Guide to Dsm-iv Diagnoses: Mood Disorders

Mood disorders are problems with a person's general emotional state being inappropriate to the situation. There are two types: unipolar and bipolar mood disorders. To represent them, we use a visual mood spectrum that ranges from D (major depression) at the bottom to M (mania) at the top. (If you like diagrams, the HTML version of this article, complete with mood spectrum diagrams, is available at http://www.archetypewriting.com/articles/articles_ck/moodOverview.htm.)

We'll look at each area of the mood spectrum, but first, let's identify what "normal" is. Someone without a mood disorder may have changing emotional states throughout the day, but the person's moods, the ongoing emotional tones of his or her life, are fairly stable. More importantly, the person is able to manage his or her life from one day to the next, and feels extremely good, irritable, or bad only if something happens to cause those feelings.

Unipolar Disorders

People with unipolar mood disorders get depressed and only depressed.

Dysthymia

People with dysthymia, the mildest form of unipolar depression, tend to have a chronic case of the "blahs." Things aren't bad, exactly, it's just that sufferers don't enjoy much and often feel like they're going through the motions of life without getting much gratification in return. They often feel pessimistic or "bummed out," tired, indecisive, and/or bad about themselves and their lives; they also tend to have problems with appetite and sleep patterns.

Dysthymia tends to last, and last, and last, making the disorder a long-term, low-grade problem that wears on a person. Andrew Solomon describes it well in The Noonday Demon: An Atlas of Depression

Mild depression is a gradualthing that undermines people the way rust weakens iron Like physical pain that becomes chronic, it is miserable not so much because it is intolerable in the moment as because it is intolerable to have known it in the moments gone and to look forward only to knowing it in the moments to come.

Major Depression

Major or "clinical" depression, by contrast, usually comes in "waves" that can last anywhere from two weeks to years at a time. In between episodes many people with major depression feel "normal."

People with major depression have much more severe symptoms than people with dysthymia. They don't just feel bad about themselves, they feel worthless and hopeless; they don't just feel indecisive, they have trouble thinking, concentrating, and making decisions. They may experience overwhelming and inappropriate guilt, lose all motivation to pursue work and hobbies, experience mental and physical sluggishness, want to sleep all the time or have trouble sleeping at all, and contemplate suicide. Other symptoms include

* Crying spells
* Poor hygiene (not bothering to brush their hair, change their clothes, or wash regularly)
* Withdrawal from friends
* Weight loss because food no longer tastes good or a need to eat (often carbohydrates) and weight gain
* Chronic pain or aches that have no physical cause
* Excessive worry and guilt
* Sleep problems: Inability to fall asleep, waking up during the night, waking up early in the morning and not being able to go back to sleep, excessive sleeping, or daytime sleepiness
* Feeling overwhelmed by daily life tasks

Abraham Lincoln struggled with a major depressive disorder and was so consumed by thoughts of suicide he was afraid to carry even a pocketknife.

I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I can not tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.

Few people realize how painful major depression really is. Sufferers drown in an unending flood of self-loathing thoughts like those described by Lesley Dormen in Planet No:

One of the many things I hate about the word "depression" is the assumption of blankness attached to it, as if the experience of depression is as absent on the inside as it looks to be from the outside. That is wrong. Depression is a place that teems with nightmarish activity. It's a one-industry town, a psychic megalopolis devoted to a single twenty-four-hour-we-never-close product. You work misery as a teeth-grinding muscle-straining job (is that why it's so physically exhausting?), proving your shameful failures to yourself over and over again.

Bipolar Disorders

Let's start with terminology: Bipolar disorder and manic depression are the same thing.

German psychiatrist Emil Kraepelin, who created the first diagnostic system for psychology, brought the term "manic-depression" into common use, and it wasn't until 1994 that the disorder's name was changed in the Diagnostic and Statistical Manual of Psychological Disorders (DSM-IV) to "bipolar disorder" in an attempt to reduce the stigma that had come to be associated with it.

People with Bipolar Disorder experience both the "down" state already described in the major depression section above and an "up" state of "elevated, expansive, or irritable" moods.

In a full-blown manic state, people experience

* An increase in energy, flamboyance
* Decreased need for sleep (think little to none)
* Inflated self esteem, sometimes to the point of grandiosity
* Talkativeness to the point that they sound "pressured," as if they can't stop talking
* Racing thoughts, which usually manifests as jumping from topic to topic, sometimes so quickly they don't make much sense.
* Short attention span and easy distractibility (yes, this gets misdiagnosed as ADHD a lot)
* Poor judgment, often leading to decisions that are harmful, such as spending sprees, careless sex (even when married), and dangerous risk-taking
* Poor impulse control, including saying things that cause later repercussions
* Irritability and aggressiveness, including starting fights
* Strange thoughts not based in reality (delusions) and strange behaviors
* Increased sex drive
* Hallucinations (seeing, hearing, or feeling things that are not really there)

Allan Seager relates poet Theodore Roethke's experience of mania in From The Glass House: The Life of Theodore Roethke:

"For no reason I started to feel very good. Suddenly I knew how to enter into the life of everything around me. I knew how it felt to be a tree, a blade of grass, even a rabbit. I didn't sleep much. I just walked around with this wonderful feeling. One day I was passing a diner and all of a sudden I knew what it felt like to be a lion. I went into the diner and said to the counter-man, Bring me a steak. Don't cook it. Just bring it.So he brought me this raw steak and I started eating it. The other customers made like they were revolted, watching me. And I began to see that maybe it WAS a little strange."

Bipolar II

People with Bipolar II have major depressive episodes, but they also have hypomania -- periods of euphoria without the extremes and ridiculously poor judgment of true mania. Over the last decade, clinicians and researchers have realized that many people with recurrent depression that "resists" treatment or fails to be "cured" through normal means may also have bipolar disorder. When clinicians began treating these people with bipolar medications, most of them started to get better!

Symptoms that tend to suggest bipolar disorder even if there's never been a manic or hypomanic episode:

* Meds tend to "wear off" after a year or two (this is called "Prozac poop-out")
* Hypomania (feeling really good and becoming very productive) on higher levels of SSRIs or stimulants
* Early onset of symptoms -- bipolar disorder tends to show up in the teens; true unipolar depression doesn't usually appear until at least the mid-20s. The earlier the onset, the more likely it is to be bipolar, and a hypomanic or manic episode just hasn't happened yet
* High reactivity to the environment -- being "moody" in response to what's going on around you because you're really sensitive to it
* Feeling worse during the winter
* Abuse of alcohol or drugs (the alcoholism rate in people with bipolar disorder is 60%)
* Ongoing or repeated problems with depression rather than just one or two episodes
* "Treatment resistant" depression - not getting better with standard antidepressant treatments, or even feeling worse on them
* When depressed, symptoms are "atypical" (sleeping more than 10 hours a day, appetite goes up rather than down usually for fatty and carbohydrate heavy foods, extremely low activity and energy)

Mixed States

Many people with bipolar disorder experience mixed states, which means they're both depressed and hypomanic/manic at the same time. This tends to manifest as anger or irritability. The person has more energy than when in a pure depressive state, but still feels awful, leading to "prickly," aggressive, and/or angry feelings and behavior.

Genetics

What makes Bipolar disorder in particular a challenge is that it is a hereditary disease, and one that requires the individual to be on medication for life. It tends to get worse as one ages, partly because each time one has a manic episode, the brain becomes more prone to depression and additional manic episodes. Because hypomania and mania can feel good, it can be difficult to get people to take their medications, making them more prone to the devastating depressions.

Treatments

Because negative and "irrational" thoughts are such a big part of depression, therapy addressing them and teaching the person to think differently is one of the most effective treatments. Cognitive-behavioral therapy, which helps people identify and defeat irrational thoughts, has been shown to be particularly effective with depression, as has Interpersonal Therapy, which addresses relationships with others and ways to improve them.

Despite the importance of therapy, there are several things that indicate that medications might be a good idea:

1. There is a family history of depression, and other family members are taking (and have been helped by) medications.
2. The individual is so depressed that s/he is unable to do much work in therapy.
3. The individual is suicidal and needs symptom relief as quickly as possible.

Bipolar Disorder, by contrast, almost always requires medication, and the individual must continue that medication for life to avoid relapsing. Though hypomania and mania can feel good, they increase the likelihood of depressive episodes, so they are controlled through medication.

Individuals with bipolar disorder are often on a "cocktail" of medications including one or more antidepressants (to increase levels of the neurotransmitters serotonin and norepinephrine and thereby get rid of the depression), a mood stabilizer (to suppress hypomania and mania and to treat depression, especially treatment-resistant depressions), and sometimes an antipsychotic to reduce levels of a neurotransmitter called dopamine, which causes the delusions and hallucinations of extreme mania.