CHAPTER 3

Mood and Anxiety Disorders

OBJECTIVES:
a.) To determine the different the different mood disorders
b.) To examine the common features of Anxiety Disorder
c.) To explore the different Anxiety disorder

❖ Depressive Disorders
Major Depressive Episode

A major depressive episode (MDE) is the building block for a diagnosis of major
depressive disorder (MDD): When a person has an MDE, he or she is diagnosed with
MDD. Symptoms of an MDE can arise in three areas: affect (anhedonia, weepiness, and
decreased sexual interest), behavior (vegetative signs), and cognition (sense of
worthlessness or guilt, diffi culty concentrating, and recurrent thoughts of death or
suicide). Most people who have an MDE return to their premorbid level of functioning after
the episode, but some people will have symptoms that do not completely resolve even
after several years.

Behavioral and Physical Symptoms

Psychomotor agitation is an inability to sit still, evidenced by pacing, hand

wringing, or rubbing or pulling the skin, clothes or other objects.

Psychomotor retardation is an slowing of motor functions indicated by slowed

bodily movements and speech and lower volume, variety, or amount of speech.

Vegetative signs (of depression) Psychomotor symptoms as well as changes in

appetite, weight, and sleep

Hypersomnia Sleeping more hours each day than normal. Prodrome Early
symptoms of a disorder. Premorbid Referring to the period of time prior to a patient’s
illness
Major Depressive Disorder

Major depressive disorder (MDD) The mood disorder marked by five or more
symptoms of an MDE lasting more than 2 weeks.

Age cohort is a group of people born in a particular range of years.

Depression is becoming increasingly prevalent in younger cohorts. Depression

and anxiety disorders have a high comorbidity—around 50%.
2 Patterns of seasonal affective disorder (SAD)

1. Winter depression is characterized by recurrent depressive episodes,

hypersomnia, increased appetite (particularly for carbohydrates), weight
gain, and irritability. These symptoms begin in autumn and continue through
the winter months. The symptoms either disappear or are much less severe
in the summer. Surveys fi nd that approximately 4–6% of the general
population experiences a winter depression, and the average age of onset
is 23 years
2. Summer depression, which is less common, tends to appear in late spring.
Symptoms often include poor appetite and weight loss, less sleep, and
psychomotor changes.

❖ Dysthymic Disorder

Dysthymic disorder differs from major depressive disorder in that it involves

fewer of the symptoms of a major depressive episode, but they persist for a longer
period of time. Specifi cally, dysthymic disorder is characterized by depressed
mood and as few as two other depressive symptoms that last for at least 2 years
and that do not recede for longer than 2 months at any time during that period .
Understanding Depressive Disorders
Neurological factors that contribute to depressive disorders can be classified
into three categories: brain systems, neural communication, and genetics. Stress
related hormones—which underlie a specific kind of neural communication—are
particularly important in understanding depressive disorders, and thus we consider
them in a separate section below
Brain systems- Researchers have refined this general observation and
reported that one aspect of depression—lack of motivated behavior—is specifically
related to reduced activity in the frontal (and parietal) lobes (Milak et al., 2005). In
addition, these researchers report that depression does not simply reflect that the
brain as a whole has become sluggish. Rather, they found that more severe
depression is associated with greater activity in the emotion-related limbic system,
which fi ts with the idea that emotions are not being effectively regulated.
Neural communication- depression is not caused by too much or too little of
a specific neurotransmitter. Instead the disorder arises in part from complex
 interactions among numerous neurotransmitter substances, which depend on how
much of each is released into the synapses, how long each substance lingers in
the synapse, and how the substances interact with receptors in other areas of the
brain that are involved in the symptoms of depression
Stress related hormones-

Psychological Factors affects Depressive Disorders

1. Attentional Biases
2. Dysfunctional Thoughts
3. Rumination
Social Factors affects Depressive Disorders
1. Stressful Life Events
2. Social Exclusion
3. Social Interactions
4. Culture
5. Gender Difference
Treating Depressive Disorders
Biomedical treatments that target neurological factors for depressive disorders are
medications (SSRIs, TCAs, MAOIs, SNRIs, St. John’s wort, and SAMe) and brain
stimulation (ECT or TMS).
Selective serotonin reuptake inhibitors (SSRIs)- Medications that slow the
reuptake of serotonin from the synapse.
Tricyclic antidepressants (TCAs)-Older antidepressants named after the three
rings of atoms in their molecular structure.
 Monoamine oxidase inhibitors (MAOIs) -Antidepressant medications that
increase the amount of monoamine neurotransmitter in the synapse.
Treatments for depression that target psychological factors include CBT
(particularly with behavioral activation).
Cognitive behavioral therapy (CBT) of psychological treatment that has been
demonstrated to be effective for a range of problems including depression, anxiety
disorders, alcohol and drug use problems, marital problems, eating disorders and severe
mental illness.
Treatments that target social factors include IPT and family systems therapy.
Interpersonal therapy for depression the links between mood and events in a patient’s
recent and current relationships .A family systems therapy is a family’s functioning may
be a target of treatment; this usually occurs when a family member’s depression is related
to either a maladaptive pattern of interaction within the family or a confl ict that arose
within the family.

❖ Bipolar Disorders
Building Blocks for Bipolar Disorders
Bipolar disorders Mood- disorders in which a person’s mood is often
persistently and abnormally upbeat or shifts inappropriately from upbeat to
markedly down.
Manic episode- A period of at least 1 week characterized by abnormal and
persistent euphoria or expansive mood or irritability.
Expansive mood -A mood that involves unceasing, indiscriminate enthusiasm
for interpersonal or sexual interactions or for projects.
Hypomanic episode-involves mood that is persistently elated, irritable, or
euphoric; unlike other mood episodes, hypomanic episodes do not impair
functioning
The Two Types of Bipolar Disorder
1. Bipolar I disorder- usually more severe—requires only a manic or mixed
episode; an MDE may occur but is not necessary for this diagnosis.
2. Bipolar II disorder- requires alternating hypomanic episodes and MDEs
and no history of manic or mixed episodes. Both disorders may involve rapid
cycling.
Cyclothymic Disorder
Cyclothmic disorder is a more chronic but less intense version of bipolar
II disorder.
Understanding Bipolar Disorders
Neurological factors that are associated with bipolar disorders include an
enlarged and more active amygdala. Norepinephrine, serotonin, and glutamate are
also involved. Bipolar disorders are influenced by genetic factors, which may
influence mood disorders in general.
Psychological factors that are associated with bipolar disorders include the
cognitive distortions and negative thinking associated with depression. Moreover,
some people with bipolar I disorder may have residual cognitive deficits after a
manic episode is over.
Social factors that are associated with bipolar disorders include disruptive
life changes and social and environmental stressors. The different factors create
feedback loops that can lead to a bipolar disorder or make the patient more likely
to relapse.

Treating Bipolar Disorders

Treatments that target neurological factors include lithium and
anticonvulsants, which act as mood stabilizers. When manic, patients may receive
an antipsychotic medication or a benzodiazepine. Patients with a bipolar disorder
who have MDEs may receive an antidepressant along with a mood stabilizer.
Treatment that targets psychological factors—particularly CBT—helps
patients recognize warning signs of mood episodes, develop better sleeping
strategies, and, when appropriate, stay on medication.
Treatments that target social factors include:
-interpersonal and social rhythm therapy (IPSRT), which can
increase the regularity of daily events and decrease social stressors;
-family therapy, which is designed to educate family members about
bipolar disorder, improve positive communication, and decrease
criticism by family members; and
- group therapy or a self-help group, which is intended to decrease
shame and isolation
❖ Suicide
Suicidal Thoughts and Suicide Risks
When suffering from a mood disorder, people may have thoughts of death
or thoughts about committing suicide, known as suicidal ideation
Neurological factors that are associated with suicide include structural
abnormalities in the frontal lobes and altered serotonin activity. In addition, suicide
may be associated with a genetic risk for mood disorders. Psychological risk
 factors for suicide include poor coping and problem-solving skills, distorted and
rigid thinking, and a sense of hopelessness. Variations in suicide rates across
countries point to the role of social factors in influencing people to commit suicide.
Understanding Suicide and Preventing Suicide

Suicide prevention efforts target neurological, psychological, and social factors.

Neurological factors are targeted by medications. Treatments that target
psychological factors are designed to ensure that the suicidal individual is safe and
then to help the person see past the hopelessness and rigidity that pervade his or
her thinking. Suicide prevention may also help the patient identify the stressors
that led him or her to feel suicidal and develop new solutions to the problems. To
address social factors, prevention programs may target risk factors that are
associated with suicide, such as child abuse
 Anxiety Disorders

❖ Common Features of Anxiety Disorders

Like the term depression, the words anxiety and anxious are used in
everyday speech. But what do mental health professionals and researchers mean
when using these terms? Anxiety refers to a sense of agitation or nervousness,
which is often focused on an upcoming potential danger.
Anxious apprehension Anxiety that arises in response to a high level of
fear of a particular stimulus.
Anxiety disorder .A category of psychological disorders in which the
primary symptoms involve extreme anxiety, intense arousal, and/or extreme
attempts to avoid stimuli that lead to fear and anxiety.
Fight-or-fl ight response. The automatic neurological and bodily response
to a perceived threat; also called the stress response.
Panic. An extreme sense (or fear) of imminent doom, together with an
extreme stress response.
Phobia. An exaggerated fear of an object or a situation, together with an
extreme avoidance of the object or situation.
The high comorbidity of depression and anxiety disorders suggests that the
two disorders share some of the same features, specifically high levels of negative
emotions and distress—which can lead to concentration and sleep problems and
irritability.

❖ Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by uncontrollable
worry and anxiety about a number of events or activities (which are not solely the
focus of another Axis I disorder, such as about having a panic attack).

Neurological factors associated with GAD include:

• more gray and white matter in the areas of the brain related to
hearing and language comprehension—the superior temporal
gyrus—particularly in the right hemisphere. Moreover, unlike most
other anxiety disorders, GAD is associated with decreased arousal
because the parasympathetic nervous system is extremely
responsive.
• unusually strong activation in the right front lobe when viewing angry
faces, which may be related to the operation of coping mechanisms.
• abnormal activity of serotonin, dopamine, and other
neurotransmitters, which in turn infl uences motivation, response to
reward, and attention.
• a genetic predisposition to become anxious and/or depressed. This
predisposition, however, is not specifi c to GAD.
 Psychological factors that contribute to GAD include being hypervigilant for
possible threats, a sense that the worrying is out of control, and the reinforcing experience
that worrying prevents panic.
Social factors that contribute to GAD include stressful life events, which can
trigger the disorder.
Treatments for GAD include:
• medication (which targets neurological factors), such as buspirone
or an SNRI or SSRI when depression is present as a comorbid
disorder; and
• BT (which targets psychological factors), which may include
breathing retraining, muscle relaxation training, worry exposure,
cognitive restructuring, self-monitoring, problem solving,
psychoeducation, and/or meditation. CBT may be employed in a
group format.

❖ Panic Disorder (With and Without Agoraphobia)

Panic disorder is anxiety disorder characterized by frequent, unexpected
panic attacks, along with fear of further attacks and possible restrictions of
behavior in order to prevent such attacks.
The hallmark of panic disorder is recurrent panic attacks— periods of
intense dread, fear, and feelings of imminent doom along with increased heart rate,
shortness of breath, and other signs of hyperarousal. Panic attacks may be cued
by particular stimuli (usually internal sensations), or they may arise without any
clear cue. Panic disorder also involves fear of further attacks and, in some cases,
restricted behavior in an effort to prevent further attacks.
Agoraphobia is the persistent avoidance of situations that might trigger
panic symptoms or from which escape would be difficult.
Neurological factors that contribute to panic disorder and agoraphobia
include:
• A heightened sensitivity to detect breathing changes, which in turn leads
to hyperventilation, panic, and a sense of needing to escape. This
mechanism involves withdrawal emotions and the right frontal lobe, the
amygdala, and the hypothalamus.
• Too much norepinephrine (produced by an over-reactive locus
coeruleus), which increases heart and respiration rates and other
aspects of the fi ght-or-fl ight response.
• A genetic predisposition to anxiety disorders, which makes some people
vulnerable to panic disorder and agoraphobia.
Psychological factors that contribute to panic disorder and agora phobia include:
 • Conditioning of the initial bodily sensations of panic (interoceptive cues)
or of external cues related to panic attacks, which leads them to become
learned alarms and elicit panic symptoms. Some individuals then
develop a fear of fear and avoid panic-related cues.
• Heightened anxiety sensitivity and misinterpretation of bodily symptoms
of arousal as symptoms of a more serious problem, such as a heart
attack, which can, in turn, lead to hypervigilance for—and fear of—
further sensations and cause increased arousal, creating a vicious
cycle.
Social factors related to panic disorder and agoraphobia include
• greater than average number of social stressors during childhood and
adolescence
• the presence of a safe person, which can decrease catastrophic thinking
and panic
• Cultural factors, which can influence whether people develop panic
disorder.
The treatment that targets neurological factors is medication, specifically
benzodiazepines for short-term relief and antidepressants for long-term use.
CBT is the first-line treatment for panic disorder and targets psychological
factors. Behavioral methods focus on the bodily signals of arousal, panic, and
agoraphobic avoidance. Cognitive methods (psychoeducation and cognitive
restructuring) focus on the misappraisal of bodily sensations and on mistaken inferences
about them.
Treatments that target social factors include group therapy focused on panic
disorder, and couples or family therapy, particularly when a family member is a safe
person.
❖ Social Phobia (Social Anxiety Disorder)
Social phobia, also called social anxiety disorder, is an intense fear of public
humiliation or embarrassment, together with the avoidance of social situations likely to
cause this fear.
Psychological factors that give rise to social phobia include cognitive distortions
and hypervigilance for social threats— particularly about being (negatively) evaluated.
Classical conditioning of a fear response in social situations may contribute to social
phobia; avoiding feared social situations is then negatively reinforced (operant
conditioning).
Social factors that give rise to social phobia include parents’ modeling or
encouraging a child to avoid anxiety-inducing social interactions. Moreover, people in
different cultures may express their social fears somewhat differently (e.g., taijin
kyofusho). The rate of social phobia appears to be increasing in more recent birth cohorts.
Medication is the treatment that targets neurological factors, specifically, beta-
blockers for periodic performance anxiety, and SSRIs or SNRIs for more generalized
social phobia. The treatment that targets psychological factors is CBT, specifically,
exposure and cognitive restructuring. Treatments that target social factors include group
CBT and exposure to feared social stimuli.
❖ Specific Phobias
Specific phobia is the anxiety disorder characterized by excessive or
unreasonable anxiety or fear related to a specific situation or object.

Neurological factors, such as an overly reactive amygdala, appear to

contribute to specific phobias. Neurotransmitters involved in specific phobias
include GABA, serotonin, acetylcholine, and norepinephrine. Research suggests
a role for genetics as well: Some genes are associated with specific phobias
generally, whereas other genes are associated with particular types of specific
phobias.
Psychological factors that give rise to specific phobias include possibly
classical conditioning (but rarely), operant conditioning (negative reinforcement of
avoiding the feared stimulus), and cognitive biases related to the stimulus (such
as overestimating the probability that a negative event will occur following contact
with the feared stimulus).
Observational learning—a social factor—can influence what particular
stimulus a person comes to fear.
Treatment for specific phobias can include medication (targeting
neurological factors), specifically a benzodiazepine. However, medication is
usually not necessary because CBT—the treatment of choice for specific phobia—
is extremely effective (targeting psychological factors). CBT—particularly when
exposure is part of the treatment—can work in just one session.

❖ Obsessive-Compulsive Disorder
The key element of obsessive-compulsive disorder (OCD) is one or more
obsessions, which may occur together with compulsions (American Psychiatric
Association, 2000; see Table 7.13). The obsession can cause great distress and anxiety,
despite a person’s attempts to ignore or drive out the intrusive thoughts. It marked by
persistent and intrusive preoccupations and—in most cases—repetitive, compelled
behaviors that usually correspond to the obsessions. Although people with OCD
recognize that their obsessions are irrational, they cannot turn off the preoccupying
thoughts; they feel driven to engage in the compulsive behaviors, which provide only brief
respite from the obsessions.
 Neurological factors associated with OCD include disruptions in the normal
activity of the frontal lobes, the thalamus, and the basal ganglia; the frontal lobes do not
turn off activity of the neural loop among these three brain areas, which may lead to the
persistent obsessions. Lower than normal levels of serotonin also appear to play a role,
although this may be more directly related to some types of OCD than others. Genes
appear to make some people more vulnerable to anxiety disorders in general—not
necessarily to OCD specifically.
Psychological factors that may underlie OCD include negative reinforcement of
the compulsive behavior, which temporarily relieves the anxiety that arises from the
obsession. In addition, normal preoccupying thoughts may become obsessions when the
thoughts are deemed “unacceptable” and hence require controlling. In turn, the thoughts
lead to anxiety, which is then relieved by a mental or behavioral ritual. Like people with
other anxiety disorders, people with OCD have cognitive biases related to their feared
stimuli, in this case, regarding the theme of their obsessions.
Social factors related to OCD include socially induced stress, which can infl
uence the onset and course of the disorder, and culture, which can influence the particular
content of obsessions and compulsions.
Medication (such as an SSRI or clomipramine) is the treatment for OCD that
directly targets neurological factors. The primary treatment for OCD—exposure with
response prevention—directly targets psychological factors. Cognitive restructuring to
reduce the irrationality and frequency of the patient’s intrusive thoughts and obsessions
may also be employed. Family education or therapy, targeting social factors, may be used
as an additional treatment to help the patient’s family function in a more normal way.

❖ Posttraumatic Stress Disorder

Some people who experience a traumatic event go on to develop a stress
disorder, which according to DSM-IV-TR (American Psychiatric Association, 2000)
is marked by three types of persistent symptoms.
• Reexperiencing the traumatic event. Reexperiencing may involve
flashbacks that can include illusions, hallucinations, or a sense of reliving
the experience, as well as intrusive and distressing memories, dreams,
or nightmares of the event.
• Avoidance. The individual avoids anything related to the trauma. The
person may also experience a general emotional numbness.
• Increased arousal and anxiety. Arousal and anxiety symptoms include
difficulty sleeping, hypervigilance, and a tendency to be easily startled
(referred to as a heightened startle response).
DSM-IV-TR includes two types of stress disorders:
1. acute stress disorder, which is the diagnosis when the above
symptoms emerge within 4 weeks of a traumatic event and last less than
1 month and the person also experiences dissociation .
2. posttraumatic stress disorder (PTSD) is the diagnosis if the
symptoms last more than 1 month.
Psychological factors that exist before a traumatic event contribute to PTSD;
these factors include a history of depression or other psychological disorders, a belief in
being unable to control stressors, the conviction that the world is a dangerous place, and
lower IQ. After a traumatic event, classical and operant conditioning contribute to the
avoidance symptoms.
Social factors that contribute to PTSD include the stress of low socioeconomic
status and a relative lack of social support for the trauma victim. Culture can influence the
ways that individuals cope with traumatic stress.
Medication is the treatment that directly targets neurological factors, specifically
an SSRI. Treatments that target psychological factors include CBT, specifically
psychoeducation, exposure, relaxation, breathing retraining, and cognitive restructuring.
Treatments that target social factors are designed to ensure that the individual is as safe
as possible from future trauma and to increase social support through group therapy or
family therapy.