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1Slides & Handouts by Karen Clay Rhines, Ph.D.Northampton Community College
Fundamentals of Abnormal Psychology, 6e
Ronald Comer
Mood DisordersMood DisordersChapter 7
2
Mood DisordersMood Disorders
Two key emotions on a continuum:
◦ Depression
Low, sad state in which life seems dark and its challenges overwhelming
◦ Mania
State of breathless euphoria or frenzied energy
3
Mood DisordersMood Disorders
Most people with a mood disorder suffer only from depression
◦ This pattern is called unipolar depression
Person has no history of mania
Mood returns to normal when depression lifts
Others experience periods of mania that alternate with periods of depression
◦ This pattern is called bipolar disorder
These disorders have always captured people’s interest
4
Unipolar DepressionUnipolar Depression
The term “depression” is often used to describe general sadness or unhappiness
◦ This loose use of the term confuses a normal mood swing with a clinical syndrome
Clinical depression can bring severe and long-lasting psychological pain that may intensify over time
5
How Common Is Unipolar How Common Is Unipolar Depression?Depression? Almost 7% of adults in the U.S. suffer from
severe unipolar depression in any given year
◦ As many as 5% suffer from mild forms
Approximately 17% of all adults experience unipolar depression at some time in their lives
The prevalence is similar in Canada, England, France, and many other countries
6
How Common Is Unipolar How Common Is Unipolar Depression?Depression?
Women are at least twice as likely as men to experience severe unipolar depression◦ Lifetime prevalence: 26% of women vs. 12% of men
◦ Among children, the prevalence is similar among boys and girls
Approximately 50% recover within six weeks and 90% within a year, some without treatment◦ Most will experience another episode at some point
7
What Are the Symptoms of What Are the Symptoms of Depression?Depression?
Symptoms may vary from person to person Five main areas of functioning may be affected:◦ Emotional symptoms Feeling “miserable,” “empty,” “humiliated”
Experiencing little pleasure (anhedonia)
◦ Motivational symptoms Lacking drive, initiative, spontaneity
Between 6% and 15% of those with severe depression commit suicide
8
What Are the Symptoms of What Are the Symptoms of Depression?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
9
Diagnosing Unipolar DepressionDiagnosing Unipolar Depression
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
10
11
Diagnosing Unipolar DepressionDiagnosing Unipolar Depression
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”
12
What Causes Unipolar Depression?What Causes Unipolar Depression?
Stress may be a trigger for depression
◦ People with depression experience a greater number of stressful life events during the month just before the onset of their symptoms
◦ Some clinicians distinguish reactive (exogenous) depression from endogenous depression, which seems to be a response to internal factors
Today’s clinicians usually concentrate on recognizing both the situational and the internal aspects of any given case
13
What Causes Unipolar Depression?What Causes Unipolar Depression?The Biological ModelThe Biological Model
Genetic factors
◦ Family pedigree, twin, adoption, and molecular biology gene studies suggest that some people inherit a biological 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:
Concordance rates for identical (MZ) twins = 46%
Concordance rates for fraternal (DZ) twins = 20%
Adoption studies also have implicated a genetic factor in cases of severe unipolar depression
Using techniques from the field of molecular biology, researchers have found evidence that unipolar depression may be tied to specific genes
14
What Causes Unipolar Depression?What Causes Unipolar Depression?The Biological ModelThe Biological Model
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
The discovery of truly effective antidepressant medications, which relieved depression by increasing either serotonin or norepinephrine, further confirmed the NT role
Now, research suggests that interactions between these NTs and/or other NTs in the brain, rather than the operation of any one NT alone, may account for unipolar depression
15
What Causes Unipolar Depression?What Causes Unipolar Depression?The Biological ModelThe Biological Model
Biochemical factors◦ 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
16
What Causes Unipolar Depression?What Causes Unipolar Depression?The Biological ModelThe Biological Model
Biochemical factors
◦ These explanations have produced much enthusiasm but have certain limitations:
Rely on analogue studies: depression-like symptoms created in lab animals
Do these symptoms correlate with human emotions?
Measuring brain activity has been difficult an indirect
Current studies using modern technology are attempting to address this issue
17
What Causes Unipolar Depression?What Causes Unipolar Depression?The Biological ModelThe Biological Model
Brain anatomy and brain circuits
◦ Biological researchers have determined that emotional reactions of various kinds are tied to brain circuits
These are networks of brain structures that work together, triggering each other into action and producing a particular kind of emotional reaction
It appears that one circuit is tied to GAD, another to panic disorder, and yet another to OCD
◦ Although research is far from complete, a circuit responsible for unipolar depression has begun to emerge
Likely brain areas in the circuit include the prefrontal cortex, hippocampus, amygdala, and Brodmann’s Area 25
18
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Usually biological treatment means
antidepressant drugs, but for severely depressed individuals who do not respond to other forms of treatment, it sometimes includes electroconvulsive therapy or brain stimulation
19
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Electroconvulsive therapy (ECT)
◦ The use of ECT was – and is – controversial
◦ The procedure consists of targeted electrical stimulation to cause a brain seizure
The usual course of treatment is 6 to 12 sessions
20
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Electroconvulsive therapy (ECT)
◦ The discovery of the effectiveness of ECT was accidental
◦ 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
21
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Electroconvulsive therapy (ECT)
◦ ECT is clearly effective in treating unipolar depression
Studies find improvement in 60%–80% 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
22
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression 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
23
24
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression 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 of patients who take these drugs are helped by them
25
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression 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 MAOIs
Thus, people on MAO inhibitors must stick to a rigid diet
26
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression 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
27
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Antidepressant drugs: Tricyclics
◦ Hundreds of studies have found that depressed patients taking tricyclics have improved much more than similar patients taking placebos
Drugs must be taken for at least 10 days before such improvement is seen
About 60%–65% of patients find symptom improvement
28
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Antidepressant drugs: Tricyclics
◦ 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
29
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Antidepressant drugs: Tricyclics
◦ Tricyclics are believed to reduce depression by affecting neurotransmitter (NT) “reuptake” mechanisms
To prevent a NT from remaining in the synapse too long, a pump-like 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
31
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression 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), sertraline (Zoloft), and escitalopram (Lexapro)
◦ Selective norepinephrine reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are also now available
32
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Second-generation antidepressant drugs◦ The effectiveness and speed of action of these
drugs is on par with the tricyclics, yet their sales have skyrocketed 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
They have fewer side effects than the tricyclics
◦ These drugs may cause some undesired effects of their own, including a reduction in sex drive
33
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Brain stimulation
◦ As one third or more of people with unipolar depression are not helped by any of the treatments discussed previously, clinical investigators continue to search for alternative approaches, including:
Vagus nerve stimulation
Transcranial magnetic stimulation
Deep brain stimulation
34
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Vagus nerve stimulation
◦ Depression researchers surmised they might be able to stimulate the brain by electrically stimulating the vagus nerve through the use of a pulse generator implanted under the skin of the chest
◦ Research has found that the procedure brings significant relief to as many as 40% of those with treatment-resistant depression
35
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression
Transcranial magnetic stimulation
◦ Another technique designed to stimulate the brain without the undesired effects of ECT, TMS has been found to reduce depression when administered daily for 2 to 4 weeks
Deep brain stimulation
◦ Theorizing a “depression switch” located deep within the brain, researchers have successfully experimented with electrode implantation in the brain’s Brodman Area 25
36
Biological Treatments for Unipolar Biological Treatments for Unipolar DepressionDepression Brain stimulation
◦ While such positive initial findings have produced considerable enthusiasm in the clinical field, it is important to recognize that research on DBS is in its earliest stages
37
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Three main models:
◦ Psychodynamic model
No strong research support
◦ Behavioral model
Modest research support
◦ Cognitive views
Considerable research support
38
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Psychodynamic view
◦ Link between depression and grief
When a loved one dies, an unconscious process begins and the mourner regresses to the oral stage and experiences a merging of his/her own identity with that of the lost person
For most people, this reaction 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” (or imagined) loss
Newer psychoanalysts (object relations theorists) propose that depression results when people’s relationships leave them feeling unsafe and insecure
39
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Psychodynamic view
◦ Studies have offered general support for the psychodynamic idea that depression may be triggered by a major loss
◦ However, research does not indicate that loss is always at the core of depression
40
Psychodynamic Treatments for Psychodynamic Treatments for Unipolar DepressionUnipolar Depression Psychodynamic therapists use the same
basic procedures for all psychological disorders:
◦ Free association
◦ Therapist interpretation
◦ Review of past events and feelings
41
Psychodynamic Treatments for Psychodynamic Treatments for Unipolar DepressionUnipolar Depression 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 therapy discussions
◦ Depressed clients may become discouraged and end treatment too early when treatment is unable to provide quick relief
Short-term approaches have performed better than traditional approaches
42
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models Behavioral view
◦ Depression results from changes in rewards and punishments people receive in their lives
Lewinsohn suggests that the positive rewards in life dwindle for some people, leading them to perform fewer and fewer constructive behaviors and they spiral toward depression
◦ Research supports the relationship between the number of rewards received and the presence or absence of depression
Social rewards are especially important
43
Behavioral Treatments for Unipolar Behavioral Treatments for Unipolar DepressionDepression Behavioral therapy
◦ Lewinsohn developed a behavioral therapy for unipolar depression in the 1970s:
Reintroduce clients to pleasurable activities and events, often using a weekly schedule
Appropriately reinforce their depressive and nondepressive behaviors
Help them improve their social skills
44
Behavioral Treatments for Unipolar Behavioral Treatments for Unipolar DepressionDepression
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 more of the techniques, depressive symptoms (especially mild symptoms) seem to be reduced
It is worth noting that Lewinsohn himself has combined behavioral techniques with cognitive strategies in recent years
45
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views
◦ Two main theories:
Learned helplessness
Negative thinking
46
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views
◦ Learned helplessness
Theory holds that people become depressed when they think that:
They no longer have control over the reinforcements (rewards and punishments) in their lives
They themselves are responsible for this helpless state
47
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views
◦ Learned helplessness
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” to do anything to change negative situations, and drew parallels to human depression
48
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views
◦ Learned helplessness
There has been significant research support for this model
Human subjects who undergo helplessness training score higher on depression scales and display reactions similar to depressive symptoms
Animal subjects lose interest in sex and social activities
49
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views◦ Learned helplessness 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: “I am inadequate at everything and I always will be”
If people make other kinds of attributions, this reaction is unlikely
Example: “The way I’ve behaved the past couple weeks blew this relationship” [specific]. “I don’t know what got into me – I don’t usually act like that” [unstable]. “She never did know what she wanted” [external].
50
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
Cognitive views
◦ Learned helplessness
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
51
Cognitive views
◦ Learned helplessness
Although this theory has been very influential, it has imperfections:
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
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
52
Cognitive views
◦ Negative thinking
Beck believes 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 an extended round of negative thinking
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
53
Cognitive views
◦ Negative thinking
2. This negative thinking typically 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
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
54
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
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
55
Cognitive views
◦ Negative thinking
Many studies have produced evidence in support of Beck’s explanation:
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
What Causes Unipolar Depression?What Causes Unipolar Depression?The Psychological ModelsThe Psychological Models
56
Cognitive Treatment for Unipolar Cognitive Treatment for Unipolar DepressionDepression Beck’s cognitive therapy – which includes a number
of behavioral techniques – 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:
◦ Increasing activities and elevating mood
◦ Challenging automatic thoughts
◦ Identifying negative thinking and biases
◦ Changing primary attitudes
57
Cognitive Treatment for Unipolar Cognitive Treatment for Unipolar DepressionDepression Over the past several decades, hundreds of
studies have shown that cognitive and cognitive-behavioral approaches help unipolar depression
◦ Around 50%–60% of clients show a near-total elimination of symptoms
It is worth noting that a growing number of today’s cognitive-behavior therapists disagree with Beck’s proposition that individuals must fully disregard negative cognitions
58
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
Sociocultural theorists propose that unipolar depression is greatly influenced by the social context that surrounds people
◦ This belief is supported by the finding that depression is often triggered by outside stressors
◦ There are two kinds of sociocultural views:
The family-social perspective
The multicultural perspective
59
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Family-Social Perspective
◦ The connection between declining social rewards and depression (as discussed by the behaviorists) is a two-way street
Depressed people often display social deficits that make other people uncomfortable and may cause them to avoid the depressed individuals
This leads to decreased social contact and a further deterioration of social skills
60
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Family-Social Perspective
◦ Consistent with these findings, depression has been tied repeatedly to the unavailability of social support such as that found in a happy marriage
People who are separated or divorced display three times the depression rate of married or widowed persons and double the rate of people who have never been married
◦ People whose lives are isolated and without intimacy seem particularly likely to become depressed at times of stress
61
Family-Social Treatments for Family-Social Treatments for Unipolar DepressionUnipolar Depression 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
62
Family-Social Treatments for Family-Social Treatments for Unipolar DepressionUnipolar Depression 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
63
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Two kinds of relationships have captured the interest of multicultural theorists:
Gender and depression
A strong link exists between gender and depression
Women cross-culturally are twice as likely as men to receive a diagnosis of unipolar depression
64
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Various theories have been offered:
The artifact theory holds that women and men are equally prone to depression, but that clinicians often fail to detect depression in men
The hormone explanation holds that hormone changes trigger depression in many women
The life stress theory suggests that women in our society experience more stress than men
65
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Various theories have been offered:
The body dissatisfaction theory state that females in Western society are taught, almost from birth, to seek a low body weight and slender body shape – goals that are unreasonable, unhealthy, and often unattainable
The lack-of-control theory picks up the learned helplessness research and argues that women may be more prone to depression because they feel less control than men over their lives
66
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Various theories have been offered:
The rumination theory holds that people who ruminate when sad – keep focusing on their feelings and repeatedly consider the causes and consequences of their depression – are more likely to become depressed and stay depressed longer
67
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Each explanation offers food for thought and has gathered just enough supporting evidence to make it interesting (and just enough contrary evidence to raise question about its usefulness)
68
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Two kinds of relationships have captured the interest of multicultural theorists:
Cultural background and depression
Depression is a worldwide phenomenon, and certain symptoms seem to be constant across all countries, including sadness, joylessness, anxiety, tension, lack of energy, loss of interest, and thoughts of suicide
Beyond such core symptoms, research suggests that the precise picture of depression varies from country to country
69
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective
◦ Depressed people in non-Western countries are more likely to be troubled by physical symptoms of depression than by cognitive ones
70
What Causes Unipolar Depression?What Causes Unipolar Depression?The Sociocultural ModelThe Sociocultural Model
The Multicultural Perspective◦ Within the United States, researchers have found
few differences in depression symptoms among members of different ethnic or racial groups, however, sometimes striking differences exist in specific populations living under special circumstances 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
71
Multicultural Treatments for Multicultural Treatments for Unipolar DepressionUnipolar Depression Culture-sensitive approaches are
increasingly being combined with traditional forms of psychotherapy to help maximize the likelihood of minority clients overcoming their disorders
72
Bipolar DisordersBipolar Disorders
People with a bipolar disorder experience both the lows of depression and the highs of mania
◦ Many describe their lives as an emotional roller coaster
73
What Are the Symptoms of Mania?What Are the Symptoms 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
74
What Are the Symptoms of Mania?What Are the Symptoms of Mania?
Five main areas of functioning may be affected:
◦ 3. Behavioral symptoms
Very active – move quickly; talk loudly or rapidly
Flamboyance is not uncommon
◦ 4. Cognitive symptoms
Show poor judgment
Especially prone to poor (or no) planning
◦ 5. Physical symptoms
High energy level – often in the presence of little or no rest
75
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
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
76
77
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
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
78
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
Without treatment, the mood episodes tend to recur for people with either type of bipolar disorder
◦ In most cases, the individual’s depressive episodes outnumber his or her manic episodes
79
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
Between 1% and 2.6% of all adults in the world suffer from a bipolar disorder at any given time
The disorders are equally common in women and men and among all socioeconomic classes and ethnic groups
80
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
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
81
Diagnosing Bipolar DisordersDiagnosing Bipolar Disorders
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 at least 0.4% of the population
May eventually blossom into bipolar I or II disorder
82
What Causes Bipolar Disorders?What Causes Bipolar 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
◦ These insights have come from research into NT activity, ion activity, brain structure, and genetic factors
83
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
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
84
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
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…
85
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
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
86
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
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
◦ Some theorists believe that irregularities in the transport of these ions may cause neurons to fire too easily (mania) or to stubbornly resist firing (depression)
There is some research support for this theory
87
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
Brain structure
◦ 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 among others
It is not clear what role such structural abnormalities play
88
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
Genetic factors
◦ Many theorists believe that people inherit a biological predisposition to develop bipolar disorders
Family pedigree studies support this idea; 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
89
What Causes Bipolar Disorders?What Causes Bipolar Disorders?
Genetic factors
◦ Recently, genetic linkage studies have tried to identify possible patterns in the inheritance of bipolar disorders
◦ 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
90
Treatments for Bipolar DisorderTreatments for Bipolar Disorder
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
91
Treatments for Bipolar Disorder: Treatments for Bipolar Disorder: Lithium and Other Mood StabilizersLithium and Other Mood Stabilizers
The use of lithium (a metallic element occurring as mineral salt) and other mood-stabilizers has dramatically changed this picture
All manner of research has attested to the effectiveness of lithium and other mood stabilizers in treating manic episodes◦ More than 60% of patients with mania improve
on these medications
◦ Most individuals experience fewer new episodes while on the drug
92
Findings suggest that the mood stabilizers are also prophylactic drugs, ones that actually help prevent symptoms from developing
Mood stabilizers also help those with bipolar disorder overcome their depressive episodes to a lesser degree
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Researchers do not fully understand how mood stabilizing drugs operate
◦ They suspect that the drugs change synaptic activity in neurons, but in a different way from that of antidepressant drugs
Although antidepressant drugs affect a neuron’s initial reception on NTs, mood stabilizers seem to affect a neuron’s second messengers
◦ These drugs also increase the production of neuroprotective proteins – key proteins within certain neurons whose job it is to prevent cell death, which may indirectly reduce bipolar symptoms
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Treatments for Bipolar Disorder: Treatments for Bipolar Disorder: Adjunctive PsychotherapyAdjunctive Psychotherapy Psychotherapy alone is rarely helpful for
persons with bipolar disorder
Mood stabilizing drugs alone are also not always sufficient
◦ 30% or more of patients don’t respond, may not receive a proper dose, and/or may relapse while taking it
As a result, clinicians often use psychotherapy as an adjunct to mood-stabilizing drugs
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Treatments for Bipolar Disorder: Treatments for Bipolar Disorder: Adjunctive PsychotherapyAdjunctive Psychotherapy
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, improves social functioning, and increases clients’ ability to obtain and hold a job