]Module 5 | Mood Disorders

I. Mood Disorders along the Continuum

• Functional: Feeling blue or down but able to function normally; feeling happy and
exuberant because something good happened.
• Dysfunctional: Expansive mood including irritability, grandiosity, racing thoughts,
and a decreased need for sleep that significantly interferes with functioning. Severe
symptoms of sadness, apathy, hopelessness, low energy, etc., that significantly interfere
with functioning.
A. Depressive Disorders
• Major Depressive Disorder
• Persistent Depressive Disorder
• Premenstrual Dysphoric Disorder
• Disruptive Mood Dysregulation Disorder
• Substance/Medication-Induced Depressive Disorder
• Depressive Disorder Due to Another Medical Condition
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder
• Unspecified Mood Disorder

B. Other Specified Depressive Disorder

• Recurrent Brief Depression
• Short-Duration Depressive Episode (4-13 days)
• Depressive Episode with Insufficient Symptoms
• Major Depressive Episode Superimposed

C. Bipolar and Related Disorders

• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Substance/Medication-Induced Bipolar and Related Disorder
• Bipolar and Related Disorder Due to Another Medical Condition
• Unspecified Bipolar and Related Disorder
• Other Specified Bipolar and Related Disorder
• Unspecified Mood Disorder

D. Other Specified Bipolar and Related Disorder

• Short-Duration Hypomanic Episodes (2-3 days) and Major Depressive Episodes
• Hypomanic Episodes with Insufficient Symptoms and Major Depressive Episodes
• Hypomanic Episode without Prior Major Depressive Episode
• Short-Duration Cyclothymia (Less than 24 months)
• Manic Episode Superimposed

II. Understanding and Defining Mood Disorders

A. Overview of Depression and Mania
• Major Depressive Episode: A period in which the individual experiences intense
psychological and physical symptoms accompanying feelings of overwhelming sadness
(dysphoria).
• Manic Episode: A person shows a markedly elevated, euphoric, or expansive mood for
at least 7 days, often interrupted by occasional outbursts of intense irritability or even
violence.
• Hypomanic Episode: A person experiences abnormally elevated, expansive, or irritable
mood for at least 4 days and is not severe enough to cause marked impairment.

B. Major Depressive Episode

Mnemonic for Symptoms of Major Depressive Episode
S - Sleep disorder (either increased or decreased sleep)
I - Interest deficit (anhedonia)
G - Guilt (worthlessness, hopelessness, regret)
E - Energy deficit
C - Concentration deficit
A - Appetite disorder (either decreased or increased)
P - Psychomotor retardation or agitation
S - Suicidality

C. Manic Episode
Mnemonic for Symptoms of Manic Episode
D - Distractibility
I - Indiscretion
G - Grandiosity
F - Flight of ideas
A - Activity increase
S - Sleep deficit (decreased need for sleep)
T - Talkativeness (pressured speech)
D. Hypomanic Episode
Mnemonic for Symptoms of Hypomanic Episode
D - Distractibility
I - Indiscretion
G - Grandiosity
F - Flight of ideas
A - Activity increase
S - Sleep deficit (decreased need for sleep)
T - Talkativeness (pressured speech)

III. Prevalence of Mood Disorders

A. Course, Outcome and Frequency of Depressive Disorders
• People with depressive mood disorders, typically, have their first episode in their early
thirties; the average age of onset is 32.
• The results of long-term follow-up studies of treated patients indicate that a major
depressive disorder is frequently a chronic and recurrent condition in which episodes of
severe symptoms may alternate with periods of full or partial recovery.
• Approximately half of all depressive patients recover within six months of the
beginning of an episode. After recovery from an episode of major depression, the risk of
relapse goes down as the period of remission increases. The longer the person remains
free of depression, the better his or her chance of avoiding relapse.

B. Course, Outcome and Frequency of Bipolar Disorders

• Onset of bipolar disorders usually occurs between the ages of 18 and 22 years, which is
younger than the average age of onset for depressive disorders.
• The long-term course of bipolar disorders is most often intermittent.
• The long-term prognosis is mixed for patients with bipolar disorder. Although some
patients recover and function very well, others experience continued impairment.
C. Incidence and Prevalence
• Lifetime risk for persistent depressive disorder (dysthymia) was approximately 3
percent and 16 percent for major depressive disorder.
• The lifetime risk for bipolar I and II disorders combined was close to 4 percent.
• Depressive disorders are much more common than bipolar disorders. The ratio of
depressive to bipolar disorders is at least 5:1.

D. Gender Differences
• Women are two or three times more vulnerable to depression than men are.
• Some observers have suggested that the high rates for depression in women reflect
shortcomings in the data collection process.
• Culturally determined sanctions make it more difficult for men to admit to subjective
feelings of distress, such as hopelessness and despair.

IV. Depressive Disorders

A. Major Depressive Disorder
• 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.
B. Depression as a Recurrent Disorder
• When a diagnosis of MDD is made, it is usually also specified whether this is a first,
and therefore, single episode or a recurrent episode.
• Depressive episodes typically last about 6 to 9 months if untreated.
• Although most depressive episodes remit, depressive episodes often return at some
future point. This return of symptoms is of one of two types: relapse (part of the cycle;
shortly after a period of recovery, let us say a year, they experience symptoms again) and
recurrence (long after a period of recovery).

C. Depression throughout the Life Cycle

• The incidence of depression rises sharply during adolescence—a period of great turmoil
for many people.
• The occurrence of major depression continues into later life.
• Depression in later life can be difficult to diagnose because many of the symptoms
overlap with those of several medical illnesses and dementia.

D. Specifiers for Major Depressive Episodes

• Anxious Distress: Prominent anxiety symptoms.
• Mixed Features: Presence of at least three manic/hypomanic symptoms, but does not
meet criteria for a manic episode.
• Melancholic Features: The full criteria for a major depressive episode have been met.
• Psychotic Features: Presence of mood-congruent or mood-incongruent delusions or
hallucinations.
• Catatonic Features: Not actively relating to the environment, mutism, posturing,
agitation, or mimicking another’s speech or movements.
• Atypical Features: Individuals with this specifier consistently oversleep and overeat
during their depression.
• Peripartum Onset: Onset of a major depressive episode during pregnancy or in the 4
weeks following delivery.
• Seasonal Pattern: History of at least 2 years in which major depressive episodes occur
during one season of the year and remit when the season is over.

E. Persistent Depressive Disorder (Dysthymia)

• A disorder characterized by a persistently depressed mood most of the day, for more
days than not, for at least 2 years for adults or 1 year for children and adolescents.
• Although persistent depressive disorder is distinct from MDD, the two disorders
sometimes co-occur in the same person, a condition given the designation double
depression.
• It is quite common, with a lifetime prevalence estimated at between 2.5 and 6 percent.
• It often begins during adolescence, and over 50 percent of those who present for
treatment have an onset before age 21.
• With pure dysthymic syndrome: Full criteria for a major depressive episode have not
been met in at least the preceding 2 years.
• With persistent major depressive episode: Full criteria for a major depressive episode
have been met throughout the preceding 2-year period.
• With intermittent major depressive episodes, with current episode: Full criteria for a
major depressive episode are currently met, but there have been periods of at least 8
weeks in at least the preceding 2 years with symptoms below the threshold for a full
major depressive episode.
• With intermittent major depressive episodes, without current episode: Full criteria
for a major depressive episode are not currently met, but there has been one or more
major depressive episodes in at least the preceding 2 years.
F. Premenstrual Dysphoric Disorder (PMDD)
• Changes in mood, irritability, dysphoria, and anxiety that occur during the
premenstrual phase of the monthly menstrual cycle and subside after the menstrual
period begins for most of the cycles of the preceding year.
• Critics argue that the PMDD diagnosis pathologizes the normal variations in mood
that can occur over the course of a woman’s monthly menstrual cycle.
• By making this disorder part of the standard psychiatric nomenclature, better diagnosis
and treatment could be available for women who experience its symptoms.
G. Disruptive Mood Dysregulation Disorder
• A depressive disorder in children who exhibit chronic and severe irritability and have
frequent temper outbursts.
• The disorder was meant to address the fact that many children with these symptoms
may have been diagnosed and treated for bipolar disorder.
V. Biological Causal Factors in Unipolar Mood Disorders
A. Genetic Influences
• Family studies have shown that the prevalence of mood disorders is approximately two
to three times higher among blood relatives of persons with clinically diagnosed unipolar
depression than the general population.
• Monozygotic co-twins of a twin with MDD are about twice as likely to develop the
disorder as are dizygotic co-twins, with about 31 to 42 percent of the variance in liability
due to genetic influence.
• One candidate for a specific gene that might be implicated in depression is the
serotonin-transporter gene—a gene involved in the transmission and reuptake of
serotonin.
B. Neurochemical Factors
• The monoamine theory of depression suggested that depression was at least
sometimes due to an absolute or relative depletion of serotonin and norepinephrine or
both at important receptor sites in the brain.
• Dopamine dysfunction - reduced dopaminergic activity plays a significant role in at
least some forms of depression, including depression with atypical features and bipolar
depression.
• A number of integrative theories have been proposed that include a role for
neurotransmitters, not alone but rather as they interact with other disturbed hormonal
and neurophysiological patterns and biological rhythms.

C. Abnormalities of Hormonal Regulatory and Immune Systems

• The majority of attention has been focused on the hypothalamic-pituitary-adrenal
(HPA) axis and, in particular, on the hormone cortisol.
• The other endocrine axis that has relevance to depression is the
hypothalamic-pituitary-thyroid axis.
• Depression is associated with the dysregulation of the immune system, specifically the
activation of the inflammatory response system.

D. Neurophysiological and Neuroanatomical Influences

• Several regions of the prefrontal cortex, including the orbital prefrontal cortex, which
is involved in responsivity to reward.
• Lower levels of activity in the dorsolateral prefrontal cortex, which are associated
with decreased cognitive control.
• Another area involved is the hippocampus, which is critical to learning and memory
and regulation of adrenocorticotropic hormones.
• The anterior cingulate cortex, which is implicated in self-regulation and adaptability,
has both decreased volume and abnormally low levels of activation in patients with
depression.
• The amygdala, which is involved in the perception of threat and in directing attention,
tends to show increased activation in individuals with depression.

E. Sleep and Other Biological Rhythms

• Many patients with depression enter the first period of REM sleep after only 60 minutes
or less of sleep, show greater amounts of REM sleep during the early cycles, and have
more intense and frequent rapid eye movements.
• Research has found some abnormalities in their circadian rhythms in patients with
depression, including drastic changes in mood, sleep, appetite, and social interactions.
• People with seasonal affective disorder show abnormalities in their responsiveness to
the total quantity of available light in the environment.
VI. Psychological Causal Factors in Unipolar Mood Disorders
A. Stressful Life Events as Causal Factors
• Many studies have shown that severely stressful life events often serve as precipitating
factors for unipolar depression.
• Most of the episodic stressful life events involved in precipitating depression concern
loss of a loved one, serious threats to important close relationships or to one’s
occupation, or severe economic or serious health problems.
• An important distinction has been made between stressful life events that are
independent of the person’s behavior and personality and events that may have been at
least partly generated by the depressed person’s behavior or personality.
• Research on stress and the onset of depression is complicated by the fact that people
with depression have a distinctly negative view of themselves and the world around
them.
• Researchers have developed more sophisticated interview-based measures of life stress
that do not rely on the depressed person’s self-report of how stressful an event is and that
take into account the biographical context of a person’s life.

B. Different Types of Vulnerabilities for Unipolar Depression

• Researchers have concluded that neuroticism is the primary personality variable that
serves as a vulnerability factor for depression.
• There is more limited evidence that high levels of introversion may also serve as
vulnerability factors for depression, either alone or when combined with neuroticism.
• A range of adversities in the early environment can create both a short-term and a
long-term vulnerability to depression.

C. Psychodynamic Theories
• Freud noted the important similarity between the symptoms of clinical depression and
the symptoms seen in people mourning the loss of a loved one.
• Freud and Karl Abraham both hypothesized that when a loved one dies the mourner
regresses to the oral stage of development and introjects or incorporates the lost person,
feeling all the same feelings toward the self as toward the lost person.
• Freud hypothesized that depression could also occur in response to imagined or
symbolic losses.
D. Behavioral Theories
• People become depressed either when their responses no longer produce positive
reinforcement or when their rate of negative experiences increases.
• 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.
• Behavioral theories of depression suggest that life stress leads to depression because it
reduces the positive reinforcers in a person’s life.

E. Beck’s Cognitive Theory

• Beck hypothesized that the cognitive symptoms of depression often precede and cause
the affective or mood symptoms rather than vice versa.
• There are the underlying dysfunctional beliefs, known as "depressogenic schemas,"
which are rigid, extreme, and counterproductive.
• These depression-producing beliefs or schemas are thought to develop during
childhood and adolescence as a function of negative experiences with parents and
significant others, and they are thought to serve as the underlying diathesis, or
vulnerability, to developing depression.
• Although they may lie dormant for years in the absence of significant stressors, when
dysfunctional beliefs are activated by current stressors or depressed mood, they tend to
fuel the current thinking pattern, creating a pattern of negative automatic thoughts.
• These pessimistic predictions tend to center on the three themes of what Beck calls the
negative cognitive triad, which include negative thoughts about (1) self, (2) world, and
(3) future.
• Overgeneralizing: If it’s true in one case, it applies to any case that is even slightly
similar.
• Using Selective Abstraction: Taking seriously only events that represent failures,
deprivation, loss, or frustration.
• Taking Excessive Responsibility: Feeling responsible for all bad things that happen to
you or to others to whom you are close.
• Assuming Temporal Causality: Assuming that if it has been true in the past, it’s always
going to be true.
• Making Excessive Self-References: Feeling at the center of everyone else’s attention
and assuming everyone can see your flaws and errors.
• Catastrophizing: Always thinking the worst and being certain that it will happen.
• Engaging in Dichotomous Thinking: Seeing everything as either one extreme or
another rather than as mixed or in between.

F. The Helplessness Theory of Depression

• It states that when animals or humans find that they have no control over aversive
events, they may learn that they are helpless, which makes them unmotivated to try to
respond in the future.
• Research demonstrated that helpless animals also show other depressive symptoms
such as lower levels of aggression, loss of appetite and weight, and changes in
monoamine neurotransmitter levels.
• People undergoing stressful life events over which they have little or no control may
develop a syndrome like the helplessness syndrome seen in animals.

G. The Reformulated Helplessness Theory of Depression

• People (probably unlike animals) are exposed to uncontrollable negative events; they
ask themselves why, and the kinds of attributions that people make are, in turn, central
to whether they become depressed.
• Investigators proposed three critical dimensions on which attributions are made: (1)
internal/external, (2) global/specific, and (3) stable/unstable.
• People who have a relatively stable and consistent pessimistic attributional style have a
vulnerability or diathesis for depression when faced with uncontrollable negative life
events.

H. The Hopelessness Theory of Depression

• 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.
• Depression-prone individuals not only tend to make global and stable attributions for
negative events but also tend to make negative inferences about other likely negative
consequences of the event and negative inferences about the implications of the event
for the self-concept.

I. The Ruminative Response Style Theory of Depression

• People have different kinds of responses when they experience feelings and symptoms
of sadness and distress, and their differing response styles affect the course of their
depression.
• Rumination involves a pattern of repetitive and relatively passive mental activity.
• There are stable individual differences in the tendency to ruminate, and people who
ruminate a great deal tend to have more lengthy periods of depressive symptoms.
VII. Bipolar and Related Disorders
A. Bipolar I Disorders
• 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.

B. Bipolar II Disorders
• 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.

C. Cyclothymic Disorder
• A mood disorder with symptoms that are more chronic and less severe than those of
bipolar disorder.
• People with this disorder have not fully met the criteria for a hypomanic episode many
times over a span of at least 2 years in adults or 1 year in children and adolescents and
also experience numerous periods of depressive symptoms but never meet the criteria for
a major depressive episode.
• During their respective time frames, adults, children, or adolescents have never been
without these symptoms for more than 2 months at a time.
D. Specifiers for Major Depressive Episodes
• Anxious Distress: Prominent anxiety symptoms.
• Mixed Features: Presence of at least three manic/hypomanic symptoms, but does not
meet criteria for a manic episode.
• Melancholic Features: The full criteria for a major depressive episode have been met.
• Psychotic Features: Presence of mood-congruent or mood-incongruent delusions or
hallucinations.
• Catatonic Features: Not actively relating to environment, mutism, posturing,
agitation, mimicking another’s speech or movements.
• Atypical Features: Individuals with this specifier consistently oversleep and overeat
during their depression.
• Peripartum Onset: Onset of major depressive episode during pregnancy or in the 4
weeks following delivery.
• Seasonal Pattern: History of at least 2 years in which major depressive episodes occur
during one season of the year and remit when the season is over.
E. Rapid-Cycling Specifier
• An individual with bipolar disorder who experiences at least four manic or depressive
episodes within a year is considered to have a rapid-cycling pattern.
• Approximately 20% to 50% of bipolar patients experience rapid cycling.
• There are also cases of ultra-rapid cycle lengths that only last for days to weeks and
ultra-ultra-rapid cycling in cases where cycle lengths are less than 24 hours.

VIII. Biological Causal Factors in Bipolar Disorders

A. Genetic Influences
• Approximately 8 to 10 percent of the first-degree relatives of a person with bipolar I
illness can be expected to have bipolar disorder, compared to 1 percent in the general
population.
• The average concordance rate is about 60 percent for monozygotic twins and only
about 12 percent for dizygotic twins. This and other studies suggest that genes account
for about 80 to 90 percent of the variance in the liability to develop bipolar I disorder.
• Efforts to locate the chromosomal site(s) of the implicated gene or genes in this genetic
transmission of bipolar disorder suggest that it is polygenic.

B. Neurochemical Factors
• The hypothesis being that if depression is caused by deficiencies of norepinephrine or
serotonin, then perhaps mania is caused by excesses of these neurotransmitters.
• Evidence for the role of dopamine stems in part from research showing that increased
dopaminergic activity in several brain areas may be related to manic symptoms of
hyperactivity, grandiosity, and euphoria.
• In depression, there appear to be decreases in both norepinephrine and dopamine
functioning.

C. Abnormalities of Hormonal Regulatory and Immune Systems

• Some neurohormonal research on bipolar disorder has focused on the HPA axis.
Cortisol levels are elevated in bipolar depression, but they are usually not elevated during
manic episodes.
• Research also has focused on abnormalities of the hypothalamic-pituitary-thyroid axis
because abnormalities of thyroid function are frequently accompanied by changes in
mood.
• Many bipolar patients have subtle but significant abnormalities in the functioning of
this axis, and administration of thyroid hormone often makes antidepressant drugs work
better.

IX. Psychological Causal Factors in Bipolar Disorders

A. Stressful Life Events and Other Psychological Factors in Bipolar Disorder
• Stressful life events appear to be as important in precipitating bipolar depressive
episodes as they are in triggering unipolar depressive episodes.
• Other social environmental variables such as social support, including personality and
cognitive variables, may also affect the course of bipolar disorder.
• Personality variables and cognitive styles that are related to goal striving, drive, and
incentive motivation have been associated with bipolar disorder.

X. Treatment of Mood Disorders

A. Monoamine Oxidase Inhibitors (MAOIs)
• MAO is an enzyme that causes the breakdown of the monoamine neurotransmitters in
the synapse.
• MAOIs decrease the action of MAO and thereby increase the levels of these
neurotransmitters in the synapses.
• The MAOIs are as effective as the tricyclic antidepressants, but their side effects are
potentially quite dangerous.

B. Tricyclic Antidepressants (TCAs)

• The tricyclic antidepressants were some of the first drugs shown to consistently relieve
depression.
• TCAs increase neurotransmission of the monoamines, primarily norepinephrine and,
to a lesser extent, serotonin.
• TCAs have unpleasant side effects for some people such as dry mouth, constipation,
sexual dysfunction, and weight gain.

C. Selective Serotonin Reuptake Inhibitors (SSRIs)

• The selective serotonin reuptake inhibitors, or SSRIs, are widely used to treat
depressive symptoms.
• SSRIs are not more effective in the treatment of depression than the other available
antidepressants, but they have fewer difficult-to-tolerate side effects.
• The most common side effects are gastrointestinal symptoms, tremor, nervousness,
insomnia, daytime sleepiness, diminished sex drive, and difficulty achieving orgasm.

D. Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

• It was designed to affect levels of norepinephrine as well as serotonin.
• They act in the same way as SSRIs, but perhaps because these drugs influence both
neurotransmitters, they show a slight advantage over the selective serotonin reuptake
inhibitors in preventing a relapse of depression.

E. The Course of Treatment with Antidepressant Drugs

• If there are no signs of improvement after about 6 weeks, physicians try a new
medication because about 50 percent of those who do not respond to the first drug
prescribed do respond to a second one.
• Antidepressant drugs usually require at least 3 to 5 weeks to take effect.
• Because depression is often a recurrent disorder, physicians have increasingly
recommended that patients continue for very long periods of time on the drugs in order
to prevent recurrence.

F. Lithium and Other Mood Stabilizing Drugs

• Lithium therapy has now become widely used as a mood stabilizer in the treatment of
both depressive and manic episodes of bipolar disorder.
• The term "mood stabilizer" is often used to describe lithium and related drugs because
they have both antimanic and antidepressant effects; that is, they exert mood-stabilizing
effects in either direction.
• People maintained on adequate doses of lithium have significantly fewer relapses of
mania and depression.
• Evidence has emerged for the usefulness of another category of drugs known as the
anticonvulsants in the treatment of bipolar disorder.
• These drugs are often effective in patients who do not respond well to lithium or who
develop unacceptable side effects from it.
• A number of studies have indicated that risk for attempted and completed suicide was
nearly two to three times higher for patients on anticonvulsant medications than for
those on lithium.

G. Cognitive-Behavioral Therapy
• Cognitive-behavioral therapy is designed to be brief and time-limited. The therapist
and client usually will agree on a set of goals they wish to accomplish in 6 to 12 weeks.
• To change the negative, hopeless patterns of thinking described by the cognitive
models of depression.
• To help people with depression solve concrete problems in their lives and develop skills
for being more effective in their world so they no longer have the deficits in reinforcers
described by behavioral theories of depression.
• The first step in cognitive-behavioral therapy is to help clients discover the negative
automatic thoughts they habitually have and understand the link between those
thoughts and their depression.
• The second step in cognitive-behavioral therapy is to help clients challenge their
negative thoughts.
• The third step in cognitive-behavioral therapy is to help clients recognize the deeper,
basic beliefs or assumptions they might hold that are fueling their depression.
H. Behavioral Activation Treatment
• This treatment approach focuses intensively on getting patients to become more active
and engaged with their environment and with their interpersonal relationships.
• These techniques include scheduling daily activities and rating pleasure and mastery
while engaging in them, exploring alternative behaviors to reach goals, and role-playing
to address specific deficits.
• Early results were very promising, suggesting it may be as effective as more traditional
cognitive therapies, and there is now meta-analytic support for this notion.

I. Interpersonal Therapy
• Many depressed people are grieving the loss of a loved one, perhaps not from death but
instead from the breakup of an important relationship.
• It focuses on interpersonal role disputes, which arise when people do not agree on their
roles in a relationship.
• It addresses role transitions, such as the transition from college to work or from work to
full-time motherhood.
• People with depression also turn to interpersonal therapy for help with problems
caused by deficits in interpersonal skills.