Table of Contents
| Preface | |
| 1 | Introduction to Effective Treatment Planning | 1 |
| 2 | Mental Disorders in Infants, Children, and Adolescents | 50 |
| 3 | Situationally-Precipitated Conditions and Disorders | 126 |
| 4 | Mood Disorders | 150 |
| 5 | Anxiety Disorders | 190 |
| 6 | Disorders of Behavior and Impulse Control | 238 |
| 7 | Disorders in Which Physical and Psychological Factors Combine | 304 |
| 8 | Personality Disorders | 328 |
| 9 | Disorders Involving Impairment in Awareness of Reality: Psychotic and Dissociative Disorders | 386 |
| 10 | The Future of Diagnosis and Treatment Planning | 420 |
| References | 427 |
| The Author | 475 |
| Name Index | 477 |
| Subject Index | 487 |
Read an Excerpt
Mood Disorders
Karen C., a thirty-year-old married African American woman, was brought to a therapist by her mother. Karen reported feeling severe depression and hopelessness. She was barely able to care for her five-year-old child or her home, and she had not gone to her part-time job as an aide at her child's school for over two weeks. Her accompanying symptoms included significant weight gain, excessive fatigue and sleeping, and severe guilt.
Karen and her husband had been married for eight years. Karen's husband was in the military, which meant that he was frequently away from home. Karen had always found his absences difficult and had encouraged her husband to leave the service. He complained that she was too dependent on him, and he urged her to develop her own interests.
Apart from her work at their child's school, Karen had few outside activities, and she had few supports other than her mother, who had been widowed when Karen was a child (the only one). Her mother had not remarried. She told Karen that she had been so devastated by the death of Karen's father that she would never get involved with another man. The mother seemed to have experienced episodes of severe depression, although she had never received treatment for them.
Conflict had been increasing in Karen's marriage and had reached a peak about three weeks before, when Karen's husband had left for an overseas tour of duty. Karen was fearful that he would become involved with another woman and never return home, even though her husband's behavior gave her no justification for her concerns. She berated herself for not being a good wife and stated that life was not worth living without her husband. The only bright spot for Karen over the past few weeks had come when she received a letter from him. She read it again and again and did feel better for a few hours, but her depression soon returned.
Karen's developmental history was unremarkable except for her having been ill quite often. After her graduation from high school she had worked as a secretary and lived with her mother until her marriage. She had dated little before her marriage, but she did remember having felt very depressed at least once before in her life, when a young man she had dated a few times became engaged to another woman.
Karen is suffering from a severe depression that has impaired her level of functioning. A precipitant can be identified for Karen's current episode of depression, but her symptoms do not suggest either an Adjustment Disorder or a Condition: her reactions show too much dysfunction to be reflective of either one, and the precipitant-her husband's departure for an overseas tour of duty-is less disruptive than the sort of precipitant that usually would spark a Situationally-Precipitated Disorder. Instead, Karen is experiencing another prevalent condition, a Mood Disorder, characterized by depression. This chapter provides information on the diagnosis and treatment of the various types of Mood Disorders-Major Depressive Disorder, Dysthymic Disorder, Depressive Disorder Not Otherwise Specified, Bipolar I Disorder, Bipolar II Disorder, and Cyclothymic Disorder, all of which typically include significant depression. Although three of these disorders (Bipolar I and II and Cyclothymic Disorder) also include inordinately elevated moods (mania or hypomania), the focus of this section of the chapter will be on depression, the common ingredient of all these disorders.
OVERVIEW OF MOOD DISORDERS
Description of the Disorders
Primary Symptoms
Primary symptoms of depression are feelings of discouragement and hopelessness, a dysphoric mood, a loss of energy, and a sense of worthlessness and excessive guilt. Physiological symptoms are common and typically include changes in appetite and sleep, with insomnia and loss of appetite the most common. A physical examination sometimes is indicated to ascertain whether medical treatment is needed for the specific physical complaints.
Some sources (for example, Atwood & Chester, 1987) distinguish between exogenous or reactive depression, linked to an external event or situation, and endogenous, melancholic, or biochemical depression, apparently having a physiological basis. Endogenous depressions are less common than reactive ones. Severe and reversed physiological symptoms (increased appetite, early-morning awakening rather than insomnia) are more common in endogenous depression than in reactive depression. Melancholia, or an absence of pleasure or interest, typically accompanies this form of depression. Endogenous depressions are also far more likely than reactive ones to involve delusions or hallucinations, psychomotor retardation or agitation, extreme guilt, and worsening in the morning (Gotlib & Colby, 1987). Depressions beginning during the postpartum period (within four weeks of giving birth) or the involutional period (late in life) are more likely to be endogenous (Atwood & Chester, 1987).
Common Secondary or Underlying Symptoms Suicidal ideation is a common symptom in depression, one that obviously requires attention. People suffering from depression may be in such severe emotional pain that they feel as if their symptoms will never end, and suicide may seem to be the only escape. Records reveal approximately 25,000 suicides and 200,000 suicide attempts annually in the United States; 80 percent of these seem linked to depression (Gotlib & Colby, 1987). Suicidal ideation, like depression, seems to have a genetic or familial component. Roy (1983) studied 243 people with a family history of suicide and found that 48.6 percent of them had also attempted suicide and that 84.4 percent had experienced a depressive episode. Therefore, depressed clients should be asked about suicidal thinking. If suicidal ideation is present, information should be gathered about any plans that have been formulated, as well as about the availability of means. Preventing suicide must be a first priority, and if a threat of suicide is present, consideration should be given to hospitalization, to notifying friends and relatives (ideally with the client's consent), and to developing a written agreement with the client that is designed to ensure safety and provide alternatives to self-injury.
Most people with Mood Disorders are not psychotic. They do not have hallucinations or delusions, although their reality testing is likely to be impaired. They generally will not manifest true paranoia but are likely to feel bereft of supports and to feel that even those who care about them are undermining them. The following are some other secondary symptoms common in depression (Gotlib & Colby, 1987):
- Emotional symptoms: anxiety, guilt, anger and hostility, irritability and agitation, social and marital distress
- Behavioral symptoms: crying, neglect of appearance, withdrawal, dependence, lethargy, reduced activity, poor social skills, psychomotor retardation or agitation
- Attitudinal symptoms: pessimism, helplessness, thoughts of death or suicide, low self-esteem
- Cognitive symptoms: reduced concentration, indecisiveness, distorted thinking
- Physiological symptoms: sleep disturbances, loss of appetite, decreased sexual interest, gastrointestinal and menstrual difficulties, muscle pains, headaches
Typical Onset, Course, and Duration of the Disorder
A first episode of depression generally occurs during young or middle adulthood but may occur at any age, as can a recurrence. The initial episode of depression tends to occur earlier in women than in men, who are more likely to have an initial episode in midlife. Depression may also begin in childhood. In this case, it is often typified by agitation rather than by overt sadness. Depression may be primary or secondary to a preexisting chronic mental or physical disorder (such as Alcohol Dependence). Depression often coexists with a Personality Disorder (most often Borderline, Histrionic, or Dependent Personality Disorders) and, in children, with Attention-Deficit and Disruptive Behavior Disorders.
Relevant Predisposing Factors
Depression can have many possible origins, dynamics, and precipitants. Familiarity with these and an ability to understand the determinants of a particular person's depression will be essential to the formulation of any treatment plan likely to be effective (Goldfried, Greenberg, & Marmar, 1990). Freud viewed depression as representing the symbolic loss of a love object, accompanied by the turning inward of anger toward the parents. In these circumstances, according to Freud, self-esteem becomes contingent on receiving constant affirmation from others, and depression can result if sufficient affirmation is not received. The social learning theorists believe that depression can become a learned response when it is rewarded and reinforced: the secondary gains it brings outweigh the negative experience of being depressed. Beck (Beck, Rush, Shaw, & Emery, 1979) and other cognitive theorists view depression as a result of faulty logic and misinterpretation, involving a negative cognitive set. Behavioral theorists hypothesize that people who become depressed have poor interpersonal skills and therefore receive little positive social reinforcement. The interpersonal model explains depression as stemming from undue dependence on others as well as from friction and poor communication in relationships. Biological approaches view depression as resulting from a dysfunctional level of serotonin, a neurotransmitter (Atwood & Chester, 1987). Developmental models suggest that people who experience depression are more likely to have had difficult childhoods with parental discord, an inappropriate level of maternal care, low cohesion or adaptability in the family, and controlling and/or rejecting parents (Gotlib & Colby, 1987).
The onset of depression often follows one or more negative and stressful life events, which frequently involve a real or threatened interpersonal loss, and the anticipation of an impending loss can trigger a return of unresolved feelings about an earlier loss. This pattern is particularly likely in people who have few social supports, no intimate confidants, and generally negative social relationships. Unfortunately, the proverbial vicious circle is likely to appear in this situation: depression is exacerbated by a lack of friends, but because people are depressed, forming new friends is very difficult. Giesler, Josephs, and Swann (1996) have identified another sort of self-perpetuating cycle as contributing to depression. They found that people who were depressed emphasized negative self-evaluations and failed to seek out or recognize positive self-evaluations, and this pattern served to maintain their depression.
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