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MOOD DISORDERS

General Characteristics of Mood Disorders

 A mood is a relatively long lasting emotional state.

 A mood disorder involves disturbance in a person’s emotional state or mood.


Characteristics:
Mood: Euphoria, Dysphoria, Mixed
Episode: A time-limited period during which specific, intense symptoms of a disorder are evident.

The Clinician notes:


1. Severity: mild, moderate, severe
2. First episode / recurrence
3. Nature of symptoms (catatonic, postpartum, atypical, melancholic seasonal, rapid cycling, with psychosis)
Depressive Disorders
There are 2 serious forms of depression:
1. Major Depressive Disorder
2. Dysthymic Disorder

Major Depressive Disorder


This involves acute, time-limited periods of depressive symptoms.

Characteristics of Major Depressive Disorder

 Diagnostic criteria on page 298

 Emotional symptoms:
1. Sadness
2. Depressed mood
3. Anhedonia
4. Irritability

 Cognitive symptoms:
1. Poor concentration and attention
2. Indecisiveness
3. Sense of worthlessness or guilt
4. Poor self-esteem
5. Hopelessness
6. Suicidal thoughts
7. Delusions and Hallucinations with depressing themes
 Physical signs:
1. Sleep disturbances
2. Appetite disturbances
3. Psychomotor retardation or agitation
4. Catatonia
5. Fatigue and loss of energy

Types of Depression:
The DSM-IV-TR recognizes five further subtypes of MDD, called specifiers, in addition to noting the length,
severity and presence of psychotic features:

Melancholic depression

 a loss of pleasure in most or all activities


 a failure of reactivity to pleasurable stimuli
 a quality of depressed mood more pronounced than that of grief or loss
 a worsening of symptoms in the morning hours,
 psychomotor retardation
 excessive weight loss, or excessive guilt

Atypical depression

 mood reactivity (paradoxical anhedonia) and positivity


 significant weight gain or increased appetite (comfort eating)
 excessive sleep or sleepiness (hypersomnia)
 a sensation of heaviness in limbs known as laden paralysis
 significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.

Catatonic depression is a rare and severe form of major depression involving disturbances of motor behavior
and other symptoms.

Postpartum depression: intense, sustained and sometimes disabling depression experienced by women after
giving birth.

Seasonal affective disorder (SAD)

 Depressive episodes come on in the autumn or winter, and resolve in spring.


 The diagnosis is made if at least two episodes have occurred in colder months with none at other times, over a
two-year period or longer.

Prevalence and Course of the Disorder:

 It’s a common disorder with a lifetime prevalence of 16.6 %.

 It is suggested that the younger age groups (cohorts) have higher prevalence rates than the old.

 Depression is a heterogeneous disorder with many possible courses:


 About 40 % of the people who have one episode never have another major depressive episode; about 60% do
 Among those with 2 episodes, 70% will have a 3rd and among those who have 3 episodes, 90% will have a 4th.
Dysthymic Disorder

 Diagnostic criteria on page 301.

 In dysthymic disorder, the severity and number of depressive symptoms are less but are present for a longer
duration.

 People with dysthymia feel inadequate in most of their endeavors and are unable to experience pleasure or
interest in the events of life.

 They show withdrawn behavior and spend time brooding or feeling guilty or act with anger, irritability
towards others.

 About one-tenth of them develop M.D.D.

 Comorbidity with other serious psychological disorders is high.

 Hospitalization is uncommon except in cases of suicidal behaviours.

 Approximately 2.5 % of eh adult population is thought to develop this disorder in the course of their lives, with a
peak age of onset being 45-59.

 Adults are more likely to report physical symptoms.


Disorders Involving Alterations in Mood
There are 2 disorders characterized by alterations in mood:
1. Bipolar disorder, which involves an intense and disruptive experience of extreme elation, or euphoria,
possibly alternating with major depressive episodes.
2. Cyclothymic disorder, involves alterations between dysphoria and briefer, less intense and less disruptive
states of euphoria called hypomanic episodes.

Bipolar disorder

 Diagnostic criteria of a manic episode on page 302, diagnostic features of Bipolar 1 on page 303.
Characteristics of a manic episode

 The term bipolar implies two poles - mania and depression, but not all people with bipolar disorder show signs
of depression. (the assumption underlying the diagnosis is that, at some point, the patient will become depressed)

 Mania is associated with a feeling of being ‘on top of the world’.

 People with mania have grossly inflated self-esteem; their thinking may be grandiose and have a psychotic
quality.

 Their thoughts race, they may jump from idea to idea or activity to activity.

 They are more talkative and louder than usual such that their rapidity may make it difficult to keep up with
them or to interrupt.

 People with mania are usually energetic and may be unable to sleep or sit still.

 They experience intense euphoria that nothing can disturb, but if their plans are foiled they may become
irritable or uncontrollably furious.
 There is excessive involvement in pleasurable activities without any regard for its consequences.

 Unlike a major depressive episode, a manic episode emerges and ends suddenly.

Types of Bipolar Disorder


1. Bipolar I, describes a clinical course in which the individual experiences one or more manic episodes with
or without having experienced one or more major depressive episodes.
2. Bipolar II involves one or more major depressive episodes and at least one hypomanic episode.

Prevalence and Course of the Disorder

 The lifetime prevalence is 3.9%.

 It’s equally prevalent in men and women but there’s a gender difference in the way the disorder presents.

 The peak age of onset for bipolar is the twenties.

 Pediatric bipolar disorder (diagnosis complicated by coexisting conditions).

 90% of the patients who have had a single manic episode experience subsequent episodes (kindling).

 Untreated bipolar disorder is characterized by four episodes on an average in a decade, with the inter-episode
period decreasing as age increases.

 About less than 15 % of individuals with bipolar disorder are rapid cyclers.

 Hypothyroidism, disturbances in sleep-wake cycles and use of antidepressants are thought to be associated
with rapid cycling.

 Most people with bipolar disorder act and feel normal between episodes - about 1/4th continue to have unstable
mood.

 Bipolar disorder is a very serious condition if untreated, with a risk of suicide estimated at 15%.
Cyclothymic Disorder

 People with this disorder exhibit unusually dramatic and recurrent mood shifts but not as intense as those
experienced with bipolar disorder.

 It’s a chronic condition that lasts for a minimum of 2 years.

 People with Cyclothymic disorder may be seen as moody and unreliable.

 Its prevalence is less than 1% with the peak age of onset being the twenties. But patients of cyclothymic disorder
are at considerable risk of developing full-blown bipolar disorder.

Theories of Mood Disorders


Biological Perspective
1. Genetics:

 First degree relatives of people with major depression are twice as likely to develop depressive disorders as
compared to the general population.
The risk is greater if the first degree relatives’ own parents have the disorder.

 Findings from a study on three generations


show that a child with an anxiety disorder who comes from a family in which depression has been diagnosed is
at much greater risk of developing depression in adulthood.

 Studies based on the inheritance patterns in families suggest that the heritability of major depressive disorder is
estimated to be 31 to 42%.

 Bipolar disorder is being increasing thought of as a spectrum.

 Gender and social support seem to influence the gene-environment interaction in the development of mood
disorders.
This offers support to the biopsychosocial model.
2. Biochemical factors:

 The catecholamine hypothesis suggests that ↓ norepinephrine causes depression and an overabundance of it
causes mania.

 An alternative to the catecholamine hypothesis states that a deficiency of serotonin contributes to the behavioural
symptoms of depression.

 In accordance to the monoamine depletion model (as the above hypothesis are now referred to) all the current
antidepressant medications work to ↑ the availability of these neurotransmitters at the synapse.

 Neuroendocrine research is trying to explore the relationship between cortisol levels and depression.
Psychological Perspective
1. Psychodynamic theories

 John Bowlby proposed that people can become depressed as adults if they are raised by parents who failed to
them with stable and secure relationships.

 Jules Bemporad suggested that children with deficient parenting become preoccupied with the need to be
loved by others.

 Psychoanalysts see mania as a defense against feelings of inadequacy, loss and helplessness.

2. Behavioural and Cognitively Based Theories

 Behaviourists see depression as a result of reduction in positive reinforcements.

 Lewinsohn maintained that people suffering from depression have a low rate of response contingent positive
reinforcement, behaviours that increase in frequency as the result of performing actions that produce pleasure.

 Aaron Beck suggested that people suffering from depression react to stressful life events by activating a set of
thoughts that he referred to as the cognitive triad: a negative view of self, others and the future, which
continues itself through a cyclic process.

 Complicating this cycle of depressive thinking is the cognitive distortions (page 311- table 8.1).

 This distortion in the content of thoughts results in feelings of low on well-being, energy, desire to be with
others and interest in the environment.
3. Sociocultural and Interpersonal Perspectives

 Some depressed individuals have faulty interaction patterns.

 Interpersonal therapy is based on the idea that disturbed social functioning (interpersonal stress) induces an
episode of depression in people who are genetically vulnerable to it.
 IPT is based on the attachment theories of Meyer, Sullivan, and Bowlby.
 IPT also relates to the CBT approach and suggests steps that lead to depression:
1. Failure in childhood to acquire skills needed to develop satisfying intimate relationships, leading to a sense
of despair resulting in depression.
2. This once established is maintained through the lack of skills and consequent rejection from others.
3. Reactive depression in adulthood may arise in facing a stressful event such as ending of a relationship.
4. After the depression develops, maladaptive social skills maintain it.

 The sociocultural theory also focuses on stressful life events as increasing the risk of depression.
Treatment of Mood Disorders
Biological Treatment

 The most common medications used to treat depression are Tricyclic antidepressants (TCAs), MAOIs
and SSRIs.
1. The TCAs such as desipramine or imipramine, work by blocking the reuptake of serotonin and
norepinephrine are effective in helping depressed patients with physical symptoms.
2. MAOIs such as Nardil or Pardate, are particularly effective in treating chronic depression and patients who
have not responded to tricyclics. They work by prolonging the presence of norepinephrine, serotonin and
dopamine in the synapses.
3. SSRIs such as fluoxetine or setraline block very specific receptors, unlike other antidepressants, thus
causing fewer side-effects.
Some issues:
 Limitations to the reports of the effectiveness of serotonin.
 Investigations have revealed a lower rate of suicides among those treated with SSRIs as compared to other
antidepressants (contrary to media reports).
 However there is concern about SSRIs provoking extreme impulsive behaviours, in a small number of
people.
 Other variables such as comorbid psychological disorders, gender, etc.
 Particularly, administration of SSRIs among adolescents and children needs to be closely monitored.
 Several factors need to be considered in resolving these conflicting findings:
1. Antidepressants are prescribed to severely depressed individuals who are already at ↑ risk for suicide.
2. The research participants of the study may not have been matched.
3. The medicine use may not be uniform for all.
4. The accuracy of the death category of suicide may be questionable due to social stigma and religious
beliefs.

 Improvement takes atleast 2 to 6 weeks. The medication may be continued for 4 to 5 months or more.

 The treatment for bipolar includes administering lithium, whose pharmacological effect is to calm the
manic individual by decreasing the catecholamine levels in the nervous system.

 Those with frequent manic episodes are advised to remain on lithium continuously as a preventive
measure.

 Its side-effects include mild central nervous system disturbances, gastrointestinal upsets and more serious
cardiac effects.

 Lithium compliance tends to be poor because lithium interferes with the highs associated with bipolar
disorder and also due to its side-effects.

 In addition to lithium, administration of antidepressants is beneficial in treating some symptoms.


Those with psychotic symptoms may benefit from antipsychotics. At times, anticonvulsant medication is
used for those who experience rapid cycling.

 ECTs.
Maintenance ECT is used in case of severely depressed patients to prevent recurrence.

 TMS

 Light therapy involves exposing depressed individuals to special lights, which alleviates depressive
symptoms by resetting the biological clock.

Psychological Treatment

 Behaviour therapy, aimed at helping clients change their environment and acquire social and mood management
skills can be effective.

 Cognitively based therapy, is based on active collaboration between the client and the therapist which involves
didactic work, cognitive restructuring and behavioural techniques.

 Short term psychodynamic interventions can have positive effects.

 Bipolar disorder is treated primarily through medication but clinicians are also focusing on teaching clients
better coping strategies.

 Interpersonal and Social Rhythm Therapy (IPSRT)


− According to this model, mood episodes are likely to emerge from medication non-compliance, disturbed
circadian rhythms, problems in interpersonal relationships and stressful life events.
o Thus, the goal of therapy is to increase stability in the above areas.
− IPSRT believes that reduction in interpersonal stress in clients is important because:
1. Stressful life events affect circadian rhythms.
2. Many life events cause changes in daily routines.
3. Major life stressors affect mood and lead to significant changes in interpersonal relationships.
 Researchers have found this form of therapy to improve relationship functioning and life satisfaction
among those with bipolar disorder.

Sociocultural and Interpersonal Intervention

 Couple or family therapy is based on strategies for dealing with individual symptoms and disorder
within the interpersonal system.

 Interpersonal therapy (based on the interpersonal theory) is divided in 3 phases:


1. Assessing the nature and magnitude of individual’s depression using quantitative methods.
2. Formulating a treatment plan that focuses on the primary problem - grief, interpersonal disputes, role
transitions, and other problems resulting from lack of social skills.

3. Using combination of techniques, focus on the here and now, to help the client.

 A large scale study on IPT showed that compared to cognitive-behavioural therapy and medications,
interpersonal therapy was significantly more effective.

Suicide

 Suicide is defined as death from injury, poisoning, or suffocation where there is evidence that the injury was self-
inflicted and that the decedent intended to kill him/herself.

Who commits suicide?

 Women are more likely to attempt suicide but men are more likely to complete it.

 About 90% of adults who commit suicide have a diagnosable psychological disorder.

Why do people commit suicide?


Biological Perspective:

 Genetic studies have shown that the relatives of suicide completers were 10 times more likely than relatives of
matched controls to have completed or attempted suicide.

 Altered serotonin pathways are also thought to play role. This vulnerability is associated with certain personality
traits which interact with life events to increase a person’s risk of attempting suicide.

 People in Europe (J curve) with heightened suicidal risks may share genes that lower their tolerance for
alcohol; genetic vulnerability with alcohol consumption may place these individuals at greater risk.

Psychological Perspective

 According to Shneidman, people attempting suicide are trying to communicate frustrated psychological
needs to important people in their life.

 Beck proposes that suicide is the expression of feelings of hopelessness.


The term suicidal mode is used to describe the frame of mind of people who have made multiple suicide
attempts.

 Impaired decision-making skills (combined with altered serotonin pathways) may predispose a person to
committing suicide.

 Research suggests that there may be a relationship between intelligence and suicide risk.
Sociocultural Perspective

 According to Emile Durkheim, the principal reason for suicide is a feeling of alienation from society (anomie).

 The role of media in publicizing suicides.


Assessment and Treatment of Suicidality

 Suicide intent refers to how committed a person is to dying.

 Suicidal lethality refers to the dangerousness of the person’s intended method of dying.

 One aid to assessing suicide is asking the individual if he or she has a ‘plan’ (asking is not suggesting). Study on
page 322.

 Identifying signs that a person is suicidal may be difficult. However behavioural cues may indicate the level of a
person’s level of Suicidality.

 Table 8.2 lists the risk and protective factors for suicide.

Interventions:
1. 2 basic strategies include providing social support and helping the individual regain a sense of control
over their lives.
2. Cognitive behavioural techniques.
3. Brent (2001) suggested a comprehensive model of treatment for adolescents that involves treating the
underlying psychopathology, reduction of cognitive distortion, improving social skills and problem
solving, regulation of affect and family intervention.

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