8.1: Major Depressive Disorder
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Source: Winnie the Pooh (TV Show, 1966)
Eeyore is an older gray donkey. There are no documents indicating the exact age or specified background information, and he chooses not to share this information. Eeyore does not have an occupation. His health compared to other donkeys is slightly underweight, but slender. He chooses not to share his family background. One main difficulty Eeyore has elaborated on is his detachable tail, which seems to cause him several problems. He has indicated that his goals are to remain strong for his friends despite his lack of confidence within himself, and as a result he often feels lonely without support from others that he is close to. Some forms of coping mechanisms include trying to feel useful in the presence of others and also trying his best to find pleasure in life.
Description of the Problem
Eeyore constantly insists that his tail falls off rather frequently. Eeyore’s posture typically involves a slumped head, droopy eyes, and commonly says “thanks for noticing me.” Sluggish movement is also apparent, without any physical cause for movement delay. He seems to step on his tail often and fall down. Eeyore indicates that sometimes it seems that even his close friends do not need him. Around friends, he typically makes comments about his relative unimportance and travels near the back of the pack. He also stated that although he tries to force a smile, a real smile has not existed in a long time, even though others try to cheer him up. He often feels empty even when accompanied by friends. Eeyore also seems to experience a loss of energy throughout the day, although sleeping habits are not explicitly expressed.
296.2x Major Depressive Disorder, Single Episode
Eeyore exhibits five symptoms of a major depressive episode, and has also experienced these for several years, therefore meeting full criteria. Criteria met include depressed mood most of the day, markedly diminished interest or pleasure in activities, fatigue or loss of energy nearly every day, feelings of worthlessness, and diminished ability to think or concentrate were indicated. Overall, Eeyore exhibits severe clinical major depression without psychotic features. Further diagnosis will be needed to determine catatonic, melancholic, or atypical features as details are limited at this point. Postpartum onset is not a factor.
Accuracy of Portrayal
Eeyore is a character that displays a relatively accurate example of major depressive disorder. One major issue with the character portrayed is his consistent involvement with a support group. A lack of interest in activities is common with this disorder, causing most persons with depression to not frequently spend time with others. This is in contrast to Eeyore, who seems to be surrounded by friends much of the time. Also, his support groups seems rather sarcastic at times, as well as exhibiting their own issues so it may be hard to diagnose if environmental factors may prolong the depression longer than it may otherwise last. Some would argue that this may be closer to a diagnosis of Dysthymia, but since Eeyore seems to exhibit more severe symptoms closer to major depression and each season of the show lasts less than two years, it is hard to fully identify a long term timespan of his disorder.
Although various treatments exists, I would recommend cognitive behavioral therapy, and possibly electroconvulsive therapy if CBT does not work alone. Since donkeys have not been tested with medication normally given to persons suffering from depression, I would not advise any type of tricyclics, MAO inhibitors, or SSRIs be used. Regarding cognitive behavioral therapy, it is important that Eeyore first understands the relationship between events, emotions, and cognitions. As mentioned, he must first realize that if his tail falls off that he is not less of an individual. Furthermore, he must also realize that the need to be of worth can be self-induced and that he does not need to rely on others to find this feeling. Treatment would then be followed by instructing Eeyore on identifying, evaluating, and modifying automatic negative though patterns that exist. He acknowledges his feelings of worthlessness, but also having the tools to evaluate his negative thoughts as something he can control should enable him to eventually take control over his thoughts. Stress management, social skills, and activities training will then follow to give Eeyore a path to improve his well-being by being able to optimally connect with others and join in on activities that spark his interests.
Name: Anthony Soprano, Jr.
Source: The Sopranos (television series, 1999-2005)
Anthony Soprano, Jr., referred to as A.J., is a male born on July 15, 1986 to Anthony and Carmela Soprano. The family is of Italian decent and they live in New Jersey. From a very young age, A. J. had disciplinary problems in school and a possible learning disability. After extensive testing and meeting with school counselors, he was deemed to be suffering from Attention-Deficit Hyperactivity Disorder.
It was very obvious throughout the various seasons that A. J. had a strong family history of multiple psychiatric disorders. His father was diagnosed with depression from the beginning of the series. He was on medication and would see a therapist regularly. In addition, his father had antisocial personality disorder and panic disorder without agoraphobia. His father was involved in organized crime, which caused strains on his parents’ relationship. Due to these marital issues between his parents, A. J. would often act out during their period of separation and possible divorce. As A. J. got older, his father insisted on him becoming more responsible and not a failure in life. As a way to make A. J. more productive, his father got him a job at a construction site. A. J. started the job and was doing well. He met a Puerto Rican girl named Blanca at the construction site and they started dating.
The two became really close, and A. J. eventually proposed to Blanca. After some reconsideration, she decided that A. J. was not right for her and broke up with him. This is when he became depressed. A. J. continued to work at the construction site for some time, but the site of Blanca talking to other men became too much for him, so he eventually quit. Just as things seemed like they would never improve, A. J. met some childhood friends whose fathers were also in the Mafia with his father.
He started hanging out with them and seemed to be improving. He also began seeing a therapist and was prescribed Prozac. He improved to the point that he even began to take some college courses. However, these new friends turned out to be a bad influence. They were running some illegal gambling on campus and would use violence to collect money. A. J. did not seem to be affected by this, but when they badly beat up an African American student, this sent A. J. spiraling down once again.
Description of the Problem
After the breakup with Blanca, A. J. started sleeping all the time and would not come out of his room. He had a decreased appetite and anhedonia. He seemed to lack energy for quite some time. There were no suicidal ideations initially. After the African-American student incident, he again confined himself to his room and developed similar symptoms to what he was displaying after his break up with Blanca. It progressed to the point that he attempted to kill himself by tying a plastic bag around his face, wrapping a cinder block around his leg, and jumping in the pool while his parents were out of the house. Luckily, his father came home and saved him prior to there being any significant damage. A. J. was admitted to an inpatient psychiatric facility and received the therapy he needed.
The diagnosis for A. J. Soprano is Major Depressive Disorder (recurrent), 296.3x. According to the DSM-IV-TR, the following are eight of nine criteria that are met for the diagnosis:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
- A. J. exhibits a depressed mood consistently for at least two weeks in both of his major depression episodes.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
- A. J.’s mother noticed that he quit attending his job at the pizza parlor, even though he used to enjoy working there.
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
- A. J.’s mother would constantly cook different things that A. J. used to enjoy before his decrease in appetite, but none of the things she cooked seemed appealing to him.
- Insomnia or hypersomnia nearly every day
- A. J. could be seen sleeping throughout most of the day due to his depression.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- This is the only criterion that does not pertain to A. J.
- Fatigue or loss of energy nearly every day
- A. J. appeared to be tired at all times of the day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
- After Blanca broke up with him, A. J. appeared to have feelings of worthlessness.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
- A. J. stopped attending his college classes due to his inability to concentrate.
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
- A. J. actually attempts suicide, but failed to drown himself.
- Longitudinal Course Specifiers (With and Without Interepisode Recovery)
A. J. displays interepisode recovery between his two major depressive episodes, making his a case of major depressive disorder, recurrent.
Accuracy of Portrayal
The average person watching A. J. on the Sopranos would receive an accurate portrayal of Major Depressive Disorder (recurrent). He displays a majority of the symptoms for the disorder in both episodes he has had. These breaks of normalcy between the two episodes are crucial in understanding major depression episodes, especially when the depression is recurrent. Major Depressive Disorder is highly heritable, so watching A. J.’s father, who also displays signs of depression, helps to understand some of the genetic influence on depression.
Proper treatment of A. J.’s Major Depressive Disorder would, given his severe symptom levels, include beginning with antidepressant medication. Psychotherapy might also be added in A. J. case in order to increase effectiveness of treatment. It does not seem that electroconvulsive therapy would be necessary in A. J.’s case since he does not exhibit psychotic symptoms or catatonia.