1. Chapter 6 Psy 303 Abnormal Psych
2013

2. Mood disorders
Disturbances in emotion that cause discomfort or hinder functioning
Rank among the top 10 causes of worldwide disability
a leading cause of absenteeism and diminished productivity in workplace
prevalence for all mood disorders is 15 percent for males, 24 percent for females

3. Mood disorders: General Stats
Likelihood of recurrence is
50 percent after one episode
70 percent after two
90 percent after three
Women twice as likely as men to become depressed except for Bipolar 1

4. Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note:  Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day. Note: In children and adolescents, can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities (3) significant weight loss when not dieting or weight gain, decrease or increase in appetite nearly every day. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (8) diminished ability to think or concentrate, or indecisiveness (9) recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

5. Major Depressive Episode cont’d
B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism; hypercortisolism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

6. Manic Episode: For a week, or less of manic symptoms (less only if symptoms are severe manic symptoms enough for hospitalization)
Affective symptoms: ELEVATED OR IRRITABLE MOOD (expansive mood, boundless energy, and enthusiasm)
Cognitive symptoms: Speech, attention, judgment
Behavioral symptoms:
Mania: more disruptive grandiosity, incoherent speech; hallucinations and delusions possible
Physiological symptoms: High arousal and decreased need for sleep, weight loss
Elevated mood,
Expansiveness,
Irritability,
Hyperactivity

7. Manic Episode
NOTE: The person may become involved in more activities than usual – starting new projects etc also shopping sprees, money on luxury items, reckless sexual behavior or driving etc….

8. Hypomanic Episodes – a minimum duration of four days
Less severe mania that does not cause impairment in social or occupational functioning
Overactive in behavior but no delusions like mania

9. Classification of Mood Disorders: Depressive Disorders
Major depressive disorder (Single episode or recurrent)
Dysthymic disorder
Depressive disorder not otherwise specified
Double depression – major depressive episodes and dysthymic disorder
Episodic illness – Single or recurrent (more than two episodes with at least 2 months interval)

10. Classification of Mood Disorders: Bipolar Disorder Mood shifts between two emotional “poles”
Cyclothymic disorder (fluctuations between hypomanic and depressive symptoms)

11. Bipolar Disorder
Bipolar I (full blown mania alternates with episodes of major depression)
Bipolar II (hypomania mood elevation that is abnormal yet not severe enough to impair functioning or require hospitalization, at least one episode of hypomania and one episode of major depression)
Bipolar II is more common than Bipolar I; however, because of the high levels of productivity and creativity associated with the hypomania, one may view the episodes in a more positive light.

12. Cyclothymic Disorder
A condition characterized by fluctuations that alternate between hypomania and depression
Episodes not as severe as with mania or major depression
Persist for at least two years
Puberty, premenstrual period, pregnancy, post partum period, and menopause are all considered risk factors for mood disorders.
Fact or fiction?
Yes, rates of depression do vary by age, but these reproductive events are all indentified as risk factors.

13. Course of Bipolar Disorders
Rapid cycling specifier
Four or more mood disturbances within a year
Extreme cycling: multiple shifts within a single day
Mixed state is symptoms of mania and depression that occur at the same time

14. Comparison between depressive and bipolar disorders
Bipolar more genetically based
Bipolar much less common
Bipolar disorders equally affect males and females.
Onset of both bipolar and unipolar early twenties (bipolar a little earlier), but onset is acute in bipolar disorders
Bipolar displays psychomotor retardation and more suicide attempts
Completed suicides: four times higher than for MDD, recurrent (Brown et al., 2006)
Bipolar responds to Lithium

15. Epidemiology of Depression
Approximately 16.2% of people age 18 and older report major depressive disorder at some point.
Most common psychiatric disorder worldwide
Median age of onset is 30 years (Kessler et al., 2005)
Prevalence rates:
-Major depression million U.S. adults
-Dysthymia 2.5% of general population
-Depression ranks fourth in Global Burden of Disease (WHO, 2011)

16. Approximately 80% of new mothers will develop the “baby blues.”
Sex, Race, and Ethnicity
Women are twice as likely to suffer from major depression (10%) than men (5%)
Common in lower SES
Impact of unemployment and lack of education and financial resources
Impact of reproductive events
Postpartum Depression (PPD)
Higher rates of depression in Whites at 17.9%
Approximately 80% of new mothers will develop the “baby blues.”

17. Further on Epidemiology: Depression and Anxiety
Overlap between anxiety and depression
Most depressed are also anxious.
Not all anxious individuals are depressed.
Mixed anxiety and depression symptoms

18. Epidemiology of Bipolar Disorder
Less common than major depression
Unrelated to race, sex, and family income
Affects people of all ages
More common in:
-Lower SES
-Anxiety disorder (comorbidity)
-Substance abuse disorder (comorbidity)
-Affects males and females equally % (Merikangas, 2007)
Men & mania vs. Women & depression when it comes to episodes with bipolar disorder?
The average age of onset of the first manic episode is 18 years old.

19. Developmental Factors in Depression
In childhood both boys and girls are equally affected.
After adolescence rates of depression increases for girls (2 to 1)
Risk factors for depression:
Hormonal changes, self-consiousness of bodily changes, poor sense of competency, disadvantaged environments, abuse, life stress, low self-esteem, high neuroticism, high reactivity to stress…
Age risk between 18 and 43, with the typical onset occurring at the age of 30
Typical warning signs: Absenteeism, physical complaints, irritability, tiredness, substance abuse, anger/hostility, relationship difficultires

20. Epidemiology: Elderly Depression
In the Elderly (65 and higher)
Medical illnesses or dementia complicate the diagnosis
Sex ratio balanced

21. Developmental Factors in Bipolar Disorder
In children, mania may be chronic (irritability and temper tantrums)
Difficulty in differentiating bipolar disorder from ADHD, conduct disorder, ODD, and schizophrenia
Onset in childhood and adolescent more severe
Older adult population 1% over 60 report bipolar disorder
After that age, mania and depression symptoms result from medical illness especially stroke (Van Gerpen et al., 1999)
Time span between mania and depression factors

22. But It’s Not Just Depression: Comorbidity Factors
Can occur with medical conditions (heart disease, CNS disease, cancer, & migraines, Fleischhacker et al., 2008)
72.1% of people with major depressive disorder had additional disorders
59.2% anxiety disorder
24% substance abuse disorder
30% impulse disorders
Genetic and environmental factors
Quick Recap
1. _____ involves a persistent sad or low mood that is severe enough to impair a person’s interest in or ability to engage in normally enjoyable activities.
(a) Borderline disorder
(b) Bipolar disorder
(c) Major depressive disorder
(d) Manic-depressive disorder
2. ______consists of a chronic state of depression; the symptoms are the same as those of major depression but are less severe.
(a) Bipolar II
(b) Hypomania
(c) Bipolar I
(d) Dysthymia

23. Suicide

24. Suicide ranks as the eighth leading cause of death in United States—2 to 5% of people have attempted suicide (Moscicki, 1999).
Males are more likely to commit suicide (usually by violent methods hanging or firearms) than females, even though females attempt suicide more often.

25. …the facts about suicide…
Components of depression
Eighth leading cause of death
2 to 5% of people in the United States attempt suicide (Moscicki, 1999)
U.S per 100,000 males, 4.5 per 100,000 females
Underreported due to misclassification of single- vehicle car accidents
WHO estimates that one million people die from suicide every year, 16 per 100,000
Highest rate of male suicides in Belarus, Lithuania, 50 per 100,000

26. Suicidal Ideation, Suicide Attempts, and Completed Suicide
Range from thoughts to detailed plans
Suicidal ideation (SI) (thoughts of suicide)
-Passive (wish to be dead without a plan)
-Active (thoughts and includes a detailed plan)
Parasuicides (superficial cutting and OD on nonlethal medications)
Previous attempts at suicide increase the risk of suicide times (Harris & Barraclough, 1997)

27. Who Is at Risk and/or Commits Suicide?
Males vs. Females
Methods used by males
Events to spark SI for adolescents: socially disadvantaged, social disconnection, adverse family circumstances and parental psychiatric illness and suicide history
Events to spark SI for elderly: chronic illness and decreasing social support
Highest rates among whites and American Indian/Native Indians
The lowest rates of male suicides were found in Asian/Pacific Islanders and for females Non-Hispanic Blacks had the lowest suicide rate (CDC, 2009)What factors do you think contribute to these lower rates of suicide among these populations?

28. Risk Factors for Suicide
Family history (family members across generations have committed suicide)
Psychiatric illness (90% of attempted or completed suicides are committed by people with mental illness)
Approximately 50% of patients with bipolar disorders attempt suicide during their lifetime.
If one is diagnosed with depression, there is an increased risk for suicide and suicidal ideation.
Biological factors (very low levels of serotonin, impulsivity, and pathological aggression)

29. Understanding Suicide: The Aftermath
Only 1/5 to 1/3 leave behind suicide notes
Psychological autopsy (interviews with family, friends, coworkers, and health care providers in an attempt to identify psychological causes of suicide)
Impact on those left behind
Severity of suicidal ideation – get help!

30. Prevention of Suicide Crisis intervention (suicide hotlines)
Focus on high-risk groups (children of parents with mood disorders who have attempted suicide themselves)
Societal level prevention (using teacher and peer support)
Preventing suicidal contagion (copycat suicides)
Use of critical incident debriefing (CID)
Interventions serve as a preventative measure. Do you believe that if one is engaging in self-injurious behavior (cutting, burning, biting, etc.) that they want to commit suicide? Why or why not? In regards to treatment, do we target these individuals differently than those with a plan of suicide?

31. Treatment after Suicide Attempts
Deliberate self-harm risk factor for suicide
Psychological intervention
Psychosocial intervention
Follow-up psychiatric care

32. The Etiology of Mood Disorders
Biological
-Genetics and family studies
-Neuroimaging studies
-Environmental factors and life events
Both genes and environmental factors are involved in the onset of depression
Stress-sensitive short version vs. protective long version
Gene’s double the risk of depression following life stressors
The study suggests that for one to possess the genes and also be exposed to multiple environmental stressors is the primary risk factor in the development of depression

33. The Etiology of Mood Disorders
Psychological
-Psychodynamic theory
-Attachment theory
-Behavioral theories
-Learned helplessness
-Cognitive theory

34. Distortions in thoughts
See the figure in the textbook and the handout presented in class period

35. My life is out of control, life sucks.

36. I failed to prepare breakfast for my daughter, I am a really bad mom… look at Joe’s mom, I can never be like her.

37. I will not be understood if I try to explain myself, so I rather shut up and not talk to anyone.

38. Treatment of Mood Disorders: Major Depression
Psychological
- Focus on understanding how thoughts, perceptions, and behaviors influence depression
- Cognitive-behavioral therapy (CBT)
- Interpersonal psychotherapy (IPT)
- Behavioral activation (focuses on increased contact with positive reinforcement for healthy behaviors which results in positive mood)

39. Treatment of Mood Disorders: Major Depression
Biological
- First-generation antidepressants (Tricyclic antidepressants and monoamine oxidase inhibitors, MAOIs)
- Second-generations antidepressants (SSRIs)
- Electroconvulsive Therapy (ECT) - Light therapy - Transcranial magnetic stimulation - Deep brain stimulation

40. Treatment of Mood Disorders: Bipolar Disorder
Psychological
-Cognitive-behavioral therapy (CBT to develop skills to change inappropriate or negative thought patterns)
- Interpersonal and social rhythm therapy (IPSRT promotes adherence to regular daily routines)

41. Treatment of Mood Disorders: Bipolar Disorder
Biological
- Lithium (a naturally occurring metallic element used to treat bipolar disorder, which moderates glutamate levels in the brain)
- Anticonvulsant
- Atypical antipsychotics - Electroconvulsive Therapy (ECT)