Abnormal affect Types, characteristics, examples of and sex differencesTypes: depression (unipolar) and mania (bipolar); causes and treatments for manic depression; sex differences in depression• explanations of depressionBiological: genetic and neurochemical; cognitive: Beck’s cognitive theory; learned helplessness/attributional style (Seligman, 1979)• treatments for depressionBiological: chemical/drugs (MAO, SSRIs); electro- convulsive therapy. Cognitive restructuring (Beck, 1979); rational emotive therapy (Ellis, 1962)
Some facts By the year 2020, the World Health Organization (WHO) estimates that depression will be the number two cause of "lost years of healthy life" worldwide Depression considered the common cold of mental illness in America
Depression Emotional state marked by great sadness feelings of worthlessness and guilt withdrawal from others loss of sleep , appetite , sexual desire and interest and pleasure in usual activities.
Often associated with other psych. disorders ( eg. panic attacks, substance abuse, sexual dysfunction and personality disorders) Paying attention can be exhausting Conversations are a chore Some prefer to sit alone while others are agitated and cannot sit still. Pace, wring their hands, continually sigh and moan or complain.
Can not find solutions when confronted with problems. May neglect personal hygiene and appearance and complain about numerous somatic symptoms (with no physical basis) Depression although recurrent tends to dissipate with time. Untreated depression may stretch on for 5 mnths or longer with a risk of suicide. Chronic depression- earlier level of functioning
DSM IV –TR Criteria for Depression Sad depressed mood, most of the day, nearly evdy for 2 weeks or loss of interest in pleasure in usual activities, plus 4 of the following:1. Difficulties in sleeping - insomnia, sleeping too much, early morning awakenings etc.2. Shift in activity level- lethargic or agitated3. Poor appetite and weight loss or increased appetite and weight gain.4. Loss of energy, great fatigue5. Negative self-concept, self-reproach and self blame; feelings of worthlessness and guilt6. Complaints or evidence of difficulty in concentrating – slowed thinking, indecisiveness7. Recurrent thoughts of death or suicide.
Sex differences in depression Significant research shows that women are diagnosed with depression twice as much as men . In 7/8 studies of treated cases (ppl undergoing therapy) in the US females outnumbered males 2:1. In 10 studies outside the US 9 showed more females than males as depressed. Why?
Mania Emotional state/ mood of unfounded elation or irritability accompanied by : Hyperactivity Talkativeness Flight of ideas Distractibility Impractical and grandiose plans(refer to pg 269 of text for eg)
Mania Some people who experience episodes of depression at times suddenly become manic. Pure cases of mania are rare Manic episodes vary from days to months Comes on suddenly Subject is loud and has incessant stream of remarks (jokes, puns, rhymes) may shift from topic to topic, be annoyingly sociable . Imprudent sexual behavior Any attempt to curb these excesses can lead anger or rage.
DSM –IV-TR Criteria for a ManicEpisode Elevated or irritable mood for at least one week plus 3 of the following (4 if the mood is irritable):1. Increase in activity level at work socially or sexually2. Unsual talkativeness; rapid speech3. Flights of ideas or subjective impression that thoughts are racing4. Less than usual amount of sleep needed5. Inflated self-esteem; belief that one has special powers, talents and abilities.6. Distractibility; attention easily diverted.7. Excessive involvement in pleasurable activities that are likely to have undesirable consequences (eg. Reckless spending)
Some facts about Bipolar Disorder Between .6 and 1.1 % of the US population will have bipolar in their lifetime (as opposed to 1/20 being depressed) Occurs equally in both sexes (unlike unipolar depression) First episode is usually manic not depressive Tends to recur and each episode lasts from several days to several months No regular cycling (3 months manic followed by 3 months depressive)
Causes of bipolarBIPOLAR DISORDER UNDERSTOOD BEST WITHIN THE BIOLOGICAL MODEL. Some theorists believe that bipolar disorder results from self-correcting biological processes that are ungoverned. States of depression or euphoria are kept from spiralling out of bounds by switching from one state to another. Other theorists mention 3 separate systems in the brain (controlled by neurotransmitters)that may become unbalanced and cause different groups of symptoms:
Causes of bipolar1. Lack of enjoyment /interest excessive pleasure seeking activity due to brain’s disinhibition-inhibition process.2. High sensitivity to pain/negative events low sensitivity due to a separate disinhibition-inhibition process of the brain.3. Retarded motor activity hyperactivity due to an unregulated movement processing system .
Causes of bipolar disorder Individuals are genetically vulnerable to bipolar disorder Family , twin and adoption method to see if genetic factors are responsible.Relatives of bipolar patients have 5 times the normal 1 % risk of developing the disorder (Rice et al. 1987)Identical twins have 5 times the concordance for bipolar than do fraternal twins.
Treatment of bipolar Lithium carbonate is the most effective treatment for bipolar disorder. Considered miracle drug for bipolar disorder However quite toxic on overdose New treatments use anticonvulsant (drugs used to control seizures) drugs:Carbomezapine, valproate, Iamotrigine and gabapentin .
Biological Explanations ofDepression – GeneticFamily , twin and adoption method to see if genetic factors are responsible. Research indicates that genetic factors less responsible for depression than bipolar disorder. However twin studies of depression report higher concordances in monozygotic than dizygotic twins with some suggestion that genetics may play a stronger role in women than in men (Bierut et al 1999; McGuffin at al 1996 etc) Small scale adoption studies have also shown that depression has a modest genetic component.
Biological Explanation ofDepression – BiochemicalChanges in brain and body chemistry certainly accompany depression.Evidence:1. depression in women after giving birth to a child, at menopause and just before menstruation.2. Symptoms similar across cultures, sexes, ages3. Drug therapies focusing on neurotransmitters are effective in treatment
BUT…. They measured the metabolic breakdown products of these transmitters normally found in blood or urine- results have been inconsistent Medications increase neurotransmitters immediately but any relief from them takes 2 to 3 weeks.
Biological Expln of Depression-Biochemical This initial evidence led to the hpothesis that chemical abnormalities in monoamines (a class of neurotransmitters) cause depression Manoamines: norepinephrine, dopamine , seratonin. Early on researchers thought that decreased levels of norepinephrine and dopamine cause depression
Hence the norepinephrine and dopamine hypotheses have been abandoned. “Downregulation theory”: monoamine levels are not low but postsynaptic monoamine receptors are inadequate. Thus the growth of receptors or increasing the sensitivity of exisitng receptors might be why antidepressants take time.
Theory of “kindling” : a process by which certain neurons, by firing repeatedly make themselves more sensitive to subsequent stimulation – each episode of depression makes subsequent ones increasingly likely because the relevant neurochemical systems become easily “dysregulated”. None of these theories have been adequate in proving depression but have helped in treating it.
2 important lessons from the mass of theories looked at:1. Neurochemical deficits observed only when person is depressed .2. Drugs produce other changes as well .Hence although monoamine levels correlate with depression and relief from depression, they do not cause either one.
Cognitive Explanation ofDepression According to Beck depression is caused by 2 mechanisms: 1. Cognitive triad 2. Errors in logic AARON T. BECK
Beck’s Cognitive Theory1. The cognitive triad consists of negative thoughts about : Ongoing The self experiences Future
Negative thoughts about… Ongoing Self Future experiences• Defective- • Interpretation • Negative things never attain that whatever that happen happiness happens to now will• Worthless- him/her is bad. continue in the unpleasant • Drawn to the future… experiences most negative • Future view is attributed to possible one of this interpretation helplessness.• Inadequate- • Small obstacles Such thoughts impassable lead to low self barriers. esteem
Errors in Logic Beck believed that systematic “errors in logic” are the second mechanism of depression. A person makes five different logical errors in thinking :
Logical errorsArbitrary inference: drawing a conclusion when there is noevidence to support it Selective abstraction: consistently focusing on one insignificant detail while ignoring the more important features of a situation Overgeneralization:drawing global conclusions about worth , ability or performance on the basis of a single fact.Magnification and Minimization : magnifying small bad events and minimizing large good events.Personalization: incorrectly taking responsibility for bad events in the world
Evaluation of Beck’s theory Research confirms that depressed patients in contrast to non depressed individuals, think in the negative ways enumerated by Beck. However, we can cannot determine if the negative thoughts cause depression or that depression causes the negative thoughts (chicken or egg??) this relationship can perhaps work both ways… Beck’s theory is testable and has led to much research on the treatment of depression.
Learned helplessness Unpleasant traumas/ experiences lead to individual’s passivity and helplessness. Unpleasant traumas/experiences Sense of helplessness Depression
Attribution and LearnedHelplessness Problem with the learned helplessness theoryEg I am responsible for my depression . How am I helpless then???
Attribution and learnedhelplessness Seligman and colleagues came up with a revised version of the learned helplessness theory which involves ATTRIBUTION ATTRIBUTION- the explanation one has for his/her behavior Given a situation in which a person experiences failure, he/she will attribute the failure to some cause.
Attribution and learnedhelplessness People become depressed when they attribute negative life events to personal, stable and global causes.
Attributions Global Specific Stable Unstable Internal Externalwhen theindividual believes that the individual when the assigns cause of believes individual causality negative that the thinks to factors cause of a individual that the events is believes within theconsistent negative cause is person. Assigns event is the cause specific to causality across to be different unique to one point to a consistent in time situational contexts across particular or situation time external factors
Evaluation of LearnedHelplessness/Attribution Expl. Which type of depression is being modeled? Accumulating evidence indicates that selecting subjects solely on the basis of elevated BDO scores, does not yield a group who can serve as a good analogue for clinical depression. Even if we allow that attributions are relevant and powerful determinants of behavior, findings that support the learned helplessness theory have been conducted in the lab.
Treatment of DepressionTreatment either biological or psychological can treat 80 to 90 % of severe depressions.Recurrence remains substantial with all forms of treatments.
Biological treatments ofdepression Drug treatment ECT
3 classes of drugs to treat depression: Tricyclic Monoamine oxidase Serotonin reuptake antidepressants inhibitors (MAO inhibitors (SSRI’s) (TCA’s) inhibitors) • Block the reuptake • Prevent the • Eg Zoloft, Paxil and of norepinephrine breakdown of Prozac prescribed (NE) leading to more norepinephrine widely for less NE. • More NE – less severe depression. • B/w 60 to 75% depressed • Selectively inhibit patients show • Prescribed less often the reuptake of clinical improvement than TCA’s or SSRI’s serotonin. . because inhibition of • 60 to 70 % patients • Also reduces MAO enzyme can with severe recurrence have lethal side depression relieved. • Reduction of “5-HT effects. Low risk of receptors” which • When combined with overdose. participate in the shellfish, bp • Altough popular, reuptake of reducing drugs, red efficacy about the serotonin might wine, aged cheese same as that of MAO actually be how the and narcotics , can inhibitors and TCA’s. TCA’s work (Taylor et be fatal. • Still some concern al. 1995) • Should be used as that Prozac may lead the last option from to suicide. 3.
ATYPICAL Depressants are now also used to treat depression (eg . Wellbutin). They affect the availability of both serotonin and norepinephrine. Wellbutin, the most widely used drug affects dopamine levels . Although Wellbutin has its own side effects, it is free of sexual side effects
Evaluation of biological treatments Large part of the effect of antidepressant drugs, is the placebo effect (30-40%). Once the drug is stopped, recurrence and relapse rates are also high. However, in profound psychotic depression psychotherapy is useless and only drugs or ECT will work. Palliative vs curative drugs Every single drug for mental illness is palliative rather than curative.
They suppress the symptoms but these symptoms have the same risk of returning once the drug is stopped, as if the drug had never been taken in the first place! Patients who respond well to antidepressants, might take them indefinitely to prevent recurrence.
Electroconvulsive shock treatment-ECTStrong evidence exists thatECT is highly effective whengiven to patients with severedepression. 80% of patients with majordepression respond to ECT.Recurrence of depression issubstantial with about 60% ofthose being treated with ECTbecoming depressed again thenext year (Sackheim et al ,1993)Exactly how ECT works, isunknown.
Cognitive therapy Attempts to counter negative thoughts and errors in logic. The therapist actively guides the patient into reorganizing his thinking and actions not about the past but the present. The cognitive therapist talks a lot and is directive. She/he argues with the patient. She persuades; she cajoles; she leads.
Cognitive restructuring (Beck1979) One of the most important tools used in CBT is cognitive restructuring aims to change maladaptive cognitions and replace them with more adaptive ways of information processing. However, maladaptive thinking patterns are sometimes so strong and automatic that they tend to persist and bias the process of acquiring new adaptive ones.
According to Beck et al. (1979) cognitive restructuring involves:(1) identifying maladaptive cognitions(2) modifying maladaptive cognitions and(3) assimilating adaptive cognitions. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable. Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.
Ellis’s Rational Emotive Therapy Some people hold assumptions that are largely irrational about themselves and their world. “Basic irrational assumptions” Some common irrational assumptions:
The idea that one should be thoroughly competent at everything The idea that is it catastrophic when things are not the way you want them to be The idea that people have no control over their happiness The idea that you need someone stronger than yourself to be dependent on The idea that your past history greatly influences your present life The idea that there is a perfect solution to human problems, and it’s a disaster if you don’t find it. REBT employs highly emotive, techniques to help patients vigorously and forcefully change this irrational thinking.
Ellis’s Rational Emotive Therapy A major aid in cognitive therapy is what Albert Ellis called the ABC Technique of Irrational Beliefs. A • Activating event or objective situation . Eg Sana scores low in a Math test B • Beliefs - the negative thoughts that occurred . Eg: Sana believes she must have good grades or she is worthless c • Consequence- the negative feelings and dysfunctional behavior that ensues . Eg: Sana feels depressed
Ellis’s Rational Emotive Therapy Ellis believes that it is not (A) the activating event that causes (C), but rather the irrational belief system (B) that helps cause the consequences (C). * Reframing* - After irrational beliefs have been identified, the therapist will often work with the client in challenging the negative thoughts on the basis of evidence from the clients experience by reframing it, meaning to re- interpret it in a more realistic light. This helps the client to develop more rational beliefs and healthy coping strategies.
Depression Cognitive Drugs ECT Therapy Improvement 60-75% 60-75% 80% markedly markedly markedly improvedtreatments improved improved relapse Moderate High relapse High relapse relapse Side effects None Moderate Rather severe Cost inexpensive inexpensive inexpensive Time scale A month weeks days overall V good V good V good