preety shekhar - magadh university

BY

PREETY SHEKHAR

ASSISTANT PROFESSOR, DEPARTMENT OF PSYCHOLOGY

GAUTAM BUDDHA MAHILA COLLEGE, GAYA

MAGADH UNIVERSITY, BODH GAYA

Contents:

➢ What are Mood Disorders ?

➢ Types of Mood Disorder Episodes

➢ What is Depression ?

➢ Definitions of Depression

➢ How it feels like ?

➢ Types of Depressive Disorders

➢ DSM-IV-TR Diagnostic Criteria for Major Depressive Episode

➢ Symptoms of Depression

✓ Behavioural and Physical symptoms of Depression

✓ Cognitive symptoms of Depression

*Most of the time feeling SORRY FOR EVERYTHING

➢ Major Depressive Disorder ‘Facts at a Glance’

➢ Causes of Major Depressive Disorder

➢ Treatment of Major Depressive Disorder

➢ How to help someone battling Depression

MOOD DISORDERS: Psychological disorders characterized by prolonged and marked

disturbances in mood that affect how people feel, what they believe and expect, how they think

and talk, and how they interact with others.

Mood disorders are among the leading causes of disability worldwide (World Health

Organization [WHO], 2008).

DSM-IV-TR distinguishes between two categories of mood disorders: Depressive disorders and

Bipolar disorders.

Depressive disorders are mood disorders in which someone’s mood is consistently low; in

contrast, bipolar disorders are mood disorders in which a person’s mood is sometimes decidedly

upbeat, perhaps to the point of being manic, and sometimes may be low. Note that the mood

disturbances that are part of depressive disorders and bipolar disorders are not the normal ups

and downs that we all experience; they are more intense and longer lasting than just feeling

“blue” or “happy.”

What are Mood Disorders?

Depressive Episode: A major depressive episode involves symptoms of

depression.

Hypomanic Episode: A hypomanic episode involves elated, irritable, or

euphoric mood that is less distressing or severe than mania and is different than the individual’s nondepressed state. That is, how

a person behaves during a hypomanic episode is different from his or her usual

state.

Manic Episode: A manic episode involves elated, irritable, or euphoric mood (mood that is extremely positive and may

not necessarily be appropriate to the situation).

Mixed Episode: A mixed episode involves symptoms of both a major

depressive episode and a manic episode.

DSM-IV-TR defines four types of Mood

Disorder episodes: major depressive episode,

manic episode, hypomanic episode, and

mixed episode

Types of Mood Disorder Episodes

What is DEPRESSION ?

Definitions of

DEPRESSION

Definition According to WHO (World Health Organization)

• Depression is a common mental disorder, characterized by sadness, loss of interest or pleasure,

feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness and poor

concentration.

• It can be long lasting or recurrent, substantially impairing a person’s ability to function at work or

school, or cope with daily life. At its most severe, depression can lead to suicide. When mild,

depression can be treated without medicines but, when moderate or severe, people may need

medication and professional talking treatments.

• Non-specialists can reliably diagnose and treat depression as part of primary health care. Specialist

care is needed for a small proportion of people with complicated depression or those who do not

respond to first-line treatments.

• Depression often starts at a young age. It affects women more often than men, and unemployed

people are also at high risk.

Definition According to APA (American Psychological Association)

• Depression is more than just sadness. People with depression may experience a lack of interest

and pleasure in daily activities, significant weight loss or gain, insomnia or excessive sleeping,

lack of energy, inability to concentrate, feelings of worthlessness or excessive guilt and recurrent

thoughts of death or suicide.

• Depression is the most common mental disorder. Fortunately, depression is treatable. A

combination of therapy and antidepressant medication can help ensure recovery.

How it feels like?

DSM-IV-TR Diagnostic Criteria for Major

Depressive Episode

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

(1) depressed mood (symptom 1, below) or

(2) loss of interest or pleasure (symptom 2, below).

Note: Do not include symptoms that are clearly due to a general medical condition or mood-

incongruent [i.e., not consistent with the mood] delusions or hallucinations.

(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report

(e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In

children and adolescents, can be irritable mood.

(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly

every day (as indicated by either subjective account or observation made by others).

(3) Significant weight loss when not dieting or weight gain (e.g., a 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 gains.

(4) Insomnia or hypersomnia nearly every day.

(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely

subjective feelings of restlessness or being slowed down).

(6) Fatigue or loss of energy nearly every day.

(7) 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) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by

subjective account or as observed by others).


Depressive Episode

(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation [i.e., thoughts about

suicide] without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms do not meet criteria for a mixed episode [discussed later in this chapter].

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a

medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one. The

symptoms persist for longer than 2 months or are characterized by marked functional impairment,

morbid

preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Source: Reprinted with permission from the DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition, Text Revision, (Copyright 2002) American Psychiatric Association.


Depressive Episode

Behavioural and Physical Symptoms of Depressions:o People who are depressed make more negative comments, make less eye contact, are less

responsive, speak more softly, and speak in shorter sentences than people who are not

depressed (Gotlib & Robinson, 1982; Segrin & Abramson, 1994).

o Depression is also evident behaviorally in one of two ways: Psychomotor agitation or

Psychomotor retardation.

o Psychomotor agitation is an inability to sit still, evidenced by pacing, hand wringing, or

rubbing or pulling the skin, clothes, or other objects.

o Psychomotor retardation is a slowing of motor functions indicated by slowed bodily

movements and speech (in particular, longer pauses in answering) and lower volume, variety,

or amount of speech.

o These two psychomotor symptoms, along with changes in appetite, weight, and sleep, are

classified as Vegetative signs of depression.

Symptoms of DEPRESSIONS

Cognitive Symptoms of Depressions:o People often feel worthless or guilt-ridden, may evaluate themselves negatively for no objective

reason, and tend to ruminate over their past failings (which they may exaggerate).

o They may misinterpret ambiguous statements made by other people as evidence of their

worthlessness.

o Depressed patients can also feel unwarranted responsibility for negative events, to the point of

having delusions that revolve around a strong sense of guilt, deserved punishment, worthlessness, or

personal responsibility for problems in the world.

o They blame themselves for their depression and for the fact that they cannot function well.

o During a depressive episode, people may also report difficulty thinking, remembering, concentrating,

and making decisions.

o People with depression experience these symptoms in different combinations. No single set of

symptoms is shared by all people with depression (Hasler et al., 2004).

. According to DSM-IV-TR, once someone’s symptoms meet the criteria for a major depressive episode,

he or she is diagnosed as having MAJOR DEPRESSIVE DISORDER (MDD)—five or more

symptoms of an MDE lasting more than 2 weeks.

Most of the time feeling SORRY FOR EVERYTHING

Major Depressive Disorder Facts at a Glance

Prevalence

• Around 10–25% of women and 5–12% of men will develop MDD over their lifetimes.

• Before puberty, however, boys and girls develop MDD in equal numbers (Kessler et al., 2003).

• People with different ethnic backgrounds, education levels, incomes, and marital statuses are

generally afflicted equally over their lives (American Psychiatric Association, 2000; Kessler et

al.,2003; Weissman et al., 1991).

Comorbidity

• Most people with MDD also have an additional psychological disorder (Rush et al., 2005),

such as an anxiety disorder (Barbee, 1998; Kessler et al., 2003) or substance abuse (Rush

et al., 2005).

Onset

• MDD can begin at any age, with the average age of onset in the mid-20s, although people are

developing MDD at increasingly younger ages.


Course

• Among individuals who have had a single MDE, approximately 50–65% will go on to

have a second episode (Angst et al., 1999; American Psychiatric Association, 2000;

Solomon et al., 2000).

• Those who have had two episodes have a 70% chance of having a third, and those who

have had three episodes have a 90% chance of having a fourth.

Gender Differences

• As noted above, women are almost twice as likely as men to develop MDD (American

Psychiatric Association, 2000; Kessler, 2003).

• Some women report that depressive symptoms become more severe premenstrually.

Source: the source for information is American Psychiatric Association, 2000.


CAUSES OF

MAJOR

DEPRESSIVE

DISORDER

The exact cause of MDD isn’t known. However, there are several factors that can increase the risk of developing

the condition. A combination of genes and stress can affect brain chemistry and reduce the ability to maintain mood

stability. Changes in the balance of hormones might also contribute to the development of MDD.

MDD may also be triggered by:

• alcohol or drug abuse

• certain medical conditions, such as cancer or hypothyroidism

• particular types of medications, including steroids

Studies indicate that a number of different genetic, biological, environmental and psychological factors can raise a

person’s risk for developing depression.

As outlined by the National Institute of Mental Health, these can include having a personal or family history of

depression, experiencing major life changes, trauma, stress and certain physical ailments and medications. These

include drugs prescribed for everything from controlling high blood pressure to treating asthma to helping with

smoking cessation. Serious and chronic medical illnesses, such as heart disease and diabetes, are also associated

with higher rates of depression. So-called early life adversity like childhood trauma – including physical or sexual

abuse – has also been linked to higher rates of depression not only around the time of the trauma but later in life as

well.

Causes of Major Depressive Disorder

Causes of Major Depressive Disorder

Like all psychological disorders, depressive disorders are also best understood as arising

from neurological, psychological, and social factors and their interconnections.

NEUROLOGICAL FACTORS that contribute to depressive disorders can be classified

into three categories: brain systems, neural communication, and genetics.

Brain systems:

• Researchers have refined this general observation and reported that one aspect of

depression—lack of motivated behavior—is specifically related to reduced activity in the

frontal (and parietal) lobes (Milak et al., 2005).

• Some of the brain areas involved in attention (in particular, the thalamus) and in

controlling movements (basal ganglia) are overactive in depressed people, which again

suggests that the functions carried out by these brain areas are not being regulated

normally.

Neural communication:

• Researchers have long known that the symptoms of depression can be alleviated by

medications that alter the activity of serotonin or norepinephrine (Arana & Rosenbaum,

2000).

• According to the catecholamine hypothesis, which posits that symptoms of depression

arise when levels of norepinephrine fall too low (Schildkraut, 1965).

• Support for the Catecholamine hypothesis came from the finding that depression can be

treated by drugs that block norepinephrine reuptake (Brunello & Racagni, 1998;

Schatzberg, 2000).

• Additional studies have implicated the neurotransmitter serotonin in depression (Booij &

Van der Does, 2007; Munafò et al., 2006)

• Dopamine also appears to play several roles in depression (Nutt, 2008); too little of it not

only can undermine the effects of reward (and hence can lead to lack of pleasure), but

also can produce psychomotor retardation (Clausius, Born & Grunz, 2009; Martin-Soelch,

2009; Stein, 2008).

Genetics:

Twin studies show that when one twin of a monozygotic (identical) pair has MDD, the

other twin has a risk of also developing the disorder that is four times higher than when

the twins are dizygotic (fraternal; Bowman & Nurnberger, 1993; Kendler, Karkowski, &

Prescott, 1999)

The environment clearly plays an important role in whether a person will develop

depression (Eley et al., 1998; Hasler et al., 2004; Rice, Harold, & Thaper, 2002; Wender et

al., 1986).

Whether a person gets depressed depends partly on his or her life experiences, including

the presence of hardships and the extent of social support.

PSYCHOLOGICAL FACTORS

Particular ways that people think about themselves and events, in concert with stressful or

negative life experiences, can increase the risk of depression.

Attentional Biases

Some people see a glass that is half full of water as being half empty. Similarly, some people

focus their attention—consciously or unconsciously—on stimuli that are sad. People who are

depressed are more likely to pay attention to sad and angry faces than to faces that display

positive emotions (Gotlib, Kasch, et al., 2004; Gotlib, Krasnoperova, et al., 2004; Leyman et al.,

2007); people who do not have a psychological disorder spend equal time looking at faces that

express different emotions. This attentional bias has also been found for negative words and

scenes, as well as for remembering depression-related—versus neutral—stimuli (Caseras et al.,

2007; Gotlib, Kasch, et al., 2004; Matt, Vasquez, & Campbell, 1992; Mogg, Bradley, &

Williams, 1995). Such an attentional bias may leave depressed people more sensitive to other

people’s sad moods and to negative feedback from others (or even a lack of positive feedback, as

occurs when a person fails to smile when greeting you), compounding their depressive thoughts

and feelings.

Dysfunctional Thoughts

Aaron Beck proposed that cognitive distortions are the root cause of many disorders. Beck

(1967) has suggested that people with depression tend to have overly negative views about (1)

the world, (2) the self, and (3) the future, referred to as the negative triad of depression. These

distorted views can cause and maintain chronically depressed feelings and depression-related

behaviors.

Rumination

While experiencing negative emotions, some people reflect on these emotions; during such

ruminations, they might say to themselves: “Why do bad things always happen to me?” or

“Why did they say those hurtful things about me—is it something I did?” or “Should I have

spoken more during the discussion?” (Nolen-Hoeksema & Morrow, 1991). Such ruminative

thinking has been linked to depression (Just & Alloy, 1997; Nolen-Hoeksema, 2000; Nolen-

Hoeksema & Morrow, 1991, 1993).

Attributional Style

When something bad happens, people who consistently attribute negative events to their own

qualities—called an internal attributional style—are more likely to become depressed.

Learned Helplessness

Hopelessness depression is not always based on incorrect attributions. It can arise from

situations in which, in fact, undesirable outcomes do occur and the individual is helpless to

change the situation, such as the situation of children who experience physical abuse or neglect

(Widom, Dumont, & Czaja, 2007). Such circumstances lead to learned helplessness, in which a

person gives up trying to change or escape from a negative situation (Overmier & Seligman,

1967).

SOCIAL FACTORSStressful Life Events

In approximately 70% of cases, an MDE occurs after a significant life stressor, such as getting fi red from a

job or losing an important relationship. Such events are particularly likely to contribute to a first or second

depressive episode (American Psychiatric Association, 2000; Lewinsohn et al., 1999; Tennant, 2002).

Social Exclusion

Feeling the chronic sting of social exclusion—being pushed toward the margins of society—is also

associated with depression.

Social Interactions

To a certain extent, emotions can be contagious: People can develop depression, sadness, anxiety, or anger

by spending time with someone who is already in such a state (Coyne, 1976; Hsee et al., 1990; Joiner, 1994;

Segrin & Dillard, 1992; Sullins, 1991).

Culture

A person’s culture and context can infl uence how the person experiences and expresses depressive

symptoms (Lam, Marra, & Salzinger, 2005).

Gender Difference

In North America, women are about twice as likely as men to be diagnosed with depression (American

Psychiatric Association, 2000; Marcus et al., 2005), and studies in Europe find a similar gender difference

(Angst et al., 2002; Dalgard et al., 2006).

TREATMENT OF MAJOR DEPRESSIVE DISORDER

How to

MEDICATIONPrimary care providers often start treatment for MDD by prescribing antidepressant medications.

Selective serotonin reuptake inhibitors (SSRIs)

These antidepressants are frequently prescribed. SSRIs work by helping inhibit the breakdown of

serotonin in the brain, resulting in higher amounts of this neurotransmitter.

Serotonin is a brain chemical that’s believed to be responsible for mood. It may help improve

mood and produce healthy sleeping patterns. People with MDD often have low levels of serotonin.

An SSRI can relieve symptoms of MDD by increasing the amount of available serotonin in the

brain.SSRIs include well-known drugs such as fluoxetine (Prozac) and citalopram (Celexa). They

have a relatively low incidence of side effects that most people tolerate well.

Tricyclic antidepressants (TCAs) and Monoamine oxidase inhibitors (MAOIs) medications known

as atypical antidepressants may be used when other drugs haven’t helped. They can cause several

side effects, including weight gain and sleepiness.

Brain StimulationElectroconvulsive therapy may be used when a patient’s symptoms are severe and he or she (1)

cannot take medication because of side effects or other medical reasons, (2) has a psychotic

depression (depression with psychotic features) that does not respond to medication (Fink, 2001), or

(3) has severe depression that has not improved significantly with either medication or

psychotherapy (Lam et al., 1999).

PsychotherapyPsychotherapy can be an effective treatment for people with MDD. It involves meeting with a

therapist on a regular basis to talk about the condition and related issues. It is helpful in:

✓ adjust to a crisis or other stressful event

✓ replace negative beliefs and behaviors with positive, healthy ones

✓ improve your communication skills

✓ find better ways to cope with challenges and solve problems

✓ increase your self-esteem

✓ regain a sense of satisfaction and control in your life

Cognitive behavioral therapy CBT is highly effective, the beneficial effects of CBT can persist after

treatment ends (Hollon et al., 2005). Another possible treatment is group therapy, which allows to

share your feelings with people who can relate to what you’re going through.

Lifestyle changesIn addition to taking medications and participating in therapy, one can help improve MDD

symptoms by making some changes to one’s daily habits.

Eating right: Consider eating foods that contain omega-3 fatty acids, such as salmon. Foods

that are rich in B vitamins, such as beans and whole grains, have also been shown to help

some people with MDD. Magnesium has also been linked to fighting MDD symptoms. It’s

found in nuts, seeds, and yogurt.

Avoiding alcohol and certain processed foods: It’s beneficial to avoid alcohol, as it’s a

nervous system depressant that can make your symptoms worse. Also, certain refined,

processed, and deep-fried foods contain omega-6 fatty acids, which may contribute to MDD.

Getting plenty of exercise: Although MDD can make you feel very tired, it’s important to be

physically active. Exercising, especially outdoors and in moderate sunlight, can boost your

mood and make you feel better.

Sleeping well: It’s vital to get at least 6 to 8 hours of sleep per night. Talk to your doctor if

you’re having trouble sleeping.

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