Depression, Reward Regions, and the Brain: Erika Forbes
1. How did you become interested in developmental psychology?
> I came to child development in a nontraditional kind of way. My undergraduate work was in history and literature, so I was in a humanities field. And then while I was, after I finished college, I moved to Washington, D.C. and was working, and starting thinking about what I might like to do. I thought I wanted to go into academia, but I wanted to consider different fields. And as it happened, I had done some volunteering with children in an urban hotline where kids could call to ask questions about homework or call with questions about safety, or get sort of basic counseling. And it got me really interested in children and their needs and their struggles. And around the same time, I also started doing some work with a researcher at George Washington University who was studying emotion regulation in kids, and so I started really thinking about, what about kids, regulation of their emotions and their moods, might put them risk for disorders? What about it might actually protect them and help them develop well in a healthy, positive way? How do we understand what emotion is and how do we understand it developmentally? So as a result of that, I decided to sort of retool and go back and take courses in psychology and apply. And I did my PhD in clinical and developmental psychology.
2. What is your current area of research?
> My work focuses on the brain processes and behavioral processes in affect regulation in depression that happens in young people. And it -- there's so much to learn about how the brain functions; how the brain functions in normal emotions, and how it might function in emotions that are examples of things that have gone awry. So we know that depression is really a disorder of emotion, and people consider it now a disorder of emotion regulation. Meaning that emotions are not happening in a flexible way, or the intensity is unusual, or they're lasting longer. There's many different ways that emotions can be dysregulated. And it's quite clear that depression involves regulation of negative affect, or maybe poor regulation of negative affect, because the main symptom people report is feeling sad most of the day on most days, and then it impairs them from doing the things they normally do to live their lives. But it's pretty clear from the symptom profile and people's experience, that depression probably also involves reduced positive affect. So people don't feel as happy. They don't feel motivated to go out and do the fun things they usually do. If a pleasant thing's happening, they're not really appreciating the way they usually would. In the example of young people, like children and adolescence, it might mean that they're not interested in hanging out with their friends as much as they would. They're not working as hard in school. They're not finding sports or other activities as interesting as they used to be. And we see this a lot clinically, that young people who have depression just have kind of backed off from all their activities. And so we're thinking of that as an example of how positive affect is altered; they're not doing the enjoyable things they used to do. That's true for the symptoms of depression too, even as we diagnosis it. So one of the key symptoms is anhedonia, which means difficulty with enjoying pleasant things. So they -- pleasant things might happen and they might not enjoy them, for example. I was working with a boy who was 12 years old, who was depressed, and he had won an award in school for an essay he wrote. And he was going to get to read it in front of the school and win an award, and he just didn't even care. Normally it was something he would have been so excited about, and he'd worked really hard on it, but he just didn't have the enthusiasm he would have. And it didn't feel as exciting and, you know, satisfying as it would have to win that award. So that's an example. From a brain point of view, we're trying to understand what about brain development might be contributing to depression. Is something going in another direction in the way the brain is developing. Adolescence is a time when depression becomes much more common; it goes from a pretty rare disorder to a common one. And it seems that emotion regulation is a key issue because as -- as a lot of people know, adolescents feel emotions more intensely. Adolescence isn't typically the time of struggle and mood swings that we used to think of it as being. That's really kind of an old-fashion view now. Adolescents, you know, do pretty well, but they do have pretty intense emotions, and it is a time when things are shifting and they're becoming more focused on their peer group and their friends and romantic relationships, and that involves a lot of new emotions for them. So even though adolescents do a lot of risk taking and impulsive things and do wild stuff when they're with their friends, somehow a subgroup of them end up at risk for developing depression, which, you know, seems the opposite in a way. If positive affect is increased at this age, or if certain kinds of reward seeking are more common or more frequent, why would it be that some people are going in the opposite direction? So we're trying to understand that. What is it about brain development? Is it that the affect regulatory areas of the brain are still developing? That turns out to be true. So those areas develop into early adulthood, into the 20s, and so is it that the reactivity area that kind of produce the emotions are kind of more active at that age, but the parts of the brain that are involved in circuits and regulating them, you know, reducing the intensity of negative or enhancing the intensity of positive, for example, are just not fully functioning at their adult level yet? It's not clear. Another hypothesis is that maybe those areas of the brain that perform higher functions, like being able to plan, coordinate behavior, understand events far in the future, look at future rewards, maybe predispose people to depression because when you're able to do that, then you can really feel more crushed if things don't go the way you want them to. So it's really wide open. It's such an interesting area, but we know so little about it now.
3. What methods do you use to measure affects in children and adolescents?
> And we use a whole host of methods with the idea that emotion is a multifaceted construct, and to really measure affect and affect regulation you need to go at it from a lot of different angles. So we use all the above. We use questionnaires where people tell us about their symptoms and their mood and things like that. We use diagnostic interviews because if we want to focus on people who have depression, we want to make sure that we're identifying them properly. And we're using a couple of newer technologies that are pretty exciting, and I think can give us a unique sense of what is going on with positive affect and affect regulation and depression. And those are functional MRI, which you just mentioned, which allows us to measure brain function, not directly but through blood flow in the brain; that tells us which areas of the brain are active during a certain experience. So we want to measure blood flow in the brain during emotional experiences. So we might measure when people are looking at faces with facial expressions of emotions. The main thing I'm doing right now actually though is measure brain response to reward. So we do this really simple guessing game where people can guess about a number and they can win or lose money. And that's very removed from the real world of rewarding events. I mean, a lot of rewards involve social things like friends, you know, feeling affiliated with your friends, feeling loved and cared about by the people who are close to you, and that's so different than just looking at a number and winning money, of course, but we do think that reward processing is really important part of positive affect. So to understand that, we need to understand more about reward. So we're measuring that. And then as a complement to that, we're trying to measure something that's had lot more relevant to real life which is young people's emotions and activities and emotional related behaviors in their natural settings. So we actually have this system called "Ecological Momentary Assessment," which means you can measure whatever you want --behavior or something internal like mood -- in a way that's ecologically valid, which means that we're measuring it in a real life setting that has relevance to true human behavior; not in a lab, not inside an MR scanner, which have very important contributions to make, but they're definitely not the way we all live our lives. And it also basically means you can measure them in the moment. So we're asking them, what are you doing? who were you with?what's your mood like right now? And we're trying to understand what's going on with mood, what is unusual about mood or emotion in young people with depression, and then relating that back hopefully to their brain function and trying to understand how these things go together to get, understand lots of different angles from the same question.
4. What issues arise when studying depression in adults versus depression in children and adolescents?
> There are a lot of differences in studying adult depression and depression in children and adolescents. There's a lot of differences. One is that depression itself might be experienced differently, it might look a little different in adults versus in younger people, so the symptoms are little bit different in the diagnostic manual, for example. So young people with depression might have irritability as their main mood symptom. In adults, it's more sadness. Another issue is that young people with depression are often having their first episode, that's when -- depression often starts in adolescence or young adulthood. So if you're studying adolescents, you're often studying people who've never had depression before, and whose brain development might not ever, you know, have experienced this. If you're studying adults, you might be studying people who've had previous experiences, and that might change their brain development. So there might be differences that don't reflect their current state, but might reflect something about having had episodes in the past. I think another important issue is that depression's really heterogeneous; there's not probably one single disorder, there seem to be different forms and different subtypes. And studying young people might give you a kind of more focused view of depression.
5. What risk factors are associated with child and adolescent depression?
> Depression tends to begin during adolescence. It's pretty unusual in childhood. It's not so unusual in adulthood anymore, but I think understanding adolescent development that goes in the typical direction is really critical to understanding adolescent depression, because there's something that's unusual that's going a different way in this group of people, and we need to understand what that is. Depression in adolescence is often sparked by a stressful event, often an interpersonal kind of event, so a break up or end of a romantic relationship is an example. So a young, like say, an adolescent young woman who experiences a break up with her romantic partner, say her boyfriend, might be at risk for developing depression. There also is risk involved in some kind of inherited liability, so people who have family histories of depression are more likely, so they're vulnerable. So there's a combination of kind of biological predisposition probably and even temperament, people who tend to have more negative mood on the typical day or less positive mood, are more vulnerable. The depression often happens in result in response to an event. It tends to be episodic, and so we think of it as kind of a time limited thing, it doesn't just start then and last the rest of their lives. So that's a positive thing for treatment, I think, to remind people that this isn't the way they are, this is just a temporary state. And they often, you know, feel sad mood, but also find themselves withdrawing from the usual things that they like to do, not enjoying things as much as they used to. They could feel kind of tired and run down and have some things like that.
6. What kinds of treatments do you use with depressed children and adolescents?
> As a clinical psychologist, I use a psychosocial treatment, so I'm not a medical doctor, and I don't prescribe medication, and that's one avenue for treating depression in young people. But we use psychosocial treatments which involve dealing with thoughts and emotions and behaviors, and understanding how these fit together for that person and what we can do to address those and kind of improve their mood. One thing that's very effective in depression and has been used a lot with young people is treatments that involve behavioral activation. The idea is that there's a motivational system in the brain and in our behavior that involves pursuing rewards and going after pleasant things, and that there's, obviously, we'd say something that's unusual about that system during depression. But it seems that even doing things like finding ways to build in more pleasant activities to people's lives has an effect on mood. So rather than saying, I'm not going to do those things because I don't feel like it, we get people to say, Okay, I'm going to do them, and then feeling like it will come later. And it does seem to work. And it's nice and straight forward. Another approach is more cognitive where we get people to address their thoughts that might not be accurate or appropriate and get them it challenge those with the idea that those thoughts lead to emotions. So if you get a grade on a test back, you say, “That proves it, I'm an idiot. I'm so stupid, I have no future.” You might feel really sad about yourself and sad about, you know, your ability to be competent as a student and to go on to the things that you're hoping to do with your life. Instead, you'll be able to say, “Okay, this is one thing that didn't go the way I wanted it to, but I can think of lots of examples from the past where things I did turned out successfully. I'm a capable student, and this doesn't say everything about who I am.” Finding that that, of course, will lead to feeling better, and that behavior’s going to lead to more – sorry -- that mood’s going to lead to behavior that takes people into more rewarding settings, gets them to experience good things, and then targets their mood that way.
7. What research findings most surprised you?
> One thing that was surprising to me starting out was how little we know. We have lots of different theoretical models about emotion and about psychopathology, but in fact we know so little about what people are experiencing day to day or moment to moment. Or we can say that, you know, affect regulation is this, and we think depression is a disorder of affect regulation. But we really don't even all agree on a definition of affect regulation. And we don't even really know exactly what's dysregulated and how it's dysregulated. So I think in a way, it was a surprise to realize that, you know, from a negative point of view, we know so little, but from a positive point of view, there's so much opportunity to learn more. And hopefully, what we learn can be used for treatment and to really help people and to prevent future depression from occurring.
8. What factors or processes come into play during “affect regulation”?
> Well, one thing we're really focusing on, as I said, is positive affect. So we're thinking that there's something dysregulated, and I know it can be confusing because when we talk about regulation, we think of people reducing their negative emotions. So you feel sad, you want to feel less like you're going to kind of dampen down the intensity or shorten the period of time that you feel that way. But it can also be used to enhance. So what we -- what we're thinking is that a possibility is that young people with depression have trouble getting motivated to do pleasant things. That's kind of that one angle. Another one is that when pleasant things happen, they don't appreciate them. So maybe they're not savoring good experiences the way they might typically or the way another person might. So first, looking at it from a positive emotions point of view is a little bit different, and, then, second, trying to figure out which processes within an affect experience or affect regulation are unusual.
9. Where do you see your research heading in the future?
> Yeah. I see it heading in a way that, hopefully, incorporates lots of different perspectives on emotion and on depression and on typical development in young people. I think it's important to understand more of the kind of components of emotion and emotion regulation and how those unfold, and I think that using lots of different methods is important to that. So I'd like to continue to do brain imaging and to measure experience in real settings. I'd also like, continue doing observation behavior, which is another technique I've used and I think it's really important, so to bring all that together. Another thing I think is important is to have treatment relevance. So I'd like my work to influence treatment, and I'd like to be able to use it to try to develop or improve treatments that will really be effective for people in real life.