Outline Primary vs. secondary symptoms Mood vs. affect Panic - - PDF document
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
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Primary vs. secondary symptoms Mood vs. affect Panic attack vs. panic disorder Acute Stress Disorder/PTSD Mood disorders: major depression and
Mood disorder treatment: CBT, IPT, and
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Major Depressive Episode Major Depressive Disorder Dysthymic Disorder “Double Depression”
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A pervasive and
A pattern of observable
Variable over time, in
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Primary Symptoms (9 MDE symptoms from
Secondary symptoms: social withdrawal,
Onset: age 5-19 Course: Variable; 26% to 70% have
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Duration: median duration = 8 months for
Prevalence:
Children: 2% Adolescents: 4-8%
Severity and duration: differential for MDD
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Euthymic – normal mood state Dysphoric – unpleasant mood (e.g., depression, anxiety,
Elevated – more cheerful than normal; not necessarily
Euphoric – exaggerated sense of well-being; implies a
Expansive – lack of restraint in expressing one’s feelings,
Irritable – internalized feelings of tension associated with
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Appropriate – consistent with content of person’s
Inappropriate when not consistent
Broad – normal Restricted – limited in expressive range and/or intensity Blunted – marked by severe reduction in the intensity of
Flat – virtually no affective expression; voice is
Labile – characterized by repeated, rapid, and abrupt
e.g., tearful vs. combative vs. gregarious, vs. angry and abusive
without apparent reason
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Middle childhood
Begin to report hopelessness and self-
Throughout childhood: difficult/impossible
Measurement issue or developmental
Adolescent
Begins to look more like adult depression
May be differences between prepubertal
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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
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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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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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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depression.
between the ages of 19 and 24 (i.e., annual reoccurrence rate of 9% over a 5-year time span).
between 19 and 24 years of age, as well as elevated antisocial and borderline personality traits relative to TD controls.
rates of future MDD and nonaffective disorder for adolescents with adjustment disorder are as high as for those initially presenting with MDD.
in the face of a stressor are more vulnerable for developing future MDD as young adults (i.e., implies inherent vulnerability).
disorder.
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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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comorbidity, hopelessness, residual subsyndromal symptoms, negative cognitive style, family problems, low SES, & exposure to
reoccurrence.
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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Rapid onset Psychosis Psychomotor retardation Psychotic features Family history of bipolar disorder Tricyclic induced hypomania
19 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
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.
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Structured and Semi-Structured Clinical Interviews (e.g., K-SADS) CBLC/TRF:
T-scores relative to ADHD-ODD and no disorder children
anxiety, withdrawal, and somatization subscale scores relative to children with ADHD/ODD and no disorder children. Symptoms not reported by typically developing controls:
don’t have depression [reported by 0% in typical children]
depression -- 98% -- report this symptom.
21 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.
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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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Primary Symptoms: Two or more from
Secondary symptoms: social withdrawal,
Onset: age 8.5 Course: Variable Duration: At least 1 year; chronic,
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80% of kids with depression have MDD 10% have double depression 10% dysthymia May be underestimated Episodes common in adolescence Gender differences do not
girls report depression more often
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Time Mood (+) (–) Hypomania Mania Dysthymia Major Depression Normal Range
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Cognitive Behavioral therapy (Beck) Interpersonal Psychotherapy (Klerman)
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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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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
32 Reactions Emotional Behavioral Physiological
Heaviness in abdomen Closes book Sadness
Situation
Reading textbook
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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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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