Mood Disorders

Mood refers to a pervasive and sustained emotional response that, in its extreme form, can colour
the person’s perception of the world (APA, 2013). The disorders discussed here are primarily
associated with two specific moods: depression and elation

Mood disorders are defined in terms of episodes—discrete periods of time in which the person’s
behaviour is dominated by either a depressed or manic mood. Unfortunately, most people with a
mood disorder experience more than one episode (Monroe & Harkness, 2011).

Important Considerations in Distinguishing Clinical Depression from Normal Sadness

1. The mood change is pervasive across situations and persistent over time. The person’s mood does
not improve, even temporarily, when he or she engages in activities that are usually experienced as
pleasant.

2. The mood change may occur in the absence of any precipitating events, or it may be completely
out of proportion to the person’s circumstances.

3. The depressed mood is accompanied by impaired ability to function in usual social and
occupational roles. Even simple activities become overwhelmingly difficult.

4. The change in mood is accompanied by a cluster of additional signs and symptoms, including
cognitive, somatic, and behavioural features.

5. The nature or quality of the mood change may be different from that associated with normal
sadness. It may feel “strange,” like being engulfed by a black cloud or sunk in a dark hole.

DSM-5 Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is either

(1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are
clearly attributable to another medical condition.

1. Depressed mood most of the day, every day, as indicated by either subjective report (e.g., feels
sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and
adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or all, activities most of the day, every day (as
indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month) or decrease or increase in appetite every day. (Note: In children, consider failure
to make expected weight gain.)

4. Insomnia or hypersomnia every day.

5. Psychomotor agitation or retardation every day (observable by others; not merely subjective
feelings of restlessness or being slowed down).

6. Fatigue or loss of energy every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly

every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, every day (either by subjective

account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan to take one’s own life.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
key areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical
condition.

Note: Criteria A–C represent a major depressive episode. Note: Responses to a significant loss (e.g.,
bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may
include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and
weight loss noted in Criterion A, which may resemble a depressive episode. Although such
symptoms may be understandable or considered appropriate to the loss, the presence of a major
depressive episode in addition to the normal response to a significant loss should also be carefully
considered. This decision inevitably requires the exercise of clinical judgment based on the
individual’s history and the cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and
unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-
induced or are attributable to the physiological effects of another medical condition.

PERSISTENT DEPRESSIVE DISORDER (dysthymia)

 differs from major depression in terms of both severity and duration.

 Persistent depressive disorder represents a chronic mild depressive condition that has been
present for many years.
 In order to fulfil DSM-5 criteria for this disorder, the person must, over a period of at least
two years, exhibit a depressed mood for most of the day on more days than not.

Two or more of the following symptoms must also be present:

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

 These symptoms must not be absent for more than two months at a time during the
two-year period.
 If, at any time during the initial two years, the person met criteria for a major
depressive episode, the diagnosis would be major depression rather than persistent
depressive disorder.
 As in the case of major depressive disorder, the presence of a manic episode would
rule out a diagnosis of persistent depressive disorder

Risk factors for Unipolar Mood Disorder

Biochemical factors

Depression is a type of mood disorder that some believe is triggered when neurotransmitters in the
brain are out of balance. Neurotransmitters are chemical messengers that help the brain
communicate with other parts of the body. These chemicals help regulate many physiological
functions.

Low levels of neurotransmitters may play a role in why some people are more susceptible to
depression, including the neurotransmitters:

 serotonin

 norepinephrine

 dopamine

Genetic factors

Having an immediate family member with depression or a mood disorder can increase your risk for
depression. The American Psychiatric association states that if one identical twin is diagnosed with
depression, the other twin has a 70 percent chance of developing it.
However, depression can occur in people with no family history, which is why some scientists believe
it can be a product of both genes and life experiences.

Abuse

People who were neglected or abused as children have an elevated risk for major depression. Such
negative experiences can cause other mental disorders as well.

Gender

Women are twice as likely to have depression as men, but this may be due to the fact that more
women seek treatment for their symptoms than men. Some believe depression can be caused by
hormonal changes throughout life. Women are particularly vulnerable to depression during
pregnancy and after childbirth, which is called postpartum depression, as well as during menopause.

Lack of social support

Prolonged social isolation and having few friends or supportive relationships is a common source of
depression. Feelings of exclusion or loneliness can bring on an episode in people who are prone to
mood disorders.

Major life events

Even happy events, such as having a baby or landing a new job, can increase a person’s risk for
depression. Other life events linked to depression include:

 losing a job

 buying a house

 getting a divorce

 moving

 retiring
Substance abuse

In many cases, substance abuse and depression go hand-in-hand. Drugs and alcohol may lead to
chemical changes in the brain that raise the risk for depression. Self-medication with drugs and
alcohol can also lead to depression.

Medications

Certain medications have been linked to depression, including:

 blood pressure medication

 sleeping pills

 sedatives

 steroids

 prescription painkillers

Bipolar Disorders

DSM 5 criteria for Maniac Episode

A. 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, every day (or any duration if hospitalization is necessary).

B. During the period of mood disturbance and increased energy or activity, three (or more) of the
following symptoms (four if the mood is only irritable) are present to a significant degree and
represent a noticeable change from usual behaviour:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., 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. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation (i.e., purposeless non-goal-directed activity).

7. Excessive involvement in activities that have a high potential for painful consequences (e.g.,
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 hospitalization to prevent harm to self or others, or there are psychotic
features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication, other treatment) or to another medical condition. Note: A full manic episode that
emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists
at a fully syndrome level beyond the physiological effect of that treatment is sufficient evidence for a
manic episode and, therefore, a bipolar I diagnosis.

Bipolar Disorders (I and II)

Bipolar I disorder is distinguished from major depressive disorder by the presence of mania
A mixed episode is characterized by symptoms of both full-blown manic and major
depressive episodes for atleast1 week, whether the symptoms are intermixed or alternate
rapidly every few days.

DSM-5 also identifies a distinct form of bipolar disorder called bipolar II disorder, in which the person
does not experience full-blown manic (or mixed) episodes but has experienced clear-cut hypomanic
episodes as well as major depressive episodes

Distinguishing between Bipolar I and Bipolar II

Bipolar I: The most important aspect of bipolar I disorder is the presence of mania. People with
bipolar I disorder experience episodes of mania and periods of depression. Even It the periods of
depression do not reach the threshold for a major depressive episode, the diagnosis of bipolar I
disorder is still given.
Bipolar II: People with bipolar II disorder experience periods of hypomania but their symptoms are
below the threshold for full-blown mania. The person diagnosed with bipolar II disorder also
experiences periods of depressed mood that meet the criteria for major depression.

Cyclothymic Disorder
Cyclothymia is considered by DSM-5 to be a chronic but less severe form of bipolar disorder.

It is, therefore, the bipolar equivalent of persistent depressive disorder.

In order to meet criteria for cyclothymia,

 the person must experience several periods of time with hypomanic symptoms and frequent
periods of depression (or loss of interest or pleasure) during a period of two years.
 There must be no history of major depressive episodes and no unmistakable evidence of a
manic episode during the first two years of the disturbance.
Causal Factors in Bipolar Disorder

Genetics and gene environment interactions

The contribution of genetic factors to bipolar has long been identified, with evidence from twin
studies suggesting monozygotic concordance of between 40–70%, and lifetime risk in first-degree
relatives is 5–10%; around seven times higher than the general population risk.5 However, relatives
of patients with bipolar are more likely to develop unipolar depression than bipolar themselves,
suggesting the genetic risk transcends diagnostic categories.

Environmental risk factors

Childhood maltreatment is a well-studied environmental risk factor with high-quality evidence that it
confers a risk for later development of bipolar, although it is also associated with behavioural
problems and other mental illnesses. When investigating specific subtypes of abuse, several studies
have identified a link between emotional abuse or emotional neglect and the later the development
of bipolar, while emotional abuse appears to be the most frequent subtype of abuse experienced in
bipolar patients

Substance abuse

Bipolar is frequently comorbid with misuse of substances, including cannabis, opioids, cocaine,
sedatives and alcohol, and causality has been suggested in both directions.
Schizophrenia and other spectrum
Disorders
Includes Schizophrenia, other psychotic disorders, and schizotypal (personality) disorder.

They are defined by abnormalities in one or more of the following five domains: delusions,
hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behaviour
(including catatonia), and negative symptoms.

Key Features That Define the Psychotic Disorders

Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their
content may include a variety of themes

Persecutory delusions (i.e., belief that one is going to be harmed, harassed, and so forth by an
individual, organization, or other group) are most common.

•Referential delusions (i.e., belief that certain gestures, comments, environmental cues, and so forth
are directed at oneself) are also common.

•Grandiose delusions (i.e., when an individual believes that he or she has exceptional abilities,
wealth, or fame)

•Erotomania delusions (i.e., when an individual believes falsely that another person is in love with
him or her) are also seen.

•Nihilistic delusions involve the conviction that a major catastrophe will occur, and

•Somatic delusions focus on preoccupations regarding health and organ function.

Delusions: Bizarre or Non-Bizarre

Bizarre delusions: If they are clearly implausible and not understandable to same-culture peers and
do not derive from ordinary life experiences.
•Delusions that express a loss of control over mind or body are considered to be bizarre
•These include the belief that one's thoughts have been "removed" by some outside force {thought
withdrawal) that alien thoughts have been put into one's mind (thought insertion), or that one's
body or actions are being acted on or manipulated by some outside force (delusions of control).
Hallucinations are the unreal perceptual experiences. Four types of hallucination.

1. Auditory hallucination
2. Visual hallucination
3. Tactile hallucination
4. Somatic hallucination
Disorganised thoughts or speech is also knowns as Formal thought disorder; slip from the topic to
unrelated topic with little coherent transition, often referred as loosening of associations or
derailment.

Catatonic Behaviour; often frightened other people. Unpredictable and untriggered agitation;
suddenly shouting, swearing, and pacing rapidly. This behaviour may occur in response to
hallucinations or delusions.
Increased difficulty in organising daily routine.

Negative Symptoms

● Active Flattening or Blunted affect: severe reduction or absence of affective (emotional)

response to the environment.
● Alogia: poverty of speech, massive reduction in speaking

● Avolition: Inability to persist a common goal directed activity. Gets trouble in completing
task. disorganised and careless.

Cognitive deficits

People with schizophrenia show deficits in basic cognitive processes, including attention and
memory. People with schizophrenia show deficits in working memory, the ability to hold information
in memory and manipulate it. These deficits in attention and working memory make it difficult for
people with schizophrenia to pay attention to relevant information and to suppress unwanted or
irrelevant information.

Types of Schizophrenia

● Paranoid schizophrenia: Delusions and hallucinations with themes of persecution and

grandiosity
● Disorganized schizophrenia: Incoherence in cognition, speech, and behaviour and flat or
inappropriate affect
● Catatonic schizophrenia: Nearly total unresponsiveness to the environment, as well as
motor and verbal abnormalities
● Undifferentiated Diagnosed: when a person experiences schizophrenia schizophrenic
symptoms but does not meet the criteria for paranoid,
disorganized, or catatonic schizophrenia
● Residual schizophrenia: History of at least one episode of acute positive symptoms but
currently no prominent positive symptoms

Paranoid Schizophrenia: People with paranoid schizophrenia have prominent delusions and
hallucinations that involve themes of persecution and grandiosity. They often do not show grossly
disorganized speech or behaviour. People with paranoid schizophrenia are highly resistant to any
arguments against their delusions and may become angry if someone argues with them. They may
act arrogantly, as if they are superior to others, or may remain aloof and suspicious.
The combination of persecutory and grandiose delusions can lead people with this type of
schizophrenia to be suicidal or violent toward others.
Disorganised Schizophrenia: People with disorganized schizophrenia do not have well-formed
delusions or hallucinations. The emotional experiences and expressions of people with disorganized
schizophrenia are also disturbed. They may not show any emotional reactions, or they may have
inappropriate emotional reactions to events, such as laughing uncontrollably at a funeral. This type
of schizophrenia tends to have an early onset and a continuous course, which often is unresponsive
to treatment. People with disorganized schizophrenia are among the most disabled by the disorder.
Catatonic Schizophrenia: People with catatonic schizophrenia show a variety of motor behaviours
and ways of speaking that suggest almost complete unresponsiveness to their environment. The
diagnostic criteria for catatonic schizophrenia require two of the following symptoms: (1) catatonic
stupor (remaining motionless for long periods of time); (2) catatonic excitement (excessive and
purposeless motor activity); (3) the maintenance of rigid postures or being completely mute for long
periods of time; (4) odd mannerisms, such as grimacing or hand flapping; and (5) echolalia (the
senseless repetition of words just spoken by others) or echopraxia
(Repetitive imitation of the movements of others).

Undifferentiated Schizophrenia

People with undifferentiated schizophrenia have symptoms that meet the criteria for schizophrenia
(delusions, hallucinations, disorganized speech, disorganized behaviour, negative symptoms) but do
not meet the criteria for paranoid, disorganized, or catatonic schizophrenia. This type of
schizophrenia tends to have an early onset and to be chronic and difficult to treat.

Residual Schizophrenia

People with residual schizophrenia have had at least one acute episode of acute positive symptoms
of schizophrenia but do not currently show any prominent positive symptoms. They continue to
have signs of the disorder, however, including the negative symptoms and mild versions of the
positive symptoms. These residual symptoms may be chronic over several years

Course of Development-Prodromal phase

•The period of gradual deterioration. •It is characterized by subtle symptoms involving unusual
thoughts or abnormal perceptions (but not outright delusions or hallucinations).
•Waning interest in social activities.
•Difficulty meeting responsibilities of daily living.
•Impaired cognitive functioning involving problems with memory and attention, use of language,
and ability to plan and organize one’s activities.
•One of the first signs of a prodromeis often a lack of attention to one’s appearance. The person
may fail to bathe regularly or wear the same clothes repeatedly.
Course of Development-Acute phase
•The person’s behaviour becomes increasingly odd.
•There are lapses in job performance or schoolwork.
•Speech becomes vague and rambling.
•These changes in personality so gradual that they raise little concern at first among friends and
family.
•The changes may be attributed to “a phase” the person is passing through. But as behaviour
becomes more bizarre—such as hoarding food, collecting garbage, or talking to oneself on the street
—the acute phase of the disorder begins.
•Frankly, psychotic symptoms then develop, such as wild hallucinations, delusions, and increasingly
bizarre behaviour.
Course of Development-Residual phase
•Following acute episodes, some people with schizophrenia enter the residual phase, in which their
behaviour returns to the level of the prodromal phase.
•Flagrant psychotic behaviours are absent, but the person is still impaired by significant cognitive,
social, and emotional deficits, such as a deep sense of apathy and difficulties in thinking or speaking
clearly, and by harbouring unusual ideas, such as beliefs in telepathy or clairvoyance.
•These cognitive and social deficits can make it difficult for schizophrenia patients to function
effectively in their social and occupational roles (Harvey,2010; Hooley,2010).