MODULE 4: MOOD DISORDERS

Module Overview

In Module 4, matters related to mood disorders to include their clinical presentation,

epidemiology, comorbidity, etiology, according to DSM are covered. Discussion will
include Major Depressive Disorder, Persistent Depressive Disorder (formerly
Dysthymia), Bipolar I disorder, Bipolar II disorder, and Cyclothymic disorder.

Module Outline

 4.1. Clinical Presentation – Depressive Disorders

 4.2. Clinical Presentation – Bipolar Disorders
 4.3. Epidemiology
 4.4. Comorbidity
 4.5. Etiology

Module Learning Outcomes

 Describe the clinical presentations of depressive and bipolar disorders.

 Describe the epidemiology, etiology, comorbidity and treatment of mood
disorders.

4.1. Clinical Presentation – Depressive Disorders

Section Learning Objectives

 Identify and describe the two types of depressive disorders.

 Classify symptoms of depression.

Within mood disorders are two distinct groups- individuals with depressive
disorders and individuals with bipolar disorders. The key difference between
the two groups is that those in the depressive disorder
category only experience symptoms of depression, while those in the bipolar
disorder category have periods of mania/hypomania that alternate with
periods of depression.

The two most common types of depressive disorders are Major Depressive
Disorder and Persistent Depressive Disorder.
Persistent Depressive Disorder, previously known as Dysthymia, is thought to be
a more chronic, less severe depression.

In order to be diagnosed with either major depressive disorder or persistent depressive

disorder, the individual must never have had a manic or hypomanic episode.

Symptoms of depression can generally be categorized into four categories to include

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 and/or feelings of anhedonia, which is the loss
of interest in previously interesting activities.

Behavioral. Behavioral issues such as decreased physical activity and reduce

productivity- both at home and at work- are often observed in individuals with
depression. This is typically where a disruption in daily functioning is observed as
individuals with depressive disorders are unable to maintain their social interactions
and employment responsibilities.

Cognitive. 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.
They also report difficulty concentrating on tasks, as they are easily distracted from
outside stimuli. Finally, thoughts of suicide and self-harm do occasionally occur in
those with depressive disorders.

Physical. Changes in sleep patterns are often common: excessive sleeping and
insomnia. 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 suggest that these symptoms are a component of the disorder
rather than a secondary symptom of sleep disturbance.

Additional physical symptoms include change in weight or eating behaviors. Some

individuals report a lack of appetite and others eat excessively, often seeking “comfort
foods” such as those high in carbohydrates.

Psychomotor agitation or retardation, which is the purposeless or slowed physical

movement of the body (i.e. pacing around a room, tapping toes, restlessness etc.) is
also reported in individuals with depressive disorders.

Major depressive disorder and persistent depressive disorder are diagnosed according
to the criteria earlier mentioned. Although symptoms for both are nearly identical, the
time frame of symptoms are significantly different, with symptoms presenting
for a 2-week period for major depressive disorder and symptoms present
for majority of 2-years for persistent depressive disorder.
 4.2. Clinical Presentation – Bipolar Disorders

Section Learning Objectives

 Distinguish the forms bipolar disorder takes.

 Describe manic episode.
 Define cyclothymic disorder.

There are two types of Bipolar Disorder- Bipolar I and Bipolar II.

A diagnosis of Bipolar I Disorder is made when there is at least one manic episode.
This manic episode can be preceded by or followed by a hypomanic or major
depressive episode.

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.

In more simple terms, if an individual has ever experienced a manic episode, they
qualify for a Bipolar I diagnosis; however, if the criteria has only been met for a
hypomanic episode, the individual qualifies for a Bipolar II diagnosis.

The key feature of a manic episode is a specific period of time in which an individual
experiences abnormally, persistently, expansive or irritable mood for nearly all day,
every day, for at least one week which is manifested in increased activity or energy;
and excessive happiness. There is also a display of rapid shifts in mood, also known
as mood lability, ranging from happy, neutral, to irritable.

Inflated self-esteem, or grandiosity is also present during a manic episode.

Occasionally these inflated self-esteem levels can appear delusional. Individuals may
believe they are friends with a celebrity, do not need to abide laws, or even at times
think they are God.

Experiencing a manic episode also require a decreased need for sleep, which may be
an indicator that it is to begin imminently.

Rapid, pressured speech is common. It can be difficult to follow their conversation due
to the fast nature of their talking, as well as the tangential story telling. Manic episodes
are also marked by racing thoughts and flights of ideas. Because of these rapid
thoughts, speech may become disorganized or incoherent.

There are a subclass of individuals who experience periods of hypomanic symptoms

and mild depressive symptoms (i.e. do not fully meet criteria for a depressive episode).
These individuals are diagnosed with cyclothymic disorder. Presentation of these
symptoms occur for two or more years, and are typically interrupted by periods of
normal moods. While only a small percentage of the population develop cyclothymic
disorder, it can eventually progress into bipolar I or bipolar II disorder.

Bipolar I and Bipolar II disorder also require the presence of a Major Depressive
Episode. The Major Depressive Episode can occur before or after the
manic/hypomanic episode, as the two types of episodes will alternate or “cycle”
throughout one’s life.

4.3. Epidemiology

Section Learning Objectives

 Describe the epidemiology of depressive & bipolar disorders and suicidality.

4.3.1. Depressive Disorders

Individuals in the 18- to 29- year-old age bracket has the highest rates of depression
than any other age group. Depression is approximately 1.5 to 3 times higher in females
than males.

4.3.2. Bipolar Disorders

Significantly lower prevalence rate for both bipolar I and bipolar II compared to
depression. There are no apparent differences in the frequency of men and women
diagnosed with bipolar I; however, bipolar II appears to be more common in women.

4.3.3. Suicidality

Suicidality in depressive disorders, particularly bipolar disorder, is much higher than

the general public. In depressive disorders, males and those with a past history of
suicide attempts/threats are most at risk for attempting suicide. Individuals with
bipolar disorder are approximately 15 times greater than the general population to
attempt suicide.

4.4. Comorbidity

Section Learning Objectives

 Describe the comorbidity of depressive and bipolar disorders.

4.4.1. Depressive Disorders

Show a substantial pattern of comorbidity with other mental disorders, particularly

substance use disorders. Among those that are the most common are anxiety disorders
and ADHD.

Majority of the studies have identified most depression cases occur secondly to
another mental health disorder meaning that the onset of depression is a direct result
to the onset of another disorder.

4.4.2. Bipolar Disorders

Bipolar disorder also has a high comorbidity rate with other metal disorders,
particularly anxiety disorders and any disruptive/impulse-control disorders such as
ADHD and Conduct Disorder. Substance abuse disorders are also commonly seen in
individuals with Bipolar Disorder.

4.5. Etiology

Section Learning Objectives

 Describe the biologica, cognitive, behavioral, and sociocultural causes of mood

disorders.

4.5.1. Biological

There is nearly a 30 percent increase in relatives diagnosed with depression, compared

to 10 percent of the general population. There is also an elevated prevalence among
first-degree relatives for both bipolar I and bipolar II disorders as well.

There is nearly a 46% chance that if one identical twin was diagnosed with depression,
that the other was as well.

There is some evidence that depression may be tied to the 5-HTT gene on chromosome
17, as this is responsible for the activity of serotonin.

Bipolar disorder yield concordance rates for identical twins at as high as 72%, and 5-
15% for fraternal twins, siblings, and other close relatives.

Low activity levels of norepinephrine and serotonin have long been documented as
contributing factors to developing depressive disorders.

Mania episodes may in fact be explained by low levels of serotonin and high levels of
norepinephrine.
Cortisol was found responsible in the development of depression. 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
(seasonal affective disorder).

Drastic changes in blood flow throughout the prefrontal cortex has been linked with
depressive symptoms. Smaller hippocampus, and consequently, fewer number of
neurons, have also been linked to depressive symptoms. Finally, heightened activity
and blood flow in the amygdala, is also consistently found in individuals with
depressive symptoms.

4.5.2. Cognitive

One theory often equated with the cognitive model of depression is learned
helplessness. Animals essentially learn that they are unable to avoid shock and
therefore, learn that they are helpless in avoiding the shocks. When being placed in a
similar environment but have the opportunity to escape the shock, their learned
helplessness are carried over and they continue to believe they are unable to escape
the shock.

Individuals with a negative attributional style are more likely to experience depression.
This is likely due to their negative interpretation of daily events.

Negative thinking is a precursor to depressive disorders.

Maladaptive attitudes, or negative attitudes about one self, others, and the world
around them, are often present in those with depressive symptoms. The cognitive
triad also plays into the maladaptive attitudes in that the individual interprets these
negative thoughts about their experiences, themselves, and their futures.

Cognitive distortions, also known as errors in thinking, such as catastrophizing,

jumping to conclusions, and overgeneralization are linked with depressive disorders

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.

4.5.3. Behavioral

The behavioral model explains depression as a result of change in the number of

rewards and punishments one receives throughout their life. Depression occurred in
most people due to the reduced positive rewards in their life. Because they were not
being positively rewarded, their constructive behaviors occurred more infrequently
until they stop engaging in the behavior completely

4.5.4. Sociocultural
Depression is related to the unavailability of social support. 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.

Stress and marital discord leads to increased rates of depression in one or both
spouses. Women who had three or more young children who also lacked a close
confidante and outside employment, were more likely that other mothers to become
depressed.

One’s cultural background may influence what symptoms of depression are

presented. Common depressive symptoms such as feeling sad, lack of energy,
anhedonia, difficulty concentrating and thoughts of suicide are hallmark in most
societies, other symptoms may be more specific to one’s nationality.

The fartifact theory- suggests that the difference between genders is due to clinician
or diagnostic systems being more sensitive to diagnosing women with depression than
men. Men and women are equally likely to seek out treatment and discuss their
depressive symptoms.

The hormone theory– suggests that variations in hormone levels trigger depression in
women more than men.

The life stress theory- suggests that women are more likely to experience chronic
stressors than men, thus accounting for their higher rate of depression.

The fourth theory- gender roles theory- suggests that social and or psychological
factors related to traditional gender roles also influence the rate of depression in
women. For example, men are often encouraged to develop personal autonomy, seek
out activities that interest them, and display achievement oriented 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