopeless about the future

Most important trigger of

depression is hopelessness

• Desirable outcomes will

not occur

• Person has no ability to

change situation

Due to global or specific causes and stable or unstabe

Global causes

Effects all areas

Specific causes

Only effects on area

Stable

Will always last is true

Unstable

Temporary

Rumination

o Tendency to repetitively dwell on sad thoughts

o Most detrimental form is to brood regretfully over causes of event

Predictors of mania

Reward sensitivity

• High responsively to rewards

• Life events that involve attaining goals

• Excessive goal pursuit

o Sleep disruption

Bipolar and MDD similarity

Triggers of depressive episodes in BD appear similar to triggers in MDD

Psychological Treatment of Depression

Interpersonal psychotherapy (IPT)

Cognitive therapy (CT)

Mindfulness-based cognitive therapy (MBCT)

Behavioral activation (BA) therapy

 Behavioral couples therapy

Interpersonal psychotherapy (IPT)

o Focus on major interpersonal problems (e.g., role transitions) (relations)

o Identify feelings, make decisions, and resolve problems related to interpersonal issues

Cognitive therapy (CT)

o Altering maladaptive thought patterns

o Monitor and identify automatic thoughts

• Challenge and replace negative thoughts with more neutral or

positive thoughts

Mindfulness-based cognitive therapy (MBCT)

o Use of strategies, including meditation, to detach from depression-related thoughts and prevent relapse

o Evidence stronger when depression is highly recurrent

Behavioral activation (BA) therapy

Increase participation in positively reinforcing activities to disrupt spiral of depression, withdrawal, and avoidance

o BA is also one component of cognitive therapy

Behavioral couples therapy

Enhance communication and relationship satisfaction

Psychological Treatment of Bipolar Disorder

Psychoeducational approaches

Cognitive Therapy (CT)

Family-focused treatment (FFT)

Psychoeducational approaches for BD

o Provide information about symptoms, course, triggers, and treatments

 Cognitive Therapy (CT) for BD

o Similar to depression treatment with additional content to address early signs of mania

Family-focused treatment (FFT)

o Educate family about disorder, enhance family communication, improve problem solving (BD)

Biological Treatment of Mood Disorders

Electroconvulsive therapy (ECT)

Transcranial Magnetic Stimulation for Depression (rTMS)

Electroconvulsive therapy (ECT)

Reserved for treatment non-responders o Induce brain seizure and momentary unconsciousness o Side effects: Short- term confusion and memory loss

Transcranial Magnetic Stimulation for Depression (rTMS)

• o Electromagnetic coil placed against scalp

• o Pulses of magnetic energy increase activity in key regions of

• the brain (different target regions)

• o For those that fail to respond to first antidepressant

• o Questions about how well controlled the trials are

Medications for Depressive Disorders stats

• • 75% of people in US receiving treatment for depression are

• prescribed antidepressants

• Effective at treating severe, persistent depression

  • o May not be helpful for those with mild or moderate Symptoms

Medication to treat severe persistent depression

Antidepressants

• May not be helpful for those with mild or moderate Symptoms

STAR-D

(Sequenced Treatment Alternatives to Relieve Depression)

•  Attempted to evaluate effectiveness of antidepressants in real-

• world settings (comorbid psychiatric conditions)

• • Only 33% achieved full symptom relief with citalopram

• • About 30% of non-responders achieved remission with a

• different anti-depressant

• • Remission rates were low and relapse rates were high

Medication for severe depression

 CT (Cognitive therapy) as effective as medication for severe depression

CT more effective than medication at preventing relapse

Combining psychotherapy and medication

Combining psychotherapy and antidepressant medications

increases odds of recovery over either alone by 10-20%

Medications for Bipolar Disorder

Lithium

(80% relief but toxic)

Anticonvulsants

Antipsychotics

(if unable to tolerate lithium effects)

Suicide ideation

thoughts of killing oneself

Suicide attempt

behavior intended to kill oneself

Suicide

death from deliberate self-injury

Non-suicidal self-injury

behaviors intended to injure oneself

without intent to cause death

Epidemiology of Suicide and Suicide Attempts

• 10th leading cause of death in US

• Rates are increasing in the US but not in other Western countries

• Guns are the most common means of suicide in the US (50%)

• Rates of suicide are highest in states with more gun

Women and men Suicide stats

Men are more likely than women to kill themselves

• Women are more likely than men are to make suicide attempts that do not result in death

• Men are more likely to shoot or hang themselves

• Women more likely to use less lethal means

• The highest rates of suicide in the United States are for white males over age 50

• The rates of suicide for adolescents and children in the United States are increasing dramatically

• Being divorced or widowed elevates suicide

risk four- or fivefold

Risk Factors for Suicide

• Psychological Disorders

o 90% of people who attempt suicide meet diagnostic criteria for a psychological disorder

More than half of those who attempt suicide are depressed

Suicide heritability

Heritability of about 50% for suicide attempts

Social Factors for suicide

o Economic recessions

o Media reports of suicide

o History of multiple physical and sexual assaults

o Perceived sense of burden to others and a lack of social belonging

Psychological Models for suicide

o Ineffective problem-solving

o Hopelessness

o Impulsivity

Preventing Suicide

Talk about it

Hospitalization

Broader Approaches to Suicide Prevention

• Studying suicide prevention within the military

o Higher rates of suicide than the general population

o Programing to encourage and destigmatize help seeking,

o Make highly lethal methods less available

• Keep guns in locked cabinets

• Restrict access to lethal drugs

normalize distress, and promote effective coping

Anxiety

Apprehension/worry over an anticipated problem

Fear

 A reaction to immediate danger

What does Fear and anxiety both envolve?

Arousal

o Anxiety – moderate arousal (e.g., restless energy,

tension)

o Fear – higher arousal (e.g., overpowering urge to run)

Anxiety pros and cons

• Absence of anxiety interferes with performance

• Moderate levels of anxiety improve performance

• High levels of anxiety are detrimental to performance

U shape curve

Fear pros and cons

o Fear triggers “fight or flight” response

o In the right circumstance, fear saves lives

o Fear system seems to misfire in some anxiety

DSM-5 TR Anxiety Disorders List

o Specific phobias

o Social anxiety disorder

o Panic disorder

o Agoraphobia

o Generalized anxiety disorder

(5)

 Most common psychological disorders

Anxiety disorders

28% of people report anxiety symptoms

• 10th leading cause of disability worldwide in 2015

Specific phobia

Fear of objects or situations that is out of proportion to any real danger

Social anxiety disorder

Fear of unfamiliar people or social scrutiny

Panic disorder

Anxiety about recurrent panic attacks

Agoraphobia

anxiety about being in places where escaping or getting help would be difficult if anxiety symptoms occurred

Generalized anxiety Disorder

Uncontrollable worry