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Chapter 5 Mood Disorders and Suicide Copyright © 2006 Pearson Education Canada Inc. Overview Several terms to describe problems associated with emotional response systems – – – – Emotion Affect Mood Clinical Syndrome Copyright © 2006 Pearson Education Canada Inc. 2 Overview Emotion - refers to a state of arousal that is defined by subjective states of feelings, such as sadness, anger, and happiness. Affect - refers to pattern of observable behaviours associated with emotions (e.g. facial expression, voice pitch). Mood - refers to a pervasive and sustained emotional response that can influence a person’s perception of the world (e.g. depressed mood). Clinical Syndrome - is a combination of emotional, cognitive, and behavioural symptoms associated with a depressed mood (e.g. clinical depression). Copyright © 2006 Pearson Education Canada Inc. 3 Overview How can we differentiate between normal sadness & clinical depression? 1. The mood change is pervasive across situations and persistent over time. 2. The mood change may occur in the absence of any precipitating events. 3. The depressed mood impairs social and occupational functioning. 4. The change in mood is accompanied symptoms that include cognitive, somatic, and behavioral features. 5. The nature of the mood change is different than normal sadness. Copyright © 2006 Pearson Education Canada Inc. 4 Overview Mood disorders - are defined in terms of episodes – discreet periods of time in which the person’s behaviour dominated by depressed or manic mood or both. Copyright © 2006 Pearson Education Canada Inc. 5 Symptoms & Features emotional symptoms cognitive symptoms somatic symptoms behavioural symptoms Copyright © 2006 Pearson Education Canada Inc. 6 Emotional Symptoms brief negative emotions serve a useful communicating function prolonged, intense emotions become problematic to our daily functioning dysphoric mood (e.g. feeling gloomy), anxiety In mania there is euphoria, elation, as well as irritability Copyright © 2006 Pearson Education Canada Inc. 7 Cognitive Symptoms changes in the way people think unrealistic expectations preoccupations and cognitive distortions thinking slowed down or sped up memory difficulties self-blame Suicidal ideation Copyright © 2006 Pearson Education Canada Inc. 8 Somatic Symptoms Clinically significant changes in: – – – – – – fatigue aches & pains sleep patterns appetite hygiene Sexual drive Copyright © 2006 Pearson Education Canada Inc. 9 Behavioural Symptoms apparent lack of caring for others changes in the things people do and how they do them psychomotor retardation in depressed individuals sped up, impulsive behaviour in mania Copyright © 2006 Pearson Education Canada Inc. 10 Contemporary Perspective Unipolar Disorders – – dysthymia major depressive disorder Bipolar Disorders – – – – bipolar I bipolar II cyclothymic disorder Mixed episode Copyright © 2006 Pearson Education Canada Inc. 11 Copyright © 2006 Pearson Education Canada Inc. Dysthymia Represents a chronic mild depressive condition that has been present for many years (i.e., at least 2) - depressed mood most of the day on more days than not, plus 2 or more of the following: – – – – – – Poor appetite or overeating Insomnia or hypersomnia Low energy Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness Copyright © 2006 Pearson Education Canada Inc. 13 Copyright © 2006 Pearson Education Canada Inc. Copyright © 2006 Pearson Education Canada Inc. Bipolar II A person who has experienced at least one major depressive episode, at least one hypomanic episode, and no full blown manic episodes. Hypomania - episodes of increased energy that is not as severe as full blown mania. Cyclothymia - numerous hypomanic episodes and numerous periods of depression during a 2 year period. Mixed Episode – The criteria is met for a manic and major depressive episode for 1 week period. Copyright © 2006 Pearson Education Canada Inc. 16 Subtypes and Descriptors episode specifiers – – – – Early vs. late onset psychotic post-partum onset melancholia severe form of depression possible different etiology biological treatments successful course specifiers – – seasonal affective disorder rapid cycling denotes poor prognosis for bipolar disorder Copyright © 2006 Pearson Education Canada Inc. 17 Course and Outcome Unipolar Disorders – – – – onset generally in middle age, average age is mid 40s 10% have depression for 2 years 50% will recover within 6 months of those, 50% will relapse in 3 years Bipolar Disorders – – – – onset typically between 28-33 yrs - 1% of population could start as manic or depressive average duration of an episode: 2-3 months Onset is gradual - 5 - 15% will be rapid cyclers 18 Copyright © 2006 Pearson Education Canada Inc. Comorbidity 40% of alcohol dependent people are alcohol dependent – Anxiety disorder and depression is closely linked – Psychotic features – Copyright © 2006 Pearson Education Canada Inc. 19 Epidemiology incidence/prevalence – – gender – – difficult to measure as many people do not seek treatment Approximately 30% seek treatment women are far more vulnerable to depression 12% women and 7% males culture – – depression is a universal phenomena Higher in some cultures (e.g., Aboriginal Canadians) Copyright © 2006 Pearson Education Canada Inc. 20 Epidemiology Lifespan Risk – – most frequent among young and middle-aged adults Elderly is hard to diagnose Cross-Generational Comparisons – People born after WW II more likely to develop a mood disorder then previous generations Copyright © 2006 Pearson Education Canada Inc. 21 Etiological Considerations Social Factors – – Depression: Stressful life events Bipolar: goal-attainment events Psychological factors – Cognitive vulnerability Copyright © 2006 Pearson Education Canada Inc. 22 Etiological Considerations: Cognitive Theory Beck’s theories: – – – – distortions leading to and sustaining depression depressive triad (demeaning sense of self, world, others) negative schema formation ABCD Model hopelessness – – refers to the person’s negative expectations about future events and the associated belief that these events cannot be controlled depressogenic attributional style Copyright © 2006 Pearson Education Canada Inc. 23 Etiological Considerations: Interpersonal Factors certain people create difficult circumstances that increase stress self-critical people elicit criticism and rejection from others person’s own behaviour causes negative life events Copyright © 2006 Pearson Education Canada Inc. 24 Specific Interpersonal Factors A) social relationships – – – negative effects on others’ moods negative interactions smaller social networks B) response styles & gender – ruminative vs. distracting style Copyright © 2006 Pearson Education Canada Inc. 25 Biological Factors: Genetics family studies twin studies – – genetic risk/sensitivity to stress – heritability of depression: 52% 80% for bipolar disorder predisposition to coping ability mode of transmission & linkage studies – – single-gene vs. polygenic chromosome 18: bipolar Copyright © 2006 Pearson Education Canada Inc. 26 Twin study DANISH STUDY: Bertelson (1977) bipolar probands MZ 69 % DZ 19 % unipolar probands MZ 54 % DZ 24 % Copyright © 2006 Pearson Education Canada Inc. 27 Biological Factors: Neurotransmitters catecholamine hypothesis (not enough norepinephrine) SSRIs (selective serotonin reuptake inhibitors) – – – – block re-uptake of serotonin 6-8 weeks for optimal effectiveness Prozac, Paxil, Zoloft Side effects are less severe, however, the side effects are weight gain, headaches, sexual dysfunction Copyright © 2006 Pearson Education Canada Inc. 28 Treatment: Unipolar Disorders Cognitive Therapy – Interpersonal Therapy – alter maladaptive schemas focus on relationships Antidepressant medications – – – SSRIs TCAs (dopamine, norepinepherine) MAOIs Copyright © 2006 Pearson Education Canada Inc. 29 Depression Medications 40-50% improve 20-30 improve partially 20-25 do not respond at all Copyright © 2006 Pearson Education Canada Inc. 30 Treatment: Bipolar Disorders Lithium – 75% success rate anticonvulsant medications – 60% success rate psychotherapy Copyright © 2006 Pearson Education Canada Inc. 31 Electroconvulsive Therapy (ECT) severe cases/last resort Unilateral vs. bilateral 2-3 sessions per week, 6-8 session overall reason for effectiveness not understood ethics of ECT controversial Pervasive and persistant Memory losss Copyright © 2006 Pearson Education Canada Inc. 32 Suicide 15-20% of mood disordered patients commit suicide 50% of completed suicides occur as a result of a mood disorder Suicide rates among Canadian adolescents have doubled over the past 30 years Ratio of attempted suicides to completed suicides are 10:1 More women than men attempt suicide, however, men are 4x more likely to kill themselves Copyright © 2006 Pearson Education Canada Inc. 33 Suicide: Durkheim’s Classification egoistic – altruistic – sacrifice self for the group anomic – sense of meaninglessness social crisis fatalistic – traumatic conditions Copyright © 2006 Pearson Education Canada Inc. 34 Treatment of Suicidal Individuals: crisis centres/hot lines medication involuntary hospitalization psychotherapy – – – – reduce lethality negotiate agreements offer support expand perspective Copyright © 2006 Pearson Education Canada Inc. 35