Somatic Symptom & Related Disorders - Test #2 PDF

Test \#2 **Chapter 6: Preoccupation and obsession** **Somatic symptom and related disorders** - Previously called somatoform disorder (DSM-IV-TR) - DSM-IV-TR definitions: - Overemphasized that bodily symptoms are medically unexplained - DSM-5 TR definitions: - Emphasize distress tha...

Test \#2 **Chapter 6: Preoccupation and obsession** **Somatic symptom and related disorders** - Previously called somatoform disorder (DSM-IV-TR) - DSM-IV-TR definitions: - Overemphasized that bodily symptoms are medically unexplained - DSM-5 TR definitions: - Emphasize distress that accompanies or is in response to the bodily concerns **Somatic symptom disorder** - Pierre briquet (1859) -- briquet's syndrome - Preoccupation with health or body ("soma" meaning body) - Example; they get a rash and think its skin cancer Clinical description - Continuously feeling weak and ill - Life revolves around symptoms - Ex. Severe pain exacerbated by psychological factors - Leads to anxiety and distress - May not be clear physical reason for pain - DSM-5 TR emphasizes psychological symptoms - For diagnosis there has to be one or more physical symptoms. - Excessive thoughts and worries - Specify if: with predominant pain (individuals whose somatic complaints predominantly involve pain) - Specify if it is persistent (a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months)) - Specify if it is mild, moderate, or severe. - Mild: only one of the symptoms specified in criterion B is fulfilled - Moderate: two or more of the symptoms specified in criterion B are fulfilled - Severe: two or more of the symptoms specified in criterion B are fulfilled, plus there are multiple somatic complaints - Important factor in this condition is not whether the physical symptom, has a clear medical cause but rather that psychological or behavioural factors, particularly anxiety and distress, are compounding the severity and impairment associated with the physical symptoms. - Also important to note that the physical symptoms, such as pain, is that they are real and they hurt, whether or not there are clear physical reasons for pain. **Illness Anxiety disorder** - Formerly known as hypochondriasis - People with this disorder have a persistent fear that they have a serious or life-threatening illness despite few or no symptoms - Categorical vs dimensional approach (all/none vs. more/less) - Physical symptoms are absent or mild - Concern is "idea" of being sick - Reassurance from physicians is not helpful - They are convinced they have some form of illness but no physical symptoms. Clinical description - Anxiety focused on the possibility of disease; preoccupied with bodily symptoms - "disease conviction" -- a belief that a person has a disease - Remain unconvinced and unsure of absence of disease; go from doctor to doctor - Focus on a long-term process of illness and disease - E.g., cancer, autoimmune disease. - Two types care-seeking type or a care-avoidant type - Care-seeking type: medical care, including physician visits or undergoing tests and procedures, is frequently used - Care-avoidant type: medical care is rarely used. - Tend to be less concerned with any specific physical symptom and more worried about the idea that they were either ill or developing an illness. - Anxiety and mood disorder are often comorbid with somatic symptom disorders - In illness anxiety disorders, the individual is preoccupied with bodily symptoms misinterpreting them as indicative of illness or disease. - Patients with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack, and these concerns lessen between attacks; individuals with somatic symptoms disorders focus on a long-term process of illness and disease. (e.g., cancer) **Statistics for somatic symptom and illness anxiety disorder** - Lifetime prevalence: 1-5% - Severe illness anxiety: - Late age onset - Somatic symptom disorder - Onset -- adolescence - More common in unmarried women - Lower SES - Culture-specific (burning sensations in the hands and feet -- Pakistan -- India) - Comorbidity -- anxiety and mood disorders. - Example; may be diagnosed with GAD **Causes of somatic symptom and illness anxiety disorder** - Cognitive factors are considered central in illness anxiety disorder -- disorders of cognition - "catastrophic" misinterpretations of bodily sensations - Strong beliefs that unexplained bodily changes are always a sign of serious illness - Dysfunctional mind-set -- leads to worry about health and illness - Cognitive model of the development of health anxiety - Four contributing factors: 1. Critical precipitating incident (significant event happens in someone's life) 2. Previous experiences of illness and related medical factors (did you have a disease or did someone you know have a serious disease) 3. Presence of inflexible or negative cognitive assumptions 4. Severity of anxiety (a function of the two factors that will increase anxiety and tow factors that will reduce health anxiety) - Perceived likelihood of illness and perceived costs and burden of illness (eg., any change in the body will lead to illness, and cost so much)(going to cause very severe health anxiety) - The perceived ability to cope and the perceived presence of rescue factors (e.g., can they cope and is their treatment for that symptom, will reduce anxiety) - enhanced somatic sensitivity - interpret ambiguous stimuli as threatening - genetic causes (modest -- nonspecific- a tendency to overrespond to stress) - stressful life events - focus on physical symptoms - disproportionate incidence of disease in the family - social and interpersonal influences -- "attention seeking" through illness **treatment of somatic symptom and illness anxiety disorder** - hard to treat - explanatory therapy (education and reassurance) - cognitive-behavioural therapy (CBT) - reduce stress - minimize help-seeking behaviours - therapy broadens basis for relating to others -- reducing the supportive consequences of relating to others (on the basis of physical symptoms only) - exposure based therapies (behavioural therapy) -- reduction in anxiety symptoms (news story about a disease; documentaries, etc.) without safety behaviours **psychological factors affecting medical condition** - the essential feature of this disorder is the presence of a diagnosed medical condition, that is adversely affected (increased in frequency or severity) by one or more psychological and behavioural factors - diagnosed medical condition - e.g., asthma, diabetes, severe pain - adversely affected by psychological or behavioural factor(s) - e.g., anxiety, denial - there is a diagnosed medical condition but there are psychological factors that make the disorder worse - e.g., high blood pressure has to be managed but a large portion of people who have it have denial and believe they don't have it. **functional neurological symptom disorder (conversion disorder)** - hysteria: term originally used to describe what are now known as conversion disorders - was specific to women due to the wandering of the uterus through the body -- presumed to symbolize the longing to produce a child. - now called functional neurological symptom disorder (DSM-5 TR) also termed conversion disorder - the term "conversion" derived originally from Freud -- the energy of a repressed instinct was diverted into sensory-motor channels and blocked functioning - unconscious conflicts expressed through (converted to) physical symptoms - "functional": severe physical dysfunction without an organic cause. Clinical description - Physical health people experience sensory or motor symptoms suggesting a neurological illness (although the body organs and nervous system are found to be fine) - Examples: - Globus hystericus -- the sensation of lump in the throat that makes swallowing eating difficult - Astasia -- abasia -- the inability to stand and to walk, despite sparing of motor function underlying the required balance and gestors - Psychogenic nonepileptic seizures (no significant EEG changes can be documented) Symptoms - Motor symptoms or deficits: the most common group of symptoms - Impaired coordination or balance - Paralysis - Abnormal limb posturing - Muscle weakness -- the most frequent symptom in this group - Anaesthesia (loss or impairment of sensations) -- a less common symptom group - Sudden loss of partial loss of vision (blindness or tunnel vision) - Aphonia (loss of the voice and all but whispered speech) - Anosmia (loss or impairment of the sense of smell) - Hallucinations - Psychogenic seizures - Tends to appear suddenly in stressful situations - Psychological stress is important, is in acute or persistent (add notes) Unconscious mental processes - People with conversion symptoms dissociate experiences from awareness - Malingerers and people with factitious disorders could be pretending symptoms Statistics - Conversion disorders rare in mental health settings - Prevalence in neurological setting is 30% - Primarily in women, developing in adolescence Causes - Biological factors: evidence is weak - May be some relationship between brain structure/function and conversion disorder - Conversion symptoms are more likely to occur on the left side than on the right side of the body - fMRI study -- stressful events -\> a failure to activate the right inferior frontal cortex (stress processing by contributing to emotional regulation -- the suppression by contributing to emotional responses) - the connectivity between the amygdala and motor areas of the brain are enhance in these people - Behavioural view -- the maladaptive pattern may strengthen because of attention it receives or the excuses it provides - A strategy to explain poor performance in evaluative situations - Illness behaviours -- learned behaviours acquired via exposure to parental illness and health anxiety in childhood - Freud proposed four basic processes i. Traumatic event leads to a conflict = anxiety ii. Repression of conflict (unconscious) iii. When anxiety becomes conscious person converts it to physical symptoms (reduction of anxiety -- primary gain) (when the unconscious conflict is converted into physical symptoms, there's anxiety around the conflict) iv. Person gets attention (secondary gain) - Interpersonal factors: - Substantial stress: abuse, parental divorce - Social and cultural factors: - Less educated, lower socioeconomic groups - Knowledge about disease and medical illness is not well developed - Prior experience with real physical problems -\> choice of specific conversion symptoms. Treatment - challenging - Identify source of stress; reduce stress - Reduce any supportive consequences of the conversion symptoms -- minimize help-seeking behaviours - Cognitive-behavioural programs -- driving attention away from physical symptoms and cognitive restructuring - Symptom-focused cognitive behavior therapy -- teach patients to cope with physical symptoms by emphasizing how current psychological and social factors affect their symptoms **Closely related disorders** - Malingering (faking) - The classic description of conversion disorder includes a symptom -- **la belle indifference (beautiful indifference)** -- substantial emotional indifference to the presence of the dramatic physical symptoms - E.g., inability to walk -- some people appear undisturbed by their paralysis - Can help differentiate conversion disorder from malingering - Often present, however, is not a necessary symptom of conversion disorder - Factitious disorders - The symptoms are under voluntary control - But no obvious reason for voluntarily producing the symptoms -- "sick role"; attention - Two types: - Factitious disorder imposed on self (they are creating the symptoms, and they know they can control them) - Factitious disorder imposed on another (previously called Munchausen syndrome by proxy) (different from malingering because we do not know why they are doing it) - Diagnosis needs to specify if it is a single episode or recurrent **Obsessive-compulsive and related disorders** - DSM-IV-TR -- anxiety disorders Clinical description -- a chronic disorder: - Fear of unwanted and intrusive thoughts (obsessions) - Repeated ritualistic actions or mental acts (compulsions) designed to neutralize the unwanted thoughts - Both behavioural and mental - The activity is not always realistically connected with its apparent purpose and is clearly excessive - Significant distress and interference with everyday functioning - Specify if OCD occurs with tic disorder - Specify is: - With good or fair insight: the individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true - With poor insight: the individual thinks obsessive-compulsive disorder beliefs are probably true - With absent insight/delusional beliefs: the individual is completely convinced that obsessive-compulsive disorder beliefs are true - Tic-related: the individual has a current t or past history of a tic disorder Types of obsessions and associated compulsions - Symmetry/exactness/ "just right" - Obsession: - Needing things to be symmetrical/aligned just so - Urges to do things over and over until they feel "just right" - Compulsion - Putting things in a certain order - Repeating rituals - Forbidden thoughts or actions (aggressive/sexual/religious) - Obsession - Fears, urges to harm self or others - Fears of offending god - Compulsion - Checking - Avoidance - repeated requests for reassurance - cleaning/contamination - obsession - germs - fears of germs or contaminates - compulsion - repetitive or excessive washing - using gloves, masks to do daily tasks - hording - obsession: - fears of throwing anything away - compulsion: - collecting/saving objects with little or no actual or sentimental value, such as food wrappings **Obsessive-compulsive disorder** - In addition to obsessive compulsive symptoms individuals with OCD may also experience - Severe generalized anxiety - Recurrent panic attacks - Debilitating avoidance - Major depression - Suicidal ideation and suicide attempts - Severe obsessions -- more relevant for predicting suicide risk than compulsions - Obsessions are ego-dystonic -- (when thoughts are experiences as being "out of line" with one's own identity and values) - One of the top ten conditions causing impairment, according to WHO - Severity of obsession -- poorer quality of life - High degree of comorbidity -- anxiety disorders, mood disorders, impulse-control disorders, substance use disorders -\> high degree of impairment and difficulty in treating the disorder **Tic disorder and OCD** - Involuntary movements - Tourette's syndrome - Co-occurs with OCD - Movements may not be tics but compulsions - Obsessions in OCD tic-related OCD -- symmetry (what obsessions are most common) **OCD statistics** - 1-3%: lifetime prevalence of OCD - Children -- more males than females -- sex-ratio becomes equal by mid-adolescence - Onset in early adolescence to mid-20s -- late onset OCD (beyond early 30s) is very rare - Chronic when develops - Culture -- the content of the obsessions and the nature of the compulsions - Middle east -- cleanliness -- religion? - Look at table 6.2 **Causes** - Biological factors - Brain structure - Encephalitis, head injuries, and brain tumours associated with the development of OCD - Research focus -- two brain areas that could be affected by such trauma - Two brain areas - The frontal lobes -- PET scan -- increase activation in the frontal lobes (perhaps a reflection of the person's overconcern with their own thoughts) - Basal ganglia (a set of subcortical structures the caudate, putamen, globus pallidus and amygdala) -- a system linked to the control of motor behaviour - PET findings increase activation in basal ganglia, unclear if cause or consequence of OCD (cause or consequence?) - Tourette's syndrome is marked by both motor and vocal tics and has been linked to basal ganglia dysfunction - People with Tourette's often have OCD as well - Psychoanalytic theory - Fixated at anal stage -- overly harsh toilet training - Rection formation -- resists the urge to soil (id) and become compulsively neat and clean - Behavioural and cognitive theories - Learned behaviours reinforced by fear reduction - Rachman and Shafran's theory of obsessions - An inflated sense of personal responsibility for outcomes - A cognitive bias involving thought-action fusion - Thought-action-fusion involves two beliefs: 1. The mere act of thinking about unpleasant events increases the perceived likelihood that they will actually happen 2. At a moral level, thinking something unpleasant is the same as actually having carried it out Treatment - SSRIs (seem to benefit up to 60% of patients -- relapse is common) - Exposure and ritual prevention (ERP) -- most effective (behavioural technique, if client has fear of germ as them to touch surface and not allow them to wash their hands) (when they don't get to perform the compulsive behaviour they are being told that noting bad will happen if they don't and that the thought is just a thought) - CBT and internet-based CBT - Psychosurgery -- cingulotomy -- surgical lesions to the cingulate bundle (an area near the corpus callosum) - Deep brain stimulation **Body dysmorphic disorder** - Previously known as dysmorphophobia (fear of ugliness) - Preoccupation with some imagined defect in appearance, though looks reasonably normal - "Imagined ugliness" - Repeated looking in mirrors - Co-occurs with OCD - Some believed OCD and body dysmorphic should be combined because of the compulsions Clinical description - Checking and compensating rituals - Excessive grooming, skin picking, mirror checking - Some avoid mirrors - Suicidal ideation and attempt - A variety of checking or compensating rituals are common in people with BDD in attempts to alleviate their concerns - We also see avoidance behaviour - Many patients with severe cases become house-bound for fear of showing themselves to other people - Specify if: - With muscle dysmorphia: the individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifiers is used even if the individual is preoccupied with other body areas, which is often the case - Specify if: - Indicate degree of insight regarding body dysmorphic disorder beliefs - With good or fair insight: the individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true - With poor insight: the individual thinks that the body dysmorphic disorder beliefs are probably true - With absent insight/delusional beliefs: the individual is completely convinced that the body dysmorphic disorder beliefs are true Statistics - Serious psychological disorder - Prevalence -- difficult to estimate -- tends to be kept secret - Affects 1.7-2.4% people worldiwde - Strong interest in art and design - Onset in early adolescence through the 20s - High degree of stress, reduced quality of life, and impairment common Causes - Insufficient information on psychological or biological predisposing factors - Biological -- brain volume research: decreases volumes right orbitofrontal cortex and left cingulate cortex - Cognitive factors - Catastrophic interpretations of appearance-related thoughts, focus on unwanted thoughts - Efforts to regulate the resulting emotions are not adaptive: (avoidance of social situations, engaging in mirror checking, and applying make-up to hind imperfections) - Psychoanalytic explanation - Displacement Treatment - Two treatments with some evidence of effectiveness - Drugs that block reuptake of serotonin - SSRIs -- fluvoxamine (an SSRI specifically indicated for OCD) - Exposure and response prevention **Plastic surgery and other medical treatments** - Skin treatments most sought after - Many patients of plastic surgeons return for additional surgery - 8-25% who request plastic surgery have BDD; should be screened by plastic surgeons **Hording disorder** - Appears as a separate disorder in DSM-5 TR - Hoarding starts early in life; gets worse - Can be hazardous - Patients come for treatment after age 50 - Animal hoarders -0p - Three major characteristics of hoarding - Excessive acquisition of things - Difficulty discarding anything - Living with excessive clutter under conditions best characterized as gross disorganization Causes - Evidence for genetic contribution - Cognitive factors - Erroneous cognitions about the importance and meaning of possessions - Misguided attachments with objects to seemingly compensate for emotional deficits in attachment to people Treatment - SSNRI (venlafaxine) - Cognitive-behavioural therapy **Body-focused repetitive behaviours** - Trichotillomania (hair-pulling disorder) - Disorder has severe social consequences - 1-5% college students: more in females - Hair can be pulled from any part of the body -- but usually from scalp, eyebrows, or eyelids - Intense shame following a hair-pulling episode, try to hide it by wearing hats, wigs etc. - Excoriation (skin-picking disorder) New in DSM-5 - Afflicts 1-5% of general population - Scabs, scars, open wounds common - Can take place at any part of the body -- but mostly face, hands, and/or arms - Fingernails are usually used, but some people also use implements (e.g., tweezers, needles) - The skin-picking behaviour must be chronic such that it leads to lesions on the skin - both often co-occur with OCD and BDD **Causes** - Emotion regulation model - Trigger-negative emotions - Hair-pulling and skin-picking behaviours serve to decrease the negative emotions (it is negatively reinforced) - Frustrated action model - Triggers -- boredom and frustration - Engaging in hair-pulling and skin-picking alleviates frustration and boredom Treatment - Habit reversal training - Self-monitoring - Awareness training (identification of trigger) - Competing response **Chapter 8: Mood** **Mood disorders: general characteristics** - Much more serious than typical emotional states that everyone feels - Involve significant disturbances in mood, including extreme sadness (depression) or elation/irritability (mania) - Are disabling (i.e., interfere with daily activities/functioning) - Are often associated with other serious psychological problems: - Panic attacks; anxiety; substance abuse; personality disorders **An overview of depression and mania** **Depression** - Mood disturbances - An emotional state marked by great sadness - Feelings of worthlessness and guilt - Cognitive disturbances - Self-criticism, self-blame - Indecisiveness, slowed thinking, thoughts of death/suicide - Physiological (somatic) and behavioural disturbances - Loss or excess of sleep, appetite - Loss of interest and pleasure in usual activities (Anhedonia) (means they lost interest in activates that were originally a source of pleasure) **Mania** - A period of abnormal elevated or irritable mood lasting for at least one week or requires hospitalization - Extreme pleasure in every activity - Individual must possess three or more of the following: a. Inflated self esteem b. Decrease need for sleep c. Talkativeness d. Fight of ideas e. Distractibility f. Increased goal-directed activity **Hypomanic episode** - Not as severe as a manic episode - No marked impairment in social or occupational functioning - "hypo" : below **The structure of mood disorders** - Depressive disorders -- marked by low mood only - Major depressive disorder (formerly unipolar disorder) - Disruptive mood dysregulation disorder - Persistent depressive disorder (dysthymia) - Premenstrual dysmorphic disorder - Bipolar and related disorders -- characterized by both highs and lows in mood - Bipolar disorder - Bipolar I - Bipolar II - Cyclothymic disorder **Depressive disorders** **Major depressive disorder**: presence of severe depression, absence of mania; severe enough to impair a person's interest in or ability to engage in normally enjoyable activities - Recurrent or single episode - Recurrent -- two or more major depressive episodes separated by at least two months of euthymia (euthymia: is the state of stable mood) - MDD -- currently the second leading cause of disability worldwide - Age of onset -- mid and late 20s; average age of onset seems to be decreasing - Most common psychiatric disorder worldwide - Major depressive disorder -- presence of 5 of the following symptoms for at least 2 weeks - Note: depressed mood or loss of interest and pleasure must be 1 of the 5 symptoms (know how many are required) - Sad, depressed mood, most of the day, nearly everyday (very important, has to be one of the five) - Loss of interest and pleasure in usual activates (very important, has to be one of the five) - Difficulties in sleeping - Shift in activity level - Changes in appetite and weight - Loss of energy, great fatigue - Negative cognitive appraisal - Difficulty in concentrating - Recurrent thoughts of death or suicide - Duration of episodes is variable -- two weeks to several years; average duration of first depressive episode: 2-9 months, if untreated. - Median duration of recurrent major depressive episode: 4-5 months - Median lifetime number of depressive episodes: 4-7 episodes **Persistent depressive disorder (dysthymia)**: depression relatively unchanged over long periods - Chronic depression: the symptoms are the same as those of major depression, but fewer in number - Lasting two or more years and an individual is never without symptoms for more than two months - Persistent depressive disorder may last 20-30 years - Double depression -- people with persistent depressive disorder may also experience episodes of major depressive disorder (becomes difficult to treat) **Additional defining criteria for depressive disorder specifiers**, or symptoms, that may or may not accompany a depressive disorder - Clinicians use eight specifiers 1. With psychotic features (mood-congruent (auditory hallucination is congruent) or mood-incongruent (doesn't go along with the sad state of mood)) hallucinations, delusions - Generally, do not respond to the usual drug therapies - Combined with drugs to treat psychotic disorders such as schizophrenia 2. With anxious distress (restless, concentration issues due to worry, fear of losing control) 3. With mixed features (e.g., people experiencing an episode with mixed features may feel very sad, empty or hopeless while at the same time feeling extremely energized) 4. With melancholic features 5. With atypical features 6. With catatonic features (e.g., motoric immobility or excessive movement, mutism, posturing, compulsive repetition of someone else's movements or words) 7. With peripartum onset (postpartum depression) 8. With seasonal pattern - Accompanies episodes during certain seasons - Depressive episode: begins in the late fall; ends with the start of spring (for at least 2 years) - Bipolar: depression -- winter; mania -- summer - Condition: **seasonal affective disorder (SAD)** **Premenstrual dysphoric disorder (PMDD)** - New to DSM-5 - Physical symptoms, severe mood swings, and anxiety - Decreased interest in usual activities; difficulty in concertation; lack of energy; hypersomnia or insomnia; changes in appetite; interference with work, relationships - Controversial because of how normal it is **Disruptive mood dysregulation disorder** - Common in children - Chronic irritability, anger, aggression, hyperarousal, frequent temper tantrums that are grossly out of proportion to the situation - Different from ADHD - Supporters: too many children diagnosed with bipolar, need this diagnostic category - Critics: don't think temper tantrums should be considered mental illness; labeling **Bipolar disorders** **Bipolar I disorder -** Major depressive episodes alternate with full manic episodes - Diagnosis of a manic episode requires the presence of elevated or irritable mood and increased activity level (both have to be present) (this requirement was added in DSM-5) + 3 additional symptoms -- 4 symptoms if mood is only irritable (if person has elevated and irritated mood and increased activity level -- 3 symptoms, if elevated mood or irritable mood and increased -- 4 symptoms) (lasting at least one week): - Increase in goal-directed activity at work, socially, or sexually or psychomotor agitation (non-goal directed activities) - Unusual talkativeness; rapid speech - Flight of ideas or subjective impression that thoughts are racing - Less than the usual amount of sleep needed - Inflated self-esteem - Distractibility - Excessive involvement in pleasure activities that are likely to have undesirable consequences - Implication for drug compliance **Additional defining criteria for bipolar disorders** **Rapid-cycling specifier** - Moving quickly in and out of depressive and manic episodes at least four manic or depressive episodes within a year (does not seem to be permanent) - At least four manic or depressive episodes within a year - 20-50% experience rapid cycling; 60-90% female - Rapid switching or rapid mood switching -- the direct transition from one mood state to another (no euthymic mood period in between) - Ultra rapid cycle -- cycle lengths that only last for day to weeks - Ultra-ultra-rapid cycle -- cycle lengths are less than 24hrs **Bipolar II disorder** - A pattern of depressive episodes and hypomanic episodes, but the episodes are less severe than the manic episodes in bipolar I disorder **Onset and duration** - Average age of onset: - Bipolar I disorder: 15 to 18 years - Bipolar II disorder: 19 to 22 years (10-13% progress to bipolar I) - Develop more suddenly as compared to depressive disorders - Rare to develop bipolar disorder after the age of 40 - High risk of suicide - Less common than major depression **Cyclothymic disorder** - a chronic condition characterized by fluctuations that alternate between hypomanic symptoms and depression - episodes not intense enough or do not last long enough to qualify as hypomanic or depressive episodes - persist for at least two years - age of onset -- 12 to 14 years **comorbidity** - often occurs with other physical disorders - thyroid disorder, migraine headaches, hearts disease, diabetes, obesity - may self medicate for these illnesses triggering mania or depression - often occur with other mental disorder - anxiety disorders, eating disorders, ADHD, substance use **prevalence of mood disorders** - 2.9 million Canadians reported a mood disorder - Worldwide: MDD 16% lifetime, 6% in preceding year - Prevalence rates seem to be stable over time in Canada - Depression -- 2X more common in women than in men - Bipolar disorders -- distributed equally across gender - In women, episodes of depression are more common - In men, episodes of mania are more common - Women: self objectification theory, look at themselves as an object) **lifespan developmental influences on mood disorders** **in children and adolescents** - mood disorder in children similar to mood disorder in adults - manifestation -- age-specific - difficulty in differentiating bipolar disorder form ADHD and conduct disorder - in childhood both boys and girls are equally affected - after adolescence rates of depression increases for girls (2 to 1) **in older adults** - depression is often characterized by distractibility and complaints of memory loss - comorbid with anxiety disorders, particularly GAD and panic disorder - affects older men and women in equal numbers **across cultures** - more in individualistic cultures - somatic vs. psychological symptoms - Canadian occurrence: moderate (8% prevalence) - Indigenous people -- history of cultural marginalization and oppression -- chronic major life stressors - Lifetime prevalence of mood disorders -- four times as high as in general population **Among the creative** - Creativity associated with manic episodes - Genetics may play a role too - artists - Many poets and writers -- bipolar and suicide **Causes** **Biological dimensions** - Familial and genetic influences - Two to three times in relatives of probands - Twin studies -- mood disorders heritable (meta-analysis in 2000, 37%) - Sex differences in genetic vulnerability -- 36-44% for women; 18-24% for men - Genetic contribution to bipolar disorders seems to be higher (most inherited) - People who possess one or two copies of the short variant of the 5-HTTLPR (serotonin transporter) gene, involved in modulating serotonin levels -\> high levels of depression and suicidality following a recent stressful event - Joint heritability of anxiety and depression - Same genetic factors contribute to both anxiety and depression - Biological vulnerability for mood disorders may not be specific to that disorder but a general predisposition to anxiety or depression. - Neurotransmitter systems (DA, NE, SE) - Early theories postulated that: - Low levels of norepinephrine and dopamine lead to depression; increased levels lead to mania - MAO-A levels in the brain are elevated during untreated depression - Low levels of serotonin - Serotonin -- regulates emotional reactions and regulate systems involving NE and DA - Permissive hypotheses -- low levels of serotonin -\> dysregulation in other neurotransmitters and contribute to irregularities - Clues for theories based on drug effectiveness - Tricyclic drugs prevent some of the reuptake of NE, SE, and/or DA - Monoamine oxidase (MAO) inhibitors -- keep the enzyme monoamine oxidase for deactivating SE, NE, and/or DA - SSRIs -- inhibit the reuptake of SE - SNRIs -- block the reuptake of SE and NE - Current view -- the balance of the various neurotransmitters more important than the absolute level of any neurotransmitter - The endocrine system - Diseases (e.g., hypothyroidism) leading to excessive secretion of cortisol lead to depression - Elevated levels of cortisol in people with depression - The dexamethasone suppression test -- a biological test for depression? - Sleep and circadian rhythms - REM starts sooner after falling asleep in depressed people - People with depression experience more intense REM activity; slow wave sleep occurs later - Bidirectional relationship between sleep and mood - Additional studies of brain structure and function - Depressed individuals show: - Greater right-sided anterior activation of brain - Less left-sided activation - May be a biological vulnerability to depression - Neuroimaging studies - Hyperactive amygdala and hypoactive prefrontal regions -\> diminished cognitive appraisals and depression - Recurrent depression and long-duration untreated depression -\> less hippocampal volume and neurocognitive impairment **Psychological dimensions** - Stressful life events - In 60-80% of cases, depression is caused by psychological experiences - Interpretation of stressful events - Link between stressful life events and depression not straightforward -- gene -- environment correlation model - Bipolar disorder -- strong relationship between stressful life events and the onset of episodes in bipolar disorders - Cognitive theories of depression - **Learned helplessness theory of depression** - Seligman: people become depressed when they feel they have no control over life's stresses - Learned helplessness theory of depression - Depressive attributional style is: - Internal, stable, global - Depressive paradox - Depressive attributional style (diathesis) is: - Internal: the individual attributes negative events to personal failings ("it is all my fault") - Stable: even after a particular negative event passes, the attribution that "additional bad things will always be my fault" remains - Global: the attributions extend across a wide variety of issues - Hopelessness theory - Hopelessness -- an expectation that desirable outcomes will not occur or that undesirable ones will occur and the person has no responses available to change the situation - Two more diatheses - Low self-esteem - A tendency to infer that negative life events will have severe negative consequences - Becks cognitive theory/ negative cognitive styles - According to beck, people with depression make the worst of everything; for them, the smallest setbacks are major catastrophes - According to beck, people who are depressed make cognitive errors in thinking negatively about themselves, their immediate works, and their future, three areas that together are called the cognitive triad - Negative life events -\> development of negative schema - Negative schema + cognitive biases -\> negative cognitive triad -- thinking negatively about the self, immediate world, and future - Repeated activation -\> negative schemas organized into a depressive mode - Cognitive biases/errors - Arbitrary inferences - Overgeneralization - Dichotomous or "all or nothing" thinking - Selective thinking - Catastrophizing - Personalizing - The implications of becks theory are very important. By recognizing cognitive errors and the underlying schemas, we can correct them and potentially alleviate depression and related emotional disorders **Interpersonal theory of depression** - Sparse social networks that provide little support - Decreased an individual's ability to handle negative life events - Increase vulnerability to depression - Depressed people also elicit negative reactions from others and are low in social skills - They constantly seek the reassurance of others **Social and cultural dimensions** **Marital relations** - Marital dissatisfaction: disruptions lead to depression - High conflict, low support -- deterioration in marital relationships - Bipolar individuals less likely to marry, more likely to divorce (if they marry) **Social support** - Rate of depression 80% higher for those who live alone - Lack social support predicts onset of symptoms of depression - Social support enables speedy recovery from depressive episodes and postpartum depression **Treatment** **Medications** - First generation antidepressants - Tricyclics -- targets NE but other neurotransmitters SE, DA are also effected - Block the reuptake of certain neurotransmitters, allowing them to pool in the synapse and, as the theory goes desensitize or down regulate the transmitting of that particular neurotransmitter - Takes 2 to 8 weeks to work - Many patients may feel worse during this period -\> adherence issues - Cardiac side effects lethal if taken in excessive doses - MAOIs - As effective as tricyclics with fewer side effects - Used less often -- two serious issues - Consuming food containing tryptamine -\> severe hypertension - Interaction with common medications such as cold medications - Second generation antidepressant **SSRIs** - First choice in drug treatment for depression -- inhibits reuptake of serotonin - Initial reports of relationship with suicided preoccupations, paranoid reactions, occasionally violence - Recent findings -- risk of suicide with fluoxetine are no greater than any other antidepressants - Major side effects: physical agitation, sexual dysfunction - Third generation antidepressants - SNRIs -- serotonin and norepinephrine reuptake inhibitor - Natural herb -- St. john's wort (hypericum) - Lithium - Lithium carbonate: a common salt - Effective in preventing and treating manic episodes for 50% of patients - Mood-stabilizing drug - Careful dosage to prevent toxicity - Other drugs for bipolar disorder - People who do not respond to lithium may be prescribed: - Drugs with antimanic properties such as antipsychotics and anticonvulsants - Valproate - Commonly prescribed but less effective in preventing suicide as compared to lithium **Electroconvulsive therapy and transcranial magnetic stimulation** - Electroconvulsive therapy (ECT) - Early 20^th^ century -- two Italian physicians cerletti and bini - Safe and effective for those who do not respond to other treatments - Anesthesia; muscle relaxant - Electric shock (between 70 and 130 volts) -- less than a second - Follow up with medication and/or psychological therapy - Side effects -- short-term memory loss and confusion - Transcranial magnetic stimulation (TMS): - Effective in treating depression - Magnetic coil over the head -\> localized electromagnetic pulse - Less effective than the ECT in severe cases - Deep brain stimulation **light therapy/phototherapy** - SAD -- winter depression exposure to bright, white light - Within first hour of waking up in the morning - 20-30 mins - More effective if combined with CBT - Severe cases -- CBT may be more effective **Psychosocial treatments** - Cognitive therapy - Correcting cognitive errors in deep-seated negative thinking - Between sessions -- realistic thinking encouraged by monitoring and logging thought processes - Homework -- other activities to decrease depression are encouraged - Behavioural experiment - Interpersonal psychotherapy (IPT): focuses on resolving problems in existing relationships - Highly structured; 15-20 sessions (once a week) i. Identify and define an interpersonal issue - Typically, include one or more of the following: - Dealing with interpersonal disputes - Acquiring new relationship - Identifying and correcting deficits in social skills ii. Bring the dispute to a resolution - Stage of the dispute - Negotiation stage. Both partners are ware it is a dispute, and they are trying to renegotiate it. - Impasse stage. The dispute smoulders beneath the surface and result in low-level resentment, but no attempts are made to resolve it. - Resolution stage. The partners are taking some action, such as divorce or separation - Strategies to resolve the dispute **Combined treatments** - Combined treatment generally just as effective as separate drug or psychosocial therapies in treatment of depression - In severe depression, combination of drug and psychosocial treatments effective **Preventing relapse** - Maintenance treatment to prevent relapse; CBT - Mindfulness-based cognitive therapy - Teaches recovered depressed patients to disengage from negative thinking - Mindfulness meditation -- awareness of thoughts and feelings - Viewing thoughts as mental events rather than as accurate reflections of reality **Psychosocial treatments for bipolar disorder** - Treatment compliance -- psychoeducation -- reduction in mood swings -- stability - Interpersonal and social rhythm therapy -- treatment that regulates circadian rhythms by helping patients regulate their eating and sleep cycles and other daily schedules and cope more effectively with stressful life events, particularly interpersonal issues - Family-focused treatment combined with medication - Family tension -\> relapse - New coping and communication skills -\> change in communication styles - Combined drug and family-focused treatment - CBT is effective for bipolar patients with rapid cycling **Suicide** - Completed suicide/suicide - Suicidal attempts (the person survives) - Suicidal ideation (thinking seriously about suicide) - Passive or active - Suicide gestures/ parasuicides - Self-injury in which there is no intent to die **Risk factors** - Psychological autopsy Family history - A suicidal family member (trait such impulsivity or observational learning?) - Twin and adoption studies - Some biological contribution, even if it is relatively small Neurobiology - Low level of serotonin - Vulnerability to act impulsively - May lead to suicide Existing psychological disorders - 90% have psychological disorders - 60% suicides associated with mood disorders - Hopelessness, alcohol use, sensation seeking, borderline personality disorder Stressful life events - Severe experiences: - E.g., rejection, physical or sexual abuse, natural disasters - Preexisting vulnerabilities, lack of social support **Durkheim's sociological theory** - Sociologist -- Emile Durkheim (1951) - Suicide types based on social or cultural conditions: - Altruistic: formalized suicides -- sacrificing one's life to benefit others -- preserve tradition or honour of the family -- as in an ancient Japanese custom hara-kiri - Egoistic -- the loss of social supports as an important provocation for suicide **Baumeister's escape theory** - Painfully aware of personal shortcomings -\> emotional suffering, depression - Become suicidal to escape aversive self-awareness - Unrealistically high expectation -- failing to meet these expectations - Perfectionists have such impossibly high self-standards **Is suicide contagious?** - Positive relationship between suicidal behaviour and exposure to media coverage - Clusters of suicides - Teenagers - Romanticising suicide in media - Media accounts often describe the methods used in the suicide -- providing a guide to potential victims **Prevention** - Assess for possible suicide ideation - No-suicide contract (refusal -- high risk -\> immediate hospitalization) - Curriculum -- base programs (schools; other originations -- education about suicide and coping with life stressors) - Suicide prevention and crisis centres - Targeting high-risk individuals/groups - Emphasizing protective factors - Cognitive-behavioural interventions