Depression. Aaron T. Beck, M.D.

in the hypothalamic-pituitary-adrenocortical axis in chronic depression are similar to those in nonchronic types. Also, no consistent differences in sleep physiology have been found to be related to course. Immunology studies suggest increased natural killer cell activation in both dysthymia and major depression, but the overactive immune response in dysthymia may be more trait-like compared to nonchronic depression.

Cognitive Factors

      The role of cognitive factors in chronic depression is “perhaps the most understudied area.”⁴¹ However, one study found that several cognitive variables differentiated chronically depressed individuals from those with major depression.⁴² The study included 42 outpatients with chronic depression (CD), 27 outpatients with nonchronic major depressive disorder (NCMDD), and 24 never psychiatrically ill controls (NPI). The cognitive variables included a Schema Questionnaire, the Dysfunctional Attitudes Scale, the Attributional Style Questionnaire, and a ruminative response style questionnaire (see Table 3-7).

      Results showed that the two depressed groups were elevated on every cognitive measure compared to the control group. The depressed groups were higher on the schema clusters, dysfunctional attitudes, stable and global attributional style, and rumination. Moreover, the chronic depression group compared to the nonchronic group was significantly elevated on all cognitive measures except for ruminative response and attributional style. In general, the chronic group of patients were more elevated on measures of cognitive variables even after taking into account (statistically controlling for) mood state and personality disorder symptoms. Thus, this preliminary study suggests that the cognitive perspective may be of some utility in distinguishing between those with chronic depression compared to nonchronic major depressive disorder.

      Overall, Riso et al.⁴¹ concluded by suggesting that continued research is needed with (1) better definitions of chronicity, (2) utilization of more appropriate comparison groups, and (3) prospective follow-up studies across longer time periods. To more completely ascertain the causes of chronic depression is one of the most important areas for researchers in the field of experimental psychopathology.

Conclusions

      1. In naturalistic studies, complete remission from an episode of depression occurs in 70–95 percent of the cases. About 95 percent of the younger patients remit completely.

      2. When the initial attack occurs before age 30, it tends to be shorter than when it occurs after 30. Acute onset also favors shorter duration.

      3. After an initial attack of depression, 47–79 percent of the patients will have a recurrence at some time in their lives. The correct figure is probably closer to 79 percent, because this is based on a longer follow-up period.

      4. Individuals who have experienced a major depressive disorder, single episode, have at least a 60 percent chance of having a second episode; those who have had two episodes have a 70 percent chance of a third; and those with three prior episodes have a 90 percent chance of having a fourth.³⁵

      5. The likelihood of frequent recurrences is greater in the biphasic cases than in cases of depression without a manic phase. Between 5 and 10 percent of individuals with major depressive disorder, single episode, later develop a manic episode.³⁵

      6. Although the duration of multiple episodes remains about the same, the symptom-free interval tends to decrease with each successive attack. In the biphasic cases the intervals are consistently shorter than in the simple depressions.

      7. Approximately 5 percent of hospitalized bipolar patients subsequently commit suicide. The suicidal risk is especially high on weekend leaves from the hospital and during the month following hospitalization and remains high for six months after discharge.

      8. The rate of suicide attempts appears to be higher among those with chronic depressive illness (dysthymic disorder) compared to episodic major depression.

       9. The notion that a person who threatens suicide will not carry out the threat is fallacious. The communication of suicidal intent is the best single predictor of a successful suicidal attempt. Previously unsuccessful suicidal attempts are followed by successful suicides in a substantial proportion of the cases.

      10. Suicide risk in patients with bipolar disorder is increased in those with greater severity and higher body mass.

      11. The search for determinants of chronic depression includes developmental factors like childhood adversity (early trauma or maltreatment); personality, psychological stressors, comorbid disorders, biological factors, and cognitive factors. In studies of chronic depression, the strongest evidence of etiology is developmental factors, with some support for chronic stressors and stress reactivity.

      12. The role of cognitive factors in chronic depression is “perhaps the most understudied area.”⁴¹ However, one study suggested the cognitive perspective may be of some utility in distinguishing between chronic and nonchronic forms of depressive disorder.

      Chapter 4

      Classifying Mood Disorders

The Official Nomenclature

      Classification of the mood disorders has evolved in the more than 50 years since the American Psychiatric Association’s first diagnostic and statistical manual was published. As research and theory have advanced, they have been reflected in the four editions and two revisions of the manual.

      The current criteria for classifying Major Depressive Episodes and Manic Episodes are listed in Tables 4-1 and 4-2 from DSM-IV-TR.¹ It might be noted that the DSM-IV criteria for major depressive episode (as in Table 4-1) include “biological” or physiological symptoms along with cognitive ones. For example, these four symptoms are largely physiological in nature: (3) weight loss (or, in children, failure to make expected weight gains); (4) insomnia or hypersomnia; (5) psychomotor agitation or retardation; and (6) fatigue or loss of energy nearly every day. These five are cognitive or motivational symptoms: (1) depressed mood (or, in children and adolescents, irritability); (2) markedly diminished interest or pleasure in activities; (7) feelings of worthlessness or excessive or inappropriate guilt; (8) diminished ability to think or concentrate, or indecisiveness; (9) recurrent thoughts of death or suicidal ideation. The various types of mood disorder are listed in Table 4-3.¹

      To find the various types of depression in the earlier nomenclature of the American Psychiatric Association,^2,3 compared to subsequent versions,^1,4,5,6 it was necessary to hunt through many sections. This scattering of the affective disorders contrasted with the consolidation found in other classification systems (e.g., the British Classification).⁷ This prior scattering of the mood disorders was a reflection of several historical trends, including the dissolution of Kraepelin’s grand union of all affective disorders into the manic-depressive category, the isolation of new entities such as neurotic-depressive reaction, and the attempt to separate the disorders on the basis of presumed etiological differences.

      Schizoaffective disorder, which has salient affective features, was at one time listed as a subtype of the schizophrenic reaction. In terms of its historical conceptualization, its course, and its prognosis, this disorder may be more closely allied to bipolar disorder (see Chapter 8).

TABLE 4-1. Criteria for 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. Note: Do not include symptoms that are clearly due to a general medical condition, Скачать книгу В начало < 21 22 23 24 25 26 27 28 29 30 > В конец