Week 8 Mood disorders

Question 1

Characteristics of of Mood Disorders

Answer 1

Feelings
Behavioural Symptoms
Motivational changes
Physical symptoms
Cognitive features

Question 2

Depressive Disorders

Answer 2

Disruptive Mood Dysregulation Disorder

Major Depressive Disorder
– Single episode
* Mild/moderate/severe/with psychotic features/in partial remission/in full remission/unspecified
– Recurrent episode
Mild/moderate/severe/with psychotic features/in partial remission/in full remission/unspecified

Persistent Depressive Disorder
(Dysthymia) - chronicity, 2 years

Premenstrual Dysphoric Disorder

Question 3

Bipolar and Related Disorders

Answer 3

Bipolar I Disorder
– Current or most recent episode manic
* Mild/moderate/severe/with psychotic features/in partial remission/in full remission/unspecified
– Current or most recent episode hypomanic
* In partial remission/in full remission/unspecified
– Current or most recent episode depressed
* Mild/moderate/severe/with psychotic features/in partial remission/in full remission/unspecified

Bipolar II Disorder

Cyclothymic Disorder

Due to another Medical Condition

Question 4

Manic Episode

Answer 4

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 hospitalisation is necessary)

Question 5

Hypomanic Episode

Answer 5

A distinct period of abnormally and persistently elevate, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day

Not severe enough to cause marked impairment in social or occupational functioning, or necessitate hospitalisation, and there are no psychotic features, the episode is manic

Question 6

Prevalence of Mood Disorders

Answer 6

UK Figures (NICE, 2014):
* Major Depressive Disorder 5%-10% (primary care) and 10%-14% (medical inpatients)
* 10%-15% of older people have symptoms of DP
* Risk of relapse is 50%, 70%, and 90% after 1st, 2nd, 3rd episodes respectively
* Rate in women is twice as high as in men

Question 7

Psychodynamic Explanations

Answer 7

Depression is a response to loss of a loved one
(Freud, 1917/1963 and Abraham, 1916/1960)
Introjection
– Regression to oral stage of development allowing integration of identity of loved one lost with own
– Direct feelings for loved one onto self
– Leads to self-hatred and low self-esteem
* Adds to feelings of depression and hopelessness
* Freudian concept of ‘symbolic loss’

Question 8

Behavioural Explanations

Answer 8

Depression results from a lack of
appropriate reinforcement for positive and
constructive behaviours (Lewinsohn, 1974)
Life losses
– Lead to extinction of existing behaviours
– Individual becomes inactive and withdrawn
Vicious cycle
– Individual – lack of initiative, withdrawal and
demeanour unlikely to lead to reinforcement

Question 9

Behavioural Explanations cont.

Answer 9

Individuals with depression sig more likely
to elicit negative responses in others
(Joiner, 2002)

Interpersonal Theories
– Reassurance-seeking behaviour by individuals with depression rejected by family and friends maintains depression (Joiner, 1995)
– Individuals doubt reassurances, continual
doubting annoys friends and family (Joiner &
Metalsky, 1995)

Question 10

Beck’s Cognitive Theory (1967, 1987)

Answer 10

Depression is a result of biases in ways of thinking and processing information

Negative Schema
– Set of beliefs that tends individuals towards viewing the world and themselves in a negative way

– Relatively stable characteristics of the individual’s personality
– Develop due to early adverse childhood experiences
– Reactivated by stressful life experiences
– Maintain some interrelated aspects of negative thinking – negative triad

Question 11

Negative Triad

Answer 11

Themselves ‘I am ugly, worthless, a failure’
->
Their Future ‘I’m hopeless because things will always be this way’
->
The World ‘…no one loves me’

Self-fulfilling prophecy
Systematic biases in thinking

Question 12

Self-fulfilling Prophecy

Answer 12

Negative Triad (negative views of the self, the world and the future)
->
Cognitive biases (all events interpreted negatively)
->
Failure and losses (individual fails to take initiatives and opportunities are lost)
->
Depression

Question 13

Thinking Biases in Beck’s Model - Arbitrary inference

Answer 13

Conclusion drawn on lack of evidence or
contrary evidence

Question 14

Selective abstraction

Answer 14

Abstracting detail out of context, missing significance of total situation

Question 15

Overgeneralisation

Answer 15

Unjustified generalisation on basis of
single incident (e.g., ‘I never do anything
right’)

Question 16

Magnification and minimisation

Answer 16

Scratch on car means it needs replacing

Question 17

Personalisation

Answer 17

Interpreting events in terms of personal
meaning

Question 18

All-or-nothing (dichotomous) thinking

Answer 18

Event labelled as black or white, good or
bad, wonderful or horrible (e.g.,
everyone will either accept or reject you)

Question 19

Learned helplessness and Attribution

Answer 19

Seligman (1975)
– Depression follows unavoidable negative life events
– A cognitive set that makes individuals learn to become
‘helpless’, lethargic and depressed
Experiencing unavoidable traumatic losses or failures may cause learned helplessness (Seligman, 1975)

Learning to be helpless produces symptoms of depression such as lack of initiative

Perceived uncontrollability of events

Question 20

Learned helplessness cont.

Answer 20

Attribution theories
– Abramson, Seligman & Teasdale (1978)

People become depressed because of their
attributional styles

Attribute negative events to causes that cannot easily be changed or manipulated

Question 21

Attributional Styles

Answer 21

Individuals with depression tend to
attribute negative events to:
– Internal rather than external factors
– Stable rather than unstable factors
– Global rather than specific facto

Question 22

Hopelessness Theory

Answer 22

Hopelessness (Abramson, Metalsky & Allow,
1989)
– Negative attributional style
* Positive outcomes will NOT occur
* Negative outcomes WILL occur
* Have no responses available to change this state of affairs

Question 23

Hopelessness Theory cont.

Answer 23

Negative attributional style together with experiencing negative life events

• Gives rise to a cluster of symptoms of depression

Lack of initiative
Apathy
Lack of energy
Feelings of hopelessness

Question 24

Genetic Factors

Answer 24

Both bipolar and major depressive symptoms
run in families (Gershon, 2000)
– Bipolar Disorder
* 10%-25% of 1st degree relatives also report significant
symptoms of a mood disorder (Gershon, 2000)
* 7% 1st degree relatives also have BP (Kelsoe, 2003)– Major Depression
* 5%-10% depressive symptoms (Kendler et al., 1993)

MD -> MZ 46%-> DZ 20%
BD -> MZ 58%-> DZ 17%

Question 25

Neurochemical Factors

Answer 25

Delgardo & Moreno (2000)
– Serotonin
– Norepinephrine
Depression can be alleviated by drugs that
raise the levels of serotonin and norepinephrine
* Tricyclic Drugs
* Monoamine Oxidase Inhibitors
* Selective Serotonin Reuptake Inhibitors (SSRIs)

Question 26

Drug Therapy for Major Depression

Answer 26

Tricyclic Drugs (e.g. imipramine)

Monoamine Oxidase Inhibitors (MAOIs)
(e.g. tranylcypromine)

Selective Serotonin Reuptake Inhibitors
(SSRIs) (e.g. Prozac)

Increase levels of serotonin and norepinephrine

Question 27

Drug Therapy for Bipolar Disorder

Answer 27

Lithium carbonate main drug treatment

Around 80% of sufferers benefit from
lithium

As yet unclear exactly how lithium
moderates bipolar symptoms (Swonger &
Constantine, 1983)

Question 28

Side effects of Drugs used to Treat Depression

Answer 28

Tricyclic - blurred vision, anxiety, fatigue, dry mouth, increased risk of heart attack and stroke, constipation, gastric disorders, hypotension, sexual dysfunction, weight gain

Question 29

Side effects cont.

Answer 29

MAOIs -> hypertension, dry mouth, dizziness, headaches and nausea

SSRIs -> Anxiety, fatigue, gastric disorders, headaches, sleeping difficulties

Lithium -> Cardiac arrhythmia, fatigue, blurred vision, tremors; on overdose can cause delirium, convulsions and fatalities

Question 30

Bini (1938)

Answer 30

Used primarily with severely depressed
individuals who do not respond to other
treatment

Considerable debate over the
effectiveness of ECT as a treatment for
depression (Breggin, 1997)

Electro-shock therapy, induce a fit
used primarily with individuals who are not responding to other forms of treatment and are severely depressed

Question 31

Social Skills Training

Answer 31

An inability to communicate and socialise appropriately

Addressing skill deficits
Features:
– Role playing tasks, feedback, modelling and positive reinforcement for appropriate behaviours
– Attention to the specific details of social interactions such as
smiles, gestures, and the use of eye contact
Clients show an increase in social skills and a decrease in
depression symptoms (Zeiss et al., 1979)

Question 32

Behavioural Activation

Answer 32

Lack of reward generates depressive symptoms

Increasing client’s access to pleasant
events and rewards

Daily monitoring of pleasant/unpleasant
events

Social skills and time management training

As effective as many other psychotherapies (Hopko et al., 2003)

Question 33

Behavioural Activation Therapy

Answer 33

8-15 sessions
1. Assess function of DP behaviour; establishing
rapport; introducing treatment rationale
2. Increasing the frequency/reinforcement of
healthy behaviour; weekly self-monitoring
exercise (insight and focus on target behaviour)
3. Identification of behavioural goals (e.g.,
relationships, education, employment,
recreational activities)
4. Construction of activity hierarchy

Question 34

Cognitive Therapy

Answer 34

Derives primarily from the work of Aaron Beck

Helping individuals identify their negative beliefs
->
Assisting clients to challenge these negative beliefs as dysfunctional and irrational
->
Replacing negative and dysfunctional thoughts with adaptive and rational beliefs

Question 35

Mindfulness-based Cognitive Therapy

Answer 35

CBT Theory and mindfulness-based stress reduction
Mindfulness
Elements of meditation
Redirection of attention

MBCT
– Awareness of all incoming thoughts and feelings
– Accepting, not attaching or reacting
Helps protect against relapse (Ma & Teasdale, 2004)
– Research supports the effects of MBCT in people who have been depressed three or more times and demonstrates reduced relapse rates by 50% (Teasdale, 2004)

Question 36

Beating the Blues

Answer 36

Based on CBT
– Computerised CBT

Helps people to learn to cope with AN and DP

Recommended for use in the NHS by NICE

Evidence base (RCTs)
– An effective treatment for AN and DP and is better than GP treatment as usual

Question 37

Janet Case Study

Answer 37

Therapist and Janet decide Adam only a small part of the problem
To work together on an individual basis
Precipitating factor = Janet’s divorce

• Increased financial burden
• Impact on interpersonal relationships
• Relationship had been an important part of how Janet thought about herself

Therapist adopted a problem-solving approach

Initial focus to shift preoccupation from unpleasant factors
– Janet asked to list activities had enjoyed

Question 38

Janet cont.

Answer 38

List included:
– Riding horses
– Talking with a friend over a cup of coffee
– Listening to music late at night after the children were asleep
– Going for walks in the woods behind her home
Choose one, try twice before next meeting
Contact campus riding club

Interactions with others
– Identified problematic areas for Janet, discussed solutions and role-played various social interactions

Question 39

Janet setback

Answer 39

During first few weeks Janet’s mood seemed to be improving

Janet also found a part time job at local riding stable

Serious setback followed
– Financial aid discontinued, no longer keep up mortgage payments and
received a letter from bank
– Comment re: a fault with her car that required fixing immediately –
‘that’s a good way to kill yourself’

Janet’s appearance noticeably changed and she was lethargic, tearful and pessimistic
– Experiencing intrusive thoughts about suicide

Question 40

Janet referred to Psychiatrist

Answer 40

Increase frequency of appointments to 3x/wk

Thoughts not particularly lethal, no intent, frightened by idea of death, no specific plan

3 weeks later
– Mood seemed to lighten, suicidal ideation disappeared, financial situation resolved, resumed normal activities, problem-solving and social skills programme worked well

Addressed Adam’s behaviour – beh techniques
Therapy discontinued after 9 months
– Planning on returning to school, dating a man from work, continued
to take med., managed to keep house, children happy

Question 41

Janet: Psychodynamic

Answer 41

Formed a serious of dependent
relationships with men

Incurred loss by separation and divorce
from David
Resented separation deeply
However, Janet was open in David’s
presence re: anger and resentment
– Seems unlikely therefore that Janet’s depression was a simple manifestation of misdirected hostility

Question 42

Janet: Behavioural

Answer 42

Following the separation and divorce Janet
became isolated
– Janet discontinued minimal efforts she had
made to socialise with friends of her and David
– Best friend became distant
Lack of reinforcement re: interpersonal relating – extinction of behaviours?
Elicitation of negative responses in others
– Rejection of Janet’s reassurance-seeking
behaviour?

Question 43

Thinking Biases in Beck’s Model: Janet: Some examples

Answer 43

Magnification and minimisation ->
E.g., scratch on car means
it needs replacing ->Differences (spending money on clothes, not liking sport, wanting to talk about the relationship) blown out of proportion – felt like terrible sins

Personalisation -> Interpreting events in
terms of personal meaning -> Differences interpreted as being solely her
fault

Overgeneralisation -> Unjustified generalisation on basis of single incident
(e.g., ‘I never do anything
right’) -> Believed ‘My first marriage has failed, I will never have a satisfactory relationship with
another man’

Question 44

Janet: Hopelessness Theory

Answer 44

Failed marriage (aversive event)
->
‘It was my fault because I’m a poor marital partner’…and characteristic in
her interactions with all men’ (attribution to internal, stable and global factors)
->
‘There’s nothing I can do to change things’
Maintained that she would never be able
to change this pattern of behaviour
->
Depression

Question 45

Janet: Biological

Answer 45

Several neurotransmitters implicated in
depression – dopamine, serotonin,
norepinephrine (Kring et al., 2010, p.35).

Janet prescribed Fluoxetine (Prozac)

SSRI
– Act on neurotransmitter Serotonin
– Selectively inhibit the reuptake of serotonin,
increasing amount in synaptic cleft (Oltmanns et al., 2009)