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

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