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Brandon Neo

on 22 April 2010

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Transcript of S.A.D

Mood disorder.
Family of Major depression.
Normal people with normal mental health. Dependent on seasonal changes
(Wehr et al., 1991). Winter Depression. Spring / Summer depression. Symptoms..... Winter
Difficulty in waking up (morning).
Tendency to oversleep / overeat.
Lack of energy.
Difficulty in concentrating on completing tasks.
Social withdrawal.

Spring / summer
Decreased appetite.
Weight loss.
Increased sex drive.
Hypomanic episodes (bipolar II disorder)
Persistent and pervasive elevated or irritable mood.
Thoughts and behaviors consistent with the mood state.
Decreased need for sleep / rest.
Involvement in pleasurable activities that have high potential for negative psycho-social or physical consequences. Recent studies S.A.D. occur within unipolar major depression.
Minority have hypomanic episodes (bipolar II disorder).
A few associated with manic episodes (Oren et al., 1992). Unipolar major depression (Solomon et al., 2000)
An all-encompassing low mood.
Low self-esteem.
Loss of interest in normally enjoyable activities. Prevalence (Kasper et al., 1989)
Surveys estimated four to six percent of general population. .Nordic countries (Iceland, Scandinavia). .United States (Alaska). .Japan. .Canada. .More common in women than men (ratio 1:4).
.Average age of onset is about 23 years old.
.Decreases with age (American Psychiatric Association, 1994). Pilot studies of children suggested 1.7 and 5.5 percent, between nine and nineteen years (Swedo et al., 1995) DSM-IV-TR TABLE 1
Diagnostic Criteria for a Major Depressive Episode

A least five of the following symptoms have been present during the same two-week period, nearly every day, 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.

NOTE: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

(1) Depressed mood (or alternatively can be irritable mood in children and adolescents).
(2) Markedly diminished interest or pleasure in all, or almost all, activities.
(3) Significant weight loss when not dieting or weight gain or decrease or increase in appetite.
(4) Insomnia or hypersomnia.
(5) Psychomotor agitation or retardation.
(6) Fatigue or loss of energy.
(7) Feelings of worthlessness or excessive or inappropriate guilt.
(8) Diminished ability to think or concentrate, or indecisiveness.
(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 commiting suicide.

The symptoms are not better accounted for by a mood disorder due to a general medical condition, a substance-induced mood disorder, or bereavement (normal reaction to the death of a loved one.

The symptoms are not better accounted by a psychotic disorder like schizoaffective disorder.

Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:327. Copyright 1994. TABLE 2
Criteria for Seasonal Pattern Specifier

Regular temporal relationship between the onset of major depressive episodes and a particular time of the year (unrelated to obvious season-related psychosocial stressors).

Full remissions (or a change from depression to mania or hypomania) also occur at a characteristic time of the year.

Two major depressive episodes meeting criteria A and B in last two years and no nonseasonal episodes in the same period.

Seasonal major depressive episodes substantially outnumber the nonseasonal episodes over the individual's lifetime.
Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:390. Copyright 1994.
Case Study Selena is a twenty-three-year-old University student, who had moved to Vancouver about two years ago. She got her first strong SAD "attack" in her first winter in Vancouver. The condition that has possibly triggered the problem was both the lack of snow that used to reflect and almost double the sunlight in the geographical area where she used to live before. The description of her condition during that winter follows. As the sun stopped shining bright, Selena gradually became very lethargic, sad and withdrawn. She felt like she had to kick and drag herself from one place to another. Any kind of communication became a major burden. She officially refused to pick up the phone in her house, explaining this by the fact that her friends never called her home number anyway. In truth, her reason was that it was extremely hard for her to answer to her parents' friends, to be chatted up by relatives. She would shudder every time her own cell phone rang. Selena became very forgetful. After a certain point that year, she stopped being able to keep track of dates, which created even more problems in her school. After forgetting about an exam for the first time in her life, she realized that the situation was getting serious. The girl would usually sleep anywhere from 7 to 9 hours during the "warm" part of the year, but in the late fall she would start needing more sleep - anywhere from 10 to 12 hours a night on the weekdays, and up to 14 hours on her days off. She would also feel tired during the day and would have no problem taking a one or two hour naps during the day forgetting about all the sleep she got at night. Selena would eat more in the winter and gain more weight, go on a diet in the summer, get the drive to exercize and would lose some of the weight gained during the "dark" months. As the years went by, though, it became harder and harder for her to lose the pounds gained, which added to her diminutive view of herself. As a result, she would feel very heavy, every pound of her body counted as ten. At this time, the weight problem, she has always been suffering with, became even more burdening, as it seemed to her that the heaviness of her body came from the extra weight she had. Calling friends was a major effort, a totally impossible thing sometimes. Setting up time for socializing was a burden and, even more so, keeping the times set. In case if she actually managed to make it to the appointment with her friend, she would be sitting there both waiting for the person and hoping that he/she would not show up, and thus she would have this time left for herself. She left relieved when an appointment got cancelled.
Even when she used an online chat service she would hide under the "Invisible" status, so that none of her online friends could see whether she was really available until she chose to contact them. This is how burdensome the idea of communicating became.
New Year's resolutions would routinely come in July and August and never in December. "How can anyone be inspired to make any kinds of decisions in the winter?..", she would always wonder. Finally, the girl kept repeating to her friends: "Bears are so lucky. I wish I was allowed to hibernate." Aetiology of S.A.D. Seasonal changes in production of melatonin (Goodwin & Jamison, 1990).
Disturbance of normal circadian rhythm of the body (Jindal et al., 2002).
Low levels of serotonin (Goodwin & Jamison, 1990).
Therapy Cognitive Behavioral Therapy (Butler et al., 2006)

Psychotheraputic approach to solve problems through goal-oriented, systematic procedure.
Combination of basic behavioral and cognitive research.
Research conducted by Rohan et al. (2002) on the use of cognitive behavioral therapy without the using light therapy, achieved some significant results. Treatments Bright light therapy, using doses of 2,500 - 10,000 lux (Avery et al., 2001). Dawn simulation (Avery et al., 2001) Improve self-Evaluation

Evaluation of life task management.
Depressed people tends to be too critical which feeds on their low self-esteem and a sense of failure.

Help Selena to lose weight. Identification of Skill Deficits

E.g. " things i cannot do"
Identify social skill deficits.
Work together to develop a plan to improve skills.
Help them to manage life problems.

Help Selena to let her friends and family into her life again.
Evaluation of life experiences.

Depressed people tend to remember minor negative aspects of a positive life experience. E.g. "remembering it rained on one of six days i spent at the beach..".

Work with them to develop realistic expectations on life.
Help them to determine what is needed vesus what is wanted.
When problem occurs, learn to resolve, recover and start again.
Injecting the sense of hope.

Allow her to realise the importance of waking up for school during spring / summer. Self-talk

A way of describing things we say to ourselves.
E.g. "I can't do this, I'm just going to foul it up again".

Identify negative self-talk.
Work together to challenge these negative statements.

Inspire Selena to make decisions in winter.
Not knowing about SAD, she knew that she was in her best mood when during the sunniest days of summer. Her dream was to live in a country where it was really hot, very sunny and rained only once in a while, pouring for five minutes. "We get my ideal weather for as little as one week a year... Should I consider moving?.." She would start panicking when thinking about the grey fall coming or even of a cloudy grey day in the middle of the summer. "My mood completely depends on the weather... Isn't this scary?" Selena would dream of having an apartment on the top floor (so that the sun would not be blocked by anything around the windows), on the East side of the building (so that the sun could wake her up each morning), with large windows from floor to the ceiling (so that maximum amount of sun could enter through them). Yellow became her favorite color just because it reminded her of the sun and felt like an "energy-boosting" color.
She would usually be excited about school in September, but got weighed down with it closer to November, December, or January, depending on the location she was living in at that time. While she was living in the Eastern Europe where the winter started around November each year, her "dark" periods would come around the end of October and end by the middle or end of April. She would get excited about the coming of the white snow, but get depressed again when the shininess of it would be covered with dirt. These were the only "light" periods during the winter. She would fear the rain and cloudy days.
Change irrational ideas and beliefs

Belief in irrational ideas are correct.

Selena's dream on having apartment on the top floor
Questions? Outline of S.A.D. References American Psychiatric Association. Diagnostic
and statistical manual of mental disorders.
4th ed. Washington, D.C.: American
Psychiatric Association, 1994:317-91.

Avery, D. H.; Kizer D, Bolte MA, Hellekson C
(2001). "Bright light therapy of
subsyndromal seasonal affective disorder in
the workplace: morning vs. afternoon
exposure". Acta Psychiatrica Scandinavica
103 (4): 267–274.

Avery, D H; Eder DN, Bolte MA, Hellekson CJ,
Dunner DL, Vitiello MV, Prinz PN (2001).
"Dawn simulation and bright light in the
treatment of SAD: a controlled study".
Biological Psychiatry 50 (3): 205–216.

Butler AC, Chapman JE, Forman EM, Beck AT
(January 2006). "The empirical status of
cognitive-behavioral therapy: a review of
meta-analyses". Clin Psychol Rev 26 (1):
17–31. Free essays, (2005) SAD Case study.
Retrieved from

Goodwin, F.K., & Jamison, K.R. (1990). Manic
depression illness. New York: Oxford
University Press.

Jindal, R. D., Thase, M. E., Fasiczka, A. L.,
Friedman, E. S., Buysse, D. J., S., E., et al.
(2002). Electronencephalographic sleep
profiles in single-episode and recurrent
unipolar forms of major depression: II.
Comparison during remission. Biological
Psychiatry, 1, 230-236.

Kasper S, Wehr TA, Bartko JJ, Gaist PA, Rosenthal
NE. Epidemiological findings of seasonal
changes in mood and behavior. Arch Gen
Psychiatry 1989; 46:823-33. Oren DA, Rosenthal NE. Seasonal affective
disorders. In: Paykel ES, ed. Handbook
of affective disorders. 2d ed. London:
Churchill Livingstone, 1992:551-67.

Rohan, K. J., Lindsey, K. T., Roecklein, K. A.,
Lacy, T. J., (2003). Cognitive-behavioral
therapy, light therapy, and their
combination in treating seasonal
affective disorder. Journal of Affective
Disorders 80 (2004) 273–283

Solomon, D.A., Keller, M.B., Leon, A.C.,
Muelle, T.I., Lavori, P.W., Shea, T.,
Coryell, W., Warshaw, M., Turvey, C.,
Maser, J.D., & Endicott, J. (2000).
Multiple recurrences of major
depressive disorder. American Journal
of Psychiatry, 157(2), 229-233.

Swedo SE, Pleeter JD, Richter DM,
Hoffman CL, Allen AJ, Hamburger SD,
et al. Rates of seasonal affective
disorder in children and adolescents.
Am J Psychiatry 1995;152:1016-9.

Wehr TA, Giesen HA, Schulz PM, Anderson
JL, Joseph-Vanderpool JR, Kelly K, et al.
Contrasts between symptoms of
summer depression and winter
depression. J Affect Disord 1991;23:173
-83. Overgeneralizing or Catastrophizing

"Making a mountain out of molehill"
One person at work does not like you, then you assume that NO ONE at work likes you.

Need to let client know everyone makes mistakes.
Help client to identify and change negative overgeneralization.

When Selena forgets taking her exams. Cognitive Distortions

Another way of describing irrational ideas.
Distorting reality by the way we evaluating a situation.
Highlights the importance of perceptions, assumptions and judgments in coping with the world.

Help client to determine what evaluations are distortions by providing objective feedback, changing the way client perceives problems

Selena's using tanning to raise her mood during 'dark' periods. Pessmistic Thinking & Hoplessness

Tendency to think things won't work out.
Viewing the world as bad, thinking you cannot do anything about it.

Research ways to inject optimism as a way to fight depression. Tanning would raise her mood during the "dark" periods. She would tan during the summer as much as she could, feeling that she had to use every single moment she had to "absorb" as much sun as it was possible. She could hardly resist dropping whatever she was doing in order to spend time under the sun.
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