CPch5 - Mood disorders

Question 1

Mood disorders

Answer 1

Involve profound disturbances in emotion - from the deep sadness and disengagement of depression to the extreme elation and irritability of mania

Question 2

What is affect?

Answer 2

Feeling
Mood and emotion fall under this umbrella

Question 3

What is mood?

Answer 3

Long duration, not directed at an/one object
Mostly bias cognition - think differently depending on the mood
e.g. angry, sad, happy, anxious

Question 4

What is emotion

Answer 4

Short-lived, directed at an object
Bias cognition and (immediate) action
Basic: fear, anger, sadness, happiness, disgust, suprise, etc

Question 5

What are the two approaches to mood?

Answer 5

1. Feeling theory of moods
2. Dispositional theory of moods

Question 6

Feeling theory of moods

Answer 6

Moods are raw feelings (i.e. objectless)
Feeling sad, feeling angry
These also make up the core of emotions, which are more complex

Question 7

Dispositional theory of moods

Answer 7

Mood generates cognitions and mood-congruent appraisals
Being in a sad mood = appraising situations as uncontrollable
Being in an angry mood = appraising situations as threatening

Question 8

When does mood become a problem - pathology? Why is depression/mania dysfunctional?

Answer 8

Symptoms must cause the individual clinically significant distress and impairment in social, occupational, or other important areas of functioning
The symptoms must also not be a result of substance abuse or another medical condition

Question 9

What are the 2 poles of mood disorders

Answer 9

Mania > hypomania > normal elation > neutral/balanced mood > normal sadness > mild - moderate depression > major depressive disorder

Question 10

Two types of mood disorders

Answer 10

1. Depressive symptoms (unipolar depressive symptoms)
2. Manic symptoms (bipolar disorders)

Question 11

What is the difference between unipolar and bipolar mood disorder?

Answer 11

Bipolar - switch between mania and depression
Unipolar - stay on one side of the pole (e.g. Major Depressive Disorder (MDD))

Question 12

DSM-5 Major unipolar depressive disorders

Answer 12

1. Major depressive disorder
2. Persistent depressive disorder
3. Premenstrual dysphoric disorder - mood symptoms in the week before menstruation
4. Disruptive mood dysregulation disorder - severe recurrent temper outbursts and persistent negative mood for at least 1 year beginning before age 10

Question 13

What are the major bipolar disorders according to the DSM-5?

Answer 13

1. Bipoler I disorder
2. Bipolar II disorder
3. Cyclothymia - recurrent mood changes from high to low for at least 2 years, without hypomanic or depressive episodes; the symptoms present at least 1/2 the time for more than 2 months at a time

Question 14

Why is prevalence important to know in psychological disorders?

Answer 14

We can decide how likely it is that a patient coming in has or has not a disorder and maybe start the tests for the most prevalent disorders that match the presented symptoms

Question 15

What is the prevalence of mood disorders?

Answer 15

Lifetime - MDD 18.7% (one of the most prevalent of psych. dis.), Dysthymia (PDD) 1.3%, Bipolar 1.3%
↪ More prevalent in females (more likely to experience sexual violence or cultural stress, cost of caring, hormones, more inclined to externelize and verbalise feelings)
Chronicity - MDD 27.8% (turns into PDD), Dysthymia 65.9%, Bipolar 63.5%

Question 16

How is the chronicity after treatment? And what are the % of people who return to treatement later in life?

Answer 16

80% recovers within 12 months
Relapse/return to clinic:
* 25-40% within 2 yrs
* 60% within 5 yrs
* 91% within 20 yrs

Treatements effective but high relapse - treating symptoms not the disorder

Question 17

MDD DSM-5 criteria

Answer 17

5 or more symptoms nearly every day, most of the day, at least 2 weeks:
Affect
1. Sad mood OR
2. Loss of interest or pleasure (anhedonia)
↪ one of these must be present
Physical
Plus 3 or 4 of the following:
3. Poor appetite and weight loss, or increased appetite and weight gain
4. Loss of energy
5. Psychomotor retardation (slow thoughts and movements) or agitation (pacing, fidgeting, wringing hands)
6. Sleeping too much or too little
Cognitive
7. Feelings of worthlessness or excessive guilt
8. Difficulty concentrating, thinking, or making decisions
9. Recurrent thoughts of death or suicide

Question 18

What is the criticism of the criteria in DSM-5 to diagnose MDD?

Answer 18

It requires 5 symptoms to be present but little evidence present to support this threshold
↪ depressive severity - increases in functional imparememt and suicidality as the number of symptoms increases

Question 19

Persistent Depressive Disorder + DSM - 5 criteria

Answer 19

Depressed mood for at least 2 years (>1/2 of days)
↪ or 1 year with children and adolescents
Combines DSM-IV Dysthymia & MDD, chronic subtype
PLUS 2 other symptoms
1. Feelings of hopelessness
2. Sleeping too much or too little
3. Poor appetite or overeating
4. Trouble concentrating or making decisions
5. Poor self-esteem

Question 20

Biological etiology of depression

Part of bio-psycho-social model of depression

Answer 20

1. Heritability 37% (more severe, higher)
2. Serotonin/dopamine (dopamine system disrupted - less responsive to drugs increasing dopamine levels)
3. Several brain regions
4. Cortisol dysregulation
5. Pro-inflammatory cytokines - prolonged inflammation > sickness behaviour seen in depression: decreased motor activity, reduced food consumption, social withdrawal, disturbed sleep patterns…

Question 21

Biological etiology

Brain regions involved in depression

Answer 21

• Amygdala - overreactivity to emotion-relevant stimuli; vulnerability to depression not just aftermath of depression
• ↑activation in anterior cingulate and ↓activation of hippocampus and regions of PFC when viewing negative stimuli
  ↪ interfere with effective emotion regulation
• overactivity in the amygdala = oversensitivity to emotionally relevant stimuli + systems regulating emotion compromised
• striatum underactive to reward stimuli
  ↪ nucleus accumbens (dopamine release center) - key in motivation to pursue rewards
  ↪ explains why less motivated by the positive events

Question 22

Biological etiology

Cortisol dysregulation in depression

Answer 22

• HPA axis - overly active in MDD (stress reactivity hightened)
  ↪ Heigtened cortisol awakening response
• amygdala sends signals to HPA, HPA releases cortisol
• cortisol injected in animals - decreased interest in sex, food and sleep disturbances

Question 23

Psychological etiology of depression

Part of Bio-psycho-social model of depression

Answer 23

1. Neuroticism - tendency to experience frequent and intense negative affect
   Cognitive theories:
2. Beck’s negative triad
3. Hopelessness theory
4. Rumination theory - dwelling on negative experiences and views about the self which increases negative mood
   ↪ women ruminate more

Question 24

Psychological etiology

Beck’s negative triad

Answer 24

• Negative views of the self, the world, and the future
• Negative schemas acquired in childhood through experiences
  ↪ Activated when similar situations encountered - cause negative information-processing biases
• Tested with:
  1. Self-report scale called Dysfunctional Attitudes Scale - hard to interpret whether negative thoughts cause or a symptom
  2. Studies of information processing - bias in the way they attend to (attention) and recall info (memory - remember negatives more, look at negative facial expressions more)
• Recall biases related to some symptoms (sadness, self-dislike…) but not physical ones (e.g. low energy)

Question 25

# Psychological etiology Hopelessness Theory

Answer 25

- Depends on person's attributional style: 1. Stable (permanent) vs unstable (temporary) causes 2. Global (relevant to many life domains) vs specific (limited to one area) causes - Stable and global AS = become hopeless

Question 26

Social etiology of depression | Part of bio-psycho-social model of depression

Answer 26

1. **Childhood adversity** - parental death, physical or sexual abuse 2. **Stressful life events** (not caused by early mild depressive symptoms - losing a job because of demotivation) ↪ vulnaribilities: lack of social support 3. **Expressed emotions** - critical or hostile comments from people around you = lower social competence 4. **Interpersonal problems** - interpersonal loss, isolation or concern can trigger depression but can also be triggered by depression

Question 27

How can we integrate social and biological influences on depression?

Answer 27

- Social stressors (major life events, childhood abuse) → changes in sensitivity of serotonin receptors + increase in pro-inflammatory cytokines + function of dopamine system - Short alleles of **serotonin transporter gene** only with combination of childhood maltreatment = depression ↪ More severe stressful events, the number of short alleles related to greater risk of developing depression

Question 28

What is the overlap in anxiety and depression? How does it reflect in DSM-5?

Answer 28

- 60% of people with anxiety have depression and vice versa (also 60%) - overlap in etiology - neuroticism and childhood adversity - DSM-5 specifier (subtype): *with anxious distress* ↪ depressive episodes accompanied with at least two anxiety symptoms ↪ poor response to anti-depressant treatement

Question 29

Biological treatment

Answer 29

- Based on biological theories of serotonin/dopamine - Antidepressants and ECT Work very well - quicker relief than psychotherapy - rTMS for treatment-resistant depression - coil with magnetic pulses to increase activity in the left dorsolateral prefrontal cortex

Question 30

What antidepressants are there? Are they effective? Side effects?

Answer 30

1. Monoamine oxidase inhibitors (MAOIs) 2. Tricyclic antidepressants 3. SSRIs (e.g. prozac) 4. Serotonin-norepinephrine reuptake inhibitors (SNRIs) - Mostly best for severe MDD; placebo for mild or moderate - 60% of people experience at least one side effect ↪ Under 25 yrs taking SSRIs: increased suicidality - Mostly positive findings are published = higher perceived effectiveness ↪ Large sample study: only 43% recovered (even with combinations of treatments and different meds)

Question 31

Electroconvulsive Therapy | What is it? How does it work? What are the risks?

Answer 31

- Used to treat MDD unresponsive to meds - Inducing momentary seizure by placing an electrode on the nondominant side of the forehead - Also muscle relaxant and the patient sleeps - 6-12 treatments, spaced several days apart - Risks: short-term confusion or memory loss

Question 32

# Treatment Psychological treatments

Answer 32

1. **Psychodynamic theory** - problem: grief over loss > intervention: acceptance & mourning (evidence: +/-) 2. **Behaviourism/learning** - anhedonia > e.g. behavioural activation, activity scheduling (evid. ++) 3. **Cognitive theory** - negative triad, hopelessnes, rumination > Cognitive therapy, mindfulness based CT, interpersonal therapy (evid: +++) 4. **CBT** - Various problems > various interventions (evid: +++) 5. Behavioural Couples Therapy - experiencing marital distress increases depressive symptoms

Question 33

Interpersonal Psychotherapy

Answer 33

- Examine major interpersonal problems, e.g. role transitions, interpersonal conflicts, grief... - Identify one's feelings about those issues, make important decisions and resolve problems related to those issues

Question 34

Cognitive therapy & Behavioural Activation

Answer 34

Situation > Automatic neg. thoughts > Neg. feelings > Behaviour: doing nothing (results in neg. feelings) Putting apart feelings and beliefs (I am worthless - I feel worthless - is it a feeling or do you actually believe it)

Question 35

Cognitive therapy

Answer 35

Situation > Automatic thought > feeling Tries to identify, **challenge** negative thoughts of a person and make them aware of them = **cognitive reconstructing** ↪ Help increase awarness of connection between thoughts and mood ↪ Then, change self-beliefs E.g. I am worthless - therapist challenges that: what does a worthless person look like, do your children think you're worthless

Question 36

Behavioural activation

Answer 36

Focuses on the behavioural part of the model: on the feeling and behaviour E.g. I'm staying in bed Encourages to enagage in pleasant and rewarding activities Start with something the person likes and start small and build up so that there is positive reinforcement Positive reinforcement can change the feeling, then the automatic thought and then the situation

Question 37

Mindfulness-based cognitive therapy

Answer 37

-To prevent relapse after successful treatement - History of MDD, sadness is more likely to escalate - Focused on developing a detached relationship to depression-related thoughts and feelings (*I am not my thougths*)

Question 38

# Which therapy? Stepped care

Answer 38

Starting with the least costly, intensive and have the least amount of side effects

Question 39

Which therapy to choose? Based on stepped care

Answer 39

1. Psychoeducation 2. Meta-analyses: most psychotherapies equally effective (CBT, MBCT...) 3. Anti-depressants ↪ only in severe depression, then just as effective as psychotherapy ↪ overprescription 4. Intemsification or Electroconvulsive therapy

Question 40

Suicide numbers with depression

Answer 40

- Untreated depression: 20% risk for suicide - 50% of those who attempt suicide have MDD - Men are four times more successful

Question 41

Symptoms of (hypo)mania DSM-5

Answer 41

Criterion A. *Affect* A distinct period of abnormally and persistently elevated or irritable mood: - at least 1 week or hospitalization > mania - at least 4 days > hypomania Criterion B. During this period, at least 3 (4, if only irritable) are noticeably changed from baseline *Cognitive* 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g. feels rested after 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing *Physical* 5. Distractibility 6. Increase in goal-directed activity or psychomotor agitation 7. Excessive involvement in pleasurable, risky activities

Question 42

What is the difference between mania and hypomania?

Answer 42

Duration: 1 week vs 4 days Severity: - Functioning impared for mania not for hypo. - Hospitalization in mania - Psychotic symptoms in mania - Behaviour different from normal: both yes but mania more - Difference clear to others: both but more for mania (but for hypomania to be diagnosed this has to be present because functioning is high)

Question 43

Diagram of differential diagnoses of mood disorders with very elated mood

Answer 43

Very elated mood (VEM) > complete mania = **Bipolar I** (depression might not be there) VEM > complete hypomania + major depressive episode > **Bipolar II** VEM > some hypomanic symptoms + some depressive symptoms = **Cyclothymic disorder**

Question 44

Does it mean that when someone has mania = Bipolar I?

Answer 44

No, mania can be present in schizoaffective disorders spectrum disorders Always have to look whether there are other disorders that might explain the symptoms better

Question 45

Explanatory models bipolar | Bio + psycho

Answer 45

**Biological** - heritability very high 93% (SNPs and CNVs identified as a genetic base - mixed evidence though), serotonin/dopamine (reward system - increase in dopamine triggers manic episode; unclear evidence from PET) ↪ Brain regions: elevated activity in amygdala, anterior cingulate, and striatum(MDD - diminished); diminished activity in regions of PFC and hippocampus **Psychological** - reward sensitivity (success in life may trigger cognitive changes in confidence > excessive goal pursuit) **Other** - major life event > sleep deprivation

Question 46

Treatments of bipolar mood disorders | Meds + psychological

Answer 46

1. **Medications** - chronic so take it for majority of life - Mood-stabilizer (Lithum) - If not tolerable: anticonvulsant (antiseizure) or antipsychotic - Antidepressants also prescribed if depressive episodes present ↪ risk of increase of mania if taken without mood-stabilizer 2. **Psycho-education** and Family-Focused therapy 3. **Cognitive therapy** - mainly for depressive part, problem-solving, recognizing symptoms