Depression:Psychopathology & diagnosis

Dr Brijesh Desai, Consultant psychiatrist

Northwestern School of Psychiatry MRCPsych course

Contents

Clinical features of depression

Assessing psychopathology

Rating scales for depression

Classification in ICD10 and DSM IV

Differential diagnoses

References & Further Reading

Clinical features - mood

Mood of misery – persistent

Mood does not get better in circumstances where ordinary feelings of sadness would be alleviated.

Often experienced as different from ordinary sadness.

Diurnal variation – usually worse in the morning, improving a little as the day wears on.

Clinical features- depressive cognitions

Negative cognitions

Worthlessness

Pessimism

Guilt

Hopelessness

Can progress to thoughts of suicide

Clinical features – goal-directed behavoiur

Anhedonia - lack of interest and enjoyment [Roots: Latin- An=not; hedon = pleasure]

Social withdrawal

Lethargy, reduced energy, everything is an effort.

Clinical features – psychomotor changes

Psychomotor retardation- slow speech, actions, thoughts, delays in responding to questions.

Psychomotor agitation – restlessness, can’t relax, can’t sit for long

Anxiety – frequent in moderate depression

Irritability

Clinical features- biological symptoms

Sleep disturbance – early morning waking with depressive thinking is usually characteristic; also delay in falling asleep and waking during the night.

Diurnal variation of mood

Loss of appetite

Loss of weight

Constipation

Loss of libido

Amenorrhoea

Complaints about physical symptoms are common (fatigue, aches and pains, constipation). More worries about pre-existing physical problems.

Clinical features - other

Depersonalization

Obsessional symptoms

Panic attacks

Dissociative symptoms (fugue, loss of function of a limb)

Memory problems – impairments in the retrieval and recognition of recently learned material particularly prominent [If severe, it may resemble dementia: depressive pseudodementia]

Psychotic depression

‘Mood congruent’ delusions – delusions have the same theme as the non-delusional thinking, on depressive themes – worthlessness, guilt, ill-health, poverty (rare).

Persecutory delusions also occur (usually the patient believes that the supposed persecution is brought upon by himself/herself; he/she is ultimately to blame); indicates worse prognosis.

Cotard’s syndrome – extreme nihilistic delusion (rare)

Clinical variants of depression

Agitated depression – with agitation as a prominent feature

Retarded depression – with prominent psychomotor retardation

Depressive stupor- motionless and mute patient

Atypical depression – variably depressed mood with mood reactivity to positive events; overeating and oversleeping; extreme fatigue and heaviness in the limbs; pronounced anxiety.

Pointers for assessment

Severity

Duration

Social network

Views of self, world and future

Suicidal thoughts

Past history

Factors affecting symptoms

Biological features

Course - Kupfer’s curve

ICD-10 criteria [F32, F33]

Key Symptoms(MUST have at least 2)

A. Persistent low moodB. Loss of interest or pleasureC. Fatigue or low energy

If any of the above then ask about: 1. Disturbed sleep2. Poor conc. Or indecisiveness3. Low self confidence4. Poor or increased appetite5. Suicidal thoughts or acts6. Agitation or slowing of movement7. Guilt or self blame

Severity 4 symptoms = mild5-6 symptoms = moderate7+ symptoms= severe (+/- psychotic symptoms)

Classification of depressive disordersICD-10 DSM IV

Depressive episode Major Depressive episode

Mild, moderate, severe, severe with psychotic symptoms

Same

Other depressive episodes

Atypical depression -

Recurrent depressive disorder Major depressive disorder- recurrent

Currently mild, moderate, severe, severe with psychotic symptoms, in remission

-

Persistent mood disorders Dysthymic disorder

Cyclothymia Dysthymia

Other mood disorders Depressive disorders, NOS

Recurrent brief depression Recurrent brief depression

[ Shorter Oxford Textbook of Psychiatry, Ed 5th ]

Major Rating Scales

Scale Salient features

Hamilton Scale for Depresion (HAM-D)

Clinician-rated; 17 item, derived from clinical interview, refers to previous 1-2 weeks, for rating severity.

Montgomery-Asberg Depression Rating Scale (MADRS)

Observer-rated, 10 item, sensitive to response to treatment, for measuring change in depressed patient.

Beck Depression Inventory (BDI) Self-reported, 21 item, lacks discriminatory power among those with very severe depression

Zung Depression Scale Self-rating, 20 item; >=50 indicates depression, global index of intensity of patient’s depressive symptoms

[ Seminars in general adult psychiatry, Synopsis of Psychiatry ]

Differential diagnoses

Normal sadness

Anxiety disorders

Schizophrenia

Organic brain syndromes

References & Further Reading

Gelder M, Harrison P, Cowen P (2006) Shorter Oxford Textbook of Psychiatry (Ed 5th) Oxford University Press.

Stein G, Wilkinson G (Ed)(2007) Seminars in General Adult Psychiatry (Ed 2nd) Gaskell.

Sadock BJ, Sadock VA (2007) Kaplan & Sadock’s Synopsis of Psychiatry (Ed 10th) Lippincott, Williams & Wilkins.

WORLD HEALTH ORGANIZATION. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva, World Health Organization.