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