4 depressive disorders Flashcards
How does the DSM-5 cluster mood disorders?
- depressive disorders
- MDD
- persistent depressive disorder (dysthymia)
- bipolar and related disorders
- bipolar I
- bipolar II
- cyclothymic disorder
How can the clusters of mood disorders in the DSM-5 be better understood?
continuous, low mood - dystymia
continuous, exaltation - cyclothymia
episodic, low mood - MDD
episodic, exaltation - BD
How does the ICD-10 cluster mood (affective) disorders?
- mood disorders
- depressive episode
- manic episode
- recurrent depressive episode
- bipolar affective disorder
- persistent mood disorders (cyclothymia + dystymia)
How does the DSM-5 classify a major depressive episode?
DURATION: everyday for two weeks presenting with symptoms
KEY SYMPTOMS:
- depressed mood
- anhedonia (diminished pleasure)
ANCILLIARY SYMPTOMS
- change in appetite
- insomnia or hypersomnia
- psychomotor retardation
- fatigue
- worthlessness, guilt
- poor thinking skills
- suicidal ideation
What needs to be present for the diagnosis of a major depressive episode in the DSM-5?
one key symptom
+
5 in total
+
distress or impairment
-> level can be mild, moderate or severe
EXCLUSION:
no history of manic or hypomanic episodes or substance abuse effects
What is recurrent depression according to the DSM-5?
two or more episodes with 2 months in between them
criteria for MDD are not met
What is a major depressive episode with melancholic features?
loss of pleasure
lack of reactivity to pleasurable stimuli
3+ of:
- distinct depressed mood
- worse in the morning
- early awakening
- marked psychomotor agitation
- weight loss
- guilt
What is a major depressive episode with mood-congruent psychotic features?
delusions and hallucinations with theme of
inadequacy
guilt
disease
death
nihilism
punishment
What is a major depressive episode with mood incongruent features features?
delusions and hallucinations without depressive theme
What is a major depressive episode with anxious distress?
tense
restless
poor concentration
worry, fear
fear of loss of control
What is a major depressive episode with mixed features?
elevated mood, grandiosity
pressure of speech
flight of ideas
increased energy
risk taking
decreased need for sleep
What is a major depressive episode with atypical features?
mood reactivity
+
- increased appetite or weight gain
- hypersomnia
- leaden paralysis
- chronic interpersonal rejection sensitivity
- melancholic and catatonic features are absent
What is a major depressive episode with catatonia?
stupor
cataplexy
waxy flexibility
mutism
negativism
posturing
mannerism
stereotypy
grimacing
echolalia
echopraxia
What is a major depressive episode with peripartum onset?
onset during pregnancy or withing a month of delivery
What is a major depressive episode with seasonal patterns?
onset in fall and winter and remission in spring over a 2-year period
What are clinical features of depression in adults regarding perception and cognition?
- perceptual bias towards negative events
- mood congruent hallucinations + delusions
- negative view
- over-general memory
- cognitive distortions
- inability to concentrate
- indecision
- suicidal ideation
- suicidal intention
- excessive guilt
What are the clinical features of depression in adults regarding mood and behaviour?
- depressed mood
- diurnal variation in mood
- irritable mood
- anxiety and apprehension
- loss of interest and pleasurable activities
- lack of emotional reactivity
- self-defeating behaviour
- psychomotor retardation or agitation
- depressive stupor
- self harm
What are clinical features of depression in adults regarding the somatic state?
fatigue
diminished activity
loss of appetite or overeating
aches and pains
early morning waking
change in weight
loss of interest in sex
What are clinical features of depression in adults regarding relationships?
deterioration in family relationships
withdrawal from peer relationships
poor work or educational performance
What are subtypes of mood disorders?
you have three types of episodes:
- major depressive episode
- hypomanic episode
- manic episode
-> depending on the prevalence of either episode, you may diagnose:
1 -> MDD
1+2 -> bipolar II
1+2+3 -> bipolar I
What is a hypomanic episode?
- abnormally and persistenly elevated, expansive, or irritable mood, increased activity
- 3+ present:
- inflated self-esteem
- decreased need for sleep
- more talkative
- flight of ideas
- distractibility
- increase in goal-directed activity or psychomotor agitation
- excessive involvement in activities that are high risk
How does a manic episode differ from a hypomanic episode?
all symptoms are present
+
marked impairment (eventually hospitalisation) or psychotic features
What are predisposing factors for depression?
genetic factors,
family history,
anxiety or neuroticism → genetic vulnerability in mood dysregulation
heritability estimates: 40-70%
12% of children from depressed parents will develop depression
biological vulnerability is probably inherited - polygenetically transmitted
What are neurological features of depression?
limbic system and prefrontal cortex: abnormalities in the functioning of brain structures dealing with experience and expression of emotion
limbic system (amygdala and anterior cingulate cortex) is overactive
dorsolateral prefrontal cortex is underactive
intense negative emotions and deficit in regulating these
neurotransmitters and antidepressants:
serotonergic and noradrenergic neurotransmission system - potential candidate genes
efficiency is reduced in depression
-> antidepressants increase this
neuroendocrine and immune systems: overactivity of HPA axis
→ raised cortisol levels
some evidence: early childhood adversity → increases risk
What is the sleep architecture in depression?
more time in REM sleep,
less time in slow wave sleep
light treatment is effective - seasonal affective disorder
What are social and psychological risk factors for depression?
range of them,
low SES,
childhood adversity,
attachment insecurity,
depressive temperament, neuroticism,
negative cognitive style,
self-regulation skills deficits,
life stress,
low social support
What are precipitating factors for depression?
major stressful life events, particularly loss
seasonal depression (overeating, carbs cravings, weight gain)
threshold decreases with subsequent episodes
→ might be due to neurobiological process of kindling and cognitive process of rumination
What are maintaining factors of depression?
ongoing high levels of environmental stress
exceeding personal coping and self-regulation resources
tendency to create stressful situations, low activity, constricted lifestyle,
little positive social interaction, poor social support
What are protective factors for depression?
one positive relationship with an adult
high intelligence, unique talent
social support, confiding relationships, supportive marriage
learned self-regulation skills and functional coping strategies
What are some facts around the response of acute depression to treatment?
- two-thirds recover after treatment
- currently multimodal programme: therapy and pharmacological
- relapse is to be expected: relapse is delayed longer after medication is terminated
US and UK treatment outcome studies show that after 14– 24 months, 50– 80% clients who only receive antidepressants relapse, compared with 20– 35% of those who also receive CBT.
Current maintenance therapies that include continuation of antidepressant pharmacological treatment or psychological maintenance treatment can reduce relapse rates from about 60– 80% to about 20– 37%.
interpersonal therapy over a 1-year period reduces relapse from two-thirds to one-third
What is the average experience of the course of depression?
85% experience recurrent episodes of depression
5-9 episodes of 20-30 weeks over the course of their life
frequency and duration increases over time
relapse from antidepressant treatment is 20-35%
with a history of >3 episodes: 60-80%
What therapies are commonly applied to treat depression?
CBT
IPT
ISCT (integrative systemic couple therapy)
What is the theoretical basis of CBT for depression?
Beck´s cognitive therapy proposes that significant problematic lessons, learned through exposure to early stressful life events, frustration of important needs, and modelling and identification in early family relationships, are encoded in maladaptive schemas
clusters of interconnected core beliefs and assumptions about self and others in signifcant relationships
when these are activated, ppl become prone to interpreting ambiguous situations in problematic ways → cognitive distortions
clients need to understand vicious cycles - model of CBT
What is the cognitive-behavioural model of depression?
What and how I think
How I treat my body
What I do
How I feel
What is the goal of CBT?
goal is to help the client monitor all mood changes (C) and link them to changes in activating events (A)
reactivating themselves by using behavioural strategies
scheduling activities or pleasant events
What is maintenance-oriented-mindfulness-based CBT?
meditation to prevent relapse
When we are on automatic pilot we are more likely to slip into patterns of thinking that precipitate depression, so practise mindfulness every day.
Negative emotions arise from negative interpretations and judgements of situations, so allow yourself to acknowledge situations without judging them.
When practising mindfulness, allow attention to move to positive and negative thoughts, feelings and sensations as they arise, and then gently return attention to breathing.
Thoughts are not facts and we are not our thoughts, so depressive thinking need not be grounds for despair.
Know the signs of relapse, and plan to practise mindfulness when relapse threatens.
How would insomnia be treated?
sedative antidepressants, benzodiazepines
What are some strategies used in CBT to adress the maladaptive schemas?
- questioning the evidence
- behavioural experiments
- modifying negative cognitions
- building self-compassion to tackle self-criticism
- developing effective coping strategies
- address resistance in CBT
- disengagement
What is the cognitive behavioural analysis system according to McCullough (2000)?
Clients are invited in each therapy session to describe problematic or challenging interpersonal situation. For each situation, they must describe in detail
(1) the sequence of events;
(2) their interpretation and beliefs about the situation;
(3) what exactly they did and said to cope with the situation;
(4) the actual outcome specifying what happened, what they thought and what they felt;
(5) the desired outcome specifying what they would have liked to have happened and what they would have liked to have thought and felt; and
(6) whether the desired outcome was achieved.
What are assumptions IPT makes?
Harry Stack Sullivan (1953)
assumed that depression is multifactorially determined, but interpersonal difficulties play a central role in maintenance of symptoms
(1) grief associated with the loss of a loved one;
(2) role disputes involving family members, friends or colleagues;
(3) role transitions such as starting or ending relationships within the family or work context, moving jobs or houses, graduation, promotion, retirement, or diagnosis of an illness; and (
4) interpersonal deficits, particularly poor social skills for making and maintaining relationships.
What does treatment with IPT look like?
12-16 sessions are required for treatment to be effective
assessment and formulation stage
- it is legitimate to adopt the “sick role” → no judgment
→ posibility to take responsibility for recovery from their depressive illness
What are some things that are being adressed in IPT?
grief
-> facilitate mourning
role disputes
-> identification and resolution
role transitions
social skills deficits
disengagement
-> acknowledge ineffectiveness
maintenance
-> review current challenges
What are specific techniques applied in IPT?
- exploratory techniques
nondirective and direct elicitation, open questions, supportive
acknoledgement, extension of topic discussed, specific line of
questioning - clarification
restructure what the client has said, repeating of key phrases,
paraphrase and encapsulate their words
pinpoint negative automatic thoughts - communication analysis
identify communication failures, reconstruct a verbatim transcript in
therapy, specify hoped outcome, invite pinpointing, direct verbal
communication - encouragement of affect
difficulty acknoledging, accepting, understanding, and regulating
their emotions
→ train acceptance of emotions, compare to others → normal to feel - use of the therapeutic relationship
- behaviour change techniques
psychoeducation, decision analysis, role-play
What is the aim of ISCT for depression?
aim is to help couples understand these types of three-column formulations of episodes that strengthen depression and expectations of these situation, and finding new ways to deal with depression that promote recovery and prevent relapse
What is being assessed in ISCT?
planning and developing hypotheses
assessment session together
partners perspective in giving a fuller account of the difficulties may be offered as rationale
behaviour patterns
unsuccessful attempted solutions
caregiving and care-receiving, decomposition criticism or mutual distancing
belief systems
pessimism
exacerbated by all types of events and stressors
predisposing constitutional, historical, and contextual factors
protective factors
How would the formulation process go in ISCT?
assessment and formulation
understanding of the main problems, suitability for treatment and treatment goals
engagement is a therapeutic priority
explore behaviours and beliefs
emphasise with each partners position
set realistic achievable goals
What does treatment with ISCT look like?
up to 20 sessions
evidence suggest two-thirds benefit from this type of therapy
commitment to remain together
What are some specific techniques administered in ISCT?
- scheduling conjoint pleasant events and routines
reactivtated by listing and scheduling regular mutually pleasurable events
demandiness, degree of activity, normal family routines - externalising depression and building on exceptions
problem distinct from the couple
negative force that they can jointly defeat - enactment
accurately identifying the point of which couples usually get stuck and create new alternatives to manage their difficulties - challenging rigid behaviour patterns
disruption, unbalancing, intensification, boundary making - communication training
- problem-solving training
reframe large complex problems as a series of small solvable problems - creating partner support
- remembering pleasant events
- compliments and statements of affection
- writing positive requests for the future
- expressing attachment needs
- role reversal
role become polarised → difficulty empathising
practice assertive responses - opening space for recovery and taking it slow
- pacing timing and ownership in therapy
- individual and family sessions
- managing resistance
- disengagement
What steps does the treatment process entail?
- Defining the problem or ailment
- Describing the treatment prescribed by the health/mental healthprofessional
- Setting a timeline for treatment progress (whether it’s a vague timeline or includes specific milestones)
- Identifying the major treatment goals
- Noting important milestones and objectives
What are some factors contributing to a good treatment plan?
- Treatment Goals – the “building blocks” of the plan, which should be specific, realistic, customized for the client, and measurable.
- Objectives – goals are the larger, more broad outcomes the therapist and client are working for, while multiple objectives make up each goal; they are small, achievable steps that make up a goal.
- Modality, Frequency, and Targets – different modalities are often applied to different goals, requiring a plan that pairs modalities, a frequency of sessions, anticipated completion date, etc., with the respective goal.
- Interventions– the techniques, exercises, interventions, etc., that will be applied in order to work toward each goal.
- Progress/Outcomes – a good treatment plan must include space for tracking progress towards objectives and goals (Hansen, 1996)
What should a treatment goal be?
specific
measurable
achievable
realistic and resourced
time-limited
How should a treatment plan be created?
- Name of client and diagnosis.
- Long term goal(such as client stating, “I want to heal my depression.”)
- Short terms goals or objectives(Client will reduce depression severity from 8/10 to 5/10 within six months). A good treatment plan will have at least three goals.
- Clinical interventions/Type of services(individual, group therapy, Cognitive-behavioral therapy, etc)
- Client involvement(what the client agrees to do such as attend therapy once per week, complete therapy homework assignments, and practice coping skills learned in treatment)
- Dates and signatures of therapist and client
