ABNORMAL PSYCHOLOGY: MOOD DISORDERS A mood disorder is the term given for a group of diagnoses in the DSM IV TR classification system where a disturbance in the person’s emotional mood is hypothesised to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10. English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.
Definition Depression: A low, sad state marked by significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms. Mania: a state of or episode of euphoria or frenzied activity in which people may have an exaggerated believe that the world is theirs for the taking. Symptoms of Depression •Affective symptoms: The most striking symptom is depressed mood, with feelings of sadness, dejection, and excessive and prolonged mourning. Feelings of worthlessness and of having lost the joy of living are common. Wild weeping may occur as a general reaction to frustration or anger.
Such crying spells do not seem to be directly correlated with a specific function. Example: It’s hard to describe the state I was in several months ago. The depression was total – it was as if everything that happened to me passed through this filter which colored all experiences. Nothing was exciting to me. I felt I was no good, completely worthless, and deserving or nothing. The people who tried to cheer me up were just living in a different world. •Cognitive symptoms: Besides general feelings of futility, emptiness, and hopelessness, certain thoughts (e. g. egative view of the self, of the outside world and of the future [Beck, 1974]) and ideas are clearly related to depressive reactions. Disinterest, decreased energy and loss of motivation make it difficult for the depressed person to cope with everyday situations. Work responsibilities become monumental tasks and the person avoids them. Self-accusations of incompetence and general self-denigration are common. Other symptoms include difficulty in concentrating and in making decisions. •Behavioral symptoms: Shows social withdrawal and lowered work productivity.
Other symptoms include sloppy or dirty clothing, unkempt hair, and lack of concern of personal hygiene. Slowing down of all body movements, expressive gestures and spontaneous responses is called psychomotor retardation. •Physiological symptoms: – – Loss of appetite and weight – Constipation -Sleep Disturbance, e. g: insomnia, nightmares & hypersomnia -Disruption of the normal menstrual cycle -Aversion to sexual activity Symptoms of Mania •Affective Symptoms: The person’s mood is elevated, expansive, or irritable. Show boundless, energy, enthusiasm and self-assertion.
If frustrated, they may become profane and quite belligerent. •Cognitive symptoms: flightiness, pressured thoughts, lack of focus and attention, and poor judgment. Although much of what they say is understandable to others, the accelerated and disjointed nature of their speech makes it difficult to follow their train of thought. They seem incapable of controlling their attention, as though they are constantly distracted by new and more exciting thoughts and ideas. •Behavioral Symptoms: Uninhibited, engaging impulsively in sexual activity or abusive discourse. DSM-IV-TR recognizes 2 levels of manic intensity:- Hypomania: affected people seem to be ‘high’ in mood and overactive in behavior. Their judgment is usually poor, although delusions are rare. When they interact with others, people with hypomania dominate the conversation and are often grandiose (meant to produce an imposing effect) . – Mania: more disruptive behaviors, including pronounced over activity, grandiosity and irritability. Their speech may be incoherent and they do not tolerate criticisms or restraints imposed by others. Hallucinations and delusions may appear. •Physiological Symptoms: decreased need for sleep, accompanied by high levels of arousal.
The energy and excitement these patients show may cause them to lose weight or to go without sleep for long periods. UNIPOLAR DISORDERS – Depression without a history of mania In almost all countries, women are at least twice as likely as men to experience episodes of severe unipolar depression. Approximately half of people with unipolar depression recover within six weeks and 90% recover within a year, some without treatment (Kessler, 2002; Kendler et al. , 1997). However, most of them have at least one other episode of depression later on their lives (Boland & Keller, 2002).
The DSM-IV-TR approach to classifying mood disorders recognizes several subtypes of depression, placing special emphasis on the distinction between unipolar and bipolar disorders. Diagnostic Criteria of Major Depressive Disorder A minimum of five of the following symptoms must be present for at least 2 weeks. Depressed mood or loss of interest or pleasure must be one of them. •Depressed mood most of the day, nearly every day. •Diminished interest or pleasure in all or almost all activities nearly every day. •Significant weight loss or weight gain. •Insomnia or hypersomnia (excessive sleeping) nearly every day. Restlessness or lethargy nearly every day. •Frequent fatigue or loss of energy. •Feelings of worthlessness or in appropriate guilt. •Difficulty 1st subtype: depression with melancholic features, in which psychological symptoms of depression are particularly prominent. 2nd subtype: depression with psychotic features, in which people experience delusions and hallucinations during a major depressive episode. 3rd subtype: depression with catatonic features show the strange behaviors collectively known as catatonia, which can range from a complete lack of movement to excited agitation. th subtype: depression with atypical features, odd assortment of symptoms. 5th subtype: depression with postpartum onset. This diagnosis is given to women when the onset of a major depressive episode occurs within four weeks of the delivery of a child. More rarely, women develop mania postpartum and are given the diagnosis of bipolar disorder with postpartum onset. 6th subtype: depression with seasonal pattern, (Seasonal Affective Disorder or SAD). The symptoms seem to be tied to the number of daylight hours in a day.
People become depressed when the daylight hours are short and recover when the daylight hours are long. A person’s mood changes cannot be the result of psychosocial events, such as regularly being unemployed during the winter. Rather, the mood changes must seem to come on without reason or cause. *Dsythmia Differs from major depression in terms of both severity and duration. Dsythmia represents a chronic mild depressive condition that has been present for many years. In order to fulfill DSM-IV-TR criteria for this disorder, the person must, over a period of at least 2 years, exhibit a epressed mood for most of the day on more days than not. These symptoms must not be absent for more than 2 months at a time during the 2-year period. If at any time during the initial 2 years the person met criteria for a major depressive episode, the diagnosis would be major depression rather than dsythmia. As in the case of major depression disorder, the presence of a manic episode would rule out a diagnosis of dsythmia. When dysthymic disorder leads to major depressive disorder, the sequence is called double depression (Boland & Keller, 2002).
The distinction between major depressive disorder and dsythmia is somewhat artificial because both of sets of symptoms are frequently seen in the same person. In such cases, rather than thinking of them as separate disorders, it is more appropriate to consider them as two aspects of the same disorder, which waxes and wanes over time. Some experts have argued that chronic depression is a single, broadly conceived disorder that can be expressed in many different combinations of symptoms over time (McCullough et al. , 2003). BIPOLAR DISORDER A disorder marked by alternating or intermixed periods of mania and depression People with a bipolar disorder experience both the lows of depression and the highs of mania. Many describe their life as an emotional roller coaster. They shift back and forth between extreme moods. The essential feature of bipolar disorders is the occurrence of one or more manic or hypomanic episodes; the term bipolar is used because the disorders are usually accompanied by one or more depressive episodes. Bipolar disorders include subcategories which describe the nature of the disorder; Bipolar I and Bipolar II.
Bipolar I (Formally known as manic depression) where normal mood is interrupted by manic and major depressive episodes, or, occasionally, by what are referred to as mixed episodes in which manic and major depressive symptoms are both present. •Single manic episode- Presence of only one manic episode and no past major depressive episodes. •hypomanic- in a hypomanic episode, with at least one previous manic episode. •Manic- in a manic episode, with at least one previous major depressive, hypomanic, or manic episode. •mixed- in a mixed episode(i. e. or everyday during at least a one-week period, the criteria for a major depressive episode-except for duration-and a manic episode have both been met) •Depressed- in a major depressive episode, with at least one previous manic episode. •Unspecified- meets criteria for manic, hypomanic, or major depressive episode except for duration (i. e. the episode does not last long enough to meet the criteria for each): at least one previous manic episode. Bipolar II This is similar to bipolar I except that hypomanic episodes occur instead of manic episodes.
The distinction between the two disorders was clarified in the DSM-IV. •Recurrent major depressive episodes with hypomania- one or more major depressive episodes and presence of at least one hypomanic episode: never has a manic episode. Cyclothymic Disorder Manic and depressed moods that are chronic and relatively continual in nature. Depressive (Unipolar)Bipolar Disorders – Low incidence of manic disturbances -the late twenties -low tendency to attempt suicide, anxiety -lithium has little effect- higher incidence of manic disturbances -Age of onset is earlier (the early twenties) Display psychomotor retardation & a greater tendency to attempt suicide -respond to lithium Causes •Genetic Factors Family, twin and adoption studies suggest the involvement of genetic factors. The prevalence of depression in the random population (10% for men and 20% for women) is the baseline against which the concordance rates can be compared. -Family pedigree studies select people with unipolar depression as probands(the person who is the focus of a study), examine their relatives, and see whether depression also afflicts other members of the family.
If a predisposition to unipolar depression is inherited, a proband’s relatives should have a higher rate of depression than the population at large. -One of twin studies looked at nearly 200 pairs of twins. When a monozygotic twin had unipolar depression, there was a 46% chance that the other twin would have the same disorder. In contract, when a dizygotic twin had unipolar depression, the other twin had only 20% chance of developing the disorder. (McGuffin et al. ,1996). -One study looked at the families of adopted persons who had been hospitalized for this disorder in Denmark.
The biological parents of these adoptees turned out to have a higher incidence of severe depression than did the biological parents of a control group of nondepressed adoptees. (Wender et al. ,1986) Evaluation 1. Nature vs. Nuture It is difficult to separate out the influence of nature and nurture. Whilst the twin studies provide strong evidence for the role of genetic factors and the adoption studies point to the role of nature over nurture this is not conclusive. 2. Diathesis-stress model Genes alone do not determine who will develop depression – they only create vulnerability.
Thus, they are not a direct cause as other factors must trigger the disorder. Evidence for this is that the concordance rates are not 100%, which shows that depression is due to an interaction of genetic and other factors. •Biochemical Factors The monoamine hypothesis suggests that depression is due to abnormal levels of neurotransmitters in the monoamine group. This was expanded upon the permissive anime theory (Kety,1975), which proposes that the level of noradrenaline and dopamine are controlled by serotonin.
When serotonin is low the levels of noradrenaline fluctuate wildly; low levels are associated with depression and high levels with mania. The low levels of serotonin may be genetically inherited. – The three neurotransmitters – serotonin, dopamine and noradrenaline – are part of the monoamine group and play a role in normal arousal and mood. – By-product compounds of the enzymes that act upon noradrenaline and serotonin were lower than normal in the urine of depressives. (Teuting, Rosen & Hirschfeld, 1981) Antidepressant drugs such as the monoamine oxidase inhibitors (MAOIs) increase the levels of noradrenaline and serotonin and alleviate the symptoms of drepssion, which supports the influence of the biochemical on mood. -Post-mortem studies of patients who committed suicide show reduced levels of serotonin and an increased number of serotonin receptor sites. Evaluation 1. Cause, effect or correlate It is difficult to establish whether the low levels of neurotransmitters cause depression, are an effect of having the disorder or are merely associated.
Causation cannot be inferred as associations only have been identified. 2. Treatment aetiology fallacy The success of antidepressant drugs as a treatment does not necessarily mean the biochemical are the cause of the depression in the first place. MacLeod (1998) described this as the treatment aetiology fallacy and used headaches as an example. Aspirin works well as a treatment but this doesn’t mean the headache was due to an absence of aspirin. 3. Reductionist and deterministic Biological explanations are reductionist as they focus on only one factor and t present our understanding of biochemistry is oversimplified. This means other biological factors, such as hormones and psychological factors are ignored. The biological explanations are also deterministic because they ignore the individual’s ability to control their own behavior. •Psychodynamic Factors According to Freud, we are victims of our feelings, as repression and displacement are defense mechanisms in response to actual loss ( death of a loved one) and symbolic loss (loss of status) that enable us to cope with the emotional turmoil, but can result in depression.
Individuals with excessive dependence on others for self-esteem as a consequence of oral fixation are particularly vulnerable and unable to cope with loss. Anger at the loss is displaced onto the self, which affects self-esteem and causes the individual to re-experience loss that occurred in childhood. Freud believed that superego (or conscience) is dominat in the depressed person and this explains the excessive guilt experienced by many depressives. In contrast, the manic phase occurs when the individual’s ego, or rational mind, asserts itself and s/he feels in control.
However, early loss does not consistently predict depression. Evaluation 1. Although the findings indicate that losses and inadequate parenting sometimes relate to depression, they do not establish that such factors are typically responsible for the disorder. In the studies of young children and young monkeys, for example, only some of the subjects who were separated from their mothers showed depressive reactions. 2. Many findings are inconsistent. Though some studies find evidence of a relationship between childhood loss and later depression, others do not. (Parker,1992; Owen, Lancee & Freeman, 1986) 3.
Certain features of the psychodynamic explanation are nearly impossible to test. Because symbolic loss, fixation at the oral stage, and introjection are said to operate at an unconscious level, it is difficult for researchers to determine if and when they are occurring. Similarly, other psychodynamic ideas can be measured only by retrospective self-reports of people who are or have been depressed. •Behavioral Factors depression is due to maladaptive learning. The principles of operant conditioning have been applied to explain depression using reinforcement and punishment.
Many behaviorists view depression as a product of inadequate or insufficient reinforcers in a person’s life, leading to a reduced frequency of behavior that previously was positively reinforced. oThe number of events and activities that are potentially reinforcing to the person. This number depends very much on individual differences and varies with the biological traits and experiential history of the person. For example, age, gender, or physical attributes may determine the availability of reinforcers. Handsome people are more likely to receive positive attention than are nondescript people.
Young people are likely to have more social interaction than retirees are. A task-oriented person who values intellectual pursuits may not respond to interpersonal or affiliative forms of reinforcement as readily as other people would. To such a person, a compliment such as ‘I like you’ may be less effective than ‘I see you as an extremely competent person. ’ oThe availability of reinforcements in the environment, Harsh environments, such as regimented institutions or remote isolated places, reduce reinforcements. oThe instrumental behavior of the individual.
People in depression lack social behaviors that can elicit positive reinforcements. They feel more uncomfortable in social situations and the elicit depression in others. They tend to talk about themselves (more so than other people do) without being asked to do so. By creating conditions that further their depression or drive others away, these individuals thereby lose any social reinforcement that others could provide. Evaluation 1. Reductionist The behavioral explanations are greatly oversimplified as they focus on only one factor, the environment.
This focus on the external means internal factors that may bee more influential, such as biological and cognitive are ignored. 2. Environmentally deterministic The behavioral explanations are deterministic as they suggest that behavior is controlled by the environment, which ignores the individual’s ability to control their own behavior. 3. Ignore nature The behavioral explanations overemphasize nurture and ignore nature. 4. Population validity Learned helplessness are an explanation of the development of depression may be more relevant to certain types of people, e. . those who lack social skills and so have limited emotional support. •Cognitive Factors 1. Arbitrary inference- The person with depression tends to draw conclusions that are not supported by evidence. For example, a woman may conclude that ‘people dislike me’ just because no one speaks to her on the bus or in the class. A man who invites a woman to dinner and finds the restaurant closed that evening may see this as evidence of his own unworthiness. In both cases, the person draws erroneous conclusions from the available evidence.
People with depression are apparently unwilling or unable to see other, more probable, explanations. 2. Selected Abstraction- The individual takes a minor incident or detail out of context and focuses on it, and these incidents tend to be trivia. A person corrected for a minor aspect of his work may take the correction sign of incompetence or inadequacy – even when the supervisor’s overall feedback is highly positive. 3. Overgeneralization- The individual tends to draw a sweeping conclusion about his ability, performance or worth from one single experience or incident.
The comments of a student seen by one of the authors at a university psychology clinic provide another illustration of overgeneralization: when he missed breakfast at the dormitory because his alarm clock didn’t ring, the student concluded, ‘I don’t deserve my own body because I don’t take care of it. ’ Later, when he showed up late for class through no fault of his own, he thought, ‘ what a miserable excuse for a student I am. ’ When a former classmate passed by and smiled, he thought, ‘I must look awful today or she won’t be laughing at me. ’ 4.
Magnification and minimization- The individual tends to exaggerate limitations and difficulties and play down accomplishments, achievements and capabilities. Asked to evaluate personal strengths and weaknesses, the person lists many shortcomings or unsuccessful efforts but finds it almost impossible to name any achievements. Evaluation 1. Causes or effect? The evidence is not convincing that negative cognitions precede the disorder but nor has this been disproved. Therefore, conclusions are limited. It may be that the relationship is curvilinear, . i. e. negative thinking predisposes depression and depression increases negative thinking, 2.
Descriptive not explanatory. The research may describe the nature of depressives’ thoughts rather than explain the development of depression if negative cognition is a consequence, not a cause, of depression. If it is a cause then it is not clear what causes the negative cognitions in the first place. 3. Success of cognitive treatments. Cognitive behavioral therapy (CBT) has been found to be as effective as antidepressants (Elkin at al. , 1985), which supports the role of cognitive factors in depression. But the cure does not necessarily indicate the cause, as the treatment aetiology fallacy states. 4.
Lack of reliability. The prospective research is inconsistent and so we cannot be sure if negative cognitions cause or are a consequence of depression. Treatments for Depressive Disorders 1. Medication 4 kinds of antidepressant medication: – tricyclic antidepressants (TCAs) – Heterocyclic antidepressants (HCAs) – Monoamine oxidase inhibitors (MAOIs) – Selective serotonin reuptake inhibitors (SSRIs) Each medication is designed to heighten the level of a target neurotransmitter at the neuronal synapse. This heightening can be accomplished by: – – boosting the neurotransmitter’s synthesis – blocking its degradation preventing its reuptake from the synapse, or – Mimicking its binding to postsynaptic receptors 2. Electroconvulsive Therapy Electroconvulsive Therapy (ECT) is generally reserved for patients with severe unipolar depression who have not responded to antidepressant medications. It consists of applying a moderate electrical voltage to the person’s brain for up to half a second. The patient’s response to the voltage is a convulsion (seizure) lasting thirty to forty seconds, followed by a five- to thirty- minute coma. Most patients with serious depression show at least a temporary improvement after about 4 ECT treatments (R.
Campbell,1981). The ECT mechanism is not fully understood; it may operate on neurotransmitters at the synapses, as do antidepressants. One major advantage of ECT is that the response to treatment is relatively fast (Gangadhar, Kapur & Kalyanasundaram, 1982). However, common side effects include headaches, confusion and memory loss. Many clinicians believe that ECT is the most rapid and effective treatment for major depressive episodes. ECT is controversial and critics have urged that it be banned as form of treatment. 3. Psychotherapy and Behavioral Treatments
Because the use of antidepressant medication or ECT involves a number of disadvantages, clinicians have sought other approaches to either supplement or replace medical treatment of depression. A variety of psychological forms of treatment have been used, such as psychoanalysis, behavior therapy, group psychotherapy and family therapies – all with some success. -Interpersonal Therapy is a short term, psychodynamic-eclectic type of treatment for depression. It targets the client’s interpersonal relationships and uses strategies found in psychodynamic, cognitive-behavioral and other forms of therapy.
Clients gain insight into conflicts in social relationships and strive to change these relationships. For example, by improving communications with others, by identifying role conflicts and by increasing social skills, clients are able to find relationships more satisfying and pleasant. Although interpersonal psychodynamic resembles psychoanalysis and psychodynamic approaches in acknowledging the role of early life experiences and traumas, it is oriented primarily toward present, not past, relationships. Cognitive-Behavioral Therapy combines cognitive and behavioral strategies.
The cognitive component involves teaching the patient the following:- a. to identify negative, self-critical thoughts (cognitions that occurs automatically) b. to note the connection between negative thoughts and the resulting depression. c. to carefully examine each negative thought and decide whether it can be supported d. to try to replace distorted negative thoughts with realistic interpretations of each situation At the outset of the cognitive therapy, the client is usually asked to begin monitoring his or her negative thoughts and list them on a chart.
It is important for the client to include all thought and emotions associated with each distressing event that takes place each day. The second part of the cognitive-behavioral approach is behavior therapy, which is usually indicated in cases of severe depression in which the patient is virtually inactive. One primary assumption underlying this approach is that the patient is not doing enough pleasant, rewarding activities. During depression, people tend to belittle themselves and to withdraw from others; they can interpret their self-imposed social isolation as sign of being unpopular and inadequate.
To address this problem, the therapist asks the patient to keep a daily activity schedule, listing life events hour by hour and rating the ‘pleasantness’ of each event. Once the client becomes more active, the therapist may ask the person to attend a social skills training program. Improvements in social skills generally help clients become more socially involved and can make that involvement rewarding. Treatments for Bipolar Disorders Although the forms of psychotherapy and behavior therapy used for depressive disorders are also used for bipolar disorders (e. g.
MAOIs and SSRIs), drugs (especially lithium) are typically given to bipolar clients. Lithium is used as a mood-stabilizing drug to prevent or reduce future episodes of bipolar disorder. As noted, the manic phase of bipolar disorder may be caused by too much neurotransmitter (primarily norepinephrine) at brain synapses or by neurotransmitter dysfunction. Lithium decreases the total level of neurotransmitters in the synaptic areas by increasing the reuptake of norepinephrine into the nerve cells. Accurate measurements of lithium blood levels are easily obtained and dosages can be adjusted accordingly. Summary Severe depression is a major component of the mood disorders; it involves affective, cognitive, behavioral, and physiological symptoms, such as sadness, pessimism, low energy and sleep disturbances. ?Mania, which may accompany depression, is characterized by elation, lack of focus, impulsive actions and almost boundless energy, DSM-IV-TR recognizes hypomania and mania. ?In bipolar mood disorders, maniac episodes occur or alternate with depressive episodes. ?Depressive disorders (major depression and dysthymic disorder) involve only depression. ?Psychotic and other features may also appear in persons with severe mood disorders. The depressive disorders are the most common mood disorders; some evidence suggests that they are fairly distinct from the bipolar disorders. ?The factors in depression can be organized into those that create a vulnerability (predisposing), those that trigger the disorder (precipitating) and those that maintain it (perpetuating). – Predisposing: genetics, early childhood experience of loss, negative thinking and self-criticism. -Precipitating: life events, family conflict, adult experience of loss, biochemistry, ideals standards of society -Perpetuating: faulty cognition, reinforcement. Genetic and biochemical research has demonstrated that heredity plays a role in depression and mania, probably by affecting neurotransmitter activity or levels in the brain. ?For example, according to the catecholamine hypothesis, a decrease in the amount of norepinephrine causes depression. Sensitivity of neurotransmitter receptors may also be a factor. ?Biomedical approaches to treating depression focus on increasing the amounts of neurotransmitters available at brain synapses or affecting the sensitivity of postsynaptic receptors through either medication or electroconvulsive therapy. Different forms of psychological and behavioral treatments have been found to be effective with mood disorders such as cognitive-behavioral treatment, which seeks to replace negative thoughts with more realistic ( or positive) cognitions, and interpersonal therapy, which is a short-term treatment focused on interpersonal issues. ?The most effective treatment for bipolar and maniac disorder is lithium, a drug that lowers the level of neurotransmitters at synapses by increasing the reuptake of norepinephrine, although other drugs are being tested for use in these disorders.