DEPRESSIVE DISORDER
or UNIPOLAR DISORDER
Introduction
For nearly 2,500 years, mood disorders have been described as one of the most common illnesses of humankind, but only recently have they commanded major public health interest. The World Health Organization (WHO) has ranked depression fourth in a list of the most urgent health problems worldwide.
DEPRESSIVE DISORDER is also known as unipolar disorder. It comes under DSM – IV Axis I. It is a neurotic disorder (when without hallucination, dellusions, etc). To be more clear :
MOOD DISORDER
1)Unipolar 2)Bipolar 3)Schizo affective
a) Dysthymia a) Cyclothymia
b) adjustment disorder b) bipolar I
c) major depression c) bipolar II
d)seasonal
affective
AFFECT DISORDER – DEPRESSION
Therapist: Good morning, how are you today?
Patient: [pause] I don’t know, I just feel sort of discouraged.
Therapist: is there anything in particular that worries you?
Patient: I don’t know doctor…. Everything seems to be futile.. Nothing seems to be worthwhile anymore. It seems as if all that was beautiful has lost its beauty. I guess I expected more then life has given. It just does not seem worthwhile going on. I cant seem to make up my mind about anything..
Therapist: can you share a little more about your feelings?
Patient: I feel it’s my entire fault. I can’t blame anybody. I am worthless. Nobody can love me. I don’t deserve friends or success. I am just no good. I am a failure. All my flaws stand out and I am repugnant to everyone [sighs]. There is no hope for me
WHAT IS NEUROSES?
The individual is said to exhibit neurotic behavior if he frequently misevaluates adjustive demands.
Becomes anxious in situations that most people would not regard as threatening.
Tends to develop behavior patterns aimed at avoiding rather than coping with his problems.
He may realize his behavior is irrational or maladaptive but is unable to alter it
THE BASIC NATURE OF NEUROSES
Basic to neurotic lifestyle are:
The neurotic nucleus- the faulty evaluation of reality and the tendency to avoid rather then cope with stress.
The neurotic paradox- the tendency to maintain this lifestyle despite its self defeating and mal adaptive nature.
THE NEUROTIC NUCLEUS
The three key facets of neurotic nucleus Feelings of inadequacy and anxiety
Avoidance instead of coping
Self defeating behavior and blocked personality growth
THE NEUROTIC PARADOX
The neurotic paradox can be understood in terms of two basic patterns:
The immediate relief from anxiety that comes from the momentary avoidance of threatening situations.
Continued and inappropriate perception of certain everyday situations as threatening.
AFFECT DISORDER MORE COMMONLY KNOWN AS MOOD DIORDER
“Mood disorders” involve much more severe alterations in mood, and for much more prolonged period of time.
Disturbance of mood are intense and persistent enough to be clearly maladaptive often leading to serious problems in relationships and work performance.
CASE STUDY, A VERY SUCCESSFUL “TOTAL FAILURE”:
A prominent business woman, Margaret, in her middle years, noted for her energy and productivity, was unexpectedly deserted by her husband for a younger woman.
Following her initial shock and rage, she began to have controllable weeping spells and doubts about her business acumen.
Decision making became an ordeal.
Her spirits rapidly worsened, and she began to spend more and more time in bed, refusing to deal with anyone.
Her alcohol consumption increased and within a period of weeks, serious financial losses were incurred owing to her inability to keep her affairs in order.
She felt she was a “total failure”, her self criticism gradually spread to all aspects of her life and her personal history.
IS DEPRESSION AN AFFECT DISORDER?
Mood or affect is often used alternatively by psychologists to refer to “emotional states”.
The term “affect disorder” groups together a number of clinical conditions whose common and essential feature is a disturbance of mood accompanied by related cognitive, psychomotor, psycho physiological and interpersonal difficulties.
Affect sometimes refers to the “subjective aspect of emotion”, apart from its bodily component ; mood reefers to the “pervasive and prevailing emotion”.
WHAT DO YOU UNDERSYTAND BY THE TERM DEPRESSION?
The term depression refers to both a mood and psychopathological syndrome.
Negative affective states are so prevalent, depression is sometimes referred as “ the common cold of psychopathology
CLASSIFICATORY SCHEME OF DEPRESSION
ENDOGENOUS – EXOGENOUS:
Depression that seems to be a response to an outside event, is called “exogenous .
The term “endogenous” meaning originating within the body, is used to describe depression that result from internal physiological malfunction.
PSYCHOTIC – NEUROTIC:
Psychotic depression – characteristic symptoms like delusion, confusion or other cognitive disturbance.
Neurotic depression- depressive symptoms in the absence of psychotic features and the individual is in touch with reality.
UNIPOLAR – BIPOLAR:
Unipolar depression can be endogenous or exogenous.
In contrast “bipolar depression” is commonly believed to be the result of an internal bio chemical or psychological fluctuation sometimes resulting in mania and at other times in depression.
AGITATED DEPRESSION:
Agitated persons may pace back and forth excitedly, moaning and crying, beating their breasts and wringing their hands.
Loose control over themselves entirely and run about purposelessly shouting and crying and sometimes even attacking others
INVOLUTIONAL MELANCHOLIA
Involution melancholia is a psychotic type of mood disorder usually marked by guilt, somatic delusions and some agitated depression.
Involutional melancholia to be largely exogenous
UNIPOALR MOOD DISORDERS
Under unipolar depression the following classification is made:
TYPES / INTRODUCTION TO DEPRESSIVE DISORDERS
Depressions that are not mood disorders.
-loss and grieving process
-Other normal mood variation.
Mild to moderate depressive disorders.
-Dysthymia
-Adjustment disorder with depressed mood.
Major depressive disorder.
-Melancholic type.
-Severe major depressive episode with psychotic features.
Seasonal affective disorder
CASE PROFILE: UNIPOLAR DEPRESSION
Karen S., 35, was hospitalized because of overwhelming feelings of depression. On admission she had a very sad appearance, sat in a hunched position and moved very slowly.
She avoided eye contact and replied to questions with a soft monotonous murmur. Karen continuously clasped her hands together. She complained of feeling “totally wretched” and frequently spoke of “pointlessness of it all”.
She tended to wake very early in the morning and would then be unable to sleep again.
Her family said that she often wept and rarely ate. Karen maintained on several occasions that she would be “better off dead”, but although she made frequent references to suicide there was no evidence that she made any attempt to end her life.
She said that she felt “worthless” and “no good to anybody”, although her marriage had been apparently a happy one and she had been successful in raising her two children before the onset of her depression
THE PREVALENCE
SEX: lifetime prevalence of major depression for males at nearly 13 %, and lifetime prevalence rates for females at 21 %.
AGE :2% of school age children may be severely depressed at any point of time, and the rate for adolescence appear to be around 4%
MARITAL STATUS :Married people are less at risk of developing a depressive disorder than those who are widowed or divorced (Bloom ET AL.,1979).
SOCIAL CLASS 
revalence of depression is roughly the same for people from each social class
Depressive disorders afflict one out of five women and one out of ten men at some time during their lives.
Despite the availability of effective treatments, many persons with mood disorders are disabled, and rates of suicide (which occurs in approximately 15 percent of depressive patients, especially in those with bipolar II disorder) are high in young and, particularly, elderly men
UNIPOLAR DEPRESSION: SYMPTOMS
The principal symptoms of depression are:
Sadness.
Pessimism.
Self dislike.
Loss of interest and motivation.
Psychomotor retardation.
Agitation.
Somatic complaints like aches and pains may be present.
Loss of appetite and weight.
Poor sleep.
Menstrual changes.
Loss of libido.
Suicidal tendencies.
Impaired capacity to perform everyday social functions.
Physical alterations as anorexia, constipation, headache and other bodily complaints.
AFFECTIVE SYMPTOMS:
“anger” and “anxiety
sharp loss of interest and enthusiasm
AN EXAMPLE: During most of the period that I was depressed life seemed hopeless and futile
I frequently sought escape in sleep and would stay in bed until mid day.
At times panic and anxiety would come upon me for no apparent reason, often resulting in irrational fears. ( Rippere and Williams, 1985).
COGNITIVE SYMPTOMS
difficult to concentrate .
spend a considerable proportion of their time dwelling on unpleasant thoughts and memories .
Their pessimism may be associated with severe loss of self esteem and feelings of unworthiness.
self blame and guilt.
delusions may involve unrealistic assumptions and inferences that promote feelings of persecution and jealousy.
BEHAVIORAL SYMPTOMS:
Clinically depressed people often look profoundly sad .
woeful facial expressions and a hunched posture, and they may weep frequently.
Their sleep patterns are usually disturbed and self destructive behavior include self mutilation and attempts at suicide .
They may engage in stereotyped movements or other activities like wringing their hands
SOMATIC SYMPTOMS
physically very “run down .
loose weight, frequently feel physically tired and suffer from a variety of aches and pains .
tiredness, fatigue, weight loss, head aches or some other pain or physical discomfort .
A somatic symptom of depression may maintain or deepen the negative mood
SOCIAL SYMPTOMS
Avoid the company of others, including close friends and relatives.
They may have lost interest in conversation and social activities.
When they are with other people they may experience a strong desire to escape
TYPES
1) DEPRESSION THAT ARE NOT MOOD DISORDER
a. Loss and grieving process
– following the: death of a loved one, separation, financial loss, etc.
– Characteristic qualities of grief: Bowlby, 1980
Different Clinical Manifestations of Unipolar Depression
as Defined by Severity and Duration Threshold
b. Other normal mood variation
– Success Depression
– depression during carefree personal growth and freedom
– Postpartum depression
2) MILD TO MODERATE DEPRESSIVE DISORDER
a. DYSTHYMIA
DSM-IV Diagnosis:
– Dysthymic Disorder
Noteworthy DSM-IV Specifiers:
– Early Onset
– Late Onset
- Diagnostic Features,
- Complications,
- Co morbidity,
- Associated Laboratory Findings,
- Prevalence,
- Course,
- Familial Pattern,
- Treatment
Diagnostic Features
Dysthymic Disorder is a chronic condition characterized by depressive symptoms that occur for most of the day, more days than not, for at least 2 years
In children, the mood may be irritable rather than depressed, and the required minimum duration is only 1 year. During this 2-year period (1 year for children or adolescents), any symptom-free interval can not last longer than 2 months.
By definition, this diagnosis is not made if there are any Hypomanic, Manic or Mixed Episodes
This disorder’s depressive symptoms are not due to a medical condition, medication, illegal drug, or Psychotic Disorder
Complications
By definition, there must clinically significant distress or impairment in social, occupational, or other important functioning as result of the mood disturbance.
In childhood, this disorder is often associated with impaired school performance and poor social interaction.
Children and adolescents with this disorder are usually irritable and cranky as well as depressed. They have low self-esteem, poor social skills, and are pessimistic.
Co morbidity
In adults, this disorder is associated with an increased risk of having Major Depressive Disorder and Substance-Related Disorders.
In children, this disorder is associated with an increased risk of having Attention-Deficit/Hyperactivity Disorder, Conduct Disorder, Anxiety Disorders, Learning Disorders, and Mental Retardation.
Associated Laboratory Findings
No laboratory test has been found to be diagnostic of this disorder
Sleep EEG abnormalities are evident in 25%-50% of adults with this disorder.
Dexamethasone nonsuppression (which often occurs in Major Depressive Disorder) is not common in Dysthymic Disorder (unless it co-exists with Major Depressive Disorder)
Prevalence
Lifetime prevalence for this disorder in the general population is 6%.
In any year, 3% of the general population has this disorder
In adulthood, women are 2-3 times more likely to develop this disorder than men.
Course
This chronic disorder usually has an early and insidious onset in childhood or adolescence.
In adults, up to 75% of individuals with this disorder will develop Major Depressive Disorder within 5 years.
The spontaneous recovery rate for this disorder is approximately 10% per year. This recovery rate is significantly better with active treatment.
Familial Pattern
First-degree biological relatives of individuals with disorder have elevated rates of Dysthymic Disorder and Major Depressive Disorder compared with the general population.
Dysthymic Disorder is more common in the first-degree biological relatives of individuals with Major Depressive Disorder
Treatment
Medical Treatment
Recent research shows that approximately 62% of patients with dysthymic disorder will benefit from antidepressant medication.
Antidepressant Drugs: Both fluoxetine and imipramine have repeatedly been shown to be effective treatments for this disorder in placebo-controlled randomized double-blind studies
Antianxiety Drugs: A number of drugs are not of value for long-term treatment. Those drugs include the amphetamines, the barbiturates, and the benzodiazepines. Those drugs are often prescribed for patients with chronic symptoms of insomnia, fatigue, or tension.
However, clinical experience and systematic research indicate that they are little better than a placebo and are at times worse
Psychosocial Treatment
Psychotherapy is the principal treatment resource for patients with dysthymic disorder. Reassurance that the clinician understands the depth of the patient’s pain, assessment of suicidal and other self-destructive potential, and optimism for the future are all useful.
Individual Psychotherapy: Patients who receive psychotherapy of any of several types – notably cognitive, interpersonally-oriented, or behavior therapy with social skills training – tend to have a good prognosis, with or without antidepressant medication
Group Therapy
Although individual psychotherapy is the most common psychosocial treatment offered, many individuals with dysthymic disorder will benefit from group therapy and from active investigation and restructuring of maladaptive social functioning.
Family Therapy
Family-centered approaches differ from individual methods in their direct focus on the “role of the sick member” in the family system rather than on the symptoms of the identified patient.
CASE STUDY – Dysthymia
A 27-year-old, male, grade-school teacher presented with the chief complaint that life was a painful duty that had always lacked luster for him. He said that he felt enveloped by a sense of gloom that was nearly always with him. Although he was respected by his peers, he felt like a grotesque failure, a self-concept I have had since childhood.€ He stated that he merely performed his responsibilities as a teacher and that he had never derived any pleasure from anything he had done in life. He said that he had never had any romantic feelings; sexual activity, in which he had engaged with two different women, had involved pleasure less orgasm. He said that he felt empty, going through life without any sense of direction, ambition, or passion, a realization that itself was tormenting. He had bought a pistol to put an end to what he called his useless existence€ but did not carry out suicide, believing that it would hurt his students and the small community in which he lived.
b. ADJUSTMENT DISORDER WITH DEPRESSED MOOD
Behaviorally indistinguishable from dysthymia.
It differs from dysthymia in that it does not exceed six month in duration, and it requires the existence of an identifiable psychological stressor in the clients life within three months before the onset of depression.
Also, the diagnosis assumes that the person’s problem will remit when the stressor ceases or when a new level of adjustment is achieved.
Presumably, chronic cases of this sort would need to be rediagnosed as dysthymia.
3) MAJOR DEPRESSIVE DISORDER
When Sonya came to Dr. Bolio he observed that her depression was so severe, “She had no interest in anything.“ Her physical symptoms included low energy, shaking and trembling throughout her body, heart palpitations, irregular menstrual flows, a medical history of cysts in the pancreas, liver and intestine, insomnia, constipation (since age six, when her parents divorced) and bad breath.
Sonya’s previous medical doctor had placed her on antidepressants and hormone therapy, which she felt had only worsened her condition and made her feel more anxious and withdrawn.
At the onset of therapy with Dr. Bolio, Sonya displayed extreme suicidal feelings, profound resentment towards her mother, anger and frustration with her oldest daughter (aged 26), and poor communication with her husband.
WHAT IS MAJOR DEPRESSIVE DISORDER
The diagnostic criteria for “major depressive disorder” require that the person exhibit more symptoms than are required for “ dysthymia” and the symptoms be more persistent (not interwoven with periods of normal mood).
An affected person must experience either markedly depressed mood or marked loss of interest in pleasurable activities in most of everyday for at least “two weeks
SYMPTOMS
Depressed mood. For children and adolescents, this may be irritable mood.
A significantly reduced level of interest or pleasure in most or all activities.
A considerable loss or gain of weight (e.g., 5% or more change of weight in a month when not dieting). This may also be an increase or decrease in appetite. For children, they may not gain an expected amount of weight.
Difficulty falling or staying asleep (insomnia), or sleeping more than usual (hypersomnia).
Behavior that is agitated or slowed down. Others should be able to observe this.
Feeling fatigued, or diminished energy.
Thoughts of worthlessness or extreme guilt (not about being ill).
Ability to think, concentrate, or make decisions is reduced.
Frequent thoughts of death or suicide (with or without a specific plan), or attempt of suicide
SUB TYPES OF MAJOR DEPRESSION:
-MAJOR DEPRESSION ON MELANCHOLIC TYPE .
-MAJOR DEPRESSIVE EPISODE WITH PSYCHOTIC FEATURES .
-DOUBLE DEPRESSION (major depression & dysthymia both)
-DEPRESSION AS A RECURRENT DISORDER .
4) SEASONAL AFFECTIVE DISORDER .
Depression showing a seasonal pattern; in the fall or winter.
The person must have had atleast two episodes of depression in the past two years occuring at hte same time of the year (fall or winter) and full remission must have occured at hte same time of the year (commonly in spring).
CAUSAL FACTORS -
BIOLOGICAL
Genetics
There exists incontrovertible evidence that both unipolar depression and bipolar disorder are genetically linked.
In monozygotic (MZ), or identical, twins, there was a concordance rate of 54 – 65% for unipolar depression.
There was only a concordance rate of 14 – 19% percent in dizygotic (DZ) or fraternal, twins.
Unipolar depression also appears frequently among relatives of those with bipolar disorder, although bipolar disorder does not occur more frequently than normal among family members of those diagnosed with unipolar depression (Feldman, Meyer, & Quenzer, 1997, p. 821) .
General Biological Hypotheses of Affective Disorders
Dysregulation Model: The dysregulation model of depression, as proposed by Siever and Davis (1985), suggests that depression is due to inappropriate (i.e. less selective) environmental responsiveness, and defective habituation (i.e. a slower return to baseline functioning following a perturbation). They believe that this is due to a chronic abnormality with the pattern and degree of responsiveness of a neurotransmitter
Learned Helplessness: It is hypothesized that either dopamine or norepinephrine functions are being altered in susceptible individuals. (Willner, 1994, p. 297-298).
Desynchronization of Circadian Rhythms: This includes: decreased total sleep time, increase sleep onset latency, decreased sleep arousal threshold, increased wakefulness, more frequent changes between sleep stages, and terminal insomnia.
Additionally, there is rapid eye movement (REM) sleep effects also associated with affective disorders
The effectiveness of phototherapy in seasonal affective depression (SAD) also is supportive of the theory of a desynchronization of circadian rhythms.
Behavioral Sensitization: When behavior become more severe and occurs more rapidly in response to the same dose of a given psychomotor stimulant, behavioral sensitization is said to have occurred. It is believed to involve dopamine at some point in the process, and can be modified by other neurochemicals such as sex hormones and vasopressin (Goodwin & Jamison, 1990, p.406)
PSYCHOLOGICAL ACCCOUNTS
LOSS AND REJECTION :Freud proposed that loss of a love object can also be withdrawal of love and affection by an important figure during a critical development period which can pre dispose an individual to develop depression later in life in response to similar situations involving real or imagined withdrawal or loss of love
LEARNED HELPNESS THEORY
This learned helplessness will produce three kinds of deficits:
Motivational deficiet .
Cognitive deficiets .
Emotional deficits
COGNITIVE THEORY:
Underlying “ depressogenic schemas or dysfunctional beliefs” which are rigid, extreme , counter productive.
Cognitive triad :
Negative thoughts about the self ( “ I am ugly”, “ iam worthless” , “ I am failure” )
Negative thoughts about one’s experiences and the surrounding world ( “ no one loves me” , “ people treat me badly” )
Negative thoughts about one’s future( “ its hopeless because things wil always be this way” )
STRESSFUL LIFE EVENTS HAVE CAUSAL EVENTS
Situations that tend to lower self esteem like being fired or faioing in an important exam.
The thwarting of an imortnat goal or the posing of an insoluable dilemma such as being told the fellowship you were counting on to support in graduate school is no longer available.
Developing a physical diseases or abnormality that activated the idea of death or deteroration.
Single stressor of overwhelming magnitute like loss of a parent.
Several stressors occurring in a series.
Insidious stressors unrecognized as such by an affected person such living with a depressed or physically diabled person for a long time.
TYPES OF DIATHESIS STRESS MODELS FOR UNIPOLAR DEPRESSION -
PERSONALITY AND COGNITIVE DIATHESIS.
EARLY PARENTAL LOSS AS A DIATHESIS .
BEHAVIORAL THEORIES
Depressed person indeed receive fewer positive verbal reinforcement from their families than do non depressed person and fewer social reinforeceemnt in their lives in general.
They also have lower level of activity and report less pleasure from seemingly positive events .
INTERPERSONAL EFFECT OF MOOD DISORDER
LACK OF SOCIAL SUPPORT AND SOCIAL SKILL DEFICIET
VULNERABILITY FACTORS +PROVOKING AGENTS = DEPRESSION
( IN THE ABSENSE OF
PROTECTIVE FATORS)
EARLY LOSS OF MOTHER+ A RECENT FAMILY = DEPRESSION
DEATH
TREATMENT
Antidepressants, antipsychotic and antianxiety drugs are all used in treatment of mood disorders.
Tricyclics have unpleasant side effects and are highly toxic.
Antidepressants not used for bipolar disorder treatment.
SSRIs have fewer side effects and less toxic.
Prozac is used in significant depression and also in mild depressive symptoms.
Lithium is often effective in preventing cycling between manic and depressive episodes.
ECT is used with severely depressed who may present an immediate and serious suicidal risk including those with psychotic or melancholic features.
ECT is also used with patients who have not responded with other forms of pharmacological treatments.
However, maintenance on mood-stabilizing drugs following ECT is still usually required to prevent relapse.
Psychotherapy
Drugs plus electroconvulsive therapy that are used in the treatment of depression are combined with individual or group psychotherapy directed at helping a patient develop a more stable long range adjustment.
Cognitive behavioral therapy
Interpersonal therapy
Family and marital therapy.
your success on your own too when you achieve your short term goals.
Yadav, D.S., and Kumar, G., (2008). Comparative study among juvenile delinquents and normal children in relation to different dimensions of creativity. Disabilities and Impairments: an interdisciplinary Research Journal, 22, 43-48.