Professor Paul Bloom: I
am extremely pleased to
introduce the fourth and final
guest lecture of the semester.
Professor Susan Nolen-Hoeksema.
Susan is a professor in the
Department of Psychology and the
Director of Graduate Studies.
She is well known for her work
in clinical psychology and
especially her research in
depression,
the nature and causes of people
with depression,
with special focus on sex
differences in depression.
She basically does everything
someone can do.
She is a noted scientist,
winning many awards and
publishing massive amounts of
work in scientific journals.
She is an award-winning teacher
and has authored what,
in my mind, is the very best
textbook in her area.
And she's a noted popular
writer who has written popular
and accessible books bringing
the message and ideas and
theories of clinical psychology
to the broader public.
The only other thing I'll
mention before we welcome her is
that she's going to teach next
year her course in clinical
psychology,
which has a superb reputation
as an extremely interesting
course.
If you are interested in what
you hear today and you want to
learn more about it,
that's the course you should
take.
So, let's please welcome Dr.
Susan Nolen-Hoeksema.
[applause]
Professor Susan
Nolen-Hoeksema: Thank you
Paul.
Can everybody hear me okay?
Okay.
So, what I want to do today is
to give you a very brief
overview of how modern clinical
psychology looks at mental
disorders,
some of the ways we think about
what constitutes a mental
disorder, some of the
characteristics that kind of cut
across mental disorders,
and then I'm going to use the
case of mood disorders,
that is depression and what is
now called bipolar disorder,
what you may know more
popularly as manic-depression,
as sort of examples of how we
think about a particular set of
disorders and some of the ways
we go about researching the
theories -- different theories
for the disorders and some of
the prominent treatments for
disorders these days.
Okay?
So, I'm going to do both a fair
amount of lecturing,
and then I've got lots of video
clips to show you as well.
So, I'm going to be roaming
around and changing venues here
fairly often.
So, the first and most
fundamental question in clinical
psychology is,
"What is abnormality?"
Where do we draw the line
between normal,
healthy, typical behavior and
what we might want to call
abnormal,
atypical, deviant,
unhealthy, maladaptive mental
problems?
We tend to have an intuitive
sense of what we mean by
abnormality, and we'd like to
believe--a lot of people who
come into my course say,
"Well, of course,
you know, you guys have figured
it out.
You know where to draw the line.
You have criteria.
You have blood tests, right?
--that tell me whether I have
depression or schizophrenia or
one of the things I've read
about."
Well, the reality is that we
don't.
First of all,
there is no biological test for
any of the known mental
disorders right now.
And instead what we have is a
set of behavioral criteria for
how to diagnose different mental
disorders.
And what I mean by behavioral
criteria is a set of symptoms
that the person reports to you
about how they feel,
how they think,
and a set of observations about
their behavior and how typical
or atypical it is.
And you take the sort of set of
symptoms the person shows or
reports, and you match them up
against the existing criteria
for different mental disorders.
And then it comes down to a
fairly subjective judgment call
about whether the person meets
the criteria or not.
Unfortunately,
these judgment calls,
because they are so subjective,
can be influenced by a lot of
factors.
And we won't have a chance to
go into these too much today,
but just to highlight a few of
them.
The first is social norms.
Whether you get labeled as
having a mental disorder or a
problem depends very heavily on
what your social or cultural
norms are.
So, a woman wearing a veil in a
Muslim community or culture
would be seen as typical,
even prescribed,
behavior.
Whereas a woman wearing a veil
in a non-Muslim culture,
especially until fairly
recently, was often looked upon
as very atypical or abnormal
behavior.
The second kind of thing that
gets--that influences whether
something is called normal or
abnormal is certain
characteristics of the target
person.
In particular,
I've highlighted here,
gender.
Whether you're a man or you're
a woman really influences how
unusual a certain behavior is.
So, crying is a good example.
A man crying in our culture is
seen as fairly unusual,
whereas a woman crying is seen
as much less unusual.
On the other hand,
a woman beating up someone is
taken as quite unusual behavior
where it's less unusual for a
man.
So, we have gender stereotypes,
gender roles for what is
acceptable behavior,
and our judgments as to whether
something is normal or abnormal
get influenced by those gender
roles.
And the third thing that can
influence whether something is
labeled abnormal or not is the
context.
And here I'm giving you the
example of "paranoia."
If you're paranoid and
hyper-vigilant,
looking for threat in downtown
Baghdad,
that's considered very adaptive
behavior these days because it
could prevent you from getting
hurt or killed.
Whereas, if you're in a quiet
little farm in Central
Connecticut, being extremely
paranoid and believing there's
someone who's going to shoot you
around the corner is not
considered as normal or as
acceptable or adaptive behavior.
So, the context in which you
exhibit a particular behavior
also can heavily influence
whether it gets labeled by
others as normal or abnormal.
In the field of clinical
psychology we have a number of
different ways,
kind of heuristics that we use
to label things as abnormal or
unhealthy or troubling.
And three of these
characteristics are what we
often call the three Ds:
distress, dysfunction,
and deviance.
So, behaviors that cause the
individual or others significant
distress often get labeled as
abnormal or unhealthy.
Depression is a prime example,
as we'll see when we talk about
the characteristics of it.
It's a miserable state of being;
you're unhappy,
you're sad, you may even feel
so badly you want to kill
yourself.
And that very,
very high level of distress is
part of the reason why it's
labeled as a mental disorder.
Other mental disorders don't
cause the individual distress,
but they may cause other people
distress.
So, one example of this is
something called "antisocial
personality disorder,"
where the individual has no
regard for the rights of other
people, has no hesitation to
steal or--steal from or hurt
other people,
has no empathy or sympathy for
other people's feelings and so
can inflict a lot of harm on
other people and has absolutely
no distress over this
whatsoever.
But this behavior causes other
people distress,
and that's one of the reasons
why that's labeled an abnormal
behavior or a mental health
problem.
The second general criterion is
"dysfunction."
If a set of behaviors prevents
the person from functioning in
daily life, then it might be
labeled as abnormal or might end
up being labeled as a mental
health problem.
Again, depression is a good
example.
People who are depressed often
become completely
non-functional.
They can't get up and go to
class;
they can't go to work;
they can't interact with their
friends;
they withdraw and become
totally isolated socially.
So, they might lose their job;
they might flunk out of school.
And this complete decline in
functioning is one of the major
reasons that we consider
depression one of the most
debilitating disorders.
And then finally,
"deviance," the behaviors or
feelings are highly unusual.
This is probably the most
controversial of the three
because it weighs,
it is so heavily influenced by
the social norms.
What's deviant in one culture
is not deviant in another
culture.
But if a set of behaviors is
completely unacceptable to a
culture, highly unusual,
they're more likely to end up
getting labeled as abnormal.
Okay.
So, how do we pull this all
together?
Well, these days the manual for
making diagnoses in clinical
psychology and psychiatry in the
United States is called the
Diagnostic and Statistical
Manual or the DSM,
and it's in its fourth revision.
It's been around since the,
I believe the '50s,
and the early editions in the
'50s and '60s were highly
subjective and based on Freudian
theory.
But since 1980 there's been
real effort to make the criteria
much more objective,
to make the set of behaviors or
observations that are required
to diagnose someone be things
that are observable,
that you can see in other
people that they can report on
reliably, and that one clinician
and another clinician will agree
upon.
So, the DSM gives lists
of symptoms with the required
symptoms for a diagnosis,
the number of symptoms that
have to be present,
and the notions of deviation,
dysfunction and distress are
built into these criteria.
And I'm going to give you a
couple of examples of these
criteria when we talk about the
specific types of mood disorder.
So as I said,
I'm going to use mood disorders
as kind of a case example here
of how we go about diagnosing
and understanding
psychopathology,
but I also just want to impart
some information because mood
disorders are one of the most
common problems that people
face.
As many as one in four women
will have an episode of serious
depression at some time in her
life,
and about 13% of men will have
an episode of serious depression
in their lives.
So, these are extremely common
kinds of problems that people
experience, particularly at your
age.
The college years are one of
the peak times of onset,
first onset,
of depression in particular.
And also, for bipolar disorder,
or manic-depression,
the late adolescent,
early 20s are the peak onset
times for these disorders as
well.
So, the mood disorders divide
into what's called unipolar
depression disorders,
which is depression only and
then bipolar disorders where the
person cycles between depression
and mania.
And here are the DSM
criteria for major depression,
one of the most severe forms of
depression.
And as I said,
the DSM sets up these
relatively observable criteria
and how many you have to have
and what absolutely has to be
present in order to get the
diagnosis.
So, the first criterion in the
DSM for major depression
is that the individual has to
either show sadness or a
diminished interest or pleasure
in their usual activities,
which is referred to as
anhedonia.
So, you have to have one or the
other of these to sort of pass
the first criterion.
So, you might say that you feel
sad and blue and just--or
actually say you feel depressed.
Some people feel those feelings
very strongly.
Other people don't really feel
so sad or blue,
but what they'll say is that
nothing interests them anymore.
It's like the emotion has been
sucked out of their life
altogether.
They don't have any fun doing
the activities they used to do
before.
They don't want to hang with
their friends.
They just--they don't care
about eating.
Just nothing feels right,
feels good, anymore.
And then the individual has to
have four of the--at least four
of the following symptoms in
addition to sadness or
anhedonia.
First, they can show
significant weight or appetite
change.
So, you may completely lose
your interest in eating and lose
a lot of weight,
or some people go on eating
binges.
I had a very good friend who
was depressed for about a year,
and she gained fifty pounds
because she would just eat.
She would binge eat,
especially at night.
There are sleep
disturbances--insomnia,
which is having trouble
sleeping, or hypersomnia,
which is sleeping all the time.
There's a particular form of
insomnia that's especially
likely in depression where you
can go to sleep at night,
but then you wake up at about
three or four in the morning
every night and you can't go
back to sleep at all.
You're just up for the rest of
the night.
But other people want to sleep
all day long,
and in the clip I'm going to
show you in just a minute the
woman talks about sleeping
twenty,
twenty-two hours a day,
getting up, eating a little
bit, and then going back to bed
because she was exhausted still.
The third criterion is
psychomotor retardation or
agitation.
The retardation is much more
common, and what this means is
that sort of everything about
the person's movement is slowed
down.
They'll walk more slowly.
Their reaction times will be
slowed down.
And because they're so much
more slow moving,
depressed people are often more
prone to accidents.
They just can't react as
quickly as they need to when
they're driving or when they're
crossing the road and a car is
coming at them suddenly.
So, they get into more
accidents.
And their speech may be slowed
down.
They may talk very,
very slowly and it's as though
it just takes a tremendous
amount of energy to get even a
common sentence out.
A much more,
much smaller number of people
get agitated instead of slow
down.
They may be hyper and just feel
like they can't sit still and
such, but the agitation is much
more rare than the retardation.
People feel really tired,
fatigued and like they have
absolutely no energy.
They can't get up and can't get
moving.
As I said, they may want to
just sleep all of the time.
Number five is feelings of
worthlessness or excessive
guilt.
They may feel as though
everything is their fault,
and the guilt feelings or sense
of worthlessness can even get
psychotic.
They can lose touch with
reality.
When a person loses touch with
reality when they're depressed,
it typically has really
depressing themes.
They may believe that they are
Satan and that they have to
commit suicide because they're
inflicting evil on the world.
They may believe as though
random events are their fault,
you know, that a flood that
just happened somehow they
caused.
So, the feelings of
worthlessness and guilt can get
completely out of touch with
reality, psychotic.
More commonly,
they're just unrealistic.
They're negative self-esteem,
just being down on yourself,
feeling stupid and worthless
and ugly and bad.
Number six is diminished
ability to concentrate or
indecisiveness.
When you are depressed it's
really hard to pay attention.
You'll read a passage over and
over again and you just can't
process it at all.
You can't concentrate on a
lecture so going to class is
just useless.
You have to make a decision
about what a paper topic is,
and it just seems like the most
monumental thing on earth.
You just can't decide anything,
you can't think anything;
your thoughts are completely
clouded and overwhelmed.
And then suicidal ideation or
behavior;
it means you think about
committing suicide,
you think about dying.
And a subset of people actually
take action to try to hurt
themselves or kill themselves.
Now, it should be said that
suicidal thoughts and behavior
don't only happen in depression.
They actually happen in all
types of psychopathology,
but they're particularly common
in depression.
So, you have to have at least
one--four of those symptoms plus
sadness or anhedonia,
and these symptoms--it can't
just be a bad day that you're
having.
These symptoms have to be
present persistently for at
least two weeks to get the
diagnosis.
Now, truth be told,
most episodes of major
depression actually last a lot
longer than two weeks.
In fact, the average length of
an episode, if it's not treated,
is at least six months.
So, people stay this miserable
for a very long period of time,
but the minimum criterion in
the DSM is at least two
weeks.
So, what I want to do is to
just show you a short clip of a
woman who has had a lot of
episodes of depression.
Fortunately,
at the moment she's not in an
episode.
But she can speak very
articulately about what it's
like to be in the midst of an
episode and some of the
significant symptoms that she
had.
Okay.
There are couple of things she
talks about that I just want to
comment on.
One is this differentiation
between everyday sad mood and
the kind of depressions we all
experience and the kind of
debilitating,
overwhelming depression that
she experiences.
And it is true that there is
this continuum from getting
bummed out because you didn't do
well on a test or because you
broke up with a boyfriend or
girlfriend or something like
this and being completely not
functional,
vegetative, the way that this
woman becomes whenever she gets
depressed.
And it would be nice if we were
really sure where the cutoff was
between those normal everyday
depressions and what's really a
disorder.
But the reality is we don't
really have real clear
demarcation lines.
There are a lot of people who
have more moderate forms of
depression than Tara here talks
about but who still would
qualify for a diagnosis and are
still suffering and impaired by
their symptoms.
So, I don't want you to get the
sense that if you don't have the
kind of horrible version on the
extreme end of the continuum of
depression that Tara has,
then there's nothing wrong with
you, because that's not the
case.
People who are really slowed,
whom their functioning is
interfered with--they're just
really unhappy with life--have
problems that can be helped and
do need attention.
And it is the case that much
more moderate forms of
depression can morph into more
serious forms if they're left
untreated.
So, there is this continuum.
The other things I wanted to
comment on that she talks about
early on in this piece is the
fact that she hauls herself up
and goes through her day,
even when she's feeling really,
really depressed.
And there is this
characteristic of a lot of
depressed people that I call the
"walking wounded."
They just haul themselves
through the day trying to act
normal, trying not to let
anybody know that there's
anything wrong with them,
trying to keep up with their
schoolwork or their employment.
But they're miserable and
they're not functioning at the
level that they're capable of
and such.
And that's something that's
very, very common,
and it's in part because people
don't feel as though they should
have to get treatment or they're
ashamed of getting treatment or
seeking help for depression.
And so, they just keep going on
and going on,
sometimes for years,
in a very sorry state
before--sometimes they
just--they end up actually
falling apart to the point where
they have to get help.
Okay.
The other category of mood
disorders that I mentioned is
bipolar disorders.
And as I said,
bipolar disorder involves
symptoms or periods of
depression but then also
distinct periods of the opposite
of depression,
which we call "mania."
So, the person cycles back and
forth between debilitating
depressions and manic episodes.
So, let me describe manic
episodes to you now.
So, the first criterion is that
instead of feeling down,
blue or depressed the person
has an abnormally and
persistently elevated expansive
or irritable mood that isn't
just,
again, a good day because you
won a prize or got an "A," but
rather, it's this unusually
positive,
expansive mood for at least one
week persistently.
And then the person has to have
three or more of the following
symptoms.
First, inflated self-esteem or
grandiosity.
The individual may feel as
though they are the smartest,
the most creative,
insightful,
powerful person on earth,
and they are perfectly happy to
tell you this.
So, there is no problem with
self-esteem, thank you very
much.
"If you can't keep up with me
it's your fault."
There's a decreased need for
sleep;
they may only sleep a couple of
hours a night and get up raring
to go.
They tend to be more talkative
than usual, and there's a really
pressure to their talk.
They'll talk really pressured,
and they'll talk really,
really fast.
And one of the reasons they're
talking really,
really fast is they have this
flight of ideas.
The thoughts are just racing
through their mind,
and they can't talk fast enough
to get them out.
And if you can't follow them,
that--well, that's because
you're not smart enough to
follow them.
But they've just got too many
good ideas and they've got to
get them out.
They're highly distractible.
And then there is this increase
in this--what the DSM
calls this "goal-directed
activity."
Out of their grandiosity will
come these grand schemes
for--often for making a lot of
money and they'll pursue these
with great vigor no matter how
totally irrational they are.
So, it's not at all uncommon
for them to cash out all the
family bank accounts,
to sell the house,
to sell the car,
to sell the kids so that they
can finance this great scheme
for making a zillion dollars on
the Internet tomorrow.
Right?
Okay.
And they'll pursue this with
tremendous vigor.
They'll also get involved in
all kinds of,
what the DSM discreetly
calls "pleasurable but dangerous
activities."
There's a lot of sexual
promiscuity, a lot of drug
abuse, a lot of,
as I said,
getting--going and gambling,
believing that you're on a hot
streak, there's nothing can stop
you.
You know, you're just so
brilliant and you've got this
scheme, you've got the plan.
You're going to make it.
Okay?
So, the individual has three of
more of these kinds of symptoms
plus this elevated,
expansive and often quite
irritable mood.
It's not just that they're
happy, you know,
and sort of upbeat.
It's just that they're just
impatient and irritable and
trigger-fire.
And sometimes they can become
violent because they're
just--they're so incredibly
agitated and irritable.
So, let me show you a couple of
clips.
I have one really short one.
It's not a real high quality
clip, but it's a very,
very nice example of an older
woman who is in the midst of a
manic episode.
And it shows what this kind of
agitation and flight of ideas
and racing thoughts can look
like.
And then the other one is--I'll
introduce whenever you--we do
it.
So while she was at the
hairdresser's it's a nice
example of how she was just
pressured to speak.
Nobody was telling her that she
had to say all of these things.
They were just standing there
with a camera and she was going
on and on and on about these
things.
And as you could see she was
getting more and more agitated
and more and more irritated as
she was retelling her story.
And then what?
In the last little bit there
you saw her flip from her mania
into a more depressed state.
And this poor lady,
unfortunately,
is having a hard time finding a
stable point.
He talked about lithium there,
and I'll talk about it in a
little bit--about the use of
lithium as a drug to try to
stabilize these mood swings.
But at this point in this
video, it's not working for this
lady.
And so, she's flipping back and
forth, but they're having a hard
time finding that middle ground.
So, I want to show you another
clip--it's a little bit
longer--of a man who has bipolar
disorder.
He is not currently in an
episode of either depression or
mania, but again,
he can talk about some of the
things he got himself into and
how it manifested in his
behavior.
Okay.
Just a couple of things that
Bernie talks about that I want
to comment on.
One is that just as in
depression, mania has--runs
along a continuum.
So, it can be relatively mild
all the way to extremely severe
and even psychotic.
So, when a person with mania
loses touch with reality,
instead of having beliefs that
they are Satan or they've done
some horrible thing,
they'll believe that they are
some supernatural being.
They may believe that they are
the Messiah or that they are
Albert Einstein,
you know, come back to life,
or that they have supernatural
powers or something of this
sort,
so that their false beliefs,
their delusions and their
hallucinations,
the things that they see and
hear that aren't really there
tend to be very grandiose in
their themes.
Bernie's mania is not on the
far end of the continuum by any
stretch, but you can see it
still gets him into trouble.
Now, there are people who
have--who cycle between fairly
low levels of mania and fairly
low levels of depression,
back and forth.
And there's been some argument
that people who are kind of
chronically, mildly
manic--especially if they're
really smart or they have a
special talent – can make it
work for them.
And there is a wonderful book
by Kay Jamison,
who is a professor at Johns
Hopkins where she
chronicles--She does sort of
historical biographies on a
number of well-known authors and
poets and musicians,
Robert Schumann and a number of
politicians, Winston Churchill
and such, arguing that they
actually had mild forms of
bipolar disorder and that they
were able to sort of channel the
manic episodes through
extraordinary talent or
intelligence in ways that made
it work for them.
There are also a number of
arguments that very,
very successful CEOs sometimes
are people who are chronically
slightly manic.
They can go on a couple of
hours a night of sleep;
they're obviously really quite
grandiose and self-confident,
and that they can maintain this
kind of moderate level of mania,
keep it under control and
channel it in ways that work for
them.
So, if you're interested in
that book, send me an email and
I'm happy to send you the
citation for it.
But for the most part,
mania can get people into
tremendous trouble.
They can, as I said,
get involved in sexual
promiscuity that puts them at
risk for sexually transmitted
diseases.
They can get involved in drug
activity.
They can get themselves
arrested.
They can certainly send
themselves and their family into
bankruptcy.
And these kinds of negative
consequences of the mania often
are what motivates the person to
get help because the mania
itself can be rather pleasurable
to have.
Also, what motivates them to
get help is the plunge into
depression, the knowledge that
they will,
at some point,
come out of the mania and go
into a debilitating depression.
Bipolar disorder is much less
common than depression.
I said that about 22% of women
and about 13% of men will have
an episode of serious depression
at some time in their lives.
Bipolar disorder occurs in only
about 1% of the population,
and it's equally prevalent in
women and men.
So, it's a really quite
different disorder in many ways
from depression alone.
I want to give you some other
statistics about depression per
se, and this only applies to
depression.
There are quite large age
differences in the prevalence of
depression.
These are data from a
nationwide study of people
between the ages of fifteen and
fifty-five, and these are the
percentages of people in this
study.
And there were several thousand
people in the study.
These are not people who have
sought treatment for depression
but just a random community
sample.
And this is the percentage
who've had an episode of major
depression in the past month.
And as you can see,
the fifteen to twenty-four age
range has the highest rates,
and then they go down somewhat,
although the thirty-five to
forty-four is fairly high as
well with age.
You might be surprised to learn
that the rates of major
depression in the elderly are
actually quite low by most
national statistics.
And that's true up to about age
eighty or eighty-five.
And the arguments for why this
is the case are very
interesting.
There are some people who argue
that as you get older you get
wiser, and so that's why we see
lower rates of depression in
older age.
There are other people who
argue that current
generation--younger generations
now;
your generation and the one
above you--are more prone to
depression and will be for the
rest of your life compared to
your grandparents,
because of historical changes
in the kinds of social support
and family networks available
and a number of other historical
cultural changes.
The other sort of side of the
argument is that because
depression is known to impact
negatively your physical health
– depression is associated
with higher rates of
cardio-vascular disease,
stroke, immune system diseases,
a whole host of diseases that
people die from--that people who
have a lifelong history of
depression are actually more
likely to die at an earlier age,
and that's why we see
relatively low rates in older
age people.
We don't know yet which of
these explanations is true.
It may be that they're all true
to some extent.
There are also gender
differences in depression.
These are data from a
compilation of hundreds of
studies of children and
adolescents,
looking at not full-blown
depression but levels of
depression on self-report
questionnaires.
Probably most of you have
filled out these questionnaires,
like the Beck Depression
Inventory that ask you how
you've been feeling in the last
month.
And there's a kiddy version of
this, and these are data from
that, from several thousand
children.
And as you can see here,
prior to the age of about
thirteen, boys and girls have
relatively similar levels of
depression.
But beginning around the
pubertal years,
girls' rates of depression go
up quite dramatically and boys'
rates stay the same or go down.
And by the time they're
eighteen or twenty you get
almost a two-to-one ratio of
depressed girls to depressed
boys.
And then this is true for the
rest of the adult age span.
There are lots of hypotheses
about this, why it's true.
There are biological hypotheses
that have to do with hormones.
There are sociological
hypotheses that have to do with
the kinds of stress,
and particularly abuse,
in girls' lives relative to
boys'.
We don't know exactly why.
It's probably a lot of these
things coming together that make
this huge two-to-one ratio true.
So, let's talk a little bit
about the major theories and
treatments for the mood
disorders.
There are biological theories
and treatments,
what are known as cognitive
behavioral theories and
treatments and then
interpersonal theories and
treatments.
And I'll walk you through
examples of each of these.
So, first, genetics.
It's pretty clear that genetics
are involved in the mood
disorders, especially bipolar
disorder.
There is very strong evidence
in bipolar disorder,
and there are a number of
ways--Have you talked about how
you do genetic studies?
Okay.
So, you guys know about twin
studies for example and family
history studies.
So, this is actually a
compilation of a group of
studies.
And here you've got some of
them – twin studies--compared.
So, in monozygotic twins,
if your identical twin has
bipolar disorder,
you have over a 60% chance of
having the disorder yourself.
In contrast,
if it's your--if you're just a
fraternal twin of a person with
bipolar disorder,
you only have about a 12%
chance of having the disorder.
So, that massive difference
there is very strong evidence
that there's a genetic component
to the transmission of the
disorder.
Similarly, the more distant you
get in terms of your biological
relation to a person with
bipolar disorder,
the lower your rate or your
risk of the disorder is.
So, the second degree relatives
of a person with bipolar
disorder only have about 2%
chance of getting the disorder.
And that's barely above what's
in the general population,
which is about a 1% chance of
getting the disorder.
So, it's very clear that
bipolar disorder has a genetic
component to it.
With depression alone,
major depression,
there are probably versions of
the disorder that have a
stronger genetic component to
them than others.
And in particular,
folks who have what's called
"early onset depression," where
their first episodes come on in
childhood or very early
adolescence,
seem to have a form of
depression that has a stronger
genetic component to it.
Whereas, people who have
depression that is clearly
triggered by a major life event
like a trauma or a loss--those
types of depression are less
clearly linked strongly to
genetic factors.
There are also a number of
neurotransmitters that have been
implicated in the mood
disorders.
And the class of
neurotransmitters that's been
researched most often is what's
called the monoamines.
I'm sure you've heard about the
link between serotonin and
depression, but there are two
other monoamines,
norepinephrine and dopamine,
that have also been linked to
both of the mood disorders,
both bipolar disorder and
depression.
And it used to be thought that
it was just that in people with
depression they didn't have
enough of these
neurotransmitters,
enough serotonin,
in particular,
in the system,
in the brain,
in order to function normally.
But now the theories on what
the role of neurotransmitters is
have a lot more to do with the
receptors for these
neurotransmitters and their
functioning.
And the notion is that the
receptors for neurotransmitters
like serotonin don't function
efficiently.
So, even if there's enough of
the chemicals in the synapses in
the brain, the neurons can't
make use of them because the
receptors aren't functioning
appropriately.
And so what the drugs that help
relieve depression do is to
improve the functioning of these
neurotransmitters.
There's a very interesting line
of work that's going on right
now looking at the intersection
of genetic predisposition
neurotransmitter functioning and
stress.
And we have one of the world's
experts on this kind of work now
here at Yale,
Julia Kim-Cohen,
who just joined us in the last
year.
But there are several recent
studies.
There's another person in
psychiatry, Joan Kaufman,
who's done some of this work.
But there are several recent
studies that find that certain
variations or polymorphisms on
the serotonin transporter gene
predict who will become
depressed in the face of stress.
So, a classic study was done by
Avshalom Caspi and colleagues,
and they found that people who
have one or two of what's called
the short allele on the
serotonin transporter gene--so
this is a particular variation
on the serotonin transporter
gene--if they had one or two of
these short alleles and they
were confronted with stress,
they were more likely to
develop depression.
But it's important to sort of
dissect this.
So people who had--it didn't
really matter which of these
genes you had.
If you were never confronted
with major kinds of stress,
like maltreatment,
if you weren't confronted with
stress,
you were no more likely to have
depression regardless of what
kind of serotonin gene you had.
But if you had either one short
allele or two short alleles and
you were confronted with
maltreatment as a child,
you had a much greater
probability of becoming
depressed at some time in your
life.
And this has been replicated
with other samples,
with other forms of major
trauma.
And basically the story is,
it takes the intersection of a
genetic predisposition and major
stress to create full-blown
depression in some people.
Now, that may not be true for
all genetic predispositions or
all forms of depression,
but this serotonin finding has
actually been replicated now in
at least four different studies.
So, it seems to be a pretty
reliable effect.
So again, genes do not
determine the disorder,
but the intersection of genes
and stress seems to be a major
risk factor for the disorder.
There are a number of brain
areas that seem to be involved
in the mood disorders where
there is just dysregulation or
dysfunction.
The prefrontal cortex,
as you probably have studied,
is an area of the brain that's
very involved in higher order
complex thinking and problem
solving and in goal-directed
behavior.
In people with depression,
there's lowered activity in the
prefrontal cortex,
suggesting that--which may play
a role in the difficulties in
concentration,
in goal-directed behavior,
in planning and problem solving
and in regulating emotion.
The amygdala is an area of the
brain that is involved in the
processing of emotional
information.
And people with mood disorders
show overactive amygdala
responses to emotional
information.
This is true in both bipolar
and in depression.
The hippocampus is an area of
the brain that's very involved
in memory and in concentration.
And in people with chronic
depression, you often see
shrinkage in the hippocampus,
and this may be related to
their problems in concentration
and attention.
And then finally,
the anterior cingulate is an
area of the brain that's
involved in a lot of different
activities,
but pertinent to the mood
disorders, particularly in
responses to distress--to stress
and in sort of the choice of
behaviors.
And it may be that
dysregulation of the anterior
cingulate may be involved in the
person's difficulty in
responding appropriately to
stress,
in choosing good coping
behaviors and changing their
behaviors whenever their
behaviors aren't working well.
So, from the biological
theories come a number of
different drugs to treat the
mood disorders.
Two of the older classes are
called the monoamine oxidase
inhibitors and the tricyclic
antidepressants.
The tricyclics are still used
these days to some extent.
They're relatively effective.
About 60% of people respond
well to the tricyclics,
but they have a lot of side
effects, and they can be fatal
in overdose.
And so there was a--has been
always a search for other
alternatives to them.
The drugs that have really
taken over the market are the
selective serotonin re-uptake
inhibitors or SSRIs.
This is Paxil,
Prozac and the like.
They were introduced in
1987--Prozac was--in the U.S.
market and truly took over the
market in the treatment of
depression and anxiety and a
number of other disorders.
Now, they're not that much more
effective than the sort of old
style antidepressants,
but they have fewer side
effects and they tend to be
easier for people to tolerate.
More recently,
there are selective
serotonin/norepinephrine
re-uptake inhibitors.
These drugs,
by the way, what these drugs
supposedly do is to prevent the
re-uptake of serotonin or
serotonin and norepinephrine
back into the sending neuron.
So, it creates more of the
neurotransmitter there in the
synapse.
And these are reasonably
effective drugs,
although, again,
there's a substantial number of
people who don't respond to
them, especially immediately.
And they'll often have to cycle
through a number of drugs before
they find one that works.
Lithium is the drug of choice
for the treatment of bipolar
disorder.
It seems to stabilize the mood
swings by stabilizing the number
of different neurotransmitter
systems.
But the lithium is problematic
because there are tremendous
side effects.
It's also dangerous for women
to take while they're pregnant
in terms of fetal development.
So, it's a very tough drug to
stay on.
There are lots of
gastrointestinal side effects
and such, and people are often
on lithium and the
antidepressants because lithium
often only affects the manic
episodes but it doesn't really
relieve the depression.
And then finally anti-psychotic
medications, that is those help
people who've lost touch with
reality,
are sometimes used to treat the
mood disorders whenever the
person has lost touch with
reality.
I'm going to go through and
talk about some of the
psychosocial treatments because
I want to get to them as well.
The cognitive behavioral
therapies are based on Aaron
Beck's Negative Cognitive Theory
of Depression.
Aaron Beck is a psychiatrist at
the University of Pennsylvania
who really founded this whole
line of work.
And according to Beck,
this--now, this applies to
depression alone.
It doesn't really apply to
bipolar disorder.
People who are depressed have a
negative view of the self,
of the future and of the world,
and he calls this the "negative
cognitive triad."
And this negative cognitive
triad is fed by specific
cognitive deficits or biases.
So, depressed people show a lot
of distortions in thinking.
"All-or-nothing thinking" is
thinking that things are either
all good or all bad.
They can't sort of see the gray
areas in between.
There's "emotional reasoning,"
and an example of that is just
if I feel like a loser I must be
a loser.
Of if I feel stupid,
I must be stupid.
And then "personalization,"
that is the self-blame that you
often see in depressed people.
And these kinds of distortions
in thinking, these distorted
ways of interpreting situations,
feed a kind of general negative
view of the self and
hopelessness about the future.
People who are depressed also
make attributions for negative
events that are internal,
that is, they blame
themselves--that are stable.
They see bad things as lasting
forever and that are global.
They see bad events as
affecting many areas of their
life, which, again,
feeds their depression and
their general assumption that
life is terrible.
And evidence that these--for
these cognitive theories,
that these negative cognitive
styles predict depression--one
of the best studies predicting
this was a study that was
jointly done at Temple
University and the University of
Wisconsin where they identified
first year college students with
a negative cognitive or
attributional style.
But these were people who had
never experienced an episode of
depression yet.
They then tracked them for the
next two years,
and the bars here--the red bars
are the percent of those with a
negative cognitive style who
developed an episode of major
depression in that two and a
half years versus the percent of
those without a negative
cognitive style.
And as you can see,
there's quite a substantial
difference between the two.
So prospectively,
these characteristics seem to
predict your risk for
depression.
In turn, there is a cognitive
behavioral therapy that's based
on Beck's theory.
And the major steps in this
involve identifying the themes
in a person's negative thoughts
and triggers for them and in
helping the person challenge
those thoughts by asking them
what the evidence is for their
interpretations,
whether there are other ways of
looking at the situation,
how they could cope with the
situation if a bad thing really
did happen.
So, the therapist helps the
client recognize negative
beliefs or assumptions and then
challenges the truth value of
these,
and then change aspects of the
environment that are related to
depressive symptoms.
So, they challenge your
rational thinking,
but they also recognize that
there are really bad things that
sometimes are going on the life
of a person who is depressed,
and they help them engage in
more active problem solving to
change those environments.
They also teach the person ways
to manage their mood so that
they don't tumble down into
depression.
And these cognitive behavioral
therapies have been shown to be
extremely effective and as
effective in some ways as the
drug treatments.
So, this is a recent study in
which they had 240 patients with
major depressive disorder.
They gave them four months of
acute treatment with either
cognitive behavioral therapy or
Paxil, which is an SSRI.
And in eight weeks here--they
also had a placebo control group
where they just got a pill,
but it was a sugar pill.
At eight weeks,
the Paxil group,
which is in red,
and the CBT group,
which is in yellow,
were relatively even,
although the Paxil group had a
little bit of an edge over the
CBT group.
But by sixteen weeks the Paxil
and CBT group were absolutely
even in terms of the percent of
people who were no longer
depressed.
So, both of them resulted in
about 60% of people not being
depressed.
And then one of the things
that's been found over and over
again with cognitive behavioral
therapy is that it not only
helps people get out of a
current episode of depression,
it helps to prevent future
episodes of depression because
it teaches the person new coping
skills for dealing with new
stressors that arise.
So, in this same study they
followed the patients for an
additional twelve months.
And of the Paxil group,
half were left on full-dose
medications to see if you could
prevent depression by just
keeping people on the meds,
and half of the Paxil group
were withdrawn to a placebo.
And let's look at the placebo
group first here.
This is the sad news about
depression.
If you just take drugs to get
out of a current episode and you
go off of the drugs without
having any kind of
psychotherapy,
your rate of relapse tends to
be very high.
So, in this group of 240,
almost 80% relapsed in the
first year after going off of
the active medication.
Again, these were people who
did not get any cognitive
behavioral therapy.
Of those people who stayed on
Paxil alone, about 50% relapsed.
But of those people who got
cognitive behavioral therapy,
only about 35% relapsed.
And this kind of finding has
been replicated over and over
again, namely that CBT can
reduce the rate of relapse in
depression quite dramatically.
I want to give you a flavor for
what CBT looks like,
and I've got a short clip of a
therapist who is actually,
interestingly,
the daughter of Aaron Beck and
his heir in terms of the
practice and development of
cognitive behavioral therapy.
And she's demonstrating CBT.
This is actually a role play,
but it's a pretty realistic
role play, of how she goes after
and helps to challenge a
gentleman's negative cognitions
about himself.
This is a guy in the role who's
recently lost his job and is
really depressed over his job
loss.
Okay.
I'm going to stop there because
we're running out of time.
But I just want to comment on a
couple of things that she's
doing.
So, you see that she's having
him generate his own challenges
to his negative thoughts and
write them down.
And the whole--one of the major
premises in CBT is it's not just
what goes on in the therapy
session that is effective.
In fact, that's a minor part of
it, but what the person
practices in the time between
therapy sessions.
And so, what she's doing is
helping him come up with a
series of phrases he can say to
himself when he feels
discouraged and plunging down.
She's also helping him do
what's called "anticipatory
coping," anticipating those
situations that are going to
trigger negative feelings and
negative thoughts and coming up
with ways of combating them in
the moment that he can enact at
the time.
Cognitive behavioral therapy is
very structured,
it's very focused and it's
designed to be relatively
short-term.
The one other major kind of
psychotherapy for depression is
interpersonal therapy.
It's based on the theory that
negative views of the self and
expectations about the self and
relationships are based on
upbringings that really fostered
these kinds of negative
self-views.
And so, what you need to do is
to help clients understand their
negative self-views and how
they're rooted in their past
relationships.
Interpersonal therapy is less
structured than cognitive
behavioral therapy,
and it's more focused on the
past.
CBT is very focused on the
present and dealing with the
current situation that you're
facing and combating that and
developing coping styles for
that.
There are a few studies
comparing interpersonal therapy
with CBT, but much less research
has been done on IPT than CBT.
But it is a positive
alternative for some people,
particularly those who find
that their depression is very
tied-up in recurrent themes in
their relationships that seem to
happen over and over and over
again.
But to end, the good news about
depression is that there are
these alternative therapies.
There is a number of drug
therapies and there are at least
two psychotherapies that good
controlled research has shown
can be very helpful.
So, people have a choice,
and there is absolutely no need
for people to stay in depression
but rather to seek out the kind
of therapy that applies to and
appeals to them the most.
Good.
Thanks very much.
