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Persistent Depressive Disorder (Dysthymia)

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Claudia Salinas

on 14 December 2014

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Transcript of Persistent Depressive Disorder (Dysthymia)

DSM-5 Diagnosis
This disorder represents a
consolidation
of DSM-IV-defined chronic
major depressive disorder
and
dysthymic disorder
. The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year for children and adolescents (Criterion A).

Major Depressive Disorder may precede PDD, and MDD episodes may occur during PDD episodes
Individuals whose whose symptoms meet MDD criteria for 2 years should be given a diagnosis of PDD as well as MDD.

Diagnostic Criteria
(Symptoms)
A.
Depressed mood (
or irritable mood
)
most of the day
, for more days than not, (subjective account/observation by others ), for at least 2 years.
Specifiers for Persistent Depressive Disorder

Severity
:
Mild, moderate or severe

Remission status
:
In partial or full remission (if applicable)

Onset
:
Early (before 21) or late (21 or older) onset

Specify mood features
:
With anxious distress, mixed features,
melancholic features, atypical features, mood- congruent or
mood-incongruent psychotic features, and peripartum onset







Sample code
:
300.4 Persistent Depressive Disorder, mild severity, early onset,
with atypical features, with pure dysthymic syndrome

Persistent Depressive Disorder (Dysthymia)
Claudia Salinas
November 16, 2014
Nova Southeastern University
PSY 8115: Child and Adolescent Psychopathology
Individuals with PDD describe their mood as:
Sad or “
down in the dumps


Difference Between MDD and PDD

This is a
mild, long-term
depression that persists for
2 years or more!
A typical major depressive episode may last for
about
six months
Although, symptoms of PDD are chronic, they are
less
severe
than those for children with MDD

During the 2-year period ( 1 year for children or adolescents):
Any
symptom-free intervals
last no longer than 2 months (Criterion C)



Symptoms become a part of an individual’s day-to-day experience (particular in the case of early onset)
(e.g., “
I’ve always been this way
”)
May not be reported unless the individual is directly prompted.

B.
Presence, while depressed, of
two (or more
)
of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of Hopelessness
C.
During the 2-year period (1 year for children and adolescents) of disturbance:
Individual has
never been
without symptoms in
Criterion A & B
for more than
2 months
.
D.
Criteria for MDD
may be continuously

present for 2 years
E.
There has
never
been
a
manic

episode
or a
hypomanic
episode & criteria have never
been met for
cyclothymic
disorder (
chronic, fluctuating mood disturbance, involving numerous periods of hypomanic and depressive symptoms
)
F.
The disturbance
is not

better explained by:
a persistent schizoaffective disorder, schizophrenia,
delusional disorder, or
other specified/unspecified schizophrenia spectrum and other psychotic disorder
G.
The symptoms
are not attributable
to the physiological effects of a substance ( e.g., a drug,
abuse, medication ) or another medical condition
(e.g., hypothyroidism).
H.
The symptoms cause
clinically significant
distress
or
impairment
in social, occupational or other important areas of functioning
Prevalence and Comorbidity
Development and Course
Risk and Prognostic Factors
Course specifiers:

With pure dysthymic syndrome
( full criteria for MDD has not been met in at least the preceding 2 yrs)

With persistent major depressive episode
( full criteria for MDD has been met in at least the preceding 2 yrs)

With intermittent major depressive episodes, with current episode
( full criteria for MDD, 8 weeks with symptoms below threshold for major depressive episode)

With intermittent major depressive episodes, without current episode
( full criteria for MDD has not been met, but there has been one or more depressive episodes in at least the preceding 2 yrs)
Children with PDD (Dysthymia)
What to look for
:

Poor emotion regulation
Constant feelings of sadness/pessimism
Feelings of being unloved and forlorn
Self-deprecation (self-doubt)
Low self-esteem
Anxiety
Irritability (moody)
Anger/Temper Tantrums
Behavior Problems
Poor performance at school
Difficulty interacting with others
in social situations
Rates of Dysthymia are
lower
than those of MDD
Approx.
1% of children
and
5% of adolescents
displaying the disorder
During course of Dysthymia as many as
70% of children
may have an episode of major depression

Comorbidity
:
Most prevalent co-occurring diagnosis with dysthymia is MDD
About 1/2 of the children with dysthymic disorder also have one or more co-occurring nonaffective disorders that preceded the dysthymia:
Anxiety disorders
( SAD & GAD most common)
Conduct disorder
ADHD
Also at an increased risk for:
Bipolar disorder
Substance abuse disorder


Who tends to be Most Depressed?
Women
According to the NIMH, African-Americans have a lower lifetime risk of depression than whites. But according to a 2010 study by the CDC, African-Americans have the highest rate of current depression (12.8 percent), followed by Hispanics (11.4 percent), and whites (7.9 percent

Persistent depressive disorder often has an
early
and
insidious onset
( i.e., in childhood, adolescence, or early adult life) and, by definition
a chronic course
.

Dysthymic disorder develops about
3 years earlier
than MDD, commonly around 11 to 12 years of age
Early onset
(i.e., < 21 yrs) is
associated
with higher likelihood of comorbid
personality disorders
and
substance abuse disorders
Childhood-onset
dysthymia has a
prolonged duration
, with an average episode length of
2 to 5 years
Almost all children
eventually recover
from dysthymia

The early onset and extended duration of dysthymia make it a serious problem!

Children who
develop
the disorder at
age 9
then recover
4 years later
will have spent
more than 30%
of their entire lives and
over 50%
of their school-age years being
depressed
Since depression is
associated
with many
academic,cognitive,family, and social problems
,
these long-lasting episodes
of dysthymia can have
extremely harmful effects
on development



Temperamental
Factors predictive of
poorer long-term outcome
include:
Higher levels of neuroticism (negative affectivity)
Greater symptom severity
Poorer global functioning
Presence of anxiety disorders or conduct disorder
Environmental
Childhood risk factors include:
loss of a parent or sibling
or
separation/divorce

Genetic and Physiological
Children are at
higher risk
of developing persistent depressive disorder if they have a
first-degree relative
with the disorder.
A number of brain regions (e.g., prefrontal cortex, anterior cingulate, amygdala, hippocampus) have been implicated in PDD.
Possible
polysomnograhic abnormalities
exist as well
(Polysomnography : a comprehensive recording of the biophysiological changes that occur during sleep )
Performance on IQ and achievement
Evaluation and Assessment
Role of the Family and Access to Treatment
Community and Technological
Resources
References
Jean Baker (1995)
administered
the Reynolds Adolescent Depression Scale (
RADS
) and the Suicidal Ideation Questionnaire (SIQ)
to 58 moderately academically gifted students
(top 5% class rank or earning total score of 600 or less on SAT at age 13), 56 average students (middle class rank) and 32 exceptionally gifted (total score of 900 or more on SAT at age 13) from midwestern junior high and high schools.

“The major finding from this study is that academically able and exceptionally able students are not distinguishable from average students by differences in levels of depression or suicidal ideation
” (p. 222).

Baker acknowledged that she may have undersampled distressed children in this study because of the parental consent requirement, but she did not think selection bias influenced her results. However, she did stress that her study evaluated depression and suicidal ideation among highly achieving students from schools with gifted programs in place.

Different results might be expected from samples with students who are not so high achieving.
Certain depressive symptoms such as
difficulty concentrating, loss of interest, and slowness of thought and movement
are likely to have
harmful effect
on a child's intellectual and academic functioning
However, the
overall intellectual potential
of depressed youth is
comparable to the potential
of non-depressed youth

The
association
between
severity of depression
and children's
overall intelligence
is
weak
Suggests the
effects of depression
on
cognitive functions
may be
selective


A study by Guyer and colleagues (2011) they examine the association between memory for previously encoded emotional faces and depression symptoms assessed over 4 years in adolescent girls. Investigating the interface between memory deficits and depression in adolescent girls
Findings
: Girls with higher depression symptom levels from ages 9 to 12 years evidenced
lower accuracy i
n identifying previously encoded emotional faces. Controlling for IQ,
higher depression symptom level
was
associated
with a
memory deficit
specific to previously encoded sad and happy faces. These effects were not moderated by race.
Conclusions
: Depression may be associated with
impairments
on "
nonverbal tasks
" that require attention, coordination, speed, or recall of emotionally coded information

Children with depression perform more poorly than others in school (Cole, 1990)
They score lower on standard achievement tests
Are rated by their teachers as achieving less academically
Have lower levels of grade attainment

Children, adolescents, and young adults with
specific learning disorders
have a
high prevalence of depression
. Sixty to eighty percent (
60-80%
) of learning disabled children
failing in school
will fulfill criteria for depression at the time of initial clinical evaluation. (Weinberg, Harper & Emslie, 1995)
Gifted
In a study by Wilkinson and Goodyer (2006), Adolescents with current unipolar depression (n = 40) were compared with age and sex-matched controls (n = 38)
on tests of attention
and
general cognitive abilities
and completed the mood-related ruminative response style questionnaire.
Findings
: Compared to controls, depressed participants were
significantly slower
at switching attention. There was no association between attentional switching and mood-related ruminations and both processes contributed to the likelihood of being depressed.
Findings were not accounted for by slowness in reading and speaking, the effects of antidepressants nor being more careful on tasks.
Attention Difficulties
Seeking diagnosis.
Fortunately, depression can be identified and effectively treated even in very young children. Unfortunately, diagnosis and treatment of childhood depression require very specialized training and skills.
For example, infants and preschoolers rarely have the ability to express feelings well using language. So depressive symptoms must be inferred from:
overt behavior,
information gleaned from interviewing parents and other caregivers,
observation of the child’s interactions with other people, and play
interviews.

****
Only child psychiatrists, child psychologists, school psychologists, and other mental health professionals with specific training in working with young children are likely to have the expertise necessary to conduct such evaluations appropriately.

Comprehensive evaluation:
A
thorough evaluation should begin with a physical examination to rule out identifiable physical causes for the behavior patterns that suggest depression. This should be carried out by a pediatrician or other physician trained to work with
children.
The physical exam usually includes assessment of the child’s visual and auditory acuity. Undiagnosed vision and/or hearing impairment can cause a child to appear depressed or even trigger depression.
For older children the examination should also include screening for drug and alcohol use, since this is occurring in our society at earlier and earlier ages and the use can mimic or bring on depressive episodes.


After the physical examination and any necessary medical treatment, qualified, child-oriented mental health professionals should see the child. They should:
Interview
the parents and other caregivers as necessary
Consult
with other professionals including the
pediatrician, teachers, and other school or daycare
personnel.
Choose evaluative tests and observational procedures as needed, inform the parents of the results of the evaluation, and then formulate a
comprehensive treatment/intervention plan in collaboration with the parents.



Psychological evaluation
:
This evaluation includes a discussion with parents about child's thoughts, feelings and behavior and may include a questionnaire to help pinpoint a diagnosis
Screening Tools and Rating Scales:
Weinberg Depression Scale for Children and Adolescents (WDSCA)
The WDSCA self-report contains 56 yes/no items designed for individuals ages 5-21. This screening tool can be used as an initial assessment scale and can be repeated to measure response to treatments. It takes 3-5 minutes to complete.

Children's Depression Rating Scale-Revised (CDRS-R)
The CDRS-R is a clinical interview tool designed for assessing 6-12 year-olds, also successfully used for adolescents. It helps clinicians rate 17 symptom areas:
impaired schoolwork, difficulty having fun, social withdrawal, appetite disturbance, sleep disturbance, excessive fatigue, physical complaints, irritability, excessive guilt, low self-esteem, depressed feelings, morbid ideas, suicidal ideas, excessive weeping, depressed facial affect, listless speech, and hypoactivity
. It is used to diagnose depression and can be repeated to measure response to treatments. CDRS-R can be administered in 15-20 minutes.

Beck Depression Inventory for Youth (BDI-Y)
This is a 20-item, self-report inventory, for early identification of symptoms of depression in children and adolescents ages 7-14.
It screens
for emotional and social difficulties
that may impair a child's ability to function in school settings.
It includes items related to
sleep disturbance; negative thoughts about self, life, and the future; and feelings of sadness and guilt
.
It is useful in
planning and monitoring educational placement
and clinical treatment settings. (written at a second-grade level), but may be administered orally (usually in 5-10 minutes).

Family influences play a vital supportive role in any treatment process:
Encouragement of developmentally appropriate play, physical exercise, and pleasurable activities are appropriate for children with anhedonia (inability to feel pleasure).
Physical exercise has been shown to improve mood. Active play or sports (if psychologically supportive, rather than an opportunity for criticism) can accomplish these aims

Parents and family members need to be informed about clinical aspects and biological/psychological determinants of depression and instructed about the child’s need for reassurance and support, rather than punishment for unacceptable behavior.

Education of all family members is essential because the symptoms of of depression (lack of interest, fatigue, isolation and irritability) may affect the response of each member of the family to the patient and increase their emotional involvement, "causing more stress, guilty or angry feelings for the child to cope with".
Treatments for Youngsters with Depression
Behavior Therapy
:
Aims to increase behaviors that elicit positive reinforcement & reduce punishment from environment
(may involve: teaching social and other coping skills,)
Anxiety management
Relaxation training
Cognitive Therapy
:
Helps children become more aware of pessimistic and negative thoughts
Once self-defeating thought patterns are recognized, child is taught to change from a negative view to a optimistic one
Cognitive-Behavioral Therapy
(CBT):
Most common psychosocial
intervention
Combines elements of behavioral
& cognitive therapies in an integrated
approach
Attribution retraining may also be used
to challenge the youngster's
pessimistics beliefs
Interpersonal Psychotherapy
for Adolescent Depression (ITP-A)
:
Explores family and interpersonal interactions that maintain depression
Family sessions are supplemented with individual sessions where:
children are encouraged to understand their own neg. cognitive style
Effects of their depression on others
Increase pleasant activities with family members & peers
Medications
:
Treats mood disturbances
and other symptoms of depression
using antidepressants
especially selective serotonin reuptake inhibitors (SSRIs)
American Psychological Association, 750 First Street, NE, Washington, DC 20002; (202) 336-5500;
www.apa.org
American Psychiatric Association, 1400 K Street, NW, Washington, DC 20005; (202) 682-6000;
www.psych.org
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5). Washington DC: American Psychiatric Association
National Association of School Psychologists, Suite 402, 4340 East West Highway, Bethesda, MD 20814;
www.nasponline.org
Guyer, A.E., Chaote, V.R., Grimm, K. J., Pine, D. S., & Keenan, K. (2011). Emerging depression is associated with face memory deficits in adolescent girls. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 180-190.
Mash, E.J. & Wolfe, D.A. (2012). Abnormal child psychology (5th edition). Belmont, CA: Wadsworth Publishing
National Institute of Mental Health, Office of Communications and Public Liaison, Information Resources and Inquiries Branch, Room 8184, 6001
Executive Boulevard, MSC 9663, Bethesda, MD 20892; (310) 443-4513; www.nimh.nih.gov
National Mental Health Association, 1021 Prince Street, Alexandria, VA 22314;
www.nmha.org
Wilkinson, P.O., & Goodyer, I. M. (2006). Attention difficulties and mood-related ruminative response style in adolescents with unipolar depression. Journal of Child Psychology and Psychiatry, 47, 1284-1291
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