1. Neuropsychology of Depression
Clinical case
Diagnostic criteria
Clinical Features
Cognitive Deficits
Neuroanatomical differences

2. Lynn 50 year old, right handed woman
1 yr. history of gradually progressive cognitive difficulties
Decreased vocabulaty, word-finding, inability to multi-task, poor short-term memory
Poor work evaluations, and work is more “effortful”
Mild difficulty managing finances
Dx question: dementia vs. depression

3. History Family issues beginning in teen years Diagnoses
1st psychiatric hospitalization age 16
Diagnoses
Major Depression
Bi-polar depression
Personality Disorder
Major Depressive Episode 9 months ago
Out of work 2 months
Currently resolved
Current tx: pharmacotherapy and psychotherapy
Early onset AD in mother and maternal grandmother

4. Mood Disorders Thought Disorders Anxiety Disorders
Major
Depressive
Disorder (MDD)
MDD w/
Psychotic
Features
Schizophrenia
BPD w/
Psychotic
Features
Schizotypal
Personality
Disorder
Bipolar
Disorders
(BPD)
Schizoaffective
Disorder
Schizoid
Personality
Disorder
Dysthymic
Disorder
Generalized
Anxiety
Disorder
Obsessive
Compulsive
Disorder
Panic
Disorder
Agoraphobia
Post-Traumatic
Stress Disorder
Simple
Phobias
Anxiety
Disorders

5. Fine Line Between Normal Mood & Disorders
Hypo-motivated, low pleasure:
Gloomy, incapable of fun
Humorless
Pessimistic, skeptical
Guilt-prone, low self-esteem
Introverted, restricted social life
Sluggish, inactive, passive
Few interests
Long sleeper (> 10 hrs/night)
Thoughtful, deeply emotional
Hyper-motivated
Cheerful, exuberant
jocular
Optimistic, carefree
self-assured
Extroverted, people-seeker
High energy level, several plans, lots of ideas
Versatile with broad interests
Short sleeper (< 5 hrs/night)
Flighty, impulsive, over-confident
Over-involved, meddlesome

6. What is abnormal? Major Depression
Yes N
‘Often
Sad’
‘Often
Tearful’
‘+ Sad
< 2 wks’
‘+ Can’t
Cheer Up’
‘+ Interferes
w/ Functioning’
Sadness

7. DSM-V Depressive Disorders
Disruptive mood dysregulation disorder
Major Depressive disorder
Persistent depressive disorder (dysthymia)
PMDD
Substance/medication-induced depressive disorder
Depressive Disorder due to another medical condition
Sad, empty, or irritable mood
2) Somatic and cognitive changes that affect capacity to function
Vary in duration, timing, and/or etiology

8. Major Depressive Disorder
 2 weeks of 5 or more of the following representing a change from previous functioning (one must be depressed mood or loss of interest or pleasure):
Depressed mood, most of the day
Markedly diminished interest or pleasure in most or almost all, activities
Weight loss or gain (or ↑↓ in appetite)
Sleep disturbance (hyper- or hyposomnia)
Feeling worthless, excessive guilt
Diminished energy, fatigue
Trouble concentrating or indecisiveness
Psychomotor agitation or retardation
Recurrent thoughts of death, suicidal ideation without a specific plan, suicide attempt or a specific plan for committing suicide
Clinically significant distress or impairment
Not attributable to direct physiologic effects of drug or medical condition
Never been a manic or hypomanic episode

9. Bipolar and Related Disorders
Bipolar I
Bipolar II
Cyclothymic disorder
Substance/medication-induced bipolar and related disorder
Bipolar and related disorder due to another medical condition

10. Manic Episode
Distinct period of 1 week of elevated, expansive, or irritable mood
At least 3 manic symptoms (4 if mood only irritable)
Increased self-esteem or grandiosity
Decreased need for sleep
Increased talking or pressure of speech
Racing thoughts or flight of ideas
Distractibility
Agitation or increased goal-directed activity
Excessive involvement in pleasurable activities with high potential for adverse consequences
Causes significant impairment in functioning
Not due to a general medical condition or caused by drug use

11. Hypomanic episode
Distinct period of 4 consecutive days of elevated, expansive, or irritable mood
At least 3 manic symptoms (4 if mood only irritable)
Increased self-esteem or grandiosity
Decreased need for sleep
Increased talking or pressure of speech
Racing thoughts or flight of ideas
Distractibility
Agitation or increased goal-directed activity
Excessive involvement in pleasurable activities with high potential for adverse consequences
Clear change in functioning
Observable by others
Function intact
Not due to a general medical condition or caused by drug use

12. Bipolar Subtypes Bipolar I Bipolar II
One or more Manic Episodes, with or without a Major Depressive Episode
Bipolar II
One or more hypomanic episodes and at least one Major Depressive Episode
no full Manic episodes

13. MANIA MIXED EPISODE HYPOMANIA NORMAL MOOD DEPRESSION
Stahl S M, Essential Psychopharmacology (2000)

14. Cognitive Deficits in MDD
Subcortical-frontal pattern
Attention
Psychomotor speed
Executive function
Impacted by
Severity
Age of onset
Number of prior episodes
Current state (remitted/in episode)

15. Depression Neuropsychological Profile
Deficits
Preserved
Slowed information processing
Executive
Attention/concentration
Verbal fluency
Cognitive flexibility
Problem solving
Memory
Encoding
retrieval
Orientation
Language
Visuo-spatial
Motor (non-timed)

16. Epidemiology MDD Prevalence Females > Males (1.5-3x)
1 yr: 6.7% (15.7 million adults in US)
Lifetime: 16.2% (32-35 million adults in US)
Females > Males (1.5-3x)
Typical onset – late 20s
Increases after puberty
1st onset in latelife not uncommon
Often associated with neurological impairment
Risk factors
Lower SES

17. Epidemiology - Bipolar
Bipolar I
.06% prevalence
M = F
Mean age onset: 18y
90% of those with single ME go on to have recurrent mood episodes
Bipolar II
.08% prevalence
F> M (clinic samples)
Mean age onset: mid 20s
Most often begins with MDE
12% initial dx MDD
5-15% rapid cycling
5-15% will experience ME (bipolar I)

18. Risk Factors - MDD Early parental loss Adverse life events
often trigger incidence/relapse
‘Neurotic’ personality style
Chronic stress

19. Gender differences - MDD
F>M, but no difference in Sx, course, tx response, or functional consequences
Suicide attempt F>M
Suicide completion M>F

20. Gender differences - BPD
Females more likely to experience rapid cycling and mixed states
Comorbidity patterns differ
f: eating disorder
m: alcohol use disorder
Females more likely to experience depressive symptoms
Childbirth may trigger hypomanic episode
10-20% in non-clinic samples

21. Consequences of disorder - MDD
High individual variability
Severe - complete incapacity
Cognitive impairments
more pain, physical illness, decreased functioning
Comorbidities: SUD, Panic disorder, OCD, eating disorders, BPD

22. Consequences of disorder
Bipolar I
Bipolar II
Lifetime suicide risk: 15X
36.3%
¼ all suicides
30% severe impairment in work function
Cognitive impairments
Comorbidities
Anxiety (3/4), ADHD, impulse control/conduct, SUD (1/2 alcohol)
Lifetime risk: 32.4%
1/3 report SA
Lethality > BPI
20% no inter-episode recovery
Functional recovery < BPI
Cognitive impairments
Comorbidities
60% have 3 or more
75% anxiety disorder, 37% SUD

23. Sensitization Hypothesis of Recurrence
Bipolar/unipolar episodes more likely to recur with
higher number of prior episodes
milder/no stressors as number of episodes increase
earlier onset of illness
more severe early stressor
Post, 1992

24. Dienes, 2006

25. Multi-center (n=11) Meta-analysis of HC & Amyg.Volumes
Bipolar Disorder vs HC
Hallahan, 2011

26. Amygdala Changes in New-onset Adolescent BPD
Bitter, 2011

27. Blood Flow Blue = BPD < Controls Red = BPD > Controls
Independent
Of Mood State
Blood Flow Blue = BPD < Controls Red = BPD > Controls
Chen, 2011

28. Blood Flow Blue = BPD < Controls Red = BPD > Controls
BPD Patients in
Specific Mood
States
Blood Flow Blue = BPD < Controls Red = BPD > Controls
Chen, 2011

29. Lynn’s Test Results Digit Span 9 Letter Number Sequencing SS MMSE
28/30
Hooper Visual Org Test 8
Digit Span 9
Trail Making A 5
Letter Number Sequencing
Trail Making B 3
WMS-III Imm Verbal Memory 7
Phonemic Fluency
Imm Visual Memory
Category Fluency
Del Verbal Memory 11
Boston Naming Test
Delayed Visual Memory 13
Recognition