ABNORMAL AFFECT

Abnormal affect

Types, characteristics, examples of and sex differences

Types: 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

Types

Depression (unipolar) Mania (bipolar)

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 :

HyperactivityTalkativenessFlight of ideasDistractibility 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 Manic Episode 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)

Famous people with bipolar

Causes of bipolar

BIPOLAR 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 bipolar

1. 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 of Depression – Genetic

Family , 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 of Depression – Biochemical Changes 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, ages

3. 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 of Depression According to Beck depression is

caused by 2 mechanisms:

AARON T. BECK

1. Cognitive triad2. Errors in logic

Beck’s Cognitive Theory

1. The cognitive triad consists of negative thoughts about :

The self Ongoing experiences

Future

Negative thoughts about…

Self•Defective- never attain happiness •Worthless- unpleasant experiences attributed to this•Inadequate-Such thoughts lead to low self esteem

Ongoing experiences

•Interpretation that whatever happens to him/her is bad.•Drawn to the most negative possible interpretation •Small obstacles impassable barriers.

Future •Negative things that happen now will continue in the future…•Future view is one of helplessness.

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 errors

Arbitrary inference: drawing a conclusion when there is no evidence 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

Martin Seligman

Learned helplessness

Unpleasant traumas/ experiences lead to individual’s passivity and helplessness. U

npleasant traumas/experiences

Sense of helplessness

Depression

Attribution and Learned Helplessness Problem with the learned

helplessness theory Eg I am responsible for

my depression . How am I helpless

then???

Attribution and learned helplessness 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 learned helplessness People become depressed when they

attribute negative life events to personal, stable and global causes.

Attributions

Global

when the individual

believes that the cause of

negative events is consistent

across different contexts

Specific

individual believes that the cause of a negative

event is unique to a particular situation

Stable

individual believes

the cause to be

consistent across time

Unstable

when the individual thinks that the cause is specific to

one point in time

Internal

assigns causality to factors within the person.

Evaluation of Learned Helplessness/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 Depression

Treatment either biological or psychological can treat 80 to 90 % of severe depressions.

Recurrence remains substantial with all forms of treatments.

Biological treatments of depression Drug treatment ECT

Tricyclic antidepressants

(TCA’s)•Block the reuptake of norepinephrine (NE) leading to more NE.•B/w 60 to 75% patients show clinical improvement .•Also reduces recurrence •Reduction of “5-HT receptors” which participate in the reuptake of serotonin might actually be how the TCA’s work (Taylor et al. 1995)

Monoamine oxidase inhibitors (MAO inhibitors)

•Prevent the breakdown of norepinephrine •More NE – less depressed•Prescribed less often than TCA’s or SSRI’s because inhibition of MAO enzyme can have lethal side effects.•When combined with shellfish, bp reducing drugs, red wine, aged cheese and narcotics , can be fatal.•Should be used as the last option from 3.

Serotonin reuptake inhibitors (SSRI’s)

•Eg Zoloft, Paxil and Prozac prescribed widely for less severe depression.•Selectively inhibit the reuptake of serotonin.•60 to 70 % patients with severe depression relieved. Low risk of overdose.•Altough popular, efficacy about the same as that of MAO inhibitors and TCA’s.•Still some concern that Prozac may lead to suicide.

3 classes of drugs to treat depression:

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-ECT

Strong evidence exists that ECT is highly effective when given to patients with severe depression. 80% of patients with major depression respond to ECT. Recurrence of depression is substantial with about 60% of those being treated with ECT becoming depressed again the next year (Sackheim et al , 1993)Exactly how ECT works, is unknown.

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 (Beck 1979) 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 (1962)

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.

• Activating event or objective situation . Eg Sana scores low in a Math testA

• Beliefs - the negative thoughts that occurred . Eg: Sana believes she must have good grades or she is worthlessB

• Consequence- the negative feelings and dysfunctional behavior that ensues . Eg: Sana feels depressed c

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 client's 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 Therapy

Drugs ECT

Improvement

60-75% markedly improved

60-75% markedly improved

80% markedly improved

relapse Moderate relapse

High relapse High relapse

Side effects None Moderate Rather severe

Cost inexpensive inexpensive inexpensive

Time scale A month weeks days

overall V good V good V good

treatm

ent

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