Chapter 8 Mood Disorders

•General Characteristics of Mood Disorders

•Psychological Theories of Mood Disorders •Biological Theories of Mood Disorders •Therapies for Mood Disorders •Suicide

Chapter Outline

Mood Disorders: General Characteristics

•Much more serious than typical emotional states that everyone feels

• Involve significant disturbances in emotion, including extreme sadness (depression) or elation/irritability (mania)

•Are disabling (i.e, interfere with daily activities/ functioning

•Are often associated with other serious psychological problems:• Panic attacks• Substance abuse• Sexual dysfunction• Personality disorders

Depression: Signs and Symptoms•Depression – mood disturbance:

• emotional state marked by great sadness• feelings of worthlessness and guilt

•Depression – cognitive or ‘thinking’ disturbance:• self-criticism, self-blame • Indecisiveness, slowed thinking, thoughts of death or

suicide

•Depression – physiological (somatic) and behavioural disturbance• loss of sleep, appetite, and sexual desire • loss of interest and pleasure in usual activities

•Symptoms vary between cultures•Children: somatic symptoms are most common

early signs•Most depressed individuals focus on somatic

symptoms (~85%)

Mania: Signs and Symptoms

•Mania: An emotional state or mood of intense but unfounded elation accompanied by irritability, hyperactivity, talkativeness, flight of ideas, distractibility, and impractical, grandiose plans

•Noticed by others due to loud and incessant remarks, sometimes full of puns, jokes, rhyming, etc., difficult to interrupt, shifting from topic to topic, need for activity that can be annoying to others and with poor planning

Diagnosis of DepressionMajor Depressive Disorder (DSM-

5)• Presence of 5 of the following symptoms for at

least 2 weeks. • Note: Depressed mood or loss of interest and

pleasure must be 1 of the 5 symptoms• Symptoms

• Sad, depressed mood, most of the day, nearly every day

• Loss of interest and pleasure in usual activities• Difficulties in sleeping • Shift in activity level• Changes in appetite and weight • Loss of energy, great fatigue• Negative cognitive appraisal (feeling worthless)• Difficulty in concentrating• Recurrent thoughts of death or suicide

Major Depressive Disorder (MDD) - continued

• Lifetime prevalence rates in U.S.: from 5.2% to 17.1% • Similar ranges were found in a cross-cultural study• In Canada lifetime prevalence could vary from 20% to

50% • 2x more common in women than in men

• Difference appears in adolescence and is maintained across the lifespan

• See Focus on Discovery 8.1

Diagnosis of Bipolar Disorder

•Bipolar I disorder– involves episodes of mania or mixed episodes that include symptoms of both mania and depression• Diagnosis of a manic episode requires the

presence of elevated or irritable mood and increased activity level (this requirement was added by DSM-5) + 3 additional symptoms (4 if mood is irritable): • in activity level at work, socially, or sexually• Unusual talkativeness; rapid speech• Flight of ideas or subjective impression that thoughts

are racing• Less than the usual amount of sleep needed• Inflated self-esteem• Distractibility• Excessive involvement in pleasurable activities that are

likely to have undesirable consequences

Bipolar Disorder (cont.)

• Occurs less often than MDD• Lifetime prevalence rate for Bipolar Disorders (I

and II) of 4.4% of the population • Average age of onset is in the 20s• Bipolar Disorders occur equally often in men and

women, however, the kinds of episodes vary:• In women, episodes of depression are more

common• In men, episodes of mania are more common

• Bipolar Disorders tend to recur• More than 50% have a recurrence within 12

months • More than 50% of cases have 4+ episodes

Heterogeneity

•Examples•Bipolar I Disorder with mixed episodes•Bipolar II Disorder (no ‘full-blown mania)

• episodes of major depression accompanied by hypomania (less extreme than Bipolar I mania)

•MDD with psychotic features•Bipolar and unipolar disorders can be

also sub-diagnosed as seasonal• Seasonal affective disorder (SAD)• Highest rates of SAD can be found among

people who live in the Canadian Arctic (up to 18% of population)

Persistent Mood Disorders

•Symptoms of disorders must have been evident for at least 2 years and are not severe enough to warrant a diagnosis of MDD or manic episode.• Cyclothymic disorder

• Lifetime prevalence of 2.5% • Persistent Depressive disorder (DSM-5)

• Lifetime prevalence of 4.6%;• Double Depression

• People with persistent depressive disorder may also experience episodes of major depressive disorder

Psychological Theories

•Psychoanalytic Theory of Depression• Analogy to bereavement, according to Freud• depression is seen to be like a mourner who over-

identifies with (introjects) lost love one• anger turned inward (resents feeling abandoned)• research: some individuals who show high

dependency traits are more prone to depression following loss experiences

Psychological Theories (cont.)

•Beck’s Theory of Depression• Thinking is biased toward negative interpretations

•Negative triad• Negative views of the self, the world, and the future

•Principal Cognitive Biases

• Arbitrary inference• Selective

abstraction• Overgeneralization• Magnification and minimization

Helplessness/Hopelessness Theories

•Learned Helplessness • Individual’s passivity and sense of being

unable to act and control own life is acquired through unpleasant experiences and traumas that were unsuccessfully controlled.

•Attribution and Learned Helplessness • Revised theory is the concept of attribution • Global attributions • Attributions to stable factors • Attributions to internal characteristics

•Hopelessness Theory• Advantage of theory is that it can deal the

comorbidity of depression and anxiety disorders

Other Theories of Depression

• Interpersonal Theory of Depression • Sparse social networks that provide little

support• an individual’s ability to handle negative

life events • vulnerability to depression

• Depressed people also elicit negative reactions from others and are low in social skills

• They also constantly seek the reassurance of others

•Psychological Theories of Bipolar Disorder•Largely neglected by scholars and

clinicians

Biological Theories

Genetic Data• Bipolar

• Concordance rate is as high as 85% • Adoption studies provide support for a strong

heritable component • May be linked to a dominant gene on the 11th

chromosome • Brain-derived neurotrophic factor (BDNF)

gene also implicated

•MDD• Heritability estimate= 35% • Relatives of unipolar probands are at risk for

unipolar depression• Serotonin transporter gene-linked promoter

region (5-HTTLPR) is being considered

Biological Theories (cont.)

•Early theories postulated that• levels of norepinephrine and dopamine lead to

depression• levels lead to mania

•Serotonin theory • Serotonin (which regulates norepinephrine) produces

both depression and mania

•Clues for theories based on drug effectiveness• Tricyclic drugs prevent some of the reuptake of

norepinephrine, serotonin, and/or dopamine by the presynaptic neuron after it has fired,

• Monoamine oxidase (MAO) inhibitors keep the enzyme monoamine oxidase from deactivating neurotransmitters therefore the levels of serotonin, norepinephrine, and/or dopamine in the synapse.

• Selective serotonin reuptake inhibitors inhibit the reuptake of serotonin

Biological Theories (cont.)

•Drug actions suggest that depression and mania are related to serotonin, norepinephrine, and dopamine• BUT the biological mechanisms of the disorders are not

straightforward and perhaps not just related to levels of neurotransmitters

• Anti-depressants and mood stabilizer (anti-manic) medications may work by changing the responsiveness of receptors (which may be too insensitive in people with depression) and too sensitive in people with mania) for these neurotransmitters

Biological Theories (cont.)

•Neuroimaging studies • hippocampal volume and neurocognitive

impairment

•Functional imagining of cingulated area 25 • Induction of dysphoria in healthy people caused

glucose metabolism in cingulated area 25• Treatment with paroxetine showed

hypermetabolism in cingulated area 25

•MAO-A levels in the brain are elevated during untreated depression.

Biological Theories (cont.)

Neuroendocrine System •HPA axis may play a role in depression

• Limbic area of brain (closely linked to emotion) affects the hypothalamus which in turn controls endrocine glands (release of hormones)

• levels of cortisol in depressed patients

•Disorders of thyroid function are often seen in bipolar patients • Thyroid hormones can induce mania

• Right hemisphere dysfunction – sense of indifference or flatness

Summary of Biological Theories

Beck’s Developmental Model of Depression

Therapies for Mood Disorders

• Psychological Therapies• Psychodynamic Therapies• Cognitive and Behaviour Therapies• Mindfulness-Based Cognitive Therapy• Psychological Treatment for Bipolar Disorder

•Biological Therapies• Electroconvulsive therapy (ECT)• Drug therapy

Suicide

•Suicide was the 9th leading cause of death in Canada in 2005

•Suicide is the 2nd cause of death (after accidents) in youth ages 15 to 24 (Statistics Canada, 2009)

•Women have higher rates of suicide attempts but lower rates of suicide as compared to men, a phenomenon called gender paradox of suicidal behaviour

Suicide - Terminology•Suicidal ideation

•Thoughts and intentions of killing oneself

•Suicide attempts•Self-injury behaviours intended to

cause death but that do not lead to death

• Suicide gestures •Self-injury in which there is no intent

to die•Suicide

•Behaviours intended to cause death and death occurs

Psychological Theories of Suicide

•Risk Factor Model • 4 categories of relevant factors:

• Predisposing (vulnerability) factors (such as psychological disorder, abuse, early loss)

• Precipitating (crisis) factors (such as end of relationship, job loss, rejection)

• Contributing factors (such as physical illness, isolation)

• Protective (decrease risk)factors (such as personal resilience, active coping skills, positive future expectations, social support)

Psychological Theories of Suicide(continued)

•Shneidman’s Approach• Perturbation of mind is a key feature• Suicidal individuals are experiencing psychache which

is intense anguish

•Baumeister’s Escape Theory and Perfectionism• Painfully aware of personal shortcomings• Become suicidal to escape aversive self-awareness• Perfectionists have such impossibly high self-

standards

•Perfection and Social Disconnection•Additional Psychological Factors

• Suicidal individuals have constricted thinking – makes it hard to see options - need to help them see a wider range of alternatives to solve the problem that provoked the suicidal distress

Physical factors in suicide

•Repeated concussion injuries (such as hockey ‘enforcers’) develop chronic traumatic encephalopathy (CTE)

•MZ twins have a much concordance for suicidality than DZ twins

• levels of 5-HIAA may be especially related to impulsive suicide

Preventing Suicide

•Treating the underlying mental disorder

•Treating Suicidality Directly

•Suicide Prevention Centres

•Government Suicide Prevention Programs in Canada

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