Chapter 10 Depressive and Bipolar Disorders PDF

Depressive and Bipolar Disorders ★ Depression:A low, sad state marked by significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms ★ Mania: A state or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the worl...

Depressive and Bipolar Disorders ★ Depression:A low, sad state marked by significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms ★ Mania: A state or episode of euphoria or frenzied activity in which people may have an exaggerated belief that the world is theirs for the taking ★ Depressive disorders: The group of disorders marked by unipolar depression ★ Unipolar depression: Depression without a history of mania ★ Bipolar disorder: A disorder marked by alternating or intermixed periods of mania and depression. Unipolar Depression: The Depressive Disorders ★ How Common Is Unipolar Depression ○ Around 8 percent of U.S. adults suffer from severe unipolar depression in any given year; 5 percent suffer from mild forms. ○ Around 20 percent of all adults experience unipolar depression at some time in their lives. ○ Average age of onset is 19 years. ○ Lifetime prevalence: 26 percent of women versus 12 percent of men ○ Some(85%) recoover without treatment ★ Symptoms of Depression ○ Emotional symptoms Feeling miserable, empty, or humiliated; anger, anxiety, or agitation Experiencing little pleasure (anhedonia) ○ Motivational symptoms Lacking drive, initiative, and spontaneity Between 6 percent and 15 percent of those with severe depression die by suicide ○ Behavioral symptoms Less active, less productive; slower movement or speech ○ Cognitive symptoms Hold negative views of themselves Blame themselves for unfortunate events; procrastination Pessimistic ○ Physical symptoms Headaches, dizzy spells, indigestion, constipation, or general pain Sleep disturbances, fatigue ○ Symptoms vary each person ★ Diagnosing Unipolar Depression ○ DSM-5 lists several types of depressive disorders. Major depressive disorder A severe pattern of depression that is disabling and is not caused by such factors as drugs or a general medical condition Persistent depressive disorder A chronic form of unipolar depression marked by depression.  Premenstrual dysphoric disorder A disorder marked by repeated episodes of significant depression and related symptoms during the week before menstruation. ★ Major Depressive Episode ○ For a 2-week period, a person displays an increase in depressed mood for the majority of each day and/or a decrease in enjoyment or interest across most activities for the majority of each day. ○ For the same 2 weeks, person also experiences at least three or four of the following symptoms: Considerable weight change or appetite change Daily insomnia or hypersomnia Daily agitation or decrease in motor activity Daily fatigue or lethargy Daily feelings of worthlessness or excessive guilt Daily reduction in concentration or decisiveness ○ Repeated focus on death or suicide, a suicide plan, or a suicide attempt ○ Significant distress or impairment ★ Major Depressive Disorder ○ Presence of a major depressive episode ○ No pattern of mania or hypomania ★ Persistent depressive Disorder ○ Person experiences the symptoms of major or mild depression for at least 2 years ○ During the 2-year period, symptoms not absent for more than 2 months at a time ○ No history of mania or hypomania ○ Significant distress or impairment ★ 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 ★ Stress and unipolar depression ○ Stressful events may trigger episode; ○ 80 percent of severe episodes occur within a month or two of a significant negative event. ★ Kinds of depression ○ Reactive (exogenous) depression: Depression caused by external factors, e.g The Environment ○ Endogenous depression: Depression caused by endogenous depression ★ Postpartum (peripartum) depression ○ Symptoms may last up to year or more Extreme sadness, despair, tearfulness, insomnia, anxiety, intrusive thoughts, compulsions, panic attacks, inability  to cope, suicidal thoughts Impact on mother–infant relationship and child well-being Causes Triggered by hormonal changes of childbirth Genetic predisposition Psychological and social change Treatment Self-help groups Antidepressant medications, cognitive-behavioral therapy, interpersonal psychotherapy, or combination of these Treatment helps most women if it is sought ★ Biological model of unipolar depression ○ Genetic factors Family pedigree studies Twin studies Gene studies Molecular biology ○ Biochemical factors Low activity of two neurotransmitters: serotonin and norepinephrine Early studies on high blood pressure and antidepressant drugs Later neurotransmitter interaction research; glutamate included ○ Hormones and HPA(Hypothatlamic-Pituitary-Adrenal) pathway Stress studies Release of hormones at various locations throughout body spur assorted body organs into action, causing temporary experience of heightened state of arousal (e.g., PTSD) Research indicates that the HPA axis of people with depression is also overly reactive in the face of stress, causing excessive releases of cortisol and related hormones at times of stress. ○ Brain Circuits Brain circuit dysfunction; brain imaging studies Subgenual cingulate(plays a role in emotions), degeneration in this area causes depressed and anhedonia makes a distinct contribution Abnormal activity and flow rate in various brain locations Structure problems: interconnectivity Abnormal neurotransmitter activity ○ REFER TO PAGE 13 ON THE SLIDES ★ Immune System ○ the body’s network of activities and cells that fight off bacteria and other foreign invaders ○ Under intense stress, dysregulation of the immune system occurs and contributes to depression. Slower functioning of lymphocytes, increased pro-inflammatory cytokines production, and greater inflammation. ★ What are the biological treatments for unipolar depression? ○ Antidepressant drugs Monoamine oxidase (MAO), tricyclics, second-generation antidepressants, ketamine-based drugs ○ Brain stimulation Electroconvulsive therapy; other forms of brain stimulation ○ MAO inhibitors Increases activity level of neurotransmitters serotonin and norepinephrine Iproniazid; tyramine ○ Tricyclics Acts on neurotransmitter reuptake mechanism of key neurons; biological corrections Imipramine; Tofranil ○ Second-generation antidepressants Selective serotonin reuptake inhibitors (SSRIs) that increase serotonin activity without affecting other transmitters Fluoxetine/Prozac; sertraline/Zoloft; escitalopram/Lexapro Selective norepinephrine reuptake inhibitors that increase norepinephrine activity only Atomoxetine/Strattera Serotonin–norepinephrine reuptake inhibitor that increases both serotonin and norepinephrine activity Venlafaxine/Effexor REFER TO PAGE 18 ON GOOGLE SLIDES ○ Ketamine-based antidepressants Increases activity of glutamate in the brain; may aid in new neural pathway development. Often alleviates depression quickly, combines well with other drugs, used to those unresponsive to other drugs or who are suicidal; short-term impact. Special K/party drug; esketamine/Spravato ○ Brain stimulation Biological treatments that directly or indirectly stimulate certain areas of the brain Methods Electroconvulsive therapy (ECT) ○ : A treatment for depression in which electrodes attached to a patient’s head send an electrical current through the brain, causing a convulsion(relaxation of muscles and involuntary movement) Vagus nerve stimulation ○ A treatment for depression in which an implanted pulse generator sends regular electrical signals to a person’s vagus nerve; the nerve then stimulates the brain Transcranial magnetic stimulation (TMS)  ○ A treatment in which an electromagnetic coil, which is placed on or above a patient’s head, sends a current into the individual’s brain. Deep brain stimulation (DBS) ○ A treatment that works much like a pacemaker, sending electrical signals to the brain to help reduce brain activity to a normal level and recalibrate the depression-related brain circuit ★ The psychological models of unipolar depression ○ Psychodynamic model Freud and Abraham: When some people experience real or imagined losses (symbolic loss) Object relations theorists: Depression results when people’s relationships leave them feeling unsafe and insecure (especially in early life) ○ Supported ideas Major losses, especially early life ones, may set the stage for later depression. Poorly met childhood needs are related to depression after loss. ○ A young daughter stands by the casket of her father, a firefighter who died helping to bring a large wildfire under control. ○ Research has found that people who lose their parents as children have an increased risk of experiencing depression as adults. ★ Psychodynamic treatments for unipolar depression ○ Free association ○ Interpretations of client associations, dreams, and displays of resistance and transference ★ Psychodynamic view ○ Strengths General research support Depression may be triggered by major loss; early losses set the stage for later depression. Depression after loss may be related to poorly met childhood needs. Limitations Depressed clients may be too passive and feel too weary to join fully in the subtle therapy discussions. Clients may become discouraged and end treatment too early. ★ Cognitive-behavioral model ○ Depression results from problematic behaviors and dysfunctional thinking. ○ Theoretical perspectives Behavioral dimension Negative thinking Complex cognitive and behavioral factor interplay ○ Behavioral dimension (Lewinsohn and others) Number of life rewards related to presence or absence of depression. Large reduction in positive life rewards may cause increasingly fewer positive behaviors, even lower positive rewards rate, and eventual depression. Social rewards are important in a downward depression spiral.  Strong relationship between positive life events and feelings of life satisfaction and happiness ○ Negative thinking Beck: Unipolar depression is produced by a combination of maladaptive attitudes, cognitive triad, errors in thinking, and automatic thoughts. Cognitive triad: Negative view of experiences, oneself, and future Watkins and colleagues: Ruminative(involving deep thought) responses during depressed moods are linked to longer feelings of dejection(Sad, low spirit state) and increased likelihood of later life clinical depressions. ○ Learned helplessness Cognitive-behavioral interplay Seligman: Depression occurs when people believe they have no control over life’s reinforcements and assume responsibility for this helpless state ○ Attribution-helplessness theory Modified learned helplessness theory Internal (global and stable) attribution of present lack of control leading to feeling helpless to prevent future negative outcomes. depression ○ Challenges Much research relies on results from animal subjects. Attribution features raise difficult questions. ○ Cognitive-behavioral therapy Key components to behavioral activation Reintroduction to pleasurable events/activities Consistently reward non-depressive behaviors and withhold rewards for depressive ones Help clients improve social skills Challenges Limited help as a solo treatment; more helpful in combination with cognitive techniques New-wave approach suggests individuals do not need to fully discard negative cognitions to overcome depression. Acceptance and commitment therapy (ACT) Cognitive therapy (Beck) Phase 1: Increasing activities and elevating mood Phase 2: Challenging automatic thoughts Phase 3: Identifying negative thinking and biases Phase 4: Changing primary attitudes Often follow-up with preventive cognitive therapy Around 50 to 60 percent of patients show significant improvement in or elimination of their symptoms. ★ Sociocultural model of unipolar depression  ○Unipolar depression influenced by social context and often triggered by outside stressors Family-social perspective Multicultural perspective ○ Family-social perspective A decline in social rewards impacts depression. Social deficits may cause avoidance by others, thereby decreasing their social contacts and rewards. Weak or unavailable social support, isolation, and lack of intimacy; tied repeatedly to troubled or unhappy marriage. Social isolation and imposed social distancing (e.g., COVID-19). Family-social treatments Interpersonal psychotherapy (IPT) Interpersonal loss Interpersonal role dispute Interpersonal role transition Interpersonal deficits IPT and related interpersonal treatments for depression have a success rate similar to that of cognitive-behavioral therapy. Couples therapy involves two people who share a long-term relationship. Integrative behavioral couples therapy combines cognitive-behavioral and sociocultural techniques. ★ The multicultural perspective ○ Gender and depression Across various cultures, women are twice as likely as men to receive a diagnosis of unipolar depression. Women with depression appear to be younger, have more frequent and longer-lasting bouts, and respond less successfully to treatment. Two kinds of relationships have captured the interest of multicultural theorists: (1) links between gender and depression, and (2) ties between cultural and ethnic background and depression. Reported symptoms include sadness, joylessness, tension, lack of energy, loss of interest, loss of ability to concentrate, ideas of insufficiency, and thoughts of suicide ★ Gender and depression explanations ○ Artifact theory The artifact theory holds that women and men are equally prone to depression, but that clinicians often fail to detect depression in men. ○ Hormone explanation The hormone explanation holds that hormone changes trigger depression in many women ○ Life stress theory The life stress theory suggests that women in our society experience more stress than men do ○ Body dissatisfaction explanation  The body dissatisfaction explanation states that females in Western society are taught, almost from birth, but particularly during adolescence, to seek a low body weight and slender body shape—goals that are unreasonable, unhealthy, and often unattainable. ○ Lack-of-control theory The lack-of-control theory draws on the learned helplessness research and proposes that women may be more prone to depression because they feel less control than men over their lives ○ Rumination theory Research reveals that women are more likely than men to ruminate when their mood darkens, perhaps making them more vulnerable to the onset of clinical depression ★ Cultural background and depression ○ Precise picture of depression varies from country to country. Non-Western countries: Higher likelihood of physical symptoms; fewer cognitive symptoms Ethnic or racial groups Few differences in overall rates or symptoms; recurrence rate differences Uneven distribution within some minority groups ○ Multicultural treatments Culture-sensitive therapies address unique issues faced by members of cultural minority groups. Cultural training and heightened awareness Development of comfortable bicultural balance Recognition of impact of own and dominant culture Combined with traditional forms of psychotherapy ★ Integrating the models: the developmental psychopathology ○ Unipolar depression is caused by a combination of the factors cited by various models. Genetically inherited biological predisposition influenced by significant early life trauma Magnitude and timing of negative factors Resiliency linked to moderate and manageable adversities throughout childhood ○ These factors unfold and intersect in a developmental sequence. Bipolar Disorders ★ Involve lows of depression and highs of mania ★ Shift between extreme moods ★ Have dramatic impact on relatives and friends ★ What are the symptoms of mania?  ○ Unlike those experiencing depression, people in a state of mania typically experience dramatic and inappropriate rises in mood. ○ Emotional symptoms Active, powerful emotions in search of an outlet ○ Motivational symptoms Need for constant excitement, involvement, companionship ○ Behavioral symptoms Very active—move quickly; talk loudly or rapidly; flamboyance is not uncommon ○ Cognitive symptoms : Show poor judgment or planning; may have trouble remaining coherent or in touch with reality ○ Physical symptoms High energy level—often in the presence of little or no rest ★ Diagnosing bipolar disorders: Manic episode ○ For 1 week or more, person displays a continually abnormal, inflated, unrestrained, or irritable mood as well as continually heightened energy or activity, for most of every day. ○ Person also experiences at least three of the following symptoms: Grandiosity or overblown self-esteem Reduced sleep need Rapidly shifting ideas or the sense that one’s thoughts are moving very fast Attention pulled in many directions Heightened activity or agitated movements Excessive pursuit of risky and potentially problematic activities ○ Significant distress or impairment ★ Diagnosing bipolar disorders: Bipolar I disorder ○ Occurrence of a manic episode ○ Hypomanic or major depressive episodes may precede or follow the manic episode ★ Diagnosing bipolar disorders: Bipolar II disorder ○ Presence or history of major depressive episode(s) ○ Presence or history of hypomanic episode(s) ○ No history of a manic episode ★ Diagnosing bipolar disorders: Cyclothymic disorder ○ Milder form of bipolar disorder ○ Continues for 2 or more years, interrupted by occasional normal moods lasting for only days or weeks ○ Usually begins in adolescence or early adulthood; no gender differences ○ May evolve into bipolar I and bipolar II disorder ★ Bipolar disorders ○ Worldwide, 1 to 2.8 percent of all adults have bipolar disorder at any given time: 4.4 percent have it at some point in life. ○ Onset usually between the ages of 15 and 44 years. ○ No gender differences, but higher rates in low-income populations. ★ What causes bipolar disorders? ○ Throughout the first half of the twentieth century, the search for the cause of bipolar disorders made little progress. ○ More recently, biological research has produced some promising clues. Research into neurotransmitter activity, ion activity, brain structure, and genetic factors ★ Biological research and perspectives ○ Neurotransmitter activity: Mania may be related to high norepinephrine activity along with a low level of serotonin activity. 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 ○ Ion activity: Improper transport of ions back and forth between the outside and the inside of a neuron’s membrane Some theorists believe that irregularities in the transport of these ions cause neurons to fire too easily (mania) or to stubbornly resist firing (depression); there is some research support for this theory. ○ Brain structure and circuitry Brain imaging and postmortem studies have identified a number of abnormal brain structures in people with bipolar disorder—in particular, the basal ganglia and cerebellum. It is not clear what role such structural abnormalities play. Bipolar-related brain circuit; depression-related circuit ○ Genetic factors Many theorists believe that people inherit a biological predisposition to develop bipolar disorders. Family pedigree studies Molecular biology techniques ○ Mood-stabilizing drugs and strategies Effective in treating mania alone or in combination; prophylactic Lithium (FDA approved in 1970) Antiseizure drugs: lamotrigine (Lamictal), carbamazepine (Tegretol), and valproate (Depakote) Antipsychotic drugs: Originally used to treat schizophrenia Limited effective in treating bipolar depression May be combined with antidepressants Ketamine usefulness under investigation Why do lithium and antiseizure drugs help in bipolar cases? they can help stabilize mood swings by influencing the brain's electrical activity, potentially by regulating neurotransmitters and reducing abnormal neuronal firing ★ Adjunctive psychotherapy  ○ Includes individual, group, or family therapy as adjunct to mood-stabilizing drugs. ○ At least doubles likelihood that bipolar individuals continue to take medicine properly, helps reduce hospitalizations, improve social functioning, increase patients’ ability to obtain and hold a job. ○ Plays more central role in cyclothymic disorder therapy. ○ Therapists use these formats to emphasize the importance of continuing to take medications; to improve social skills and relationships that may be affected by bipolar episodes; to educate patients and families about bipolar disorders; to help patients solve the family, school, and occupational problems caused by their disorder; and to help prevent patients from attempting suicid Depressive and Bipolar Disorders: Making Sense Of All That Is Known Unipolar Depression Factors Bipolar Depression Factors Biological abnormalities Biological Abnormalities Positive Reinforcement Inherited Negative thinking Stress triggered Perception of helplessness Life Stress Sociocultural Influences