Exam 2 - Chapter 6 & 8

Chapter 6 - Trauma & Stressor Related Disorders

Intro

• stressors - external events or situations, e.g. challenging or difficult life circumstances

• stress - internal psychological or physiological response to a stressor

  • exposure to worrisome but less traumatic events can also significantly influence our health and well-being

• everyday stress can negatively influence our health → development of both psychological and physical conditions

• long-term exposure to adversities can suppress our immune system and subsequently increase the risk of illness

Trauma & Stressor Related Disorders

• category includes disorders involving intense reactions to traumatic or stressful events

Adjustment Disorder

• occurs when someone has difficulty coping with or adjusting to a specific life stressor—the reactions to the stressor are disproportionate to the severity or intensity of the event or situation

• the following is necessary for a diagnosis of AD:

  • Exposure to an identifiable stressor that results in the onset of significant emotional or behavioral symptoms that occur within 3 months of the event

  • Emotional distress and behavioral symptoms that are out of proportion to the severity of the stressor (normal bereavement is excluded from the AD diagnosis) and result in significant impairment in social, academic, or work-related functioning, or other life activities

  • These symptoms last no longer than 6 months after the stressor or consequences of the stressor have ended

• common diagnosis among people seeking help from medical or mental health professionals

• prevalence in the general population is about 2 percent and is higher in certain groups, such as the unemployed (27.5 percent) and recently bereaved (18 percent)

• more common in women and those with disadvantaged life circumstances

• most adults recover, adolescents may be at risk for other disorders

• can be acute, occurring immediately after a specific onetime stressor, or chronic, involving multiple or repeated stressors

• time-limited, often resolves without treatment BUT symptoms can remain 12 months after the traumatic event

• often involve mood or behavioral changes, including symptoms of anxiety or depression → not always easy to distinguish

  • look at emotional functioning prior to stressor

  • a specific stressor precedes the symptoms seen in AD and that the person experiences an unusually intense reaction to the stressor

• concern - category may be pathologizing normal responses to stressors

  • how to decide if “out of proportion”?

• four common outcomes or trajectories after exposure to traumatic incidents:

  • resilience - relatively stable functioning & few symptoms resulting from the trauma

  • recovery - initial distress with reduction in symptoms over time

  • delayed symptoms - few initial symptoms followed by increasing symptoms over time

  • chronic symptoms - consistently high trauma-related symptoms that begin soon after the event

Acute Stress Disorder

• DSM:

  • Direct or indirect exposure to a traumatic stressor involving actual or threatened death, serious injury, or sexual violence

  • Nine or more symptoms involving

    • intrusive memories

    • avoidance of reminders of event

    • negative thoughts or emotions

    • heightened arousal

    • dissociation or inability to remember details

  • disturbance persists from 3 days to 1 month after exposure to trauma

• prevalence

  • about 2% in the general population

  • from 7% to 28% in medical and psychiatric samples, recently bereaved, and unemployed

• More common in women and those with disadvantaged life circumstances

• most adults recover

• adolescents may be at risk for other disorders

Posttraumatic Stress Disorder

• DSM

  • Direct or indirect exposure to a traumatic stressor involving actual or threatened death, serious injury, or sexual violence

  • One or two symptoms involving each of the following:

    • intrusive memories

    • avoidance of reminders of the event

    • negative thoughts or emotions

    • heightened arousal and hypervigilance

  • symptoms are present for at least 1 month

• prevalence

  • Lifetime prevalence for U.S. adults is about 8.7%

  • 12-month prevalence is 3.5%

  • Varies according to the traumatic stressor and population involved; higher rates for rape, military combat, and emergency responders

• Twice as prevalent in women

• Female adolescents have higher prevalence (6.6%) compared to males (1.6%)

• Low prevalence in Asian Americans

• Higher prevalence in Latinx and African Americans

• Symptoms may vary cross-culturally

• Symptoms fluctuate

• Over 50% recover within the first 3 months

• For a minority, PTSD is a chronic condition

Diagnosis of Acute & Posttraumatic Stress Disorders

• begin with direct or indirect exposure to specific traumatizing stressors (actual/threatened death, serious injury, sexual violence)

• initial stress reactions that occur shortly after a traumatic event are normative responses to an overwhelming and threatening stimulus

• most individuals recover from traumatic events and demonstrate a marked lessening of symptoms as time passes, but for some…

  • lasts for more than several days

  • heightened reactivity

  • ongoing fear, alarm, distress

• Indirect exposure to trauma such as witnessing a traumatic event involving others, learning of a traumatic event involving loved ones, or repeated contact with aversive details of a traumatic event can also result in ASD or PTSD

• diagnosis requires symptoms from major symptom clusters:

  • intrusive symptoms

    • intrusive thoughts, including distressing recollections, nightmares, or flashbacks of the trauma

    • psychological distress triggered by external or internal reminds of the trauma

    • physical symptoms such as increased heart rate or sweating

  • avoidance

    • avoidance of thoughts, feelings, or physical reminders associated with the trauma (& places, events, or objects that trigger distressing memories of the experience)

  • negative alterations in mood or cognition

    • difficulty remembering details of the event

    • persistent negative views about oneself or the world

    • distorted cognitions leading to self-blame or blaming others

    • frequent negative emotions

    • limited interest in important activities

    • feeling emotionally numb, detached, or estranged from others

    • persistent inability to experience positive emotions

  • arousal and changes in reactivity

    • feelings of irritability that may result in verbal or physical aggression

    • engaging in reckless or self-destructive behaviors

    • hypervigilance involving constantly remaining alert for danger

    • heightened physiological reactivity such as exaggerated startle response

    • difficulty concentrating

    • sleep disturbance

• clinicians also specify if there are recurrent symptoms of:

  • depersonalization - feeling detached from one’s body or thoughts

  • derealization - a persistent sense of unreality

• dissociation - protective reaction involving mental disconnection from an overwhelming situation, commonly associated with trauma

• diagnostic criteria for ASD and PTSD are very similar

  • ASD requires at least 9 from symptom clusters

    • involves symptoms that persist for at least 3 days but no longer than 1 month after event

  • PTSD requires one or two from each cluster

    • symptoms present for at least 1 month

    • expression is occasionally delayed

Etiology of Trauma & Stressor-Related Disorders

Biological Etiology

• normal response to a fear-producing stimulus is quite rapid, occurring in milliseconds, and involves the amygdala

  • amygdala - part of the brain that is involved with threat detection, major interface between events occurring in the environment and physiological fear responses, multiple connections to regions of prefrontal cortex (attention, managing emotional reactions, and anticipating events)

    • sends out a signal to the prefrontal cortex and the sympathetic nervous system, preparing the body for action (i.e., to fight or to flee)

    • HPA - releases hormones, including epinephrine and cortisol

      • prepare the body for “fight or flight” by raising blood pressure, blood sugar levels, and heart rate
        

  • Homeostasis returns once it becomes evident that the danger has passed and the “fight or flight” response is dampened

• with PTSD, continue to demonstrate an enhanced startle response and exaggerated physiological sensitivity to stimuli associated with the traumatic event

  • persist even when the stressor is no longer present

• exhibit minimal fear extinction, their trauma-related fear responses do not decline with the passage of time

  • possible that the chronic release of stress hormones such as cortisol alters brain structures associated with stress regulation

  • disruptions caused by excess cortisol can lead to neuronal loss and affect brain structure in the hippocampus, amygdala, and cerebral cortex

  • heightened physiological arousal and cortisol production associated with PTSD have been associated with oxidative stress and inflammation throughout the brain and body

  • alterations in connectivity within the orbitofrontal cortex may also help explain the vigilance and cognitive rigidity

  • individuals with PTSD show altered structural and functional connectivity between the amygdala and the ventromedial prefrontal cortex

  • genetics

Psychological Etiology

• Preexisting conditions such as anxiety and depression and negative emotions such as hostility and anger are risk factors

• Individuals with higher anxiety or negative emotions may react more intensely to a traumatic event because they ruminate about the event or overestimate the probability that additional aversive events will follow

• tendency to generalize trauma-related stimuli to other situations and to avoid circumstances associated with the trauma

• individuals with specific cognitive styles or dysfunctional thoughts about themselves or the environment are more likely to develop PTSD

  • a negative worldview may have difficulty envisioning a positive future → sustain hyperarousal, trauma-related symptoms, negative appraisals

• a cognitive style that results in active problem solving, reframing traumatic events in a more positive light, and optimistic thinking can increase resilience and reduce risk of PTSD

• recovery from PTSD symptoms is also more prevalent with individuals who possess psychological flexibility, practice mindfulness, and demonstrate self-compassion

Social Etiology

• Social support can prevent or diminish PTSD symptoms by affecting brain processes (such as the release of endorphins) that reduce stress and anxiety

  • may dampen anxiety associated with trauma or prevent negative cognitions from occurring

• Preexisting family conflict or overprotective family interactions may also increase the impact of stress following exposure to a traumatic event

  • increase anxiety

  • lead to negative cognitive styles

  • alter stress-related physiological activity & HPA axis functioning

  • trigger genetic predisposition toward greater physiological reactivity

Sociocultural Dimension

• ethnic differences have been found in the prevalence of PTSD

  • race-based discrimination:

    • “being called names or insulted,”

    • “witnessing friends of your ethnic group treated unfairly,”

    • “being treated as not as smart because of your ethnic group”

  • differential exposure to previous trauma or cultural differences in responding to stress

• women are twice as likely as men to suffer from a trauma-related disorder

  • physiological differences or because women have greater risk of exposure to stressors

Medication Treatment of Trauma-Related Disorders

• certain anti-depressant medications (SSRIs) → moderate effectiveness in some

  • alter serotonin levels, decrease reactivity of the amygdala, desensitize fear network

  • effective in less than 60% of people with PTSD, & only 20-30% of those who respond show full recovery

• D-cycloserine - a medication that appears to act on the brain to boost fear extinction processes

  • initially promising, but further findings → mixed findings (some improved, others reported increases in symptom severity)

  • appears to have a small augmentative effect on improving the outcome of cognitive-behavioral therapy for PTSD

• Prazosin - a hypertension medication sometimes prescribed to reduce nightmares associated with PTSD → has not demonstrated substantial effectiveness in reducing distressing dreams or improving sleep quality

• Propranolol - a beta-blocker believed to reduce memory consolidation of traumatic memories, has been investigated as a treatment for the intrusive reexperiencing of trauma → appear to produce significant improvement in sleep quality and reductions in symptoms of hyperarousal

• MDMA - shows promise when combined with exposure-based therapy; suppressing the emotional memory circuits involved with intrusive memories, thus permitting the use of exposure therapy (without client being overwhelmed by fear)

Psychotherapy for Trauma-Related Disorders

• CBT - most effective form of treatment for PTSD

  • generally focus on extinguishing the fear of trauma-related stimuli and correcting dysfunctional cognitions that perpetuate symptoms

• Prolonged exposure therapy (PE), cognitive-behavioral therapy (CBT), trauma-focused cognitive-behavioral therapy (TF-CBT), and eye movement desensitization and reprocessing (EMDR) have all proven to be effective

  • all are more successful than use of medication and also preferred

• Prolonged exposure therapy (PE)

  • involves imaginary and real-life exposure to trauma-related cues

  • extended exposure to avoided thoughts, places, or people can help them to realize that those situations do not pose a danger

  • more commonly, exposure therapy involves asking participants to re-create the traumatic event in their imagination

  • a preferred treatment modality among military personnel and is used in both individual and group sessions

  • has also reduced depressive symptoms among veterans

• trauma-focused cognitive-behavioral therapy (TF-CBT)

  • combination of CBT techniques and trauma-sensitive principles, focus on helping clients identify and challenge dysfunctional cognitions about the traumatic event and current beliefs about themselves and others

  • address underlying dysfunctional thinking or pervasive concerns about safety

  • may include education about PTSD, developing a solution-oriented focus, reducing negative self-talk, and receiving therapeutic exposure to fear triggers

  • mindfulness training - paying attention to emotions & thoughts on a nonjudgment basis without reacting to symptoms

• eye movement desensitization and reprocessing (EMDR)

  • nontraditional

  • decrease physiological reactivity, weaken impact of negative emotions

  • clients visualize their traumatic experience while engaged in an activity involving both sides of the body, such as visually following a therapist’s fingers moving from side to side

    • therapist prompts with substitute positive cognitions for negative cognitions associated with experience

  • Processing the trauma in a relaxed state allows the client to detach from negative emotions and replace them with more adaptive appraisals

  • many individuals with PTSD report significant reductions in hyperarousal and other trauma-related symptoms

Psychological Factors Affecting Medical Conditions

• Stress causes a multitude of physiological, psychological, and social changes that influence health conditions

• psychosomatic was the term applied to physical disorders—such as asthma, hypertension, and headaches—made worse by psychological influences

• refers to situations where psychological or behavioral factors adversely influence the course or treatment of a medical disorder, constitute an additional risk factor for the medical condition, or make the illness worse

• examples - emotional states, patterns of interpersonal interaction, and coping styles

• sometimes substitute the term psychophysiological disorder (any physical disorder that has a strong psychological basis or component) instead of “psychological factors affecting other medical conditions.”

Medical Conditions Influenced by Psychological Factors

• Broken Heart Syndrome - reversible cardiac condition

  • occurs when severe stress results in the release of high levels of norepinephrine (i.e., noradrenaline) and a sudden reduction in heart function

  • symptoms & test results very similar to those of hear attack but with no evidence of blocked heart arteries or other cardiac abnormalities

  • 7.5 times more likely to occur in women, particularly between 65 and 70

• can involved actual tissue damage, a disease response, physiological dysfunction

• Coronary Heart Disease (CVD)

  • narrowing of cardiac arteries due to atherosclerosis (hardening of the arterial walls), resulting in complete or partial blockage of the flow of blood and oxygen to the heart

    • less oxygen-rich blood reaches heart muscle → angina (chest pain) or if blood flow to the heart is completely blocked, a heart attack

  • leading cause of death in the US, someone dies every 38 seconds

  • risk factors/affect on prognosis

    • unhealthy eating habits

    • hypertension

    • cigarette smoking

    • diabetes

    • cholesterol

    • obesity

    • lack of physical activity

    • depression

    • perceived stress

    • difficult life events

  • stress can also affect heart rhythm - stressor causes the release of hormones that activate the sympathetic nervous system → heart rhythm changes

    • ventricular fibrillation - rapid, ineffective contractions

    • bradycardia - slowing of heartbeat

    • tachycardia - speeding up of heartbeat

    • arrhythmia - irregular heartbeat

• hypertension

  • blood pressure - measurement of the force of blood against the walls of the arteries

  • normal blood pressure - systolic pressure (contraction) lower than 120 & diastolic pressure (relaxation after contraction) lower than 80

  • hypertension = systolic blood pressure equals or exceeds 130 or the diastolic pressure is 80 or higher

  • elevated blood pressure - borderline level of blood pressure - systolic pressure between 120 & 129, diastolic pressure less than 80

    • precursor to hypertension, stroke, heart disease

  • Chronic hypertension leads to arteriosclerosis (hardening of the arteries) and to increased risk of stroke and heart attack

• Migraine, Tension, Cluster Headaches

  • headaches very common

    • intensity of headaches can vary from dull and annoying to excruciating

    • debilitating headaches decrease quality of life and impair family, social, and occupational functioning

  • medication-overuse headache is a common secondary headache disorder that affects up to 5 percent of some population groups

    • results from rebound headache effects associated with excessive use of headache medication

  • Migraine

    • often one side of head but location varies

    • hours to 4 days

    • mild to severe

    • nausea, sensitivity to light, sound, odors, and movement

    • more common in young adult women (3-4x more common than men)

    • often hereditary

    • Up to 1/3 of individuals with migraines experience an aura prior to the headache— unusual physical sensations or visual symptoms such as flashes of light, unusual visual patterns, or blind spots

    • associated with an increased risk of cardiovascular events such as strokes and heart attack

    • associated with modifiable risk factors such as high levels of caffeine consumption, overeating, and poor sleep quality

    • affect about 20 percent of the U.S. population

  • Tension Headache

    • both sides of head, often concentrated

    • hours to days

    • mild to moderate

    • tightness or pressure around neck, head, or shoulders

    • more common in women

    • probably not hereditary

    • produced when stress creates prolonged contraction of the scalp and neck muscles, resulting in vascular constriction and steady pain

    • most common form of headache

    • 70 percent of adolescents and adults experience tension headaches each year

  • Cluster Headache

    • centered on one eye on same side of head

    • usually less than an house

    • excrutiating

    • eye often teary, nose clogged on side of head with pain; pacing and rubbing head

    • more common in men

    • sometimes hereditary

    • rapid onset of an excruciating stabbing or burning sensation located in the eye or cheek

    • often causing tears and redness of the eye, and sometimes resulting in drooping of the eyelid and nasal congestion on the affected side

    • 55 percent of affected individuals in one study reported suicidal thoughts while enduring an episode of cluster headaches

    • relatively uncommon, affecting about 1 in 1,000 adults

    • generally develop during adulthood and are six times more prevalent in men

    • occur in cycles, with incapacitating episodes that may arise several times a day

      • each attack - 15 min to 3 hrs

      • may continue over period of a few days to sever months, followed by pain-free periods

    • Only about 10–20 percent of cluster headaches are chronic, with no periods of respite

    • about 25 percent of cases, cluster headaches are preceded by migraine-like symptoms such as nausea and sensitivity to light and noise

• Asthma

  • chronic inflammatory disease of the lungs, can be aggravated by stress or anxiety

• various environmental influences trigger excessive mucus secretion as well as spasms and swelling of the airways → reduce the amount of air that can be inhaled

• range from mild and infrequent wheezing or coughing to severe respiratory distress requiring emergency care

• often underestimate magnitude of airflow obstruction, may neglect to self-administer medication/seek treatment

• ongoing psychological or economic stressors can interfere with adherence to protocols for the use of preventative medications or rescue inhalers

• prevalence of asthma has increased dramatically since the 1980s - affects up to 8.2 percent of the U.S. population, more prevalent among women, those living on poverty, African Americans, Puerto Ricans

• youth between the ages of 12 and 17 have the highest prevalence rate, 16.7 percent

Biological Etiology on Physical Disorders

• stressors can dysregulate physiological processes occurring throughout the brain and body

• stressor activates HPA axis & sympathetic nervous system → hormones released (epinephrine, norepinephrine, cortisol) → prepare body for emergency action (increasing heart rate, respiration, alertness) → when occurring over extended period of time, psychophysiological disorder can develop

• while brief exposure to stressors enhances immune functioning, long-lasting stress can impair immune response

• results in increased cortisol production, which can have a detrimental effect on physiological processes

  • suppresses the immune system → white blood cells, responsible for destroying pathogens such as bacteria, viruses, fungi, and tumors, may be less able to multiply and we are therefore less capable of fighting infection

• genetic influences contribute to psychophysiological disorders

  • cardiovascular stress reactivity, as measured by blood pressure, is more similar among identical twins than among fraternal twins

  • having purer African ancestry increases the risk of developing severe asthma

  • twin studies have estimated the heritability of asthma to be around 35 percent

  • early environmental influences (traumatic childhood experiences) interacting with the alleles of certain genes → changes in stress-responsive neurobiological systems → increased vulnerability to the development of a psychophysiological disorder through epigenetic mechanisms

Psychological Etiology on Physical Disorders

• Positive emotions, such as optimism, happiness, joy, and contentment, can help regulate heart rate, blood pressure, and other physiological stress reactions, whereas negative emotions accentuate the stress response

• High levels of well-being and life satisfaction are associated with increased likelihood of disease-free living and six more years of life compared to low levels of well-being

• Control and the perception of control over the environment and its stressors can mitigate the negative effects of stress

• negative emotional states such as depression, hostility, anxiety, and cynicism increase the risk for psychophysiological disorders

• depression and anxiety can influence both physiological functioning and behaviors that affect health

  • exhibit irregularities in the autonomic nervous system → exaggerated cardiovascular responses to stressors

  • depression may result in behaviors - excessive sleep, reduced exercise, consumption of unhealthy food, increased use of alcohol or cigarettes

• Hostility is associated with several psychophysiological disorders, particularly CVD

  • negative emotions such as hostility can increase cardiovascular reactivity, subsequently increasing the risk of developing CVD

  • anger produces pathophysiological reactions such as coronary vascular constriction and the formation of plaques

Social Etiology on Physical Disorders

• social stressors can influence immunological functioning and produce undesired health outcomes

• acute and chronic stress associated with the physical or emotional abuse that occurs in intimate partner relationship violence can produce a wide range of health conditions

• adversities such as physical, emotional, or sexual abuse in pregnant women increase the likelihood of headaches and hypertension

• asthma symptoms increase in response to social stress

• lack of social support can lead to immune system dysregulation with less natural killer cell activity and elevated inflammation

• good relationships may moderate the link between hostility and poor health

• social isolation is more likely to negatively affect the health of women

Sociocultural Etiology on Physical Disorders

• factors associated with gender, race, or ethnicity can have a major impact on health

• women:

  • have an increased likelihood of exposure to stressors associated with their role as caregivers for children, partners, and parents

  • more likely to live in poverty and experience the sociocultural stressors and chronic disparities associated with having limited economic resources

  • more likely to report physical or emotional reactions to stress, not getting enough sleep, and using food as a way of dealing with stress

  • married - have a greater frequency of suffering from headaches or experiencing emotions such as fatigue, irritability, anger, or feeling as if they are on the verge of tears

• stressful experiences associated with race and ethnicity affect the health of people who are socially oppressed

  • exposure to discrimination has been found to heighten stress responses and elevate blood pressure and heart rate among African Americans—conditions that increase risk for chronic hypertension and CVD

    • higher risk of sudden cardiac deaths compared to European Americans

    • incidence of sudden cardiac arrest

    • come from severely disadvantaged backgrounds, but who excel in school, succeed at work, and achieve upward mobility experience an unusual degree of adverse health consequences was up to 80 percent greater in low socioeconomic neighborhoods compared to the neighborhoods with the highest income level

Treatment of Psychophysiological Disorders

• Relaxation Treatment

  • therapeutic technique in which a person acquires the ability to relax the muscles of the body under almost any circumstance

    • tightening and relaxing cycle

  • the contrast between the feelings produced during tensing and those produced during relaxing

  • effective in reducing physiological arousal and mitigating the physiological impact of stressors

  • experience decreases in stress hormones and autonomic reactivity, and report less pain, less anxiety, improved sleep, and a higher quality of life

• Biofeedback Training

  • self-regulation technique that allows people to alter physiological processes in order to improve physical or mental health

  • therapist teaches you to voluntarily control a physiological function, such as heart rate or blood pressure

  • continue the improvement in physiological responses outside of the training setting

  • visual and auditory feedback reinforces relaxation responses

  • help people lower their heart rates and decrease their blood pressure during stressful situations, treat migraine and tension headaches, and reduce stress-induced airway constriction

• Cognitive-Behavioral Therapy

  • designed to enhance coping skills and stress management can improve physiological functioning and psychological distress in individuals with chronic illness

  • proven effective in controlling asthma symptoms, reducing anxiety levels, and enhancing the quality of life for those living with illness

  • Mindfulness strategies have proven effective in improving emotional regulation and reducing symptoms of stress

    • nonjudgmental awareness of sensations and feelings

    • producing significant decreases in stress, anxiety, depression, and physiological markers associated with stress

  • acceptance and commitment therapy

    • helping clients accept life difficulties and commit to behaviors that are consistent with their personal values

Chapter 8 - Depressive & Bipolar Disorders (pg 280-316)

• mood - refers to our emotional state or our prevailing frame of mind

• mood can significantly affect our perceptions of the world, sense of well-being, and interactions with others

Symptoms Associated with Depressive and Bipolar Disorders

• the mood symptoms in depressive and bipolar disorders:

  • affect the person’s well-being and school, work, or social functioning

  • continue for days, weeks, or months

  • often occur for no apparent reason

  • involve extreme reactions that cannot be easily explained by what is happening in the person’s life

• depressive disorders involve only one troubling mood (depression), those with bipolar disorders (previously called manic-depression) often cope with two mood extremes—overwhelming depression and periods involving an elevated or abnormally energized mood

• Bipolar refers to the fact that the condition involves mood extremes at both emotional “poles'“

• Depression

  • sadness, emptiness & worthlessness, apathy, hopelessness

  • pessimism, guilt, difficulty concentrating, negative thinking, suicidal thoughts

  • social withdrawal, crying, low energy, lowered productivity, agitation, poor hygiene

  • appetite and weight changes, sleep disturbance, aches and pain, loss of sex drive

• Hypomania/Mania

  • elevated mood, extreme confidence, grandiosity, irritability, hostility

  • disorientation, racing thoughts, decreased focus, and attention, creativity, poor judgment

  • overactivity, rapid or incoherent speech, impulsivity, risk-taking behaviors

  • high levels of arousal, decreased sleep, increased sex drive

Depression

• involves intense sadness or loss of interest in normally enjoyed activities

• emotional symptoms

  • sadness, emptiness, hopelessness, worthlessness, or low self-esteem

  • little enthusiasm for things they once enjoyed, including spending time with family and friends

  • feeling irritable or anxious and worried is also common

• cognitive symptoms

  • pessimistic, self-critical beliefs

  • rumination - continually thinking about upsetting topics or repeatedly reviewing distressing events

    • intensify feelings of depression, especially when it involves self-criticism, feelings of guilt, irrational beliefs

  • distractibility

  • interfere with ability to concentrate, remember things, or make decisions

  • thoughts of suicide

    • may be from feelings of being a burden to friends and family or belief that there is little hope for the future

    • belief that emotional pain will never end can lead to thoughts of suicide

• behavioral symptoms

  • fatigue, social withdrawal, and reduced motivation are common with depression

  • some speak slowly or quietly, may respond only in short phrases or not respond at all

  • some appear agitated and restless, pacing, finding it difficult to sit still

  • may cry for no particular reason or in reaction to sadness, frustration, or anger

  • may appear to no longer care about their grooming or personal cleanliness - occurs because daily activities such as getting out of bed, bathing, dressing, or preparing for work or class may feel overwhelming

• physiological symptoms

  • appetite and weight changes

    • increased or decreased eating

  • sleep disturbance

    • difficulty falling asleep or staying asleep

    • sleep much more than usual, but wake up feeling tired and unrefreshed

  • unexplained aches and pain

    • headaches, stomachaches, other body aches

  • aversion to sexual activity

    • reduced sexual interest and arousal

Hypomania or Mania

• elevated mood

  • hypomania - characterized by increased levels of activity or energy combined with a self-important, expansive mood or an irritable, agitated mood

    • distractible, change topics frequently, have many ideas, talk excessively, dominate conversations

    • may feel creative and start various projects

  • mania - even more pronounced mood change involving extremely exaggerated activity levels and emotionality that significantly impair normal functioning

    • range from extreme giddiness, excitement, euphoria (exceptionally elevated mood) to intense irritability, hostility, agitation

    • marked impairment in social or occupational functioning

    • may involve psychosis (loss of contact with reality) and need for psychiatric hospitalization

    • manic episode - obvious to others, hypomania - more subtle

• emotional symptoms of hypomania/mania

  • unusually high spirits, full of energy & enthusiasm

  • uncharacteristically irritable, low tolerance for frustration, overreact with anger or hostility in response to environmental stimuli or people around them

  • emotional lability - unstable and rapidly changing emotions and mood

  • inappropriate use of humor, poor judgment in expressing feelings or opinions

  • grandiosity - inflated self-esteem and beliefs of being special, chosen, or superior to others

• cognitive symptoms of hypomania/mania

  • energized, goal-oriented behavior

  • seem excited and talk more than usual, engage in one-sided conversations, demonstrate little concern about giving others opportunity to speak

  • difficulty focusing their attention, show a flight of ideas/racing thoughts, distractibility, poor judgement

  • fail to recognize the inappropriateness of their behavior

  • mania - more likely to appear disoriented and exhibit cognitive difficulties

    • pressured speech - rapid, loud, difficult to understand

    • flight of ideas - change topics, become distracted with new thoughts, make irrelevant or illogical comments

• behavioral symptoms

  • appear energetic, productive, display mood of extreme confidence and self-importance, taking on complex or creative tasks

  • might also become easily agitated and react angrily with little provocation

  • seem uninhibited and act impulsively

  • engage in uncharacteristic behaviors like reckless driving, excessive drinking, illegal drug use, promiscuous behavior, uncontrolled spending, making impulsive decisions such as changing jobs or developing plans to move to a new location

  • difficulty with delayed gratification

  • motor movement rapid, incoherent speech

  • wild excitement, ranting, constant movement, agitation

  • psychotic symptoms - paranoia, hallucinations, delusions (false beliefs)

• Physiological Symptoms of Hypomania/Mania

  • high levels of physiological arousal

  • intense activity, extreme recklessness, need to be constantly on the go

  • increased libido (sex drive) - reckless sexual activity or other impulsive behaviors

  • decreased need for sleep - a person may go for days without sleep

Evaluating Mood Symptoms

• careful assessment because…

• brief depressive or hypomanic symptoms also occur in people who don’t have a mood disorder

• depression occurs in both depressive and bipolar disorders

• symptoms may vary considerable from person to person

• people often fail to report hypomanic symptoms to their medical or mental health providers because energetic episodes often do not cause significant problems or impair functioning

• people experiencing a depressive or hypomanic/manic episode sometimes exhibit symptoms from the opposite pole

• When extreme mood changes the clinician specifies that the mood episode has mixed features

• take note of: frequency, duration, seasonal changes, are they mild/moderate/severe symptoms, medical conditions, drug use

Depressive Disorders

Major Depressive Disorder

• diagnosis occurs when a person experiences impaired functioning due to a major depressive episode - severe depressive symptoms that have negatively affected functioning most of the day, nearly every day, for at least 2 full weeks

• DSM-5 → major depressive episode involves

  • depressed mood, feelings of sadness or emptiness and/or…

  • loss of interest or pleasure in previously enjoyed activities

  • four additional changes in functioning

    • significant alteration in weight or appetite

    • atypical sleep patterns

    • restlessness or sluggishness, low energy, feelings of guilt or worthless ness, difficulty concentrating making decisions

    • preoccupation with death or suicide

• anxious distress

  • feel unusally tense or restless or experience pervasive worries that make it difficult to concentrate

  • worry about losing self-control or something bad will happen

• suicide

  • people who feel hopeless may act on suicidal thoughts

  • up to 45% of those with MDD also have a substance use disorder - further increases suicide risk

• MDD with a seasonal pattern

  • some begin to develop depression when daylight decreases as the seasons change

    • depressive symptoms begin in the fall or winter and remit during the spring or summer

    • small number of people have the opposite pattern

  • vegetative depressive symptoms

    • low energy, social withdrawal, increased need for sleep, carbohydrate craving

  • winter depressive episodes occur most frequently

    • among younger individuals

    • in regions with less light in the winter months (northern latitudes)

    • among those whoa re sensitive to the influence of environmental light on their circadian rhythm

  • many clinicians use seasonal affective disorder (SAD) for this seasonal pattern

    • affect up to 3% of world’s population

    • more prevalent in women than men

    • not an official DSM-5 diagnostic category

      • MDD with a seasonal pattern instead - at least two seasonal episodes of severe depression ending at a predictable time of year combined with a pattern of depressive episodes that occur seasonally more than nonseasonally

Persistent Depressive Disorder

• chronic depressive symptoms that are present most of the day for more days than not during a 2 year period (w no more than 2 months symptom-free)

• ongoing presence of at least 2 of the following symptoms

  • feelings of hopelessness

  • low self-esteem

  • poor appetite or overeating

  • low energy or fatigue

  • difficulty concentrating or making decisions

  • sleeping too little or too much

  • negative thinking patterns, pessimistic outlook on future

  • for many - lifelong, pervasive → long periods of depression, few periods without symptoms, poor response to treatment

Premenstrual Dysphoric Disorder

• controversial

• serious symptoms of depression, irratibility, tension that appear the week before menstruation and disappear soon after menstruation beings

• between 3 and 8% of women meet the criteria for PMDD

• presence of five premenstrual symptoms

  • at least one - significantly depressed mood, mood swings, anger, anxiety, tenssion, irritability, or increased interpersonal conflict

  • others - difficulty concentrating, social withdrawal, lack of energy, food cravings or overeating, insomnia or excessive sleepiness, feeling overwhelmed

  • physical symptoms - bloating, weight gain, breast tenderness

• similar to premenstrual syndrome but produces much greater distress and interferes with social, interpersonal, academic, or occupational function

Depressive Reactions to Grief

• important to distinguish normal grief-related reactions from the severe depression and impaired functioning associated with MDD

  • Grief often involves feelings of emptiness associated with the loss rather than the more persistent depressed mood or inability to experience pleasure that occurs with MDD

• persistent complex bereavement disorder

  • apply to individuals who have intense and persistent preoccupation or debilitating sorrow that continues for over a year after the death of a loved one

  • experience continued longing for the deceased, preoccupation with the way the person died, distress or anger over the death, or difficulty accepting the death

  • diagnosis would require that the death have a significant effect on the person’s interpersonal relationships or sense of identity

Prevalence of Depressive Disorders-

• one of the most common psychiatric disorders and the second leading disability worldwide

• 264 million people each year

• 21% of US population will experience a mejor depressive episode at some point in their lives

• women have nearly twice the risk

  • 2-5% of women experience PMDD

• symptoms also subject to external stressors

• for many, chronic disorder and chances of relapse

  • Childhood maltreatment, rumination, and residual depressive symptoms after treatment increase the risk of recurrent depressive episodes

Biological Etiology of Depressive Disorders

• neurotransmitters and depressive disorders

  • low levels of certain neurotransmitters (serotonin, norepinephrine, and dopamine) are associated with depression

  • neurotransmitters regulate our emotions and basic physiological processes involving appetite, sleep, energy, and libido; however, biochemical irregularities can produce the physiological symptoms

  • accidentally discovered that when the drug reserpine was used to treat hypertension, many patients became depressed (reserpine depletes certain neurotransmitters)

  • the drug isoniazid, given to patients with tuberculosis, induced biochemical changes that resulted in mood elevation

  • therapies involving electrical stimulation of brain regions that have high concentrations of brain cells that release dopamine have implicated dopamine deficiencies in depression

  • treatment-resistant depression - does not respond to antidepressant medications

• the role of heredity

  • depression tends to run in families

  • genetics estimated to contribute about half of the variance

  • incidence is significantly higher among biological relatives compared to adoptive family members, although the child-rearing environment exerts an equal influence on the development of major depression in children

  • the chances of inheriting depression are greatest for female twins, suggesting gender differences

  • genetic influence on depression becomes most evident after puberty

• cortisol, stress, depression

  • dysregulation and overactivity of the hypothalamic-pituitary-adrenal (HPA) axis and overproduction of the stress-related hormone, cortisol, appear to play an important role in the development of depression

  • exposure to stress during early development and the resultant increases in cortisol production can increase susceptibility to depression in later life

  • genetic predisposition, stress, and the timing of stress can interact to increase cortisol production and produce depressive symptoms

  • chronic stress and associated high levels of cortisol can damage the hippocampus & interfere with systems involved in our stress response

  • overactive stress response system and excessive cortisol production → depleting certain neurotransmitters (serotonin), affect production of enzymes

• functional & anatomical brain changes with depression

  • decreased brain activity and other brain changes in people with depression

  • brain alterations have been found in the medial prefrontal cortex, anterior cingulate cortex, and hippocampus → areas associated with negative thoughts and memories, rumination, impairment in executive functioning

  • ongoing depression is associated with reduced neuroplasticity

    • decreased neurogenesis in the hippocampus and in synapses around cortex

  • individuals experiencing depression have increased connectivity in the default mode network, regions that are associated with a wakeful resting state

  • individuals with depression show different patterns of neural reactivity compared to controls - the pattern of neural activation depends on whether the emotional stimuli are positive or are negative

• circadian rhythm disturbances in depression

  • internal biological rhythms, maintained by the hormone melatonin, that influence a number of our bodily processes, including body temperature and sleeping patterns

  • insomnia (difficulty falling or staying asleep) increases the risk of developing depression and is related to the severity of depressive symptoms

  • a study involving twin pairs, excessively short or long sleep duration appeared to activate genes related to depression

  • Disrupted sleep is also linked to the onset of postpartum depression

  • people with depression have irregularities in rapid eye movement (REM) sleep, the stage of sleep during which dreaming occurs

Psychological Etiology of Depressive Disorders

• behavioral explanations

  • depression occurs when people receive insufficient social reinforcement - unemployment, divorce, death of a friend or family member

  • behaviorists believe that those affected by depression can reduce their depressive symptoms if they become more physically and socially active

  • risk of depression is increased when:

    • a person has limited opportunities to engage in activities that are potentially reinforcing

    • there are few reinforcements available in the person’s environment

    • a person’s behavior reduced the likelihood of positive social interactions

  • stressful circumstances - disrupt predictable patterns of social reinforcement and initiating a cycle that further reduces social opportunities and increases vulnerability to depression

  • positive attributes can also increase the risk of depression - people who are prosocial are more likely to develop symptoms than those who are individualist

    • increased stress & activation of amygdala in situations associated with unfairness and inequality

• cognitive explanations

  • disturbance in thinking rather than a disturbance in mood

  • our internal responses to what is happening around us and the way we interpret our experiences affects our emotions

    • pessimism

    • damaging self-views

    • feelings of helplessness

  • Aaron Beck - individuals experiencing depression have a negative self-schema or way of looking at self

    

  • rumination - continually thinking about an upsetting situation keeps the distressing emotions “alive” rather than allowing them to diminish

  • co-rumination - process of constantly talking over problems or negative events with others, also increases risk for depressions

• learned helplessness and attributional style

  • attributional style - how we explain events that occur in our lives; can have powerful effects on our mood

  • pessimistic attributional style - focus on causes that are internal, stable, and global

  • those with a positive attributional style focus on explanations that are external, unstable, and specific

  • learned helplessness - a belief that we have little influence over what happens to us

• factors associated with negative thinking patterns

  • patterns of pessimistic thinking often interact with biological and social factors

  • maltreatment occurring during childhood is associated with increased risk of depression - emotional abuse, neglect

  • self-criticism is strongly associated with depression

Social Etiology of Depressive Disorders

• maltreatment during early childhood is strongly associated with later depression

• ACEs - appear to modify the expression of genes associated with the HPA axis, increase reactivity to stress and affect the function and structure of cortical and subcortical areas of the brain

• parental depression

• individuals who fail to develop secure attachments and trusting relationships with caregivers early in life have increased vulnerability to depression

• stressful events later in life can also increase the risk of depression

• acute stress is much more likely to cause a first depressive episode than is chronic stress but once someone has experienced a serious depression, less severe stressors can subsequently trigger additional depressive episodes

• stress generation or engaging in behaviors that lead to stressful events plays an important role in depression

• distressing social interactions increase likelihood of depression - especially those who have genetic vulnerability, prior life stressors, or previous depressive episodes

Sociocultural Etiology of Depressive Disorders

• culture, race and ethnicity, sexual orientation, and gender

• people who are struggling financially have high rates of depression

• lack of security and self-sufficiency associated with poverty often find it difficult, or even impossible, to access the education, employment, or housing that would allow them to envision a more hopeful future

• racial & ethnic influences on depression

  • influence a variety of factors associated with depression: descriptions of depressive symptoms, decisions about treatment, client–therapist interactions, and the likelihood of outcomes such as suicide

  • perceived discrimination based on race or ethnicity is strongly associated

• influences of sexual and gender orientation of depression

  • prejudice & discrimination related to LGBTQ orientation

  • lack of family acceptance, bullying, and societal rejection exert a significant effect on risk of depression

  • how and when to disclose their sexual or transgender orientation to family and friends

  • negative reactions that sometimes occur during the disclosure process can further increase risk of depression

• gender and depressive disorders

  • nearly twice as common among women than among men

  • higher prevalence of depression in women is due to sociological variables such as poverty, violence, restrictive gender roles, and discrimination or if women are simply more likely to seek treatment or to discuss depression

  • traditional symptoms of depression (such as sadness and hopelessness) are more likely to be displayed by women, whereas men who are depressed are more likely to display symptoms such as anger, aggression, burying themselves in their work, or substance abuse

  • Gender differences in depression begin appearing during adolescence and are greatest during the reproductive years

  • Life stressors may interact with physiological factors to influence the development of depression - alterations in connectivity in the fear circuitry of the brain, reduced connectivity between amygdala and hippocampus

  • social modeling and socialization practices can influence feelings of self-worth

Biomedical Treatment for Depression

• medication

  • antidepressants - increase availability of certain neurotransmitters

    • tricyclics

    • monoamine oxidase inhibitors (MAOIs)

    • serotonin-norepinephrine reuptake inhibitors (SNRIs)

    • selective serotonin reuptake inhibitors (SSRIs)

  • atypical antidepressants - affect other neurotransmitters like dopamine

• medical providers consider multiple factors:

  • the presence of other symptoms (such as anxiety, overeating, or nicotine addiction) that might also be helped by certain antidepressants

  • the person’s prior response to antidepressants (or family patterns of response)

  • desire to avoid certain side effects such as weight gain, sexual side effects, or gastrointestinal problems

• estimated 1/3 - ½ of those taking antidepressants discontinue their use of the medication due to side effects often without informing prescriber

  • associated with withdrawal symptoms - dizziness, drowsiness, impaired balance, headache, insomnia, confusion, irritability

• adjunctive treatments - adding something different to initial treatments

  • commonly used to supplement antidepressant use

  • Omega-3 fatty acid supplements have been found to reduce depressive symptoms and are often used in combination with antidepressant medications

  • Intravenous administration of the anesthetic ketamine has shown some promising results for treatment-resistant depression

• nontraditional treatments for depression

  • efforts to reset the circadian clock

    • a night of total sleep deprivation followed by a night of sleep recovery has improved depressive symptoms in some individuals with MDD

  • use of specially designed lights is an effective and well-tolerated treatment for those with a seasonal pattern of depression

  • probiotics

• brain stimulation therapies

  • electroconvulsive therapy - involves applying moderate electrical voltage to a person’s brain to produce a very brief seizure

    • typically treated several times weekly under anesthesia

  • vagus nerve stimulation - implanting a pacemaker-like device in the chest that then delivers a frequent electronic impulse that travels from the vagus nerve to the brain

  • transcranial magnetic stimulation - noninvasive treatment, which uses magnetic pulses to stimulate specific areas of the brain

    • 5 days per week over a period of 4 to 6 weeks

Psychological & Behavioral Treatments for Depressive Disorders

• behavioral activation therapy

  • helping those who are depressed to increase their participation in enjoyable activities and social interactions → improvements in mood

    • individuals with depression often lack the motivation to participate in social activities

    • based on the idea that depression results from diminished reinforcement

  • treatment focuses on increasing exposure to pleasurable events and activities, improving social skills, and facilitating social interactions

    • identifying and rating different activities in terms of the pleasure or the feelings of self-confidence they might produce

    • performing some of the selected activities, thereby increasing feelings of pleasure or mastery

    • identifying day-to-day problems and developing strategies to deal with them

    • improving social and assertiveness skills

• interpersonal psychotherapy

  • focused on current interpersonal problems

  • approach presumes that depression occurs within an interpersonal context, therapy focuses on relationship issues

  • Clients learn to evaluate their role in interpersonal conflict and make positive changes in their relationships

    • improving communication

    • identifying role conflicts

    • increasing social skills

• cognitive-behavioral therapy

  • altering the negative thought patterns and distorted thinking associated with depression

  • teach clients to identify thoughts that precede upsetting emotions, distance themselves from these thoughts, and examine the accuracy of their beliefs

  • less likely to relapse after treatment has stopped compared to individuals taking antidepressants

  • Cognitive bias modification—a guided self-help intervention aimed at minimizing rumination and overgeneralization and enhancing specific problem-solving skills

• mindfulness-based cognitive therapy

  • calm awareness of one’s present experience, thoughts, and feelings, and promotes an attitude of acceptance rather than judgment, evaluation, or rumination

  • allows those affected by depression to disrupt the cycle of negative thinking by directing attention to the present moment

  • prevents the development of maladaptive beliefs and thus reduces depressive thinking

Bipolar Disorders - Page 307