Depression – an overview

Depression is a surprisingly common mental health issue, affecting 17% of Americans at some point throughout their lifetimes. Depressions almost always are a result of a stressful life event, though not all of these depressions are severe enough or long enough in duration to be considered a mood disorder.

For instance, grief or bereavement often occurs when an individual has lost a loved one. Grievers tend to experience numbness and disbelief, yearning and searching for the lost person before acceptance that he is gone, disorganization and despair as realization is reached, and finally acceptance and reorganization of life. The DSM-IV had a bereavement exclusion for major depressive disorder (MDD): a person might not receive a diagnosis for MDD if he had experienced a major loss in the last two months. However, in a controversial move, this exclusion principle was left out of the DSM-5, allowing clinicians to diagnosis MDD soon after a major loss.

There are a surprising number of types of depression – many of them are well-known but not generally considered when we think about depression. For instance, postpartum depression is a negative mood response to the birth of a child. Feelings of changeable mood, crying easily, sadness, and irritability occur in 50 to 70 percent of women within 10 days of the birth. These symptoms generally subside on their own.

Another type of DSM-5 diagnosable depression is premenstrual dysphoric disorder. (That’s right. PMS.) In order to get this diagnosis, one of four symptoms must occur a week before onset of menses, and disappear within the first couple of days after onset. Those four symptoms are: mood swings, irritability or anger, depressed mood or self-deprecation, and anxiety or being “on edge.”

MDD is characterized by persistent symptoms that occur most of the day, every day for at least two weeks. The patient must either have a depressed mood or a loss of interest or pleasure (anhedonia). There is also a list of 7 symptoms, of which the patient must have 4: significant weight change, hypersomnia or insomnia, psychomotor agitation or retardation, fatigue, inability to concentrate, and recurrent thoughts of death. Untreated, these symptoms generally last 6 to 9 months.

There are several types of MDD. The specifiers are: “with melancholic features,” “with psychotic features,” “with atypical features,” “with catatonic features,” and “with seasonal pattern.”

The melancholic patient awakens early in the morning, has depression that is worse in the morning, exhibits psychomotor agitation or retardation, loss of appetite, and/or excessive guilt.

Psychotic features are delusions or hallucinations that are “mood congruent” (in other words, they tend to be a very depressing psychotic experiences). One example is the belief that one’s internal organs have completely deteriorated, leading to the depression. Patients with psychotic features generally experience extreme guilt and feelings that they deserve depression as punishment.

Atypical features include more mood fluctuations than a person with MDD would usually experience. The patient’s spirits might temporarily lift at a positive event. Other atypical features are increase in appetite, hypersomnia, arms and legs feel as heavy as lead, and being acutely sensitive to interpersonal reaction.

I find the description of atypical features to be interesting because in the times that I have experienced severe depression, I have experienced all of these symptoms. But apparently people with bipolar disorder tend to have atypical features to their depressive episodes. In fact, a person should not be diagnosed with MDD if they have ever experienced a manic or hypomanic episode, as I have. Another interesting difference between MDD and bipolar disorder is that those with bipolar tend to have much deeper depression than those with “unipolar” depression.

Catatonic depressives experience extreme psychomotor retardation often to the point of complete immobility. They often stop talking as well. I have an aunt who experienced these symptoms for weeks at a time during her teenage years. Apparently, she would just sit at the kitchen table all day, every day. Not moving, not talking, just staring. I’ve asked my dad “didn’t she eat or go to the bathroom or to bed?” He just answers “I don’t know. I never saw her doing those things.”

In order to be diagnosed with a seasonal pattern, you must have experienced two or more depressive episodes in the past two years that occurred at the same time of year, usually fall or winter, with a full remission at the same time of year, usually spring or summer. Sometimes the seasons can be switched – these patients tend not to get as much sympathy as those who get depressed in the winter. To get this diagnosis, non-seasonal depression must not have occurred in this 2 year period.

When depression occurs almost every day for most of the day for more than two years, the patient is generally diagnosed with persistent depressive disorder. “Normal” moods may occur, but they generally only last for a few days. This depression contains many of the same characteristics of MDD, though they are not as severe. Persistent depressive disorder generally lasts for 4-5 years, but can last longer than 20 years. It often starts during adolescence. This disorder is quite common, occurring with a lifetime prevalence of 2.5-6% in Americans.

Depression has been attributed to many biological causes. There is a genetic factor – people with family members who have MDD are more likely to develop MDD themselves. The serotonin-transporter gene, which is responsible for the uptake of serotonin in the brain, has a heritable mutation which makes depression much more likely. An imbalance of the neurotransmitters norepinephrine or serotonin is strongly associated with depression, and most anti-depressant medications target these neurotransmitters.

Another biological cause can be a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. In response to a perceived threat, norepinephrine signals the hypothalamus to release a signal which eventually leads to release of the stress hormone cortisol from the adrenal gland. Cortisol is not harmful for short periods of time, but long-term it can promote hypertension, heart disease, and obesity. It is hypothesized that during MDD, the signal stimulating cortisol release is continuously present in the system, or the feedback inhibition mechanism, which tells the adrenal gland that it should stop releasing cortisol, is not functional. The HPA axis is related to the stress response, which explains the onset of depression after stressful life events, and also explains the concurrence of depression with anxiety.

There are several theories about psychological causes of depression. In 1967, Aaron Beck proposed the cognitive theory of depression – which led to the development of cognitive behavioral therapy (discussed in my post Contemporary viewpoints on treating mental illness – psychology). Beck proposed that before experiencing depression, a person experienced dysfunctional thinking – these thoughts could be about oneself, about the world, or about one’s future. Dysfunctional thinking may include: 1) all-or-none thinking, for example someone thinks he must get 100% on a test or he is a complete loser; 2) selective abstraction, which includes a tendency to focus on one negative event even if surrounded by positive events; and 3) arbitrary inference in which the individual jumps to a conclusion based on little to no evidence. (Examples of these are given in my previous post.) Although research shows that this dysfunctional thinking occurs during depression, research leaves it unclear whether dysfunctional thinking occurs prior to depression, suggesting that such thinking might not be the cause of depression, as theorized by Beck.

There are also the hopelessness and helplessness theories of the psychological causes of depression. In these, the individual might feel incredibly pessimistic about the future, or incapable of having any impact on himself or his environment. A final theory is the ruminative theory, in which a person’s tendency to roll negative thoughts over-and-over in her head leads to depression. Women tend to ruminate more than men, and they also are more likely to experience depression than men. But when a study controls for rumination, the sex difference disappears, suggesting that rumination has a strong impact on depression.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 7: Mood Disorders and Suicide. Abnormal Psychology, sixteenth edition (pp. 212-262). Pearson Education Inc.

Post Traumatic Stress Syndrome – the Basics

I think we all have some idea of what we think PTSD is, but it turns out PTSD isn’t as clear-cut as I thought.

Apparently, when PTSD was first introduced into the DSM, the diagnostic criteria required a traumatic event “outside the range of usual human experience” that would cause “significant symptoms of distress in almost anyone.” That fits pretty well with my own perception of PTSD. Rape, war, torture, violent experiences…these all fit into that description. PTSD is a normal response to an abnormal stressor.

However, in the DSM-IV, the nature of the “traumatic event” broadened drastically, and a requisite response was “intense fear, helplessness, or horror.” So in the DSM-IV, PTSD was a pathological response to a potentially less extreme stressor. Someone could be diagnosed with PTSD if they experienced “intense horror or helplessness” after watching a scary TV show or upon being diagnosed with a terminal illness.

Although I don’t wish to undermine the intense stress that someone with pathological responses may feel, I think this definition undermines the intensely awful experience that someone with PTSD (in my mind) has encountered. The statistics agree with my assessment of these criteria: in a community survey, 89.6% of people reported that they had been exposed to a traumatic event and had responses that could potentially qualify them for a PTSD diagnosis.

Luckily, the DSM-5 tightened the traumatic event criteria again, and broadened the range of response to the traumatic event. Now, the traumatic event must occur directly to the subject, and they can exhibit other pathological responses besides “intense fear, helplessness, or horror.”

To be diagnosed with PTSD by DSM-5 standards, a person must be exposed to “actual or threatened death, serious injury, or sexual violence.” They must exhibit one of the following symptoms: intrusive distressing memories of the event, distressing dreams reliving the event, dissociative reactions, intense psychological distress at cues that remind the person of the event, or marked physiological reactions to cues that remind the person of the event. Additionally, the person must persistently avoid stimuli associated with the traumatic event, have negative alterations in cognitions and moods associated with the event (e.g. distorted cognitions about the cause or consequences of the event), and alterations in arousal and reactivity (e.g. hypervigilance or angry outbursts).

In general, people respond to trauma with decreasing pathological symptoms. In order to be diagnosed with PTSD, the patient must have experienced these negative responses for more than 1 month, otherwise they are experiencing “acute stress disorder.”

Despite the common association of PTSD with war veterans, PTSD is actually more common in women than in men – and the traumatic events are more often domestic violence or rape than war. However, a great deal of money and time has gone into research of PTSD in war veterans.

During WWI, symptoms of PTSD were called “shell shock,” and were thought to be caused by brain hemorrhages. However, this belief slowly subsided as doctors realized that the symptoms presented themselves regardless of injury. By WWII, traumatic reactions were known as “operational fatigue” and “war neuroses,” before the terminology finally settled on “combat fatigue” during the Korean and Vietnam wars. A rigorous longitudinal study of PTSD by Smith et. al. in 2008 found that 4.3% of military personnel deployed to Iraq or Afghanistan had PTSD. Of those, the rate was higher (7.8%) in those that had experienced combat compared to those who hadn’t (1.4%). An issue that is (rightfully!) getting much attention lately is the high rate of soldier suicide. Between 2005 and 2009, more than 1,100 soldiers took their own lives – generally with a gun.

There are several risk factors that increase the likelihood of PTSD – being female, lower social support, neuroticism, preexisting depression or anxiety, family history of depression, substance abuse, lower socioeconomic status, and race/ethnicity. (Apparently, compared to whites, African Americans and Hispanics who were evacuated from the World Trade Center in 2001 were more likely to get PTSD.) There is also a genetic factor that increases susceptibility to PTSD. Preliminary studies suggest that people with a particular form of the serotonin transporter gene may be more susceptible to PTSD than those with the “normal” form of this gene.

On the other hand, there is at least one factor that promotes resilience to traumatic events: intelligence. It’s possible that people with higher intelligence are better able to make “sense” of the event by viewing it as a larger whole. Or an intelligent person may be better able to recognize and buffer cognitive distortions such as “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”

Researchers have come up with several ways to decrease likelihood of succumbing to PTSD after a traumatic event.

Stress-inoculation training has proved successful with members of the Armed Forces. Soldiers can be exposed, through virtual reality, to the types of stressors that might occur during deployment. Thus they are better able to deal with the trauma when exposed to the events in real life.

Debriefing after a traumatic event can also be helpful. This allows the victim to process the event in a safe environment, before the details become internalized.

Interestingly, one study showed that subjects who were exposed to a highly disturbing film were less likely to report flashbacks if they played Tetris for 10 minutes after the film than if they sat quietly for those 10 minutes. This team of researchers also showed that simply being distracted after the disturbing video was not enough to decrease flashbacks, and that doing a verbal task actually increased the number of flashbacks. So, apparently, visio-spacial tasks decrease the likelihood of intrusive flashbacks if performed immediately after the traumatic event. I’m not sure this information is particularly useful, but it’s interesting.

As of yet, there isn’t a highly successful way to “cure” people with PTSD. Cognitive behavioral therapy, which helps the victims recognize cognitive distortions (e.g. “I deserved that,” “why should I have lived when they died?” and “If I had only done _______, this wouldn’t have happened.”), can be helpful in reducing anxiety. Antidepressant medications can alleviate some of the depression and anxiety experienced by victims.

One up-and-coming treatment has shown promising results. Someone with PTSD can undergo prolonged exposure to the traumatic events. They can do this through repeatedly reliving the events out loud, or even by re-experiencing them through virtual reality. Unfortunately, many PTSD vitimcs drop out of such treatments because reliving the events is too difficult. However, this treatment method has proven very helpful to people who complete the process, and I hope that work in this area continues.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 5: Stress and Physical and Mental Health. Abnormal Psychology, sixteenth edition (pp. 129-161). Pearson Education Inc.

Clinical Mental Health Diagnosis – Biological Assessment

One of the most difficult tasks for mental health workers is to clinically assess and diagnose mental illnesses – especially when comorbidity (having more than one mental illness) is so common. It usually begins with a psychological assessment through tests, observation, and interviews so the clinician can catalog the symptoms. Then the DSM-5 is consulted to give the diagnosis.

A clinician may focus the assessment in three ways – biological, psychodynamic, and behaviorally.

Biological approach

For the sake of appropriate treatment, it is very important to make sure that the symptoms are not due to a physical rather than a mental illness. In my experience, many doctors shrug off certain types of symptoms as those of a mentally ill patient. For instance, when I fainted at work a while back I was told it was “anxiety.” (And because it was diagnosed as a mental problem, my insurance didn’t pay – but that’s a problem to discuss on another day.) Granted, my fainting spell could have been anxiety-induced, but it could have been many things.

A more extreme example that I heard of from a doctor at a large university hospital was that a foreign patient (I can’t remember his origin) kept coming in complaining that there was a worm in his head. The doctors kept shunting him off to mental health. Eventually, the man came back and said “There’s a worm in my eye!” They looked, and sure enough there was a worm in his eye. (Possibly something like this?) Yeah. Sometimes the patient knows what he’s talking about.

Of course generally there aren’t really worms in people’s heads – but symptoms that seem mental could be due to head injuries, strokes, seizures, etc. There are a number of brain scans that can be performed to check for such problems.

One is computerized axial tomography (CAT) scan, which moves X-ray beam around the head to create a 2D image of the brain. CAT scans have become more rare because of the availability of magnetic resonance imaging (MRI). MRI quantifies magnetic fields affecting varying amounts of water content in tissue, thus giving a sharp image of different structures (or lesions / tumors) in the brain.

Another brain imaging technique is the positron emission tomography (PET) scan. PET scans measure the metabolic activity in the brain, thus allowing more clear-cut diagnoses to be made. PET can reveal problems that are not anatomically obvious. However, the images in PET images are low-fidelity and the scans are prohibitively expensive.

Functional MRI (fMRI) measures blood flow of specific areas of tissues, thus providing information about which areas of the brain are active. fMRI is the scan that helps researchers discover which parts of the brain are important for certain types of thoughts or activities. At the moment, it is more important in the research than in the clinical world, but there is some optimism that fMRI might eventually be used to map cognitive processes in mental disorders.

Sometimes, a lesion hasn’t developed enough to be recognizable by brain scans. In this case, neuropsychological tests can be performed to quantify a person’s cognitive, perceptual, and motor performance to determine what parts of the brain might be affected. The neuropsychological assessment usually involves a battery of tests such as the Halstead-Reitan assessment for adults. This assessment is composed of 5 tests.

1. Halstead Category Test: Measures learning, memory, judgement, and impulsivity. Patient hears a prompt and selects a number 1-4. A right choice gets a pleasent bell sound and a wrong choice gets a buzzer. Patient must determine the underlying pattern in prompt-number combinations.

2. Tactual Performance Test: Measures motor speed, response to the unfamiliar, and the ability to use tactile / kinesthetic cues. A blindfolded patient is asked to place blocks in the correct spaces on a board. Then she draws the board from memory, without ever seeing the board.

3. Rhythm Test: Measures attention and concentration. The patient listens to 30 pairs of rhythmic beats and must determine whether the pairs are the same or different.

4. Speech Sounds Perception Test: Determines whether patient can identify spoken words, and measures concentration, attention, and comprehension. Nonsense words are spoken, and the patient must choose the word from a list of four printed words.

5. Finger Oscillation Task: Measures the speed at which the patient can press a lever.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 4: Clinical Assessment and Diagnosis. Abnormal Psychology, sixteenth edition (pp. 101-127). Pearson Education Inc.

A History of Abnormal Psychology

Chapter 2 of Butcher’s Abnormal Psychology is a bit harder to summarize than Chapter 1. It covered the reactions of people towards the mentally ill throughout history. There were lots of names mentioned, and trends galore. But I will try to focus on the ones that I found most interesting.

During the classical age of Greek and Roman philosophers, mental illness began to be viewed more as a physiological trait than as demonic possession, which was the common viewpoint before this time. Hippocrates, a Greek philosopher considered the father of modern medicine, believed that mental illnesses were due to brain pathology. He recognized heredity, predisposition, and head injuries as common causes of mental illness. The doctrine of the four humors was related to Hippocrates and later to the Roman physician Galen. These four fluids in the body could combine in different ways to regulate the personality of an individual. Hippocrates promoted healthy living as a remedy to mental illness.

Plato, also, supported the kind, empathetic treatment of mentally ill individuals. He suggested that mentally disturbed individuals were not responsible for criminal acts. However, Plato viewed mental illness, at least partly, as an effect of spirituality. Hippocrates’ and Plato’s support of humane treatments for mental illness influenced later Greek and Roman philosophers.

During the Middle Ages, the belief that mental illness had physiological origins almost disappeared in Europe. The texts of the Greeks and Romans survived in Islamic and Middle Eastern regions, but very few Europeans of this time were able to read Greek or Roman texts. The Middle Ages marked a regression in both scientific and philosophical thought. The Greek and Roman texts weren’t “rediscovered” until the Renaissance.

Supernatural explanations for mental illness gained popularity, and treatment was left mainly to the clergy. At least the treatment of the mentally ill by the clergy was mainly humane.

It is commonly thought that the mentally ill were often accused of being witches during the Middle Ages, and were thus cruelly executed. However, recent research suggests that witchcraft was not believed to be an effect of possession, as mental illness was. Usually the accused were ill-tempered, impoverished women.

Scientific explanations for mental illness reemerged in the late Middle Ages and Renaissance. Even some of the clergy were falling away from possession as the cause of mental illness. Saint Vincent de Paul declared “Mental disease is no different than bodily disease and Christianity demands of the humane and powerful to protect, and the skillful to relieve the one as well as the other.”

Despite the resurgence in the belief of physiological explanations for mental illness during the Renaissance, inhumane asylums for the storage of individuals who could not care for themselves were on the rise.

In the late 1700s, humanitarians began to intervene on behalf of the mentally ill. Physicians began to experiment with more humane treatment of individuals. The French physician Philippe Pinel demonstrated that the removal of chains, and introduction of healthy living in an asylum had extraordinary effects on the recovery of mentally ill individuals. English Quaker William Tuke later established a pleasant retreat for mentally ill patients, with similar positive results.

The success of Pinel and Tuke led to a period of humanitarian reform and the use of moral management. This movement promoted the rehabilitation of moral and spiritual character, as well as manual labor. Moral management was highly effective. Recovery and discharge rates increased dramatically.

Unfortunately, moral management made way to the mental hygiene movement, which emphasized the physical (rather than spiritual) treatment of institutionalized patients. Although hygiene and the belief in physiological as well as spiritual causes of mental illness were important, improving the hygiene of the patients alone was not successful, and recovery rates plummeted. However, the mental hygiene movement was meant to create a more humane environment for the institutionalized – so in that way it was progress.

The number of institutionalized patients increased throughout the 19th and 20th centuries, but during the late 20th century humanitarians began to support deinstitutionalization of the mentally ill. Popular culture seems to believe deinstitutionalization to be a good thing – and for many, it was. Reintroduction of the mentally ill and developmentally challenged to their supportive families was a huge success when that family had the resources to care for its loved one. However, deinstitutionalization occurred too quickly, leaving many people without shelter, and of those who had shelter, many families didn’t have the resources to care for the patients. Many of the shelterless people became homeless, and others were quickly shunted off into prisons.

During the 19th and 20th centuries, four major themes in psychology developed: 1) biological discoveries, 2) classification system for mental disorders, 3) the emergence of psychological causations and views 4) experimental and research psychology.

The first major breakthrough in biological treatment of mental illness was the discovery that a form of paresis was caused by syphilis. This discovery boded well for the discovery of more biological treatments for other illnesses. Later discoveries showed deterioration of the brain led to senility and that some disorders could be caused by exposure to toxic substances. Biological treatments also had some mishaps – such as surgical removal of body parts including tonsils, part of the colon, gonads, and the frontal lobe of the brain.

Emil Kraepelin, a German psychiatrist, pioneered classification of mental illnesses, and his system became the forerunner to the DSM.

The Nancy school began a movement exploring psychological causations of mental illness. Two scientists in Nancy, France, discovered that some of the traits observed in hysteria – psychological paralysis, blindness, deafness, and pain – could be introduced in healthy patients through hypnosis. These symptoms could also be removed by hypnosis. Therefore, the Nancy school believed that hysteria, and later other disorders, were a form of self-hypnosis. Jean Charcot, a French neurologist, disagreed with the Nancy School. His research suggested that mental disorders were caused by brain degeneration. Toward the end of the 19th century, it was accepted that mental disorders could have a psychological basis, biological basis, or both.

Sigmund Freud was a student of Charcot, but later leant more towards the psychological causations mental illness. Freud discovered that if patients were encouraged to discuss their problems under hypnosis, they felt considerable emotional release. The patients, upon awakening, made no connection between their problems and their disorder. This led to the discovery of the unconscious mind. Freud also discovered that free-association and dream analysis had the same cathartic effect on his patients.

By the first decade of the 20th century clinical psychology labs, which performed experiments on causes and treatments of mental illness, were on the rise. Soon, the behavioral perspective developed. This perspective emphasized the role of learning in disorders. It began with Ivan Pavlov’s serendipitous discovery that he could condition dogs to salivate upon the ringing of a bell. Watson used Pavlov’s discovery to develop behaviorism – the belief that humans gain personalities through changes in their environments. Watson believed that he could train a child to become anyone he wanted the child to become simply by creating the right environment. (Stephen Pinker’s argument against this belief is discussed in my review of The Blank Slate.)

B. F. Skinner developed his own form of behaviorism in which consequences of behavior influenced subsequent behavior. This type of learning was named “operant conditioning.” For example, positive conditioning occurs when someone is rewarded for a behavior, such as when we give a treat to a potty-training child who has successfully used the toilet. Negative conditioning occurs when a child receives a shock when sticking his finger into an electrical outlet.

And thus abruptly ended Chapter 2 – after a long list of names and dates that the book thought were important for us to remember.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 2: Historical and Contemporary Views of Abnormal Behavior. Abnormal Psychology, sixteenth edition (pp. 29-53). Pearson Education Inc.