Category: Mental Health History

On This Day … 27 January

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People (Births)

  • 1904 – James J. Gibson, American psychologist and academic (d. 1979).

James J. Gibson

James Jerome Gibson (27 January 1904 to 11 December 1979), was an American psychologist and one of the most important contributors to the field of visual perception.

Gibson challenged the idea that the nervous system actively constructs conscious visual perception, and instead promoted ecological psychology, in which the mind directly perceives environmental stimuli without additional cognitive construction or processing. A Review of General Psychology survey, published in 2002, ranked him as the 88th most cited psychologist of the 20th century, tied with John Garcia, David Rumelhart, Louis Leon Thurstone, Margaret Floy Washburn, and Robert S. Woodworth.

Education and Career

Gibson began his undergraduate career at Northwestern University, but transferred after his freshman year to Princeton University, where he majored in philosophy. While enrolled at Princeton, Gibson had many influential professors including Edwin B. Holt who advocated new realism, and Herbert S. Langfeld who had taught Gibson’s experimental psychology course. After taking Langfeld’s course, Gibson decided to stay at Princeton as a graduate student and pursued his Ph.D. in psychology with Langfeld serving as his doctoral adviser. His doctoral dissertation focused on memory of visual forms, and he received his Ph.D. in 1928.

E.B. Holt, who was taught by William James, inspired Gibson to be a radical empiricist. Holt was a mentor to Gibson. While Gibson may not have directly read William James’ work, E.B. Holt was the connecting factor between the two. Holt’s theory of molar behaviourism brought James philosophy of radical empiricism into psychology. Heft argues that Gibson’s work was an application of William James’. Gibson believed that perception is direct and meaningful. He discussed the meaning of perception through his theory of affordances. Gibson also was influenced by James’ neutral monism, nothing is solely mental or physical.

Gibson started his career at Smith College where he taught psychology. While at Smith, Gibson encountered two influential figures in his life, one of which was the Gestalt psychologist Kurt Koffka. Although Gibson did not agree with Gestalt psychology, he nevertheless agreed with Koffka’s belief that the primary investigations of psychology should be problems related to perception. The other important figure Gibson met during his time at Smith College was his wife, Eleanor Jack, who became a prominent psychologist known for her investigations such as the “visual cliff.” The two were married on 17 September 1932, and later had two children, James Jerome Jr. in 1940 and Jean Grier in 1943.

In 1941, Gibson entered the US Army, where he became the director of a unit for the Army Air Forces’ Aviation Psychology Programme during World War II. Of particular interest to him was the effect flying an aircraft had on visual perception. He used his findings to help develop visual aptitude tests for screening out pilot applicants. He was promoted to the rank of lieutenant colonel in 1946. After the war ended, he returned to Smith College for a short period during which he began writing his first book, The Perception of the Visual World, in which he discussed visual phenomena such as retinal texture gradient and retinal motion gradient. Before the book was published in 1950, Gibson moved to Cornell University where he continued to teach and conduct research for the rest of his life.

What is Multiple Impact Therapy?

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Introduction

Multiple impact therapy (MIT) is a group psychotherapy technique most often used with families in extreme crisis.

It was one of the first group therapy programmes developed in the United States. In multiple impact therapy (MIT), families are seen concurrently by a number of multi-disciplinary medical professionals. The duration of the therapy is short, typically ranging from one to two full treatment days.

The focus of treatment is to find and evaluate structural patterns within the family, evaluate those patterns to see if they are the source of the problem, then modify the structure to alleviate the problem.

Background

MIT as a therapy technique was developed at the University of Texas Medical Branch in the 1950s. At the time, Texas had very few psychoanalysts and those that were available were unaffordable to most families. Because treatment was scarce, there were few specialised programmes for adolescents, many were admitted as patients to psychiatric hospitals. Beginning in 1957, parents began bringing their troubled kids to the University of Texas Medical Branch for treatment.

Dr. Robert MacGregor, the lead researcher of group psychotherapy at the University of Texas Medical Branch, began developing MIT by interviewing entire families together in a single session. MacGregor and his team established their main goal as highlighting and emphasizing the parent’s concern to the disturbed child. Between 1957 and 1958, the team saw 12 families as the procedures were being developed. The initial sessions showed that therapy with individual members, together with group sessions, produced the most effective results. The individual sessions gave members the opportunity to voice their personal resentments while the group sessions gave therapists the opportunity to repair poor communication between family members. The therapy’s short, intensive time frame was originally due to life constraints involving time and travel; however, researchers kept the structure because the momentum created in the two day meetings reduced the overall number of sessions needed for the family to improve.

Procedure

MIT may be prescribed to families as a treatment option for a number of reasons: when conventional therapy fails to show results, as an alternative to hospitalisation, as a final course of action before hospitalisation, or for families who were already in group therapy but were seeing few results.

Treatment occurs in approximately seven steps over a two-day period.

Planning

Because many families participating in MIT are unfamiliar with the treatment and with psychotherapy, the planning phase informs the family about what is to be expected over the two days of treatment. Therapists use this time to review current information about the child and interview the community representative (or inpatient staff member) to gather personal details.

Briefing

After the family arrives, the therapy team and family meet for an initial conference to establish why they are gathered there. Intergroup conflict may be high in this phase. Blaming, criticism and aggressive accusations are commonplace. Therapists typically look for signs of defective communication among the family members and make note for later meetings. At the end of this group meeting, each member meets with an individual therapist.

Pressurised Ventilation

In individual meetings with the parents, parents are under a high degree of stress from the full group meeting. Therapists specifically look for the hardships the parents have faced in dealing with their child’s delinquency.

Initial Interview with the Child

The brief initial interview with the child takes place to match family patterns with the child’s behaviour.

Multiple Therapist Situation

After the initial group meet and individual meetings, therapists meet with any member or any number of members together as they see fit. Notes and other data collected (some studies video recorded the group meetings) are used in this procedure to address behavioural patterns and breakdowns in communication. This phase takes up the majority of the first day.

Team-Family Conference

A final group meeting convenes at the end of day one. Family members face each other again for the first time since the initial meeting. The sharing of the revised attitudes the group have towards one another takes place. The shift from conflict in the initial interview to the improved attitudes in the final team conference leads to the creation of a climate of change among the group.

Second Day Procedures

The second day attempts to begin in the same climate that created in the first. Day one often illuminates many of the breakdowns the family has experienced while day two focuses on retention of improved attitudes and application to the family’s unique situation. On day two, logistical considerations are often discussed such as: should the child remain hospitalised, continue schooling, or consider a different method of treatment. A two-month and six month follow up appointment is typically scheduled.

Potential Positive and Negative Outcomes

The use of an interdisciplinary team allows the parents, the child and the group as a whole to be seen from multiple viewpoints and through the lens of professionals with different experience and expertise. A typical interdisciplinary team as used in Macgregor’s studies at the University of Texas consisted of a psychologist, an associate therapist, a social worker, a nurse, and a member of the family’s community or inpatient clinic, however, other researchers have used up to 9 therapists in a single session. By including the community or inpatient staff member in MIT, trust and respect with the child’s parents increases.

Fifty-five additional families were seen between 1958 and 1962 when MacGregor first published his findings on MIT. Within the fifty-five families, only seven were considered unsuccessful cases. Despite the apparent success of MIT, two major drawbacks, the relative efficiency of the programme and conflict between the interdisciplinary team, were noted.

What is Helper Theory?

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Introduction

Helper theory or the helper therapy principle was first described by Frank Riessman (1965) in an article published in the journal Social Work. The principle suggests that when an individual (the “helper”) provides assistance to another person, the helper may benefit.

Riessman’s model has inspired subsequent research and practice by scholars, clinicians, and indigenous populations to address a variety of social and health-related issues plaguing individuals and communities around the world.

Refer to Peer Support and Skills and Abilities Required for Peer Support.

Riessman’s Formulation

Riessman’s seminal article explored how non-professionals supported one another in self-help/mutual-aid support groups based on Riessman’s observations of a sample of these groups, as well as his summary of the findings of research in the areas of social work, education, and leadership. This article suggested that although the “use of people with a problem to help other people who have the same problem in [a] more severe form” is “an age-old therapeutic approach,” the traditional focus on outcomes for those receiving help to the exclusion of considering outcomes for those providing help is too narrow; instead, Riessman (1965, p.27) advocated for increased consideration of the experience of “the individual that needs the help less, that is, the person who is providing the assistance” because “frequently it is he who improves!”

Although Riessman expressed doubt that individuals receiving help always benefit from the assistance provided to them, he felt more sure that individuals providing help are likely experiencing important gains; thus, according to Riessman, the helping interaction at least has the potential to be mutually beneficial for both parties involved (i.e. for both the individual giving and for the individual receiving aid), but it is not absolutely necessary for the “helpee” to benefit in order for the “helper” to enjoy the benefits of helping. In instances where true mutual benefit occurs, the helper and helpee benefit in different ways, such that the person receiving help benefits by way of receiving whatever specific form of assistance is offered to them (e.g. emotional support, information, etc.) while the person providing help benefits by the very act of providing help, regardless of the type of aid they provide.

Riessman posited several different mechanisms which may facilitate the benefits experienced by an individual engaged in a helping role:

  • Gaining an improved self-image;
  • Becoming more committed to a position through the process of advocating it (i.e. “self-persuasion through persuading others”);
  • Experiencing meaningful development of abilities after having been given a stake in a system and learning through teaching others;
  • Gaining access to a socially-valued role and the resultant sense of social status and importance;
  • Enjoying opportunities to affirm one’s own wellness following placement in a system as a role model; and
  • Shifting one’s focus from self-concerns and problems to assisting others (and thus distracting oneself from ongoing difficulties).

Health Care

Lepore, Buzaglo, Liberman, Golant, Greener, and Davey (2014) investigated the helper-therapy principle in a randomised control trial of a “prosocial”, other-focused Internet Support Group (P-ISG) designed to elicit peer-instigated, supportive interactions online among female breast cancer survivors. When compared to female breast cancer survivors who participated in a standard, self-focused Internet Support Group (S-ISG), which was not designed to explicitly provide opportunities for helping interactions to take place, analyses found that individuals in the P-ISG condition did provide more support to others yet P-ISG participants experienced a higher level of depression and anxiety following the intervention than those in S-ISG. These results fail to provide support for the helper-therapy principle which posits that “helping others is effective at promoting mental health” (Lepore et al., 2014, p.4085). In accounting for these results, Lepore et al. (2014) suggest that it is possible that women in the P-ISG condition felt hesitant to express their negative feelings out of fear that doing so might impact others adversely, whereas women in the S-ISG felt more able to unburden themselves of emotional pain and thus enjoyed better mental health outcomes.

Arnold, Calhoun, Tedeschi, and Cann (2005) explored both the positive and negative sequelae of providing psychotherapy to clients who had experienced trauma and subsequent posttraumatic growth by conducting naturalistic interviews with a small sample of clinicians (N = 21). Although all interviewees indicated experiencing some degree of negative experience as a result of engaging in trauma-focused psychotherapy (such as intrusive thoughts, negative emotional responses, negative physical responses, and doubts about clinical competence), all participants also indicated some sort of positive personal outcome occurred as a result of assisting psychotherapy clients with these types of experiences. The positive reactions experienced by clinicians engaged in trauma work included: enjoying the gratification that comes through watching others grow and triumph following difficult times; increasing recognition of one’s own personal growth and development; expanding ability to connect emotionally with others; impacting one’s own sense of spirituality; increased awareness of one’s own good fortune in life; and increasing appreciation for the strength and resiliency of human beings. This finding suggests that the helper-therapy principle may operate in a clinical context whereby therapists (i.e. the helpers) benefit from engaging in the process of providing treatment to psychotherapy clients who have survived traumatic experiences.

Pagano, Post, and Johnson (2011) reviewed recent evidence examining “helper health benefits” among populations experiencing problematic involvement with alcohol, other mental health conditions, and/or general medical problems. In brief, their review suggests that when individuals with chronic health conditions (e.g. alcohol use disorder, body dysmorphic disorder with comorbid alcohol dependence, multiple sclerosis, chronic pain) help others living with the same chronic condition, the individual helper benefits (e.g. longer time-to-relapse, remission, reduced depression and other problematic symptoms, and increased self-confidence, self-esteem, and role functioning).

Additionally, Post’s (2005, p.73) review of the literature on altruism, happiness, and health indicates that “a strong correlation exists between the well-being, happiness, health, and longevity of people who are emotionally kind and compassionate in their charitable helping activities”. However, Post also notes that individual helpers may become overwhelmed by over-involvement in the lives of others, and that giving assistance beyond a certain variable threshold may lead to deleterious rather than beneficial outcomes for helpers.

Social Work

Melkman, Mor-Salwo, Mangold, Zeller, & Benbenishty (2015) used a grounded theory approach to understand:

  1. The motivations and experiences which led young adult “careleavers” (N = 28, aged 18-26) in Israel and Germany to assume a helper role; and
  2. The benefits they report enjoying as a result of helping others through volunteerism and/or human-service focused careers.

Participants reported that observing role models involved in helping roles, being exposed to prosocial values, and having opportunities to volunteer within the system in which they were simultaneously receiving care all contributed to later assumption of more stable and regular helping roles. These participants felt obliged to provide assistance to others, desired to provide this assistance to others, and felt sufficiently competent to carry out the tasks required of them in their helping role. These participants reported that helping others provided them with a sense of purpose in their lives, and also increased self-efficacy, social connectedness, and ability to cope with personal issues. Additionally, participants reported that assuming a helping role provided a sense of normalcy to their lives, as well as providing a sense of perspective on their own journey and outcomes. As one participant (a volunteer with a police department who was assigned to work with at-risk youth) shared with the researchers:

“The fact that I could bring a runaway girl back to her home and I made her trust me, the fact that I located a missing girl, the fact that I escorted a rape victim to hospital and I managed to give her strength and support her, these are the things that give me meaning, tell me that I’m in a much better situation than others” (Melkman et al., 2015, p.45).

Self-Help/Mutual-Help

Roberts, Salem, Rappaport, Toro, Luke, and Seidman (1999, p.859) found support for the helper-therapy principle among participants of GROW, a mutual-help group for individuals with serious mental illness, whereby “participants who offered help to others evidenced improvement over time in psychosocial adjustment”.

Maton (1988) reports that occupying both “helper” and “helpee” roles in a self-help/mutual-aid group (i.e. bidirectional support) was positively correlated with psychological well-being and positive perceptions regarding the benefits of group membership, and that these members with dual-roles had a greater sense of well-being and a more favourable opinion of the group than members who were helpees (i.e. recipients of assistance) only.

Olson, Jason, Ferrari, and Hutcheson (2005) reviewed the existent literature on four mutual-help organisations (Alcoholics Anonymous, Oxford House, GROW, and Schizophrenics Anonymous). They suggest that the processes of change framework found within the transtheoretical model of intentional behaviour change (Prochaska, Diclemente, and Norcross, 1992) is a useful model to conceptualise the activities of mutual-help organization members throughout their journey of mental health recovery. They explicitly link social liberation, the last of the ten processes of change articulated by the model (the others being: consciousness raising, self-re-evaluation, helping relationships, self-liberation, environmental re-evaluation, dramatic relief/emotional arousal, stimulus control, reinforcement management, and counterconditioning) to the helper-therapy principle, along with a related concept known as bidirectional support (Maton, 1988). Per Olson et al. (2005), social liberation “involves the person in recovery focusing attention away from oneself and developing a broader recognition of social issues that contributed to the targeted problem” which encourages “recovering individuals to take more helping-related attitudes toward others who face similar problems” (Olson et al., 2005, p.174). In reviewing the research conducted among members of these four self-help/mutual-help organisations, they identify three different mechanisms which might underlie the therapeutic effect of mutual-help:

  1. When an individual helps another, the helper’s social functioning improves because the act of providing help to another allows the helper to work through their own difficulties;
  2. When an individual helps another, the helper’s social functioning improves because the act of providing help to another allows the helper to reinforce their own personal learning about recovery; and/or
  3. When an individual helps another, the helper experiences an increase in their own sense of competence and usefulness to others and enables the helper to adopt a “strength-based roles that have not been fully exercised in other areas of life” (Olson et al., 2005, p.175).

In reviewing the research on GROW, specifically, 67% of members of this organisation sampled by Young and Williams (1987) who were asked how they most benefited from participation reported that involvement in GROW “taught [them they] could help others” (the most endorsed answer among all listed categories). As suggested by a study by Maton and Salem (1995), this idea is most succinctly expressed by way of an axiom of GROW which is often recited at meetings: “If you need help, help others.”

A review of empirical studies investigating the effect of mutual help group participation for individuals with mental health problems by Pistrang, Barker, and Humphreys (2008, p.110) provides “limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety, and bereavement”.

References

Arnold, D., Calhoun, L. G., Tedeschi, R. & Cann, A. (2005). Vicarious posttraumatic growth in psychotherapy. Journal of Humanistic Psychology. 45(2), pp.239-263.

Lepore, S.J., Buzaglo, J.S., Liberman, M.A., Golant, M., Greener, J.R. & Davey A. (2014) Comparing standard versus prosocial internet support groups for patients with breast cancer: A randomized controlled trial of the helper therapy principle. Journal of Clinical Oncology. 32(36), pp.4081-4086.

Maton, K.I. (1988). Social support, organization characteristics, psychological wellbeing and group appraisal in three self-help populations. American Journal of Community Psychology. 16(1), pp.53-77.

Maton, K.I. & Salem, D.A. (1995). Organizational characteristics of empowering community settings: A multiple case study approach. American Journal of Community Psychology. 23(5), pp631-656.

Melkman, E., Mor-Salwo, Y., Mangold, K., Zeller, M. & Benbenishty, R. (July 2015). Care leavers as helpers: Motivations for and benefits of helping others. Children and Youth Services Review. 54, pp.41-48.

Olson, B.D., Jason, L.A., Ferrari, J.R. & Hutcheson, T.D. (2005). Bridging professional and mutual-help: An application of the transtheoretical model to the mutual-help organization. Applied and Preventive Psychology. 11(3), pp.167-178.

Pagano, M.E., Post, S.G. & Johnson, S.M. (2011). Alcoholics Anonymous-Related Helping and the Helper Therapy Principle. Alcoholism Treatment Quarterly. 29(1), pp.23-34.

Pistrang, N., Barker, C. & Humphreys, K. (2008). Mutual Help Groups for Mental Health Problems: A Review of Effectiveness Studies. American Journal of Community Psychology. 42(1-2), pp.110-121.

Post, S.G. (2005). Altruism, happiness, and health: it’s good to be good. International Journal of Behavioral Medicine. 12(2), pp.66-77.

Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to the addictive behaviors. American Psychologist. 47(9), pp.1102-1114.

Riessman, F. (1965) The ‘Helper’ Therapy Principle. Social Work. 10(2), pp.27-32.

Roberts, L., Salem, D., Rappaport, J., Toro, P.A., Luke, D.A. & Seidman, E. (1999). Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology. 27(6), pp.841-868.

Young, J. & Williams, C.L. (1987). An Evaluation of Grow, a Mutual-Help Community Mental Health Organisation. Community Health Studies. 11(1), pp.38-42.

On This Day … 25 January

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People (Births)

  • 1923 – Shirley Ardell Mason, American psychiatric patient (d. 1998).

Shirley Ardell Mason

Shirley Ardell Mason (25 January 1923 to 26 February 1998) was an American art teacher who was reputed to have dissociative identity disorder (previously known as multiple personality disorder).

Her life was purportedly described, with adaptations to protect her anonymity, in 1973 in the book Sybil, subtitled The True Story of a Woman Possessed by 16 Separate Personalities. Two films of the same name were made, one released in 1976 and the other in 2007. Both the book and the films used the name Sybil Isabel Dorsett to protect Mason’s identity, though the 2007 remake stated Mason’s name at its conclusion.

Mason’s diagnosis and treatment under Cornelia B. Wilbur have been criticised, with allegations that Wilbur manipulated or possibly misdiagnosed Mason.

Biography

Mason was born and raised in Dodge Centre, Minnesota, the only surviving child of Walter Wingfield Mason (a carpenter and architect) and Martha Alice “Mattie” Atkinson. In regard to Mason’s mother: “…many people in Dodge Centre say Mattie” – “Hattie” in the book – “was bizarre,” according to Bettie Borst Christensen, who grew up across the street. “She had a witch-like laugh….She didn’t laugh much, but when she did, it was like a screech.” Christensen remembers Mason’s mother walking around after dark, looking in the neighbours’ windows. At one point, Martha Mason was reportedly diagnosed with schizophrenia.

Mason graduated from Dodge Centre High School in 1941 and became an art student at Mankato State College, now Minnesota State University, Mankato. In the early 1950s, Mason was a substitute teacher and a student at Columbia University. She had long suffered from blackouts and emotional breakdowns, and finally entered psychotherapy with Cornelia B. Wilbur, a Freudian psychiatrist. Their sessions together are the basis of the book. From 1970-1971, she taught art at Rio Grande College in Rio Grande, Ohio (now the University of Rio Grande).

Some people in Mason’s home town, reading the book, recognised Mason as Sybil. By that time, Mason had severed nearly all ties with her past and was living in West Virginia. She later moved to Lexington, Kentucky, where she lived near Wilbur. She taught art classes at a community college and ran an art gallery out of her home for many years.

Wilbur diagnosed Mason with breast cancer in 1990, and she declined treatment; it later went into remission. The following year, Wilbur developed Parkinson’s disease, and Mason moved into Wilbur’s house to take care of her until Wilbur’s death in 1992. Mason was a devout Seventh-day Adventist. When her breast cancer returned Mason gave away her books and paintings to friends. She left the rest of her estate to a Seventh-day Adventist TV minister. Mason died on 26 February 1998.

Over one hundred paintings were found locked in a closet in Mason’s Lexington home when it was being emptied after her estate sale. These paintings, often referred to as the “Hidden Paintings”, span the years 1943, eleven years before starting psychotherapy with Dr. Wilbur, to 1965, the year of her successful integration. Several of the paintings were signed by Shirley. However, many remained unsigned, and include examples of some of the artwork presumably created by, and signed by the alternate personalities.

Sybil

Flora Rheta Schreiber’s non-fiction book Sybil: The True Story of a Woman Possessed by 16 Separate Personalities told a version of Mason’s story with names and details changed to protect her anonymity. The book, whose veracity was challenged (e.g. Sybil Exposed by Debbie Nathan), stated that Mason had multiple personalities as a result of severe child sexual abuse at the hands of her mother, who, Wilbur believed, had schizophrenia.

The book was made into a highly acclaimed TV movie starring Sally Field and Joanne Woodward, in 1976. The TV movie was remade in 2007 with Tammy Blanchard and Jessica Lange.

Controversy

Mason’s diagnosis had been challenged. Psychiatrist Herbert Spiegel saw Mason for several sessions while Wilbur was on vacation and felt that Wilbur was manipulating Mason into behaving as though she had multiple personalities when she did not. Spiegel suspected Wilbur of having publicised Mason’s case for financial gain. According to Spiegel, Wilbur’s client was a hysteric but did not show signs of multiple personalities; in fact, he later stated that Mason denied to him that she was “multiple” but claimed that Wilbur wanted her to exhibit other personalities. Spiegel confronted Wilbur, who responded that the publisher would not publish the book unless it was what she said it was.

Spiegel revealed that he possessed audio tapes in which Wilbur tells Mason about some of the other personalities she has already seen in prior sessions. Spiegel believes these tapes are the “smoking gun” proving that Wilbur induced her client to believe she was multiple. Spiegel made these claims 24 years later, after Schreiber, Wilbur and Mason had all died and he was finally asked about the topic.

In August 1998, psychologist Robert Rieber of John Jay College of Criminal Justice stated that the tapes belonged to him and that Wilbur had given them to him decades earlier. He cited the tapes to challenge Mason’s diagnosis. Rieber had never interviewed or treated Mason but asserted that she was an “extremely suggestible hysteric.” He claimed Wilbur had manipulated Mason in order to secure a book deal.

In a review of Rieber’s book, psychiatrist Mark Lawrence asserts that Rieber repeatedly distorted the evidence and left out a number of important facts about Mason’s case to advance his case against the validity of the diagnosis.

Debbie Nathan’s Sybil Exposed draws upon an archive of Schreiber’s papers stored at John Jay College of Criminal Justice and other first-hand sources. Nathan claims that Wilbur, Mason, and Schreiber knowingly perpetrated a fraud and describes the purported manipulation of Wilbur by Mason and vice versa and that the case created an “industry” of repressed memory. Nathan hypothesizes that Mason’s physical and sensory issues may have been due to untreated pernicious anaemia, the symptoms of which were mistaken at the time for psychogenic issues. She notes that after Mason was treated with calf’s-liver supplements for chronic blood disorders as a child and young woman, her psychological symptoms likewise went into remission for years at a time, and that Wilbur herself noted that “Sybil” suffered from pernicious anaemia later in life. Nathan’s writing and her research methods have been publicly criticised by Mason’s family and by Dr. Patrick Suraci, who was personally acquainted with Shirley Mason.

In addition, Suraci claims that Spiegel behaved unethically in withholding tapes which supposedly proved Wilbur had induced Mason to believe she had multiple personalities. Spiegel also claimed to have made films of himself hypnotising Mason, supposedly proving that Wilbur had “implanted false memories” in her mind, but when Suraci asked to see the films Spiegel said he had lost them. Although Wilbur’s papers were destroyed, copies and excerpts within Flora Rheta Schreiber’s papers at the Lloyd Sealy Library of John Jay College were unsealed in 1998.

In 2013, Nancy Preston published After Sybil, a personal memoir which includes facsimile reproductions of Mason’s personal letters to her, along with colour plates of her paintings. According to Preston, Mason taught art at Ohio’s Rio Grande College, where Preston was a student. The two became close friends and corresponded until a few days before Mason’s death. In the letters, Mason claimed that she had had multiple personalities.

On This Day … 24 January

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People (Births)

  • 1850 – Hermann Ebbinghaus, German psychologist (d. 1909).
  • 1853 – Sigbert Josef Maria Ganser, German psychiatrist (d. 1931).

Hermann Ebbinghaus

Hermann Ebbinghaus (24 January 1850 to 26 February 1909) was a German psychologist who pioneered the experimental study of memory, and is known for his discovery of the forgetting curve and the spacing effect. He was also the first person to describe the learning curve. He was the father of the neo-Kantian philosopher Julius Ebbinghaus.

Early Life

Ebbinghaus was born in Barmen, in the Rhine Province of the Kingdom of Prussia, as the son of a wealthy merchant, Carl Ebbinghaus. Little is known about his infancy except that he was brought up in the Lutheran faith and was a pupil at the town Gymnasium. At the age of 17 (1867), he began attending the University of Bonn, where he had planned to study history and philology. However, during his time there he developed an interest in philosophy. In 1870, his studies were interrupted when he served with the Prussian Army in the Franco-Prussian War. Following this short stint in the military, Ebbinghaus finished his dissertation on Eduard von Hartmann’s Philosophie des Unbewussten (philosophy of the unconscious) and received his doctorate on 16 August 1873, when he was 23 years old. During the next three years, he spent time at Halle and Berlin.

Professional Career

After acquiring his PhD, Ebbinghaus moved around England and France, tutoring students to support himself. In England, he may have taught in two small schools in the south of the country (Gorfein, 1885). In London, in a used bookstore, he came across Gustav Fechner’s book Elemente der Psychophysik (Elements of Psychophysics), which spurred him to conduct his famous memory experiments. After beginning his studies at the University of Berlin, he founded the third psychological testing lab in Germany (third to Wilhelm Wundt and Georg Elias Müller). He began his memory studies here in 1879. In 1885 – the same year that he published his monumental work, Über das Gedächtnis. Untersuchungen zur experimentellen Psychologie, later published in English under the title Memory: A Contribution to Experimental Psychology – he was made a professor at the University of Berlin, most likely in recognition of this publication. In 1890, along with Arthur König, he founded the psychological journal Zeitschrift für Physiologie und Psychologie der Sinnesorgane (“The Psychology and Physiology of the Sense Organs'”).

In 1894, he was passed over for promotion to head of the philosophy department at Berlin, most likely due to his lack of publications. Instead, Carl Stumpf received the promotion. As a result of this, Ebbinghaus left to join the University of Breslau (now Wrocław, Poland), in a chair left open by Theodor Lipps (who took over Stumpf’s position when he moved to Berlin). While in Breslau, he worked on a commission that studied how children’s mental ability declined during the school day. While the specifics on how these mental abilities were measured have been lost, the successes achieved by the commission laid the groundwork for future intelligence testing. At Breslau, he again founded a psychological testing laboratory.

In 1902, Ebbinghaus published his next piece of writing entitled Die Grundzüge der Psychologie (Fundamentals of Psychology). It was an instant success and continued to be long after his death. In 1904, he moved to Halle where he spent the last few years of his life. His last published work, Abriss der Psychologie (Outline of Psychology) was published six years later, in 1908. This, too, continued to be a success, being re-released in eight different editions. Shortly after this publication, on 26 February 1909, Ebbinghaus died from pneumonia at the age of 59.

Sigbert Ganser

Sigbert Josef Maria Ganser (24 January 1853 to 04 January 1931) was a German psychiatrist born in Rhaunen.

He earned his medical doctorate in 1876 from the University of Munich. Afterwards he worked briefly at a psychiatric clinic in Würzburg, and later as an assistant to neuroanatomist Bernhard von Gudden (1824-1886) in Munich. In 1886, he became head of the psychiatric department at Dresden General Hospital. Among his students was neurologist Hans Queckenstedt (1876-1918).

Sigbert Ganser is remembered for a hysterical disorder that he first described in 1898. He identified the disorder in three prisoners while working at a prison in Halle. The features included approximate or nonsensical answers to simple questions, perceptual abnormalities, and clouding of consciousness. Ganser believed that these symptoms were an associative reaction caused by an unconscious attempt by the patient to escape from an intolerable mental situation. The disorder was to become known as Ganser syndrome.

What is Group Psychotherapy?

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Introduction

Group psychotherapy, or group therapy, is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including Art therapy, cognitive behavioural therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

The broader concept of group therapy can be taken to include any helping process that takes place in a group, including support groups, skills training groups (such as anger management, mindfulness, relaxation training or social skills training), and psychoeducation groups. The differences between psychodynamic groups, activity groups, support groups, problem-solving and psychoeducational groups have been discussed by psychiatrist Charles Montgomery. Other, more specialised forms of group therapy would include non-verbal expressive therapies such as art therapy, dance therapy, or music therapy.

Brief History

The founders of group psychotherapy in the USA were Joseph H. Pratt, Trigant Burrow and Paul Schilder. All three of them were active and working at the East Coast in the first half of the 20th century. In 1932 Jacob L. Moreno presented his work on group psychotherapy to the American Psychiatric Association, and co-authored a monograph on the subject. After World War II, group psychotherapy was further developed by Moreno, Samuel Slavson, Hyman Spotnitz, Irvin Yalom, and Lou Ormont. Yalom’s approach to group therapy has been very influential not only in the USA but across the world.

An early development in group therapy was the T-group or training group (sometimes also referred to as sensitivity-training group, human relations training group or encounter group), a form of group psychotherapy where participants (typically, between eight and 15 people) learn about themselves (and about small group processes in general) through their interaction with each other. They use feedback, problem solving, and role play to gain insights into themselves, others, and groups. It was pioneered in the mid-1940s by Kurt Lewin and Carl Rogers and his colleagues as a method of learning about human behaviour in what became the National Training Laboratories (also known as the NTL Institute) that was created by the Office of Naval Research and the National Education Association in Bethel, Maine, in 1947.

Moreno developed a specific and highly structured form of group therapy known as psychodrama (although the entry on psychodrama claims it is not a form of group therapy). Another recent development in the theory and method of group psychotherapy based on an integration of systems thinking is Yvonne Agazarian’s systems-centred therapy (SCT), which sees groups functioning within the principles of system dynamics. Her method of “functional subgrouping” introduces a method of organizing group communication so it is less likely to react counterproductively to differences. SCT also emphasizes the need to recognise the phases of group development and the defences related to each phase in order to best make sense and influence group dynamics.

In the United Kingdom group psychotherapy initially developed independently, with pioneers S. H. Foulkes and Wilfred Bion using group therapy as an approach to treating combat fatigue in the Second World War. Foulkes and Bion were psychoanalysts and incorporated psychoanalysis into group therapy by recognising that transference can arise not only between group members and the therapist but also among group members. Furthermore, the psychoanalytic concept of the unconscious was extended with a recognition of a group unconscious, in which the unconscious processes of group members could be acted out in the form of irrational processes in group sessions. Foulkes developed the model known as group analysis and the Institute of Group Analysis, while Bion was influential in the development of group therapy at the Tavistock Clinic.

Bion’s approach is comparable to social therapy, first developed in the United States in the late 1970s by Lois Holzman and Fred Newman, which is a group therapy in which practitioners relate to the group, not its individuals, as the fundamental unit of development. The task of the group is to “build the group” rather than focus on problem solving or “fixing” individuals.

In Argentina an independent school of group analysis stemmed from the work and teachings of Swiss-born Argentine psychoanalyst Enrique Pichon-Rivière. This thinker conceived of a group-centred approach which, although not directly influenced by Foulkes’ work, was fully compatible with it.

Therapeutic Principles

Irvin Yalom proposed a number of therapeutic factors (originally termed curative factors but renamed therapeutic factors in the 5th edition of The Theory and Practice of Group Psychotherapy).

  • Universality:
    • The recognition of shared experiences and feelings among group members and that these may be widespread or universal human concerns, serves to remove a group member’s sense of isolation, validate their experiences, and raise self-esteem
  • Altruism:
    • The group is a place where members can help each other, and the experience of being able to give something to another person can lift the member’s self esteem and help develop more adaptive coping styles and interpersonal skills.
  • Instillation of hope:
    • In a mixed group that has members at various stages of development or recovery, a member can be inspired and encouraged by another member who has overcome the problems with which they are still struggling.
  • Imparting information:
    • While this is not strictly speaking a psychotherapeutic process, members often report that it has been very helpful to learn factual information from other members in the group.
    • For example, about their treatment or about access to services.
  • Corrective recapitulation of the primary family experience:
    • Members often unconsciously identify the group therapist and other group members with their own parents and siblings in a process that is a form of transference specific to group psychotherapy.
    • The therapist’s interpretations can help group members gain understanding of the impact of childhood experiences on their personality, and they may learn to avoid unconsciously repeating unhelpful past interactive patterns in present-day relationships.
  • Development of socialising techniques:
    • The group setting provides a safe and supportive environment for members to take risks by extending their repertoire of interpersonal behaviour and improving their social skills
  • Imitative behaviour:
    • One way in which group members can develop social skills is through a modelling process, observing and imitating the therapist and other group members.
    • For example, sharing personal feelings, showing concern, and supporting others.
  • Cohesiveness:
    • It has been suggested that this is the primary therapeutic factor from which all others flow. Humans are herd animals with an instinctive need to belong to groups, and personal development can only take place in an interpersonal context.
    • A cohesive group is one in which all members feel a sense of belonging, acceptance, and validation.
  • Existential factors:
    • Learning that one has to take responsibility for one’s own life and the consequences of one’s decisions.
  • Catharsis:
    • Catharsis is the experience of relief from emotional distress through the free and uninhibited expression of emotion.
    • When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and guilt.
  • Interpersonal learning:
    • Group members achieve a greater level of self-awareness through the process of interacting with others in the group, who give feedback on the member’s behaviour and impact on others.
  • Self-understanding:
    • This factor overlaps with interpersonal learning but refers to the achievement of greater levels of insight into the genesis of one’s problems and the unconscious motivations that underlie one’s behaviour.

Settings

Group therapy can form part of the therapeutic milieu of a psychiatric in-patient unit or ambulatory psychiatric partial hospitalisation (also known as day hospital treatment). In addition to classical “talking” therapy, group therapy in an institutional setting can also include group-based expressive therapies such as drama therapy, psychodrama, art therapy, and non-verbal types of therapy such as music therapy and dance/movement therapy.

Group psychotherapy is a key component of milieu therapy in a therapeutic community. The total environment or milieu is regarded as the medium of therapy, all interactions and activities regarded as potentially therapeutic and are subject to exploration and interpretation, and are explored in daily or weekly community meetings. However, interactions between the culture of group psychotherapeutic settings and the more managerial norms of external authorities may create ‘organisational turbulence’ which can critically undermine a group’s ability to maintain a safe yet challenging ‘formative space’. Academics at the University of Oxford studied the inter-organisational dynamics of a national democratic therapeutic community over a period of four years; they found external steering by authorities eroded the community’s therapeutic model, produced a crisis, and led to an intractable conflict which resulted in the community’s closure.

A form of group therapy has been reported to be effective in psychotic adolescents and recovering addicts. Projective psychotherapy uses an outside text such as a novel or motion picture to provide a “stable delusion” for the former cohort and a safe focus for repressed and suppressed emotions or thoughts in the latter. Patient groups read a novel or collectively view a film. They then participate collectively in the discussion of plot, character motivation and author motivation. In the case of films, sound track, cinematography and background are also discussed and processed. Under the guidance of the therapist, defence mechanisms are bypassed by the use of signifiers and semiotic processes. The focus remains on the text rather than on personal issues. It was popularised in the science fiction novel, Red Orc’s Rage.

Group therapy is now often utilised in private practice settings.

Group analysis has become widespread in Europe, and especially the United Kingdom, where it has become the most common form of group psychotherapy. Interest from Australia, the former Soviet Union and the African continent is also growing.

Research on Effectiveness

A 2008 meta-analysis found that individual therapy may be slightly more effective than group therapy initially, but this difference seems to disappears after 6 months. There is clear evidence for the effectiveness of group psychotherapy for depression: a meta-analysis of 48 studies showed an overall effect size of 1.03, which is clinically highly significant. Similarly, a meta-analysis of five studies of group psychotherapy for adult sexual abuse survivors showed moderate to strong effect sizes, and there is also good evidence for effectiveness with chronic traumatic stress in war veterans.

There is less robust evidence of good outcomes for patients with borderline personality disorder, with some studies showing only small to moderate effect sizes. The authors comment that these poor outcomes might reflect a need for additional support for some patients, in addition to the group therapy. This is borne out by the impressive results obtained using mentalisation-based treatment, a model that combines dynamic group psychotherapy with individual psychotherapy and case management.

Most outcome research is carried out using time-limited therapy with diagnostically homogenous groups. However, long-term intensive interactional group psychotherapy assumes diverse and diagnostically heterogeneous group membership, and an open-ended time scale for therapy. Good outcomes have also been demonstrated for this form of group therapy.

Computer-Supported Group Therapy

Research on computer-supported and computer-based interventions has increased significantly since the mid-1990s. For a comprehensive overview of current practices (refer to Computer-supported psychotherapy).

Several feasibility studies examined the impact of computer-, app- and media-support on group interventions. Most investigated interventions implemented short rationales, which usually were based on principles of cognitive behaviour therapy (CBT). Most research focussed on:

  • Anxiety disorders (e.g. social phobia, generalised anxiety disorder).
  • Depression (e.g. mild to moderate Major Depression).
  • Other disorders (e.g. hoarding).

While the evidence base for group therapy is very limited, preliminary research in individual therapy suggests possible increases of treatment efficiency or effectiveness. Further, the use of app- or computer-based monitoring has been investigated several times. Reported advantages of the modern format include improved between-session transfer and patient-therapist-communication, as well as increased treatment transparency and intensity. Negative effects may occur in terms of dissonance due to non-compliance with online tasks, or the constriction of in-session group interaction. Last but not least, group phenomena might influence the motivation to engage with online tasks.

What is Dispossession, Oppression, and Depression?

Published on by Andrew Marshall2 Comments

Introduction

Supplementing the medical model of depression, many researchers have begun to conceptualise ways in which the historical legacies of racism and colonialism create depressive conditions. Given the lived experiences of marginalised peoples, ranging from conditions of migration, class stratification, cultural genocide, labour exploitation, and social immobility, depression can be seen as a “rational response to global conditions”, according to Ann Cvetkovich.

Background

Psychogeographical depression overlaps somewhat with the theory of “deprejudice”, a portmanteau of depression and prejudice proposed by Cox, Abramson, Devine, and Hollon in 2012, who argue for an integrative approach to studying the often comorbid experiences. Cox, Abramson, Devine, and Hollon are concerned with the ways in which social stereotypes are often internalised, creating negative self-stereotypes that then produce depressive symptoms.

Unlike the theory of “deprejudice”, a psychogeographical theory of depression attempts to broaden study of the subject beyond an individual experience to one produced on a societal scale, seeing particular manifestations of depression as rooted in dispossession; historical legacies of genocide, slavery, and colonialism are productive of segregation, both material and psychic material deprivation, and concomitant circumstances of violence, systemic exclusion, and lack of access to legal protections. The demands of navigating these circumstances compromise the resources available to a population to seek comfort, health, stability, and sense of security. The historical memory of this trauma conditions the psychological health of future generations, making psychogeographical depression an intergenerational experience as well.

This work is supported by recent studies in genetic science which has demonstrated an epigenetic link between the trauma suffered by Holocaust survivors and the genetic reverberations for subsequent generations. Likewise, research by scientists at Emory University suggests that memories of trauma can be inherited, rendering offspring vulnerable to psychological predispositions for stress disorders, schizophrenia, and PTSD.

Vacant Lot Greening and Mood

A 2018 study asked low income residents of Philadelphia “how often they felt nervous, hopeless, restless, depressed and worthless.” As an experimental mental health intervention, trash was removed from vacant lots. Some of the vacant lots were “greened”, with plantings of trees, grass, and small fences. Residents near the “greened” lots who had incomes below the poverty line reported a decrease in feelings of depression of 68%, while residents with incomes above the poverty line reported a decrease of 41%. Removing trash from vacant lots without installing landscaping did not have an observable mental health impact.

What is Mood Disorder?

Published on by Andrew Marshall11 Comments

Introduction

Mood disorder, also known as mood affective disorders, is a group of conditions where a disturbance in the person’s mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Mood disorders fall into the basic groups of elevated mood, such as mania or hypomania; depressed mood, of which the best-known and most researched is major depressive disorder (MDD) (commonly called clinical depression, unipolar depression, or major depression); and moods which cycle between mania and depression, known as bipolar disorder (BD) (formerly known as manic depression). There are several sub-types of depressive disorders or psychiatric syndromes featuring less severe symptoms such as dysthymic disorder (similar to but milder than MDD) and cyclothymic disorder (similar to but milder than BD). Mood disorders may also be substance induced or occur in response to a medical condition.

English psychiatrist Henry Maudsley proposed an overarching category of affective disorder. The term was then replaced by mood-disorder, as the latter term refers to the underlying or longitudinal emotional state, whereas the former refers to the external expression observed by others.

Refer to Depression (Mood).

Epidemiology

According to a substantial amount of epidemiology studies conducted, women are twice as likely to develop certain mood disorders, such as major depression. Although there is an equal number of men and women diagnosed with bipolar II disorder, women have a slightly higher frequency of the disorder.

The prevalence of depressive symptoms has increased over the years with recent generations reporting a 6% increase in symptoms of depression compared to individuals from older generations.

In 2011, mood disorders were the most common reason for hospitalization among children aged 1-17 years in the United States, with approximately 112,000 stays. Mood disorders were top principal diagnosis for Medicaid super-utilisers in the United States in 2012. Further, a study of 18 States found that mood disorders accounted for the highest number of hospital readmissions among Medicaid patients and the uninsured, with 41,600 Medicaid patients and 12,200 uninsured patients being readmitted within 30 days of their index stay – a readmission rate of 19.8 per 100 admissions and 12.7 per 100 admissions, respectively. In 2012, mood and other behavioural health disorders were the most common diagnoses for Medicaid-covered and uninsured hospital stays in the United States (6.1% of Medicaid stays and 5.2% of uninsured stays).

A study conducted in 1988 to 1994 amongst young American adults involved a selection of demographic and health characteristics. A population-based sample of 8,602 men and women ages 17-39 years participated. Lifetime prevalence were estimated based on six mood measures:

  • Major depressive episode (MDE) 8.6%.
  • Major depressive disorder with severity (MDE-s) 7.7%.
  • Dysthymia 6.2%.
  • MDE-s with dysthymia 3.4%.
  • Any bipolar disorder 1.6%.
  • Any mood disorder 11.5%.

Classification

Depressive Disorders

  • Major depressive disorder (MDD):
    • Commonly called major depression, unipolar depression, or clinical depression, wherein a person has one or more major depressive episodes.
    • After a single episode, Major Depressive Disorder (single episode) would be diagnosed.
    • After more than one episode, the diagnosis becomes Major Depressive Disorder (Recurrent).
    • Depression without periods of mania is sometimes referred to as unipolar depression because the mood remains at the bottom “pole” and does not climb to the higher, manic “pole” as in bipolar disorder.
  • Individuals with a major depressive episode or major depressive disorder are at increased risk for suicide.
  • Seeking help and treatment from a health professional dramatically reduces the individual’s risk for suicide.
  • Studies have demonstrated that asking if a depressed friend or family member has thought of committing suicide is an effective way of identifying those at risk, and it does not “plant” the idea or increase an individual’s risk for suicide in any way.
  • Epidemiological studies carried out in Europe suggest that, at this moment, roughly 8.5% of the world’s population have a depressive disorder. No age group seems to be exempt from depression, and studies have found that depression appears in infants as young as 6 months old who have been separated from their mothers.
  • Depressive disorder is frequent in primary care and general hospital practice but is often undetected.
  • Unrecognised depressive disorder may slow recovery and worsen prognosis in physical illness, therefore it is important that all doctors be able to recognise the condition, treat the less severe cases, and identify those requiring specialist care.

Diagnosticians recognise several subtypes or course specifiers:

  • Atypical depression (AD):
    • This is characterised by mood reactivity (paradoxical anhedonia) and positivity, significant weight gain or increased appetite (“comfort eating”), excessive sleep or somnolence (hypersomnia), a sensation of heaviness in limbs known as leaden paralysis, and significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection.
    • Difficulties in measuring this subtype have led to questions of its validity and prevalence.
  • Melancholic depression:
    • This is characterised by a loss of pleasure (anhedonia) in most or all activities, a failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced than that of grief or loss, a worsening of symptoms in the morning hours, early-morning waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia nervosa), or excessive guilt.
  • Psychotic major depression (PMD):
    • Or simply psychotic depression, is the term for a major depressive episode, in particular of melancholic nature, wherein the patient experiences psychotic symptoms such as delusions or, less commonly, hallucinations.
    • These are most commonly mood-congruent (content coincident with depressive themes).
  • Catatonic depression:
    • This is a rare and severe form of major depression involving disturbances of motor behaviour and other symptoms.
    • Here, the person is mute and almost stuporose, and either is immobile or exhibits purposeless or even bizarre movements.
    • Catatonic symptoms can also occur in schizophrenia or a manic episode, or can be due to neuroleptic malignant syndrome.
  • Postpartum depression (PPD)
    • This is listed as a course specifier in DSM-IV-TR; it refers to the intense, sustained and sometimes disabling depression experienced by women after giving birth.
    • Postpartum depression, which affects 10-15% of women, typically sets in within three months of labour, and lasts as long as three months.
    • It is quite common for women to experience a short-term feeling of tiredness and sadness in the first few weeks after giving birth; however, postpartum depression is different because it can cause significant hardship and impaired functioning at home, work, or school as well as, possibly, difficulty in relationships with family members, spouses, or friends, or even problems bonding with the newborn.
    • In the treatment of postpartum major depressive disorders and other unipolar depressions in women who are breastfeeding, nortriptyline, paroxetine (Paxil), and sertraline (Zoloft) are in general considered to be the preferred medications.
    • Women with personal or family histories of mood disorders are at particularly high risk of developing postpartum depression.
  • Premenstrual dysphoric disorder (PMDD):
    • This is a severe and disabling form of premenstrual syndrome affecting 3-8% of menstruating women.
    • The disorder consists of a “cluster of affective, behavioural and somatic symptoms” that recur monthly during the luteal phase of the menstrual cycle.
    • PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013.
    • The exact pathogenesis of the disorder is still unclear and is an active research topic. Treatment of PMDD relies largely on antidepressants that modulate serotonin levels in the brain via serotonin reuptake inhibitors as well as ovulation suppression using contraception.
  • Seasonal affective disorder (SAD):
    • Also known as “winter depression” or “winter blues”, is a specifier.
    • Some people have a seasonal pattern, with depressive episodes coming on in the autumn or winter, and resolving in spring.
    • The diagnosis is made if at least two episodes have occurred in colder months with none at other times over a two-year period or longer.
    • It is commonly hypothesised that people who live at higher latitudes tend to have less sunlight exposure in the winter and therefore experience higher rates of SAD, but the epidemiological support for this proposition is not strong (and latitude is not the only determinant of the amount of sunlight reaching the eyes in winter).
    • It is said that this disorder can be treated by light therapy.
    • SAD is also more prevalent in people who are younger and typically affects more females than males.
  • Dysthymia:
    • This is a condition related to unipolar depression, where the same physical and cognitive problems are evident, but they are not as severe and tend to last longer (usually at least 2 years).
    • The treatment of dysthymia is largely the same as for major depression, including antidepressant medications and psychotherapy.
  • Double depression:
    • Can be defined as a fairly depressed mood (dysthymia) that lasts for at least two years and is punctuated by periods of major depression.
  • Depressive Disorder Not Otherwise Specified (DD-NOS):
    • This is designated by the code 311 for depressive disorders that are impairing but do not fit any of the officially specified diagnoses.
    • According to the DSM-IV, DD-NOS encompasses “any depressive disorder that does not meet the criteria for a specific disorder.”
    • It includes the research diagnoses of recurrent brief depression, and minor depressive disorder listed below.
  • Depressive personality disorder (DPD)
    • This is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features.
    • Originally included in the DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R.
    • Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study.
  • Recurrent brief depression (RBD):
    • Distinguished from major depressive disorder primarily by differences in duration.
    • Individuals with RBD have depressive episodes about once per month, with individual episodes lasting less than two weeks and typically less than 2-3 days.
    • Diagnosis of RBD requires that the episodes occur over the span of at least one year and, in female patients, independently of the menstrual cycle.
    • Individuals with clinical depression can develop RBD, and vice versa, and both illnesses have similar risks.
  • Minor depressive disorder:
    • Or simply minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.

Bipolar Disorders

Bipolar disorder (BD) (also called “manic depression” or “manic-depressive disorder”), an unstable emotional condition characterised by cycles of abnormal, persistent high mood (mania) and low mood (depression), which was formerly known as “manic depression” (and in some cases rapid cycling, mixed states, and psychotic symptoms). Subtypes include:

  • Bipolar I:
    • This is distinguished by the presence or history of one or more manic episodes or mixed episodes with or without major depressive episodes.
    • A depressive episode is not required for the diagnosis of Bipolar I Disorder, but depressive episodes are usually part of the course of the illness.
  • Bipolar II :
    • Consisting of recurrent intermittent hypomanic and depressive episodes or mixed episodes.
  • Cyclothymia:
    • This is a form of bipolar disorder, consisting of recurrent hypomanic and dysthymic episodes, but no full manic episodes or full major depressive episodes.
  • Bipolar disorder not otherwise specified (BD-NOS):
    • Sometimes called “sub-threshold” bipolar, indicates that the patient has some symptoms in the bipolar spectrum (e.g. manic and depressive symptoms) but does not fully qualify for any of the three formal bipolar DSM-IV diagnoses mentioned above.

It is estimated that roughly 1% of the adult population has bipolar I, a further 1% has bipolar II or cyclothymia, and somewhere between 2% and 5% percent have “sub-threshold” forms of bipolar disorder. Furthermore, the possibility of getting bipolar disorder when one parent is diagnosed with it is 15-30%. Risk, when both parents have it, is 50-75%. Also, while with bipolar siblings the risk is 15-25%, with identical twins it is about 70%.

A minority of people with bipolar disorder have high creativity, artistry or a particular gifted talent. Before the mania phase becomes too extreme, its energy, ambition, enthusiasm and grandiosity often bring people with this type of mood disorder life’s masterpieces.[29]

Substance-induced

A mood disorder can be classified as substance-induced if its aetiology can be traced to the direct physiologic effects of a psychoactive drug or other chemical substance, or if the development of the mood disorder occurred contemporaneously with substance intoxication or withdrawal. Also, an individual may have a mood disorder coexisting with a substance abuse disorder. Substance-induced mood disorders can have features of a manic, hypomanic, mixed, or depressive episode. Most substances can induce a variety of mood disorders. For example, stimulants such as amphetamine, methamphetamine, and cocaine can cause manic, hypomanic, mixed, and depressive episodes.

Alcohol-Induced

High rates of major depressive disorder occur in heavy drinkers and those with alcoholism. Controversy has previously surrounded whether those who abused alcohol and developed depression were self-medicating their pre-existing depression. But recent research has concluded that, while this may be true in some cases, alcohol misuse directly causes the development of depression in a significant number of heavy drinkers. Participants studied were also assessed during stressful events in their lives and measured on a Feeling Bad Scale. Likewise, they were also assessed on their affiliation with deviant peers, unemployment, and their partner’s substance use and criminal offending. High rates of suicide also occur in those who have alcohol-related problems. It is usually possible to differentiate between alcohol-related depression and depression that is not related to alcohol intake by taking a careful history of the patient. Depression and other mental health problems associated with alcohol misuse may be due to distortion of brain chemistry, as they tend to improve on their own after a period of abstinence.

Benzodiazepine-induced

Benzodiazepines, such as alprazolam, clonazepam, lorazepam and diazepam, can cause both depression and mania.

Benzodiazepines are a class of medication commonly used to treat anxiety, panic attacks and insomnia, and are also commonly misused and abused. Those with anxiety, panic and sleep problems commonly have negative emotions and thoughts, depression, suicidal ideations, and often have comorbid depressive disorders. While the anxiolytic and hypnotic effects of benzodiazepines disappear as tolerance develops, depression and impulsivity with high suicidal risk commonly persist. These symptoms are “often interpreted as an exacerbation or as a natural evolution of previous disorders and the chronic use of sedatives is overlooked”. Benzodiazepines do not prevent the development of depression, can exacerbate pre-existing depression, can cause depression in those with no history of it, and can lead to suicide attempts. Risk factors for attempted and completed suicide while using benzodiazepines include high dose prescriptions (even in those not misusing the medications), benzodiazepine intoxication, and underlying depression.

The long-term use of benzodiazepines may have a similar effect on the brain as alcohol, and are also implicated in depression. As with alcohol, the effects of benzodiazepine on neurochemistry, such as decreased levels of serotonin and norepinephrine, are believed to be responsible for the increased depression. Additionally, benzodiazepines can indirectly worsen mood by worsening sleep (i.e. benzodiazepine-induced sleep disorder). Like alcohol, benzodiazepines can put people to sleep but, while asleep, they disrupt sleep architecture: decreasing sleep time, delaying time to REM sleep, and decreasing deep sleep (the most restorative part of sleep for both energy and mood). Just as some antidepressants can cause or worsen anxiety in some patients due to being activating, benzodiazepines can cause or worsen depression due to being a central nervous system depressant – worsening thinking, concentration and problem solving (i.e. benzodiazepine-induced neurocognitive disorder). However, unlike antidepressants, in which the activating effects usually improve with continued treatment, benzodiazepine-induced depression is unlikely to improve until after stopping the medication.

In a long-term follow-up study of patients dependent on benzodiazepines, it was found that 10 people (20%) had taken drug overdoses while on chronic benzodiazepine medication despite only two people ever having had any pre-existing depressive disorder. A year after a gradual withdrawal programme, no patients had taken any further overdoses.

Just as with intoxication and chronic use, benzodiazepine withdrawal can also cause depression. While benzodiazepine-induced depressive disorder may be exacerbated immediately after discontinuation of benzodiazepines, evidence suggests that mood significantly improves after the acute withdrawal period to levels better than during use. Depression resulting from withdrawal from benzodiazepines usually subsides after a few months but in some cases may persist for 6-12 months.

Due to Another Medical Condition

“Mood disorder due to a general medical condition” is used to describe manic or depressive episodes which occur secondary to a medical condition. There are many medical conditions that can trigger mood episodes, including neurological disorders (e.g. dementias), metabolic disorders (e.g. electrolyte disturbances), gastrointestinal diseases (e.g. cirrhosis), endocrine disease (e.g. thyroid abnormalities), cardiovascular disease (e.g. heart attack), pulmonary disease (e.g. chronic obstructive pulmonary disease), cancer, and autoimmune diseases (e.g. multiple sclerosis).

Not Otherwise Specified

Mood disorder not otherwise specified (MD-NOS) is a mood disorder that is impairing but does not fit in with any of the other officially specified diagnoses. In the DSM-IV MD-NOS is described as “any mood disorder that does not meet the criteria for a specific disorder.” MD-NOS is not used as a clinical description but as a statistical concept for filing purposes.

Most cases of MD-NOS represent hybrids between mood and anxiety disorders, such as mixed anxiety-depressive disorder or atypical depression. An example of an instance of MD-NOS is being in minor depression frequently during various intervals, such as once every month or once in three days. There is a risk for MD-NOS not to get noticed, and for that reason not to get treated.

Causes

Meta-analyses show that high scores on the personality domain neuroticism are a strong predictor for the development of mood disorders. A number of authors have also suggested that mood disorders are an evolutionary adaptation. A low or depressed mood can increase an individual’s ability to cope with situations in which the effort to pursue a major goal could result in danger, loss, or wasted effort. In such situations, low motivation may give an advantage by inhibiting certain actions. This theory helps to explain why negative life incidents precede depression in around 80% of cases, and why they so often strike people during their peak reproductive years. These characteristics would be difficult to understand if depression were a dysfunction.

A depressed mood is a predictable response to certain types of life occurrences, such as loss of status, divorce, or death of a child or spouse. These are events that signal a loss of reproductive ability or potential, or that did so in humans’ ancestral environment. A depressed mood can be seen as an adaptive response, in the sense that it causes an individual to turn away from the earlier (and reproductively unsuccessful) modes of behaviour.

A depressed mood is common during illnesses, such as influenza. It has been argued that this is an evolved mechanism that assists the individual in recovering by limiting his/her physical activity. The occurrence of low-level depression during the winter months, or seasonal affective disorder, may have been adaptive in the past, by limiting physical activity at times when food was scarce. It is argued that humans have retained the instinct to experience low mood during the winter months, even if the availability of food is no longer determined by the weather.

Much of what is known about the genetic influence of clinical depression is based upon research that has been done with identical twins. Identical twins have exactly the same genetic code. It has been found that when one identical twin becomes depressed the other will also develop clinical depression approximately 76% of the time. When identical twins are raised apart from each other, they will both become depressed about 67% of the time. Because both twins become depressed at such a high rate, the implication is that there is a strong genetic influence. If it happened that when one twin becomes clinically depressed the other always develops depression, then clinical depression would likely be entirely genetic.

Bipolar disorder is also considered a mood disorder and it is hypothesized that it might be caused by mitochondrial dysfunction.

Sex Differences

Mood disorders, specifically stress-related mood disorders such as anxiety and depression, have been shown to have differing rates of diagnosis based on sex. In the United States, women are two times more likely than men to be diagnosed with a stress-related mood disorder. Underlying these sex differences, studies have shown a dysregulation of stress-responsive neuroendocrine function causing an increase in the likelihood of developing these affective disorders. Overactivation of the hypothalamic-pituitary-adrenal (HPA) axis could provide potential insight into how these sex differences arise. Neuropeptide corticotropin-releasing factor (CRF) is released from the paraventricular nucleus (PVN) of the hypothalamus, stimulating adrenocorticotropic hormone (ACTH) release into the blood stream. From here ACTH triggers the release of glucocorticoids such as cortisol from the adrenal cortex. Cortisol, known as the main stress hormone, creates a negative feedback loop back to the hypothalamus to deactivate the stress response. When a constant stressor is present, the HPA axis remains overactivated and cortisol is constantly produced. This chronic stress is associated with sustained CRF release, resulting in the increased production of anxiety- and depressive-like behaviours and serving as a potential mechanism for differences in prevalence between men and women.

Diagnosis

DSM-5

The DSM-5, released in May 2013, separates the mood disorder chapter from the DSM-TR-IV into two sections: Depressive and related disorders and bipolar and related disorders. Bipolar disorders falls in between depressive disorders and schizophrenia spectrum and related disorders “in recognition of their place as a bridge between the two diagnostic classes in terms of symptomatology, family history and genetics” (Ref. 1, p 123). Bipolar disorders underwent a few changes in the DSM-5, most notably the addition of more specific symptomology related to hypomanic and mixed manic states. Depressive disorders underwent the most changes, the addition of three new disorders: disruptive mood dysregulation disorder, persistent depressive disorder (previously dysthymia), and premenstrual dysphoric disorder (previously in appendix B, the section for disorders needing further research). Disruptive mood dysregulation disorder is meant as a diagnosis for children and adolescents who would normally be diagnosed with bipolar disorder as a way to limit the bipolar diagnosis in this age cohort. Major depressive disorder (MDD) also underwent a notable change, in that the bereavement clause has been removed. Those previously exempt from a diagnosis of MDD due to bereavement are now candidates for the MDD diagnosis.

Treatment

There are different types of treatments available for mood disorders, such as therapy and medications. Behaviour therapy, cognitive behaviour therapy and interpersonal therapy have all shown to be potentially beneficial in depression. Major depressive disorder medications usually include antidepressants; a combination of antidepressants and cognitive behavioural therapy has shown to be more effective than one treatment alone. Bipolar disorder medications can consist of antipsychotics, mood stabilisers, anticonvulsants and/or lithium. Lithium specifically has been proven to reduce suicide and all causes of mortality in people with mood disorders. If mitochondrial dysfunction or mitochondrial diseases are the cause of mood disorders like bipolar disorder, then it has been hypothesized that N-acetyl-cysteine (NAC), acetyl-L-carnitine (ALCAR), S-adenosylmethionine (SAMe), coenzyme Q10 (CoQ10), alpha-lipoic acid (ALA), creatine monohydrate (CM), and melatonin could be potential treatment options. In determining treatment, there are many types of depression scales that are used.

  • One of the depression scales is a self-report scale called Beck Depression Inventory (BDI).
  • Another scale is the Hamilton Depression Rating Scale (HAMD).
    • HAMD is a clinical rating scale in which the patient is rated based on clinician observation.
  • The Centre for Epidemiologic Studies Depression Scale (CES-D) is a scale for depression symptoms that applies to the general population.
    • This scale is typically used in research and not for self-reports.
  • The PHQ-9 which stands for Patient-Health Questionnaire-9 questions, is a self-report as well.
  • Finally, the Mood Disorder Questionnaire (MDQ) evaluates bipolar disorder.

Research

Kay Redfield Jamison and others have explored the possible links between mood disorders – especially bipolar disorder – and creativity. It has been proposed that a “ruminating personality type may contribute to both [mood disorders] and art.”

Jane Collingwood notes an Oregon State University study that:

“…looked at the occupational status of a large group of typical patients and found that ‘those with bipolar illness appear to be disproportionately concentrated in the most creative occupational category.’ They also found that the likelihood of ‘engaging in creative activities on the job’ is significantly higher for bipolar than nonbipolar workers”.

In Liz Paterek’s article “Bipolar Disorder and the Creative Mind” she wrote:

“Memory and creativity are related to mania. Clinical studies have shown that those in a manic state will rhyme, find synonyms, and use alliteration more than controls. This mental fluidity could contribute to an increase in creativity. Moreover, mania creates increases in productivity and energy. Those in a manic state are more emotionally sensitive and show less inhibition about attitudes, which could create greater expression. Studies performed at Harvard looked into the amount of original thinking in solving creative tasks. Bipolar individuals, whose disorder was not severe, tended to show greater degrees of creativity.”

The relationship between depression and creativity appears to be especially strong among poets.

What are the Differential Diagnoses of Depression?

Published on by Andrew Marshall2 Comments

Introduction

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. For example, depression in the United States (US) alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the US. In approximately 75% of completed suicides, the individuals had seen a physician within the prior year before their death, 45-66% within the prior month. About a third of those who completed suicide had contact with mental health services in the prior year, a fifth within the preceding month.

There are many psychiatric and medical conditions that may mimic some or all of the symptoms of depression or may occur comorbid to it. A disorder either psychiatric or medical that shares symptoms and characteristics of another disorder, and may be the true cause of the presenting symptoms is known as a differential diagnosis.

Many psychiatric disorders such as depression are diagnosed by allied health professionals with little or no medical training, and are made on the basis of presenting symptoms without proper consideration of the underlying cause, adequate screening of differential diagnoses is often not conducted. According to one study, non-medical mental health care providers may be at increased risk of not recognising masked medical illnesses in their patients.

Misdiagnosis or missed diagnoses may lead to lack of treatment or ineffective and potentially harmful treatment which may worsen the underlying causative disorder. A conservative estimate is that 10% of all psychological symptoms may be due to medical reasons, with the results of one study suggesting that about half of individuals with a serious mental illness have general medical conditions that are largely undiagnosed and untreated and may cause or exacerbate psychiatric symptoms.

In a case of misdiagnosed depression recounted in Newsweek, a writer received treatment for depression for years; during the last 10 years of her depression the symptoms worsened, resulting in multiple suicide attempts and psychiatric hospitalisations. When an MRI finally was performed, it showed the presence of a tumour. However, she was told by a neurologist that it was benign. After a worsening of symptoms, and upon the second opinion of another neurologist, the tumour was removed. After the surgery, she no longer suffered from depressive symptoms.

Autoimmune Disorders

  • Celiac disease:
    • This is an autoimmune disorder in which the body is unable to digest gluten which is found in various food grains, most notably wheat, and also rye and barley.
    • Current research has shown its neuropsychiatric symptoms may manifest without the gastrointestinal symptoms.
    • However, more recent studies have emphasized that a wider spectrum of neurologic syndromes may be the presenting extraintestinal manifestation of gluten sensitivity with or without intestinal pathology.
  • Lupus:
    • Systemic lupus erythematosus (SLE), is a chronic autoimmune connective tissue disease that can affect any part of the body.
    • Lupus can cause or worsen depression.

Bacterial-Viral-Parasitic Infection

  • Lyme disease:
    • This is a bacterial infection caused by Borrelia burgdorferi, a spirochete bacterium transmitted by the Deer tick (Ixodes scapularis).
    • Lyme disease is one of a group of diseases which have earned the name the “great imitator” for their propensity to mimic the symptoms of a wide variety of medical and neuropsychiatric disorders.
    • Lyme disease is an underdiagnosed illness, partially as a result of the complexity and unreliability of serologic testing.
    • Because of the rapid rise of Lyme borreliosis nationwide and the need for antibiotic treatment to prevent severe neurologic damage, mental health professionals need to be aware of its possible psychiatric presentations.
  • Syphilis:
    • The prevalence of which is on the rise, is another of the “great imitators”, which if left untreated can progress to neurosyphilis and affect the brain, can present with solely neuropsychiatric symptoms.
    • This case emphasises that neurosyphilis still has to be considered in the differential diagnosis within the context of psychiatric conditions and diseases.
    • Owing to current epidemiological data and difficulties in diagnosing syphilis, routine screening tests in the psychiatric field are necessary.
  • Neurocysticercosis (NCC):
    • This is an infection of the brain or spinal cord caused by the larval stage of the pork tapeworm, Taenia solium.
    • NCC is the most common helminthic (parasitic worm) infestation of the central nervous system worldwide. Humans develop cysticercosis when they ingest eggs of the pork tapeworm via contact with contaminated fecal matter or eating infected vegetables or undercooked pork.
    • While cysticercosis is endemic in Latin America, it is an emerging disease with increased prevalence in the United States.
    • The rate of depression in those with neurocysticercosis is higher than in the general population.
  • Toxoplasmosis:
    • This is an infection caused by Toxoplasma gondii an intracellular protozoan parasite. Humans can be infected in 3 different ways:
      • Ingestion of tissue cysts;
      • Ingestion of oocysts; or
      • In utero infection with tachyzoites.
    • One of the prime methods for transmission to humans is contact with the faeces of the host species, the domesticated cat.
    • Toxoplasma gondii infects approximately 30% of the world’s human population, but causes overt clinical symptoms in only a small segment of those infected.
    • Exposure to Toxoplasma gondii (seropositivity) without developing Toxoplasmosis has been proven to alter various characteristics of human behaviour as well as being a causative factor in some cases of depression, in addition, studies have linked seropositivity with an increased rate of suicide
  • West Nile virus (WNV):
    • This can cause encephalitis has been reported to be a causal factor in developing depression in 31% of those infected in a study conducted in Houston, Texas and reported to the Centre for Disease Control (CDC).
    • The primary vectors for disease transmission to humans are various species of mosquito.
    • WNV which is endemic to Southern Europe, Africa the Middle East and Asia was first identified in the United States in 1999.
    • Between 1999 and 2006, 20,000 cases of confirmed symptomatic WNV were reported in the US, with estimates of up to 1 million being infected.
    • WNV is now the most common cause of epidemic viral encephalitis in the United States, and it will likely remain an important cause of neurological disease for the foreseeable future.

Blood Disorders

  • Anaemia:
    • This is a decrease in normal number of red blood cells (RBCs) or less than the normal quantity of haemoglobin in the blood.
    • Depressive symptoms are associated with anaemia in a general population of older persons living in the community.

Chronic Fatigue Syndrome

Between 1 and 4 million Americans are believed to have chronic fatigue syndrome (CFS), yet only 50% have consulted a physician for symptoms of CFS. In addition individuals with CFS symptoms often have an undiagnosed medical or psychiatric disorder such as diabetes, thyroid disease or substance abuse. CFS, at one time considered to be psychosomatic in nature, is now considered to be a valid medical condition in which early diagnosis and treatment can aid in alleviating or completely resolving symptoms. While frequently misdiagnosed as depression, differences have been noted in rate of cerebral blood flow.

CFS is underdiagnosed in more than 80% of the people who have it; at the same time, it is often misdiagnosed as depression.

Dietary Disorders

  • Fructose malabsorption and lactose intolerance; deficient fructose transport by the duodenum, or by the deficiency of the enzyme, lactase in the mucosal lining, respectively.
  • As a result of this malabsorption the saccharides reach the colon and are digested by bacteria which convert them to short chain fatty acids, CO2, and H2.
  • Approximately 50% of those afflicted exhibit the physical signs of irritable bowel syndrome.
  • Fructose malabsorption may play a role in the development of depressed mood. Fructose malabsorption should be considered in patients with symptoms of major depression.
  • Fructose and sorbitol reduced diet in subjects with fructose malabsorption does not only reduce gastrointestinal symptoms but also improves mood and early signs of depression.

Endocrine System Disorders

Dysregulation of the endocrine system may present with various neuropsychiatric symptoms; irregularities in the hypothalamic-pituitary- adrenal (HPA) axis and the hypothalamic-pituitary-thyroid (HPT) axis have been shown in patients with primary depression.

HPT and HPA axes abnormalities observed in patients with depression:

  • HPT axes irregularities:
    • Alterations in thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH).
    • An abnormally high rate of antithyroid antibodies.
    • Elevated cerebrospinal fluid (CSF) TRH concentrations.
  • HPA axes irregularities:
    • Adrenocorticoid hypersecretion.
    • Enlarged pituitary and adrenal gland size (organomegaly).
    • Elevated corticotropin-releasing factor (CSF) concentrations.

Adrenal Gland

  • Addison’s disease:
    • Also known as chronic adrenal insufficiency, hypocortisolism, and hypocorticism) is a rare endocrine disorder wherein the adrenal glands, located above the kidneys, produce insufficient steroid hormones (glucocorticoids and often mineralocorticoids).
    • Addison’s disease presenting with psychiatric features in the early stage has the tendency to be overlooked and misdiagnosed.
  • Cushing’s Syndrome:
    • Also known as hypercortisolism, is an endocrine disorder characterised by an excess of cortisol.
    • In the absence of prescribed steroid medications, it is caused by a tumour on the pituitary or adrenal glands, or more rarely, an ectopic hormone-secreting tumour.
    • Depression is a common feature in diagnosed patients and it often improves with treatment.

Thyroid and Parathyroid Glands

  • Graves’ disease:
    • An autoimmune disease where the thyroid is overactive, resulting in hyperthyroidism and thyrotoxicosis.
  • Hashimoto’s thyroiditis:
    • Also known chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is gradually destroyed by a variety of cell and antibody mediated immune processes.
    • Hashimoto’s thyroiditis is associated with thyroid peroxidase and thyroglobulin autoantibodies
  • Hashitoxicosis.
  • Hypothyroidism.
  • Hyperthyroidism.
  • Hypoparathyroidism:
    • Can affect calcium homeostasis, supplementation of which has completely resolved cases of depression in which hypoparathyroidism is the sole causative factor.

Pituitary Tumours

Tumours of the pituitary gland are fairly common in the general population with estimates ranging as high as 25%. Most tumours are considered to be benign and are often an incidental finding discovered during autopsy or as of neuroimaging in which case they are dubbed “incidentalomas”. Even in benign cases, pituitary tumours can affect cognitive, behavioural and emotional changes. Pituitary microadenomas are smaller than 10 mm in diameter and are generally considered benign, yet the presence of a microadenoma has been positively identified as a risk factor for suicide.

Patients with pituitary disease are diagnosed and treated for depression and show little response to the treatment for depression.

Pancreas

  • Hypoglycemia:
    • An overproduction of insulin causes reduced blood levels of glucose.
    • In one study of patients recovering from acute lung injury in intensive care, those patients who developed hypoglycaemia while hospitalised showed an increased rate of depression.

Neurological

Central Nervous System Tumours

In addition to pituitary tumours, tumours in various locations in the central nervous system (CNS) may cause depressive symptoms and be misdiagnosed as depression.

Post Concussion Syndrome

Post-concussion syndrome (PCS), is a set of symptoms that a person may experience for weeks, months, or occasionally years after a concussion with a prevalence rate of 38-80% in mild traumatic brain injuries, it may also occur in moderate and severe cases of traumatic brain injury. A diagnosis may be made when symptoms resulting from concussion, depending on criteria, last for more than three to six months after the injury, in which case it is termed persistent post-concussive syndrome (PPCS). In a study of the prevalence of post concussion syndrome symptoms in patients with depression utilising the British Columbia Post-concussion Symptom Inventory: “Approximately 9 out of 10 patients with depression met liberal self-report criteria for a post-concussion syndrome and more than 5 out of 10 met conservative criteria for the diagnosis.” These self reported rates were significantly higher than those obtained in a scheduled clinical interview. Normal controls have exhibited symptoms of PCS as well as those seeking psychological services. There is considerable debate over the diagnosis of PCS in part because of the medico-legal and thus monetary ramifications of receiving the diagnosis.

Pseudobulbar Affect

Pseudobulbar affect (PBA) is an affective disinhibition syndrome that is largely unrecognised in clinical settings and thus often untreated due to ignorance of the clinical manifestations of the disorder; it may be misdiagnosed as depression. It often occurs secondary to various neurodegenerative diseases such as amyotrophic lateral sclerosis, and also can result from head trauma. PBA is characterised by involuntary and inappropriate outbursts of laughter and/or crying. PBA has a high prevalence rate with estimates of 1.5-2 million cases in the United States alone.

Multiple Sclerosis

Multiple sclerosis is a chronic demyelinating disease in which the myelin sheaths of cells in the brain and spinal cord are irreparably damaged. Symptoms of depression are very common in patients at all stages of the disease and may be exacerbated by medical treatments, notably interferon beta-1a.

Neurotoxicity

Various compounds have been shown to have neurotoxic effects many of which have been implicated as having a causal relationship in the development of depression.

Cigarette Smoking

There has been research which suggests a correlation between cigarette smoking and depression. The results of one recent study suggest that smoking cigarettes may have a direct causal effect on the development of depression. There have been various studies done showing a positive link between smoking, suicidal ideation and suicide attempts.

In a study conducted among nurses, those smoking between 1-24 cigarettes per day had twice the suicide risk; 25 cigarettes or more, 4 times the suicide risk, than those who had never smoked. In a study of 300,000 male US Army soldiers, a definitive link between suicide and smoking was observed with those smoking over a pack a day having twice the suicide rate of non-smokers.

Medication

Various medications have been suspected of having a causal relation in the development of depression; this has been classified as “organic mood syndrome”. Some classes of medication such as those used to treat hypertension, have been recognised for decades as having a definitive relationship with the development of depression.

Monitoring of those taking medications which have shown a relationship with depression is often indicated, as well as the necessity of factoring in the use of such medications in the diagnostic process.

  • Topical Tretinoin (Retin-A):
    • Derived from Vitamin A and used for various medical conditions such as in topical solutions used to treat acne vulgaris.
    • Although applied externally to the skin, it may enter the bloodstream and cross the blood brain barrier where it may have neurotoxic effects.
  • Interferons:
    • Proteins produced by the human body, three types have been identified alpha, beta and gamma.
    • Synthetic versions are utilised in various medications used to treat different medical conditions such as the use of interferon-alpha in cancer treatment and hepatitis C treatment.
    • All three classes of interferons may cause depression and suicidal ideation.

Chronic Exposure to Organophosphates

The neuropsychiatric effects of chronic organophosphate exposure include mood disorders, suicidal thinking and behaviour, cognitive impairment and chronic fatigue.

Neuropsychiatric

Bipolar Disorder

Bipolar disorder is frequently misdiagnosed as major depression, and is thus treated with antidepressants alone which is not only not efficacious it is often contraindicated as it may exacerbate hypomania, mania, or cycling between moods. There is ongoing debate about whether this should be classified as a separate disorder because individuals diagnosed with major depression often experience some hypomanic symptoms, indicating a continuum between the two.

Nutritional Deficiencies

Nutrition plays a key role in every facet of maintaining proper physical and psychological wellbeing. Insufficient or inadequate nutrition can have a profound effect on mental health. The emerging field of nutritional neuroscience explores the various connections between diet, neurological functioning and mental health.

  • Vitamin B6:
    • Pyridoxal phosphate (PLP), the active form of B6, is a cofactor in the dopamine serotonin pathway, a deficiency in vitamin B6 may cause depressive symptoms.
  • Folate (vitamin B9) – Vitamin B12 cobalamin:
    • Low blood plasma and particularly red cell folate and diminished levels of vitamin B12 have been found in patients with depressive disorders.
    • Research suggests that oral doses of both folic acid (800 μg/(mcg) daily) and vitamin B12 (1 mg daily) should be tried to improve treatment outcome in depression.
  • Long chain fatty acids:
    • Higher levels of omega-6 and lower levels of omega-3 fatty acids has been associated with depression and behavioural change.
  • Vitamin D deficiency is associated with depression

Sleep Disorders

  • Insomnia:
    • While the inability to fall asleep is often a symptom of depression, it can also in some instances serve as the trigger for developing a depressive disorder.
    • It can be transient, acute or chronic.
    • It can be a primary disorder or a co-morbid one.
  • Restless legs syndrome (RLS):
    • Also known as Wittmaack-Ekbom’s syndrome, is characterised by an irresistible urge to move one’s body to stop uncomfortable or odd sensations.
    • It most commonly affects the legs, but can also affect the arms or torso, and even phantom limbs.
    • Restless Leg syndrome has been associated with Major depressive disorder.
    • Adjusted odds ratio for diagnosis of major depressive disorder suggest a strong association between restless legs syndrome and major depressive disorder and/or panic disorder.
  • Sleep apnea:
    • This is a sleep disorder characterised by pauses in breathing during sleep.
    • Each episode, called an apnoea, lasts long enough for one or more breaths to be missed; such episodes occur repeatedly throughout the sleep cycle.
    • Undiagnosed sleep apnoea may cause or contribute to the severity of depression.
  • Circadian rhythm sleep disorders:
    • Few clinicians are aware, and often goes untreated or are treated inappropriately, as when misdiagnosed as either primary insomnia or as a psychiatric condition.

What is Depression (Mood)?

Published on by Andrew Marshall68 Comments

Introduction

Depression is a state of low mood and aversion to activity. It can affect a person’s thoughts, behaviour, motivation, feelings, and sense of well-being.

The core symptom of depression is said to be anhedonia, which refers to loss of interest or a loss of feeling of pleasure in certain activities that usually bring joy to people. Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments.

It may feature sadness, difficulty in thinking and concentration and a significant increase or decrease in appetite and time spent sleeping. People experiencing depression may have feelings of dejection, hopelessness and, sometimes, suicidal thoughts. It can either be short term or long term.

Epidemiology

Depression is the leading cause of disability worldwide, the United Nations (UN) health agency reported, estimating that it affects more than 300 million people worldwide – the majority of them women, young people and the elderly. An estimated 4.4% of the global population suffers from depression, according to a report released by the UN World Health Organisation (WHO), which shows an 18 percent increase in the number of people living with depression between 2005 and 2015.

Global Health

Depression is a major mental-health cause of disease burden. Its consequences further lead to significant burden in public health, including a higher risk of dementia, premature mortality arising from physical disorders, and maternal depression impacts on child growth and development. Approximately 76% to 85% of depressed people in low- and middle-income countries do not receive treatment;[48] barriers to treatment include: inaccurate assessment, lack of trained health-care providers, social stigma and lack of resources.

The WHO has constructed guidelines – known as The Mental Health Gap Action Programme (mhGAP) – aiming to increase services for people with mental, neurological and substance-use disorders. Depression is listed as one of conditions prioritised by the programme. Trials conducted show possibilities for the implementation of the programme in low-resource primary-care settings dependent on primary-care practitioners and lay health-workers. Examples of mhGAP-endorsed therapies targeting depression include Group Interpersonal Therapy as group treatment for depression and “Thinking Health”, which utilises cognitive behavioural therapy to tackle perinatal depression. Furthermore, effective screening in primary care is crucial for the access of treatments. The mhGAP programme adopted its approach of improving detection rates of depression by training general practitioners. However, there is still weak evidence supporting this training.

History of the Concept

The Greco-Roman world used the tradition of the four humours to attempt to systematise sadness as “melancholia”.

The well-established idea of melancholy fell out of scientific favour in the 19th century.

Emil Kraepelin tried to give a scientific account of depression (German: das manisch-depressive Irresein) in 1896.

Factors

Life Events

Adversity in childhood, such as bereavement, neglect, mental abuse, physical abuse, sexual abuse, or unequal parental treatment of siblings can contribute to depression in adulthood. Childhood physical or sexual abuse in particular significantly correlates with the likelihood of experiencing depression over the victim’s lifetime.

Life events and changes that may influence depressed moods include (but are not limited to): childbirth, menopause, financial difficulties, unemployment, stress (such as from work, education, family, living conditions etc.), a medical diagnosis (cancer, HIV, etc.), bullying, loss of a loved one, natural disasters, social isolation, rape, relationship troubles, jealousy, separation, or catastrophic injury. Adolescents may be especially prone to experiencing a depressed mood following social rejection, peer pressure, or bullying.

Personality

Changes in personality or in one’s social environment can affect levels of depression. High scores on the personality domain neuroticism make the development of depressive symptoms as well as all kinds of depression diagnoses more likely, and depression is associated with low extraversion. Other personality indicators could be: temporary but rapid mood changes, short term hopelessness, loss of interest in activities that used to be of a part of one’s life, sleep disruption, withdrawal from previous social life, appetite changes, and difficulty concentrating.

Medical Treatment

Depression may also be the result of healthcare, such as with medication induced depression. Therapies associated with depression include interferon therapy, beta-blockers, isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics, and hormonal agents such as gonadotropin-releasing hormone agonist.

Substance-Induced

Several drugs of abuse can cause or exacerbate depression, whether in intoxication, withdrawal, and from chronic use. These include alcohol, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs such as heroin), stimulants (such as cocaine and amphetamines), hallucinogens, and inhalants.

Non-Psychiatric Illnesses

Refer to Differential Diagnoses of Depression.

Depressed mood can be the result of a number of infectious diseases, nutritional deficiencies, neurological conditions, and physiological problems, including hypoandrogenism (in men), Addison’s disease, Cushing’s syndrome, hypothyroidism, hyperparathyroidism, Lyme disease, multiple sclerosis, Parkinson’s disease, chronic pain, stroke, diabetes, and cancer.

Psychiatric Syndromes

Refer to Depressive Mood Disorders.

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood disorders are a group of disorders considered to be primary disturbances of mood. These include major depressive disorder (MDD; commonly called major depression or clinical depression) where a person has at least two weeks of depressed mood or a loss of interest or pleasure in nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which do not meet the severity of a major depressive episode.

Another mood disorder, bipolar disorder, features one or more episodes of abnormally elevated mood, cognition, and energy levels, but may also involve one or more episodes of depression. When the course of depressive episodes follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be described as a seasonal affective disorder.

Outside the mood disorders: borderline personality disorder often features an extremely intense depressive mood; adjustment disorder with depressed mood is a mood disturbance appearing as a psychological response to an identifiable event or stressor, in which the resulting emotional or behavioural symptoms are significant but do not meet the criteria for a major depressive episode; and posttraumatic stress disorder, a mental disorder that sometimes follows trauma, is commonly accompanied by depressed mood.

Historical Legacy

Refer to Dispossession, Oppression and Depression.

Researchers have begun to conceptualise ways in which the historical legacies of racism and colonialism may create depressive conditions.

Measures of Depression

Measures of depression as an emotional disorder include (but are not limited to) the Beck Depression Inventory-11 and the 9-item depression scale in the Patient Health Questionnaire.

Both of these measures are psychological tests that ask personal questions of the participant, and have mostly been used to measure the severity of depression. The Beck Depression Inventory (BDI) is a self-report scale that helps a therapist identify the patterns of depression symptoms and monitor recovery. The responses on this scale can be discussed in therapy to devise interventions for the most distressing symptoms of depression. Several studies, however, have used these measures to also determine healthy individuals who are not suffering from depression as a mental disorder, but as an occasional mood disorder. This is substantiated by the fact that depression as an emotional disorder displays similar symptoms to minimal depression and low levels of mental disorders such as major depressive disorder; therefore, researchers were able to use the same measure interchangeably. In terms of the scale, participants scoring between 0-13 and 0-4 respectively were considered healthy individuals.

Another measure of depressed mood would be the IWP Multi-affect Indicator. It is a psychological test that indicates various emotions, such as enthusiasm and depression, and asks for the degree of the emotions that the participants have felt in the past week. There are studies that have used lesser items from the IWP Multi-affect Indicator which was then scaled down to daily levels to measure the daily levels of depression as an emotional disorder.

Connections

Alcoholism

Alcohol can be a depressant which slows down some regions of the brain, like the prefrontal and temporal cortex, negatively affecting rationality and memory. It also lowers the level of serotonin in the brain, which could potentially lead to higher chances of depressive mood.

The connection between the amount of alcohol intake, level of depressed mood, and how it affects the risks of experiencing consequences from alcoholism, were studied in a research done on college students. The study used 4 latent, distinct profiles of different alcohol intake and level of depression; Mild or Moderate Depression, and Heavy or Severe Drinkers. Other indicators consisting of social factors and individual behaviours were also taken into consideration in the research. Results showed that the level of depression as an emotion negatively affected the amount of risky behaviour and consequence from drinking, while having an inverse relationship with protective behavioural strategies, which are behavioural actions taken by oneself for protection from the relative harm of alcohol intake. Having an elevated level of depressed mood does therefore lead to greater consequences from drinking.

Bullying

Social abuse, such as bullying, are defined as actions of singling out and causing harm on vulnerable individuals. In order to capture a day-to-day observation of the relationship between the damaging effects of social abuse, the victim’s mental health and depressive mood, a study was conducted on whether individuals would have a higher level of depressed mood when exposed to daily acts of negative behaviour. The result concluded that being exposed daily to abusive behaviours such as bullying has a positive relationship to depressed mood on the same day.

The study has also gone beyond to compare the level of depressive mood between the victims and non-victims of the daily bullying. Although victims were predicted to have a higher level of depressive mood, the results have shown otherwise that exposure to negative acts has led to similar levels of depressive mood, regardless of the victim status. The results therefore have concluded that bystanders and non-victims feel as equally depressed as the victim when being exposed to acts such as social abuse.

Creative Thinking

Divergent thinking is defined as a thought process that generates creativity in ideas by exploring many possible solutions. Having a depressed mood will significantly reduce the possibility of divergent thinking, as it reduces the fluency, variety and the extent of originality of the possible ideas generated.

However, some depressive mood disorders might have a positive effect for creativity. Upon identifying several studies and analysing data involving individuals with high levels of creativity, Christa Taylor was able to conclude that there is a clear positive relationship between creativity and depressive mood. A possible reason is that having a low mood could lead to new ways of perceiving and learning from the world, but it is unable to account for certain depressive disorders. The direct relationship between creativity and depression remains unclear, but the research conducted on this correlation has shed light that individuals who are struggling with a depressive disorder may be having even higher levels of creativity than a control group, and would be a close topic to monitor depending on the future trends of how creativity will be perceived and demanded.

Stress Management Techniques

There are empirical evidences of a connection between the type of stress management techniques and the level of daily depressive mood.

Problem-focused coping leads to lower level of depression. Focusing on the problem allows for the subjects to view the situation in an objective way, evaluating the severity of the threat in an unbiased way, thus it lowers the probability of having depressive responses. On the other hand, emotion-focused coping promotes a depressed mood in stressful situations. The person has been contaminated with too much irrelevant information and loses focus on the options for resolving the problem. They fail to consider the potential consequences and choose the option that minimises stress and maximises well-being.

Management

Depressed mood may not require professional treatment, and may be a normal temporary reaction to life events, a symptom of some medical condition, or a side effect of some drugs or medical treatments. A prolonged depressed mood, especially in combination with other symptoms, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment. The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicated that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. Physical activity can have a protective effect against the emergence of depression.

Physical activity can also decrease depressive symptoms due to the release of neurotrophic proteins in the brain that can help to rebuild the hippocampus that may be reduced due to depression. Also yoga could be considered an ancillary treatment option for patients with depressive disorders and individuals with elevated levels of depression.

Reminiscence of old and fond memories is another alternative form of treatment, especially for the elderly who have lived longer and have more experiences in life. It is a method that causes a person to recollect memories of their own life, leading to a process of self-recognition and identifying familiar stimuli. By maintaining one’s personal past and identity, it is a technique that stimulates people to view their lives in a more objective and balanced way, causing them to pay attention to positive information in their life stories, which would successfully reduce depressive mood levels.

Self-help books are a growing form of treatment for peoples physiological distress. There may be a possible connection between consumers of unguided self-help books and higher levels of stress and depressive symptoms. Researchers took many factors into consideration to find a difference in consumers and non-consumers of self-help books. The study recruited 32 people between the ages of 18 and 65; 18 consumers and 14 non-consumers, in both groups 75% of them were female. Then they broke the consumers into 11 who preferred problem-focused and 7 preferred growth-oriented. Those groups were tested for many things including cortisol levels, depressive symptomatology, and stress reactivity levels. There were no large differences between consumers of self-help books and non-consumers when it comes to diurnal cortisol level, there was a large difference in depressive symptomatology with consumers having a higher mean score. The growth-oriented group has higher stress reactivity levels than the problem-focused group. However, the problem-focused group shows higher depressive symptomatology.