MOOD

DISORDERS

AAVLEEN BAKSHI
ASSISTANT PROFESSOR
PSYCHOLOGY
 MOOD

pervasive and sustained emotion that colours the

person’s perception of the world.

-Fish’s clinical psychopathology, Third edition

 AFFECT

short-lived emotion, is defined as the patient’s present

emotional responsiveness

-Fish’s clinical psychopathology, Third edition

 DIFFERENCES
•Disease: A particular distinctive process in the body with a specific
cause and characteristic symptoms.
•Disorder: Irregularity, disturbance, or interruption of normal functions.
•Syndrome: A number of symptoms occurring together and
characterizing a specific disease.
 Mood disorders

Mood disorders are best considered as syndromes (rather than

discrete diseases) consisting of a cluster of signs and
symptoms, sustained over a period of weeks to months, that
represent a marked departure from a person’s habitual
functioning and tend to recur, often in periodic or cyclical
fashion.

-COMPREHENSIVE TEXTBOOK OF
PSYCHIATRY. 10 th edition
 PREVALENCE

National Mental Health Survey of India, 2015-16:

Prevalence, Pattern and Outcomes
 AGE OF ONSET
• The onset of bipolar I disorder is earlier than that of major depressive
disorder. The age of onset for bipolar I disorder ranges from childhood
(as early as age 5 or 6 years) to 50 years or even older in rare cases,
with a mean age of 30 years.
• The mean age of onset for major depressive disorder is about 40 years,
with 50 percent of all patients having an onset between the ages of 20
and 50 years. Major depressive disorder can also begin in childhood or
in old age.
 GENDER DIFFERENCES
• Twofold greater prevalence of major depressive disorder in women than in men.
The reasons for the difference are hypothesized to involve hormonal differences,
the effects of childbirth, differing psychosocial stressors for women and for men,
and behavioral models of learned helplessness.
• Bipolar I disorder has an equal prevalence among men and women. Manic
episodes are more common in men, and depressive episodes are more common
in women.
• Women also have a higher rate of being rapid cyclers, defined as having four or
more manic episodes in a 1-year period.
BIPOLAR & RELATED DISORDERS
BIPOLAR & RELATED DISORDERS
MANIA
DIFFERENTIAL DIAGNOSIS OF BIPOLAR I
• MDD
• Other bipolar disorders- Cyclothymia, etc.
• GAD, Panic disorder, PTSD, other anxiety disorders
• Substance induced bipolar disorders
• Schizoaffective disorder
• ADHD
• Disruptive mood dysregulation disorder
• Personality disorders- BPD
F31.81
BIPOLAR II DISORDER
DIFFERENTIAL DIAGNOSIS OF BIPOLAR II
• MDD
• Cyclothymia
• Schizophrenia
• Substance/ medication induced bipolar disorders
• Bipolar and related disorders due to another medical condition
• Schizoaffective disorder
• ADHD
• Personality disorders- BPD
SPECIFIERS FOR BIPOLAR AND RELATED DISORDERS

1. WITH MIXED FEATURES

SPECIFIERS FOR BIPOLAR
AND RELATED DISORDERS

1. WITH MIXED FEATURES

 DEPRESSION
• Globally more than 350 million people of all ages suffer from depression. (WHO

World Mental Health Survey Consortium, 2004))

• The mean age of onset is 40.

• Median duration – 6 months (ICD -10)

• About 10% of men and 20% of women suffer from depression at some of life.

• Women are nearly twice as likely to suffer from a major depressive disorder than

men are.
ICD 10
 MANIA

• Manic episodes are characterized by elevated mood and

increased in quantity and speed of physical and mental
activity.
• They begin abruptly & last for 2 weeks – 5 months.
• Mean duration – 4 months
• Hypomania is a lesser degree of mania, an intermediate
state without delusions, hallucinations, or complete
disruption of normal activities.
• Three degrees of severity of manic episode are
specified in ICD- 10:
• Hypomania F 30.0
• Mania without psychotic symptoms F 30.1
• Mania with psychotic symptoms F 30.2
SYMPTOMS OF MANIA
ETIOLOGY OF MOOD DISORDER
Neurotransmitters

• Dopamine
• Norepinephrine DEPRESSION
• Serotonin

• Dopamine MANIA
Alterations of Hormonal
Regulation.
• GROWTH HORMONE - Decreased CSF somatostatin levels
have been reported in depression, and increased levels have been
observed in mania

• THYROID AXIS ACTIVITY - Approximately 5 to 10 percent

of people evaluated for depression have previously undetected
thyroid dysfunction, as reflected by an elevated basal
thyroid-stimulating hormone (TSH)
 Alterations of Sleep
Neurophysiology
Depression is associated with a premature loss of deep (slow-wave)
sleep and an increase in nocturnal arousal. The latter is reflected by
four types of disturbance:

(1) an increase in nocturnal awakenings,

(2) a reduction in total sleep time,

(3) increased phasic rapid eye movement (REM) sleep, and

(4) increased core body temperature.

 Immunological Disturbance

Depressive disorders are associated with several

immunological abnormalities, including decreased
lymphocyte proliferation.
 Neuroanatomical
Consideration
Four brain regions in the regulation of normal emotions:

• the prefrontal cortex (PFC) : representations of goals and

appropriate responses to obtain these goals = multiple,
conflicting behavioral responses

• the anterior cingulate: integration of attentional and emotional

inputs = facilitates control of emotional arousal, particularly
when goal attainment has been thwarted or when novel
problems have been encountered

• the hippocampus : learning and memory

• the amygdala : station for processing novel stimuli

 Genetic Factors
Family Studies
• if one parent have mood disorder = 10 and 25 percent for mood disorder.
• If both parents have mood disorder = this risk roughly doubles.
Twin Studies
• concordance rate for mood disorder in the monozygotic (MZ) twins of 70 to 90 percent compared with
the same-sex dizygotic (DZ) twins of 16 to 35 percent.
Linkage Studies
• DNA markers are segments of DNA = track the segregation of specific chromosomal regions within
families affected with a disorder.
• Chromosomes 18q and 22q are the two regions with strongest evidence for linkage to bipolar disorder.
 Personality Factors

1. Persons with certain personality disorders may be at greater

risk for depression
• OCD,
• histrionic,
• Borderline

2. Neuroticism
Predicts onset of depression (Jorm et al., 2000)
3. introversion - may also serve as vulnerability factors for
depression, either alone or when combined with neuroticism
(Watson et al., 2005).
Psychodynamic Factors in Depression
Sigmund Freud and Karl Abraham gave the classic view of depression.

1. Disturbances in the infant mother relationship during the oral phase (the first 10 to 18

months of life predispose to subsequent vulnerability to depression;

2. Depression can be linked to real or imagined object loss;

3. Introjection of the departed objects is a defense mechanism invoked to deal with the

distress connected with the object's loss

4. Because the lost object is regarded with a mixture of love and hate, feelings of anger are

directed inward at the self.

• Edward Bibring regarded depression as a phenomenon that sets in
when a person becomes aware of the discrepancy between
extraordinarily high ideals and the inability to meet those goals.

• Edith Jacobson saw the state of depression as similar to a

powerless, helpless child victimized by a tormenting parent.

• John Bowlby believed that damaged early attachments and

traumatic separation in childhood predispose to depression. Adult
losses are said to revive the traumatic childhood loss and so
precipitate adult depressive episodes.

• Fairbairn (1940,1941) viewed depression as a reaction in which

hate and aggression are turned inward against the self when
circumstances disturb the object relations of individuals of the
depressive type.
 Psychodynamic Factors in Mania
1. Most theories = defense against underlying depression.

2. Abraham, for example, believed that the manic episodes may reflect an
inability to tolerate a developmental tragedy, such as the loss of a parent.

– The manic state may also result from a tyrannical superego, which produces
intolerable self-criticism that is then replaced by euphoric self-satisfaction.

3. Bertram Lewin regarded the manic patient's ego as overwhelmed by

pleasurable impulses, such as sex, or by feared impulses, such as aggression.

4. Klein also viewed mania as a defensive reaction to depression, using manic

defenses such as omnipotence, in which the person develops delusions of
grandeur.
BEHAVIORAL APPROACH
1. Depression is the result of a person's interaction with their
environment.

2. Ferster (1973) defined depression as a reduction in the frequency of

positively reinforced behaviors.

3. In operant or Skinnerian terms, the depressed person is on a prolonged

extinction schedule (Lewisohn, Weinstein, & Shaw, 1968; Lewinsohn
& Shaeffer, 1971; Lazarus, 1968; Seitz, 1971b). To be on an extinction
schedule simply means that a learned behavior decreases in frequency
due to lack of positive reinforcement .

4. Depression is caused by the removal of positive reinforcement from

the environment (Lewinsohn, 1974).
JOSEPH WOLPE’S MODEL

1. Introduced the idea of ‘neurotic depression’ (1986)

2. Wolpe believed that depression occurred secondary to

maladaptive anxiety

3. He considered neurotic depression to arise:

a) secondary to a severe and prolonged conditioned anxiety

b) as a consequence of a cognitively-based anxiety

c) secondary to social anxiety or to a feeling of interpersonal

intimidation

d) as a result of unresolved bereavement.

INTERACTIONAL THEORY

• By James Coyne (1976)

• Based on the concept of reciprocal interaction.

• At first people who become depressed may succeed in

garnering social support.

• However, over time their demands and behavior begin to elicit

anger or annoyance.

• Depressed people may react to rejection with deeper depression

& greater demands, triggering a vicious cycle of further
rejection and more profound depression
COGNTIVE THEORIES
Beck’s cognitive model of depression
• Hypothesized that the cognitive symptoms of depression
often precede and cause the affective or mood symptoms.

1. First, there are the underlying dysfunctional beliefs,

known as depressogenic schemas, which are rigid,
extreme, and counterproductive.

2. When dysfunctional beliefs are activated by current

stressors or depressed mood, they tend to fuel the current
thinking pattern, creating a pattern of negative automatic
thoughts.
3. These pessimistic predictions tend to center on the three
themes of what Beck calls the negative cognitive triad

a) a negative view of the self

b) a negative view of the world

c) a negative view of the future

Beck also postulated that the negative cognitive triad tends to be
maintained by a variety of negative cognitive biases or errors.

Each of these involves biased processing of negative self-relevant

information. Examples include

1. Dichotomous or all-or-none reasoning, which involves a tendency

to think in extremes.

2. Selective abstraction, which involves a tendency to focus on one

negative detail of a situation while ignoring other elements of the
situation.

3. Arbitrary inference, which involves jumping to a conclusion based

on minimal or no evidence
 LEARNED HELPLESSNESS
• Seligman (1974) proposed the theory of learned
helplessness.

• It states that when animals or humans find that they

have little or no control over the aversive events, they
may feel helpless, which makes them unmotivated to
respond to the failure and they exhibit passivity.

• This model is primarily used to explain depression.

 LEARNED HELPLESSNESS
• Later Seligman modified the learned helplessness
theory.(1975)

• Incorporated person's thinking style as a factor

determining whether learned helplessness would occur.

• Depressed people use more pessimistic explanatory

style when thinking about stressful events than did

non-depressed people.
 ABRAMSON(1978) THEORY ON
DEPRESSION
ATTRIBUTIONAL BIAS

• Abramson, Seligman, and Teasdale (1978) consequently introduced a

cognitive version of the theory by reformulating learned helplessness in
term of attributional processes (i.e. how people explain the cause of an
event).

• The depression attributional style is based on three dimensions, namely :

a. locus (whether the cause is internal - to do with a person themselves, or

external - to do with some aspect of the situation),

b. stability (whether the cause is stable and permanent or unstable and

transient) and

c. global or specific (whether the cause relates to the 'whole' person or

just some particular feature characteristic).
 HOPELESSNESS THEORY OF
DEPRESSION

• Abramson, Seligman & Teasdale (1978) proposed that:

• a proximal sufficient cause of depression is an

expectation that highly desired outcomes are unlikely to
occur

• or that highly aversive outcomes are likely to occur and

that no response in one’s repertoire will change the
likelihood of occurrence of these outcomes.
 The Ruminative Response
Styles Theory of Depression

• By: Nolen-Hoeksema’s (1991, 2000, 2012).

• rumination consists of repetitive thinking about the causes,

consequences and symptoms of one’s negative mood. (1991)

• people who ruminate a great deal tend to have more lengthy

periods of depressive symptoms. They are also more likely to
develop full-blown episodes of major depressive disorder
(Nolen-Hoeksema, 2000; NolenHoeksema & Hilt, 2009).

• women are more likely to show a ruminative coping style

compared to men
 BIPOLAR AFFECTIVE DISORDER

• Beck (1967) suggested that mania was a mirror image of depression and was
characterized by a positive cognitive triad of self, world, and future.

• The self is seen as extremely loveable and powerful with unlimited potential and
attractiveness.

• The world is filled with wonderful possibilities and experiences were viewed as
overly positive. The future is full of unlimited opportunity and promise.

• Hyper-positive thinking (stream of consciousness) is characterized by cognitive

distortions
 Self –
I am
special

Positive
Cognitive
Triad of
Mania
World: Life Future:
is beautiful; Nothing is
there can be impossible
no danger for me

Positive Cognitive Triad of Mania

(Beck,1967)
 BANDURA'S SOCIAL COGNITIVE THEORY OF
DEPRESSION
• Depressed people's self-concepts are different from
non-depressed people's self-concepts.

• Consider themselves solely responsible for bad things in

their lives

• Full of self-recrimination & self-blame

• Low levels of self-efficacy

Humanist Paradigm to
depression

• Anything that blocks our striving to fulfill the need

to self-actualize can be a cause of depression.

• What could cause this – Parents imposing conditions

of worth on their children. I.e. rather than accepting
the child for who s/he is and giving unconditional
love, parents make love conditional on good
behavior.
Existentialists Paradigm to
depression

• Existentialists view emotional disorder as a response to the

difficulties of coping with freedom.

• This freedom necessitates that a person is responsible for the

choices that he makes which govern the quality of his life.

• Man can obstruct an awareness of his freedom and his resultant

responsibility only through a process of self-denial that results
in personal alienation and loss of self.
 Stress-Diathesis model
• (Ingram, Miranda & Segal, 1998; Ingram, Atchley, & Segal, 2011).
• The stress-diathesis model states that all individuals have varying degrees of
“diathesis” or vulnerability to depression.
• The extent to which one is vulnerable to developing depressive symptoms
depends on a number of factors, such as negative cognitive processes
(Abramson, Metalsky, & Alloy, 1989) and family history of depression
(Husain et al., 2009).
• The diathesis alone does not cause the onset of depression, but it can be
triggered when individuals experience stressful life events (Ingram, Atchley,
& Segal, 2011).
• The stress-diathesis model thus represents a linear relationship in that as
individuals experience more stress, they are more vulnerable to developing
depressive symptoms (Ingram, 14 Miranda, & Segal, 1998).
© 2015 John Wiley & Sons, Inc. All rights reserved.

Social Factors
Life events
• Prospective research
• 42-67% report a stressful life event in year prior to depression onset
• e.g., romantic breakup, loss of job, death of loved one
• An important distinction has been made between stressful life events that are independent of the
person’s behavior and personality
I. (independent life events- losing a job because one’s company is shutting down
II. (dependent life events) - being unable to resolve conflicts with a spouse

Interpersonal difficulties
• High levels of expressed emotion by family member predict relapse
• Marital conflict also predicts depression
• lonely, socially isolated, or lacking social support are more vulnerable to being depressed.
 Bipolar Disorder
Treatment
• Psychoeducation:
▪ Causes
▪ Symptoms & course
▪ Different treatments and risks vs no treatment
• Importance of sleep hygiene and routine
• Evidence base: few studies on pre-pubertal children or with
comorbid disorders
• Acute treatment:
▪ Mood stabilizers=lithium, anticonvulsants and antipsychotics
▪ Start low and go slow
▪ Doses similar to adults
Treatment: Sleep Hygiene
• Maintain regular sleep routine: same bedtime and wake time
• Avoid naps
• Do not stay in bed awake for more than 5-10 minutes; move to
a chair in the dark
• Do not watch TV or read in bed
• Avoid substances that interfere with sleep: caffeine, cigarettes,
alcohol, over the counter medications
• Exercise before 2 pm everyday, not before bed
• Have a quiet, comfortable bedroom
• Hide the clock if you are a clock watcher
• Have a comfortable pre-bedtime routine
 Bipolar Disorder
Psychosocial Treatments
• Supportive psychotherapy necessary for all youth with
BD and families
• Specific treatments help with
▪ Psychoeducation
▪ Management of acute manic and depressive symptoms
▪ Improvement of coping skills
▪ Adherence to treatment
▪ Management of comorbid conditions: oppositional
behaviors, substance abuse, anxiety disorders
▪ Prevention of recurrences
• Currently: 5 lines of overlapping psychosocial
therapies for specific ages and intervention methods
 Bipolar Disorder
Treatment: Psychotherapy
• West et al (2007)Child and Family Focused Cognitive
behavior Therapy (CFF-CBT)
• Fristad (2006) Multi-family Psychoeducation Groups
(MFPG) and Individual Family Psychoeducation (IFP)
• Miklowitz et al (2011) Family Focused Therapy (FFT)
specifically for adolescents with BD (FFT-A)
• Goldstein et al adapted Dialectical Behavior Therapy (DBT)
for the treatment of adolescents
• Hlastala et al (2010) adapted Interpersonal and Social
Rhythm Therapy (IPSRT)
 IPSRT
• Interpersonal and Social Rhythm Therapy (IPSRT) helps people improve
their mood and overall mental health by building a regular routine and improving
their interpersonal relationships.
• Sleep disruption and stress can both increase the chance of hypomania or mania. Since IPSRT
can reduce sleep irregularities and ease stress, it can be an effective treatment for bipolar
disorder.
• Social rhythm metrics are used in IPSRT to keep track of a person’s daily activities,
engagements, and responsibilities. Developing this set routine can help a client and their
therapist understand how certain social disruptions can impact their sleep, depression
symptoms, or stress levels.
Bipolar Disorder
Pharmacotherapy:
Acute manic & mixed episodes
• Monotherapy with lithium, valproate or carbamazepine
▪ Comparable for non psychotic mania/mixed episodes
▪ Manic symptoms response 23-55%
▪ Lithium=1st approval for mania (age 12-17) by US
Food & Drug Administration (US FDA)
• Secondary Generation Antipsychotics (SGAs)
▪ Manic/mixed symptoms response 33-75%
▪ May yield quicker response
▪ FDA approvals:
o Risperidone for age 10-17
o Olanzapine for age 13-17
o Aripiprazole for age 10-17
o Quetiapine for age 10-17
 Bipolar Disorder
Pharmacotherapy: Lithium (Li)

• Narrow therapeutic window: blood levels 0.6-1.2 mEq/L

• Toxicity signs: dizziness, clumsiness, unsteady gait, slurred
speech, coarse tremors, abdominal pain, vomiting,
sedation, confusion, blurred vision
• Common side effects: Tremor, weight gain, nausea,
diarrhea, hypothyroidism, cognitive dulling, sedation, Fluid
loss, marijuana
• Alcohol: increase Li levels
• Caffeine lowers Li levels
• Obtain blood levels 4-5 days after dose changes, or every
3-6 months
 CONCLUSION
• Affective disorders remain one of the most commonly occurring mental illnesses in adults.
• It is often undiagnosed and untreated.
• Knowledge and awareness about the underlying theories would allow an insight into the cause
of the illness.
• This would further assist us to make predictions about treatment mechanisms and outcomes.
• Hence understanding the theoretical backgrounds is crucial.
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