Chapter 5: Mood Disorders:
A mood can be defined as a sustained emotional state that lasts over a period of time, unlike
emotions, which are more spontaneous and reactive to a particular stimulus or event.
Mood disorder: A disorder where a person feels depressed and/or elated, and outwardly
shows signs of depression and/or mania for a significant period of time, and which is severe
enough to impair normal functioning, and which occurs in the absence of a clearly
identifiable trigger.
In the DSM-5, bipolar and depressive disorders have been split into two distinct categories,
where they were previously classified together under “Mood Disorders”.
Mood disorders are the most common disorders. The following definitions are important:
o Emotion: A complex psychophysical process that arises spontaneously, evokes a
positive or negative psychological response and physical expressions. Completely
involuntary. Brief experience of emotion regarding something.
o Feeling: This conveys information about situations, on both a conscious and a
subconscious level. Describe self in situation. More consistent than emotions.
o Affect: The scientific word for a person's mood as displayed in their behavioural
response. The ICD-10 usually refers to affect. Behavioural indication of a mood. Ex:
depression in teen boy –affect = irritability whereas 26yo woman might be more
tearful.
o Mood: Sustained emotional states that are less specific and intense, last longer and
are less likely to be triggered by a stimulus. The DSM-5 usually refers to mood.
To understand mood disorders, we must keep in mind:
o There are two extreme poles in mood disorders. We have dysphoria, which is a
depressive episode, and euphoria, which is a manic episode. If someone only
experiences one extreme, their disorder is unipolar, while bipolar is when the person
experiences both extremes.
o The severity of the symptoms. Everyone experiences both positive and negative
emotions throughout different situations in life. However, when an individual's
functioning is impaired by these emotions, one may find a mood disorder present.
o The duration of the symptoms. These differ from one mood disorder to the next. In
major depression, symptoms must be present for two weeks, while symptoms must
be present for two years for someone to be diagnosed with dysthymic disorder. With
bipolar disorder, symptoms of mania must be present for a week, while symptoms
must be present for two years for cyclothymia
1
, History
The first accounts of depression date back to the Mesopotamian era and is also found in the
writings of medical scholars from ancient Greek and Roman civilisation. Since then, there
have been many theories on what causes disorders, but the descriptions of these disorders
have remained fairly constant.
About 5-10% of South Africans suffer from Major Depression, which is very high when
compared to other countries, such as Belgium, France, Lebanon and Colombia. This is
influenced by socio-economic and political factors. Women (in South Africa) were at a higher
risk of major depression, especially those that were separated, widowed or divorced, and
those who only had basic schooling. Depression is the main cause for years (of productivity)
being lost in low, middle and high-income countries. There is not much difference in terms of
the prevalence of mental illness between developed and developing countries, except when
it comes to mood disorders –people in developing countries are more likely to develop a
mood disorder. A Kenyan study showed that women in urban areas were at the highest risk,
possibly due to two reasons –one being the lack of social support in urban areas, and the
other being the practise of polygamy in developing countries.
The DSM-5 accommodates the fact that mood disorders may develop in childhood in two
ways: Firstly, many of the criteria allow for the fact that symptoms may manifest differently
in childhood (for example, children might become irritable instead of depressed). Secondly, a
new disorder was created for children, and is called Disruptive Mood Dysregulation Disorder.
However, the worldwide peak age for the risk of depression is 32. In South Africa, it is 26. The
elderly also has a high risk for developing depression due to a lack of social support. In the
elderly, symptoms of depression include cognitive symptoms such as memory impairments,
which make it difficult to distinguish between depression and neurocognitive disorders.
Depression is also co-morbid (meaning it occurs alongside) with strokes, heart disease,
Parkinson's disease, etc.
Depressive Disorders:
This includes disorders that consist of a sad, empty or irritable mood.
Disruptive Mood Dysregulation Disorder:
Sometimes children show small signs of bipolar disorder, specifically no episodic irritability,
which can be attributed to this disorder rather than bipolar disorder. This disorder is limited
to children between 6 and 18 years of age, but most often manifests before the age of 10.
The main symptom of this disorder is chronic and severe irritability that manifests either as
frequent temper outbursts or an angry mood in-between temper outburst.
2
,This disorder is not classified as a bipolar disorder as it does not turn into bipolar disorder as
the child grows older. The most prominent symptom of disruptive mood dysregulation
disorder is an angry or irritable mood characterized by verbal or aggressive outbursts that are
out of proportion to the trigger. The outbursts occur at least 3 times each week. Outbursts
must occur both at two different locations, such as both home and school. Between
outbursts, the child’s mood is pervasively irritable and unhappy. This is not a covert
experience, as parents, teachers and others will notice that something is wrong. Further
DSM-5 diagnostic criterion requires that the pattern of behaviour must persist for at least 12
months.
Major Depressive Disorder:
This is also called “clinical depression”. It should be thought of as episodic as the minimum
duration of a depressive episode is two weeks but can last longer. The core features are a
depressed mood and the loss of interest or pleasure in most activities. It shouldn’t be
confused with temporary sadness or depression.
Other symptoms can be described as follows:
o Cognitive symptoms: Negative view of themselves, the world and the future; low self-
esteem; circular negative thought patterns which revolve around loss, guilt, suicide
and death; thought blocking, impaired concentration and forgetfulness.
o Somatic symptoms: Somatic symptoms are symptoms resulting in physical problems,
such as fatigue, lethargy, aches and pains, changes in appetite and weight, changes in
sleep patterns, anhedonia (lack of pleasure), loss of libido (sex drive). In the case of
depression, the main somatic symptom includes a loss of energy, disruptions in
sleeping patterns (either sleeping too much or, more commonly, not sleeping
enough), declined sexual activity, fatigue, loss of appetite, weight loss, (although
some people gain weight during a depressive episode).
o Behavioural symptoms: Depending on the type of depression the person is suffering
from, they may either experience psychomotor retardation (stooped posture, little
spontaneous movement, poor eye contact, impaired co-ordination, slow speech,
difficulty with articulation) or psychomotor agitation (general restlessness). Other
behavioural symptoms include social withdrawal, irritability, decreased rate and
volume of speech, monosyllabic answers, delayed responses, etc.
o Emotional symptoms: Dysphoric mood, sadness, feelings of guilt and worthlessness.
o Perceptual symptoms: Mood congruent hallucinations may occur, but they are rare.
Mood congruent hallucinations are hallucinations which adhere to the person's
mood, e.g. If the person is feeling guilty, this guilt might manifest in their
hallucinations.
3
, Diagnosed if someone experiences a depressive episode involving severe depressive
symptoms that has a negative effect on functioning most of the day, every day for at least
2 weeks.
Diagnostic Criteria for Major Depressive Disorder
(A.) Five (or more) of the following symptoms have to be present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is
either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, and hopeless) or observation made by others (e.g.,
appears tearful). (NOTE: in children and adolescence, can be irritable mood).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day
(as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g. A change of more than
5% of body weight in a month), or decrease or increase in appetite nearly every day.
(Note: in children, consider failure to make expected weight gain).
4. Insomnia or hypersonic nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feeling of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either
by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing suicide.
(B.) The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
(C.) The episode is not attributable to the physiological effects of a substance or to another
medical condition.
(D.) The occurrence of the major depressive episode is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or
other specified and unspecified schizophrenia spectrum and other psychotic disorders.
4
