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Chapter 7

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Queen's University
PSYC 235
Meredith Chivers

Chapter 7: Mood Disorders - case of Katie: 16 yr-old rarely interacted with people outside famile due to considerable social anxiety • depression affects how you interpret events, way you see yourself & others • patient began drinkings herselp to sleep to escape her depression • had constant suicidal thoughts • this form of depression was outside the boundaries of normal experience in terms of intensity & duration • her “clinical” depression interfered substantially w/ ability to function • she also experienced several associated psychological & physical symptoms characteristic of clinical depression - feelings of depression (& joy) are universal, which makes it all the more difficult to understand disorders of mood An Overview of Depression & Mania - mood disorders: group of disorders involving severe & enduring disturbances in emotionality ranging from elation to severe depression - 3 major mood disorder categories (all characterized by gross deviations in mood): 1. depressive disorders 2. affective disorders 3. depressive neuroses - the fundamental experience of depression & mania contribute, either singly or together, to all the mood disorders Major Depressive Episode - major depressive episode: most common & severe experience of depression, includes feelings of worthlessness, disturbances in bodily activities (sleep), loss of interest & inability to experience pleasure, persisting at least 2 weeks - DSM criteria • an extremely depressed mood state lasting at least 2 weeks & includes cognitive symptoms (ie. feelings of worthlessness & indecisiveness) & disturbed physical function (ie. altered sleeping patterns, significant changes in appetite & weight, or notable loss of energy) • episode typically marked by general loss of interest & inability to experience any pleasure (anhedonia) • physical changes (sometimes call somatic or vegetative symptoms) are central to this disorder as they strongly indicate a full major depressive episode • untreated duration -> 9 months Manic Episode - manic episode: period of abnormallyelevated or irritable mood that may include inflated self-esteem, decreased needfor sleep, pressured speech, flight ofideas, agitation, or self-destructive behavior - mania: period of abnormally excessive elation or euphoria, associated w/ some mood disorders - individuals find extreme pleasure in every activity by abnormally exaggerating joy or euphoria - become extraordinarily active (hyperactive), require very little sleep & may develop grandiose plans (believing they can accomplish anything) - speech is typically rapid & sometimes incoherent; attempting to express multiple exciting ideas at once (flight of ideas) - DSM criteria • manic episode requires duration of only one week, less if the episode is severe enough to require hospitalization (ie. self-destructive shopping sprees) • irritabiltiy often seen near end of manic episode (anxiety or depression commonly part of mania) • untreated duration = 2-6 months Hypomanic Episode - hypomanic episode: less severe & less disruptive variation of a manic episode - DSM criteria states hypomanic episodes don’t cause marked impairment in social or occupational functioning • hypo = “below” (the episode is below the level of a manic episode) The Structure of Mood Disorders - unipolar mood disorder: characterized by depression or mania but not both; most cases involve unipolar depression • almost everyone w/ a unipolar mood disorder has unipolar depression (mania alone is rare) - bipolar mood disorder: individuals alternating b/w depression & mania, traveling from one “pole” of the depression- mania continuum to the other & back again - however, an individual can experience manic symptoms but feel somewhat depressed or anxious at the same time - dysphoric manic/mixed episode: condition where individual experiences mania, but also suffers depression or anxiety • may experience manic symptoms as out of control or dangerous & become anxious or depressed about them - in rare cases, where an individual only suffers manic episodes also meets criteria for bipolar mood disorder • this is because individual is expected to become depressed at a later time Depressive Disorders Clinical Descriptions - major depressive disorder, single episode: most easily recognized mood disorder, defined by the absence of manic or hypomanic episodes before or during the episode • occurrence of just one isolated depressive episode in a lifetime is rare - major depressive disorder, recurrent: suffering 2+ major depressive episodes separated by at least 2 months where individual was not depressed • recurrence is very important in predicting future course of disorder & choosing appropriate treatment • individuals w/ recurrent major depression usually have a family history of depression • 85% is single-episode cases later experience a 2 episode (meeting criteria for recurrent type) - clinical scientists have concluded that unipolar derpression is often chronic - median lifetime major depressive episodes -> 4-7 episodes - median duration of recurrent major depressive episodes -> 4-5 months - dysthymic disorder: persistently depressed mood for at least 2 years, w/ no absence of symptoms for more than 2 months - shares many of the symptoms (milder versions) of major depressive disorder, but remains relatively unchanged over long periods of time • dysthymic disorder differs from major depressive episodes in severity, chronicity & number of symptoms, which are milder & fewer, but last longer - double depression: severe mood disorder, patient experiences both major depression episodes & dysthymic disorder - dysthymic disorder usually develops first, then one or more major depressive episodes occur after Onset & Duration - mean age of onset for major depressive disorder -> 25 (not in treatment) & 29 (in treatment) • avergae age of onset seems to be decreasing - prevalence of major depression  dramatically during adolescence (especially girls) - important subtypes of dysthymic disroder have been identified - although onset of dysthymic disorder is early 20s, adolescent onset of depression is associated w/: 1. greater chronicity – it last longer 2. relatively poor prognosis (response to treatment) 3. stronger likelihood of the disorder running in the family of the affected individual - common for major depressive episodes & dysthymic disorder to co-occur (double depression) From Grief to Depression - severe depression after death of a loved one is so common (62%) that it’s not consider a disorder unless very severe symptoms appear (psychotic features or suicidal thoughts) or the less alarming symptoms last longer than 2 months - many psychological & social factors related to mood disorders in general, including history of past depressive episodes, also predict development of a normal grief response into a pathological grief reaction or impacted grief reaction - pathological/impacted grief reaction: extreme reaction to death of a loved one, involves psychotic features, suicidal thoughts, or severe loss of weight or energy persisting more than 2 months Bipolar Disorders - the key-identifying feature of bipolar disorders is the tendency of manic episodes to alternate w/ major depressive episodes in an unending roller coaster ride - bipolar II disorder: alternation of major depressive episodes w/ hypomanic episodes - bipolar I disorder: alternation of major depressive episodes w/ full manic episodes - criteria for the manic episodes to be considered separate -> must have a symptom-free period of at least 2 months b/w them, otherwise one episode is seen as a continuation of the last - patients often stop taking medication during periods of distress or discouragement, attempting to induce a manic state - cyclothymic disorder: (like dysthymic disorder) a chronic alternation of mood elevation & depression levels that don’t meet the severity of manic or major depressive episodes • criteria -> pattern must last for at least 2 years (1 year for children & adolescents) • tend to be in one mood state or the other for many years w/ relatively few periods of neutral (euthymic) mood • individuals often condsidered moody, but the chronically fluctuating mood states are substantial enough to interfere w/ functioning Onset & Duration - average age of onset for bipolar I disorder -> 18 - average age of onset for bipolar II disorder -> 22 - bipolar disorder age of onset is somewhat younger than in major depressive disorder & begins more acutely (suddenly) although cases of both begin in childhood (1/3 of most cases) - rare to develop bipolar disorder after 40, course appears chronic (depression & mania alternate indefinitely) - in typical cases, cyclothymia is chronic & lifelong • in ⅓-½ of patients, cyclothymic mood swings develop into full-blown bipolar disorder • this disorder is often not recognized, individuals are thought to be high-strung, explosive, moody or hyperactive Postpartum Depression - other symptoms, or specifiers, may or may not accompany a mood disorder • when they do, they often help to determine the most effective treatment - ie. the postpartum onset specifier can apply to both major depressive & manic episodes • characterized by severe manic or depressive episodes that first occur during the postpartum period (4 weeks immediately following childbirth), typically 2-3 days after delivery - having an infant w/ a difficult temperament is an important type of stressor that can contribute to postpartum depression • low socioeconomic status & high levels of life stress are also related to the persistence of postpartum depression • early recognition is very important because a mother in the midst of an episode has killed her newborn child Specific Describing Course of Mood Disorders - 3 specifiers may accompany recurrent mania or depression: 1. longitudinal course specifiers: whether individual has had major episodes of depression or mania in the past & whether they fully recovered b/w past episodes is important • also important to determine whther patient w/ a major depressive episode had dysthymis before the episode (double depression) • whether the patient w/ bipolar disorder experiences a previous cyclothymic disorder • antecedent dysthymia or cyclothymia predicts a decreasing chance of full interepisode recovery • most likely, patient will require a long & intense course of treatment to maintain a normal mood state for as long as possible after recovering from the current episode 2. rapid-cycling specifier: temporal specifier, only applies to bipolar I & bipolar II disorders • some people move very quickly in & out of depressive or manic episodes • an individual w/ bipolar disorder who experiences at least 4 manic or depressive episodes within a year is considered to have rapid-cycling pattern • this severe variety of bipolar disorder doesn’t respond well to standard treatments & is associated w/ higher chance of suicide attempts • 20% of bipolar patients experience rapid-cycling, 90% are female • unlike bipolar disorder, most people w/ rapid-cycling begin w/ a depressive episode rather than a manic one • rapid-cycling tends to increase in frequency over time 3. seasonal pattern specifier: temporal specifier, applies to both bipolar disorders & to recurrent major depressive disorder • it accompanies episodes that occur during certain seasons (ie. winter depression) • most usual pattern is a depressive episode beginning in late fall and ending at the beginning of spring • in bipolar disorder, individuals may become depressed during winter & manic during summer • seasonal affective disorder (SAD): seasonal cycling of episodes, typically depression occurrs during winter - unlike more severe types of depression, people w/ winter depression tend toward excessive sleep (rather than decreased sleep), increased appetite (rather than decreased appetite), & weight gain (rather then weight loss), symptoms shared w/ atypical depressive episodes - SAD is thought to be related to daile & seasonal changes in melatonin production (hormone secreted by pineal gland) • exposure to light supresses melatonin production, it is only produced at night • melatonin tends to increase in winter (thought to trigger depression in certain vulnerable individuals) Prevalence of Mood Disorders - women are 2x more likely to have mood disorders than men In Children &Adolescents - babies can be depressed; infants of depressed mothers show marked depressive behaviours (sad faces, slow movement) - depressive disorders occur less frequently in children than in adults but ride dramatically in adolescence, when depression is more frequent than in adults • in young children, dysthymia is more prevalent than major depressive disorder, but this ratio reverses in adolescence • like adults, adolescents (especially females) experience major depressive disorder more frequently than dysthymia - one developmental difference b/w children & adolescents on the one hand & adults on the other is that children (especially boys) tend to become aggressive & even destructive during depressive episodes • for this reason, childhood depression is sometimes misdiagnosed as hyperactivity or conduct disorder • however, often conduct disorder & depression co-occur - young adults who had experienced an episode of major depressive disorder in adolescence exhibited a very pervasive pattern of psychosocial impairments in areas such as interpersonal functioning, quality of life & occupational performance In the Elderly - 18-20% of nursing home residents experience major depressive episodes, likely to be chronic if first sppearing after 60 - late-onset depression associated w/ marked sleep difficulties, hypnochandriasis & agitation - difficult to diagnose because the symptoms are often similar to those of physical illness or dementia • anxiety disorders frequently accompany depression - in early childhood, boys are more depressed; in adolescence an overwhelming surge of depression in girls • the gender imbalance in depression remains until 65, where the sex ratio is balanced Anxiety & Depression - anxiety & depression show overlap in psychopathology; these two moods are more alike than different - almost all depressed patients are anxious, but not all anxious patients are depressed - major depression usually follows anxiety & may be the consequence of it - certain core symptoms of depression are not found in anxiety: • anhedonia (inability to experience pleasure) • a depressive “slowing” of both motor & cognitive functions - cognitive content (what is thought about) usually more negative in depressed individuals than in anxious ones - panic symptoms: • primarily excessive physiological symptoms (ie. heart palpitations & dizziness) - many symptoms define both anxiety & depressive disorders • not specific to either kind of disorder, called symptoms of negative affect - pure anxiety symptoms: • muscle tension • apprehension • excessive worry about future - pure depression symptoms: • helplessness • depressed mood • loss of interest & pleasure • suicidal ideation - negative affect (mixed anxiety & depression) symptoms • anticipating the worst, hopelessness • worry • poor concentration • irritability • hypervigilance • poor sleep, fatigue • crying • guilt Causes Biological Dimensions Familial & Genetic Influence - family studies – shown that both unipolar depression & bipolar disorder run in families (relatives 2-3x higher chance) • increasing severity & recurrence of major depression in the proband (individual in family w/ disorder) was associated w/ higher rates of depression in relatives - adoption studies – if a genetic contribution exists, the adopted probands w/ the disorder should have more biological relatives with the same disorder than the adopted probands without the disorder (data is mixed) - twin studies – if a genetic contribution exists, the disorder should be present in identical twins to a much greater extent than in fraternal twins • identical twins 2-3x more likely than fraternal twins if the first twin has a mood disorder - severe mood disorders may have a stronger genetic contribution than less severe disorders - environmnetal event play a larger role in causing depression in men than in women - bipolar disorder confers an increased risk of developing some mood disorder but not necessarily bipolar disorder • bipolar disorder may simply be a more severe variant of mooddisorders rather than a fundamentally different disorder - 60-80% of the causes of depression can be attributed to environmental factors • unique nonshared events (rather than what is shared) interacts w/ biological vulnerability to cause depression - findings suggest that the biological vulnerability for mood disorders may not be specific to that disorder but may reflect a more general predisposition to anxiety or mood disorders • the specific type of disorder is determined by social, psychological & other biological factors Neurotransmitter Systems - low levels of serotonin are implicated in etiology of mood disorders but only in relation to other neurotransmitters • apparent primary function of serotonin is to regulate emotional reactions, so we become more impulsive & have wide mood swings when serotonin levels are low, possibly because one of the functions of serotonin is to regulate systems involving norepinephrine & dopamine - according to the “permissive” hypothesis, when serotonin levels are low, other neurotransmitters are permitted to range more widely, become dysregulated, & contribute to mood irregularities, including depression - the accepted view is that the balance od various neurotransmitters & their subtypes is more important than the absolute level of any one neurotransmitter - role of dopamine of interest in relation to manic episodes, atypical depression, or depression w/ psychotic features • chronic stress reduces dopamine & produces depressive-like behaviour The Endocrine System - the HPA axis begins in the hypothalamus & runs through the pituitary gland, which coordinates the endocrine system • one of the glands influenced by the pituitary is the cortisol section of the adrenal gland • the adrenal gland produces the stress hormone cortisol (called a stress hormone bc it  during stressful life events) • cortisol levels are elevated in depressed patients makes (relationship b/w depression & severe life events) - dexamethasone suppresses cortisol secretion • but, when given to depressed patients, much less supression displayed & didn’t last long • in depressed patients, adrenal cortex secreted too much cortisol, which overwhelms the suppressive effects of dexamethasone in depressed people - neurotransmitter activty in the hypothalamus regulates the release of hormones that affect the HPAaxis • neurohormones (hormones that affect the brain) are increasingly important in studying psychopathology Sleep & Circadian Rhythms - depressed people have a significantly shorter period b/w falling asleep & the onset of REM sleep • depressed individuals have diminished slow-wave sleep, which is the deepest, most restful part of sleep • experience much more intense REM activity & the stages of sleep don’t occur until later (sometimes not at all) - unclear whether sleep disturbances also characterize bipolar patients (evidence of increased, rather than decreased sleep) - depriving depressed patients of sleep, particularly during second half of the night, causes temporary improvement in • sleep deprivation also helpful for some bipolar patients during depressed phase - patients w/ bipolar disorder & their children show increased sensitivity to light (greater suppression of melatonin when exposed to light at night) - extended bouts of insomnia trigger manic episodes - mood disorders may be related to disruptions in circadian (daily) rhythms - measuring electrical activity in the brain w/ electroencephalogram (EEG) showed that depressed individuals exhibit greater right-side anterior activation of their cerebral hemisphere than nondepressed • right-sided anterior activation also found in patients who are no longer depressed, suggesting this brain function might represent a vulnerability to depression Psychological Dimensions Stressful Life Events - 60-80% of the causes of depression could be attributed to psychological experiences • stress & trauma are among the most striking unique contributions to the etiology of all psychological disorders - instead of asking whether events in a patient’s life were bad (or good), they began to look at the context of the event & the meaning it had to the individual • the context of the life event & its meaning are important - one crucial issue is the bias inherent in remembering events, comparing the answers from someone who is currently depressed & those who are not currently depressed • current moods distort memories - reciprocal gene-environment model • our genetic endowment may increase the probability that we will experience stressful life events • individuals vulnerable to depression may place themselves in high-risk stressful environments -several issues may be particularly relevant to the etiolofy of bipolar disorders 1. stressful life events seem to trigger early mania & depression, but as the disorder progresses these episodes seem to develop lives of their own o once the cycle begins, a psychological or pathophysiological process takes over & ensures the disorder will continue 2. some of the precipitants of manic episodes seem to be related to loss of sleep or disturbed circadian rhythms o in most c
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