Transcript Schizophrenia & Other Psychotic Disorders

Mood Disorders
Mood Disorders
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1.
2.
Involve severe and
enduring disturbances
in emotionality
Range from elation to
severe depression
Depression
Bipolar Disorder
Mental Health Resources at UD
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Center for Counseling and Student
Development
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Psychological Services Training Center
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831-2141
831-2717 (Sliding scale)
Delaware Help Line
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1-800-464-HELP
Mood Disorders Overview
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Symptoms, onset, prevalence (Depression,
Bipolar)
Causes (Depression, Bipolar)
Suicidality
Treatment of Depression
Treatment of Bipolar
Depressive Disorders
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There are several types:
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Major depression
Dysthymia
Double depression
Seasonal Affective Disorder
Postpartum Depression
Childhood Depression
Symptoms of Major
Depression
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Depressed Mood
(Irritable in children)
Decreased interest in
activities
Weight or appetite
changes
Sleep changes
Psychomotor agitation
or retardation
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Fatigue/loss of energy
Feelings of
worthlessness or
excessive guilt
Concentration problems
Thoughts of death,
suicide, or suicide
attempt
Distress or impairment
Not associated grief
Onset and Duration
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Age of onset = 25 years
Avg episode length = 6 months
Recurrent, especially w/ early onset (50, 70,
90)
Median # of episodes = 4
Most no treatment
Earlier onset = poorer prognosis, more
chronicity, worse response to treatment
Gender Differences
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Equal among boys and
girls
2:1 women
25% female lifetime
prevalence (12% male)
Historical Changes
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Depression in youth increased 10x (2
generations)
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Age of onset is decreasing
25% of those aged 18-29 one episode (2003)
Symptoms vary by age and culture
Cultural Differences
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African American rates similar to Caucasian
Asian Americans lowest rates
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0.8% report lifetime prevalence
0.8% dysthymia
Less common among recently immigrated
Hispanics vs. Hispanic Americans (who have
rates similar to Caucasians)
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Can cope better? Stress of immigration?
Dysthymia
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Chronic (2 years)
Same symptoms, but less severe (but still
debilitating)
Entire life
Lifetime prevalence 6%
Few seek treatment
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Personality?
Seasonal Affective Disorder
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Develops in late fall/early winter
Remits in spring
Prevalence = 3%
Length of day/avg temp?
Iceland low (expect high)
Changes in hormone with seasons?
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Melatonin up in winter
Postpartum Depression
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During first few weeks post-delivery
(not postpartum blues - 50-80%)
Massive hormone change as trigger?
Other hormone changes similar
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Oral contraceptives, puberty, menopause
Childhood Depression
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Occurring more frequently & earlier
Is this the same as adult depression?
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Different cognitive/emotional development
Gender rates equal until teens
Symptom patterns look different, not as “obvious”
Predictive of adult depression
When Depression is Not
Depression
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Bereavement (not diagnosed up to 2 months)
Adjustment disorders
Medical conditions
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“Depression due to a general medical condition”
Everyone experiences normal sadness
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Difficulty coping, interferences with daily activities
What is Bipolar Disorder?
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Experience of mania
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Excessive energy
Decreased need for sleep
Rapid speech (pressured speech) & movement
Impulsive and/or dangerous behavior
Spending sprees, investments
 Unsafe sexual behavior
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Hypomania = less severe mania
What is Bipolar Disorder?
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Extreme shifts between
mania & depression
(days to months)
Lifetime prevalence =
1% - 5%
Equal rates across
gender, culture
Early onset = more
severe & more chronic
Bipolar Disorder
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Avg age onset 18 (I) and 22 (II)
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50% patients ill before age 30 (25% by 20)
Course is unpredictable
Diagnosis is often delayed
10-15% of patients commit suicide
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20-50% will attempt at some point
Bipolar Disorder in Children
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Irritability, emotional swings
More chronic (not episodic)
Often misdiagnosed (ADHD, Conduct
Disorder)
Causes of Depression
and Bipolar Disorder
Causes of Depression
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Biological Dimensions
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Social and Cultural
Dimensions
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Psychological
Dimensions
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Integrative Theory
Familial and Genetic
Influences
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36-44% heritable
women, 18-24% men
(major depression)
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Stronger genetic
influences bipolar
Familial and Genetic
Influences
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Certain pattern most genetic, depression:
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Early age of onset
Greater number of episodes
Long longest episode
More impairment
Suicidality
Probably polygenic
Neurotransmitter Systems
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Low relative levels of serotonin
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Serotonin = regulation of emotional reactions
Indirect evidence
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Metabolites of serotonin & norepinephrine lower
Drugs increasing serotonin help
Drugs decreasing serotonin ruin the effects of
antidepressants
Receptors abnormal (PET)
Neuroendocrine Influences
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Hormonal diseases can = depression
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Cortisol (stress hormone) is elevated
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E.g. Hypothyroidism
May not be specific to depression
Hormones likely associated with post-partum
depression
Circadian Rythyms & Sleep
Disturbances
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Excess vs. lack
Falling asleep, waking up, early waking
Circadian rythym: Our normal daily pattern of
biological changes (hormones)
How do depressed people
sleep?
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Shortened REM latency
(quick)
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Sooner, longer, more
intense
Expense: deep sleep
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Energy restoring
Sleep of Nondepressed
Individuals
Sleep for Depressed
Sleep Disturbances
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Early awakening an early marker?
General poor sleepers?
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Sleep as predictor
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Influence treatment?
Reduced REM latency more pronounced in
absence of stressful life event
A biological process that can bring on
depression alone?
Psychological Perspectives on
Depression
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Stressful Life Events
Learned Helplessness
Negative Cognitive Styles
Behavioral Approaches
Stressful Life Events
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Strongly related to onset
80% of depressive episodes, in community samples,
preceded by event
Stronger predictor initial episode
Poorer response to treatment
Longer recovery
Increased chance recurrence
Stressful Life Events
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Relationship breakup
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10x increase over twin
Humiliation
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20x increase in
depressive episode than
a twin with same genes,
but no event
Learned Helplessness Model
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Seligman’s dogs
Learned helplessness: depression as a result of
aversive situations which we cannot control
Or, attributions of lack of control
Learned Helplessness Model
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Attributions:
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Internal/external
Global/specific
Stable/unstable
Worst combination:
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Internal + global + stable
“It is all my fault, always. Additional bad things will
always be my fault”
Cognitive Model (Beck)
Development of depression
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How do we think about ourselves?
How do we think about the world?
Cognitive triad (Self, World,
Future)
Self
World
Future
Cognitive Model (Beck)
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Depression = interpreting many events in
negative ways
Cognitive errors
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Overgeneralization
Arbitrary influence
Cognitive Model (Beck)
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Maladaptive schemas - seeds
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Way we organize the world
How we experience life, the way we feel about us
and the world
Children with maladaptive schemas distort
perceptions & at risk
Cognitive Model (Some
Examples)
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Normal disappointments are unbearable
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I am deficient, especially at handling stress
that other people can handle
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My future is hopeless. My stress will never
end and there is nothing I can do to help
The Behavioral Component
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Behaviors reinforce/maintain depressive
feelings
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E.g. withdraw from society b/c depression leaves
people with little energy
BUT withdrawing from society minimizes chance
they will experience fun and feel better
A cycle -> behaviors maintain symptoms
Social and Cultural Influences
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Marital Relations
Gender Differences
Social Support
Marital Relations
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Strongly related to depression
Marriage seems to have greater impact on
men’s depression
Depression may erode relationships
Gender Differences
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70% of individuals with depression are
women
Consistent across cultures
Uncontrollability, due to socialization?
Differences in rumination
Social disadvantages
Social Support
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Major buffer
Brown et al: of women
experiencing a stressful
event, only 10% of those
who became depressed
had a confidante
Faster recovery
Causes of Bipolar Disorder
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Biological Dimensions
Psychological Dimensions
Social and Cultural Dimensions
Integrative Theory
Familial and Genetic
Influences
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Stronger genetic than
depression
Risk in 1st degree
relatives 10x general
pop.
Attempts to isolate
genes unsuccessful
Neurotransmitters
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Depression = low levels serotonin & NP
Mania = high levels of NP
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Lithium reduces NP
No evidence serotonin is involved
Sleep and Circadian Rhythms
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Bipolar patients show
sensitivity to light
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More suppression of
melatonin when exposed
to light at night
Regulates sleep
Insomnia can trigger
manic episodes
Stressful Life Events
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Also strong relationship
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Especially early mania
Can also prevent recovery
Upward spiral of positive events
Severe will trigger for 50%
Disrupted social interactions worst
Social Support
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Speeds recovery from
depressive, not manic,
episodes
Bipolar Disorder in Children
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Underdiagnosis vs. overdiagnosis
Prevalence likely same as adult
BUT earlier age of onset w/ later age of birth
20-40% of adults report childhood onset
What do Bipolar Children Look
Like?
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Difficult to see? (Happy = good)
Delusions of grandeur & failure of logic
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How to teach classes
Permission to steal
Prominent profession, despite failing
Lots of activity before bedtime & difficulty
falling asleep
Pressured speech & racing thoughts
What do Bipolar Children Look
Like?
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Minor changes in environment increase
distractibility
Increased motor activity
Increased goal-directed behavior
Pleasurable, high-risk activities
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Hypersexuality
Spending money
Reckless behavior (e.g. driving, drinking)
What Else Does Bipolar Look
Like in Children?
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Sexual Abuse
Language Disorders
ADHD - 30% comorbidity
Conduct Disorder - 18% comorbidity
Schizophrenia - history of mania?
Substance Abuse
How is this different from
Adults?
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Continuous rapid cycling, rather than
discrete episodes
Initial episode is depression, not mania
No inter-episode normal functioning
(perhaps even no inter-episode period)
What do we need to know?
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How to treat childhood BP (because
outcomes may be worse)
Better education re: diagnosis
More research on treatment
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Are the same meds safe?
Do we need psychosocial interventions?
Epidemiological research on rates, etc.
Suicidality
Suicidality
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Most commonly associated with depression
Common with other disorders
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Schizophrenia
Substance abuse
Borderline Personality Disorder
Large stigma = more common than know
Statistics on Suicidality
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8th leading cause of death 25-34 year olds
Actual number is likely 2-3x higher
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Increase among teenagers (3rd leading
cause)
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Difficult to estimate
200% increase 1960-1988
10-25% college students thoughts
Attempts, Gender Differences
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Most people do not succeed
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Women 3x more likely attempt, Men 4-5 more
times likely to succeed
Why Gender Differences?
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College students - men/women who complete
are more masculine
Women who survive an attempt = less
stigma?
Men choose more fatal methods
Risk Factors
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Family history
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Low levels of serotonin (impulsivity,
overreactions, instability)
Psychological disorder
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6x increase in offspring of attempters
90% of completers have a mental health disorder
Especially impulsive disorders (Borderlines)
Alcohol use
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25-50% of suicides
Risk Factors
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Previous attempts
Hopelessness (above depression & ideation)
Meaningless or lack of purpose? (Especially
for men)
Feelings of being a burden
Prior exposure to pain
Intent and access
Misconceptions of Suicide
People who talk about it are unlikely to commit
it
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People who commit suicide are irrational
People who commit suicide are all very
depressed
Asking people whether they are suicidal
increases their risk
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OR People who do it don’t talk about it
Can decrease due to intervention
People commit suicide b/c of the way they feel
Treatment of Depression
and Bipolar Disorder
Types of Treatment
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Medication
Electoconvulsive Therapy and Transcranial
Magnetic Stimulation
Psychological Treatments
Medications for Depression
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Tricyclic Antidepressants
Monoamine oxidase
inhibitors (MAOIs)
Selective Serotonergic
Reuptake Inhibitors
(SSRIs)
Medication for Bipolar
Disorder - Lithium
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Serious side effects = close regulation
Mechanism unclear
30-60% patients good response
Prevent mania in 66% of patients
Compliance is a concern
Electroconvulsive Therapy &
Transcranial Magnetic Stimulation
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Electric shock to brain
for < 1 second
Produces seizure
6-10 treatments, every
other day
Some memory loss and
confusion
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Magnetic coil generates
localized
electromagnetic pulse
Psychological Treatments for
Depression
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Cognitive Therapy
Interpersonal Therapy
Behavior Therapy
Cognitive Therapy for
Depression
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Examine thought processes, recognize errors
Examine negative automatic thoughts
Later examine negative schemas
Interpersonal Psychotherapy
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Disruptions of relationships often lead to
depression
Four general interpersonal areas:
Interpersonal role changes
Loss of relationships
Acquiring new relationships
Social Skills deficits
Preventing Relapse
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Maintenance treatment – prevents relapse
CT reduces relapse by more than 50% vs.
meds
Mindfulness-Based Cognitive
Therapy
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Developed specifically for relapse prevention
MBCT vs CT
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Patients with 3+ episodes do better in MBCT
Psychotherapy for Bipolar
Disorder
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Focus on increasing medication compliance
Interpersonal & Social Rhythm Therapy
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Regulate sleep
Daily schedules
56% recover, vs. 20% drug alone
Psychotherapy for Bipolar
Disorder
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Family tension can predict relapse
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Understand symptoms
New coping skills
Communication styles
Prevent relapse