Mood Disorders and Suicide PDF

6 Mood Disorders and Suicide CHAPTER OUTLINE Understanding and Defining Mood Disorders An Overview of Depression and Mania The Structure of Mood Disorders Depressive Disorders Other Depressive Disorders Bipolar Disorders Prevalence of Mood Disorders Prevalence in Children, Adolescents, and Older...

6 Mood Disorders and Suicide CHAPTER OUTLINE Understanding and Defining Mood Disorders An Overview of Depression and Mania The Structure of Mood Disorders Depressive Disorders Other Depressive Disorders Bipolar Disorders Prevalence of Mood Disorders Prevalence in Children, Adolescents, and Older Adults Life Span Developmental Influences on Mood Disorders Across Cultures Among Creative Individuals Causes of Mood Disorders Biological Dimensions Psychological Dimensions Social and Cultural Dimensions An Integrative Theory Treatment of Mood Disorders Medications Electroconvulsive Therapy and Transcranial Magnetic Stimulation Psychological Treatments for Depression Combined Treatments for Depression Preventing Relapse of Depression Psychological Treatments for Bipolar Disorder Suicide Treatment pixelheadphoto digitalskillet/Shutterstock.com Statistics Causes Risk Factors Is Suicide Contagious? 200 Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. student learning outcomes* Use scientific reasoning to interpret behavior: cc Identify basic biological, psychological, and social com­ponents of behavioral Describe key concepts, principles, and overarching themes in psychology: cc Analyze the variability and continuity of behavior and mental processes within Engage in innovative and integrative thinking and problem solving: cc Describe problems operationally to study them empirically (APA SLO 2.3a) Develop a working knowledge of the content domains of psychology: cc Recognize major historical events, theoretical perspectives, and figures in Describe applications that employ discipline-based problem solving: cc Correctly identify antecedents and consequences of behavior and mental explanations (e.g., inferences, observations, operational definitions and interpretations) (APA SLO 2.1a) (see textbook pages 201–202, 219–226, 227–230) and across animal species (APA SLO 1.2d2) (see textbook pages 218, 221, 225–226) (see textbook pages 204–205, 206–208, 209–211, 213–214) psychology and their link to trends in contemporary research (APA SLO 1.2c) (see textbook pages 225–226, 234–235) processes (APA SLO 1.3c) (see textbook pages 218–230) cc Describe examples of relevant and practical applications of psychological principles to everyday life (APA SLO 1.3a) (see textbook pages 205–206, 212, 242) * Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2013) in its guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO). Understanding and Defining Mood Disorders cc What is the difference between a depressive episode and a manic or hypomanic episode? cc What are the clinical symptoms of major depressive disorder, persistent depressive disorder, and bipolar disorder? Think back over the last month of your life. It may seem normal in most respects; you studied during the week, socialized on the weekend, and thought about the future once in a while. Perhaps you were anticipating with some pleasure the next school break or seeing an old friend. But maybe sometime during the past month you also felt kind of down, because you got a lower mark than you expected on a test or broke up with your boyfriend or girlfriend. Think about your feelings during this period. Were you sad? Maybe you couldn’t seem to get up the energy to study or go out with your friends. It may be that you feel this way once in a while for no good reason and your friends think you’re moody. If you are like most people, you know that such a mood will pass. You will be back to your old self in a few days or a week. If you never felt down and always saw only what was good in a situation, it would be more unusual than if you were depressed once in a while. Feelings of depression (and joy) are universal, which makes it all the more difficult to understand disorders of mood, disorders that can be so incapacitating that violent suicide may seem by far a better option than living. Consider the case of Katie. Katie... ● Weathering Depression Katie was an attractive but shy 16-year-old who came to our clinic with her parents. For several years, Katie had seldom interacted with anybody outside her family because of her considerable social anxiety. Going to school was difficult, and as her social contacts decreased, her days became empty and dull. By the time she was 16, a deep, all-encompassing depression blocked the sun from her life. Here is how she described it later: The experience of depression is like falling into a deep, dark hole that you cannot climb out of. You scream as you fall, but it seems like no one hears you. Some days you float upward without even trying; on other days, you wish that you would hit bottom so that you would never fall again. Depression affects the way you interpret events. It influences the way you see yourself and the way you see other people. I remember looking in the mirror and thinking that I was the ugliest creature in the world. Understanding and Defining Mood Disorders Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • 201 Later in life, when some of these ideas would come back, I learned to remind myself that I did not have those thoughts yesterday and chances were that I would not have them tomorrow or the next day. It is a little like waiting for a change in the weather. But at 16, in the depths of her despair, Katie had no such perspective. She often cried for hours at the end of the day. She had begun drinking alcohol the year before, with the blessing of her parents, strangely enough, because the pills prescribed by her family doctor did no good. A glass of wine at dinner had a temporary soothing effect on Katie, and both she and her parents, in their desperation, were willing to try anything that might make her a more functional person. But one glass was not enough. She drank increasingly more often. She began drinking herself to sleep. It was a means of escaping what she felt: “I had very little hope of positive change. I do not think that anyone close to me was hopeful, either. I was angry, cynical, and in a great deal of emotional pain.” For several years, Katie had thought about suicide as a solution to her unhappiness. At 13, in the presence of her parents, she reported these thoughts to a psychologist. Her parents wept, and the sight of their tears deeply affected Katie. From that point on, she never expressed her suicidal thoughts again, but they remained with her. By the time she was 16, her preoccupation with her own death had increased. I think this was just exhaustion. I was tired of dealing with the anxiety and depression, day in and day out. Soon I found myself trying to sever the few interpersonal connections that I did have, with my closest friends, with my mother, and my oldest brother. I was almost impossible to talk to. I was angry and frustrated all the time. One day I went over the edge. My mother and I had a disagreement about some unimportant little thing. I went to my bedroom where I kept a bottle of whiskey or vodka or whatever I was drinking at the time. I drank as much as I could until I could pinch myself as hard as I could and feel nothing. Then I got out a very sharp knife that I had been saving and slashed my wrist deeply. I did not feel anything but the warmth of the blood running from my wrist. The blood poured out onto the floor next to the bed that I was lying on. The sudden thought hit me that I had failed, that this was not enough to cause my death. I got up from the bed and began to laugh. I tried to stop the bleeding with some tissues. I stayed calm and frighteningly pleasant. I walked to the kitchen and called my mother. I cannot imagine how she felt when she saw my shirt and pants 202 • Chapter 6 covered in blood. She was amazingly calm. She asked to see the cut and said that it was not going to stop bleeding on its own and that I needed to go to the doctor immediately. I remember as the doctor shot novocaine into the cut he remarked that I must have used an anesthetic before cutting myself. I never felt the shot or the stitches. After that, thoughts of suicide became more frequent and more real. My father asked me to promise that I would never do it again, and I said I would not, but that promise meant nothing to me. I knew it was to ease his pains and fears and not mine, and my preoccupation with death continued. Clearly, Katie’s depression was outside the boundaries of normal experience because of its intensity and duration. In addition, her severe or “clinical” depression interfered substantially with her ability to function. Finally, a number of associated psychological and physical symptoms accompany clinical depression. Sometimes, mood disorders lead to tragic consequences. So developing a full understanding of them is key. In the following sections, we describe how various ­emotional experiences and symptoms interrelate to produce specific mood disorders. We offer detailed descriptions of different mood disorders and examine the many criteria that define them. We discuss the relationship of anxiety and depression and the causes and treatment of mood disorders. We conclude with a discussion of suicide. An Overview of Depression and Mania The fundamental experiences of depression and mania contribute, either singly or together, to all the mood disorders. The most commonly diagnosed and most severe depression is called a major depressive episode. The DSM-5 criteria describes it as an extremely depressed mood state that lasts at least two weeks and includes cognitive symptoms (such as feelings of worthlessness and indecisiveness) and disturbed physical functions (such as altered sleeping patterns, significant changes in appetite and weight, or a notable loss of energy) to the point that even the slightest activity or movement requires an overwhelming effort. The episode is typically accompanied by a general loss of interest in things and an inability to experience any pleasure from life, including interactions with family or friends or accomplishments at work or at school. Although all symptoms are important, evidence suggests that the most central indicators of a full major depressive episode are Mood Disorders and Suicide Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. DSM Disorder Criteria Summ ary 5 Major Depressive Episode DSM Disorder Criteria S ummary 5 Manic Episode Features of a major depressive episode include the following: Features of a manic episode include the following: • Depressed mood (may be irritable mood in children or adolescents) • A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week • Markedly diminished interest or pleasure in most daily activities • Significant degree of at least three of the following: inflated self-esteem, decreased need for sleep, excessive talkativeness, racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, excessive involvement in high-risk behaviors • Significant weight loss when not dieting, weight gain, or significant decrease or increase in appetite • Insomnia or hypersomnia • Noticeable psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or excessive guilt • Mood disturbance is severe enough to cause impairment in normal functioning or requires hospitalization, or there are psychotic features • Diminished ability to think, concentrate, or make decisions • Symptoms are not caused by the direct physiological effects of a substance or a general medical condition • Recurrent thoughts of death, suicide ideation, or suicide attempt From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. • Clinically significant distress or impairment • Symptoms are not due to the effects of a substance (e.g., drug abuse) or a general medical condition (e.g., hypothyroidism) From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. the physical changes (sometimes called somatic or vegetative symptoms) (Bech, 2009; Kessler & Wang, 2009), along with the behavioral and emotional “shutdown,” as reflected by low behavioral activation (Dimidjian, Barrera, Martell, Muñoz, & Lewinsohn, 2011). Anhedonia (loss of energy and inability to engage in pleasurable activities or have any “fun”) is more characteristic of these severe episodes of depression than are, for example, reports of sadness or distress ­(Pizzagalli, 2014). Nor does the tendency to cry, which occurs equally in depressed and non-depressed individuals (mostly women in both cases) reflect severity—or even the presence of a depressive episode (Vingerhoets, Rottenberg, Cevaal, & Nelson, 2007). This anhedonia reflects that these episodes represent a state of low positive affect and not just high negative affect (Brown & Barlow, 2009). The duration of a major depressive episode, if untreated, is approximately four to nine months (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler & Wang, 2009). The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or euphoria. In mania, individuals find extreme pleasure in every activity; some patients compare their daily experience of mania with a continuous sexual orgasm. They become extraordinarily active (hyperactive), require little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. DSM-5 highlights this feature by adding “persistently increased goal-directed activity or energy” to the criteria (American Psychiatric Association, 2013). Speech is typically rapid and may become incoherent, because the individual is attempting to express so many exciting ideas at once; this feature is typically referred to as flight of ideas. DSM-5 also defines a hypomanic episode, a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and need last only four days rather than a full week. (Hypo means “below”; thus the episode is below the level of a manic episode.) A hypomanic episode is not in itself necessarily problematic, but its presence does contribute to the definition of several mood disorders. The Structure of Mood Disorders Individuals who experience either depression or mania are said to suffer from a unipolar mood disorder, because their mood remains at one “pole” of the usual depression–mania continuum. Mania by itself (unipolar mania) probably does occur (Angst & Grobler, 2015; Baek, Eisner, & Nierenberg, 2014 but seems to be rare, because most people with a unipolar mood disorder eventually develop depression. On the mood disorders One of a group of disorders involving severe and enduring disturbances in emotionality ranging from elation to severe depression. major depressive episode Most common and severe experience of depression, including feelings of worthlessness, disturbances in bodily activities such as sleep, loss of interest, and inability to experience pleasure, persisting at least 2 weeks. mania Period of abnormally excessive elation or euphoria associated with some mood disorders. hypomanic episode Less severe and less disruptive version of a manic episode that is one of the criteria for several mood disorders. Understanding and Defining Mood Disorders Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • 203 other hand, manic episodes alone may be somewhat more frequent in adolescents (Merikangas et al., 2012). Someone who alternates between depression and mania is said to have a bipolar mood disorder traveling from one “pole” of the depression–elation continuum to the other and back again. This label is somewhat misleading, however, because depression and elation may not be at exactly opposite ends of the same mood state; although related, they are often relatively independent. An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time, or be depressed with a few symptoms of mania. This episode is characterized as having “mixed features” (Angst, 2009; Angst et al., 2011; Swann et al., 2013). In DSM-5,the term “mixed features” requires specifying whether a predominantly manic or predominantly depressive episode is present and then noting if enough symptoms of the opposite polarity are present to meet the mixed features criteria. Depressive Disorders DSM-5 describes several types of depressive disorders. These disorders differ from one another in the frequency and severity with which depressive symptoms occur and the course of the symptoms (chronic—meaning almost continuous—or non-chronic). In fact, a strong body of evidence indicates that the two factors that most importantly describe mood disorders are severity and chronicity (Klein, 2010, and see below). Clinical Descriptions The most easily recognized mood disorder is major depressive disorder, defined by the presence of depression and the absence of manic, or hypomanic episodes, before or during the disorder. An occurrence of just one isolated depressive episode in a lifetime is now known to be relatively rare (Eaton et al., 2008; Kessler & Wang, 2009). If two or more major depressive episodes occurred and were separated by at least two months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Recurrence is important in predicting the future course of the disorder, as well as in choosing appropriate treatments. From 35% to 85% of people with single-episode occurrences of major depressive disorder later experience a second episode (Angst, 2009; Souery et al., 2012), based on follow-ups as long as 23 years (Eaton et al., 2008). In the first year following an episode, the risk of recurrence is 20%, but it rises as high as 40% in the second year (Boland & Keller, 2009). Because of this finding and others reviewed later, clinical scientists have recently concluded that unipolar depression is often a chronic condition that waxes and wanes over time but seldom disappears (Judd, 2012). The median lifetime number 204 • Chapter 6 of major depressive episodes is four to seven; in one large sample, 25% experienced six or more episodes (Angst, 2009; Kessler & Wang, 2009). The median duration of recurrent major depressive episodes is four to five months (Boland & Keller, 2009; Kessler et al., 2003), somewhat shorter than the average length of the first episode. On the basis of these criteria, how would you diagnose Katie? Katie suffered from a severely depressed mood, feelings of worthlessness, difficulty concentrating, recurrent thoughts of death, sleep difficulties, and loss of energy. She clearly met the criteria for major depressive disorder, recurrent. Katie’s depressive episodes were quite severe when they occurred, but she tended to cycle in and out of them. Persistent depressive ­d isorder (dysthymia) shares many of the symptoms of major depressive disorder but differs in its course. There may be fewer symptoms, but depression remains relatively unchanged over long periods, ­sometimes 20 or 30 years or more (Cristancho, Kocsis, & Thase, 2012; Murphy & Byrne, 2012). Persistent depressive disorder is defined as depressed mood that continues at least two years, during which the patient cannot be symptom free for more than two months at a time even though they may not experience all of the symptoms of a major depressive episode. It identifies patients who were formerly diagnosed with dysthymic disorder and other depressive disorders (Rhebergen & Graham, 2014). Persistent depressive disorder differs from a major depressive disorder in the number of symptoms required, but mostly it is in the chronicity. It is considered more severe, since patients with persistent depression present with higher rates of comorbidity with other mental disorders, are less responsive to ­treatment, and show a slower rate of improvement over time. About 20% of patients with a major depressive episode report chronicity of this episode for at least two years, thereby meeting criteria for persistent depressive disorder (Klein, 2010). Also, 22% of people suffering from persistent depression with fewer symptoms (specified as “with pure dysthymic syndrome,” see below) eventually experienced a major depressive episode (Klein et al., 2006). These individuals who suffer from both major depressive episodes and persistent depression with fewer symptoms are said to have double depression. Typically, a few depressive symptoms develop first, perhaps at an early age, and then one or more major depressive episodes occur later only to revert to the underlying pattern of depression once the major depressive episode has run its course (Boland & Keller, 2009; Klein et al., 2006). Identifying this pattern is important because it is associated with more severe psychopathology and a problematic future course (Boland & Keller, 2009; Rubio, Markowitz, Alegria, PerezFuentes, Liu, Lin, & Blanco, 2011). For example, Klein et al. (2006) found that the relapse rate of depression among people meeting criteria for DSM-IV dysthymia was 71.4%. ­Consider the case of Jack. Mood Disorders and Suicide Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Jack... ● A Life Kept Down Jack was a 49-year-old divorced white man who lived at his mother’s home with his 10-year-old son. He complained of chronic depression, saying he finally realized he needed help. Jack reported that he had been a pessimist and a worrier for much of his adult life. He consistently felt kind of down and depressed and did not have much fun. He had difficulty making decisions, was generally pessimistic about the future, and thought little of himself. During the past 20 years, the longest period he could remember in which his mood was “normal” or less depressed lasted only four or five days. About five years before coming to the clinic, Jack had experienced a bout of depression worse than anything he had previously known. His self-esteem went from low to non-existent. From indecisiveness, he became unable to decide anything. He was exhausted all the time and felt as if lead had filled his arms and legs, making it difficult even to move. He became unable to complete projects or to meet deadlines. Seeing no hope, he began to consider suicide. After tolerating a listless performance for years from someone they had expected to rise through the ranks, Jack’s employers finally fired him. After about six months, the major depressive episode resolved and Jack returned to his chronic but milder state of depression. He could get out of bed and accomplish some things, although he still doubted his own abilities. He was unable to obtain another job, however. After several years of waiting for something to turn up, he realized he was unable to solve his own problems and that without help his depression would continue. After a thorough assessment, we determined that Jack suffered from a classic case of double depression. Onset and Duration Generally the risk for developing major depression is fairly low until the early teens, when it begins to rise in a steady (linear) fashion (Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013). A longitudinal study with 2,320 individuals from the Baltimore Longitudinal Study of Aging spanning from age 19 to 95 showed that symptoms of depression followed a U-shaped pattern, such that symptoms of depression were highest in young adults, decreased across middle adulthood, and then increased again in older age, with older people also experiencing an increase in distress associated with these symptoms (Sutin et al., 2013). Another alarming finding is that the incidence of depression and consequent suicide seem to be steadily increasing. Kessler and colleagues (2003) compared four age groups and found that fully 25% of people 18 to 29 years had already experienced major depression, a rate far higher than the rate for older groups when they were that age. As we noted previously, the length of depressive episodes is variable, with some lasting as little as two weeks; in more severe cases, an episode might last for several years, with the typical duration of the first episode being two to nine months if untreated (Boland & Keller, 2009; Rohde et al., 2013). Although nine months is a long time to suffer with a severe depressive episode, evidence indicates that, even in the most severe cases, the probability of remission of the episode within one year approaches 90% (Kessler & Wang, 2009). In those severe cases in which the episode lasts five years or longer, 38% can be expected to eventually recover (Mueller et al., 1996). Occasionally, however, episodes may not entirely clear up, leaving some residual symptoms. In this case, the likelihood of a subsequent episode with another incomplete recovery is much higher (Boland & Keller, 2009; Judd, 2012). Awareness of this increased likelihood is important to treatment planning, because treatment should be continued much longer in these cases. Investigators have found a lower (0.07%) prevalence of persistent mild depressive symptoms in children compared with adults (3% to 6%) (Klein, Schwartz, Rose, & Leader, 2000), but symptoms tend to be stable throughout childhood (Garber, Gallerani, & Frankel, 2009). Kovacs, Akiskal, Gatsonis, and Parrone (1994) found that 76% of a sample of children with persistent mild depressive symptoms later developed major depressive disorder. Persistent depressive disorder may last 20 to 30 years or more, although studies have reported a median duration of approximately five years in adults (Klein et al., 2006) and four years in children (Kovacs et al., 1994). Klein and colleagues (2006), in the study mentioned earlier, conducted a 10-year follow-up of 97 adults with mixed features Condition in which the individual experiences both elation and depression or anxiety at the same time. Also known as dysphoric manic episode or mixed manic episode. major depressive disorder Mood disorder involving one (single episode) or more (separated by at least 2 months without depression, recurrent) recurrent Repeatedly occurring. persistent depressive disorder (dysthymia) Mood disorder involving persistently depressed mood, with low self-esteem, withdrawal, pessimism, or despair, present for at least 2 years, with no absence of symptoms for more than 2 months. double depression Severe mood disorder typified by major depressive episodes superimposed over a background of dysthymic disorder. Understanding and Defining Mood Disorders Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • 205 DSM-IV dysthymia (now known as persistent depressive disorder, which is characterized by fewer or more mild symptoms of depression) and found that 74% had recovered at some point but 71% of those had relapsed. The whole sample of 97 patients spent approximately 60% of the 10-year ­f ollow-up period meeting full criteria for a mood disorder. This compares with 21% of a group of patients with major depressive ­disorder also followed for 10 years. Even worse, patients with persistent depressive disorder with less severe depressive symptoms (dysthymia) were more likely to attempt suicide than a comparison group with (non-­p ersistent) episodes of major depressive disorder during a five-year period. As noted above, it is relatively common for major depressive episodes and dysthymia (now persistent depressive disorder) to co-occur (double depression) (Boland & Keller, 2009; McCullough et al., 2000). If someone you love has died, you may have experienced a number of depressive symptoms as well as anxiety, emotional numbness, and denial (Shear, 2012; Simon, 2012). Usually the natural grieving process has peaked within the first six months, although some people grieve for a year or longer (Currier, Neimeyer, & Berman, 2008; ­Maciejewski et al., 2007). The acute grief most of us would feel eventually evolves into what is called i­ ntegrated grief, in which the finality of death and its consequences are acknowledged and the individual adjusts to the loss. New, bittersweet, but mostly positive memories of the deceased person that are no longer dominating or interfering with functioning are then incorporated into memory (Shear et al., 2011). Integrated grief often recurs at significant anniversaries, such as the birthday of the loved one, holidays, and other meaningful occasions, including the anniversary of the death. This is all a very normal and positive reaction. In fact, mental health professionals are concerned when someone does not grieve after a death, because grieving is our natural way of confronting and handling loss. When grief lasts beyond the typical time, mental health professionals again become concerned (Neimeyer & Currier, 2009). After six months to a year or so, the chance of recovering from severe grief without treatment is considerably reduced, and for approximately 7% of bereaved individuals, a normal process becomes a disorder (Kersting, Brahler, Glaesmer, & Wagner, 2011; Shear et al., 2011). At this stage, suicidal thoughts increase substantially and focus mostly on joining the beloved deceased (Stroebe, Stroebe, & Abakoumkin, 2005). The ability to imagine events in the future is generally impaired, since it is difficult to think of a future without the deceased (MacCallum & Bryant, 2011; Robinaugh, & McNally, 2013). Individuals also have difficulty regulating their own emotions, which tend to become rigid and 206 • Chapter 6 Bob Thomas/Popperfoto/Getty Images From Grief to Depression ▲▲Queen Victoria remained in such deep mourning for her husband, Prince Albert, that she was unable to perform as monarch for several years after his death. inflexible (Gupta & Bonanno, 2011). Many of the psychological and social factors related to mood disorders in general, including a history of past depressive episodes, also predict the development of what is called the syndrome of complicated grief, although this reaction can develop without a preexisting depressed state (Bonanno, Wortman, & Nesse, 2004). Features of normal grief, integrated grief, and complicated grief are listed in Table 6.1 (Shear et al., 2011). Indeed, some have proposed that this unique cluster of symptoms, combined with other differences, should be sufficient to make complicated grief a separate diagnostic category distinct from depression (Bonanno, 2006; Shear et al., 2011). For example, the very strong yearning in complicated grief seems to be associated with the activation of the dopamine neurotransmitter system; this is in contrast to major depressive disorder, in which activation is reduced in this system (O’Connor et al., 2008). Also, brain-imaging Mood Disorders and Suicide Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Table 6.1 Normal and Complicated Grief Common symptoms of acute grief that are within normal limits within the first 6–12 months after: • Recurrent, strong feelings of yearning, wanting very much to be reunited with the person who died; possibly even a wish to die in order to be with deceased loved one • Pangs of deep sadness or remorse, episodes of crying or sobbing, typically interspersed with periods of respite and even positive emotions • Steady stream of thoughts or images of deceased, may be vivid or even entail hallucinatory experiences of seeing or ­hearing deceased person • Struggle to accept the reality of the death, wishing to protest against it; there may be some feelings of bitterness or anger about the death • Somatic distress, e.g., uncontrollable sighing, digestive symptoms, loss of appetite, dry mouth, feelings of hollowness, sleep disturbance, fatigue, exhaustion or weakness, restlessness, aimless activity, difficulty initiating or maintaining o ­ rganized activities, and altered sensorium • Feeling disconnected from the world or other people, indifferent, not interested, or irritable with others Symptoms of integrated grief that are within normal limits: • • • • • • Sense of having adjusted to the loss Interest and sense of purpose, ability to function, and capacity for joy and satisfaction are restored Feelings of emotional loneliness may persist Thoughts and memories of the deceased person accessible and bittersweet but no longer dominate the mind Occasional hallucinatory experiences of the deceased may occur Surges of grief in response to calendar days or other periodic reminders of the loss may occur Complicated grief: • Persistent intense symptoms of acute grief • The presence of thoughts, feelings, or behaviors reflecting excessive or distracting concerns about the circumstances or consequences of the death Source: Shear, M. K., Simon, N., Wall, M., Zisook, S., Neimeyer, R., Duan, N., & Keshaviah, A. (2011). Complicated grief and related bereavement issues for DSM-5. Depression and Anxiety, 28, 103–117. studies indicate that areas of the brain associated with close relationships and attachment are active in grieving people, in addition to areas of the brain associated with more general emotional responding (Gündel, O’Connor, Littrell, Fort, & Lane, 2003). Persistent Complex Bereavement ­Disorder is now included as a diagnosis requiring ­further study in ­section III of DSM-5. Other Depressive Disorders Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder, both depressive disorders, were added to DSM-5. Premenstrual Dysphoric Disorder (PMDD) The history of the development of PMDD over the past several decades as a diagnosis was described in some detail in Chapter 3. Basically clinicians identified a small group of women, from 2% to 5%, who suffered from severe and sometimes incapacitating emotional reactions during the premenstrual period (Epperson et al., 2012). But strong objections to making this condition an official diagnosis were based on concerns that women who were experiencing a very normal monthly physiological cycle, as part of being female, would now be classified as having a disorder, which would be very stigmatizing. It has now been clearly established that this small group of women differs in a number of ways from the 20% to 40% of women who experience uncomfortable premenstrual symptoms (PMS) that, nevertheless, are not associated with impairment of functioning. Criteria defining PMDD are presented in the nearby DSM Disorder Criteria Summary. A combination integrated grief Grief that evolves from acute grief into a condition in which the individual accepts the finality of a death and adjusts to the loss. complicated grief Grief characterized by debilitating feelings of loss and emotions so painful that a person has trouble resuming a normal life; designated for further study as a disorder by DSM-5. premenstrual dysphoric disorder Clinically significant emotional problems that can occur during the premenstrual phase of the reproductive cycle of a woman. disruptive mood dysregulation disorder Condition in which a child has chronic negative moods such as anger and irritability without any accompanying mania. Understanding and Defining Mood Disorders Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • 207 DSM Disorde r Criteria Summ ary 5 Premenstrual Dysphoric Disorder Features of premenstrual dysphoric disorder include the following: • In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses. • One (or more) of the following symptoms must be present: (1) marked affective lability (e.g., mood swings) (2) marked irritability or anger (3) marked depressed mood (4) marked anxiety and tension. • One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms above: (1) decreased interest in usual activities (2) difficulty in concentration (3) lethargy, fatigability, lack of energy (4) marked change in appetite; overeating; or specific food cravings (5) hypersomnia or insomnia (5) a sense of being overwhelmed or out of control (7) physical symptoms such as breast tenderness or swelling. • Clinically significant distress or interference with work, school, usual social activities, or relationships. • Symptoms are not attributable to the effects of a substance (e.g., drug abuse) or another medical condition. From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. of physical symptoms, severe mood swings, and anxiety are associated with incapacitation during this period of time (Hartlage, Freels, Gotman, & Yonkers, 2012). All of the evidence indicates that PMDD is best considered a disorder of mood as opposed to a physical disorder (such as an endocrine disorder), and, as pointed out in Chapter 3, the creation of this diagnostic category should greatly assist the thousands of women suffering from this disorder to receive the treatment they need to relieve their suffering and improve their functioning. Disruptive Mood Dysregulation Disorder Children and adolescents are being diagnosed with bipolar disorder (which we discuss next) at greatly increasing rates over the past several years. In fact, from 1995 to 2005, the diagnosis of bipolar disorder in children increased 40-fold overall and has quadrupled in U.S. community hospitals (up to 40%) (Leibenluft & Rich, 2008; Moreno et al., 2007). Why the increase? Many clinicians are now using much broader diagnostic criteria that would not correspond to current definitions of bipolar I or bipolar II disorder, but rather fall under the relatively vague category of bipolar 208 • Chapter 6 disorder not otherwise specified (NOS) and include children with chronic irritability, anger, aggression, hyperarousal, and frequent temper tantrums that are not limited to an occasional episode. But the most important observation is that these children show no evidence of periods of elevated mood (mania), which has been a requirement for a diagnosis of bipolar disorder (Liebenluft, 2011). Additional research demonstrated that these children with chronic and severe irritability and difficulty regulating their emotions resulting in frequent temper tantrums are at increased risk for additional depressive and anxiety disorders rather than manic episodes and that there is no evidence of excessive rates of bipolar disorder in their families, which one would expect if this condition were truly bipolar disorder. It was also ­recognized that this severe irritability is more common than bipolar disorder but has not been well studied ­(Brotman et al., 2006). This irritability is associated with substantial suffering in the children themselves, reflecting as it does chronically high rates of negative affect and marked disruption of family life. Though these broader definitions of symptoms do display some similarities with more classic bipolar disorder symptoms (Biederman et al., 2005; Biederman et al., 2000), the danger is that these children are being misdiagnosed when they might better meet criteria for more classic diagnostic categories, such as attention-deficit/hyperactivity disorder (ADHD) or conduct disorder (see Chapter 13). In that case, the very potent drug treatments for bipolar disorder with substantial side effects would pose more risks for these children than they would benefits. But these cases also differ from more typical conduct or ADHD conditions as well, since it is the intense negative affect that seems to be driving the irritability and marked inability to regulate mood. In view of the distinctive features of this condition, it seemed important to better describe these children up to 18 years of age as suffering from a diagnosis termed ­d isruptive mood dysregulation disorder rather than have them continue to be mistakenly diagnosed with bipolar disorder or perhaps conduct disorder (Roy, Lopes, & Klein, 2014). Criteria for this new disorder are presented in the DSM Disorder Criteria Summary below. In one case seen at our clinic, a nine-year-old girl we will call Betsy was brought in by her father for evaluation for severe anxiety. The father described a situation in which Betsy, although a very bright child who had done well in school, was continually irritable and increasingly unable to get along at home, engaging in intense arguments at the slightest provocation. Her mood would then deteriorate into a full-blown aggressive temper tantrum and she would run to her room and on occasion begin throwing things. She began refusing to eat meals with the family, since bitter arguments would often arise and it just became easier to allow her to eat in her Mood Disorders and Suicide Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. DSM Disorder Criteria Summ ary 5 Disruptive Mood Dysregulation Disorder Features of disruptive mood dysregulation disorder include the following: • Severe recurrent (three or more times per week present for 12 or more months) temper outburst manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation and are inconsistent with developmental level. • The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others in at least two of three settings (i.e., at home, at school) and is severe in at least one of these. • The diagnosis should not be made for the first time before age six years or after age 18 years. • There has never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. • The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition. From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. room. Since nothing else seemed to work to calm her down, her father resorted to something he used to do when she was a baby: take her for a long ride in the family car. After a while, Betsy would begin to relax but during one long ride turned to her father and said, “Daddy, please help me feel better, because if I keep feeling like this I just want to die.” Adults with a history of disruptive mood dysregulation disorder are at increased risk for developing mood and anxiety disorders as well as many other adverse health outcomes (Copeland, Shanahan, Egger, Angold, & Costello, 2014). Therefore, a very important objective for the immediate future will be developing and evaluating treatments for this difficult condition, both psychological and drug. For example, it is very possible that new psychological treatments under development for severe emotional ­dysregulation in children may be useful with this condition (Ehrenreich, Goldstein, Wright, & Barlow, 2009). Jane... ● Funny, Smart, and Desperate Jane was the wife of a well-known surgeon and the loving mother of three children. She was nearly 50; her older children had moved out; her youngest son, 16-year-old Mike, was having academic difficulties in school and seemed anxious. Jane brought Mike to the clinic to find out why he was having problems. As they entered the office, I observed that Jane was well dressed, vivacious, and personable; she had a bounce to her step. She began talking about her successful family before she and Mike even reached their seats. Mike, by contrast, was quiet and reserved. He seemed resigned and perhaps relieved that he would have to say little during the session. By the time Jane sat down, she had mentioned the personal virtues and material achievement of her husband, and the brilliance and beauty of one of her older children, and she was proceeding to describe the second child. But before she finished, she noticed a book on anxiety disorders and, having read voraciously on the subject, began a litany of various anxiety-related problems that might be troubling Mike. In the meantime, Mike sat in the corner with a small smile on his lips that seemed to be masking considerable distress and uncertainty over what his mother might do next. It became clear as the interview progressed that Mike suffered from obsessivecompulsive disorder, which disturbed his concentration both in and out of school. He was failing all his courses. It also became clear that Jane herself was in the midst of a hypomanic episode, evident in her unbridled enthusiasm, grandiose perceptions, “uninterruptable” speech, and report that she needed little sleep these days. She was also easily distracted, as when she quickly switched from describing her children to the book on the table. When asked about her own psychological state, Jane readily admitted that she was a “manic depressive” (the old name for bipolar disorder) and that she alternated rather rapidly between feeling on top of the world and feeling depressed; she was taking Bipolar Disorders The key identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller-coaster ride from the peaks of elation to the depths of despair. Beyond that, bipolar disorders are parallel in many ways to depressive disorders. For example, a manic episode might occur only once or repeatedly. Consider the case of Jane. disruptive mood dysregulation disorder Condition in which a child has chronic negative moods such as anger and irritability without any accompanying mania. bipolar II disorder Alternation of major depressive episodes with hypomanic episodes (not full manic episodes). bipolar I disorder Alternation of major depressive episodes with full manic episodes. Understanding and Defining Mood Disorders Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. • 209 medication for her condition. I immediately wondered if Mike’s obsessions had anything to do with his mother’s condition. Mike was treated intensively for his obsessions and compulsions but made little progress. He said that life at home was difficult when his mother was depressed. She sometimes went to bed and stayed there for three weeks. During this time, she seemed to be in a depressive stupor, essentially unable to move for days. It was up to the children to care for themselves and their mother, whom they fed by hand. Because the older children had now left home, much of the burden had fallen on Mike. Jane’s profound depressive episodes would remit after about three weeks, and she would immediately enter a hypomanic episode that might last several months or more. During hypomania, Jane was mostly funny, entertaining, and a delight to be with—if you could get a word in edgewise. Consultation with her therapist, an expert in the area, revealed that he had prescribed a number of medications but was so far unable to bring her mood swings under control. Billy... ● The World’s Best at Everything Before Billy reached the ward, you could hear him laughing and carrying on in a deep voice; it sounded as if he was having a wonderful time. As the nurse brought Billy down the hall to introduce him to the staff, he spied the Ping-Pong table. Loudly, he exclaimed, “PingPong! I love Ping-Pong! I have only played twice, but that is what I am going to do while I am here; I am going to become the world’s greatest Ping-Pong player! And that table is gorgeous! I am going to start work on that table immediately and make it the finest Ping-Pong table in the world. I am going to sand it down, take it apart, and rebuild it until it gleams and every angle is perfect!” Billy soon went on to something else that absorbed his attention. The previous week, Billy had emptied his bank account, taken his credit cards and those of his elderly parents with whom he was living, and bought every piece of fancy stereo equipment he could find. He thought that he would set up the best sound studio in the city and make millions of dollars by renting it to people who would come from far and wide. This episode had precipitated his admission to the hospital. DSM Disorde r Criteria Summ ary 5 Bipolar II Disorder Features of bipolar II disorder include the following: • Presence (or history) of one or more major depressive episodes • Presence (or history) of at least one hypomanic episode • No history of a full manic episode • Mood symptoms are not better accounted for by another disorder • Clinically significant distress or impairment of functioning From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. Jane suffered from bipolar II disorder, in which major depressive episodes alternate with hypomanic episodes rather than full manic episodes. As we noted earlier, hypomanic episodes are less severe. Although she was noticeably “up,” Jane functioned pretty well while in this mood state. The criteria for bipolar I disorder are the same, except the individual experiences a full manic episode. As in the criteria set for major depressive disorder, for the manic episodes to be considered separate, there must be a symptom-free period of at least two months between them. Otherwise, one episode is seen as a continuation of the last. The case of Billy illustrates a full manic episode. This individual was first encountered when he was admitted to a hospital. 210 • Chapter 6 During manic or hypomanic phases, patients often deny they have a problem, which was characteristic of Billy. Even after spending inordinate amounts of money or making foolish business decisions, these individuals, particularly if they are in the midst of a full manic episode, are so wrapped up in their enthusiasm and expansiveness that their behavior seems reasonable to them. The high during a manic state is so pleasurable that people may stop taking their medication during periods of distress or discouragement in an attempt to bring on a manic state again; this is a serious challenge to professionals. Returning to the case of Jane, we continued to treat Jane’s son Mike for several months. We made little progress before the school year ended. Because Mike was doing so poorly, the school administrators informed his parents that he would not be accepted back the next year. Mike and his parents wisely decided it might be a good idea if he got away from the house and did something different for a while, and he began working and living at a ski and tennis resort. Several months later, his father called to tell us that Mike’s obsessions and compulsions had completely lifted since he’d been away from home. The father thought Mike should continue living at the resort, where he had entered school and was doing better academically. He now agreed with our previous assessment that Mike’s condition might be related to his relationship with his mother. Several years later, we heard that Jane, in a depressive stupor, had killed herself, an all-too-tragic ­outcome in bipolar disorder. Mood Disorders and Suicide Copyright 2019 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 5 Cyclothymic Disorder Features of cyclothymic disorder include the following: • For at least two years, numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. • Since onset, the person has not been without the symptoms for more than two months at a time. • No major depressive episode, manic episode, or hypomanic episode has been present during the first two years of the disturbance. • Mood symptoms are not better accounted for by another disorder, the physiological effects of a substance, or a general medical condition. • Clinically significant distress or impairment of functioning. From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. A milder but more chronic version of bipolar disorder is called cyclothymic disorder (Akiskal, 2009; Parker, McCraw, & Fletcher, 2012). Cyclothymic disorder is a chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes. Individuals with cyclothymic disorder tend to be in one mood state or the other for years with relatively few periods of neutral (or euthymic) mood. This pattern must last for at least two years (one year for children and adolescents) to meet criteria for the disorder. Individuals with cyclothymic disorder alternate between the kinds of mild depressive symptoms Jack experienced during his dysthymic states and the sorts of hypomanic episodes Jane experienced. In neither case was the behavior severe enough to require hospitalization or immediate intervention. Much of the time, such individuals are just considered moody. However, the chronically fluctuating mood states are, by definition, substantial enough to interfere with functioning. Furthermore, people with cyclothymia should be treated because of their increased risk to develop the more severe bipolar I or bipolar II disorder (Goodwin & Jamison, 2007; Otto & Applebaum, 2011). Onset and Duration The average age of onset for bipolar I disorder is from 15 to 18 and for bipolar II disorder from 19 to 22, although cases of both can begin in childhood (Judd et al., 2003; Merikangas & Pato, 2009). This is somewhat younger than the average age of onset for major depressive disorder, and bipolar disorders begin more acutely; that is, they develop more suddenly (Angst & Sellaro, 2000; Johnson et al., 2009). About one-third of the cases of bipolar disorder begin in adolescence, and the onset is often preceded by minor oscillations in mood or mild cyclothymic mood swings (Goodwin & Jamison, 2007; Merikangas et al., 2007). Between 10% and 25% of people with bipolar II disorder will progress to full bipolar I disorder (Birmaher et al., 2009; Coryell et al., 1995). Though unipolar and bipolar disorder have been thought distinct disorders some studies suggest they may be on a continuum (called a ▲▲In April 2013, Catherine “spectrum” in psychopaZeta-Jones again sought thology) (Johnson et al., help for bipolar II disorder, a condition for which she has 2009; Merikangas et al., received years of treatment. 2011). It is relatively rare for someone to develop bipolar disorder after the age of 40. Once it does appear, the course is chronic; that is, mania and depression alternate indefinitely. Therapy usually involves managing the disorder with ongoing drug regimens that prevent recurrence of episodes. Suicide is an all-too-common consequence of bipolar disorder, almost always occurring during depressive episodes, as it did in the case of Jane (Angst, 2009; Valtonen et al., 2007). A large Swedish study showed that, on average, people with bipolar disorder died eight to nine years earlier of various medical diseases