chapter 8 mood

mood disorders

characterized by gross deviations in mood

general characteristics of mood disorders

- much more serious than typical emotional states that everyone feels
- involves significant disturbances in emotion; extreme sadness (depression) or elation/irritability (mania)
- are disabling
- associated with other serious psychological problems (panic attacks, substance abuse, sexual dysfunction, personality disorders, anxiety)

depression (mood disturbances)

- an emotional state marked by great sadness
- feelings of worthlessness and guilt

depression (cognitive disturbance)

- self-criticism, self blame
- indecisiveness, slowed thinking, thoughts of death or suicide

depression (physiological (somatic) and behavioural disturbances)

- loss or excess of sleep, appetite
- loss of interest and pleasure in usual activities (anhedonia)

anhedonia

inability to experience pleasure

mania

- a period of abnormal elevated or irritable mood lasting for at least one week or requires hospitalization
- extreme pleasure in every activity

diagnostic criteria for manic episodes

individual must possess three or more of the following
- inflated self esteem
- decrease need for sleep
- talkativeness
- flight of ideas
- increased goal-directed activity

hypomanic episode

not as severe as a manic episode
- no marked impairment in social or occupational functioning
- hypo = below

depressive mood disorders

mood remains at one pole of depression-mania continuum

bipolar mood disorders

mood travels between depression-elation poles

mixed featuresa

mix of symptoms

depressive disorders

- marked by low mood only
- major depressive disorder (formerly unipolar disorder)
- persistent depressive disorder (dysthymia)
- premenstrual mood dysregulation disorder

bipolar and related disorders

- characterized by both high and lows in moods
- bipolar disorder
- bipolar 1
- bipolar 2
- cyclothymic disorders

major depressive disorder

presence of severe depression, absence of mania; severe enough to impair a persons interest in or ability to engage in normally enjoyable activities

diagnosis of major depressive disorder

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
- sad, depressed mood, most of the day, nearly every day
- loss of interest and pleasure in usual activities
- difficulties sleeping
-shift in activity level
- changes in appetite and weight
- loss of energy, fatigue
- negative cognitive appraisal (feeling worthless)
- difficulty concentrating
- recurrent thoughts of death or suicide

persistent depressive disorder (dysthymia)

depression relatively unchanged over long periods
- a chronic state of depression; the symptoms are the same as those of major depression, but they are less severe
- lasting 2 or more years (at least one in children and teens) and never without symptoms for more than 2 months

double depression

people with persistent depressive disorder may also experience episodes of major depressive disorder

clinicians use 8 specifiers

1. with psychotic features (mood-congruent or mood incongruent) hallucinations, delusions
2. with anxious distress (restlessness, concentration, issues due to worry, fear or losing control)
3. with mixed features
4. with melancholic features
5. with atypical features
6. with catatonic features (e.g., motoric immobility) or excessive movement, mutism, posturing, compulsive repetition of someone else's movements or words
7. with peripartum onset (post partum depression)
8. with seasonal pattern (seasonal affective disorder SAD) accompanies episodes during certain seasons (winter depression); depressive episode: begins in late fall; ends start of spring; bipolar: depression- winter, mania-summer

integrated grief

the finality of death and its consequences are acknowledged and the individual adjusts to the loss

complicated grief

grief characterized by debilitating feelings of loss and emotions so painful that a person has trouble resuming a normal life; designated for further study as a disorder by DSM-5

premenstrual dysphoric disorder (PMDD)

- physical symptoms, severe mood swings, and anxiety
- decreased interest in usual activities; difficulty in concentration; lack of energy; hypersomnia or insomnia
- changes in appetite
- interference with work, relationships
incapacitation during most menstrual cycles, starting in the final week before the onset of menses

disruptive mood dysregulation disorder

condition in which a child has chronic negative moods such as anger and irritability without any accompanying mania
- different from ADHD
- supporters: too many children diagnosed with bipolar, needs this diagnostic criteria
- critics: don't think temper tantrums should be considered mental illness, labeling

bipolar 1 disorder

major depressive episodes alternate with full manic episodes
- involves episodes of mania or mixed episodes that include symptoms of both mania and depression

rapid cycling specifier

moving quickly in and out of depressive and manic episodes (does not seem to be permanent)
- at least 4 manic or depressive episodes within a year
- rapid switching/rapid mood switching
- ultra rapid cycle
- ultra-ultra rapid cycle

rapid switching or rapid mood switching

the direct transition from one mood state to another (no euthymic mood period in between)

ultra rapid cycle

cycle length that only lasts for days to weeks

ultra ultra rapid cycle

cycle lengths are less than 24 hours

bipolar 2 disorder

a pattern if major depressive episodes and hypomanic episodes, but the episodes are less severe than the manic episodes in bipolar 1 disorder

onset and duration of bipolar disorders

- bipolar 1: 18 years
- bipolar 2: 22 years
- rare to develop bipolar disorder after the age of 40
- develop more suddenly as compared to depressive disorders
- high risk of suicide

cyclothymic disorder

a chronic condition ( at least two years) characterized by fluctuations that alternate between hypomania and depressions
- episodes not as severe as with mania or major depression
- age of onset: 12 to 14
- episodes not intense enough or do not last long enough to qualify as hypomanic or depressive episodes

comorbidity and bipolar disorder

- physical disorders (thyroid disorder, migraine headaches, heart disease, diabetes, obesity)
- metal disorders (anxiety disorders, eating disorders, ADHD, substance use)

objectification theory

tendency to be viewed as an object, appraised by others -> negative influence on self esteem
- estrogen and progesterone (mixed support)

mood disorders across cultures

more in individualistic cultures

mood disorders among the creative

- creativity associated with manic episodes
- many poets and writers bipolar and suicidal

joint heritability of anxiety and depression

- close relationship among depression, anxiety, and panic
- same genetic factors contribute to both anxiety and depression
- biological vulnerability

neurotransmitter systems in mood disorders

- low levels of norepinephrine and dopamine lead to depression
- high levels lead to mania
- low levels of serotonin
- chronic stress reduces dopamine levels
- MAO-A levels in brain are elevated during untreated depression

MOA-A

an enzyme that metabolizes monoamines such as serotonin, norepinephrine, and dopamine

the endocrine system

- diseases (e.g., hypothyroidism) leading to excessive secretion of cortisol leads to depression
- elevated levels of cortisol in people with depression (stressful events)
- the dexamethasone suppression test - a biological test for depression
- neurotransmitter activity in hypothalamus regulates HPA axis

sleep and circadian rhythms

- REM starts sooner after falling sleep in depressed people
- people with depression experience more intense REM activity
- slow wave (deep) sleep occurs later
- bidirectional relationship between sleep and mood

depressed individuals show:

greater right-sided anterior activation of brain and less left-sided activation

psychological factors of mood disorders

- stressful life events: interpretation of stressful events
- psychoanalytic theory of depression: fixation during oral stage -> dependency to maintain self esteem; depression is seen to be like a mourner who over-identifies with (introjects) the loss if a loved one
- freud-analysis of bereavement

learned helplessness theory of depression

- seligman: people become depressed when they feel they have no control over life's stresses
- some studies with humans: helpessness inductions -> subsequent improvement of performance
- depressive paradox: if people see themselves as helpless, how can they blame themselves?

learned helplessness theory

depressive attribution style is:
- internal: the individual attributes negative events to personal failings/external
- stable: even after a particular negative event passes, the attribution that "additional bad things will always be my fault" remains/unstable
- global: the attributions extend across a wide variety of issues/specific

hopelessness theory

- hopelessness: an expectation that desirable outcomes will not occur or that undesirable ones will occur and the person has no responses available to change the situation
- 2 more diathesis (in addition to negative attribution style): low self esteem, a tendency to infer that negative life events will have severe negative consequences
- anxiety and depression: helplessness; believe they lack control
- depression: hopelessness about ever regaining control

Beck's cognitive theory/negative cognitive styles

- depression arises from interpreting everyday events negatively
- negative life events -> development of negative schema in childhood and adolescence- a tendency to see the world negatively
- thinking is biased towards negative interpretations
- automatic, not necessarily conscious
- self blame schema, self evaluation schema
- negative schema + cognitive biases -> negative cognitive triad-thinking negatively about the self, immediate world, and future

arbitrary inferences

a conclusion drawn in the absence of sufficient evidence or of any evidence at all
- e.g., a man concluded he is worthless because it's raining the day he is hosting an outdoor party

overgeneralization

an overall sweeping conclusion drawn on the basis of a single perhaps, trial, event
- e.g., i got a C on a psychology test. i will never be a psychologist

dichotomous or "all or nothing" thinking

thinking in all or nothing terms
- e.g., if i can't do something perfectly i may as well quit

selective thinking

concentrating on your weaknesses and forgetting your strengths
- e.g., it does not matter that i am a good singer. i cannot dance or act

catastrophizing

only paying attention to the dark side of things, or overestimating the chances of disaster
- e.g., i didn't get into the best university. i will never have a decent career

personalizing

taking things personally that have little or nothing to do with you
- e.g., jenny is so quiet. she must be really angry with me

cognitive vulnerability for depression: an integration

- depression always associated with: pessimistic/depressive explanatory style and negative cognitions
- cognitive vulnerabilities predispose some people to view events in a very negative way; puts them at risk for depression

interpersonal theory of depression

- sparse social networks that provide little support
- decrease an individuals ability to handle negative life events
- increase vulnerability to depression
- seek reassurance of others; validation

marital relations

- marital dissatisfaction: disruptions lead to depression
- high conflict, low support: deterioration in marital relationships
- bipolar individuals less likely to marry, more likely to divorce if they marry

mood disorders in women

- 70% with major depressive and persistent depressive disorders are women
- perceptions of uncontrollability
- societal roles assigned to women, poverty, childbirth, menopause, single mothers, abuse histories

treatments for mood disorder

- first generation antidepressants: tricyclics (imipramine, amitriptyline), MAOIs (tranylcypromine)
- second generation antidepressants: SSRIs (fluoxetine-prozac)
- third generation antidepressants: SNRIs (venlafaxine-effexor)

what do tricyclics (imipramine, amitriptyline) do and what are the side effects

- targets NE but other neurotransmitters SE, DA are also effected
- side effects: blurred vision, dry mouth, constipation, difficulty urinating, drowsiness, weight gain, cardiac side effects, sexual dysfunction (in some)
- lethal if taken in excessive doses

what are MAOIs (tranylcypromine)and what are the two serious issues with their use?

- as effective as tricyclics with fewer side effects
- used less often
- 2 serious issues: consuming food containing tryptamine (cheese, red wine) -> severe hypertension -> death; interaction with common medications such as cold medications

SSRIs (fuoxetine-Proazac) reports, findings and side effects

- initial reports of relationship with suicide preoccupations, paranoid reactions, occasionally violence
- recent findings: risk of suicide with fluoxetine are no greater than any other antidepressants
- major side effects: physical agitation, sexual dysfunction (50-70% of cases)

SNRIs (venlafaxine)

- selective norepinephrine reuptake inhibitor-reboxetine-edronax

natural herb - st John's Wort (hypericum)

response to antidepressant medications
- better in people with good social support
- worse in people with co-occuring anxiety disorders

lithium for bipolar

effective in preventing and treating manic episodes for 50% of patients
- mood stabilizing drug
- careful dosage to prevent toxicity

people who do not respond to lithium may be prescribed:

- drugs with anti-manic properties such as antipsychotics and anticonvulsants (carbamazepine; valproate)
- valproate is less effective in preventing suicide

electroconvulsive therapy (ECT)

- Cerletti & Binni
- biological treatment for severe, , chronic depression involving the application of electrical impulses through the brain to produce seizures. unknown reason for effectiveness
- unilateral/unilateral (non-dominant, typically right cerebral hemisphere)

transcranial magnetic stimulation (TMS)

- effective in treating depression
- magnetic coil over head -> localized electromagnetic pulse
- less effective than ECT in severe cases
- deep brain stimulation

light therapy/phototherapy

- SAD- winter depression, exposure to bright white light
- within first hour of waking up in the morning
- 20-30 minutes
- more effective if combined with CBT
- CBT may be more effective in severe cases

cognitive therapy

- correcting cognitive errors in deep-seated negative thinking
- between sessions-realistic thinking encouraged by monitoring and logging thought processes
- homework-other activities to decrease depression encouraged (behavioural experiment)

psychodynamic therapies

- depression-insight into the repressed conflict and outward release of anger
- research on the effectiveness-sparse; mixed results

interpersonal psychotherapy (IPT)

- Weissman & Klerman
- focuses on resolving problems in existing relationships
- highly structured; 15-20 sessions
- identify and define an interpersonal issue; bring the dispute to a resolution
- stage of the dispute: negotiation stage, impasse stage, resolution stage

negotiation stage of dispute

both partners are aware of dispute

impasse stage of dispute

low-level resentment-no attempts to resolve it

resolution stage of dispute

take action: divorce or separation

behavioural activation

focuses on increased contact with positive reinforcement for healthy behaviours which results in positive mood

combined treatment

generally just as effective as separate drug or psychosocial therapies in treatment of depression
- in severe depression, combination of drug and psychosocial treatments effective

preventing relapse

- maintenance treatment; CBT
- mindfulness-based cognitive therapy (MBCT-Vindel Segal); group therapy teaches recovered depressed patients to disengage from negative thinking; mindfulness meditation; viewing thoughts as mental events rather than accurate reflections of reality; therapy

psychosocial treatments for bipolar disorder

- treatment compliance-psychoeducation: reduction in mood swings; stability
- interpersonal and social rhythm therapy (IPSRT): regulates circadian rhythms by helping patients regulate their eating and sleep cycles and other daily schedules and cope more effectively with stressful life events, particularly interpersonal issues
- family-focused treatment combined with meditation: new coping and communication skills
- CBT with rapid cycling patients

suicide gestures/parasuicides

self injury in which there is no intent to die

risk factors for suicide

- depression
- personality disorders
- drug abuse (alcohol or cannabis)
- childhood abuse
- family history of depression and suicide
- suicide ideation increase in indigenous peoples living off reserve

psychological autopsy

post-mortem psychological profile of a suicide victim constructed from interviews with people who knew the person before death

neurobiology risk factor for suicide

- low levels of serotonin
- vulnerability to act impulsively
- overreacting to situations

stressful life events risk factor for suciide

severe experiences:
- shame, humiliation, unexpected arrest, rejection, physical or sexual abuse, natural disasters
- preexisting vulnerabilities, lack of social support

Durkheim's sociological theory

- Emile Durkheim
- suicide types based on social or cultural conditions: altruistic (formalized suicides), egoistic, anomic, and fatalistic

altruistic (formalized suicide)

sacrificing one's life to benefit others-to preserve tradition or honour of the family-as in ancient Japanese custom Hara-Kiri

egoistic suicide

the loss of social supports as an important provocation for suicide

anomic suicide

the result of marked disruptions, such as the sudden loss of a high-prestige job

fatalistic suicide

result from a loss of control over our own destiny

Baumeister's escape theory

painfully aware of personal shortcomings-> emotional suffering, depression:
- become suicidal to escape aversive self-awareness
- unrealistically high expectation-failing to meet these expectations

Joiner's interpersonal theory of suicide

the tendency to commit suicide is a product of two interpersonal constructs:
1. need to belong
2. perceived burdensomeness
- people at risk when they feel excluded and they are also at risk when they regard themselves a burden and that other people would be better off without them

Shneidman's approach

- conscious effort to stop unbearable pain
- suicidal individuals are experiencing psychache which is intense anguish
- sufferer-suicide ends consciousness and unendurable pain

is suicide contagious? treatment

- positive relationship between suicidal behaviour and exposure to media coverage
- clusters of suicides
- teenagers
- romanticizing suicide in media

clinical and ethical issues in dealing with suicide

- therapists' responsibilities
- physician-assisted suicide