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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 26. This is the beginning of the thread.
Posted by psychobot5000 on May 8, 2012, at 23:59:45
What the hell does it mean if you meet the criteria for both melancholic and atypical depression?
I know there's an exclusion under atypical for patients who are melancholic, but this strikes me as arbitrary, especially since so many of the gritty details of atypical depression fit me so well.
Does anyone know how much evidence we have that these categories are actually useful for diagnosis, treatment, or...anything? Are the distinctions valid? If so, are the prescriptions (biologically based treatment (i.e. drugs and neuronstimulation?) for melancholic depression...everything in the bag for atypical, but among medications, look to MAOis) actually useful?
F*ck this noise,
Psychobot5000
Posted by SLS on May 9, 2012, at 5:20:29
In reply to Melancholic vs Atypical depression, posted by psychobot5000 on May 8, 2012, at 23:59:45
> What the hell does it mean if you meet the criteria for both melancholic and atypical depression?
Bipolar depression looks very similar to atypical depression, but can have psychomotor retardation and melancholic ruminations. I guess it looks like a hybrid of both types of depression.
Treating bipolar depression can involve using mood stabilizers along with antidepressants. Some people who have bipolar depression have never experienced a spontaneous manic episode. This pretty much describes me. I have had a few drug-induced manias, though. I profit from combining lithium and lamotrigine along with Parnate and nortriptyline.
For unipolar melancholic depression, tricyclics are considered to be more effective than the SSRIs.
- Scott
Posted by Phillipa on May 9, 2012, at 10:17:47
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 9, 2012, at 5:20:29
I always thought the mood stabalizers were used to prevent manic episodes? Now am more confused that before. Very complicated. Phillipa
Posted by psychobot5000 on May 9, 2012, at 11:53:10
In reply to Re: Melancholic vs Atypical depression » SLS, posted by Phillipa on May 9, 2012, at 10:17:47
> I always thought the mood stabalizers were used to prevent manic episodes? Now am more confused that before. Very complicated. Phillipa
My guess is it's the antidepressants, not the mood stabilizers, that precipitated Scott's manic episodes. (?)
Posted by lawgrindmeintoground on May 9, 2012, at 18:58:24
In reply to Re: Melancholic vs Atypical depression, posted by psychobot5000 on May 9, 2012, at 11:53:10
I've found that the mood stabilizers (lithium, depakote, etc.) do just that - stabilize both ways. However, since I'm more a depressive/negative-mixed bipolar, I almost have to have some sort of antidepressant in the mix to lift me back up.
Posted by Phillipa on May 9, 2012, at 20:56:26
In reply to Re: Melancholic vs Atypical depression, posted by psychobot5000 on May 9, 2012, at 11:53:10
I'm sure they are. I just wonder why they are necessary if not on any? Phillipa
Posted by phidippus on May 9, 2012, at 22:14:52
In reply to Melancholic vs Atypical depression, posted by psychobot5000 on May 8, 2012, at 23:59:45
Most psychiatrists I know prescribe according to symptomology and largely disregard disgnosis.
Eric
Posted by policebox on May 10, 2012, at 1:42:22
In reply to Melancholic vs Atypical depression, posted by psychobot5000 on May 8, 2012, at 23:59:45
I can't see how you could be have both melancholic and atypical depression, as the diagnoses are mutually exclusive.
Melancholia involves the inability to find pleasure in positive things and lack of mood reactivity. Melancholic depression generally involves weight loss or loss of appetite and insomnia.
Whereas atypical depression involves mood reactivity in that you are able to feel an improved mood in response to positive events. Atypical depression has a triad of reversed vegetative symptoms, specifically over-eating, hypersomnia, and accute sensitivity to interpersonal rejection (which is another form of mood reactivity).
I'd base a diagnosis on what you experience most of the time. If you mostly fit melancholic, then I'd say you have that. If you mostly fit atypical, then I'd say you have that.
Although I sometimes lose my appetite when I'm particularly upset or sometimes my mood doesn't improve despite positive events, I am largely atypical the vast majority of the time.
> What the hell does it mean if you meet the criteria for both melancholic and atypical depression?
>
> I know there's an exclusion under atypical for patients who are melancholic, but this strikes me as arbitrary, especially since so many of the gritty details of atypical depression fit me so well.
>
> Does anyone know how much evidence we have that these categories are actually useful for diagnosis, treatment, or...anything? Are the distinctions valid? If so, are the prescriptions (biologically based treatment (i.e. drugs and neuronstimulation?) for melancholic depression...everything in the bag for atypical, but among medications, look to MAOis) actually useful?
> F*ck this noise,
> Psychobot5000
Posted by psychobot5000 on May 10, 2012, at 2:59:45
In reply to Re: Melancholic vs Atypical depression, posted by policebox on May 10, 2012, at 1:42:22
> I can't see how you could be have both melancholic and atypical depression, as the diagnoses are mutually exclusive.
>
In the original post, I specifically mentioned that (supposed) point. However, a detailed look at the symptomology of the two indicates that:1) I have the salient features of both
2) Said salient features are not mutually exclusive(which, along with other details, suggests that)
3) The exclusion between the two is, to an extent, arbitrary, a grasping after clarity amid a disorder which, in the early 21st century, is still fairly poorly understood (or can you explain to me how a vagus nerve stimulator treats affective disorders?).> Melancholia involves the inability to find pleasure in positive things and lack of mood reactivity. Melancholic depression generally involves weight loss or loss of appetite and insomnia.
>
> Whereas atypical depression involves mood reactivity...Not to go through the entire symptomology of the two disorders, I'll skip to noting that mood reactivity and anhedonia, the two focal points of the diagnosis, are NOT mutually exclusive. 'Mood' and 'ability to experience pleasure,' are simply not the same thing, though naturally they are interrelated (like almost all depressive symptoms). Thus it's possibly to have variable mood in response to external events, yet a severely reduced ability to experience pleasure, at the same time. Ta-daa!
Along the same lines, 'hypersomnia' (characteristic of atypical dep.) and 'insomnia' (characteristic of other kinds) are likewise not mutually exclusive. At all. Trust me.
Which brings us full circle, to me saying: I have both atypical and melancholic symptoms most or all of the time, and my condition often fits the characteristics of both like a hand in a glove. I wonder if there is anything to be learned from this?
Posted by SLS on May 10, 2012, at 5:27:08
In reply to Re: Melancholic vs Atypical depression, posted by policebox on May 10, 2012, at 1:42:22
> I can't see how you could be have both melancholic and atypical depression, as the diagnoses are mutually exclusive.
Where did you read or hear this?
I have never heard that the two depressive subtypes were mutually exclusive. In fact, Frederick Quitkin diagnosed me as having atypical reactive type depression with endogenomorphic characteristics. It was Quitkin and his research team at Columbia that first defined the two subtypes. If they felt that these subtypes were mutually exclusive, they would not have diagnosed me as having a hybrid presention. Of course, bipolar depression had not been carefully described and scrutinized at this time. Since bipolar depression can look like a hybrid between atypical and melancholic depression, I could see how they missed my diagnosis.
- Scott
Posted by SLS on May 10, 2012, at 5:30:06
In reply to Re: Melancholic vs Atypical depression » policebox, posted by psychobot5000 on May 10, 2012, at 2:59:45
> In the original post, I specifically mentioned that (supposed) point. However, a detailed look at the symptomology of the two indicates that:
>
> 1) I have the salient features of both
> 2) Said salient features are not mutually exclusive
Is there any family history of affective or schizoid disorders?
- Scott
Posted by psychobot5000 on May 10, 2012, at 13:37:54
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 10, 2012, at 5:30:06
> > In the original post, I specifically mentioned that (supposed) point. However, a detailed look at the symptomology of the two indicates that:
> >
> > 1) I have the salient features of both
> > 2) Said salient features are not mutually exclusive
>
>
> Is there any family history of affective or schizoid disorders?
>
>
> - ScottWow. Yes, there is. In my parents' generation, there's one case of schizophrenia, and an occasional episode of unipolar mood troubles. Do those suggest something?
-pb5000
Posted by policebox on May 10, 2012, at 20:16:03
In reply to Re: Melancholic vs Atypical depression, posted by SLS on May 10, 2012, at 5:27:08
It's common sense. A person can't both be fat and thin simultaneously the majority of the time.
Similarly, you can't, the majority of the time, have have an inability to feel pleasure over positive things and have the ability to feel pleasure over positive things.
A client and provider need to base a diagnosis on the symptoms which are present more frequently, or alternatively, the symptoms which are causing the more severe disability, then treat accordingly.
> > I can't see how you could be have both melancholic and atypical depression, as the diagnoses are mutually exclusive.
>
> Where did you read or hear this?
>
> I have never heard that the two depressive subtypes were mutually exclusive. In fact, Frederick Quitkin diagnosed me as having atypical reactive type depression with endogenomorphic characteristics. It was Quitkin and his research team at Columbia that first defined the two subtypes. If they felt that these subtypes were mutually exclusive, they would not have diagnosed me as having a hybrid presention. Of course, bipolar depression had not been carefully described and scrutinized at this time. Since bipolar depression can look like a hybrid between atypical and melancholic depression, I could see how they missed my diagnosis.
>
>
> - Scott
Posted by SLS on May 10, 2012, at 20:16:50
In reply to Re: Melancholic vs Atypical depression » SLS, posted by psychobot5000 on May 10, 2012, at 13:37:54
> > > In the original post, I specifically mentioned that (supposed) point. However, a detailed look at the symptomology of the two indicates that:
> > >
> > > 1) I have the salient features of both
> > > 2) Said salient features are not mutually exclusive
> >
> >
> > Is there any family history of affective or schizoid disorders?
> >
> >
> > - Scott
>
> Wow. Yes, there is. In my parents' generation, there's one case of schizophrenia, and an occasional episode of unipolar mood troubles. Do those suggest something?
It suggests to me that you might have a diathesis for bipolar disorder, even if mania has not occurred. If your physiology is more bipolar than it is unipolar, you might profit from taking drugs like Lamictal, Abilify, or lithium in combination with antidepressants. What you describe as depression does fit the bipolar type.
- Scott
Posted by SLS on May 10, 2012, at 20:50:02
In reply to Re: Melancholic vs Atypical depression, posted by policebox on May 10, 2012, at 20:16:03
> > > I can't see how you could be have both melancholic and atypical depression, as the diagnoses are mutually exclusive.
> > Where did you read or hear this?
> It's common sense.
That's not what I asked.
I am not inclined to accept the conclusions you derive from your common sense as being fact. I was hoping you could produce some facts or theories that would preclude the existence of a hybridization of depressive symptoms between those seen in atypical and melancholic presentations.
> A person can't both be fat and thin simultaneously the majority of the time.
I don't think your analogy fits, but, okay.
If atypical and melancholic phenotypes represent different genotypes, perhaps one can have the genotypes for both disorders simultaneously. This would be analogous to someone having lupis and diabetic nephropathy simulataneously. This is just my attempt at exercising common sense. It is far from being fact. It is only speculative.
> Similarly, you can't, the majority of the time, have have an inability to feel pleasure over positive things and have the ability to feel pleasure over positive things.I'm not sure what you are talking about here.
Mood reactivity is no longer considered to be a reliable indicator of atypical depression. You can have atypical depression without being able to feel pleasure.
As I said, I would describe bipolar depression as being a hybrid of atypical and melancholic depressions.
The definition of atypical depression is far from being globally agreed upon.
http://www.mcmanweb.com/atypical_depression.html
- Scott
Posted by Emme_v2 on May 10, 2012, at 21:09:26
In reply to Re: Melancholic vs Atypical depression, posted by policebox on May 10, 2012, at 20:16:03
> It's common sense. A person can't both be fat and thin simultaneously the majority of the time.
Ah, but you can be of medium build.....a kind of fat/thin hybrid. :) Or maybe have skinny legs and a plump middle. Just thinkin' creatively here.
Posted by psychobot5000 on May 10, 2012, at 22:20:15
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 10, 2012, at 20:16:50
> > > > In the original post, I specifically mentioned that (supposed) point. However, a detailed look at the symptomology of the two indicates that:
> > > >
> > > > 1) I have the salient features of both
> > > > 2) Said salient features are not mutually exclusive
> > >
> > >
> > > Is there any family history of affective or schizoid disorders?
> > >
> > >
> > > - Scott
> >
> > Wow. Yes, there is. In my parents' generation, there's one case of schizophrenia, and an occasional episode of unipolar mood troubles. Do those suggest something?
>
>
> It suggests to me that you might have a diathesis for bipolar disorder, even if mania has not occurred. If your physiology is more bipolar than it is unipolar, you might profit from taking drugs like Lamictal, Abilify, or lithium in combination with antidepressants. What you describe as depression does fit the bipolar type.
>
>
> - Scott
Hmm. Thank you, Scott. That's potentially tremendously useful. Looking at those...I'm guessing they're all recommended because they have mood-stabilizing properties. ...Abilify is probably one I might possibly give a fuller trial of, at some point...Do you mind if I ask what about my symptoms 'fits the bipolar type'? Are you speaking of the variability in mood reactivity, say, or something more else?
I also appreciated your other response, which laid out in a more restrained and erudite manner why the relationship between atypical and other forms of depression is not as simple as 'common sense' may seem to indicate, even aside from the conflation of (an)hedonic symptoms with mood. It's also good to know that mood reactivity is no longer considered a reliable indicator of the one type. I will pass on that tidbit to a friend who recently looked over the symptomology of atypical depression, was shocked by it, and is now going through the process of getting a possible diagnosis of same.
-P
Posted by SLS on May 11, 2012, at 6:26:42
In reply to Re: Melancholic vs Atypical depression, posted by psychobot5000 on May 10, 2012, at 22:20:15
http://www.psycheducation.org/depression/MorePresentingSx.htm"* - bipolar depressions can manifest the entire gamut of endogenous, nonendogenous and/or atypical depressive symptomatology, and they are always recurrent over time . Soft bipolar depressions usually show atypical depressive features."
I disagree with the supposition appearing later in the article that bipolar depression includes mood reactivity just because it is thought of as being "atypical". It may with some people, but obviously not for all. The point is, bipolar depression can look like a hybridization of melancholic and atypical depression; with symptoms being predominantly atypical.
Your describing yourself as having symptoms of both melancholic and atypical, plus having a family history of affective and schizoid disorders suggest a closer look at bipolar depression. Even though some people might define your presentation as "soft bipolar", there is nothing soft about it. A "hard" bipolar presentation of depression can be severe, and does not always include manic or hypomanic episodes. The term "Bipolar V" would describe this condition best, I think. Of course, treatment resistance to traditional antidepressants is a feature to be taken into consideration. They might not be sufficient to bring someone to remission.
What are some of the other features of your illness? Do you have comorbid GAD, ADHD, or OCD? Has it followed a recurrent pattern with periods of euthymia (normothymia)?
For me, Bipolar IV fits because I am chronically depressed with the exception of drug-induced mania.
- Scott
Posted by emmanuel98 on May 11, 2012, at 18:55:33
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 11, 2012, at 6:26:42
I've never found the distinction that helpful. I have had periods where I sleep constantly and periods where I am up all night. I never over-eat and generally lose my appetite. I have had periods where my mood is reactive and periods when it is not. My p-doc says I have a mood disorder, call it bipolar 3-b or whatever you want. The major problem, whatever you call it, is that I become severely suicidal, which is not necessarily a symptom of either type of depression, but is a problem in my life.
Posted by Phillipa on May 11, 2012, at 19:08:24
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 11, 2012, at 6:26:42
I disagree that PMS and thyroid disorders fit under soft bipolar as they are all hormones. Phillipa
Posted by psychobot5000 on May 11, 2012, at 20:46:54
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 11, 2012, at 6:26:42
Emmanuel, you may well be right, that the labeling is not necessarily precise or useful.
Scott, I did not know there were so many types of bipolar. I have taken mood-stabilizing agents without notably more success with them than with traditional antidepressants. In answer to your question, I do seem to have some generalized anxiety (and social anxiety), as well as ADD-like symptoms and some OCD, so, yeah, kind of all of the above. I do not have euthymic periods, but I do seem to go through cycles where my symptoms (including mood, cognition, and sleep. Also mild headaches start) get worse over a period of weeks for no discernable reason before returning to their previous, moderately less bad, level. Perhaps that's a manifestation of some sort of mood cycling--such had never occurred to me. I'd given up trying to understand the phenomenon, but now I wonder.
-Pb> Your describing yourself as having symptoms of both melancholic and atypical, plus having a family history of affective and schizoid disorders suggest a closer look at bipolar depression. Even though some people might define your presentation as "soft bipolar", there is nothing soft about it. A "hard" bipolar presentation of depression can be severe, and does not always include manic or hypomanic episodes. The term "Bipolar V" would describe this condition best, I think. Of course, treatment resistance to traditional antidepressants is a feature to be taken into consideration. They might not be sufficient to bring someone to remission.
>
> What are some of the other features of your illness? Do you have comorbid GAD, ADHD, or OCD? Has it followed a recurrent pattern with periods of euthymia (normothymia)?
>
> For me, Bipolar IV fits because I am chronically depressed with the exception of drug-induced mania.
>
>
> - Scott
>
>
Posted by psychobot5000 on May 15, 2012, at 17:31:19
In reply to Re: Melancholic vs Atypical depression » psychobot5000, posted by SLS on May 11, 2012, at 6:26:42
Thought it worth mentioning the results of my followup research in case any others stumble on this thread. Bipolar V appears to be a speculative and unofficial diagnosis defined by the presence of relatives with bipolar disorder, all of which is fine. However, the rationale for its existence as a category, and for its treatment indications, appears not to be greater efficacy for mood stabilizers, but to avoid bringing out a latent manic phase, as in Bipolar IV. Thus, in someone such as myself, treated with standard antidepressants for many years without mania or hypomania or anything like it, there may not be a rationale for any Bipolar V classification, at least as the disorder is currently thought of (regardless of whether there's some cycling between better and worse unipolar depression, though if schizoid disorders have a similar etiology to bipolar, perhaps it might be worthwhile for a new patient with such relatives to stay aware of possible manias[?]).
Best,
Pb
Posted by SLS on May 15, 2012, at 20:36:56
In reply to Re: Melancholic vs Atypical depression » SLS, posted by psychobot5000 on May 15, 2012, at 17:31:19
> Thought it worth mentioning the results of my followup research in case any others stumble on this thread. Bipolar V appears to be a speculative and unofficial diagnosis defined by the presence of relatives with bipolar disorder, all of which is fine. However, the rationale for its existence as a category, and for its treatment indications, appears not to be greater efficacy for mood stabilizers, but to avoid bringing out a latent manic phase, as in Bipolar IV. Thus, in someone such as myself, treated with standard antidepressants for many years without mania or hypomania or anything like it, there may not be a rationale for any Bipolar V classification, at least as the disorder is currently thought of (regardless of whether there's some cycling between better and worse unipolar depression, though if schizoid disorders have a similar etiology to bipolar, perhaps it might be worthwhile for a new patient with such relatives to stay aware of possible manias[?]).
http://www.dsm5.org/ProposedRevision/Pages/BipolarandRelatedDisorders.aspxApparently, the DSM V is scheduled to have five categories of bipolar disorder. The authors chose to include drug-induced mania as part of a bipolar III diagnosis. I guess they couldn't find a justification for describing depression-only or mania-only bipolar disorders. It would be interesting to know what their reasons were for rejecting the Gerald Klerman model that was first published in 1987 (Psychiatric Annals 17: Jan. 1987). Perhaps the statistics didn't warrant it.
Klerman Subtypes:Bipolar I - Mania and Major Depression
Bipolar II - Hypomania and Major Depression
Bipolar III - Cyclothymia
Bipolar IV - Antidepressant Induced Hypo/mania
Bipolar V - Major Depression with a family history of Bipolar Disorder
Bipolar VI - Unipolar Mania
All in all, I don't see why the physiological pathology of the depressive phase of bipolar disorder can't remain dominant and be the only observed mood state of an individual. In other words, if a bipolar depressive episode can last for days, weeks, months, and years, why not decades? To me, it doesn't make sense that manic-depression, as envisaged by Emil Kraeplin, can't include a depression-only presentation. Perhaps the conceptualization of "bipolar" is too limiting to describe "manic-depression".
- Scott
Posted by Phillipa on May 16, 2012, at 19:01:22
In reply to Re: Melancholic vs Atypical depression, posted by SLS on May 15, 2012, at 20:36:56
Personally I don't get this new category. What types of medical conditions could result in a diagnosis of bipolar? Wouldn't the medical condition treated result in loss of the mental diagnosis hence no mental health tx needed? Phillipa
Posted by SLS on May 17, 2012, at 23:51:35
In reply to Re: Melancholic vs Atypical depression » SLS, posted by Phillipa on May 16, 2012, at 19:01:22
> Personally I don't get this new category. What types of medical conditions could result in a diagnosis of bipolar?
Lupus is one.
In addition, I found this:
http://www.rightdiagnosis.com/symptoms/mania/causes.htm
> Wouldn't the medical condition treated result in loss of the mental diagnosis hence no mental health tx needed?
The authors don't specify that the manic state must continue after the associated medical condition resolves in order to make the diagnosis. I suppose that a medical condition can trigger a latent, but persistent presentation of bipolar I or bipolar II. However, the proposed language does not preclude that a mania associated with a medical condition can resolve once the medical condition remits in order to be eligible for a bipolar diagnosis.
- Scott
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