Affective Disorders 1 Affective Disorders 2 U S

Affective Disorders 1

Affective Disorders 2 U. S. Canada Anxiety Disorder BR 12 LTR 18% 30% 12% 20% Mood Disorder BR 12 LTR 9% 17% 6% 12%

Affective Disorders Issues 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 3

Affective Disorders Issues Ø Normal and clinical depression Ø Primary and secondary affective disorders (e. g. “dual diagnosis”) Ø Comorbidity (especially with Anxiety disorders) 4

Affective Disorders Differential Diagnosis Ø Mood disorder due to General Medical Condition Ø Substance-induced Mood Disorder Ø Adjustment Disorder with Depressed Mood Ø “Negative emotion disorder Ø “Pseudodementia” Ø “Manic Depression” 5

Affective Disorders Types: Prevalence Lifetime risk A. Unipolar 4+% 12% 2+% 3. Manic depression 1% 4. Cyclothymia 1% 1% 6+% 12+% 1. Major depression 2. Dysthymia 12+% B. Bipolar Canadian Totals 6 2+%

Affective Disorders Dysthymia Ø Clinical picture Ø Personality: from “neurosis” to “temperament” Ø “Double depression” 7

Affective Disorders Major Depressive Disorder Descriptive features Ø symptoms Ø severity Ø single & recurrent episodes Ø incidence Ø course 8

Affective Disorders Major Depressive Disorder Treatment Ø chemotherapy (“antidepressants”) Ø Spontaneous remission and. . . ØOld research ØNewer research ØNewest research 9

Affective Disorders Major Depressive Disorder Distinctions a. b. c. d. 10 exogenous/endogenous (distal causes? ) major/minor (severity)? psychotic/neurotic (severity → cause)? melancholic/non-melancholic (proximal causes) e. Note: f. depression with “psychotic” features depression with “atypical” features

Affective Disorders Major Depressive Disorder Signs of “melancholia”: Ø Ø 11 family history early onset insidious onset normally not

Affective Disorders Major Depressive Disorder Symptoms of “melancholia”: Ø Ø 12 vegetative appetite and weight loss early morning wakening pleasures of the chase and the feast

Affective Disorders Explanations A. Biogenesis 1. Genetics Ø concordance rates, old and new Ø adoptions, old and new Ø Ø prospective retrospective Ø possibilities Ø Ø Ø 13 direct influence of genes interactive influence of genes

Affective Disorders Explanations A. Biogenesis 2. Biology of negative emotionality Ø The original theory Ø The monoamine hypotheses, old and new 14

Biology of negative emotionality: 15

Affective Disorders Explanations A. Biogenesis 2. Biology of negative emotionality Ø The “first generation” antidepressants Ø Ø tricyclics and their anticholinergic “side effects” MAOIs and “the cheese effect Ø The “second generation” antidepressants Ø Ø 16 SSRIs (eg Prozac, Paxil, Zoloft Atypicals (eg Asendin, Effexor, Wellbutrin Dual action (eg Serzone, Remeron) Others (eg SNRIs, reversible MAOIs, herbs

Affective Disorders Explanations Do antidepressants work? Ø The controversy, revisited Ø The new numbers Ø The drug alternatives Ø Ø Ø Cocaine : dopamine reuptake Ecstasy : serotonin release Amphetamines : monoamine release Ø The suicide risk 17

Affective Disorders Explanations Ø Biological factors, continued § § 18 genes age experience gene/experience interactions

Affective Disorders Explanations 3. Developments 1. 2. 19 Body: cortisol and the DST Brain: lateralization of emotion Ø frontal involvement of glutamate Ø involvement of memory : hippocampus & amygdala Ø neurobiology of sleep

Affective Disorders Explanations B. Psychogenesis 1. Psychodynamic theory Ø Freud’s “anaclitic” depression Ø Bowlby’s Attachment theory Ø Klerman’s Interpersonal therapy (IPT) 20

Affective Disorders Explanations 2. Learning theory Ø Rewards : “Response contingent positive reinforcement Ø rewards activities Ø Behavioural Activation Treatment 21

Affective Disorders Explanations Punishments : “Learned Helplessness” and beyond Ø Cognition : “Pessimistic Attributional Style” (internal, global, stable) Ø Learned Helplessness: “The negative triad” (helplessness and hopelessness) thoughts emotions Ø Psychological immunization (helplessness and hopelessness) Ø Modern Cognitive Therapy Ø “Mindfulness-based Cognitive Therapy” 22

Affective Disorders Explanations Some research: “The Dodo Bird Verdict” . . . and beyond 1. 2. 3. 4. 23 drugs IPT cognitive therapy placebo

Affective Disorders Explanations 2. Phenomenological theory Ø Humanistic perspective : actualization Ø The alternative (and the Existentialists) Ø Logotherapy 24

Affective Disorders Explanations C. Sociocultural aspects Cause: sociogenesis Content: autonomous and sociotropic people Course: interpersonal factors in prognosis 25

Affective Disorders Summary Major Depressive Disorders: melancholic and non-melancholic: personality factors & disorders? Dysthymia primary and secondary: melancholic and non-melancholic? Treatment drugs and the alternatives: specific patient-symptom & non-specific factor approaches 26

Affective Disorders Notes 1. ECT (“Shock Theraoy”) Ø Ø Transcranial Magnetic Stimulation Deep Brain Stimulation 2. SAD (“Depression with a Seasonal Pattern”) Ø Ø Melatonin and the Pineal Gland Light Therapies 3. PDD (“Premenstrual Dysphoric Disorder”) Ø Ø 27 Premenstrual Syndrome The controversy

Affective Disorders Notes 4. Post-Partum Syndromes: Ø Ø Ø “Maternity Blues” “Post-Partum Depression” “Psychotic Depression in the Postpartum Period” 5. The Sex Difference Ø Ø 28 Predisposing factors Reinforcing factors

Affective Disorders Bipolar Disorder and Cyclothymia A. Descriptive factors: 1. Manic and depressed episodes Ø Ø Ø Mixed and rapid cycling Bipolar I and II Suicide 2. Cyclothymia Ø Ø 29 Personality Controversy

Affective Disorders Bipolar Disorder and Cyclothymia A. Biogenesis 1. Genetic Ø Ø Concordance rates, then and now Adoptions, retrospective and prospective Possibilities: direct influence of genes? 2. Biology of mania Ø The hypotheses B. Psychogenesis Ø 30 cause and content

Affective Disorders Bipolar Disorder and Cyclothymia C. Therapy Ø Ø 31 Lithium and its alternatives Anticonvulsants (e. g. Tegretol, Valproate, Lamictal) Atypical Antipsychotics (e. g Risperadol, Zyprexa, Abilify) What else?

Affective Disorders Schizoaffective Disorder Differential Diagnosis Ø Depression with “mood congruent delusions” Ø Schizophrenia with “secondary depression” Ø A perspective, and a treatment (Symbyax) 32

Affective Disorders Suicide Ø Social problems and psychiatric ones Ø Rates, worldwide and Canadian Ø Trends in Canada 33

Affective Disorders Suicide Reasons: 1. Disinhibitors: “social involvement and identity” Ø egoistic Ø altruistic Ø anomic 2. Motivations: “escape from self” / ”psychache” Ø standards and expectations Ø stresses, setbacks and self-blame Ø self-awareness 34

Affective Disorders Suicide Summary: “Why people die by suicide”: “Disconnectedness and Ineffectiveness” Issues: 1. Ambivalence Ø Ø Ø “to be” “not to be” “maybe” 2. Intervention Ø Ø Ø 35 passive suicide assisted suicide euthanasia

Affective Disorders Issues: 3. Prevention Ø Ø Ø societal solutions imitation and contagion (“The Werther Effect”) the biology of suicide 4. Prediction Ø Ø Ø predicting rare events predicting in practice the predictors • • • 36 past attempts (the best predictor) present plan (availability of lethal means) person (social support)

Somatoform & Dissociative Disorders 37

Somatoform disorder What is happening here? 1. Conversion (“hysteria”) – – – 38 Sensory and motor symptoms Over and under-diagnosis Purpose? Compare: “self serving bias” and “self-handicapping” Notes: “La belle indefference” and lateralizatoin Conversion, selective attention and dissociation

Somatoform disorder 2. Somatization Diagnosis – Theory – Therapy – Chronic Conversion? – 39

Somatoform disorder 3. Hypochondriasis (and “cyberchondria”) Medical preoccupations – Other needs (and “medical offset”)? – 40

Somatoform disorder 4. Somatoform pain Painful preoccupations – Primary and secondary gains? – 5. Body Dismorphia Physical preoccupations – Some possibilities (and “muscle dysmorphia”)? – Groups, forms, old and new 41

Somatoform disorder Malingering: Malingering deceit with a purpose Factitious disorder: disorder Munchausen syndrome Note: self-induced and “proxy” forms 42

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” 43

Dissociative disorder Autobiographies: “deep” and “superficial” memories Autobiographies. . . the facts, feelings and fictions Demonstrations of dissociation: group & personal ones dissociation. . . the Dissociative Experience Scale 44

Dissociative disorder 1. Dissociative Amnesia Ø Motivated lack of awareness Ø 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 complexity of awareness about highly traumatic events” 45

Dissociative disorder 2. Dissociative Fugue Ø Motivated lack of awareness and movement Ø Episodic, declarative and procedural memory 46

Dissociative disorder 3. Dissociative Identity Disorder Ø Over and under-diagnosis: “Multiple Personality Disorder” and its problems Ø Post-traumatic Theory (and “asymmetrical amnesia”) Ø Sociocognitive view (and “iatrogenic illness”) Ø Notes: suggestibility and dissociation-proneness 47

Dissociative disorder 4. Depersonalization Disorder Ø Derealization: “where am I? ” and “out-of-body” experiences Ø Depersonalization: “who am I? ” and “partial dissociation” Note: The story of “Possession/trance disorder” 48

Eating Disorders and Obesity 49

Eating Disorders and Obesity 1. Anorexia Diagnosable and otherwise 2. Bulimia Purging and non-purging 3. “Binge-eating disorder” DSM – V controversies 50

Eating Disorders and Obesity Base rates, clinical and sub-clinical A. Family context: “expressed emotionality” B. Personal context: “Clusters B and C” C. Cultural context: social expectations 51

Eating Disorders and Obesity Beyond the obvious, clinical and sub-clinical The biological context • causes, effects and correlates • comorbidities with eating disorder 52

Psychological Factors and Physical Illness (Axis IV) History 1. Psychodynamic (“psychological”) viewpoint: Personality Illness 2. Psychophysiological (“biological”) viewpoint: “Weak link” + stress Illness 53

Psychological Factors and Physical Illness (Axis IV) History 3. Modern Behavioral Medicine and “Health Psychology” Cause, course, care and cure Comparisons of physical health { 2000 { 1900 54 45 – 50 dehydration, TB, pneumonia 80+ coronary and cancers

Psychological Factors and Physical Illness (Axis IV) 1. Peptic Ulcers Dispositional and situational factors in doudenal ulcers. . . from monkeys to men to helicobacter pylori and beyond 2. Immunocompetence Stress and the hypothalamus in immunosuppression. . . from cortisol to hormones to neurons, and beyond 55

Psychological Factors and Physical Illness (Axis IV) 3. Cardiovascular disorders Coronary heart disease Type A in causation and prognosis Beyond Type A: anxiety, depression and “Type D” 1. Exercise: the evidence 2. Alcohol: the evidence 56

Psychological Factors and Physical Illness (Axis IV) 57

Psychological Factors and Physical Illness (Axis IV) 3. Cardiovascular disorders Essential hypertension Factors: “repressed rage” and beyond Implications for treatment: constructive expression of anger 58

Psychological Factors 59

Psychological Factors and Physical Illness (Axis IV) The importance of prevention! 60

Personality Disorders (Axis II) 61

Personality Disorders (Axis II) • • • 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 62

Personality Disorders (Axis II) • Base rates (and comorbidity) • Prognosis 63

Personality Disorders (Axis II) Cluster A: “Eccentric” 1. Schizoid (solitary) 2. Schizotypal (idiosyncratic) 3. Paranoid (vigilant) 64

Personality Disorders (Axis II) Cluster B: “Erratic” 1. Borderline (mercurial) 2. Narcissistic (self-confident) 3. Histrionic (dramatic) 4. Antisocial (adventurous) 65

Personality Disorders (Axis II) Cluster C: “Anxious” 1. Avoidant (sensitive) 2. Obsessive-compulsive (conscientious) 3. Dependent (devoted) 66

Personality Disorders (Axis II) Cluster D: In the appendix. . . 1. Passive-aggressive 2. “Depressive” 67

Personality Disorders (Axis II) Note, also. . 1. “Sadistic” 2. “Self-defeating” 68

Antisocial Personality Disorder 69

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 70

History The Modern Criteria and prevalence rates The new problem: criteria “too broad and too narrow” The Psychopathy Checklist “Successful Psychopaths” 71

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 72

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 73

Theory 1. The (“primary”) Psychopath 2. The Sociopath (or “secondary psychopath”) e. g Two types of children (Frick) The difference it makes 74

Theory The nature of psychopathy The context (e. g “mixed incentive task”) Passive avoidance conditioning The “low fear” model (Lykken) 75

Theory: “an inhibitory deficiency” BAS (Behavioral Activation System) BIS (Behavioral Inhibition System) Theory, updated: Emotional and cognitive components 76

Theory The “two-edged sword” of antisocial behavior: comorbidities and their implications 77

Theory C. Sociocultural factors, then and now “The Psychopathic Society” “The Psychopath within” Beyond psychopathy: the nature of evil the concept of insanity 78

Impulse Control Disorder 1. Intermittent explosion 2. Kleptomania 3. Pyromania 4. Pathological gambling 5. Trichotillomania 79