Abnormal Affect

Meaning of Affect

Affect is the psychological description of mood

Often, affect refers to the behavioral expression of mood

E.g. someone’s mood may be sad or depressed, but their affectmight be smiling, or laughing

Similarly, someone’s mood might be sad or depressed, and theiraffect might be crying, or frowning

Abnormal Affect refers to Mood Disorders such as Major DepressiveDisorder (Unipolar Depression), and Bipolar Disorder (Manic-Depressive Disorder)

Remember, as always, mental health is on a spectrum, so we all getsad/hyper/crazy/weepy. It’s the degree and frequency with which weexperience these emotions, that determine whether our affect isnormal/abnormal

How common is Unipolar

Depression?5-10% of adults in the U.S. suffer severe unipolar depression while 3-5% suffer from mild depression

17% of adults in the world may experience of server unipolar depression at some point in their lives

Average onset is late teens to early adulthood

Women are twice as likely to experience episodes of depression than men

These rates hold steady for socio-economic classes and ethnic groups

About 2/3rd people recover from depression within 4-6 months, some without treatment

Depression: Endogenous vs.

ReactiveEndogenous or reactive depression: this is a second way ofdistinguishing between depressions that relates more tocauses rather than symptoms.

Endogenous depression (as the name suggests) comes fromwithin and is thought to be caused by chemical imbalance andis explained and treated best by the medical model.

Reactive depression on the other hand is caused by externalfactors such as loss of job, death of relative etc. and is usuallyexplained using psychological approaches such as behavioristor cognitive models.

Depression is also a major factor in a number of other relateddisorders such as Seasonal Affective Disorder (SAD),Premenstrual syndrome (PMS) and Postpartum depression(PPD). The latter was formerly known as post nataldepression.

Symptoms of Depression

Emotional Symptoms – feeling of sadness and

dejection. They describe themselves as ‘miserable’ and

‘empty.’ They report getting little pleasures from anything

and tend to lose their sense of humour.

Motivational Symptoms – loss of desire to pursue

usual activities. Lack of drive, initiative, spontaneity.

Individuals have to force themselves to go to work,

socialize and do normal day to day activities. It is also

called a “paralysis of will.”

Behavioural Symptoms – Less active and less

productive. Spend more time alone or in bed for long

periods of time. Some move or speak slowly with lack of

energy.

Symptoms of Depression

Cognitive Symptoms – hold negative views of

themselves, their lives and the future. They find

themselves undesirable, inferior and blame themselves

for any negative event that occurs. They are also very

pessimistic. They also complain that their intellectual

functioning is poor and that they are able to remember

less, feel confused and are unable to solve problems.

Physical Symptoms – suffer from physical ailments like

headaches, indigestion, constipation, dizzy spells and

general pain. In a number of cases, depression is

misdiagnosed as a medical ailment. Depressed

individuals sleep and eat less and feel more fatigued.

Diagnosing Depression

Major Depressive DisorderThe presence of at least five of the following symptoms during the same two-week period

Depressed mood most the day, nearly every day

Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day

Significant weight loss or gain, or decrease or increase in appetite nearly every day

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive guilt nearly every day

Reduced ability to think or concentrate, indecisiveness, nearly every day

Recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for committing suicide

Significant distress or impairment

Unipolar Depression -

CausesBiological

Genetic Factors – family pedigree, twin and adoption studies suggest that people inherit a predisposition to unipolar depression.

Harrington et al (1993) conducted research on individuals with unipolar depression and found that 20% of relatives were depressed compared with fewer than 10% in normal population.

McGuffin et al (1996) conducted twin studies. They found that when a monozygotic twin had unipolar depression, there was a 46% chance that the other twin had the same disorder. In contrast, when a dizogytic twin had unipolar depression, the other twin had only a 20% chance of developing the disorder

Wender et al (1986) looked at adoption studies. The study looked at families of adopted persons who had been hospitalized with the disorder in Denmark. The biological parents of these adoptees turned out to have a higher incidence of severe depression (but not mild) than biological parents of a non-controlled group of non-depressed adoptees.

Biochemical Factors

Low activity in two neurotransmitter chemicals –Norepinepherine and serotonin.

Medical researchers found that some medications for high blood pressure caused depression. What they discovered was that some of the medications lowered norepinepherine while other lowered serotonin.

Another evidence was the discovery of the first effective antidepressant drugs. Researchers found that these drugs increased norepinepherine and serotonin activity.

For years it was thought that depression was caused due to a low activity in either of these neurotransmitters. Now researchers think that it could be a combination of imbalance with not just these two but other neurotransmitters as well (Rampello, Nicolleti & Nicolleti, 2000).

Other researchers believe that serotonin helps regulate the other neurotransmitters and with low serotonin activity, the activity of other neurotransmitters gets effected, leading to


Causes

Biochemical Factors

Researchers have learned that the body’s endocrine system may have a role to play in unipolar depression. The endocrine glands release hormones throughout the body that spur the body’s organs into action. People with unipolar depression have been found to have abnormal levels of cortisol, the hormone released by the adrenal glands at the time of stress (Hedaya, 1996).

Another hormone that has been tied to depression is melatonin which is released only in the dark.

Pre-menstrual syndrome (PMS) - Abramowitz et al (1982) reported that41% of women admitted to a psychiatric hospital were admitted eitheron the first day of their monthly cycle or the day before.

Post-partem depression (PPD) - 20% of women report feelings ofdepression after the birth of a child. Normally this occurs within a fewdays but typically only lasts for about a week or so.*

Seasonal affective disorder (SAD) - The most common form of SAD isexperienced in the winter and is associated with falling light levels. Inthe summer, light levels suppress melatonin production and darknessstimulates its production which is a factor in the onset of sleep. It isthought that lack of natural light in the winter months desynchronisesour daily fluctuations of melatonin which in turn will affect serotoninproduction.


Causes

Psychodynamic

As always Freud was the first to offer possible explanations of depressionand was also the first to notice the similarity in feelings reported by patientssuffering from depression and those who had recently sufferedbereavement.

According to Freud:

1. Loss could be ‘actual,’ as in the case of death of a close friend orrelative, or it could be ‘symbolic’, as in the case of a lost job etc. Eitherway loss in adulthood causes us to relive childhood experiences of lossexplaining the clingy behaviour of some types of bereavement. Inextreme cases regression to childhood may occur, particularly if thechild had suffered bereavement during their own childhood.

2. Hostility and aggression are also involved. Death causes feelings ofanger at our loss and this has to be displaced inwards towardsourselves since outward expression of anger at such a sensitive timewould not be acceptable to the superego. Anger directed towardsourselves causes the feelings of guilt and despair associated with manyforms of depression.

3. Freud also assumed that in most cases we would have had falling outwith the deceased which would also cause guilt on their death.


Causes

Behavioural

Behaviourists believe that unipolar depression results from major shifts in the rewards and punishments people receive in their lives.

Peter Lewinsohn (1990) developed one of the leading behaviourialexplanations. He suggested that positive rewards diminish for some people, leading them to perform fewer and fewer constructive behaviours. Examples of these could be a mother feeling depressed when all children go away to college “empty nest syndrome.” Or an individual retiring. Or a person graduating from college. Or a person who has undergone a major medical illness.

While some individuals manage to put these changes in perspective and fill their lives with other positive rewards, others find it difficult to do so and become disheartened.

This results in a decline in their lives, giving them fewer and fewer rewards leading them to perform less constructive behaviours. Resulting in a spiral towards depression.


Causes

Cognitive

Cognitive theorists believe that people with unipolar depression persistently interpret events in negative ways and that such perspectives lead to their disorder.

Aaron Beck (1997) believes that negative thinking, rather than underlying conflicts or a reduction in positive rewards, lies at the heart of depression.

According to Beck,

Maladaptive attitudes – these are usually formed from a person’s own experiences, family relationships or judgments of people around them. They become schemas, or principles that are then used to evaluate situations.

Cognitive triad – individuals repeatedly interpret their experiences, themselves and their future in negative ways.

Errors in thinking – depressed people make negative conclusions based on little evidence. They minimize their positive experiences or magnifynegative ones. They also focus on one negative detail instead of looking at the larger context (arbitrary inference) or overgeneralize on a broad context based on an insignificant event.

Automatic thoughts – depressed people experience a steady flow of unpleasant thoughts that keep suggesting to them that they are inadequate and their situation is hopeless.

Unipolar Depression - Causes


CausesCognitive

According to Martin Seligman (1975, 1992) feelings of helplessness are the center of depression. His theory learned helplessness states that people become depressed when they no longer have control over their reinforcements in lives and that they themselves are responsible for this helpless state.

Seligman & Maier (1967) carried out their classic study in which dogswere given electric shocks to the feet.

In the control condition the dogs could jump a small barrier andescape the shocks, but in the experimental condition the barrier washigher and the foot shocks were therefore inescapable.

In the follow up trial dogs that could not escape in the first part of thestudy made no attempt to escape the shocks even when they weregiven the opportunity.

Past experience had taught them that they had no control overoutcomes, in effect they had learned to be helpless!


CausesCognitive

Seligman noticed the similarity between learned helplessness

and some of the symptoms of human depression in which

patients become passive and accepting of their situation and

make little or no attempt to resolve their problems.

This similarity was reinforced by findings that showed a

reduction in serotonin and noradrenalin levels in rats that had

become helpless in this way.

Would humans placed in a similar situation behave in a similar

way? Hiroto (1974) got participants to endure inescapable loud

noise. In a follow up trial when they were provided with a

handle that would turn the sound off they sat back and

endured it.


CausesCognitive

Abramson et al’s theory (1978) can be seen as a logical extension of learned helplessnesstheory. They combined the theory with attribution theory. Basically any kind of experience wehave in life we try and account for using attributions. However, according to this theory, thedepressed patient faced with an experience of failure, attributes the failure in a particular wayaccording to three variables.

1. Internal or external?

Internal: The person blames themselves. In the case of exams, I failed to put in the necessarywork or I wasn’t up to the task.

External: The person blames others or look for external excuse. We had a crap teacher or therewas too much noise in the exam hall.

2. Stable or unstable?

Stable: The idea that things will always be this bad and won’t get better in future. I just can’t doexams!

Unstable: Things will improve. Next time I’ll be prepared and will succeed

3. Global or specific?

Global: The failure will apply in all other situations. There’s no point in sitting other examsbecause I’m no good at them.

Specific: The failure applies only to this examination. Math and psychology will be fine.

Sociocultural ViewWhy women?

Artifact theory – clinicians fail to detect depression in men. Depressed men may mask their depression behind traditionally “masculine” symptoms such as anger. Women have more emotional symptoms.

Hormone theory – from teen age to middle age, women go through several hormonal changes. Besides hormones, important social and life events occur like puberty, pregnancy and menopause.

The quality of life theory – women face more poverty, more menial jobs, less adequate housing and more discrimination than men. They bear a disproportionate share of responsibility for child care and housework.

Societal pressure theory – taught to aspire to a low body weight and slender body shape. Peer pressure, self-focus. Appear first in adolescence. Eating disorders.

Lack of control theory – feel less in control of their lives. Women are more likely to develop learned helplessness in the laboratory than men. More prone to sexual attack, abuse.

Self-blame theory – blame their failures on lack of ability and their successes to luck.

Sociocultural ViewCulture and Depression

Depressed people in non-Western countries show more physical symptoms like fatigue, sleep disturbances, weight loss. While in Western countries, it is more psychological symptoms.

Gender and Race

Much higher among women than men

Women appear to be younger when depression strikes

They have longer and more frequent bouts

Respond less successfully to treatment

Social Support

People who are separated or divorced display three times the depression rate

People who don’t marry have double the rate

Interpersonal conflicts at home and lack of mutual support. Nagging, critical home environment and emotional outbursts

Isolated lives without intimacy


TreatmentsMedical

Antidepressants affect the levels of brain chemicals, such

as serotonin and norepinephrine. There are dozens of

options. Antidepressants take a few weeks of use to take

effect.

Good follow-up with your doctor is important to evaluate

their effectiveness and make dosage adjustments. If the first

medication tried doesn't help, there's a good chance

another will. The combination of talk therapy and medication

appears particularly effective.

2 particularly effective classes of drugs, are SSRIs –

selective serotonin reuptake inhibitors, and MAOIs -

Monoamine Oxidase Inhibitors.


TreatmentsHow SSRIs work:

The antidepressant action of SSRIs is not thoroughly

understood but is possibly due to the ability of SSRIs to

block the uptake of serotonin, thereby providing higher

levels of serotonin at the brain receptor site.

How MAOIs work:

Neurotransmitters in the brain e.g. serotonin and

dopamine are all known as monoamines. In the gap

between nerve cells, used neurotransmitters are destroyed

by an enzyme called monoamine oxidase (MAO). If this

results in too low concentrations of neurotransmitters,

depression can result. MAOIs work by blocking the activity

of this enzyme, resulting in higher levels of

neurotransmitters in the brain, relieving depression.


TreatmentsMedical

Electroconvulsive Therapy (ECT):

Another option for patients with treatment-resistant or

severe melancholic depression is electroconvulsive

therapy (ECT.)

This treatment uses electric charges to create a

controlled seizure. (Patients are not conscious for the

procedure.) ECT helps 80% to 90% of patients who

receive it, giving new hope to those who don't improve

with medication.

Psychodynamic

Psychodynamic therapists seek to help clients bring underlying issues to consciousness and work them through. They encourage depressed clients to associate freely during therapy, suggest interpretations of the clients’ associations, dreams and help the person reexperience and review past events and feelings.

Behavioural

Peter Lewinsohn also developed a behavioural treatment for unipolar depression in the 1970s. In this approach therapists reintroduce clients to pleasurable events and activities, appropriately reinforce nondepressivebehaviour and help them improve their social skills.


Treatments

Cognitive – Cognitive Behavioural Therapy (CBT)

Beck’s cognitive therapy is the leading cognitive treatment for unipolar depression. It is designed to help clients recognize and change their negative cognitive processes and thus to improve both their mood and their behaviour. Beck’s approach follows 4 phases and usually requires fewer than 20 sessions.

Phase I – using behavioural techniques, therapists first encourage clients to become more active. This can be done by making an Activity schedule.

Phase II – therapists now start educating clients about their negative thoughts and beliefs. Individuals record and recognize automatic thoughts and bring lists to each session.

Phase III – the therapist now start showing how illogical thinking processes are contributing to the above thoughts.

Phase IV – therapists help clients change the maladaptive attitudes


Treatments

Cognitive – Rational Emotive Behavioural Therapy (REBT)

• REBT was established by Albert Ellis in 1955.

• REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc. The idea that our beliefs upset us was first articulated by Epictetus around 2,000 years ago: "Men are disturbed not by events, but by the views which they take of them.”

Albert Ellis and REBT posit that our reaction to having our goals blocked (or even the possibility of having them blocked) is determined by our beliefs. To illustrate this, Dr. Ellis developed a simple ABC format to teach people how their beliefs cause their emotional and behavioral responses:

A. Something happens.B. You have a belief about the situation.C. You have an emotional reaction to the belief.

The ABC model shows that A does not cause C. It is B that causes C


Treatments

Cognitive – REBT

Although we all express ourselves differently, according to Albert Ellis and REBT, the beliefs that upset us are all variations of three common irrational beliefs. Each of the three common irrational beliefs contains a demand, either about ourselves, other people, or the world in general. These beliefs are known as "The Three Basic Musts."

I must do well and win the approval of others for my performances or else I am no good.

Other people must treat me considerately, fairly and kindly, and in exactly the way I want them to treat me. If they don't, they are no good and they deserve to be condemned and punished.

I must get what I want, when I want it; and I must not get what I don't want. It's terrible if I don't get what I want, and I can't stand it.

The first belief often leads to anxiety, depression, shame, and guilt. The second belief often leads to rage, passive-aggression and acts of violence. The third belief often leads to self-pity and procrastination. It is the demanding nature of the beliefs that causes the problem. Less demanding, more flexible beliefs lead to healthy emotions and helpful behaviors


Treatments

http://www.rebtnetwork.org/library/musts.html

Bipolar DisordersExperience both lows of depression and the highs of mania. Roller coaster ride.

Symptoms

Experience dramatic and inappropriate rises in mood

Span the same areas of emotional, motivational, behavioral, cognitive and physical

Not every person with mania is a picture of happiness and some become irritable and angry

Want constant excitement, involvement and companionship

Move quickly, talk rapidly and loudly, conversations filled with jokes, efforts to be clever. Dress flashy, some get involved in dangerous activities.

In extreme cases, some have trouble remaining coherent or in touch with reality

Bipolar DisordersFull manic episode when for at least one week they

display an abnormally high or irritable mood, along with

3 other symptoms of mania

Manic episode

A period of abnormally and persistently elevated,

expansive or irritable mood, lasting at least one week

3 of the following:

Inflated self-esteem or grandiosity/ decreased need of sleep/

more talkativeness than usual/ flight of ideas/ distractibility/

increase in activity/ excessive involvement in pleasurable

activities


Bipolar DisordersBipolar Disorder I

The presence of a manic, hypomanic or major depressive episode

If currently in a hypomanic or major depressive episode, history of a manic episode


Bipolar Disorder IIThe presence of a hypomanic or major depressive episode

If currently in a major depressive episode, history of a hypomanic episode and vice versa. No history of a manic episode.


If 4 or more episodes a year, the disorder is classified as rapid cycling

If episodes vary by season, it is classified as seasonal

Bipolar Disorders

1-1.5% adults suffer from bipolar disorder

Prevalence is equal in men and women although women

experience more depressive episodes and rapid cycling is

more common amongst women

Prevalence rates are similar across socio-economic

classes and ethnic groups

Onset of disorder is 15-44 years, usually beginning in late

adoelsence and early adulthood

Bipolar Disorders - CausesMedical

High norpinepherine activity

Low serotonin activity

At first this did not make sense to researchers. Hence, they proposed the permissive theory.

Low serotonin activity opens the door to a mood disorder and permits the activity of norepinepherine to define the particular form the disorder will take

Low serotonin activity with low norepinepherinedepression

Low serotonin activity with high norepinepherinemania

Bipolar Disorders - Causes

Ion Activity

On both sides of the cell membrane of each neuron sit positively charged sodium ions. These ions send incoming messages down the neuron to nerve endings.

Improper transport of these ions may cause neurons to fire too easily (mania) or to resist firing (depression)

Genetics

1% general rate in population. Fraternal twins 5-10%. Identical twins 40%.

A number of researchers have tried to pin point which particular chromosome is involved. However, there have been wide-ranging findings meaning that gene studies may be flawed and bipolar disorder may not be due to genetic factors.

Bipolar Disorder - CausesGenetic explanation (continued):

Identifying specific genes for depression:-

The first attempt was by Egeland et al (1987) who researched 81members of the Old Order Amish Community ofPennsylvania. Four families within the community showed a muchhigher than expected incidence of bipolar (manic) depression. Ofthe 81 studied 14 were diagnosed with bipolar disorder and allhad abnormalities on the tip of chromosome 11. This causedparticular interest at the time since this location is adjacent togenes known to be involved in the production of serotonin (seebiochemical section below).

However, other studies have failed to replicate the findingssuggesting that either this gene is not responsible or more likely;more than one gene is involved. Nemeroff (1998) has implicateda gene on the X chromosome.

A possible link between genetic and biochemicalinfluences…Ogilvie et al (1996) found that people with depression were farmore likely to have abnormalities on a gene known as SERT thatis used to make serotonin-transporter protein. New drugs used totreat depression are believed to act on serotonin-transporter

Bipolar Disorders -

TreatmentsMedical

Medications are key in helping people with bipolar disorderlive stable, productive lives.

Mood stabilizers can smooth out the cycle of ups and downs.Patients may also be prescribed antipsychotic drugs andanticonvulsant drugs.

Between acute states of mania or depression, patientstypically stay on maintenance medication to avoid a relapse.

A very common mood stabilizer is Lithium.

Electroconvulsive therapy can help some people with bipolar disorder. ECT uses an electric current to cause a seizure in the brain. It is one of the fastest ways to ease severe symptoms. ECT is usually a last resort when a patient does not improve with medication or psychotherapy.

Bipolar Disorders -

TreatmentsOther treatments

Talk therapy can help patients stay on medication and cope with their disorder'simpact on work and family life.

Cognitive behavioral therapy focuses on changing thoughts and behaviors thataccompany mood swings.

Interpersonal therapy aims to ease the strain bipolar disorder may place onpersonal relationships.

Social rhythm therapy helps patients develop and maintain daily routines.

Establishing firm routines can help manage bipolar disorder. Routines shouldinclude sufficient sleep, regular meals, and exercise.

Because alcohol and recreational drugs can worsen the symptoms, these shouldbe avoided.

Patients should also learn to identify their personal early warning signs of maniaand depression. This will allow them to get help before an episode spins out ofcontrol.

Abnormal Affect - Psychology

Education

Transcript of Abnormal Affect - Psychology