Depression Disorder Psychology-Disorders This Paper

Depression Disorder

Psychology-Disorders

This paper is about depression. It will cover the DSM diagnostic criteria, and discuss the development of depression from two viewpoints, CBT (cognitive-behavioral therapy) and the biochemical and environmental components which are linked causative factors. This paper will then cover the four key indicators of depression, including physical, cognitive, social and emotional symptoms.

Description of depression

DSM-IV criteria

Depression is typified by a number of key diagnostic factors. One can differentiate between generalized depression and major depressive episodes. In order to be diagnosed as a depressive episode, five of the following elements must be present, according to DSM-IV criteria:

Depressed mood most of the day, and every day.

Reduced sensory interest, including taste, visual, smell.

Significant change in body weight (up or down 5% per month). In children, weight gain is most common.

Insomnia or too much sleep.

Agitation or hyper retardation (of psychomotor skills) every day, observable by others.

Fatigue almost every day

Reduced ability to think or concentrate.

Feelings of low self-worth.

Recurrent thoughts about death (Fleener, 2007)

Depression's various aspects

Depression can be seen from several aspects. These are included in the above DSM criteria, but can be expanded as follows:

Physical: Depression can be both the cause and the effect of physical disabilities. It has been found, for example, that most CHF (Congestive Heart Failure) patients suffer from depression. CHF patients are generally in a downward spiral, in which they eat too much, do not exercise, and withdraw from others, including family (Freedland KE, 2003). Depression can also be a cause of stroke, heart disease and other circulatory ailments (Musselman, 1998).

Cognitive: Contrary to outward signs, depressed patients suffer from brain hyperactivity and stress, which makes it difficult to learn. Depression can lead to reductions in the ability to pay attention, to retain memories, and carrying out tasks (Austin, 2001). Because of this inner turmoil, many depressed people are unable to carry out their daily tasks.

Social: Patients who are depressed tend to withdraw from friends and family. They are unable to communicate effectively because of internal turmoil and a general wish to withdraw from all outside stimuli.

Emotional: Depressed patients tend to be in emotional pain, which includes prolonged sadness, feelings of guilt and poor self-image. As with the above aspects, emotional turmoil can also be a causative factor for depression: moving, divorce and death in the family or of close friends can trigger a major depressive episode or chronic depression.

Nature: Twins Studies Demonstrate Predisposition

Several studies have been performed on twins, including subsets in Denmark, on men only, and in a U.S. community. The special interest of twins' studies is that, to some degree, the impact of genetic factors can be determined independent of environment. Of course, twins many times grow up with one another, which is a factor that can confound the nature vs. nurture result.

Danish study of twins 75 years of age and older revealed that same-sex (although not identical) twins were much more likely to be subject to depression (McGue, 1997). Although not statistically significant, it appears that females were more likely to share depressive traits than men. The correlation is far from perfect: somatic heritability estimates (.31) and affect (.27) demonstrated that only 1/3 to 1/4 of twins were likely to share depression. If Danish twins are comparable to U.S. depression sufferers, which means that they are 4-5 times more likely to suffer depression than their non-twin counterparts. The 406-pair study was well-powered, particularly because age differences were filtered out. The study would have been helped, however, by adding more twins who grew up in separate families (due to adoption, for example).

Nature: Differences between Men and Women

Men and women may suffer from depression for different reasons. While it is well-established that women suffer depression more often than men, the reasons are not well-known (Brommelhoff, 2004). One theory, the "artifact hypothesis," is that women are more likely to seek diagnosis and treatment for depression.

A major Austrian study of 2,662 pairs of twins points to some of the differences between men and women. Whereas women tended to share a genetic predisposition to major depression (36-44%), men's predisposition to depression was only modestly related to "nature." Men who became depressed seemed much more likely to do so due to environmental factors rather than familial or genetic factors.

This Austrian study focused almost exclusively on Major Depressive Disorder, which is a more severe form of depression, using the DSM-IV and DSM-III criteria. This study does not cover specific depressive events. There was little difference, however, in genetic tendencies when three types of depression were analyzed: R major depressive disorder, major depressive disorder, and severe major depressive disorder.

Psychological Aspects of Depression

Depression can be addressed therapeutically from several viewpoints. The author has chosen two: CBT and biochemical approaches. Although CBT has been available since BF Skinner's day, it has gained currency as a short, intense method to reduce the triggers of depression. Biochemical means of controlling depression have made a significant improvement, but should not be used without additional forms of therapy. As we will see in this section, depression should be treated with at least one psychotropic therapy and one behavioral-changing therapy.

The underlying philosophy of CBT is that the patient can change his/her mental state with changes in stimulus and expected response. CBT offers the advantages of being targeted and relatively short-acting, meaning that lasting improvement can be realized in a short period of time. The fundamental theory behind CBT is the "desensitization" of the patient to certain stimuli (Rupke, 2006).

Rupke et al. (ibid.) found that CBT is best recommended on its own for unipolar (i.e. not in concert with manic behavior) depression, and that it should be used in concert with anti-depressant drugs for patients with severe or chronic depression, or for those who do not respond to medication. It should not be used for teens with severe depression.

Patients undergoing CBT are led by the therapist through their vision of themselves and the world around them. Feelings of low self-worth and futility are addressed logically ("This can't be so, because..."), which helps the patient to understand rationally that his/her feelings cannot be accurate. Thus CBT is initially an attempt by the rational side to confront the emotional side.

CBT then delves into changing stimuli to improve a patient's depressive symptoms. Since many of the symptoms mentioned above cause withdrawal, CBT counter-therapy does the opposite:

Schedules events with others which are pleasurable.

Giving measurable tasks which provide positive reinforcement when completed ("I can do it")

Physical activity, which helps biochemically as well as emotionally.

CBT focuses on specific parts of a depressive person's symptoms, then moves outward to deal with longer-lasting and underlying causes of depression. These can deal with distortions in thinking which affect a depressed person's self-image and reaction to the world, then moving on to longer-lasting "schemas" (or underlying assumptions) which take additional work and stimulus to correct.

One of the benefits of using CBT is that it can be more easily-tested and -standardized than other forms of 'talk therapy.' A study performed in 1996 analyzed 150 randomly-selected outpatients to full CBT, and to a partial CBT called "behavioral activation (Jacobson NS, 1996)." Full CBT included "schema" modification over a longer period of time. The ultimate result of the study was that those patients undergoing behavioral activation were just as likely to see reductions in their depression scores than patients who undergo the full cycle of CBT, including long-term "schema" activation. The study would have been more helpful if it had included an anti-depression drug arm, which would have indicated if longer-term "schema" therapy would have been helped by the increased awareness and calmness conferred by the psychotropic drugs.

A meta-analysis on combination therapy revealed that most patients benefit from CBT in conjunction with anti-depressive medicines than with the medicines alone (Coltraux, 1998) (Thase ME, 1997). Part of the reason that therapist-led activity is important is that the underlying causes of depression are not addressed by drugs alone. In some cases, anti-depression medicines can exacerbate the situation, making the patient face his/her causes of depressive symptoms without the psychological tools to combat it.

Major contribution: nature or nurture?

Until psychotropic drugs were introduced in the 1950s, there was little that could be done to alter the course of depression. The first generation of drugs, including Lithium and Valium, worked primarily to dull the brain's activity, including the hyperactivity in some segments which caused depression. More recent drugs have targeted serotonin receptors more specifically; this has caused none of the previous patient complaints of feeling removed or dulled, although there have been some complaints of sexual dysfunction and suicide may be increased in teens.

The success of serotonin inhibitors has led to additional research into the biochemical causes of depression. Depression runs through families, which can contribute both environmental and biochemical elements to a patient's depression. Although the biochemical and hormonal causes are not known, it has been demonstrated that depression can run for generations. Perhaps the best way to regard the genetic component which predisposes a person to become depressed, generally with the help of his/her environment or a specific set of stress-producing depressive triggers, such as death, bereavement, loss of employment or other major family problem.

Depression affects about 5% of the U.S. population, and has remained steady since 1970, with the exception of women under 45; in this subset of the population, depression rates have doubled in the past three decades. This increase has been offset by reductions in other population subsets, including younger men, older men and older women (Fleischmann, 2000). This increasing prevalence amongst this group suggests that there is a social component to depression which has changed in those women born in the baby boom. While there may be a biochemical origin in those increases, life stresses could also be a contributor. Specifically, during that period more women below age 45 have entered the workforce, and therefore are balancing the multiple stressors of job and childcare.

Typically, chronic depression is triggered by one or two "major" events, which start the cycle (Fleischmann, 2000) of depression, depressive behavior, and continued or deepened depression. Subsequent chronic depression is a devil's circle, which uses the negative stimuli of withdrawing from social contact, poor health and continued worry to maintain or deepen the depression.

Depression: The Scent of a Woman

There are a number of films which feature depressed leading actors. The author has chosen the Scent of a Woman because the character had real-world reasons for contracting depression (blindness) which may not have been present prior to his becoming visually impaired.

Al Pacino played Colonel Frank Slade, who had planned a wild weekend with his reluctant 'caretaker,' Charlie, who was hired for that period to accompany Slade on his trip (imdb, 1992). Slade's depression is initially caused by his going blind, but exacerbated by his withdrawal from society as none of his senses could be used in a way that he could use them before.

The author uses this example because, although it was never stated that way in the movie, Frank Slade was clinically depressed due to external traumatic events. His plan was to kill himself after his "blowout" weekend. Thus, by DSM-IV criteria, Slade was depressed:

He had thoughts of death.

He had withdrawn from society.

He suffered from hyperactivity, and yet could not sleep.

He suffered as well from sensory deprivation -- or the lack of sensory stimuli.

He had feelings of low self-worth which, in the movie.

Charlie offered a mirror to Slade in a way which allowed him to rationally accept that he was in fact a worthy human being, and that he could pursue sensual experiences despite his handicaps. The movie ends on a triumphal note with Charlie convincing Slade that he should live. One is left to wonder whether it would be so simple for Slade; subsequent events in his therapy should include more positive stimuli (going out and dancing with women, for example) and supplemented by additional social contact. It is in Slade's reaching out to someone that he was ultimately saved.