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CHAPTER 14
Psychological
Disorders
Affective Disorders
Affective Disorders
• Affective disorders
– Disorder of mood
– Include depression, bipolar disorder, mania
– Any disorder of affect
• Disorder must be relatively enduring
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Not a change in “mood” per se, but change in ability to regulate mood
Disturbance must last for several months
Set of criteria for each disorder
Emerging question: with available pharmaceuticals, are we overdiagnosing “depression” for normal mood changes?
depression
• Major depression
– Person often feels sad …..but that is an insufficient diagnosis
– Feels extreme:
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hopelessness for weeks at a time
loss of the ability to enjoy life
Disturbances in relationships and sexual interest
loss of energy and appetite
slowness of thought
sleep disturbance.
– In some cases the person is also agitated or restless.
– Stress is often a contributing factor, but major depression can occur for no
apparent reason.
• Depression may appear alone as unipolar depression, or depression
and mania may occur together in bipolar disorder.
mania
• Mania involves
– excess energy and confidence
– often leads to grandiose schemes.
– Typically also involves
• Decreased need to sleep,
• increased sexual drive,
• Often, abuse of drugs or alcohol
• Mania may also appear alone as unipolar mania, or
depression and mania may occur together in bipolar
disorder.
Bipolar disorder
• Individual alternates between periods of depression and
mania.
– Mania can occur without periods of depression, but this is
rare.
– Bipolar patients often show psychotic symptoms
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Delusions
Hallucinations
Paranoia
Other bizarre behavior.
• Incidence rate is fairly high: 4.4% of population in U.S.
• Many “famous” people diagnosed with Bipolar disorder
http://www.youtube.com/watch?v=9ZnAG38CWZI
Bipolar subtypes
• Bipolar I: individual has experienced one or more manic
episodes with or without major depressive episodes.
• Bipolar II: characterized by hypomanic episodes rather
than actual manic episodes
– At least one major depressive episode
– No full manic or mixed episode.
– Hypomanic episodes not show full extremes of mania
– Makes Bipolar II more difficult to diagnose,
• For both Bipolar I and II: number of specifiers that indicate
the presentation and course of the disorder,
– chronic, rapid cycling
– catatonia
– melancholia
Bipolar subtypes
• Bipolar NOS
– Meet criteria for Bipolar disorder
– Not clear whether are type I or type II
– May be comorbid with other disorders
• Rapid cycling
– Most people who meet criteria for bipolar disorder experience a
average of 0.4 to 0.7 cycles per year, lasting three to six months
– defined as having four or more episodes per year
– found in a significant fraction of individuals with bipolar disorder.
Bipolar subtypes
• Cyclothymia
– involves a presence or history of hypomanic episodes
with periods of depression that not meet criteria for
major depressive episodes
– Requires presence of numerous hypomanic episodes
intermingled with depressive episodes
• Again do not meet full criteria for major depressive
episodes.
– low-grade cycling of mood which appears to the
observer as a personality trait, but interferes with
functioning.
Incidence of
affective disorders
• 1 in 5 people (20% of population) will suffer a true mood
disorder in their lifetime, most likely depression.
• Women are 2-3x more likely than men to suffer from unipolar
depression during their lifetime
– May be social/reporting issue however
– Women more likely to report symptoms than men
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• Bipolar illness occurs equally often in both sexes: about 4%.
• Risk
– The risk for major depression increases with age in men,
– Women experience peak risk between the ages of 35 and 45.
– Greatest risk for bipolar disorder: early 20s to around age 30.
Heritability?
• Depression shows fairly high heritability
– When one identical twin has an affective disorder, probability the other
twin will have illness as well is about 69%,
– Only 3% in fraternal twins.
• Mania: Heritability is somewhere around .37
– number somewhat higher for women than for men
– Again, may be reportability issue.
• Bipolar disorder is more heritable, with recent estimates of .85
and .93.
Durg Treatment of
Affective Disorders
• One of first antidepressants = Iproniazid
– introduced as a treatment for tuberculosis
– discovered that the drug produced elevation of mood and was an
effective antidepressant.
• Iproniazid increases activity at monoamine receptors
– Remember: monoamine receptors = dopamine, norepinephrine, and
serotonin
• Led researchers to the monoamine hypothesis
– depression involved reduced activity at norepinephrine, dopamine and
serotonin synapses.
Drug treatments
• All effective antidepressant drugs increase activity of
norepinephrine and serotonin, or both, at the synapses.
• MAO inhibitors: monoamine oxidase inhibitors
– block the destruction of excess monoamines in the terminals
– Include Parnate (tranylcypromine sulfate) and Nardil (phenelzine
sulfate
• Tricyclic antidepressants
– block reuptake at the synapse
– Include Elavil (amytriptaline), amitriptyline, ortriptyline, doxepin and
desipramine
Drug treatments
• Second-generation antidepressants
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Affect a single neurotransmitter or set of neurotransmitters
E.g., SSRIs, serotonin selective reuptake inhibitors
SNRIs: norepinephrine selective reuptake inhibitors
For example, Prozac (fluoxetine); Lexapro, Effexor
• These synaptic effects occur within hours, but symptom
improvement takes two to three weeks.
• Some significant side effects
– Weight loss/gain
– Sexual side effects
Non-drug treatment
• Electroconvulsive therapy (ECT)
– Originally a horrid treatment
• No analgesia
• No control
• Held down and shocked to induce seizure
– But it worked!
• Modern ECT
– Involves applying 70 to 130 volts of electricity to the head of an
anesthetized patient,
– produces a seizure and convulsions.
– Essentially CONTROL-ALT-DELETE
– http://www.youtube.com/watch?v=zYl13Relzbs
Non-drug treatment
• Without the seizure activity in the brain that produces the
convulsions, the treatment does not work.
– Seems to “reset” the brain
– Almost a “Ctrl-Alt-Delete:
• ECT : usually reserved for patients who
– Do not respond to the medications or behavior treatment
– Who cannot take meds due to extreme side effects
• Like drugs, ECT increases sensitivity of postsynaptic
serotonin receptors.
– Produces reduction in sensitivity of autoreceptors on the
terminals of norepinephrine- and dopamine-releasing neurons
– Result is increased release of those transmitters is increased.
Other issues occurring with
Affective Disorders
• Changes in circadian rhythm
– Circadian rhythm: day/light regulatory cycle
• Slightly long than 24 hours
• – tends to be phase advanced in affective disorder patients.
• Patients with depression enter rapid eye movement sleep
(REM) earlier in the night and spend more time in REM than
normal.
• Alternative treatment: change circadian rhythm
– Some patients who unresponsive to medication get relief from
depression by readjusting their circadian rhythm.
– Some depressed patients also benefit from reducing time in REM
sleep.
Seasonal-Affective
Disorders
• Seasonal Affective Disorder(SAD).
– Some people’s depression rises and falls with the seasons: known as SAD
– Most SAD patients more depressed during fall /winter,
– improve in spring and summer.
– Smaller number experience depression in the summer and
improve in the winter.
– What about Southern hemisphere?
• Depression worse in June, July, August
• Their winter!
• Treatment for SAD: Phototherapy
– sit in front of high-intensity lights for couple of hours or more a day.
– Why? Resets circadian rhythm, increases melatonin
– Suggests that depression tied to circadian rhythm
Treatment for bipolar
Disorders
• Lithium
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metal administered in the form of lithium carbonate
Typically the medication of choice for bipolar illness.
It is most effective during the manic phase
also prevents further depressive episodes.
• Why?
– most likely stabilizes neurotransmitter and receptor systems
– prevents the large swings seen in manic-depressive cycling.
Treatment for bipolar
Disorders
• Anticonvulsant medications
– Generally decrease likelihood of action potential
– Next best medication of choice for bipolar illness.
• Include gabapentin (Neurontin), zonisamide (Zonegran)
and topiramate (Topamax); Tegretol, etc.
– Again, works best for manic episodes but also prevents
further depressive episodes.
– Works for similar reasons as lithium
• What about antidepressants for bipolar?
– Generally contraindicated
– Why? May kick start manic episode
– If used, under careful watchful eye of physician/psychologists
Brain changes in
Affective Disorders
• Affective disorders are associated with structural
abnormalities in several brain areas.
– Much like schizophrenia, but slightly different brain areas
• Volume deficits or excesses
– Deficits or decreases in hippocampus, prefrontal areas
– The amygdala is increased in volume.
• All these structural alterations are accompanied by changes in
activity level of those areas
• In most cases, affective disorders are not as debilitating as
schizophrenia
– Most individuals respond well to treatment
– Must change social/life coping skills to prevent relapse
– Only very small percentage is treatment-resistant
Blood flow was decreased (a) in the caudate nucleus and (b) in the
dorsolateral prefrontal cortex (where the arrows point). The color scale
is reversed in the scan in (a); yellow and red in that image indicate
decreased activity.
Increased activity in the ventral
prefrontal cortex and amygdala in
depression
Cognitive Behavioral
Treatments
• Structured, brief psychosocial approach
• Based on premise that problems in vulnerable individuals'
lives and behavioral responses reduce ability to experience
positive reward from their environments
• Aims to systematically increase activation such that patients
may experience greater contact with sources of reward in
their lives and solve life problems
• Focuses directly on activation and on processes that inhibit
activation, such as escape and avoidance behaviors and
ruminative thinking
Cognitive Behavioral
Treatments
• Orient to treatment
– Treatment rationale, including conceptualization of depression and
primary treatment strategies
• Develop treatment goals: Individualize treatment targets
• Reviewing and consolidating treatment and treatment gains
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Identify and set goals
Define and specifically describe problems in behavioral terms
Assesses consequences of behavior
Examine behavioral patterns
Focus on context and consequences of thinking and behavior
• Help client gain positive behavioral strategies that reduce
likelihood of depression
Brain changes in
Affective Disorders
• In most cases, affective disorders are not as
debilitating as schizophrenia
• Most individuals respond well to treatment
• Must change social/life coping skills to prevent relapse
• Most effective therapy:
– Initially drug treatment + cognitive behavioral therapy
– Cognitive behavioral therapy may be sufficient if no crisis
• Only very small percentage is treatment-resistant