Depression Flashcards
What is major depresive episode?
A) 5/9 symptoms present across 2 week period. Must include Change from previous functioning
And 1and/or 2):
1) Depressed mood and/or
2) Diminished interest (not just one activity but broad)
3) Significant weight or appetite change
4) Insomnia/hypersomnia
5) Psychomotor agitation/retardation (fast paced or slow, must be expressed by others)
6) Fatigue/energy loss
7) Worthlessness or excessive/inappropriate guilt
8) Diminished ability to think or concentrate, or indecisiveness
9) Recurrent thoughts of death, suicidal ideation, attempt, or plan
B) Clinically significant distress or impairment in social, occupational or other important areas of functioning
C) Not due to direct or psychological effects of a substance or general medical condition
What is major depresive disorder
A,B,C from major depressive episode
D) Episode not better explained by a psychotic disorder (e.g., schizophrenia, schizoaffective delusional disorder)
E) There has never been a manic or hypomanic episode
Major depressive disorder VS grief?
Can be both:
Major depressive disorder vs grief
- Responses to a significant loss may resemble a depressive episode
- Now recognised that major depression may occur as part of the grieving
process, therefore no longer an exclusion criterion
- Consider cultural norms for expression of distress in context of loss
Grief is not an exclusion of depression but depression can be a common consequence of grief. Grief isn’t just about death but about: bankrupt, losing body part, losing dream, etc.
Epidemiology (prevelance, gender, age, comorbidity %, worldwide, prognosis)
16% lifetime
4th leading disease in the world
½ cases by 14 years old decreases as you get older
High comorbidity 75%
Prevalence similar worldwide
2:1 female: male
o Report bias
o Hormones
o Different gender roles affects manifestation of distress
o “Response Theory” (Nolem-Hoeksema) – Males learn ACTIVE and Females learn RUMINATIVE response styles.
40% recover after 3 months, 80% recover within a year
What is persistent depressive disorder
A) Depressed mood for most of the day, for more days than not, for at least 2years
B) 2 of the 6:
1) Poor appetite/overeating
2) Insomnia/hypersomnia
3) Low energy or fatigue
4) Low self-esteem
5) Poor concentration or difficulty making decisions
6) Feelings of hopelessness
C) Never more than 2 months without A and B symptoms during the 2yrs
D) Continuous major depressive disorder does not preclude diagnosis
E) There has never been a manic/hypomanic episode, nor cyclothymic disorder
F) Not better explained by a persistent psychotic disorder
G) Not due to physiological effects of a substance or medical condition
H) Clinically significant distress/impairment in social, occupational, or other areas of functioning
Premenstrual Dysphoric Disorder
A) Majority of menstrual cycles
At least 5 symptoms (B and C) present in final week before onset of menses
Start to improve within a few days after onset. Become minimal or absent in the week postmenses
5 from B and C at least one from each category + 4 from the other
B)
1. Mood swings
2. irritability, anger, or interpersonal conflicts
3. depressed mood, hopelessness, or self-deprecating thoughts
4. anxiety, tension, keyed up or on edge
C)
1. Decreased interest in activities
2. Difficulty concentrating
3. Fatigue/ low energy
4. appetite change, overeating, or specific food cravings
5. Hypersomnia or insomnia
6. feeling overwhelmed or out of control
7. Physical symptoms e.g. breast tenderness, joint or muscle pain, bloating, or weight gain
D) Clinically significant distress/interference with work, school, social activities, or relationships
E) Not merely an exacerbation of symptoms of e.g. MDD, PDD, PD, Personality Disorders
F) Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles
G) Not due to physiological effects of a substance or medical condition e.g. hypothyroidism
Disruptive mood dysregulation disorder
Core feature: chronic, severe persistent irritability:
A. out of proportion temper outbursts verbally and/or behaviourally (e.g. physical aggression toward people/property),
B. inconsistent with developmental level
C. Temper outbursts 3+ times a week
D. Mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. parents, teachers, peers)
E. 12+ months
F. All symptoms present in at least 2 out of 3 settings (i.e. home, school, peers)
G. Diagnosis not to be made before 6 yrs or after 18 yrs
Risk factors of mood disorder
Stressful life event
Social support
Coping style
Genetic & other biological factors
Learning & modelling
Gender
Assessment
- Risk (self, to others, from others) - eating, interpersonal problems
- Differentials eg substance use, Ax, psychosis, mania, medical
- Family history, developmental history
Suicide + self-harm: Up to 15% of patients with severe MDD die by suicide.
Medical disorders: 25% of individuals with severe, chronic medical illness develop depression.
- Psychotic features in nearly 19% of people meeting criteria for MDD,
- Even those who do not have hallucinations/ delusions may have impaired reality
testing e.g. those around them are undermining them. - expression differently across culture
- risk factors - coping, social support etc
- Endogenous (melancholic) =lack of reactivity to pleasurable stimuli, more intense in morning early waking, excessive guilt, weight loss. May be more biological.
- Exogenous (atypical) =primarily caused by stressful life events/psychosocial probs. Have some reactivity to pleasure, weight gain, hypersomnia, heavy feelings, sensitivity to interpersonal rejection
Etiology: Biological causes
Biological
Genetics
- Higher chance in identical twins than non-identical
- Heritability higher for females than males
- Genetic factors act as a susceptibility, which is only realised through interactions with environment
Neurochemistry
- Problems with neurotransmitter systems: serotonin and dopamine
Endocrine system
- Impacts stress hormones such as cortisol
Etiology: Life events causes
- Long exposure to psychosocial stress can bring about an episode
- Majority (66-90%) triggered by severe life event but not all – sometimes just depressed and no one cause
- NOT determinative –mediated by coping skills, attributions, social support, genetic make-up, etc.
Vulnerabilities alone and life experiences alone do not lead to depression but a mix of both of these – being vulnerable and negative experience is what leads to depression
Behavioural theories
Seligman
- Learning Helplessness: uncontrollable bad events perceived lack of control generalised helpless behaviour
- If a person experiences negative events that are uncontrollable they will feel a lack of control which leads to generalized helplessness
- Repeated exposure to stress leads to being motivated to avoid things
- Being passive is due to trying to control things unsuccessfully therefore, become passive
Hopelessness: Abrahamson revision: added attributional style
- Global attribution = generalise “everything is bad”
- stable = “things will stay this bad and won’t get better”
- Internal = “it’s about me, it’s my fault, bad things always happen to me”
- When there are positive events they will attribute it to external, variable, specific
- Recently added in child maltreatment, more that maltreatment occurs it affirms their negative attributions (stable, global, internal).
Lewinsohn
Low rate response-contingent positive reinforcement
1. Differences in what is reinforcement (chocolate may not reinforce everyone)
2. Availability of what is reinforcing (voucher but can’t spend it)
3. Level of skill in obtaining and maintaining that reinforcement (making new friends is reinforcing but if they lack the skills then they can’t get that reinforcement)
- Lack of positive reinforcement for behavioural response = response extinguishment
o Those with depression don’t get joy from doing things so stop doing behaviour - Subsequent loss of reinforcement deprives individual of pleasure, leading to dysphoria (dis-satisfaction)
- Dysphoria + low rate of response drives the other primary depression symptoms
- Symptoms then reinforced (attention, sympathy)
Jacobson –
Behavioural activation model
- Increased attention on negative reinforcement (as opposed to simply lack of positive) - something adverse taken away so more likely to do it (avoid)
- Central role of avoidance: provides short-term relief but maintains the problem
- Model shows depression as a cycle, person wants to escape their environment
- Low reinforcement leads to depressed behaviours which leads to low mood which leads to decreased healthy behaviour and more avoidance therefore more depressive symptoms.
Cognitive model- Beck
1. The cognitive triad (negative automatic thoughts of self, world and future)
- Short, specific, occur rapidly, key words/images, not summoned, seem reasonable (takes training to start qs these thoughts)
- Other depressive symptoms seen as a consequences of triad activation
2. Schemas
- Structural organisation of peoples past experiences which impacts how people view things, schemas are self-perpetuating and are hard to change
- Build from peoples experiences and create a (lens for people, self-fulfilling prophesy)
- Impact selective attention, organisation, and interpretation of stimuli
3. Cognitive errors (faulty information processing)
- Systematic errors in thinking that maintain belief in negative concepts, despite contradictory evidence
- Arbitrary inference – a conclusion drawn in absence of sufficient or any evidence
- Selective abstraction – a conclusion drawn on basis of but one of many elements
- Overgeneralisation – an overall sweeping conclusion drawn on basis of single event
- Exaggeration
- Dichotomous thinking – all-or-nothing, black & white
Wells metacognitive
Triggers activate positive meta beliefs about rumination (i.e. ruminating is problem solving) which results in period of rumination. Cognitive attentional syndrome including rumination-a persistent perseverative thinking pattern focussed on past events about negative aspects of oneself, others and one’s life. Often called dwelling on/over analysing/obsessing. Sustained periods of rumination are associated in low mood. Sustained rumination activates negative metacognitions, including beliefs around uncontrollability of rumination which in results in depression symptoms (behaviour, thoughts, affect).
Psychometrics
Psychometrics:
- Beck Depression Inventory (inc risk item, age 13 – 80, 29+ = severe)
- DASS-42
- Beck Hopelessness Scale (age 17-80, 14+ severe hopelessness)
- Beck Youth Inventories (7-18 years)
- Geriatric Depression Scale (65+, less focus somatic symptoms)
- Edinburgh Postnatal Depression Scale (Used during pregnancy to 8 wks postpartum) - Measures guilt, tearfulness, irritability, anxiety without somatic questions & one item suicide
Differentials
- Sadness: Periods of sadness is normal. Distinguished by severity, duration, and impairment
- Bipolar disorder – Important to rule out as antidepressants can precipitate episodes of hypomania
- Persistent depressive disorder
- MEDICAL CAUSE: Endocrine disorders: Hypothyroidism, Hyperparathyroidism, and diabetes.
- Substance-induced
- ADHD
- Adjustment disorder with depressed mood: After a stressor, full criteria for MDD not met.
- Schizoaffective disorder
- Schizophrenia: Rule out as negative symptoms may look like depressive symptoms.
In severe cases of depression, individuals may report mood-congruent auditory hallucinations. We may assume that this severe perceptual abnormality is present when individuals report hearing voices criticising them or telling them depressive things - Dementia: similar cognitive symptoms (e.g. concentration) but distinguished by onset, course, and
treatment response.
Treatment
Pharmacology
Formulation:
* Education around what is maintaining depression (i.e., depressed physical state, action, thinking,and relationships)
Early stages of therapy should focus on symptom reduction - Behavioural Activation - monitor clients activity, plan activities aim of pleasure &/or mastery, highlight links between activity and mood/motivation
* Activity scheduling to increase opportunity for positive reinforcement and social interactions
* Self-reward with task achievement and sense of mastery
Cognitive Restructuring- Identification of ATs & cognitive distortions (thought catching and self-monitoring), Evaluating (evidence for and against) and modifying negative thoughts/cognitions,
Behavioural experiments to test out predictions and NATs (trace, face, replace/name, tame reframe)
Other
* Lifestyle changes: food, alcohol/caffeine, sleep hygiene.
* Keeping the number of stresses in life to manageable proportions
* Developing effective coping strategies and problem-solving skills
Note:
- Evidence that therapeutic alliance is more important than intervention strategy.
- Determining form and comorbidity is key to determining the best treatments.
