Essentials of Understanding Essentials of Understanding Abnormal BehaviorAbnormal Behavior

Mood Disorders and Mood Disorders and SuicideSuicide

Mood Disorders & SuicideMood Disorders & Suicide

Mood Disorders: Disturbances in emotions Mood Disorders: Disturbances in emotions that cause subjective discomfort, hinder a that cause subjective discomfort, hinder a person’s ability to function, or both; person’s ability to function, or both; depression & mania are central to these depression & mania are central to these disordersdisorders

Depression: Emotional state characterized by Depression: Emotional state characterized by intense sadness, feelings of futility & intense sadness, feelings of futility & worthlessness, & withdrawal from othersworthlessness, & withdrawal from others

Mania: Emotional state characterized by Mania: Emotional state characterized by elevated mood, expansiveness, or irritability, elevated mood, expansiveness, or irritability, often resulting in hyperactivityoften resulting in hyperactivity

Depression and ManiaDepression and Mania

In the “World of Mood,” there are two In the “World of Mood,” there are two poles: mania and depression.poles: mania and depression.

Unipolar disorders:Unipolar disorders: involve involve only depressiononly depression

Bipolar disorders:Bipolar disorders: involve both involve both manic and depressive episodesmanic and depressive episodes

Note that there are no mood Note that there are no mood disorders involving mania alone. disorders involving mania alone.

Mood Disorders Mood Disorders (cont’d)(cont’d)

Depression occurs ten times as Depression occurs ten times as frequently as mania.frequently as mania.

Depression is the most common Depression is the most common complaint of individuals seeking complaint of individuals seeking mental health care.mental health care.

Epidemiologic catchment area survey:Epidemiologic catchment area survey:– 2.3% of adult males and 5% of adult 2.3% of adult males and 5% of adult

females in the U.S. have a mood disorder females in the U.S. have a mood disorder in a one-year period.in a one-year period.

Mood Disorders Mood Disorders (cont’d)(cont’d)

Lifetime prevalence:Lifetime prevalence:– Severe depression: 5-12% of males and Severe depression: 5-12% of males and

10-25% of females10-25% of females– Mood disorder: 15% of males and 24% Mood disorder: 15% of males and 24%

of femalesof females Risk of another episode increases Risk of another episode increases

with each episodewith each episode– 50% after one episode, 70% after 50% after one episode, 70% after

second, 90% after thirdsecond, 90% after third

Mood Disorders Mood Disorders (cont’d)(cont’d)

Lifetime prevalence:Lifetime prevalence:– Severe depression: 5-12% of males and Severe depression: 5-12% of males and

10-25% of females10-25% of females– Mood disorder: 15% of males and 24% Mood disorder: 15% of males and 24%

of femalesof females Risk of another episode increases Risk of another episode increases

with each episodewith each episode– 50% after one episode, 70% after 50% after one episode, 70% after

second, 90% after thirdsecond, 90% after third

The Symptoms of DepressionThe Symptoms of Depression Affective:Affective: Depressed mood, dejection, excessive Depressed mood, dejection, excessive

and prolonged mourning, worthlessness, lack of joyand prolonged mourning, worthlessness, lack of joy Cognitive:Cognitive: Pessimism, decreased energy, Pessimism, decreased energy,

disinterest, loss of motivationdisinterest, loss of motivation– Cognitive triad: Negative views of self, outside world, Cognitive triad: Negative views of self, outside world,

and the futureand the future– Avolition: lack of motivation to do things. This Avolition: lack of motivation to do things. This

symptom is often responsible for the impairment of symptom is often responsible for the impairment of functioning that occurs with depression.functioning that occurs with depression.

– don’t expect to be successful so don’t try, so they are don’t expect to be successful so don’t try, so they are more likely to experience failures.more likely to experience failures.

– depressed individuals may be less effective at solving depressed individuals may be less effective at solving intellectual problems and may also have memory intellectual problems and may also have memory problemsproblems

The Symptoms of Depression The Symptoms of Depression (cont’d)(cont’d) Behavioral:Behavioral: Social withdrawal, lowered work productivity, Social withdrawal, lowered work productivity,

lack of personal cleanliness, slow speechlack of personal cleanliness, slow speech– Psychomotor retardation:Psychomotor retardation: Slowing of bodily Slowing of bodily

movements, expressive gestures, and spontaneous movements, expressive gestures, and spontaneous responses responses

People with this symptom have more problems with thinking People with this symptom have more problems with thinking and memory and take longer to recover from depressionand memory and take longer to recover from depression

Physiological:Physiological: Loss of appetite/weight, constipation, sleep Loss of appetite/weight, constipation, sleep disturbance, disruption of menstrual cycle, aversion to disturbance, disruption of menstrual cycle, aversion to sexual activitysexual activity– depression also causes decline in the function of the depression also causes decline in the function of the

immune system and depressed people produce fewer white immune system and depressed people produce fewer white blood cells blood cells

– There may be agitation; high levels of random activity There may be agitation; high levels of random activity which does not help them achieve any particular goals-which does not help them achieve any particular goals-

The Symptoms of DepressionThe Symptoms of Depression

Culture influences the experience & Culture influences the experience & expression of symptomsexpression of symptoms– Sadness/guilt (U.S. & Western European) Sadness/guilt (U.S. & Western European)

versus somatic/bodily complaints (Asian)versus somatic/bodily complaints (Asian)– ““Nerves” and headaches (Latino & Nerves” and headaches (Latino &

Mediterranean)Mediterranean)– Weakness, tiredness, “imbalance” (Asian)Weakness, tiredness, “imbalance” (Asian)– Problems of the “heart” (Middle Eastern)Problems of the “heart” (Middle Eastern)– Being “heartbroken” (Hopi)Being “heartbroken” (Hopi)

The Symptoms of ManiaThe Symptoms of Mania

Affective: Affective: – Elevated, expansive, irritable mood, if Elevated, expansive, irritable mood, if

frustrated, may become belligerentfrustrated, may become belligerent– Impaired social & occupational functioningImpaired social & occupational functioning– Boundless energy, enthusiasm, self-Boundless energy, enthusiasm, self-

assertionassertion Cognitive: Cognitive:

– Flightiness, pressured thoughts, lack of Flightiness, pressured thoughts, lack of focus & attention, poor judgment focus & attention, poor judgment

Table 10.1: Symptoms of Table 10.1: Symptoms of Depression and ManiaDepression and Mania

Figure Figure 10.1 10.1

Disorders Disorders Chart: Chart: Mood Mood

DisordersDisorders

Source: American Psychiatric Association (2000).

Figure 10.1: Disorders Chart: Figure 10.1: Disorders Chart: Mood Disorders Mood Disorders (cont’d)(cont’d)

Source: American Psychiatric Association (2000).

Depressive DisordersDepressive Disorders

Major depressionMajor depression: A disorder in which : A disorder in which a group of symptoms, such as a group of symptoms, such as depressed mood, loss of interest, depressed mood, loss of interest, sleep disturbances, feelings of sleep disturbances, feelings of worthlessness, and inability to worthlessness, and inability to concentrate, are present for at least concentrate, are present for at least two weekstwo weeks

Depressive Disorders Depressive Disorders (cont’d)(cont’d)

Dysthymic disorderDysthymic disorder: Characterized by chronic and : Characterized by chronic and relatively continual depressed mood that does not relatively continual depressed mood that does not meet the criteria for major depressionmeet the criteria for major depression

persistently depressed mood, more days than not persistently depressed mood, more days than not for at least 2 years (1 for kids)for at least 2 years (1 for kids)

includes poor appetite or overeating, sleep includes poor appetite or overeating, sleep disturbance, low energy level, low self-esteem, disturbance, low energy level, low self-esteem, difficulties in concentration or decisions making, difficulties in concentration or decisions making, feelings of hopelessnessfeelings of hopelessness

average duration 5 years - can last 20. average duration 5 years - can last 20. Symptoms are NOT less severe; they just do not Symptoms are NOT less severe; they just do not

occur everyday occur everyday – Pessimism, guilt, loss of interest, poor appetite or Pessimism, guilt, loss of interest, poor appetite or

overeating, low self-esteem, chronic fatigue, social overeating, low self-esteem, chronic fatigue, social withdrawal, concentration difficultieswithdrawal, concentration difficulties

Bipolar DisordersBipolar Disorders

Bipolar I disordersBipolar I disorders: The most severe form : The most severe form of bipolar disorder involving full blown of bipolar disorder involving full blown mania which includes serious impairment mania which includes serious impairment of functioning and/or psychotic features.of functioning and/or psychotic features.– Psychoses tend to be mood-congruent, Psychoses tend to be mood-congruent,

meaning they fit the person’s expansive meaning they fit the person’s expansive mood. A person in full-blown mania would be mood. A person in full-blown mania would be more likely to believe that he is Superman more likely to believe that he is Superman than to believe he is dying.than to believe he is dying.

– To qualify for a diagnosis of manic To qualify for a diagnosis of manic episode (bipolar disorder), symptoms episode (bipolar disorder), symptoms must last at least a week.must last at least a week.

Bipolar Disorders Bipolar Disorders (cont’d)(cont’d)

Bipolar II disordersBipolar II disorders: Recurrent major : Recurrent major depressive episodes with hypomanic depressive episodes with hypomanic episodeepisode– Hypomania is a less severe form of Hypomania is a less severe form of

mania which is experienced as an mania which is experienced as an increased in goal-directed activity and increased in goal-directed activity and energy. A person with hypomania may energy. A person with hypomania may go unnoticed by others and will not lose go unnoticed by others and will not lose contact with reality.contact with reality.

Bipolar Disorders Bipolar Disorders (cont’d)(cont’d)

Cyclothymic disorderCyclothymic disorder: Chronic and : Chronic and relatively continual mood disorder relatively continual mood disorder with hypomanic episodes and with hypomanic episodes and depressed moods that do not meet depressed moods that do not meet criteria for major depressive episodecriteria for major depressive episode– Symptoms present for more than 2 Symptoms present for more than 2

years, never symptom free for more years, never symptom free for more than 2 monthsthan 2 months

Other Mood DisordersOther Mood Disorders

Mood disorder due to general medical Mood disorder due to general medical conditioncondition: Characterized by depressed : Characterized by depressed mood and/or elevated or irritable mood mood and/or elevated or irritable mood as a direct result of a general medical as a direct result of a general medical conditioncondition

Substance-induced mood disorderSubstance-induced mood disorder: : Prominent and persistent disturbance of Prominent and persistent disturbance of mood attributable to use of a substance mood attributable to use of a substance or cessation of substance useor cessation of substance use

Symptom Features and Symptom Features and SpecifiersSpecifiers

SpecifiersSpecifiers: Describe major depressive : Describe major depressive episodes in terms of severity, presence or episodes in terms of severity, presence or absence of psychotic symptoms, and absence of psychotic symptoms, and remission statusremission status– Useful for prognosisUseful for prognosis– May include information such as:May include information such as:

MelancholiaMelancholia: Loss of pleasure, lack of reactivity to : Loss of pleasure, lack of reactivity to pleasurable stimuli, depression that is worse in the pleasurable stimuli, depression that is worse in the morning, early morning awakening, excessive morning, early morning awakening, excessive guilt, weight lossguilt, weight loss

CatatoniaCatatonia: Motoric immobility, extreme agitation, : Motoric immobility, extreme agitation, negativism, or mutismnegativism, or mutism

Symptom Features and Symptom Features and Specifiers Specifiers (cont’d)(cont’d)

Course specifiers:Course specifiers:– Rapid cycling: Episodes occurred 4 or more Rapid cycling: Episodes occurred 4 or more

times during the previous 12 monthstimes during the previous 12 months– Seasonal pattern: Moods are accentuated Seasonal pattern: Moods are accentuated

during certain timesduring certain times Seasonal affective disorder (SAD): Serious Seasonal affective disorder (SAD): Serious

depression fluctuates according to the seasondepression fluctuates according to the season– Postpartum onset: Occurs within 4 weeks of Postpartum onset: Occurs within 4 weeks of

childbirth and lasts longer than 1 month.childbirth and lasts longer than 1 month. Hallmark symptom: inability to be around the Hallmark symptom: inability to be around the

baby or care for the baby. baby or care for the baby. Affects 8-10% of new moms.Affects 8-10% of new moms. 75-80% experience “post-partum blues,” lasting 75-80% experience “post-partum blues,” lasting

3-4 days after the birth of the child.3-4 days after the birth of the child.

The Etiology of Mood DisordersThe Etiology of Mood Disorders

Psychological or Sociocultural Psychological or Sociocultural Approaches to Depression:Approaches to Depression:– Psychodynamic: Focus on separation & Psychodynamic: Focus on separation &

angeranger– Behavioral: Reduced reinforcement Behavioral: Reduced reinforcement

leads to less activity; secondary gain leads to less activity; secondary gain from reinforcement of inactivityfrom reinforcement of inactivity

– Cognitive: Negative thoughts & errors in Cognitive: Negative thoughts & errors in thinking thinking

Psychological or Sociocultural Approaches Psychological or Sociocultural Approaches to Depressionto Depression

Cognitive-Learning: Cognitive-Learning: – Learned helplessness: The belief that one is helpless & unable to Learned helplessness: The belief that one is helpless & unable to

affect outcomes in one’s lifeaffect outcomes in one’s life– Attributional style: People who feel helpless make speculations Attributional style: People who feel helpless make speculations

(causal attributions) about why they are helpless(causal attributions) about why they are helpless

– Depressed people operate from a primary triad of negative Depressed people operate from a primary triad of negative self-views, present experiences, and future expectations.self-views, present experiences, and future expectations.

Four errors in logic typify this negative schema:Four errors in logic typify this negative schema:– Arbitrary inference– Selected abstraction– Overgeneralization– Magnification/ minimization

Sociocultural: – Culture, social experiences, & psychosocial stressors, including

stress & gender

Table 10.2: Explaining the Findings That Rates Table 10.2: Explaining the Findings That Rates of Depression Are Higher Among of Depression Are Higher Among

Women Than Among MenWomen Than Among Men

Biological Perspectives on Biological Perspectives on Mood DisordersMood Disorders

The Role of Heredity: The Role of Heredity: – Adoption studies: Incidence of mood Adoption studies: Incidence of mood

disorders is higher among biological disorders is higher among biological families than among adoptive familiesfamilies than among adoptive families

– Twin studies: Concordance rates are Twin studies: Concordance rates are higher for monozygotic twins than for higher for monozygotic twins than for dizygotic twins (especially for bipolar dizygotic twins (especially for bipolar disorders), although non-genetic factors disorders), although non-genetic factors also have an influencealso have an influence

Neurotransmitters & Mood Neurotransmitters & Mood DisordersDisorders

Neurotransmitters: Chemical substances that are Neurotransmitters: Chemical substances that are released by axons of sending neurons & that are released by axons of sending neurons & that are involved in the transmission of neural impulses to involved in the transmission of neural impulses to the dendrites of receiving neuronsthe dendrites of receiving neurons

Catecholamine HypothesisCatecholamine Hypothesis– Neurotransmitters are broken down or chemically Neurotransmitters are broken down or chemically

depleted by MAOsdepleted by MAOs– Neurotransmitters are reabsorbed by the releasing Neurotransmitters are reabsorbed by the releasing

neuron in the reuptake processneuron in the reuptake process

Figure 10.2: The Catecholamine Hypothesis: Figure 10.2: The Catecholamine Hypothesis: A Proposed Connection Between A Proposed Connection Between Neurotransmitters & DepressionNeurotransmitters & Depression

The Treatment of Mood The Treatment of Mood DisordersDisorders

Biomedical Treatments for Biomedical Treatments for Depressive Disorders:Depressive Disorders:– Medication:Medication:

Tricyclic antidepressants (TCAs)Tricyclic antidepressants (TCAs)Heterocyclic antidepressants (HCAs)Heterocyclic antidepressants (HCAs)Monoamine Oxidase Inhibitors (MAOIs)Monoamine Oxidase Inhibitors (MAOIs)Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors

(SSRIs)(SSRIs)

– Electroconvulsive Therapy (ECT)Electroconvulsive Therapy (ECT)

The Treatment of Mood The Treatment of Mood DisordersDisorders

Psychotherapy & Behavioral Treatments Psychotherapy & Behavioral Treatments for Depressive Disorders:for Depressive Disorders:– Psychoanalysis: gain insight into unconscious & Psychoanalysis: gain insight into unconscious &

unresolved feelings of separation or angerunresolved feelings of separation or anger– Behavior therapy: increase exposure to Behavior therapy: increase exposure to

pleasurable events & to improve social skillspleasurable events & to improve social skills– Interpersonal psychotherapy & cognitive-Interpersonal psychotherapy & cognitive-

behavioral therapy effective for treating less behavioral therapy effective for treating less severe cases severe cases

– Combination of psychotherapy & medication Combination of psychotherapy & medication may be bestmay be best

Treatment for Bipolar DisordersTreatment for Bipolar Disorders

Same forms of psychotherapy & Same forms of psychotherapy & behavior therapy used for Unipolar behavior therapy used for Unipolar Disorder are also used for Bipolar Disorder are also used for Bipolar DisorderDisorder

Typical treatment for Bipolar involves Typical treatment for Bipolar involves lithium carbonate, which is 60-80% lithium carbonate, which is 60-80% effectiveeffective

Anticonvulsant drugs are also being Anticonvulsant drugs are also being usedused

SuicideSuicide

Suicide: The intentional, direct, & Suicide: The intentional, direct, & conscious taking of one’s own lifeconscious taking of one’s own life

Suicide is not classified as a mental Suicide is not classified as a mental disorder, although the suicidal disorder, although the suicidal person usually has psychiatric person usually has psychiatric symptoms, such as:symptoms, such as:– DepressionDepression– Alcohol dependenceAlcohol dependence– SchizophreniaSchizophrenia

Figure 10.3: SuicideFigure 10.3: Suicide

10 common characteristics of 10 common characteristics of suicidesuicide

The common purpose is to seek a solutionThe common purpose is to seek a solution: : suicide is seen as the solution to an unsolvable suicide is seen as the solution to an unsolvable problem; it is not pointless or accidental.problem; it is not pointless or accidental.

The cessation of consciousness is a common The cessation of consciousness is a common goal: goal: consciousness represent constant consciousness represent constant psychological painpsychological pain

The stimulus for suicide is generally The stimulus for suicide is generally intolerable psychological painintolerable psychological pain::

The common stressor in suicide is The common stressor in suicide is frustrated psychological need: frustrated psychological need: feelings of feelings of frustration, failure, worthlessness, etc.frustration, failure, worthlessness, etc.

A common emotion in suicide is A common emotion in suicide is hopelessness-helplessnesshopelessness-helplessness

10 common characteristics of 10 common characteristics of suicide (cont.)suicide (cont.)

The cognitive state is one of ambivalenceThe cognitive state is one of ambivalence: : although the person may be strongly motivated to end although the person may be strongly motivated to end his/her life, there is usually a strong desire to live, as his/her life, there is usually a strong desire to live, as well.well.

The cognitive state is one of tunnel visionThe cognitive state is one of tunnel vision: the : the person has great difficulty seeing the big picture and person has great difficulty seeing the big picture and believes death is the only way outbelieves death is the only way out

The common action in suicide is escapeThe common action in suicide is escape: goal is : goal is escape from an intolerable situationescape from an intolerable situation

The common interpersonal act in suicide is The common interpersonal act in suicide is communication of intentioncommunication of intention: At least 80% of : At least 80% of suicides are precipitated by verbal or nonverbal cues suicides are precipitated by verbal or nonverbal cues of suicidal intention.of suicidal intention.

The common consistency is in the area of The common consistency is in the area of lifelong coping patterns that predispose the lifelong coping patterns that predispose the person to suicideperson to suicide

Study of SuicideStudy of Suicide

Psychological Autopsy: Systematic Psychological Autopsy: Systematic examination of existing information to examination of existing information to understand & explain a person’s behavior understand & explain a person’s behavior before his/her deathbefore his/her death

Suicide survivors are different from those Suicide survivors are different from those who succeed:who succeed:– Attempter: white female housewife in 20s-30s, Attempter: white female housewife in 20s-30s,

marital difficulties, uses barbituratesmarital difficulties, uses barbiturates– Succeeder: white male, 40s or older, ill health Succeeder: white male, 40s or older, ill health

or depression, use guns or hangs himselfor depression, use guns or hangs himself

Facts About SuicideFacts About Suicide

Alcohol frequently implicatedAlcohol frequently implicated Men are more likely than women to kill Men are more likely than women to kill

themselves (men use firearms)themselves (men use firearms) Common among people under age 25Common among people under age 25 Men 3 to 4 times as likely to be successful, Men 3 to 4 times as likely to be successful,

women more likely to attempt suicidewomen more likely to attempt suicide Married people are less vulnerableMarried people are less vulnerable Socioeconomic level is not a factorSocioeconomic level is not a factor

More Facts About SuicideMore Facts About Suicide

Over 60% of suicides are committed using Over 60% of suicides are committed using firearms, 70% of attempts are from drug firearms, 70% of attempts are from drug overdoseoverdose

Suicide rates are lower in Catholic & Muslim Suicide rates are lower in Catholic & Muslim countriescountries

Highest rates in U.S. are for Native Americans, Highest rates in U.S. are for Native Americans, lowest for Asian Americanslowest for Asian Americans

More than 66% of those who commit suicide More than 66% of those who commit suicide communicate their intent to do so beforehandcommunicate their intent to do so beforehand

High correlation with alcohol consumptionHigh correlation with alcohol consumption

Perspectives on SuicidePerspectives on Suicide

Emile Durkheim: suicide may occur Emile Durkheim: suicide may occur because of:because of:– alienation from society (egoistic suicide)alienation from society (egoistic suicide)– unbalanced relation to society (anomic unbalanced relation to society (anomic

suicide)suicide)– for the greater good (altruistic suicide)for the greater good (altruistic suicide)

Sigmund Freud: Suicide results from the Sigmund Freud: Suicide results from the existence of Thanatos, the death instinct existence of Thanatos, the death instinct antagonistic to the life instinctantagonistic to the life instinct

Perspectives on Suicide Perspectives on Suicide (cont’d)(cont’d)

Biological explanations:Biological explanations: Research suggests that low levels of serotonin contribute to Research suggests that low levels of serotonin contribute to

vulnerability to suicide.vulnerability to suicide.– Evidence suggests that patients with low levels of 5HIAA Evidence suggests that patients with low levels of 5HIAA

((5 hydroxyindoleacetic acid 5 hydroxyindoleacetic acid - a chemical produced when - a chemical produced when serotonin is broken down in the body) are more likely than serotonin is broken down in the body) are more likely than others to commit suicide, more likely to use violent others to commit suicide, more likely to use violent methods, and more likely to have a history of violence, methods, and more likely to have a history of violence, aggression, and impulsivenessaggression, and impulsiveness

– Other evidence suggests impairment of serotonin Other evidence suggests impairment of serotonin receptors in the brain stem and frontal cortex of suicidal receptors in the brain stem and frontal cortex of suicidal individuals.individuals.

Genetics: Genetics: Although there appears to be a higher rate of suicide Although there appears to be a higher rate of suicide among parents and close relatives of people who commit among parents and close relatives of people who commit suicide, more evidence is needed to understand this suicide, more evidence is needed to understand this relationship.relationship.

Preventing SuicidePreventing Suicide

Assumption: Potential victims are ambivalent Assumption: Potential victims are ambivalent – they have a strong wish to die, but also a – they have a strong wish to die, but also a wish to live.wish to live.

LethalityLethality: The probability that a person will : The probability that a person will choose to end his/her lifechoose to end his/her life

Three-step process for working with a Three-step process for working with a potentially suicidal person:potentially suicidal person:– Know factors correlated with suicideKnow factors correlated with suicide– Determine probability for person attempting Determine probability for person attempting

suicidesuicide– Implement appropriate actionImplement appropriate action

Preventing SuicidePreventing Suicide

Telephone Crisis Intervention:Telephone Crisis Intervention:– Maintain contact/establish relationshipMaintain contact/establish relationship– Obtain necessary informationObtain necessary information– Evaluate suicidal potentialEvaluate suicidal potential– Clarify nature of stress & focal pointClarify nature of stress & focal point– Assess strengths & resourcesAssess strengths & resources– Recommend & initiate action planRecommend & initiate action plan