Lecture 8 - Mood Disorders

suicide risk factors

ADHD because it causes someone to act more impulsively, self injury because ppl use it as a coping mechanism when they have strong emotions + common in teens with ADHD, even when there is no clear depression, feeling uneasy + have a hard time dealing with emotions, most likely had an episode of depression before or mood disorder, often could be confused with puberty, parents normalize it more than they should, changed from highly sensitive child to one who is not, often dismissed as teen years

depression (symptom)

feeling of sad or miserable, the symptom itself, occurs without existence of serious problem and common in all ages

depression (syndrome)

a group of symptoms that occur together more often than by chance, mixed symptoms of anxiety and depression that tend to cluster on a single dimension of negative affect

major depressive disorder

symptoms have to last a minimum of 2 weeks, it is associated with depressed mood, loss of interest and other symptoms, need to significantly impair normal functioning so not even having the energy to cry, staying in bed seems like the only thing that makes sense, naturally impacts functioning

historical perspective of depression in young people

the psychodynamic perspective, the superego not being present in children made people think that children couldn’t experience depression, thought it was more like hostility turned towards you which is linked to the superego which kids wouldn’t have yet

how was depression discovered in kids?

in the 40s, there were lots of studies of children raised in institutional environment showing symptoms of anaclitic depression

anaclitic depression

depression like reactions and sometimes the kids were not feeding themselves, absence of attachment figures, kids that are not engaging in the environment as they should, very passive and looking for physical closeness with the adults

depression in kids

Children who are depressed cannot shake their sadness interferes with their daily routines, social relationships, school performance and overall functioning: often accompanied by anxiety or conduct disorders, often goes unrecognized and untreated

impact of depression in kids

children from all development phases had high rates of depression, anxiety (going out of the house might have been a positive buffer to feelings of depression)

depression in preschoolers

lack of energy that they should naturally have, flat affect, appear somber and tearful, lacking exuberance, excessively more anxious around their attachment figures expressing clinging and whiny behavior around mothers (most of the time it is clearly triggered by something)

depression in school age children

get more disruptive behaviors and irritability, tantrums

depression in pre teens and teens

in addition to the other symptoms they show more self blame, low self esteem, persistent sadness and social inhibition (more classic symptoms but can be misperceived as normal teen behavior, supposed to be moody and irritable)

grief

feeling empty, dysphoria decreases in intensity over days to weeks, pain + positive emotions, thoughts/memories of the deceased increased by specific days or events, preserved self esteem, bigger range of emotions they can experience, when they have a lot of negative expression, it could be linked to grief felt from the person that was lost, thoughts about death is more about joining the deceased, guilt is linked to the failings (shock you have depends on how predictable the death was, sudden vs expected)

depression

depressed mood and inability to anticipate happiness and pleasure, persistent low moods, more ruminations + criticisms, some teens can have ruminations about the whole situation not only themselves, pervasive unhappiness, self critical, common feelings of worthlessness, guilt/being a burden, death due to worthlessness/coping with pain

prevalence of depression

from grade 8 to 10 this is when first time episodes occur, if there is a parent that has history of depression this increases the risk, more chronic when anxiety is co-occurring, quite at risk for a later episode, between 2 and 8% of children aged 4-18 experience MDD, it is rare in preschool and school aged kids increasing 3x in adolescence, onset typically 13 - 15 yrs old, average episode lasts 8months and length is longer if the parent has history of depression, most kids recover from the initial episode but disorder has 25% chance of recurrence in 1 yr, 40% in 2yrs and 70% in 5yrs, 1/3 develop bipolar 5yrs post onset of MDD

MDD comorbid disorders

anxiety disorders like GAD, specific phobias and separation anxiety disorders, dysthymia, conduct issues, ADHD, substance use disorder and in older teens often have traits of BPD, especially if you have impulsivity with your depression

gender differences in MDD

these differences don’t arise until puberty, at that point females are 2 to 3 times more likely to suffer from depression due to psychological hormones affecting these traits, estrogen makes them more depressed and lowers mood, symptom presentation is similar for both sexes, psychological and social changes are related to the emergence of sex differences in adolescence, biology differences in the brain processes that regulate emotion (ie; the amygdala is bigger in females, easier activation of limbic system so better at inhibiting emotions)

depression in girls

excessive empathy, compliance and overcontrol, this impacts their self confidence, assertiveness and emotional expressiveness, difficulty to deal with stressors of puberty, often depression is more common in young girls, hard time expressing range of emotions they are feeling, lots of things that are hard to navigate if you have these limitations

excessive empathy

assume unwarranted responsibility for others’ negative emotions (might try to help adults in their life and feel a sense of helplessness when they can't do anything to help the situation)

excessive compliance

strong need to meet others’ needs and approval (sacrifice wellbeing and autonomy to please others, too passive in interpersonal situations just cause you want to be well perceived)

excessive overcontrol

hide their feelings (limited number of coping strategies to deal with negative emotions, leads to development of mood problems, happens in families where you only talk about positive things so this leads to discomfort around difficult situations)

persistent depressive disorder/dysthymia

its hard to characterize when it comes to intensity of the symptoms they are less severe than MDD, affects functioning way more in the long term, impacts support system + own development, more cognitive biases found that you find in the beck model of depression, lots of problems around feeling accepted and love, episodes can get worse for a few months, it can appear very subtle, characterized by symptoms of depressed mood that occur on most days + persist for at least one year, child with PDD also displays at least 2 somatic or cognitive symptoms, poor emotion regulation, those who have comorbid PDD are more severely impaired than children with just one disorder

poor emotion regulation

constant feelings of sadness, being unloved, self-deprecation, low self-esteem, anxiety, irritability, anger, and temper tantrums

what is the main difference between dysthymia and major depressive disorder?

dysthymia has a more gradual onset, it lasts longer, and symptoms are less severe, while depression is more rapid, lasts for several months, and has more severe symptoms like anhedonia and suicidal ideation, they are distinct conditions but they can co-occur, if someone has both they will be MDD with specifier of PMDD

prevalence of dysthymia

rates are much lower than MDD, most common comorbid disorder is MDD, nearly 70% of children with DD have an episode of major depression, about 50% of children with dysthymia have one or more non affective disorder that preceded dysthymia like anxiety, conduct disorder or ADHD

disruptive mood dysregulation disorder

this is a newer diagnosis, it is more common in boys and school age children, lots of temper outbursts, could be verbally or behavioral, outbursts are disproportionate and emotionally inconsistent, mood between outbursts is persistently angry and irritable, symptoms have to last over a year, diagnosed between ages 6 and 18, its not situational so reflects temperament not external triggers, no typical depressive symptoms and persistent irritability not specific to any person or situation, about emotional dysregulation not defiance like we see in ODD, rarely comorbid with ADHD, could evolve into anger management issues in adulthood

what was seen in the DMDD video?

the girl has temper tantrum issues at 4-5 yrs old and they persisted, she gets embarrassed when she has a tantrum, cries and feels odd, yells and throws things, it happens 2 to 6x a week, only a week or 2 here or there over the years that there has been no temper tantrums, pretty consistent, she never showed any symptoms of depression or anxiety, she’s shy and her mind doesn’t go blank during the tantrums, shows activity and irritability, mother has a hard time connecting the child + seeing some patterns

DMDD etiology

brain areas involved include the anterior cingulate cortex, underactivity in the frontal and striatal brain regions, amygdala, high levels of frustration and less levels of frustration, cognitive biases, emotion recognition biases,

anterior cingulate cortex (DMDD)

heightened activity in this area, associated with feelings of distress and frustrations

frontal and striatal brain regions (DMDD)

underactive, this usually regulates emotions, involved in planning and acceptable responses even when we’re angry, high levels of frustration and less ability to regulate their emotions in response to minor provocations when impaired

cognitive biases (DMDD)

focus their attention on threatening stimuli/things that will set them off, trying to see those facial cues and noticing that the other person is embarrassed or has opinions about her but frustrated about that cause she’s not expressing it

emotional recognition biases (DMDD)

misinterpret actions and expression of others, neutral faces that wouldn’t show a disgusting look, etc, have a lot more errors when it comes to interpreting the emotions of others, hard time putting the right label

amygdala (DMDD)

it is underactive during tasks where they have to interpret other people’s emotions, usually it should help you process emotion content, background noise of being frustrated and have confirmation that they should be in that state of mind

what is the main difference between DMDD and ODD?

ODD is when you’re in an argument you often have a tantrum about not having autonomy and you’re more rebellious whereas in DMDD you have no difficulty with authority figures, rather you’re more pessimistic/dysregulated kid, often those with DMDD are misdiagnosed with bipolar disorder, usually due to hypomanic episode but not a perfect category for them cause its just a child who is irritable or sad, disproportionate reactions to stress, with ODD there is a focus on parents and their style of discipline which could be too harsh, help their child learn to cope with emotions/emphasis on emotion regulation

developmental framework for depression

mix of disposition or trigger that puts you more at risk later on, lots of work done on genetics and temperament + family experiences with attachment style, emotional dysregulation is a key component, right before the first depressive episode there will be a trigger we can identify, wont be able to be resilient due to all these different factors

behavioral theories

emphasizes on the importance of learning, environmental consequences and skills, deficits during onset and maintenance of depression, not able to experience the effects of reinforcement, hard to make new friends if you move to a new place or lose someone and experiencing grief (ex: if you suddenly think you are not good at soccer and stop the sport cause you feel like everyone is better than you, learned helplessness, related to a lack of response-contingent positive reinforcement

cognitive biases and distortions in mood disorders

more focused on the way you think and how you feel, lots of work on the negative beliefs you can have, how you attribute failure, ruminative style and pessimistic outlook and hopelessness, negative self esteem, selective attentional biases, emphasizes depressogenic cognitions, more concerned with past failures and looking back, hopelessness theory, its about your filters and how you interpret life events

depressogenic cognitions

negative perceptual and attributional styles and beliefs associated with depressive symptoms, feelings of worthlessness, negative beliefs, attributions of failure, self critical and automatic thoughts

hopelessness theory

depression-prone individuals have a negative attributional style (blaming themselves for negative events in their lives), its about your filters and how you interpret life events

beck’s cognitive model of depression

suggests that depressed individuals make negative interpretations about life events, biased and negative beliefs are used as interpretative filters for understanding events, schemas bias their beliefs and make them stay in this depressed state, long standing beliefs you have influenced by early life experiences, trigger in the environment, stressful life event that happens

what are the three cognitive issues according to beck’s cognitive model?

information-processing biases, negative outlook regarding oneself, the world, and the future, negative cognitive triad

negative cognitive triad

only looking for evidence that confirms your negative self view, overgeneralization is a bias we often see like saying you always screw up, not able to see the full pattern of what happens in your life, jumping to conclusions, can come from parental figures that have this negative view already pushing you to think in a similar way

genetic and family risk of acquiring mood disorder

twins and other genetic studies show that there is moderate genetic influence with heritability estimates ranging from 30 to 45%, children of parents with depression have 3x higher risk of having depression

temperament

how we physiologically and emotionally react to what we encounter in our environment, largely predetermined genetically, early life experience can change our profile a lot, tend to overreact to negative life events, difficult temperament can place a child at risk for depression by enhancing negative emotions, interfering with quality of parent-child interactions or limiting the development of children's coping skills, gonna be harder to have a secure attachment when infant has a difficult temperament, parents may adopt a more angry/hostile tactics to deal with them which only makes things worse, at first looks more like a behavioral issue due to how parents cope with the child

monoamine hypothesis

this has been debunked but it suggests that norepinephrine, serotonin and dopamine have similar chemical structures that play a role in depressive disorders, SSRIs can act as a band aid rather than a permanent solution, some still believe depression is associated with dysregulation in one or more of these neurotransmitters

neurotransmitters

studies mostly done on adults are supported by the fact that antidepressants help alleviate symptoms but pushed by medication that SSRIs were popular, found no association between serotonin levels and depression, no support for lower serotonin activity causing depression, long term use of SSRIs might reduce serotonin levels even more, helps stabilize someone but shouldn’t be the only thing you do to treat depression, CBT could help reduce the likelihood of subsequent episodes

neurobiological influences in mood disorders

abnormalities in brain regions that regulate emotional functions like the amygdala, cingulate, and prefrontal cortex, cortical thinning in the right hemisphere, HPA axis dysregulation, sleep abnormalities, variants in BDNF and neurotransmitters have also been implicated

BDNF

brain derived neurotrophic factor

amygdala + HPA axis (neurobiological influences

produces effective states, and when it’s enlarged it fits with their symptoms, and if you have a lot of stress, dysregulating the HPA axis, you could be depressed and overworked or stressed in a specific situation in your life, getting depressive symptoms because of this, reduction in hippocampal volume has been found in these patients too, chronic stress puts you at risk for many different disorders

what happens when kids are depressed?

families display more critical and punitive behavior toward the depressed child than towards other kids

what happens when parents are depressed?

won't be able to meet the needs of their child, they could internalize this and think the parent doesn't care about them, children will then experience higher rates of depression, phobias, panic disorder and alcohol dependence as adolescents and adults

how is self control and emotional regulation linked to depression?

kids who experience prolonged periods of emotional distress and sadness or who are exposed to maternal negative moods might have issues regulating emotional states + prone to depression, might use avoidance or negative behavior to regulate distress rather than problem-focused and adaptive coping strategies, might also make poor choices in dealing with social problems, turning to alcohol and/or drugs

low social status of depressed youths

this can cause symptoms which include helpless behavior or aggressive behavior

Klerman and Weissman

defines depression as a disorder that interferes with an individual’s psychosocial functioning, relationship issues don’t necessarily cause depression but they do exacerbate mood problems

how can relationship problems lead to depression?

they exacerbate mood problems, depressive symptoms promote socially helpless behavior but it could lead to you being irritable causing you to be rejected by your peers

interpersonal approach of depression

depression is exacerbated by one or more of the following relationship problems, grief or loss of a loved one, role transitions, role disputes (varying views between you and your parents of your future) and interpersonal deficits

interpersonal deficits

more about lack of social skills that are needed to develop those bonds, could be social anxiety, sensitivity to rejection and being misunderstood exacerbating your depression

how can stressful life events lead to depression?

major life stressors predict onset of depression, sometimes its not a single event but a series, more of a slow build and hard to dig yourself out of the hole, between 20 and 50% of youths don’t have a clear stressor, many kids can experience tragic events and never have depression, this triggers the first episode, later episodes are less closely connected to specific stressors

kindling hypothesis (stress sensitization)

explains long term susceptibility to depression, idea that being more reactive later on to stress because of that episode of depression, therefore the second episode is triggered by a lesser stressor, first episode is linked to a specific stressor like lasting changes in biological processes, heightens future reactivity to stress, the second episode may be triggered by a non severe stress or minor events

gene-environment interactions study

this study examined part of the dopamine transporter gene which regulates dopamine activity in the synapse

gene-environment interaction study (results)

adolescents who experienced parental rejection were at an increased risk for developing depression but only if inherited 2 minor alleles of the recessive gene, those who experienced moderate to high social stress were at increased likelihood of developing depression but only if they inherited a short (s) allele gene

gene-environment interactions

not just about lower serotonin levels to get depression but also people’s cognitive styles, some kids with certain genes will be more sensitive to rejection, specific kids that are more reactive to the environment, they are the ones who are affected by their environment way more, some take it personally and internalize that rejection, its less about serotonin/dopamine imbalance but rather you have genes that give you a different outlook