Overview of the major DSM-5 mood disorders
- 2 broad types of mood disorders: those that involve only depressive symptoms and those that involve manic symptoms (bipolar disorders)
- Major depressive disorder: Five or more depressive symptoms, including sad mood or loss of pleasure, for two weeks
- Persistent depressive disorder: Low mood and at least two other symptoms of depression at least half of the time for two years
- Premenstrual dysphoric disorder: Mood symptoms in the week before menses
- Disruptive mood dysregulation disorder: Severe recurrent temper outbursts and persistent negative mood for at least one year beginning before age 10
- Bipolar I disorder: At least one lifetime manic episode
- Bipolar II disorder: At least one lifetime hypomanic episode and one major depressive episode
- Cyclothymia: Recurrent mood changes from high to low for at least two years, without hypomanic or depressive episodes
- Psychomotor retardation: Thoughts and movements may slow for some
- Psychomotor agitation: others cannot sit still — they pace, fidget and wring their hands
Major depressive disorder
DSM-5 criteria for major depressive disorder
Sad mood or loss of pleasure in usual activities are a symptom of major depressive disorder.
Additional criteria includes experiencing at least five of the following symptoms (counting sad mood and loss of pleasure):
- sleeping too much or too little
- psychomotor retardation or agitation
- weight loss or change in appetite
- loss of energy
- feelings of worthlessness or excessive guilt
- difficulty concentrating, thinking or making decisions
- recurrent thoughts of death or suicide.
Symptoms are present nearly every day, most of the day, for at least two weeks. Symptoms are distinct and more severe than a normative response to significant loss.
- An episodic disorder: symptoms tend to be present for a period of time and then clear.
- Major depressive episodes tend to recur
- The average number of episodes is about four
- With every new episode that a person experiences, his or her risk for experiencing another episode goes up by 16 percent
Persistent depressive disorder
People with persistent depressive disorder are chronically depressed
DSM-5 criteria for persistent depressive disorder (dysthymia)
The criteria for persistent depressive disorder includes having a depressed mood for most of the day more than half of the time for two years (or one year for children and adolescents).
Individuals will experience at least two of the following symptoms during that time:
- poor appetite or overeating
- sleeping too much or too little
- low energy
- poor self-esteem
- trouble concentrating or making decisions
- feelings of hopelessness.
depressive disorder can be diagnosed if symptoms do not clear for more than two months at a time and bipolar disorders are not present.
Gender differences in depression
- Women are twice as likely as men are to experience depression
- The gender ratio is particularly pronounced in countries and cultural groups with more traditional gender roles.
- Twice as many girls as boys are exposed to childhood sexual abuse.
- During adulthood, women are more likely than men to be exposed to chronic stressors such as poverty and caretaker responsibilities.
- Acceptance of traditional social roles among girls may intensify self-critical attitudes about appearance.
- Exposure to childhood and chronic stressors, as well as the effects of female hormones, could change the reactivity of the HPA axis, a biological system guiding reactions to stress.
- Social roles promote emotion-focused coping among women, which may then extend the duration of sad moods after major stressors. Research suggests that rumination will intensify and prolong sad moods.
Other DSM 5 depressive disorders
- Disruptive mood dysregulation disorder
- Premenstrual dysphoric disorder
Epidemiology and consequences of depressive disorders
- MDD is one of the most common psychological disorders.
- MDD is three times as common among people who are impoverished.
- Different rates in different countries. One factor may be distance from the equator.
- Correlation of per-capita fish consumption with depression (lower).
- The symptom profile of a depressive episode also varies across cultures and one likely reason is the differences in cultural standards regarding acceptable expressions of emotional distress.
- Prevalence has increased over time
- Age onset has decreased over time
- Estimated that MDD is associated with $12.6 billion per year in lost productivity and job turnover in Australia.
- MDD also has important implications for the next generation: offspring who are exposed to their mother’s MDD during early childhood are at high risk for developing depression
Seasonal affective disorder
- Criteria for the seasonal specifier of MDD specify that a person experiences depression during two consecutive winters and that the symptoms clear during the summer.
- More common in northern than southern climates.
- Believed that seasonal affective disorder is related to changes in the levels of melatonin in the brain and sensitivity to light.
- Intriguingly, light therapy has been shown to help relieve depression even among those without a seasonal pattern to their depressions.
- MDD is also related to a high risk of other health problems (eg. cardiovascular)
- The DSM-5 recognises three forms of bipolar disorders: bipolar I disorder, bipolar II disorder and cyclothymic disorder.
- The bipolar disorders are differentiated by how severe and long-lasting the manic symptoms are.
- Mania: a state of intense elation, irritability or activation accompanied by other symptoms. During mania, people will act and think in ways that are highly unusual compared to their typical selves.
- They can also become excessively self-confident.
- May stop sleeping but remain incredibly energetic. Trying to stop it can be quickly met by anger.
: less extreme than — mania. hypomania involves a change in functioning that does not cause serious problems. The person with hypomania may feel more social, energised, productive and sexually alluring.
Bipolar I disorder and Bipolar II
- Bipolar I: In the DSM-5, the criteria for diagnosis of bipolar I disorder (formerly known as manic-depressive disorder) include a single episode of mania during the course of a person’s life.
- Even more than episodes of MDD, bipolar episodes tend to recur.
- More than half of people with bipolar I disorder experience four or more episodes during their lifetimes
Bipolar II: a milder form of bipolar disorder. A person must have experienced at least one major depressive episode and at least one episode of hypomania
(and no lifetime episode of mania).
- A chronic mood disorder
- The DSM-5 criteria require that symptoms be present for at least two years among adults.
- Person has frequent but mild symptoms of depression, alternating with mild symptoms of mania.
DSM-5 criteria for cyclothymic disorder
For at least two years (or one year in children or adolescents):
- numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode
- numerous periods with depressive symptoms that do not meet criteria for a major depressive episode
- The symptoms do not clear for more than two months at a time. Criteria for a major depressive, manic or hypomanic episode have never been met. Symptoms cause significant distress or functional impairment.
DSM 5 criteria for manic and hypomanic episodes
Criteria for manic and hypomanic episodes includes experiencing an elevated or irritable mood.
The person displays increased activity or energy, and at least three of the following are noticeably changed from baseline (four, if mood is irritable):
- increase in goal-directed activity or psychomotor agitation
- unusual talkativeness; rapid speech
- flight of ideas or subjective impression that thoughts are racing
- decreased need for sleep
- increased self-esteem; belief that one has special talents, powers or abilities
- distractibility; attention easily diverted
- excessive involvement in activities that are likely to have painful consequences, such as reckless spending, sexual indiscretions or unwise business investments
- symptoms are present most of the day, nearly every day.
- For a manic episode:
- symptoms last one week, require hospitalisation or include psychosis
- symptoms cause significant distress or functional impairment.
- For a hypomanic episode:
- symptoms last at least four days
- clear changes in functioning are observable to others, but impairment is not marked
- no psychotic symptoms are present.
Epidemiology and consequences of bipolar disorders
- Bipolar I disorder is much rarer than MDD.
- 0.6 percent people met the criteria for bipolar I disorder.
- More than half of those with bipolar spectrum disorders report onset before age 25.
- Although bipolar disorders occur equally often in men and women, women diagnosed with bipolar disorder experience more episodes of depression than do men with this diagnosis.
- About two-thirds of people diagnosed with bipolar disorder meet diagnostic criteria for a comorbid anxiety disorder and many report a history of substance abuse.
- Suicide rates are high for both bipolar I and bipolar II disorders.
- People with these disorders are at high risk for a range of other medical conditions.
Subtypes of depressive disorders and bipolar disorders
- The mood disorders are highly heterogeneous.
- The DSM-5 addresses this by providing criteria for dividing MDD and bipolar disorders into a number of specifiers (subtypes).
- Some based on pattern of episodes or the specific symptoms.
Aetiology of mood disorders- genetic factors
- Heritability estimates of 37 percent for MDD.
- Bipolar disorder is among the most heritable of disorders- heritability estimate of 93 percent.
- Likely due to the very small effects of any one gene, have failed to identify specific genes associated with MDD .
- several genetic polymorphisms related to bipolar disorder have been identified. These polymorphisms explain a very small proportion of the risk for bipolar disorder.
- Some people seem to inherit a propensity for a weaker serotonin system, which is then expressed as a greater likelihood to experience depression after childhood maltreatment or an adulthood severe stressor.
Aetiology of mood disorders- neurotransmitters
- People with depression are less responsive than other people are to drugs that increase dopamine levels and it is thought that the functioning of dopamine might be lowered in depression.
- Dopamine plays a major role in the sensitivity of the reward system in the brain.
- The diminished function of the dopamine system could help explain the deficits in pleasure, motivation and energy in depression.
Among people with bipolar disorder, several different drugs that increase dopamine
levels have been found to trigger manic symptoms
. One possibility is that dopamine receptors may be overly sensitive in bipolar disorder.
- Studies show that depleting tryptophan (and so lowering serotonin levels) causes temporary depressive symptoms among people with a history of depression or a family history of depression.
- Current thinking is that people who are vulnerable to depression may have less sensitive serotonin receptors, causing them to respond more dramatically to lower levels of serotonin.
Aetiology of mood disorders- Brain function: regions involved in emotion
- Functional brain-imaging studies suggest that episodes of MDD are associated with changes in many of the brain systems that are involved in experiencing and regulating emotion.
- Functional brain activation studies show elevated activity of the amygdala among people with MDD.
- This overreactivity is also shown in relatives, suggesting this may be a vulnerability to depression rather than just the aftermath of being depressed.
- MDD is associated with greater activation of the anterior cingulate and diminished activation of the hippocampus and dorsolateral prefrontal cortex when viewing negative stimuli.
- Disturbances in these regions are believed to interfere with effective emotion regulation.
- people with depression demonstrate diminished activation of the striatum during exposure to emotional stimuli.
- A specific region of the striatum (called the nucleus accumbens) is a central component of the reward system in the brain and plays a key role in motivation to pursue rewards.
- Many of the brain structures implicated in MDD also appear to be involved in bipolar disorder.
- Difference: People with bipolar disorder tend to show high activation of the striatum.
- High activation of the striatum may help explain increased levels of reward sensitivity in people with bipolar disorder.
Aetiology of mood disorders- Brain function:
The neuroendocrine system: cortisol dysregulation
- The HPA axis (hypothalamic–pituitary–adrenocortical axis; may be overly active during episodes of MDD.
- Evidence that the amygdala is overly reactive among people with MDD and the amygdala sends signals that activate the HPA axis. The HPA axis triggers the release of cortisol, the main stress hormone.
- Various findings link depression to high cortisol levels.
- Among people who are depressed, cortisol levels are often poorly regulated.
- Long-term excesses of cortisol have been linked to damage to the hippocampus.
- Like people with MDD, people with bipolar disorder fail to demonstrate the typical suppression of cortisol after the dex/CRH test.
- Dysregulation in cortisol levels also predicts a more severe course of illness for bipolar disorder and MDD.
Aetiology- Social factors in depression: childhood adversity, life events and interpersonal difficulties
- Childhood adversity, such as early parental death, physical abuse or sexual abuse, increases the risk and that the depressive symptoms will be chronic.
- Child abuse acts as a non-specific risk factor for psychopathology generally.
- Life events often precede a depressive episode. However remains possible that some life events are caused by early symptoms of depression.
- Certain types of life events, such as those involving interpersonal loss and humiliation, appear particularly likely to trigger depressive episodes.
- Diatheses: pre-existing vulnerabilities. Diatheses could be biological, social or psychological.
- One diathesis may be a lack of social support. Low social support may lessen a person’s ability to handle stressful life events.
- Family problems are another important interpersonal predictor of depression.
- Expressed emotion (EE): defined as a family member’s critical or hostile comments towards or emotional overinvolvement with the person with depression.
- High EE strongly predicts relapse in depression.
- Interpersonal styles: An excessive need for reassurance has been found to predict depression.
- Among adolescents, poor interpersonal problem-solving skills predicted increases in depression.
- Once depressive symptoms emerge, they can create interpersonal problems.
Psychological factors in depression- Neuroticism
- Neuroticism: a personality trait that involves the tendency to experience frequent and intense negative affect, predicts the onset of depression.
- Neuroticism is also associated with anxiety.
Psychological factors in depression- cognitive theories
In cognitive theories, these negative thoughts and beliefs are seen as major causes of depression.
- Beck's Theory: argued that depression is associated with a negative triad; negative views of the self, their world and the future.
- According to this model, in childhood, people with depression acquired negative schemas through experiences such as loss of a parent, the social rejection of peers or the depressive attitude of a parent.
- The negative schema is activated whenever the person encounters situations similar to those that originally caused the schema to form.
- Once activated, negative schemas are believed to cause cognitive biases, or tendencies to process information in certain negative ways.
- That is, people with depression might attend to and remember even the smallest negative feedback about themselves, while at the same time failing to notice or remember positive feedback about themselves.
- People with a schema of ineptness might readily notice and remember signs that they are inept, while ignoring or forgetting signs that they are competent.
- Together, these cognitive errors lead them to make conclusions that are consistent with their underlying schema, which then maintains the schema (a vicious circle).
- How to test Beck's theory?
- Dysfunctional Attitudes Scale (DAS): which includes items concerning whether people would consider themselves worthwhile or lovable.
- Hundreds of studies have shown that people demonstrate negative thinking on scales like the DAS during depression.
- Several major longitudinal studies suggest that people with negative cognitive styles are at elevated risk for developing depressive symptoms.
- In studies of how people process information, depression is associated with a tendency to stay focused on negative information once it is initially noticed.
- People with depression also tend to remember more negative than positive information. (Negative bias)
Psychological factors in depression- cognitive theories
- According to hopelessness theory, the important trigger of depression is hopelessness, which is defined by the belief that desirable outcomes will not occur and that there is nothing a person can do to change this.
- The model places emphasis on two key dimensions of attributions — the explanations a person forms about why a stressor has occurred.
- 1. stable (permanent) versus unstable (temporary) causes
- 2. global (relevant to many life domains) versus specific (limited to one area) causes.
- People whose attributional style leads them to believe that negative life events are due to stable and global causes are likely to become hopeless and this hopelessness will set the stage for depression.
- Attributional Style Questionnaire: Those who attributed poor grades to global and stable factors experienced more hopelessness and in turn, hopelessness predicted depressive symptoms.
Psychological factors in depression- cognitive theories
- Rumination is defined as a tendency to repetitively dwell on sad experiences and thoughts, or to chew on material again and again.
- Tendencies to ruminate, as measured using self-report scales, have been found to predict the onset of major depressive episodes among initially non-depressed persons.
- The most detrimental form of rumination may be a tendency to brood regretfully about why a sad event happened.
- Theory, it is evolutionarily adaptive to focus on negative events in order to solve problems.
- A different model suggests that getting stuck on negative thoughts results from a basic inability to control the focus of thoughts.
- Research shows that people with depression do have a hard time ignoring irrelevant information to complete a task, particularly when they are asked to ignore negative information.
Social and psychological factors in bipolar disorder
The triggers of depressive episodes in bipolar disorder appear to be similar to the triggers of major depressive episodes.
- Predictors of mania
- Reward sensitivity: Being highly reward sensitive has also been shown to predict the onset of bipolar disorder.
- Researchers have proposed that life events involving success may trigger cognitive changes in confidence, which then spiral into excessive goal pursuit.
- This excessive goal pursuit may help trigger manic symptoms among people who are biologically vulnerable to bipolar disorder.
- Sleep deprivation: Experimental studies indicate that sleep deprivation can precede the onset of manic episodes.
- People often report that they had experienced a life event that disrupted their sleep just before the onset of manic episodes.
- Just as sleep deprivation can trigger manic symptoms, protecting sleep can help reduce symptoms of bipolar disorder.
- Sleep and circadian rhythm disruption appear to be important aspects of mania risk.
Integrating biological and social risk factors for depression: cytokines
- Depression rates are very high among people with medical conditions such as obesity, cardiovascular disorder, cancer, diabetes and Alzheimer’s disease.
- The key to this model is that medical conditions often trigger elevations in cytokines.
- Cytokines are proteins that are released as part of an immune response.
- Two of these pro-inflammatory cytokines, have been shown to cause a syndrome called sickness behaviour, which includes many of the symptoms that are seen in depression; decreased motor activity, reduced food consumption, social withdrawal, changes in sleep patterns and reduced interest in rewards.
- In naturalistic studies without experimental manipulation, many people with major depressive disorder and even those with no medical disorder, show elevated levels of cytokines.
Psychological treatment of depression
- Interpersonal psychotherapy (IPT): IPT builds on the idea that depression is closely tied to interpersonal problems.
- The core of the therapy is to examine major interpersonal problems, the therapist and the patient focus on one or two such issues, with the goal of helping the person identify his or her feelings about these issues, make important decisions and effect changes to resolve problems related to these issues.
- Several studies have found that IPT is effective in relieving MDD and that it prevents relapse when continued after recovery.
- Cognitive-behavioural therapy (CBT): aimed at altering maladaptive thought patterns. The client is taught to understand how powerfully our thoughts can influence our moods and actions.
- The therapist then tries to help the person with depression to change his or her opinions about the self, others and the world.
- Medium effect size supporting CBT for depression in adults.
- Behavioural activation (BA) is a technique used in CBT in which people are encouraged to engage in pleasant activities that might bolster positive thoughts about one’s self and life.
- Behavioural couples therapy: Because depression is often tied to relationship problems.
- Behavioural couples therapy is as effective in relieving depression as individual therapy.
- Third wave cognitive therapies: cognitive therapies such as mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT).
- this wave of therapies suggests that changing patients’ relationships to their thoughts, rather than challenging the content of thoughts, can improve depression.
- Assist patients to adopt a ‘decentred’ or ‘defused’ perspective by teaching them to view thoughts as ‘mental events’ rather than accurate reflections of reality or the self.
- The client is helped to accept that the experience of negative thoughts and feelings is a normal part of human existence and in doing so reduce feelings of distress that come with the struggle to be rid of painful experiences.
Psychological treatment of bipolar disorder
- Medication is a necessary part of treatment for bipolar disorder, but psychological treatments can supplement medication to help address many of its associated social and psychological problems.
- Psychoeducational approaches typically help people learn about the symptoms of the disorder, the expected time course of symptoms, the biological and psychological triggers for symptoms and treatment strategies.
- CBT draws on many of the types of techniques that are used in major depressive disorder, with some additional content designed to address the early signs of manic episodes.
- family-focused therapy (FFT).
- Interpersonal and social rhythm therapy (IPSRT) was designed to stabilise daily rhythms and thus avoid disruptions to the circadian system which can trigger episodes of mania.
Biological treatment of mood disorders
- Electroconvulsive therapy for depression (ECT):
- For the most part now, ECT is only used to treat MDD that has not responded to medication. ECT entails deliberately inducing a momentary seizure by passing a 70- to 130-volt current through the patient’s brain.
- ECT is more powerful than antidepressant medications for the treatment of depression.
- Medications: Drugs are the most commonly used and best-researched treatments for depressive disorders.
- Treatment guidelines recommend continuing antidepressant medications for at least 12 months after a depressive episode ends.
- Transcranial magnetic stimulation (rTMS): for a small subset of those with depression: patients who have failed to respond to at least two adequate trials of an antidepressant medication.
- In this approach, an electromagnetic coil is placed against the scalp and intermittent pulses of magnetic energy are used to increase activity in the dorsolateral prefrontal cortex.
- Multiple randomised controlled trials suggest that rTMS can help relieve treatment-resistant depression compared to the false treatment.
Comparing treatments for major depressive disorder
- Combining psychotherapy and antidepressant medications bolsters the odds of recovery by more than 10–20 percent above either psychotherapy or medications alone for most people with depression.
- Antidepressants work more quickly than psychotherapy, thus providing immediate relief.
- Cognitive therapy (CT) was as effective as antidepressant medication for severe depression and both treatments were more effective than placebo. CT had two advantages; it was less expensive than medication and over the long term it helped protect against relapse once treatment was finished.
Medications for bipolar disorder
- Medications that reduce manic symptoms are called mood-stabilising medications.
- Lithium: has mood stabilising properties
- Up to 80 percent of people with bipolar I disorder experience at least mild benefit from taking this drug.
- Even though symptoms are usually decreased with medications, most patients continue to experience at least mild manic and depressive symptoms.
- Medications other than lithium for acute mania: anticonvulsant (antiseizure) medications and antipsychotic.
- These other treatments are recommended for people who are unable to tolerate lithium’s side effects.
- Suicidal ideation: refers to thoughts of killing oneself and is much more common than attempted or completed suicide.
- Suicide attempts: involve behaviours that are intended to cause death. Most suicide attempts do not result in death.
- Suicide: involves behaviours that are intended to cause death and actually do so.
- Non-suicidal self-injury: involves behaviours that are meant to cause immediate bodily harm but are not intended to cause death
Epidemiology of suicide and suicide attempts
- Estimated that suicide is the thirteenth leading cause of death in Australia.
- In Australia, the overall suicide rate is about 12.6 per 100 000 in a given year.
- Worldwide, about 9 percent of people report suicidal ideation at least once in their lives and 2.5 percent have made at least one suicide attempt.
- Suicide rates are higher in regions where more people own guns.
- Men are three times more likely than women to die by suicide.
- Women are more likely than men are to make suicide attempts that do not result in death.
- The suicide rate increases in old age. The highest rates of suicide in Australia are for males over age 85, with the next highest rate being for males aged 45 to 49 years.
- The rates of suicide for adolescents and children in Australia are increasing dramatically but are still far below the rates of adults.
- The rate of death by suicide for Aboriginal and Torres Strait Islander peoples is almost double the rate of non-Indigenous Australians.
Risk factors for suicide
- Psychological disorders: More than half of those who attempt suicide are depressed at the time of the act.
- as many as 90 percent of people who attempt suicide are suffering from a psychological disorder.
- Neurobiological factors: Twin studies suggest that heritability is about 48 percent for suicide attempts.
- Serotonin dysfunction appears to be particularly relevant for understanding violent suicide.
- Cortisol dysregulation and serotonin deficits, then, appear to be important predictors of suicidality.
- Social factors: Economic and social events have been shown to influence suicide rates.
- suicide rates have been shown to increase modestly during economic recessions.
- Media coverage of a celebrity suicide is much more likely to spark an increase in suicidality than coverage of a non-celebrity suicide.
- not grief per se that is the influential factor.
- It has been suggested that media reporting of suicide can influence vulnerable individuals by raising awareness of suicide methods and normalising of suicidal behaviour.
- Argue that social isolation and a lack of social belonging are among the most powerful predictors of suicidal ideation and behaviour.
- Psychological factors: Several researchers relate suicide to poor problem-solving skills.
- A person who has trouble resolving problems can be expected to be more vulnerable to hopelessness.
- High levels of hopelessness are associated with a fourfold elevation in the risk of suicide.
- People with more reasons to live tend to be less suicidal than those with few reasons to live.
- People who are more impulsive are more likely to attempt suicide or to die from suicide.