Mood Disorders Mood Disorders �An unquiet mind��An unquiet mind��An unquiet mind��An unquiet mind�

Cornelia Pinnell, Ph.D.Cornelia Pinnell, Ph.D.Argosy University/PhoenixArgosy University/Phoenix

Lecture OutlineLecture Outline

nn DefinitionsDefinitionsnn History of relevant conceptsHistory of relevant conceptsnn Phenomenology of depression/maniaPhenomenology of depression/mania

Structure of mood disordersStructure of mood disordersnn Structure of mood disordersStructure of mood disordersnn UnipolarUnipolarnn Bipolar Bipolar –– I & III & II

nn Cultural issuesCultural issuesnn Etiological models of depressionEtiological models of depression

Mood ConceptsMood Concepts

nn AFFECT = AFFECT = Broad term encompassing moods, Broad term encompassing moods, emotions, motivations and feelings, the whole sphere of emotions, motivations and feelings, the whole sphere of psychic life psychic life

nn MOOD = MOOD = Relatively persistent, dominating affectRelatively persistent, dominating affect

nn EMOTION = EMOTION = Fleeting experienceFleeting experience

Paul McHugh & Phillip Slavney, 1998Paul McHugh & Phillip Slavney, 1998

Mood ConceptsMood Concepts

nn AFFECT = AFFECT = A A pattern of pattern of observable behaviorsobservable behaviorsthat is the expression of a subjectively experienced that is the expression of a subjectively experienced feeling state feeling state -- refers to refers to emotional emotional ‘‘weatherweather’’. . ExamplesExamples: sadness, elation, anger, etc. : sadness, elation, anger, etc. ExamplesExamples: sadness, elation, anger, etc. : sadness, elation, anger, etc.

nn MOODMOOD = = Pervasive and sustained Pervasive and sustained emotional emotional ‘‘climateclimate’’DSMDSM--IVIV--TRTR

Disturbances in affectDisturbances in affect

nn BluntedBlunted = significant reduction in intensity of = significant reduction in intensity of emotional expressionemotional expression

nn FlatFlat = Absence or near absence of any signs of = Absence or near absence of any signs of affective expressionaffective expressionaffective expressionaffective expression

nn Restricted/ constrictedRestricted/ constricted = Mild reduction in the range = Mild reduction in the range and intensity of emotional expressionand intensity of emotional expression

Disturbances in affectDisturbances in affect

nn LabileLabile = Abnormal variability in affect with = Abnormal variability in affect with repeated, rapid and abrupt shifts in affective repeated, rapid and abrupt shifts in affective expressionexpression

nn InappropriateInappropriate = Discordance between affective = Discordance between affective nn InappropriateInappropriate = Discordance between affective = Discordance between affective expression and the content of speech or ideationexpression and the content of speech or ideation

History of ConceptsHistory of Concepts

nn Pinel & other early clinicians (late 18Pinel & other early clinicians (late 18thth century) century) distinguished between two clinical aspects of distinguished between two clinical aspects of severe insanity:severe insanity:nn Affectional insanityAffectional insanity (characterized by (characterized by nn Affectional insanityAffectional insanity (characterized by (characterized by

disturbed emotions)disturbed emotions)nn Ideational insanityIdeational insanity (characterized by (characterized by

disturbed thoughts and beliefs, without a disturbed thoughts and beliefs, without a prominent change in mood)prominent change in mood)

History of ConceptsHistory of Concepts

nn Emil KraepelinEmil Kraepelin first described manicfirst described manic--depressive depressive disorder and schizophreniadisorder and schizophreniann ManicManic--depressive insanitydepressive insanity =circular insanities, =circular insanities,

simple manias, & involutional melancholia; it never simple manias, & involutional melancholia; it never led to a profound deterioration of personality or led to a profound deterioration of personality or led to a profound deterioration of personality or led to a profound deterioration of personality or thinkingthinking

nn Dementia preacoxDementia preacox (term first used by the French (term first used by the French psychiatrist Benopsychiatrist Benoîît Morel) = a disturbance in t Morel) = a disturbance in thinking, emotion, and volition which eventually led thinking, emotion, and volition which eventually led to the destruction of the personalityto the destruction of the personality

History of ConceptsHistory of Concepts

nn Eugen BleulerEugen Bleuler coined the word coined the word ‘‘schizophreniaschizophrenia’’ and and described a group of schizophrenias where described a group of schizophrenias where thought disorder was centralthought disorder was central

nn Adolf MeyerAdolf Meyer characterized maniccharacterized manic--depressive depressive nn Adolf MeyerAdolf Meyer characterized maniccharacterized manic--depressive depressive disorder and schizophrenia as disorder and schizophrenia as reactionsreactions

nn Karl JaspersKarl Jaspers -- similar psychological events might similar psychological events might be produced by circumstance in some case, by be produced by circumstance in some case, by disease processes in othersdisease processes in others

Phenomenology of depressionPhenomenology of depression

The depressed patient may feel diseased, poor, The depressed patient may feel diseased, poor, blameworthy, or useless; becomes withdrawn and loses blameworthy, or useless; becomes withdrawn and loses interest in most activities, including those that usually interest in most activities, including those that usually give him pleasure and comfort. Even the perceptions give him pleasure and comfort. Even the perceptions of the environment may become dulled, sounds are of the environment may become dulled, sounds are muffled, colors faded or darkened, food tasteless. muffled, colors faded or darkened, food tasteless. muffled, colors faded or darkened, food tasteless. muffled, colors faded or darkened, food tasteless. There may be a generalized slowing down, There may be a generalized slowing down, psychomotor retardation, answering slowly if at all, can psychomotor retardation, answering slowly if at all, can appear ill, thinking is slow and inefficient, fatigue and appear ill, thinking is slow and inefficient, fatigue and physical discomfort; walking with a gait, posture, physical discomfort; walking with a gait, posture, rigidity and facial expression suggestive of rigidity and facial expression suggestive of Parkinsonism. Parkinsonism.

Phenomenology of depressionPhenomenology of depression

A A stuporous conditionstuporous condition is the most is the most severe manifestation, with the patient severe manifestation, with the patient bedridden, incontinent, mute, unable bedridden, incontinent, mute, unable bedridden, incontinent, mute, unable bedridden, incontinent, mute, unable to feed or care for himself, and in to feed or care for himself, and in danger of death if not properly danger of death if not properly diagnosed and treated.diagnosed and treated.

Criteria for Criteria for Major Depressive EpisodeMajor Depressive Episode

nn Criterion A: Criterion A: Five (or more)Five (or more) of the following sxs of the following sxs present for 2 weekspresent for 2 weeks, a change from previous , a change from previous functioning: depressed mood, anhedonia, sig. functioning: depressed mood, anhedonia, sig. weight loss/gain, insomnia/hypersomnia, weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, psychomotor agitation/retardation, psychomotor agitation/retardation, psychomotor agitation/retardation, fatigue/anergia, poor concentration, fatigue/anergia, poor concentration, worthlessness, suicidal ideationworthlessness, suicidal ideation

nn Criterion B: Sxs do not meet criteria for a Mixed Criterion B: Sxs do not meet criteria for a Mixed episodeepisode

nn Criterion C: Sxs cause significant distress or Criterion C: Sxs cause significant distress or impairmentimpairment

Phenomenology of maniaPhenomenology of mania

The manic patient may believe he is healthy, The manic patient may believe he is healthy, rich, famous, talented, powerful. Social and rich, famous, talented, powerful. Social and other activities increase and perceptions become other activities increase and perceptions become brighter and more intense. Thoughts might be brighter and more intense. Thoughts might be experienced effortless and rapid, body filled with experienced effortless and rapid, body filled with experienced effortless and rapid, body filled with experienced effortless and rapid, body filled with energy & healthy. The patient becomes energy & healthy. The patient becomes increasingly active until the behavior takes on an increasingly active until the behavior takes on an uncontrollable driven quality, thoughts become uncontrollable driven quality, thoughts become chaotic & responsive to every distraction so that chaotic & responsive to every distraction so that sustained, goalsustained, goal--directed thinking is impossible.directed thinking is impossible.

Criteria for Manic EpisodeCriteria for Manic Episode

nn Criterion A:Criterion A: A distinct period of abnormally persistently A distinct period of abnormally persistently elevated, expansive, or irritable mood, lasting at least elevated, expansive, or irritable mood, lasting at least 1 week1 week (or (or any duration if hospitalization is necessary)any duration if hospitalization is necessary)

nn Criterion B:Criterion B: During the period of mood disturbance, 3 (or During the period of mood disturbance, 3 (or more) of the following sxs are present: inflated selfmore) of the following sxs are present: inflated self--esteem or esteem or grandiosity, decreased need for sleep, pressured speech, flight of grandiosity, decreased need for sleep, pressured speech, flight of ideas/racing thoughts, distractibility, increased goalideas/racing thoughts, distractibility, increased goal--directed directed activity/psychomotor agitation, excessive involvement in activity/psychomotor agitation, excessive involvement in pleasurable activities with high potential for painful pleasurable activities with high potential for painful consequencesconsequences

Structure of Mood DisordersStructure of Mood Disorders

nn Unipolar (depression)Unipolar (depression)nn BipolarBipolar

nn Bipolar I (with mania)Bipolar I (with mania)nn Bipolar II (with hypomania)Bipolar II (with hypomania)nn Bipolar II (with hypomania)Bipolar II (with hypomania)

Depressive DisordersDepressive Disorders

nn 296.2x Major depressive disorder296.2x Major depressive disorder, single episode , single episode (50%)(50%)

nn 296.3x Major depressive disorder296.3x Major depressive disorder, recurrent (2ms+ , recurrent (2ms+ btw. episodes)btw. episodes)btw. episodes)btw. episodes)

nn 300.4 Dysthymic disorder300.4 Dysthymic disorder (persistent depressed (persistent depressed mood 2 y+ ); mood 2 y+ ); specifiersspecifiers: early (before age 21) or : early (before age 21) or late onset; atypical late onset; atypical

nn Double depressionDouble depression (dysthymia + major depressive (dysthymia + major depressive episode)episode)

Specifiers for MDDSpecifiers for MDD

nn If full criteria for MDD If full criteria for MDD are metare metnn Mild, Moderate, Severe with/without psychotic Mild, Moderate, Severe with/without psychotic

featuresfeaturesnn ChronicChronicnn ChronicChronicnn With Catatonic featuresWith Catatonic featuresnn With Melancholic featuresWith Melancholic featuresnn With Atypical featuresWith Atypical featuresnn With Postpartum onsetWith Postpartum onset

Specifiers for MDDSpecifiers for MDD

nn If full criteria for MDD If full criteria for MDD are not metare not metnn In Partial Remission/Full RemissionIn Partial Remission/Full Remissionnn ChronicChronicnn With Catatonic featuresWith Catatonic featuresnn With Catatonic featuresWith Catatonic featuresnn With Melancholic featuresWith Melancholic featuresnn With Atypical featuresWith Atypical featuresnn With Postpartum onsetWith Postpartum onset

311 Depressive Disorder NOS311 Depressive Disorder NOS

nn Premenstrual Dysphoric DisorderPremenstrual Dysphoric Disordernn Minor Depressive DisorderMinor Depressive Disordernn Recurrent Brief Depressive DisorderRecurrent Brief Depressive Disordernn Recurrent Brief Depressive DisorderRecurrent Brief Depressive Disorder

(2 days +, but less than 2 weeks)(2 days +, but less than 2 weeks)nn Postpsychotic Depressive DisorderPostpsychotic Depressive Disorder

(Major Depressive Episode during the (Major Depressive Episode during the residual phase of Schizophrenia)residual phase of Schizophrenia)

Further study

nn Alternative Criterion B for Dysthymic DisorderAlternative Criterion B for Dysthymic Disordernn Minor Depressive Disorder Minor Depressive Disorder

(less impairment & fewer symptoms)(less impairment & fewer symptoms)(less impairment & fewer symptoms)(less impairment & fewer symptoms)nn Recurrent Brief Depressive DisorderRecurrent Brief Depressive Disorder

(2 days +, but less than 2 weeks)(2 days +, but less than 2 weeks)nn Mixed AnxietyMixed Anxiety--Depressive DisorderDepressive Disorder

Alternative Criterion B for Alternative Criterion B for Dysthymic DisorderDysthymic Disorder

Presence, while depressed, of 3 (or Presence, while depressed, of 3 (or more) of the following:more) of the following:

nn Low selfLow self--esteem or selfesteem or self--confidence, or confidence, or nn Low selfLow self--esteem or selfesteem or self--confidence, or confidence, or feelings of inadequacyfeelings of inadequacy

nn Feelings of pessimism, despair, or Feelings of pessimism, despair, or hopelessnesshopelessness

nn Generalized loss of interest or pleasureGeneralized loss of interest or pleasurenn Social withdrawalSocial withdrawal

Alternative Criterion B for Alternative Criterion B for Dysthymic DisorderDysthymic Disorder

nn Chronic fatigue or tirednessChronic fatigue or tirednessnn Feelings of guilt, brooding about the pastFeelings of guilt, brooding about the pastnn Subjective feelings of irritability or excessive Subjective feelings of irritability or excessive nn Subjective feelings of irritability or excessive Subjective feelings of irritability or excessive

angerangernn Decreased activity, effectiveness, or Decreased activity, effectiveness, or

productivityproductivitynn Difficulty in thinking Difficulty in thinking –– poor concentration/ poor concentration/

memory, indecisivenessmemory, indecisiveness

Mixed AnxietyMixed Anxiety--Depressive DisorderDepressive Disorder

nn Criterion A:Criterion A: Persistent or recurrent dysphoric Persistent or recurrent dysphoric mood lasting mood lasting at least 1 monthat least 1 month

nn The dysphoric mood is accompanied by at The dysphoric mood is accompanied by at least 1 month of four (or more) of the least 1 month of four (or more) of the least 1 month of four (or more) of the least 1 month of four (or more) of the following symptoms:following symptoms:

1.1. Difficulty concentrating or mind going blankDifficulty concentrating or mind going blank2.2. Sleep disturbance (difficulty falling or staying Sleep disturbance (difficulty falling or staying

asleep, or restless, unsatisfying sleep)asleep, or restless, unsatisfying sleep)3.3. Fatigue or low energyFatigue or low energy

Mixed AnxietyMixed Anxiety--Depressive DisorderDepressive Disorder(continued)(continued)

4.4. IrritabilityIrritability5.5. WorryWorry6.6. Being easily moved to tearsBeing easily moved to tears6.6. Being easily moved to tearsBeing easily moved to tears7.7. HypervigilanceHypervigilance8.8. Anticipating the worstAnticipating the worst9.9. Hopelessness (pervasive pessimism about the future)Hopelessness (pervasive pessimism about the future)10.10. Low selfLow self--esteem or feelings of worthlessnessesteem or feelings of worthlessness

Bipolar I DisorderBipolar I Disorder

nn 296.0x Bipolar I, Single Manic Episode296.0x Bipolar I, Single Manic Episodenn 296.40 Bipolar I, Most Recent Hypomanic 296.40 Bipolar I, Most Recent Hypomanic

EpisodeEpisodenn 296.4x Bipolar I, Most Recent Manic Episode296.4x Bipolar I, Most Recent Manic Episodenn 296.4x Bipolar I, Most Recent Manic Episode296.4x Bipolar I, Most Recent Manic Episodenn 296.6x Bipolar I, Most Recent Episode Mixed296.6x Bipolar I, Most Recent Episode Mixednn 296.5 Bipolar I, Most Recent Episode 296.5 Bipolar I, Most Recent Episode

DepressedDepressednn 296.7 Bipolar I, Most Recent Episode 296.7 Bipolar I, Most Recent Episode

UnspecifiedUnspecified

Specifiers for Bipolar I DisorderSpecifiers for Bipolar I Disorder

nn If criteria If criteria are metare met for a manic or mixed episode:for a manic or mixed episode:nn Mild, Moderate, Severe with/without psychotic Mild, Moderate, Severe with/without psychotic

features, In Partial Remission, In Full Remissionfeatures, In Partial Remission, In Full Remissionnn With Catatonic FeaturesWith Catatonic Featuresnn With Catatonic FeaturesWith Catatonic Featuresnn With Postpartum OnsetWith Postpartum Onset

Specifiers for Bipolar I DisorderSpecifiers for Bipolar I Disorder

nn Only to the current (or most recent) Major Only to the current (or most recent) Major Depressive EpisodeDepressive Episodenn ChronicChronicnn With Melancholic FeaturesWith Melancholic Featuresnn With Melancholic FeaturesWith Melancholic Featuresnn With Atypical FeaturesWith Atypical Features

Specifiers for Bipolar I DisorderSpecifiers for Bipolar I Disorder

nn Longitudinal Course Specifiers (With/Without Longitudinal Course Specifiers (With/Without Interepisode Recovery)Interepisode Recovery)

nn With Seasonal Pattern (applies only to the With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)pattern of Major Depressive Episodes)pattern of Major Depressive Episodes)pattern of Major Depressive Episodes)

nn With Rapid CyclingWith Rapid Cycling

Bipolar II DisorderBipolar II Disorder

nn 296.89 Bipolar II Disorder (Recurrent Major 296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes with Hypomanic Episodes)Depressive Episodes with Hypomanic Episodes)

nn Specify current or most recent episode:Specify current or most recent episode:nn Specify current or most recent episode:Specify current or most recent episode:nn HypomanicHypomanicnn DepressedDepressed

Bipolar II DisorderBipolar II Disorder

nn Specifiers to describe the current/most recent Major Specifiers to describe the current/most recent Major Depressive Episode in Bipolar II DisorderDepressive Episode in Bipolar II Disordernn Mild, Moderate, Severe with/without psychotic Mild, Moderate, Severe with/without psychotic

features, In Partial Remission, In Full Remission features, In Partial Remission, In Full Remission features, In Partial Remission, In Full Remission features, In Partial Remission, In Full Remission nn ChronicChronicnn With Catatonic Features With Catatonic Features nn With Melancholic FeaturesWith Melancholic Featuresnn With Atypical FeaturesWith Atypical Featuresnn With Postpartum OnsetWith Postpartum Onset

301.13 Cyclothymic Disorder301.13 Cyclothymic Disorder

nn Criterion A:Criterion A: For For at least 2 yearsat least 2 years, presence of numerous , presence of numerous hypomanic sxs and depressive sxs that do not meet hypomanic sxs and depressive sxs that do not meet criteria for a Major Depressive Episodecriteria for a Major Depressive Episode

nn Criterion B:Criterion B: During the During the 22--year periodyear period, the person has , the person has nn Criterion B:Criterion B: During the During the 22--year periodyear period, the person has , the person has not been without sxs for more than 2 months at a timenot been without sxs for more than 2 months at a time

nn No Major Depressive, Manic or Mixed Episode during No Major Depressive, Manic or Mixed Episode during the first 2 years of the disturbance the first 2 years of the disturbance –– After 2 years, both After 2 years, both Cyclothymia and Bipolar I or II may be dxCyclothymia and Bipolar I or II may be dx

EpidemiologyEpidemiology

nn Prevalence ratesPrevalence rates for MDD:for MDD:nn Female to Male ratio = 2 : 1Female to Male ratio = 2 : 1nn Lifetime risk for females: 10Lifetime risk for females: 10--25%25%

Incidence ratesIncidence rates for MDD (increasing):for MDD (increasing):nn Incidence ratesIncidence rates for MDD (increasing):for MDD (increasing):nn 1% by age 75 (of Am. born before 1905)1% by age 75 (of Am. born before 1905)nn 6% by age 24 (of Am. born after 1955)6% by age 24 (of Am. born after 1955)

Lifetime PrevalenceLifetime Prevalence

Lifetime PrevalenceLifetime Prevalence

Course of Depressive DisordersCourse of Depressive Disorders

nn Age of onset:Age of onset:nn Major DD Major DD –– mid 20smid 20snn Early onset Dysthymia Early onset Dysthymia –– before age 21before age 21

nn Onset often related to a psychosocial stressorOnset often related to a psychosocial stressornn Onset often related to a psychosocial stressorOnset often related to a psychosocial stressornn Variable length of episodes (from 2 weeks to Variable length of episodes (from 2 weeks to

years, average 9 months; for Dysthymia, from years, average 9 months; for Dysthymia, from 2020--30 years, median duration 5 years)30 years, median duration 5 years)

nn 5050--60% will have more than one depressive 60% will have more than one depressive episode; 5episode; 5--10% will develop Bipolar I Disorder10% will develop Bipolar I Disorder

Course of Depressive DisordersCourse of Depressive Disorders

Comorbidity

n High comorbidity of mood disorders with anxiety disorders and alcohol abuse/dependence

n Men (both unipolar and bipolar disorders) more frequently present with substance abuse; womenfrequently present with substance abuse; womenmore frequently present with anxiety & eating disorders

n Substance use disorders, panic d. and OCD are 2x more frequently (each) present in patients with bipolar d. vs. unipolar d.

Cultural issues in mood disordersCultural issues in mood disorders

nn Cultural differences in the experience and Cultural differences in the experience and expression of sadness and other depressed expression of sadness and other depressed emotions emotions –– different idiomsdifferent idiomsnn Westerners tend to psychologizeWesterners tend to psychologizenn Westerners tend to psychologizeWesterners tend to psychologizenn Nonwesterners tend to somaticizeNonwesterners tend to somaticize

Depression in MicronesiaDepression in Micronesia

nn LalomweiuLalomweiu, the closest to the western idea of , the closest to the western idea of major depression, is conceptualized as loneliness major depression, is conceptualized as loneliness or sadness caused by the loss of a loved one or sadness caused by the loss of a loved one

nn FagoFago means feeling sorrow and compassion for means feeling sorrow and compassion for nn FagoFago means feeling sorrow and compassion for means feeling sorrow and compassion for others’ loss of loved onesothers’ loss of loved ones

nn PakPak is homesickness experienced by travelers is homesickness experienced by travelers who are missing their loved ones at homewho are missing their loved ones at home

Depression Depression among Native Americansamong Native Americans

For Native Americans of the Flathead For Native Americans of the Flathead Reservation, depression can have positive Reservation, depression can have positive connotations, as it may be interpreted as connotations, as it may be interpreted as signifying maturity and recognition of the signifying maturity and recognition of the signifying maturity and recognition of the signifying maturity and recognition of the tremendous loss experienced by Native tremendous loss experienced by Native Americans through domination by Anglo Americans through domination by Anglo American societyAmerican society

Castillo, 1997Castillo, 1997

Etiological models of depressionEtiological models of depression

nn Biological modelsBiological modelsnn Genetic vulnerability Genetic vulnerability (polygenic)(polygenic)

nn Neurotransmitters Neurotransmitters -- shift toward studying shift toward studying neurobehavioral systems, neural circuits & neurobehavioral systems, neural circuits & neurobehavioral systems, neural circuits & neurobehavioral systems, neural circuits & neuroregulatory mechanismsneuroregulatory mechanisms

nn Pathology of the brain/ neuroanatomyPathology of the brain/ neuroanatomynn Endocrine hypothesisEndocrine hypothesisnn Circadian rhythmsCircadian rhythms

Genetic vulnerabilityGenetic vulnerability

nn The search for one gene, markers on the X The search for one gene, markers on the X chomozomechomozome or on or on chromozomechromozome 11 for bipolar I 11 for bipolar I disorder have not been supporteddisorder have not been supported

nn There is some evidence for There is some evidence for polygenic transmissionpolygenic transmission

Genetic vulnerabilityGenetic vulnerability

nn Twin studies: Twin studies: 3x higher incidence in MZ than 3x higher incidence in MZ than DZ (concordance increases with severity)DZ (concordance increases with severity)

nn Adoption studies: Adoption studies: inconsistent findingsinconsistent findings

nn Useful terms:Useful terms:nn Proband (individual with the disorder)Proband (individual with the disorder)nn Relatives (higher morbid risk for a mood disorder in Relatives (higher morbid risk for a mood disorder in

relatives of a proband)relatives of a proband)

Genetic vulnerabilityGenetic vulnerability

nn There is some evidence of There is some evidence of joint heritability for joint heritability for anxiety & depression.anxiety & depression.

nn It is not possible to separate genetic from It is not possible to separate genetic from nn It is not possible to separate genetic from It is not possible to separate genetic from environmental factors. Depressed mothers are environmental factors. Depressed mothers are ineffectual disciplinarians, unable to cope with ineffectual disciplinarians, unable to cope with stress, model depressive behaviors (Sherman, stress, model depressive behaviors (Sherman, 1987). 1987).

Neurotransmitter hypothesesNeurotransmitter hypotheses

nn Cathecolamine hypothesisCathecolamine hypothesisnn Low epinephrine Low epinephrine –– depressiondepressionnn High epinephrine High epinephrine -- maniamania

nn Indolamine hypothesisIndolamine hypothesisnn Low serotonin levels Low serotonin levels -- depressiondepression

Neurotransmitter hypothesesNeurotransmitter hypotheses

nn Permissive hypothesisPermissive hypothesis: : low levels of serotonin low levels of serotonin interact with other neurotransmitter systems interact with other neurotransmitter systems (norepinephrine & dopamine)(norepinephrine & dopamine)(norepinephrine & dopamine)(norepinephrine & dopamine)

Pathological neuroanatomy

Endocrine hypothesisEndocrine hypothesis

nn High cortisol levels in depression. High cortisol levels in depression.

50%of depressed Ps show reduced suppression 50%of depressed Ps show reduced suppression nn 50%of depressed Ps show reduced suppression 50%of depressed Ps show reduced suppression in the in the dexamethazone suppression testdexamethazone suppression test

Circadian rhythms hypothesisCircadian rhythms hypothesis

nn Depressed peopleDepressed people: REM sleep starts earlier; : REM sleep starts earlier; stages of deep sleep occur later, if at all; sleep stages of deep sleep occur later, if at all; sleep deprivation (2deprivation (2ndnd stage of night sleep) leads to stage of night sleep) leads to improvement. improvement. nn Extended insomnia may trigger a Extended insomnia may trigger a manic episodemanic episode

nn Bipolar disorderBipolar disorder Ps: increased sensitivity to light Ps: increased sensitivity to light (greater suppression(greater suppression of melatonin when exposed of melatonin when exposed to light at night)to light at night)

Psychological Psychological models of depressionmodels of depression

AllAll psychological modelspsychological models have in common the theme have in common the theme of of losslossnn Psychoanalytic formulationsPsychoanalytic formulationsnn Psychoanalytic formulationsPsychoanalytic formulationsnn Psychosocial modelsPsychosocial modelsnn Behavioral modelsBehavioral modelsnn Cognitive modelsCognitive models

Psychoanalytic formulationsPsychoanalytic formulations

nn AbrahamAbraham--FreudFreud (1911, 1917) (1911, 1917) -- ‘‘blockage of libidoblockage of libido’’through object loss; ambivalent feelings (lovethrough object loss; ambivalent feelings (love--hate) toward the object hate) toward the object –– unacceptable unacceptable hostility is hostility is turned inwardturned inward (retroflected) (retroflected) turned inwardturned inward (retroflected) (retroflected) nn No empirical supportNo empirical support

Psychoanalytic formulationsPsychoanalytic formulations

nn SpitzSpitz (1945) described (1945) described ‘‘anaclitic depressionanaclitic depression’’ in in infants separated from their mothers in the 2infants separated from their mothers in the 2ndnd

half of their liveshalf of their lives -- characterized by characterized by apprehension, crying, withdrawal, psychomotor apprehension, crying, withdrawal, psychomotor apprehension, crying, withdrawal, psychomotor apprehension, crying, withdrawal, psychomotor slowing, dejection, stupor, insomnia, anorexia, slowing, dejection, stupor, insomnia, anorexia, weight loss, gross retardation in growth and weight loss, gross retardation in growth and developmentdevelopment

Psychoanalytic formulationsPsychoanalytic formulations

BribringBribring(1965):(1965): Depression results from the ego being Depression results from the ego being cognizant of its goals and its cognizant of its goals and its helplessnesshelplessness to attain them to attain them --inabilityto live up to oneto live up to one’’s ego ideals (e.g., wish to be s ego ideals (e.g., wish to be worthy and to be loved, the strivings to be secure, worthy and to be loved, the strivings to be secure, strong and superior, the aspiration to be good, kind, strong and superior, the aspiration to be good, kind, strong and superior, the aspiration to be good, kind, strong and superior, the aspiration to be good, kind, loving, and humane); the ego suffers a narcissistic injury loving, and humane); the ego suffers a narcissistic injury and and collapse in selfcollapse in self--esteemesteemnn Hostility is secondary to object loss and/or targeting Hostility is secondary to object loss and/or targeting

objects that prevent the attainment of desired/ objects that prevent the attainment of desired/ cherished aspirationscherished aspirations

Psychoanalytic formulationsPsychoanalytic formulations

nn BowlbyBowlby(1973): Depression results from object (1973): Depression results from object loss, traumatic separation from significant loss, traumatic separation from significant objects of attachment, especially from an objects of attachment, especially from an ambivalently loved one. No empirical support.ambivalently loved one. No empirical support.ambivalently loved one. No empirical support.ambivalently loved one. No empirical support.

nn KohutKohut: A damaged self, with a fragile sense of : A damaged self, with a fragile sense of selfself--esteem may result in esteem may result in ““empty depressionempty depression””(dominated by feelings of boredom) or in (dominated by feelings of boredom) or in ““guilty guilty depressiondepression””..

Psychoanalytic formulationsPsychoanalytic formulations

n Psychodynamic factors in manian Manic episodes = defense against underlying

depression; may result as a reaction to a tyrannical and overcritical superego, replacing tyrannical and overcritical superego, replacing intolerable self-criticism with euphoric self-satisfaction

Karl Abraham

Behavioral modelsBehavioral models

nn FersterFerster (1966, 1973): loss of reinforcible behavior(1966, 1973): loss of reinforcible behavior

nn LewinsohnLewinsohn (1970): (1970): social skill deficitssocial skill deficits: low amount of : low amount of verbal production, low # of times behavior is verbal production, low # of times behavior is verbal production, low # of times behavior is verbal production, low # of times behavior is initiated; delayed latency of response to others; initiated; delayed latency of response to others; low rate of positive/reinforcing behaviorslow rate of positive/reinforcing behaviors

Behavioral modelsBehavioral models

nn CostelloCostello (1972): (1972): reinforcers are available and the reinforcers are available and the individual may still be capable of procuring individual may still be capable of procuring them, but they have them, but they have lost their potency as reinforcerslost their potency as reinforcers

nn Coyne Coyne (1976): (1976): depressed individuals have an depressed individuals have an alienating effect on othersalienating effect on others (during phone (during phone interactions) interactions) –– low frequency & quality of social low frequency & quality of social reinforcersreinforcers

Behavioral modelsBehavioral models

nn RehmRehm(1977) developed Kanfer(1977) developed Kanfer’’s (1970) s (1970) selfself--control control & self& self--regulation modelregulation model which divided the control which divided the control that individuals have over their behaviors into 3 that individuals have over their behaviors into 3 that individuals have over their behaviors into 3 that individuals have over their behaviors into 3 stages: 1) selfstages: 1) self--monitoring, 2) selfmonitoring, 2) self--evaluation, 3) evaluation, 3) selfself--reinforcement. reinforcement.

Depressed individuals are hypothesized to Depressed individuals are hypothesized to attend selectively to negative aspects of themselvesattend selectively to negative aspects of themselves..

Behavioral modelsBehavioral models

nn LewinsohnLewinsohn (1988) (1988) -- correlates of depression: correlates of depression: nn DemographicsDemographics (young, female, low SES, low (young, female, low SES, low

education, divorced/separated, unemployed); education, divorced/separated, unemployed); high levels of high levels of stressstress;;high levels of high levels of stressstress;;

nn Social relationshipsSocial relationships (isolated; uncomfortable (isolated; uncomfortable in social interactions; reduced pleasure); in social interactions; reduced pleasure);

nn Personal factorsPersonal factors: low self: low self--esteem, negative esteem, negative cognitive triad, less control in life, irrational cognitive triad, less control in life, irrational beliefsbeliefs

Psychosocial modelsPsychosocial models

Emphasis on Emphasis on social & cultural factorssocial & cultural factors::nn Marital statusMarital status: marital disruption often precedes : marital disruption often precedes

depressiondepressionnn Gender rolesGender roles: mastery & controllability of events : mastery & controllability of events nn Gender rolesGender roles: mastery & controllability of events : mastery & controllability of events

strongly encouraged in males, but not in strongly encouraged in males, but not in females; females value intimacy; rumination over females; females value intimacy; rumination over emotionsemotions

nn Social supportSocial support: support & conflict as separate : support & conflict as separate dimensionsdimensions

Psychosocial modelsPsychosocial models

Life events & copingLife events & coping::nn Brown & HarrisBrown & Harris (1978): depression often occurs (1978): depression often occurs

following a severe/acute stressful event or after following a severe/acute stressful event or after major chronic difficulties lasting more than 2 ymajor chronic difficulties lasting more than 2 ymajor chronic difficulties lasting more than 2 ymajor chronic difficulties lasting more than 2 y

nn BillingBilling (1983): vulnerability to depression (1983): vulnerability to depression increases with the number of increases with the number of ““life strainslife strains””

nn Lazarus & Lazarus & FolkmanFolkman (1986) depressed people (1986) depressed people have highly ineffective coping styleshave highly ineffective coping styles

Cognitive modelsCognitive models

nn Martin SeligmanMartin Seligman (1974, 1975): (1974, 1975): learned helplessnesslearned helplessness & & perception of noncontrol; perception of noncontrol; specificity of specificity of helplessness to depressionhelplessness to depression: a number of studies : a number of studies have shown that helplessness induction results have shown that helplessness induction results have shown that helplessness induction results have shown that helplessness induction results in increased anxiety, hostility and depressionin increased anxiety, hostility and depression

Cognitive modelsCognitive models

nn Martin SeligmanMartin Seligman (1981): (1981): attributional reformulationattributional reformulation --maladaptive attributional style of depressed maladaptive attributional style of depressed individuals is characterized by internal, global, individuals is characterized by internal, global, stable attributions; integrates the concepts of stable attributions; integrates the concepts of stable attributions; integrates the concepts of stable attributions; integrates the concepts of cognitive vulnerabilitycognitive vulnerability& & stressful life eventsstressful life events & & inability inability to copeto cope

Cognitive modelsCognitive models

nn Aaron BeckAaron Beck (1967, 1974): (1967, 1974): Depressed affect is secondary Depressed affect is secondary to a set of negative cognitions.to a set of negative cognitions.

Depressive cognitionsDepressive cognitions are at the root of depression are at the root of depression --Depressive cognitionsDepressive cognitions are at the root of depression are at the root of depression --negative cognitive triad (self, world, future) and faulty negative cognitive triad (self, world, future) and faulty reasoning; the development of depressive schemas reasoning; the development of depressive schemas occurs over a period of years. occurs over a period of years. nn Cognitive negative triadCognitive negative triad plays an important role both in plays an important role both in

the etiology and the maintenance of depression.the etiology and the maintenance of depression.

Integrative Integrative multifactorialmultifactorial modelmodel

nn Hagop AkiskalHagop Akiskal (1976): (1976): “Depressive illness, as a “Depressive illness, as a final common pathway, is the culmination of final common pathway, is the culmination of various processes that conceivably converge in various processes that conceivably converge in those area of the diencephalon that modulate those area of the diencephalon that modulate those area of the diencephalon that modulate those area of the diencephalon that modulate arousal, mood, motivation and psychomotor arousal, mood, motivation and psychomotor functioning.” functioning.”

Integrative Integrative multifactorialmultifactorial modelmodel

nn Hagop AkiskalHagop Akiskal (1976): (1976): The specific form that the The specific form that the syndrome will take in a given individual will syndrome will take in a given individual will depend on the interaction of:depend on the interaction of:nn Genetic vulnerabilityGenetic vulnerabilitynn Genetic vulnerabilityGenetic vulnerabilitynn Developmental events Developmental events -- sensitization to sensitization to

depressiondepressionnn Psychosocial acute or chronic stressorsPsychosocial acute or chronic stressorsnn Physiological stressors Physiological stressors nn Personality traitsPersonality traits

References

n American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, (4th ed., Text Revision). Washington, DC: Author.

n Castillo, R. J. (1997). Culture and mental illness. A n Castillo, R. J. (1997). Culture and mental illness. A client-centered approach. New York: Brooks/Cole.

n Jamison, K. R. (1997). An unquiet mind. A memoir of moods and madness. New York: Alfred A. Knopf.

References

n McHugh, P. R , & Slavney, P.R. (1998). The Perspectives of Psychiatry (2nd ed.). Baltimore, MD: The Johns Hopkins University Press.

n Sadock, B. J., & Sadock, V. A. (2007). Kaplan & n Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s synopsis of psychiatry (10th ed.). Baltimore, Maryland: Williams and Wilkins.