Diagnostic Features of Persistent Depressive Disorder
SYMPTOM
DEFINITION
SELF-DESCRIPTION
2-YEARS OF DEPRESSIVE SYMPTOMS
Depressed Mood
Feeling down or depressed
"I often feel down or depressed."
(While depressed must have at least 2 of the
following:)
Hopelessness
A feeling of despair; lack of hope
"I feel my future is hopeless and cannot improve."
Distractibility
Difficulty concentrating on doing something for 10 minutes; easily
distracted; poor attention span
"I am easily distracted." "I can't focus on things for very long."
Fatigue
Tired; lack of energy
"Im tired all the time."
Abnormal Sleep
Under- or over-sleeping
"My sleep is a problem."
Abnormal Appetite
Under- or over-eating
"My eating is a problem."
Loss of Interest or Pleasure
Lacking interest or pleasure in doing one’s usual activities
"I rarely get enthusiastic about anything."
Onset:
Persistent Depressive Disorder
consists of at least 2 years of chronic mild unhappiness which causes significant distress
or disability. This disorder is best thought of as a mild form of Major Depressive Disorder
in which the criteria for a major depressive episode has never been met. The spells of
unhappiness consist of mild:
Low Intellect
(e.g., distractibility),
emotional distress
(e.g., depressed mood, low self-esteem), and
physical symptoms
(e.g., fatigue, altered
sleep and appetite).
Treatment:
Although there are no randomized controlled trials, cognitive behavioral therapy (CBT),
interpersonal therapy (IPT), and cognitive behavioral analysis system of psychotherapy
(CBASP) are believed to be effective for the treatment of patients with this disorder. The
rate of relapse/recurrence of symptoms has been shown to be reduced by long-term treatment
with antidepressant medication and with long-term use of these psychotherapies.
Prognosis:
In adults, up to 75% of individuals with this disorder will develop Major Depressive
Disorder within 5 years. The spontaneous recovery rate for this disorder is approximately
10% per year (which is much lower than that of Major Depressive Disorder). This recovery
rate is significantly better with active treatment.
Individuals with this
disorder would have a significant impairment in the behaviors that are displayed in
red
:
Most of the time and in most situations:
In general, do you have difficulty making and
keeping friends?
Would you normally describe yourself as a
loner?
In general, do you trust other people?
("No")
Do you normally lose your temper easily?
Are you normally an impulsive sort of
person?
Are you normally a worrier?
In general, do you depend on others a lot?
In general, are you a
perfectionist?
Answer "Yes" or "No" to each of these 8
questions.
7-Question Well-Being Screening Test (By P. W. Long MD, 2020
Individuals
with this disorder would have a significant impairment in the behaviors that are
displayed in
red
:
Agreeableness: I was kind and honest. Conscientiousness: I was diligent and self-disciplined. (Instead had distractibility) Openness/Intellect: I showed good problem-solving and curiosity. Sociality:
I was gregarious, enthusiastic, and assertive. (Instead had loss of
interest or pleasure) Emotional
Stability: I was emotionally stable and calm. (Instead had
depressed mood, hopelessness) Physical
Health: I was physically healthy. (Instead had fatigue,
weight gain/loss, increased/decreased sleep) Role Functioning: I functioned well socially and at school/work.
How often in the past
week did you do each of these 7 behaviors:
Problems
Occupational-Economic Problems:
Causes significant impairment in academic, occupational and/or social functioning
Emotional Distress (Negative Emotion):
While depressed almost continuously for at least 2 years, had 2 or more of the
following:
Poor appetite or overeating
Insomnia or Hypersomnia
Low energy or fatigue
Low self-esteem or low self-confidence
Poor concentration or difficulty making decisions
Feelings of hopelessness
Medical Problems:
Chronic or disabling medical conditions increase risk of this disorder
Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder
requires assessment by a qualified practitioner trained in psychiatric diagnosis and
evidence-based treatment.
However, if no such professional is available, our free computerized diagnosis is usually
accurate when completed by an informant who knows the patient well. Computerized
diagnosis is less accurate when done by patients (because they often lack insight).
Example Of Our Computer Generated Diagnostic Assessment
This diagnosis is based on the following findings:
Never had psychotic symptoms in the absence of prominent mood disturbances
(when off drugs)
This long-lasting depression was not better accounted for by Schizoaffective
Disorder
This long-lasting depression was not superimposed on Schizophrenia or
Schizophreniform Disorder
This long-lasting depression was not superimposed on Delusional Disorder or
Psychotic Disorder N.O.S.
This long-lasting depression never met the criteria for a Manic, Mixed, or
Hypomanic Episode
This long-lasting depression never met the criteria for Cyclothymic Disorder
Criteria for Major Depressive Disorder may be continuously present for 2 years
Depressed mood for most of at least 2 years (still present)
During this long-standing depression, never had a 2-month depression-free
period
This long-lasting depression was not due to a general medical condition
This long-lasting depression was not due to a drug of abuse, a medication, or
other treatment
For most of this long-lasting depression, had poor appetite or overeating
(still present)
For most of this this long-lasting depression, had insomnia or hypersomnia
(still present)
For most of this this long-lasting depression, had low energy or fatigue (still
present)
For most of this this long-lasting depression, had low self-esteem (still
present)
For most of this this long-lasting depression, had poor concentration or
indecisiveness (still present)
For most of this long-lasting depression, had feelings of hopelessness (still
present)
This long-lasting depression started before age 21 years
Treatment Goals:
Goal: prevent depressed mood.
If this problem worsened: She could feel sad, hopeless, discouraged, "down in
the dumps", or "blah". She could emphasize somatic complaints (e.g., bodily
aches and pains) rather than reporting feelings of sadness. She could exhibit
increased irritability
(e.g., persistent anger, a tendency to respond to events with angry outbursts or
blaming others, or an exaggerated sense of frustration over minor matters).
Goal: prevent appetite or weight disturbance.
If this problem worsened: She could have either abnormally decreased or
increased appetite. This could progress to significant loss or gain in weight.
Goal: prevent insomnia or hypersomnia.
If this problem worsened: She could sleep too little or too much. Typically she
could have middle insomnia (i.e., waking up during the night and having
difficulty returning to sleep) or terminal insomnia (i.e., waking too early and
being unable to sleep).
Initial insomnia (i.e., difficulty falling asleep) could also occur. Less
frequently, she could have oversleeping (hypersomnia).
Goal: prevent fatigue or loss of energy.
If this problem worsened: She could experience decreased energy, tiredness, and
fatigue. Eventually, even the smallest tasks could seem to require substantial
effort. She could find that washing and dressing in the morning are exhausting
and take twice as long
as usual.
Goal: prevent low self-esteem.
If this problem worsened: She could have unrealistic negative evaluations of her
worth. She could often misinterpret neutral or trivial day-to-day events as
evidence of her defects. She could become highly self-critical, often seeing
herself as uninteresting
or incapable.
Goal: prevent poor concentration or indecisiveness.
If this problem worsened: She could have an impaired ability to think,
concentrate, or make decisions.
Goal: prevent feelings of hopelessness.
If this problem worsened: She could feel that there is no hope for her life to
improve, believing "I've always been this way" or "That's just how I am".
Persistent Depressive Disorder is characterized by a chronically depressed mood, lasting at
least 2 years, which is not sufficiently severe, or in which individual episodes are not
sufficiently prolonged, to justify a diagnosis of major depressive disorder. This depressed
mood occurs for most of the day, for more days than not, for at least 2 years (or at least 1
year in children and adolescents). During this 2-year period (1 year for children and
adolescents), depression-free intervals last no longer than 2 months. Accompanying the
chronically depressed mood, there are 2 (or more) of the following: appetite disturbance,
sleep disturbance, low energy, low self-esteem, poor concentration or difficulty making
decisions, and feelings of hopelessness. Episodes of Major Depressive Disorder may precede
Persistent Depressive Disorder, and Major Depressive Episodes may occur during Persistent
Depressive Disorder; in which case both are diagnosed. To be diagnosed, this disorder must
cause significant impairment in an individual's life, and not be due to Cyclothymic
Disorder, Bipolar Disorder, a psychotic disorder, Substance Use Disorder or another medical
condition.
Complications
In childhood, this disorder is often associated with impaired school performance and poor
social interaction. Children and adolescents with this disorder are usually irritable and
cranky as well as depressed. They have low self-esteem, poor social skills, and are
pessimistic.
Adults
with this disorder may be as impaired as those with Major Depressive Disorder.
Comorbidity
This disorder increases the risk for psychiatric comorbidity in general, and for Anxiety
Disorders and Substance Use Disorders in particular. Onset before age 21 of this disorder is
strongly associated with the following personality disorders: Borderline PD, Narcissistic
PD,
Antisocial PD, Avoidant, Dependent PD and Obsessive-Compulsive PD.
Associated Laboratory Findings
No laboratory test has been found to be diagnostic of this disorder.
Prevalence
The U.S. 12-month community prevalence is 0.5%. In adulthood, women are 2-3 times more
likely to develop this disorder than men.
Course
This chronic disorder usually has an early and insidious onset in childhood, adolescence or
early adult life. By definition, it has a chronic course. Personality Disorders and
Substance Use Disorders are more likely to be associated with this disorder if Persistent
Depressive
Disorder starts before age 21.
Outcome
In adults, up to 75% of individuals with this disorder will develop Major Depressive
Disorder within 5 years. The spontaneous recovery rate for this disorder is approximately
10% per year (which is much lower than that of Major Depressive Disorder). This recovery
rate is
significantly better with active treatment.
Familial Pattern
First-degree relatives of individuals with Persistent Depressive Disorder have increased
rates of Persistent Depressive Disorder and Major Depressive Disorder.
Controlled Clinical Trials Of Therapy
Click here for a list of all the controlled clinical trials of
therapy for this disorder.
Effective Therapy
The effectiveness of psychotherapy or pharmacotherapy for Persistent Depressive Disorder is
unknown because there are no randomized controlled trials of therapy. However, amongst
clinicians, there is a consensus that individuals with this disorder may respond to
psychotherapy, pharmacotherapy, or a combination of both. The medications that are effective
in treating Major Depressive Disorder are believed to be also effective in Persistent
Depressive Disorder. These individuals require a longer treatment period, more psychotherapy
sessions, and/or higher doses of antidepressant medication than do patients with acute forms
of depression. Treatment is less effective in elderly individuals with this disorder.
Although there are no randomized controlled trials, cognitive behavioral therapy (CBT),
interpersonal therapy (IPT), and cognitive behavioral analysis system of psychotherapy
(CBASP) are believed to be effective for the treatment of patients with this disorder. The
rate
of relapse/recurrence of symptoms has been shown to be reduced by long-term treatment with
antidepressant medication and with long-term use of specific psychotherapies.
Ineffective therapies
Vitamins,
dietary supplements and acupuncture are all ineffective for depressive disorders.
Lack Of Social Skills During Persistent Depressive Disorder
There are social skills that are essential for healthy social functioning. During persistent
depressive disorder, individuals lack the essential social skills of self-confidence,
optimism, belonging, and sociability.
These
are the same social skills that are lacking in individuals with major depressive disorder,
avoidant personality disorder and social anxiety disorder.
SOCIAL SKILL
MAJOR DEPRESSION
NORMAL
Self-Confidence
Feeling inferior or shy
Having a good opinion of one's self and abilities; socially confident
and out-going
Optimism
Pessimism or expecting the worst
Having a positive outlook on life; expecting a good outcome; hopeful
Belonging
Fearing rejection by others
Feeling liked and accepted by friends, and included in their group; not
fearing rejection
Sociality
Social withdrawal
Friendly; interested in social contacts and activities
A chronic depression of mood, lasting at least several years, which is not sufficiently
severe, or in which individual episodes are not sufficiently prolonged, to justify a
diagnosis of severe, moderate, or mild recurrent depressive disorder (F33.-).
This disorder represents a consolidation of DSM-IV-defined chronic major depressive
disorder and dysthymic disorder. An individual diagnosed with persistent depressive
disorder (dysthmia) needs to meet all of the following criteria:
Depressed mood for most of the day, for more days than not, as indicated either
by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration
must be at least 1 year.
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.
During the 2-year period (1 year for children or adolescents) of the
disturbance, the person has never been without the above symptoms for more than
2 months at a time.
Criteria for a major depressive disorder may be continuously present for 2
years.
There has never been a manic episode or a hypomanic episode, and criteria have
never been met for cyclothymic disorder.
The disturbance is not better explained by a persistent schizoaffective
disorder, schizophrenia, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.
The symptoms are not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g.,
hypothyroidism).
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Note: Because the criteria for a major depressive episode include four
symptoms that are absent from the symptom list for persistent depressive disorder
(dysthymia), a very limited number of individuals will have depressive symptoms that
have persisted longer
than
2
years but will not meet criteria for persistent depressive disorder. If full
criteria for major depressive episode have been met at some point during the current
episode of illness, they should be given a diagnosis of major depressive disorder.
Otherwise, diagnosis of
other
specified depressive disorder or unspecified depressive disorder is warranted.
Some individuals are constantly at war with themselves.
They believe: "I am stupid", "I am a failure", "Nothing goes right for me". They constantly
analyze themselves and their behavior for flaws. They are cynical and pessimistic. Because
of their gloomy, depressed or angry mood, they withdraw and socially isolate themselves.
This
lack of cooperation with others makes them feel even more hopeless, depressed or angry.
These individuals are at a high risk for developing Persistent Depressive Disorder or Major
Depressive Disorder. Healthy people are self-confident, optimistic, sociable, and feel
accepted and supported by friends. Individuals suffering from excessive self-blaming are
pessimistic,
socially withdrawn, and feel rejected by others.
If you suffer from excessive self-blaming; here are ways you can remedy this by learning
increased self-compassion and social cooperation:
Self-Confidence vs. Self-Blaming:
You must be kind towards yourself, instead of always blaming yourself for
everything. Accept and love yourself for who you are - with all your human
imperfections. You must strive to have a good opinion of yourself and your
abilities, and to be socially confident.
Quit
constantly comparing yourself to others.
Optimism vs. Pessimism:
Strive to replace your unrealistic, pessimistic, negative thinking with more
realistic, optimistic, positive thinking.
Sociality vs. Social Withdrawal:
In order to feel good, you have to do good. Thus to feel better, you have to get out
and help others (and remember to frequently smile).
Feeling Accepted vs. Feeling Rejected:
You can not control how other people behave towards you. All you can do is control
how you behave towards other people. Much of your life is not under your control;
hence you can not change it. You are only responsible for the small part of your
life which is
under
your
control - the part you can change. Thus remain friendly and out-going - especially
towards people that haven't accepted you.
Monitoring Your Progress
NOTE: When each of the following presentations finish; you must exit
by manually closing its window in order to return to this webpage.
The Healthy Social Behavior Scale lists social behaviors that research has
found to be associated with healthy social relationships. You can keep score (totaling its
4-point scale answers) on a separate piece of paper to monitor your progress.
The Mental Health Scale lists behaviors and symptoms that research has found
to be associated with mental health (or disorder). You can keep score (totaling its 4-point
scale answers) on a separate piece of paper to monitor your progress.
The Life Satisfaction Scale lists the survey questions often used to measure
overall satisfaction with life. You can keep score (totaling its 4-point scale answers) on a
separate piece of paper to monitor your progress.
This website uses these 5 major dimensions of human behavior (i.e., Agreeableness,
Conscientiousness, Openness/Intellect, Extraversion/Sociability, and Emotional
Stability) to describe all mental disorders. This website adds one more dimension,
"Physical Health", to create the "Big 6" dimensions of mental health.
The behaviors of the "Five Factor Model of Personality" represent five adaptive functions
that are vital to human survival. For example, when one individual approaches another, the
individual must: (1) decide whether the other individual is friend or foe [
"Agreeableness"
], (2) decide if this represents safety or danger [
"Emotional Stability"
], (3) decide whether to approach or avoid the other individual [
"Extraversion/Sociability"
], (4) decide whether to proceed in a cautious or impulsive manner [
"Conscientiousness"
], and (5) learn from this experience [
"Openness/Intellect"
].
"In physical science a first essential step in the direction of learning any
subject is to find principles of numerical reckoning and practicable methods for
measuring some quality connected with it. I often say that
when you can measure what you are speaking about and express it in
numbers you know something about it; but when you cannot measure it,
when you cannot express it in numbers, your knowledge is of a meagre and
unsatisfactory kind: it may be the beginning of knowledge,
but you have scarcely, in your thoughts, advanced to the stage of science,
whatever the matter may be."
Lord Kelvin (1824 – 1907)
The best
summary on bad research is given by Laura Arnold in this TEDx lecture.
If you read nothing else about research, you owe it to
yourself to watch this short video - it is excellent!
The active placebo effect: 2300 years ago, the Greek Stoic philosophers
taught that it is not the objective event, but our subjective
judgment about the event, that determines our behavior. The active placebo
effect bears witness to this ancient wisdom.
Randomized Controlled Trial:
Ask: Was the trial randomized? Was the randomization
procedure described and was it appropriate?
The best research design is to have research subjects randomly assigned
to an experimental or control group. It is essential that confounding
factors be controlled for by having a control group or comparator condition
(no intervention, placebo, care as usual etc.).
Representative Sample:
Ask: Do the research subjects represent a normal
cross-section of the population being studied?
Many psychological research studies using university students are
flawed because their subjects are not representative of the normal
population since they are all W.E.I.R.D. (White, Educated, Intelligent,
Rich, and living in a Democracy).
Single Blind Trial:
Ask: Was the treatment allocation concealed?
It is essential that the research subjects are kept "blind" as to
whether they are in the experimental or control group (in order to control
for any placebo effects).
Double Blind Trial (Better Than Single Blind Trial):
Ask: Were blind outcome assessments conducted?
In a double blind study, neither the research subjects nor the outcome
assessors know if the research subject is in the experimental or control
group. This controls for both the placebo effect and assessor bias.
Baseline Comparability:
Ask: Were groups similar at baseline on prognostic
indicators?
The experimental and control groups must be shown to be comparable at
the beginning of the study.
Confounding Factors:
Ask: Were there factors, that weren't controlled for,
that could have seriously distorted the study's results?
For example, research studies on the effectiveness of mindfulness cognitive therapy in
preventing depressive relapse forgot to control for whether the research
subjects were also simultaneously receiving antidepressant medication or
other psychological treatments for depression.
Intervention Integrity:
Ask: Was the research study protocal strictly
followed?
The research subjects must be shown to be compliant (e.g., taking their
pills, attending therapy) and the therapists must be shown to be reliably
delivering the intervention (e.g., staying on the research protocol).
Statistical analysis:
Ask: Was a statistical power calculation described?
The study should discuss its statistical power analysis; that is
whether the study size is large enough to statistically detect a difference
between the experimental and control group (should it occur) and usually
this requires at least 50 research subjects in the study.
Ask: Are the results both statistically
significant and clinically significant?
Many medical research findings are statistically significant
(with a p-value <0.05), but they are not clinically significant
because the difference between the experimental and control groups is
too small to be clinically relevant.
For example, the effect of a
new drug may be found to be 2% better than placebo. Statistically (if
the sample size was large enough) this 2% difference could be
statistically significant (with a p-value <0.05). However,
clinicians would say that this 2% difference is not
clinically significant (i.e., that it was too small to really
make any difference).
Statistically, the best way to test for
clinical significance is to test for effect size (i.e., the
size of the difference between two groups rather than confounding
this with statistical probability).
When the outcome of
interest is a dichotomous variable, the commonly used measures of
effect size include the odds ratio (OR), the relative risk (RR), and
the risk difference (RD).
When the outcome is a continuous
variable, then the effect size is commonly represented as either the
mean difference (MD) or the standardised mean difference (SMD)
.
The MD is the difference in the means of the treatment
group and the control group, while the SMD is the MD divided by the
standard deviation (SD), derived from either or both of the groups.
Depending on how this SD is calculated, the SMD has several versions
such, as Cohen's d, Glass's Δ, and Hedges' g.
Clinical Significance: With Standard Mean Difference, the
general rule of thumb is that a score of 0 to 0.25 indicates
small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate
to large benefit, and above 1.0 a huge benefit. It is a
convention that a SMD of
0.5
or larger is a standard threshold for clinically
meaningful benefit.
The statistical summary
should report what percentage of the total variance of the dependent
variable (e.g., outcome) can be explained by the independent
variable (e.g., intervention).
In clinical studies, the study
should report the number needed to treat for an additional
beneficial outcome (NNTB), and the number needed to treat for
an additional harmful outcome (NNTH).
Number Needed To Benefit (NNTB): This is defined as the
number of patients that need to be treated for one of them to
benefit compared with a control in a clinical trial. (It is
defined as the inverse of the absolute risk reduction.)
Note: Statistically, the NNTB depends on which control group is used for
comparison - e.g., active treatment vs. placebo
treatment, or active treatment vs. no
treatment.
Number Needed To Harm (NNTH): This is
defined as the number of patients that need to be treated for
one of them to be harmed compared with a control in a clinical
trial. (It is defined as the inverse of the absolute increase in
risk of harm.)
Ask: Does the researcher accept full
responsibility for the study's statistical analysis?
The researcher should not just hand over the study's raw
data to a corporation (that may have $1,000 million invested in the
study) to do the statistical analysis.
Completeness of follow-up data:
Ask: Was the number of withdrawals or dropouts in each
group mentioned, and were reasons given for these withdrawals or
dropouts?
Less than 20% of the research subjects should drop out of the study.
The intervention effect should persist over an adequate length of time.
Handling of missing data:
Ask: Was the statistical analysis conducted on the
intention-to-treat sample?
There must be use of intention-to-treat analysis (as opposed to a
completers-only analysis). In this way, all of the research subjects that
started the study are included in the final statistical analysis. A
completers-only analysis would disregard those research subjects that
dropped out.
Replication of Findings:
Ask: Can other researchers replicate this study's
results?
The research study's methodology should be clearly described so that
the study can be easily replicated. The researcher's raw data should be
available to other researchers to review (in order to detect errors or
fraud).
Fraud:
Ask: Is there a suspicion of fraud?
In a research study, examine the independent and dependent variables
that are always measured as a positive whole number (e.g., a variable
measured on a 5-point Likert-type scale ranging from "1 = definitely
false to 5 = definitely true" etc.). For each of these
variables, look at their sample size (
n
), mean (
M
) and standard deviation (
SD
) before they undergo statistical analysis. There is a high suspicion of
fraud in a study's statistics:
If the M is mathematically impossible (online
calculator): This is one of the easiest ways to
mathematically detect fraud. The mean (
M
) is defined as "the sum (
Sum
) of the values of each observation divided by the total number
(
n
) of observations". So:
M
=
Sum
/
n
. Thus: (
Sum
) = (
M
) multiplied by (
n
). We know that, if a variable is always measured as a positive
whole number, the sum of these observations always has to be a whole
number. For these variables to test for fraud: calculate (
M
) multiplied by (
n
). This calculates the
Sum
which MUST be a positive whole number. If the calculated
Sum
isn't a positive whole number; the reported mean (
M
) is mathematically impossible - thus the researcher either
cooked the data or made a mistake. A recent study of 260 research papers
published in highly reputable psychological journals found that
1 in 2 of these research papers reported at
least one impossible value
, and 1 in 5 of these research papers reported multiple
impossible values. When the authors of the 21 worst offending
research papers were asked for their raw data (so that its
reliability could be checked) - 57% angrily refused. Yet such
release of raw data to other researchers is required by most
scientific journals. (Here is an example of a research paper filled with mathematically
impossible means.)
If the SD is mathematically impossible (online
calculator): When researchers fraudulently "cook" their
data, they may accidently give their data a mean and standard
deviation that is mathematically impossible.
If the
SD/M is very small
(i.e., the variable's standard deviation is very small compared
to the mean suggesting data smoothing).
If the
SD's are almost identical
(i.e., the variables have different means but almost identical
standard deviations).
If the 4th digit of the values of the variables aren't uniformly
distributed - since each should occur 10% of the time (Benford's Law).
If the researcher is
legally prevented from publishing negative
findings
about a drug or therapy because that would violate the
"nondisclosure of trade secrets" clause in the research contract
(i.e., it is a "trade secret" that the drug or therapy is
ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical
trials fail to publish their results.
If the
researcher refuses to release his raw data to
fellow researchers
(so that they can check its validity). In order to be published
in most scientific journals, a researcher must promise to share his
raw data with fellow researchers. Thus a researcher's refusal to do
so is almost a sure indicator of fraud.
If the
research study's data contradicts the study's
own conclusions
- surprisingly, this often occurs.
Calling Bullshit
In The Age of Big Data - "Bullshit is language, statistical figures,
data graphics, and other forms of presentation intended to persuade by
impressing and overwhelming a reader or listener, with a blatant disregard for
truth and logical coherence." Reading the syllabus of this university course
should be required reading for every student of mental health. This syllabus is
absolutely fantastic!
Major pharmaceutical company fined $3 billion US for making
false claims - (text and video) [Editor: This is an
example of how a major pharmaceutical company purposely produced fraudulant
research in order to increase its sales.] In 2001, GlaxoSmithKline, the
manufacturer of the antidepressant Paxil, published research that falsely
claimed that Paxil was effective in the treatment of adolescent
depression. This claim and others were found to be fraudulant, and in 2012
GlaxoSmithKline was fined $3 billion
US in court settlements. Subsequent independent reanalysis of the
original Paxil research data clearly proved that the original study was fraudulant. This fraudulant research
paper was published in a top psychiatric journal, and has never been retracted
or corrected.
A randomized clinical
trial of a brief, problem-focused couple therapy for depression. (2010)
"Results showed a significant effect of treatment in reducing women's depressive
symptoms, with 67% of women
improved and 40% to 47% recovered at follow-up, compared to only 17% improved
and 8% recovered among women in the control group. Treatment was also effective
in secondarily improving women's marital satisfaction, reducing husbands' levels
of psychological
distress and
depression-specific burden, and improving both partners' understanding and
acceptance of depression."
A comparative trial of
psychotherapy and pharmacotherapy for "pure" dysthymic patients. (2005)
"This article reports outcomes of an acute randomized trial of 94 subjects
treated for 16 weeks with either
interpersonal psychotherapy (IPT), brief supportive psychotherapy (BSP),
sertraline, or sertraline plus IPT... Response rates were 58% for sertraline
alone, 57% for combined treatment, 35% for IPT, and 31% for BSP."
A comparison of active
drugs for the treatment of dysthymia. (2003) "All studied drugs promoted
similar clinical responses, although with different side effect profiles. The
evidence for TCAs and SSRIs
was the
most robust, considering the number of trials and participants."
Benefits and risks of
pharmacotherapy for dysthymia: a systematic appraisal of the evidence.
(2003) "Regarding placebo-controlled trials (n = 16), similar results were
obtained in terms of efficacy for
different groups of drugs, such as tricyclic antidepressants (TCAs) [NNT= 4.3],
selective serotonin reuptake inhibitors (SSRIs) [NNT= 5.1], monoamine oxidase
inhibitors (MAOIs) [NNT= 2.9]. In general, patients treated with a TCA were more
likely to report
adverse
events, compared with placebo and SSRIs."
Treatment of dysthymia and
minor depression in primary care: a randomized trial in patients aged 18 to
59 years. (2001) "This was an 11-week randomized placebo-controlled
trial conducted in primary care
practices. Paroxetine (n=80) or placebo (n=81) therapy was started at 10 mg per
day and increased to a maximum 40 mg per day, or Problem-Solving Treatment for
Primary Care (PST-PC) was provided (n=80). There were 6 scheduled visits for all
treatment
conditions. For
dysthymia the remission rate for paroxetine (80%) and PST-PC (57%) was
significantly higher than for placebo (44%).
A comparison of drugs
versus placebo for the treatment of dysthymia. (2000) Regarding
placebo-controlled trials (n = 15), "similar results were obtained in terms of
efficacy for different groups of
drugs, such as tricyclic antidepressants (TCAs) [NNT= 4.3], selective serotonin
reuptake inhibitors (SSRIs) [NNT= 4.7], monoamine oxidase inhibitors (MAOIs)
[NNT= 2.9]. Drugs are effective in the treatment of dysthymia with no
differences between and within
class of
drugs. Tricyclic antidepressants are more likely to cause adverse events and
dropouts."
Treatment of dysthymia and
minor depression in primary care: A randomized controlled trial in older
adults. (2000) "Patients were randomly assigned to receive paroxetine (n
= 137) or placebo (n = 140),
starting
at 10 mg/d and titrated to a maximum of 40 mg/d, or problem-solving
treatment-primary care (PST-PC; n = 138). For the paroxetine and placebo groups,
the 6 visits over 11 weeks included general support and symptom and adverse
effects monitoring; for the PST-PC
group,
visits were for psychotherapy. For dysthymia, paroxetine improved mental health
functioning vs placebo among patients whose baseline functioning was high or
intermediate. Mental health functioning in dysthymia patients was not
significantly improved by PST-PC
compared
with placebo."
The long-term outcome of
dysthymia in private practice: clinical features, temperament, and the art
of management. (1999) "The highest level of adaptive functioning was
observed among fluoxetine-treated
dysthymics (50% of responders [N = 12] achieved DSM-III-R GAF score of 81-90).
Of TCA-treated patients, 39% had intolerable side effects, necessitating
switch-over to fluoxetine. Agitation occurred in 11% of fluoxetine-treated
patients (N = 4) and was
associated with
nonresponse and/or dropout; otherwise, this selective serotonin reuptake
inhibitor was well tolerated, thereby contributing to long-term compliance. More
provocatively, patients with dysthymia who had required extensive
psychotherapeutic attention prior to
state-of-the-art pharmacotherapy no longer required such therapy."
Controlled efficacy study
of fluoxetine in dysthymia. (1997) "After three months of treatment,
response was seen more frequently in the fluoxetine group (42/72) than in the
placebo group (14/39, P < 0.0001). Improved patients at 3 months were still
improved at 6 months. Furthermore, 50% of the nonresponders at 3 months
improved and rated as responders at 6 months, after fluoxetine was increased
to 40 mg daily."
Community-integrated
home-based depression treatment in older adults: a randomized controlled
trial. (2004) "Patients were randomly assigned to the Program to
Encourage Active, Rewarding Lives for
Seniors
(PEARLS) intervention (n = 72) or usual care (n = 66). The PEARLS intervention
consisted of problem-solving treatment, social and physical activation, and
potential recommendations to patients' physicians regarding antidepressant
medications. At 12 months,
compared
with the usual care group, patients receiving the PEARLS intervention were more
likely to achieve complete remission from depression (36% vs 12%)."
No evidence of effectiveness:
Randomized, double-blind,
placebo-controlled trial of fluoxetine treatment for elderly patients with
dysthymic disorder. (2005) "Fluoxetine had limited efficacy in elderly
dysthymic patients. In the
intent-to-treat sample, response rates were 27.3% for fluoxetine and 19.6% for
placebo. The clinical features of elderly dysthymic patients are typically
distinct from those of dysthymic disorder in young adults, and the findings
suggest that treatments
effective for young adult dysthymic patients may not be as useful in elderly
dysthymic patients."
Treatment of primary
dysthymia with group cognitive therapy and pharmacotherapy: clinical
symptoms and functional impairments. (1999) "Treatment with sertraline,
with or without group cognitive behavior
therapy, reduced the functional impairment of depression. The reductions were
similar in the drug-cognitive therapy group and in subjects who received the
drug alone. Furthermore, while group cognitive behavior therapy alone reduced
the depression scores, this
effect
was not significantly greater than the effect of the placebo."
This website uses these 5
major dimensions of human behavior to describe all mental disorders. (This website adds
one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.)
The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that
are vital to human survival. For example, when one individual approaches another, the individual
must: (1) decide whether the other individual is friend or foe [
"Agreeableness"
], (2) decide if this represents safety or danger [
"Emotional Stability"
], (3) decide whether to approach or avoid the other individual [
"Extraversion/Sociability"
], (4) decide whether to proceed in a cautious or impulsive manner [
"Conscientiousness"
], and (5) learn from this experience [
"Openness/Intellect"
].
Which "Big 6" Dimensions of Mental Health are Impaired in Persistent Depressive
Disorder?
THE POSITIVE SIDE OF THE "BIG 6" DIMENSIONS OF MENTAL HEALTH
THE NEGATIVE SIDE OF THE "BIG 6" DIMENSIONS OF MENTAL HEALTH
THIS DISORDER
Agreeableness Being kind and honest.
Antagonism Being unkind or dishonest.
Conscientiousness Being diligent and self-disciplined.
Disinhibition Being distractible,
impulsive, or undisciplined.
Openness/Intellect Showing good creativity, problem-solving, and learning ability
Impaired Intellect Showing decreased creativity, problem-solving, or learning ability.
Extraversion Being gregarious, assertive and
enthusiastic.
Detachment Being detached,
unassertive, and unenthusiastic.
Emotional Stability Being emotionally stable and calm.
Emotional Distress Being emotionally unstable/distressed.
Emotional Distress
Physical Health Being physically fit and healthy.
Physical Symptoms Being physically unfit or ill.
Physical Symptoms
The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder
The problems that
are characteristic of this disorder are highlighted with this pink
background color.
EMOTIONAL STABILITY VS. EMOTIONAL DISTRESS
EMOTIONAL STABILITY (Stability)
Description:
Emotional Stability is synonymous with stability and
calm. The Emotional Stability dimension measures the
behaviors that are central to the concept of COURAGE - having calm
composure and endurance when confronting adversity. Individuals with high
Emotional Stability are relatively tough, brave, and insensitive to
physical pain, feel little worry even in stressful situations, and have
little need to share their concerns with others. High Emotional
Stability is associated with better: longevity, leadership, job
[team] performance, and marital success. (This dimension appears to measure
the behaviors that differentiate safety from danger.)
Descriptors:
Calm, rarely angry, rarely depressed or moody, rarely anxious or
embarrassed.
Language Characteristics: Pleasure talk, agreement, compliment,
low verbal productivity, few repetitions, neutral content, calm, few self-references, many short
silent pauses, few long silent pauses, many tentative words, few aquiescence, little
exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
EMOTIONAL
DISTRESS (Impaired Stability)
Description:
Emotional Distress is synonymous with emotional volatility and negative emotion.
Individuals with high emotional volatility are easily upset or angered. They often are very
moody and emotionally labile. Individuals that have high negative emotion exhibit
over-sensitivity to threat or stress. They exhibit excessive fear, anxiety, depression, or
irritability.
ICD-11 Description:
The core feature of the Emotional Distress (or Negative Affectivity) trait domain is the
tendency to experience a broad range of negative emotions. Common manifestations of Emotional
Distress include: experiencing a broad range of negative emotions with a frequency and
intensity out of proportion to the situation; emotional lability and poor emotion regulation;
negativistic attitudes; low self-esteem and self-confidence; and mistrustfulness.
Descriptors:
Easily upset, angry, depressed, moody, anxious, embarrassed.
Evolution:
All animals have evolved a "fight or flight" response to threat to ensure their survival.
Mammals went one step further and evolved a "fight, flight, or freeze" response to threat. In
humans, this mammalian "freeze" response to threat involves inhibition of behavior in response to
threat, punishment, and emotional distress. This threat response of "freezing", shutting down or
passively avoiding is commonly seen in human anxiety or depression (e.g., freezing with fear or
being immobilized by indecision, worry or depression). Language Characteristics: Problem talk, dissatisfaction, high verbal
productivity, many repetitions, polarised content, stressed, many self-references, few short silent
pauses, many long silent pauses, few tentative words, more aquiescence, many self references,
exaggeration, frustration, high concreteness. Screening Questions:
"I worry about almost everything."
"I get emotional easily, often for very little reason."
"I fear being alone in life more than anything else."
"I get stuck on one way of doing things, even when it’s clear it won’t work."
"I get irritated easily by all sorts of things."
Research:
Lower scores on Emotional Stability are associated with unhappiness, dysfunctional
relationships, and mental health problems. *MRI research found that Low Emotional Stability
(= Emotional Distress or Neuroticism) was associated with increased volume of brain regions
associated with threat, punishment, and emotional distress.
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."