Lecture 9: Natural history and differential diagnosis of major depressive disorder

Question 1

Name some characteristics about MDD course

Answer 1

• Course:
- Recover without further symptoms: 50%. The other half: Recurrent (35%) > Unremitting (15%)

• Gender of patients not related to recovery
• Median episode length: 12 weeks
• Cancer and cardiovascular disorders have better outcome than depression

Question 2

What is the impact of discontinuing antidepressant medications in MDD?

Answer 2

Higher risk of recurrence

Question 3

What instrument is useful for identifying MDD symptoms?

Answer 3

SCID. Look for persistence of symptoms, lifetime episodes, and impairment in life.

Question 4

Which are the core symptoms (over 90% occurrence) in MDD, according to Roland?

Answer 4

• Depressed mood
• Hopelessness
• Feelings of inadequacy (severe: self worthlessness)
• Lack of drive
• Social withdrawal
• Blunted affect
• Affective rigidity

Question 5

What can be said about MDD interrater reliability in the DSM-5 field trials?

Answer 5

• Its reliability was poor, possibly because:
  • Raters only used checklists (no interviews)
  • Confusion in distinguishing MDD from persistent depressive disorder
  • Accurate diagnosis depends on ability of interviewer
  • It is difficult to establish time criterion for MDD

Question 6

How does the SCID explore depressed mood?

Answer 6

• Ask if patient has been feeling depressed or down (most of day, every day).

If answers no: ask for “Empty or hopeless”

• Ask what it has been like
• Ask how long it has lasted

Question 7

What areas are explored by the SCID for MDD, besides depressed mood and diminished interest in activities?

Answer 7

(follows DSM criteria in order)

• Weight change
• Sleep
• Psychomotor agitation/retardation
• Worthlessness/guilt
• Diminished ability to concentrate
• Thoughts of death

Question 8

Name one instrument useful to assess depression

Answer 8

PHQ-9

Question 9

How can we screen for bipolar depression?

Answer 9

With the SCID. Patient must confirm both:

• Elated mood
• Time criterion for elated mood (most of the day, nearly every day, for at least four days)

Question 10

How can we distinguish MDD with mixed features from BD - Other specified?

Answer 10

• MDD with mixed features:
  • Does not fulfil hypomanic/manic criteria
  • Can have 3 or more hypomanic/manic symptoms
  • Symptoms cannot occur outside of MDD episode
• BD, other specified:
  • Manic/hypomanic symptoms occur outside of MDD episode
  • Does not fulfil hypomanic/manic criteria

Question 11

What is a delusion?

Answer 11

Unshakable rigid incorrect belief, not in line with sociocultural belief system

Question 12

Are delusions explainable on the basis of one’s mood state?

Answer 12

No

Question 13

How can we screen for schizophrenia and schizoaffective disorder?

Answer 13

Prompted by the presence of at least one of the following:

• Auditory hallucinations
• Delusion of control
• Delusion of reference

Question 14

What is the first-line treatment for anxiety disorder according to the NICE guidelines?

Answer 14

Psychological therapy

Question 15

If a patient presents with depression and anxiety, which should be addressed first?

Answer 15

Depression

Question 16

Name some possible neurological causes of affective disorders

Answer 16

• Frontal brain tumours, intracerebral lymphoma
• Frontotemporal dementia
• Frontotemporal lobar degeneration (FTLD)

Question 17

How does major depression differ to non-major depression?

Answer 17

Major depression - low mood nearly and persistently every day for 2 weeks with psychosocial impairment

Non-major depression - no psychosocial impairment or not everyday/for most of the day

(ask Roland what is this imaginary diagnosis)

Question 18

Why was the inter-rate reliability for MDD so low in DSM5 field trials?

Answer 18

• Criteria given but no semi-structured interview

- New diagnosis of persistent depressive disorder to encompass chronic major depression and non-major “dysthymia”

Question 19

Outline DSM criteria for other depressive disorder

Answer 19

Symptoms of depressive disorder but not meeting full criteria for any of the disorders in the depressive disorders diagnostic class (e.g., MDD) nor adjustment Disorder (considered if temporally associated with psychosocial stressor).

Psychosocial distress, impairment

Not attributable to physiological effects of a drug or other medication

Question 20

Outline 6 possible presentations that can be made using other specified depressive disorder?

Answer 20

1. Recurrent Brief Depression: 2-13 days of low mood and four other symptoms at least once a month not in conjunction with menstrual cycle,
   Occurs for at least 12 consecutive months.
   Not attributable to other depressive, bipolar or psychotic disorder
2. Short-duration depressive episode:
   4-13 days of depressed mood with 4 other symptoms. Not meeting criteria for other depressive, bipolar or psychotic illness.
3. Depressive episode with insufficient symptoms - depressed affect with at least one more associated symptoms but not enough to meet criterion illness. Not attributable to BD or Psychotic disorder
4. Depressive disorder but unsure if primary or secondary to medical condition/substances (in the ppt, but not in the DSM5)
5. Other (in the ppt, but not in the DSM5)
6. Unspecified - insufficient information to make the diagnosis (in the ppt, but in the DSM5 is a different category)

Question 21

What do validation studies show the cut off for the PHQ-9 is?

Answer 21

> 14 to meet MDE

Question 22

Describe some screening questions for Bipolar disorder (adapted from the SCID for DSM-IV):

Answer 22

Have you ever had a period of time when you feeling so good, high, excited or hyper that other people thought:
you were not your normal self or you were so hyper you may get into trouble??

If so was this most of the day and nearly every day for at least four days??

Question 23

Describe differences between MDD with mixed features and other specified bipolar disorder?

Answer 23

MDD with mixed features:

• At leat 3 hypomanic/manic symptoms nearly every day during a MDE
• Symptoms not enough to meet threshold for hypomanic or manic episode

For other specified bipolar disorder - MDE and hypomanic/manic features occur at different times and neither meeting criteria for hypomania/mania (reason needs to be given otherwise would be other unspecified bipolar disorder)

Question 24

Describe some screening quesitions for Schizophrenia/Schizo-affective disorder?

Answer 24

(Auditory hallucinations and delusions)

Have you ever heard voices with no person or audio-device as a source? (auditory hallucinations)

Have you ever lost control of your body movements or your thoughts and felt controlled by an external power? (delusion of control)

Have you ever experienced unusual signs referring specifically to you and indicating great danger
-for example by a group or person threatening your life? (delusion of reference)

Not delusion of reference or delusional perception should be explained by one’s mood state

Question 25

Outline criterion A of Schizophrenia?

Answer 25

Two or more over significant portion of 1 month (less if treated), one from 1-3: 1. Delusions 2. Hallucinations 3. Disorganised speech - actually thoughts i.e incoherence 4. Grossly disorganzed or catatonic behaviour 5. Negative symptoms (i.e reduced affect or avolition)

Question 26

Outline the DSM-V diagnosis for Schizoaffective disorder?

Answer 26

A - Uninterrupted period of illness with major mood episode and concurrent criterion A of Schizophrenia B. Delusions or hallucinations for 2 or more weeks in lifetime without major mood episode C, Major mood episode symptoms are present for majority of active and residual portions of illness (i.e. mostly shared psychotic and mood symptoms) D. Not due to substance or other medical condition

Question 27

Who came up with first rank symptoms?

Answer 27

Kurt Schneider (German Psychiatrist taught by Karl Jaspers) "First-rank" symptoms (FRS) have played an extremely important role in the recent diagnostic systems ICD-10 and DSM-IV - where one of FRS is symptomatically sufficient for Schz diagnosis

Question 28

Outline the 1st rank symptoms

Answer 28

a) Thought echo, thought insertion or withdrawal or thought broadcasting b) Delusions of control or passivity - referring to body, limb movements or thoughts c) Hallucinatory voices giving a running commentary on the patient's behaviour or discussing him between themselves. d) Persistent delusions of other kinds that are culturally inappropriate and impossible

Question 29

How can anxiety disorders also be inquired about other than asking about worry?

Answer 29

Ask about avoiding

Question 30

Outline the criteria for persistent depressive disorder?

Answer 30

1. Depressed mood for most of the day, more days than not for at least 2 years 2. At least 2 additional symptoms 3. No cyclothymia or hypomanic symptoms in the past 4. Not better explained by other psychiatric/medical condition or substance 5. Causes significant distress or impairment Specify: - With pure dysthymic syndrome (never met MDE criteria) - With persistent major depressive episode (patients with persistent depressive disorder can have a long MDE) - With intermittent major depressive episodes (subthreshold symptoms in the past 2 years), with current MDE episode - With intermittent major depressive episodes (at least once in last 2 years), without current MDE episode • People with persistent depressive symptoms not listed in this disorder: - If they have ever had MDE: code as MDE - If they have never had MDE: code as other specified depressive disorder or unspecified depressive disorder Issues with persistent depressive disorder as a diagnosis: - Mixing major and non-major depression --> poor reliability - Doesn't consider other causes of depressive symptoms (anxiety)

Question 31

What are the criteria for adjustment disorder?

Answer 31

1. Symptoms occurring within 3 months of identifiable stressor 2. Marked distress out of proportion to the severity of the stressor (reference to cultural context) or significant impairment 3. Not met criteria for exacerbation of other disorder 4. Not bereavement 5. Once stressor terminated symptoms don't persist > 6 months

Question 32

Outline the criteria for general personality disorder?

Answer 32

A. An enduring pattern of inner experience and behaviour that markedly deviates from the individual's culture. Pattern is manifested in the following: - Cognition (ways of perceiving and interpreting self, other people and events) - Affectivity (range, lability, intensity and appropriateness of emotional response) - Interpersonal functioning - Impulse control B. Pattern is inflexible and pervasive across a broad range of personal and social fluctuations C. Leads to clinically significant distress or impairment D. Stable pattern and long duration routes traced back to early adulthood E. Not explained as a manifestation or consequence of another psychiatric condition F. Not due to a substance or another medical condition

Question 33

What tests can diagnose dementia or Parkinson's disease?

Answer 33

Dopamine transporter (123FP-CIT)-SPECT - Parkinsons Non-contrast MRI - frontal or temporal atrophy for frontotemporal dementia

Question 34

How can we screen for depressive episodes? (According to Roland)

Answer 34

Ask for depressed mood or loss of interest/pleasure 1) Lifetime episodes • Pay attention to persistence of symptoms 2) Interference • In different areas in their lives • Social: often they deflate and isolate/cancel all engagements even when they can work or study

Question 35

Which MDD criterion does not need to meet the 2-week temporal criterion to be valid?

Answer 35

Suicidality

Question 36

A 40 year old women presents to you with depression. She says she has always had depressed mood. What do you ask her to come to a likely diagnosis?

Answer 36

examples: - any possible change in her mood - when was her lowest point (worst symptoms) - (add more)

Question 37

What was the diagnosis of the singing lady case? Why is it relevant in the context of a dx?

Answer 37

Frontotemporal lobar degeneration (FTLD) | important because we should always consider the possibility of organic disorders

Question 38

What should the clinician do if the patient states that there is no disturbance/impairment due to MDD?

Answer 38

Explore organic causes

Question 39

Does a lifetime episode of schizophrenia exclude MDE?

Answer 39

No. Patient could even have post-schizophrenia depression

Question 40

When should the clinician screen for Adjustment Disorder in MDD?

Answer 40

When there is a psychosocial stressor and there is a temporal relationship with it. Stressor cannot be trauma (if trauma: PTSD)

Question 41

What's the difference in the quality of mood in ADHD/BPD vs MDD?

Answer 41

In ADHD/BPD, mood is a response to external events and thus can change rapidly within the same day

Question 42

Which diagnoses should always be excluded in MDD?

Answer 42

- BD | - Schizophrenia spectrum

Question 43

Which type of hallucination is characteristic of schizophrenia?

Answer 43

Auditory Visual hallucinations could be due to other disorders (e.g., organic)

Question 44

Which criterion was included in DSM5 for schizoaffective disorder?

Answer 44

C: Major mood episode symptoms should be present for majority of active and residual portions of illness

Question 45

How many first-rank symptoms are necessary for a schizophrenia dx in ICD 10?

Answer 45

Only one: a) Thought echo, thought insertion/withdrawal, or thought broadcasting b) Delusions of control or passivity - referring to body, limb movements or thoughts, or delusional perceptions c) Hallucinatory voices giving a running commentary on the patient's behaviour or discussing him between themselves. d) Persistent delusions of other kinds that are culturally inappropriate and impossible