CHAPTER FIVE

1
CHAPTER FIVE

• Mood Disorders

2
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

3
Types of Mood Disorders
Unipolar Mood Disorders Bipolar Mood Disorders (previously manic-depression)
Person experiences only episodes of depression Person experiences episodes of mania and in most cases episodes of depression
Major Depressive Disorder Dysthymia Bipolar I disorder Bipolar II disorder Cyclothymia
4
Episodic vs. Continuous

• Mood disorders should be thought of as episodic

5
Chart MDD Bipolar Disorder
6
Types of Mood Disorders
Unipolar Mood Disorders Bipolar Mood Disorders (previously manic-depression)
Person experiences only episodes of depression Person experiences episodes of mania and in most cases episodes of depression
Major Depressive Disorder (MDD) Dysthymia Bipolar I disorder Bipolar II disorder Cyclothymia
7
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

8
Depressed Mood vs. Major Depressive Disorder
(MDD)

• Major Depressive Disorder is more than just
  feeling depressed
• Sadness alone is insufficient and unnecessary for
  a diagnosis
• Severity, intensity, duration and impairment

9
Symptoms ofMajor Depressive Episode

• Depressed/dysphoric mood
• Anhedonia loss of interest or pleasure
• Weight loss/gain or appetite increase/decrease
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or inappropriate guilt
• Diminished ability to concentrate or make
  decisions
• Suicidal ideation, plan or attempt

10
Criteria for Unipolar Mood Disorder
Major depressive disorder
At least 1 major depressive episode (lasting at least 2 weeks)
No manic or hypomanic episodes
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Symptoms of Dysthymia

• Depressed mood for most of
• the day on more days than not
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

12
Chart Dysthymia
13
Criteria for Unipolar Mood Disorder
Major Depressive Disorder Dysthymia
At least 1 major depressive episode (lasting at least 2 weeks) Depressive symptoms for at least 2 years
No manic or hypomanic episodes No manic or hypomanic episodes
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Clinical Impairment in MDD and Dysthymia

• Occupational / Academic
• Social
• Other important domains of life

15
Exclusion Criteria

• Not due to a general medical condition (e.g.,
  thyroid condition)
• Not due to substance use (e.g., alcohol)
• Not bereavement normal grief

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Depression Interpersonal Relationships

• Special Topic

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Interpersonal Relationships Depression Coyne,
1976

• Questions
• Do people respond differently to depressed
  patients?
• Do depressed people induce depression and
  hostility in others? Are they rejected socially?
• Method
• Students spoke on the phone with either a
  depressed outpatient, non-depressed outpatient,
  or non-psychiatric control
• Completed questionnaires on mood, perceptions,
  and willingness to interact

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Interpersonal Relationships Depression Coyne,
1976

• Results
• Participants were more
• depressed, anxious hostile after interacting
  with depressed patients than with any other
  group.
• rejecting of the depressed patients than they
  were of any other group.
• likely to reject opportunities for future
  interaction if their own mood was depressed
  following the conversation.

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Interpersonal Relationships Depression
Marriage Depression

• People who are separated or divorced are the most
  likely to be depressed.
• Depression is also higher in those who are
  never-married than those who are married which
  may suggest the importance of social support.
• But, if you are in an unhappy marriage that may
  cause depression.
• Depression can also lead to marital problems
• NOTE potentially vicious feedback cycle

20
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

21
Symptoms of Manic Hypomanic Episodes

• Elevated mood
• Irritable/angry mood
• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative than usual or pressure
• to keep talking
• Flight of ideas or racing thoughts
• Distractibility
• Increase in goal-directed activity or psychomotor
  agitation
• Excessive involvement in pleasurable activities
  that have a high potential for painful
  consequences

22
Manic vs. Hypomanic Episode
Manic Episode Hypomanic Episode
Symptoms Same Same
Duration 1 week 4 days
Severity Must interfere with social or occupational functioning Must be noticeable to others, but not severe enough to impair functioning or to require hospitalization
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Criteria for Bipolar Mood Disorder
Bipolar I Disorder Bipolar II Disorder Cyclothymia
Mania At least one manic episode At least one hypomanic episode At least 2 years of hypomanic symptoms (no manic episodes)
Depression Not required, but could have a major depressive episode At least one major depressive episode At least 2 years of depressive symptoms (no major depressive episodes)
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Charts Bipolar I Disorder
25
ChartsBipolar II Disorder Cyclothymia
26
Chart Bipolar I Disorder

• As is the case with unipolar mood disorders,
  there must be clinical impairment or distress
• The symptoms cannot be
• Due to a medical condition
• Due to substance use

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Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

28
Mood Disorders with Psychotic Features
Major Depressive Episode Mood-congruent Major Depressive Episode Mood incongruent Manic Episode Mood-congruent Manic Episode Mood-incongruent
Delusion One day I will be punished for being such a bad person. Aliens are putting thoughts into my head. I am the smartest person o n earth and I will rule the world. Someone is trying to poison me.
Hallucination Voices tell me that I am a bad person. I hear sleigh bells ringing. Voices tell me how great I am. I see purple monkeys.
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Mood Disorders with Postpartum Onset

• Denotes a major depressive or manic episode
  beginning within 4 weeks after childbirth
• The available evidence suggests that it is not
  caused primarily, if at all, by hormones
• Most women do not get this out of the blue most
  of them have had prior depressive episodes.

30
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

31
Epidemiology Culture

• Cross-cultural differences
• Vocabulary and social differences
• make this difficult to investigate.
• Symptoms are interpreted differently and emotions
  have different expressions.
• Most studies indicate, however, that
• clinical depression is a universal phenomenon
  (although symptoms may vary considerably from
  culture to culture).

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Lifetime Prevalence of Major Depressive Manic
Episodes by Race
33
Epidemiology of Mood Disorders by Gender
Lifetime Prevalence
34
Prevalence of MDD Employment Income
35
Prevalence of MDD by Age
36
Epidemiology Age

• Researchers previously thought
• that depression occurred more
• frequently in the elderly.
• Mood disorders are less common
• among elderly people than they are
• among younger adults.
• Certain subgroups of the elderly population,
  however, may have high incidence of mood
  disorders (e.g., those about to enter residential
  care).
• Birth cohort trend Those born after WWII are
  more likely to develop mood disorders and have an
  earlier age of onset than people from previous
  generations.

37
Chart What is Cohort Effect?
38
Chart What is Cohort Effect?
39
Comorbidity Definition

• Comorbidity
• the manifestation of more than one disorder
  simultaneously
• Of those with mental disorders, 25 have two or
  more disorders.

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Comorbidity Major Depressive Disorder
DISORDERS DATA FROM NCS
Social phobia 27.1
Alcohol dependence 23.5
PTSD 19.5
Generalized Anxiety Disorder 17.2
Conduct disorder 15.2
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Course Outcome Major Depressive Disorder

• Average age of onset is 23 for males and 25 for
  females.
• Minimum duration of at least 2 weeks.
• Most people who have major depression will have
  at least 2 depressive episodes.
• MDD is frequently a chronic and recurrent
  condition.
• Half recover from their episode of major
  depression within 6 months 40 of people who
  recover relapse within a year.

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Course Outcome Bipolar Disorders

• Onset is usually between ages 18-20.
• Average duration of manic episode is 2-3 months
  bipolar II patients tend to have shorter and less
  severe episodes.
• Long-term course
• Most will have more than one episode
• Length of intervals between episodes varies and
  is difficult to predict
• 40-50 of patients are able to achieve a
  sustained recovery rapid cycling patients have a
  worse prognosis

43
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

44
Etiology Social Factors Depression

• Loss and depression
• significant others
• social role
• self-esteem
• Relationships and depression
• Social support (or lack of) and depression

45
Etiology Mood Disorders Life Events

• Stressful life events and mood disorders
• causality can go both ways
• Severely stressful life often precede the
  development of mood disorders and relapse
• Stressful life events may be generated by those
  with mood disorders

46
Etiology Learned Helplessness TheorySeligman
(1965)

• Learned Helplessness
• passive behavior in the face of
• negative situations
• Uncontrollable negative events
• ? learned helplessness
• Learned helplessness
• ? depression
• But model does not explain why some become
  depressed and others do not!

47
Reformulated Learned Helplessness Theory
(Abramson, Seligman, Teasdale, 1978)

• Uncontrollable event
• Belief that what happens is uncontrollable
• Depressogenic Attributional Style
• Attribute negative event to stable, global, and
  internal factors
• Expectation of future uncontrollable events
• Symptoms of helplessness and depression

48
Cognitive Responses to Failure Examples

• Arbitrary Inference (Jumping to Conclusions)
• conclusions drawn in the absence of sufficient
  evidence or of any evidence at all
• Example 1
• You are romantically attracted to someone in your
  class. You plan to approach him/her after class
  to ask them out. Youre sitting in front of the
  class and he/she is sitting in back. As soon as
  class is over they rush out of the room before
  you get a chance to approach them. You conclude
  the person dislikes you and was trying to avoid
  you.

49
Cognitive Responses to Failure Examples
Selective Magnification and Minimization
exaggerations in evaluating performance Example
2 A person hoping to get an A instead gets an A-
and interprets this outcome as total failure
(magnification exaggerating the
negative) Example 3 A person makes the deans
list but believes it is really not a big deal and
that it does not mean she is smart
(minimization discounting the positive)
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Why is this important?

• These biases act as a lens through which people
  view and interpret the world
• A schema is an expectation for how things work in
  the world
• A depressive schema is a risk factor to
  depression in the face of failure events
• Becks Cognitive Triad Negative thoughts about
  the self, the world, and the future

51
Etiology Biological Factors

• Genetics
• Family studies and twin studies suggest a mild
  genetic influence for unipolar depression and a
  stronger one for bipolar disorder
• Unipolar depression concordance rates
• MZ .54, DZ .24
• Bipolar disorder concordance rates
• MZ .43, DZ .06
• No strong evidence of a single gene responsible
  for mood disorders.

52
Etiology Stress-Gene Interactions

• We know that stress leads to depression in some
  people, but not others.
• Why?
• Could genes have something to do with it?
• Behavioral genetics suggest that they do, but we
  would like to be able to support this with actual
  genes!

53
Etiology Stress-Gene Interactions(Caspi et al.,
2003)

• Prospective-longitudinal study with a
  representative sample of 1037 people
• Level of genetic risk based on the serotonin
  transporter gene
• 2 short alleles (ss) highest genetic
  vulnerability (low serotonin level)
• 2 long alleles (SS) lowest genetic
  vulnerability (high serotonin level)
• Serotonin is a neurotransmitter that is
  associated with depression. Simply, more
  serotoninless depression

54
Etiology Stress-Gene Interactions(Caspi et al.,
2003)

• The effect of life events on depression symptoms
  at age 26 was significantly stronger among those
  with the genetic vulnerability
• Stressful life events predicted major depressive
  disorder as well as suicidal ideation/attempts
  only among those with the genetic vulnerability

55
Etiology Stress-Gene Interaction(Caspi et al.,
2003)
ss sS
SS
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Etiology Neurotransmitters

• Early theories emphasizing the inability to
  utilize serotonin and norepinephrine were
  probably overly simplistic.
• Recent theories focus more on the interaction
  between neurotransmitters and the sensitivity and
  density of postsynaptic receptors.
• Current theories emphasize the interaction
  between neurotransmitter systems including
  serotonin, norepinephrine, dopamine and
  neuropeptides.

57
Mood Disorders

• Basic definitions
• Unipolar mood disorders
• Special topic Depression interpersonal
  relationships
• Bipolar mood disorders
• Subtypes
• Epidemiology
• Etiology
• Treatment

58
Interventions for Unipolar DisordersCognitive
Therapy

• Becks approach focuses on
• recognizing, challenging and overcoming cognitive
  distortions and errors in logic
• replacing self-defeating cognitions with more
  rational self-statements.

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Cognitive Distortions

• Event ? Cognitive Distortions ? Emotions
• Event
• Getting a B on a quiz
• Thought (Cognitive Distortion)
• Im a failure (labeling)
• Im going to fail the class (all-or-nothing
  thinking)
• Emotion
• sadness, disappointment, etc.
• Thought (Cognitive Restructuring)
• I have never failed a class before (base
  rate)
• Emotion
• decrease in sadness

60
Interventions for Unipolar DisordersInterpersona
l Therapy (IPT)

• Focuses on
• interpersonal factors in current relationships
  that cause and maintain depression building
• communication and problem-solving skills
• Four Areas
• Grief
• Role dispute
• Role transition
• Interpersonal deficits

61
Interventions for Unipolar Depression
Effectiveness

• Effectiveness of psychotherapy vs.
  antidepressants the Treatment of Depression
  Collaborative Research Program (TDCRP) findings
• Cognitive, interpersonal therapy, and an
  antidepressant (imiprimine) were all superior to
  placebo plus clinical management condition for a
  16-week treatment.
• No significant differences emerged between the
  effectiveness of the three treatment conditions.

62
Effectiveness continued TDCRP

• Drug treatment led to a more rapid improvement
  initially, although effects were equivalent over
  the 16 weeks.
• Type of improvement was independent of type of
  treatment (e.g., medication changed cognitions
  just as much as cognitive therapy).

63
Components of Psychotherapy for Bipolar Disorder

• Medication compliance
• Psychoeducation family or individual
• Regulating sleep, work and socialization
• Identifying and reducing triggers such as stress,
  interpersonal conflict and substance use
• Symptom monitoring and relapse prevention

64
Suicide Not Covered in Class

• But you do need to know the chapter, especially
• Rates of suicide by age and gender
• Why people commit suicide
• The effectiveness of various intervention
  programs
• You do not need to know Durkheims typology

65
Optional Slides

• Mood Disorders

66
Clarifications

• Remission
• Partial 2 months with some symptoms but not
  meeting criteria
• Full 2 months without any symptoms
• For episodes to be considered separate, a
  remission period of at least 2 months has to
  occur.
• Specifier
• Chronic meeting criteria for MDE for 2 years
• Single episode Just one episode of depression in
  a lifetime
• Recurrent two or more episodes in a lifetime

67
Recurrent

• Two or more episodes

68
Chronic
69
Sociotropy Autonomy (Personality Traits
Associated with Depression)

• Autonomy-Achievement
• Excessive concern for independence and a lack of
  concern for others highly achievement oriented
  in areas such as work/school
• Sociotropy
• Excessive investment in interpersonal
  relationships
• Personality-Event Congruence Hypothesis
• People become depressed when experience the type
  of stress that matches your personality trait

70
Research Finding Sociotrophy Autonomy

• Studies have consistently found that sociotropy
  leads to depression when stressful life events
  are interpersonal in nature
• Sociotropy interacts with interpersonal events to
  predict the severity of bipolar symptoms
• There is inconsistent evidence about whether or
  not autonomy leads to depression when stressful
  life events are related to achievement

71
Etiology The Hopelessness Theory of Depression

• Negative events can lead to hopelessness when
• Negative events attributed to global, stable and
  internal causes
• Negative consequences of the event viewed as
  important, not remediable, unlikely to change,
  and as affecting many areas of her life
• A person draws inferences about her/his own
  worth, abilities, personality, etc.
• This is a Diathesis-Stress theory of depression

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Seeking Help

• Only about 30 of those diagnosed as suffering
  from a mood disorder made contact with a mental
  health professional within 6 months prior to the
  diagnostic interview.
• Alternatives General practitioners, religious
  leaders, and books.
• Social Stigma
• Problems with access information, resources

73
Intervention for Unipolar Disorders Behavioral
Activation

• Highlight the connection between the context and
  the impact of behaviors on mood
• Increase pleasant activities
• Increase mastery activities
• Reduce avoidance behaviors

74
What are the two key symptoms that are present
in dysthymia but not major depression?

1. anhedonia and irritable mood
2. feelings of hopelessness and low self-esteem
3. increase in goal oriented activities and flight
   of ideas
4. depressed mood and suicidal ideation

75
When a persons symptoms are diminished or
improved, the disorder is considered to be in

1. relapse
2. remission
3. recovery
4. recycle

76
Rates of successful suicide are highest among

1. women
2. teenagers
3. the elderly
4. college students

77
What are the two key symptoms that are present
in dysthymia but not major depression?

1. anhedonia and irritable mood
2. feelings of hopelessness and low self-esteem
3. increase in goal oriented activities and flight
   of ideas
4. depressed mood and suicidal ideation

78
Jack is worried about his friend Patrick. When
asked, Patrick says that he is feeling fine
just as good as ever. But Jack doesnt quite
believe him. Even though Patrick says he feels
fine, Jack thinks he often looks a little bit
sad. Even his body seems a little slumped
over.Which of the following terms best
describes Jacks source of information about how
Patrick feels?

• A. Observer report
• B. Mood
• C. Affect
• D. Emotion
• E. Self-report

Correct Answer C What is Affect? How is it
different from Mood and Emotion?
79
Some researchers have suggested that all people
have basic needs, including a need to belong. It
might be further suggested that this need is part
of the reason why lacking an adequate social
support network can put a person at greater risk
of suicide. The need to belong is an example of
a factor, related to suicide.

• A. Social
• B. Psychological
• C. Biological

Correct Answer B Why? What are examples of
Social and Biological factors that are
mentioned in your book?
80
http//www.youtube.com/watch?vtZIvgQ9ik48Which
one does not belong as a symptom of dysthymia?

• A. Insomnia or Hypersomnia
• B. Feelings of Hopelessness
• C. Poor Concentration/Decision-Making
• D. Feelings of Worthlessness
• E. Low Self-Esteem

Correct Answer D Which of the them are more
defining features of dysthymia?
81
Which of the following is not a feature of
bipolar I disorder?

• A. Has lasted at least two years
• B. Elevated/euphoric mood
• C. Racing thoughts
• D. Psychomotor agitation
• E. At least one manic episode

Correct Answer A What disorders are marked by
this at least 2 years feature?
82
During adolescence, males are three times more
likely to attempt suicide than are females.

• A. True
• B. False

Correct answer False. Why? What do we know
about gender differences in suicide?
83
Which of the following is not one of the
recommendations for what to do when working with
a client who is suicidal?

• A. Reduce lethality
• B. Negotiate agreements
• C. Provide support
• D. Create a broader perspective
• E. Hospitalize first

Correct Answer E What do the other four
options mean?
84
One type of depression is marked particularly by
somatic symptoms (e.g. overeating, craving carbs,
gaining weight, etc.) The specifier used for
this type of depression is

• A. Melancholia
• B. Seasonal Affective
• C. with Psychotic Features
• D. Binging
• E. Postpartum

Correct Answer B What is a distinguishing
feature of these other specifiers?
85
Rates of successful suicide are highest among

• A. Women
• B. Teenagers
• C. Elderly
• D. College Students
• E. Men

Correct Answer C What other demographic
features of these elderly individuals are
relevant to suicide?