Psychological Disorders and Therapies Chapter 15 and 16

1. To study the abnormal is the best way of understanding the normal. William James (1842-1910) Psychological Disorders and TherapiesChapter 15 and 16

2. Rates of Psychological Disorders • There are 450 million people suffering from psychological disorders (WHO, 2004). • Depression and schizophrenia exist in all cultures of the world. • Two Major Classifications • Neurotic: Distressing but one can still function in society and act rationally • Psychotic: Person loses contact with reality, experiences distorted perceptions http://www.learner.org/resources/series60.html?pop=yes&pid=780

3. Common Culture Bound Syndromes

4. Defining Psychological Disorders Mental health workers view psychological disorders as persistently harmful thoughts, feelings, and actions. Behavior is judged to be: • Atypical – statistically infrequent; uncommon • Disturbing – socially disagreeable behaviors (varies with time and culture) • Maladaptive – cause social or physical harm a. To self - Inability to reach goals, to adapt to the demands of life b. To society – interferes, disrupts social group functioning • Personal Distress – behavior causes a person discomfort, anxiety, depression. • Unjustifiable – no good reason for behavior

5. DSM IV: Multiaxial Classification (pg. 623-626 in CP ) Axis I Is a Clinical Syndrome (cognitive, anxiety, mood disorders [16 syndromes]) present? Axis II Is a Personality Disorder or Mental Retardation present? Axis III Is a General Medical Condition (diabetes, hypertension or arthritis etc) also present? Axis IV Are Psychosocial or Environmental Problems (school or housing issues) also present? Axis V What is the Global Assessment of the person’s functioning? • The most recent edition, DSM-IV-TR (Text Revision, 2000), describes 400 psychological disorders compared to 60 in the 1950s. DSM-V is supposed to come out in May 2013

6. Strengths/Weaknesses of DSM

7. History of Mental Disorders: Early Theories • Afflicted people were possessed by evil spirits. • Music or singing was often used to chase away spirits. • In some cases trephening was used: cutting a hole in the head of the afflicted to let out the evil spirit. • Another theory was to make the body extremely uncomfortable.

8. Trephening

9. History of Mental Disorders: Hospitalization • In the 1800’s, disturbed people were no longer thought of as madmen, but as mentally ill. • They were first put in hospitals; however, they were nothing more than barbaric prisons. • The patients were chained and locked away and some hospitals even charged admission for the public to see the “crazies”, just like a zoo. • Philippe Panel - French doctor who was the first to take the chains off and declare that these people are sick and “a cure must be found!!!” Insisted that madness was not due to demonic possession, but an ailment of the mind

10. Current Perspectives: Medical Model When physicians discovered that syphilis led to mental disorders, they started using medical models to review the physical causes of these disorders. Psychological disorders are sicknesses and can be diagnosed, treated and cured. • Etiology: Cause and development of the disorder. • Diagnosis: Identifying (symptoms) and distinguishing one disease from another. • Treatment: Treating a disorder in a psychiatric hospital. • Prognosis: Forecast about the disorder.

11. Current Perspectives: Biopsychosocial Perspective Assumes that biological, socio-cultural, and psychological factors combine and interact to produce psychological disorders (Mental illnesses are socially defined - major disorders, like depression and schizophrenia appear to be universal, however; other disorders appear to be tied to specific cultures) Used to be called Diathesis-Stress Model: diathesis meaning predisposition and stress meaning environment.

12. Models of Abnormality and Therapy: Biological Perspective Physiological factors (brain activity, genes, hormones, NTs, nervous) determine behavior and mental processes Causes of Mental Disorders • Physical diseases that can be treated medically • Brain abnormalities • Chemical imbalances • Birth difficulties • Heritability Treatment of Mental Disorders • Drug Therapy • Electroconvulsive Therapy (ECT) – effective for certain kinds of severe, otherwise-untreatable depression. • Psychosurgery/neurosurgery – surgery to destroy selected areas of the brain thought to be responsible for emotional disorders. Prefrontal lobotomy.

13. Brain Abnormalities A PET scan of the brain of a person with Obsessive-Compulsive Disorder (OCD). High metabolic activity (red) in the frontal lobe areas are involved with directing attention. Generalized anxiety, panic attacks, and even OCD are linked with brain circuits like the anterior cingulate cortex. PET scans of 41 murderers revealed reduced activity in the frontal lobes. In a follow-up study repeat offenders had 11% less frontal lobe activity compared to individuals without antisocial personality disorder

14. Brain Abnormalities Schizophrenia patients may exhibit morphological changes in the brain like enlargement of fluid-filled ventricles. Dopamine Overactivity: Researchers found that schizophrenic patients express higher levels of dopamine D4 receptors in the brain (neurons using dopamine fire too often).

15. Drug Therapy Anti-anxiety drugs: Xanax , Valium, Klonopin, Ativan depress the central nervous system and reduce anxiety and tension by elevating the levels of the (GABA) neurotransmitter. Atypical antipsychotic drugs: Clozapine (Clozaril) blocks receptors for dopamine and serotonin to remove the negative symptoms (apathy, jumbled thoughts, concentration difficulties, and difficulties in interacting with others) of schizophrenia but does not restore normal thought patterns. Classical antipsychotics:Chlorpromazine (Thorazine) removes a number of positive symptoms associated with schizophrenia such as agitation, delusions, and hallucinations.

16. Drug Therapy Anti-depressants: Monoamine Oxidase (MAO) inhibitors elevate levels of norepinephrine and serotonin by blocking or inhibiting the enzyme that deactivates these NT. Serotonin-norepinephrine inhibitors (SNRIs) also elevate levels of norepinephrine and serotonin by blocking the reuptake of these NT. Pre-synaptic Neuron Serotonin Norepinephrine Post-synaptic Neuron Anti-depressants: Selective serotonin reuptake inhibitors (SSRIs) – (Prozac,Zoloft, and Paxil) elevate levels of serotonin by preventing its reuptake Lithium Carbonate, a common salt, has been used to stabilize manic episodes in bipolar disorders reducing levels of norepinephrine and glutuamate

17. Brain Stimulation Electroconvulsive Therapy (ECT) ECT is used for severely depressed patients who do not respond to drugs. The patient is anesthetized and given a muscle relaxant. Patients usually get a 100 volt shock that relieves them of depression. Transcranial Magnetic Stimulation (TMS) In TMS, a pulsating magnetic coil is placed over prefrontal regions of the brain to treat depression with minimal side effects.

18. Models of Abnormality and Therapy: Psychodynamic Perspective Unconscious desires, needs, memories, and conflicts determine behavior and mental processes. Struggle to fulfill instinctive desires and wishes despite society’s rules Causes of Mental Disorders • Repressed unconscious conflicts and drives • Early childhood trauma Treatment for Mental Disorders • Free association – patient reports all feelings, thoughts, memories, and images that come to mind in order to bring repressed feelings into conscious awareness where the patient can deal with them • Dream analysis • When energy devoted to id-ego-superego conflicts is released, the patient’s anxiety lessens.

19. Psychoanalysis Eventually the patient opens up and reveals his or her innermost private thoughts, developing positive or negative feelings (transference) towards the therapist. During free association, the patient lies on a couch and speaks about whatever comes to his or her mind. Often, the patient will edit his thoughts, resisting his or her feelings to express emotions. Such resistance becomes important in the analysis of conflict-driven anxiety. Dissatisfied with hypnosis, Freud developed the method of free association to unravel the unconscious mind and its conflicts. Interpersonal psychotherapy, a variation of psychodynamic therapy, is effective in treating depression. It focuses on symptom relief here and now, not an overall personality change.

20. Models of Abnormality and Therapy: Cognitive Perspective The way we process, interpret, and store information determines behavior and mental processes. Emphasize cognitions (mental processes such as learning, memory, perception, thinking, and decision making) Causes of Mental Disorders • Mental disorders are a result of learned maladaptive thought patterns or irrational thoughts (a misinterpretation of what is happening and is not supported by the available evidence) Treatment for Mental Disorders • Rational Emotive Behavior Therapy (Albert Ellis) – therapist challenges illogical beliefs directly with rational arguments; aim is to identify self-defeating thought patterns and replace them with more constructive thoughts • Cognitive Therapy (Aaron Beck) – cognitive restructuring in which a client sees that his/her depression is due in part to erroneous and illogical thought patterns. Therapist helps point out those thoughts that precede anxiety and depression and then works with the client to test the logic of these thoughts.

21. Models of Abnormality and Therapy: Humanistic Perspective One’s inborn tendency to grow toward his/her unique potential determines behavior and mental processes. Emphasize free will, self-concept, and self-actualization Causes of Mental Disorders • Distorted sense of self • Growth-thwarting environment (real and ideal self are incongruent; did not receive unconditional positive regard or empathy) Treatment • Do not delve into the past; help people to feel better about themselves here and now; boost self-fulfillment by helping people grow in self-awareness and self-acceptance. • Client-centered therapy (Carl Rogers) - therapist offers unconditional positive regard (non-judgemental) to build self-esteem; therapist must be warm, genuine, and empathic so client can adopt these views and become self-accepting • Active listening- echoes, restates, and clarifies the patient’s thinking, acknowledging expressed feelings

22. Models of Abnormality and Therapy: Behaviorist Perspective Learning through rewards and punishments in our external environment (classical conditioning, operant conditioning, observational learning) determines behavior and mental processes. Causes of Mental Disorders • Learned maladaptive patterns of behavior cause mental disorders Treatment • Counterconditioning • Flooding or exposure treatments – therapist accompanies client into the feared situation • Systematic desensitization – a step by step process of desensitizing a client to a feared object or experience; based on counterconditioning • Aversive conditioning – substitutes punishment for the reinforcement that has perpetuated a bad habit • Behavior Modification • Skills training – practice in specific acts needed to achieve goals • Token economy - in institutional settings therapists may create a token economy in which patients exchange a token of some sort, earned for exhibiting the desired behavior, for various privileges or treats

23. Anxiety Disorders Anxiety (a sense of apprehension that shares many of the same symptoms as fear but builds more slowly and lingers longer) that persists to the point that it interferes with one’s life. The CNS’s physiological and emotional response to a vague sense of threat or danger. http://www.youtube.com/watch?v=_Cr7IomSy8s • Generalized anxiety disorders • Phobias • Copycat Agoraphobia http://www.youtube.com/watch?v=u0dpgmwETcg&playnext=1&list=PLD14A589E28BB9502 • Obsessive-compulsive disorders • As Good as it Gets http://www.youtube.com/watch?v=44DCWslbsNM • Aviator http://www.youtube.com/watch?v=7FapiKgs4y8&feature=related • Grey’s Anatomy http://www.youtube.com/watch?v=ETFQ9fyRP0s&feature=related • Exposure Therapy Aims to Curb OCD http://www.youtube.com/watch?v=B-qtnCiX5b4 • Deep Brain Stimulation for OCD http://abcnews.go.com/video/playerIndex?id=3379057 • Panic disorders • Posttraumatic Stress Disorder

24. Generalized Anxiety Disorder Symptoms • Feeling unexplainably tense and uneasy • Anxiety and worry are associated with at least 3 of these symptoms: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep problems • Difficulty controlling the worry, which may develop into “panic attacks” • Inability to identify or avoid the cause of certain feelings. • Occurs more days than not for six months I wish I could tell you what’s the matter. Sometimes I feel like something terrible has just happened when actually nothing has happened at all. Other times, I’m expecting the sky to fall down any minute. Most of the time I can’t point my finger at something specific. The fact is that I am tense and jumpy almost all the time. Sometimes my heart beats so fast, I’m sure it’s a heart attack. Little things can set it off. The other day I thought a supermarket clerk had overcharged me a few cents on an item. She showed me that I was wrong, but that didn’t end it. I worried the rest of the day . I kept going over the incident in my mind, feeling terribly embarrassed at having raised the possibility that the clerk had committed an error. The tension was so great, I wasn’t sure I’d be able to go to work in the afternoon.

25. Panic Disorder It happened without any warning, a sudden wave of terror. My heart was pounding like mad, I couldn’t catch my breath, and the ground underfoot seemed unstable. I was sure it was a heart attack. It was the worst experience of my life. Symptoms: • Recurrent, unexpected attacks of acute anxiety , peaking within 10 minutes. • Such panic may occur in a familiar situation, such as a crowded elevator. • May include feelings of terror, chest pains, nausea, choking, or other frightening sensations. • Can cause secondary disorders, such as agoraphobia (phobia of open places)

26. Phobia Disorder I can’t tell you why I’m afraid of rats. They fill me with terror. Even if I just see the word “rat” my heart starts pounding. I worry about rats in restaurants I go to, in my kitchen cupboard, and anywhere I hear noise that sounds like a small animal scratching or running. Symptoms: • Marked by a persistent and irrational fear of an object or situation that disrupts behavior and is often accompanied by extreme anxiety symptoms • Participate in elaborate ways to avoid the object or situation; just thinking about the thing you fear causes anxiety

27. Types of Phobic Disorder • Specific Phobia • Most common phobias: specific animals or insects, heights, enclosed spaces, thunderstorms, and blood • Social Phobia • Severe, persistent and unreasonable fears of social or performance situations in which embarrassment may occur • Agoraphobia • Intense fear of being alone in public places from which escape would be difficult or help is not readily available

28. Obsessive-Compulsive Disorder Persistence of unwanted thoughts, wishes, images, ideas, doubts (obsessions) and urges to engage in senseless rituals (compulsions) that cause distress.

29. Obsessive-Compulsive Disorder I felt the need to clean my room … spent four to five hour at it … At the time I loved it but then didn't want to do it any more, but could not stop … The clothes hung … two fingers apart …I touched my bedroom wall before leaving the house … I had constant anxiety … I thought I might be nuts. • 20% of those with OCD have only obsessions or only compulsions; all others experiences both • Obsession: A young woman is continuously terrified by the thought that cars might careen onto the sidewalk and run over her. Compulsion: She always walks as far from the street pavement as possible and wars red clothes so that she will be immediately visible to an out-of-control car • Obsession: A college student has the urge to shout obscenities while sitting through lectures in classes. Compulsion: Carefully monitoring his watch, he bites his tongue every sixty seconds in order to ward off the inclination to shout • Obsession: A young boy worries incessantly that something terrible might happen to his mother while sleeping at night. Compulsion: ON his way up to bed each night, he climbs the stairs according to a fixed sequence of three steps up, followed by two steps down in order to ward off danger.

30. Common Examples of OCD

31. Acute Stress Disorder • Characteristics of traumatic event: • Threatened death or serious injury • Person’s response involved intense fear, helplessness, or horror • During/after event person has 3 or more dissociative symptoms: • Feel numb, detached, or lack of emotional responsiveness • Less aware of surroundings • Derealization - an alteration in the perception or experience of the external world so that it seems strange or unreal • Depersonalization - subjective experience of unreality in one's sense of self • Dissociative amnesia • Traumatic event is persistently re-experienced • Avoidance of stimuli that reminds one of the traumatic event • Disturbance lasts for a minimum of 2 days and a maximum of 4 weeks of the traumatic event

32. Post-Traumatic Stress Disorder Repeated, anxious reliving of a horrifying event over an extended period of time. • Haunting memories 2. Nightmares 3. Social withdrawal 4. Jumpy anxiety 5. Sleep problems Bettmann/ Corbis http://www.mtv.com/videos/true-life-i-have-post-traumatic-stress-disorder/1601333/playlist.jhtml

33. Etiology of Anxiety Disorders • Behavioral: • Through observational learning, children adopt behaviors of anxiety disorders displayed by their parents. • As demonstrated in the Little Albert experiment, fear can be classically conditioned and then maintained through operant conditioning • Cognitive: • A lack of perceived control (social-cognitive) • Inaccurate or irrational interpretation of an event/stimulus. • Psychodynamic: • Ego defense mechanisms are inadequate. • Sociocultural Perspective • Pressures, such as poverty or race, that cause anxiety. Biological: • Genetic; runs in families • Inherit overly responsive autonomic nervous system • Overactivity of norepinephrine, (noradrenaline), specifically connected to the onset of panic attacks • Lack of serotonin function, especially in OCD and social phobias. • Deficiency in GABA • Too much glutamate in OCD patients, which causes the alarm center in the brain to keep going off • Overactive amygdala or an underactive prefrontal cortex, which creates an inability to turn off the initial stress response by the amygdala Evolutionary: • Biological preparedness to acquire some fears much more easily than others

34. Treatment of Anxiety Disorders Behavioral: • Counterconditioning • Exposure Therapy • Systematic desensitization (Video 13) • Flooding • Aversion conditioning Biological: • Antianxiety drugs (Valium, Xanax) – reduce the symptoms of anxiety, nervousness, and sleeping problems by increasing the level of GABA, which inhibits nerve impulses in the brain.

35. Generalized Anxiety Disorder results from… • Psychodynamic Perspective • Ego defense mechanisms are inadequate • Severe punishment for expressing id impulses, which causes high levels of anxiety • Cognitive Perspective • Unrealistic goals or unreasonable beliefs about the world and ourselves that foster worry and fears. • Inaccurate or irrational interpretation of an event/stimulus Tendency to overgeneralize and magnify the significance of an event. • Lack of perceived control. • Sociocultural Perspective • Pressures, such as poverty or race, that cause anxiety. • Behavioral Perspective • Observational learning – parents model the characteristics of anxiety disorders for their children; trouble leaving the house or being overly concerned about certain events. • Humanistic Perspective • People not looking at themselves honestly and acceptingly

36. Generalized Anxiety Disorder results from… • Biological Perspective • Certain people inherit autonomic nervous system traits that make them vulnerable or predisposed to anxiety (such as, overly responsive or reactive, strong alarm tendencies,). Minor events trigger anxiety. • Heritability of anxiety is 30 to 40% • Anxiety disorders run in families • Breakdown in the neural circuitry that signals the brain to stop responding. May be a result of an overactive amygdala or an underactive prefrontal cortex, which creates an inability to turn off the initial stress response by the amygdala • Anti-anxiety drugs: Xanax , Valium, Klonopin, Ativan depress the central nervous system and reduce anxiety and tension by elevating the levels of the neurotransmitter GABA. Deficiency in GABA, inhibitory disorder, which could account for racing thoughts.

37. Panic Disorder results from… • Biological Perspective • Heightened startle response – hypersensitivity to neurochemicals that alert sympathetic nervous system. • Overactive norepinephrine (NT linked with arousal) • Cognitive Perspective • Full panic reactions are experienced only be people who misinterpret bodily events

38. Phobia Disorder results from… • Behavioral Perspective • Learning theorists suggest that fear conditioning leads to anxiety. This anxiety then becomes associated with other objects or events (stimulus generalization) and is reinforced. • Fear is initially learned through classical conditioning • Claustrophobia • NS (closet)  no response • UCS (lack of oxygen)  UCR (gasping for air) • UCS (lack of oxygen) + NS (closet)  UCR (gasping for air) • CS (closet)  CR (gasping for air) • Generalization: closet to enclosed spaces • Fear is then maintained through avoidance (operant conditioning) because the individual avoids the thing he/she is afraid of, there are no opportunities for “reality testing” and new learning. • Investigators believe that fear responses are inculcated through observational learning. Young monkeys develop fear when they watch other monkeys who are afraid of snakes.

39. Phobia Disorder results from… • Since phobias most likely develop as a result of fear conditioning, therapists use learning principles to eliminate unwanted behaviors. • Counterconditioning is a classical conditioning procedure that conditions new responses to stimuli that trigger unwanted behaviors. • Exposure Therapy - expose (in real or virtual environments) patients to things they fear and avoid. Through repeated exposures, anxiety lessens because the brain habituates to the fear. • Systematic Desensitization - A type of exposure therapy that associates a pleasant, relaxed state with gradually increasing anxiety-triggering stimuli • Flooding – immediate, direct and constant exposure to feared object, no chance of escape • Aversive Conditioning - associates an unpleasant state with an unwanted behavior. I

41. Phobia Disorder results from… • Operant conditioning procedures enable therapists to use behavior modification, in which desired behaviors are rewarded and undesired behaviors are either unrewarded or punished. • Token Economy - In institutional settings therapists may create a token economy in which patients exchange a token of some sort, earned for exhibiting the desired behavior, for various privileges or treats. I

42. Phobia Disorder results from… • Biological Perspective • Natural Selection has led our ancestors to learn to fear snakes, spiders, and other animals. Therefore, fear preserves the species. Role of biological preparedness – people are biologically prepared by their evolutionary history to acquire some fears much more easily than others • Twin studies suggest that our genes may be partly responsible for developing fears and anxiety. Twins are more likely to share phobias • Giving anti-depressants, such as SSRIs

43. Obsessive Compulsive Disorder results from… • Psychodynamic Perspective • Id battles with ego on conscious level • Id impulses = obsessive thoughts • Ego defenses = counter-thoughts or compulsive actions • Behavioral Perspective • Compulsions are learned by chance • Exposure and response prevention (ERP), in which OCD sufferers don’t try to avoid their particular source of anxiety but actually seek it out. Eventually, emotional nerve endings grow desensitized to the stimulus. • Cognitive Perspective • Overreact to unwanted thoughts • Try to neutralize these thoughts with actions • If neutralizing activity reduces anxiety, it becomes reinforced • Biological Perspective • Twin studies – genetic component • 53% in identical twins • 23% in fraternal twins • Brain abnormalities • Too much glutamate, which causes the alarm centers in the brain to keep going off • Lack of serotonin functioning (NT involved with regulation of sleep and mood • High level of activity in frontal lobes, associated with attention • In the future, OCD patients may receive deep brain stimulation. High metabolic activity (red) in frontal lobes

44. Causes of Stress Disorders • Combat • Disasters • Abuse and victimization • Why doesn’t everyone develop psychological stress disorders? • Biological and genetic factors • Physical changes in body • Abnormal NT and hormonal activity • Personality factors • Preexisting high anxiety • History of psychological problems • Negative worldview • Negative childhood experiences • Weak social support • Severity of the trauma • Psychological Debriefing • Normalize responses to the disaster • Encourage expressions of anxiety, anger, and frustration • Teach self-help skills • Provide referrals

45. Additional Anxiety Disorder Videos • OCD Videos • http://www.metacafe.com/watch/84755/true_life_living_with_ocd/ • http://www.metacafe.com/watch/yt-SH0r44qn6pI/my_life_with_ocd_laurens_story_part_i_dramatic_health/ • http://www.metacafe.com/watch/yt-T0FMXyp6ZEs/my_life_with_ocd_laurens_story_part_ii_dramatic_health/ • PTSD Videos • http://www.mtv.com/videos/true-life-i-have-post-traumatic-stress-disorder/1601333/playlist.jhtml

46. Mood Disorders • Unipolar disorders – experience emotional extremes at just one end of the mood continuum • Major depressive disorder • Dysthymic disorder • Seasonal Affective disorder • Bipolar disorders – experience emotional extremes at both ends of the mood continuum – depression and mania Emotional extremes, which come in two principal forms.

47. Major Depressive Disorder Symptoms • Signs of depression last two weeks or more and are not caused by drugs or medical conditions • Signs include: Lethargy and fatigue (takes tremendous effort to get up and get dressed); feelings of worthlessness (tearfulness and weeping; exaggerate minor failings, discount positive events, interpret things that go wrong as evidence that nothing will ever go right); loss of interest in family & friends; recurrent thoughts of death/suicide; loss of interest in activities; depressed most of the day; significant weight gain/loss; insomnia; psychomotor agitation/retardation; concentration difficulties or indecisiveness I was seized with an unspeakable physical weariness. There was a tired feeling in the muscles unlike anything I had ever experienced… my nights were sleepless. I lay with dry, staring eyes gazing into space. The most trivial duty became a formidable task. Finally mental and physical exercises were impossible; the tired muscles refused to respond, my “thinking apparatus” refused to work, ambition was gone. My general feeling might be summed up in the familiar saying “What’s the use.”

48. Blue Mood Dysthymic Disorder Major Depressive Disorder Dysthymic Disorder Symptoms • Mild but chronic; lies between a blue mood and major depressive disorder • Characterized by daily depression lasting two years or more; longer lasting but less disabling • When dysthymic disorder leads to major depressive disorder, the sequence is called “double depression”

49. Seasonal Affective Disorder Symptoms • Depression on a recurring basis in one season of the year when it gets dark early and light late in the day Treatment • Light Therapy – exposure to bright light for a specific length of time • The level of light produced must match that of visible light outdoors shortly after sunrise or before sunset

50. Etiology of Mood Disorders • Psychodynamic: • Link between depression and grief: when a loved one dies, the mourner regresses to the oral stage: • Cognitive: • Ruminating response style, self-defeating thoughts, external locus of control, learned helplessness, and pessimistic views of: themselves, the world, the future. Biological: • Genetic; runs in families • Low serotonin may “open the door” to a mood disorder and permit norepinephrine activity to define the particular form the disorder will take: • Low serotonin + Low norepinephrine = Depression • Low serotonin + High norepinephrine = Mania. • An excessive release of the stress hormone cortisol, which could be connected to impaired functioning of the hypothalamus and pituitary gland of the endocrine system • Malfunctions in the body’s circadian clock, specifically for SAD. Socio-cultural: • Dysfunctional family systems, poverty, high-crime neighborhoods, domestic violence, and other stressful situations • Women have a higher chance than men of developing a mood disorder