Lecture 8
Mood Disorders
Lecture Outline
I. Introduction
A. Manic States
B. Major Depression
II. The DSM-III-R Mood Disorder Categories
A. Bipolar Disorders
1. Bipolar Disorder
2. Cyclothymia
B. Depressive Disorders
1. Major Depression
2. Dysthymia
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I. Introduction
Mood disorders can be traced to our earliest times (indeed, to the
Book of Genesis by some writers: Ostow, 1980) and across cultures (Al-
Issa, 1982; Carson, et al., 1988). Many famous people apparently
suffered from these disorders. Eg: Lincoln and Freud suffered from
depression. They are among the most prevalent of psychological
disorders (Reus, 1988).
The Mood Disorders are characterized by prolonged and persistent
positive and/or negative emotions, which are of such intensity that they
can color and interfere with all aspects of one's life. The key
ingredient here is mood. Although thoughts may also be disturbed,
thought disorder (ie: impairment of intellectual functioning - reflected
by incoherence, unconnected, chaotic thoughts, bizarre speech and the
like) is not a defining feature (Thought disorder is central to
Schizophrenia, which we will be discussing in later lectures).
The emotions experienced in these disorders are typically thought
to exist along a continuum with normal emotions (Beck, 1967; Reus,
1988). For example, we've all experienced sadness at some point in our
lives. But such experiences do not warrant a diagnosis. As we shall
see, clinical depression is very different from sadness.
The emotions (or moods) we will be focusing on are excessively
elevated moods and excessively depressed moods, or in other words, Mania
and Depression.
A. Manic States: elevated, expansive, grandiose, or irritable
mood.
A person in a manic state feels euphoric and high, eager to be
involved with others and with life in general. This expansive and
elevated mood may have an infectious quality for the uninvolved
observer, but for those who know the person well, the mood is
recognized as excessive.
Other characteristics:
inflated self-esteem
decreased need for sleep (eg: only 3 hours a night, or
stays awake for 3 or 4 days at a time)
talkative (eg: loud, difficult to interrupt, continuous
flow of speech)
racing ideas
easily distracted
nervous activity
high degree of risk taking (often dangerous)
One patient who went on to write a book about his experiences
(Custance, 1952), similarly describes mania:
intense sense of well-being
heightened sense of reality
release of inhibitions (sexual, moral)
delusions of grandeur and power
Others who have published personal accounts report similar
experiences when in a manic state (see Lerner, 1980).
Case Study:
When experiencing manic symptoms, a 38 year old woman,
periodically hospitalized because of her extreme moods, would
become "overactive and exuberant in spirits and visited her
friends, to whom she outlined her plans for reestablishing
different forms of lucrative business. She purchased many clothes,
bought furniture, pawned rings, and wrote checks without funds.
(She) played her radio until late in the night, smoked excessively,
took out insurance on a car that she had not yet bought. Contrary
to her usual habits, she swore frequently and loudly, (and) created
a disturbance in a club to which she did not belong. On the day
prior to her second admission to the hospital, she purchased 57
hats" (Kolk, 1973, pp376-377).
These states of mania occur as discreet episodes: a distinct
period of time during which the symptoms described above are
predominant. Episodes typically begin suddenly, initially with a
decreased need for sleep (Reus, 1988), and then escalate to last
for a few days, or months in some cases (APA, 1987). Initially,
the person's behavior may be quite creative and productive, and
other people may enthusiastically join in with him or her. Such
people can at first be quite engaging. But it soon becomes clear
that little caution or judgment is being exercised, and the
behavior deteriorates to socially inappropriate or self-destructive
activities (esp. substance abuse) (Reus, 1988). Hospitalization
often becomes necessary to prevent harm to self or others (APA,
1987).
In some cases, the person's thoughts and perceptions lose
contact with reality - psychotic symptoms arise (these symptoms are
not, however, a defining feature of mania). These include
delusions and hallucinations.
Delusions: False beliefs based on an inaccurate inference or
understanding of reality. For example: The person may
believe he is being persecuted for his special or even divine
powers
Hallucinations: Sensory perceptions (hearing, touch, sight,
etc.) that seem real when in fact there is no external
stimulation. So, for example, our person might hear the voice
of alien beings instructing him to carry out some dangerous
mission.
Usually these psychotic experiences are mood-congruent. That is,
they are consistent with the extreme mood the person is
experiencing. In rarer cases, the psychotic experiences are mood-
incongruent: The content of the delusion or hallucination does not
involve the themes typical in manic episodes (eg: delusions of
being controlled, refusing to move or speak).
There is a milder form of mania, known as hypomania: In
hypomania the extreme social and occupational impairments do not
occur, and hospitalization is never required. Nor do psychotic
features occur in hypomania.
B. Major Depression: depressed mood for most of the day, nearly
every day, or loss of interest or pleasure in all, or almost all,
activities, for a period of at least two weeks (APA, 1987). Note:
It is not necessary for the person to report feeling depressed to
be diagnosed with Major Depression. The presence of depressed mood
can be inferred from observing the person's behavior (see "Other
features" listed below). Similarly, s/he may not complain of a
loss of interest or pleasure, but withdrawal from once pleasurable
activities and from friends has usually been observed by others
(family, friends).
Other features include:
often a diminished interest or pleasure in most activities.
significant weight change
appetite disturbance (especially loss of appetite)
sleep disturbance (eg: insomnia)
slowed movements and speech
restlessness
decreased feelings of energy
feelings of worthlessness
excessive or inappropriate guilt
difficulty thinking, concentrating, or remembering
indecisiveness
thoughts of death and suicide
suicide attempts
As a consequence, a person can end up unable to function even
minimally (feeding, hygiene, etc.).
Case Study:
"I was seized with an unspeakable physical weariness. There
was a tired feeling in the muscles unlike anything I had ever
experienced...My nights were sleepless. I lay with dry, staring
eyes gazing into space...The most trivial duty became a formidable
task. Finally mental and physical exercises were impossible; the
tired muscles refused to respond, my "thinking apparatus" refused
to work, ambition was gone. My general feeling might be summed up
in the familiar saying "What's the use." I had tried so hard to
make something of myself, but the struggle seemed useless. Life
seemed utterly futile" (Reid, 1910, quoted in Davison & Neale,
1986, p.194).
The typical age of onset is between about 20 and 40 years, but
can occur at any age (APA, 1987; Reus, 1988). The earlier the
onset, the more likely the depression will recur later in life.
Major Depression, like Mania, occurs in discreet episodes. These
episodes develop gradually over many months, or sometimes more
quickly, perhaps following some stressful event (although that
isn't necessary). The symptoms will typically last six months or
more (if untreated), and then subside, although there is some
evidence that such recovery is not as common as once thought.
Recent studies suggest that only about 50% of people suffering from
Major Depression recover over a 12 month period (Reus, 1988).
Relapse is much more likely if the episodes are brief and age of
onset is early (Reus, 1988).
For some individuals, the depressive symptoms are chronic:
they last for two years without a remission greater than two
months.
As with mania, in certain cases the person's thoughts or
perceptions may lose contact with reality, so that delusions,
hallucinations or other psychotic features will be present. These
can include mood-congruent delusions (eg: persecuted for moral
transgressions, or otherwise self-deprecatory) and hallucinations
(eg: berating voices blaming him/her for sins). Less common are
mood-incongruent delusions and hallucinations (eg: belief in the
ability to read minds).
There has been considerable interest in recent years in trying
to identify sub-types of depression (different etiology, different
responses to treatment methods). Thus, DSM-III-R requires
specification as to whether or not the major depression is of the
"melancholic type". This sub-type is characterized by symptoms
such as a loss of interest in almost all (or all) activities, an
inability to experience pleasure, depression usually worse in the
morning, early morning wakings, good response to antidepressant
medications. The hypothesis has been (although the DSM-III-R takes
no explicit stand on this) that this type of depression is due to
internal, perhaps biological processes, and is relatively unrelated
to external events (we'll have more to say on this in the lectures
on etiology).
Note: A person is not diagnosed with Major Depression if there
are organic/biological causes or if the mood is the result of
normal grieving over a death.
II. The DSM-III-R Mood Disorder Categories
The DSM-III-R divides the Mood Disorders into two major categories:
Bipolar Disorders and Depressive Disorders. The Bipolar Disorders are
characterized by alternating periods of mania and depression. The
Depressive Disorders do not have periods of mania. These two classes of
disorders are further sub-divided based on whether the disorder is
chronic or episodic (see Handout 8-1).
A. Bipolar Disorders
1. Bipolar Disorder: one or more Manic episodes usually
accompanied by one or more Major Depressive episodes (this is
the disorder sometimes known as "manic-depressive disorder").
Typically the mania and depression alternate, although in rare
cases they may coexist. Although the DSM-III-R does not
provide a category for this, there is some evidence that there
may be a "unipolar" disorder: mania without any episodes of
depression (Andreasen, 1982).
A Manic period is usually the reason the person comes to the
attention of professionals.
Prevalence: .4% to 1.2% of the adult population.
Sex Ratio: Recent studies indicate this disorder to be
equally common in males and females (APA, 1987).
2. Cyclothymia: a mood disturbance characterized by
alternating Hypomanic episodes with depressed mood; this mood
disturbance having lasted for at least two years. Both ends
of the "cycle" are never severe enough to be called Mania or
Major Depression, and there are never any psychotic symptoms.
This is apparently a common disorder, possibly making up as
much as 3 - 4% of the clinical population (Reus, 1988).
Prevalence: .4 - 3.5%. Possibly more prevalent in women
(APA, 1987, Reus, 1988).
People suffering from this disorder tend to be extroverted and
sociable, appearing self-assured, energetic and impulsive and
daring. Yet, they will also suddenly turn irritable and
sensitive to rejection or loss. Substance abuse is a common
complication (Reus, 1988).
There is a growing body of evidence that Cyclothymics are at
risk to go to develop Bipolar Disorder and other Mood
Disorders (Klein & Depue, 1984).
B. Depressive Disorders
1. Major Depression: one or more Major Depressive episodes as
described above, without Mania or Hypomania. Episodes can be
separated by years, or cluster around particular periods of
time. Some fascinating recent work suggests that there may be
a connection between the time of the year and the occurrence
of a depressive episode. In other words, the occurrence of an
episode may depend on the season. We will discuss this in an
upcoming lecture.
Prevalence: 3% for men
4 - 9% for women (Reus, 1988)
50% of sufferers will have more than one episode, and are at
greater risk for developing Bipolar Disorder.
2. Dysthymia: chronic depressed mood for most of the day,
more days than not, for at least two years. Often considered
to be a "characterological" depression - the depression is the
very core of how the person operates and thinks. These
individuals experience chronic feelings of inadequacy and
worthlessness. The symptoms are thus similar to Major
Depression, just not as severe. There is, however, no "loss
of interest in pleasurable activities" nor an "inability to
experience pleasure" which sometimes accompanies Major
Depression.
The disorder is apparently common and somewhat more prevalent
in women (APA, 1987).
The different categories of Mood Disorders and how they are related
are summarized in Handout 8-1.
Handout 8-1
MOOD DISORDER
|
|
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| |
| DEPRESSIVE DISORDERS
BIPOLAR DISORDERS |
| |
| episodic--------------chronic
episodic-------chronic | |
| | | |
| | MAJOR DEPRESSION DYSTHYMIA
BIPOLAR CYCLOTHYMIA |
| -------------------------------
-------------------- psychotic/ melancholia/ |
| | nonpsychotic no melancholia |
psychotic/ | | |
nonpsychotic | | seasonal/
| seasonal/ | not seasonal
| not seasonal mood congruent/
| incongruent
mood congruent/
incongruent
(Adapted from Kupfer & Thase, 1987).