DevelopmentStages 1 & 2

Anxiety & Mood Disorders

THE SCIENTIFIC METHODScience is a systematic pursuit of

knowledge through observation Forming a theory Systematically gathering data to test

a theory (Observations must be replicable)

Forming a Hypothesis (what should occur if the theory is true)

Science proceeds by disproving theories

SCIENCE IN MENTAL HEALTHMental health is a term used to describe

either a level of cognitive or emotional wellbeing or an absence of a mental disorder

APA DSM-IV-TR

American Psychiatric Association (2000) Diagnostic and Statistical Manual Revision IV, Text Revision

Reliability & Validity – PsychometricsDSM is so widely accepted that a psychiatrist must classify

their patients’ disorders according to DSM listing number in order to be reimbursed by government of insurance companies

Psychodynamics Childhood experiences help shape adult

personality There are unconscious influences on

behaviour The causes and purposes of human

behaviour are not always obvious

Freud: Psychopathology results from unconscious conflict- Anecdotal evidence, not the scientific method

Benefits of gameplay, maintenance of negative schema internal cognitive processes

Cognitive Behaviourism Thorndike (1874-1949): Law of Effect

Behaviour that is followed by consequences satisfying to the organism will be repeated, and behaviour that is followed by noxious or unpleasant consequences will be discouraged

Skinner (1904-1990): operant conditioning-Positive reinforcement-Negative reinforcement-Automatic reinforcement

Reinforcement of behaviourProblem behaviour is thought to be reinforced

by four possible consequences: Getting attention Escaping from tasks Generating sensory feedback (automatic) Gaining access to desirable things or

situations

Behavioural Treatments

TraumaFearConduct DisorderAutistic Spectrum Disorder

etc

Cognition Perceiving, recognising, conceiving, judging

and Reasoning

The learning process is far more complex than stimulus-response associations (behaviourism)

The learner is an active interpreter of a situation using past experience in a cognitive set/schema

Attention

Individuals with psychopathologies tend to focus their attention on threats or anxiety, producing events or situations in the environment.e.g. “The world is a dangerous place”

Self-fulfilling prophecy

Many people who are depressed believe that they have no important effect on their surroundings regardless of what they do

Developmental Stages Completing a developmental stage supports

the healthy awakening of the next stage Developmental behaviour usually graduates

in sequence along with chronological age

Maslow’s Hierarchy of Needs

Maslow’s Heirarchy of Needs Needs on lower levels must be met before

larger identities can be sustained. Lower identities take their places as no less

important, but supporting of a larger and more powerful whole.

A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.

Stage 1: Womb – 12 months◦ Motor Functions and security

Stage 2: 6 months – 2 years old◦ Mobility and emotion

Stage 3: 18 months – 4 years old◦ Will and action

Stage 4: 4 – 7 years old◦ Social Identity

Stage 5: 7 – 12 years old◦ Social contract

Stage 6: Adolescence◦ Reconstitution

Stage 7: Early Adulthood and Beyond◦ Self-knowledge

Stage 1: Womb – 12 months Formation of the physical body during

prenatal development and infancy Body growth is rapid at this stage Motor operations: suck, eat, digest, grasp,

crawl, stand, walk, manipulate objects, gravity

Little awareness of the outside world Fused symbiosis with the mother No separate sense of self Awareness of survival and physical comfort

Stage 1: Comparative Models Freud: Oral Stage

◦ Oral cavity is primary focus of libidal energy- Characterised by under-nursing: pessimism, envy,

suspicion and sarcasm- Characterised by over-nursing: optimistic, gullible,

admiration for others- Conflicts in nursing: deprivation of sensory pleasure

and mothering

Erikson: Trust vs Mistrust (predictability)

Stage 1: Comparative Models Piaget: Sensory-motor stage 1 & 2

◦ All knowledge is acquired through senses ◦ No sign of object permanence (ability to know

that an object exists when it is out of reach of your senses)

◦ Primary circular reactions: repetition of movement (e.g. touching hand and foot)

◦ Vision can follow moving objects

Stage 1: Psychological Development Basic psychological identity associates with the

physical body. The self is identified with biological urges

- I Am hungry When to eat, When to rest, Limitations of the body Individuality & The feeling of having the right to

exist Independence & The right to take care of ourselves Interaction & The right to have, contain and create

Self-preservation

Stage 1: Trauma Trauma may result in fear, insecurity,

confusion Symptoms of disorganisation or depression Feelings of insanity, excessive thinking Little “grounding” – detachment from body

and basic consensus reality structures Anxiety in mundane tasks, hypervigilance

(high responsiveness to stimuli and constant scanning of environment for threats)

Healthy development teaches security, focus, calm and vigilance

Stage 2: 6 months – 2 years Visual acuity allows the child to focus on

outside objects and gain a wider visual perspective

Awareness grows of objects outside of immediate range

“Hatching” (Mahler) – moving away from mother in brief episodes of independence

Begins to separate self from other eliciting◦ Fear and excitement◦ Diversity and choice

Stage 2: Emotions Primary method of obtaining information

about our well-being

Primary language prior to verbal language

Adds dimension and texture to the mind-body experience

Identification with emotional body◦ I am scared, rather than I have fear

Stage 2: Comparative models Freud: Oral stage

◦ The id: need, sensation and desire is the fundamental cause of motivation.

◦ Seeing something, moving towards it, merging with it (usually through the mouth)

Erikson: ◦ Trust vs mistrust◦ Attachment vs separation

Stage 2: Separation and Connection Separation from the mother corresponds

with separation of self from other

Separation from primary attachment figure leads to binary distinctions

Duality:good-bad, pleasure-pain, closeness-distance, self-other

Stage 2: Trauma Trauma may cause numbness (lack of

feeling), disconnection with self

Difficulty in knowing what we want

Unhealthy sexuality

Excessive inhibition Guilt

Anxiety Disorders ‘Angere’: to choke, to torment Fear: Reaction to immediate danger Anxiety: Apprehension over an anticipated

problem

Both are adaptive strategiesA small degree of anxiety has been found to

improve performance on laboratory tasks

Anxiety Disorders Specific Phobia Panic Disorder Separation Anxiety Disorder Generalised Anxiety Disorder Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder

Anxiety Disorders Phobia: A disruptive fear of a particular

object or situation that is out of proportion to any danger posed

3-5% prevalence in children and adolescents

Anxiety Disorders There is a great deal of overlap

between Axis I Anxiety Disorders and axis II Personality Disorders.

Personality disorders (e.g. Borderline, Paranoid, or Avoidant Personality Disorders) may be considered to evoke contrasting ways of perceiving and coping with Axis I disorders

Children’s Anxiety may not be focused enough to make specific diagnoses useful for intervention.

Culture influences the development of anxiety disorders

Specific Phobias Alliumphobia

Fear of garlic

Musophobia

Fear of mice

Helienophobia

Fear of pseudoscientific terminology

Arachibutyrophobia

Fear of peanut butter sticking to the roof of the mouth

www.phobialist.com

Specific Phobias 2 - 4% prevalence in children More common in girls

Some have clear genetic influences (e.g. snakes, injections)

Social Phobia 1% prevalence in children and adolescents May lead to substance related disorders and

depression 33% concordant with Avoidant Personality

Disorder

Panic Disorder (w/without Agoraphobia Panic attacks:

◦ Intense apprehension, terror, feelings of impending doom

◦ Choking, nausea, sweating, etc.◦ Recurrent, uncued panic attacks

Agoraphobia◦ Anxiety about situations in which it would be

embarassing or difficult to escape

Separation Anxiety Disorder 2 – 4% prevalence from preschool

Specific to children

Often tied to stressful life event of loss/separation

Generalized Anxiety Disorder Unable to let go of a worrisome problem

Typically chronic, beginning in adolescence or late adolescence

Obsessive-Compulsive Disorder (OCD)

2% prevalence, common onset around age 10

Obsessions: ◦ Intrusive and recurring thoughts, images or

impulses that are uncontrollable and come unbidden

◦ e.g. contamination, safety, religious issues Compulsions:

◦ Repetitive, clearly excessive behaviours or mental acts to reduce anxiety caused by obsessive thoughts.

◦ e.g. elaborate rituals of orderliness, repetitive, magically protective acts (superstitions)

◦ Repeatedly checking that these acts are carried out- lack of confidence in memory, unduly

concerned about gaps in memory

Obsessive-Compulsive Disorder (OCD)

78% of compulsives viewed their rituals as rather silly or absurd, but unable to stop performing them.

Rituals allow attention to be drawn away from the obsessions.

This perpetuated the obsessions, as thought supression makes thoughts stronger and more frequent

Exposure and Ritual prevention (ERP)

Post-Traumatic Stress Disorder (PTSD)

Also Acute Stress Disorder

Extreme response to an actual stressor involving threatened death, serious injury, or threat of these.◦ E.g. war veterans, rape victims

Symptoms are categorised under◦ Re-experiencing the trauma (e.g.

night terrors)◦ Avoidance of associated stimuli

(numbing)◦ Increased arousal high anxiety

(problems with sleep and concentration)

Anxiety Disorders Comorbidity

◦ Over 50% of those diagnosed meet criteria for another anxiety disorder

◦ ~60% of people in treatment for Anxiety disorders meet criteria for Depression

◦ Substance disorders and Personality Disorders

Women are twice as likely to be diagnosed with anxiety disorders (except in OCD)

Syndromes are related to beliefs and attitudes of specific cultures

Common Etiology of Anxiety Disorders

Genetic vulnerability Increased activity in the fear circuit of the

brain (amygdala) Decreased functioning of GABA and

serotonin, increased norepinephrine activity Behavioural Inhibition – agitation to new

stimuli in infancy◦ Predictive to a 30% level of development of

social anxiety Neuroticism

◦ Personality trait with a tendency to react with greater than average negative emotion

◦ Twice as likely to develop into an Anxiety Disorder

Cognitive Factors (e.g. attention to cues of threat and low perception of control)

Negative Life events

Common Treatments of Anxiety Disorders Fewer than 20% of people with

Anxiety Disorders receive minimally adequate treatment

Psychological: - Exposure- Cognitive reorganization, rationalizing, etc.

Medical Treatment:Sedatives, tranquilizers and anxiolytics

(“to loosen”)- Benzodiaxepines (e.g. Valium, Xanax) GABA.

- Cognitive and motor side effects memory lapses and addiction

- Antidepressants, tricyclics and SSRIs (e.g. Fluoxetine, Imipraming – Prozac, Zoloft)- Jitteriness, weight gain, high blood pressure,

sexual dysfunction

Mood DisordersE.g. Depression: Depressed mood, inability to experience pleasure, fatigue, concentration problems and suicidal ideation.

Children and adolescents show higher rates of suicide attempts and guilt

Major Depressive Disorder (MDD)Diagnosis

MDD: Sad mood or loss of pleasure for 2 weeks, with at least 4 other symptoms, such as Changes in sleep pattern Change in appetite Problems with attention Feelings of worthlessness Suicidality Not just a single episode

Episodic Disorder: may be periodic, then clearSubclinical depression can remain for yearsDysthymic Disorder (Dysthymia): Chronic

depression for more than half the time for 2 years

DepressionOne of the most prevalent psychiatric disordersAdults:

~ 16.4% of adults are diagnosed with MDD 2.5% with dysthymia

Children & Adolescents:1% in preschoolers2-3% in school-age children7-13% in adolescent (girls)Up to 18% in late adolescentsover 20% in 12-16 year olds (Burns and Rapee, 2006)

Twice as common among girls than boys (women than men) after the age of 12

Twice as common in women (except for Jewish men)Three times more common in impoverished Socio-economic

conditions

DepressionAge of Onset is in late teens, early 20s,

and decreasingVaries culturally

People of Mexican descent are more likely to develop MDD if born in USA

1.5% in Taiwan, 19% in Beirut, LebanonComorbidity:

Two thirds of MDD diagnoses will meet criteria for diagnosis of an anxiety disorder

Comorbid with Anxiety and Substance-related disorders

Bipolar DisorderMania:

A state of intense elation or irritability lasting from weeks to months

Flight of ideasImprudent sexual activities, over-spending,

risk-taking, anger or rageHypomania: less extreme

Bipolar DisorderBipolar I Disorder: “Manic Depressive

Disorder”Bipolar II DisorderCyclothymic Disorder (Cyclothymia)

Chronic mood disorders for at least 2 yearsMild alternative depression and mania

1% Prevalence rate for BPI, 40,000 in Ireland

4% for BPII and Cyclothymia

Bipolar DisorderAverage age is in the 20’s, but is

increasing among children and adolescents

Equal in men and women (more depression in women)

High risk for cardiovascular disease, diabetes, obesity and thyroid disease

Associated with creativity and achievement

Etiology of Mood DisordersGeneticsNeurobiologySocial FactorsPsychological Factors

Etiology of Mood DisordersGenetics:

Heritability estimates of 37% for depression (i.e. 37% of variance in whether or not a person will develop depression is explained by genes)

70% concordance rate for Bipolar Disorder in monozygotic twins 25% in fraternal twins

85% heritability estimates for BP

Genes may guide the way people regulate emotions or respond to life stressors

Etiology of Mood DisordersNeurobiology

Amygdala – elevatedHippocampus – diminishedPrefrontal cortex – diminishedAnterior cingulate – diminished

Assessment of how emotionally important a stimulus is

Effective focusMaking plans based on emotionally

relevant cues

Etiology of Mood DisordersNeurobiologySeratonin regulates norepinephrine and

dopamine.Mania and depression were thought to be

symptoms of low levels of seratonin, but the research indicates otherwise

Sensitivity of neurotransmitter uptake(Poor seratonin sensitivity)

Etiology – Conflicting ResearchDepression is a result of low absolute levels of

neurotransmitters? Antidepressants take 7 to 14 days to relieve depression, by

which time the neurotransmitter levels have already returned to their previous state

Metabolite studies (enzymes that break down neurotransmitters) are not consistent

Caused by low sensitivity of post-synaptic receptors (that detect the presence of a neurotransmitter)

Dopamine can be overly sensitive in Bipolar disorder Depleting tryptophan causes temporary depressive symptoms

relationship with other neurotransmitters Second messengers adjust postsynaptic receptor sensitivity

(e.g. G-proteins – guanine nucleotide-binding proteins)

Etiology of Mood DisordersNeurobiology

Over-activity of the amygdala (threat) during depression causes oversensitivity to emotionally relevant stimuli

Less activity in systems involved in weighing rewards and costs, making decisions and systematically pursuing goals in the face of emotions Feel the fear and Do It Anyway May react with increased emotion, but decreased ability to

plan

In Bipolar Disorder, there are neurological changes in the sensitivity of the reward system Basal ganglia Increased amygdala

Etiology of Bipolar DisorderMania may be a protective ‘mechanism’

against a painful psychological state Grandiosity Compensation

Reflects a disturbance in the reward system (Highly responsive)

Marshmallow Test

Etiology of Mood DisordersCortisol (Stress Hormone)

Hypothalamus-Pituitary-Adrenocortical Axis (HPA)

Signals transmitted from the Amygdala

E.g. Cushings Syndrome- Oversecretion of cortisol- Frequent depressive symptoms

Dexamethasone Supression Test- Should supress corticol secretion- In some mood disorders, it does not

Treatment of DepressionMedication:

Monoamine Oxidase Inhibitors (MAOIs)

Tricyclic AntidepressantsSelective serotonin reuptake inhibitors

(SSRIs)(e.g. Fluoxetine, Imipramine – Prozac,

Zoloft)50-70% show improvementSuicidality associated with SSRIsRelapse is common after drugs are

withdrawn

Treatment of DepressionElectroconvulsive Therapy (ECT)

Only used in cases that do not respond to medication

Involve deliberate induction of seizure and momentary unconsciousness by passing a current of 70-130V through the non-dominant brain hemisphere

Short-acting anesthetic and strong muscle relaxant administered

ECT is the most reliable treatment available for depression with psychotic features

We don’t know why it works.

Treatment of Bipolar DisorderMedication: Lithium

mostly for prevention of manic episodes

Lithium toxicity – tremor, nausea, confusion, seizure, coma, death

Olanzapine (antipsychotic) e.g. Haldol

Treatment of Bipolar DisorderPsychoeducational approaches

Family-focused Treatment (FFT) High Expressed Emotion (EE) predicts faster

relapse

Childhood Depression in Ireland90% of Irish Child Psychiatrists prescribed

psychotropic drugsThe prevalence of use of medication was

lowest at 8% in Denmark

75% of MDD cases do not receive effective treatment

May stop treatment early Too low dosage

Childhood Depression in IrelandNo anti-depressant medications are licensed for use in

children (up to 18 years of age) in Ireland. This is mainly the case because of the expense involved in clinical trials to be undertaken by drug companies to have these products licensed. Some trials are being conducted in the US at the moment.

Doctors do have the discretion to prescribe any medication they deem necessary for their patient of any age.

The Irish Medicines Board has acknowledged that depression can be a serious condition in children and that drug treatment may be necessary. They are currently working on guidelines and have issued a warning about the use of Seroxat as it increases the risk of agitation.

Fitzpatrick Coping with Depression in Young People

Treatment of DepressionInterpersonal Psychotherapy

Focus on current life, rather than trauma Transitions, conflicts, bereavement Decision making, techniques to improve communication

etc Prevents relapse

Cognitive Therapy Altering maladaptive thought patters More successful than imipramine (tricyclic

antidepressant)Mindfulness-based Cognitive therapy

Decentered perspective “I am not my thoughts”

Etiology of Mood DisordersSocial FactorsStressful life events

42-67% of depression occurs within a year of a major stressful life event

Long-term chronic stressorse.g. poverty

Vulnerability to stressLack of social support

Support minimises the effect of social stressorsE.g. 40% prevalence in women without confidants, 4% in

women with confidantsInterpersonal relations

Depressive symptoms elicit negative reactionsExcessive reassurance seeking results in rejection

Etiology of Mood DisordersPsychological FactorsAffect

Negative affect: distress and worryPositive affect: happiness, contentmentSomatic arousal

Negative Affect Positive Affect Somatic Arousal

Depressive Disorders High Low Moderate

Anxiety Disorders High Moderate High

Comorbidity of Depressive and Axiety Disorders

High Low High

Etiology of Depression Schemata:

Pay more attention to negative stimuli Remembers negative information more than positive

information Hopelessness Theory

Feeling of being in an uncontrollable aversive situation (e.g. abusive family)

1. “Desirable outcomes will not occur”2. “I cannot change my situation”

Neuroticism predicts the onset of depression Remember: Genes + Stressful Life Event risk

of depression

Nutritional TreatmentPotential therapeutic benefit of n-3

polyunsaturated fatty acids (Omega 3)Vitamin B12, B3 - necessary for the

synthesis of red blood cells, the maintenance of the nervous system and growth and development in children deficiency of this particular vitamin results in

an build up of a compound called homocysteine - this may enhance depression.

Depression in Children Early onset depression Depression with an onset in early adolescence

Remember: 2% children 4% mid adolescent 18% late adolescent

Behaviours to note: Chronic sadness and/or irritability Decline in interest in activity Sleep disturbance, fatigue, appetite change Worthlessness, concentration problems Withdrawn, social exclusion Poor concentration

Children12-20% children and adolescents would be

diagnosed with anxiety disorders

Parent-Child relationships – criticism, hostility

Suicide10-20% of people report suicidal ideation2-5% make attempts7% deliberately harm themselves.

Men are 4 times more likely to kill themselves60% of all suicides are with guns

Up to 90% of people who attempt suicide are suffering from mental illness (usually comorbid with Depression or Borderline Personality Disorder)

Suicide is now the leading cause of death in young men in the 15-24 year old age range

Suicide in IrelandIn a study of suicide victims in Dublin over a year

it was found that 70% were male, 35% had previously attempted suicide, and 53% saw a Doctor in the previous month. 44% experienced hopeless feelings.

The Central Statistics Office at the time the study was done underestimated the suicide rate by 20%

An eight year follow-up of attempted suicide found that 2 out of the 26 had died and 19% had further suicide attempts

SuicidePossible Reasons

Few ties to family or community Atruism: for the good of society Anomic – sudden change in persons relation to

society (e.g. in rural china, suicide is one of the leading causes of death)

Retaliation – to induce guilt in others To force love/attention from others To rejoin a dead loved one Sociocultural models (suicide rose 12% after

Marilyn Monroe’s suicide)

Prevention of Suicide Who is at Higest Risk?

Desire to escape aversive self-awareness Problem-solving deficits Hopelessness

Prevention1. Reduce intense psychological pain2. Help the person see options other than

suffering3. Encourage the person to pull back from the

self-destructive act Reasons for Living Inventory Suicide prevention centres Phone services

Prevention of SuicidePsychoeducation

“Mental Health Literacy”, help-seeking adolescents do not consider doctors appropriate

helpers for a depressed peer in-adequate service provision

Cognitive RestructuringExposureModelingSkills trainingRelapse prevention

Prevention of Suicide