Download Depression Clinical features & communication skills

Depression
Clinical features &
communication skills
Nimalee Kanakkahewa
October 2012
Clinical features:
Central features of syndrome of depressive disorders –
•
depressed mood
•
negative thinking
•
lack of enjoyment
•
reduced energy
•
slowness
Depressed mood is normally but not invariably the most
prominent symptom
ICD – 10 (criterion B)
1. depressed mood to a degree that is definitely
abnormal for the individual, present for most of the
day and almost every day, largely uninfluenced by
circumstances, and sustained for at least 2 weeks.
2.
loss of interest or pleasure in activities that are
normally pleasurable
3. decreased energy or increased fatiguability.
ICD – 10 contd. (criterion C)
1.
2.
3.
4.
5.
6.
7.
loss of confidence and self-esteem
unreasonable feelings of self-reproach or excessive
and inappropriate guilt
recurrent thoughts of death or suicide, or any
suicidal behaviour
complaints or evidence of diminished ability to think
or concentrate, such as indecisiveness or vacillation
change in psychomotor activity, with agitation or
retardation (either subjective or objective)
sleep disturbance of any type
change in appetite (decrease or increase) with
corresponding weight change).
To make a diagnosis:
1. The depressive episode should last for at
least 2 weeks.
2. There have been no hypomanic or manic
symptoms sufficient to meet the criteria for
hypomanic or manic episode (F30.-) at any
time in the individual's life.
3. Most commonly used exclusion clause. The
episode is not attributable to psychoactive
substance use (F10-F19) or to any organic
mental disorder (in the sense of F00-F09).
Severity:
•Mild – 2 of B and at least 2 of C
•Moderate – 2 of B and at least 3 of C
•Severe – all of B and at least 4 of C
- without psychotic symptoms
- with psychotic symptoms
Severe depression with psychotic
symptoms:
The general criteria for depressive episode (F32) must be met.
Criteria B & C as for a severe depressive episode
The criteria for schizophrenia (F20.-) or schizoaffective disorder, depressive type (F25.1) are not
met.
Either of the following must be present:
(1) delusions or hallucinations, other than those listed as typically schizophrenic in F20,
criterion G1(1)b, c, and d (i.e. delusions other than those that completely impossible
or culturally inappropriate and hallucinations that are not in the third person or
giving a running commentary); the commonest
examples are those with
depressive, guilty, hypochondriacal, nihilistic, self-referential, or persecutory content
(2) depressive stupor. (
Severe depression with psychotic symptoms:
• psychotic symptoms can be congruent or incongruent with
mood:
• Mood congruent
(i.e. delusions of guilt, worthlessness, bodily disease, or
impending disaster, derisive
or condemnatory
auditory hallucinations)
Cotard’s syndrome
•
With mood-incongruent psychotic symptoms
(i.e. persecutory or self-referential delusions and
hallucinations without an affective
content)
DSM IV – Criteria for major depressive
episode (1)
• A. Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either
• (1) depressed mood or (2) loss of interest or pleasure.
• Note: Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
DSM IV – Criteria for major depressive episode
(2)
(1)
depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty)
or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2)
markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated
by either subjective account or observation made by others)
(3)
significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or
decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4)
Insomnia or Hypersomnia nearly every day
(5)
psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of
restlessness or being slowed down)
(6)
fatigue or loss of energy nearly every day
(7)
feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely
self-reproach or guilt about being sick)
(8)
diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as
observed by others)
(9)
recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide
DSM IV – Criteria for major depressive
episode (3)
• B. The symptoms do not meet criteria for a Mixed Episode (see p. 335).
• C. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
• D. The symptoms are not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism).
• E. The symptoms are not better accounted for by Bereavement, i.e., after
the loss of a loved one, the symptoms persist for longer than 2 months or
are characterized by marked functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation.
ICD 10 Recurrent depressive disorder:
• There has been at least one previous episode, mild (F32.0), moderate
(F32.1), or severe (F32.2 or F32.3),
• lasting a minimum of 2 weeks and separated from the current episode by
at least 2 months free from any significant mood symptoms.
• At no time in the past has there been an episode meeting the criteria
for hypomanic or manic episode (F30.-).
• Most commonly used exclusion criteria: the episode is not attributable to
psychoactive substance use (F1) or any organic mental disorder, in the
sense of F0.
• It is recommended to specify the predominant type of previous episodes
(mild, moderate, severe, uncertain).
Melancholia, Melancholic Depression:
The quintessential 'biological' sub-type of depression; it has been
variously described as:
•
likely to emerge without any immediately preceding
stressor;
•
having certain clinical features (such as observable
psychomotor disturbance) and
•
having over-represented features (for example, nonreactive mood, loss of pleasure, mood worse in the morning);
•
having genetic and biological causes; being unlikely to
respond to placebo medication and
•
being highly likely to respond to physical treatments.
http://www.blackdoginstitute.org.au
(Parker & Manicavasagar, 2005)
A review of depression diagnosis and management, Associate Professor
Vijaya Manicavasagar MAPS, Director, Psychology Services
ICD 10 - Somatic syndrome
(1) marked loss of interest or pleasure in activities that are normally
pleasurable;
(2) lack of emotional reactions to events or activities that normally produce
an emotional response;
(3) waking in the morning 2 hours or more before the usual time;
(4) depression worse in the morning;
(5) objective evidence of marked psychomotor retardation or agitation
(remarked on or reported by other people);
(6) marked loss of appetite;
(7) weight loss (5% or more of body weight in the past month);
(8) marked loss of libido.
Atypical depression:
• Typically applied to a disorder of moderate severity
• Characterised by;
• Variably depressed mood with reactivity to positive events
• Overeating or oversleeping
• Extreme fatigue and heaviness in the limbs (leaden paralysis)
• Pronounced anxiety
Differential diagnoses:
Bipolar or Unipolar:
Advances in Psychiatric Treatment (2011)17: 283-291doi:10.1192/apt.bp.109.007047
Features indicative of bipolarity in depressive
episodes
Family history of bipolar disorder
Nature of the onset:
abrupt onset and offset of episode
antidepressant-induced mania, hypomania or mixed states
younger age at onset of major depression
postnatal onset
Symptom features:
psychomotor retardation/agitation
atypical features such as hypersomnolence, hyperphagia, leaden paralysis
psychotic features
melancholia
pathological guilt
lability of mood
irritability
mixed depression (manic features during depressive episode)
Other features:
comorbid substance misuse
seasonality
brief episodes of depression (<3 months)
antidepressant wear-off (rapid emergence of depressive symptoms after remission
while on antidepressants)
Depression or dementia:
Recognizing Delirium, Depression and
Dementia (3D’s)
• http://rgp.toronto.on.ca/torontobestpractice/Thr
eeDresourceguide.pdf
Psychotic illness:
• Schizophrenia can have a depressive
prodrome
• May cause diagnostic problems if the patient
has depressive psychosis
Careful history and examination of the
mental state
(Depressive symptoms commonly occur in
schizophrenia)
Anxiety
Anxiety is a common symptom in depressive
disorder
Diagnosis is decided on the basis of the severity
of the two groups of symptoms and the order
in which they appeared
Agitated type of severe depression can be
commonly mistaken
Substances:
• Alcohol
• Cannabis
• Mood dip following stimulant use
• Prescribed drugs can influence mood
Physical illness:
•
Central nervous system diseases (e.g., Parkinson disease, dementia, multiple sclerosis,
neoplastic lesions, stroke, subarachnoid haemorrhage)
•
Endocrine disorders (e.g., hyperthyroidism, hypothyroidism, Cushing's syndrome,
adrenal insufficiency, hyperparathyroidism)
•
Infectious disease (e.g., mononucleosis)
•
Sleep-related disorders
•
Chronic diseases such as diabetes and cardiac disease.
•
Cancer, especially pancreatic, some paraneoplastic syndromes
•
Autoimmune conditions.
•
Anaemia
Don’t forget risk assessment
Any questions?
References:
• New Oxford Textbook of Psychiatry, 2003
• Shorter Oxford Textbook of Psychiatry, 5th Edition
• ICD 10: DCR – 10, WHO
• DSM IV – tr
• http://www.cks.nhs.uk/depression/management/scenario_detection_
assessment_diagnosis/differential_diagnosis
You may also be interested in reading;
•
Major depression: revisiting the concept and diagnosis, Advances in Psychiatric
Treatment (2009) 15: 279-285 doi: 10.1192/apt.bp.108.005827
•
The course of bipolar disorder, Kate E. A. Saunders & Guy M. Goodwin Advances in
Psychiatric Treatment (2010) 16: 318-328 doi: 10.1192/apt.bp.107.004903
•
Depression and schizophrenia, David Castle & Peter Bosanac, Advances in Psychiatric
Treatment (2012) 18: 280-288 doi: 10.1192/apt.bp.111.008961