Chapter 5: Mood Disorders & Suicide

Major Depressive Episode

Characterized by a depressed mood with symptoms that persistent almost everyday for at least 2 weeks

Major Depressive Episode Symptoms

- Depressed mood
- Anhedonia: Loss of interest or pleasure
- Weight or appetite change
- Sleep disturbance
- Psychomotor agitation or retardation
- Fatigue
- Worthlessness or excessive guilt
- Inability to concentrate
- Thoughts of death, suicidal ideation or attempt

Persistent Depressive Episode

Characterized by a depressed mood on more days than not over a period of at least two week

Persistent Depressive Episode Symptoms

- Poor appetite or overeating
- Insomnia or hypersomnia
- Low energy or fatigue
- Low self esteem
- Poor concentration or difficulty making decisions
- Feeling of hopelessness

Major Depressive Disorder (MDD)

Mood disorder characterized by at least 1 major depressive episode that lasts at least 2 weeks

No manic or hypomanic episodes

DSM-5 Criteria for MDD

A. Five (or more) of MDD symptoms that have to include either depressed mood and loss of interest/pleasure

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

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

D. The occurrence of major depressive episode is not better explained by another mental disorder

E. There has never been a manic episode or a hypomanic episode.

Persistent Depressive Disorder (Dysthymia)

Mood disorder characterized by depressive symptoms that persistent for at least 2 years

No manic or hypomanic episodes

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

Premenstrual Dysphoric Disorder (PMDD)

Defined in terms of various mood-related symptoms that occur repeatedly during the pre-menstrual phase of the cycle, and are diminished at the onset or shortly after menses

PMDD Symptoms

Mood Symptoms:
- Mood lability
- Irritability
- Dysphoria
- Anxiety

Cognitive Symptoms:
- Difficulty concentrating
- Feeling of being overwhelmed or out of control

Somatic Symptoms
- Lethargy
- Changes in appetite
- Sleep problems
- Join or muscle pain
- Sensation of bloating

DSM-5 Criteria for PMDD

A person must exhibit at least five symptoms and at least one of those symptoms must involve a disturbance in mood

These symptoms must have been present for most of a person's menstrual cycles in the past year

Symptoms must be associated with clinically significant distress or interference with social or occupational functioning

Manic Episodes

Periods of mania, or unusually elevated mood and extreme restlessness

Should cause impairment or hospitalization for psychotic features (delusional beliefs)

These symptoms cannot be due to the effects of a substance or general medical condition

Manic Episode Symptoms

- Elevated mood, expensive, or irritable mood
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Racing thoughts
- Distractibility (very high levels)
- Increase in goal-directed activity or psychomotor agitation
- Excessive involvement in pleasurable activities that have high potential for painful consequences

DSM-5 for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, last at least 1 week and present most of the day, nearly every day.

B. During the period of mood disturbance and increased energy or activity three symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior.

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or other, or there are psychotic features.

D. The episode is not attributable to the physiological effects of oa substance or to another medical condition.

Hypomanic Episodes

Have symptoms same as manic episode but is shorter (at least 4 days) and the symptoms are less severe

Must be noticeable to others but does not cause impairment

NO psychotic symptoms, like delusions.

Bipolar I Disorder

A type of bipolar disorder marked by full manic and major depressive episodes

At least one manic episode. Depressive episodes are not required but could happen.

Bipolar II Disorder

A type of bipolar disorder marked by mildly manic (hypomanic) episodes and major depressive episodes

At least one hypomanic episodes and one major depressive episode

Cylcothymic Disorder (Cyclothymia)

Characterized by periods of depression and hypomania over two years

Two period with no more than 2 months without them

No history of major depressive episodes or manic episodes

Specifier of Mood Disorder: Melancholia

Used to describe a particularly severe type of depression.

Subtype of depression that is caused by different factors than those response for other forms of depression.

Melancholic features may indicate that the person is likely to have a good response to biological forms of treatment.

DSM-5 Criteria for Melancholia

A depressed patient must either
(1) Lose the feeling of pleasure associated with all activities
(2) Lose the capacity to feel better

The person must also exhibit at least three of the following
(1) The depressed mood feels distinctly different from depression a person would feel after the loss of a loved one
(2) The depression is most often worst in the morning
(3) The person awakens early, at least two hours before usual
(4) Marked psychomotor retardation or agitation
(5) Significant loss of appetite or weight loss
(6) Excessive or inappropriate guilt

Specifier of Mood Disorder: Psychotic Features

The presence of hallucination or delusions during depressive or manic episodes.

The psychotic features can be either consistent or inconsistent with a patient's mood

Specifier of Mood Disorder: Postpartum Onset

Applies to women who become depressed or manic followinf pregnancy.

This episode begins within four weeks after childbirth and must meet full diagnostic criteria for a depression.

Specifier of Mood Disorder: Rapid Cycling

A person experiences at least four episodes of major depression, mania, or hypomania within a 12 month period

Specifier of Mood Disorder: Seasonal Affective Disorder

A mood disorder that follows a seasonal pattern, there is a regular relationship between the onset of a person's episodes and the particular times of the year

This pattern must be continuous for at least two years with no other episode outside this seasonal pattern

Course & Outcome of Major Depressive Disorder

Average age of onset is in the 20s

Episodes often last much longer than two weeks

Frequently a chronic and recurrent condition

5-10% of people who have MDD go on to have a manic episode

MDD has high comorbidity with anxiety disorders like social phobia, PTSD, and GAD, as well as substance abuse

Course & Outcome of Dysthymia

Often begins in teenage years

The 10-year recovery rate was found to be 74%, however among ⅓ of them relapsed in 3 years.

Course & Outcome of Bipolar I

Average age of onset: 18-28

Long term course: recurrent

Manic episodes tend to be shorter. 60% of manic episodes happen immediately after a depressive episode.

Rapid cycling

More frequent and severe episodes compared to MDD

Course & Outcome of Bipolar II

Average age of onset: Mid 20s

Usually begins with a depressive episode

Time between episodes decreases over life

More frequent and less intense episodes

Depression Etiology

Environmental Factors
- Stressful life events
- Interpersonal factors

Biological Factors
- HPA axis
- Genetic vulnerability
- Brain function
- Neurochemical s

Psychological Factors
- Information processing bias
- Cognitive dissertations
- Ruminations
- Personality

Bipolar Etiology

Environmental Factors
- Stressful life events
- Interpersonal factors
- Schedule disruption

Biological Factors
- Genetic vulnerability
- Brain function

Psychological Factors
- Cognitive distortions
- Grandiose thinking

Social Rhythms Stability Theory

People with bipolar I have a sensitivity to things that disrupt their daily rhythm. This situation can increase the symptoms of people with bipolar I.

Cognitive Vulnerability

Depressed people often exhibit certain biases, errors, and distortions in the interpretation of events

Cognitive Vulnerabilities: Hopelessness

Refers to the person's negative expectations about future events and the associated belief that these events cannot be controlled

Cognitive Vulnerabilities: Depressogenic Attributional Style

A cognitive style that includes people who tend to explain negative events in terms of internal, stable, global factors.

Cognitive Vulnerabilities: Ruminative Style

A cognitive style that includes people who respond feelings of depression by turning their attention inward, contemplating the causes and implications of their sadness

Cognitive Vulnerabilities: Distracting Style

A cognitive style that includes people who divert themselves from their unpleasant mood

Thought Inhibition

"Inhibiting" in the processing of ideas which is subjectively perceived as foreign and unwanted

Can contribute to the maintenance of depressive episodes by preventing executive controls from shifting away from distressing thoughts.

Coyne (1976) Method

Undergrad psychology students participated in a study on the "acquaintance process".

They had to interact on the phone for 20 minutes with some from one of three groups: someone with depression, someone with a mental health disorder other than depression, and someone with no mental health disorder.

Afterwards, participants completed a questionnaire about their experience.

Coyne (1976) Result

Participants were significantly more depressed, anxious, and hostile following interaction with depressed patients than any other group

Participants were more rejecting of the depressed patients compared to any other groups

More likely to reject opportunities for future interaction if their own mood was depressed following the conversation.

Cognitive Therapy

Based on the assumption that depression will be relieved if maladaptive schemas are changed.

Cognitive therapists focus on helping their patients replace self-defeating thoughts with more rational self-statements

Interpersonal Therapy

Therapy focused on current relationships to help the patient develop a better understanding of the interpersonal problems that presumably give rise to depression, and attempts to improve the patient's relationships with other people by building communication and problem-solving skills

Behavioral Activation (BA)

Based on how depressed people often disengage from routines . This can exacerbate a depressed mood.

Focuses on increasing activities
- Pleasant
- Mastery, going things that increase sense of achievement

Helps people build self esteem

Monoamine Oxidase Inhibitors (MAOIs)

Class of antidepressant drugs sometimes used for treating depression

Inhibit the enzyme monoamine oxidase (MAO) in the brain, and raise the levels of neurotransmitters, such as norepinephrine, dopamine, and serotonin

Tricyclic Antidepressants (TCAs)

Class of antidepressant drugs that block the uptake of neurotransmitters, such as norepinephrine and dopamine from the synapse.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Antidepressant drugs that achieve their agonistic effect on serotonin by selectively blocking its reuptake

Common side effects:
- GI issues
- Changes in sexual experience
- Weight gain

Atypical

Class of antidepressants that inhibit the uptake of dopamine, epinephrine, and serotonin

Have less side effects

Electrocompulsive Therapy (ECT)

A treatment only used for severe and treatment-resistant depression

Involves administering an electrical current to the brain to induce a seizure. Happens 2 or 3 times a week for approximately 7 weeks.

Good response rates - 80% of people who have treatment-resistant depression responded to ETC

Has transietty side effects but no long term effects

Deep Brain Stimulation

A neurostimulator in the brain send high frequency electrical impulses via an implanted electrode to specific regions with depression

Effectiveness for treatment of MDD is inconsistent, data is promising but unclear

Lithium Carbonate

The chemical used in the treatment of bipolar disorders.

40% of bipolar patients do not improve when they take lithium

Non-compliance issues

Side effects: nausea, weight gain, and memory problems

Anticonvulsants

Medication used to prevent seizures (usually given to people who don't respond to lithium)

Examples: Tegretol & Depakene

~50% respond

Side effects: GI issues and sedation

Family Focused Therapy

Stage 1: Psychoeducation (stabilization)
- Focuses on stabilization
Trying to teach the nature of the disorder of the patient and their family
- Encouraging supportive behavior from family members

Stage 2: Communications Enhancement Training
- Continues to target negative attitudes the family might have and any negative interpersonal conflicts
- Teaches the person with bipolar to be more cognizant of the negative emotions they may have on people

Stage 3: Problem-solving Skills
- Focuses on general life issues, and developing skills to combat them

Objectives:
- Accept vulnerability of future episodes & long-term use of medication
- Distinguish personality versus disorder
- Learn to cope with stressful life events
- Establish functional relationships

Interpersonal and Social Rhythm Therapy

Treatment developed for bipolar patients

Based on the recognition that a repeated episode of either mania or depression is often precipitated by one of the following:
(1) Stressful life events
(2) Disruptions of social rhythms
(3) Failure to take medication

Therapists help patients learn to lead more orderly lives and to resolve interpersonal problems effectively

Light Therapy

Use of specialized illuminating light boxes and visors to treat seasonal affective disorder.

Effective form of treatment for seasonal affective disorders.

Classification of Suicide

A diagnostic category that plays a role in a variety of mental disorder.

Suicidal intention refers the intention to end their life, but this can differ in motives (regardless of the presence or absence of specific mental disorders)

Nonsuicidal Self-Injury

An individual intentionally inflicting damage on the surface of their body in a way that is likely to cause bleeding, bruising, or pain (without the intent to die)

Causal Factors to NSSI

For some people, NSSI is a way to punish the self and is a reflection of frustration and anger

Person uses self-inflicted pain in an effort to combat extended periods of disassociation

Self-injury is a maladaptive way to regulate intense, negative emotional states