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
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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
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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)