Affective Disorders and Suicide

8/3/2019 Affective Disorders and Suicide

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Epidemiology of Affective Disorders Bipolar disorder

o Childhood to 50 years of age, earliest is 5-6 yrs. old

o The stronger the family background, the earlier the age of onset of bipolar

disorder Major depression

o Mean age of onset = 40 years

o 50% of cases onset is between 20 50 years old. Doc suspects that it is due to

menopause and mid life crisis.o Marital status: higher in those who have no close interpersonal relationships or

those who have been divorced, annulled, or separated.o No difference in regards to race or socioeconomic status

o F:M2:1. May be due to hormonal changes in menopause or post partum

period.o in terms of comorbidity, there is a higher risk of Axis 1 disorders**

o Aka, unipolar depression. 1 major episode of depression.

Minor depressiono Unable to fulfill criteria of major depression.

Maniao Bipolar I: manic depressive episode.

o Bipolar II: hypomania, which is milder than manic episode.o Both are psychotic in proportion.

Cyclothymiao Non psychotic disorder

o Cyclic nature of manic and depressive episodes, but to a lesser degree. Patient

is still able to function in terms of academic or work function. Dysthmia

o Non psychotic disorder

**Note: most people suffering from affective disorders do not finish college. This may bedue to a disruption in their functioning rather than academic functioning. Comorbidity:increased association with Axis I disorders like alcohol or substance abuse among men and

anxiety disorders (OCD or panic disorder) among women. Major and minor depression arepsychotic in nature vs. dysthymia which is not.

Etiology of Affective Disorders Biological

o Norepinephrine, dopaminergic, and serotonin systems are affected. There is a

decrease in all of this in depressiono Neuroendocrine: TSH and GH responses, but HPA (hypothalamic pituitary

adrenal axis) activityo Immunologic: lymphocytes

o Brain structure abnormalities: left anterior cerebral activity, cerebral blood

flow to mesocortical and mesolimbic pathways. glucose metabolism in limbicsystem in depression. Enlarged ventricles with cortical atrophy and widenedsulci.

Genetico Penetrance


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o Variable expressivity: those who have the genes but have different forms of the

illness. This is determined by studies on twins who have the depressive gene,but who had different presentations of the illness.

o Heterogeneity: multiple genes for the illness.

o Imprinting: parent of origin will affect certain genetic phenomenon.

o Anticipation: severity of disease increases and age of onset decreases with each

generation of the illness.

Genetic Etiology of Affective DisordersChromosome Locus Clinical

2 cAMP responseelement binding protein(CREB1)

Unipolar depression

11 Bipolar disorder

13 13qG72

BPD and schizophrenia

18 q arm Bipolar 2Panic symptomsPassed on by mother

21 BPD and schizophrenia

22 q arm Bipolar (one of the earliestchromosomes discovered

Note: We werent able to grab a screenshot. What is above is taken from the book andthe recording.

Etiology of Depression Biological

o Temperamental dysregulation

Patients who develop depression also come from dysfunctional families with

parents who have low threshold for frustration, etc.

home environment ismore chaotic and leaves the child prone to developing depression Parents who criticize the child excessively Parents who are divorced/separated

o Biological stressors

Certain drugs can cause depression or maniao Medical conditions

Thyroid dysfunctiono Sex

Women have higher risk for depression (than mania) most likely due toanxious/depressive traits women are born with.

Women tend to have more monoamine oxidase, which breaks down

monoamine neurotransmitters in the brain. Low progesterone/high estrogen levelsPMS, post partum depression and

oral contraceptives Women tend to have more dysthymic attributes than men.

Behavioral: Cognitive Theoryo Aaron Beck: negative thinking more so in depressive patients.

o Cognitive triad: helpless, unfavorable perception of self and/or world around

themo Interpretation of events, hopeless future

o Learned helplessness: person has learned to take on such a passive view of life

that they just give up.o Reinforcement: depressive behavior is associated with lack of rewards, so

patient does not try as hard.o Arbitrary inference: drawing conclusions without evidence or support. It is

overcome by finding evidence to support the conclusion. Eg, someone does notsmile back at you and you come to the conclusion that they do not like you.

o Specific abstraction: focusing on a certain detail while ignoring another more

important aspect of an experience. Eg, youve had a great day but one badthing happens and all you can focus on is that bad thing.


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o Overgeneralization: general conclusion based on too little or too narrow an

experience. Eg, having one bad boyfriend makes patient assume all men are nottrustworthy.

o Magnification and minimization: overvaluing or undervaluing the significance of

an event.o Personalization: tendency to self reference actual events without actual basis.

Eg, parent gets mad at one sibling, but not patient. Patient may think they areto blame as well.

o Absolutist, dichotomous thinking: black and white thinking, considering

extremes. Eg, if I dont get a 90 in psychiatry, I will quit medicine. Sociocultural

o Developmental predisposition: linking genetic tendency + dysfunctional home

patient more prone to depressiono Object loss: early breaks in affectional bonds + adult losses. Eg, loss of parent,

especially father, in early life may lead to depression as an adult. 2 step processin break of early bonds. Loss of parent may be through divorce, death,separation via job abroad, etc. There will be a social stressor (eg, bad break upwith boyfriend) that leads to a manic or depressive episode. Succeedingepisodes may not have stressor.

o

(+)life events and environmental stress 1st

episode in mood disorder. Insucceeding episodes, there may not be stressors. Psychodynamic: classic view

o Karl Abraham and Sigmund Freud

Disturbances in infant mother relationship x oral phase Real or imagined object loss Introjection of departed objects Retroflexed anger

o Melanie Klein: express aggression toward loved ones through a passive way. Eg,

the patient is angry at loved one, who is trying to cheer them up. By refusing tocheer up, the patient is showing their anger passively.

o Edward Bibring: aware of discrepancy between extraordinary high ideals and

inability to meet these ideals.o Edith Jacobson: powerless, helpless child victimized by tormenting parent.

o Silvano Arieti: depressed individuals live for others and if that person rejects

them, they get depressed.o Heinz Kohut: loss of self esteem

o John Bowlby: damaged early attachment and traumatic separation

Etiology of Dysthymia Mild depression in a chronic scale Asch: masochistic character. These people enjoy being depressed. Mardi Horowitz: pleasure of revenge. Patient tries to defeat pleasure of those

around them. Tries to fail, is negative, etc.

David Milrod: wallowing in self pity. Cindy Black:

o Anaclitic depression: very anxiously attached to loved ones around them. These

individuals tend to express loneliness, weakness, hopelessness and needsomeone to always show love.

o Interjective depression: individuals who are very self reliant. Experience

depression when they feel guilt, worthlessness, etc.

Depression vs. ManiaPlease review in the book as this is only a short list of what was discussed in class.

Maniao Feelings of elation, invulnerability, energetic, euphoric

o Hyperactive

o Anger

Depressiono Hypoactive, sad

o Low self worth

o Anger

Mixed episodeo Patient has both manic and depressive episodes at the same time. Eg, someone

who is talking a mile a minute but has suicidal thoughts.


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Rapid cyclingo >4 episodes of mania/depression per year.

Etiology of Mania Psychodynamic

o Defense vs. emotional pain, stress, depression

o Denial, distortion delusions. Eg, patient has failed the bar exam but believes

theyre God as a means of cushioning the blow of the failureo Tyrannical superego: intolerable self-criticism replaced by euphoric self

satisfaction. A defense against the superego that tells them they are worthless.There is an idealization mechanism that paints themselves as great.

o Regression: reinstatement of pleasure principle. Overwhelmed by id, sex and

aggression come out. Manic/depressive patient is regressed to the oral stage.Reinstatement of the pleasure principle through expression of sexual andaggressive impulses.

Epidemiology of Suicide Gender: Females tend to attempt suicide more. Males, however, tend to be more

successful.

Age: 15 24 y.o., then another peak at 40 50 (end of life) Race: mostly Caucasians, more immigrants in US. Religion: In US, non Catholics since Catholics view suicide as a mortal sin.

Religion helps some people cope with life and/or suffering. Marital status: higher in singles, separated, never married, annulled, single parents,

etc. because of lack of support systems. Occupation: high stress jobs, soldiers, anesthesiologist (due to access of meds),

ophthalmologist, psychiatrist. Climate: higher rates in winter prone countries Physical health: high in terminally ill Mental illness: more common in

o Substance abusers: alcohol and drugs disinhibit individuals so id impulses come

out.o Depressed individuals

Previous suicidal behavior: if at first you dont succeed, try, try again.

Definition of Suicide Self murder, fatal act, wish to die Thinking vs. acting: In general, the act of attempted suicide indicates an underlying

mental illness because most people are pro life, not pro death. Attempt vs. completed: Attempts are suicides that are unsuccessful and not

completed, naturally. Impulsive vs. premeditated: Impulsive is done on the spur of the moment and

usually in front of someone else, who can prevent the suicide. Premeditated tend to

write notes, give away possessions, reconcile with loved ones, tie up all loose endsbefore committing suicide. They tend to have a sense of calm before the suicideattempt.

Suicide vs. parasuicide: Parasuicide is a suicidal gesture and is not as serious aboutkilling themselves. It can be an attempt at seeking attention, a means tomanipulate another person, or perhaps they are just bored with life.

Etiology of Suicide Biological

o Neurotransmitters

Decreased serotonin Genetic

o Tryptophan hydroxylase gene is associated with patients who commit suicideviolently. It is also associated with alcoholism.

Cognitive theoryo Sense of hopelessness

o (+)family history no acceptable means of coping.

Socioculturalo (-)social support

o (+)stressful life events

Psychodynamic


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o Durkheims theory

Egoistic: lack integration into a group or any social support group. Higher inurban areas where people are less integrated.

Altruistic: excessive integration into a group. Eg, kamikaze pilots, cults,reincarnation believers (ie, Buddhists monks)

Anomic: integration into society is disturbed. Eg, person who declaresbankruptcy kills themselves because they are unable to maintain theirlifestyle.

o Freud Aggression directed inwardly towards the interjected, ambivalently affected

love object.o Menningers Theory

Inverted murder: self directed instinct hostility wish to kill, wish to be killed,wish to die.

Other psychodynamic theories:o Wish for revenge (making people you are angry at feel guilt for your suicide),

power, control, punishment (guilt), atonement, sacrifice, restitution, sleep,escape, rescue from loved one, rebirth or reunion with loved one who died,narcissistic injury (shame), rage, id with suicide victim.

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To this end we always pray for you, that our God will make you worthy of His calling and

may fulfill every resolve for good and every work of faith by His power, so that the name

of our Lord Jesus may be glorified in you, and you in Him, according to the grace of our

God and the Lord Jesus Christ. 2 Thessalonians 1:11-12

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Affective Disorders and Suicide