Diagnosis and classification in mood disorders
Dr Lenny CornwallHonorary 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 syndromesMania M
Hypomania m
Depression D
Depressive symptoms d
Mood disordersDD unipolar major depression
Dd unipolar major depression
MD bipolar I
Md bipolar I
Dm bipolar II, bipolar NOS
md cyclothymia
dd dysthymia
Diagnosis of MDDDiagnosis of exclusion
rule out 20 depression
usually no family history, no past history
older age of onset
rule out bipolar disorder
Unipolar / bipolar distinctionage on onset
duration of episode
genetics
antidepressant prophylaxis
symptomatology
response to treatment
pre-morbid personality
Bipolar disorderYoung and Klerman subtypes (1992)
Bipolar I depression and mania
Bipolar IIdepression and hypomania
Bipolar III cyclothymia
Bipolar IV antidepressant induced mania
Bipolar V depression with FH bipolar
Bipolar VI unipolar mania
Bipolar spectrum disorderDSM-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 QuestionnaireScreens 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
DepressionAffect
transient state
Mood pervasive state
Syndrome longer duration, associated symptoms
Small group taskList diagnostic categories in which a depressive
syndrome can occur.
Depressive syndromeOrganic 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 subtypesDSM-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 melancholiaanhedonia OR unreactivity
plus 3 of distinct quality
DMV
EMW
retardation / agitation
weight loss
guilt
ICD-10 somatic typeAt 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 debateThe 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 practice1. 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. distal / proximal stressors
2. hostile / anxious personality style
2. bipolar
Why challenge/change the Unitarian ParadigmIf 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 11Latest 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
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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 11Andrews, 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)