Chapter 6Chapter 6

Mood DisordersMood Disorders

And SuicideAnd Suicide

Mood DisordersMood Disorders

And SuicideAnd Suicide

What Are Mood Disorders?What Are Mood Disorders?

Mood DisordersMood Disorders Disturbances of mood that are intense and Disturbances of mood that are intense and

persistent enough to be clearly maladaptive.persistent enough to be clearly maladaptive. ManiaMania

Intense and unrealistic feelings of excitement Intense and unrealistic feelings of excitement and euphoria.and euphoria.

DepressionDepression Feelings of extraordinary sadness and dejection.Feelings of extraordinary sadness and dejection.

Unipolar disordersUnipolar disorders Bipolar disordersBipolar disorders

Unipolar Mood DisordersUnipolar Mood Disorders

Depressions that are not mood disordersDepressions that are not mood disorders Loss and the grieving processLoss and the grieving process Other normal mood variationsOther normal mood variations

Lifetime prevalence rates areLifetime prevalence rates are 13% for males and 21 % for females13% for males and 21 % for females

Average age for adolescent depression is Average age for adolescent depression is decreasing over the past decade.decreasing over the past decade.

Highly correlated with suicideHighly correlated with suicide

Unipolar Mood DisordersUnipolar Mood Disorders

Mild to moderate depressive disordersMild to moderate depressive disorders DysthymiaDysthymia

Persistently depressed mood, more days than not for Persistently depressed mood, more days than not for the past 2 years and have two of the symptoms of the past 2 years and have two of the symptoms of major depressive disorder (see next slides).major depressive disorder (see next slides).

Not less severe symptoms than major depression. Not less severe symptoms than major depression. Differs from MDD in that symptoms are not every dayDiffers from MDD in that symptoms are not every day Average duration for dysthymia is five years.Average duration for dysthymia is five years.

Adjustment disorder with depressed moodAdjustment disorder with depressed mood Identifiable stressorIdentifiable stressor Less than six monthsLess than six months

Major Depressive DisorderMajor Depressive Disorder Major Depressive Disorder (DSM-IV Criteria)Major Depressive Disorder (DSM-IV Criteria)

Person must experience either markedly Person must experience either markedly depressed mood or marked loss of interest in depressed mood or marked loss of interest in pleasurable activities most of every day for at pleasurable activities most of every day for at least 2 weeks.least 2 weeks.

The person must experience at least 4 or more The person must experience at least 4 or more of the symptoms below during the same period:of the symptoms below during the same period:

Fatigue or loss of energyFatigue or loss of energy Insomnia or hypersomniaInsomnia or hypersomnia Decreased appetite and weight loss or gain Decreased appetite and weight loss or gain Psychomotor agitation or retardationPsychomotor agitation or retardation Diminished ability to think or concentrateDiminished ability to think or concentrate Self denunciation (worthlessness) or excessive guiltSelf denunciation (worthlessness) or excessive guilt Recurrent thoughts of suicide or deathRecurrent thoughts of suicide or death

Major Depressive Disorder SubtypesMajor Depressive Disorder Subtypes Melancholic TypeMelancholic Type

Loss of pleasure & other symptoms.Loss of pleasure & other symptoms. Severe Major Depressive Episode with Severe Major Depressive Episode with

Psychotic SymptomsPsychotic Symptoms Loss of contact with reality including delusions Loss of contact with reality including delusions

or halucinations.or halucinations. Mood-Congruent and Mood IncongruentMood-Congruent and Mood Incongruent

Congruent (negative content – disease or Congruent (negative content – disease or death)death)

Incongruent (Positive content – hero)Incongruent (Positive content – hero) PostpartumPostpartum

More closely fits adjustment disorder diagnosisMore closely fits adjustment disorder diagnosis

Major Depressive DisorderMajor Depressive Disorder Distinguishing major depressionDistinguishing major depression Depression as a recurrent disorderDepression as a recurrent disorder

Single Episode vs Recurrent EpisodeSingle Episode vs Recurrent Episode Average duration of untreated MDD (6 months)Average duration of untreated MDD (6 months) Recurrence vs RelapseRecurrence vs Relapse

Relapse is when symptoms return quickly before the Relapse is when symptoms return quickly before the depressive episode has run its course.depressive episode has run its course.

26% of patients have a recurrence within 1 yr26% of patients have a recurrence within 1 yr 76% of patients have a recurrence within 10 yrs76% of patients have a recurrence within 10 yrs

Seasonal affective disorderSeasonal affective disorder

Biological Causal Factors In Unipolar Biological Causal Factors In Unipolar DisordersDisorders

Heredity factorsHeredity factors Biochemical factorsBiochemical factors Neuroendocrine factorsNeuroendocrine factors Sleep and other biological rhythmsSleep and other biological rhythms

Psychosocial Causal Factors In Psychosocial Causal Factors In Unipolar DisordersUnipolar Disorders

Stressful life eventsStressful life events Endogenous depressionEndogenous depression Chronic stressChronic stress Individual differences in responses to Individual differences in responses to

stressorsstressors Vulnerability and invulnerability factorsVulnerability and invulnerability factors

Psychosocial Causal Factors In Psychosocial Causal Factors In Unipolar DisordersUnipolar Disorders

Diathesis-stress modelsDiathesis-stress models Personality and cognitive diathesisPersonality and cognitive diathesis NeuroticismNeuroticism Early parental loss as a diathesisEarly parental loss as a diathesis

Psychosocial Causal Factors In Psychosocial Causal Factors In Unipolar DisordersUnipolar Disorders

Psychodynamic theoriesPsychodynamic theories Behavioral theoriesBehavioral theories

Depressed persons receive fewer Depressed persons receive fewer positive verbal reinforcements and positive verbal reinforcements and moods tend to vary with both their moods tend to vary with both their positive rates of reinforcement and their positive rates of reinforcement and their negative experiences.negative experiences.

Beck’s Cognitive Model of DepressionBeck’s Cognitive Model of Depression

Helplessness and Hopelessness Helplessness and Hopelessness Theories of DepressionTheories of Depression

Learned helplessnessLearned helplessness Similarities between depression and Similarities between depression and

helplessnesshelplessness The role of attributional styleThe role of attributional style

Three critical dimensionsThree critical dimensions Internal/ExternalInternal/External Global/SpecificGlobal/Specific Stable/UnstableStable/Unstable

The hopelessness theory of depressionThe hopelessness theory of depression

Bipolar DisordersBipolar Disorders

CyclothymiaCyclothymia HypomaniaHypomania

Bipolar disorderBipolar disorder Bipolar disorder with a seasonal patternBipolar disorder with a seasonal pattern

Schizoaffective disorderSchizoaffective disorder

Causal Factors in Bipolar DisorderCausal Factors in Bipolar Disorder

Biological causal factorsBiological causal factors Heredity factorsHeredity factors

Higher heritability than unipolar depressionHigher heritability than unipolar depression Biochemical factorsBiochemical factors

Serotonin remains low in both up and down of cycleSerotonin remains low in both up and down of cycle Dopamine and noripinephrine appear to be elevated in Dopamine and noripinephrine appear to be elevated in

manic state.manic state. OtherOther

Hormonal ProblemsHormonal Problems Blood flow in areas of the brainBlood flow in areas of the brain

Bipolar Disorders: FeaturesBipolar Disorders: Features

Causal Factors in Bipolar Causal Factors in Bipolar DisorderDisorder

Psychosocial causal factors in bipolar Psychosocial causal factors in bipolar disorderdisorder Stressful life eventsStressful life events Psychodynamic viewsPsychodynamic views

Sociocultural Factors Affecting Unipolar Sociocultural Factors Affecting Unipolar and Bipolar Disordersand Bipolar Disorders

Cross-cultural differences in depressive Cross-cultural differences in depressive symptomssymptoms

A belief in self-sufficiencyA belief in self-sufficiency Relieving lossesRelieving losses Demographic differencesDemographic differences

Interpersonal Effects of Mood Interpersonal Effects of Mood DisordersDisorders

Lack of social support and social skills Lack of social support and social skills deficitsdeficits

The effects of depression on othersThe effects of depression on others Marriage and familyMarriage and family

Rates of Mood Disorders in Writers and Rates of Mood Disorders in Writers and ArtistsArtists

Robert Schumann’s Work: Number of Robert Schumann’s Work: Number of Compositions by YearCompositions by Year

Treatments and OutcomesTreatments and Outcomes

PharmacotherapyPharmacotherapy Selective Serotonin-Reuptake Inhibitors Selective Serotonin-Reuptake Inhibitors

(SSRIs)(SSRIs) Lithium and other mood-stabilizing drugsLithium and other mood-stabilizing drugs

Electroconvulsive therapy (ECT)Electroconvulsive therapy (ECT)

Treatments and OutcomesTreatments and Outcomes

PsychotherapyPsychotherapy Cognitive-behavioral therapyCognitive-behavioral therapy Interpersonal therapy (IPT)Interpersonal therapy (IPT) Family and marital therapyFamily and marital therapy

Suicide: Clinical PictureSuicide: Clinical Picture

SuicideSuicide Ninth leading cause of death for adults in U.S.Ninth leading cause of death for adults in U.S. At least 2/3 of suicide attempters are under 35At least 2/3 of suicide attempters are under 35 Every 20 minutes someone in the U.S. suicidesEvery 20 minutes someone in the U.S. suicides May be as many as 6 million attempts per yearMay be as many as 6 million attempts per year Women are 3 -4 times more likely to attempt Women are 3 -4 times more likely to attempt

suicidesuicide Men are 4-5 times more likely to succeedMen are 4-5 times more likely to succeed Rates of attempts are 3-4 times higher in people Rates of attempts are 3-4 times higher in people

who are divorced or separated who are divorced or separated Most attempts are related to relational discordMost attempts are related to relational discord Guns are the means in 60% of suicidesGuns are the means in 60% of suicides

Adolescent Suicide Adolescent Suicide Seventh leading cause of death in 5-14 yo.Seventh leading cause of death in 5-14 yo. Third leading cause of death in 15-24 yo.Third leading cause of death in 15-24 yo.

First two are accidents and homicides)First two are accidents and homicides) Suicide rate in teens tripled from 1950’s to mid Suicide rate in teens tripled from 1950’s to mid

1980’s. 1980’s. Similar trends are noted in 23 out of 29 countries studied Similar trends are noted in 23 out of 29 countries studied

(Lester, 1988).(Lester, 1988). Between 7-16% of high school students report a Between 7-16% of high school students report a

suicide attemptsuicide attempt Between 4-8% of 11Between 4-8% of 11thth and 12 and 12thth graders report a graders report a

suicide attemptsuicide attempt These are the highest rates of attempts at any point in the These are the highest rates of attempts at any point in the

life span (large proportion have low lethality).life span (large proportion have low lethality). However, 9% of males in this age range and 1-4% of However, 9% of males in this age range and 1-4% of

females complete within 5 years.females complete within 5 years.

Gender DifferencesGender Differences

More females attempt becauseMore females attempt because Puberty, middle school, and identity transitionsPuberty, middle school, and identity transitions Hormonal changesHormonal changes

Diathesis-Stress Model (predisposition+stressorDiathesis-Stress Model (predisposition+stressor Females tend to focus on emotions and related Females tend to focus on emotions and related

thoughts more than malesthoughts more than males Females face more descriminationFemales face more descrimination

For malesFor males Socialization is more counter to suicideSocialization is more counter to suicide

Risk Factors for Adolescent SuicideRisk Factors for Adolescent Suicide Mental Disorders (more = more risk)Mental Disorders (more = more risk)

Conduct Disorder and Substance Abuse are Conduct Disorder and Substance Abuse are more common in completers.more common in completers.

Mood Disorders (Depression & Anxiety) are Mood Disorders (Depression & Anxiety) are more common among nonfatal attempters.more common among nonfatal attempters.

Negative life events (emotional pain)Negative life events (emotional pain) Availability of firearms in the home.Availability of firearms in the home. Stage of life transitions (autonomy vs Stage of life transitions (autonomy vs

control)control) Genetic factors (twin studies )Genetic factors (twin studies )

Hospitalized pts with low serotonin 10x riskHospitalized pts with low serotonin 10x risk Contagion factors 1-13% Contagion factors 1-13% (Velting, 1997)(Velting, 1997)

In almost every case suicide is caused by pain, a In almost every case suicide is caused by pain, a certain kind of pain—psychological pain, or certain kind of pain—psychological pain, or “psychache”… Suicidal death, in other words, is an “psychache”… Suicidal death, in other words, is an escape from pain… Pain is nature’s great signal. Pain escape from pain… Pain is nature’s great signal. Pain warns us; pain both mobilizes us and saps our warns us; pain both mobilizes us and saps our strength; pain, by its very nature, makes us want to strength; pain, by its very nature, makes us want to stop it or escape from it… Psychache is the hurt, stop it or escape from it… Psychache is the hurt, anguish or ache that takes hold in the mind. It is anguish or ache that takes hold in the mind. It is intrinsically psychological, the pain of excessively felt intrinsically psychological, the pain of excessively felt shame, guilt, fear, anxiety, loneliness, angst, and shame, guilt, fear, anxiety, loneliness, angst, and dread of growing old or of dying badly. When dread of growing old or of dying badly. When psychache occurs, its introspective reality is psychache occurs, its introspective reality is undeniable. Suicide happens when the psychache is undeniable. Suicide happens when the psychache is deemed unbearable and death is actively sought to deemed unbearable and death is actively sought to stop the unceasing flow of painful consciousness. stop the unceasing flow of painful consciousness. Suicide is a tragic drama in the mind (Schneidman, Suicide is a tragic drama in the mind (Schneidman, 1997, pp23, 29)1997, pp23, 29)

Depression Signs and SymptomsDepression Signs and Symptoms

Depressed mood most of the dayDepressed mood most of the day Reduced interest in pleasurable activitiesReduced interest in pleasurable activities Weight changesWeight changes Sleep ProblemsSleep Problems Psychomotor agitation or retardationPsychomotor agitation or retardation Lack of energy and motivationLack of energy and motivation Poor concentrationPoor concentration Feelings of worthlessness Feelings of worthlessness Thoughts of deathThoughts of death

Assessment of Suicidality IAssessment of Suicidality I

Depressive Disorders and other Mental Depressive Disorders and other Mental Health problemsHealth problems

Alcoholism and other Substance AbuseAlcoholism and other Substance Abuse Suicide IdeationSuicide Ideation Prior AttemptsPrior Attempts Lethal MethodsLethal Methods Isolation (friends and family)Isolation (friends and family) Cognitive Rigidity (Hopelessness)Cognitive Rigidity (Hopelessness)

Modeling (suicide in the family)Modeling (suicide in the family) Economic or Work ProblemsEconomic or Work Problems Marital ProblemsMarital Problems Stress and Stressful EventsStress and Stressful Events Anger, Aggression, IrritabilityAnger, Aggression, Irritability Physical IllnessPhysical Illness Giving away personal itemsGiving away personal items Sudden happinessSudden happiness Repetition and Combination of All FactorsRepetition and Combination of All Factors

Assessment of Suicidality IIAssessment of Suicidality II

InterventionIntervention

Be directBe direct Pay attentionPay attention Accept without judgementAccept without judgement Be calmBe calm AssureAssure Seek helpSeek help