Disorders of mood

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This section outlines the psychopathological elements comprising mood disorders, in particular the different varieties of depression, mania, anxiety states, and depersonalization. The account of symptoms will refer mainly to descriptive phenomenology, and only briefly to the interpretative concepts of anthropological phenomenology.

Mood can be considered as a quality of the state of mind which is more lasting than affects and feelings. Mood encompasses the whole of mentation, is not influenced by will, and is strongly related to values. The philosopher Heidegger(21) considered mood (Stimmung, Befindlichkeit) as the most fundamental expression of an individual's being (Daseinsverfassung). Kierkegaard(22> emphasized the role of existential orientation in determining mood, especially general anxiety.

The principal but not the only domain of symptoms in mood disorders is the extent and type of mood deviation. Although there are no sharp boundaries between the normal variations and pathological states of mood, the severe states are clearly abnormal and difficult to empathize. Mood can be abnormal in several ways: sad or anxious in depressive disorders; euphoric in mania; irritated in mania or agitated depression; dysphoric in depression or in mixed manic-depressive disorders; morose in chronic depressed states, often with a component of resentment; blunted (the feeling of 'having no feelings' or 'petrified' feelings) in prolonged very severe depressive disorder. Stanghellini(23) performed phenomenological analyses of depressed patients and described how a morose affect may emerge when the patient struggles against declining abilities and experiences resistance. In such cases feelings of timidity and despair may contrast with an outward appearance of hostility.

Two types of euphoria should be differentiated: a vital type with elation and feelings of increased spiritual, intellectual, or physical power, and a type which results from disinhibition in organic states and dementia. Other people may see this second type not as elation but as lack of interest and a negligent attitude towards the patient's actual situation.

These abnormal moods are closely related to altered body feelings and thinking.

Abnormal somatic symptoms can be divided into vegetative symptoms, such as cardiovascular dysregulation, increased sweating, and feelings of cold, and hypochondriacal symptoms, such as headaches and feelings of tightness in the chest, heavy limbs, being choked, or difficulty in swallowing. In Germany, the latter symptoms have been called 'vital' and depressive disorders which include such symptoms are known as 'vitalized'. They are considered to be related to subjective loss of energy, and are different from vegetative symptoms which represent a real somatic dysfunction.

Lopez-Ibor(24) suggested the term 'depression-equivalent' for conditions in which somatic symptoms (e.g. headaches which vary on a diurnal pattern) dominate the clinical picture. Cross-cultural research has found higher rates of such somatic symptoms in depression in Africa (25> and South America,(26) and a lower rate of guilt compared with Western industrialized countries. However, the results are not wholly consistent and reports of changing symptom profiles in American and African studies pose the question as to whether these changes are related to acculturization or to methological shortcomings in earlier studies.

A feedback loop may develop between anxiety and the vegetative arousal, e.g. palpitation, that accompanies it.(2,2§ The prevalence of mitral valve prolapse is higher in anxiety disorder (37 per cent) than in the general population (5 per cent). (29) This finding is consistent with the idea that palpitation may lead to a conditioned anxiety response. The behaviour therapy technique of exposure aims to decondition this reflex. In social phobia and panic disorder anxiety is often complicated by anxiety-provoking situations which may lead to severe social disablement. Somatic symptoms of anxiety may be so prominent in some depressive states that patients are misdiagnosed as medically ill, with loss of weight, atypical pain, or sensory or motor disturbances. This type of depression has been called 'depressio sine depressione' or 'somatoform depression'.

Disturbances of diurnal rhythms can also be regarded as vegetative symptoms, although they influence all domains of symptomatology in mood disorders. (30> The underlying biological processes result in altered sleep architecture in the electroencephalogram with shorter REM latency (phase advance) and changes in endocrinological and cardiovascular circadian rhythms. In depression, sleep disturbance is characterized by early awakening, whereas falling asleep in the evening is often undisturbed. About 70 per cent of melancholic patients show diurnal distribution of mood, psychomotor activity, somatic symptoms, and slowed and impoverished thinking. The worst state is in the morning, with improvement in the afternoon and evening. (31>

Psychomotor retardation or acceleration is one of the most prominent symptoms of mood disorder. Often the patient's appearance and expressive movements reveal more than his or her words. The retarded patient's movements are slow, the limbs are rigid, the body is bent, and the expression is sad or anxious and does not respond to the situation. The subjective feeling may be of emptiness, weakness, and tension. If the condition is severe, it can be difficult to discriminate depressive and catatonic stupor; patients with depressive stupor seldom have increased muscular tension or rigidity. Increased psychomotor activity can appear in depression as agitation, i.e. restlessness without the ability to attain goals or organize behaviour. In mania, increased psychomotor activity is also seen in sexual excesses and extravagant spending on unnecessary items.

Psychomotor retardation, and probably also acceleration, may be accompanied by a changed experience of time.(32) Depressed patients overemphasize the past, remembering guilt-connected events (petits faux); manic patients feel that the future is at hand. Inability to distinguish wishes from reality results in poor decision-making in both depressives and manics. Some depressives are unable even to decide how to dress in the morning. A manic patient's workroom can reflect the dissolution of his ability to distinguish between more and less important things, for example tools for immediate and frequent use and those seldom used. (33> Extreme retardation is seen in depressive stupor when patients do not move, speak, eat, or drink. Extreme acceleration occurs in mania ('the boiling over of mania') and may be accompanied by a sense of confusion.

Retardation and acceleration are closely related to depressive and manic thought disorders. In depression the flow of associations is reduced and slowed, and short-term memory can appear impaired (pseudodementia) (see Chapter4.:.5.2). Depressed patients often ruminate about negative topics and have difficulty in terminating these thoughts. In mania, acceleration of thinking leads to a plethora of associations, 'flight of ideas', and logorrhea. Unlike patients with schizophrenic thought disorder, depressed patients retain logical connections.

The content of thoughts in mood disorders is coloured by the mood. Negative thinking about the self, the future, and the world prevails. (34> Mishaps and failures are attributed to personal faults; success is attributed to the action of other people. This depressive thinking spreads from the starting point of negative life events to more general events, and it tends to become long lasting. The fixed viewpoint that emerges is called 'cognitive schema'. After recovery from an acute episode this schema may become latent, but it can be reactivated by distressing life events. It can also prolong symptoms. Negative thinking started by minor misfortunes can become autonomous, driving down mood—which in turn intensifies negative thinking. The negative schema can prolong a depressive episode or precipitate a new one. It is uncertain whether such schemas are activated by cognitions or emotions. Probably both can do this. Guilty thoughts are closely connected with this type of thinking, and may reach the intensity of a delusion. To a degree, guilty thinking in depression is dependent on culture. In mania, the content of thought is related to the mood of elation, with diminished self-criticism and excessive self-importance. In phobic and other anxiety states, thinking centres on situations leading to anxiety. Typical contents of delusional thinking in depression concern guilt, religious failure, condemnation, personal insufficiency, impoverishment, hypochondriasis, and nihilistic ideas (e.g. the conviction of having died). In mania, delusional ideas may concern religion, with unrealistic feelings of spiritual or economic power. In contrast with schizophrenic delusions, affective delusions are synthymic, i.e. they grow out of the underlying mood exaggeration and do not appear as something new and alien to the personalilty.

Depersonalization (see later) can occur alone or as part of a depressive state. In the latter, part of the body, the self, the mind, actions, or thinking are sensed as being alienated—not belonging to the self. In mood disorders, depersonalization does not usually reach the intensity of delusion that it can in schizophrenia. Depersonalization in depression can be related to the fading of vital energy but also to anxiety, comparable with the 'emotional stupor' or 'black-out' experienced, for example, in an examination situation when a person loses memories that are normally easy to access.

Although anxiety disorders and major depression have been defined by operational criteria in the diagnostic manuals, the clinical symptoms of mood states vary considerably. Attempts have been made to define a core syndrome by using factor analyses to identify latent trait symptom profiles derived from several assessment scales and from different samples of depressives. Cross-cultural comparisons of symptom profiles can also help to identify core symptoms. Among the latent traits, retardation was found most often, together with loss of interest and alterations of diurnal rhythms. Guilt, death wishes, and affective reactivity occurred inconsistently.^5,35)

The personalities of depressive, manic, and bipolar patients have been studied before and after the onset of the disorder. There is agreement that social sensitivity, perfectionism, and dependency are very frequent features in the personality of depressives. The common features in bipolar patients are striving for autonomy, unconventional behaviour, and norm-giving behaviour. Dependency and perfectionism are probably coping attitudes to disturbed affect regulation, as well as risk factors for decompensation in response to certain life events.

Akiskafe has emphasized the importance of minor signs of affect dysregulation, such as temper tantrums, before the onset of affective disorders. His model of temperament (biological disposition), personality (psychological development), and character (amalgamation of both) takes into account the long-term development of the manifest syndrome, which can take a decade or more. Among the precursors to the full-blown major depression are single depressive symptoms, recurrent brief depression, and dysthymia. The viewpoint of comorbidity tries to separate personality and depression, as well as other Axis I syndromes like anxiety and alcoholism.(37>

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