Week 8 Lecture 8 - Depressive disorders, bipolar and related disorders - Jo Fielding (DN) Flashcards Preview

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What does Jo say is a take home message about mood disorders (right at beginning of lecture)?


It is the pattern of episodes; whether they recur, whether they alternate that determines which mood disorder a person has?


What are the two main 'mood disorder' categories in DSM-5?

  1. Depressive disorders
  2. Bipolar and related disorders



What are disorders that only involve depressive symptoms commonly referred to as?

How are these disorders differentiated?

  • Unipolar
  • Differentiatied by the severity & duration




What are the subset of the mood disorders that involve manic symptoms referred to as?


How are these differentiated?

  • Bipolar
  • Differentiated by intensity, duration & types of symptoms




What emotions are involved in mood disorders?

Involve disabling disturbances in emotion

  • extreme sadness & disengagement of depression
  • extreme elation & irritability of mania


Temporal patterning important in determining diagnoses & treatment

  • dealing with treating current symptoms
  • preventing future episodes


What are the defining features of Depressive Disorders?

  • profound sadness
  • inability to experience pleasure


What are the 4 Depressive Disorders covered in the lecture?

  • Major Depressive Disorder
  • Dysthymia (Persistent Depressive Disorder)
  • Premenstrual Dysphoric Disorder
  • Disruptive Mood Dysregulation Disorder


What differentiates the 4 Depressive Disorders?

differentiated by intensity & duration of symptoms


What disorders come under each of  the two main 'mood disorder' categories in DSM-5?

Depressive disorders

  • Major depressive disorder
  • Persistent (chronic) depressive disorder (dysthymia)
  • Premenstrual dysphoric disorder
  • Disruptive mood dysregulation disorder
  • Substance/medication induced
  • Disorder due to another medical condition
  • Specified/unspecified disorder

Bipolar and related disorders

  • Bipolar I disorder
  • Bipolar II disorder
  • Cyclothymic disorder
  • Substance/medication induced
  • Disorder due to another medical condition
  • Specified/unspecified disorder


What are some additional features of

Depressive disorders?

Cardinal symptoms profound sadness &/or ability to experience pleasure

  • Self-recrimination
  • Difficulty paying attention
  • Physical symptoms very common:
    • fatigue, low energy, aches & pains o sleeping problems
    • sexual interest disappears
    • psychomotor retardation
    • psychomotor agitation
  • Initiative may disappear
  • Social withdrawal
  • Neglect appearance


What are some really important components in the diagnosis of Major Depressive Disorder?

  • Must not have had a manic episode
  • needs to be almost all of the time for at least 2 weeks


5:00 - 7:00 approx


What is DSM-5 criteria for Major Depressive Disorder?

At least 5 symptoms,

including (1) depressed mood and/or (2) loss of pleasure

  • Significant weight loss or change in appetite
  • Sleeping too much or too little
  • Psychomotor retardation or agitation
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive/inappropriate guilt
  • Difficulty concentrating
  • Recurrent thoughts of death or suicide (or attempt/plan)
  • Symptoms are present for at least 2 weeks and represent a change from previous functioning



What are some other features of Major Depressive Disorder?

MDD is an episodic disorder

  • Can last for months at a time
  • may become chronic
  • Subclinical depression possible for years
  • Major episodes tend to recur (2/3 of people)
  • Average number of episodes ~4
  • Risk increases each time
  • Controversial criteria re: number of symptoms
  • But impairment appears higher with greater number of symptoms



What is the time course for Major Depressive Disorder?

  • an episodic disorder
    • (symptoms come & go)
  • although can drag on for months
  • tends to recur


5:00-7:00 approx


What is psychomotor retardation?

  • physical symptom of depressive disorders
  • when thoughts & movements slow down



What is psychomotor agitation?

  • physical symptom of depressive disorders
  • restlessness, figeting



DSM-5 criteria for Dysthymia - Persistent depressive disorder?

Depressed mood for most of the day, for more days than not, for at least 2 years (1 year for children/adolescents)

At least 2 of the following during that time:

  • Poor appetite or overeating
  • Sleeping too much or too little
  • Poor self esteem
  • Trouble concentrating or making decisions
  • Feelings of hopelessness

The symptoms do not clear for more than 2 months at a time




Which depressive disorder is most likely to require hospitalisation?



because of its chronicity


What are the defining features of Dysthymia (Persistent depressive disorder)

  • persistent depressed mood
  • no relief more than 2 years


How does Dysthymia differ from Major Depressive Disorder?

Dysthymia (persistent depressive disorder)

  • 2 symptoms
  • 2 years (1yr for child)
  • chronic

Major Depression

  • 5 Symptoms
  • 2 week period
  • episodic


Which two Depressive Disorders are new to DSM-5?

Premenstrual Dysphoric Disorder

Dysruptive Mood Dysregulation Disorder



Premenstrual Dysphoric disorder: DSM-5 criteria?

In most menstrual cycles, 5+ symptoms present in final week before menses, improving within few days of menses onset:

Including ≥1:

  • Affective lability
  • Marked irritability, anger, arguments
  • Depressed mood, hopelessness, self-deprecating thoughts
  • Anxiety diminished interest in usual activities, difficulty concentrating

Including ≥ 1:

  • Decreased interest in usual activities
  • Difficulty concentrating
  • Lack of energy
  • Change in appetite, overeating, or food craving
  • Sleeping too much or too little
  • Subjective sense of being overwhelmed or out of control
  • physical symptoms


What are the defining features of Premenstrual Dysphoric Disorder?

  • affect up & down (moody)
  • impacted concentration, energy, sleep, appetite, physical pain
  • must cause significant distress/impairment


Disruptive mood dysregulation disorder: DSM-5 criteria?

Severe recurrent temper outbursts in response to common stressors, out of proportion in intensity or duration to the provocation

  • Temper outbursts are inconsistent with developmental level
  • Temper outbursts tend to occur at least 3 times per week
  • Persistent negative mood between temper outbursts most days, & the negative mood is observable to others
  • Symptoms present for at least 12 months, do not clear for more than 3 months at a time
  • Temper outbursts or negative mood present in at least 2 settings
  • Age 6 +
  • Onset before age 10
  • In past year, no distinct period lasting >1 day where elevated mood & at least 3 other manic symptoms present


What are the defining features of Disruptive Mood Dysregulation Disorder?

  • Chronic, severe & persistent irritability
  • negative mood
  • in at least 2 settings, 12 months
  • no mania



  • extreme recurrent temper outbursts
  • inconsistent with developmental level


  • present most of the time
  • must be differentiated from other disorders





What distinguishes Disruptive Mood Dysregulation Disorder from other disorders?

such as Bipolar, ADHD (may be comorbid), Oppositional Defiance Disorder (children), Intermittent Explosive Disorder.

its the level of chronicity that distinguishes this disorder from others with similar symptoms




Which is rarer Major Depressive Disorder or Dysthymia?





What other disorders often coexist with Major Depressive Disorder & Dysthymia?

  • Anxiety Disorder
    • 60% Depressives also have anxiety


  • Substance-related disorders
  • Sexual dysfunction
  • Personality disorders
  • Cardiovascular disease


What may the varied prevalence rates of Depressive Disorders across cultures be due to?

What may varied symptoms across cultures be due to?

  • may vary due to different environmental stressors e.g., Beirut 19%, Taiwan 1.5%



  • may reflect differences in acceptable expression
    • e.g., Latino - nerves, headaches
    • e.g., Asian - fatigue & weakness

Cultural differences - bound to be more complex relationship


17:45 approx


How do symptoms of Depressive Disorders behave across the lifespan?

Symptoms change over lifespan

  • children → somatic complaints
  • older adults → distractibility & memory loss


Depressive Disorders: prevalence - lecture slide 1 

  • MDD one of most prevalent psychiatric disorders (~16%)
  • Dysthymia rarer (~2.5%)
  • Twice as common in women?
    • Reported more often?
  • Three times more common in low SES individuals
  • Prevalence varies across cultures
    • e.g 1.5% in Taiwan, 19% in Beirut
  • Symptoms also vary across cultures
    • Nerves & headaches common in Latino cultures
    • Fatigue & weakness in Asian cultures
  • But may be a complex relationship:
    • Distance from equator?
    • Fish consumption?
    • Wealth disparity & family cohesion important


Depressive Disorders: prevalence - lecture slide  2?

  • In most countries prevalence of MDD increased steadily until late 20th century
  • Median age of onset now late teens to early 20s
    • support structures like extended family non-existent
    • marital stability often absent
  • Symptoms appear to change over lifespan:
    • children → somatic complaints
    • older adults → distractibility & memory loss
  • Often comorbid with other psychiatric problems:
    • 60% also meet criteria for anxiety disorder
  • Other comorbidities:
    • substance-related disorders
    • sexual dysfunction
    • personality disorders
    • cardiovascular disease


What differentiates Bipolar disorders from Depressive Disorders?

Presence of Mania

  • Manic episode
  • Hypomanic episode





How does a manic episode differ from a hypomanic episode?


  • Significant impairment
  • psychotic symptoms
  • Symptoms - 1 week or hospitailisation
  • cause distress/functional impairment



  • Impairment not marked 
    • but observable to others
  • no psychotic symptoms
  • at least 4 days
  • no hospitalisation


What are the defining features of a Manic episode?

extreme dysfunction/impairment

  • elevated, expansive mood
  • psychotic episodes
  • odd behaviour
  • no insight
  • 1 week/  possible hospitalisation


What are the defining features of a Hypomanic episode?

  • elevated, expansive or irritable mood
  • goal-directed activity
  • 4 days, most of time
  • no significant impairment
  • no hospitilisation


Why is treatment a patient experiencing mania so challenging for clinicians?

the highs of mania are quite pleasurable

they are really enjoying their disorder!

will rarely seek treatment for the mania

normally seek treatment for the depression




Manic episode: DSM-5 criteria?

Manic episode:
Distinctly elevated, expansive or irritable mood, and abnormally increased goal-directed activity for 1 week, most of the day, nearly every day.

At least 3 symptoms noticeably changed from baseline (4 if mood is only irritable):

  • Inflated self-esteem
  • Decreased need for sleep
  • Unusual talkativeness
  • Flight of ideas or subjective impression that thoughts are racing
  • Distractibility
  • Increased goal-directed activity
  • Excessive involvement in activities that are likely to have undesirable consequences
  • Symptoms last for 1 week or require hospitalisation
  • Symptoms cause significant distress or functional impairment


Hypomanic episode: DSM-5 criteria?

For a hypomanic episode:

  • Symptoms last at least 4 days
  • Clear changes in functioning that are observable to others, but impairment is not marked
  • Does not require hospitalisation
  • No psychotic symptoms are present


What is a key point which differentiates Bipolar I and Bipolar II?

Bipolar I - diagnosis requires

Criteria met for one single manic episode 


Bipolar II - diagnosis requires

Criteria met for at least one hypomanic episode AND
Criteria met for at least one major depressive episode


28:30 >


What one criteria meets the diagnosis of Bipolar I Disorder?

one single manic episode

other symptoms exist, but not required for diagnosis

  • hypomania
  • depressive episodes




Bipolar I Disorder: DSM-5 criteria?

Criteria met for at least one manic episode

  • If mood is irritable rather than elevated – requires 4 , not 3 ,other symptoms
  • Hypomanic and depressive episodes common (not necessary)
  • Diagnostic code based on:
    • type of current/most recent episode (e.g. manic, hypomanic, depressed)
    • Severity (mild, moderate, severe)
    • Presence of psychotic features
    • In remission/not
  • May or may not be experiencing current symptoms of mania
  • Episodes tend to reoccur


Bipolar II Disorder: DSM-5 criteria?

Criteria met for at least one hypomanic episode AND

Criteria met for at least one major depressive episode

  • Diagnostic code as for BP I
  • Characterised by recurring mood episodes – usually more frequent and lengthier than BPI
  • Usually present with MD episode - unlikely to complain of hypomania


What symptoms characterises Bipolar II Disorder?

recurring mood


What component of Bipolar II generally promopts an invidiual to seek help?

  • the depressive component
  • the hypomania is quite enjoyable, very rare they would seek help for it




Cyclothymic Disorder: DSM-5 criteria?

For at least 2 years (1 in children/adolescents):

  • Numerous periods of hypomanic symptoms that do not meet criteria for a manic episode
  • Numerous periods with depressive symptoms that do not meet criteria for a MDD
  • Symptoms do not clear for >2 mths
    • cause significant distress/impairment


What are the defining features of Cyclothymic Disorder?

  • chronic fluctuating mood disturbance
  • distinct periods of hypomania & depressive symptoms
  • > 2 months
  • significant distress/impairment




Which other disorder does Cyclothymic Disorder most resemble?

What differentiates these two disorders?

Cylothymic Disorder resembles Bipolar II

Although in Cyclothymic Disorder, the:

  • hypomanic symptoms DO NOT meet 'manic' criteria
  • depressive symptoms DO NOT meet major depressive disorder criteria
  • > 2 months
  • must have never previously met criteria for either mania or major depressive disorder
    • as this would be Bipolar I (even just one episode of mania)



Bipolar and related Disorders: Epidemiology




(lecture slide)


  • Bipolar I disorder much rarer than MDD
  • Bipolar I ~ 0.6%
  • Bipolar II more difficult to gauge ~ 0.4 – 2%
  • Cyclothymia ~4% of mood disorders
  • Cultural variation may reflect differences in labelling behaviours as manic symptoms


  • > half before 25, increasing frequency in children
  • Equally in men & women, women more episodes of depression


  • 2/3 meet diagnostic criteria for comorbid anxiety disorder
  • 1/3 report history of substance abuse


What other disorders commonly co-exist with the Bipolar Disorders?

  • Anxiety Disorders
    • 2/3 have anxiety
  • Substance Abuse
    • 1/3 have history 




Which of the Bipolar Disorders is amongst the most severe forms of mental illness?

Bipolar I

  • 1/3 remain unemployed 1 year after hospitalisation for mania
  • Unable to work ~25% of the time




What is a high risk in people with Cyclothymia Disorder?

50% risk of going on to develop episodes of 

  • mania
  • major depression


Bipolar and related Disorders: Outcomes/consequences?

lecture slide

Bipolar I disorder amongst most severe forms of mental illness

  • 1/3 remain unemployed 1 year after hospitalisation for mania
  • Unable to work ~25% of the time

Suicide attempts:

  • Bipolar I ~1 in 4
  • Bipolar II ~1 in 5

High risk for other medical condition:

  • Cardiovascular disease
  • Diabetes
  • Obesity
  • Thyroid disease
  • Often severe

Cyclothymia = high risk for developing episodes of mania & major depression ~ 50%


How are the Seasonal Pattern & Rapid Cycling subtypes (specifiers) different to the other subtypes of MDD & BP disorders?

Seasonal Pattern & Rapid Cycling subtypes

  • refer to the overall pattern of the episodes over time


Other subtypes

  • refer to current episode




What is Rapid Cycling?

  • Unique to Bipolar Disorders
  • Move quickly in & out of depressive or manic episodes
  • >3 manic or depressive episodes
  • increased suicide attempts & episodes of depression
    • 20-40% (60-90% female)
    • people on anti-depressant medication tend to have more cycling
  • increase in frequency over time
  • Can transform to ‘rapid switching pattern’ without breaks
  • most people stop cycling within 2 years




What is  Seasonal Affective Disorder?

Does it occur in MDD & Bipolar?

When is it likely to occur?

Depressed episodes that occur only during certain seasons

Applies to MDD & bipolar disorders

  • Depressive Disorders
    • late autumn > early spring
  • Biplolar Disorder 
    • depressed in winter, manic in summer


Most involve winter depression

  • Excessive sleep & increased appetite
  • Evidence links melatonin produced by pineal gland
    • Suppressed by light
    • Increases in winter
    • More prevalent in extreme latitudes
    • Trigger in vulnerable people?



Almost all of the subtypes (specifiers) can be applied to both MDD & BP disorders, what are the two exceptions?

Rapid cycling  subtype

  • only applies to Bipolar
  • not applicable to MDD


Melancholic subtype

  • only applies to depressive component of BP
  • not applicable to mania component of BP




What two new MDD & BP disorder subtypes (specifiers) were added to DSM-5?

'With anxiety'

'Suicide risk severity'


Why are the MDD & BP disorder subtypes (specifiers) useful to a clinician?

enables them to build up a heterogeneous (individual) picture of how an individual may be presenting




What are the subtypes of MDD & bipolar disorders covererd in the lecture?

  • Psychotic features
  • Mixed
  • Catatonic
  • Melancholic
  • Atypical
  • Postpartum


One of the 6 subtypes of MDD & bipolar disorder is Psychotic features, what:

  • happens with mood?
  • is the prevalence?
  • the treatment outcome?


Psychotic features:

  • Mood congruent - hallucinations, delusions consistent with mood state
  • Mood incongruent (serious sub-type)
    • thought broadcasting
    • thought insertion
    • continuum - may progress to schizophrenia?
  • Rare: 5-20%
  • poor treatment response
  • greater impairment


One of the 6 subtypes of MDD & bipolar disorder is
'Mixed', what is the DSM-5 criteria?



• At least 3 manic symptoms present during depressive episode, or
• At least 3 depressive symptoms present during a manic episode


Describe the 'Catatonic' subtype?


  • Marked by motor disturbance
  • Stuporous state or catalepsy
  • thought to reflect end state reaction to imminent doom?

may include

  • echolalia - immitate speach
  • echopraxia - immitating movements




Describe the 'Melancholic' subtype?


  • less rare than Psychotic & Catatonic
  • Full criteria met for MDD
  • More severe somatic symptoms
  • Complete loss of interest in just about every activity
    • e.g. loss of libido, anhedonia, guilt
  • early morning awakenings (2am)
  • whether its actually a subtype or exists on a continuum is difficult to determine
    (sounds like a continuum to me, DN!!!)



Describe the 'Atypical' subtype?


  • Applies to depressive episodes & dysthymia
  • Oversleep, overeat
  • Can still find pleasure
  • More common in women, early age of onset
  • More: symptoms, severe, suicide,
  • comorbidity


(DN question: Table 5.2 on slide 24 shows 'Atypical' applying to both MDD & BP, but Jo & slide 29 say it applies to depressive episodes & dysthymia. Slide 24, Table 5.2 doesn't specify its only applicable to the depressive component of bipolar.........just sayin.......)


Describe the 'Postpartum' subtype?


• Onset within first 4 weeks of childbirth
• 13% post-childbirth, hormonal?
• NOT “baby blues” – 80% for few days,
normal stress response


What distinguishes Postpartum subtype from the baby blues?

What are some possible causes for Postpartum?

Duration & intensity of symptoms distinguish them

Baby blues

  • most women (80%) experience
  • about 3 days after birth


  • some women (13%) develop major depression within first 4 weeks after birth


Cause unclear but may be

  • decline in reproductive hormones after delivery
  • elevated corticotropin producing hormone has been proposed



Does depression require life experience?

How does it appear at different ages?


Apparently not
  • Evidence that babies can become depressed
    • Genetics, environment, both?

Depression fundamentally similar across lifespan

Its presentation differs though

  • Babies/Toddlers: sad faces, irritability, fatigue, fussiness, tantrums, eating, sleeping problems
  • Children: loss of enjoyment, loss of sleep, social withdrawal
  • Adults: more exaggerated, severe with age
    • i.e., life experience?



How does the presentation of Mania differ between adults & children?

Children under 9 - present with more irritability & emotional swings rather than classic manic states

Children experience “Swings” less distinct than adults

Children: only brief manic states, come in & out throughout a day, not full blown as in adults


How do depressive & bipolar disorder comorbidities differ between children & adults

  • Adults - anxiety disorder
  • Children - ADHD & CD
    • Up to 90% meet criteria for ADHD
    • raises diagnosis issues




What factors have been described in the Aetiology of Mood Disorders?

  • Neurobiological factors, including:
    • Genetic factors
    • Neurotransmitters
    • Neuroimaging
    • Neuroendocrine system
  • Social factors


  • Psychological factors
    • Personality factors
  • Cognitive theories
    • Learned helplessness



Describe the genetic factors described as having a neurobiological implication in mood disorders?

Genetic factors:

  • Probability of having a mood disorder 2-3 x greater if relative has a mood disorder
    • Severity, recurrence, age at onset predict rate
  • Twin studies support relationship with depression ~37%
  • Bipolar - 90% inc. risk of any mood 
  • >160 loci linked – few well studied or replicated
    • “disconfirmation appears to be the rule rather than the exception”
    • Polymorphism of Serotonin transporter gene inc. vulnerability
    • DRD4.2 gene
    • Likely a set of genes that confers vulnerability


What is important to note about the influence of genes in mood disorders?

  • they don't cause disorders
  • they confer a vulnerability
  • sets stage for disorder in context of other factors




Describe the Neurotransmitters described as having a neurobiological implication in mood disorders?


  • Norepinephrine, dopamine, serotonin most studied
  • Serotonin thought to regulate emotional reaction
  • decreased serotonin dysregulates others?
    • balance rather than absolute levels?
  • dysfunction = altered sensitivity of postsynaptic receptors?
  • increased dopamine = hypomania
    • receptors oversensitive?
  • decreased dopamine = depressive b/h
  • G Protein high in mania, low in depression



What has been hypothesised about the role of neurotransmitter serotonin in the aetiology of mood disorders?


BALANCE of neurotransmitterrs  is important

Serotonin's primary function - regulate emotional reaction

  • lower levels seen in mood disorders
  • decreased serotonin thought to lead to dysregulation in other neurotransmitters

when serotonin is low

it allows other neurotransmitters are able to range more widely > imbalance




Which neurotransmitter has been thought to contribute to hypomania & depression?

What has been found to trigger instability in this neurotransmitter?


Dopamine agonist (L Dopa)


  • Increased Dopamine levels

> oversensitive  receptors?


Depression (atypical & with psychotic features)

  • Decreased Dopamine levels


Possible Triggers to imbalanced Neurotransmitters:

  • Chronic Stress has been linked to reduced Dopamine levels & depression


Describe Neuroimaging evidence described as a Neurobiological factor in the Aetiology  of mood disorders?


  • Amygdala, prefrontal cortex, hippocampus, sub-genual anterior cingulate
  • Functional imaging
    • elevated activity of amygdala > vulnerability?
    • dimished activation / volume of other regions
  • Theory > react with increased emotion but decreased ability to plan
  • Mania similar to depression
    • basal ganglia more active?
    • changes to neuronal membranes?
    • Kinase C abnormally high?



What happens in the amygdala during depression?

What is generally seen in other brain regions?

What are the behavioural outcomes?


  • increased activity
  • hyper-reactivity to emotional stimuli


Other regions

  • diminished activation
  • decreased volume in other regions
  • less activity in these regions involved in planning etc



  • react with increased emotion
  • less ability to plan




What new lines of neurobiological research have shed some light on what differentiates Major Depressive DIsorder from Bipolar Disorder? 


Manic Episode

  • basal ganglia particularly active
  • involved in reward reactions
    • differentiates from MDD

Bipolar Disorder

  • Changes in neuronal membranes 
  • influencing how readily they can be activated
    • not seen in MDD




Describe Neuroendocrine system involvement (Neurobiological factor) in the Aetiology  of mood disorders?

Neuroendocrine system:

  • Hypothalamic-pituitary-adrenocortical axis overly active
    • Triggers release of cortisol
  • Known link between depression & high cortisol levels
    • e.g. Cushing’s syndrome, animal studies
  • Dexamethasone suppression test
    • Cortisol not suppressed in MDD – esp psychotic features
    • Normalises when depressive episode ends
    • Poor regulation of HPA axis?
  • Reduced hippocampal volumes
    • Consequence of high cortisol levels?
    • Precedes/contributes to onset of depression?



What aspect of the HPA axis is hypothesised to contribute to Depressive Disorders & Bipolar Disorder?

poorly regulated cortisol system




What Social Factors are considered in the Aetiology of mood disorders?

Stressful life events (key take home message)

  • Role well established
  • 42-67% report serious life event prior to depression
  • Loss, humiliation, chronic stressors particularly likely triggers


Lack of social support

  • Sparse social networks, regarded as unsupportive
  • Having a confidante reduces risk from 40% to 4%


Interpersonal problems

  • Expressed emotion predicts relapse
  • Poor IP problem solving predicts onset
  • But depression, constant reassurance-seeking can also create IP problems?




Considering personality factors, what tends to be a risk factor for developing Mood Disorders?

the propensity to experience negative & positive affect 




What personality trait predicts Depressive Disorders?



What three dimensions does one model use to organise mood disorders?


How do Depressive Disorders, Anxiety Disorders & Comorbid Depression/Anxiety fit in with this model?

  • Negative affect
  • Positive affect
  • Somatic Arousal


Depressive Disorders

  • Negative affect - high
  • Positive affect - low
  • Somatic Arousal - moderate


Anxiety Disorders

  • Negative affect - high
  • Positive affect - moderate
  • Somatic arousal - high



  • Negative affect - high
  • Positive affect - low
  • Somatic arousal - moderate





What did Beck's cognitive theory suggest about the aetiology of Depression?


What did he use to illustrate his theory?

Negative thinking led to depression

Beck's Negative triad: Negative views of


proposed to be caused by

  • Negative schemata acquired thru experience
  • Schemata lead to negative biases (i.e., cognitive errors)
    • which lead to negative views
  • viscious cycle




What are some Cognitive theories of Depression?

Becks negative triad



Learned helplessness

  • (Martin Seligman)
  • later revised to incorporate 'attributional style"
    • Internal
    • Stable
    • Global
  • revised again to highlight sense of hopelessness
  • sttributions only impt if contribute to hopelessness




What are some social & psychological factors thought to contribute to Bipolar Disorder?


  • Triggers similar to MDD
  • Negative events important precipitator
  • Predicted by neuroticism, negative cognitions, expressed emotion, lack of support


  • One psychosocial model – reflects disturbance in brains reward system
  • Events involving attaining goals predict increases in manic symptoms
    • Getting married, graduating
  • Proposed that life events involving success may trigger cognitive changes in confidence
  • Spiraling into excessive goal pursuit



Describe the integrative theory of mood disorders.

  • Depression & anxiety share a common genetic vulnerability explaining between 20% and 40% of the variance in mood disorders
  • Environmental & psychological vulnerabilities explain the rest
  • Often experienced as an inability to cope with life’s stressors (i.e. lack of resilience) leading to learned helplessness and a sense of hopelessness
  • Causes of psychological vulnerabilities can be traced back to childhood adversity
  • Stressful life events act as triggers
  • Interpersonal relationships can act as either protective or risk factors



What are some treatment options for Depresssive Disorders?

Cognitive therapy

  • Alter maladaptive thoughts
  • Behavioural activation therapy
  • Mindfulness-based Cognitive Therapy


What are some psychological treatment options for Bipolar Disorder?


Psycho-educational approaches

  • educate about disorder management

Cognitive Therapy

Family-focussed treatment





What are biological treatments for Bipolar disorder?

Antidepressant medications:

75% show improvement

  • 1. Selective serotonin re-uptake inhibitors
  • 2. Mono-amine oxidase (MAO) inhibitors
  • 3. Tri-cyclic antidepressants


Combining psychotherapy with medication bolsters odds of recovery by up to 20% above either alone


What is the drug of first choice for treating Depressive Disorders?

How does it act?

What are some side effects?

Selective serotonin re-uptake inhibitors (SSRI's)

e.g., prozac, sertraline

blocks presynaptic reuptake of Serotonin - leaving higher quantities available in the synapse

Side effects:

may inc suicidal ideation in first few weeks

physical agitation, sexual dysfunction, insomnia, gastrointestinal upset


What is typically the last line of medication used for depressive disorders?

Why are they not preferred?

Which subtypes respond well to this medication?

Mono-amine oxidase (MAO) inhibitors:

  • Block the enzyme MAO
  • MAO breaks down nor-epinephrine, dopamine & serotonin
  • Increasing availability


Last line because

  • Potentially serious consequences:
  • Consuming tyramine (red wine, cheese, beer)  > hypertension
  • Some everyday medications (cold medications) > dangerous interaction


More effective with ‘atypical’ 'melancholia' features


Which antidepressent was widely used pre SSRI's, but is not as commonly used now?

Tricyclic antidepressants:

  • Named after chemical structure
  • Mode unclear, initial block re-uptake of norepinephrine & serotonin
  • Complex effect on pre- & post-synaptic regulation


Not widely used now

  • Side effects: blurred vision, dry mouth, drowsiness, weigh gain
  •  Consequence: ~40% discontinue
  • Lethal if taken in excessive doses
  • increases chance of suicidal behaviour




What is the gold standard Biological treatment for bipolar disorder:

Mood stabilisers reduce manic symptoms:

  • Lithium remains gold standard
  • Up to 80% experience some benefit
  • 70% relapse in 5 years
    • effects wear off


Side effects = blurred vision > coma, death!


If Lithium is not tolerated:

  • Anticonvulsants (e.g. Valproate)
  • Antipsychotics (e.g. Olanzapine)



Why do so many people discontinue use of Lithium?

Flattened affect

Feel nothing, when used to experiencing enjoyable highs


When is Electroconvulsive therapy generally resorted to?

How/why does it work?

What are some side effects?

When patient is treatment resistant

  • Most dramatic & controversial treatment for MDD 
  • 70-130 volt current through brain

How/why it works?

  • Massive functional/structural changes?
  • Increases serotonin levels
  • Blocks stress hormones
  • Neurogenesis in the hippocampus?


Side effects

  • Short-term memory loss
  • Decline in cognitive function 6 months