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Chapter 8

Chapter 8 Mood Disorders

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Western University
Psychology 2320A/B
Elizabeth Hayden

Chapter 8: Mood Disorders  Mood disorder (also called an affective disorder) – disturbance in mood is the central feature o Mood is broadly defined as a feeling or emotion o Children with mood disorders suffer from extreme, persistent, or poorly regulated emotional states, such as excessive happiness or swings in mood from deep sadness to high elation o One of the most common, chronic and disabling illnesses in young people Overview of Mood Disorders  Come in several brands o At one end of the spectrum are children who experience severe depression – suffer from dysphoria, a state of prolonged bouts of sadness  Feel little joy in anything they do and lose interest in nearly all activities, a state known as anhedonia  Some express depression through irritable mood – irritability refers to easy annoyance and touchiness, characterized by an angry mood and temper outbursts  Irritability is one of the most common symptoms of depression, occurring in about 80% of clinic- referred children with depression o At the opposite end of the mood spectrum are a smaller number of youths who also experience episodes of mania, an abnormally elevated or expansive mood, and feelings of euphoria, which is an exaggerated sense of well-being  Suffer from an ongoing combination of extreme highs and extreme los, a condition known as bipolar disorder (BP) or manic-depressive illness  DSM-IV-TR divides mood disorders into two general categories – depressive disorders and bipolar disorders Depression  Refers to a pervasive unhappy mood  Symptoms are so universal  History o People once doubted the existence of depression in children o Symptoms of depression were considered normal and passing expressions of certain stages of development  Almost all young people experience some symptoms of depression – as many as 5% of children and 10-20% of adolescents experience significant depression at times  The way in which children express and experience depression changes with age  It is important to distinguish between depression as a symptom, as a syndrome, and as a disorder o As a symptom, depression refers to feeling sad or miserable  Often occur without existence of a serious problem, and are relatively common at all ages o As a syndrome, depression refers to a group of symptoms that occur together more often  Along with sadness, child may display a reduced interest in activities, cognitive and motivational changes, and somatic/psychomotor changes  Far less common than isolated depressive symptoms and often includes mixed symptoms of anxiety and depression  At times, may occur following certain life events – for example, as a normal grief reaction following a loss of a loved one o As a disorder, depression comes in two types  Major depressive disorder (MDD) – minimum duration of 2 weeks and is associated with depressed mood, loss of interest, other symptoms (e.g. sleeplessness, hopelessness, negative self esteem), and significant impairment in functioning  Dysthymic disorder (DD) – associated with depressed mood, generally less severe but longer lasting symptoms (a year or more), and significant impairment in functioning Major Depressive Disorder  Key features – sadness, loss of interest or pleasure in nearly all activities, irritability, plus a number of additional specific symptoms for at least 2 weeks  Three important points about the diagnosis of MDD in children and adolescents: o Same DSM criteria for diagnosing adults can be used to diagnose school-age children and adolescents o Because children’s disruptive behaviours attract more attention, or are more easily observed compared with internal, subjective suffering, depression in children can be easily overlooked o Some features of depression are likely more common in children and adolescents than in adults – notably, irritable mood  Prevalence o Between 2% and 8% of all children aged 4 to 18 experience MDD o Depression is relatively rare (about 1-2%) among preschool and school-age children, but increases two- to threefold by adolescence o Since depression comes and goes, prevalence estimates vary with the time frame in which symptoms are assessed  In 13 – 18 year olds, the prevalence of depression is about 3% when taken at a single point in time, and about 8% when taken over a 1-year period  However, lifetime prevalence estimates range from about 10% to 14%  Comorbidity o 90% of young people with depression have one or more other disorders, and 50% have two or more o Most frequent co-occurring disorders in clinic-referred youngsters with MDD are anxiety disorders, particularly generalized anxiety disorders, specific phobias, and separation anxiety disorders o Dysthymia, conduct problems, ADHD and substance use disorder are also common o About 60% of adolescents with MDD have a comorbid personality disorder, which is most commonly borderline personality disorder – characterized by instability of interpersonal relationships, self-image, and affects, and marked impulsivity o Many co-occurring disorders are present before depression and are likely to persist after the child is no longer depressed – pathways to comorbid conditions however, differ by disorder and sex o Presence of a co-occurring disorder is significant because it can increase the risk for recurrent depression, increase the duration and severity of depressive episodes, and increase the risk for suicide attempts, all of which may in turn increase the co-occurring problems  Onset, course, and outcome o Onset may be gradual or sudden – typically have history of milder episodes of depression that do not meet DSM criteria o Most common age of onset is between 13 and 15 o Average episode of MDD lasts about 8 months, with longer episodes if a parent has a history of depression o MDD is a recurrent condition with a change of recurrence of about 25% within 1 year, 40% within 2 years, and 70% within 5 years  Thus, significant number of children develop a chronic, relapsing disorder that persists into young adulthood o Those with onset prior to age 15 and a recurrent episode prior to age 20 display more severe, chronic, suicidal depressions, greater co-occurring anxiety and worse social functioning at age 15 and poorer psychosocial outcomes at age 20 o About one-third of adolescents with MDD will develop a bipolar disorder within 5 years after the onset of their depression, known as bipolar switch o Why do depressive episodes reoccur?  A reason may be that the first episode may sensitize child to future episodes  First episode may be linked to a specific stressor and is accompanied by lasting changes in biological processes that heighten future reactivity to stress  Individuals are thus increasingly vulnerable to stress and even non-severe stress or minor events  This process is known as stress sensitization o As they become adults, children/adolescents with MDD continue to experience many negative outcomes that include suicide/suicide attempts, psychiatric/medical hospitalizations, alcohol abuse/dependence, psychosocial impairments, etc.  Gender, ethnicity, and culture o Females are twice as likely as males to suffer from depression, are more susceptible to milder mood disorders, and are more likely to experience recurrent episodes o Sex difference is not present among ages 6 – 11, where depression is equally common in boys and girls o However, sex differences in emotional reactivity are present in children who are depressed or at-risk for depression as early as the preschool period  Boys display more anger and girls display more sadness o Sex difference begins between ages 13 and 15, when the rate rises for girls, and rates of depression/ gender differences increase rapidly between ages 15 and 18  Ratio of girls to boys is about 2:1 to 3:1 after puberty, a pattern that continues throughout adolescence/adulthood o Race and ethnicity are known sources of varying levels of exposure to stress and availability of resources  As a result, low SES may increase vulnerability to stress and increase likelihood of depression o Initial rates of depressive symptoms highest for Hispanic and Asian teens and lowest for whites, with African American youths falling in between Dysthymic Disorder (Dysthymia)  Young people who suffer from dysthymic disorder (DD) or dysthymia experience symptoms of depressed mood that occur on most days and that persist for at least 1 year  Unhappy and irritable most of the time  Combined with chronic depressed mood, children also display at least two somatic problems (e.g. eating problems, sleep disturbances, low energy) or cognitive symptoms (e.g. lack of concentration, low self-esteem)  Symptoms are chronic, but less severe than those for children with MDD  Characterized by poor emotion regulation – constant sadness, feelings of being unloved and forlorn, self- deprecation, low self-esteem, anxiety, irritability, anger, and temper tantrums  Some may experience double depression – major depressive episode is superimposed on the child’s previous dysthymia causing child to present with both disorders  Lack of differences between youth with a dysthymic disorder and those with a chronic type of major depression has led to the proposal that the term chronic depressive disorder be used to describe both conditions in DSM-5  Prevalence and comorbidity o Rates of dysthymia are lower than those of MDD, with approx. 1% of children and 5% of adolescents displaying the disorder o Most prevalent co-occurring diagnosis with dysthymia is MDD o During course of dysthymia, as many as 70% of children may have an episode of major depression o About ½ of children also have one or more co-occurring non-affective disorders that precede the dysthymia including anxiety disorders, conduct disorder, and ADHD  Onset, course, and outcome o Develops about 3 years earlier than MDD, most commonly around 11 – 12 years of age o Since dysthymia frequently precedes MDD, it could be a precursor to its development o Childhood-onset dysthymia has a prolonged duration, with average episode length of 2 – 5 years o Almost all children recover from dysthymia, but have extremely high risk of developing other disorders, especially MDD, anxiety disorders and conduct disorder Associated Characteristics of Depressive Disorders  Intellectual and academic functioning o Certain depressive symptoms such as difficulty concentrating, loss of interest and slowness of thought may have a harmful effect on a child’s intellectual and academic functioning o Association between severity of depression and children’s overall intelligence is weak, suggesting that the effects of depression on cognitive function may be selective o Perform more poorly than others in school – poor concentration and thinking ability, slowed movement or agitation, fatigue, insomnia, and somatic complaints may lead to problems in school  Cognitive biases and distortions o Experience biases, deficits, and distortions in their thinking o Negative beliefs and attributions of failure typically accompany the disorder (not part of diagnosis) o Depressive ruminative style – focus narrowly on negative events for long periods  Negative self-esteem o Symptom most specifically related to depression in adolescents o Self-esteem problems in adolescent girls are often related to negative body image, and may partly contribute to their higher risk for depression  Social and peer problems o Significant disruptions in their relationships – few friends or close relationships, feel lonely and isolated, feel that others do not like them, and display extensive impairments in their social skills o Strong risk factor for the onset of depression in adolescent females is co-rumination, a negative form of self-disclosure and discussion between peers focused narrowly on problems or emotions to the exclusion of other activities/dialogue o Depressed teens may also make poor choices in dealing with social problems, such as turning to alcohol or drugs  Family problems o Experience less supportive and more conflictual relationships with their families o Socially isolated from their families and prefer to be alone  Depression and suicide o Drug overdose and wrist cutting are most common methods for adolescent suicide o For children, most common methods are firearms (57%), hanging or suffocation (28.4%) and poisoning or overdose (7.6%) o Although rates of suicide vary worldwide, two strongest risk factors for suicidal behaviour are consistent – having a mood disorder and being a young female o Suicidal ideation is common among many different types of psychological disorders, but suicide attempts are more common during depression o About 60% of youngsters who are clinically depressed report having thoughts about suicide, and 30% actually attempt it by 17 years of age o Ages 13 – 14 are peak periods for a first suicide attempt by youngsters with depression o Suicide attempts decrease with maturation, possibility of being able to tolerate negative mood states and acquire more resources for coping Theories of Depression  Psychodynamic theories o Viewed depression as the conversion of aggressive instinct into depressive affect o Depression is presumed to result from a loss that is either actual like the death of a parent of symbolic, as a result of emotional deprivation, rejection or inadequate parenting o High levels of maladaptive guilt and shame are related to depression in children as young as 3 – 5 years o Depression does however occur in children who do not experience loss or rejection – this casts doubt on the psychodynamic model  Attachment theories o Focus on parental separation and disruption of an attachment bond as predisposing factors for depression o Parent’s consistent failure to meet child’s needs is associated with development of an insecure attachment, and a view of others as threatening and undependable o Attachment relationships also serve to regulate biological and behavioural systems related to emotion  Behavioural theories o Emphasize importance of learning, environmental consequences, and skills and deficits during the onset and maintenance of depression o Depression is related to a lack of response-contingent positive reinforcement – this lack of positive reinforcement may occur for three reasons  May be unable to experience available reinforcement, often due to interfering anxiety  Changes in the environment, such as the loss of a loved one, may result in a lack of availability of rewards  May lack the skills needed to have rewarding and satisfying social relationships o Reduction in attention may lead to withdrawal, impairment in functioning, and heightened feelings of depression  Cognitive theories o Focus on the relation between negative thinking and mood – how young people view themselves and their world will influence their mood and behaviour, and cognitive vulnerabilities interact with negative events to increase depressive symptoms o Emphasize depressogenic cognitions, which are the negative perceptual and attributional styles and beliefs associated with depressive symptoms o Hopelessness theory proposes that depression-prone individuals tend to make internal, stable and global attributions to explain the causes of negative events o Cognitive model – developed by Aaron Beck (1967  Proposes that depressed individuals make negative interpretations about life events because they use biased and negative beliefs as interpretive filters for understanding these events o Depressed individuals show cognitive problems in three areas:  Display information-processing biases, or errors in their thinking in specific situations, called negative automatic thoughts  Often include thoughts of physical and social threat, personal failure, and hostility  Associated with a negative outlook in the following three areas, referred to as the negative cognitive triad  Negative views about oneself  Negative views about the world (day-to-day experiences)  Negative views about the future  Have negative cognitive schemata, which are stable structures in memory that guide information processing, including self-critical beliefs and attitudes  Other theories o Self-control theories – difficulty organizing behaviour in relation to long-term goals and display deficits in self-monitoring, self-evaluation and self-reinforcement o Interpersonal models – view disruptions in interpersonal relationships, especially with family and peers, as the basis for the onset and maintenance of depression o Socio-environmental models – emphasize the relationship between stressful life events and depression  Depression can be a direct reaction to the occurrence of stressful life events, such as the loss of a parent  Impact of stress may be moderated by individual risk factors, such as genetic risk  Referred to as the diathesis-stress model of depression because the occurrence of depression depends on the interaction between the youngster’s personal vulnerability  Negative environmental events may be internalized as negative cognitive styles, which then predispose the child to develop depression  Depression may result in behaviours and impairments in functioning that generate stressful life circumstances that in turn lead to depressive reactions o Neurobiological models – focus on genetic vulnerabilities and neurobiological processes Causes of Depression  Genetic risk influences neurobiological processes, and is reflected in an early temperament characterized by oversensitivity to negative stimuli, high negative emotionality, and a disposition to feeling negative affect o Early dispositions increase exposure to and are shaped by negative experiences within the family, and continue to exert influence through development  Cognitive, emotional and interpersonal problems may lead directly to depression, or they may elicit conflict, rejection by others, poor social relationships, and difficulty in regulating emotions which creates a vulnerability to develop depression when confronted with life stress  Genetic and family risk o Studies suggest moderate genetic influence on depression in children and adolescents, with heritability estimates ranging from 30% to 45% across studies o Consistent evidence that MDD in young people runs in families across generations o Children of parents with depression have about 3 times the risk of having depression compared with children of parents having no psychiatric
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