Ch. 16 Depressive Disorders Flashcards
Mood vs. Affect
Mood is a pervasive and sustained emotion that may have a major influence on a person’s perception of the world. Examples of mood include depression, joy, elation, anger, and anxiety.
Affect is described as the external, observable emotional reaction associated with an experience. A flat affect describes someone who lacks emotional expression and is often seen in severely depressed clients.
Depression is…
An alteration in mood that is expressed by feelings of sadness, despair, and pessimism. There is a loss of interest in usual activities, and somatic symptoms may be evident. Changes in appetite, sleep patterns, and cognition are common.
Comorbidities of depression
Anxiety disorders
Psychotic disorders (Schizophrenia)
Substance use disorders (Alcohol = depressant)
Eating disorders
Personality disorders
Who does depression affect?
Age and Gender
Socioeconomic Factors
Race and Culture
Marital Status
- Lifetime prevalence of depressive disorders is higher in those aged 45 years or younger
- Research indicates that the incidence of depressive disorder is higher in women than it is in men by almost 2 to 1
- Results of some studies have indicated an inverse relationship between social class and report of depressive symptoms. However, there has yet to be a definitive causal understanding in the socioeconomic status-mental illness relationship.
- No consistent relationship with race and culture
- A number of studies have suggested that marriage has a positive effect on the psychological well-being
- Studies have suggested that marital status alone is not a valid indicator of risk for depression
How does seasonality affect depression?
What could benefit those experiencing seasonal depression?
Affective disorders are more prevalent in the Winter and in the Fall.
The reported benefits of light therapy seem to support a seasonal cause for depression during winter months when there may be less exposure to natural sunlight
Major Depressive Disorder is…
- Characterized by depressed mood or loss of interest or pleasure in usual activities.
- Evidence will show impaired social and occupational functioning that has existed for at least 2 weeks, no history of manic behavior, and symptoms that cannot be attributed to use of substances or a general medical condition.
Diagnostic Criteria of Major Depressive Disorder
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2)
- 1.Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful)
- 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)
- 3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day
- 4. Insomnia or hypersomnia nearly every day
- 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- 6. Fatigue or loss of energy nearly every day
- 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or another medical condition.
D. The episode is not attributable to the physiological effects of a substance or another medical condition.
E. There has never been a manic episode or a hypomanic episode.
Specify:
- With anxious distress
- With mixed features
- With melancholic features
- With atypical features
- With mood-congruent psychotic features
- With mood-incongruent psychotic features
- With catatonia
- With peripartum onset
- With seasonal pattern
Persistent Depressive Disorder (Dysthymia) is…
Age of onset
- Characteristics are similar to, if somewhat milder than, MDD
- Individuals with this mood disturbance describe their mood as sad or “down in the dumps.”
- There is no evidence of psychotic symptoms.
- The essential feature is a chronically depressed mood (or possibly an irritable mood in children or adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents).
- Early onset: before 21
- Late onset: after 21
Diagnostic Criteria for Persistent Depressive Disorder (Dysthymia)
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following:
- 1. Poor appetite or overeating
- 2. Insomnia or hypersomnia
- 3. Low energy or fatigue
- 4. Low self-esteem
- 5. Poor concentration or difficulty making decisions
- 6. Feelings of hopelessness
C. During the 2-year period of the disturbance, the individual has never been without the symptoms in A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if…
- With anxious distress
- With mixed features
- With melancholic features
- With atypical features
- With mood-congruent/mood-incongruent psychotic features
- With peripartum onset
- Partial/full remissions
- Early or late onset (before or after 21 years old)
- Mild, moderate, severe
- With pure dysthymic syndrome
- With persistent major depressive episode
- With intermittent major depressive episodes, with or without current episode
Premenstrual Dysphoric Disorder is…
- Markedly depressed mood, excessive anxiety, mood swings, and decreased interest in activities during the week prior to menses, improving shortly after the onset of menstruation, and becoming minimal or absent in the week postmenses
- Different from Premenstrual mood changes: intensity and frequency of symptoms.
- Symptoms of PMDD are severe enough to interfere with one’s ability to function socially, at work, or at school and they are recurrent for the majority of menstrual cycles over the course of a year.
Substance/Medication-Induced Depressive Disorder is…
Meds that evoke mood symptoms:
- Symptoms are a direct result of physiological effects of a substance.
- This disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The depressed mood is associated with intoxication or withdrawal from substances such as alcohol, amphetamines, cocaine, hallucinogens, opioids, phencyclidine-like substances, sedatives, hypnotics, or anxiolytics.
- Symptoms meet criteria for MDD
Meds that evoke mood symptoms: - Anesthetics, analgesics, anticholinergics, anticonvulsants, antihypertensives, antiparkinsonian agents, antiulcer agents, cardiac medications, oral contraceptives, psychotropic medications, muscle relaxants, steroids, and sulfonamides.
Depressive Disorder Due to Another Medical Condition
Examples of medical conditions that influence depression
- Symptoms associated with a major depressive episode that are the direct physiological consequence of another medical condition
- Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- Examples of medical conditions that influence depression include stroke, traumatic brain injuries, thyroid disorders, Cushing’s disease, Huntington’s disease, Parkinson’s disease, and multiple sclerosis.
Predisposing Factors of Depression
Genetics
- Twin studies suggest a strong genetic factor in the etiology of affective illness, including depressive disorders and bipolar disorders.
- Family studies have shown that major depression is seven times more common among 1st degree biological relatives of people with the disorder than among the general population
- Adoption studies
Predisposing Factors of Depression
Biochemical Influences
It has been hypothesized that depressive illness may be related to a deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine at functionally important receptor sites in the brain.
Cholinergic transmission (acetylcholine) is thought to be excessive in depression
Predisposing Factors of Depression
Neuroendocrine Disturbances
Hypothalamic-Pituitary-Adrenocortical Axis
- Hypersecretion of cortisol
- This elevated serum cortisol is the basis for the dexamethasone suppression test that is sometimes used to determine if an individual has somatically treatable depression.
Hypothalamic-Pituitary-Thyroid Axis
- Diminished TSH response is observed in some individuals with depression
- Individuals with hypothyroidism often manifest with signs of depression
Predisposing Factors of Depression
Physiological Influences
Medication Side Effects
A number of drugs, either alone or in combination with other medications, can produce a depressive syndrome.
- Antibacterial, antifungal, and antiviral agents
- Antibacterial, antifungal, and antiviral agents
- Antineoplastics (including vincristine and zidovudine)
- Dermatologics (including Accutane and finasteride)
- Hormones (including contraceptives)
- Respiratory agents (leukotriene inhibitors)
- Statins
- Steroids
- Smoking cessation agents (varenicline)
- Anticonvulsants
Predisposing Factors of Depression
Physiological Influences
Neurological Disorders
Electrolyte Disturbances
Hormonal Disturbances
Nutritional Deficiencies
Physiological Conditions
Inflammation
- Neurological disorders: CVA, brain tumors, Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, Multiple Sclerosis
- Electrolyte Disturbances: Excessive levels of sodium bicarbonate or calcium, Potassium excess or depletion
- Hormonal disturbances: Cushing’s, Addison’s, hypoparathyroidism, hypothyroidism, and hyperthyroidism, imbalance of the hormones estrogen and progesterone (PMDD)
- Nutritional Deficiencies: Deficiencies in proteins, carbohydrates, vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B6 (pyridoxine), vitamin B9 (folate), vitamin B12, iron, zinc, calcium, chromium, iodine, lithium, selenium, and potassium
- Physiological Conditions: Lupus, polyarteritis nodosa, CVD, infection, metabolic disorders
- Role of Inflammation: function of immune system in psychiatric disorders; ndividuals with treatment-resistant depression manifest with high CRP and TNF (biomarkers of inflammation
Psychoanalytical Theory behind depression
Freud
- He observed that “melancholia” occurs after the loss of a loved object, either actually by death or emotionally by rejection, or the loss of some other abstraction of value to the individual.
- Freud indicated that the depressed patient’s rage is internally directed because of identification with the lost object
- He postulated that once the loss had been incorporated into the self (ego), the hostile part of the ambivalence that had been felt for the lost object is then turned inward against the ego.
Learning Theory behind depression
- “Learned helplessness”
- State of helplessness that exists in humans who have experienced numerous failures (either real or perceived). The individual abandons any further attempt to succeed.
- Learned helplessness predisposes individuals to depression by imposing a feeling of lack of control over their life situation.
- They become depressed because they feel helpless; they have learned that whatever they do is futile.
Object Loss Theory behind depression
- The theory of object loss suggests that depressive illness occurs as a result of having been abandoned by or otherwise separated from a significant other during the first 6 months of life.
- This absence of attachment, which may be either physical or emotional, leads to feelings of helplessness and despair that contribute to lifelong patterns of depression in response to loss.
- Object loss theory suggests that loss in adult life afflicts people much more severely in the form of depression if the individuals have suffered early childhood loss.
Cognitive Theory behind depression
- Theory suggesting that the primary disturbance in depression is cognitive rather than affective.
- The underlying cause of the depression is cognitive distortions that result in negative, defeated attitudes.
- 3 cognitive distortions that are the basis for depression
1. Negative expectations of the environment
2. Negative expectations of the self
3. Negative expectations of the future - These cognitive distortions arise out of a defect in cognitive development, and the individual feels inadequate, worthless, and rejected by others. Outlook for the future is one of pessimism and hopelessness.
- Depression is the product of negative thinking.
Symptoms of depression in children up to 3 years old
Signs may include
- Feeding problems
- Tantrums
- Lack of playfulness and emotional expressiveness
- Failure to thrive
- Delays in speech and gross motor development.
Symptoms of depression from ages 3 to 5
Common symptoms may include
- Accident proneness
- Phobias
- Aggressiveness
- Excessive self-reproach for minor infractions.
Symptoms of depression from ages 6 to 8
These children may have…
- Vague physical complaints
- Display aggressive behavior.
They may…
- Cling to parents
- Avoid new people and challenges.
- Lag behind their classmates in social skills and academic competence.
Symptoms of depression from ages 9 to 12
Common symptoms include..
- Morbid thoughts
- Excessive worrying.
They may reason that they are depressed because…
- They have disappointed their parents in some way.
There may be…
- Lack of interest in playing with friends.
Common precipitating factors for childhood depression
Treatment
- Common precipitating factors include physical or emotional detachment by the primary caregiver, parental separation or divorce, death of a loved one (person or pet), a move, academic failure, or physical illness. In any event, the common denominator is loss.
- The focus of therapy for depressed children is to alleviate the child’s symptoms and strengthen the child’s coping and adaptive skills with the hope of possibly preventing future psychological problems.
- Parental and family therapy are commonly used to help the younger depressed child.
Common symptoms of depression in adolescence
What is the indicator that differentiates mood disorder from the typical turbulent behavior of adolescence?
What is the most common precipitant to adolescent suicide?
Treatment
- Inappropriately expressed anger
- Aggressiveness
- Running away
- Delinquency
- Social withdrawal
- Sexual acting out
- Substance abuse
- Restlessness
- Apathy
- Loss of self-esteem
- Sleeping and eating disturbances,
- Psychosomatic complaints
A visible manifestation of behavioral change that lasts for several weeks is the best clue for a mood disorder.
The perception of abandonment by parents or closest peer relationship is thought to be the most frequent immediate precipitant to adolescent suicide.
Treatment - In addition to supportive psychosocial intervention, antidepressant therapy
- Black box warning on antidepressants: Increased risk of suicidal thoughts and behavior in children and adolescents
Senescence
What predisposes the elderly to depression?
What is it confused with?
Treatment
- Bereavement overload occurs when individuals experience so many losses in their lives that they are not able to resolve one grief response before another one begins. Predisposes elderly to depression
- The elderly account for a proportionately larger percentage of the suicides in the United States.
- Symptoms of depression are often misdiagnosed as neurocognitive disorder when, in fact, the memory loss, confused thinking, or apathy symptomatic of NCD may be the result of depression.
- Antidepressant medications are administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity.
- ECT in the elderly is “highly effective, safe, and well tolerated” in the geriatric population. May be considered the tx of choice for the elderly individual who is an acute suicidal risk or is unable to tolerate antidepressant medications.
- Also interpersonal, behavioral, cognitive, group, and family psychotherapies.
“Baby blues” is…
Symptoms of the “baby blues” include…
- Worry
- Sadness
- Fatiguea
These symptoms affect about 80 percent of mothers and usually subside within a week or two
Postpartum depression is…
Etiology
Treatment
Symptoms include…
- Depressed mood varying from day to day, with more bad days than good tending to be worse toward evening and associated with…
- Fatigue
- Irritability
- Loss of appetite
- Sleep disturbances
- Loss of libido
- Expresses a great deal of concern about her inability to care for her baby.
Symptoms begin somewhat later than those described in the maternity blues and take from a few weeks to several months to abate.
Etiology may very likely be a combination of hormonal, metabolic (tryptophan), and psychosocial influences.
Treatment varies with the severity of the illness.
Psychotic depression may be treated with antidepressant medication, along with supportive psychotherapy, group therapy, and possibly family therapy.
Symptoms of depression can be described as alterations in four spheres of human functioning:
(1) affective, (2) behavioral, (3) cognitive, and (4) physiological
Alterations within these spheres differ according to degree of severity of symptomatology.
Transent Depression
Affective:
Behavioral:
Cognitive:
Physiological:
Symptoms at this level of the continuum are not necessarily dysfunctional.
Transient depression subsides quickly, and the individual is able to refocus on other goals and achievements.
■ Affective: Sadness, dejection, feeling downhearted, having the blues
■ Behavioral: Some crying
■ Cognitive: Some difficulty getting mind off one’s disappointment
■ Physiological: Feeling tired and listless
Mild Depression
Affective:
Behavioral:
Cognitive:
Physiological:
Symptoms at the mild level of depression are like those associated with uncomplicated grieving
■ Affective: Denial of feelings, anger, anxiety, guilt, helplessness, hopelessness, sadness, despondency
■ Behavioral: Tearfulness, regression, restlessness, agitation, withdrawal
■ Cognitive: Preoccupation with the loss, self-blame, ambivalence, blaming others
■ Physiological: Anorexia or overeating, insomnia or hypersomnia, headache, backache, chest pain, or other symptoms associated with the loss of a significant other
Moderate Depression
Affective:
Behavioral:
Cognitive:
Physiological:
Dysthymia (persistent depression disorder) is an example.
Characterized by symptoms that are enduring for at least 2 years
■ Affective: Feelings of sadness, dejection, helplessness, powerlessness, hopelessness; gloomy and pessimistic outlook; low self-esteem; difficulty experiencing pleasure in activities
■ Behavioral: Sluggish physical movements (i.e., psychomotor retardation); slumped posture; slowed speech; limited verbalizations, possibly consisting of ruminations about life’s failures or regrets; social isolation with a focus on the self; increased use of substances possible; self-destructive behavior possible; decreased interest in personal hygiene and grooming
■ Cognitive: Slowed thinking processes; difficulty concentrating and directing attention; obsessive and repetitive thoughts, generally portraying pessimism and negativism; verbalizations and behavior reflecting suicidal ideation
■ Physiological: Anorexia or overeating; insomnia or hypersomnia; sleep disturbances; amenorrhea; decreased libido; headaches; backaches; chest pain; abdominal pain; low energy level; fatigue and listlessness; feeling best early in the morning and continually worse as the day progresses
Severe Depression
Affective:
Behavioral:
Cognitive:
Physiological:
Also called Major Depressive Disorder
■ Affective: Feelings of total despair, hopelessness, and worthlessness; flat (unchanging) affect, appearing devoid of emotional tone; prevalent feelings of nothingness and emptiness; apathy; loneliness; sadness; inability to feel pleasure
■ Behavioral: Psychomotor retardation so severe that physical movement may literally come to a standstill, or psychomotor behavior manifested by rapid, agitated, purposeless movements; lumped posture; sitting in a curled-up position; walking slowly and rigidly; virtually nonexistent communication (verbalization reflect delusional thinking); no personal hygiene and grooming; social isolation is common, with virtually no inclination toward interaction with others
■ Cognitive: Prevalent delusional thinking with delusions of persecution and somatic delusions being most common; confusion, indecisiveness, and an inability to concentrate; hallucinations reflecting misinterpretations of the environment; excessive self-deprecation, self-blame, and thoughts of suicide
■ Physiological: A general slowdown of the entire body, reflected in sluggish digestion, constipation, and urinary retention; amenorrhea; impotence; diminished libido; anorexia; weight loss; difficulty falling asleep and awakening very early in the morning; feeling worse early in the morning and somewhat better as the day progresses
The following criteria may be used for measurement of outcomes in the care of the depressed patient.
■ Has experienced no physical harm to self.
■ Discusses feelings with staff and family members.
■ Expresses hopefulness.
■ Sets realistic goals for self.
■ Is no longer afraid to attempt new activities.
■ Is able to identify aspects of self-control over life situation.
■ Expresses personal satisfaction and support from spiritual practices.
■ Interacts willingly and appropriately with others.
■ Is able to maintain reality orientation.
■ Is able to concentrate, reason, solve problems, and make decisions.
■ Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status.
■ Sleeps 6 to 8 hours per night and reports feeling well rested.
■ Bathes, washes and combs hair, and dresses in clean clothing without assistance.
Behaviors associated with nursing diagnosis: Risk for Suicide
Depressed mood
Feelings of hopelessness and worthlessness
Anger turned inward in the self
Misinterpretations of reality
Suicidal ideation, plan, and available means
Behaviors associated with nursing diagnosis: Complicated Grieving
Depression
Preoccupation with thoughts of loss
Self-blame
Grief avoidance
Inappropriate expression of anger
Decreased functioning in life roles
Behaviors associated with nursing diagnosis: Low Self-Esteem
Expressions of helplessness, uselessness, guilt, and shame
Hypersensitivity to slight or criticism
Negative, pessimistic outlook
Lack of eye contact
Self-negating verbalizations
Behaviors associated with nursing diagnosis: Powerlessness
Apathy
Verbal expressions of having no control
Dependence on others to fulfill needs
