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Mood DisordersAn unquiet mindCornelia Pinnell, Ph.D.Argosy University/Phoenix

Lecture OutlinennnnDefinitionsHistory of relevant conceptsPhenomenology of depression/maniaStructure of mood disordersUnipolarn Bipolar – I & IInnnCultural issuesEtiological models of depression

Mood ConceptsnAFFECT Broad term encompassing moods,emotions, motivations and feelings, the whole sphere ofpsychic lifenMOOD Relatively persistent, dominating affectnEMOTION Fleeting experiencePaul McHugh & Phillip Slavney, 1998

Mood Conceptsn AFFECT A pattern of observable behaviorsthat is the expression of a subjectively experiencedweather’’.feeling state - refers to emotional ‘weatherExamples:: sadness, elation, anger, etc.Examplesn MOOD Pervasive and sustained emotional ‘climateclimate’’DSM--IVDSMIV--TR

Disturbances in affectnnnBlunted significant reduction in intensity ofemotional expressionFlat Absence or near absence of any signs ofaffective expressionRestricted/ constricted Mild reduction in the rangeand intensity of emotional expression

Disturbances in affectnnLabile Abnormal variability in affect withrepeated, rapid and abrupt shifts in affectiveexpressionInappropriate Discordance between affectiveexpression and the content of speech or ideation

History of ConceptsnPinel & other early clinicians (late 18th century)distinguished between two clinical aspects ofsevere insanity:n Affectional insanity (characterized bydisturbed emotions)n Ideational insanity (characterized bydisturbed thoughts and beliefs, without aprominent change in mood)

History of ConceptsnEmil Kraepelin first described manicmanic-depressivedisorder and schizophrenianManic--depressive insanity circular insanities,Manicsimple manias, & involutional melancholia; it neverled to a profound deterioration of personality orthinkingn Dementia preacox (term first used by the Frenchpsychiatrist BenoîBenoît Morel) a disturbance inthinking, emotion, and volition which eventually ledto the destruction of the personality

History of ConceptsnnnEugen Bleuler coined the word ‘schizophreniaschizophrenia’’ anddescribed a group of schizophrenias wherethought disorder was centralAdolf Meyer characterized manicmanic-depressivedisorder and schizophrenia as reactionsKarl Jaspers - similar psychological events mightbe produced by circumstance in some case, bydisease processes in others

Phenomenology of depressionThe depressed patient may feel diseased, poor,blameworthy, or useless; becomes withdrawn and losesinterest in most activities, including those that usuallygive him pleasure and comfort. Even the perceptionsof the environment may become dulled, sounds aremuffled, colors faded or darkened, food tasteless.There may be a generalized slowing down,psychomotor retardation, answering slowly if at all, canappear ill, thinking is slowand inefficient, fatigue andphysical discomfort; walking with a gait, posture,rigidity and facial expression suggestive ofParkinsonism.

Phenomenology of depressionA stuporous condition is the mostsevere manifestation, with the patientbedridden, incontinent, mute, unableto feed or care for himself, and indanger of death if not properlydiagnosed and treated.

Criteria forMajor Depressive EpisodennnCriterion A: Five (or more) of the following sxspresent for 2 weeks,weeks, a change from previousfunctioning: depressed mood, anhedonia, sig.weight loss/gain, insomnia/hypersomnia,psychomotor agitation/retardation,fatigue/anergia, poor concentration,worthlessness, suicidal ideationCriterion B: Sxs do not meet criteria for a MixedepisodeCriterion C: Sxs cause significant distress orimpairment

Phenomenology of maniaThe manic patient may believe he is healthy,rich, famous, talented, powerful. Social andother activities increase and perceptions becomebrighter and more intense. Thoughts might beexperienced effortless and rapid, body filled withenergy & healthy. The patient becomesincreasingly active until the behavior takes on anuncontrollable driven quality, thoughts becomechaotic & responsive to every distraction so thatsustained, goalgoal-directed thinking is impossible.

Criteria for Manic EpisodenCriterion A: A distinct period of abnormally persistentlyelevated, expansive, or irritable mood, lasting at least 1 week (orany duration if hospitalization is necessary)nCriterion B: During the period of mood disturbance, 3 (ormore) of the following sxs are present: inflated selfself-esteem orgrandiosity, decreased need for sleep, pressured speech, flight ofideas/racing thoughts, distractibility, increased goalgoal-directedactivity/psychomotor agitation, excessive involvement inpleasurable activities with high potential for painfulconsequences

Structure of Mood DisordersnnUnipolar (depression)BipolarBipolar I (with mania)n Bipolar II (with hypomania)n

Depressive Disordersnnnn296.2x Major depressive disorder,disorder, single episode(50%)296.3x Major depressive disorder,disorder, recurrent (2ms btw. episodes)300.4 Dysthymic disorder (persistent depressedmood 2 y ); specifiersspecifiers:: early (before age 21) orlate onset; atypicalDouble depression (dysthymia major depressiveepisode)

Specifiers for MDDnIf full criteria for MDD are metMild, Moderate, Severe with/without psychoticfeaturesn Chronicn With Catatonic featuresn With Melancholic featuresn With Atypical featuresn With Postpartum onsetn

Specifiers for MDDnIf full criteria for MDD are not metIn Partial Remission/Full Remissionn Chronicn With Catatonic featuresn With Melancholic featuresn With Atypical featuresn With Postpartum onsetn

311 Depressive Disorder NOSnnnnPremenstrual Dysphoric DisorderMinor Depressive DisorderRecurrent Brief Depressive Disorder(2 days , but less than 2 weeks)Postpsychotic Depressive Disorder(Major Depressive Episode during theresidual phase of Schizophrenia)

Further studynnnnAlternative Criterion B for Dysthymic DisorderMinor Depressive Disorder(less impairment & fewer symptoms)Recurrent Brief Depressive Disorder(2 days , but less than 2 weeks)Mixed AnxietyAnxiety-Depressive Disorder

Alternative Criterion B forDysthymic DisorderPresence, while depressed, of 3 (ormore) of the following:nnnnLowself-esteem or selfLowselfself-confidence, orfeelings of inadequacyFeelings of pessimism, despair, orhopelessnessGeneralized loss of interest or pleasureSocial withdrawal

Alternative Criterion B forDysthymic DisordernnnnnChronic fatigue or tirednessFeelings of guilt, brooding about the pastSubjective feelings of irritability or excessiveangerDecreased activity, effectiveness, orproductivityDifficulty in thinking – poor concentration/memory, indecisiveness

Mixed AnxietyAnxiety-Depressive DisordernnCriterion A: Persistent or recurrent dysphoricmood lasting at least 1 monthThe dysphoric mood is accompanied by atleast 1 month of four (or more) of thefollowing symptoms:1.2.3.Difficulty concentrating or mind going blankSleep disturbance (difficulty falling or stayingasleep, or restless, unsatisfying sleep)Fatigue or lowenergy

Mixed AnxietyAnxiety-Depressive yBeing easily moved to tearsHypervigilanceAnticipating the worstHopelessness (pervasive pessimism about the future)Lowself--esteem or feelings of worthlessnessLowself

Bipolar I Disordernnnnnn296.0x Bipolar I, Single Manic Episode296.40 Bipolar I, Most Recent HypomanicEpisode296.4x Bipolar I, Most Recent Manic Episode296.6x Bipolar I, Most Recent Episode Mixed296.5 Bipolar I, Most Recent EpisodeDepressed296.7 Bipolar I, Most Recent EpisodeUnspecified

Specifiers for Bipolar I DisordernIf criteria are met for a manic or mixed episode:Mild, Moderate, Severe with/without psychoticfeatures, In Partial Remission, In Full Remissionn With Catatonic Featuresn With Postpartum Onsetn

Specifiers for Bipolar I DisordernOnly to the current (or most recent) MajorDepressive EpisodeChronicn With Melancholic Featuresn With Atypical Featuresn

Specifiers for Bipolar I DisordernnnLongitudinal Course Specifiers (With/WithoutInterepisode Recovery)With Seasonal Pattern (applies only to thepattern of Major Depressive Episodes)With Rapid Cycling

Bipolar II Disordern296.89 Bipolar II Disorder (Recurrent MajorDepressive Episodes with Hypomanic Episodes)nSpecify current or most recent episode:n Hypomanicn Depressed

Bipolar II DisordernSpecifiers to describe the current/most recent MajorDepressive Episode in Bipolar II Disordern Mild, Moderate, Severe with/without psychoticfeatures, In Partial Remission, In Full Remissionn Chronicn With Catatonic Featuresn With Melancholic Featuresn With Atypical Featuresn With Postpartum Onset

301.13 Cyclothymic DisordernCriterion A: For at least 2 years,years, presence of numeroushypomanic sxs and depressive sxs that do not meetcriteria for a Major Depressive EpisodennCriterion B: During the 2-year period,period, the person hasnot been without sxs for more than 2 months at a timeNo Major Depressive, Manic or Mixed Episode duringthe first 2 years of the disturbance – After 2 years, bothCyclothymia and Bipolar I or II may be dx

EpidemiologynnPrevalence rates for MDD:n Female to Male ratio 2 : 1n Lifetime risk for females: 1010-25%Incidence rates for MDD (increasing):n 1% by age 75 (of Am. born before 1905)n 6% by age 24 (of Am. born after 1955)

Lifetime Prevalence

Lifetime Prevalence

Course of Depressive DisordersnnnnAge of onset:n Major DD – mid 20sn Early onset Dysthymia – before age 21Onset often related to a psychosocial stressorVariable length of episodes (from 2 weeks toyears, average 9 months; for Dysthymia, from2020-30 years, median duration 5 years)5050-60% will have more than one depressiveepisode; 55-10% will develop Bipolar I Disorder

Course of Depressive Disorders

ComorbiditynnnHigh comorbidity of mood disorders withanxiety disorders and alcohol abuse/dependenceMen (both unipolar and bipolar disorders) morefrequently present with substance abuse; womenmore frequently present with anxiety & eatingdisordersSubstance use disorders, panic d. and OCD are2x more frequently (each) present in patientswith bipolar d. vs. unipolar d.

Cultural issues in mood disordersnCultural differences in the experience andexpression of sadness and other depressedemotions – different idiomsn Westerners tend to psychologizen Nonwesterners tend to somaticize

Depression in MicronesiannnLalomweiu, the closest to the western idea ofLalomweiu,major depression, is conceptualized as lonelinessor sadness caused by the loss of a loved oneFago means feeling sorrowand compassion forothers’ loss of loved onesPak is homesickness experienced by travelerswho are missing their loved ones at home

Depressionamong Native AmericansFor Native Americans of the FlatheadReservation, depression can have positiveconnotations, as it may be interpreted assignifying maturity and recognition of thetremendous loss experienced by NativeAmericans through domination by AngloAmerican societyCastillo, 1997

Etiological models of depressionnBiological modelsn Genetic vulnerability (polygenic)n Neurotransmitters - shift toward studyingneurobehavioral systems, neural circuits &neuroregulatory mechanismsn Pathologyof the brain/ neuroanatomyn Endocrine hypothesisn Circadian rhythms

Genetic vulnerabilitynThe search for one gene, markers on the Xchomozome or on chromozome 11 for bipolar Idisorder have not been supportednThere is some evidence for polygenic transmission

Genetic vulnerabilitynnnTwin studies: 3x higher incidence in MZ thanDZ (concordance increases with severity)Adoption studies: inconsistent findingsUseful terms:n Proband (individual with the disorder)n Relatives (higher morbid risk for a mood disorder inrelatives of a proband)

Genetic vulnerabilitynThere is some evidence of joint heritabilityforanxiety& depression.nIt is not possible to separate genetic fromenvironmental factors. Depressed mothers areineffectual disciplinarians, unable to cope withstress, model depressive behaviors (Sherman,1987).

Neurotransmitter hypothesesnCathecolamine hypothesisn Lowepinephrine – depressionn High epinephrine - manianIndolamine hypothesisn Lowserotonin levels - depression