Chapter 7Mood Disorders

Rick Grieve, Ph.D.Psy 440: Abnormal PsychologyWestern Kentucky University

Fall, 2003

Mood Disorders - OverviewCharacterized by gross deviations in mood– Mood – enduring states of feeling;

pervasive quality of an individual’s experience

Depression and mania, either singly or together, contributeMood disturbances are severe or prolonged and impair ability to function

Mood DisordersDSM-IV Depressive Disorders (Unipolar)– Major depressive disorder– Dysthymic disorder– Double depression– Seasonal Affective Disorder (SAD)– Postpartum Onset Depression

Types of DSM-IV Bipolar Disorders– Bipolar I disorder– Bipolar II disorder– Cyclothymic disorder

Major Depression: An OverviewMajor Depressive Episode: Overview and Defining Features– Extremely depressed mood state lasting at

least 2 weeks– Cognitive symptoms (e.g., feeling worthless,

indecisiveness)– Vegetative or somatic symptoms – Central to

the disorder.– Anhedonia – Loss of pleasure/interest in usual

activitiesMajor Depressive Disorder– Single episode – Highly unusual – Recurrent episodes – More common

Dysthymia: An OverviewOverview and Defining Features– Defined by persistently depressed mood that

continues for at least 2 years– Symptoms of depression are milder than major

depression– Symptoms can persist unchanged over long

periods (e.g., 20 years or more)Facts and Statistics– Late onset – Typically in the early 20s– Early onset – Before age 20, greater chronicity,

poorer prognosis

Overview and Defining Features– Person experiences major depressive

episodes and dysthymic disorder– Dysthymic disorder often develops first

Facts and Statistics– Quite common – Associated with severe psychopathology– Associated with a problematic future course

Double Depression: An Overview

Bipolar I Disorder: OverviewOverview and Defining Features– Alternations between full manic

episodes and depressive episodes-Manic episode: distinct period of time (1

wk. min.), abnormal & persistently elevated, expansive or irritable mood

Facts and Statistics– Average age on onset is 18 years, but

can begin in childhood– Tends to be chronic– Suicide is a common consequence

Bipolar II Disorder: OverviewOverview and Defining Features– Alternations between major depressive

episodes and hypomanic episodes– Hypomanic – same as mania but less severe (4

days vs 1 wk; doesn’t impair functioning)Facts and Statistics– Average age of onset is 22 years, but can

begin in childhood– Only 10 to 13% of cases progress to full

bipolar I disorder– Tends to be chronic

Cyclothymic Disorder: OverviewOverview and Defining Features– More chronic version of bipolar disorder– Manic and major depressive episodes are less

severe– Manic or depressive mood states persist for

long periods – Pattern must last for at least 2 years (1 year for

children and adolescents)Facts and Statistics– Average age of onset is about 12 or 14 years– Cyclothymia tends to be chronic and lifelong– Most are female– High risk for developing bipolar I or II disorder

Symptom Specifiers– Atypical – Oversleep, overeat, gain weight, and

are anxious– Melancholic – Severe somatic symptoms, more

severe depression– Chronic – Major depression only, lasting 2 years– Catatonic – Very serious condition, absence of

movement– Psychotic – Mood congruent/incongruent

hallucinations/delusions– Postpartum – Severe manic or depressive

episodes post childbirth

Additional Defining Criteria for Mood Disorders

Course Specifiers– Longitudinal course – Past history and

recovery from depression and/or mania– Rapid cycling pattern – Applies to

bipolar I and II disorder only– Seasonal pattern – Episodes are more

likely during a certain season

Additional Defining Criteria for Mood Disorders (cont.)

Lifetime Prevalence– About 7.8% of United States population

Sex Differences– Females to males - 2:1 up to age 65 then gender

imbalance disappears– Bipolar disorders are distributed equally between

males and femalesMood Disorders Are Similar in Children and Adults – but symptoms are developmentally linkedPrevalence Similar Across SubculturesMost Depressed Persons are Anxious, Not All Anxious Persons are Depressed

Mood Disorders: Additional Facts and Statistics

Family Studies – Mood disorder rates high in first degree relatives– Relatives of persons with bipolar are more likely to

have unipolar depressionTwin Studies

– Concordance rates for mood disorders high in identical (MZ) twins

– Severe mood disorders have a stronger genetic contribution

– Heritability rates are higher for females compared to males

– Vulnerability for unipolar or bipolar disorder appear to be inherited separately

Mood Disorders: Familial and Genetic Influences

Figure 7.3Mood disorders among twins

Mood Disorders: Neurobiological Influences

Neurotransmitters– Low levels of serotonin relative to other

neurotransmitters– Mood disorders are related to low levels of

serotonin– The permissive hypothesis and the regulation

of neurotransmittersEndocrine System– Elevated cortisol levels (stress hormone)

Sleep Disturbance– Hallmark of most mood disorders– Relation between depression and sleep

uncertain

Mood Disorders: Psychological Influences (Stress)

The Role of Stress in Mood Disorders– Stress is strongly related to mood

disorders• Frequent precipitator

– Return of diathesis-stress and reciprocal-gene environment models

Mood Disorders: Psychological Influences

Learned Helplessness - Seligman– Lack of perceived control over life events

contributes to viewing self as helpless to controlLearned Helplessness and a Depressive Attributional Style– Internal attributions – Negative outcomes are

one’s own fault– Stable attributions – Believing future negative

outcomes will be one’s fault– Global attribution – Believing negative events will

disrupt many life activities – All three domains contribute to a sense of

hopelessness

UnstableSpecific

I was caught off guard by the focus of this interview and therefore made a bad impression.

I think the interviewer woke up on the wrong side of the bed today, because he was simply nasty in the interview.

UnstableGlobal

I never do well at interviews. They probably rejected me because they had another candidate in mind all along.

StableSpecific

I never interview well when I do not have enough time to prepare.

That interviewer likes to ask impossible questions so that she can reject candidates.

StableGlobal

I am so incompetent that I will never get hired.

The job interview is such an unfair way to assess the competence of prospective employees.

TYPES OF ATTRIBUTIONSINTERNALINTERNAL EXTERNALEXTERNAL

Mood Disorders: Psychological Influences

Aaron T. Beck’s Cognitive Theory of Depression– Cognitive Triad:

• Think negatively about oneself• Think negatively about the world• Think negatively about the future

– Cognitive Errors/Distortions• All or Nothing Thinking,Overgeneralization,

Mental Filter, Disqualifying the Positive, Jumping to Conclusions, Magnification & Minimization, Emotional Reasoning, Should Statements, Labeling & Mislabeling, Personalization

Figure 7.5Beck’s cognitive triad for depression

Mood Disorders: Social and Cultural Dimensions

Marriage and Interpersonal Relationships– Marital dissatisfaction is strongly related to

depression – strongest for malesGender Imbalances– Females > Males - except bipolar disorders– Gender imbalance likely due to socialization (i.e.,

perceived uncontrollability)Social Support– Lack of social support predicts late onset

depression– High expressed emotion and/or family conflict

predicts relapse– Substantial social support predicts recovery

Integrative Model Mood Disorders

Shared Biological Vulnerability– Overactive neurobiological response to stress

Exposure to Stress– Activates hormones that affect neurotransmitter

systems– Turns on certain genes– Affects circadian rhythms– Activates dormant psychological vulnerabilities

(i.e., negative thinking)– Contributes to sense of uncontrollability– Fosters a sense of helplessness & hopelessness

Social/Interpersonal Relationships/Support are Moderators

Monoamine Oxidase (MAO)– Enzyme that breaks down

serotonin/norepinephrineMAO Inhibitors Block Monoamine OxidaseMAO Inhibitors Are Slightly More Effective Than TricyclicsMust Avoid Foods Containing Tyramine(e.g., beer, red wine, cheese)

Treatment of Mood Disorders:MAO Inhibitors

Treatment of Mood Disorders: Tricyclic Medications

Widely Used (e.g., Tofranil/Imipramine, Elavil/amitriptyline)Block Reuptake of Norepinephrine and Other NeurotransmittersTakes 2 to 8 Weeks for the Effects to be KnownNegative Side Effects Are CommonMay be Lethal in Excessive Doses

Treatment of Mood Disorders: (SSRIs)

Specifically Block Reuptake of Serotonin– Fluoxetine (Prozac) is the most popular

SSRISSRIs Pose No Unique Risk of Suicide or ViolenceNegative Side Effects Are Common

Table 7.7Efficacy of various antidepressant drugs for major depressive disorder

Treatment of Mood Disorders: Lithium

Lithium Is a Common Salt– Primary drug of choice for bipolar

disordersSide Effects May Be Severe– Dosage must be carefully monitored

Why Lithium Works Remains Unclear

Figure 7.10Percentage of patients with bipolar disorder recovered after standard

drug treatment or drug treatment plus family therapy

Treatment of Mood Disorders:Electroconvulsive Therapy (ECT)

ECT – Involves applying brief electrical current to the

brain– Results in temporary seizures – Usually 6 to 10 treatments (3 per wk) are

requiredECT Is Effective for Cases of Severe DepressionSide Effects Are Few and Include Short-Term Memory Loss, ConfusionUncertain Why ECT works and Relapse Is Common

Psychological Treatment of Mood Disorders

Cognitive Therapy– Addresses cognitive errors in thinking– Also includes behavioral components

Behavioral Activation– Involves helping depressed persons make

increased contact with reinforcing eventsInterpersonal Psychotherapy– Focuses on problematic interpersonal

relationships Outcomes with Psychological Treatments Are Comparable to Medications

Figure 7.9Data from Teasdale 2000 study on patients treated with severe

depression

SuicideSuicide

Suicide in KentuckySuicide in Kentucky

Suicide is the second leading cause of death among 15-34 year olds in KY. (1996-99 data)

State has a suicide rate of 12.8 per 100,000 which is higher than the national average of 11.45 per 100,000

Associated Press, 2002

The Nature of Suicide: Facts The Nature of Suicide: Facts and Statisticsand Statistics

Eighth Leading Cause of Death in the United StatesOverwhelmingly a White and Native American PhenomenonSuicide Rates Are Increasing, Particularly in the YoungGender Differences– Males are more successful at committing

suicide than females– Females attempt suicide more often than

males

Suicide: Risk FactorsSuicide in the Family Increases RiskLow Serotonin Levels Increase RiskA Psychological Disorder Increases RiskAlcohol Use and AbusePast Suicidal Behavior Increases Subsequent RiskExperience of a Shameful/Humiliating Stressor Increases RiskPublicity About Suicide and Media Coverage Increase RiskSuicide is viewed as the only solution – there is no other way out

SUICIDEAS A FUNCTION OF SEX AND AGE

0

100

200

300

400

500

600

700

Suicides(in millions)

5 to 15 15 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85+Age Range

MalesFemales

ReferencesAmerican Psychiatric Association. (2000), Diagnostic and statistical manual of mental disorders. (4th Ed. , Text Revision). Washington, DC: Author.Associated Press. (2002, September 16). State suicide rate higher than national average. The Paducah Sun, 5A.Barlow, D., & Durand, V. M. (2002). Abnormal psychology, An integrative approach (3rd. Ed.). Belmont, CA: Wadsworth.Jak, A. J., Shear, P. K., Rosenberg, H. L., DelBello, M. P., & Strakowski, S. M. (2002, August). Intellectual functioning in children with bipolar disorder. Poster presented at the annual convention of the American Psychological Association, Chicago, IL.Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. R., Hughes, M.,Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.Koplewicz, H. S. (2002). More than moody: Recognizing and treating adolescent depression. Brown University Child and Adolescent Behavior Letter, 18(12), 6-7.

References

Nairne, J. S. (1999). Psychology: The adaptive mind (2nd Ed.). Albany, NY: Brooks/Cole Publishing Company.Nevid, J., Rathus, S., & Greene, B. (2002). Abnormal psychology in a changing world. 5th edition. NJ: Prentice HallRaulin, M. L. (2003). Abnormal psychology. Boston, MA: Allyn & Bacon.Seligman, M. E. P. (1990). Learned optimism: How to change your mind and your life. New York: Pocket Books.Waters, M. (1999). Men and women handle negative situations differently, study says. APA Monitor, 30(9), 8.