Chapter 6: Mood Disorders and Suicide Overview of Mood Disorders Normal: mood is responsive to the environment o Good things happen, you feel good for awhile. o Bad things happen you feel bad for awhile. o Things stay in some sort of proportion most of the time. o As you get older, it takes even more to throw you off stride. To understand mood disorders: o You have to understand their phenomenology -- You have to know what it feels like to be depressed or manic. o Additionally, much of what is different about people with affective disorders involves physically feeling bad. Depression is not severe sadness o People with a clinical depression are sometimes sad and sometimes not sad at all. o Depression is a constellation of psychological and physiological states o There are a variety of physical signs, most obviously disruption of circadian rhythms, that are part of the picture Symptoms of Depression o Depressed or irritable mood o Diminished interest/pleasure daily activity o Weight loss or gain w/o trying o Early morning awakening or hypersomnia o Psychomotor agitation or retardation o Fatigue/no energy o Feeling worthless/overwhelmed by guild o Can’t seem to think or concentrate o Recurrent thoughts of suicide, a suicide plan or suicide attempt o Life is getting more and more of a mess o All for at least 2 solid months Age and Gender o Disorders with earlier onset tend to be more biologically driven and more severe. o Unipolar depression = twice as many women as men. o Bipolar disorder = just as many women as men o More severe disorders leave you less choice about how to be crazy so tend toward less gender distinction. o Remember the parallel case in anxiety disorders: lots more females with a specific phobia, but no gender difference in OCD, a more severe disorder. Key Point o Major disorders lie to you. o You crave the things that are worst for you. o Depression says “Just relax for a little.” means sit quietly alone in the dark for awhile and you will feel better. o Exactly the wrong prescription for depression. o Do just the opposite.
The Major Depressive Disorders are in three categories: o Major Depressive Disorder Major period of time where you're sad, where things are going wrong Single episode – highly unusual Recurrent episodes – more common Single manic episode or only manic episodes is very, very rare Cognitive symptoms - feelings of worthless, indecisiveness Anhedonia - Loss of pleasure/interactions of usual activites o Dysthymic Disorder Lower grade of depression but more chronic Overview and defining features Symptoms are milder than major depression Persists for at least 2 years No more than 2 weeks symptom free Symptoms can persist unchanged over long periods (≥ 20 years) o Double Depression Basically both a major depressive disorder and dysthymic disorder where you have someone who basically throughout his or her life has been sad, has had this kind of overlying depression, and then has episodes of major depressive episodes Major depressive episodes and dysthymic disorder Dysthymic disorder often develops first Facts and statistics Associated with severe psychopathology Associated with a problematic future course Bipolar Disorders o Common name -- Manic Depressive o Bipolar I Disorder: where you have very distinct major depressive periods of time and very distinct manic depressive, manic periods of time. It is as if you have to go 130 mph. Everything going very fast. Pretty selfdestructive. Alternations between full manic episodes and depressive episodes Facts and statistics Average age of onset is 18 years Can begin in childhood Tends to be chronic Suicide is a common consequence o Bipolar II Disorder: you would have mania that wouldn't be as high, so you'd have depressive periods and then kind of little blips of feeling manic, but not the very high highs that you would see in bipolar one Alternations between major depressive and hypomanic episodes Facts and statistics Average age of onset is 22 years Can begin in childhood 10% to 13% of cases progress to full bipolar I disorder
Tends to be chronic o Cyclothymic Disorder: kind of like dysthymic disorder where you're kind of getting ups and downs, but not high peaks that you would in bipolar disorder where you have people being sad and then people up and then people being sad Chronic version of bipolar disorder Manic and major depressive episodes are less severe Manic or depressive mood states persist for long periods Must last for at least 2 years (1 year for children and adolescents) Facts and statistics Average age of onset is 12 to 14 years Most are female Cyclothymia tends to be chronic and lifelong High risk for developing bipolar I or II disorder o Typical pattern: Mania, depression, normal mood o Atypical: Depression, mania normal mood o Rapid cycling: Depression, mania, depression, mania At least 4 times a year. Little or no normal mood. Really hard to successfully treat Differences in the Course of Mood Disorders o Course specifiers Longitudinal course Past history of mood disturbance History of recovery from depression and/or mania Rapid cycling pattern Applies to bipolar I and II disorder only Seasonal pattern Episodes covary with changes in the season Many view seasonal affective disorder as a mild form of bipolar disorder Mood Disorders: Additional Facts and Statistics o Worldwide lifetime prevalence 16% for major depression o Sex differences Females are twice as likely to have major depression Gender imbalance disappears after age 65 Why? Possibly because guys often have highly structured environments, women less so? Differential reward systems? Hormonal variation? Post partum depression Bipolar disorders equally affect males and females o Book: Fundamentally similar in children and adults (Karlin has reservations) o Prevalence of depression seems to be similar across subcultures (Although some differences. African-americans slightly less. American Indians more o Relation between anxiety and depression – negative affect Most depressed persons are anxious Not all anxious persons are depressed
Mood Disorders: Familial and Genetic Influences o Family Studies Rate is high in relatives of probands Relatives of bipolar probands tend to have unipolar depression o Adoption studies – data are mixed o Twin studies Concordance rates are high in identical twins Severe mood disorders have a strong genetic contribution Heritability rates are higher for females compared to males Vulnerability for unipolar or bipolar disorder Appears to be inherited separately. Karlin Question: Does that make them separate disorders? What does that mean for the spectrum view? KQ: Relatives of bipolar probands tend to have unipolar depression. If really different disorders, how come? Neurological Influences o Neurotransmitter systems Serotonin and its relation to other neurotransmitters Mood disorders are related to low levels of serotonin Karlin: It ain’t that simple. When SSRIs such as prosac and zoloft are given, levels of serotonin go up. By the time SSRIs are effective, however, serotonin levels back down to level at which you started. Like diuretics for blood pressure o Permissive hypothesis: Serotonin (5HT) regulates norepinephrine (NE). NE gets dysregulated with less 5HT. o Simple notion: low NE + 5HT = Depression o High DA adds psychotic symptoms o The endocrine system Elevated cortisol Karlin: Current medical thinking: Depression is an inflammatory disease. Whichever: Nerve cell death and disturbance of neurogenesis, especially in the hypocampus o Sleep disturbance Hallmark of most mood disorders Relation between depression and sleep and circadian rhythms in general Psychological Dimensions (Stress) o Stressful life events Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission o The relation between context of life events and mood What’s good for you may not be good for others Karlin: Remember the humiliation research. Social rejection related to depression. E.g. bad marriages go hand in hand w depression. Remember imagainings: Bad marriages cause depression or depression causes bad marriages or both caused by common factor????
At beginning, Stress triggers depression: Think back to imaginings: depression triggers stress? Reciprocal-gene environment model Psychological Dimensions (Learned Helplessness) o The learned helplessness theory of depression Lack of perceived control over life events Karlin: Lousy theory of depression. You have to know it, but I don’t have to teach it. Martin Seligman's theory that people become anxious and depressed when they make an attribution that they have no control over the stress in their lives (whether or not they actually have control) o Karlin; Theories authors both at Penn. Are theories related? Beck is better. o Learned helplessness and a depressive attributional style Internal attributions Negative outcomes are one’s own fault Stable attributions Believing future negative outcomes will be one’s fault Global attribution Believing negative events will disrupt many life activities All three domains contribute to a sense of hopelessness Psychological Dimensions (Cognitive Theory) o Negative coping styles Depressed persons engage in cognitive errors Tendency to interpret life events negatively o Types of cognitive errors Arbitrary inference – overemphasize the negative Overgeneralization – negatives apply to all situations o Cognitive errors and the depressive cognitive triad Think negatively about oneself Think negatively about the world Think negatively about the future In bipolar depression add: Ambitious striving for goals, perfectionism, self-criticism and often other criticism Social and Cultural Dimensions o Marital relations Marital dissatisfaction is strongly related to depression This relation is particularly strong in males o Mood disorders in women Females over males Except bipolar disorders Gender imbalance likely due to socialization Karlin: Read the section on cognitive disorders among women. I think it is one of the best sections in the book o Social support Extent of social support is related to depression Lack of social support predicts late onset depression
Substantial social support predicts recovery from depression An Integrated Theory o Shared biological vulnerability Overactive neurobiological response to stress o Exposure to stress Activates hormones that affect neurotransmitter systems Turns on certain genes Affects circadian rhythms Activates dormant psychological vulnerabilities Contributes to sense of uncontrollability Fosters a sense of helplessness and hopelessness o Social and interpersonal relationships/support are moderators Treatment of Mood Disorders: Trycyclic Medications o Widely used (e.g., Tofranil, Elavil) o Block reuptake Norepinephrine and other neurotransmitters o Therapeutic effects Can takes 2 to 8 weeks o Negative side effects are common: Constipation; dry eyes; rapid heartbeat o May be lethal in excessive doses Scares MDs for good reason. So, usually, only psychiatrists prescribe Monoamine Oxidase (MAO) Inhibitors o Monoamine oxidase (MAO) Block monoamine oxidase This enzyme breaks down serotonin/norepinephrine Slightly more effective than tricyclics Good drugs for smart and compliant patients o Must avoid foods containing tyramine Examples include beer, red wine, cheese Many patients don’t like the dietary restrictions Karlin: MDs afraid of lawsuits. Think patients are stupid or won’t listen. Do not know of anyone who even knows anyone who has actually seen a hypertensive (high BP) crisis. Selective Serotonergic Reuptake Inhibitors (SSRIs) o Specifically block reuptake of serotonin Fluoxetine (Prozac) is the most popular SSRI o SSRIs pose no unique risk of suicide or violence o Negative side effects are common Lithium o Lithium is a common salt Primary drug of choice for bipolar disorders Can be toxic o Side effects may be severe Dosage must be carefully monitored o Why lithium works remains unclear
o Karlin: All drugs are, in sufficient quantity toxic. Usually toxic level is well above effective level. With lithium, the toxic and effective doses overlap Electroconvulsive Therapy (ECT) o ECT is often effective for cases of severe depression and when nothing else works Karlin: Once upon a time, ECT caused permanent damage, mostly due to oxygen deprivation during procedure. Quite violent seizures in old days Result: Bad rep for ECT Brilliant answer: AN ANAESTHESIOLOGIST Lots of oxygen, no moving around on the table, undetectable side effects o Now, side effects are few and include short-term memory loss o 8-10 sessions administered as oupatient o Karlin: there are advantages and disadvantages to shocking only the nondominant hemisphere. o You want quick onset and quick offset of seizure. Solution: have another ECT guy look over the EEG. Then the first doc gets very careful o Uncertain why ECT works o Relapse is common Psychosocial Treatments o Cognitive therapy Addresses cognitive errors in thinking Also includes behavioral components o Interpersonal psychotherapy Focuses on problematic interpersonal relationships o Outcomes with psychological treatments Comparable to medications Research does not suggest advantage for combined treatment Karlin: Better for selected cases, worse for others. Remember antidepressants can make things worse for people with bipolar aspects. Otherwise, meds can make people able to do psychological treatments. Meds can add “bounce” to the system The Nature of Suicide o Facts and Statistics Eighth leading cause of death in the United States. Leading cause of death among young people Overwhelmingly a white and Native American phenomenon Suicide rates are increasing, particularly in the young o Gender differences Males are more successful at committing suicide than females Females attempt suicide more often than males o Risk Factors Family History Suicide in the family Neurobiology Low serotonin levels Preexisting psychological disorder
Alcohol use and abuse Past suicidal behavior Experience of a shameful/humiliating stressor Publicity about suicide and media coverage Psychache --Karlin o Suicide is a response to unbearable pain. The pain is not physical, but psychological. o The source of the pain can be and not infrequently is anticipated embarrassment, rejection, social opprobrium and/or humiliation. o The highest suicide rate is for white males over 50. (Note, not suicide attempt, completed suicide) o Men who are occupationally successful, but whose status is threatened or lost, are the most likely to commit suicide Social Rejection -- Karlin o Notice that it is not the guys who never made it, who are born losers or at least not winners. o Rather, it is the seemingly successful who kill themselves. o The humiliation/rejection thing works for kids too, to some degree. o They “can’t face” parents or peers for some failure or betrayal. o Leaving to avoid consequences such as prison Lethality -- Karlin o You must assess how lethal are possible ways to kill a patient o A patient with guns needs to be hospitalized. Someone with pills is a little less dangerous. o Religious beliefs prevent suicide. o Family obligations prevent suicide. o Youth and being female predict suicide attempts, but not completed suicide. o Many people die seemingly unintentionally. For example, someone is supposed to come home and gets seriously delayed. Treatment for Suicide o No-suicide Contract: a promise not to do anything remotely connected with suicide without contacting the mental health professional first If refuses contract and the suicidal risk is high, immediate hospitalization is indicated, even against the will of the patient o Suicide Prevention Programs o Cognitive-behavioral problem-solving approach Summary of Mood Disorders o All mood disorders share Gross deviations in mood Common biological and psychological vulnerability o Occur in children, adults, and the elderly o Onset, maintenance, and treatment are affected by Stress Social support o Suicide is an increasing problem Not unique to mood disorders
o Medications and psychotherapy produce comparable results o High rates of relapse
Chapter 8 -- Eating and Sleep Disorders Eating Disorders: An Overview Two major types of DSM-IV-TR eating disorders o Anorexia nervosa and Bulimia nervosa o Severe disruptions in eating behavior o Extreme fear and apprehension about gaining weight o Strong sociocultural origins – Westernized views Other Subtypes of DSM-IV-TR eating disorders o Binge Eating Disorder o Obesity – A growing epidemic Bulimia Nervosa: Overview and Defining Features Binge eating – hallmark of bulimia o Binge Eating excess amounts of food o Eating is perceived as uncontrollable Compensatory Behaviors o Purging Self-induced vomiting, diuretics, laxatives o Some exercise excessively, whereas others fast DSM-IV-TR subtypes of bulimia o Purging subtype – most common subtype o Nonpurging subtype – about one-third of bulimics Bulimia Nervosa: Associated Features Associated medical features o Most are within 10% of target body weight o Purging methods can result in severe medical problems Erosion of dental enamel, electrolyte imbalance Kidney failure, cardiac arrhythmia, seizures, intestinal problems, permanent colon damage Associated psychological features o Most are overly concerned with body shape o Fear of gaining weight o Most have comorbid psychological disorders Medical consequences: o Salivary gland enlargement causes by repeated vomiting. The result is a chubby facial appearance. o Erosion of dental enamel on the inner surface of the front teeth.
o May produce an electrolyte imbalance (i.e., disruption of sodium and potassium levels) which, in turn, can lead to potentially fatal cardiac arrhythmia and renal failure. o Intestinal problems resulting from laxative abuse are also potentially serious. Some individuals with bulimia also develop marked calluses on the fingers and backs of hands resulting from efforts to vomit by stimulating the gag reflex.
Anorexia Nervosa: Overview and Defining Features Successful weight loss – hallmark of anorexia o Defined as 15% below expected weight o Intense fear of obesity and losing control over eating o Anorexics show a relentless pursuit of thinness o Often begins with dieting DSM-IV-TR subtypes of Anorexia o Restricting subtype – limit caloric intake via diet and fasting o Binge-eating-purging subtype Associated features o Most showed marked disturbance in body image o Most are comorbid for other psychological disorders o Method of weight loss have life threatening consequences Binge-Eating Disorder: Overview and Defining Features Binge-eating disorder – appendix B of DSM-IV-TR o Experimental diagnostic category o Engage in food binges without compensatory behaviors Associated Features o Many persons with binge-eating disorder are obese o Concerns about shape and weight o Often older than bulimics and anorexics o More psychopathology vs. non-binging obese people Bulimia and Anorexia: Facts and Statistics Bulimia o Majority are female – 90%+ o Onset around 16 to 19 years of age o Lifetime prevalence is about 1.1% for females, 0.1% for males o 6-7% of college women suffer from bulimia o Tends to be chronic if left untreated Anorexia o Majority are female and white o From middle- to upper-middle-class families o Usually develops around age 13 or early adolescence o More chronic and resistant to treatment than bulimia Cross-cultural considerations Developmental considerations
Causes of Bulimia and Anorexia: Toward an Integrative Model Media and cultural considerations o Being thin = success, happiness…really? o Cultural imperative for thinness Translates into dieting o Standards of ideal body size Change as much as fashion o Media standards of the ideal Are difficult to achieve Biological Considerations o Can lead to neurobiological abnormalities Psychological and behavioral considerations o Low sense of personal control and self-confidence o Perfectionistic attitudes o Distorted body image Preoccupation with food o Mood intolerance Dietary restraint Family influences Biological dimensions Psychological dimensions An integrative model Medical and Psychological Treatment of Bulimia Nervosa Psychosocial treatments o Cognitive-behavioral Therapy (CBT) Is the treatment of choice Basic components of CBT Medical and Drug Treatments o Antidepressants Can help reduce binging and purging behavior Are not efficacious in the long-term Tricyclics and SSRI (Prozac) help reduce frequency of binging and purging Medical Treatment o Sibutramine (Meridia) o Psychological Treatment CBT Similar to that used for bulimia Appears efficacious Interpersonal psychotherapy Equally as effective as CBT Self-help techniques Also appear effective Goals of Psychological Treatment of Anorexia Nervosa
General goals and strategies o Weight Restorations First and easiest goal to achieve o Psychoeducation o Behavioral and cognitive interventions Target food, weight, body image, thought and emotion o Treatment often involves the family o Long-term prognosis for anorexia is poorer than bulimia o Preventing eating disorders
Obesity: Background and Overview Not a formal DSM disorder Statistics o In 2000, 30.5% of adults in the United States were obese; 33.8% in 2008 o Mortality Rates Are close to those associated with smoking o Increasing more rapidly For teens and young children o Obesity Is rapidly growing in developing nations Obesity and Disordered Eating Patterns Obesity and night eating syndrome o Occurs in 7-19% of treatment seekers o Occurs in 42% of individuals seeking bariatric surgery o Patients are wide awake and do not binge eat Causes o Obesity is related to technological advancement o Genetics account for about 30% of obesity cases o Biological and psychosocial factors contribute as well Obesity Treatment Treatment o Moderate success with adults o Greater success with children and adolescents Treatment progression – from least to most intrusive options First Step o Self-directed weight loss programs Second Step o Commercial self-help programs Third Step o Behavior modifications programs Last Step o Bariatric surgery Sleep Disorders: An Overview
Two major types of DSM-IV-TR sleep disorders o Dyssomnias Difficulties in amount, quality, or timing of sleep o Parasomnias Abnormal behavioral and physiological events during sleep Assessment of disordered sleep: o Polysomnographic (PSG) evaluation Electroencephalograph (EEG) – brain wave activity Electrooculograph (EOG) – eye movements Electromyography (EMG) – muscle movements Detailed history, assessment of sleep hygiene and sleep efficiency o Actigraph -- This instrument records the number of arm movements, and the data can be downloaded into a computer to determine the length and quality of sleep o Sleep Efficiency (SE)
The Dyssomnias: Overview and Defining Features of Insomnia Insomnia and primary insomnia o One of the most common sleep disorders o Microsleeps o Problems initiating/maintaining sleep, and/or nonrestorative sleep o Primary insomnia – unrelated to any other condition o 35% of adults report daytime sleepiness Facts and Statistics o Often associated with medical and/or psychological conditions o Affects females twice as often as males Associated Features o Unrealistic expectations about sleep o Believe lack of sleep will be more disruptive than it usually is An integrated model The Dyssomnias: Overview and Defining Features of Hypersomnia Hypersomnia and primary hypersomnia o Sleeping too much or excessive sleep o Experience excessive sleepiness as a problem o Primary hypersomnia – unrelated to any other condition Facts and Statistics o Often associated with medical and/or psychological conditions Associated Features o Complain of sleepiness throughout the day o Able to sleep throughout the night The Dyssomnias: Overview and Defining Features of Narcolepsy Narcolepsy – daytime sleepiness and cataplexy o Cataplexic attacks REM sleep, precipitated by strong emotion o Facts and Statistics – rare condition
Affects about 0.3% to .16% of the population Equally distributed between males and females Onset during adolescence Typically improves over time o Associated Features Cataplexy, sleep paralysis, and hypnagogic hallucinations Daytime sleepiness does not remit without treatment The Dyssomnias: Overview of Breathing-Related Sleep Disorders Breathing-related sleep disorders o Sleepiness during the day and/or disrupted sleep at night o Sleep Apnea Restricted air flow and/or brief cessations of breathing Subtypes of Sleep Apnea o Obstructive sleep apnea (OSA) Airflow stops, but respiratory system works o Central Sleep Apnea (CSA) Respiratory systems stops for brief periods o Mixed Sleep Apnea Combination of OSA and CSA Facts and Statistics o Occurs in 1-2% of population o More common in males o Associated with obesity and increasing age Associated Features o Persons are usually minimally aware of apnea problem o Often snore, sweat during sleep, wake frequently o May have morning headaches o May experience episodes of falling asleep during the day Circadian Rhythm Sleep Disorders Circadian rhythm disorders o Disturbed sleep (i.e., either insomnia or excessive sleepiness) o Due to brain’s inability to synchronize day and night Nature of circadian rhythms and body’s biological clock o Circadian rhythms – do not follow 24hr clock o Suprachiasmatic nucleus Brain’s biological clock, stimulates melatonin o Types of circadian rhythm disorders Jet lag type Shift work type Medical Treatments Insomnia o Benzodiazepines and over-the-counter sleep medications o Prolonged use
Can cause rebound insomnia, dependence o Best as short-term solution Hypersomnia and narcolepsy o Stimulants (i.e., Ritalin) o Cataplexy Usually treated with antidepressants Breathing-related Sleep Disorders o May include medications, weight loss, or mechanical devices Circadian Rhythm Sleep Disorders o Phase delays Moving bedtime later (best approach) o Phase advances Moving bedtime earlier (more difficult) o Use of very bright light Trick the brain’s biological clock Environmental treatments
Psychological Treatments Relaxation and stress reduction o Reduces stress and assists with sleep o Modify unrealistic expectations about sleep Stimulus control procedures o Improved sleep hygiene – bedroom is a place for sleep o For children – setting a regular bedtime routine Combined treatments o Insomnia – short-term medication plus psychotherapy o Other dyssomnias Little evidence for the efficacy of combined treatments The Parasomnias: Nature and General Overview Nature of Parasomnias o The problem is not with sleep itself o Problem is abnormal events during sleep, or shortly after waking Two classes of parasomnias o Those that occur during REM (i.e., dream) sleep o Those that occur during non-REM (i.e., non-dream) sleep The Parasomnias: Overview of Nightmare Disorder Nightmare disorder o 10-50% of children and 1% of adults have nightmares o Occurs during REM sleep o Involves distressful and disturbing dreams o Such dream interfere with daily life functioning and interrupt sleep Facts and Associated Features o Dreams often awaken the sleep o Problem is more common in children than adults
Treatment o May involve antidepressants and/or relaxation training
