Major depressive disorder (MDD) is characterized by depressed mood and/or loss of interest lasting at least two weeks, along with other cognitive and physical symptoms. MDD has biological, genetic, psychological, and social risk factors and causes significant impairment. The diagnosis and treatment of MDD is outlined according to criteria in the DSM-IV-TR which recognizes subtypes and specifiers of depressive episodes.

1. MAJOR DEPRESSIVE DISORDER
(MDD)
AlanaT. Kristen

3. Historical Perspective
 The term depression was derived from the Latin verb deprimere - "to press down".
 Ancient Egyptians recognized depression 6000 years ago as a unitary dimension
attributed to hearth malfunction. Because of attribution to the heart disease there was no
stigma around depression or mental disorders (Okashaand Okasha, 2000).
 The Ancient Greek physician Hippocrates described a syndrome of melancholia as a
distinct disease with particular mental and physical symptoms
 It was a broader concept than today's depression; importance was given to symptoms
such:
 sadness,
 dejection, misery also often
 fear, anger, delusions and obsessions were included
 Since Aristotle, melancholia had been associated with men of learning and intellectual
brilliance - a risky child of thought and creativity.
 Through the 19th century these associations were abandoned and depression became
more associated with women.
 German psychiatrist Emil Kraeplin – one of the first to use the term depression an
encompassing concept, referring to different kinds of melancholia as depressive states.

4. Major Depressive Disorder
Single Episode:
A. Presence of a single Major Depressive Episode
B. The Major Depressive Episode is not better accounted for by
Schizoaffective Disorder and is not superimposed on
Schizophrenia, Schizophreniform Disorder, Delusional Disorder,
or Psychotic Disorder NOS.
C. There has never been a Manic Episode, a Mixed Episode, or a
Hypomanic Episode.
Note: This exclusion does not apply if all the manic-like, mixed-
like, or hypomanic-like episodes are substance or treatment
induced or is due to the direct physiological effects of a general
medical condition.
DSM-IV-TR Diagnostic Criteria

5. Recurrent Episodes:
 A. Presence of two or more Major Depressive Episodes.
Note: To be considered separate episodes, there must be
an interval of at least 2 consecutive months in which
criteria are not met for a Major Depressive Episode.

6. Major depressive episode:
 A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed mood
or (2) loss of interest or pleasure.
 (1) depressed mood most of the day, nearly every day, as indicated
by either subjective report ( feelings of sadness or emptiness) or
observation made by others ( appears tearful).
Note: In children and adolescents depression might be expressed by
irritable mood.
 (2) markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation made by others)
 (3) significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day.
Note: In children, is considered failure to make expected weight gains.

7.  (5) insomnia or hypersomnia nearly every day
 (6) fatigue or loss of energy nearly every day
 (7) feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional)
 (8) diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others)
 (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide
 B. The symptoms do not meet criteria for a Mixed Episode.
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance
( a drug .abuse, a medication) or a general medical condition (
hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, such as after
the loss of a loved one; the symptoms persist for longer than 2 months or are
characterized by marked functional impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or psychomotor
retardation.

8.  The DSM-IV-TR recognizes five subtypes of MDD called
specifiers:
 Melancholic depression
 Atypical depression Catatonic depression
 Postpartum depression, or mental and behavioral
disorders associated with the puerperium, not elsewhere
classified
 Seasonal affective disorder

9. Epidemiology
 Extremely high prevalence rate of approximately 17% in the
general population
 The disorder tends to persist, with approximately 20% of sufferers
developing a chronic depressive disorder of more than 2 years
duration (Angst, 1988).
 Extremely recurrent, with risk of relapse ranging from
approximately 50% to 70% or 80%, with the average number of
major depressive episodes estimated to be 4 (Judd, 1997)
 Major Depressive Disorder may be preceded by Dystimic
Disorder (estimation vary from 10% in epidemiological samples
and 15 to 25% in clinical samples).
 Frequent Comorbide disorders include: Substance Related
Disorders, Panic. Disorders, Obsessive-Compulsive Disorders,
Anorexia Nervosa, Bulimia Nervosa, Borderline Personality
Disorder).
DSM-IV-TR, 2000

10. Etiological Theories
What causes MDD?
Interaction of multiple factors/variables factor into development
of MDD:
 Biological factors (genetic predisposition, brain structures,
neurotransmitters)
 Personality Styles
 Socio-cultural factors,
 Early family relationships
 Cognitive styles

11. Genetic Factors
Family studies:
 Relatives of those with MDD are two to three times more likely to
have a mood disorder (usually major depression).
Twin studies:
 If one identical twin has a depressive disorder the other twin is 3
times more likely than a fraternal twin to have the disorder disorder.
 Severe depressive episodes may have stronger genetic
contribution than less severe episodes.
 Heritability rates are higher for females.

12. Brain structure abnormalities
 Smaller hypocampus – important serotonin receptor
Neurotransmitters
 Low levels of serotonin disregulates the activity of other
neurotransmitters and leads to mood destabilization and
depression.
 Permissive hypothesis
 http://www.youtube.com/watch?v=FTXvWU258FM
Endocrine system
Elevated cortizol levels

13. Personality Styles:
 Passive personality style
 High Harm Avoidance
 Beck highlights two personality dimensions that have
some specific content which is represented within the self-
schemas:
 Sociotrophy – refers as defining self worth in terms of
interpersonal approval and acceptance (negative thinking
related to interpersonal themes confers a particular risk
factor for depression)
 Autonomy - concerned with achievement, independence
and control

14. Social and Cultural Factors
 Negative life events (early abuse, criticism)
 Social support (marital relationship) (see chart)
 Gender
 Culture (see chart)

15. Socio-cultural Factors:
 Negative impact of Interpersonal Relationships:
 Research shows that social relations can contribute to the
development, maintenance or relapse of emotional problems such
as depression, especially within the context of the romantic
relationships.
 Studies in this area focus on variety of negative social factors such
lack of social support (specific types of poor social exchange)
 Negative social interactions, contribute to development of MDD,
particularly the aspect of (NSI) - criticality or “expressed
emotion” (a component of broader construct of “social
“undermining” is theorize to exacerbate the effects of stress in
individuals suffer from depression (Rook, 1998).
 Social undermining has been defined as:
 Negative affect (anger /dislike)
 Negative evaluation of the person in terms of her/his attributes,
action and effort (criticism).
 Behavior that make difficult or obstruct the achievement of
instrumental goals.

16. Marital Status and MDD
(Percentage w/MDD)
2.1 2.1
2.8
6.3
0
1
2
3
4
5
6
7
Married Widowed Never M. M/D/W
Married
Widowed
Never M.
M/D/W

17. Ethnicity and Prevalence of MDD
(Percentage by Ethnicity)
3.1
4.4
5.1 4.9
0
1
2
3
4
5
6
Af. Am Latina White Average
Af. Am
Latina
White
Average

18. Cognition
 Learned helplessness (Seligman)
 Attribution of lack of control over stress leads to anxiety and depression
 Negative cognitive styles (Beck)
 Cognitive models of depression share the premise that maladaptive
thinking and negative appraisals of life circumstances contribute
to the development of depression.
 depression is the result of negative interpretations (wearing gray
instead of rose colored glasses, e.g. Everyone in Winnie the Pooh)
Key Components of Negative Interpretations:
 Maladaptive attitudes (negative schema)
 Automatic thoughts
 Cognitive Triade – negative interpretations about self, future and the
world.
 Errors in thinking

19. Beck’s original model of depression:
According to Beck (1967) there are three main levels of thinking
involved in the onset, maintenance and exacerbation of depression:
 Depressive self-schemas (central to Becks’ cognitive model)
 Maladaptive core believes/assumptions (organized within the self
schemas) - internal, stable, global about self, feature, the world.
 Dysfunctional believes, rules and assumptions
 These believes often pertain to maladaptive themes of contingent self
worth.
 Characterized by “If -Than” statements.
 Negative automatic thoughts
 These thoughts usually take a form of negative view of self, future and
the world – Cognitive Triad, term coined by Beck et al (1979).

20.  Dichotomous thinking – things are seen in term of two mutually
exclusive categories, no “shades of gray in between”
 Ex: One might believe that he Is a complete success or a complete
failure, thus anything short of a perfect performance is a total failure.
 Overgeneralization – A specific event is being characteristic of
life in general, rather than as being one even among many.
 Mind Reading – Individual assumes that others are reacting
negatively without evidence that this is the case.
 Selective Abstraction – One aspect of the situation is the focus of
attention,. and other relevant aspects of the situation are ignore
 Ex: Focusing on one negative comment in a performance evaluation
at work and ignoring a number of positive comments.

21. Core Believes
“I am incompetent”
↓
Intermediate Believes
“If I do not do well all of the time, then people will not respect me”
“Making a mistake is equivalent to a complete failure”
↓
Coping, Compensatory Strategies
“Strive for perfection”
“You must succeed in everything you do”
↓
Activation of the self-schema via stress
Situation (stress imposing) ↓ Automatic Thoughts
Studying for a test “This is too difficult. I will never
understand this”.
Upcoming test “There is too much to cover. I will
never get it done. I can’t cope”
Being asked to meet with employer “He probably thinks I’m doing a
terrible job.

22. Seligman and Beck
Seligman
Attributions are:
 Internal
 Stable
 Global
I am inadequate
(internal) at everything
(global)
and I always will be (stable).
“Dark glasses about why
things are bad”
Interpretation (theory)
Beck
Negative interpretations about:
 Themselves
 Future (their place)
 Immediate world (their place)
I am not good at school (self).
I hate this campus (world). Things
are not going to go
well in college (future).
“Dark glasses about what is going
on”

23. Daniel was a 52 years old man who lived with his wife and two daughters’ (ages 10 and 13).
He was employed at the as insurance adjuster for a large insurance company. His chief
complains included feeling gloomy most of the time, loss of sleep, inability to concentrate
and presently intensified marital discord. He, met DSM IV TR criteria for dystymic disorder,
which had been present for the past 20 years and his level of depression has fluctuated over
the years. He describes his feelings as anxious most of the time but had no history of
genuine anxiety disorder. He exhibited a number of avoidant personality disorder traits
including fear of being criticized and ridiculed, being shy and reserved around others, and
being unwilling to take interpersonal risks. While he did not me the full criteria for APD, Daniel
had difficulties identifying determinants of his depression, although he mentioned not getting
along with his wife and a recent job loss as contributing factors. Although he described
treatment with previous therapy as “somewhat helpful”, he still felt depressed much of the
time and said he felt “there was nowhere to do”.
As a child, Daniel was well behaved although early in life he had difficulties at school. He
was slightly overweight . As a result he was often avoided and ridiculed by peers. In the first
grade, his extreme nearsightedness was discovered. His parent’s have failed to take him for
regular checkups and his nearsightedness went undiagnosed for years. His difficulties in
school apparently were a result of poor vision. When he received corrective lenses, his
school performance improved dramatically. In grade 6 Daniel joined the school football teem
and become to exhibit excellent athletic performance and physical fitness. Nonetheless,
years of struggling in classes and additional rejection by peers have left him feeling
“incompetent” and like a “screw up” or a “big, fat looser”.
Daniels parents were described as neglectful and highly critical. Both abused substances.
Daniels mother, who has been diagnosed with bipolar disorder, has never considered a
treatment, instead has been used her diagnoses to obtain antidepressants which she used
in excess for “personal pleasure”. In addition , it has been reported that Daniels mother have
been using substances while pregnant with Daniel. .
The behavior of both parents toward s Daniel was extremely erratic. His father in particular
would yell and scream at Daniel with little or no provocation. A particularly traumatic event
occurred when Daniel was 10 years old. Daniel was taking to his grandparent’s house,
apparently for a visit. Without Daniel noticing his parents drove away, abandoning him;
Case study

24. Diathesis Stress Model:
.
↓ Polygenes:
Maternal mood disorder
Biological Stressors: Brain System:
Maternal prenatal substance abuse Brain structure
Nearsightedness abnormalities -
smaller hypocampus;
reduced levels of neurotransmission
Social Environment: Temperament/Personality
Parental Criticism Avoidant Personality Style
High Harm Avoidaince(
Early Trauma (abandonment)
Peer Rejection
School Difficulties
Life Stresors: Job Loss MDD