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Outline

Primary vs. secondary symptoms

Mood vs. affect

Panic attack vs. panic disorder

Acute Stress Disorder/PTSD

Mood disorders: major depression and dysthymia

Mood disorder treatment: CBT, IPT, and Recovery/empowerment model

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Mood Disorders

Major Depressive Episode

Major Depressive Disorder

Dysthymic Disorder

“Double Depression”

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Mood vs. Affect

Mood

A pervasive and sustained emotion that, in the extreme, colors the person’s perception of the world

Affect

A pattern of observable behaviors that is the expression of a subjectively experienced state (emotion)

Variable over time, in response to changing emotional states (vs. mood, which is pervasive and sustained

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DSM Classification

Major depressive episode

Depressed mood or loss of interest or pleasure

Manic

Persistently elevated, expansive, irritable mood

Mixed

Manic and depressive symptomology

Hypomanic

Similar to manic, not as severe

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Major Depressive Episode

Depressed or irritable mood Loss of interest or pleasure [anhedonia] Weight changes Sleep problems [DFA, SCD, EMA] Motor agitation or retardation Loss of energy Feeling worthless or guilty Poor concentration Thoughts of death or suicide 5 of 9 symptoms for 2+ weeks Problems must cause impairment

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Major Depressive Disorder

Primary Symptoms (9 MDE symptoms from previous slide)

Secondary symptoms: social withdrawal, temper tantrums, poor schoolwork, poor peer relations, alcohol and substance use

Onset: age 5-19

Course: Variable; 26% to 70% have multiple MDE episodes within 5 years

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Major Depressive Disorder

Duration: median duration = 8 months for clinical samples [but for >1 yr for a majority of youth]; 1-2 months for community samples

Prevalence:

Children: 2%

Adolescents: 4-8%

Severity and duration: differential for MDD vs. dysthymic disorder

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Mood Descriptors

Euthymic – normal mood state

Dysphoric – unpleasant mood (e.g., depression, anxiety, irritability)

Elevated – more cheerful than normal; not necessarily indicative of psychopathology

Euphoric – exaggerated sense of well-being; implies a pathological mood state (e.g., “up in the clouds”, “flying high”)

Expansive – lack of restraint in expressing one’s feelings, frequently with an overvaluation of one’s significance or importance

May be accompanied by elevated or euphoric mood

Irritable – internalized feelings of tension associated with being easily annoyed and provoked to anger

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Affect Descriptors Appropriate – consistent with content of person’s

speech or ideation

Inappropriate when not consistent

Broad – normal

Restricted – limited in expressive range and/or intensity

Blunted – marked by severe reduction in the intensity of affective expression

Flat – virtually no affective expression; voice is monotonous and face is frequently immobile

Labile – characterized by repeated, rapid, and abrupt shifts

e.g., tearful vs. combative vs. gregarious, vs. angry and abusive without apparent reason

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Depression & Development

Infancy

Lethargy

Feeding problem

Sleep problem

Irritability

Sad expression

Crying

Failure to thrive

Associated with maternal depression

Preschool Lethargy

Feeding problem

Sleep problem

Irritability

Sad facial expression

Crying

Mood changes

Hard to assess

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Depression & Development

Middle childhood Begin to report hopelessness and self-

deprecation around age 9-12

Throughout childhood: difficult/impossible

to disentangle depression from anxiety Measurement issue or developmental

phenomenon?

Adolescent Begins to look more like adult depression

May be differences between prepubertal and postpubertal depression

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Major Depressive Disorder

Point prevalence rate: 2% in school-age children; 4% in adolescents 1:1 gender ratio before puberty; female excess after puberty 1:2 males to females Cumulative incidence by age 18: 20% of community samples A majority of children w/depressive illness will have a recurrent illness: 20% - 60% by 1 to 2 years following remission; 70% after 5 years following remission (Birhaher et al. 2002; Costello et al., 2002). Episodes typically last 8 wks – 9 months, and for more than 1- year for a significant majority [up to 14 months]

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Major Depressive Disorder

The clinical picture in children is similar to that observed in adults with some exceptions:

Melancholy is usually not observed in children. Suicide attempts are less frequent in children. Lethality of suicide attempts is lower [note: children show a similar frequency of suicidal ideation & equal intent]. Children: higher frequency of comorbid separation disorder, phobias, somatic complaints, & externalizing problems [42% w/ADHD, 62% w/ODD, 41% w/both disorders – Luby et al., 2003].

Approximately 5% - 10% of children & adolescents have subsyndromal symptoms of MDD, including significant psycho- social impairment & increased risk of suicide & developing MDD [also have high family loading for depressive illness].

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Diagnosis of Major Depression and Dysthymia in Pediatric Patients Primary obstacle: children cannot reliably report their internal feelings [i.e., identify and label mood states]. Children are notoriously poor at reporting time concepts &

questions in which they have to exercise judgment – use anchors and usually remembered dates (summer, holidays, birthdays).

Use simple questions asked sequentially rather than complex

questions. Must rely heavily on parental report, which in turn, is hampered by several variables including parental psychopathology, attachment/ closeness to child, observation of child, & ability to identify internal feelings in children [note: depressed mothers tend to over report depressive symptoms in their children]. Mood states are highly comorbid with ADHD, CD, and anxiety disorders.

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Important Predictors of Depression & Recurrent Depression

Comorbid nonaffective disorders predict a more severe course of depression.

45% of adolescents with a history of MDD develop a new episode of MDD between the ages of 19 and 24 (i.e., annual reoccurrence rate of 9% over a 5-year time span).

Adolescents with MDD have an elevated rate of nonaffective disorders between 19 and 24 years of age, as well as elevated antisocial and borderline personality traits relative to TD controls.

The prognosis of Adjustment Disorder is nearly as poor as for MDD – rates of future MDD and nonaffective disorder for adolescents with adjustment disorder are as high as for those initially presenting with MDD.

Adolescents who succumb to adjustment disorder with depressed mood in the face of a stressor are more vulnerable for developing future MDD as young adults (i.e., implies inherent vulnerability).

Nearly all adolescents with MDD & dysthymia also had a non-affective disorder.

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Depression and Anxiety in Children

Kovacs et al. (1989): 2/3’s of children with comorbid anxiety and depression develop anxiety before depressive symptoms. Orvaschel et al. (1995): 64.5% of adolescents with anxiety disorder later develop a 2nd diagnosis of MDD; but only 6.5% with MDD first later develop an anxiety disorder. Cole et al. (1998): Anxiety Depression

Depression & anxiety are highly stable temporal traits [.49-.74 over a 30 month interval] High rates of depression & anxiety predict increases in these constructs over time. The probability of developing depressive symptoms after manifesting symptoms of anxiety is 31%. The probability of developing depressive symptoms without previous symptoms of anxiety is less than 1%. There a 3-fold increase in the likelihood of experiencing depressive symptoms due to prior symptoms of anxiety but the converse does not hold.

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Important Predictors of Depression & Recurrent Depression

Greater severity, chronicity, multiple recurrent episodes, comorbidity, hopelessness, residual subsyndromal symptoms, negative cognitive style, family problems, low SES, & exposure to ongoing negative life events predict recovery, relapse, and reoccurrence. Dysthymia – characterized by a prolonged course, with a mean episode of 3 – 4 years for clinical and community samples; also associated with an increased risk of subsequent MDD and substance abuse disorders (Kovacs et al., 1994).

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Best predictors of which depressed children will later develop bipolar disorder: Rapid onset

Psychosis Psychomotor retardation Psychotic features Family history of bipolar disorder Tricyclic induced hypomania

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Based on the following misconceptions: Children are too immature cognitively and emotionally to experience core depressive affects. Children younger than 9 do not have a sufficiently developed self-concept and thus could not experience the discrepancy between the real and ideal self that is a necessary precursor to guilt – a core emotion of depression. Psychoanalytic – the superego has not fully developed at this age. “Masked Depression” – conveys the notion that children will not express depression directly but rather indirectly through somatic complaints, aggression, and other nonaffective symptoms instead of typical symptoms of depression (sadness, anhedonia, etc). Joaquim Puig-Antich (1982) study: many children presenting with with CD symptoms may have an underlying depressive illness & CD symptoms may resolve following successful Rx of depression.

Masked Depression

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Diagnosis of Depression in Children Structured and Semi-Structured Clinical Interviews (e.g., K-SADS) CBLC/TRF: 1. Depressed school-age children have significantly higher internalizing T-scores relative to ADHD-ODD and no disorder children 2. Depressed school-age children have significantly higher depression/ anxiety, withdrawal, and somatization subscale scores relative to children with ADHD/ODD and no disorder children. Symptoms not reported by typically developing controls:

a. Anhedonia 58% - high NPP: don’t exhibit it, you probably don’t have depression [reported by 0% in typical children] a. Withdrawn b. Afraid to leave home c. Unexcited d. Sadness/irritability – high sensitivity – almost all children with depression -- 98% -- report this symptom.

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A majority of children with primary affective disorder exhibit behavioral problems that are viewed by their parents as disturbing; however, these problems are not viewed as the child’s major problem (Carlson & Cantwell, 1980). The behavior problems of children with externalizing disorders are typically viewed as more serious by parents. A traditional evaluation with only the parent will miss approximately 60% of affective cases. ‘Masking behaviors’ are typically nothing more than presenting complaints. In children with depression – behavior problems are typically viewed as less severe and postdate the onset of depressive symptoms.

Diagnosing Depression in Children

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Major Depressive Disorder

Primary Treatments

Tricyclic Antidepressants (TCAs) or SSRIs

Puig-Antich et al. “conduct disorder” study

Cognitive behavioral intervention

Behavioral family systems therapy

Interpersonal psychotherapy

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Dysthymic Disorder

Depression less severe, but more chronic Depressed or irritable mood Appetite disturbance Sleep disturbance Low energy Low self-esteem Poor concentration Hopelessness Symptoms last for a year or more Double depression is a term used when the child has

both MDD and dysthymia Dysthymia usually begins before MDD

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Dysthymic Disorder

Primary Symptoms: Two or more from previous slide

Secondary symptoms: social withdrawal, temper tantrums, poor schoolwork, poor peer relations, alcohol and substance use

Onset: age 8.5

Course: Variable

Duration: At least 1 year; chronic, variable, or remits

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Adjustment Disorder with Depressed Mood

Child has depressive symptoms in response to a clear stressor (e.g., move, divorce)

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Epidemiology

MDD the most common type 80% of kids with

depression have MDD 10% have double

depression 10% dysthymia May be underestimated Episodes common in

adolescence Gender differences do not

occur until age 13 when girls report depression more often

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Course of major mood disorders

Time Mood

(+)

(–)

Hypomania

Mania

Dysthymia

Major Depression

Norm

al

Range

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Psychosocial Treatments for Depression

Cognitive Behavioral therapy (Beck)

Interpersonal Psychotherapy (Klerman)

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Cognitive Behavioral Therapy (CBT)

Beck (Cognitive Therapy)

Ellis (Rational Emotive Behavior Therapy)

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Perceived absence of contingency between person's efforts and reinforcing nature of consequences that follow

Target distorted

perceptions

Why is ability lacking?

Depression/Dysthymia

Physio/Chemical/ Hormonal

Imbalances

Efforts to Bring (+) Reinforcement

Inadequate

Perceptions of ability to control own world

are distorted

Target Environment

Target Perceptions

Consider antidepressant

medication

Bx Rehearsal

Bx Deficits (Lack appropriate skills)

Inhibitions

“Find other satisfactions”

Reduce Anxiety

Desensitization

Prompting

Modeling

Self-monitoring Feedback Therapist & Peer

“Learn to like what you're

doing”

Problem Solving, etc.

Environment is Unresponsive (Few reinforcements)

Objectively competent, accurate perceptions i.e., the situation IS the problem

Rational Restructuring Evaluate realistically demands

and ability to meet then

Post-Competency Change view of self-efficacy

Reinforce New Thoughts & Behaviors

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Anxiety

Conditioned Instrumental Deficits

Lack of certain skills

Self-generated Statements

Self-induced Behaviors

Life Situations

Desensitization

Can client be taught to relax? Can client clearly imagine and

become anxious? Will client agree to graduated

exposure?

Modeling

in vivo

Imaginal

Modeling

Self-monitor

Bx Rehearsal

Overextending Self/ Too Much Responsibility

Unrealistic Self-demands

Shoulds/Musts

Perception of Other's

Reactions

Desensitization

Anxiety Level

Supplements

Coping Skills

Modify Environment

Yes

Tenable Environment?

No

Rational Restructuring

Evaluate realistically

demands and ability to meet then

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Reactions

Emotional

Behavioral

Physiological

Heaviness in abdomen

Closes book

Sadness

Situation

Reading textbook

Cognitive Behavioral Therapy (CBT) Core Belief

I’m incompetent

Intermediate Belief

If I don’t understand something perfectly, then I’m dumb

Automatic Thoughts

This is too hard. I’ll never

understand this.

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Automatic Thoughts Situation: Reading your textbook

Reader’s automatic thought

“This makes sense! Finally, a book that explains things clearly!”

“This is too general – when will I learn what I need to work with kids?”

“This book is a waste of money”

“I have to learn all this?! What if I don’t understand it?!?”

“This is too hard. I’ll never be a good therapist”

The reader feels:

Mildly excited

Disappointed

Disgusted

Anxious

Sad

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Cognitive Behavioral Therapy (CBT)

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CBT: Eliciting automatic thoughts