Epidemiology of Affective Disorders Bipolar disorder o Childhood to 50 years of age, earliest is 5-6 yrs.

. old o The stronger the family background, the earlier the age of onset of bipolar disorder Major depression o Mean age of onset = 40 years o 50% of cases onset is between 20 50 years old. Doc suspects that it is due to menopause and mid life crisis. o Marital status: higher in those who have no close interpersonal relationships or those who have been divorced, annulled, or separated. o No difference in regards to race or socioeconomic status o F:M2:1. May be due to hormonal changes in menopause or post partum period. o in terms of comorbidity, there is a higher risk of Axis 1 disorders** o Aka, unipolar depression. 1 major episode of depression. Minor depression o Unable to fulfill criteria of major depression. Mania o Bipolar I: manic depressive episode. o Bipolar II: hypomania, which is milder than manic episode. o Both are psychotic in proportion. Cyclothymia o Non psychotic disorder o Cyclic nature of manic and depressive episodes, but to a lesser degree. Patient is still able to function in terms of academic or work function. Dysthmia o Non psychotic disorder **Note: most people suffering from affective disorders do not finish college. This may be due to a disruption in their functioning rather than academic functioning. Comorbidity: increased association with Axis I disorders like alcohol or substance abuse among men and anxiety disorders (OCD or panic disorder) among women. Major and minor depression are psychotic in nature vs. dysthymia which is not. Etiology of Affective Disorders Biological o Norepinephrine, dopaminergic, and serotonin systems are affected. There is a decrease in all of this in depression o Neuroendocrine: TSH and GH responses, but HPA (hypothalamic pituitary adrenal axis) activity o Immunologic: lymphocytes o Brain structure abnormalities: left anterior cerebral activity, cerebral blood flow to mesocortical and mesolimbic pathways. glucose metabolism in limbic system in depression. Enlarged ventricles with cortical atrophy and widened sulci. Genetic o Penetrance <100%, so not everyone who has the gene will present will the disease. o Nonpenetrant carriers: the gene is present but do not have the disorder. o Phenocopies: these are people who do not have the gene but have the manifestations of the affective disorder.

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Variable expressivity: those who have the genes but have different forms of the illness. This is determined by studies on twins who have the depressive gene, but who had different presentations of the illness. Heterogeneity: multiple genes for the illness. Imprinting: parent of origin will affect certain genetic phenomenon. Anticipation: severity of disease increases and age of onset decreases with each generation of the illness. Clinical Unipolar depression Bipolar disorder BPD and schizophrenia Bipolar 2 Panic symptoms Passed on by mother BPD and schizophrenia Bipolar (one of the earliest chromosomes discovered

Genetic Etiology of Affective Disorders Chromosome Locus 2 cAMP response element binding protein (CREB1) 11 13 13q G72 18 q arm 21 22

q arm

Note: We werent able to grab a screenshot. What is above is taken from the book and the recording. Etiology of Depression Biological o Temperamental dysregulation Patients who develop depression also come from dysfunctional families with parents who have low threshold for frustration, etc. home environment is more chaotic and leaves the child prone to developing depression Parents who criticize the child excessively Parents who are divorced/separated o Biological stressors Certain drugs can cause depression or mania o Medical conditions Thyroid dysfunction o Sex Women have higher risk for depression (than mania) most likely due to anxious/depressive traits women are born with. Women tend to have more monoamine oxidase, which breaks down monoamine neurotransmitters in the brain. Low progesterone/high estrogen levelsPMS, post partum depression and oral contraceptives Women tend to have more dysthymic attributes than men. Behavioral: Cognitive Theory o Aaron Beck: negative thinking more so in depressive patients. o Cognitive triad: helpless, unfavorable perception of self and/or world around them o Interpretation of events, hopeless future o Learned helplessness: person has learned to take on such a passive view of life that they just give up. o Reinforcement: depressive behavior is associated with lack of rewards, so patient does not try as hard. o Arbitrary inference: drawing conclusions without evidence or support. It is overcome by finding evidence to support the conclusion. Eg, someone does not smile back at you and you come to the conclusion that they do not like you. o Specific abstraction: focusing on a certain detail while ignoring another more important aspect of an experience. Eg, youve had a great day but one bad thing happens and all you can focus on is that bad thing.

Overgeneralization: general conclusion based on too little or too narrow an experience. Eg, having one bad boyfriend makes patient assume all men are not trustworthy. o Magnification and minimization: overvaluing or undervaluing the significance of an event. o Personalization: tendency to self reference actual events without actual basis. Eg, parent gets mad at one sibling, but not patient. Patient may think they are to blame as well. o Absolutist, dichotomous thinking: black and white thinking, considering extremes. Eg, if I dont get a 90 in psychiatry, I will quit medicine. Sociocultural o Developmental predisposition: linking genetic tendency + dysfunctional home patient more prone to depression o Object loss: early breaks in affectional bonds + adult losses. Eg, loss of parent, especially father, in early life may lead to depression as an adult. 2 step process in break of early bonds. Loss of parent may be through divorce, death, separation via job abroad, etc. There will be a social stressor (eg, bad break up with boyfriend) that leads to a manic or depressive episode. Succeeding episodes may not have stressor. o (+)life events and environmental stress 1st episode in mood disorder. In succeeding episodes, there may not be stressors. Psychodynamic: classic view o Karl Abraham and Sigmund Freud Disturbances in infant mother relationship x oral phase Real or imagined object loss Introjection of departed objects Retroflexed anger o Melanie Klein: express aggression toward loved ones through a passive way. Eg, the patient is angry at loved one, who is trying to cheer them up. By refusing to cheer up, the patient is showing their anger passively. o Edward Bibring: aware of discrepancy between extraordinary high ideals and inability to meet these ideals. o Edith Jacobson: powerless, helpless child victimized by tormenting parent. o Silvano Arieti: depressed individuals live for others and if that person rejects them, they get depressed. o Heinz Kohut: loss of self esteem o John Bowlby: damaged early attachment and traumatic separation o

Etiology of Dysthymia Mild depression in a chronic scale Asch: masochistic character. These people enjoy being depressed. Mardi Horowitz: pleasure of revenge. Patient tries to defeat pleasure of those around them. Tries to fail, is negative, etc. David Milrod: wallowing in self pity. Cindy Black: o Anaclitic depression: very anxiously attached to loved ones around them. These individuals tend to express loneliness, weakness, hopelessness and need someone to always show love. o Interjective depression: individuals who are very self reliant. Experience depression when they feel guilt, worthlessness, etc. Depression vs. Mania Please review in the book as this is only a short list of what was discussed in class. Mania o Feelings of elation, invulnerability, energetic, euphoric o Hyperactive o Anger Depression o Hypoactive, sad o Low self worth o Anger Mixed episode o Patient has both manic and depressive episodes at the same time. Eg, someone who is talking a mile a minute but has suicidal thoughts.

Rapid cycling o >4 episodes of mania/depression per year.

Etiology of Mania Psychodynamic o Defense vs. emotional pain, stress, depression o Denial, distortion delusions. Eg, patient has failed the bar exam but believes theyre God as a means of cushioning the blow of the failure o Tyrannical superego: intolerable self-criticism replaced by euphoric self satisfaction. A defense against the superego that tells them they are worthless. There is an idealization mechanism that paints themselves as great. o Regression: reinstatement of pleasure principle. Overwhelmed by id, sex and aggression come out. Manic/depressive patient is regressed to the oral stage. Reinstatement of the pleasure principle through expression of sexual and aggressive impulses. Epidemiology of Suicide Gender: Females tend to attempt suicide more. Males, however, tend to be more successful. Age: 15 24 y.o., then another peak at 40 50 (end of life) Race: mostly Caucasians, more immigrants in US. Religion: In US, non Catholics since Catholics view suicide as a mortal sin. Religion helps some people cope with life and/or suffering. Marital status: higher in singles, separated, never married, annulled, single parents, etc. because of lack of support systems. Occupation: high stress jobs, soldiers, anesthesiologist (due to access of meds), ophthalmologist, psychiatrist. Climate: higher rates in winter prone countries Physical health: high in terminally ill Mental illness: more common in o Substance abusers: alcohol and drugs disinhibit individuals so id impulses come out. o Depressed individuals Previous suicidal behavior: if at first you dont succeed, try, try again. Definition of Suicide Self murder, fatal act, wish to die Thinking vs. acting: In general, the act of attempted suicide indicates an underlying mental illness because most people are pro life, not pro death. Attempt vs. completed: Attempts are suicides that are unsuccessful and not completed, naturally. Impulsive vs. premeditated: Impulsive is done on the spur of the moment and usually in front of someone else, who can prevent the suicide. Premeditated tend to write notes, give away possessions, reconcile with loved ones, tie up all loose ends before committing suicide. They tend to have a sense of calm before the suicide attempt. Suicide vs. parasuicide: Parasuicide is a suicidal gesture and is not as serious about killing themselves. It can be an attempt at seeking attention, a means to manipulate another person, or perhaps they are just bored with life. Etiology of Suicide Biological o Neurotransmitters Decreased serotonin Genetic o Tryptophan hydroxylase gene is associated with patients who commit suicide violently. It is also associated with alcoholism. Cognitive theory o Sense of hopelessness o (+)family history no acceptable means of coping. Sociocultural o (-)social support o (+)stressful life events Psychodynamic

Durkheims theory Egoistic: lack integration into a group or any social support group. Higher in urban areas where people are less integrated. Altruistic: excessive integration into a group. Eg, kamikaze pilots, cults, reincarnation believers (ie, Buddhists monks) Anomic: integration into society is disturbed. Eg, person who declares bankruptcy kills themselves because they are unable to maintain their lifestyle. o Freud Aggression directed inwardly towards the interjected, ambivalently affected love object. o Menningers Theory Inverted murder: self directed instinct hostility wish to kill, wish to be killed, wish to die. Other psychodynamic theories: o Wish for revenge (making people you are angry at feel guilt for your suicide), power, control, punishment (guilt), atonement, sacrifice, restitution, sleep, escape, rescue from loved one, rebirth or reunion with loved one who died, narcissistic injury (shame), rage, id with suicide victim. o

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~End of Transcription~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ To this end we always pray for you, that our God will make you worthy of His calling and may fulfill every resolve for good and every work of faith by His power, so that the name of our Lord Jesus may be glorified in you, and you in Him, according to the grace of our God and the Lord Jesus Christ. 2 Thessalonians 1:11-12