Mild and temporary forms are part of ordinary existence
Mood Disorders
Conditions of mood in which mood swings are so prolonged and extreme that life is seriously disrupted
Mood Disorders
Have been of interest since beginning of history of medicine
Depressive and Manic Episodes
Mood Disorders
Have an episodic quality
Nature of the Episode and Duration
Can determine diagnosis and often treatment
Major Depressive Episode
Major depressive episode develops gradually over weeks
or months, last several months, and ends gradually
Most of a person's mind and body is affected by depression
Major depressive episode has several characteristics
Depressed mood; deeply depressed people see no way that it
can be helped, called helplessness-hopelessness syndrome
Loss of pleasure or interest in usual activities; loss of
pleasure is known as anhedonia and is far-reaching
Disturbance of appetite
Sleep disturbance
Psychomotor retardation or agitation; in retarded depression,
person seems overcome by fatigue; agitated depression involves
incessant activity and restlessness
Loss of energy
Feelings of worthlessness and guilt
Difficulties in thinking
Recurrent thoughts of death or suicide
Manic Episode
Manic episode typically begins suddenly over a few days and is
usually shorter than a depressive episode
Manic episode may last days to several months and ends abruptly
Manic episode has several characteristics
Elevated, expansive, or irritable mood
Inflated self-esteem
Sleeplessness
Talkativeness
Flight of ideas
Distractibility
Hyperactivity
Reckless behavior
For diagnosis, manic episode must have lasted at least a week
and seriously interfered with person's functioning
A briefer, less severe manic condition is called a hypomanic
episode
Individuals who simultaneously meet diagnostic criteria for both
manic episode and major depressive episode are diagnosed with mixed
episode
Mood Disorder Syndromes
Major Depressive Disorder
People who experience one or more major depressive episodes with
no mania are diagnosed with major depressive disorder
One of the greatest mental health problems in United States
Prevalence is 4% of men and 6% of women
Lifetime risk is 17%
Second only to schizophrenia for admissions to mental hospitals
Often more debilitating than many other chronic medical conditions
Major depression is fourth leading cause of disability and
premature death worldwide
Course
In 80% of cases, first episode is not the last
Median number of episodes is 4, with median duration of 4.5
months
Course varies considerably; some come in clusters
Some return to their premorbid adjustment
Depressive episodes generate stressful life events that can
maintain depression
Groups at Risk for Depression
Race and marital status are risk factors
Risk for women is one to three times higher than for men
Men and women respond to depressed moods differently
Women wonder why depression is occurring; men distract
themselves
The young are at greater risk than the old for depression
Symptoms differ depending on age group
Bipolar Disorder
Bipolar disorder involves both manic and depressive phases
Common pattern is initial manic episode followed by normal phase,
then a depressed episode, then normal period
In rapid-cycling type, there are swings between depressive and
manic or mixed episodes over long period with little or no normal
functioning between
Other differences exist between bipolar and major depression
Bipolar disorder much less common
Two disorders show different demographic profiles
Married or those in intimate relationships less likely to
develop major depression; does not matter in bipolar disorder
People with major depression tend to have histories of low
self-esteem, dependency, and obsessional thinking; those with
bipolar tend to have history of hyperactivity
Depressive episodes in bipolar disorder more likely to show
pervasive slowing down
Two disorders differ in their course
Two disorders differ in their prognosis
Bipolar disorder more likely to run in families
DSM-IV and DSM-IV-TR divide bipolar disorder into
two groups
Bipolar I disorder--person has had at least one manic or mixed
episode and usually, not necessarily, at least one major depressive
episode
Bipolar II disorder--person has had at least one major depressive
episode and at least one hypomanic episode but does not meet criteria
of manic or mixed episode
Dysthymic Disorder and Cyclothymic Disorder
Dysthymic disorder involves a mild, persistent depression
Cyclothymic disorder is a chronic pattern of hypomanic
and depressive behavior
Both disorders have slow gradual onset often in adolescence
Individuals with these disorders tend to have relatives with
mood disorders
Prevalence and gender difference tend to mirror their graver
counterparts
Dimensions of Mood Disorder
Psychotic Versus Neurotic
Depressive and manic episodes can have psychotic features
where the individual loses touch with reality
Many cases remain at the neurotic level
Some argue that neurotic and psychotic level mood disorders
are different entities altogether
The continuity hypothesis says that distinction
is more quantitative than qualitative
Endogenous versus Reactive Disorder
Some regard neurotic forms of mood disorders as psychogenic
and psychotic forms as biogenic
Depression linked to external event was called reactive
Depression not linked to external event was called endogenous
Reactive and endogenous actually refer to different patterns
of symptoms and reflect other differences
Early versus Late Onset
The earlier the onset of disorder, the more likely person's
relatives share, or have had, mood disorders
Findings suggest that early onset cases have higher "genetic
loading" for mood disorders
Could also mean that environmental factors account for
onset
Comorbidity: Mixed Anxiety-Depression
Comorbidity is the co-occurrence of disorders
Symptomotology of anxiety and depression show overlap
Findings raise questions about disorders being two distinct
entities or different manifestations of same underlying disorder
It has been proposed to include new category in DSM
reflecting mixed anxiety-depression
Suicide
A common reason for suicide
Depression
Lifetime risk of suicide
People with mood disorders = 19%; 55% were depressed before fatal attempt
The Prevalence of Suicide
Many people who commit suicide make their deaths look accidental
Eight people attempt suicide for every one who commits suicide
Suicide is 8th most common cause of death in United States
Groups at Risk for Suicide
Certain demographic variables are strongly correlated with suicide
The modal suicide attempter is native-born Caucasian woman, a
homemaker in her 20s or 30s who attempts suicide by swallowing barbiturates
and gives the reason as marital difficulties or depression
The modal suicide committer is native-born Caucasian man in his
40s or older for reasons of ill health, depression, or marital difficulties;
commits suicide by shooting or hanging himself or by carbon monoxide
poisoning
Recent shifts have been observed in suicide-related variables,
particularly with age and race
Teenage Suicide
Suicide rate has risen 200% since 1960
Teenagers exposed to situations as stressful as those facing
adults, but lack resources such as emotional self-control
Trouble within family another major risk factor
Problems of suicidal teenagers rooted in families' problems;
they feel there is no solution to their problems
Myths About Suicide
More than half of all suicide victims had clearly communicated
their suicidal intent within 3 months of fatal act
About 40% of suicides made previous attempts or threat
Most clinicians agree that encouraging patients to talk about
suicidal wishes helps them overcome their wishes
Suicide Prediction
Suicide is often directly related to stress; preceded by "exit"
events
Cognitive variables, such as hopelessness, may be useful predictors
A suicidal scenario is made up of several elements
Pain, related to thwarted psychological needs
Self-denigration
Constriction of the mind
Sense of isolation
Hopelessness
Decision that egression is only solution to problem
Suicide notes express suffering and neutral statements
Most suicide attempters do not really wish to die but are
communicating intensity of their feelings
Suicide Prevention
Telephone hot lines established in later 1950s
School-based workshops that cover warning signs
Efforts have not been very successful, with only slight drops
or not reaching those at risk for suicide
Mood Disorders: Theory and Therapy
The Psychodynamic Perspective
Reactive Loss
Depression was due to massive defense mounted by the ego against
intrapsychic conflict
Abraham suggests that depression arises when one loses a love
object toward whom one had ambivalent feelings
The positive feelings give rise to guilt
The negative feelings give rise to intense anger
Anger is turned inward, producing self-hatred and despair
Modern theorists have revised theory
Depression is rooted in a very early defect
The primal wound is reactivated by recent setback or
blow and person experiences infantile trauma
Regression leads to hopelessness and helplessness
Ambivalence toward love object is fundamental to emotion
Loss of self-esteem is primary feature of depression
Depression has functional role
Some research support for dependency on others and role of
parental loss and poor parenting
Repairing the Loss
Therapist tries to uncover childhood roots of depression and
to explore ambivalent feelings about lost object
Interpersonal psychotherapy has been used and consists of
identifying core problem and discussion of solutions
The Behavioral and Interpersonal Perspective
Extinction
Many behaviorists regard depression as result of extinction
Amount of positive reinforcement person receives is dependent
on several factors
Number and range of stimuli that are reinforcing to person
Availability of such reinforcers in the environment
Person's skill in obtaining reinforcement
Some studies have produced supporting results
Aversive Social Behavior
Depressives are more likely to elicit negative reactions from
others
This has formed basis for interpersonal theories of depression
Depressives try to force caring behavior from others
Reactions tend to be ineffective, which aggravates their
depression
Some studies have found that rejecting responses do
maintain or exacerbate depression
Poor social skills help to maintain depression
Increasing Reinforcement and Social Skills
Treatments involve at increasing patient's rate of reinforcement
Another approach is social-skills training
Most behavioral treatments are multifaceted that include monitoring
self-statements and training in variety of areas
None of behavioral therapies is more effective than drugs
With rise of cognitive therapy, behavioral therapies without
cognitive components were abandoned
The Cognitive Perspective
The way the person thinks about himself/herself, the world, and
the future gives rise to other factors in depression
Helplessness and Hopelessness
Depression may be link to learned helplessness, where
the critical factor is the expectation of lack of control over
reinforcement
Hopelessness theory says that depression depends on a helplessness
expectancy and a negative outcome expectancy
Source of expectations of helplessness and negative outcomes
are the attributions and inferences people make about stressful
life events
Causes are permanent rather than temporary
Generalized rather than specific to one area of their
functioning
Internal rather than external
Negative Self-Schema
Negative bias--seeing oneself as a "loser" is fundamental
cause of depression
Stress can activate the negative schema
Research finds that depressives have very negative self-schemas
Studies indicate that depressives selectively attend to and
remember more negative than positive information about themselves
Cognitive Retraining
Multifaceted therapy developed to modify dysfunctional thinking
and to change schemas
In Beck's therapy, alteration of the schema inoculate the
person against future depression
Another treatment, reattribution training, is attempt to correct
negative attributions
Cognitive therapies have been found to be at least as effective
as drug therapy and perhaps superior at 1-year follow-up
Combining cognitive therapy and drug therapy may be superior
Cognitive therapy has relapse-prevention effect, unlike
drug therapy
The Sociocultural Perspective
Society and Depression
Durkheim saw suicide as an act that occurs within society
and under control of society
Socioeconomic conditions affect suicide rate
Prevalence of depression in United States has increased and
age of onset has dropped
Social change may account for the prevalence
Family structures, moving away, moving down socioeconomic
ladder may be related
2.Suicide prevention programs have not been especially effective
Perhaps better approach is to attack social problems associated
with suicide such as delinquency, teenage pregnancy, and family distress
The Neuroscience Perspective
Genetic Research
Family studies suggest genetic component in mood disorders;
first-degree relatives of those with mood disorder are more likely
to develop disorders
Concordance rates for bipolar disorder was 72% among MZ twins
and 14% for DZ; for unipolar disorder, 40% for MZ twins and 11%
for DZ
Genetic factors are more important in bipolar disorder than
in depression
Environmental factors such as individual-specific environments
are important; less important are shared environmental factors
Adoption studies provide most impressive evidence for the
heritability of mood disorders
Linkage analysis provides mixed results
Neurophysiological Research
Mood disorders may be related to biological rhythms such as
sleep disturbances like shortened REM latency
One theory suggests that when important social zeitgeber is
removed from person's life, its removal is a loss but also disrupts
body's circadian rhythms leading to consequences
Seasonal Affective Disorder(SAD) is closely
related to biological rhythms
For diagnosis of SAD, person must meet criteria for major
depressive episode, remission and onset tied to seasons, and
pattern must have lasted for at least 2 years
Winter version of SAD tied to shorter photoperiod
Women are at greater risk with average age at onset
of 23
Theory suggests that lag in circadian rhythms causes
SAD
Most SAD patients report improvement with light therapy
Neuroimaging Research
CT and MRI studies suggest mood disorders involve abnormalities
in brain structure (e.g., ventricles, frontal lobe, cerebellum,
basal ganglia)
Suggests that these brain areas are involved in mood regulation
Biochemical Research
Hormone Imbalance
Depression is due to malfunction in hypothalamus
Dysfunction may be related to control of hormone production
Depression can sometimes be treated by altering hormone
levels
Hormone imbalances are characteristic of endogenous and
psychotic depression
Dexamethasone suppression test used to differentiate
between endogenous and reactive cases
Hormone imbalances occur both in major depression and
in depressive episodes of bipolar disorder, but does not seem
to be a primary cause
Neurotransmitter Imbalance
Catecholamine hypothesis argues that increased levels
of norepinephrine produce mania, whereas decreased levels
produce depression
Tricyclic drugs block reuptake of norepinephrine and
serotonin
Serotonin involved in mood disorders and suicide by
indirect evidence
Another theory suggests that atrophy of certain neurons
in the hippocampus triggers depression; antidepressant drugs
may influence brain-derived neurotrophic factor
Antidepressant Medication
The major classes of antidepressant medication are Monoamine
Oxidizers (MAO) inhibitors, the tricyclic antidepressants (TCAs),
and selective serotonin reuptake inhibitors (SSRIs)
Drugs work by increasing levels of neurotransmitters by interfering
with an enzyme or reuptake
Balancing symptoms' relief with side effect an important consideration
Tricyclics effective 50-70% of patients with depression
