MOOD DISORDERS – DEPRESSION
Although mood disorders have some symptoms in common, they are very different in terms of their prevalence and causes. Major depressive disorder, also called Unipolar depression, is one of the most common of these disorders, whereas bipolar disorder (also known as manic-depression), like schizophrenia, is less prevalent.
Both disorders often result in severe impairment. Symptoms of major depressive disorder The primary symptom of major depressive disorder is, not surprisingly,
a depressed or sad mood. Almost everyone experiences a sad mood some time in their life, but major depressive disorder goes much further than simply feeling sad. Other symptoms include:
Losing interest or pleasure in things that you usually enjoy
- an experience called anhedonia. psychosocial factors psychological, environmental and social factors that may play a role in psychopathology expressed emotion (EE) specific set of feelings and behaviours directed at people with schizophrenia by their family members % relapsing in 9–12 months High EE Low EE
100
90
80
70
60
50
40
30
20
10
0
Bipolar disorder
Alcoholism
Depression
Schizophrenia
Across many disorders, people who have family members who are high on EE are more likely to relapse than are people who have family members who are low on EE. Source: Adapted from Butzlaff & Hooley (1998); O’Farrell et al. (1998).n Changes in ppetite – some find nothing appealing and have to force themselves to eat, resulting in significant weight loss, while others want to eat more and gain a lot of weight.
n Changes in sleep habits – depressed people may be unable to sleep or want to sleep all the time. n A very low level of energy, extreme fatigue and poor concentration.
Depressed people have no motivation to do anything, often find themselves unable to get out of bed and unable to complete school or work assignments. They may move through their lives very slowly, feeling that even simple activities require too much energy. n Feeling very badly about themselves – low self-esteem, feeling worthless and blaming themselves for all that has gone wrong in their lives and the world. Depressed people tend to feel hopeless about the future and don’t believe they will ever feel better.
Major depressive disorder has negative consequences not only for how people feel about themselves and their future, but also for their relationships. During a depressive episode people tend to withdraw socially, feel insecure in relationships, elicit rejection from others and experience high levels of interpersonal conflict
and stress. Romantic, family and peer relationships all suffer.
Given their level of suffering, impairment and hopelessness, it is hardly surprising that depression is one of the biggest risk factors for suicide, with around 15 per cent of depressed people committing suicide (Clark & Goebel-Fabbri, 1999).
The course of the disorder Major depressive disorder follows a recurrent course. Although some people have isolated episodes, most experience multiple episodes of depression that may become more severe over time (e.g. Lewinsohn, Zeiss & Duncan, 1989). Mild forms of depressionwith just a few symptoms rather than full-blown major
depressive disorder can predict the onset of more serious depression later on (e.g. Pine et al., 1999). Although depression was once thought to be a disorder of adulthood, we now know that it affects people of all ages, including children (figure 15.9). In fact, the age of onset of majordepressive disorder is decreasing, and the rates of major depressive disorder in childhood and adolescence are ncreasing rapidly.
Early onset predicts a worse course of depression over time (e.g. Lewinsohn et al., 1994), so depression in childhood and adolescence is a serious problem that can lead to ongoing difficulties throughout life.
Causes of major depressive disorder and factors affecting its course 1 Genetic and biological factors Like schizophrenia, major depressive disorder can be genetically transmitted (e.g. McGuffin et al., 1996). As for biological factors, the current view is that no single neurotransmitter is associated with major depressive disorder.
Instead, it most likely involves dysregulation of the entire neurotransmitter system (Siever & Davis, 1991). Indeed, it may be the balance of various neurotransmitters that regulate mood. Major depressive disorder may also involve neuroendocrine dysfunction. Depressed people tend to have elevated cortisol levels (e.g. Halbreich, Asnis & Shindledecker, 1985). Cortisol is involved in regulating the body’s reaction to stress and becomes elevated under stress. This suggests that, physiologically, depressed people may be in a state of chronic stress and they are perhaps more reactive to stress than are non-depressed people (e.g. Gold, Goodwin & Chrousos, 1988). As we see in the next section, stress plays an important role in ulnerability to major depressive disorder.
2 Psychosocial factors Unlike schizophrenia, which almost certainly has a genetic and/or biological trigger, major depressive disorder can be caused by either genetic/biological or psychosocial factors.
One of the primary psychosocial factors is life stress, including significant negative life events and chronically stressful circumstances (e.g. Brown & Harris, 1989). Of course, many people experience stressful situations, but they don’t all become depressed, suggesting that a diathesis–stress process might be occurring.
Specifically, it may be the particular way we perceive and think about life tressors that leads to depression. Consistent with a cognitive model of sychopathology, people who think about life events in a pessimistic, dysfunctional way are more likely to get depressed than people who think about life events in an
optimistic way (e.g. Metalsky, Halberstadt & Abramson, 1987). Beck (1967; Beck et al., 1979) describes pessimistic ways of thinking about ourselves, the world and the future as cognitive distortions. Examples are viewing things in a black and white manner, focusing on and exaggerating negative aspects and minimizing our positive qualities. When people engage in cognitive distortions, like those below, to explain their life circumstances, they put themselves at risk for experiencing negative moods like depression:
All or nothing thinking – ‘I’m a total loser!’
Overgeneralization – ‘I’m always going to be a total loser!’
Catastrophizing – ‘I’m so bad at my job that I’m sure to fail, then I’ll get fired, I’ll be totally humiliated, nobody will ever hire me again, and I’ll be depressed forever!’
Personalization – ‘It’s all my fault that my sister’s boyfriend broke up with her – if I hadn’t been so needy of her attention, she would have spent more time with him and they would have stayed together!’
Emotional reasoning – ‘I feel like an incompetent fool, therefore I must be one!’
Similarly, Seligman and colleagues (e.g. Abramson, Seligman & Teasdale, 1978) suggest that people who are vulnerable to depression tend to offer internal, global and stable causal explanations for negative events (see also chapter 14). For example, if a date goes badly, reactions might include:
It’s all because of me (internal);
I always do the wrong thing (global); and
I’ll never have a proper boyfriend (stable).
Negative interpersonal circumstances are particularly likely to play a role in epression. Marital, family and peer relations are often troubled, and interpersonal forms of stress – such as relationships ending, conflicts and lack of supportive relationships – are consistently associated with depression (see Beach & Fincham, 1998; Davila, 2000; Hammen, 1991).
Interpersonal models of depression highlight how the disorder can be both a cause and a consequence of interpersonal problems.
For example, Coyne (1976) suggested that depressed people engage in behaviours that elicit rejection from others, and this rejection leads to further depression. Similarly, Hammen (1991) proposed that depressed people generate interpersonal stress
in their lives, which then makes them more depressed. It’s possible that, for some people, depression has its roots in childhood experiences (Cicchetti et al., 1994). An insecure attachment in childhood may set the stage for depression by putting children at a disadvantage in four important areas:
1. Low self-esteem puts them at risk for a pessimistic way of viewing themselves and the world.
2. Inability to successfully regulate their negative emotions leaves them unable to fend off feelings of depression.
3. Never having learned to cope well with stress, they may employ inappropriate strategies (such as keeping problems hidden or ruminating on them).
4. Negative views of others and learned dysfunctional ways of interacting with others (e.g. excessive dependence on, or complete avoidance, of others) puts them at risk for depression through the negative effect it has on their interpersonal relationships.
Symptoms of bipolar disorder
In bipolar disorder, depression alternates with periods of mania, which is virtually the polar opposite of depression. During amanic period, people feel euphoric or elated. And just as major depression isn’t the same as simply feeling sad, mania is not the same as simply feeling happy. Mania is characterized by these symptoms:
An excessively euphoric mood typically associated with a sense of grandiosity. Manic people feel unbelievably good about themselves, to the extent that they often believe they can do anything. And they frequently try to!
Engaging in many more activities than usual. This increase in activity often becomes excessive to the point of being dangerous. For example, manic people may go on shopping sprees, spend amounts of money that go well beyond their means, and incur enormous levels of debt. They may takeoff on a trip in their car, driving recklessly and leaving responsibilities behind. They may engage in frequent sexual indiscretions, putting themselves at risk for sexually transmitted diseases, pregnancy and relationship conflict.
A decreased need for sleep – even staying awake for days at a time.
High distractibility and poor concentration as the mind races with a million thoughts.
Speaking very quickly – others can barely get a word in during conversations.
The course of the disorder The most common onset for bipolar disorder is in early adulthood, but, like major depressive disorder, it can occur earlier. Bipolar disorder is a lifelong, recurrent disorder that can take a variable course. Although some people regularly alternate between mania and depression, the number of pisodes, their timing and their order can vary widely.
Bipolar disorder can be seriously debilitating, but with appropriate medication many sufferers live highly productive, normal lives between episodes.
Causes of bipolar disorder and factors affecting its course
1 Genetic and biological factors There is even more evidence of genetic transmission for bipolar disorder than for major depressive disorder (Gershon, 1995).
There is also evidence of dysfunction of various neurotransmitters, including serotonin, dopamine and norepinephrine, although it may not be the levels of eurotransmitters themselves that are problematic, but the pattern of neuronal firing. Sodium ions are critical in proper neuronal firing (see chapter 1), and lithium, which is used to treat bipolar disorder, is chemically similar to sodium, so lithium may work by regulating dysfunctional neuronal firing (e.g. Goodwin & Jamison, 1990).
2 Psychosocial factors Like schizophrenia, there is no evidence that psychosocial factors are the initial cause of bipolar disorder.
But they do influence the course of the disorder. Stressful life events, articularly those that disrupt social and biological regularities (e.g. birth of a child, change in work hours, travel), may lead to relapse (see Johnson & Roberts, 1995). Negative social relations may also lead to relapse. In particular, sufferers with high EE families are more likely to relapse (Miklowitz et al., 1988)
Although mood disorders have some symptoms in common, they are very different in terms of their prevalence and causes. Major depressive disorder, also called Unipolar depression, is one of the most common of these disorders, whereas bipolar disorder (also known as manic-depression), like schizophrenia, is less prevalent.
Both disorders often result in severe impairment. Symptoms of major depressive disorder The primary symptom of major depressive disorder is, not surprisingly,
a depressed or sad mood. Almost everyone experiences a sad mood some time in their life, but major depressive disorder goes much further than simply feeling sad. Other symptoms include:
Losing interest or pleasure in things that you usually enjoy
- an experience called anhedonia. psychosocial factors psychological, environmental and social factors that may play a role in psychopathology expressed emotion (EE) specific set of feelings and behaviours directed at people with schizophrenia by their family members % relapsing in 9–12 months High EE Low EE
100
90
80
70
60
50
40
30
20
10
0
Bipolar disorder
Alcoholism
Depression
Schizophrenia
Across many disorders, people who have family members who are high on EE are more likely to relapse than are people who have family members who are low on EE. Source: Adapted from Butzlaff & Hooley (1998); O’Farrell et al. (1998).n Changes in ppetite – some find nothing appealing and have to force themselves to eat, resulting in significant weight loss, while others want to eat more and gain a lot of weight.
n Changes in sleep habits – depressed people may be unable to sleep or want to sleep all the time. n A very low level of energy, extreme fatigue and poor concentration.
Depressed people have no motivation to do anything, often find themselves unable to get out of bed and unable to complete school or work assignments. They may move through their lives very slowly, feeling that even simple activities require too much energy. n Feeling very badly about themselves – low self-esteem, feeling worthless and blaming themselves for all that has gone wrong in their lives and the world. Depressed people tend to feel hopeless about the future and don’t believe they will ever feel better.
Major depressive disorder has negative consequences not only for how people feel about themselves and their future, but also for their relationships. During a depressive episode people tend to withdraw socially, feel insecure in relationships, elicit rejection from others and experience high levels of interpersonal conflict
and stress. Romantic, family and peer relationships all suffer.
Given their level of suffering, impairment and hopelessness, it is hardly surprising that depression is one of the biggest risk factors for suicide, with around 15 per cent of depressed people committing suicide (Clark & Goebel-Fabbri, 1999).
The course of the disorder Major depressive disorder follows a recurrent course. Although some people have isolated episodes, most experience multiple episodes of depression that may become more severe over time (e.g. Lewinsohn, Zeiss & Duncan, 1989). Mild forms of depressionwith just a few symptoms rather than full-blown major
depressive disorder can predict the onset of more serious depression later on (e.g. Pine et al., 1999). Although depression was once thought to be a disorder of adulthood, we now know that it affects people of all ages, including children (figure 15.9). In fact, the age of onset of majordepressive disorder is decreasing, and the rates of major depressive disorder in childhood and adolescence are ncreasing rapidly.
Early onset predicts a worse course of depression over time (e.g. Lewinsohn et al., 1994), so depression in childhood and adolescence is a serious problem that can lead to ongoing difficulties throughout life.
Causes of major depressive disorder and factors affecting its course 1 Genetic and biological factors Like schizophrenia, major depressive disorder can be genetically transmitted (e.g. McGuffin et al., 1996). As for biological factors, the current view is that no single neurotransmitter is associated with major depressive disorder.
Instead, it most likely involves dysregulation of the entire neurotransmitter system (Siever & Davis, 1991). Indeed, it may be the balance of various neurotransmitters that regulate mood. Major depressive disorder may also involve neuroendocrine dysfunction. Depressed people tend to have elevated cortisol levels (e.g. Halbreich, Asnis & Shindledecker, 1985). Cortisol is involved in regulating the body’s reaction to stress and becomes elevated under stress. This suggests that, physiologically, depressed people may be in a state of chronic stress and they are perhaps more reactive to stress than are non-depressed people (e.g. Gold, Goodwin & Chrousos, 1988). As we see in the next section, stress plays an important role in ulnerability to major depressive disorder.
2 Psychosocial factors Unlike schizophrenia, which almost certainly has a genetic and/or biological trigger, major depressive disorder can be caused by either genetic/biological or psychosocial factors.
One of the primary psychosocial factors is life stress, including significant negative life events and chronically stressful circumstances (e.g. Brown & Harris, 1989). Of course, many people experience stressful situations, but they don’t all become depressed, suggesting that a diathesis–stress process might be occurring.
Specifically, it may be the particular way we perceive and think about life tressors that leads to depression. Consistent with a cognitive model of sychopathology, people who think about life events in a pessimistic, dysfunctional way are more likely to get depressed than people who think about life events in an
optimistic way (e.g. Metalsky, Halberstadt & Abramson, 1987). Beck (1967; Beck et al., 1979) describes pessimistic ways of thinking about ourselves, the world and the future as cognitive distortions. Examples are viewing things in a black and white manner, focusing on and exaggerating negative aspects and minimizing our positive qualities. When people engage in cognitive distortions, like those below, to explain their life circumstances, they put themselves at risk for experiencing negative moods like depression:
All or nothing thinking – ‘I’m a total loser!’
Overgeneralization – ‘I’m always going to be a total loser!’
Catastrophizing – ‘I’m so bad at my job that I’m sure to fail, then I’ll get fired, I’ll be totally humiliated, nobody will ever hire me again, and I’ll be depressed forever!’
Personalization – ‘It’s all my fault that my sister’s boyfriend broke up with her – if I hadn’t been so needy of her attention, she would have spent more time with him and they would have stayed together!’
Emotional reasoning – ‘I feel like an incompetent fool, therefore I must be one!’
Similarly, Seligman and colleagues (e.g. Abramson, Seligman & Teasdale, 1978) suggest that people who are vulnerable to depression tend to offer internal, global and stable causal explanations for negative events (see also chapter 14). For example, if a date goes badly, reactions might include:
It’s all because of me (internal);
I always do the wrong thing (global); and
I’ll never have a proper boyfriend (stable).
Negative interpersonal circumstances are particularly likely to play a role in epression. Marital, family and peer relations are often troubled, and interpersonal forms of stress – such as relationships ending, conflicts and lack of supportive relationships – are consistently associated with depression (see Beach & Fincham, 1998; Davila, 2000; Hammen, 1991).
Interpersonal models of depression highlight how the disorder can be both a cause and a consequence of interpersonal problems.
For example, Coyne (1976) suggested that depressed people engage in behaviours that elicit rejection from others, and this rejection leads to further depression. Similarly, Hammen (1991) proposed that depressed people generate interpersonal stress
in their lives, which then makes them more depressed. It’s possible that, for some people, depression has its roots in childhood experiences (Cicchetti et al., 1994). An insecure attachment in childhood may set the stage for depression by putting children at a disadvantage in four important areas:
1. Low self-esteem puts them at risk for a pessimistic way of viewing themselves and the world.
2. Inability to successfully regulate their negative emotions leaves them unable to fend off feelings of depression.
3. Never having learned to cope well with stress, they may employ inappropriate strategies (such as keeping problems hidden or ruminating on them).
4. Negative views of others and learned dysfunctional ways of interacting with others (e.g. excessive dependence on, or complete avoidance, of others) puts them at risk for depression through the negative effect it has on their interpersonal relationships.
Symptoms of bipolar disorder
In bipolar disorder, depression alternates with periods of mania, which is virtually the polar opposite of depression. During amanic period, people feel euphoric or elated. And just as major depression isn’t the same as simply feeling sad, mania is not the same as simply feeling happy. Mania is characterized by these symptoms:
An excessively euphoric mood typically associated with a sense of grandiosity. Manic people feel unbelievably good about themselves, to the extent that they often believe they can do anything. And they frequently try to!
Engaging in many more activities than usual. This increase in activity often becomes excessive to the point of being dangerous. For example, manic people may go on shopping sprees, spend amounts of money that go well beyond their means, and incur enormous levels of debt. They may takeoff on a trip in their car, driving recklessly and leaving responsibilities behind. They may engage in frequent sexual indiscretions, putting themselves at risk for sexually transmitted diseases, pregnancy and relationship conflict.
A decreased need for sleep – even staying awake for days at a time.
High distractibility and poor concentration as the mind races with a million thoughts.
Speaking very quickly – others can barely get a word in during conversations.
The course of the disorder The most common onset for bipolar disorder is in early adulthood, but, like major depressive disorder, it can occur earlier. Bipolar disorder is a lifelong, recurrent disorder that can take a variable course. Although some people regularly alternate between mania and depression, the number of pisodes, their timing and their order can vary widely.
Bipolar disorder can be seriously debilitating, but with appropriate medication many sufferers live highly productive, normal lives between episodes.
Causes of bipolar disorder and factors affecting its course
1 Genetic and biological factors There is even more evidence of genetic transmission for bipolar disorder than for major depressive disorder (Gershon, 1995).
There is also evidence of dysfunction of various neurotransmitters, including serotonin, dopamine and norepinephrine, although it may not be the levels of eurotransmitters themselves that are problematic, but the pattern of neuronal firing. Sodium ions are critical in proper neuronal firing (see chapter 1), and lithium, which is used to treat bipolar disorder, is chemically similar to sodium, so lithium may work by regulating dysfunctional neuronal firing (e.g. Goodwin & Jamison, 1990).
2 Psychosocial factors Like schizophrenia, there is no evidence that psychosocial factors are the initial cause of bipolar disorder.
But they do influence the course of the disorder. Stressful life events, articularly those that disrupt social and biological regularities (e.g. birth of a child, change in work hours, travel), may lead to relapse (see Johnson & Roberts, 1995). Negative social relations may also lead to relapse. In particular, sufferers with high EE families are more likely to relapse (Miklowitz et al., 1988)
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