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 model 1

Mood Disorders  Major Depressive Episode  Major Depressive Disorder  Dysthymic Disorder  “Double Depression” 2

Mood vs. Affect Mood Affect  A pervasive and  A pattern of observable sustained emotion behaviors that is the that, in the extreme, expression of a colors the person’s subjectively experienced perception of the world state (emotion)  Variable over time, in response to changing emotional states (vs. mood, which is pervasive and sustained 3

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 4

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 5

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 6

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 7

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 8

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 9

Depression & Development Infancy Preschool Lethargy Lethargy Feeding problem Feeding problem Sleep problem Sleep problem Irritability Irritability Sad facial expression Sad expression Crying Crying Mood changes Failure to thrive Associated with Hard to assess maternal depression 10

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 11

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] 12

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]. 13

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. 14

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. 15

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 2 nd 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. 16

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). 17

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 18