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Transcript of Stages 1 & 2 Anxiety & Mood Disorders. Science is a systematic pursuit of knowledge through...
DevelopmentStages 1 & 2
Anxiety & Mood Disorders
THE SCIENTIFIC METHODScience is a systematic pursuit of
knowledge through observation Forming a theory Systematically gathering data to test
a theory (Observations must be replicable)
Forming a Hypothesis (what should occur if the theory is true)
Science proceeds by disproving theories
SCIENCE IN MENTAL HEALTHMental health is a term used to describe
either a level of cognitive or emotional wellbeing or an absence of a mental disorder
APA DSM-IV-TR
American Psychiatric Association (2000) Diagnostic and Statistical Manual Revision IV, Text Revision
Reliability & Validity – PsychometricsDSM is so widely accepted that a psychiatrist must classify
their patients’ disorders according to DSM listing number in order to be reimbursed by government of insurance companies
Psychodynamics Childhood experiences help shape adult
personality There are unconscious influences on
behaviour The causes and purposes of human
behaviour are not always obvious
Freud: Psychopathology results from unconscious conflict- Anecdotal evidence, not the scientific method
Benefits of gameplay, maintenance of negative schema internal cognitive processes
Cognitive Behaviourism Thorndike (1874-1949): Law of Effect
Behaviour that is followed by consequences satisfying to the organism will be repeated, and behaviour that is followed by noxious or unpleasant consequences will be discouraged
Skinner (1904-1990): operant conditioning-Positive reinforcement-Negative reinforcement-Automatic reinforcement
Reinforcement of behaviourProblem behaviour is thought to be reinforced
by four possible consequences: Getting attention Escaping from tasks Generating sensory feedback (automatic) Gaining access to desirable things or
situations
Behavioural Treatments
TraumaFearConduct DisorderAutistic Spectrum Disorder
etc
Cognition Perceiving, recognising, conceiving, judging
and Reasoning
The learning process is far more complex than stimulus-response associations (behaviourism)
The learner is an active interpreter of a situation using past experience in a cognitive set/schema
Attention
Individuals with psychopathologies tend to focus their attention on threats or anxiety, producing events or situations in the environment.e.g. “The world is a dangerous place”
Self-fulfilling prophecy
Many people who are depressed believe that they have no important effect on their surroundings regardless of what they do
Developmental Stages Completing a developmental stage supports
the healthy awakening of the next stage Developmental behaviour usually graduates
in sequence along with chronological age
Maslow’s Hierarchy of Needs
Maslow’s Heirarchy of Needs Needs on lower levels must be met before
larger identities can be sustained. Lower identities take their places as no less
important, but supporting of a larger and more powerful whole.
A.H. Maslow, A Theory of Human Motivation, Psychological Review 50(4) (1943):370-96.
Stage 1: Womb – 12 months◦ Motor Functions and security
Stage 2: 6 months – 2 years old◦ Mobility and emotion
Stage 3: 18 months – 4 years old◦ Will and action
Stage 4: 4 – 7 years old◦ Social Identity
Stage 5: 7 – 12 years old◦ Social contract
Stage 6: Adolescence◦ Reconstitution
Stage 7: Early Adulthood and Beyond◦ Self-knowledge
Stage 1: Womb – 12 months Formation of the physical body during
prenatal development and infancy Body growth is rapid at this stage Motor operations: suck, eat, digest, grasp,
crawl, stand, walk, manipulate objects, gravity
Little awareness of the outside world Fused symbiosis with the mother No separate sense of self Awareness of survival and physical comfort
Stage 1: Comparative Models Freud: Oral Stage
◦ Oral cavity is primary focus of libidal energy- Characterised by under-nursing: pessimism, envy,
suspicion and sarcasm- Characterised by over-nursing: optimistic, gullible,
admiration for others- Conflicts in nursing: deprivation of sensory pleasure
and mothering
Erikson: Trust vs Mistrust (predictability)
Stage 1: Comparative Models Piaget: Sensory-motor stage 1 & 2
◦ All knowledge is acquired through senses ◦ No sign of object permanence (ability to know
that an object exists when it is out of reach of your senses)
◦ Primary circular reactions: repetition of movement (e.g. touching hand and foot)
◦ Vision can follow moving objects
Stage 1: Psychological Development Basic psychological identity associates with the
physical body. The self is identified with biological urges
- I Am hungry When to eat, When to rest, Limitations of the body Individuality & The feeling of having the right to
exist Independence & The right to take care of ourselves Interaction & The right to have, contain and create
Self-preservation
Stage 1: Trauma Trauma may result in fear, insecurity,
confusion Symptoms of disorganisation or depression Feelings of insanity, excessive thinking Little “grounding” – detachment from body
and basic consensus reality structures Anxiety in mundane tasks, hypervigilance
(high responsiveness to stimuli and constant scanning of environment for threats)
Healthy development teaches security, focus, calm and vigilance
Stage 2: 6 months – 2 years Visual acuity allows the child to focus on
outside objects and gain a wider visual perspective
Awareness grows of objects outside of immediate range
“Hatching” (Mahler) – moving away from mother in brief episodes of independence
Begins to separate self from other eliciting◦ Fear and excitement◦ Diversity and choice
Stage 2: Emotions Primary method of obtaining information
about our well-being
Primary language prior to verbal language
Adds dimension and texture to the mind-body experience
Identification with emotional body◦ I am scared, rather than I have fear
Stage 2: Comparative models Freud: Oral stage
◦ The id: need, sensation and desire is the fundamental cause of motivation.
◦ Seeing something, moving towards it, merging with it (usually through the mouth)
Erikson: ◦ Trust vs mistrust◦ Attachment vs separation
Stage 2: Separation and Connection Separation from the mother corresponds
with separation of self from other
Separation from primary attachment figure leads to binary distinctions
Duality:good-bad, pleasure-pain, closeness-distance, self-other
Stage 2: Trauma Trauma may cause numbness (lack of
feeling), disconnection with self
Difficulty in knowing what we want
Unhealthy sexuality
Excessive inhibition Guilt
Anxiety Disorders ‘Angere’: to choke, to torment Fear: Reaction to immediate danger Anxiety: Apprehension over an anticipated
problem
Both are adaptive strategiesA small degree of anxiety has been found to
improve performance on laboratory tasks
Anxiety Disorders Specific Phobia Panic Disorder Separation Anxiety Disorder Generalised Anxiety Disorder Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder
Anxiety Disorders Phobia: A disruptive fear of a particular
object or situation that is out of proportion to any danger posed
3-5% prevalence in children and adolescents
Anxiety Disorders There is a great deal of overlap
between Axis I Anxiety Disorders and axis II Personality Disorders.
Personality disorders (e.g. Borderline, Paranoid, or Avoidant Personality Disorders) may be considered to evoke contrasting ways of perceiving and coping with Axis I disorders
Children’s Anxiety may not be focused enough to make specific diagnoses useful for intervention.
Culture influences the development of anxiety disorders
Specific Phobias Alliumphobia
Fear of garlic
Musophobia
Fear of mice
Helienophobia
Fear of pseudoscientific terminology
Arachibutyrophobia
Fear of peanut butter sticking to the roof of the mouth
www.phobialist.com
Specific Phobias 2 - 4% prevalence in children More common in girls
Some have clear genetic influences (e.g. snakes, injections)
Social Phobia 1% prevalence in children and adolescents May lead to substance related disorders and
depression 33% concordant with Avoidant Personality
Disorder
Panic Disorder (w/without Agoraphobia Panic attacks:
◦ Intense apprehension, terror, feelings of impending doom
◦ Choking, nausea, sweating, etc.◦ Recurrent, uncued panic attacks
Agoraphobia◦ Anxiety about situations in which it would be
embarassing or difficult to escape
Separation Anxiety Disorder 2 – 4% prevalence from preschool
Specific to children
Often tied to stressful life event of loss/separation
Generalized Anxiety Disorder Unable to let go of a worrisome problem
Typically chronic, beginning in adolescence or late adolescence
Obsessive-Compulsive Disorder (OCD)
2% prevalence, common onset around age 10
Obsessions: ◦ Intrusive and recurring thoughts, images or
impulses that are uncontrollable and come unbidden
◦ e.g. contamination, safety, religious issues Compulsions:
◦ Repetitive, clearly excessive behaviours or mental acts to reduce anxiety caused by obsessive thoughts.
◦ e.g. elaborate rituals of orderliness, repetitive, magically protective acts (superstitions)
◦ Repeatedly checking that these acts are carried out- lack of confidence in memory, unduly
concerned about gaps in memory
Obsessive-Compulsive Disorder (OCD)
78% of compulsives viewed their rituals as rather silly or absurd, but unable to stop performing them.
Rituals allow attention to be drawn away from the obsessions.
This perpetuated the obsessions, as thought supression makes thoughts stronger and more frequent
Exposure and Ritual prevention (ERP)
Post-Traumatic Stress Disorder (PTSD)
Also Acute Stress Disorder
Extreme response to an actual stressor involving threatened death, serious injury, or threat of these.◦ E.g. war veterans, rape victims
Symptoms are categorised under◦ Re-experiencing the trauma (e.g.
night terrors)◦ Avoidance of associated stimuli
(numbing)◦ Increased arousal high anxiety
(problems with sleep and concentration)
Anxiety Disorders Comorbidity
◦ Over 50% of those diagnosed meet criteria for another anxiety disorder
◦ ~60% of people in treatment for Anxiety disorders meet criteria for Depression
◦ Substance disorders and Personality Disorders
Women are twice as likely to be diagnosed with anxiety disorders (except in OCD)
Syndromes are related to beliefs and attitudes of specific cultures
Common Etiology of Anxiety Disorders
Genetic vulnerability Increased activity in the fear circuit of the
brain (amygdala) Decreased functioning of GABA and
serotonin, increased norepinephrine activity Behavioural Inhibition – agitation to new
stimuli in infancy◦ Predictive to a 30% level of development of
social anxiety Neuroticism
◦ Personality trait with a tendency to react with greater than average negative emotion
◦ Twice as likely to develop into an Anxiety Disorder
Cognitive Factors (e.g. attention to cues of threat and low perception of control)
Negative Life events
Common Treatments of Anxiety Disorders Fewer than 20% of people with
Anxiety Disorders receive minimally adequate treatment
Psychological: - Exposure- Cognitive reorganization, rationalizing, etc.
Medical Treatment:Sedatives, tranquilizers and anxiolytics
(“to loosen”)- Benzodiaxepines (e.g. Valium, Xanax) GABA.
- Cognitive and motor side effects memory lapses and addiction
- Antidepressants, tricyclics and SSRIs (e.g. Fluoxetine, Imipraming – Prozac, Zoloft)- Jitteriness, weight gain, high blood pressure,
sexual dysfunction
Mood DisordersE.g. Depression: Depressed mood, inability to experience pleasure, fatigue, concentration problems and suicidal ideation.
Children and adolescents show higher rates of suicide attempts and guilt
Major Depressive Disorder (MDD)Diagnosis
MDD: Sad mood or loss of pleasure for 2 weeks, with at least 4 other symptoms, such as Changes in sleep pattern Change in appetite Problems with attention Feelings of worthlessness Suicidality Not just a single episode
Episodic Disorder: may be periodic, then clearSubclinical depression can remain for yearsDysthymic Disorder (Dysthymia): Chronic
depression for more than half the time for 2 years
DepressionOne of the most prevalent psychiatric disordersAdults:
~ 16.4% of adults are diagnosed with MDD 2.5% with dysthymia
Children & Adolescents:1% in preschoolers2-3% in school-age children7-13% in adolescent (girls)Up to 18% in late adolescentsover 20% in 12-16 year olds (Burns and Rapee, 2006)
Twice as common among girls than boys (women than men) after the age of 12
Twice as common in women (except for Jewish men)Three times more common in impoverished Socio-economic
conditions
DepressionAge of Onset is in late teens, early 20s,
and decreasingVaries culturally
People of Mexican descent are more likely to develop MDD if born in USA
1.5% in Taiwan, 19% in Beirut, LebanonComorbidity:
Two thirds of MDD diagnoses will meet criteria for diagnosis of an anxiety disorder
Comorbid with Anxiety and Substance-related disorders
Bipolar DisorderMania:
A state of intense elation or irritability lasting from weeks to months
Flight of ideasImprudent sexual activities, over-spending,
risk-taking, anger or rageHypomania: less extreme
Bipolar DisorderBipolar I Disorder: “Manic Depressive
Disorder”Bipolar II DisorderCyclothymic Disorder (Cyclothymia)
Chronic mood disorders for at least 2 yearsMild alternative depression and mania
1% Prevalence rate for BPI, 40,000 in Ireland
4% for BPII and Cyclothymia
Bipolar DisorderAverage age is in the 20’s, but is
increasing among children and adolescents
Equal in men and women (more depression in women)
High risk for cardiovascular disease, diabetes, obesity and thyroid disease
Associated with creativity and achievement
Etiology of Mood DisordersGeneticsNeurobiologySocial FactorsPsychological Factors
Etiology of Mood DisordersGenetics:
Heritability estimates of 37% for depression (i.e. 37% of variance in whether or not a person will develop depression is explained by genes)
70% concordance rate for Bipolar Disorder in monozygotic twins 25% in fraternal twins
85% heritability estimates for BP
Genes may guide the way people regulate emotions or respond to life stressors
Etiology of Mood DisordersNeurobiology
Amygdala – elevatedHippocampus – diminishedPrefrontal cortex – diminishedAnterior cingulate – diminished
Assessment of how emotionally important a stimulus is
Effective focusMaking plans based on emotionally
relevant cues
Etiology of Mood DisordersNeurobiologySeratonin regulates norepinephrine and
dopamine.Mania and depression were thought to be
symptoms of low levels of seratonin, but the research indicates otherwise
Sensitivity of neurotransmitter uptake(Poor seratonin sensitivity)
Etiology – Conflicting ResearchDepression is a result of low absolute levels of
neurotransmitters? Antidepressants take 7 to 14 days to relieve depression, by
which time the neurotransmitter levels have already returned to their previous state
Metabolite studies (enzymes that break down neurotransmitters) are not consistent
Caused by low sensitivity of post-synaptic receptors (that detect the presence of a neurotransmitter)
Dopamine can be overly sensitive in Bipolar disorder Depleting tryptophan causes temporary depressive symptoms
relationship with other neurotransmitters Second messengers adjust postsynaptic receptor sensitivity
(e.g. G-proteins – guanine nucleotide-binding proteins)
Etiology of Mood DisordersNeurobiology
Over-activity of the amygdala (threat) during depression causes oversensitivity to emotionally relevant stimuli
Less activity in systems involved in weighing rewards and costs, making decisions and systematically pursuing goals in the face of emotions Feel the fear and Do It Anyway May react with increased emotion, but decreased ability to
plan
In Bipolar Disorder, there are neurological changes in the sensitivity of the reward system Basal ganglia Increased amygdala
Etiology of Bipolar DisorderMania may be a protective ‘mechanism’
against a painful psychological state Grandiosity Compensation
Reflects a disturbance in the reward system (Highly responsive)
Marshmallow Test
Etiology of Mood DisordersCortisol (Stress Hormone)
Hypothalamus-Pituitary-Adrenocortical Axis (HPA)
Signals transmitted from the Amygdala
E.g. Cushings Syndrome- Oversecretion of cortisol- Frequent depressive symptoms
Dexamethasone Supression Test- Should supress corticol secretion- In some mood disorders, it does not
Treatment of DepressionMedication:
Monoamine Oxidase Inhibitors (MAOIs)
Tricyclic AntidepressantsSelective serotonin reuptake inhibitors
(SSRIs)(e.g. Fluoxetine, Imipramine – Prozac,
Zoloft)50-70% show improvementSuicidality associated with SSRIsRelapse is common after drugs are
withdrawn
Treatment of DepressionElectroconvulsive Therapy (ECT)
Only used in cases that do not respond to medication
Involve deliberate induction of seizure and momentary unconsciousness by passing a current of 70-130V through the non-dominant brain hemisphere
Short-acting anesthetic and strong muscle relaxant administered
ECT is the most reliable treatment available for depression with psychotic features
We don’t know why it works.
Treatment of Bipolar DisorderMedication: Lithium
mostly for prevention of manic episodes
Lithium toxicity – tremor, nausea, confusion, seizure, coma, death
Olanzapine (antipsychotic) e.g. Haldol
Treatment of Bipolar DisorderPsychoeducational approaches
Family-focused Treatment (FFT) High Expressed Emotion (EE) predicts faster
relapse
Childhood Depression in Ireland90% of Irish Child Psychiatrists prescribed
psychotropic drugsThe prevalence of use of medication was
lowest at 8% in Denmark
75% of MDD cases do not receive effective treatment
May stop treatment early Too low dosage
Childhood Depression in IrelandNo anti-depressant medications are licensed for use in
children (up to 18 years of age) in Ireland. This is mainly the case because of the expense involved in clinical trials to be undertaken by drug companies to have these products licensed. Some trials are being conducted in the US at the moment.
Doctors do have the discretion to prescribe any medication they deem necessary for their patient of any age.
The Irish Medicines Board has acknowledged that depression can be a serious condition in children and that drug treatment may be necessary. They are currently working on guidelines and have issued a warning about the use of Seroxat as it increases the risk of agitation.
Fitzpatrick Coping with Depression in Young People
Treatment of DepressionInterpersonal Psychotherapy
Focus on current life, rather than trauma Transitions, conflicts, bereavement Decision making, techniques to improve communication
etc Prevents relapse
Cognitive Therapy Altering maladaptive thought patters More successful than imipramine (tricyclic
antidepressant)Mindfulness-based Cognitive therapy
Decentered perspective “I am not my thoughts”
Etiology of Mood DisordersSocial FactorsStressful life events
42-67% of depression occurs within a year of a major stressful life event
Long-term chronic stressorse.g. poverty
Vulnerability to stressLack of social support
Support minimises the effect of social stressorsE.g. 40% prevalence in women without confidants, 4% in
women with confidantsInterpersonal relations
Depressive symptoms elicit negative reactionsExcessive reassurance seeking results in rejection
Etiology of Mood DisordersPsychological FactorsAffect
Negative affect: distress and worryPositive affect: happiness, contentmentSomatic arousal
Negative Affect Positive Affect Somatic Arousal
Depressive Disorders High Low Moderate
Anxiety Disorders High Moderate High
Comorbidity of Depressive and Axiety Disorders
High Low High
Etiology of Depression Schemata:
Pay more attention to negative stimuli Remembers negative information more than positive
information Hopelessness Theory
Feeling of being in an uncontrollable aversive situation (e.g. abusive family)
1. “Desirable outcomes will not occur”2. “I cannot change my situation”
Neuroticism predicts the onset of depression Remember: Genes + Stressful Life Event risk
of depression
Nutritional TreatmentPotential therapeutic benefit of n-3
polyunsaturated fatty acids (Omega 3)Vitamin B12, B3 - necessary for the
synthesis of red blood cells, the maintenance of the nervous system and growth and development in children deficiency of this particular vitamin results in
an build up of a compound called homocysteine - this may enhance depression.
Depression in Children Early onset depression Depression with an onset in early adolescence
Remember: 2% children 4% mid adolescent 18% late adolescent
Behaviours to note: Chronic sadness and/or irritability Decline in interest in activity Sleep disturbance, fatigue, appetite change Worthlessness, concentration problems Withdrawn, social exclusion Poor concentration
Children12-20% children and adolescents would be
diagnosed with anxiety disorders
Parent-Child relationships – criticism, hostility
Suicide10-20% of people report suicidal ideation2-5% make attempts7% deliberately harm themselves.
Men are 4 times more likely to kill themselves60% of all suicides are with guns
Up to 90% of people who attempt suicide are suffering from mental illness (usually comorbid with Depression or Borderline Personality Disorder)
Suicide is now the leading cause of death in young men in the 15-24 year old age range
Suicide in IrelandIn a study of suicide victims in Dublin over a year
it was found that 70% were male, 35% had previously attempted suicide, and 53% saw a Doctor in the previous month. 44% experienced hopeless feelings.
The Central Statistics Office at the time the study was done underestimated the suicide rate by 20%
An eight year follow-up of attempted suicide found that 2 out of the 26 had died and 19% had further suicide attempts
SuicidePossible Reasons
Few ties to family or community Atruism: for the good of society Anomic – sudden change in persons relation to
society (e.g. in rural china, suicide is one of the leading causes of death)
Retaliation – to induce guilt in others To force love/attention from others To rejoin a dead loved one Sociocultural models (suicide rose 12% after
Marilyn Monroe’s suicide)
Prevention of Suicide Who is at Higest Risk?
Desire to escape aversive self-awareness Problem-solving deficits Hopelessness
Prevention1. Reduce intense psychological pain2. Help the person see options other than
suffering3. Encourage the person to pull back from the
self-destructive act Reasons for Living Inventory Suicide prevention centres Phone services
Prevention of SuicidePsychoeducation
“Mental Health Literacy”, help-seeking adolescents do not consider doctors appropriate
helpers for a depressed peer in-adequate service provision
Cognitive RestructuringExposureModelingSkills trainingRelapse prevention
Prevention of Suicide