PSY 183 Practice

Major Depressive Disorder (MDD)

• Cognitive Features:
  • Pervasive sadness, tearfulness, guilt, helplessness, emptiness, worthlessness.
  • Recurrent thoughts of death, suicidal ideation, or suicide attempts.
• Motivational Features:
  • Pervasive anhedonia (lack of pleasure).
• Neurovegetative Features:
  • Significant weight change due to decreased or increased appetite (females more likely to experience increased appetite).
  • Sleep disturbance: insomnia or hypersomnia (females more likely to experience hypersomnia).
  • Psychomotor agitation or retardation (females more likely to experience retardation).
  • Pervasive fatigue or loss of energy.
  • Difficulty thinking, concentrating, or making decisions.

Prevalence of Major Depressive Disorder (MDD)

• Point Prevalence: Approximately 5% of the U.S. population are diagnosable with depression.
• One-Year Prevalence: Approximately 7% in the U.S., but prevalence varies widely across geographic regions.
• Lifetime Prevalence: 20.1% (26% of females, 12% of males), mostly moderate or severe.
• Subsyndromal Depression: 15-20% of the U.S. population may experience depressive symptoms that don't meet the criteria for diagnosis.

Risk Factors for Major Depressive Disorder

• Genetic predisposition: Evidence suggests a genetic link to depression.
• Premenstrual Dysphoric Disorder (PMDD): This affects females and includes mood swings and other MDD symptoms that begin the week before menstruation and improve within a few days afterward.

Depression Treatment

• First-Line Treatments:
  • Psychotherapy, particularly Cognitive Behavior Therapy (CBT) and Interpersonal Therapy (IPT).
  • Antidepressant medication.
  • Phototherapy for Seasonal Affective Disorder.
• Treatment-Refractory Depression (TRD):
  • Augmented (multiple) medications.
  • Electroconvulsive Therapy (ECT).

Cognitive Behavior Therapy (CBT)

• Focuses on uncovering automatic self-defeating thinking patterns.
• Developing new interpretations of setbacks through normalization, logical analysis, and decatastrophizing.
• Replacing old automatic thoughts with new ones.
• Examining the patient's views of self, important life events, and the future.

Panic Disorder

• Panic attacks can be triggered by stimulants such as caffeine, nicotine and marijuana.
• People with Panic Disorder seem to be more aware of internal sensations than others, leading to a feedback loop of anxiety.
• 25% of people with Panic Disorder have suicidal ideation.

1st Line Panic Disorder Treatments

• Dietary and medication control can help reduce panic attacks.
• Anxiolytic medication, mainly benzodiazepines, can be used for acute treatment but often leads to rebound anxiety.
• Antidepressant medication, particularly SSRIs, can be used chronically to prevent panic attacks.
• Psychotherapy, such as cognitive therapy and supportive therapy, can be helpful.

Agoraphobia

• Marked fear or anxiety triggered by situations where escape may be difficult or help unavailable.
• Prevalence is around 1.5% with a 2:1 female to male ratio.
• Often develops after panic attacks, as individuals avoid situations that could trigger them.
• Treatment involves antidepressants and in vivo desensitization.

Generalized Anxiety Disorder (GAD)

• Debilitating worry and fretfulness for at least 6 months.
• The worry is excessive and difficult to control.

Common Signs/Symptoms of Anxiety

• Cognitive: Objectless fear, heightened sense of vulnerability, worrying, rumination, going blank, irritability, impatience, distractibility, hypervigilance.
• Physiological: Trembling, twitching, fatigue, restlessness, muscle tension, dizziness, lightheadedness, increased heart rate, sweating, cold or clammy hands, dry mouth, nausea, diarrhea, altered appetite and sleep.

Signs/Symptoms of Panic Attack (Acute Anxiety Episode)

• Palpitations, pounding heart, accelerated heart rate, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, lightheadedness, fainting, derealization, depersonalization, fear of dying, losing control, numbness, tingling, chills, hot flushes.

Fear, Anxiety, and the Brain

• The amygdala registers emotional aspects of situations, including threat.
• The locus coeruleus controls arousal of the neocortex and activates the hypothalamic-pituitary axis and the Autonomic Nervous System.

Autonomic Nervous System (ANS)

• The ANS consists of the sympathetic and parasympathetic nervous systems.

Anxiety-Related Actions of the Sympathetic Nervous System

• The pituitary gland releases ACTH, which triggers the release of steroid hormones from the adrenal gland causing increased appetite and anti-inflammatory actions.
• The adrenal gland secretes epinephrine and norepinephrine.
• Effects: Pupillary dilation, drying of mucosal linings, sweating, increased heart rate, constriction of blood vessels in the skin and gut, diversion of blood flow to muscles, speeded respiration, airway relaxation, emergency release of glucose into the circulation.

GABA and Anxiety

• GABA plays a role in anxiety regulation.
• Anxiety-prone individuals may have deficits in GABA.
• Blocking GABA chemically increases anxiety.
• Ethanol (alcohol) and some anti-anxiety medications bind to GABA receptor areas, mimicking GABA.
• Other neurotransmitters besides GABA are involved in anxiety.

Anxiety Disorders

• Most common psychiatric problems, increasing in adolescents and young adults.

Monism vs Dualism in Psychopathology

• Monism: mind and body are one
  • Reductive Materialism: everything is based on physiological mechanisms.
  • Mental disorders = brain disorders
• Dualism: Mind and body different;
  • Mind = brain's software, behavior = hardware
  • Mental disorders = disorders of mental processes

The Scope of Mental Disorders

• Originally, "mental illness" = "insanity" - now strictly a legal term
• Mental disorder = preferred to "mental illness"
• Range of severity:
  • Brain diseases: Schizophrenia, Alzheimer's
  • Behavior patterns: Homosexuality, Alcoholism, Psychopathy
  • Troublesome conditions: OCD, Premenstrual Dysphoria
• Defining mental disorders is difficult; no consistent and universally accepted definition

Why Is Defining Mental Disorders Challenging?

• Diagnoses can be stigmatizing.
• Diagnoses can be used for political persecution.
• Can be misused to excuse individuals from responsibility for their actions

Dichotomies in Definitions

• "Normal" vs "Abnormal":
  • Deviance (statistical, moral, cultural)
  • Distress (one's own and/or others')
  • Dysfunction (inability, efficiency, maladaptation)
  • Danger (to self and/or others)

Prototypes and DSM-5-TR

• Most people have "prototype" conceptions of mental disorders.
• These are based on:
  • Direct experience: personal situations, mental health services
  • Indirect experience: books, films, TV, friends
  • Training: Classic case studies.
• DSM-5-TR - Current Diagnostic Bible
  • Mental disorder = clinically significant behavioral/psychological syndrome
  • Associated with: Distress, Disability, Increased risk of suffering
  • Must not be a normal response to an event (e.g., grief)

Diagnostic Terminology and Process

• Nosology: Science of disease categorization and classification
• Diagnosis: Assigning a nosological category to a patient
• Etiology: Cause
• Course: Trajectory of the disorder
• Prognosis: Outcome
• Signs: Observable markers
• Symptoms: Patient reports
• Syndrome: Signs + Symptoms
• Disorder: Syndrome + Course
• Disease: Disorder + Tissue Damage (few mental disorders meet disease criteria)

Purpose of Diagnosis

• Prognosis: understand anticipated outcome
• Treatment: Inform treatment decisions
• Communication: between professionals
• Contagion: Assess risk of spread
• Legal reasons: competence, insanity determinations
• Financial reasons: insurance claims, compensation
• Research:

Problems with Diagnosis

• Uniqueness: sacrifices individual patient characteristics
• Etiology: Can falsely imply cause.
• Treatment rigidity: Limits possible options.
• Iatrogenic illness: Treatment itself may be harmful
• Stigmatization: Negative social labeling
• Secondary gain: Using symptoms for benefits

Phenotypic vs Genotypic Diagnosis

• Phenotypic: Signs, symptoms, course, outcome, response to treatment
• Genotypic: Causes - genes, germs, tissue abnormalities.
• Endophenotypic: subclinical, behavioral, or lab-based markers (e.g., brain imaging, cognitive tests); may be present in family members of those with the disorder

Ingredients of a Diagnosis

• Symptoms (patient reports)
• Signs (observable markers)
• Course of illness
• Age of onset
• Family history
• Recent events (triggers, stressors)
• Recent behavior
• Psychological tests (IQ, personality)
• Laboratory tests (neuroimaging, hormone levels, genetics)
• Response to treatment (past or current)

Diagnosis is Multifactorial

• Pattern-based:*
• No single sign/symptom is pathognomonic (indicative) of a disorder.
• E.g., Trauma is required for PTSD, but many other factors are needed to develop PTSD.
• Diagnosis based on a syndrome (pattern of signs and symptoms)
• Nosology: the patterns of syndromes and courses of illness that define mental disorders

About Diagnoses

• Informed guesses: Best fitting diagnoses
• Not set in stone: May change with new information
• Comorbidity: Multiple diagnoses are frequently present

Current DSM-5-TR Diagnostic Features

• Phenotypic diagnosis: Observations only
• Abandonment of intra-psychic concepts: "neurosis" and "internal conflicts"
• Field-tested for reliability
• Importance of medical/psychosocial factors:
• Decision-tree approach:
  • Inclusion criteria: signs/symptoms supporting the diagnosis
  • Exclusion criteria: signs/symptoms ruling out the diagnosis

Examples of DSM-5-TR Diagnostic Criteria

• Specific Phobia:
  • Inclusion criteria: Marked fear/anxiety about specific object/situation; provokes immediate fear; actively avoided or endured; disproportionate to actual danger; persistent; causes significant distress/impairment.
  • Exclusion criteria: Not better explained by other mental disorders, obsessions, traumatic events, separation anxiety, etc.

Clinical Assessment

• Clinical interview: most valuable assessment tool
  • Length: ~ 1 hour
• Information and Goals:
  • Current/past symptoms onset, intensity
  • Signs from presentation
  • Personal/family history (parenting, childhood, abuse, substance use, medical, social, financial)
  • Mental health history (hospitalizations, therapy)
  • Goals:
    • Assess suitability for therapy
    • Determine referral needs: psychiatrist, PCP, neurologist, social worker

Signs Noted in Clinical Interviews

• Attire and grooming
• Posture: (defiant, compliant, guarded, etc.)
• Physical characteristics: skin tone, weight, symmetry
• Mannerisms, spasms, or tics
• Speech: Articulation, Prosody (tone of voice)
• Consciousness: (alertness, fogginess, hypervigilance)
• Emotional state: (upbeat, hopeless, frustrated)
• Thought content: (delusions, hallucinations)
• Thought processes: (boundary violations, broadcasting)
• General knowledge:
• Abstract thinking
• Social judgment
• Insight
• Cognitive functioning: (usually assessed with brief screening)

Montreal Cognitive Assessment (MOCA)

• Screening tool for dementia
• Areas Assessed:
  • Visuospatial/executive
  • Naming
  • Memory
  • Attention
  • Abstraction
  • Language
  • Delayed recall
  • Orientation

Ancillary Diagnostic Information

• Information from:
  • Family members
  • Physicians
  • Employers
  • Medical chart
  • Previous psychological testing
  • Previous therapists' summaries
  • Hospital discharge summaries

The Importance of Family History

• Helps identify risk factors for specific mental disorders: AN (Anxiety disorders), BPD (Bipolar disorder), SZ (Schizophrenia), PANIC (Panic disorders), UP (Unipolar depression), ALC (Alcoholism)

Mental Disorders: Prevalence & Impact

• Mental disorders are common and can affect anyone.
• They can significantly impact individuals, families, and society as a whole.
• In 2021, 1 in 4 adults experienced a diagnosable mental disorder, with a 25-30% increase since pre-COVID levels.
• The COVID-19 pandemic exacerbated mental health issues due to social isolation, loss of recreational outlets, and disrupted treatment access.
• Mental health decline in youth is particularly concerning, with increased rates of depression, suicidal ideation, and sexual violence.
• College mental health has also declined, with significant increases in students seeking help and a surge in psychological distress.

Early Views of Psychopathology

• During the Middle Ages, mental disorders were often attributed to demonic possession and treated through exorcism and even burning at the stake.
• From the 1700s to the 1800s, mental illness was seen as a form of evolutionary regression, comparing individuals with mental disorders to animals.
• Mentally ill individuals were often housed in deplorable conditions, restrained, and treated through inhumane methods like bloodletting.

The Rise of "Moral Treatment"

• Philippe Pinel, a French physician, advocated for "moral treatment" which emphasized humane care and individual attention for individuals with mental disorders.
• This approach marked a significant shift away from the brutal practices of the past.

The State Hospital Era (1900-1960)

• State-run mental hospitals became the primary institutions for managing people with mental disorders.
• However, the state hospital era saw the rise of questionable and often harmful treatments, including:
  • Pyrotherapy (1930-40s): This involved inducing fever through malaria inoculation to treat general paresis.
  • Insulin Coma Therapy (1930-40s): A treatment based on inducing comas with insulin.
  • Metrazol Shock Therapy (1930s-40s): This treatment involved inducing convulsions with metrazol.
  • Electroconvulsive Therapy (ECT) (1940s-present): Convulsions are produced using electrical stimulation.
  • Prefrontal Lobotomy (1940s): Surgical procedures designed to sever connections in the prefrontal area of the brain.
• Despite its limitations, the development of medication like Thorazine (Chlorpromazine) in the 1950s led to a significant reduction in the need for long-term hospitalization.

Deinstitutionalization (1960-present)

• The movement to deinstitutionalize individuals with mental disorders began in the 1960s, motivated by factors like the availability of medication, concerns about civil rights, and cost considerations.
• Unfortunately, the transition was often poorly planned, leading to inadequate community mental health facilities, a rise in homelessness among individuals with mental illness, and increased reliance on the criminal justice system to manage these individuals.

Contemporary Views of Psychopathology

• Psychodynamic Views: Based on the work of Freud and others, this approach emphasizes unconscious conflicts and early childhood experiences.
• Behavioral Views: Focus on the role of learning and environmental factors in shaping behavior and influencing mental disorders.
• Biological Views: Focus on the role of biological factors, including genetics, neurotransmitters, and brain structure, in contributing to mental disorders.

Explore the cognitive, motivational, and neurovegetative features of Major Depressive Disorder (MDD). Learn about its prevalence in the U.S. along with key symptoms and statistics related to this mental health condition. This quiz helps to deepen your understanding of MDD's various aspects.