Mood Disorders

Diagnoses

  • Classification of Psychiatric Disorders

    • Based on:

    • Combinations of symptoms

    • Intensity of disruption and distress

    • Degree of potential risk for self and others

    • Time course of symptoms

    • Overlap of symptoms makes diagnosis challenging.

  • Diagnostic and Statistical Manual (DSM)

    • Published by the American Psychiatric Association (APA)

    • Serves as a changeable document; categories evolve (e.g., bipolar disorder separated from depression).

  • Psychologist vs. Psychiatrist?

    • Psychologists generally provide therapy and counseling, often holding a PhD or PsyD. They are not medical doctors and cannot prescribe medication. Some specialize in assessment.

    • Psychiatrists are medical doctors (MDs or DOs) who can prescribe medication. Some also provide psychotherapy.

    • Other professionals like psychiatric social workers may also be part of a team.

    • It's recommended for individuals with psychopathology to receive supportive counseling in addition to medication, even if the issue is physiological.

Mood Disorders
Depression

  • Major Depression

    • Described as an extreme condition that usually lasts for months.

    • Characteristic symptoms:

    • Loss of interest in activities and lack of pleasure

    • Low motivation and productivity (can feel like paralysis, even for fundamental drives like eating and sex).

    • Associated Features:

    • Loss of interest in food and sex

    • Feelings of worthlessness, guilt (often objectively unreasonable, not prompting positive action), and powerlessness.

    • Sleep abnormalities, such as rapid onset of REM sleep, spending less time in slow-wave sleep, and often feeling unrested despite sleeping longer. (Correlation observed, not causation established for sleep disruption and depression).

    • Potential for suicide attempts; increased risk compared to those not experiencing major depression.

  • Depression – Seasonal Affective Disorder (SAD)

    • Definition

      • Depression that occurs at a specific time of year, often in winter due to low sunlight. Appears to be a product of sensitivity to light patterns affecting circadian rhythms. More common in areas closer to the poles with dramatic changes in sunlight availability.

    • Treatment:

      • Light therapy, which involves sitting in front of a bright light for several hours daily, is effective for treating SAD by helping to reset circadian patterns. Professional guidance is recommended for safe and effective use. Symptoms generally improve with increased natural sunlight in spring.

  • Genetic Predisposition to Depression

    • Influence of Biological Relatives

      • Probable increase in risk if close biological relatives (parent, sibling, grandparent) have been diagnosed with depression. Adoptive relatives having depression increases risk but to a lesser extent, suggesting both genetic and environmental factors. Risk is not destiny.

    • Influence of Early Onset:

      • Higher risk for individuals with biological relatives diagnosed before age 30, suggesting a stronger genetic vulnerability if depression manifests at a younger age (when fewer life stressors might typically trigger it). Younger children are less likely to be diagnosed than older adults.

    • Genetic Influence:

      • No single gene responsible for depression; genes likely involve patterns across multiple chromosomes influencing temperament (physiological structure, nervous system reactivity) and responses to life events. Finding a "magic key combination" is difficult.

    • Diathesis-Stress Model of Disorders:

      • Suggests that a genetic predisposition (diathesis) interacts with environmental stressors to produce disorders. A higher vulnerability may require fewer or less intense stressors to trigger depression, while lower vulnerability requires more or more intense stressors.

  • Sex Differences in Depression

    • Pre-Adolescence:

      • Depression prevalence is approximately equal among boys and girls.

    • Post-Adolescence:

      • Women are about twice as likely to experience depression compared to men (overrepresentation of females, underrepresentation of males in diagnosed populations).

    • Potential contributing factors include differences in seeking/discussing help (men discouraged from expressing emotions/weakness), and societal expectations (women as "keepers of emotional life"). Underrepresentation in men may stem from failure to seek help due to cultural emphasis on strength (e.g., first responders, military).

  • Hormonal Influences

    • Women's hormonal fluctuations (menstrual cycles, pregnancy, childbirth, menopause) do not significantly correlate with depression in terms of actual hormone levels.

    • However, these life events involve physical pain, disruption, and stress, which can contribute to depressive vulnerability.

    • It may also relate to how a woman's body responds to the presence of hormones, potentially through an autoimmune response where the body's immune system reacts to internal substances or changes (e.g., like allergies or type 1 diabetes).

  • Coping Mechanisms

    • Coping Strategies:

      • Men often distract themselves from depressive feelings, denying or deferring attention from negative experiences, which can lead to less effective intervention if symptoms are significant.

      • Women are more likely to dwell on feelings (rumination), which is a non-productive focus on experience that can intensify sadness rather than resolve it.

      • The difference in coping strategies between genders is still unexplained but influenced by societal attitudes and expectations.

    • Social Support: The nature of social support matters; interactions that become "gripe sessions" can reinforce negative views. Lack of social support raises the risk of developing depression.

  • Events That Precipitate Depression

    • Common Triggers:

      • Depressive episodes often follow significant losses or negative events.

    • Event Significance:

      • There is a lack of clear correlation between the scale of an event and the intensity/duration of depression (two people can experience similar events, one triggers, one doesn't). Interpretation of experiences plays a role.

    • Early Life Losses:

      • Severe losses or trauma during formative years (early childhood) increase vulnerability to future depression. Implicit memory of trauma and limited coping resources at a young age can make it harder to adjust later in life. Addressing childhood trauma and providing support is crucial.

  • Cognitive Aspects of Depression

    • Explanatory Style:

      • Individuals have a tendency to explain successes and failures:

      • Internal Attributions: Causes from within the person ("it's about me and who I am").

      • External Attributions: Causes outside the person ("what's going on outside of me, circumstances").

      • Those with a pessimistic explanatory style blame themselves for all failures (internal attributions), viewing them as global (will happen in all situations) and stable (will always happen), leading to negative implications and a sense of powerlessness. This results in pessimism, where they anticipate negative outcomes and see no potential upside ("every silver lining has a cloud").

      • This attributional pattern is predictive of depression but not necessarily causal. Depression may influence attribution, or vice-versa, or both are influenced by other factors.

  • Treatments for Depression

    • Cognitive Therapy:

      • Helps develop positive belief systems by challenging problematic automatic thought patterns and constructing new, healthier habits of thought.

    • Medications:

      • Focused on reducing symptoms and improving functioning, not cures. Prescriptions can be long-lasting.

      • Types include: Tricyclics, Selective serotonin reuptake inhibitors (SSRIs), Monoamine oxidase inhibitors (MAOIs), Atypical antidepressants.

      • St. John's Wort: An herb with antidepressant effects. It is a chemical and must be used with caution, informing doctors due to potential interactions with other medications (e.g., like grapefruit interacting with blood thinners).

    • Neurotransmitter Mechanisms:

      • After neurotransmitter release, some reabsorbed molecules are broken down by the enzyme monoamine oxidase (MAO).

      • SSRIs block serotonin reabsorption, leaving more in the synapse to increase serotonin activation.

      • Tricyclics block reabsorption for dopamine, norepinephrine, and serotonin.

      • MAOIs inhibit MAO, increasing neurotransmitter availability.

      • All designed to affect how neurons communicate at the synapse.

    • Electroconvulsive Shock Therapy (ECT):

      • Description

        • Involves administering an electrical shock to the brain to induce a convulsion, aiming to disrupt existing electrical communication patterns and "reset" them.

      • Controversy and History: Highly controversial due to historically misused applications (e.g., non-consensual, excessive, as a behavioral control method, linked to severe side effects like prolonged comatose states or brain damage if uncontrolled). Technology allowed its use, and the brain's electrochemical nature suggested it could be effective.

      • Effectiveness:

        • While effective, results are often temporary; it is not a cure.

      • Current Use:

        • Highly restricted. Used primarily for treatment-resistant depressions (when other interventions fail) or during severe suicidal ideation (due to immediate risk). The purpose is not to cure depression but to change the individual's activation level to make them responsive to other interventions.

Bipolar Disorders (formerly a subtype of depression, now separate category)
Bipolar Disorder: Symptoms

  • Characterized by mood swings between extreme mania and depression (bipolar: "two poles" or extremes).

  • During manic phases (opposite of depression, high over-activation):

    • Individual is highly active (may not sleep for days or only a few hours), uninhibited (impulsive, unwarranted risks), and may experience significant emotional highs (unsupported optimism, e.g., gambling money away) or irritability.

    • Associated features: Grandiosity (belief of being more powerful/intelligent), paranoia (belief others are trying to stop them).

    • Can be misdiagnosed as attention deficit hyperactivity disorder (ADHD) due to high activation and impulsivity, but stimulant medications for ADHD can be catastrophic for bipolar disorder.

    • Psychotic symptoms (delusions, hallucinations) can occur, leading to confusion with disorders like schizophrenia. Example: a woman painting her whole house impulsively without preparation.

Types of Bipolar Disorder

  • Bipolar I Disorder:

    • Involves at least one episode of mania.

  • Bipolar II Disorder:

    • Involves alternation between major depression and hypomania (a less intense form of mania, not as severe as full mania and might not have psychotic features).

Prevalence of Bipolar Disorder

  • Approximately 1% of the adult U.S. population diagnosed.

  • Similar features may overlap with other mental disorders, making distinction challenging. Diagnosis in children is relatively new and often controversial; children may be misdiagnosed.

  • Hereditary factors influence the likelihood of developing bipolar disorder.

Drug Therapies for Bipolar Disorder

  • Mood Stabilizers: Medications designed to reduce the degree of mood swing. Often the most common recommendation due to the physiologically-based nature of the disorder (not strongly linked to specific external triggering events).

  • Lithium:

    • Naturally occurring chemical used to treat mania. Its precise mechanism of action is not fully understood, but it is effective in stabilizing mood. Monitoring is required due to toxicity at high doses (regular blood tests to check kidney/liver function due to potential for organ damage).

  • Alternative Treatments:

    • Valproate and anticonvulsant medications also utilized.

  • Medication Adherence: A significant challenge is that patients often stop taking medication when symptoms improve, believing they are "cured." However, these are not cures, and abrupt cessation can lead to dangerous withdrawal effects or symptom recurrence.

Suicide

  • Definition: Individuals taking action to intentionally end their own lives. Involves ideation, attempts, and unfortunately, completions.

  • Estimating Rates: Not straightforward due to:

    • Difficulty determining intent (e.g., accidental drug overdose vs. intentional).

    • Intentional disguise by individuals to protect family from stigma or secure insurance benefits.

    • Misinterpretation of self-protective actions (e.g., a person with schizophrenia jumping from a window due to hallucinations).

    • Stereotypes (e.g., not all suicides involve notes).

  • Factors Influencing Likelihood: Differences seen with gender, culture, and age (more likely as people get older due to losses, less hope).

  • Risk Factors (Indicators of vulnerability):

    • Recent death of a spouse or child (major emotional loss). Men are particularly at risk after the loss or disruption of a primary relationship, potentially due to lower self-care and increased life disruption.

    • Major recent setbacks in job, finances, or social life (e.g., economic downturns can lead to spikes in suicide rates).

    • Presence of depression or bipolar disorder, especially untreated (increases risk; a sense of overwhelming hopelessness is a key feature).

    • Previous suicide attempts (one of the most powerful predictors; not merely a "cry for help" but a serious indication of risk).

    • Drug and alcohol issues (can be difficult to distinguish accidental overdose from intentional attempts).

    • Loss of a parent by death or divorce during childhood or adolescence (early loss affects coping resources, increasing later vulnerability). It can be challenging to determine if a child understands the permanence of suicide.

    • Presence of guns in the home (increased ease of availability is a risk factor).

    • Having a family member who completed suicide (suggests shared genetic or experiential risk factors).

  • Gender Differences in Method and Outcome:

    • Women make more attempts but tend to use less lethal means (e.g., overdose), allowing more time for intervention.

    • Men are more likely to use lethal means (e.g., guns, hanging) and are more likely to complete suicide when they attempt.

    • Historically, women's attempts were often misinterpreted as less serious "attention-seeking," leading to missed intervention opportunities.

  • Warning Signs and Intervention:

    • Suicidal Ideation: Talking about suicide directly or through suggestive behaviors should always be taken seriously, not dismissed as attention-seeking.

    • Provide support and friendship, encourage expression of feelings within comfortable and appropriate relationship boundaries.

    • Strongly encourage seeking professional help; individuals are not therapists for friends/family.

    • National Suicide Prevention Lifeline: 988 (available 24/7/365, emergency number).

    • It is also crucial for those supporting someone with suicidal ideation to seek their own support for coping with the stress of the situation.