Diseases, Disorders information

4. DSM

5. The Nosology of DSM IV
A core concept in DSM IV is the distinction between the episodes of abnormal mood (eg depression, mania, hypomania and mixed) from the illnesses characterized by these episodes.
1. Current Nosology

1. DSM IV has Four Mood disorder categories and a residual category
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The diagnostic criteria for current episodes (mania, hypomania, depression and mixed) are distinguished from the criteria illnesses characterized by the longitudinal pattern of episodes. Explicit in the DSM IV is the concept that a primary mood disorder is only one of possible causes that can produce a mood episode. Other common causes of mood episodes include medical disorders, substance abuse disorders, and other psychiatric illness.
2. Unipolar Mood Disorders

1. Major Depressive Disorder
2. Dysthymia
3. Depressive Disorder NOS

3. Bipolar Disorders

1. Bipolar I

1. Last episode can be specified

1. mixed
2. manic
3. Hypomanic
4. depressed

2. Bipolar II
3. Cyclothymia
4. Bipolar disorder NOS

1. became the more generally applied term by the close of the 19th century.
2. Gull (1894) described it, “a condition characterized by a sinking of the spirits, lack of courage or initiative, and a tendency to gloomy. The symptom occurs in weakened conditions of the nervous systems, such as neurasthenia and is specifically characteristic of melancholia.”
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3. Psychodynamic

1. Classical formulation = anger turned inward
2. Freud 1915

1. Mourning and Melancholia
1. “The disturbance of self-regard is absent in mourning; but otherwise the features are the same”
2. “Moreover, the exciting causes due to environmental influences are, so far as we can discern them at all, the same for both conditions.”.

2. Kraepelin’s synthesis

1. Set the stage for the current classification system. The initial division of mad patients or “dements” was based on the age of onset. Those that developed psychotic symptoms late in life (senile dementia) were placed under the care of Dr. Alzheimer. Those who were ill earlier in life were distinguished into two groups based on the course of illness. Patients with a chronic course of unremitting deterioration were diagnosed “dementia praecox” and those considered to recover completely between their episodes of illness were noted to have prominent mood symptoms and received the diagnosis “manic-depressive insanity”.
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2. Basic Characteristics of Kraepelin’s Mood disorder
1. Usually early age of onset
2. Prominent mood symptoms
3. Recurrent Episodes
4. Periods of recovery
5. Variable Courses

3. Leonhard

1. The Classification of Endogenous Psychosis
1. Found Kraepelin’s classification wholly inadequate and described 56 separate psychotic illnesses including several varieties of illness which alternated between specific affective states (eg “anxiety-euphoria psychosis”). Such bipolar illnesses were separated form the “monopolar” types. Subsequent research failed to validate Leonhard’s illnesses except for the division of manic depressive insanity into unipolar and bipolar depression based on the occurrence of manic episodes during the course of the illness.

Burton’s Anatomy of Melancholia (1621)

1. “A kind of dotage without a fever, having for his ordinary companions fear and sadness, without any apparent occasion”
2. Sadness among symptoms but not the defining characteristic.
3. 3 Subtypes: Primary: Generalized: Hypochondriacal
4. Clinico-anatomical (19 th century)

1. Associated overt signs of illness with anatomical lesions. Failure to identify lesions in patients with mental illness had two major consequences;

1. The concept of neurosis gradually changed from a label implying tissue pathology to a psychodynamic formulation.

2. In the absence of etiological classification the basis of nosology was descriptive classification

1. Under the descriptive system separate clusters of mental functions could become diseased separately.

1. Intellectual
2. Emotional

3. Volitional

5. Falret 1854
1. Memoire sur la Folie Circulaire
1. Described cyclical course of mood including “folie a double forme”

1. Pre- Kraepelin

1. History records recognition of profound disturbances of emotions in its most ancient accounts of the human condition.
1. Gilgemesh the first single-case report
2. Hippocrates Melancholia = Humoral Imbalance (5th century BC)

1. Ancient concepts of melancholia bear little correspondence to its modern meaning or to the idea of depression or even mood. The historical idea of melancholia most nearly conveys the same meaning as “madness”. Hippocrates observed symptoms of delirium in patients suffering from quartan malaria and noted their darkened skin. He ascribed this over abundance of black bile, melancholia. This term like depression became nonspecific as it became associated with character traits, grief, and illness.

1. Divine Affliction
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1. The severity of suffering was interpreted even by many otherwise physicianly experts as evidence of punishment by the gods rather than the result of a lesion like other disease states. Galen (2nd century) attempted to correct this asserting his belief that the causes of mental illness was based on the same principles as other medical illness. Unfortunately through the middle ages the prevailing view (adopted by the church) followed Malleus Maleficarum (1486, The Hammer of witchcraft).

2. Burton’s Anatomy of Melancholia (1621)
1. Sadness among symptoms but not the defining characteristic.

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Overview of Mood Disorders
Introduction
1. Mood disorders occupy a place of special importance in the clinical practice and nosology of psychiatry.

1. Mood disorders are common

1. Most epidemiological studies find the lifetime prevalence of mania be about one percent. When bipolar type II, cyclothymia and other forms of bipolar illness are included the prevalence increases to between 2 and 3 %.
2. Unipolar Depression lifetime prevalence Male12%, Female 25%

3. High rate of suicide

1. 15% Lifetime risk of suicide
2. Risk is 30 times greater than general population
3. 50% of all suicides are committed by depressed patients
4. The most common reason for psychiatric hospitalization
1. At any time 2-3% of the population (USA and Europe) are seriously -impaired are hospitalized due to affective illness.
5. The annual direct cost of mood disorders in the USA = $16 billion
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2. Mood disorder is often hard to recognize

1. encompass patients ranging from mildly ill to severely disabled
2. the value of patient self report is excellent for ruling out depression
3. the value of patient self report is poor for ruling out mania
4. Reporting is heavily influenced by current mood state

3. The course of mood disorders can be greatly influenced

1. Cycle promoting Treatments
2. Mood Stabilizing treatments
3. Substance abuse
4. Life style

4. Subtpying Mood disorders can guide treatment decisions because the different disorders have prognostic significance and
2. This presentation will focus on the development of the mood disorder concept , current diagnostic criteria and the clinical features of bipolar illnesses.