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hypomanic episode
These episodes show symptoms of mania but they're less intense. Does not involve significant impairment
manic episode
Elevated, expansive mood for at least one week, inflated self-esteem, decreased need for sleep, racing thought, easily distracted, pleasurable but risky behavior, more goal-directed activity. Impairment not normal in functioning, not caused by direct physiological events or medical condition.
bipolar disorder
All forms of bipolar disorder have the defining feature of mania. Usually involves episodes of depression alternating with mania.
mood disorder
-gross deviations in mood
- unipolar: involves only depressive symptoms
- bipolar: involves manic symptoms also
mood episode
-Periods of depressed or elevated mood lasting days or weeks
- MDE
- Persistent depression
- Manic and hypomanic episodes
neurobiological factors in mood disorder etiology
- genetics: heritability factors (37% MDD, 93% bipolar disorder)
- neurotransmitters (norepinephrine and serotonin)
- concordance rates are high in identical twins (two or three times more likely to present with mood disorders than a fraternal twin of a depressed co-twin
- heritability rates are higher compared to males
- much research to identify specific genes involved in mood disorders, but the results of most studies have not been replicated
- gene influencing dopamine function appears related to MDD
psychological factors that play a role in mood disorder etiology
- psychodynamic model: no strong research support
- behavioral model: modest research support
- cognitive views: considerable research support
Beck's cognitive theory of depression
- 1967, 1976
- Negative triad: Broadly negative views of self, world, future, self defeating attitudes learned during childhood
- Negative schema: underlying tendency to see the world negatively
- Negative schema cause cognitive biases/errors: tendency to process information in negative ways, minimization of the positive and magnification of the negative
Treatments for mood disorders
- half of people with MDD, PDD receive professional treatment, can be divided into: psychological, sociocultural, biological
- psychodynamic: widely used, no strong research to support its effectiveness
- behavioral: used for mild or moderate depression, practiced less in the last decade
- cognitive: performs well, large and growing clinical following, likely the most effective, but not relapse proof, cognitive-behavioral, interpersonal, biological
Theories on how psychopharmacological interventions affect symptoms of mood disorders
the intervention of drugs alone or psychological treatments alone do not prove as effective as the combination of psychological therapy and pharmacological interventions in mood disorders
ECT
- reserved for treatment non- responders
- induce brain seizure and momentary unconsciousness
- 6 to 12 sessions over 2 to 4 weeks
- bilateral or unilateral
- causes memory loss
ECT leading hypothesis in severe mood symptoms
- more effective than any other treatment for severe depression
- combination of psychotherapy and drug therapy is modestly more helpful to depressed people than either treatment alone
- depression may be having too many connections between certain brain areas. ECT may help to reduce connections between areas such as the frontal lobe with regions involved in emotional control
- it has been found to increase levels of nerve growth factor that trigger the birth of new brain cells and revitalize damaged connections in the hippocampus
Suicidal ideation
- thoughts of killing oneself
Non-suicidal self injury
- behaviors intended to injure oneself without the intent to kill oneself
- cutting, burning, scratching, interfering with wound healing
- does not include overdosing, substance use, eating disorders, body piercing, or tattooing
Consistent risk factors for suicide
- mental illness
- previous suicide attempt
- serious physical illness/chronic pain
- family history
- history of mental illness and suicide
- shame/despair
- aggression/ impulsivity
- triggering event
- access to lethal means
- suicide exposure
- inflexible thinking
- genes, stress, and mood
Suicide contagion
- a person is more likely to commit suicide after hearing about someone else committing suicide
- family members, friends, celebrities, other highly publicized suicides are common triggers
- The media can worsen the problem
- sensationalizing/ romanticizing suicide
- describing lethal methods of committing suicide
Common suicide myths
- People who discuss it won't do it; 3/4 of people who commit communicate their intentions before
- Its committed without warning; people usually give many warnings ("the world would be better without me"
- suicidal people want to die; most people are thankful after suicide is prevented
- people who attempt with law lethal methods are not serious; many are uninformed about pill dosages and human anatomy
Secondary reinforcer in somatic symptom disorders
- attention, sympathy, etc.
- conversion disorder treatment removes sources of these
Which somatic symptom disorders require evidence that the symptoms exist in the absence of an organic or biological cause
- conversion disorder (functional neurological symptom disorder)
- physical problems without an organic cause
Factitious disorder imposed on another
a condition in which one person induces illness symptoms in someone else
Depersonalization
- distortion in perception of one's own body or experience (your own body isn't real)
- lose your own sense of reality
Derealization
- losing sense of the external world (sense of living in a dream)
- sense of reality of the external world is not
Fugue state
- a person travels or wanders, sometimes assuming a new identity in a different place
- they're unable to remember how or why they ended up in a new place
In what disorder do fugue states appear
- dissociative amnesia
- generalized vs. localized or selective
Host
This personality appears more often than the others
Alters
All personalities besides the host
Switching
- the transition from one subpersonality to the next
- usually sudden and may be dramatic
Role of trauma in DID
- having a history of trauma makes this disorder more likely to manifest
- thought to occur as a result of repeated traumatic experiences in early life
- as a kid, you have no way of coping with severe recurrent trauma, especially abuse
- the best way to deal with it is sometimes to pretend or feel like you aren't which may happen involuntarily
False memories in DID
- self-hypnosis
- although hypnosis can help people remember events that occurred and were forgotten years ago, it can also help people forget facts and personal identity
- Called hypnotic amnesia
- the parallels between amnesia and dissociative disorders are striking and have led researchers to conclude that dissociative disorders may be a form of self-hypnosis
Gender dysphoria
- trapped in the body of the wrong sex
- desire to assume the identity of the desired sex
- goal is not sexual
- causes are unclear
- gender identity develops between 18 months and 3 years of age
- fluid or cross-gendered identity is not a disorder; only becomes one when it causes distress or impairment
- some consider this a medical problem while other say it is not pathological, rather an alternative way of experiencing one's gender identity
General gender differences in sexual behaviors
- males ejaculate, females experience vaginal contractions
- males and females experience parallel versions of most dysfunctions
Models aim to describe the development of a paraphilia
- misplaced sexual attraction and arousal
- inappropriate people or objects
- high comorbidity with anxiety, mood, and substance use disorders
Difference between Bipolar I and Bipolar II
A depressive episode is required for Bipolar II, but not Bipolar II
DSM Major Depressive Disorder
-occurring most of the day, every day for at least two weeks
- symptoms may not be due to substances or medical condition
- depressed mood (irritable mood in children/adolescents)
- less interest in daily activities
- weight loss or gain, increase or decrease in appetite
- insomnia or hypersomnia
- psychomotor agitation of retardation
- fatigue, loss of energy
- feelings of worthlessness or guilt
- thoughts of death, ideation of suicide
- distress/impairment
- diminished ability to think, make decisions
DSM Bipolar I Disorder
- five or more symptoms present during the same two week period
- at least one five manic episode
- current or recurrent Major Depressive Episode (at least one)
DSM Cyclothymia
- milder, chronic form of bipolar disorder, at least 2 years in adults, 1 year in kids
- for at least 2 years, numerous periods with hypomanic and depressive symptoms that don't meet the MDE criteria
- not without symptoms for more than 2 months at a time
- no MDE, manic or hypomanic episodes during first 2 years of disturbance
- distress, impairment of functioning
DSM Premenstrual Dysphoric Disorder
- sign: depressive disorders prior to menses during majority of cycles, leads to distress or impairment
- At least 5 symptoms must be present in final week before onset of menses, improve within a few days after onset, become minimal or absent in the week post menses
- One or more must be present: mood swings, marked irritability or anger, marked depressed mood, marked anxiety and tension
- Additionally must reach 5 total in combo with others: decreased interest in usual activities, difficulty in concentrating, lethargy/fatigue, change in appetite, hypersomnia, insomnia, sense of being overwhelmed, breast tenderness, weight gain
- controversial diagnosis
DSM Disruptive Mood Dysregulation Disorder
-combats overdiagnosis of bipolar disorder in youth
- criteria for manic/hypomanic episodes are not met
- Severe, frequent temper outbursts most of the day
- observable in at least two of three settings (severe in one of them)
- manifested verbally or behaviorally out of proportion in intensity or duration and inconsistent with developmental level
- only diagnosed between 6 years or after 18 years
- Never been a distinct period lasting more than one day during which the full symptom criteria have been met.
- Not attributed to substance or other medical condition
Strengths of Beck's theory
- high correlation between level of depression and number of maladaptive attitudes held
- cognitive triad and errors in logic are seen in people with depression
- automatic thinking has been linked to depression
Limitations of Beck's theory
- research fails to show that such cognitive patterns are the cause and core of unipolar depression
What group of people is suicide common in?
- whites
- native americans
Suicide is the _____ leading cause of death
10th
Development of sexual orientation
- through adolescence, youth can feel somewhat uncertain about their sexual orientation
- as physical sexual development takes place, most youth begin to identify themselves
- constantly evolving and changing throughout the adolescent period
DSM Sexual Dysfunction and Paraphilia
- all involve problems related to desire, arousal, and/or orgasm
- pain associated with sex can lead to dysfunction
- symptoms present for 6+ months for diagnosis
- impairment or distress to be a disorder
- VERY prevalent (not always distressing)
- 40% men
- 63% women
- most rapists do not show these patterns
Female sexual interest/ arousal disorder
- manifested by at least 3: (absent/ reduced interest in sex)
1. sexual thoughts/fantasies
2. initiation of sexual activity (unreceptive of partners attempts)
3. sexual excitement/pleasure, sensations during sex
Male hypoactive sexual desire disorder
- persistent deficient sexual thoughts or fantasies
- judgement of deficiency is made by clinician, taking into account age, and context of person's life
Premature ejaculation
- persistent, recurring pattern of ejaculation within approximately 1 minutes following vaginal penetration, and before the wish
Female orgasmic disorder
- presence of either of the following on almost all occasions:
1. marked delay in, infrequency of, or absence of orgasm
2. markedly reduced intensity of orgasmic sensations
Genito-pelvic pain/ penetration disorder
- one or more of the following (persistent, recurrent) difficulties
1. vaginal penetration during intercourse
2. marked vulvovaginal or pelvic pain in anticipation of, during, or after penetration
3. tensing or tightening of pelvic floor muscles
Fetishistic Disorder
- sexual arousal from the use of nonliving objects, focus on nongenital body part
- fantasies, urges, or behaviors cause distress or impairment
- not limited to clothing (cross-dressing) or other devices (vibrators)
Frotteuristic Disorder
- often occurs in crowds/confining situations
- sexual arousal from touching/rubbing against a non-consenting person (manifested by fantasies, urges, behaviors)
- if person acts on the sexual urges, may be diagnosed
Voyeuristic disorders
- "peeping" may intensify arousal
- observing an unsuspecting person for recurrent and intense sexual arousal
- individual must be at least 18 years of age for diagnosis
Exhibitionistic disorders
- element of thrill and risk is necessary
- exposure of one's genitals to an unsuspecting person bringing recurrent and intense sexual arousal
Transvestic disorder
- sexual arousal with the act of cross-dressing
- males may rarely show highly masculine compensatory behaviors (most do not)
- many are married and the behavior are known to the spouse
- not inherently pathological; only considered disordered if it causes distress or impairment
Sexual Sadism
-arousal from inflicting psychological or physical suffering of another person
- arousal from the act of inflicting humiliation, beaten, bound, or otherwise made to suffer
- person has acted, has distress or impairment
Sexual masochism disorder
-arousal from suffering from psychological or physical suffering of another person
- arousal from the act of suffering from humiliation, beaten, bound, or otherwise made to suffer
- person has acted, has distress or impairment
Pedophillic disorder
- sexual attraction to prepubescent children
- most sufferers are males
- rare in females
- in some cases, these urges can be limited to incest
- many sufferers do not act on desires
- some rationalize the behavior
Models that describe the development of paraphilia
- theorists have proposed explanations for paraphilias, but there is little evidence to support them
- difficulty forming 'normal' relationships
- relationship difficulties (childhood/adolescence)
- deficits in sexual experiences
- early experiences: sexual associations by chance
- high sex drive
Behavioral view of mood disorders
- depression results from changes in rewards and punishments people receive in their lives
- Lewinsohn suggests that the positive rewards in life dwindle for some people, leading them to perform fewer and fewer constructive behaviors, and they spiral toward depression
- research supports the relationship between the number of rewards received and the presence or absence of depression
- social rewards are especially important
Strengths of the behavioral view of mood disorders
researchers have compiled significant data to support this theory
Limitations of the behavioral view of mood disorders
- research has relied heavily on the self-reports of depressed subjects
- behavioral studies are largely correlational and do not establish that decreases in rewards are the initial cause of depression
Cognitive views of mood disorder
2 theories:
- cognitive theory and the role of negative thinking
- learned helplessness
Strengths of the cognitive views of mood disorders
- many studies have produced evidence in support of Beck's explanation
- high correlation between the level of depression and the number of maladaptive attitudes held
- both the cognitive triad and errors in logic are seen in people with depression
- automatic thinking has been linked to depression
Limitations of the cognitive views of mood disorders
research fails to show that such cognitive patterns are the cause are core of unipolar depression
Learned helplessness theory of depression (Seligman)
- lack of perceived control over life events leads to decreased attempts to improve own situation
- negative cognitive styles are a risk factor for depression
- depressed individuals may believe that they no longer have control over the reinforcements (rewards and punishments) in their lives
- they themselves are responsible for this helpless state
Rapid cycling
- qualifier for either bipolar I or II
- four or more mood episodes (any type) within any one year period
- occurs in 10-20% of patients with bipolar disorder
- 70-90% of rapid-cyclers are women
- can be very difficult to treat
Epidemiology and consequences of bipolar disorder
- prevalence rates lower than MDD
- 1% for bipolar I
- 0.2-2% for bipolar II
- 4% for cyclothymia
- rates of bipolar disorders consistent across the children, adolescents, and adults
- few gender differences (women experience more depressive episodes)
- a severe mental illness: a third unemployed a year after hospitalization and suicide rates are high
Role of Neurotransmitters
- original models (monoamine hypothesis) absolute levels of NTs
- MDD: low levels of norepinephrine, dopamine, and serotonin
- Mania: high levels of norepinephrine and dopamine, low levels of serotonin
- medication alters levels immediately, yet symptom relief takes 2-3 weeks
- causal role of NT's in mood disorders is more complex than whether a given NT is high or low
New models focusing on sensitivity of postsynaptic receptors
- dopamine receptors may be overly sensitive in BD but lack sensitivity in MDD
- depleting tryptophan, a precursor of serotonin, causes depressive symptoms in individuals with personal or family history of depression
- individuals who are vulnerable to depression may have less sensitive serotonin receptors
Permissive hypothesis
- low serotonin "permits" other neurotransmitters to vary more widely, increasing vulnerability to depression
Brain imaging
- structural studies: focus on number of connections among cells
- functional activation studies: focus on activity levels
Levels of activity in brain structures associated with mood disorders
- amygdala: elevated
- subgenual anterior cingulate: elevated
- dorsolateral prefrontal cortex: diminished during emotion regulation
- hippocampus: diminished
Key brain structures involved in mood disorders
- dorsolateral prefrontal cortex
- hippocampus
- amygdala
- anterior cingulate cortex
- subgenual anterior cingulate
The endocrine system in mood disorders
- elevated cortisol
- stress hormones decrease neurogenesis in the hippocampus> less able to make new neurons
Sleep disturbance in mood disorders
- hallmark of most mood disorders
- depressed patients have quicker and more intense REM sleep
- sleep deprivation may temporarily improve depressive symptoms in bipolar patients
Depressive attributional style
- internal attributions: negative outcomes are one's own fault
- stable attributions: believing future negative outcomes will be one's own fault
- global attributions: believing negative events will disrupt many life activities
- all three domains contribute to a sense of hopelessness
Social factors in mood disorders
- stressful life events
- stress is strongly related to mood disorders
- 42-67% report a stressful life event in year prior to depression onset
- poorer response to treatment
- longer time before remission
gene- environment correlation
people who are vulnerable to depression might be more likely to enter situations that will lead to stress
Gene and environment interactions
- life events interact with serotonin transporter gene to predict symptoms of depression longitudinally
Interpersonal difficulties in mood disorders
- high levels of expressed emotions by family member predicts relapse
- marital conflicts also predicts depression
Behavior of depressed people leads to rejection
- role of self- verification and negative feedback seeking
- we seek to be close to those who confirm our self- views
- excessive reassurance seeking
- few positive facial expressions
- negative self disclosures
- slow speech and long silences
Consequences of social factors in mood disorders
- leads to decreased social contact and a further deterioration of social skills
- lack of social support may be one reason a stressor triggers depression
Family- social perspective
- consistent with these findings, depression has been tied repeatedly to the unavailability of social support such as that found in stable marriage
- people who are separated or divorced display three times the depression rate of married or widowed persons and double the rate of people who have never been married
- there also is a high correlation between level of marital conflict and degree of sadness that is particularly strong among those who are clinically depressed
- it also appears that people who are isolated and without intimacy are particularly likely to become depressed in times of stress
Triggers of depressive episodes in bipolar disorder
- negative life events
- neuroticism
- negative cognitions
- expressed emotion
- lack of social support
Predictors of mania
- reward sensitivity
- sleep disruption
Treatment of mood disorders
- half of people with unipolar depression (MDD, PDD) receive treatment from a mental health professional each year
- many people in therapy experience depressed feelings as a part of another disorder
- much of therapy being done today is for unipolar depression
Psychological treatment of mood disorders
- psychodynamic theory
- behavioral therapy
- cognitive therapy
- mindfulness- based cognitive therapy (MBCT)
- behavioral activation (BA) therapy
- interpersonal psychotherapy (IPT)
- behavioral couples therapy
- psychoeducational approaches
- family focused treatment (FFT)
- electroconvulsive therapy (ECT)
MAO inhibitors
- originally used to treat TB, doctors noticed that the medication seemed to make patients happier
- the drug works biochemically by slowing down the body's production of monoamine oxidates
- stops the breakdown of norepinephrine
- leads to a rise in norepinephrine activity and a reduction in depressive symptoms
- half of patients who take these drugs are helped by them
Dangers of MAO inhibitors
- people who take this drug experience a dangerous rise in blood pressure if they eat foods containing tyramine (cheese, bananas, wine)
Tricyclics
- in searching for medications for schizophrenia, researchers discovered that imipramine relieved depressive symptoms
- imipramine and related drugs share a three ring molecular structure
- hundreds of studies have found that depressed patients taking this drug have improved much more than similar patients taking placebos
- drugs must be taken for at least 10 days before such improvement is seen
- 60-65% of patients find symptom improvement
- most patients who immediately stop taking this drug upon relief of symptoms relapse within one year
- patients who take this drug for five additional months (continuation therapy) have a significantly decreased risk of relapse
- patients who take antidepressant drugs for three or more years after initial improvement (maintenance therapy) may reduce the risk of relapse even more
- block the reuptake process, increasing NT activity in the synapse
- when ingested, the slow down the activity of the neurons that use norepinephrine and serotonin
- after a week or who the neurons adapt to the drugs and go back to releasing normal amounts of the NTs ( the desired effect of the reuptake mechanism)
- this drug is prescribed more often than MAO inhibitors
- do not require dietary restrictions
- some patients show higher rates of improvement
Second- generation antidepressants
- SSRIs are most of the drugs in this group
- Increase serotonin activity specifically
- fluoxetine (prozac), sertraline (zoloft), escitalopram (lexapro)
- selective norepinephrine reuptake inhibitors and serotonin- norepinephrine reuptake inhibitors are also now available
- effectiveness and speed: on par with tricyclics yet their sales have skyrocketed
- clinicians prefer these drugs because it is harder to OD on them than on other kinds of antidepressants
- no dietary restrictions
- fewer side effects
- may cause some undesired effects such as decreased sex drive
Antidepressants do not work for everyone
even the most successful of them fails to help at least 35% of clients with depression
How effective are medications alone
- published studies may overestimate the effectiveness of medications alone
- medication is quicker but therapy has longer lasting effects
- combining psychotherapy and antidepressant medications increase odds of recovery over either alone by 10-20%
- CT is as effective as medication for severe depression
- CT more effective than medication at preventing relapse
STAR-D
- attempted to evaluate effectiveness of antidepressants in real-world settings
- 3671 patients across 41 sites
- only 33% achieved full symptom relief with citalopram
- 30% of non-responders achieved remission with a different anti-depressant
Lithium
- used to treat bipolar disorder
- up to 80% receive at least some relief with this mood stabilizer
- potentially serious side effect: toxicity
Newer mood stabilizers
- anticonvulsants: depakote
- antipsychotics: zyprexa
- both also have serious side effects
Medications for bipolar disorder
- researchers do not fully understand how mood stabilizing drugs operate
- they suspect that the drugs change synaptic activity in neurons, but in a different way from that of antidepressant drugs
- although antidepressant drugs affect a neuron's initial reception on NTs, mood stabilizers seem to affect a neuron's second messengers
- Increase production of neuroprotective proteins, which may decrease bipolar symptoms
- mood stabilizers correct bipolar functioning by directly changing sodium and potassium ion activity in neurons
Biological treatment of mood disorders
- vagus nerve stimulation
- transcranial magnetic stimulation
- deep brain stimulation
Vagus nerve stimulation
- depression researchers surmised they might be able to stimulate the brain by electrically stimulating a nerve through the use of a pulse generator implanted under the skin of the chest
- research has found that the procedure brings significant relief to as many as 40% of those with treatment- resistant depression
- as with ECT, researchers do not yet know precisely why this technique reduces depression
Transcranial magnetic stimulation
- another technique designed to stimulate the brain and without the undesired effects of ECT, TMS has been found to reduce depression when administered daily for 2 to 4 weeks
