Depressive and Bipolar Disorders Flashcards
2 categories of mood disorders
1) depressive disorders: dysphoria (excessive unhappiness) and anhedonia (loss of interest)
2) bipolar disorders: mood swings between deep sadness to euphoria and mania
3 meanings of depression
1) as a symptom
2) as a syndrome
3) as a disorder
90% of young people with depression show…
significant impairment in daily functioning
Depression for children under 7
Diffuse symptoms, harder to identify
Preschoolers depression
May be extremely somber and tearful, lacking exuberance; may display excessive clinging and whiney behaviour around mothers
School-age children depression
Same as preschoolers, plus irritability, disruptive behaviour, tantrums
Preteens depression
The same as preschooler and school-age, plus self-blame, low self-esteem, persistent sadness and social inhibition
Diagnostic criteria for MDD: Criterion A
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) depressed mood or (2) loss of interest or pleasure.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation).
(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gains).
(4) Insomnia or hypersomnia nearly every day.
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.
Diagnostic criteria for MDD: Criterion B
The symptoms cause clinically significant distress or impairment in social, occupation or other important areas of functioning
Diagnostic criteria for MDD: Criterion C
(C) The episode is not attributable to the physiological effects of a substance or to another medical condition.
Criteria A-C of MDD represent…
a major depressive episode
Diagnostic criteria for MDD: Criteria D and E
D)The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
(E)There has never been a manic episode or hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
MDD Diagnosis in children
Same criteria for school-age and adolescents
Depression often overlooked because other behaviours attract attention
Some features such as irritability are more common in children and adolescents than in adults
Prevalence of MDD
2 – 8% of children aged 4 – 18 experience MDD
Rare among preschool and school-aged children (1 – 2%)
Sharp increase in adolescence may result from interaction of biological aspects of puberty with developmental changes
Comorbidity with MDD
Up to 90% of depressed youth have 1+ disorders
Usually anxiety related
Also: dysthymia, conduct problems, ADHD, substance use disorder, personality disorder
Onset, course and outcome of MDD
- Gradual or sudden
- Average age onset b/w 13-15 years
- Length of episode around 8 months
- Usually recover from first episode, but disorder doesn’t go away (25% of recurrence in 1 year; 40% in 2 yr, 70% in 5yrs. About 1/3 develop bipolar disorder in 5 years).
- Overall outcome is not optimistic
Depression - gender differences
Age 11-13: same (around 3%)
Age 15: female around 5%, male around 3%
Age 18-21: female around 24%, male around 11%
Persistent Depressive Disorder P-DD: Criteria for adults
- Depressed mood for most of the day, for more days than not, for at least 2 years
- Presence of (2): poor appetite/overeating, insomnia/hypersomnia, low energy/fatigue, low self-esteem, poor concentration, hopelessness
- No mania
- Significant distress or impairment in social, occupation or other areas of functioning
P-DD characteristics
Characterized by poor emotion regulation
Constant feelings of sadness, being unloved, self-deprecation, low self0esteem, anxiety, irritability, anger, temper tantrums
Children with both MDD and P-DD are more severely impaired than children with just one
P-DD prevalence
P-DD less common than MDD: ~1% of children, 5% adolescents
Most common comorbidity is MDD: nearly 70% of children with P-DD may have MDD episode
~50% of children with P-DD also have one ore more disorder unrelated to mood prior to onset
Onset, Course, Outcome of P-DD
11/12 years onset
Childhood-onset associated with prolonged duration (2-5 years)
Most recover, but high risk of developing other disorders
Adolescents with P-DD receive less social support than those with MDD
Disruptive Mood Dysregulation Disorder (DMDD)
Central feature: chronic, severe, persistent irritability
Irritability takes two forms: temper outbursts & irritable/angry mood
Cannot be diagnosed along with ODD or bipolar disorders
New to DSM-5
Associated difficulties with depression: intellectual/academic
Cognitive difficulties:
- Difficulty concentrating, loss of interest/motivation, slowed thought and movement
- Problems with tasks requiring attention, coordination speed
Interference with academic performance
-Lower test scores, poorer teacher rating, lower grades
Cognitive biases and distortions with depression
Selective attentional biases
Negative beliefs, attributions of failure, self-critical, maladaptive automatic thoughts, faulty conclusions
Depressive ruminative style, pessimistic outlook, negative self-esteem
Comes to feelings of worthlessness, hopelessness
Social difficulties with depression
Few close friendships loneliness and isolation
Social withdrawal
Ineffective coping styles in social situations
Family difficulties with depression
Typically has less supportive, more conflictual, familial relationships
Feels isolated from from family
Prefers to be alone – often hear that they are withdrawing (e.g., spending all their time in their room, etc.)
Suicide
Most youth with depression think about suicide
As many as 1/3 of those who think about it will attempt it
Worldwide, strongest risk factors are having a mood disorder and being a young female
Ages 13 – 14 are peak periods for first suicide attempt by those with depression
Theories of depression (8)
- Psychodynamic - symbolic loss of love object
- Attachment - insecure attachment
- Behavioural -lack/loss of reinforcement
- Cognitive - depressive mindset
- Self-Control - problems in organizing behaviour for long term goals
- Interpersonal - impaired interpersonal functioning
- Socio-environmental - stressful life circumstances
- Neurobiological - various abnormalities
Behavioural Theory
Emphasis on importance of learning, environment, skills/deficits during onset and maintenance of depression
See depression as being related to a lack of response-contingent positive reinforcement
Cognitive Theory
Negative thinking -> mood
Negative thinking styles: a pattern of negative perceptions and attributions and beliefs lead to depressive symptoms
Hopelessness: depression-prone individuals engage in self-blame thinking, leads to hopelessness that things can get better
Beck’s Model
Beck’s model of depression
Individuals with depression interpret life events negatively
These biases/negative beliefs act as ”interpretive filters” for how they understand events, the world
Three main areas of cognitive problems:
Information-processing biases
Negative outlook regarding self, world, future
Negative cognitive schemata
Causes of depression
Complex interaction between many factors -> many pathways to a diagnosis
Genetic risk
Heritability estimates ranging from 30 – 45%
Children with parents who have depression have about 3X the risk
Likely inherit the vulnerability to depression and anxiety more generally, which then interacts with the environment
Neurobiological causes
Abnormalities in structure, function of brain regions associated with regulating emotions
Amygdala, cingulate, prefrontal cortex, hippocampus
Cortical thinning in right hemisphere
HPA axis dysregulation, sleep architecture, growth hormone, neurotransmitters have all been implicated
Family causes
When parents are depressed, parent’s ability to meet child’s needs are impaired
Increases chance pf child having depression, anxiety, substance use disorders in adolescence and adulthood
When children are depressed, families tend to display more critical and punitive behaviour towards them than other children
Stressful life events causes
Often act as triggers (precipitating factors)
Interpersonal stress, personal losses (perceived or actual)
Life changes
Violent family environment
Persistent daily hassles or stressful life events
Traumatic event
Emotion regulation causes
Prolonged periods of emotional distress and sadness, or exposure to maternal negative moods:
May lead to problems regulating negative emotional states, leading to higher likelihood of experiencing depression
May lead youth to use negative coping strategies (e.g., avoidance, negative behaviours) to regulate themselves
Treatment types (5)
- Behavioural therapy
- Cognitive therapy
- CBT
- interpersonal Psychotherapy for Adolescent Depression (ITP-A)
- Medication
Medication for depression
Tricyclics consistently fail to treat youth with depression
SSRIs most commonly prescribed for childhood depression
Can have side effects, some serious ones: suicidal thoughts, self-harm
Lack of information re: long-term effects in youth
As many as 60% of youth with depression respond to placebo medication
Consideration of the risks of side effects needs to be balanced with benefits of the use of medication and the risks that are associated with not using medications
Behaviour Therapy for depression
Focus on increasing positive behaviour – behavioural activation
Small steps towards increasing pleasurable activities and events
Manageable – want feelings of success, positive reinforcement for their efforts
Support skills building to facilitate this process
Cognitive therapy for depression
Focus on changing the negative thinking styles/patterns
Teach skills such as:
Identifying automatic thoughts
Challenging those thoughts (e.g., thought records, detective thinking)
Challenging core beliefs, biases that drive automatic thoughts
CBT for depression
Combines behavioural and cognitive approaches
Most common psychosocial intervention for depression
Research suggests it’s the most effective approach
Some flexibility in where to start treatment – behavioural or cognitive?
Systems treatment for depression
Interpersonal: focuses on improving interpersonal functioning, combines individual (cognitive, behavioural activation, skills-building) and family-based sessions
Family based sessions: supporting the family system. Teaching communication, skills to support depressed youth, working on relationships within family (can address attachment issues, emotion validation)
Prevention of Depression
CBT-based programs have been shown to lower risk of depression, as well as lowering risk of re-occurring episodes
School-based initiatives have been a focus in this area – opportunity to enhance protective factors, promote resiliency skills, and identify those at risk
Bipolar Disorder (BD)
Alternating between MDD episodes and striking periods of unusually and persistently elevated, expansive or irritable mood.
Elation and euphoria can quickly change to anger and hostility if they experience barriers to behaviour
Symptoms of mania
Symptoms of mania include restlessness, agitation, sleeplessness, pressured speech, flight of ideas, racing thoughts, sexual disinhibition, surges of energy, expansive grandiose beliefs
3 subtypes of BD
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Bipolar I
Periods of severe mood episodes: full mania and MDD
Episodes last at least 1 week with symptoms present most of the day, nearly every day
OR episodes that required hospitalization, regardless of duration
Bipolar II
Requires at least one MDD episode and one hypomanic episode during lifetime
Periods of mood episodes: hypomania and MDD
hypomanic episodes : similar to mania in symptoms, but only needs to last at least 4 days with symptoms present most of the day, nearly every day
Often referred to as “milder bipolar”
Not accurate – significant time spent in MDD episodes and the instability still results in major impairment in functioning
Cyclothymic disorder
Experience at least 1 year (in children, adolescents) of cycling between numerous hypomanic and depressive periods without ever reaching full criteria for hypomania or MDD
Spent at least ½ of that year with one of these periods present
No consistent two month period without any symptoms
Have never met criteria for mania, hypomania, or MDD
BD in Youth
Significant impairment in functioning
Can include previous hospitalizations, MDD, medical treatment, disruptive behaviour
History of psychotic symptoms and suicidal ideation/attempts is common
Mania in youth may present atypically
Mixed manic-depressive symptoms may be more frequent than euphoria
Atypical mania symptoms
Volatile and erratic mood changes Psychomotor agitation Mental excitation Irritability Belligerence
Manic symptoms in children
manic symptoms often include pressured speech, racing thoughts, flight of ideas
