Chapter 6: Mood Disorders and Suicide

Overview of Mood Disorders Normal: mood is responsive to the environment

o Good things happen, you feel good for awhile. o Bad things happen you feel bad for awhile.o Things stay in some sort of proportion most of the time.o As you get older, it takes even more to throw you off stride.

To understand mood disorders:o You have to understand their phenomenology -- You have to know what it feels

like to be depressed or manic.o Additionally, much of what is different about people with affective disorders

involves physically feeling bad. Depression is not severe sadness

o People with a clinical depression are sometimes sad and sometimes not sad at all.o Depression is a constellation of psychological and physiological states o There are a variety of physical signs, most obviously disruption of circadian

rhythms, that are part of the picture Symptoms of Depression

o Depressed or irritable moodo Diminished interest/pleasure daily activityo Weight loss or gain w/o tryingo Early morning awakening or hypersomnia o Psychomotor agitation or retardationo Fatigue/no energyo Feeling worthless/overwhelmed by guildo Can’t seem to think or concentrateo Recurrent thoughts of suicide, a suicide plan or suicide attempto Life is getting more and more of a messo All for at least 2 solid months

Age and Gendero Disorders with earlier onset tend to be more biologically driven and more severe.o Unipolar depression = twice as many women as men.o Bipolar disorder = just as many women as meno More severe disorders leave you less choice about how to be crazy so tend toward

less gender distinction. o Remember the parallel case in anxiety disorders: lots more females with a specific

phobia, but no gender difference in OCD, a more severe disorder. Key Point

o Major disorders lie to you. o You crave the things that are worst for you.o Depression says “Just relax for a little.” means sit quietly alone in the dark for

awhile and you will feel better.o Exactly the wrong prescription for depression.

o Do just the opposite.

The Major Depressive Disorders are in three categories:o Major Depressive Disorder

Major period of time where you're sad, where things are going wrong Single episode – highly unusual Recurrent episodes – more common Single manic episode or only manic episodes is very, very rare Cognitive symptoms - feelings of worthless, indecisiveness Anhedonia - Loss of pleasure/interactions of usual activites

o Dysthymic Disorder Lower grade of depression but more chronic Overview and defining features

Symptoms are milder than major depression Persists for at least 2 years No more than 2 weeks symptom free Symptoms can persist unchanged over long periods (≥ 20 years)

o Double Depression Basically both a major depressive disorder and dysthymic disorder where

you have someone who basically throughout his or her life has been sad, has had this kind of overlying depression, and then has episodes of major depressive episodes

Major depressive episodes and dysthymic disorder Dysthymic disorder often develops first Facts and statistics

Associated with severe psychopathology Associated with a problematic future course

Bipolar Disorderso Common name -- Manic Depressiveo Bipolar I Disorder: where you have very distinct major depressive periods of

time and very distinct manic depressive, manic periods of time.  It is as if you have to go 130 mph. Everything going very fast. Pretty self-

destructive. Alternations between full manic episodes and depressive episodes Facts and statistics

Average age of onset is 18 years Can begin in childhood Tends to be chronic Suicide is a common consequence

o Bipolar II Disorder: you would have mania that wouldn't be as high, so you'd have depressive periods and then kind of little blips of feeling manic, but not the very high highs that you would see in bipolar one

Alternations between major depressive and hypomanic episodes Facts and statistics

Average age of onset is 22 years Can begin in childhood

10% to 13% of cases progress to full bipolar I disorder Tends to be chronic

o Cyclothymic Disorder: kind of like dysthymic disorder where you're kind of getting ups and downs, but not high peaks that you would in bipolar disorder where you have people being sad and then people up and then people being sad

Chronic version of bipolar disorder Manic and major depressive episodes are less severe Manic or depressive mood states persist for long periods Must last for at least 2 years (1 year for children and adolescents) Facts and statistics

Average age of onset is 12 to 14 years Most are female Cyclothymia tends to be chronic and lifelong High risk for developing bipolar I or II disorder

o Typical pattern: Mania, depression, normal moodo Atypical: Depression, mania normal moodo Rapid cycling: Depression, mania, depression, mania At least 4 times a year.

Little or no normal mood. Really hard to successfully treat Differences in the Course of Mood Disorders

o Course specifiers Longitudinal course

Past history of mood disturbance History of recovery from depression and/or mania

Rapid cycling pattern Applies to bipolar I and II disorder only

Seasonal pattern Episodes covary with changes in the season Many view seasonal affective disorder as a mild form of bipolar

disorder Mood Disorders: Additional Facts and Statistics

o Worldwide lifetime prevalence 16% for major depression

o Sex differences Females are twice as likely to have major depression Gender imbalance disappears after age 65

Why? Possibly because guys often have highly structured environments, women less so?

Differential reward systems? Hormonal variation? Post partum depression

Bipolar disorders equally affect males and femaleso Book: Fundamentally similar in children and adults (Karlin has reservations)o Prevalence of depression seems to be similar across subcultures (Although some

differences. African-americans slightly less. American Indians moreo Relation between anxiety and depression – negative affect

Most depressed persons are anxious Not all anxious persons are depressed

Mood Disorders: Familial and Genetic Influenceso Family Studies

Rate is high in relatives of probands Relatives of bipolar probands tend to have unipolar depression

o Adoption studies – data are mixed o Twin studies

Concordance rates are high in identical twins Severe mood disorders have a strong genetic contribution Heritability rates are higher for females compared to males Vulnerability for unipolar or bipolar disorder

Appears to be inherited separately. Karlin Question: Does that make them separate disorders? What

does that mean for the spectrum view? KQ: Relatives of bipolar probands tend to have unipolar

depression. If really different disorders, how come? Neurological Influences

o Neurotransmitter systems Serotonin and its relation to other neurotransmitters Mood disorders are related to low levels of serotonin Karlin: It ain’t that simple. When SSRIs such as prosac and zoloft are

given, levels of serotonin go up. By the time SSRIs are effective, however, serotonin levels back down to level at which you started. Like diuretics for blood pressure

o Permissive hypothesis: Serotonin (5HT) regulates norepinephrine (NE). NE gets dysregulated with less 5HT.

o Simple notion: low NE + 5HT = Depressiono High DA adds psychotic symptomso The endocrine system

Elevated cortisol Karlin: Current medical thinking: Depression is an inflammatory disease. Whichever: Nerve cell death and disturbance of neurogenesis, especially

in the hypocampus o Sleep disturbance

Hallmark of most mood disorders Relation between depression and sleep and circadian rhythms in general

Psychological Dimensions (Stress)o Stressful life events

Stress is strongly related to mood disorders Poorer response to treatment Longer time before remission

o The relation between context of life events and mood What’s good for you may not be good for others Karlin: Remember the humiliation research. Social rejection related to

depression. E.g. bad marriages go hand in hand w depression. Remember imagainings: Bad marriages cause depression or depression causes bad marriages or both caused by common factor????

At beginning, Stress triggers depression: Think back to imaginings: depression triggers stress?

Reciprocal-gene environment model Psychological Dimensions (Learned Helplessness)

o The learned helplessness theory of depression Lack of perceived control over life events Karlin: Lousy theory of depression. You have to know it, but I don’t have

to teach it. Martin Seligman's theory that people become anxious and depressed when

they make an attribution that they have no control over the stress in their lives (whether or not they actually have control)

o Karlin; Theories authors both at Penn. Are theories related? Beck is better.o Learned helplessness and a depressive attributional style

Internal attributions Negative outcomes are one’s own fault

Stable attributions Believing future negative outcomes will be one’s fault

Global attribution Believing negative events will disrupt many life activities

All three domains contribute to a sense of hopelessness Psychological Dimensions (Cognitive Theory)

o Negative coping styles Depressed persons engage in cognitive errors Tendency to interpret life events negatively

o Types of cognitive errors Arbitrary inference – overemphasize the negative Overgeneralization – negatives apply to all situations

o Cognitive errors and the depressive cognitive triad Think negatively about oneself Think negatively about the world Think negatively about the future In bipolar depression add: Ambitious striving for goals, perfectionism,

self-criticism and often other criticism Social and Cultural Dimensions

o Marital relations Marital dissatisfaction is strongly related to depression This relation is particularly strong in males

o Mood disorders in women Females over males Except bipolar disorders Gender imbalance likely due to socialization Karlin: Read the section on cognitive disorders among women. I think it is

one of the best sections in the book o Social support

Extent of social support is related to depression Lack of social support predicts late onset depression

Substantial social support predicts recovery from depression An Integrated Theory

o Shared biological vulnerability Overactive neurobiological response to stress

o Exposure to stress Activates hormones that affect neurotransmitter systems Turns on certain genes Affects circadian rhythms Activates dormant psychological vulnerabilities Contributes to sense of uncontrollability Fosters a sense of helplessness and hopelessness

o Social and interpersonal relationships/support are moderators Treatment of Mood Disorders: Trycyclic Medications

o Widely used (e.g., Tofranil, Elavil)o Block reuptake

Norepinephrine and other neurotransmitterso Therapeutic effects

Can takes 2 to 8 weeks o Negative side effects are common: Constipation; dry eyes; rapid heartbeato May be lethal in excessive doses Scares MDs for good reason. So, usually,

only psychiatrists prescribe Monoamine Oxidase (MAO) Inhibitors

o Monoamine oxidase (MAO) Block monoamine oxidase This enzyme breaks down serotonin/norepinephrine Slightly more effective than tricyclics Good drugs for smart and compliant patients

o Must avoid foods containing tyramine Examples include beer, red wine, cheese Many patients don’t like the dietary restrictions Karlin: MDs afraid of lawsuits. Think patients are stupid or won’t listen.

Do not know of anyone who even knows anyone who has actually seen a hypertensive (high BP) crisis.

Selective Serotonergic Reuptake Inhibitors (SSRIs)o Specifically block reuptake of serotonin

Fluoxetine (Prozac) is the most popular SSRIo SSRIs pose no unique risk of suicide or violenceo Negative side effects are common

Lithiumo Lithium is a common salt

Primary drug of choice for bipolar disorders Can be toxic

o Side effects may be severe Dosage must be carefully monitored

o Why lithium works remains unclear

o Karlin: All drugs are, in sufficient quantity toxic. Usually toxic level is well above effective level. With lithium, the toxic and effective doses overlap

Electroconvulsive Therapy (ECT)o ECT is often effective for cases of severe depression and when nothing else works

Karlin: Once upon a time, ECT caused permanent damage, mostly due to oxygen deprivation during procedure.

Quite violent seizures in old days Result: Bad rep for ECT Brilliant answer: AN ANAESTHESIOLOGIST Lots of oxygen, no moving around on the table, undetectable side effects

o Now, side effects are few and include short-term memory losso 8-10 sessions administered as oupatient o Karlin: there are advantages and disadvantages to shocking only the nondominant

hemisphere. o You want quick onset and quick offset of seizure. Solution: have another ECT

guy look over the EEG. Then the first doc gets very carefulo Uncertain why ECT workso Relapse is common

Psychosocial Treatmentso Cognitive therapy

Addresses cognitive errors in thinking Also includes behavioral components

o Interpersonal psychotherapy Focuses on problematic interpersonal relationships

o Outcomes with psychological treatments Comparable to medications Research does not suggest advantage for combined treatment Karlin: Better for selected cases, worse for others. Remember

antidepressants can make things worse for people with bipolar aspects. Otherwise, meds can make people able to do psychological treatments.

Meds can add “bounce” to the system The Nature of Suicide

o Facts and Statistics Eighth leading cause of death in the United States. Leading cause of death among young people Overwhelmingly a white and Native American phenomenon Suicide rates are increasing, particularly in the young

o Gender differences Males are more successful at committing suicide than females Females attempt suicide more often than males

o Risk Factors Family History

Suicide in the family Neurobiology

Low serotonin levels

Preexisting psychological disorder Alcohol use and abuse Past suicidal behavior Experience of a shameful/humiliating stressor Publicity about suicide and media coverage

Psychache --Karlino Suicide is a response to unbearable pain. The pain is not physical, but

psychological.o The source of the pain can be and not infrequently is anticipated embarrassment,

rejection, social opprobrium and/or humiliation.o The highest suicide rate is for white males over 50. (Note, not suicide attempt,

completed suicide)o Men who are occupationally successful, but whose status is threatened or lost, are

the most likely to commit suicide Social Rejection -- Karlin

o Notice that it is not the guys who never made it, who are born losers or at least not winners.

o Rather, it is the seemingly successful who kill themselves.o The humiliation/rejection thing works for kids too, to some degree.o They “can’t face” parents or peers for some failure or betrayal.o Leaving to avoid consequences such as prison

Lethality -- Karlino You must assess how lethal are possible ways to kill a patiento A patient with guns needs to be hospitalized. Someone with pills is a little less

dangerous.o Religious beliefs prevent suicide.o Family obligations prevent suicide.o Youth and being female predict suicide attempts, but not completed suicide.o Many people die seemingly unintentionally. For example, someone is supposed to

come home and gets seriously delayed. Treatment for Suicide

o No-suicide Contract: a promise not to do anything remotely connected with suicide without contacting the mental health professional first

If refuses contract and the suicidal risk is high, immediate hospitalization is indicated, even against the will of the patient

o Suicide Prevention Programso Cognitive-behavioral problem-solving approach

Summary of Mood Disorderso All mood disorders share

Gross deviations in mood Common biological and psychological vulnerability

o Occur in children, adults, and the elderlyo Onset, maintenance, and treatment are affected by

Stress Social support

o Suicide is an increasing problem Not unique to mood disorders

o Medications and psychotherapy produce comparable resultso High rates of relapse

Chapter 8 -- Eating and Sleep Disorders

Eating Disorders: An Overview Two major types of DSM-IV-TR eating disorders

o Anorexia nervosa and Bulimia nervosao Severe disruptions in eating behavioro Extreme fear and apprehension about gaining weighto Strong sociocultural origins – Westernized views

Other Subtypes of DSM-IV-TR eating disorderso Binge Eating Disordero Obesity – A growing epidemic

Bulimia Nervosa: Overview and Defining Features Binge eating – hallmark of bulimia

o Binge Eating excess amounts of food

o Eating is perceived as uncontrollable Compensatory Behaviors

o Purging Self-induced vomiting, diuretics, laxatives

o Some exercise excessively, whereas others fast DSM-IV-TR subtypes of bulimia

o Purging subtype – most common subtypeo Nonpurging subtype – about one-third of bulimics

Bulimia Nervosa: Associated Features Associated medical features

o Most are within 10% of target body weighto Purging methods can result in severe medical problems

Erosion of dental enamel, electrolyte imbalance Kidney failure, cardiac arrhythmia, seizures, intestinal problems,

permanent colon damage Associated psychological features

o Most are overly concerned with body shapeo Fear of gaining weighto Most have comorbid psychological disorders

Medical consequences: o Salivary gland enlargement causes by repeated vomiting. The result is a chubby

facial appearance.

o Erosion of dental enamel on the inner surface of the front teeth.o May produce an electrolyte imbalance (i.e., disruption of sodium and potassium

levels) which, in turn, can lead to potentially fatal cardiac arrhythmia and renal failure.

o Intestinal problems resulting from laxative abuse are also potentially serious. Some individuals with bulimia also develop marked calluses on the fingers and backs of

hands resulting from efforts to vomit by stimulating the gag reflex.

Anorexia Nervosa: Overview and Defining Features Successful weight loss – hallmark of anorexia

o Defined as 15% below expected weighto Intense fear of obesity and losing control over eatingo Anorexics show a relentless pursuit of thinnesso Often begins with dieting

DSM-IV-TR subtypes of Anorexiao Restricting subtype – limit caloric intake via diet and fastingo Binge-eating-purging subtype

Associated featureso Most showed marked disturbance in body imageo Most are comorbid for other psychological disorderso Method of weight loss have life threatening consequences

Binge-Eating Disorder: Overview and Defining Features Binge-eating disorder – appendix B of DSM-IV-TR

o Experimental diagnostic categoryo Engage in food binges without compensatory behaviors

Associated Featureso Many persons with binge-eating disorder are obeseo Concerns about shape and weighto Often older than bulimics and anorexicso More psychopathology vs. non-binging obese people

Bulimia and Anorexia: Facts and Statistics Bulimia

o Majority are female – 90%+o Onset around 16 to 19 years of ageo Lifetime prevalence is about 1.1% for females, 0.1% for maleso 6-7% of college women suffer from bulimiao Tends to be chronic if left untreated

Anorexiao Majority are female and whiteo From middle- to upper-middle-class familieso Usually develops around age 13 or early adolescenceo More chronic and resistant to treatment than bulimia

Cross-cultural considerations

Developmental considerations

Causes of Bulimia and Anorexia: Toward an Integrative Model Media and cultural considerations

o Being thin = success, happiness…really?o Cultural imperative for thinness

Translates into dietingo Standards of ideal body size

Change as much as fashiono Media standards of the ideal

Are difficult to achieve Biological Considerations

o Can lead to neurobiological abnormalities Psychological and behavioral considerations

o Low sense of personal control and self-confidenceo Perfectionistic attitudeso Distorted body image Preoccupation with foodo Mood intolerance

Dietary restraint Family influences Biological dimensions Psychological dimensions An integrative model

Medical and Psychological Treatment of Bulimia Nervosa Psychosocial treatments

o Cognitive-behavioral Therapy (CBT) Is the treatment of choice Basic components of CBT

Medical and Drug Treatmentso Antidepressants

Can help reduce binging and purging behavior Are not efficacious in the long-term Tricyclics and SSRI (Prozac) help reduce frequency of binging and

purging Medical Treatment

o Sibutramine (Meridia)o Psychological Treatment

CBT Similar to that used for bulimia Appears efficacious

Interpersonal psychotherapy Equally as effective as CBT

Self-help techniques Also appear effective

Goals of Psychological Treatment of Anorexia Nervosa General goals and strategies

o Weight Restorations First and easiest goal to achieve

o Psychoeducationo Behavioral and cognitive interventions

Target food, weight, body image, thought and emotiono Treatment often involves the familyo Long-term prognosis for anorexia is poorer than bulimiao Preventing eating disorders

Obesity: Background and Overview Not a formal DSM disorder Statistics

o In 2000, 30.5% of adults in the United States were obese; 33.8% in 2008o Mortality Rates

Are close to those associated with smokingo Increasing more rapidly

For teens and young childreno Obesity

Is rapidly growing in developing nations

Obesity and Disordered Eating Patterns Obesity and night eating syndrome

o Occurs in 7-19% of treatment seekerso Occurs in 42% of individuals seeking bariatric surgeryo Patients are wide awake and do not binge eat

Causeso Obesity is related to technological advancemento Genetics account for about 30% of obesity caseso Biological and psychosocial factors contribute as well

Obesity Treatment Treatment

o Moderate success with adultso Greater success with children and adolescents

Treatment progression – from least to most intrusive options First Step

o Self-directed weight loss programs Second Step

o Commercial self-help programs Third Step

o Behavior modifications programs Last Step

o Bariatric surgery

Sleep Disorders: An Overview Two major types of DSM-IV-TR sleep disorders

o Dyssomnias Difficulties in amount, quality, or timing of sleep

o Parasomnias Abnormal behavioral and physiological events during sleep

Assessment of disordered sleep:o Polysomnographic (PSG) evaluation

Electroencephalograph (EEG) – brain wave activity Electrooculograph (EOG) – eye movements Electromyography (EMG) – muscle movements Detailed history, assessment of sleep hygiene and sleep efficiency

o Actigraph -- This instrument records the number of arm movements, and the data can be downloaded into a computer to determine the length and quality of sleep

o Sleep Efficiency (SE)

The Dyssomnias: Overview and Defining Features of Insomnia Insomnia and primary insomnia

o One of the most common sleep disorderso Microsleepso Problems initiating/maintaining sleep, and/or nonrestorative sleepo Primary insomnia – unrelated to any other conditiono 35% of adults report daytime sleepiness

Facts and Statisticso Often associated with medical and/or psychological conditionso Affects females twice as often as males

Associated Featureso Unrealistic expectations about sleepo Believe lack of sleep will be more disruptive than it usually is

An integrated model

The Dyssomnias: Overview and Defining Features of Hypersomnia Hypersomnia and primary hypersomnia

o Sleeping too much or excessive sleepo Experience excessive sleepiness as a problemo Primary hypersomnia – unrelated to any other condition

Facts and Statisticso Often associated with medical and/or psychological conditions

Associated Featureso Complain of sleepiness throughout the dayo Able to sleep throughout the night

The Dyssomnias: Overview and Defining Features of Narcolepsy Narcolepsy – daytime sleepiness and cataplexy

o Cataplexic attacks REM sleep, precipitated by strong emotion

o Facts and Statistics – rare condition Affects about 0.3% to .16% of the population Equally distributed between males and females Onset during adolescence Typically improves over time

o Associated Features Cataplexy, sleep paralysis, and hypnagogic hallucinations Daytime sleepiness does not remit without treatment

The Dyssomnias: Overview of Breathing-Related Sleep Disorders Breathing-related sleep disorders

o Sleepiness during the day and/or disrupted sleep at nighto Sleep Apnea

Restricted air flow and/or brief cessations of breathing Subtypes of Sleep Apnea

o Obstructive sleep apnea (OSA) Airflow stops, but respiratory system works

o Central Sleep Apnea (CSA) Respiratory systems stops for brief periods

o Mixed Sleep Apnea Combination of OSA and CSA

Facts and Statisticso Occurs in 1-2% of populationo More common in maleso Associated with obesity and increasing age

Associated Featureso Persons are usually minimally aware of apnea problemo Often snore, sweat during sleep, wake frequentlyo May have morning headacheso May experience episodes of falling asleep during the day

Circadian Rhythm Sleep Disorders Circadian rhythm disorders

o Disturbed sleep (i.e., either insomnia or excessive sleepiness)o Due to brain’s inability to synchronize day and night

Nature of circadian rhythms and body’s biological clocko Circadian rhythms – do not follow 24hr clocko Suprachiasmatic nucleus

Brain’s biological clock, stimulates melatonino Types of circadian rhythm disorders

Jet lag type Shift work type

Medical Treatments Insomnia

o Benzodiazepines and over-the-counter sleep medicationso Prolonged use

Can cause rebound insomnia, dependenceo Best as short-term solution

Hypersomnia and narcolepsyo Stimulants (i.e., Ritalin)o Cataplexy

Usually treated with antidepressants Breathing-related Sleep Disorders

o May include medications, weight loss, or mechanical devices Circadian Rhythm Sleep Disorders

o Phase delays Moving bedtime later (best approach)

o Phase advances Moving bedtime earlier (more difficult)

o Use of very bright light Trick the brain’s biological clock

Environmental treatments

Psychological Treatments Relaxation and stress reduction

o Reduces stress and assists with sleepo Modify unrealistic expectations about sleep

Stimulus control procedureso Improved sleep hygiene – bedroom is a place for sleepo For children – setting a regular bedtime routine

Combined treatmentso Insomnia – short-term medication plus psychotherapyo Other dyssomnias

Little evidence for the efficacy of combined treatments

The Parasomnias: Nature and General Overview Nature of Parasomnias

o The problem is not with sleep itselfo Problem is abnormal events during sleep, or shortly after waking

Two classes of parasomniaso Those that occur during REM (i.e., dream) sleepo Those that occur during non-REM (i.e., non-dream) sleep

The Parasomnias: Overview of Nightmare Disorder Nightmare disorder

o 10-50% of children and 1% of adults have nightmareso Occurs during REM sleep

o Involves distressful and disturbing dreamso Such dream interfere with daily life functioning and interrupt sleep

Facts and Associated Featureso Dreams often awaken the sleepo Problem is more common in children than adults

Treatmento May involve antidepressants and/or relaxation training