Unit 2 Mood Disorders*

Structure
2.0 Objectives
2.1 Introduction
2.2 Mood Disorders: An Introduction
2.3 Unipolar Mood Disorders
2.3.1 Major Depressive Mood Disorders
2.3.2 Dysthymia/Persistent Depressive Disorders
2.3.3 Additional Defining Criteria for Depressive Disorders: Specifiers
2.4 Causal Factors of Unipolar Mood Disorders
2.4.1 Biological Factors
2.4.2 Psychosocial Factors
2.4.3 Theoretical Perspectives on Unipolar Depression
2.5 Bipolar Mood Disorders
2.5.1 Manic Episode
2.5.2 Types of Bipolar Disorders
2.5.3 Additional Specifiers for Bipolar Disorders
2.6 Causal Factors of Bipolar Mood Disorders
2.6.1 Biological Factors
2.6.2 Psychosocial Factors
2.7 Sociocultural Causal Factors of Mood Disorders
2.8 Treatment of Mood Disorders
2.8.1 Biological Treatment
2.8.2 Psychotherapy
2.9 Suicide
2.10 Let Us Sum Up
2.11 References
2.12 References for Images
2.13 Key Words
2.14 Answers to Check Your Progress
2.15 Unit End Questions
2.16 Web Resources

2.0 OBJECTIVES
After reading this Unit, you will be able to:
●● explain the nature of mood disorders;
●● differentiate between unipolar and bipolar mood disorders; Discuss
the different types of unipolar and bipolar disorders;
* Dr. Itisha Nagar, Assistant Professor, Kamla Nehru College, University of Delhi, New
delhi:
45
Mental Disorders- II ●● identify the causal factors underlying unipolar and bipolar disorders;
●● discuss the treatment approaches for mood disorders; and
●● elucidate suicide.

2.1 INTRODUCTION
Academic Counsellor Dr. Mahima was again having session with her
learners and they were discussing about certain psychological disorders.
Let us have a look at their conversation.
Dr. Mahima: Hello learners.
Learners: Hello Maam.
Dr. Mahima: So in the last session we discussed about schizophrenia. Can
any one of you tell me about it.
Jenny (Learner): Maam, we discussed that schizophrenia is a broad
spectrum of condition that affects individual’s cognitive and emotional
functioning including delusions and hallucinations, disorganised speech,
behaviour and inappropriate emotions.
Seema (Learner): And Maam, the symptoms of schizophrenia can be
categorised in to positive symptoms, negative symptoms and disorganised
symptoms.
Dr. Mahima: Yes Jenny and Seema, that correct. What else did we cover in
the session?
Rizwana (Learner): And Maam, we also discussed about various biological,
psychosocial and cultural causes of schizophrenia.
Sameer (Learner) : Also Maam, we looked at the treatment of schizophrenia.
Dr. Mahima: Yes thats correct. Well learners, in todays session, we will
discuss about another significant psychological disorder that is mood
disorder.
Navjyot (Learner): Maam, does this have to do with mood swings?
Dr. Mahima: Well Navjyot, it is definitely more than mood swings and can
be explained as serious changes in a person’s mood that may lead to distress
and dysfunction. And mood disorders are mainly classified in to unipolar
and bipolar mood disorders. So let’s discuss mood disorders further.
Learners: Yes Maam.
In the present Unit, we will look into mood disorders, their prevalence,
causal factors and the treatment options. A serious aspect of mood disorder
is suicide. The last section of this Unit will focus on, suicide and suicidal
ideation.

2.2 MOOD DISORDERs: AN INTRODUCTION

Mood disorders are serious changes in one’s mood that may lead to distress
and dysfunction. Mild mood disturbances are on the same continuum as
mood disorders. A typical person experiencing fluctuations in mood in
every day life is different from a person with mood disorder only in terms
of degree and not in the kind of emotions experienced (see Fig. 2.1). This
46
is known as dimensional approach to mood disorders. People are able to Mood Disorder
bounce back from periods of sadness/euphoria to normalcy,unlike people
with mood disorders. Typically, a person is able to “feel normal” after a
short duration of time. They experience relatively greater degree of control
over their mood than people with mood disorder.
A discussion on mood disorders warrants a distinction to be made between
the terms ‘mood’ and ‘emotion’. Emotions are short-lived affect with
usually a known cause. However, mood is longer lasting emotions with no
clear starting point. There are diverse kinds of emotions such as joy, pride,
anger, guilt, sad, etc. whereas, mood is classified as positive or negative.

Fig, 2.1 Depression-Elation Continuum

(Source: http://www.stomponstep1.com/mood-disorders-major-depressive-
disorder-bipolar-type-1-cyclothymia-hypomania-mdd/)
Studies indicate the incidence rate of mood disorders is on the rise. Almost
20 percent of adults and 50 percent of youth report recent symptoms of
depression Kessler (2002). According to World Health Organisation
(2012), approximately 9 percent of people in India have reported having
an extended period of depression within their lifetime. Relative to unipolar
mood disorder, bipolar disorder is less common with lifetime prevalence
rate to be about 3.9 percent. Average age of onset is somewhat younger for
bipolar disorders than unipolar disorders. For Bipolar I disorder is 18 years
and for Bipolar II is between 19-22 years, although cases of both can begin
in childhood. It is considered rare for someone to develop bipolar after
the age of 40 years. Gender differences in unipolar disorder as seen with
higher number of women (2:1) receiving diagnosis of depression. However,
gender differences are not present for bipolar disorder. With respect to the
age of onset, although severe depression and dysthymia usually begin in late
adolescence or early adulthoods (mid 20s), but they can occur at any age.
It is not uncommon for many adults to have depression for several years
before seeking treatment; diagnosis is most common between the ages of
30-59 years. Studies have found that less than half of the people with major
mood disorders sought treatment. Mood disorders are highly comorbid with
anxiety, personality disorders and substance abuse disorder.
Mood disorders are classified as unipolar and bipolar disorder. Bipolar
disorder was earlier known as manic-depression. Figure 2.2 illustrates the
types of mood disorders.
47
Mental Disorders- II
Mood Disorder

Unipolar Mood Bipolar Mood

Disorder Disorder

Major Depressive Bipolar I

Disorder (MDD)

Dysthymia Bipolar II

Cyclothymia

Fig. 2.2: Types of Mood Disorders

In the next sections of this unit, let us now focus on unipolar and bipolar
mood disorders.

2.3 UNIPOLAR MOOD DISORDERS

In unipolar mood disorders, a person experiences extraordinary sadness/
depression. The types of unipolar mood disorder are major depression
(clinical depression), and persistent mood disorder (dysthymia in DSM-IV).
On the basis of duration and severity of depressive symptoms, unipolar mood
disorder is classified into two types namely, Major Depressive Disorder
(MDD) and dysthymia/Persistent Mood Disorder. MDD is considered to
be more severe but of shorter duration, whereas dysthymia is relatively
less intense but lasts for a longer duration. Generally, the symptoms of
depression can be classified as affective, cognitive, and physical.
2.3.1 Major Depressive Disorder
Rajesh a 38-year-old unemployed man had been feeling frustrated with
his life over the past few months. Family reports that that they noticed a
number of changes in him after he lost a lot of money in a business venture.
He began to spend a lot of time alone in his room; his mother would serve
him food but he would not eat it, instead would just stare at it. He used to
enjoy going for morning walks and spend time with his children, but lately
had stopped doing both. Initially, the family thought that he was upset over
the failure of his business, and would soon “snap out of it”. But over the
period of next few days he became more and more miserable and refused
to talk to anyone. He would sleep till the afternoon and then spend most of
his day on his bed. The family brought him to a psychiatrist after they found
him one morning standing by the window crying uncontrollably and saying
he just wanted to end everything.

48
uncontrollably and saying he just wanted to end everything.

Mood Disorder
Symptoms of Depression

Affective Physical Cognitive

Depressed mood Agitation or Feelings of

psychomotor worthlessness or
retardation excessive guilt
noticed by others

Anhedonia

Insomnia or Diminished ability

hypersomnie to think or
concentrate or
indecisiveness
SigniÞcant
unintentional
weight loss or
gain Recurrent
thoughts of death

Fatigue of loss of
energy

Fig. 2. 3: Symptoms of Major Depressive Disorder (DSM-5)

Fig. 2. 3: Fig. 2. 4: Symptoms of Major Depressive Disorder (DSM-5)
Major Depressive Disorder (MDD) is one of the most easily recognised
depressive disorders; it is defined by absence of manic or hypomanic episode
before or during the disorder. According to DSM-5, a person experiencing
MDD episode has depressed mood and/or loss of interest or pleasure in life
activities for at least two weeks (APA, 2000). MDD is an episodic disorder,
that is, the symptoms are present for a period of time and then the person
recovers. An untreated episode may stretch for 4-9 months. Generally, MDD
consists of recurrent episodes of severe depression; approximately 40 to 50
percent of people with initial episode will go on to experience another episode
(Monroe & Harkness, 2011).The probability of recurrences increases with
the number of prior episodes. Occurrences of isolated depressive episodes
are rare. Thus, MDD is usually a chronic condition, consisting of recurrent
depressive episode, with average number of episodes for an individual to be
four. DSM-5 lists the nine symptoms for MDD episode; a person needs to
be diagnosed with five out of nine symptoms for diagnosis. While making
diagnosis for depression, it is important to specify whether it is: (1) initial/
first episode, (2) recurrent episode (preceded by one or more previous
episodes separated by at least two months with recover in between), or (3)
chronic (although rare, in some cases major depression does not remit for
over 2 years.
The symptoms of major depressive disorder include:
Depressed mood most of the day: Depression is not temporary sadness that
lasts for a day or two or only part of the day. It is experience of significantly
low mood for different times of the day for almost every day of the week.
49
Mental Disorders- II For instance, Rajesh was upset and was found crying uncontrollably for
almost every day of the week.
Anhedonia/loss of pleasure: MDD is not just a state of high negative
affect but also low positive affect. In fact, anhedonia or the loss of ability to
experience pleasure is considered to be far more characteristic of severity of
MDD, than reports of distress/sadness. A person suffering from MDD may
lose interest in all those activities that they may have found enjoyable such
as going to school/work, being with friends and family, watching movies,
eating good food, and hobbies. The individual may withdraw from people
and activities as they no longer gets pleasure from them. Rajesh enjoyed
going for morning walks and spending time with his children, but had
stopped doing both.
Psychomotor retardation or agitation noticed by others: Evidence
suggests that the most central indicator along with anhedonia is a somatic or
vegetative state. A person with MDD exhibits “behavioural and emotional
shutdown.”It is described as feeling “slowness” or having trouble in
gathering “energy to get up”. Consequently, the person might want to just
lie all day on the couch, surf internet, watch TV, or sleep a lot. For instance,
Rajesh found it hard to get up every morning and get out of his bed. People
with very severe cases may be so slowed down that they may not move
any muscles for hours (vegetative state). While some people experience
psychomotor retardation, others, may find it extremely difficult to sit still.
They are likely to be in a state of psychomotor agitation, pacing about in
a room, wringing one’s hands, pulling off clothing and putting it back on,
continuously fiddling with objects, keeping them down, and then fiddling
again, and other similar actions.
Fatigue or loss of energy: Apart from psychomotor retardation, physical
symptoms of depression include fatigue and low energy as well as physical
aches and pains. Such symptoms may make people believe that they may be
suffering from some medical condition, even though there are no physical
cause for the aches and pains.
Insomnia or sleeping too much (hypersomnia): Although some people
with MDD may experience exhaustion, aches and pains, they may find
it difficulty in sleeping and may wake up frequently. They may wake up
very early each morning, lying in bed until it is time to rise (early morning
wakening). Conversely, some people like Rajesh may have a heavy feeling
of fatigue and loss of energy that leads to over sleeping. Over sleeping may
be seen as a way to escape the extreme sadness felt in awake states.
Significant unintentional weight loss or gain: People with depression may
fail to eat complaining of finding food to taste bland or not feeling hungry
thereby losing significant amount of weight. Unlike Rajesh who had stopped
eating when offered food by his mother, other people with depression may
often overeat to compensate for experience of intense sadness.
Feelings of worthlessness and guilt about things beyond their control:
Cognitive symptoms of depression include increased focus on one’s flaws
and deficits. The individual is likely to be highly self-critical, for instance
they may blame themselves for not being a good son, friend, or father, may
call themselves “good for nothing”, “useless”, “stupid”, “not good enough”,
50
“loser” etc. A victim of abuse may continue to blame themselves for their Mood Disorder
condition.
Diminished ability to think or concentrate, or indecisiveness: Another
cognitive symptom of depression is the inability to pay attention or make
decisions. Patients of depression describe that paying attention can prove to
be very exhausting, leading to problems at work and school. The inability
to perform well at work and school further deteriorates feeling of worth and
self-esteem.
Recurrent thoughts of death: Low positive affect, high negative affect,
problems with sleeping, eating, loss of energy, and feelings of worthlessness
and lack of concentration may make an individual feel utterly dejected and
hopeless. There is a high risk for suicidal ideation and suicide attempts in
such individuals. Suicidal ideation refers to morbid thoughts and fantasies
about dying, funerals, self-destructive behaviours, such as cutting and
burning.
A conversation between a therapist and client who is severely depressed
Therapist: Can you tell me what do you have planned for today?
Client: (long pause) Well... not sure... might get up today.
Therapist: Ok, what next... after getting up? Client: Well... (long pause)
Therapist: Yes.... go on...
Client: I don’t know. I really just want to sleep.
(Kearney & Trull, 2012, p.176)

Fig.2.4: Specifiers of Major Depressive Disorder

51
Mental Disorders- II
Box 2.1: DSM-5 Criteria for Major Depressive Disorder (APA,2013)
A. The individual must be experiencing five or more symptoms during
the same 2-week period and at least one of the symptoms should be
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 most of the day, nearly every day.
3)   Significant weight loss when not dieting or weight gain, or
decrease or increase in appetite nearly every day.
4) Sleep disturbance (insomnia or hypersomnia)
5)   A slowing down of thought and a reduction of physical
movement (observable by others, not merely subjective feelings
of restlessness or being slowed down).
6) Fatigue or loss of energy nearly every day.
7) Feelings of worthlessness or excessive or inappropriate guilt
nearly every day.
8)   Diminished ability to think or concentrate, or indecisiveness,
nearly every day.
9)   Recurrent thoughts of death, recurrent suicidal ideation without
a specific plan, or a suicide attempt or a specific plan for
committing suicide.
B. At least one of the symptoms is anhedonia or low mood.
C. The symptoms cause clinically significant distress or impairment in
social, occupational or other important areas of functioning.
D. The episode is not attributable to the physiological effects of a
substance or another medical condition.
E. There has never been a manic episode.
2.3.2 Dysthymia/Persistent Depressive Disorder
Mihir is an 18-year-old college student went to college counsellor
because he felt that he was suffering from ‘depression’. Even though he
was performing well in class, he complained of feeling a constant sense of
tiredness. However, along with feeling tiredness, he also felt blue, down and
hopeless since “a very long time”. He described himself as being a loner
and did not have any friends since school. He felt nobody wanted to be
his friend because he was uninteresting and boring person. He shared that
his parents would constantly fight; his mother wanted to separate from her
abusive husband but was unable to do so because she was concerned about
Mihir’s future.It soon became clear that he never really felt loved by his
parents. Mihir admited experiencing a vague sense of guilt for his parent’s
conflicted relationship,”lives of my parents would have been better if I was
never been born.”
Dysthymia or Persistent Depressive Disorder as DSM-5 calls it, shares
many features with Major Depressive Disorder, but is different in two
regards. First, dysthymia has fewer and less intense symptoms and second,
52
depression lasts for a long period. Depressed mood in dysthymia may last Mood Disorder
for most of the day, but the depression is of mild-to-moderate intensity.
The central feature of dysthymia is its chronicity, DSM-5 specifies, chronic
feeling of depression for at least two years. On an average, people with
dysthymia have had mild-moderate symptoms for five years, but in some
cases, it may last for 20 years or more. It includes intense feeling of being
sad most of every day with relief from symptoms never longer than 2
months at a time.
Box 2.2: DSM-5 Criteria for Dysthymia/Persistent Depressive
Disorder (APA, 2013)
A. Depressed mood for most of the day, for more days than not, as indicated
by either subjective account or observation by others, for at least 2 years.
B. Presence, while depressed, of two (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.
C. During the 2-year period (1 year for children or adolescents) of the
disturbance, the individual has never been without the symptoms in
Criteria A and B for more than 2 months at a time.
Criteria for a major depressive disorder may be continuously present for
2 years.
D. There has never been a manic episode or a hypomanic episode, and
criteria have never been met for cyclothymic disorder.
E. The disturbance is not better explained by a persistent schizoaffective
disorder, schizophrenia, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
F. The symptoms are not attributable to the physiological effects of a
substance (for example, a drug of abuse, a medication) or another medical
condition (for example, hypothyroidism).
G. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

Double Depression
Individuals with double depression meet the criteria for both Major
Depressive Disorder and Persistent Depressive Disorder. In a typical case,
at an early age mild-moderate intensity of depressive symptoms develop
first, the person in this case likely to be relatively more functional and then
one or more MDD episodes occur only to revert to dysthymia once the
MDD has run its course. Double depression is difficult to ascertain unless a
professional who has been seeing the client with dysthymia since some time
spots sudden or gradual worsening of the client’s symptoms. It is important
for professionals to recognize double depression, as it is associated with
poorer prognosis that is, high rates of relapse and recurrence
2.2.3 Additional Defining Criteria for Depressive Disorders: Specifiers
Some individuals who meet the basic criteria for diagnosis of major
depression may also meet additional patterns of symptoms called specifiers.
Specifiers influence the course of the disorder and effective treatment.
53
Mental Disorders- II Psychotic Features: In MDD with psychotic features, the person in midst of a
depressive episode may experience loss of contact with reality and delusions
or hallucinations. Mood congruent hallucinations/delusions have negative
tone, themes of personal inadequacy, guilt, deserved punishment, death, and
disease. For example, one’s internal organs have totally deteriorated. In rare
condition, it may be severe and may mark the beginning of schizophrenia. It
could be possible that the patient may have had symptoms of schizophrenia
to begin with. The clinician in this case may consider possible diagnosis of
schizoaffective disorder. MDD with psychotic feature is difficult to treat,
responds poorly to treatment, is associated with greater impairments with
fewer weeks of minimal symptoms.
Anxious Distress Features: The individual exhibits severity of anxious
symptoms, which may meet criteria for anxiety disorders (comorbidity) or
do not meet full criteria for anxiety disorders (sub-threshold). Presence of
anxiety indicates a more severe condition, suicidal ideation and completed
suicides more likely, and poorer outcome of treatment.
Mixed Features:The person is predominantly experiencing depressive
episodes but also experiences several (at least three) symptoms of mania.
Many researchers find bipolar to be a misleading label. This is because
clinicians have noted occurrences of mixed episodes, that is, a person with
bipolar disorder may not always alternate between the opposite ends of the
depression-elation continuum, instead in a mixed episode a patient may
become anxious or depressed about experience symptoms of mania as being
out of control, reckless, dangerous, and racing thoughts. Mixed episodes
may be more common that previously thought. In one study it was found
that about 30 percent of the patients hospitalised for acute mania had mixed
episodes (Hantouche, et al., 2006)
Melancholic Features: This specifier only applies in case of Major
Depressive Disorder (separately or in double depression). The person with
MDD with melancholic features has lost interest in almost all activities or
desired events (anhedonia). They experience more severe physical symptoms
like significant psychomotor retardation, early morning awakenings, weight
loss, and loss of libido.
Atypical features: This specifier applies to both MDD and Dysthymia. It
is used for people who display “unusual” depressive symptoms. Relative
to most people with depression, those with atypical features consistently
oversleep/overeat during their depressive episode and thus gain weight. The
person’s mood may brighten in response to positive events.
Postpartum Onset Specifier: The onset of major depressive episode occurs
during the post-partum period (4 weeks immediately after childbirth). For
the woman and her family, it may be difficult to understand why they are
depressed because they are expected to be joyous at the arrival of their baby.
Seasonal Pattern Feature: At least 2 or more episodes in past two years
that have occurred at the same time (usually in winter), and full remission
at the same time (usually spring). There are no other non-seasonal episodes
in two-year period. MDD with this specifier is called, Seasonal Affective
Disorder (SAD). SAD is related to secretions of melatonin hormone and
circadian rhythm.
54
Catatonic Feature: MDD with catatonic feature is rare. Catatonia is serious Mood Disorder
absence of movement in which patient’s arms or legs remain in any position
in which they are placed (waxy flexibility). Catatonia was earlier associated
with schizophrenia; recent studies suggest it is more common in depression
than schizophrenia.
Check Your Progress I
1) List the symptoms of MDD.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

2.4 CAUSAL FACTORS OF UNIPOLAR MOOD

DISORDERs
A number of different causal factors have been studied in context of the
etiology of unipolar mood disorder including biological, psychological, and
sociocultural factors. Researchers believe that interaction between these
causal factors that is, the biopsychosocial model.
2.3.1 Biological Factors
There are many different approaches to understand the biological factors
underlying the development of unipolar mood disorders. Researchers
have found the possible role of genetics, neurochemistry, hormones,
neuroanatomy, neurophysiology, sleep and circadian rhythms.
Genetics: Family studies report that first-degree relatives of a person has
depression have an increased risk (about 2-3 times higher) to develop
depression than relatives of control group. Also, factors such as severity,
recurrence of major depressive episodes and earlier age of onset are
associated with higher rates of depression in relatives. Twin studies have also
found higher concordance rate for depression in identical twins relative with
non-identical twins. Moreover, concordance rates are found to be higher for
females than males. Adoption studies also provide support for genetic basis
of unipolar mood disorders; chances of unipolar depression were higher
in biological relatives of adopted children than in biological relatives of
control-adopted children. The serotonin-transporter gene, which is involved
in transmission and reuptake of the neurotransmitter serotonin, has been
identified. Researchers in the field believe that there is no one faulty gene
underlying depression, in fact there are several “pattern of genes.”Genetic
factors have been found to underlie the temperament of neuroticism that
predisposes an individual to both anxiety and depression. Taken together,
family, twin, and adoption studies make a strong case for moderate genetic
contribution to the causal pattern of depression, but not as large a genetic
contribution as for bipolar disorder. Genetic factors may provide a diathesis
for development of depression. Faulty genes may produce neurochemical,
neuroanatomical, neurophysiological and hormonal changes in an individual.
Neurotransmitters: Electroconvulsive therapy and anti-depressant
medicines found to be effective in case of unipolar depression suggest
55
Mental Disorders- II neurotransmitter activities to play a role in depression. Such findings have
led to the development of neurochemical theories of etiology of depression.
The monoamine hypothesis of depression presented in 1960s-70s focused
on three neurotransmitters of the monoamine class namely, norepinephrine,
dopamine, and serotonin. According to the monoamine hypothesis,
depression is a result of absolute or relative depletion of the one or all of
these neurotransmitters at important receptor sites in the brain. Depletion
is hypothesised to be because of either: (1) reduced production, (2)
increased degradation of the neurotransmitters at the synapse, or (3) altered
functioning of the postsynaptic receptors. Follow up studies found some
contrary evidence to the monoamine hypothesis. First, some studies have
found that there may actually be an increase in norepinephrine (a class of
monoamine neurotransmitters). Second, only a minority of patients with
depression that is, those with more severe symptoms and suicidal ideas
had reduced serotonin activity. Third, medicines immediately increase the
availability of neurotransmitters, but they take about 2-4 weeks to show
effect. Finally, it was found that people with depression did not have
disturbance in the ‘absolute’ level of neurotransmitters. By 1980s, it was
clear that a straightforward mechanism is not possible. Newer studies suggest
that depression may be related to the sensitivity of post-synaptic receptors
that is, reduced sensitivity for dopamine and serotonin levels. Serotonin
in particular has been implicated in unipolar depression. People who are
vulnerable to depression may have less sensitive serotonin receptors. Apart
from serotonin, reduced sensitivity to dopamine is related to anhedonia,
lack of motivation and energy. Most recent studies have focused on the
interaction of neurotransmitters, and hormones, brain activity, and biological
rhythms.
Endocrine System/Hormones: In search for identifying the causal factors
underlying depression, attention has moved from a focus on neurotransmitters
to the endocrine system, in particular the Hypothalamic- Pituitary-Adrenal
(HPA) axis. According to the stress hypothesis, people with depression have
dysfunction in the HPA axis leading to the increased blood plasma levels of
cortisol (stress hormone). Thus, cortisol levels are poorly regulated in people
with depression. Elevated stress hormone (cortisol) levels are consistent
with the relationship between depression and severe stress. High cortisol
levels are harmful to neurons. Neurons in hippocampus are affected leading
to problems with memory impairments and problems with abstract thinking.
Hippocampus also keeps regulating cortisol. Some researchers suggest that
perhaps, low hippocampal neuronal volume precedes and contributes to
onset of depression. The findings are supporting of evidence that has found
that treatments for unipolar depression like Electroconvulsive Therapy
and exercise promotes neurogenesis in hippocampus. Another hormonal
system the Hypothalamic-Pituitary- Thyroid (HPT) axis has been linked to
depression. About 40-60 percent of depressed patients show dysregulation
of the axis.(Keller, et. al. 2017)

56
 Mood Disorder

Fig. 2.5: The Hypothalamic-Pituitary-Adrenal (HPA) axis

(Source: https://commons.wikimedia.org/w/index.php?curid=23363130)
Neuroanatomy and Neurophysiology: Neurofunctional studies have
found many regions of the brain are functioning atypically. Over-activity has
been reported in amygdala that is related to oversensitivity to emotionally
relevant stimuli. Those systems involved in weighing rewards and costs,
making decisions, and systematically planning and pursuing goals in the
face of emotions appear less active.That is, face of emotional stimuli (for
example, experience of failure) a person with depression responds with
increased emotion but has decreased ability to plan (to deal with the stimuli).
Apart from the brain systems involved in emotion, sensitivity of the brain
structures part of the reward system in the brain is also altered. Researchers
are trying to understand whether structural and functional changes in brain
in depression are cause or effect of unipolar depression.

Fig. 2.6: Cortisol level in people with depression and control group
(Source: https://www.semanticscholar.org/paper/SERUM-CORTISOL-LEVELS-IN-
DEPRESSION-PATIENTS-Bakheet/8c0d8d6a73259523b44d1550fb9a3570f2063275)
Sleep and Circadian Rhythms:The common sleep problems in depressed
outpatients show a variety of patterns like, early morning awakenings,
periodic awakening during night, and difficulty falling asleep. Studies have
found that, people with depression enter REM sleep more quickly (usually
after an hour when typical people take about 1.5 hours) and have lower- than-
normal amount of deep sleep than normal. Sleep alternations precede the
onset of depression and persist following recovery, which suggests that they
57
Mental Disorders- II may be vulnerability markers for certain forms of depression. Apart from
sleep, disruption in circadian rhythms (for example, secretion of hormones
like Thyroid Stimulating Hormones (TSH), cortisol, or internal sleep-wake
cycle has also been reported in people with early morning wakening or those
with depression with the seasonal feature (Seasonal Affective Disorder;
SAD). Seasonal changes in the production of melatonin (hormone secreted
by pineal gland) have been related to SAD. Exposure to light suppresses
melatonin production and is produced only at night; its production tends
to increase in the winter, when there is less sunlight. Studies have shown
that melatonin secretions increase in winter but only in patients with SAD
and not in healthy controls. Thus, sensitivity to increase in melatonin is a
vulnerability marker to development of unipolar depression.
Table 2.1: Summary of Neurofunctional Studies in Unipolar Depression

Fig. 2.7: Circadian Rhythms in Humans

Source: https://www.fullspectrumsolutions.com/pages/circadianrhythm
2.3.2 Psychosocial Factors
Evidence for psychosocial risk factors is as strong as biological risk
factors. According to the diathesis-stress model, neurobiological factors
58
may be the diatheses that interact with the psychosocial stressors leading Mood Disorder
to development of unipolar depression. Although many people experience
psychosocial stressors, not everyone develops depression. Also, many
experience psychosocial stressors, but not all become depressed. This is only
true for those with biological vulnerability. Psychosocial factors include
psychological diathesis, stressful life events, and interpersonal factors.
Stressful Life Events: Many studies have shown that severely stressful life
events such as loss of loved one, serious threats to important relationships,
or to one’s occupation, severe economic or health problems often serve
as a precipitating factor (trigger) for unipolar depression. However, the
relationship between stressful events and depression is not a simple one.
Studies have found that the nature of stressful event is a moderating factor.
For instance, events that involve experience of loss, humiliation, and social
rejection are likely to trigger depression. Additionally, the perceived severity
of the event is an important factor too. Recent and severe stressful life event
plays a role in people with first episode of depression whereas minor and
less severe events may me enough to trigger subsequent episodes. Finally,
chronic stressors such as poverty, social discrimination, domestic abuse,
marital discord, chronic illnesses in family members or oneself lead to
increased risk of onset and maintenance of depression. While the relationship
between stressful events and depression is well established, researchers are
trying to understand whether stressful events cause depression, or does
vulnerability to depression cause one to be sensitive to stressful events.
Stressors can be understood in terms of independent life events such as loss
of job in recession, earthquake, loss of someone close, etc., or dependent life
events that is, those related to one’s interpersonal skills, problem solving
and coping skills, such as constant reassurance seeking, poor management
of time or self-medication (use of alcohol or drugs to feel relaxed, calm, and
sleep). Research suggests that dependent life events play a stronger role in
the onset of major depression than do independent life events.
Psychological Diathesis: An individual high on the personality trait
of neuroticism and/or pessimistic attributional style is considered to be
vulnerable to unipolar depression. Individuals with neuroticism tend to
be sensitive to a broad range of negative moods including sadness, guilt,
anxiety, hostility etc. Those high on neuroticism generally have been
found to have poorer prognosis. Beck (1967) has found that pessimistic
attributional style or the tendency to interpret every day events in negative
way also makes one prone to depression. Pessimistic attributional style is
finding internal, stable, and global attributions to negative events. Such as:
“It’s all my fault”, “It happens all the time”, “It happens with everything.”
Psychological/ cognitive diathesis has been discussed later in the Unit.
Interpersonal Factors: Early childhood adversity, lack of social support,
marital and familial discord, and parental depression have been identified
as possible triggers for the development of depression in someone with
biological and psychological diatheses for development of childhood
adversities like losing a parent early in life, parental depression, family
turmoil, physical or sexual abuse, intrusive, harsh, neglectful and coercive
parenting can make an individual vulnerable to development. Supportive and
healthy relationships can play a supportive role in people with vulnerability
59
Mental Disorders- II to develop depression. Conversely, socially isolated individuals or those
with smaller and less supportive social networks tend to become vulnerable
to becoming depressed. Lack of social support can become form a reciprocal
relationship with depression, since behaviour of people with depression
may produce sympathy in short term but in long- term may lead to neglect
rejection by others. Similarly, two-way relationship has also been found for
marital and familial discord. Domestic discord can lead to depression and
depression can in turn lead to heightened domestic discord.
2.4.3 Theoretical Perspectives on Unipolar Depression
The different theoretical perspectives in depression provide explanation
for unipolar depression. The cognitive-behavioural theories of unipolar
depression have proven to be effective in its treatment where as
psychodynamic explanations of depression explains it as a result of
“excessive and irrational grief” reaction to loss (real, imagined, or symbolic)
have failed to find support.
Beck’s Cognitive Theory: One of the most prominent theories of depression
was given by Aaron Beck who proposed that the cognitive symptoms of
depression, (for example, “I’m hopeless, total failure”) precede and cause
the affective symptoms of depression (for example, upset and miserable).
Beck proposed that dysfunctional/depressogenic beliefs that are rigid,
extreme and counterproductive are formed during early childhood through
interactions with parents and significant others (for example, “I must be
perfect in everything”, “I’m unworthy of being loved.). These beliefs may
lie dormant and form a cognitive diathesis to develop depression in life
later on. These beliefs are never challenged and become self-fulfilling. For
instance, a person who has a core belief that they are unworthy of being
loved may reject loving advances of others and may withdraw from others
making others reject than in turn. Under stressful situation in life called
critical incidents, such as those involving humiliation, loss, and social
rejection, these dormant beliefs may become dominant and may generate
automatic negative thoughts. These thoughts are below the surface level
of awareness and are negative and pessimistic predictions about one’s
self (I’m a loser), others (nobody loves me), and future (it’s all hopeless,
nobody will ever love me). Beck labeled this as cognitive triad. Cognitive
distortion is maintained by cognitive distortions that are errors in one’s
thinking and leads to biased processing of information. Some examples of
cognitive errors are, all or none thinking (I’m either best at something or
I’m nothing), overgeneralisation, (I failed in my job, I’m an absolute loser),
arbitrary reference (nothing good can ever happen to me and I can never get
well), and personalisation (it’s all my fault). Automatic negative thoughts
can cause depressed mood and depressed mood in turn can make negative
thoughts salient, this has been labeled as the ‘vicious cycle of depression.’
Check Your Progress II
1) List the psychosocial causal factors of unipolar mood disorder.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
60
 Mood Disorder
2.5 BIPOLAR MOOD DISORDERs
People with bipolar mood disorder alternate between depressive and
manic episode(s) on the depression-elation continuum. Bipolar disorders
are classified as Bipolar I, Bipolar II, and cyclothymic disorder. It is rare
for mania to occur by itself in the absence of a manic episode(s). Bipolar
disorders were previously known as manic-depressive illness. Presence of
mania distinguishes bipolar from unipolar disorders. A person diagnosed
with bipolar disorder experiences depressive episodes that alternate with
manic episodes. Mania can be distinguished into two types depending
on severity, hypomania and full-blown mania. Full-blown mania leads to
significant occupational and social functioning. Hospitalisation is often
necessary in case of full-blown mania. Manic symptoms in hypomania are
similar, but the severity is lesser. Impairment caused by hypomania is to a
lesser degree than for full-blown mania and hospitalisation is not required.
2.5.1 Manic Episode
Ankit is 40-year-old man brought to the emergency department with cuts to
his arms, chest and face, which he received as a result of a fight in on the
street. In the hospital, Ankit finds it extremely difficult to stay in bed and is
constantly wandering around the ward into other rooms. When he is in bed,
Ankit is constantly ringing the buzzer. He is frequently found talking to other
patients, staff and visitors about his wonderful new invention. His family
was called who informed the doctors that Ankit has a history of bipolar
disorder. Ankit’s wife informed that he had been finding it difficult to sleep in
the past few days. He had stopped taking his medicines for bipolar disorder.
He seemed to be in a good mood and would stay up the entire night working
on his laptop. Before leaving the house that morning, Ankit told his wife
that he was going to quit his job because he was too good for the job and
he was wasting his talent at the job. He told his wife that he was bursting
with energy and that he wanted to buy laptops from the market for his new
invention. When his wife tried to stop him, he got irritable and aggressive
and left the house after pushing her away.
Mania is an emotional state where intense elation, unusual irritability, or
heightened goal directed activity or energy exists for at least one week.
In case of hypomania, the symptoms last for 4 days in a row and are not
severe enough to require hospitalization. Hypomania may be experiences
as pleasurable as it leads to increased energy and creativity. However, it
may have undesirable consequences like suicidal tendencies when the
predominant mood is irritable instead of euphoric. Psychotic features are
also likely to be absent in hypomania. According to DSM-5, three or more
of the following symptoms must be present to a significant degree for the
diagnosis of a manic episode.
Grandiosity: Refers to inflated self-esteem or the feeling of being able to
do something unlikely or impossible. A person may feel they are capable
of making great inventions, be in the same league as famous personalities
or be capable of great creativity. People feel on top of the world, with the
ability to do great many things.

61
Mental Disorders- II Decreased need for sleep: An individual experiencing a manic episode
tends to feel rested with very little sleep. They may experience insomnia
and may need very little food.
More talkative than usual or pressure to keep talking: In a manic episode
the person may start talking excessively, they experience a heightened
need to talk to others. Their speech is paced; sometimes others may find it
difficult to understand them. Excessive speech is related to racing thoughts
in manic episode.
Box 2.5: DSM 5 Criteria for Manic Episode (APA, 2013)
A. Distinct period of abnormally and persistently elevated, expansive
or irritable mood and abnormally and persistently increased goal
directed activity or energy, lasting at least 1 week and present most
of the day nearly every day (or any duration if hospitalisation is
required).
B. During the period of mood disturbances or increased activity,
three (3) or more of the following symptoms must be present to
a significant degree and represent a noticeable change from usual
behaviour.
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (for example, one feels rested after only 3
hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Attention is easily drawn to unimportant or irrelevant items.
6. Increase in goal-directed activity (either socially, at work or school;
or sexually) or psychomotor agitation.
7. Excessive involvement in pleasurable activities that have a high
potential for painful consequences (for example, engaging in
unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked
impairment in social or occupational functioning or to necessitate
hospitalisation to prevent harm to self or others, or there are
psychotic features.
D. The episode is not attributable to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication, or other treatment)
or another medical condition.
Note: A full manic episode that emerges during antidepressant treatment
(e.g., medication, electroconvulsive therapy) but persists at fully
syndromal level beyond the physiological effect of that treatment is
sufficient evidence for a manic episode and therefore a bipolar I diagnosis
2.4.2 Types of Bipolar Disorder
DSM-5 classifies bipolar disorder into three types namely, Bipolar I, Bipolar
II, and Cyclothymic disorder. People with bipolar I disorder experience
episodes of full-blown mania and periods of Major Depressive Disorder.
62
Even if the individual does not meet the threshold for a major depressive Mood Disorder
episode, the diagnosis of bipolar I disorder is still given. A mixed episode
characterised by symptoms of both full-blown manic and major depressive
episodes for at least 1 week, also receives the diagnosis of bipolar I disorder
whether the symptoms are intermixed or alternate rapidly every few days.
Bipolar II disorder is characterised by episodes of hypomania and depressed
mood that meets the criteria for Major Depressive Disorder. In bipolar
II disorder, the person does not experience full-blown mania (or mixed)
episode. If a person only shows manic symptoms then it is assumed that the
person will experience a depressive episode also or may have experiences
symptoms of mild depression that went unrecognized. Finally, cyclothymic
disorder is defined as a less serious version of full-blown bipolar disorder
because it lacks certain extreme symptoms and psychotic features such
as delusions and the marked impairment caused by full-blown manic or
major depressive episodes. The depressed mood in cyclothymic disorder
is similar to the depressed mood in dysthymia such as low energy, feelings
of inadequacy, social withdrawal, and a negative, brooding attitude. The
person’s mood is dejected; they experience distinct loss of interest or
pleasure in customary activities and pastimes. Similarly, the manic mood
in cyclothymia is similar to symptoms of hypomania. The person displays
surge in creativity, bursts of energy, increased productivity and physical/
mental energy. The duration of cyclothymia is at least a period of two years
during which numerous periods of hypomanic and depressive symptoms
are experienced that cause clinically significant impairment (although not
as severe as bipolar I and II) disorder. In between there may be significant
period of normal mood in which the person may function in relatively
adapted manner. features can be as high strung, explosive, moody, or even
hyperactive. Cyclothymia is a chronic and lifelong condition. Some of them
go on to develop full-blown bipolar disorder later in life.
2.5.3 Additional Specifiers for Bipolar Disorder
Along with the diagnosis for bipolar disorder, clinicians make note of
specifiers to make a more specific diagnosis. Bipolar disorder has the same
specifiers as unipolar disorder, that is, mixed feature, anxious distress
feature, psychotic feature, melancholic feature, postpartum feature, seasonal
pattern, catatonic and atypical features. In addition, there is another feature
called rapid cycling. Individual given this specifier quickly move in and
out of depressive or manic episodes, that is, at least four manic/depressive
episodes in a year. Some people with bipolar can “switch” to a rapid cycling
pattern but most return to their normal bipolar pattern in time. This pattern
is likely to have an earlier age of onset and make more suicide attempts.
Rapid cycling is usually temporary and disappears within a period of two
years.
Check Your Progress III
1) State how bipolar disorders are classified in DSM-5.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
63
Mental Disorders- II
2.6 CAUSAL FACTORS OF BIPOLAR MOOD
DISORDERS
As is the case with unipolar mood disorder, interaction of biological,
psychological and social causal factors have been posited. However, in case
of bipolar disorders, biological causal factors are clearly dominant, and the
role of psychological causal factors has received significantly less attention.
2.6.1 Biological Factors
A number of biological factors are thought to play a causal role in the
onset of bipolar disorder including genetic, neurochemical, hormonal,
neurophysiological, neuroanatomical, and biological rhythm influences.
Genetic Factors: There is greater influence of genes in etiology of bipolar
disorder than unipolar disorder. Studies report that genes account for about
80-90 percent (Goodwin & Jamison, 2007) of variance in the tendency to
develop bipolar disorder. The heritability estimates are higher than for any
other major adult psychiatric disorders including schizophrenia. Family
studies have found that being related to a person with bipolar disorder (first
degree relatives) increases one’s chances of developing bipolar disorder to
9 percent which is approximately 1 percent for general population. First-
degree relatives of person with bipolar are also at the risk for developing
unipolar mood disorder, although reverse is not true. Twin studies have
found concordance rate to be a high 60 percent for monozygotic twins and
12 percent for dizygotic twins (Kelsoe, 1997, as cited in Butcher et al.,
2017).
Neurochemical Factors: The monoamine hypothesis posits that
depression is caused by decrease in norepinephrine, dopamine and/or
serotonin. It was hypothesised that perhaps mania is caused by excess
of these neurotransmitters. Some evidence has been found for increased
norepinephrine activity and dopaminergic activity in manic phase. Increased
dopaminergic activity in several brain areas maybe related to manic
symptoms of hyperactivity, grandiosity, and euphoria. However, serotonin
level has not been found to increase and tends to remain same in manic
and depressive phases. Lithium is a natural element and has found to be an
effective mood stablizer. It has been hypothesised that lithium may act as a
substitute for sodium ions in neural conduction.
Neurohormonal Factors, Neurophysiological and Neuroanatomical:
Hypothalamic-Pituitary-Adrenal (HPA) axis is implicated in both unipolar
and bipolar disorder. Cortisol levels are elevated in bipolar depression as
well as manic episodes. Neurophysiological and neuroanatomical findings
have also failed to obtain any difference in unipolar and bipolar depression.
That is, changes seen in unipolar disorder in brain structures (amygdala,
hippocampus, cingulate cortex and anterior cingulate cortex) are also seen
in bipolar disorder. Differences emerge during the manic phase; blood flow
to the brain increases, blood flow to left prefrontal cortex is reduced during
depression, during mania it is reduced in the right frontal and temporal
regions. In normal moods, blood flow across two brain hemispheres is
approximately equal. Brain region involved in reaction to reward is overly
active.
64
Circadian Rhythms: Given the cyclic nature of bipolar disorders, circadian Mood Disorder
rhythm disturbances have been found to be common in bipolar patients, even
when symptoms have remitted. Manic episodes may be precipitated by loss
of sleep, pregnancy (post-partum), jet lag etc. Insomnia is the most common
symptom before the onset of the manic phase. During manic phases patients
tend to sleep very little, this is the most common symptom.
2.6.2 Psychosocial Factors
Although biological factors play a dominant role in etiology of bipolar
disorders, psychosocial factors such as stressful life events, poor social
support, and certain personality traits and cognitive styles have also been
identified as important. Stressful life events are found to precipitate manic/
depressive episodes in bipolar life events. Further, stressors in life make
recovery more difficult and more difficult to recover from the episodes. It
has been hypothesised that stress may disrupt the critical circadian rhythms
and trigger manic/depressive episode.
Check Your Progress IV
1) List the biological causal factors of bipolar mood disorders.
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

2.7 SOCIOCULTURAL CAUSAL FACTORS OF

MOOD DISORDERS
Depression occurs in all cultures however the form of depression and
prevalence rates are different from culture to culture. Higher rates of
depression have been seen in western/westernized cultures. In cultures
like China and Japan the rates of depression are low and the psychological
symptoms of depression may not show (guilt, pessimistic attributions,
hopelessness), instead somatic/vegetative symptoms (aches and pains, lack
of energy, sleep and eating disturbances) may be more prominent. This may
be because in individualistic cultures, the self is viewed as independent
and autonomous. In face of failures in individualistic cultures, internal
attributions are made. Whereas in collectivistic cultures, there is reciprocity
between culture and individual and when loss occurs, most likely it is made
sure that hopelessness and helplessness do not set in an individual. Also,
even where psychological symptoms may be present, somatic symptoms
may be given more legitimacy because stigma attached to mental illness
and because of the belief in the unity of the mind and body. Socio Economic
Status (SES) has been found to be inversely proportional to depression.
This may be because low SES leads to increased life adversity and stress.
Whereas, bipolar disorder is more common in higher SES possibly because
the personality and behavioural correlates of bipolar illness in hypomanic
phases (outgoingness, increased energy, and increased productivity) may
65
Mental Disorders- II lead to increased achievements and accomplishments. Many famous poets,
writers, composers, and artists have been found to have bipolar disorder. It
has been proposed that either, hypomania facilitates creative processes (for
example,Vincent Van Gough) or that intense negative emotional experiences
of depression provide material for creative activity (for example, Sylvia
Plath).

2.8 TREATMENT OF MOOD DISORDERS

Discussed below are the main treatment options for mood disorders.
Biological Treatment
Biological treatment of mood disorders includes pharmacological
intervention (medications) and other treatments such as electroconvulsive
therapy. Since serotonin, norepinephrine and dopamine are implicated
in depression, most anti- depressant medicines work by increasing the
availability of these neurotransmitters. Monoamine Oxidase Inhibitors
(MAOIs) were first used in the treatment of tuberculosis but were found
to improve the mood of TB patients; they were the first anti-depressants.
Monoamine Oxidase (MAO) are linked to degradation of norepinephrine
in synaptic cleft. Monoamine Oxidase Inhibitors (MAOI) inhibit the action
of MAO thereby increasing availability of norepinephrine. Since newer
evidence has found greater role of serotonin in depression, new anti-
depressants focus on the action of serotonin. Tricyclic anti- depressants and
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) have been found to
increase both serotonin and norepinephrine, however they are also found to
have more severe side effects like nausea, dizziness, headache, etc. Recently
discovered anti-depressant Selective Serotonin Reuptake Inhibitors (SSRIs)
has been found to less effective than tricyclics and SNRIs but have less severe
side-effects and are thus first line of treatment. Prozac, a SSRI, is one of the
most famously prescribed anti-depressants. Most anti-depressants take 2-5
weeks to be effective. Mood stablizer (lithium) has been found to improve
the functioning of bipolar patients. Many patients may discontinue lithium
because of the severe side effects such as increased thirst, gastrointestinal
difficulties, weight gain, tremor and fatigue. However, discontinuation of
lithium can be very risky as the probability of relapse is very high.
In more severe cases of depression where medications have proven to be
ineffective, doctors may prescribe Electroconvulsive Therapy (ECT). In
ECT electric currents are passed through electrodes to cause convulsions
in anesthetized patients. After ECT is over, the patient has amnesia for
the period immediately preceding the therapy and is usually somewhat
confused for the next hour or so. Typically, treatment consists of fewer than
a dozen sessions. Physicians must make the judgment of use of ECT with
a patient by weighing the greater clinical benefits against the cognitive side
effects. Apart from ECT non-pharmacological approaches to treatment of
depression include some promise new treatment approaches. Transcranial
Magnetic Stimulation (TMS) is a non-invasive technique in which brief but
intense pulsating magnetic fields are delivered to induce electrical activity
in certain parts of the brain. Treatment usually occurs 5 days a week for 2-6
weeks. This approach has been found to be effective for patients who are
moderately resistant to medications. Deep brain stimulation.

66
is another approach used in patients who have failed to respond to Mood Disorder
medications, ECT, and psychotherapy. In this an electrode is implanted in
brains and then the area is stimulated with electric current. Finally, bright
light therapy initially used only to treat season affective depression has been
also found to be effective in non-seasonal depression.
Psychotherapy
Cognitive-behavioural therapy (also known as CBT or cognitive therapy)
originally developed by Beck and colleagues is a relatively brief form of
treatment (usually 10 to 20 sessions) that focuses on here-and-now problems,
has been found to be effective in treatment of depression. The therapy is based
on the cognitive theory of depression by Beck in which the patient is taught
to systematically evaluate their dysfunctional beliefs and negative automatic
thoughts. They are also taught to identify and correct their cognitive errors
and to uncover and challenge their underlying depressogenic assumptions
and beliefs. Recent evidence has suggested that CBT and medications are
equally effective in treatment of severe depression. Behavioural activation
treatment is a relatively new treatment that focuses intensively on getting
patients to become more active and engaged with their environment and
with their inter- personal relationships. These techniques include scheduling
daily activities and rating pleasure and mastery while engaging in them,
exploring alternative behaviours to reach goals, and role-playing to address
specific deficits. Traditional cognitive behaviour therapy also addresses the
behavioural activation issues but to a lesser extent. Interpersonal, family,
and marriage therapy focus on improving the interpersonal relationship of
the patients so as to prevent relapse. Educating people about their illness is a
common component of treating many disorders, including bipolar disorder
and schizophrenia. Psychoeducational approaches are commonly used in
individual and interpersonal therapy. Typically mental health professional
helps patient and the family learn about the symptoms of the disorder, the
expected time course of symptoms, the biological and psychological triggers
for symptoms, and treatment strategies. Overall, combining psychotherapy
and biological treatments in mood disorders is considered to be more
effective in cases of moderate to severe depression.
Check Your Progress V
1) What is Transcranial Magnetic Stimulation?
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

2.9 SUICIDE
Suicide is one of the most tragic and serious aspects of mood disorders.
At least, 90 percent of the people who commit suicide have a psychiatric
disorder at the time (Goodwin & Jamison, 2007). Suicide attempts were
earlier common between 25-44 years of age, but in the past few years risk
67
Mental Disorders- II for suicide has increased for all age groups (Stolberg et al., 2002). For
instance, there has been a dramatic increase in recent years in suicide in
adolescents. It is the third leading cause of death in teenagers after accidents
and homicides. Children who have lost a parent or have been abused are
at an increased risk. There is dramatic increase in suicide among elderly.
Elderly suffering from chronic physical illness, widowed, divorced are more
vulnerable. There is a high risk of suicide in all depressive states. According
to WHO, 1 person dies by suicide every 40 seconds. India has the sixth
highest rate of suicide in the world. Suicide is said to cause more death per
year than homicide or war. People with depression are 20 times more likely
to die by suicide than non-depressed people. The dual tragedy of suicide is
that an individual who dies by suicide is experiencing severe psychological
distress and often the family who looses someone close because of suicide
becomes vulnerable to psychological distress and illness.
Suicidal ideation includes morbid thoughts related to one’s death, killing
oneself, funerals, etc. Suicidal ideation does not mean one will commit
suicide, but such thoughts can be a risk factor. Suicidal behaviour/deliberate
self-harm may or may not indicate a wish to die. Some individuals indulge
in cutting, burning self, and/or hurting themselves by other means. Suicidal
attempt is a self-destructive behaviour in which the person is trying to kill
self and finally suicide completion is a suicidal attempt that leads to death
of an individual. Some of the commonly used methods include hanging,
firearms, drug/alcohol/medication overdose, carbon monoxide poisoning,
jumping from high place, and deliberate accidents to save family from the
grief.
For someone with depression, the life time risk of committing suicide is
about 15 percent (Stolberg et al.2002). Men commit suicide four times more
than the rate of women. This is because men choose more violent/lethal
methods of suicide such as firearms and hanging whereas women try to use
methods in ways that take longer and have higher chance of rescue such as
through drug overdose, poisoning, etc. A small minority is intent on dying;
they give little or no warning, and generally rely on more violent and certain
means of suicide such as shooting or jumping from a high place. About 80
percent of those hospitalised, denied suicidal ideation the last time they
spoke with a clinician before actually committing suicide (Busch. Fawcette,
& Jacobs, 2003).
For many people suicidal thoughts are often ambivalent; these individuals
are not intend on dying but want to communicate dramatic gestures of
distress to others. They may attempt methods with minor risks, like minimal
drug ingestion. It is important for clinicians to focus on suicidal ideations
of the patient as part of the treatment program for mood disorders. Suicidal
prevention programs consist of suicide intervention by providing suicide
hotline.

2.10 LET US SUM UP

Now that we have come to the end of this unit, let us list all the major points
that we have already learnt.Mood disorders are extreme variations in mood-
either high or low that cause significant distress and lead to significant
dysfunction in everyday life. They are classified as unipolar and bipolar
68
mood disorders. Presence of mania in bipolar mood disorder distinguishes Mood Disorder
unipolar from bipolar disorder.
People with unipolar mood disorder experience some form of depression-
major depression or dysthymia. Such individuals experience a range of
cognitive, somatic, and affective symptoms including depressed mood,
inability to experience pleasure, hopelessness, helplessness, lack of
motivation, sleep and eating difficulties, suicidal ideations, and physical
aches and pains.
There is evidence of moderate genetic contribution for unipolar mood
disorders. Genetic factors interact with a number of interacting disturbances
including neurochemical, neurophysiological, and neuroendocrine.
The most prominent theories of depression are Beck’s cognitive theory,
Seligman’s helplessness theory and hopelessness theory. According to the
cognitive model, individuals with depression have a cognitive diathesis (for
example, depressogenic beliefs and pessimistic attributional style) that lies
dormant for many years. Stressful events are important in precipitating an
episode of depression.
In the bipolar disorders (cyclothymia and bipolar I and II disorders), the
person experiences episodes of both depression and hypomania or mania.
During manic or hypomanic episodes, the symptoms are essentially the
opposite of those experienced during a depressive episode.
Biological causal factors play a more prominent role for bipolar disorder
than for unipolar disorders. The genetic contributions for bipolar disorder
are strongest amongst all adult psychiatric disorders.
Biological based therapies like medications or electroconvulsive therapy are
often used in the treatment of the more severe major disorders. Biological
therapies in combination with psychotherapy (cognitive therapy, behavioural
activation treatment, and interpersonal therapy) are often advisable for more
severe as well as milder forms of mood disorders.

2.11 REFERENCES
Barlow, D.H. & Durand, M.V. (2015). Abnormal Psychology (7th Edition).
New Delhi: Cengage Learning India Edition.
Bennett, P. (2011). Abnormal and clinical psychology: An introductory
textbook. New Delhi: Tata McGraw-Hill Education (UK).
Goodwin, F. K., & Jamison, K. R. (2007). (as cited in Butcher et al., 2017).
Manic depressive illness: Bipolar disorders and recurrent depression (2nd
ed.). New York: Oxford University Press
Jamison, K. R. (2011). Night falls fast: Understanding suicide.USA:
Random House Inc.
Keller, J., Gomez, R., Williams, G, Seambke, A, Lazzeronia, L., Murphy. Jr.,
G.M. & Schatzberg, A.F. (2017). HPAAxis in major Depression: Cortisol,
Clinical Symptomatology, and Genetic Variation Predict Cognition.
Molecular psychiatry 2017 (APR); 22 (4): 527-536
Kelsoe, J. R. (1997). The genetics of bipolar disorder. Moskovskogo
Nauchno- Issledovatel’Skogo Instituta Psikhiatrii, 27(4), 285–92.

69
Mental Disorders- II Kring, A. M., Davison, G. C., Neale, J. M., & Johnson, S. L. (2015).
Abnormal psychology (13th Edition). New York: John Wiley & Sons Inc.
Hantouche, E., Akiskal, H., Azorin, J., ChatenetDuchene, L., & Lancrenon,
S. (2006). Clinical and psychometric characterization of depression in
mixed mania: A report from the French National Cohort of 1090 manic
patients. Journal of Affective Disorders, 96, 225–232
Mineka, S., Hooley, J.M., & Butcher, J.N., (2017). Abnormal Psychology
(16th Edition). New York: Pearson Publications.
Monroe, S. M., & Harkness, K. L. (2011). Recurrence in major depression:
A conceptual analysis. Psychol. Rev. Doi:10.1037/a0025190

2.12 REFERENCES FOR IMAGES

Depression-Elation Continuum. Retrieved 7th October 2019, from https://
www.stomponstep1.com/mood-disorders-major-depressive-disorder-
bipolar- type-1-cyclothymia-hypomania-mdd/
Pictorial Representation of Depression. Retrieved 7th October 2019, from
https:/ /slideplayer.com/slide/5181380/
The Hypothalamic-Pituitary-Adrenal (HPA) axis. Retrieved 7th October
2019, from https://commons.wikimedia.org/w/index.php?curid=23363130.
Cortisol level in people with depression and control group. Retrieved
7th October 2019, from https://www.semanticscholar.org/paper/
SERUM-CORTISOL-LEVELS-IN-DEPRESSION-PATIENTS-
Bakheet/8c0d8d6a73259523b44d 1550fb9a3570f2063275
Circadian rhythms in humans. Retrieved 7th October 2019 from https://
www.fullspectrumsolutions.com/pages/circadianrhythm.

2.13 KEY WORDS

Mood disorders: Classified as unipolar and bipolar disorder. In mood
disorders, a person experiences extraordinary sadness/depression, elation
or both.
Major Depressive Disorder (MDD): A chronic condition, consisting of
recurrent severe depressive episodes with a range of cognitive, somatic,
and affective symptoms including depressed mood, inability to experience
pleasure, hopelessness, helplessness, lack of motivation, sleep and eating
difficulties, suicidal ideations, and physical aches and pains.
Dysthymia: Also known as Persistent Depressive Disorder in DSM-5
shares many features with Major Depressive Disorder, has fewer and less
intense symptoms and the depression lasts for a long period (at least 2 years
in adults).
Double Depression: Individuals with double depression meet the criteria
for both Major Depressive Disorder and Persistent Depressive Disorder.
Mania: An emotional state where intense elation, unusual irritability, or
heightened goal directed activity or energy exists for at least one week.
Hypomania: Includes experiences that are pleasurable as it leads to
increased energy and creativity.
70
Monoamine Hypothesis of Depression: According to the monoamine Mood Disorder
hypothesis, depression is a result of absolute or relative depletion of the
one or all of neurotransmitters namely, norepinephrine, dopamine, and
serotonin, at important receptor sites in the brain.

2.14 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress I
1) List the symptoms of MDD.
The symptoms of major depressive disorder include the following:
●● Depressed mood most of the day
●● Anhedonia/loss of pleasure
●● Psychomotor retardation or agitation noticed by others
●● Fatigue or loss of energy
●● Insomnia or sleeping too much (hypersomnia)
●● Significant unintentional weight loss or gain
●● Feelings of worthlessness and guilt about things beyond their control
●● Diminished ability to think or concentrate, or indecisiveness
●● Recurrent thoughts of death
Check Your Progress II
1) List the psychosocial causal factors of unipolar mood disorder.
The psychosocial factors of unipolar mood disorder include stressful life
events, psychological diathesis and interpersonal factors.
Check Your Progress III
1) State how bipolar disorders are classified in DSM-5.
DSM-5 classifies bipolar disorder into three types namely, Bipolar I, Bipolar
II, and Cyclothymic disorder. People with bipolar I disorder experience
episodes of
Check Your Progress IV
1) List the biological causal factors of bipolar mood disorder.
The biological causal factors of bipolar mood disorder include the following:
●● Genetic Factors
●● Neurochemical Factors
●● Neurohormonal Factors, Neurophysiological and Neuroanatomical
●● Circadian Rhythms
Check Your Progress V
1) What is Transcranial Magnetic Stimulation?
Transcranial Magnetic Stimulation (TMS) is a non-invasive technique in
which brief but intense pulsating magnetic fields are delivered to induce
electrical activity in certain parts of the brain.

71
Mental Disorders- II
2.15 UNIT END QUESTIONS
1) Explain unipolar mood disorders.
2) Describe the causal factors of unipolar mood disorders.
3) Describe bipolar mood disorders.
4) Discuss the biological causal factors of bipolar mood disorders.
5) Describe the main features and diagnostic criteria of a manic episode.

2.16 WEB RESOURCES

●● For an interesting documentary on living with bipolar disorder
visit:
-https://www.youtube.com/watch?v=FtImgnj5DN0 (Part 1)
-https://www.youtube.com/watch?v=ECv-24Ruu-o (Part 2)
For a brief discussion on mood disorders visit:
-https://www.stomponstep1.com/mood-disorders-major-depressive-
disorder-bipolar-type-1-cyclothymia-hypomania-mdd/
For personal blogs and stories on depression visit: -https://www.time-
to-change.org.uk/category/blog/depression For depression in India
visit: -http://www.searo.who.int/india/depression_in_india.pdf

72