The Mood Disorders

Dr. Kayj Nash Okine

The Mood Disorders

Unipolar Disorders: Major Depressive Disorder Dysthymic Disorder

Bipolar Disorders: Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder

Major Depression

Emotional Symptoms: Sadness, depressed mood Anhedonia – lack of interest or pleasure Irritability Excessive or inappropriate guilt Hopelessness Feelings of worthlessness Low self-esteem

Major Depression

Vegetative Symptoms: Lack of motivation Insomnia or hypersomnia Increased or decreased appetite Weight loss or gain Fatigue, loss of energy Psychomotor retardation or agitation

Major Depression

Cognitive Symptoms: Impaired concentration & attention Indecisiveness Suicidal ideation Delusions Hallucinations

Major Depression

Social Symptoms: Social withdrawal & isolation Lack of communication Lack of social initiation Relationship problems & conflict Dependency – clinginess, neediness

Diagnostic Criteria for a Major Depressive Episode

5+ symptoms are present for at least 2 weeks:Depressed mood*Loss of interest or pleasure in most activities*Significant increase or decrease in appetite or weightInsomnia or hypersomniaPsychomotor agitation or retardationFatigue or loss of energyFeelings of worthlessness or excessive or inappropriate guiltDiminished ability to think or concentrate or indecisivenessSuicidal ideation

Diagnostic Criteria for a Major Depressive Episode

At lease one of the symptoms is either depressed mood or loss of interest or pleasure in most activities.

Symptoms represent a change from previous functioning.

Symptoms cause significant distress or impairment.

Symptoms aren’t better accounted for by bereavement (2 month mourning period after loss of a loved one).

Specifiers for Major Depression

Mild, Moderate, and SevereSingle Episode or RecurrentChronicWith Melancholic FeaturesWith Psychotic FeaturesWith Catatonic FeaturesWith Atypical FeaturesWith Postpartum OnsetWith Seasonal PatternsLongitudinal Course Specifiers

Criteria for Specifiers

Severity: Mild, Moderate, or Severe level of functional impairment

Single Episode: single episode of major depression

Recurrent: 2 or more episodes of major depression

Chronic: full criteria for a major depressive episode have been met continually for at least the past 2 years

Criteria for Specifiers

Psychotic Features: delusions or hallucinations Mood Congruent: depressive themes

of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment

Mood Incongruent: content doesn’t involve depressive themes, e.g. thought insertion, thought broadcasting, delusions of control, delusions of grandeur, persecutory delusions

Criteria for Specifiers: Catatonic Features: at least 2 of the

following: Motoric immobility – catalepsy or stupor Excessive motor activity Extreme negativism (resistance to

instructions or attempts to be moved) or mutism

Posturing, stereotyped movements, prominent mannerisms or grimacing

Echolalia or echopraxia

Criteria for Specifiers

Melancholic Features: 4 or more of the following

Loss of pleasure in activities and/or* Lack of reactivity to pleasurable stimuli* Quality of mood is distinct Depression regularly worse in the morning Early morning wakening (2+ hrs) Marked psychomotor retardation or agitation Significant anorexia or weight loss Excessive or inappropriate guilt

Criteria for Specifiers

Atypical Features: 3 or more of the following: Mood reactivity* Significant weight gain or increase in

appetite Hypersomnia Heavy, leaden feeling in arms or

legs Interpersonal rejection sensitivity

Criteria for Specifiers

Longitudinal Course Specifiers: With Full Interepisode Recovery – full

remission is attained between 2 most recent mood episodes

Without Full Interepisode Recovery – full remission is not attained between mood episodes

Postpartum Onset: Onset of episode within 4 weeks postpartum

Criteria for Specifiers

Seasonal Pattern: Depressive episodes have developed at a

particular time of the year for past 2 years Depression remits or switches to mania or

hypomania at a characteristic time of year No nonseasonal major depressive episodes

have occurred during the 2 year period Seasonal major depressive episodes

substantially outnumber nonseasonal depressive episodes over the course of person’s lifetime

Prevalence Rates For Major Depressive Disorder

Lifetime prevalence: 10-25% for women; 5-12% for menPoint prevalence: 5-9% for women; 2-3% for menGender: women have 2x the rates as menAge: highest rates among 15-24 year oldsOnset: early 20’sOther variables: no consistent differences in rates across levels of ethnicity, education, income, or marital status

Diagnostic Criteria For Dysthymia

A. Depressed mood for at least 2 years. For children & adolescents, mood may be irritable and duration may be 1 year.

B. Presence of 2 or more of the following:-Poor appetite or over-eating-Insomnia or hypersomnia-Low energy or fatigue-Low self esteem-Poor concentration or difficulty making decisions-Feelings of hopelessness

Diagnostic Criteria For Dysthymia

C. During the 2 yr period, the person has not been without symptoms for more than 2 months at a time.

D. No major depressive episode has been present during the 1st 2 yrs of the disturbance. After the initial 2 yrs, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses are given.

Dysthymic Disorder

Specifiers: Early Onset - onset before 21 yrs old Late Onset - onset at age 21 yrs old or older With Atypical FeaturesPrevalence: Lifetime prevalence: 6% Point prevalence: 3%Gender Differences: 2-3x more likely for women than men

Major Depression vs. Dysthymia

Major Depression: 5 or more

symptoms including depressed mood or loss of interest or pleasure

At least 2 weeks in duration

Dysthymia: 3 or more

symptoms including depressed mood

At least 2 years in duration

Manic Features

Changes in Mood: Irritability Excitability, exhilaration Hostility Anxious Hyper, wound-up

Manic Features

Increased Energy: Little fatigue, despite decreased sleep;

insomnia, and difficulty sleeping Increase in activities; increased productivity Doing several things at once Making lots of plans Taking on too many responsibilities Others seem slow Restlessness, difficulty staying still

Manic Features

Changes in speech Rapid, pressured speech Incoherent speech, clang associationsImpaired judgment Lack of insight Inappropriate humor and behaviors Impulsive or thrill-seeking behaviors:

increased alcohol consumption; financial extravagance, spending too much money; dangerous driving; sexual promiscuity

Manic Features

Changes in Thought Patterns Distractibility, inability to concentrate Creative thinking Flight of ideas Racing thoughts Disorientation Disjointed thinking Grandiose thinking

Manic Features

Changes in Perceptions Inflated self esteem, feeling superior More sensitive than usual: noises seem

louder & lights seem brighter than usual Hallucinations Paranoia Increased appetiteIncreased Social Behavior Unnecessary phone calls Increased sexual activity Talkative & sociable

Criteria for Mania & Hypomania

4+ of the following symptoms have persisted to a significant degree for at least a week:

Elevated, expansive, irritable mood* Inflated self-esteem, grandiosity Decreased need for sleep Flight of ideas, racing thoughts More talkative than usual, pressured speech Distractibility Increase in goal-directed activity, psychomotor agitation Excessive involvement in pleasurable but dangerous

activities, e.g. unrestrained shopping sprees, sexual indiscretions, reckless driving

Differential Diagnosis

MANIC EPISODE (Bipolar I) Mood disturbance is

severe Causes marked

impairment in social or occupational functioning

Necessitates hospitalization

Has psychotic features

HYPOMANIC EPISODE (Bipolar II & Cyclothymia) Mood disturbance is less

severe Does not cause marked

impairment in functioning The person’s behavior

and mood significantly & noticeably change

The person no longer seems like him/herself

Mixed Episode

The criteria are met (except for duration) for both Mania & Major Depression nearly every day for at least a week

Mood disturbance is severe enough to: cause marked impairment in functioning necessitate hospitalization contain psychotic features

Bipolar I Disorder

Characterized by the occurrence of: 1 or more Manic or Mixed Episodes (usually) 1 or more Major Depressive

Episodes

Bipolar II Disorder

Characterized by the occurrence of: 1 or more Major Depressive Episodes At least 1 Hypomanic Episode There has never been a Manic or

Mixed Episode

Cyclothymic Disorder

Characterized by: Chronically fluctuating mood states – numerous

periods of hypomania and depression Duration of at least 2 years in adults & 1 year in

adolescents and children Person is not without symptoms for more than 2

months at a time There are no Major Depressive, Manic, or Mixed

Episodes during the initial 2 years. After the initial 2 years, there may be superimposed Manic, Mixed, or Depressive episodes

Bipolar Specifiers

Current or Most Recent Episode Longitudinal Course Specifiers With Rapid Cycling (at least 4 episodes of mood

disturbances in the past 12 months) Mild, Moderate, Severe With Psychotic Features With Postpartum Onset With Catatonic Features (very rare in manic

episodes) With Seasonal Pattern

Prevalence Rates

Lifetime Prevalence Rates: Bipolar I: 0.4%-1.6% Bipolar II: 0.5% Cyclothymia: 0.4%-1.0%

Course

Average age of onset: 18 for Bipolar I, 22 for Bipolar II, midteens for Cyclothymia

1/3 of bipolar cases begin in adolescence 1/3 of cyclothymics develop full-blown bipolar Chronic & lifelong course Suicide attempts: 17% for Bipolar I & 24% for

Bipolar II Rapid cycling responds poorly to treatment

Gender Features

Bipolar I and Cyclothymia are equally common in men and women

Bipolar II is more common in women. Men tend to have more Manic Episodes Women tend to have more Major

Depressive Episodes Women are more likely to be rapid

cyclers

Biological Theories for Mood Disorders

Genetic Theories: If an individual has a mood disorder, the rates of mood disorders in his/her relatives is 2-3x greaterIf one twin has a mood disorder, an identical twin is 2-3x more likely than a fraternal twin to have a mood disorderSevere mood disorders have a stronger genetic contributionBipolar disorder has a stronger genetic loadingWomen have a stronger genetic contribution for depression than men do

Biological Theories for Mood Disorders

Neurotransmitter Theories: Low levels of serotonin (5HT) Permissive hypothesis: when 5HT levels are low,

other neurotransmitters, such as norepinephrine and dopamine, range more widely & become dysregulated, contributing to mood irregularities

Kindling-sensitization model: neurotransmitter systems become more easily dysregulated with each episode of depression or mania

Dopamine may play a role in manic episodes

Biological Theories for Mood Disorders

Neurophysiological AbnormalitiesSleep EEG abnormalities:

Sleep continuity disturbances – the person takes longer to fall asleep, wakes more throughout the night, & wakes much earlier than usual in the morning

Reduced slow wave sleep Earlier onset of REM sleep Increased duration & intensity of REM sleep

Biological Theories for Mood Disorders

Neurophysiological Abnormalities

Alterations in cerebral blood flow & metabolism:

Increased blood flow to limbic system

Decreased blood flow to prefrontal cortex

Overactivation of nondominant side of brain

Biological Theories for Mood Disorders

Hormonal Factors (“The Stress Hypothesis”) Chronic hyperactivity in the hypothalamic-

pituitary-adrenal (HPA) axis Inability of HPA axis to return to normal following

a stressor Heightened HPA activity produces excess of the

stress hormone cortisol, which may inhibit monoamine receptors

Chronic stress poorly regulated neuroendocrine systems

Drug Treatments for Mood Disorders

Drug Treatments for Major Depression – Monoamine Oxidase Inhibitors (MAOI’s) Tricyclic Antidepressants (TCA’s) Selective Serotonin Reuptake Inhibitors (SSRI’s) SNRI’s Dopamine Agonists

Drug Treatments for Bipolar Disorder - Lithium, anticonvulsants, calcium channel blockers, antipsychotics

Electroconvulsive Therapy (ECT) Light Therapy (for SAD)

Biological Treatments

Electroconvulsive Therapy (ECT): person is anesthetized & given muscle relaxant drugs & then electric shock is administered directly to the brain, producing a seizure and convulsions

Transcranial Magnetic Stimulation (TMS): magnetic coil is placed over the indiviuals head to generate a precisely localized electromagnetic pulse

Behavioral Theories of Mood Disorders

Lewinsohn’s Behavioral ModelDepression is due to:A lack of rewarding, pleasurable experiences or reinforcement.Stressful, negative life events or aversive consequences.Behavioral deficits and excesses, such as a lack of social skills, continued complaining, & self-preoccupation.Passive, repetitious, unrewarding behavior.

Stressor leads to reduction in reinforcers

Person withdraws

Reinforcers further reduced

More withdrawal and depression

Lewinsohn’s Behavioral Theory of Depression

Behavioral Theories of Mood Disorders

Behavioral Theories of Mood Disorders

Learned Helplessness TheoryExposure to Frequent, Chronic, Negative Uncontrollable Events

↓Sense of Helplessness

↓Learned Helplessness Deficits:

Lack of motivationPassivity – the person stops trying

Indecisiveness Inability to effect change or establish control,

even in controllable situations

Behavioral Therapy for Mood Disorders

Increase positive reinforcers & decrease aversive eventsChange aspects of the environment related to depressionTeach person skills for addressing negative circumstances and social interactions more effectivelyTeach person skills for managing their emotions and moods.

Cognitive Theories

Aaron Beck’s TheoryThe Negative Cognitive Triad: Depressed people tend to have negative views of: (1) themselves; (2) the world; (3) the future.Cognitive distortions cause or maintain depression:Distorted Automatic Thoughts – pervasive, negative thoughts regarding oneself, one’s experience, and one’s future, e.g. “Nothing I do works out.”Maladaptive Assumptions – rigid, punitive, unreasonable rules or guiding principles, e.g. “I don’t deserve to be happy.”Negative Schemas – core beliefs about oneself and others, e.g. “I’m such a loser.”

Cognitive Theories

Seligman’s Theory of the Depressive Attributional Style

Self-critical depression and helplessness stem from certain patterns of causal attributions for negative events or failure:

Internal (vs. external) – blame self, e.g. lack of effort

Global (vs. specific) – touches many areas of one’s life

Stable – e.g. lack of ability or aptitude

Cognitive-Behavioral Therapy

Help person identify and challenge negative, distorted thinking and maladaptive beliefs

Help the person learn more adaptive ways of thinking

Help clients learn new behavioral skills

Psychodynamic Theory

Early childhood experiences unhealthy relationship patterns dependence on the approval of others anxiety about separation and

abandonmentIntrojected hostility – person perceives

rejection or abandonment and turns anger in on self, e.g. by blaming or punishing him/herself

Psychodynamic Therapy

Insight Oriented Approach:Help the person gain insight into “old wounds” and unconscious conflicts and themes, such as introjected hostility and fears of abandonment stemming from childhood, in order to facilitate change

Interpersonal Theory of Depression

(Klerman, Weissman, Rounsaville, & Chevron)Depression is precipitated or maintained by problematic childhood relationships and current interpersonal difficulties or patterns.Depression occurs in the interpersonal context of:

Grief over loss of significant relationshipsInterpersonal role disputes & conflictRole transitionsInterpersonal deficits – e.g. lack of social support or intimacy

Interpersonal Therapy

Focuses on four types of interpersonal problems: Grief & loss Role disputes & conflict Role transitions Deficits in interpersonal skills

Helps the person to establish more social support and more positive, healthy relationships

Treatments for Bipolar Disorder

Psychotherapy: supportive, psychoeducational, self-care, family involvement

Drug Treatments: Lithium Carbonate Anticonvulsants – Depakote, Lamictal Calcium Channel Blockers Antipsychotics