Mood Disorders ...no longer Mood Disorders... M.docx

Mood Disorders
...no longer Mood Disorders...
Major Depressive Disorder
! Depressed mood or loss of interest over a 2 week period
! 5 or more symptoms present (with at least 1 symptom being
depressed mood or loss of interest/pleasure)
! Depressed mood (in kids, can be irritability)
! Diminished interest or pleasure in all, or almost all, activities
! Significant weight loss or weight gain (not from dieting;
change of more than 5%)
! Insomnia or hypersomnia
! Psychomotor agitation or retardation
! Fatigue/loss of energy
! Feelings of worthlessness/excessive guilt
! Diminished ability to think or concentrate
! Suicidal ideation
! Criterion B: Symptoms cause clinically significant
distress or impairment in social/occupational
! Criterion C: Not attributable to physiological effects
of a substance or general medical condition

! Criterion D: Depressive episode not better
explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder,
delusional disorder
! Criterion E: No history of manic or hypomanic
episode
Specifiers
! Severity: mild, moderate, severe
! With mixed features (experience at least 3 manic or
hypomanic symptoms during the course of a major
depressive episode)
! With anxious distress (experience of at least 2 anxiety
symptoms during course of depressive episode)
! Melancholic features, atypical features, mood-congruent
psychotic features, mood-incongruent psychotic
features, with catatonia, with seasonal pattern
Bye Bye Bereavement
Exclusion
! Removed exclusion that depression cannot be
diagnosed in context of bereavement within 2
months of loss
! Ensured that someone grieving was not diagnosed as
ill/depressed

! Why did DSM 5 get rid of it?
! Used Wakefield’s research against him
Wakefield’s Research on
Loss
! Why are/were other serious losses that can cause sadness
ignored? Why only exclusion for bereavement?
! Is bereavement different than other losses/stresses?
! Mined data from NIMH survey
! No differences between those whose symptoms were triggered
by bereavement vs. different losses (e.g., divorce, financial)
! Looked at how bereaved vs. nonbereaved differed on number
of,
and duration of, symptoms (as well as which symptoms were
reported)
! Conclusion: other losses just as likely to leave a person
depressed
! No scientific reason to treat death of loved one differently
! Expand bereavement exclusion to “other life stressors” to
distinguish disorder from suffering?
Wakefield vs. DSM 5
! Return to pre-DSM II idea that sadness in response
to loss is normal/human condition (reaction)
! Differentiates suffering from disorder

! DSM 5 taskforce: these findings show that
bereavement should not be a special exclusion
! All qualify as mentally ill
! Oh…I see what you did there…
Persistent Depressive
Disorder
! The new dysthymia and chronic MDD
! This is about chronicity more than severity
! Depressed mood for 2 years (1 year in children)
! At least 2 of the following:
! Poor appetite/overeating
! Insomnia/hypersomnia
! Low energy/fatigue
! Low self-esteem
! Poor concentration/indecisive
! Hopelessness
! Never without depressed mood or 2 symptoms for more than 2
months
! No history of manic, mixed, hypomanic episode
Specify Me
! Mild, moderate, severe

! Early onset (before 21) vs. Late onset
! With mixed features
! With anxious distress
! Melancholic features, yada, yada, yada
! Pure dysthymic syndrome
! Never met criteria for major depression
! With persistent major depressive episode
! With intermittent major depressive episodes (with or without
current episode)
Age-Specific Features of
Depression
! Similar to adults for the most part
! Young children (7+): irritability, comorbid anxiety
(phobias, separation anxiety), tantrums, oppositional/
argumentative
! Adolescents: Antisocial behaviour, aggression,
inattention, social withdrawal
! Cognitive symptoms begin to emerge: guilt, low self-
esteem/body image/worthlessness, anhedonia,
hoplelessness
! Gender differences
! Implications for potential misdiagnosis? Amorphous

blob??
- in childhood: M=F prevalence
- in adolescent: F>M
Why the gender differences?
! Hormones?
! Estrogen
! Social role changes from sexual maturity
! Early maturing girls have worst outcomes
! Negotiating interpersonal relationships
! Females more concerned with cooperation/being social
! More sensitive to interpersonal loss/rejection
! Girls more likely to ruminate
! Socialized to be more dependent, less assertive = less
autonomous ! depression
Holly
- hormone affects moods, especially estrogen
Holly
Comorbidity
! Up to 90% of kids/adolescents with depression
meet criteria for another diagnosis

! Most frequent: anxiety disorders
! GAD, specific phobia, separation anxiety
! Dysthymia (double depression), conduct problems,
ADHD, substance use also common
! Is it comorbid condition ! depression or vice
versa?
Course of Depression
! Onset in most cases is in adolescence
! Sudden vs. gradual
! Average episode: 8 months
! Recurring pattern
! 25% within 1 year
! 40% within 2 years
! 70% within 5 years
! Acute condition????
! The earlier the onset, the more comorbidity, and the more
severe the
suicidal ideation = worse prognosis
! 1/3 depressed adolescents develop bipolar (bipolar switch)
! Sensitized to future depressive responses to stressors ?
Holly
This slide says depression is all over the place.

not important
Depression in Infants/
Toddlers?
! Not clearly recognizable using DSM criteria
! Rare, but present at toddler/young child age
! Possible to identify depression in 3-7 year olds
! Withdrawn, inhibited (lack of spark/energy), clingy, whiny,
irritable without apparent trigger, somatic symptoms
! Anaclitic depression
! Usually associated with early attachment disruptions
! Removed from mother
! No opportunity to form attachment
! Weeping, withdrawal, apathy, weight loss, sleep
disturbance
Pretty clear, right?
! Not entirely. Depression in adolescents seems to
vary
! Story time
! Are these kids depressed?
! Something else?
! Comorbidity explain differences?

! Is discrete depressive episode (2 weeks) similar or
categorically different from pervasive depression?
! Discrete vs. dispositional
Theories of Depression
! Psychodynamic
! Internalized rage, anger, aggression
! Often triggered by loss of ambivalently loved object
! Attachment
! Insecure attachment ! increased distress, distorted
internal working models
! Behavioral
! Lack of reinforcement for social/adaptive responses
! Cognitive
! Depressogenic cognitions (hopelessness, negative view of
self/world/future)
Holly
make more internal station global statements
Causes of Depression (get
your flow charts out...)
! Genetics
! Depression tends to run in families

! Neurobiology
! Samey, samey (limbic system, prefrontal cortex,
hippocampus, HPA axis)
! Family
! Parents more critical/punitive; more conflict; intrusive vs.
uninvolved; lack of warmth; disengagement
! Parents with depression (less emotional availability/
responsiveness, affection, positive affect)
! Coregulation issues anyone?
! Overinvolved or withdrawn
! Kids get parentified ! grow up fast but arrested development
! Anxiety
! Tends to precede depression
! Bowlby: object loss ! anxiety ! despair ! giving up
! Heightened physiological arousal of anxiety ! organism shut
down and withdrawal
! Rumination from anxiety magnifies problems ! depression
! For adolescents: not achieving developmental goals
! Autonomy; peer acceptance
! Stressful Life Events
! Emotion regulation
! Self-awareness
! Coping

Treatment
! See, you already know...
! Medication
The Trouble with Trials –
FDA Version
! Approx 50% of drug trials submitted to FDA for 12
leading antidepressants show advantage over
placebo
! When present, the advantage is small
! Publication bias: 36/38 “successful” trials
published vs. only 14/36 of “unsuccessful” trials
published
! 11 of those framed in positive manner
How Could You Let this
Happen FDA?
! FDA traditionally granted very little power over drug
industry. Original laws…
! Responsible for certifying drugs but not permitted to
make decisions based on efficacy
! That would be a matter of opinion
! Can only comment on safety
! Short time to respond to new drug applications with a

budget 1/20th of the pharmaceutical companies
! In 50s, “wonder drugs” (antibiotics, corticosteroids,
diuretics) give everyone confidence in drug industry
! In 60s, law changes (slightly): FDA can require drugs
to be proven safe and efficacious
But what is efficacy/
effectiveness?
! Definition: “substantial evidence” that the drug is
effective
! Loophole city: Don’t need a “preponderance” of
evidence
! So, contrary evidence can exist
! FDA: 2 independent trials with statistically significant
results is “substantial” evidence
Manipulating Statistics: The
RCT
! Randomized, clinical trial used to “prove” effectiveness
! Used Fisher statistics
! Not intended to “prove” anything; intended to “disprove” that
there are differences between groups
! Design aimed at retaining null hypothesis

! Popperian: trying to disprove theories
! Stats only inform of probability that result is found by
chance
! P value not meaningful indicator of degree of difference or
effectiveness
! Supposed to replicate and if repeatedly reject null
hypothesis,
then gaining some degree of certainty that result is not
random
Facepalm (cont’d)
! But, medicine/drug companies are using research design to
claim that drugs are effective (they work)
! It’s a tightly controlled, unbiased study!
! Presume research paradigm eliminates chance
! Just gives you an idea, on test day, what probability is of
results being due to chance
! Not only are you meant to replicate, replicate, replicate, but,
according to definition, only need 2 studies rejecting null
hypothesis and can ignore studies in which null is not rejected
! Popperian disconfirmation
! By the power of science….I HAVE THE POWER
! Using “science” to lend air of objectivity/authority to results

…and the advertising
doesn’t hurt either
! Drug companies advertise directly to MDs
! Provide scripts of what to say even
! In 80s, SSRIs marketed as superior because they
are “selective” and “targeted”
! Prozac: “the first highly specific, highly potent
blocker of serotonin uptake”
! Marketed as “clean”, “strong”, “effective”
! Advertise directly to consumers
Disruptive Mood
Dysregulation Disorder
! Brand spanking new!!!
! Severe recurrent temper outburst manifested verbally (e.g.,
verbal rages) and/or behaviorally (e.g., physical aggression
toward people or property) that are grossly out of proportion
in intensity or duration to the situation or provocation
! Temper outbursts are inconsistent with developmental level.
! Temper outbursts occur, on average, 3 or more times per
week.
! The mood between temper outbursts is persistently irritable
or angry most of the day, nearly every day, and is observable

by others (e.g., parents, teachers, peers).
! These criteria are present for 12 or more months
! Present in at least 2 of 3 settings (at home, at
school, with peers); severe in at least 1
! Can’t diagnose this before 6 or after 18
! Age at onset before 10
! No signs of manic/hypomanic episode for >1 day
! Symptoms do not happen exclusively during MDD
and not better explained by another disorder (e.g.,
autism, PTSD, separation anxiety)
Manic Episode
! A distinct period of abnormally and persistently elevated,
expansive, or irritable mood, increased goal-directed activity or
energy
! lasting at least 1 week and present most of the day, nearly
every day
! 3 or more of the following (4 if the mood is only irritable)
are
present:
! Inflated self-esteem or grandiosity.
! Decreased need for sleep
! More talkative than usual or pressure to keep talking
! Flight of ideas/thoughts racing

! Distractibility
! Increase in goal-directed activity or psychomotor agitation
! Excessive involvement in pleasurable activities that have a
high
potential for painful consequences (e.g., spending sprees, sexual
indiscretions, or foolish business investments)
Hypomanic Episode
! Main difference is that it is not severe enough to
cause marked impairment in social or occupational
functioning or to necessitate hospitalization.
! If there are psychotic features, the episode is, by
definition, manic.
Bipolar Disorder I
! At least one manic episode
! May have been preceded or followed by hypomanic or
major depressive episode
! Specify current or most recent episode: Manic or Major
Depressive Episode
! Mild, moderate, severe
! With Mixed Features
! With anxious distress:
! With rapid cycling; mood-congruent psychotic features.
Etc. etc.

Bipolar Disorder II
! At least one hypomanic episode and at least one
major depressive episode
! No history of manic episode
! Everything else = same
Cyclothymic Disorder
! For 2 years, numerous periods with hypomanic
symptoms that do not meet criteria for a
hypomanic episode and numerous periods with
depressive symptoms that do not meet criteria for a
major depressive episode.
! at least 1 year in children and adolescents
! Not without symptoms for more than 2 months
! Symptoms present “at least half the time”
! Never met criteria for manic, hypomanic, or major
depressive episode
Holly
如果在抑郁过程中间或出现兴奋、情绪高涨等轻度躁狂状态则称为
循环性情绪障碍 ( cyclothymic disorder )
Does BP exist in youth?
! Occurs infrequently

! Presentation is extremely variable (even within kid)
! Overlap with other disorders (e.g., ADHD)
! Jumping between activities, risk-taking
! Biggest controversy is pre-pubertal BP
! Mood swings, lability, irritability, aggression
! Is this BP???
! If not, functioning still severely impaired
! Atypical symptoms (mood changes more erratic, volatile than
persistent – often don’t meet 1 week criterion)
! Irritability more common than euphoria
! Restraints on reckless behaviour
Bad Bad Biederman….
! Joseph Biederman
! Originator of childhood bipolar
! Used to be believed that onset was early adulthood
! Originally an ADHD expert
! Believed a particular group of ADHD kids were
distinct
! Quick to anger, hard to comfort, precocious, defiant,
cranky, mood swings (in addition to fidgety/distractible)
! The chronic irritability ! mood disorder
! These kids are bipolar and need mood stabilizers, not

stimulants
Adjusting the Diagnostic
Criteria
! But, bipolar required distinct manic episodes and
these kids do not demonstrate this (no high highs)
! Also, the criterion B symptoms overlap
substantially with ADHD
! Excessive talkativeness, distractibility, restlessness
! Biederman believed that his subset of ADHD kids
more likely to have the other criterion B symptoms
not shared with ADHD
! Kids with this profile are bipolar (even though not
manic)
Critical Reception?
! Flies in the face of established knowledge re: episodic nature
of mania
! These kids are like this all the time
! Studies have not turned up episodes of mania in kids
! Remaining criterion B symptoms are characteristic of
childhood!
! Grandiosity, flight of ideas, involvement in pleasurable
activities with high potential for pain

! This would lower threshold for diagnosis of a severe illness
! Biederman responds: his subset of kids are more irritable
than ADHD kids, more withdrawn, and more likely to sulk
! Even though this is all inconsistent with mania, he persists…
Biederman Persists…
! Begins using the Bipolar NOS category
! Others follow suit
! There is a need here. These kids are volatile and
very difficult to manage/parent
! Give parents a diagnosis and a medication !
serenity now
! Self-validating nature of diagnosis
! Now Biederman’s subset is a juvenile form of bipolar
Let’s Treat Juvenile Bipolar!
! Treatment for bipolar in adults ! severe mood
stabilizers
! Let’s use them with kids too because they have
bipolar too!
! Heavily sedating (treating or tranquilizing?)
! Side effects: obesity, diabetes, tardive dyskinesia,
possible decrease of life expectancy

Why Bipolar, Biederman?
! Could have tinkered with ADHD, ODD, or even Disruptive
Behaviour Disorder
! Why not a new diagnosis? Scary Impossible Child
Disorder?
! Insurance won’t pay for ODD treatment
! New mood stabilizing meds coming on the market as
Biederman pounds the pavement. Hmmmm…
! Atypical antipsychotics beginning to emerge (although
effectiveness/side effects on kids not studied)
! Biederman in bed with Big Pharma developing these drugs
! Big Pharma funding research on Bipolar in kids (just so
happens antipsychotics are treatment of choice for this)
The Biederman Effect
! By 2003, prevalence of bipolar in children/
adolescents increased by factor of 40
! By 2005, antipsychotic use in youth increased by
73%
! In 2007, half a million children (20, 000 under 6
years of age) were prescribed these heavy
antipsychotics now that bipolar diagnosis justifies

this type of treatment
! Needed severe diagnostic label to justify severe
treatment
Diagnostic Considerations
! Psychotic symptoms not uncommon
! Hallucinations, delusions (paranoia), thought disorder
! Schizophrenia vs. Bipolar?
! Hypomanic, mixed, or rapid cycling more common
than manic episode
! Course tends to be chronic
! Long term prognosis not great
Causes and Treatment
! Genetic component
! Limbic system, prefrontal cortex, hippocampus
(surprise!!)
! Also, basal ganglia, thalamus
! Treatment: mood stabilizers
! Lithium/anti-seizure meds/antipsychotics
! Adherence to med treatment a big problem
! Psychosocial interventions focus primarily on this

�
· Age, presenting issues, family composition
�
· - Identify which DSM diagnoses he/she is meeting
criteria for…
· - Discuss differential diagnoses (why you would
consider one diagnosis over another if meeting criteria for
multiple)
· �
· - The heart of the conceptualization
· - Create the narrative of how we got here
· - Family dynamics and formative experiences are
key
· - Discuss how events, reactions to events, and ways
of coping with these events/the world current situation
PSYC 356 Term Paper – Spring 2017
(…or Where the 356 Paper Are)
You will write a 6-8 page, double-spaced paper containing 2
sections.
First things first though, get yourself to the nearest video rental
store (do those still
exist?) and procure yourself a copy of Spike Jonze’s (2009)
motion picture adaptation of
the children’s book, Where the Wild Things Are. Your job is to
watch said movie
(possibly even more than once) and provide a case

conceptualization of the main
character, Max. This conceptualization will be the first section
of the paper.
What is a case conceptualization you ask? Go to class and find
out…but here are the
Coles Notes just in case: this should involve a description of
Max’s current functioning,
including observable symptoms, possible diagnoses,
underlying/latent issues, and
identification of possible developmental pathways resulting in
his current functioning. Be
sure to include a discussion of the manifest/observable
symptoms (which would inform
your diagnosis) as compared with the apparent underlying/latent
issues and emotions.
There are many ways to write a good case conceptualization,
however a good general
framework is to summarize current functioning (along with
possible diagnostic
labels/considerations) followed by something that reads like a
narrative as to how Max’s
current situation developed over time. Make note of family
dynamics in the case
conceptualization that are apparent in the film. You are also
welcome to extrapolate and
fill in some gaps that are not directly addressed in the movie. I
am not asking you to
completely make events up, however, as you will see, certain
events can be reasonably
extrapolated (e.g., his father must have left the family at some
point; job related stresses
for mom). It will be important for you to justify the claims you
make in terms of your
case conceptualization. For instance, if you want to make an
interpretation about Max’s

manifest behaviour and infer the meaning of the behaviour or
the underlying needs being
expressed, you will need to justify your interpretation with a
cogent rationale/argument.
The second section of this paper will address thematic elements
involved in Max’s
fantasy play, identifying what issues he is working through in
his fantasy and how he is
working through/resolving them, thereby facilitating his
rejoining of the family at the end
of the film. Multiple themes emerge within his fantasy so be
sure to address at least two
of them.
Twenty marks will be allocated for the conceptualization
section, while the second
section will be worth 10 marks, for a total of 30 marks, which
lines up nicely with this
paper being worth 30% of your final grade. You will be graded
on the thoughtfulness,
depth, and “in the right ballpark”-ness of your paper (i.e., is
your conceptualization and
interpretation of fantasy play grounded in the information
provided in the film). You do
not need to provide brilliant and unique interpretations. Rather,
what we are looking for is
thoughtfulness and empathy (your ability to understand Max’s
world and your sensitivity
to what he is experiencing) in combination with solid, well
organized, and grammatically
correct writing. Your ability to articulate your thoughts in a
clear and coherent manner
will be critical. While there are not specific marks allocated for
spelling, grammar,

writing style, and clarity, the quality of your writing will be
considered throughout the
paper and will be reflected in your final mark. Please include a
title page with your name
and student number (if not included, you will be penalized 1
mark). While there are no
references required for this paper, if you choose to discuss a
relevant theorist’s or
practitioner’s work, make sure that all in text citations, in
addition to your reference page,
are in APA format.
Your paper is due at 9:30 a.m. on Monday, March 20th. You DO
NOT need to hand
in a paper copy. Canvas submissions only please.
Late term papers will be penalized 3 marks/day late. Note that
this is 3 marks out of
the 30 that this term paper is worth towards your final grade.
Here is a quick breakdown of the marking scheme:
Section I – Case Conceptualization /20
Presenting issues and identification of applicable diagnoses /5
Discussion of underlying/latent issues (contrasting with
observable /5
and manifest symptoms)
Developmental narrative (the story of how it got to this point)
/10
Be sure to include relevant history, family dynamics, and
normative
developmental considerations

Section II /10
Interpretation of fantasy play
(identify main themes, identify how he is resolving these
issues)
**At least 2 themes must be identified for 5 marks each

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