Mood Disorders

1. Mood Disorders

2. Mood Disorders • Two key emotions on a continuum: • Depression • Low, sad state in which life seems dark and overwhelming • Mania • State of breathless euphoria and frenzied energy Depression Mania

3. Mood Disorders • Most people with a mood disorder experience only depression • This pattern is called unipolar depression • Person has no history of mania • Mood returns to normal when depression lifts • Some people experience periods of depression that alternate with periods of mania • This pattern is called bipolar disorder

4. Mood Disorders • These disorders have always captured people’s interest • Millions of people have mood disorders • Economic costs of mood disorders amount to more than $40 billion each year

5. Unipolar Depression • The term “depression” is often used to describe general sadness or unhappiness • This usage confuses a normal mood swing with a clinical syndrome • Clinical depression can bring severe and long-lasting psychological pain that may intensify over time

6. How Common Is Unipolar Depression? • 5 to 10% of the U.S. population experiences severe unipolar depression each year • An additional 3 to 5% experience mild depression • ~17% of the world population experiences unipolar depression at some time in their lives • Rates have been steadily increasing since 1915

7. How Common Is Unipolar Depression? • In almost all countries, women are twice as likely as men to experience severe unipolar depression • Lifetime prevalence: 26% of women vs. 12% of men • These rates hold true across socioeconomic classes and ethnic groups • ~50% recover within six weeks, some without treatment • Most will experience another episode at some point

8. What Are the Symptoms of Depression? • Symptoms may differ dramatically from person to person • Five main areas of functioning may be affected: • Emotional symptoms • feeling “miserable,” “empty,” “humiliated” • Motivational symptoms • lack drive, initiative, spontaneity • 6 to 15% of those with severe depression commit suicide

9. What Are the Symptoms of Unipolar Depression? • Five main areas of functioning may be affected: • Behavioral symptoms • less active, less productive • Cognitive symptoms • hold negative opinion of themselves • blame themselves for unfortunate events • Physical symptoms • headaches, dizzy spells, general pain

10. Diagnosing Unipolar Depression • Criteria 1: Major depressive episode • Marked by five or more symptoms lasting two or more weeks • In extreme cases, symptoms are psychotic, including • Hallucinations • Delusions • Criteria 2: No history of mania

11. Diagnosing Unipolar Depression • Two diagnoses to consider: • Major depressive disorder • Criteria 1 and 2 are met • Dysthymic disorder • Symptoms are “mild but chronic” • Experience longer-lasting but less disabling depression • Consistent symptoms for at least two years • When dysthymic disorder leads to major depressive disorder, the sequence is called “double depression”

12. What Causes Unipolar Depression?The Biological View • Biochemical factors • NTs: serotonin and norepinephrine • In the 1950s, medications for high blood pressure were found to increase depression • Some lowered serotonin, others lowered norepinephrine • Led to “discovery” of effective antidepressant medications • It is likely not just one NT or the other – a complex interaction is at work

13. What Causes Unipolar Depression?The Biological View • Biochemical factors • Endocrine system hormone release • People with depression have been found to have abnormal levels of cortisol • Released by the adrenal glands during times of stress • People with depression have been found to have abnormal melatonin secretion • “Dracula hormone”

14. Cognitive Deficits in Depression • Deficits in explicit verbal and visual memory, but not implicit memory • Could be related to hippocampal volume • Impairment in executive tasks • Verbal fluency • Set shifting • Motor speed

15. Cognitive Deficits in Depression It may be that depressed patients have more difficulty with “effortful” as compared to “automatic” tasks Motivational factors, particularly lack of reward sensitivity, may play a role Some cognitive deficits improve when there is inter-episode recovery, but there are still some “cognitive” scars (executive functioning, some types of memory)

16. Cognitive Deficits in Depression- Limitations “Localising” neuropsychological tests may actually involve a number of brain regions Medication history Hx of symptoms

17. Endophenotypes Children with a first-degree relative with mood disorder Verbal learning and suspectibility to interference Contradictory EF demands Social reasoning? Interaction with other biological factors (e.g., thyroid dysfunction)

18. Tissue volume loss Hippocampus: results are contradictory * Age * Medication history * Number of episodes * Genetic factors * Levels of circulating cortisol

19. Tissue volume loss Orbitofrontal cortex and amygdala * very preliminary * affective processing Dorsolateral prefrontal cortex * also preliminary * cognitive processing Drug effects Cortisol

20. Mayberg model of depression

21. Goldapple et al. (2004) • 2 groups: 18 unmedicated, unipolar depressed outpatients and 13 patientstreated with drug (anti-depressant SSRI) • CBT • Drug • Both approaches equally effective: 50 percent success rate

22. Goldapple et al. (2004) • Cognitive behavior therapy is thought of as a top-down approach because it focuseson using thinking functions to modulateabnormal mood states, modify attentionand memory functions, change affective bias,and correct maladaptive informationprocessing

23. Goldapple et al. (2004) • CBT: successful treatment increases incognitive processing regions (e.g.,hippocampus) and decreases in emotionalprocessing areas (e.g., ventral medial cortex)

24. Goldapple et al. (2004) • Drug therapy is seen as a bottom-upapproach because it first changes thechemistry in the brainstem, limbic, and subcortical sites system. • It then produces secondary cortical changeswith chronic treatment, altering more basicemotional and circadian behaviors andeventually causing “upstream” changes in depressive thinking.

25. Goldapple et al. (2004) • With drug therapy, metabolism (blood flow) decreases in the limbic area and increases in the cortical area. • With CBT, limbic increases (in the hippocampus, dorsal mid cingulate) and cortical decreases (in the dorsolateral, ventrolateral, and medial orbital frontal; inferior temporal and parietal).

26. Goldapple et al. (2004) • As CBT patients learn to turn off the thinking paradigm that leads them to dwell on negative thoughts and attitudes, activity in certain areas in the cortical (thinking, attention) region are decreasing as well. • Drug leads to increases in cognitive oversight and decreases in ruminative, negative moodstates

27. Goldapple et al. (2004) • 2 types of depressed patients • Differ at baseline

28. Lobotomy’s back!

29. Anterior cingulotomy • Advances in neurosurgical equipment andtechniques allow for new approaches totreating psychiatric problems • Researchers have demonstrated that psychosurgery has helped a considerablenumber of treatment-resistant patients (lown)

30. Counterpoint • Withholding psychosurgery becomes ethically questionable for severely ill, treatment resistant patients • A theoretical justification is not required forthe ethical use of psychosurgery, only adequate demonstrations of safety and efficacy (effectiveness) ???

31. Bipolar Disorders • People with a bipolar disorder experience both the lows of depression and the highs of mania • They describe their life as an emotional roller coaster

32. What Are the Symptoms of Mania? • Unlike those experiencing depression, people in a state of mania typically experience dramatic and inappropriate rises in mood • Five main areas of functioning may be affected: • Emotional symptoms • active, powerful emotions in search of outlet • Motivational symptoms • need for constant excitement, involvement, companionship

33. What Are the Symptoms of Mania? • Five main areas of functioning may be affected: • Behavioral symptoms • very active – move quickly; talk loudly or rapidly • Key word: flamboyance! • Cognitive symptoms • show poor judgement or planning • Especially prone to poor (or no) planning • Physical symptoms • high energy level – often in the presence of little or no rest

34. Diagnosing Bipolar Disorders • Criteria 1: Manic episode • Three or more symptoms of mania lasting one week or more • In extreme cases, symptoms are psychotic • Criteria 2: History of mania • If currently experiencing hypomania or depression

35. Diagnosing Bipolar Disorders • Two kinds of bipolar disorder: • Bipolar I disorder • Full manic and major depressive episodes • Most sufferers experience an alternation of episodes • Some experience mixed episodes • Bipolar II disorder • Hypomanic episodes and major depressive episodes

36. Diagnosing Bipolar Disorders • Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder • If people experience four or more episodes within a one-year period, their disorder is further classified as rapid cycling • If their episodes vary with the seasons, their disorder is further classified as seasonal

37. Diagnosing Bipolar Disorders • Between 1 and 1.5% of adults in the world suffer from a bipolar disorder at any given time • The disorders are equally common in women and men • Women may experience more depressive and fewer manic episodes than men • Rapid cycling is more common in women

38. What Causes Bipolar Disorders? • Neurotransmitters (NTs) • After finding a relationship between low norepinephrine and unipolar depression, early researchers expected to find a link between high norepinephrine and mania • This theory is supported by some research studies; bipolar disorders may be related to overactivity of norepinephrine

39. What Causes Bipolar Disorders? • Neurotransmitters (NTs) • Because serotonin activity often parallels norepinephrine activity in unipolar depression, theorists expected that mania would also be related to high serotonin activity • While no relationship with HIGH serotonin has been found, bipolar disorder may be linked to LOW serotonin activity, which seems contradictory…

40. What Causes Bipolar Disorders? • Neurotransmitters (NTs) • This apparent contradiction is addressed by the “permissive theory” about mood disorders: • Low serotonin may “open the door” to a mood disorder and permit norepinephrine activity to define the particular form the disorder will take: • Low serotonin + Low norepinephrine = Depression • Low serotonin + High norepinephrine = Mania

41. What Causes Bipolar Disorders? • Ion activity • Ions, which are needed to send incoming messages to nerve endings, may be improperly transported through the cells • This improper transport may cause neurons to fire too easily (mania) or to resist firing (depression) • There is some research support for this theory

42. Hippocampal volume INCREASES • We have reported increases in hippocampal volume in BD patients both cross-sectionallyand prospectively • Lithium • Other antipsychotics • No drug • Control

43. Dx: PTSD • A. The person has been exposed to a traumatic event in which both of the following have been present:  • (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

44. Dx: PTSD • A. The person has been exposed to a traumatic event in which both of the following have been present:  • (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

45. Dx: PTSD • B. The traumatic event is persistently reexperienced in one (or more) of the following ways:  • (1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

46. Dx: PTSD • B. The traumatic event is persistently reexperienced in one (or more) of the following ways:  • (2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

47. Dx: PTSD • B. The traumatic event is persistently reexperienced in one (or more) of the following ways:  • (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

48. Dx: PTSD • B. The traumatic event is persistently reexperienced in one (or more) of the following ways:  • (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

49. Dx: PTSD • C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  • (1) efforts to avoid thoughts, feelings, or conversations associated with the trauma  • (2) efforts to avoid activities, places, or people that arouse recollections of the trauma  • (3) inability to recall an important aspect of the trauma *****

50. Dx: PTSD • C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:  • (4) markedly diminished interest or participation in significant activities  • (5) feeling of detachment or estrangement from others