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PSYC*3390 Ch 7.doc

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PSYC 3390
Mary Manson

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Monday, Oct 22, 2012 Chapter 7: Mood Disorders and Suicide Mood Disorders - severe alternations in mood for long periods of time - in 2000, depression ranked among the top 5 health conditions in terms of years lot to disability in all parts of the world except Africa - depression costs Canadians at least $14.4 billion a year in treatment, lost productivity and premature death - in all mood disorders (formerly called affective disorders), extremes of emotion or af- fect-soaring elation or deep depression- dominate the clinical picture What are Mood Disorders - there are 2 key moods involved in mood disorders: Mania - intense, unrealistic feelings of excitements and euphoria Depression - feelings of extraordinary sadness and dejection - they are on a continuum - mixed episode cases are when patients have symptoms of mania and depression at the same time Unipolar Disorders - only depressive episodes - it is customary to differentiate among mood disorders in terms of severity and duration - the most common form of mood episode that people have is a major depressive episode - markedly depressed for most of everyday and for most days for at least 2 weeks, cognitive symptoms (guilt), behavioural and physical symptoms - another primary kind of mood episode is a manic episode - elevated, euphoric mood interrupted by occasional outburst of intense irritability or even violence particularly when others refuse to go along with the manic person’s wishes and schemes - there is considerable heterogeneity in the ways mood disorders manifest themselves The Prevalence of Mood Disorders - unipolar major depression is more common and its appearance has increased - lifetime prevalence of unipolar major depression is 12%, the US is 17% - rates for unipolar depression are higher for women - bipolar disorder is the other type and it is much less common, the lifetime risk is 0.4% to 2.2% and there is so difference between sexes Unipolar Mood Disorders Monday, Oct 22, 2012 - mild and brief depression may be “normal” and adaptive because much of the “work” of depression seems to involve facing images, thoughts, feelings that one would normal- ly avoid - it slows us down and saves us from wasting a lot of energy Depressions That Are Not Mood Disorders Loss and the Grieving Process - there are 4 stages of normal response: 1. Numbing and disbelief that may last from a few hours to a week and may be interrupt- ed by outbursts of intense distress, panic, or anger 2. Yearning and searching for the dead person (similar to anxiety), which may last for weeks or months. Symptoms include restlessness, insomnia, and preoccupation or anger with the dead person 3. Disorganization and despair that set in after yearning diminishes. The person finally accepts the loss as permanent and tries to establish a new identity. Criteria for major depressive disorder may be met during this phase 4. Some level of reorganization when people gradually begin to rebuild their lives, sad- ness abates, and zest for life returns - some people get stuck in the middle - uncomplicated grief has an adaptive function, failing to exhibit grief is concerning be- cause it was thought to suggest that the person was not fully procession the loss - however, recent studies show that 50% of people exhibit genuine resilience in the face of loss with minimal, very short-lived symptoms Postpartum “Blues” - very common, symptoms include emotional lability, crying easily and irritability, inter- mixed with happy feelings - symptoms happen to as many as 50-70% of women within 10 days of giving birth and usually go away on their own - major depression occurs no more frequently in the postpartum period than in women of the same age and socioeconomic status who had not given birth - there is a greater change of developing major depression is post-partum is severe Dysthymic Disorder - mild to moderate intensity, but its hallmark is its chronicity - persistently depressed mood most of the day, for more days than not, for at least 2 years, must have at least 2 of 6 symptoms when depressed (poor appetite or overeat- ing, insomnia or hypersomnia) Monday, Oct 22, 2012 - periods of normal moods may occur briefly but usually only last for a few days, weeks - 3-6% of Canadians have it at some point in their lives - average duration is 5 years and often begins during the teenage years Major Depressive Disorder - must be in a major depressive episode to be diagnosed - must experience either depressed mood or loss of interest in pleasurable activities most of everyday, nearly everyday for at least 2 weeks, and must experience at least 3 or 4 additional symptoms that are cognitive, behavioural or physical - few, if any depressions occur in the absence of anxiety, there are very high levels of comorbidity between mood and anxiety disorders Depression Throughout the Life Cycle - onset most often occurs during late adolescence to middle adulthood but may begin anytime - 2-3% of schoolchildren show some signs of unipolar depression - even infants may experience a form of depression (anaclitic depression) if they are separated for a prolonged period from their attachment figure - 15-20% of adolescents experience it at some point - the average age of onset has been decreasing Specifiers for Major Depression - some individuals who meet the basic criteria for diagnosis of major depression also have additional patterns of symptoms called Specifiers - e.g. major depressive episode with melancholic features - lost interest or pleasure in almost al activities as well as the criteria for major depression - e.g. severe major depressive episode with psychotic features- psychotic symptoms (loss of contact with reality, delusions, hallucinations) accompany other symptoms - any delusions or hallucinations are mood-congruent (they seem appropriate to serious depression because the content is negative in tone) - psychotically depressed people are likely to have a poorer long-term prognosis - treatment generally involves an antipsychotic medication and an antidepressant - e.g. major depressive episode with atypical features - mood reactivity, mood brightens in response to potential positive events - often females who are young and often show suicidal thoughts - may respond better to monoamine oxidase inhibitors for medication - e.g. double depression - major depression and dysthymia, moderately depressed on a chronic basis but undergo increased problems from time to time Monday, Oct 22, 2012 - appears to be common although not recognized as an official specifier Depression as a Recurrent Disorder - when a diagnosis is made, it is usually also specified whether this is a first/single episode or a recurrent episode - depressive episodes are usually time-limited, the average duration is 6 months - when major depression does not remit for over 2 years, chronic major depressive dis- order is diagnosed - recurrence is distinguished from relapse (the return of symptoms within a fairly short period of time, this episode is not done yet) - the proportion of patients who exhibit recurrence is very high (80%) - many people have lingering or residual depressive symptoms in between Seasonal Affective Disorder - at least 2 episodes of depression in the past 2 years at the same time of year (most of- ten fall or winter) and full remission have occurred at the same time of the year Causal Factors in Unipolar Mood Disorders Biological Causal Factors - diseases and drugs can affect mood Genetic Influences - family studies show that the prevalence of mood disorders is 3x higher among blood relatives of someone diagnosed with unipolar depression - twin studies suggest a moderate genetic contribution, 13-42% of variance - even more variance in the liability to major depression is due to nonshared environ- mental influence and not genetics - depressive symptoms vary in their heritabilities but even for heritable symptoms, envi- ronmental influences are very important - early-onset, severe, and recurrent depression may be more heritable - the adoption method found that depression occurred 7x more often in the biological relatives than in the biological relatives of control adoptees - there is not as large of a genetic contribution as for bipolar disorder where genetic fac- tors account for about 80% of the risk but there is a moderate contribution - the serotonin-transporter gene, a gene involved in the transmission and reuptake of serotonin is a candidate for a specific gene that is implicated - there are 2 different alleles involves, short ones and long ones, people either have 2 shorts alleles, 2 long or one of each, and having 2 short may predispose people Neurochemical Factors Monday, Oct 22, 2012 - the 60s & 70s focused on 3 NTs, norepinephrine, dopamine and serotonin because antidepressants seems to have the effect of increasing their availability at synaptic junc- tions - this led to the monamine hypothesis: depression was at least sometimes due to an ab- solute or relative depletion of one or all of these NTs at important receptor sites - these NTs are not known to be involved in the regulation of behavioural activity, emo- tional expression and vegetative function, all disturbed in mood disorders - by the 80s it was clear that no such straightforward mechanisms could be responsible - studies have found that depressed patients actually had increases in norepinephrine Abnormalities of Hormonal Regulatory Systems - attention has been focused on the hypothalamic-pituitary-adrenal (HPA) axis and on the hormone cortisol - the stress response is associated with elevated activity of the HPA axis which is partly controlled by norepinephrine and serotonin - stress can lead to norepinephrine activity in the hypothalamus, causing the release of corticotropin-releasing hormone (CRH) from the hypothalamus which triggers the re- lease of adrenocorticotropic hormone (ACTH) from the pituitary - there is a failure of feedback systems, high rates of nonsupression - depressed patients with elevated cortisol tend to show memory impairments and prob- lems with complex problem solving which may be related to cell death in the hippocam- pus - the other endocrine system that is relevant is the hypothalamic-pituitary-thyroid axis - people with low thyroid levels often become depressed Neurophysiological and Neuroanatomical Influences - depression may be linked to lowered levels of brain activity in a certain region - EEGs show there is an asymmetry or imbalance of the 2 sides of the prefrontal regions of the brain in depressed people - plow activity in the left hemisphere and high activity in the right - lower activity on the left side is thought to be related to symptoms of reduced positive affect and approach behaviours to rewarding stimuli, and increased right-sided activity is thought to underlie increased anxiety symptoms and increased negative affect - the anterior cingulate cortex shows abnormally low levels of activation - the orbitofrontal cortex shows decreased volume - the hippocampus is smaller in volume possibly from cell death Sleep and Other Biological Rhythms Monday, Oct 22, 2012 Sleep - sleep is characterized by 5 stages, many depressed patients enter their first pe- riod of REM sleep after only 60 minutes of sleep and show greater amounts of REM sleep, the intensity and frequency of rapid eye movements are greater - they experience lower-than normal deep sleep Circadian Rhythms - some depressed patients have abnormal rhythms possibly be- cause the size or magnitude of the rhythm is blunted or they are desynchronized Sunlight and Seasons - in seasonal affective disorder, patients are responsive to the total quality of available light in the environment, sleep, activity and appetite are affected - may alter biological rhythms that regulate processes like body temperature and sleep- wake cycles Psychosocial Causal Factors Stressful Life Events as Causal Factors - severely stressful events often serve as precipitating factors - stressors may interact with one another to increase risk for depression - loss of a loved one, serious threats to important close relationships or one’s occupa- tion or severe economic or serious health problems - losses that involve an element of humiliation can be especially potent - the stress of caregiving to a spouse with a debilitating disease like Alzheimer’s - there is a distinction between stressful life events that are independent of the person’s behaviour and personality (losing a job because the company shut down) and events that may have at least partly generated by the person’s behaviour or personality (depen- dent life events) - dependent play a stronger role in depression - research on stress and the onset of depression is complicated by the fact that de- pressed people have a distinctly negative view of themselves and the world - their own perceptions of stress may result from the cognitive symptoms of the disorder rather than causing the disorder - self-report is not relied on as much to measure how stressful the event was - severe stressful events play a causal role in about 20-50% of cases - depressed people who have experienced a stressful life event show more symptoms - this is stronger in the first onset than recurrent Mildly Stressful Events and Chronic Stress - minor stressful events have been asso- ciated with the onset of clinical depression Individual Differences in Responses to Stressors: Vulnerability and Invulnerabili- ty Factors - women (and perhaps men) at genetic risk for depression are 3x more likely to experience stressful life event and are more sensitive to them Monday, Oct 22, 2012 - those with a low genetic risk are more invulnerable to the effects of stress - in one study, there were 4 factors associated with not becoming depressed after a se- vere event: (1) intimate relationship with a spouse or lover, (2) no more than 3 children still at home, (3) a job outside of home and (4) serious religious commitment - having lost a parent by death before the age of 11 was associated with depression Different Types of Vulnerabilities for Unipolar Depression Personality and Cognitive Diatheses - neuroticism is the primary personality variable that serves as a vulnerability factor for depression and a worse prognosis - high levels of introversion (low positive affectivity) may also be a vulnerability factor - negative patterns of thinking make people who are prone to depression more likely to get depressed when faced with one or more stressful life event - people who attribute negative events to internal, stable and global causes are at risk Early Adversity and Parental Loss as a Diathesis - research has shown that early parental loss through death or parental separation creates vulnerability - the child’s response is determined by what happens after the loss (if good parental care is continued, vulnerability is not there) - family turmoil, parental psychopathology, physical or sexual abuse can also create long-term vulnerability by increasing the individual’s sensitivity - some individuals remain resilient, a form of stress inoculation that makes the individual less susceptible to the effects of later stress because of strengthened socioemotional and neuroendocrine resistance to subsequent stressors Summary of Different Types of Vulnerabilities - genetic diathesis, personality vari- ables, cognitive variable, early parental loss - not mutually exclusive: genetic basis for neuroticism which causes pessimism Psychodynamic Theories - when a loved one dies, the mourner regresses to the oral stage of development (when the infant cannot distinguish self from others) and incorporates the lost person, feeling all the same feelings toward the self as toward the lost person (anger, hostility) - depression could occur in response to imagined or symbolic losses - a secure attachment as a child protects against depression - notes the importance of loss to the onset of depression and noting the striking similari- ties between the symptoms of mourning and depression Behavioural Theories Monday, Oct 22, 2012 - people become depressed either when their responses no longer produce positive re- inforcement or when their rate of negative reinforcements increases - depressed people receive fewer positive verbal and social reinforcement - they have lower activity levels - not caused by these but they may be symptoms Beck’s Cognitive Theory - the cognitive symptoms of depression often precede and cause the affective or mood symptoms rather than vice versa - Depressogenic Schemas or dysfunctional beliefs are rigid, extreme and counterpro- ductive e.g. if everyone doesn’t love me, my life is worthless - the beliefs predispose the person to depression if they perceive social rejection - develop during childhood and adolescence as a function of negative experiences - they fuel a thinking pattern of Negative Automatic Thoughts - thoughts that occur just below the surface of awareness and involve unpleasant pessimistic predictions that centre on 3 themes of the Negative Cognitive Triad: (1) negative thoughts about self, (2) negative thoughts about experiences in the surrounding world, and (3) negative thoughts about one’s future - the negative cognitive tried is maintained by negative cognitive biases or errors e.g. di- chotomous or all-or-none reasoning, selective abstraction, and arbitrary inference (jump- ing to conclusions based on minimal or no evidence) Evaluating Beck’s Theory as a Descriptive Theory - Beck’s theory has generated cognitive therapy for depression which is very effective - it has been well supported as a descriptive theory that explains many prominent char- acteristics of depression - nondepressed people show a large positivity bias in attributions that may serve as a protective factor - Beck’s theory proposed that stressors are necessary to activate depressogenic schemas that lie dormant between episodes but recent research has shown that they are not necessary - depressed people show better or biased recall of negative information and draw nega- tive conclusions Evaluating the Causal Aspects of Beck’s Theory - results have been mixed The Helplessness and Hopelessness Theories of Depression Monday, Oct 22, 2012 - learned helplessness - when animals or humans find that they have no control over aversive events, they may learn that they are helpless which makes them unmotivated to try to respond in the future - they exhibit passivity and even depressive symptoms and are slow to learn that any re- sponse they do is effective The Reformulated Helplessness Theory - when people are exposed to uncontrollable negative events, they as themselves why, and the kinds of attributions that people make are central to whether they become depressed - they propose 3 critical dimensions on which attributions are made: (1) internal/external, (2) global/specific, and (3) stable/unstable - a depressogenic or pessimistic attribution for a negative event is an internal, stable and global one - people who have a relatively stable and consistent pessimistic attributional style have a vulnerability or diathesis for depression when faced with uncontrollable negative life events - this kind of cognitive style seems to develop in some part through social learning The Hopelessness Theory of Depression - having a pessimistic attributional style in conjunction with one or more negative life events was not sufficient to produce depres- sion unless one first experienced a state of hopelessness - a hopelessness expectancy was defined by the perception that one had no control over what was going to happen and by absolute certainty that an important bad out- come was going to occur or that a highly desired good outcome was not - there are 2 other dimensions of pessimistic attributional style: depression-prone people tend to make global and stable attributions for negative events but also make negative inferences about other likely negative consequences of the event Interpersonal Effects of Mood Disorders - interpersonal problems and social-skills deficits may well play a causal role - depression creates interpersonal difficulties Lack of Social Support and Social-Skills Deficits - people who are socially isolated or lack social support are more vulnerable to becoming depressed and depressed indi- viduals have smaller and less supportive social networks, which tend to precede the on- set of depression - some depressives have social-skills deficits (speak slowly and monotonously) - depressed people are poorer at solving interpersonal problems Monday, Oct 22, 2012 The Effects of Depression on Others - places others in the position of providing sym- pathy, support and care, such positive reinforcement does not necessarily follow - depressive behaviour can elicit negative feelings and rejection in other people - social rejection is especially likely if the depressed person engages in excessive reas- surance seeking Marriage and Family Life - a significant proportion of couples experiencing marital distress have at least one part- ner with clinical depression, and there is a high correlation between marital dissatisfac- tion and depression for both women and men - marital distress spells a poor prognosis for a depressed spouse whose symptoms have remitted - the depressed partner’s behaviours may trigger negative effect in the spouse - depressed individuals may also be so preoccupied with themselves that they are not very sensitive or responsive to the needs of their spouses - stress-generation model of depression helps explain the two-way relationship between marital discord and depression - a significant amount of the stress that depressed individuals experience is somehow at least partially generated by their own behaviours, but this stress in turn also serves to exacerbate depressive symptoms - depression also sets the scene for marital violence - parental depression puts children at high risk for problems, especially depression - depressed mothers show more friction and less playful, mutually rewarding interactions with their children, they are also less sensitively attuned to their kids - the children receive multiple opportunities for observational learning of negative cogni- tions, depressive behaviour, and depressed affect Bipolar Disorders - extreme moods persist for at least a week for a diagnosis - 3 or more additional symptoms must occur in the same period - there must also be a significant impairment of occupational and social functioning and hospitalization is often necessary during manic episodes - in milder forms, similar kinds of symptoms can lead to a diagnosis of hypomanic episode, where a person experiences abnormally elevated, expansive, or irritable mood for at least 4 days and have 3 other symptoms Monday, Oct 22, 2012 Cyclothymic Disorder - cyclical mood changes less severe than in bipolar - a less serious version of major bipolar disorder, minus certain extreme symptoms and psychotic features, such as delusions, and minus the marked impairment caused by full- blown manic or major depressive episodes - a person’s mood is dejected, or they experience a distinct loss of interest or pleasure in customary activities and pastimes - must show other symptoms such as low energy, feelings of inadequacy, social with- drawal and a pessimistic, brooding attitude - symptoms are similar to someone with dysthymia except without the duration criteria - symptoms of the hypomanic phase are essentially the opposite of the symptoms of dysthymia, the person become creative and productive because of increased physical and mental energy - for a diagnosis, there must be at least a 2-year span during which there are numerous periods of hypomanic and depressed symptoms and they must cause clinically signifi- cant distress or impairment in functioning Bipolar Disorders (I and II) - sometimes called manic-depressive illness Bipolar I Disorder - distinguished from major depressive disorder by at least one episode of mania or a mixed episode (symptoms of both full-bowl mania and major de- pressive episodes for at least a week) - even if a patient is exhibiting only manic symptoms, it is assumed that a bipolar disor- der exists and a depressive episode will eventually occur Bipolar II Disorder - when a person does not experience full-blown manic episodes but has experienced clear-cut hypomanic episodes as well as major depressive episodes - II is more common and when combined, estimates are that about 3% of people will suffer from one or the other - II evolves into I in 5-15% of cases - starts in adolescence and young adulthood, typically recurrent - manic and depressive episodes are separated by intervals of relatively normal func- tioning - recurrences can be seasonal on nature, in which case bipolar disorder with a seasonal pattern is diagnosed Features of Bipolar Disorder Monday, Oct 22, 2012 - symptoms of depressive episodes are clinically indistinguishable from those of unipolar major depressive disorder - many people are misdiagnosed as depressed at first - 10-13% of people who have a major depressive episode will later have a manic one - misdiagnosing is bad because some antidepressant drugs may precipitate manic episo
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