ASSIGNMENT 2: Pathology, Diagnosis, and the DSM-5

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Learning Objectives

After reading this chapter, you should be able to:

Differentiate among anxiety, fear, and panic.

Understand the causes and treatments of specific phobias.

Discuss the causes and treatment of social anxiety disorder (social phobia).

Summarize the causes and treatment of generalized anxiety disorder.

Explain the causes and treatment of panic disorder and agoraphobia.

3 Anxiety and Obsessive-Compulsive Disorders

lolloj/iStock/Thinkstock

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Discuss the causes and treatment of obsessive-compulsive disorder and related disorders.

Understand anxiety related to substance use and medical conditions.

Discuss the causes and treatment of obsessive-compulsive disorder and related disorders.

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3.1 Anxiety, Fear, and Panic When we encounter any kind of threat or stressor, we experience a number of physiological responses: Heart rate, blood pressure, and breathing increase; muscles tense; blood vessels constrict; the liver releases glucose to provide quick energy to muscles; and the spleen releases red blood cells to help carry oxygen. We feel fear or dread; we may also feel irritable or restless. We scan our environment for signs of danger. The intensity of our responses depends on the perceived magnitude of the stressor or threat.

The Anxiety Spectrum

For people with anxiety disorders, these responses occur continuously or intermittently when no real threat or stressor is present or when they encounter a stimulus that is similar in some way to the original threat or stressor. Typically, their reaction is out of proportion to the degree of danger. Anxiety manifests itself in a spectrum from mild to severe (see Figure 3.1).

Figure 3.1: Anxiety spectrum

Anxiety can manifest itself as something as mild as worry or something as severe as a panic attack.

Source: A d a p t e d A d a p t e d f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l dM a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 4 . 4 , 4 . 4 , p . p . 1 4 3 . 1 4 3 .

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Anxiety Disorders Related to Medical Conditions and Substance or Medication Use

A variety of medical conditions can cause symptoms similar to those associated with anxiety disorders. An overactive thyroid gland, heart disease, vitamin deficiencies, respiratory disease, and brain tumors are among the conditions that share symptoms with the anxiety disorders. Alcohol, caffeine, and many prescription and illicit drugs can also cause anxiety symptoms. Before diagnosing an anxiety disorder, we need to be sure that an individual’s anxiety is not related to a medical condition or to substance use or withdrawal from a substance. A prudent method is to make sure the individual has had a complete physical before starting psychotherapy.

Let’s consider the case of Carole Ballodi.

The Case of Carole Ballodi: Part 1

On the night of February 24, three seriously injured infantry soldiers were transported by helicopter to Medivac Unit 4 CB, which was under the command of Captain Carole Ballodi. Captain Ballodi and her team of medics and nurses began to stabilize the wounded in preparation for surgery, when they found themselves under fire. They called for assistance, but before air strikes could be ordered, their Medivac unit was hit by a rocket. One of the wounded soldiers was struck in the head by shrapnel and killed instantly while Captain Ballodi was taking his pulse. A nurse was gravely injured. Although electrical supplies were cut off, and the shelling continued, Captain Ballodi and her team managed to tend to the wounded until the shelling stopped. She then assisted in an emergency surgery that required the amputation of one soldier’s leg. Captain Ballodi’s actions during that night saved the lives of the injured soldiers. She is worthy of the highest commendation.

Initial Interview Between Carole Ballodi and Psychiatrist Dr. Sally Kahn

UNIVERSITY HOSPITAL

Psychiatry Service

Consultation Transcript

Referring Physician: Dr. Berg

Reason for Referral: Carole Ballodi is an internal medicine specialist at University Hospital. She was brought to the emergency room complaining of chest pain. A physical examination proved negative. Because of her agitation, she was referred for a psychiatric consultation.

Posttraumatic stress disorder (PTSD) appeared in the “Anxiety Disorders” chapter of the DSM–IV–TR. In the DSM–5 it was moved to the “Trauma and Stressor-Related Disorders” chapter. Because Carole demonstrates signs and symptoms of panic disorder as well as PTSD we have decided to keep her case in this chapter.

DR. KAHN: Tell me, what do you consider your main problem?

CAROLE: I have these pains in my chest and feel like I can’t catch my breath.

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DR. KAHN: When does this occur?

CAROLE: One time was in my car. I was just about to get on the bridge. I was at the toll booth when I heard a helicopter overhead. I panicked. I couldn’t catch my breath. I broke out in a sweat, and I could feel my heart pounding. I felt like there was a tight band across my chest. I got dizzy, hot, and nauseous. And I was very frightened. I thought I was dying.

DR. KAHN: Can you recall what thoughts were going through your head when this happened?

CAROLE: Actually, I can. I thought that the helicopter sounded like the ones that delivered the wounded to the Medivac unit in Iraq. I think I just panicked.

DR. KAHN: You panicked?

CAROLE: Yes. I was afraid that the helicopter would come down and crash into my car.

DR. KAHN: What would happen to you?

CAROLE: I would be disabled for life and have to use a wheelchair.

DR. KAHN: So, you were thinking about these things and then began to feel the chest pain?

CAROLE: I’m not sure—it all seemed to happen together. I was thinking about the helicopters and my car, and then I felt the pain in my chest and had trouble breathing.

DR. KAHN: What happened next?

CAROLE: I pulled over to the side and just sat there. Traffic backed up behind me, but there was nothing I could do. It was like it was happening to someone else. Finally, someone called an ambulance.

DR. KAHN: What happened in the hospital?

CAROLE: I felt better by the time I got to the hospital. They ran the usual tests but found nothing. They suggested that I see you.

DR. KAHN: Have you “panicked” at any other time?

CAROLE: Yes. Mostly at night. I wake up at two or three in the morning. I’m covered in sweat and my heart is racing. I can hardly catch my breath. I think I’m going to die.

DR. KAHN: Is there anything specific that set all this off?

CAROLE: I had a patient die in my office. It brought back the war. I never used to, but now I spend hours each night going over things that have happened in the past. I relive what happened in Iraq. It’s like a videotape that I play over and over again in my mind while I ask myself whether I could have done things differently.

DR. KAHN: What do you do when you wake up during the night?

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CAROLE: I usually check all the windows and door locks and then I go back to sleep.

DR. KAHN: What about your work?

CAROLE: I can’t concentrate on anything. I’ve taken practically all of my sick days.

DR. KAHN: What are you doing about your problems?

CAROLE: Mostly I stay home, hoping that rest will help. I have a few drinks to help me sleep.

DR. KAHN: Has this worked?

CAROLE: Well, the drinks knock me out, but I’m missing lots of work.

DR. KAHN: Do you go out with friends?

CAROLE: No. I’m afraid to leave home. I’m afraid to get in my car. I might have another incident. I’m not interested in seeing anyone, and sex leaves me cold.

DR. KAHN: Do you ever see anyone you served with in Iraq?

CAROLE: No. I was never really bothered by the war, but I don’t want to talk to anyone. Who knows what they might think? I don’t know what’s happening to me. I think I’m going mad.

On the basis of their discussion, Dr. Kahn felt certain that Carole Ballodi was suffering from an anxiety disorder or a trauma or stressor-related disorder, probably related to her war experiences. Before Dr. Kahn could be more certain, however, she had to consider the possibility that Carole’s behavior was the result of a general medical condition. A variety of medical disorders can cause symptoms similar to Carole’s. Because alcohol, caffeine, and many prescription and illicit drugs can also cause anxiety symptoms, Dr. Kahn had to be sure that Carole’s behavior was not substance related (or related to withdrawal from a substance). Thus, Dr. Kahn began by ordering a medical history as well as physical and laboratory examinations. These found no evidence of a relevant medical condition or substance-induced anxiety.

Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch03.pdf) for full case study.

Before we continue, we need to define anxiety, fear, and panic. These concepts may seem similar if not identical, but you will soon see that they are not.

Anxiety

Anxiety is an emotional state marked by an intense feeling of foreboding and somatic signs such as a racing heart, sweating, and difficulty breathing. The individual is afraid that the future will bring only bad results. Anxiety is a feature of everyday life. Anxiety is similar to fear but with a less specific focus. Whereas fear is usually a response to some immediate threat, anxiety is characterized by apprehension about imagined or real unpredictable dangers that

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may lie in the future. The limbic system, a complex set of brain structures that controls our emotions (see Figure 3.2), is involved in mediating anxiety levels. Low levels of anxiety are adaptive; they help us avoid danger (“I don’t like the look of that dark street”) and plan for the future (“I better study for the final exam or I will fail”). Anxiety becomes maladaptive when it interferes with a person’s relationships and daily functioning. Table 3.1 lists the DSM– 5 anxiety disorders.

Figure 3.2: The limbic system

Except for the pituitary, all the highlighted areas in the forebrain are part of the limbic system and normally receive signals from neurons that secrete mood-altering neurotransmitters. Some neurotransmitter pathways are indicated by arrows.

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Source: A d a p t e d A d a p t e d f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l dM a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 4 . 3 , 4 . 3 , p . p . 1 4 1 . 1 4 1 .

Table 3.1: The DSM–5DSM–5 anxiety disorders

Separation anxiety disorder Agoraphobia

Selective mutism Generalized anxiety disorder

Specific phobia Substance/medication-induced anxiety disorder

Social anxiety disorder (social phobia) Anxiety disorder due to another medical condition

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Panic disorder Other specified anxiety disorder

Note: The DSM–5 includes an additional diagnostic category for “Unspecified anxiety disorder.” Vague references to “unspecified” disorders appear throughout the DSM–5. Because they have no specific symptoms, etiology, or treatment, these disorders are not discussed in this book.

Fear

Fear is an emotion that occurs in response to some real immediate threat or danger. Fear serves a positive purpose: It helps mobilize the body’s defenses quickly in situations requiring fight or flight (defending oneself or running away) from a dangerous situation or an enemy. Lineage studies have found a tendency for fear to run in families (Van Houtem et al., 2013). Twin studies, for example, help us to determine whether behavior and mental illness, among other things, are caused by the environment or by biology. Because identical twins have the same genes and DNA, differences can be attributed to their environments. Identical twins raised apart are equally likely to develop fears and to be afraid of similar things (Kendler et al., 2008).

Panic and Panic Attacks

Panic is an extreme anxiety reaction that can result when a real threat suddenly emerges. Some definitions might add that the threat can be perceived instead of an actual threat. The experience of panic attacks, however, is different. Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass. Sufferers often fear they will die, go crazy, or lose control. Attacks happen in the absence of a real threat. We will discuss panic, panic attacks, and panic disorder in depth later in this chapter.

Panic attack was not a diagnosis in the DSM–IV–TR and is not in the DSM–5. However, the specifiers for different types of panic attacks have been changed from cued, situationally predisposed, and uncued to unexpected and expected panic attacks. Panic attack is a specifier that can now apply to all DSM–5 diagnoses (American Psychiatric Association [APA], 2013).

Comorbidity and the Anxiety Disorders

Recall the term comorbidity from Chapter 1. Comorbidity (when a disorder has a high level of co-occurrence with other disorders) is common with the anxiety disorders. Anxiety disorders are frequently accompanied by depression (Kessler, Sampson, et al., 2015). This association is so common that Brown and Barlow (2002) theorized that anxiety and depression may share a common feature: They both involve emotional distress, but they vary in how the distress is expressed. People with other psychological disorders (for example, schizophrenia) commonly report anxiety symptoms as well.

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william87/iStock/Thinkstock

For some people, going to the dentist can be a frightening experience, leading to heightened anxiety about going for necessary checkups.

Death Storms

Flying Enclosed places

Snakes Illness/injury

Dentists Traveling alone

Heights

Table 3.2: Common fears and phobias

3.2 Specific Phobias At one time or another, everyone is afraid of something: snakes, storms, airplanes, or dentists. Fear is an important evolutionary adaptation (LeDoux & Pine, 2016). But fear can also be debilitating. It can torment us, destroy our sleep, and rob our lives of pleasure. In extreme cases, it can cause disease or even death. Rational fears are not phobias. If you hurry home after hearing a storm warning on your car radio, you do not have a phobia—no matter how frightened you may feel. However, if your fear of storms is so intense that you board up all your windows and at the slightest threat of a rain shower you run home and barricade all of the doors and windows, and head to the basement, then you probably have a phobia. Fears become phobias when they disrupt daily life enough to justify clinical intervention (APA, 2013).

A specific phobia consists of a persistent, excessive, and irrational fear of an object or situation coupled with a strong desire to avoid the feared

object or situation. People with phobias display extreme fear reactions when exposed to the feared stimuli. They recognize that their reaction is excessive and unreasonable, yet their fear disrupts their everyday lives (APA, 2013).

Etiology of Phobias

It has been estimated that anywhere from 7.7% to 12.5% of the world’s population will meet the criteria for a specific phobia disorder at some time in their lives (Wardenaar et al., 2017). The overall average lifetime prevalence is estimated to be approximately 7.4% (Wardenaar et al., 2017). Once a phobia is established, it tends to last a lifetime unless it is ​specifically treated. The Encyclopedia of Phobias, Fears, and Anxieties (Doctor, Kahn, & Adamec, 2008) has more than 2,000 entries. Phobias are determined by the complex interaction of cultural and social norms (fears vary across cultures), learning experiences (your best friend screams when she sees a spider and you become afraid of spiders), and cognitive components (your thoughts and beliefs). Table 3.2 lists some of the more common phobias.

CulturalCultural and and Social Social Determinants Determinants To a large extent, our culture and society determine the objects and situations we fear (Sato, Yuki, & Norasakkunkit, 2014; Yeh, Nguyen, & Lizarraga, 2014). The Aborigines of Central Australia, for example, have an intense fear of violating sacred tribal sites (Strehlow, 1985). Those who violate taboo areas are subject to “bone-pointing,” in which a tribal elder takes the leg bone of a kangaroo, dips it into an anthill, covers the end with human hairs, and points it at the transgressor while chanting a curse. Aborigines fear bone-pointing so much that some of those subjected to the curse have reportedly died from fright (Basedow, 1925). When culture-bound fears become extreme enough to interfere with normal daily functioning, they cross over into becoming phobias.

LearningLearning Experiences Experiences

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According to behavioral psychologists, a phobia is acquired initially through classical conditioning: A neutral stimulus that is repeatedly paired with a fear-inducing stimulus will, in time, elicit the fear response even in the absence of the primary fear-inducing stimulus. A bell doesn’t evoke a fear response, but if it is paired with a feared stimulus—a painful shock—it will eventually evoke a fear response even in the absence of the painful shock. Over time, a person comes to avoid situations related to the one that originally caused a fear response. Once the phobia is generalized (occuring in situations similar but not identical to the original situation), the avoidance response continues because avoiding feared objects reduces anxiety, which in turn reinforces future avoidance.

Behaviorists note that phobias may be acquired indirectly by observing fear in others (Bunaciu, Fleschin, & Aboul- Enein, 2014). Mineka (1985) found that rhesus monkeys raised in captivity were not afraid of snakes until they observed the fearful reactions of monkeys raised in the wild. Although observational learning may account for many fears acquired in the absence of aversive experiences, exposure alone may not be sufficient for phobias to develop. Mineka’s monkeys did not develop fears of flowers or a toy rabbit, even when exposed to apparently fearful models (Mineka 1985; see also Cook & Mineka, 1991). Perhaps observational learning produces phobias only for dangerous objects and situations that evolution has genetically “prepared” us to fear (McNally, 2016). For example, humans are genetically prepared to acquire a fear of heights (we can fall from a high place and be injured or killed) and spiders (some spider bites can be lethal). Through evolution, we have developed phobias to make our survival more likely. Of course, even this “preparedness” hypothesis has difficulty determining whether our fears are due to evolution or to the environment (McNally, 2016).

CognitiveCognitive Determinants Determinants Cognitive therapists believe that some people habitually make fearful attributions to objects or situations, overestimate the probability of risk, and underestimate their personal ability to cope (Beck & Haigh, 2014). Bandura (1986) suggested that, for some people, perceived inability to cope is responsible for anxiety and avoidance behaviors. In other words, the real cause of fear is not the feared stimulus but rather the feelings of inadequacy in dealing with the challenge it presents. Fearful thoughts may become self-fulfilling prophecies: For example, fearing failure on an examination may cause people to fail.

Treatment for Specific Phobias

Therapeutic and drug treatments for specific phobias are described in the treatment sections related to social anxiety disorder, since the treatment approaches are similar.

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Evan Agostini/Invision/AP Photos

Barbra Streisand, the famous singer, actress, director, and producer is a well-known individual with social phobia.

3.3 Social Anxiety Disorder (Social Phobia) The fear of examinations and speaking in front of other people (“stage fright”) are both forms of performance anxiety. For example, employment tests, driver’s license tests, and medical examinations can produce feelings of apprehension and dread in many people, and can significantly impact one’s life (Cooper, Hildebrandt, & Gerlach, 2014; Morrison & Heimberg, 2013; Sloboda, 1990). Although low to moderate levels of anxiety may facilitate performance, high levels of anxiety lower performance (Sodhi, Luthra, & Mehta, 2016). In some instances, extreme anxiety may render people unable to perform at all. It can produce eating and sleeping disorders, and it can make sufferers physically ill (Culbert, Racine, & Klump, 2015; Shanahan, Copeland, Angold, Bondy, & Costello, 2014; Vogelzangs, Beekman, De Jonge, & Penninx, 2013). Performance anxiety occurs in both Western and Eastern cultures (Ruscio et al., 2007), but cultural sensitivity is necessary when interpreting performance anxiety. Among Native American cultures, for instance, it is considered improper, impolite, and even disloyal to stand out from one’s peers (Dasen, Berry, & Sartorius, 1988; Kagitçibasi & Berry, 1989). Because people with performance anxiety can usually interact successfully with others (provided they do not have to perform), few seek professional help. For some people, however, the fear of being evaluated by others extends to most aspects of social interaction. These people may curtail their social lives, even sacrifice their careers, to avoid threatening social situations. Such persons are likely to be suffering from social anxiety disorder (also known as social phobia; APA, 2013).

Social phobia, which usually begins in adolescence, represents an extreme form of performance anxiety in which the fear of social evaluation may severely restrict a person’s life (Iverach & Rapee, 2014). Like most anxiety disorders, social phobia affects more females than males (Pesce et al., 2016). Social phobias may sometimes be traced to a specific triggering event, such as an inability to find a date for the senior prom or being bullied during early adolescence (McEvoy & Saulsman, 2014). It is more often due to innately fearing angry, critical, or rejecting people or their faces (McEvoy & Saulsman, 2014; Prater, Hosanagar, Klumpp, Angstadt, & Phan, 2013).

Therapeutic Treatment for Specific and Social Phobias

Many different treatments have been developed to deal with specific phobias and social phobia (Arroll, Wallace, Mount, Humm, & Kingsford, 2017; Mayo-Wilson et al., 2014). Although each has its specific aspects, they all seek to motivate people to change, ensure that they prepare, and expose them to the feared stimulus. No matter what treatment is used, an important factor in helping someone to overcome any problem is to establish a trusting therapeutic relationship.

PsychoanalyticPsychoanalytic Treatment Treatment of of Specific Specific and and Social Social Phobias Phobias Psychoanalysts view phobias as surface manifestations of unconscious conflicts that are displaced onto an object or situation with some symbolic connection to the conflict. Psychoanalytic treatment consists of uncovering the repressed memories assumed to underlie fear and avoidance. Dream interpretation, free association, and other psychoanalytic techniques are used to lift repression and make unconscious conflicts conscious. Psychoanalysts may expose patients to the object they fear (Karon & Widener, 2013). In such cases, exposure is not expected to

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lemhartley/iStock/Thinkstock

Part of the flooding technique involves exposing the fearful individual to the feared stimulus.

extinguish the fear but to help retrieve repressed conflicts and desires. Psychoanalytic treatments are rarely used today in the treatment of specific phobias and social anxiety disorder.

BehavioralBehavioral Treatment Treatment of of Specific Specific and and Social Social Phobias Phobias Behavioral treatments focus on exposure. Perhaps the best-known exposure technique is systematic desensitization, developed by Joseph Wolpe (1997). The technique has three parts. The first is relaxation training; the second is the construction of an anxiety hierarchy in which fear-related images are arranged according to the degree of anxiety they elicit. The third part involves the gradual presentation of the hierarchy images while the person attempts to maintain a relaxed state. The rationale is that one cannot be both fearful and relaxed at the same time. Thus, a fearful person who can learn to relax while imagining anxiety-provoking scenes will eventually cease being afraid.

Another behavioral technique, flooding, requires fearful individuals to become “flooded” with emotion through exposure to the feared stimulus. Because their fear is not “reinforced” (nothing bad actually happens), repeated exposure should eventually cause them to no longer feel afraid. Implosive therapy is a type of flooding in which exposure is done through imagery rather than in real life (Schare & Wyatt, 2013).

Cognitive-BehavioralCognitive-Behavioral Treatment Treatment of of Specific Specific and and Social Social PhobiasPhobias The goal of cognitive-behavioral treatment is to help clients learn to reappraise feared situations so that they can replace maladaptive cognitions (thoughts and attributions) about dangerous objects or situations and fear of failure with positive cognitions (McAleavey,

Castonguay, & Goldfried, 2014).

One cognitive-behavioral technique that has been applied to social phobia is stress inoculation (Jackson, Compton, Thorton, & Dimmock, 2017). Stress inoculation begins with an educational phase in which people are taught about the role that negative self-statements play in performance anxiety. Next, clients are taught more accurate self- statements that they can then practice in stressful evaluative situations. In the final stage, clients are taught coping skills designed to help them deal with, rather than avoid, evaluative situations.

Drug Treatment for Specific and Social Phobias

Many people with performance anxiety, specific phobia, social phobia, or any other anxiety disorder might be offered anxiolytic drugs (lysis is Greek for “dissolve”; anxiolytics dissolve anxiety). The most popular anxiolytic medications today are the benzodiazepines. All benzodiazepines are descendants of chlordiazepoxide (Librium), whose anxiolytic effects were discovered accidentally by researchers observing how various chemical compounds affect animal behavior (Calcaterra & Barrow, 2014; Dell’osso & Lader, 2013). Diazepam (Valium) remains one of the most widely prescribed medications. Xanax (alprazolam), a high-potency benzodiazepine, is a reasonable alternative medication (Calcaterra & Barrow, 2014; Griffin, Kaye, Bueno, & Kaye, 2013). Table 3.3 contains the chemical (generic) names and the U.S. trade (brand) names of some of the most commonly prescribed benzodiazepines.

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Table 3.3: Common benzodiazepines

Common U.S. Trade Name Generic Name

Xanax alprazolam

Librium chlordiazepoxide

Tranxene clorazepate

Valium diazepam

Dalmane flurazepam

Serax oxazepam

Note: Medication trade names always begin with a capital letter. Generic names always begin with a lowercase letter.

Even though benzodiazepines can temporarily relieve anxiety (Starcevic, 2014), they are not without risk. Benzodiazepines are known to cause drowsiness (so they may adversely affect school or work performance), and they may harm cognitive functioning (Chen et al., 2016; Starcevic, 2014). Starcevic et al. (2014) note that findings about benzodiazepines causing cognitive changes are conflicting, which may be the result of confounding variables. Benzodiazepines may cause sleep issues, but again the evidence is conflicting. Chen et al. (2016) found that subjects who used long-acting benzodiazepines (that is, those with a longer half-life) had higher quality nighttime sleep than did those who used short-acting ones or who had longer daytime naps. They concluded that the subjects’ improvements were modest at best, and the evidence remains inconclusive. Benzodiazepines are also associated with injury due to falling (hip fractures), especially in senior citizens (Ham et al., 2017; Starcevic, 2014). Starcevic et al. (2014) note that antidepressants and antipsychotics also increase fall risks in senior citizens, which indicates other factors may be involved in the increased risk. Finally, even standard doses of benzodiazepines may cause tolerance, in which people require larger and larger doses to achieve the same therapeutic effect (Calcaterra & Barrow, 2014). For example, a 2013 SAMHSA study found that, on a typical day, 31 out of 174 emergency department visits for drug misuse or abuse by children aged 12 to 17 (about 18%) were for benzodiazepine abuse. If a medication not only calms you down but also relaxes your muscles, it has potential to become physiologically addicting. Benzodiazepine abuse is a real problem, and clinicians need to be especially aware of it.

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3.4 Generalized Anxiety Disorder (GAD) People with generalized anxiety disorder (GAD) feel apprehensive about vague or future events that may or may not occur. As soon as one cause for worry is eliminated, they become anxious about another or they worry about several things simultaneously. Their anxiety arises without any provocation; it is “free-floating.” Along with their many worries, people with GAD are often restless and irritable. They describe themselves as being “on edge,” and their muscles are habitually tense.

Etiology of GAD

Although probably the most common anxiety disorder after phobias, GAD is not frequently diagnosed in the psychology clinic. One researcher (Allgulander, 2012; Mackenzie, Reynolds, Chou, Pagura, & Sareen, 2011) estimated that only about 28.3% of individuals who have GAD sought treatment over a 12-month timeframe. For older individuals who did not have a concurrent diagnosis, the percentage fell to 18%. Allgulander (2012) found that in Great Britain only 8% of those diagnosed with GAD sought treatment. Many individuals never get to the clinic because they “treat” themselves with alcohol or other means. The individuals who do get to the clinic frequently receive some other diagnosis because GAD is often co-morbid with other disorders (Allgulander, 2012; Moreno- Peral et al., 2014). (Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch03.pdf) and see Part 2 of Carole Ballodi’s case.)

PsychoanalyticPsychoanalytic Views Views of of GAD GAD Psychoanalysts attribute GAD to a subconscious conflict between the ego and the id. The ego attempts to prevent the id’s sexual impulses from breaking through to the surface because it fears the punishment that might ensue. But the ego’s repressive strategy is only partly successful. Sexual impulses remain unconscious but not the associated fear of punishment. The result is that the person is always fearful and apprehensive but does not know why. Like most psychoanalytic hypotheses, this explanation for GAD relies on clinical observations rather than controlled research for its support.

BehavioralBehavioral Views Views of of GAD GAD Behaviorists view GAD as a form of classically conditioned (learned) fear that differs from a specific phobia or social phobia only by its greater generality (Lissek et al., 2014). People with GAD are always afraid because they are always encountering feared stimuli.

Cognitive-BehavioralCognitive-Behavioral Views Views of of GAD GAD Cognitive psychologists propose that people with GAD fear loss of control and helplessness. Experimental support for this theory comes from several classical experiments conducted in the 1940s by Mowrer and Viek (1948). These researchers administered electric shocks to rats while the animals ate (see Figure 3.3). Rats that were unable to control the shock came to fear and avoid the area in which they were shocked, even though this was also the place in which they were fed. Rats that were taught how to terminate the shock—given a means of control—did not avoid the feeding area (Mineka, 1992).

Figure 3.3: An experiment illustrating the consequence of controllability

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The “executive” rat can control the electric shock to its tail by turning a wheel. The “subordinate” rat has no control over the shock. The control rat receives no shock at all. Neither the control rat nor the executive rat avoids the feeding place. The subordinate, by contrast, becomes vigilant and anxious.

Source: J . J . M a s e r M a s e r a n d a n d M . M . E . E . P. P. S e l i g m a n S e l i g m a n ( E d s . ) , ( E d s . ) , Psychopathology: Experimental Models. S a n S a n F r a n c i s c o :F r a n c i s c o : W. H . W. H . F re e m a n , F re e m a n , 1 9 7 7 . 1 9 7 7 . R e p r i n t e d R e p r i n t e d b y b y p e r m i s s i o n . p e r m i s s i o n .

Because most people have sexual and aggressive thoughts at one time or another and because everyone feels frightened or helpless sometimes, psychoanalysts, behaviorists, and cognitive psychologists agree that GAD develops only when there is a preexisting diathesis (vulnerability). Although there is evidence that the diathesis for GAD may be inherited (Newman, Llera, Erickson, Przeworski, & Castonguay, 2013; Sharma, Powers, Bradley, & Ressler, 2016; Stein & Sareen, 2015), there is also evidence that it is acquired (Newman et al., 2013). We know that the social environment contributes to the disorder because GAD is more common in dangerous environments, such as in war-torn areas and inner-city ghettos (Sheidow, Henry, Tolan, & Strachan, 2014). (See the accompanying Highlight.)

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Highlight: How Does Hollywood Portray Anxiety Disorders?

Have you ever seen the movie Vertigo? It stars Jimmy Stewart as a police detective who has a crippling case of acrophobia—an extreme fear of heights. How about Marathon Man, in which Sir Laurence Olivier stars as a sadistic Nazi dentist who tortures Dustin Hoffman in an effort to get him to reveal information related to a stash of stolen diamonds? He drills into Hoffman’s teeth without using Novocain, among other horrors. How about any of the Peanuts specials? In virtually all of them, Charlie Brown is afraid that something disastrous will occur to him in the future, so much so that he either avoids situations (asking the little red-haired girl out) or sets himself up for failure (though, to his credit, he keeps trying). How accurate are these portrayals of acrophobia, an event that could trigger a dental phobia, and a child’s experience with what might appear to be GAD? As with anything else, Hollywood tends to exaggerate and misinterpret anxiety disorders, as well as mental illness in general. Although Vertigo is a classic film, how likely is it that a police detective could hold down his job if he suffered from acrophobia? How realistic is it to think that people develop dental phobias because of sadistic dentists just waiting to work on their patients without using anesthetic? And how accurate is the portrayal of Charlie Brown’s near-constant experience of anxiety? He never succeeds in anything; indeed, he cannot even buy a good Christmas tree. His creator, Charles Schulz, got one aspect of GAD right: Even though Charlie Brown rarely if ever succeeds, and is convinced he will always fail, he never stops trying. Is this because of his determination to succeed, his optimism that he will eventually succeed, or his inability to learn from past experiences?

Therapeutic Treatment for GAD

Therapeutic treatment for GAD is determined largely by the theoretical orientation of the practitioner. Psychoanalysts use free association, dream interpretation, and other techniques to help people confront their repressed impulses and conflicts, whereas practical, traditional behavioral clinicians use desensitization and other forms of exposure therapies. Relaxation training may help people reduce their level of anxiety in general, especially if it is used in conjunction with cognitive therapy (Heimberg & Magee, 2014; Lang, 2004). Cognitive interventions are usually aimed at the chronic worry that is characteristic of people with GAD (Hanrahan, Field, Jones, & Davey, 2013). In a safe therapeutic environment, clients can face the anxiety-producing images, thoughts, and ideas directly. They learn to use coping techniques to control their worrying. Behavioral and cognitive treatments are reported to be about equally effective in the treatment of GAD, and both are better than no treatment at all (Newman & Fisher, 2013).

Drug Treatment for GAD

Anxiolytics can be prescribed for GAD; however, the selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac) and paroxetine (Paxil) are preferred because of their lack of physiological addiction potential (Bandelow et al., 2013; Newman et al., 2013). Of course, even when medication relieves anxiety temporarily, it does nothing to overcome helplessness or to teach new coping skills.

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Garo/Phanie/SuperStock

People who have agoraphobia often avoid going out in public, as they are afraid of having panic attacks in public places or in situations in which escape would be difficult.

3.5 Panic Disorder and Agoraphobia You suddenly feel very scared. Your heart beats so hard you think it will burst through your chest. You can barely catch your breath. Your mouth is totally dry; you are dizzy and shaking. You feel like you are going to faint, maybe even die. This is panic. Panic is not, by itself, abnormal. It is the intense fear produced by an especially frightening situation: You lose control of your car on an icy road; you hear footsteps following you down a dark street. It is perfectly normal to feel panic in such situations.

Panic attacks are common occurrences; they may occur as part of everyday life. They are also associated with many psychological disorders (Meuret, Kroll, & Ritz, 2017). When panic attacks become recurrent and when people become so anxious about them that they change their lives to avoid them, then panic attacks can become a full-blown panic disorder. In the United States and in several European countries, panic disorder affects between 2% and 3% of adults (APA, 2013; Inoue, Kaiya, Hara, & Okazaki, 2016), and women are twice as likely as men to receive the diagnosis (APA, 2013). Panic disorder and related anxiety conditions appear to be universal, occurring in all cultures (de Jonge et al., 2016). (Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch03.pdf) and see Part 3 of Carole Ballodi’s case.)

Panic disorder usually begins in early adulthood, and most people report clear memories of their first panic attack. This initial attack, which may come on without warning, is often followed by further attacks. In such cases, the person comes to associate panic attacks with the situations in which they occur. Fearing further attacks, the person avoids these situations. Over time, panic attacks occur in other situations, which must then also be avoided. As the number of situations that must be avoided increases, the person’s movements become increasingly restricted. In this way, panic disorder may give rise to agoraphobia. About one third to one half of people diagnosed with panic disorder develop agoraphobia (Wittmann et al., 2014).

The term agoraphobia comes from the Greek for “fear of the marketplace.” The lifetime prevalence for agoraphobia has been estimated at between 1% and 7% (Taylor & Asmundson, 2016). At least 20% of those who have agoraphobia are currently in treatment, based on one survey (National Institute of Mental Health, 2011). This makes it by far one of the most common phobias seen in the psychology clinic (Marks, 1987). Agoraphobia begins in late adolescence or early adulthood and is twice as likely to appear in women (APA, 2013). People with agoraphobia worry about having panic-like symptoms or panic attacks in places or situations from which escape might be difficult (or embarrassing) or in which help might be unavailable. (See Figure 3.4.) They avoid feared situations in the hope that doing so will help them avoid panic attacks. Some people with agoraphobia cannot avoid fearful situations, and they enter feared situations full of dread. Agoraphobic people, men particularly, may resort to alcohol or drugs just to get by. In extreme cases, they may escape by suicide (Henriksson et al., 1996), although this is rare (Friedman, Jones, Chernen, & Barlow, 1992). In the DSM–IV–TR, agoraphobia was diagnosed with panic disorder as a specifier: panic disorder

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with or without agoraphobia. In the DSM–5, agoraphobia is its own diagnosis and is diagnosed whether panic disorder is present or not. If both panic disorder and agoraphobia are present, then both diagnoses are assigned.

Figure 3.4: Causes of panic disorder and agoraphobia

Agoraphobia is determined by cultural, social, and pragmatic factors, and moderated by the presence or absence of safety signals.

Source: “ P a n i c “ P a n i c D i s o rd e r D i s o rd e r a n d a n d A g o r a p h o b i a , ” A g o r a p h o b i a , ” b y b y K . K . S . S . W h i t e W h i t e a n d a n d D . D . H . H . B a r l o w, B a r l o w, i n i n Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic, 2 n d 2 n d e d . , e d . , b y b y D . D . H . H . B a r l o w. B a r l o w. N e w N e w Yo r k : Yo r k : G u i l f o rdG u i l f o rd P re s s . P re s s . C o p y r i g h t C o p y r i g h t © © 2 0 0 2 2 0 0 2 b y b y G u i l f o rd G u i l f o rd P re s s . P re s s . R e p r i n t e d R e p r i n t e d b y b y p e r m i s s i o n . p e r m i s s i o n .

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Etiology of Panic Disorder

About 1% to 7% of people will develop panic disorder at some time (APA, 2013; Kimmel, Roy-Byrne, & Cowley, 2015; Taylor & Asmundson, 2016); onset usually occurs between late adolescence and the mid-30s and is more common in women. There is indirect evidence that some people are predisposed to develop panic disorder. It seems, for example, that panic disorder runs in families and that there is a greater concordance for such disorders among identical than fraternal twins (Shimada-Sugimoto, Otowa, & Hettema, 2015). There may even be a genetic component for panic and/or panic disorders (APA, 2013; Shimada-Sugimoto et al., 2015). Because of the genetic evidence, considerable research has been devoted to understanding the physiological causes of panic disorder (Maron, Hettema, & Shlik, 2010). The bulk of this research focuses on the way certain physiological processes may interact with cognitions to produce panic disorder.

People prone to panic attacks may have a general tendency to appraise benign physiological sensations as threatening (Meuret et al., 2017). They may focus on their body’s sensations too often and may misinterpret them as harmful. Panic-prone individuals are highly sensitive to their internal physiology. Whenever they detect any change, no matter how slight, they become fearful.

Therapeutic Treatment for Panic Disorder

Psychological treatment approaches vary according to theoretical orientation. They are aimed at one or more of the variables that contribute to the vicious “fear of fear” cycle: the preoccupation with internal bodily states, excessive physiological responsiveness to threat, faulty cognitive appraisals, or the quickly spiraling loss of control. The goal of treatment for panic disorder is to break the vicious cycle that maintains it. Taylor and Asmundson (2016) have suggested an integrated treatment program for panic disorder that treats the cognitive, physiological, and behavioral aspects of panic disorder rather than focusing on only one element.

Drug Treatment for Panic Disorder

Medications are often prescribed in an attempt to prevent emergency reactions, or alarm reactions (see Chapter 2), that trigger panic attacks (see Figure 3.5). Early observations suggested that tricyclic antidepressant medications blocked panic attacks but had little effect on general anxiety, which responded to benzodiazepines (Klein, 1964). This observation was taken as support for the idea that the fear felt in a panic attack is physiologically different from the anxiety felt in GAD. However, we now know that SSRIs such as fluoxetine (Prozac) or paroxetine (Paxil) (Kimmel et al., 2015), or powerful benzodiazepines like alprazolam (Xanax), are helpful to people who have panic attacks with agoraphobia (Van Apeldoorn, Van Hout, Timmerman, Mersch, & den Boer, 2013). Thus, fear and anxiety may not be as different as once thought. A combination of medications and psychological treatment can be effective in treating panic disorder with agoraphobia (Van Apeldoorn et al., 2013).

Figure 3.5: Nervous system pathway

The alarm reaction starts a chain of physical responses through both hormonal and nerve pathways (ACTH = adrenocorticotropic hormone).

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Source: A d a p t e d A d a p t e d f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l dM a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 4 . 1 , 4 . 1 , p . p . 1 4 0 . 1 4 0 .

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Adam Gault/Photodisc/Thinkstock

An obsession with infection and contamination may result in compulsive cleanliness rituals.

3.6 Obsessive-Compulsive Disorder (OCD) Obsessions are unwelcome, intrusive, and recurring thoughts or images that appear irrational and uncontrollable to the individual experiencing them. Compulsions are repetitive ritualistic behaviors (counting, cleaning, checking) that a person feels driven to perform to ward off some calamity. Compulsive people feel obligated to dress, clean house, or fold clothes in just the “right” way. Their rituals often involve repetitions: counting certain numbers, touching some religious icon, or going back several times to check that the doors are locked and the lights have been switched off. Often, compulsions are linked to obsessive thoughts. Thus, a person obsessed with infection and contamination may develop compulsive cleanliness rituals. All of us have obsessive thoughts at times as well as minor compulsions (Grant, 2014), but people with obsessive-compulsive disorder (OCD) have them often.

Before the DSM–5, obsessive-compulsive disorder was classified as an anxiety disorder. In the DSM–5, the disorder was moved to the “Obsessive-Compulsive and Related Disorders” chapter, since the disorders here are related to each other diagnostically (APA, 2013). Despite the new classification, OCD still has many symptoms in common with anxiety disorders. In particular, if those with OCD are prevented from performing compulsive rituals, the typical result is intense anxiety.

Etiology of OCD

Obsessive-compulsive disorder affects anywhere from 1.2% of the U.S. population (APA, 2013) to as much as 2% to 3% of the population (Grant, 2014). Women are slightly more likely than men to be affected by OCD (APA, 2013). Even though it does occur in childhood, OCD

generally makes its first appearance in late adolescence or early adulthood, often in conjunction with some significant life event, such as pregnancy or the start of a new job. The specific nature of obsessions and compulsions varies across cultures. In some cultures, obsessions and compulsions have religious themes. In most modern countries, obsessions center around dirt or contamination (Olatunji, Ebesutani, Haidt, & Sawchuk, 2014), and compulsions center around checking and cleaning (Coleman et al., 2011; Radomsky, Ashbaugh, Gelfand, & Dugas, 2008).

The diagnosis of OCD is often complicated because clients show considerable comorbidity (Gillan, Fineberg, & Robbins, 2017). Sometimes it is difficult to determine whether an individual has depression, a phobia, OCD, GAD, or all four disorders (Hunt & Andrews, 1995). The diagnosis is often based on the presumed etiology. People with OCD get no pleasure from their compulsive behaviors, and they typically know that their obsessions and compulsions are odd and irrational. Like the anxiety disorders, OCD appears to run in families (Pauls, Abramovitch, Rauch, & Geller, 2014). Some family studies have found OCD to be related to anxiety disorders and depression (Bienvenu, Busti, Magill, Ferraguti, & Capogna, 2012). See the accompanying Highlight.

Highlight: What Is the Difference Between Being an Avid Fan and Having an Unhealthy Obsession?

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As you have just read, obsessions are unwelcome, intrusive, and recurring thoughts or images that appear irrational and uncontrollable to the individual experiencing them. One might say, “Oh, of course I can easily distinguish between the two.” Let’s discuss this. You have all had an “earworm,” a song or a tune that is running constantly through your head, like elevator music. The award-winning song “Don’t Worry, Be Happy” is an example of such a song. Heard often on radio, through music streaming services, and on commercials, it became so ubiquitous that it was impossible to avoid, much less get out of one’s head. This can be unwelcome (especially if you dislike Bobby McFerrin), intrusive, recurring, and, yes, uncontrollable. Note, however, that the term song or tune is not a part of the definition of an obsession. So, can we classify having a song stuck in your head as an obsession? What if you are a Star Wars devotee? Suppose you see each new movie the day it opens, fully dressed as your favorite Jedi knight. Is this an obsession, or simply fandom? These behaviors would classify as diagnosable obsessions if they caused you marked anxiety or distress (APA, 2013). Like many other concepts we will discuss, the line between what is deemed abnormal and what is deemed fandom, really liking something, or an earworm is fine and at times blurred.

PsychoanalyticPsychoanalytic Views Views of of OCD OCD According to psychoanalytic theory, experiences that produce obsessive-compulsive behavior take place early in life, when children learn to suppress their id impulses because of the demands of society. In toilet training, for example, children must learn to replace their instinctual impulses to defecate anywhere with socially approved toileting behaviors. The resolution of this conflict between a child’s biological impulses and society’s demands has important implications for later behavior. Children who are trained harshly may become obsessively orderly and conformist and remain this way throughout their lives. As is the case with other psychoanalytic explanations, there is little experimental evidence for the relationship between toilet training (or other early conflicts) and the later development of OCD.

BehavioralBehavioral and and Cognitive-Behavioral Cognitive-Behavioral Views Views of of OCD OCD Once compulsive behaviors are established, it is not difficult to see how they may be reinforced by their anxiety- reducing consequences. Hand washing reduces worry about germs and illness; compulsive checking reduces concern about potential burglary or fire. But how do compulsive rituals get started in the first place? One possibility is that compulsions are learned “superstitiously” (Skinner, 1948). Pure coincidences (rubbing a lucky rabbit’s foot before winning a sporting event) may lead people into ritualistic behavior patterns (rubbing a rabbit’s foot before every contest). This explanation seems inadequate, however, because it fails to explain why all of us are not obsessive- compulsive, given the occurrence of such coincidences in everyone’s lives. Another problem with the superstitious- learning explanation is that it fails to explain obsessions. Obsessive thoughts do not reduce anxiety—usually they increase it.

In contrast to behavioral theorists, cognitive behaviorists emphasize the importance of obsessive thoughts. From the cognitive-behavioral viewpoint, we all have distressing thoughts at one time or another, but people with a tendency toward anxiety are unable to dismiss them from their minds (Couge & Lee, 2014). They dwell on the unwanted thoughts, which makes them feel even more anxious. Compulsive rituals arise to distract people from obsessive thoughts and reduce the anxiety that accompanies them (Grant, 2014).

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BiologicalBiological Views Views of of OCD OCD Encephalitis, brain tumors, and closed-head injuries can produce obsessive-compulsive behavior (Karadag et al., 2011; Veale & Roberts, 2014). This suggests that the disorder is at least partly physiological. The precise nature of the biological cause may lie in the metabolism of the neurotransmitter serotonin, as well as dopamine and glutamate (Bokor & Anderson, 2014b). Antidepressant drugs that block serotonin reuptake, such as fluoxetine (Prozac), reduce the intensity and severity of obsessive-compulsive disorder (Bokor & Anderson, 2014b). In the reuptake process, a neurotransmitter is quickly brought back to the same neuron from which it was released a short time earlier. (See Figure 3.6.) Serotonin is involved with inhibition and restraint, and with regulating appetite and sexual and aggressive behaviors. This suggests that OCD may result from a defect in serotonin metabolism (Stein & Fineberg, 2007).

Figure 3.6: Serotonin receptors and reuptake transporters

Serotonin secreted by a synaptic cell binds to receptors on a postsynaptic cell and directs the postsynaptic cell to fire or stop firing. Serotonin levels in synapses are reduced by autoreceptors, which direct the cells to inhibit serotonin production, and reuptake transporters, which absorb the neurotransmitter. Antidepressants, such as Prozac and Paxil, increase synaptic serotonin by inhibiting its reuptake. Antidepressants can be similarly used to inhibit the reuptake of the neurotransmitter norepinephrine.

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Source: A d a p t e d A d a p t e d f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l dM a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 4 . 9 , 4 . 9 , p . p . 1 6 9 . 1 6 9 .

Therapeutic Treatment for Obsessive-Compulsive Disorder

As with other disorders, treatment modalities depend on the orientation of the treating clinician. Although a psychoanalytic approach is still used by some, the biological and cognitive-behavioral treatment approaches appear to be most helpful for individuals who have OCD.

PsychoanalyticPsychoanalytic Treatment Treatment for for OCD OCD Freud considered OCD to be among the most difficult disorders to treat. This was ironic, he thought, because people with obsessive-compulsive disorder knew they were “sick,” hated their symptoms, and were highly motivated to change. Freud’s initial impressions have proven accurate over time; OCD remains one of the most difficult anxiety disorders to treat. Psychoanalytic treatment attempts to make conscious the repressed conflicts presumed to be responsible for obsessive-compulsive behavior. Psychoanalysts do not attempt to inhibit the intrusive thoughts and

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ritualistic behaviors directly because they believe that these symptoms are keeping even more debilitating anxiety in check.

BehavioralBehavioral and and Cognitive-Behavioral Cognitive-Behavioral Treatment Treatment of of OCD OCD The behavioral approach to OCD treatment usually consists of exposure and response prevention (Veale & Roberts, 2014). Clients who fear germs may be asked to enter a hospital, touch the walls, and shake hands with patients while refraining from their normal ritualistic hand-washing response. Inhibiting hand washing causes these individuals to experience the anxiety that hand washing helps them to avoid. Because nothing untoward actually happens, their anxiety is not reinforced. Repeated exposure should extinguish the anxiety associated with the obsession.

In a related manner, behavioral psychologists have treated obsessions using thought stopping, which requires clients to say “stop” to themselves each time they begin to dwell on an obsessive thought, and then attempt to distract themselves and think of something else that competes with the obsessive thoughts. Perhaps the major problem faced by behavior therapists treating OCD is getting clients to complete the treatment. Some people find behavioral treatment too threatening and drop out (Öst, Havnen, Hansen, & Kyale, 2015; Veale & Roberts, 2014). Cognitive restructuring may help some clients persist with therapy because it provides them with a set of motivating self- statements that they can use to help deal with anxiety-producing situations, including the anxiety associated with the therapy itself (Ponniah, Magiati, & Hollon, 2013).

Drug Treatment for OCD

People with OCD gain little relief from benzodiazepines or other anxiolytics. However, antidepressant medications —SSRIs like fluoxetine (Prozac) and the tricyclic antidepressant clomipramine (Anafranil)—have proven to be quite effective (Veale & Roberts, 2014). These medications suppress symptoms; they do not teach people new behaviors. Clients treated solely with medication may require medication indefinitely (Fineberg, Reghunandanan, Brown, & Pampaloni, 2013). They also run the risk of serious side effects and relapse when the drug is terminated (Veale & Roberts, 2014).

Disorders Related to Obsessive-Compulsive Disorder

Located within the “Obsessive-Compulsive and Related Disorders” chapter in the DSM–5 is a new disorder, hoarding disorder, which involves a persistent difficulty discarding or parting with possessions due to a perceived need to save them. Individuals with this disorder experience significant distress associated with discarding these items if indeed they must. In the DSM–IV–TR, hoarding was included as a possible symptom of obsessive- compulsive personality disorder. It was also noted that extreme hoarding (which was not clearly defined) might occur in obsessive-compulsive disorder (APA, 2000). The DSM–5 notes that data available at the time of publication (2013) did not indicate that hoarding was a variant of obsessive-compulsive disorder or another mental disorder. The DSM–5 team determined that this disorder warranted its own category.

In some instances, the individual’s entire home is filled with unnecessary and/or unused items like loads of clothes that are never worn or useless items like broken furniture, dishes, and toys. The hoarding may be so severe that parts of the individual’s home become inaccessible. Furniture may be covered with hoarded items, resulting in a fire hazard or worse. The individual may be unable to leave his or her home due to the quantity of hoarded items. In addition, the costs involved with purchasing so many things can be considerable.

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New York Daily News/Getty Images

When the police were finally able to

Since hoarding disorder is a newly diagnosed condition, some clinicians attempt to treat it in a fashion similar to the treatment for obsessive-compulsive disorder, since the two disorders appear to have some aspects in common. This includes using behavioral as well as cognitive-behavioral techniques, and SSRIs such as fluoxetine (Prozac). Sometimes using professional “declutterers” can be successful. Interestingly, it is not so much the hoarding that causes distress as it is the requirement of discarding so many useless objects. Hoarding disorder is associated with significant impairment; it may have unique neurobiological correlates and may respond to clinical intervention (Mathews et al., 2016; Morein-Zamir et al., 2014; Williams & Viscusi, 2016). The accompanying Highlight describes a well-known case of hoarding.

Highlight: The Strange Case of the Collyer Brothers

Perhaps one of the most famous hoarding cases is that of the Collyer brothers, who were found dead in their Harlem, New York brownstone in 1947. Homer and Langley Collyer were born in 1881 and 1885, respectively, to Dr. Herman Livingston Collyer, a gynecologist at Bellevue Hospital, and Susie Gage Frost, a former opera singer. According to some accounts, Dr. Collyer was rather eccentric. For example, he would often paddle a canoe from Manhattan to the City Hospital on Blackwell’s Island (now called Roosevelt Island) where he sometimes worked. In 1919, Dr. Collyer left the family without explanation. He died in 1923, and his wife died in 1929. Upon their parents’ deaths, the brothers inherited all their property and possessions and became shut-ins, never leaving the house, sealing themselves up in their house, away from the world.

There were rumors that the brothers were bathing themselves in riches when in fact their eccentricities moved closer to mental illness. They had their phone disconnected in 1917, stating that they had been billed for long- distance calls they didn’t make. When their gas was turned off in 1928, they lived without heat or hot water, using kerosene for cooking and lighting. When vandals used rocks to smash their windows, the brothers boarded up the windows rather than fixing them or asking someone to fix them. In fact, asking someone in was impossible, as the brothers had collected so much garbage and other items that it became virtually impossible to move in their apartment. As interest in the rather unusual brothers increased, the younger brother, Langley, became more anxious and paranoid. He began to arrange his collection of junk into a series of mazes, tunnels, and booby traps lest anyone try to enter.

On March 21, 1947, the New York City Police Department received an anonymous call that there was a dead body in the Collyer house. Once they finally breached the front door, they found it blocked by stacks of boxes. The basement entrance was similarly blocked. After forcing open a first-floor window, they found the house filled with piles of junk and trash, and overrun with rats. Around noon of that day, officers forced open a window on the second floor, where they found Homer Collyer dead. He had not eaten or drunk any water for days. There was no sign of Langley. After 10 days of searching the house, and subsequently removing two organs, multiple guns, bowling balls, pickled human organs in jars, and eight live cats (all found in just two rooms on the first floor), they finally found

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enter the Collyer brothers’ brownstone, they found garbage piled to the ceiling.

Langley, crushed to death by one of his booby traps (York, 2012).

Of course, this is an extreme case of hoarding disorder that ended tragically, but perhaps we can look at this in another way. According to the blog post from which the details of this story were drawn, these men just wanted to be left alone. Is this a sign of a mental illness, or were they just extremely eccentric individuals? Did their father’s leaving without explanation and their parents’ death cause negative reactions? Suppose they just liked to collect various things. After all, don’t all of us save important papers and articles at times because we know we will read them eventually, or use them for a term paper or for research (your author, like many others, does this)? Is this hoarding? Did the brothers die happily? Perhaps most important, we must ask again: When does an example of extreme behavior such as this cross the line into a diagnosable illness?

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Chapter Summary

Anxiety, Fear, and Panic Anxiety is a negative emotional state marked by foreboding and somatic signs of tension, such as a racing heart, sweating, and difficulty breathing. Fear is a negative emotion that occurs in response to some immediate threat or danger. Panic is the intense fear produced by an especially frightening situation. Anxiety disorders not only seem to occur with one another, but they are also frequently accompanied by depression.

Specific Phobias A phobia consists of a persistent and irrational fear coupled with a desire to avoid the feared object or situation. Specific phobias are determined by the interaction of cultural and social norms, learning experiences, and cognitive components.

Social Anxiety Disorder (Social Phobia) Performance anxiety occurs in both Western and Eastern cultures. Performance anxiety is rarely the result of a traumatic experience. It is more often related to shyness and lack of confidence. Social anxiety disorder (social phobia) begins in adolescence and represents an extreme form of performance anxiety in which fear of social evaluation can produce panic attacks and can severely restrict a person’s life. Social phobias usually develop slowly in people who either inherit a tendency toward shyness or become shy early in life. No matter what treatment method is used, an important factor in helping someone to overcome any problem is to establish a trusting relationship. People with phobias habitually avoid the feared object or situation. Successful treatment almost always requires overcoming this avoidance and getting the client to confront his or her fear. Anxiolytic drugs (antianxiety medications) may also be used to treat phobias.

Generalized Anxiety Disorder (GAD) People with GAD are not fearful of specific objects or situations; they are apprehensive about everything. Many cases of GAD never get to the clinic because people “treat” themselves with alcohol. Psychoanalysts, behaviorists, and cognitive psychologists agree that GAD develops only when there is a preexisting vulnerability. Psychoanalysts attribute GAD to a conflict between the ego and the id. Some behaviorists view GAD as a form of classically conditioned (learned) fear that differs from a simple phobia only in its greater generalization. Anxiolytics are frequently prescribed for GAD.

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Panic Disorder and Agoraphobia A panic attack consists of an abrupt and intense feeling of fear accompanied by somatic symptoms, usually in the absence of any objective danger. When panic attacks become recurrent and when people become so anxious about them that they change their lives to avoid them, panic attacks can become a full-blown panic disorder. People prone to panic attacks may have a general tendency to appraise benign physiological sensations as threatening. Panic disorder usually begins in early adulthood; it is rare in children. There is strong evidence that panic disorder is hereditary. People with agoraphobia worry about and avoid having panic-like symptoms in places or situations from which escape might be difficult (or embarrassing) or in which help might be unavailable. Agoraphobia begins in early adulthood and is particularly common in older women. Psychoanalysts assume that agoraphobia manifests in children who are fearful by nature. These children experience an unconscious conflict, wherein they wish to be independent, but they also fear being on their own. Cognitive restructuring and relaxation training are two therapy modalities used to treat panic disorder and/or agoraphobia. Long-acting benzodiazepines are helpful in treating people who have panic disorder and/or agoraphobia.

Obsessive-Compulsive Disorder (OCD) Obsessions are unwelcome, intrusive, and recurring thoughts or images that are recognized as irrational and are uncontrollable to the individual experiencing them. Compulsions are repetitive ritualistic behaviors (counting, cleaning, checking) that a person feels driven to perform to ward off some calamity. OCD generally makes its first appearance in late adolescence or early adulthood, often in conjunction with some significant life event. According to psychoanalytic theory, the special experiences that produce obsessive-compulsive behavior take place early in life, when children learn to suppress their id impulses because of the demands of society. Psychoanalysts do not attempt to inhibit the intrusive thoughts and ritualistic behaviors directly because they believe that these symptoms are keeping even more debilitating anxiety in check. Behaviorists note that compulsive behaviors are reinforced by their anxiety-​reducing consequences and often treat OCD with exposure and response prevention therapy. According to cognitive behaviorists, people with a vulnerability for anxiety are unable to dismiss distressing thoughts from their minds. Compulsive rituals arise to distract them from obsessive thoughts and reduce the anxiety that accompanies them. Encephalitis, brain tumors, and closed-head injuries can all produce obsessive-​compulsive behavior. People with obsessive-compulsive disorder gain little relief from antianxiety drugs, although some seem to respond to antidepressant medications. Hoarding disorder is related to obsessive-compulsive disorder; in this disorder, the individual has persistent difficulty discarding or parting with possessions due to a perceived need to save the items. Significant distress is associated with discarding such items. Some clinicians attempt to treat hoarding disorder in a fashion similar to treatment for OCD, since the two disorders appear to have some aspects in common. Behavioral as well as cognitive-behavioral treatment techniques, and SSRIs such as Prozac, may be useful.

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Critical Thinking Questions 1. Everyone has a superstition or two (or perhaps even more!). Discuss the difference between superstitious

behavior (yours, or perhaps a friend’s) and a phobia. How do the two differ? 2. Discuss some of the more common venues in which social anxiety disorder could present itself. How would

you best handle this if a client came to see you with this concern? 3. Some people say that GAD should have been removed from the DSM–5 because it is too common a disorder

and is difficult to accurately define. Discuss and give your views on this. 4. Like many people, you most likely enjoy collecting certain things: souvenirs from a trip, baseball cards,

comics, your child’s drawings and accomplishments. You may have significantly large collections. When does this become hoarding, and then hoarding disorder? Should hoarding disorder in fact be a diagnostic category?

5. No doubt you have gone back inside your house or apartment to check the stove to make sure it’s off, to check the lights, and so on. What is the difference between this kind of behavior and OCD?

6. Some observers believe that certain phobias, such as a fear of snakes and acrophobia (fear of heights) are innate. Discuss your views on this belief.

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Key Terms

agoraphobia The fear of being in a place or in a situation where escape might be difficult, impossible, or embarrassing if a panic attack or panic symptoms occur.

anxiety A negative emotional state marked by a feeling of foreboding and bodily signs of tension such as a racing heart, sweating, and difficulty breathing.

anxiety disorder Any of a number of disorders characterized by feelings of fear, dread, or panic plus physiological symptoms such as racing heart, sweating, and difficulty breathing.

benzodiazepines

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A class of antianxiety medications.

classical conditioning A learning procedure in which a neutral stimulus is paired repeatedly with a fear-inducing stimulus. In time, the neutral stimulus will elicit the fear response even in the absence of the primary fear-inducing stimulus.

compulsions Repetitive ritualistic behaviors (counting, cleaning, checking) that a person feels driven to perform to ward off some imagined or unknown calamity.

emergency reaction Another name for an alarm reaction; how we react in response to a dangerous situation.

flooding A therapeutic technique that requires fearful individuals to become “flooded” with emotion through exposure to their most feared stimulus in order to realize that the feared outcome does not occur.

generalized anxiety disorder (GAD) An anxiety disorder characterized by “free-floating” anxiety not specific to real objects or situations but to real or imagined uncontrollable future events or situations.

hoarding disorder A disorder related to OCD, in which the individual has persistent difficulty discarding or parting with possessions due to a perceived need to save the items; significant distress is associated with discarding the items if indeed they must.

implosive therapy A type of flooding in which exposure is done through imagery rather than in vivo (real life).

limbic system A complex set of brain structures that controls our emotions.

obsessions Unwelcome, uncontrollable, intrusive, and recurring thoughts or images that are recognized as irrational to the individual experiencing them.

obsessive-compulsive disorder (OCD) A disorder in which individuals suffer from obsessions and compulsions that may take up the majority of their time and interfere with daily functioning.

panic attack An abrupt and intense feeling of fear accompanied by bodily symptoms, usually in the absence of any objective danger.

panic disorder An anxiety disorder characterized by recurrent, unexpected panic attacks.

performance anxiety

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The fear of speaking or performing in front of other people.

response prevention A form of therapy for OCD in which the individual encounters or is exposed to the feared stimuli while refraining from the usual compulsive behavior.

social anxiety disorder (social phobia) An anxiety disorder in which individuals have an excessive concern about being in social situations where they may be evaluated by others.

specific phobia An anxiety disorder in which a person experiences extreme anxiety or panic when confronted with a specific object or situation that triggers the response.

stress inoculation A cognitive-behavioral treatment modality in which people are taught about the role that negative self-statements play in performance anxiety; more accurate self-statements that they can then practice in stressful evaluative situations; and coping skills designed to help them deal with, rather than avoid, evaluative situations.

systematic desensitization A behavioral treatment modality that attempts to reduce an individual’s anxiety through relaxation techniques paired with progressive exposure to a hierarchical presentation of feared stimuli.

thought stopping A cognitive-behavioral treatment intervention that instructs clients to say “stop” to themselves each time they begin to dwell on an obsessive thought.

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Learning Objectives

After reading this chapter, you should be able to:

Understand the difference between normal emotions and pathological emotions.

Explain what depressive disorders are.

Explain what bipolar and related disorders are.

Know and discuss what causes depressive, bipolar, and related disorders.

6 Depressive Disorders and Bipolar and RelatedDisorders

tommaso79/iStock/Thinkstock

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Explain and discuss how depressive, bipolar, and related disorders are treated.

Analyze the relationships among depressive, bipolar, and related disorders and suicide.

It is mid-June in a city known for a temperate climate. You awaken to a blue sky with puffy clouds; the sun is bright but not too hot, with low humidity. After eating your favorite breakfast, you go for a walk before heading off to your summer job. All seems right with the world, yet you are not happy. The sky appears gray to you, the sun covered by clouds. Breakfast seemed bland, almost tasteless. You didn’t sleep well; in fact, you awakened, again, in the middle of the night and couldn’t fall back to sleep. You were hoping to be intimate with your partner last night, but the desire and the drive remain missing.

Does this scenario sound familiar to you? Perhaps it sounds like an everyday experience for many people. Have you ever had days with some, if not all, of these experiences? Before we continue, consider the next scenario.

You awaken to the same sunny day, although this time the sun seems exceptionally bright and energizing. After making yourself a gourmet breakfast and wolfing it down in about three minutes, you go for a power walk, completing your usual course in record time and engaging everyone you pass in conversation, though the conversations have no connection to each other. Returning home, you decide, after showering, to clean the entire house as well as clean the windows and mow the lawn. You then head to work, put in a 13-hour day with a 15- minute lunch break, during which you consume a PowerBar and some Red Bull. At home you prepare a four-course meal from scratch. You should be tired but you’re not, so you call your best friend and see if she wants to go out to a bar for a few drinks. She calls it a night at 11 p.m., but you are going strong. You meet an attractive person and go back to his or her apartment for a while. You return home at about 2 a.m. and go to sleep. . .until 4 a.m., when you awaken, ready to start the new day, repeating this pattern for at least seven days.

How does the second scenario sound to you? Does this sound like a normal day and night for some people? Let’s take a closer look at what these scenarios seem to describe.

The first scenario could illustrate some of the classic signs of depression, including sadness, hopelessness, self- blame, anger, insomnia, and loss of appetite. Depression is one of several depressive, bipolar, and related disorders, abnormal conditions characterized by persistent extremes of mood. Depression represents one pole of a person’s mood (see Figure 6.1) and is typically characterized by extreme sadness, lack of energy and sex drive, low self- worth, guilt, and oftentimes thoughts of suicide.

Figure 6.1: The mood spectrum

Most of the time, we find ourselves in the middle of the spectrum, not too high or too low. Notice that the two extremes, mania and depression, are closer to one another than they are to the normal mood state. In fact, some people cycle between depression and mania, and a few manage to be both depressed and manic at the same time.

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EgudinKa/iStock/Thinkstock

Typically, the majority of people are somewhere in the middle of the mood

Source: Adapted from S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.1, p. 319.

The second scenario might illustrate the other pole, which is known as mania. Mania is marked by extreme elation. People who are in the grip of mania have lots of energy, form grandiose plans (to make a fortune or cure cancer), display a cavalier attitude toward money, and usually have a strong sex drive. At first glance, this may not seem to be much of a problem; left unchecked, however, mania can cause just as many difficulties as depression.

Happily, most of us spend the bulk of our time somewhere in the middle of the mood spectrum, neither very high nor very low. A telephone conversation, a walk in the park, or a dinner with friends can lift our mood. By contrast, a bad day at work, failing an exam, losing a tennis match, indeed any of life’s disappointments can bring on the “blues.” When our mood rises, we feel happy, energized, confident, and optimistic. When we get the blues, we feel sad, tired, and pessimistic. When we are low, we may decide to drown our sorrows in a drink, or maybe just go to bed.

The main difference between the blues, an emotion we all experience, and a depressive disorder is one of degree (Oyama & Piotrowski, 2017). The blues pass quickly. In a day or two, we pick ourselves up and start again. However, when a negative mood persists for a long period of time, affecting social and occupational

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spectrum and experience a range of emotions that are neither very high nor very low.

functioning, clinicians begin to suspect the presence of a depressive disorder.

This chapter is concerned with the diagnosis, etiology, treatment, and prevention of depressive, bipolar, and related disorders. It also includes a discussion of suicide, which is sometimes (but not always) caused by one of these disorders.

Before we continue, let’s examine the case of Bernard Louis, a man whose manic episodes severely affected his life.

The Case of Bernard Louis: Part 1

Note Dictated by Psychiatrist, Dr. Kahn, When Admitting Bernard Louis to the Hospital

UNIVERSITY HOSPITAL

Intake Note

CONFIDENTIAL

Admitting Psychiatrist: Dr. Sally Kahn

Bernard Louis was brought involuntarily to the admitting ward by county police who were acting on a court order to have him committed for 24 hours of psychiatric observation.

Mr. Louis is a large man, well over 6 feet tall. He weighs more than 200 pounds. When he appeared at the hospital, his face was very red, and his hair and clothing were disheveled. Otherwise, he seemed normal. According to his wife, who accompanied him to the hospital, Mr. Louis had been working alone, 18 hours a day, building a “golf course” in their suburban backyard. His plan was to turn their half-acre lot into a private country club with a clubhouse. He hoped to sell memberships at $5,000 a year. The clubhouse would offer catering facilities as well as a bar and pro shop. He planned to build sand and water traps and to invest in a fleet of motorized golf carts. When his wife suggested that he might be getting a little carried away, Mr. Louis lost his temper, shouted in rage, and threatened to leave her for another woman. He claimed to have four girlfriends whom he regularly “satisfied” ten times a night. Two days earlier, when his wife had left the house, Mr. Louis had taken all her jewelry to a pawnshop. He had used the money to invite strangers off the street to an all-night party that finally had to be stopped by the police. Mr. Louis had not slept at all for three days before his wife obtained the court order that brought him to the hospital.

Mr. Louis was difficult to interview because he talked nonstop. He complained that he was being persecuted and that his wife was just jealous of the many women who were after him because of his sexual prowess. There was nothing wrong with him. In fact, he claimed, “I’ve never felt better in my life.” When asked if he was happy, Mr. Louis responded, “Am I happy? Why, if I felt any happier, you could sell tickets. I’m so happy, it should be illegal.”

Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Get- zfeld.3794.18.1/{misc}casestudies_ch06.pdf) for full case study.

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Kimberley French/© Paramount Pictures/Courtesy Everett Collection

As StarStar Trek Trek fans know, Mr. Spock differs from humans because he, as a half Vulcan, does not express emotions. Sometimes his cold rationality is an advantage, but at other times his lack of emotion cuts him off from intuition and social connection.

6.1 Emotions: Normal and Pathological Admirers of the original (and often-replicated) Star Trek television series and films will recall the Starship Enterprise’s Vulcan officer, Mr. Spock. Spock differed from earthlings in two ways: He had odd, pointy ears, and he was rarely emotional. Unlike Captain Kirk, Spock was never tempted by the seductive outer-space sirens who regularly tried to lure the space mariners to destruction. Even when the murderous Romulans seemed certain to destroy the Enterprise, Spock never panicked. As he coldly evaluated the ship’s predicament, the other crew members would accuse Spock of being “inhuman.” To them, the essential characteristic of a human being is the ability to feel emotions—and most psychologists agree.

Emotions are so much a part of life, we never stop to ask ourselves why they exist in the first place. What is the biological function of negative emotions, such as fear and sorrow? Why did they evolve? Would we not be better off being unemotional like Spock?

As is the case with many questions surrounding evolution, the first place to look for answers is in the works of Charles Darwin (1809–1882). In his book The Expression of Emotions in Man and Animals (1872), Darwin hypothesized that emotions evolved because they have survival value. Fear helps us to survive because, when we are afraid of something, we flee and avoid possible harm. Sorrow also has survival value. Parent-child bonds are cemented by the feelings of sadness parents and their children experience when they are separated. To avoid sadness, parents stay close to their children, thereby increasing their offspring’s chances of survival. Of course, it is possible to have too much of a good thing. Unrelenting fear or sorrow can be so debilitating that, instead of increasing a person’s chances of survival, they can actually decrease those chances.

Grieving

The loss of a loved one or a friend usually sets off a grieving process. The first reaction is usually emotional numbness and disbelief punctuated with acute bouts of distress. Social support is an important determinant of how quickly, and how well, people cope with the grieving process (Prest, 2017).

Within a week or so after a loss, disbelief is replaced with a period of pining for the lost person. The survivors dwell on their loss, have trouble sleeping, neglect other aspects of life, and display anger at their fate (“Why me?”). This stage may last months or years, but most people eventually acknowledge the permanency of their loss (“I am now a widow”). In the final stage of grieving, people gradually regain their interest in life, and their sadness abates. The whole process may take a year or more and may involve significant periods of psychological distress. Still, the process is perfectly normal (see the accompanying Highlight). In fact, not grieving over the death of a loved one would be viewed by most psychologists as abnormal. Because grieving is normal, treatment is not indicated unless people become dangerous to themselves or are unable to function (Prest, 2017). In such cases, clinicians would probably consider the individual to be suffering from one of the depressive, bipolar, or related disorders described in the DSM–5.

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Highlight: Removal of the Bereavement Exclusion Criterion From Depressive Disorders

How do you handle the loss of a loved one? Most likely you go into a period of mourning, handling the situation in a way that is unique to you. This is called bereavement, a normal part of the grieving process. In the DSM–IV–TR (American Psychiatric Association [APA], 2000), psychologists, psychiatrists, and psychiatric social workers were advised (by the authors of the DSM–IV–TR) not to diagnose major depression in individuals within the first two months following the death of a loved one. This was called the “bereavement exclusion.” The inclusion of this criterion in the DSM–IV–TR meant that grieving a recent loss prevented a person from being diagnosed with major depression.

The bereavement exclusion was removed from the DSM–5 (APA, 2013) in order to ensure that unipolar depression (major depressive disorder) was not overlooked and that appropriate treatment could be implemented quickly before trouble ensued. The rationale behind this is simple enough: Normal grieving and unipolar depression, while sharing some common facets like withdrawal from everyday activities and intense overwhelming sadness, also differ in some very important ways.

For example, during grieving, the painful feelings come in waves of grief when they occur; positive memories of the deceased individual also occur. However, in major depressive disorder (MDD), the mood and feelings and ideas are almost always negative and unpleasant. Second, while you are grieving, self- esteem (positive feelings about yourself) is usually maintained, whereas in MDD, feelings of worthlessness and self-loathing are common. Normal grieving can lead to MDD, but clinicians are cautioned not to confuse a normal process with a mental disorder.

There is another perspective. The DSM–5 characterizes bereavement as a severe psychological stressor that can incite a major depressive episode even shortly after the loss of a loved one. Some critics say the risk is that of pathologizing grief, a normal human process. Individuals may be diagnosed with depression even in the absence of severe depressive symptoms (such as suicidal ideation) and even though their symptoms may be transient.

A person who meets the diagnostic criteria for MDD will no longer be excluded from that diagnosis solely because the person recently lost a loved one and is in the process of normal grieving or bereavement. The death of a loved one may or may not be the main, underlying cause of the person’s unipolar depression.

What are your views on the bereavement exclusion?

DSM–5DSM–5 Depressive, Bipolar, and Related Disorders

By definition, a mood disorder is an abnormal condition characterized by persistent extremes of mood. The DSM– IV–TR categorized depressive and bipolar disorders in a single chapter titled “Mood Disorders.” The DSM–5 has divided the categories into two separate chapters: “Depressive Disorders” and “Bipolar and Related Disorders.” According to the DSM–5, there are two general types of mood disorder: unipolar mood disorder and bipolar mood

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disorder. The “poles” referred to by these diagnostic labels are the extremes of the mood spectrum—depression and mania. Unipolar mood disorders are characterized by depression, whereas bipolar disorders combine depression with manic periods. Both unipolar and bipolar disorders are divided into subtypes. The unipolar subtypes include a relatively mild condition known as persistent depressive disorder (dysthymia) and a more serious one called major depressive disorder. Bipolar disorders are divided into bipolar I disorder, which includes both depression and mania; bipolar II disorder (depression and hypomanic episodes, or episodes that do not cause as much impairment as manic episodes); and cyclothymic disorder (cycling between hypomanic periods and mildly depressed periods without ever fulfilling criteria for episodes of mania, hypomania, or major depression; APA, 2013). For adults to be diagnosed with cyclothymic disorder, the symptoms must be present for at least two years; for children, they must be present for at least one year (APA, 2013). Hypomanic episodes, unlike mania, do not require hospitalization (APA, 2013).

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In approximately the 5th century BCE, Hippocrates inscribed what is now known as the “Hippocratic Oath.” The oath includes references to “melancholia,” or depression, and this ancient idea posited that depression resulted from an excess of black bile in the body. Although this antiquated conclusion was proved incorrect by modern medicine, it contributed to the possibility that depression is caused by a chemical imbalance.

6.2 Depressive (Unipolar) Disorders Depression is as old as recorded history. The Hippocratic Oath contains numerous references to depression, or as it was known during Hippocrates’s time (approximately 2,400 years ago in Greece), “melancholia.” Melancholia is derived from the Greek word melanchole, which means “black bile.” According to Hippocrates, the human body is filled with four basic substances, or bodily “humors,” which are in balance when a person is healthy. Ancient healers believed that depression, a “black” mood, resulted from an excess of black bile. Even though modern medicine has proved this to be incorrect, the idea that depression is caused by a chemical imbalance in the body remains popular today and will be discussed later in the chapter.

Clearly, depression takes an enormous toll not only on the individual but also on society—particularly on the economy. Each year, the costs of major depressive disorder for the U.S. workplace average about $43 billion (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2014). The overall costs of treating depression are estimated to be $210.5 billion per year (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2014).

The signs of depression are common. We all experience periods of sadness and self-doubt, although these are not usually severe enough to qualify for a psychological diagnosis (Oyama & Piotrowski, 2017). Typically, these feelings begin with a reaction to some stressful life circumstance (losing one’s job, for example). If these feelings dissipate within six months after the stressor or its consequences end, the DSM–5 labels them an adjustment disorder with depressed mood—a transient reaction to a stressful circumstance. A major depressive episode may appear superficially similar to an adjustment disorder, but it is more extreme.

Major Depressive Episodes

Major depressive episodes are part of the diagnostic criteria for bipolar I disorder. Although we can expect to see them in bipolar I disorder, they are not required to make a bipolar I disorder diagnosis (APA, 2013). The hallmark of a major depressive episode is a sad mood. Depressed people feel down and apathetic. They may go through the motions of daily existence—get up, go to class, go to the library—but there is no enjoyment in it. Life seems dull and gray, and formerly pleasurable activities no longer bring any enjoyment. (This inability to feel pleasure is known as anhedonia.) Starting a new activity seems impossibly difficult. Sufferers describe themselves as constantly tired and just barely

dragging themselves through life. Depressed people may talk and think slowly; some may be unable to get out of bed in the morning. Although slowness is more typical, some depressed people become agitated. Instead of lying around in bed, they are unable to sit still. They pace the floor, shaking their heads and restlessly wringing their hands.

A major depressive episode may affect the way people sleep; they may wake in the night or early morning and be unable to return to sleep. (However, some depressed people sleep most hours of the day.) Changes in appetite

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(usually eating less but sometimes eating more) and loss of interest in sex are also associated with a major depressive episode. Some writers believe that the presence of these so-called vegetative symptoms (appetite change, sleep disturbance, loss of sex drive, fatigue) is what distinguishes a major depressive episode from less severe forms of depression (Jaffe & Holle, 2017).

Although a down mood and vegetative symptoms are the most obvious signs of a major depressive episode, cognition and memory are often affected as well (Jaffe & Holle, 2017). Depressed people have difficulty concentrating on cognitive tasks (Jaffe & Holle, 2017). They tend to see the downside of everything, dwelling on their failures and ignoring their successes. Because of their pessimism, they lose motivation. Depressed people judge themselves to be less liked and less capable than other people rate them (Ledrich & Gana, 2012). In children and adolescents, a depressive episode may look different. Children are more likely to be irritable than sad, for example, and they may show different symptoms at different developmental stages (Jaffe & Holle, 2017).

It is difficult for depressed people to change because depression has a tendency to feed on itself. The vicious cycle begins with depressed people becoming irritable and short-tempered. They snap at their partners and their children. Regretting their behavior, they then feel guilty about mistreating their loved ones. These feelings of guilt, in turn, make them even more depressed (Roepke & Seligman, 2016). (See Table 6.1 for a summary of the diagnostic criteria for major depressive disorder.)

Table 6.1: DSM–5DSM–5 diagnostic criteria for a major depressive disorder

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad) or observation made by others (e.g., appears fearful). (Note: In children and adolescents, can be irritable mood.)

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

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely

subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly

every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific

plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Note: Criteria A–C represent a major depressive episode

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Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance- induced or are attributable to the physiological effects of another medical condition.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), p.160-161. American Psychiatric Association. All Rights Reserved.

Depression and physical symptoms often go together; for instance, headaches, dizzy spells, and general pain have been associated with depression (Trivedi, 2004). In addition to comorbid physical conditions, there is considerable psychological comorbidity. Depressed children frequently display other problems, especially unruly misbehavior and conduct disorder (Riglin et al., 2016). In adults, depression is often accompanied by substance abuse. In addition, depression and anxiety are often related and show some clinical similarities in most adults (Jaffe & Holle, 2017).

Persistent Depressive Disorder (Dysthymia)

Persistent depressive disorder (dysthymia) is a chronic, relatively mild, depressive disorder that lasts at least two years but may last for decades (Oyama & Piotrowski, 2017). In children or adolescents, the diagnosis requires that the symptoms last at least one year. The person may experience occasional symptom-free days, but symptoms never disappear completely for more than two months at a time. In addition to a depressed mood (or irritability in children and adolescents), the DSM–5 diagnostic criteria for persistent depressive disorder (​dysthymia) require the presence of at least two specific depressive symptoms.

Prevalence and Course of Depressive Disorders

Clinical depression is the “common cold” of psychological disorders (Lorenzo-Luaces, 2015). About 300 million people worldwide suffer from depression, and the number of cases seems to be rising in most countries, putting considerable pressure on health expenditures (World Health Organization [WHO], 2017). The widespread use of psychoactive substances, mass international migrations, the breakdown of the traditional family, crime, unemployment, and poverty all make some contribution to the rising incidence of depressive disorders.

A person’s first major depressive episode is now more likely to occur before age 19 than after (Gotlib & Hammen, 2009; Kessler, Berglund, Borges, Nock, & Wang, 2005). Most major depressive episodes begin gradually, usually with a prolonged period of anxiety or mild depression. Although they can last for years, most episodes improve within nine months to one year (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler, 2002).

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Commonly, women are more likely than men to be diagnosed with depression. There are several explanations for this statistic, yet all possibilities are still under debate.

Sex, Ethnic, and Cultural Differences

In general, women are about twice as likely as men to be diagnosed as depressed (Oyama & Piotrowski, 2017). Why women should be more prone to depression than men has been the subject of substantial debate. Some researchers say women are more likely to seek assistance for psychological problems than men, so they turn up more often in the statistics (Rutter et al., 2016). Depressed men presumably cope in other ways such as hiding behind anger, but these theories have not received much support (Ramirez & Badger, 2014).

If women seek psychological help more often than men, we would expect to find more women than men in all of the DSM–5 diagnostic groups. Because we do not, alternative explanations have been offered that specifically target depression. For example, critics of the DSM–IV–TR and the DSM–5 allege that the diagnostic criteria for mood disorders are subtly biased to include more women than men. Still another explanation for the sex difference is that women blame themselves for being depressed and ruminate on this more than men, who tend to ignore their feelings (Ramirez & Badger, 2014). Instead of being diagnosed as depressed, men are diagnosed as substance abusers or as suffering from an antisocial personality disorder (discussed, respectively, in Chapters 4 and 9).

In the Pennsylvania Amish (where all women work), depression is equally common in both sexes (Parker & Brotchie, 2010). The prevalence of depression varies across ethnic groups. For example, Native

Americans are reputed to have higher rates of depression than the rest of the population (Roh et al., 2015). In addition, Latinos have higher rates of depression than African Americans, with Asians having the lowest rate of those ethnic groups sampled in one rather dated study (Algeria et al., 2008).

Otake (2008) looked at how unipolar depression is viewed in Japan. According to the Japanese Health, Labor and Welfare Ministry, 1 in 15 people in Japan suffer clinical depression at some point in their lives. Depression is considered one of the leading causes of suicide; in the industrialized world, Japan has the highest rate (Otake, 2008). Out of 100,000 people, 12.8 females and 35.6 males will kill themselves. This has translated into more than 30,000 suicides annually in recent years. Although these statistics are somewhat dated, they speak to the fact that untreated unipolar depression is a serious mental health concern in Japan. One reason the numbers appear as high as they are is that treatment options are limited. Most people in Japan use antidepressants and other drugs. More important, according to Otake (2008), few have access to, or seek out, psychotherapy. Japan’s national health insurance system discourages doctors from spending a lot of time with patients, and there is a shortage of professionals trained in verbal forms of therapy (Otake, 2008). One thing to ponder is whether increasing awareness of the seriousness of unipolar depression, or increasing the number of trained clinicians, would help to reduce the numbers of suicides.

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6.3 Bipolar and Related Disorders Although it is possible to experience manic episodes without any periods of depression, clinicians dating back to ancient Greece have noted that this is exceedingly rare. In the vast majority of people, manic episodes are either preceded or followed by depression (although there may be intervening periods of relative calm). By the 19th century, it was taken for granted that depression and mania go together. This is why Kraepelin coined the term manic-depressive to describe people with wide mood swings. The DSM–5 term bipolar conveys a similar picture: episodes of elevated mood (one pole) alternating with periods of depression (the other pole). (Click here (https://me- dia.thuze.com/MediaService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestudies_ch06.pdf) and see Part 2 of Bernard Louis’s case.)

Manic, Hypomanic, and Mixed Episodes

The hallmark of a manic episode is an overly elevated mood. Manic people feel high and excited, although, like Bernard Louis, they are also easily irritated. In addition to an expansive mood, manic episodes are marked by grandiosity. In the grip of mania, people believe that they have unusual abilities and that they can accomplish anything. Convinced of their great wealth, manic people have been known to hand out money to strangers they meet on the street or to make enormous wagers at racecourses or casinos.

In the midst of a manic episode, people find it impossible to focus on a single task. Their minds race from one idea to another, known as flight of ideas. They begin various grand projects but do not see them through to completion. Not only are their thoughts rapid and unfocused, but their physical activities are also energized and chaotic. They have little need for sleep, and their sex drive is heightened. Manic individuals speak quickly and rarely fall silent. Their speech is so rapid, and they switch topics so often, that they may become incoherent. See Table 6.2 for a summary of the diagnostic criteria for a manic episode.

Table 6.2: Main DSM–5DSM–5 diagnostic criteria for a manic episode

A. A distinct period of abnormally and persistent elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three or more of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. Inflated self-esteem or grandiosity 2. Decreased need for sleep 3. More talkative than usual or a perceived pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (attention is easily drawn to unimportant or irrelevant stimuli) 6. Increase in goal-directed activity (either socially, at work or school, or sexually), or psychomotor

agitation 7. Excessive involvement in pleasurable activities that have a high potential for painful

consequences (buying sprees, sexual indiscretions, foolish business ventures) C. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or

in usual activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not the result of substance abuse, a medical condition, or drug treatment.

D. The episode is not attributable to the physiological effects of a substance, or to another medical condition.

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Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013), p. 124. American Psychiatric Association. All Rights Reserved.

Some people display manic symptoms while suffering from a depressed mood. They are said to have a mixed episode. A milder form of a manic episode is called a hypomanic episode, which is marked by an elated mood, little need for sleep, and intense periods of activity. Unlike a manic episode, a hypomanic episode need only last at least four consecutive days, whereas a manic episode needs to last at least one week. Additionally, an individual with a hypomanic episode can function and does not require hospitalization. If psychotic features are present (hallucinations and so on), by definition the episode is manic (APA, 2013). Because they feel energetic and healthy, hypomanic (and manic) people do not seek professional assistance, nor do they recognize that anything is wrong with them.

Specific Bipolar Disorders

There are three main bipolar disorders:

Bipolar I disorder consists of one or more manic or mixed episodes. In most cases, individuals will also have had one or more major depressive episodes. Bipolar II disorder is characterized by recurrent major depressive episodes and at least one hypomanic episode. Cyclothymic disorder involves periods during which hypomanic symptoms are present alternating with periods of mild depression over the course of two years (or one year in children and adolescents). These periods may be mixed with periods of normal moods.

There is a high comorbidity between bipolar disorders and substance abuse, but the reasons for this remain unclear (Gooding, Wolford, & Gooding, 2016). Because substances such as cocaine can cause manic behavior, and because many people use alcohol and drugs to control their moods, it is often impossible to tell whether changes in mood are the result of substance abuse or are responsible for it.

Prevalence and Course of Bipolar Disorders

Bipolar disorders are rarer than unipolar disorders. More recent figures place the prevalence rate at 1.8% in the U.S. population, with a prevalence rate of 2.7% in children aged 12 or older (APA, 2013). Between 1% and 2.6% of all adults will develop a bipolar disorder in their lifetime (Gooding et al., 2016). Although it is not the case with unipolar disorders, men and women are equally likely to be diagnosed with a bipolar disorder (APA, 2013; Gooding et al., 2016). Many famous people have allegedly suffered from bipolar disorders (from Herman Melville, Ernest Hemingway, and Vincent van Gogh to actors Carrie Fisher and Catherine Zeta-Jones and singer Demi Lovato).

About 15% of people initially diagnosed with some form of depression go on to experience manic or hypomanic episodes (Angst, Gamma, Rössler, Ajdacic, & Klein, 2009). Although some people with bipolar disorder have only a few manic episodes over the course of their lives, others, known as rapid cyclers, can have four or more. The first signs of bipolar disorder usually appear from ages 18 to 25 and appear rather suddenly (APA, 2013; Angst et al., 2009; Simon & Zieve, 2013). Bipolar disorder rarely appears after age 40. Follow-up studies have found the prognosis for bipolar disorder to be poor. Even among those who are treated, relapse is common, and social and occupational functioning becomes progressively worse over the years (Gitlin & Miklowitz, 2017).

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Painter Vincent van Gogh was also thought to suffer from bipolar disorder. Van Gogh voluntarily entered a sanatorium in 1889 and completed this self-portrait during the year he spent there.

Diagnostic Specifiers

Postpartum depressions are those that occur in the four weeks following childbirth (APA, 2013). Most of these episodes are mild and brief. In severe cases, the depression is probably not caused solely by the birth of a child but is likely to be the end result of many preexisting factors, including low self-esteem (Cabrera & Schub, 2017). The specifier with peripartum onset is used to designate an unspecified depressive disorder with an onset either during pregnancy or in the four weeks following delivery (APA, 2013).

Premenstrual dysphoric disorder was moved from the DSM–IV–TR’s Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of the DSM–5. In this disorder, a majority of symptoms must be present in the week before menstruation, improve a few days after menstruation begins, and remit in the week following the end of menstruation (APA, 2013). Symptoms include, but are not limited to, mood swings, feeling overwhelmed or out of control, hypersomnia or insomnia, and difficulty in concentration (APA, 2013).

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Researchers believe the causes of mood disorders may relate to biology

6.4 Etiology of Mood Disorders Biologically oriented researchers have concluded that mood disorders must have a physiological etiology. Psychologically oriented researchers have focused on possible social and psychological causes. The etiology of bipolar disorders remains poorly understood.

Genetic Factors

Although the diagnostic criteria for mood disorders have been revised repeatedly, the research data accumulated over the decade or more strongly suggest that these disorders run in families (Gooding et al., 2016). Most studies have found that first-degree relatives (parents, siblings, and children) of people with mood disorders are more likely to have mood disorders themselves than are people without affected relatives (Gooding et al., 2016). (See Table 6.3.) (Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestud- ies_ch06.pdf) and see Part 3 of Bernard Louis’s case.)

Table 6.3: Average risk for mood disorders in first-degree relatives of people with mood disorders

Percentage of relatives with

Patient’s disorder Major depressive disorder Bipolar disorder

Major depression 9.1 0.6

Bipolar disorder 11.4 7.8

No disorder (general population) 8 <1

Source: Katz and McGuffin (1993) and various epidemiological studies, as appearing in S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Table 8.6, p. 334.

Searches for the gene(s) responsible for mood disorders began with a search for specific genetic markers, genetic material present in relatives with mood disorders. Finding such material requires two important ingredients: technology capable of identifying parts of chromosomes and a sufficiently large number of affected family members who can be studied over several generations. Nevertheless, given the accumulated data, it seems reasonable to conclude that genetics plays a role in rendering people susceptible to mood disorders (Gooding et al., 2016).

WhatWhat Is Is Inherited? Inherited? If genetics plays a role in the development of mood disorders, then it follows that sufferers must inherit something that renders them especially susceptible to mood disorders. This “something” turns out to be faulty neurotransmitter regulation.

In Hippocrates’s time, mood disorders were attributed to an imbalance in the chemicals (humors) of the body. In the 1950s, it was observed that about 15% of patients treated with reserpine to reduce their high blood pressure were found to develop major depressive episodes. Because reserpine was thought to reduce the level of a neurotransmitter known as norepinephrine, researchers hypothesized that depression might be the

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(physiological etiology) or psychology (social environment). Studies within the Amish community proved there may be a genetic marker within families, but the study was difficult to replicate.

result of diminished levels of norepinephrine. Around the same time that these observations were being made, clinicians using the drug iproniazid to treat tuberculosis noted that their patients not only improved physically but also seemed to be in a much better mood. By the late 1950s, the drug was being widely used to treat depression even though no one had any idea how it worked.

Ultimately, scientists discovered that iproniazid, like reserpine, affects neurotransmitter levels. Specifically, iproniazid inhibits the activity of an enzyme known as monoamine oxidase (MAO), a chemical that plays a crucial role in neurotransmitter regulation. MAO facilitates the chemical breakdown and reuptake of neurotransmitters such as norepinephrine, dopamine, and serotonin after they have done their job (see Figure 6.2). Because iproniazid inhibits the activity of MAO, it slows the reuptake process. The result is a higher concentration of norepinephrine.

Figure 6.2: The neurotransmitter cycle

Disruption of any stage of this process can lead to over- or underproduction of a neurotransmitter or interfere with its reuptake. A variety of drugs have been created to regulate the cycle of specific neurotransmitters.

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Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 8.3, p. 336.

Pharmaceutical companies rushed to market other MAO inhibitors (MAOIs). Unfortunately, these drugs had a serious drawback; they interact with certain foods to cause potentially life-threatening conditions such as stroke. This is why MAO inhibitors have been largely abandoned in favor of much less lethal antidepressant drugs such as fluoxetine (Prozac) and sertraline (Zoloft). (See Thase [2005] for further discussion of low serotonin levels being implicated in unipolar depression.)

Psychosocial Factors

Although there is clear evidence that genetics plays a role in mood disorders, and we have several plausible candidates for the biological diathesis, it is important to keep in mind that the concordance rate, even among

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Although genetics plays a role in mood disorders, an individual’s environment is also important when determining the cause of a mood disorder.

identical twins, is less than 100% (concordance rate refers to the proportion of identical twins in a random sample who share a certain characteristic with their twin; Flint & Kendler, 2014). Thus, the environment must also play a role in determining who develops a mood disorder. In this section, we look at how psychoanalytic, behavioral, cognitive, and social psychologists explain how stress interacts with preexisting vulnerabilities to produce mood disorders.

PsychoanalyticPsychoanalytic Views Views According to Freud (1917/1959) and his followers, depression is a form of grief produced in reaction to a loss, especially the loss of an important personal relationship through death, divorce, or separation. People who become clinically depressed tend to blame themselves for their loss. This pattern of self-blame is established early in life, usually because of the loss of parental affection. Rejecting parents, or early separation from one’s parents through death, divorce, or desertion, can cause a child to become fixated at the oral stage of psychosexual development. Because children at this early developmental stage depend on their caregivers to satisfy their physical and psychological needs, fixation produces a passive and emotionally dependent adult. They blame themselves for their loss of parental affection; these children grow up feeling unwanted and worthless. They are angry about their loss, but they turn their anger inward, thereby setting the stage for a lifetime habit of self-blame and a consequent vulnerability to depression.

Psychoanalysts now believe that mood disorders can be traced back not just to the loss of parental affection but also to the loss, early in life, of any person who was of special importance to the child (Keyes et al., 2014). Related to this is the concept that stressful life events often lead to a mood disorder (Gooding et al., 2016).

BehavioralBehavioral Views Views Behavioral psychologists originally emphasized the loss of important relationships in the etiology of depression. Their basic premise was that the behavior of other people is an important source of reinforcement for our own behavior. When we lose a friend or loved one, we also lose the reinforcement they provided. As a consequence, we may go out less, tell fewer jokes, and lose interest in social activities; in other words, once people become depressed, they set in motion a vicious cycle. Depressed people are bad company, so they are avoided. This furthers their isolation and makes them even more depressed. Even worse, if other people show sympathy for depressed friends and relatives, then the depressive behaviors may be reinforced and the depression may become chronic. Behavioral psychologists now believe that any life event that disrupts habitual behaviors can potentially lead to the loss of reinforcers and, therefore, to depression (Gooding et al., 2016).

The main problem with these behavioral formulations is their lack of specificity. We know that many people experience the loss of a loved one without becoming clinically depressed. Similarly, very few people respond to praise and success by becoming manic.

CognitiveCognitive Views Views Cognitive psychologists such as Aaron Beck (1991) view mood disorders as mainly the result of distorted

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attributions. They believe that depressed people are biased toward negative attributions. These negative attributions constitute what Beck calls the negative cognitive triad of depression: negative feelings about the self, the world, and the future. People with depressive mood disorders also have characteristic ways of interpreting and responding to life events.

People who feel worthless distort events to justify their low opinion of themselves. These distorted appraisals then make them depressed. Once depression sets in, they tend to make more negative self-appraisals, assuring further “failures” and making them feel more worthless and even more depressed. Once this process takes hold, depression becomes self-perpetuating. Like psychoanalysts and behaviorists, cognitive psychologists make room for individual differences in their theory. The main tenet of the cognitive view is indisputable; the research evidence showing that depressed people are self-critical is overwhelming (Kannan & Levitt, 2013).

LearnedLearned Helplessness Helplessness In contrast to Beck’s cognitive theory, which was derived from clinical observations, Martin Seligman’s theory of learned helplessness was derived from animal research (Seligman, 1975). In the typical experiment, dogs were confined in a box with an electrified floor. They received electric shocks, which they could not avoid because there was no escape route. Later, the same dogs were tested in an apparatus known as a “shuttle box.” This box consisted of two compartments separated by a small partition. One side of the box had an electrified floor; the other did not. Once again electric shocks were delivered through the floor, but this time they were preceded by a buzzer or a light signal. The animals who were attracted to the electrified compartment by food or drink could avoid the pain of a shock by jumping over the wall whenever they heard or saw the signal (see Figure 6.3). Animals that had never been exposed to the inescapable shock eventually learned to jump out of the electrified side of the box whenever the signal was presented. This allowed them to eat or drink in the electrified box without ever feeling any shock. The animals that had previously been exposed to the unavoidable shock never learned to make the required escape response. Instead, they just lay down on the grid, cowered, whined, and accepted their fate. According to Seligman, these animals had learned that painful outcomes were beyond their control. Instead of learning to avoid shock, they simply learned to act helpless.

Figure 6.3: Learned helplessness

In Martin Seligman’s (1975) research into learned helplessness, dogs that had been confined in a box with an electrified floor and were unable to avoid being shocked were subsequently unable to learn to jump to safety over the partition in a half-electrified shuttle box at the signal of a buzzer or a light.

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Source: S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 6.6, p. 343.

Seligman noted parallels between the animal research and human depression. For example, many depressed people have experienced tragedy and loss over which they have had no control. In response, they may give up trying to cope and react to life’s problems with passivity and helplessness.

Over the years, Seligman and his colleagues have gathered additional evidence for his learned helplessness theory (Peterson, Maier, & Seligman, 1993) and have revised it. According to the revised theory, we attribute our failures and losses to either internal or external causes. External attributions (where the individual attributes failure to environmental events and to other people) lead to temporary feelings of helplessness and depression but not to self- blame. Internal attributions (where the individual attributes negative events to a personal failing of some sort), by contrast, produce more chronic forms of depression in which low self-esteem and self-blame play an important role. An important prediction of the revised helplessness theory is that serious depressions require not only a triggering event (such as failing to make the Olympic team) but also a depressive internal attributional style that assigns such failure to personal, usually global, failings (Liu, Kleiman, Nestor, & Cheek, 2015).

InterpersonalInterpersonal and and Social Social Support Support As we have seen, loss and stressful life events, especially the deaths of loved ones, are often associated with mood disorders. The effects of stress and loss can be minimized by supportive friends and family (Gooding et al., 2016). Recovery from depression can be accelerated by strong social support (Gooding et al., 2016). This is why mood disorders are less likely among people who have strong social support networks (Liu et al., 2015).

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Elizabeth Cardoso/Hemera/Thinkstock

Modern drug treatments focus on blocking the reuptake of serotonin, or SSRIs. These drugs increase serotonin levels and are effective against depression with minimal side effects.

6.5 Treatment of Mood Disorders As mentioned earlier, Hippocrates believed that depression was caused by the supposed excess of black bile in the body. Bloodletting, the administration of drugs that caused vomiting and diarrhea, diets, massages, baths, and exercise were all prescribed. Even when doctors no longer believed in the four humors, regular exercise continued to be prescribed (Jaffe & Holle, 2017).

Biological Treatments

Biological treatments cover a wide range, including electroconvulsive therapy, light treatment, and many other interventions. However, by far the most common biological treatment is the administration of mood-altering drugs.

DrugDrug Treatment Treatment As mentioned earlier, MAO inhibitors’ side effects, and the difficulty in maintaining dietary restrictions to avoid potentially life-threatening reactions, are too serious to make them the drug of first choice. MAO inhibitors were first replaced by imipramine, which was originally synthesized to treat schizophrenia. It did not do much to help the symptoms of schizophrenia, but it did seem to lift people’s depression. Thus, by accident rather than by design, imipramine became the first in a series of tricyclic antidepressants (TCAs). Tricyclic refers to the chemical structure of these substances, which contains three rings of atoms. Although these drugs work differently from MAO inhibitors, they also increase neurotransmitter levels. Specifically, they block the proteins that transport neurotransmitter residues back to synaptic terminals. This keeps the neurotransmitters from being reabsorbed, thereby increasing their levels (Nelson, 2016).

More recent drugs have targeted another neurotransmitter, serotonin. Fluoxetine (Prozac), for example, is an antidepressant drug that blocks the reuptake of serotonin (thereby increasing serotonin levels) while leaving other neurotransmitters unaffected. Fluoxetine and related drugs are known as selective serotonin reuptake inhibitors (SSRIs). The drug has become popular because it not only is effective against depression but also has relatively mild side effects, such as increased agitation, lowered libido, insomnia, and stomach upset (Nelson, 2016).

These reduced side effects are especially important. It takes a minimum of two weeks before any of the antidepressant drugs exert their therapeutic effect. During these two weeks, patients develop the side effects of the drugs but receive no benefits. Some give up the drugs in disgust. Because fluoxetine has few side effects, people are more likely to stick with it long enough to obtain the benefits. Reduced side effects also save money because drug side effects often require treatment (Auday,

2016).

Because most depressions eventually lift whether they are treated or not, the main goal of drug treatment is to hasten recovery and prevent recurrence (Safer, 2017). The latter goal may require that patients be given “maintenance” doses of antidepressant medication for prolonged periods lasting months or even years (Safer, 2017). Antidepressants do not “cure” depression and recurrences may still occur, even among those treated with maintenance doses (Auday,

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2016).

Drug treatment for bipolar disorder was discovered by John Cade (1912–1980) in the 1940s. Cade, an Australian psychiatrist, studied people who had mania, trying to find some biochemical cause for their behavior. One of his experiments involved injecting guinea pigs with urine samples taken from manic patients and noting whether the animals’ behavior changed. Nothing happened. Cade could not find any particular ingredient that caused mania. Instead, he found that lithium urate (a salt found in everyone’s urine) caused the guinea pigs to become lethargic. Since lithium carbonate, a naturally occurring salt, had the same effect, he concluded that it was the lithium that was calming down the animals. Cade himself took lithium first and, noting no ill effects, he tried lithium on one of his patients. The patient, whom Cade described as “dirty, destructive, mischievous, and interfering” and who had “enjoyed pre-​eminent nuisance value in a back ward for years,” became perfectly well.

Perhaps Cade’s most extraordinary discovery was that lithium not only was effective against mania but also seemed to prevent the depressive episodes of bipolar disorder. Thus, although antidepressants helped relieve depression and strong tranquilizers calmed mania, lithium helped both conditions. Moreover, unlike imipramine or fluoxetine, lithium does not affect neurotransmitters. Instead, it seems to reduce the excitability of the nervous system.

Although Cade initially reported that bipolar disorder patients will not have a recurrent manic episode if they take lithium indefinitely, more recent studies estimate the recurrence rate among treated patients to be around 40% to 50% (Goodwin & Jamison, 2007). One difficulty in judging lithium’s effectiveness is ensuring that people take their medication as prescribed. Some people stop taking lithium because they like the feeling of well-being and energy that accompanies a manic state (Goodwin & Jamison, 2007). Others forego lithium because of its side effects: diarrhea, stomach upset, weakness, and frequent urination. In high dosages, lithium can even be fatal. Ensuring patient compliance is especially important because discontinuing lithium actually increases the probability of a manic episode. In other words, discontinuing lithium is not recommended as relapse may occur (Sportiche et al., 2016).

Anticonvulsant medications typically used to treat seizures have also been used to treat bipolar disorder (Gooding et al., 2016). Individuals who have at least four episodes of mania or depression within a 12-month time period are specified as having a rapid-cycling ​pattern. This type of bipolar disorder is quite difficult to treat effectively (for example, Gooding et al., 2016); nevertheless, anticonvulsants have shown some efficacy for this group (Gooding et al., 2016).

ElectroconvulsiveElectroconvulsive Therapy Therapy Electroconvulsive therapy (ECT) was introduced in the 1930s. ECT involves sending electrical impulses through the brain with the goal of inducing a seizure. Like many drug treatments, it also had its origins in an accident. A Viennese doctor named Manfred Sakel noted that a patient who had accidentally been put in a coma by an overdose of insulin became less anxious and depressed. Because it was difficult to determine the exact amount of insulin required to produce a seizure without inflicting serious harm or even killing the patient, clinicians experimented with “safer” methods to induce seizures. One method was ECT. ECT fell out of use in the 1950s due to the memory loss that often occurred and the scary nature of the procedure itself. In addition, antidepressant medications made the use of ECTs less warranted (Piotrowski & Hartmann, 2017). By the 1970s, however, it began to make a comeback. Today, ECT is used to treat depression in patients who do not respond to drugs or psychological therapy.

Today’s ECT patients are given a general anesthetic so that they are not conscious during the procedure. They also

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This early electroconvulsive therapy machine was first used in the 1930s, and by the 1970s ECT treatment was administered to patients who failed to respond to drugs or therapy.

receive drugs that inhibit body movements. Electrodes are then placed on the head, usually on the right side only. Because the left side of the brain normally contains the speech centers, applying shock only to the right minimizes any disruption in communicative ability (Heering & Schub, 2017). Once the electrodes are in place, a current is passed through the head for about half a second. The patient’s response is a convulsion (seizure) that lasts for around a minute, followed by a coma that lasts from a few minutes to half an hour.

ECT can rapidly clear a depression without needing to wait the weeks required with drugs or psychotherapy (Piotrowski, 2016). However, ECT may have side effects. One of these is memory loss, especially for events just before the seizure. Modern practice is to minimize the number of treatments so that memory loss is not extensive and new learning is unaffected. ECT is generally reserved for people who do not respond to other forms of interventions. After more than 80 years of use, we still have no theory to explain the therapeutic effects of ECT. The lack of a theory about how ECT works, coupled with reports of serious side effects, even death, have made ECT controversial.

LightLight Treatment Treatment For hundreds of years, clinicians have prescribed a trip to a sunny climate as the best cure for the winter blues. Light treatment provides similar benefits, but without the travel. Unspecified depressive disorder with seasonal pattern (commonly called seasonal affective disorder [SAD]) is a unipolar depression that occurs only during a particular time of year—typically in winter, when the days are shorter. Light treatment for people with this disorder involves exposure to a few hours of bright light every morning (Piotrowski, 2016). The light is designed to mimic the spectrum of sunlight. In any event, side effects are rare, although exposure to light may cause eyestrain and headache (Piotrowski, 2016). (See Figure 6.4.)

Figure 6.4: Prevalence of seasonal affective disorder by latitude

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Source: D a t a D a t a f ro m f ro m R o s e n R o s e n e t e t a l . a l . ( 1 9 9 0 ) , ( 1 9 9 0 ) , f ro m f ro m S . S . S c h w a r t z , S c h w a r t z , Abnormal Psychology: A Discovery Approach. M o u n t a i n M o u n t a i n Vi e w, Vi e w, C A : C A : M a y fie l d M a y fie l d P u b l i s h i n g P u b l i s h i n g C o m p a n y, C o m p a n y, 2 0 0 0 , 2 0 0 0 , F i g u re F i g u re 8 . 5 , 8 . 5 , p . p . 3 4 0 . 3 4 0 .

TranscranialTranscranial Magnetic Magnetic Stimulation Stimulation Transcranial magnetic stimulation (TMS) is a painless, noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression, typically when other treatments haven’t been effective (see also Chapter 1). Even though we are unsure why TMS works, it may activate regions of the brain that have decreased activity in people with depression.

Psychological Treatments

Medications, ECT, light, and TMS are aimed at alleviating the symptoms of depression. They do not teach people who are prone to depression how to cope with the loss of a loved one, unemployment, or any of the other triggers of depression. Psychological treatment, by contrast, is designed to help people learn more effective ways of behaving. Most psychological treatments have focused on depression rather than bipolar disorder (other than those that try to devise ways of making sure that people with bipolar disorder take their lithium).

PsychoanalyticPsychoanalytic and and Interpersonal Interpersonal Treatment Treatment Psychoanalytic treatment is designed to help patients achieve insight into the repressed conflicts that are presumed to be responsible for their mood disorder. Most often, these conflicts involve the loss of a loved one, accompanied by guilt and self-blame. Once the therapist has helped the person to recognize the conflict, the therapist encourages the person to release the inwardly directed hostility and, through this catharsis, eliminate inner-directed anger.

InterpersonalInterpersonal Psychotherapy Psychotherapy (IPT) (IPT)

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Interpersonal psychotherapy (IPT), developed by Gerald Klerman in 1988, aims to help clients examine the ways in which their present social behavior keeps them from forming satisfactory interpersonal relationships (Lemmens et al., 2017). Instead of focusing on the past, IPT is concerned with the present, especially problems in adjusting to grief; fights with friends, coworkers, and relatives; role transitions (new job, divorce); and social deficits (such as a difficulty in acquiring new relationships). In addition to gaining insight, clients are taught assertiveness and communication skills as well as other ways of improving their ability to form supportive relationships.

Cognitive-BehavioralCognitive-Behavioral Treatment Treatment As its name suggests, cognitive-behavioral treatment combines cognitive and behavioral interventions. The cognitive component involves teaching clients to identify self-critical and negative thoughts, to note the connection between such thoughts and depression, and to challenge negative thoughts to see if they are supportable. If they are not, the client is taught to replace them with more realistic evaluations of present and future circumstances.

Outside of cognitive-behavioral therapy sessions, some clients find that programmed aerobic exercise (such as spinning or aqua-aerobics) can help them understand and control their depression and lead to better relapse prevention (Olson, Brush, Ehmann, & Alderman, 2017).

Drugs Versus Psychological Treatment

One of the first studies to compare psychological with drug treatments found that ​cognitive-behavioral therapy was superior to imipramine in the treatment of depression (Rush, Beck, Kovacs, & Hollon, 1977). Several studies found that cognitive-behavioral treatment and IPT reduce the probability of a relapse (Hollon et al., 1992; Hollon, Shelton, & Davis, 1993; Lewinsohn, Clarke, Hops, & Andrews, 1990). But combining psychological treatments with antidepressant medication seems to produce a greater prevention effect than use of either treatment alone (Nelson, 2016). One reason for this is that people in psychotherapy are more likely to take their drugs regularly (Jin, Sklar, Oh, & Li, 2008).

Undertreatment

Some people do not seek help because they fail to recognize the signs of depression, others fear the stigma of “mental illness,” and still others cannot afford treatment costs. Medical professionals also contribute to undertreatment. Many medical practitioners are poorly informed about mood disorders and the benefits of treatment (Vermani, Marcus, & Katzman, 2011). The worst outcome of an untreated mood disorder is a despair that becomes so extreme that the person takes his or her own life. However, mood disorders are not the only cause of suicide. (Click here (https://media.thuze.com/MediaService/MediaService.svc/constellation/book/Getzfeld.3794.18.1/{misc}casestud- ies_ch06.pdf) and see Part 4 of Bernard Louis’s case.)

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6.6 Suicide Suicide, self-inflicted death in which the person deliberately, consciously, and intentionally acted to kill himself or herself, is a disorder under further study in the DSM–5; the disorder is called suicidal disorder (APA, 2013). In some times and places, suicide has been socially acceptable. For example, in 2014 in the United States, Brittany Maynard announced that she intended to end her life by physician-assisted suicide. In early 2014, Maynard had been diagnosed with a brain tumor, which quickly advanced and eventually became terminal. She then moved from California to Oregon, where physician-assisted suicide is legal, and ultimately ended her life by that means (Pierre, 2015). In Japan it was, and still is to a certain extent, considered socially acceptable to commit seppuku, or suicide, to save the family from disgrace. Even though social views are thought to be more tolerant in the United States, suicide is often still considered a social disgrace here. Suicidal behavior is surrounded by many myths. Some of these are highlighted in the accompanying Highlight.

Highlight: Suicide Myths and Reality

Over the centuries, myths have developed around suicide. Some of the more prevalent myths, and the corresponding realities, are addressed in the table that follows.

Suicide Myth Suicide Reality

Those who talk about suicide never do it. The vast majority of people who kill themselves give some warning.

Suicide is related to social class. People of all social and educational classes kill themselves. Although more educated people are less likely to turn to suicide, there are some notable exceptions. Highly educated people, such as doctors, have among the highest suicide rates (Kent, 2010). Some occupations that require advanced education—such as dentists and physicians—are associated with higher suicide rates, presumably because they often are highly stressful professions, and perhaps because practitioners have easy access to lethal drugs such as barbiturates and narcotics.

Everyone who dies by suicide is depressed. Many people who kill themselves are not depressed. Indeed, suicides are most likely to occur just when it appears that a person has recovered from depression.

Suicide is influenced by weather (“the suicide season”).

Suicides can occur at any time of year.

Suicidal people always want to die. Most people who kill themselves are not sure they want to die. Many gamble with their lives, hoping

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that others will save them.

Only insane people contemplate suicide. Suicidal thoughts are common in the general population. Among the terminally ill, suicide may be considered a rational act.

Once people try suicide, they remain forever suspect.

Most people attempt suicide only once, but up to 40% of those who complete suicide will have made previous attempts (Cavanagh, Carson, Sharpe, & Lawrie, 2003).

Those who unsuccessfully attempt suicide were never serious.

Some people are poorly informed about the lethality of different acts.

Suicidology (the study of suicide, suicidal behavior, and suicide prevention) has become a scientific field in its own right. Still, many people who take their own lives do suffer from a mental disorder (Piotrowski & Hartmann, 2017). Because suicide is frequently associated with depression, it has been included in this chapter.

Prevalence and Incidence

Suicide is universal and has occurred throughout history. It is among the top 10 causes of death in the United States and a common cause of death among young people (Centers for Disease Control and Prevention [CDC], 2015). The reported suicide rate in the United States is 42,826 per year; the actual number is probably higher (CDC, 2017). About 50% of suicides involve the use of firearms (CDC, 2017). The remaining are by suffocation and poisoning. Many suicides go unreported because of the ambiguity surrounding the death or because families try to cover up the circumstances to avoid social stigma (Piotrowski & Hartmann, 2017). Although suicide occurs everywhere, cross- cultural comparisons are difficult because cultures may record suicides differently, based on how suicide is treated in a given culture. According to recent research, a large disparity exists between suicide attempters and suicide completers in terms of demographics, means, and the setting (see Table 6.4).

Table 6.4: Suicide attempts versus suicide completers

Characteristic Attempters Completers

Sex Female Male

Age Under 35 Over 60

Means Low lethality (pills) High lethality (firearms)

Diagnosis None or rare Depression; substance abuse

Setting Public, easy to discover Private and isolated

Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Table 8.7, p. 357.

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KMazur/WireImage/Getty Images

Rock musician Kurt Cobain, of the 1990s band Nirvana, died by suicide on April 5, 1994. Cobain suffered from depression and also had severe issues coping with worldwide media attention.

Age, Sex, and Ethnic Differences

Although suicide is a relatively more common cause of death among young people than among older ones (because young people are less likely to die from disease), suicide is not uncommon among older persons (CDC, 2005). For example, in 2000, when 12.5% of the U.S. population was older than 65, this group accounted for almost 20% of all suicides (CDC, 2003). It is particularly prevalent among white males older than age 65 (CDC, 2003). Divorced, widowed, and other single people have higher suicide rates than married people. In all instances, more men than women take their own lives (APA, 2003).

The circumstances of people who take their own lives are remarkably similar across cultures. Suicides are most common among people whose families have been affected by death or divorce, who have unhappy love affairs, who suffer serious illness, or who experience severe economic setbacks.

Assessing Suicidal Intentions

It is not easy to predict who will kill themselves; many suicides seem to happen without prior warning (Apter et al., 1993; Maris, Berman, Maltsberger, & Yuflt, 1992). Nevertheless, suicidologists have been able to identify a set of risk factors that seem to be correlated with suicide (see Table 6.5).

Table 6.5: Risk factors and suicide

Factor Low Risk High Risk

Sex Female Male

Marital status Married Single/divorced/living alone

Age Middle years Adolescence/old age

Psychiatric status

Normal/character disorders/situational disturbances

Depression/alcoholism/conduct disorder/schizophrenia

Setting Rural Urban/prisons

Assault victim No history Multiple physical and sexual assaults

Religious activity

Regular churchgoer Non-churchgoer

Nationality Italian/Dutch/Spanish Scandinavian/Japanese/German-speaking countries

Source: Adapted from Nock and Kessler (2006), Nock et al. (2008), and Stevenson et al. (1972).

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Causes of Suicide

The motive for attempting suicide varies from person to person (Piotrowski & Hartmann, 2017). Some suicides are attempts to extract retribution or obtain martyrdom, others are a way to end a life of intolerable pain, and still others are the result of risk taking or “playing with death.” Edwin Shneidman, who studied risk factors for suicide, noted that there are certain commonalities among people who display suicidal behavior (Shneidman, 1992): They are seeking a solution to a problem, wish to end consciousness, have either psychological or physical pain (or both), have frustrated psychological needs, feel hopeless, cannot see alternatives, and are “escapers” rather than problem solvers. (See Figure 6.5.)

Figure 6.5: Threshold model for suicidal behavior

Source: A d a p t e d A d a p t e d f ro m f ro m “ C l i n i c a l “ C l i n i c a l A s s e s s m e n t A s s e s s m e n t a n d a n d Tre a t m e n t Tre a t m e n t o f o f Yo u t h Yo u t h S u i c i d e , ” S u i c i d e , ” b y b y S . S . J . J . B l u m e n t h a l B l u m e n t h a l a n da n d D . D . J . J . K u p f e r, K u p f e r, 1 9 8 8 , 1 9 8 8 , Journal of Youth and Adolescence, 17, 1 – 2 4 . 1 – 2 4 . C o p y r i g h t C o p y r i g h t © © 1 9 8 8 1 9 8 8 b y b y P l e n u m P l e n u m P u b l i s h i n gP u b l i s h i n g C o r p o r a t i o n . C o r p o r a t i o n . R e p r i n t e d R e p r i n t e d w i t h w i t h k i n d k i n d p e r m i s s i o n p e r m i s s i o n o f o f S p r i n g e r S p r i n g e r S c i e n c e S c i e n c e + + B u s i n e s s B u s i n e s s M e d i a . M e d i a .

PsychologicalPsychological Disorders Disorders and and Suicide Suicide A psychological disorder, usually a bipolar disorder or a major depression, appears in the history of many cases of

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suicide (Piotrowski & Hartmann, 2017; Shneidman, 1992). Interestingly, people rarely attempt suicide while in the depths of depression. The year following a major depressive episode is the most dangerous period (Isometsä, Sund, & Pirkola, 2014), perhaps because the person is still unhappy but now has the energy required to carry out self- destructive intentions.

Most people with mood disorders do not kill themselves; however, alcohol abuse makes suicide more likely. The presence of a psychological disorder, such as depression, combined with the poor judgment and reduced inhibition produced by alcohol create a lethal combination (Piotrowski & Hartmann, 2017).

PsychologicalPsychological Factors Factors Freud and his followers construe suicide as a form of murderous anger at another person turned inward against oneself. A child whose mother dies may become angry about this loss, but the child is unable to vent this anger because its target, the dead mother, is unavailable. Instead, the child turns this anger inward.

Despite the confirmation of early loss in the childhood of many people who kill themselves, the overall evidence for the psychoanalytic view of suicide is far from compelling. Although hate and revenge are sometimes the motives for suicide, they are not the only reasons people take their own lives (Tucker, Crowley, Davidson, & Gutierrez, 2015). Shame, guilt, and hopelessness are considerably more common motives. Hopelessness is particularly important (Piotrowski & Hartmann, 2017; Sadock & Sadock, 2007; Shneidman, 2005).

GeneticsGenetics and and Physiology Physiology Suicide, like depression, tends to run in families (Zai et al., 2012). The concordance rate for suicide among monozygotic twins is 20 times higher than it is among dizygotic twins, 0.7% compared with 14.9% (Brent & Melhem, 2008). Because most suicidal twins are also depressed (or suffering from some other mental disorder), it may be the mental disorder, rather than the tendency toward suicide, that is inherited. In any event, there does seem to be a genetic factor involved, although it is worth noting that, even among monozygotic twins, the concordance rate for suicide is not 100%.

Treatment and Prevention

Since medical science can now keep some people alive indefinitely, there is considerable debate about the ethics of doing so. Perhaps people should be able to die with dignity when they no longer wish to live. Some say yes, others no. For psychologists, their stance is more clearly defined. Because suicide is an irreversible act, the professional ethics of psychologists require that they try to prevent people from harming themselves, even if this means breaking client-therapist confidentiality.

CrisisCrisis Intervention Intervention Crisis intervention is aimed at overcoming immediate problems. This is often done through telephone crisis lines and walk-in prevention centers that were first established in most cities in the 1960s. The counselors who answer these phones and who work in these centers have been taught to maintain contact with the person in crisis, develop a relationship, clarify the source of stress, and recommend an action plan—usually a place the person can go for help.

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HOME BOX OFFICE/SuperStock

Robin Williams took his own life in 2014.

PsychologicalPsychological Interventions Interventions The first issue to be faced in the treatment of suicide is the potential for another attempt. If the likelihood seems high (and that is often difficult to judge), then the safest place for the person is in the hospital, even if this means involuntary commitment and breaking therapist-client confidentiality. Once the immediate danger subsides, treatment is usually aimed at overcoming any immediate life-stress and at teaching clients how to go about solving problems before they become hopeless. (See the accompanying Highlight.)

Highlight: Celebrities and Suicide

We can safely say that you know about Robin Williams. Perhaps you know of, or saw, Chris Cornell of Soundgarden. Maybe you know about Chester Bennington of Linkin Park. Robin Williams of course was a multitalented actor and comedian, while Cornell and Bennington were successful rock stars, front men for their bands. What is it that led these three men, as well as a number of other celebrities, to take their own lives? Fast (2017) has an interesting perspective. Many articles mentioned that Cornell and Bennington were tormented by “inner demons” and that they dealt with them through their music and singing, almost like a form of catharsis. Bennington was very candid about being sexually molested by a close friend from age 7 until 13, and he talked about how he never completely got past this history, leading to addictions, among other issues. Fast (2017) says that part of the problem is that we and the media are too quick to characterize depression as fighting with inner demons, not recognizing it as an illness similar to diabetes or cancer. In other words, we are ascribing mythical aspects to a very real illness that affects tens of millions of people worldwide and that plays no favorites, multitalented or not. When people suffering from depression take their lives, they are doing so because of a treatable illness, not because of inner demons. Perhaps if more people understood this, lives could be saved through prevention, treatment, and education.

Postvention

Suicide has a shattering impact on the survivors (Piotrowski & Hartmann, 2017). Family and friends must cope not only with the death of a loved one but also with the circumstances of the death. Postvention (Shneidman, Farberow, & Litman, 1970) is aimed at helping relatives and friends cope with grief. Friends and relatives of a suicide victim often feel guilty and anxious because they believe that they should have done something to prevent the death. Sometimes they may become suicidal themselves (Piotrowski & Hartmann, 2017). Group therapy can sometimes help provide a supportive environment, but postvention involves more than just group therapy. Postvention also includes rumor control and identifying those people at high risk of imitation. A number of postvention programs have been developed, mainly for schools.

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Chapter Summary

Mood disorders (depressive, bipolar, and related disorders) tend to occur most often among people who have experienced a severe loss early in life. Mood disorders run in families. Pharmaceuticals, electroconvulsive therapy, and psychological treatments (alone or in combination) seem to help shorten depressive and manic episodes and prevent relapses.

Emotions: Normal and Pathological Emotions are normal. They help us survive. We flee from danger when afraid. Sadness at parting cements parent-child bonds. Overwhelming fear or sadness can hinder normal life processes. Mood disorders (depressive, bipolar, and related disorders) tend to occur most often among people who have experienced a severe loss early in life. Mood disorders run in families.

Depressive (Unipolar) Disorders Depression is marked by a sad mood, loss of interest in formerly pleasurable activities, sleep disturbances, changes in appetite, loss of interest in sex, irritability, inability to concentrate, and a wide variety of aches and pains. In adults, depression, physical illness, and substance abuse often go together. In children, the most frequently reported comorbid conditions are disorders of conduct. Persistent depressive disorder (dysthymia) is a moderate depression that lasts two years or more (one year in children and adolescents). Depression is common, and the number of cases seems to be rising, especially among young people. Women are more than twice as likely to be depressed as men.

Bipolar and Related Disorders Manic episodes are marked by an expansive mood, grandiosity, diminished sleep, heightened sex drive, and rapid-fire speech. Hypomanic episodes are similar to manic episodes but milder. When the depressions are mild and mood is highly variable, the diagnosis is cyclothymic disorder. Bipolar disorders are less common than unipolar disorders and affect men and women of different ethnic groups equally. The first signs of bipolar disorder usually appear in early adulthood, but the incidence of bipolar disorders seems to be rising among young people. Typically, onset is sudden; follow-up studies have found the prognosis to be poor.

Etiology of Mood Disorders The response of some mood disorders to light therapy, the effectiveness of antidepressant drugs, the evidence for heredity, and the relationship between mood and hormonal imbalances are all compatible with

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a biological etiology. Psychoanalysts focus on the loss of affection and “fixation” in early childhood. Behavioral theories emphasize learned helplessness and loss of reinforcement. Cognitive theories focus on faulty attributions.

Treatment of Mood Disorders Biological treatments for mood disorders cover a wide range and include drug therapy, ECT, light treatment, and transcranial magnetic stimulation. Psychological treatment attempts to teach people more effective ways of coping with problems.

Suicide Suicide is the tragic result of the complex interaction of social, psychological, and biological forces. People who take their own lives are seeking a solution to a problem, wish to end consciousness, have intolerable psychological or physical pain, have frustrated psychological needs, feel hopeless, cannot see alternatives, and are “escapers” rather than problem solvers. Suicide is among the world’s top 10 causes of death and a common cause of death among young people. Divorced, widowed, and other single people have higher suicide rates than do married people; in all instances, more men than women take their own lives. Early life events, genetic predispositions, and psychological disorders all play some role in suicide, though none of these factors by itself is a good predictor of who will complete suicide. Crisis intervention is aimed at overcoming current problems and reducing the probability of a suicide attempt; if the probability seems high, then the safest place for the person is in the hospital. Once the immediate danger subsides, cognitive-behavioral treatment can be used to teach clients how to go about solving problems before they become hopeless. Family therapy may also be useful in helping to improve family communication and joint problem solving. Postvention is aimed at helping relatives and friends cope with the grief of a suicide.

Critical Thinking Questions 1. Based on what you have read, think about and discuss why it would be difficult to distinguish between

unipolar depression and an adjustment disorder with depressed mood. 2. What, in your opinion, is the best method for treating unipolar depression? 3. Presume you have a friend who has bipolar I disorder. She tells you that she is on lithium and has decided

not to take it because she wants her “highs” to return and says that she is all better. Discuss what you would say to her based on what you have read and discussed in class.

4. Freudians believe that depression is anger turned inward and is also a result of a loss that occurred during childhood. Give your views on what causes depression.

5. If you had a friend who you thought was suicidal, how would you handle it, based on what you have read?

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Key Terms

adjustment disorder with depressed mood

anhedonia

bipolar I disorder

bipolar II disorder

cyclothymic disorder

depression

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electroconvulsive therapy (ECT)

hypomanic episode

interpersonal psychotherapy (IPT)

learned helplessness

lithium carbonate

major depressive disorder

major depressive episode

mania

manic episode

MAO inhibitors (MAOIs)

melancholia

mixed episode

mood disorder

negative cognitive triad

persistent depressive disorder (dysthymia)

postpartum depression

postvention

rapid-cycling pattern

selective serotonin reuptake inhibitor (SSRI)

suicide

suicidology

transcranial magnetic stimulation (TMS)

tricyclic antidepressant (TCA)

unipolar mood disorder

unspecified depressive disorder with seasonal pattern (seasonal affective disorder, or SAD)

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with peripartum onset