Depressive Disorders

Depressive Disorders

Depressive Disorders • Disruptive mood dysregulation disorder • Major Depressive Disorder • Dysthymic Disorder (Persistent depressive disorder) • Premenstrual dysphoric disorder • Substance/medication-induced depressive disorder. • Depressive disorder due to another medical condition • Other specified depressive disorder • Unspecified depressive disorder

Disruptive Mood Dysregulation Disorder • Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times per week.

Differential Diagnosis D. The 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. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.

Differential Diagnosis G. The diagnosis should not be made for the first time before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

Differential Diagnosis J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Major Depressive Disorder

Differential Diagnosis 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 (Anhedonia). 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.)

Differential Diagnosis 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 (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 gain.) 4. Insomnia or hypersomnia nearly every day.

Differential Diagnosis 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).

Differential Diagnosis 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 to another medical condition. Note: Criteria A-C represent a major depressive episode.

Differential Diagnosis 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 a 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.

Differential Diagnosis • Slow thinking and speech, long pauses before answering, • Monotone or mute • Poor memory loses perspectives in situations because of the use of generalization, negative thinking (all or nothing thinking; mind reading; negative prediction; catastrophizing; overgeneralization; personalization)

Differential Diagnosis • In severe situations thought may indicate delusional thinking • May be preoccupied with bodily symptoms (headaches; backaches…etc) • Overreaction to criticism • Verbal pessimism about the future

Prevalence • Approximately 7% Have MDD • the prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals age 60 years or older. • Females experience 1.5- to 3-fold higher rates than males beginning in early adolescence. • Recovery typically begins within 3 months of onset for two in five individuals with major depression and within 1 year for four in five individuals.

Specifiers Increase diagnostic Specificity and improve the prediction of prognosis • Describing the episode status: mild, moderate, severe with psychotic features, severe with no psychotic features, partial remission, full remission • Describing features of the last episode: catatonic, atypical, peri-partum, or melancholic features • Describing course of recurrent episodes: with seasonal pattern, with rapid cycling

Specifiers • Chronic (after 2 years) • Melancholic • Anhedonia, lack of reactivity to usual pleasurable stimuli, psychomotor retardation, anorexia or weight loss, guilt, depression worse in the AM • Atypical • Mood reactivity (mood brightens in response to positive events), weight gain, hypersomnia, increased appetite and weight gain, leaden paralysis • Seasonal Affective Disorder • Episodes begin in fall or winter and remit in the spring • Pattern has occurred for 2 yrs.

Specifiers • Psychotic features • Indicate the presence of delusions (guilt, being punished for sins), somatic (horrible disease or body rotting), poverty (going bankrupt,), or hallucinations (usually auditory, voices berating for sins or shortcomings). • Post partum • Occurs 4 weeks after child birth. Can present with or without psychotic features. Severe ruminations or delusional thoughts about infant signifying increased risk of harm to the infant.

Persistent Depressive Disorder (Dysthymia) This disorder represents a consolidation of DSM-lV-defined chronic major depressive disorder and dysthymic disorder. 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. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

Differential Diagnosis 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.

Differential Diagnosis C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria 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.

Differential Diagnosis 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.

Premenstrual Dysphoric Disorder A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses. B. One (or more) of the following symptoms must be present: • Marked affective liability (e.g., mood swings: feeling suddenly sad or tearful, or increased sensitivity to rejection). • Marked irritability or anger or increased interpersonal conflicts.

Differential Diagnosis 3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being tense or on edge. C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 1. Decreased interest in usual activities (e.g., work, school, friends, hobbies). 2. Subjective difficulty in concentration.

Differential Diagnosis 3. Lethargy, easy fatigability, or marked lack of energy. 4. Marked change in appetite; overeating; or specific food cravings. 5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control. 7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.

Differential Diagnosis D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

Differential Diagnosis F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.) G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

Depression continuum

Etiology of Depression • Biological Theories: • Genetics: no definitive mode of genetic transmission • Twin studies: Monozygotic twins 37% concordance. Meanwhile other factors such as environment accounts for the large portion of risk for Depression. • Family studies: 1.5 – 3 times common among 1st degree biological relatives of people with the disorder than general population • Adoption studies: children of parents with depression are at an increased risk of developing a mood disorder even when adopted & raised by healthy parents

Etiology of Depression • Biochemical influences: • Biogenic amines: deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine at functionally important receptors in the brain. • The catecholamine norepinephrine has been identified as a key component in the mobilization of the body to deal with stressful situations. • Neurons that contain serotonin are critically involved in the regulation of many psychobiological functions, such as mood, anxiety, arousal, vigilance, irritability, thinking, cognition, appetite, aggression, and circadian rhythm (Tryptophan, the amino acid precursor of serotonin) • A diminished supply of these biogenic amines inhibits the transmission of impulses from one neuronal fiber to another, causing a failure of the cells to fire or become charged

Etiology of Depression • The biogenic amine hypothesis has been expanded to include another neurotransmitter, acetylcholine. Because cholinergic agents do have profound effects on mood, electroencephalogram, sleep, and neuroendocrine function, it has been suggested that the problem in depression and mania may be an imbalance between the biogenic amines and acetylcholine. • Cell bodies of origin for Serotonin pathways lie within the raphe nuclei located in the brain stem • Projections for both neurotransmitters extend through out the forebrain, prefrontal cortex, cerebellum, and limbic system

Etiology of Depression AREAS OF THE BRAIN AFFECTED Areas of the brain affected by depression and the symptoms that they mediate include the following: • Hippocampus: memory impairment, feelings of worthlessness, hopelessness & guilt • Amygdala: anhedonia, anxiety, reduced motivation • Hypothalamus: increased or decreased sleep & appetite, decreased energy & libido • Other Limbic structures: emotional alteration • Frontal Cortex: depressed mood, problems concentration • Cerebellum: Psychomotor retardation / agitation

Etiology of Depression -Neuroendocrine Disturbances: a. Hypothalamic-Pituitary-Adrenocortical Axis: • In clients who are depressed, the normal system of hormonal inhibition fails, resulting in a hypersecretion of cortisol. b. Hypothalamic-Pituitary-Thyroid Axis: • Thyrotropin-releasing factor (TRF) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH) from the anterior pituitary gland.

Etiology of Depression 2. Psychosocial Theories: - Psychoanalytical Theory • Freud (1957) presented his classic paper “Mourning and Melancholia” • 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 in melancholia, the depressed patient’s rage is internally directed because of identification with the lost object. - Learning Theory • The model of “learned helplessness” arises out of Seligman’s (1973) experiments with dogs. • This can be especially damaging very early in life, because the sense of mastery over one’s environment is an important foundation for future emotional development.

Etiology of Depression - Object Loss Theory • 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.

Etiology of Depression 3. Cognitive Theory: • Beck and colleagues (1979) proposed a theory suggesting that the primary disturbance in depression is cognitive rather than affective. • Beck identifies three cognitive distortions that he believes serve as 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.

Depressive Disorders