Psychopathology Exam 2

2/10/25

Ch 6- Mood Disorders

Depression: term and syndrome

·       Depression: often leads to semantic confusion for 2 reasons:

o   Denotes a issue of “mood”, a “symptom of”, and/or “syndrome” each discussed out of context from different life contexts that shape experience, communication, and responses

o   Melancholy

o   Simultaneously carries the connotation a range of emotional experiences and social consequences

• Not an intellect disorder, but rather a mood disorder

• Rumination

• Poor/negative self-concept and self-image, dominant and persistent mental pain, lack of motivation/inability to do anything that could result in an increase in well-being or pleasure à anhedonia

• Negative perception of self, world, and others à impacts experience of the world

• Can experience psychotic episodes if depression persists

Importance: used out of context permits researchers, clinicians, and public to assign their idiosyncratic meanings and interpretations to this mood disturbance independent of the context in which it emerges and is sustained

·       Significance: early writings and especially those of Krafft-Ebing and Kraepelin reflect a culmination in the emergence of the modern concept we now call depression; a clear continuity from these clinicians to the DSM system

·       Defined: a condition resulting primarily from a disorder of mood

o   Manifested in cognitive distortions

o   Do not reflect an independent disorder of judgement or intellect

o   Develop in an understandable manner, from a disturbance of mood in the signs and symptoms of what we now call major depression

Mood disorder

-        Unipolar vs.

-        Bipolar

Major Depressive Disorder (MDD)  

·       Classification of unipolar mood disorders

o   Normal mood fluctuations

o   Major depression

§  Aka clinical depression

o   Dysthymia

§  Persistent depressive disorder

§  Experience little to no distress with persistent depression

o   “Double” depression

§  2 major depression disorders

·       MDD episode

o   Global prevalence: affecting 185 million people

o   Duration: at least 2 weeks

o   Manifestations: feeling sad, can’t enjoy life, problems eating and sleeping, feelings of guilt, low/limited energy/fatigue, trouble concentrating, recurrent thoughts about death

§  Debilitating

§  Suffering and dysfunction

o   Increased risk of negative outcomes: education, employment and personal relationships

o   Associated experiences: stigma, higher rates of physical co-morbidities (i.e. cardiovascular disease, obesity, type 2 diabetes)

·       DSM 5-TR diagnostic criteria

o   5 or more of following symptoms (with at least 1 of the first two) during the same 2-week period, representing a change from previous functioning

§  Depressed mood

·       Most of the day, nearly every day, by either subjective report or observation made by others

§  Markedly diminished interest or pleasure

·       In all or almost all activities, most of the day, nearly everyday

·       Anhedonia

§  Significant weight loss/gain

·       +/- 5% of body weight in a month when not dieting or weight gain OR decrease or increase in appetite nearly every day

§  Insomnia or hypersomnia nearly every day

§  Psychomotor agitation or retardation nearly every day

§  Fatigue or loss of energy (anergia) nearly every day

§  Feelings of worthlessness, excessive, or inappropriate guilt nearly every day

§  Diminished ability to think or concentrate, or indecisiveness, nearly every day

§  Recurrent thoughts of death, recurrent suicidal ideation without a specific plan

o   S.I.G. E. C.A.P.S. (mnemonic)

§  Sleep, interest, guilt

§  Energy

§  Concentration, appetite, psychomotor, suicide

·       Depressed mood

o   Defined: refers to negative affective arousal, i.e. depressed, anguished, mournful, irritable, or anxious

o   3 caveats:

§  Often terms tend to understate what is a “morbidly painful emotion”

§  Depressed mood has a somatic (physical) quality that in the extreme is indescribably painful

§  Even in mild forms, depressive suffering is qualitatively distinct from its neurotic parallels, i.e. groundless apprehensions (thinking disturbances) with severe inner turmoil and torment

2/17/25 - continued à Mood disorders: major depression and persistent depressive disorder

Episodes

·       Collection of symptoms that occur over a certain period of time

o   Depressive episode: at least two weeks of sadness and loss of pleasure in what were once enjoyable activities

o   Manic episode: markedly elevated, expansive, or irritable mood for at least 4 days

o   Hypomanic episode: less severe or lighter form of mania, but can be accompanied by an elevated or irritable mood

o   Mixed episode: both manic and depressive symptoms

Mood (i.e. internal amplifier)

·       A sustained, enduring emotions

·       Felt long enough to be felt inwardly

·       Manifested in subtle ways

·       Affect displayed may not be consistent with mood

Affect (i.e. what comes out of the speaker)

·       The manner a person’s emotional state is conveyed through facial expressions, vocal inflection, gestures, and posture

·       Function: signals our satisfaction, distress, disgust, or whether we are in danger

·       Short-lived expression

Why is major depression a problem?

·       Leading cause of disability

·       Represents a significant health concern for adolescents and adults alike

·       Global burden of disease

o   Depression accounts for more than 40% of the DALY’s

§  1 DALY = the loss of 1 year of otherwise healthy life

Current understanding

·       About 20% of children will experience an episode of major depression before age 18

o   At any one point in time, up to 2% of pre-pubertal and up to 8% of post pubertal kids have depression

·       Prevalence of bipolar disorder is controversial

o   Reports range from 0.6% and 6%

·       Becomes apparent in adolescence between ages 15-18, pre-onset

Risk and protective factors

·       Risk factors: increase onset of symptoms or likelihood of developing disorder

o   i.e. genetics, culture, environment, temperament, socio-economic status

·       Protective factors: increase resilience

o   Ability to maintain or regain mental health in the face of adversity

·       Effect of risk and protective factors can be:

o   Context-specific

o   Time-specific

·       Operate in a bi-directional manner with MDD

o   Low SES or lack of support contribute to MDD risk

o   However, those with MDD also have deteriorating social functioning that could result in smaller social networks, unemployment and lower income (social drift)

·       Many risk factors interact randomly and non-linearly and can be a stand-in of other factors

o   i.e. childhood trauma negatively affecting beliefs regarding interpersonal relationships and self-efficacy, which in turn negatively impact adaptive health and lifestyle behaviors such as unhealthy sleep patterns, physical activity, diet, increase substance abuse

·       Demographic factors

o   Risk:

§  Female

§  Adolescent and emerging adults

§  Low SES

o   Protective:

§  Male

§  Older adult- age

§  High SES

·       Psychological factors

o   Risk:

§  Neurotic, introversion

§  Rumination and external locus of control

§  Childhood trauma

§  Poor parental bonding

o   Protective:

§  Extraversion

§  Internal locus of control, self-worth, mastery

§  Good parenting

·       Sociocultural community factors

o   Risk:

§  Poverty, unemployment

§  Recent negative events

§  Lack of social support, bullying, discrimination, partner violence

§  War, natural disasters, air pollution, ambient noise

o   Protective:

§  Economic security

§  Social protection

§  Recent positive events

§  Social support and equality

§  Green spaces, exposure to nature

§  Neighborhood security and safety

·       Behavioral health factors

o   Risk:

§  Unhealthy lifestyle

§  No or poor treatment, treatment non-adherence

§  Somatic disease, obesity, and functional limitations

§  Early-onset anxiety or other mental disorders

o   Protective:  

§  Healthy lifestyle

§  Adequate tx provision and compliance

§  Physical health

§  Good youth mental health

2/19/25 Major Depression continued and persistent depression disorder

Global burden of disease

·       Burden of disease = sum of mortality and morbidity

o   Measured by a metric called “Disability Adjusted Life Years” (DALYs)

·       DALYs are a measure of lost health

o   A standardized metric allowing direct comparisons of disease burdens of different diseases across countries, between different populations and over time

o   1 DALY = equivalent of losing 1 year in good health because of either premature death, disease, or disability

o   1 DALY = one lost year of healthy life

Normal sadness vs Depression

·       Normal emotion, a part of everyday life

o   It’s an adaptive function

§  Expected sadness in response to one of the above may be adaptive (evolutionary sense) by:

·       Permitting withdrawal to conserve inner resources

·       A signal for your need for support from significant others

§  Transient periods of sadness

·       i.e. holiday blues for anniversaries or holidays

§  Normal sadness may occur during a premenstrual phase or during postpartum

§  Although not psychopathological per se, but predispose to mood disorder à may develop clinical depression if feelings persist

Persistent Depressive Disorder (aka Dysthymia)

·       Characterized by:

o   Depressed mood for most of the day, on most days, for at least 1 year

o   It’s less severe but more chronic than MDD

·       Symptoms:

o   Poor emotional regulation

§  Temper tantrums

o   Constant feelings of sadness *

o   Feeling unloved

o   Forlorn *

o   Self-deprecation *

o   Low self-esteem

o   Anxiety

o   Irritability

o   Anger

Side by side comparison of MDD and PDD

·       MDD

o   Symptoms are more impairing

o   Onset of MDD symptoms – usually rapid

o   MDD usually lasts for a few months but may reoccur (episodic)

o   Anhedonia and suicidal ideation are characteristic of MDD

·       PDD

o   Chronically depressed or irritable mood that lasts at least one year

o   Not as severe, but last a long time

o   Symptoms begin more gradually

o   Long-term condition

o   Anhedonia and suicidal ideation are NOT characteristic of PDD

§  Are able to enjoy life and be functional, but baseline mood is forlorn

MDD vs PDD- a helpful metaphor

·       Think of MDD as a severe and chronic bout of the flu… or like in most cases of PDD as chronic problems with allergies… not as severe but they DO persist and affect every aspect of that person’s life

·       Some who experience PDD for long enough that they normalize it and think that they have just always been this way AND there is no problem

PDD- self attributions

·       Youth as described by others

o   Uninteresting

o   Unlikable

o   Ineffective

·       Youth self-descriptions

o   Moody

o   Sluggish

o   Down

o   Cranky

Diagnostic conundrum

·       Personality disorder OR mood disorder?

o   Infused into identity and effects life/living

Grief vs depression

·       Same versions of the same affective reaction OR two differing ones?

o   Distinction is the duration and intensity of grief

§  A year or longer might point more towards depression

·       Comparison

o   Grief reaction

§  Dominant affect: feelings of emptiness and loss

§  Dysphoria: occurs in waves, vacillates with exposure to reminders and decreases with time

§  Retain capacity for positive emotional experiences

§  Self-esteem preserved

§  Fleeting thoughts of joining deceased (if grief is about the death of a loved one)

o   Major depression

§  Dominant affect: depressed mood

§  Persistent dysphoria: accompanied by self-critical preoccupation and negative thoughts about the future

§  Limited capacity to experience happiness or pleasure

§  Worthlessness clouds esteem

§  Suicidal ideas about escaping life versus joining a loved one

Cognitive Model of Depression

·       Cognitive behavioral perspective – Aaron Beck and Albert Ellis (in textbook)

o   Learn to think and feel a certain way

§  CBT- if you learned it, then unlearn it

o   Beck- Cognitive Behavioral Therapy

o   Ellis- Rational Emotive Behavior Therapy

§  Focused on tendency to think irrationally

·       View of human nature

o   We are born with a potential for both rational and irrational thinking

o   We have the biological and cultural tendency to think crookedly and to needlessly disturb ourselves

o   We learn and invent disturbing beliefs and keep ourselves disturbed through our negative automatic thoughts

o   We have the capacity to change our cognitive, emotive, and behavioral processes

·       Origins

o   Outgrowth of behavioral psychology

o   Leading proponents were Aaron Beck and Albert Ellis in the 1960s in the treatment of unipolar depression

o   Beck developed cognitive therapy after noticing that depressed patients had negative cognitions regarding:

§  Loss

§  Failure

§  Abandonment

§  Rejection

·       Fundamental assumption

o   THINKING MATTERS

§  How we think and attach meaning to experience determines emotions and behaviors

§  “people contribute to their own psychological problems, as well as specific symptoms, by the way in which they interpret events and situations in their life”

·       CBT identifies at least 4 problematic aspects of cognition:

o   Dysfunctional automatic thoughts aka: internal dialogue

o   Errors in logic aka: cognitive distortions

§  i.e. dichotomous thinking, mind reading, overgeneralization, personalization, catastrophic thinking

o   Dysfunctional attitudes

§  Assumptions/rules; “if à then”

o   Negative core beliefs

§  Lovability, helplessness, competency

§  Cognitive triad: views of self, world/others, future

·       Negative view of the SELF: I’m unlovable, ineffective

·       Negative view of the WORLD: world is hostile

·       Negative view of the FUTURE: nothing will work out

o   Learned Helplessness (Martin Seligman)

o   Self-attribution Theory

§  Lynn Abramson

§  Perspective: internal (something about me), stable (it’ll never change), global (it applies to all areas)

§  i.e. “I’m stupid” vs “I can’t do math”

§  Views become our schemas

o   Levels of thinking

§  Automatic thoughts- rapid thoughts, often beyond awareness, that influence emotions

§  Core beliefs- key assumptions about experiences concerning self, world, future

§  Schema- stable structures that color perception of daily experience  

§  Example

·       Situation: a friend doesn’t call you on the weekend as promised

·       schema: “I’m unlovable” à core belief: “I need his approval to be worthwhile” à automatic thought: “He doesn’t like me”

·       Emotions related: sadness, depressed, helpless

2/24/25- Mood Disorder Genetics and Biogenic Amine Hypothesis

Ch. 2 in text

MDD- Etiological Overview

·       Etiologies: combination of effects/factors:

o   Environmental: i.e. risk/protective factors, recent negative life events and childhood maltreatment and poverty

o   Psychological: i.e. cognitive patterns

o   Genetic: polymorphisms; GWAS; GXE

o   Biological: structural and functional alterations; inflammatory and monoamine pathways

Elements of Genetic Risk

·       Estimated heritability of MDD is about 37%

o   Lower than the heritability of most other mental disorders

·       Children of individuals with MDD have a 35-40% risk of developing MDD by early adulthood

o   2x the risk found in children of parents without MDD

·       Significance: genetics AND within-family environmental factors are equal contributors to the familial risk of MDD

MDD- Genome wide association studies

·       About 500,000 people with MDD against >3 million controls illustrated that very small effects of several common genetic variants that underlie the genetic risk of MDD

·       Single Nucleotide Polymorphism (SNP)

o   Is a DNA sequence variation arising when single nucleotide in the genome sequence is altered

o   When a single nucleotide, substitutes one of the other three nucleotide letters – this is referred to as SNP

·       Genome-wide association study (GWAS)

o   Method used to find out common SNPs associated with complex diseases

§  SNPs from the whole genome are scanned and compared between case and control group

o   GWAS are accurate and reliable, especially for the single gene defects

o   But GWAS reveal a…

§  High genetic correlation (rG > 0.6) among some mental disorders and relevant personality traits

·       i.e. neuroticism, subjective well-being, and anxiety

§  Moderate genetic correlation for ADHD, bipolar disorder, and schizophrenia

§  Significance: suggests shared genetic risks might explain the high comorbidity between various mental disorders

·       Influence of Gene X environment:

o   Genetic factors related to MDD can be influenced by environmental factors specific to that person, i.e. childhood trauma and/or life adversity

o   Significance: certain epigenetic mechanisms, i.e. environmental influences might mediate gene and environment interactions

Structural Alterations- Interpretive Caution

·       Effect sizes of structural brain

·        Differences: in MDD are smaller (< 0.2%)

·       Data from large analyses suggest differences have limited predictive value at the individual level

·       Remains unclear to what extent these differences should be interpreted as:

o   Etiological risk factors

o   Early manifestation

o   Consequence of long exposure

o   Scarring effect of illness-related processes or progression

Structural Alternations- Convergent Evidence

·       Substantial number of MDD-associated genetic variants found in genes expressed in these brain regions à frontal lobe

·       Reduced neurogenesis and grey matter volume in prefrontal cortex and anterior cingulate of people with MDD

o   Regions involved in emotion, attention, and cognitive control

·       Subtle but extensive differences in white matter microstructure in multiple brain regions

o   i.e. corpus callosum- suggesting some structural dysconnectivity

·       General findings – smaller brain region volume, especially the hippocampus

Functional Alterations- 3 major networks

1)     Salience

2)     Fronto-parietal

3)     Default mode

Biogenic Amine Hypothesis of Depression

·       Antidepressants

o   Tricyclics and Tetracyclic (TCAs)

§  Imipramine – Doxepin – Desipramine – Amoxepine – Trimipramine - Maprotiline – Clomipramine – Amitriptyline – Nortriptyline – Protriptyline

o   Monoamine Oxidase Inhibitors (MAOIs)

§  Tranylcypromine, Phenelzine, Moclobemide

§  Last resort if someone does not respond to SSRIs

o   Selective Serotonin Reuptake Inhibitors (SSRIs)

§  Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Citalopram

§  Only affect serotonin à mood neurotransmitter

§  Most commonly prescribed

o   Serotonin and Norepinephrine Reuptake Inhibitor (SNRIs)

§  Venlafaxine, Duloxetine

§  Selective for both neurotransmitters, serotonin and norepinephrine à for mood and energy levels

o   Serotonin-2 Antagonist and Reuptake Inhibitors (SARIs)

§  Nefazodone, Trazodone

·       Catecholamines

o   Hormones the brain, nerve tissues, and adrenal glands produce

o   Neurotransmitters released in response to emotional or physical stress

o   Dopamine, Epinephrine, Norepinephrine

·       Serotonin – The Mood NT

o   Serotonin is a indoleamine neurotransmitter chemical structure related to melatonin

o   Most of the serotonin is found in the intestines of the body

§  90% is found in the cells lining your gastrointestinal tract

§  Released into your blood and absorbed by platelets

o   Serotonin is made from the essential amino acid- tryptophan

§  Can’t be made in the body, has to be obtained from foods you eat

·       Caused because neurotransmitters are not in the synapse gaps long enough to adequately deliver messages or hormones/chemicals

2/26/25- review biogenic amine hypothesis, SAD, bipolar disorder

Seasonal Affective Disorder (SAD)

·       Syndrome: recurrent, seasonal pattern of depressive episodes

o   May also describe other affective episodes (mania or hypomania) that occur in a seasonal pattern

o   Recurrent depressions that occur annually at the same time each year

·       Possible treatment: bright light therapy

·       Not listed in DSM V-TR as a disorder, but as a specifier

o   Instead listed under MDD and Recurrent Bipolar Disorder as a “specifier” à “with a seasonal pattern” ranging from mild to severe

·       Relatively common- significantly impacts mood and psychosocial functioning

·       Particularly problematic because it is a recurring syndrome with symptoms that may last 40% of the year

·       Usually more common in the fall/winter (Winter SAD), though spring/summer (Spring SAD) may occur

o   Winter-onset characteristics: atypical depressive symptoms, i.e. hypersomnia, increased appetite, craving carbs

o   Spring/Summer SAD onset characteristics: more frequently associated with typical depressive symptoms, i.e. insomnia and appetite loss

·       Etiology not completely understood

o   Posited etiologies: combination of physiologic, psychologic, genetic and environmental factors

o   Hypotheses:

§  Circadian phase delay

§  Retinal sub-sensitivity to light

§  Altered neurotransmitter release

§  Hypovitaminosis D and genetic variations in clock

§  Monoamine and retinal photopigment genes

o   Important qualifier: SAD may be heterogeneous condition; some factors may play a role in some individuals with the disorder and not others

·       Prevalence (also uncertain):

o   Varies across populations influenced by latitude

o   Tends to be more prevalent with higher latitudes

·       Risk and protective factors:

o   Significant evidence of greater susceptibility in those who migrate from lower to higher altitudes

o   SAD seems to affect more women than men (4:1 ratio)

o   Appears to decrease in prevalence with age

Bipolar Mood Disorder: bipolar disorder I and II, cyclothymic disorder

·       Patterns of mood fluctuations: bipolar type

o   Normal mood fluctuations

o   Bipolar I

§  More debilitating than MDD

§  Higher levels of mania à hypermania

§  Same level of depression as bipolar II

o   Bipolar II

§  Hypomania

§  Same level of depression as bipolar I

o   Cyclothymia

§  Exaggerated mood fluctuations

§  No prevalence of mania or depression

·       Rapid cycling: 4 or more manic episodes in 1 calendar year

·       What we see in adults

o   Biologically based disorder causing unusual/extreme shifts in a person’s

§  Mood AND

§  Energy

o   Leading to impairment in the ability to function

·       Manic episode- defined

o   Distinct period of abnormal and persistently elevated, expansive, or irritable mood and abnormal and persistent increased activity or energy

§  Lasting at least 1 week and present most of the day, nearly every day

o   During this period, 3 or more symptoms are present…

§  To a significant degree AND

§  Represent a noticeable change from usual behavior

·       Expansive mood

o   An emotional state characterized by:

§  Feelings of grandiosity (delusions)

§  Exaggerated sense of self-importance

§  Overwhelming optimism extending beyond the realms of reality

o   What it is: prolonged and heightened sense of self, teetering between healthy self-assurance and potentially unhealthy delusions of grandeur

§  What it is not: the occasional burst of confidence we all experience

o   Individuals demonstrating an expansive quality of their mood may:

§  Display a magnified belief in their capabilities and worth

§  Feel a surge of creative ideas and the urge to act on them immediately

§  Speak rapidly, driven by a rush of thoughts

§  Exhibit reduced inhibitions à leads to impulsive decisions and actions

§  Experience a feeling that they are destined for greatness or have a unique mission

·       Epidemiology and prevalence

o   Affects about 8 million people in the U.S.

o   About 40 million worldwide

o   Symptoms onset typically start between ages 15 to 25, often with an initial episode of depression

o   No difference between men and women

3/10/25

Ch. 6 continued- Bipolar I and II

What is “classic” bipolar?

·       Defined by the overall pattern

o   Hypomania/mania involves discrete episodes of mood change of 4 -7 day minimum duration

o   Episodes mark a clear departure from baseline function

What mania means to us

·       8 points of emphasis

o   Inflated self-esteem or grandiosity

o   Decreased need for sleep

o   More talkative than usual or feeling pressure to keep talking

o   Racing thoughts

o   Distractibility

o   Increased goal-directed activity (either socially, for school/work, sexually) or psychomotor agitation

o   Excessive involvement in pleasurable activities that have high potential for negative consequences

o   Poor judgement leads to social or work problems, often leading to hospitalization

What mania looks like in real life

·       Limited duration of sleep

·       Poor judgement

·       Spending sprees

·       Increased sexual drive or hedonistic pursuits

·       Abuse of drugs, particularly cocaine, alcohol, or sleeping medications

·       Provocative, intrusive, or aggressive behavior

·       Denial that anything is wrong (reflecting poor/limited insight)

What mania “feels like”

·       Is the complete opposite to depression, BUT not a pleasant “high”

·       This is a slight misconception

·       More often: a sense of “intense” euphoria or elation accompanied by many negative symptoms that make the experience of mania far from pleasant

Typical mania progression à 4 stages (derived from research by Emanuel Mendel)

·       Stage 1: Initial stage

o   2-3 months

o   Poor physical well-being, depressed disposition and depression symptoms

·       Stage 2: Exalted stage

o   Recovering from depressed symptoms

o   Relieved inhibition on thinking

o   Each person has their own cycle, time wise, of lifting of symptoms

·       Stage 3: Furious stage

o   Escalation of manic symptoms

·       Stage 4: Recovery stage

o   De-escalation of manic symptoms

o   Enters depressive state

o   “hangover” after the rapture

Impact of expansive moods in BP-1

·       Work and professional life

o   Self-importance and impulsiveness related to expansive moods can prompt self-defeating working environment choices

§  i.e. impulsively leaving workplace, estrange co-workers, aggressive in tasks without planning

·       Relationships

o   Personal relationships can suffer due to erratic and exaggerated behaviors

o   People may find it challenging to cope with the individual’s excessive demands for attention and/or their unpredictable mood swings

·       Financial stability

o   Tendency towards financial extravagance can jeopardize financial stability

§  Can lead to debt and economic crisis, further complicating life

·       Community and social interactions

o   Expansive moods can reduce an individual’s ability to function within their community

Manifestations of Mania

·       What is a delusion

o   A fixed false belief system, not easily refuted even with incontrovertible evidence

§  i.e. a person believes they are someone other than who they are or have special abilities/powers

§  Potential problem: can become unsafe when someone may take risks because they feel protected by their special abilities

·       Delusional characteristics

o   Believes it is true

o   Person will not listen to other viewpoints about the belief despite contradicting evidence to challenge the delusion

o   Delusions content is impossible or implausible

o   Impacts the person’s daily life

·       Typical beliefs: delusions of grandeur

o   Believes they have a specific ability

o   Believe they are a famous person

o   Believe they have secret connection to someone important

o   Religious themed delusions that they are a religious leader

Co-morbidities

·       Anxiety disorders

o   Panic disorder

o   Well established relationship between anxiety symptoms and BPD 1 usually results in a more complicated course

·       Substance abuse

·       ADHD

·       Personality disorders

Bipolar II Disorder

Difference between BPD I and II

·       Spend more time experiencing depressive symptoms

o   Versus MDD and hypermania of BP-I

·       Dominated by depressive symptoms rather than hypomania

o   Ration of time spent with depressive symptoms relative to time with hypomanic symptoms is about 30:1

·       Clinical concern

o   Need to balance risk of over-diagnosing BP-II and possibly prescribing unneeded mood-stabilizers to those with MDD

o   Under-diagnosing BP-II and exposing those with BP-I to potentially ineffective or harmful antidepressants

Hypomanic episode

·       Duration: 4 consecutive days

·       Symptoms: much like manic episode but briefer and less severe, NO hospitalization required

·       Mixed episode

o   Duration: 1 week

o   A combination of manic and depressive episodes becoming superimposed so that symptoms of both are present (at different times) during the same day

o   Criteria is met both for a manic episode and a MDD episode nearly every day

Suicide and Non-Suicidal Self-injury

Suicide

·       Increasing public health problem

o   10h leading cause of death in the US

·       Huge across youth

o   Ages 10-24

·       NSSI: Non-suicidal self-injury

o   Cutting, burning, skin picking

·       Suicide gesture

o   Sub-lethal self-harming without life-threating intent

o   However…

§  Must be taken seriously

§  Decreases fear of death

·       Used to be a crime

o   Connotation is erased now

§  Thank goodness

·       Youth Suicide vs NSSI

o   Youth Suicide

§  End how they’re feeling

§  Select 1 method

§  Often give advance warning

§  Pain persistent + undesirable

§  Make infrequent attempts

o   NSSI

§  Want to feel better à relieve tension

§  Often multiple methods

§  Rarely give advanced warning

§  Pain intermittent + uncomfortable

§  Repeated behaviors

§  Often try to hide their true feelings

o   The more NSSI occurs, the more likely youth suicide will happen

·       NSSI DSM 5 Criteria

o   5 or more episodes in 1 year

o   2 or more of these:

§  Preceded by a negative affect

§  Preoccupation difficult to resist

§  Urge occurs frequently

§  Activity engaged with a purpose

§  Must have intent

o   Behavior + consequences of act cause distress

o    

o   Not exclusively during intoxication or psychosis

·       Durkheim’s Sociological Theory

·       Egotistical Suicide

§  Detachment from society

§  Moral deregulation + lack of social restraint

·       Fatalistic Suicide

·       Joiner: “Interpersonal Theory of Suicide” (IPTS)

o   Individual must

a.      Want to die

b.     Developed capacity to enact a plan of lethal self-harm

                                                                          i.     Feeling like a burden

                                                                        ii.      Feelings of not belonging

·       Perceived Burdensomeness

o   When one beliefs their death is worth more than their life

o   What it feels like

§  Flawed in some capacity (damaged)

§  Existence burdens friends + family

·       fully believes this to be correct

§  Aaron Beck: cognitive distortions

·       Failed Belongingness

o   Basic human need of connection is not met

§  What it feels like

·       Alienated from significant others

·       Ties are cut off

o   Death becomes an option

Ch. 8

3/17/25 Fear, Phobias, and Anxiety

·       Anxiety

o   Perceived threat

§  Fear is natural, survival response but can lead to potential phobias and anxieties in the case of a mental disorder

o   Arousal and performance

§  Yerkes-Dodson Law

§  Optimizes level of arousal that is needed to complete the proper response, however leads to a performance decline due to increased levels of stress

§ 

§  Can tolerate more or less anxiety in that task depending on our skill level in that area

o   Person is responding to a threat that is objectless, directionless, and located somewhere far off in the future involving perceived ruination, humiliation, decay

·       Fear

o   Normal response to a realistic danger

o   Initiates the fight or flight reaction

·       “Fight or flight”: activation of the sympathetic nervous system

o   Leads to hyper-arousal symptoms

o   Increased:

§  Strength of the skeletal muscles

§  Heart rate and force of contraction

§  Basal metabolism

§  Secretion of adrenaline

o   Dilation of:

§  Lungs to increase oxygen supply

§  Pupils for improved vision

o   Cease of digestive activity

·       Phobia: a special kind of fear defined by 4 characteristics

o   Out of proportion to the reality of the situation

o   Can neither be reasoned or explained away

o   Largely beyond voluntary control

§  Associated learning à classical conditioning

o   Avoidance of the phobic situation

·       Mower’s Two Factory Theory

o   Criterion 3 and 4

§  Largely beyond of your voluntary control and avoidance

o   Associating an objective or situation with pain and/or trauma results in fear of it

§  Classical conditioning

o   Development of avoidance behaviors prevent identification of evidence that would disconfirm fears

§  Operant conditioning à avoidance and escape (negative reinforcement)

·       What is atypical, diagnosable anxiety?

o   Prevalence in the US

§  Lifetime prevalence rates

·       40 million adults (31.6%) with any anxiety disorder

§  Yearly prevalence rates

·       Any anxiety disorder- about 18% of adults

o   A multidimensional pattern or set of complex and interactive self-defeating responses that is “inferred” from an individual’s:

§  Self-report,

§  Physiological activity, and/or

§  Observable performance (behavioral responses) in certain situations

·       Significance of anxiety

o   Most common mental health problem

§  31.6% lifetime prevalence

§  1.6x more likely in women

o   Increased use of medical treatment

§  Double the likelihood of an ER visit or hospitalization

§  3-5x more likely to go to their physician

§  6x more likely to be hospitalized for psychiatric disorders compared to those without

§  74% higher health care costs than control

§  Over $63 billion in total medical costs

o   Health risks

§  Panic disorder double risk of stroke and cardiac mortality rates in men

§  Post-menopausal panic attack triple risk of cardiac mortality in women

§  May with anxiety have a co-occurring disorder or physical illness, can make their symptoms worse and recovery more difficult

o   Mental health risks

§  22% co-morbid substance abuse

§  High rate of suicide attempts especially with PTSD and panic disorder

·       Phobia vs anxiety disorders

o   Beck sees it

§  A primitive automatic physiological state of alarm involving the cognitive appraisal of imminent threat or danger to the safety and security of individuals

§  Anxiety is complex cognitive, affective, physiological and behavior response system

·       Threat mode activated when anticipated events or circumstances are deemed to be highly aversive because they are perceived to be unpredictable, uncontrollable events that could potentially threaten the vital interests of the individual

§  Ergo: the anxiety “exaggerates” actual risks: disease, dismemberment, assault, humiliation, loss, failure, success, madness, death

·       Anxiety disorders

o   Persistent apprehension over time around situations that are not objectively/proportionally dangerous

§  Qualifier: the anxiety is not appropriate to the developmental level

·       What is the source of the danger and/or threat?

o   Process of exposure is similar across all anxiety disorders, what varies is the fear trigger

§  Separation anxiety

§  Specific phobia

§  Social anxiety

§  Hypochondriasis**

§  Panic/agoraphobia

§  GAD

§  PTSD**

§  OCD**

§  **not officially classified as anxiety disorders

3/19/25 anxiety disorders continued

Generalized Anxiety Disorder

·       “What if” anxiety

·       Epidemiology

o   One of the most common mental health disorders in U.S.

o   Annual prevalence rate of 1.8% among adults in the U.S.

o   Lifetime prevalence 3.7% (6.8 million) U.S. adults

§  2x as common in women than men

·       GAD history

o   First introduced in DSM III (1980)

o   Originally considered a “wastebasket diagnosis” presumed to be associated with fairly modest impairment

o   GAD diagnosis has undergone frequent substantial revision, challenging efforts to accumulate a knowledge base for the disorder

o   “worried well”

o   Understanding GAD has lagged behind understanding of other anxiety disorders

·       Principle features- DSM V

o   Core diagnostic features:

§  Emphasis on the central role of excessive, persistent, and uncontrollable worry

§  Requires the presence of a physiological complaint

·       i.e. feelings of restlessness, easily fatigued, irritability

·       Normal worry vs GAD

o   Worry is normal… we all do so about the same kind of issues

§  i.e. families, relationships, school/work lives, health, finances

o   Important distinction: those who worry excessively is not a “what problem” rather the ease with which they fall into worry

o   Worry more often and for longer periods of time

o   Worry much more about:

§  Little things

§  Remote or unlikely events

§  Future: with no specific event in mind but the possibilities

o   Consequence: worry gives small things a big shadow

·       GAD

o   Characterized by:

§  Core feature: worry- about practically anything

§  Excessive free-floating anxiety under most circumstances

§  Worries are unrealistic, difficult to control, excessive

§  Verbal thoughts rather than images

§  Motor tension, vigilance, scanning

o   Symptoms: feeling restless or on edge, fatigue, difficulty concentrating, muscle tension, and/or sleep problems

o   Duration of at least 6 months for diagnosis

·       GAD etiology

o   Largely unknown

o   Believed the combination of genetics, environmental factors

§  i.e. adverse childhood experiences, somatic disorders, alcohol and substance abuse

o   Impact of stressful life events is thought to contribute to the onset, course, and persistence of GAD across lifetime

o   Brain imaging studies: support role in expression of GAD symptoms in areas related to decision making, memory, cognitive flexibility, emotion appraisal and regulation, and detection of threat

·       Age of onset

o   18-mid 20s

o   Evident in young adulthood

·       GAD comorbidities

o   One of the most identified diagnoses in mental health

§  Ironically, the validity of the diagnosis has been questioned by findings of some epidemiological surveys

o   3 reasons:

§  Some of the symptoms required for MDD overlap with GAD

§  Symptoms of GAD overlap with a large proportion with those of many other psychiatric conditions

§  Only 17% of those diagnosed with GAD do not show another mental health diagnosis

·       Worry vs rumination

o   Worry: more often about future events or things that have not happened yet but seem “as if” they could or will

§  One caveat: the person who worries can flip-flop between worry and rumination

o   Rumination: going over past events or negative experiences

·       3 key schemas of GAD

o   Uncontrollability

o   “what if”

§  The background of “intolerance of uncertainty”

o   Ineffective problem-solving skills

·       GAD: more worries

o   Perfectionism: fear of making mistakes, unfavorable assessment of their abilities and outcomes

o   Cognitive distortion: over responsibility

§  “If something happens, it’s my fault”

o   Negative news that happens to others à fear it will happen to them

§  Core belief: everything is contagious by association

·       Coping strategies

o   Seeking excessive reassurance: asking others to review something, for feedback on performance or actions

o   Checking: consistent asking to ensure that they are okay or what they did is okay

o   Information-seeking: list making, obsessive research before making a decision

3/24/25-

Social anxiety disorder

·       Imaginary audience = typical

o   Social anxiety disorder = atypical

·       Behavioral model- Mower’s 2 factor theory

o   Classical conditioning- onset

o   Operant conditioning- maintenance

·       Barlow’s model

o   Behavioral inhibition

o   Blush response

·       Behavioral inhibition

o   Jerome Kagan and Nancy Snidman

o   Vulnerability factor to psychological disorders

§  Also dependent on environmental factors

§  Parenting à “goodness of fit”

o   BI: high negative emotionality + low extraversion

o   Defined: tendency to demonstrate restraint and fear, when presented with novel situations and/or people

o   Characterized by:

§  Extreme wariness

§  Withdrawal in the face of novelty, particularly social novelty

§  Present in 10-15% of 2 year olds

§  Is relatively stable

o   Significance: highly related to shyness and social anxiety

o   Precursor to BI: negative reactivity

§  i.e. increased motor activity and negative affect when novel stimuli are presented to young infant

o   The Amygdala

§  Hypothesis: amygdala is hyper-reactive due to genetic influences à quick trigger in brain’s “danger alarm”

§  High reactivity in young children- high distress and motor activity

§  High reactivity in older children- higher SNS arousal, i.e. higher resting heart rate, increased cortisol levels, pupil dilation

·       Blush response

o   Evolutionary hypothesis: serves as a social function

§  Purpose: blushing softens the negative evaluation from others in the group when we feel we’ve done something embarrassing or have become center of attention

o   Disordered blushing: misappraisal of an experience, instead of viewing it as the softening of negative evaluation, blushers perceive it as an occasion to be “judged for being flawed”

·       Cognitive model

o   Characterized by a:

§  Strong motivation to make a positive impression

§  Belief that one is likely to behave in an incompetent and inappropriate way when encountering a social situation

§  Belief that one will suffer disastrous consequences as a result

§  Tendency to view oneself from an observer’s perspective

·       Cognitive model- 3 stages of distorted processing

o   Anticipatory processing stage

§  Anxious apprehension, rumination

o   In-situation processing stage

§  Negative core self-beliefs (i.e. self/word/others/future)

§  Assumptions

§  Rigid rules

§  Focus on self as a social object

§  Diminished attention to external social cues

§  Increased safety behaviors

o   Post-mortem processing

§  Person will likely have missed signs of social approval due to self-foucs

·       Associated cognitive and (observed) behavioral features

o   Cognitive

§  Fear negative evaluation

·       i.e. being humiliated, embarrassed, or rejected by others in performance, interaction, or observation situations

o   Behavioral

§  Inadequately assertive or excessively submissive behavior

§  Rigid body posture

§  Inadequate eye contact

§  Overly soft voice tone

§  Blushing

·       Associated personality traits and social limitations

o   Traits

§  Difficulty being assertive

§  Feelings of inferiority

§  Hypersensitivity to criticism

§  Hypersensitivity can lead to fear of others making both direct or indirect judgements

§  Extreme test anxiety, common

§  Limited participation in class

o   Social limitations

§  Less likely to marry- develop and maintain fulfilling friendships

§  More likely to live with members of their biological family

§  Comorbidity: suicidal thoughts (associated with severe cases), particularly when other mental disorders are present

·       Social anxiety disorder: dx criteria

o   Marked fear/anxiety about 1 or more social situations in which person is exposed to possible scrutiny by others

o   Person fears they will show symptoms of anxiety that will be negatively evaluated

§  Social situations

·       Almost always provokes fear/anxiety

·       Are avoided or endured with intense/fear anxiety

§  Anxiety/avoidance

·       Out of proportion to actual danger

·       Persists for more than 6 months

·       Causes significant impairment

§  Increased self-focus and perception

·       Everyone is watching you and thinking negatively of what you do, say, how you look

·       Changing nomenclature

o   Classified as a mental disorder in the DSM-III (1980)

§  Originally termed: social phobia

§  Renamed Social Anxiety Disorder in DSM V (2013)

o   Principle feature: ongoing fear and worry surrounding myriad of social situations

§  One of the most common mental disorders: lifetime prevalence >10%

§  Majority of diagnoses made during childhood or early adolescence

§  Often seen in conjunction with MDD, other anxiety disorders, and substance use disorders

·       Common experience: anxiety is out of proportion to the actual threat posed by the social situation and context

·       Social anxiety vs shyness

o   Occasional shyness or anxiety is not the same as having a social anxiety disorder

o   It is common to experience the feelings discussed from time-to-time

o   These occasional feelings typically do not hinder and/or impair someone’s normal functioning in the way social anxiety disorder does

·       Commonly feared situations

o   Formal presentations and unstructured social interactions

o   Common trigger: being the center of attention, even the mere possibility of being the center of attention

·       SAD in youth

o   Harder to diagnose in youth

o   ANS: because children do not have the language to describe the quality of their anxiety as effectively as adults

o   Consequence: SAD may go unrecognized despite a child developing habits frequently encountered with social anxiety

§  i.e. crying, tantrums, clinging to familiar people, extreme shyness, refusing to speak in front of others, fear or timidity in new settings or with new people

o   Dx requirements: child must…

§  Experience anxiety with their peers as well as with adults

§  Also show the capacity to form social relationships with familiar people

3/26/25- panic disorder and agoraphobia

Panic Disorder- an out of the blue experience

·       Panic attacks

o   Fear is activated at the wrong time

o   Symptoms often are not provoked by an identifiable trigger

§  May occur in seemingly least likely situations such as during relaxation or sleep (i.e. nocturnal panic)

o   Symptoms:

§  Skipping, racing, or pounding heart

§  Sweating

§  Trembling

§  Shortness of breath

§  Choking sensations

§  Chest pains, pressure, discomfort

§  Nausea, stomach problems, sudden diarrhea

§  Feeling dizzy, faint, lightheaded

§  Tingling or numbness in the body

§  Hot flashes or chills

§  Feeling detached from surroundings, thoughts of losing control or going crazy, fear of dying

o   Diagnosis

§  Panic attacks need to include (1) abrupt onset (2) of at least 4 of 13 symptoms

§  Often not correctly diagnosed for years

·       What is a panic attack?

o   ANS: condition where there are repeated; often unexpected, panic attacks

o   Conundrum: a brief, intense episode of fear or uneasiness just like you might have in response to real danger except it occurs in situations most people would not be afraid

o   Panic attack is more intense than usual

§  Peaks within 10 minutes

o   Psychological experience: can be very frightening, results in desire to escape the situation or seek emergency assistance

o   Psychological consequence: often afraid of having another attack or worries about the consequences of their panic attacks

§  Many people change their behavior to try to prevent attacks

o   Untoward consequence: some affected avoid any place where it might be difficult to get help or to escape

§  When this avoidance is that severe, it is called Agoraphobia

·       Panic disorder: condition where there are repeated; often unexpected panic attacks that often come out of the blue, on a frequent basis

o   DSM-V criteria: person must have experienced recurrent, unexpected attacks and been persistently concerned about have another attack

§  Anticipatory anxiety

·       Panic attack vulnerabilities: setting the stage for an initial panic attack

o   There can be several reasons especially for an initial panic attack

o   Could include a combination of a person’s:

§  Biological make up

§  Personality

§  Tendency for the body to develop a fear response, i.e. anxiety sensitivity

o   Additional factors:

§  Experience of stress especially after prolonged stressful periods

·       i.e. negative life events, relationship difficulties, significant loss

§  Period of acute stress- begin in a situation where they suddenly felt very frightened

·       i.e. being stuck in a crowded shopping center

·       Panic attack triggers

o   Panic attacks may begin to build when an external or internal trigger is perceived as threatening

§  External triggers: situations in which you feel a little apprehensive

·       i.e. going into a room that is stuffy or crowded

§  Internal triggers: thoughts, images, memories, and bodily sensations

·       i.e. triggers may be ordinary events until you interpret them as somehow threatening— tightness in chest or increase heart rate and thought of, “what’s wrong with me?”

o   Important: the belief that something is threatening leads to anxious feelings

§  A perception of a situation, thought, image, or sensation as somehow threatening, initiates the anxious or apprehensive cascade

·       Clark’s Model of Panic (1986)

o   Internal/external trigger à perceived threat à anxiety à physical/cognitive symptoms à misinterpretation à continuation or intensification of anxiety

·       Anxiety sensitivity

o   Defined: fear of fear, behaviors/sensations associated with the experience of anxiety AND a misinterpretation of such sensations as dangerous

o   Consequential cognitions:

§  Being sensitive to anxiety symptoms often results in scanning the environment for possible cues for anxiety

§  Focusing inward noticing all the different physical sensations such as sweating or trembling

§  Under these circumstances it can be easy to convince yourself that you have a mental or physical problem

§  When there seems to be no obvious external reason for the panic attacks, appearing unpredictably “as if” out of the blue adds to the very distressing experience and/or because it is difficult to escape from places where they might occur

o   Important: Reiss and McNally suggested AS arises from beliefs that the experience of anxiety is itself harmful

o   2 facets:

§  Implied that “fear of fear” is at least sometimes rooted in cognition or beliefs, associations with prior panic experiences

§  Implied that “fear of fear” precedes panic experiences and can even predict panic attacks, as well as other anxiety conditions and PTSD

·       Cognitions associated with panic attacks

o   Roles of misinterpretation (cognitive distortions)

§  Catastrophic thoughts about normal or anxious physical sensations

§  Over-estimating the chances of having a panic attack

§  Over-estimating the cost of having a panic attack: thinking the consequences of a panic attack will be very serious or negative

§  Under-estimating your ability to cope

·       Secondary avoidance behaviors

o   Safety behaviors to make yourself feel better or try to stop a panic attack from occurring

§  Strategies are numerous with people just trying to feel better include:

·       Distracting

·       Planning escape route

·       Carrying objects to make yourself feel better or safe

·       Staying around significant others that you can ask for help

·       Complete Clark Model of Panic

Agoraphobia

·       Relationship to panic disorder

o   DSM V: agoraphobia has been separated from panic disorder as an independent condition based on:

§  Can occur without panic symptoms

§  Is not always secondary to panic symptoms

§  There are differences in prevalence, sex specific incidence rate, and treatment outcome between agoraphobia and panic disorder

o   Why do they “date” so often?

§  2 hypotheses:

·       Agoraphobia is a subtype of panic disorder

o   i.e. a severe complication of panic disorder so agoraphobia is considered to result from recurrent panic attacks

·       Agoraphobia could be a distinct condition, independent of panic disorder

·       Defined: irrational or disproportionate fear of a range of situations

o   Individual believes escape or access to help may be impossible, difficult, or embarrassing if they develop panic symptoms

·       Epidemiology

o   Lifetime prevalence in the general US population is about 2%

o   Prevalence is higher (10.4%) in adults over 65 years of age

o   2x more likely to occur in women than men

o   Average age of onset is between 25-30

o   Over the lifetime, 87% of individuals with agoraphobia will meet criteria for another form of atypical adjustment

o   Lifetime odds ratio of comorbidity with:

§  Panic disorder (11.9%), social anxiety disorder (7.1%), specific phobia (8.7%), GAD (5.8%), substance use disorder (1.78%)

·       Known risk factors

o   History of physical or sexual abuse

o   Behavioral inhibition

o   High neuroticism and low extraversion

o   Parental over protection

o   Separation from or death of a parent