Transcript Major Depressive Disorder

Mood Disorders
Major Depressive Disorder
 Five or more of the following:
– Depressed mood most of the day, nearly every day
– Markedly diminished interest or pleasure in all, or almost
all, activities most of the day
– Significant weight loss when not dieting or gaining
weight or decrease in appetite
– Insomnia or hypersomnia nearly every day
– Psychomotor agitation or retardation nearly every day
– Fatigue or loss of energy nearly every day
– Feelings of worthlessness or excessive or inappropriate
guilt nearly every day
Major Depressive Episode
– Diminished ability to think or concentrate, or
indecisiveness, nearly every day
– 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
 Either depressed mood or loss of interest and pleasure
must be one of the five symptoms
 Symptoms cannot be due to the direct physiological effects
of a substance (e.g., drug of abuse, medication) or a
general medical condition (e.g., hypothyroidism).
Bipolar I Disorder
 Episodes of mania or mixed episodes that include
symptoms of both mania and depression.
 Three of the following (four if mood is irritability)
– Increase in activity level - at work, socially, or sexually
– Unusual talkativeness, rapid speech
– Flight of ideas or subjective impression that thoughts
are racing
– Less than the usual amount of sleep needed
– Inflated self-esteem, belief that one has special powers,
talents, abilities
– Distractibility; attention easily diverted
– Excessive involvement in risky activities
Unipolar-Bipolar Distinction
Variable
Unipolar
Motor Activity
Typically agitated
Sleep
Difficulty sleeping
Age of onset
Late 30s to early 40s
Family History First-degree relatives at
high risk for unipolar
depression
Gender
Much more common
among women
Biological
Some response to
Treatment
lithium but better to
tricyclics
Bipolar
Typically retarded
when depressed
Sleeps more than
usual when depressed
Thirty
First-degree relatives
at high risk for
unipolar and bipolar
About equal in
gender
Best response to
lithium
Cyclothymic Disorder
 For at least 2 years (1 year for children), the
presence of numerous periods with hypomanic
symptoms and numerous periods with depressive
symptoms that do not meet criteria for a Major
Depressive Disorder
 During the above 2-year period, the person has not
been without symptoms for more than 2 months at a
time
 No Major Depressive Disorder, Manic Episode, or
Mixed Episode has been present during the first 2
years of the disturbance
Dysthymic Disorder
 Depressed mood for most of the day, for more days than
not, for at least 2 years (1 year in children)
 Presence, while depressed, of two or more of the
following:
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poor appetite or overeating
insomnia or hypersomnia
low energy or fatigue
low self-esteem
poor concentration or difficulty making decisions
feelings of hopelessness
 During the 2 years of the disturbance, the person has never
been without the symptoms for more than 2 months at a
time
Cognitive Theory of Depression
 People are depressed because their thinking is
biased toward negative interpretations
 People acquire negative schema due to experiences
in childhood (loss of a parent, rejection by peers)
 Negative schema are activated whenever they
encounter new situations which resemble (even
vaguely), the conditions in which the schemata
were learned
 The negative schemata fuel and are fueled by
cognitive biases, which lead depressed people to
misperceive reality
Beck’s Negative Triad
Self
“I am inadequate”
World
“I cannot cope”
Future
“Things will always
turn out poorly”
Examples of Cognitive Biases
 After failing a math exam: “I’m a big
failure.”
 Following a disagreement with the boss
“She thinks everything I say is stupid.”
 During an argument with her husband “He
thinks I never get anything right.”
 After a complement from a friend “He just
said that because he feels sorry for me.”
Evaluation of Cognitive Theory
 Depressed people judge themselves in biases ways
 Depressed people demonstrate the cognitive biases
which Beck outlines
 Negative thinking decreases after treatment
 Although pessimistic, depressed people sometimes
are actually more accurate than normal (e.g.,
judging probability of success)
 Whether depression is the result of cognitive
biases or vice versa is not clear
Learned Helplessness
Uncontrollable
Aversive
Event
Sense of
Helplessness
Depression
Attributional Theory
Aversive
events
Attributed
to global
and stable
factors
Sense of
helplessness;
no response
available to
alter the
situation
Depression
Why I Failed My Math Test
Internal (Personal)
Degree
Global
Stable
I lack
Unstable
I am exhausted
intelligence
External (Environmental)
Stable
Unstable
These tests are
It’s an unlucky
all unfair
day, Friday the
13th
Specific
I lack math
I am fed up with The math tests
My math test
ability
math
was numbered
are unfair
“13”
Hopelessness Theory
Aversive
events
Attributed
to global
and stable
factors, or
other
cognitive
factors
Sense of
hopelessness;
no response
available to
alter the
situation and
expectation
that desirable
outcomes will
not occur
Depression
Interpersonal Theory
 Depressed people may elicit negative reactions
from others
 The interactions of depressed people and their
spouses are characterized by hostility on both
sides
 Depressed people are often low in social skills
and their own behavior contributes to the high
levels of stress they experience
 The constant seeking of reassurance is a
critical interpersonal variable in depression
Genetics of Mood Disorders
 About 10 to 25 percent of the first-degree
relatives of bipolar patients also have
experienced an episode of mood disorder
 For bipolar disorder, the concordance rate
for identical twins is 72% and in fraternal
twins about 14%
 The information indicated that for unipolar
depression, genetic factors, although
influential, are not as decisive as with
bipolar disorder
Neurochemistry of Mood Disorders
 For bipolar disorder: low levels of norepinephrine
leads to depression and a high level to mania.
 Depression due to low levels of Serotonin.
 Tricyclic drugs - prevent the reuptake of both
norepinephrine and serotonin by the presynaptic
neuron after it has fired.
 Monoamine oxidase inhibitors - keep the enzyme
monoamine oxidase from deactivating
neurotransmitters, thus increasing the levels of
norepinephrine and serotonin
 Selective serotonin reuptake inhibitors - specifically
inhibit the reuptake of serotonin
Pharmacotherapy for Mood Disorders
Category
Generic
Tricyclic
Imipramine
Antidepressants Amitriptyline
Trade
Some Side Effects
Tofranil Heart attack, stroke,
Elavil
hypotension, dry mouth,
gastric disorders, erectile
failure
MAO Inhibitors Tranylcypromine Parnate Possible fatal hypertension
Dry mouth, dizziness, nausea,
headaches
SSRIs
Fluoxetine
Prozac
Nervousness, fatigue, GI
complaints, headaches,
insomnia
Lithium
Lithium
Lithium Tremors, GI distress, lack of
coordination, dizziness.
Cardiac arrhythmia, blurred
vision, fatigue
Problems with Neurochemical
Theories of Mood Disorders
 These drugs do increase levels of
norepinephrine and serotonin when they are
first taken, but after several days the
neurotransmitters return to their earlier levels.
 The drugs take 7-14 days to work
 Drugs which involve other mechanisms also
relieve depression
 Future research will center on serotonin
receptors
The Neuroendocrine System
 The limbic area of the brain is closely linked to emotion and
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also has effects on the hypothalamus (hormonal secretion)
Hormones secreted by the hypothalamus also affect the
pituitary gland and the hormones it produces
Because of its relevance to the vegetative symptoms of
depression (e.g., disturbances in appetite and sleep), the
hypothalamic-pituitary-adrenocortical axis is thought to be
overactive in depression.
Levels of cortisol (an adrenocortical hormone) are high in
depressed patients.
High levels of cortisol may lower the density of serotonin
receptors and impair the function of noradrenergic receptors.
Treatments for Depression
 Cognitive Behavioral Therapy
– Beck’s Cognitive Therapy
– Ellis’s REBT
 Interpersonal Therapy
 Drug Therapies
– Tricyclics
– MAO Inhibitors
– SSRIs
 Electroconvulsive Therapy
Childhood Depression
 As with adults, depression in childhood is
recurrent and has high rates of comorbidity (e.g.,
anxiety disorders, conduct disorder)
 Theories of etiology point to genetic factors and
interpersonal relationships.
 Research on the treatment of childhood depression
does not support the use of antidepressants. Both
CBT and Interpersonal therapies have been used
and combined with family and school
interventions
Suicide
Characteristic
Attempters
Completers
Gender
Majority Female
Majority Male
Age
Predominantly Young
Risk increases with age
Method
Low lethality (e.g., pills)
More violent (e.g., guns)
Dominant Affect Depression with anger
Motivation
Attitude Toward
Attempt
Change in situation
Cry for help
Relief to have survived
Promises not to repeat
Depression with
hopelessness
Death
Shneidman’s Approach to Suicide
 The common purpose of suicide is to seek a solution
 The common goal of suicide is the cessation of
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consciousness
The common stimulus in suicide is intolerable psychological
pain
The common stressor in suicide is frustrated psychological
needs
The common emotion in suicide is hopelessnesshelplessness
The common cognitive state in suicide is ambivalence
The common perceptual state in suicide is constriction
Shneidman’s Approach to Suicide
 The common action in suicide is egression
 The common interpersonal act in suicide is
communication of intention
 The common consistency in suicide is with
lifelong coping patterns