Mood Disorders

Depressive disorders
Affective disorders
Depressive neuroses
APA grouped under the heading “MOOD DISORDERS”

The most diagnosed and most severe depression is called a major depressive episode.
The DSM-5 criteria describes it as an extremely depressed mood state that lasts at least 2 weeks
and includes cognitive symptoms (such as feelings of worthlessness and indecisiveness)

Disturbed physical functions (such as altered sleeping patterns, significant changes in appetite
and weight, or a notable loss of energy) to the point that even the slightest activity or movement
requires an overwhelming effort.

The episode is typically accompanied by a general loss of interest in things and an inability to
experience any pleasure from life, including interactions with family or friends or
accomplishments at work or at school.
Although all symptoms are important, evidence suggests that the most central indicators of a full
major depressive episode are the physical changes.
(sometimes called somatic or vegetative symptoms)

Anhedonia (loss of energy and inability to engage in pleasurable activities or have any “fun”) is
more characteristic of these severe episodes of depression than are, for example, reports of
sadness or distress.
The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or
euphoria.

DSM-5 highlights this feature by adding “persistently increased goal-directed activity or

energy” to the “A” criteria
They become extraordinarily active (hyperactive), require little sleep, and may develop
grandiose plans, believing they can accomplish anything they desire.
In mania, individuals find extreme pleasure in every activity; some patients compare their daily
experience of mania with a continuous sexual orgasm.
DSM-5 also defines a hypomanic episode, a less severe version of a manic episode that does
not cause marked impairment in social or occupational functioning and need last only 4 days
rather than a full week.

(Hypo means “below”; thus, the episode is below the level of a manic episode.)
The Structure of Mood disorders
Individuals who experience either depression or mania are said to suffer from a unipolar mood
disorder, because their mood remains at one “pole” of the usual depression-mania continuum.
Individuals who experience either depression or mania are said to suffer from a unipolar mood
disorder, because their mood remains at one “pole” of the usual depression-mania continuum.
Someone who alternates between depression and mania is said to have a bipolar mood disorder
traveling from one “pole” of the depression-elation continuum to the other and back again
An individual can experience manic symptoms but feel somewhat depressed or anxious at the
same time; or be depressed with a few symptoms of mania. This episode is characterized as
having “mixed features”

Depressive Disorders
These disorders differ from one another in the frequency and severity with which depressive
symptoms occur and the course of the symptoms (chronic—meaning almost continuous—or
nonchronic)

Clinical Descriptions
● The most easily recognized mood disorder is major depressive disorder, defined by the
absence of manic, or hypomanic episodes before or during the disorder.
● If two or more major depressive episodes occurred and were separated by at least 2
months during which the individual was not depressed, the major depressive disorder is
noted as being recurrent
● From 35% to 85% of people with single-episode occurrences of major depressive
disorder later experience a second episode.
● In the first year following an episode, the risk of recurrence is 20%, but rises as high as
40% in the second year.
● Unipolar depression is often a chronic condition that waxes and wanes over time but
seldom disappears.
● Persistent depressive disorder (dysthymia) shares many of the symptoms of major
depressive disorder but differs in its course.
● There may be fewer symptoms, but depression remains relatively unchanged over long
periods, sometimes 20 or 30 years or more.
● Persistent depressive disorder (dysthymia) is defined as depressed mood that continues at
least 2 years, during which the patient cannot be symptom free for more than 2 months at
a time even though they may not experience all the symptoms of a major depressive
episode.
● These individuals who suffer from both major depressive episodes and persistent
depression with fewer symptoms are said to have double depression
Additional Defining Criteria for Depressive Disorders
These are
(1) with psychotic features (moodcongruent or mood-incongruent)
(2) with anxious distress (mild to severe)
(3) with mixed features
(4) with melancholics
(5) with atypical features
(6) with catatonic features
(7) with peripartum onset
(8) with seasonal pattern.

Psychotic features specifiers.

Some individuals in the midst of a major depressive (or manic) episode may experience
psychotic symptoms, specifically hallucinations (seeing or hearing things that aren’t there) and
delusions (strongly held but inaccurate beliefs)
Some may hear voices telling them how evil and sinful they are (auditory hallucinations).
Such hallucinations and delusions are called mood congruent, because they seem directly related
to the depression
Delusions of Grandeur

Anxious distress specifier

The presence and severity of accompanying anxiety, whether in the form of comorbid anxiety
disorders.
DSM-5. For all depressive and bipolar disorders, the presence of anxiety indicates a more severe
condition, makes suicidal thoughts and completed suicide more likely, and predicts a poorer
outcome from treatment

Mixed features specifier

Predominantly depressive episodes that have several (at least three) symptoms of mania as
described above would meet this specifier, which applies to major depressive episodes both
within major depressive disorder and persistent depressive disorder.

Melancholic features specifier.

Melancholic specifiers include some of the more severe somatic (physical) symptoms, such as
early-morning awakenings, weight loss, loss of
libido (sex drive), excessive or inappropriate guilt, and anhedonia (diminished interest or
pleasure in activities)

Catatonic features specifier

This serious condition involves an absence of movement (a stuporous state) or catalepsy, in
which the muscles are waxy and semirigid, so a patient’s arms or legs remain in any position in
which they are placed.

Atypical features specifier

While most people with depression sleep less and lose their appetite, individuals with this
specifier consistently oversleep and overeat during their depression and therefore gain weight,
leading to a higher suicide attempts, and higher rate of comorbid disorders including alcohol
abuse

Peripartum onset specifier

Peri means “surrounding”, in this case the period of time just before and just after the birth. This
specifier can apply to both major depressive and manic episodes

Seasonal pattern specifier

These episodes must have occurred for at least two years with no evidence of nonseasonal major
depressive episodes occurring during that period of time. This condition is called seasonal
affective disorder (SAD).
This temporal specifier applies to recurrent major depressive disorder (and also to bipolar
disorders). It accompanies episodes that occur during certain seasons (for example, winter
depression)

Other Depressive Disorders

Premenstrual Dysphoric Disorder
Basically, clinicians identified a small group of women, from 2% to 5%, who suffered from
severe and sometimes incapacitating emotional reactions during the premenstrual period.

Disruptive Mood Dysregulation Disorder

Children and adolescents are being diagnosed with bipolar disorder at greatly increasing rates
over the last several years.
Children with chronic and severe irritability and difficulty regulating their emotions resulting in
frequent temper tantrums are at increased risk for additional depressive and anxiety disorders
rather than manic episodes.

In view of the distinctive features of this condition reviewed above, it seemed very important to
better describe these children up to 12 years of age as suffering from a diagnosis termed
disruptive mood dysregulation disorder rather than have them continue to be mistakenly
diagnosed with bipolar disorder or perhaps conduct disorder.

Bipolar Disorders
The criteria for bipolar I disorder are the same, except the individual experiences a full manic
episode.
Bipolar II disorder, in which major depressive episodes alternate with hypomanic episodes
rather than full manic episodes
The key identifying feature of bipolar disorders is the tendency of
manic episodes to alternate with major depressive episodes in an unending roller-coaster ride
from the peaks of elation to the depths of despair

The high during a manic state is so pleasurable that people may stop taking their medication
during periods of distress or discouragement to bring on a manic state again; this is a serious
challenge to professionals.

Cyclothymic disorder
A milder but more chronic version of bipolar disorder called cyclothymic disorder is similar in
many ways to persistent depressive disorder.
Cyclothymic disorder is a chronic alternation of mood elevation and depression that does not
reach the severity of manic or major depressive episodes.
This pattern must last for at least 2 years (1 year for children and adolescents) to meet the
criteria for the disorder. Individuals with cyclothymic disorder alternate between the kinds of
mild depressive symptoms.

Onset and Duration

The average age of onset for bipolar I disorder is from 15 to 18 and for bipolar II disorder from
19 and 22.
This is somewhat younger than the average age of onset for major depressive disorder, and
bipolar disorders begin more acutely; that is, they develop more suddenly.

Causes of Mood disorder

Biological Dimensions
The best estimates of genetic contributions to depression fall in the range of approximately 40%
for women but seem to be significantly less for men (around 20%). Genetic contributions to
bipolar disorder seem to be somewhat higher. This means that from 60% to 80% of the causes of
depression can be attributed to environmental factors.
In family studies, we look at the prevalence of a given disorder in the first-degree relatives of an
individual known to have the disorder (the proband)

Three separate genetic factors underlie the syndrome of major depression with one factor
associated with cognitive and psychomotor symptoms, a second factor associated with mood,
and a third factor with neurovegetative (melancholic) symptoms (Kendler et al., 2013)
Neurotransmitter
Research implicates low levels of serotonin in the causes of mood disorders, but only in relation
to other neurotransmitters, including norepinephrine and dopamine

Endocrine System
This hypothesis focuses on overactivity in the hypothalamic– pituitary–adrenocortical (HPA)
axis which produces stress hormones.
For example, hypothyroidism, or Cushing’s disease, which affects the adrenal cortex, leads to
excessive secretion of cortisol and often to depression (and anxiety)

Sleep and Circadian Rhythms

Most important, in people who are depressed, there is a significantly shorter period after falling
asleep before rapid eye movement (REM) sleep begins

Psychological DImensions
Stress and Depression

Stress and Bipolar Disorder

The relationship of stressful events to the onset of episodes in bipolar disorder is also strong.
First, typically negative stressful life events trigger depression, but a somewhat different, more
positive, set of stressful life events seems to trigger mania.
Second, stress seems to initially trigger mania and depression, but as the disorder progresses,
these episodes seem to develop a life of their own.
Third, some precipitants of manic episodes seem related to loss of sleep, as in the postpartum
period

Finally, although almost everyone who develops a mood disorder has experienced a significant
stressful event, most people who experience such events do not develop mood disorders.

Learned Helplessness
(1) internal, in that the individual attributes negative events to personal failings (“it is all my
fault”)
(2) stable, in that, even after a particular negative event passes, the attribution that “additional
bad things will always be my fault” remains
(3) global, in that the attributions extend across a variety of issues

Negative Cognitive Styles

Beck observed that all his depressed patients thought this way, and he began classifying the
types of “cognitive errors” that characterized this style
Arbitrary inference and overgeneralization.
Arbitrary inference is evident when a depressed individual emphasizes the negative rather than
the positive aspects of a situation
According to Beck, people who are depressed think like this all the time. They make cognitive
errors in thinking negatively about themselves, their immediate world, and their future, three
areas that together are called the depressive cognitive triad

Social and Cultural Dimensions

Marital Relations
Mood Disorders in Women
Social Support

Treatment
Medications
Antidepressants:
Four basic types of antidepressant medications are used to treat depressive disorders:
selective-serotonin reuptake inhibitors (SSRIs), mixed reuptake inhibitors, tricyclic
antidepressants, and monoamine oxidase (MAO) inhibitors. I
Lithium
ECT and Transcranial Magnetic Stimulation
CBT and Interpersonal Psychotherapy.

Integrative Model of Mood Disorders