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6 Depressive Disorders and Bipolar and Related Disorders


Learning Objectives

After reading this chapter, you should be able to:

• Understand the difference between normal emotions and pathological emotions.

• Explain what depressive disorders are.

• Explain what bipolar and related disorders are.

• Know and discuss what causes depressive, bipolar, and related disorders.

• Explain and discuss how depressive, bipolar, and related disorders are treated.

• Analyze the relationships among depressive, bipolar, and related disorders and suicide.

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Depressive Disorders and Bipolar and Related Disorders

It is mid-June in a city known for a temperate climate. You awaken to a blue sky with puffy clouds; the sun is bright but not too hot, with low humidity. After eating your favorite break- fast, you go for a walk before heading off to your summer job. All seems right with the world, yet you are not happy. The sky appears gray to you, the sun covered by clouds. Breakfast seemed bland, almost tasteless. You didn’t sleep well; in fact, you awakened, again, in the middle of the night and couldn’t fall back to sleep. You were hoping to be intimate with your partner last night, but the desire and the drive remain missing.

Does this scenario sound familiar to you? Perhaps it sounds like an everyday experience for many people. Have you ever had days with some, if not all, of these experiences? Before we continue, consider the next scenario.

You awaken to the same sunny day, although this time the sun seems exceptionally bright and energizing. After making yourself a gourmet breakfast and wolfing it down in about three minutes, you go for a power walk, completing your usual course in record time and engag- ing everyone you pass in conversation, though the conversations have no connection to each other. Returning home, you decide, after showering, to clean the entire house as well as clean the windows and mow the lawn. You then head to work, put in a 13-hour day with a 15-min- ute lunch break, during which you consume a PowerBar and some Red Bull. At home you pre- pare a four-course meal from scratch. You should be tired but you’re not, so you call your best friend and see if she wants to go out to a bar for a few drinks. She calls it a night at 11 p.m., but you are going strong. You meet an attractive person and go back to his or her apartment for a while. You return home at about 2 a.m. and go to sleep. . .until 4 a.m., when you awaken, ready to start the new day, repeating this pattern for at least seven days.

How does the second scenario sound to you? Does this sound like a normal day and night for some people? Let’s take a closer look at what these scenarios seem to describe.

The first scenario could illustrate some of the classic signs of depression, including sadness, hopelessness, self-blame, anger, insomnia, and loss of appetite. Depression is one of several depressive, bipolar, and related disorders, abnormal conditions characterized by persistent extremes of mood. Depression represents one pole of a person’s mood (see Figure 6.1) and

is typically characterized by extreme sadness, lack of energy and sex drive, low self-worth, guilt, and oftentimes thoughts of suicide.

The second scenario might illustrate the other pole, which is known as mania. Mania is marked by extreme elation. People who are in the grip of mania have lots of energy, form grandiose plans (to make a fortune or cure cancer), display a cavalier attitude toward money, and usually have a strong sex drive. At first glance, this may not seem to be much of a problem; left unchecked, however, mania can cause just as many difficulties as depression.

Happily, most of us spend the bulk of our time some- where in the middle of the mood spectrum, neither very high nor very low. A telephone conversation, a walk in the park, or a dinner with friends can lift

EgudinKa/iStock/Thinkstock Typically, the majority of people are somewhere in the middle of the mood spectrum and experience a range of emotions that are neither very high nor very low.

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Depressive Disorders and Bipolar and Related Disorders

our mood. By contrast, a bad day at work, failing an exam, losing a tennis match, indeed any of life’s disappointments can bring on the “blues.” When our mood rises, we feel happy, ener- gized, confident, and optimistic. When we get the blues, we feel sad, tired, and pessimistic. When we are low, we may decide to drown our sorrows in a drink, or maybe just go to bed.

The main difference between the blues, an emotion we all experience, and a depressive disor- der is one of degree (Oyama & Piotrowski, 2017). The blues pass quickly. In a day or two, we pick ourselves up and start again. However, when a negative mood persists for a long period of time, affecting social and occupational functioning, clinicians begin to suspect the presence of a depressive disorder.

This chapter is concerned with the diagnosis, etiology, treatment, and prevention of depres- sive, bipolar, and related disorders. It also includes a discussion of suicide, which is some- times (but not always) caused by one of these disorders.

Figure 6.1: The mood spectrum

Most of the time, we find ourselves in the middle of the spectrum, not too high or too low. Notice that the two extremes, mania and depression, are closer to one another than they are to the normal mood state. In fact, some people cycle between depression and mania, and a few manage to be both depressed and manic at the same time.

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.1, p. 319.

Normal mood


Depression Mania

The “blues”

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Section 6.1 Emotions: Normal and Pathological

Before we continue, let’s examine the case of Bernard Louis, a man whose manic episodes severely affected his life.

The Case of Bernard Louis: Part 1

Note Dictated by Psychiatrist, Dr. Kahn, When Admitting Bernard Louis to the Hospital UNIVERSITY HOSPITAL

Intake Note


Admitting Psychiatrist: Dr. Sally Kahn

Bernard Louis was brought involuntarily to the admitting ward by county police who were acting on a court order to have him committed for 24 hours of psychiatric observation.

Mr. Louis is a large man, well over 6 feet tall. He weighs more than 200 pounds. When he appeared at the hospital, his face was very red, and his hair and clothing were disheveled. Otherwise, he seemed normal. According to his wife, who accompanied him to the hospital, Mr. Louis had been working alone, 18 hours a day, building a “golf course” in their suburban backyard. His plan was to turn their half-acre lot into a private country club with a clubhouse. He hoped to sell memberships at $5,000 a year. The clubhouse would offer catering facilities as well as a bar and pro shop. He planned to build sand and water traps and to invest in a fleet of motorized golf carts. When his wife suggested that he might be getting a little carried away, Mr. Louis lost his temper, shouted in rage, and threatened to leave her for another woman. He claimed to have four girlfriends whom he regularly “satisfied” ten times a night. Two days earlier, when his wife had left the house, Mr. Louis had taken all her jewelry to a pawnshop. He had used the money to invite strangers off the street to an all-night party that finally had to be stopped by the police. Mr. Louis had not slept at all for three days before his wife obtained the court order that brought him to the hospital.

Mr. Louis was difficult to interview because he talked nonstop. He complained that he was being persecuted and that his wife was just jealous of the many women who were after him because of his sexual prowess. There was nothing wrong with him. In fact, he claimed, “I’ve never felt better in my life.” When asked if he was happy, Mr. Louis responded, “Am I happy? Why, if I felt any happier, you could sell tickets. I’m so happy, it should be illegal.”

See appendix for full case study.

6.1 Emotions: Normal and Pathological Admirers of the original (and often-replicated) Star Trek television series and films will recall the Starship Enterprise’s Vulcan officer, Mr. Spock. Spock differed from earthlings in two ways: He had odd, pointy ears, and he was rarely emotional. Unlike Captain Kirk, Spock was never tempted by the seductive outer-space sirens who regularly tried to lure the space mariners to destruction. Even when the murderous Romulans seemed certain to destroy the Enterprise, Spock never panicked. As he coldly evaluated the ship’s predicament, the other

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Section 6.1 Emotions: Normal and Pathological

crew members would accuse Spock of being “inhuman.” To them, the essential charac- teristic of a human being is the ability to feel emotions—and most psychologists agree.

Emotions are so much a part of life, we never stop to ask ourselves why they exist in the first place. What is the biological func- tion of negative emotions, such as fear and sorrow? Why did they evolve? Would we not be better off being unemotional like Spock?

As is the case with many questions sur- rounding evolution, the first place to look for answers is in the works of Charles Dar- win (1809–1882). In his book The Expres- sion of Emotions in Man and Animals (1872), Darwin hypothesized that emotions evolved because they have survival value. Fear helps us to survive because, when we are afraid of something, we flee and avoid possible harm. Sorrow also has survival value. Parent-child bonds are cemented by the feelings of sadness parents and their children experience when they are separated. To avoid sadness, parents stay close to their children, thereby increas- ing their offspring’s chances of survival. Of course, it is possible to have too much of a good thing. Unrelenting fear or sorrow can be so debilitating that, instead of increasing a person’s chances of survival, they can actually decrease those chances.

Grieving The loss of a loved one or a friend usually sets off a grieving process. The first reaction is usu- ally emotional numbness and disbelief punctuated with acute bouts of distress. Social sup- port is an important determinant of how quickly, and how well, people cope with the grieving process (Prest, 2017).

Within a week or so after a loss, disbelief is replaced with a period of pining for the lost per- son. The survivors dwell on their loss, have trouble sleeping, neglect other aspects of life, and display anger at their fate (“Why me?”). This stage may last months or years, but most people eventually acknowledge the permanency of their loss (“I am now a widow”). In the final stage of grieving, people gradually regain their interest in life, and their sadness abates. The whole process may take a year or more and may involve significant periods of psychological distress. Still, the process is perfectly normal (see the accompanying Highlight). In fact, not grieving over the death of a loved one would be viewed by most psychologists as abnormal. Because grieving is normal, treatment is not indicated unless people become dangerous to themselves or are unable to function (Prest, 2017). In such cases, clinicians would probably consider the individual to be suffering from one of the depressive, bipolar, or related disorders described in the DSM–5.

Kimberley French/© Paramount Pictures/ Courtesy Everett Collection

As Star Trek fans know, Mr. Spock differs from humans because he, as a half Vulcan, does not express emotions. Sometimes his cold ratio- nality is an advantage, but at other times his lack of emotion cuts him off from intuition and social connection.

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Section 6.1 Emotions: Normal and Pathological

DSM–5 Depressive, Bipolar, and Related Disorders By definition, a mood disorder is an abnormal condition characterized by persistent extremes of mood. The DSM–IV–TR categorized depressive and bipolar disorders in a single chapter titled “Mood Disorders.” The DSM–5 has divided the categories into two separate chapters: “Depressive Disorders” and “Bipolar and Related Disorders.” According to the DSM– 5, there are two general types of mood disorder: unipolar mood disorder and bipolar mood disorder. The “poles” referred to by these diagnostic labels are the extremes of the mood spectrum—depression and mania. Unipolar mood disorders are characterized by depres- sion, whereas bipolar disorders combine depression with manic periods. Both unipolar and

Highlight: Removal of the Bereavement Exclusion Criterion From Depressive Disorders

How do you handle the loss of a loved one? Most likely you go into a period of mourning, handling the situation in a way that is unique to you. This is called bereavement, a normal part of the grieving process. In the DSM–IV–TR (American Psychiatric Association [APA], 2000), psychologists, psychiatrists, and psychiatric social workers were advised (by the authors of the DSM–IV–TR) not to diagnose major depression in individuals within the first two months following the death of a loved one. This was called the “bereavement exclusion.” The inclusion of this criterion in the DSM–IV–TR meant that grieving a recent loss prevented a person from being diagnosed with major depression.

The bereavement exclusion was removed from the DSM–5 (APA, 2013) in order to ensure that unipolar depression (major depressive disorder) was not overlooked and that appropriate treatment could be implemented quickly before trouble ensued. The rationale behind this is simple enough: Normal grieving and unipolar depression, while sharing some common facets like withdrawal from everyday activities and intense overwhelming sadness, also differ in some very important ways.

For example, during grieving, the painful feelings come in waves of grief when they occur; positive memories of the deceased individual also occur. However, in major depressive disorder (MDD), the mood and feelings and ideas are almost always negative and unpleasant. Second, while you are grieving, self-esteem (positive feelings about yourself) is usually maintained, whereas in MDD, feelings of worthlessness and self-loathing are common. Normal grieving can lead to MDD, but clinicians are cautioned not to confuse a normal process with a mental disorder.

There is another perspective. The DSM–5 characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one. Some critics say the risk is that of pathologizing grief, a normal human process. Individuals may be diagnosed with depression even in the absence of severe depressive symptoms (such as suicidal ideation) and even though their symptoms may be transient.

A person who meets the diagnostic criteria for MDD will no longer be excluded from that diagnosis solely because the person recently lost a loved one and is in the process of normal grieving or bereavement. The death of a loved one may or may not be the main, underlying cause of the person’s unipolar depression.

What are your views on the bereavement exclusion?

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Section 6.2 Depressive (Unipolar) Disorders

bipolar disorders are divided into subtypes. The unipolar subtypes include a relatively mild condition known as persistent depressive disorder (dysthymia) and a more serious one called major depressive disorder. Bipolar disorders are divided into bipolar I disorder, which includes both depression and mania; bipolar II disorder (depression and hypomanic episodes, or episodes that do not cause as much impairment as manic episodes); and cyclo- thymic disorder (cycling between hypomanic periods and mildly depressed periods without ever fulfilling criteria for episodes of mania, hypomania, or major depression; APA, 2013). For adults to be diagnosed with cyclothymic disorder, the symptoms must be present for at least two years; for children, they must be present for at least one year (APA, 2013). Hypomanic episodes, unlike mania, do not require hospitalization (APA, 2013).

6.2 Depressive (Unipolar) Disorders Depression is as old as recorded history. The Hippocratic Oath contains numerous refer- ences to depression, or as it was known during Hippocrates’s time (approximately 2,400 years ago in Greece), “melancholia.” Melancholia is derived from the Greek word melanchole, which means “black bile.” According to Hippocrates, the human body is filled with four basic substances, or bodily “humors,” which are in balance when a person is healthy. Ancient healers believed that depression, a “black” mood, resulted from an excess of black bile. Even though modern medicine has proved this to be incorrect, the idea that depression is caused by a chem- ical imbalance in the body remains popular today and will be discussed later in the chapter.

Clearly, depression takes an enormous toll not only on the individual but also on society—particularly on the economy. Each year, the costs of major depressive dis- order for the U.S. workplace average about $43 billion (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2014). The overall costs of treating depression are estimated to be $210.5 billion per year (Greenberg, Fournier, Sis- itsky, Pike, & Kessler, 2014).

The signs of depression are common. We all experience periods of sadness and self-doubt, although these are not usually severe enough to qualify for a psychological diagnosis (Oyama & Piotrowski, 2017). Typically, these feelings begin with a reaction to some stressful life cir- cumstance (losing one’s job, for example). If these feel- ings dissipate within six months after the stressor or its consequences end, the DSM–5 labels them an adjust- ment disorder with depressed mood—a transient reaction to a stressful circumstance. A major depres- sive episode may appear superficially similar to an adjustment disorder, but it is more extreme.

gameover2012/iStock/Thinkstock In approximately the 5th century BCE, Hippocrates inscribed what is now known as the “Hippocratic Oath.” The oath includes references to “melancholia,” or depression, and this ancient idea posited that depression resulted from an excess of black bile in the body. Although this antiquated conclusion was proved incorrect by modern medi- cine, it contributed to the possibil- ity that depression is caused by a chemical imbalance.

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Section 6.2 Depressive (Unipolar) Disorders

Major Depressive Episodes Major depressive episodes are part of the diagnostic criteria for bipolar I disorder. Although we can expect to see them in bipolar I disorder, they are not required to make a bipolar I disorder diagnosis (APA, 2013). The hallmark of a major depressive episode is a sad mood. Depressed people feel down and apathetic. They may go through the motions of daily exis- tence—get up, go to class, go to the library—but there is no enjoyment in it. Life seems dull and gray, and formerly pleasurable activities no longer bring any enjoyment. (This inability to feel pleasure is known as anhedonia.) Starting a new activity seems impossibly difficult. Suf- ferers describe themselves as constantly tired and just barely dragging themselves through life. Depressed people may talk and think slowly; some may be unable to get out of bed in the morning. Although slowness is more typical, some depressed people become agitated. Instead of lying around in bed, they are unable to sit still. They pace the floor, shaking their heads and restlessly wringing their hands.

A major depressive episode may affect the way people sleep; they may wake in the night or early morning and be unable to return to sleep. (However, some depressed people sleep most hours of the day.) Changes in appetite (usually eating less but sometimes eating more) and loss of interest in sex are also associated with a major depressive episode. Some writers believe that the presence of these so-called vegetative symptoms (appetite change, sleep dis- turbance, loss of sex drive, fatigue) is what distinguishes a major depressive episode from less severe forms of depression (Jaffe & Holle, 2017).

Although a down mood and vegetative symptoms are the most obvious signs of a major depressive episode, cognition and memory are often affected as well (Jaffe & Holle, 2017). Depressed people have difficulty concentrating on cognitive tasks (Jaffe & Holle, 2017). They tend to see the downside of everything, dwelling on their failures and ignoring their suc- cesses. Because of their pessimism, they lose motivation. Depressed people judge themselves to be less liked and less capable than other people rate them (Ledrich & Gana, 2012). In chil- dren and adolescents, a depressive episode may look different. Children are more likely to be irritable than sad, for example, and they may show different symptoms at different develop- mental stages (Jaffe & Holle, 2017).

It is difficult for depressed people to change because depression has a tendency to feed on itself. The vicious cycle begins with depressed people becoming irritable and short-tempered. They snap at their partners and their children. Regretting their behavior, they then feel guilty about mistreating their loved ones. These feelings of guilt, in turn, make them even more depressed (Roepke & Seligman, 2016). (See Table 6.1 for a summary of the diagnostic criteria for major depressive disorder.)

Depression and physical symptoms often go together; for instance, headaches, dizzy spells, and general pain have been associated with depression (Trivedi, 2004). In addition to comor- bid physical conditions, there is considerable psychological comorbidity. Depressed children frequently display other problems, especially unruly misbehavior and conduct disorder (Rig- lin et al., 2016). In adults, depression is often accompanied by substance abuse. In addition, depression and anxiety are often related and show some clinical similarities in most adults (Jaffe & Holle, 2017).

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Section 6.2 Depressive (Unipolar) Disorders

Persistent Depressive Disorder (Dysthymia) Persistent depressive disorder (dysthymia) is a chronic, relatively mild, depressive disor- der that lasts at least two years but may last for decades (Oyama & Piotrowski, 2017). In children or adolescents, the diagnosis requires that the symptoms last at least one year. The person may experience occasional symptom-free days, but symptoms never disappear com- pletely for more than two months at a time. In addition to a depressed mood (or irritability in children and adolescents), the DSM–5 diagnostic criteria for persistent depressive disorder ( dysthymia) require the presence of at least two specific depressive symptoms.

Table 6.1: DSM–5 diagnostic criteria for a major depressive disorder

A. Five (or more) of the following symptoms have been present during the same 2-week period and repre- sent 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, nearly every day, as indicated by either subjective report (e.g., feels

sad) or observation made by others (e.g., appears fearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

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 nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective

feelings of restlessness or being slowed down). 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 self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 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 for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other impor-

tant areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to 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 schizo- phrenia 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.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), p.160-161. American Psychiatric Association. All Rights Reserved.

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Section 6.2 Depressive (Unipolar) Disorders

Prevalence and Course of Depressive Disorders Clinical depression is the “common cold” of psychological disorders (Lorenzo-Luaces, 2015). About 300 million people worldwide suffer from depression, and the number of cases seems to be rising in most countries, putting considerable pressure on health expenditures (World Health Organization [WHO], 2017). The widespread use of psychoactive substances, mass international migrations, the breakdown of the traditional family, crime, unemployment, and poverty all make some contribution to the rising incidence of depressive disorders.

A person’s first major depressive episode is now more likely to occur before age 19 than after (Gotlib & Hammen, 2009; Kessler, Berglund, Borges, Nock, & Wang, 2005). Most major depressive episodes begin gradually, usually with a prolonged period of anxiety or mild depression. Although they can last for years, most episodes improve within nine months to one year (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler, 2002).

Sex, Ethnic, and Cultural Differences In general, women are about twice as likely as men to be diagnosed as depressed (Oyama & Piotrowski, 2017). Why women should be more prone to depression than men has been the subject of substantial debate. Some researchers say women are more likely to seek assistance for psychological problems than men, so they turn up more often in the statistics (Rutter et al., 2016). Depressed men presumably cope in other ways such as hiding behind anger, but these theories have not received much support (Ramirez & Badger, 2014).

If women seek psychological help more often than men, we would expect to find more women than men in all of the DSM–5 diagnostic groups. Because we do not, alter- native explanations have been offered that specifically target depression. For example, critics of the DSM–IV–TR and the DSM–5 allege that the diagnostic criteria for mood disorders are subtly biased to include more women than men. Still another explanation for the sex difference is that women blame themselves for being depressed and rumi- nate on this more than men, who tend to ignore their feelings (Ramirez & Badger, 2014). Instead of being diagnosed as depressed, men are diagnosed as substance abusers or as suf- fering from an antisocial personality disorder (discussed, respectively, in Chapters 4 and 9).

In the Pennsylvania Amish (where all women work), depression is equally common in both sexes (Parker & Brotchie, 2010). The prevalence of depression varies across ethnic groups. For example, Native Americans are reputed to have higher rates of depression than the rest of the population (Roh et al., 2015). In addition, Latinos have higher rates of depression than African Americans, with Asians having the lowest rate of those ethnic groups sampled in one rather dated study (Algeria et al., 2008).

natalie_board/iStock/Thinkstock Commonly, women are more likely than men to be diagnosed with depression. There are several explanations for this statistic, yet all possibilities are still under debate.

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Section 6.3 Bipolar and Related Disorders

Otake (2008) looked at how unipolar depression is viewed in Japan. According to the Japa- nese Health, Labor and Welfare Ministry, 1 in 15 people in Japan suffer clinical depression at some point in their lives. Depression is considered one of the leading causes of suicide; in the industrialized world, Japan has the highest rate (Otake, 2008). Out of 100,000 people, 12.8 females and 35.6 males will kill themselves. This has translated into more than 30,000 suicides annually in recent years. Although these statistics are somewhat dated, they speak to the fact that untreated unipolar depression is a serious mental health concern in Japan. One reason the numbers appear as high as they are is that treatment options are limited. Most people in Japan use antidepressants and other drugs. More important, according to Otake (2008), few have access to, or seek out, psychotherapy. Japan’s national health insurance system discourages doctors from spending a lot of time with patients, and there is a short- age of professionals trained in verbal forms of therapy (Otake, 2008). One thing to ponder is whether increasing awareness of the seriousness of unipolar depression, or increasing the number of trained clinicians, would help to reduce the numbers of suicides.

6.3 Bipolar and Related Disorders Although it is possible to experience manic episodes without any periods of depression, clini- cians dating back to ancient Greece have noted that this is exceedingly rare. In the vast major-

ity of people, manic episodes are either preceded or followed by depression (although there may be intervening periods of relative calm). By the 19th century, it was taken for granted that depression and mania go together. This is why Kraepelin coined the term manic-depressive to describe people with wide mood swings. The DSM–5 term bipolar con- veys a similar picture: episodes of elevated mood (one pole) alternating with periods of depression (the other pole). (See Part 2 of Bernard Louis’s case in the appendix.)

Manic, Hypomanic, and Mixed Episodes The hallmark of a manic episode is an overly ele- vated mood. Manic people feel high and excited, although, like Bernard Louis, they are also easily irritated. In addition to an expansive mood, manic episodes are marked by grandiosity. In the grip of mania, people believe that they have unusual abili- ties and that they can accomplish anything. Con- vinced of their great wealth, manic people have been known to hand out money to strangers they meet on the street or to make enormous wagers at racecourses or casinos.

STUDIOGRANDQUEST/iStock/Thinkstock Bipolar disorders are characterized by feelings of extreme elation followed by depression. Individuals suffering from bipolar disorders usually experience symptoms starting at around age 18.

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Section 6.3 Bipolar and Related Disorders

In the midst of a manic episode, people find it impossible to focus on a single task. Their minds race from one idea to another, known as flight of ideas. They begin various grand proj- ects but do not see them through to completion. Not only are their thoughts rapid and unfo- cused, but their physical activities are also energized and chaotic. They have little need for sleep, and their sex drive is heightened. Manic individuals speak quickly and rarely fall silent. Their speech is so rapid, and they switch topics so often, that they may become incoherent. See Table 6.2 for a summary of the diagnostic criteria for a manic episode.

Table 6.2: Main DSM–5 diagnostic criteria for a manic episode

A. A distinct period of abnormally and persistent elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or a perceived pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (attention is easily drawn to unimportant or irrelevant stimuli) 6. Increase in goal-directed activity (either socially, at work or school, or sexually), or psychomotor

agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful consequences

(buying sprees, sexual indiscretions, foolish business ventures) C. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or

in usual activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not the result of substance abuse, a medical condition, or drug treatment.

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

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), p. 124. American Psychiatric Association. All Rights Reserved.

Some people display manic symptoms while suffering from a depressed mood. They are said to have a mixed episode. A milder form of a manic episode is called a hypomanic episode, which is marked by an elated mood, little need for sleep, and intense periods of activity. Unlike a manic episode, a hypomanic episode need only last at least four consecutive days, whereas a manic episode needs to last at least one week. Additionally, an individual with a hypomanic episode can function and does not require hospitalization. If psychotic features are present (hallucinations and so on), by definition the episode is manic (APA, 2013). Because they feel energetic and healthy, hypomanic (and manic) people do not seek professional assistance, nor do they recognize that anything is wrong with them.

Specific Bipolar Disorders There are three main bipolar disorders:

• Bipolar I disorder consists of one or more manic or mixed episodes. In most cases, individuals will also have had one or more major depressive episodes.

• Bipolar II disorder is characterized by recurrent major depressive episodes and at least one hypomanic episode.

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Section 6.3 Bipolar and Related Disorders

• Cyclothymic disorder involves periods during which hypomanic symptoms are present alternating with periods of mild depression over the course of two years (or one year in children and adolescents). These periods may be mixed with periods of normal moods.

There is a high comorbidity between bipolar dis- orders and substance abuse, but the reasons for this remain unclear (Gooding, Wolford, & Good- ing, 2016). Because substances such as cocaine can cause manic behavior, and because many people use alcohol and drugs to control their moods, it is often impossible to tell whether changes in mood are the result of substance abuse or are responsible for it.

Prevalence and Course of Bipolar Disorders Bipolar disorders are rarer than unipolar disorders. More recent figures place the prevalence rate at 1.8% in the U.S. population, with a prevalence rate of 2.7% in children aged 12 or older (APA, 2013). Between 1% and 2.6% of all adults will develop a bipolar disorder in their lifetime (Gooding et al., 2016). Although it is not the case with unipolar dis- orders, men and women are equally likely to be diag- nosed with a bipolar disorder (APA, 2013; Gooding et al., 2016). Many famous people have allegedly suffered from bipolar disorders (from Herman Mel- ville, Ernest Hemingway, and Vincent van Gogh to actors Carrie Fisher and Catherine Zeta-Jones and singer Demi Lovato).

About 15% of people initially diagnosed with some form of depression go on to experience manic or hypomanic episodes (Angst, Gamma, Rössler, Ajdacic, & Klein, 2009). Although some people with bipolar disorder have only a few manic episodes over the course of their lives, others, known as rapid cyclers, can have four or more. The first signs of bipolar disorder usually appear from ages 18 to 25 and appear rather suddenly (APA, 2013; Angst et al., 2009; Simon & Zieve, 2013). Bipolar disor- der rarely appears after age 40. Follow-up studies have found the prognosis for bipolar disorder to be poor. Even among those who are treated, relapse

Nordic Photos/SuperStock American author Ernest Hemingway allegedly suffered from a bipolar disorder.

Sylvain Grandadam/age fotostock/SuperStock Painter Vincent van Gogh was also thought to suffer from bipolar disorder. Van Gogh voluntarily entered a sanato- rium in 1889 and completed this self- portrait during the year he spent there.

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Section 6.4 Etiology of Mood Disorders

is common, and social and occupational functioning becomes progressively worse over the years (Gitlin & Miklowitz, 2017).

Diagnostic Specifiers Postpartum depressions are those that occur in the four weeks following childbirth (APA, 2013). Most of these episodes are mild and brief. In severe cases, the depression is probably not caused solely by the birth of a child but is likely to be the end result of many preexisting factors, including low self-esteem (Cabrera & Schub, 2017). The specifier with peripartum onset is used to designate an unspecified depressive disorder with an onset either during pregnancy or in the four weeks following delivery (APA, 2013).

Premenstrual dysphoric disorder was moved from the DSM–IV–TR’s Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of the DSM–5. In this disorder, a majority of symptoms must be present in the week before menstruation, improve a few days after menstruation begins, and remit in the week following the end of menstruation (APA, 2013). Symptoms include, but are not limited to, mood swings, feeling overwhelmed or out of control, hypersomnia or insomnia, and difficulty in concentration (APA, 2013).

6.4 Etiology of Mood Disorders Biologically oriented researchers have concluded that mood disorders must have a physi- ological etiology. Psychologically oriented researchers have focused on possible social and psychological causes. The etiology of bipolar disorders remains poorly understood.

Genetic Factors Although the diagnostic criteria for mood disorders have been revised repeatedly, the research data accumulated over the decade or more strongly suggest that these disorders run in families (Gooding et al., 2016). Most studies have found that first-degree relatives (parents, siblings, and children) of people with mood disorders are more likely to have mood disorders themselves than are people without affected relatives (Gooding et al., 2016). (See Table 6.3.) (See Part 3 of Bernard Louis’s case in the appendix.)

Table 6.3: Average risk for mood disorders in first-degree relatives of people with mood disorders

Percentage of Relatives With

Patient’s Disorder Major Depressive Disorder Bipolar Disorder

Major depression 9.1 0.6

Bipolar disorder 11.4 7.8

No disorder (general population) 8 <1

Source: Katz and McGuffin (1993) and various epidemiological studies, as appearing in S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Table 8.6, p. 334.

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Section 6.4 Etiology of Mood Disorders

Searches for the gene(s) responsible for mood disorders began with a search for spe- cific genetic markers, genetic material pres- ent in relatives with mood disorders. Find- ing such material requires two important ingredients: technology capable of identify- ing parts of chromosomes and a sufficiently large number of affected family members who can be studied over several genera- tions. Nevertheless, given the accumulated data, it seems reasonable to conclude that genetics plays a role in rendering people susceptible to mood disorders (Gooding et al., 2016).

What Is Inherited? If genetics plays a role in the development of mood disorders, then it follows that suf-

ferers must inherit something that renders them especially susceptible to mood disorders. This “something” turns out to be faulty neurotransmitter regulation.

In Hippocrates’s time, mood disorders were attributed to an imbalance in the chemicals (humors) of the body. In the 1950s, it was observed that about 15% of patients treated with reserpine to reduce their high blood pressure were found to develop major depressive epi- sodes. Because reserpine was thought to reduce the level of a neurotransmitter known as norepinephrine, researchers hypothesized that depression might be the result of diminished levels of norepinephrine. Around the same time that these observations were being made, clinicians using the drug iproniazid to treat tuberculosis noted that their patients not only improved physically but also seemed to be in a much better mood. By the late 1950s, the drug was being widely used to treat depression even though no one had any idea how it worked.

Ultimately, scientists discovered that iproniazid, like reserpine, affects neurotransmitter lev- els. Specifically, iproniazid inhibits the activity of an enzyme known as monoamine oxidase (MAO), a chemical that plays a crucial role in neurotransmitter regulation. MAO facilitates the chemical breakdown and reuptake of neurotransmitters such as norepinephrine, dopamine, and serotonin after they have done their job (see Figure 6.2). Because iproniazid inhibits the activity of MAO, it slows the reuptake process. The result is a higher concentration of norepinephrine.

Pharmaceutical companies rushed to market other MAO inhibitors (MAOIs). Unfortunately, these drugs had a serious drawback; they interact with certain foods to cause potentially life-threatening conditions such as stroke. This is why MAO inhibitors have been largely aban- doned in favor of much less lethal antidepressant drugs such as fluoxetine (Prozac) and ser- traline (Zoloft). (See Thase [2005] for further discussion of low serotonin levels being impli- cated in unipolar depression.)

Dino Fracchia/agf photo/SuperStock Researchers believe the causes of mood dis- orders may relate to biology (physiological etiology) or psychology (social environment). Studies within the Amish community proved there may be a genetic marker within families, but the study was difficult to replicate.

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Section 6.4 Etiology of Mood Disorders

Figure 6.2: The neurotransmitter cycle

Disruption of any stage of this process can lead to over- or underproduction of a neurotransmitter or interfere with its reuptake. A variety of drugs have been created to regulate the cycle of specific neurotransmitters.

Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.3, p. 336.

Neurotransmitter diffuses and is metabolized and/or transported back into presynaptic neuron.

Postsynaptic neuron

C22+ Synaptic




Presynaptic neuron


Neurotransmitter molecules

Neurotransmitter is synthesized in presynaptic neuron

Neurotransmitter is packaged into vesicles.

Neurotransmitter is released when vesicles fuse with cell membrane.

Neurotransmitter binds to and activates postsynaptic receptors






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Section 6.4 Etiology of Mood Disorders

Psychosocial Factors Although there is clear evidence that genet- ics plays a role in mood disorders, and we have several plausible candidates for the biological diathesis, it is important to keep in mind that the concordance rate, even among identical twins, is less than 100% (concor- dance rate refers to the proportion of identi- cal twins in a random sample who share a certain characteristic with their twin; Flint & Kendler, 2014). Thus, the environment must also play a role in determining who develops a mood disorder. In this section, we look at how psychoanalytic, behavioral, cognitive, and social psychologists explain how stress interacts with preexisting vulnerabilities to produce mood disorders.

Psychoanalytic Views According to Freud (1917/1959) and his followers, depression is a form of grief produced in reaction to a loss, especially the loss of an important personal relationship through death, divorce, or separation. People who become clinically depressed tend to blame themselves for their loss. This pattern of self-blame is established early in life, usually because of the loss of parental affection. Rejecting parents, or early separation from one’s parents through death, divorce, or desertion, can cause a child to become fixated at the oral stage of psychosexual development. Because children at this early developmental stage depend on their caregivers to satisfy their physical and psychological needs, fixation produces a passive and emotionally dependent adult. They blame themselves for their loss of parental affection; these children grow up feeling unwanted and worthless. They are angry about their loss, but they turn their anger inward, thereby setting the stage for a lifetime habit of self-blame and a consequent vulnerability to depression.

Psychoanalysts now believe that mood disorders can be traced back not just to the loss of parental affection but also to the loss, early in life, of any person who was of special impor- tance to the child (Keyes et al., 2014). Related to this is the concept that stressful life events often lead to a mood disorder (Gooding et al., 2016).

Behavioral Views Behavioral psychologists originally emphasized the loss of important relationships in the eti- ology of depression. Their basic premise was that the behavior of other people is an important source of reinforcement for our own behavior. When we lose a friend or loved one, we also lose the reinforcement they provided. As a consequence, we may go out less, tell fewer jokes, and lose interest in social activities; in other words, once people become depressed, they set in motion a vicious cycle. Depressed people are bad company, so they are avoided. This furthers their isolation and makes them even more depressed. Even worse, if other people

James Woodson/Digital Vision/Thinkstock Although genetics plays a role in mood dis- orders, an individual’s environment is also important when determining the cause of a mood disorder.

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Section 6.4 Etiology of Mood Disorders

show sympathy for depressed friends and relatives, then the depressive behaviors may be reinforced and the depression may become chronic. Behavioral psychologists now believe that any life event that disrupts habitual behaviors can potentially lead to the loss of reinforc- ers and, therefore, to depression (Gooding et al., 2016).

The main problem with these behavioral formulations is their lack of specificity. We know that many people experience the loss of a loved one without becoming clinically depressed. Similarly, very few people respond to praise and success by becoming manic.

Cognitive Views Cognitive psychologists such as Aaron Beck (1991) view mood disorders as mainly the result of distorted attributions. They believe that depressed people are biased toward negative attribu- tions. These negative attributions constitute what Beck calls the negative cognitive triad of depression: negative feelings about the self, the world, and the future. People with depressive mood disorders also have characteristic ways of interpreting and responding to life events.

People who feel worthless distort events to justify their low opinion of themselves. These dis- torted appraisals then make them depressed. Once depression sets in, they tend to make more negative self-appraisals, assuring further “failures” and making them feel more worthless and even more depressed. Once this process takes hold, depression becomes self-perpetuating. Like psychoanalysts and behaviorists, cognitive psychologists make room for individual dif- ferences in their theory. The main tenet of the cognitive view is indisputable; the research evidence showing that depressed people are self-critical is overwhelming (Kannan & Levitt, 2013).

Learned Helplessness In contrast to Beck’s cognitive theory, which was derived from clinical observations, Mar- tin Seligman’s theory of learned helplessness was derived from animal research (Seligman, 1975). In the typical experiment, dogs were confined in a box with an electrified floor. They received electric shocks, which they could not avoid because there was no escape route. Later, the same dogs were tested in an apparatus known as a “shuttle box.” This box consisted of two compartments separated by a small partition. One side of the box had an electrified floor; the other did not. Once again electric shocks were delivered through the floor, but this time they were preceded by a buzzer or a light signal. The animals who were attracted to the electrified compartment by food or drink could avoid the pain of a shock by jumping over the wall when- ever they heard or saw the signal (see Figure 6.3). Animals that had never been exposed to the inescapable shock eventually learned to jump out of the electrified side of the box whenever the signal was presented. This allowed them to eat or drink in the electrified box without ever feeling any shock. The animals that had previously been exposed to the unavoidable shock never learned to make the required escape response. Instead, they just lay down on the grid, cowered, whined, and accepted their fate. According to Seligman, these animals had learned that painful outcomes were beyond their control. Instead of learning to avoid shock, they simply learned to act helpless.

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Section 6.4 Etiology of Mood Disorders

Seligman noted parallels between the animal research and human depression. For example, many depressed people have experienced tragedy and loss over which they have had no con- trol. In response, they may give up trying to cope and react to life’s problems with passivity and helplessness.

Over the years, Seligman and his colleagues have gathered additional evidence for his learned helplessness theory (Peterson, Maier, & Seligman, 1993) and have revised it. According to the revised theory, we attribute our failures and losses to either internal or external causes. External attributions (where the individual attributes failure to environmental events and to other people) lead to temporary feelings of helplessness and depression but not to self-blame. Internal attributions (where the individual attributes negative events to a personal failing of some sort), by contrast, produce more chronic forms of depression in which low self-esteem and self-blame play an important role. An important prediction of the revised helplessness theory is that serious depressions require not only a triggering event (such as failing to make the Olympic team) but also a depressive internal attributional style that assigns such failure to personal, usually global, failings (Liu, Kleiman, Nestor, & Cheek, 2015).

Figure 6.3: Learned helplessness

In Martin Seligman’s (1975) research into learned helplessness, dogs that had been confined in a box with an electrified floor and were unable to avoid being shocked were subsequently unable to learn to jump to safety over the partition in a half-electrified shuttle box at the signal of a buzzer or a light.

Source: S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.6, p. 343.

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Section 6.5 Treatment of Mood Disorders

Interpersonal and Social Support As we have seen, loss and stressful life events, especially the deaths of loved ones, are often associated with mood disorders. The effects of stress and loss can be minimized by support- ive friends and family (Gooding et al., 2016). Recovery from depression can be accelerated by strong social support (Gooding et al., 2016). This is why mood disorders are less likely among people who have strong social support networks (Liu et al., 2015).

6.5 Treatment of Mood Disorders As mentioned earlier, Hippocrates believed that depression was caused by the supposed excess of black bile in the body. Bloodletting, the administration of drugs that caused vomit- ing and diarrhea, diets, massages, baths, and exercise were all prescribed. Even when doctors no longer believed in the four humors, regular exercise continued to be prescribed (Jaffe & Holle, 2017).

Biological Treatments Biological treatments cover a wide range, including electroconvulsive therapy, light treat- ment, and many other interventions. However, by far the most common biological treatment is the administration of mood-altering drugs.

Drug Treatment As mentioned earlier, MAO inhibitors’ side effects, and the difficulty in maintaining dietary restrictions to avoid potentially life-threatening reactions, are too serious to make them the drug of first choice. MAO inhibitors were first replaced by imipramine, which was originally synthesized to treat schizophrenia. It did not do much to help the symptoms of schizophre- nia, but it did seem to lift people’s depression. Thus, by accident rather than by design, imip- ramine became the first in a series of tricyclic antidepressants (TCAs). Tricyclic refers to the chemical structure of these substances, which contains three rings of atoms. Although these drugs work differently from MAO inhibitors, they also increase neurotransmitter levels. Specifically, they block the proteins that transport neurotransmitter residues back to synaptic terminals. This keeps the neurotransmitters from being reabsorbed, thereby increasing their levels (Nelson, 2016).

More recent drugs have targeted another neu- rotransmitter, serotonin. Fluoxetine (Prozac), for example, is an antidepressant drug that blocks the reuptake of serotonin (thereby increasing serotonin levels) while leaving other neurotransmitters unaf- fected. Fluoxetine and related drugs are known as selective serotonin reuptake inhibitors (SSRIs).

Elizabeth Cardoso/Hemera/Thinkstock Modern drug treatments focus on blocking the reuptake of serotonin, or SSRIs. These drugs increase serotonin levels and are effective against depres- sion with minimal side effects.

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Section 6.5 Treatment of Mood Disorders

The drug has become popular because it not only is effective against depression but also has relatively mild side effects, such as increased agitation, lowered libido, insomnia, and stom- ach upset (Nelson, 2016).

These reduced side effects are especially important. It takes a minimum of two weeks before any of the antidepressant drugs exert their therapeutic effect. During these two weeks, patients develop the side effects of the drugs but receive no benefits. Some give up the drugs in disgust. Because fluoxetine has few side effects, people are more likely to stick with it long enough to obtain the benefits. Reduced side effects also save money because drug side effects often require treatment (Auday, 2016).

Because most depressions eventually lift whether they are treated or not, the main goal of drug treatment is to hasten recovery and prevent recurrence (Safer, 2017). The latter goal may require that patients be given “maintenance” doses of antidepressant medication for prolonged periods lasting months or even years (Safer, 2017). Antidepressants do not “cure” depression and recurrences may still occur, even among those treated with maintenance doses (Auday, 2016).

Drug treatment for bipolar disorder was discovered by John Cade (1912–1980) in the 1940s. Cade, an Australian psychiatrist, studied people who had mania, trying to find some biochem- ical cause for their behavior. One of his experiments involved injecting guinea pigs with urine samples taken from manic patients and noting whether the animals’ behavior changed. Noth- ing happened. Cade could not find any particular ingredient that caused mania. Instead, he found that lithium urate (a salt found in everyone’s urine) caused the guinea pigs to become lethargic. Since lithium carbonate, a naturally occurring salt, had the same effect, he con- cluded that it was the lithium that was calming down the animals. Cade himself took lithium first and, noting no ill effects, he tried lithium on one of his patients. The patient, whom Cade described as “dirty, destructive, mischievous, and interfering” and who had “enjoyed pre- eminent nuisance value in a back ward for years,” became perfectly well.

Perhaps Cade’s most extraordinary discovery was that lithium not only was effective against mania but also seemed to prevent the depressive episodes of bipolar disorder. Thus, although antidepressants helped relieve depression and strong tranquilizers calmed mania, lithium helped both conditions. Moreover, unlike imipramine or fluoxetine, lithium does not affect neurotransmitters. Instead, it seems to reduce the excitability of the nervous system.

Although Cade initially reported that bipolar disorder patients will not have a recurrent manic episode if they take lithium indefinitely, more recent studies estimate the recurrence rate among treated patients to be around 40% to 50% (Goodwin & Jamison, 2007). One difficulty in judging lithium’s effectiveness is ensuring that people take their medication as prescribed. Some people stop taking lithium because they like the feeling of well-being and energy that accompanies a manic state (Goodwin & Jamison, 2007). Others forego lithium because of its side effects: diarrhea, stomach upset, weakness, and frequent urination. In high dosages, lith- ium can even be fatal. Ensuring patient compliance is especially important because discon- tinuing lithium actually increases the probability of a manic episode. In other words, discon- tinuing lithium is not recommended as relapse may occur (Sportiche et al., 2016).

Anticonvulsant medications typically used to treat seizures have also been used to treat bipo- lar disorder (Gooding et al., 2016). Individuals who have at least four episodes of mania or

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Section 6.5 Treatment of Mood Disorders

depression within a 12-month time period are specified as having a rapid-cycling pattern. This type of bipolar disorder is quite difficult to treat effectively (for example, Gooding et al., 2016); nevertheless, anticonvulsants have shown some efficacy for this group (Gooding et al., 2016).

Electroconvulsive Therapy Electroconvulsive therapy (ECT) was introduced in the 1930s. ECT involves sending elec- trical impulses through the brain with the goal of inducing a seizure. Like many drug treat- ments, it also had its origins in an accident. A Viennese doctor named Manfred Sakel noted that a patient who had accidentally been put in a coma by an overdose of insulin became less anxious and depressed. Because it was difficult to determine the exact amount of insu-

lin required to produce a seizure without inflicting seri- ous harm or even killing the patient, clinicians experi- mented with “safer” methods to induce seizures. One method was ECT. ECT fell out of use in the 1950s due to the memory loss that often occurred and the scary nature of the procedure itself. In addition, antidepres- sant medications made the use of ECTs less warranted (Piotrowski & Hartmann, 2017). By the 1970s, however, it began to make a comeback. Today, ECT is used to treat depression in patients who do not respond to drugs or psychological therapy.

Today’s ECT patients are given a general anesthetic so that they are not conscious during the procedure. They also receive drugs that inhibit body movements. Elec- trodes are then placed on the head, usually on the right side only. Because the left side of the brain normally contains the speech centers, applying shock only to the right minimizes any disruption in communicative abil-

ity (Heering & Schub, 2017). Once the electrodes are in place, a current is passed through the head for about half a second. The patient’s response is a convulsion (seizure) that lasts for around a minute, followed by a coma that lasts from a few minutes to half an hour.

ECT can rapidly clear a depression without needing to wait the weeks required with drugs or psychotherapy (Piotrowski, 2016). However, ECT may have side effects. One of these is memory loss, especially for events just before the seizure. Modern practice is to minimize the number of treatments so that memory loss is not extensive and new learning is unaffected. ECT is generally reserved for people who do not respond to other forms of interventions. After more than 80 years of use, we still have no theory to explain the therapeutic effects of ECT. The lack of a theory about how ECT works, coupled with reports of serious side effects, even death, have made ECT controversial.

Light Treatment For hundreds of years, clinicians have prescribed a trip to a sunny climate as the best cure for the winter blues. Light treatment provides similar benefits, but without the travel. Unspecified depressive disorder with seasonal pattern (commonly called seasonal affective disorder [SAD]) is a unipolar depression that occurs only during a particular time of year—typically in

SSPL/Getty Images This early electroconvulsive ther- apy machine was first used in the 1930s and by the 1970s, ECT treat- ment was administered to patients who failed to respond to drugs or therapy.

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Section 6.5 Treatment of Mood Disorders

winter, when the days are shorter. Light treatment for people with this disorder involves expo- sure to a few hours of bright light every morning (Piotrowski, 2016). The light is designed to mimic the spectrum of sunlight. In any event, side effects are rare, although exposure to light may cause eyestrain and headache (Piotrowski, 2016). (See Figure 6.4.)

Figure 6.4: Prevalence of seasonal affective disorder by latitude

Source: Data from Rosen et al. (1990), from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.5, p. 340.

New York


























Atlantic Ocean

Pacific Ocean















250 Miles





250 Kilometers

42.5°: Nashua, NH 40.5°: New York, NY 39.0°: Montgomery County, MD 27.0°: Sarasota, FL

Montgomery County






Transcranial Magnetic Stimulation Transcranial magnetic stimulation (TMS) is a painless, noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression, typi- cally when other treatments haven’t been effective (see also Chapter 1). Even though we are unsure why TMS works, it may activate regions of the brain that have decreased activity in people with depression.

Psychological Treatments Medications, ECT, light, and TMS are aimed at alleviating the symptoms of depression. They do not teach people who are prone to depression how to cope with the loss of a loved one, unemployment, or any of the other triggers of depression. Psychological treatment, by con- trast, is designed to help people learn more effective ways of behaving. Most psychological treatments have focused on depression rather than bipolar disorder (other than those that try to devise ways of making sure that people with bipolar disorder take their lithium).

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Section 6.5 Treatment of Mood Disorders

Psychoanalytic and Interpersonal Treatment Psychoanalytic treatment is designed to help patients achieve insight into the repressed con- flicts that are presumed to be responsible for their mood disorder. Most often, these conflicts involve the loss of a loved one, accompanied by guilt and self-blame. Once the therapist has helped the person to recognize the conflict, the therapist encourages the person to release the inwardly directed hostility and, through this catharsis, eliminate inner-directed anger.

Interpersonal Psychotherapy (IPT) Interpersonal psychotherapy (IPT), developed by Gerald Klerman in 1988, aims to help clients examine the ways in which their present social behavior keeps them from forming satisfactory interpersonal relationships (Lemmens et al., 2017). Instead of focusing on the past, IPT is concerned with the present, especially problems in adjusting to grief; fights with friends, coworkers, and relatives; role transitions (new job, divorce); and social deficits (such as a difficulty in acquiring new relationships). In addition to gaining insight, clients are taught assertiveness and communication skills as well as other ways of improving their ability to form supportive relationships.

Cognitive-Behavioral Treatment As its name suggests, cognitive-behavioral treatment combines cognitive and behavioral interventions. The cognitive component involves teaching clients to identify self-critical and negative thoughts, to note the connection between such thoughts and depression, and to chal- lenge negative thoughts to see if they are supportable. If they are not, the client is taught to replace them with more realistic evaluations of present and future circumstances.

Outside of cognitive-behavioral therapy sessions, some clients find that programmed aero- bic exercise (such as spinning or aqua-aerobics) can help them understand and control their depression and lead to better relapse prevention (Olson, Brush, Ehmann, & Alderman, 2017).

Drugs Versus Psychological Treatment One of the first studies to compare psychological with drug treatments found that cognitive-behavioral therapy was superior to imipramine in the treatment of depression (Rush, Beck, Kovacs, & Hollon, 1977). Several studies found that cognitive-behavioral treat- ment and IPT reduce the probability of a relapse (Hollon et al., 1992; Hollon, Shelton, & Davis, 1993; Lewinsohn, Clarke, Hops, & Andrews, 1990). But combining psychological treatments with antidepressant medication seems to produce a greater prevention effect than use of either treatment alone (Nelson, 2016). One reason for this is that people in psychotherapy are more likely to take their drugs regularly (Jin, Sklar, Oh, & Li, 2008).

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Section 6.6 Suicide

Undertreatment Some people do not seek help because they fail to recognize the signs of depression, others fear the stigma of “mental illness,” and still others cannot afford treatment costs. Medical pro- fessionals also contribute to undertreatment. Many medical practitioners are poorly informed about mood disorders and the benefits of treatment (Vermani, Marcus, & Katzman, 2011). The worst outcome of an untreated mood disorder is a despair that becomes so extreme that the person takes his or her own life. However, mood disorders are not the only cause of sui- cide. (See Part 4 of Bernard Louis’s case in the appendix.)

6.6 Suicide Suicide, self-inflicted death in which the person deliberately, consciously, and intentionally acted to kill himself or herself, is a disorder under further study in the DSM–5; the disorder is called suicidal disorder (APA, 2013). In some times and places, suicide has been socially acceptable. For example, in 2014 in the United States, Brittany Maynard announced that she intended to end her life by physician-assisted suicide. In early 2014, Maynard had been diag- nosed with a brain tumor, which quickly advanced and eventually became terminal. She then moved from California to Oregon, where physician-assisted suicide is legal, and ultimately ended her life by that means (Pierre, 2015). In Japan it was, and still is to a certain extent, con- sidered socially acceptable to commit seppuku, or suicide, to save the family from disgrace. Even though social views are thought to be more tolerant in the United States, suicide is often still considered a social disgrace here. Suicidal behavior is surrounded by many myths. Some of these are highlighted in the accompanying Highlight.

Suicidology (the study of suicide, suicidal behavior, and suicide prevention) has become a scientific field in its own right. Still, many people who take their own lives do suffer from a mental disorder (Piotrowski & Hartmann, 2017). Because suicide is frequently associated with depression, it has been included in this chapter.

Prevalence and Incidence Suicide is universal and has occurred throughout history. It is among the top 10 causes of death in the United States and a common cause of death among young people (Centers for Disease Control and Prevention [CDC], 2015). The reported suicide rate in the United States is 42,826 per year; the actual number is probably higher (CDC, 2017). About 50% of suicides involve the use of firearms (CDC, 2017). The remaining are by suffocation and poisoning. Many suicides go unreported because of the ambiguity surrounding the death or because families try to cover up the circumstances to avoid social stigma (Piotrowski & Hartmann,

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Section 6.6 Suicide

Highlight: Suicide Myths and Reality

Over the centuries, myths have developed around suicide. Some of the more prevalent myths, and the corresponding realities, are addressed in the table that follows.

Suicide Myth Suicide Reality

Those who talk about suicide never do it. The vast majority of people who kill them- selves give some warning.

Suicide is related to social class. People of all social and educational classes kill themselves. Although more educated people are less likely to turn to suicide, there are some notable exceptions. Highly educated people, such as doctors, have among the highest sui- cide rates (Kent, 2010). Some occupations that require advanced education—such as dentists and physicians—are associated with higher suicide rates, presumably because they often are highly stressful professions, and perhaps because practitioners have easy access to lethal drugs such as barbiturates and narcotics.

Everyone who dies by suicide is depressed. Many people who kill themselves are not depressed. Indeed, suicides are most likely to occur just when it appears that a person has recovered from depression.

Suicide is influenced by weather (“the suicide season”).

Suicides can occur at any time of year.

Suicidal people always want to die. Most people who kill themselves are not sure they want to die. Many gamble with their lives, hoping that others will save them.

Only insane people contemplate suicide. Suicidal thoughts are common in the general population. Among the terminally ill, suicide may be considered a rational act.

Once people try suicide, they remain forever suspect.

Most people attempt suicide only once, but up to 40% of those who complete suicide will have made previous attempts (Cavanagh, Carson, Sharpe, & Lawrie, 2003).

Those who unsuccessfully attempt suicide were never serious.

Some people are poorly informed about the lethality of different acts.

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Section 6.6 Suicide

Age, Sex, and Ethnic Differences Although suicide is a relatively more common cause of death among young people than among older ones (because young people are less likely to die from disease), suicide is not uncom- mon among older persons (CDC, 2005). For example, in 2000, when 12.5% of the U.S. population was older than 65, this group accounted for almost 20% of all suicides (CDC, 2003). It is par- ticularly prevalent among white males older than age 65 (CDC, 2003). Divorced, widowed, and other single people have higher suicide rates than married people. In all instances, more men than women take their own lives (APA, 2003).

The circumstances of people who take their own lives are remark- ably similar across cultures. Suicides are most common among people whose families have been affected by death or divorce, who have unhappy love affairs, who suffer serious illness, or who experience severe economic setbacks.

Assessing Suicidal Intentions It is not easy to predict who will kill themselves; many suicides seem to happen without prior warning (Apter et al., 1993; Maris, Berman, Maltsberger, & Yuflt, 1992). Nevertheless, suicidologists have been able to identify a set of risk factors that seem to be cor- related with suicide (see Table 6.5).

Table 6.4: Suicide attempts versus suicide completers

Characteristic Attempters Completers

Sex Female Male

Age Under 35 Over 60

Means Low lethality (pills) High lethality (firearms)

Diagnosis None or rare Depression; substance abuse

Setting Public, easy to discover Private and isolated

Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Table 8.7, p. 357.

2017). Although suicide occurs everywhere, cross-cultural comparisons are difficult because cultures may record suicides differently, based on how suicide is treated in a given culture. According to recent research, a large disparity exists between suicide attempters and suicide completers in terms of demographics, means, and the setting (see Table 6.4).

KMazur/WireImage/Getty Images Rock musician Kurt Cobain, of the 1990s band Nirvana, died by suicide on April 5, 1994. Cobain suffered from depression and also had severe issues coping with worldwide media attention.

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Section 6.6 Suicide

Causes of Suicide The motive for attempting suicide varies from person to person (Piotrowski & Hartmann, 2017). Some suicides are attempts to extract retribution or obtain martyrdom, others are a way to end a life of intolerable pain, and still others are the result of risk taking or “playing with death.” Edwin Shneidman, who studied risk factors for suicide, noted that there are cer- tain commonalities among people who display suicidal behavior (Shneidman, 1992): They are seeking a solution to a problem, wish to end consciousness, have either psychological or physical pain (or both), have frustrated psychological needs, feel hopeless, cannot see alter- natives, and are “escapers” rather than problem solvers. (See Figure 6.5.)

Psychological Disorders and Suicide A psychological disorder, usually a bipolar disorder or a major depression, appears in the history of many cases of suicide (Piotrowski & Hartmann, 2017; Shneidman, 1992). Interest- ingly, people rarely attempt suicide while in the depths of depression. The year following a major depressive episode is the most dangerous period (Isometsä, Sund, & Pirkola, 2014), perhaps because the person is still unhappy but now has the energy required to carry out self-destructive intentions.

Most people with mood disorders do not kill themselves; however, alcohol abuse makes sui- cide more likely. The presence of a psychological disorder, such as depression, combined with the poor judgment and reduced inhibition produced by alcohol create a lethal combination (Piotrowski & Hartmann, 2017).

Table 6.5: Risk factors and suicide

Factor Low Risk High Risk

Sex Female Male

Marital status Married Single/divorced/living alone

Age Middle years Adolescence/old age

Psychiatric status Normal/character disorders/ situational disturbances

Depression/alcoholism/conduct disorder/ schizophrenia

Setting Rural Urban/prisons

Assault victim No history Multiple physical and sexual assaults

Religious activity Regular churchgoer Non-churchgoer

Nationality Italian/Dutch/Spanish Scandinavian/Japanese/German-speaking countries

Source: Adapted from Nock and Kessler (2006), Nock et al. (2008), and Stevenson et al. (1972).

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Section 6.6 Suicide

Psychological Factors Freud and his followers construe suicide as a form of murderous anger at another person turned inward against oneself. A child whose mother dies may become angry about this loss, but the child is unable to vent this anger because its target, the dead mother, is unavailable. Instead, the child turns this anger inward.

Figure 6.5: Threshold model for suicidal behavior

Source: Adapted from “Clinical Assessment and Treatment of Youth Suicide,” by S. J. Blumenthal and D. J. Kupfer, 1988, Journal of Youth and Adolescence, 17, 1–24. Copyright © 1988 by Plenum Publishing Corporation. Reprinted with kind permission of Springer Science + Business Media.

Suicidal behavior

Risk factors

Protective factors

Precipitating factors

Environmental factors/suicide


Cognitive flexibility Strong social support Hopefulness No losses

Lack of precipitating life events Treatment of psychiatric disorder Treatment of personality disorder

Availability of method

Humiliating precipitating

life event Threshold

Vulnerability for suicidal


Psychiatric diagnosis

Genetic/family history

Biological factors (for example, SHIAA,

perinatal factors)

Personality traits (for example, impulsivity)

Predisposing risk factors

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Section 6.6 Suicide

Despite the confirmation of early loss in the childhood of many people who kill themselves, the overall evidence for the psychoanalytic view of suicide is far from compelling. Although hate and revenge are sometimes the motives for suicide, they are not the only reasons people take their own lives (Tucker, Crowley, Davidson, & Gutierrez, 2015). Shame, guilt, and hope- lessness are considerably more common motives. Hopelessness is particularly important (Piotrowski & Hartmann, 2017; Sadock & Sadock, 2007; Shneidman, 2005).

Genetics and Physiology Suicide, like depression, tends to run in families (Zai et al., 2012). The concordance rate for suicide among monozygotic twins is 20 times higher than it is among dizygotic twins, 0.7% compared with 14.9% (Brent & Melhem, 2008). Because most suicidal twins are also depressed (or suffering from some other mental disorder), it may be the mental disorder, rather than the tendency toward suicide, that is inherited. In any event, there does seem to be a genetic factor involved, although it is worth noting that, even among monozygotic twins, the concordance rate for suicide is not 100%.

Treatment and Prevention Since medical science can now keep some people alive indefinitely, there is considerable debate about the ethics of doing so. Perhaps people should be able to die with dignity when they no longer wish to live. Some say yes, others no. For psychologists, their stance is more clearly defined. Because suicide is an irreversible act, the professional ethics of psychologists require that they try to prevent people from harming themselves, even if this means breaking client-therapist confidentiality.

Crisis Intervention Crisis intervention is aimed at overcoming immediate problems. This is often done through telephone crisis lines and walk-in prevention centers that were first established in most cities in the 1960s. The counselors who answer these phones and who work in these centers have been taught to maintain contact with the person in crisis, develop a relationship, clarify the source of stress, and recommend an action plan—usually a place the person can go for help.

Psychological Interventions The first issue to be faced in the treatment of suicide is the potential for another attempt. If the likelihood seems high (and that is often difficult to judge), then the safest place for the person is in the hospital, even if this means involuntary commitment and breaking therapist-client confidentiality. Once the immediate danger subsides, treatment is usually aimed at overcom- ing any immediate life-stress and at teaching clients how to go about solving problems before they become hopeless. (See the accompanying Highlight.)

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Section 6.6 Suicide

Postvention Suicide has a shattering impact on the survivors (Piotrowski & Hartmann, 2017). Family and friends must cope not only with the death of a loved one but also with the circumstances of the death. Postvention (Shneidman, Farberow, & Litman, 1970) is aimed at helping relatives and friends cope with grief. Friends and relatives of a suicide victim often feel guilty and anxious because they believe that they should have done something to prevent the death. Sometimes they may become suicidal themselves (Piotrowski & Hartmann, 2017). Group therapy can sometimes help provide a supportive environment, but postvention involves more than just group therapy. Postvention also includes rumor control and identifying those people at high risk of imitation. A number of postvention programs have been developed, mainly for schools.

Highlight: Celebrities and Suicide

We can safely say that you know about Robin Williams. Perhaps you know of, or saw, Chris Cornell of Soundgarden. Maybe you know about Chester Bennington of Linkin Park. Robin Williams of course was a multitalented actor and comedian, while Cornell and Bennington were successful rock stars, front men for their bands. What is it that led these three men, as well as a number of other celebrities, to take their own lives? Fast (2017) has an interesting perspective. Many articles mentioned that Cornell and Bennington were tormented by “inner demons” and that they dealt with them through their music and singing, almost like a form of catharsis. Bennington was very candid about being sexually molested by a close friend from age 7 until 13, and he talked about how he never completely got past this history, leading to addictions, among other issues. Fast (2017) says that part of the problem is that we and the

media are too quick to characterize depression as fighting with inner demons, not recognizing it as an illness similar to diabetes or cancer. In other words, we are ascribing mythical aspects to a very real illness that affects tens of millions of people worldwide and that plays no favorites, multitalented or not. When people suffering from depression take their lives, they are doing so because of a treatable illness, not because of inner demons. Perhaps if more people understood this, lives could be saved through prevention, treatment, and education.HOME BOX OFFICE/SuperStock

Robin Williams took his own life in 2014.

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Chapter Summary

Chapter Summary • Mood disorders (depressive, bipolar, and related disorders) tend to occur most often

among people who have experienced a severe loss early in life. • Mood disorders run in families. • Pharmaceuticals, electroconvulsive therapy, and psychological treatments (alone or

in combination) seem to help shorten depressive and manic episodes and prevent relapses.

Emotions: Normal and Pathological • Emotions are normal. They help us survive. We flee from danger when afraid. Sad-

ness at parting cements parent-child bonds. Overwhelming fear or sadness can hinder normal life processes.

• Mood disorders (depressive, bipolar, and related disorders) tend to occur most often among people who have experienced a severe loss early in life.

• Mood disorders run in families.

Depressive (Unipolar) Disorders • Depression is marked by a sad mood, loss of interest in formerly pleasurable activi-

ties, sleep disturbances, changes in appetite, loss of interest in sex, irritability, inabil- ity to concentrate, and a wide variety of aches and pains.

• In adults, depression, physical illness, and substance abuse often go together. • In children, the most frequently reported comorbid conditions are disorders of

conduct. • Persistent depressive disorder (dysthymia) is a moderate depression that lasts two

years or more (one year in children and adolescents). • Depression is common, and the number of cases seems to be rising, especially

among young people. • Women are more than twice as likely to be depressed as men.

Bipolar and Related Disorders • Manic episodes are marked by an expansive mood, grandiosity, diminished sleep,

heightened sex drive, and rapid-fire speech. • Hypomanic episodes are similar to manic episodes but milder. • When the depressions are mild and mood is highly variable, the diagnosis is cyclo-

thymic disorder. • Bipolar disorders are less common than unipolar disorders and affect men and

women of different ethnic groups equally. • The first signs of bipolar disorder usually appear in early adulthood, but the inci-

dence of bipolar disorders seems to be rising among young people. • Typically, onset is sudden; follow-up studies have found the prognosis to be poor.

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Chapter Summary

Etiology of Mood Disorders • The response of some mood disorders to light therapy, the effectiveness of antide-

pressant drugs, the evidence for heredity, and the relationship between mood and hormonal imbalances are all compatible with a biological etiology.

• Psychoanalysts focus on the loss of affection and “fixation” in early childhood. • Behavioral theories emphasize learned helplessness and loss of reinforcement. • Cognitive theories focus on faulty attributions.

Treatment of Mood Disorders • Biological treatments for mood disorders cover a wide range and include drug

therapy, ECT, light treatment, and transcranial magnetic stimulation. • Psychological treatment attempts to teach people more effective ways of coping with


Suicide • Suicide is the tragic result of the complex interaction of social, psychological, and

biological forces. • People who take their own lives are seeking a solution to a problem, wish to end

consciousness, have intolerable psychological or physical pain, have frustrated psychological needs, feel hopeless, cannot see alternatives, and are “escapers” rather than problem solvers.

• Suicide is among the world’s top 10 causes of death and a common cause of death among young people.

• Divorced, widowed, and other single people have higher suicide rates than do mar- ried people; in all instances, more men than women take their own lives.

• Early life events, genetic predispositions, and psychological disorders all play some role in suicide, though none of these factors by itself is a good predictor of who will complete suicide.

• Crisis intervention is aimed at overcoming current problems and reducing the prob- ability of a suicide attempt; if the probability seems high, then the safest place for the person is in the hospital.

• Once the immediate danger subsides, cognitive-behavioral treatment can be used to teach clients how to go about solving problems before they become hopeless.

• Family therapy may also be useful in helping to improve family communication and joint problem solving.

• Postvention is aimed at helping relatives and friends cope with the grief of a suicide.

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Chapter Summary

Key Terms adjustment disorder with depressed mood A temporary reaction to a stressful circumstance.

anhedonia A loss of pleasure in all activi- ties; the inability to feel pleasure.

bipolar I disorder A mood disorder in which the individual’s moods fluctu- ate between mania (abnormal highs) and depression (lows).

bipolar II disorder A mood disorder in which the individual’s moods fluctu- ate between hypomania (a milder form of mania) and depression.

cyclothymic disorder When the individual cycles between hypomanic and mildly depressed moods.

depression An abnormally low mood state typically characterized by extreme sadness, lack of energy and sex drive, low self-worth, guilt, and oftentimes thoughts of suicide.

electroconvulsive therapy (ECT) A treat- ment for unipolar depression, where elec- tricity is passed through the brain to induce a seizure. ECT is used to treat depression in people who do not respond to drugs or psychological therapy.

hypomanic episode A milder form of a manic episode.

interpersonal psychotherapy (IPT) A mood disorder therapy aimed at helping cli- ents examine the ways in which their pres- ent social behavior keeps them from forming satisfactory interpersonal relationships.

learned helplessness When, based on past experiences, individuals determine that they have no control over the reinforcements and/or the stress in their lives.

lithium carbonate Lithium, a naturally occurring salt, used to treat bipolar disorder.

major depressive disorder A mood disor- der in which an individual has one or more major depressive episodes.

major depressive episode An episode of unipolar depression.

mania A state of extreme elation and giddi- ness, accompanied by excessive energy.

manic episode A condition characterized by extreme elation as well as other mania features. Left untreated, a manic episode might last six months.

Critical Thinking Questions

1. Based on what you have read, think about and discuss why it would be difficult to distinguish between unipolar depression and an adjustment disorder with depressed mood.

2. What, in your opinion, is the best method for treating unipolar depression? 3. Presume you have a friend who has bipolar I disorder. She tells you that she is on

lithium and has decided not to take it because she wants her “highs” to return and says that she is all better. Discuss what you would say to her based on what you have read and discussed in class.

4. Freudians believe that depression is anger turned inward and is also a result of a loss that occurred during childhood. Give your views on what causes depression.

5. If you had a friend who you thought was suicidal, how would you handle it, based on what you have read?

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Chapter Summary

MAO inhibitors (MAOIs) A type of antide- pressant medication typically used if other antidepressants are ineffective; an example is phenelzine (Nardil).

melancholia Hippocrates’s term for depression.

mixed episode A condition in which an individual has manic symptoms while also having a depressed mood.

mood disorder An abnormal condition characterized by persistent extremes of mood.

negative cognitive triad Attributions in which the individual has negative feelings about the self, the world, and the future.

persistent depressive disorder (dysthy- mia) A chronic, relatively mild, depressive disorder that lasts at least two years but may last for decades.

postpartum depression A unipolar depression that occurs in the four weeks fol- lowing childbirth.

postvention After a suicide, a program that is aimed at helping relatives and friends cope with grief.

rapid-cycling pattern The diagnosis given when an individual has at least four episodes of mania or depression within a 12-month time period.

selective serotonin reuptake inhibitor (SSRI) Medications that increase serotonin reuptake and thus increase the serotonin activity in the brain; typically used as antide- pressant medications; fluoxetine (Prozac) is an example.

suicide Self-inflicted death in which the person deliberately, consciously, and inten- tionally acted to kill himself or herself.

suicidology The study of suicide, suicidal behavior, and suicide prevention.

transcranial magnetic stimulation (TMS) A noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typically used when other depression treatments haven’t been effective.

tricyclic antidepressant (TCA) One of the earliest types of antidepressant medication classes; imipramine is an example.

unipolar mood disorder A mood disorder characterized by depression.

unspecified depressive disorder with seasonal pattern (seasonal affective disorder, or SAD) A seasonal mood disor- der that typically recurs at specific times of the year. Typically, people feel depressed in winter, improve in spring, and then become depressed again as autumn turns to winter.

with peripartum onset A diagnostic specifier used to designate an unspecified depressive disorder with onset either during pregnancy or in the four weeks following delivery.

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