Chapter 10 (Mood disorders)

Mood disorder

suffers from extreme, persistent, or poorly regulated emotional states.

• a disturbance in mood is the central feature.

• Rising in youth.

Two types of negative moods?

1. dysphoria

2. anhedonia

dysphoria

A negative mood state characterized by prolonged bouts of sadness.

anhedonia

A negative mood state characterized by a lack of enjoyment in anything one does and a loss of interest in nearly all activities.

Instead of the negative mood states, some will instead express ___________

irritability

Irritability

easy annoyance and touchiness, an angry mood, and temper outbursts.

________ is one of the most common co-occurring symptoms of depression

Irritability

• present in as many as 80% of clinic-referred

• 36% of community samples of youths with depression

Some may express moods on the other end of the spectrum, including:

• Mania: An abnormally elevated or expansive mood.

• Euphoria: An exaggerated sense of well-being.

The two major types of mood disorders are:

1. Depressive disorders

2. Bipolar disorders

Depression

 A pervasive unhappy mood 

• Children who are depressed cannot shake their sadness- interferes with their daily routines, social relationships, school performance, and overall functioning

masked depression

view that children express depression in a much different way than adults, ways that are often indirect and hidden (ex. through aggression, bed-wetting, sleep problems, etc.)

______ of youngsters with depression show significant impairment in daily functions (thinking, physical behaviour, social behaviour)

90%

Depression in children under the age of 7 is

diffuse and less easily identified

some studies have found that age-adjusted diagnostic criteria can be used to identify and treat depression in children as young as

3 to 5 years

Symptoms of depression in Infancy

 being passive and unresponsive

Symptoms of depression in preschool

May appear extremely somber and tearful, lacking exuberance; may display excessive clinging and whiny behaviour around mothers, fears of separation or abandonment.

Symptoms of depression in school aged children

 The above, plus increasing irritability, disruptive behaviour, combativeness, and tantrums

Symptoms of depression in preteens

The above, plus self-blame, low self-esteem, persistent sadness, and social inhibition

Depression as a symptom vs syndrome

Depression (symptom): feeling sad or miserable

 

Depression (syndrome): a group of symptoms that occur together more often than by chance 

What are the 3 depressive disorders?

1. major depressive disorder (MDD)

2. disruptive mood dysregulation disorder (DMDD)

3. Persistent depressive disorder (PDD/ dysthymic disorder)

most children with depression display either depressed mood alone (58%) or depressed and irritable mood (36%)—irritable mood alone is______

rare (6%)

Diagnostic criteria for major depressive disorder?

(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 depressed mood or l oss of interest or pleasure.

 

1. Depressed mood

2. Markedly diminished interest or pleasure

3. Significant weight loss

4. Insomnia or hypersomnia nearly every day

5. Fatigue or loss of energy nearly every day.

6. Feelings of worthlessness or excessive or inappropriate guilt

7. Diminished ability to think or concentrate

8. Recurrent thoughts of death

 

(B) cause clinically significant distress or impairment

(C) Not something else

(E) NEVER a manic episode or hypomanic episode.

Major depressive disorder requires ________ of the following symptoms have been present during the _________and represent a change from previous functioning

Five (or more)
same 2-week period

For major depressive disorder, at least one of the symptoms needs to be either

depressed mood or loss of interest or pleasure.

Lifetime prevalence estimates of major depressive disorder—whether a young person has ever been depressed—range from _______

11% to 20%

Between_______ of children aged 4-18 experience MDD each year.

2% and 8%

• Depression is rare among preschool and school-age children (1-3%)

As many as ______ of young people with depression have one or more other disorders;

90%

• 50% have two or more

• Many co-occurring disorders are present before MDD manifests, and they are likely to persist after the child is no longer depressed

Most common comorbid disorders with major depressive disorder?

• Anxiety disorders (especially GAD), specific phobias, and separation anxiety disorders-

• Persistent depressive disorder, conduct problems, ADHD, and substance-use disorder

Onset of major depressive disorder?

• Onset may be gradual or sudden

• Age of onset usually between 13 and 15 years (first depressive episode)

 

• Average episode lasts eight months

Chance of recurrence of a depressive episode is ____ within one year, ____ within two years, and _____ within five years

25%, 40%, 70%

About _____ develop bipolar disorder within five years after onset of depression (bipolar switch)

one-third

Stress sensitization

brain can be conditioned so that following the first depressive episode, individuals are increasingly vulnerable to stress, and even nonsevere stress or minor events that resemble loss or stress experiences may result in depression.

Sex differences in major depressive disorder?

• No sex differences until puberty; then, females are two to three times more likely to suffer from depression

  •  ratio of girls to boys is about 2:1 to 3:1 after puberty.

• Presentation is similar for both sexes, although correlates of depression differ for the sexes

gender intensification hypothesis

the difference is due to the increased societal pressure for girls and boys to conform to normative gender roles during adolescence

Disruptive mood dysregulation disorder (DMDD)

Chronic, severe and persistent irritability with two main features:

 

1. Frequent verbal or physical temper outbursts that occur in response to frustration or are out of proportion to the provocation or situation.

 

• Occur frequently (3-4 times per week over one year in at least two or three settings) and are age inappropriate.

 

2. Chronic, persistently irritable or angry mood that is present most of the day, nearly every day, between the severe temper outbursts

 

• Mood onset must be prior to 10 years old, characteristic of the child, and noticeable.

___________ Cannot co-occur with ODD or BP

disruptive mood dysregulation disorder

The development of the DMDD category was a response to

increasing rates of bipolar disorder (BP) diagnoses in young children; it was intended to provide an alternative to diagnosing BP in young children too frequently.

Persistent depressive disorder (PDD) (Dysthymic disorder)

Is characterized by

 

1. Symptoms of depressed mood that occur on most days, and persist for at least one year

 

2. Displays at least two somatic (ex. eating, sleep, energy) or cognitive symptoms (ex. concentration, self-esteem, hopelessness) that are present at the same time as the depressed mood.

 

3. Poor emotion regulation

 

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

 

• Symptoms are less severe, but more chronic than those of MD

prevalence of persistent depressive disorder?

• Rates of PDD are lower than those of MDD

  • 1% of children

  • 5% of adolescents

Most common comorbid disorder of PDD is

major depressive disorder
- During the course, 70% of children may have an episode of major depression

double depression

An instance in which a major depressive episode is superimposed on the individual’s previous persistent depressive disorder, causing the individual to present with both disorders.

About ______ of children with PDD also have one or more nonaffective disorders that preceded dysthymia

50%

• Such as anxiety disorders, conduct disorder, or ADHD

•  Associated with greater familial loading for affective disorders

Most common age of onset for PDD is

11-12 years (i.e. 3 years earlier than MDD)

• May precede MDD (and be a precursor)

• Associated with poorer response to treatment, greater long-term morbidity.

Adolescents with PDD receive _________ than those with MDD

less social support

Depressive disorders impact on intellectual and academic functioning

• Difficulty concentrating, loss of interest, and slowness of thought and movement may have a harmful effect on intellectual and academic functioning

 

• Interference with academic performance, but not necessarily related to intellectual deficits

Depressive disorders impact on cognitive biases and distortions

• Selective attentional biases

• Feelings of worthlessness, negative beliefs, attributions of failure, self-critical and automatic thoughts

• Depressive ruminative style, pessimistic outlook, and negative self-esteem

• Negative thinking and faulty conclusions generalized across situations, hopelessness, and suicidal ideation

Depressive disorders impact on negative self-esteem

• Low self-esteem is the symptom that seems most specifically related to depression in adolescents

• Daily fluctuations in self-esteem appear to be related to depression following exposure to major life stresses

• Self-esteem problems in adolescent girls are often related to a negative body image

• Children whose self-views are negative and narrowly focused in one domain

  • May show instability in their self-esteem because they lack alternative compensatory areas of functioning

 

Depressive disorders impact on social and peer problems

• Few close friendships, feelings of loneliness, and isolation

• Social withdrawal and ineffective styles of coping in social situation

• Two pathways:

   

  1. Depressive symptoms --> socially helpless behaviour and neglect from peers

  2. Depressive symptoms --> aggressive behaviour and rejection from peers.

____ of youths who are clinically depressed report having thoughts about suicide, and 30% attempt suicide by 17 years of age

60%

Behavioural theory of depression

Emphasize the importance of learning, environmental consequences, and skills and deficits during the onset and maintenance of depression

 

• Depression is related to a lack of response-contingent positive reinforcement

  • Cannot experience it --> anxiety

  • Lack of availability/quality of rewards --> environment changes

  • Lack of skills to have rewarding relationships.

Cognitive theory of depression

Focus on relationship between negative thinking and mood

 

• Emphasize “depressogenic” cognitions

  • Negative perceptual and attributional styles and beliefs associated with depressive symptoms

 

• Hopelessness theory

  • Depression-prone individuals have a negative attributional style (blame themselves for negative events in their lives)

• becks cognitive model

becks cognitive model of depression

Devaluation/negative view on the world --> tied to world, self, and future.

• Depressed individuals make negative interpretations about life events

• Biased and negative beliefs are used as interpretive filters for understanding events

• Three areas of cognitive problems

  • Information-processing biases

  • Negative cognitive triad: Negative outlook regarding oneself, the world, and the future (negative cognitive triad)

  • Negative cognitive schemata: stable structures in memory that guide information processing, including negative self-critical beliefs and attitudes

negative cogntive triad

Negative outlook regarding oneself, the world, and the future (negative cognitive triad)

heritability estimates for depression ranging from ____

30 to 45% (moderate genetic influence)

Children of parents with depression have about _____ risk of having depression

three times

• single best predictor of a child’s risk for MDD is a high family incidence for this disorder

neurobiological causes for depression

Irregularities in the structure and function of several brain regions that regulate emotional function

 

• Abnormalities in amygdala, cingulate, prefrontal cortex, hippocampus

• Cortical thinning in the right hemisphere

• HPA axis dysregulation, sleep abnormalities, variants in BDNF, and neurotransmitters (serotonin, dopamine, and norepinephrine) have also been implicated

family causes of depression

• When children are depressed

  • Families display more critical and punitive behaviour toward the depressed child than toward other children

 

• When parents are depressed

  • Depression interferes with the parent’s ability to meet the needs of the child

  • Child experiences higher rates of depression phobias, panic disorder, and alcohol dependence as adolescents and adults

cognitive behavioural therapy

• Has shown the most success in treating children and adolescents with depression

• Combines elements of behavioral and cognitive therapies in an integrated approach. Attribution retraining may also be used to challenge the youth’s pessimistic beliefs

 

Ex. Primary and secondary control enhancement training (PASCET) --> 15 session CBT program for 8-15 year olds with depression.

interpersonal psychotherapy for adolescent depression

• Focuses on improving interpersonal communication single best predictor of a child’s risk for MDD is a high family incidence for this disorder, has also been effective.

 

• Explores family and interpersonal interactions that maintain depression. Family sessions are supplemented with individual sessions in which youths with depression are encouraged to understand their own negative cognitive style and the effects of their depression on others and to increase pleasant activities with family members and peers (Mufson et al., 2004)

medications for depression

• Tricyclic antidepressants consistently fail to demonstrate any advantage over placebo in treating depression in youth

  • They have potentially serious cardiovascular side effects

• SSRIs (e.g., Prozac, Zoloft, and Celexa) are the most prescribed medications for treating childhood depression

• Up to 60% of depressed youngsters respond to placebo

Bipolar disorder

Characterized by:

 

• a striking period of unusually and persistently elevated, expansive, or irritable mood, accompanied by increased goal-directed activity or energy, and…

 

• Alternating with or accompanied (at the same time) by one or more major depressive episodes

The two mood states of the manic phase of BP are

elation and euphoria.

• Elation and euphoria can quickly change to anger and hostility if behaviour is impeded

(May be experienced simultaneously with depression)

manic episode

discrete period of a week or more during which the youth displays an ongoing, pervasive, and unusually elevated or irritable mood and persistently increased goal-directed activity or energy.

hypomanic episode

has features that resemble a manic episode in quality but are less intense—the mood disturbance and increased activity or energy are less severe, of shorter duration, and produce less impairment in functioning than a manic episode

3 types of bipolar disorder?

• Bipolar I disorder: occurrence of at least one manic episode

• Bipolar II disorder: occurrence of a hypomanic episode with one or more major depressive episodes

• Cyclothymic disorder: display many and persistent hypomanic and depressive symptoms for a year or more with considerable distress and impairment.

BP in young people is difficult to identify because it

occurs infrequently, shows extreme variability of clinical presentation within and across episodes, and overlaps in symptoms with more common childhood disorders such as ADHD and conduct problems.

symptoms of bipolar disorder include:

• restlessness, agitation, sleeplessness, pressured speech (too much, too fast), flight of ideas, racing thoughts, sexual disinhibition, surges of energy, expansive grandiose beliefs

 

• Severe and cyclical mood changes and outbursts + inconsistency

 

• Display significant impairment in functioning (ex. hospitalizations, MDEs, medications, co-occurring disruptive behaviours or anxiety disorders)

 

• Youngsters during a manic episode may present with atypical symptoms – volatile and erratic changes in mood, psychomotor agitation, and mental excitation

  • Irritability, belligerence, and mixed manic-depressive features occur more frequently than euphoria

  • Show great conviction about the correctness or importance of their ideas.

prevalence of bipolar disorder is

• 0.5% to 2.5% from 7-21 years old.

• Very rare to meet the 1 week threshold to be a manic episode (0.3%)

• Boys often show more manic moods, whereas girls more often show depressed.

most common type of bipolar disorder

mild bipolar II > cyclothymic > other specified > bipolar I

Co-occuring disorders with bipolar disorder?

• anxiety disorders, generalized anxiety disorders

  • 60% have one or more, and 50% have two or more

• ADHD

  • 60-90% of children

  • 30% of adolescents

• oppositional and conduct disorders

  • 80% of children and adolescents

• Substance use disorders

• Suicidal thoughts and ideation

 

• Co-occurring medical problems

  • Cardiovascular and metabolic disorders, epilepsy, and migraine headaches

About ____ of patients with BP have a first episode prior to age 19

60%

• Peak age of onset is 15-19 years old.

BP is one of the most _______ forms of mental disorder – but multiple genes involved

heritable

• Family and gene studies indicate that BP is the result of a genetic vulnerability combined with environmental factors, stress, and negative family climate.

• 65% same in twin studies (--> environmental aspect)

Treatment for BP

A multimodal plan includes:

 

• Monitoring symptoms closely

• Educating the patient and the family

• Matching treatments to individuals

• Administering medication (ex. lithium)

• Addressing symptoms and related psychosocial impairments with psychotherapeutic interventions