Mood Disorders

 

Euthymia disrupted by:

 

á   Dysphoria (disordered sadness)

 

á   Euphoria (disordered happiness)

 

á   Irritability (disordered anger)

 

 

 

2 Major Types of Mood Disorders

 

á   Major Depressive Disorder

 

(unipolar depression)

 

 

á   Bipolar Disorder

 

(manic-depression; bipolar depression)

 

 

 

 

Major Depressive Disorder (MDD)

 

á   Central symptom:

 

Disproportionate sadness or loss of interest in pleasure

 

á   Temporal condition:

 

Symptoms occur most of day nearly every day for 2 weeks & is a change from previous functioning

 

 

 

Major Depressive Disorder

 

Plus at least 4 of the following 7:

 

á    Significant weight loss or gain when not dieting

á    Insomnia or hypersomnia

á    Psychomotor agitation or retardation

á    Fatigue or loss of energy

á    Feelings of worthlessness or excessive/inappropriate guilt

á    Diminished ability to think, concentrate, or make decisions

á   Recurrent thoughts of death or suicide; suicide plan or attempt (15% with MDD commit suicide)

 Major Depressive Disorder

 

Characteristics

 

á    Untreated lasts 6 months to 2  years

 

á    Recurrent among 80% w/ MDD

 

á    Lifetime prevalence rates range from 5.2% to 17.1%

 

 

Temporal vagueness for establishing prevalence:

 

Nelson & Heiby (2001) found 0 – 5 MDD episodes in 6 months  of hourly ratings by the same person

 

Major Depressive Disorder

 

Suicide as a symptom of MDD

 

á   Recall, 15% of people with MDD commit suicide

 

á   MDD is a very lethal behavioral disorder

 

á   Some accidental deaths may be suicides, so statistics are not accurate

 

 

 

Major Depressive Disorder

 

Suicide contÕd

 

á    Rate of suicide in the U.S. is 0.00012% [12 per 100,000]

 

á    Rate increases to 0.00024% for people between age 75 and 84, making depression among elders of particular concern [24 per 100,000]

 

á    Suicide is 9th cause of death among adults in U.S.

 

á    Suicide is the 3rd cause of death those 15-24 y/o

 

Major Depressive Disorder

 

Psychological Autopsies: Suicide Notes 

 

To whom it may concern: I live at 400 Oak Drive, Cincinnati, Ohio. You will find on the kitchen table a letter with instructions to my wife on the disposition of my estate. Please notify all of my friends. Do not mourn me. H. Smith. 

 

I thought things would work out between us, but now I see that they won't. I thought you were the only one for me, but now I see differently. Couldn't you have understood my unhappiness. Why didn't you care? Perhaps we'll meet together in the next world. Bill. 

 

 Major Depressive Disorder

 

Risk factors for suicide:

 

á   Plan and resources to execute plan

á   History of suicide attempt

á   Putting affairs in order

á   Unexplained elevation of mood

á   MDD

á   Male

 

 

 

Major Depressive Disorder Etiology

 

 

Psychoanalytic Paradigm

 

á   Fixation during the oral stage of development when dependent and no reality distinction (id)

 

á   Fixation because childÕs primitive needs are either under gratified or over gratified

 

 

Major Depressive Disorder Etiology

 

Empirical status of Psychoanalytic Paradigm

 

á   No measure of psychic energy or fixation

 

á   No measure of "anger turned inward" or introjection

 

á   Can measure dependency

 

á   Some evidence that some w/ MDD also dependent

 

 

Major Depressive Disorder Etiology

 

Biological Paradigm

 

á   Genetic Transmission

o   first degree relatives of people with MDD are 2 – 3 times more likely to also exhibit MDD than are first degree relatives of people without MDD (Klein et al., 2001)

o   higher concordance rate of MDD among monozygotic twins than dizygotic twins

o   concordance rate of MDD is 13% for monozygotic twins

o   adoption studies much lower concordance

o   over 87% environmental

o what is genetically transmitted for risk is unknown

 

Major Depressive Disorder Etiology

 

Biological Paradigm contÕd

 

á   Neurotransmitter Dysregulation

o Deficient levels of serotonin and norepinephrine neurotransmitters

o Lacasse & Leo (2005) no evidence of neurotransmitter deficiency

o Error of etiological inference from effect of psychoactive drugs

o Normal amount of neuro. unknown

Major Depressive Disorder Etiology

 

Biological Paradigm contÕd

á    Anti-depressant medications interfere w/ reuptake of serotonin & norepinephrine

á    Tricyclic drugs (e.g., imipramine or Tofranil) and Monoamin oxidase (MAO) inhibitors (e.g., tranylcypromine or Parnate) implicate both neurotransmitters

á    Selective Serotonin Reuptake Inhibitors (SSRIs) increase level of serotonin only (e.g., fluoxetine/Prozac)

á   All 3 types of anti-depressants result in improvement in about 50% to 70% of cases of MDD if the person remains on the drug VS. 50% placebo

 

Major Depressive Disorder Etiology

 

Humanistic/Existential Paradigm

 

á    Depression results when a person no longer strives to self-actualize

á    Lack of goals in life

á    Life has lost meaning

á    Treatment is to provide acceptance and empathy as well as interpretation that one is responsible for own existence and happiness and goals/meaning of life

á    Effectiveness: necessary but not sufficient

 

Major Depressive Disorder Etiology

 

Cognitive Behavioral Paradigm

 

o Depressogenic environment

o Mood regulation skills deficits

o Cognitive dysfunctions

 

á   All have empirical support

 

 

 

Major Depressive Disorder Etiology

 

Cognitive Behavioral Paradigm contÕd

Depressogenic Environment

 

1. Excessively low reinforcement (ratio strain)

2. No relation between behavior and desired consequence    3. Contingent reinforcement for depressive behavior

4. Reduction in sources of environmental reinforcement that places much of the individualÕs adaptive behavior on an extinction schedule

5. Punishment of large classes of behavior

 

 

 

Major Depressive Disorder Etiology

Cognitive Behavioral Paradigm contÕd

Mood Regulation Skills Deficits

 

6. Social skills

7. Self-control skills

8. Academic and/or occupational skills

9. Learn the environmentsÕ behavior – consequence contingencies

10. Recreational activities

11.  Problem-solving skills

 

 

 

Major Depressive Disorder Etiology

Cognitive Behavioral Paradigm contÕd

Cognitive Dysfunctions

 

Depressogenic cognitive schema = Negative Triad

= Negative  Biases = Misattributions:

 

Arbitrary inference

Selective abstraction

Overgeneralization

Magnification & minimization

 

Major Depressive Disorder Etiology

Cognitive Behavioral Paradigm contÕd

 

 

e.g., Varese et al. (1998)

 

-female prisoners (depressogenic environment)

-rate of MDD = 66% (vs. 20% gen. female pop.)

-those prisoners with MDD:

     -deficit social skills (aggressive vs. assertive)

     -deficit self-control skills

     -cognitive dysfunctions

Cognitive Behavioral TxÕs of MDD

 

á   Environmental engineering

 

á   Skills training: social, self-control, academic, occupational, self-efficacy, problem-solving

 

á   Cognitive restructuring

 

 

Major Depressive Disorder

Treatments for MDD

 

á   Biological-some empirical support for short-term effects of anti-depressants; some support for ECT, electroconvulsive therapy

á   Psychoanalytic no empirical support

á   Humanistic-basic elements only supported

á   Cognitive-behavioral:  some support

á   Combine antidepressant and CBT:

Medication for short-term

CBT for long-term

Future Directions for Treatment  of MDD

 

No general tx for all cases of MDD

Deficit-tx matching = subtypes of MDD based on etiology

 

For example, Heiby (1985):

 

á    4 depressed clients

á    2 had social skills deficits

á    2 had self-control skills deficits

á    All 4 received social skills and self-control skills training

á    2 were matched to tx and 2 were unmatched to tx in first phase

á    In second phase of study, txÕs were reversed

á    Depression decreased to non-clinical level only when tx matched mood regulation skill deficit

 

 

Mood Disorders

Bipolar Disorder

 

á   Involves episodes of mania and episodes of depression

 

á   In some cases, mania only

 

á   Mania = maladaptive euphoria or anger

 

 

Bipolar Disorder

 

Mania

 

1.  Abnormally & persistently elevated, expansive or irritable mood lasting at least 1 week

 

30% show euphoria only,

8% irritability only,

62% both euphoria and irritability

 

 

Bipolar Disorder

 

Mania conÕd

 

2. While mood is euphoric or irritable, 3-4 of the following 7:

 

á    Inflated self-esteem or grandiosity

 

á    Decreased need for sleep

 

á    More talkative than usual; speech is pressured

 

á    Flight of ideas;  thoughts are racing

 

Bipolar Disorder

 

Mania contÕd

 

á    Distractibility

 

á    Increase in goal-directed activity or psychomotor agitation

 

á   Excessive involvement in risky pleasurable activities
 Bipolar  Disorder

 

Other characteristics of BD:

 

Person does not recognize behavior is abnormal

 

Often resist treatment

 

May travel impulsively and lose contact with family and friends

 

May change appearance to be more sexually suggestive or flamboyent

 

Bipolar Disorder

 

Other characteristics contÕd

 

á   May engage in disorganized or bizarre behavior such as distributing money to strangers

 

á   Gambling

 

á   Antisocial behavior

 

á   Ethical concerns may be disregarded

 

 

Bipolar Disorder

 

Prevalence of BD

 

á   Lifetime estimates vary from 0.4% to 1.6%

 

á   30% euphoria only

 

á   8% irritability only

 

á   62% both euphoria and irritability

 

 Bipolar Disorder

 

Paradigms of the etiology and treatment of BD

 

á   Most theorizing and research is on MDD

 

á   Generalize findings from MDD to the depressive phase of BD

 

 

 

 

 

Bipolar Disorder

Paradigms contÕd

 

Biological Etiology and  TX

 

á   Only researched treatment is medication

o Usual biological treatment is lithium bicarbonate which helps up to 80%  who remain on drug

o Mechanism unknown

o Side effects serious & must continue drug for benefits

o Poor compliance to treatment

 

 

 

 

Bipolar Disorder

Paradigms contÕd

 

Biological Etiology conÕd

 

 

á    Genetic

o  72% concordance rate in monozygotic twins (VS. 13% for MDD)--ˆ28% environmental

o  14% concordance rate in dizygotic twins

o  Need adoption studies

o  what may be transmitted is unknown

 

 

 

 

Bipolar Disorder

 

Paradigms contÕd

 

á    Psychoanalytic: mania is defense mechanism for depression

á    Humanistic/Existential:  need to self-actualize

á    Cognitive-behavioral: only focus is adherence to meds

á    Diathesis-stress

o  Psychological Behaviorism Theory (Reidel, H.P.R., Heiby,E.M., Kopetskie, S. (2001). Psychological behaviorism theory of bipolar disorder. The Psychological Record., 51, 507-532.)

 

Bipolar Disorder

Paradigms contÕd

Diathesis stress conÕd

 

á    Psychological Behaviorism Theory (PB)

o  Integrative "diathesis-stress" model of BD posited by Riedel, Heiby, & Kopetskie (2001)

o  PB theory of BD is guided by the theoretical framework of Arthur W. Staats (1975,1986, 1996), Professor Emeritus at UH Manoa

o  Asserts BP with euphoria is different from BP with irritability because extreme happiness and chronic anger are quite different emotional states with different causal and maintenance factors

 

Bipolar Disorder

 

Paradigms: Psychological Behaviorism Theory contÕd

 

á   Current version of theory is limited to BP with euphoria

 

á   Has not yet generated a body of research

 

á   Small population of people with BD slows investigations of all theories and is one reason few theories are proposed

 

Bipolar Disorder

Psychological Behaviorism Theory contÕd

 

Includes the following etiological factors:

 

á   biological (O1,O2,O3)

á   environmental (S1, S2)

á   personality (BBRs):

     language-cognitive

     verbal-emotional

     emotional-motivational

     sensory-motor

 

Psychological Behaviorism Theory

 

 

Bipolar

 
 

BBRÕsÕs
 
S1

Language-Cognitive

 

Verbal-Emotional

 

Emotional-Motivational

 

Sensory-Motor
 
                                                        

O3
 

S2
 

O2
 
O1  

 

 

 

 

Bipolar Disorder

Psychological Behaviorism Theory contÕd

 

á    Some etiological BBRs are adaptive

 

á    Biological, situational, & BBR variables are etiologic in BD

 

á    Cases of BD can be subtyped according to etiological factors.

 

á    Subtypes guide prevention & treatment programming

 

 

 

Bipolar Disorder

 

Hypotheses Generated by the PB Theory of BD

Biological factors

 

1. O1 conditions create vulnerability to extreme euphoria (e.g. inheritance of limbic system characteristics that create the potential for extreme euphoria).

2. O2 conditions may interfere with expression of BBRs necessary for mood regulation (e.g. uncontrolled diabetes).

3. Transient O3 conditions may precipitate the onset of bipolar symptoms (e.g., medication side effects and sleep deprivation)

Bipolar Disorder

Hypotheses Generated by the PB Theory of BD

Past situational factors (S1)

 

4. Bipolar individuals have had developmental histories in which significant others reinforced or modeled risky types of activities

 

5. Significant others  did not reinforce or model a cautious or realistic attitude towards the future but instead encouraged impulsivity and, perhaps, denial of consequences.

 

6. Significant others reinforced and modeled the use grandiose self-labeling and denial as ways to cope with stress as well as to enhance feelings of elation and confidence in response to superficial successes.

 Bipolar Disorder

Hypotheses Generated by the PB Theory of BD

Concurrent situational factors (S2)

 

7. .Manic episodes may be triggered by pleasant events, such as superficial successes (e.g., winning at gambling) as well as major successes (e.g., school honors, job promotion).

8. Lack of adequate social support systems that involve significant other who model and reinforce euthymic emotions, veridical self-labeling, and cautionary statements, and safe behavior.

9 .Significant others may provide reinforcement for elevated emotions, gradiose self-labeling, and risky behavior.

 

 

 

Bipolar Disorder

Hypotheses Generated by the PB Theory of BD

BBRs (Personality Variables)

Emotional-motivational BBR

 

10. Bipolar emotional responses to certain stimulus situations are excessive (i.e., non veridical).

 

11. Bipolar individuals respond with positive emotional arousal to situations that others would find threatening or anxiety provoking.

 

 

 

Bipolar Disorder

Hypotheses Generated by the PB Theory of BD

BBRs (Personality Variables)

Sensory-motor BBRs

 

12. Above average skills for engaging in risky types of activities, which produce short-term reinforcement and long-term punishment. (e.g., persuasive conversational techniques & manipulativeness).

 

13. Deficit social skills in maintaining adequate social support networks.

 

 

Bipolar Disorder

Hypotheses Generated by the PB Theory of BD

BBRs (Personality Variables)

Language-cognitive BBRs

 

14. Deficit in estimating long-term negative consequences (poor at assessing risks).

 

15. Tend to employ grandiose self-labeling and denial to elevate mood.

 

16. Poor problem solving skills