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Perugi G, Toni C, Travierso MC, Akiskal HS.
The
role of cyclothymia in atypical depression: toward a data-based reconceptualization
of the borderline-bipolar II connection.
J Affect Disord
2003 Jan;73(1-2):87-98
"OBJECTIVE: Recent data, including our own, indicate
significant overlap between atypical depression and bipolar II. Furthermore, the
affective fluctuations of patients with these disorders are difficult to separate,
on clinical grounds, from cyclothymic temperamental and borderline personality
disorders. The present analyses are part of an ongoing Pisa-San Diego investigation
to examine whether interpersonal sensitivity, mood reactivity and cyclothymic
mood swings constitute a common diathesis underlying the atypical depression-bipolar
II-borderline personality constructs. METHOD: We examined in a semi-structured
format 107 consecutive patients who met criteria for major depressive episode
with DSM-IV atypical features. Patients were further evaluated on the basis of
the Atypical Depression Diagnostic Scale (ADDS), the Hopkins Symptoms Check-list
(HSCL-90), and the Hamilton Rating Scale for Depression (HRSD), coupled with its
modified form for reverse vegetative features as well as Axis I and SCID-II evaluated
Axis II comorbidity, and cyclothymic dispositions ('APA Review', American Psychiatric
Press, Washington DC, 1992). RESULTS: Seventy-eight percent of atypical depressives
met criteria for bipolar spectrum-principally bipolar II-disorder. Forty-five
patients who met the criteria for cyclothymic temperament, compared with the 62
who did not, were indistinguishable on demographic, familial and clinical features,
but were significantly higher in lifetime comorbidity for panic disorder with
agoraphobia, alcohol abuse, bulimia nervosa, as well as borderline and dependent
personality disorders. Cyclothymic atypical depressives also scored higher on
the ADDS items of maximum reactivity of mood, interpersonal sensitivity, functional
impairment, avoidance of relationships, other rejection avoidance, and on the
interpersonal sensitivity, phobic anxiety, paranoid ideation and psychoticism
of the HSCL-90 factors. The total number of cyclothymic traits was significantly
correlated with 'maximum' reactivity of mood and interpersonal sensitivity. A
significant correlation was also found between interpersonal sensitivity and 'usual'
and 'maximum' reactivity of mood. LIMITATION: Correlational study. CONCLUSIONS:
Mood lability and interpersonal sensitivity traits appear to be related by a cyclothymic
temperamental diathesis which, in turn, appears to underlie the complex pattern
of anxiety, mood and impulsive disorders which atypical depressive, bipolar II
and borderline patients display clinically. We submit that conceptualizing these
constructs as being related will make patients in this realm more accessible to
pharmacological and psychological interventions geared to their common temperamental
attributes. More generally, we submit that the construct of borderline personality
disorder is better covered by more conventional diagnostic entities." [Abstract] Benazzi
F.
Should mood reactivity be included in the DSM-IV atypical features
specifier?
Eur Arch Psychiatry Clin Neurosci 2002 Jun;252(3):135-40
"BACKGROUND:
The definition of atypical depression is still an unsolved issue. DSM-IV atypical
features specifier criteria always require mood reactivity, but why mood reactivity
should be included is unclear. The study aim was to test whether mood reactivity
should be included in DSM-IV atypical features specifier. METHODS: Consecutively,
164 unipolar and 241 "soft" bipolar II major depressive episode (MDE)
outpatients were interviewed with the Structured Clinical Interview for DSM-IV.
The DSM-IV criteria for atypical features specifier were strictly followed. Associations
were tested by univariate logistic regression. RESULTS: MDE with atypical features
was present in 41.4 % of patients. Bipolar II disorder was significantly more
common in patients with atypical features. MDE with atypical features was significantly
associated with bipolar II, female gender, lower age of onset, more axis I comorbidity,
fewer psychotic features, and more depressive mixed states. In the whole sample,
mood reactivity was significantly associated with all the atypical symptoms, apart
from leaden paralysis, and all the other atypical symptoms were significantly
associated with each other. In the bipolar II sub-sample, mood reactivity was
associated with many, but not all, atypical symptoms, while in the unipolar sub-sample
it was associated with no atypical symptom. Atypical symptoms were significantly
more common in mood reactive than in non-mood reactive patients, apart from leaden
paralysis. Bipolar II disorder and mood reactivity were strongly associated. CONCLUSIONS:
Results may support the inclusion of mood reactivity in the DSM-IV atypical features
specifier for bipolar II disorder, but not for unipolar depression." [Abstract] Posternak
MA, Zimmerman M.
Symptoms of atypical depression.
Psychiatry
Res 2001 Nov 1;104(2):175-81
"Studies examining the demographic and clinical
features of depressed patients who meet criteria for the atypical features subtype
have often yielded conflicting results. The present study sought to evaluate the
demographic and clinical correlates associated with each of the five symptoms
(mood reactivity, hypersomnia, hyperphagia, leaden paralysis and rejection sensitivity)
that constitute the DSM-IV criteria set of atypical depression. Symptom prevalence
rates were determined for 661 psychiatric outpatients diagnosed with a major depressive
disorder, and were analyzed as a function of age, sex, severity, and episode duration.
We found that: (1) younger age was positively associated with hypersomnia and
negatively associated with leaden paralysis, while middle age was positively associated
with both hyperphagia and rejection sensitivity; (2) female sex was associated
with all of the atypical symptoms except rejection sensitivity; (3) a greater
severity of illness was positively associated with leaden paralysis and rejection
sensitivity, and negatively associated with mood reactivity; and (4) a duration
of illness of greater than 3 months was positively associated with hyperphagia,
leaden paralysis, and rejection sensitivity. Thus, the five atypical features
do not appear to be associated with the same clinical profiles." [Abstract] Parker
G, Roy K, Mitchell P, Wilhelm K, Malhi G, Hadzi-Pavlovic D.
Atypical
depression: a reappraisal.
Am J Psychiatry 2002 Sep;159(9):1470-9
"OBJECTIVE:
The study evaluated the DSM-IV definition of the atypical features specifier for
a major depressive episode in major depressive disorder. METHOD: Nonpsychotic
patients with major depressive disorder were assessed to determine if the DSM-IV
model and decision rules for the atypical features specifier for a major depressive
episode could be supported. RESULTS: The five clinical features of the DSM-IV
atypical features specifier for a major depressive episode showed weak internal
consistency, and the mandatory criterion A feature of mood reactivity did not
show specificity in relation to any of the four criterion B accessory symptoms.
The more severe the depression, the less likely the patient was to report criterion
A and hence to meet criteria for the atypical features specifier. Remodeling the
five features favored the personality style descriptor of interpersonal rejection
sensitivity as an alternate primary feature. A reformulated model also suggested
lifetime panic disorder and social phobia as higher-order determinants of atypical
features in major depressive disorder. Additional analyses of criteria suggested
that interpersonal rejection sensitivity and leaden paralysis had a phenomenological
base in anxiety, that mood reactivity was linked with irritability, and that neither
weight gain nor hypersomnia were clearly aligned with anxiety or depression, raising
questions about their status as symptoms. CONCLUSIONS: The current definition
and modeling of the DSM-IV atypical features specifier for a major depressive
episode in major depressive disorder appears problematic. As suggested by earlier
descriptions of atypical depression, certain expressions of anxiety may have primacy,
and some clinical features associated with the DSM-IV model may be adaptive homeostatic
responses rather than pathological symptoms." [Abstract] Gold
PW, Chrousos GP.
Organization of the stress system and its dysregulation
in melancholic and atypical depression: high vs low CRH/NE states.
Mol
Psychiatry 2002;7(3):254-75
"Stress precipitates depression and alters
its natural history. Major depression and the stress response share similar phenomena,
mediators and circuitries. Thus, many of the features of major depression potentially
reflect dysregulations of the stress response. The stress response itself consists
of alterations in levels of anxiety, a loss of cognitive and affective flexibility,
activation of the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous
system, and inhibition of vegetative processes that are likely to impede survival
during a life-threatening situation (eg sleep, sexual activity, and endocrine
programs for growth and reproduction). Because depression is a heterogeneous illness,
we studied two diagnostic subtypes, melancholic and atypical depression. In melancholia,
the stress response seems hyperactive, and patients are anxious, dread the future,
lose responsiveness to the environment, have insomnia, lose their appetite, and
a diurnal variation with depression at its worst in the morning. They also have
an activated CRH system and may have diminished activities of the growth hormone
and reproductive axes. Patients with atypical depression present with a syndrome
that seems the antithesis of melancholia. They are lethargic, fatigued, hyperphagic,
hypersomnic, reactive to the environment, and show diurnal variation of depression
that is at its best in the morning. In contrast to melancholia, we have advanced
several lines of evidence of a down-regulated hypothalamic-pituitary adrenal axis
and CRH deficiency in atypical depression, and our data show us that these are
of central origin. Given the diversity of effects exerted by CRH and cortisol,
the differences in melancholic and atypical depression suggest that studies of
depression should examine each subtype separately. In the present paper, we shall
first review the mediators and circuitries of the stress system to lay the groundwork
for placing in context physiologic and structural alterations in depression that
may occur as part of stress system dysfunction." [PDF] Levitan
RD, Vaccarino FJ, Brown GM, Kennedy SH.
Low-dose dexamethasone challenge
in women with atypical major depression: pilot study.
J
Psychiatry Neurosci 2002 Jan;27(1):47-51
"OBJECTIVE: To examine if atypical
depression may be associated with hypersuppression of the hypothalamic-pituitary-adrenal
(HPA) axis. METHOD: Eight women with atypical major depression and 11 controls
with no history of psychiatric illness, matched on age and body mass index, were
challenged with low-dose dexamethasone (0.25 mg and 0.50 mg in random order and
1 week apart). Dexamethasone was self administered at 11 pm, and plasma cortisol
samples were drawn at 8 am and 3 pm on the following day. RESULTS: After the 0.50-mg
dexamethasone challenge, mean suppression of morning cortisol was significantly
greater in patients with atypical depression (91.9%, standard deviation [SD] 6.8%)
than in the controls (78.3%, SD 10.7%; p < 0.01). CONCLUSION: These preliminary
data add to the growing body of literature that suggests atypical depression,
in contrast to classic melancholia, may be associated with exaggerated negative
feedback regulation of the HPA axis." [Abstract] McGinn
LK, Asnis GM, Rubinson E.
Biological and clinical validation of atypical
depression.
Psychiatry Res 1996 Mar 29;60(2-3):191-8
"Depressed
patients with (a) mood reactivity alone (MR group), (b) mood reactivity plus one
or more associated features (atypical depression, AD group), and (c) patients
with neither mood reactivity nor atypical depression (non-MR/AD group) were compared
on their cortisol response to 75 mg of desipramine (DMI), a relatively selective
norepinephrine reuptake inhibitor. AD patients exhibited a significantly higher
cortisol response to DMI compared with MR and non-MR/AD patients, suggesting that
atypical depression may be associated with a less impaired norepinephrine system.
MR and non-MR/AD patients did not differ, suggesting that mood reactivity alone
is not associated with the biological profile observed in atypical depression.
Results indicate that while mood reactivity may be necessary for the diagnosis
of atypical depression, the additional presence of at least one associated symptom
is required for a distinct biological profile. Our findings provide further biological
validation of the concept of atypical depression." [Abstract] Lam
RW, Stewart JN.
The validity of atypical depression in DSM-IV.
Compr
Psychiatry 1996 Nov-Dec;37(6):375-83
"Atypical depression has been included
in the DSM-IV as an episode specifier of major depressive episodes and dysthymia.
This report will review evidence for the clinical validity of atypical depression
using operational criteria for the validation of clinical syndromes. English language
articles between 1969 and March 1996 were found using a computerized and manual
reference search and were selected according to the following criteria: (1) primary
research, (2) definition of atypical depression, which includes depression and
not anxiety alone, and (3) relevance of data for validation of atypical depression.
Studies were evaluated on Kendall's six criteria for establishing clinical validity.
There are supporting data for diagnostic validity of atypical depression in the
criteria of clinical description and differential treatment response, with atypical
depression having a superior response to monoamine oxidase (MAO) inhibitors compared
to tricyclic antidepressants." [Abstract] Kasckow
JW, Baker D, Geracioti TD Jr.
Corticotropin-releasing hormone in
depression and post-traumatic stress disorder.
Peptides
2001 May;22(5):845-51
"Corticotropin-releasing hormone (CRH) has been
implicated in the regulation of a wide range of behaviors including arousal, motor
function, feeding, and reproduction. Because depressed patients are often hypercortisolemic
and intracerebroventricular administration of CRH to experimental animals produces
a syndrome reminiscent of depression, dysregulation of this compound has been
suggested to be involved in the pathogenesis of depressive and anxiety disorders.
Studies of cerebrospinal fluid CRH levels and clinical neuroendocrine tests in
patients with anxiety and affective disorders have supported this hypothesis.
This review discusses these neuroendocrine findings in melancholic and atypical
depression as well as post-traumatic stress disorder (PTSD). Overall, the data
suggest that melancholic depression is characterized by hyperactive central CRH
systems with overactivity of the pituitary-adrenal (HPA) axis. On the other hand,
atypical depression is characterized by hypoactive central CRH systems and accompanying
underactivity of the hypothalamic-pituitary-adrenal axis. Furthermore, the neuroendocrinology
of PTSD appears to be unique, in that patients have hyperactive central CRH systems
with underactivity of the pituitary-adrenal axis." [Abstract]
Tsigos C, Chrousos GP.
Hypothalamic-pituitary-adrenal
axis, neuroendocrine factors and stress.
J Psychosom Res
2002 Oct;53(4):865-71
"The stress system coordinates the adaptive responses
of the organism to stressors of any kind.(1). The main components of the stress
system are the corticotropin-releasing hormone (CRH) and locus ceruleus-norepinephrine
(LC/NE)-autonomic systems and their peripheral effectors, the pituitary-adrenal
axis, and the limbs of the autonomic system. Activation of the stress system leads
to behavioral and peripheral changes that improve the ability of the organism
to adjust homeostasis and increase its chances for survival. The CRH and LC/NE
systems stimulate arousal and attention, as well as the mesocorticolimbic dopaminergic
system, which is involved in anticipatory and reward phenomena, and the hypothalamic
beta-endorphin system, which suppresses pain sensation and, hence, increases analgesia.
CRH inhibits appetite and activates thermogenesis via the catecholaminergic system.
Also, reciprocal interactions exist between the amygdala and the hippocampus and
the stress system, which stimulates these elements and is regulated by them. CRH
plays an important role in inhibiting GnRH secretion during stress, while, via
somatostatin, it also inhibits GH, TRH and TSH secretion, suppressing, thus, the
reproductive, growth and thyroid functions. Interestingly, all three of these
functions receive and depend on positive catecholaminergic input. The end-hormones
of the hypothalamic-pituitary-adrenal (HPA) axis, glucocorticoids, on the other
hand, have multiple roles. They simultaneously inhibit the CRH, LC/NE and beta-endorphin
systems and stimulate the mesocorticolimbic dopaminergic system and the CRH peptidergic
central nucleus of the amygdala. In addition, they directly inhibit pituitary
gonadotropin, GH and TSH secretion, render the target tissues of sex steroids
and growth factors resistant to these substances and suppress the 5' deiodinase,
which converts the relatively inactive tetraiodothyronine (T(4)) to triiodothyronine
(T(3)), contributing further to the suppression of reproductive, growth and thyroid
functions. They also have direct as well as insulin-mediated effects on adipose
tissue, ultimately promoting visceral adiposity, insulin resistance, dyslipidemia
and hypertension (metabolic syndrome X) and direct effects on the bone, causing
"low turnover" osteoporosis. Central CRH, via glucocorticoids and catecholamines,
inhibits the inflammatory reaction, while directly secreted by peripheral nerves
CRH stimulates local inflammation (immune CRH). CRH antagonists may be useful
in human pathologic states, such as melancholic depression and chronic anxiety,
associated with chronic hyperactivity of the stress system, along with predictable
behavioral, neuroendocrine, metabolic and immune changes, based on the interrelations
outlined above. Conversely, potentiators of CRH secretion/action may be useful
to treat atypical depression, postpartum depression and the fibromyalgia/chronic
fatigue syndromes, all characterized by low HPA axis and LC/NE activity, fatigue,
depressive symptomatology, hyperalgesia and increased immune/inflammatory responses
to stimuli." [Abstract] Davidson
JR, Abraham K, Connor KM, McLeod MN.
Effectiveness of chromium in
atypical depression: a placebo-controlled trial.
Biol Psychiatry
2003 Feb 1;53(3):261-4
"BACKGROUND: Chromium picolinate (CP) has been
reported to benefit patients with symptoms of atypical depression. METHODS: A
placebo-controlled, double-blind, pilot study of CP was conducted in 15 patients
with DSM-IV major depressive disorder, atypical type. Patients received 600 micro
g of CP or matching placebo (PBO) for 8 weeks. RESULTS: Seven (70%) CP and zero
(0%) PBO patients met responder criteria (p =.02). Other outcomes were consistent
with greater effect of CP. Three patients on CP failed to show any improvement.
Chromium picolinate was well tolerated. CONCLUSIONS: Chromium picolinate shows
promising antidepressant effects in atypical depression. Its mechanism of action
may relate to 5HT2A downregulation, increased insulin sensitivity, or to other
effects." [Abstract]
Bouwer C, Claassen J, Dinan TG, Nemeroff CB.
Prednisone
augmentation in treatment-resistant depression with fatigue and hypocortisolaemia:
a case series.
Depress Anxiety 2000;12(1):44-50
"Abnormalities
of the hypothalamic-pituitary-adrenal (HPA) axis have long been implicated in
major depression with hypercortisolaemia reported in typical depression and hypocortisolaemia
in some studies of atypical depression. We report on the use of prednisone in
treatment-resistant depressed patients with reduced plasma cortisol concentrations.
Six patients with treatment-resistant major depression were found to complain
of severe fatigue, consistent with major depression, atypical subtype, and to
demonstrate low plasma cortisol levels. Prednisone 7.5 mg daily was added to the
antidepressant regime. Five of six patients demonstrated significant improvement
in depression on prednisone augmentation of antidepressant therapy. Although hypercortisolaemia
has been implicated in some patients with depression, our findings suggest that
hypocortisolaemia may also play a role in some subtypes of this disorder. In treatment-resistant
depressed patients with fatigue and hypocortisolaemia, prednisone augmentation
may be useful." [Abstract] Anisman
H, Ravindran AV, Griffiths J, Merali Z.
Endocrine and cytokine correlates
of major depression and dysthymia with typical or atypical features.
Mol
Psychiatry 1999 Mar;4(2):182-8
"Depression has been associated with both
suppression and enhancement of various aspects of immune functioning. It was of
interest to determine whether cytokine alterations associated with depression,
including interleukin-1 (IL-1beta) and interleukin-2 (IL-2), were related to the
neurovegetative symptom profile or to the chronicity of the illness. Circulating
ACTH, cortisol, norepinephrine (NE) and epinephrine levels, and production of
IL-1beta and IL-2 from mitogen-stimulated lymphocytes were assessed in classical
major depression, atypical depression (ie, with reversed neurovegetative features),
and dysthymia (chronic depression without comorbid major depression) with either
typical or atypical profiles, as well as nondepressed control subjects. Among
atypical depressives, plasma ACTH levels were elevated while cortisol was reduced
relative to controls. Irrespective of neurovegetative profile, IL-1beta production
was increased in dysthymic patients, and was highly correlated with age-of-onset
and duration of illness. In contrast, IL-2 production was reduced in each of the
groups, although less so among atypical major depressives. Moreover, IL-2 production
in the depressive groups was directly related to plasma NE levels. While neither
depressed mood per se nor neurovegetative features accounted for this effect,
it seemed likely that chronicity of illness or age-of-onset were associated with
cytokine alterations. Given that circulating cytokines influence neuroendocrine
functioning, and may affect neurovegetative features, a role for interleukins
may exist with respect to the pathophysiology of certain subtypes of depression."
[Abstract] Geracioti
TD Jr, Loosen PT, Orth DN.
Low cerebrospinal fluid corticotropin-releasing
hormone concentrations in eucortisolemic depression.
Biol
Psychiatry 1997 Aug 1;42(3):165-74
"Hypersecretion of corticotropin-releasing
hormone (CRH) and resulting hypercortisolism have been implicated in the pathogenesis
of major depression. To test this CRH hypersecretion hypothesis, cerebrospinal
fluid (CSF) was continuously withdrawn from 11:00 AM to 5:00 PM via an indwelling
subarachnoid catheter (placed at 8:00 AM), and immunoreactive CRH concentrations
were determined at 10-min intervals in 10 depressed patients, the majority of
whom exhibited at least one "atypical" symptom, and in 15 normal volunteers.
CSF CRH was low, plasma adrenocorticotropin (ACTH) tended to be low, and plasma
cortisol was normal in the depressed patients. Also, tobacco smokers had lower
CSF CRH than nonsmokers. CRH increased acutely in response to lumbar puncture,
had a brief half-life, showed rapid variability in concentration over time, and
displayed a diurnal concentration rhythm that was preserved in fasting individuals
and in most depressed patients. CSF CRH did not correlate with plasma ACTH or
cortisol; this and its rapidly fluctuating levels suggest a primarily extrahypothalamic
origin of lumbar CSF CRH." [Abstract] Young
EA, Carlson NE, Brown MB.
Twenty-four-hour ACTH and cortisol pulsatility
in depressed women.
Neuropsychopharmacology 2001 Aug;25(2):267-76
"Increased
plasma cortisol in patients with major depression is a well documented finding,
although it is present in only 25-30% of subjects with major depression. However,
ACTH and cortisol are secreted in a pulsatile manner, so it is unclear if increased
ACTH secretion occurs in depression and if there are changes in the pulsatile
components of ACTH secretion. Ten-minute sampling for ACTH and cortisol was performed
for 24 hr in 25 premenopausal depressed women, whose age and menstrual cycle day
matched control women. As a group, the depressed women demonstrated a trend to
increase cortisol secretion (p = 0.089). There was no difference in mean cortisol
between the patient group as a whole (8.36 +/- 2.9 microg/dl) and those patients
meeting criteria for atypical depression (8.38 +/- 1.9 microg/dl), but patients
meeting criteria for endogenous showed increased cortisol (12.17 +/- 4 microg/dl)
Mean ACTH was not significantly different between patients and controls. Pulse
analyses revealed similar number of secretory events and similar amplitudes for
cortisol secretory bursts in patients and controls. The baseline component area
under the curve of cortisol secretion was increased at a trend level (p =.064)
in depressed patients, and the baseline AUC for ACTH was significantly increased
in depressed patients (p =.045). No differences were found in pulsatile components
of ACTH secretion between patients and matched controls. Harmonic analyses indicated
no significant differences between patients and controls on any detected rhythm
for ACTH or cortisol. These data suggest that the pulsatile and circadian components
of the HPA axis are normal in premenopausal depressed women and that only 24%
of depressed women demonstrate hypercortisolemia." [Abstract] McGrath
PJ, Stewart JW, Harrison WM, Ocepek-Welikson K, Rabkin JG, Nunes EN, Wager SG,
Tricamo E, Quitkin FM, Klein DF.
Predictive value of symptoms of
atypical depression for differential drug treatment outcome.
J
Clin Psychopharmacol 1992 Jun;12(3):197-202
"Data for 401 depressed outpatients
with mood reactivity who participated in a randomized trial comparing placebo,
imipramine, and phenelzine were analyzed for predictors of differential response
by stepwise multiple regression techniques. Features of the Columbia criteria
for atypical depression including oversleeping, overeating, severe anergy, and
pathologic rejection sensitivity were each predictive of a poorer response to
imipramine than to phenelzine only when compared to those patients with none of
the features. These features were not additive in their contribution to differential
outcome. Lack of endogenous features was not predictive of a differential drug
treatment response. Compared with patients who have no symptoms of atypical depression,
patients with any of the four features had an inferior imipramine response rather
than a superior phenelzine response. These analyses indicate that the clear differential
responsivity to medication treatment in atypical depression is not simply related
to any one defining symptom and that further correlates of this apparent biological
heterogeneity need to be explored." [Abstract]
Wager S, Robinson D, Goetz R, Nunes E, Gully R, Quitkin
F.
Cholinergic REM sleep induction in atypical depression.
Biol
Psychiatry 1990 Feb 15;27(4):441-6
"The arecoline REM induction test,
a measurement of central cholinergic sensitivity, was performed in 10 patients
with atypical depression. Arecoline induced REM sleep significantly more rapidly
than placebo. Atypical depressives without evidence of anxiety, in particular
those without panic attacks, had a more rapid REM induction response to arecoline
than atypicals with anxiety symptoms. We compared our atypical depressives with
normal controls and affectively ill patients studied in other laboratories. The
rapid REM induction response observed in atypical depressives without anxiety
was comparable to that seen in endogenous depressives and euthymic bipolars. Previous
studies have demonstrated the presence of cholinergic supersensitivity in the
latter two groups of patients. Our results suggest that atypical depressives may
be distinguished in their response to arecoline based on their anxiety history,
and that cholinergic supersensitivity is present in atypical depressives without
anxiety. Additional studies with larger samples and simultaneously studied control
groups are necessary to test these preliminary findings." [Abstract] Quitkin
FM, Rabkin JG, Stewart JW, McGrath PJ, Harrison W, Davies M, Goetz R, Puig-Antich
J.
Sleep of atypical depressives.
J Affect
Disord 1985 Jan-Feb;8(1):61-7
"Patients who met provincial criteria for
atypical depression were contrasted with a group of patients who met RDC criteria
for endogenous depression and a group of normal controls on a standard series
of sleep variables. Atypical depressives were differentiated from normal controls
by a shortened REMP latency. They did not, however, appear to have the sleep continuity
disturbance exhibited by endogenous depressives. This preliminary work suggests
that atypical depressives may have a unique pattern of sleep variables consisting
of REM abnormalities without continuity disturbance. If this pattern is observed
in additional studies, it would add to the validity of considering atypical depression
a subtype of unipolar depressive illness." [Abstract]
Moller SE.
[Carbohydrates and depression]
Ugeskr
Laeger 1989 Sep 4;151(36):2250-2
"In the past decade, several related
behavioural disorders have been recognized which are characterized by disturbances
of mood and appetite. Some authors have reported that a significant number of
patients suffering from some of these diseases, i.e. subtypes of atypical depression
or obesity, crave carbohydrates. It is suggested that the common neurobiological
substrate for this symptom is disturbed function of central serotonin, which may
play a role in the regulation of carbohydrate intake. Other authors have disputed
hypothetical regulation of carbohydrate intake by serotonin and doubt the existence
of true carbohydrate cravers. Evidence from basal and clinical studies of these
topics is reported and discussed." [Abstract] Bruder
GE, Stewart JW, McGrath PJ, Ma GJ, Wexler BE, Quitkin FM.
Atypical
depression: enhanced right hemispheric dominance for perceiving emotional chimeric
faces.
J Abnorm Psychol 2002 Aug;111(3):446-54
"Two
studies compared hemispatial bias for perceiving chimeric faces in patients having
either atypical or typical depression and healthy controls. A total of 245 patients
having major depressive disorder (MDD) or dysthymia (164 with atypical features)
and 115 controls were tested on the Chimeric Faces Test. Atypical depression differed
from typical depression and controls in showing abnormally large right hemisphere
bias. This was present in patients having either MDD or dysthymia and was not
related to anxiety, physical anhedonia, or vegetative symptoms. In contrast, patients
having MDD with melancholia showed essentially no right hemisphere bias. This
is further evidence that atypical depression is a biologically distinct subtype
and underscores the importance of this diagnostic distinction for neurophysiologic
studies." [Abstract] Kendler
KS, Eaves LJ, Walters EE, Neale MC, Heath AC, Kessler RC.
The identification
and validation of distinct depressive syndromes in a population-based sample of
female twins.
Arch Gen Psychiatry 1996 May;53(5):391-9
"BACKGROUND:
Depression, a clinically heterogeneous syndrome, may also be etiologically heterogeneous.
Using a prospective, epidemiologic, and genetically informative sample of adult
female twins, we identify and validate a typology of depressive syndromes. METHODS:
Latent class analysis was applied to 14 disaggregated DSM-III-R symptoms for major
depression reported over the last year by members of 1029 female-female twin pairs.
RESULTS: Seven classes were identified, of which 3 represented clinically significant
depressive syndromes: (1) mild typical depression, (2) atypical depression, and
(3) severe typical depression. Severe typical depression was characterized by
comorbid anxiety and panic, long episodes, impairment, and help seeking. Atypical
depression was similar in severity to mild typical depression, but was characterized
by increased eating, hypersomnia, frequent, relatively short episodes, and a proclivity
to obesity. Individuals with recurrent episodes tended to have the same syndrome
on each occasion. The members of twin pairs concordant for depression had the
same depressive syndrome more often than expected by chance and this resemblance
was greater in monozygotic than in dizygotic pairs. CONCLUSION: In an epidemiologic
sample of female twins, depression is not etiologically homogeneous, but is instead
made up of several syndromes that are at least partially distinct from a clinical,
longitudinal, and familial/genetic perspective." [Abstract] Sullivan
PF, Kessler RC, Kendler KS.
Latent class analysis of lifetime depressive
symptoms in the national comorbidity survey.
Am J Psychiatry
1998 Oct;155(10):1398-406
"OBJECTIVE: Although clinical trials have documented
the importance of identifying individuals with major depression with atypical
features, there are fewer epidemiological data. In a prior report, the authors
used latent class analysis (LCA) to identify a distinctive atypical depressive
subtype; they sought to replicate that finding in the current study. METHOD: Using
the National Comorbidity Survey data, the authors applied LCA to 14 DSM-III-R
major depressive symptoms in the participants' lifetime worst episodes (N=2,836).
Validators of class membership included depressive disorder characteristics, syndrome
consequences, demography, comorbidity, personality/attitudes, and parental psychiatric
history. RESULTS: The best-fitting LCA solution had six classes. Four were combinations
of atypicality and severity: severe atypical, mild atypical, severe typical, and
mild typical. Syndrome severity (severe atypical and typical versus mild atypical
and typical classes) was associated with a pronounced pattern of more and longer
episodes, worse syndrome consequences, increased psychiatric comorbidity, more
deviant personality and attitudes, and parental alcohol/drug use disorder. Syndrome
atypicality (severe and mild atypical versus severe and mild typical classes)
was associated with decreased syndrome consequences, comorbid conduct disorder
and social phobia, higher interpersonal dependency and lower self-esteem, and
parental alcohol/drug use disorder. CONCLUSIONS: As in prior reports, the atypical
subtype of depression can be identified in epidemiological samples and, like typical
depression, exists in mild and severe variants. Atypical depressive subtypes were
characterized by several distinctive features. However, the correspondence between
epidemiologically derived typologies of atypical depression and DSM-IV major depression
with atypical features is not yet known." [Abstract]
| Benazzi
F.
Can only reversed vegetative symptoms define atypical depression?
Eur
Arch Psychiatry Clin Neurosci 2002 Dec;252(6):288-93
"BACKGROUND: The
definition of atypical depression (AD) has recently seen a rebirth of studies,
as the evidence supporting the current DSM-IV atypical features criteria is weak.
Study aim was to compare a definition of AD requiring only oversleeping and overeating
(reversed vegetative symptoms) to the DSM-IV AD definition (always requiring mood
reactivity, plus overeating/weight gain, oversleeping, leaden paralysis, and interpersonal
sensitivity [at least 2]). METHODS: Consecutive 202 major depressive disorder
(MDD) and 281 bipolar II outpatients were interviewed, during a major depressive
episode (MDE), with the Structured Clinical Interview for DSM-IV. The DSM-IV criteria
for AD were compared to a new AD definition based only on oversleeping and overeating,
which was the one often used in community studies. Associations were tested by
univariate logistic regression. RESULTS: The frequency of DSM-IV AD was 42.8 %,
and that of the new AD definition was 38.7 %. DSM-IV AD, and the new AD definition,
had almost all the same significant associations: bipolar II, female gender, lower
age, lower age of onset, axis I comorbidity, depressive mixed state, MDE symptoms
lasting more than 2 years, and bipolar family history. DSM-IV AD was present in
86 % of the new AD definition sample. The new definition of AD was significantly
associated with all the other DSM-IV AD symptoms not included in it. The new AD
definition was strongly associated with DSM-IV AD (odds ratio = 17.8), and had
sensitivity = 77.7 %, specificity = 90.5 %, positive predictive value = 86.1 %,
negative predictive value = 84.4 %, and ROC area curve = 0.85, for predicting
DSM-IV AD. CONCLUSIONS: Results support a simpler definition of AD, requiring
only oversleeping and overeating, and support the similar AD definition previously
used in community studies. This definition is easier and quicker to assess by
clinicians than the DSM-IV definition (mood reactivity and interpersonal sensitivity
are more difficult to assess). Some pharmacological studies support this new AD
definition (by showing better response to MAOI than to TCA, as shown in DSM-IV
AD)." [Abstract] Benazzi
F.
Testing DSM-IV definition of atypical depression.
Ann
Clin Psychiatry. 2003 Mar;15(1):9-16.
"The definition of atypical depression
(AD) has recently seen a rebirth of studies, as the evidence supporting DSM-IV
atypical features criteria is weak. Study aim was to test the validity of DSM-IV
definition of AD. Consecutive 202 major depressive disorder (MDD) and 281 bipolar
II outpatients were interviewed, during a major depressive episode (MDE), with
the Structured Clinical Interview for DSM-IV. The relationships of DSM-IV AD versus
variables often reported to distinguish AD and non-AD (gender, age, onset, bipolar
II, axis I comorbidity, MDE severity, residual MDE symptoms, depressive mixed
state), and versus bipolar family history, were tested. Each DSM-IV AD symptom's
relationship with the variables found significantly associated to DSM-IV AD was
then tested, in order to assess the degree of concordance among all AD symptoms.
Associations were tested by univariate logistic regression (STATA 7). Frequency
of DSM-IV AD was 42.8%. DSM-IV AD was significantly more common in bipolar II
versus MDD (53.7% vs. 27.7%, p = 0.0000). DSM-IV AD significant associations were
the following: bipolar II, female gender, lower age, lower age of onset, residual
MDE symptoms, axis I comorbidity, psychotic features, depressive mixed state,
and bipolar family history. Testing associations of each DSM-IV AD symptom versus
the variables found associated to DSM-IV AD showed high concordance. All AD symptoms
were significantly associated with DSM-IV AD, and with most study variables. Results
support the current DSM-IV definition of AD." [Abstract] Benazzi
F.
Is atypical depression a moderate severity depression? A 536-case
study.
J Psychiatry Neurosci 1999 May;24(3):244-7
"OBJECTIVE:
To determine if atypical depression is less common among outpatients with severe
depression than among those with nonsevere depression. DESIGN: Case series. SETTING:
Private practice. PATIENTS: Five hundred and thirty-six consecutive outpatients
presenting for treatment of unipolar or bipolar II depression. OUTCOME MEASURES:
Prevalence of atypical depression among patients with severe depression (Global
Assessment of Functioning Scale [GAF] score of 50 or less) and nonsevere depression.
RESULTS: There was no significant difference in the prevalence of atypical depression
between patients with severe and nonsevere depression. CONCLUSIONS: Results do
not support previous studies that atypical depression is usually of moderate severity.
A rating scale like the GAF, which assesses both symptom severity and impairment
of functioning, may give a more complete assessment of depression severity than
a symptoms rating scale (used in previous studies), which does not cover atypical
features and does not assess functioning." [Abstract] Williamson
DE, Birmaher B, Brent DA, Balach L, Dahl RE, Ryan ND.
Atypical symptoms
of depression in a sample of depressed child and adolescent outpatients.
J
Am Acad Child Adolesc Psychiatry 2000 Oct;39(10):1253-9
"OBJECTIVE: To
examine the presence of symptoms of atypical depression among children and adolescents
with a major depressive disorder (MDD). METHOD: One thousand forty-six youths
(aged 6-19 years) meeting DSM-III-R criteria for MDD were included in the study.
All subjects had presented at an outpatient clinic seeking treatment and were
identified as having MDD via clinical interviews using the semistructured Schedule
for Affective Disorders and Schizophrenia for School-Age Children-Present Episode
(K-SADS-P) with the youngster themselves and a parent/guardian. A diagnosis of
atypical depression was derived from the symptoms of depression assessed in the
K-SADS-P and required the presence of mood reactivity and at least one the following
symptoms: hypersomnia, increased appetite, weight gain, or psychomotor retardation
(substituted for leaden paralysis). RESULTS: One hundred sixty-two (15.5%) of
the depressed youths met criteria for atypical depression. The symptoms of atypical
depression were found to correlate marginally, and the diagnosis of atypical depression
had marginal construct validity for both children and adolescents. CONCLUSIONS:
The findings from this large sample of depressed children and adolescents suggest
that atypical features of depression occur in this age group. However, the diagnosis
of atypical depression appears to have only marginal construct validity for both
children and adolescents." [Abstract] Benazzi
F.
Psychomotor changes in melancholic and atypical depression: unipolar
and bipolar-II subtypes.
Psychiatry Res 2002 Nov 15;112(3):211-20
"Psychomotor
changes are reported to be 'nearly always present' in the melancholic subtype
of major depressive episode (MDE) in DSM-IV-TR, and are believed by some researchers
to be markers of melancholia. The aim of this study was to compare melancholic
and atypical forms of MDE and to determine whether psychomotor changes are core
features of melancholic MDE. The Structured Clinical Interview of DSM-IV was used
to consecutively assess 107 unipolar and 164 bipolar-II MDE outpatients. The criteria
used to define melancholic and atypical MDE followed DSM-IV-TR. Melancholic MDE
was present in 17.7% of patients; atypical MDE, in 35.0%. The group of patients
with melancholic MDE had the following differences from the atypical group: higher
age, higher age at onset, fewer females, more unipolar cases, fewer bipolar-II
cases, lower Global Assessment of Functioning scores, more MDE symptoms, and more
psychotic features. Percentages of observable and marked psychomotor changes (agitation
and retardation combined) did not differ significantly between the two groups,
though the melancholic group tended to have more symptoms. Retardation was significantly
more common in melancholic MDE, but its frequency was very low in both melancholic
and atypical cases (12.5 vs. 0.0%). Logistic regression controlling for age, gender
and illness duration had little effect on the findings, which suggests that psychomotor
changes are not core features of melancholic MDE." [Abstract] Perugi
G, Akiskal HS, Lattanzi L, Cecconi D, Mastrocinque C, Patronelli A, Vignoli S,
Bemi E.
The high prevalence of "soft" bipolar (II) features
in atypical depression.
Compr Psychiatry 1998 Mar-Apr;39(2):63-71
"Seventy-two
percent of 86 major depressive patients with atypical features as defined by the
DSM-IV and evaluated systematically were found to meet our criteria for bipolar
II and related "soft" bipolar disorders; nearly 60% had antecedent cyclothymic
or hyperthymic temperaments. The family history for bipolar disorder validated
these clinical findings. Even if we limit the diagnosis of bipolar II to the official
DSM-IV threshold of 4 days of hypomania, 32.6% of atypical depressives in our
sample would meet this conservative threshold, a rate that is three times higher
than the estimates of bipolarity among atypical depressives in the literature.
By definition, mood reactivity was present in all patients, while interpersonal
sensitivity occurred in 94%. Lifetime comorbidity rates were as follows: social
phobia 30%, body dysmorphic disorder 42%, obsessive-compulsive disorder 20%, and
panic disorder (agoraphobia) 64%. Both cluster A (anxious personality) and cluster
B (e.g., borderline and histrionic) personality disorders were highly prevalent.
These data suggest that the "atypicality" of depression is favored by
affective temperamental dysregulation and anxiety comorbidity, clinically manifesting
in a mood disorder subtype that is preponderantly in the realm of bipolar II.
In the present sample, only 28% were strictly unipolar and characterized by avoidant
and social phobic features, without histrionic traits." [Abstract] Benazzi
F.
Is there a link between atypical and early-onset "unipolar"
depression and bipolar II disorder?
Compr Psychiatry 2003
Mar-Apr;44(2):102-9
"The aim of the present study was to determine whether
there is a link between "unipolar" depression with atypical features
and early onset, and bipolar II disorder, using atypical features and early onset
as markers of bipolarity. A total of 158 consecutive unipolar and 234 bipolar
II major depressive episode (MDE) outpatients were interviewed using the Structured
Clinical Interview for DSM-IV (SCID). Patients were divided into those with and
without atypical features, and into those with and without early onset. Comparisons
were made on variables reported to distinguish bipolar from unipolar: age of onset,
recurrences, atypical features, depressive mixed state (MDE plus three or more
concurrent hypomanic symptoms [DMX3]), and bipolar II family history. Compared
to bipolar II patients, patients with atypical unipolar were not significantly
different regarding age of onset, DMX3, recurrences, and bipolar II family history.
Compared to non-atypical unipolar patients, atypical unipolar patients had a significantly
different age of onset. Nonatypical unipolar patients, versus bipolar II patients,
were significantly different regarding age of onset, recurrences, DMX3, and bipolar
II family history. Early onset unipolar, versus bipolar II, were not significantly
different regarding atypical features, recurrences, DMX3, and bipolar II family
history. Later onset unipolar patients, versus bipolar II patients, were significantly
different regarding atypical features, recurrences, DMX3, and bipolar II family
history. These results support a link of atypical and early-onset "unipolar"
depression with bipolar II disorder, and support Pages and Dunner's suggestion
to combine bipolar II and recurrent unipolar into a single group." [Abstract] Matza
LS, Revicki DA, Davidson JR, Stewart JW.
Depression with atypical
features in the National Comorbidity Survey: classification, description, and
consequences.
Arch Gen Psychiatry. 2003 Aug;60(8):817-26.
"BACKGROUND:
Atypical depression has been found to be distinct from other types of depression
in terms of psychiatric symptom profile and treatment response. However, debate
continues regarding its specific characteristics, impact, and diagnostic criteria.
The current study was conducted to increase understanding of atypical depression
diagnosed using only the reversed vegetative symptoms of hypersomnia and hyperphagia.
METHODS: An atypical depression group (n = 304 [36.4% of the depressed sample;
39.0% when weighted to approximate the national population]) was identified within
the US National Comorbidity Survey, which assessed psychiatric disorders among
a nationally representative sample using the Composite International Diagnostic
Interview. The atypical group was identified based on DSM-III-R criteria for a
major depressive episode, in addition to atypical features of hypersomnia and
hyperphagia. Comparison groups were those with nonatypical depression (n = 532)
and individuals without a psychiatric disorder (n = 4071). RESULTS: Compared with
nonatypical depression, atypical depression was associated with a greater percentage
of women and an earlier age of onset. The atypical group also reported higher
rates of most depressive symptoms, suicidal thoughts and attempts, psychiatric
comorbidity (panic disorder, social phobia, and drug dependence), disability and
restricted activity days, use of some health care services, paternal depression,
and childhood neglect and sexual abuse (P<.05). Compared with people without
psychiatric disorders, the atypical group reported higher rates of disability
and restricted activity days, use of all mental health care services, parental
depression, and childhood abuse (P<.001). CONCLUSIONS: This analysis of a nationally
representative US sample suggests that overeating and oversleeping can be used
to identify an atypical depression subgroup that is distinct from other depressed
patients in terms of demographics, psychiatric comorbidities, and abuse history.
Findings also suggest that atypical depression is associated with increased distress,
suicidal ideation, and disability compared with nonatypical depression."
[Abstract] Derecho
CN, Wetzler S, McGinn LK, Sanderson WC, Asnis GM.
Atypical depression
among psychiatric inpatients: clinical features and personality traits.
J
Affect Disord 1996 Jun 20;39(1):55-9
"OBJECTIVE: This study investigates
the frequency and characteristics of Atypical Depression (AD) among depressed
inpatients. METHOD: Twenty-one depressed inpatients received DSM-IV diagnoses,
were rated on the Hamilton Depression Rating Scale (HAMD), and assessed for AD
using the Atypical Depressive Disorder Scale. AD was defined as the presence of
mood reactivity and two of four associated features: hyperphagia, hypersomnia,
leaden paralysis, rejection sensitivity. Mood reactivity was defined as the ability
to reach 50% of a non-depressed mood. All subjects completed the SCL-90, MCMI-II,
and a suicide survey. RESULTS: Seven patients (33%) met criteria for AD. AD and
non-AD patients did not differ in terms of severity of depression, history of
suicide attempts, levels of clinical symptomatology, age of onset of depression,
prior hospitalizations, and most personality characteristics. However, AD patients
scored significantly higher than non-AD patients on the SCL-90 Interpersonal Sensitivity
and MCMI-II Avoidant scales, and were more likely to be single. CONCLUSION: AD
is fairly prevalent on an inpatient service, comparable to the frequency found
in outpatient settings. AD is not a milder form of depression. The only differences
between AD and non-AD patients reflect the personality trait of rejection sensitivity
which is a defining feature of AD." [Abstract] Posternak
MA, Zimmerman M.
The prevalence of atypical features across mood,
anxiety, and personality disorders.
Compr Psychiatry 2002
Jul-Aug;43(4):253-62
"This study examines and compares the prevalence
rates of the atypical features subtype across each of the major mood, anxiety,
and personality disorders (PDs). It also evaluates the impact that comorbid anxiety
and PDs have on the likelihood that depressed patients will present with atypical
symptoms. Eleven hundred thirty psychiatric outpatients were evaluated for the
presence of atypical symptoms. All axis I diagnoses were made using the Structured
Clinical Interview for DSM-IV (SCID). PDs were assessed in a subset of 530 patients
using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). From
a sample of 579 patients diagnosed with a current major depressive disorder, 22.5%
met criteria for the atypical subtype. Prevalence rates were similar in bipolar
and unipolar patients, although the pattern of symptoms was distinct. Prevalence
rates were lower in patients with dysthymic disorder (12.5%), adjustment disorder
with depressed mood (9.4%), and depression not otherwise specified (NOS) (7.9%).
When major depression existed in the presence of a comorbid anxiety disorder,
the likelihood of presenting with atypical features doubled. Nine percent of the
patients diagnosed with an anxiety disorder (without a comorbid depressive disorder)
met criteria for atypical features. Two of the four atypical symptoms, leaden
paralysis and rejection sensitivity, were found to be especially prominent in
nondepressed anxiety disorder patients. Of the 10 PDs listed in DSM-IV, only avoidant
PD was associated with the atypical features subtype. In large part, this was
accounted for by the high rate of rejection sensitivity in these patients. In
conclusion, as many as one quarter of depressed patients who present for outpatient
psychiatric treatment meet criteria for the atypical features subtype. There appears
to be a strong association between anxiety and atypical depression, but the exact
nature of this relationship needs to be further elucidated. It is unclear whether
personality pathology is independently associated with the atypical features subtype."
[Abstract] Benazzi
F.
Prevalence and clinical features of atypical depression in depressed
outpatients: a 467-case study.
Psychiatry Res 1999 Jun 30;86(3):259-65
"The
prevalence of DSM-IV atypical depression and differences between atypical versus
non-atypical depression were investigated in 467 unipolar and bipolar depressed
outpatients in private practice. Consecutive outpatients presenting for treatment
of a major depressive episode were assessed with the Comprehensive Assessment
of Symptoms and History following DSM-IV criteria, the Montgomery-Asberg Depression
Rating Scale, and the Global Assessment of Functioning Scale. The prevalence of
atypical depression was 38.1%. Of the variables investigated (unipolar and bipolar
diagnoses, age at onset, gender, psychosis, comorbidity, chronicity, duration
of illness, recurrences, and severity), age at onset was significantly lower,
and female gender, comorbidity, and bipolar II disorder were significantly more
common in atypical than nonatypical depression. Comparisons between bipolar II
atypical depression and unipolar atypical depression did not show significant
differences, apart from age at onset. Findings suggest that there are important
clinical differences between atypical and non-atypical depression in private practice
outpatients." [Abstract]
Benazzi F.
Early-onset versus late-onset
atypical depression: unipolar and bipolar II.
J Affect Disord
2000 Dec;61(1-2):95-9
"BACKGROUND: To find differences between early-
and late-onset atypical depression (AD). METHODS: 211 unipolar/bipolar II AD outpatients,
interviewed with DSM-IV Structured Clinical Interview and depression rating scales.
Logistic regression was used. RESULTS: Early-onset AD was significantly associated
with age, female gender, duration of illness, recurrences, chronicity, MADRS,
bipolar II and unipolar. Early-onset bipolar II AD was significantly associated
with age, female gender, duration of illness, recurrences and chronicity. Early-onset
unipolar AD was significantly associated with age. Limitations: Age at onset recall
bias, single interviewer, non-blind, cross-sectional assessment, bipolar II diagnosis
reliability. CONCLUSIONS: Bipolar II AD is more likely to be chronic if early
onset." [Abstract] Benazzi
F.
Atypical depression with hypomanic symptoms.
J
Affect Disord 2001 Jul;65(2):179-83
"BACKGROUND: Depressive mixed states
(major depressive episodes with some hypomanic symptoms) (DMS) are not classified
in DSM-IV and are understudied. The aims of this study were to find the prevalence
and clinical features of DMS in atypical depression. METHODS: A total of 87 bipolar
II and unipolar depressed outpatients were interviewed within the DSM-IV Structured
Clinical Interview. RESULTS: More than two hypomanic symptoms were present in
50.0% of the atypical and 20.3% of the non-atypical depression cases (P=0.006).
DMS mainly included irritable mood, distractibility, racing thoughts, and increased
talking. LIMITATIONS: There was a single interviewer, and it was a non-blind,
cross-sectional assessment, with bipolar II reliability. CONCLUSIONS: Findings
have treatment implications, as antidepressants may worsen DMS, and mood stabilizers
may improve it." [Abstract] Benazzi
F.
Atypical depression in private practice depressed outpatients:
a 203-case study.
Compr Psychiatry 1999 Jan-Feb;40(1):80-3
"The
prevalence of DSM-IV atypical depression and comparisons between atypical and
typical depression were studied in 203 consecutive unipolar and bipolar depressed
outpatients presenting for treatment of depression in private practice. The prevalence
of atypical depression was 31%. Of the variables investigated (unipolar/bipolar
diagnosis, age at baseline/onset of first major depressive episode, gender, psychosis,
comorbidity, chronicity, duration of illness, recurrence, and severity), a bipolar
II diagnosis was significantly more common, the age at baseline and duration of
illness were significantly lower, and the proportion of females and psychiatric
comorbidity were significantly higher in atypical versus typical depression. Secondary
analysis showed that bipolar II atypical depression had a significantly earlier
age at baseline/onset and affected more females, but there were no other significant
differences versus typical depression. The findings suggest important clinical
differences between atypical and typical depression, and a bipolar II subtype
may be separated from the broad category of atypical depression." [Abstract] Angst
J, Gamma A, Sellaro R, Zhang H, Merikangas K.
Toward validation of
atypical depression in the community: results of the Zurich cohort study.
J
Affect Disord 2002 Nov;72(2):125-38
"AIMS: This paper (1) examines the
validity of the atypical subtype of depression in a community-based longitudinal
cohort study, (2) presents estimates of the prevalence and sex differences of
DSM-IV atypical depression and a newly more broadly defined atypical syndrome
in the community and (3) compares the clinical correlates and treatment patterns
of those with atypical depression with other depressives. METHODS: The Zurich
cohort study is comprised of 591 subjects selected from a population-based cohort
of young adults representative of the canton of Zurich in Switzerland, who were
screened in 1978 with the Symptom Checklist 90-R [L.R. Derogatis (1977)] and followed
prospectively with five interviews between 1979 and 1993. Atypical depression
was defined on a spectrum ranging from atypical major to minor to atypical depressive
symptoms alone. RESULTS: The rate of DSM-IV atypical major depressive episodes
in this community is 4.8% and for major atypical depression syndrome is 7.3%.
Whereas there was no marked sex difference for nonatypical features, there was
a significant female preponderance for DSM-IV and broadly defined atypical depressive
subtypes. Systematic investigation of the diagnostic criteria for atypical depression
revealed that a nonhierarchical definition of atypical depression with respect
to mood reactivity yielded as valid a syndromic definition as the current hierarchy
based on mood reactivity as an essential feature. Very high comorbidity (odd ratios>2.0)
was found with seasonality, bipolar II, social phobia, binge eating, neurasthenia
and sociopathy. LIMITATIONS: Atypical depression was not defined a priori, its
criteria were derived from two sections of the Zurich interview. CONCLUSIONS:
Atypical depression has high population prevalence and substantial significance
in terms of clinical severity, impairment, and service use. The intriguing finding
that the sex difference in depression may be attributed to atypical features of
depression will need further investigation. Overall, our data indicate that the
atypical subtype of depression is a valid entity based on evidence from such traditional
indicators of validity as inclusion criteria and indicators of course. However,
there are some problems with discriminatory validity from other disorders. Although
comorbidity with these disorders may in part reflect an operational artifact of
symptom overlap, further work needs to be done in distinguishing atypical depression
from bipolar II." [Abstract] Posternak
MA, Zimmerman M.
Lack of association between seasonality and psychopathology
in psychiatric outpatients.
Psychiatry Res 2002 Nov 15;112(3):187-94
"There
exists an extensive literature documenting the impact of seasonality on rates
of depression, atypical depression, bulimia, and suicide. In the present report
drawn from the Rhode Island Methods to Improve Diagnostic Assessment and Services
(MIDAS) project, we reviewed the results of 1500 diagnostic evaluations of patients
who presented to our psychiatric outpatient practice between 1995 and 2001. We
sought to determine whether seasonal fluctuations in psychopathology were discernible
at the level of how patients present for psychiatric treatment. Contrary to our
hypotheses, we did not find (1) higher rates of onset of major depressive disorder
in the spring and fall, (2) higher rates of depressive symptoms or rates of atypical
depression in the winter, (3) higher rates of bulimia in the winter, or (4) higher
rates of suicidal ideation in the spring. We conclude from these results that
the association between seasonality and psychopathology may not be discernible
at the level of presentations to an outpatient psychiatric practice." [Abstract] Tam
EM, Lam RW, Robertson HA, Stewart JN, Yatham LN, Zis AP.
Atypical
depressive symptoms in seasonal and non-seasonal mood disorders.
J
Affect Disord 1997 Jun;44(1):39-44
"The authors examined the rates of
atypical depression and prevalence of specific atypical symptoms in patients with
seasonal versus non-seasonal depression. Fifty-three patients with seasonal affective
disorder (SAD) were compared to 54 patients with non-seasonal major depressive
disorder (MDD) using the atypical depression diagnostic scale (ADDS). SAD patients
scored significantly higher than non-seasonal MDD patients in hyperphagia and
hypersomnia, and significantly lower in interpersonal sensitivity and other rejection
avoidance. There was no difference in the rate of ADDS diagnosis of atypical depression.
Differences between atypical depression and SAD suggest that they are separate
subtypes of depression with an overlapping symptom picture." [Abstract] Stewart
JW, Quitkin FM, Terman M, Terman JS.
Is seasonal affective disorder
a variant of atypical depression? Differential response to light therapy.
Psychiatry
Res 1990 Aug;33(2):121-8
"Similar symptomatology has been described for
both seasonal affective disorder (SAD) and atypical depression. For example, hyperphagia,
hypersomnia, and intense lethargy are common to both, suggesting that they might
be subtypes of the same disorder. If SAD and atypical depression are different
manifestations of the same underlying pathophysiology, treatment effective for
one might also benefit the other. Bright artificial lights (2500 lux, 6-8 a.m.
and p.m.) were significantly less effective in treating eight patients diagnosed
as having atypical depression without a seasonal pattern than 25 SAD patients.
Differential treatment outcome suggests that SAD and atypical depression are separate
disorders." [Abstract] Sullivan
PF, Prescott CA, Kendler KS.
The subtypes of major depression in
a twin registry.
J Affect Disord 2002 Apr;68(2-3):273-84
"OBJECTIVE:
The subtypes of major depression (MD) remain incompletely understood. While there
is consensus about the existence of MD with 'typical' vegetative features, further
data are required to evaluate the existence of MD with atypical features. METHOD:
Assessment of MD symptomatology in year prior to interview was available in 6846
individual twins from a population-based twin registry. The nine 'A' criteria
for DSM-IV MD were unpacked so that the nature of sleep disturbance, appetite
and weight changes, and motoric alterations were recorded. Latent class analysis
was used to create an empirical typology of MD. RESULTS: Seven latent classes
appeared to provide the best representation of the data. The most severe of these
classes had interpretable profiles corresponding to typical MD, atypical MD, and
'minor' but seemingly important depressive states. These classes were generally
more deviant than a comparison group for nearly all available validators. There
tended to be a gradient with the typical class being most extreme, minor depressive
classes the least extreme, and the atypical class having an intermediate position.
CONCLUSIONS: Our findings support the existence of atypical depression as a phenomenological
subtype of MD. Besides the differences in symptom patterns, there are many more
similarities than differences across a range of external validators. Similar to
other reports, we found evidence of the importance and morbidity of depressive
symptomatology that does not meet the DSM-IV MD thresholds." [Abstract] Agosti
V, Stewart JW.
Atypical and non-atypical subtypes of depression:
comparison of social functioning, symptoms, course of illness, co-morbidity and
demographic features.
J Affect Disord 2001 Jun;65(1):75-9
"BACKGROUND:
There are scant data regarding the demographic and psychosocial characteristics
of outpatients with Atypical Depression (AD). METHODS: The demographic characteristics,
rates of chronic dysphoria, baseline Symptom Check List Revised, and Social Adjustment
Scale scores of 320 moderately depressed patients with and without AD were compared.
RESULTS: ADs had a higher number of self-reported symptoms, greater impairments
in functioning, and higher rates of chronic dysphoria and bipolar II than patients
without Atypical Depression (NAD). LIMITATIONS: Variables used in this study were
mostly cross-sectional, and the analyses were performed post-hoc. CONCLUSIONS:
These data suggest ADs had a more pernicious course of illness than NADs, and
that patients with AD were more symptomatic and dysfunctional at admission."
[Abstract] Derecho
CN, Wetzler S, McGinn LK, Sanderson WC, Asnis GM.
Atypical depression
among psychiatric inpatients: clinical features and personality traits.
J
Affect Disord 1996 Jun 20;39(1):55-9
"OBJECTIVE: This study investigates
the frequency and characteristics of Atypical Depression (AD) among depressed
inpatients. METHOD: Twenty-one depressed inpatients received DSM-IV diagnoses,
were rated on the Hamilton Depression Rating Scale (HAMD), and assessed for AD
using the Atypical Depressive Disorder Scale. AD was defined as the presence of
mood reactivity and two of four associated features: hyperphagia, hypersomnia,
leaden paralysis, rejection sensitivity. Mood reactivity was defined as the ability
to reach 50% of a non-depressed mood. All subjects completed the SCL-90, MCMI-II,
and a suicide survey. RESULTS: Seven patients (33%) met criteria for AD. AD and
non-AD patients did not differ in terms of severity of depression, history of
suicide attempts, levels of clinical symptomatology, age of onset of depression,
prior hospitalizations, and most personality characteristics. However, AD patients
scored significantly higher than non-AD patients on the SCL-90 Interpersonal Sensitivity
and MCMI-II Avoidant scales, and were more likely to be single. CONCLUSION: AD
is fairly prevalent on an inpatient service, comparable to the frequency found
in outpatient settings. AD is not a milder form of depression. The only differences
between AD and non-AD patients reflect the personality trait of rejection sensitivity
which is a defining feature of AD." [Abstract]
Alpert
JE, Uebelacker LA, McLean NE, Nierenberg AA, Pava JA, Worthington JJ 3rd, Tedlow
JR, Rosenbaum JF, Fava M.
Social phobia, avoidant personality disorder
and atypical depression: co-occurrence and clinical implications.
Psychol
Med 1997 May;27(3):627-33
"BACKGROUND: Increasing attention has been directed
in recent years to the detection and treatment of psychiatric co-morbidity among
depressed individuals. The overlap of social phobia (SP) and avoidant personality
disorder (APD) has been well recognized and a relationship between these disorders
and depression has been suggested. METHODS: The pattern and clinical implications
of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed
by DSM-III-R criteria, were studied among 243 out-patients presenting with depression.
RESULTS: Overall, 26.7% of adults in our sample with MDD met criteria for SP and
28.4% for APD. Almost two-thirds of depressed adults meeting criteria for social
phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed
adults who met criteria for both SP+APD exhibited a significantly higher proportion
of atypical depression (54.8%) compared with those with neither SP nor APD (31.1%).
Among depressed patients, the co-occurrence of SP with APD was also associated
with an earlier age of onset of MDD, a greater number of comorbid Axis I diagnoses,
and greater impairment of social adjustment and assertiveness. CONCLUSIONS: Results
confirm the overlap of SP and APD in a depressed population and the high prevalence
of these disorders in MDD. They suggest that depressed individuals with both SP
and APD but not SP alone are at particularly high risk for atypical depression
and for social dysfunction in excess of that caused by a current major depression."
[Abstract] Nierenberg
AA, Phillips KA, Petersen TJ, Kelly KE, Alpert JE, Worthington JJ, Tedlow JR,
Rosenbaum JF, Fava M.
Body dysmorphic disorder in outpatients with
major depression.
J Affect Disord 2002 May;69(1-3):141-8
"BACKGROUND:
Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with
an imagined or slight defect in appearance, with depression as its most frequent
comorbid condition. The purpose of this study was to evaluate the rate of BDD
in a cohort of consecutive outpatients with typical and atypical major depressive
disorder. METHODS: Three hundred and fifty consecutive outpatient subjects with
major depression who entered an antidepressant treatment study were evaluated
drug-free with the SCID-P, SCID-II, a diagnostic module for BDD, and other measures.
Depressed subjects with comorbid BDD were compared to those without BDD with regard
to demographics, course of depression, comorbid conditions, and other relevant
variables. RESULTS: Twenty-eight (8.0%) subjects had a lifetime history of BDD
and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier
age of onset of depression and longer duration of the current episode, but not
a greater number of depressive episodes or greater severity of depression. Subjects
with and without BDD were similar with respect to age, gender, and marital status.
There was a higher rate of lifetime and current BDD in subjects with atypical
depression than in those with non-atypical depression (14.4% compared to 5.1%;
chi(2)=6.63; P=0.01: 11.6% vs. 4.1%; chi(2)=7.02; P=0.02). Subjects with BDD also
had higher rates of social phobia, any eating disorder, and any somatoform disorder
but not obsessive compulsive disorder. They also had higher rates of avoidant,
histrionic, and dependent personality disorders. LIMITATIONS: As we did not specifically
examine bipolar spectrum conditions, the present study cannot address to what
extent BDD is comorbid with Bipolar-II disorder. CONCLUSIONS: BDD is frequently
comorbid with major depression, is associated with an earlier age of onset of
depression and longer duration of depressive episodes, and is found more frequently
with atypical than non-atypical depression." [Abstract] Mannuzza
S, Schneier FR, Chapman TF, Liebowitz MR, Klein DF, Fyer AJ.
Generalized
social phobia. Reliability and validity.
Arch Gen Psychiatry
1995 Mar;52(3):230-7
"OBJECTIVE: To investigate the reliability and validity
of DSM-III-R "generalized" social phobia by examining interrater agreement
and comparing patients with generalized and "nongeneralized" social
phobia on demographic characteristics, clinical variables, and familial social
phobia. DESIGN: Two senior clinicians classified 129 patients attending an anxiety
clinic as having DSM-III-R social phobia that is generalized (fears most social
situations) or nongeneralized (less than most) based on independent narrative
review. RESULTS: Good reliability was achieved (kappa = 0.69). Patients with generalized
social phobia were more often single, had earlier onsets of social phobia, had
more interactional fears, and had higher rates of atypical depression and alcoholism.
Familial social phobia was more common among patients with generalized social
phobia than patients with nongeneralized social phobia and controls, with no difference
between the latter two groups. CONCLUSIONS: Generalized social phobia (1) can
be distinguished reliably from nongeneralized social phobia, (2) is a valid subtype,
and (3) may characterize a familial form of the disorder." [Abstract]
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