Introduction to Mood Disorders

Emotional experiences and moods are an important part of our world as humans. Sometimes we
feel happy; other times we feel sad. We have all experienced ourselves as having different
moods. Our thoughts are often consistent with our moods as when we feel sad and think we are
not doing things well. Likewise, our behaviors match our moods. To want to stay in bed in the
morning or not want to be with others is often the outcome of feeling blue. Other times we go in
the opposite direction and feel full of energy. Our thoughts when we are in a positive mood
influence what activities we can engage in or what we can accomplish. Behaviorally, we tend to
seek social interactions and start new projects.

Neither positive nor negative moods, as most of us experience them, interfere with our daily life
or separate us from ourselves or others. However, the mood disorders that we will discuss today
do. Not only do these disorders separate us; they also last for a long time and in some cases are
experienced throughout one’s life. First we will focus on depression. Then we will discuss about
those who experience both depression and mania, previously referred to as manic depression.
Mania is the experience of tremendous energy and euphoria. Today we call these periods of
depression and bipolar disorder. This is in contrast to unipolar depression which is the
experience of depression without mania.

Both depression and mania have been described for more than 2000 years. The ancient Greeks
referred to it as melancholia. Hippocrates described both melancholia and mania. He saw these
disorders as separate produced by underlying conditions related to an imbalance in the four
humors.

The mood disorders are psychological disorders in which there is a primary disturbance of mood
(prolonged emotion that colors the individual’s entire emotional state.) The mood disturbance
can include cognitive, behavioral, and somatic symptoms as well as interpersonal difficulties.
Depression has been related to a variety of physiological, psychological, family and social
components. It is the leading cause of disability worldwide and is a major contributor to the
overall global burden of disease.
Depression is characterized by depressed mood in which one feels sad or empty without any
sense of pleasure in one’s activities. All individuals experience depressed moods for brief
periods, which is usually accompanied by feelings of sadness, loss of energy, social withdrawal,
and often negative thoughts about one’ self. With a depressive disorder, the individual may also
experience sleep problems and weight changes. Included with the disorder is a sense of
worthlessness and self-blame. Clinical depression is seen when the majority of these symptoms
last for an extended period of time. At its worst depression can lead to suicide.

Clinical depression is different from normal sadness — like when you lose a loved one — as it
usually completely consumes a person in their day-to-day living. It doesn’t stop after just a day
or two — it will continue for weeks on end, interfering with the person’s work or school, their
relationships with others, and their ability to just enjoy life and have fun. Some people feel as if a
huge hole of emptiness has opened inside when experiencing the hopelessness associated with
this condition.

DSM-5 distinguishes between a single depressive episode and the case in which there are
recurrent depressive episodes punctuated by at least 2-month periods without depression. Three
fourths of those with MDD would also meet criteria for another mental disorder. Anxiety
disorder, obsessive-compulsive disorder, and substance abuse are all frequently comorbid with
MDD.

Today, major depressive disorder (MDD) is one of the most commonly diagnosed mental
disorders among adults. It has been called the “common cold” of mental disorders. In MDD
individuals experience a major depressive episode and depressed characteristics, such as lethargy
and hopelessness, for at least two weeks. The individual’s daily functioning becomes impaired.

The symptoms of MDD include the majority of the following signs, experienced more days than
not over the course of two or more weeks:
• a persistent feeling of loneliness or sadness;
• lack of energy;
• feelings of hopelessness;
 • difficulties with sleeping;
• difficulties with eating;
• difficulties with concentration or attention;
• total loss of interest in enjoyable activities or socializing;
• feelings of guilt and worthlessness; and/or
• thoughts of death or suicide.

Most people who are feeling depressed don’t experience every symptom, and the presentation of
symptoms varies in degree and intensity from person to person.
Significant losses such as bereavement, financial ruin and natural disaster may resemble a
depressive episode including feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss.

Seasonal affective disorder (SAD): This type of depression typically strikes during the short
days of the year when the sun isn't out as long.

Bipolar disorders
Bipolar disorder was previously referred to as manic-depressive disorder.
According to the American Psychiatric Association, there four major categories of bipolar
disorder: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder
due to another medical or substance abuse disorder (APA, 2013).

DSM-5 classifies the disorder in terms of the manic and depressive symptoms. Bipolar I
disorder does not require any depressive symptoms for the diagnosis. In fact, some individuals
with bipolar never report depression. Bipolar IIdisorder, on the other hand, requires an episode
of a MDD along with a hypomanic episode. A hypomanic episode is similar to mania but shorter
in duration and less severe. Further, an individual with bipolar II cannot have had a manic
episode. Cyclothymic disorder is characterized by mood changes that are not as severe as
would be required in the criteria for manic or depressive episodes.
Changes in mood are an important aspect of bipolar disorders. Bipolar means that the person
may experience both depression and mania. It is characterized by extreme mood swings that
include one or more episodes of mania (an overexcited, unrealistically optimistic state). These
include the intense sense of well-being along with high energy seen in mania and its opposite
seen in depression. Changes in cognition and perception also accompany these states. In mania,
thoughts seem to flow easily, and many individuals find themselves very productive during
mania. Perceptions and sensations may also be heightened. However, mania can also increase a
feeling of pressure with racing thoughts and ideas that do not make sense. Sometimes this
includes a feeling of “I can do anything” and the sense that nothing will not work out.
Individuals in a manic state may buy expensive items they cannot afford, place large bets, and
engage in all types of risky sexual behavior. It is as if there is nothing to worry about. The
depressive episodes show the opposite picture with the person experiencing a bleak outlook.

A manic episode is like the flip side of a depressive episode. Instead of feeling depressed, the
person feels euphoric and on top of the world. However, as the manic episode unfolds, the
person can experience panic and eventually depression. Instead of feeling fatigued, as many
depressed individuals do, when individuals experience mania they have tremendous energy and
might sleep very little. There is often an impulsivity when individuals are in a manic state that
can get them in trouble in business and legal transactions.

Most bipolar individuals experience multiple cycles of depression interspersed with mania. Less
than 10 percent of bipolar individuals tend to experience manic-type episodes without
depression.

Bipolar disorder is much less common than depressive disorder, and equally common in males
and females. About 1 to 2 in 100 people are estimated to experience bipolar disorder at some
point in their lifetimes.

New Mood Disorders

There are three new depressive disorders included in the DSM-V, including:
Disruptive mood dysregulation disorder: This depressive disorder was added to the DSM-V
for children up to 18 years of age who exhibit persistent irritability and frequent episodes of
extreme behavioral dyscontrol, which is a pattern of abnormal, episodic, and frequently violent
and uncontrollable social behavior without any significant provocation.

Persistent depressive disorder: This diagnosis is meant to include both chronic major
depressive disorder that has lasted for two or more years and what was previously known as
dysthymic disorder or dysthymia, a low-grade form of depression. Two or more of these six
symptoms must be present: poor appetite or overeating, sleep problems, low energy or fatigue,
low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

Premenstrual dysphoric disorder: This diagnosis is based on the presence of specific

symptoms in the week before the onset of menstruation, followed by the resolution of these
symptoms after onset. The symptoms must include one or more of the following: mood swings,
irritability or anger, depressed mood or hopelessness, and anxiety or tension, as well as one or
more of an additional seven symptoms, with a total of at least five symptoms.

Causes of mood disorders

Mood disorders can involve biological, psychological, and sociocultural factors.

Biological factors of mood disorders include heredity, neurophysiologicalabnormalities,
neurotransmitter deregulation, and hormonal factors. The links between biology and mood
disorders is well established.

Depressive and bipolar disorders tend to run in families, although the family link is stronger for
bipolar disorder than for depressive disorders. One of the greatest risks for developing a mood
disorder, is having a biological parent who suffers from a mood disorder.

One of the most consistent findings of neurobiological abnormalities in individuals with mood
disorders is altered brain-wave activity during sleep. Depressed individuals experience less
slow-wave sleep and go into rapid-eye-movement sleep earlier in the night than nondepressed
individuals. This prevents them from feeling rested and restored.

Neuroimaging studies also reveal decreased metabolic activity in the cerebral cortex of
individuals with severe major depressive disorder. Most areas of the brains of depressed
individuals are underactive. However, certain brain areas are overactive. Another
neurobiological abnormality in depression is neuron death or disability.

Deregulation of a number of neurotransmitters is likely involved in depression. Abnormalities

in the monoamine neurotransmitters, such as norepinephrine, serotonin, and dopamine, have
been indicated in mood disorders.

Depressed individuals show chronic hyperactivity in the neuroendocrine glandularsystem

and an inability to return to normal functioning following a stressful experience. It has been
argued that women’s increased vulnerability to depression is linked to their ovarian hormones,
estrogen and progesterone. Some women do experience more depression during the postpartum
period, menopause, and other times when their hormone levels are changing.

Psychodynamic, behavioral, and cognitive theories have all proposed explanations for
depression.

Psychodynamic theories emphasize that depression stems from individuals’ childhood

experiences that prevented them from developing a strong, positive sense of self. In this view,
depressed individuals become overly dependent on the evaluations and approval of others for
their self-esteem because of inadequate nurturing by parents.

Many modern psychodynamic theorists still rely on Freud’s theory that depression is a turning
inward of aggressive instincts. Freud theorized that a child’s early attachment to a love object
(usually the mother0 contains a mixture of love and hate. When the child loses the love object or
when his or her dependency needs are frustrated, feelings of loss coexist with anger. Because the
child cannot openly accept such angry feelings toward the individual he or she loves, the hostility
is turned inward and experienced as depression. The unresolved mixture of anger and love is
carried forward to adolescence and adulthood, when loss can bring back these early feelings of
abandonment.

According to the behavioral explanation, life’s stresses can lead to depression by reducing the
positive reinforcers in a person’s life. When people experience considerable stress in their lives,
they may withdraw from the stress. The withdrawal produces a further reduction in positive
reinforcers, which can lead to more withdrawal, which leads to even fewer reinforcers.

Another behavioral view of depression focuses on learned helplessness, which occurs when
individuals are exposed to aversive stimulation, such as prolonged stress, over which thy have no
control. The inability to avoid such aversive stimulation produces an apathetic state of
helplessness. Martin Seligman proposed that learned helplessness is one reason that some
individuals become depressed. When individuals cannot control the stress they encounter, they
eventually feel helpless and depressed.

Susan Nolen-Hoeksema found that some depressed individuals use a ruminative coping style,
in which they focus intently on how they feel (sadness and hopelessness) but do not try to do
anything about their feelings: they just ruminate about their depression. Research also indicates
that individuals with depression remain depressed longer when they use a ruminative coping
style rather than an action-oriented coping style. Women are more likely to ruminate when they
are depressed than men are.

The cognitive approach provides another perspective on mood disorders. Individuals who are
depressed rarely think positive thoughts. They interpret their lives in self-defeating ways and
have negative expectations about the future. Psychologist Aaron Beck believes that such
negative thoughts reflect schemas that shape the depressed individual’s experiences. These
habitual negative thoughts magnify and expand a depressed person’s negative experiences. The
depressed person might overgeneralize about a minor occurrence and think that he is worthless
because a work assignment was turned in late, his son was arrested for shoplifting, or a friend
made a negative comment about his hair. The accumulation of such negative distortions can lead
to depression.

Another cognitive view of depression involves a cognitive reformulation of the helplessness

involved in learned helplessness. When people make attributions, they attempt to explain what
caused something to happen. In this attributional view of depression, individuals who regularly
explain negative events as being caused by internal (“It’s my fault that I failed the exam”), stable
(“I’m going to fail again and again”), and global (“Failing this exam shows how I won’t do well
in any of my courses”) causes blame themselves for these negative events, expect the events to
recur in their lives in the future, and tend to experience negative events in many areas of their
lives.

Sociocultural factors include Interpersonal Relationships, Socioeconomic and Ethnic

Factors, cultural variations, and gender.
Interpersonal Relationships One view of depression is that it may stem from problems
that develop in relationships with other people. Recent marital conflict might trigger
depression. Possibly inadequate early relationships with parents are carried forward to influence
the occurrence of depression later in a person’s life. John Bowlby suggested that both
interpersonal relationships and cognitive factor can explain the development of depression. He
believes that the combination of an insecure attachment to the mother, a lack of love and
affection as a child,and the actual loss of a parent during childhood gives rise to a negative
cognitive set, or schema. The schema built up during childhood causes the individual to interpret
later losses as yet other failures in one’s efforts to establish enduring and close relationships.

Socioeconomic and Ethnic Factors Individuals with a low socioeconomic status,

especially those living in poverty, are more likely to develop depression than their higher SES
counterparts. Very high rates of depression have been found in certain ethnic groups among
whom poverty, hopelessness, and alcoholism are widespread.

Cultural Variations Depressive disorders are found in virtually all the cultures
in the world, but their incidence, intensity, and components vary across cultures. The incidence
of depressive disorders is lower in less industrialized, less modernized countries than in more
industrialized, modernized countries. This difference likely is due to fast-paced, stressful
lifestyles of individuals in industrialized modernized countries and the stronger family,
community orientation of people in less industrialized, less modernized countries.

Gender Bipolar disorder occurs about equally among women and men, but women are
about twice as likely as men to develop depression. This gender difference occurs in many
countries. Studies have shown that depression is especially high among single women who are
the heads of households and among young married women who work at unsatisfying, dead-
end jobs. Marriage often confers a greater protective buffer against stress for men rather than for
women. In unhappy marriages, women are three times as likely as men to be depressed.
Mothers of young children are especially vulnerable to stress and depression. Also, the more
children in the household, the more depression women report.

Over 56 million or 4.5% of the Indian population suffer from depression. A 2016 mental health
survey by NIMHANS Bengaluru reports that the incidence of depression is roughly one in every
20 individuals or 5% of the population. Also, from all those who suffer from depression only
about half seek treatment. The inadequate care that results from a lack of understanding or a
misunderstanding of mood disorders is tragic. Given the range of psychological and
pharmacological treatments available today, those individuals who go untreated suffer
needlessly. Therefore, it is important that people understand these disorders and seek help from
mental health professionals.

CASE STUDY
In his early school years Rajesh had been a remarkable student and had shown a gift for
painting. Later he studied art in Mumbai and married a girl he met in college. Eventually they
settled in Mumbai.

Ten years later, when he was thirty-four, he had persuaded by his wife and only son to
accompany him to London, where, he assured them, he would be considered famous. He felt he
would be able to sell his paintings at many times the prices he would get in Mumbai. According
to his wife, he had been in an accelerated state, but at that time the family had left, unsuspecting,
believing with the patient in their imminent good fortune. When they arrived they found almost
no one in the art world that he was supposed to know and no connections for sales and deals.
Settling down, the patient began to behave more peculiarly than ever. After enduring several
months of the patient’s exhilaration, overactivity, weight loss, constant talking, and unbelievably
little sleep. The young wife and child began to fear for his sanity. None of his plans materialized.
After five months in London, with finances growing thin, the patient’s overactivity subsided and
he fell into a depression. During that period, he refused to move, paint, or leave the house. He
lost several kilos, became utterly dependent on wife, and insisted on seeing none of his friends he
had accumulated in his manic state. His despondency became so severe that several doctors
came to the house and advised psychiatric hospitalization. He quickly agreed and received
twelve electroshock treatments, which relieved his depressed state. Soon afterward he began to
paint again and to sell his work modestly. Recognition began to come from galleries and critics
far and wide. Several reviews acclaimed his work as exceptionally brilliant.

This was the beginning of his lifelong career of his moodswing. Later, while still in London, he
became severely depressed……four years later he returned to Mumbai in a high…..When the
manic period subsided and he surveyed the wreckage of his life, an eight-month interval of
normal mood followed, after which he again switched into a profound depression.