Mood disorders
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Mood Disorders. Mood Disorders. Depressive Disorders Major Depressive Disorder Dysthymic Disorder Bipolar Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder. Major Depressive Disorder. aka unipolar depression lifetime prevalence: up to 21% in women 13% in men

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Mood Disorders

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Mood disorders

Mood Disorders


Mood disorders1

Mood Disorders

  • Depressive Disorders

    • Major Depressive Disorder

    • Dysthymic Disorder

  • Bipolar Disorders

    • Bipolar I Disorder

    • Bipolar II Disorder

    • Cyclothymic Disorder


Major depressive disorder

Major Depressive Disorder

  • aka unipolar depression

  • lifetime prevalence:

    • up to 21% in women

    • 13% in men

  • typical age of onset:

    • 20s, but can occur at any time


Major depressive episode

Major Depressive Episode

  • DSM-IV-TR criteria include

    • 1 of 2 mood symptoms

    • at least 5 symptoms total

    • duration of at least 2 weeks


Mood symptoms of depression

Mood Symptoms of Depression

  • persistent sad, depressed mood

  • loss of interest or pleasure in previously enjoyable activities

  • DSM-IV criteria specify that person must have 1 of above plus 4 additional sx for at least 2 weeks


Physical symptoms of depression

Physical Symptoms of Depression

  • Sleep disturbance

    • too much or too little

  • loss of energy, fatigue

  • appetite disturbance/weight change

    • loss of appetite or increase in appetite

  • changes in activity level

    • psychomotor retardation or agitation


Cognitive symptoms of depression

Cognitive Symptoms of Depression

  • difficulty concentrating, thinking, and making decisions

  • feelings of worthlessness, guilt, or hopelessness

  • recurrent thoughts of death or suicide


Course of depression

Course of Depression

  • if untreated, average duration of first episode is 6-9 months

  • often recur


Dysthymic disorder

Dysthymic Disorder

  • Less severe, but more chronic

  • Chronic “low grade” depression

  • Depressed mood, plus 2 additional sx

    • poor appetite or overeating

    • insomnia or hypersomnia

    • low energy or fatigue

    • low self-esteem

    • poor concentration or difficulty making decisions

    • feelings of hopelessness


Dysthymic disorder continued

Dysthymic Disorder (continued)

  • Sx must have lasted for at least 2 yrs

  • Never without symptoms for longer than 2 mos.


Double depression

Double-Depression

  • dysthymic disorder with episodes of major depression

  • prognosis more negative


Bipolar i disorder

Bipolar I Disorder

  • often called manic depression

  • typically involves episodes of major depression and mania

  • lifetime prevalence is 1% for both men and women

  • typical age of onset is late teens-early 20s


Symptoms of manic episodes

Symptoms of Manic Episodes

  • elevated, expansive, or irritable mood for at least 1 week, plus 3 additional symptoms


Symptoms of manic episodes1

Symptoms of Manic Episodes

  • inflated self-esteem/grandiosity

  • decreased need for sleep (3 hrs.)

  • unusual talkativeness or pressured speech

  • flight of ideas/racing thoughts

  • marked distractibility

  • increased activity at work, school, or in social situations

  • excessive involvement in pleasurable activities with potential for painful consequences


Course of bipolar i disorder

Course of Bipolar I Disorder

  • there is great variability in cycle time

  • 35% of individuals go through only 1 cycle in 5 years

  • 1% of individuals go through 1 cycle every 3 months

  • rapid cycling: 4 or more cycles per year


Other bipolar disorders

Other Bipolar Disorders

  • Bipolar II

    • Alternate between hypomanic and major depressive episodes

  • Cyclothymic Disorder

    • Alternate between depressive (not MDE) and hypomanic episodes for at least 2 yrs.

    • Never without symptoms for longer than 2 mos.


Hypomanic episode

Hypomanic Episode

  • Elevated, expansive, or irritable mood for at least 4 days

  • Symptoms similar to manic episode, except no marked impairment/hospitalization


Causes of mood disorders genetics

Causes of Mood Disorders: Genetics

  • twin studies and adoption studies show genetic link for mood disorders

  • link is stronger for bipolar disorder than unipolar depression


Concordance rates

Concordance Rates

  • likelihood that if one member of pair has disease, other member will also have disease

  • unipolar depression

    • MZ twins = 36%

    • DZ twins = 17%

    • rates are higher for severe depression


Concordance rates continued

Concordance Rates (continued)

  • bipolar disorder

    • MZ twins = 80%

    • DZ twins = 16%


Causes neurotransmitters

Causes: Neurotransmitters

  • depression is associated with low levels of serotonin in relation to norepinephrine and dopamine

    • primary function of serotonin is to regulate our emotional reactions

    • when levels of serotonin are low, we are more impulsive and our moods swing more wildly


Causes neurotransmitters continued

Causes: Neurotransmitters (continued)

  • medications that treat depression increase the availability of serotonin and/or norepinephrine in the synapse

  • within a few weeks, this changes postsynaptic receptor sensitivity

  • change in postsynaptic receptor sensitivity (down-regulation) correlates with symptom improvement


Causes the endocrine system

Causes: The Endocrine System

  • depression can be a symptom of some endocrine disorders

    • hypothyroidism

    • Cushing’s syndrome

  • HPA axis

    • hypothalamus

    • pituitary gland

    • adrenal gland

  • hypothalamus sends signals to pituitary gland, which sends signals to adrenal gland to secrete hormones related to stress response

    • 50% of depressed individuals show elevated levels of cortisol


Causes circadian rhythms

Causes: Circadian Rhythms

  • overview

    • circadian rhythms (sleep-wake, temperature, hunger) are regulated by hypothalamus

    • exposure to light affects circadian rhythms (suppresses melatonin)


Causes circadian rhythms continued

Causes: Circadian Rhythms (continued)

  • interesting findings:

    • prevalence of seasonal affective disorder is higher in extreme northern and southern lattitudes

    • depriving depressed patients of sleep can temporarily reduce their depression

    • extended bouts of insomnia can trigger manic episodes


Causes circadian rhythms continued1

Causes: Circadian Rhythms (continued)

  • theory

    • mood disorders are caused by disturbance in circadian rhythms


Causes stress

Causes: Stress

  • general finding: stressful life events are strongly related to the onset of mood disorders

    • 20-50% of individuals who experience stressful life events become depressed


Causes stress continued

Causes: Stress (continued)

  • a few caveats:

    • same stressors that are associated with depression are associated with other disorders

    • new data indicate that approximately 1/3 of the association between stressful life events and depression is due to the tendency of people who are vulnerable to depression to place themselves in high-risk stressful environments

    • social support seems to reduce risk for developing depression when exposed to stress


Causes learned helplessness

Causes: Learned Helplessness

  • animal research

    • animals who have been exposed to inescapable aversive events do not make adequate attempts to escape in the future

  • learned helplessness theory of depression

    • people become anxious and depressed when they make an attribution that they have no control over the stress in their lives


Depressive attributional style

Depressive Attributional Style

  • attribution

    • the way in which people assign causes to events in their lives

  • people who are depressed tend to make attributions that are

    • Internal

    • Stable

    • Global

  • sense of hopelessness is important


Causes negative cognitive style

Causes: Negative Cognitive Style

  • tendency to interpret everyday events in a negative way

  • reflects cognitive errors

    • all or nothing

      • seeing things in “black or white”

      • one order of french fries means I’ve blown my whole diet

    • overgeneralization

      • one critical remark on paper means I will fail class

    • arbitrary inference

      • selective attention to negative aspects

      • I assume I’m a terrible teacher because 2 students fell asleep


Causes negative cognitive style continued

Causes: Negative Cognitive Style (continued)

  • make negative interpretations about

    • self

    • world

    • future

  • depressive cognitions emerge from distorted and probably automatic methods of processing information


Causes cognitive vulnerability for depression

Causes: Cognitive Vulnerability for Depression

  • 5-year longitudinal study of college students

  • method

    • at first assessment: subjects who were not depressed filled out questionnaires to assess cognitive vulnerability to depression

    • questionnaires: measured dysfunctional attitudes and hopelessness attributions

    • subjects were assessed every several months for next 5 years for symptoms of depression


Causes cognitive vulnerability for depression continued

Causes: Cognitive Vulnerability for Depression (continued)

  • Results

    • negative cognitive styles do indicate a vulnerability to later depression

    • subjects who scored high on measures of cognitive vulnerability were far more likely to experience later depression (17% vs. 1%)


Treatment of depression

Treatment of Depression

  • Medical

    • antidepressants

    • electroconvulsive therapy (ECT)

  • Psychosocial

    • cognitive-behavioral therapy

    • interpersonal therapy


Antidepressant medication

Antidepressant Medication

  • most meds increase levels of serotonin and/or norepinephrine

    • result in down-regulation of these systems

  • take 2-8 weeks to work

  • effective

    • 65-70% of those on meds improve, vs. 25-30% of those taking placebos

    • however, 40% will stop taking drugs due to side effects

  • relapse rate after going off medications is high (50%)


Types of antidepressants

Types of Antidepressants

  • tricyclics

  • MAO inhibitors

  • SSRIs

  • others


Tricyclics

Tricyclics

  • block reuptake of norepinephrine and (to a lesser extent) serotonin

  • examples:

    • amitriptyline (Elavil)

    • imipramine (Tofranil)

  • side effects:

    • dry mouth, constipation, blurred vision, weight gain, orthostatic hypotension

  • are likely to be lethal if taken in overdose


Mao inhibitors

MAO Inhibitors

  • block enzyme (monoamine oxidase) which breaks down norepinephrine and serotonin (monoamines)

  • examples:

    • phenelzine (Nardil)

    • tranylcypromine (Parnate)

  • problem:

    • dangerously interact with many other drugs (nasal decongestants, SSRIs) and with foods containing tyramine (smoked meats, ages cheeses, beer)

    • can produce hypertensive crisis


Ssris

SSRIs

  • selectively inhibit reuptake of serotonin

  • side effects:

    • physical agitation, insomnia, gastrointestinal upset, and sexual dysfunction (low desire)

  • examples

    • fluoxetine (Prozac)

    • paroxetine (Paxil)

    • sertraline (Zoloft)

  • are less likely to be lethal if taken in overdose


Other antidepressants

Other Antidepressants

  • buproprion (Wellbutrin)

    • blocks reuptake of dopamine

  • venlaxafine (Effexor) and nefazodone (Serzone)

    • inhibit reuptake of serotonin and norepinephrine


Electroconvulsive therapy

Electroconvulsive Therapy

  • used for depression that doesn’t respond to other treatments

  • effective

  • exact mechanism of action is unknown

  • receive treatments every other day for total of 6-10 treatments

  • side effects: short-term memory loss


Cognitive behavioral therapy

Cognitive-Behavioral Therapy

  • focuses on changing dysfunctional beliefs associated with depression

  • clients do homework

    • monitor and log thought processes

    • engage in hypothesis testing

  • important to reactivate client

  • 10-20 weekly sessions

  • effective


Interpersonal psychotherapy

Interpersonal Psychotherapy

  • focuses on resolving problems in client’s existing interpersonal relationships and forming new ones

  • 4 major areas

    • dealing with interpersonal role disputes (marital conflict, conflict with friends)

    • adjusting to the loss of a relationship (death, divorce)

    • acquiring new relationships (getting married or establishing professional relationships)

    • identifying and correcting deficits in social skills


Interpersonal psychotherapy continued

Interpersonal Psychotherapy (continued)

  • 15-20 weekly sessions

  • effective


Comparing treatments

Comparing Treatments

  • studies compare CBT and IPT to antidepressant meds and other control conditions

  • results

    • CBT, IPT, and meds are equally effective

    • CBT, IPT, and meds are more effective than

      • placebo conditions

      • brief psychodynamic treatments

      • other control conditions

  • 50-70% of people benefit from treatment to a significant extent, compared to 30% in placebo or control conditions


Combined treatments

Combined Treatments

  • Meds work more quickly

  • Psychosocial treatments

    • Increase long-range social functioning

    • Prevent relapse


Treatment of bipolar disorder

Treatment of Bipolar Disorder

  • lithium is best known treatment

  • not sure how it works

  • side effects

    • excessive thirst and urination, eventual damage to kidneys and thyroid

  • blood levels must be carefully monitored

  • effective

    • 30-60% respond well initially


Treatment of bipolar disorder continued

Treatment of Bipolar Disorder (continued)

  • other approaches include anticonvulsant medications

    • example: valproate (Depakote)

  • psychosocial treatment

    • family therapy: increase medication compliance, educate family about symptoms, help family develop new coping skills and communication styles

    • decreases relapse


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