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6 Depressive, Bipolar, and Related Disorders Chapter Objectives After reading this chapter, you should be able to:

• Explain what depressiv e, bipolar, and related disorders are.

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

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

• Analyze the rela tionship betw een depr essive, bipolar , and re lated disorder s and suicide. © Louie Psihoyos/Science Faction/Corbis get81325_06_c06.indd 139 12/5/13 3:33 PM Depressive, Bipolar, and Related Disorders The classic signs of depression include sadness, hopelessness, self-blame, anger, insom- nia, and loss of appetite. Depression is one of several depressive, bipolar, and related disorders, abnormal conditions characterized by persistent extremes of mood. Depres - sion represents one pole of a person’s mood (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 other pole, which is known as 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.

Figure 6.1: The mood spectrum Most of the time, we find ourselves in the middle, 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 actually cycle between depression and mania, and a few manage to be both depressed and manic at the same time.

Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 8.1, p. 319. Normal mood Joy Depression Mania The “blues” get81325_06_c06.indd 140 12/5/13 3:33 PM CHAPTER 6 Depressive, Bipolar, and Related Disorders Happily, most of us spend the bulk of our time somewhere in the middle of the mood spectrum, neither very high nor very low. A telephone con- versation, a walk in the park, or a dinner with friends can lift our mood. On the other hand, 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, energized, 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 to go to bed.

The main difference between the blues, an emo - tion we all experience, and a depressive disorder is one of degree (Flett, Vredenburg, & Krames, 1997). 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, cli - nicians begin to suspect the presence of a depres - sive disorder.

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

Before we continue, let us examine the case of Bernard Louis, a man whose manic epi - sodes severely affected his life. Illustration Works/Corbis 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. get81325_06_c06.indd 141 12/5/13 3:33 PM CHAPTER 6 Section 6.1 Emotions: Normal and Pathological Case Study: Bernard Louis, Part 1 Note Dictated by Psychiatrist, Dr. Kahn, When Admitting Bernard Louis to the Hospital UNIVERSITY HOSPITAL Intake Note CONFIDENTIAL 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.” 6.1 Emotions: Normal and Pathological Admirers of the original (and often-repeated) 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 pre - dicament, the other crewmembers would accuse Spock of being “inhuman.” To them, the essential characteristic 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 function of negative emotions, such \ as fear and sorrow?

Why did they evolve? Would we not be better off being unemotional like Spock? get81325_06_c06.indd 142 12/5/13 3:33 PM CHAPTER 6 Section 6.1 Emotions: Normal and Pathological As is the case with many questions surrounding evolution, the first place to look for answers is in the works of Charles Darwin (1809–1882). In his book The Expression 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 sad- ness, parents stay close to their children, thereby increasing 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 debili- tating that, instead of increasing a person’s chances of survival, they can actually decrease it.

Grieving The loss of a loved one or a friend usually sets off a grieving process. The first reaction is usually emotional numbness and disbelief punctuated with acute bouts of distress. Social support is an important determinant of how quickly, and how well, people cope with the grieving process (Kis - sane, McKenzie, & Bloch, 1997; Shear, 2006).

Within a week or so after a loss, disbelief is replaced with a period of pining for the lost person. The survivors dwell on their loss, have trouble sleeping, neglect other aspects of life, and display anger at their fate (“Why me?”). This stage ma\ y 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 sad - ness abates. The whole process may take a year or more and may involve significant periods of psychological distress. Still, the process is perfectly normal. In fact, not griev- ing 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 (Maciejewski, Zhang, Block, & Prigerson, 2007). I\ n 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. Mary Evans/PARAMOUNT PICTURES/ Ronald Grant/Everett Collection As Star Trek fans know, Mr. Spock differs from humans because he, as a half Vulcan, does not experience emotions. Sometimes his cold rationality is an advantage, but at other times his lack of emotion cuts him off from intuition and social connection. get81325_06_c06.indd 143 12/5/13 3:34 PM CHAPTER 6 Section 6.1 Emotions: Normal and Pathological 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 griev- ing process. In the DSM-IV-TR (APA, 2000), psychologists, psychiatrists, and psychiatric social work- ers were advised (by the authors of the DSM-IV-TR) to not diagnose major depression in individuals within the first two months following the death of a loved one. This has been called the “bereave- ment 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 unipo- lar (major depressive disorder) was not overlooked and that appropriate treatment could be imple- mented 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 grieving, self- esteem (positive feelings about yourself) is usually maintained, while in MDD feelings of worthless- ness and self-loathing are common. Normal grieving can lead to MDD, but clinicians are cautioned to not 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 opponents say the risk is that of pathologizing a normal human process, grief. Individuals may be diagnosed with depression even in the absence of severe depressive symptoms (such as suicidal ide- ation) and even though their symptoms may be transient. Therefore we can conclude the following: a person who meets the diagnostic criteria for major depressive disorder (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/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? 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 called Mood Disorders. The DSM-5 has divided the categories into 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 depression, whereas bipolar disorders combine depression with manic periods. Both unipolar and 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 get81325_06_c06.indd 144 12/5/13 3:34 PM CHAPTER 6 Section 6.2 Depressive (Unipolar) Disorders are divided into bipolar I disorder, which mixes depression and mania, bipolar II disorder (depression and hypomanic episodes, or episodes that do not cause as much impairment as manic episodes), and cyclothymic 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 melan- chole, 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 proven this to be incorrect, the idea that depression is caused by a chemical 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 disorder for the U.S. work- place average about $36.6 billion (Kessler et al., 2006). The overall costs of treating depression are estimated to be $83.1 billion per year (Greenberg et al., 2003).

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 (McClure, Rogeness, & Thompson, 1997; Rosal, Ockene, Barrett, et al., 1997). Typically, these feelings begin with a reaction to some stressful life circumstance (losing one’s job, for example). If these feelings dissipate within six months after the stressor or its consequences end, the DSM-5 labels them an adjustment disorder with depressed mood—a transient reaction to a stressful circumstance. A major depressive episode may appear superfi- cially similar to an adjustment disorder, but it is more extreme. © Bettmann/CORBIS In approximately 5th century BC, 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 medicine, it contributed to the possibility that depression is caused by a chemical imbalance. get81325_06_c06.indd 145 12/5/13 3:34 PM CHAPTER 6 Section 6.2 Depressive (Unipolar) Disorders Major Depressive Episodes Major depressive episodes are part of the diagnostic criteria for bipolar I disorder. While 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 existence—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. Sufferers 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.

Figure 6.2: Depression This graph shows how depression affects the daily relationship between parent and child. Nondepressed parents are more likely to show affection and cultivate a creative environment for their children.

Source: Adapted from Princeton Survey Research Associates, 1996, as appears in Corner, R. J. 2007. Abnormal Psychology. 6e. NY:

Worth Publishers, Fig. 8.1, p. 235. Pe rcentage Who Act This Way Every Day Parent Behavior Yell at child sometimes or of ten Get frustrated with child 010203040506070809 0100 Employ set routine (e.g., bedtime) with child Read to child Sing or play music with child Hug and cuddle child Play with child 87% 72% 90% 80% 43% 27% 61% 54% 58% 31% 64% 78% 34% 51% Nondepr essed par ents Depr essed parents ND N D N D N D N D N D N D N D get81325_06_c06.indd 146 12/5/13 3:34 PM CHAPTER 6 Section 6.2 Depressive (Unipolar) Disorders 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. (On the other hand, 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 disturbance, loss of sex drive, fatigue) is what distinguishes a \ major depressive epi- sode from less severe forms of depression (Rottenberg, Gross, & Gotlib, 2005).

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 (Taube-Schiff & Lau, 2008). Depressed people have difficulty concentrating on cognitive tasks (Bremner, Vythilingham, Vermetten, Vaccarino, & Charney, 2004). They tend to see the downside of everything, dwelling on their failures and ignoring their successes. Because of their pessimism, they lose motivation. Depressed people judge themselves to be less liked and less capable than other people rate them (Gotlib & Hammen, 1992). In c\ hildren and ado - lescents, 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 developmental stages (Garber & Carter, 2006).

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 (Hammen, 1991). (See Table 6.1 for a summary of the diagnos - tic criteria for major depressive disorder.) 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 represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition 1. Depressed mood most of the day, 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 (continued) get81325_06_c06.indd 147 12/5/13 3:34 PM CHAPTER 6 Section 6.2 Depressive (Unipolar) Disorders Table 6.1: DSM-5 diagnostic criteria for a major depressive disorder (continued) 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 important 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 schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. Source: American Psychiatric Association (2013, pp. 160–161).

Depression and physical symptoms often go together: for instance, headaches,\ dizzy spells, and general pain have been associated with depression (Fishbain, 2000).

In addition to co-morbid physical conditions, there is considerable psychological co- morbidity as well. Depressed children frequently display other problems, especially unruly misbehavior and conduct disorder (Lewinsohn, Rohde, & Seeley, 1993). 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 (Uliaszek et \ al., 2011) get81325_06_c06.indd 148 12/5/13 3:34 PM CHAPTER 6 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 (Klein, Shan\ kman, & Rose, 2006).

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 disap - pear completely 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 dysthymic disorder require the presence of at least two specific depressive symptoms.

Prevalence and Course of Depressive Disorders Clinical depression is the “common cold” of psychological disorders (Gotlib, 1992). About 17% of the U.S. population will experience a major depressive episode sometime in their lives (Taube-Schiff & Lau, 2008). About 121 million people worldwide suffer from depres - sion, and the number of cases seems to be rising in most countries, putt\ ing considerable pressure on health expenditures (World Health Organization [WHO], 2011). The wide - spread use of psychoactive substances, mass international migrations, the b\ reakdown 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 et al., 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, Good - win, 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 (Taube- Schiff & Lau, 2008). 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 (Brommelhoff, Conway, Merikangas, & Levy, 2004). Depressed men presum- ably cope in other ways such as hiding behind anger, but these theories have not received much support (McSweeney, 2004).

If females seek psychological help more often than males, we would expect to find more females than men in all of the DSM–5 diag- nostic groups. Because we do not, iStockphoto/Thinkstock Commonly, women are more likely to be diagnosed with depression than men. There are several explanations for this statistic, yet all possibilities are still under debate. get81325_06_c06.indd 149 12/5/13 3:34 PM CHAPTER 6 Section 6.3 Bipolar and Related Disorders alternative explanations have been offered that specifically target depression. For exam- ple, 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 ruminate on this more than men, who tend to ignore their feelings (Nolen-Hoeksema, 2000). Instead of being diagnosed as depressed, men are diagnosed as substance abusers or as suffering from an antisocial personality disorder (antisocial personality disorders are discussed in Chapter 9).

In the Pennsylvania Amish (where all women work), depression is equally common in both sexes (Egeland, Gerhard, Pauls, et al., 1987). This study has not been replicated (Craddock & Jones, 2001). 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 (Hasin et al., 2005). In addition Latinos have highe\ r rates of depres - sion than African Americans, with Asians having the lowest rate of those ethnic groups sampled (Alegria, Canino, Shrout, Woo, Duan, Vila, et al., 2008).

6.3 Bipolar and Related Disorders Although it is possible to experience manic episodes without any periods\ of depression, clinicians dating back to ancient Greece have noted that this is exceedingly rare. In the vast majority 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 conveys a similar picture: episodes of elevated mood (one pole) alternating with periods of depression (the other pole).

(See Part 2 of the Bernard Louis case study in your e-book.) Manic, Hypomanic, and Mixed Episodes The hallmark of a manic epi- sode is an overly elevated mood.

Manic people feel high and excited, although, like Bernard Louis, they are also easily irri - tated. In addition to an expan- sive mood, manic episodes are marked by grandiosity. In the grip of mania, people believe that they have unusual abilities and that they can accomplish anything. Convinced of their iStockphoto/Thinkstock Bipolar disorders are characterized by feelings of extreme elation followed by depression. Individuals suffering from bipolar disorders, like manic-depressive disorder, usually experience symptoms around age 18. get81325_06_c06.indd 150 12/5/13 3:34 PM CHAPTER 6 Section 6.3 Bipolar and Related Disorders 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.

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 projects but do not see them through to completion. Not only are their thoughts rapid and unfocused, but their physical activities are also energized and chaotic. They have little need for sleep, and their sex drive is heightened. Manic individu\ als speak quickly and rarely fall silent. Their speech is so rapid, and they switch topics so oft\ en, 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 attributable to the physiological effects of a substance, or to another medical condition. Source: Adapted from American Psychiatric Association (2013, p. 124).

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 hypo - manic episode, which is marked by an elated mood, little need for sleep,\ and intense periods of activity. 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. get81325_06_c06.indd 151 12/5/13 3:34 PM CHAPTER 6 Section 6.3 Bipolar and Related Disorders Specific Bipolar Disorders There are three main bipolar disorders: 1. 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. 2. Bipolar II disorder is characterized by recurrent major depressive episodes and at least one hypomanic episode. 3. 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 peri- ods of normal moods.

There is a high co-morbidity between bipolar disorders and substance abuse, but the rea - sons for this remain unclear (Bizzarri et al., 2007). Because substances such as coca\ ine 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 preva - lence rate at 1.8% in the U.S. population, with a prevalence rate of 2.7% in children ages 12 and up (APA, 2013). Between 1% and 2.6% of all adults will develop a bipolar diso\ rder in his or her lifetime (Merikangas et al., 2007). Although it is not the case with unipolar disor - ders, men and women are equally likely to be diagnosed with a bipolar disorder (Depres - sion Perception, 2010; APA, 2013). Many famous people have allegedly suffered from bipolar disorders (from Herman Melville, 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 et al., 2010). Although some people with bipolar dis- order have only a few manic episodes over the course of their lives, others, known as rapid cyclers, can have four or more episodes of mania, hypomania, or major depression in a single year (APA, 2013). © Bettmann/CORBIS American author Ernest Hemingway allegedly suffered from a bipolar disorder. get81325_06_c06.indd 152 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders The first signs of bipolar disorder usually appear from ages 19 to 22 and appear rather suddenly (Angst et al., 2009). Bipolar disorder 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 is common, and social and occupational functioning becomes progressively worse over the years (Angst & Sel- laro, 2000).

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 pre-existing factors, including low self-esteem (Fontaine & Jones, 1997). The specifier “with peripartum onset” is used to designate an unspecified depressive disorder that onsets either during pregnancy or in the four weeks following delivery (APA, 2013).

Premenstrual dysphoric disorder (more commonly referred to as premenstrual syndrome or PMS) was moved from the DSM-IV-TR’s Appen- dix 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 to name a few (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. It should be noted that the etiology of bipola\ r disorders remains poorly understood.

Genetic Factors Although the diagnostic criteria for mood disorders have been repeatedly revised, the research data accumulated over the past 10+ years strongly suggest that these disorders run in families (Richard & Lyness, 2006; Carlson, 2008; Taube-Schiff & Lau, 2008). Cubo Images/SuperStock Painter Vincent van Gogh was also thought to suffer from bipolar disorder. Van Gogh voluntarily entered a sanatorium in 1889 and completed this self-portrait during the year he spent there. get81325_06_c06.indd 153 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders Most studies have found that first-degree relatives (parents, siblings, and children) of peo- ple with mood disorders are more likely to have mood disorders themselves than are peo - ple without affected relatives (McGuffin, Rijsdijk, Andrew, Sham, Katz, & Cardno, 2003). (See Part 3 of the Bernard Louis case study in your e-book.) Searches for the gene or genes responsible for mood disorders began with a search for specific genetic markers, genetic mate- rial present in relatives with mood disorders. Finding such material requires two important ingredients: technology capable of identifying parts of chromo - somes and a sufficiently large number of affected family mem - bers who can be studied over several generations.

The Amish are a close-knit group whose members seldom leave or marry outside their Source: From R. Katz and McGuffin (1993) and various epidemiological studi\ es, as appears in Schwartz, S. 2000. Abnormal Psychology:

A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Table 8.6, p. 334.

Figure 6.3: Mood disorders Major depression Bipolar disorder No disorder (general population) Note: From R. Katz and McGuffin (1993) and va rious epidemiological studies. 0.6 7.8 <1 9.1 11.4 8 Patient’s disorder Pe rcentage of relatives with Major depressive disorder Bipolar disorder A verage Risk f or Mood Disorders in First-Degree Relatives of People With Mood Disorders Photononstop/Superstock Researchers believe the causes of mood disorders 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. get81325_06_c06.indd 154 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders community. It is also helpful that the Amish eschew drugs and alcohol. This means that their mood disorders cannot be attributed to substances. Studies of Amish families with a high prevalence of mood disorders claimed to find a genetic marker (Egeland et al., 1987), but these results have proved difficult to replicate (Berrettini, Goldin, Gelernter, et al., 1990). Nevertheless, given the accumulated data, it seems reasonable to conclude that genetics plays a role in rendering people susceptible to mood disorders (Garlow, Boone, Li, Owens, & Nemeroff, 2003).

What Is Inherited?

If genetics plays a role in the development of mood disorders, then it follows that sufferers 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 episodes. Because reserpine was thought to reduce the level of a neurotransmitter known as norepinephrine, researchers hypothesized that depression might be the result of dimin- ished 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 they 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. get81325_06_c06.indd 155 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders Figure 6.4: 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.

From Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig. 8.3, p. 336. Neurotransmitter diffuses and is metabolized and/or transported back into presynaptic neuron. Postsynaptic neuron C 2 2+ Synaptic cleft Tr anspor ter Precursor Pr esynaptic neuron Neurotransmit ter Neurotransmit ter molecules Neurotransmit ter is synthesized in presynaptic neuron Neurotransmit ter is packaged into vesicles.

Neurotransmit ter is released when vesicles fuse with cell membrane.

Neurotransmit ter binds to and activates postsynaptic receptors Biosynthetic enzymes 1 2 4 5 3 Ultimately, scientists discovered that iproniazid, like reserpine, affects neurotransmitter levels. Specifically, iproniazid inhibits the activity of an enzyme known as monoamine get81325_06_c06.indd 156 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders oxidase (MAO), a chemical that plays a crucial role in neurotransmitter regulation. MAO facilitates the chemical breakdown and reuptake of neurotransmitters such as nor - epinephrine, dopamine, and serotonin after they have done their job. Because iproniazid inhibits the activity of MAO, it slows the reuptake process. The result is a higher concen - tration of norepinephrine.

Pharmaceutical companies rushed to market other MAO inhibitors (MAOIs). Unfor- tunately, these drugs had a serious drawback; they interact with certain foods to cause such potentially life-threatening conditions as stroke. This is why MAO inhibitors have been largely abandoned in favor of much less lethal antidepressant drugs such as Prozac (fluoxetine) and Zoloft (sertraline). (See Thase, 2005, for further\ discussion of low sero - tonin levels being implicated in unipolar depression).

Psychosocial Factors Although there is clear evidence that genetics 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% (concordance rate refers to the proportion of iden- tical twins in a random sample where both individuals share a certain characteristic; McGuffin et al., 2003). Thus, the environ - ment must also play a role in determining who develops a mood disorder. In this section, we look at how psychoanalytic, behavioral, cognitive, and social psychol\ ogists explain how stress interacts with pre-existing vulnerabilities to produce mood disorders.

Psychoanalytic Views According to Freud (1917/1959b) and his followers, depression is a form of grief pro- duced 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 establish\ ed early in life, usu - ally 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 caretakers 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. James Woodson/Digital Vision/Thinkstock Although genetics plays a role in mood disorders, an individual’s environment is also important when determining the cause of a mood disorder. get81325_06_c06.indd 157 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders Psychoanalysts now believe that mood disorders can be traced back not just to the loss of parental affection, but to the loss, early in life, of any person who was of specia\ l impor- tance to the child (Blatt & Zuroff, 1992). Related to this is the concept that often stressful life events will lead to a mood disorder (Hammen, 2005).

Behavioral Views Behavioral psychologists originally emphasized the loss of important relationships in the etiology 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 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 behav- iors can potentially lead to the loss of reinforcers and, therefore, to depression (Hammen, 2005).

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 becomin\ g 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 attributions. 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 distorted 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, cogniti\ ve psychologists make room for individual differences in their theory. The main tenet of the cognitive view is indisputable; the research evidence showing that depressed people are self-critical is overwhelming (Garber & Carter, 2006).

Learned Helplessness In contrast to Beck’s cognitive theory, which was derived from clinical observations, Martin Seligman’s theory of learned helplessness was originally derived from animal research (Seligman, 1975). In the typical experiment, dogs were confined in a box with an get81325_06_c06.indd 158 12/5/13 3:34 PM CHAPTER 6 Section 6.4 Etiology of Mood Disorders 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 par\ tition. One side of the box had an electrified floor; the other did not. Once again electric\ shocks were deliv- ered 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 whenever they heard or saw the signal (Figure 6.5). 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 fe\ eling 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 sim- ply learned to act helpless.

Figure 6.5: 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.

From Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig. 6.6, p. 343. get81325_06_c06.indd 159 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders Seligman noted parallels between the animal research and human depression. For exam- ple, many depressed people have experienced tragedy and loss over which they have had \ no control. 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. Accord - ing to the revised theory, we attribute our failures and losses to either internal or exter - nal 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), on the other hand, 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 (Alloy & Abramson, 2007). Interpersonal and Social Support As we have seen, loss and stress- ful 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 (Wang, Wang, & Shen, 2006). Recovery from depression can be accelerated by strong social support (Sherbourne, Hays, & Wells, 1995). This is why mood disorders are less likely among people who have strong social sup - port networks (Kendler, Kuhn, Vittum, Prescott, & Riley, 2005). 6.5 Treatment of Mood Disorders As mentioned earlier, Hippocrates believed that depression was caused by the supposed excess of black bile in the spleen. Bloodletting, the administration of \ drugs that caused vomiting 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 (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005). Hemera/Thinkstock Stressful life events are commonly associated with mood disorders, but a strong social support group, like family or friends, can minimize the effects of life events. get81325_06_c06.indd 160 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders 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 treat- ment is the administration of mood-altering drugs.

Drug Treatment As mentioned earlier, MAO inhibitors’ side effects are too serious to make them the drug of first choice. MAO inhibitors were first replaced by imipramine, which was originally syn - thesized to treat schizophrenia. It did not do much to help the symptoms of schizophrenia, but it did seem to lift people’s depression. Thus, by accident rather than by design, imipra - mine became the first in a series of tricyclic antidepressants. 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. Specifi - cally, they block the proteins that transport neurotransmitter residues back to synaptic ter - minals. This keeps the neurotransmitters from being reabsorbed, thereby increasing their level (Virani, Bezchlibnyk-Butler, & Jeffries, 2009).

More recent drugs have targeted another neurotransmitter, serotonin. Prozac (fluoxetine), for example, is an antidepressant drug that blocks the reuptake of serotonin (thereby increasing serotonin levels) while leaving other neurotransmitters unaffected. Fluoxetine and related drugs are known as selective serotonin reuptake inhibitors (SSRIs) . The drug has become popular because it not only is effective against depression but also has rela- tively mild side effects, such as increased agitation, lowered libido, insomnia, and stom - ach upset (Virani et al., 2009).

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 ben - efits. 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 (Hughes, Morris, & McGuire, 1997).

Because most depressions eventually lift whether they are treated or not, the main goal of drug treatment is to hasten recovery and prevent recurrence (National Institute of Mental Health [NIMH], 2003). The latter goal may require that patients be given “maintenance” doses of antidepressant medication for prolonged periods lasting months or even years Hemera/Thinkstock Modern drug treatments focus on blocking the reuptake of serotonin, or SSRIs. These drugs increase serotonin levels and are effective against depression with minimal side effects. get81325_06_c06.indd 161 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders (Insel, 2006). Antidepressants do not “cure” depression and recurrences may still occur, even among those treated with maintenance doses (NIMH, 2003).

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 bio- chemical 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. Nothing 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 concluded that it was the lithium that was calming down the animals.

Cade himself took lithium first and, noting no ill effects, he tried lithium out 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, lith- ium 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 recur - rence 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 medi - cation 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). Oth - ers forego lithium because of its side effects: diarrhea, stomach upset, weakness, and fre - quent urination. In high dosages, lithium can even be fatal. Ensuring pa\ tient compliance is especially important because discontinuing lithium actually increases the probability of a manic episode. In other words, discontinuing lithium is not recommended as relapse may occur (Yatham et al., 2006).

Anticonvulsant medications normally used to treat seizures have also been used to treat bipolar disorder (Goodwin, Fireman, Simon, Hunkeler, Lee, & Revicki, 2003). When an individual has at least four episodes of mania or depression within a 12-month time period, they are specified as having a rapid-cycling pattern. This type of bipolar disorder is quite difficult to effectively treat (e.g., Ozcan, Shivakumar, & Suppes, 2006); neverthe - less, anticonvulsants have shown some efficacy for this group (Kilzieh & Akiskal, 1999).

Electroconvulsive Therapy Electroconvulsive therapy (ECT) was first introduced in the 1930s. ECT involves sending electrical impulses through the brain with the goal of inducing a seizure. Like many drug treatments, 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 get81325_06_c06.indd 162 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders of insulin required to produce a seizure without inflicting seri- ous harm or even killing the patient, clinicians experimented 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, antidepressant medi- cations made the use of ECTs less warranted (Cauchon, 1995).

By the 1970s, however, it began to make a comeback. Today, ECT is used for depressed people who do not respond to drugs or psychological therapy.

Today’s ECT patients are given a general anesthetic so they are not conscious during the procedure. They also receive drugs that inhibit body move - ments. Electrodes 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 ability (Abrams, Swartz, & Vedak, 1991). 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 bring a rapid clearing of a depression without the need to wait the weeks that are required with drugs or psychotherapy (Nemeroff, 2006). 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.

People with Seasonal Affective Disorder (SAD) , unipolar depression that occurs only during a particular time of year, are exposed to a few hours of bright light every morn - ing (Dalgleish, Rosen, & Marks, 1996). The light is designed to mimic \ the spectrum of sunlight. In any event, side effects are rare, although exposure to light may cause eye - strain and headache (Levitt, Joffe, Moul, et al., 1993). Brooks/Brown/Getty Images This early electroconvulsive therapy machine was first used in the 1930s and by the 1970s, ECT treatment was administered to patients who failed to respond to drugs or therapy. get81325_06_c06.indd 163 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders Psychological Treatments Medications, light, and ECT are aimed at alleviating the symptoms of depression. They do not teach people prone to depression how to cope with the loss of a loved one, unem- ployment, or any of the other triggers of depression. Psychological treatment, on the other hand, is designed to help people learn more effective ways of behaving. Most psycho - logical 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).

Psychoanalytic and Interpersonal Treatment Psychoanalytic treatment is designed to help patients achieve insight into the repressed conflicts 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 per - son to release the inwardly directed hostility and, through this catharsis, eliminate their inner-directed anger.

Figure 6.6: Prevalence of seasonal affective disorder by latitude SAD occurs less often at latitudes with longer hours of sunlight and more often farther north.

Source: Data from Rosen et al., 1990, from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA:

Mayfield Publishing Company, Fig. 8.5, p. 340. Ne wY ork AL MS TX CA NV OR WA ID MT WY UT AZ NM MEXICO CANADA OK KS CO NE SD ND WI MN IL IA MOAR LA GA Sarasota Atlantic Ocean Pacific Ocean FL SC NC TN KY MI IN OH PANY WV VA ME VT MA NH RI MD DENJ CT 0 0 250 Miles 27.0° 39.0° 40.5° 42.5° 250 Kilometers 42.5°: Nashua, NH 40.5°: Ne wYork, NY 39.0°: Montgomery County, MD 27.0°: Sarasota, FL Montgomery County Nashua 20.7% 17.2% 16.7% 4.0% get81325_06_c06.indd 164 12/5/13 3:34 PM CHAPTER 6 Section 6.5 Treatment of Mood Disorders 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 form - ing satisfactory interpersonal relationships (Weissman, 1995; Kendler, Hettema, Butera, Gardner, & Prescott, 2003). Instead of focusing on the past, IPT is concerned with t\ he 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 assertive - ness 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 iden\ tify self-critical and negative thoughts, to note the connection between such thoughts and \ depression, and to challenge 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 aer - obic exercise (such as spinning or aqua-aerobics) can help them understand and control their depression and lead to better relapse prevention (Babyak et al., 2000).

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 treatment and interpersonal treatment reduce the probability of a relapse (Hollon, DeRubeis, Evans, 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 (Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2004). One reason for this is that people in psychotherapy are more likely to take their drugs regularly (Paykel, 1995).

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 professionals also contribute to undertreatment. Many medical practitioners are poorly informed about mood disorders and the benefits of treatment (Shao, Wil - liams, Lee, et al., 1997). 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 dis - orders are not the only cause of suicide. (See Part 4 of the Bernard Louis case study in your e-book.) get81325_06_c06.indd 165 12/5/13 3:34 PM CHAPTER 6 Section 6.6 Suicide 6.6 Suicide Suicide, self-inflicted death where the person deliberately, consciously, and intentionally acted to kill themselves, 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. However, today, even though our social views in the United States are con - sidered more tolerant, suicide is often considered a social disgrace. Suicidal behavior is surrounded by many myths. Some of these are highlighted here.

Highlight: Suicide Myths and Reality Over the centuries, myths have developed around suicide. Some of the more prevalent myths, and the corresponding realities, follow. Suicide Myth Suicide Reality Those who talk about suicide never do it. The vast majority of suicides give some warning.

Suicide is related to social class. People of all social and educational classes commit suicide. Highly educated people, such as doctors, have among the highest suicide rates (North & Ryall, 1997).

Everyone who commits suicide is depressed. Many people who commit suicide 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 suicides 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 normal 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 note that anywhere from 25–30% of those who attempt suicide will make more attempts (APA, 2013).

Those who unsuccessfully attempt suicide were never serious. Some people are poorly informed about the lethality of different acts. Suicidology (the study of suicide) has become a scientific field in its own right\ . Still, many people who take their own lives do suffer from a mental disorder (Joe, Baser, Breeden, Neighbors, & Jackson, 2006). Because suicide is frequently associated with depression, it has been included in this chapter. get81325_06_c06.indd 166 12/5/13 3:34 PM CHAPTER 6 Section 6.6 Suicide Prevalence and Incidence Suicide is universal and has occurred throughout history. It is among the top 11 causes of death in the United States and a common cause of death among young peopl\ e (Suicide .org, 2011). The reported suicide rate in the United States is 32,000 per year; the actual\ number is probably higher (Centers for Disease Control and Prevention [CDC], 2005).

Many suicides go unreported because of the ambiguity surrounding the death or because they are covered up by families trying to avoid social stigma (Bongar, 1991). Although suicide occurs everywhere, cross-cultural comparisons are difficult because cultures may record suicides differently, based on how suicide is treated in that person’s culture.

Figure 6.7: Suicide facts According to recent research, there is a large disparity between the demographics, means, and setting of suicide attempters versus suicide completers.

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

Sex Age Means Diagnosis SettingFemale Under 35 Low lethality (pills) None or rare Public, easy to disco ver Male Over 60 High lethality (firearms) Depression; substance abuse Private and isolated Characteristic Attempters Completers Suicide Attempts Versus Suicide Completers 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 uncommon among older per - sons (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 particularly 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 remarkably 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. © Joe Giron/CORBIS Rock musician Kurt Cobain, of the 1990s band Nirvana, committed suicide on April 5, 1994. Cobain suffered from depression and also had severe issues coping with worldwide media attention. get81325_06_c06.indd 167 12/5/13 3:34 PM CHAPTER 6 Section 6.6 Suicide Assessing Suicidal Intentions It is not easy to predict who will commit suicide; many suicides seem to happen without prior warning (Apter, Bleich, King, et al., 1993; Maris, Berman, Maltsberger, & Yuflt, 1992).

Nevertheless, suicidologists have been able to identify a set of risk fa\ ctors that seem to be correlated with suicide (see Table 6.4).

Table 6.4: Risk factors and suicide FactorLow RiskHigh Risk Sex FemaleMale Marital status Married Single/divorced/living alone AgeMiddle years Adolescence/old age Psychiatric status Normal/character disorders/ situational disturbances Depression/alcoholism/ conduct disorder/schizophrenia SettingRuralUrban/prisons Assault victim No history Multiple physical and sexual assaults Religious activity Regular churchgoer Non-churchgoer Nationality Italian/Dutch/SpanishScandinavian/Japanese/ German-speaking countries Source: Adapted from Nock & Kessler, (2006); Nock et al., (2008); Stevenson, Hudgens, & Held (1972).

Causes of Suicide The motive for committing suicide varies from person to person (Maris, 1992). Some sui - cides 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 certain com - monalities 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 alternatives, and are “escapers” rather than problem solvers. get81325_06_c06.indd 168 12/5/13 3:34 PM CHAPTER 6 Section 6.6 Suicide Figure 6.8: Threshold model for suicidal behavior Source: Adapted from 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. Rep\ rinted with kind permission of Springer Science + Business Media. Suicidal behavior Risk factors Protective factors Precipitating factors Environmentalfactors/suicide exposure Cognitive flexibility Strong social support Hopefulness No losses Lack of precipitating life ev ents Treatment of psychiatric disorder Treatment of personality disorder Av ailability of method Humiliating precipitating life ev ent Threshold Vulnerability for suicidal behavior Psychiatric diagnosis Genetic/family history Biological factors (for example, SHIAA, perinatal factors) Personality traits (for example,impulsivity) Predisposing risk factors Psychological Disorders and Suicide A psychological disorder, usually a bipolar disorder or a major depression, appears in the history of many cases of suicide (Joe, Romer, & Jamieson, 2007; Shneidman, 1992).

Interestingly, people rarely attempt suicide while in the depths of depression. The year following a major depressive episode is the most dangerous period (Klerman, 1982), per - haps 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 suicide more likely. The presence of a psychological disorder, such as depression, com - bined with the poor judgment and reduced inhibition produced by alcohol create a lethal combination (Lejoyeux, Huet, Claudon, Fichelle, Casalino, & Lequen, 200\ 8). get81325_06_c06.indd 169 12/5/13 3:34 PM CHAPTER 6 Section 6.6 Suicide Psychological Factors Freud and his followers construe suicide as a form of murderous anger at another per- son 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.

Despite the confirmation of early loss in the childhood of many suicides\ , the overall evi - dence 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 that people take their own lives (Shneidman, 1992). Shame, guilt, and hopelessness\ are considerably more common motives. Hopelessness is particularly important (Shneidman, 20\ 05; Sadock & Sadock, 2007).

Genetics and Physiology Suicide, like depression, tends to run in families (Mann, Nortinger, Oquendo, Currier, Li, & Brent, 2005). The concordance rate for suicide among monozygotic twins is 20 times higher than it is among dizygotic twins (Roy, Segal, Centerwall, & Robinette, 1991).

Because most suicidal twins are also depressed (or suffering from some other mental disorder), it may be their 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 psycholog\ ists, 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 get81325_06_c06.indd 170 12/5/13 3:34 PM CHAPTER 6 Chapter Summary therapist-client confidentiality. Once the immediate danger subsides, treatment is usually aimed at overcoming any immediate life-stress and at teaching clients how to go about solving problems before they become hopeless.

Postvention Suicide has a shattering impact on the survivors (Lukas & Seiden, 1990; Ross, 1997). Fam- ily and friends must cope not only with the death of a loved one but als\ o with the cir - cumstances 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 (Ness & \ Pfeffer, 1990). Group therapy can sometimes help provide a supportive environment, but post - vention 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.

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 pre- vent relapses. Symptoms and Signs of Major Depressive Episodes and Disorders • Depression is marked by a sad mood, loss of interest in formerly pleasurable activities, sleep disturbances, changes in appetite, loss of interest in sex, irritabil - ity, inability 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 co-morbid 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). Prevalence and Course of Depressive Disorders • 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. Symptoms and Signs of Bipolar 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 cyclothymic disorder. get81325_06_c06.indd 171 12/5/13 3:34 PM CHAPTER 6 Chapter Summary Prevalence and Course of Bipolar Disorders • 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. Etiology of Mood Disorders • The response of some mood disorders to light therapy, the effectiveness of anti - depressant 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 ECT, light treatment, sleep deprivation, and the administration of mood-altering drugs. • Psychological treatment attempts to teach people more effective ways of coping with problems. 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 11 causes of death and a common cause of death among young people. • Divorced, widowed, and other single people have higher suicide rates than do \ married people. • In all instances, more men than women take their own lives. Causes of Suicide • One of the reasons that it is so difficult to understand suicide is the large number of possible causes. • Early life events, genetic predispositions, and psychological disorders all play some role. • None of these factors by itself is a good predictor of who will commit suicide. Treatment of Suicide • Crisis intervention is aimed at overcoming current problems and reducing the probability of a suicide attempt. • If the probability seems high, then the safest place for the person is in the hos\ pital. • 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. get81325_06_c06.indd 172 12/5/13 3:34 PM CHAPTER 6 Key Terms Prevention and Postvention of Suicide • Postvention is aimed at helping relatives and friends cope with the grief of a suicide. 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 to use to treat 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 “high\ s” 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 i\ t, based on what you have read? 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 where the individual’s moods fluctuate between mania (abnormal highs) and depression (lows). bipolar II disorder A mood disorder where the individual’s moods fluctuate between hypomania (a milder form of mania) and depression. cyclothymic disorder When the individ- ual 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 electricity is passed through the brain to induce a seizure. ECT is used for depressed 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 help- ing clients examine the ways in which their present social behavior keeps them from forming satisfactory interpersonal relationships. learned helplessness A theory that states that, based on past experiences, an indi- vidual has no control over their reinforce- ments and/or over the stress in their lives. lithium carbonate Lithium, a natu- rally occurring salt, used to treat bipolar disorder. get81325_06_c06.indd 173 12/5/13 3:34 PM CHAPTER 6 Key Terms major depressive disorder Diagnosis when an individual has one or more major depressive episodes. major depressive episode An episode of unipolar depression. mania A state of extreme elation and gid- diness, accompanied by excessive energy. manic episode Condition characterized by extreme elation as well as other mania features. Left untreated, a manic episode might last six months.

MAO inhibitor (monoamine oxidase inhibitor) One type of antidepressant medication typically used if other antide- pressants are ineffective; one type is Nardil. melancholia Hippocrates’s term for depression. mixed episode Diagnosis when an indi- vidual has manic symptoms while also having a depressed mood. mood disorders Abnormal conditions char - acterized by persistent extremes of mood. negative cognitive triad Diagnosis when the individual has negative feelings about the self, the world, and the future. peripartum onset A diagnostic specifier used to designate an unspecified depres- sive disorder that onsets either during pregnancy or in the four weeks following delivery. persistent depressive disorder (dysthymia) A chronic, relatively mild, depressive disor - der that lasts at least two years but may last for decades. postpartum depression Unipolar depres - sion that occurs in the 4 weeks following childbirth.

postvention After a suicide, a program that is aimed at helping relatives and friends cope with grief. rapid-cycling pattern Diagnosis when an individual has at least four episodes of mania or depression within a 12-month time period. seasonal affective disorder (SAD) A sea- sonal mood disorder 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.

selective serotonin reuptake inhibitor (SSRI) Medications that increase sero- tonin reuptake and thus increase the sero- tonin activity in the brain; typically used as antidepressant medications; Prozac is an example. suicide Self-inflicted death where the person deliberately, consciously, and inten- tionally acted to kill themselves. suicidology The study of suicide. tricyclic antidepressant One of the earli- est types of antidepressant medication classes; imipramine is an example. unipolar mood disorder A mood disorder characterized by depression. get81325_06_c06.indd 174 12/5/13 3:34 PM CHAPTER 6