Affective Disorders

Affective Disorders

U.S.CanadaAnxiety DisorderBR1218%12%LTR30%20%Mood DisorderBR129%+6%+LTR17%+12%+

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

Affective DisordersIssues

Normal and clinical depression

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

Comorbidity (especially with Anxiety disorders)

Affective DisordersDifferential Diagnosis

Mood disorder due to General Medical ConditionSubstance-induced Mood DisorderAdjustment Disorder with Depressed Mood Negative emotion disorder Pseudodementia Manic Depression

Affective Disorders

Types:BR12Lifetime riskA. Unipolar1. Major depression4+% 12% 12+% 2. Dysthymia2+%3+%B. Bipolar3. Manic depression1%1%2+%4. Cyclothymia1%1%Canadian Totals6+% 12+%

Affective DisordersDysthymia Clinical picture Personality: from neurosis to temperament Double depression

Affective DisordersMajor Depressive Disorder

Descriptive features symptoms severity single & recurrent episodes incidence course


Treatment chemotherapy (antidepressants) Spontaneous remission and ...Old researchNewer researchNewest research


Distinctionsexogenous/endogenous (distal causes?)major/minor (severity)?c.psychotic/neurotic (severity cause)?melancholic/non-melancholic (proximal causes)

Note: depression with psychotic featuresdepression with atypical features


Signs of melancholia:family historyearly onsetinsidious onsetnormally not


Symptoms of melancholia:vegetativeappetite and weight lossearly morning wakeningpleasures of the chase and the feast

Affective DisordersExplanations

A. Biogenesis1. Geneticsconcordance rates, old and newadoptions, old and newprospectiveretrospectivepossibilitiesdirect influence of genesindirect influence of genesinteractive influence of genes


A. Biogenesis2. Biology of negative emotionality

The original theoryThe monoamine hypotheses, old and newCatecholamines : Dopamine + NorepinephrineIdoleamine : Serotonin (5-HT)

Biology of negative emotionality:


A. Biogenesis2. Biology of negative emotionalityThe first generation antidepressantstricyclics and their anticholinergic side effectsMAOIs and the cheese effectThe second generation antidepressantsSSRIs (eg Prozac, Paxil, Zoloft)Atypicals (eg Asendin, Effexor, Wellbutrin)Dual action (eg Serzone, Remeron)Others (eg SNRIs, reversible MAOIs, herbs)


Do antidepressants work?

The controversy, revisitedThe new numbers

The drug alternativesCocaine : dopamine reuptakeEcstasy : serotonin releaseAmphetamines : monoamine release

The suicide risk


Biological factors, continuedgenesageexperiencegene/experience interactions


3. DevelopmentsBody: cortisol and the DSTBrain: lateralization of emotionfrontal involvement of glutamateinvolvement of memory : hippocampus & amygdalaneurobiology of sleep


B. Psychogenesis1. Psychodynamic theoryFreuds anaclitic depressionBowlbys Attachment theory: working modelsKlermans Interpersonal therapy (IPT)


2. Learning theory

Rewards : Response contingent positive reinforcementrewards activitiesBehavioural Activation Treatment


Punishments : Learned Helplessness and beyondCognition : Pessimistic Attributional Style(internal, global, stable)Learned Helplessness: The negative triad(helplessness and hopelessness)thoughts emotionsPsychological immunization(helplessness and hopelessness)Modern Cognitive TherapyMindfulness-based Cognitive Therapy


Some research: The Dodo Bird Verdict ... and beyond

drugsIPTcognitive therapyplacebo


3. Phenomenological theoryHumanistic perspective : actualizationThe alternative (and the Existentialists)Logotherapy


Sociocultural aspects

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

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

Affective DisordersNotes

ECT (Shock Therapy)Transcranial Magnetic StimulationDeep Brain Stimulation

SAD (Depression with a Seasonal Pattern) Melatonin and the Pineal GlandLight Therapies

PDD (Premenstrual Dysphoric Disorder)Premenstrual SyndromeThe controversy

Affective DisordersNotes

Post-Partum Syndromes: Maternity BluesPost-Partum Depression Psychotic Depression in the Postpartum Period

The Sex DifferencePredisposing factorsReinforcing factors

Affective DisordersBipolar Disorder and Cyclothymia

A. Descriptive factors:

Manic and depressed episodesMixed and rapid cyclingBipolar I and IISuicide

CyclothymiaPersonalityControversy


BiogenesisGeneticConcordance rates, then and nowAdoptions, retrospective and prospectivePossibilities:direct influence of genes?

Biology of maniaThe hypotheses

Psychogenesiscause and content


Therapy

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

Affective DisordersSchizoaffective Disorder

Differential Diagnosis

Depression with mood congruent delusionsSchizophrenia with secondary depressionA perspective, and a treatment (Symbyax)

Affective DisordersSuicide

Social problems and psychiatric onesRates, worldwide and CanadianTrends in Canada

Affective DisordersSuicideReasons:Disinhibitors: social involvement and identityegoisticaltruisticanomicMotivations: escape from self / psychachestandards and expectationsstresses, setbacks and self-blameunbearable self-awareness

Affective DisordersSuicide

Summary:Why people die by suicide:Disconnectedness and IneffectivenessIssues:Ambivalenceto benot to bemaybeInterventionpassive suicideassisted suicideeuthanasia

Affective Disorders

Issues:Preventionsocietal solutionsimitation and contagion (The Werther Effect)the biology of suicidePredictionpredicting rare eventspredicting in practicethe predictorspast attempts (the best predictor)present plan (availability of lethal means)person (social support)

Somatoform & Dissociative Disorders

Somatoform disorderWhat is happening here?

1. Conversion (hysteria)

Sensory and motor symptomsOver and under-diagnosisPurpose?Compare: self serving bias and self-handicappingNotes: La belle indifference and lateralizatoin Conversion, selective attention and dissociation

Somatoform disorderSomatization

DiagnosisTheoryTherapyChronic Conversion?

Somatoform disorderHypochondriasis (and cyberchondria)

Medical preoccupationsOther needs (and medical offset)?

a disorder of cognition and perception

Somatoform disorderSomatoform pain

Painful preoccupationsPrimary and secondary gains?

Body Dysmorphia

Physical preoccupationsSome possibilities (and muscle dysmorphia)?

Group forms, old and new

Somatoform disorder

Malingering: deceit with a purpose

Factitious disorder: Munchausen syndromeNote: self-induced and proxy forms

How do you know?What do you do?

Dissociative disorderWhat is happening here?

Hypnosis and the study of dual consciousness

Pre-attentive Processing1. Dry: the research in the lab... the how of implicit perception and memory2. Wet: the experience of everyday life... the why of intentional not-thinking

Dissociative disorder

Autobiographies: deep and superficial memories... the facts, feelings and fictions

Demonstrations of dissociation: group & personal ones... the Dissociative Experiences Scale

Dissociative disorder1. Dissociative AmnesiaMotivated lack of awarenessRecovered Memories1. Dry: the learning theory view of memory ... how learning and memory serve external, adaptive needs2. Wet: the psychodynamic view of memory . .. how learning and memory serve internal, personal needs

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

Dissociative disorder2. Dissociative Fugue

Motivated lack of awareness and movementEpisodic, declarative and procedural memory

Dissociative disorder3. Dissociative Identity Disorder

Over and under-diagnosis:Multiple Personality Disorder and its problemsPost-traumatic Theory (and asymmetrical amnesia)Sociocognitive view (and iatrogenic illness)Notes: suggestibility and dissociation-proneness

Dissociative disorder4. Depersonalization Disorder

Derealization:where am I? and out-of-body experiencesDepersonalization:who am I? and partial dissociation

Note: The story of Possession/trance disorder

Eating Disorders and Obesity

Eating Disorders and Obesity1. AnorexiaDiagnosable and otherwise

2. BulimiaPurging and non-purging

Binge-eating disorderDSM V controversies

Eating Disorders and ObesityBase rates, clinical and sub-clinical

Family context: expressed emotionality

Personal context: Clusters B and C

Cultural context: social expectations

Eating Disorders and ObesityBeyond the obvious, clinical and sub-clinical

The biological context

causes, effects and correlatescomorbidities with eating disorder

Course and treatment

Binge-eating Disorder

The social problemBeyond the BMIRecognition and getting resultsBlaming biology and beyondPsychological, biological and social factorsPrevention

Psychological Factorsand Physical Illness (Axis IV)Old and new diagnostic practices:Psychological factors affecting medical condition

History

Psychodynamic (psychological) viewpoint:Personality Illness

Psychophysiological (biological) viewpoint:Weak link + stress Illness

Psychological Factorsand Physical Illness (Axis IV)History

Modern Behavioral Medicine and Health PsychologyCause, course, care and cureComparisons of physical health

1900 {45 50dehydration, TB, pneumonia

2000 {80+coronary and cancers

Psychological Factorsand Physical Illness (Axis IV)

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

ImmunocompetenceStress and the hypothalamus in immunosuppression and autoimmune disorders... from the hypothalamus to hormones to neurons and beyond

Psychological Factorsand Physical Illness (Axis IV)3. Cardiovascular disorders

Coronary heart disease Type A in causation and prognosis Beyond Type A: anxiety, depression and Type D

Exercise: the evidenceAlcohol: the evidence

Dispositional and situational factors

Psychological Factorsand Physical Illness (Axis IV)

Psychological Factorsand Physical Illness (Axis IV)3. Cardiovascular disorders

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

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

PsychologicalFactors

Psychological Factorsand Physical Illness (Axis IV)The importanceof prevention!

Personality Disorders (Axis II)

Personality Disorders (Axis II)Why axes?Why diagnosis?Diagnostic criteria that dont work:1. Theoretical criterion: personality isnt pathology2. Personal criterion: ego syntonic vs. ego dystonic disorders3. Social criterion: eccentricity isnt pathology


Base rates (and comorbidity)

Prognosis


Cluster A: Eccentric

Schizoid (solitary)Schizotypal (idiosyncratic)Paranoid (vigilant)


Cluster B: Erratic

Borderline (mercurial)Narcissistic (self-confident)Histrionic (dramatic)Antisocial (adventurous)


Cluster C: Anxious

Avoidant (sensitive)Obsessive-compulsive (conscientious)Dependent (devoted)


In the appendix...

Passive-aggressiveDepressive


Note, also....

Sadistic Self-defeating

Antisocial Personality Disorder

HistoryMoral 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

The Modern Criteria ... and prevalence ratesThe new problem: criteriatoo broad and too narrow

The Psychopathy ChecklistSuccessful PsychopathsASPD (DSM III)ASPD (DSM IV)psychopath/sociopath

ResearchBiology, then and now

Concordances: monozygous and dizygousAdoption: retrospective and prospectiveCross-fostering observationsOther longitudinal research:Deviant children grown up : predictors (Robins)Prognosis in adulthood

ResearchPsychological 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 (Moffitt et al)Cross-cultural studiesGene-environment interactions:MAO-A and maltreatment

TheoryThe (primary) Psychopath... and biological precursorsThe Sociopath (or secondary psychopath)... and psychosocial precursors

e.g Two types of children (Frick)

The difference it makesremissionprognosistreatment

TheoryThe nature of psychopathyThe context: a mixed incentive taskABCDPassive avoidance conditioning and the low fear model (Lykken)

wrongWRONG!RIGHTwrong

TheoryThe Theory: an inhibitory deficiencyBAS (Behavioral Activation System)BIS (Behavioral Inhibition System)The Theory, updated:Emotional and cognitive componentsdual deficit modelattention model

TheorySuccessful psychopaths, revisitedThe two-edged sword of antisocial behavior:means and motives

... comorbidities and their implications

TheoryC. Sociocultural factors, then and nowThe Psychopathic Society (learning)The Psychopath within (psychodynamics)Beyond psychopathy:the nature of evilthe concept of insanity

Impulse Control Disorders

1.Intermittent explosion2.Kleptomania3.Pyromania4.Pathological gambling5.Trichotillomania

Documents

Affective Disorders