1 stress, coping, and adaption march 24, 2008 stressful life events and depression curry college...

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Stress, Coping, and Stress, Coping, and AdaptionAdaption

March 24, 2008March 24, 2008

Stressful Life Events and Depression Stressful Life Events and Depression

Curry CollegeEric Weiser

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Stressful Life EventsStressful Life Events(SLEs)(SLEs)

Catastrophic eventsCatastrophic events Hurricanes, earthquakes, fires, terrorist attacksHurricanes, earthquakes, fires, terrorist attacks

Life changesLife changes Death in the family, job loss, divorce, moving, break-Death in the family, job loss, divorce, moving, break-

ups and other “exits” from the social realm ups and other “exits” from the social realm

Daily hasslesDaily hassles Rush hour traffic, job stress, financial problems, Rush hour traffic, job stress, financial problems,

home foreclosure home foreclosure

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DepressionDepression Depression is a Depression is a heterogeneous syndromeheterogeneous syndrome, ,

meaning that it is comprised of many different meaning that it is comprised of many different variations of symptomsvariations of symptoms

Affective symptomsAffective symptoms Profound sadness, dejection, inability to experience pleasureProfound sadness, dejection, inability to experience pleasure

Cognitive symptomsCognitive symptoms Self-recriminations, difficulty concentrating, viewing world Self-recriminations, difficulty concentrating, viewing world

in negative light, hopelessness in negative light, hopelessness

Physical and behavioral symptoms Physical and behavioral symptoms Fatigue, low energy, difficulty falling asleep, loss of appetite, Fatigue, low energy, difficulty falling asleep, loss of appetite,

lethargy, agitation, social withdrawal, somatic complaints lethargy, agitation, social withdrawal, somatic complaints

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Major Depressive Disorder Major Depressive Disorder (MDD)(MDD)

Depressed moodDepressed mood OR OR loss of interest or pleasure loss of interest or pleasure (anhedonia)(anhedonia) Minimum period of 2 weeksMinimum period of 2 weeks Not due to normal bereavementNot due to normal bereavement

PLUS four of the following symptoms:PLUS four of the following symptoms:1.1. Change in sleep patterns (sleeping Change in sleep patterns (sleeping moremore or or less)less) 2.2. Change in appetite or weight (eating Change in appetite or weight (eating moremore or or less)less)3.3. Agitation or psychomotor retardation (lethargy) Agitation or psychomotor retardation (lethargy) 4.4. Loss of energy, fatigueLoss of energy, fatigue5.5. Feelings of self-blame, worthlessness, guiltFeelings of self-blame, worthlessness, guilt6.6. Difficulty concentrating, indecisivenessDifficulty concentrating, indecisiveness7.7. Thoughts of death or suicideThoughts of death or suicide

MDD is sometimes referred to as “unipolar depression,” or just “depression.”

5Depressive Symptoms Depressive Symptoms Mnemonic:Mnemonic:

“Space Drags”“Space Drags”S leep disturbance

P leasure/interest (lack of)

A gitation

C oncentration

E nergy (loss of)/fatigue

D epressed mood

R etardation movement

A ppetite disturbance

G uilt, worthless, self-blame

S uicidal thoughts

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Stress and DepressionStress and Depression

Overactivity of HPA axisOveractivity of HPA axis Triggers release of cortisolTriggers release of cortisol

Stress hormoneStress hormone

High cortisol levels linked to depressionHigh cortisol levels linked to depression Cushing’s syndromeCushing’s syndrome

Causes oversecretion of cortisolCauses oversecretion of cortisol Symptoms include depressive symptomsSymptoms include depressive symptoms

Injecting cortisol in animals produce Injecting cortisol in animals produce depressive symptomsdepressive symptoms

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Stress and DepressionStress and Depression

Even among people who are depressed but do Even among people who are depressed but do not have Cushing’s, cortisol is poorly regulatednot have Cushing’s, cortisol is poorly regulated

Dexamethasone suppression testDexamethasone suppression test Dexamthethason suppresses cortisol in most people, but Dexamthethason suppresses cortisol in most people, but

does not seem to do suppress cortisol in people with does not seem to do suppress cortisol in people with history of depressionhistory of depression

Thus, there is good reason, physiologically Thus, there is good reason, physiologically speaking, why stress and depression are speaking, why stress and depression are linked. linked.

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Stressful Life Events and Stressful Life Events and DepressionDepression

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Mazure (1998)Mazure (1998) Reviews research examining the relationship Reviews research examining the relationship

between exposure to stressful life events between exposure to stressful life events (SLE) and depression (SLE) and depression

Studies using two primary forms of Studies using two primary forms of methodology are included in the review methodology are included in the review Case-control studies Case-control studies Community studies Community studies

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MazureMazure (1998)(1998)

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MazureMazure (1998)(1998)

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There are four models that have been proposed There are four models that have been proposed to characterize the SLE-depression relationshipto characterize the SLE-depression relationship Victimization modelVictimization model

SLE SLE depression depression

Diathesis-stress model Diathesis-stress model SLE lead to depression in people with an underlying SLE lead to depression in people with an underlying

biological diathesis (personality, genes, etc.) biological diathesis (personality, genes, etc.)

Additive burden modelAdditive burden model SLE, personality dispositions, social situations, etc. all SLE, personality dispositions, social situations, etc. all

contribute additively to the development of depressioncontribute additively to the development of depression

Proneness model Proneness model Depression Depression SLE SLE recurrence of depression recurrence of depression

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Paykel et al. (1969)Paykel et al. (1969) Classic studyClassic study Examined the types and frequencies of life events Examined the types and frequencies of life events

that preceded the onset (six months) of depression in that preceded the onset (six months) of depression in 185 patients, and compared them to the types and 185 patients, and compared them to the types and frequencies of life events (one year prior to frequencies of life events (one year prior to interview) among a matched community sample of interview) among a matched community sample of 185 non-depressed people. 185 non-depressed people.

The life events of interest were derived from the The life events of interest were derived from the Holmes and Rahe SRRS, and consisted of a list of 33 Holmes and Rahe SRRS, and consisted of a list of 33 items (Table 1). items (Table 1).

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Paykel’s Study Paykel’s Study

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Paykel’s StudyPaykel’s Study

ResultsResults Depressed individuals appear to experience a Depressed individuals appear to experience a

large number of life events prior to the onset large number of life events prior to the onset of depression, compared to non-depressed of depression, compared to non-depressed individuals. individuals.

Most of these life events involve:Most of these life events involve: Undesirable life eventsUndesirable life events LossesLosses or exits from the social field (i.e., “social or exits from the social field (i.e., “social

exits”) exits”)

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The Work of George W. The Work of George W. BrownBrown

George W. Brown, a distinguished professor George W. Brown, a distinguished professor from University of London, was an from University of London, was an international pioneer in the investigation of international pioneer in the investigation of “life events” and depression “life events” and depression His research dates back to the 1960s His research dates back to the 1960s He is regarded as one of the world’s foremost He is regarded as one of the world’s foremost

experts in the psychosocial aspects of mental experts in the psychosocial aspects of mental illnessillness

His most famous study is known as the His most famous study is known as the Camberwall StudyCamberwall Study

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Brown & HarrisBrown & Harris(1978)(1978)

The Camberwall StudyThe Camberwall Study Sample consisted of the following: Sample consisted of the following:

114 female psychiatric inpatients and outpatients 114 female psychiatric inpatients and outpatients from Camberwall from Camberwall

485 females from same community (while 485 females from same community (while screening for mental disorders) screening for mental disorders)

Both groups were interviewed using the LEDSBoth groups were interviewed using the LEDS Purpose was to compare both groups of Purpose was to compare both groups of

women to determine whether stressful life women to determine whether stressful life events occurred more commonly before the events occurred more commonly before the onset of depression onset of depression

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Brown & HarrisBrown & Harris(1978)(1978)

Stressful life events (or, events that entailed Stressful life events (or, events that entailed long-term long-term threatthreat) were coded in one of 10 categories ) were coded in one of 10 categories

1.1. DeathsDeaths2.2. Illness and accidents to subject Illness and accidents to subject 3.3. Interaction changes (e.g., close friend moves away) Interaction changes (e.g., close friend moves away) 4.4. Disappointments Disappointments 5.5. Miscellaneous crises (e.g., lost pets, burglaries, etc)Miscellaneous crises (e.g., lost pets, burglaries, etc)6.6. Illness and accidents to others Illness and accidents to others 7.7. Role change to subject (subject divorces husband) Role change to subject (subject divorces husband) 8.8. Job changesJob changes9.9. Residence changes Residence changes 10.10. Role changes to others (e.g., son breaks off engagement) Role changes to others (e.g., son breaks off engagement)

These events were rated as either These events were rated as either severesevere or or non-severenon-severe, , as well as involving as well as involving markedmarked vs. vs. moderatemoderate long-term long-term threat threat

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Brown & HarrisBrown & Harris (1978)(1978)

78 of the original 458 “normal” women were excluded from the analysis because they were found to have a psychiatric disorder

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Brown & HarrisBrown & Harris (1978)(1978)

Brown and Harris noted that “loss” and “disappointment” Brown and Harris noted that “loss” and “disappointment” were common themes in the severe events were common themes in the severe events

So, they examined the relationship between these kinds of So, they examined the relationship between these kinds of events and depression; long-term threatening events were events and depression; long-term threatening events were thus classified into one of six categories thus classified into one of six categories Separation or threat of itSeparation or threat of it Unpleasant revelation about someone close that forces a Unpleasant revelation about someone close that forces a

reassessment of the person and relationshipreassessment of the person and relationship Life-threatening illness to someone closeLife-threatening illness to someone close Major material loss or disappointment Major material loss or disappointment Enforced change of residence (or threat of it) Enforced change of residence (or threat of it) Miscellaneous crises involving some element of loss (e.g., layoff, Miscellaneous crises involving some element of loss (e.g., layoff,

legal separation) legal separation)

24Brown & Harris (1978)

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Freud and Depression Freud and Depression The notion that loss leads to depression can be The notion that loss leads to depression can be

traced to the writings of Freudtraced to the writings of Freud

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Freud and DepressionFreud and Depression Freud (1917) Freud (1917)

In his classic paper, In his classic paper, Mourning and MelancholiaMourning and Melancholia, Freud , Freud described his famous “hatred-turned-inward” theory of described his famous “hatred-turned-inward” theory of depression (melancholia) depression (melancholia)

Freud directed his attention to the loss of self-esteem in Freud directed his attention to the loss of self-esteem in melancholia melancholia

In Freud’s view, In Freud’s view, lossloss of a loved or cherished person causes one of a loved or cherished person causes one to to introjectintroject (i.e., incorporate) the lost person (i.e., incorporate) the lost person

Because we unconsciously harbor negative feelings toward Because we unconsciously harbor negative feelings toward those we love (ambivalence), the mourner turns those feelings those we love (ambivalence), the mourner turns those feelings of hatred inward toward the self (because the lost person has of hatred inward toward the self (because the lost person has been introjected) been introjected)

So, mourners castigate, vilify, and reproach themselves for the So, mourners castigate, vilify, and reproach themselves for the faults and shortcomings perceived in the lost one who has been faults and shortcomings perceived in the lost one who has been introjected (loss of self-esteem) introjected (loss of self-esteem)

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The Work of Edward Bibring The Work of Edward Bibring

Bibring (1953)Bibring (1953) Like Freud, he focused on loss of Like Freud, he focused on loss of self-esteemself-esteem in in

depressiondepression

Unlike Freud, Bibring thought self-esteem may be Unlike Freud, Bibring thought self-esteem may be lowered (thus producing depression) in ways other than lowered (thus producing depression) in ways other than by the frustration of the need for affection and love by the frustration of the need for affection and love

Three types of aspirations which the (pre)depressive Three types of aspirations which the (pre)depressive may seek:may seek:

1.1. The wish to be worthy and loved, and to avoid inferiority The wish to be worthy and loved, and to avoid inferiority and unworthinessand unworthiness

2.2. The wish to be strong, superior, secure, and to avoid being The wish to be strong, superior, secure, and to avoid being weak and insecureweak and insecure

3.3. The wish to be loving and good, and not aggressive, The wish to be loving and good, and not aggressive, hateful, or destructive hateful, or destructive

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Brown, Harris, & HepworthBrown, Harris, & Hepworth(1995)(1995)

The purpose of this study was to get a clearer The purpose of this study was to get a clearer picture of the picture of the specificspecific kinds of stressful life kinds of stressful life events that are most likely to lead to depressionevents that are most likely to lead to depression

A total of 404 women living in Islington (an A total of 404 women living in Islington (an inner city section of London) were interviewed inner city section of London) were interviewed using the LEDSusing the LEDS

In addition, the interviewers probed for the In addition, the interviewers probed for the presence of psychiatric disorder (depression) presence of psychiatric disorder (depression)

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A.A. Humiliation/trapped Humiliation/trapped 1.1. Humiliation: separationHumiliation: separation

Some element of failure or rejection in a relationshipSome element of failure or rejection in a relationship

2.2. Humiliation: other’s delinquencyHumiliation: other’s delinquency

3.3. Humiliation: put downHumiliation: put down e.ge.g., infidelity, verbal or physical attack, daughter wanting ., infidelity, verbal or physical attack, daughter wanting

to leave mother to leave mother

4.4. Trapped Trapped An on-going marked difficulty (e.g., learning that a An on-going marked difficulty (e.g., learning that a

paralyzed and bedridden husband will not improve) paralyzed and bedridden husband will not improve)

Classification of Events

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B.B. Loss aloneLoss alone1.1. Death Death

2.2. Separation-subject initiatedSeparation-subject initiated Subject plays a major part in bringing on a separation (but, Subject plays a major part in bringing on a separation (but,

excluding those following the discovery of infidelity or excluding those following the discovery of infidelity or extreme abuse) extreme abuse)

3.3. Other key lossOther key loss Moderate losses, such as abortion or giving up a valued jobModerate losses, such as abortion or giving up a valued job

4.4. Lesser lossLesser loss Death of cat, distant relative, husband being laid off, etc.Death of cat, distant relative, husband being laid off, etc.


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C.C. Danger alone Danger alone Covers events not meeting criteria for other Covers events not meeting criteria for other

categories, categories, e.ge.g., serious car accident, violent ex-., serious car accident, violent ex-

husband calling to say he knows where you husband calling to say he knows where you live, serious asthma attack live, serious asthma attack


32Rate of depression onset by humiliation/trapped, loss

alone, and danger, following 377 event sequences among Islington women

Humiliation/TrappedHumiliation/Trapped

% onset and provoking agent % onset and provoking agent

TotalTotal: 41/131 (31%): 41/131 (31%)

Humiliation: separationHumiliation: separation

12/34 (35%)12/34 (35%)

Humiliation: other’s Humiliation: other’s delinquencydelinquency

7/36 (19%) 7/36 (19%)

Humiliation: put downHumiliation: put down

12/32 (38%)12/32 (38%)

Trapped Trapped

10/29 (34%)10/29 (34%)

Loss AloneLoss Alone

% onset and provoking agent% onset and provoking agent

Total: 14/157 (9%)Total: 14/157 (9%)

DeathDeath

7/24 (29%)7/24 (29%)

Separation: subject-initiatedSeparation: subject-initiated

2/18 (11%) 2/18 (11%)

Other key lossOther key loss

4/58 (7%)4/58 (7%)

Lesser loss Lesser loss

1/57 (34%)1/57 (34%)

DangerDanger

% onset and provoking agent % onset and provoking agent

3/89 (3%)3/89 (3%)

TotalTotal

% onset and provoking agent% onset and provoking agent

58/377 (15%)58/377 (15%)

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Kendler et al.Kendler et al. (2003)(2003)

A total of 7,322 adult twins were interviewedA total of 7,322 adult twins were interviewed

During interview, the interviewers probed for During interview, the interviewers probed for the presence of either major depression (MD), the presence of either major depression (MD), generalized anxiety “syndrome” (GAS), or generalized anxiety “syndrome” (GAS), or mixed MD-GASmixed MD-GAS

In another interview, researchers assessed the In another interview, researchers assessed the monthly occurrence of certain “personal monthly occurrence of certain “personal events” (i.e., SLE) using a classification scheme events” (i.e., SLE) using a classification scheme that was mostly inspired by G.W. Brown that was mostly inspired by G.W. Brown

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Kendler’s StudyKendler’s Study1.1. LossLoss

• Reduced sense of connectedness due to loss of Reduced sense of connectedness due to loss of person, material possessions, job, health, or respect person, material possessions, job, health, or respect by othersby others

2.2. Humiliation Humiliation • Feeling devalued, usually due to rejection or role Feeling devalued, usually due to rejection or role

failurefailure

3.3. EntrapmentEntrapment• Ongoing unpleasant circumstances that are expected Ongoing unpleasant circumstances that are expected

to persist or get worse, and nothing can be done to persist or get worse, and nothing can be done about it about it

4.4. DangerDanger• Exposure to circumstances in which there is a good Exposure to circumstances in which there is a good

chance traumatic or dire consequences could have chance traumatic or dire consequences could have occurredoccurred

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Kendler’s Study Kendler’s Study

Note: Higher numbers (e.g., 1.70 vs. 0.95 in upper left section) indicate greater likelihood of developing the psychiatric disorder

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Kendler’s Study Kendler’s Study

Again, higher numbers (e.g., 3.09 vs. 2.99) indicate greater likelihood of developing the psychiatric disorder

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So, there does appear to be a strong and So, there does appear to be a strong and consistent relationship between life consistent relationship between life events and depressionevents and depression

Events involving a combination of loss Events involving a combination of loss and humiliation (i.e., loss of self-esteem) and humiliation (i.e., loss of self-esteem) play very significant roles in provoking play very significant roles in provoking the onset of depression, above and the onset of depression, above and beyond events involving pure lossbeyond events involving pure loss

1 stress, coping, and adaption march 24, 2008 stressful life events and depression curry college...

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