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)