MOOD DISORDERS:DIAGNOSIS, Further Descriptions and Subtypes, Social Factors

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Abnormal Psychology PSY404

LESSON 27

MOOD DISORDERS

Recap Lecture No. 26

DIAGNOSIS

Unipolar Disorders

The unipolar disorders include two specific types: major depressive disorder and dysthymia.

In order to meet the criteria for major depressive disorder, a person must experience at least one

major depressive episode in the absence of any history of manic episodes.

Dysthymia differs from major depression in terms of both severity and duration.

Dysthymia represents a chronic mild depressive condition that has been present for many years.

In order to fulfill DSM-IV-TR criteria for this disorder, the person must, over a period of at least 2

years, exhibit a depressed mood for most of the day on more days than not.

Two or more of the following symptoms must also be present for a diagnosis of dysthymia:

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness

These symptoms must not be absent for more than 2 months at a time during the 2-year period.

If at any time during the initial 2 years the person met criteria for a major depressive episode, the

diagnosis would be major depression rather than dysthymia.

As in the case of major depressive disorder, the presence of a manic episode would rule out a

diagnosis of dysthymia.

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The distinction between major depressive disorder and dysthymia is somewhat artificial because

both sets of symptoms are frequently seen in the same person.

In such cases, rather than thinking of them as separate disorders, it is more appropriate to consider

them as two aspects of the same disorder, which waxes and wanes over time.

Bipolar Disorders

· All three types of bipolar disorders involve manic or hypomanic episodes.

· The mood disturbance must be severe enough to interfere with occupational or social functioning.

· A person who has experienced at least one manic episode would be assigned a diagnosis of bipolar

I disorder.

Bipolar Disorders (continued)

Hypomania refers to episodes of increased energy that are not sufficiently severe to qualify as full-

blown mania.

A person who has experienced at least one major depressive episode, at least one hypomanic

episode, and no full-blown manic episodes would be assigned a diagnosis of bipolar II disorder.

The differences between manic and hypomanic episodes involve duration and severity.

The symptoms need to be present for a minimum of only 4 days to meet the threshold for a

hypomanic episode (as opposed to 1 week for a manic episode).

The mood change in a hypomanic episode must be noticeable to others, but the disturbance must

not be severe enough to impair social or occupational functioning or to require hospitalization.

Cyclothymia is considered by DSM-IV-TR to be a chronic but less severe form of bipolar

disorder.

In order to meet criteria for cyclothymia, the person must experience numerous hypomanic

episodes and numerous periods of depression (or loss of interest or pleasure) during a period of 2

years.

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There must be no history of major depressive episodes and no clear evidence of a manic episode

during the first 2 years of the disturbance.

Further Descriptions and Subtypes

DSM-IV-TR includes several additional ways of describing subtypes of the mood disorders.

These are based on two considerations:

1) more specific descriptions of symptoms that were present during the most recent episode

of depression (known as episode specifiers) and

2) more extensive descriptions of the pattern that the disorder follows over time (known as

course specifiers).

One episode specifier allows the clinician to describe a major depressive episode as having

melancholic features.

Melancholia is a term that is used to describe a particularly severe type of depression.

In order to meet the DSM-IV-TR criteria for melancholic features, a depressed patient must either

lose the feeling of pleasure associated with all, or almost all, activities or

Lose the capacity to feel better--even temporarily--when something good happens.

The person must also exhibit at least three of the following to meet the criteria of melancholia:

the depressed mood feels distinctly different from the depression a person would feel after the

death of a loved one;

the depression is most often worst in the morning;

the person awakens early, at least 2 hours before usual;

marked psychomotor retardation or agitation;

significant loss of appetite or weight loss; and

excessive or inappropriate guilt.

Another episode specifier allows the clinician to indicate the presence of psychotic features--

hallucinations or delusions--during the most recent episode of depression or mania.

Depressed patients who exhibit psychotic features are more likely to require hospitalization and

treatment with a combination of antidepressant and antipsychotic medication.

Another episode specifier applies to women who become depressed or manic following pregnancy.

A major depressive or manic episode can be specified as having a postpartum onset if it begins within

4 weeks after childbirth.

Because the woman must meet the full criteria for an episode of major depression or mania, this

category does not include minor periods of postpartum "blues," which are relatively common.

A mood disorder (either unipolar or bipolar) is described as following a seasonal pattern if, over a

period of time, there is a regular relationship between the onset of a person's episodes and

particular times of the year.

Researchers refer to a mood disorder in which the onset of episodes is regularly associated with

changes in seasons as seasonal affective disorder.

Unipolar Disorders

People with unipolar mood disorders typically have their first episode in middle age; the average

age of onset is in the mid-forties.

DSM-IV-TR sets the minimum duration at 2 weeks, but they can last much longer.

In one large-scale follow-up study, 10 percent of the patients had depressive episodes that lasted

more than 2 years.

Most unipolar patients will have at least two depressive episodes.

The mean number of lifetime episodes is five or six.

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When a person's symptoms are diminished or improved, the disorder is considered to be in

remission, or a period of recovery.

Relapse is a return of active symptoms in a person who has recovered from a previous episode.

Approximately half of all unipolar patients recover within 6 months of the beginning of an episode.

The probability that a patient will recover from an episode decreases after 6 months, and 10 to 20

percent do not recover after 5 years.

Among those who recover, 50 percent relapse within 3 years.

Bipolar Disorders

Onset of bipolar mood disorders usually occurs between the ages of 28 and 33 years, which is

younger than the average age of onset for unipolar disorders.

The first episode is just as likely to be manic as depressive.

The average duration of a manic episode runs between 2 and 3 months.

The long-term course of bipolar disorders is most often episodic, and the prognosis is mixed.

Most patients have more than one episode, and bipolar patients tend to have more episodes than

unipolar patients.

Several studies that have followed bipolar patients over periods of up to 10 years have found that

40 to 50 percent of patients are able to achieve a sustained recovery from the disorder.

Incidence and Prevalence

· Unipolar depression is one of the most common forms of psychopathology.

· Among people who were interviewed for the ECA study, approximately 6 percent were suffering

from a diagnosable mood disorder during a period of 6 months.

· The ratio of unipolar to bipolar disorders is at least 5:1.

Lifetime risk for major depressive disorder was approximately 5 percent, averaged across sites in

the ECA program.

The lifetime risk for dysthymia was approximately 3 percent and the lifetime risk for bipolar I

disorder was close to 1 percent.

Almost half the people who met diagnostic criteria for dysthymia had also experienced an episode

of major depression at some point in their lives.

The National Comorbidity Survey produced even higher figures for the lifetime prevalence of

mood disorders; therefore the prevalence estimates for mood disorders in the ECA study are

probably conservative.

Slightly more than 30 percent of those people in the ECA study who met diagnostic criteria for a

mood disorder made contact with a mental health professional during the 6 months prior to their

interview.

Gender Differences

Women are two or three times more vulnerable to depression than men are.

The increased prevalence of depression among women is apparently limited to unipolar disorders.

Possible explanations for this gender difference have focused on a variety of factors, including sex

hormones, stressful life events, and childhood adversity as well as response styles that are

associated with gender roles.

Cross-Cultural Differences

Comparisons of emotional expression and emotional disorder across cultural boundaries encounter

a number of methodological problems.

One problem involves vocabulary.

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Cross-cultural differences have been confirmed by a number of research projects that have

examined cultural variations in symptoms among depressed patients in different countries.

These studies report comparable overall frequencies of mood disorders in various parts of the

world, but the specific type of symptom expressed by the patients varies from one culture to the

next.

In Chinese patients, depression is more likely to be described in terms of somatic symptoms, such

as sleeping problems, headaches, and loss of energy.

Depressed patients in Europe and North America are more likely to express feelings of guilt and

suicidal ideas.

These cross-cultural comparisons suggest that, at its most basic level, clinical depression is a

universal phenomenon that is not limited to Western or urban societies.

They also indicate that a person's cultural experiences, including linguistic, educational, and social

factors, may play an important role in shaping the manner in which he or she expresses and copes

with the anguish of depression.

Risk for Mood Disorders Across the Life Span

· Data from the ECA project suggest that mood disorders are most frequent among young and

middle-aged adults.

· Prevalence rates for major depressive disorder and dysthymia were significantly lower for people

over the age of 65.

· The frequency of bipolar disorders was also low in the oldest age groups.

The frequency of depression is much higher among certain subgroups of elderly people.

The prevalence of depression is particularly high among those who are about to enter residential

care facilities.

Elderly people in nursing homes are more likely to be depressed in comparison to a random sample

of elderly people living in the community.

People born after World War II seem to be more likely to develop mood disorders than were

people from previous generations.

The average age of onset for clinical depression also seems to be lower in people who were born

more recently; a pattern sometimes called a birth cohort trend.

At low levels and over brief periods of time, depressed mood may help us refocus our motivations

and it may help us to conserve and redirect our energy in response to experiences of loss and

defeat.

A disorder that is as common as depression must have many causes rather than one.

The principle of equifinality, which holds that there are many ways to reach the same outcome,

clearly applies in the case of mood disorders.

Social Factors

· The experience of stressful life events is associated with an increased probability that a person will

become depressed.

· Prospective studies have found that stressful life events are useful in predicting the subsequent

onset of unipolar depression.

· Although many kinds of negative events are associated with depression, a special class of

circumstances--those involving major losses of important people or roles--seem to play a crucial

role in precipitating unipolar depression.

Brown and his colleagues believe that depression is more likely to occur when severe life events are

associated with feelings of humiliation, entrapment, and defeat.

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Variations in the overall prevalence of depression are driven in large part by social factors that

influence the frequency of stress in the community.

Social Factors and Bipolar Disorders

· Some studies have found that the weeks preceding the onset of a manic episode are marked by an

increased frequency of stressful life events.

· The kinds of events that precede the onset of mania tend to be different from those that lead to

depression.

· While the latter include primarily negative experiences involving loss and low self-esteem, the

former include schedule-disrupting events (such as loss of sleep) as well as goal attainment events.

Some patients experience an increase in manic symptoms after they have achieved a significant goal

toward which they had been working.

Aversive patterns of emotional expression and communication within the family can also have a

negative impact on the adjustment of people with bipolar mood disorders.

Bipolar patients who have less social support are more likely to relapse and recover more slowly

than patients with higher levels of social support.

Stressful life events can also delay recovery from an episode of depression in bipolar patients.

The course of bipolar mood disorder can be influenced by the social environment in which the

person is living.

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