MAJOR DEPRESSIVE DISORDER (MDD)

Ilona Tsvetkova

Historical Perspective

The term depression was derived from the Latin verb deprimere - "to press down". Ancient Egyptians recognized depression 6000 years ago as a unitary dimension

attributed to hearth malfunction. Because of attribution to the heart disease there was no stigma around depression or mental disorders (Okashaand Okasha, 2000).

The Ancient Greek physician Hippocrates described a syndrome of melancholia as a distinct disease with particular mental and physical symptoms

It was a broader concept than today's depression; importance was given to symptoms such: sadness, dejection, misery also often fear, anger, delusions and obsessions were included

Since Aristotle, melancholia had been associated with men of learning and intellectual brilliance - a risky child of thought and creativity.

Through the 19th century these associations were abandoned and depression became more associated with women.

German psychiatrist Emil Kraeplin – one of the first to use the term depression an encompassing concept, referring to different kinds of melancholia as depressive states.

Major Depressive DisorderSingle Episode:A. Presence of a single Major Depressive Episode

B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NOS.

C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.

Note: This exclusion does not apply if all the manic-like, mixed-like, or hypomanic-like episodes are substance or treatment induced or is due to the direct physiological effects of a general medical condition.

DSM-IV-TR Diagnostic Criteria

Recurrent Episodes: A.  Presence of two or more Major Depressive Episodes.

Note: To be considered separate episodes, there must be an interval of at least 2 consecutive months in which criteria are not met for a Major Depressive Episode.

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 or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated

by either subjective report ( feelings of sadness or emptiness) or observation made by others ( appears tearful).

Note: In children and adolescents depression might be expressed by 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, is considered failure to make expected weight gains.

(5) insomnia or hypersomnia nearly every day (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which

may be delusional) (8) diminished ability to think or concentrate, or indecisiveness, nearly

every day (either by subjective account or as observed by others) (9) 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. The symptoms do not meet criteria for a Mixed Episode. 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 ( a drug .abuse, a medication) or a general medical condition ( hypothyroidism).E. The symptoms are not better accounted for by Bereavement, such as 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.

The DSM-IV-TR recognizes five subtypes of MDD called specifiers: Melancholic depression Atypical depression Catatonic depression Postpartum depression, or mental and behavioral

disorders associated with the puerperium, not elsewhere classified

Seasonal affective disorder

Epidemiology

Extremely high prevalence rate of approximately 17% in the general population

The disorder tends to persist, with approximately 20% of sufferers developing a chronic depressive disorder of more than 2 years duration (Angst, 1988).

Extremely recurrent, with risk of relapse ranging from approximately 50% to 70% or 80%, with the average number of major depressive episodes estimated to be 4 (Judd, 1997)

Major Depressive Disorder may be preceded by Dystimic Disorder (estimation vary from 10% in epidemiological samples and 15 to 25% in clinical samples).

Frequent Comorbide disorders include: Substance Related Disorders, Panic. Disorders, Obsessive-Compulsive Disorders, Anorexia Nervosa, Bulimia Nervosa, Borderline Personality Disorder).

DSM-IV-TR, 2000

Etiological TheoriesWhat causes MDD?

Interaction of multiple factors/variables factor into development of MDD:

Biological factors (genetic predisposition, brain structures, neurotransmitters)

Personality Styles Socio-cultural factors, Early family relationships Cognitive styles

Genetic FactorsFamily studies:

Relatives of those with MDD are two to three times more likely to have a mood disorder (usually major depression).

Twin studies: If one identical twin has a depressive disorder the other twin is 3

times more likely than a fraternal twin to have the disorder disorder.

Severe depressive episodes may have stronger genetic contribution than less severe episodes.

Heritability rates are higher for females.

Brain structure abnormalities

Smaller hypocampus – important serotonin receptor

Neurotransmitters

Low levels of serotonin disregulates the activity of other neurotransmitters and leads to mood destabilization and depression.

Permissive hypothesis

http://www.youtube.com/watch?v=FTXvWU258FM

Endocrine system

Elevated cortizol levels

Personality Styles: Passive personality style High Harm Avoidance Beck highlights two personality dimensions that have

some specific content which is represented within the self- schemas:

Sociotrophy – refers as defining self worth in terms of interpersonal approval and acceptance (negative thinking related to interpersonal themes confers a particular risk factor for depression)

Autonomy - concerned with achievement, independence and control

Social and Cultural Factors

Negative life events (early abuse, criticism) Social support (marital relationship) (see chart) Gender Culture (see chart)

Socio-cultural Factors: Negative impact of Interpersonal Relationships:

Research shows that social relations can contribute to the development, maintenance or relapse of emotional problems such as depression, especially within the context of the romantic relationships.

Studies in this area focus on variety of negative social factors such lack of social support (specific types of poor social exchange) 

Negative social interactions, contribute to development of MDD, particularly the aspect of (NSI) - criticality or “expressed emotion” (a component of broader construct of “social “undermining” is theorize to exacerbate the effects of stress in individuals suffer from depression (Rook, 1998). Social undermining has been defined as:

Negative affect (anger /dislike) Negative evaluation of the person in terms of her/his attributes, action

and effort (criticism). Behavior that make difficult or obstruct the achievement of

instrumental goals.

Marital Status and MDD(Percentage w/MDD)

2.1 2.1

2.8

6.3

0

1

2

3

4

5

6

7

Married Widowed Never M. M/D/W

Married

Widowed

Never M.

M/D/W

Ethnicity and Prevalence of MDD(Percentage by Ethnicity)

3.1

4.4

5.1 4.9

0

1

2

3

4

5

6

Af. Am Latina White Average

Af. Am

Latina

White

Average

Cognition

Learned helplessness (Seligman) Attribution of lack of control over stress leads to anxiety and depression

Negative cognitive styles (Beck) Cognitive models of depression share the premise that maladaptive

thinking and negative appraisals of life circumstances contribute to the development of depression. depression is the result of negative interpretations (wearing gray

instead of rose colored glasses, e.g. Everyone in Winnie the Pooh)

Key Components of Negative Interpretations: Maladaptive attitudes (negative schema) Automatic thoughts Cognitive Triade – negative interpretations about self, future and the

world. Errors in thinking

Beck’s original model of depression:

  According to Beck (1967) there are three main levels of thinking involved in the onset, maintenance and exacerbation of depression:

Depressive self-schemas (central to Becks’ cognitive model) Maladaptive core believes/assumptions (organized within the self

schemas) - internal, stable, global about self, feature, the world.

Dysfunctional believes, rules and assumptions These believes often pertain to maladaptive themes of contingent self

worth. Characterized by “If -Than” statements.

Negative automatic thoughts These thoughts usually take a form of negative view of self, future and

the world – Cognitive Triad, term coined by Beck et al (1979).

Dichotomous thinking – things are seen in term of two mutually exclusive categories, no “shades of gray in between”

Ex: One might believe that he Is a complete success or a complete failure, thus anything short of a perfect performance is a total failure. Overgeneralization – A specific event is being characteristic of

life in general, rather than as being one even among many. Mind Reading – Individual assumes that others are reacting

negatively without evidence that this is the case. Selective Abstraction – One aspect of the situation is the focus of

attention,. and other relevant aspects of the situation are ignore Ex: Focusing on one negative comment in a performance evaluation

at work and ignoring a number of positive comments.

Core Believes

“I am incompetent” ↓

Intermediate Believes

“If I do not do well all of the time, then people will not respect me” “Making a mistake is equivalent to a complete failure”

↓ Coping, Compensatory Strategies “Strive for perfection” “You must succeed in everything you do”

↓ Activation of the self-schema via stress

Situation (stress imposing) ↓ Automatic Thoughts

Studying for a test “This is too difficult. I will never understand this”.

Upcoming test “There is too much to cover. I will never get it done. I can’t cope”

Being asked to meet with employer “He probably thinks I’m doing a terrible job.

Seligman and Beck

Seligman

Attributions are: Internal Stable Global

I am inadequate (internal) at everything(global)

and I always will be (stable).

“Dark glasses about why things are bad”

Interpretation (theory)

Beck

Negative interpretations about:

Themselves Future (their place) Immediate world (their

place)

I am not good at school (self). I hate this campus (world).

Things are not going to go well in college (future).

“Dark glasses about what is going on”

 

Daniel was a 52 years old man who lived with his wife and two daughters’ (ages 10 and 13). He was employed at the as insurance adjuster for a large insurance company. His chief complains included feeling gloomy most of the time, loss of sleep, inability to concentrate and presently intensified marital discord. He, met DSM IV TR criteria for dystymic disorder, which had been present for the past 20 years and his level of depression has fluctuated over the years. He describes his feelings as anxious most of the time but had no history of genuine anxiety disorder. He exhibited a number of avoidant personality disorder traits including fear of being criticized and ridiculed, being shy and reserved around others, and being unwilling to take interpersonal risks. While he did not me the full criteria for APD, Daniel had difficulties identifying determinants of his depression, although he mentioned not getting along with his wife and a recent job loss as contributing factors. Although he described treatment with previous therapy as “somewhat helpful” , he still felt depressed much of the time and said he felt “there was nowhere to do”. As a child, Daniel was well behaved although early in life he had difficulties at school. He was slightly overweight . As a result he was often avoided and ridiculed by peers. In the first grade, his extreme nearsightedness was discovered. His parent’s have failed to take him for regular checkups and his nearsightedness went undiagnosed for years. His difficulties in school apparently were a result of poor vision. When he received corrective lenses, his school performance improved dramatically. In grade 6 Daniel joined the school football teem and become to exhibit excellent athletic performance and physical fitness. Nonetheless, years of struggling in classes and additional rejection by peers have left him feeling “incompetent” and like a “screw up” or a “big, fat looser”. Daniels parents were described as neglectful and highly critical. Both abused substances. Daniels mother, who has been diagnosed with bipolar disorder, has never considered a treatment, instead has been used her diagnoses to obtain antidepressants which she used in excess for “personal pleasure”. In addition , it has been reported that Daniels mother have been using substances while pregnant with Daniel. . The behavior of both parents toward s Daniel was extremely erratic. His father in particular would yell and scream at Daniel with little or no provocation. A particularly traumatic event occurred when Daniel was 10 years old. Daniel was taking to his grandparent’s house, apparently for a vis it. Without Daniel noticing his parents drove away, abandoning him; he lived at his grandparent house for several years.

Case study 

Diathesis Stress Model:. ↓ Polygenes:

Maternal mood disorder

Biological Stressors: Brain System:Maternal prenatal substance abuse Brain structure

Nearsightedness abnormalities - smaller hypocampus;

reduced levels of neurotransmission

Social Environment: Temperament/Personality Parental Criticism Avoidant Personality Style

High Harm Avoidaince( Early Trauma (abandonment)

Peer Rejection

School Difficulties

Life Stresors: Job Loss MDD Intensified Marital Discord