Mood Disorders. how turbulent emotions can push us way down or too high

Transcription

1 Mood Disorders how turbulent emotions can push us way down or too high

2 Overview Two basic types Those that involve only depressive symptoms, and Those that involve manic symptoms sometimes alternating with depression The latter is often labeled bipolar Also, DSM 5 added two new mds disruptive mood dysregulation & premenstrual dysphoric

3 The Depressive Disorders in general Overriding symptoms deep sadness and/or inability to experience pleasure These feelings far exceed normal blues and are different from typical grief Styron.. A despairing, unchanging paralysis of the spirit

4 Major Depressive Disorder - Other symptoms Cognitive pervasive thoughts concerning guilt, death, suicide, trouble with decesions, trouble concentrating Physiological sleep troubles, too little, too much, early waking, slowing of movements psychomotor retardation, or excessive physical restlessness psychomotor agitation, wight loss or gain, lack of energy

5 More re MDD diagnosis Need five of listed symptoms Must have a duration of at least 2 or more weeks Nearly everyday, most of the day An episodic disorder symptoms come and go All sorts of variation re duration and intensitysome are chronic and never fully recover

6 Recurrence For most (2/3) it s not a one time thing Most endure four The more you experience, the more likely it ll happen again 16% greater chance of return with every bout Recurrence predicts a worse outcome than the initial number of symptoms

7 Dysthymia Persistent Depressive Disorder If at least two symptoms persist (most of the day, ½ of the days) for at least two years Overwhelming majority will develop MDD over 10 years

8 Common? Sure is Estimate that 16% of us will develop MDD at some point Only 2.5 % get Dysthemia Women are twice as likely to experience Poor three times Rates vary widely from one culture to another

9 More More distance from equator, more MDD SAD More fish consumed, less More, and younger, victims recently not sure why MDD and Dysthemia are often comorbid with anxiety type mds Also, substance abuse, personality disorders, and sex dysfunction

10 Consequences Disability Shortened life-span Suicide Death from other diseases, especially cardiovascular Chronic nature of dysthemia makes it even more dangerous

11 Bipolar disorders Must involve some type of mania intense elation or irritability, along with excessive talkativeness, big plans, flight of ideas, increased activity and poor insight These symptoms are markedly different from normal activities Bipolar I just mania necessary Bipolar II mania and depression

12 Bipolar I Simple criteria, just one manic episode 1) lasts at least a week 2) leads to hospitalization, psychosis 3) significant distress or impairment Great chance of recurrence Most endure at least 4 episodes

13 Bipolar II Milder symptoms At least one major depressive episode, and 1 episode of hypomania similar to mania but without the severe functional problems

14 Cyclothymic Disorder Another chronic mood disorder 2 year minimum Mild depression alternating with mild mania

15 Prevalence Bipolar I is relatively rare, only.6% But in the US it s 1% Diagnoses of Bipolar II are unreliable Best estimate 4% For either Bipolar, men=women But for Depression, more women are affected

16 Severity Bipolar I is a severe md Big trouble getting or keeping jobs High suicide rates Many have serious health problems Mortality high Those just with cyclothymia have greater chance of developing BI And bipolar does not increase creativity

17 What causes mood disorders? Many factors seem to be responsible While there are many mood disorders, studies have focused on uncovering the cause of Bipolar I and MDD Neurobiological and psychosocial explanations have proven most fruitful

18 Neurobiological roots Genetics varies in importance between MDD & BI MDD heritability is 37%, but higher with more severe cases BI 93%! drawn from a community, not treatment But molecular studies have failed to reliably locate the specific genes responsible

19 Insights from genetic studies Though we haven t found a smoking gun we now can conclude that: 1) variants of the serotonin transporter gene might make us more vulnerable to depression, and that 2) types of a gene which controls dopamine (DRD4.2) might lead to MD

20 Neurotransmitters Three appear to have influence serotonin, dopamine and norepinephrine All are widespread in the brain Dopamine, for example, guides systems that motivate us to achieve reward If these systems don t work, we endure the lack of pleasure, motivation, and energy we find in MDD

21 How do neurotransmitters cause mood disorders? Despite what was presumed, it s not just how much of these are present in the synapse Instead problems might arise from the sensitivity of post-synaptic receptors Excesses of dopamine can trigger manic episodes Decreasing serotonin can cause depression & Bi if there is a family history of depression

22 Looking at the brain Two ways to investigate Structural studies are parts of the brain larger or smaller than controls? Functional studies does the area work differently? inspect blood flow

23 Structural Brain Studies Show obvious changes in those who have endured numerous MDD episodes

24 Functional Studies Four areas are especially noteworthy for MDD/B1 sufferers The hippocampus is relatively inactive when exposed to emotional stimuli The dorsolateral prefrontal cortex is inactive during attempts to regulate emotion In contrast, the subgenual anterior cingulate is too active

25 The amygdala Allows us to instantly assess how important a stimulus is, especially alert to danger MDD/B1 victims show overreactivity to emotional stimulus compared to others This makes people more vulnerable In sum, hyperactive amygdala can t be controlled by other structures, so MDD/B1 results

26 The Neuroendocrine System The amygdala activates the hypothalamicpituitary-adrenocortical axis (HPA axis) This causes cortisol to be released If the amygdala over reacts, too much cortisol Also some have trouble decreasing levels High cortisol has been linked to MDD & B1 If cortisol stays high high odds of relapse

27 Life stresses and Depression Neurobiological problems provide diathesis Stress arises from adverse life events It appears that stress can cause depression 42-67% of MDD cases - big stress year before Loss of job, break-up, humiliation, etc. Crucial in precipitating first event Not so much subsequent

28 Why are some susceptible? Risk factors whether physiological or social Another risk factor is poor or nonexistent social support Can increase chances of sustaining depression ten fold (from 4% to 40%) Marital discord and negative family reactions, Expressed Emotion, can trigger Of course, MDD can lead to interpersonal woe

29 Can social support help? Sadly, even sincere reassurance from others only temporarily holds off depression Constant needs can eventually stir annoyance and hostility

30 Psychological factors in Depression Sometimes psychological factors provide the risk factor (diatheses) One of the Big 5 personality traits can provide the diatheses Neuroticism the tendency to be overly sensitive to adverse stimulus People high in this trait are more likely to suffer from depression and anxiety

31 Cognitive risks Cognitivists argue that negative thoughts and beliefs can cause depression Three theories attempt to explain this 1) Beck s Negative Triad, 2) Hopelessness theory, and 3) Rumination theory

32 Beck s view Depression can be caused by negative views of the self, the world the person encounters, and the future The Negative Triad As children, these people developed negative schemas beliefs and attitudes which unknowingly influence and organize their perception of the world and what happens to them

33 Where do these negative schemas originate? Schemas arise from unpleasant childhood experiences such as 1) death of a parent, 2) rejection of peer group, or 3) a depressed parent. Whenever they encounter a situation similar to these, the schema rises up and causes depressive thoughts

34 From schema to bias The schema then causes them to interpret certain situations in a negative way Focus on negative comments, experiences Worse yet, the schema can cause them to overlook their strengths and successes Self-perpetuating the schema causes people to look for facts that corroborate it, further strenghthening it.

35 Does Beck s theory hold up? Clear that the depressed have negative thoughts People with depression do focus on, and remember, negative information However, studies are inconsistent as to whether negative thinking causes depression or vice versa

36 Hopelessness Theory is based on two assumptions: 1) nothing good will happen, and 2) nothing can change this. Can explain the lack of motivation, sadness, thoughts of suicide, decreased energy, psychomotor problems, etc. that sufferers experience

37 How does hopelessness arise? Life events These are attributed (explained) in two ways 1) as stable versus temporary, and 2) as global (effects entire life) or specific Those who consider their problems to be both stable and global will experience hopelessness and this could lead to depression Studies have corroborated these

38 The danger of Rumination The tendency to mull over negative events excessively can increase depression risk Worst type endlessly thinking about how a sad event happened Women suffer from this more Interferes w/ problem solving, and increases negative moods Antidote? distraction

39 Big Picture causes of depression Genetic flaws in transporting serotonin can predispose to depression after adverse life event Also can cause problems for the amygdala

40 Social/Psychological causes of B1 Triggers for depressive episodes for B1 are similar to MDD negative life events, neuroticism, lack of support, etc. But what predicts mania?

41 Mania Predictors 1)Reward Sensitivity getting rewards, or, especially, achieving a major life goal pushes them into a manic state & frantic goal pursuit Excessively boosts self-confidence? 2) Sleep Disruption play around w/ someone s sleep/circadian rhythm and mania might result In contrast, protecting sleep prevents mania

42 Treatment of Mood Disorders While most mood disorders pass through the passage of time every day they endure can be devastating, expensive, even deadly Treatment is essential & the sooner the better Lots of treatment is given 180 million/year! But, amazingly, ½ of victims receive none

43 Psychological Treatments Interpersonal focuses on relationship problems conflicts, transitions & isolation Therapy involves identifying feelings, making choices, and adapting to resolve issues Effective in a variety of contexts Treatments are typically brief 16 sessions

44 Cognitive Therapy Focus change maladaptive thought patterns Challenge negative generalizations Monitor thoughts, identify defeating patterns Encourage rational, positive self-assessment Behavioral activation schedule positive behaviors that will help build a + self-image Effective for current episodes and in preventing relapses, even for most vulnerable

45 CT cont. Computer programs can deliver CT Mindfulness-based CT (MBCT) is effective in preventing relapse People are trained to recognize the first onset of relapse and then to separate himself from depressing thoughts and feelings Works best for those w/ 3 or more episodes

46 Psychological Treatment of Bipolar Used to supplement meds& diminish depression Psychoeducational Approaches carefully explain the illness 1) symptoms, 2) duration, 3) warning signs 4) treatments helps med compliance

47 Is psychotherapy justified? After all, everyone w/ BI should be medicated Big study looked at Bi w/ current depression Everyone received meds Some got psychotherapy (CT, Family Therapy) Others just brief collaborative care Everyone who got psychotherapy, of whatever type, did better than collaborative group

48 Electroconvulsive Therapy (ECT) Controversial and hard to watch Intentionally produce a seizure ( volts!) Amnesia (limited) can follow Only tried when meds don t work Most powerful treatment available Not sure why it works, but it does With suicide a real possibility..

49 Meds for Depressive Disorders Most common and best researched treatment Three types: 1) Monoamine oxidase inhibitors (MAOIs) 2) Tricyclic antidepressants 3) Selective Serotonin Reuptake Inhibitors All three are equally effective But substantial concern remains regarding studies biased towards positive findings?

50 Do meds reliably cure depression? Big, comprehensive, innovative study revealed: 1) only 1/3 were symptom free from SSRI use 2) few who failed would help pay for CT 3) if switched to a second med, only 30% 4) even fewer responded to 3 rd or 4 th 13% 5) many suffered relapses 6) only 43% enjoyed a sustained recovery

51 Why do meds often fail? Seem to work better for more severe cases 40% stop after less than a month side effects, especially MAOI s Even with SSRIs slight chance of suicidality Even if they work, relapse is common after meds stop continuing to take drops relapse from 40% to 20%

52 Therapy vs. Meds? Combining increases chances for recovery by 10 to 20% Meds work faster but therapy provides skills that can work for years In an impressive direct comparison: a) both worked better than placebos b) CT = Meds c) CT was cheaper & more effective long term

53 Lithium and Bipolar Mood-stabilizing medications are used Lithium first and foremost (helps 80%) Still substantial threat of relapse (40%) even while taking Lithium Dangerous, must be followed carefully Most need to take forever

54 More lithium If its side effects are too much, alternatives are available Often taken in combination w/ other meds, especially in acute situations Can help reduce depression but often fails Combining is questionable 1) not sure they add anything beneficial 2) can increase odds of mania returning

55 Therapies all seem to change crucial brain areas Meds & CT cause neuron growth in hippocampus Receptor sensitivity has emerged as important Controlling G-proteins seems important

56 Suicide A bleak but essential topic Dramatic, often debilitating effect on survivors Ideation thinking about doing it Attempts trying to do it Suicide succeeding

57 Facts & Figures Around 25k in US/year 1 of every 20 attempts succeeds 9% consider at some point 2.5 % attempt Men are much more likely to succeed Risk increases w/ age, but more youth try now Guns Divorce increases risk fourfold

58 Why? Mds 90% suffer, especially depression Neurobiological moderate heritability, serotonin dysfunction Social copying celebrities, social isolation Psychological hopelessness, poor problem solving, impulsivity

59 Prevention Discussion Be wary of warning signs, most are ambivalent and will tip their hand in some manner Treat the underlying md psychotherapy (especially CT) and meds both reduce risk