Mood Disorders

Chapter Five

Introduction

What is sadness and how does it differ from a Mood Disorder?

DSM-IV Classifications Axis One-Clinical Disorder

Axis Two-Personality Disorder/Mental Retardation

Axis Three-General Medical Condition

Axis Four-Psychosocial and Environment

Axis Five- Educational Problems

Terms used in Psychopathology of Depression

Emotion- state of arousal defined by subjective states of feeling such as sadness, anger and disgust.

Affect- pattern of observable behavior associated with subjective feelings such as facial expression, tone of voice and gestures.

Mood- pervasive and sustained emotional response that can color the person’s perception of the world

Additional Terms Mood Disorders- discrete periods of time when a person’s

behavior is dominated by either a depressive or a manic mood.

Mania- flip side of depression that involves a disturbance in mood characterized by elation including inflated self-esteem, euphoria, decreased need for sleep and pressure to keep talking and racing thoughts.

Unipolar Mood Disorder-behavior is dominated by either a depressed or manic mood

Bipolar disorder (aka manic depressive disorder)- person experiences episodes of mania as well as depression.

Relapse- return of active symptoms in a person who has recovered from a previous episode.

Remission-when a person’s symptoms diminish or improve

Symptoms and Considerations when

diagnosing clinical depression Differential symptoms between

Clinical Depression and Normal Sadness.

Four General types of symptoms.• Emotional• Cognitive • Behavioral• Somatic

Emotional Symptoms

• Dysphoric (unpleasant) mood• Diagnostic distinction made between

normal sadness and clinical depression Severity, quality and pervasive impact of the depressed mood.

• Anxiety-often a co-morbid diagnosis with depression

• Manic symptoms-euphoric and energetic at the beginning of the cycle, changing to irritable, angry, out of control, self-destructive.

Cognitive Symptoms

• Slowed thinking, trouble concentrating and easily distracted

• Pre-occupied with guilt and worthlessness • Focus attention on the depressive triad:

Self Environment Future

Manic symptoms easily distracted by random stimuli and often

respond inappropriately Grandiose ideas and inflated self-esteem Quick to anger, argumentative and abusive

Somatic Symptoms

• Sleeping Problems-trouble falling asleep, fatigue, early morning waking, spend more or less time sleeping than usual

• Appetite-changes—eating more or less than usual

• Libido-loss of sexual desire

Manic-drastic reduction in need for sleep, extremely energetic

Behavioral Symptoms

• Psychomotor retardation-slowed movements, may walk or talk as if they are in slow motion

Manic-gregarious, energetic, provocative, flirtatious and often sexually inappropriate.

Classification of Mood Disorders

Unipolar Disorders• Major Depressive Disorder-

One or more depressive episodes No manic or hypomanic episode ( hypomanic episode

is an episode of increased energy that are not sufficiently severe to classify as full blown mania)

Major Depressive Disorder most often follows a course of repeated episodes through life

• Dsythymic Disorder Depressed mood for at least two years, without

cessation or remission of symptoms for longer than 2 months during this period.

No major depressive episodes during the first two years.

Bipolar Disorders• Bipolar I disorder

One or more manic episodes Usually accompanied by major depressive episodes in

between manic episodes• Bipolar II disorder

One or more major depressive episodes At least one hypomanic episode No manic episodes

• Cyclothymic Disorder Numerous periods with hypomanic symptoms as well

as periods of depressed mood for at least 2 years. No remission of symptoms for longer than 2 months

during the 2 year period. No major depressive episodes No manic episodes.

Further Descriptions: Subtypes Episode Specifier-specific descriptions of symptoms that were

present during the most recent episode of depression.

melancholia-episode specifier used to describe a particularly severe type of depression, the presence of which indicates the person is likely to be responsive to antidepressant therapy or ECT.

psychotic features- an episodic feature that indicates the presence of hallucinations or delusions during the most recent episode of mania or depression, the presence of which usually requires hospitilization.

Course Specifier-extensive descriptions of the pattern that the disorder follows over time, as well as adjustment between episodes.

rapid cycling-if the person experiences at least four episodes of major depression, mania, or hypomania within a 12-month period.

Seasonal affective disorder-onset of episodes is regularly associated with a change in seasons.

Unipolar Disorder: Outcome, Incidence and Prevalence & Etiology

Incidence and Prevalence:• One of the most common forms of

psychopathology, the lifetime risk of suffering from this disorder for the general population is 5%.

• Gender• Cross Cultural-Universal • Incidence increasing at earlier ages

(M=45 years)

Unipolar Disorder: Course, Episodes

and Outcome Duration

Episodes

Recovery

Bi-Polar Disorders: Course and Outcome

Onset-usually occurs between the ages of 18-22 years which is younger than the average age of onset for unipolar

Course and Duration-intermittent. Most patients tend to have more than one episode, however the length of time between episodes is difficult to predict.

Incidence and Prevalence-

Etiology and Theories

Unipolar Mood Disorder Social

Interpersonal loss or separation Major disappointments dealing with acceptance such as

getting fired Stressful events

Psychological• Cognitive Vulnerability: Beck-Depressive Triad • Theory of Hopelessness• Interpersonal Perspective

Biological-Genetic contribution appears to be highest for bipolar disorder then major depressive disorder and relatively minor for dysthymia.

Etiology and Theories

BiPolar DisorderSocial Factors

Increased frequency of stressful life events the weeks preceding a manic episode.

Schedule disrupting events such as loss of sleep, holidays Goal attainment events, such as a major job promotion,

acceptance to medical school and graduate school or a new romance.

Social Environments Aversive emotional stress in the family.

Biological-Genetic contribution appears to be highest for bipolar disorder. Men and women are equally likely to develop bipolar disorder.

Biological

Endocrine system

Hypothalamic Pituitary Adrenal Axis (HPA)

Neurotransmitter Levels • Serotonin• Current Neurotransmitter theories • Bidirectional effects

Treatment- Unipolar

Cognitive-focus on helping patients replace self-defeating thoughts with more rational self statements

Interpersonal Therapy-attempts to improve the patient’s relationships with other people by building communication and problem solving skills.

Antidepressant Medications –Selective Serotonin re-uptake inhibitors developed in the 1980’s. They are the most frequently prescribed treatment, however medication with other mechanisms of action are also used.

Antidepressant Therapy Selective Serotonin Re-uptake Inhibitors

• Mechanism of action-reuptake pump• Side Effects

Tricyclics (Tofranil)• Mechanisms of action ( Considered 5 drugs in one)

SRI- reuptake pump NRI-reuptake pump Anti-Cholinergic Alpha 1 antagonists (blocks) Histaminergic

• Side Effects• Onset of Effectiveness• Comparisons of TCA & SSRI

Monoamine Oxidase Inhibitors-Inhibits the breakdown of NE into its by-products. Not used as often due to its interaction with tyrosine which is found in many foods such as cheese, chocolate and wine which must be completely avoided.

Serotonin Norepinephrine Reuptake inhibitor

Two Very Cute Babies

Treatment-Bipolar Disorders Antidepressants-sometimes used in

combination with a mood stabilizer. Lithium Carbonate-first line treatment-

eliminates manic episodes. Large number of non-responders ( up to 40%)

Anti-convulsants-more effective in treating rapid cyclers.

Anti-psychotics-sometimes used to alleviate symptoms of psychosis—not always present.

Psychotherapy

Psychotherapy as a treatment of BiPolar Disorder

Used as a supplement to medication. Cognitive Therapy-

• Interpersonal Therapy-emphasis on monitoring the interaction between symptoms and social interaction. Help patients lead more orderly lives, especially with regard to sleep wake cycles and work patterns ( aka-social rhythm therapy).

Suicide

DSM IV-TR-Classification of Suicide Four types of Suicide (Durkheim)

• Egoistic suicide-(diminished integration)

• Altruistic suicide-(excessive integration)

• Anomic suicide-(diminished regulation) • Fatalistic suicide-(excessive regulation)

Etiology of Suicide

Psychological Factors

Biological Factors

Social Factors

Treatment

Crisis Hotlines

Psychotherapy

Medication• Serotonin Dysregulation

Involuntary Hospitalization