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Diagnosis and classification in
mood disorders
Dr Lenny Cornwall
Honorary Senior Lecturer in Psychiatry
University of Newcastle upon Tyne
Dr Sharon Beattie
Medical Education Teaching Fellow and Honorary Specialty Registrar
TEWV NHS Foundation Trusts
MRCPsych course year 1
Affective disorders module
Mood syndromes
Mania
M
Hypomania
m
Depression
D
Depressive symptoms
d
Mood disorders
DD unipolar major depression
Dd unipolar major depression
MD bipolar I
Md bipolar I
Dm bipolar II, bipolar NOS
md cyclothymia
dd dysthymia
Diagnosis of MDD
Diagnosis of exclusion
rule out 20 depression
usually no family history, no past history
older age of onset
rule out bipolar disorder
Unipolar / bipolar distinction
age on onset
duration of episode
genetics
antidepressant prophylaxis
symptomatology
response to treatment
pre-morbid personality
Bipolar disorder
Young and Klerman subtypes (1992)
Bipolar I
depression and mania
Bipolar II depression and hypomania
Bipolar III cyclothymia
Bipolar IV antidepressant induced mania
Bipolar V depression with FH bipolar
Bipolar VI unipolar mania
Bipolar spectrum disorder
DSM-IV definition of hypomania - symptoms of elation
lasting 4 days but with no functional impairment.
Bipolar II disorder has prevalence of 0.5%.
Reduce criteria for hypomania to 2 days and
prevalence rises to 5.5%.
Softening criteria further increases the rate of bipolar
diagnoses to 50% of ‘unipolar’ cases of depression
Mood Disorder Questionnaire
Screens for Bipolar Spectrum Disorder
Positive screen
7 or more out of 13 items from
elation, irritability, self confidence, needing less sleep, more talkative,
racing thoughts, distractible, ↑energy
symptoms occurring concurrently
moderate or serious level of problem
Depression
Affect
transient state
Mood
pervasive state
Syndrome
longer duration, associated symptoms
Small group task
List diagnostic categories in which a depressive
syndrome can occur.
Depressive syndrome
Organic depressive disorder (F06.32)
Substance induced mood disorder (F1x.54)
Schizoaffective disorder (F25.1)
Bipolar disorder (F31.3)
Depressive episode (F32)
Recurrent depressive disorder (F33)
Dysthymic disorder (F34.1)
Mixed anxiety and depressive disorder (F41.2)
Adjustment disorder (depressed) (F43.21)
Emotionally unstable personality disorder (F60.3)
Determinants of differential diagnosis of
depression
Aetiology
organic depressive disorder
substance induced
adjustment disorder, depressed
emotionally unstable personality disorder
Course
schizoaffective disorder
bipolar disorder
Clinical features
dysthymic disorder
mixed anxiety and depressive disorder
Depressive subtypes
DSM-IV
severity, psychotic, remission specifiers
chronic episode
melancholic, catatonic or atypical features
seasonal pattern
post-partum onset
ICD-10
severity: mild, moderate, severe
somatic syndrome
psychotic symptoms
DSM-IV melancholia
anhedonia OR unreactivity
plus 3 of
distinct quality
DMV
EMW
retardation / agitation
weight loss
guilt
ICD-10 somatic type
At least 4 of
anhedonia
unreactivity
EMW
DMV
retardation / agitation
weight loss
loss of libido
The first description of types of
depression – the start of the depression
debate?
St Paul, 2 Corinthians 7:10
“For godly sorrow worketh repentance to salvation not
to be repented of, but the sorrow of the world worketh
death”
depression from God (inexplicable / endogenous)
depression of the world (reactive / exogenous)
The Depression debate
The three principle models are argued for on basis of presumed
number of types: one (unitarian), two (binary model) & many
(depression spectrum).
Arguably dates back to St Paul’s original comment in the bible –
endogenous vs exogenous, the binary model.
1926 British psychiatrist Mapother proposed – both ‘psychotic’ &
‘neurotic’ forms are on spectrum of one type of depression.
Study by Lewis in 1930s seemed to support unitarian view
1973 influential paper by Akiskal & McKinney again supporting the
Unitarian view
Evidence/discussion proposing alternative
classification
Paykel (1971)
Parker (2000)
Paykel (1971)
Article in British Journal of Psychiatry
165 depressed patients were subjected to special
cluster analysis for classifying people
Cluster analysis from heterogeneous sample identified
4 groups
psychotic / endogenous depression
anxious “neurotic” depression
younger, hostile patients
younger patients with personality disorder
Parker (2000)
psychotic melancholic
may deny / minimise depressed mood
constipation common
good response to ECT
non-psychotic melancholic
observed psychomotor disturbance
non-melancholic
hostile subtype
externalise anxiety, cluster B personality
anxious subtype
internalise anxiety, cluster C personality
better response to SSRIs
Parkers hierarchical model
Parker’s schematic model
Using Parker’s model in practice
1. Is a depressive disorder present?
1. symptoms, duration, severity
2. If yes, what is the likely subtype?
1. unipolar
1.
psychotic: presence of psychotic symptoms
2.
melancholic: presence of psychomotor disturbance
3.
non-melancholic: by default
1.
2.
2. bipolar
distal / proximal stressors
hostile / anxious personality style
Why challenge/change the Unitarian
Paradigm
If this is flawed concept then this has impact on:
Research (esp neurobiological research)
Treatment Utility
If different subtypes exist this could have treatment
specific implications
If it is correct then we need to develop a more
sophisticated understanding
DSM V & ICD 11
Latest evidence to inform changes
Co-morbidity studies in
USA
Netherlands
Australia
DSM V
final version due May 2013
Proposed revisions available at www.dsm5.org
ICD-11
11th revision due by 2015
Krueger (1999)
Is co-morbidity noise or signal?
noise – try to avoid and seek pure cases of disorder
signal – an indication that current diagnoses are inadequate
US national co-morbidity survey (n = 8098)
diagnostic data analysed by factor analysis for 10
common mental disorders, including depression
3 factor model best fit:
internalising disorders – anxious / misery
internalising disorders – fear
externalising disorders
Copyright restrictions may apply.
Vollebergh et al (2001)
Netherlands mental health survey (n = 7076)
latent structure of 9 DSM-III-R disorders
3 dimensional model had best fit
substance misuse disorders
mood disorders
depression, dysthymia, GAD
anxiety disorders
panic disorder, agoraphobia, simple phobia, social phobia
Slade & Watson (2006)
Australian co-morbidity survey (n = 10641)
best model to fit 10 common mental disorders
3 factor model
internalising disorders – distress factor
major depression, GAD, PTSD, neurasthenia
internalising disorders – fear factor
panic disorder, agoraphobia, OCD
externalising disorders
alcohol & drug misuse
replicates findings of Krueger
A new proposal for DSM V & ICD 11
Andrews, Goldberg, Krueger et al (2009)
Neuro-cognitive disorders
neural substrate abnormalities
Neuro-developmental disorders
early & continuing cognitive deficits
Psychotic disorders
biomarkers for information processing deficits
Emotional disorders
temperamental antecedent of negative emotionality
Externalising disorders
temperamental antecedent of disinhibition
“By three methods we may learn
wisdom: first by reflection, which
is the noblest; second by
imitation, which is the easiest;
and third by experience, which is
the bitterest”
(Confucius, 551 – 479 BC)