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Mood Disorder and Suicide

Chapter 7 Click to edit Master subtitle style



Enduring period of emotionality Mood disorder is related to a persons emotional tone or affective state and can have an effect on behavior and can influence a persons personality and world view.


An overview of Depression and Mania

Depressive disorders, affective disorders or depressive neuroses (DSM-III) The most commonly diagnosed and most severe depression is MAJOR DEPRESSIVE EPISODE.


Major Depressive Episode

- an extremely depressed mood state that lasts at least 2 weeks

include cognitive symptoms (such as feelings of worthlessness and indecisiveness) Physical functions (such as altered sleeping patterns, significant changes in appetite and weight, or notable loss of energy)

Anhedonia loss of energy and

Major Depressive Disorder: Diagnostic Criteria

5 of following symptoms, must include one of first two, occurred almost every day for two weeks

Depressed mood Pleasure or interest/ Loss Appetite Sleep disturbance, too much or too little Agitation or retardation Fatigue Feelings of worthlessness or guilt

Difficulty concentrating or deciding Recurrent thoughts of death

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 due to a general medical 4/22/12

Criteria for Major Depressive Episode


(6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely selfreproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly 4/22/12 every day

S leep (increase / decrease) I nterest (diminished) G uilt / low self-esteem E A nergy (poor/low) C oncentration (poor)

Depressive Symptoms Mnemonic: SIGECAPS

ppetite (increase/ decrease)

P sychomotor (agitation /retardation) 4/22/12


Period of abnormally excessive elation or euphoria, associated with some mood disorders. Find extreme pleasure in every activity. duration if untreated typically 3to 6 months




A distinct period of abnormally and persistently elevated, expansive, or irritable mood Mood disturbance plus three of the following symptoms (four if the mood is only irritable): 1.) Inflated self esteem or grandiosity 2.) Decreased need for sleep 3.) More talkative than usual or pressure to keep talking 4.) Flight of ideas, or racing thoughts 5.) Distractibility 6.) Increase in goal directed activity 7.) Excessive involvement in pleasurable activities Marked impairment No psychosis

Manic Episode: Diagnostic Criteria (DSM-IV-TR)


C. D.


Hypomanic episode

a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning Hypo means below is not in itself problematic, but it does contribute to the definition of several mood disorders.

The Structure of Mood Disorders

Unipolar Mood Disorder Individuals who experience either depression or mania. Bipolar Mood Disorder Someone who alternates between depression and mania, travelling from one pole of the depression-elation continuum to the other and back 4/22/12 again

The Structure of Mood Disorders

Dysphoric Manic episode or mixed manic episode An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time. - usually experiences the symptoms of manic as being our of control or dangerous anxious or depressed about 4/22/12 this uncontrollability.

Mood Disorders and Suicide

Depression and mania may differ from one person to another in terms of their severity, their course (frequency), and occasionally, the accompanying symptoms. An important feature of major depression episodes is that THEY DONT GO ON FOREVER. Lasting from as little as 2 weeks to several months or more if untreated (Boland & Keller, 2002) 4/22/12

Mood Disorders and Suicide

Manic episode abate on their own without treatment after approximately 3 to 4 months. Therefore it is important to DETERMINE the course of temporal patterning of the episodes.

Course modifiers for mood disorders characterize the mood state in the past which helps us better predict the 4/22/12

Mood Disorders

are divided into:

1.) Depressive disorders include major depressive disorder, dysthymic disorder and depressive disorder NOS 2.) Bipolar disorders include bipolar 1 disorder, bipolar II disorder, cyclothymic disorder and bipolar disorder NOS.

1.) Depressive Disorders

DSM-IV-TR describes several types of depressive disorders differ from one another in the frequency with which depressive symptoms occur and the severity of the symptoms.


the most easily recognized mood disorder absence of manic or hypomanic episodes before or during the disorder. Median lifetime number : 4

1. a.) Major Depressive disorder, Single Episode

(25% experienced 6 or more episodes)

Median duration of recurrent : 4 to 5 4/22/12

Major Depression
MDD, Single episode Recurrent

2 major of mania or hypomania Absencedepression episodes, separated by at least a 2 month period with more or less normal functioning/mood


1. b.)Dysthymic disorder

as a persistently depressed mood that continues at least 2 years, during which the patient cannot be symptom free for more than 2 months at a time. differs from a Major Depressive episode only in the severity, chronicity and number of its symptoms which are milder and fewer but last longer. 4/22/12

Diagnostic Criteria for Dysthymic Disorder (DSM-IV-TR)

A. B. .

Depressed/irritable mood Presence of two of the following: Appetite disturbance Sleep disturbance Low energy/fatigue Poor concentration of difficulties making decision Feelings of hopelessness

C. Present for two year period (one year in children and adolescents) D. No evidence of a Major Depressive Epidsode during the first two years (one year for children) E. No manic or hypomanic episode F. No chronic psychotic disorder 4/22/12

Double Depression

individuals have been studied who suffer from both major depressive episodes and dysthmic disorder. Not a diagnosis Meet diagnostic criteria for both MDD and Dysthymic Disorder


1.c.) Depression NOS

does not meet the criteria for major depression and other disorders (APA 2000)


2.) Bipolar disorders

is the tendency of manic episodes to alternate wit major depressive episodes in an unending rollercoaster ride from the peak of elation to the depth of despair.



Bipolar Disorder
Bipolar I II

Alternation of full manic and Major Depression with hypomania depressive episodes Average onset is 18 years 22 Tends to be chronic 10% risk for to full High progesssuicide biploar I disorder


Bipolar I - Average age : 18 Bipolar II - Average age: between 1922 Cyclothymia most common age of onset to be 12 to 14 years

Diagnostic Criteria for Cyclothymia disorder (DSM-IV-TR)


For at least two years (one year for children and adolescents) presence of numerous hypomanic episodes and numerous periods with depressed mood or loss of interest or pleasure that did not meet criterion A (5 symptoms) of Major Depression During a two-year period (1 year in children and teens) of disturbance, never without hypomanic or depressive symptoms for more than tow months at a time No evidence of MDD or Manic episode during the first two years of disturbance No psychotic disorder No organic cause The Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.







Mood Disorders: Summary

Bipolar Disorders Depressive Disorders

Bipolar I Disorder Major Depressive Disorder (single, recurrent) Bipolar II Disorder [Major Depressive Disorder: Cyclothymic Disorder Postpartum onset]** Dysthymic Disorder


Mood Disorders: Prevalence

Prevalence Disorders 4.9% Major Depression 3.2% Dysthymia 0.8% Bipolar I 0.5 Biploar II

13% MDD (Postpartum) 4/22/12

Major Depressive Disorder: Etiological Theories

Biological (genetic, brain structures, neurotransmitters) Behavior and cognition Emotion Social and cultural factors Developmental factors


Major Depression: Genetics

Family studies:

Relatives of those with a mood disorder are two to three times more likely to have a mood disorder (usually major depression)

Twin studies: If one identical twin has a mood disorder the othe twin is 3 times more likely than a fraternal twin to have a mood disorder (particulrly for bipolar disorder)

Major Depression: Genetics

Severe mood disorders may have stronger genetic contribution than less severe disorders Heritability rates are higer for females


Major Depression: Neurotransmitters

Low levels of serotonin deregulates the activity of other neurotransmitters Permissive hypothesis


Major Depression: Endorcrine System

Elevated cortisol


Major Depression: Cognition

Learned helplessness (Seligman) -Experience of uncontrollable events

-outcomes were independent of responses - Loss of self-esteem after adverse external events - Loss of sense of control

Learned Helplessness

Attribution of lack of control over stress leads to anxiety and depression Depressive attributional style is internal, stable, and global


Major Depression: Cognition

Negative cognitive styles (Beck)

Aaron Becks


Negative view if self World is hostile and demanding Expectation of suffering and failure


Negative Cognitive Styles Aaron Beck

Depression is the result of negative interpretations (wearing gray instead of rose colored glasses, e.g. Eyore in Winnie the Pooh) Key Components of Negative Interpretations

Maladaptive attitudes (negative schema) Automatic thoughts Cognitive 4/22/12 triad

Seligman and Beck

Beck Seligman Negative interpretations about: Attributions are:

Themselves Internal Immediate world (their place) Stable Future Global (their place)

I am inadequate (internal) at everything (global) and I always not good at school (self). I hate this campus (world). Things are not going to go well in college (future). will be (stable). Dark glasses about what is going on Dark glasses about why things are bad Description
4/22/12 Interpretation (theory)

Major Depression: Social and Cultural Factors

Stressful life events Social support -marital relationship (see chart) - Mood disorders in women

Gender Culture (see chart)


Marital Status and MDD Percentage w/MDD

7 6 5 4 3 2 1 0 Married Widowed Never M. M/D/W 2.1 2.1 2.8 Married Widowed Never M. M/D/W 6.3

Ethnicity and Prevalence of MDD Percentage by Ethnicity

6 5 4 3 2 1 0 Af. Am Latina White Average

5.1 4.4 3.1

Af. Am Latina White Average

Children Teens Elderly

Major Depression: Developmental Factors



Treatment Major Depression: Overview

Biological Treatments Medication ECT Special note about antidepressants and children Psychological Treatments Cognitive Therapies Interpersonal Psychotherapy (IPT)

Antidepressant Medication with Children

The effectiveness of antidepressant medication with children is questionable. December 2003 British drug regulators told physicians to stop writing perscriptions for all but one of the newer generation of antideressant drugs to treat children under 18. Benefit did not outweigh the risks (including suicidal thoughts and behavior and agression) Prozac was exempted.


Psychological Treatments

Cognitive-Behavioral Treatment

- Clients are taught to examine carefully their thought processes while they are depressed and to recognize depressive errors in thinking.

Interpersonal Therapy (IPT)

- Focuses on resolving problems in existing relationships and learning to 4/22/12 form important new interpersonal

8th leading cause of death in the U.S. Overwhelmingly white phenomena Suicide rates also quite high in Native American Rate of suicide is increasing in adolescents and elderly Males are more likely to commit suicide Females are more likely to attempt 4/22/12 suicide (except China)

5 Myths and Facts About Suicide

Myth #1:


People who talk about killing themselves rarely commit suicide.

Most people who commit suicide have given some verbal clues or warnings of their intentions


5 Myths and Facts About Suicide

Myth #2:


The suicidal person wants to die and feels there is no turning back.


Suicidal people are usually ambivalent about dying; they may desperately want to live but can not see alternatives to

5 Myths and Facts About Suicide

Myth # 3:

If you ask someone about their suicidal intentions, you will only encourage them to kill themselves.

Fact: The opposite is true. Asking lowers their anxiety and helps deter suicidal behavior. Discussion of suicidal feelings allow for

5 Myths and Facts About Suicide

Myth # 4:


All suicidal people are deeply depressed.

Although depression is usually associated with depression, not all suicidal people are obviously depressed. Once they make the decision, they may appear happier/carefree.


5 Myths and Facts About Suicide

Myths # 5:


Suicidal people rarely seek medical attention.

75% of suicidal individuals will visit a physician within the month before they kill themselves.


Sociodemographic Risk Factors

Male > 60 years Widowed or Divorced White or Native American Living alone (social isolation) Unemployed (financial difficulties) Recent adverse life events Chronic Illness

Clinical Risk Factors

Previous Attempts Clinical depression or schizophrenia Substance Abuse Feelings of hopelessness Severe anxiety, particularly with depression Severe loss of interest in usual activities Impaired thought process Impulsivity 4/22/12

Clinical Considerations of Suicide Assessment

For those who are reluctant to assess suicide:

Asking questions may feel intrusive but not asking has dangerous consequences A calm and genuinely concerned approach is effective


Past Conceptions Risk Factors

Family History

- if a family member committed suicide, there is an increased risk in the family.


- low level of serotonin ( associated with impulsivity, instability and the tendency to overreact to situations.

Existing Psychological Disorders

- more than 90%ofpeople who kill themselves suffer from a psychological disorder

Stressful life

- severe stressful event experienced as shameful or humiliating such as a failure (real or imagined) in school or at work, an unexpected arrest or 4/22/12 rejection by a loved one.


Problem-solving Cognitive behavioral therapy Coping skills Stress reduction


Suicides types:
1.) Altruistic suicide- individual who brought dishonor to himself or his family. 2.) Egoistic suicide loss of social support 3.)Anomic suicide result of marked disruptions, such as sudden loss of a high-prestige job. (Anomie is the feeling of lost and confused)