Mood Disorders

Dr. C. George Boeree

As the name implies, mood disorders are defined by pathological

extremes of certain moods - specifically, sadness and elation. While
sadness and elation are normal and natural, they may become
pervasive and debilitating, and may even result in death, either in the
form of suicide or as the result of reckless behavior. In any one year,
roughly 7% of Americans suffer from mood disorders.

[Note: The quotations below are from Mental Health: A Report of

the Surgeon General, U.S. Public Health Services (1999), available at
http://www.surgeongeneral.gov/library/mentalhealth/home.html]

Major Depression
The cardinal symptoms of major depressive disorder are depressed
mood and loss of interest or pleasure. Other symptoms vary
enormously. For example, insomnia and weight loss are considered to
be classic signs, even though many depressed patients gain weight and
sleep excessively.

It is twice more common in women than in men.

What is now called major depressive disorder, however, differs both

quantitatively and qualitatively from normal sadness or grief. Normal
states of dysphoria (a negative or aversive mood state) are typically
less pervasive and generally run a more time-limited course.
Moreover, some of the symptoms of severe depression, such as
anhedonia (the inability to experience pleasure), hopelessness, and
loss of mood reactivity (the ability to feel a mood uplift in response to
something positive) only rarely accompany “normal” sadness.
Suicidal thoughts and psychotic symptoms such as delusions or
hallucinations virtually always signify a pathological state.

When untreated, a major depressive episode may last, on average,

about 9 months. Eighty to 90 percent of individuals will remit within 2
years of the first episode (Kapur & Mann, 1992). Thereafter, at least
50 percent of depressions will recur, and after three or more episodes
the odds of recurrence within 3 years increases to 70 to 80 percent if
the patient has not had preventive treatment (Thase & Sullivan, 1995).

Anxiety is commonly comorbid with [occuring at the same time as]

major depression. About one-half of those with a primary diagnosis of
major depression also have an anxiety disorder (Barbee, 1998; Regier
et al., 1998). The comorbidity of anxiety and depression is so
pronounced that it has led to theories of similar etiologies [causes],
which are discussed below. Substance use disorders are found in 24 to
40 percent of individuals with mood disorders in the United States
(Merikangas et al., 1998). Without treatment, substance abuse
worsens the course of mood disorders. Other common comorbidities
include personality disorders (DSM-IV) and medical illness,
especially chronic conditions such as hypertension [high blood
pressure] and arthritis.

Suicide is the most dreaded complication of major depressive

disorders. About 10 to 15 percent of patients formerly hospitalized
with depression commit suicide (Angst et al., 1999). Major depressive
disorders account for about 20 to 35 percent of all deaths by suicide
(Angst et al., 1999). Completed suicide is more common among those
with more severe and/or psychotic symptoms, with late onset, with co-
existing mental and addictive disorders (Angst et al., 1999), as well as
among those who have experienced stressful life events, who have
medical illnesses, and who have a family history of suicidal behavior
(Blumenthal, 1988). In the United States, men complete suicide four
times as often as women; women attempt suicide four times as
frequently as do men (Blumenthal, 1988).

Dysthymia is a chronic [recurring, usually less severe] form of

depression.

Depression is related, of course, to sadness. Sadness is a natural

response to difficult circumstances that cannot be resolved by running
away (that would be fear) or attacking the problem (that would be
anger). Instead, there is the sense that one must wait for the problem
to resolve by itself. In grief, for example, we ultimately realize that
only time will lessen the pain.

We consider sadness to have passed over into pathology when we lose

the sense that the pain will lessen. We continue to suffer, we have
guilt feelings, we dwell on the problem, we even try to shut down our
feelings altogether. Traumatic events such as the sickness or death of a
loved one are common causes of depression.

But continual stress is also a common cause of depression. Living

with stress causes the depletion of the body's resources, including
changes in the availability of the neurotransmitters associated with
energy, happiness, and calm. With repeated stress, the nervous system
becomes increasingly sensitive to additional stress, until it no longer
seems to be able to cope. A simple way to say this is that you become
emotionally exhausted from life's difficulties.

We find depression more commonly in people who live in the face of

poverty, discrimination, and exploitation. It is not a complete surprise
that 70% of depressed people are women, as living in a male-
dominated society adds to the stresses women must deal with. It is
also more common among people in stigmatized populations. Cultural
psychologist Richard Castillo even suggests that treating depression as
a "brain disease" is a way society avoids facing the significant social
problems that lead to depression.

One well-known explanation of depression considers it a matter of

learned helplessness. If we see ourselves as helpless in the face of
stress and trauma, if we see our suffering as hopeless, we develop
depression. This leaves a dilemma for psychologists: It often helps
people to see depression as a "brain disease" involving low seratonin
levels, since they can stop seeing themselves as somehow responsible
for their condition. But that also means they now see depression as
something that can only be helped by external medical intervention.

Depression is not as common in many nonwestern and premodern

cultures. In those cultures, it is more likely that emotional exhaustion
is expressed via somatization, i.e. in the form of physical complaints.
Castillo suggests that the prevalence of depression in modern western
societies such as the U.S. is due to our emphasis on financial success,
material values, and the idea that we each have individual
responsibility for our own happiness. In other societies, people rely
more on defined status, tradition, and the social support of extended
family. Also in other societies, people don't see happiness as a right.
In the U.S., if you are not happy, we assume that there is something
terribly wrong!

Bipolar Disorder

Bipolar disorder is a recurrent mood disorder featuring one or more

episodes of mania or mixed episodes of mania and depression (DSM-
IV; Goodwin & Jamison,1990). Bipolar disorder is distinct from major
depressive disorder by virtue of a history of manic or hypomanic
(milder and not psychotic) episodes.

Mania is derived from a French word that literally means crazed or

frenzied. The mood disturbance can range from pure euphoria [strong
happiness] or elation to irritability to a labile [changeable] admixture
that also includes dysphoria [unhappiness] (Table 4-4). Thought
content is usually grandiose but also can be paranoid. Grandiosity
usually takes the form both of overvalued ideas (e.g., “My book is the
best one ever written”) and of frank delusions (e.g., “I have radio
transmitters implanted in my head and the Martians are monitoring
my thoughts.”) Auditory and visual hallucinations complicate more
severe episodes. Speed of thought increases, and ideas typically race
through the manic person’s consciousness. Nevertheless, distractibility
and poor concentration commonly impair implementation. Judgment
also can be severely compromised; spending sprees, offensive or
disinhibited behavior, and promiscuity or other objectively reckless
behaviors are commonplace. Subjective energy, libido [sexual desire],
and activity typically increase but a perceived reduced need for sleep
can sap physical reserves. Sleep deprivation also can exacerbate
[make worse] cognitive difficulties and contribute to development of
catatonia [staying in one position for long periods of time] or a florid
[fully developed], confusional state known as delirious mania.

Cyclothymia is marked by manic and depressive states, yet neither are

of sufficient intensity nor duration to merit a diagnosis of bipolar
disorder or major depressive disorder.

It is likely that mania involves a certain amount of dissociation - that

is, a refocussing of attention away from painful situations (especially
social ones) and onto a powerful, grandiose fantasy. So bipolar
disorder may be a matter of an energetic fantasy phase followed by
emotional exhaustion followed by another energetic fantasy phase, and
so on.

Mania is sometimes associated with creativity, and a number of

famous writers, artists, musicians, and others are believed to have been
bipolar. They would be depressed for months, and then have bursts of
energetic creative activity, only to fall back into depression. People
believed to have been bipolar include Ludwig von Beethoven,
Abraham Lincoln, Winston Churchill, Isaac Newton, Charles Dickens,
Edgar Allen Poe, Mark Twain, Virginia Woolf, Kurt Vonnegut Jr.,
Edvard Munch, Vincent van Gogh, Marilyn Monroe, Jimmy Hendrix,
Sting, Ozzie Osbourne, Adam Ant, and Kurt Cobain.

© Copyright 2003, C. George Boeree