Affective Disorders
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Affective Disorders
U.S.
Canada
BR12
LTR
18%
30%
12%
20%
Mood Disorder
BR12
9%+
6%+
LTR
17%+
12%+
Anxiety Disorder
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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
4

Normal and clinical depression

Primary and secondary affective disorders
(e.g. “dual diagnosis”)

Comorbidity
(especially with Anxiety disorders)
Affective Disorders
Differential Diagnosis
5

Mood disorder due to General Medical Condition

Substance-induced Mood Disorder

Adjustment Disorder with Depressed Mood

“Negative emotion disorder”

“Pseudodementia”

“Manic Depression”
Affective Disorders
Types:
BR12
Lifetime risk
4+% 
12% 
2+%
3+%
3. Manic depression
1%
1%
4. Cyclothymia
1%
1%
6+% 
12+% 
A. Unipolar
1. Major depression
2. Dysthymia
12+% 
B. Bipolar
Canadian Totals
6
2+%
Affective Disorders
Dysthymia
 Clinical picture
 Personality: from “neurosis” to “temperament”
 “Double depression”
7
Affective Disorders
Major Depressive Disorder
Descriptive features





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symptoms
severity
single & recurrent episodes
incidence
course
Affective Disorders
Major Depressive Disorder
Treatment
 chemotherapy (“antidepressants”)
 Spontaneous remission and ...
Old research
Newer research
Newest research
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Affective Disorders
Major Depressive Disorder
Distinctions
a.
b.
c.
d.
exogenous/endogenous (distal causes?)
major/minor (severity)?
psychotic/neurotic (severity → cause)?
melancholic/non-melancholic (proximal causes)
Note: depression with “psychotic” features
depression with “atypical” features
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Affective Disorders
Major Depressive Disorder
Signs of “melancholia”:




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family history
early onset
insidious onset
normally not
Affective Disorders
Major Depressive Disorder
Symptoms of “melancholia”:




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vegetative
appetite and weight loss
early morning wakening
pleasures of the chase and the feast
Affective Disorders
Explanations
A. Biogenesis
1. Genetics
 concordance rates, old and new
 adoptions, old and new


prospective
retrospective
 possibilities



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direct influence of genes
indirect influence of genes
interactive influence of genes
Affective Disorders
Explanations
A. Biogenesis
2. Biology of negative emotionality
 The original theory
 The monoamine hypotheses, old and new


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Catecholamines : Dopamine + Norepinephrine
Idoleamine : Serotonin (5-HT)
Biology of
negative emotionality:
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Affective Disorders
Explanations
A. Biogenesis
2. Biology of negative emotionality

The “first generation” antidepressants



The “second generation” antidepressants




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tricyclics and their anticholinergic “side effects”
MAOIs and “the cheese effect”
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?

The controversy, revisited


The drug alternatives


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The new numbers
Cocaine : dopamine reuptake
Ecstasy : serotonin release
Amphetamines : monoamine release
The suicide risk
Affective Disorders
Explanations
 Biological factors, continued




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genes
age
experience
gene/experience interactions
Affective Disorders
Explanations
3. Developments
1.
2.
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Body: cortisol and the DST
Brain: lateralization of emotion
 frontal involvement of glutamate
 involvement of memory : hippocampus & amygdala
 neurobiology of sleep
Affective Disorders
Explanations
B. Psychogenesis
1. Psychodynamic theory



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Freud’s “anaclitic” depression
Bowlby’s Attachment theory: “working models”
Klerman’s Interpersonal therapy (IPT)
Affective Disorders
Explanations
2. Learning theory
 Rewards : “Response contingent positive
reinforcement”
 rewards
activities
 Behavioural Activation Treatment
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Affective Disorders
Explanations
Punishments : “Learned Helplessness” and beyond

Cognition : “Pessimistic Attributional Style”
(internal, global, stable)

Learned Helplessness: “The negative triad”
(helplessness and hopelessness)
thoughts
emotions

Psychological immunization
(helplessness and hopelessness)


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Modern Cognitive Therapy
“Mindfulness-based Cognitive Therapy”
Affective Disorders
Explanations
Some research: “The Dodo Bird Verdict”
... and beyond
1.
2.
3.
4.
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drugs
IPT
cognitive therapy
placebo
Affective Disorders
Explanations
3. Phenomenological theory



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Humanistic perspective : actualization
The alternative (and the Existentialists)
Logotherapy
Affective Disorders
Explanations
C. Sociocultural aspects
Cause: sociogenesis
Content: autonomous and sociotropic people
Course: interpersonal factors in prognosis
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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
approaches
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Affective Disorders
Notes
1. ECT (“Shock Therapy”)


Transcranial Magnetic Stimulation
Deep Brain Stimulation
2. SAD (“Depression with a Seasonal Pattern”)


Melatonin and the Pineal Gland
Light Therapies
3. PDD (“Premenstrual Dysphoric Disorder”)


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Premenstrual Syndrome
The controversy
Affective Disorders
Notes
4. Post-Partum Syndromes:



“Maternity Blues”
“Post-Partum Depression”
“Psychotic Depression in the Postpartum Period”
5. The Sex Difference


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Predisposing factors
Reinforcing factors
Affective Disorders
Bipolar Disorder and Cyclothymia
A. Descriptive factors:
1. Manic and depressed episodes



Mixed and rapid cycling
Bipolar I and II
Suicide
2. Cyclothymia


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Personality
Controversy
Affective Disorders
Bipolar Disorder and Cyclothymia
A. Biogenesis
1. Genetic


Concordance rates, then and now
Adoptions, retrospective and prospective
Possibilities:
direct influence of genes?
2. Biology of mania

The hypotheses
B. Psychogenesis

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cause and content
Affective Disorders
Bipolar Disorder and Cyclothymia
C. Therapy



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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
 Depression with “mood congruent delusions”
 Schizophrenia with “secondary depression”
 A perspective, and a treatment (Symbyax)
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Affective Disorders
Suicide
 Social problems and psychiatric ones
 Rates, worldwide and Canadian
 Trends in Canada
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Affective Disorders
Suicide
Reasons:
1. Disinhibitors: “social involvement and identity”



egoistic
altruistic
anomic
2. Motivations: “escape from self” / ”psychache”
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

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standards and expectations
stresses, setbacks and self-blame
unbearable self-awareness
Affective Disorders
Suicide
Summary:
“Why people die by suicide”:
“Disconnectedness and Ineffectiveness”
Issues:
1. Ambivalence



“to be”
“not to be”
“maybe”
2. Intervention



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passive suicide
assisted suicide
euthanasia
Affective Disorders
Issues:
3. Prevention



societal solutions
imitation and contagion (“The Werther Effect”)
the biology of suicide
4. Prediction



predicting rare events
predicting in practice
the predictors
•
•
•
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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”)
–
–
–
–
–
–
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Sensory and motor symptoms
Over and under-diagnosis
Purpose?
Compare: “self serving bias” and “self-handicapping”
Notes: “La belle indifference” and lateralizatoin
Conversion, selective attention and dissociation
Somatoform disorder
2. Somatization
–
–
–
–
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Diagnosis
Theory
Therapy
Chronic Conversion?
Somatoform disorder
3. Hypochondriasis (and “cyberchondria”)
–
–
Medical preoccupations
Other needs (and “medical offset”)?
“a disorder of cognition and perception”
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Somatoform disorder
4. Somatoform pain
–
–
Painful preoccupations
Primary and secondary gains?
5. Body Dysmorphia
–
–
Physical preoccupations
Some possibilities (and “muscle dysmorphia”)?
Group forms, old and new
41
Somatoform disorder
Malingering:
deceit with a purpose
Factitious disorder:
Munchausen syndrome
Note: self-induced and “proxy” forms
How do you know?
What do you do?
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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
... the facts, feelings and fictions
Demonstrations of dissociation: group & personal ones
... the Dissociative Experiences Scale
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Dissociative disorder
1. Dissociative Amnesia
 Motivated lack of awareness
 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”
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Dissociative disorder
2. Dissociative Fugue
 Motivated lack of awareness and movement
 Episodic, declarative and procedural memory
46
Dissociative disorder
3. Dissociative Identity Disorder
 Over and under-diagnosis:
“Multiple Personality Disorder” and its problems
 Post-traumatic Theory
(and “asymmetrical amnesia”)
 Sociocognitive view
(and “iatrogenic illness”)
 Notes: suggestibility and dissociation-proneness
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Dissociative disorder
4. Depersonalization Disorder
 Derealization:
“where am I?” and “out-of-body” experiences
 Depersonalization:
“who am I?” and “partial dissociation”
Note: The story of “Possession/trance disorder”
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Eating Disorders and Obesity
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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
Course and treatment
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Binge-eating Disorder
•
•
•
•
•
•
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The social problem
Beyond the BMI
Recognition and getting results
Blaming biology and beyond
Psychological, biological and social factors
Prevention
Psychological Factors
and Physical Illness (Axis IV)
Old and new diagnostic practices:
“Psychological factors affecting medical condition”
History
1. Psychodynamic (“psychological”) viewpoint:
Personality  Illness
2. Psychophysiological (“biological”) viewpoint:
“Weak link” + stress  Illness
54
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
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45 – 50
dehydration, TB, pneumonia
80+
coronary and cancers
Psychological Factors
and Physical Illness (Axis IV)
1. Peptic Ulcers
Dispositional and situational factors in duodenal ulcers
... from monkeys to men to helicobacter pylori and beyond
2. Immunocompetence
Stress and the hypothalamus in immunosuppression and
autoimmune disorders
... from the hypothalamus to hormones to neurons and
beyond
56
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
Dispositional and situational factors
57
Psychological Factors
and Physical Illness (Axis IV)
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Psychological Factors
and Physical Illness (Axis IV)
3. Cardiovascular disorders
Essential hypertension
Diet, exercise, stress...
Type A...
Factors: “repressed rage” and beyond
Implications for treatment: constructive expression of anger
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Psychological
Factors
60
Psychological Factors
and Physical Illness (Axis IV)
The importance
of prevention!
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Personality Disorders (Axis II)
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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
63
Personality Disorders (Axis II)
• Base rates (and comorbidity)
• Prognosis
64
Personality Disorders (Axis II)
Cluster A: “Eccentric”
1. Schizoid (solitary)
2. Schizotypal (idiosyncratic)
3. Paranoid (vigilant)
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Personality Disorders (Axis II)
Cluster B: Erratic
1. Borderline (mercurial)
2. Narcissistic (self-confident)
3. Histrionic (dramatic)
4. Antisocial (adventurous)
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Personality Disorders (Axis II)
Cluster C: “Anxious”
1. Avoidant (sensitive)
2. Obsessive-compulsive (conscientious)
3. Dependent (devoted)
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Personality Disorders (Axis II)
In the appendix...
1. Passive-aggressive
2. “Depressive”
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Personality Disorders (Axis II)
Note, also....
1. “Sadistic”
2. “Self-defeating”
69
Antisocial Personality Disorder
70
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
71
The Modern Criteria ... and prevalence rates
The new problem: criteria
“too broad and too narrow”
“psychopath”/”sociopath”
The Psychopathy
Checklist
“Successful
Psychopaths”
ASPD (DSM IV)
ASPD (DSM III)
72
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
73
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” (Moffitt et al)
Cross-cultural studies
Gene-environment interactions:
MAO-A and maltreatment
74
Theory
1. The (“primary”) Psychopath
... and biological precursors
2. The Sociopath (or “secondary psychopath”)
... and psychosocial precursors
e.g Two types of children (Frick)
The difference it makes



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remission
prognosis
treatment
Theory
The nature of psychopathy
The context: “a mixed incentive task”
A
wrong
B
WRONG!
C
D
RIGHT
wrong
Passive avoidance conditioning and the “low fear” model (Lykken)
76
Theory
The Theory: “an inhibitory deficiency”
BAS (Behavioral Activation System)
BIS (Behavioral Inhibition System)
The Theory, updated:
Emotional and cognitive components


77
“dual deficit” model
“attention” model
Theory
Successful psychopaths, revisited
The “two-edged sword” of antisocial behavior:
means and motives
... comorbidities and their implications
78
Theory
C. Sociocultural factors, then and now
“The Psychopathic Society” (learning)
“The Psychopath within” (psychodynamics)
Beyond psychopathy:
the nature of evil
the concept of “insanity”
79
Impulse Control Disorders
1. Intermittent explosion
2. Kleptomania
3. Pyromania
4. Pathological gambling
5. Trichotillomania
80