AP Psychology

Module 67 – Mood Disorders

LEARNING OBJECTIVES:
FOCUS QUESTION: What are mood disorders? How does major depressive disorder differ from bipolar disorder?

The emotional extremes of mood disorders come in two principal forms: (1) major depressive disorder, with its prolonged hopelessness and lethargy, and (2) bipolar disorder (formerly called manic-depressive disorder), in which a person alternates between depression and mania, an overexcited, hyperactive state.

Major Depressive Disorder

If you are like most high school students, at some time during this year - more likely the dark months of winter than the bright days of summer - you will probably experience some of depression’s symptoms. You may feel deeply discouraged about the future, dissatisfied with your life, or socially isolated. You may lack the energy to get things done or even to force yourself out of bed; be unable to concentrate, eat, or sleep normally; or even wonder if you would be better off dead. Perhaps academic success came easily to you in middle school, and now you find that disappointing grades jeopardize your goals. Maybe social stresses, such as feeling you don’t belong or experiencing the end of a romance, have plunged you into despair. And maybe brooding has at times only worsened your self-torment. Likely you think you are more alone in having such negative feelings than you really are (Jordan et al., 2011). In one survey of American high school students, 29 percent “felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities” (CDC, 2008). In another national survey, of American collegians, 31 percent agreed when asked if in the past year they had at some time “felt so depressed that it was difficult to function” (ACHA, 2009). Misery has more company than most suppose.

Although phobias are more common, depression is the number-one reason people seek mental health services. At some point during their lifetime, depression plagues 12 percent of Canadian adults and 17 percent of US. adults (Holden, 2010; Patten et al., 2006). Moreover, it is the leading cause of disability worldwide (WHO, 2002). In any given year, a depressive episode plagues 5.8 percent of men and 9.5 percent of women, reports the World Health Organization.

As anxiety is a response to the threat of future loss, depressed mood is often a response to past and current loss. About one in four people diagnosed with depression is debilitated by a significant loss, such as a loved one’s death, a ruptured marriage, or a lost job (Wakefield et al., 2007). To feel bad in reaction to profoundly sad events is to be in touch with reality. In such times, there is an up side to being down. Sadness is like a car’s low-fuel light - a signal that warns us to stop and take appropriate measures. Recall that, biologically speaking, life’s purpose is not happiness but survival and reproduction. Coughing, vomiting, swelling, and pain protect the body from dangerous toxins. Similarly, depression is a sort of psychic hibernation: It slows us down, defuses aggression, helps us let go of unattainable goals, and restrains risk taking (Andrews & Thomson, 2009a,b; Wrosch & Miller, 2009). To grind temporarily to a halt and ruminate, as depressed people do, is to reassess one’s life when feeling threatened, and to redirect energy in more promising ways (Watkins, 2008). Even mild sadness can improve people’s recall, make them more discerning, and help them make complex decisions (Forgas, 2009). There is sense to suffering.

But when does this response become seriously maladaptive? Joy, contentment, sadness, and despair are different points on a continuum, points at which any of us may be found at any given moment. The difference between a blue mood after bad news and a mood disorder is like the difference between gasping for breath after a hard run and being chronically short of breath.

Major depressive disorder occurs when at least five signs of depression last two or more weeks (TABLE 67.1). To sense what major depression feels like, suggest some clinicians’ imagine combining the anguish of grief with the sluggishness of bad jet lag.

Adults diagnosed with persistent depressive disorder (also called dysthymia) experience a mildly depressed mood more often than not for at least two years (American Psychiatric Association, 2013). They also display at least two of the following symptoms:

  1. Problems regulating appetite
  2. Problems regulating sleep
  3. Low energy
  4. Low self-esteem
  5. Difficulty concentrating and making decisions
  6. Feelings of hopelessness

Bipolar Disorder

With or without therapy, episodes of major depression usually end, and people temporarily or permanently return to their previous behavior patterns. However, some people rebound to, or sometimes start with, the opposite emotional extreme - the euphoric, hyperactive, wildly optimistic state of mania. If depression is living in slow motion, mania is fast forward. Alternating between depression and mania (week to week, and not day to day or moment to moment) signals bipolar disorder.

Adolescent mood swings, from rage to bubbly, can, when prolonged, produce a bipolar diagnosis. Between 1994 and 2003, U.S. National Center for Health Statistics annual physician surveys revealed an astonishing 40-fold increase in diagnoses of bipolar disorder in those 19 and under-from an estimated 20,000 to 800,000 (Carey, 2007; Flora & Bobby, 2008; Moreno et al., 2007). The new popularity of the diagnosis, given in two-thirds of the cases to boys, has been a boon to companies whose drugs are prescribed to lessen mood swings. The DSM-5 will likely reduce the number of child and adolescent bipolar diagnoses, by classifying as disruptive mood dysregulation disorder some of those with emotional volatility (Miller, 2010).

During the manic phase, people with bipolar disorder are typically overtalkative, overactive, and elated (though easily irritated); have little need for sleep; and show fewer sexual inhibitions. Speech is loud, flighty, and hard to interrupt. They find advice irritating. Yet they need protection from their own poor judgment, which may lead to reckless spending or unsafe sex.

In milder forms, mania’s energy and free-flowing thinking does fuel creativity. George Frideric Handel, who may have suffered from a mild form of bipolar disorder, composed his nearly four-hour-long Messiah (1742) during three weeks of intense, creative energy (Keynes, 1980) . Robert Schumann composed 51 musical works during two years of mania (1840 and 1849) and none during 1844, when he was severely depressed (Slater & Meyer, 1959). Those who rely on precision and logic, such as architects, designers, and journalists, suffer bipolar disorder less often than do those who rely on emotional expression and vivid imagery (Ludwig, 1995). Composers, artists, poets, novelists, and entertainers seem especially prone (Jamison, 1993, 1995; Kaufman & Baer, 2002; Ludwig, 1995).

It is as true of emotions as of everything else: What goes up comes down. Before long, the elated mood either returns to normal or plunges into a depression. Though bipolar disorder is much less common than major depressive disorder, it is often more dysfunctional, claiming twice as many lost workdays yearly (Kessler et al., 2006). Among adults, it afflicts men and women about equally.

Understanding Mood Disorders

How do the biological and social-cognitive perspectives explain mood disorders?

In thousands of studies, psychologists have been accumulating evidence to help explain mood disorders and suggest more effective ways to treat and prevent them. Researcher Peter Lewinsohn and his colleagues (1985, 1998, 2003) summarized the facts that any theory of depression must explain, including the following:

The factors that put women at risk for depression (genetic predispositions, child abuse, low self-esteem, marital problems, and so forth) similarly put men at risk (Kendler et al., 2006). Yet women are more vulnerable to disorders involving internalized states, such as depression, anxiety, and inhibited sexual desire. Men’s disorders tend to be more external - alcohol use disorder, antisocial conduct, lack of impulse control. When women get sad, they often get sadder than men do. When men get mad, they often get madder than women do.

Today’s researchers propose biological and cognitive explanations of depression, often combined in a biopsychosocial approach.

The Biological Perspective

GENETIC INFLUENCES

Mood disorders run in families. As one researcher noted, emotions are “postcards from our genes” (Plotkin, 1994). The risk of major depression and bipolar disorder increases if you have a parent or sibling with the disorder (Sullivan et al., 2000). If one identical twin is diagnosed with major depressive disorder, the chances are about 1 in 2 that at some time the other twin will be, too. If one identical twin has bipolar disorder, the chances are 7 in 10 that the other twin will at some point be diagnosed similarly. Among fraternal twins, the corresponding odds are just under 2 in 10 (Tsuang & Faraone, 1990). The greater similarity among identical twins holds even among twins raised apart (DiLalla et al., 1996). Summarizing the major twin studies, one research team estimated the heritability (extent to which individual differences are attributable to genes) of major depression at 37 percent (FIGURE 67.2 on the next page).

Moreover, adopted people who suffer a mood disorder often have close biological relatives who suffer mood disorders, develop alcohol use disorder, or commit suicide (Wender et al., 1986), (Close-up: Suicide and Self-Injury reports other research findings,)

Close-up: Suicide and Self-Injury

What factors affect suicide and self-injury, and what are some of the important warning signs to watch for in suicide prevention efforts?

Each year nearly 1 million despairing people worldwide will elect a permanent solution to what might have been a temporary problem, Comparing the suicide rates of different groups, researchers have found

The risk of suicide is at least five times greater for those who have been depressed than for the general population (Bostwick & Pankratz, 2000), People seldom commit suicide while in the depths of depression, when energy and initiative are lacking, The risk increases when they begin to rebound and become capable of following through, Among people with alcohol use disorder, 3 percent die by suicide, This rate is roughly 100 times greater than the rate for people without alcohol use disorder (Murphy & Wetzel, 1990; Sher, 2006),

Because suicide is so often an impulsive act, environmental barriers (such as jump barriers on high bridges and the unavailability of loaded guns) can reduce suicides (Anderson, 2008), Although common sense might suggest that a determined person would simply find another way to complete the act, such restrictions give time for self-destructive impulses to subside,

Social suggestion may trigger suicide, Following highly publicized suicides and TV programs featuring suicide, known suicides increase, So do fatal auto and private airplane “accidents,” One six-year study tracked suicide cases among all 1,2 million people who lived in metropolitan Stockholm at any time during the 1990s (Hedstrom et al., 2008). Men exposed to a family suicide were 8 times more likely to commit suicide than were non exposed men. Although that phenomenon may be partly attributable to family genes, shared genetic predispositions do not explain why men exposed to a co-worker’s suicide were 3.5 times more likely to commit suicide, compared with nonexposed men.

Suicide is not necessarily an act of hostility or revenge. The elderly sometimes choose death as an alternative to current or future suffering. In people of all ages, suicide may be a way of switching off unendurable pain and relieving a perceived burden on family members. “People desire death when two fundamental needs are frustrated to the point of extinction,” notes Thomas Joiner (2006, p. 47): “The need to belong with or connect to others, and the need to feel effective with or to influence others.” Suicidal urges typically arise when people feel disconnected from others, and a burden to them (Joiner, 2010), or when they feel defeated and trapped by an inescapable situation (Taylor et al., 201 1). Thus, suicide rates increase a bit during economic recessions (Luo et al., 2011). Suicidal thoughts also may increase when people are driven to reach a goal or standard -to become thin or straight or rich -and find it unattainable (Chatard & Selimbegovic, 2011).

In hindsight, families and friends may recall signs they believe should have forewarned them -verbal hints, giving possessions away, or withdrawal and preoccupation with death. To judge from surveys of 84,850 people across 17 nations, about 9 percent of people at some point in their lives have thought seriously of suicide. About 30 percent of these (3 percent of people) actually attempt it (Nock et al., 2008). For only about 1 in 25 does the attempt become their final act (MS, 2009). Of those who die, one-third had tried to kill themselves previously. Most discussed it beforehand. So, if a friend talks suicide to you, it’s important to listen and to direct the person to professional help. Anyone who threatens suicide is at least sending a signal of feeling desperate or despondent.

NONSUICIDAL SELF-INJURY

Suicide is not the only way to send a message or deal with distress. Some people, especially adolescents and young adults, may engage in nonsuicidal self-injury (NSSI) (FIGURE 67.3). Such behavior includes cutting or burning the skin, hitting oneself, pulling hair out, inserting objects under the nails or skin, and self-administered tattooing (Fikke et al., 2011).

Why do people hurt themselves? Those who do so tend to be less able to tolerate emotional distress, are extremely self-critical, and often have poor communication and problem-solving skills (Nock, 2010). They engage in NSSI to

Does NSSI lead to suicide? Usually not. Those who engage in NSSI are typically suicide gesturers, not suicide attempters (Nock & Kessler, 2006). Suicide gesturers engage in NSSI as a desperate but non-life-threatening form of communication or when they are feeling overwhelmed. But NSSI has been shown to be a risk factor for future suicide attempts (Wilkinson & Goodyer, 2011). If people do not get help, their nonsuicidal behavior may escalate to suicidal ideation and finally, to attempted suicide.

To tease out the genes that put people at risk for depression, some researchers have turned to linkage analysis. After finding families in which the disorder appears across several generations, geneticists examine DNA from affected and unaffected family members, looking for differences. Linkage analysis points us to a chromosome neighborhood, note behavior genetics researchers Robert Plomin and Peter McGuffin (2003); “a house-to-house search is then needed to find the culprit gene.” Such studies are reinforcing the view that depression is a complex condition. Many genes work together, producing a mosaic of small effects that interact with other factors to put some people at greater risk. If the culprit gene variations can be identified - with chromosome 3 genes implicated in separate British and American studies (Breen et al., 2011; Pergadia et al., 2011) - they may open the door to more effective drug therapy.

THE DEPRESSED BRAIN

Using modern technology, researchers are also gaining insight into brain activity during depressed and manic states, and into the effects of certain neurotransmitters during these states. One study gave 13 elite Canadian swimmers the wrenching experience of watching a video of the swim in which they failed to make the Olympic team or failed at the Olympic games (Davis et al., 2008). Functional MRI scans showed the disappointed swimmers experiencing brain activity patterns akin to those of patients with depressed moods.

Many studies have found diminished brain activity during slowed-down depressive states, and more activity during periods of mania (FIGURE 67.4). The left frontal lobe and an adjacent brain reward center are active during positive emotions, but less active during depressed states (Davidson et al., 2002; Heller et al., 2009). In one study of people with severe depression, MRI scans also found their frontal lobes 7 percent smaller than normal (Coffey et al., 1993). Other studies show that the hippocampus, the memory-processing center linked with the brain’s emotional circuitry, is vulnerable to stress-related damage.

Bipolar disorder likewise correlates with brain structure. Neuroscientists have found structural differences, such as decreased axonal white matter or enlarged fluid-filled ventricles, in the brains of people with bipolar disorder (Kempton et al., 2008; van der Schot et al., 2009).

Neurotransmitter systems influence mood disorders. Norepinephrine, which increases arousal and boosts mood, is scarce during depression and overabundant during mania. (Drugs that alleviate mania reduce norepinephrine.) Many people with a history of depression also have a history of habitual smoking, and smoking increases one’s risk for future depression (Pasco et al. 2008). This may indicate an attempt to self-medicate with inhaled nicotine, which can temporarily increase norepinephrine and boost mood (HMHL, 2002b).

Researchers are also exploring a second neurotransmitter, serotonin (Carver et al., 2008). One well-publicized study of New Zealand young adults found that the recipe for depression combined two necessary ingredients - significant life stress plus a variation on a serotonin-controlling gene (Caspi et al., 2003; Moffitt et al., 2006). Depression arose from the interaction of an adverse environment plus a genetic susceptibility, but not from either alone. But stay tuned: The story of gene-environment interactions is still being written, as other researchers debate the reliability of this result (Caspi et al., 2010; Karg et al., 2011; Munafo et al., 2009; Risch et al., 2009; Uher & McGuffin, 2010).

Drugs that relieve depression tend to increase norepinephrine or serotonin supplies by blocking either their reuptake (as Prozac, Zoloft, and Paxil do with serotonin) or their chemical breakdown. Repetitive physical exercise, such as jogging, reduces depression as it increases serotonin (Ilardi, 2009; Jacobs, 1994). Boosting serotonin may promote recovery from depression by stimulating hippocampus neuron growth (Airan et al., 2007; Jacobs et al.,2000).

What’s good for the heart is also good for the brain and mind. People who eat a heart-healthy “Mediterranean diet” (heavy on vegetables, fish, and olive oil) have a comparatively low risk of developing heart disease, late-life cognitive decline, and depression - all of which are associated with inflammation (Dowlati et al., 2010; Sanchez-Villegas et at., 2009; Tangney et al., 2011). Excessive alcohol use also correlates with depression - mostly because alcohol misuse leads to depression (Fergusson et al., 2009).

The Social-Cognitive Perspective

Depression is a whole-body disorder. Biological influences contribute to depression but don’t fully explain it. The social-cognitive perspective explores the roles of thinking and acting.

Depressed people view life through the dark glasses of low self-esteem (Orth et at., 2009). Their intensely negative assumptions about themselves, their situation, and their future lead them to magnify bad experiences and minimize good ones. Listen to Norman, a Canadian college professor, recalling his depression:

I [despaired] of ever being human again. I honestly felt subhuman, lower than the lowest vermin. Furthermore, I was self-deprecatory and could not understand why anyone would want to associate with me, let alone love me.... I was positive that I was a fraud and a phony and that I didn’t deserve my Ph.D. I didn’t deserve to have tenure; I didn’t deserve to be a Full Professor.... I didn’t deserve the research grants I had been awarded; I couldn’t understand how I had written books and journal articles.... I must have conned a lot of people. (Endler, 1982, pp. 45-49)

Research reveals how self-defeating beliefs and a negative explanatory style feed depression’s vicious cycle.

NEGATIVE THOUGHTS AND NEGATIVE MOODS INTERACT

Self-defeating beliefs may arise from learned helplessness. As we saw in Module 29, both dogs and humans act depressed, passive, and withdrawn after experiencing uncontrollable painful events. Learned helplessness is more common in women than in men, and women may respond more strongly to stress (Hankin & Abramson, 2001; Mazure et at., 2002; Nolen-Hoeksema, 2001, 2003). For example, 38 percent of women and 17 percent of men entering U. S. colleges and universities report feeling at least occasionally “overwhelmed by all I have to do” (Pryor et al., 2006). (Men report spending more of their time in “light anxiety” activities such as sports, TV watching, and partying, possibly avoiding activities that might make them feel overwhelmed.) This may help explain why, beginning in their early teens, women are nearly twice as vulnerable to depression. Susan Nolen-Hoeksema (2003) believed women’s higher risk of depression relates to what she described as their tendency to overthink, to ruminate. Rumination - staying focused on a problem (thanks to the continuous firing of a frontal lobe area that sustains attention) - can be adaptive (Altamirano et at., 2010; Andrews & Thomson, 2009a,b). But when it is relentless, self-focused rumination diverts us from thinking about other life tasks and produces a negative emotional inertia (Kuppens et al., 2010).

But why do life’s unavoidable failures lead only some people to become depressed? The answer lies partly in their explanatory style - who or what they blame for their failures (or credit for their successes). Think of how you might feel if you failed a test. If you can externalize the blame (“What an unfair test!”), you are more likely to feel angry. If you blame yourself, you probably will feel stupid and depressed.

So it is with depressed people, who tend to explain bad events in terms that are stable (“It’s going to last forever”), global (“It’s going to affect everything I do”), and internal (“It’s all my fault”) (FIGURE 67.5). Depression-prone people respond to bad events in an especially self-focused, self-blaming way (Mor & Winquist, 2002; Pyszczynski et al., 1991; Wood et al., 1990a,b). Their self-esteem fluctuates more rapidly up with boosts and down with threats (Butler et al., 1994).

The result of these pessimistic, overgeneralized, self-blaming attributions may be a depressing sense of hopelessness (Abramson et al., 1989; Panzarella et al., 2006). As Martin Seligman has noted, “A recipe for severe depression is preexisting pessimism encountering failure” (1991, p. 78). What then might we expect of new college students who are not depressed but do exhibit a pessimistic explanatory style? Lauren Alloy and her collaborators (1999) monitored Temple University and University of Wisconsin students every 6 weeks for 2.5 years. Among those identified as having a pessimistic thinking style, 17 percent had a first episode of major depression, as did only 1 percent of those who began college with an optimistic thinking style.

Seligman (1991, 1995) has contended that depression is common among young Westerners because the rise of individualism and the decline of commitment to religion and family have forced young people to take personal responsibility for failure or rejection. In non-Western cultures, where close-knit relationships and cooperation are the norm, major depression is less common and less tied to self-blame over personal failure (WHO, 2004a). In Japan, for example, depressed people instead tend to report feeling shame over letting others down (Draguns, 1990a).

There is, however, a chicken-and-egg problem with the social-cognitive explanation of depression. Self-defeating beliefs, negative attributions, and self-blame coincide with a depressed mood and are indicators of depression. But do they cause depression, any more than a speedometer’s reading causes a car’s speed? Before or after being depressed, people’s thoughts are less negative. Perhaps this is because, as we noted in our discussion of state-dependent memory (Module 32), a depressed mood triggers negative thoughts. If you temporarily put people in a bad or sad mood, their memories, judgments, and expectations suddenly become more pessimistic.

DEPRESSION’S VICIOUS CYCLE

Depression, as we have seen, is often brought on by stressful experiences - losing a job, getting divorced or rejected, suffering physical trauma - by anything that disrupts our sense of who we are and why we are worthy human beings. This disruption in turn leads to brooding, which amplifies negative feelings. But being withdrawn, self-focused, and complaining can by itself elicit rejection (Furr & Funder, 1998; Gotlib & Hammen, 1992). In one study, researchers Stephen Strack and James Coyne (1983) noted that “depressed persons induced hostility, depression, and anxiety in others and got rejected. Their guesses that they were not accepted were not a matter of cognitive distortion.” Indeed, people in the throes of depression are at high risk for divorce, job loss, and other stressful life events. Weary of the person’s fatigue, hopeless attitude, and lethargy, a spouse may threaten to leave or a boss may begin to question the person’s competence. (This provides another example of genetic-environmental interaction: People genetically predisposed to depression more often experience depressing events.) The losses and stress only serve to compound the original depression. Rejection and depression feed each other. Misery may love another’s company, but company does not love another’s misery.

We can now assemble some of the pieces of the depression puzzle (FIGURE 67.6): (1) Negative, stressful events interpreted through (2) a ruminating, pessimistic explanatory style create (3) a hopeless, depressed state that (4) hampers the way the person thinks and acts. This, in turn, fuels (1) negative, stressful experiences such as rejection.

None of us is immune to the dejection, diminished self-esteem, and negative thinking brought on by rejection or defeat. As Edward Hirt and his colleagues (1992) demonstrated, even small losses can temporarily sour our thinking. They studied some avid Indiana University basketball fans who seemed to regard the team as an extension of themselves. After the fans watched their team lose or win, the researchers asked them to predict the team’s future performance and their own. After a loss, the morose fans offered bleaker assessments not only of the team’s future but also of their own likely performance at throwing darts, solving anagrams, and getting a date. When things aren’t going our way, it may seem as though they never will.

It is a cycle we can all recognize. Bad moods feed on themselves: When we feel down, we think negatively and remember bad experiences. On the brighter side, we can break the cycle of depression at any of these points - by moving to a different environment, by reversing our self-blame and negative attributions, by turning our attention outward, or by engaging in more pleasant activities and more competent behavior.

Winston Churchill called depression a “black dog” that periodically hounded him. Poet Emily Dickinson was so afraid of bursting into tears in public that she spent much of her adult life in seclusion (Patterson, 1951). As each of these lives reminds us, people can and do struggle through depression. Most regain their capacity to love, to work, and even to succeed at the highest levels.

Before You Move On

ASK YOURSELF: Has your high school experience been a challenging time for you? What advice would you have for other students about to enter high school?

TEST YOURSELF: What is the most common psychological disorder? What is the disorder for which people most often seek treatment?