Abnormal Psychology, Thirteenth Edition, DSM-5 Update

Abnormal Psychology, Thirteenth
Edition, DSM-5 Update

by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
© 2015 John Wiley & Sons, Inc. All rights reserved.
 Chapter 5: Mood Disorders
I. Clinical Descriptions and Epidemiology of

Mood Disorders
II. Etiology of Mood Disorders
III. Treatment of Mood Disorders
IV. Suicide

 Two broad types:
• Involves only depressive symptoms
• Involves manic symptoms (bipolar disorders)
 DSM-5 depressive disorders:
• Major depressive disorder
• Persistent depressive disorder
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
 DSM-5 Bipolar Disorders:
• Bipolar I disorder
• Bipolar II disorder
• Cyclothymia

DSM-5 Diagnoses Major Features
Major depressive disorder • Five or more depressive symptoms, including sad mood or loss of
pleasure, for 2 weeks
Persistent depressive • Low mood and at least two other symptoms of depression at least half
disorder of the time for 2 years
Premenstrual dysphoric • Mood symptoms in the week before menses

disorder
Disruptive mood • Severe recurrent temper outbursts and persistent negative mood
dysregulation disorder for at least 1 year beginning before age 10
Bipolar I disorder • At least one lifetime manic episode
Bipolar II disorder • At least one lifetime hypomanic episode and one major depressive
episode
Cyclothymia • Recurrent mood changes from high to low for at least 2 years,
without hypomanic or depressive episodes
 Sad mood OR loss of interest or pleasure (anhedonia)
• Symptoms are present nearly every day, most of the day, for at
least 2 weeks
• Symptoms are distinct and more severe than a normative response
to significant loss
 PLUS four of the following symptoms:

• Sleeping too much or too little
• Psychomotor retardation or agitation
• Poor appetite and weight loss, or increased appetite and weight
gain
• Loss of energy
• Feelings of worthlessness or excessive guilt
• Difficulty concentrating, thinking, or making decisions
• Recurrent thoughts of death or suicide

 Episodic
• Symptoms tend to dissipate over time
 Recurrent
• Once depression occurs, future episodes likely
 Average number of episodes is 4
 Subclinical depression
• Sadness plus 3 other symptoms for 10 days
• Significant impairments in functioning even though full
diagnostic criteria are not met

 Depressed mood for at least 2 years; 1 year for
children/adolescents
 PLUS 2 other symptoms:
• Poor appetite or overeating
• Poor self-esteem
• Trouble concentrating or making decisions
• Feelings of hopelessness
 Symptoms do not clear for more than 2 months at a

time
 Bipoloar disorders are not present
 In most menstrual cycles during the past year, at least five of the
following symptoms were present in the final week before
menses and improved within a few days of menses onset:
• Affective lability
• Irritability
• Depressed mood, hopelessness, or self-deprecating thoughts
• Anxiety
• Diminished interest in usual activities
• Difficulty concentrating
• Lack of energy
• Changes in appetite, overeating, or food craving
• Subjective sense of being overwhelmed or out of control
• Physical symptoms such as breast tenderness or swelling, joint or muscle
pain, or bloating

 Severe recurrent temper outbursts, including verbal or behavioral
expressions of temper that are out of proportion in intensity or duration to
the provocation.
 Temper outbursts are inconsistent with developmental level.
 The temper outbursts tend to occur at least three times per week.
 Negative mood between temper outbursts most days.
 These symptoms have been present for at least 12 months and do not clear
for more than 3 months at a time.
 Temper outbursts and negative mood are present in at least two settings (at
home, at school, or with peers) and are severe in at least one setting.
 Age 6 or older (or equivalent developmental level).
 Onset before age 10.
 There has never been a distinct period lasting more than 1 day during
which elevated mood and at least three other manic symptoms were
present.
 The behaviors do not occur exclusively during the course of major
depressive disorder and are not better accounted for by another mental
disorder.
 This diagnosis cannot coexist with oppositional defiant disorder, attention-
deficit/hyperactivity disorder, intermittent explosive disorder, or bipolar
disorder.
 Depression is common
• Lifetime prevalence (Kessler et al., 2005):
 16.2% MDD
 2.5% Dysthymia
• Twice as common in women as in men
• Three times as common among people in poverty
 Prevalence varies across cultures
• MDD
 1.5% in Taiwan
 19% in Beirut, Lebanon
 People who move to the U.S. from Mexico have lower
rates than people of Mexican descent who were born in
the United States
 Symptom variation across cultures
• Latino cultures
 Complaints of nerves and headaches
• Asian cultures
 Complaints of weakness, fatigue, and poor concentration
• Smaller distance from equator (longer day length) and
higher fish consumption associated with lower rates of
MDD
 Symptom variation across life span
• Children
 Stomach and headaches
• Older adults
 Distractibility and forgetfulness
 Co-morbidity
• 2/3 of those with MDD will also meet criteria for anxiety
disorder at some point

 Three forms:
• Bipolar I, Bipolar II, and Cyclothymia
 Mania defining feature of each
 Differentiated by severity and duration of mania
• Usually involve episodes of depression alternating with
mania
 Depressive episode required for Bipolar II, but not Bipolar I
 Mania
• State of intense elation or irritability
• Hypomania (hypo = “under”; hyper = “above”)
 Symptoms of mania but less intense
 Does not involve significant impairment, mania does

 Distinctly elevated or irritable mood for most of the day nearly every day
 Abnormally increased activity and energy
 At least three of the following are noticeably changed from baseline (four if mood is
irritable):
• Increase in goal-directed activity or psychomotor agitation
• Unusual talkativeness; rapid speech
• Flight of ideas or subjective impression that thoughts are racing
• Decreased need for sleep
• Increased self-esteem; belief that one has special talents, powers, or abilities
• Distractibility; attention easily diverted
• Excessive involvement in activities that are likely to have undesirable consequences,
such as reckless spending, sexual behavior, or driving
 For a manic episode:
• Symptoms last for 1 week or require hospitalization or include psychosis
• Symptoms cause significant distress or functional impairment
 For a hypomanic episode:
• Symptoms last at least 4 days
• Clear changes in functioning that are observable to others, but impairment is not marked
• No psychotic symptoms are present

 Bipolar I
• At least one episode or mania
 Bipolar II
• At least one major depressive episode with at least one
episode of hypomania
 Cyclothymic disorder (Cyclothymia)
• Milder, chronic form of bipolar disorder
 Lasts at least 2 years in adults, 1 year in children/adolescents
• Numerous periods with hypomanic and depressive
symptoms
 Does not meet criteria for mania or major depressive episode
 Symptoms do not clear for more than 2 months at a time
 Symptoms cause significant distress or impairment
 Prevalence rates lower than MDD
• 1% in U. S.; 0.6% worldwide for Bipolar I
• 0.4% – 2% for Bipolar II
• 4% for Cyclothymia
 Averageage of onset in 20s
 No gender differences in rates of bipolar disorders
• Women experience more depressive episodes
 Severe mental illness
• A third unemployed a year after hospitalization (Harrow
et al., 1990)
• Suicide rates high (Angst et al., 2002)

 Whatfactors contribute to onset of mood
disorders?
• Neurobiological factors
• Psychosocial factors

 Genetic factors
• Heritability estimates
 37% MDD (Sullivan et al., 2000)
 93% Bipolar Disorder (Kieseppa et al., 2004)
• Much research in progress to identify specific
genes involved but the results of most studies
have not been replicated (Kato, 2007)
 DRD4.2 gene, which influences dopamine
function, appears to be related to MDD
(Lopez Leon et al., 2005).
 Neurotransmitters (NTs): norepinephrine, dopamine, and
serotonin
• Original models focused on absolute levels of NTs
 MDD
 Low levels of norepinephrine, dopamine, and serotonin
 Mania
 High levels of norepinephrine and dopamine, low levels of serotonin
• However, medication alters levels immediately, yet relief takes 2-3 weeks
 New models focus on sensitivity of postsynaptic receptors
• Dopamine receptors may be overly sensitive in BD but lack
sensitivity in MDD
• Depleting tryptophan, a precursor of serotonin, causes depressive
symptoms in individuals with personal or family history of
depression
 Individuals who are vulnerable to depression may have less sensitive serotonin
receptors (Sobczak et al., 2002)

 Brain Imaging
• Structural studies
 Focus on number of or connections among cells
• Functional activation studies
 Focus on activity levels
Table 5.4 Activity of Brain Structures Involved in Emotion Responses
among People with Mood Disorders
Brain Structure Level in Depression Level in Mania
Amygdala Elevated Elevated
Subgenual anterior cingulate Elevated Elevated
Dorsolateral prefrontal cortex Diminished Diminished
Hippocampus Diminished Diminished
Striatum Diminished Elevated
 Overactivity of HPA axis
• Triggers release of cortisol, stress hormone
 Amygdala overreactive
 Findings that link depression to high cortisol levels
• Cushing’s syndrome
 Causes oversecretion of cortisol
 Symptoms include those of depression
• Injecting cortisol in animals produces depressive
symptoms
• Dexamethasone suppression test
 Lack of cortisol suppression in people with history of depression

 Life events
• Prospective research
 42-67% report a stressful life event in year prior to depression onset
 e.g., romantic breakup, loss of job, death of loved one
 Replicated in 12 studies across 6 countries (Brown & Harris, 1989b)
• Lack of social support may be one reason a stressor triggers depression
 Interpersonal difficulties
• High levels of expressed emotion by family member predict relapse
• Marital conflict also predicts depression
 Behavior of depressed people often leads to rejection by others

• Excessive reassurance seeking
• Few positive facial expressions
• Negative self-disclosures
• Slow speech and long silences

 Why do some people become depressed
after a stressful life event and others do
not?
• Social support
• Neuroticism
• Cognitive theories

 Neuroticism
• Tendency to react with higher levels of negative
affect
• Predicts onset of depression (Jorm et al., 2000)

 Cognitive theories
• Beck’s Theory
 Negative triad: negative view of self, world, future
 Negative schema: underlying tendency to see the world negatively
 Negative schema cause cognitive biases: tendency to process information in
negative ways
• Hopelessness Theory
 Most important trigger of depression is hopelessness
 Desirable outcomes will not occur
 Person has no ability to change situation
 Attributional Style
 Stable and global attributions can cause hopelessness
• Rumination Theory
 A specific way of thinking: tendency to repetitively dwell on sad thoughts
(Nolen-Hoeksema, 1991)
 Most detrimental is to brood over causes of events

Stable Unstable
Global I lack intelligence. I am exhausted.
Specific I lack mathematical ability. I am fed up with math.

 Triggersof depressive episodes in bipolar
disorder appear similar to the triggers of
major depressive episodes
• Negative life events, neuroticism, negative
cognitions, expressed emotion, and lack of social
support
 Predictors of mania
• Reward sensitivity
• Sleep disruption

 Interpersonal psychotherapy (IPT)
• Short-term psychodynamic therapy
• Focus on current relationships
 Cognitive therapy
• Monitor and identify automatic thoughts
 Replace negative thoughts with more neutral or positive thoughts
 Mindfulness-based cognitive therapy (MBCT)
• Strategies, including meditation, to prevent relapse
 Behavioral activation (BA) therapy
• Increase participation in positively reinforcing activities
to disrupt spiral of depression, withdrawal, and avoidance
 Behavioral couples therapy
• Enhance communication and satisfaction
 Psychological treatment of bipolar disorder
• Psychoeducational approaches
 Provide information about symptoms, course, triggers, and
treatments
• Family-focused treatment (FFT)
 Educate family about disorder, enhance family
communication, improve problem solving

 Electroconvulsive therapy (ECT)
• Reserved for treatment non-responders
• Induce brain seizure and momentary unconsciousness
 Unilateral ECT
• Side effects
 Memory loss
• ECT more effective than medications
 Unclear how ECT works
 Transcranial Magnetic Stimulation for
Depression (rTMS)
• Electormagnetic coil placed against scalp
• For those that fail to respond to first antidepressent

 Published studies may overestimate the
effectiveness of medication (Turner et al.,
2008)
 STAR-D (Rush et al., 2006)
• Sequenced Treatment Alternatives to Relieve
Depression
• Attempted to evaluate effectiveness of antidepressants
in real-world settings
 3671 patients across 41 sites
 Only 33% achieved full symptom relief with citalopram (the SSRI Celexa)
 About 30% of non-responders achieved remission with a different anti-
depressant

 Combining psychotherapy and antidepressant
medications increases odds of recovery over either alone
by 10-20%
• Medications quicker, therapy longer-lasting effects
 Later studies (Hollon & DeRubeis, 2003)
• CT as effective as medication for severe depression
• CT more effective than medication at preventing relapse

 Lithium
• Up to 80% receive at least some relief with this mood
stabilizer
• Potentially serious side effect
 Lithium toxicity
 Newer mood stabilizers
• Anticonvulsants
 Depakote
• Antipsychotics
 Zyprexa
• Both also have serious side effects

 Suicide ideation: thoughts of killing oneself
 Suicide attempt: behavior intended to kill
oneself
 Suicide: death from deliberate self-injury
 Non-suicidal self-injury: behaviors
intended to injure oneself without intent to
kill oneself

 Suicide rate in US is 1 per 10,000 in a given year; worldwide, 9%
report suicidal ideation at least once in their lives, and 2.5% have
made at least one suicide attempt
 Men are four times more likely than women to kill themselves;
women are more likely than men are to make suicide attempts
that do not result in death
 Guns are by far the most common means of suicide in the United
States (60%); men usually shoot or hang themselves; women more
likely to use pills
 The suicide rate increases in old age. The highest rates of suicide
in the United States are for white males over age 50
 The rates of suicide for adolescents and children in the United
States are increasing dramatically
 Being divorced or widowed elevates suicide risk four- or fivefold

 Psychological Disorders
• Half of suicide attempts are depressed at the time of the act
 Neurobiological Models
• Heritability of 48% for suicide attempts
• Low levels of serotonin
• Overly reactive HPA system
 Social Factors
• Economic recessions
• Media reports of suicide
• Social isolation and a lack of social belonging
 Psychological Models
• Problem-solving deficit
• Hopelessness
• Life satisfaction
• Impulsivity

 Talk about suicide openly and matter-of-
factly
 Most people are ambivalent about their
suicidal intentions
 Treat the associated mental disorder
 Treat suicidality directly
 Suicide prevention centers

Copyright 2015 by John Wiley & Sons, Inc. All
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by this copyright may be reproduced or utilized in
any form or by any means, electronic or
mechanical, including photocopying, recording
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Abnormal Psychology, Thirteenth

Edition, DSM-5 Update

I. Clinical Descriptions and Epidemiology of

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

Premenstrual dysphoric • Mood symptoms in the week before menses

 PLUS four of the following symptoms:

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Symptoms do not clear for more than 2 months at a

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Behavior of depressed people often leads to rejection by others

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

Global I lack intelligence. I am exhausted.

Specific I lack mathematical ability. I am fed up with math.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

© 2015 John Wiley & Sons, Inc. All rights reserved.

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