Abnormal Psychology: Mood Disorders PDF

Abnormal Psychology Fourteenth Edition Ann M. Kring & Sheri L. Johnson Chapter 5 Mood Disorders Chapter Outline Clinical Descriptions and Epidemiology of Depressive Disorders Clinical Descriptions and Epidemiology of Bipolar Disorders Etiology of Mood Disord...

Abnormal Psychology Fourteenth Edition Ann M. Kring & Sheri L. Johnson Chapter 5 Mood Disorders Chapter Outline Clinical Descriptions and Epidemiology of Depressive Disorders Clinical Descriptions and Epidemiology of Bipolar Disorders Etiology of Mood Disorders Treatment of Mood Disorders Suicide Copyright ©2018 John Wiley & Sons, Inc. 2 Table 5.1 Overview of the Major DSM-5 Mood Disorders Unipolar Depressive Disorders DSM-5 Diagnoses Major Features Major depressive disorder Five or more depressive symptoms, including sad mood or loss of pleasure, for 2 weeks Persistent depressive disorder Low mood and at least two other symptoms of depression at least half of the time for 2 years Premenstrual dysphoric disorder Mood symptoms in the week before menses Disruptive mood dysregulation disorder Severe recurrent temper outbursts and persistent negative mood for at least 1 year beginning before age 10 Bipolar Disorders DSM-5 Diagnoses Major Features Bipolar I disorder At least one lifetime manic episode Bipolar II disorder At least one lifetime hypomanic episode and one major depressive episode Cyclothymia Recurrent mood changes from high to low for at least 2 years, without hypomanic or depressive episodes Copyright ©2018 John Wiley & Sons, Inc. 3 DSM-5 Criteria for Major Depressive Disorder (1 of 2) Sad mood OR loss of interest and pleasure PLUS four other symptoms: o Sleeping too much or too little o Psychomotor retardation or agitation o Poor appetite and weight loss, or increased appetite and weight gain o Loss of energy o Feelings of worthlessness or excessive guilt o Difficulty concentrating, thinking, or making decisions o Recurrent thoughts of death or suicide Copyright ©2018 John Wiley & Sons, Inc. 4 DSM-5 Criteria for Major Depressive Disorder (2 of 2) Symptoms are present: o Nearly every day o Most of the day o For at least 2 weeks Symptoms are distinct and more severe than a normative response to significant loss Copyright ©2018 John Wiley & Sons, Inc. 5 Major Depressive Disorder (MDD) Episodic o Symptoms tend to dissipate over time Recurrent o Once depression occurs, future episodes likely o Among people with a first depressive episode 15% report persistent depressive symptoms Half report at least one additional episode Copyright ©2018 John Wiley & Sons, Inc. 6 DSM-5 Criteria for Persistent Depressive Disorder (PDD) Depressed mood for at least 2 years o 1 year for children/adolescents PLUS 2 other symptoms: o Poor appetite or overeating o Sleeping too much or too little o Low energy o Poor self-esteem o Trouble concentrating or making decisions o Feelings of hopelessness Symptoms do not clear for more than 2 months at a time Bipolar disorders are not present Copyright ©2018 John Wiley & Sons, Inc. 7 Epidemiology and Consequences of Depression (1 of 2) Depression is common o Lifetime prevalence: 16.2% MDD 5% Depression more than 2 years Twice as common in women as in men o Three times as common among people in poverty Prevalence varies across cultures o MDD 6.5% in China 21% in France o Cultural factors play an important role in depression rates Copyright ©2018 John Wiley & Sons, Inc. 8 Epidemiology and Consequences of Depression (2 of 2) Symptoms vary across cultures o Focus on somatic symptoms (e.g., pain, fatigue) Ethnic minorities in the US People from Latin America and some Asian countries Age of onset o Early 20s o Decreased over past 50 years Co-morbidity o 5-30% with MDD experience PDD o 60% of those with MDD will also meet criteria for anxiety disorder at some point Copyright ©2018 John Wiley & Sons, Inc. 9 Figure 5.1: With Each Generation, The Median Age Of Onset For MDD Gets Younger Copyright ©2018 John Wiley & Sons, Inc. 10 Bipolar Disorders Severity and duration of mania defining feature of each: Bipolar I, Bipolar II, Cyclothymia Mania o State of intense elation, irritability, or activation o Hypomania (hypo = “under”) Symptoms of mania but less intense Does not involve significant impairment Most people will also experience an episode of depression Depressive episode required for Bipolar II, but not Bipolar I Copyright ©2018 John Wiley & Sons, Inc. 11 DSM-5 Criteria for Manic and Hypomanic Episodes (1 of 2) Distinctly elevated or irritable mood Abnormally increased activity and energy PLUS 3 other symptoms (four if mood is irritable): o Increased goal-directed activity or psychomotor agitation o Talkativeness or rapid speech o Flight of ideas or racing thoughts o Decreased need for sleep o Increased self-esteem or grandiosity o Distractibility o Excessive involvement in activities that are likely to have undesirable consequences (e.g., reckless spending/sexual behavior/driving) Copyright ©2018 John Wiley & Sons, Inc. 12 DSM-5 Criteria for Manic and Hypomanic Episodes (2 of 2) Symptoms are present most of the day, nearly every day For a manic episode: o Symptoms last at least 1 week, require hospitalization, or include psychosis o Symptoms cause significant distress or functional impairment For a hypomanic episode: o Symptoms last at least 4 days o Clear changes in functioning that are observable to others, but impairment is not marked o No psychotic symptoms are present Copyright ©2018 John Wiley & Sons, Inc. 13 DSM-5 Criteria for Bipolar Disorders (1 of 2) Bipolar I o At least one episode or mania Bipolar II o At least one major depressive episode o At least one episode of hypomania o No episodes of mania Copyright ©2018 John Wiley & Sons, Inc. 14 DSM-5 Criteria for Bipolar Disorders (2 of 2) Cyclothymic disorder (Cyclothymia) o Milder, chronic form of bipolar disorder o Symptoms lasts at least 2 years in adults 1 year in children/adolescents o Numerous periods with hypomanic and depressive symptoms Does not meet criteria for hypomania or major depressive episode Symptoms do not clear for more than 2 months at a time Symptoms cause significant distress or impairment Copyright ©2018 John Wiley & Sons, Inc. 15 Epidemiology and Consequences of Bipolar Disorder Prevalence rates lower than MDD o 1% in U S; 0.6% worldwide for Bipolar I o 0.4% – 2% for Bipolar II o 4% for Cyclothymia Average age of onset in 20s No gender differences in rates of bipolar disorders o Women experience more depressive episodes Severe mental illness o 15% unemployed full-time in past year o Suicide rates high o One in four report suicide attempt More than half report suicidal ideation in past 12 months Copyright ©2018 John Wiley & Sons, Inc. 16 Etiology of Mood Disorders: An Overview Factors contributing to the onset of mood disorders o Genetic factors o Neurotransmitters o Brain function o Neuroendocrine System o Social factors o Psychological factors Copyright ©2018 John Wiley & Sons, Inc. 17 Etiology of Mood Disorders: Genetic Factors Heritability estimates o 37% MDD o 93% Bipolar Disorder Unlikely one gene explains these illnesses o More likely Gene x Environment Interaction How a gene might increase risk in presence of environmental risk factor Serotonin transporter gene (5-HTT) polymorphism o Short allele combination of the 5-HTT gene and childhood maltreatment or adulthood stressful life events increases risk of MDD Copyright ©2018 John Wiley & Sons, Inc. 18 Figure 5.2 Stressful life events interact with serotonin transporter gene to predict depression Copyright ©2018 John Wiley & Sons, Inc. 19 Etiology of Mood Disorders: Neurotransmitters (NTs) Norepinephrine, dopamine, and serotonin 37% MDD Original models focused on absolute levels of NTs New models focus on sensitivity of postsynaptic receptors o Stress may lead to changes in sensitivity of serotonin receptors o Dopamine plays a major role in the reward system o Dopamine dysfunction may be connected to specific symptoms (e.g., changes in energy and motivation) o Dopamine receptors may be overly sensitive in BD but lack sensitivity in MDD Copyright ©2018 John Wiley & Sons, Inc. 20 Figure 5.3: Serotonin and Dopamine Pathways Copyright ©2018 John Wiley & Sons, Inc. 21 Figure 5.4: Drug Action on Synaptic Activity Copyright ©2018 John Wiley & Sons, Inc. 22 Etiology of Mood Disorders: Brain Function Oversensitivity to emotional stimuli (elevated amygdala) Interference with emotion regulation (elevated anterior cingulate, diminished prefrontal cortex and hippocampus) Motivation to pursue rewards (striatum) Disruptions in the connectivity of these regions Copyright ©2018 John Wiley & Sons, Inc. 23 Table 5.2 Summary of Neurobiological Hypotheses About Major Depression and Bipolar Disorder Neurological Hypothesis Major Depression Bipolar Disorder Genetic Contribution Moderate High Neurotransmitter (serotonin, Mixed evidence Mixed evidence dopamine) dysfunction Changes in activation of Present Present regions in the brain in response to emotion stimuli Activation of regions in the Diminished Elevated brain in response to emotion stimuli Cortisol awakening Response Elevated Elevated among those with depression Copyright ©2018 John Wiley & Sons, Inc. 24 Figure 5.5: Key Brain Regions Involved in Mood Disorders Copyright ©2018 John Wiley & Sons, Inc. 25 Etiology of Mood Disorders: Neuroendocrine System (1 of 2) Overactivity of HPA axis o Amygdala activates HPA axis, which releases cortisol o Cortisol, stress hormone, increases activity of immune system to prepare for threat o Prolonged high cortisol levels can cause harm to body systems Damage to hippocampus More severe course of illness for MDD and BD Copyright ©2018 John Wiley & Sons, Inc. 26 Etiology of Mood Disorders: Neuroendocrine System (2 of 2) Overactivity of HPA axis o Amygdala activates HPA axis, which releases cortisol o Cortisol, stress hormone, increases activity of immune system to prepare for threat o Prolonged high cortisol levels can cause harm to body systems Damage to hippocampus More severe course of illness for MDD and BD Copyright ©2018 John Wiley & Sons, Inc. 27 Etiology of Mood Disorders: Social Factors in Depression Life events o 42-67% report a stressful life event in year prior to depression o 40% risk of developing depression when experiencing stressful life event without support (4% risk with support) Interpersonal difficulties o High levels of expressed emotion predict relapse o Marital conflict also predicts depression Copyright ©2018 John Wiley & Sons, Inc. 28 Etiology of Mood Disorders: Psychological Factors in Depression (1 of 4) Neuroticism o Tendency to experience frequent and intense negative affect o Predicts onset of anxiety, which is highly comorbid with depression Cognitive Theories o Negative thoughts and beliefs cause depression o Beck’s Theory, Hopelessness Theory, Rumination Theory Copyright ©2018 John Wiley & Sons, Inc. 29 Etiology of Mood Disorders: Psychological Factors in Depression (2 of 4) Beck’s Theory o Negative triad Negative view of self, world, future o Negative schema Underlying tendency to see the world negatively o Cognitive biases Tendency to process information in negative ways due to negative schema Copyright ©2018 John Wiley & Sons, Inc. 30 Figure 5.6: Beck’s Theory of Depression Copyright ©2018 John Wiley & Sons, Inc. 31 Etiology of Mood Disorders: Psychological Factors in Depression (3 of 4) Hopelessness Theory o Most important trigger of depression is hopelessness Desirable outcomes will not occur Person has no ability to change situation o Attributional Style Negative life events are due to stable and global causes Copyright ©2018 John Wiley & Sons, Inc. 32 Table 5.4: An Example of Attributions: Why I Failed My GRE Exam Stable Unstable Global I lack intelligence I am exhausted Specific I lack mathematical I am fed up with math ability right now Copyright ©2018 John Wiley & Sons, Inc. 33 Etiology of Mood Disorders: Psychological Factors in Depression (4 of 4) Rumination Theory o A specific way of thinking: tendency to repetitively dwell on sad thoughts o Most detrimental form is to brood regretfully over causes of events Copyright ©2018 John Wiley & Sons, Inc. 34 Social and Psychological Factors in Bipolar Disorder Triggers of depressive episodes in BD appear similar to triggers in MDD o Negative life events, neuroticism, negative cognitions, expressed emotion, and lack of social support Predictors of mania o Reward sensitivity High responsively to rewards Life events that involve attaining goals Excessive goal pursuit o Sleep disruption Copyright ©2018 John Wiley & Sons, Inc. 35 Psychological Treatment of Depression (1 of 2) Interpersonal psychotherapy (IPT) o Focus on major interpersonal problems (e.g., role transitions) o Identify feelings, make decisions, and resolve problems related to interpersonal issues Cognitive therapy (CT) o Altering maladaptive thought patterns o Monitor and identify automatic thoughts Challenge and replace negative thoughts with more neutral or positive thoughts Copyright ©2018 John Wiley & Sons, Inc. 36 Table 5.5 Example of Cognitive Therapy Thought Monitoring Log How much Re-rate did you your Date Automatic believe this belief in and Negative negative thought? (0- the initial Time Situation: emotion type thought 100) Alternative thought thought Outcome Tues I made a Sad–90 I always mess 90 My boss didn’t give me 50 Relief–30 9:30 mistake on a Embarrassed– things up. I’m enough time to prepare Sad–30 am report at work. 80 never going the report. I could have to be good at done a better job with anything. more time. Wed Eating dinner Sad–95 I’m a 100 I’ve changed my hair 25 Sad-25 7 pm at a restaurant. nobody. drastically since then. An old friend Many people don’t from high school recognize me, but maybe was at the next she would have been table and didn’t happy to see me if I had recognize me reminded her of who I was. Thurs My Sad–90 Even the 100 I know that he had a huge 20 Sad-20 8:30 husband left for people I love presentation and he gets am work without don’t seem to stressed. saying goodbye notice me to me. Copyright ©2018 John Wiley & Sons, Inc. 37 Psychological Treatment of Depression (2 of 2) Mindfulness-based cognitive therapy (MBCT) o Use of strategies, including meditation, to detach from depression-related thoughts and prevent relapse Behavioral activation (BA) therapy o Increase participation in positively reinforcing activities to disrupt spiral of depression, withdrawal, and avoidance o BA is also one component of cognitive therapy Behavioral couples therapy o Enhance communication and relationship satisfaction Copyright ©2018 John Wiley & Sons, Inc. 38 Psychological Treatment of Bipolar Disorder Psychoeducational approaches o Provide information about symptoms, course, triggers, and treatments Cognitive Therapy (CT) o Similar to depression treatment with additional content to address early signs of mania Family-focused treatment (FFT) o Educate family about disorder, enhance family communication, improve problem solving Copyright ©2018 John Wiley & Sons, Inc. 39 Biological Treatment of Mood Disorders Electroconvulsive therapy (ECT) o Reserved for treatment non-responders o Induce brain seizure and momentary unconsciousness o Side effects: Short-term confusion and memory loss o Unclear how ECT works Transcranial Magnetic Stimulation for Depression (rTMS) o Electormagnetic coil placed against scalp o Pulses of magnetic energy increase activity in the brain o For those that fail to respond to first antidepressant Copyright ©2018 John Wiley & Sons, Inc. 40 ECT Copyright ©2018 John Wiley & Sons, Inc. 41 Table 5.6 Medications for Treating Mood Disorders Antidepressants Category Generic Name Trade Name MAO inhibitors tranylcypromine Parnate Tricyclic antidepressants Imipramine, amitriptyline Tofranil, Elavil Selective serotonin reuptake inhibitor fluoxetine, sertraline Prozac, Zoloft (SSRI) Serotonin norepinephrine reuptake venlafaxine, duloxetine Effexor, inhibitor (SNRI) Cymbalta Mood Stabilizers Category Generic Name Trade Name lithium Lithium Anticonvulsants divalproex sodium Depakote Antipsychotics olanzapine Zyprexa Copyright ©2018 John Wiley & Sons, Inc. 42 Medications for Depressive Disorders (1 of 2) Most commonly used and best-researched treatments o 75% of people in US receiving treatment for depression are prescribed antidepressants Very effective at treating severe, persistent depression o May not be helpful for those with mild or moderate symptoms Copyright ©2018 John Wiley & Sons, Inc. 43 Medications for Depressive Disorders (2 of 2) STAR-D (Rush et al., 2006) o Sequenced Treatment Alternatives to Relieve Depression o Attempted to evaluate effectiveness of antidepressants in real-world settings (comorbid psychiatric conditions) Only 33% achieved full symptom relief with citalopram About 30% of non-responders achieved remission with a different anti-depressant Remission rates were low and relapse rates were high Copyright ©2018 John Wiley & Sons, Inc. 44 Research Comparing Treatments for Major Depressive Disorder Combining psychotherapy and antidepressant medications increases odds of recovery over either alone by 10-20% o Medications quicker, therapy longer-lasting effects Later studies (Hollon & DeRubeis, 2003) o CT as effective as medication for severe depression o CT more effective than medication at preventing relapse Copyright ©2018 John Wiley & Sons, Inc. 45 Medications for Bipolar Disorder Lithium o Up to 80% receive at least some relief o Potentially serious side effect Lithium toxicity Other mood stabilizers o Anticonvulsants Divalproex (Depakote) o Antipsychotics (offer immediate calming effect) Olanzapine (Zyprexa) o Recommended if people are unable to tolerate lithium side effects o Can be combined with lithium Copyright ©2018 John Wiley & Sons, Inc. 46 Key Terms in the Study of Suicidality Suicide ideation: thoughts of killing oneself Suicide attempt: behavior intended to kill oneself Suicide: death from deliberate self-injury Non-suicidal self-injury: behaviors intended to injure oneself without intent to cause death Copyright ©2018 John Wiley & Sons, Inc. 47 Epidemiology of Suicide and Suicide Attempts (1 of 2) 10th leading cause of death in US Worldwide: 9% report suicidal ideation at least once in their lives and 2.5% have made at least one suicide attempt Guns are the most common means of suicide in the US (50%) Men are more likely than women to kill themselves Women are more likely than men are to make suicide attempts that do not result in death Copyright ©2018 John Wiley & Sons, Inc. 48 Epidemiology of Suicide and Suicide Attempts (2 of 2) Men usually shoot or hang themselves Women more likely to use less lethal means The highest rates of suicide in the United States are for white males over age 50 The rates of suicide for adolescents and children in the United States are increasing dramatically Being divorced or widowed elevates suicide risk four- or fivefold Copyright ©2018 John Wiley & Sons, Inc. 49 Figure 5.8: Annual Deaths in the US Due to Suicides Copyright ©2018 John Wiley & Sons, Inc. 50 Risk Factors for Suicide (1 of 2) Psychological Disorders o 90% of people who attempt suicide have a psychological disorder o More than half of those who attempt suicide are depressed Neurobiological Models o Heritability of about 50% for suicide attempts o Low levels of dopamine o Abnormal cortisol regulation Copyright ©2018 John Wiley & Sons, Inc. 51 Risk Factors for Suicide (2 of 2) Social Factors o Economic recessions o Media reports of suicide o History of multiple physical and sexual assaults o Perceived sense of burden to others and a lack of social belonging Psychological Models o Ineffective problem-solving o Hopelessness o Impulsivity Copyright ©2018 John Wiley & Sons, Inc. 52 Preventing Suicide Talk about suicide openly and matter-of-factly Most people are ambivalent about their suicidal intentions Talking about suicide can help the person identify other ways to relieve the pain Treat the associated mental health disorder Treat suicidality directly Hospitalization for safety Copyright ©2018 John Wiley & Sons, Inc. 53 Suicide Hotlines on Bridges Copyright ©2018 John Wiley & Sons, Inc. 54 Broader Approaches to Suicide Prevention Studying suicide prevention within the military o Higher rates of suicide than the general population o Programing to encourage and destigmatize help seeking, normalize distress, and promote effective coping 25% drop in rates of completed suicide among Air Force Airmen Means Restriction o Make highly lethal methods less available Keep guns in locked cabinets Restrict access to lethal drugs Copyright ©2018 John Wiley & Sons, Inc. 55 Copyright Copyright © 2018 John Wiley & Sons, Inc. 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