Abnormal Psychology Chapter 5

Therapeutic Approaches to Depressive Disorders

Cognitive and Interpersonal Therapy

Cognitive Symptoms of Mood Disorders

Depressive Triad, Sped Up Thoughts, Self-Destructive Ideas

Areas of the Brain Involved in Depression

Dorsolateral prefrontal cortex, Orbital and Ventromedial Prefrontal Cortex, Anterior Cingulate Cortex, Amygdala and Hippocampus

The Four Types of Suicide Identified by Émile Durkheim

Egoistic suicide, Altruistic suicide, Anomic suicide, Fatalistic suicide

Reasons for Nonsuicidal Self-Injury

For some people, cutting is a way to punish the self and is a reflection of frustration and anger. In other cases, the person uses self-inflicted pain in an effort to combat extended periods of dissociation and feelings of emptiness that accompany the absence of family members and friends. But the most commonly reported mechanism suggests that self-injury becomes a maladaptive way to regulate intense, negative emotional states. The final phase of the sequence involves the experience of shame or guilt when the episode is completed and the person reflects on what they have done.

Depressive Triad

Guilt and worthlessness are common preoccupations. Depressed patients blame themselves for things that have gone wrong, regardless of whether they are in fact responsible. They focus considerable attention on the most negative features of themselves, their environments, and the future—a combination known as the "---" (Beck, 1967).

Inhibition of Negative Thoughts

If depressed people begin to think unpleasant thoughts, they have difficulty inhibiting or disengaging from them. The manner in which a person responds to the onset of a depressed mood can influence the duration and severity of the mood

Sped Up Thoughts

In contrast to the cognitive slowness associated with depression, manic patients commonly report that their thoughts are ---. Ideas flash through their minds faster than they can articulate their thoughts. Manic patients can also be easily distracted, responding to seemingly random stimuli in a completely uninterpretable and incoherent fashion. Grandiosity and inflated self-esteem are also characteristic features of mania.

Self-Destructive Ideas

Interest in suicide, usually, develops gradually and may begin with the vague sense that life is not worth living. Such feelings may follow directly from the overwhelming fatigue and loss of pleasure that, typically, accompany a seriously depressed mood. In addition, feelings of guilt and failure can lead depressed people to consider killing themselves. Over a period of time, depressed people may come to believe that they would be better off dead or that their family would function more successfully and happily without them. Preoccupation with such thoughts then leads to specific plans and may culminate in a suicide attempt.

clinical depression

People who are in a severely --- mood describe the feeling as overwhelming, suffocating, or numbing. In the syndrome of ---, which is also called --- ---, a depressed mood is accompanied by several other symptoms, such as fatigue, loss of energy, difficulty sleeping, and changes in appetite. Also involves a variety of changes in thinking and overt behavior. The person may experience cognitive symptoms, such as extreme guilt, feelings of worthlessness, concentration problems, and thoughts of taking their own life. Behavioral symptoms may range from constant pacing and fidgeting to extreme inactivity.

"bereavement exclusion"

People who had recently experienced the death of a close relative or friend could not qualify for a diagnosis of depression until two months after the loss. eliminated in the DSM-5 and caused controversy

Interventions for Suicidal People

Psychotherapy, Medication, Involuntary Hospitalization

hopelessness

Refers to the person's negative expectations about future events and the associated belief that these events cannot be controlled.

Somatic Symptoms of Mood Disorders

Sleeping problems, Change in Appetite, Loss of Interest in various activities, Ill-defined Complaints

ill-defined complaints

Some patients complain of frequent headaches and muscular aches and pains. These concerns may develop into a preoccupation with bodily functions and fear of disease.

sleeping problems

Some people also report having difficulty staying asleep throughout the night, and they awaken two or more hours before the usual time. Early morning waking is often associated with particularly severe depression. A less common symptom is for a depressed individual to spend more time sleeping than usual. In the midst of a manic episode, a person is likely to experience a drastic reduction in the need for sleep. Some patients report that reduced sleep is one of the earliest signs of the onset of an episode. Although depressed patients, typically, feel exhausted when they cannot sleep, a person in a manic episode will probably be bursting with energy inspite of the lack of rest.

Symptoms of Premenstrual Dysphoric Disorder

Symptoms include mood lability, irritability, dysphoria, and anxiety as well as cognitive (difficulty concentrating, feeling of being overwhelmed or out of control), and somatic symptoms (e.g., lethargy, changes in appetite, sleep problems, joint or muscle pain, a sensation of bloating, etc.).

DSM-5: Criteria for Diagnosis of Manic Episode

1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). 2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 3. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. 4. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Types of Bipolar Disorders

1. Bipolar I 2. Bipolar II 3. Cyclothymic Disorder

Important Issues Regarding the Diagnosis of Mood Disorders

1. Breadth of the diagnostic category 2. Heterogeneity

Symptoms of Major Depressive Disorder

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.) 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.) 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Cognitive Vulnerabilities to Depression

1. Distortions 2. Maladaptive Schemas 3. Causal Attributions 4. Inhibition of Negative Thoughts

DSM-5: Criteria for Major Depressive Disorder

1. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Do not include symptoms that are clearly attributable to another medical condition.) 2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 3. The episode is not attributable to the physiological effects of a substance or another medical condition. 4. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. 5. There has never been a manic episode or a hypomanic episode. (The episodes can't be substance induced)

Diagnostic Criteria for Nonsuicidal Self-Injury

1. In order to meet criteria for this disorder, the person must have intentionally inflicted damage to the surface of his or her body in a way that was likely to cause bleeding, bruising, or pain (without the intent to die). 2. The diagnostic manual also specifies that the person engaged in the self-injurious behavior with one or more of the following expectations: to obtain relief from negative feelings, to solve an interpersonal difficulty, or to induce a positive emotional state. 3. The third aspect of the diagnostic criteria for nonsuicidal self-injury holds that the self-injurious behavior must occur after one of the following: interpersonal difficulties or negative feelings or thoughts (e.g., depression or anxiety); a period of time in which the person is preoccupied with self-harm behaviors; or frequent thoughts about self-injury, even if the person does not act on these thoughts

Symptoms of a Manic Episode

1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity). 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

DSM-5 Subtypes and Episode Specifiers of Mood Disorders

1. Melancholia 2. Psychotic Features 3. Postpartum Onset 4. Rapid Cycling 5. Seasonal Affective Disorder

Symptoms of Persistent Depressive Disorder (Dysthymia)

1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness

Psychotherapy (Suicidal Patients) Goals

1. Reduce lethality. The most important task is to reduce the person's experience of psychological pain from which the person is seeking escape. At a more concrete level, this also involves reducing access to means that could be used to commit suicide, such as guns and pills. 2. Negotiate agreements. Therapists frequently ask clients who have threatened to kill themselves to sign a contract, in which the client agrees to postpone self-destructive behavior for at least a short period of time. Of course, these agreements can be broken, but they may provide brakes to inhibit impulsive actions. 3. Provide support. It is often useful to make concrete arrangements for social support during a suicidal crisis. Friends and family members are alerted and asked to be available so that the person is not alone. 4. Replace tunnel vision with a broader perspective. People who are seriously contemplating suicide are, typically, unable to consider alternative solutions to their problems. The therapist must help potential suicide victims develop or recover a more flexible and adaptive pattern of problem solving.

Social Factors Affecting Bipolar Disorders

1. Schedule-Disrupting and Goal-Attained Events 2. Emotional Climate Within Families

What factors affect the relationship between stress and depression?

1. The Circumstances 2. Stress Generation 3. Gender Differences

Important Considerations in Distinguishing Clinical Depression From Normal Sadness

1. The mood change is pervasive across situations and persistent over time. The person's mood does not improve, even temporarily, when he or she engages in activities that are usually experienced as pleasant. 2. The mood change may occur in the absence of any precipitating events, or it may be completely out of proportion to the person's circumstances. 3. The depressed mood is accompanied by impaired ability to function in usual social and occupational roles. Even simple activities become overwhelmingly difficult. 4. The change in mood is accompanied by a cluster of additional signs and symptoms, including cognitive, somatic, and behavioral features. 5. The nature or quality of the mood change may be different from that associated with normal sadness. It may feel "strange," like being engulfed by a black cloud or sunk in a dark hole.

DSM-5: Criteria for Premenstrual Dysphoric Disorder

1. a woman must exhibit at least five of these symptoms, and at least one of those symptoms must involve a disturbance in mood (e.g., mood swings or marked irritability). 2. The symptoms must have been present for most of the woman's menstrual cycles in the past year, and they must be associated with clinically significant distress or interference with social or occupational functioning

Onset of bipolar disorders usually occurs between the ages of

18 and 22 years

Interpersonal Therapy

A brief, psychodynamic psychotherapy that focuses on current relationships and is based on the assumption that symptoms are caused and maintained by interpersonal problems. (such as with family members)

depressive disorders

A category of psychopathology that includes various conditions that involve episodes of depressed mood and associated symptoms that include cognitive symptoms (such as feelings of guilt, difficulty concentrating, and thoughts of suicide) and somatic symptoms (such as changes in appetite, sleep problems, and loss of energy)

distracting style

A cognitive style that includes people who divert themselves from their unpleasant mood.

ruminative style

A cognitive style that includes people who respond to feelings of depression by turning their attention inward, contemplating the causes and implications of their sadness.

depressogenic attributional style

A cognitive style that includes people who tend to explain negative events in terms of internal, stable, global factors.

psychomotor retardation

A generalized slowing of physical and emotional reactions. The slowing of movements and speech; frequently seen in depression.

Persistent Depressive Disorder (Dysthymia)

A mild form of depressive disorder characterized by a chronic course (the person is seldom without symptoms)

Bipolar II Disorder

A person who has experienced at least one major depressive episode, at least one hypomanic episode, and no full-blown manic episodes

analogue study

A research procedure in which the investigator studies behaviors that resemble mental disorders or isolated features of mental disorders. Usually employed in situations in which the investigator hopes to gain greater experimental control over the independent variable.

Causal Attributions

According to this view, depression is associated with the expectation that desirable events probably will not occur or that aversive events probably will occur regardless of what the person does. Following a negative life event, the probability that the person will become depressed is a function of the explanations and importance that the person ascribes to these events.

change in appetite

Although some patients report that they eat more than usual, most reduce the amount that they eat; some may eat next to nothing. Food just doesn't taste good any more. Depressed people can also lose a great deal of weight, even without trying to diet.

Why do bipolar patients stop taking lithium?

The main reasons given by patients for discontinuing lithium involve its negative side effects, including nausea, memory problems, weight gain, and impaired coordination.

Bipolar I Disorder

The mood disturbance must be severe enough to interfere with occupational or social functioning. A person who has experienced at least one manic episode

suicidal behavior disorder

This diagnosis is intended to describe the behavior of a person who has made a suicide attempt within the last 24 months. It does not apply to people who experience suicidal ideation without making a deliberate attempt to end their own lives or to those who engage in nonsuicidal self-injury.

Modern Light Therapy

Typical treatment involves exposure to bright (2,500 lux), broad-spectrum light for one to two hours every day. Improvement in the person's mood is often seen within two to five days. Used to treat seasonal mood disorders.

hypothalamic-pituitary-adrenal (HPA) axis

a central stress response system that involves a dynamic and complex system of communication and feedback between the central nervous system and three organs of the endocrine system: the hypothalamus, the pituitary gland, and the adrenal glands.

Cyclothymic Disorder

a chronic but less severe form of bipolar disorder. It is, therefore, the bipolar equivalent of persistent depressive disorder. the person must experience several periods of time with hypomanic symptoms and frequent periods of depression (or loss of interest or pleasure) during a period of two years. There must be no history of major depressive episodes and no clear evidence of a manic episode during the first two years of the disturbance.

bipolar disorders

a form of mood disorder in which the person experiences episodes of mania as well as episodes of depression

tricyclic antidepressants (TCAs)

a group of antidepressant drugs that block the uptake of neurotransmitters, such as norepinephrine and dopamine, from the synapse. use has declined since the introduction of the SSRIs because they have more side effects.

monoamine oxidase inhibitors (MAOIs)

a group of antidepressant drugs that inhibit the enzyme monamine oxidase (MAO) in the brain, and raise the level of neurotransmitters, such as norepinephrine, dopamine and serotonin. These drugs have not been used as extensively as tricyclics, however, primarily for two reasons. First, patients who use MAOIs and also consume foods containing large amounts of the compound tyramine, such as cheese and chocolate, often develop high blood pressure. Second, some early empirical evaluations of antidepressant medications suggest that MAOIs are not as effective as tricyclics.

selective serotonin reuptake inhibitors (SSRIs)

a group of antidepressant drugs that inhibit the reuptake of serotonin into the presynaptic nerve endings and therefore promote neurotransmission in serotonin pathways. considered to be easier to use than other antidepressant drugs. They also have fewer side effects (such as constipation and drowsiness), and they are less dangerous in the event of an overdose.

Melancholia

a particularly severe type of depression. a depressed patient must either (1) lose the feeling of pleasure associated with all, or almost all, activities or (2) lose the capacity to feel better—even temporarily—when something good happens. The person must also exhibit at least three of the following: (1) the depressed mood feels distinctly different from the depression a person would feel after the death of a loved one; (2) the depression is most often worst in the morning; (3) the person awakens early, at least two hours before usual; (4) marked psychomotor retardation or agitation; (5) significant loss of appetite or weight loss; and (6) excessive or inappropriate guilt.

remission

a stage of disorder characterized by the absence of symptoms

Cognitive Therapy

a treatment method designed to identify and correct distorted thinking patterns that can lead to feelings and behaviors that may be troublesome, self-defeating, or self-destructive (effective in the treatment of non psychotic depression)

loss of interest in various activities

activities that are otherwise sources of pleasure and fulfillment. One common example is a loss of sexual desire. Depressed people are less likely to initiate sexual activity, and they are less likely to enjoy sex if their partners can persuade them to participate.

--- and depression are closely related phenomena.

alcoholism

Postpartum Onset

applies to women who become depressed or manic following pregnancy. This episode begins within four weeks after childbirth. Because the woman must meet the full criteria for an episode of major depression or mania, this category does not include minor periods of postpartum "blues," which are relatively common

Genes play a more important role in --- disorders than in --- disorders.

bipolar, depressive

depression

can refer either to a mood or to a clinical syndrome, a combination of emotional, cognitive, and behavioral symptoms. The feelings associated with a --- mood often include disappointment and despair. Although sadness is a universal experience, profound --- is not.

Distortions

characteristic of the thinking of depressed people. 1. One is the tendency to assign global, personal meaning to experiences of failure. 2. Another cognitive --- associated with depression is the tendency to overgeneralize conclusions about the self, based on negative experiences. 3. A third type of cognitive error involves drawing arbitrary inferences about the self in the absence of supporting evidence (often in spite of contradictory evidence). 4. The final type of cognitive bias related to depression is the tendency to recall selectively events with negative consequences and to exaggerate the importance of negative events while simultaneously discounting the significance of positive events.

The DSM-5 approach to classifying mood disorders recognizes two distinct types:

depressive disorders and bipolar disorders

episodes

discrete periods of time in which the person's behavior is dominated by either a depressed or manic mood. Unfortunately, most people with a mood disorder experience more than one

People with depressive mood disorders, typically, have their first episode in their ---

early thirties

Clinical depression is less common among --- than it is among ---

elderly people, young adults

4 most important symptoms of mood disorders

emotional, cognitive, somatic, behavioral

hypomania

episodes of increased energy that are not sufficiently severe to qualify as full-blown mania. The symptoms need to be present for a minimum of only four days to meet the threshold. The mood change must be noticeable to others, but the disturbance must not be severe enough to impair social or occupational functioning or to require hospitalization.

Maladaptive Schemas

general patterns of thought that guide the ways in which people perceive and interpret events in their environment. are enduring and highly organized representations of prior experience. may be latent—that is, not prominently represented in the person's conscious awareness at any given point in time—they are presumably reactivated when the person experiences a similar event. Depressive --- increase the probability that the person will overreact to similar stressful events in the future.

Psychotic Features

hallucinations or delusions—during the most recent episode of depression or mania. The psychotic features can be either consistent or inconsistent with the patient's mood. Depressed patients who exhibit --- are more likely to require hospitalization and treatment with a combination of antidepressant and antipsychotic medication

dexamethasone suppression test (DST)

has been used extensively to study endocrine dysfunction in patients with mood disorders

Depressive disorders include three main types among adults:

major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder. A fourth type of depressive disorder, known as disruptive mood dysregulation disorder, was added with the publication of DSM-5. It is intended to describe children with chronic, severe irritability

bipolar disorder used to be called ---

manic-depressive disorder

course specifiers

more extensive descriptions of the pattern that the disorder follows over time

episode specifiers

more specific descriptions of symptoms that were present during the most recent episode of depression

Anomic suicide (diminished regulation)

occurs following a sudden breakdown in social order or a disruption of the norms that govern people's behavior. explains increased suicide rates that occur following an economic or political crisis, or among people who are adjusting to the unexpected loss of a social or occupational role. The typical feelings associated with anomie (a term coined by Durkheim, which literally means "without a name") are anger, disappointment, and exasperation.

egoistic suicide (diminished integration)

occurs when people become relatively detached from society and when they feel that their existence is meaningless. is presumably more common among groups such as people who have been divorced and those who are suffering from mental disorders. The predominant emotions associated with --- are depression and apathy.

fatalistic suicide (excessive regulation)

occurs when the circumstances under which a person lives become unbearable. A slave, for example, might choose to commit suicide in order to escape from the horrible nature of his or her existence. This type of suicide was mentioned only briefly by Durkheim, who thought that it was extremely uncommon.

Altruistic suicide (excessive integration)

occurs when the rules of the social group dictate that the person must sacrifice his or her own life for the sake of others. One example is the former practice in some Native American tribes of elderly persons voluntarily going off by themselves to die after they felt they had become a burden to others.

euphoria

or elated mood, is the opposite emotional state from a depressed mood. It is characterized by an exaggerated feeling of physical and emotional well-being (APA, 2013). Manic symptoms that frequently accompany an elated mood include inflated self-esteem, decreased need for sleep, distractibility, pressure to keep talking, and the subjective feeling of thoughts racing through the person's head faster than they can be spoken. Mania is, therefore, a syndrome in the same sense that clinical depression is a syndrome.

Seasonal Affective Disorder

over a period of time, there is a regular relationship between the onset of a person's episodes and particular times of the year. The episodes most commonly occur in winter, presumably in response to fewer hours of sunlight. usually characterized by somatic symptoms, such as overeating, carbohydrate craving, weight gain, fatigue, and sleeping more than usual. Among outpatients who have a history of at least three major depressive episodes, approximately one out of six will meet criteria. Most patients also have a depressive disorder.

mood

refers to a pervasive and sustained emotional response that, in its extreme form, can color the person's perception of the world (APA, 2013). The disorders discussed here are primarily associated with two specific moods: depression and elation.

emotion

refers to a state of arousal that is defined by subjective states of feeling, such as sadness, anger, and disgust. --- are often accompanied by physiological changes, such as changes in heart rate and respiration rate.

affect

refers to the pattern of observable behaviors, such as facial expression, that are associated with these subjective feelings. People also express --- through the pitch of their voices and with their hand and body movements.

The types of medications that are used most frequently in the treatment of depressive mood disorders fall into four general categories:

selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and "other," more recently developed drugs

somatic symptoms (mood disorders) definition

symptoms that are related to basic physiological or bodily functions, including fatigue, aches and pains, and serious changes in appetite and sleep patterns

mania

the flip side of depression, also involves a disturbance in mood that is accompanied by additional symptoms. The central feature of --- is a persistently elevated or irritable mood that lasts for at least one week.

Rapid Cycling

the pattern and sequence of episodes, as well as the person's adjustment between episodes. For example, the course of a bipolar disorder can be specified as --- if the person experiences at least four episodes of major depression, mania, or hypomania within a 12-month period. Patients whose disorder follows this problematic course are likely to show a poor response to treatment and are at greater risk than other types of bipolar patients to attempt suicide

DSM-5: Criteria for Persistent Depressive Disorder

the person must, over a period of at least two years, exhibit a depressed mood for most of the day on more days than not. Two or more of the following symptoms must also be present.

relapse

the reappearance of active symptoms following a period of remission (such as a return to heavy drinking by an alcoholic after a period of sustained sobriety)

--- is an effective form of treatment in the alleviation of manic episodes, and it remains the first choice for treating bipolar disorders

the salt lithium carbonate

heritability

the variability in a behavioral characteristic that is accounted for by genetic factors

The development of depression must be understood in terms of three stages:

vulnerability, onset, and maintenance

The highest rate of suicide in the United States is found among --- over the age of ---.

white males, 50