Transcript Clinical features of depression

Clinical features of depression
Dr. Jorge Zimbron
ST4 in General Adult Psychiatry
Overview
• Definitions of ‘depression’
• Exam questions
• CASC practice
Definitions of depression
• ICD-10
• DSM IV TR
• Both make divisions in view to testing their
usefulness.
• Mood: a relatively long lasting emotional
state.
Clinically tricky areas
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Substance abuse
Organic pathology
Negative symptoms vs depression
Dementia
Personality disorders
Bereavement
Interphase with other disorders (anxiety,
somatoform disorders, etc).
ICD-10
• Defines depressive episode
• Defines somatic episode
• More critical and humble
• More concrete on mild, moderate, severe
– “unwise to include social performance amongst
essential criteria of severity” (but a guide)
• Looser definitions on ‘unspecified’ or ‘other’.
ICD-10
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F32.0Mild depressive episode
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.10 Without somatic syndrome
.11 With somatic syndrome
F32.2 Severe depressive episode without
psychotic symptoms
F32.3 Severe depressive episode with psychotic
symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F33 Recurrent depressive disorder
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F33.0 Recurrent depressive disorder, current
episode mild
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.10 Without somatic syndrome
.11 With somatic syndrome
F33.2Recurrent depressive disorder, current
episode severe without psychotic symptoms
F33.3Recurrent depressive disorder, current
episode severe with psychotic symptoms
F33.4Recurrent depressive disorder, currently in
remission
F33.8Other recurrent depressive disorders
F33.9Recurrent depressive disorder, unspecified
F34 Persistent mood [affective] disorders
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F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective]
disorders
F34.9 Persistent mood [affective] disorder,
unspecified
F38 Other mood [affective] disorders
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F38.0 Other single mood [affective] disorders
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.00 Without somatic syndrome
.01 With somatic syndrome
F33.1 Recurrent depressive disorder, current
episode moderate
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.00 Without somatic syndrome
.01 With somatic syndrome
F32.1 Moderate depressive episode
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F32 Depressive episode
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F38.1 Other recurrent mood [affective] disorders
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F38.8 Other specified mood [affective] disorders
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.00 Mixed affective episode
.10 Recurrent brief depressive disorder
F39 Unspecified mood [affective] disorder
Mild Depressive episode
• At least 2 weeks...but shorter periods if severe or rapid in onset.
• At least two of:
– Depressed mood
– Loss of interest and enjoyment
– Increased fatigability
• Plus two of:
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reduced concentration and attention;
reduced self-esteem and self-confidence;
ideas of guilt and unworthiness
bleak and pessimistic views of the future;
ideas or acts of self-harm or suicide;
disturbed sleep
diminished appetite.
• Usually, some difficulty in functioning
• Mnemonic: DIE GAS FASS
Moderate Depressive episode
• At least 2 weeks...but shorter periods if severe or rapid in onset.
• At least two of:
– Depressed mood
– Loss of interest and enjoyment
– Increased fatigability
• Plus at least three of:
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reduced concentration and attention;
reduced self-esteem and self-confidence;
ideas of guilt and unworthiness
bleak and pessimistic views of the future;
ideas or acts of self-harm or suicide;
disturbed sleep
diminished appetite.
• Usually, considerable difficulty functioning
Severe Depressive episode
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At least 2 weeks...but shorter periods if severe or rapid in onset.
All three of:
– Depressed mood
– Loss of interest and enjoyment
– Increased fatigability
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Plus at least four of:
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reduced concentration and attention;
reduced self-esteem and self-confidence;
ideas of guilt and unworthiness
bleak and pessimistic views of the future;
ideas or acts of self-harm or suicide;
disturbed sleep
diminished appetite.
Very unlikely to be able to function
Psychotic symptoms: hallucinations, delusions, depressive stupor.
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Mood congruent or incongruent.
Recurrent depressive episode
• More than one episode lasting 2 weeks or
more...separated by several months.
– Otherwise recurrent affective disorder F38.1
(Recurrent brief depressive disorder)
• ~1/month
• <2weeks in duration (typically 2-3 days)
• Fulfil symptomatic criteria for mild, moderate, or severe
• Absence of mania.
• Hypomania acceptable if following treatment
with antidepressant.
Persistent mood [affective] disorder
F34
• Rarely if ever sufficiently severe to reach
hypomania or mild depression.
• At least one year.
• Eg. Dysthymia
• Excludes bereavement (lasting <2y)
Somatic Syndrome ICD-10
• “scientific status...questionable...can also be
ignored”
• At least four:
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Loss of interest or pleasure in activities
Lack of emotional reactivity
EMW (2h)
Diurnal variation (worse in the mornings)
Psychomotor retardation/agitation
Loss of appetite
Weight loss (5% in one month)
Loss of libido
• Mneumonic: DEAR WALI
ICD-10
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F32.0Mild depressive episode
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.10 Without somatic syndrome
.11 With somatic syndrome
F32.2 Severe depressive episode without
psychotic symptoms
F32.3 Severe depressive episode with psychotic
symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
F33 Recurrent depressive disorder
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F33.0 Recurrent depressive disorder, current
episode mild
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.10 Without somatic syndrome
.11 With somatic syndrome
F33.2Recurrent depressive disorder, current
episode severe without psychotic symptoms
F33.3Recurrent depressive disorder, current
episode severe with psychotic symptoms
F33.4Recurrent depressive disorder, currently in
remission
F33.8Other recurrent depressive disorders
F33.9Recurrent depressive disorder, unspecified
F34 Persistent mood [affective] disorders
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F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective]
disorders
F34.9 Persistent mood [affective] disorder,
unspecified
F38 Other mood [affective] disorders
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F38.0 Other single mood [affective] disorders
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.01 With somatic syndrome
F33.1 Recurrent depressive disorder, current
episode moderate
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.01 With somatic syndrome
F32.1 Moderate depressive episode
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F32 Depressive episode
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F38.1 Other recurrent mood [affective] disorders
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F38.8 Other specified mood [affective] disorders
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.00 Mixed affective episode
.10 Recurrent brief depressive disorder
F39 Unspecified mood [affective] disorder
DSM IV TR
• Mood Episodes
• Mood Disorders
• Specifiers
Major Depressive Episode
• One of:
– Depressed mood (A1)
– Loss of interest or pleasure in nearly all activities (A2)
• C&A – may be irritable rather than sad.
• PLUS(at least four):
– Changes in appetite or weight(+/- 5%) (A3), sleep (A4), and psychomotor
activity (A5).
– Decreased energy (A6)
– Worthlessness or guilt (A7)... but not guilt about being ill...unless
delusional.
– Difficulty thinking, concentrating, or making decisions (A8)
– Recurrent thoughts of death or suicidal ideation, plans or attempts (A9).
• Most of the day, nearly every day, for 2 consecutive weeks.
Major Depressive Episode
• Symptoms must be new or a clear worsening from premorbid
status.
• Must accompany clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
• No mania, no drugs, no organic pathology, no bereavement
(2m) causing it.
• Not ‘sadness’.
• Course: develops over days to weeks. Prodrome may be
longer. Usually >4m if untreated. If >2 years, then ‘chronic’.
Major Depressive Disorder (MDD)
• 1 or more depressive episodes.
– End of episode = 2 consecutive months of not
meeting criteria.
• No mixed/manic/hypomanic episodes.
• Not organic/substance induced.
• Not schizophrenia, schizoaffective, etc.
Specifiers
• Mild, moderate, severe (with or w/o psychotic sx).
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Mild = 5-6 Sx + mild disability or substantial effort.
Severe = nearly all Sx and severe disability.
Moderate = somewhere in between.
Psychotic Sx= Mood congruent or incongruent (poorer prognosis).
• Chronic
– At least 2 years
• Catatonic - at least 2 of:
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Catalepsy or stupor
Excessive motor activity
Negativism or mutism
Posturing, stereotyped movements, mannerisms, grimacing
Echolalia or echopraxia
Specifiers
• Melancholic
One of:
– Loss of pleasure in all, or almost all, activities
– Lack of reactivity to pleasurable stimuli
Plus at least 3 of:
– Distinct quality of depressed mood
– Worse in the morning
– EMW (2h before).
– Psychomotor retardation or agitation
– Anorexia or weight loss
– Excessive or inappropriate guilt
Specifiers
• Atypical
– Mood reactivity
Plus two or more of:
– Weight gain or increase in appetite
– Hypersomnia
– Leaden paralysis
– Long-standing interpersonal rejection sensitivity
• Postpartum (within 4 weeks)
• With seasonal pattern
Specifiers
• In remission (partial/full)
• With/without full inter-episode recovery
DSM-IV TR
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296.20Major Depressive Disorder, Single Episode, Unspecified.
296.21Major Depressive Disorder, Single Episode, Mild.
296.22Major Depressive Disorder, Single Episode, Moderate.
296.23Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
296.24Major Depressive Disorder, Single Episode, Severe With Psychotic Features.
296.25Major Depressive Disorder, Single Episode, In Partial Remission.
296.26Major Depressive Disorder, Single Episode, In Full Remission.
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296.30Major Depressive Disorder, Recurrent, Unspecified.
296.31Major Depressive Disorder, Recurrent, Mild.
296.32Major Depressive Disorder, Recurrent, Moderate.
296.33Major Depressive Disorder, Recurrent, Severe Without Psychotic Features.
296.34Major Depressive Disorder, Recurrent, Severe With Psychotic Features.
296.35Major Depressive Disorder, Recurrent, In Partial Remission.
296.36Major Depressive Disorder, Recurrent, In Full Remission
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300.04Dysthymic Disorder
309.0 Adjustment Disorder with Depressed Mood
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311Depressive Disorder NOS (premenstrual dysphoric disorder, minor depressive disorder (single and recurrent), post-psychotic
disorder of schizophrenia, depressive episode superimposed on delusional disorder, schizophrenia, psychotic disorder NOS), confusion
with regards to aetiology.
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V62.82 Bereavement
Dysthymic disorder
• At least 2 years of depressed mood
• Additional depressive symptoms that DO NOT
meet criteria for a major depressive episode.
Main differences
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ICD 10
DSM IV
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– Episode
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4 symptoms for episode (2+2)
10 symptoms in total
Bleak future
Reduced self-esteem and confidence
– Somatic syndrome
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4 symptoms
libido
Bereavement 2y
No chronic depression
Dysthymia = 1y
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5 symptoms for episode (1+4)
9 symptoms in total
Weight changes
Psychomotor activity
Excludes certain guilt
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– Melancholic
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1 + 3 symptoms
Distinct quality of mood
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Bereavement 2m
Chronic Depression
Dysthymia = 2y
Atypical depression
More specifiers
The future...
• ICD 11 (2015)
DSM V (2013)
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D 00 Disruptive Mood Dysregulation
Disorder
D 01 Major Depressive Disorder, Single
Episode
D 02 Major Depressive Disorder,
Recurrent
D 03 Chronic Depressive Disorder
(Dysthymia)
D 04 Premenstrual Dysphoric Disorder
D 05 Mixed Anxiety/Depression
D 06 Substance-Induced Depressive
Disorder
D 07 Depressive Disorder Associated with
a Known General Medical Condition
D 08 Other Specified Depressive Disorder
D 09 Unspecified Depressive Disorder
Premenstrual Dysphoric Disorder
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A. In most menstrual cycles during the past year, five (or more) of the following symptoms occurred during the
final week before the onset of menses, started to improve within a few days after the onset of menses, and were
minimal or absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):
(1) marked affective liability (e.g., mood swings; feeling suddenly sad or teaful or increased sensitivity to
rejection)
(2) marked irritability or anger or increased interpersonal conflicts
(3) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
(4) marked anxiety, tension, feelings of being "keyed up" or "on edge"
(5) decreased interest in usual activities (e.g., work, school, friends, hobbies)
(6) subjective sense of difficulty in concentration
(7) lethargy, easy fatigability, or marked lack of energy
(8) marked change in appetite, overeating, or specific food cravings
(9) hypersomnia or insomnia
(10) a subjective sense of being overwhelmed or out of control
(11) other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of
“bloating,” weight gain
B. The symptoms are associated with clinically significant distress or interferences with work, school, usual
social activities or relationships with others (e.g. avoidance of social activities, decreased productivity and
efficiency at work, school or home).
Scales
• Beck Depression Inventory (BDI)
– 21-question multiple-choice self-report inventory
• Hamilton Rating scale for depression (HRSD or HAM-D)
– multiple choice questionnaire clinicians use to rate the severity of a
patient's major depression.
– 17 questions (although longer versions available)
• Montgomery-Åsberg Depression Rating Scale (MADRS)
– 10 items.
– Used by clinicians
– More sensitive to antidepressant effects than HSRD
• Geriatric Depression Scale (GDS)
– 30 item (yes/no)
– Self report
– Simpler. Allows more cognitively impaired individuals to complete it.
Psychology
Beck’s Cognitions
• Triad of negative thoughts about
– Self
– Ongoing experiences
– Future
Cognitive distortions
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Arbitrary inference
Selective abstraction
Overgeneralization
Magnification and minimization
Dichotomous thinking
Subspecialties
Differences in Old Age
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Mood disturbance less often as symptom
More somatic
? More agitated
? More delusional
• Difficulties when symptoms overlap with
physical ill health
Depression and cognition
• If cognition normal in depression then no
increased risk of dementia
• If cognition impaired in depression then risk of
dementia increased x4
(even if cognition normalizes with treatment)
• Is there a sub-type of depression in old age
that is different from younger adults ?
• Is “vascular depression” a useful
concept ?
Depression in Children &
Adolescents
- More often presents with irritability – DSM IV
Depression in LD
• Also irritability…
Questions
True or false
• In adults depression occurs more in females
compared to males
• The Geriatric Depression Scale is an observerrated scale that concentrates on biological
symptoms of depression
• Presence of psychosis may interfere with
assessment of mood disorder
• The minimum duration of illness for a
diagnosis of major depression according to
DSM-IV is 2 weeks
MCQ
MCQ
MCQ
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Depression in Children and Adolescents:
Please choose the correct answers. There may be more than one correct answer or no correct answer for each
question
Prevalence of depression in young people
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Approximately 1 in 10 Adolescents will get depression in their life-time
At age 8 more common in girls than in boys
Prevalence in young people is increasing
Uncommon in pre-pubertal children
The first line of treatment for depression in young people?
a) Family therapy
b) Cognitive behaviour therapy
c) Inter personal therapy
d) Fluoxetine
e) Sertraline
f) Combination of b and d
g) Psycho education and watchful waiting
f) Any of the above
CASC
• Elicit a collateral history of depression
• Suggest management
• DIE GAS FASS
• DEAR WALI
CASC
• You are seeing Mrs Grey, 38-year-old woman
because she wants a second opinion on her
management. She has a diagnosis of recurrent
depression and has been well for a year on an
antidepressant and lithium. She would like to
discontinue them. You don’t have access to her
previous notes.
• Please assess the need to continue her
medication.
CASC
• A 35 year old lady with "depression" is
attending psychotherapy and wants to
terminate therapy. Give a management plan
to the patient and discuss that plan with her.
CASC
• You are asked to take a history from a 15-yearold girl with a history of depression. There are
some trauma-related symptoms, related to
bullying, which are unlikely to meet diagnostic
criteria for PTSD.
CASC
• You must interview a woman with post-natal
depression and a 7-month old baby. She is
now 10 weeks pregnant again.
You are asked to take a history of depression
and not required to assess risk.
CASC
• Take a history from a man with a history of
depression who is complaining of sexual
dysfunction.
Questions
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The common co morbidities in depression in include?
a) separation anxiety
b) conduct disorder
c) substance misuse disorder
d) learning difficulties
e) ADHD
f)OCD
Which of the following about depression in young people is true?
a) It is normal to be depressed in adolescence
b) Children less than 6 years don’t get depressed
c) Suicide is a high risk in adolescents
d) Detection rates of depression in young people are very high
e)Mild forms of depression in young people does not cause impairment
A 8 year old child with depression present with the following symptoms (choose one or more)
Separation anxiety specific phobias Irritability
nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self
esteem failure to thrive behavioural problems enuresis obsessive behaviour menstruation problems
What about a 16 year old girl....? Choose one or more.
Irritability
nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self esteem failure to thrive behavioural
problems enuresis obsessive behaviour menstruation problems
Questions
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Children with depression are at
a)increased risk of conduct disorders in later life
b)increased risk of depression in later life
c) increased risk of bi-polar in later life
d) increased risk of substance misuse
Depression in Children and Adolescents:
Please choose the correct answers. There may be more than one correct answer or no correct answer for each question
Prevalence of depression in young people
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Approximately 1 in 10 Adolescents will get depression in their life-time
At age 8 more common in girls than in boys
Prevalence in young people is increasing
Uncommon in pre-pubertal children
The first line of treatment for depression in young people?
a) Family therapy
b) Cognitive behaviour therapy
c) Inter personal therapy
d) Fluoxetine
e) Sertraline
f) Combination of b and d
g) Psycho education and watchful waiting
f) Any of the above
Questions
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The common co morbidities in depression in include?
a) separation anxiety
b) conduct disorder
c) substance misuse disorder
d) learning difficulties
e) ADHD
f)OCD
Which of the following about depression in young people is true?
a) It is normal to be depressed in adolescence
b) Children less than 6 years don’t get depressed
c) Suicide is a high risk in adolescents
d) Detection rates of depression in young people are very high
e)Mild forms of depression in young people does not cause impairment
A 8 year old child with depression present with the following symptoms (choose one or more)
Separation anxiety specific phobias Irritability
nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self esteem failure to thrive
behavioural problems enuresis obsessive behaviour menstruation problems
What about a 16 year old girl....? Choose one or more.
Irritability
nightmares inability to gain weight auditory hallucinations delusions of nilhism poor self esteem failure to thrive behavioural problems enuresis
behaviour menstruation problems
Children with depression are at
a)increased risk of conduct disorders in later life
b)increased risk of depression in later life
c) increased risk of bi-polar in later life
d) increased risk of substance misuse
obsessive