Download Mood Disorders

Mood
Disorders
Aims
 By the end of the session you will be able to do the
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following:
Recognize symptoms that contribute to the diagnosis of
unipolar and bipolar depression.
Compare and contrast contemporary perspectives in
their explanations of unipolar and bipolar depression.
Describe and compare different treatment approaches
used to treat unipolar and bipolar depression.
Critically be aware of the shortcomings of assessment,
diagnosis and treatment and their implications socially,
ethically and legally.
Depression types
Depression Types
Unipolar Depression
Bipolar Depression
Unipolar Depression
DSM-IV-TR
Major depressive episode
1. Presence of at least five of the following symptoms
during the same two week period:
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depression mood for most of the day, nearly everyday,
markedly diminished interest or pleasure in almost all activities, most of the day,
nearly every day,
insomnia or hypersomina nearly everyday, psychomotor agitation or retardation
nearly everyday,
fatigue or loss of energy nearly everyday,
feelings of worthlessness or excessive guilt nearly everyday, reduced ability to
think or concentrate, or indecisiveness, nearly everyday,
recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for
committing suicide.
Significant distress or impairment.
Major Depressive Disorder
1. The presence of a major depressive episode
2. No history of a manic or hypomanic episode.
Epidemiology
 7% adults suffer from severe unipolar depression, 5%
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mild form, in any given year (Kessler et al, 2005).
17% will experience an episode of severe unipolar
depression at some point in their life (Kessler et al 2005).
Women are twice as likely to experience severe
episodes (26% women compared to 12% of men
experience have an episode as some point in their life)
(Weissman et al, 1991).
Half people with unipolar depression recover within six
weeks and 90% recover within a year, some without
treatment (Kessler, 2002).
Most of them will have at least one other episode of
depression later in their lives (Boland & Keller, 2002).
Symptoms
Emotional
Motivational Behavioural
Cognitive
Physical
Sad.
Lack of drive,
spontaneity,
initiative.
Less active,
productive.
Negative view of
themselves.
Headache,
indigestion,
dizzy spells,
pain.
Anger, anxiety,
agitation.
Force to go to
work, talk to
friends.
Move slowly
Inadequate,
undesirable,
inferior, evil
Depression
misdiagnosed
as other
medical
problems.
Miserable,
empty,
humiliated.
Uninterested in
life
Speak slowly
Expect the worst,
hopelessness,
helplessness.
Disturbances in
sleep, appetite,
Little pressure
out of anything.
Wish to kill
themselves
Confused,
distracted, not
solve simple
problems.
1. Biological Model
Evidence from genetic
and biochemical studies
suggests that
Unipolar depression has
biological causes.
1a. Genetic Factors
 Family pedigree studies:
Person with unipolar
depression will have 20% of
relatives with depression,
compared with 10% relatives
(non-depressed).
 Twin Studies:
 (Study 200 twins) identical
twins 46% higher, fraternal
twins 20% (McGuffin et al
1996).
 Molecular Biology:
Abnormality of 5-HTT gene
(which transports serotonin in
the brain). (Hecimovic &
Gilliam, 2006).
1b. Biochemical Factors
 Low activity of norepinephrine and serotonin
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(neurotransmitters).
Medication for high blood pressure (lowered activity of the 2
neurotransmitters). (Ayd, 1956).
Antidepressant drugs found by accident (increase activity).
More complicated, not as simple as one NT alone causes
depression (Thase et al 2002).
Adrenal glands. Abnormal levels of cortisol (stress
hormone) (Neumesiter et al 2005).
Melatonin “Dracula hormone” released in the dark (SAD
produced more melatonin during winter) Neto & Aranjo,
2004).
Within neurons. Chemicals that carry messages which lead
to deficiencies of proteins & other chemicals which impair
the health of neurons (Julien, 2005).
1c.Biological Treatments ECT
 Electroconvulsive therapy
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discovered by Ugo Cerletti
Electric current 65 to 140 volts
sent through the brain causing
a brain seizure that lasts from
25 seconds to a few minutes.
6 to 12 treatments, spaced
over 2 to 4 week patients feel
less depressed (Andreasen &
Black, 2006).
Memory regained after a few
months but some will have
permanent amnesia (Fink,
2001).
Declined since the 1950’s
because of effective antidepressant drugs.
1c. Biological Treatments Antidepressant drugs
Sub-types
MAO INHIBITORS
Slow down
Monoamine Oxidase
MAO break down
norepinephrine
TRICYCLICS
Three-ring
molecule structure
60-65% helped
significantly
(Khun, 1958)
Block reuptake
process,
increasing
neurotransmitter
SECOND
-GENERATION
ANTIDEPRESSANTS
Selective serotonin
reuptake
Increase serotonin
uptake specifically.
* Most in demand
2. Psychological Models of
Unipolar depression
 Psychodynamic
 Behavioural
 Cognitive***********
2a. Psychodynamic Explanations
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Freud (1917) & Abraham (1916, 1911)
Emphasis on dependence and loss.
Grief and depression commonalities
Sadness, anger for the loved ones towards themselves.
In the face of loss the following groups are more likely to become clinically
depressed:
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Parents who failed to meet their needs during the oral stage
Parents gratified needs excessively
Devote their life to others, greater sense of loss.
Become depressed without loss
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Symbolic or imagined loss- equate other events to the loss of a loved one
Object relations theorist: peoples relationships leave them feeling unsafe and
insecure (Allen et al., 2004)
Support early life experiences and depression
Depressed scale administered to 1,250 medical patients, patients whose fathers died
during their childhood scored higher on depression (Barnes & Prosen, 1985)
Parental bonding instrument: chid rearing style as affectionless control- low care and
high protection (Shah & Waller, 2000)
Psychodynamic Treatments
 Associate freely during therapy- suggest
interpretations of the individual's
associations, dreams and displays of
resistance and transference, help review
past events and feelings (Busch et al.,
2004)
 “early recall of loss may have spiralled into
current depression”
 Long term- only occasionally helpful.
2b. Behavioural Explanations
 Depression results from significant changes in the numbers of rewards and
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punishments people receive in their lives.
Lewinsohn: positive rewards dwindle, leading to fewer constructive
behaviors.
Depressed individuals experience fewer social rewards than
nondepressed- environment and dark and flat mood promote this reduction
(Joiner, 2002).
Treatments
Variety of strategies to increase positive behaviors (Lewinsohn et al.,
1990).
Tasks pleasurable: set up weekly diary to incorporate these.
Ignore client’s depressive behaviors whilst rewarding constructive
statements and behavior (i.e., going to work)
Teach effective social skills (Segrin, 2000)
Combination need to be applied for effectiveness: track record of
pleasurable compared to diary of pleasant activities: effectiveness the same
(Jacobson et al., 1996).
2c. Cognitive Explanations
Two explanations
Learned
Helplessness
Negative Thinking
Learned Helplessness
 Feelings of helplessness are at the centre
of depression Seligman (1975).
 Learned Helplessness Theory of
Depression Seligman 1960’s.
 (1). No longer have control over the
reinforcements in their life
 (2). They themselves are responsible for
this helpless state.
 Humans exposed to uncontrollable negative events, they
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later score higher than other subjects on a depressive
mood survey (Miller & Seligman, 1975).
Attribution-helplessness theory (Mezulis et al 2004;
Abramson et al 2002).
Attribute lack of control to internal, global and stable
causes “I am useless and everything and I always will
be”- more likely to have depression.
Depressed people filled out the Attribution Style
Questionnaire both before and after therapy.
Before therapy: internal/global/stable pattern of
attribution.
End of therapy (& 1 year later): depression improved and
attribution style less likely to be internal, global and
stable (Seligman et al 1988).
Analysis
Relies on animal studies (Henn & Vollmayr, 2005)
Can animals make attributions, even implicitly?
Negative Thinking
 Beck (2002, 1967)
 Maladaptive attitudes, cognitive
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triad, errors in thinking, automatic
thoughts combine to produce a
clinical disorder.
Children- “my general worth is tied
to the tasks I perform”
maladaptive
Attitudes: own experiences, family
relationships, judgements from
other people, inaccurate
Cognitive Triad: repeatedly
interpret
1. their experience
2. themselves
3. their future in negative ways
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Errors in thinking:
Arbitrary inferences: negative conclusions based on limited evidence.
Minimize positive experiences and magnify negative experiences.
Automatic thoughts
They are inadequate and situation is hopeless.
“Everyone hates me” “I'm worthless”
Support
Depressed people hold maladaptive attitudes, the more held the more
depressed they are (Evans et al., 2005).
 Cognitive triad- depressed recall more negative events than positive ones,
select pessimistic statements, rate their behaviour in labs as poor (Ridout et
al., 2003).
 Errors in logic: female subjects asked to read and interpret paragraphs
about women in difficult situations. Depressed subjects made more errors
in logic (arbitrary inferences), in their interpretation than non-depressed
women (Hammen & Krantz, 1976).
Treatment: Cognitive Therapy
 Designed to recognise and change their
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maladaptive behaviours.
Beck (1985, 1967) similar to Ellis’s Rational
Emotive Therapy
Phase 1: Increase activities and elevate mood
Phase 2: Challenging automatic thoughts
Phase 3: Identifying negative thinking and
biases
Phase 4: Changing primary attitudes
50-60% show a near total elimination of
symptoms (Petrocelli, 2002).
Stress Link
Link between stress and
depression (Costantino et al 2006)
Depressed people are more likely
to have experienced stressful
events one month before the onset
of their disorder
(Monoe &
Hadjiyannakis, 2002).
Sociocultural Model
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Everyone at risk (WHO, 2004); vary culture to culture (Draguns, 2006).
Gender: higher in women- special pressures and complex roles.
Rise with poverty, minorities, family size and number of health problems (Comer,
2007)
Social Support: influences depression (Kendler et al., 2005)
Separated or divorced x3 more depression (Weissman et al., 1991).
Live in isolation without intimacy seem to become more depressed during times of
stress (Kendler et al., 2005)
Treatments
Interpersonal Psychotherapy and couple therapy
Klerman & Weissman IPT
4 interpersonal problem areas: interpersonal loss (explore grief and relationship with
the lost person & explore feelings of anger-develop new ways of remembering the
lost person), interpersonal role dispute (ways of resolving them), interpersonal role
transition (develop social support and skills the new role requires) interpersonal
deficits (extreme shyness, social awkwardness- teach them social skills and
assertiveness) (Weissman & Markowitz, 2002).
Success rate similar to that of Cognitive Therapy.
Couple Therapy: depressed person in a dysfunctional relationship, recovery slower
for those in a non-supportive relationship. If there is conflict this approach is
beneficial and effective as the above therapies (Snyder & Castellani, 2006).
Bipolar Depression
DSM-IV-TR
Manic Episode
 A period of abnormally and persistently elevated, expansive or irritable mood, lasting at least
one week.
 Persistence of at least three of the following:
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Inflated self-esteem or grandiosity, decreased need for sleep, more talkativeness than usual or pressure
to keep talking, flight of ideas or the experience of thoughts are racing, distractibility, increase in activity
or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for
painful consequences.
Significant distress or impairment
Bipolar i Disorder (full manic and depressive episodes)
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The presence of a manic, hypomanic or major depressive episode
If currently in a hypomanic or major depressive episode, history of a manic episode.
Bipolar ii Disorder (mildly manic- over a course of time)
 The presence of a hypomanic or major depressive episode
 If currently in a major depressive episode, history of a hypomanic episode. If currently in a
hypomanic episode, history of a major depressive episode. No history of a manic episode.
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Significant distress or impairment.
 (APA,2000)
Causes: Biological
 Neurotransmitters:
 Norepinephrine activity higher with mania than of depressed control
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subjects (Post et al., 1980)
Resprine drug (reduce norepinephrine), mania subsided (Telner et
al., 1986)
Ion activity: improper transport of these ions may cause neurons to
fire too easily, resulting in depression (El-Mallakh, 2004)- abnormal
functioning in the proteins that transport ions across a neurons
membrane (Monkul et al.,2005)
Brain structure:
Brain imaging studies: abnormal brain structures (Lambert &
Kinsley, 2005)
Basal ganglia and cerebellum is smaller- not clear of the role these
play in bipolar depression yet (Monkul et al., 2005)
 Genetic Factors
 Inherit a biological predisposition to develop bipolar disorders.
 Identical twins of person with bipolar depression have 40%
likelihood of developing BD, fraternal twins, siblings have 5-10%
compared to 1-2% general population (Swann, 2008).
 Molecular biology:
 Genes on chromosomes 1,4,6,10,11,12,13,15,18,21,22 (Hayden et
al., 2008)
 Genetic abnormalities combine to create BD (Payne et al., 2005)
Treatments
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Psychotherapist- no success
Anti-depressant drugs- limited effectiveness
Lithium Therapy (Cade, 1949)
Doses: too little- no effect; too much: intoxication-slurred speech, dizziness,
kidney failure, death.
Effective in treating manic episodes (Grof, 2005)
60% patients improve and experience fewer new episodes as long as they
carry on taking lithium (Carney & Goodwin, 2005)
Relapse risk 28x greater when stop taking antibipolar drugs (Suppes et al.,
1991).
Helps overcome depressive episodes to a lesser degree than manic
episodes (El-Mallakh, 2006)
Changes synaptic activity
Adjunctive Psychotherapy
Lithium therapy alone is not effective, 30% may not respond to this therapy
or relapse (Julien, 2005)
Use individual, group, family therapy as an adjunct to lithium treatment
(Colom & Vieta, 2006) helps to hold a job and social functioning.
On a lighter note: creativity and
abnormality: The price of
creativity
 Useful in the arts (Ludwig, 1995)
 Ancient Greeks: divine madness-inspired creative arts
 Today- expectation that creative geniuses to be
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psychologically disturbed.
Artists and writers more likely to suffer from mood
disorders (Lauronen et al., 2004)
Sources of inspiration?
Work results in becoming disturbed?
Predisposition, early life experiences?
Majority are stable and medication for those who need it
Frezied Masterpiece: Messiah
(wrote it in less than a month during a manic episode)
Today: preventative measures in a hectic
and pressurised world
Laughter being the best medicine
Symptoms of
Mania
 Dramatic and inappropriate rises in mood.
 Active and powerful emotions in search of an
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outlet.
Irritable and angry- others get in the way.
Want constant excitement, involvement &
companionship
Do not know that they are overwhelming,
domineering & excessive.
Talk and walk fast- there is not enough time
Flamboyant- clothes, money
Poor judgement, cannot see pitfalls because
of being too quick, do not listen to others.
Inflated opinion of themselves
Self-esteem- approaches grandiosity.
Difficulty to be in touch with reality
Energetic- little sleep, feel and act wide
awake (Gupta et al., 2004)
Seminar Reading
 Is Electroconvulsive Therapy Ethical?
 YES: Max Fink from Electroshock:
Restoring the Mind (Oxford University
Press, 1999)
 No: Leonard R. Frank from “Shock
Treatment IV: Resistance in the 1990’s,” in
Robert F. Morgan, ed., Electroshock: The
Case Against (Morgan Foundation, 1999).
Reading
 Nevid, J.S., Rathus, S.A., & Greene, B. (2008).
Abnormal Psychology In A Changing World. (7th
ed.). Pearson Prentice Hall: London. Chapter 8,
pp. 246-289.
 Oxman, T., Hegel, M., Hull, J., & Dietrich, A.
(2008, December). Problem-solving treatment
and coping styles in primary care for minor
depression. Journal of Consulting and Clinical
Psychology, 76(6), 933-943. Retrieved January
23, 2009, doi:10.1037/a0012617
 Cohen, L., Gunthert, K., Butler, A., Parrish, B., Wenze,
S., & Beck, J. (2008, December). Negative affective spill
over from daily events predicts early response to
cognitive therapy for depression. Journal of Consulting
and Clinical Psychology, 76(6), 955-965. Retrieved
January 23, 2009, doi:10.1037/a0014131
 Constantino, M., Manber, R., DeGeorge, J., McBride, C.,
Ravitz, P., Zuroff, D., et al. (2008, December).
Interpersonal styles of chronically depressed outpatients:
Profiles and therapeutic change. Psychotherapy: Theory,
Research, Practice, Training, 45(4), 491-506. Retrieved
January 23, 2009, doi:10.1037/a0014335
 Tackett, J., Quilty, L., Sellbom, M., Rector, N., & Bagby,
R. (2008, November). Additional evidence for a
quantitative hierarchical model of mood and anxiety
disorders for DSM-V: The context of personality
structure. Journal of Abnormal Psychology, 117(4), 812825. Retrieved January 23, 2009, doi:10.1037/a0013795
 Lau, J., & Eley, T. (2008, November). Attribution style as
a risk marker of genetic effects for adolescent
depressive symptoms. Journal of Abnormal Psychology,
117(4), 849-859. Retrieved January 23, 2009,
doi:10.1037/a0013943
 Gross, H., Shaw, D., Moilanen, K.,
Dishion, T., & Wilson, M. (2008, October).
Reciprocal models of child behaviour and
depressive symptoms in mothers and
fathers in a sample of children at risk for
early conduct problems. Journal of Family
Psychology, 22(5), 742-751. Retrieved
January 23, 2009, doi:10.1037/a0013514
One Hour Video
 Chapter Eight Mood Disorders
Depression is one of the most common
psychological problems. In this program,
psychologists and biologists look at the causes
and treatment of both depression and bipolar
disorder and show the progress that has been
made in helping people return to productive and
satisfying lives.
 http://www.learner.org/resources/series60.html
End