Chapter 7: Mood Disorders and Suicide

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Bipolar Disorder

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Disorder marked by cycles between manic episodes and depressive episodes; also called manic-depression

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Mania

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State of persistently elevated mood, feelings of grandiosity, over enthusiasm, racing thoughts, rapid speech, and impulsive actions

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102 Terms

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Bipolar Disorder

Disorder marked by cycles between manic episodes and depressive episodes; also called manic-depression

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Mania

State of persistently elevated mood, feelings of grandiosity, over enthusiasm, racing thoughts, rapid speech, and impulsive actions

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Depression

State marked by either a sad mood or a loss of interest in one's usual activities, as well as feelings of hopelessness, suicidal ideation, psychomotor agitation or retardation, and trouble concentrating

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Depressive disorders

a set of disorders characterized by depressed mood and/or anhedonia (and not mania)

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Cardinal symptom of depression is

depressed mood out of proportion to any cause

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Anhedonia

lost interest in everything in life

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People with depression experience changes in

appetite, sleep, and activity levels

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Psychomotor retardation

Behaviorally, people with depression are slowed down... walking more slowly, gesturing more slowly, and talking more slowly and quietly.

They lack energy and report feeling chronically fatigued.

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Psychomotor agitation

People feeling physically agitated, cannot sit still, and may move around or fidget aimlessly.

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The thoughts of people with depression may be filled with themes of

worthlessness, guilt, hopelessness, and even suicide.

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Severe symptoms of Depression

Losing touch with reality, experiencing delusions, and hallucinations

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Major Depressive Disorder

Depressive symptoms lasting two weeks or more

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Diagnosis of Major Depressive Disorder requires that a person experience...

- either depressed mood or loss of interest in usual activities

- at least four other symptoms of depression

- chronically for at least 2 weeks

**symptoms must be severe enough to interfere with the person's ability to function in everyday life

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Major Depressive Disorder, single episode

Experience only one depressive episode

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Major Depressive Disorder, recurrent episode

Experience two or more episodes separated by at least 2 consecutive months without symptoms

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Complicated grief

a syndrome showed by 10-15% of bereaved people, characterized by strong yearning for the deceased person and preoccupation with the loss, persistent regrets about one's own or others' behavior toward the deceased, difficulty accepting the finality of the loss, and a sense that life is empty and meaningless.

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Persistent Depressive Disorder

Depressed mood for most of the day for at least two years (1 year in kids)

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Persistent Depressive Disorder requires the presence of two or more of the following symptoms:

- low appetite

- insomnia or hypersomnia

- low energy or fatigue

- low self-esteem

- poor concentration

- hopelessness

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The subtypes of Major Depressive Episodes includes

- Anxious Distress

- Mixed features

- Melancholic features

- Psychotic features

- Catatonic features

- Seasonal Pattern

- Peripartum onset

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Anxious distress

Prominent anxiety symptoms

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Mixed features

Presence of at least three manic/hypomanic symptoms, but does not meet criteria for a manic episode.

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Melancholic features

Inability to experience pleasure, distinct depressed mood, depression regularly worse in morning, early morning awakening, marked psychomotor retardation or agitation, significant anorexia or weight loss, excessive guilt

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Psychotic features

Presence of mood-congruent or mood-incongruent delusions or hallucinations

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Catatonic features

Catatonic behaviors: not actively relating to environment, mutism, posturing, agitation, mimicking another's speech or movements

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Atypical features

Positive mood reactions to some events, significant weight gain or increase in appetite, hypersomnia, heavy or leaden feelings in arms or legs, long-standing pattern of sensitivity to interpersonal rejection

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Seasonal pattern

History of at least two years in which major depressive episodes occur during one season of the year (usually the winter) and remit when the season is over

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Peripartum onset

Onset of major depressive episode during pregnancy or in the 4 weeks following delivery

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Seasonal Affective Disorder (SAD)

Disorder identified by a 2-year period in which a person experiences major depression during winter months and then recovers fully during the summer; some people with this disorder also experience mild mania during summer months.

Also become depressed when the daylight hours are short and recover when the daylight hours are long.

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Premenstrual Dysphoric Disorder

Increase in distress during the premenstrual phase

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It is complicated to diagnose depression in older adults because

- older adults are less willing to report symptoms

- symptoms occur in the context of a serious medical illness

- people with a history of depression are more likely to die before reaching old age

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Prevalence and course of depressive disorders

- Less common among children

- Women are more susceptible

- Long-lasting, recurrent problem for some people

- Costly for both the individual and the society

- People tend to recover with treatment

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Mania symptoms:

- inflated self-esteem or grandiosity

- decreased need for sleep

- more talkative than usual or pressure to keep talking

- flight of ideas or subjective experience that thoughts are racing

- distractibility

- increase in goal-directed activity or psychomotor agitation

- excessive involvement in activities that have a high potential for painful consequences

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Bipolar I Disorder

Form of bipolar disorder in which the full symptoms of mania are experienced; depressive aspects may be more infrequent or mild

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Bipolar II Disorder

Form of bipolar disorder in with hypomanic episodes and severe depression

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Hypomania

State in which an individual shows mild symptoms of mania. Does not interfere with daily functioning, and do not involve hallucinations or delusions.

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Cyclothymic disorder

Less severe but more chronic (at least 2 years) bipolar condition. Alternates between periods of hypomanic symptoms and periods of depressive symptoms that does not qualify for either full hypomanic or major depressive episode.

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Presence of hypomanic and depressive symptoms but DOES NOT qualify for either full hypomanic or major depressive episode

Cyclothymic Disorder

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Rapid Cycling Bipolar (or Bipolar II disorder)

Four or more mood episodes that meet criteria for manic, hypomanic, or major depressive episode within 1 year.

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Disruptive Mood Dysregulation Disorder

Severe temper outbursts that are grossly out of proportion in intensity and duration to a situation and inconsistent with developmental level

> In children age 6 and over

> Must have at least three temper outbursts per week for at least 12 months and in at least two settings

*Difficult to distinguish manic symptoms from ADHD or ODD

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Prevalence and Course of Bipolar Disorder

- Less common than depressive disorders

- Men and women are equally susceptible

- No consistent differences among ethnic groups or across cultures (suggests more of a biological component)

- Develops mainly in late adolescence or early adulthood

- People with bipolar disorders often face problems on the job and in their relationships

- Often abuse substances such as alcohol and hard drugs

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Creativity and the Mood Disorders

- Symptoms of mania can have benefits in certain settings

- Writers, artists, and composers seem to have a higher than normal prevalence of mania and depression

- Mood disorders substantially impair thinking and productivity

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Genetic Theory of Depression

Genes predispose people to depression

- 1st degree relatives of people with major depressive order are two to three times more likely to also have depression

- Twin studies of major depression find higher concordance rates for monozygotic twins than for dizygotic twins

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Neurotransmitter theories of Depression

Dysregulation of neurotransmitters and their receptors

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What neurotransmitters have been implicated most often in depression?

Monoamines: Norepinephrine, serotonin, dopamine

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Which area of the brain is affected by depression?

Prefrontal cortex, anterior cingulate, hippocampus, and amygdala

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Critical functions of the prefrontal cortex include

attention, working memory, planning, novel problem solving, motivation and goal-orientation

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Anterior cingulate (subregion of prefrontal cortex) plays an important role in the body's

response to stress, emotional expression, and in social behavior.

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Hypothalamic-pituitary-adrenal axis (HPA axis)

Key components of the neuroendocrine system that works together in a biological feedback system richly interconnected with the amygdala, hippocampus, and cerebral cortex. Is also involved with the fight-or-flight response.

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Depression and HPA axis

Tend to show elevated levels of cortisol and CRH, indicating chronic hyperactivity in the HPA axis and difficulty in the HPA axis's returning to normal functioning following a stressor.

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Behavioral theories of depression

suggests that life stress leads to depression because it reduces the positive reinforcers in a person's life. Person begins to withdraw, which results in a further reduction in reinforcers, which leads to more withdrawal, creating a self perpetuating chain.

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Learned Helplessness theory

suggests that the type of stressful event most likely to lead to depression is an uncontrollable negative event.

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Negative Cognitive Triad

People have negative views of themselves, the world, and the future

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One of the most widely used and successful therapies for depression

Cognitive-behavioral Therapy

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Reformulated learned helplessness theory

explains how cognitive factors might influence whether a person becomes helpless and depressed following a negative event. This theory focuses on causal attributions for events.

According to this theory, people who habitually explain negative events by causes that are internal, stable, and global tend to blame themselves for these negative events, expect negative events to recur in the future, and expect to experience negative events in many areas of their lives.

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Hopelessness depression

develops when people make pessimistic attributions for the most important events in their lives and perceive that they have no way to cope with the consequences of these events.

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Pessimistic attributional style predicts

both first onset and relapse of depression

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Ruminative Response style

Focuses on the process of thinking than on the content of thinking as a contributor to depression

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Rumination

Focusing on one's personal concerns and feelings of distress repetitively and passively

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Interpersonal theories of depression

Theories that view the causes of depression as rooted in interpersonal relationships

- Interpersonal difficulties and losses are commonly reported stressors that trigger depression

- Depression may engender interpersonal conflict

- Rejection sensitivity

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Rejection Sensitivity

Easily perceiving rejection by others

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Cohort effects

Historical changes may have put more recent generations at higher risk for depression than previous generations

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Ethnicity/race differences in depression

Hispanic/Latino & Native American > Caucasian > African American (more prone to anxiety)

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Bipolar Disorder are strongly and consistently linked to

genetic factors

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Bipolar Disorder Structural and functional brain abnormalities in what areas of the brain?

- Amygdala (processing of emotions)

- Prefrontal cortex (cognitive control of emotion, planning, and judgement)

- Hyperactive striatum (environmental cues of reward)

- Abnormalities in the white matter of the brain, particularly in the prefrontal cortex

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What neurotransmitter dysregulation contributes to bipolar disorder?

Dopamine

*high levels of dopamine are thought to be associated with high reward seeking, while low levels are associated with insensitivity to reward.... therefore explaining the manic and depressive phase

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Psychological contributors to Bipolar Disorder

- Greater sensitivity to rewards

- Increased stress

- Disruptions in routines can trigger episodes in people with bipolar disorder

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Antidepressants includes

SSRIs

SNRIs

Norepinephrine-dopamine reuptake inhibitor

Tricyclic antidepressants

MAOIs

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Selective Serotonin Reuptake Inhibitors (SSRIs)

- Widely used to treat depressive symptoms.

- Fewer difficult-to-tolerate side effects

- Safer if taken in overdose

- Positive effects on a wide range of symptoms that co-occur with depression, including anxiety, eating disorders, and impulsiveness.

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Common side effects of SSRIs

- gastrointestinal symptoms (i.e. nausea and diarrhea)

- tremor

- nervousness

- insomnia

- daytime sleepiness

- diminished sex drive

- difficulty achieving orgasm

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Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Designed to affect levels of norepinephrine as well as serotonin. Show a slight advantage over the SSRIs in preventing a relapse of depression.

**MORE side effects than SSRIs

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Norepinephrine-Dopamine Reuptake Inhibitor

- Bupropion

- Useful in treating people suffering from psychomotor retardation, anhedonia, hypersomnia, cognitive slowing, inattention, and craving

- Overcome the sexual dysfunction side effects of the SSRIs and is sometimes used in conjunction with them

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Tricyclic antidepressants

First drug to relieve depression, but is now used less frequently.

> Numerous side effects (related to acetylcholine)

> Can cause a drop in blood pressure and cardiac arrhythmia in people with heart problems

> Fatal in overdose

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Monoamine Oxidase Inhibitors (MAOIs)

No longer used frequently.

Mao is an enzyme that causes the breakdown of the monoamine neurotransmitter in the synapse.

- Decrease the action of MAO and thereby increase the levels of these neurotransmitters in the synapses.

- Side effects are dangerous

- Can cause fatal rise in blood pressure, liver damage, weight gain

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Mood stabilizers includes

Lithium

Anticonvulsant and Atypical Antipsychotic Medications

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Lithium

- Work by improving the functioning of the intracellular processes that appear to be abnormal in mood disorders

- Help prevent relapses

- Effective in reducing suicide risks

- Doses of lithium have to be monitored carefully

- Side effects of lithium can be life threatening

- Resistance to lithium can be developed within 3 years

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Anticonvulsant and Atypical Antipsychotic Medications

- Valproate: helps reduce seizures, valproate, and stabilize mood in people with bipolar disorder

- Carbamazepine (anti-epileptic medication)

- Valproate is more commonly used because of the fewer side effects

- Birth defect if taken during pregnancy

- Atypical antipsychotic medications can reduce functional levels of dopamine and is useful in psychotic manic symptoms

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Electroconvulsive Therapy (ECT)

Induces a brain seizure by passing electrical current through the patient's head

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Results of ECT

Neuroimaging studies show a decrease in metabolic activity in several regions of the brain, including the frontal cortex and the anterior cingulate

Effective in eliminating the symptoms of depression but the relapse rate among people who have undergone ECT is as high as 85%

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Repetitive Transcranial Magnetic Stimulation (rTMS)

Patients are exposed to repeated high-intensity magnetic pulses focused on particular brain structures

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Vagus Nerve Stimulation

The vagus nerve, part of the autonomic nervous system, is stimulated by a small electronic device that is surgically implanted under the patient's skin in the left chest wall.

**treats serious depression

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Deep Brain Stimulation

Electrodes are surgically implanted in specific areas of the brain.

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Light Therapy

Exposing people with SAD to bright light for a few hours everyday by resetting their circadian rhythms.

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Behavioral Therapy

Focuses on increasing positive reinforcers and decreasing aversive experiences in an individual's life by helping the depressed person change his or her patterns of interaction with the environment and with other people.

- Analyzing connections between life circumstances and symptoms

- Teaching a person new skills for managing behavior in interpersonal situations and environment

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Cognitive-Behavioral Therapy (CBT) aims to

- Change the negative, hopeless patterns of thinking

- Help people solve concrete problems in their lives and develop skills for being more effective in their world

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Steps in CBT

1. Help clients discover the negative automatic thoughts they habitually have and understand the link between those thoughts and their depression.

2. Help clients challenge their negative thoughts.

3. Help clients recognize the deeper, basic beliefs or assumptions they might hold that are fueling their depression.

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Interpersonal Therapy (IPT)'s four type of problem

1. Grief, loss

2. Interpersonal role disputes

3. Role transitions

4. Interpersonal Skills deficits

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Interpersonal and Social Rhythm Therapy and Family-Focused Therapy (ISRT)

- Designed specifically for bipolar disorder.

- Combines interpersonal therapy techniques with behavioral techniques to help patients maintain regular routines of eating, sleeping, and activity, as well as stability in their personal relationships.

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Family-Focused Therapy (FFT)

Reduces interpersonal stress in people with bipolar disorder, particularly within the context of families

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Suicide is associated with

mood disorders

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Personality characteristic that seems to predict suicide best is

impulsivity

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Cognitive variable that has most consistently predicted suicide is

hopelessness

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Suicide is linked to low level of

serotonin