Mood Disorders

Introduction

    At some point in life, any given individual will experience challenging days that bring about a depressed mood.  A person may feel sad, hopeless, and tired.  A depressed mood is a natural and common occurrence in our lives.  For some individuals, it becomes more than a simple depressed mood, it becomes a mood disorder.  Mood disorders include the following diagnoses: dysthymic disorder, major depressive disorder, double-depression disorder, bipolar I disorder, bipolar II disorder, and cyclothymic disorder.  This paper will examine all of these disorders, with the exception of substance abuse induced mood disorders.  

Description of Sympotomology

    Mood disorders are described by some in the mental health field as the "common cold" of mental illness.  It is estimated that over twenty-million Americans will develop a mood disorder at some point in life (Papolos & Lachman, 1994, p.xiii).  Mood disorders have existed throughout time.  Public opinion of individuals who suffer from mood disorders has not changed significantly.  In early writings, people with chronic depression were viewed as being insecure, cynical, and critical of others (Riso, Du Toit, Blandino, Penna, Dacey, Duin et al, 2003).  In today's society there is a great need to educate individuals on the debilitating effects of mood disorders and the need to demonstrate compassion to these individuals.  

     Mood disorders are different from a depressed mood.  A depressed mood is a natural occurrence that normally occurs after a person has experienced loss.  A mood disorder is accompanied by severe depression that is not within the normal range of sadness.  The depression experienced by a person with a mood disorder is so overwhelming that it interferes with normal daily functioning (Sarason & Sarason, 2002, p.306).  

    In order to better understand mood disorders it is vital to examine the biological processes that occur in a person's body.  The brain is a complex and amazing organ that controls our beings.  Neurotransmitters are important chemicals in the brain that send messages from one nerve to the next.  Problems with a person's mood can occur when a neutral cell is not able to create enough neurotransmitters, store them or receive them properly (Copeland, 1992, p.20).  Some biological theories fault the neurotransmitters serotonin, dopamine, norepinephrine, epine-phrine, gamma-aminobutyric acid, and acetylcholine for depressed moods (Sarason & Sarason, 2002, p.313). 

    Other medical conditions can also cause a person to have a mood disorder.  Ten to fifteen percent of individuals suffering from depression have a malfunction in the thyroid gland (Copeland, 1992, p.21).  Some of the symptoms of mood disorders can be the same as the symptoms of a major medical condition, so it is important to rule out the medical causes before diagnosing a mood disorder.   

    Dysthymic disorder- also referred to as unipolar disorder- is characterized by a depression lasting at least two years.  The depression experienced in dysthymic is considered to be milder than that observed in major depressive disorder.  It is diagnosed as a chronic condition that can generate more cumulative symptoms than those diagnosed with major depression.  Symptoms include suicide attempts, social impairment, and hospitalization (Dougherty, Klein, & Davila, 2004).  Individuals with this disorder normally have difficulty remembering a time in life that they were not depressed (Sarason & Sarason, 2002, p.309).

    Major depressive disorder is diagnosed when an individual has at least one major depressive episode lasting continuously for at least two weeks.  It is a condition that occurs suddenly and is accompanied by thoughts of worthlessness, guilt, suicide, and/or death.  Other symptoms include weight gain or loss, loss of energy, insomnia or hypersomnia, and inability to concentrate or make decisions (O'Connor, 2001, p.2).  A manic or hypomanic episode during a depressive state does not qualify for a major depressive disorder diagnosis (Sarason & Sarason, 2002, p.310).  Double depression is a classification given to individuals suffering from dysthymic disorder and major depressive disorder at the same time (Riso, Du Toit, Blandino, Penna, Dacey, Duin et al, 2003).

    Bipolar was previously known as manic-depressive disorder.  It is one of the most misdiagnosed and undetected mental illnesses.  Individuals with bipolar disorder are commonly misdiagnosed as having major depressive disorder.  Symptoms of bipolar tend to begin in a person between the ages of seventeen to twenty-five (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, 2002).  There are two classifications of bipolar, bipolar I disorder and bipolar II disorder.  The symptoms of bipolar I disorder include a period of mania and then a period of depression.  The individual suffering from bipolar I will cycle between periods of extreme emotional highs to periods of extreme emotional lows (Miklowitz & Goldstein, 1997, p.29).

    Men and women tend to be equally affected by bipolar I disorder, whereas bipolar II disorder affects more women than men (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, 2002).  Bipolar II is different from bipolar I in that individuals will have less obvious manic episodes.  Hospitalization and psychotic behavior rarely occurs in individuals with bipolar II disorder.  The extreme depressive states are of the same severity for persons with bipolar I and bipolar II disorder (Miklowitz & Goldstein, 1997, p.29). 

     Cyclothymic disorder is commonly found in families with a history of bipolar disorder.  It is a cyclic disorder that has highs and lows, but not as severe as bipolar I or II disorder (Papolos & Lachman (ed), 1994, p.35).  Symptoms of hypomanic behavior and depressive behavior must be present for at least 2 years to qualify for a cyclothymic disorder.  Episodes in this disorder often follow a seasonal pattern.  Spring and fall are typical periods of time for an episode to occur (Sarason & Sarason, 2002, pp.334, 335).  Rivas-Vazquez, Johnson, Rey, Blais, and Rivas-Vazquez (2002) found in their research that many individuals suffering from cyclothymic disorder will develop bipolar at some point.  Many individuals with cyclothymic disorder have family members that suffer from bipolar I or II disorder. 

Differential Diagnosis Questions

    Mood disorder symptoms may overlap with each other.  In the initial therapy session it is important to ask the right questions to determine a precise diagnosis.  The first question should be, "When did the symptoms first start?"  Major depressive disorder normally occurs later in life, whereas dysthymic disorder and bipolar normally occur before a person's middle twenties.  Gender also plays a role. More women than men are diagnosed with bipolar II disorder (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, 2002). 

    Questions concerning manic episodes and severity of depression should also be addressed.  Along this line of questions, the emotional state of the client should be discussed.  Has he or she considered committing suicide or attempted suicide?  Among all individuals who suffer from a mood disorder, those diagnosed with bipolar disorder are more likely to commit suicide than any other group (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, 2002).  It is advantageous for the client and therapist to gather information from family and friends about the individual when any mood disorder is suspected (Rivas-Vazquez, Johnson, Rey, Blais, and Rivas-Vazquez, 2002). Appendix I provides suggestions to aid the therapist in asking differential diagnosis questions.

Possible Etiology Factors to Assess and Questions to Ask in Assessment
     Mood disorders have many possible causes.  Etiology factors addressed here do not apply to every client and case.  The therapist should uncover biological factors that might contribute to the client's symptoms.  Dr. Peter Whybrow, director of the Neuro-psychiatric Institue at UCLA, believes that many individuals view depression as a moral weakness and thus, judge themselves morally before examining the biological factors that could be causing the symptoms (1997, pp.98, 99).  Biological factors are significantly linked to mood disorders.  As mentioned earlier, the brain contains neurotransmitters that are essential to a balanced mood.  If there is a problem in this area mood disorders are very likely to occur.  Therapist should educate individuals of the biological nature of mood disorders. 

    Heredity plays a significant role in mood disorders.  One study of twins suggested that genetics plays a more significant role in individuals with bipolar than in individuals with schizophrenia.  The study examined pairs of twins with mental illnesses and discovered that among twins where one was diagnosed bipolar the other was bipolar 56% of the time.  In the same scenario, but with a diagnosis of schizophrenia, it occurred 28% of the time (Torrey, Bowler, Taylor, & Gottesman, 1994, p.12).  Another study of adopted children showed a higher incidence in mood disorders when there was a biological family history of bipolar or unipolar disorders.  This supports the theory that mood disorders are biologically based and the environment is a lesser factor in the development of a mood disorder (Papolos & Lachman, 1994, pp.18, 19).    

    The biopsychological model emphasizes that all parts of a person, biological, social, and psychological, have a role to play in the causes of mental illness.  The biological part of the disorder may be more to blame, but external stressors and negative thought patterns might also be contributing to the disorder (O'Connor, 2001, p.69). 

    Stressful life events can precipitate mood disorders.  Beach edited Marital and Family Process in Depression, (2001, p.167) a compilation of studies on depression.  One study in this book suggested that forty-six percent of women who had strenuous relationships with their husbands developed major depression.  Dr. Copeland, distinguished teacher and lecturer on the subject of mood disorders, agrees that stressful life events play a role in precipitating mood disorders.  Her book states that fifty percent of individuals diagnosed with post-traumatic stress also suffer from depression (1992, p.20).

    If the client is gaining attention, sympathy, or any other form of positive or negative feedback, he or she may resist treatment because he or she does not want to change.  It is important for the therapist to recognize this and work with the client to help him or her overcome this resistance.  The following questions should be answered during the initial session:   

  • How long have you been experiencing these symptoms?
  • Are you taking any medications?
  • Does anyone in your family suffer from depression?
  • Has anyone in your family been diagnosed with a mood disorder?
  • Why are you seeking treatment now?
  • What are you hoping to accomplish through therapy?
  • Tell me about your expectations during the treatment process.
  • What efforts are you willing to make before, during, and after treatment?
Preferred Therapeutic Interventions of Treatment           

    Four psychological theories have produced successful treatment results when applied to clients suffering from mood disorders.  These are the biological, cognitive, behavioral, and cognitive-behavioral approaches.  There are many variations of these treatment approaches used in therapy.

    The biological approach examines the physiological causes of a disorder.  The body is a complicated and intricate design. All parts must work together in harmony and balance.  As discussed earlier, the brain plays a vital role in regulating a person's mood.  In most cases, psychotherapy alone cannot correct the symptoms of mood disorders.  Depression often requires antianxiety medication, such as Prozac, Elavil, and Nardil, to help elevate the level of monoamine transmitters in the brain.  A lack of monomine transmitters in the brain is a common cause of depressive episodes.  Monoamine oxidase inhibitors (MAOIs) are proactive in preventing the breakdown of neurotransmitters, which are associated with major depressive disorder.  Two commonly prescribed MAOIs are Nardil and Parnate (Glick & Yalom, 1995, p.156).  The biological approach to treatment is normally accompanied by one of the other four approaches.          

    The cognitive approach encourages the therapist to work with the individual as a team to empower him or her to identify thinking patterns, feelings and behaviors that either help or hinder his or her journey to wholeness (Wolman & Stricker, 1990, p. 346).  A person's functional thoughts are often referred to as an individual's schemata.  Schematas normally develop in childhood and continue throughout life.  An individual might have a schemata, or internal dialogue, that is constantly negative, such as, "I'll never be anyone important.  No one likes me."  The cognitive approach suggests that these thoughts must be stopped and replaced by positive ones in order for a person to move forward (Sarason & Sarason, 2002, p. 327).    

    The behavioral approach focuses on changing the person's behavior. This approach tends to be especially beneficial to individuals when they first begin treatment for a mood disorder.  This approach helps individuals schedule activities, use diversion techniques, break activities into small steps, role-play situations, and use relaxation training.  The depression that accompanies mood disorders can be so overwhelming for clients that if there is no daily schedule, the day can be very unproductive.  Scheduling activities will help the individual accomplish tasks and monitor their conduct more effectively.  The other strategies are helpful for making the individual more aware of his or her behavior and more able to self-correct destructive behaviors (Glick & Yalom, 1995, pp.48-53).

    Cognitive-behavior therapy has proved to be particularly successful for individuals suffering from major depression, dysthymia, or double depression.  There is more research needed to prove the long-term benefits of CBT, but treatment with this method is successful with most clients  (Glick & Yalom, 1995, p.63).  This approach uses a combination of the cognitive and the behavioral techniques to help individuals accept and change their behavior.   

    Many individual diagnosed with a mood disorder are also diagnosed with another disorder.  Peselow, Sanfilipo, and Fieve (1994) found in their research that thirty to seventy percent of depressed individuals have also been diagnosed with a personality disorder.  In addition to personality disorders, individuals with mood disorders often have other diagnoses such as anxiety disorders and/or substance abuse problems.  This can present a challenge for mental health professionals when treating individuals with multiple diagnoses.  

Basic Treatment Recommendations and Likely Prognosis
     Mood disorders are treatable.  It is important for the therapist to treat each client individually.  There is not one treatment that will "cure" every client.  The therapist will probably experience resistance from the client to the treatment at some point.  This is a healthy dynamic that will allow the person and therapist to work together through the issue.  The therapist must keep in mind that his or her job is to give the client tools to work with. The client is ultimately in charge of his or her prognosis.

    Family therapy is strongly advocated by many mental health professionals for the treatment of mood disorders.  Family dynamics and interactions are studied and discussed in order for the family environment to facilitate healing (Glick, 1995, pp.24-28).  A study conducted by Rea, Tompson, Miklowitz, Goldstein, Hwang, and Mintz compared the prevention of relapse for bipolar patients.  They found that family therapy is more successful in bipolar patients not experiencing relapse than individual therapy.  According to their study only 28% of the individuals in family therapy experienced relapse as opposed to 60% of those in individual therapy (2003).  Another study conducted by three psychologists from the State University of New York at Stony Brook researched the family dynamics of individual with dysthymic disorder and their response to chronic stress.  The study found that adverse parent-child relationships increased the symptoms of dysthymic disorder and stress in the individual (Dougherty, Klien, & Davila, 2004).  Family therapy used to work through parent-child relationship issues can be very beneficial to individuals suffering from mood disorders.  

    Major depression is a treatable condition.  The key to successful treatment is early detection and treatment.  A study found that individuals treated immediately after their first episode of depression enjoyed more symptom-free time compared to individuals who did not seek treatment immediately (O'Connor, 2001, pp.9-10).  However, no single approach is successful in all cases.  A combination of medication and cognitive or behavioral approaches will be more successful than the use of only one approach (Sarason & Sarason, 2002, pp. 211-212).  The client must take ownership of his or her treatment in order to receive healing from major depressive disorder.

    The prognosis for dysthymic disorder can be good if effective treatment strategies are administered.  Chronic stress has been found to be a determining element of whether an individual recovers from dysthymic disorder or not.  One study found that fifty-three percent of patients recover from dysthymic disorder within five years if chronic stress is diminished significantly (Dougherty, Klein, & Davila, 2004).  To reduce the risk of relapse, one to two years of maintenance treatment is recommended for individuals with dysthymia, major depressive disorder, or double depression (Klein, Santiago, Vivian, Arnow, Blalock, Dunner et al, 2004).

    Bipolar disorder remains a chronic condition, but it is treatable.  Typically, individuals diagnosed with bipolar I disorder are more successful with treatment than those diagnosed with bipolar II disorder (Rivas-Vazquez, Johnson, Rey, Blais, & Rivas-Vazquez, 2002).  Most patients with bipolar I disorder receive treatment sooner because the symptoms are more observable than those diagnosed with bipolar II disorder.  This is one reason why treatment is more successful.

    Lithium, antidepressants, mood stabilizers and other medicines or combinations of these medicines are used to reduce the number of episodes a person experiences.  An individual suffering from bipolar has a better outcome the less he or she experiences episodes (Sarason & Sarason, 2002, p. 336).  It is vital that individuals with bipolar disorder continue to take their medication to avoid other episodes.  Many individuals cease taking medication when the symptoms cease or lessen and this causes a relapse. 

    Miklowitz and Goldstein advocate family-focused treatment for individuals with bipolar disorder.  The effects of bipolar bring questions and conflict to all those directly involved in the individual's life and therefore this treatment not only benefits the client, but his or her family as well (1997, p.12).  It is important for family and friends to support individuals before, during, and after episodes of mania.  Copeland in her book, "The Depression Workbook" states that people want to be treated with love, compassion, and patience when they are manic (1992, p.91).  Family-focused treatment is also beneficial for any individual suffering from a mood disorder.  

References- Five Key Books

    There are many valuable resources for professionals on the topic of mood disorders.  Current research on the topic is finding many beneficial treatment approaches to administer in therapy.  Any professional treating individuals with mood disorders should have these recommended resources in his or her library.

  • The Depression Workbook by Mary Ellen Copeland
  • Treating Depression edited by Ira D. Glick & Irvin D. Yalom
  • Genetic Studies in Affective Disorders: Overview of basic methods, current directions, and critical research issues edited by Demitri F. Papolos & Herbert M. Lachman
  • Active Treatment of Depression by Richard O'Connor
  • A Mood Apart by Peter C. Whybrow
Conclusion 

    As Jeremiah said in Jeremiah 8:18, "My sorrow is beyond healing, my heart is faint within me."  This is the cry of individuals suffering from mood disorders.  Their hopelessness can be overwhelming and paralyzing.  All people have issues and problems that they face every day and each person responds to those challenges differently.  When professional counselors have the privilege of treating someone and walking with them through their moods, it is essential for them to see the person as God sees them- a whole person who is loved.  Therapists must always strive to view the person as a unit: body, mind, and spirit.  All three areas must be addressed if an individual is to receive complete healing and wholeness.    

Appendix

Information taken from Sarason & Sarason, 2002, pp. 304-344.  

 

 

DYSTHYMIC DISORDER

MAJOR
DEPRESSIVE DISORDER

BIPOLAR I

DISORDER

BIPOLAR II disorder

Cyclothymic
DISORDER
Gender most affected
FEMALE
FEMALE
MALE FEMALE
FEMALE
MALE
FEMALE

How long have you been depressed?

At least
2 years
Not long. 

I've had at least one major depressive episode lasting

2 weeks.
NO
YES

At least 2 years with hypomanic behavior as well

Have you experienced a manic or hypomanic episode?

NO
NO
YES
NO
NO

Do others notice your depression?

Sometimes
YES
YES
YES
Sometimes

Do you experience days of extreme creativity and energy?

NO
NO
YES
NO
NO

Do you frequently experience insomnia?

NO
YES

During a manic episode I do.

NO
NO

Do you experience more episodes of depression or hypomanic behavior during certain seasons of the year?

NO
NO
NO
NO
YES

Is your job performance impaired during an "high" episode?

NO
NO
Frequently
YES
NO
NO

Are others concerned about your "highs"?

NO
NO
YES
YES
Sometimes
 
Bibliography

 

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    Beach, S. R. H.  (Ed.).  (2001).  Marital and family processes in depression: a scientific foundation for clinical practice.  Washington, DC:  American Psychological Association.

    Copeland, M. E.  (1992).  The depression workbook: a guide for living with depression and manic depression.  Oakland, CA:  New Harbinger Publications.

    Dougherty, L. R., Klein, D. N., & Davila, J.  (2004).  A growth curve analysis of the course of dysthymic disorder: the effects of chronic stress and moderation by adverse parent-child relationships and family history.  Journal of Consulting and Clinical Psychology, 72 (6), 1012-1021.  Retrieved March 26, 2005, from PsycARTICLES database.

    Glick, I. D., & Yalom, I. D. (Eds.).  (1995).  Treating depression.  San Francisco, CA: Jossey-Bass Publications.

    Klein, D. N., Santiago, N. J., Vivian, D., Arnow, B. A., Blalock, J. A., Dunner, D. L. et al. (2004).  Cognitive-behavioral analysis system of psychotherapy as a maintance treatment for chronic depression.  Journal of Consulting and Clinical Psychology, 72 (4), 681-688.  Retrieved March 26, 2005, from PsycARTICLES database.

    Miklowitz, D. J., & Goldstein, M. J.  (1997).  Bipolar disorder: a family-focused treatment approach.  New York, NY:  The Guilford Press.

    O'Connor, R.  (2001).  Active treatment of depression.  New York, NY:  W.W. Norton & Company.

    Papolos, D. F., & Lachman, H. M.  (Eds.).  (1994).  Genetic studies in affective disorders: overview of basic methods, current directions, and critical research issues.  New York, NY: John Wiley & Sons.

    Peselow, E. D., Sanfilipo, M. P., & Fieve, R. R.  (1994).  Patients' and informants' reports of personality traits during and after major depression.  Journal of Abnormal Psychology, 103 (4), 819-824.  Retrieved March 26, 2005, from PsycARTICLES database.

    Riso, L. P., Du Toit, P. L., Blandino, J. A., Penna, S., Dacey, S., Duin, J. S., et al.  (2003). 

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