Wednesday, March 23, 2011

Atypical Depression - Entirely Too Atypical?

I just finished uploading four new articles on depression on my mcmanweb site. The articles replace and greatly expand upon two earlier pieces that introduced depression. In addition, I also wrote a new article to replace my old one on atypical depression.

In the second of my introductory pieces, I propose a “vegetative-agitated” depression distinction that would better serve patients than the highly confusing “typical-atypical” distinction. The following extracts from my two articles make my case ...

Vegetative or Agitated?

In other words, are you feeling sort of like you have a bad cold but without the runny nose, fever, and diarrhea? No energy? Can't get started? No motivation? Can barely string two thoughts together? Just want to curl up into a ball and not wake up? Your clinical condition is dead but breathing. You get the picture.

Or does your depression feel more like you're in neutral, but with the motor running out of control? "If only, if only," a piece of your over-ruminating prefrontal cortex may be chanting. "I can't take it!" the primitive reacting limbic region of the brain may be screaming. You want to grab the world by the throat and shake it. Folded into all of this may be anxiety. You get the picture.

Two very different mental states, obviously. But way too many doctors (my guess is most) refer to both conditions as "depression" and send patients out the door with the exact same prescription.

Figuring out depression is very binary, really. Emotion, mental activity, physical activity, and tell-tale behavior - too much or too little, high or low, up or down, under or over. Gradually a picture begins to emerge, a very complex one full of anomalies, a testament to your uniqueness and to the fact that no two depressions are alike. Nevertheless, the picture is likely to resolve one of two ways.

Which side of the universe you find yourself on suggests different (though overlapping) treatment and recovery strategies: energizing agents and lifestyle practices for vegetative depressions, calming agents and lifestyle practices for agitated depressions.

Typical or Atypical?

According to the DSM-IV, as opposed to major depression, the patient with atypical features experiences mood reactivity, with improved mood when something good happens. This would broadly translate to an individual momentarily taking leave of his or her Stygian gloom to laugh at a friend slipping on a banana peel.

Likewise, there would be an element of enthusiasm to news of winning the Powerball lottery.

In addition, the DSM-IV mandates at least two of the following: Increase in appetite or weight gain (as opposed to the reduced appetite or weight loss of "typical" depression); excessive sleeping (as opposed to insomnia); leaden paralysis; and sensitivity to rejection.

Sensitivity to rejection could be interpreted as the flip side to mood reactivity. Here, there is a visible response to bad news rather than good. Either way - mood reactivity or sensitivity to rejection - beneath despair that borders on catatonic, we see signs of life, of a "dead but breathing" individual capable of animation.

But is this only confusing the picture?

A 2001 study by Posternak and Zimmerman cast doubt on the only feature of atypical depression that is mandatory under the DSM - that of mood reactivity. In their study, the authors evaluated the five symptoms of atypical depression across five different groups of patients (including women, different age groups, and according to severity and length of time of symptoms), and discovered mood reactivity only featured among the women patients, suggesting this particular criteria should be dropped.

In practice, psychiatry is retrofitting a set of diagnostic anomalies over the notorious DSM symptom check-list. Thus, before we can even determine if an individual has atypical depression, a clinician must first find evidence of "major depressive disorder." (Check-list depression, in other words.)

Then, in making a diagnosis of "major depressive disorder with atypical features" the clinician, in effect, is asked to contradict parts of that same check-list.

A 2010 abstract to a review article (the full article is in Japanese) tells us that we are probably looking at four views of atypical depression. To give you an indication of the complexity of the discussion, following is a representative segment of one sentence of the abstract:

...reflects the theory that mood nonreactivity is the essential symptom of "endogenomorphic depression", which was proposed by Klein as typical depression.

The original Japanese would have been no less confusing, a point which the author seems to happily acknowledge. Indeed, the abstract resolves into brutal clarity in its summary dismissal of the diagnosis:

Consequently, the concept of atypical depression has become overextended and gradually lost its construct validity.

In the current discussion over what constitutes atypical, psychiatry has lost sight of the fact of how the term came about in the first place - as a hypothesis for why certain patients with unipolar depression responded to MAOIs rather than tricyclics.

Let the conversation build on that important piece.


My new depression articles:

What Is It? 
Figuring Out Depression 
Placing Depression in Context
Depression Plus
Atypical Depression


butterflywings said...

...'discovered mood reactivity only featured among the women patients, suggesting this particular criteria should be dropped'.
Why does this suggest that the criteria should be dropped?
I wonder if this just reflected the self-report nature of depression questionnaires - women are more likely to *see themselves* as emotionally reactive, since society tells us that women are emotional. It's like the studies that show women report themselves as more empathetic - but when measures that are not self-report are used, we aren't.

John McManamy said...

Many thanks for picking this up, Butterflywings. Now I have to put my thinking cap on. Please feel free to add more comments. :)

Ross Vaughn said...

People who suffer from atypical depression also exhibit other symptoms that aren't normally associated with "normal" depression The Ups And Downs Of Atypical Depression