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CHAPTER 3

MOOD DISORDERS

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AIMS AND OBJECTIVES

Provide overview of unipolar and bipolar depression

Describe historical approaches, diagnostic criteria, and epidemiology

Discuss current biopsychosocial approaches to the aetiology and treatment of mood disorders

3-3PPTs t/a Abnormal Psychology 1e by Rieger - Copyright 2009 McGraw-Hill Australia Pty Ltd

UNIPOLAR DEPRESSION

History of Classification

In Ancient Greece, term “melancholia” to describe fear and depression

Kraeplin (1896) used the term manic depressive insanity, which encompassed all mood disorders

Since 1950s, classification system has distinguished between bipolar and unipolar depression

Two types of unipolar depression: major depressive disorder and dysthymia

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UNIPOLAR DEPRESSION

DSM-IV-TR Diagnosis of Major Depressive Disorder (MDD)

Characterized by the occurrence of > 1 Major Depressive Episodes (MDEs)

Criteria for an MDE

Depressed mood and/or loss of interest (anhedonia) for > 2 weeks At least 4 of these additional symptoms:

Appetite disturbance Sleep disturbance Fatigue Restlessness or slowed movements Poor concentration Feelings of worthlessness or guilt Thoughts of death or suicide

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UNIPOLAR DEPRESSION

DSM-IV-TR Diagnosis of Dysthymia

Diagnosed when depression is not severe to meet for MDD, but is of longer duration (> 2 years)

Dysthymia + MDD referred to as “double depression”

Other subtypes of depression

Melancholic depression Psychotic depression Postnatal depression Seasonal affective disorder

3-6PPTs t/a Abnormal Psychology 1e by Rieger - Copyright 2009 McGraw-Hill Australia Pty Ltd

UNIPOLAR DEPRESSION Epidemiology of depression

Prevalence In Australia: 3.4% of men, 6.8% of women over 1-year period Lifetime prevalence ~ 17% Women 2x as likely to have depression – cause of gender difference

not completely known

Age of onset As early as 3 years old, median age of onset = 30 years old

Course Up to 50% with depression recover within 6 months of treatment 10% experience a chronic course Most who have an MDE will have another episode within 5 years

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UNIPOLAR DEPRESSION

Aetiology of unipolar depression

Biological factors Genetic factors – family history 2-3x increased risk Neurotransmitters – serotonin, norepinephrine, dopamine Neuroendocrine – hyperactivity in HPA axis Neurophysiological – abnormalities in brain structures, including

prefrontal cortex, hippocampus, anterior cingulate, and amygdala

Environmental factors Stressful life events Interpersonal difficulties High level of “expressed emotion” in families of depressed patients

3-8PPTs t/a Abnormal Psychology 1e by Rieger - Copyright 2009 McGraw-Hill Australia Pty Ltd

UNIPOLAR DEPRESSION Aetiology of unipolar depression

Psychological factors

Cognitive theories Seligman’s Learned Helplessness Model – depression linked with

expectancy of helplessness in face of adverse events Beck - childhood experiences lead to dysfunctional beliefs, which

are triggered by relevant events Negative Cognitive Triad = Negative view of self, world, and future

Behavioural theories Influence of adverse events and/or lack of positive reinforcement Poor coping skills to deal with stressors Protective factors may reduce risk (e.g., good interpersonal skills,

optimism)

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UNIPOLAR DEPRESSION

Treatment

Medical approaches

Antidepressant medication Repetitive transcranial magnetic stimulation / Vagus nerve

stimulation Bright light therapy (seasonal affective disorder) Electroconvulsive therapy (severe depression)

Psychological approaches

Cognitive behaviour therapy Behavioural activation and problem-solving Cognitive restructuring for dysfunctional thoughts

Interpersonal psychotherapy Focus on interpersonal problems related to the depression

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BIPOLAR DISORDER History

Descriptions of mania date back to ancient Greece In 19th century, mania and melancholia began to be considered

as a single entity Kraeplin distinguished between “manic depressive insanity” and

“dementia praecox”, e.g., schizophrenia In 1949 Australian researcher John Cade discovered lithium,

which revolutionized the treatment of bipolar disorder

Bipolar Diagnoses:

Bipolar I, Bipolar II, and cyclothymia All 3 of these conditions involve mania or hypomania

3-11PPTs t/a Abnormal Psychology 1e by Rieger - Copyright 2009 McGraw-Hill Australia Pty Ltd

BIPOLAR DISORDER DSM-IV-TR defines a manic episode:

Elevated, expansive or irritable mood > 1 week, plus 3 of the following: Inflated self-esteem Grandiosity Sleep disturbance Pressured speech Flight of ideas Distractibility Heightened activity Excessive risk taking

Must be out of character for the individual

DSM-IV-TR defines a hypomanic episode: Same symptom profile as mania, except Symptoms not severe enough to interfere with functioning, necessitate

hospitalisation, or involve hallucinations/delusions

DSM-IV-TR also includes the controversial construct of a mixed episode, in which both symptoms of a manic and major depressive episode present for > 1 week

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BIPOLAR DISORDER

Bipolar I > 1 manic or mixed episodes (MDE can be present but not

necessary)

Bipolar II >1 MDE plus >1 hypomanic episode

Cyclothymia Lacks severity to meet for Bipolar I or II Hypomanic episodes plus depressive symptoms that don’t meet

for an MDE

Relationship between schizophrenia and bipolar Often a mixture between mania and psychotic features Bipolar can be initially misdiagnosed as schizophrenia

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BIPOLAR DISORDER Epidemiology

Lifetime prevalence of Bipolar I and II = 3.9% Men and women equally likely to meet for Bipolar I

Women more likely to meet for Bipolar II High rates of relapse (73% over 5 years) Often problems with medication compliance

Problems associated with bipolar disorders

High rates of anxiety disorders and substance abuse among bipolar patients

Substantial social and economic costs High rate of suicide (15x rate in general population)

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BIPOLAR DISORDER

Aetiology Biological Factors

Strong genetic component 13x increased risk among 1st degree relatives 85% heritability in large twin study

Neurotransmitters play a role

Stressful Events Diathesis-Stress Model – interaction between underlying vulnerability

and stressful life event Goal Dysregulation Model – excessive goal engagement

Psychological factors Cognitive disturbances – cause or consequence? Temperament – perfectionism and high need for social approval

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BIPOLAR DISORDER

Treatment

Pharmacological Mood stabilisers

lithium, chlorpromazine, valproate, zyprexor, lamictal

Psychological Psychoeducation for patients and families Cognitive behaviour therapy Interpersonal and social rhythm therapy Family interventions Relapse prevention

3-16PPTs t/a Abnormal Psychology 1e by Rieger - Copyright 2009 McGraw-Hill Australia Pty Ltd

SUMMARY

Unipolar and Bipolar Depression

History Diagnostic criteria Epidemiology Aetiology

Biological Psychological Environmental

Treatment Biological Psychological