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AQA A2 Psychology Depression
Terms in this set (23)
The different types of depression
- Unipolar depression such as post-natal, or seasonal affective disorder (SAD).
- Dysthymic disorder (chronic depression).
- Bipolar (manic depression).
- Endogenous or reactive depression, such as, a chemical imbalance in the brain, or caused by external factors.
Classification of Depression
Diagnostic and Stastical Manual (DSM IV)
To be diagnosed with major depressive disorder, five or more of the following symptoms must be present during the same 2 week period, one of which must be a depressed mood, or, a loss of interest or pleasure.
Other symptoms may include:
- significant weight loss when not dieting or gain. (In children consider failure to make expected weight gains).
- insomnia or hypersomnia everyday.
- recurrent thoughts of death or suicidal thoughts.
- diminished interest in all or most activities nearly everyday.
- feelings of worthlessness or excessive inappropriate guilt.
When this was devised from the DSM III disrupted mood disregulation disorder and pre-menstrual dysphic disorder were added.
Disruptive mood disorder is reserved for children aged between 6-18 years who show persistent irritability and frequent out-of-control behaviour due to concerns of over-diagnosing and over-treating children with bipolar disorder.
PMDD is a more severe form of premenstrual syndrome, including strong emotional symptoms such as anxiety, moodiness and irritability.
Dysthymia and chronic major depression are both under the heading 'persistent depressive disorder' as there was found to be no scientifically differences between the two.
Bereavement exlusion was removed as there is no scientifically valid reason for treating the grieving process any differently from other stressors.
Was published by the WHO and is used world-wide unlike the DSM which is primarily used in the USA and UK.
It is a much larger manual and encompasses all types of disorders unlike the DSM V which only focuses on mental disorders.
The DSM requires the psychiatrists to evaluate the patient in five axes:
Clinical disorders (such as depression)
Personality disorders (such as mental retardation)
Environmental factors (optional)
Global assessment of functioning (optional)
The ICD-10 includes 10 groups such as delusional disorders, mood disorders and personality disorders. It is also more symptom-based than the DSM-IV.
The issues of reliability and validity in diagnosing and classifying depression
Reliability can be improved upon by using the test-retest method or inter-rater. Lobbestael et al assessed the inter-rater reliability of the Structured Clinical Interview for the assessment of major depressive disorder in a mixed sample of patients and non-patient controls. Results revealed moderate agreement with an inter-rater reliability coefficient of 0.66.
A current measurement scale, the BDI, Beck's Depression Inventory involves a 21-item questionnaire designed to measure the severity of symptoms in individuals diagnosed with depression. He then tested their responses after 2 therapy sessions 1 week apart. Finding a correlation of 0.93 indicates a significant level of test-retest reliability.
Reasons for low reliability
Keller et al. DSM. To be diagnosed with major depression an minimum of 5 out of 9 symptoms must be present, a 1 item disagreement makes the difference between a major depressive disorder or a less serious illness.
And, moods greatly vary over time, making reliability even more difficult.
Zimmerman et al claim the DSM-IV criteria to be considerably lengthy such that treatment doctors have troubles recalling even 5 of the 9 symptoms. So a briefer definition of major depressive disorder was devised, including only the cognitive and mood symptoms, and found that there was in excess of 95% agreement using the brief and full definitions.
Comorbidity, refers to the extent that two or more, conditions occur e.g. the presence of an anxiety disorder is the biggest clinical risk for the development of depression. The experience of anxiety serves as a compounding stressor that leads to major depression.
Concurrent validity, is a measure of the extent to which a test concurs with already existing standard ways of assessing the characteristic in question. Research has consistently demonstrated concurrent validity between the BDI and other measures of depression such as the Hamilton Depression Scale.
Issues with validity
Weel-Baumgerten et al. suggested that the diagnoses made by GP's rather than secondary care specialists are made against a background of previous patient knowledge and so could be biased as a result.
Burrows et al found that healthcare providers under-diagnosed depression in 56% of nursing home residents as they assumed the symptoms were caused by other factors such as ageing
DSM vs ICD
Research has shown the concordance between the two to be 75%. For the ICD-10 a patient must have two of the following three symptoms unlike the DSM-IV, they include, sad depressed mood, loss of interest or lack of energy.
However Andrews et al demonstrated that this difference in classification systems did not produce a high number of matched diagnoses and that therefore one classification system is not more valid than the other at diagnosing depression.
Biological explanations of depression
Biology psychologists believe that depression is inherited and/or and in our genes rather than what we learn as a result of experience. Yet there is difficulty in isolating the effects from genes from the effects of the environment
Wender found that biological parents of adoptive suffers of depression were 7x more likely to have had depression then their adoptive parents. Adopted children who later developed aggression found that their biological parents were 8x more likely to have had suffered from depression then their adoptive parents.
The 5HTT gene is a serotonin transporter gene on chromosome 17. Moffit et al found that 43% of those who had the 5HTT gene had developed depression, and that those with a different gene the percentage of depressed people dropped to 17%. This is specific and not just an assumption, given that it has a role in serotonin production it makes it even more likely to be linked with depression. Following the diathesis-stress model, that believes that genetic factors predispose someone to depression but that depression is expressed after environmental influences. One way of trying to untangle genes from the environment would be to use biological methods of treatment and then cognitive based treatment, which ever is the most effective has the strongest link, yet it is almost impossible to separate the link between nature and nurture.
Kendler et al found that women who were the co-twin of a depressed person were more likely to become depressed themselves because they share the same genetics. Even higher levels were in those that are genetically at risk and had experiences negative life events e.g. death.
Gene mapping offers the possibility of developing tests to identify individuals with a high risk of developing depression, though this raises many socially sensitive and ethical concerns.
Biochemical explanations of depression
Low levels of monoamines (a group of neurotransmitters) e.g. serotonin, dopamine and noradrenaline were found in low levels in the brains of individuals with depression. The low levels could be because of the lack of brain sites to receive serotonin, insufficient production or inability for it to travel to brain sites. Malinson used PET scan techniques to observe the activity of serotonin receptor sites in the brain, finding that the number of serotonin receptor sites in the brain was lower for depressed people than in a control group.
SSRI's (selective serotonin re-uptake inhibitors) increase the availability of serotonin by inhibiting their uptake. 96 patients with MDD were treated for 6 weeks with an SNRI (serotonin-noropinephrine re uptake inhibitors), depressed people given this demonstrated a positive response unlike those on the placebo (Kraft). Therefore insinuating that there is a strong link between the depletion of sero and nora in depression.
HOWEVERRRR, it is unknown whether fluctuations on neurotransmitter and hormone levels are a cause or an effect of depression.
IN CONTRAST TO THIS, Kirsch found that SSRI's work no better than placebos for most patients with mild and even severe depression, and accused drug companies of suppressing research evidence that cast doubt on their effectiveness.
In Britain, more than £291 million was spent on antidepressants in 2006, these include, MAOI's (monoamine oxidase inhibitors), tricyclics and SSRI's (selective serotonin reuptake inhibitors). All three of which increase serotonin production but cause different side effects. There is no best drug to treat depression, as patients respond differently to different drugs, and drug choice is also affected by symptoms displayed and side effects exhibited.
Kirsch's study ^^^ highlights that the placebo effect of drug treatment is high, suggesting a psychological rather than biological effect.
Depressed people selected for clinical trials are usually only moderately depressed and free from other disorders, making accurate evaluation of antidepressants difficult, especially to generalise to all cases of depression, this is too complex to do. Assigning depressives to placebo conditions and therefore depriving them of possibly effective treatment is ethically problematic. As well as the fact that they were deceived.
ECT, originally used for schizophrenics has become a treatment of severe cases of depression. By administering electric shocks through electrodes on the temples (bilateral shocks) causes a seizure lasting for up to 1 minute. Yet, bilateral treatment does cause more side effects than unilateral. It seems to be a controversial treatment, brutal with side effects such as memory loss yet if an individual is at risk of suicide it is regarded as appropriate. Offering support is Paguin et al, perfumed a meta-analysis of ECT, comparing studies of ECT, placebos and antidepressant drugs, finding ECT to be superior and thus suggesting that it is a valid therapy for depression, including severe and restraint forms.
In order for an individual to undergo this seemingly brutal treatment for depression ps should be evaluated to a set of criteria, a review of previous psychiatric history, gaining informed consent, and appropriate diagnostic tests before ECT is prescribed (Coffey).
Psychological explanations of depression
inc. cognitive and behavioural explanations
Cognitive psychologists believe that people have faulty thinking which leads to irrational beliefs about how they see themselves and how others do and the world. The greater the severity of ones negative thoughts, the greater the severity of depression. (Beck's cognitive triad) we see ourselves as worthless, the world: emphasises our defeats and failures, future: envision a future like the past and present, despair and hopelessness. This triad is maintained by cognitive biases such as:
-Overgeneralisation, sweeping conclusions drawn on the basis of a single event e.g. poor performance on one test will mean poor performance on them all.
-Magnification and minimisation, e.g. a man has ruined his car merely by a small scratch, and a woman sees herself as worthless despite much praise. McIntosh and Fischer tested Becks cognitive triad to see if it contained three distinct types of negative thoughts, there found to be no separation between them but a single one-dimensional negative perspective of oneself. Suggesting that retention of all three areas of the triad as separate dimensions is unnecessary for representing the structure of depressive cognition.
Studiessss + therapies
Cognitive therapies include CBT, the idea behind this is that beliefs and expectations and the nature of personal problems affect how individuals perceive themselves and others and thus, how problems are approached. CBT assists patients in identifying irrational and maladaptive thoughts and altering them so that their behaviour can be modified to reduce depressive symptoms.
High degrees of success from therapies based on cognitive explanations, March et al found that 30% of depressed people experienced suicidal thoughts, this dropped to 15% with the use of drugs, and even lower at 6% with the use of CBT. Suggesting therapeutic treatments are much more successful than biological advances as well as it being a long-term treatment. (You can become addicted and dependent on drugs). However, for patients with difficult concentrating as is often the case for those with depression, CBT can be unsuitable, leading to feelings of being overwhelmed and disappointed, which strengthens depressive symptoms rather than reducing them.
The majority of evidence linking negative thinking to depression is correlational and does not indicate that negative thoughts cause depression. Beck came to believe that it was a bidirectional relationship where depressed individuals' thoughts cause depression and visa versa.
Behaviourism perceives depression as a learned condition, and not as a mental illness with a physical cause. Lewinsohn proposed that depression occurs due to a decline in positive reinforcement, for example, after a romance ends there are reduced opportunities for experiencing enjoyable outcomes and therefore fewer positive reinforcements, resulting in depression. (operant conditioning) Rice and McLaughin provided support for Lewinsohn's learning theory, finding that depressive individuals focus on negative events, set overly stringent criteria for evaluating their performance and administer little reinforcement to themselves.
Behaviourism also explains depression through learned helplessness, where individuals learn through experience that seemingly they cannot influence events, for instance, being unemployed and applying for jobs but not getting any interviews, leads to a chronic loss of motivation and eventually depression.
Alloy et al compared the ability of 144 clinically depressed and 144 non-depressed participants to estimate the relationship between pressing a button and various outcomes. Non-depressed participants overestimated the relationship for desirable outcomes and underestimated it for non-desirable outcomes, while depressed ps were consistent throughout.
Learned helplessness has not proven to be a universal occurrence: in some cases where individuals were placed in situations of helplessness, the experience actually led to improved performance.
behaviourist therapies - BAT
Behavioural therapies are based on the idea that depression is acquired through environmental experience and can be modified through learning theory principles such as OC and social learning. Reinforcements, in the form of rewards for desirable behaviour, are used to elevate mood and encourage participation in positive behaviours, while social reinforcements, in the form of family members and social networks are utilised to provide support for depressed individuals. Use is also made of social models who demonstrate desirable behaviours to be imitated.
BAT (behavioural activation therapy) a schedule of activities that deliver feelings of joy, is built up that sufferers need to participate in to create normal and satisfying lives. BAT offers a quick relief from depression, connecting patients with simple, naturally occurring reinforcements that seek to change how they approach day-to-day activities, make life choices and deal with crises.
-De Jong-Meyer and Hautzinger assessed 'Coping with Depression', a course of group therapy treatment based on BAT, finding that it achieved a comparable rapid outcome and a better long-term outcome than antidepressant medication, indicating that the therapy provides clinicians with a convenient, cost effective treatment that can be tailored to the needs of the ps, such as elderly or adolescents.
behaviourist therapies - SST
SST (social skills training) is a form of behaviour therapy that helps those who have difficulties in relating to others, a frequent feature of patients suffering from depression. Individuals lacking social skills have difficulties in building networks of supportive friends and become increasingly socially isolated, so by improving these skills and practising selected behaviours, it will give those the ability to function in everyday social situations.
La Fromboise and Rowe found that structured learning therapy, a treatment based on SST, is more readily employable for different groups of patients and improves the psychosocial functioning of people of varying ages and ethnic backgrounds.
Therapists using SST should progress slowly do patients are not overwhelmed by attempting to change too many behaviours at once, which may intensify feelings of social incompetence and deepen depression rather than reducing it. (it may also make them aware of how bad their past behaviours were).
Freud defined depression in terms of a person experiencing a real or imagined loss. As a result, a person may develop guilt, shame or self hatred and ultimately blame themselves.
Mourning is, where an individual has experienced a specific loss and is going through a grieving process. They know what the original cause is e.g. loss of a family member.
Melancholia is, where the nature of the loss is not known to the patient, the true loss is hidden in their subconscious. They cannot identify the nature and so are unable to successfully complete the mourning process.
Freud also believed that depression was related to childhood experiences of loss, and that depression in adulthood was a delayed reaction for this loss. Children repress any extreme feelings of loss or grief as their ego is not yet developed enough to deal with it. Later adult trauma or stress may lead to people re-experiencing the negative emotions of childhood, and they therefore regress to an earlier stage of their development. This can lead to depression in some sufferers and possibly even to suicide.
Harlows monkeys suffered depression, offering support that depression stems from childhood.
It explains a persistent pattern of depression where there is no obvious case. Individuals who suffer from depression often relapse, the model makes sense of this, as the cause clearly has not been addressed, the symptoms have just bee suppressed. Therefore it will keep expressing itself in the individuals' own mood.
Swaffer and Hollin showed that young offenders who repressed feelings of anger had increased vulnerability to developing depression.
His theory cannot explain why only 10% of those who experienced early loss go on to develop depression (Paykel and Cooper). Some argue that the cause is not known to the patient and so cannot be consciously recalled. Whatever the reason, psychodynamic theory cannot provide empirical evidence for the onset of depression, unlike neural explanations which rely on empirical methods such as PET scanners and genetic screening methods.
PIT (psychodynamic interpersonal therapy) was developed by Robert Hobson, who wanted to move away from the traditional psychodynamic approach and encourage the client and the therapist to engage in therapeutic conversation.
Rather than talking about feeling in an abstract way, an attempt is made to recreate them in a therapeutic environment. The therapist tries to understand what the individual is really experiencing or feeling, by saying, 'this is what I'm hearing you say, have i got it right?'.
Interpersonal difficulties in the individuals' life are identified and the therapist tries to find a rationale of the individual that links their current symptoms with these difficulties. The therapist acknowledges and encourages changes made during therapy.
Paley et al. investigated the effectiveness of PIT in a routine clinical practice setting. 62 ps received a course of PIT over a 52 month period and their outcomes were assessed using BDI, (there was a sig diff pre and post treatment). Showing that PIT can be an effective treatment for depression in hospitals and surgeries.
Psychoanalysis, dream analysis, ps record dreams and the therapist interprets them for hidden meanings, the manifest content is what the dream is about and the therapist tried to uncover the lateral content, the real meaning behind the dream. Critics claim that therapists aren't helping ps to recover repressed memories but are (without knowing) placing false memories in to their mind. Focusing on the therapist as the tool for recovery and not the patient, therefore becoming dependent on their therapist, even for many years.
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