Mood Disorders Chapter 11

1. Mood DisordersChapter 11

2. Mood Disorders Disturbances in emotions that cause subjective discomfort, hinders a person�s ability to function, or both. Depression and mania are central to these disorders. Depression: Emotional state characterized by intense sadness, feelings of futility and worthlessness, and withdrawal from others. Mania: Emotional state characterized by elevated mood, expansiveness, or irritability, often resulting in hyperactivity. -Read Amanda�s story on page 354-Read Amanda�s story on page 354

3. Mood Disorders Depression occurs ten times as frequently as mania. Depression is the most common complaint of individuals seeking mental health care. Epidemiologic catchment area survey: 2.3% of adult males and 5% of adult females in the U.S. have a mood disorder in a one-year period.

4. Mood Disorders Lifetime prevalence: Severe depression: 5-12% of males and 10-25% of females Mood disorder: 15% of males and 24% of females Risk of another episode increases with each episode 50% after one episode, 70% after second, 90% after third

5. One-Year and Lifetime Prevalence Rates of Mood Disorders in the United States -Figure 11.1: One-Year and Lifetime Prevalence of Mood Disorders in the United States.-Figure 11.1: One-Year and Lifetime Prevalence of Mood Disorders in the United States.

6. The Symptoms of Depression Affective: Depressed mood, dejection, excessive and prolonged mourning, worthlessness, lack of joy. Cognitive: Pessimism, decreased energy, disinterest, loss of motivation, self-accusations of being incompetent Cognitive Triad: Negative views of self, outside world, and the future.

7. The Symptoms of Depression Behavioral: Social withdrawal, lowered work productivity, lack of personal cleanliness, slow speech. Psychomotor Retardation: Slowing of bodily movements, expressive gestures, and spontaneous responses. Physiological: Loss of appetite/weight, constipation, sleep disturbance, disruption of menstrual cycle, aversion to sexual activity.

8. The Symptoms of Depression

9. The Symptoms of Depression Culture influences the experience and expression of symptoms: Sadness/guilt (U.S. and Western European) versus somatic/bodily complaints (Asian) �Nerves� and headaches (Latino and Mediterranean) Weakness, tiredness, �imbalance� (Asian) Problems of the �heart� (Middle Eastern) Being �heartbroken� (Hopi)

10. The Symptoms of Mania Affective: Elevated, expansive, irritable mood; if frustrated, may become belligerent Impaired social and occupational functioning Boundless energy, enthusiasm, self-assertion Cognitive: Flightiness, pressured thoughts, lack of focus and attention, poor judgment

11. The Symptoms of Mania Behavioral: Uninhibited, impulsive sexual activity, abusive discourse Hypomania: �High� mood and overactive behavior; poor judgment, delusions (rare), start many projects but complete few, dominate conversations, often grandiose. Mania: Pronounced overactivity, grandiosity, irritability; incoherent speech, no tolerance for criticism or restraint Physiological: Decreased need for sleep, plus high levels of arousal.

12. Classification of Mood Disorders Depressive Disorders (also called unipolar disorders because no mania is exhibited): Major depressive disorders Dysthymic disorder Depressive disorders not otherwise specified

13. Classification of Mood Disorders Bipolar Disorders: Characterized by one or more manic or hypomanic episodes and usually by one or more depressive episodes. Bipolar disorder I Bipolar disorder II Cyclothymic disorder -Personal experience about issues with college and video of how bipolar works http://abilify.com/-Personal experience about issues with college and video of how bipolar works http://abilify.com/

14. -Table 11.1: Mood Disorders.-Table 11.1: Mood Disorders.

15. -Table 11.2: Symptoms of Depression and Mania.-Table 11.2: Symptoms of Depression and Mania.

16. Depressive Disorders Major Depression: A disorder in which a group of symptoms, such as depressed mood, loss of interest, sleep disturbances, feelings of worthlessness, and inability to concentrate, are present for at least two weeks.

17. -Table 11.3: Criteria for DSM Diagnosis of Major Depressive Disorder.-Table 11.3: Criteria for DSM Diagnosis of Major Depressive Disorder.

19. Depressive Disorders Dysthymic Disorder: Characterized by chronic and relatively continual depressed mood that does not meet the criteria for major depression. Pessimism, guilt, loss of interest, poor appetite or overeating, low self-esteem, chronic fatigue, social withdrawal, concentration difficulties.

20. Bipolar Disorders Bipolar I Disorders: Single manic episodes, most recent episode hypomanic, most recent episode manic, most recent episode mixed, most recent episode depressed, and most recent episode unspecified. Bipolar II Disorders: Recurrent major depressive episodes with hypomanic episode. Manic episodes without depressive episodes are extremely rare.

21. Bipolar Disorders Cyclothymic Disorder: Chronic and relatively continual mood disorder with hypomanic episodes and depressed moods that do not meet criteria for major depressive episode. Symptoms present for more than 2 years, never symptom free for more than 2 months

22. Other Mood Disorders Mood Disorder Due to General Medical Condition: Characterized by depressed mood and/or elevated or irritable mood as a direct result of a general medical condition. Substance-Induced Mood Disorder: Prominent and persistent disturbance of mood attributable to use of a substance or cessation of substance use.

23. Symptom Features and Specifiers Specifiers: Describe major depressive episodes in terms of severity, presence or absence of psychotic symptoms, and remission status. Useful for prognosis May include information such as: Melancholia: Loss of pleasure, lack of reactivity to pleasurable stimuli, depression that is worse in the morning, early morning awakening, excessive guilt, weight loss. Catatonia: Motoric immobility, extreme agitation, negativism, or mutism.

24. Symptom Features and Specifiers Course specifiers: Rapid Cycling: Episodes occurred 4 or more times during the previous 12 months. Seasonal Pattern: Moods are accentuated during certain times. Seasonal Affective Disorder (SAD): Serious depression fluctuates according to the season. Postpartum Onset: Occurs within 4 weeks of childbirth.

25. Comparison of Depressive and Bipolar Disorders Genetic studies: Increased incidence of manic disturbances for blood relatives of bipolar patients. More evidence of genetic/ psychophysiological influences for bipolar than unipolar disorders. Relatives of unipolar patients have a greater probability of having unipolar disorders, but relatives of bipolar patients have a greater probability of having bipolar AND unipolar disorders.

26. Comparison of Depressive and Bipolar Disorders Age of onset is earlier for bipolar (early 20s) than unipolar (late 20s). Psychomotor retardation and risk of suicide greater for bipolar than unipolar. Unipolars are more likely to exhibit anxiety.

27. Comparison of Depressive and Bipolar Disorders Bipolar patients respond to lithium. Prevalence differences: 1-2% of adult population has experienced bipolar disorder. 8-19% of adult population has experienced major depressive disorder. No gender differences in bipolar I disorder. Women are more likely than men to experience major depression and bipolar II disorder.

28. -Figure 11.1: Twelve-month and Lifetime Prevalence of Unipolar and Bipolar Disorders I and II.-Figure 11.1: Twelve-month and Lifetime Prevalence of Unipolar and Bipolar Disorders I and II.

29. -Figure 11.2: Multipath Model for Unipolar Depression. The dimensions interact with one another and combine in different ways to result in unipolar depression.-Figure 11.2: Multipath Model for Unipolar Depression. The dimensions interact with one another and combine in different ways to result in unipolar depression.

30. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Psychodynamic: Focus on separation and anger (�symbolic loss�) Cognitive: Low self-esteem, stable and enduring cognitive styles: Negative thoughts and errors in thinking Beck: Depression is a disturbance in thinking, not mood. Schemas set people up for depression.

31. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Cognitive: Depressed people operate from a primary triad of negative self-views, present experiences, and future expectations. Four errors in logic typify this negative schema: Arbitrary inference Selected abstraction Overgeneralization Magnification/ minimization

32. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Behavioral: Separation or loss, but reduced reinforcement is the cause and leads to less activity; secondary gain from reinforcement of inactivity. Lewinsohn suggests 3 sets of variable that help or hinder access to positive reinforcement Number of potentially reinforcing events/activities Availability of reinforcements Individual�s instrumental behavior

33. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Cognitive-learning approaches: Learned Helplessness: The belief that one is helpless and unable to affect outcomes in one�s life. Seligman: Belief in one�s own helplessness Attributional Style: People who feel helpless make speculations (causal attributions) about why they are helpless. Internal/external, stable/unstable, global/specific -Describe experiment with dogs harnessed which received electric shock.-Describe experiment with dogs harnessed which received electric shock.

34. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Cognitive-learning approaches: Response Styles: People have consistent styles of responding to depressed moods that affect the course of depression. Ruminative Responses: Dwelling on why one feels bad, considering possible consequences of symptoms, and expressing how badly one feels.

35. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Cognitive-learning: Diathesis-Stress: Vulnerability (negative cognitions or pessimistic attributional styles) in the presence of stress (negative life events) results in depression.

36. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Sociocultural: Culture, social experiences, and psychosocial stressors (including stress and gender) Social support: Acts as a buffer against depression Stress and depression: Diathesis: Individual genetic, constitutional, or social conditions may produce vulnerability to developing depression. Chronic stress more strongly related to depression than acute stress

37. The Etiology of Mood DisordersPsychological or Sociocultural Approaches to Depression Gender and depression: Universally, women are twice as likely as men to develop major depression. Women are more likely to seek treatment or report their depression to others. Possible diagnostic bias Depression may take other forms in men. Possible biological factors Traditional gender roles Response styles (women ruminate)

38. Explaining the Findings That Rates of Depression Are Higher Among Women Than Among Men Table 11.4: Explaining the Findings That Rates of Depression Are Higher Among Women Than Among Men.Table 11.4: Explaining the Findings That Rates of Depression Are Higher Among Women Than Among Men.

39. The Etiology of Mood DisordersBiological Perspectives on Mood Disorders Role of heredity: Adoption studies: Incidence of mood disorders is higher among biological families than among adoptive families. Twin studies: Concordance rates are higher for monozygotic twins than for dizygotic twins (especially for bipolar disorders), although non-genetic factors also have an influence. Polygenetic interactions

40. The Catecholamine Hypothesis: A Proposed Connection Between Neurotransmitters and Depression -Figure 11.5: The Catecholamine Hypothesis: A Proposed Connection Between Neurotransmitters and Depression. On the left is a representation of the production of neurotransmitter substances at a synapse between two neurons in the brain of a person with no depression. Some of the neurotransmitter is reabsorbed by the transmitting neuron in a process known as reuptake. Neurotransmitters are also broken down or chemically depleted by the enzyme monoamine oxidase (MAO), which is normally found in the body. In people with depression, either or both of these two processes may reduce neurotransmitters to a level that is insufficient for normal functioning.-Figure 11.5: The Catecholamine Hypothesis: A Proposed Connection Between Neurotransmitters and Depression. On the left is a representation of the production of neurotransmitter substances at a synapse between two neurons in the brain of a person with no depression. Some of the neurotransmitter is reabsorbed by the transmitting neuron in a process known as reuptake. Neurotransmitters are also broken down or chemically depleted by the enzyme monoamine oxidase (MAO), which is normally found in the body. In people with depression, either or both of these two processes may reduce neurotransmitters to a level that is insufficient for normal functioning.

41. Etiology of Mood DisordersNeurotransmitters and Mood Disorders Neurotransmitters: Chemical substances that are released by axons of sending neurons and that are involved in the transmission of neural impulses to the dendrites of receiving neurons. Catecholamine Hypothesis: Depression results from a deficit of specific neurotransmitters, mania is caused by too much. Neurotransmitters are broken down or chemically depleted by MAOs. Neurotransmitters are reabsorbed by the releasing neuron in the reuptake process.

42. Etiology of Mood DisordersNeurotransmitters and Mood Disorders Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms -Some symptoms (e.g. appetite, attention) seem to be mediated more by one neurotransmitter than the other. Some other symptoms (e.g. anxiety) seem to be mediated by either. -There are other symptoms (e.g. aches and pain) that seem to be mediated more consistently by a combination of both the neurotransmitters. -Some symptoms (e.g. appetite, attention) seem to be mediated more by one neurotransmitter than the other. Some other symptoms (e.g. anxiety) seem to be mediated by either. -There are other symptoms (e.g. aches and pain) that seem to be mediated more consistently by a combination of both the neurotransmitters.

43. Etiology of Mood DisordersNeurotransmitters and Mood Disorders Dysregulation of Serotonin (5HT) and Norepinephrine (NE) in the brain are strongly associated with depression. Dysregulation of 5HT and NE in the spinal cord may explain an increased pain perception among depressed patients. Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression.

44. The Etiology of Mood DisordersNeurotransmitters and Mood Disorders Low norepinephrine levels related to inaction. Other possible neurotransmission issues: Blunted receptor response Dysregulation in neurotransmission Neuroendocrine abnormalities: Depression is linked with high levels of cortisol (hormone secreted by adrenal cortex). Dexamethasone suppression test (DST) measures cortisol levels.

45. The Etiology of Mood DisordersNeurotransmitters and Mood Disorders REM sleep disturbances: Depression is linked to relatively rapid onset of and increase in REM sleep. May be connected to severe life stress

46. Etiology of Mood DisordersEvaluating Causation Theories Longitudinal/prospective studies allow more insight into links between life experiences and depression. Technological advances in identifying biological markers and processes in mood disorders. Increased attention to viewing depression as a heterogeneous collection of disorders. Many theories are too simplistic or too complex, hard to test empirically, don�t account for relevant variables, or are too limited. Range of mood stages result from interaction between environmental and biological factors.

47. The Treatment of Mood Disorders Biomedical treatments: Medications heighten level of a target neurotransmitter at the neuronal synapse: Boost neurotransmitter�s synthesis Block its degradation Prevent its reuptake from synapse Mimick its binding to postsynaptic receptors Electroconvulsive therapy (ECT): For severe depression Only used after drug treatments have not worked.

48. The Treatment of Mood Disorders Virginia Teen Charged With Raping, Killing Sister, Beating Toddler Niece With Sledgehammer MARY SMITH SAID SHE DOES NOT BELIEVE WALTER SMITH KILLED HIS SISTER. "HE DON'T REMEMBER NOTHING HE DID," SHE SAID. "HE WAS OUT OF IT OR SOMETHING LIKE THAT. IT WAS AN ACCIDENT. HE DON'T REMEMBER THAT STUFF." MARY SMITH SAID HER SON HAD NO HISTORY OF VIOLENCE, BUT SAID HE WAS ON MEDICATION FOR DEPRESSION. From FoxNews 9-5-07 -Six years after Kip Kinkel, dosed up with Prozac, killed his parents and two students at Thurston High, in Oregon; five years after Eric Harris, dosed with Luvox, embarked on his day of slaughter at Columbine; well over a decade after naysayers, including Dr. Peter Breggin, the Scientologists and this columnist, raised the alarm about links between antidepressants and violence, the FDA has issued a warning that ten antidepressants can cause deeper depression and, for gosh sakes, even agitation, mania and other forms of violent behavior, even SUICIDE! Who says government doesn't work? -Six years after Kip Kinkel, dosed up with Prozac, killed his parents and two students at Thurston High, in Oregon; five years after Eric Harris, dosed with Luvox, embarked on his day of slaughter at Columbine; well over a decade after naysayers, including Dr. Peter Breggin, the Scientologists and this columnist, raised the alarm about links between antidepressants and violence, the FDA has issued a warning that ten antidepressants can cause deeper depression and, for gosh sakes, even agitation, mania and other forms of violent behavior, even SUICIDE! Who says government doesn't work?

49. The Treatment of Mood Disorders Psychotherapy and behavioral treatments for depressive disorders: Psychoanalysis: Gain insight into unconscious and unresolved feelings of separation or anger. Behavior therapy: Increase exposure to pleasurable events and to improve social skills.

50. The Treatment of Mood Disorders Psychotherapy and behavioral treatments: Interpersonal: Short-term, psychodynamic-eclectic; targets interpersonal relationships. Cognitive-behavioral: Teaches patient to identify negative, self-critical thoughts, to see their connection with depression, to examine distorted thoughts and to replace them with realistic interpretations.

51. The Treatment of Mood Disorders Interpersonal psychotherapy and cognitive-behavioral therapy are both effective for treating depression. Combination of psychotherapy and medication (imipramine) may be best. Effects of treatment diminish over time, although cognitive therapy has better long-term outcomes.

52. Treatment for Bipolar Disorders Same forms of psychotherapy and behavior therapy used for unipolar disorder are used for bipolar disorder (particularly family therapy). Typical treatment for bipolar patient involves lithium carbonate, which is 60-80% effective. Negative physical side effects; also, lack of compliance or self-regulation of dosage. Anticonvulsant drugs are also being used.