Psychopathology

Chapter 7: Depression and Mood disorders

 Two types of events are particularly important in triggering periods of

depression: losses and failures

Depression A mood disorder involving emotional, motivational, behavioural,

physical and cognitive symptoms.
 The emotional experiences of depressed individuals are usually
restricted to negative ones and these are often described as ‘sad,
hopeless, miserable, dejected, and discouraged’
 motivational deficits. include a loss of interest in normal daily activities
or hobbies
 behavioural symptoms. slowness of speech and behaviour generally
 Physical symptoms. sleep disturbance such as middle insomnia
 cognitive features. extremely negative views of themselves, the world
around them, and their own future. pessimistic thinking where sufferers
believe nothing can improve their own lot
Mania An emotion characterised by boundless, frenzied energy and feelings
of euphoria.
bipolar disorder A psychological disorder characterised by periods of mania
that alternate with periods of depression.
 There are two main types of clinical depression
major depression (unipolar depression) A psychological problem
characterised by relatively extended periods of clinical depression which
cause significant distress to the individual and impairment in social or
occupational functioning.
Bipolar disorder is characterised by periods of mania that alternate with
periods of depression, and this leads individuals with bipolar disorder to
describe their lives as an ‘emotional roller‐coaster’. Sufferers experience the
extremes of these emotions in ways that cause emotional discomfort and
distress.

FOCUS POINT 7.1 DEPRESSION, EMBODIMENT, AND THE

ROLE OF EXERCISE
recent evidence suggests that the experience of ‘depression’ also has an
embodied component. That is, there is a reciprocal relationship between
bodily expression and how an emotion is experienced and processed

7.1 MAJOR DEPRESSION

7.1.1 The Diagnosis and Prevalence of Major Depression

major depressive episode Episode of major depression, defined by the

presence of five or more depressive symptoms during the same 2-week
period, as stated by the DSM-5.
 two main types of depressive disorder based on the criteria for a major
depressive episode
1. major depressive disorder, single episode
2. major depressive disorder, recurrent
Summary: DSM‐5 criteria for a major depressive episode

Summary: DSM‐5 criteria for major depressive disorder, single episode &
recurrent

 Chronic mood disturbances primarily characterised by depressive

symptoms can also be diagnosed, although these conditions must have
been apparent for at least 2 years, and would normally not be severe
enough to disrupt normal social and occupational functioning and
warrant a diagnosis of major depression
dysthymic disorder A form of depression in which the sufferer has
experienced at least 2 years of depressed mood for more days than not.
Summary: DSM‐5 criteria for dysthymic disorder

 However, diagnosing depression is a controversial issue for a number of

reasons
1. are such people any different in their experiences and their
functioning from someone who exhibits only three symptoms
2. depression is one of the most prevalent of all psychological problems
and is experienced in some form or other by almost everyone at
some time in their life
3. depression occurs in a variety of different guises within
psychopathology and is commonly comorbid with other important
disorders

 Prominent examples of diagnosable problems which have depression as

a significant core element include

premenstrual dysphoric disorder (PMDD) A condition in which

some women experience severe depression symptoms between 5 and
11 days prior to the start of the menstrual cycle. Symptoms then
improve significantly within a few days after the onset of menses.

seasonal affective disorder (SAD) A condition of regularly occurring

depressions in winter with a remission the following spring or summer.

chronic fatigue syndrome (CFS) A disorder characterised by

depression and mood fluctuations together with physical symptoms
 such as extreme fatigue, muscle pain, chest pain, headaches and noise
and light sensitivity.

 depression is highly comorbid with anxiety problems and around 60%

of people with depression will also experience an anxiety disorder
Mixed anxiety/depressive disorder is used to describe a significant
number of people who experience this mix of anxiety and depression

FOCUS POINT 7.2 DEPRESSION‐RELATED PROBLEMS

SEASONAL AFFECTIVE DISORDER (SAD)

melatonin A hormone that acts to slow organisms down, making them sleepy
and less energetic.
CHRONIC FATIGUE SYNDROME (CFS)
 CFS is characterised by depression and mood fluctuations together with
physical symptoms such as extreme fatigue, muscle pain, chest pain,
headaches, and noise and light sensitivity
PREMENSTRUAL DYSPHORIC DISORDER (PMDD)
 some women will experience severe depression symptoms between 5
and 11 days prior to the start of the menstrual cycle, but these
symptoms then improve significantly within a few days after the onset
of menses

7.1.2 The Aetiology of Depression and Mood Disorders

Risk factors for depression
 risk factors are important when it comes to helping to identify people
who may possibly be at risk for depression, but they tell us relatively
little about the actual causes of depression, and discovering the
mechanisms that underlie the development of depression is the
purpose of more detailed research.

Biological theories
Genetic factors
 first‐degree relatives of major depression sufferers are around two to
three times more likely to develop depressive symptoms than are
individuals who are not first‐degree relatives of sufferers
Neurochemical factors
 reliably associated with abnormalities in the levels of certain brain
neurotransmitters, and three neurotransmitters are particularly
significant—namely the monoamines serotonin,
norepinephrine and dopamine
 major depression is often associated with low levels of these
neurotransmitters
 1950s also saw the development of drugs that significantly alleviated
the symptoms of depression
 tricyclic drugs (such as imipramine) and monoamine oxidase(MAO)
inhibitors (such as trancylcypromine). Both of these drugs have their
effects by increasing levels of both serotonin and norepinephrine in the
brain.
tricyclic drugs Drugs which block the reuptake of both serotonin and
norepinephrine.
 More recently, the development of selective serotonin reuptake
inhibitors (SSRIs) (such as fluoxetine) and serotonin‐noradrenaline
reuptake inhibitors (such as Duloxetine) has allowed researchers to
assess the specific roles of serotonin and noradrenaline in depression,
and researchers now believe that serotonin levels in particular play a
central role in major depression

Brain abnormalities and depression

 depression is associated with significantly lower levels of activation in
the prefrontal cortex and this area is important in maintaining
representations of goals and the means to achieve them.
 decreased ACC activation is also reported in major depression
 individuals with depression and mood disorders also show signs of
dysfunction in the hippocampus
 major depression has also been found to be associated with structural
and functional abnormalities in the amygdala, and especially with
increased amygdala activation
anterior cingulate cortex (ACC) The frontal part of the cingulate cortex
resembling a ‘collar’ form around the corpus callosum, used for the relay of
neural signals between the right and left hemispheres of the brain.
Prefrontal Cortex An area of the brain which is important in maintaining
representations of goals and the means to achieve them.
  structural anatomical abnormalities in depressed individuals have been
found for grey matter and white matter in the brain. Decreased grey
matter levels. White matter lesions are frequently found

Neuroendocrine factors
 Depression is regularly associated with problems in the regulation of
body cortisol levels—a hormone that is secreted in times of stress
 hippocampal abnormalities are regularly linked with high levels
of cortisol (an adrenocortical hormone)—especially high cortisol levels
at the time of wakening—and patients receiving chronic corticosteroid
therapy for endocrine problems have smaller hippocampal volumes and
higher depression ratings than non‐patient controls

Psychological theories
Psychodynamic explanations
 a response to loss, and, in particular, a response to the loss of a loved
one such as a parent
 During their depressed state, this regression to the oral stage allows the
individual to become dependent on their relationships with others in
order to utilise the support that this will offer.

FOCUS POINT 7.3 DEPRESSION AND INFLAMMATION

 depression is not just a consequence of physical illness, it is also in
many cases a predictor of future illness
 inflammation may contribute to the experience of depression
 cytokines—proteins made by immune cells that control responses to
foreign antigens and germs, generating inflammation and fever.
Consistent with this is the fact that depression also seems to be
associated with changes in the immune system, especially those
changes that involve cytokines

symbolic loss A Freudian concept whereby other kinds of losses within one’s
life (e.g. losing a job) are viewed as equivalent to losing a loved one.
affectionless control A type of parenting characterised by high levels of
overprotection combined with a lack of warmth and care.
Behavioural theories
 depression results from a lack of appropriate reinforcement for positive
and constructive behaviours
behavioural activation therapy (BA) A therapy for depression that attempts
to increase clients’ access to pleasant events and rewards and decrease their
experience of aversive events and consequences.
 interpersonal theories of depression. These theories argue that
depression is maintained by a cycle of excessive reassurance
seeking from depressed individuals that is subsequently rejected by
family and friends because of the negative and repetitive way in which
depression leads the individual to talk about their problems 

Negative cognitions and self‐schema

 One of the most influential of all the theories of depression is Beck's
Cognitive Theory
 depression could be caused by biases in ways of thinking and
processing information
 depressed individuals have developed a broad‐ranging negative
schema that tends them towards viewing the world and themselves in
a negative way
 these negative schemas influence the selection, encoding,
categorisation, and evaluation of stimuli and events in the world in a
way that leads to a vicious cycle of depressive affect and
symptomatology
negative schema A set of beliefs that tends individuals towards viewing the
world and themselves in a negative way.
negative triad A theory of depression in which depressed people hold
negative views of themselves (e.g. ‘I am unattractive’), of their future (e.g. ‘I
will never achieve anything’) and of the world (e.g. ‘The world is a dangerous
and unsupportive place’).
  considerable evidence
1. some studies have shown attentional biases to negative information
in depressed individuals that results in them prioritising that
negative information
2. important memory biases are also apparent in depression, with
depressed individuals able to recall more negative words than
positive words in explicit memory tests
3. experimental evidence that depressed individuals exhibit the
interpretational bias that would lead them to interpreting
ambiguous events negatively or to judge events more negatively
pessimistic thinking A form of dysfunctional thinking where sufferers
believe nothing can improve their lot.

Learned helplessness and attribution

 the perceived uncontrollability of these negative life events that is
important and leads the individual to the pessimistic belief that
negative life events will happen whatever they do
battered woman syndrome The view that a pattern of repeated partner
abuse leads battered women to believe that they are powerless to change
their situation.
learned helplessness A theory of depression that argues that people become
depressed following unavoidable negative life events because these events
give rise to a cognitive set that makes individuals learn to become ‘helpless’,
lethargic and depressed.
attribution theories Theories of depression which suggest that people who
are likely to become depressed attribute negative life events to internal, stable
and global factors.

Hopelessness theory
 Hopelessness theory is very similar to attributional/helplessness
accounts in that negative life events are viewed as interacting with a
global/stable attributional style to generate depressed
symptomatology.
 also predicts that other factors, such as low self‐esteem, may also be
involved as vulnerability factors
Hopelessness theory A theory of depression in which individuals exhibit an
expectation that positive outcomes will not occur, negative outcomes will
occur, and that the individual has no responses available that will change this
state of affairs.
 a number of limitations to hopelessness theory
1. carried out on healthy or only mildly depressed participants who are
not representative of individuals who are clinically depressed
2. correlational in nature, and so cannot provide any evidence on the
possible causal role of hopelessness cognitions in generating
depression
3. the model does not explain all of the depressive symptoms required
for a DSM‐5 diagnosis, only those related to hopelessness
4.  it may not be a universal or enduring feature of individuals who
experience depression

Rumination theory
Rumination The tendency to repetitively dwell on the experience of
depression or its possible causes.
 Tendency to ruminate has been shown to predict the onset of
depressive episodes (Morrow & Nolen‐Hoeksema, 1990; Nolen‐
Hoeksema, 2000), and relapse back into bouts of depression
7.2 BIPOLAR DISORDER

 Bipolar disorder is a mood disorder characterised by alternating

periods of depression and mania
 the swings between these two states can be very rapid, taking the
individual from an extreme ‘high’ to an extreme ‘low’ very quickly
7.2.1 The Diagnosis and Prevalence of Bipolar Disorder
 DSM‐5 defines two main types of bipolar disorder, namely bipolar I
disorder and bipolar II disorder
 bipolar I disorder where individuals exhibit full manic and major
depressive episodes in alternating sequences
 bipolar II disorder, major depressive episodes alternate with periods
of hypomania (can often be relatively productive during their periods
of hypomania)
hypomania Mild episodes of mania.

Summary: DSM‐5 definition of hypomania

Summary: DSM‐5 criteria for cyclothymic disorder

 Cyclothymic disorder is a mild form of bipolar disorder in which the

sufferer has mood swings over a period of years that range from mild
depression to euphoria and excitement
Cyclothymic disorder A form of depression characterized by at least 2
years of hypomania symptoms that do not meet the criteria for a manic
episode and in which the sufferer experiences alternating periods of
withdrawal then exuberance, inadequacy and then high self-esteem.

7.2.2 The Aetiology of Bipolar Disorder

Biological theories
Genetic factors
 There is good evidence that bipolar disorder has an inherited
component.
Neurochemical factors
 Bipolar disorder has also been shown to be reliably associated with
abnormalities in levels of brain neurotransmitters
Cognitive deficits in bipolar disorder
  associated with a variety of deficits in cognitive functioning, and these
are deficits that could be linked to difficulties in emotion regulation
 effective executive functioning (this is a set of cognitive processes that
are necessary for the cognitive control of behaviour) (verbal and
nonverbal memory, attention, and working memory)
Triggers for depression and mania in bipolar disorder
 The triggers for a depressive episode in bipolar disorder appear to be
very similar to the factors that instigate depression generally, namely
experiences such as losses, failures, and negative life events generally
 The triggers for bouts of mania also appear to be varied and include an
increased responsiveness to rewards (e.g., mania can be a reaction to a
positive life event such as passing an exam), reactions to antidepressant
medication, disrupted sleep patterns and circadian rhythms, seasonality
(bouts of mania increase in either spring or summer), stressful life
events generally, and exposure to high emotional expression in family
members or caregivers
7.3 THE TREATMENT OF DEPRESSION

electroconvulsive therapy (ECT) A method of treatment for depression or

psychosis, first devised in the 1930s, which involves passing an electric
current of around 70â €“130 volts through the head of the patient for around
half a second.
Stepped-care models A treatment for psychopathology that emphasises that
the type of treatment provided for those individuals should be tailored to the
severity of their symptoms and their personal and social circumstances.
7.3.1 Biological Treatments
Antidepressant medications
 The three main types of medication for depression
1. trycyclic drugs (such as imipramine)
2. MAO inhibitors (such as tranylcypromine)
3. SSRIs (such as Prozac) and serotonin and norepinephrine reuptake
inhibitors (SNRIs)
 first two types of drug increase levels of both serotonin and
norepinephrine in the brain
 SSRIs and SNRIs act selectively on serotonin and prevent its reuptake
by the presynaptic neurone

 The traditional treatment for bipolar disorder has been lithium

carbonate
lithium carbonate A drug used in the treatment of bipolar disorder.
olanzapine An antipsychotic drug commonly prescribed in combination with
the antidepressant SSRI drug fluoxetine as a treatment for bipolar disorder.
fluoxetine (Prozac) A selective serotonin reuptake inhibitor (SSRI) which
reduces the uptake of serotonin in the brain and is taken to treat depression.

Transcranial magnetic stimulation (rTMS)

 electromagnetic coil is placed on the scalp and pulses of magnetic
energy are used to increase activity in the left dorsolateral prefrontal
cortex
 30–60 minutes
 between 2 and 6 weeks
Electroconvulsive therapy (ECT)
 passing an electric current of around 70–130 V through the head of the
patient for around half a second
 a number of side effects
1. memory loss that affects the ability to learn new material
(anterograde amnesia). the ability to recall material learned before
the treatment (retrograde amnesia)
2. the idea of having a strong electric current passed through their
brain frightening and will be resistant to the use of this kind of
therapy
3. no one is clear how ECT does work in alleviating the symptoms of
severe depression

7.3.2 Psychological Treatments

Psychoanalysis
 help the depressed individual achieve insight into this repressed
conflict and to help release the inwardly directed anger.
 using various techniques to help people explore the long‐term sources
of their depression, and this will involve exploring conflicts and
problematic relationships with attachment figures—such as parents—
and discussing long‐standing defensive patterns.
  free association or dream interpretation to help the individual recall
early experiences of loss that may have contributed to repressed
conflicts and symptoms of depression
dream interpretation The process of assigning meaning to dreams.

Social skills training

 Social skills training assumes that depression in part results from the
individual's inability to communicate and socialise appropriately, and
that addressing these skill deficits should help to alleviate many of the
symptoms of depression.
 This may involve training assertion skills, conversational interaction
skills, dating skills, and job‐interview skills, and can involve procedures
such as modelling, rehearsal, role‐playing, and homework assignments
out of the therapeutic setting
Behavioural activation
 Behavioural theories of depression emphasis that depression may be
triggered by a life‐event loss (such as a bereavement), and this event
may represent the loss of important sources of reward and
reinforcement for the individual
 behavioural activation (BA) therapies for depression that attempt to
increase the client's access to pleasant events and rewards and
decrease their experience of aversive events and consequences

Cognitive therapy
 one of the most successful and widely adopted therapeutic approaches
for depression, and this has come to be known by various names
including cognitive therapy, cognitive retraining, or cognitive
restructuring
1. to help the depressed individual identify their negative beliefs and
negative thoughts
2. to challenge these thoughts as dysfunctional and irrational
3. to replace these negative beliefs with more adaptive or rational
beliefs
cognitive therapy A form of psychotherapy based on the belief that
psychological problems are the products of faulty ways of thinking about the
world.
negative automatic thoughts Negatively valenced thoughts that the
individual finds difficult to control or dismiss.
reattribution training A technique used in the treatment of depression
which attempts to get clients to interpret their difficulties in more hopeful and
constructive ways rather than in the negative, global, stable ways typical of
depressed individuals.

Mindfulness‐based cognitive therapy (MBCT)

 developed in order to try to combat this linkage between periods of
dysphoria and the onset of negative thinking, and it aims to get
individuals to take a ‘decentred’ perspective by being aware of negative
thinking patterns and viewing them purely as mental events rather
than accurate reflections of reality
 Clients are taught to become more aware of, and relate differently to,
their thoughts, feelings, and bodily sensations, and treat thoughts and
feelings as passing events in the mind rather than identifying with them
7.4 NONSUICIDAL SELF‐INJURY (NSSI)
 Nonsuicidal self‐injury (NSSI), sometimes known as deliberate self‐
harm, is defined as direct and deliberate bodily harm in the absence of
suicidal intent and most frequently takes the form of cutting and
carving the skin with a knife or similar sharp instrument (usually on
arms, legs, and stomach)
nonsuicidal self-injury (NSSI) The act of deliberately causing injury to ones
body without conscious suicidal intent.
deliberate self-harm A parasuicidal phenomenon that commonly includes
cutting or burning oneself, taking overdoses, hitting oneself, pulling hair or
picking skin, or self-strangulation.
7.5 SUICIDE
suicide The action of killing oneself intentionally.
 women are around three times more likely to attempt suicide than men,
but the rate for successful suicide is around four times higher in men
than women

 a number of factors may be relevant

1. modern teenagers are probably exposed to many of the life stressors
experienced by adults, yet may lack the coping resources to deal
with them effectively
2. suicide is also a sociological as well as a psychological phenomenon,
and media reports of suicide often trigger a significant increase in
suicides
3. there has been a recognised increase in stress‐ and anxiety‐related
problems amongst children and adolescents over the past decade

7.5.1 Risk Factors for Suicide

 One of the best predictors of future suicide attempts is a history of at
least one previous suicide attempt
 risk factors encompass a broad range of domains such as psychiatric,
psychological, physical, personal, familial, and social factors
  being female, being young, lower education and income, unmarried
status, unemployment, parent psychopathology, childhood adversities,
and a current DSM psychiatric diagnosis.
 life stress is one of the most significant predictors of suicide, and suicide
attempts are often preceded by a significant negative life event
 also a genetic element to suicidal behaviour
 complex interplay between sociocultural factors, traumatic events,
psychiatric history, personality traits and genetic vulnerability

7.5.2 Identifying and Preventing Suicide

brief intervention and contact(BIC) a 1‐hour individual information session
as close to the time of discharge from hospital as possible, followed by
periodic follow‐up contacts (phone calls or visits) over the ensuing 18‐month
period by experienced clinical professionals.