Contents
In mood disorders, a person is seized with severe depression or mania (a violent upsurge in mood) or at times depressed, at times manic. Mood disorders are divided into depressive disorders, in which a person has one or more periods of depression, but no periods of mania, and bipolar disorders, in which periods of depression are followed by periods of uplift, with the individual usually returning to normal mood in between. Periods of mania without periods of depression are extremely rare.
Depression
Almost everyone feels overwhelmed from time to time. Most of us have periods when we feel sad, apathetic and not interested in anything. Depression is a normal response to many of life’s stresses. Some of the most common triggers for depression include trouble at school and work, the loss of a loved one, and the realization that illness or age is draining your energy. Depression is considered abnormal only when it is out of proportion to the event and continues past the point at which most people are already recovering.
Depression becomes a disorder when symptoms get worse enough to interfere with normal functioning and continue unabated for weeks. Depressive disorders are relatively common; about 17% of people experience periods of severe depression at some point in their lives (Kessler et al., 1994).
Although depression is classified as a mood disorder, it actually includes four sets of symptoms. In addition to emotional, mood-related symptoms, there are also cognitive, motivational, and physical symptoms. It is not necessary that all of them be present for a diagnosis of depression, but the more symptoms and the more severe they are, the more certain that the individual is suffering from depression.
Among the emotional symptoms of depression, sadness and depression are the most prominent. The person is unhappy and hopeless, often has bouts of crying and may contemplate suicide. (Depression and suicide are discussed in the U.S. At the forefront of psychological research.) Just as common with depression is a loss of satisfaction and enjoyment of life. What once brought satisfaction, seems boring and joyless. A person with depression gradually loses interest in hobbies, recreation and family affairs. Patients with the most severe depression say that they no longer get satisfaction from what was once the main interest in their lives, many lose interest and attachment to other people.
Cognitive symptoms include mostly negative thoughts. Individuals with depression have low self-esteem, they feel inadequate and blame themselves for any failures. They feel hopeless about the future and are pessimistic about doing anything to improve their lives.
Depression lowers motivation. The person is passive, and it is difficult for him to get involved in some kind of activity. Passivity is illustrated by the following dialogue between a doctor and a patient. This man was hospitalized after a suicide attempt and spent his days sitting motionless on a couch. His doctor decided to try something to captivate him:
Doctor: I understand that you spend most of the day on this couch. Is it so?
Patient: Yes, when I am still it gives my thoughts the rest I need.
Q: When you are sitting here, how are you feeling?
P: I am constantly terrified. I only dream to fall into a hole somewhere and die.
Q: Do you feel better when you sit for two or three hours?
P: No, the same.
Q: So you’re sitting there hoping to find rest for your thoughts? But your depression doesn’t seem to be abating.
P: I’m so tired of everything.
Q: You didn’t think about being a . more active? For a variety of reasons, I believe that if you became more active it would help.
P: There is nothing to do here.
Q: And if I prepare a list for you, will you try something to do?
P: If you think it will help. But I think you are wasting your time. I don’t have any interests.
(Beck et al., 1979, p. 200).
Physical symptoms of depression include loss of appetite, sleep disturbances, fatigue, and loss of energy. Because a depressed person’s thoughts are inward rather than outward, they may exaggerate their pain and worry about their health.
As we will see from the description of its symptoms, depression can weaken the body. Unfortunately, severe depression can be long lasting. In one study of people with severe depression, they were found to be symptom-free only 27% of the time over a nine-year period (Judd et al., 1998). And even if these people recovered from one bout of depression, they continued to have a high probability of the onset of new bouts. As we will soon see, it is possible to significantly reduce the duration of the current period of depression and prevent the onset of new ones with the help of drug therapy or psychotherapy.
Depression sometimes leads to suicide. Women are more likely to attempt suicide than men, but in men these attempts result in death more often.
depression and suicide
The worst consequence of depression is suicide. Of the 30 people reported to die each year in the US, most suffer from depression. However, since not all suicides are known (some are hidden for fear of stigma, and besides, many accidents may actually be the result of suicide), the number of actual suicides seems to be closer to 50 per year. The number of people who have attempted and failed to commit suicide is estimated to be anywhere from 2 to 8 times the number of reported suicides (Shneidman, 1985).
Women attempt suicide about 3 times more often than men, but men are more likely to succeed in attempting to kill themselves. The higher number of suicide attempts among women may be due to their higher incidence of depression. The fact that men are more successful in their attempts is due to the choice of method. Until recently, women tended to use less than lethal means, such as cutting the veins in their wrists or taking large doses of sleeping pills; men are more likely to use firearms, carbon monoxide fumes, or hang themselves. However, with a marked increase in the number of women owning guns, gun-assisted suicide has taken the lead among women (Wintemute et al., 1988). As a result, the proportion of fatal outcomes among women also changed. When using firearms, 80% of attempts are successful, while when using drugs and poisons, only 10% of attempts are fatal — a strong argument against having a weapon in the house.
Depression, loneliness, poor health, marital problems, and difficulties with money and work are the most common causes of suicide attempts (Petronis et al., 1990; Shneidman, 1985).
The highest number of suicides has traditionally been and still is among the elderly, but in percentage terms, the proportion is decreasing. In contrast, suicide rates in adolescents and young adults (traditionally low) are on the rise. The number of suicides among people aged 15 to 24 in the United States has quadrupled over the past 40 years. In a recent nationwide survey of high school students, 4% reported having «seriously considered» committing suicide, and one in 27 said they actually tried to do so (Centers for Desease Control, 12).
College students are twice as likely to kill themselves as non-students of the same age (Murphy & Wetzel, 1980). An increased suicide rate among college students has been found not only in the US, but also in Europe, India, and Japan. The growing desperation among college students has a number of possible causes: the need to live away from home for the first time and deal with new challenges; an attempt to lead in academic performance with tougher competition than at school; fluctuations in career choice; loneliness due to the absence of old friends and anxiety due to new ones.
A study of the lives and academic affairs of college students who committed suicide showed that they were more sullen, stricter and more depressed than their more prosperous peers. They also periodically informed others of their suicidal intentions. The main precipitating event appears to have been anxiety about school, physical health, and difficulties in relationships with others (Seiden, 1966). However, it is not certain that these factors led to suicide and that learning and interpersonal problems were second only to major depression. Perhaps, before going to college, students who contemplated suicide never learned to deal with personal problems and emotions. One study, for example, found that students with suicidal thoughts were no more stressful than other students, but had less strength to deal with problems and strong emotions (Carson & Johnston, 1985).
College students who commit suicide have higher than average academic performance, while teenagers who commit suicide perform exceptionally poorly in high school. Suicidal teens were generally expelled from school or had behavioral difficulties, although some were academically gifted and felt the need for excellence and the need to remain at the top of the class (Leroux, 1986).
Social isolation is a distinctive feature of adolescents who have attempted suicide: they considered themselves loners, most had divorced parents, many had alcoholic parents, and parental attachment was weak (Berman & Jobes, 1991; Rohnetal., 1977).
In addition to depression, the main factor contributing to suicide was addiction to drugs. For example, one study of 283 suicide cases found that almost 60% of those who died were drug addicts, and 84% were addicted to alcohol and other drugs (Rich et al., 1988). It is not clear whether drug addiction caused these people to become depressed and died, or whether they resorted to drugs as a remedy for depression and killed themselves when it did not help. But in many cases, drug addiction preceded psychological problems.
Young drug addicts (under 30) who committed suicide had strong interpersonal conflicts, and the loss of a marriage partner or romantic partner in the weeks leading up to suicide was more common than expected.
Perhaps they felt that they had lost the only support in life. And if their personal strength had not been undermined by drugs, they could have coped with stress without resorting to suicide.
Some commit suicide because they are unable to endure their emotional suffering and see no other solution to their problems than death. Their only motive is to end their lives. In other cases, the person doesn’t really want to die, but wants to impress others with the severity of their problems. The suicide attempt is then motivated by the desire to speak out about one’s despair and influence the behavior of others. An example would be the woman who takes a heavy dose of sleeping pills because her lover threatens to leave her, or the student who does the same when his parents demand more than his ability allows. This suicide attempt is a cry for help.
Some experts use the term «parasuicide» to refer to non-fatal acts in which a person voluntarily harms himself, such as taking a drug at a dose that is higher than prescribed by a doctor (Kreitman, 1977). The term «parasuicide» is preferred over «suicide attempt» because it does not necessarily mean a desire to die. As noted earlier, there are many more parasuicides than suicides. But most suicidal people experience such turmoil and stress that their thoughts are far from clear. They don’t know if they want to live or die; they want both at the same time, usually more of the former than of the latter. Since the best predictor of future suicide is past attempts, any parasuicide must be taken seriously. A person talking about suicide may actually try to do so. Many countries have established suicide prevention centers where people with difficulty can seek help over the phone or in person.
Bipolar Disorders
Most depressions occur without periods of mania. However, 5 to 10% of mood disorders involve both mood poles and are classified as bipolar disorders, also known as manic depression. In this case, a person alternates between depression and an unusual upsurge in mood. In some cases, the transition between depressive and manic periods occurs very quickly, with a very brief return to normal between them.
At first glance, the behavior of people experiencing a period of mania seems to be the opposite of depression. During episodes of mild mania, the person is energetic, enthusiastic, and confident. He talks incessantly, changes from one occupation to another, sleeps little and makes grandiose plans, the practicality of which worries him little. In contrast to the abundance of joyful feelings inherent in the usual high spirits, manic behavior is directed and often expresses not jubilation, but hostility.
People who experience episodes of severe mania behave according to the worldly idea of a «rampant maniac.» They are extremely excited and constantly active. They walk back and forth, sing, shout, or bang on the wall for hours. They get angry when trying to interfere with their activities and may act offensively. Impulses (including sexual impulses) are immediately embodied in words or actions. These individuals are confused and disoriented and may experience delusions of great wealth, achievement and power.
Tony was a middle-aged man with a rather shabby appearance; he was taken to the hospital by relatives as he was «out of control» and «going crazy». Just a month ago, Tony had been a sensible, rather accommodating person, but suddenly there was a dramatic change in his behavior. While working as a bus driver in Philadelphia, Tony suddenly stopped his bus at. dense stream of cars, turned to the passengers and burst into song. When asked about the incident, Tony said that he decided that he wanted to be a nightclub singer and that he was glad that he was fired from his driver’s job, as it would allow him more time to devote to his singing career. According to those present, Tony’s voice was terrible when singing. Two weeks ago, he went to Las Vegas, where he tried to meet with the managers of several casinos to convince them that he should be the one to run the show at their casinos. There, he was repeatedly arrested for threatening remarks about these managers and escorted out of the office. Then Tony decided that he should open his own casino in Philadelphia (although gambling is prohibited here), so that he could sing every night. To finance his plan, he emptied his family’s savings accounts and put his house up for sale.
Episodes of mania may not be interspersed with depression, but this is a very rare case. Typically, a period of depression occurs over time, after the person has experienced an episode of mania. This depression is similar to the one we have already described.
Bipolar disorders are relatively rare. While 21% of adult women and 13% of adult men in the United States experience major depression at some time in their lives, bipolar disorder occurs in less than 2% of the adult population, and with equal frequency among men and women (Kessler et al., 1994 ). Manic depression differs from other mood disorders in its earlier onset, greater family prevalence, and in the fact that it responds to various treatments and, in the absence of such, almost always recurs. It follows that biological variables play a larger role than psychological variables in bipolar disorder.
On the nature of mood disorders
As in the case of anxiety disorders, a combined biological-psychological model can more successfully explain the nature of mood disorders. Most people who develop depression, especially bipolar disorder, may have a biological predisposition to these disorders. However, experiences associated with certain types of events, along with a tendency to negative thinking, certainly also increase the likelihood of developing these disorders.
Biological approach
The tendency to develop mood disorders, especially bipolar disorders, is inherited. Twin data show that if one identical twin is diagnosed with bipolar disorder, the other twin has a 69% chance of having the same disorder. In related twins, the corresponding figure is only 19% (BerteIsenetaI., 1977). These numbers reflect concordance—the likelihood that both twins will have a certain property, provided that one of them already has it. The concordance value for depression in identical twins (53%) also
exceeds this indicator for related twins (28%), but in the case of depression, the difference in these values is less than in the case of bipolar disorder (McGuffin et al., 1991). This comparison shows that bipolar disorder has a stronger association with genetic factors than depression.
[…]
There is no doubt that mood disorders are associated with biochemical changes in the nervous system. The question remains whether these physiological changes are the cause or the effect of psychological changes. For example, people who intentionally behave as if they were going through a manic period show changes in mediator levels similar to those found in real patients with mania (Post et al., 1973).
Behavioral approach
Supporters of the theory of learning believe that the main role in the development of depression belongs to the lack of reinforcement. The depressed person’s inactivity and feelings of sadness are explained by the low frequency of positive reinforcement and/or the high frequency of unpleasant experiences (Lewinsohn et al., 1980; Lewinsohn et al., 1985). Many of the events that trigger depression (such as the death of a loved one, loss of a job, or illness) reduce the amount of habitual reinforcement. In addition, people who are prone to depression lack the social skills to either receive positive reinforcement or successfully deal with unpleasant events.
After a person has become depressed and inactive, the main source of reinforcement for him is the sympathy and attention received from friends and relatives. Such attention may initially reinforce the very behavior that turned out to be maladapted (crying, complaining, self-criticism, talking about suicide). But because it is tiring to be around someone who rejects fun, the depressed person’s behavior gradually alienates even those close to them, leading to further reductions in reinforcement, increased social isolation and unhappiness. A low frequency of positive reinforcement further reduces an individual’s activity, including those activities that could be rewarded. In a vicious circle, both the level of activity and the level of reward are reduced.
Cognitive approach
Cognitive theories of depression focus not on what a person does, but on how they perceive themselves and their environment. One of the most influential cognitive theories developed by Aaron Beck is based on extensive experience in the treatment of patients with depression (Beck, 1976; Beck, 1991; Beck et al., 1979). Beck was struck by the consistency of negative and self-critical evaluation of events by these patients. When evaluating their performance, they expect failure rather than success, exaggerate failures and downplay successes. When something goes wrong, they blame themselves, not the circumstances.
As noted in Chapter 11, emotions depend on our assessment of the situation. We all constantly evaluate what happens to us and what we do. We are sometimes aware of our assessments, and sometimes not. It seemed to Beck that in individuals with depression, negative thoughts arise quickly and automatically, as if reflexively. These thoughts are usually followed by unpleasant emotions (sadness, despair), which patients are very well aware of, despite the fact that the automatic thoughts preceding these emotions are not recognized by them or are barely recognized. Later, while studying patients with more severe depression, Beck noticed that negative thoughts no longer remained on the periphery, but dominated and recurred in the mind (Week, 1991).
Beck divided the negative thoughts of depressed individuals into three categories, which he called the cognitive triad: negative thoughts about oneself, about present experiences, and about the future. Negative thoughts about oneself (negative self-schema) include the conviction of a person in their worthlessness and inadequacy. In all current failures, a person blames his inability or shortcomings. Even in ambiguous situations where there is a more plausible explanation for failure, the depressed person blames himself. His negative view of the future is one of hopelessness. He is sure that his shortcomings will not allow him to improve the situation.
Beck believes that the negative self schema (“I am worthless,” “I can’t do anything,” “I can’t be loved”) in a depressed person is formed in childhood or adolescence by such experiences as the loss of a parent, social rejection by peers, criticism of parents or teachers. or a series of tragedies. These negative beliefs are activated whenever the new situation in any way resembles, perhaps only remotely, the conditions in which these beliefs were acquired, and then depression can develop. In addition, according to Beck, systematic errors (cognitive distortions) occur in the thinking of depressed individuals, which lead them to an incorrect perception of reality, which reinforces their negative schema of the Self. These cognitive distortions are shown in Table 15.5. XNUMX.
Table 15.5. Cognitive distortions in depression
According to Beck’s theory, fundamental errors of thinking are characteristic of depressed individuals.
Another strand of cognitive thought that addresses the various types of attribution, or explanations people use for unpleasant events, was discussed in Chapter 14. It is assumed here that people who tend to attribute negative events to causes that are internal (“ it’s my fault»), stable over time («it will always be like this») or spanning many areas of their lives («it will affect everything I do»), more prone to depression than people with a less pessimistic attribution style (Peterson & Seligman, 1984; Abramson et al., 1978). This theory does not claim that having such an attribution style is sufficient to cause depression. A pessimistic attribution style is only effective when a person encounters strong or frequent negative events in their lives (Abramson, Metalsky & Alloy, 1989; Peterson & Seligman, 1984).
Cognitive theories of depression have stimulated a lot of research. The results of some supported them, while others raised questions (for a review, see Haaga, Dyck & Ernst, 1991). On scales measuring negative thinking, depressed people were consistently higher than non-depressed people (the latter included both healthy and people suffering from other mental disorders). Their negative thinking includes all the components of Beck’s cognitive triad—self, present, and future. However, the argument that depressive thinking is particularly wrong or illogical seems weak. It is by no means obvious that only depressed people distort information and evaluate themselves illogically. Although depressed individuals are consistently pessimistic, in some cases their perception of reality is more accurate than that of normal individuals. It is also unclear to what extent self-criticism and/or a pessimistic attribution style precedes rather than accompanies episodes of depression. A number of studies in which subjects (mostly college students) had mild depression found an association between a pessimistic explanatory style and the degree of depression experienced when faced with bad events (Peterson & Seligman, 1984). However, a study of patients hospitalized with major depression has shown that depressive cognitions accompany depression but do not reappear after a period of depression. When patients’ depression dissipated, they no longer differed from control subjects (who were borderline depressed) in interpreting bad events (Fennell & Campbell, 1984; Hamilton & Abramson, 1983). Thus, a pessimistic attribution style is a symptom, not a cause, of depression. However, this is an important symptom because the strength of a person’s negative beliefs predicts how quickly they will recover from depression (Brewin, 1985).
Perhaps the style of interpreting bad events is important not so much for the development of depression, but for the belief in control over one’s own life. As we noted in Chapter 14, stressful situations are less disturbing if a person believes that to some extent he can control them. Confidence in one’s ability to cope with bad events increases depression resilience (Abramson, Metalsky & Alloy, 1989).
Psychoanalytic approach
According to psychoanalytic theories, depression is a reaction to loss (Fig. 15.6). Whatever the loss (rejected by a loved one, lost status, lost the moral support of a group of friends), the depressed person reacts to it very intensely, because the current situation returns him to an early state of fear of loss that existed in childhood — the fear of losing parental affection. . For some reason, the individual’s need for affection and care was not met in childhood. The loss experienced in a later life brings the individual mentally back to his helplessness and dependence, at the time when the original loss occurred. The behavior of the depressed person thus partly reflects a call for love and is a manifestation of helplessness, a call for affection and protection (Blatt, 1974; Bibring, 1953).
The reaction to the loss is complicated by anger at the person who left. According to one of the main tenets of psychoanalytic theory, depressed people have learned to suppress their hostile feelings because they fear alienating those on whose support they depend. When things are bad, they turn their anger inward and blame themselves. For example, a woman may feel extreme hostility towards the employer who fired her. But because her anger breeds anxiety, she turns her feelings inward: it is not she who is angry, but others who are angry with her. She admits that the employer had reasons to fire her: she is incompetent and worthless.
According to psychoanalytic theory, depressed people’s low self-esteem and feelings of worthlessness stem from a child’s need for parental approval. In a young child, self-esteem is built on the approval and affection of the parents. But when a person matures, self-esteem must also flow from a sense of personal achievement and success. In a depressed person, the sources of self-esteem are mainly external: it is the approval and support of others. When this support is lost, the person may fall into a state of depression.
Thus, psychoanalytic theories of depression focus on the role of loss, overdependence on external approval, and the inward turning of anger. They provide a reasonable explanation for some of the behavior of depressed individuals, but it is difficult to prove or disprove.
split personality
Split personality disease, also called multiple personality disease, is the existence in one person of two or more different selves, or personalities, that alternately control behavior. Usually each such personality has its own name and age, a certain set of memories and characteristic features of behavior. In most cases there is a primary self which bears the name of the individual and which is passive, dependent and repressed. The characteristics of the other selves tend to contrast with those of the primary self, such as being hostile, domineering, and self-destructive (American Psychiatric Association, 1994). See →