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Chapter 8
Mood Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Mood Disorders

Two broad types:
I.
II.

Depression characterized by:
»
»
»
»

Involves only depressive symptoms
Involves manic symptoms (Bipolar Disorder)
Sadness
Feelings of worthlessness and guilt
Withdrawal from others
Changes in sleep and appetite
Mania characterized by:
» Intense elation or irritability
» Hyperactivity, talkativeness, distractibility
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Table 8.1 Mood Disorder Diagnoses
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Major Depressive Disorder (MDD)

Depressed mood OR loss of interest or pleasure
(anhedonia)
» Minimum period of 2 weeks
» Not due to normal bereavement

PLUS four of the following symptoms:
»
»
»
»
»
»
»
Change in sleep patterns (sleeping more or less)
Change in appetite or weight (eating more or less)
Psychomotor agitation or retardation
Loss of energy, fatigue
Feelings of self-blame, worthlessness, guilt
Difficulty concentrating, indecisiveness
Thoughts of death or suicide
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Major Depressive Disorder (MDD)

Episodic
» Symptoms tend to dissipate over time

Recurrent
» Once depression occurs, future episodes likely
– Average number of episodes is 4 (Judd, 1997)

Subclinical depression
» Sadness plus 3 other symptoms for 10 days
» Significant impairments in functioning even though
full diagnostic criteria are not met
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Dysthymic Disorder (Dysthymia)

Chronic depression
»

PLUS 2 other symptoms:
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»
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»

Poor appetite or overeating
Sleeping too much or too little
Psychomotor agitation or retardation
Loss of energy
Feelings of worthlessness
Difficulty concentrating or indecisiveness
Recurrent thoughts of death or suicide
Double depression
»

Depressed mood for at least 2 years (w/out major depression)
Dysthymia PLUS major depressive episode
In a 10-year study, 95% of patients with dysthymic
disorder developed MDD (Klein, Shankman, & Rose,
2006).
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Gender Differences in Depression

MDD twice as common in women than men
» Similar discrepancy occurs in many countries
» Does not hold true for Jewish adults


Differences emerge in adolescence
Some biological and psychological factors may factors:
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»
»
»
»
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Hormones
Girls twice as likely to experience sexual abuse
Women more likely to experience chronic stressors
Girls and women more likely to worry about body image
Women may react more intensely to interpersonal loss
Women spend more time ruminating; men tend to distract.
– Ruminating may intensity and prolong sad moods (NolenHoeksema, et al., 1993)
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Epidemiology and Consequences

Depression is common
» Lifetime prevalence (Kessler et al., 2005)
– 16.4% MDD
– 2.5% Dysthymia

Prevalence varies across cultures
» MDD
– 1.5 % in Taiwan
– 19 % in Beirut, Lebanon (Weissman et al., 1996).
– People who move to the US from Mexico have lower
rates than people of Mexican descent who were
born in the United States (Vega et al., 1998).
– More common among people in poverty (Kessler, et al., 2005)
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Epidemiology and Consequences

Symptom variation across cultures
» Latino cultures
– Complaints of nerves and headaches
» Asian cultures
– Complaints of weakness, fatigue, & poor concentration

Symptom variation across life span
» Children
– Stomach & headaches
» Older adults
– Distractibility and forgetfulness

Co-morbidity
» 2/3 of those with MDD will also meet criteria for anxiety
disorder at some point (Mineka, et al., 1998)
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Figure 8.1 Median Age of Onset by
Generation
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Bipolar Disorders

Usually involve episodes of depression
alternating with mania
» Mania
– States of intense elation or irritability
» Mixed episode
– Symptoms of both mania and depression in the same
week
» Hypomania
– Symptoms of mania but less intense
– Four or more days of elevated mood
– Doesn’t interfere with functioning

Hypomania alone is not a DSM diagnostic category
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Bipolar Disorders: Three Forms

Bipolar I
» At least one episode or mania or mixed
episode

Bipolar II
» At least one major depressive episode with
at least one episode of hypomania

Cyclothymic disorder (Cyclothymia)
» Milder, chronic form of bipolar disorder
– Lasts at least 2 years
» Numerous periods with hypomanic and
depressive symptoms
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DSM-IV-TR Criteria for Manic and
Hypomanic Episodes


Elevated, expansive, or irritable mood
PLUS 3 of the following (4 if mood is irritable):
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»
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Psychomotor agitation or increase in goal-directed behavior
Excessive talking or pressured speech
Flights of ideas; racing thoughts
Reduced need for sleep
Grandiosity or inflated self esteem
Easily distractible
Excessive involvement in pleasurable activities with negative
consequences
»

e.g., unprotected sexual activity, spending sprees
For manic episode:
» Symptoms last for 1 week OR require hospitalization
» Symptoms cause significant distress or functional impairment

For hypomanic episode:
» Symptoms last at least 4 days
» Clear changes in functioning but impairment is not marked
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Epidemiology and Consequences

Prevalence rates lower than MDD
» 1% for Bipolar I (Weissman et al., 1996)




Average age of onset in 20s
No gender differences
Tends to be recurrent
Severe mental illness
» A third unemployed a year after hospitalization
(Harrow et al., 1990)
» Suicide rates high (Angst et al., 2002)
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Subtypes of Depressive and Bipolar
Disorders

Seasonal
» Episodes happen regularly at a particular time of
year

Rapid cycling
» At least 4 episodes within past year

Postpartum onset
» Within 4 weeks of giving birth

Catatonic features
» Extreme physical immobility or excessive peculiar
physical movement

Psychotic features
» Delusions or hallucinations

Melancholic
» Inability to experience pleasure (anhedonia)
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Figure 8.2 Rapid Cycling Subtype of
Bipolar Disorder
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Table 8.2 Neurobiological
Hypotheses
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Etiology of Mood Disorders:
Neurobiological Factors

Genetic factors
» Heritability estimates
– 93% Bipolar Disorder (Kieseppa et al., 2004)
– 37% MDD (Sullivan, et al., 2000)

Heritability estimates higher for women than men
» Much research in progress to identify specific
genes involved but the results of most studies
fail to replicate (Kato, 2007)

DRD4.2 gene, which influences dopamine
function, appears to be related to MDD
(Lopez Leon et a., 2005).
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Etiology of Mood Disorders:
Neurobiological Factors

Neurotransmitters
» Original models
– MDD

Low levels of norepinephrine, dopamine, and serotonin
– Mania



High levels of norepinephrine and dopamine, low levels of serotonin
However, medication alters levels immediately yet
relief takes 2-3 weeks
New models focus on sensitivity of postsynaptic
receptors
» Dopamine receptors may be overly sensitive in BD but lack
sensitivity in MDD
» Depleting tryptophan, a precursor of serotonin, causes
depressive symptoms in individuals with personal or family
history of depression
– Individuals who are vulnerable to depression may have less sensitive
serotonin receptors (Sobczak et al., 2002)
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Figure 8.3 Serotonin and Dopamine
Pathways
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Figure 8.4 Drug Action on Synaptic
Activity
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Etiology of Mood Disorders:
Neurobiological Factors

Brain Imaging
» Structural studies
– Focus on number of
or connections among
cells
» Functional activation
studies
– Focus on activity
levels
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Figure 8.5 Key Brain Structures
Involved in MDD
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Etiology of Mood Disorders:
Neuroendocrine System

Overactivity of HPA axis
» Triggers release of cortisol
– Stress hormone

Findings that link depression to high cortisol
levels
» Cushing’s syndrome
– Causes oversecretion of cortisol
– Symptoms include those of depression
» Injecting cortisol in animals produce depressive
symptoms
» Dexamethasone suppression test
– Lack of cortisol suppression in people with history of
depression
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Etiology of Mood Disorders: Social
Factors

Life events

» Prospective research
» High levels of expressed emotion by
family member predicts relapse
» Marital conflict also predicts depression
– 42-67% report a stressful
life event in year prior to
depression onset

e.g., romantic breakup,
loss of job, death of loved
one
– Replicated in 12 studies
across 6 countries
(Brown & Harris, 1989b)
» Lack of social support
may be one reason a
stressor triggers
depression.
Interpersonal Difficulties

Behavior of depressed people often
leads to rejection by others
»
»
»
»
Excessive reassurance seeking
Few positive facial expressions
Negative self disclosures
Slow speech and long silences
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Etiology of Mood Disorders:
Psychological Factors

Freud’s theory
» Oral fixation leads to excessive
dependency
» Depression
– Anger towards loved ones who reject us is
turned inward

Lack of empirical support for theory
» Depressed individuals express more anger
towards others than non-depressed people
(Biglan et al., 1988)
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Etiology of Mood Disorders:
Psychological Factors

Affect
» High negative affect
» Low positive affect

In response to positive stimuli, depressed
individuals experience:
»
»
»
»
Fewer positive facial expressions
Report less pleasant emotion
Show less motivation
Demonstrate less psychophysiological activity
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Table 8.4 Affective Dimensions in
Depression and Anxiety
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Etiology of Mood Disorders:
Psychological Factors

Neuroticism
» Tendency to react with higher levels of
negative affect
» Predicts onset of depression (Jorm et al.,
2000)

Extraversion
» Associated with high levels of positive affect
» Low extraversion does not always precede
depression
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Etiology of Mood Disorders:
Psychological Factors

Cognitive theories
» Beck’s theory
» Negative triad
– Negative view of:



Self
World
Future
» Negative schemata
– Underlying tendency to
see the world negatively
» Negative schemata cause
cognitive biases
– Tendency to process
information in negative
ways
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Figure 8.7 Three Helplessness/Hopelessness
Theories
of Depression
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Etiology of Mood Disorders:
Psychological Factors
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Figure 8.8 Life Events Interact with Serotonin
Transporter Gene to Predict Symptoms of Depression
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Figure 8.9 More than 180,000,000 prescriptions
per year are filled for antidepressants in the
United States
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Psychological Treatment of Mood
Disorders

Interpersonal Psychotherapy (IPT)
» Short term psychodynamic therapy
» Focus on current relationships

Cognitive therapy
» Monitor and identify automatic thoughts
– Replace negative thoughts with more neutral or positive
thoughts

» Behavioral activation
Mindfulness based cognitive therapy (MBCT)
» Strategies, including meditation, to prevent relapse
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Treatment of Mood Disorders

Behavioral Couples therapy
» Enhance communication and satisfaction

Psychological treatment of bipolar disorder
» Psychoeducational approaches
– Provide information about symptoms, course, triggers,
and treatments
» Family-focused treatment (FFT)
– Educate family about disorder, enhance family
communication, improve problem solving.
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Biological Treatment of Mood
Disorders

Electroconvulsive therapy (ECT)
» Reserved for
– Severe depression with high risk of suicide
– Depression with psychotic features
– Treatment non-responders
» Induce brain seizure and momentary
unconsciousness
– Unilateral ECT
» Side effects
– Memory loss
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Table 8.6 Medications for Treating
Mood Disorders
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Biological Treatment of Mood
Disorders


Published studies may overestimate the
effectiveness of medication (Turner et al.,
2008)
STAR-D (Rush et al., 2006)
» Attempted to evaluate effectiveness of antidepressants in real-world settings
– 3671 patients across 41 sites
– 33% achieved full symptom relief with citalopram
(Trivedi et al., 2006)

About 30% of non-responders achieved remission with
another anti-depressant
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Medication vs. Psychological Treatment of
Major Depressive Disorder

NIMH Treatment of Depression Collaborative
Research Program (Elkin et al., 1985)
» Cognitive therapy vs. Interpersonal Therapy vs. mediation
(imipramine)
– Medication more effective than psychotherapy early in treatment
– With less severe MDD, placebo as effective as all other
treatments
– With more severe MDD, imipramine more effective than all other
treatments


IPT, but not CT more effective than placebo
Later studies (Hollon & DeRubeis, 2003)
» CT as effective as medication for severe depression
» CT more effective than medication at preventing relapse
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Medications for Bipolar Disorder

Lithium
» Up to 80% receive at least some relief with this
mood stabilizer
» Potentially serious side effect
– Lithium toxicity

Newer mood stablizers
» Anticonvulsants
– Depakote
» Antipsychotics
– Zyprexa
» Both also have serious side effects
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Models of Suicide

Psychological Disorders
» ½ of suicide attempts are depressed

Neurobiological Models
» Low levels of serotonin
» Overly reactive HPA system

Sociocultural models
» Egoistic
» Altruistic
» Anomic

Psychological models
»
»
»
»
Problem solving deficit
Hopelessness
Impulsivity
Life satisfaction
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Table 8.7 Myths about Suicide
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