LECTURE NOTES - Chapter 8

Mood Disorders

Characteristics of Mood Disorders

• Are more serious than typical emotional states that everyone feels

• Involve significant disturbances in emotion, including sadness or anhedonia (inability to feel interest or pleasure) or elation/irritability (mania)

• Cause dysfunction in social and occupational realms

Mood Disorders Affect All Aspects of Functioning

• Mood disorders affect physical, perceptual, social, biological, and thought processes

• Not due to substance use

Symptoms in Multiple Areas of Functioning in Major Depressive Disorder

• Emotional - depressed mood

• Motivational - loss of desire to do usual activities, lack of drive

• Behavioral - less active and productive, may move and speak slowly or seem physically agitated

• Cognitive - negative self-evaluation, self-blame, pessimism, guilt, indecisiveness, difficulty concentrating, thoughts of death or suicide

• Physical - headaches, indigestion, constipation, dizzy spells, pain, sleep and eating disturbance, fatigue

Core Symptoms of Major Depressive Disorder (DSM-5)

• Sad or blue mood most of the day, everyday, or loss of interest and pleasure for two weeks or longer is a core (required) symptom; without 1 or both of these symptoms a diagnosis of major depressive disorder (MDD) is not possible

Major Depressive Disorder (MDD)

• The diagnosis requires one or both core symptoms + 4 of eleven symptoms

  • Hopelessness

  • Tiredness and lack of energy 

  • Low self-esteem, self-criticism or feeling incapable

  • Trouble concentrating and trouble making decisions

  • Irritability or excessive anger

  • Decreased activity, effectiveness and productivity 

  • Avoidance of social activities 

  • Feelings of guilt and worries over the past

  • Poor appetite or overeating 

  • Sleep problems

  • Psychosis - some people experience mood-congruent delusions and hallucinations

• Lifetime prevalence rates in U.S.: from 5.2% to 17.1%

  • Similar ranges were found in a cross-cultural study

  • According to Scott Patton, an epidemiologist, the lifetime prevalence in Canada could vary from 20% to 50%

• 2x more common in women than in men

  • Sex difference appears in adolescence and is maintained across the lifespan

Gender Difference in Incidence of MDD

• The gender difference is found in all 23 countries where differences in the incidence of depression were studied

• Rumination, brooding, and co-rumination are associated with depression & are more common in females than in males

  • Objectification theory - being viewed and evaluated as an object - reduces self esteem

  • A history of sexual abuse is associated with increased risk of depression

  • 52% of women undergoing in-patient treatment for depression were victims of sexual abuse in childhood

  • Differences in the hormones estrogen and progesterone may increase vulnerability to depression; mixed findings

Unipolar or Major Depressive Disorder with Mixed Features

Persistent Depressive Disorder (PDD)

• Depressed mood for most of the day, for more days than not for 2 years or longer; In children and adolescents, the mood can be irritable, and duration must be at least 1 year

• Presence, while depressed, of two (or more) symptoms listed on this page & the next

  • 1. Poor appetite or overeating 

  • 2. Insomnia or hypersomnia

  • 3. Low energy or fatigue

  • 4. Low self-esteem

  • 5. Poor concentration or difficulty making decisions

  • 6. Feelings of hopelessness

    • Lifetime prevalence of 4.6%

Double Depression

• The person with Persistent depressive disorder can have one or more episode of Major Depressive Disorder

Bipolar Disorder 

• Occurs less often then MDD

• Lifetime prevalence rate for Bipolar Disorders (I and II) is 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

• Sex differences in bipolar disorder

  • 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

Bipolar I Disorder

• Depression that meets the criteria for MDD + at least one episode of mania

• Or…

• Mixed episodes that include symptoms of both mania and depression

Core Symptoms Required for a Diagnosis of a Manic Episode (Necessary but not Sufficient)

• Requires the distinct presence of a persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, lasting at least one week + 3 additional symptoms (4 if mood is irritable)

Diagnosis of a Manic Episode

• Core symptoms for at least one week, and 3 more symptoms, or 4 of if the 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 II Disorder

• At least one episode of depression that meets the criteria for MDD

• One or more episodes of hypomania; in hypomania the symptoms last at least 4 days

Core Symptoms for Hypomania

• Requires the distinct presence of a persistently elevated, expansive, or irritable mood and persistently increased activity or energy, lasting at least 4 days, and 3 additional symptoms (4 if mood is irritable)

• The symptoms are a change from usual behavior, and there is a clear change in functioning; the disturbance in mood and change in functioning are noticeable by others

• The symptoms are not due to the effect of a substance

Hypomania

• Feel extra energetic, decreased need for sleep

• Feel unusually optimistic

• Increased self esteem 

• Elevated mood and/or irritability

• Increased talkativeness, increased level of activities

• Risky, impulsive behavior

• These symptoms can damage or ruin relationships with friends, family, and in the workplace

Bipolar Disorder with Rapid Cycling

• The person has four or more episodes mood disturbance in a year

Bipolar Disorders I or II with Mixed Features

• The person has a combination of depression and mania or hypomania occurring at the same time

• The person may be depressed and crying but their mind is racing and they feel very irritable and may be impulsive

Bipolar Disorder with Predominant Polarity

• The more classic pattern is to have alternating periods of depression and hypomania 

• In bipolar disorder with predominant polarity, the person spends significantly more time in one state over the other

• For example, the person with depression predominance has many more episodes of depression than hypomania or mania

• The person with mania or hypomania predominance has more episodes of mania or hypomania than depression

Cyclothymic Disorder

• Periods of symptoms of hypomania and periods with mild depression over a period of 2 years + (adults) or 1 year (children)

• Lifetime prevalence of .04-1%

Seasonal Affective Disorder (SAD)

• Usually involves depression in the winter, but some people experience depression in the summer; it can be bipolar or unipolar

The Heterogeneity of Mood Disorders

• Bipolar I Disorder with mixed episode

• Bipolar II Disorder

• Bipolar disorder with rapid cycling

• Bipolar disorder with predominant polarity

• Cyclothymia

• MDD with mixed features

• MDD with psychotic features

• Seasonal affective disorder (SAD)

• Bipolar and unipolar disorders can be also sub-diagnosed as seasonal

• Persistent depressive disorder

• Postpartum depression

Psychological Theories

• Psychoanalytic theory of depression

  • Analogy to bereavement, according to Freud; depression is seen to be like grief

  • People with introjective (or self-critical) depression carry feelings of inferiority, inadequacy, self-criticism and guilt

  • Anaclitic (dependent) depression is characterized by feelings of being unloved and unwanted

Other Theories of Depression

• Psychological Theories of Bipolar Disorder

  • Largely neglected by scholars and clinicians

Interpersonal Models of Depression

• Sparse social networks that provide little support

  • An individual’s ability to handle negative life events

  • Vulnerability to depression

• Self-verification theory refers to the tendency for depressed individuals to seek confirmation from other that is consistent with their negative self-view, and gravitate toward individuals who will evaluate them negatively 

• Stress generation hypothesis depressed individuals tend to experience negative interpersonal situations

Beck’s Negative Schemata

• Some people have experiences that lead to the development of negative schemata (tendency to see the world negatively 

• Schemata are perceptual sets and influence how we perceive and understand the world

• A person who has been criticized excessively may develop a schema that they are incompetent, and this will result in expecting to fail

• A person may develop a schema that they are unlikable and unlovable, and this will lead them to expect rejection and possibly to accept abusive behaviors from others

Dysfunctional Attitudes

• Negative cognitions that distort how the person interprets situations that make them more vulnerable to depression after particular events

• Dysfunctional beliefs related to the need for approval

• Dysfunctional beliefs reflecting the need for achievement and perfection

Beck’s Negative Cognitive Triad - Depression

• Depression is associated with dysfunctional thoughts

  • 1. Self is worthless

  • 2. Future is hopeless

  • 3. Cannot cope/helpless to change events in one’s life

Helplessness/Hopelessness Theories

• Learned Helplessness involves passivity and having a sense of being unable to act and control one’s own circumstances

• It is acquired through unpleasant experiences and traumas that the person was unable to control at the time

Attribution and Learned Helplessness

• Imagine a person who receives a low grade on a test and has the following thoughts:

  • Attribution to stable factors:

    • “I am lazy” instead of “I didn’t leave myself enough time to prepare for the exam”

  • Attribution to internal characteristics:

    • “I am not smart enough” Instead of “I haven’t been putting in the effort that it takes to do well in this course”

  • Global attributions:

    • “I am a failure” Instead of “There is much about me that is important than how well I do on a test or in a course”

Hopelessness Theory

• Expectation that desirable outcomes will not occur

• Or, that undesirable ones will occur and that the person has no responses available to change this situation

• Negative life events interact with diathesis (vulnerabilities such as having a negative attributional style) and lead to a state of hopelessness

• Other vulnerabilities (diathesis) include low self-esteem & the belief that negative life events will have severe negative consequences

Depression and Relationships

• Having a spouse who is critical puts the target of criticism at risk of depression as much as 10 years later

• Others become annoyed by partners who frequently seek reassurance

Stress Generation

• Behaviors such as frequent reassurance-seeking create a stressful environment, and lead to rejection by the friend or partner who is asked to provide reassurance

• Stress generation is associated with depression in adolescent girls but not in boys

• Interpersonal stress generation predicted depression in girls with a history of childhood maltreatment but not in girls without a history of childhood maltreatment

Social Skills Deficits and Depression

• Low social competence predicts the onset of depression in children

• Poor interpersonal problem-solving predicted increases in depression in adolescents 

Advances in Knowledge of Biological Processes in Mood Disorders

• There have been numerous breakthroughs in our understanding of biological factors

• Genetic sequencing has become much faster than it was in the past

• Developments in imaging have contributed to the growth in knowledge

• Structural differences found in schizophrenia, such as enlarged ventricles, are also found in people with affective disorders

Biological Theories

• MDD

  • Heritability estimate = 35%

  • Relatives of unipolar probands are at = risk for unipolar depression

  • Serotonin transporter gene linked promoter region (5-HTTLPR) is a risk factor for depression & anxiety

• Biological & Environmental Risk Factors for MDD

  • Many genes have been found to be involved in the onset of MDD, making MDD a polygenic disorder

  • Childhood trauma i associated with the development of MDD

  • Genetic predisposition for MDD is associated with negative styles of information processing

• Bipolar disorder

  • 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

  • BDNF is involved in the growth and survival of neurons 

  • Level of BDNF are negatively associated with the severity of bipolar symptoms and with stress

• Neuroimaging studies

• Hippocampal volume and neurocognitive impairment

• Inconsistencies in Biological Findings in Bipolar Disorder

  • Egeland et al. found evidence from a study of the Amish population that bipolar disorder is due to a dominant gene on the 11th chromosome, but this finding has not been consistently replicated

  • Variation in BDNF was thought to predict risk for rapid cycling bipolar disorder, but this was not replicated with other ethnicities

• 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; however the increase is only temporary

  • Selective serotonin reuptake inhibitors inhibit the reuptake of serotonin and this increases the levels of serotonin in the brain

Serotonin

• A diet that reduces tryptophan, which is needed to produce serotonin, leads to the return of depressive symptoms in people who had recovered from a depression

Biological Theories

• Drug actions suggests 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 neurotransmitter

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

• Neuroendocrine System

  • HPA axis may play a role in depression

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

    • Level 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

• Some drugs used in the treatment of mood disorder

Other Biological Treatments

• ECT for depression

• Transcranial magnetic stimulation (rTMS)

  • rTMS treatment start at 1’25”

• Ketamine for depression

Psychological Therapy for Mood Disorders

• Psychodynamic therapies

• Cognitive and behavior therapies

• Mindfulness-based cognitive therapy