Chapter 9 Mood disorders.doc

Chapter 9: Mood Disorders Unipolar depression Symptoms Emotional- sadness; anhedonia (loss of interest in everything) Physiological and behavioral- changes in appetite, sleep, and activity levels (psychomotor retardation) Cognitive- feelings of worthlessness, guilt, hopelessness, and even suicide Delusions- beliefs with no basis in reality Hallucinations- involve seeing, hearing, or feeling things that are not real Diagnosis Major depression Requires that a person experience either depressed mood or loss of interest in usual activities plus four other symptoms of depression chronically for at least two weeks These symptoms have to be severe enough to interfere with the person?s ability to function in everyday life Dysthymic disorder A less severe form of depressive disorder than is major depression, but it is more chronic A person must be experiencing depressed mood plus two other symptoms of depression for at least two years. During these two years, the person must never have been without the symptoms of depression for more than a two month period. Double depression People are chronically dysthymic, then occasionally sink into episodes of major depression. As the major depression passes, they return to dysthymia rather than recover to a normal mood. People with double depression are even more debilitated than are people with major depression or dysthymia, and are less likely to respond to treatments. Subtypes Depression with melancholic features- physiological symptoms are prominent Depression with psychotic features- delusions and hallucinations during an episode Depression with catatonic features- catatonia: complete lack of movement to agitation Depression with atypical features- assortment of symptoms Depression with postpartum onset- onset of depression occurs within 4 weeks of birth Depression with seasonal pattern- (SAD) symptoms tied to number of hours of daylight Course/prevalence 16% of Americans experience an episode of major depression, and rates of depression goes up among the ?old old,? those above 85. Women are twice as likely as men to experience both mild depressive symptoms and severe depressive disorders. This is not because females are more willing to admit to depression than males. The gender difference in depression is found even in studies that use relatively objective measures of depression Depression appears to be a long-lasting, recurrent problem for some people, and can be a costly disorder to the individual and to society Childhood/Adolescence Depression is less common among children than among adults, but depression is more likely to leave psychological and social scars if it occurs initially during childhood, rather than adulthood. Self-concept is still being developed in childhood and adolescence and a period of significant depressive symptoms while one?s self concept is undergoing substantial change can have long-lasting effects on the content or structure of one?s self concept. Girls? rates of depression escalate dramatically over the course of puberty, but boys? rates do not. This is not related to hormonal changes, but rather the observable physical changes of adolescence affect boys? and girls? self-esteem differently. This increase in depression related to puberty may only affect European American girls Bipolar mood disorders Symptoms of mania The moods of people who are manic can be elated, but that elation is often mixed with irritation and agitation. The manic person is filled with a grandiose self esteem, thoughts and impulses, may speak rapidly and forcefully, engage in impulsive behaviors, and have grand plans and goals. Diagnosis of mania Bipolar I disorder- manic episodes are necessary, severe or mild depression Bipolar II disorder- depression is necessary, milder episodes of mania (hypomania) Cyclothymic disorder- a less severe but more chronic form of bipolar disorder. A person alternates between episodes of hypomania and moderate depression chronically over at least a two year period. Rapid cycling bipolar disorder- four or more cycles of mania and depression within a year Course/prevalence Men and women seem equally likely to develop the disorder, and there are no consistent differences among ethnic groups in the prevalence of the disorder. People with bipolar disorder often face chronic problems on the job and in their relationships between episodes. The best predictor of recovery is full compliance with medication taking and higher social class, which may have afforded people better health care and social support. People with bipolar disorder often abuse substances, which impairs their control over their disorder and affects their willingness to take medications. A controversial issue in research on bipolar disorder is the extent to which it exists and can be diagnosed reliably in children and young adolescents. Research supports the diagnosis of bipolar disorder in children and suggests that pediatric bipolar disorder tends to be chronic. Creativity and bipolar disorder Bipolar disorder can actually benefit certain people, especially highly intelligent or talented people. Writers, artists, and composers of music have a higher than normal prevalence of mania and depression. Researchers hypothesized that the genetic abnormalities that cause bipolar disorder are in close proximity to the genetic abnormalities that cause great creativity. The results of this study suggested that the relatives of the people with bipolar disorder or cyclothymia were more creative than the participants with no history of bipolar disorder or cyclothymia or their relatives. The people with cyclothymia and the healthy relatives of those with bipolar disorder had somewhat higher creativity scores than did the patients who had bipolar disorder. This suggests that creativity that is associated with a predisposition towards bipolar disorder is more easily expressed in people who do not suffer from full episodes of mania and depression, but may suffer from milder mood swings. Biological theories of mood disorders The role of genetics Genetics plays a substantial role in vulnerability to bipolar disorder (60% concordance rate among identical twins, 13% concordance rate among fraternal twins) Depression also runs in families, but the relatives of people with depression do not tend to have any greater risk for bipolar disorder than do relatives of people with no mood disorder. This suggests that bipolar disorder has a genetic basis different from that of unipolar depression. One specific genetic abnormality that some studies suggest may be involved in the vulnerability to depression is on the serotonin transporter gene. Abnormalities on the serotonin transporter gene could lead to dysfunction in the regulation of serotonin, which in turn could affect the stability of individuals? moods. It is likely however, that there is no single location on a gene that leads to mood disorders, but rather the genetic predisposition might be multifactorial, and a particular configuration of several disordered genes may be necessary to create a particular mood disorder. Neurotransmitter dysregulation Monoamines are the specific neurotransmitters related to mood disorders. The specific monoamines that have been implicated are norepinephrine, serotonin, and to a lesser extent dopamine. These neurotransmitters are found in the limbic system, associated with the regulation of sleep, appetite, and emotional processes. Monoamine theories- depression was thought to be a reduction in the amount of norepinephrine or serotonin in the synapses between neurons, and mania was thought to be caused by an excess, or perhaps dysregulation of the levels of these amines, particularly dopamine. Recent studies suggest that people with major depression or bipolar disorder may have abnormalities in the number and sensitivity of receptors for the monoamine neurotransmitters. These differences tend to be present when the mood disorder is present but tends to disappear when the mood disorder subsides. Brain abnormalities Prefrontal cortex- reductions in metabolic activity and a reduction in the volume of gray matter, particularly on the left side, have been found in people with serious depression or bipolar disorder. Anterior cingulated- plays an important role in the body?s response to stress, in emotional expression, and in social behavior, as well as the processing of difficult information and has decreased activity for people with depression Hippocampus- critical in memory and in fear-related learning and people with major depression or bipolar disorder show a smaller volume and lower metabolic activity. Damage to the hippocampus could be the result of chronic arousal of the body?s stress response. Amygdala- helps direct attention to stimuli that are emotionally salient and have major significance for the individual and the amygdala is enlarged in people with mood disorders. Many of these brain abnormalities can be cuased by conditions in the environment, including chronic stress and chronic lack of control Neuroendocrine factors The neuroendocrine system regulates a number of important hormones, which in turn affect basic functions, such as sleep, appetite, sexual drive, and the ability to experience pleasure. Hypothalamic-pituitary-adrenal axis, or HPA axis- the hypothalamus, pituitary, and adrenal cortex work together in a biological feedback system interconnected with the limbic system and cerebral cortex. Normally when we are confronted with a stressor, the HPA axis becomes more active and stress hormones such as cortisol are released. Once the stressor is gone, the HPA axis activity returns to baseline levels. People with depression tend to show chronic hyperactivity in the HPA axis and an inability for the HPA axis to return to normal functioning following a stressor. Women?s hormonal cycles In the past, many people argued that women?s greater vulnerability to depression is tied to hormones. Research over the past several decades however has shown that most women do not experience significant changes in their moods during times of hormonal change. Early stress as a vulnerability Studies of children who have been abused or neglected show that their biological responses to stress, particularly the response of their HPA axis, often are either exaggerated or blunted Psychological theories of mood disorders Behavioral theories Behavioral theory of depression (Peter Lewinsohn)- life stress leads to depression because it reduces the positive reinforcers in a person?s life. Such a pattern is especially likely in people with poor social skills, because they are more likely to experience rejection by others and to withdraw in response to this rejection. Learned helplessness theory- suggests that the type of stressful event most likely to lead to depression is uncontrollable negative events. A belief of helplessness leads people to lose their motivation, to reduce actions that might control the environment, and to be unable to learn how to control situations that are controllable. These deficits are known as learned helplessness deficits and are similar to the symptoms of depression: low motivation, passivity, and indecisiveness. Cognitive theories Negative cognitive triad- Aaron Beck argued that people with depression have negative views of themselves, of the world, and of the future. Often, these negative thoughts are so automatic that people with depression do not realize how they are interpreting situations. Reformulated learned helplessness theory- cognitive factors might influence whether a person becomes helpless and depressed following a negative event. This theory focuses on people?s causal attributions for events- an explanation why an event happened. People who habitually explain negative events by causes that are internal, stable, and global blame themselves for these negative events, expect negative events to recur in the future, and expect to experience negative events in many areas of their lives. These expectations lead them to experience long term learned helplessness deficits plus self esteem loss in many areas of their lives. Depressive realism- when asked to make judgments about how much control they have over situations that are actually uncontrollable, people with depression are quiet accurate. On the other hand, nondepressed people have a robust illusion that they can control all sorts of situations that truly are out of their control and that they have superior skills, compared with most people. This research calls into question the notion that depression results form unrealistic beliefs that one cannot control one?s environment or from negative errors in thinking about oneself and the world. Ruminative process styles theory- focuses more on the process of thinking rather than the content of thinking, and explains how some people when sad or upset focus intently on how they feel and can identify many possible causes of these symptoms. They do not attempt to do anything about these causes however, and continue to engage in rumination about their depression. Psychodynamic theories Suggest that such patterns of unhealthy relationships stem from people?s childhood experiences that prevented them from developing a strong and positive sense of self reasonably independent of others? evaluations. Interojected hostility theory- Freud pointed out that people who are depressed have many of the symptoms of people who are grieving the death of a loved one. They feel sad, alone, unmotivated, and lethargic. Freud believed depressed people were blaming or punishing those who they perceived abandoned them. People with depression are so dependent on the approval and love of others that much of their ego or sense of self is made up of their images of others- ?love objects.? People with depression turn their anger inward on the parts of their won egos that have incorporated the love objects. Their self blame and punishment is actually blame and punishment of the others who have abandoned them. Interpersonal theories Concerned with people?s close relationships and their roles in those relationships, and disturbances in these roles are thought to be the main source of depression. Often, the disturbances are rooted in long standing patterns of interactions the people with depression typically have with important others. Contingencies of self worth- children with insecure attachments develop expectations that they must be or do certain things in order to win the approval of others. As long as an individual meets the contingencies of self-worth set up in his or her working model, then he or she will maintain positive self esteem and remain nondepressed. Excessive reassurance seeking- people who are so insecure in their relationships with others constantly look for assurances from others that they are accepted and loved. The insecure person picks up on cues of annoyance and becomes panicked over them, leading him or her to feel even more insecure and to engage in even more excessive reassurance seeking. Social perspectives on mood disorders The cohort effect People born in one historical period are at different risk for a disorder than are people born in another historical period. Proponents of the cohort explanation suggest that more recent generations are more at risk for depression because of the rapid changes in social values that began in the 1960s and the disintegration of the family unit. Another possible explanation is that younger generations have higher expectations for themselves than did older generations, but these expectations are too high to be met. Social status People who have lower status in society generally tend to show more depression. Women?s lower social status puts them at high risk for physical and sexual abuse, and these experiences often lead to depression. Cross cultural differences One cultural group within the U.S. that has an especially low prevalence of unipolar depression s the Old Order Amish. Perhaps the simple, agrarian lifestyle of the Amish, with its emphasis on family and community, helps protect its members against depression. The prevalence of major depression is lower among less industrialized and less modern countries than among more industrialized and more modern countries. The community and family oriented lifestyles of less modern societies may be beneficial to mental health, despite the physical hardships that many people in these societies face because of their lack of modern conveniences. People in less modern cultures may tend to manifest depression with physical complaints, rather than psychological symptoms of depression, such as sadness, loss of motivation, and hopelessness about the future. Mood disorder treatments Biological treatments for mood disorders Drug treatments for depression Tricyclic antidepressants help reduce the symptoms of depression apparently by preventing the reuptake of norepinephrine and serotonin in the synapses or by changing the responsiveness of the receptors for these neurotransmitters. These drugs are reasonably effective, but unfortunately, the tricyclic antidepressants have a number of side effects and can take four to eight weeks to show an effect. Additionally, they can be fatal in overdose. Monoamine oxidase inhibitors is an enzyme that causes the breakdown of the monoamine neurotransmitters in the synapse. MAO inhibitors decrease the action of MAO and thus bring about increases in the levels of the neurotransmitters in the synapse. The side effects are potentially more dangerous. SSRIs work more directly to affect serotonin than do the tricyclics and these drugs have become very popular in the treatment of depression. The SSRIs are not more effective in the treatment of depression than the antidepressants but SSRIs have several advantages over other antidepressants. These drugs provide relief from depression after a couple of weeks, the side effects are less severe, these drugs are not fatal in overdose, and appear to be helpful in a wide range of symptoms in addition to depression such as anxiety symptoms, binge eating, and premenstrual symptoms. Electroconvulsive therapy- ECT is controversial and consists of a series of treatments in which a brain seizure is induced by passing electrical current through the brain. ECT is most often given to people with depression who have no responded to drug therapies, and it relieves depression in 50-60% of these people. ECT results in decreases in metabolic activity in several regions of the brain, including the frontal cortex and the anterior cingulated. The relapse rate among people who have undergone ECT is as high as 85%. Repetitive transcranial magnetic stimulation- researchers recently have been investigating new methods for stimulating the brain without electrical current. RTMS exposes patients to repeated, high intensity magnetic pulses focused on particular brain structures, such as the left prefrontal cortex, which tends to show abnormally low metabolic activity in some people with depression. The electrical stimulation of neurons can result in long term changes in neurotransmission across synapses. Vagas nerve stimulation- the vagas nerve is stimulated by a small electronic device much like a cardiac pacemaker, which is surgically implanted under a patient?s skin in the left chest wall. The vagus nerve carries information from the head, neck, thorax, and abdomen to several areas of the brain, including the hypothalamus and amygdala, which are involved in depression. Light therapy- people with SAD who are exposed to bright lights for a few hours each day during the winter months experience complete relief from their depression within a couple of days. Light therapy resets circadian rhythms and thereby normalize the production of hormones and neurotransmitters. Light therapy might also work by decreasing the levels of the hormone melatonin, which can increase levels of norepinephrine and serotonin and thereby reduce the symptoms of depression. Drug treatments for mania Lithium lithium- the most common treatment for bipolar disorder. Lithium seems to stabilize a number of neurotransmitter systems, including serotonin, dopamine, and glutamate. It appears to be more effective in reducing the symptoms of mania than the symptoms of depression. It poses some problems however, because the propor dosage of lithium differs from person to person and there is a small gap between acceptable dosage and fatal dosage. Anticonvulsants- can be effective in reducing the symptoms of severe and acute mania, although it is not clear if they are as effective as lithium in the long term treatment of bipolar disorder. Antipsychotic drugs- reduce functional levels of dopamine and seem especially useful in the treatment of psychotic manic symptoms. They have many neurological side effects however (tardive dyskinesia- uncontrollable tics and movements of the face and limbs) Calcium channel blockers- are safe for women to take during pregnancy. They seem to induce fewer side effects than lithium and perhaps the anticonvulsants. Psychological treatments for depression Behavior therapies- focus on increasing the number of positive reinforcers and decreasing the number of aversive experiences in an individual?s life by helping the depressed person change his/her way of interaction with the environment and other people. These therapies are designed to be short term, about 12 weeks long. Cognitive behavioral therapies- clients often report that they did not realize the types of thoughts that went through their heads when certain types of events happened. People with depression often believe that there is only one way to interpret a situation- their negative way. Therapists help clients recognize the deeper, basic beliefs of assumptions they hold that are feeding their depression. Cognitive behavioral therapy has proven quiet effective in treating depression, including major depression. Interpersonal therapies- therapists look for four types of problems in depressed patients. 1) Many depressed patients truly are grieving the loss of loved ones, perhaps not from death but from the breakup of important relationships. 2) Interpersonal role disputes that arise when people do not agree on their roles in a relationship 3) Role transitions, for instance the transition from college to work. Sometimes people become depressed over the roles they must leave behind. 4) Deficits in interpersonal skills. Such skill deficits can be the reason that people with depression have inadequate social support networks. Interpersonal therapy has been shown to be highly effective in the treatment of depression. Psychodynamic therapies- the therapist will acknowledge and interpret the themes he or she observes in the client?s behaviors and recollections, to help the client gain insight, accept these unconscious concerns, and move beyond them. These therapies have not proven very effective in the treatment of depression. Comparisons of cognitive-behavioral, interpersonal, and drug therapies These three therapies, despite their vast differences, appear equally effective for the treatment of most people with depression. A combination of psychotherapy and drug therapy is more effective in treating people with chronic depression than is either type of therapy alone. Many psychologists argue that people with a history of recurrent depression should be kept on a maintenance dose of therapy even after their depression has been relieved because relapse rates are so high. Depression prevention Community based interventions can prevent first onsets of depression in people at high risk. Evidence that depression first arises in adolescence has led several researchers to focus on preventing depression in high risk adolescents. Findings show that interventions seem to reduce the risk for future depression in children.