Hoofdstuk 7 - week 2

Two Major Types of Mood Disorders

• Depressive disorders: Characterized only by depression (unipolar), without any mania.

• Bipolar disorder (manic depression): Characterized by alternating episodes of mania and depression.

Core Symptoms of Depression: Mood and Motor Features

• Depressed mood: Out of proportion to any cause.

• Anhedonia: Loss of interest in everything in life and inability to feel pleasure or emotion.

• Psychomotor retardation: Walking and speaking more slowly and quietly, with prolonged reaction times.

• Psychomotor agitation: Feeling physically agitated, restless, and unable to sit still.

Diagnostic Criteria: Major Depressive Disorder (MDD)

• Symptoms must last 2 weeks or more and be severe enough to interfere with everyday functioning.

• Mandatory Rule: At least one of the two cardinal symptoms—depressed mood OR anhedonia—MUST be present.

• Single vs. Recurrent: A single bout is a single episode; two or more episodes separated by at least 2 consecutive months without symptoms is a recurrent episode.

Major Subtypes and Specifiers of Depression

• Anxious distress: Prominent anxiety symptoms alongside depressive symptoms.

• Mixed features: Meets criteria for MDD plus at least 3 symptoms of mania, but not enough for a full manic episode.

• Melancholic features: Prominent physiological symptoms (early morning awakening, severe anhedonia, weight loss).

• Psychotic features: Presence of delusions or hallucinations.

• Catatonic features: Strange motor behaviors ranging from complete immobility (stupor) to purposeless movement.

• Atypical features: Odd assortment of symptoms such as weight gain and oversleeping.

• Seasonal pattern (Seasonal Affective Disorder - SAD): At least 2 years of experiencing and fully recovering from major depressive episodes tied to daylight hours (depressed in winter, recovering when daylight hours are long).

• Peripartum onset: Onset occurs during pregnancy or in the 4 weeks following childbirth.

Persistent Depressive Disorder (Dysthymia)

• Depressed mood for most of the day, for more days than not, for at least 2 years in adults (1 year in children/adolescents).

• Requires at least two of the following: poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration, or hopelessness.

Persistent Depressive Disorder (Dysthymia)

• Depressed mood for most of the day, for more days than not, for at least 2 years in adults (1 year in children/adolescents).

• Requires at least two of the following: poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration, or hopelessness.

Premenstrual Dysphoric Disorder (PMDD)

• Severe mood changes occurring during the premenstrual phase that improve once menses begins.

• Requires at least 5 physical (breast tenderness, muscle pain), affective, or behavioral symptoms, including at least one unstable emotion symptom (mood swings, anxiety, irritability, anger).

• Must cause significant distress and impairment in daily life.

Disruptive Mood Dysregulation Disorder (DMDD)

• Severe, recurrent temper outbursts out of proportion in intensity/duration to the situation, occurring ≥3 times per week in at least two settings.

• Diagnosed in children starting from age 6.

• Between outbursts, mood is persistently irritable or angry.

• Purpose in DSM-5: Created to distinguish children with explosive temper tantrums from classic bipolar disorder and prevent overmedication.

Prevalence, Gender Differences, and Relapse in Depression

• Lifetime prevalence of MDD is approximately 16%; individuals aged 18–29 are most likely to experience an episode.

• Women are about twice as likely as men to experience depression.

• Rates drop in people over 65, though diagnosing older adults is complicated by physical illness and they don’t report psychological symptoms.

• People who recover from one episode remain at a high risk of relapse (75%).

Risk SSRIs treatment depression

SSRIs prescribed to children and young adults carry a warning because early treatment can restore physical energy before improving mood. → Can increase the risk of suicidal ideation.

Symptoms of Mania

• An elevated, euphoric, or irritated mood with high energy.

• Symptoms: unrealistic self-esteem (grandiosity), racing thoughts, rapid/pressured speech, impulsivity, distractibility, and decreased need for sleep.

• Must last at least 1 week and impair daily functioning or require hospitalization.

Bipolar I vs. Bipolar II vs. Cyclothymic Disorder

• Bipolar I: Requires at least one full manic episode (can include psychosis or hospitalization; depressive episodes are typical but not strictly required).

• Bipolar II: Requires at least one hypomanic episode (milder mania lasting ≥4≥4 days; no psychosis; does not impair daily functioning) PLUS a mandatory Major Depressive Episode.

• Cyclothymic disorder: A chronic condition lasting at least 2 years with periods of hypomanic symptoms and mild depressive symptoms that do not meet full criteria for an episode.

Rapid Cycling Bipolar Disorder

Diagnosed when an individual experiences four or more mood episodes (manic, hypomanic, or major depressive) within a single 1-year period.

Genetic Factors & The 5-HTTLPR Gene

• First-degree relatives of people with MDD are 2 to 3 times more likely to develop depression.

• 5-HTTLPR (serotonin transporter gene): Carrying the short allele does not directly cause depression, but it lowers emotional resilience and sensitizes the brain, increasing vulnerability when exposed to severe life stressors.

Core Domain Regulated by Each Monoamine (communication nerve cells)

• Serotonin: Regulates mood and impulse stability.

• Norepinephrine: Regulates energy and physical alertness.

• Dopamine: Regulates pleasure and reward (dysfunction links to anhedonia).

Brain Structural and Functional Abnormalities in Depression

Four key areas:

1. Prefrontal cortex (PFC): Reduced volume of gray matter and reduced metabolic activity → difficulties in goal pursuit, planning, and emotional control.

2. Anterior cingulate cortex (ACC): Abnormal activity → problems with stress response and social/emotional regulation.

3. Hippocampus: Shrinkage/reduced volume due to chronic exposure to cortisol → memory and learning deficits.

4. Amygdala: Structural and functional enlargement/hyper-reactivity to emotionally salient negative stimuli.

Adverse Childhood Experiences (ACEs) & The HPA Axis

• Severe early childhood stress/abuse (ACEs) permanently sensitizes the HPA axis.

• Under adult stress, the system over-reacts and fails to return to baseline, causing chronic excess cortisol that alters neurotransmitter functioning and reduces hippocampal volume.

Gut Microbiome and Neuroinflammation in Depression

• Microbiome gut-brain axis: Altered gut flora composition affects immune pathways, increases HPA axis activity, and impacts the release of serotonin and GABA.

• Neuroinflammation: Chronic inflammatory responses in the brain/spinal cord triggered by stress, illness, or infection are linked to major depressive pathology.

Neurobiology of Bipolar Disorder: Striatum & Dopamine Pathways

• Striatum: Part of the basal ganglia involved in reward processing; hyper-activated in people with bipolar disorder, indicating hypersensitivity to environmental reward cues.

• Dopamine dysregulation: Hyper-reactivity sparks goal-seeking and manic episodes, whereas hypo-reactivity leads to depressed episodes.

• White matter abnormalities: Dysfunctional structural connections between the frontal cortex and deeper brain areas.

Behavioral Theories of Depression (Learned helplessness)

Life stress leads to depression because it reduces the positive reinforcers in a person’s life.

• Once a person begins engaging in depressive behaviors, these behaviors are reinforced by the sympathy and attention they get from others.

• Learned Helplessness: Occurs when people view negative life events as uncontrollable.

Cognitive theories: The Reformulated Learned Helplessness Theory

• Negative cognitive triad: Always negative views of themselves, the world and the future and ignoring good events.

• Depressive attributional style: Explaining negative events through causes that are internal ("my fault"), stable ("will never change"), and global ("affects everything").

• Hopelessness depression: Develops when people make pessimistic attributions and perceive that they have zero power to change the outcome, creating absolute hopelessness.

Ruminative Response Styles Theory

• Focuses on the process of thinking rather than the content.

• People fixate intensely on why they feel sad and review their feelings without taking any active steps to solve the underlying problem, which prolongs and deepens the depression.

Interpersonal Theories: Rejection Sensitivity & Excessive Reassurance-Seeking

• Rejection sensitivity: Easily perceiving rejection from others in social situations.

• Excessive reassurance-seeking: Constantly demanding proof of love and acceptance from friends and partners, which eventually frustrates others, causes actual social rejection, and worsens the depression.

Sociocultural theories: Cohort Effects & Gender Differences in Coping

• Cohort effect: Historical shifts (breakdown of family support, high expectations because of social media) place recent generations at a higher risk of depression.

• Gender differences: Women are socialized toward a ruminative response style (focusing on feelings, increasing depression risk), whereas men are socialized toward distraction or substance misuse to mask distress.

Biological contribution Bipolar Disorder: dysregulation in the dopamine reward pathways

Hyper-reactivity sparks goal seeking maniac episodes, whereas hypo-reactivity sparks depressive episodes.

Psychosocial contributors to Bipolar Disorder

• Stressful evens and an unsupportive family may trigger new episodes.

• Goal striving situations may trigger high reward sensitivity, → triggers manic or hypomanic symptoms.

  • Vice versa with depression

Biological treatment depression: Antidepressant Lag Time & Response Rates

• Antidepressants reduce depression in roughly 50% to 60% of patients (most effective for severe depression).

• Lag time: Biochemical changes in the synapse occur quickly, but the clinical reduction in depressive symptoms typically takes weeks to appear.

Biological treatment depression: SSRIs and SNRIs

• SSRIs (Selective Serotonin Reuptake Inhibitors): Most widely prescribed; safer in overdose than older drugs. (Positive) Side effects: GI distress, tremor, insomnia, and sexual dysfunction.

• SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors): Block reuptake of both serotonin and norepinephrine; show a slight advantage in preventing relapse, with a broader range of side effects.

Biological treatment depression: Bupropion (Wellbutrin)

Targeting dopamine and norepinephrine, it avoids sexual dysfunction aan boosts energy.

Useful for overcoming psychomotor retardation, severe anhedonia, and fatigue

Older Antidepressants: TCAs and MAOIs

• Tricyclic Antidepressants (TCAs): Effective, but have troublesome anticholinergic side effects and can be fatal in overdose.

• Monoamine Oxidase Inhibitors (MAOIs): Block the enzyme MAO from breaking down monoamines. Require strict dietary restrictions (avoiding tyramine) to prevent dangerous liver damage or sudden, life-threatening spikes in blood pressure (hypertensive crisis).

Lithium for Bipolar Disorder as a mood stabilizer

• The primary mood stabilizer for bipolar disorder; highly effective in preventing both manic and depressive relapses, and significantly reduces suicide risk.

• Narrow therapeutic window: The difference between an effective dose and a toxic dose is very small.

• Requires regular blood monitoring to avoid poisoning (tremors, vomiting, diarrhea, blurred vision, seizures).

Lithium toxicity

• Lithium has a narrow therapeutic window.

  • Small increases in blood concentration can quickly produce severe toxicity: marked tremors, vomiting, diarrhea, blurred vision, confusion, seizures, and kidney failure. Up to 55% of patients develop resistance within 3 years.

Anticonvulsants & Atypical Antipsychotics in Bipolar Disorder

• Anticonvulsants: Originally used for epilepsy, discovered to stabilize mood and prevent seizures. Side effects include blurred vision, fatigue, dizziness, rash, liver disease, and birth defects.

• Atypical antipsychotics: Effective in calming acute mania, particularly when psychotic symptoms are present. Side effects include significant weight gain and problematic metabolic changes.

Electroconvulsive Therapy (ECT): Procedure, Relapse & Side Effects

• An electric current passes through the head under anesthesia to induce a 1-second brain seizure (6 to 12 sessions total), introduced as treatment for schizophrenia.

• Action: Reduces metabolic overactivity in the frontal cortex and anterior cingulate.

• Indications: Highly effective for severe psychotic depression and rapid relief of acute suicidal ideation.

• Relapse & Side effects: Relapse rate is high (up to 85%); causes temporary confusion and difficulty learning new information (anterograde amnesia).

Newer Brain Stimulation: rTMS, VNS & Deep Brain Stimulation (DBS)

• rTMS: Repeated high-intensity magnetic pulses target the left prefrontal cortex; patients remain awake with minimal side effects.

• Vagus Nerve Stimulation (VNS): An implanted chest device stimulates the vagus nerve, sending signals to the hypothalamus and amygdala.

• Deep Brain Stimulation (DBS): Electrodes surgically implanted deep into specific brain regions stimulate circuits connected to a pulse generator.

Light Therapy for Seasonal Affective Disorder (SAD)

• Bright light exposure resets disrupted 24-hour circadian rhythms during dark winter months.

• Suppresses excess daytime melatonin production, which increases circulating norepinephrine and serotonin levels to lift mood.

Behavioral therapy mood disorders: Behavioral Activation Therapy for Depression

• A short-term treatment (~12 weeks) designed to break the vicious cycle of depression.

• Focuses on scheduling pleasant events and mastery tasks to increase positive reinforcement from the environment and eliminate avoidance behaviors.

Cognitive-Behavioral Therapy (CBT) for Depression

• Two general goals: 1. Identify and challenge negative, automatic thoughts and cognitive distortions (cognitive restructuring). 2. Develop practical problem-solving skills to build environmental rewards.

• Clients test catastrophic thoughts as empirical hypotheses using behavioral experiments.

Interpersonal Therapy (IPT): Four Core Focus Areas

Focuses directly on resolving relationship problems that trigger and maintain depression:

1. Grief / Unresolved loss: Coping with the death or loss of an important person.

2. Interpersonal role disputes: Disagreements in major relationships (learning communication skills and negotiating concessions).

3. Role transitions: Stress from life-stage shifts (e.g., college to career, becoming a parent, retirement).

4. Interpersonal deficits: Difficulty initiating and maintaining close relationships due to poor social skills or extreme isolation.

Bipolar Disorder: Interpersonal and Social Rhythm Therapy (ISRT) & Family-Focused Therapy (FFT)

• ISRT (for Bipolar Disorder): Combines IPT with behavioral techniques to help patients keep strict daily routines (fixed sleep, wake, meal, and activity schedules) because biological rhythm disruptions trigger manic episodes.

• FFT: Educates the family about bipolar disorder, trains communication, and improves problem-solving to reduce high expressed emotion at home and prevent relapses. Bipolar people are highly effective by their social environment.

Combining Psychotherapy and Medication (Maintenance Therapy)

• Combining psychotherapy with medication is significantly more effective than either treatment alone for chronic/persistent depression.

• In bipolar disorder, psychological therapy improves adherence to lithium/mood stabilizers.

• Maintenance therapy: Long-term supportive sessions reduce relapse rates in individuals with a history of recurrent depressive episodes.

Defining Suicide & Non-Suicidal Self-Injury (NSSI)

• Suicide: Death caused by self-inflicted injury, poisoning, or suffocation with evidence of explicit or implicit intent to die.

• Suicide thoughts: May or may not end in death.

• Suicidal ideation: Thoughts about wanting to die or killing oneself without taking action.

• NSSI: Repeated cutting, burning, or puncturing of the skin without any intent to die, used primarily to regulate overwhelming emotional distress.

The Gender Paradox of Suicide

• Women: Attempt suicide 2 to 3 times more often than men (higher attempt rate, often using non-lethal methods such as poisoning/pills).

• Men: Are 4 times more likely to die by suicide (higher completion rate because they choose more lethal methods, such as firearms or suffocation).

Suicide Risk Across Specific Populations

• Suicide rates are higher among low SES status people or availability to firearms. Religious people that forbid suicide are less likely to attempt.

• Children & Adolescents: Risk rises sharply in early adolescence; girls attempt more, boys succeed more; self-harm within the past 6 months is the highest risk window.

• LGBTQ+ Youth: Elevated risk due to minority stress, rejection from family, bullying, and relational victimization.

• Older Adults (>65, especially older men): Highest completion rates. When they attempt, they fully intend to die due to the loss of a spouse, loneliness, severe pain, or chronic debilitating illnesses.

Non-suicidal Self Injury

People (mostly adolescents) repeatedly cut, burn, puncture or hurt themself with no intent to die.

• Increased risk for suicide attempts

• It functions as a way of regulating emotion and/or influencing the social environment.

Historical Perspectives of suicide: Freud vs. Durkheim's Three Types of Suicide

• Freud: Anger originally aimed at a loved one is redirected inward toward the self to destroy the internalized lost person.

• Émile Durkheim (Sociological Theory):

  1. Egoistic suicide: Committed by people who feel completely alienated from society, empty of social bonds, and alone.

  2. Anomic suicide: Triggered by severe disorientation caused by a sudden, massive societal or personal economic collapse.

  3. Altruistic suicide: Committed by people who believe sacrificing their own life will directly benefit their group or society.

Psychological, Personality Cognitive Risk Factors for Suicide

• More than 90% of completed suicides involve a diagnosable psychological disorder (especially mood disorders, borderline personality, and substance abuse).

• Strongest predictor: A history of past suicidal thoughts and prior suicide attempts.

• Hopelessness (cognitive factor) believing the future is completely bleak with zero chance of improvement and combined with high impulsivity (personality factor).

Suicide Contagion & Suicide Clusters

• Suicide cluster: Non-randomly grouped suicide attempts in space and time (e.g., inside a single school or community).

• Contagion: Modeling effect; sensationalized media reports of a celebrity's suicide or a friend's death lower the inhibition against suicide for vulnerable individuals.

Medical Treatments for Suicidal Individuals

• Lithium: Consistently proven in clinical trials to directly reduce suicidal behavior in bipolar and unipolar mood disorders.

• SSRIs: Treat underlying depressive symptoms and improve impulse control, lowering suicide rates.

Dialectical Behavior Therapy (DBT) & TIPP Skill for Suicidal Crises

• DBT: Designed specifically for borderline personality disorder and chronic suicidality; teaches emotion regulation and distress tolerance.

• TIPP skill: Acute crisis-survival tool (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation). Putting cold water/ice on the face triggers the parasympathetic mammalian dive reflex to instantly lower heart rate and emotional arousal.

Guns and Suicide: Means Restriction

• The presence of a firearm in the home increases suicide risk by 4 to 5 times.

• Suicidal impulses are often short-lived; restricting immediate access to lethal means directly lowers overall suicide rates because people do not automatically find alternative, equally lethal methods.

Eleven Steps When a Friend is Suicidal (What to Do)

• Take the person seriously.

• Get help.

• Express concern.

• Pay attention.

• Ask direct questions about whether they have a suicide plan (and what that plan is).

• Acknowledge the person's feelings nonjudgmentally.

• Reassure them that things can get better.

• Never promise confidentiality / secrecy.

• Make sure guns, medications, and other lethal means are completely removed.

• Do not leave the person alone until they are safely under professional care.

• Take care of yourself.