# Motivation and emotion/Book/2021/Affective disorders

* Multimedia presentation (3 min)

## Overview

Affective disorders are psychological disorders characterised by abnormalities of emotional state, commonly referred to as mood disorders (Scott, 1996). Affective disorders may include manic (elevated, expansive, or irritable mood with hyperactivity, pressured speech, and inflated self-esteem) or depressive (dejected mood with disinterest in life, sleep disturbance, agitation, and feelings of worthlessness or guilt) episodes, or a combination of both (Goodwin & Jamison, 2007). The diagnosis of an affective disorder relies on a thorough clinical assessment of a patient's signs, symptoms and past history (American Psychiatric Association [APA], 2013).
This chapter discusses affective disorders and illustrates how theories of emotion can enhance our understanding of the mechanisms underlying these disorders. An emotion is defined as a brief response to salient environmental events that includes changes in subjective experience, behaviour, and physiology (Watson, 2000). Emotional reactions function to facilitate adaptive behaviour to the current environmental context. (Gruber, 2011).
* Focus questions:
* What affective disorders occur?
* What causes them?
* How can they be managed?

## What are the types of affective disorders?

Affective or 'mood' disorders include:

### Depression

Depression can be described as mild, moderate or severe; melancholic or psychotic. Symptoms of depression interfere with all areas of a person's life, including social relationships and work (Holtzheimer III & Nemeroff, 2006).
Depression includes the following subtypes:
* Major depressive disorder (MDD): A prevalent, heterogeneous illness characterised by depressed mood, anhedonia, and altered cognitive function. The lifetime prevalence is approximately 17% of the population and is usually ﬁrst noticed during adolescence or early adulthood. (Kessler, et al., 2005). It is a major cause of death (mainly from suicide) and disability (Mann et al., 2013) and is a significant socio-economic burden. There is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities (APA, 2013). * Dysthymia: Symptoms are similar to MDD but less severe and symptoms last longer. A person has to have this milder depression for more than two years for diagnosis (APA, 2013).
* Seasonal affective disorder (SAD): Recurrent depressive episodes, occurring typically in winter. Episodes are mostly mild to moderate severity, with marked impairment of functioning at work and socially and an increased appetite and duration of sleep (Magnusson & Boivin, 2003).
* Postpartum depression and antenatal depression: An episode of major or minor depression that occurs during pregnancy (antenatal) or the first 12 months after birth. Postpartum depression is a common and serious mental health problem associated with maternal suffering and negative consequences for offspring (O'Hara & McCabe, 2013). *Atypical depression: Significant mood reactivity accompanied by two of four associated features including significant degrees of hyperphagia or weight gain, hypersomnia, leaden paralysis and pathologic rejection sensitivity (Mann et al., 2013).

### Bipolar

Bipolar disorder (BD) is a severe, chronic mood disorder, previously known as 'manic depression' because the person experiences periods of depression and periods of mania, with periods of normal mood in between. It is associated with high rates of comorbidity and is a leading cause of premature mortality due to suicide. BD often results in enduring work and social impairment. Typical onset occurs in late adolescence to early adulthood. BD has a population prevalence of around 1%–5%, however, evidence suggests this may be a substantial underestimation, due to difficulties in diagnosis (Fagiolini, et al., 2013).
Bipolar includes the following subtypes:
* Bipolar I: At least one manic episode which may be preceded by and may be followed, by a hypomanic or major depressive episode (APA, 2013).
* Bipolar II: Frequent alternation between periods of depression and hypomania causes significant distress or impairment in social, occupational or other important areas of functioning.
* Cyclothymia: Often described as a milder form of bipolar disorder as the duration of the symptoms are shorter, less severe and not as regular. A 15-50% risk it will develop into BP I or BP II (APA, 2013).

## Signs and symptoms of affective disorders

* Case study
* Emily's family have been noticing over the past couple of months that Emily, who is 16 years old, has become withdrawn and sad. She has stopped playing netball, avoids going out with friends and spends a lot of time alone in her room. She always looks tired and says she is not sleeping. Even her usually ravenous appetite has dissipated. Her teacher has said that she has been missing classes and that her grades have dropped. Concerned, Emily's parents arranged for her to see a psychiatrist who diagnosed her with major depressive disorder.
Symptoms of affective disorders can range from mild, such as worry, sadness and mood dysregulation to severe, such as suicide attempts. Mood disturbance symptoms were historically interpreted as normative and transient events of development (Weller et al., 2005).
Bipolar disorder is diagnosed in patients with manic and depressive features and major depression is diagnosed for those with depressive symptoms only (Power, 2004).
The Diagnostic and Statistical Manual of Mental Disorders (2013) outlines the following diagnostic criteria:

#### Bipolar disorders

Bipolar I: it is necessary to meet the following criteria for a manic episode[factual?].
Manic episode:
* A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.
* During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms are present to a significant degree and represent a noticeable change from usual behavior:
*** Inflated self-esteem or grandiosity.
** Decreased need for sleep.
** More talkative than usual or pressure to keep talking.
** Flight of ideas or subjective experience that thoughts are racing.
** Distractibility.
** Increase in goal-directed activity or psychomotor agitation.
** Excessive involvement in activities that have a high potential for painful consequences.
Hypomanic episode (same criteria as above but the period lasts at least 4 consecutive days).
Bipolar II: it is necessary to meet the criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode, there has never been a manic episode.
Cyclothymia: chronic, fluctuating mood disturbance with numerous periods of hypomanic symptoms and periods of depressive symptoms, but does not meet the full criteria for either.
[factual?]

#### Major depressive disorder:

At least five of the following criteria, must co-occur during the same period of time and symptoms are experienced most days and last for at least two weeks[factual?]:
* Depressed mood most of the day.
* Markedly diminished interest or pleasure in all, or almost all, activities most of the day.
* Significant weight loss when not dieting or weight gain, or decrease or increase in appetite.
* Insomnia or hypersomnia.
* Psychomotor agitation or retardation.
* Fatigue or loss of energy.
* Feelings of worthlessness or excessive or inappropriate guilt.
* Diminished ability to think or concentrate, or indecisiveness.
* Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

## What causes affective disorders?

The risk factors associated with affective disorders can be broken down into two main categories, biological and psychosocial.

#### Biological factors

* Family history is one of the strongest and most consistent risk factors in bipolar disorders, with an average of a ten fold increased risk. This has been shown in family, twin, and adoption studies (Goodwin & Jamison, 1990).
* Depression has a higher prevalence in females (APA, 2013).
* Genetic vulnerability in temperament.
* Genes are an important cause of affective disorders, however the identity of the responsible genes is not yet confirmed (Mann, 2013).
* MDD is characterized by increased brain activity in many ventral brain structures, including limbic structures, and hypoactivity in dorsal and lateral prefrontal cortex. These brain areas which regulate emotional, cognitive, autonomic, sleep, and stress response behaviors, are impaired (Power, 2004).

#### Psychosocial factors

* Poor social support.
* Abusive experiences.
* Bullying or exclusion from peer group.
* Stressful life events (e.g. a death) and conflict (Fink, 2009).
* Poor marital and familial relationships.
* Bipolar is more common in high income countries. Separated, divorced or widowed people have higher rates of BP I (APA, 2013).

## How can affective disorders be treated?

The main types of treatment are psychological therapy and/or medication, however, successful treatment may involve a combination of psychotherapy, education and pharmacotherapy. For patients who cannot tolerate medication or do not wish to, there is growing evidence to support alternative therapies.[factual?]

### Pharmacological

Although pharmaceutical treatments are effective, a significant number of patients do not respond or achieve sustained remission despite aggressive management (Holtzheimer III & Nemeroff, 2006).
* Serotonin norepinephrine reuptake inhibitors (SNRIs): antidepressant that inhibits the reuptake of serotonin and norepinephrine (neurotransmitters involved in mood regulation).
* Selective serotonin reuptake inhibitors (SSRIs): antidepressant which acts to selectively block the reuptake of only serotonin.
* Monoamine oxidase inhibitors (MAOIs): antidepressants that inhibit the activity of one or both monoamine oxidase enzymes. Mainly used for treatment-resistant and atypical depression.
* Tricyclic antidepressants (TCAs): antidepressants that inhibit the reuptake of monamines, norepinephrine and serotonin. Largely replaced by SSRIs and SNRIs.
* Mood stabilisers: psychiatric medications used to treat mood disorders.
* Lithium facilitates the release of serotonin, and increases activity of postsynaptic norepinephrine, serotonin, and dopamine receptors. Used for maintenance treatment of bipolar disorder to prevent episodes of mania and depression, and in major depressive disorder for prevention of recurrence of depressive episodes (Mann et al., 2013).
* Anticonvulsants such as Lamotrigine – for bipolar disorder maintenance therapy, and Carbamazepine – for treatment of acute manic or mixed episodes in bipolar I.
* Antipsychotic drugs to treat bipolar disorder or treatment resistant depression.

### Psychological

* Cognitive behavioural therapy is one of the most widely used and best studied psychotherapies. It aims to:
** educate patients about their conditions and to help them gain greater awareness of the functional relationships between how and what they are thinking and their emotional and behavioral difficulties
** learn and master more adaptive ways of coping with problems. Includes behavioral activation strategies, such as graded task assignments and scheduled participation in activities intended to increase involvement in activities that are associated with feelings of fulfillment (mastery) and enjoyment (pleasure) (Mann, et al., 2013). Cognitive therapy appears to reduce the risk of depressive relapse and may have a more durable effect than pharmacotherapy alone (Scott, 1996).
* Interpersonal psychotherapy frames therapy around a central interpersonal problem in the patient's life, a current crisis or relational predicament that is disrupting social support and increasing interersonal stress. By mobilising and working collaboratively with the patient to resolve this problem, IPT seeks to activate several interpersonal change mechanisms. These include (Lipsitz & Markowitz, 2013).:
** enhancing social support
** decreasing interpersonal stress
** facilitating emotional processing
** improving interpersonal skills

### Other

Remission of illness in patients with major depressive disorder (MDD) is achieved in less than half of patients initially treated with medication, in which case alternate treatments may be considered (Holtzheimer III & Nemeroff, 2006).
* Electroconvulsive therapy (ECT): an effective medical treatment for severe and persistent psychiatric disorders, whereby an epileptic seizure is induced in the brain. It relieves depressed mood and thoughts of suicide, as well as mania (Fink, 2009).
* Transcranial direct current stimulation (tDCS): A non-invasive brain stimulation method used to modulate cortical excitability, producing facilitatory or inhibitory effects upon a variety of behaviours (Thair et al., 2017). It changes cortical tissue ‘excitability' by applying a weak (0.5-2 mA) direct current to specific brain areas via electrodes placed on the scalp.
* Transcranial magnetic stimulation (TMS): is a powerful, non-invasive tool. A pulsed magnetic field creates current flow in the brain and can temporarily excite or inhibit specific areas, even beyond the time of stimulation (Hallett, 2000).
* Protective factors: sleep hygiene, exercise, healthy eating.

## Theories of emotion

Theories of emotion can assist our understanding of the aetiology, course, and treatment of affective disorders. Depressive and bipolar disorders involve disturbed emotional responses which theories can help explain.

#### Self regulation theory

Self-regulation theory stems from Bandura's social cognitive theory. It outlines the process and components involved when we decide what to think, feel, say, and do. It is about individuals working towards goals so as to maintain emotional comfort and decrease the affect of a negative health event on their daily lives. Steps include: identify, cause, timeline, consequences, control/ cure.
Baumeister (2007) suggests there are four components involved:
* Standards of desirable behavior;
* Motivation to meet standards;
* Monitoring of situations and thoughts that precede breaking standards;
* Willpower allowing one’s internal strength to control urges.
Bandura (1991), states self-regulation is a continuously active process in which we:
* Monitor our own behavior, the influences on our behavior, and the consequences of our behavior;
* Judge our behavior in relation to our own personal standards and broader, more contextual standards;
* React to our own behavior (i.e., what we think and how we feel about our behavior)
Social cognitive theory
Bandura's social cognitive theory suggests that people are shaped by the interactions between their behaviors, thoughts, and environment. Human behavior is learned through observation, imitation and reinforcement (Bandura, 1991). People with depression tend to hold themselves completely responsible for bad things in their lives and are full of self-blame. Successes tend to get viewed as having been caused by external factors outside of the person's control. In addition, people with depression tend to have low levels of the belief that they are capable of influencing their situation (known as self-efficacy).

#### Locus of control

Rotter's concept of locus of control (Rotter, 1954), posits when people believe that they can affect and change their situations, they may be said to have an internal locus of control and a relatively high sense of self-efficacy. When individuals feel that they are mostly at the mercy of the environment and cannot change their situation, they have an external locus of control, and a relatively low sense of self-efficacy. People with depression tend to have an external locus of control and a low sense of self-esteem.

#### Classical and operant conditioning

* Classical conditioning proposes depression is learned through associating certain stimuli with negative emotional states.
* Operant conditioning states that depression is caused by the removal of positive reinforcement from the environment (Lewinsohn, 1974). Certain events, such as losing your job, induce depression because they reduce positive reinforcement from others (e.g. being around people who like you). Depression can also be caused through inadvertent reinforcement of depressed behavior by others.

#### Learned helplessness

The learned helplessness model of depression claims that a belief in independence between responding and reinforcement is central to the aetiology, symptoms, and cure of reactive depression (Miller & Seligman, 1975, p. 228).
Seligman (1974) explained depression in humans in terms of learned helplessness, whereby the individual gives up trying to influence their environment because they have learned that they are helpless as a consequence of having no control over what happens to them. As a consequence they become passive and will endure aversive stimuli or environments even when escape is possible. Seligman based his theory on research using dogs. A dog put into a partitioned cage learns to escape when the floor is electrified. If the dog is restrained whilst being shocked it eventually stops trying to escape. Dogs subjected to inescapable electric shocks later failed to escape from shocks even when it was possible to do so.

#### Cognitive theory

Beck's Cognitive Model of Depression (1967) shows how early experiences can lead to the formation of dysfunctional beliefs, which in turn lead to negative self views, which in turn lead to depression. According to Beck’s cognitive theory of affective disorder, individuals with extreme dysfunctional assumptions are prone to developing affective disorders such as depression (Power, 2004). Beck identified three mechanisms responsible for depression:
* The cognitive triad (of negative automatic thinking)
* Negative self schemas
* Errors in Logic (i.e. faulty information processing)
The cognitive triad are three forms of negative thinking that are typical of individuals with depression: namely negative thoughts about the self, the world and the future. This triad interferes with normal cognitive processing, leading to impairments in perception, memory and problem solving with the person becoming obsessed with negative thoughts.

#### Positive emotion persistence

This theory explains how positive emotions may go awry in bipolar disorder. Bipolar disorder is associated with large positive emotional responses both when anticipating and in response to rewarding stimuli. Bipolar disorder involves periods of abnormally and persistently elevated mood (APA, 2013). Troubled emotional functioning that promotes an upwards spiral of positive mood states, can lead to negative outcomes such as engaging in risky or problematic behaviours or the persistence of good feelings in situations that call for wariness to potential threats (Gruber, 2011).
Quiz
1
What did Seligman base his research on?
Mice
Dogs
Humans
2
Which is one of the most common psychotherapies?
Chat therapy
Cognitive behavioural therapy
Cognitive bias therapy :

## Conclusion

Many people who suffer from affective disorders are able to manage their symptoms through ongoing treatment or develop strategies to lead healthy, functional lives.
Affective disorders are potentially long-term or even lifelong. Maintenance therapy is designed to prevent relapse in patients in remission. Work is undertaken on recognition of early signs of relapse and coping techniques. This includes developing self-monitoring of symptoms, identifying possible prodromal features (the “relapse signature”), developing a list of “at risk situations” (e.g. exposure to situations that activate specific personal beliefs), high risk behaviours (e.g. increased alcohol intake), combined with a hierarchy of coping strategies for each; identifying strategies for managing medication intake and obtaining advice regarding it; and planning how to cope and self-manage problems after discharge from cognitive therapy. Family-focused psychoeducation is to educate patients and their families/spouses about affective disorders, enhance communication skills and family social support, and teach patients problem-solving skills in order to reduce the chance of relapse (Power, 2004).
Self-management techniques provide people with the information and skills to help them actively manage some or all of the key aspects of their disorder. It enables individuals to make informed choices about the treatments and approaches they wish to pursue to manage their health and well-being. The added beneﬁt is that they gain conﬁdence about their capacity to take control of their lives (Power, 2004).
Theories of emotion are important in guiding therapy and reversing negative cognitions.
* Case study
* Emily sees a psychologist regularly and engages in cognitive behavioural therapy (CBT) which has helped her to understand and work towards improving her condition. She has a strong support network of family and friends and can talk more openly about her feelings.
* Focus question answers:
* What affective disorders occur?
* The two main groups are depression and bipolar and their associated subtypes.
* What causes them?
* There is typically a combination of biological and psychosocial factors that can predispose a person to suffer from an affective disorder.
* How can they be managed?
* The main types of treatment are psychological therapies and pharmacological. Alternate therapies include tDCS, TMS and electroconvulsive therapy. Treatment depends on the individual, health practitioner advice, and the severity of their illness. A combination of treatments and education can be successful. It is important for the patient to feel supported, through family focused therapy, individual and/or group therapy, and to maintain social connections.
* What are the take-home messages?
* Be aware of any persistent and significant symptoms impacting your mental wellbeing. Check up on family and friends and provide or seek support. With growing education and awareness, stigma surrounding affective disorders has reduced and is becoming normalised in society which aids those suffering in their recovery.