Module 3 - Mood Disorders & Suicide

Question 1

Whose work of began the modern age of theories about the etiology of depression? This person coined the term manic-depression and described both depressive and manic forms of this disorder. His descriptions formed the basis for the definition of the mood disorders contained in the modern diagnostic systems.

Answer 1

Emil Kraepelin (1855–1926)

Question 2

At times we’ve all felt sad, “down” and depressed or good, excited and “high”. What distinguishes these very normal mood fluctuations from the changes seen in clinical mood disorders?

Answer 2

Their duration and their severity.

Question 3

Mood disorders in the DSM-5 are classified into what two broad categories?

Answer 3

Unipolar and Bipolar.

Question 4

Which disorder is often referred to as the “common cold” of mental disorders because it is so prevalent?

Answer 4

Major Depressive Disorder (MDD).

Question 5

True or False?

One of the main factors that accounts for the devastating impact of MDD is the disorder’s recurrent course.

Answer 5

True.

(Approximately 50% of individuals who experience one episode of depression will have a second, and up to 90% of those who experience two or three episodes will have future recurrences.)

Question 6

Flip to see the DSM-5 Diagnostic Criteria for Major Depressive Disorder (MDD). Take a look at it, and then try to answer the following question cards.

Answer 6

A: Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

Insomnia or hypersomnia nearly every day.

Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

Fatigue or loss of energy nearly every day.

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 7

For MDD, at least how many criteria symptoms have to be present in a 2 week period to warrant a diagnosis?

Answer 7

Five (or more).

Question 8

For MDD, what does ONE of the 5 symptoms have to be in order to meet the diagnosis?

Answer 8

At least one symptom has to be:
(1) depressed mood
(2) loss of interest or pleasure.

Question 9

For MDD, how often do the symptoms (depressed mood, loss of interest, increased/decreased appetite, insomnia/hypersomnia, psychomotor issues, fatigue, attention difficulties), need to occur in a 2 week period?

Answer 9

Most of the day, nearly every day.

Question 10

For MDD, if they meet Criterion A, what does criterion B say they also need to experience in order to meet a diagnosis?

Answer 10

Clinically significant distress or impairment in social, occupational, or other important areas of functioning due to the symptoms.

Question 11

Flip to see the DSM-5 Diagnostic Criteria for Persistent Depressive Disorder*. Take a look at it, and then try to answer the following question cards.

*In the following cards, I’ll refer to it as PDD even though the textbook doesn’t.

Answer 11

A: Depressed mood for most of the day, for more days than not, as indicated by either subjective account for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B: Presence, while depressed, of two (or more) of the following:

Poor appetite or overeating.

Insomnia or hypersomnia.

Low energy or fatigue.

Low self-esteem.

Poor concentration or difficulty making decisions.

Feelings of hopelessness.

C: During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D: Criteria for a major depressive disorder may be continuously present for 2 years.

E: There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F: The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G: The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 12

For a diagnosis of adult PDD, how long must the depressed mood (for most of the day, for more days than not) be occurring for?

A) 3 years
B) 2 years
C) 1 year
D) 6 months

Answer 12

B) 2 years

(Note: for children/youth, it’s 1 year).

Question 13

In PDD, while depressed, how many of the following symptoms do they need to have to fulfill criteria B?

1.Poor appetite or overeating.

2.Insomnia or hypersomnia.

3.Low energy or fatigue.

4.Low self-esteem.

5.Poor concentration or difficulty making decisions.

6. Feelings of hopelessness.

Answer 13

They must have two (or more) of these symptoms listed.

Question 14

In PDD, during the 2-year period of the disturbance, the individual must never have been without the symptoms in Criteria A and B for more than ____ months at a time.

Answer 14

Two.

So I like to remember PDD as 2 years, 2 symptoms, 2 months at a time. When in doubt - think 2 for PDD. (Unless it’s for a child/youth. Haha.)

Question 15

True or False?

Individuals with persistent depression are also less likely to respond to standard depression treatment than are those with episodic major depression.

Answer 15

True.

Question 16

True or False?

MDD has a younger age of onset than PDD.

Answer 16

False.

(It’s the other way around. PDD has a younger age of onset as well as higher rates of comorbidity, higher levels of stress, lower levels of social support and higher levels of dysfunctional personality traits than those with MDD.)

Question 17

What is the difference between mania and hypomania?

Answer 17

Mania is a distinct period of elevated, expansive, or irritable mood that lasts at least one week and is accompanied by at least three associated symptoms.

Hypomania is a less severe form of mania that involves a similar number of symptoms, but those symptoms need to be present for only four days.

Question 18

True or False?

Some individuals can experience both manic/hypomanic and depressive symptoms at the same time.

Answer 18

True.

This is called a “mixed” state. At least three symptoms of the opposing episode state are required to meet criteria for mixed features.

Question 19

Flip to see the DSM-5 Diagnostic Criteria for a Manic Episode.

Answer 19

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

Inflated self-esteem or grandiosity.

Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

More talkative than usual or pressure to keep talking.

Flight of ideas or subjective experience that thoughts are racing.

Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).

Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

Question 20

Fill in the blanks for criterion A of a manic episode:

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least ___________ and present most of the day, nearly every day. (Or ________ if hospitalization is necessary).

Answer 20

First blank: 1 week

Second blank: any duration

Question 21

True or False?

A depressive episode is not required for a diagnosis of bipolar I disorder?

Answer 21

True.

A depressive episode is not required for the diagnosis of bipolar I disorder, but most patients have both manic and depressive episodes.

Question 22

Why is Bipolar II disorder often more difficult to diagnose than Bipolar I?

Answer 22

Because hypomanic episodes are not as severe as manic episodes. Hypomanic episodes may be experienced as a period of successful high productivity, and many people with bipolar II are reluctant to take mood-stabilizing medication because they experience their hypomania as enjoyable.

Question 23

Bipolar II disorder is defined as a history of one or more ___________ episodes with one or more major __________ episodes.

Answer 23

Hypomanic, Depressive

Question 24

What is Cyclothymia?

Answer 24

A chronic, but less severe, form of bipolar disorder. It involves a history of at least two years of alternating hypomanic episodes and episodes of depression that do not meet the full criteria for major depression.

Question 25

What is rapid cycling bipolar disorder?

Answer 25

The presence of four or more manic and/or major depressive episodes in a 12-month period. The episodes must be separated from each other by at least two months of full or partial remission, or by a switch to the opposite mood state (i.e., mania to depression or vice versa).

Question 26

True or False?

Bipolar patients with a rapid cycling presentation have lower rates of disability and higher rates of response to treatment.

Answer 26

False.

They have higher rates of disability and lower rates of response to treatment.

Question 27

True or False?

Rapid cycling can be induced, or made worse, by antidepressant medications.

Answer 27

True.

Therefore, it is important for patients who are receiving antidepressant treatment to also receive a mood stabilizer (e.g., lithium).

Question 28

What disorder is characterized by recurrent depressive episodes that are tied to the changing seasons?

Answer 28

Seasonal affective disorder (SAD) - which can occur in both unipolar MDD and bipolar disorder.

Question 29

Some evidence suggests that patients with SAD (seasonal affective disorder) have phase-delayed circadian rhythms. What does this term mean?

Answer 29

A dysregulation of the natural biological pattern of sleep and wakefulness.

Question 30

As many as _______ percent of women experience mood swings and feelings of depression up to two weeks after childbirth.

A) 38%
B) 50%
C) 70%
D) 43%

Answer 30

C) 70%

(In most new mothers these symptoms resolve themselves over time and do not impair functioning. However, in approximately 10 to 15 percent of new mothers, the mood swings are chronic and severe enough to meet the criteria for a major depressive or manic episode.

Question 31

True or False?

Peri- and postpartum depression affect women similarly across cultures and socio-economic levels.

Answer 31

True.

Question 32

What are some risk factors for postpartum depression?

Answer 32

1. a family history of depression
2. a history of previous depressive episodes
3. a poor marital relationship and low social support
4. stressful life events concurrent with, or immediately following, childbirth.

Question 33

True or False?

Answer 33

A mother’s postpartum depression is associated with poorer cognitive test scores in her children.

Question 34

What is Premenstrual Dysphoric Disorder (PMDD)?

Answer 34

PMDD is characterized by marked affective lability, irritability/anger, depressed mood, and/or anxiety, plus the presence of additional symptoms of loss of interest in activities, concentration difficulties, low energy, changes in appetite and/or sleep, feelings of loss of control, and/or physical symptoms.

Five symptoms must be present to meet DSM-5 criteria for PMDD, and these symptoms must significantly interfere with the woman’s functioning. Further, these symptoms must be present for most menstrual cycles in the past year.

Question 35

Why was the recent addition of PMDD as a diagnostic category in the DSM controversial?

Answer 35

Some groups have been concerned that the diagnosis pathologizes a normal biological process in women (menstruation), and could lead to the inappropriate, and potentially stigmatizing, treatment of women.

Question 36

What are the treatment recommendations for PMDD?

Answer 36

Selective serotonin reuptake inhibitors (SSRIs), and birth control medications that suppress ovarian cyclicity or contain novel progestins.

Question 37

How does psychodynamic theory view the etiology of depression?

Answer 37

1) Neglectful and/or abusive parenting confers a strong risk for later depression.

2) Research has confirmed the theory that individuals with a temperamental vulnerability to depression do interpret life events as having a greater impact, and that these events are more strongly related to depression than they are in individuals who do not have this pre- existing vulnerability.

3) Dependent individuals rely excessively on their interpersonal relationships for their sense of identity. They are described as being excessively needy, fearing abandonment, and feeling helpless in relationships. In contrast, self-critical individuals are prone to fears of failure, self-blame, inferiority, and guilt, particularly in areas of achievement. Blatt theorized that these personality styles, which develop as a function of maladaptive parenting styles and/or traumas early in development, render people vulnerable to depression when they face a stressful life event that triggers the personality theme. A great deal of research supports the role of these personality styles as predictors of depression in the face of stress.

Question 38

How does cognitive theory view the etiology of depression?

Answer 38

People with depression/people prone to depression, are more likely to appraise situations negatively and will be more likely to experience negative mood in response to such situations.

According to Beck’s model, the foundation of the depressed person’s negative cognitive style is the depressive schema. (Schemas are hypothetical structures in the mind that contain core beliefs about the self, the world, and the future—the cognitive triad.)

The key feature of the depressed individual’s schemas are their rigidly negative quality (e.g., “I’m a failure,” “My future is hopeless,” “No one loves me”), from negative experiences early in life (which is complementary to psychodynamic theory).

Beck’s cognitive model is a diathesis-stress model. Specifically, Beck proposed that the negative cognitive schemas of the depression-prone person remain inactive in the mind, and thus serve as silent vulnerability factors (diatheses) that do not express themselves until activated, or “primed,” by a stressful life event that matches the theme of the schema.

So a negative cognitive style may be a cause of depression and not just part of the symptom profile once the disorder has started.

Question 39

What is the negative attentional bias seen in depression?

Answer 39

Research has also focused on how persistently negative ways of thinking makes depressed individuals more likely than never-depressed individuals to preferentially attend to negative information in their environment.

(In direct contrast, individuals with bipolar disorder have been shown to display preferential attention to positive stimuli, and particularly cues of reward or incentive, in the environment when they are in the manic or euthymic phases of the illness.)

Question 40

True or False?

The negative attentional bias seen in depression was even shown to affect young girls who had never themselves been depressed, but whose mothers had a history of depression.

Answer 40

True.

Further, the presence of a negative attentional bias predicted these girls’ development of depression in adolescence. Dr. Joelle LeMoult reported success in training girls with a maternal history of depression to direct their attention away from negative stimuli as a way to repair negative mood.

Question 41

How does the interpersonal model view the etiology of depression?

Answer 41

There is emerging evidence that a particular type of impaired social skill—negative feedback seeking—may serve as a risk factor for depression. According to Dr. William Swann’s self-verification theory, negative feedback seeking is defined as the tendency to actively seek out criticism and other negative interpersonal feedback from others that is consistent with their self-schemas.

There is also evidence that an excessive need for inter- personal attachment, support, and acceptance (i.e., interpersonal dependency) leads to behaviours that cause and maintain depression (ie: excessive reassurance seeking).

Question 42

How does the life stress perspective view the onset of depression?

Answer 42

Individuals with depression are nearly three times more likely than those without depression to have experienced a stressful life event prior to onset.

In individuals with bipolar disorder, negative loss events preferentially predict increases in depressive symptoms, whereas life events related to reward and goal attainment (e.g., getting into graduate school, recognition for a work success) preferentially predict increases in manic symptoms.

Life Stressors:

1) Childhood stressful events (abuse, maltreatment etc) which is then is internalized by the child in the form of negative cognitive schemas (“I’m unlovable”).

Question 43

True or False?

child abuse is associated with the death of cells in the hippocampus and amygdala. , two areas of the brain that are critically involved in the regulation of mood and emotional memory.

Answer 43

True.

These two areas of the brain that are critically involved in the regulation of mood and emotional memory. Child abuse is associated with dysregulation of the body’s biological stress response system—the hypothalamic-pituitary-adrenal (HPA) axis. Research suggests that child abuse even leaves marks at the genomic level; that is, it affects the way different genes turn on and off over the lifespan.

Question 44

What Biological Casual Factors contribute to the etiology of mood disorders?

Answer 44

Genetics - MDD and BPD run in families. Heritability estimate for MDD = 0.36 and BPD = 0.75. Candidate genes include: serotonin transporter gene (HTT) - the “s” allele of the HTT gene is associated with the sort of negative cognitive style and personality described earlier that indicates a vulnerability to depression.

Neurotransmitters - low NE (norepinephrine) activity appears to be a key feature of both bipolar disorder and severe unipolar depression. Depressed individuals have fewer 5-HT (indoleamine serotonin/5-hydroxytryptamine) receptors. low levels of DA (dopamine) neurotransmitter are thought to be responsible for depressed individuals’ reduction in the capacity to experience pleasure and their symptoms of psychomotor retardation. Abnormal DA levels may trigger the hyperactivity and psychosis seen in severe mania. Abnormal NE levels may trigger euphoria and grandiosity. Low levels of 5-HT can lead to activation (or disinhibition) of a variety of behaviours. Therefore, a defect in the inhibitory effects of serotonin could lead to wide swings between depression and mania.

Hypothalamic-pituitary-adrenal (HPA) axis: how stress is modulated. Depressed individuals, and those who have been exposed to traumatic stressors, show elevated levels of cortisol in comparison to control groups. Activation of the HPA axis results in the release of pro-inflammatory cytokines, which are part of the immune response. individuals with depression have higher levels of certain pro-inflammatory cytokines than non-depressed individuals, and that high levels of these same cytokines prospectively predict the onset of depression.

Sleep physiology - When suffering from depression, people experience a loss of slow-wave sleep and an early onset of the first REM stage, which appear to be controlled by 5-HT and NE, uggesting that they may play a role in causing the disorder. People with bipolar disorder have a genetic vulnerability to sleep–wake cycle disruption. And sleep deprivation triggers the onset of mania in approximately 77 percent of bipolar patients.

Neuroimaging - Both bipolar and unipolar depression are associated with decreased blood flow and reduced glucose metabolism in the frontal regions of the cerebral cortex, particularly on the left side. Interestingly, there is a reversal of this effect when patients shift from depression into mania, with greater right hemisphere reductions seen in mania. Increased glucose metabolism has also been observed in several subcortical regions in depression. Depressed individuals showed elevated activity in the amygdala when they rated the negative words - a key feature of depression may be the inability to disengage from negative information. They cannot shut off their brains when faced with negative information and they continue to ruminate about this information even after the stimulus itself is no longer present.

Question 45

True or False?

Individuals with a family history of bipolar disorder tend to develop the disorder earlier (i.e., in childhood or adolescence) than those without.

Answer 45

True.

Question 46

What is a neurotransmitter?

Answer 46

Chemical substances manufactured at the neuron and released at the synapse, or the gap between one neuron and another.

Question 47

The strongest risk factor for completed suicide is _______.

Answer 47

Being male.

(Males aged 19 to 24 and over 70 being at greatest risk.)

Question 48

What is the leading cause of death for First Nations males between the ages of 10 and 44?

Answer 48

Suicide.

Question 49

What is the number one cause of suicide?

Answer 49

Untreated mental disorder.

Question 50

Emile Durkheim believed that suicide is caused by a sense of “anomie”. What does this term mean?

Answer 50

The feeling that one is rootless and lacks a sense of belonging.

Question 51

While suicidal behaviour is likely determined by many genes, what candidate gene has received research attention?

Answer 51

The serotonin transporter gene (5-HTT).

Question 52

What two psychological theories of suicide predominate in the literature?

Answer 52

1) Interpersonal model - high levels of perceived burdensomeness, and thwarted belongingness + feelings of hopelessness about the future, lead to suicidal ideation and intent.

2) Motivational-Volitional model - Cognitions of defeat, humiliation, and entrapment in response to stressful life events will result in a motivation for suicidal ideation when motivational moderators, such as feelings of thwarted belongingness and perceived burdensomeness, are high. Suicidal ideation will progress to action when volitional moderators, such as acquired capability (habituation/fearlessness about death), impulsivity, and social models of suicide (e.g., family members or friends who have engaged in self-harm or suicide), are high.

Question 53

True or false?

Broad public education programs for suicide prevention are highly successful.

Answer 53

False.

Research examining such programs taught in high schools has found that they are not successful. In fact, some researchers have expressed concern that they actually plant the idea of suicide in vulnerable teens, thus increasing their risk.

Question 54

True or False?

Treating depression with standard anti-depressants or CBT is enough to reduce suicidal ideation and attempts.

Answer 54

False.

Question 55

What does CBT specifically designed to prevent suicide attempts involve?

Answer 55

1) identify and modify the thoughts, images, and core beliefs that were activated prior to previous suicide attempts.

2) address specific vulnerability factors for suicide, including hopelessness, poor problem solving, poor impulse control, and social isolation.

3)

Question 56

A small randomized controlled trial showed that a single intravenous infusion of ___________ resulted in a significant drop in suicidal ideation relative to placebo within 48 hours.

Answer 56

Ketamine.

(A glutamate N-methyl-d-aspartate (NMDA) receptor antagonist.