AFFECTIVE DISORDERS

INTRODUCTION
Mood - a pervasive and sustained feeling tone that
is experienced internally and that influences a
person's behavior and perception of the world.

Affect - the external expression of mood.

Mood - Normal, elevated, or depressed.

Healthypersons experience a wide range of moods

and have an equally large repertoire of affective
expressions; they feel in control of their moods
and affects.
 INTRODUCTION: contd…
 Mood disorders – one of the most common illnesses of
humankind for the past 2500years.

 Depression - fourth in a list of the most urgent health

problems worldwide & by 2030 will over take all other
diseases to top the list (WHO).

 Afflict one out of five women and one out of ten men at
some time during their lives.

 Many persons with mood disorders are disabled, and rates

of suicide are high in young and, particularly, elderly men.

 Although depressive disorders are more common in women,

more men than women die of suicide.
 History
TheOld Testament story of King Saul describes a
depressive syndrome.

About400 BC, Hippocrates used the terms mania

and melancholia to describe mental disturbances.

Celsus - described melancholia (from Greek melan

[black] and chole [bile]) in his work De re medicina as
a depression caused by black bile.

In1899, Emil Kraepelin – described the manic-

depressive psychosis; also described a depression
that came to be known as involutional melancholia.
 Epidemiology: Depression
Incidence & prevalence: The highest lifetime
prevalence (almost 17 %) of any psychiatric disorder.

Sex: F:M>2.

Age:The mean age of onset - 40 years; with 50

percent of all patients having an onset between the
ages of 20 and 50.

Major depressive disorder can also begin in

childhood or in old age.
 Diagnosis: Depression
 Typical symptoms: The above symptoms must be:
1. Sadness - Depressed  Present for at least 2 weeks and

mood, represent a change from normal.

 Are not secondary to the effects

2. Anhedonia - Loss of of drug/alcohol misuse,
interest and enjoyment, medication, a medical disorder,
and or bereavement.

 May cause significant distress

3. Anergia - Reduced and/or impairment of social,
energy leading to occupational, or general
increased fatiguability functioning.
and diminished activity.
 Diagnosis
 Core symptoms:  Somatic symptoms:
1. Reduced concentration and 1. Loss of emotional reactivity.
attention.
2. Diurnal mood variation.
2. Reduced self-esteem and self-
confidence. 3. Anhedonia.
3. Ideas of guilt and unworthiness 4. Early morning wakening.
(even in a mild type of episode). 5. Psychomotor agitation or
4. Bleak and pessimistic views of retardation.
the future. 6. Loss of appetite and weight.
5. Ideas or acts of self-harm or
7. Loss of libido.
suicide.
6. Disturbed sleep.
7. Diminished appetite.
 Diagnosis

Psychotic symptoms/features:

1. Delusions e.g. poverty; personal inadequacy; guilt over

presumed misdeeds; responsibility for world events: accidents,
natural disasters, war; deserving of punishment; other nihilistic
delusions.

2. Hallucinations e.g. auditory: defamatory or accusatory voices,

cries for help or screaming; olfactory: bad smells such as
rotting food, faeces, decomposing flesh; visual: tormentors,
demons, the Devil, dead bodies, scenes of death or torture.

3. Catatonic symptoms or marked psychomotor retardation

(depressive stupor).
Severity of episode:

Mild: 2 typical symptoms & 2 other core symptoms.

Moderate: 2 typical symptoms & 3+ other core symptoms.

Severe: 3 typical symptoms & 4+ other core symptoms

 Recurrent Depressive Disorder
Characterized by repeated episodes (>2) of
depression:
1. As specified in depressive episode (mild, moderate, or
severe),
2. Without any history of independent episodes of mood
elevation and overactivity that fulfil the criteria of mania.
3. Still use if there is evidence of brief episodes of mild mood
elevation and overactivity which fulfil the criteria of
hypomania immediately after a depressive episode
(sometimes apparently precipitated by treatment of a
depression).
4. 1st episode later than age of BPAD; mean age-5th decade;
mean duration 6 months; complete recovery in most
episodes with at least 2 months asymptomatic period.
 Etiology: Psychosocial Factors
Life Events and Environmental Stress:
1. Stressful life events more often precede first, rather than
subsequent, episodes of mood disorders.

2. Disruption of normal social, marital, parental, or familial

relationships is correlated with high rates of depression, and
are risk factors to recurrence.

Personality Factors:
1. No single personality trait or type uniquely predisposes a
person to depression.

2. Persons with certain personality disorders - OCPD, histrionic,

and borderline may be at greater risk for depression than
persons with antisocial or paranoid personality disorder.
PSYCHODYNAMIC THEORIES
Abraham 1911
 Theory of Freud was expanded by Abraham and
involves 4 key points.

(1) disturbances in the infant-mother relationship

during the oral phase (the first 12 to 18 months of
life) predispose to subsequent vulnerability to
depression;
(2) depression can be linked to real or imagined object
loss;
(3) introjection of the departed object is a defense
mechanism invoked to deal with the distress
connected with the object loss; and
(4) because the lost object is regarded with a mixture
of love and hate, feelings of anger are directed
inward at the self.
Klein, 1934
 Paranoid- Schizoid position-
◦ infant projects highly destructive fantasies into its
mother and then becomes terrified of the mother as
a sadistic persecutor. That terrifying “bad” mother is
kept separate from the loving, nurturing “good”
mother through the defense mechanism of splitting.

 Depressive Position-
◦ In the course of normal development, according to
Klein, the positive and negative images of the mother
are integrated into a more ambivalent view.
Realization that bad and good mother are the same.
This recognition that one can hurt loved ones is the
depressive position.
 Depressed phase must be passed through to
develop confidence in mother- child relationship. If
not, it can result in depression.

 Depressed individuals- extraordinary concern that

loved good objects have been destroyed by their
greed and destructiveness.

 Self reproaches are directed against self and

internal impulses rather than to an introjected
object
Bibring, 1953
 loss of self esteem is of central importance

 could occur when narcissistic aspiration (desire to

be good or strong) were frustrated

 The three narcissistic aspirations- to be good and

loving, superior and strong, worthy and loved.

 Depression is an ego phenomena

 Depression is the result of awareness of discrepancy

between these ideals and reality.
Arieti
 Depressed people live for someone else, the
dominant other, who is generally spouse or parent.

 Realize that the person can never meet his

expectations→ helplessness

 inflexible perspective on how to live life and how

gratification or fulfillment can be obtained
Karen Horney
 Basic evil is a lack of genuine warmth and affection for the
child. The parent is not so much abusive as indifferent, and
unaware of the effect of his/her behavior on the child.

 The first reaction is hostility

 But, as the child needs the parent, and hostility threatens

that bond, hostility is repressed.

 The repression of basic hostility results in basic anxiety:

feeling lonely and helpless in a hostile world.

 Despised real self (im a bad person) and striving for the
ideal self (people would love you if you were kinder, more
athletic, more outgoing, more unselfish),
 This is a neurotic solution to the conflict -as no
one can be such a person.

 A person can be driven by these demands of the

ideal self.

 As these demands are impossible, the attempts to

satisfy the "shoulds" is bound to fail.

 Thus self hate and feelings of false guilt increase,

as well as despair and helplessness.
Adler
 Always present as motivating force in behavior
 Source of all human striving
 Growth results from compensation: attempts to
overcome inferior feelings
 Inability to overcome inferiority feelings: helpless,
poor self-opinion
 3 Sources:
◦ Organic: Physical deficits
◦ Spoiling: Immediate gratification, little regard for needs of
others
◦ Neglect: Lack love, security, develop feelings of
worthlessness
Inadequate Parenting
 Klein (1935) : depression prone individual as one
who has been unable to work through the depressive
position because her or his mother was ineffective in
providing consistent nurturance.
 Jacobson(1971) : He attributed a predisposition to

depression to the self devaluation caused by

excessive negative experience with parental figures.
 Bonime(1966): postulated that an individual learns

and purposefully uses depressive symptoms in an

attempt to elicit from others what her or his
exploitative parents failed to provide : love and
nurturance.
Object loss
 Akiskal (1979) & Heinicke (1973): Parental death
during early developmental year has been
associated with severity of adult depression, a
higher frequency of suicide attempts, an early
onset of unipolar depression.
 Childhood object loss may be indirectly linked

with propensity toward depression by predisposing

individual to the development of aversive character
logical traits and resultant interpersonal friction,
which in turn, may generate life situations that
directly precipitate depression.
ATTACHMENT THEORIES
According to attachment theory, attachment in infants
is primarily a process of proximity seeking to an
identified attachment figure in situations of perceived
distress or alarm for the purpose of survival. Infants
become attached to adults who are sensitive and
responsive insocial interactions with the infant, and
who remain as consistent caregivers for some months
during the period from about 6 months to two years
of age. in Bowlby's approach, the human infant is
considered to have a need for a secure relationship
with adult caregivers, without which normal social
and emotional development will not occur.
According to Bowlby:

 During times of stress people turn to actual

attachment figures or their internalized
representations.

 Individual differences in attachment depends on

availability, responsiveness and supportiveness of
attachment figures in times of need.

 Attachment security increases self confidence and

confidence in attachment figure

 fearing abandonment, persons with an insecure style

of attachment can become suspicious and hostile,
react when there is psychological distance resulting in
dysphoria
 Insecurity leads to hyperactivation or deactivation
of attachment system(Shaver, Mikulincer, 2005).

 Insecure attachment→ distort understanding and

evaluations of social relations → in difficulty
maintaining satisfying relationships, impaired
social system → depression (Anderson et al., 1995;
Ghammen, 1999)

 Insecure attachment → increased vulnerability

→poor affect regulation → depression(Solman,
Gilbert, Hasey, 2002).
 Bartholomew and Horowitz (1991)- four
attachment styles based on Ainsworth’s three-fold
taxonomy .

 Based on models of self and models of others

 Attachment styles-
◦ Secure
◦ Preoccupied
◦ Fearful avoidant
◦ Dismissing avoidant
 Securely attached have high relational satisfaction and
decreased severity of depressive symptoms

 Preoccupied attachment have low relational satisfaction and

increased depressive symptoms.

 Carnelley, Pietromonaco and Jaffe (1994)- depressed college

women evidenced greater preoccupation and fearful
avoidance in romantic relationships than did non depressed
women

 Overall, the results reveal that the long-term course of

depression of the fearfully attached primary care patients
compared with the securely attached group is unfavorable
( Conradi, George, 2009).
BEHAVIOURAL AND COGNITIVE
Behavioural and Interpersonal model
 Behavioral Model of Depression
 Lewinsohn’s (1974): depression as due to low
rate of response- contingent positive
reinforcement. When individual fail to receive
positive reinforcement that is dependent on the
execution of some behavioral response (eg,
initiating a conversation), those behavioral
responses become extinguished. This
subsequent loss of response-based positive
reinforcement deprives the individual of
pleasure and lead to feelings of dysphoria.
 According to Lewinsohn, depressive
symptoms are then reinforced by a social
environment that responded with sympathy,
interest, and concern, thus rewarding and
maintaining the depressive person’s low rate
of responding and display of dysphoria.
Lewinsohn’s Revised Integrative
Model of Depression
 Revised theory, depression onset is caused by one or
more stressful life events occurring in an individual who
possesses inadequate coping skills or other such
vulnerabilities. In these vulnerable individuals, events
that disrupt meaningful but largely automatic behavior
such as personal relationships and job tasks lead to an
initial negative emotional response. Both life events
disruptions and the experience of dysphoric mood lead
to a decrease in response- contingent reinforcement.
Several cognitive and behavioral consequences the
ensue. These cognitive and behavioral consequences
combine to spiral the individual in to yet a deeper state
o depression.
Albert Ellis
 A-B-C model states that it normally is not merely an A, adversity
(or activating event) that contributes to disturbed and dysfunctional
emotional and behavioral Cs, consequences, but also what people
B, believe about the A, adversity. A, adversity can be either an
external situation or a thought or other kind of internal event, and
it can refer to an event in the past, present, or future
 REBT claims that people to a large degree consciously and
unconsciously construct emotional difficulties such as self-blame,
self-pity, clinical anger, hurt, guilt, shame, depression and anxiety,
and behaviors and behavior tendencies like procrastination, over-
compulsiveness, avoidance, addiction and withdrawal by the means
of their irrational and self-defeating thinking, emoting and
behaving
Cognitive Model

 Beck theory of Depression (1967-87) :

nonendogenous depression results from the
activation of depressive self- schema. Self
schema are described as organized
representations of an individual’s prior
experiences, particularly early childhood
experiences. However, schemas have tended
to be operationali zed as tacit beliefs. In the
depression- vulnerable individual, negative
beliefs are primitive , excessive and rigid.
Early experience

Formulation of dysfunction

Critical incidents

beliefs activated

negative automatic thoughts

depression
Information processing theory
 Ingram’s (1984) : cognitive – affective networks:
These network consist of primitive emotion
nodes that possess link to affective features of
the respective emotion and to similarly
valenced cognitive- associative networks.
 In depression, an appraisal of loss results in the

activation of the sadness emotion node. The

experience of sadness results in a process of
spreading activation that occurs throughout the
associate linkages that make up the entire
interconnected affective-cognitive network.
Information processing theory
 Ingram’s (1984) : cognitive – affective networks:
These network consist of primitive emotion
nodes that possess link to affective features of
the respective emotion and to similarly
valenced cognitive- associative networks.
 In depression, an appraisal of loss results in the

activation of the sadness emotion node. The

experience of sadness results in a process of
spreading activation that occurs throughout the
associate linkages that make up the entire
interconnected affective-cognitive network.
Information processing theory
 Ingram’s (1984) : cognitive – affective networks:
These network consist of primitive emotion
nodes that possess link to affective features of
the respective emotion and to similarly
valenced cognitive- associative networks.
 In depression, an appraisal of loss results in the

activation of the sadness emotion node. The

experience of sadness results in a process of
spreading activation that occurs throughout the
associate linkages that make up the entire
interconnected affective-cognitive network.
Learned Helplessness Model
Seligman (1975): His model was based on an
observation of apparent similarity between
the responses of depressed people and the
behaviour of laboratory dogs who exhibited a
lack of escape behaviour after they had been
unable to control intermittent electrical shocks
to their feet. Seligman’s theory focused on
depressed person’s expectations that they are
helpless to control aversive outcomes, and
the ensuing behavior that is consistent with
these expectations.
Abramson et al.(1978)
 Reformulate theory of learned helplessness
exposed to series of noncontigent
outcome

perceive noncontigency

Attributional style ( failure –

internal & success –external)

Depression
Abramson et al.(1989)
 New version of attributional model-
hopelessness theory of depression.
 They have proposed type of depression as a

specific subtype that they refer to as

hopelessness depression. The cause of this
subtype is the expectation that desired
outcome are unlikely to occur or, conversely,
that aversive outcomes are likely and that no
response will alter this likelihood.
Humanistic existential theory
 Hoag & Deffenbacher, 1986 : The humanistic-
existential theory of interpersonal therapy
states that depression results from poor self-
concept and low self-esteem. It is a function
of interpersonal process groups to create an
environment which clients may experience
themselves fully and develop positive self-
esteem.. Acceptance by others is thought to
promote increased self-acceptance and self-
esteem which as a result will reduce
depression .
LIFE EVENTS
 It is difficult to understand life events acting as
causal factors due to various reasons.

 life events have to be separated as those occurring

due to the illness and those resulting in the illness.

 Two types- Independent life events and dependent

life events.

 Kendler et al., 2000- Relationship between

independent life events and depression much
stronger in first episode depression
Holmes and Rahe, 1967
 clustering of events in an individual’s life and reaching
a sufficient magnitude

 created the Social Readjustment rating scale

 Life Change Units

 Criticisms- (Huggens, 1974)- many events could occur

as a result of illness rather than precede it. (Brown,
1974)- There is considerable variation in LCU ratings
from individuals with different social and cultural
backgrounds.
Brown & Harris, 1978
 Chronic difficulties that are threatening and
persistent (more than 2 years) are independently
associated with a greater risk of depression.

 life events can act as a last straw for these people.

 depressed individuals report more independent

undesirable life events 6 months prior to episode,
with only suicidal patients having more negative
life events preceding.
 Paykel et al., 1969- Bereavement also shows a high
rate of association with depression. As compared
to controls, loss of immediate family member is 4
times more common in depressed, loss of child
reported only in the depressed group.

 Many studies (Smith & Weissman, 1992; Banks &

Jackson, 1982, Jenkins et al., 1982) found that risk
of depression in unemployed people is about three
times higher and is also associated with greater
severity
 Beck et al. developed the Sociotropy-Autonomy Scale (SAS)
which distinguished between people who are sociotropic
and need affiliation, and those who are autonomous and
need achievement. Patients who experience stress
consistent with their SAS type reported more depressive
symptoms.

 Brown (1993) showed that loss provoked depression,

danger provoked anxiety, and a combination of the two
provoked comorbid anxiety and depression. Also, a
negative coping pattern of inferred denial, self-blame and
pessimism increased depression risk. Depressed people
may also create more negative life events than those not
prone to depression, particularly in the interpersonal
domain, which may contribute to the chronic nature of the
illness
 Russo et al., 1995- Losses that involve a sense of
humiliation care giving to a spouse with
debilitating disease like Alzheimer's can be
associated with onset of major depression.

 Studies such as by Brown (1988, 1993) showed that

in women with chronic depression, positive life
events which promised some hope (‘Fresh start
events’) were linked with recovery or improvement.
DIATHESES STRESS MODEL
 According to the Diathesis-Stress theory, a
person may suffer from some diathesis, which
is a vulnerability to developing depression later.

 Different diatheses-
◦ Genetic risk
◦ Personality factors
◦ negative ways of thinking, wrong beliefs and
pessimistic thought patterns
◦ early parental loss
◦ Harsh parenting
◦ Abuse
◦ No close intimate relationship
Etiology: Biological Factors
 Biogenic Amines.

 Endocrine changes.

 Changes in sleep pattern.

 Genetic factors.
Mood Disorders - Neurochemical
 Abnormality in neurochemicals
 Too much or too little of some chemicals e.g.

serotonin affects the functioning of the brain

– this might have an effect on emotion
regulation
Mood Disorders - Neurochemical
 Noradrenanaline (NA)
◦ Too little leads to depression, too much to mania
(catecholamine hypothesis)
 Serotonin (5-HT)
◦ Regulates NA activity, so too little allows
abnormal fluctuations in NA (permissive amine
hypothesis)
 Dopamine (DA)
◦ Involved in reinforcement, so too little results in
anhedonia (dopamine hypothesis)
Observations about depression
in women
 Women are twice as likely to develop major
depression as men
 Women are also more likely to develop

dysthymic disorder (1.5-3 times) & seasonal

affective disorder(4 times)
 Until recently, gender differences in

depressive disorders have received little

attention
 Both the psychology and biology of women

have become areas of interest

Depression & hormones
 Increased rates of depression in females
begin at puberty
 Concentrations of gonadal hormones are

stable and low in prepubertal children

 After menarche, the female brain is exposed

to monthly surges of estrogen and

progesterone until menopause
 Across the life cycle, mood symptoms often

correlate with hormonal changes

◦ (Kessler et al 1993)
Correlation of hormonal & mood
changes in women
 Estrogen & progesterone drop prior to
menses
 Estrogen & progesterone levels drop

precipitiously after childbirth

 Estrogen & progesterone levels drop (more

gradually) at menopause
 Estrogen withdrawal theory (Schmidt &
Rubinow 1994)
Depression During
Pregnancy
 Pregnancy was previously believed to be
protective against depression, but 10-15%
women have depressive symptoms during
pregnancy
 Prevalence is higher among women with

mood disorder history

 No RCTs of psychotropics in pregnancy;

evidence largely retrospective, data

inadequate
Depression & Menopause
 Previous concept of Involutional Melancholia
(increased depression at menopause) has
been disputed
 Current evidence does suggest increased risk

for depression during perimenopause for

women with past history of depression
Mood Disorders – Genetic
 Zubenko et al (2001)
◦ Family history – 50% of FD relatives, 25% of SD
relatives also had mood disorder
◦ Relatives had increased risk of suicide
◦ MZ 46%, DZ 20%
Mood Disorders – Genetic
 Depression tends to run in families
 The closer the relationship with a sufferer,

the more likely a person will have a mood

disorder
 Genetic evidence is strongest for most severe

forms of the disorder

 Concordance rates also indicate a substantial

environmental contribution
BIPOLAR AFFECTIVE DISORDERS
• Manic-Depressive illness

• Symptoms: severe; involves dramatic shifts in mood from the

highs of mania to the lows of major depression

• Cycles of bipolar disorder last for days, weeks, or months.

• BPAD: intense and disruptive to everyday functioning,

affecting energy, activity levels, judgment, and behavior

• First manic or depressive episode of bipolar disorder usually

occurs in the teenage years or early adulthood.
 MANIC episode
Abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week (or for 3 days, if hospitalization is
necessary).

Three (or more) of the following symptoms have persisted (four if

the mood is only irritable):
1. inflated self-esteem

2. decreased need for sleep

3. pressured speech

4. flight of ideas or racing thoughts

5. distractibility

6. increase in goal-directed activity

7. increased involvement in pleasurable activities with a high

potential for negative consequences.
BPAD: Mixed Episode
 Symptoms of a Manic Episode and a Major Depressive
Episode nearly every day during at least a 1-week period;
cause marked impairment.

BPAD: Hypomanic Episode

 Elevated,expansive, or irritable mood, lasting at least 4
days, that is clearly different from the usual non-depressed
mood.

 Three (or more) of the symptoms of a manic episode have

persisted (four if the mood is only irritable).

 No psychotic symptoms; usually last several weeks.

 Does not cause marked impairment in social or occupational

functioning, and does not necessitate hospitalization.
 BPAD: Subtypes
BAPD - I
At least one manic or mixed episode (lasting for at least
a week) within his or her lifetime.
A depressive episode is not necessarily a diagnostic

criteria

BPAD - II
At least one episode of hypomania

at least one episode of depression

BPAD Rapid Cycling – 4 or more episodes in a year

BPAD - NOS
 Comorbidities: BPAD
Substance Abuse – At least 61% .

Effect– More mixed and rapid cycling, poorer

response to Lithium, slower time to recovery, and
more lifetime hospitalizations

Personality Disorder (PD): Narcissistic & Borderline

Anxiety disorders: Phobia, GAD, OCD, Panic Disorder

 Persistent Affective Disorders
Cyclothymia
A persistent instability of mood, involving numerous
periods of mild depression and mild elation.
 This instability usually develops early in adult life and

pursues a chronic course, although at times the mood

may be normal and stable for months at a time.
 The mood swings are usually perceived by the individual

as being unrelated to life events.

 The diagnosis is difficult to establish without a prolonged

period of observation or an unusually good account of the

individual's past behaviour.
 Frequently fails to come to medical attention.
 Persistent Affective Disorders
Dysthymia
 Verylong-standing depression of mood which is never, or only
very rarely, severe enough to fulfil the criteria for recurrent
depressive disorder, mild or moderate severity.

 It usually begins early in adult life,

 Lasts for at least several years, sometimes indefinitely.

 Lateonset dysthymia: often the aftermath of a discrete

depressive episode and associated with bereavement or other
obvious stress.
 Initial assessment

 History: Key areas of enquiry include:

1. Any clear psychosocial precipitants,

2. Current social situation,
3. Use of drugs / alcohol,
4. Past history of previous mood symptoms (including subclinical periods of
low or elevated mood, previous Deliberate Self Harm (DSH) / suicide
attempts),
5. Previous effective treatments,
6. Premorbid personality,
7. Family history of mood disorder,
8. Physical illnesses,
9. Current medication.
 Initial assessment

Mental Status Examination :

 Focused enquiry about subjective mood symptoms, somatic

symptoms, psychotic symptoms, symptoms of anxiety,
thoughts of suicide.

 Objectiveassessment of psychomotor retardation/agitation,

evidence of DSH, cognitive functioning (MMSE).

.