Depressive Disorders
A depressed mood and a loss of interest or pleasure are the key
symptoms of depression.
For a patient, the depressed mood often has a distinct quality that
differentiates it from the normal emotion of sadness or grief.
Patients often describe the symptom of depression as one of agonizing
emotional pain
The most typical somatic symptoms of depression are called the
neurovegetative symptoms of depression.
Common
- Fatigue, low energy
- Inattention
- Insomnia, early morning awakening
- Poor appetite, associated weight loss
Sometimes included:
- Decreased libido and sexual performance
- Menstrual irregularities
- Worse depression in the AM
Depression is, by definition, a mood disorder, and disturbances of mood
are at the core. Patients feel “bad” and may use words such as “sad,”
“depressed,” “blue,” “down,” or similar words to describe this feeling.
Here we use the term dysphoria to encompass these various depressive
feelings to avoid the confusion inherent in using the word “depressed” to
mean both the diagnosis and the core symptom.
Some patients deny dysphoria altogether, but instead, describe feeling
unable to enjoy things that are usually enjoyable to them. We call this
anhedonia or a lack of pleasure. In addition to dysphoria and anhedonia,
many depressed patients also report feeling anxious
Diagnosis as per ICD 10
low mood, low energy, low activity
low capacity for enjoyment
low interest
low concentration
• Fatigue after even minimal effort
• Disturbed sleep/early morning awakening
• Disturbed appetite/ low weight
• low self esteem
• low self-confidence
• Guilt or worthlessness
• Mood unreactive to circumstances
• Anhedonia
• Worse symptoms in the AM
• Psychomotor disturbance: agitation or retardation
1. Psycho-Social Theories
Life Events and Environmental Stress. A long-standing clinical
observation is that stressful life events more often precede first, rather
than subsequent, episodes of mood disorders.
- One theory proposed to explain this observation is that the stress
accompanying the first episode results in long lasting changes in the
brain’s biology. As a result, a person has a high risk of undergoing
subsequent episodes of a mood disorder, even without an external
stressor.
2. Psycho-analytic description of MDD
1 Response to anger/loss turned inward (Freud,Abraham and
Rado)
- The profound response to loss is believed to occur in part because
the current loss invokes an earlier, childhood loss, also either of a
fantasy or a reality nature.
- Depressed patients’ ambivalent or hostile object relations, along
with object attachments characterized by excessive dependency,
laced with an emphasis on need gratification in emotionally charged
relationships. Major depression occurs
only after the tie to the object is shattered.
- Depressed patients’ ambivalent or hostile object relations, along
with object attachments characterized by excessive dependency,
laced with an emphasis on need gratification in emotionally charged
relationships. Major depression occurs
only after the tie to the object is shattered.
- Joseph Sandler and Walter Joffe, also focusing on the phenomenon
of
loss leading to depression, called the Hampstead Index, a
comprehensive
clinical registry of childhood responses to abandonment and loss, for
cases
of childhood depression. They inferred that depression is a basic
affective
response to loss. They emphasized that more than just the other
person is
lost and that the child feels that he or she has also lost a sense of
self in
relationship to the lost object, or a previous set of feelings about the
self.
Thus, as Freud and Abraham also noted, Sandler and Joffe
emphasize a
symbiotic or narcissistic tie to the object. They saw individuals
predisposed
to depression as struggling against feelings of helplessness and
injured selfesteem in childhood.
2 Guilt (Melanie Klein)
- Melanie Klein postulated that depressed patients fear that they
cannot
protect an idealized, or good, internalized “other” from destructive,
rageful
impulses
- Object relations theory , wherein how a child’s interaction in their
early year’s shape their personality and communication
3 Impairment in Self-Esteem Regulation (Edward Bibring)
He viewed depression instead as resulting from a sense of
helplessness, impaired self-esteem, and self-directed anger
triggered by failures to live up to the
narcissistic aspirations of any developmental phase.
COGNITIVE THEORY OF DEPRESSION
The cognitive model is based on the recognition that people
are not objective; rather, an individual’s idiosyncratic perception of
events
affects his or her emotions and behaviors. Depressed individuals
perceive
reality in subjectively depressed ways.
Beck’s initial observations about major depression have a salience
and
simplicity worth repeating. He noted that depressed patients tend to
have
characteristically skewed and negative thoughts about
(1) themselves,
(2) their environment, and
(3) the future,
a cluster he termed the cognitive
triad.
Cognitive theory has explored the form as well as the content of
thinking characteristic of depressed patients. Not only are cognitions
skewed to the negative and pessimistic, but types of distortions
occur.
- All or nothing thinking
- Overgeneralize
- Minimize
- Catastrophize
They selectively focus on negative evidence, failures, and setbacks
that
confirm their theories of defectiveness, while ignoring or discounting
the
successes that they have as “flukes.”
“Automatic thoughts” of characteristically self deprecatory
and hopeless nature pop involuntarily into the patient’s head.
Because these thoughts are mood congruent, depressed individuals
find
them believable and tend not to question them.
INTERPERSONAL THEORY OF DEPRESSION
Learned Helplessness.
The learned helplessness theory of depression
connects depressive phenomena to the experience of uncontrollable
events.
For example, when dogs in a laboratory are exposed to electrical
shocks from
which they cannot escape, they showed behaviors that differentiate
them
from dogs not exposed to such uncontrollable events. The dogs
exposed to
the shocks would not cross a barrier to stop the flow of electric
shock when
put in a new learning situation. They remained passive and did not
move.
According to the learned helplessness theory, the shocked dogs
learned that
outcomes were independent of responses, so they had both
cognitive
motivational deficits (i.e., they would not attempt to escape the
shock) and
emotional deficits (indicating decreased reactivity to the shock).
In the
reformulated view of learned helplessness as applied to human
depression,
internal causal explanations may produce a loss of self-
esteem after adverse
external events.
Behaviorists who subscribe to this theory often stress that
improvement of depression is contingent on the patient’s learning a
sense of
control and mastery of the environment.
Biological Theories
Brain Dysfunction.
Theories of brain dysregulation attempt to incorporate both findings
of dysregulation with the increased and decreased responses to
various negative stimuli observed in studies.
The amygdala. Part of the limbic system, the amygdala appears to
be a
crucial way station for processing novel stimuli of emotional
significance and
coordinating or organizing cortical responses.
The hippocampus. Adjacent to the amygdala, the hippocampus is
most
associated with learning and memory. Emotional or contextual
learning
appears to involve a direct connection between the hippocampus
and the
amygdala. Also, the hippocampus regulates the HPA axis by
inhibiting
activity.
Neurogenesis Hypotheses. Neurogenesis hypotheses suppose
that the
brain abnormalities leading to depression are the result of
abnormalities in
development such that there is a deficit in the number of newborn
neurons in
the brain.
There are several explanations for the cause of this deficit. Some
versions
attempt to link the role of stress, particularly chronic stress, in
causing
depression. Stress can cause increased activity in the HPA axis,
which results
in increased glucocorticoid production
