Mood Disorders - Anx-Dep Overlap, MDD, DD Flashcards
Describe the overlap between axniety and depression
anxiety and depression share common symptoms
anxiety and depressive symptoms commonly co-occur
child and adult ratings of anxiety sx’s and depressive sx’s demonstrate a high degree of overlap
clinician ratings are typically better at differentiating depression from anxiety in adults as opposed to kids
anxiety disorders are commonly comorbid with depressive disorders
anxiety d/o and depressive d/o are commonly cormobid with other disorders (e.g. personality disorders)
there is a sequential relationship between anixety and depression
differential comorbidity between depression and specific anxiety disorders
pure depression is less common that n pure anixety
which anixety d/o’s are most commonly comorbid with depression
OCD, PTSD, and PDA
which anixety disorder is the least comorbid with depression?
SP
Who do you make sense of the OCD PTSD and PDA rates of comorbidity?
Alloy’s helplessness/hopelessness model
OCD PTSD and PDA perhaps assocaited with certain rather than uncertain helplessness
What are three theories we can turn to to understand the overlap between anxiety and depression?
tripartite model (watson)
helplessness/hopelessness model (alloy et al.)
rumination model (nolen-hoeksema et al.)
describe Clark and Watson’s (1991) Tripartite model (of comobrbidity)
conceptualizes the overlap as being underlain by common and specific generalized vulnerabilities (factors)
the general distress factor (high NA)
- common to anxiety and depression
- accounts for the shared symptoms: anxious/depressed mood, insomnia, poor concentration
low PA factor (anhedonia)
- lack of interest, loss of energy
- specific to depression
the anxious arousal factor
- dry mouth, rapid heart beat, and dizziness
- specific to anxety
What was Alloy et al. (1999) rationale for proposing her Helplessness/hopelessness model of depression?
theory needs to account for:
- the seq relationship between anxiety and depression
- differential comorbidity of depression with specific anxiety disorders
- relative lack of pure depression vs. pure anxiety
describe Alloy et al.’s (1999) Helplessness/Hopelessness model of depression
her theory proposes that depressive/anxiety syndromes are determined by:
- helplessness expectancies
- negative-outcome expectancies
- the certainty of these expectancies
helplessness represents a vulnerability to stressors
failure (or success) to cope with stressors contributes to to the relative certainty-uncertainty of negative-outcomes expectancies
- a pessimistic attributional style contributes to certainty/development of depression
hopelessness represents a subset of helplessness (i.e. certain helplessness) - specific to depression
using Alloy et al’s (1999) model, describe the “equations” that lead to pure anxiety, comorbid anxiety and depression, and hopelessness depression
uncertain helplessness + uncertain negative-outcome expectancies = pure anxiety
certain helplessness + uncertain negative-outcome expectancies = cormorbid anxiety and depression
certain helplessness + certain negative-outcome expectancies = hopelessness depression
Nolen-Hoeksema got interested in talking about __________ b/c it it ________________?
rumination; is common to both depression and anxiety
define rumination (and differentiate from worry)
thinking in a repetitive and passive way about one’s negative emotions focusing on their symptoms of distress AND the meaning of their distress
We read a study by N-H for class; he was studying the relationship between rumination and the onset of depressive episodes: what was his rationale for conducting that study (i.e. what did the previous research say)
rumination predicted depressive episodes
rumination themes often reflect uncertainty about managing/controlling one’s environment
rumination appears to contribute to hopelessness about the future and negative self-evaluations
What were the results of N-H’s study?
Rumination predicted depressive episodes, including the initial onset
rumination predicted anxiety symptoms as well as it predicted depressive symptoms
P’s that had mixed anx-dep were also higher on rumination than P’s with either anxiety or depression alone
Sum up the three models – what do they contribute to your understanding of the relationship between anxiety and depression?
Clark and Watson’s (1991) Tripartite model - contribute to my understanding of general biological vulnerabilities that underlie both (or one) kinds of syndromes)
alloy et al.s (1999) helplessness/hopelessness model - contribute to my understanding of the seq relationship, diff comorbidity, and relative lack of pure depression vs. pure anxiety - helps me understand the transition from anxiety to depression
Rumination (N-H, 2000) - contributes to my knowledge of the specific variables involved in the transition (is common to anx/depression) – rumination is one such specific variable
epidemiology of depression: point prevalence (child, adolescent, adult); lifetime prevalence; ration between men and women; proportion of P’s with MDD who report comorbidity; porportion of P’s with Hx of MDD who report recurrent episodes?
80%
Where does this data come from (Kessler, 2002; a WHO study)
Course of depression: proportion of Px’s w/ MDE that recover in the first year; prop. of Px’s w/ MDE that relapse w/in 1st year; recurrence (new episode) rates 2, 5, and 10 years after MDE
70%
22%
25-40; 60; 75%
Where does this data come from: (Boland & Kessler, 2002)
conseqeunces of depression
According to Kessler, 2002:
WHO study ranked depression as the single most burdensome disease in the world
Estimated cost of depression-related lost productivity in US exceeds $33 billion
Depression can disrupt critical role transitions
People with untreated depression are often heavy users of primary care medical services
What’s the mnemonic for depression symptoms
SIGECAPPS
Sadness (depressed mood) Interest (anhedonia) Guilt (excessive) Energy (loss of) Concentration (diminished/poor) Appetite (loss of, increase -- weight gain/loss?) Psychomotor (agitation/retardation) Sleep (insomina/hypersomina, restless sleep) Suicide
DSM IV criteria for an MDE
5 or more symptoms, in same 2 week period (at least one needs to be depressed mood or anhedonia)
Not part of a Mixed Episode
Cause clinically significant distress/ impairment
Symptoms not due to effects of GMC or substance
Symptoms are not better accounted for by Bereavement
DSM IV criteria for MDD, single episode
Presence of a single Major Depressive Episode
Major Depressive Episode is not better accounted for by a psychotic disorder
There has never been a manic, mixed, or hypomanic episode
DSM IV criteria for MDD, recurrent
Presence of two or more Major Depressive Episodes. Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode
Major Depressive Episode is not better accounted for by a psychotic disorder
There has never been a manic, mixed, or hypomanic episode
DSM IV criteria for DD
Depressed mood for most of the day, for more days than not, at least 2 years
while depression, experience 2 or more of the following Sx's: CHASES Concentration (diminshed/poor) Hopelessness (feelings of) Appetite (loss of, increase) Sleep (insomnia/hypersomnia) Energy (lack of) Self-esteem (low)
During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
No Major Depressive Episode has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
not due to substance/GMC
clinically significant distress/impairment
When can DD and MDD co-occur?
Double depression (DD for two years, then onset MDE)
MDD, full remission, at least two months no MDE, then onset DD
Coding MDD
296.xx – Major Depressive Disorder 4th digit - .2 – Single Episode, .3 – Recurrent 5th digit – severity/remission 1 = Mild 2 = Moderate 3 = Severe Without Psychotic Features 4 = Severe With Psychotic Features 5 = In Partial Remission 6 = In Full Remission 0 = Unspecified
additional MDD specifiers
Chronic With Catatonic Features With Melancholic Features With Atypical Features With Postpartum Onset With and Without Full Interepisode Recovery With Seasonal Pattern
In sum, how do we distinguish MDD and DD
based on severity, chronicity, and persistence.
Genetics of depression: family studies, twin studies, heritability estimates (what do these data tell us?)
Family studies - higher rates of MDD in first degree relatives of depressed individuals
Twin studies – higher concordance rates of MDD for MZ twins than for DZ
Heritability estimates of MDD – 40-70%
Evidence that MDD results from genetic vulnerability + environmental stress
Where’s this data from?: Wallace, Schneider, McGuffin, 2002
Depression and early life experiences…
Part of the environmental part of the genetics+environment equation
- Fetal exposure to stress can lead to depression
- Inadequate parenting can lead to depression
- Exposure to stressful life experiences can lead to depression
Fetal exposure to stress can lead to depression
- Maternal stress can affect fetal development (i.e. the cortisol itself; e.g. disrupted HPA axis and other regulatory mechnisms in the brain)
- Maternal stress also leads to poor health behaviors during pregnancy that can affect fetal development
Inadequate parenting
- exposure to poor model of social skills and affective expression
- which, can lead to more arousal modulation and affect regulation in child
- can also affect self-esteem, attachment-relationships social-cognitive biases, attribution style
exposure to stressful life events
-e.g. maternal depression, which is associated with financial difficulties, marital discord, etc)
this comes from (Goodman & Brand, 2009)
depression and stressful life events
not everyone exposed to stressful life evetns goes on to develop depression, however:
SLE’s are associated with depression
the more severe the SLE the stronger the association with depression
ppl with hx of depression report more SLE even when not in episodes of depression
independent SLE were predictive of depression
depedent SLE were more predicitive of depression
chronic role related stressors are strongly associate with chirnically depressed mood
the enduring effects of SLE’s account for most of the effects of life events on MDD
this data comes from Kessler, 1997)
depression in the social context…
MDD pos. associated with social skills deficits ( what kinds, below)
MDD negatively associated with marital and parenting relationship problems
Specific social risk factors for depression:
- Negative feedback seeking
- Interpersonal inhibition
- Dependency/Sociotropy
(Joiner, 2002)
Gender diffferences in depression, and how the field makes sense of them?
roughly twice as many women as men experinces MDD at some point in their life (approx 22:13%; Kessler, 2002: WHO)
Biological explanations
- Hormonal changes associated with puberty
- –Testosterone & estradiol levels better accounted for increases in depressive sxs than age
- Genetic factors
- –Some studies show greater genetic effects among females than males, but findings are mixed
Psychological explanations
- Interpersonal orientation
- Rumination
Social explanations
- Trauma/childhood adversity
- Interpersonal stress
Cultural difference in depression: symtpom expression
difference in symptom expression across cultures – many other cultures are more likely to endorse somatic (vs. emotional) symptoms
- -“Nerves” and headaches in Latino & Mediterranean cultures
- -Weakness, tiredness, “imbalance” in Asian cultures
- -Problems of the “heart” in Middle Eastern cultures or being “heartbroken” among Hopi
Chentsova-Dutton & Tsai, 2009
cultural differences in depression: prevalence
Cross-cultural differences in prevalence of MDD
- higher in countries with rapidly changing economic/political conditions
- US and Canada consistently higher than E. Asian countries
- in contrast bipolar spectrum d/o’s stable across cultures
Chentsova-Dutton & Tsai, 2009
risk factors consistently associated with depression across cultures & cultural factors associated with depression
female gender, low SES, stress, and not being married
- Positivity biases
- Attributional style
- Norms regarding negative emotions/ emotional expression
Chentsova-Dutton & Tsai, 2009
name three models of depression
hopelessness model (abramson, 2002)
beck’s cognitive (behahvioral) model
Joorman (2009) the cognitive aspects of depression – very similar to the other two, but makes the role of negative emotion and emotion regulation deficits more explicit
describe the CBASP model of chronic depression
mccullough, 2003
Chronically depressed patients are similar to preoperational children
- Think in a prelogical and precausal manner
- Egocentric views of self/others
- Talk in monologue fashion
- Unable to generate empathy with others
- Emotionally dysregulated
sum up the research about med treatment for depression
Antidepressants are more effective than placebo
- Limited to severely depressed individuals (e.g., Fournier et al., 2010)
- May be more effective for mild to moderate depression when course is chronic (Keller et al., 2000)
Continued tx after acute response associated with a reduced rate of relapse (Geddes et al., 2003)
- Maintenance tx is less effective for those with chronic or recurrent depression
- No guidance for the optimal length of medication maintenance
Side effects are common
sum up the research about psychotherapy for despression
Behavior therapy, Cognitive therapy and Interpersonal Psychotherapy are well-established as beneficial treatments for MDD (APA, Div. 12, Society of Clinical Psychology)
Some evidence that brief dynamic therapy, self-control therapy, and social problem-solving therapy are useful in the treatment of MDD (APA, Div. 12, Society of Clinical Psychology)
Now, more specifcally, summarize the research around CBT for depression
CBT has been widely studied and validated as a treatment for depression
Outcome research has consistently found that CBT is at least as effective as TCA’s for the treatment of MDD
Several studies have failed to find the combination of CBT and medication to be superior to either treatment alone
Research has found that patients treated with CBT alone or with CBT + Meds have lower rates of relapse compared to those treated with Meds alone
sum up treatment research for chronic depression
CBASP: Situational Analysis, Interpersonal Discrimination, Behavioral Skills Training
Keller et al., 2000 found CBASP and Serzone were equally effective in treating chronic depression and that the combination of the two was superior to the individual treatments
