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Chapter 6 Mood Disorders and Suicide Range of Emotions • A person with a mood disorder experiences emotions that are extreme and, therefore, abnormal. Types of depressive disorders – Major depressive disorder – Dysthymic disorder – Double depression Major Depression: An Overview • Major depressive episode: Overview and defining features – Extremely depressed mood lasting at least two weeks – Cognitive symptoms – feelings of worthlessness, indecisiveness – Disturbed physical functioning (sleep and eating) – Anhedonia – loss of pleasure/interest in usual activities Major Depression: An Overview • Major depressive disorder – Single episode – highly unusual – Recurrent episodes (2 or more major depressive episodes separated by at least 2 months of no depression) – more common • From grief to depression – Pathological or impacted grief reaction Major Depression: An Overview • Major depressive disorder Mean age is 30 Typical first episode is 4-9 months if untreated Dysthymia: An Overview • Overview and defining features – Symptoms are milder than major depression – Persists for at least two years in adults, one year in children and adolescents – No more than two months symptom free – Symptoms can persist unchanged over long periods (≥ 20 years) • Facts and statistics – Late onset – typically in the early 20s Double Depression: An Overview • Overview and defining features – Major depressive episodes and dysthymic disorder – Dysthymic disorder often develops first – Associated with severe psychopathology and problematic future course – High relates of relapse Types of bipolar disorders – Bipolar I disorder – Bipolar II disorder – Cyclothymic disorder The Structure of Mood Disorders • Mania • Hypomanic episode – less severe than manic episode that lasts at least 4 days The Structure of Mood Disorders • Features of a manic episode – Elevated, expansive mood for at least one week • At least 3 of the following: – Inflated self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas or sense that thoughts are racing, easy distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in pleasurable but risky behaviors – Impairment in normal functioning Bipolar I Disorder: An Overview • Overview and defining features – Alternations between full manic or mixed episodes and (but not necessarily) depressive episodes and/or hypomania • Facts and statistics – Average age of onset is 15-18 years – Can begin in childhood – Tends to be chronic and acute – Suicide is a common consequence – as high as 48% (usually during depressive episodes) Bipolar II Disorder: An Overview • Overview and defining features – Alternations between major depressive and hypomanic episodes • Facts and statistics – Average age of onset is 19-22 years – Can begin in childhood – 10% to 25% of cases progress to full bipolar I disorder – Tends to be chronic Cyclothymic Disorder: An Overview • Overview and defining features – Milder but more chronic version of bipolar disorder – hypomanic and dysthymic episodes that last a long time – Must last for at least two years (one year for children and adolescents) Cyclothymic Disorder: An Overview • Facts and statistics – Average age of onset is 12 to 14 years – 60% are female – chronic and lifelong – 1/3 to 1/2 develop bipolar Prevalence of Mood Disorders • Worldwide lifetime prevalence – 16% for major depression • Sex differences – Females are twice as likely to have major depression – Bipolar disorders equally affect males and females – 1% for bipolar disorder Prevalence of Mood Disorders • • • • • Occurs less often in prepubertal children Rapid rise in adolescence Adults over 65 have about 50% less than adults Three-month-olds can show depression Children below nine do not show classic mania or bipolar symptoms • Mood disorders are often misdiagnosed as ADHD • Children are being diagnosed with bipolar at increasingly high rates Life Span Developmental Influences on Mood Disorders • Depression in elderly between 14% and 42% – Comorbidity with anxiety disorders – Less gender imbalance after 65 years of age • Cultural differences exist – Hopi Native Americans - “Heartbroken” – Native American population - 4 X the rate Mood Disorders: Familial and Genetic Influences • Family studies – Rate is high in first-degree relatives of probands (2-3 x greater) – Relatives of bipolar probands tend to have unipolar depression • Twin studies – Concordance rates are high in identical twins (2-3 x) – Severe mood disorders have strong genetic influence – Heritability rates are higher for females compared to males; 40% women and 20% men for depression Mood Disorders: Familial and Genetic Influences • Twin studies – Vulnerability for unipolar or bipolar disorder • Appears to be inherited separately – Some genetic factors are common for mood and anxiety disorders (not mania though) Mood Disorders: Neurobiological Influences • Neurotransmitter systems – Low Serotonin and its relation to other neurotransmitters causes mood disorders – Permissive hypothesis – when serotonin is low, other neurotransmitters are “permitted” to become dysregulated Mood Disorders: Neurobiological Influences • The endocrine system – Elevated cortisol damages the hippocampus and prevents neurogenesis • Sleep disturbance – Hallmark of most mood disorders – REM and depression – Insomnia and depression linked Mood Disorders: Psychological Dimensions (Stress) • Stressful life events – Stress is strongly related to mood disorders • Poorer response to treatment • Longer time before remission – The relation between context (interpretation) of life events and mood – Reciprocal-gene environment model – Relationship between stress and bipolar is also strong Mood Disorders: Psychological Dimensions (Learned Helplessness) Learned helplessness (LH)- Lack of perceived control over life events • LH and a depressive attributional style – Internal attributions • Negative outcomes are one’s own fault – Stable attributions • Believing future negative outcomes will be one’s fault – Global attribution • Believing negative events will disrupt many life activities Mood Disorders: Psychological Dimensions (Beck’s Cognitive Theory) • Negative coping styles – Depressed persons engage in cognitive errors – Tendency to interpret life events negatively • Types of cognitive errors – Arbitrary inference – overemphasize the negative – Overgeneralization – negatives apply to all situations Mood Disorders: Psychological Dimensions (Cognitive Theory) • Cognitive errors and the depressive cognitive triad – Think negatively about oneself, the world and the future – Negative schema Mood Disorders: Social and Cultural Dimensions • Marital relations – Marital dissatisfaction is strongly related to depression especially in males • Mood disorders in women – Females over males (70:30) except bipolar disorders (50:50) – Gender imbalance likely due to socialization (perceptions of uncontrollability) • Social support – Extent of social support is related to depression and predicts recovery from depression An Integrative Theory • Shared biological vulnerability – Overactive neurobiological response to stress • Inadequate coping and depressive cognitive style – Diathesis-stress model • Biological, psychological and social factors all influence the development of mood disorders • Exposure to stress Selective Serotonergic Reuptake Inhibitors (SSRIs) • Specifically block reuptake of serotonin – Fluoxetine (Prozac) is the most popular SSRI • SSRIs pose some risk of suicide particularly in teenagers • Negative side effects Treatment of Mood Disorders: Mixed Reuptake Inhibitors • Venlafaxine (Effexor)- blocks norepinephrine as well as serotonin • Nefazodone (Serzone) – improves sleep efficiency • Both have fewer side effects than SSRIs Treatment of Mood Disorders: Monoamine Oxidase (MAO) Inhibitors • Monoamine oxidase (MAO) – Block monoamine oxidase enzyme that breaks down serotonin and norepinephrine – Slightly more effective than tricyclics • Must avoid foods containing tyramine – Examples include beer, red wine, cheese – Many patients do not like the dietary restrictions Treatment of Mood Disorders: Tricyclic Antidepressants • Used to be widely used (e.g., Tofranil, Elavil) • Block reuptake – Norepinephrine and other neurotransmitters • Therapeutic effects – Can take two to eight weeks • Negative side effects are common • May be lethal in excessive doses so not good for suicidal tendencies Treatment of Mood Disorders: Lithium • Lithium carbonate is a common salt – Primary drug of choice for bipolar disorders (50% reduction in symptoms) – Can be toxic • Side effects may be severe – Dosage must be carefully monitored – Lithium is a mood-stabilizing drug • Why lithium works remains unclear Treatment of Mood Disorders: Electroconvulsive Therapy (ECT) • ECT is effective for cases of severe depression • The nature of ECT – Involves applying brief electrical current to the brain – Results in temporary seizures – Usually six to 10 outpatient treatments are required – Side effects are few and include short-term memory loss – Uncertain why ECT works – Relapse is common (60%) Psychosocial Treatments • Cognitive-behavioral therapy – Addresses cognitive errors in thinking – Also includes behavioral components • Interpersonal psychotherapy – Identifies stressors and focuses on problematic interpersonal relationships • Prevention • Combined treatments for depression more effective (73% versus 48%) • Prevention relapse of depression • Psychosocial treatments for bipolar The Nature of Suicide: Facts and Statistics • 11th leading cause of death in the United States- maybe two to three times higher • Overwhelmingly a white and Native American phenomenon • China and suicide rates (more females) Suicidal ideation - thinking seriously about suicide Suicidal plan – formulation of a specific method Suicidal attempt – person survives The Nature of Suicide: Facts and Statistics • Gender differences – Males are more successful at committing suicide than females – Females attempt suicide more often than males The Nature of Suicide: Risk Factors • Risk factors – Suicide in the family – Low serotonin levels – Preexisting psychological disorder – Alcohol use and abuse – Stressful life event – Past suicidal behavior – Suicide contagion • Treatment Summary of Mood Disorders • All mood disorders share: – Gross deviations in mood – Common biological and psychological vulnerability • Occur in children, adults, and the elderly • Onset, maintenance, and treatment are affected by – Stress – Social support Summary • Suicide is an increasing problem – Not unique to mood disorders • Medications and psychotherapy produce comparable results • High rates of relapse DSM-5 Proposed Changes • http://www.dsm5.org/ProposedRevisions/Pag es/MoodDisorders.aspx