Stages 1 & 2
Anxiety & Mood Disorders
Science 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
Mental health is a term used to describe either
a level of cognitive or emotional wellbeing or
an absence of a mental disorder
American Psychiatric Association
(2000)
Diagnostic and Statistical Manual
Revision IV, Text Revision
Reliability & Validity – Psychometrics
DSM 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
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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
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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
Problem 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
Trauma
Fear
Conduct Disorder
Autistic Spectrum Disorder
etc
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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
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
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Completing a developmental stage supports
the healthy awakening of the next stage
Developmental behaviour usually graduates
in sequence along with chronological age
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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.
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Stage 1: Womb – 12 months
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Stage 2: 6 months – 2 years old
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Stage 3: 18 months – 4 years old
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Stage 4: 4 – 7 years old
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Stage 5: 7 – 12 years old
◦ Motor Functions and security
◦ Mobility and emotion
◦ Will and action
◦ Social Identity
◦ Social contract
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Stage 6: Adolescence
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Stage 7: Early Adulthood and Beyond
◦ Reconstitution
◦ Self-knowledge
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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
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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
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Erikson: Trust vs Mistrust (predictability)
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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
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Basic psychological identity associates with the
physical body.
The self is identified with biological urges
 I
Am
hungry
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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
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Self-preservation
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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
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Visual acuity allows the child to focus on
outside objects and gain a wider visual
perspective
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Awareness grows of objects outside of
immediate range
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“Hatching” (Mahler) – moving away from
mother in brief episodes of independence
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Begins to separate self from other eliciting
◦ Fear and excitement
◦ Diversity and choice
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Primary method of obtaining information
about our well-being
Primary language prior to verbal language
Adds dimension and texture to the mindbody experience
Identification with emotional body
◦ I am scared, rather than I have fear
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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)
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Erikson:
◦ Trust vs mistrust
◦ Attachment vs separation
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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
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Trauma may cause numbness (lack of
feeling), disconnection with self
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Difficulty in knowing what we want
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Unhealthy sexuality
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Excessive inhibition  Guilt
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‘Angere’: to choke, to torment
Fear: Reaction to immediate danger
Anxiety: Apprehension over an anticipated
problem
Both are adaptive strategies
A small degree of anxiety has been found to
improve performance on laboratory tasks
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Specific Phobia
Panic Disorder
Separation Anxiety Disorder
Generalised Anxiety Disorder
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder
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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
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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
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Alliumphobia
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Fear of garlic
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Musophobia
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Fear of mice
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Helienophobia
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Fear of pseudoscientific terminology
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Arachibutyrophobia
Fear of peanut butter sticking to the roof of
the mouth
www.phobialist.com
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2 - 4% prevalence in children
More common in girls
Some have clear genetic influences (e.g.
snakes, injections)
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1% prevalence in children and adolescents
May lead to substance related disorders and
depression
33% concordant with Avoidant Personality
Disorder
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Panic attacks:
◦ Intense apprehension, terror, feelings of impending
doom
◦ Choking, nausea, sweating, etc.
◦ Recurrent, uncued panic attacks
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Agoraphobia
◦ Anxiety about situations in which it would be
embarassing or difficult to escape
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2 – 4% prevalence from preschool
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Specific to children
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Often tied to stressful life event of
loss/separation
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Unable to let go of a worrisome problem
Typically chronic, beginning in adolescence
or late adolescence
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2% prevalence, common onset around
age 10
Obsessions:
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Compulsions:
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◦ Intrusive and recurring thoughts, images or
impulses that are uncontrollable and come
unbidden
◦ e.g. contamination, safety, religious issues
◦ 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
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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)
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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
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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)
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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
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Women are twice as likely to be diagnosed with
anxiety disorders (except in OCD)
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Syndromes are related to beliefs and attitudes of
specific cultures
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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
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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
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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”)
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 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 Disorders
 E.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
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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 clear
 Subclinical depression can remain for years
 Dysthymic Disorder (Dysthymia): Chronic depression
for more than half the time for 2 years
Depression
 One of the most prevalent psychiatric disorders
 Adults:
 ~ 16.4% of adults are diagnosed with MDD
 2.5% with dysthymia
 Children & Adolescents:
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1% in preschoolers
2-3% in school-age children
7-13% in adolescent (girls)
Up to 18% in late adolescents
over 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
Depression
 Age of Onset is in late teens, early 20s, and
decreasing
 Varies culturally
 People of Mexican descent are more likely to develop
MDD if born in USA
 1.5% in Taiwan, 19% in Beirut, Lebanon
 Comorbidity:
 Two thirds of MDD diagnoses will meet criteria for
diagnosis of an anxiety disorder
 Comorbid with Anxiety and Substance-related disorders
Bipolar Disorder
Mania:
 A state of intense elation or irritability lasting from
weeks to months
 Flight of ideas
 Imprudent sexual activities, over-spending, risk-taking,
anger or rage
 Hypomania: less extreme
Bipolar Disorder
 Bipolar I Disorder: “Manic Depressive Disorder”
 Bipolar II Disorder
 Cyclothymic Disorder (Cyclothymia)
 Chronic mood disorders for at least 2 years
 Mild alternative depression and mania
 1% Prevalence rate for BPI, 40,000 in Ireland
 4% for BPII and Cyclothymia
Bipolar Disorder
 Average 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 Disorders
 Genetics
 Neurobiology
 Social Factors
 Psychological Factors
Etiology of Mood Disorders
 Genetics:
 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
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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 Disorders
 Neurobiology
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Amygdala – elevated
Hippocampus – diminished
Prefrontal cortex – diminished
Anterior cingulate – diminished
Assessment of how emotionally important a
stimulus is
Effective focus
Making plans based on emotionally relevant cues
Etiology of Mood Disorders
 Neurobiology
Seratonin 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 Research
 Depression is a result of low absolute levels of
neurotransmitters?
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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)
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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 Disorders
 Neurobiology
 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
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 Feel the fear and Do It Anyway
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May react with increased emotion, but decreased ability to plan
 In Bipolar Disorder, there are neurological changes in the sensitivity
of the reward system
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Basal ganglia
Increased amygdala
Etiology of Bipolar Disorder
 Mania may be a protective ‘mechanism’ against a
painful psychological state
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Grandiosity
Compensation
Reflects a disturbance in the reward system (Highly
responsive)
 Marshmallow Test
Etiology of Mood Disorders
 Cortisol (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 Depression
 Medication:
 Monoamine Oxidase Inhibitors (MAOIs)
 Tricyclic Antidepressants
 Selective serotonin reuptake inhibitors (SSRIs)
(e.g. Fluoxetine, Imipramine – Prozac, Zoloft)
 50-70% show improvement
 Suicidality associated with SSRIs
 Relapse is common after drugs are withdrawn
Treatment of Depression
 Electroconvulsive 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 Disorder
 Medication: Lithium
mostly for prevention of manic episodes
Lithium toxicity – tremor, nausea, confusion, seizure,
coma, death
Olanzapine (antipsychotic) e.g. Haldol
Treatment of Bipolar Disorder
 Psychoeducational approaches
 Family-focused Treatment (FFT)
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High Expressed Emotion (EE) predicts faster relapse
Childhood Depression in Ireland
 90% of Irish Child Psychiatrists prescribed
psychotropic drugs
 The prevalence of use of medication was lowest at 8%
in Denmark
 75% of MDD cases do not receive effective
treatment
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May stop treatment early
Too low dosage
Childhood Depression in Ireland
No 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 Depression
 Interpersonal Psychotherapy
Focus on current life, rather than trauma
 Transitions, conflicts, bereavement
 Decision making, techniques to improve communication etc
 Prevents relapse
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 Cognitive Therapy
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Altering maladaptive thought patters
More successful than imipramine (tricyclic antidepressant)
 Mindfulness-based Cognitive therapy
Decentered perspective
 “I am not my thoughts”
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Etiology of Mood Disorders
Social Factors
 Stressful life events
 42-67% of depression occurs within a year of a major stressful life
event
 Long-term chronic stressors
 e.g. poverty
 Vulnerability to stress
 Lack of social support
 Support minimises the effect of social stressors
 E.g. 40% prevalence in women without confidants, 4% in women
with confidants
 Interpersonal relations
 Depressive symptoms elicit negative reactions
 Excessive reassurance seeking results in rejection
Etiology of Mood Disorders
Psychological Factors
 Affect
 Negative affect: distress and worry
 Positive affect: happiness, contentment
 Somatic 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
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Schemata:
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Hopelessness Theory
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1.
2.
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Pay more attention to negative stimuli
Remembers negative information more than positive information
Feeling of being in an uncontrollable aversive situation (e.g.
abusive family)
“Desirable outcomes will not occur”
“I cannot change my situation”
Neuroticism predicts the onset of depression
Remember: Genes + Stressful Life Event  risk of
depression
Nutritional Treatment
 Potential 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
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Early onset depression
Depression with an onset in early adolescence
 Remember:
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2% children
4% mid adolescent
18% late adolescent
 Behaviours to note:
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Chronic sadness and/or irritability
Decline in interest in activity
Sleep disturbance, fatigue, appetite change
Worthlessness, concentration problems
Withdrawn, social exclusion
Poor concentration
Children
 12-20% children and adolescents would be diagnosed
with anxiety disorders
 Parent-Child relationships – criticism, hostility
Suicide
 10-20% of people report suicidal ideation
 2-5% make attempts
 7% deliberately harm themselves.
 Men are 4 times more likely to kill themselves
 60% 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 Ireland
 In a study of suicide victims in Dublin over a year it was
found that
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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
Suicide
 Possible Reasons
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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?
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1.
2.
3.
Desire to escape aversive self-awareness
Problem-solving deficits
Hopelessness
Prevention
Reduce intense psychological pain
Help the person see options other than suffering
Encourage the person to pull back from the selfdestructive act
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Reasons for Living Inventory
Suicide prevention centres
Phone services
Prevention of Suicide
 Psychoeducation
 “Mental Health Literacy”, help-seeking
 adolescents do not consider doctors appropriate helpers for a
depressed peer
 in-adequate service provision
 Cognitive Restructuring
 Exposure
 Modeling
 Skills training
 Relapse prevention
Prevention of Suicide