1. Mood disorders (p. 353) Mood disorders, which rank among the top ten causes of worldwide disability, are disturbances in emotions that cause discomfort or hinder functioning. Depression is by far the most common mood disorder and is characterized by sadness, feelings of worthlessness, and social withdrawal. Mania is characterized by elevated mood, expansiveness, and irritability. Depression and mania are different from normal mood changes because they are more intense, last longer, and may occur for no apparent reason. Lifetime prevalence for depression ranges from 10 to 25 percent for women and 5 to 12 percent for men. A recent survey of college students found that over half reported experiencing depression, 9 percent thought about suicide, and 1 percent attempted suicide since beginning college. Prevalence for depression is more than ten times that for mania. Severe depression occurs in all socioeconomic and educational groups.
2. The symptoms of depression and mania (p. 354) The affective (emotional) symptoms of depression are sadness, dejection, crying spells, and feelings of worthlessness. Cognitive symptoms include profound pessimism, loss of interest, and suicidal thoughts. The cognitive triad (negativism, about self, others, and the future) is found in depressives. Behavioral symptoms include poor personal hygiene, slowed speech and movement (psychomotor retardation), and social withdrawal. Physiological symptoms of depression include disturbances of eating, sleeping, sexual activity, and menstruation. Culture influences the experiences and expression of depression. Also, while core symptoms remain the same with age, expression of characteristic symptoms change, with children particularly likely to exhibit somatic complaints, irritability, and social withdrawal.
   The affective symptoms of mania are elation or irritability and grandiosity. Cognitive symptoms include accelerated and disjointed speech. Behaviorally, at the level of hypomania, people are overactive but not delusional. Mania involves increased levels of activity, incoherence, and sleeplessness. In severe forms, hallucinations and delusions appear and the person is uncontrollable.
3. Classification of mood disorders (p. 358) Depressive disorders are considered unipolar, whereas disorders with manic and depressive episodes are bipolar disorders. Depressive disorders include major depressive disorder, dysthymic disorder, and depressive disorders not otherwise specified. Symptoms must be present for at least two weeks and must represent a change from typical functioning to be considered signs of a mood disorder. About half of those who have a depressive episode have another. Some depressions have psychotic features such as hallucinations and delusions. Dysthymic disorder is a chronic condition (at least two years) involving depressed mood, low self-esteem, fatigue, and apathy. Bipolar disorders are identified when manic episodes last one week or, in the case of hypomania, four days. Depression almost always follows a manic period. Bipolar I disorders include those in which a manic episode occurs; Bipolar II is reserved for hypomania that alternates with major depression. If hypomanic and depressed mood swings do not meet the criteria for bipolar disorder, the diagnosis is cyclothymic disorder, a disorder more common than bipolar and less common than dysthymic disorder.
   Mood disorders owing to general medical conditions and substance-induced mood disorders are also categories in the DSM-IV-TR. DSM-IV-TR also lists symptom featurescharacteristics that accompany mood disorders but are not criteria for diagnosis. These include melancholia (loss of pleasure, depression worse in the morning) and catatonia (immobility and negativism). Course specifiers in DSM-IV-TR indicate whether the mood disorder is cyclic (how quickly moods shift from manic to depressive), seasonal, postpartum (after giving birth), or longitudinal (length between relapses).
   Unipolar and bipolar disorders are distinguished from one another because in bipolar, inheritance plays a bigger role, the age of onset is earlier, depressive episodes involve greater motor retardation, and lithium provides effective relief. Lifetime prevalence of bipolar disorder is roughly 1 percent. Finally, there is no sex difference for bipolar disorder, but major depression is far more common in women.
4. The etiology of mood disorders: Psychological and sociocultural approaches to depression (p. 363) There are few theories explaining the cause of bipolar disorders, but some involve problems with mechanisms for maintaining homeostasis, while others look at family dysfunction, or dysregulation in the brain's activation system. For depression, psychoanalysts suggest that separation and anger are potent causal factors. Separation can be real or symbolic, but is different from normal mourning. Guilt can account for some depressive symptoms, and anger (at the lost person) turned against the self accounts for others.
   Behaviorists suggest that reduced reinforcements lead to reduced reinforceable activity, thus producing a downward spiral. A lack of self-reinforcement, social skills, and a tendency to create more stressors are also associated with depression. Lewinsohn and his colleagues have developed a comprehensive view of depression: Stress disrupts established behavior patterns, positive reinforcement declines, self-critical and low-confidence thoughts produce depressed affect, which makes functioning more difficult.
   Cognitive theorists suggest that depressivesschemas for interpreting events Produce low self-esteem. According to Beck, depressives operate from a primary triad involving negative expectations about self, others, and the future. Four errors in logic typify this schema: arbitrary inference, selected abstraction, overgeneralization, and magnification and minimization. Cognitive-learning approaches include learned helplessness and attributional theories. Learned helplessness argues that depression occurs when, after experiencing uncontrollable stressors, a person comes to believe that he or she has no effect on the environment. Coupled with a certain attributional style, learned helplessness leads to the passivity that characterizes depression. The pessimistic attributional style sees the causes of bad events as internal, global (true for many situations), and stable (a permanent condition). Attributional style may be related to achievements, health, and depression although the causal relationships are not established. Nolen-Hoeksema suggests ruminative response styles (e.g., dwelling on why one feels bad) prolong and intensify depressive moods or bring about depressive episodes. Lewinsohn et al. tested the diathesis-stress processes involved in both Beck's and Seligman's theories, found more support for Becks than Seligmans: high levels of negative cognitions coupled with stress tended to predict depression; counterintuitively, that only at low levels of stress did negative attributional styles predict depression; and that these models did not predict nondepressive disorders.
   Sociocultural explanations stress differences in prevalence rates and symptom pictures across cultures. Stress theory argues that individuals have a vulnerability to depression (diathesis), exposure to stressors, and limited resources such as social supports; cross-cultural factors have been noticed in this regard. Gender differences in depression may not be real because women are more likely to be seen in treatment and may report their symptoms more readily than men. Diagnostic bias and misdiagnosis of male depression are other explanations. Real differences may be due to biology, gender roles, or social restrictions on women. Nolen-Hoeksema concluded that women are more likely than men to ruminate in response to depressed mood.
5. The etiology of mood disorders: Biological perspectives (p. 375) Biological explanations of the causes of mood disorders emphasize evidence that genetic factors play a role, particularly in bipolar disorder. Concordance rates for bipolar disorder average 72 percent for identical twins and 14 percent for fraternals; the percentages are 40 and 11 for unipolar mood disorders. Genetic factors may predispose people to a deficit of activity in certain neurotransmitters called catecholamines. The catecholamine hypothesis proposes that low levels of norepinephrine, dopamine, or serotonin make individuals vulnerable to depression. The problem may involve dysfunction in the reception of the neurotransmitter rather than insufficient concentrations of it. Other biological factors related to depression are abnormally high cortisol levels (as measured by the dexamethasone suppression test) and rapid onset of and increased REM sleep among depressives.
6. Evaluating the causation theories (p. 378) Our knowledge has been increased by using longitudinal research designs, advanced technologies, and an awareness that there are subtypes of mood disorders. All current causation theories have weaknesses. Some seem oversimplistic, whereas others are unable to explain all forms of depression. It is likely that at the mild end of the continuum, psychological factors explain many disorders, but, as severity increases, the influence of biological factors increases, too.
7. The treatment of mood disorders (p. 379) The principal medications used to treat depression are tricyclic antidepressants, heterocyclic antidepressants, monoamine oxidase (MAO) inhibitors, and SSRIs such as fluoxetine (Prozac). Tricyclics block the reuptake of norepinephrine but cause side effects-drowsiness, insomnia, and agitation. MAO inhibitors have a serious interaction with tyramine, found in many cheeses and other fermented products. Prozac, a widely used SSRIs, blocks the reuptake of serotonin. Electroconvulsive therapy (ECT), usually reserved for severe depressives who do not respond to medications, works rapidly but can cause memory loss and so is controversial. Interpersonal psychotherapy is a short-term, psychodynamic-eclectic treatment that focuses on current conflicts in relationships and links these to earlier life experiences and traumas. Cognitive behavioral therapy teaches the patient to identify, examine, and replace distorted negative thoughts with more realistic ones. Patients increase their activity level and improve their social skills. Both forms of treatment are effective and equal to medication. Cognitive behavioral training reduces the risk of relapses and can be helpful in preventing depression.
   Drugs such as lithium are often used in the treatment of bipolar disorder, although there are side effects. Patient compliance with lithium treatment is another impediment.