1. Psychopathology II: Common Mood Disorders
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine

2. A clinical vignette…
A 24 year-old male is brought to the hospital by his family. He has only slept 3 hours a night for the last 3 days. The family tells you that he has recently withdrawn large sums of money from his savings account and gone on wild spending sprees. During the interview, he is very talkative and easily distracted. He tells you that he feels “on top of the world.” This patient is most likely to be suffering from:
dysthymic disorder
major depressive disorder
bipolar disorder
hypochondriasis
cyclothymic disorder

3. Outline What are unipolar mood disorders?
What are bipolar mood disorders?
Epidemiology of mood disorders
Biology of mood disorders
Risk of suicide

4. Mood disorders Everyone’s mood tends to rise & fall
sadness is a normal part of the human condition
very happy self-confident end = mania
very sad worthless end = depression
abnormal if people experience extremes, especially if not consistent with events

5. Chart: Unipolar Mood Disorder

6. Chart: Bipolar Mood Disorder

7. Depressed Mood versus Major Depressive Disorder (MDD)
Feeling depressed is different from major depressive disorder!!
Major depressive disorder is more than just feeling depressed!!
Just feeling sad, even very sad, not sufficient for dx of major depressive disorder
Feeling sad is not even necessary for diagnosis of major depressive disorder
Severity, intensity, duration matter

8. Signs and Symptoms of a Major Depressive Episode
Sad or empty feelings
Anhedonia – loss of interest or pleasure
Weight loss/gain or appetite increase/decrease
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or inappropriate guilt
Diminished ability to concentrate or indecisiveness
Suicidal ideation, plan or attempt
Best known by the mnemonic: SIG E CAPS

9. Criteria for Unipolar Mood Disorders
Major depressive disorder
Dysthymia
At least 1 major depressive episode (lasting at least 2 weeks)
Depressive symptoms for at least 2 years
No manic or hypomanic episodes

10. Symptoms of Dysthymia
Depressed mood for most of the day on more days than not
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness

11. Chart: Dysthymia

12. Clinical Impairment in MDD and Dysthymia
Occupationally
Socially
Other important areas

13. Exclusion Criteria
Not due to a general medical condition (e.g., thyroid condition)
Not due to substance use (e.g., alcohol)
Not bereavement (it is considered normal to have some symptoms of depression after someone dies)

14. Types of Mood Disorders
Unipolar mood disorders
Bipolar mood disorders (previously manic-depression)
person experiences only episodes of depression
person experiences episodes of mania and in most cases episodes of depression
Major depressive disorder
Dysthymia
Bipolar I disorder
Bipolar II disorder
Cyclothymia

15. Symptoms of a Manic Episode
Elevated mood
Irritable/angry mood
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in pleasurable activities that have a high potential for painful consequences

16. The Difference Between a Manic and a Hypomanic Episode
Symptoms
Same
Duration
1 week
4 days
Severity
Must interfere with occupational or social functioning
Must be noticeable to others, but not severe enough to impair functioning or to require hospitalization

17. Chart: Bipolar I Disorder

18. Chart: Bipolar I Disorder

19. Additional Criteria
As with unipolar mood disorders, must be clinical impairment or distress
The symptoms cannot be:
Due to a medical condition
Due to substance use

20. Epidemiology of Mood Disorders by Gender: Lifetime Prevalence

21. Gender & Depression
Why do almost twice as many women develop depression?
women experience more trauma
particularly sexual abuse
women have more chronic strains
poverty, harassment, etc.
with equal stressors, women still more likely to develop depression
biology, coping style

22. Prevalence of Major Depressive Disorder by Employment

23. Prevalence of Major Depressive Disorder by Income

24. Course and Outcome: Major Depressive Disorder
Average age of onset is 23 for males and 25 for females
Minimum duration of at least 2 weeks but episodes could last much longer
Most people who have major depression will have at least 2 depressive episodes
MDD is frequently a chronic and recurrent condition
Half recover from their episode of major depression within 6 months. 40% of recovered people relapse within a year

25. Course and Outcome: Bipolar Disorders
Onset is usually between ages 18-20
Average manic episode 2-3 months, bipolar II patients (have hypomania) tend to have shorter and less severe episodes
Long-term course
Most will have more than one episode
Length of intervals between episodes varies and is difficult to predict
40-50% of patients are able to achieve a sustained recovery; rapid cycling patients have a worse prognosis

26. Etiology: Social Factors and Depression
Loss (of significant others, of social role, self-esteem, etc.) plays an important role in onset of depression
Social support or lack of social support is a risk factor for depression
and suicide

27. Neurotransmitters & Depression
Early theories about lack of serotonin probably overly simplistic
Multiple transmitters involved
including serotonin, NE, lesser extent dopamine
Interaction between neurotransmitters, genes, social stresses is important

28. More neurotransmitters
Serotonin
converted from tryptophan in CNS
elevation causes improved mood, sleep, but decreased sexual function
decrease causes poor sleep, poor impulse control, depression

29. More neurotransmitters
Norepinephrine
synthesized by noradrenergic neurons, mostly located in locus ceruleus
elevation causes increased mood, anxiety, arousal, learning

30. More neurotransmitters
Dopamine
synthesized from tyrosine
involved in schizophrenia, psychosis, Parkinson’s, reward system
to a lesser extent mood disorders

31. Antidepressants
Serotonin is a particularly important neurotransmitter for mood
Selective serotonoin reuptake inhhibitors (SSRIs) are effective
Stop reuptake of serotonin at synapses
TCAs are older drugs
mostly block NE and serotonin
also have anticholinergic effects
lots of side effects
fatal in overdose
MAOs
block dopamine reuptake
lots of side effects!

32. Depression & Genetics Unipolar depression concordance rates:
MZ = .54, DZ = .24
Bipolar disorder concordance rates
MZ = .43, DZ = .06
No strong evidence of a single gene responsible for mood disorders

33. Suicide Depression is a risk factor for suicide
times more likely to commit suicide when have MDD
In 1 study*, 2.5 times more likely to commit suicide when in remission
*Sokero et al (2005) British Journal of Psychiatry

34. Suicide Increased risk Reduced risk
previous suicidal behavior, family history, severe depression, substance use, poor physical health/perception of poor health, lack of social support
Reduced risk
suicidal gesture, no family history, mild depression, no substance use, good health, married, strong social support

35. A clinical vignette…
A 24 year-old male is brought to the hospital by his family. He has only slept 3 hours a night for the last 3 days. The family tells you that he has recently withdrawn large sums of money from his savings account and gone on wild spending sprees. During the interview, he is very talkative and easily distracted. He tells you that he feels “on top of the world.” This patient is most likely to be suffering from:
dysthymic disorder
major depressive disorder
bipolar disorder
hypochondriasis
cyclothymic disorder