Depressive Disorders c.

The temper outbursts occur, on

average, three or more times per week.
- Depressive disorders include:
d. The mood between temper outbursts is
 Disruptive mood dysregulation persistently irritable or angry most of
disorder, the day, nearly every day, and is
 Major depressive disorder observable by others (e.g., parents,
(including major depressive teachers, peers).
episode), e. Criteria A-D have been present for 12
 Persistent depressive disorder or more months. Throughout that time,
(dysthymia) the individual has not had a period
 Premenstrual dysphoric disorder lasting 3 or more consecutive months
 Substance/medication-included without all of the symptoms in criteria
depressive disorder, A-D
 Depressive disorder due to another f. Criteria A and D are present in at least
medical condition, two of three settings (i.e., at home, at
 Other specified depressive disorder school, with peers) and are severe in at
 And unspecified depressive least one of these.
disorder g. The diagnosis should not be made for
the first time before age 6years or after
Unlike in DSM-IV “depressive disorders” has 18 years.
been separated from “bipolar and related h. By history or observation, the age at
disorders.” onset of criteria A-E is before 10 years
The common feature of all of these disorders in i. There has never been a distinct period
the presence of sad, empty, or irritable mood, lasting more than 1 day during which
accompanied by somatic and cognitive changes the full symptom criteria, except
that significantly affect the individual’s capacity duration, for a manic or hypomanic
of function. What differs among them are issues episode have been met.
of duration, timing or presumed etiology. Note: developmentally appropriate
mood elevation, such as occurs in the
context of a highly positive event or its
Disruptive Mood Dysregulation Disorder anticipation, should not be considered
(DMDD) as a symptom of mania or hypomania.
j. The behaviors do not occur exclusively
- Diagnostic Criterion during an episode of major depressive
disorder and are not better explained
a. Severe temper outburst manifested
by---
verbally (e.g., verbal rages) and/or
Note: This diagnosis cannot coexist
behaviorally (e.g., physical aggression
with oppositional defiant disorder,
toward people or property) that are
intermittent explosive disorder, or
grossly out of proportion in intensity or
bipolar disorder, though it can coexist
duration to the situation or
with others, including major depressive
provocation.
disorder, attention deficit/hyperactivity
b. The temper outbursts are inconsistent
disorder, conduct disorder, and
with development level.
substance use disorders. Individuals
 whose symptoms meet criteria for both develop problems with depression or
disruptive mood dysregulation disorder anxiety.
and oppositional defiant disorder
Prevalence
should only be given the diagnosis of
disruptive mood dysregulation  An epidemiologic study found a lifetime
disorder. If an individual has ever prevalence of 3.3% for a retrospectively
experienced a manic or hypomanic assigned proxy diagnosis of DMDD ion
episode, the diagnosis of disruptive children 9-19 years of age (Brotman et
mood dysregulation disorder should al, 20016),
not be assigned.  DMDD was associated with depressive
k. The symptoms are not attributable to and anxiety symptoms in later
the physiological effects of a substance adulthood (Brotman et al, 2006;
or another medical or neurological Stringaris et al, 2009); further research
condition. is available so far.

Neurobiology
Why the new diagnosis?  Participants with DMDD show an under
 First, no DSM-IV category captures the activation of amygdala
symptomatology of children  Neural recruitment during failed motor
characterized primarily and inhibition were larger in people
fundamentally by severely impairing diagnosed with DMDD that in controls
non-episodic irritability. (Deveney et al, 2012b)
 Other DSM-IV disorders do not  Underlying brain mechanisms of several
accurately capture the phenotype processes that are related to the
exhibited by severe irritability. symptomatology of DMDD are different
 Oppositional defiant disorder does have between patients with DMDD, bipolar
irritability but it is not required; can be disorder and healthy people.
diagnosed only on the basis Treatment
oppositional behavior.
 The only treatment trial of severe mood
Common indications dysregulation is a small, negative trial of
 Children with DMDD have severe and lithium
frequently temper tantrums that  Cognitive therapies:
interfere with their ability to function at - psychoeducation: clinicians, teachers
home, in school or with their friends. and parents need to work closely
 Some of these children were previously together to address and meet these
diagnosed with bipolar disorder, even patients’ special needs (e.g., classroom
though they often did not have all the support, more time to complete school
signs and symptoms. tests, etc.)
 Research has also demonstrated that  Parenting programs and family therapy
children with DMDD usually do not go  Behavioral therapy
on to have bipolar disorder in
adulthood. They are more likely to
Major depressive disorder (MDD)
Diagnostic Criteria 8. Diminished ability to think or
concentrate, or indecisiveness, nearly
A. Five (or more) of the following
every day (either by subjective account
symptoms have been present t during
or as observed by others).
the same 2-week period and represent
9. Recurrent thoughts of death (not just
a change from previous functioning: at
fear of dying), recurrent suicidal
least one o of the symptoms is either
ideation without a specific plan, or a
(1) (1) depressed mood or (2) loss of
suicide attempt or a specific plan for
interest or pleasure.
committing suicide.
Note: Do not include symptoms that are clearly
attributable to another medical condition.
B. The symptoms cause clinically
1. Depressed mood most of the day,
significant distress or impairment in
nearly every day, as indicated by either
social, occupational, or other important
subjective report (e g., feels sad, empty,
areas of functioning.
hopeless) or observation made by
C. The episode is not attributable to the
others. appears tearful). (Note: In
physiological effects of a substance or
children and adolescents, irritable in be
to another medical condition.
irritable mood.)
2. Markedly diminished interest or Note: Criteria A-C represent a major depressive
pleasure in all, or almost all, activities episode.
most of the day, nearly every day (as
Note: Responses to a significant loss (e.g.,
indicated by either subjective account
bereavement, financial ruin, losses from a
or observation).
natural disaster, a serious medical illness or
3. Significant weight loss when not dieting
disability) may include the feelings of intense
or weight gain (e.g., a change of more
sadness, rumination about the loss, insomnia,
than 5% of body weight in a month), or
poor appetite, and weight loss noted in
decrease or increase in appetite nearly
Criterion A, which may resemble a depressive
every day.
episode. Although such symptoms may be
(Note: In children, consider failure to
understandable or considered appropriate to
make expected weight
the loss, the presence of a major depressive
4. Insomnia or hypersomnia nearly every
episode in addition to the normal response to a
day. gain.)
significant loss should also be carefully
considered. This decision inevitably requires the
5. Psychomotor agitation or retardation
exercise of clinical judgment based on the
nearly every day (observable by others,
individual's history and the cultural norms for
not merely subjective feelings of
the expression of distress in the context of loss.
restlessness or being slowed down).
D. The occurrence of the major depressive
6. Fatigue or loss of energy nearly every episode is not better explained by
day. schizoaffective disorder, schizophrenia,
7. Feelings of worthlessness or excessive schizophreniform disorder, delusional
or inappropriate guilt (which may be disorder, or other specified and
delusional) nearly every day (not merely unspecified schizophrenia spectrum and
self-reproach or guilt about being sick). other psychotic disorders.
 E. There has never been a manic episode D. Criteria for a major depressive disorder
or a hypomanic episode. may be continuously present for 2
years.
Note: This exclusion or hypomanic-like
E. There has never been a manic episode
episodes are substance-induced o or are
or a hypomanic episode, and criteria
attributable to the physiological effects of
have
another medical condition.
F. The disturbance is not better explained
by a persistent schizoaffective disorder,
schizophrenia, delusional disorder, or
Persistent Depressive Disorder (Dysthymia) other specified or unspecified
Diagnostic Criteria schizophrenia spectrum and other
psychotic disorder.
 This disorder represents a consolidation G. The symptoms are not attributable to
of DSM-IV-defined chronic major the physiological effects of a substance
depressive disorder and dysthymic (e.g., a drug of abuse, a medication) or
disorder. another medical condition (e.g.
A. Depressed mood for most of the day, hypothyroidism).
for more days than not, as indicated by H. The symptoms cause clinically
either subjective account or significant distress or impairment in
observation by others, for at least 2 social, occupational, or other important
years. areas of functioning.
Note: In children and adolescents, mood can be Note: Because the criteria for a major
irritable and duration must be at least 1 year. depressive episode include four symptoms that
B. Presence, while depressed, of two (or are absent from the symptom list for persistent
more) of the following: depressive disorder (dysthymia), a very limited
number of individuals will have depressive
1. Poor appetite or overeating. symptoms that have persisted longer than 2
years but will not meet criteria for persistent
2. Insomnia or hypersomnia.
depressive disorder. If full criteria for a major
3. Low energy or fatigue. depressive episode have been met at some
point during the current episode of illness, they
4. Low self-esteem.
should be given a diagnosis of major depressive
disorder. Otherwise, a diagnosis of other
specified depressive disorder or unspecified
5. Poor concentration or difficulty making depressive disorder is warranted.
decisions.

6. Feelings of hopelessness.
Causes of depressive disorder
C. During the 2-year period (1 year for
children or adolescents) of the  Etiology of depressive disorders:
disturbance, the individual has never
Neurobiological factors
been without the symptoms in Criteria
A and B for more than 2 months at a  Genetic factor
time.  Heritability estimates
  37% MDD (Sullivan, et al., 2000) Figure 8.5 key brain structures involves in MDD
 Heritability estimates higher for women
than men
 Much research in progress to identify
specific genes involved but the results
of most studies fail to replicate (Kato,
2007)
 DRD4.2 genes, which influences
dopamine function, appears to be
related to MDD (Lopez Leon et a.,
2005).

Etiology of Mood Disorders:

 Neurobiological factors
- neurotransmitters Etiology of mood disorders:
- low levels of norepinephrine,  Social factors
dopamine, and serotonin - life events
- new models focus on sensitivity of o Prospective research
postsynaptic receptors o 42-67% reports a stressful life
o Dopamine receptors may lack event in year prior to
sensitivity in MDD depression onset
o Depleting tryptophan, a o Romantic break up, loss of job,
precursor of serotonin, causes death of loved one
depressive symptoms in - Lack of social support may be one
individuals with personal or reason a stressor triggers depression.
family history of depression  Interpersonal difficulties
o Individuals who are vulnerable - high levels of expressed emotion by
to depression may have less family member predicts relapse
sensitive serotonin receptors - martial conflict also predicts
(Sobczak et ak., 2002) depression
 Behavior of depressed people often
leads to rejection by others
- excessive reassurance seeking
- few positive facial expressions
- negative self-disclosure
- slow speech and long silence
Etiology of Mood disorders:

 Psychological factors
- Freud’s theory
o Oral fixation leads to excessive
dependency
o Depression
- anger towards loved ones who
reject us in turned inward

- lack of empirical support for theory

o Depressed individuals express

more ager towards others than
non-depressed people (Biglan
et al., 1988)

- Neuroticism
How do we see depression?
o Tendency to react with higher
level of negative affect
o Predicts onset of depression
(Jorm et al., 2000)
- Extraversion
o Associated with high levels of
positive affect
o Low extraversion does not
always precede depression

- Cognitive theories

 Beck’s theory
 Negative triad
- negative review of: Treatment
*self
*world
*future
 Negative schemata
- underlying tendency to see
the world negatively
 Negative schemata cause
cognitive biases
- tendency to process
information in negative ways
Psychoeducation adjustment disorder, uncomplicated
bereavement, or minor depression
 Psychoeducation should be provided
 Watchful waiting should incorporate
for individuals with depression at all
psychoeducation, general support, and
levels of severity and in all care settings
prospective symptoms monitoring over
and should be provided both verbally
a 4-8-week period
and with written educational materials.
 There should be education on the Psychotherapy
nature of depression and its treatment
 Interpersonal psychotherapy (IPT)
options and should include the
-a form of psychodynamic therapy that
following:
focuses on the relationships between a
a. Depressions is an illness, not a
person and significant others. It is based
character defect
on the idea that humans, as social
b. Education on the causes,
beings, have their personal
symptoms, and natural history of
relationships at the center of
major depression
psychological problems. Although a
c. Treatment is often effective and is
person’s depression may not be caused
the rule rather than the exception
by any interpersonal event or
d. The goal of treatment is complete
relationship, it usually affects
remission; this may require several
relationships and creates problems in
treatment trials
interpersonal connections.
e. Treatment of depression can lead
- the goal of IPT is to improve
to decreased physical disability and
communication skills so that a person
longer life
with depression is better able to
f. Education about various treatment
communication with others.
options, including the advantages
- focuses on current relationships
and disadvantages of each, side
 Cognitive therapy
effects, what to expect during
- monitoring and identify automatic
treatment, and the length of
thoughts
treatment
o Replace negative thoughts with
 Psychoeducation strategies should be
more neutral or positive
incorporated into structured and
thoughts.
organized treatment protocols, which
- CT as effective as medication for
entail structured systematic monitoring
severe depression
of treatment adherence and response
- CT more effective than medication at
and self-management strategies
preventing relapse
Watchful Waiting - Mindfulness based cognitive therapy
(MBCT)
 Watchful waiting (WW) is defined as
o Rationale
prospective monitoring (i.e., 4-8 weeks)
o Strategies
of symptoms and disability and is a
o Mindful medication
strategy to be used in mild cases of
o Yoga exercise
depression to differentiate a diagnosis
o 6 to 8 sessions (classes) for
of major depression from an
exercising yoga and medication
 o Homework assignments
(audiotapes)
o More suitable for relapse
patients

Biological Treatment of Mood Disorders

 Electroconvulsive therapy (ECT)

- reserved for
o Severe depression with high
risk of suicide
o Depression with psychotic
features
o Treatment non-responders

- induce brain seizure and momentary

unconsciousness

-side effects

o Memory loss
 Medication
 Light therapy
o Short wavelength on the face of
patient
o It decreases melatonin level
among depressive patients
o Initially devised for SADs
o Equally beneficial for non-
seasonal depression