CHAPTER 7 PSYCHOPATHOLOGY

Cyclothymic disorder

--- a more chronic version of bipolar disorder where manic and major depressive episodes are less severe. Such persons tend to remain in either a manic or depressive mood state for several years with very few periods of neutral (or euthymic) mood. For the diagnosis, the pattern must last for at least 2 years (1 year for children and adolescents). Such persons are also at increased risk for developing bipolar I or II disorder. a. Average age of onset is about 12 or 14 years. b. Cyclothymia tends to be chronic and lifelong. c. Most are female.

Dysthymic disorder

---many of the symptoms of major depressive, but unlike major depression, the symptoms in dysthymia tend to be milder and remain relatively unchanged over long periods of time, as much as 20 or 30 years. --Dysthymic disorder is defined by persistently depressed mood that continues for at least 2 years. During this time, the person cannot be symptom-free for more than 2 months at a time. --One 10-year study indicated that 22% of those suffering from dysthymia eventually experienced a major depressive episode. --Double depression refers to both major depressive episodes and dysthymic disorder. --Dysthymic disorder often develops first, and this condition is associated with severe psychopathology and problematic future course. Indeed, many do not recover after two years, and relapse rates are very high. ---The risk for developing depression is low until the early teens, when it begins to rise; the mean age of onset is 30. There is some evidence that the risk of developing depression while younger is on the increase. Untreated depression does tend to remit, but residual symptoms may leave the individual vulnerable to later episodes.

Additional defining criteria for mood disorders

--Atypical features specifier modifies depressive episodes and dysthymia but not manic episodes. Individuals with this specifier oversleep, overeat, gain weight, and show much anxiety. These persons are able to experience some pleasure in their lives. Depression with atypical features is associated with an earlier age of onset and a greater percentage of women. --- Melancholic features specifier applies only if the full criteria for a major depressive episode have been met; it does not apply to dysthymia. This group includes more severe somatic symptoms (e.g., early morning awakenings, weight loss, loss of sex drive, excessive guilt, and anhedonia) and indicates a more severe type of depressive episode. --- Chronic features specifier can be applied only if the full criteria for major depressive episode have been met continuously for at least the past 2 years. Does not apply to dysthymic disorder. ---Catatonic features specifier applies to major depressive episodes and manic episodes, though it is very rare. This is a very serious condition involving the total absence of movement (i.e., a stuporous state) or catalepsy (i.e., muscles are waxy and semi-rigid). Catalepsy is seen as a reaction to imminent doom, similar to animals about to be attacked. e. Psychotic features specifier applies to cases where psychotic symptoms (i.e., hallucinations, delusions) are experienced during the major depressive or manic episode. Hallucinations and delusions may be mood congruent (i.e., symptom content are directly related to depressed mood) or mood incongruent. Examples of these symptoms include auditory hallucinations and somatic or grandeur delusions. Psychotic depressive episodes are rare but associated with poor response to treatment. f. Postpartum onset specifier applies to both major depressive and manic episodes and is used to characterize severe manic or depressive episodes of a psychotic nature that first occur during the postpartum period (i.e., 4-week period immediately following childbirth). 13% of women giving birth meet criteria for a major depressive episode. This specifier is not applied to mild depressive episodes following childbirth. Although postpartum depression has been thought of as a female phenomenon, one recent study found that 10% of mothers had an increase in depression after childbirth, but so did 4% of fathers.

Causes of Mood Disorders

--Family studies indicate that the rate of mood disorders in relatives of probands (i.e., the person known to have the disorder) with mood disorders is generally two to three times greater than the rate in relatives of normal probands. The most frequent mood disorder in relatives of persons suffering from mood disorders is unipolar depression. ---Twin studies reveal that if one identical twin presents with a mood disorder, the other twin is 3 times more likely than a fraternal twin to have a mood disorder, particularly for bipolar disorder. Severe mood disorders may have a stronger genetic contribution than less severe disorders. There also appear to be sex differences in genetic vulnerability to depression, with heritability rates being higher for females compared to males. --The environment appears to play a larger role in causing depression in males than females. Twin studies also support the contention that unipolar and bipolar disorder are inherited separately. Studies now indicate the contribution of a small group of genes that explain heritability of some types of depression. --Data from family and twin studies also suggest that the biological vulnerability for mood disorders may reflect a more general vulnerability for anxiety disorders as well. Many reports indicate neurotransmitter systems in the etiology of depression. Research indicates low levels of serotonin in the cause of mood disorders but only in relation to other neurotransmitters, including norepinephrine and dopamine. One of the functions of serotonin is to regulate systems involving norepinephrine and dopamine. The permissive hypothesis stipulates that when serotonin levels are low, other neurotransmitters are permitted to range more widely, become dysregulated, and contribute to mood irregularities. ---Another theory of depression has implicated the endocrine system, particularly elevated levels of cortisol. Cortisol and other neurohormones are a key focus of study in psychopathology. This area of research has led to the controversial dexamethasone suppression test (DST). Dexamethasone is a glucocorticoid that suppresses cortisol secretion. As many as 50% of those with depression, when given dexamethasone, show less suppression of cortisol. However, persons with anxiety disorders also demonstrate nonsuppression. --New research findings indicate that elevated levels of stress hormones in the long term may interfere with the production of new neurons (i.e., neurogenesis), especially in the hippocampus, which may result in disrupted memory processes. ---Sleep disturbances are a hallmark of most mood disorders. Depressed persons move into the period of rapid eye movement sleep (REM) more quickly than nondepressed persons and also show diminished slow wave sleep (i.e., the deepest and most restful part of sleep). This REM effect is reduced for persons who have depression related to recent life stress. REM activity is intense in depressed persons. --Depriving depressed persons of sleep improves their depression. Persons with bipolar disorder and their children show increased sensitivity to light (i.e., greater suppression of melatonin when exposed to light at night). A relationship between seasonal affective disorder, sleep disturbance, and disturbance in biological rhythms has thus been proposed.

Mania refers to abnormally exaggerated elation, joy, or euphoria. DSM-IV-TR criteria for a manic episode include:

A duration of 1 week; less if the episode is severe enough to require hospitalization. b. Irritability often accompanies the manic episode toward the end of its duration. c. Anxiousness and depression are often part of a manic episode. d. Average duration of an untreated manic episode is 3-6 months

Psychological dimensions

According to the learned helplessness theory of depression, people develop depression and anxiety when they assume they have no control over life stress. A depressive attributional style has the following three characteristics. a. First, the attribution is internal in that one believes negative events are one's fault. b. Second, the attribution is stable in that one believes that future negative events will be one's fault. c. Third, the attribution is global in that the person believes negative events will influence many life activities. Studies indicate that negative cognitive styles precede, and thereby operate as a risk factor for, depression. Attributions are important as a vulnerability that contributes to a sense of hopelessness; a feature that distinguishes depressed from anxious individuals. Aaron T. Beck proposed that depression results from a tendency to interpret life events in a negative way. Persons with depression often engage in several cognitive errors and think the worst of everything. The following examples of cognitive errors are illustrated in the textbook: a. Arbitrary inference refers to the tendency of depressed persons to emphasize the negative rather than positive aspects of a situation. b. Overgeneralization refers to the tendency to take one negative consequence of some event and generalize to all related aspects of the situation.

Chapter 7: Mood Disorders and Suicide

An overview of depression and mania The disorders described in this chapter used to be called "depressive disorders," "affective disorders," or even "depressive neuroses." Beginning with the DSM-III, these problems were grouped under the heading mood disorders because they all represent gross deviations in mood. The experience of depression and mania contribute, either alone or in combination, to all mood disorders. A major depressive episode is the most commonly diagnosed and most severe form of depression (see DSM-IV-TR diagnostic criteria for major depression). The textbook illustrates clinical depression with the case of Katie. DSM-IV-TR criteria for major depressive episode includes:

Treatment of mood disorders

At least three major psychosocial treatments are available for depressive disorders. Aaron Beck's cognitive therapy involves teaching clients to examine the types of thinking processes they engage in while depressed and recognize cognitive errors when they occur. Clients are informed about how these processes lead to depression and faulty thinking patterns are modified. Clients also monitor and record their thoughts between therapy sessions and are assigned homework to change their behavior. Increased behavioral activity to elicit social reinforcement and to test hypotheses about the world is also mandated. Treatment usually takes 10 to 20 sessions. The textbook illustrates Beck's cognitive therapy with a dialogue between Beck and a patient named Irene. Lewinson and Rehm developed a form of cognitive-behavior therapy for depression that focused initially on reactivating depressed patients and countering their mood by bringing them in contact with reinforcing events. More recent approaches have also stressed the preventing avoidance of social and environmental cues that produce negative affect or depression. It is possible that increased activities alone may improve self-concept and lift depression, suggesting that the behavioral component of CBT may be the active ingredient of treatment. Interpersonal therapy (IPT) focuses on resolving problems in existing relationships and/or building skills to develop new relationships. Like cognitive-behavioral approaches, IPT is highly structured and seldom takes longer than 15 to 20 weekly sessions. The therapist and client identify life stressors that precipitate depression, and then address interpersonal role disputes, adjustments to losing a relationship, acquisition of new relationships, and social skills deficits. . Recent studies comparing the results of cognitive therapy and IPT to those of tricyclic antidepressants and other control conditions for major depressive disorder and dysthymia have shown that psychosocial approaches and medication are equally effective, and that all treatments are better than placebo and brief psychodynamic therapy.

DSM-IV-TR criteria for major depressive episode includes:

Extremely depressed mood state lasting at least 2 weeks. b. Cognitive symptoms (e.g., feeling worthless, indecisiveness). c. Disturbed physical functions (e.g., altered sleep patterns, changes in appetite/weight, loss of energy), often referred to as somatic or vegetative symptoms. Such symptoms are central to this disorder. d. Anhedonia, or the loss of interest or pleasure in usual activities. e. Average duration of an untreated major depressive episode is 4 to 9 months.

Unipolar disorder refers to the experience of either depression or mania, and most individuals with this condition suffer from unipolar depression. Bipolar disorder refers to alternations between depression and mania.

Feeling depression and mania at the same time is referred to as a dysphoric manic or mixed episode; in these episodes, patients usually feel as if their mania is out of control, and become anxious or depressed regarding this experience. A recent study indicated that 30% of patients hospitalized for acute mania actually had mixed episodes. Almost all major depressive episodes remit without treatment. Manic episodes remit without treatment after six months. Thus, it is important to determine the course or temporal patterning of the depressive and manic episodes. Different patterns appear in the DSM-IV-TR under the heading course modifiers for mood disorders. a. Course modifiers characterize the past mood state and are helpful to predict the future course of the disorder. Understanding the course is related to predicting future occurrences of mood changes and in helping to prevent them.

Specifiers describing the course of mood disorders include the following:

Longitudinal course specifiers are used to address whether a person has had a past episode of depression or mania and whether the person recovered fully from past episodes. For example, one should determine whether dysthymia preceded a major depressive episode or whether cyclothymic disorder preceded bipolar disorder. Both scenarios tend to decrease chances of recovery and increase length of treatment. b. Rapid cycling pattern applies only to bipolar I and II disorders. Rapid cycling pattern is used when a person has at least 4 manic or depressive episodes within a period of 1 year. Rapid cycling is a more severe form of bipolar disorder that does not respond well to treatment, and appears to be associated with higher rates of suicide. Alternative drug treatments (e.g., anticonvulsants, mood stabilizers) are typically utilized with individuals meeting criteria for this specifier. Around 20-40% of bipolar patients experience rapid cycling, and 60-90% of these are female. Most people with rapid cycling begin with a depressive episode, rather than a manic episode. c. Seasonal pattern applies to bipolar disorders and recurrent major depression and is used to indicate whether episodes occur during certain seasons, usually wintertime. Those with winter depressions display excessive sleep and weight gain. Seasonal affective disorder may be related to circadian and seasonal changes in the increased production of melatonin (i.e., a hormone secreted by the pineal gland). Phototherapy is a recommended effective treatment for this condition, although CBT may show better long-term results in terms of preventing recurrence of seasonal depression.

Depressive disorders

Major depressive disorder, single episode is defined, in part, by the absence of manic or hypomanic episodes before or during the episode. The occurrence of one isolated depressive episode in a lifetime is rare, and unipolar depression is almost always a chronic condition that waxes and wanes over time, but seldom disappears. Major depressive disorder, recurrent, requires that two or more major depressive episodes occur and are separated by a period of at least 2 months during which the individual is not depressed. As many as 85% of single-episode cases later have a second episode of major depression. The median lifetime number of major depressive episodes is four, and the median duration is 4 to 5 months.

Suicide

Suicide is the eighth leading cause of death in the United States, although many unreported suicides occur. B. Suicide is overwhelmingly a white phenomenon and African Americans and Hispanics seldom commit suicide. Suicide rates are also quite high in Native Americans, though rates vary considerably from tribe to tribe. C. The rate of suicide is increasing, especially among adolescents and the elderly. White men are at highest risk, particularly men over 65. However, in China, females commit suicide more often than males, and the reason seems related to the absence of stigma about suicide in Chinese society (i.e., it is viewed as honorable and a reasonable solution to problems). D. Suicidal ideation refers to serious contemplation about committing suicide, whereas suicidal attempt refers to surviving an attempted suicide. Males are 4-5 times more likely to commit suicide than females, although females are three times more likely to attempt suicide than men. This is explained by the fact that men choose more lethal methods of suicide than women. E. Emile Durkeim, a sociologist, defined a number of suicide types related to the cause of suicide: Formalized or altruistic suicide is socially or familially sanctioned (e.g., killing oneself to avoid dishonor to self or family). Egoistic suicide, which may be common in the elderly, is suicide caused by disintegration of social support. Anomic suicides occur following some major disruption in one's life (e.g., sudden loss of a high prestige job). Anomie means lost and confused. Fatalistic suicides refer to suicide related to a loss of control over one's destiny (e.g., mass suicide of Heaven's Gate cult members). Predicting suicide is difficult, but mental health professionals routinely assess for suicide, often directly via intent, a plan, and a means to carry it out. In general, the more detailed the plan, the more one is at risk for committing suicide. A suicide contract may be used to prevent a patient from killing him or herself, and at times, hospitalization is required. Programs to reduce suicide include curriculum-based programs that are designed to educate students about suicide and to provide means for handling stress. Data indicate that asking people about suicide does not seem to "put the idea in their heads." J. ) Treatments for persons at risk for suicide may employ a problem-solving cognitive-behavioral intervention, coping-based interventions, and stress reduction techniques. One recent study indicated that 10 sessions of cognitive therapy for recent suicide attempters cuts the risk of additional suicide attempts by 50% over the next 18 months.

Bipolar Disorders

The core identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes. Beyond that, bipolar disorders parallel depressive disorders (e.g., a manic episode can occur once or repeatedly). The textbook presents the case of Jane to illustrate Bipolar II disorder. Bipolar I disorder is the alternation of full manic episodes and depressive episodes. The textbook presents the case of Billy to illustrate a full manic episode. a. Average age of onset is 18 years, but it can begin in childhood. b. Tends to be chronic. c. Suicide attempts are estimated to occur in 17% of patients, usually in a depressive episode. 3. In bipolar II disorder, major depressive episodes alternate with hypomanic episodes. a. Average age of onset is 19-22 years, but it can begin in childhood. b. Only 10 to 13% of cases progress to full bipolar I disorder. c. Tends to be chronic.

An integrative theory of the etiology of mood disorders

The onset of stressful life events may then activate stress hormones that affect certain neurotransmitter systems, including turning on certain genes. Extended stress may also affect circadian rhythms and activate a dormant psychological vulnerability characterized by negative thinking and a sense of helplessness and hopelessness.

Treatment of mood disorders

Three types of antidepressant medications are used to treat depressive disorders: Tricyclic antidepressants are widely used treatments for depression, and include imipramine (Tofranil) and amitriptyline (Elavil). It is not yet clear how these drugs work, but initially at least they block the reuptake of norepinephrine and other neurotransmitters (i.e., down-regulation). This process may take anywhere between 2 to 8 weeks, and patients often feel worse and develop side-effects before feeling better. Side-effects include blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain, and sexual dysfunction. Because of the side-effects, about 40% of patients stop taking the drugs. Tricyclics alleviate, but do not eliminate, depression in 50% of cases compared to 25-30% of people taking placebo. Tricyclics may be lethal in excessive doses. Monoamine oxidase (MAO) inhibitors work by blocking an enzyme monoamine oxidase that breaks down serotonin and norepinephrine. MAO inhibitors are slightly more effective than tricyclics and have fewer side-effects. However, ingestion of tyramine foods (e.g., cheese, red wine, beer) or cold medications with the drug can lead to severe hypertensive episodes and occasionally death. New MAO inhibitors (not yet available in the U.S.) are more selective, short acting, and do not interact negatively with tyramine. Use of MAO inhibitors has decreased significantly in recent years. Selective serotonergic reuptake inhibitors (SSRIs) specifically block the pre-synaptic reuptake of serotonin, thus increasing levels of serotonin at the receptor site. Fluoxetine (Prozac) is the best known SSRI. Risks of suicide or acts of violence are no greater with Prozac than with any other antidepressant medication in adults. In adolescents, the data are mixed regarding whether or not SSRIs are related to suicidality, leading to an FDA warning. It is possible that SSRIs confer an initial risk of suicidal thoughts (in the first few weeks), but later are related to decreased suicidality. Common side-effects of Prozac are physical agitation, sexual dysfunction or low desire, insomnia, and gastrointestinal upset. Newer antidepressants, such as Venlafaxine and Nefazodone work on slightly different mechanisms than other SSRIs, and are comparable to effectiveness of older antidepressants.