Abnormal Psych Psyc 3330 - 01
University of Louisiana at Lafayette
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This 16 page Class Notes was uploaded by Lauren Notetaker on Friday February 26, 2016. The Class Notes belongs to Psyc 3330 - 01 at Tulane University taught by Constance Patterson in Winter 2016. Since its upload, it has received 26 views. For similar materials see Abnormal Psychology in Psychlogy at Tulane University.
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Date Created: 02/26/16
Week 7 Abnormal Psych • Moods • Moods are enduring states of feeling that inﬂuence our psychological functioning • Theories About Causes of Depressed moods: ◦ Seligman’s Learned helplessness theory which can lead to depression, was his early work; then he asked what can we do do be happy ◦ First response to stress is anxiety with prolonged stress that cannot be resolved (no control), experience hopelessness; when it goes on and person can't make it go away, they accept that's the way it is ◦ Thoughts become increasingly negative toward self ◦ Attitudes become negative in general ◦ The person gives up ◦ NOTE: Studies of children do not support Seligman’s theory, although it may be useful for understanding some adults; doesn't provide a really good reason for why ppl become depressed • • Theories About the Causes of Depressed Moods: ◦ Beck’s Depressive Cognitive Triad: Self / Own Situation / Future ◦ After a series of negative events in childhood, a person can develop a deep seated negative schema (enduring cognitive belief system) that promotes negative thinking and negative interpretations • Distorted thinking makes the person overly invested in controlling things; negative thoughts become automatic • Feel overly responsible for everything (bad) that happens • Constant feedback to self about failure • Negative self-evaluation – believes can’t do anything right • Thoughts become automatic and pervasive • Become increasingly negative about the world in general • See the future as negative – “nothing good can happen” • Self fulﬁlling and self-perpetuating • More individualized than we give credit to, same diagnostic often have different patterns of symptoms • • Theories About the Causes of Depression: ◦ Cognitive Vulnerability for Depression: • Underlying biological susceptibility • Depression becomes associated with a pessimistic explanatory style and negative cognitions • Cognitive vulnerabilities predispose some people to have negative expectations (future orientation - careful not to expect much out of tomorrow), then view all events negatively and interpret experiences negatively, thus raising their risk of depression • Children with depressed mothers tend to show depressive symptoms when faced with minor stress (compared to children without depressed mothers) even before age 1; powerful in predicting later problems • Casual attributions (not in textbook) • Internal Attribution – personal factors are responsible for outcome (“I am smart so I did well on the exam”) • External Attribution – some external factor is responsible for the outcome (“The teacher doesn’t like me so she gave me fewer points”) • Stable Attribution – some stable, ongoing factor is responsible (“I am the kind of person who will do well”) • Unstable (Flexible) Attribution – causes will be variable (“My poor grade is probably due to my heavy course load this term”) • Global Attribution – an overarching interpretation of causes that can be applied to many situations (“I am a lousy student”) • Speciﬁc Attribution – applies to particular situation but not others (“I struggle with advanced math, but I am a good student in all my other courses”) • Pay attention to attributional style • • Social and sex role issues ◦ Women are more likely to be depressed (70% of dysthymic or depressed individuals) ◦ Men and women experience bipolar disorders at about the same rate ◦ Socialized sex roles are likely to contribute to different rates: ◦ Women may be socialized to endure whatever happens ◦ Women are socialized to connect and care for others and tend to worry / blame selves when things happen ◦ Women experience disproportionate poverty, sexual harassment and abuse; have less social power, tend to earn less, and are more likely to experience disrespect ◦ Men are socialized to take charge ◦ Can include multiple factors, for example, single mother with low wages, poor social resources, little social power ◦ Marital Problems contribute to depression for both men and women ◦ Men typically withdraw / Women get depressed • Integrative model s n o i s n em i•D • Features l a c i g o l o i•B • Genetic predisposition, neurotransmitter dysfunction, brain structure abnormalities, abnormal cortisol (the stress hormone) levels, REM sleep disturbances • Psychological • Inadequate or insufﬁcient reinforcers, negative thoughts and speciﬁc errors in thinking, learned helplessness, stable internal and negative attributions • Sociocultural • Lower socioeconomic status, cultural differences, female socialized gender roles • Social • Stress, lack of social support; inequities and lack of opportunities for some cultural groups • Integrative theory • Genetic predisposition, Inadequate coping, Negative cognitive style • Overactive neurological response to stress in the environment (a general, likely to be an inherited tendency) • Psychological vulnerability (tendency to have negative or pessimistic thoughts; feelings of inadequacy) • When vulnerabilities are triggered by events, person may feel overwhelmed and “give up” • Stressful life events trigger stress hormones which affect neurotransmitter systems, changing brain chemistry • Interpersonal relationships serve to buffer the impact (Note: recent research has replicated the ﬁndings about the power of social support) • But why are different people vulnerable to different kinds of mood disorders? Current models do not explain the variations of Mood Disorders very well • • Two key orders - depressive kind of mood states and manic kind of mood states • Depressive moods • Signiﬁcant deviation in ongoing or episodic mood state (episodes stretch into weeks, months or years) • Depression – negative mood state that persists for some period of time and includes: • Mood = feeling sad, down, sense of emptiness • Anhedonia = loss of energy and inability to engage in anything that brings pleasure or fun • Cognitive changes = negativity, difﬁculty concentrating, feeling guilty, feel inadequate • Physical Impact = feeling of being slowed down, unmotivated, difﬁculty starting / ﬁnishing things • Emotional Impact = overwhelming sadness, may cry easily or become irritable • Additional terms • Self-denigration – disparaging or belittling oneself • Rumination – continually thinking about certain topics or reviewing events that have transpired • Anhedonia – loss of the capacity to derive pleasure form normally pleasant experiences • Grandiosity – an overvaluation of one’s signiﬁcance or importance; powerful indication of mania • Mania (manic episodes) Perceived Continuum: Depression ***********************************Mania • Abnormally elevated mood which persists for some time • Decreased need for sleep • Pressured speech, more talkative than usual • Racing thoughts or ﬂight of ideas • Highly distractible • Increase in activity may be goal directed or agitation • Excessive involvement in pleasurable activities that have high potential for painful outcomes (sexual, investment, gambling, buying) • Causes marked impairment in social, occupational or other activities • Poses threat of harm to self or others • Not due to substance abuse or medical condition • Mood disorders Unipolar: mania alone, depression alone, Bipolar: depression and mania Depressive disorders may not be a combination Patterns differ for individuals Major depressive episodes • Science is getting better so diagnosis is becoming better but some people just don't ﬁt • Five or more symptoms are present for at least the same two week period and represent a change from previous functioning: ◦ Depressed mood most of the day, every day ◦ Markedly diminished interest in almost all or all activities all day, every day ◦ Signiﬁcant weight loss (not dieting) or gain (e.g., more than 5% of body weight) or increase of loss of appetite which can cause more issues in and of itself ◦ Insomnia or hypersomnia nearly every day ◦ Psychomotor agitation or retardation nearly everyday that can be observed by others ◦ Fatigue or loss of energy nearly every day; hyper/o sonic - sleep all the time ◦ Feelings of worthlessness or excessive or inappropriate guilt ◦ Diminished ability to concentrate or think, indecisiveness nearly every day ◦ Recurrent thoughts of death or suicide, or an attempt ◦ Cause signiﬁcant distress ◦ Symptoms are not better accounted for by another depressive disorder • Symptom patterns of depression and mania***(important) n i amo •D n o i s s e r p e•D • Mania • Affective • Feelings of sadness, dejection and worthlessness, apathy, anxiety, brooding • Elation, grandiosity, irritability • Cognitive • Pessimism, guilt, inability to concentrate, negative thinking, loss of interest and motivation, suicidal thoughts • Flighty and pressured thoughts, lack of focus and attention, poor judgment l a r o i v a h e•B • Social withdrawal, lowered productivity, low energy, anhedonia, neglect of personal appearance, agitation • Overactivity, extreme talkativeness, speech difﬁcult to understand • Physiological • Appetite and weight changes, sleep disturbance, loss of sex drive • High levels of arousal, decreased need for sleep, increased sex drive • Major depressive disorder, recurrent • Presence of a major depressive episode (previously 2) • Not better accounted for by another mental disorder • There have never been manic or hypomanic episodes (unless substance induced) • • Current clinical status: Mild / Moderate / Severe ◦ Speciﬁers: • With or without psychotic features (distorted perception) • With catatonic features (“statue like”) • With anxious distress (do not meet criteria for Anxiety disorder) • With melancholic features (severe physical features) • With atypical features (e.g., overeat, oversleep) • With postpartum onset (more than “baby blues”) • *See your text for additional speciﬁers • Postpartum depression • Eating and sleeping disturbances – either too much or too little • Anxiety - mind races with fears and worries and can’t shut it off. • Feelings of guilt and shame – a sense that they are “not doing this right,” convinced they are a bad mother • Anger and irritability. • Uncontrollable thoughts of harming or harm coming to the baby. • Just not feeling “like yourself.” • • Symptoms usually appear within the ﬁrst three months after a baby is born, and peak around the four-month mark. Can go on for years if undiagnosed and untreated. • • About 10-20% of new moms have some level of depression beyond “baby blues” • • http://www.youtube.com/watch?v=wfhpgPnGhkA • National Institute of Mental Health • https://www.youtube.com/watch?v=O-A7YvrjFL8 • https://www.youtube.com/watch?v=nM3ObrdUO8E • • You may be interested in controversy with Tom Cruise’s response to Brooke Shields’ book and interviews about her experience with postpartum depression – His position is that there is no such thing • • Gwenyth Paltrow has also discussed her postpartum depression • ****************** 23 Persistent Depressive Disorder (Dysthymia) • A pattern of mild depression (may be irritable mood in children) • Occurs for an extended period of time (2 yrs. for adults/1 yr. for children) • May include: • loss of appetite OR overeating • Insomnia or hypersomnia • low energy or persistent fatigue • low self-esteem or self-conﬁdence • poor concentration, difﬁculty making decisions • feeling hopeless • During the 2 yrs. Symptoms not absent more than 2 mo. at a time • Never have a manic episode • Earlier onset, more concerned about persistent through life span • There may have been a previous depressive episode if full remission (for at least 2 months) • There has never been a manic episode • Does not occur exclusively during a psychotic episode • Not due to substance abuse or medical condition • Symptoms cause signiﬁcant distress or impairment (social/occupational/other) • Early onset: before 21; Late onset: 21 or older; Specify for most recent 2 years of disorder • With atypical features • Prementrual Dysphoric Disorder (PMDD) • First suggested in 1990s when DSM-IV was being compiled • More people being diagnosed is a concern • Tied to mood disorder, full blown set of dysphoric/depressive symptoms with physical things • Women who are regularly impaired during the week before menstruation and exhibit at least ﬁve symptoms: • Depressed or hopeless feelings • Tense or anxious feelings • Marked mood changes • Frequent irritability or anger & increased interpersonal conﬂict • decreased interest in her usual activities, • Poor concentration • Lack of energy • Changes in appetite • Insomnia or sleepiness • Sense of being overwhelmed or out of control • Physical symptoms (bloated sensation, muscle pain, swollen breasts, headaches, weight gain) • Bereavement • Normal response to death or loss; generally loved one • Usually lasts several weeks to several months • Mood state is often sad, overwhelming • May include difﬁculty concentrating, loss of motivation, physical slowing down, withdrawal from others • While unpleasant to experience, this is a minor experience of depressive symptoms and usually time limited • *10 to 20% of bereaved people do not get over their grief easily and go on to develop a syndrome of complicated grief, characterized by an intense and persistent longing for the deceased, a sense of anger and disbelief over the death, and an overwhelming preoccupation with the lost one. • DSM 5 includes grief for more than 2 weeks , even after the death of a loved one, as a symptom of Major Depressive Disorder! What are potential concerns here? ◦ Given pills and screws up their neurotransmitters ◦ Allows for all kinds of treatment for ppl who may not need or beneﬁt from it • Grief counselors: • “…grief is not a pathological condition and not an illness to be treated or cured but a healthy response to a painful reality that one’s world is forever altered, and will never be the same. Absorbing this loss, and adapting to all the changes that come with it, requires a unique course for every person, and will not be stopped by quick ﬁxes or simple solutions. • • We grieve as deeply as we love. It is natural to mourn the loss of someone we love. These feelings are not symptoms of mental illness but essential to what it means to be human.” • Seasonal affective disorder • With long dreary season of winter (or in some geographical areas) there is a tendency to experience depressive symptoms • Fatigue, excessive sleep, weight gain, overeating, pervasive sense of sadness • Most common among young people and more common among women • Hypothesis: different cycles of light with seasons affect biological cycles, and affect production of serotonin (neurotransmitter) • Generally remits with longer periods of daylight in Spring; Can be treated with full spectrum lighting • Usually in winter • Bipolar II disorder • Unipolar mania doesn't stay, just mania • Presence or history of one or more major depressive episodes • Presence or history of at least one hypomanic episode* • But there has never been a full manic or mixed episode • Not better accounted for by another mental disorder • Symptoms cause signiﬁcant clinical distress, or impairment in social, occupational or other important areas of functioning • Specify for current episode: ◦ Hypomanic (less severe pattern of behaviors) or Depressed ◦ Severity (Mild; Moderate; Severe)/ Remission / Psychotic ◦ Chronic (catatonic, melancholic, atypical features) ◦ Postpartum onset ◦ Longitudinal course ◦ Seasonal pattern (applied to depression) ◦ With rapid cycling • Bipolar I disorder • More extreme bc they have to have full blown manic episode • Criteria is the same for Bipolar II except diagnosis requires • One or more Manic Episodes or Mixed Episodes • Cyclothymic Disorder • Chronic mood disorder (at least two years) • Low levels of depressive and manic symptoms • Don't meet criteria for mania or depression • Have to rule out substance abuse • Numerous episodes of hypomania (manic features but lower degree of severity) • Numerous periods of depressed mood or loss of interest in activities which were previously enjoyable/pleasurable but do not occur with the severity to meet criteria for Major Depressive Episode • No Major Depressive Episodes, Manic episodes or mixed during the ﬁrst two years of the disorder • The symptoms are not better accounted for or superimposed on another disorder • Not due to substance abuse or any medical condition • Causes clinically signiﬁcant distress or impairment in social, occupational, or other important areas of functioning • Challenges of treating bipolar-joseph s n e e t n i t i t o•G • 36-years-old, earned an undergraduate degree in music • Underemployed in a group home for kids with disabilities • Writes music, sings in a band, maintains a music website • Has had depressive episodes since in high school • Mother, and half-sister have diagnoses of Bipolar, father has depression and all maintain some level of treatment • Several family members have committed suicide • His symptoms can be successfully controlled by medication • Periodically goes off medication – doesn’t like to “lose the high” which he associates with creativity ◦ Spent weeks without sleep • During manic phases often stays up for days ◦ -Writes music and poetry ◦ -Engages in sexual episodes with women with whom he falls “madly in love ” • Periodically requires hospitalization • Finds he has to rely on family to help him recover • Has repeated cycle over and over • Prevelance Among Adults: • Approximately 16% of the population (worldwide) experience depression in some form in their lifetime • Approximately 6% experienced it in the past year (2005) • Dysthymia = 3.5% prevalence and incidence • Bipolar Disorder = 1% prevalence and .8% in the past year • Difﬁcult to estimate with any accuracy about youth: • As many as 20 to 50% of children experience depressive symptoms that do not meet diagnostic criteria • Diagnosis of Depressive disorders in children is controversial • Sex ratio in children appears equal, but rates rise among girls at puberty, especially with depression • Accuracy of diagnosis • Research has indicated that: • Family physicians, internists, and pediatricians fail to recognize depression in over 50% of those who have it; • National Mental Health Association estimates that as many as 80% of those with bipolar disorder may be misdiagnosed or undiagnosed; • Around 123 million new cases of mood disorders occur each year, worldwide; • Immigrants to the U.S. from all other cultures are less likely to be depressed than U.S. natives (unless they come before age 12, then the rate is roughly equal); • Those with bipolar disorder are more likely than those with other mental illnesses to engage in criminal behavior, especially during manic episodes/phases; • Professional football players who had three or more concussions during their careers are 3X more likely to develop a mood disorder; 26% of former professional football players have had three or more concussions. • They may commit crimes; most likely to have criminal backgrounds bc of impulsivity with manic phase Mood disorders • Major depression • Biploar • Dysthymia • Mood disorders • Cyclothymia Different patterns of symptoms • Features of disorders may reamain similar over time or progress to become more complicated and signiﬁcant problems Development in childhood • Psychodynamic theories in 1960s-70s • postulated that children did not get depressed • Children DO get depressed: ◦ *Behavior: may be more agitated, restlessness or have reduced activity, less social contact, sarcasm, screaming ◦ *Changes in attitude: feel worthless, pessimistic, hopeless, attitudes toward school change, less motivated, dread the future and feel hopeless, may feel doomed to failure ◦ *Physical Changes: changes in appetite, sleep patterns, feeling tired; physical complaints such as headache, stomachache, nausea, nonspeciﬁc, persistent aches and pains ◦ Thinking: preoccupied, self-critical, self-conscious, slowed thoughts, difﬁculty concentrating or remembering ◦ _ Mood: irritability, exaggerated and persistent sadness, guilt, ◦ or shame, intermittent periods of sadness with other emotions in between periods Typical childhood patterns • Infants – quiet, unresponsive, passive • Preschooler – withdrawn, inhibited, appears shy • Elementary ages – argumentative, combative • Teen – express feelings of guilt or hopelessness • NO ONE PATTERN ADEQUATELY DESCRIBES CHILDHOOD PATTERNS AT ANY GIVEN AGE OR DEVELOPMENTAL STAGE • UNTILADULTHOOD • (WHEN THERE MAY STILL BE SOME INDIVIDUAL FEATURES) Childhood • Important to distinguish between: ◦ Symptom – a feature of depression, usually feeling sad or miserable without other signiﬁcant features ◦ Syndrome – a group of features that occur together but are not serious enough when taken together to meet diagnostic criteria. Sadness may be accompanied by features such as negative thinking, reduced interest in activities, or somatic (bodily) changes ◦ Disorder – meets criteria for a disorder with identiﬁable sets of characteristics that have existed for speciﬁc periods of time. (NOTE: DSM-IV-TR does not have much information about children). • NOTE: these distinctions are often ignored in diagnostic decisions • Adding in mania complicates the already unclear picture: • Mania can introduce aggression, overactive behavior, destructive acts, taking physical risks • American Academy of Child and Adolescent Psychiatrists – recommendation - most children meeting the broad criteria of Bipolar Disorder should not be diagnosed with Bipolar unless they meet the very stringent criteria of a classic Bipolar disorder.; unless a parent has it they should be careful diagnosing • The need for skilled clinicians who will gather a detailed history and conduct signiﬁcant investigation to make the diagnosis is clear. • There are enormous voids in our research about children, and it is complicated by poor diagnostic decisions Childhood/adolescence • We don’t know as much about depression in childhood as we need to know: • Estimates for prevalence and incidence are varied • Ages 2-5 estimates are about 1.5% of U.S. pop. • About 20-50% of children experience symptoms or syndrome • Adolescents experience depression at the same rate as adults • About 50% males/50% females in childhood at adolescence, girls have higher rates • High levels of comorbidity: anxiety, conduct disorders, AD/HD • Rates of Bipolar diagnoses in clinics has doubled , and has quadrupled in hospitals over the past few years Adolescence • Symptoms are more like adults: ◦ Heightened risks with adolescents, especially with manic episodes: dangerous and risky behaviors, suicide attempts ◦ Complicated by expectations of culture (e.g., independence vs. dependence; acculturation demands, etc.) • We know from the research that stronger symptoms in childhood and adolescence predict more signiﬁcant problems with mood disorders in adulthood and less positive adult outcomes. • Many children and adolescents who have • signiﬁcant mood problems are not identiﬁed or treated Treatment Medication • Depends on the kind of mood disorder • Most medications work in one way or another with the serotonin neurotransmitter system • Prescribing medication is not an exact science, but research does inform what kinds of medication tend to work better for the varied kinds of mood disorders • Proper treatment may require persistence and patience, and a trial and error approach, as sometimes things that “should” work do not. • Tryptophan has a powerful impact on depression Talk Therapies • Cognitive Behavior Therapy works well – Uses an approach to understand negative, often automatic thought patterns and change these and learn to interrupt and then change thoughts to promote better coping; recognize, develop, and stop neg and introduce pos • Psycho-educational interventions – Teaching about the disorder and how to recognize symptoms, seek help, cope with the disease, and live in a positive way • Group therapy – helps with social isolation and increases understanding and coping strategies; members learn, model, and support each other ECT • A form of therapy for very severe or intractable depression • Highly controversial • Uses small amounts of electricity to induce seizures • Patients are anesthetized, and are given muscle relaxers • Usually effective after a few treatments (6-10) • Side effects are temporary loss of short term memory, confusion; usually restored within a few hours Prevention • General prevention strategy: • Employ a public health model with universal screening and programming to increase resilience among a large population or group • Target high risk groups and intervenes with speciﬁc training to build stronger skills and promote better coping • Identify those who are already having symptoms and intervene individually to treat early stages Prevention of Relapse • Train the client to understand the disorder • Use medication for longer periods of time to treat latest episode • Use CBT to help alleviate thought patterns that promote depression Suicide • Shocking numbers of people kill themselves each year: • Documented as about 40,000 each year, but researchers believe this may half (80,000?) or a third (120,000?) the actual number • Worldwide, suicide kills more people than homicide or HIV/AIDS • Minority groups do choose suicide in large numbers as a rule, but Native American tribes are an exception to this • Most suicide completers are white • Among teens, the rates have skyrocketed over the past • several decades to become 3 rd • leading cause of death • Prevalence among ethic group teens • varies • Suicides have also increased among senior citizens • Young children can attempt suicide (despite theory that says no) • Fifth leading cause of death for ages 5 to 14 in the U.S. • Among adolescents there is an attempt for about every 3-6 thoughts about suicide • Males are more likely to COMPLETE suicide due to more violent means chosen (e.g., guns, hanging) • Females attempt suicide about three times more frequently than men • Females generally use less painful means (e.g., overdose) • More elderly men commit suicide, more middle aged women • Among college students, suicide is the second highest • cause of death • Idle thoughts about suicide may be common but • recurrent and signiﬁcant thoughts should be taken very seriously The process of moving toward suicide The more someone thinks about suicide as an option to solve problems, the higher the risk The more planful the person’s ideas about suicide, the higher the risk Repeated attempts or gestures increase the risk Ideation 9.2% Repeated attempts; plan 3.1% Attempt 2.7% (OR gesture) Note: percentages reﬂect results of lifetime prevalence from a cross national study in 2008 Risk factors Family history of suicide: genetic or learned behavior? (risk is increased times 6 – more for sibling) Neurobiology: low levels of serotonin Existing psychological disorder: About 80% of completed suicides have a diagnosable disorder (mood/substance/impulse control) Majority of those with mood disorders DO NOT attempt suicide however a large majority of those who complete suicide do have a mood disorder Alcohol use is associated with many suicides Substance abuse coupled with other factors including disorders, impulsivity or risk seeking increase risks for adolescents Stressful life events are often a trigger Contagion Some people who are “at risk” will attempt suicide after learning about a completed suicide Widespread information about a suicide raises the risk that others will attempt As many as 5% of adolescent suicides are the result of a “contagion effect” Media treatments often “romanticize” suicide Method is described so a means to suicide is apparent The more the person represents a model (“like me” “similar problems”) or represents hopelessness (“if someone like that can’t ﬁnd a way to live, how could I?”) the more risk they confer to those at risk How to help? People who are suicidal are more likely to tell friends than seek help: Know the resources in your area. If you suspect someone is considering suicide, ask them. This will not encourage them to consider it. Take things seriously – even a casual threat is a plea for some level of support If someone makes a signiﬁcant threat, get help NOW. Don’t wait. Go talk with someone to get advice if you are afraid. Go with your friend to seek help. Drag them if necessary. Talk with your friend’s parents or signiﬁcant other – don’t keep a secret.
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