Depression & Anxiety

Introduction to Anxiety and Mood Disorders

• Unlike physical disorders, which are diagnosed through physical tests (blood tests, scans, biopsies, etc), mental illnesses are diagnosed through the assessment of signs and symptoms.

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD) are the ‘bibles’ of diagnoses

Depressive Disorders

• Within the DSM-5, there are from depressive disorders

  • Major Depressive Disorder

  • Persistent Depressive Disorder (Dysthymia)

  • Disruptive Mood

  • Dysregulation Disorder

  • Premenstrual Dysphoric Disorder

  • Substance/Medication-Induced Depressive Disorder

  • Other Specified Depressive Disorder

  • Unspecified Depressive Disorder

Major Depressive Disorder

• The diagnostic criteria states that:

  • a person needs to have demonstrated 5 or more symptoms during the same 2-week period for most of the day, nearly everyday;

  • the person’s presentation needs to represent a significant change compared to their previous functioning;

  • and that one of 5 symptoms needs to be either persistent sad mood most of the days and on most days—or loss of interest or pleasure

    • ‘sad mood’ may manifest as irritable in children and adolescents

    • loss of interest/pleasure in previously enjoyed activities is referred to anhedonia

• Some other symptoms are:

  • loss of weight or appetite in either direction — an increase or decrease

    • weight loss may be deliberate

    • weight gain needs to be a change of 5% within a month

  • change in sleep patterns — increase or decrease, insomnia or hypersomnia

    • people are more than likely to sleep more when they are depressed, as they become tired and physically exhausted when constantly sad

    • the desire to sleep can also be an escape mechanism of sorts, a desire to escape the symptoms of depresion

  • psychomotor behaviour — agitation or ‘retardation’

    • psychomotor = someone who is very fidgety and can’t sit still when they’re depression

    • psychomotor retardation = reduced and slow movement; very common

  • fatigue, loss or energy

  • thoughts of worthlessness or excessive/inappropriate guilt nearly every day, which may be delusional

  • diminished ability to think or concentrate, or indecisiveness, nearly everyday

  • suicidal thinking or ideation, reoccurring thoughts of death, but not just a fear of dying

    • suicidal thoughts/ideation without a plan, an attempt, or a specific plan for suicide.

• The DSM notes that the symptoms must represent a significant change from a person’s previous level of functioning, and the symptoms of MDD must cause clinically significant distress or impairment in a person’s functioning

  • the idea of distress and impairment is critical — this is because many symptoms of diff mental illness are things that everyone can experience from time to time

• When considering the symptoms, note that other disorders could present with these too. This requires the consideration of other potential explanations for the symptoms that the person is displaying.

• One exclusion criterion specifics that psychologists need to be sure that the symptoms are not able to be explained by physiological effects of a substance, another medical condition, or grief/loss

  • if there is reason to believe it is a substance, appropriate investigations (tox screen, blood test) should be concluded to rule out these causes.

  • grief/loss can take many forms — death, financial ruin, end of a relationship.

    • psychologists must be mindful of this as they do not want to slap a diagnostic label on a very normal process and pathologise it

    • in some cases, however, if the symptoms persist for a long time, the grief may have become a depressive disorder

• People may show symptoms of MDD as a result of a medical condition or substance use. For example, weight loss with untreated diabetes or fatigue, as a consequence of cancer, not necessarily MDD.

• Psychologists need to be mindful in thinking about, “Is the diagnosis we are considering the must accurate way of explaining or thinking about this presentation?”

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Persistent Depressive Disorder (Dysthymia)

• Eeyore has Dysthymia :(

• Dysthymia is a chronic, but lower grade intensity version of MDD. In saying this, however, it is important to emphasise that the impact of this disorder can be as or more significant than the impact of MDD

• The symptoms are very similar. In order to meet the criteria, a person needs to demonstrate depressed mood for most of the day, more days than not, for at least two years. For children and adolescents the criterion is one. In addition, people need to display two symptoms from this list:

  • poor appetite or over eating

  • insomnia or hypersomnia

  • low energy or fatigue

  • low self-esteem

  • poor concentration or problems making decisions

  • a sense of hopelessness

• This disorder is an amalgamation of two DSM-4 disorders = dysthymic disorder and chronic major depressive episode

• Someone can have both MDD and Dysthymia at the same time = double depression

Prevalence of Depression Disorders

• AUS & US data indicate that the 12-month prevalence of MDD in adults is between 6 & 7%. In 18-29 year olds, the prevalence is 3 times more than people aged 60 or older. Many adults with depression say it started within adolescence or early adulthood

• Females are more than likely to develop MDD than males, the difference 1.5 to 3 times.

The Course of Depressive Disorders

• MDD can begin at any age but onset does increase with puberty. In Western nations, incidence seems to peak in the 20s although it isn’t uncommon for onset to be later in life

• Dysthymia tends to have an early and chronic onset. MDD has remission (2 or more months with no symptoms or no more than 2 symptoms at a mild level) and some can go for a number of years without experiencing a major depressive episode.

• Most people, given enough time, will recover without intervention. This is called spontaneous recovery. For 2 in 5 people with MDD, spontaneous recovery will occur within 3 months of onset; and for 4 in 5 people this will happen within 12 months of onset

• Features associated with lower rates of recovery from a major depressive disorder include

  • symptom severity

  • personality disorders

  • psychotic features

• Factors associated with increased risk of experiencing another episode of MDD include:

  • the severity of preceding episode

  • being younger at onset

  • having experienced more prior episodes.

• If a person with dysthymia develops symptoms that meet criteria for a major depressive episode, what will typically happen is that the symptoms will return to a lower level — such that the criteria for dysthymia but not major depressive disorder continue to met

• In terms of symptom resolution, this is more likely to occur spontaneously with MDD than dysthymia.

The Causal Models of Depressive Disorders

• There is good evidence that biological and genetic factors play an important role in development of depressive disorders.

• Disrupted neurotransmitter functioning has been implicated - in particular, the neurotransmitters, serotonin, dopamine, and noradrenaline

• First degree relatives of individuals with MDD are at risk for developing this disorder compared to the general population. The increased odds are 2-4 times

• Research suggests dysthymia has an even heavier genetic loading.

• Prejudicial childhood experiences — trauma, abuse, and/or neglect — are risk factors for developing depression. Stressful life events have also been found to be associated with the onset of major depressive episodes.

• It is very unlikely for depression to occur without stressful life events—it’s just that not everyone will develop a depressive disorder in response to stressful life events

• So, the best and more accurate way of thinking about aetiology or development of a depressive illness is in terms of a diathesis-stress model.

• A person may have an underlying predisposition, this may be a genetic, physiological or a psychological vulnerability to develop depression, which is then triggered by exposure to stressful life events for example — causing the predisposition to convert into a disorder.

Cognitive Behavioural Model of Depression

• From the cognitive behavioural perspective, thinking about the development/aetiology of depressive disorders, the behavioural component suggests that depression is maintained by the lack of positive reinforcement that results from a person’s failure to engage in previously enjoyed activities

• This in turn feeds into a sense of learned helplessness; a sense of utter powerlessness in relation to the external environment

• Learned helplessness might be expressed in thoughts such as “There is nothing I can do to make myself feel better. I may as well just stop trying.” Depression is very much about negative thoughts relating to the self, the world and the future.

• People who are clinically depressed often demonstrate what is referred to as a pessimistic explanatory style, where bad things are attributed to internal, stable, and global factors; while positive things are attributed to external, random factors.

Treatment for Depressive Disorders

• Antidepressant medication is very commonly used in the management of depression. The most commonly prescribed class of antidepressants is the Selective Serotonin Reuptake Inhibitors or SSRIs

• Another biological treatment for depressive disorders that tends to be used as a last resort, for treatment-resistant depression, is Electroconvulsive therapy or ECT

• In terms of psychological interventions, cognitive behavioural therapy or CBT has the strongest evidence base, with Interpersonal therapy or IPT also showing good outcomes.

• Two of the key strategies within CBT for the treatment of depression are behavioural activation and cognitive restructuring.

• Behavioural activation, also known as Pleasant Events Scheduling, targets the depressive symptom of loss of pleasure or interest in previously enjoyed activities.

  • With this strategy, psychologist work with their client to figure out what activities they used to enjoy before they became depressed. Then, they set homework tasks in which the client has to engage in activities they previously enjoyed.

  • The rationale for behavioural activation is that, with some time, the client will begin to experience positive reinforcement for engaging in these activities, which will lead to an improvement in their mood.

• The second strategy of cognition restructuring involves working with a client to help them identify or catch the thoughts that are contributing to their sadness and hopelessness; and evaluating the evidence for and against the likelihood of these thoughts being accurate.

Anxiety

• Anxiety, as an emotion, is a normal part of being human—everyone gets anxious. The problem is how one distinguishes between anxiety that falls within the broad parameters of normal, and anxiety that as become clinically significant.

• Clinically significant is if a person’s anxiety is causing them a great deal of distress and/or it’s really interfering with their functioning. It comes down to two key constructs — distress caused and associated impairment or interference in functioning

• There are a number of DSM-5 anxiety disorders:

  • Separation Anxiety Disorder

  • Selective Mutism

  • Specific Phobia

  • Social Anxiety Disorder (social phobia)

  • Panic Disorder

  • Agoraphobia

  • Generalised Anxiety Disorder

  • Substance/Medication Induced Anxiety Disorder

  • Anxiety Disorder Due to Another Medical Condition

  • Other Specified Anxiety Disorder

  • Unspecified Anxiety Disorder

• There is an idea of 3 systems of anxiety

  • the cognitive system — what people think either before, during, or after a situation where they feel anxious

  • the behavioural system — what people do when they are anxious

  • the physiological system — what happens in people’s bodies when they are anxious

Specific Phobia

• People with a Specific Phobia demonstrate a really high level of fear, anxiety, or avoidance in relation to very specific, circumscribed situations or objects

• Essentially, very specific fears that are out of all proportion to any actual danger. The fear may be manifested in children and adolescents as behaviours such as crying. tantrums, and clinging.

• The most common types, and diagnostic specifiers, of phobic stimuli are

  • animals — snakes, spiders, etc

  • natural environment — storms

  • blood-injection-injury — injections

  • situational — enclosed spaces

  • other situations — a situation that a person associates with choking or vomiting

• In order to meet the criteria for a Specific Phobia, a person must demonstrate:

  • extreme fear or anxiety about a specific situation/object almost always when confronted with it

  • avoided or endured the phobic stimulus, which is out of proportion to any actual danger posed by it

  • the fear/anxiety/avoidance must have been experienced for 6 months or longer, and must cause clinically significant distress or interference

  • must not be better explained by symptoms of another mental illness

• These phobias usually develop in early childhood, with most cases beginning before the age of 10. The prevalence rate for Specific Phobia is around 5% going up to 16% in adolescents, and 3-5% to beyond adolescence. It affects twice as many females compared to males

Social Anxiety Disorder

• Social Anxiety Disorder is different to generally feeling anxious in social situations, as it is a fear/anxiety about or avoidance of social situations and interactions in which there is the possibility of being scrutinised or judged by others

• Common social interactions that may provoke anxiety include:

  • eating in front of others

  • performing in front of others

  • having to meet someone new

• These situations almost always provoke anxiety and are either avoided or endured with extreme anxiety. Anxiety must have been present for at least 6 months, and must be out of proportion for what it is, resulting in either intense distress and/or significant impairment in functioning

• In Western Countries, the 12-month prevalence rate for Social Anxiety Disorder is around 7% across all ages, ,ore common in females, with 75% of onset between ages of 8 and 15. Social anxiety forming in adulthood is reasonably rare.

Panic Disorder

• Characterised by recurrent, unexpected panic attacks. Panic attacks are defined as ‘an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes’

• A panic attack involves four or more of the symptoms:

  • palpitations, pounding heart, accelerated heart rate

  • sweating

  • trembling or shaking

  • sensations of shortness of breath or smothering

  • feelings of choking

  • chest pain or discomfort

  • nausea or abdominal distress

  • feeling dizzy, unsteady, lightheaded, or faint

  • chills or heat sensations

  • paresthesias —numbness or tingling sensations

  • derealisation — feelings of unreality, or depersonalisation, being detached from oneself

  • fear of losing control or going crazy

  • fear of dying

• To meet the criteria for Panic Disorder, at least one panic attack must have been followed by at least a month of either or both of:

  • persistent anticipatory anxiety or concern about having another attack or the consequences of having an attack

  • a significant and problematic behavioural change related to the attack, for example avoiding exercise as one might induce a panic attack

• While many of the listed symptoms are common in general anxiety and a panic attack, there are differences in the usual thinking. For example, someone having anxiety may think ‘the reason my heart is racing is that i’m anxious’, whereas someone having a panic attack will think ‘my heart is beating so fast, i must be having a heart attack.’

• Typically, by the time somebody with panic disorder ends up seeing a mental health professional, they have done the rounds in terms of various medical specialists. Often, people with panic disorder are pretty unhappy to be seeing a mental health professional.

• 12 month prevalence is around a 2-3 rate across adolescents and adults. Not commonly seen in children. Diagnosed about twice as often in females as males.

Comorbidity—Focus on Panic Disorder

• Comorbidity = where a person meets criteria simultaneously for more than one diagnosis.

• Somewhere between 10 and 65% of people with a primary diagnosis of Panic disorder will also meet criteria for MDD. In most cases, MDD develops either around the same time or subsequent to the panic disorder

• The co-occurrence of panic disorders and substance use problems is due to people using substances to self-medicate or to try to reduce the distress and interference caused by their anxiety symptoms. This is very common.

Generalised Anxiety Disorder

• Essentially defined by excessive worrying. Differences between GAD and non-clinical worrying would be that people with GAD may tell you that they experience their worry as totally uncontrollable.

• People with GAD may worry about all manner of things: work, school, health, health of others, the impression they make on others, things that are happening elsewhere-natural disasters, civil wars, etc

• A person must find it difficult to control worry or anxiety for more than 6 months and 3 out of 6 symptoms:

  • muscle tension & restlessness

  • distress or impairment

  • hypervigilance

  • being easily fatigued

  • difficulty concentrating or mind going blank

  • sleep disturbance.

• GAD has a 12 month prevalence rate of 0.9% in adolescents and 2.9% in adults, females twice as likely as males to be diagnosed

Causal Models of Anxiety Disorders

• Anxiety runs in families — if one your relatives with an anxiety disorder, your odds of developing an anxiety disorder increases.

• Common features across anxiety disorders are

  • heritability, which accounts for upwards of 30-40% of the variance in the development of anxiety disorders

  • temperament — an innate rather than learned aspect of personality — has been found to be important in the development. In particular, the temperamental quality of behavioural inhibition—characterised by shyness, fear of unfamiliar situations and withdrawal—has been identified as an important risk factor.

  • environmental factors including exposure to potentially traumatic events, an accumulation of stressful life events, and parenting behaviours, such as modelling and overprotection

• The best way of understanding how anxiety develops is by considering the ways in which biological risks may interact with environmental triggers

Cognitive Behavioural Models of Anxiety

• From a cognitive behavioural perspective, the behavioural component in the aetiology of anxiety disorders is informed by Stanley Rachman’s work published in 1977

  • Rachman proposed three pathways through which people might develop fear.

  • The first is through their own direction experience, which may become generalised through conditioning (eg, if you’re bit by a dog, you’re gonna fear dogs)

  • The second pathway is instructional learning, which involves the transmission of information relating to danger (eg when a parents warns a child to stay away from a pool as people drown, the child may be fearful of pools)

  • The third is vicarious learning, which is when you repeatedly see someone else, usually an important person in your life like a parent, behave fearfully the confronted by a particular stimulus, then you develop that fear.

Cognitive Behavioural Therapy for Treating Anxiety Disorders

• The frontline intervention for treating anxiety disorders is cognitive behavioural therapy (CBT)

• CBT is an efficacious treatment across diagnoses, resulting in superior outcomes compared to waitlist control conditions and expectancy control treatments.

• CBT seems to work better for GAD than Social Anxiety Disorder.

• A review of treatment in anxiety disorders in children and adolescents reported an average remission rate of 56.5%. It isn’t a perfect treatment though, as some didn’t feel it worked whatsoever and others reported reoccurring symptoms, albeit not as strong

Other Treatments for Anxiety Disorders

• Medication is an option but no the frontline intervention

• Some other treatments include

  • psychoeducation about anxiety — educating clients about anxiety, including telling them that it is normal, often adaptive or helpful, and that we understand it to consist of threep separate but interrelated systems (cognitive, behavioural, physiological systems)

  • cognitive restructuring and exposure — requires the client to understand the important of thoughts. Would ask the client to start identifying the unhelpful thoughts that are making them anxious in ways like a thought diary. These thoughts are then worked through to evaluate the evidence for and against the likelihood of the thoughts being accurate.

    • Children go through the ‘Scientific Approach’ where kids are encouraged to think of themselves as scientists who have to evaluate the evidence for and against their ‘hypotheses’ (anxious thoughts)

    • Adults go through ‘Socratic Questioning’

• These strategies tend to be used together.

• Systematic desensitisation or exposure aims to address the avoidance of feared stimuli that tends to go with the anxiety. This strategy is based on the psychological principle of habituation and involves deliberately and repeatedly placing yourself in anxiety-provoking situations that would normally be avoided.

  • Treatment begins with creating a list of anxiety provoking situations in a hierarchy. Relaxation was used before to reduce the anxiety in these situations, however research as showed this to be a subtle form of avoidance. Thus, the aim is to be exposed to the situation and fully experience the anxiety to realise that you can handle handle the situation through relaxing within it. The experiences in the hierarchy needs to be experienced (imaginally or in real life) repeatedly until the fear response has been extinguished.

• The most common behavioural response to anxiety is avoidance. Avoidance means that the individual misses out on the opportunity to discover that he or she actually can cope with that feared situation. Instead, it strengthens and reinforces anxiety