Psychopathology

You are required to write an individual term essay on one of the fivegiven mental disorders: Schizoaffective, Bipolar Disorders, Borderline Personality Disorder, Obsessive-Compulsive and Related Disorders, and Alzheimers Disease. Include in your report a criticalreview of issues related to:(1) diagnostic criteria (5%); (2) conceptualization based on your theoretical perspective(s) (5%); (3)special concerns from the legal/ethical issues (5%); (4) assessment and treatment issues (15%); (5) current research of the disorder (10%); [References: 8%; APA format: 4%; Overall writing style: 8%] Due date: 30November 2020, 7:00 pm Asoftcopy of the assignment should be submittedonline. No hardcopy is required.Ithas to be in MS Word format and throughTurnitin in Canvas. Withinthe limit of 3000 words (References included, but excluding covering page) No grade/ mark will be given if the paper exceeds the 3000 word-limit

Mood Disorders

Marcus Y.L. Chiu

City University of Hong Kong

Sources: Most materials are from DSM-5, and

Durand, Barlow & Hofmann (2017)

Outline

• Understanding Mood Disorders

• Prevalence of Mood Disorders

• Causes of Mood Disorders

• Treatment of Mood Disorders

• Suicide

Focus Questions

• What are the clinical features of mood disorders?

• How does the prevalence of mood disorders

change across the lifespan?

• What factors contribute to the development of

mood disorders?

• What treatments exist for mood disorders?

• What is the relationship between suicide and mood

disorders?

An Overview of Depression and Mania

• Mood disorders = gross deviations in mood

• Composed of different types of mood “episodes”:

periods of depressed or elevated mood lasting days

or weeks, including:

– Major depressive episodes

– Persistent depression

– Manic and hypomanic episodes

DSM-5 Depressive Disorders

• Major depressive disorder

• Persistent depressive disorder

• New to DSM-5:

– Premenstrual dysphoric disorder

– Disruptive mood dysregulation disorder

DSM-5 Bipolar Disorders

• Bipolar I disorder

• Bipolar II disorder

• Cyclothymic disorder

DSM-5 Criteria: Major Depressive Episode

Features of a major depressive episode include the

following, occurring most of the day nearly every day

for at least 2 weeks:

• Depressed mood (may be irritable mood in children or

adolescents)

• Markedly diminished interest or pleasure in most daily

activities

• Significant weight loss when not dieting, weight gain, or

significant decrease or increase in appetite

• Insomnia or hypersomnia

• Noticeable psychomotor agitation or retardation

• Fatigue or loss of energy

• Feelings of worthlessness or excessive guilt

• Diminished ability to think, concentrate, or make decisions

• Recurrent thoughts of death, suicide ideation, or a suicide

attempt

• Clinically significant distress or impairment

• Symptoms are not due to the effects of a substance (e.g.,

drug abuse) or a general medical condition (e.g.,

hypothyroidism)

From American Psychiatric Association. (2013). Diagnostic and

Statistical Manual of Mental Disorders (5th ed.). Washington, DC.

DSM-5 Disorder: Manic Episode Features of a manic episode include the following:

• A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week

• Significant degree of at least three of the following: inflated self-esteem, decreased need for sleep, excessive talkativeness, racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in high-risk behaviors

• Mood disturbance is severe enough to cause impairment in normal functioning or requires hospitalization, or there are psychotic features

• Symptoms are not caused by the direct physiological effects of a substance or a general medical condition

Types of Mood Episodes

• Major depressive episode

– Extremely depressed mood and/or loss of pleasure

(anhedonia)

 Lasts most of the day, nearly every day for at least 2

weeks

– At least four additional physical or cognitive

symptoms:

 E.g., indecisiveness, feelings of worthlessness,

fatigue, appetite change, restlessness or feeling

slowed down, sleep disturbance

Types of Mood Episodes

• Manic episode

– Elevated, expansive mood for at least 1 week

– Inflated self-esteem, decreased need for sleep,

excessive talkativeness, flight of ideas or sense that

thoughts are racing, easy distractibility, increase in

goal-directed activity or psychomotor agitation,

excessive involvement in pleasurable but risky

behaviors

– Impairment in normal functioning

Types of Mood Episodes

• Hypomanic episode

– Shorter, less severe version of manic episodes

– Last at least 4 days

– Have fewer and milder symptoms

– Associated with less impairment than a manic

episode (e.g., less risky behavior)

– May not be problematic in and of itself, but usually

occurs in the context of a more problematic mood

disorder

Types of Mood Episodes

• “Mixed features” = term for a mood episode with

some elements reflecting the opposite valence of

mood

– Example: Depressive episode with some manic

features

– Example: Manic episode with some

depressed/anxious features

Major Depressive Disorder: An Overview

• Clinical features

– One or more major depressive episodes separated

by periods of remission

– Single episode—highly unusual

– Recurrent episodes—more common

• From grief to depression

– Previously could not be diagnosed during periods of

mourning

– Now recognized that major depression may occur as

part of the grieving process

Persistent Depressive Disorder: An Overview

• At least 2 years of depressive symptoms

– Depressed mood most of the day on more than 50%

of days

– No more than 2 months symptom free

– Symptoms can persist unchanged over long periods

(≥20 years)

– May include periods of more severe major

depressive symptoms

 Major depressive symptoms may be intermittent or

last for the majority or entirety of the time period

Persistent Depressive Disorder: An Overview

• Types of PDD

– Mild depressive symptoms without any major

depressive episodes (“with pure dysthymic

syndrome”)

– Mild depressive symptoms with additional major

depressive episodes occurring intermittently

(previously called “double depression”)

– Major depressive episode lasting 2+ years (“with

persistent major depressive episode”

Premenstrual Dysphoric Disorder

Features of premenstrual dysphoric disorder include the

following:

• In the majority of menstrual cycles, at least five symptoms

must be present in the final week before the onset of menses,

start to improve within a few days after the onset of menses,

and become minimal or absent in the week post menses

• One (or more) of the following symptoms must be present:

– marked affective lability (e.g., mood swings)

– marked irritability or anger

– marked depressed mood

– marked anxiety and tension

Premenstrual Dysphoric Disorder

• One (or more) of the following symptoms must

additionally be present, to reach a total of five

symptoms when combined with symptoms above:

– Decreased interest in usual activities

– Difficulty in concentration

– Lethargy, fatigability, lack of energy

– Marked change in appetite, overeating, or specific food

cravings;

– Hypersomnia or insomnia

– A sense of being overwhelmed or out of control

– Physical symptoms such as breast tenderness or weight

gain

Premenstrual Dysphoric Disorder

• Clinically significant distress or interference with

work, school, usual social activities, or relationships

• Symptoms are not attributable to the effects of a

substance (e.g., drug abuse) or another medical

condition

From American Psychiatric Association. (2013). Diagnostic

and statistical manual of mental disorders (5th ed.).

Washington, DC.

• Premenstrual Dysphoric Disorder

– Significant depressive symptoms occurring prior to

menses during the majority of cycles, leading to

distress or impairment

– Controversial diagnosis

 Advantage: Legitimizes the difficulties some women

face when symptoms are very severe

 Disadvantage: Pathologizes an experience many

consider to be normal

Other Depressive Disorders

• Disruptive Mood Dysregulation Disorder

– Severe temper outbursts occurring frequently,

against a backdrop of angry or irritable mood

– Diagnosed only in children aged 6 to 18 years

– Criteria for manic/hypomanic episode are not met

– Designed in part to combat overdiagnosis of bipolar

disorder in youth

Disruptive Mood Dysregulation Disorder

Features of disruptive mood dysregulation disorder

include the following:

• Severe temper outbursts occurring three or more times

per week for at least 1 year, manifested verbally and/or

behaviorally that are out of proportion in intensity or

duration to the situation and are inconsistent with

developmental level

• The mood between temper outbursts is persistently

irritable or angry most of the day, nearly every day, is

observable by others in at least two of three settings

(i.e., at home, at school, with peers), and is severe in at

least one of these settings

Disruptive Mood Dysregulation Disorder

• The diagnosis should not be made for the first time

before age 6 years or after age 18 years

• There has never been a distinct period lasting more

than 1 day during which the full symptom criteria,

except duration, for a manic or hypomanic episode have

been met

• The symptoms are not attributable to the physiological

effects of a substance or to another medical or

neurological condition

From American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Washington, DC.

Bipolar I Disorder: An Overview

• Overview and defining features

– Alternations between full manic episodes and major

depressive episodes

• Facts and statistics

– Average age of onset is 15 to 18 years

– Can begin in childhood

– Tends to be chronic

– Suicide is a common consequence

Bipolar II Disorder: An Overview

• Overview and defining features

– Alternations between major depressive and

hypomanic episodes

• Facts and statistics

– Average age of onset is 19 to 22 years

– Can begin in childhood

– 10% to 25% of cases progress to full bipolar I

disorder

– Tends to be chronic

Bipolar II Disorder

Features of bipolar II disorder include the following:

• Presence (or history) of one or more major depressive

episodes

• Presence (or history) of at least one hypomanic episode

• No history of a full manic episode

• Mood symptoms are not better accounted for by

another mental disorder

• Clinically significant distress or impairment of

functioning

From American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Washington, DC.

Cyclothymic Disorder

Features of cyclothymic disorder include the following: • For at least 2 years, numerous periods with hypomanic symptoms

and numerous periods with depressive symptoms that do not meet

the criteria for a major depressive episode

• Since onset, the person has not been without the symptoms for

more than 2 months at a time

• No major depressive episode, manic episode, or hypomanic

episode has been present during the first 2 years of the

disturbance

• Mood symptoms are not better accounted for by another mental

disorder, the physiological effects of a substance, or a general

medical condition

• Clinically significant distress or impairment of functioning

Cyclothymic Disorder: An Overview • Overview and defining features

– Chronic version of bipolar disorder

– Alternating between periods of mild depressive

symptoms and mild hypomanic symptoms

 Episodes do not meet criteria for full major

depressive episode, full hypomanic episode or full

manic episode

– Hypomanic or depressive mood states may persist

for long periods

– Must last for at least 2 years (1 year for children and

adolescents)

Cyclothymic Disorder: An Overview

• Facts and statistics

– Average age of onset is 12 to 14 years

– More common among females

– Cyclothymia tends to be chronic and lifelong

– One third to one half develop full-blown bipolar

Prevalence of Mood Disorders

• Worldwide lifetime prevalence

– 16% for major depression

 6% have experienced major depression in last year

• Sex differences

– Females are twice as likely to have major

depression

– Bipolar disorders approximately equally affect males

and females

– Women more likely to experience rapid cycling

– Women more likely to be in depressive period

Prevalence of Mood Disorders

• Occurs less often in prepubertal children

• Rapid rise in adolescents

• Adults over 65 have about 50% less prevalence

than general population

• Bipolar same in childhood, adolescence, and adults

• Prevalence of depression seems to be similar

across subcultures

Life Span Developmental Influences on

Mood Disorders

• Three-month-olds can show depressive symptoms

• Young children typically don’t show classic mania or

bipolar symptoms

• Mood disorder may be misdiagnosed as ADHD

• Children are being diagnosed with bipolar at

increasingly high rates

Life Span Developmental Influences

• Depression in elderly between 14% and 42%

– Co-occurence with anxiety disorders

– Less gender imbalance after 65 years of age

• Cultural differences exist

– Hopi say they are “heartbroken”

– Native American population have four times the rate

of depressive disorders as the general population

Familial and Genetic Influences

• Family studies

– Rate is high in relatives of probands

– Relatives of bipolar probands are more likely to have unipolar depression

• Twin studies

– Concordance rates are high in identical twins

 Two to three times more likely to present with mood disorders than a fraternal twin of a depressed cotwin

– Severe mood disorders have a strong genetic contribution

– Heritability rates are higher for females compared to males

Mood Disorders: Familial and Genetic

Influences

• Twin studies

– Vulnerability for unipolar or bipolar disorder

 Appears to be inherited separately

– Some genetic factors are common for mood and

anxiety disorders

Neurobiological Influences

• Neurotransmitter systems

– Serotonin and its relation to other neurotransmitters

 Serotonin regulates norepinephrine and dopamine

– Mood disorders are related to low levels of serotonin

– Permissive hypothesis: Low serotonin “permits”

other neurotransmitters to vary more widely,

increasing vulnerability to depression

Neurobiological Influences

• The endocrine system

– Elevated cortisol

– Stress hormones decrease neurogenesis in the

hippocampus > less able to make new neurons

• Sleep disturbance

– Hallmark of most mood disorders

– Depressed patients have quicker and more intense

REM sleep

– Sleep deprivation may temporarily improve

depressive symptoms in bipolar patients

Psychological Dimensions (Stress)

• Stressful life events

– Stress is strongly related to mood disorders

 Poorer response to treatment

 Longer time before remission

– Context of life events matters

– Gene-environment correlation: People who are

vulnerable to depression might be more likely to

enter situations that will lead to stress

– The relationship between stress and bipolar is also

strong

Context and Meaning Life Stress Situation

FIGURE 6.1 Context and meaning in life stress

situations.

Mood Disorders: Psychological Dimensions

(Learned Helplessness)

• The learned helplessness theory of depression

– Lack of perceived control over life events leads to

decreased attempts to improve own situation

– First demonstrated in research by Martin Seligman

– Negative cognitive styles are a risk factor for

depression

Mood Disorders: Depressive Attributional

Style

• Internal attributions

– Negative outcomes are one’s own fault

• Stable attributions

– Believing future negative outcomes will be one’s

fault

• Global attribution

– Believing negative events will disrupt many life

activities

• All three domains contribute to a sense of

hopelessness

Psychological Dimensions (Cognitive Theory)

• Negative coping styles

– Depressed persons engage in cognitive errors

– Tendency to interpret life events negatively

• Types of cognitive errors

– Arbitrary inference—overemphasize the negative

aspects of a mixed situation

– Overgeneralization—negatives apply to all situations

Psychological Dimensions (Cognitive Theory)

• Cognitive errors and the depressive cognitive triad

– Think negatively about oneself

– Think negatively about the world

– Think negatively about the future

The Depressive Cognitive Triad

FIGURE 6.2 The depressive cognitive triad.

Social and Cultural Dimensions

• Marital relations

– Marital dissatisfaction is strongly related to

depression

– This relation is particularly strong in males

• Social support

– Extent of social support is related to depression

– Lack of social support predicts late onset depression

– Substantial social support predicts recovery from

depression

Gender Differences in Mood Disorders

• Women account for 7 out of 10 cases of major

depressive disorder

• Recall that women also have higher rates of anxiety

disorders

• Possible explanations for gender disparity

– Women socialized to have stronger perception of

uncontrollability

– Parenting style makes girls less independent

– Women more sensitive to relationship disruptions

(e.g., breakups, tension in friendships)

– Women ruminate more than men

Odds Ratio of Major Depressive Episode per

Country

An Integrative Theory

• Shared biological vulnerability

– Overactive neurobiological response to stress

• Inadequate coping and depressive cognitive style

– Diathesis-stress model

• Biological, psychological, and social factors all

influence the development of mood disorders

• Exposure to stress

An Integrative Model of Mood Disorders FIGURE 6.1 An integrative

model of mood disorders.

Treatment : Medication • Antidepressants

– Selective serotonin reuptake inhibitors

– Tricyclic antidepressants

– Monoamine oxidase inhibitors

– Mixed reuptake inhibitors (e.g., serotonin/norepinephrine reuptake inhibitors)

• Approximately equally effective

– Only 50% of patients benefit

– Only 25% achieve normal functioning

• Called SSRIs

• Specifically block reuptake of serotonin so more serotonin is available in the brain

– Fluoxetine (Prozac) is the most popular SSRI

• SSRIs pose some risk of suicide particularly in teenagers

• Negative side effects are common

Tricyclic Antidepressants

• Include Tofranil, Elavil

• Mechanisms not well understood

– Block reuptake Norepinephrine and other

neurotransmitters

• Negative side effects are common (e.g.,

drowsiness, weight gain)

– Discontinuation is common

• May be lethal in excessive doses

Mixed Reuptake Inhibitors

• Block reuptake of norepinephrine as well as

serotonin

• Best known is venlafaxine (Effexor)

• Have fewer side effects than SSRIs

Monoamine Oxidase (MAO) Inhibitors

• Block monoamine oxidase

• This enzyme breaks down

serotonin/norepinephrine

• As effective as tricyclics, with fewer side effects

• Dangerous in combination with certain foods

– Beer, red wine, cheese cannot be consumed;

patients dislike dietary restrictions

– Also dangerous in combination with cold medicine

Treatment of Mood Disorders: Lithium

• Lithium carbonate = a common salt

• Treatment of choice for bipolar disorder

• Considered a mood stabilizer because it treats

depressive and manic symptoms

• Toxic in large amounts

– Dose must be carefully monitored

• Effective for 50% of patients

• Why lithium works remain unclear

Electroconvulsive Therapy (ECT)

• Effective for medication-resistant depression

• The nature of ECT

– Brief electrical current applied to the brain

– Results in temporary seizures

– Usually 6 to 10 outpatient treatments are required

• Side effects:

– Short-term memory loss, which is usually restored

– Some patients suffer long-term memory loss

• Mechanism is unclear

Transcranial Magnetic Stimulation

• Uses magnets to generate a precise localized

electromagnetic pulse

• Few side effects; occasional headaches

• Less effective than ECT for medication-resistant

depression

• May be combined with medication

Psychosocial Treatments for Depression

• Cognitive-behavioral therapy

– Addresses cognitive errors in thinking

– Also includes behavioral components

• Interpersonal psychotherapy

– Focus: Improving problematic relationships

• Prevention

– Preemptive psychosocial care for people at risk

• Has longer-lasting effectiveness than medication

Psychosocial Treatments for Bipolar Disorders

• Medication (usually Lithium) is still first line of defense

• Psychotherapy helpful in managing the problems (e.g., interpersonal, occupational) that accompany bipolar disorder

• Family therapy can be helpful

Suicide: Facts and Statistics

• Eleventh leading cause of death in the United

States

– Underreported; actual rate may be 2x to 3x higher

• Most common among white and native Americans

• Particularly prevalent in young adults

– Third leading cause of death among teenagers

– Second leading cause of death in college students

– 12% of college students consider suicide in a given

year

Suicide: Facts and Statistics

• Gender differences

– Males complete more suicides than females

– Females attempt suicide more often than males

– Disparity is due to males using more lethal methods

– Exception: Suicide more common among women in

China

 May reflect cultural acceptability; suicide is seen as

an honorable solution to problems

Risk Factors

• General Risk Factors – Suicide in the family

– Low serotonin levels

– Preexisting psychological disorder

– Alcohol use and abuse

– Stressful life event, especially humiliation

– Past suicidal behavior

– Plan and access to lethal methods

– Older white man

• Specific Risk Factors

– Substance abuse

– Elderly with acute or

chronic illness

– Cancer or AIDS patients

– Pregnant/ delivered women

– Transexual persons

– EMA cases

– With cultural beliefs that

there is another life after

death

– Psychiatrists

Factor Contributing to Suicidal Behavior

FIGURE 6.5 Factor contributing to suicidal behavior. 62

Suicide Contagion

• Some research indicates that a person is more

likely to commit suicide after hearing about

someone else committing suicide

• Media accounts may worsen the problem by

– Sensationalizing/romanticizing suicide

– Describing lethal methods of committing suicide

Suicide Prevention

• In professional mental health – Clinician does risk assessment (ideation, plans, intent,

means, etc.)

– Clinician and patient develop safety plan (e.g., who to call, strategies for coping with suicidal thoughts)

– In some cases, sign no-suicide contract

• Preventative programs for at-risk groups

• Important: removing access to lethal methods

• If you think someone is at risk, talk to them and ensure they’re getting needed support – Talking to someone about suicide is not likely place them

at greater risk or “plant the idea”

– In contrast, the risk of not providing support to someone who may be in need is huge

Suicide support line/ Programmes

Agency Support

The Samaritans (multilingual) Hotline: +852 28 960 000

Samaritans Befrienders HK Hotline: +852 2389 2222

Mental Health Hotline, HA： 2466 7350

Social Welfare Department Hotline： 2343 2255

TWGHs CEASE Crisis Centre ： 18281

WeCare Fund 2017 for Student-Initiated Youth Suicide

Prevention Projects

Summary of Mood Disorders

• All mood disorders share:

– Gross deviations in mood

– Common biological and psychological vulnerability

• Occur in children, adults, and the elderly

• Onset, maintenance, and treatment are affected by

– Stressful life events

– Social support

– Differential response to medication

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