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25.12.2013

Depression dysthymia bipolar disorder, why sudden ringing in ears - How to DIY

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Since the classic descriptions, depression has been conceived as an episodic and recurrent illness.
This article provides an update on the diagnosis, causation, and treatment of chronic depressive problems, with a focus on the recently introduced diagnostic category of persistent depressive disorder (PDD). In DSM-III and DSM-IV, the protracted forms of depression have been conceptualized as dysthymia and by the chronic specifier of major depressive episodes. In DSM-III and DSM-IV, dysthymia was trumped by MDD and was only diagnosed if the threshold for a major depressive episode was not met in the initial 2 years of symptoms. While the merger of dysthymia and chronic depression into PDD is well justified by their strong sequential comorbidity and similar implications for prognosis and treatment, several aspects of the new diagnosis are not well supported by evidence and may not be useful. The assumption that most individuals with chronic depression also fulfill the dysthymia criteria may not hold consistently enough—it creates a group of individuals who suffer from chronic depression but do not receive the PDD diagnosis.
The DSM-IV specifier “with atypical features” can be used to characterize the current or most recent depressive episode in patients with either unipolar or bipolar type mood disorder and in patients with dysthymic disorder.10 As described in the Table, the DSM-IV specifier requires the presence of mood reactivity (criterion A) and at least 2 of 4 criterion B features (significant weight gain or hyperphagia, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity resulting in social or occupational impairment). To avoid overdiagnosis or underdiagnosis, bear in mind definitional aspects of the clinical features that constitute the criteria for atypical depression.
Interpersonal rejection sensitivity in the context of atypical depression implies a lifelong trait (during both periods of depression and periods of euthymia) that is typically exacerbated during depressive episodes.
Studies have suggested that patients with atypical depression tend to have an earlier onset of symptoms and a more chronic course than their melancholic counterparts.24,26,27Atypical depression is more common in younger women.


The validity of mood reactivity as a mandatory feature for diagnosing atypical depression has been challenged.
One established characteristic of atypical depression is its differential response to MAOIs.
The hypothesis that reactive mood as a mandatory criterion is not indispensable for the diagnosis of atypical depression was supported by the community study by Angst and colleagues.21 Although mood reactivity was the most common symptom reported by their sample of patients with atypical depression (89% to 90%), other symptoms (ie, rejection sensitivity, leaden paralysis, and hypersomnia) were also quite commonly present (78% to 89%). Clearly, the inclusion of mood reactivity as a mandatory or hierarchical criterion for the diagnosis of atypical depression should be reassessed. Depressive episodes with clear onset and offset and sharp contrast with one’s usual mood and behaviors are perhaps the most conspicuous feature of severe mood disorders.
Dysthymia was characterized by milder symptoms not fully meeting criteria for MDD, but lasting 2 years or longer and meriting clinical attention because of the cumulative burden of long-standing symptoms. Major depressive episodes could be specified as chronic if the full criteria were continuously met for 2 years or longer. This new division of depressive disorders gives more weight to duration than to severity of symptoms.
Findings from 4 studies showed that mood reactivity does not significantly correlate with the presence of criterion B features, which suggests that mood reactivity should not be considered an obligatory feature for the diagnosis of atypical depression.22,28,30,31 Furthermore, regarding melancholia (which requires the loss of mood reactivity) as exclusionary of the diagnosis of atypical depression subtype makes the presence of reactive mood largely redundant. The correlation between the presence or absence of reactive mood and a differential response to either TCAs or MAOIs has been challenged by a number of pharmacological studies.29,32-38 Findings from those studies suggest that the effectiveness of MAOIs in depression is not necessarily associated with mood reactivity, implying that the presence of this specific feature may not be essential for diagnosing this syndrome.


This suggests that atypical depression could also be effectively diagnosed when mood reactivity is not considered a mandatory criterion.21 In a more recent analysis, Angst and colleagues24 reported that diagnosis of atypical depression could be made with equal validity if 3 of 5 criteria (including mood reactivity) or 2 of 4 criteria (excluding mood reactivity) were used. Papakostas, MD is Director of Treatment-Resistant Depression Studies in the Department of Psychiatry at Massachusetts General Hospital and Associate Professor of Psychiatry at Harvard Medical School in Boston.
The symptomatic criteria for dysthymia differed in part from those for major depressive episode, with an emphasis on low self-esteem and hopelessness (Table 1). DSM-5 defines PDD on the basis of the set of symptoms for dysthymia, with the assumption that most individuals who meet the full symptoms for MDD also meet criteria for dysthymia.
The inclusion of mood reactivity as an essential feature also neglects the fact that some depressive episodes, when quite severe, manifest with a nonreactive mood, even in the presence of reversed neurovegetative symptoms.
The term “anergic depression” is sometimes used to describe depressive episodes that take this form.



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