WEEK 4 - Mood Disorders

major depressive disorder

a condition where individuals suffer from persistent low mood, lack of energy, sleep and appetite disturbances, and poor concentration and motivation. Sufferers typically withdraw from work, hobbies and personal relationships, and experience persistent negative thoughts about themselves, their world and their future. Suicidal ideation is a significant risk in this population.

dysthymia

a lower-severity but more chronic version of major depressive disorder that lasts at least two years. Symptoms are less severe than major depressive disorder, but are equally as persistent, including low energy, low self-esteem, hopelessness and changes in eating or sleeping habits.

bipolar disorder

a condition where individuals suffer from alternating depressed and elevated moods (mania). mania is characterized by abnormally energized or irritable affect, reduced sleep and high levels of impulsivity. the degree of mania can be less extreme, referred to as hypomania, and this level of severity separates the two types.

cyclothymia

bipolar equivalent of dysthymia, in that it follows the same symptom profile, but the mood fluctuations never reach the severity or duration of major depression or full mania. they typically experience short periods of mild depression, hypomania and elevated mood over two years.

mdd criteria a

five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least 1 symptom is depressed mood, loss of interest or pleasure. do not include symptoms that are clearly attributable to other medical conditions

• depressed mood most of the day, nearly every day; diminished interest or pleasure in almost or all activities most of the day, nearly every day; significant weight loss or weight gain when not dieting; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive/inappropriate guilt; diminished ability to think or concentrate; recurrent suicidal ideation or suicide plan

mdd criteria b

the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

mdd criteria c

the episode is not attributable to the physiological effects of a substance or to another medical condition

mdd criteria d

the occurrance of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders

mdd criteria e

there has never been a manic episode or a hypomanic episode

• this exclusion does not apply if all the manic-like or hypomanic-like symptoms are substance-induced or are attributable to the physiological effects of another medical condition

bipolar criteria a

criteria have been met for at least one manic episode. the manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes

bipolar criteria b

the occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders

note: major depressive episodes are common in bipolar disorder but are not required for diagnosis of bipolar type 1 disorder

note: hypomanic episodes are common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder

manic episode criteria a

a distinct period of abnormally and persistently elevated expansive or irritable mood, and abnormally and persistently increased goal directed activity or energy lasting at least one week and present most of the day nearly every day

manic episode criteria b

during the period of mood disturbance and increased energy or activity, three or more of the following symptoms are present to a significant degree and represent a noticeable change from usual behaviour

inflated self-esteem and grandiosity; decreased need for sleep; more talkative and a pressure of speech; racing thoughts and flights of ideas; distractibility; increase in goal directed activity or psychomotor agitation (purposeless activity); excessive risk-taking behaviour

manic episode criteria c

the disturbance is sufficiently severe to caused marked impairment in functioning or necessitate hospitalization to prevent risk to self or others, or there are psychotic features

manic episode criteria d and e

constitute exclusions based on substance use/drug side effects, or the presence of psychotic features in the absence of prominent mood symptoms

hypomanic episode criteria a

a distinct period of abnormally and persistently elevated expansive or irritable mood, and abnormally/persistently increased activity or energy lasting at least four days and present most of the day nearly every day

hypomanic episode criteria b

during the period of mood disturbance and increased energy or activity, three or more of the following symptoms are present to a significant degree and represent a noticeable change from usual behaviour

inflated self-esteem and grandiosity; decreased need for sleep; more talkative and a pressure of speech; racing thoughts and flight of ideas; distractibility; increase in goal directed activity or psychomotor agitation (purposeless activity); excessive risk-taking behaviour

hypomanic episode criteria c

the episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when non-symptomatic

hypomanic episode criteria d

the disturbance in mood and change in functioning is observable by others

hypomanic episode criteria e-g

exclusion based on major impairment, psychotic features, substance use, or medications

mdd comorbidity

64% develop mdd, 12.6% had it prior (Kessler et al., 2003) 50% have anxiety disorder such as gad (Kessler et al., 2005)

is associated with increased chronicity and severity (Rush et al., 2005)

serotonin transporter gene (5-htt)

a risk factor for mdd: short-allele mutations reduce efficiency and elevate stress sensitivity (Capsi et al., 2003)

mdd child maltreatment

a risk factor for mdd: the most significant predictor of depression and mediated by personality functioning (Dagino et al., 2020)

43-45% of patients with mdd have a history of CMT, with their risk for developing mdd nearly tripling (Nelson et al., 2017)

mdd perceived social status

a risk factor for mdd: partially mediates the relationship between SES and symptom severity (Hoebel et al., 2017)

additional mdd risk factors

life events increase the risk of mdd (Haberstick et al., 2016)

early maladaptive schemas: predict future depressive episodes (Halvorsen et al., 2010)

relapse and recurrence risk: comorbidity and symptom severity (Hoertel et al., 2017)

mdd functional impact

250m live with depression worldwide (WHO, 2019; 2020) accounts for 10% of disability (Moussavi et al., 2007)

depression strongly linked to chronic and unhelpful health behaviours and generally increased mortality rate (Kessler, 2012) in cardiac patients, the risk of dying within two years is doubled (Barth et al., 2004)

mdd is associated with decreased quality of life, reduced academic and occupational functioning and interpersonal problems

(Palmier-Claus et al., 2016)

a study of bipolar risk factors: bipolar risk was strongly associated with childhood abuse and neglect. emotional abuse 4x as likely to occur in those with bipolar disorder versus controls

higher rates of childhood maltreatment compared to mdd, but comparable to rates in schizophrenia patients

(Horton et al., 2005)

a study of bipolar risk factors: suicide risk in those with bipolar disorder is best predicted by prior suicide attempts and sense of hopelessness (like mdd)

for non-fatal suicidal behaviour, best predictors were family history of suicide, early bipolar onset, mdd, rapid cycling, comorbidity and substance abuse

rapid cycling

a risk factor of bipolar disorder: a severe form of bypolar 1 or 2 defined by four or mood mood episodes (mania, hypomania, depressive) within 12 months. causes frequent and intense mood shifts, often making it harder to treat and can be temporary or lifeling

(Rowland et al., 2018)

a study for bipolar disorder catalysts: combinations of genetic factors, current life stress and substance abuse may lead to bipolar catalyzing. evidence from this study suggest a concordance of 40-70%

recent twin study shows 70-80% heritability with one bipolar diagnosed parent (Craddock & Skylar, 2013)

functional impact of bipolar disorder

BP’s prevalence is low but the impact is debilitating. 21-54% of sufferers attempt suicide. in europe, between 60-70% of bipolar sufferers are unemployed and recieve disability

(Fajutrao et al., 2009)

resource conservation theories

1 evolutionary model for mdd:

learned helplessness is an example of inaction as a reaction towards events that are aversive and uncontrollable (Seligman, 1975)

depression is a response that adjusts resource allocation by inhibiting investment in behaviours that reap no rewards (Klinger, 1993; Nesse, 2000)

depressive phenomena

adaptive responses to an increased threat to interpersonal agency or affiliation, which in turn impact upon one’s percieved social burden (Allen & Badcock, 2003)

social risk hypothesis

1 evolutionary model for mdd:

depressed states evolved to minimize social risk where humans perceive that their social burden nearly equals or exceeds their social value, developing into depressive phenomena. when social investment potential (SIP) is low, depression is thought to be the result

empirical support for the social risk hypothesis with regards to mild-moderate depression, but there are other studies open to more than one interpretation that looks at data to support SIP as a measure of social risk (Dunn & Sharpe, 2012)

biological models for mdd

because human behaviours are complex and regulated by many genes individual, they are hard to detect. monozygotic and dizygotic twins concordance rates differ but their environment doesnt, therefore genes mut be a factor

(Rosenthal 1971) discovered relatives are 10x risk, but (Gerson et al., 1976) twin studies show concordance 69/13%

no single cause detected but an interaction; mood disorders are highly heritable but does not guarantee mdd emergence

genetic diathesis must likely be expressed in personality or cognition and be triggered by stress. mdd highly correlated with neuroticism, less correlated with extraversion and low conscientiousness (Hakulinen et al., 2015)

(Schildkraut, 1965)

coined the Monoamine Hypothesis, the prevailing biological theory that stated that depression was caused by a deficit in serotonin, and mania was caused by too much norepinephrine or dopamine activity in the context of too little serotonin

(Dozois, 2023)

brain imaging technique study showing those with mdd may have fewer serotonin receptors, showing the short 5HTT allele was associated with lower efficiency and mediated stress sensitivity

having fewer receptors means serotonin release at a synapse has fewer places to bind on the post-synaptic cell, thus leading to fewer action potentials and lower serotonin transmission

dopamine transmission is partly dependent on serotonin; low serotonin means dopamine decrease which is implicated in the regulation of reward processing and motor behaviour, thus resulting in ahedonia and psychomotor retardation in mdd

(Depue & Iacono, 1989)

coined the Behavioural Inhibition (BIS) versus Behavioural Activation (BAS) theory for bipolar disorder

the behavioural inhibition system is involved in regulating responses to threats and punishment, often interacting with BAS which drives reward-seeking behaviour

the behavioural activation system drives approach-related motivation, reward pursuit, and goal-directed activity. a hypersensitive BAS is strongly linked to mania, triggering high energy, goal pursuit and euphoria

bipolar neurotransmitters

(Dozois, 2023) norepinephrine, dopamine and serotonin theorized by Dozois to play a role in manic episodes of bipolar disorder

abnormal dopamine may trigger the hyperactivity and psychosis of severe mania, abnormal noepinephrine may trigger euphoria and grandiosity

normal serotonin levels inhibit neuronal activity, leading to behavioural inhibition; while low serotonin can lead to disinhibition/activation are linked to a variety of behaviour, hypothetically leading to wide swings between depression and mania

ion channelopathy

genetic variations disrupt ion channels, specifically calcium, sodium and potassium that regulate neuronal firing. dysfunctionalities in these ion channels link to altered neurotransmission, increasing intracellular calcium and neuronal hyperexcitability

(Harrison et al., 2017)

a study showcasing genetic risk factors of bipolar disorder: no single gene causes bipolar, instead many common variants of small effect contribute. no evidence suggests bipolar is inherited, yet this genome-wide association study revealed genes related to ion channelopathy are central to bipolar disorder

specifically calcium channel CACNA1C, implicated in mood instability related to bipolar and depression. neurons regulate neuroplasticity, information processing, perception, cognition and excitability. errors in these genes cause changes in signaling pathways becoming overactivated and poorly regulated

calcium signaling pathway

a dysregulation of the CSP viewed as partial cause of bipolar disorder (Heyes et al., 2015) CSP pathology exists independent of mood, suggesting a trait-like mechanism of vulnerability

lithium and antiepileptics reduce mania symptoms

a hypothetical causal chain related to CSP is when a genetic disruption of calcium channels destabilize mood circuits, making bipolar a condition of neural and affective instability that responds best to re-stabilization of neural signaling and excitability treatments

(Beck, 1979; 2008)

the cognitive model of depression coined by this scientist integrates biological, evolutionary, behavioural and environmental factors

cognitive explanations propose that a person’s beliefs and perceptions influence the emotions they experience, the intensity they are felt, and the behaviours/strategies used to manage distress

therefore, with environmental context, perception is an intrinsic factor governing whether someone gets clinically depressed and stays depressed

cognitive triad

(Beck, 2011) depressed people typically have negative perception of the self, the world and the future; these are negative core beliefs through which they interpret life events

core beliefs are: always present, unconscious, but become activated during stressful events that reflect those in which they were formed; treated as fundamental truths generally not accessible to consciousness. this can be worked on in cognitive therapy

beck proposed that core beliefs are acquired during formative life experiences from childhood such as trauma (loss of parent, peer rejection, parental behaviour, abuse and neglect)

intermediate beliefs

a part of Beck (2011)’s cognitive triad theory, in which core beliefs and assumptions are over-general and rigid, thus making them easily violated and compromise coping with life challenges

may be culturally reinforced by gender roles, conflict management, emotional control

negative automatic thoughts (NATs)

a part of Beck’s (2011) cognitive triad theory describing a concept of negative thought streams that coexist with a manifest stream of thought. everyone experiences NATs but those with mdd experience deeply distressing ones; they feel plausible, and are more associated to the emotion elicited due to the unconscious nature of their conception

automatic thoughts can be evaluated according to their validity and their utility, and thus questioning the validity of these negative thoughts can cause a shift in the belief of the thought

mdd maintenace

(Beck, 2011) negative schemas support cognitive biases and negative distortions within information processing, therefore the sufferer is more liekly to notice information consistent with a negative view, ignoring contradictory evidence (attentional bias), interpret evidence negatively (processing bias) and recall negative events more frequently (memory bias)

all-or-nothing thinking

involved in the maintenance of mdd as a cognitive error: one views a situation in only two categories instead of on a continuum

catastrophizing

involved in the maintenance of mdd as a cognitive error: one predicts the future negatively without considering other, more likely outcomes

disqualifying the positive

involved in the maintenance of mdd as a cognitive error: one unreasonably tells oneself that positive experiences, deeds or quantities do not count (“just got lucky“)

emotional reasoning

involved in the maintenance of mdd as a cognitive error: one thinks something must be true due to the strong belief and feelings, ignoring or discounting evidence to the contrary

labeling

involved in the maintenance of mdd as a cognitive error: one puts a fixed, global label on oneself or others without considering that the evidence might more reasonably lead to a less disasterous conclusion

magnifying/minimization

involved in the maintenance of mdd as a cognitive error: when one evaluates oneself, another person or a situation, one unreasonably magnifies the negative and/or minimizes the positive

selective abstraction

involved in the maintenance of mdd as a cognitive error: one pay undue attention to one negative detail instead of seeing the whole picture

mind reading

involved in the maintenance of mdd as a cognitive error: one believes they know what others are thinking, failing to consider other more likely possibilties

overgeneralization

involved in the maintenance of mdd as a cognitive error: one makes a sweeping conclusion that goes far beyond the current situation

personalization

involved in the maintenance of mdd as a cognitive error: one believes that others are behaving negatively because of oneself, without considering more plausible explanations for their behaviour

should and must statements (imperatives)

involved in the maintenance of mdd as a cognitive error: one has a precise, fixed idea on how oneself or others should behave, and one overestimates how bad it is that these expectations are not met

tunnel vision

involved in the maintenance of mdd as a cognitive error: one only sees the negative aspects of a situation

activity scheduling and graded task assignment

a treatment for mdd: helpful for depressed individuals to evaluate their level and type of activity, and its relationship to mood, energy, achievement, and social connection

tasks that give opportunity for positive reinforcement are gradually planned in while accounting for individual barriers

can increase mood, reduce lethargy (exercise), improve sleep (sleep hygiene) and reduce rumination within weeks

gives client an opportunity to record progress (countering depressive memory deficits)

cognitive restructuring

a treatment strategy for mdd: identify and challenge beliefs and biases that lie behind painful emotions

used to form new rational, realistic, and helpful perceptions

successful CR reduces distress and lays groundwork for effective coping behaviours

behavioural experiments

a treatment strategy for mdd: powerful technique for challenging old beliefs or reinforcing new ones from cognitive restructuring

create experiments that generate an outcome which unequivocally supports or invalidates a belief

Cognitive-Behaviour Therapy (Beck, 2011)

a psychological intervention for mdd: structured therapy for 12, 16 or 20 sessions

identify and modify cognitive and behavioural maintenace factors with cognitive restructuring and activity scheduling

post-COVID, can be delivered online in a guided modular fashion for mild to moderate mdd with similar effectiveness to standard delivery (Carlbring et al., 2021)

Behavioural Activation (Martell, 2004)

a psychological intervention for mdd: same behavioural components as cbt but does not address cognitive component

cognition or rumination treated as functional behaviour

aims to increase positive reinforcement and reduce negative reinforcement

rumination

a core cognitive symptom involving repetitive, negative thinking about past problems, failures and feelings. acts as a maladaptive emotion regulation strategy that intensifies depressive moods, increases the severity of episodes, and triggers a cycle of negative, self-focused and unproductive thought patterns

Mindfulness-Based Cognitive Therapy (Segal et al., 2013)

a psychological intervention for mdd: structured as an eight week group program

skills taught to pay intentional attention without judgement

designed to modify the cognitive factors (rumination) central to relapse in recurrent mdd

difference between treatments

the american national institute of mental health did a study that compared cognitive behavioural therapy, interpersonal psychotherapy, imipramine and a placebo, and was the first study to compare all three treatments using randomization

results indicated there were no differences in efficacy among cbt, ipt and imipramine and that all treatments were significantly superior to the placebo

cbt and ipt are not reccomended by the cpa task force on empirically supported treatments as psychotherapies with the strongest efficacy in the treatment of unipolar major depression (Dozois et al., 2014)

behavioural activation vs cbt

(Cuijpers et al., 2011) found that behavioural activation is still equally effective as cbt

antidepressants

tricyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors

evidence shows that all were effetive in primary care patients with mild-moderate depression (Arroll et al., 2016)

sertraline main reccomendation for moderate to severe depression (Cipriani et al., 2018)

bipolar antipsychotics

type of pharmacological treatment: aripiprazole, asenapine, lurasidone and cariprazine are all recommended but some are associated with weight gain (Nierenberg et al., 2023)