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					                         Mood Disorders

                         Theodore M. Godlaski
                         College of Social Work
                         University of Kentucky

Clients by Primary and Secondary Diagnoses, NASW PRN III 
                     0%     5%     10%   15%    20%   25%    30%   35%

        Mood Disorder

      Health Concerns
      Family Problems
      Anxiety Disorder

Substance Use Disorder
 Child/School Problems
    Couple's Problems
  Adjustment Disorder
    Psychotic Disorder

   Parent/Cbild Issues


NASW Practice Research Network, 2000 Survey, 
                 n = 2000

                       Some Basic Data
• Combined lifetime rates in the US for Major 
  Depressive Disorder and Dysthymia are 24.5%
  D      i Di d         d D th i         24 5%
   – 29.3% to 17.5% female to male differential.
• Combined 12‐month prevalence rates are 
     15.9% to 9.8% female to male differential. 
   – 15 9% to 9 8% female to male differential
   (Kessler, et al., 1994)

 Explanatory Theories and Models
• The array of theories and models put forward to 
  explain depression is truly mind boggling. 
  explain depression is truly mind boggling
• To say that it is caused by a disordering of serotonin 
  activity at the neural synapses is a tautology.
• Perhaps the most comprehensive approach is the 
  final common pathway phenomenon that implies a 
  phenotypic model.
  phenotypic model

Searching for a Theoretical Framework
  – A phenotype is the sum of the visible 
            ti    f         i th t
    properties of an organism that are 
    produced by the interaction of the 
    genotype and the environment.
  – It is the product of the interaction between 
    specific traits (temperament) and the 
     p              (   p          )

          A Phenotypic Model
• These traits interact with the environment, 
  over time, to create the behavioral 
  over time to create the behavioral
• The quality of interaction is determined by the 
  conjoint characteristics of the individual and 
  the social environment.
  What results is a phenotype that describes an 
• Wh t       lt i    h     t     th t d   ib
  individual prone to depression.

                          Shy, anxious             Social      Major Depressive
                         And withdrawn            isolation        Episode
                      Low              Mild school
                   soothability          phobia
High trait
             x                                                                     age


Low trait                                                                          Liability
                          Low      Overly    Demanding                             threshold
                                                                Deviant Demanding and
                       maternal restrictive   parenting
                                                                 peers stressful work
                      stimulation parental
                                 supervision                            environment
                         Tarter, R & Vanyukov, M. (1998). pp. 43-67.

              Common Final Pathway
  • The notion is that any number of possible genotypic 
    traits, influenced by any number of possible 
    traits, influenced by any number of possible
    environmental factors, eventually lead to depression.
  • Thus depression is the “common final pathway” to 
    which an nearly infinite number of roads lead.
  • This accords well with the high variability in the traits 
    and backgrounds of individuals who experience 
    depression as well as the large number of possible 
    d         i        ll   h l          b     f     ibl

 Depression as Adaptive Response
• There is a growing school of thought that sees 
  depression as an adaptive response to loss, failure, 
  depression as an adaptive response to loss failure
  or conflict.
• It signals others to expect little and elicits support 
  which does not require reciprocation.
• This cannot explain all forms of depression but does 
  seem applicable to the less virulent and time limited 
  seem applicable to the less virulent and time limited

           Subordination and Defeat
 • When organisms are confronted by conflict with a 
   dominant individuals they can fight, flee, or submit.
   dominant individuals they can fight, flee, or submit.
      – Fighting leads to winning or loosing.
      – Fleeing defers the conflict.
      – Submission can lead to re‐affiliation as a subordinate.
 • When all these options are thwarted, the result is a 
   defeated and depressed state.
   In this model, depression is the result of an  involuntary 
 • In this model depression is the result of an “involuntary
   defeat strategy” in which the individual cannot win, flee, 
   or affiliate.
 Sloman, L. & Gilbert, P. (2000) Subordination and defeat: An evolutionary approach to mood 
     disorders and their therapy. NY, Lawrence Earlbaum Assoc.

  win                                              defer             re-affiliate
                                       flight     conflict
      fight                           arrested                     submit

                           Involuntary subordinate
    arrested                   Self-perception                     arrested

                             defeated depression

            Non depression                                   Depression
    Assertion, anger results in win          Wants to fight but expects defeat and shame
  Take flight feel relieved at escaping        Escape blocked, may feel guilt at leaving
Submit and accept subordinate affiliation          Feels weak, inferior, and trapped
                                            Attempts at submission do not cause cessation
                                                              of conflict

         Aaron Beck’s Information Processing 
  • Beck is the originator of the cognitive approach to 
    understanding depression.
    understanding depression.
  • Basically he says that early adverse, stressful 
    developmental events tend to create a tendency 
    toward negative schemas and self‐appraisal which 
    can be activated by stressful events later in life 
    leading to increasingly negative schemas and self‐
    appraisal resulting in depressive symproms
    appraisal resulting in depressive symproms.
  • Recently, he has added new information from 
    neurobiological and genetic research.  

             Genetic diathesesis

           Reactive amygdala            Traumatic or stressful
                                        event(s) in early life
        Negative cognitive biases

     Exaggeration of stressful events

         Activation of HPA Axis

          Dominance of limbic
         over prefrontal function

   Deficient appraisal of negative events

          Depressive symptoms

     Aaron Beck’s Information Processing 
• Additionally, he maintains that subsequent 
     i d     fd        i        t “ki dli
  episodes of depression create a “kindling 
  effect” that increases the likelihood of future 
  episodes and of residual symptoms.
• Beck, A.T. (2008) The evolution of the cognitive model of 
  depression and its neurobiological correlates. American 
  Journal of Psychiatry; 165 (8): 969‐977.
  Journal of Psychiatry; 165 (8): 969 977

                   Mood Disorders
•   Major Depressive Episode
•   Manic Episode
•   Mi d Episode
    Mixed E i d
•   Hypomanic Episode
•   Major Depressive Disorder
•   Dysthymic Disorder
•   Bipolar I Disorder
•   Bipolar II Disorder
•   Cyclothymic Disorder
•   Bipolar NOS
•   Mood Disorder Due to General Medical Condition
•   Substance-Induced Mood Disorder
•   Mood Disorder NOS

          Major Depressive Episode
•   A. Five or more of the following SX present during the
    same 2 week period & represent a change from p
                  p            p              g      previous
    functioning. AND at least one of the SX is either: 1)
    depressed mood or 2) loss of interest or pleasure.
    – 1. depressed mood most of the day, nearly every day
    – 2. markedly diminished interest or pleasure in all or
       almost all activities nearly every day
    – 3. significant weight loss when not dieting
    – 4. insomnia or hypersomnia

         Major Depressive Episode
    – 5. psychomotor agitation or retardation
    – 6. fatigue or loss of energy
    – 7. feelings of worthlessness or excessive or
       inappropriate guilt
       i          i t    ilt
    – 8. diminished ability to think, to concentrate, to make
    – 9. recurrent thoughts about death
•   B. The SX do not meet criteria for a Mixed Episode
•   C. The SX cause clinically significant distress or
    impairment in social, occupational, or other areas of
•   D. The SX are not due to physiological effects of a
    substance or general medical condition.
•   E. The SX are not better accounted for by Bereavement
    (SX continue longer than 2 months, etc)

       Major Depressive Disorder
• Characterized by one or more major
  depressive episodes without a manic or
  hypomanic episode.
   – With multiple episodes, must be at least 2 months
   – Can be mild, moderate, severe without psychotic
     features, severe with psychotic features (either mood
         g                     g
     congruent or mood incongruent).  )
   – The actual diagnosis for an episode is Major Depressive
     Disorder, Single Episode. For two or more episodes it is
     Major Depressive Disorder, Multiple Episodes.

       Major Depressive Disorder
• 15% of those with HX of MDD die by suicide.
   – Lif i risk in women is 25%
     Lifetime i k i           i
   – Lifetime risk for men is 12%
• 60% of those with MDD may experience complete
  end of the disorder after TX. Other data suggests that
  among those who do not meet MDD criteria, 20%
  have d
  h            i SX just        h full di d
       depressive SX, j not the f ll disorder.
• Untreated episodes last 6 to 13 months.

       Major Depressive Disorder
• 40% still have SX one year later. Other studies
  suggest that 50% – 60% have a recurrence of MDD
  within two years (even with aggressive TX).
• Individuals with one episode have a 50% chance of a
  second, after the second, chances for a third increase
  to 70%, a third episode increases the chances of
  subsequent episodes to 90%.
• There is a high degree of co-occurrence with alcohol
  abuse and dependence.

       Major Depressive Disorder
• Men are more likely than women to experience
     h i ll i        i d
  a chronically impaired course.
• The course is often chronic with multiple
• Cessation of medication in 3 months or less
  almost always leads to reemergence of

                Dysthymic Disorder
• A. Depressed mood for most of the day, for more days than
                     y     j
  not as indicated by subjective account or observation byy
  others for at least 2 years.
• B. Presence, while depressed of 2 or more of the following:
   –   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

                Dysthymic Disorder
• C. During the 2-year period (1 year for children or
  adolescents) of the disturbance, the person has never been
  without the SX’s above for more than 2 months at a time.
• D. No MDE has been present during the first 2 years of the
  disturbance (1 year for children and adolescents) –i.e., it is
  not better accounted for by chronic MDD
• E. No Manic, Mixed, or Hypomanic episodes ever (has not
  met criteria for Cyclothymic Disorder

            Dysthymic Disorder
• F. The disturbance does not occur exclusively
  during a chronic Psychotic Disorder
• G. Not due to substance use, medication, or
  medical disorder.
• H. Symptoms are clinically significant and cause
  significant impairment or distress.
  You can specify “Early Onset” if onset before age 21, 
• Y            if “E l O       ” if      b f        21
  or “Late Onset” if after 21.

            Dysthymic Disorder
• Effects 5% to 6% overall and 30% to 50% of 
  samples from psychiatric clinics.
  samples from psychiatric clinics
• Often comorbid with MDD, anxiety disorder, 
  BPD, and substance use disorders.
• 15% to 20% symptom free after 1 year of Dx.
• Only 25% do not obtain complete recovery 
  over time.

                 Manic Episode
• A. A distinct period of abnormally and
      i t tl l t d              i      i it bl
  persistently elevated, expansive, or irritable
  mood, lasting at least 1 week.
• B. During the period of mood disturbance, 3
  or more of the following have persisted (4 if
  the mood is only irritable) and have been
  present to a significant degree:

                 Manic Episode
  – 1. Inflated self-esteem or grandiosity
  – 2 Decreased need for sleep (e g 3 hours)
    2.                            (e.g.,
  – 3. More talkative than usual – pressure of speech
  – 4. Flight of ideas or subjective belief that ideas are
  – 5. Distractibility
  – 6. Increase in goal-directed activity
  – 7. Excessive involvement in pleasurable activities that
    have high likelihood of negative consequences

                  Manic Episode
• C. The SX do not meet criteria for Mixed
  E i d
• D. The mood disturbance is severe enough
  to cause marked impairment, risk of harm,
  or requires hospitalization
• E The SX are not due to a general medical
  condition or use of a substance

                  Mixed Episode
• A. The criteria are met both for a Manic Episode and
  MDE (except for duration) nearly every day during at least
         (     p              )      y      y y         g
  a 1-week period.
• B. The mood disturbance is sufficiently severe to cause
  marked impairment in occupational or usual social
  activities or relationships or to necessitate hospitalization
  to prevent harm to self or there are psychotic features.
• C. The symptoms are not due to the direct physiological
  effects of a substance or general medical condition.

            Hypomanic Episode
• A. A distinct period of persistently elevated,
  expansive,               mood
  expansive or irritable mood, lasting at least 4 days
  that is clearly different from the non-depressed
• B. During the period of mood disturbance, 3 or
  more of the following SX’s have persisted (4 if the
  mood is irritable) and have been present to a
  significant degree:

            Hypomanic Episode
   – 1. Inflated self-esteem or grandiosity
   –2 D           d     d for l
     2. Decreased need f sleep (3 h hours) )
   – 3. More talkative than usual – pressure of
   – 4. Flight of ideas
   – 5. Distractibility
   – 6. Increase in goal-directed activity
   – 7. Excessive pursuit of pleasurable activities

             Hypomanic Episode
• C. The episode is associated with an unequivocal change in
             g                                p
  functioning that is uncharacteristic of the person when not
• D. The disturbance in mood and the change in functioning
  are observable by others.
• E. The episode is Not severe enough to cause marked
  impairment in social or occupational functioning or to
  necessitate hospitalization and there are not psychotic
• F. The SX’s are not due to the effects of a substance or a
  general medical condition.

               Bipolar Disorder I
• Presence of Manic Episodes (can alternate with
  Hypomanic Episodes) and MDE.
• Most often begins with depressive episode: 67%
  for men, 75% for women.
• About 10% - 20% of individuals experience only
  manic episodes.
• Untreated, manic episodes last about 3 months.
• Eventual interval between manic episodes is 6 – 9
  months, some experience 4 to 6 per year and are
  termed rapid cycling.

                 Bipolar Disorder I
• Can be single episode or recurrent
  Recurrent comes in 5 types:
• Recurrent comes in 5 types:
    –   Most recent episode hypomanic
    –   Most recent episode manic
    –   Most recent episode mixed
    –   Most recent episode depressed
    –   Most recent episode unspecified
• About 10% to 15% of individuals with recurrent 
  depressive episodes will eventually have a manic 

                 Bipolar Disorder II
• A. Presence of one or more MDE’s.
• B Presence of at least one Hypomanic Episode.
  B.                                       Episode
• C. There has never been a Manic Episode.
• D. The mood disorder in A and B above are not
  better accounted for by Schizoaffective Disorder
  and are not superimposed on any psychotic
• E. The Sx,s cause clinically significant distress or
  impairment in social, occupational, or other areas.

             Seasonal Fluctuation
• As with Light Sensitive Seasonal Affective 
  Disorder, Bipolar Disorder appears to be 
  Di d Bi l Di d                      t b
  seasonal in a significant number of cases.
• Recent research has indicated that it may 
  show more seasonal fluctuation than other 
  mood disorders.

Shin, K., et al. (2005) Journal of Affective Disorder. 86: 19-25

            Cyclothymic Disorder
• A. For at least 2 years (1 year in children and
  adolescents) the presence of numerous periods
  with hypomanic SX’s and depressive SX’s that do
  not meet the criteria for MDE.
• B. During the 2-year period, the person has not
  been without SX’s for more than 2 months at a
• C. No MDE, Manic or Mixed Episodes during the
  first 2 years of the disturbance.

             Cyclothymic Disorder
• D. The SX’s in A and B above are not better
  accounted for by Schizoaffective Disorder and are
  not superimposed on a psychotic disorder.
• E. The SX’s are not due to the direct physiological
  effects of a substance or a general medical
• F The SX’s cause clinically significant distress or
  impairment in social, occupational, or other areas.

             Cyclothymic Disorder
• If there are only hypomanic episodes without any symptoms 
  of depression, the diagnosis should be Bipolar Disorder Not
  of depression, the diagnosis should be Bipolar Disorder Not 
  Otherwise Specified.
• There has been very little study of this disorder.
• Some clinicians maintain that Borderline Personality Disorder 
  is actually a species of Cyclothymic Disorder.
   – 10% of outpatients and 20% of inpatients with BPD have coexisting 
     Cyclothymic Disorder.
     Cyclothymic Disorder.
   – Female to male ratio is 3 to 2
   – In 50% to 75% of cases onset is between 15 and 25 years of age.

Major Depressive Disorder must be   In Contrast to Major Depressive
differentiated from . . .           Disorder, the other condition . . .

Bipolar I or Bipolar II Disorder    Includes one or more Manic,
                                    Mixed, or Hypomanic Episodes

 ood so de             Ge e a
Mood Disorder due to a General       equ es general ed ca
                                    Requires a ge e a medical
Medical Condition                   condition as the etiology of
Substance Induced Mood Disorder     Is due to the direct physiologic
                                    effects of a substance

Dysthymic Disorder                  Characterized by depressed mood
                                    more days than not for at least 2
                                    years and no Major Depressive
                                    Episodes for those 2 years

Schizoaffective Disorder            Characterized by a period of at
                                    least 2 weeks of delusions or
                                    hallucinations in the absence of
                                    prominent mood symptoms

Major Depressive Disorder must be   In Contrast to Major Depressive
differentiated from . . .           Disorder, the other condition . . .
Schizophrenia, Delusional Disorder, May include mood symptoms that
Psychotic Disorder NOS              are brief relative to the total
                                    duration of the psychotic
Dementia                            Characterized by premorbid history
                                    of declining cognitive functioning
Adjustment Disorder with            Depressive symptoms occur in
Depressed Mood                      response to a stressor and do not
                                    meet criteria for Major Depressive
Bereavement                         Occurs in response to the loss of a
                                    loved one and is generally less
                                    severe the Major Depressive
                                    Episode or lasts for about 2 months
Nonpathological periods of sadness Characterized by short duration,
                                   few associated symptoms, and lack
                                   of functional impairment

      Mood Disorders in Children
• Most frequent symptoms of depression common to 
  children and adolescents:
  children and adolescents:
   – Suicidal ideation, depressed or irritable mood, insomnia, 
     difficulty concentrating
• Symptoms most common in children:
   – Mood‐congruent auditory hallucinations, somatic 
     complaints, withdrawal and sad appearance, poor self‐
• Symptoms most common in adolescents:
   – Pervasive anhedonia, severe psychomotor retardation, 
     delusions, sense of hopelessness 

      Mood Disorders in Children
• Suicide in children and adolescents
   –I         d i    1950 f     2 5 t 11 2/100K
     Increased since 1950 from 2.5 to 11.2/100K
   – Among 15 to 19 year olds 13.6/100K for males, 3.6/100K 
     for females.
   – <14 yrs. 50 attempts per 1 completion
   – >14 yrs. 15 attempts per 1 completion
   – Most often involve Mood Disorder
   – Often, but not always, related to chaotic and stressful 
     family situations.

Mood Disorders of Specific Etiology
• Mood Disorder Due to a General Medical Condition
   – Degenerative Neurological Illness
       • Parkinson’s Disease, Huntington’s Disease
   – Cerebrovascular Disease
       • Stroke
   – Endocrine Conditions
       • Hypo‐ and Hyperthyroidism
       • Hypo‐ and Hyperadrenocorticism
   – Autoimmune Conditions
       • Lupus erythematosus
   – Viral and Other Infections
       • Hepatitis, mononucleosis, HIV
   – Certain Cancers
       • Carcinoma of the pancreas

     Mood Disorder Due to a General 
          Medical Condition
• A prominent and persistent disturbance in 
      d   d i t        h     t i db ”
  mood predominates, characterized by”
   – 1. Depressed mood or diminished pleasure
   – 2. elevated, expansive, or irritable mood
• There is evidence from history, PE, or labs that 
  the disturbance is a direct consequence of a 
  the disturbance is a direct consequence of a
  general medical condition

    Mood Disorder Due to a General 
         Medical Condition
• The disturbance is not better accounted for by 
  another mental disorder
  another mental disorder
  – Adjustment Disorder with Depressed Mood in 
    response to having a general medical condition
• The disturbance does not occur exlusively 
  during delirium
  The symptoms cause clinically significant 
• Th       t            li i ll i ifi t
  impairment or distress

Mood Disorders of Specific Etiology
• Substance Induced Mood Disorders
  – Can be caused by intoxication, withdrawal, side 
    effects of medication, or toxic effects of a variety 
    of substances
  – Is reserved for situations in which the mood 
    symptoms are especially noteworthy.

Substance Induced Mood Disorders
• A prominent and persistent disturbance in mood 
  predominates, characterized by
  predominates, characterized by”
   – 1. Depressed mood or diminished pleasure
   – 2. elevated, expansive, or irritable mood
• There is evidence from history, PE, or labs that 
   – 1. The symptoms above developed within a month after 
        bt     i t i ti          ithd
     substance intoxication or withdrawal   l
   – 2. Medication use is etiologically related to the disturbance

Substance Induced Mood Disorders
• The disturbance is not better accounted for by a 
  mood disorder that is not substance induced.
  mood disorder that is not substance induced
   – The disturbance precedes substance use
   – The disturbance continue long after substance cessation
   – The disturbance is in excess of what could be expected 
     given the quantity and duration of substance use.
  The disturbance does not occur exclusively during 
• The disturbance does not occur exclusively during
• Cause clinically significant impairment or distress

             Eating Disorders

             Eating Disorders
• The hallmark of these disorders is a distorted 
         ti    fb d i           d      t      f
  perception of body image and an extreme fear 
  of weight gain.
• These disorders are specific to the developed 
  world, most specifically the US.
  They effect females far more often than 
• They effect females far more often than

• Prevalence conservatively estimated at .5%
     1 0%
  to 1.0% for Anorexia Nervosa - some place
  as high as 4% for eating disorders as a
• Mean onset at age 17 with peaks at 14 and
• G d distribution – 90% of th
  Gender di t ib ti                     ith
                               f those with
  eating disorders are female

• Familial/genetic factors – shows heritability, also
  associated in family histories with depression, OCD, ETOH
• Endogenous opioids may play a role in denial and in the
  reported mental states associated with anorexia
• Mortality is 5% to 18% during the condition
• Even among those who recover, the path is not clear
   – D                ii                    l f         l    ii
     Damage to cognitive systems can result from malnutrition andd
   – Susceptibility to other psychiatric conditions is increased


• A. Refusal to maintain body weight at or above a
  minimally normal weight for age & height – a
  weight less than 85% of that expected – or failure
  to make weight gain during period of growth
  resulting in less than 85% of that expected.
   – (wt. in kg/height in m2 <17.5 kg/m2)
• B Intense fear of gaining weight or becoming fat
  even though under weight.

 • C. Disturbance in the way in which
   one’s body weight or shape is
   experienced, undue influence of body
   weight or shape on self-evaluation, or
   denial of the seriousness of the current
   low body weight.
 • D. In postmenarcheal females,
   amenorrhea for 3 consecutive cycles

 • Restricting Type – has not done binge eating or
   – Controls weight through strict dieting or fasting and
   – Tends to have compulsive personality characteristic,
     is rigid, inflexible, and adheres strictly to rules and
     is morally scrupulous.
 • Binge-Eating/Purging Type
   – during the episode of Anorexia, regularly binged or
     purged or both, or used laxatives, diuretics, or
   – More likely to engage in impulsive behaviors and
     substance abuse

• Prevalence is 1%-3% among adolescent
  females, .1%-.3% among adolescent males
  f    l    1% 3%             d l      t    l
• Familial pattern – same as anorexia – some
  indication of association with obesity, but
  not definitively known yet.

• A. Recurrent episodes of binge eating –
  characterized by both of the following:
  – (1) eating, in a discrete period of time (e.g., 2 hours) an
    amount of food that is definitely larger than most
    people would eat during a similar period under same
  – (2) a sense of lack of control over eating during the
       i d (         f li     h                        i
    episode (e.g., a feeling that one cannot stop eating or
    control what or how much one is eating.

 • B. Recurrent inappropriate
   compensatory behavior in order to
                                 self induced
   prevent weight gain, such as self-induced
   vomiting, misuse of laxatives, diuretics
   enemas or other medications, fasting or
 • C. The binge eating and inappropriate
   compensatory behaviors both occur, on
   average, at least twice a week for 3

• D. Self-evaluation is unduly influenced by
  body weight and shape.
• E. The disturbance does not occur exclusively
  during d i d f
  d i and episode of anorexia.   i
• PURGING TYPE: during the current episode,
  has regularly engaged in self-induced vomiting
  or misuse of laxatives, diuretics or enemas.
• NONPURGING TYPE: during the episode has
  used other inappropriate compensatory
  behaviors such as fasting, excessive exercise,
  but has not purged.

           Sub Typing of Bulimia 
• Based on 178 bulimic women with comorbid 
  psychopathology (depression anxiety substance
  psychopathology (depression, anxiety, substance 
  use, impulsivity, self‐destructive behavior, and 
   – Affective‐Perfectionistic Cluster
       • Most severe level of symptoms and preoccupation with body 
         shape and weight.
     Impulsive Cluster
   – Impulsive Cluster
       • Highest level of dissocial behavior and lowest levels of 
   – Low Comorbid Cluster
       • Most numerous, lowest levels of all pathologies. 
   Wonderlich, S., et al. (2005) Psychological Medicine, 25: 649-657


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