Fundamentals of Psychological Disorders - 3rd edition Part II Mental Disorders - Block 1 Module 4 Mood Disorders

Fundamentals Disorders II Part II . Mental Disorders Block edition as of July 2023 Part II . Mental Disorders Block Disorders Covered . Mood Disorders . and Disorders . Dissociative Disorders Module Mood Disorders edition as of July 2023 Module Overview In Module , we will discuss matters related to mood disorders to include their clinical presentation , epidemiology , etiology , and treatment options . Our discussion will cover major depressive disorder , persistent depressive disorder ( formerly ) bipolar I disorder , bipolar II disorder , and cyclothymic disorder . We will also cover major depressive , manic , and hypomanic episodes . Be sure you refer Modules for explanations of key terms ( Module ) an overview of the various models to explain psychopathology ( Module ) and descriptions of several therapies ( Module ) Note that this module will cover two chapters from the namely , Bipolar and Related Disorders and Depressive Disorders . Module Outline . Clinical Presentation Depressive Disorders . Clinical Presentation Bipolar and Related Disorders . Epidemiology . Etiology . Treatment Module Learning Outcomes Describe how depressive disorders present . Describe how bipolar and related disorders present . Describe the epidemiology of mood disorders . Describe in relation to mood disorders . Describe the etiology of mood disorders . Describe treatment options for mood disorders . Clinical Presentation Depressive Disorders Section Learning Objectives Distinguish the two distinct groups of mood disorders . 102

Fundamentals Disorders Identify and describe the two types of depressive disorders . Classify symptoms of depression . Describe premenstrual dysphoric disorder . Distinguishing Mood Disorders Within mood disorders are two distinct with depressive disorders and individuals with bipolar disorders . The key difference between the two mood disorder groups is episodes of . More specifically , in bipolar I disorder , the individual experiences a manic episode that may have been preceded by and may be followed by hypomanic or major depressive episodes ( APA , 2022 , 139 ) whereas for bipolar II disorder , the individual has experienced in the past or is currently experiencing a hypomanic episode and has experienced in the past or is currently experiencing a major depressive episode . In contrast , individuals presenting with a depressive disorder have never experienced a manic or hypomanic episode . Types of Depressive Disorders The two most common types of depressive disorders are major depressive disorder ( and persistent depressive disorder ( Persistent depressive disorder , which in the now includes the diagnostic categories of and chronic major depression , is a continuous and chronic form of depression . While the symptoms of are very similar to , they are usually less acute , as symptoms tend to ebb and flow over a long period ( more than two years ) Major depressive disorder , on the other hand , has discrete episodes lasting at least two weeks in which there are substantial changes in affect , cognition , and functions ( APA , 2022 , 177 ) It should be noted that after a careful review of the literature , premenstrual dysphoric disorder , was moved from Criteria Sets and Axes Provided for Future Study in the to Section II of as the disorder was confirmed as a specific and form of depressive disorder that begins sometime following ovulation and within a few days of menses and has a marked impact on functioning ( APA , 2022 , 177 ) The also added a new diagnosis , disruptive mood disorder ( for children up to 12 years of age , to deal with the potential for and treatment of bipolar disorder in children , both in the United States and internationally . Children with present with persistent irritability and frequent episodes of extreme behavioral and so develop unipolar , not bipolar , depressive disorders or anxiety disorders as they move into adolescence and adulthood . For a discussion of , please visit our sister book , Behavioral Disorders of Childhood . Symptoms Associated with Depressive Disorders 103

Fundamentals Disorders When making a diagnosis of depression , there are a wide range of symptoms that may be present . These symptoms can generally be grouped into four categories mood , behavioral , cognitive , and physical symptoms . Mood . While clinical depression can vary in its presentation among individuals , most , if not all individuals with depression will report significant mood disturbances such as a depressed mood for most of the day feelings of anhedonia , which is the loss of interest in previously interesting activities . Behavioral . Behavioral issues such as decreased physical activity and reduced at home and often observed in individuals with depression . This is typically where a disruption in daily functioning occurs as individuals with depressive disorders are unable to maintain their social interactions and employment responsibilities . Cognitive . It should not come as a surprise that there is a serious disruption in as individuals with depressive disorders typically hold a negative view of themselves and the world around them . They are quick to blame themselves when things go wrong , and rarely take credit when they experience positive achievements . Individuals with depressive disorders often feel worthless , which creates a negative feedback loop by reinforcing their overall depressed mood . They also report difficulty concentrating on tasks , as they are easily distracted from outside stimuli . This assertion is supported by research that has found individuals with depression perform worse than those without depression on tasks of memory , attention , and reasoning ( Chen et , 2013 ) Finally , thoughts of suicide and do occasionally occur in those with depressive disorders ( Note this will be discussed in more detail in Section ) Physical . Changes in sleep patterns are common in those experiencing depression with reports of both hypersomnia and insomnia . Hypersomnia , or excessive sleeping , often impacts an individual daily functioning as they spend the majority of their time sleeping as opposed to participating in daily activities ( meeting up with friends or getting to work on time ) Reports of insomnia are also frequent and can occur at various points throughout the night to include difficulty falling asleep , staying asleep , or waking too early with the inability to fall back asleep before having to wake for the day . Although it is unclear whether symptoms of fatigue or loss of energy are related to insomnia issues , the fact that those experiencing hypersomnia also report symptoms of fatigue suggests that these symptoms are a component of the disorder rather than a secondary symptom of sleep disturbance . Additional physical symptoms , such as a change in weight or eating behaviors , are also observed . Some individuals who are experiencing depression report a lack of appetite , often forcing themselves to eat something during the day . On the contrary , others overeat , often seeking comfort foods , such as those high in carbohydrates . Due to these changes in eating behaviors , there may be associated changes in weight . Finally , psychomotor agitation or retardation , which is the purposeless or slowed physical movement of the body ( pacing around a room , tapping toes , restlessness , etc . is also reported in individuals with depressive disorders . Diagnostic Criteria and Features for Depressive Disorders 104

Fundamentals Disorders . Major depressive disorder ( According to the ( APA , 2022 ) to meet the criteria for a diagnosis of major depressive disorder , an individual must experience at least five symptoms across the four categories discussed above , and at least one of the symptoms is either ) a depressed mood most of the day , almost every day , or ) loss of interest or pleasure in all , or most , activities , most of the day , almost every day . These symptoms must be present for at least two weeks and cause clinically significant distress or impairment in important areas of functioning such as social and occupational . The cautions that responses to a significant loss ( such as the death of a loved one , financial ruin , and discovery of a serious medical illness or disability ) can lead to many of the symptoms described above ( intense sadness , rumination about the loss , insomnia , etc . but this may be the normal response to such a loss . Though the individual response resembles a major depressive episode , clinical judgment should be utilized in making any diagnosis and be based on the understanding of the individual personal history and cultural norms related to how members should express distress in the context of loss . Persistent depressive disorder ( For a diagnosis of persistent depressive disorder , an individual must experience a depressed mood for most of the day , for more days than not , for at least two years . APA , 2022 ) This feeling of a depressed mood is also accompanied by two or more additional symptoms , to include changes in appetite , insomnia or hypersomnia , low energy or fatigue , low esteem , feelings of hopelessness , and poor concentration or difficulty with decision making . The symptoms taken together cause clinically significant distress or impairment in important areas of functioning such as social and occupational and these impacts can be as great as or greater than . The individual may experience a temporary relief of symptoms however , the individual will not be without symptoms for more than two months during this period . Making Sense of the Disorders In relation to depressive disorders , note the following Diagnosis if symptoms have been experienced for at least two weeks and can be regarded as severe Diagnosis if the symptoms have been experienced for at least two years and are not severe . Premenstrual dysphoric disorder . In terms of premenstrual dysphoric disorder , the states in the majority of menstrual cycles , at least five symptoms must be present in the final week before the onset of menses , being improving with a few days after menses begins , and disappear or become negligible in the week . Individuals diagnosed with premenstrual dysphoric disorder must have one or more of the following increased mood swings , irritability or anger , depressed mood , or . Additionally , they must have one or more of the following to reach a total of five symptoms anhedonia , difficulty concentrating , lethargy , changes in appetite , hypersomnia or insomnia , feelings of being overwhelmed or out of control , experience breast tenderness or swelling . The symptoms lead to issues at work or school ( decreased productivity and efficiency ) within relationships ( discord in the intimate partner relationship or with children , friends , or other family members ) and with usual social activities ( avoidance of the activities ) 105

Fundamentals Disorders Key Takeaways You should have learned the following in this section Mood disorder fall into one of two groups depressive or bipolar disorders with the key distinction between the two being episodes of . Symptoms of depression fall into one of four categories mood , behavioral , cognitive , and physical . Persistent Depressive Disorder shares symptoms with Major Depressive Disorder though they are usually not as severe and ebb and over a period of at least two years . Premenstrual dysphoric disorder presents as mood lability , irritability , dysphoria , and anxiety symptoms occurring often during the premenstrual phase of the cycle and remit around the beginning of menses or shortly thereafter . Section Review Questions . What are the different categories of mood disorder symptoms ?

Identify the symptoms within each category . What are the key differences in a major depression and a persistent depressive disorder diagnosis ?

What is premenstrual dysphoric disorder ?

Clinical Presentation Bipolar and Related Disorders Section Learning Objectives Distinguish the forms bipolar disorder takes . Contrast a manic episode with a hypomanic episode . Define cyclothymic disorder . Distinguishing Bipolar I and II Disorders According to the ( APA , 2022 ) there are two types of bipolar bipolar I and bipolar II . A diagnosis of bipolar I disorder is made when there is at least one manic episode . This manic episode 106

Fundamentals Disorders can be preceded by followed by a hypomanic or major depressive episode , however , diagnostic criteria for a manic episode is the only criteria that needs to be met for a bipolar I diagnosis . A diagnosis of bipolar II Disorder is made when there is a current or history of a hypomanic episode and a current or past major depressive episode . Descriptions of both manic and hypomanic episodes follow below . Making Sense of the Disorders In relation to I and II disorders , note the following Diagnosis bipolar I disorder if an individual has ever experienced a manic episode Diagnosis bipolar II disorder if the criteria has only been met for a hypomanic episode . Manic and Hypomanic Episodes . Manic episode . The key feature of a manic episode is a specific period in which an individual reports abnormal , persistent , or expansive irritable mood for nearly all day , every day , for at least one week ( APA , 2022 ) Additionally , the individual will display increased activity or energy during this same time . With regards to mood , an individual in a manic episode will appear excessively happy , often engaging haphazardly in sexual or interpersonal interactions . They also display rapid shifts in mood , also known as mood lability , ranging from happy , neutral , to irritable . At least three of the symptoms described below ( four if the mood is only irritable ) must be present and represent a noticeable change in the individual typical behavior . or grandiosity ( Criterion ) is present during a manic episode . Occasionally these levels can appear delusional . For example , individuals may believe they are friends with a celebrity , do not need to abide by laws , or even perceive themselves as God . They also engage in multiple overlapping new projects ( Criteria and ) often initiated with no prior knowledge about the topic , and engaged in at unusual hours of the day . Despite the increased activity level , individuals experiencing a manic episode also require a decreased need for sleep ( Criterion ) sleeping as little as a few hours a night yet still feeling rested . Reduced need for sleep may also be a precursor to a manic episode , suggesting that a manic episode is to begin imminently . It is not uncommon for those experiencing a manic episode to be more talkative than usual . It can be difficult to follow their conversation due to the quick pace of their talking , as well as tangential storytelling . Additionally , they can be difficult to interrupt in conversation , often disregarding the reciprocal nature of communication ( Criterion ) If the individual is more irritable than expansive , speech can become hostile and they engage in , particularly if they are interrupted or not allowed to engage in an activity they are seeking out ( APA , 2022 ) Based on their speech pattern , it should not be a surprise that racing thoughts and of ideas ( Criterion ) also present during manic episodes . Because of these rapid thoughts , speech may become disorganized or incoherent . Finally , individuals experiencing a manic episode are ( Criterion ) Hypomanic episode . As mentioned above , for a bipolar II diagnosis , an individual must 107

Fundamentals Disorders report symptoms consistent with a major depressive episode and at least one hypomanic episode . An individual with bipolar II disorder must not have a history of a manic there is a history of mania , the diagnosis will be diagnosed with bipolar I . A hypomanic episode is like a manic episode in that the individual will experience abnormally and persistently elevated , expansive , or irritable mood and energy levels , however , the behaviors are not as extreme as in mania . Additionally , behaviors consistent with a hypomanic episode must be present for at least four days , compared to the one week in a manic episode . Making Sense of the Disorders Take note of the following in relation to manic and hypomanic episodes A manic episode is severe enough to cause in social or occupational functioning and can lead to hospitalization to prevent harm to self or others . A hypomanic episode is NOT severe enough to cause such or hospitalization . Cyclothymic Disorder Notably , there is a subclass of individuals who experience numerous periods with hypomanic symptoms that do not meet the criteria for a hypomanic episode and mild depressive symptoms ( do not fully meet criteria for a major depressive episode ) These individuals are diagnosed with cyclothymic disorder ( APA , 2022 ) Presentation of these symptoms occur for two or more years and are typically interrupted by periods of normal mood not lasting more than two months at a time . The symptoms cause clinically significant distress or impairment in important areas of functioning , such as social and occupational . While only a small percentage of the population develops cyclothymic disorder , it can eventually progress into bipolar I or bipolar II disorder ( et , 2015 ) Key Takeaways You should have learned the following in this section An individual is diagnosed with bipolar I disorder if they have ever experienced a manic episode and are diagnosed with bipolar II disorder if the criteria has only been met for a hypomanic episode . A manic episode is characterized by a specific period in which an individual reports abnormal , persistent , or expansive irritable mood for nearly all day , every day , for at least one week . A hypomanic episode is characterized by abnormally and persistently elevated , expansive , or irritable mood and energy levels , though not as extreme as in mania , and must be present for at least four days . It is also not severe enough to cause or hospitalization . Cyclothymic disorder includes periods of hypomanic and mild depressive symptoms without meeting the criteria for a depressive episode which lasts two or more years and is interrupted by periods of normal moods . 108

Fundamentals Disorders Section Review Questions . What is the difference between bipolar I and II disorder ?

What are the key diagnostic differences between a hypomanic and manic episode ?

What is cyclothymic disorder ?

Epidemiology Section Learning Objectives Describe the epidemiology of depressive disorders . Describe the epidemiology of bipolar disorders . Describe the epidemiology of . Depressive Disorders According to the ( APA , 2022 ) the prevalence rate for major depressive disorder is approximately within the United States . Recall that persistent depressive disorder is a blend of disorder and chronic major depressive disorder . The prevalence rate for disorder is much lower than , with a rate among adults in the United States , while chronic major depressive disorder is . As well , individuals in the to age bracket report the highest rates of than any other age group . Women experience about twofold higher rates than men of , especially between menarche and menopause ( APA , 2022 ) The estimated lifetime prevalence for major depressive disorder in women is compared to in men ( 2001 ) disorder and chronic major depressive disorder , the prevalence among women is and times greater than the prevalence for men for each of these diagnoses , respectively ( APA , 2022 ) Bipolar Disorders The prevalence of bipolar I disorder in the United States is and did not differ statistically between men and women . In contrast , bipolar II disorder has a prevalence rate of in the United States and internationally ( APA , 2022 ) and some clinical samples suggest it is more common in women , with approximately of individuals with episodes being women ( Bauer , 2005 ) Childbirth may be a specific trigger for a hypomanic episode , occurring in 109

Fundamentals Disorders of women in nonclinical settings and most often in the early postpartum period . Individuals with a depressive disorder have a increased risk for suicide over the and adjusted general population rate . Features associated with an increased risk for death by suicide include anhedonia , living alone , being single , disconnecting socially , having access to a firearm , early life adversity , sleep disturbance , feelings of hopelessness , and problems with decision making . Women attempt suicide at a higher rate though men are more likely to complete suicide . Finally , the premenstrual phase is considered a risk period for suicide by some ( APA , 2022 ) In terms of bipolar disorders , the lifetime risk of suicide is estimated to be to fold greater than in the general population and of individuals with bipolar disorder die by suicide . Like depressive disorders , women attempt suicide at a higher rate though lethal suicide is more common in men with bipolar disorder . About of individuals with bipolar II disorder report a lifetime history of suicide attempt , which is similar in bipolar I disorder , though lethality of attempts is higher in individuals with bipolar II ( APA , 2022 ) Key Takeaways You should have learned the following in this section Major depressive disorder is experienced by about of the population in the United States , young adults and women the most . Bipolar I disorder afflicts and bipolar II disorder of the population with bipolar II affecting women more than men and no gender difference being apparent for bipolar I . Individuals with a depressive disorder have a increased risk for suicide while the lifetime risk of suicide for an individual with a bipolar disorder is estimated to be to fold greater than in the general population and of individuals with bipolar disorder die by suicide . Section Review Questions . What are the prevalence rates of the mood disorders ?

What gender differences exist in the rate of occurrence of mood disorders ?

How do depressive and bipolar disorders compare in terms of ( attempts and lethality ) 110 Fundamentals Disorders . Section Learning Objectives Describe the of depressive disorders . Describe the of bipolar disorders . Depressive Disorders Studies exploring depression symptoms among the general population show a substantial pattern of between depression and other mental disorders , particularly substance use disorders ( Kessler , et , 2003 ) Nearly of participants with lifetime in a research study also met the criteria for at least one other disorder ( Kessler , et , 2003 ) has been found to with disorders , panic disorder , generalized anxiety disorder , OCD , anorexia , bulimia , and borderline personality disorder . Gender differences do exist within such that women report anxiety disorders , bulimia , and disorders while men report alcohol and substance abuse . In contrast , those with are at higher risk for psychiatric in general and for anxiety disorders , substance use disorders , and personality disorders in particular ( APA , 2022 ) Given the extent of among individuals with , researchers have tried to identify which disorder precipitated the other . The majority of studies found that most depression cases occur secondary to another mental health disorder , meaning that the onset of depression is a direct result of the onset of another disorder ( 2009 ) Bipolar Disorders Those with bipolar I disorder typically have a history of three or more mental disorders . The most frequent disorders include anxiety disorders , alcohol use disorder , other substance use disorder , and , along with borderline , and antisocial personality disorder . Bipolar II disorder is more often than not associated with one or more mental disorders , with anxiety disorders being the most common ( 38 with social anxiety , 36 with specific phobia , and 30 having generalized anxiety ) As with bipolar I , substance use disorders are common with alcohol use ( 42 ) leading the way , followed by cannabis use ( 20 ) Premenstrual syndrome and premenstrual dysphoric disorder are common in women with bipolar II disorder especially ( APA , 2022 ) Finally , cyclothymic disorder has been found to be with disorders and sleep disorders . 111

Fundamentals Disorders Key Takeaways You should have learned the following in this section Depressive disorders have a high with substance use disorders , anxiety disorders , and some personality disorders . Bipolar disorders have a high with anxiety disorders and substance abuse disorders while cyclothymic disorder is with disorders and sleep disorders . Section Review Questions . What are common for the depressive disorders ?

What are common for bipolar disorders ?

Etiology Section Learning Objectives Describe the biological causes of mood disorders . Describe the cognitive causes of mood disorders . Describe the behavioral causes of mood disorders . Describe the sociocultural causes of mood disorders . Biological Research throughout the years continues to provide evidence that depressive disorders have some biological cause . While it does not explain every depressive case , it is safe to say that some individuals may at least have a predisposition to developing a depressive disorder . Among the biological factors are genetic factors , biochemical factors , and brain structure . Genetics . Like with any disorder , researchers often explore the prevalence rate of depressive disorders among family members to determine if there is some genetic component , whether it be a direct link or a predisposition . If there is a genetic predisposition to developing depressive disorders , one would expect a higher rate of depression within families than that of the general population . Research supports this with regards to depressive disorders as there is nearly a 30 increase in relatives diagnosed with depression compared to 10 of the general population ( 112

Fundamentals Disorders Nichols , 2014 ) Similarly , there is an elevated prevalence among relatives for both Bipolar I and Bipolar disorders as well . Another way to study the genetic component of a disorder is via twin studies . One would expect identical twins to have a higher rate of the disorder as opposed to fraternal twins , as identical twins share the same genetic , whereas fraternal twins only share roughly 50 , similar to that of siblings . A study found that if one identical twin was diagnosed with depression , there was a 46 chance their identical twin was diagnosed with depression . In contrast , the rate of a depression diagnosis in fraternal twins was only 20 . Despite the fraternal twin rate still being higher than that of a relative , this study provided enough evidence that there is a strong genetic link in the development of depression ( et , 1996 ) More recently , scientists have been studying depression at a molecular level , exploring possibilities of gene abnormalities as a cause for developing a depressive disorder . While much of the research is speculation due to sampling issues and low power , there is some evidence that depression may be tied to the gene on chromosome 17 , as this is responsible for the activity of serotonin ( et , 2016 ) Bipolar disorders share a similar genetic predisposition to that of major depressive disorder . Twin studies within bipolar disorder yielded concordance rates for identical twins at as high as 72 , yet the range for fraternal twins , siblings , and other close relatives ranged from . It is important to note that both percentages are significantly higher than that of the general population , suggesting a strong genetic component within bipolar disorder ( et , 2008 ) The more recently reports heritability estimates around 90 in some twin studies and the risk of bipolar disorder being around in the general population compared to in a relative ( APA , 2022 ) Biochemical . As you will read in the treatment section , there is strong evidence of a biochemical deficit in depression and bipolar disorders . More specifically , low activity levels of norepinephrine and serotonin , have long been documented as contributing factors to developing depressive disorders . This relationship was discovered accidentally in the 19505 when were given to tuberculosis patients , and miraculously , their depressive moods were also improved . Soon thereafter , medical providers found that medications used to treat high blood pressure by causing a reduction in norepinephrine also caused depression in their patients ( 1956 ) While these initial findings were premature in the identification of how neurotransmitters affected the development of depressive features , they did provide insight as to what neurotransmitters were involved in this system . Researchers are still trying to determine exact pathways however , it does appear that both norepinephrine and serotonin are involved in the development of symptoms , whether it be between the interaction between them , or their interaction on other neurotransmitters ( Ding et , 2014 ) Due to the close nature of depression and bipolar disorder , researchers initially believed that both norepinephrine and serotonin were implicated in the development of bipolar disorder however , the idea was that there was a drastic increase in serotonin during mania episodes . Unfortunately , research supports the opposite . It is believed that low levels of serotonin and high levels of norepinephrine may explain mania episodes ( 2014 ) Despite these findings , additional research within this area is needed to conclusively determine what is responsible for the manic episodes within bipolar disorder . 113

Fundamentals Disorders . Endocrine system . As you may know , the endocrine system is a collection of glands responsible for regulating hormones , metabolism , growth and development , sleep , and mood , among other things . Some research has implicated hormones , particularly cortisol , a hormone released as a stress response , in the development of depression ( Owens et , 2014 ) Additionally , melatonin , a hormone released when it is dark outside to assist with the transition to sleep , may also be related to depressive symptoms , particularly during the winter months . Brain anatomy . Seeing as neurotransmitters have been implicated in the development of depressive disorders , it should not be a surprise that various brain structures have also been identified as contributors to mood disorders . While exact anatomy and pathways are yet to be determined , research studies implicate the prefrontal cortex , the hippocampus , and the amygdala . More specifically , drastic changes in blood throughout the prefrontal cortex have been linked with depressive symptoms . Similarly , a smaller hippocampus , and consequently , fewer neurons , has also been linked to depressive symptoms . Finally , heightened activity and blood in the amygdala , the brain area responsible for our or response , is also consistently found in individuals with depressive symptoms . Abnormalities in several brain structures have also been identified in individuals with bipolar disorder however , what or why these structures are abnormal has yet to be determined . Researchers continue to focus on areas of the basal ganglia and cerebellum , which appear to be much smaller in individuals with bipolar disorder compared to the general public . Additionally , there appears to be a decrease in brain activity in regions associated with regulating emotions , as well as an increase in brain activity among structures related to emotional responsiveness ( et , 2011 ) Additional research is still needed to determine precisely how each of these brain structures may be implicated in the development of bipolar disorder . Cognitive The cognitive model , arguably the most conclusive model with regards to depressive disorders , focuses on the negative thoughts and perceptions of an individual . One theory often equated with the cognitive model of depression is learned helplessness . Coined by Martin ( 1975 ) learned helplessness was developed based on his laboratory experiment involving dogs . In this study , restrained dogs in an apparatus and routinely shocked them regardless of their behavior . The following day , the dogs were placed in a similar apparatus however , this time they were not restrained and there was a small barrier placed between the shock and the safe . What observed was that despite the opportunity to escape the shock , the dogs for a bit , and then ultimately laid down and whimpered while being shocked . Based on this study , concluded that the animals essentially learned that they were unable to avoid the shock the day prior , and therefore , learned that they were helpless in preventing the shocks . When they were placed in a similar environment but had the opportunity to escape the shock , their learned helplessness carried over , and they continued to believe they were unable to escape the shock . This study has been linked to humans through research on style ( 1992 ) There are two types of and negative . A negative style focuses on the internal , stable , and global of daily lives , whereas a positive style focuses on the external , unstable , and of the environment . 114

Fundamentals Disorders Research has found that individuals with a negative style are more likely to experience depression . This is likely due to their negative interpretation of daily events . For example , if something had were to happen to them , they would conclude that it is their fault ( internal ) bad things always happen to them ( stable ) and bad things happen all day to them . Unfortunately , this thinking style often takes over an individual daily view , thus making them more vulnerable to depression . In addition to style , Beck also attributed negative thinking as a precursor to depressive disorders ( Beck , 2002 , 1991 , 1967 ) Often viewed as the grandfather of Therapy , Beck went on to coin the attitudes , cognitive triad , errors in thinking , and automatic of which combine to explain the cognitive model of depressive disorders . attitudes , or negative attitudes about oneself , others , and the world around them are often present in those with depressive symptoms . These attitudes are inaccurate and often global . For example , If I fail my exam , the world will know I Will the entire world really know you failed your exam ?

Not likely . Because you fail the exam , are you stupid ?

No . Individuals with depressive symptoms often develop these attitudes regarding everything in their life , indirectly isolating themselves from others . The cognitive triad also plays into the attitudes in that the individual interprets these negative thoughts about their experiences , themselves , and their futures . Cognitive distortions , also known as errors in thinking , are a key component in Beck cognitive theory . Beck identified 15 errors in thinking that are most common in individuals with depression ( see the end of the module ) Among the most common are , jumping to conclusions , and . I always like to use my dad ( first author dad ) as an example for . Whenever we go to the grocery store , he always comments about how whatever line he chooses , at every store , it is always the slowest line . Does this happen every time he is at the store ?

I doubtful , but his error in thinking leads to him believing this is true . Finally , automatic thoughts , or the constant stream of negative thoughts , also leads to symptoms of depression as individuals begin to feel as though they are inadequate or helpless in a given situation . While some are manipulated and interpreted negatively , Beck stated that there is another set of negative thoughts that occur automatically . Research studies have continually supported thoughts , attitudes , and errors in thinking as fundamental issues in those with depressive disorders ( Lai et , 2014 Black , 2014 ) Furthermore , as you will see in the treatment section ( Section ) cognitive strategies are among the most effective forms of treatment for depressive disorders . Behavioral The behavioral model explains depression as a result of a change in the number of rewards and punishments one receives throughout their life . This change can come from work , intimate relationships , family , or even the environment in general . Among the most in the field of depression is Peter . He stated depression occurred in most people due to reduced positive rewards in their life . Because they were not positively rewarded , their constructive behaviors occurred more infrequently until they stop engaging in the behavior completely ( et , 1990 1984 ) An example of this is a student who keeps receiving bad grades on their exam despite studying for hours . Over time , the individual will reduce the amount of time they are studying , thus continuing to 115

Fundamentals Disorders earn poor grades . Sociocultural In the sociocultural theory , the role of family and one social environment play a substantial role in the development of depressive disorders . There are two sociocultural views the perspective and the perspective . perspective . Similar to that of the behavioral theory , the perspective of depression suggests that depression is related to the unavailability of social support . This is often supported by research studies that show separated and divorced individuals are three times more likely to experience depressive symptoms than those that are married or even widowed ( Schultz , 2007 ) While many factors lead a couple to separate or end their marriage , some relationships end due to a spouse mental health issues , particularly depressive symptoms . Depressive symptoms have been positively related to increased interpersonal conflicts , reduced communication , and intimacy issues , all of which are often reported in causal factors leading to a divorce ( et , 2014 ) The perspective can also be viewed oppositely , with stress and marital discord leading to increased rates of depression in one or both spouses ( et , 2000 ) While some research indicates that having children provides a positive in ones life , it can also lead to stress both within the individual , as well as between partners due to division of work and discipline differences . Studies have shown that women who had three or more young children , and also lacked a close and outside employment , were more likely than other mothers to become depressed ( Brown , 2002 ) perspective . While depression is experienced across the entire world , one cultural background may what symptoms of depression are presented . Common depressive symptoms such as feeling sad , lack of energy , anhedonia , difficulty concentrating , and thoughts of suicide are a hallmark in most societies other symptoms may be more specific to one nationality . More specifically , individuals from countries ( China and other Asian countries ) often focus on the physical symptoms of , weakness , sleep less of an emphasis on the cognitive symptoms . Within the United States , many researchers have explored potential differences across ethnic or racial groups in both rates of depression , as well as presenting symptoms of those diagnosed with depression . These studies continually fail to identify any significant differences between ethnic and racial groups however , one major study has identified a difference in the rate of recurrence of depression in Hispanic and African Americans ( et , 2010 ) While the exact reason for this is unclear , researchers propose a lack of treatment opportunities as a possible explanation . According to and colleagues ( 2010 ) approximately 54 of depressed white Americans seek out treatment , compared to the 34 and 40 Hispanic and African Americans , respectively . The fact that there is a large discrepancy in the use of treatment between white Americans and minority Americans suggests that these individuals are not receiving the effective treatment necessary to resolve the disorder , thus leaving them more vulnerable for repeated depressive episodes . Gender differences . As previously discussed , there is a significant difference between gender and rates of depression , with women twice as likely to experience an episode of depression than 116

Fundamentals Disorders men ( et , 2014 ) There are a few speculations as to why there is such an imbalance in the rate of depression across genders . The first theory , artifact theory , suggests that the difference between genders is due to clinician or diagnostic systems being more sensitive to diagnosing women with depression than men . While women are often thought to be more emotional , easily expressing their feelings and more willing to discuss their symptoms with and physicians , men often withhold their symptoms or will present with more traditionally masculine symptoms of anger or aggression . While this theory is a possible explanation for the gender differences in the rate of depression , research has failed to support this theory , suggesting that men and women are equally likely to seek out treatment and discuss their depressive symptoms ( 2004 Bird , 2005 ) The second theory , hormone theory , suggests that variations in hormone levels trigger depression in women more than men ( 2009 ) While there is biological evidence supporting the changes in hormone levels during various phases of the menstrual cycle and their impact on ability to integrate and process emotional information , research fails to support this theory as the reason for higher rates of depression in women ( 2006 ) The third theory , life stress theory , suggests that women are more likely to experience chronic stressors than men , thus accounting for their higher rate of depression ( 2010 ) Women face increased risk for poverty , lower employment opportunities , discrimination , and poorer quality of housing than men , all of which are strong of depressive symptoms ( et , 2013 ) The fourth theory , gender roles theory , suggests that social and or psychological factors related to traditional gender roles also the rate of depression in women . For example , men are often encouraged to develop personal autonomy , seek out activities that interest them , and display goals women are encouraged to empathize and care for others , often fostering an interdependent functioning , which may cause women to value the opinion of others more highly than their male counterparts do . The final theory , rumination theory , suggests that women are more likely than men to ruminate , or intently focus , on their depressive symptoms , thus making them more vulnerable to developing depression at a clinical level ( 2012 ) Several studies have supported this theory and shown that rumination of negative thoughts is positively related to an increase in depression symptoms ( 2009 ) While many theories try to explain the gender discrepancy in depressive episodes , no single theory has produced enough evidence to fully explain why women experience depression more than men . Due to the lack of evidence , gender differences in depression remains one of the most researched topics within the subject of depression , while simultaneously being the least understood phenomena within clinical psychology . Key Takeaways You should have learned the following in this section 117

Fundamentals Disorders In terms of biological explanations for depressive disorders , there is evidence that rates of depression are higher among identical twins ( the same is true for bipolar disorders ) that the gene on chromosome 17 may be involved in depressive disorders , that norepinephrine and serotonin affect depressive ( both being low ) and bipolar disorders ( low serotonin and high norepinephrine ) the hormones cortisol and melatonin affect depression , and several brain structures are implicated in depression ( prefrontal cortex , hippocampus , and amygdala ) and bipolar disorder ( basal ganglia and cerebellum ) In terms of cognitive explanations , learned helplessness , style , and attitudes to include the cognitive triad , errors in thinking , and automatic thoughts , help to explain depressive disorders . Behavioral explanations center on changes in the rewards and punishments received throughout life . Sociocultural explanations include the perspective and perspective . Women are twice as likely to experience depression and this could be due to women being more likely to be diagnosed than men ( called the artifact theory ) variations in hormone levels in women ( hormone theory ) women being more likely to experience chronic stressors ( life stress theory ) the fostering of an interdependent functioning in women ( gender roles theory ) and that women are more likely to intently focus on their symptoms ( rumination theory ) Section Review Questions . How do twin studies explain the biological causes of mood disorders ?

What brain structures are implicated in the development of mood disorders ?

Discuss their role . What is learned helplessness ?

How has this concept been used to study the development and maintenance of mood disorders ?

What is the cognitive triad ?

What are common cognitive distortions observed in individuals with mood disorders ?

What are the identified theories that are used to explain the gender differences in mood disorder development ?

Treatment of Mood Disorders Section Learning Objectives Describe treatment options for depressive disorders . Describe treatment options for bipolar disorders . Determine the efficacy of treatment options for depressive disorders . Determine the efficacy of treatment options for bipolar disorders . 118

Fundamentals Disorders . Depressive Disorders Given that Major Depressive Disorder is among the most frequent and debilitating psychiatric disorders , it should not be surprising that the research on this disorder is quite extensive . Among its treatment options , the most efficacious ones include antidepressant medications , Therapy ( Beck et , 1979 ) Behavioral Activation ( BA et , 2001 ) and Interpersonal Therapy ( et , 1984 ) Although is the most widely known and used treatment for Major Depressive Disorder , there is minimal evidence to support one treatment modality over the other treatment is generally dictated by therapist competence , availability , and patient preference ( 2014 ) Antidepressant medications . Antidepressants are often the most common attempt at treatment for for a few reasons . Oftentimes an individual will present with symptoms to their primary caregiver ( a medical doctor ) who will prescribe them some line of antidepressant medication . Medication is often seen as an easier treatment for depression as the individual can take the medication at their home , rather than attending weekly therapy sessions however , this also leaves room for adherence issues as a large percentage of individuals fail to take prescription medication as indicated by their physician . Given the biological functions of neurotransmitters and their involvement in maintaining depressive symptoms , it makes sense that this is an effective type of treatment . Within antidepressant medications , there are a few different classes , each categorized by their structural or functional relationships . It should be noted that no specific antidepressant medication class or medication have been proven to be more effective in treating than others ( APA , 2010 ) In fact , many patients may try several different types of antidepressant medications until they find one that is effective , with minimal side effects . Selective serotonin reuptake inhibitors ( are among the most common medications used to treat depression due to their relatively benign side effects . Additionally , the required dose to reach therapeutic levels is low compared to the other medication options . Possible side effects from include but are not limited to nausea , insomnia , and reduced sex drive . improve depression symptoms by blocking the reuptake of norepinephrine serotonin in presynaptic neurons , thus allowing more of these neurotransmitters to be available for postsynaptic neurons . While this is the general mechanism through which all work , there are minor biological differences among different types of medications within the family . These small differences are beneficial to patients in that there are a few treatment options to maximize medication benefits and minimize side effects . Tricyclic antidepressants . Although originally developed to treat schizophrenia , tricyclic antidepressants were adapted to treat depression after failing to manage symptoms of schizophrenia ( 1958 ) The term tricyclic came from the molecular shape of the structure three rings . Tricyclic antidepressants are like in that they work by affecting brain chemistry , altering the number of neurotransmitters available for neurons . More specifically , they block the absorption or 119

Fundamentals Disorders reuptake of serotonin and norepinephrine , thus increasing their availability for postsynaptic neurons . While effective , tricyclic antidepressants have been increasingly replaced by due to their reduced side effects . However , tricyclic antidepressants have been shown to be more effective in treating depressive symptoms in individuals who have not been able to achieve symptom reduction via other pharmacological approaches . While the majority of the side effects are minimal dry mouth , blurry vision , constipation , others can be serious such as sexual dysfunction , tachycardia , cognitive memory impairment . Due to the potential impact on the heart , tricyclic antidepressants should not be used in cardiac patients as they may exacerbate cardiac arrhythmias ( 1999 ) Monoamine oxidase inhibitors ( The use of as a treatment for depression began as patients in the early reported reduced depression symptoms while on the medication to treat tuberculosis . Research studies confirmed that were effective in treating depression in adults outside the treatment of tuberculosis . Although still prescribed , they are not typically medications due to their safety concerns with hypertensive crises . Because of this , individuals on have strict diet restrictions to reduce their risk of hypertensive crises ( Walker , 2013 ) How do work ?

In basic terms , monoamine oxidase is released in the brain to remove excess neurotransmitters norepinephrine , serotonin , and dopamine . essentially prevent the monoamine oxidase ( hence the name monoamine oxidase inhibitors ) from removing these neurotransmitters , thus resulting in an increase in these brain chemicals ( Herman Walker , 2013 ) As previously discussed , norepinephrine , serotonin , and dopamine are all involved in the biological mechanisms of maintaining depressive symptoms . While these drugs are effective , they come with serious side effects . In addition to the hypertensive episodes , they can also cause nausea , headaches , drowsiness , involuntary muscle jerks , reduced sexual desire , weight gain , etc . APA , 2010 ) Despite these side effects , studies have shown that individuals prescribed for depression have a treatment response rate of ( 2007 ) Overall , despite their effectiveness , are likely the best treatment for , depression patients who have exhausted other treatment options ( 2007 ) It should be noted that occasionally , antipsychotic medications are used for individuals with however , these are limited to individuals presenting with psychotic features . Psychotherapy Cognitive behavioral therapy ( was founded by Beck in the 19605 and is a widely practiced therapeutic tool used to treat depression ( and other disorders as well ) The basics of involve what Beck called the cognitive ( thoughts ) behaviors , and emotions . Beck believed that these three components are interconnected , and therefore , affect one another . It is believed that can improve emotions in depressed patients by changing both ( thoughts ) and behaviors , which in return enhances mood . Common cognitive interventions with include thought monitoring and recording , identifying cognitive errors , examining evidence , and creating rational alternatives to thought patterns . Behavioral interventions of include activity planning , pleasant event scheduling , task assignments , and training . generally follows four phases of treatment 120

Fundamentals Disorders Phase Increasing pleasurable activities . Similar to behavioral activation ( see below ) the clinician encourages the patient to identify and engage in activities that are pleasurable to the individual . The clinician can help the patient to select the activity , as well as help them plan when they will engage in that activity . Phase Challenging automatic thoughts . During this stage , the clinician provides about the negative automatic thoughts that can maintain depressive symptoms . The patient will learn to identify these thoughts on their own during the week and maintain a thought journal of these to review with the clinician in session . Phase Identifying negative thoughts . Once the individual is consistently able to identify these negative thoughts on a daily basis , the clinician can help the patient identify how these thoughts are maintaining their depressive symptoms . It is at this point that the patient begins to have direct insight as to how their contribute to their disorder . Phase Changing thoughts . The final stage of treatment involves challenging the negative thoughts the patient has been identifying in the last two phases of treatment and replacing them with positive thoughts . Psychotherapy Behavioral activation ( BA ) BA is similar to the behavioral component of in that the goal of treatment is to alleviate depression and prevent future relapse by changing an individual behavior . Founded by ( 1973 ) as well as and colleagues ( 1974 , 1976 ) the goal of BA is to increase the frequency of behaviors so that individuals have opportunities to experience greater Contact with sources of reward in their lives . To do this , the clinician assists the patient by developing a list of pleasurable activities that they can engage in outside of treatment ( going for a walk , going shopping , having dinner with a friend ) Additionally , the clinician assists the patient in identifying their negative , sleeping in , avoiding monitoring them so that they do not impact the outcome of their pleasurable activities . Finally , the clinician works with the patient on effective social skills . By minimizing negative behaviors and maximizing pleasurable activities , the individual will receive more positive reward and reinforcement from others and their environment , thus improving their overall mood . Psychotherapy Interpersonal therapy ( was developed by , and colleagues in the as a treatment arm for a pharmacotherapy study of depression ( 1995 ) The treatment was created based on data from War 11 individuals who expressed a substantial impact on their psychosocial life events . and colleagues noticed a significant relationship between the development of depression and complicated bereavement , role disputes , role transitions , and interpersonal deficits in these individuals ( 1995 ) The idea behind is that depressive episodes compromise interpersonal functioning , which makes it difficult to manage stressful life events . The basic mechanism of is to establish effective strategies to manage interpersonal issues , which in return , will ameliorate depressive symptoms . There are two main principles of . First , depression is a common medical illness with a complex and etiology . Since depression is a medical illness , it is also treatable and not the patients fault . Second , depression is connected to a current or recent life event . The goal of is to identify the interpersonal problem that is related to the depressive symptoms and solve this crisis so the patient can improve their life situation while relieving depressive symptoms . Multimodal treatment . While both pharmacological and psychological treatment alone is very effective in treating depression , a combination of the two treatments may offer additional benefits , particularly in the maintenance of wellness . Additionally , multimodal treatment options may be helpful 121

Fundamentals Disorders for individuals who have not achieved wellness in a single modality . Multimodal treatments can be offered in three different ways concurrently , sequentially , or within a stepped manner ( et , 2010 ) With a stepped manner treatment , pharmacological therapy is often used initially to treat depressive symptoms . Once the patient reports some relief in symptoms , the psychosocial treatment is added to address the remaining symptoms . While all three methods are effective in managing depressive symptoms , matching patients to their treatment preferences may produce better outcomes than treatment decisions . Bipolar Disorder . Unlike treatment for , there is some controversy regarding effective treatment of bipolar disorder . One suggestion is to treat bipolar disorder aggressively with mood stabilizers such as Lithium or as these medications do not induce pharmacological . These mood stabilizers are occasionally combined with antidepressants later in treatment only if absolutely necessary ( Goodwin , 2003 ) Research has shown that mood stabilizers are less potent in treating depressive symptoms , and therefore , the combination approach is believed to help manage both the manic and depressive episodes ( et , 2011 ) The other treatment option is to forgo the mood stabilizer and treat symptoms with newer antidepressants early in treatment . Unfortunately , large scale research studies have not shown great support for this method ( Goodwin , 2004 , 2006 ) Antidepressants often trigger a manic or hypomanic episode in bipolar patients . Because of this , the treatment option for bipolar disorder is mood stabilizers , particularly Lithium . Psychological treatment . Although is the first and most widely used treatment for bipolar disorders , occasionally psychological interventions are also paired with medication as psychotherapy alone is not a sufficient treatment option . Majority of psychological interventions are aimed at medication adherence , as many bipolar patients stop taking their mood stabilizers when they feel better ( et , 2014 ) Social skills training and skills are also helpful techniques to address in the therapeutic setting as individuals with bipolar disorder often struggle in this area . Outcome of Treatment . Depressive treatment . As we have discussed , major depressive disorder has a variety of treatment options , all found to be efficacious . However , research suggests that while interventions are more effective in rapidly reducing symptoms , psychotherapy , or even a combined treatment approach , are more effective in establishing relief of symptoms . Rates of relapse for major depressive disorder are often associated with individuals whose onset was at a younger age ( particularly adolescents ) those who have already experienced multiple major depressive episodes , and those with more severe , especially those presenting with severe suicidal ideation and psychotic features ( APA , 2022 ) 122

Fundamentals Disorders . Bipolar treatment . Lithium and other mood stabilizers are very effective in managing symptoms of patients with bipolar disorder . Unfortunately , it is the adherence to the medication regimen that is often the issue with these patients . Bipolar patients often desire the euphoric highs that are associated with manic and hypomanic episodes , leading them to forgo their medication . A combination of and psychotherapy aimed at increasing the rate of adherence to medical treatment may be the most effective treatment option for bipolar I and II disorder . Key Takeaways You should have learned the following in this section Treatment of depressive disorders include options such as , tricyclic antidepressants , and psychotherapy options to include , behavioral activation ( BA ) and interpersonal therapy ( A combination of the two main approaches often works best , especially in relation to maintenance of wellness . Treatment of bipolar disorder involves mood stabilizers such as Lithium and psychological interventions with the goal of medication adherence , as well as social skills training and solving skills . Regarding depression , interventions are more effective in rapidly reducing symptoms , while psychotherapy , or even a combined treatment approach , is more effective in establishing relief of symptoms . A combination of and psychotherapy aimed at increasing the rate of adherence to medical treatment may be the most effective treatment option for bipolar I and II disorder . Section Review Questions . Discuss the effectiveness of the different pharmacological treatments for mood disorders . What are the four phases of ?

How do they address symptoms of mood disorder ?

What is and what are its main treatment strategies ?

What are the effective treatment options for bipolar disorder ?

Module Recap That concludes our discussion of mood disorders . You should now have a good understanding of the two major types of mood disorders depressive and bipolar disorders . Be sure you are clear on what makes them different from one another in terms of their clinical presentation , epidemiology , and etiology . This will help you with understanding treatment options and their efficacy . 123

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