Chapter 7- Mood Disorders PDF

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Chapter 7: Mood Disorders  Gross disturbance in mood  Mood- refers to a prolonged emotion that colors the whole psychic life—it involves either elation or depression o Types: Depression and Mania  Mood Syndrome- a group of mood and associated symptoms that occur together for a minimal duration of time  Mood Episode- a mood syndrome not due to a known organic factor and not part of a non-mood psychotic disorder, meeting symptoms and duration criteria at a single point in time  Mood Disorder- determined by the pattern of mood episodes  Anhedonia- loss of pleasure or interest in things one usually enjoys  Incidence of Mood Disorders o Mood Disorders—female to male ratio is 2:1 o Bipolar Disorders—equal rates for African Americans and whites o Bipolar I Disorder—higher rates in females o Depressive Disorders—lower rates in African Americans than whites, predicted by poor/fair health status  Unipolar Disorders o Depression or mania alone o Typically. depression  Bipolar Disorders o Depression and mania o Dysphoric manic episode o Mixed mania episode  Increasingly higher rates in youths o Increase in prevalence across the years o Radical shift downward in age of onset o Increase in suicidal ideation o Increase in suicide attempts/completion  Hypotheses: o Weissman—decline in family and marital stability o Seligman—self-esteem movement and failure of real challenges o Decline of meaningful goals beyond self o Maybe linked to decrease in age of puberty onset  Major Changes in DSM-V o Dysthymia and chronic MDD have been combined into a diagnosis of persistent depressive disorder o 2 New Mood Disorders:  Premenstrual Dysphoric Disorder- (2-5% of women meet criteria) must be present in final week before menses onsets and become minimal or absent in the week post menses; features mood swings, irritability, depressed mood, anxiety, lack of energy, and difficulty concentrating and sleeping  Disruptive Mood Dysregulation Disorder- reacts with persistent irritability and frequent episodes of extreme lack of behavioral control

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Depression Disorders o Major Depressive Disorder  Major Depressive Episode- depressed mood or lost interest or pleasure (anhedonia) during the same 2-week period  Features: 1) Vegetative Symptoms: sleep, appetite, fatigue/energy loss, psychomotor disturbance 2) Cognitive/Affective Symptoms: depression, anhedonia, concentration/decision-making, guilt, suicidality 3) Untreated duration on average 4-9 months 4) Specifiers for MDD: 5) Severity—mild, moderate, severe 6) Early Onset if onset is before age 21 7) Late Onset if onset is after age 21 8) With mixed features—if the individual experiences at least three manic or hypomanic symptoms during the course of a major depressive episode 9) With melancholic features—early morning awakening, weight loss, excessive guilt, decreased libido, anhedonia 10) With atypical features—increased appetite/sleep, hedonic, associated with being female and early age of onset 11) With mood-incongruent psychotic features 12) With catatonia—catalepsy (muscular rigidity, fixed posture, can be precipitated by a sudden shock) 13) With peripatrum onset—13-19% of birthing women meet criteria, but no different than any other MDD; may be affected by rapid decline in reproductive hormones and other stressors from caring for a baby  Onset and Duration 1) Onset average is 30 years old 2) Duration is 2 weeks to several years for depression  Recurrence of MDD 1) Single episode—no mania/hypomania, rare 2) Recurrent—4-7 episodes in a lifetime, duration of 4-5 months  From Grief to Depression 1) Depression frequently follows loss a) Bereavement exception was removed to eliminate the implication that bereavement typically lasts only 2 months when duration is more commonly 1-2 years 2) Bereavement is a severe psychosocial stressor a) Additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning b) Bereavement-related MDD most likely to occur in people with past personal and family histories of manic depressive episodes

c) Distinguishing Factor—very generally pessimistic and selfcritical, accompanied by very low self-esteem and sense of worthlessness o Persistent Depressive Disorder- (aka Dysthymia) depressed mood for most of the day, for more days than not, indicated by subjective account or others’ observations for duration longer than 2 years  Symptoms include poor appetite or overeating, insomnia or hypersomnia, low energy/fatigue, low self-esteem, poor concentration/decision-making, and feelings of hopelessness  Onset and Duration 1) Early onset has poor prognosis in dysthymic disorder 2) Dysthymic disorder may last 20-30 years  Specifiers: 1) Severity—mild, moderate, severe 2) Early Onset if onset is before age 21 3) Late Onset if onset is after age 21 4) With mixed features—experiences at least three manic or hypomanic symptoms during the course of a major depressive episode 5) With anxious distress—experiences at least two anxiety symptoms during course of a major depressive episode 6) Rest of specifiers for MDD also apply to this disorder 7) With pure dysthymic syndrome—if full criteria for a major depressive episode have not been met in at least the preceding 2 years 8) With persistent major depressive episode—if full criteria for a moajor depressive episode have been met throughout the preceding 2-years period 9) With intermittent major depressive episodes, with current episode —if full criteria for a major depressive episode is 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 10) With intermittent major depressive episodes, without current episode—if full criteria for a major depressive episode is not currently met, but there has been one or more major depressive episode in at least the preceding 2 years o Double Depression- major depressive episodes and dysthymic disorder (PDD)  Dysthymia presents first  Severe psychopathology  Poor course o Seasonal Patterns  Winter Depressions—excessive sleep, increased appetite/weight gain  May be related to seasonal changes in melatonin produced (secreted by the pineal gland)—only changes in people who are vulnerable to seasonal patterns

Cognitive/Behavioral Factors 1) Generate more autonomous negative thoughts 2) Greater emotional reactivity to light in the lab (low mood with low light) Manic Episode- distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increase goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day o Symptoms include inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual or pressure to keep talking, flights of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity, and excessive involvement in pleasurable activities that have high potential for painful consequences o Hypomania Distinctions:  Duration—hypomania only requires 4 consecutive days  Functioning—the diagnosis requires an unequivocal change in functioning that is uncharacteristic (and is observable by others)  Impairment—not severe enough to cause “marked” impairment o Criteria for Hypomanic Episode  No real differences between mania and hypomania except for degree (and impairment)  Share some key diagnostic symptoms 1) Criterion A—both involve elevated-expansive-irritable mood 2) Criterion B—3 or 4 manic symptoms out of 7 identified 3) Causation of hypomanic episode can’t be due to substance use or a general medical condition  Differences in duration and severity Bipolar Disorders o Bipolar I Disorder- at least one episode each of MDD and mania  Depressive symptoms, which are caused by frequent alternations between periods of depression and mania, causes distress/impairment  Onset—age 15-18 o Bipolar II Disorder- at least one episode each of MDD and hypomania  No mania  Depressive symptoms, which are caused by frequent alternations between periods of depression and hypomania, causes distress/impairment  Onset—age 19-22 o Cyclothymia- numerous periods with hypomanic symptoms that don’t meet criteria for a hypomanic episode and numerous periods of depressive symptoms that don’t meet criteria for a major depressive episode o Bipolar Specifiers  Same as MDD (rarely see catatonic)  Frequently psychotic features (especially delusions of grandeur)  Rapid Cycling Specifier (40-60% of bipolars and 60-90% are female):  At least 4 manic or depressive episodes in a year  Doesn’t respond well to standard treatment  Higher probability of suicide 

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 May respond to anticonvulsants and mood stabilizers  Tends to increase over time o Seasonal Affective Disorder- typically summer manias and winter depressions o Disruptive Mood Dysregulation Disorder- involves emotional and physical outbursts in which temper outbursts are inconsistent with developmental level o Higher probability for bipolar to have a future episode than unipolar, but probability for unipolar increases with each successive episode o Between episodes people with bipolar are typically irritable, warm, extraverted, and energetic while unipolar are cautious, careful, and obsessive compulsive o Course tends to be chronic o Suicide rates elevated o Rare to onset over age of 40 o Mood disorders in general fundamentally similar in children, teens, and adults Etiology—mood disorders are very complex and multifaceted o Equifinality—many different things can lead to the same risk factor  Biology 1) Genetics a) Family Studies—increasing severity, recurrence of MDD, earlier age of onset associated with highest rates in relatives of probands b) Depression and Anxiety i) Shared genetic vulnerability ii) High familial heritability iii) Same genetic factors iv) General predisposition c) Candidate Genes—HTTLPR i) Related to serotonin transporter ii) Influences response to life stress (indirect effect on mood disorders), neuroticism, anxiety, etc. d) Candidate Gene—COMT i) Regulates Catecholamines ii) Affects cognitive effort, flexibility, emotional processing, and overall executive functioning iii) Implicated in depression, mania, schizophrenia, and early onset of depression e) Oxytocin- social bonding, males/females affected differently (increased anxiety and depression—females have allele that’s more reactive to stress) f) ACTH/CRH- effects on cortisol 2) Anatomical Distinctions—PFC a) Affect-guided planning and anticipation involving emotional experience associated with an anticipated choice —hallmark of adaptive, emotion-based decision making b) Most sensory info relayed through thalamus c) Pre-frontal cortex (PFC) plays a crucial role in goal representation—sends bias signals to brain regions as

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expression tof task-appropriate responses when competition with potentially stronger alternatives (usually delay of gratification) i) BAS activity—left-sided medial OFC responsive to rewards ii) BIS activity—lateral right sided region responsive to punishments iii) Hypoactivation in regions connected with amygdala leads to regulator influence on amygdala and prolonged time course of amygdala activation when challenged Anterior Cingulate Cortex a) Critically involved in conflict monitoring (2 or more response options) b) Activated in neuroimaging studies of human emotions c) Lower levels of activation in people with depression, leading them to set fewer goals and engage in little intentional actions d) People with higher levels of ACC activation tend to respond better to treatment Amygdala a) Perception of cues signaling threat b) Production of behavioral and autonomic responses associated with aversive responding c) In negative affect—may be special case of more general role in directing attention and resources to emotionally salient stimuli, and call for further processing when the stimuli have major significance d) Hyperactivation associated with fear-like and anxiety components e) Predicts dispositional negative affect, but unrelated to positive affect f) May be associated with hypervigilance to threat-related cues—increased symptoms of depression Hippocampus a) Role in encoding context b) Related to stress response c) Depressed: shows hippocampal volume reductions— suppressed hippocampal neurogenesis d) Not clear if cause or consequence e) Related to overgeneralized memories f) Mood dependency Neurotransmitters a) Serotonin—regulates emotional reactions (low—impulsive and mood swings), permissive hypothesis is that when

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levels are low, permits other neurotransmitters to range more widely, contributing to mood irregularities b) Norepinephrine—stress hormone, decrease in it leads to decrease in stress regulation c) Dopamine—low D2 receptor-binding is found in people with social anxiety (common to negative symptoms of schizophrenia), increase in dopamine leads to manic episodes, L-dopa appears to produce hypomania in bipolar patients 7) Endocrine Influences a) Overactivity of HPA axis (associated with anxiety) b) Hypothyroidism—affects adrenal cortex and can lead to excessive secretion of cortisol, leading to depression and anxiety c) Dexamethasone Test (DST)—suppresses cortisol secretion, depression could be caused by decrease in suppression 8) Sleep and Circadian Rhythms a) Depression patients enter REM sleep more rapidly and experience REM more intensely and non-REM stages occur later if it all b) Decreased latency, severe insomnia and hypersomnia Psychoanalytic 1) Object Loss a) Love object loss leads to guilt and anxiety b) Attachment not shifted to another object c) Patient identifies with lost object d) Lost object incorporated into the patients ego e) Repressed ambivalence directed inward 2) Etiological significance of childhood loss because child cannot complete true mourning leads to vulnerability to future loss Behavioral 1) Depression = reduction in response-contingent positive reinforcement 2) Dysphoria = low rates of behavior(until extinction) 3) Circular pattern in which behavior rate and opportunity for reward go down together 4) Loss of reinforcer effectiveness (anhedonia), rewards aren’t rewarding, pain and pleasure are incompatible 5) Unavailability of reinforcing events 6) Lack of social skills—don’t have reinforcing behaviors in repertoire/cannot access rewards 7) More sensitive to aversive contingencies in lab—larger SCR to mild shock, behaviors in social situations more attenuated by aversive confederates, rate events more negatively than nondepressed subjects 8) More passive avoidance, less reward seeking

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9) Say nice things less often 10) Learned Helplessness a) Decides no control over the stress in their lives, anxiety is first response to stressful situation, so helplessness leads to hopelessness b) From negative cognitive (attributional) style to Hopelessness Theory—revision to de-emphasize negative attributions as crucial cause, and emphasize hopelessness, related to development of anxiety disorders Cognitive 1) Negative Cognitive Style—Depression Vulnerability a) Tendency to interpret everyday events negatively b) Depressive cognitive triad: self, their world, their future c) After childhood negative events, develop enduring negative cognitive belief system about some life aspect d) Automatic, not necessarily conscious e) Evidence i) Thinking of depressed people is consistently more negative than non-depressed people ii) Depressive cognitions seem to emerge from distorted and probably automatic methods of processing info iii) More likely to recall negative events when depressed 2) Cognitive Distortions a) Arbitrary Interference draw specific conclusions without supporting evidence or even in the face of contradictory evidence b) Selective Abstraction- conceptualizing a situation based on a detail taken out of context and ignoring all other possible explanations c) Overgeneralization- abstracting a general rule from 1 or 2 isolated incidents and applying it too broadly d) Magnification and Minimization- seeing an event as more or less significant than it actually is e) Personalization- attributing external events to self without evidence of connection f) Dichotomous Thinking- categorizing situations in extremes Personality 1) Sociotropic Dimension a) Dependence, need for closeness and nurturance 2) Autonomous a) Independence, goals-setting, self-determination, selfimposed obligations Socioemotional Stress

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1) Depression a) Stress precedes depression b) Decreased positive mood, social skill defecits, report more social support dissatisfaction, and seek emotional and informational support and wishful thinking c) Marriage and Depression Risk—relationship disruption precedes depression, strongest effects for males 2) Bipolar a) Negative life events trigger depression b) Positive life events trigger mania 3) Impact of Family Mood Disorders a) Caregiver Burden—lack of interest in social life, fatigue, feelings of hopelessness, and worrying lead to distress and decreased affection displays and increase in complaints about marriage b) Increase in marital conflict c) Decrease in speaking and intensity d) Effects of fatigue lead to decrease in energy and increase in self-absorption—decreased focus on children, involvement in housework, and childcare duties e) Increased criticalness of children and overall hostility Representational Gender Differences in Depression 1) Genetics—females have stronger genetic loading and males’ genes don’t seem to play a strong role 2) Hormones—oxytocin, progesterone, estrogen 3) Learned Helplessness 4) Gender Roles 5) Emotional Regulation—Rumination vs. Distraction a) Ruminative Response Style: i) Amplifies/prolongs negative mood ii) Interferes with initiating of instrumental behavior, attention, and concentration iii) Increased likelihood of depressive explanations for negative events leading to increased helplessness and hopelessness iv) Mood state has a powerful effect on individual’s recall of past events, social perceptions and ability to learn new material (mixed empirical support for this depending on severity of mood) v) Gender differences in response to depressive mood vi) Repetitively focusing on distress symptoms and possible causes and consequences of negative mood, and self-evaluations of mood vii) Higher rates in females

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Associated with increased depression, selfcriticism/blame, anxiety, and behavioral dysregulation in Borderline PD ix) Decreased problem solving x) Increased prolonged salience of perceived failure to make progress toward personal goals xi) Used to explain the sex differences in depression starting with puberty/adolescence 6) Emergence of Sex Differences in Adolescence—3 Models a) Model 1—causes of depression may be same for girls and boys, but these causes may become more prevalent in early adolescence for girls (ex. unassertiveness becoming more prevalent during adolescence) b) Model 2—different causes of depression in girls and boys that are equally prevalent in childhood and become more prevalent for girls in early adolescence (ex. for girls, interpersonal conflicts and for boys, achievement failures) —this model is consistent with the notion of equifinality (different causal pathways leading to a common final outcome) c) Model 3—causes of depression are same for both boys and girls, but girls are more likely to carry more of the risk factors for depression even before early adolescence; these risk factors only lead to depression in the face of challenges that increase in prevalence during early adolescence transitions representing the stressor leading to depression and do so disproportionately for females—best supported by data thus far d) Flynn, Kecmanovic & Alloy integrated model—both depressive rumination and subsequent dependent interpersonal stress i) Depressive rumination predicted to increase dependent on interpersonal stress over time; social support discontent accounted for this association ii) Depressive rumination + self-genera...