Abnormal psych lecture ch07

Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 7Slides & Handouts by Karen Clay Rhines, Ph.D.

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Chapter 7Chapter 7

Mood DisordersMood Disorders

Comer, Fundamentals of Abnormal Psychology, 5e – Chapter 7

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Two key emotions on a continuum:

Depression Low, sad state in which life seems dark and

overwhelming

Mania State of breathless euphoria or frenzied energy

Depression Mania


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Most people with a mood disorder experience only depression This pattern is called unipolar depression

Person has no history of mania Mood returns to normal when depression lifts

Some people experience periods of depression that alternate with periods of mania This pattern is called bipolar disorder


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These disorders have always captured people’s interest Millions of people have mood disorders

Economic costs of mood disorders amount to more than $80 billion each year

Human suffering is incalculable


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Unipolar DepressionUnipolar Depression

The term “depression” is often used to describe general sadness or unhappiness This usage confuses a normal mood

swing with a clinical syndrome

Clinical depression can bring severe and long-lasting psychological pain that may intensify over time


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How Common Is How Common Is Unipolar Depression?Unipolar Depression?

About 7% of the U.S. population experiences severe unipolar depression in any given year As many as 5% experience mild depression

The prevalence is similar in Canada, England, France, and many other countries

Approximately 17% of all adults experience unipolar depression at some time in their lives Rates have been steadily increasing since 1915


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How Common Is How Common Is Unipolar Depression?Unipolar Depression?

In almost all countries, women are twice as likely as men to experience severe unipolar depression Lifetime prevalence: 26% of women vs. 12% of men

These rates hold true across socioeconomic classes and ethnic groups

Approximately 50% recover within six weeks, some without treatment Most will experience another episode at some point


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What Are the Symptoms What Are the Symptoms of Depression?of Depression?

Symptoms may differ from person to person

Five main areas of functioning may be affected: Emotional symptoms

Feeling “miserable,” “empty,” “humiliated”

Experiencing little pleasure

Motivational symptoms Lacking drive, initiative, spontaneity

Between 6% and 15% of those with severe depression commit suicide


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What Are the Symptoms What Are the Symptoms of Unipolar Depression?of Unipolar Depression?

Five main areas of functioning may be affected: Behavioral symptoms

Less active, less productive

Cognitive symptoms Hold negative views of themselves

Blame themselves for unfortunate events

Pessimism

Physical symptoms Headaches, dizzy spells, general pain


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Diagnosing Unipolar Diagnosing Unipolar DepressionDepression

Criteria 1: Major depressive episode Marked by five or more symptoms

lasting two or more weeks In extreme cases, symptoms are psychotic,

including Hallucinations

Delusions

Criteria 2: No history of mania


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Diagnosing Unipolar Diagnosing Unipolar DepressionDepression

Two diagnoses to consider: Major depressive disorder

Criteria 1 and 2 are met

Dysthymic disorder Symptoms are “mild but chronic”

Depression is longer lasting but less disabling

Consistent symptoms for at least two years

When dysthymic disorder leads to major depressive disorder, the sequence is called “double depression”


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What Causes Unipolar What Causes Unipolar Depression?Depression?

Stress may be a trigger for depression People with depression experience a greater

number of stressful life events during the month just prior to the onset of their symptoms

Some clinicians distinguish reactive (exogenous) depression from endogenous depression, which seems to be a response to internal factors

The utility of this distinction is questionable and today’s clinicians usually concentrate on recognizing the situational and the internal aspects of any given case


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The Biological ViewThe Biological View Genetic factors

Family pedigree, twin, adoption, and molecular biology gene studies suggest that some people inherit a predisposition

Researchers have found that as many as 20% of relatives of those with depression are themselves depressed, compared with fewer than 10% of the general population

Twin studies demonstrate a strong genetic component: Rates for identical (MZ) twins = 46% Rates for fraternal (DZ) twins = 20%

Molecular biology studies also have implicated a genetic factor in many cases of unipolar depression


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The Biological ViewThe Biological View Biochemical factors

NTs: serotonin and norepinephrine In the 1950s, medications for high blood pressure

were found to cause depression Some lowered serotonin, others lowered

norepinephrine

This led to the “discovery” of effective antidepressant medications which relieved depression by increasing either serotonin or norepinephrine

Depression likely involves not just serotonin nor norepinephrine… a complex interaction is at work, and other NTs may be involved


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Endocrine system / hormone release People with depression have been found to

have abnormal levels of cortisol Released by the adrenal glands during times of stress

People with depression have been found to have abnormal melatonin secretion

“Dracula hormone”

Other researchers are investigating whether deficiencies of important proteins within neurons are tied to depression


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Model has produced enthusiasm but has significant limitations:

Relies on analogue studies: depression-like symptoms created in lab animals

Do these symptoms correlate with human emotions?

Measuring brain activity has been difficult Current studies using modern technology are

attempting to address this issue


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What Are the Biological What Are the Biological Treatments for Unipolar Treatments for Unipolar

Depression?Depression? Biological treatments can bring great

relief to people with unipolar depression

Usually biological treatment means antidepressant drugs, but for severely depressed persons who do not respond to other forms of treatment, it sometimes includes electroconvulsive therapy


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Depression?Depression? Electroconvulsive therapy (ECT)

The use of ECT was -- and is -- controversial It is now used frequently but only in severe cases

The procedure consists of targeted electrical stimulation to cause a brain seizure

The usual course of treatment is 6 to 12 sessions spaced over two to four weeks

Treatment may be bilateral or unilateral


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The discovery of the effectiveness of ECT was accidental and based on a fallacious link between psychosis and epilepsy

The procedure has been modified in recent years to reduce some of the negative effects

For example, patients are given muscle relaxants and anesthetics before and during the procedure

Patients generally report some memory loss


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ECT is clearly effective in treating unipolar depression

Studies find improvement in 60%–70% of patients

The procedure seems particularly effective in cases of severe depression with delusions, but it has been difficult to determine why ECT works so well

Although effective, the use of ECT has declined since the 1950s, because of the memory loss caused by the procedure and the emergence of effective antidepressant drugs


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Depression?Depression? Antidepressant drugs

In the 1950s, two kinds of drugs were found to be effective:

Monoamine oxidase inhibitors (MAO inhibitors)

Tricyclics

These drugs have been joined in recent years by a third group, the second-generation antidepressants


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Depression?Depression? Antidepressant drugs: MAO inhibitors

Originally used to treat TB, doctors noticed that the medication seemed to make patients happier

The drug works biochemically by slowing down the body’s production of MAO

MAO breaks down norepinephrine

MAO inhibitors stop this breakdown from occurring

This leads to a rise in norepinephrine activity and a reduction in depressive symptoms

About half the patients who take these drugs are helped by them


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Depression?Depression? Antidepressant drugs: MAO

inhibitors MAO inhibitors potentially pose a

serious danger! Blood pressure may rise to a potentially

fatal level if one eats foods with tyramine (cheese, bananas, wine) while taking MAO inhibitors


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Depression?Depression? Antidepressant drugs: Tricyclics

In searching for medications for schizophrenia, researchers discovered that imipramine lessened depressive symptoms

Imipramine and related drugs are known as tricyclics because they share a three-ring molecular structure


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Hundreds of studies have found that depressed patients taking tricyclics have improved much more than similar patients taking placebos

About 60%–65% of patients find symptom improvement


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Most patients who immediately stop taking tricyclics upon relief of symptoms relapse within one year

Patients who take tricyclics for five additional months (“continuation therapy”) have a significantly decreased risk of relapse

As a result, clinicians often keep their patients on the drugs indefinitely


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Tricyclics are believed to reduce depression by affecting neurotransmitter (NT) reuptake

To prevent an NT from remaining in the synapse too long, a pumplike mechanism recaptures the NT and draws it back into the presynaptic neuron

The reuptake process appears to be too effective in some people, drawing in too much of the NT from the synapse

This reduction in NT activity in the synapse is thought to result in clinical depression

Tricyclics block the reuptake process, thus increasing NT activity in the synapse


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Depression?Depression? Second-generation antidepressant drugs

A third group of effective antidepressant drugs is structurally different from the MAO inhibitors and tricyclics

Most of the drugs in this group are labeled selective serotonin reuptake inhibitors (SSRIs)

These drugs act only on serotonin (no other NTs are affected)

This class includes fluoxetine (Prozac) and sertraline (Zoloft)

Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are also now available


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Depression?Depression? Second-generation antidepressant drugs

The effectiveness and speed of action of these drugs is on par with the tricyclics yet they boast enormous sales

Clinicians often prefer these drugs because it is harder to overdose on them than on other kinds of antidepressants

There are no dietary restrictions like there are with MAO inhibitors

There have fewer side effects than the tricyclics

These drugs may cause some undesired effects of their own, including a reduction in sex drive


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Psychological Models of Psychological Models of Unipolar Depression Unipolar Depression

Three main models: Psychodynamic model

Not strongly supported by research

Behavioral model Modestly supported by research

Cognitive model Has considerable research support


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Psychological Models of Psychological Models of Unipolar DepressionUnipolar Depression

Psychodynamic view Link between depression and grief

When a loved one dies, the mourner regresses to the oral stage

For most people, grief is temporary

If grief is severe and long-lasting, depression results

Those with oral stage issues (unmet or excessively met needs) are at greater risk for developing depression

Some people experience “symbolic” (not actual) loss

Newer psychoanalysts focus on relationships with others (object relations theorists)


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Psychodynamic view Strengths:

Studies have offered general support for the psychodynamic idea that depression may be triggered by a major loss

Research supports the theory that early losses set the stage for later depression

Research also suggests that people whose childhood needs were improperly met are more likely to become depressed after suffering a loss


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Psychodynamic view

Limitations: Early losses don’t inevitably lead to

depression May not be typically responsible for development

of depression

Many research findings are inconsistent

Theory is largely untestable because of its reliance on unconscious processes


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Psychodynamic therapy Psychodynamic therapists use the same

basic procedures for all psychological disorders:

Free association

Therapist interpretation


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Psychodynamic therapy Despite successful case reports, researchers have

found that long-term psychodynamic therapy is only occasionally helpful in cases of unipolar depression

Two features may be particularly limiting: Depressed clients may be too passive or weary to fully

participate in clinical discussions Depressed clients may become discouraged and end

treatment too early when treatment doesn’t provide fast relief

Short-term approaches have performed better than traditional approaches


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Behavioral view Depression results from changes in rewards

and punishments people receive in their lives

As life changes, we experience a change (loss) of rewards

Research by Lewinsohn supports the relationship between the number of rewards received and the presence or absence of depression

Social rewards are especially important


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Treatments for Unipolar Treatments for Unipolar Depression: Psychological Depression: Psychological

ApproachesApproaches Behavioral therapy

Lewinsohn developed a behavioral therapy for unipolar depression:

Reintroduce clients to pleasurable activities and events, often using a weekly schedule

Appropriately reinforce their depressive and nondepressive behaviors

Use a contingency management approach

Help them improve their social skills


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Treatments for Unipolar Treatments for Unipolar Depression: Psychological Depression: Psychological

ApproachesApproaches Behavioral therapy

The behavioral techniques seem to be of only limited help when just one of them is applied

When treatment programs combine two or three of the techniques, as Lewinsohn had envisioned, depressive symptoms (especially mild symptoms) seem to be reduced


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Cognitive views Two main theories:

Learned helplessness

Negative thinking


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Cognitive views Learned helplessness

Theory holds that people become depressed when they think that:

They no longer have control over the reinforcements in their lives

They themselves are responsible for this helpless state


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Theory is based on Seligman’s work with laboratory dogs

Dogs subjected to uncontrollable shock were later placed in a shuttle box

Even when presented with an opportunity to escape, dogs that had experienced uncontrollable shocks made no attempt to do so

Seligman theorized that the dogs had “learned” to be “helpless” and drew parallels to human depression


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There has been significant research support for this model

Human subjects who undergo helplessness training score higher on depression scales and demonstrate passivity in laboratory trials

Animal subjects lose interest in sex and social activities

In rats, uncontrollable negative events result in lower serotonin and norepinephrine levels in the brain


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Recent versions of the theory focus on attributions Internal attributions that are global and stable lead to

greater feelings of helplessness and possibly depression Example: “It’s all my fault [internal]. I ruin everything

I touch [global] and I always will [stable]” If people make other kinds of attributions, this reaction is

unlikely Example: “The way I’ve behaved the past couple of

weeks blew this relationship [specific], I don’t know what got into me – I don’t usually act like that [unstable], and she never did know what she wanted [external]”


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Some theorists have refined the helplessness model yet again in recent years; they suggest that attributions are likely to cause depression only when they further produce a sense of hopelessness in an individual


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Strengths: Hundreds of studies have supported the relationship

between styles of attribution, helplessness, and depression

Limitations: Laboratory helplessness does not parallel depression in

every way Much of the research relies on animal subjects The attributional component of the theory raises

particularly difficult questions in terms of animal models of depression


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Cognitive views Negative thinking

According to Beck, four interrelated cognitive components combine to produce unipolar depression:

1. Maladaptive attitudes

Self-defeating attitudes are developed during childhood

Beck suggests that upsetting situations later in life can trigger further rounds of negative thinking


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Cognitive views

2. This negative thinking often takes three forms, called the cognitive triad: Individuals repeatedly interpret (1) their

experiences, (2) themselves, and (3) their futures in negative ways, leading to depression


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Cognitive views Negative thinking

3. Depressed people also make errors in their thinking, including: Arbitrary inferences

Minimization of the positive and magnification of the negative

4. Depressed people experience automatic thoughts A steady train of unpleasant thoughts that suggest

inadequacy and hopelessness


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Cognitive views Strengths:

There is significant research support for Beck’s model:

High correlation between the level of depression and the number of maladaptive attitudes

Both the cognitive triad and errors in logic are seen in people with depression

Automatic thinking has been linked to depression

Limitations: Research fails to show that such cognitive patterns

are the cause and core of unipolar depression


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Cognitive therapy Beck’s cognitive therapy – the leading

cognitive treatment for unipolar depression – is designed to help clients recognize and change their negative cognitive processes

This approach follows four phases and usually lasts fewer than 20 sessions

Phases:1. Increasing activities and elevate mood

2. Challenging automatic thoughts

3. Identifying negative thinking and biases

4. Changing primary attitudes


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Cognitive therapy Over the past three decades, hundreds

of studies have shown that cognitive therapy helps unipolar depression

Around 50%–60% of clients show a near-total elimination of symptoms

This treatment has also been used in a group therapy format


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The Sociocultural Model of The Sociocultural Model of Unipolar DepressionUnipolar Depression

Sociocultural theorists propose that unipolar depression is greatly influenced by the social structure in which people live This belief is supported by the finding that

depression is often triggered by outside stressors

Researchers have also found links between depression and culture, gender, race, and social support


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How are culture and depression related? Depression is a worldwide phenomena,

but the experience of symptoms differs from culture to culture

For example, non-Westerners report more physical (rather than psychological) symptoms

As cultures become more Western, symptoms shift


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How do gender and race relate to depression? Rates of depression are much higher among women than

men One sociocultural theory holds that the complexity of

women’s roles in society leaves them particularly prone to depression

Few differences have been seen overall among Caucasians, African Americans, and Hispanic Americans, but striking differences exist in specific subcultures:

In a study of one Native American village, lifetime risk was 37% among women, 19% among men, and 28% overall

These findings are thought to be the result of economic and social pressures


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How does social support relate to depression? The availability of social support seems to

influence the likelihood of depression Rates of depression vary based on marital status

Interpersonal conflict may be a factor

Isolation and lack of intimacy also are key factors

Research shows that depressed people who lack social support remain depressed longer than those who have a supportive spouse or warm friendships


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The most effective sociocultural approaches to treating unipolar depression are interpersonal psychotherapy and couple therapy The techniques used in these

approaches borrow from other models


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Interpersonal therapy (IPT) This model holds that four interpersonal

problems may lead to depression and must be addressed:

Interpersonal loss Interpersonal role dispute Interpersonal role transition Interpersonal deficits

Studies suggest that IPT is as effective as cognitive therapy for treating depression


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Couple therapy The main type of couple therapy is

behavioral marital therapy (BMT) Focus is on developing specific

communication and problem-solving skills

If marriage is conflictual, BMT is as effective as other therapies for reducing depression


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Bipolar DisordersBipolar Disorders

People with a bipolar disorder experience both the lows of depression and the highs of mania They describe their life as an emotional

roller coaster


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What Are the Symptoms What Are the Symptoms of Mania?of Mania?

Unlike those experiencing depression, people in a state of mania typically experience dramatic and inappropriate rises in mood

Five main areas of functioning may be affected:

1. Emotional symptoms Active, powerful emotions in search of outlet

2. Motivational symptoms Need for constant excitement, involvement,

companionship


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What Are the Symptoms What Are the Symptoms of Mania?of Mania?

Five main areas of functioning may be affected:

3. Behavioral symptoms Very active – move quickly; talk loudly or rapidly

Key word: flamboyance!

4. Cognitive symptoms Show poor judgment or planning

Especially prone to poor (or no) planning

5. Physical symptoms High energy level – often in the presence of little or no

rest


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Diagnosing Bipolar Diagnosing Bipolar DisordersDisorders

Criteria 1: Manic episode Three or more symptoms of mania

lasting one week or more In extreme cases, symptoms are psychotic

Criteria 2: History of mania If currently experiencing hypomania or

depression


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DSM-IV-TR distinguishes between two kinds of bipolar disorder: Bipolar I disorder

Full manic and major depressive episodes

Most sufferers experience an alternation of episodes

Some experience mixed episodes

Bipolar II disorder Hypomanic episodes and major depressive

episodes


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Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder

Regardless of particular pattern, individuals with bipolar disorder tend to experience depression more than mania over the years


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Between 1% and 2.6% of adults in the world suffer from a bipolar disorder at any given time

The disorders are equally common in women and men Women may experience more

depressive episodes and fewer manic episodes than men


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The prevalence of the disorders is the same across socioeconomic classes and ethnic groups

Onset usually occurs between 15 and 44 years of age

In most cases, the manic and depressive episodes eventually subside, only to recur at a later time


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A final diagnostic option: If a person experiences numerous

episodes of hypomania and mild depressive symptoms, a diagnosis of cyclothymic disorder is appropriate

Mild symptoms for two or more years, interrupted by periods of normal mood

Affects 0.4% of the population

May blossom into bipolar I or II disorder


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What Causes Bipolar What Causes Bipolar Disorders?Disorders?

Throughout the first half of the 20th century, the search for the cause of bipolar disorders made little progress

More recently, biological research has produced some promising clues New insights have come from research

into NT activity, ion activity, brain structure, and genetic factors


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Neurotransmitters After finding a relationship between low

norepinephrine and unipolar depression, early researchers expected to find a link between high norepinephrine levels and mania

This theory is supported by some research studies; bipolar disorders may be related to overactivity of norepinephrine


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Neurotransmitters Because serotonin activity often

parallels norepinephrine activity in unipolar depression, theorists expected that mania would also be related to high serotonin activity

Although no relationship with HIGH serotonin has been found, bipolar disorder may be linked to LOW serotonin activity, which seems contradictory…


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Neurotransmitters This apparent contradiction is addressed

by the “permissive theory” about mood disorders:

Low serotonin may “open the door” to a mood disorder and permit norepinephrine activity to define the particular form the disorder will take:

Low serotonin + Low norepinephrine = Depression

Low serotonin + High norepinephrine = Mania


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Ion activity Ions, which are needed to send incoming

messages to nerve endings, may be improperly transported through the cells of individuals with bipolar disorder

This improper transport may cause neurons to fire too easily (mania) or to resist firing (depression)

There is some research support for this theory


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Brain structure Brain imaging studies have identified a

number of abnormal brain structures in people with bipolar disorder; in particular, the basal ganglia and cerebellum among others

It is not clear what role such structural abnormalities play


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Genetic factors Many experts believe that people inherit a

biological predisposition to develop bipolar disorders

Family pedigree studies support this theory; when one twin or sibling has bipolar disorder, the likelihood for the other twin or sibling increases:

Identical (MZ) twins = 40% likelihood

Fraternal (DZ) twins and siblings = 5% to 10% likelihood

General population = 1% to 2.6% likelihood


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Genetic factors Recently, genetic linkage studies have

examined the possibility of “faulty” genes Other researchers are using techniques

from molecular biology to further examine genetic patterns

Such wide-ranging findings suggest that a number of genetic abnormalities probably combine to help bring about bipolar disorders


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What Are the Treatments What Are the Treatments for Bipolar Disorders?for Bipolar Disorders?

Until the latter part of the 20th century, people with bipolar disorders were destined to spend their lives on an emotional roller coaster Psychotherapists reported almost no success Antidepressant drugs were of limited help

These drugs sometimes triggered manic episodes

ECT only occasionally relieved either the depressive or the manic episodes of bipolar disorder


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The use of lithium, a metallic element occurring as mineral salt, has dramatically changed this picture It is extraordinarily effective in treating

bipolar disorders and mania Determining the correct dosage for a

given patient is a delicate process Too low = no effect Too high = lithium intoxication (poisoning)


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Lithium provides improvement for more than 60% of patients with mania Most patients also experience fewer new

episodes while on the drug

Lithium also is a prophylactic drug, one that actually prevents symptoms from developing

Lithium also helps those with bipolar disorder overcome their depressive episodes


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Researchers do not fully understand how lithium operates They suspect that it changes synaptic activity

in neurons, but in a different way than antidepressant drugs

Although antidepressant drugs affect a neuron’s initial reception on NTs, lithium seems to affect a neuron’s second messengers

Another theory is that lithium corrects bipolar functioning by directly changing sodium and potassium ion activity in neurons


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Psychotherapy alone is rarely helpful for persons with bipolar disorder

Lithium therapy alone is also not always sufficient, either 30% or more of patients don’t respond, may not

receive the correct dose, or may relapse while taking it

As a result, clinicians often use psychotherapy as an adjunct to lithium (or other medication-based) therapy


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Therapy focuses on medication management, social skills, and relationship issues

Few controlled studies have tested the effectiveness of such adjunctive therapy Growing research suggests that it helps

reduce hospitalization, improve social functioning, and increase clients’ ability to obtain and hold a job

Abnormal psych lecture ch07

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