1. Mood Disorders Bipolar Disorders Depressive Disorders

2. Episodes and Patterns • Major depressive episode • Manic episode • Mixed episode • Hypomanic episode • Cycling patterns

3. Major depressive episode • Five or more of the following, most of the day and/or nearly every day, including at least symptom 1 or 2: • 1. Depressed mood • Sad, empty, weepy; irritable, angry • 2. Loss of interest or pleasure in previously enjoyable activities • 3. Change in weight or appetite • 4. Sleep changes

4. More depressive symptoms • 5. Noticeable change in movement • 6. Fatigue • 7. Feelings of worthlessness or guilt • 8. Impaired cognition or volition • 9. Repeated thoughts of death or suicide, or planned or attempted suicide • The five symptoms must occur in the same two weeks

5. Manic episode • One week of persistently high, expansive, or irritable mood, and 3 of: • Grandiose self-esteem • Lower sleep need • Overly talkative • Racing thoughts • Easily distracted • Increased activity or agitation • High risk activities

6. Mixed episode • One week of both manic and major depressive symptoms with rapidly alternating moods • Common symptoms: • Agitation • Insomnia • Irregular appetite (binge-fast) • Delusions • Thoughts of suicide

7. Hypomanic episode • Four days of manic episode symptoms • Mood disturbance does not critically impair ability to work or maintain social responsibilities • Response pattern is uncharacteristic • Not euthymia

8. Bipolar disorders • Bipolar I Disorder • One or more manic or mixed episodes • Usually one or more major depressive episodes • Subcategorized based on the character of the most recent episode • Most recent episode depressed • Most recent episode manic • Most recent episode mixed

9. Bipolar disorders… • Bipolar II Disorder • One or more major depressive episodes • One or more hypomanic episodes • NO manic or mixed episode • Cyclothymic Disorder • Two years of alternating hypomanic and depressive symptoms • No remission of more than two months • NO major depressive, manic, or mixed episodes

10. Depressive disorders • No history of manic, hypomanic, or mixed episodes • Major Depressive Disorder • Current major depressive episode • Dysthymic Disorder • Two years of chronically depressed mood • Two additional depression symptoms (appetite, sleep, energy, concentration, low self-esteem, hopeless feelings)

11. Patterns of mood disorders Manic Hypo- manic De- pressed Identify episodes: Manic Mixed Weeks Hypomanic Major Depressive

12. More patterns... Manic Hypo- manic De- pressed

13. Depressive Disorders NOS • Premenstrual dysphoric disorder • Minor depressive disorder • Fewer than five symptoms • Recurrent brief depressive disorder • Monthly episodes lasting <2 weeks • Postpsychotic depressive disorder of Schizophrenia • Residual phase phenomenon

14. Mood Disorder Specifiers • These specifiers may be applied to mood disorder diagnoses, where appropriate: • Mild/moderate/severe w/o psychotic features • With:psychotic/ catatonic/ melancholic/ atypical features (m-older, a-younger) • In remission/chronic/seasonal pattern • With postpartum onset • Rapid cycling for Bipolar I or II Disorder

15. Etiology of mood disorders • Psychoanalytic theory: Evaluation of experiences • Cognitive theories: Thought patterns • Interpersonal theory: Rejection • Biological theories: Genes and NTs • Existential theory: Loss of meaning

16. Psychoanalytic theory • Oral fixation: Depends on others for self-esteem • Bereavement, introjection, and mourning work • Symbolic loss • But dream themes of depressed patients are of loss and failure, not anger and hostility (Beck and Ward, 1961) • Depressed people do express anger

17. Cognitive theories • Beck’s theory: Character of pessimism (NegativeTriad) Habits of negativity (Negative schemas) Erroneous thinking (Characteristic biases) DEPRESSION

18. Characteristic biases • Arbitrary inference • Selective abstraction • Overgeneralization • Magnification and minimization

19. Assessment of Beck’s theory • Depressed people do show cognitive biases in their thinking • Their apparent pessimism, however, is accurate • The theory is correlational, not causal • The model is multidimensional • Treatment based on the theory is helpful

20. Helplessness/hopelessness theories • Learned helplessness (Seligman & Maier, 1967) • Attributional reformulation (Abramson, Seligman & Teasdale, 1978) • Personal/Environmental (a.k.a. Internal/External) • Stable/Unstable • Global/Specific • Hopelessness: Add diatheses of low self-esteem and hopelessness

21. Interpersonal theory • Reduced interpersonal support • Experiences of rejection • Due to social structure • Inadequate social networks • Others may dislike them • Elicited by patient • Consequences of behavioral choices • Critical comments by spouse • Poor social skills and seeking reassurance

22. Behavioral theories • Learned helplessness/hopelessness is a behavioral theory with a cognitive twist. • Reduction in reinforcement leads to a reduction in activity. • Depressive behaviors are reinforced. • Depressed people have taken part in fewer pleasant events.

23. Availability of reinforcers • The amount of reinforcement available is a function of • Personal characteristics • Environment or milieu • Repertoire of reinforcement-producing behaviors.

24. Biological theories • Genetics: • Bipolar MZ concordance = 43% to 72% • Bipolar DZ concordance = 6% to 25% • Unipolar MZ concordance = 46% • Unipolar DZ concordance = 20% • Linkage analysis: Mixed results • Multiple genes? • Chromosomes 13 and 22

25. Brain chemistry theories • Serotonin and norepinephrine • Drug treatments: Tricyclics, MAOIs, and SSRIs • But the time course doesn’t match • Current hypothesis: Antidepressant drugs change the density or sensitivity of postsynaptic serotonin receptors

26. Brain structure theories • For Major Depressive Disorder only • Subgenual Cingulate Region (Mayberg, 2005):Deep brain stimulation • Ventral Anterior Capsule, white matter connecting prefrontal cortex to thalamus, has been blocked in treatment for OCD, with the observation that it affected mood as well.

27. Neuroendocrine theory • Hypothalamus-pituitary-adrenocortical axis • High levels of cortisol correlate with depression • Dexamethasone Suppression Test identifies major depressive episodes

28. Existential theory • Frankl and the search for meaning • A spiritual approach: Logotherapy • Suffering has meaning: What is it? • Reversing helplessness?