Download DSM Major Depression - Texas Psychological Association

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Understanding Depression: Diagnosis, Assessment, and Treatment
A Self-Study Course by
Thomas Joiner, Ph.D.
Department of Psychology, Florida State University
1 Continuing Education (CE) Credit Hour
Directions: To receive APA approved continuing education credit for this TPA sponsored home study
assignment, you must:
1) Read the article in its entirety;
2) Take the test at the end of the article;
3) Mail the test along with $25 (TPA Members) or $100 (Non-TPA Members) to the TPA Central Office at
1011 Meredith Drive, Ste. 4, Austin, TX 78748.
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Understanding Depression: Diagnosis, Assessment, and Treatment
Thomas Joiner, Ph.D.
Department of Psychology, Florida State University
I. Goals/Overview
1) Update on latest thinking about the nature and nosology of depression (i.e., the clinical features of
depressive disorders; more common in women; prevalence increasing).
2) Survey various interpersonal styles that influence depression and relationships.
3) Provide clinically useful assessment approaches
4) Describe new and usable treatment approaches
II. Descriptive features of depression
A. DSM Depressions
DSM Major Depression
-Anhedonia
-Sadness/irritability
-Low Self-Esteem/Guilt
-Anergia
-Concentration Difficulty
-”Motor” Change
-Appetite Change
-Sleep Change
-Suicidality
-One of either anhedonia OR sadness; at least 5 of 9 total.
-Two week minimum (but it can last far longer).
-Over 200 combinations of the 9 symptoms meet for Major Depression-- interesting that 200 people with
different constellations of symptoms still viewed as having one disorder; also means that Major Depression is
quite variable in terms of its clinical presentation.
DSM Dysthymia and Depressive Disorder NOS
-Dysthymia has a two-year minimum (one year for youth); must have depressed mood (or irritable for youth)
more days than not and 2 or more of: appetite change; sleep change; anergia; low self-esteem;
concentration difficulty; hopelessness.
-NOS can be assigned for subsyndromal situations where impairment/distress is noteworthy. For example,
someone may have all 9 symptoms of DSM Major Depression, and be in acute distress, but only for the last 8
days (doesn’t meet the two week minimum criterion for Major Depression). They should be diagnosed with
something though -- NOS is a common choice. Also for times when symptoms have lasted for months or
years, have caused considerable distress/impairment, but only 2 such symptoms are present. NOS may be
used here as well.
- NOS is not just a “throwaway” diagnosis. For example, it’s been shown that people with “subthreshold”
depressive symptoms experience a lot of pain and suffering: high numbers of bed days, high role impairment
(roles as spouse, worker, parent, etc.), and high subjective distress.
Bipolar Disorder, Seasonal Affective Disorder, and “Other Depressions”
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-Bipolar disorder, also known as manic-depression, is, in general more severe and more rare than major
depression (also known as unipolar depression). Bipolar disorder is characterized by episodes of severe
depressions, as well as episodes of mania. Manic episodes include grandiose, often delusional ideas,
expansive planning, elated mood, boundless energy (e.g., going without sleep for days).
The manic episode presents some interesting clinical dilemmas, because often depressed people who do not
have bipolar disorder will describe their non-ill times as “manic” episodes. But when asked about these
“episodes,” they are periods of normal functioning (good, stable mood; ideas more or less in tune with reality
and loved ones). Clinically, when you see a manic episode, there’s no subtle diagnostic trick to it--it’s very
obvious.
One relatively good thing about bipolar disorder is that it is reasonably responsive to medicines, usually Lithium
but more and more these days a group of drugs called mood stabilizers (things like Depakote and Valproate).
One difficult thing is that some manic patients enjoy their manias, and so getting them to give up the manias
(by taking the drugs) is not always easy.
-Seasonal Affective Disorder (SAD) has been well studied by Norm Rosenthal at the NIMH. It’s characterized
by major depression symptoms occurring at times of the year when sunlight is less abundant (i.e., in the
winter). This disorder is rare in latitudes like Florida’s, because there’s enough light year round. But in more
northern latitudes, it can be a problem, the solution to which is light exposure. Light machines are available that
patients sit in front of for a couple hours each morning (while they’re reading or something); appears to be
effective.
-Other Depressions. It’s important to at least briefly note that symptoms mimicking a depressive episode can
occur as a consequence of another medical disorder (e.g., thyroid dysfunction) or as a side effect to some
medicines.
B. Differential Diagnosis and Course: Youth Examples
-In kids, how does depression look? It looks similar to in adults, with the possible exception of an
irritable/grumpy mood in place of a depressed/hopeless mood.
-In kids, how is depression different from other things, like ADHD? It can be easy to confuse depression and
ADHD in kids, because kids in both categories often are a little irritable, have concentration difficulties, and
are down on themselves. Some discriminating features: Depressed kids are rarely overactive, whereas ADHD
kids often are; depressed kids are rarely over-impulsive, whereas ADHD kids often are; ADHD kids are rarely
anhedonic (not getting enjoyment out of things), whereas depressed kids often are; and ADHD is a constant
thing that begins early in a child’s life; it stays around at a constant level (unless well treated); whereas
depression is a more variable thing, usually starting later in a kid’s life than ADHD, and then coming and going
in episodic fashion.
C. Depression as Scourge
-Common: 3-6% current; 10-15% lifetime.
-Increasing on a world-wide basis: This finding comes out of epidemiological research conducted around the
world by Weissman, Klerman, and colleagues, and finds that people born in early generations (say, the 20’s)
are not as vulnerable to people born later (say, the 50’s), and that the most recent generation is the most
depression-prone.
-Persistent: Average episode length is 8 months (same or higher for kids); for dysthymia, it’s greater than 10
YEARS! This an amazing fact about depression; it’s one of the only medical-related disorders you can think
of where the acute phase of the problem lasts for weeks, months, and years.
-Recurrent: Single episode--rare or never. The likelihood of having an additional depressive episode after
you’ve had a first is at least 50%, probably more like 70%, and some even think it’s 100% (good treatment
can probably get this number down; but even good treatment currently can’t get it down toward 0%,
unfortunately).
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-Painful: Rivals (but does not exceed) heart disease in terms of the impairment (e.g., bed days), social impact
(e.g., role impairment), pain (subjective distress), and cost to the health care system.
-Potentially Fatal via suicide
D. Depression in women
-In general, there’s a 2-to-1 gender difference (more women than men get depressed), and the 2-to-1
difference tends to stay around virtually always (e.g., when you look at different SES groups; different
ethnicities, and so on).
-Explaining this difference is not easy. Probably not completely hormonal: For example, research shows that
there’s not as great an increase in depression at times of hormonal change as we previously expected.
Looking at gender differences as they emerge in young kids and adolescents may help explain this.
-There are no gender differences in depression rates in young kids, but, after the age of 15, girls and women
are about twice as likely to be depressed as boys and men.
-This appears to be because girls are more likely than boys to carry risk factors for depression even before
early adolescence, but these risk factors lead to depression only in the face of challenges that increase in
prevalence in early adolescence. Many of these risk factors are psychological in nature.
-Link to eating disorders. Depression and eating disorders often co-occur. Several angles to this:
- Depressed people are extremely body-dissatisfied (i.e., they don’t like their own appearance). Depressed
people without bulimia are as body dissatisfied as people with bulimia. Since body dissatisfaction is a risk for
developing bulimia, it may further explain why depression and bulimia so commonly occur together.
- Both bulimia and depression are very chronic disorders. It was stated earlier that depression may last for
years. The same is true of bulimia. In one study, a group of several hundred women were assessed regarding
eating habits and problems, and then were re-assessed 10 years later. Women with eating problems at the
earlier assessment were 15 times more likely than other women to have bulimia 10 years later.
III. Assessment
A. The Tripartite Model of Depression and Anxiety
Basic concept is that depression and anxiety overlap considerably, and that the area of overlap
consists of general, diffuse negative emotions (feeling “stressed,” upset, and so forth). But, there are areas of
differentiation. For depression, this area is anhedonia (not getting enjoyment out of things)--depressed people
almost always experience this, and anxious people rarely do (unless co-morbid for depression).
For anxiety, the area of differentiation is called physiological hyperarousal (essentially, how your body
acts when in fear; heart palpitations, shortness of breath, break out in a sweat, feelings of choking, numbness,
etc.). Anxious people often experience this; depressed people rarely do.
B. Interviewing for depression
In addition to the usual (e.g., a detailed description of the symptoms themselves; a good sense of their
course [how they come and go; how long they last]), three things will be emphasized here: 1) a description of a
non-depressed “best of times; 2) interpersonal history; and 3) suicide risk.
-Asking about “best of times”
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Simply involves some statement like: “All right, now I know about how things go for you when you’re
depressed; now I’d like to hear about how you do when you’re not depressed; how do things when you’re at
your best?”
Benefits:
1) Gives clinician an idea of just how far therapy might progress (may not be possible to get beyond
functioning level of “best of times”). Helps keep therapists’ expectations conservative (not pessimistic, just
conservative). Informs realistic goal-setting for patients too.
2) A chance at rapport-building regarding non-threatening material.
3) An opportunity to instill hope; positive emotions like hope facilitate learning and memory, which is
useful in many therapies that include “teaching” components”(e.g., cognitive therapy).
-Interpersonal History Survey
Simply involves a statement like: “List all the people in your life, from early on to the present, who have
significantly affected you, either positively or negatively. I’ll be writing down the names as you list them.”
[Write down names; also, take note of who is missing: spouse, parent, etc.?]
Then: “OK, let’s go back through the list, and for each person, I want you to answer this question,
“What did you get out of the relationship with _______ ?”
Benefits:
An enormously important contextual variable is whether the depressive symptoms are in response to
grief, either about a recent loss or a past one that has not been resolved (and may not be reported by the
patient). Unless specifically investigated, you may not know you’re dealing with a grief-related depression.
There are different therapeutic tasks for grief- and non-grief depressions, so the distinction matters.
Patients may experience this exercise, in itself, as therapeutic.
Relatedly, also gives lovely data on recurrent relationship patterns which have presented difficulties for
the patients and which may come up in the therapist-patient relationship.
-A Suicide Assessment Routine (this is laid out on next page)
Two Most Important Areas: History of Previous Attempt and Nature of Current Suicidal Symptoms
Regarding History of Previous Attempts, evidence is that people who have a history of 0 or 1 previous
attempt(s) are just in a different risk category than people who have 2 or more attempts. Regardless of all the
other things going on, this one variable tells you a lot about risk. The multiple attempters are virtually always in
a higher risk category than their counterparts with 0 or even 1 previous attempt.
Regarding nature of current suicidal symptoms, two concepts are important. The first is termed
Resolved Plans & Preparation (Developed Plan for Suicide, Sense of Courage & Competence to Commit
Suicide, Opportunity, Intensity/Duration of Ideation)
The other concept is termed Suicidal Desire & Ideation (Frequency of Ideas, Desire for Death, and so
on).
Both of these concepts represent serious things, but relatively speaking, the Resolved Plans &
Preparation symptoms are more dangerous than the Suicidal Desire & Ideation factor.
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Other Risk Factors (e.g., Substance Abuse, Marked Impulsivity, Personality Disorder, Marked
Hopelessness, Marked Loneliness, Impaired Health, Recent and Relatively Severe Negative Events, and so
on) Are Interpreted In Light of Two Main Areas Assessment--see Suicide Assessment Decision Tree (next
page)
Multiple Attempter?
Yes
No
Any Other Significant
Finding = AT LEAST
Moderate Risk
Elevated on Resolved Plans &
Preparation?
Yes
No
Any Other Significant
Finding = AT LEAST
Moderate Risk
Two or More Other Significant
Findings = AT LEAST
Moderate Risk
Elevated on Suicidal
Desire & Ideation
Yes
No
Low Risk
Note: “Other significant finding” means the “laundry list” of suicide risk factors, things like severe recent negative
life events, marked hopelessness, deteriorating health, loneliness, and so on.
-Suicide-Related Writing: Not Necessarily a Bad Thing
People who do write about suicide (even preparing a potential suicide note) appear to score low on
Resolved Plans & Preparation, perhaps because the writing has taken some of the edge off the pain, given
time for reflection, reminded them of social support, and so on. Journaling about traumatic feelings and
experiences does seem to help -- people who do this derive a physical benefit (better immune functioning) as
well as a psychological benefit (less emotional distress in the long-term, although they have a little more
distress while they’re actually revisiting the traumatic experience).
-Assessment--Summary
After about two sessions, then, information is available on: a) diagnosis; b) details of symptoms, course,
functioning, “best times;” c) goals for restored functioning; d) suicidality; e) interpersonal history; f) possibility
of unresolved grief
-And: a) some rapport is built; b) some hope instilled; c) some therapy already done
-Not bad for two sessions (sometimes one). Managed care providers would love this
pace!
IV. Interpersonal Features of Depression
There are at least two interpersonal feature of depression that should be emphasized, because they
appear to affect treatment outcome and quality of life.
The two features are:
-Excessive Reassurance-Seeking--Tendency to excessively depend on others for sense of worth and
security; and
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-Negative Feedback-Seeking--Tendency to actively solicit negative reactions from others. Why would
people do this? The theory is that the motive to confirm your self-view is so powerful that people will act to
do it even if your self-view is negative.
An example of what is meant by Negative Feedback-Seeking:

Patient: ... I did bad things as a kid; never been a nice person; there’s nothing nice about me.

Therapist: Hmm... (doubtful look)

Patient: It’s true; it is true.

Therapist: I’m not sure I see it.

Patient: People don’t think I’m good; only those who can tolerate a lot like me. This is true.

Therapist: Still not sure I see it.

Patient: Well, perhaps you will... you know, there is no need to make me feel better; I just want you to be
honest.
The patient here is insistent and persistent that the therapist confirm her negative self-view.
- Depressed people may get “Caught In The Crossfire” Between These Two Tendencies
They simultaneously need contradictory things -- they need a form of positive feedback (reassurance)
and they need negative feedback; asking for both is bewildering and frustrating to everyone involved,
especially if constantly repeated, so relationships deteriorate, which worsens depression and heightens risk for
relapse.
V. Treatment of depression
- Why Systematize or Manualize a Treatment?
-Demonstrated Efficacy
-Focus for Patient and Therapist
-Relief for Therapist from Role of Existential Philosopher, Magical Healer, Proselytizer, etc.
-Managed Care Likes It
- Treatment--Brief notes on antidepressant medicines
The old class of antidepressants (called tricyclics, an example of which is Imipramine) had
demonstrated effectiveness, but sometimes substantial side effects (dry mouth, constipation, etc.). These
drugs worked by enhancing the functioning of several neurotransmitter systems in the brain. They are lethal in
overdose.
A newer class called selective serotonin reuptake inhibitors (SSRIs, examples of which are Prozac and
Zoloft) are equal in effectiveness to the old tricyclics, but have a more comfortable side effect profile. They
work by keeping as much serotonin as possible “in play” in synapses between neurons. The drugs inhibit the
mechanism that “vacuums up” serotonin from the synapse. They tend not to be lethal in overdose.
Length of treatment for antidepressant medicines: Consensus is that, following good treatment
response, meds should be continued for an additional 6 to 9 months (longer if patient has severe past history).
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Disadvantages, of course, include cost and side effects, but these are probably worth it considering that
stopping meds early is clearly associated with relapse.
Regarding antidepressant medicines for pregnant women and nursing mothers, the consensus appears
to be that these treatments should not be ruled out, in that what data are currently available show no relation
between taking SSRIs and fetal abnormalities. (Metabolites do appear in breast milk). Obviously, caution is
warranted, but a good case can be made that, if one has the choice between: a) being the mother of an infant
while simultaneously being in a Major Depressive Episode; or b) taking an antidepressant while pregnant or
nursing, one should choose “b.”
- Treatment--Brief Sketch of Interpersonal Psychotherapy (especially Grief module); see work by Klerman,
Weissman and colleagues.
Authors encourage patients to assume the “sick role” (i.e., “this is a tough disorder; it’s normal to
struggle; you may need to marshal time, energy, and resources to fight it, much as you would for other tough
health conditions”). This indeed seems useful for patients who believe that they should overcome
depressions through force of will alone (stiff upper lip), but may not be as useful for patients who may already
gravitate to the sick role (cf. secondary gain, etc.).
Identify one of four areas of focus: Grief; Role Disputes (conflictual relationships, often marital, that are
chronic source of stress and dissatisfaction); Role Transitions (changing major life role; e.g. from married to
divorced); Social Skills Deficits (thoughts and behaviors that are socially backfiring).
Interpersonal History Survey helps identify the area.
Strategy is to focus only and always on the identified area (this provides a much
needed focus and structure to the work)
If Grief, especially important to focus here first and exclusively (else you’ll get stuck). Interpersonal
therapy is particularly indicated for complicated grief reactions. Two main tasks are emotional facilitation of
grieving process and problem-solving focus (learning what went well and what did not in grieved-for
relationship, and applying what went well in future relationships).
Grief: a) facilitate mourning by reconstructing relationship to lost person or thing (e.g., “how did you
meet __?”, “what did you like about __?”, “what did s/he like about you?”, “what didn’t you like about each
other?”, “what did you enjoy doing together?”, “what did you fight about?”)
Ask for lots of detail (“what
date was your anniversary?” “what did you do on your first anniversary?” and so on) This is painful; that’s the
point!! If it’s not painful, guilt/conflicts may be in the way (“in what way is it a relief that __ is not with you
now?”). A useful question regardless.
b) problem-solving focus: “What did you take from your relationship to __, and how will you
apply this in the future?” This is a useful approach to resolving grief in general, as well as the “mini-grief” that
can come with ending therapy; therapist can ask, “What did you take from your relationship to me, and how
will you apply this in the future?”
Role Transitions = logic and technique are highly similar to grief module, except the grief is about an
old role (e.g., being a married person)
Role Disputes and Social Skills Deficits -- a variant of Cognitive-Behavior Therapy, described next, is
better for these areas.
- Treatment--CBT for Chronic Depression
Developed for chronic depression, but useful for depression in general (and
perhaps other things, like daily living)
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The Method
1) Identify situational “slice of time” -- a 5 to 15 minute situation in which something at least mildly distressing
occurred. Note the difference between this and focusing on huge existential issues. Idea is that slices of
time are far more manageable and that corrections within a slice will reverberate out to affect other
domains.
2) Interpretations: “In the situation, this situation meant ___, ___, & ___”. Patients simply fill in the blanks.
3) Behaviors: In the situation, patient did and said what? Lots of detail here
4) Desired Outcome: How did the patient want the situation to come out? (Note to self: Is this desired
outcome realistic, attainable?) Idea here is that it’s not easy to be depressed if you are often getting what
you want situation after situation.
5) Actual Outcome: How did the situation actually come out?
6) “Did you get want you want?” [Usually the answer is no and there’s a big gap between what was wanted
and what was gotten; although it’s a little painful, it’s important to let people “stew” in this gap, so that they
will be motivated to work hard to close it.
7) “Why not?” Further “stewing.”
NOTE: So far, no intervention, only assessing
8) Let’s go back through the situation, especially what you thought and did, and let’s ask the question, “Did
your interpretation or behavior help or hurt in getting what you wanted from the situation?”
If therapist and patient agree that it helped, leave it alone!
If therapist and patient agree that it hurt, the question is how to change it so that it would help? (Best if
patient can generate this, but at first, a “nudge,” some hints or tips, may be needed)
Repeat this method as many times as possible in session; homework is to pick a situation and write out
steps
Common Problems/Additional Points
Patient cannot generate a Desired Outcome: Takes practice; “if you could call the shots, how would the
situation turn out...?”
Patients’ Interpretations and Behaviors were good, but Desired Outcome not achieved: Almost always
means that Desired Outcome was unrealistic/unattainable. If so, grief work about desired but unattainable
outcome (refer back to Interpersonal Therapy section on grief).
- Some Additional Points about Treatment
What about exercise as a treatment and preventative for depression?
There is some evidence that it is useful, but only as a supplement to treatments such as cognitive
therapy, interpersonal therapy, and/or antidepressant medicines (not a treatment in and of itself; may be a
preventative in and of itself. Possibly more effective for women than for men -- its mechanism of working is not
well known. Could be physiologic/neurochemical effect of exercise per se; could be enhanced sense of self
from exercise; could even be social support from exercising with others.
What about combined pharmacotherapy and psychotherapy?
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Currently, there is some controversy as to whether one clinically proven therapy (whether
pharmacotherapy or psychotherapy) is enough, and whether adding another therapy adds much to outcome.
Some emerging evidence that the combination is best, so if affordable, practical, etc., this may be best.
How to prevent relapse?
1) Staying on medicines for full course of prescription.
2) There is some evidence that learning skills inherent in cognitive and interpersonal therapies aid in
relapse prevention.
3) There is good evidence that low social support and perceived criticism predict depression relapse;
interventions which enhance social support and general relationship functioning are thus indicated.
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References and Recommended Reading
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York:
Guilford.
Clark, L. A., & Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and
taxonomic implications. Journal of Abnormal Psychology, 100, 316-336.
Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives: Expressed
emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98, 229-235.
Joiner, Jr., T. E. (1994). Contagious depression: Existence, specificity to depressed symptoms, and the role of
reassurance-seeking. Journal of Personality and Social Psychology, 67, 287-296.
Joiner, Jr., T. E. (1995). The price of soliciting and receiving negative feedback: Self-verification theory as a
vulnerability to depression theory. Journal of Abnormal Psychology, 104, 364-372.
Joiner, Jr., T. E., Catanzaro, S., & Laurent, J. (1996). Tripartite model of positive and negative affect,
depression, and anxiety in child and adolescent psychiatric inpatients. Journal of Abnormal Psychology, 105,
401-409.
Joiner, T.E., & Coyne, J. C. (1999). The interactional nature of depression. Washington, DC: American
Psychological Association.
Joiner, Jr., T. E., Heatherton, T. F., & Keel, P. (1997). Ten-year stability and predictive utility of five
bulimotypic indicators. American Journal of Psychiatry, 154, 1133-1138.
Joiner, Jr., T. E., & Metalsky, G. I. (1995). A prospective test of an integrative interpersonal theory of
depression: A naturalistic study of college roommates. Journal of Personality and Social Psychology, 69, 778788.
Joiner, Jr., T. E., Rudd, M. D., & Rajab, M. H. (1997). The Modified Scale for Suicidal Ideation among
Suicidal Adults: Factors of suicidality and their relation to clinical and diagnostic indicators. Journal of
Abnormal Psychology, 106, 260-265.
Joiner, Jr., T. E., & Tickle, J. (1998) Exercise and depressive and anxious symptoms: What is the nature of
their inter-relations. Journal of Occupational Rehabilitation, 8, 191-198.
Klerman, G. L., & Weissman, M. M. (1989). Increasing rates of depression. Journal of the American
Medical Association, 261, 2229-2235.
Klerman, G. L., Weissman, M. M., Rounsaville, B. J., & Chevron, E. S. (1984). Interpersonal
therapy for depression. New York: Basic Books.
Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression: Evidence and theory.
Psychological Bulletin, 101, 259-282.
Rudd, M. D., & Joiner, Jr., T. E. (1998). The assessment, management, and treatment of suicidality:
Towards clinically informed and balanced standards of care. Clinical Psychology: Science and Practice, 5,
135-150.
Rudd, M. D., Rajab, M. H., Orman, D. T., Stulman, D. A., Joiner, Jr., T. E., & Dixon, W. (1996). Effectiveness
of an outpatient problem-solving intervention targeting suicidal young adults: Preliminary results. Journal of
Consulting and Clinical Psychology, 64, 179-190.
Simon, G., Ormel, J., VonKorff, M., & Barlow, W. (1995). Health care costs associated with
depressive and anxiety disorders. American Journal of Psychiatry, 152, 352-357.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of
Positive and Negative Affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 10631070.
Weissman, M. M., & Markowitz, J. C. (1994). Interpersonal psychotherapy: Current status.
Archives of General Psychiatry, 51, 599-606.
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Questions
Directions: To receive APA approved continuing education credit for this TPA sponsored home study assignment, you
must:
4) Read the article in its entirety;
5) Take the test at the end of the article;
6) Mail the test along with $25 (TPA Members) or $100 (Non-TPA Members) to the TPA Central Office at 1011
Meredith Drive, Ste. 4, Austin, TX 78748.
1) Depressive Disorder NOS is
a) no longer included in the DSM nosology
b) a “throwaway” diagnosis
c) associated with role impairment (roles as spouse, worker, parent, etc.), and high
about as much as is major depression
d) is not diagnosed in children and adolescents
subjective distress,
2) To meet criteria for Major Depression, sadness must be a feature of the clinical presentation.
True False
3) Regarding the 9 Major Depression symptoms in DSM and the DSM decision rules regarding Major
Depression
a) There are more than 200 combinations that meet criteria for Major Depression
b) In terms of clinical presentation, Major Depression is quite variable from patient to patient
c) they are identical to the criteria for dysthymia
d) Over-eating is excluded from them
e) A and B
4) Regarding Seasonal Affective Disorder
a) it is unvalidated as a true phenomenon
b) it is quite uncommon at Florida’s latitude
c) its clinical presentation is quite unlike that of major depression
d) it appears to have little to do with ambient light fluctuations
5) Regarding course and differential diagnosis among youth
a) course is not a useful differential diagnostic tool
b) most youth disorders are both chronic and episodic
c) depressions tend to episodic, whereas things like ADHD are less episodic
d) conduct disorder is episodic, whereas depressions tend not to be
6) According to the tripartite model of anxiety and depression
a) physiological hyperarousal is a relatively specific aspect of anxiety disorders
b) anhedonia is a relatively specific aspect of depressive disorders
c) negative affect is common to both depressive and anxiety disorders, but specific to neither
d) all of the above
7) One main value of asking patients about “best of times” is
a) you learn about physiological hyperarousal
b) you learn about irritability
c) it helps in setting clinical goals
d) it may induce a positive mood which in turn may facilitate memory and learning
e) C and D
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8) Suicide-related writing:
a) may actually be helpful
b) is the most pernicious suicidal symptom
c) is a correlate of substance use
d) is a feature only of those with past suicide attempts
9) Based on the suicide assessment section, if you had one question to ask to assess for suicidality, it
would be
a) past history of attempt
b) health status
c) substance use
d) loneliness
e) personality symptoms
10) Based on the suicide assessment section, a person with four past suicide attempts and who
abuses substances but has no other risk factors would be classified in the following way
a) no risk
b) minimal risk
c) mild risk
d) at least moderate risk
e) extreme risk
11) A main value of the interpersonal history survey is
a) assessment of anhedonia
b) detection of complicated grief reactions
c) assessment of suicide risk
d) detection of anxiety vulnerability
12) Depression causes distress and impairment
a) less so than most medical disorders
b) only if sadness is one of the features
c) as much or more so than most medical disorders
d) more so than heart disease
13) Regarding antidepressant medications
a) they are relatively ineffective
b) they should be discontinued immediately after symptom remission
c) they should be discontinued after 3 months
d) they should be discontinued around 6 - 9 months after full symptom remission
14) Regarding antidepressant medications and pregnancy/nursing
a) there currently exists no evidence that antidepressants and their metabolites harm the fetus
b) there is no evidence that antidepressants metabolites are in the breast milk of mothers taking
antidepressants
c) there is evidence that antidepressants metabolites in breast milk harm the infant
d) none of the above
15) Regarding interpersonal therapy for depression
14
a) the sick role should always be encouraged
b) the sick role should never be encouraged
c) the sick role should be encouraged for “stiff upper lip” patients primarily
d) the sick role should be encouraged for “somaticizing” patients primarily
16) The four areas of emphasis for interpersonal therapy for depression are
a) role disputes, role transitions, interpretations, desired outcomes
b) grief, desired outcomes, social skills, role transitions
c) grief, role transitions, actual outcomes, social skills
d) grief, role transitions, role disputes, social skills
17) For complicated grief reactions
a) interpersonal therapy is particularly indicated
b) cognitive therapy is particularly indicated
c) antidepressant medicines are particularly indicated
d) none of the above
18) The steps of cognitive therapy for chronic depression include
a) identifying situations, interpretations, grief, role disputes, actual outcome
b) interpretations, behaviors, social skills, role transitions
c) identifying situations, interpretations, behaviors, desired and actual outcomes
d) identifying situations, interpersonal history, behaviors, desired and actual outcomes
19) Benefits of structured, manualized therapies include
a) efficacy is demonstrated clearly
b) focus for patient and therapist
c) appealing to managed care
d) all of the above
e) none of the above
20) The philosophy of cognitive therapy for chronic depression includes
a) “if you’re getting what you want in specific situations, it’s hard to also be depressed”
b) “let’s focus on manageable slices of time instead of massive existential issues”
c) “one’s thoughts and behaviors are directly linked to attaining desired outcomes”
d) “why chase after things that just aren’t possible; focus only on attainable outcomes”
e) all of the above
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