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

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 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)