Ch. 6 Depressive and Bipolar Disorders

Question 1

Unipolar Depression

Answer 1

DEPRESSION – A low, sad state marked by significant levels of sadness, lack of energy, low self-worth, guilt, or related symptoms.

UNIPOLAR DEPRESSION – Depression without a history of mania.

• Triggered by stressful events – 80% of all severe episodes occur within a month or two of a significant negative event.
• 8% of adults suffer from this each year.
• 20% of all adults at least one episode over a lifetime.
• Women are twice as likely and poor more than rich.
• The peak is in early adulthood with far fewer suffering over 65.
• 85% recover within 6 months, some without treatment.
• SYMPTOMS include:
  
  • Emotional – ANHEDONIA – an inability to experience pleasure at all.
  • Motivaiton – 6-15% die by suicide
  • Behavioral – lethargy
  • Cognitive – negative views
  • Physical – sickly
• DIAGNOSING – lasting more than two weeks and marked by 5 depressive symptoms.
• MAJOR DEPRESSIVE DISORDER – People who go through a MAJOR DEPRESSIVE EPISODE without having any history of mania. Also might be further described as:
  
  • SEASONAL DEPRESSIVE DISORDER – if it changes with the seasons.
  • CATATONIC DEPRESSIVE DISORDER – if it is marked by either immobility or excessive activity.
  • PERIPARTUM DEPRESSIVE DISORDER – if it occurs during pregnancy or within four weeks of giving birth.
  • MELANCHOLIC DEPRESSIVE DISORDER – if the person is almost totally unaffected by pleasurable events.
• PERSISTENT DEPRESSIVE DISORDER – unipolar depression is chronic with repeated major depressive episodes.
  
  • Those with LESS severe symptoms are diagnosed with PERSISTENT DEPRESSIVE DISORDER with DYSTHYMIC SYNDROME.
• PREMENSTRUAL DYSPHORIC DISORDER – diagnosis given to certain women who repeatedly have clinically significant depressive and related symptoms during the week before menstruation.
  
  • Controversial because many clinicians believe that the category is sexist and “pathologizes” severe cases of premenstrual syndrome (PMS)
• DISRUPTIVE MOOD DYSREGULATION DISORDER – characterized by a combination of persistent depressive symptoms and recurrent outbursts of severe temper.

STRESS and UNIPOLAR DEPRESSION – important to distinguish between:

• REACTIVE (EXOGENOUS) DEPRESSION – which follows clear-cut stressful events, from…
• ENDOGENEOUS DEPRESSION – which seems to be a response to internal factors.
• Depression resulting from EXOGENOUS DEPRESSION will have very different paths and outcomes from ENDOGENOUS DEPRESSION.

BIOLOGICAL MODEL – the body has a big part.

• GENETIC FACTORS – Family Pedigree studies show that there is an inherited predisposition.
• BIOCHEMICAL FACTORS – Low activity of two neurotransmitter chemicals, NOREPINEPHRINE and SEROTONIN, has been strongly linked to unipolar depression.
  
  • the HPA pathway of people with depression is also overly reactive in the face of stress, causing excessive releases of cortisol
    
    • Recall the hypothalamic-pituitary-adrenal (HPA) pathway, releases hormones that heighten arousal. The HPA pathway of people with PTSD overreacts when those individuals confront stressors. The same reaction occurs with people with depression.
  • POSTPARTUM DEPRESSION – believed to be caused by the hormonal changes accompanying childbirth.
• BRAIN CIRCUITS – There is a depression-related brain circuit, with the SUBGENUAL CINGULATE, a subregion of the brain’s anterior cingulate cortex, being a distinct part of the depression-related circuit. Indeed, some theorists believe that dysfunction by this particular structure may be the single most important contributor to depression.
  
  • Also, the INTERCONNECTIVITY (the communication between these various structures) is often problematic.
• IMMUNE SYSTEM – When people are under intense stress for a while, their immune systems may become dysregulated. I immune system dysregulation of this kind helps produce depression.
• TREATMENTS:
• Antidepressant drugs: only effective on 40% of patients
  
  • MONOAMINE OXIDASE INHIBITORS (MAO) – prevents the action of the enzyme monoamine oxidase, which is the enzyme that breaks down the neurotransmitters SEROTONIN and NOREPINEPHRINE.
    
    • Blocking MAO means higher levels of neurotransmitters.
    • Helps 50% of patients
  • TRICYCLICS – These work by inhibiting a process called REUPTAKE, which is the process of reabsorbing the neurotransmitters back into the sending neuron. Inhibiting reuptake allows the neurotransmitters SEROTONIN And NOREPINEPHRINE to remain in the synaptic space, allowing them MORE TIME to reach the receiving neurons and do their job properly.
    
    • named for its 3-ring molecule.
    • Helps about 50% of patients.
  • SECOND GENERATIONS ANTIDEPRESSANTS – Most of these second-generation antidepressants are called SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) because they increase serotonin activity specifically, without affecting norepinephrine or other neurotransmitters.
    
    • Ex: Prozac and Zoloft
    • As effective as Tricyclics without the side-effects of MOAs.
• NOTE: If recovered individuals stop taking the drugs immediately after obtaining relief, they run a high risk of relapsing. As many as half of the recovered patients who discontinue the drugs in this way relapse within a year. As a result, there is:
  
  • CONTINUATION THERAPY or MAINTENANCE THERAPY– where clinicians keep patients on antidepressant drugs for at least five months after being free of depressive symptoms, decreasing the individuals’ chances of relapse.
• BRAIN STIMULATION – yes, it’s really a thing – all of which stimulate the brain with electromagnetic pulses to one degree or another. works to improve the functioning of the brain’s “Depression-related” Circuit.
  
  • And they are actually quite effective.
  • ELECTROCONVULSIVE THERAPY (ECT) – electrodes attached to a patient’s head send an electrical current through the brain, causing a convulsion.
    
    • 50-80% improve with this, though researchers don’t really know why.
  • VAGUS-NERVE STIMULATION – implanted pulse generator sends regular (continuous low-level) electrical signals to a person’s vagus nerve; the nerve then stimulates the brain.
    
    • Attempts to replicate the effectiveness of ECT without the trauma of seizures.
  • TRANSCRANIAL MAGNETIC STIMULATION (TMS) – an electromagnetic coil is placed on or above a patient’s head and sends a current into the individual’s brain.
  • DEEP BRAIN STIMULATION (DBS) – a pacemaker powers electrodes that have been implanted in SUBGENUAL CINGULATE (a key member of the depression-related brain circuit), thus stimulating that brain area.

PSYCHODYNAMIC MODEL – believe there is a similarity between clinical depression and grief in people who lose loved ones.

• They direct all their feelings for the loved one, including sadness and anger, toward themselves, a reaction called INTROJECTION.
• For most mourners, this reaction is temporary. But for those whose various dependency needs were improperly met during infancy and early childhood leaving them feeling unsafe, insecure, and dependent on others, grief worsens over time, and they develop clinical depression.
• Of course, many people become depressed without losing a loved one. To explain why, Freud proposed the concept of SYMBOLIC LOSS or IMAGINED LOSS, in which a person equates other kinds of events with the severity of loss of a loved one.
• Studies have found support for these views, though ‘only’ 10% of those who suffer such loss actually become depressed.
• TREATMENT – psychodynamic therapists seek to help clients bring these underlying issues to consciousness and work them through.
  
  • Short-term Psychodynamic approaches along with medication seem to work best.

COGNITIVE-BEHAVIORAL – unipolar depression results from a combination of problematic behaviors and dysfunctional ways of thinking. These theories fall into three groups:

1. BEHAVIORAL DIMENSION – Peter Lewinsohn linked depression to significant changes in the number of REWARDS and PUNISHMENTS people receive in their lives (Ex: Completing college and heading out into the working world, retirement)
2. NEGATIVE THINKING – Aaron Beck says that some people develop maladaptive attitudes as children resulting from their experiences and the judgments of people around them.
   
   • Maladaptive attitudes such as “My general worth is tied to every task I perform” or “If I fail, others will feel repelled by me.” create an UNREALISTIC stage for all kinds of negative thoughts and reactions.
     
     • This sets up Beck’s COGNITIVE TRIAD, where individuals repeatedly interpret…
       
       1. Their EXPERIENCES
       2. THEMSELVES
       3. Their FUTURE
     • …in negative ways that lead to depression.
     • Depressed people often minimize the significance of positive experiences (MINIMIZATION) or magnify that of negative ones (MAGNIFICATION).
     • Depressed people have AUTOMATIC THOUGHTS, a steady train of unpleasant thoughts that keep suggesting to them that they are inadequate and that their situation is hopeless.
     • People who RUMINATE – that is, repeatedly dwell mentally on their mood without acting to change it – during their depressed mood, experience dejection longer and are more likely to develop clinical depression later in life than people who avoid such ruminations.
     • Research supports Beck’s explanations.
3. LEARNED HELPLESSNESS – Martin Seligman (1975), LEARNED HELPLESSNESS THEORY OF DEPRESSION – It holds that people become depressed when they think:
   
   1. that they no longer have control over the reinforcements (the rewards and punishments) in their lives.
   2. that they themselves are responsible for this helpless state.
   • This was displayed in an experiment with dogs where Seligman created a situation where the dog was shocked no matter what (teaching it helplessness). Once the dog had the ability to escape the shock, they didn’t even try, instead accepting the shocks as the result of LEARNED HELPLESSNESS.
   • Learned helplessness resembles the symptoms of human depression – that people become depressed after developing a general belief that they have no control over reinforcements in their lives.

• ATTRIBUTION-HELPLESSNESS THEORY – when people view events as beyond their control, they ask themselves why this is so.
  
  • If they attribute their present lack of control to some INTERNAL cause that is both GLOBAL and STABLE (“I am inadequate at everything and I always will be”), they may well feel helpless to prevent future negative outcomes and become depressed.
  • If they make other kinds of attributions, they are unlikely to have this reaction.
    
    • Provides an EXTERNAL cause.
    • Narrows the reason to something very SPECIFIC (not global).
    • Sees the cause as TEMPORARY (unstable).
  • Attributions are likely to cause depression only when they further produce a sense of hopelessness.