Lecture 3 - Classification of Affective Disorders Flashcards
Give some historical perspective on the classification of bipolar disorder
Esquirol, 1838 - Alternating mania & melancholia
Falret, 1851 - Folie circulaire
Kraepelin, 1899 - Manic-depressive insanity
Kleist 1937, 1953 - Bipolar Psychoses
Neele 1949 - Unipolar Psychoses
Since 1966 - Bipolar Disorders & Depressive DIsorders
Comment on some strength’s & weakness of diagnosis in psychiatric/affective disorders
Strength’s:
- Good reliability in research setting
- No better classification system has been devised yet
- Diagnostic criteria now hold operational criteria
- Allows communication to patients/clinicians
Con’s:
- Are the categories valid given variable presentations (heterogeneity) & pleitropy (one gene producing two phenotypes)
- Devised a long time ago - outdated
Outline the hierarchy of diagnosis in Psychiatry (from first to be considered to last to be considered)
Organic disorders Psychotic disorders (Schz) Bipolar Disorders Depressive Disorders Anxiety and somatoform disorders Personality disorders
Who devised the DSM-III and describe some significant changes to the previous
Robert Spitzer
Changes - operational criteria, multiaxial classification, diagnostic criteria & diagnostic reliability
DSM-III was atheoretical with regards to etiology
What did the DSM-V field trials demonstrate about diagnostic reliability?
Adult Diagnosis was more reliable than children’s diagnosis
- Bipolar disorder is a more reliable diagnosis than MDD
- MDD is a heterogeneous rag bag and sub classification is long overdue
- Major depressive disorder and generalised anxiety disorder: very poor in interrater reliability
- Better reliability for PTSD and BD-I
o Interrater reliability is measured with kappa values in the tables
Name some changes that occurred for DSM-V compared to DSM-IV
Bipolar BD
- Has a new chapter (no longer a mood disorder), placed between depression and schizophrenia
~Consistent with its place between the two diagnostic classes in terms of symptomatology, family history, genetics
~“Types” dropped from criteria for BD-I
~New specifiers:
- with mixed features” added for manic, hypomanic, and major depressive episode MDD. (Replaces “mixed episodes”)
- “with anxious distress” added for manic, hypomanic, and major depressive episode MDD.
- Increased activity/energy added as a core mood elevation symptom (criterion A)
- Person needs to have mood and energy changes
- Helps to separate BD from other illnesses with similar symptoms
- Helps to avoid misdiagnosis
o Episode that starts due to antidepressants and persists beyond physiological treatment is diagnosed as mania or hypomania.
o New category: “other specified bipolar and related disorders” - Deleted: bipolar disorder not otherwise specified
- In the anxiety disorders chapter:
o Now includes selective mutism and separation anxiety disorder
o Social phobia is now called “Social anxiety disorder” - New specifier: performance only (specific to speaking or performing in public, main impairment in occupational environments), has a duration of at least 6 months
- Now adults and children have the same criteria for duration
- Adult insight not longer needed (they no longer need to recognise symptoms as anxiety)
o Removed panic attack specifier for agoraphobia
o Panic attack is now a specifier that can be applied to various DSM5 diagnoses
o PTSD has its own chapter: “Trauma and stress-related disorders” - Appropriate because cognitive symptoms refer to the past, and it allows for dissociative and depressive symptoms.
- New disorders:
o Disruptive Mood Dysregulation Disorder: Disruptive mood dysregulation disorder is characterized by pervasive irritability, and intolerance of frustration, but impulsiveness and disorganized attention are not essential features. - Temper outbursts
• Verbally or behaviorally
• Grossly out of proportion in intensity and duration
• 3 or more times per week - Mood between temper outbursts: persistently irritable or angry most of the day, nearly every day, and is observable by others
- Duration: for at least 12 months (no period of 3 or more consequitive months without criteria A-D), in at least 2 of 3 settings (home, school, peers)
- Age: not before 6 years nor after 18 years
o Premenstrual Dysphoric Depression
- 5 symptoms in the final week before menses, improves within a few days after onset of menses, minimal/absent in post-menses
- Criterion B: One or more of:
• mood swings, suddenly sad/tearful/ more sensitivity to rejection
• Depressed mood/feelings of hopelessness/self-deprecating thoughts
• Irritability/anger/more interpersonal conflicts
• Anxiety, tension and/or feelings of being keyed up/on edge
- Criterion C: B + C should be 5 in total
• less interest in usual activities
• Subjective difficulty in concentration
• Lethargy, easy fatigability/marked lack of energy
• Marked change in appetite, overeating/specific food cravings
• Hypersomnia/insomnia
• A sense of being overwhelmed/out of control
• Physical symptoms: breast tenderness/swelling, joint/muscle pain, sensation of ‘bloating’ or weight gain
Criterion A-C must have been met for most menstrual cycles in the preceding year**
o Persistent depressive disorder - Depressed mood for more days than not for at least 2 years, and no more than 2 months in 2-year period without symptoms When depressed, presence of two or more of: • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self esteem • Poor concentration or indecisiveness • Feelings of hopelessness
- Deleted:
o Dysthymia and chronic MDD, now they are replaced by Persistent Depressive Disorder
o Mixed anxiety depression disorder
Outline criterion A for a manic/hypomanic episode
Period of (at least 1 week mania / 4 days hypomania): - Abnormally and persistently:
- Elevated expansive & irritable mood
WITH
- Increased directed activity or energy
Define disruptive mood dysregulation disorder:
Temper outbursts:
A - Verbally or behaviourly & out of proportion in intensity or duration
B - Not consistent with developmental level
C - At least 3 times a week
Mood between temper outbursts:
D - Irritable or angry most of the day every day and observable to others
Duration:
E - At least 12 months with no more than 3 months without criteria A-D
F - In at least 2 different settings i.e. home and school
Age:
G - 6 < Age < 18 years
Define premenstrual dysphoric disorder:
A - 5 symptoms in the final week before menses that improve after onset of menses, Absent in week following menses
B - One of the following MARKED symptoms:
Mood swings
Depression/low mood/hopelessness
Anxiety/feeling keyed up
Irritability/anger/interpersonal conflict
C - Criterion B + one of the following to reach a total of 5 symptoms:
Reduced interest in usual activities
A sense of being overwhelmed/out of control
Hypersomnia/insomnia
Difficulty concentrating
Change in appetite
Physical symptoms: breast tenderness/swellng, joint pain/muscle pain, “bloating”, weight gain
Define persistent depressive disorder
Brought together dysthymia and chronic MDD:
Depressed mood most days with two or more of:
- Hypersomnia/insomnia
- Over eating/change in appetite
- Difficulty concentrating/indecisiveness
- Low energy
- Low self-esteem
No more than 2 months without. Needs to be present for 2 years
Name the 6 mixed states Emil Kraepelin described according to changes in thought/mood/volition
Pure Mania
Elevated mood, flight of ideas, hyperactivity
- Manic with thought poverty
Elevated mood, increased will, inhibited thoughts - Manic stupor
High mood but decreased thoughts/will - Inhibited mania
High mood and thoughts but inhibited by low will - Depressive/anxious mania
Depressed mood, elevated thoughts, elevated will - Excited depression
Depressed mood/will but elevated thoughts - Depression with flight of ideas
Depressed mood/thoughts but increased will
Pure Depression
Depressed mood, thought inhibition and weakness of volition
Describe how the “mixed features” specifier can be used in DSM-V diagnoses?
- Full MDD criteria
- At least 3 of:
o Elevated expansive mood
o Inflated self esteem or grandiosity
o More talkative than usual or
o Flight of ideas or subjective experience that thoughts are racing
o Increase in energy or goal directed activity
o Increased activities with high potential for painful consequences (shopping, sexual, business)
o Decreased sleep need - Observable by others and represents a change
- Do not diagnose mixed episode if patient meets criteria for mania or hypomania
Why did MDD show low interrater reliability in the DSM5 field trials?
• Raters were given criteria checklist, but they didn’t do a semi-structured interview (could not elaborate
- SCID hasn’t been formally evaluated yet
• New category: persistent depressive disorder (encompasses chronic major depression and dysthymia). It was already hard to pinpoint duration of episodes, and with new category some people could have rated as MDD instead of persistent depressive disorder.
• Different to DSM-IV: better interrater reliability
o raters all watched the same recorded video/session
o studies were done on the bases of a joint interview (two people sitting together and listening to the same session)
o kappa values higher than 0.6 for MDD (good)
What can be said about DSM5 validity?
- There is no gold standard for dx categorisation.
- Validity of the SCID is hard to judge
- Validity should be judged on how relevant is diagnosis for treatment
