psychology term paper

Mood Disorders

...no longer Mood Disorders...

Major Depressive Disorder !  Depressed mood or loss of interest over a 2 week period

!  5 or more symptoms present (with at least 1 symptom being depressed mood or loss of interest/pleasure) !  Depressed mood (in kids, can be irritability) !  Diminished interest or pleasure in all, or almost all, activities !  Significant weight loss or weight gain (not from dieting;

change of more than 5%) !  Insomnia or hypersomnia !  Psychomotor agitation or retardation !  Fatigue/loss of energy !  Feelings of worthlessness/excessive guilt !  Diminished ability to think or concentrate !  Suicidal ideation

!  Criterion B: Symptoms cause clinically significant distress or impairment in social/occupational

!  Criterion C: Not attributable to physiological effects of a substance or general medical condition

!  Criterion D: Depressive episode not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder

!  Criterion E: No history of manic or hypomanic episode

Specifiers !  Severity: mild, moderate, severe

!  With mixed features (experience at least 3 manic or hypomanic symptoms during the course of a major depressive episode)

!  With anxious distress (experience of at least 2 anxiety symptoms during course of depressive episode)

!  Melancholic features, atypical features, mood-congruent psychotic features, mood-incongruent psychotic features, with catatonia, with seasonal pattern

Bye Bye Bereavement Exclusion

!  Removed exclusion that depression cannot be diagnosed in context of bereavement within 2 months of loss !  Ensured that someone grieving was not diagnosed as

ill/depressed

!  Why did DSM 5 get rid of it? !  Used Wakefield’s research against him

Wakefield’s Research on Loss

!  Why are/were other serious losses that can cause sadness ignored? Why only exclusion for bereavement? !  Is bereavement different than other losses/stresses?

!  Mined data from NIMH survey !  No differences between those whose symptoms were triggered

by bereavement vs. different losses (e.g., divorce, financial) !  Looked at how bereaved vs. nonbereaved differed on number of,

and duration of, symptoms (as well as which symptoms were reported)

!  Conclusion: other losses just as likely to leave a person depressed !  No scientific reason to treat death of loved one differently !  Expand bereavement exclusion to “other life stressors” to

distinguish disorder from suffering?

Wakefield vs. DSM 5 !  Return to pre-DSM II idea that sadness in response

to loss is normal/human condition (reaction) !  Differentiates suffering from disorder

!  DSM 5 taskforce: these findings show that bereavement should not be a special exclusion !  All qualify as mentally ill

!  Oh…I see what you did there…

Persistent Depressive Disorder

!  The new dysthymia and chronic MDD

!  This is about chronicity more than severity

!  Depressed mood for 2 years (1 year in children)

!  At least 2 of the following: !  Poor appetite/overeating !  Insomnia/hypersomnia !  Low energy/fatigue !  Low self-esteem !  Poor concentration/indecisive !  Hopelessness

!  Never without depressed mood or 2 symptoms for more than 2 months

!  No history of manic, mixed, hypomanic episode

Specify Me !  Mild, moderate, severe

!  Early onset (before 21) vs. Late onset

!  With mixed features

!  With anxious distress

!  Melancholic features, yada, yada, yada

!  Pure dysthymic syndrome !  Never met criteria for major depression

!  With persistent major depressive episode

!  With intermittent major depressive episodes (with or without current episode)

Age-Specific Features of Depression

!  Similar to adults for the most part !  Young children (7+): irritability, comorbid anxiety

(phobias, separation anxiety), tantrums, oppositional/ argumentative

!  Adolescents: Antisocial behaviour, aggression, inattention, social withdrawal !  Cognitive symptoms begin to emerge: guilt, low self-

esteem/body image/worthlessness, anhedonia, hoplelessness

!  Gender differences !  Implications for potential misdiagnosis? Amorphous

blob??

Why the gender differences? !  Hormones?

!  Estrogen

!  Social role changes from sexual maturity !  Early maturing girls have worst outcomes

!  Negotiating interpersonal relationships !  Females more concerned with cooperation/being social !  More sensitive to interpersonal loss/rejection

!  Girls more likely to ruminate

!  Socialized to be more dependent, less assertive = less autonomous ! depression

Comorbidity !  Up to 90% of kids/adolescents with depression

meet criteria for another diagnosis

!  Most frequent: anxiety disorders !  GAD, specific phobia, separation anxiety

!  Dysthymia (double depression), conduct problems, ADHD, substance use also common

!  Is it comorbid condition ! depression or vice versa?

Course of Depression !  Onset in most cases is in adolescence

!  Sudden vs. gradual

!  Average episode: 8 months

!  Recurring pattern !  25% within 1 year !  40% within 2 years !  70% within 5 years !  Acute condition????

!  The earlier the onset, the more comorbidity, and the more severe the suicidal ideation = worse prognosis

!  1/3 depressed adolescents develop bipolar (bipolar switch)

!  Sensitized to future depressive responses to stressors ?

Depression in Infants/ Toddlers?

!  Not clearly recognizable using DSM criteria !  Rare, but present at toddler/young child age

!  Possible to identify depression in 3-7 year olds !  Withdrawn, inhibited (lack of spark/energy), clingy, whiny,

irritable without apparent trigger, somatic symptoms

!  Anaclitic depression !  Usually associated with early attachment disruptions

!  Removed from mother !  No opportunity to form attachment

!  Weeping, withdrawal, apathy, weight loss, sleep disturbance

Pretty clear, right? !  Not entirely. Depression in adolescents seems to

vary

!  Story time !  Are these kids depressed? !  Something else? !  Comorbidity explain differences?

!  Is discrete depressive episode (2 weeks) similar or categorically different from pervasive depression? !  Discrete vs. dispositional

Theories of Depression !  Psychodynamic

!  Internalized rage, anger, aggression !  Often triggered by loss of ambivalently loved object

!  Attachment !  Insecure attachment ! increased distress, distorted

internal working models

!  Behavioral !  Lack of reinforcement for social/adaptive responses

!  Cognitive !  Depressogenic cognitions (hopelessness, negative view of

self/world/future)

Causes of Depression (get your flow charts out...)

!  Genetics !  Depression tends to run in families

!  Neurobiology !  Samey, samey (limbic system, prefrontal cortex,

hippocampus, HPA axis)

!  Family !  Parents more critical/punitive; more conflict; intrusive vs.

uninvolved; lack of warmth; disengagement !  Parents with depression (less emotional availability/

responsiveness, affection, positive affect) !  Coregulation issues anyone? !  Overinvolved or withdrawn !  Kids get parentified ! grow up fast but arrested development

!  Anxiety !  Tends to precede depression !  Bowlby: object loss ! anxiety ! despair ! giving up !  Heightened physiological arousal of anxiety ! organism shut

down and withdrawal !  Rumination from anxiety magnifies problems ! depression

!  For adolescents: not achieving developmental goals !  Autonomy; peer acceptance

!  Stressful Life Events

!  Emotion regulation !  Self-awareness !  Coping

Treatment !  See, you already know...

!  Medication

The Trouble with Trials – FDA Version

!  Approx 50% of drug trials submitted to FDA for 12 leading antidepressants show advantage over placebo !  When present, the advantage is small

!  Publication bias: 36/38 “successful” trials published vs. only 14/36 of “unsuccessful” trials published !  11 of those framed in positive manner

How Could You Let this Happen FDA?

!  FDA traditionally granted very little power over drug industry. Original laws… !  Responsible for certifying drugs but not permitted to

make decisions based on efficacy !  That would be a matter of opinion

!  Can only comment on safety !  Short time to respond to new drug applications with a

budget 1/20th of the pharmaceutical companies !  In 50s, “wonder drugs” (antibiotics, corticosteroids,

diuretics) give everyone confidence in drug industry

!  In 60s, law changes (slightly): FDA can require drugs to be proven safe and efficacious

But what is efficacy/ effectiveness?

!  Definition: “substantial evidence” that the drug is effective

!  Loophole city: Don’t need a “preponderance” of evidence !  So, contrary evidence can exist !  FDA: 2 independent trials with statistically significant

results is “substantial” evidence

Manipulating Statistics: The RCT

!  Randomized, clinical trial used to “prove” effectiveness

!  Used Fisher statistics !  Not intended to “prove” anything; intended to “disprove” that

there are differences between groups !  Design aimed at retaining null hypothesis

!  Popperian: trying to disprove theories

!  Stats only inform of probability that result is found by chance !  P value not meaningful indicator of degree of difference or

effectiveness

!  Supposed to replicate and if repeatedly reject null hypothesis, then gaining some degree of certainty that result is not random

Facepalm (cont’d) !  But, medicine/drug companies are using research design to

claim that drugs are effective (they work) !  It’s a tightly controlled, unbiased study!

!  Presume research paradigm eliminates chance !  Just gives you an idea, on test day, what probability is of

results being due to chance

!  Not only are you meant to replicate, replicate, replicate, but, according to definition, only need 2 studies rejecting null hypothesis and can ignore studies in which null is not rejected !  Popperian disconfirmation

!  By the power of science….I HAVE THE POWER !  Using “science” to lend air of objectivity/authority to results

…and the advertising doesn’t hurt either

!  Drug companies advertise directly to MDs !  Provide scripts of what to say even

!  In 80s, SSRIs marketed as superior because they are “selective” and “targeted” !  Prozac: “the first highly specific, highly potent

blocker of serotonin uptake”

!  Marketed as “clean”, “strong”, “effective”

!  Advertise directly to consumers

Disruptive Mood Dysregulation Disorder

!  Brand spanking new!!!

!  Severe recurrent temper outburst manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation

!  Temper outbursts are inconsistent with developmental level.

!  Temper outbursts occur, on average, 3 or more times per week.

!  The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers).

!  These criteria are present for 12 or more months

!  Present in at least 2 of 3 settings (at home, at school, with peers); severe in at least 1

!  Can’t diagnose this before 6 or after 18

!  Age at onset before 10

!  No signs of manic/hypomanic episode for >1 day

!  Symptoms do not happen exclusively during MDD and not better explained by another disorder (e.g., autism, PTSD, separation anxiety)

Manic Episode !  A distinct period of abnormally and persistently elevated,

expansive, or irritable mood, increased goal-directed activity or energy !  lasting at least 1 week and present most of the day, nearly every day

!  3 or more of the following (4 if the mood is only irritable) are present:  !  Inflated self-esteem or grandiosity. !  Decreased need for sleep !  More talkative than usual or pressure to keep talking  !  Flight of ideas/thoughts racing !  Distractibility  !  Increase in goal-directed activity or psychomotor agitation !  Excessive involvement in pleasurable activities that have a high

potential for painful consequences (e.g., spending sprees, sexual indiscretions, or foolish business investments)

Hypomanic Episode !  Main difference is that it is not severe enough to

cause marked impairment in social or occupational functioning or to necessitate hospitalization.

!  If there are psychotic features, the episode is, by definition, manic.

Bipolar Disorder I !  At least one manic episode

!  May have been preceded or followed by hypomanic or major depressive episode

!  Specify current or most recent episode: Manic or Major Depressive Episode

!  Mild, moderate, severe !  With Mixed Features !  With anxious distress:

!  With rapid cycling; mood-congruent psychotic features. Etc. etc.

Bipolar Disorder II !  At least one hypomanic episode and at least one

major depressive episode !  No history of manic episode

!  Everything else = same

Cyclothymic Disorder !  For 2 years, numerous periods with hypomanic

symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. !  at least 1 year in children and adolescents

!  Not without symptoms for more than 2 months !  Symptoms present “at least half the time”

!  Never met criteria for manic, hypomanic, or major depressive episode

Does BP exist in youth? !  Occurs infrequently

!  Presentation is extremely variable (even within kid)

!  Overlap with other disorders (e.g., ADHD) !  Jumping between activities, risk-taking

!  Biggest controversy is pre-pubertal BP !  Mood swings, lability, irritability, aggression

!  Is this BP??? !  If not, functioning still severely impaired

!  Atypical symptoms (mood changes more erratic, volatile than persistent – often don’t meet 1 week criterion) !  Irritability more common than euphoria !  Restraints on reckless behaviour

Bad Bad Biederman…. !  Joseph Biederman

!  Originator of childhood bipolar !  Used to be believed that onset was early adulthood

!  Originally an ADHD expert !  Believed a particular group of ADHD kids were

distinct !  Quick to anger, hard to comfort, precocious, defiant,

cranky, mood swings (in addition to fidgety/distractible)

!  The chronic irritability ! mood disorder !  These kids are bipolar and need mood stabilizers, not

stimulants

Adjusting the Diagnostic Criteria

!  But, bipolar required distinct manic episodes and these kids do not demonstrate this (no high highs)

!  Also, the criterion B symptoms overlap substantially with ADHD !  Excessive talkativeness, distractibility, restlessness

!  Biederman believed that his subset of ADHD kids more likely to have the other criterion B symptoms not shared with ADHD !  Kids with this profile are bipolar (even though not

manic)

Critical Reception? !  Flies in the face of established knowledge re: episodic nature

of mania !  These kids are like this all the time

!  Studies have not turned up episodes of mania in kids

!  Remaining criterion B symptoms are characteristic of childhood! !  Grandiosity, flight of ideas, involvement in pleasurable

activities with high potential for pain

!  This would lower threshold for diagnosis of a severe illness

!  Biederman responds: his subset of kids are more irritable than ADHD kids, more withdrawn, and more likely to sulk !  Even though this is all inconsistent with mania, he persists…

Biederman Persists… !  Begins using the Bipolar NOS category

!  Others follow suit

!  There is a need here. These kids are volatile and very difficult to manage/parent

!  Give parents a diagnosis and a medication ! serenity now

!  Self-validating nature of diagnosis !  Now Biederman’s subset is a juvenile form of bipolar

Let’s Treat Juvenile Bipolar! !  Treatment for bipolar in adults ! severe mood

stabilizers

!  Let’s use them with kids too because they have bipolar too! !  Heavily sedating (treating or tranquilizing?) !  Side effects: obesity, diabetes, tardive dyskinesia,

possible decrease of life expectancy

Why Bipolar, Biederman? !  Could have tinkered with ADHD, ODD, or even Disruptive

Behaviour Disorder

!  Why not a new diagnosis? Scary Impossible Child Disorder?

!  Insurance won’t pay for ODD treatment !  New mood stabilizing meds coming on the market as

Biederman pounds the pavement. Hmmmm… !  Atypical antipsychotics beginning to emerge (although

effectiveness/side effects on kids not studied) !  Biederman in bed with Big Pharma developing these drugs !  Big Pharma funding research on Bipolar in kids (just so

happens antipsychotics are treatment of choice for this)

The Biederman Effect !  By 2003, prevalence of bipolar in children/

adolescents increased by factor of 40

!  By 2005, antipsychotic use in youth increased by 73%

!  In 2007, half a million children (20, 000 under 6 years of age) were prescribed these heavy antipsychotics now that bipolar diagnosis justifies this type of treatment !  Needed severe diagnostic label to justify severe

treatment

Diagnostic Considerations !  Psychotic symptoms not uncommon

!  Hallucinations, delusions (paranoia), thought disorder !  Schizophrenia vs. Bipolar?

!  Hypomanic, mixed, or rapid cycling more common than manic episode

!  Course tends to be chronic

!  Long term prognosis not great

Causes and Treatment !  Genetic component

!  Limbic system, prefrontal cortex, hippocampus (surprise!!) !  Also, basal ganglia, thalamus

!  Treatment: mood stabilizers !  Lithium/anti-seizure meds/antipsychotics !  Adherence to med treatment a big problem

!  Psychosocial interventions focus primarily on this