Chapter 7 Mood Disorders and Suicide
Chapter 7 Mood Disorders and Suicide
Depressive Disorders - are also called "mood" disorders and "affective" disorders. Affect
(pronounced "ah-fect") refers to the outward expression of emotion (e.g., sad vs. happy).
In mood disorders one's range of affect is either restricted (unipolar) or expanded
(bipolar).
Depression – key features are depressed mood and loss of interest in previous activities.
Other symptoms include sleep change, appetite change, hopelessness, guilt, “suicidal
ideation” or attempts, loss of concentration, psychomotor agitation or retardation.
Prevalence - Depression is very common with prevalence similar to the anxiety disorders.
Unipolar vs. Bipolar depression – unipolar is much more common than bipolar depression.
Gender differences – unipolar is more commonly diagnosed among females whereas
bipolar is diagnosed about equally for males and females.
Post-partum blues (depression) - is very common, afffecting more than 50% of new
mothers.
Dysthymia – is a chronic low level depression, symptoms of depression must be present
“more days than not” for at least TWO YEARS to receive the diagnosis (one year for
children and adolescents). Symptoms are similar to those seen in major depression but
not as severe.
Dysthymia (and GAD) - Because these two disorders are so chronic and such as "part" of
the person's makeup, some researchers think they should be re-conceptualized as
"PERSONALITY disorders. (not in book)
Major depression – more severe than dysthymia, symptoms must be present for at least
TWO WEEKS and represent “a clear change” from previous functioning. Major
depressive disorder requires at least one “major depressive episode.” Diagnosis will
note single (initial) episode or “recurrent” episode.
Criteria for a Major Depressive Episode - include either [1] depressed mood OR
[2] marked loss of interest in activities every day for two consecutive weeks. Also, at
least three of the following: fatigue, sleep change, appetite change, psychomotor
agitation or retardation, inability to concentrate, guilt/hopelessness, or thoughts of
suicide.
Anaclitic depression – occurs in infants after significant separation from the primary
caregiver. Harry Harlow demonstrated this in primates. (not in book)
Endogenous (melancholic) depression – a more highly “biological/genetic” subtype of
depression. It is characterized by 1. early morning waking and 2. mood worse in the
morning.
Major depression with “Psychotic features” vs. Thought disorder – In this type of
depression, delusions will be “mood congruent” (e.g., aging quickly, body deteriorating).
In schizophrenia the delusions would be more varied (e.g., that aliens are controlling my
mind). This subtype has a poorer prognosis.
Double depression – Diagnosis of both major depression and dysthymia in the same
person.
Recurrence vs. Relapse:
Recurrence – the episode has run its course, a period on normal functioning has
occurred, and a new episode has begun.
Relapse – symptoms get better but then come back fairly quickly. This is taken to mean
that it is the same episode which never really remitted.
Seasonal Affective Disorder (SAD) – Involves recurrent episodes during the same time of
year, usually fall or winter.
Causal Factors in Unipolar Depression:
Heredity - twin and adoption studies suggest that heredity accounts for about 1/3 to 1/2
of the variance in risk for developing unipolar depression.
Monoamine Hypotheses – of depression. In the 1960s researchers noted that tricyclic
antidepressants increase levels of “monoamines” (serotonin, norepinephrine). Thus,
the idea that low levels of these neurotransmitters cause depression was adopted.
The mechanism is not well understood. Initially, antidepressants increase activity
of these neurotransmitters, but after a few weeks, activity actually decreases!
Hypothalamic-Adrenal-Pituitary Axis (HPA axis) - The hypothalamus, adrenal glands,
and pituitary gland are involved in controlling production of several hormones
including CORTISOL.
Cortisol - is a hormone secreted by the adrenal glands and is elevated in about
half of depressed patients.
Dexamethasone Suppression Test (DST) – thought to be a “biological marker” for
depression. Some depressed patients have elevated levels of Cortisol. More
importantly, they don’t respond to Dexamethasone with lowered levels of Cortisol
production seen in most persons. However, the test is not very conclusive and may
just a marker for general mental distress.
Individual Differences:
Stressful events - depressed persons do experience more stressful events than other
people and are also more sensitive to stressful events. BUT WHY?
Neuroticism - The most "powerful" of personality traits. People high on neuroticism
(also called negative affect or emotional instability) are subject to BOTH depression
AND anxiety. They also experience other negative emotions. These tendencies are
largely heritable.
Extraversion - (or positive affect) low levels are associated with development of depression.
Sociotropy - people high on this trait are very sensitive to "interpersonal rejection" and
may become depressed in response. Evidence for this is quite strong. (not in book
Autonomy - people high on this trait are very "achievement" oriented and may become
depressed in response to personal failure. Evidence is not as strong as for sociotropy.
(not in book)
The Psychodynamic View - According to Freud, a primary cause of depression is "Anger
Turned Inward" against the self.
Attributional styles - Abramson et al. suggest that 3 factors relating to how people perceive
negative events may predispose some to becoming depressed.
Depressives tend to make attributions that are 1. INTERNAL (vs. external), 2. STABLE
(vs. changeable) and 3. GLOBAL (vs. specific). However, is this cause or effect??
Lewinsohn's behavioral model - suggests that depression results from the "environment"
no longer providing the person with "positive events" or reinforcers. This theory would
suggest an increase in pleasurable events as treatment. However, there is question as
whether reduced reinforcement is CAUSE or EFFECT.
Cognitive diatheses - Aaron Beck and others suggest that "dysfunction" schemas or beliefs
and "pessimistic attributional styles" may put one at risk for depression. Examples are
all or none reasoning and overgeneralization.
Learned helplessness - Demonstrated by Martin Seligman. Dogs were exposed to
inescapable shock. Later, when exposed to "escapable shock," they didn't even try to
escape. This is thought to be a good model for some cases of human depression.
Helplessness Reformulated - People are more complex than animals and probably ask
themselves WHY? a negative event occurred. The kinds of "attributions" they make
(see Abramson above) may predispose some to development of depression.
"Pessimistic Attributional Style" is suggested as a risk factor by Abramson, with depression
prone persons tending to make attributions that are 1. internal, 2. global, and 3. stable.
Bipolar disorders – formerly “manic depression” Marked by alternating episodes of
depression and either mania or hypomania. There is no pure "manic disorder." Manic
episodes are virtually always intermixed with depressive episodes.
Manic Episodes – Features include grandiosity, increased energy, less need for sleep,
risky and impulsive behaviors (spending, drugs, promiscuity), OR could take the form of
irritability. Also "pressured speech" and "racing thoughts" (flight of ideas). Symptoms
must be present for a week.
Hypomanic episodes - are similar to manic episodes but symptoms are less intense.
Cyclothymia - a milder form of bipolar disorder (like dysthymia). It consists of hypomanic
episodes cycling with episodes of moderate depression. Diagnosis requires that
symptoms be present for two years for adults (one year for children and adolescents).
Mixed Episode - Once thought to be rare, this is not that uncommon. Symptoms of both
depression and mania are present in the same episode.
Prevalence and Gender differences - Bipolar disorders are less common than unipolar
disorders. In contrast to unipolar depression, there is little or NO gender
difference in bipolar disorder. It tends to have a recurring course.
Types of Bipolar Disorder:
Bipolar I – involves episodes of major depression and manic episodes.
Bipolar II – involves episodes of major depression and hypomanic episodes.
Misdiagnosis – If a bipolar person first comes to the attention of clinician during a
depressed phase, he/she might be misdiagnosed as having unipolar depression
and prescribed an antidepressant which might actually make things worse.
"Rapid Cycling type" - Four or more manic or depressive episodes in a year (5 - 10
percent of bipolar patients have this type).
Schizoaffective disorder - Patients primarily suffer from a mood disorder but have
significant psychotic symptoms (at least 2) such as mood incongruent hallucinations
and delusions that resemble schizophrenia
Causal Factors in Bipolar Disorder:
Heredity - there is a significant heritable component to bipolar disorder. Harvald and
Hague reported concordance of .67 for MZ twins. Katz and McGuffin estimate that
genetic factors account for about 80% of the variance in the tendency to develop
bipolar disorder. This is higher than for any other disorder, including schizophrenia!
Lithium carbonate - similar to common salt chemically. It is the treatment of choice for
bipolar disorder and correctly diagnosed patients respond strongly to it.
Biological mechanism - Because sodium ions crossing cell membranes control action
potentials in neurons, and lithium probably acts like sodium in the brain, the theory is
that there in an abnormality in the activity of sodium ions crossing the cell membrane
along the axon.
Blood Flow Studies - Recent evidence from PET scans shows that during depressive
episodes, blood flow to the LEFT prefrontal cortex is reduced. During manic episodes, it
is reduced to the RIGHT prefrontal cortex.
Mood disorders and creativity - Writers artists and poets are far more likely to suffer from
a mood disorder than the average person. Some have been particularly productive
during manic or hypomanic episodes.
Suicide:
Timing of attempts - Surprisingly, most attempts take place as the person is emerging
from the deepest phase of the depressive episode.
Gender differences - More women attempt suicide but more men complete suicide.
Women tend to use drugs, whereas men tend to use more lethal methods such as
gunshot.
Age differences - Rates for the elderly had been declining but are now back on the
increase. In fact, the highest rate of completed suicide if for those 65 and over.
Most alarming are increasing rates among children, adolescents and
young adults.
Suicidal Families - Suicide does tend to "run in families" and this heritability may actually
be somewhat independent of depression. The Hemmingway family, discussed in our
text, clearly has a higher than average incidence of suicide.
Gender and Ethnic differences - White males are clearly at highest risk. They are followed
by black males, white females, and black females in that order.
Suicidal Ambivalence - To be or not to be?
1. Some people really don't want to die. They are sending out a dramatic plea for help
and usually use non-lethal means.
2. Ambivalent people leave the decision to fate (e.g., taking a lethal drug dose but
leaving plenty of time to possibly be found).
3. Not to be people are sure about their decision, use lethal means, and leave little
room for error.
Those who talk about it won't do it - This is FALSE. Nearly half of completed suicides
were communicated in clear and specific terms.
Crisis intervention - can often prevent a suicide. Whereas being very directive and
fostering DEPENDENCE is not normally a goal in therapy, it is appropriate for stopping
a suicide from happening.
Danger signals - loss of interest, social withdrawal, giving away possessions, decreased
personal hygiene, talking about it. In college students, often poor grades or romantic
breakup may be the triggering factor.