Section B

Lesson 5
Psychological Disorders and Psychotherapy
(ii) Mood Disorders
Have you ever felt truly “down in the dumps” - sad, blue and
dejected? How about “up in the clouds” – happy, elated, excited? All
of us experience swings in mood or emotional state. For most of us
the swings are usually moderate in scope; periods of deep despair and
wild elation are rare. Some experience swings in emotional states that
are much more extreme and prolonged. Their highs are higher, lows
are lower, and they spend more time in these states than most people.
Surely most of us get depressed from time to time. Failing an exam,
not getting into one's first choice college or graduate school, breaking
up with a romantic partner are all examples of events that can
precipitate a depressed mood in many people.
However, mood disorders involve much more severe alterations in
mood, and for much more prolonged periods of time. In such
cases the disturbances of mood are intense and persistent enough
to be clearly maladaptive, often leading to serious problems in
relationships and work performance.
When significant mood change brings about behaviour that seriously
endangers a person's welfare, psychologists and other mental health
professionals conclude that the person has a mood disorder. Mood
disorders are diverse in nature. Nevertheless, in all mood disorders
(formerly called affective disorders), extremes of emotion or affect-
soaring elation or deep depression-dominate the clinical picture. Other
symptoms are also present, but the abnormal mood is the defining
feature.

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WHAT ARE MOOD DISORDERS?
Mood disorders are psychological disorders in which individuals
experience swings in their emotional states that are much more
extreme and prolonged than is true of most people. The two key
moods involved in mood disorders are (i) mania, characterized by
intense and unrealistic feelings of excitement and euphoria, and (ii)
depression, which involves feelings of extraordinary sadness and
dejection. Some people experience both of these kinds of moods at
one time or another, but other people only experience the depression.
These mood states are often conceived to be at opposite ends of a
mood continuum, with normal mood in the middle. Although this
concept is accurate to a degree, it cannot explain every instance of
mood disorder, because in some cases a patient may have symptoms
of mania and depression at the same time. In these cases, the person
experiences rapidly alternating moods such as sadness, euphoria, and
irritability, all within the same episode of illness.
In unipolar disorders, which are much more frequent, the person
experiences only depressive episodes. In bipolar disorders, the person
experiences both manic and depressive episodes.
It is also customary to differentiate the mood disorders by (1) severity
- the number of dysfunctions experienced in various areas of living
and the relative degree of impairment evidenced in those areas; and
(2) duration - whether the disorder is acute, chronic, or intermittent
(with periods of relatively normal functioning between the episodes of
disorder).
The Prevalence of Mood Disorders
Major mood disorders occur with alarming frequency at least 10 to
20 times more frequently than schizophrenia, for example, and at
about the same rate as all the anxiety disorders taken together. Of the
two types of serious mood disorders, unipolar major depression is

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much more common, and its occurrence has apparently increased in
recent years.
Unipolar depression is much more common in women than in men;
this difference is similar to the sex differences for many anxiety
disorders.
The other type of mood disorder, bipolar disorder (in which both
manic and depressive episodes occur), is much less common.

Depression Throughout the Life Cycle

Although most mood disorder cases occur during early and middle
adulthood, such reactions may occur any time from early childhood to
old age. Adults have reported the first onset of unipolar depression in
childhood or adolescence. Depression was once thought not to occur
in childhood, but we now know that this is not the case. Although
relatively rare, major depressions have been observed in
preadolescent youngsters.
UNIPOLAR MOOD DISORDERS
Sadness, discouragement, pessimism, and hopelessness about being
able to improve matters are familiar feelings to most people.
Depression is unpleasant when we are in it, but it usually does not last
long. Sometimes it seems almost to be self-limiting, turning off after a
period of days or weeks, or after it has reached a certain intensity
level. Sometimes we may experience it as having been in some sense
useful: We were stuck, and now we can move on; what bothered us
was easier to get out of than we thought it could be, and our new
perspective may offer new possibilities.
This scenario contains hints that may be significant to our
understanding of depression generally. For example, that mild
depression may actually be adaptive in the long run; that much of the
"work" of depression seems to involve facing images, thoughts, and
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feelings that one would normally avoid; and that depression may
sometimes be self-limiting. These considerations suggest that the
capacity to experience depression may be "normal" even desirable -
if the depression is brief and mild. They also suggest the idea of
normal depressions we would expect to occur in anyone undergoing
painful but common life events, such as significant personal,
interpersonal, or economic losses.
[***Depressions That Are Not Mood Disorders
Normal depressions are almost always the result of recent stress. In
fact, some depressions are considered adjustment disorders (those that
develop in response to stressors) rather than mood disorders.
However, such sharp distinctions may not be accurate. Indeed, many
depressions meeting criteria as "major" are also clearly related to the
prior occurrence of stress.
We will consider some of the milder forms of normal depression in
the following sections:
Loss and the Grieving Process: We usually think of grief as the
psychological process one goes through following the death of a
loved one - a process that appears to be more damaging for men than
women. Although this may be the most common and intense cause of
grieving, many other types of loss will give rise to a similar state.
Loss of a favoured status or position, separation or divorce, financial
loss, the breakup of a romantic relationship, retirement, separation
from a friend, absence from home for the first time, or even the loss of
a cherished pet may all give rise to symptoms of acute grief.
Other Normal Mood Variations: Many situations other than
obvious loss can provoke depressive feelings, and as we will see,
some people seem especially prone to develop depression. It is a
common observation, for example, that some doctoral candidates
become depressed after completing their final oral exams. Other kinds
of "success" depressions have also been observed following election
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to public office after a difficult campaign, and in successful novelists
and actors. Many students also experience mild or serious depression
during their college years of supposed freedom and carefree personal
growth. Some of these are in the normal range but some can be very
serious and require clinical attention. - Extra information
distinguishing “normal” depression which does not qualify as a
mood disorder - read and understand]
Mild to Moderate Depressive Disorders
The point at which mood disturbance becomes a diagnosable mood
disorder is a matter of clinical judgment. Unfortunately, although
criteria exist for exercising this judgment, they are not precise enough
for complete consensus among different clinicians. Although severe
mood disorders are obviously abnormal, a gray area exists where a
distinction between normal and abnormal is difficult to establish.
Dysthymia: To qualify for a diagnosis of dysthymia, a person must
have a persistently depressed mood, more days than not, for at least
two years. In addition, dysthymics must have at least two of the
following six symptoms when depressed: (1) poor appetite or
overeating, (2) sleep disturbance, (3) low energy level, (4) low self-
esteem, (5) difficulties in concentration or decision making and (6)
feelings of hopelessness. That is, they experience moderate levels of
depression over a chronic period of at least two years (one year for
children and adolescents); moreover, they are not psychotic (out of
touch with reality).
Normal moods may briefly intercede, but they last at most from a few
days to a few weeks. Indeed, this quality of intermittently normal
moods seems to be the primary characteristic distinguishing
dysthymia from major depression in that the average number of
symptoms endorsed by patients from the two categories does not
appear to differ. Thus, dysthymics do not really show less severe
symptoms than do major depressives; the difference is simply that the

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dysthymics do not necessarily have the symptoms every day. No
identifiable precipitating event or condition need be present, although
such circumstances are very frequently observed for depressions of
this general type.
1. MAJOR DEPRESSIVE DISORDER
The diagnostic criteria for major depressive disorder require that the
person exhibit more symptoms than are required for dysthymia and
the symptoms be more persistent (not interwoven with periods of
normal mood). An affected person must experience either markedly
depressed mood or marked loss of interest in pleasurable activities
most of every day for at least two weeks.
In addition, the person must experience at let four more of the
following symptoms during the same period: (1) fatigue or loss of
energy; (2) insomnia or hypersomnia (that is, too little or too much
sleep); (3) decreased appetite and significant weight loss without
dieting (or much more rarely, their opposites); (4) psychomotor
agitation or retardation (a slowdown of mental and physical activity);
5) diminished ability to think or concentrate; (6) self denunciation to
the point of claiming worthlessness or guilt out of proportion to any
past indiscretions; and (7) recurrent thoughts of death or thoughts of
suicide.
Most of these symptoms (at least five, including either sad mood, or
loss of interest or pleasure) must be present all day and nearly every
day for two consecutive weeks before the diagnosis is applicable. The
diagnosis of major depression is not made if a patient has ever
experienced a manic or hypomanic episode; in such a case, the current
depression is viewed as a depressive episode of bipolar disorder.
Cognitive and Motivational Symptoms: A person with major
depression shows not only mood symptoms of sadness but also a
variety of cognitive and motivational symptoms that are more severe
than in milder forms of depression. In this case the person shows
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various cognitive distortions, including being firmly convinced that
she is a failure and that her family also thinks so. She vacillates
between anger at her friends and family for not being trustworthy, and
self-hatred and self-blame. Because of her sense of hopelessness
about her future, she shows no motivation to try to improve her
situation. Her problems with friends who appear to no longer be close
to her occur commonly with depression because most people find it
aversive to be around depressed persons.
[*** Subtypes of Major Depression
One such subcategory in DSM-IV is major depression of the
melancholic type [[mention only this bracketed section. This
designation is applied when, in addition to meeting the criteria for
major depression, a patient has either loss of interest or pleasure in
almost all activities, or does not react to usually pleasurable stimuli or
desired events.]] In addition, the patient must also experience at least
three of the following: (1) early morning awakenings, (2) depression
being worse in the morning, (3) marked psychomotor retardation or
agitation, (4) significant loss of appetite and weight, (5) inappropriate
or excessive guilt, or (6) the depressed mood has a qualitative
difference from the sadness experienced following a loss or during a
non-melancholic depression. This severe subtype of depression is
associated with a higher genetic loading than other forms of
depression. The chief theoretical importance of the melancholia
concept is that it is strongly linked in the psychiatric literature to the
idea of endogenous causation - that is, to the notion that certain
depressions are caused "from within", so to speak, and are unrelated
to any stressful events in a patient's life.
Psychotic symptoms, characterized by loss of contact with reality,
and including delusions (false beliefs) or hallucinations (false sensory
perceptions), may sometimes accompany the other symptoms of
major depression. In such cases a diagnosis of severe major

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depressive episode with psychotic features is made. Extra
information – read and understand]
Distinguishing Major Depression: Discriminating major depression
from other forms of depressive disorders is not always easy. Major
depression may coexist with dysthymia in some people, a condition
given the designation "double depression". Double depressives are
people who are moderately depressed on a chronic basis and who
undergo increased problems from time to time, during which they
manifest "major" depressive symptoms.
Depression as a Recurrent Disorder: When a diagnosis of major
depression is made, it is usually also specified whether this is a single
(initial) episode or a recurrent episode (one or more previous episodes
have already occurred). This reflects the fact that depressive episodes
are usually time-limited (with the average duration of an untreated
episode being about six months according to DSM-IV).
Persons who experience recurrent depressions can be distinguished
from those who experience only a single episode in a number of ways.
Those with some form of recurrent depression show not only greater
severity in terms of number and frequency of symptoms, but also
many more suicide attempts, a much higher proportion with a family
history of depression, more work and social impairment, and higher
divorce rates. They also have more impaired social functioning
between episodes.

[*** Seasonal Affective Disorder: Some people who experience

recurrent depressive episodes show a seasonal pattern, commonly
known as seasonal affective disorder. To meet DSM-IV criteria for
recurrent major depression with a seasonal pattern, the person must
have had at least two episodes of depression in the past two years
occurring at the same time of the year (most commonly the fall or

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winter), and full remission must also have occurred at the same time
of the year. - extra information – read and understand]
Causes of Depression -
Biological Causes-Depression tends to run in families and is about
four times likely to occur in both members of identical-twin pairs than
in both members of nonidentical-twin pairs. Overall, however,
existing evidence suggests that genetic factors play a stronger role in
bipolar than in unipolar depression.
Other findings suggest that 'mood disorders may involve
abnormalities in brain biochemistry. For eg, it has been found that
levels of two neurotransmitters, norepinephrine and serotonin, are
lower in the brains of depressed persons than in those of nondepressed
persons. Similarly, levels of these neurotransmitters are higher in the
brains of persons showing mania. Further, when persons who have
recovered from depression undergo procedures that reduce the levels
of serotonin in their brains, their depressive symptoms return within
twenty four hours (Delgado et al., 1990).
However it must be kept in mind that not all persons suffering from
depression show reduced levels of norepinephrine or serotonin, and
not all persons demonstrating mania have increased levels of these
neurotransmitters. A current hypothesis is that low levels of serotonin
may allow other neurotransmitters such as dopamine and
norepinephrine to swing out of control and that this, in turn, may lead
to extreme changes in mood. However, this is just one possibility; at
present, the precise nature of the neurochemical mechanisms that play
a role in depression remains uncertain.

Psychological Causes Several psychological factors have been found

to play a role in depression. One of these is learned helplessness
(Seligman, 1975), or beliefs on the part of individuals that they have
no control over their own outcomes. Such views often develop after
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exposure to situations in which such lack of control is present, but
then generalize to other situations where individuals' fate is at least
partly in their hands. One result of such feelings of helplessness
seems to be depression.
Another psychological mechanism that plays a key role in depression
involves negative views about oneself 1976; Beck et al., 1979).
Individuals suffering from depression often possess negative self-
schemas—negative conceptions of their own traits, abilities, and
behavior. As a result, they tend to be highly sensitive criticism from
others. Because such persons are more likely to notice and remember
negative information, their feelings of worthlessness strengthen; and
when they are exposed to stressors (e.g., the breakup of a romantic
relationship, a failure at work), their thinking can become distorted in
important and self-defeating ways. Depressed persons begin to see
neutral or even pleasant events in a negative light—for instance, they
may interpret a compliment from a friend as insincere, or someone’s
being late for an appointment as a sign of rejection.
These distortions in thinking make it difficult for depressed people to
make realistic judgments about events and they begin to engage in
primitive thinking- thinking characterized by global judgments that
are absolute, invariant, and irreversible (for example, "I am basically
weak, and can never be strong," or "I am always a coward in every
situation I encounter"). Ultimately, depressed persons come to show
what Beck describes as the negative cognitive triad in which they
have automatic, repetitive, and negative thoughts about the self, the
world, and the future. In sum, depressed persons see themselves as
inadequate and worthless, feel that they can’t cope with the demands
made on them, and dread the future which, they believe, will bring
more of the same.
Another cognitive factor that plays a role in depression is heightened
self-awareness. Persons experiencing depression often focus their

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attention inward, on themselves. When they do, they often notice gaps
between what they would like to be or what they'd like to accomplish,
and what they are or where they are in life. Most people handle such
gaps by adjusting their goals or standards: They realize they can't be
perfect or attain every goal, so they adjust their hopes to be more in
line with reality. Persons who become depressed, however, don't
make such adjustments; they begin to torture themselves with self-
criticism and feelings of worthlessness. This generates negative
feelings, which lead to more self-criticism, and eventually to deep
depression.

2. BIPOLAR DISORDER
A mood disorder in which individuals experience very wide
swings in mood, from deep depression to wild elation. As with the
unipolar disorders, the severity of disturbance in bipolar disorder
ranges from mild to moderate to severe. In the mild to moderate
range, the disorder is known as cyclothymia, and in the moderate to
severe range the disorder is known as bipolar disorder.
Although recurrent cycles of mania and melancholia were recognized
as early as the sixth century, it remained for Kraepelin in 1899, to
introduce the term manic-depressive insanity and to clarify the
clinical picture. Kraepelin described the disorder as a series of attacks
of elation and depression, with periods of relative normality in
between, and a generally favourable prognosis. Today DSM-IV calls
this illness bipolar disorder.
Bipolar disorder is distinguished from major depression by at least
one episode of mania. Any given episode is classified as depressive,
manic, or mixed, according to is predominant features. The depressed
or manic classification is self-explanatory. A mixed episode is
characterized by symptoms of both manic and major depressive
episodes, whether the symptoms are either intermixed or alternate
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rapidly every few days. Such cases were once thought to be relatively
rare but are increasingly recognized as relatively common.
Bipolar disorder, even more than major depression, is typically a
recurrent disorder; single episodes are extremely rare. As with
unipolar major depression, the recurrences can be seasonal in nature,
in which case bipolar disorder with a seasonal pattern is diagnosed.
Although most patients with bipolar disorder experience periods of
remission when they are relatively symptom free, as many as 20 to 30
percent continue to experience significant impairment (occupational
and/or interpersonal) and mood lability. Moreover, a few chronic
patients continue to meet diagnostic criteria over long periods of time,
even years, sometimes despite the successive application of all
standard treatments.
Features of Bipolar Disorder: The features of the depressive form
of bipolar disorder are usually clinically indistinguishable from those
of major depression, although some studies do report higher rates of
psychomotor retardation, oversleeping, and overeating in the
depressed phase of bipolar disorder.
Nevertheless, the essential difference is that these depressive episodes
alternate with manic ones. In about two-thirds of cases, the manic
episodes either immediately precede or immediately follow a
depressive episode; in other cases the manic and depressive episodes
are separated by intervals of relatively normal functioning. Before
modern treatments were available, the periods of disorder often
gradually lengthened over a person's lifetime, leaving the person in
one phase of the illness or the other nearly all the time.
Manic symptoms in bipolar disorder tend to be extreme, and there is
significant impairment of occupational and social functioning. A
person who experiences a manic episode has a markedly elevated,
euphoric, and expansive mood, often interrupted by occasional
outbursts of irritability or even violence - particularly when others

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refuse to go along with the manic person's antics and schemes. This
mood must persist for at least a week to qualify for a diagnosis. In
addition, three or more of the following symptoms must also occur in
the same time period: A notable increase in goal-directed activity may
occur, which sometimes may appear as an unrelievable restlessness,
and mental activity may also speed up, so that the person may
evidence a "flight of ideas" or thoughts that "race" through the brain.
Distractibility, high levels of verbal output in speech or in writing,
and a severely decreased need for sleep may also occur. In addition,
inflated self-esteem is common and when severe becomes frankly
delusional, so that the person harbours feelings of enormous grandeur
and power. Finally, personal and cultural inhibitions loosen and the
person may indulge in foolish ventures with a high potential for
painful consequences, such as foolish business ventures, major
spending sprees, and sexual indiscretions.
During manic episodes some patients also report intermixed
symptoms of depressed mood anxiety, guilt, and suicidal thoughts.
One possible explanation is that the dysphoria comes from feelings of
being out of control with their manic behaviours and feelings. Mixed
episodes seem to be more common in women than in men.
Because a person who is depressed cannot be diagnosed as bipolar
unless he or she has exhibited at least one manic episode in the past,
many people with bipolar disorder whose initial episode or episodes
are depressive will be misdiagnosed at first, and possibly throughout
their lives (if no manic episodes are observed or reported, or if they
die before a manic episode is experienced).
Such misdiagnoses are unfortunate and important because there are
different treatments of choice for unipolar and bipolar depression.
Moreover, there is even evidence suggesting that some antidepressant
drugs used to treat what is thought to be unipolar depression may
actually precipitate manic episodes in patients who actually have as

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yet undetected bipolar disorder, thus worsening the course of the
illness.
People with bipolar disorder seem in some ways to be even more
unfortunate than those who suffer from recurrent major depression.
On average they suffer from more episodes during their lifetimes than
do persons with unipolar disorder (although these episodes tend to be
somewhat shorter).
Those who have one manic episode will go on to have further
episodes. As many as 5 to 10 percent of persons with bipolar disorder
experience at least four or more episodes (either manic or depressive)
every year, a pattern known as rapid cycling. In fact, those who go
through periods of rapid cycling usually experience many more than
four episodes a year. Rapid cycling is more common in women than
men and is sometimes precipitated by taking certain kinds of
antidepressants.
Overall, the probabilities of "full recovery" from bipolar disorder (that
is, being symptom free for a period of four to seven years) are
discouraging.
CAUSAL FACTORS IN BIPOLAR DISORDER
1. Biological Causal Factors
i. Hereditary Factors: there is a significant genetic component to
bipolar disorder, one that is stronger than that for unipolar disorder.
Although family studies cannot by themselves establish a genetic
basis for the disorder, results from twin studies also point to a genetic
basis. The concordance rates for these disorders are much higher for
identical than for fraternal twins.
The finding of elevated rates of both bipolar and unipolar forms of the
disorder in the relatives of bipolars can be taken in one of two ways.
One possibility is that the bipolar disorder does not "breed true" - that
is, that bipolar genes do not specifically predispose for bipolar
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disorder, but also for unipolar disorder. Overall, no consistent support
yet exists for any specific mode of genetic transmission of the bipolar
disorders according to several comprehensive reviews.
ii. Biochemical Factors: The monoamine hypothesis for unipolar
disorder was extended to bipolar disorder with the hypothesis being
that if depression was caused by deficiencies of norepinephrine and/or
serotonin, then perhaps mania is caused by excesses of these
neurotransmitters. Although there is some evidence for increased
norepinephrine activity during manic episodes, serotonin activity
appears to be low in both depressive and manic phases. More recently
it has been suggested that norepinephrine, serotonin, and dopamine
are all involved in regulating our mood states. Disturbances in the
balance of these neurotransmitters seem to be the key to
understanding this debilitating illness that can send its victims on an
emotional roller-coaster, although exactly how is not yet clear. Thus,
in mania both dopamine and norepinephrine appear to be elevated.
One of the thorniest issues that must be addressed by any theory is
how lithium, the most effective and widely used drug in the treatment
of bipolar disorder, can stabilize individuals from both depressive and
manic episodes. We know that lithium is closely related chemically to
sodium and that sodium plays a key role in the passage of the neural
impulse down an axon. Therefore, questions have been raised
regarding whether bipolar patients have abnormalities in the way ions
(such as sodium) are transported across the neural membranes.
Although the abnormality has not yet been identified, research
suggests that there is indeed some such kind of abnormality in bipolar
disorder. [provide only a gist of the cause]
iii. Other Biological Causal Factors: Some hormonal research on
bipolar depression has focused on the hypothalamic-pituitary-adrenal
axis. Bipolar patients, when depressed, show evidence of
abnormalities on the dexamethasone suppression test (DST), at about

15
the same rate as do unipolar depressed patients. When manic,
however, their rate of abnormalities has generally (but not always)
been found to be much lower. Research has also focused on
abnormalities of the hypothalamic-pituitary-thyroid axis because
abnormalities of thyroid function are frequently accompanied by
changes in mood. Many bipolar patients have subtle but significant
abnormalities in the functioning of this axis, and administration of
thyroid hormone is known at times to make antidepressant drugs work
better. However, thyroid hormone can also precipitate manic episodes
in bipolar patients.
There is also considerable evidence regarding disturbances in
biological rhythms in bipolar disorder. During manic episodes,
bipolar patients tend to sleep very little (seemingly by choice, not
because of insomnia). During depressive episodes, they tend toward
hypersomnia (too much sleep). Bipolar disorder also sometimes
shows a seasonal pattern as does unipolar disorder, suggesting
disturbances of different biological rhythms.
Blood flow to the left prefrontal cortex is reduced during depression,
during mania it is reduced in the right frontal and temporal regions.
During normal mood, blood flow across the two brain hemispheres is
approximately equal. Thus there are shifting patterns of brain activity
during mania and during depressed and normal moods. [provide only
a gist of the cause]
2. Psychosocial Causal Factors in Bipolar Disorder
i. Stressful Life Events: Early in the course of bipolar disorder,
stressful life events preceding manic or depressive episodes may be
precipitants. It has long been argued that as the illness unfolds, the
manic and depressive episodes become more autonomous and do not
usually seem to be precipitated by stressful events. A significant
association between the occurrence of high levels of stress and the

16
experience of manic, hypomanic, or depressive episodes has been
found.
Indeed, one study even found that patients with more prior episodes
were more likely to have episodes following major stressors than
patients with fewer prior episodes.
How might stressful life events operate to increase chance of relapse?
One hypothesized mechanism is through the destabilizing effects that
stressful life events may have on critical biological rhythms, which
are strongly implicated in biological views on bipolar disorder.
Although evidence in support of this idea is still preliminary, it
appears to be a promising hypothesis.
There are also some recent evidence that personality and cognitive
variables may interact with stress in determining the likelihood of
relapse. For example, one study found that bipolar individuals who
were highly introverted or obsessional were especially responsive to
stress. Another found that students with a pessimistic attributional
style who also had negative life events showed an increase in
depressive symptoms whether they were bipolar or unipolar
depressive.
3. Psychodynamic Views
According to psychodynamic theorists, manic and depressive
disorders may be viewed as two different but related defense-oriented
strategies for dealing with severe stress.
Manic persons try to escape their difficulties by a "flight into reality" -
that is, they try to avoid the pain of their inner lives through outer-
world distractions. In hypomania, the less severe form, this type of
reaction to stress is shown by a person who goes on a round of parties
to try to forget a broken love affair or tries to escape from a
threatening life situation by restless action, occupying every moment
with work, athletics, sexual affairs, and countless other activities - all

17
performed with professed gusto but not necessarily with true
enjoyment. In full-blown mania, this pattern is exaggerated. With a
tremendous expenditure of energy a manic person tries to deny
feelings of helplessness and hopelessness and to play a role of
domineering competence. Once this mode of coping with difficulties
is adopted, it is maintained until it has spent itself in emotional
exhaustion, for the only other alternative is an admission of defeat and
inevitable depression. Thus, as a manic episode proceeds, any
defensive value it might originally have had is negated, for thought
processes are speeded up to a point where an individual can no longer
process incoming information with any degree of efficiency. This
results in behaviour that is highly erratic at best and incomprehensible
at the extreme. Although a manic person may appear to have high
self-esteem (and even be quite grandiose), there is one study
supporting the idea that this may be a defensive posture.
According to psychodynamic views about bipolar disorder, the shift
from mania to depression may tend to occur when the defensive
function of the manic reaction breaks down. Similarly, the shift from
depression to mania may tend to occur when an individual, devalued
and guilt-ridden by inactivity and an inability to cope, finally feels
compelled to attempt some countermeasure, however desperate.
Although the view of manic and depressive reactions as extreme
defenses may seem plausible up to a point, it is difficult to account
satisfactorily for the more extreme versions of these states without
acknowledging the importance of biological causal factors. The
effectiveness of biological treatment in alleviating severe episodes
lends support to the importance of biological causal factors.
4. Socio-cultural factors affecting unipolar and bipolar disorders
Research on the association of sociocultural factors with both bipolar
and unipolar mood disorders is discussed together because much of
the research conducted in this area has not made clear-cut diagnostic

18
distinctions between the two types of disorder. The prevalence of
mood disorders seems to vary considerably among different societies:
in some, mania is more frequent, while in others, depression is more
common.

[*** TREATMENTS AND OUTCOMES

Many patients who suffer from mood disorders (especially unipolar
disorder) never seek treatment, and without formal treatment, the
great majority of manic and depressed patients will recover (at least
temporarily) within less than a year. However, given the wide variety
of treatments that are available today, and given the enormous amount
of personal suffering and lost productivity that depressed and manic
individuals endure, more and more people who experience these
disorders are seeking treatment.
i. Pharmacotherapy and Electroconvulsive Therapy:
Antidepressant, antipsychotic, and antianxiety drugs are all used in
the treatment of unipolar and bipolar disorders. For most moderately
to seriously depressed patients, including those with dysthymia, the
drug treatment of choice since the 1960s until the past decade had
been one of the standard antidepressants (called tricyclics because of
their chemical structure). The efficacy of the tricyclics has been
demonstrated in hundreds of studies where the response of depressed
patients given these drugs has been compared with the response of
patients given a placebo.
Unfortunately, the tricyclics have unpleasant side effects such as dry
mouth, constipation, sexual dysfunction, and weight gain, and many
patients do not continue long enough with the drug for it to have its
antidepressant effect. In addition, because these drugs are highly toxic
when taken in large doses, there is some risk in prescribing them for
suicidal patients who might use them for an overdose. Finally, if a
patient has bipolar disorder (either known or not yet diagnosed
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because of no prior manic episode), treatment with an antidepressant
can sometimes precipitate a manic episode or precipitate rapid-cycling
form of bipolar disorder.
ii. Selective Serotonin Re-uptake Inhibitors: For all these
reasons, physicians are increasingly choosing to prescribe one of the
antidepressants from the selective serotonin re-uptake inhibitors
(SSRIs), a new category of drugs that tend to have many fewer side
effects and are better tolerated by patients, as well as being less toxic
in large doses. One of these, Prozac (fluoxetine), is now extremely
popular among physicians in various specialties, not only to treat
significant depression but also for people with mild depressive
symptoms.
iii. Lithium and Other Mood-Stabilizing Drugs: Lithium therapy
has now become widely used as a mod stabilizer in the treatment
of both depressive and manic episodes of bipolar disorder. The term
mood stabilizer is often used to describe these drugs because they
have both anti-manic and anti-depressant effects-i.e., mood-stabilizing
effects in either direction.
iv. Electroconvulsive Therapy: Because antidepressants often take
three to four weeks to produce significant improvement,
electroconvulsive therapy (ECT) is often used with severely
depressed patients who may present an immediate and serious suicidal
risk including those with psychotic or melancholic features. ECT is
also used with patients who have not responded to other forms of
pharmacological treatment; it is frequently considered the treatment of
choice for the elderly who often either cannot take antidepressant
medications or who do not respond well to them.
v. Psychotherapy: In the best of circumstances, the drugs or drugs
plus electroconvulsive therapy that are used in the treatment of
depression are combined with individual or group psychotherapy

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directed at helping a patient develop a more stable long-range
adjustment.
Cognitive-Behavioural Therapy - Two of the best known of these
depression-specific psychotherapies for unipolar depression are the
cognitive-behavioural approach the interpersonal therapy (IPT)
program. Cognitive-behavioural techniques consist of highly
structured, systematic attempts to teach people with unipolar
depression to evaluate their beliefs and negative automatic thoughts
systematically. They are also taught to identify and correct their
biases or distortions of information processing, and to uncover and
challenge their underlying depressogenic assumptions. Cognitive
therapy relies heavily on an empirical approach, in that patients are
taught to treat their beliefs as hypotheses that can be tested through
the use of behavioural experiments.
Family and Marital Therapy: Of course, in any treatment program,
it is important to deal with unusual stressors in a patient's life, because
an unfavourable life situation may lead to a recurrence of the de
pression and may necessitate longer treatment.
A great need remains to study the factors that put people at risk for
depressive disorders and to apply relevant findings to early
intervention and prevention.

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