Mood Disorders

Question 1

• Mood Disorders

Answer 1

Disturbances of mood that are intense and persistent enoughto be clearly maladaptive.

• Severe alterations in mood for long periods of time
• Diverse in nature
• Abnormal mood is the defining feature
• emotional extremes
• other symptoms or co-occurring disorders

Keymoods in mood disorders include:

(1) Mania
(2) Depression

Question 2

Mania

Answer 2

Emotional state characterized by intense and unrealistic feelings of excitement and euphoria.

Question 3

Depression (General)

Answer 3

Emotional state characterized by extraordinary sadness and dejection.

Can be a disorder or a symptom of a disorder

Question 4

Mixed-Episode Case

Answer 4

Individual has both mania and depression at the same time

• Rapidly alternating moods (i.e. sadness, euphoria, and irritability) all within thesame episode of illness

Question 5

• Unipolar Depressive Disorders

Answer 5

Mood disorder in which a person experiences only depressive episodes, as opposed to bipolar disorder, in which both manic and depressive episodes occur.

• The most common form of mood disturbance involves depression.
• To be diagnosed with major depressive disorder, a person must be markedly depressed or lose interest in formerly pleasurable activities (or both) for at least two weeks.
• Other symptoms such as changes in sleep or appetite, or feelings of worthlessness must also be present

Question 6

• Bipolar Disorder

Answer 6

Mood disorders in which a person experiences both manic and depressive episodes.

In the bipolar disorders (cyclothymia and bipolar I and II disorders), the person experiences episodes of both depression and hypomania or mania. During manic or hypomanic episodes, the symptoms are essentially the opposite of those experienced during a depressive episode.
Mood stabilizer (lithium) most effective
- don't use antidepressants

Question 7

Manic Episode

Answer 7

A condition in which a person shows markedly elevated, euphoric, or expansive mood,often interrupted by occasional outbursts of intense irritability or even violence that lasts for at least 1 week. In addition, at least three out of seven other designated symptoms must also occur.·

• Elevated mood often interrupted by occasional outbursts of intense irritability or even violence—particularly when others refuse to go along with the manic person’swishes and schemes.
• Other designated symptoms include a notable increase in goal-directed activity, to mental symptoms where self-esteem becomes grossly inflated and mental activity may speed up (such as a “flight of ideas” or “racing thoughts”), to physical symptoms (such as a decreased need for sleep or psychomotor agitation).

Question 8

• Hypomanic Episode

Answer 8

A condition lasting at least 4 days in which a person experiences abnormally elevated,expansive, or irritable mood. At least three out of seven other designated symptoms similar to those in a manic episode must also be present but to a lesser degree than in mania (e.g., inflated self-esteem, decreased need for sleep, flights of ideas, pressured speech, etc.).

• Although the symptoms listed are the same for manic and hypomanic episodes, there is much less impairment in social and occupational functioning in hypomania, and hospitalization is not required.

Question 9

Prevalence of Unipolar Depressive Disorder

Answer 9

• Most common mood disorder
• NCS-R found a lifetime prevalence rates at nearly 17%
• rates are always much higher for women than men
• among school children, boys are equally likely or slightly more likely to be diagnosed with depression

Question 10

What symptoms are characteristic of depressive disorders?

Answer 10

Most people with mood disorders have some form of depressive disorder—dysthymia or major depression.

Such individuals experience a range of affective, cognitive, motivational, and biological symptoms including persistent sadness, negative thoughts about the self and the future, lack of energy or initiative, too much or too little sleep, and gaining or losing weight.

The DSM-IV-TR used to require a stay of diagnosis for the first two months. The DSM-5 no longer requires this.

Question 11

• Postpartum “Blues”

Answer 11

Very common

Symptoms Include: changeable mood, crying easily, sadness, and irritability, often liberally intermixed with happy feelings
- such symptoms occur in as many ads 50-70% of women within 10 days of birth

Postpartum blues or depression may be especially likely to occur if the new mother has lack of social support or has difficulty in adjusting to her new identity and responsibilities, or if the woman has a personal or family history of depression that leads to heightened sensitivity to the stress of childbirth

Question 12

• Persistent Depressive Disorder

Answer 12

A new DSM-5 disorder that involves long-standing depressed mood (2 years or more). The disorder incorporates dysthymic disorder and chronic major depression from DSM-IV.

• Quite common, with a lifetime prevalence estimated at between 2.5-6%
• Chronic stress has been shown to increase the severity of symptoms over a 7.5-year follow-up period
• Often begins during the teenage years, and over 50% of those who present for treatment have an onset before age 21
• aka dysthymia

Question 13

• Dysthymic Disorder

Answer 13

Moderately severe mood disorder characterized by a persistently depressed mood most of the day for more days than not for at least 2 years.

Additional symptoms may include poor appetite, sleep disturbance, lack of energy, low self-esteem, difficulty concentrating, and feelings of hopelessness.

Question 14

• Major Depressive Disorder

Answer 14

Moderate-to-severe mood disorder in which a person experiences only major depressive episodes but no hypomanic, manic, or mixed episodes. Single episode if only one; recurrent episode if more than one.

• To receive a diagnosis of major depressive disorder, a person must be in a major depressive episode and never have had a manic, hypomanic, or mixed episode
• Must experience either markedly depressed moods or marked loss of interest inpleasurable activities most of every day, nearly every day, for at least twoconsecutive weeks.
• very high levels of comorbidity between depressive and anxiety disorders (anxiety usually comes first - Bowlby)
• must experience additional symptoms during the same period (for a total of at least five symptoms)

These other symptoms may include:

(1) significant weight loss
(2) insomnia/hypersomnia
(3) psychomotor agitation
(4) fatigue
(5) feelings of worthlessness
(6) diminished ability to concentrate

Question 15

Recurrence

Answer 15

A new occurrence of a disorder after a remission of symptom

Recurrence and Depression:

• 40-50% will have a recurrence at some point
• Evidence that the probability of recurrence increases with the number of prior episodes and also when the person has comorbid disorders.

Question 16

Relapse

Answer 16

Return of the symptoms of a disorder after a fairly short period of time.

Question 17

• Characteristic Symptoms of Major Depressive Episode with Melancholic Features

Answer 17

Three of the following:

(1) Early morning awakening,
(2) depression worse in the morning,
(3) marked psychomotor agitation or retardation,
(4) loss of appetite or weight, excessive guilt,
(5) qualitatively different depressed mood.

Question 18

Characteristic Symptoms of Major Depressive Episode with Psychotic Features

Answer 18

Delusions or hallucinations (usually mood congruent); feelings of guilt and worthlessness common.

Question 19

Characteristic Symptoms of Major Depressive Episode with Atypical Features

Answer 19

Mood reactivity—brightens to positive events; two of the four following symptoms:

(1) weight gain or increase in appetite,
(2) hypersomnia,
(3) leaden paralysis (arms and legs feel as heavy as lead),
(4) being acutely sensitive to interpersonal rejection.

Question 20

Characteristic Symptoms of Major Depressive Episode with Catatonic Features

Answer 20

A range of psychomotor symptoms from motoric immobility to extensive psychomotor activity, as well as mutism and rigidity.

Question 21

• Characteristic Symptoms of Major Depressive Episode with Seasonal Pattern

Answer 21

At least two or more episodes in past 2 years that have occurred at the same time (usually fall or winter), and full remission at the same time (usually spring).
No other nonseasonal episodes in the same 2-year period.
Usually show increased appetite and hypersomnia rather than decreased appetite and insomnia

Question 22

Age and Incidence of Depression

Answer 22

Estimated that 1-3% of school-age children meet the criteria for some form of unipolar depressive disorder, with a smaller percentage exhibiting dysthymic disorder than major depression

Infants may experience a form of depression (formerly known as anaclitic depression or despair) if they are separated for a prolonged period from their attachment figure (usually their mother), although current thinking suggests this may not happen until at least 18 months of age

Incidence of depression rises sharply in adolescence

1-year prevalence of major depression is significantly lower in people over age 65 than in younger adults, major depression and dysthymia in older adults are still considered a major public health problem today

Research suggests that rates of depression among physically ill residents of nursing homes or residential care facilities are substantially higher than among older adults living at home

Question 23

Specifiers

Answer 23

Different patterns of symptoms that sometimes characterize major depressive episodes which may help predict the course and preferred treatments for the condition.

Question 24

• Major Depressive Disorder with Melancholic Features (Definition)

Answer 24

A type of major depressive episode which includes marked symptoms of loss of interest or pleasure in almost all activities, plus at least three of six other designated symptoms

• more heritable than most other forms of depression and is more often associated with a history of childhood trauma
• show greater cognitive impairment than with most other subtypes of depression

Question 25

Mood Congruent

Answer 25

Delusions or hallucinations that are consistent with a person’s mood.

Question 26

Severe Major Depressive Episode with Psychotic Features

Answer 26

Major depression involving loss of contact with reality, often in the form of delusions or hallucinations.

• they seem in some sense appropriate to serious depression because the content is negative in tone, such as themes of personal inadequacy, guilt, deserved punishment, death, or disease
• likely to have longer episodes, more cognitive impairment, and a poorer long-term prognosis than those suffering from depression without psychotic features, and any recurrent episodes are also likely to be characterized by psychotic symptoms

Question 27

• Major Depressive Disorder with Atypical Features

Answer 27

A type of major depressive episode which includes a pattern of symptoms characterized by marked mood reactivity, as well as at least two out of four other designated symptoms.

• A disproportionate number of individuals who have atypical features are females, who have an earlier-than-average age of onset and who are more likely to show suicidal thoughts
• Research shown that it is linked to a mild form of bipolar disorder that is associated with hypomanic rather than manic episodes. This is also an important specifier because there are indications that individuals with atypical features may preferentially respond to a different class of antidepressants—the monoamine oxidase inhibitors—than do most other individuals with depression.

Question 28

Major Depressive Disorder with Catatonic Features

Answer 28

A subset of major depressive disorders that is characterized by severe disturbances in motor function.

Question 29

Recurrent Major Depressive Episode with a Seasonal Pattern

Answer 29

A form of major depression where the episodes of depression recur on a regular seasonal basis (fall/winter), but not at other times of the year.

Question 30

• Seasonal Affective Disorder

Answer 30

Mood disorder involving at least two episodes of depression in the past 2 years occurring at the same time of year (most commonly fall or winter), with remission also occurring at the same time of year (most commonly spring).

• To meet DSM-5 criteria for this specifier, the person must have had at least two episodes of depression in the past 2 years occurring at the same time of the year (most commonly fall or winter), and full remission must also have occurred at the same time of the year (most commonly spring).
• Person cannot have had other, non-seasonal depressive episodes in the same 2-year period, and most of the person’s lifetime depressive episodes must have been of the seasonal variety.
• o Prevalence rates suggest that winter seasonal affective disorder is more common in people living at higher latitudes (northern climates) and in younger people.

Question 31

Double Depression

Answer 31

This condition is diagnosed when a person with dysthymia has a superimposed major depressive episode.

• appears to be very common, although it may be much less common in people with dysthymic disorder who never seek treatment
• recurrence is common

Question 32

Chronic Major Depressive Disorder

Answer 32

A disorder in which a major depressive episode does not remit over a 2-year period.

Question 33

Biological Factors of Unipolar Depression

Answer 33

• evidence of a moderate genetic contribution to the vulnerability for major depression and probably dysthymia as well (using family and twin studies)
• proming leads for specific genes that may be responsible for the genetic influences of unipolar mood disorders come from serotonin-transporter genes and genotype-environment interaction
• major depressions are clearly associated with multiple interacting disturbances in neurochemical, neuroendocrine, and neurophysiological systems.
• disruptions in circadian and seasonal rhythms are also prominent features of depression.

Question 34

• Psychosocial Theories of the Causes of Depressive Disorder

Answer 34

• Beck’s cognitive theory
• reformulated helplessness and hopelessness theories, which are formulated as diathesis-stress models, and a tendency to ruminate about one’s mood or problems exacerbates their effects.
• The diathesis is cognitive in nature (e.g., dysfunctional beliefs and pessimistic attributional style, respectively)
• stressful life events are often important in determining when those diatheses actually lead to depression.

Question 35

• Personality Factors of Unipolar Depression

Answer 35

Personality variables such as neuroticism may also serve as diatheses for depression.

Combining the neuroticism theory with the helplessness theory, it is important to note that there is evidence that people who are high on neuroticism are more sensitive to the effects of adversity relative to those low on neuroticism

Question 36

Psychodynamic and Interpersonal Theories of Unipolar Depression

Answer 36

Freud and Karl Abraham

emphasize the importance of early experiences (especially early losses and the quality of the parent–child relationship) as setting up a predisposition for depression.

noting the striking similarities between the symptoms of mourning and the symptoms of depression

Question 37

Monoamine Theory of Depression

Answer 37

depression was at least sometimes due to an absolute or relative depletion of one or both of these neurotransmitters at important receptor sites in the brain

• depletion could come about through impaired synthesis of these neurotransmitters in the presynaptic neuron, through increased degradation of the neurotransmitters once they were released into the synapse, or through altered functioning of postsynaptic receptors
• these neurotransmitters are now known to be involved in the regulation of behavioral activity, stress, emotional expression, and vegetative functions (involving appetite, sleep, and arousal)—all of which are disturbed in mood disorders

some studies have found the exact opposite of this hypothesis

Question 38

• Depression and the Brain

Answer 38

o evidence found from EEGs (people with depression show relatively low activity in the left hemisphere in these regions and relatively high activity in the right hemisphere) and PETs

The relatively lower activity on the left side of the prefrontal cortex in depression is thought to be related to symptoms of reduced positive affect and approach behaviors to rewarding stimuli, and increased right-side activity is thought to underlie increased anxiety symptoms and increased negative affect associated with increased vigilance for threatening information

orbital prefrontal cortex, which is involved in responsivity to reward, show decreased volume in individuals with recurrent depression relative to normal controls

Question 39

The Key Brain Regions Involved in Affect and Mood Disoders

Answer 39

(1) orbital prefrontal cortex and ventromedial prefrontal cortex
- orbiatal - decreased volume in individuals with recurrent depression
(2) Dorsolateral prefrontal cortex
(3) Hippocampus and Amygdala
- reduction of hippocampal volume may preceed onset of depression
- amygdala tends to show increased activation in depressed individuals
(4) Anterior cingulate cortex
- decreased volume and abnormally low levels of activation in patients with depression

Question 40

• Sleep and Depression

Answer 40

o Patients who are depressed often show one or more of a variety of sleep problems, ranging from early morning awakening, periodic awakening during the night (poor sleep maintenance), and, for some, difficulty falling asleep.

Such changes occur in about 80% of hospitalized patients with depression and in about 50% of outpatients with depression, and are particularly pronounced in patients with melancholic features.

Question 41

Behavioral Theories and Depression

Answer 41

people with depression do indeed receive fewer positive verbal and social reinforcements from their families and friends than do people who are not depressed and also experience more negative events, they have lower activity levels, and their moods seem to vary with both their positive and their negative experiences rates

behavioral theories of the causes of depression are no longer very influential

Question 42

• Beck’s Cognitive Theory

Answer 42

Certain kinds of early experiences can lead to the formation of dysfunctional assumptions that leave a person vulnerable to depression later in life if certain critical incidents (stressors) activate those assumptions

once activated, these dysfunctional assumptions trigger automatic thoughts that in turn produce depressive symptoms (behavioural, motivational, affective, cognitive and somatic), which further fuel the depressive automatic thoughts

Question 43

Negative Cognitive Triad (Beck)

Answer 43

Negative thoughts about the self, the world, and the future.

(1) negative thoughts about the self (“I’m ugly”; “I’m worthless”; “I’m a failure”);
(2) negative thoughts about one’s experiences and the surrounding world (“No one loves me”; “People treat me badly”); and
(3) negative thoughts about one’s future (“It’s hopeless because things will always be this way”

Question 44

• Learned Helplessness

Answer 44

A theory that animals and people exposed to uncontrollable aversive events learn that they have no control over these events and this causes them to behave in a passive and helpless manner when later exposed to potentially controllable events. Later extended to become a theory of depression.

first proposed by Martin Seligman (1974, 1975)

i.e. lab dogs exposed to random shocks

Question 45

• Hopelessness Theory

Answer 45

reformulated from the learned helplessness theory

A hopelessness expectancy was defined by the perception that one had no control over what was going to happen and by the absolute certainty that an important bad outcome was going to occur or that a highly desired good outcome was not going to occur.

Question 46

• Cyclothymic Disorder

Answer 46

Mild mood disorder characterized by cyclical periods of hypomanic and depressive symptoms

DSM-5 - cyclothymia is defined as a less serious version of full-blown bipolar disorder because it lacks certain extreme symptoms and psychotic features such as delusions and the marked impairment caused by full-blown manic or major depressive episodes.

Depressed phase of cyclothymic disorder - a person’s mood is dejected, and he or she experiences a distinct loss of interest or pleasure in customary activities and pastimes. In addition, the person may show other symptoms such as low energy, feelings of inadequacy, social withdrawal, and a pessimistic, brooding attitude. Essentially, the symptoms are similar to those in someone with dysthymia except without the duration criterion.

Symptoms of the hypomanic phase of cyclothymia are essentially the opposite of the symptoms of dysthymia. In this phase of the disorder, the person may become especially creative and productive because of increased physical and mental energy. There may be significant periods between episodes in which the person with cyclothymia functions in a relatively adaptive manner.

For a diagnosis there must be at least a 2-year span during which there are numerous periods with hypomanic and depressed symptoms (1 year for adolescents and children), and the symptoms must cause clinically significant distress or impairment in functioning (although not as severe as in bipolar disorder). Individuals with cyclothymia are at greatly increased risk of later developing full-blown bipolar I or II disorder. For this reason it is often recommended that they receive clinical attention.

Question 47

• Bipolar I Disorder

Answer 47

A form of bipolar disorder in which the person experiences both manic (or mixed) episodes and major depressive episodes.

The most important aspect of bipolar I disorder is the presence of mania.

People with bipolar I disorder experience episodes of mania and periods of depression. Even if the periods of depression do not reach the threshold for a major depressive episode, the diagnosis of bipolar I disorder is still given.

Question 48

Mixed Episode

Answer 48

A condition in which a person is characterized by symptoms of both full-blown manic and major depressive episodes for at least 1 week, whether the symptoms are intermixed or alternate rapidly every few days

Recent careful longitudinal follow-up of people presenting with a full-blown mixed episode or even a subthreshold mixed episode has shown that these individuals have a worse long-term outcome than those originally presenting with a depressive or a manic episode

Question 49

• Bipolar II Disorder

Answer 49

A form of bipolar disorder in which the person experiences both hypomanic episodes and major depressive episodes.

People with bipolar II disorder experience periods of hypomania but their symptoms are below the threshold for full-blown mania.
The person diagnosed with bipolar II disorder also experiences periods of depressed mood that meet the criteria for major depression.

Question 50

• Bipolar Depressive Episode v.s. Unipolar Depression

Answer 50

People with a bipolar depressive episode tend to show more mood labililty, more psychotic features, more Psychomotor retardation, and more substance abuse
individuals with unipolar depression tend to show more anxiety, agitation, insomnia, physical complaints, and weight loss
Research indicates that major depressive episodes in people with bipolar disorder are usually more severe than those seen in unipolar disorder and they also cause more role impairment
On average, people with bipolar disorder suffer from more episodes during their lifetimes than do persons with unipolar disorder (although these episodes tend to be somewhat shorter, averaging 3 to 4 months)

Question 51

Causal Factors of Bipolar Disorder

Answer 51

Biological causal factors probably play an even more prominent role for bipolar disorders than for unipolar disorders.
The genetic contribution to bipolar disorder is among the strongest of such contributions to the major psychiatric disorders.
Neurochemical imbalances, abnormalities of the hypothalamic-pituitary-adrenal axis, and disturbances in biological rhythms all play important roles in bipolar disorders.
Stressful life events may be involved in precipitating manic or depressive episodes, but it is unlikely that they cause the disorder.

Question 52

• Suicide

Answer 52

Suicide is a constant danger with depressive syndromes of any type or severity. Accordingly, an assessment of suicide risk is essential in the proper management of depressive disorders.

Suicide now ranks among the 10 leading causes of death in most Western countries

Seems to coincide with psychopathology, loss, and sometimes high creativity

Coincides with feelings of hoplessness and strong implicit associations between the self and death

People between 18 and 24 years old have the highest rates
Rates with children are increasing (3rd most common cause of death in USA, age 15-19)

Genetic factors may play a role religious taboos are important determinants of rates

Question 53

What role does ambivalence play in thoughts of suicide?

Answer 53

A small minority of suicides appear unavoidable—chiefly those where the person really wants to die and uses a highly lethal method. However, a substantial amount of suicidal behavior is performed as a means of indirect interpersonal communication.

Somewhere between these extremes is a large group of people who are ambivalent about killing themselves and who initiate dangerous actions that they may or may not carry to completion, depending on momentary events and impulses.

Question 54

Types of Emotions Behind Suicide

Answer 54

(1) Do not really wish to die but instead want to communicate a dramatic message to others concerning their distress. Their suicide attempts tend to involve nonlethal methods such as minimal drug ingestion or minor wrist cutting. Usually arrange matters so that intervention is inevitable.
(2) A small minority of suicidal people are seemingly intent on dying. They give little or no warning of their intent, and they generally rely on the more violent and certain means of suicide such as shooting themselves or jumping from high places.
(3) Ambivalent about dying and tend to leave the question of death to fate. A person in this group may entertain and tend to use methods that are often dangerous but moderately slow acting, such as drug ingestion. The feeling during such attempts can be summed up as, “If I die, the conflict is settled, but if I am rescued that is what was meant to be.”

Question 55

• Suicide Prevention

Answer 55

Suicide prevention (or intervention) programs generally consist of crisis intervention in the form of suicide hotlines. Although these programs undoubtedly avert fatal suicide attempts in some cases, the long-term efficacy of treatment aimed at preventing suicide in those at high risk is much less clear at the present time.

Lithium and Benzodiazepines have proven effective as treatments