Lecture 10
      
                              Mood Disorders: Etiology
                                Psycho-Social Factors
      
      Lecture Outline
      
      I.   Introduction
      II.  Vulnerability
           A. Personality
           B. Upbringing
           C. Learning
           D. Social Factors
      III. Provoking Factors
      IV.  Mediating Factors
           A. Cognitive 
                1. Appraisal
                2. Memory
                3. Network Theory
                4. Self-Complexity
           B. Social Support
      V.   Conclusion
      
                     -------------------------------------------
      
      I. Introduction
           In this lecture and the next, we will examine possible etiological
      factors for the Mood Disorders.  Our focus today will be on Psycho-
      Social factors; the focus next lecture will be on Biological factors. 
      Our emphasis in these lectures will tend to be  on depression.
           Interestingly, you will note a significant overlap with Mood
      Disorder etiology and Anxiety Disorder etiology.  Today we will examine
      familiar factors such as cognitions, learning, and network theories.  In
      fact, there is a long-standing debate over whether anxiety and
      depression as diagnostic categories should be distinguished (Roth &
      Mountjoy, 1982).  Studies have shown a certain degree of overlap between
      the two (Barlow, DiNardo, Vermilyea, et al., 1986;  Foa & Foa, 1982;
      Klerman, Hirschfeld, Andreasen, et al., 1987).  For example:
      physiological similarities, etiological similarities, and the tendency
      for the two disorders to co-occur.  The percentage of persons with
      Anxiety Disorders who also have a Mood Disorder (Major Depression or
      Dysthymia) are as follows:
      
      agoraphobia          39%
      social phobia        19%
      panic disorder       35%
      generalized anxiety  17%
      obsessive-compulsive 67%
           (Barlow, et al., 1986)
      
      Such overlap is important:  1. Clinically: should the disorders be
      treated as distinct "entities" or should they be seen as coexisting
      problems within a more general overall pattern of psychopathology?
      Barlow, et al., 1986)  2. Theoretically:  what does this observed
      overlap tell us about the nature of these disorders?
           As we turn to an examination of etiological factors, we will be
      looking at factors that make a person vulnerable to Mood Disorder, that
      actually provoke a disorder, and that mediate the course of the
      disorder.  The relationship between these factors is potentially
      complex, probably operating as a system of more or less continuously
      ongoing feedback loops (cf. Ohman, 1987).  As such, the distinction
      between them is somewhat arbitrary: for example, a particular mediating
      factor could also be seen as a vulnerability factor in other situations.
      
      II. Vulnerability
           Numerous factors have been identified that may predispose someone
      to Mood Disorder.  These factors, while not directly causing depression
      or other disorders, reduce a person's psychological resources (eg: self
      esteem) making it more difficult for the person to cope with problems
      when they do arise.
      A. Personality:  It has been suggested that certain personality
      characteristics predispose one to abnormal affect.  Thus, the
      affect per se is not the problem; the major problem is a lifelong
      personality disturbance that, on occasion, breaks down into, say,
      Major Depression (Winokur, 1985).  For example:  People who tend to
      be introspective, introverted, and dependent are more likely to be
      depressed (Watson & Clark, 1984; Akiskal, Hirschfeld & Yerevanian,
      1983).  These are long-standing personality characteristics, and it
      is these characteristics which are the primary problem; the Mood
      Disorder is the secondary problem - a symptom, if you will
      (Winokur, 1985).  
           The DSM-III-R diagnostic system allows one to distinguish
      these enduring characteristics from particular episodes of a
      disorder:  Axis I for episodes (relatively transitory or situation-
      dependent responses), Axis II for relatively enduring personality
      characteristics.  Eg: a person's anxiety towards a particular
      stimulus, vs. "he's an extroverted person - always so outgoing!". 
           An interesting alternative conceptualization has been offered
      concerning the relationship between personality and Mood Disorder
      (Akiskal, 1984):  Rather than personality being a cause of or
      setting up a predisposition for Mood Disorder, some personalities
      may be a manifestation of the Mood Disorder.  Personality is thus
      just another symptom of the Mood Disorder, or an alternative
      manifestation of the disorder.
      
      B. Upbringing:  Past experiences in one's life can have a
      significant impact on one's current situation.  Research has shown
      that various family characteristics are associated with Mood
      Disorders.  For example, some of the things which are associated
      with vulnerability to depression include:
      
           -parents who had their own psychological problems (Miller,     
           1981)
           -an alcoholic family member (Winokur, 1985)
           -loss of a parent or other important person (Akiskal &         
           McKinney, 1975)
           
           An interesting area of research involves studies with animals.
      Animals, such as monkeys, that are socially isolated during infancy
      (ie: no contact with mother and/or with peers) go on to develop
      behavior patterns remarkably similar to symptoms found in humans
      who are depressed.  Eg: despair, crying, withdrawal, appetite loss,
      sleep disturbance, and agitation.  Similar findings have been
      observed in a wide range of animals, including dogs, parrots, and
      geese (Colotla, 1979).  Some people argue that animals are not just
      uncomplicated humans, and so question the usefulness of these
      findings.  However, studies that have used humans have found
      similar results.  For example, babies who are orphaned and left in
      institutions where they receive limited contact with others show
      significant behavioral and psychological deficits, and even have a
      higher mortality rate than normal.  Other studies have demonstrated
      that infants separated from their families exhibit significant
      despair and detachment.  Such findings indicate the importance of
      early attachment for later mental health.  Not coincidentally,
      hospitals are now letting mothers have immediate and prolonged
      contact with the newborn to facilitate this attachment process.
      
      C. Learning:  What we learn about ourselves, the world and our
      ability to control these things can set us up to experience
      depression and other negative affect in subsequent situations.  A
      model of depression which looks at some of these variables and that
      has gained much attention is Seligman's Learned Helplessness model
      (Seligman, 1975; Abramson, Seligman & Teasdale, 1978).  Like some
      of the social deprivation studies, this model has its roots in
      animal experiments.  Here's a typical experiment:
      One group of dogs is restrained in harnesses, where they learn
      to turn off (escape) a painful electrical shock by pressing a
      bar with their nose.  Another  group of dogs is similarly
      restrained and also receives shocks.  However, the responses
      of these dogs have no effect, they are unable to escape the
      shocks.  A third group (the control group) is restrained, but
      experiences no shocks.  24 hours later, the dogs are placed in
      a cage that has an electric grid on the floor which delivers a
      shock to the dogs feet.  The dogs who had learned to escape
      and the dogs in the control group readily learned to jump over
      a low wall to escape the shock.  The dogs from the other
      group, however, completely failed to learn: they lay down and
      passively accepted the shocks (Colotla, 1979).  
      What has happened here is these dogs learned to be helpless. They
      have learned that their responses have no effect on their
      environment or their experiences, and that their responses are
      independent of reinforcement (in this case, escape).  Interest-
      ingly, many of the behaviors of these dogs parallel symptoms of
      depression (see Handout 10-1).  Thus, it is thought that certain
      forms of depression may be due to a person having learned to be
      helpless.  When they are confronted with difficulties and stress,
      they become depressed because they believe they have no control
      over the situation.   In other words, their belief in their own
      helplessness predisposes them to develop depression.  
           If you look at Handout 10-1, you will notice there are
      symptoms that depression and anxiety share.  Here we see an example
      of the overlap between depression and anxiety.
           The implications:  Children should experience challenging and
      difficult situations so they can learn that their responses do have
      an effect.  A child who is overprotected, or who grows up in a
      chaotic or abusive environment will learn that his or her actions
      have no power to bring about good things.  They have learned to be
      helpless (Colotla, 1979).
      
      D. Social factors:  Women are more frequently diagnosed with Mood
      Disorder, especially with some forms of depression.  Why might this
      be?  There is growing evidence that certain social factors may
      account for this phenomenon.  Such a "sociological" approach to
      psychological disorder suggests that it may be as important for
      treatment to pay attention to a person's environment as it is his
      or her internal psychological processes.
           A variable that is commonly found to be associated with Mood
      Disorder is the lack of an intimate, confiding relationship
      (Campbell, Cope & Teasdale, 1983).  Other factors that have been
      identified include the loss of a parent or sibling by death or
      separation before the age of 11, the presence of three or more
      children aged 14 or under at home, and unemployment (Brown &
      Harris, 1978; Campbell, et al., 1983).  Not all of these factors,
      however, are unique to women's depression (eg: Phifer & Murrell,
      1986) - loss, limited social support, unemployment are associated
      with men's depression as well.
           An alternative sociological explanation identifies sexism as
      the key variable for why women are more often diagnosed with Mood
      Disorder.  Because of the way our culture defines gender roles,
      women are taught to be passive, unassertive, and dependent,
      behaviors which can be seen as a form of learned helplessness.  In
      contrast, men are taught to be assertive, competent, and in
      control.  It has been suggested that these socialization
      differences predispose women to be depressed when under stress,
      while men are more likely to become alcoholic (Weissman & Klerman,
      1977).  
           In addition, women in general have limited access to power and
      resources (see, for example, Chesler, 1972).  They have lower
      social and economic status, they are discriminated against, they
      are physically more vulnerable to rapists, etc.  The roles they do
      have are restrictive - there were traditionally few alternatives to
      "wife/mother".  Betty Friedan, in her famous book The Feminine
      Mystique (1963), attempted to expose the myth that all women are
      fulfilled as wife and mother solely through the emotions arising
      within the context of the marriage.  To make matters worse, an
      despite the fact that there are many woman today who work and have
      careers, women who act assertively and independently are still
      often labelled odd, bitchy, or even mentally ill.  But if they
      stick to female stereotypic roles, they set themselves up for
      depression, anxiety and other problems (Kaplan, 1983). 
      
      III. Provoking Factors
           Although someone may be predisposed to Mood Disorder, this does not
      mean he or she will necessarily develop a disorder.  One of the most
      commonly identified psycho-social "provoking agents" (Brown & Harris's
      [1978] term) is stress (Blaney, 1985; Brown & Harris, 1978; Dohrenwend &
      Dohrenwend, 1974; Hammen, Mayol, deMayo & Marks, 1986).  That is, when
      confronted with threatening situations or negative life events, a person
      who is already vulnerable to depression, is more likely to develop a
      disorder.  (This is the diathesis-stress model we have discussed).
           Examples of stress that may provoke a Mood Disorder include:
      
      death of a friend, family member, etc
      illness/accident 
      important news, decisions, disappointments
      burglary
      illness/accident to others
      role or job change
      residence change
           (Brown & Harris, 1978)
      
           It's important to note that two classes of depression are often
      identified: those which are in response to a stressful event, and those
      which seem to be internally caused, perhaps biologically (Akiskal,
      1983).  Not all depression neatly fits into the diathesis-stress model
      (but more on this next lecture).
      
      IV. Mediating factors
           
      A.  Cognitive processes
           The actual course of a disorder depends on numerous factors. 
      Although two people may be given the same diagnosis, the actual
      experience will be different for the two individuals.  This is
      because there are many factors that mediate, or shape and alter,
      the way a disorder manifests itself in any particular person. 
      Perhaps the most well researched psycho-social mediating factor is
      our cognitions and cognitive processes - our thoughts, beliefs, and
      memories.  These factors have been shown to have a significant
      impact on things like the severity and duration of a disorder.  
      
      1. Appraisal:  As described in our discussion of the Anxiety
      Disorders, one's belief, interpretation, or appraisal of a
      situation can have a marked influence on exactly what you
      experience.  Some theorists suggest that how one appraises his
      or her experience will determine the nature of the emotional
      reaction (eg: Lazarus, 1984).  This particular theory has been
      criticized, as we noted before.  For example, if this theory is
      correct, how could an infant (too young to know labels and other
      words used in an appraisal process) experience any emotions!
      (Strongman, 1987).  Nevertheless, the process of appraisal does
      seem to be important, especially in how a person perceives an
      event (stressful or not stressful) and how he or she responds to
      the event.  The emotional impact of an event is very much
      determined by the person's assessment of the event's severity
      and the actions available to him or herself.  This will depend
      in large part on his or her beliefs/assessment regarding the
      predictability and controllability of the situation, and his or
      her perception of self-efficacy (the degree to which one
      believes one can be successful in a situation) (Ohman, 1987).
      
      2. Memory - A reconstructive process:  Perhaps the most widely
      researched area is the relationship between memory and affect. 
      Our memories in general are biased in numerous ways.  There is a
      lot of evidence that we selectively remember our past: we
      remember that which fits with our current conception of ourself
      and that which justifies our current attitudes and judgments
      (eg: Conway & Ross, 1984; Greenwald, 1980).  Not only do people
      selectively recall, they also distort or reconstruct their past. 
      If I believe I'm a happy person, then I'll not only selectively
      remember those times when I was happy, but I'll also remember
      times of being happy that never occurred!  
           Why might people do this?  One possible explanation: The
      guarantee of continuity in ones life - inconsistencies are
      smoothed out.  (Recall our earlier discussion of self-fulfilling
      prophecies).  Selective memory insures confirmation and
      maintenance of a stable self-concept, even when that self-
      concept is negative (Blaney, 1986).  People are able to maintain
      a "thematic unity" (Fischoff, 1980) or consistent sense of self
      - a very important thing.  Without it, life would be a scary,
      unpredictable place indeed.  
           Similar findings can be seen when we look at the effect of
      emotion on memory.  For example, depressed people tend to
      selectively remember depressing events and in general think
      thoughts that are consistent with their mood: what we think
      about tends to be congruent with our current mood (eg: Beck,
      1967; Blaney, 1986; Bower, 1981; Gotlib & Cane, 1987; Diener,
      Larsen & Emmons, 1984; McDowall, 1984).  While on the one hand,
      such biased thought and memory processes are necessary if we are
      to have a stable self-concept, taken to an extreme, such as in a
      Mood Disorder, they can have devastating effects:  In a recent
      study (Williams & Broadbent, 1986) it was demonstrated that
      people who attempt suicide are much slower at retrieving
      positive memories than are nondepressed people.  In general,
      then, what is at risk is the development of a viscous circle:
      "depression ---> negative memories and cognitions --->
      depression, and so on"
      
      3. Network Theory:  Network models (see Lecture 7) of memory are
      typically proposed to account for these memory bias effects (eg:
      Bower, 1981).  The basic, terribly oversimplified, idea:  Memory
      is a network of interrelated "nodes" - there's a node for SELF,
      for MOM, for WORK, for HOME, for SADNESS, and so on.  If one
      node is activated, say "depressed memory 1", then those nodes
      that are more closely related to node 1 are more likely to be
      available to our consciousness - it will be easier to remember
      and think about those things ("depressed memory 2 through 15"). 
      Imagine shaking a leaf on a tree - those leaves that are nearest
      to that first leaf are more likely to also move than are the
      leaves on the other side of the tree.  So, if you think a sad
      thought, you increase the probability that you will think
      another sad thought, and so.  
      
      Implications:  Changing how someone feels is much more than
      changing one thing - the entire network will be altered to one
      degree or another.  Thus, changing how someone feels is not an
      easy process.  This is doubly true when we recall the over-
      arching motivation that we all have for consistency in our self-
      image (a major part of the network).
      
      4.  Self-Complexity:  An interesting outgrowth of these ideas is
      the theory that one's reaction to stress is mediated by the
      richness of one's self-concept (Linville, 1987).  In this
      theory, it is argued that the more qualities one uses in
      representing one's self the more able one is at avoiding or
      coping with depression and illness.  So, if a person sees him or
      herself in a rather limited way (just a housewife, or simply a
      quiet person) he or she is more prone to depression than a
      person who describes him or herself in a rich manner and has
      numerous distinct sets of qualities.  Such a theory makes
      intuitive sense:  If you have a rather limited conception of
      your self, then if one part of your life meets with stress, then
      there really isn't much more of you to deal with the stress. 
      If, on the other hand, you have numerous distinct qualities,
      then threat to one or more doesn't mean a threat to your entire
      self.  Perhaps the message is:  be more than just a student, or
      just a housewife, or just a sports person...take on various
      roles.  And of those roles you take on, the richer and more
      complex they are the more you will be able to face stress.  A
      simple, one-sided structure is much easier to tip over, than a
      building with a firm foundation, sophisticated internal
      structure, and braces and flexibility for possible earth-quakes.
      
      B.  Social Support
           A final psycho-social mediating factor we need to examine is
      the role of one's social environment on the course of a disorder. 
      That is, the role of Social Support.
           The presence of others in a person's life who will support him
      or her during times of stress has been identified as a key buffer
      against the unhealthy consequences of stress (Gottlieb, 1981,
      Linville, 1987).  When someone must rely solely on their own
      resources, they are much less likely to cope effectively.  By
      resources, we mean things like giving advice, socializing, praise,
      tangible assistance (eg: money), sharing tasks, and emotional
      support.  
           Limited social support has been associated with numerous
      problems, such as depression, schizophrenia, and physical illness.
      
      V. Conclusion
           As you've seen, there is complex set of psycho-social variables
      that have an impact on the genesis and course of Mood Disorder.  These
      include personality, early experiences, cognitive processes, and social
      factors.  In the next lecture, we will go "under the skin" and examine
      some of the biological aspects of the Mood Disorders.
      
      
      
        HANDOUT 10-1 Features Common to Learned Helplessness and Depression Learned Helplessness Depression -------------------------------------------------------------- passivity passivity difficulty learning that negative cognitive set responses produce relief (expecting the worst) lack of aggression introjected hostility (anger turned inward) weight loss, appetite weight loss, appetite loss, social and sexual loss, social and sexual problems problems ulcers and stress ulcers and stress Cause learning that responding belief that responding and reinforcement are is useless independent (Adapted from Seligman, 1975)
          Some Possible Features of Anxiety --------------------------------- negative cognitive set, feeling hopeless passivity, nonassertion appetite loss, nausea, diarrhea sexual problems ulcers and other physical symptoms (APA, 1987; Carson, et.al, 1988)