Mood Disorders

MOOD DISORDERS

Unipolar Depressive Disorders

Type of depression consisting of

depressive symptoms but without manicepisodes

Symptomatology of Depressive Disorders

Sadness: deep, unrelenting pain/despair Anhedonia: loss of interest in everything in life even when person tries to do something enjoyable they may feel no emotional reaction Changes in appetite, sleep, and activity levels are common (e.g., early morning awakening)

Symptomatology of Depressive Disorders

Psychomotor retardation: (eg., walk more slowly, gesture more slowly, talk quietly and slowly, slow reaction time) Fatigue: depressed people lack energy Psychomotor agitation: can’t sit still, move around and fidget aimlessly Feelings of worthlessness, guilt, hopelessness, suicide.

DSM-IV Categories of Unipolar Depressive Disorders

Major Depressive Disorder Disorder involving a sad mood or anhedonia, plus four or more of the following symptoms: Weight loss or a decrease in appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or severe guilt, trouble concentrating, and suicidal ideation; These symptoms must be present for at least two weeks and must produce marked impairments in normal functioning

Dysthymic Disorder Type of depression that is less severe than major depression but more chronic Diagnosis requires the presence of a sad mood or anhedonia, plus two other symptoms of depression, for at least two years during which symptoms do not remit for two months or longer

DSM-IV Categories of Unipolar Depressive Disorders

Over half of the people diagnosed with major depression or dysthymia also have another psychological disorder E.g., borderline personality disorder, substance abuse (alcohol), anxietydisorders such as panic disorder, and eating disorders.

Double Depression Disorder involving a cycle between major depression and dysthymic disorder These patients are less likely to respond to treatment

With melancholia With psychotic features With catatonia With atypical features With postpartum onset With seasonal pattern

Subtypes of Depression

Depression with melancholic features:

The physiological symptoms of depression are particularly prominent. The diagnosis requires that the person show the inability to experience pleasure plus at least three of the following symptoms: distinct quality of depressed mood, depression that is regularly worse in the morning, early morning awakening, marked psychomotor retardation or agitation, significant anorexia or weight loss, and excessive or inappropriate guilt.


Depression with Psychotic Features: People experience delusions and hallucinations during a major depressive episode. Delusions: fixed beliefs with no basis in reality Hallucinations: perceptual experiences that are not real The delusions and hallucinations that depressed people experience usually are depressing and negative in content


Depression with Catatonic Features: Catalepsy: a condition characterized by trance-like states and a waxy rigidity of the muscles, so that they tend to remain in any position in which they are placed Catatonia: involves excessive motor activity, such as fidgeting hands, foot tapping, rocking back and forth, and pacing, all without an apparent purpose.


Depression with Atypical Features: To be diagnosed, patient must show positive mood reactions to positive events and at least two of these four features: significant weight gain or increase in appetite, hypersomnia, heavy or leaden feelings in the arms or legs, and a long-standing pattern of sensitivity to interpersonal rejection.


Depression with Postpartum Onset: This diagnosis is given to women when the onset of a major depressive episode occurs within four weeks of delivery of a child. These women meet full criteria for

a major depressive disorder. Must be distinguished from postpartum blues (emotional lability [unstable and quickly shifting moods]), frequent crying, irritability, and fatigue). As many as 30% of women experience postpartum blues. Typically passes within 2 weeks. Caused by massive changes in hormone levels and perhaps, sleep deprivation and stress of having a new born baby.


Seasonal Affective Disorder (SAD): Disorder identified by a two-year period in which a person experiences major depression during winter months and then recovers fully during the summer; some people with this disorder also experience mild mania during summer months. The symptoms seem to be tied to the number of hours of daylight in a day. People become depressed when the daylight hours are short and recover when the daylight hours are long.


17% of the population experience an episode of major depressionduring their lifetime 6% experience dysthymic disorder Women are about twice as likely as men toexperience both mild depressive symptoms andsevere depressive disorders. Children do not show this gender difference indepression, but around 14 or 15, girls begin toshow dramatic increases in their rates of depression, while boys’ rates remain quite stable

Gender & Age Differences in DepressionMiscellaneous Information About Depressive Disorders

Gender & Age Differences in Depression

15-24 yr-olds are most likely to have had a major depressive episode Lowest rates are among the 45 to 54 yr- olds The rates of depression do go up among those over 85 yrs of age.

Why the low rates of depression in elderly?

Depression appears to interfere with physical health and as a result, people with a history of depression may be more likely to die before they reach old age. As people age, they may develop more adaptive coping skills and a psychologically healthier outlook on life, and this may lead them to experience fewer episodes of depression Cohort effect: People born in one historical period are at different risk for a disorder than are people born in another historical period.

The Course of Depression 20% were still depressed a year after diagnosis About half of the people who have one episode of major depression will experience another episode at some time in their lives. Most who relapse tend to do so within 2 yrs of recovering from their first episode. The more episodes of depression, the more likely they are to relapse into further episodes of depression. Persons with inadequate social support from friends and family are more likely to relapse

Bipolar Disorder Symptoms of mania: Elevated mood (high, elated, euphoric, ecstatic)

Irritability, hostility, and belligerenceIncreased self-esteemGrandiosityPoor judgmentOveractivity (motor, social, sexual)Flight of ideasDecreased need for sleepDistractibilitySpending spreesSocial intrusivenessInappropriate collection of clothes, possessions or other objects

Bipolar I Disorder: Form of bipolar disorder in which the full symptoms of mania are experienced while depressive aspects may be more infrequent or mild.

Bipolar II Disorder Form of bipolar disorder in which only hypomanic episodes are experienced, and the depressive component is more pronounced.

Bipolar Disorder

Cyclothymic disorder: Milder but more chronic form of bipolar disorder that consists of alternating between hypomanic episodes and mild depressive episodes over a period of at least two years.

Who has Bipolar Disorder

1-2 in 100 people will experience at least one episode of bipolar disorder at some time in their lives No gender differences No differences among ethnic groups in the prevalence of the disorder Onset usually in late adolescence or early adulthood 90% of persons with bipolar disorder have multiple episodes or cycles during their lifetimes. The length of an individual episode varies

Rapid cycling bipolar disorder Diagnosis given when a person has four or more cycles of mania and depression within a single year

Leadership, Creativity, & Bipolar Disorder

Increased self-esteem A rush of ideas The courage to pursue these ideas High energy Little need for sleep Hypervigilance Decisiveness

Might these be beneficial qualities?

Biological Theories of Mood Disorders

Four clues that support a biological etiology: Depression and mania tend to be episodic in nature, as are many physical diseases Many of the symptoms of depression and mania represent disruptions in vital bodily functions, such as sleep, eating, and sexual activity Depression and mania are heritable Depression and mania respond to biological treatments such as drug therapies, and can be induced by certain drugs

The group of neurotransmitters that has been implicated in the mood disorders is called the MONOAMINES These include *norepinphrine, *serotonin, and dopamine Found in large concentrations in the limbic system, a part of the brain associated with the regulation of sleep, appetite, and emotional processes (and memory).

Neurotransmitter Theories

Monoamine Theories: Theories that low levels of monoamines, particularly norepinephrine and serotonin, cause depression, whereas excessive or imbalanced levels of monoamines, particularly dopamine, cause mania.

Neurotransmitter Theories

With each episode of depression or mania, neurotransmitter systems become more easily dysregulated. The first episode may take a strong stressor to initiate dysregulation, but subsequent episodes require much more mild stressors to cause dysregulation. Model explains why with each new episode of depression or mania, the cumulative risk of new episodes increases. Also helps to explain why the period between episodes decreases over time in many people with mood disorders

Kindling-Sensitization Model

CT and MRI scans have found atrophy or deterioration in the cerebral cortex and cerebellum in severe cases of unipolar depression and bipolar depression

Structural Evidence

PET scans show decreased metabolic activity in the frontal area of the cortex of people with severe depression (left > right)

Functional Evidence

Patients with left frontal stroke often manifest depressive symptomatology

Patients with right frontal stroke often manifest manic symptomatology

Lesion Evidence

Lithium

– Most common treatment for bipolar disorder, a drug that reduces levels of certain neurotransmitters and decreases the strength of neuronal firing

– 30-50% response rate

– More effective in reducing the symptoms of mania than the symptoms of depression

– Used as a prophylactic to avoid relapse

– Side effects: abdominal pain, nausea, vomiting, diarrhea, tremors, twitches, blurred vision, problems in concentration and attention; greater risk of diabetes and kidney failure, weight gain

Biological Therapies

Biological Therapies for Mood Disorders

Anticonvulsants, Antipsychotics, and Calcium Channel Blockers as alternatives to lithium and its side effects: Anticonvulsant drugs: effective in reducing mania symptoms but also carrying side effects such as dizziness, rash, nausea, and drowsiness Antipsychotic drugs: effective by reducing levels of dopamine but also carrying neurological side effects such as tics Calcium Channel Blockers: found to be effective

Biological Therapies for Mood Disorders

Tricyclic Antideprssants – Treatments for depression that prevent reuptake of monoaamines in the synapse while also changing the sensitivity and number of monoamine receptors

– 60-85% response rate

– Side effects include dry mouth, excessive perspiration, blurring of vision, constipation, urinary retention, & sexual dysfunction

– Can take 4-8 weeks to show an effect

– Eg., imipramine (Tofranil), amitriptylene (Elavil), desipramine (Norpramin)

Biological Therapies for Mood Disorders Monamine Oxidase Inhibitors (MAOIs) – Treatment for depression that inhibit monoamine oxidase, an enzyme that breaks down monoamines in the synapse, thereby yielding more monoamines

– Side effects: liver damage, weight gain, severe lowering of blood pressure, and a very strict diet must be followed (no foods rich in an amino acid called tyramine such as cheese, red wine, beer, and chocolate.

– Studies show that MAOIs are less effective than the tricyclic antidepressants

– Eg., phenelzine (Nardil), tranyclpromine (Parnate)

Biological Therapies for Mood Disorders Selective Serotonin Reuptake Inhibitors – Treatments for depression that inhibit the reuptake of serotonin by the sending neuron, increasing the amount in the synapse

– Benefits: quick acting (first couple of weeks), less severe side effects, not fatal in overdose

– Side effects: increased agitation or nervousness, weakness, hyper, jittery, mild tremors, increased perspiration, decreased sexual drive, stomach cramps

– Eg., fluoxetine (Prozac), paroxetine (Paxil)

Biological Therapies for Mood Disorders Electroconvulsive Therapy – Treatment for depression that involves the induction of a brain seizure by passing electrical current through the patient’s brain while he or she is anesthetized

– Most often given to those who do not respond to drug therapy. Relieves depression in 50-60 percent of patients

– No one knows for sure why it works…speculations include:

1. Increase permeability of the blood-brain barrier, allowing the antidepressant medications more fully into the brain. 2. Severe stimulation of the hypothalamus (part of brain regulating sleep, eating, sexual drive, and emotion). 3. Increases the number and sensitivity of serotonin receptors

ECT Controversy Used as punishment for patients who were unruly Leads to memory loss and difficulty learning new information

Relapse rate can be as high as 85% Frightening

Light Therapy • Treatment for seasonal affective disorder that involves exposure to bright lights during the winter months.

• Resets depressed people’s circadian rhythms (natural cycles of biological activities that occur every 24hrs.)

• Alternative theory for its effectiveness suggests that exposure to bright lights may increase serotonin levels, thereby decreasing depression

Psychosocial Theories of Mood Disorders

• Behavioral Theories of Depression

– View that depression results from negative life events that represent a reduction in positive reinforcement; sympathetic responses to depressive behavior then serve as positive reinforcement for the depression itself.

Psychosocial Theories of Mood Disorders: Behavioral Theories

• Learned Helplessness Theory

– View that the type of stressful event most likely to lead to depression is an uncontrollable negative event. Such an event, especially if frequent or chronic, can lead people to believe that they are helpless to control important outcomes in their environment. In turn, this belief in helplessness leads people to lose their motivation, to reduce actions that might control the environment, and to be unable to learn how to control situations that are controllable.

Cognitive Theories

• Cognitive Distortion Theory (A. Beck)

– Theory that depression results from errors in thinking– such as jumping to conclusions, exaggerating the negative, and ignoring the positive– that lead one to a gloomy view of the self, the world, and the future.

Distorted Thinking in Depression

All or nothing thinking (seeing things in black or white) Overgeneralization Mental Filter (seeing a single negative event as part of a large pattern of negative events) Disqualifying the positive (rejecting positive experiences by discounting them) Jumping to conclusions (concluding that something negative will happen or is happening with no evidence) Emotional reasoning (assuming that negative emotions necessarily reflect reality) Should statements (putting constant demands on oneself) Labeling (overgeneralizing by attaching a negative, global label to a person or situation)

Cognitive Theories

• Reformulated Learned Helplessness Theory

– View that people who attribute negative events to internal, stable, and global, causes, are more likely than other people to experience learned helplessness deficits following such events and are thus predisposed to depression

Depressive Realism

• Is it possible that depressed people are not distorted in their negative views of the world but actually are seeing the world realistically for the terrible place that it is?

– Eg., when asked to make judgments about how much control they have over situations that are actually uncontrollable, depressed people are quite accurate. In contrast, nondepressed people greatly overestimate the amount of control they have, especially positive events.

Question

• If depressed people are more realistic about life, is it possible or ethical to try to change their outlook through psychotherapy?

Psychosocial Therapy of Depression

• Cognitive-Behavioral Therapy

– Treatment that works by changing negative patterns of thinking and by solving concrete problems through brief sessions in which a therapist helps a client challenge negative thoughts, consider alternative perspectives, and take effective actions

– 6-12 weeks

Cognitive-Behavioral Therapy

1. Help client discover the negative automatic thoughts habitually used and to understand the link between those thoughts and his depression 2. Help the client challenge his negative thoughts 3. Train the client in new skills needed to cope better in life

Psychosocial vs. Drug Therapies

• CBT, IPT, and drug therapies are generally equally effective for the treatments of most people with depression

• Placebo effects

• Drug therapy works faster and is more effective for the severely depressed patient

• Yet, CBT or IPT participants are less likely to relapse within 2 yrs.

Psychosocial vs. Drug Therapies

• Conclusions

– Severely depressed or in need of fast relief (eg., suicidal): drug therapies, ECT

– Mild depression can benefit from either the drug therapies or psychosocial therapies equally

– Psychosocial therapies may more effectively prevent relapse than the drug therapies

– Maintenance does of drugs or the psychosocial therapies can reduce the risk of relapse in patients with histories of recurrent depression

THE END

Health & Medicine

Mood Disorders