Aggression & Neuropsychological Functioning among Depressed Patients

AMRITHA HARIKUMAR

Introductory Key Points

- Patients with MDD have a greater likelihood of having neuropsychological deficits in functioning

- Cognitive Deficits in executive functioning, new learning, working memory, & processing speed

-Individual differences increase risk of cognitive impairment

-Examples of these individual differences are:

1. Psychotic Features v.s. non-psychotic

2. Recurrent episodes v.s first episode

3. Older age

4. Melancholic features

-MDD patients showing greater amounts of irritability & hostility

-Main goal : Understanding brain-behavior relationships and examining the relationship of the two main sub-facets & neuropsychological functioning with MDD patients

1. Irritability

2. Hostility

Major Depressive Disorder Overview

Primary Symptoms

1. Two weeks of anhedonia ( Kessler & Wang ., 2009)

2. Weight gain, hypersomnia, and increase in appetite ( Kessler et al., 2009)

- Average age of onset : 32

- Age range of depression ranging from 19-44 years ( Hasin, D. S., Goodwin, R. D., Stinson, F. S., & Grant, B. F. (2005)

- Prevalence: Environment, genetic, ethnicity, & age are important factors ( Hasin et al., 2005)

Prevalence factors (as listed below) include:

1. First degree relatives

2. Psychosocial stressors

3. Neurotransmitter deficiencies (dopamine & serotonin)

4. Higher risk of suicide

5. Lifetime prevalence [ 5% of the population, ]

Major Depressive Disorder Overview (cont’d)

-Etiology: Brain trauma & neurotic behaviors > amounts of MDD incidences ( Kendler, Thornton, & Gardner., 2001)

-Pathology : Structural & Functional Abnormalities

1. Diminished glial cell count , less neuronal density (Drevets, Price, & Furey, 2008 ; Harrison., 2002)

2. Reduced tissue volume, reduced cerebral volume in orbital & dorsal lateral frontal cortex (Beyer & Krishnan, 2002; Drevets et al., 2008; Mayberg, H. S. 2003).

Cognitive Deficits

What are deficits?

-Issues in memory, speed, and cognition

-Factors also include stressors (such as psychosocial), & age

-Determine areas in which depression can be controlled or reduced (Christensen, H., Griffiths, K., MacKinnon, A., & Jacomb, P. 1997)

- Large differences in recall and recognition memory when comparing middle aged inpatients v.s. normal individuals (Burt, D. B., Zembar, M. J., & Niederehe, G.,1995)

- Constructs also include attention & executive functioning

Attention : Divided into selective and sustained attention

What is the difference? Sustained focuses on the task at whole

Executive Functioning : Planning, judgement , decision making ( Porter, Bourke, & Gallagher .,

2007)

Examples of Cognitive Deficits

Researchers Richard Porter, Cecilia Bourke, and Peter Gallagher focused on various cognitive deficits in MDD patients such as :

1. Effortful v.s. automatic processing

Results: Recognition memory as well as non-effortful tasks impaired

2. Verbal v.s. non-verbal learning memory

Results : Better performance on verbal learning, memory, reaction time

3. Effects of age

Results: Late onset depression in older individuals also relating w/ pre-existing conditions

4. Comparison of UP v.s. BP disordered

Results: BP disordered patients exhibited > impairment

- Possible confounding, due to all being psychotic patients

5. Catastrophic response to failure

Results: Once patient made an error, errors more likely to increase

Source: (Porter et al., 2007)

Individual Differences in Neuropsychological Impairment

Psychotic v.s. non psychotic

1. Hypothalamic- Pituitary- Axis

2. Attention, Concentration, Psychomotor speed & memory affected ( (Fleming, Blasey & Schatzberg ., 2004)

3. Cortisol release a key factor in neuropsychological impairment ( Fleming et al., 2004 ; Porter et al., 2007)

Recurrent episode v.s. First episode

1. First episode patients > greater memory dysfunction

2. Recurrent UP depression correlated with increased memory dysfunction (Fossati, Harvey., Bastard, Ergis,, Jouvent, & Allilaire, 2004)

Older Age

1. Psychomotor speed affected in older patients (Porter et al., 2007)

2. Executive tasks greatly impaired ( Porter et al., 2007)

Melancholic Features

1. Psychomotor slowing

2. Cognitive & Motor Slowing ( Porter et al., 2007)

Irritability, Hostility, & Aggression

- Some patients with MDD exhibit these facets (Akiskal, Benazzi, Perugi, & Rihmer., 2004)

- Relates to impulsivity and poor judgment (Benazzi & Akiskal., 2004)

Hypotheses

A) This reflects possible dysfunction on frontal lobes, so poor performance on neuropsychological tests that measure frontal lobe activity should reflect this.

( Basso et al., 2011)

B)Greater amounts of hostility present in patients exhibiting MDD leads to increased amounts of neuropsychological deficit. Finding hostility in patients will relate this symptom along with other facets to greater amounts of impulsivity.

Relationship with Irritability, Hostility & Aggression

- Depressive Mixed State [DMX] strongly related to irritability ( Benazzi et al., 2004)

-DMX defined as major depressive episode with three or more hypomanic symptoms ( Benazzi et al., 2004)

-Robust association between DMX symptoms and agitated depression (Akiskal et al., 2004)

-Agitated depressed patients > likelihood of suicide (Akiskal et al., 2004)

Our Study : Mood, Reasoning, & Learning

- Attempted to measure neuropsychological deficits concerning the constructs of irritability and hostility, and the closeness of the relationship

-Sample : Undergraduate students at the University of Tulsa ; N=60

-Mood, Reasoning, and Learning study run by the neuropsychology lab

-Three hour long study

-Primarily measures subject's response to a series of questionnaires, a psychological interview, and several executive function measuring tasks

Analysis & Conclusions

-Found no relationship between irritability & hostility

-Used SPSS(a statistics computing software) to calculate the data as well as the Barratt Impulsivity Scale [BIS] (to calculate irritability), and the Brief Symptom Inventory [BSI] to calculate hostility

-Conclusion: There may be other relationships with the neuropsychological deficits mentioned previously

- There may be different batteries that measure these relationships with a higher correlation

Future Research Ideas

-Other possible constructs to measure relationships of neuropsychological impairment

-Use of different neuropsychological batteries besides the BSI and BIS

-Measuring different constructs altogether in depression

-Measuring two different constructs for other relationships

Acknowledgements

-Dr. Michael Basso

-Abby Carter, Eduardo Estevis, Ashley Miller, and Lily Lau

Thank you!

References

Akiskal, H. S., Benazzi, F., Perugi, G., & Rihmer, Z. (2005). Agitated “unipolar” depression re- conceptualized as a depressive mixed state: Implications

for the antidepressant-suicide controversy. Journal of Affective Disorders- Elsevier, 85(3), 245-258. Retrieved March 18, 2013.

Basso, M., Miller, A., Estevis, E., & Combs, D. (2011). Neuropsychological Deficits in MajorDepressive Disorder: Correlates and Conundrums (pp. 1-45).

Benazzi, F., & Akiskal, H. (2005). Irritable-hostile depression: Further validation as a bipolar depressive mixed state. Journal of Affective Disorders-

Elsevier, 84(2-3), 197-207. Retrieved March 18, 2013

Beyer, J. L., & Krishnan, K. R. R. (2002). Volumetric brain imaging findings in mood disorders. Bipolar Disorders, 4, 89-104.

Burt, D. B., Zembar, M. J., & Niederehe, G. (1995). Depression and memory impairment:

A meta-analysis of the association, its pattern, and specificity. Psychological Bulletin, 117, 285-305.

Christensen, H., Griffiths, K., MacKinnon, A., & Jacomb, P. (1997). A quantitative review of cognitive deficits in depression and Alzheimer-type dementia. Journal of the

International Neuropsychological Society, 3, 631-51.

Drevets, W. C., Price, J. L., & Furey, M. L. (2008). Brain structural and functional abnormalities in mood disorders: Implications for neurocircuitry models of depression. Brain Structure and Function, 213, 93-118.

References(cont’d)

Fleming, S. K., Blasey, C., & Schatzberg, A. F. (2004). Neuropsychological correlates of psychotic features in major depressive disorders: A review and meta-analysis. Journal of

Psychiatric Research- Elsevier, 38(1), 27-35. Retrieved March 19, 2013.

Fossati, P., Harvey, P. O., Bastard, G. L., Ergis, A. -., Jouvent, R., & Allilaire, J. F. (2004). Verbal memory performance of patients with a first depressive episode

and patients with unipolar and bipolar recurrent depression. Journal of Psychiatric Research- Elsevier, 38(2), 137-144.

Hasin, D. S., Goodwin, R. D., Stinson, F. S., & Grant, B. F. (2005). Epidemiology of

major depressive disorder: Results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Archives of General Psychiatry, 62,

1097-1106.

Harrison, P. J. (2002). The neuropathology of primary mood disorder. Brain, 125, 1428-49.

Kendler, K. S., Thornton, L. M., & Gardner, C. O. (2001). Genetic risk, number of

previous depressive episodes, and stressful life events in predicting onset of major depression. American Journal of Psychiatry, 158, 582-6.

Kessler, R. C., & Wang, P. S. (2009). Chapter 1- Epidemiology of Depression. In Handbook of Depression, Second Edition [Hardcover] (2nd ed., pp. 5-23). New York City, NY: The Guilford Press.

Mayberg, H. S. (2003). Modulating dysfunctional limbic-cortical circuits in depression: Towards development of brain-based algorithms for diagnosis and optimized treatment. British Medical Bulletin, 65, 193-207.

Porter, R. J., Bourke, C., & Gallagher, P (2007). Neuropsychological Impairment in Major Depression : it’s nature, origin and clinical significance. Australian & New Zealand Journal of Psychiatry, 41, 115-128. Taylor & Francis Ltd.