Pathology, Diagnosis, And The DSM-5

6 Depressive Disorders and Bipolar and Related Disorders

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Learning Objectives

After reading this chapter, you should be able to:

• Understand the difference between normal emotions and pathological emotions.

• Explain what depressive disorders are.

• Explain what bipolar and related disorders are.

• Know and discuss what causes depressive, bipolar, and related disorders.

• Explain and discuss how depressive, bipolar, and related disorders are treated.

• Analyze the relationships among depressive, bipolar, and related disorders and suicide.

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Depressive Disorders and Bipolar and Related Disorders

It is mid-June in a city known for a temperate climate. You awaken to a blue sky with puffy clouds; the sun is bright but not too hot, with low humidity. After eating your favorite break- fast, you go for a walk before heading off to your summer job. All seems right with the world, yet you are not happy. The sky appears gray to you, the sun covered by clouds. Breakfast seemed bland, almost tasteless. You didn’t sleep well; in fact, you awakened, again, in the middle of the night and couldn’t fall back to sleep. You were hoping to be intimate with your partner last night, but the desire and the drive remain missing.

Does this scenario sound familiar to you? Perhaps it sounds like an everyday experience for many people. Have you ever had days with some, if not all, of these experiences? Before we continue, consider the next scenario.

You awaken to the same sunny day, although this time the sun seems exceptionally bright and energizing. After making yourself a gourmet breakfast and wolfing it down in about three minutes, you go for a power walk, completing your usual course in record time and engag- ing everyone you pass in conversation, though the conversations have no connection to each other. Returning home, you decide, after showering, to clean the entire house as well as clean the windows and mow the lawn. You then head to work, put in a 13-hour day with a 15-min- ute lunch break, during which you consume a PowerBar and some Red Bull. At home you pre- pare a four-course meal from scratch. You should be tired but you’re not, so you call your best friend and see if she wants to go out to a bar for a few drinks. She calls it a night at 11 p.m., but you are going strong. You meet an attractive person and go back to his or her apartment for a while. You return home at about 2 a.m. and go to sleep. . .until 4 a.m., when you awaken, ready to start the new day, repeating this pattern for at least seven days.

How does the second scenario sound to you? Does this sound like a normal day and night for some people? Let’s take a closer look at what these scenarios seem to describe.

The first scenario could illustrate some of the classic signs of depression, including sadness, hopelessness, self-blame, anger, insomnia, and loss of appetite. Depression is one of several depressive, bipolar, and related disorders, abnormal conditions characterized by persistent extremes of mood. Depression represents one pole of a person’s mood (see Figure 6.1) and

is typically characterized by extreme sadness, lack of energy and sex drive, low self-worth, guilt, and oftentimes thoughts of suicide.

The second scenario might illustrate the other pole, which is known as mania. Mania is marked by extreme elation. People who are in the grip of mania have lots of energy, form grandiose plans (to make a fortune or cure cancer), display a cavalier attitude toward money, and usually have a strong sex drive. At first glance, this may not seem to be much of a problem; left unchecked, however, mania can cause just as many difficulties as depression.

Happily, most of us spend the bulk of our time some- where in the middle of the mood spectrum, neither very high nor very low. A telephone conversation, a walk in the park, or a dinner with friends can lift

EgudinKa/iStock/Thinkstock Typically, the majority of people are somewhere in the middle of the mood spectrum and experience a range of emotions that are neither very high nor very low.

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Depressive Disorders and Bipolar and Related Disorders

our mood. By contrast, a bad day at work, failing an exam, losing a tennis match, indeed any of life’s disappointments can bring on the “blues.” When our mood rises, we feel happy, ener- gized, confident, and optimistic. When we get the blues, we feel sad, tired, and pessimistic. When we are low, we may decide to drown our sorrows in a drink, or maybe just go to bed.

The main difference between the blues, an emotion we all experience, and a depressive disor- der is one of degree (Oyama & Piotrowski, 2017). The blues pass quickly. In a day or two, we pick ourselves up and start again. However, when a negative mood persists for a long period of time, affecting social and occupational functioning, clinicians begin to suspect the presence of a depressive disorder.

This chapter is concerned with the diagnosis, etiology, treatment, and prevention of depres- sive, bipolar, and related disorders. It also includes a discussion of suicide, which is some- times (but not always) caused by one of these disorders.

Figure 6.1: The mood spectrum

Most of the time, we find ourselves in the middle of the spectrum, not too high or too low. Notice that the two extremes, mania and depression, are closer to one another than they are to the normal mood state. In fact, some people cycle between depression and mania, and a few manage to be both depressed and manic at the same time.

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.1, p. 319.

Normal mood

Joy

Depression Mania

The “blues”

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Section 6.1 Emotions: Normal and Pathological

Before we continue, let’s examine the case of Bernard Louis, a man whose manic episodes severely affected his life.

The Case of Bernard Louis: Part 1

Note Dictated by Psychiatrist, Dr. Kahn, When Admitting Bernard Louis to the Hospital UNIVERSITY HOSPITAL

Intake Note

CONFIDENTIAL

Admitting Psychiatrist: Dr. Sally Kahn

Bernard Louis was brought involuntarily to the admitting ward by county police who were acting on a court order to have him committed for 24 hours of psychiatric observation.

Mr. Louis is a large man, well over 6 feet tall. He weighs more than 200 pounds. When he appeared at the hospital, his face was very red, and his hair and clothing were disheveled. Otherwise, he seemed normal. According to his wife, who accompanied him to the hospital, Mr. Louis had been working alone, 18 hours a day, building a “golf course” in their suburban backyard. His plan was to turn their half-acre lot into a private country club with a clubhouse. He hoped to sell memberships at $5,000 a year. The clubhouse would offer catering facilities as well as a bar and pro shop. He planned to build sand and water traps and to invest in a fleet of motorized golf carts. When his wife suggested that he might be getting a little carried away, Mr. Louis lost his temper, shouted in rage, and threatened to leave her for another woman. He claimed to have four girlfriends whom he regularly “satisfied” ten times a night. Two days earlier, when his wife had left the house, Mr. Louis had taken all her jewelry to a pawnshop. He had used the money to invite strangers off the street to an all-night party that finally had to be stopped by the police. Mr. Louis had not slept at all for three days before his wife obtained the court order that brought him to the hospital.

Mr. Louis was difficult to interview because he talked nonstop. He complained that he was being persecuted and that his wife was just jealous of the many women who were after him because of his sexual prowess. There was nothing wrong with him. In fact, he claimed, “I’ve never felt better in my life.” When asked if he was happy, Mr. Louis responded, “Am I happy? Why, if I felt any happier, you could sell tickets. I’m so happy, it should be illegal.”

See appendix for full case study.

6.1 Emotions: Normal and Pathological Admirers of the original (and often-replicated) Star Trek television series and films will recall the Starship Enterprise’s Vulcan officer, Mr. Spock. Spock differed from earthlings in two ways: He had odd, pointy ears, and he was rarely emotional. Unlike Captain Kirk, Spock was never tempted by the seductive outer-space sirens who regularly tried to lure the space mariners to destruction. Even when the murderous Romulans seemed certain to destroy the Enterprise, Spock never panicked. As he coldly evaluated the ship’s predicament, the other

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Section 6.1 Emotions: Normal and Pathological

crew members would accuse Spock of being “inhuman.” To them, the essential charac- teristic of a human being is the ability to feel emotions—and most psychologists agree.

Emotions are so much a part of life, we never stop to ask ourselves why they exist in the first place. What is the biological func- tion of negative emotions, such as fear and sorrow? Why did they evolve? Would we not be better off being unemotional like Spock?

As is the case with many questions sur- rounding evolution, the first place to look for answers is in the works of Charles Dar- win (1809–1882). In his book The Expres- sion of Emotions in Man and Animals (1872), Darwin hypothesized that emotions evolved because they have survival value. Fear helps us to survive because, when we are afraid of something, we flee and avoid possible harm. Sorrow also has survival value. Parent-child bonds are cemented by the feelings of sadness parents and their children experience when they are separated. To avoid sadness, parents stay close to their children, thereby increas- ing their offspring’s chances of survival. Of course, it is possible to have too much of a good thing. Unrelenting fear or sorrow can be so debilitating that, instead of increasing a person’s chances of survival, they can actually decrease those chances.

Grieving The loss of a loved one or a friend usually sets off a grieving process. The first reaction is usu- ally emotional numbness and disbelief punctuated with acute bouts of distress. Social sup- port is an important determinant of how quickly, and how well, people cope with the grieving process (Prest, 2017).

Within a week or so after a loss, disbelief is replaced with a period of pining for the lost per- son. The survivors dwell on their loss, have trouble sleeping, neglect other aspects of life, and display anger at their fate (“Why me?”). This stage may last months or years, but most people eventually acknowledge the permanency of their loss (“I am now a widow”). In the final stage of grieving, people gradually regain their interest in life, and their sadness abates. The whole process may take a year or more and may involve significant periods of psychological distress. Still, the process is perfectly normal (see the accompanying Highlight). In fact, not grieving over the death of a loved one would be viewed by most psychologists as abnormal. Because grieving is normal, treatment is not indicated unless people become dangerous to themselves or are unable to function (Prest, 2017). In such cases, clinicians would probably consider the individual to be suffering from one of the depressive, bipolar, or related disorders described in the DSM–5.

Kimberley French/© Paramount Pictures/ Courtesy Everett Collection

As Star Trek fans know, Mr. Spock differs from humans because he, as a half Vulcan, does not express emotions. Sometimes his cold ratio- nality is an advantage, but at other times his lack of emotion cuts him off from intuition and social connection.

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Section 6.1 Emotions: Normal and Pathological

DSM–5 Depressive, Bipolar, and Related Disorders By definition, a mood disorder is an abnormal condition characterized by persistent extremes of mood. The DSM–IV–TR categorized depressive and bipolar disorders in a single chapter titled “Mood Disorders.” The DSM–5 has divided the categories into two separate chapters: “Depressive Disorders” and “Bipolar and Related Disorders.” According to the DSM– 5, there are two general types of mood disorder: unipolar mood disorder and bipolar mood disorder. The “poles” referred to by these diagnostic labels are the extremes of the mood spectrum—depression and mania. Unipolar mood disorders are characterized by depres- sion, whereas bipolar disorders combine depression with manic periods. Both unipolar and

Highlight: Removal of the Bereavement Exclusion Criterion From Depressive Disorders

How do you handle the loss of a loved one? Most likely you go into a period of mourning, handling the situation in a way that is unique to you. This is called bereavement, a normal part of the grieving process. In the DSM–IV–TR (American Psychiatric Association [APA], 2000), psychologists, psychiatrists, and psychiatric social workers were advised (by the authors of the DSM–IV–TR) not to diagnose major depression in individuals within the first two months following the death of a loved one. This was called the “bereavement exclusion.” The inclusion of this criterion in the DSM–IV–TR meant that grieving a recent loss prevented a person from being diagnosed with major depression.

The bereavement exclusion was removed from the DSM–5 (APA, 2013) in order to ensure that unipolar depression (major depressive disorder) was not overlooked and that appropriate treatment could be implemented quickly before trouble ensued. The rationale behind this is simple enough: Normal grieving and unipolar depression, while sharing some common facets like withdrawal from everyday activities and intense overwhelming sadness, also differ in some very important ways.

For example, during grieving, the painful feelings come in waves of grief when they occur; positive memories of the deceased individual also occur. However, in major depressive disorder (MDD), the mood and feelings and ideas are almost always negative and unpleasant. Second, while you are grieving, self-esteem (positive feelings about yourself) is usually maintained, whereas in MDD, feelings of worthlessness and self-loathing are common. Normal grieving can lead to MDD, but clinicians are cautioned not to confuse a normal process with a mental disorder.

There is another perspective. The DSM–5 characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one. Some critics say the risk is that of pathologizing grief, a normal human process. Individuals may be diagnosed with depression even in the absence of severe depressive symptoms (such as suicidal ideation) and even though their symptoms may be transient.

A person who meets the diagnostic criteria for MDD will no longer be excluded from that diagnosis solely because the person recently lost a loved one and is in the process of normal grieving or bereavement. The death of a loved one may or may not be the main, underlying cause of the person’s unipolar depression.

What are your views on the bereavement exclusion?

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