Affective Disorders

1

Affective Disorders

2

Affective Disorders

U.S. Canada

Anxiety Disorder

BR12 18% 12%

LTR 30% 20%

Mood Disorder

BR12 9%+ 6%+

LTR 17%+ 12%+

3

Affective DisordersIssues

1. Emotional states: adaptive and non-adaptive negative emotionality

2. Feelings: the experience and expression of emotional states

3. Misattribution: confusing content and cause of emotional states

4

Normal and clinical depression

Primary and secondary affective disorders (e.g. “dual diagnosis”)

Comorbidity (especially with Anxiety disorders)

Affective DisordersIssues

5

Affective DisordersDifferential Diagnosis

Mood disorder due to General Medical Condition

Substance-induced Mood Disorder

Adjustment Disorder with Depressed Mood

“Negative emotion disorder”

“Pseudodementia”

“Manic Depression”

6

Affective Disorders

Types: BR12 Lifetime risk

A. Unipolar

1. Major depression 4+% 12% 12+%

2. Dysthymia 2+% 3+%

B. Bipolar

3. Manic depression 1% 1% 2+%4. Cyclothymia 1% 1%

Canadian Totals 6+% 12+%

7

Affective DisordersDysthymia

Clinical picture

Personality: from “neurosis” to “temperament”

“Double depression”

8

Affective DisordersMajor Depressive Disorder

Descriptive features symptoms severity single & recurrent episodes incidence course

9


Treatment chemotherapy (“antidepressants”) Spontaneous remission and ...

Old researchNewer researchNewest research

10


Distinctionsa. exogenous/endogenous (distal causes?)b. major/minor (severity)?c. psychotic/neurotic (severity → cause)?d. melancholic/non-melancholic (proximal causes)

Note: depression with “psychotic” features

depression with “atypical” features

11


Signs of “melancholia”: family history early onset insidious onset normally not

12


Symptoms of “melancholia”: vegetative appetite and weight loss early morning wakening pleasures of the chase and the feast

13

Affective DisordersExplanations

A. Biogenesis1. Genetics

concordance rates, old and new adoptions, old and new

prospective retrospective

possibilities direct influence of genes indirect influence of genes interactive influence of genes

14


A. Biogenesis

2. Biology of negative emotionality

The original theory The monoamine hypotheses, old and new

Catecholamines : Dopamine + Norepinephrine Idoleamine : Serotonin (5-HT)

15

Biology of negative emotionality:

16

A. Biogenesis

2. Biology of negative emotionality The “first generation” antidepressants

tricyclics and their anticholinergic “side effects” MAOIs and “the cheese effect”

The “second generation” antidepressants SSRIs (eg Prozac, Paxil, Zoloft) Atypicals (eg Asendin, Effexor, Wellbutrin) Dual action (eg Serzone, Remeron) Others (eg SNRIs, reversible MAOIs, herbs)


17

Do antidepressants work? The controversy, revisited

The new numbers

The drug alternatives Cocaine : dopamine reuptake Ecstasy : serotonin release Amphetamines : monoamine release

The suicide risk


18

Biological factors, continued genes age experience gene/experience interactions


19

3. Developments1. Body: cortisol and the DST2. Brain: lateralization of emotion

frontal involvement of glutamate involvement of memory : hippocampus & amygdala neurobiology of sleep


20

B. Psychogenesis

1. Psychodynamic theory Freud’s “anaclitic” depression Bowlby’s Attachment theory: “working models” Klerman’s Interpersonal therapy (IPT)


21

2. Learning theory

RewardsRewards : “Response contingent positive

reinforcement” rewards activities Behavioural Activation Treatment


22

PunishmentsPunishments : “Learned Helplessness” and beyond Cognition : “Pessimistic Attributional Style”

(internal, global, stable) Learned Helplessness: “The negative triad”

(helplessness and hopelessness)

thoughts emotions Psychological immunization

(helplessness and hopelessness)

Modern Cognitive Therapy “Mindfulness-based Cognitive Therapy”


23

Some research: “The Dodo Bird Verdict”

... and beyond

1. drugs2. IPT3. cognitive therapy4. placebo


24

2. Phenomenological theory Humanistic perspective : actualization The alternative (and the Existentialists) Logotherapy


25

C. Sociocultural aspects

Cause: sociogenesisContent: autonomous and sociotropic peopleCourse: interpersonal factors in prognosis


26

Affective DisordersSummary

Major Depressive Disorders:melancholic and non-melancholic:

personality factors & disorders?

Dysthymiaprimary and secondary:

melancholic and non-melancholic?

Treatmentdrugs and the alternatives:

specific patient-symptom & non-specific approaches

27

Affective DisordersNotes

1. ECT (“Shock Therapy”) Transcranial Magnetic Stimulation Deep Brain Stimulation

2. SAD (“Depression with a Seasonal Pattern”) Melatonin and the Pineal Gland Light Therapies

3. PDD (“Premenstrual Dysphoric Disorder”) Premenstrual Syndrome The controversy

28

4. Post-Partum Syndromes: “Maternity Blues” “Post-Partum Depression” “Psychotic Depression in the Postpartum Period”

5. The Sex Difference Predisposing factors Reinforcing factors

Affective DisordersNotes

29

Affective DisordersBipolar Disorder and Cyclothymia

A. Descriptive factors: 1. Manic and depressed episodes

Mixed and rapid cycling Bipolar I and II Suicide

2. Cyclothymia Personality Controversy

30

A. Biogenesis1. Genetic

Concordance rates, then and now Adoptions, retrospective and prospective

Possibilities:direct influence of genes?

2. Biology of mania The hypotheses

B. Psychogenesis cause and content


31

C. Therapy

Lithium and its alternatives Anticonvulsants (e.g. Tegretol, Valproate, Lamictal) Atypical Antipsychotics (e.g Risperadol, Zyprexa, Abilify) What else?


32

Affective DisordersSchizoaffective Disorder

Differential Diagnosis

Depression with “mood congruent delusions” Schizophrenia with “secondary depression” A perspective, and a treatment (Symbyax)

33

Affective DisordersSuicide

Social problems and psychiatric ones

Rates, worldwide and Canadian

Trends in Canada

34

Reasons:1. Disinhibitors: “social involvement and identity”

egoistic altruistic anomic

2. Motivations: “escape from self” / ”psychache” standards and expectations stresses, setbacks and self-blame unbearable self-awareness


35


Summary:“Why people die by suicide”:

“Disconnectedness and Ineffectiveness”

Issues:1. Ambivalence

“to be” “not to be” “maybe”

2. Intervention passive suicide assisted suicide euthanasia

36

Affective Disorders

Issues:3. Prevention

societal solutions imitation and contagion (“The Werther Effect”) the biology of suicide

4. Prediction predicting rare events predicting in practice the predictors

• past attempts (the best predictor)• present plan (availability of lethal means)• person (social support)

37

Somatoform & Dissociative Disorders

38

Somatoform disorder

What is happening here?

1. Conversion (“hysteria”)

– Sensory and motor symptoms– Over and under-diagnosis– Purpose?– Compare: “self serving bias” and “self-handicapping”– Notes: “La belle indifference” and lateralizatoin – Conversion, selective attention and dissociation

39

Somatoform disorder

2. Somatization

– Diagnosis– Theory– Therapy– Chronic Conversion?

40

Somatoform disorder

3. Hypochondriasis (and “cyberchondria”)

– Medical preoccupations– Other needs (and “medical offset”)?

“a disorder of cognition and perception”

41

Somatoform disorder

4. Somatoform pain

– Painful preoccupations– Primary and secondary gains?

5. Body Dysmorphia

– Physical preoccupations– Some possibilities (and “muscle dysmorphia”)?

Group forms, old and new

42

Somatoform disorder

MalingeringMalingering: deceit with a purpose

Factitious disorderFactitious disorder:

Munchausen syndrome

Note: self-induced and “proxy” forms

How do you know?

What do you do?

43

Dissociative disorder

What is happening here?

Hypnosis and the study of “dual consciousness”

“Pre-attentive Processing”1. “Dry”: the research in the lab

... the how of “implicit perception and memory”

2. “Wet”: the experience of everyday life

... the why of “intentional not-thinking”

44


AutobiographiesAutobiographies: “deep” and “superficial” memories

... the facts, feelings and fictions

Demonstrations of dissociationDemonstrations of dissociation: group & personal ones

... the Dissociative Experiences Scale

45


1. Dissociative Amnesia Motivated lack of awareness Recovered Memories

1. “Dry”: the learning theory view of memory

... how learning and memory serve external, adaptive needs

2. “Wet”: the psychodynamic view of memory . .. how learning and memory serve internal, personal needs

The lesson from life:The lesson from life: “the complexity of awareness about highly traumatic events”

46


2. Dissociative Fugue

Motivated lack of awareness and movement Episodic, declarative and procedural memory

47


3. Dissociative Identity Disorder

Over and under-diagnosis:“Multiple Personality Disorder” and its problems

Post-traumatic Theory (and “asymmetrical amnesia”)

Sociocognitive view (and “iatrogenic illness”)

Notes: suggestibility and dissociation-proneness

48


4. Depersonalization Disorder

Derealization:“where am I?” and “out-of-body” experiences

Depersonalization:“who am I?” and “partial dissociation”

Note: The story of “Possession/trance disorder”

49

Eating Disorders and Obesity

50


1. Anorexia1. AnorexiaDiagnosable and otherwise

2. Bulimia2. BulimiaPurging and non-purging

3.3. ““Binge-eating disorder”Binge-eating disorder”DSM – V controversies

51


Base rates, clinical and sub-clinical

A. Family context: “expressed emotionality”

B. Personal context: “Clusters B and C”

C. Cultural context: social expectations

52


Beyond the obvious, clinical and sub-clinical

The biological context

• causes, effects and correlates• comorbidities with eating disorder

Course and treatment

53

Binge-eating Disorder

• The social problem• Beyond the BMI• Recognition and getting results• Blaming biology and beyond• Psychological, biological and social factors• Prevention

54

Psychological Factorsand Physical Illness (Axis IV)

Old and new diagnostic practices:“Psychological factors affecting medical condition”

History

1. Psychodynamic (“psychological”) viewpoint:Personality Illness

2. Psychophysiological (“biological”) viewpoint:“Weak link” + stress Illness

55


History

3. Modern Behavioral Medicine and “Health Psychology”

Cause, course, care and cureComparisons of physical health

1900 { 45 – 50

dehydration, TB, pneumonia

2000 { 80+

coronary and cancers

56


1. Peptic UlcersDispositional and situational factors in duodenal ulcers... from monkeys to men to helicobacter pylori and beyond

2. ImmunocompetenceStress and the hypothalamus in immunosuppression and

autoimmune disorders... from the hypothalamus to hormones to neurons and

beyond

57


3. Cardiovascular disordersCoronary heart disease

Type A in causation and prognosis Beyond Type A: anxiety, depression and “Type D”

1. Exercise: the evidence2. Alcohol: the evidence

Dispositional and situational factors

58


59


3. Cardiovascular disorders

Essential hypertensionDiet, exercise, stress...Type A...

Factors: “repressed rage” and beyondImplications for treatment: constructive expression of anger

60

PsychologicalFactors

61


The importanceThe importanceof prevention!of prevention!

62

Personality Disorders (Axis II)

63


• Why axes?• Why diagnosis?• Diagnostic criteria that don’t work:

1. Theoretical criterion: personality isn’t pathology

2. Personal criterion: ego syntonic vs. ego dystonic disorders

3. Social criterion: eccentricity isn’t pathology

64


• Base rates (and comorbidity)

• Prognosis

65


Cluster A: “Eccentric”

1. Schizoid (solitary)2. Schizotypal (idiosyncratic)3. Paranoid (vigilant)

66


Cluster B: Erratic

1. Borderline (mercurial)2. Narcissistic (self-confident)3. Histrionic (dramatic)4. Antisocial (adventurous)

67


Cluster C: “Anxious”

1. Avoidant (sensitive)2. Obsessive-compulsive (conscientious)3. Dependent (devoted)

68


In the appendix...

1. Passive-aggressive2. “Depressive”

69


Note, also....

1. “Sadistic” 2. “Self-defeating”

70

Antisocial Personality Disorder

71

History

Moral insanity, psychopathy and “The Mask of Sanity”

The DSM:

from “Sociopathic Personality Disorder”

to “Antisocial Personality Disorder”

- the problem in principle: no symptoms

- the problem in practice: no reliability

72

The Modern Criteria ... and prevalence rates

The new problem: criteria

“too broad and too narrow”

The Psychopathy

Checklist

“Successful

Psychopaths”

ASPD (DSM III)

ASPD (DSM IV)

“psychopath”/”sociopath”

73

Research

A. Biology, then and now

Concordances: monozygous and dizygous

Adoption: retrospective and prospective

Cross-fostering observations

Other longitudinal research:

“Deviant children grown up” : predictors (Robins)

Prognosis in adulthood

74

Research

B. Psychological factors, then and now

Parents and their children:

Attachment Theory and the “affectionless psychopath” (Bowlby)

Adaptation to Life and “sociopathy” (Vaillant)

“Failed encounters” and the “fledgling psychopath” (Moffit et al)

Cross-cultural studies

Gene-environment interactions:MAO-A and maltreatment

75

Theory

1. The (“primary”) Psychopath... and biological precursors

2. The Sociopath (or “secondary psychopath”)... and psychosocial precursors

e.g Two types of children (Frick)

The difference it makes remission prognosis treatment

76

Theory

The nature of psychopathy

The context: “a mixed incentive task”

A B C D

Passive avoidance conditioning and the “low fear” model (Lykken)

wrong WRONG! RIGHT wrong

77

Theory

The Theory: “an inhibitory deficiency”BAS (Behavioral Activation System)

BIS (Behavioral Inhibition System)

The Theory, updated:Emotional and cognitive components

“dual deficit” model “attention” model

78

Theory

Successful psychopaths, revisited

The “two-edged sword” of antisocial behavior:

means and motives

... comorbidities and their implications

79

Theory

C. Sociocultural factors, then and now

“The Psychopathic Society” (learning)

“The Psychopath within” (psychodynamics)

Beyond psychopathy:the nature of evil

the concept of “insanity”

80

Impulse Control Disorders

1. Intermittent explosion

2. Kleptomania

3. Pyromania

4. Pathological gambling

5. Trichotillomania

Affective Disorders

Documents

mood disorderbr129

secondary affective

majorminor severity

expression of emotional

clinical depression

dopamine reuptakeecstasy

serotonin releaseamphetamines

manic depression1