social & cognitive disorders

Social and Cognitive Aspects of Depression

Major Depressive Disorder Diagnostic Criteria

  • A. General Criteria
    • Five (or more) of the following symptoms must be present during the same 2-week period and represent a change from previous functioning; at least one symptom must be either:
    1. Depressed mood, or
    2. Loss of interest or pleasure.
    • Note: Do not include symptoms that are clearly attributable to another medical condition.
Specific Symptoms

  1. Depressed Mood:

    • Most of the day, nearly every day, indicated by:
      • Subjective report (e.g., feels sad, empty, hopeless).
      • Observation by others (e.g., appears tearful).
    • Note: In children and adolescents, can be characterized as an irritable mood.

  2. Diminished Interest/Pleasure:

    • Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day, indicated by either subjective account or observation.

  3. Weight Changes:

    • Significant weight loss when not dieting or weight gain (e.g., 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. Sleep Disturbances:

    • Insomnia or hypersomnia nearly every day.

  5. Psychomotor Agitation/Retardation:

    • Observable by others, not merely subjective feelings of restlessness or being slowed down.

  6. Fatigue:

    • Fatigue or loss of energy nearly every day.

  7. Feelings of Worthlessness/Guilt:

    • 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. Cognitive Impairments:

    • Diminished ability to think or concentrate, or indecisiveness, nearly every day, either by subjective account or as observed by others.

  9. Suicidal Thoughts:

    • 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. Functional Impact:
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • C. Exclusion Criteria:
    • The episode is not attributable to the physiological effects of a substance or another medical condition.
  • D. Differential Diagnosis:
    • At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
  • E. No Manic/Hypomanic Episodes:
    • There has never been a manic episode or a hypomanic episode.

MDD and Grief

  • Context of Grief:
    • Responses to a significant loss (e.g., bereavement, financial ruin, losses from disasters, serious medical illnesses) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss, resembling a depressive episode.
    • Though these symptoms may be understandable as part of grieving, careful consideration is needed to determine if a major depressive episode is present in addition to the normal grief response.
    • This decision should be made with consideration of the individual’s history and cultural norms regarding expression of distress in the context of loss.

Persistent Depressive Disorder (Dysthymia)

  • A. General Criteria

    • Depressed mood for most of the day, for more days than not, indicated by either subjective account or observation by others, for at least 2 years.
    • Note: In children and adolescents, mood can be irritable and the duration must be at least 1 year.

  • B. Associated Symptoms:

    • Presence of two (or more) of the following while depressed:
    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.

  • C. Duration of Symptoms:

    • During the 2-year period (1 year for children and adolescents), the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

  • D. Major Depressive Disorder Criteria:

    • Criteria for a major depressive disorder may be continuously present for 2 years.

  • E. Exclusion of Manic/Hypomanic Episodes:

    • There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

Premenstrual Dysphoric Disorder

  • A. Timing and Presence of Symptoms:

    • In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, improve within a few days after the onset of menses, and become minimal or absent in the postmenstrual week.

  • B. Core Symptoms:

    • One (or more) of the following symptoms must be present:
    1. Marked affective lability (mood swings; feeling suddenly sad or tearful; increased sensitivity to rejection).
    2. Marked irritability, anger, or increased interpersonal conflicts.
    3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
    4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

  • C. Additional Symptoms:

    • One (or more) of the following symptoms must additionally be present to reach a total of five symptoms when combined from Criterion B:
    1. Decreased interest in usual activities (work, school, friends, hobbies).
    2. Subjective difficulty in concentration.
    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 (e.g., breast tenderness or swelling, joint/muscle pain, sensation of bloating, or weight gain).
    • Note: The symptoms in Criteria A – C must have been met for most menstrual cycles in the preceding year.

  • D. Functional Impact:

    • Symptoms cause clinically significant distress or interference with work, school, social activities, or relationships.

  • E. Exclusion of Other Disorders:

    • The disturbance is not merely an exacerbation of symptoms of another disorder (e.g., major depressive disorder, panic disorder, persistent depressive disorder, or personality disorder) but may co-occur.

  • F. Confirmation Requirement:

    • Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles; diagnosis may be made provisionally prior to confirmation.

  • G. Exclusion of Substance/Condition Effects:

    • Symptoms are not attributable to physiological effects of a substance or another medical condition (e.g., hyperthyroidism).

Major Depressive Disorder Overview

  • Definition:

    • Depression is a disabling disorder associated with:
      • Substantial emotional misery.
      • Severe interpersonal disruption.
      • Increased risk for physical illness and death.

  • Characterization:

    • Described as an “intrapsychic” disorder, meaning it exists within the mind and psyche but can severely disrupt the lives of those close to the sufferer.

  • Chronic Nature:

    • Frequently chronic, lasting months or years and commonly re-occurring post recovery.

  • Public Health Problem:

    • Associated with significant loss of productivity, resulting in billions of dollars in economic costs due to lost workdays and diminished work quality.

Historical Perspectives on Depression

  • Ancient Records:

    • Symptoms resembling depression documented in the Bible and Egyptian writings circa 260 B.C.
    • Ancient Greeks, notably Hippocrates, theorized that melancholia arose from an excess of black bile.

  • Early Characterizations:

    • Araetus of Cappadocia (120 B.C.) identified melancholia with sadness, suicidal tendencies, indifference, and psychomotor agitation.
    • Kant posited that emotions could not cause mental illness, viewing depression instead as a somatic ailment.
    • Abraham and Freud were among the first to link psychological/emotional factors to depression causally.

Epidemiological Insights on Depression

  • Prevalence Surveys:

    • Various surveys document prevalence, including:
      • National Institute of Mental Health Epidemiologic Catchment Area (ECA).
      • National Comorbidity Survey (NCS).
      • WHO’s Composite International Diagnostic Interview (CIDI).
      • National Comorbidity Survey - Replication (NCS-R).

  • Prevalence Rates:

    • Twelve-month prevalence rates:
      • ECA: 2.7%.
      • NCS: 4.9%.
      • NCS-R: 6.6%.
    • Lifetime prevalence rates:
      • ECA: 2.7%.
      • NCS: 15.8% (over 15 years of age).
      • NCS-R: 16.6%.
    • Variations across surveys likely reflect differences in instruments and sampling.

Gender Differences in Depression

  • Risk Factors:
    • Women have a significantly higher risk for depression, with an average female-to-male ratio of 2:1.
    • Lifetime prevalence in women (NCS): 21.3%, men: 12.7%.
    • These sex differences persist across various countries.
    • Gender disparities emerge during adolescence, with rates similar in childhood.

Age and Cohort Effects in Depression

  • Age-related Statistics:

    • Rate of onset increases notably during adolescence, with prevalence higher among individuals aged 25 to 45 years.
    • First onset rates for individuals over 65 years old are considerably lower.

  • Cohort Observations:

    • Data suggest younger generations are more vulnerable to depression compared to past cohorts.
    • Particularly noted increases in depression rates among individuals born after the mid-twentieth century, especially in young men.

Depression Models

  • Contemporary Understanding:
    • Current approaches are multifactorial, integrating:
      • Negative life experiences.
      • Genetic predispositions.
      • Biochemical factors.
      • Social interactions.
      • Cognitive processes.

Life Event Models

  • Definition:

    • Life events can be sudden, significant changes in an individual’s external environment.

  • Considerations in Models:

    • Contribution of life events to depression is complex due to various mediating factors.

  • Brown and Harris (1978, 1986):

    • Introduced the Bedford College Life Events and Difficulties Schedule (LEDS).
    • Defined:
      • Severe Events: Events with marked or moderate long-term threat, e.g., job loss, linked to onset of depressive disorders.
      • Less Severe Events: Insufficient alone to elicit depression, e.g., threats of job loss, unless combined with severe events (additivity effects).

  • Kindling Hypothesis:

    • Early depressive occurrences increase neurobiological sensitization, leading to later episodes with less severe stressors, potentially making depression autonomous.

Behavioral Models

  • Theory (Lewinsohn, 1974):
    • Depression results from a low rate of response-contingent positive reinforcement.
    • Loss of positive reinforcement can extinguish behavioral responses leading to dysphoria.
    • Noted that individuals with poor social skills may lack access to reinforcing social relationships.

Interpersonal Models

  • Coyne (1976):
    • Stressful life events lead to symptomatic displays including helplessness, withdrawal from interactions, irritability, and agitation, intended to regain support and reassurance.

Cognitive Models

  • Beck’s Cognitive Theory of Depression:

    • Proposes that depression arises from activation of negative self-schemata that bias cognition, memory, and attention.
    • Such schemata develop from adverse childhood experiences, leading to heightened focus on negative events and a perseverative recall of negative experiences.

  • Cognitive Distortions:

    • All-or-nothing thinking: Viewing situations categorically rather than on a continuum.
    • Selective abstraction: Focusing on negative details while ignoring the context.
    • Overgeneralization: Making broad conclusions from single incidents.
    • Emotional reasoning: Concluding accuracy based on feelings.
    • Personalization: Taking undue responsibility for others' negative actions.

Attribution-Based Models

  • Seligman’s Learned Helplessness:

    • Draws parallels between depressed individuals and conditioned animals who avoid escape after repeated failures.
    • Depressed individuals exhibit expectations of helplessness due to attributional styles which serve as vulnerability factors.

  • Abramson et al. (1978):

    • Suggested an attributional style where positive events receive external, unstable explanations, whereas negative events receive internal, stable attributions.

Evolutionary Models

  • Nesse (1991, 2000):
    • Suggests that depression alerts individuals to unproductive pursuits, conserving energy for functional goals and keeping energy from risky endeavors.
  • Depressive Realism:
    • Depressed individuals might possess a more accurate appraisal of reality, free from overly optimistic biases, revealing when goals become unrealistic.
  • Seasonal Affective Disorder (SAD):
    • Seen as a mechanism to prevent energy expenditure on non-fruitful endeavors during harsh conditions (e.g., winter).
  • Hagen’s Negotiation Tool Theory:
    • Proposes that post-partum depression may act as a strategy to negotiate higher investments from partners due to the considerable costs associated with child-rearing.
    • Depressed mothers might withhold investment in offspring to compel greater support.