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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by Robert_Burton_1621 on February 21, 2015, at 3:04:54
For anyone interested in the nosology of depressions and, in particular, the bearing which progress in nosology may have on the classifications authorised by DSM-5, Professor Gordon Parker and his team have just published research which is claimed to isolate (for the first time) an empirically identifiable form of neurobiological dysfunction which is specific to melancholic depression.
"Disrupted Effective Connectivity of Cortical Systems Supporting Attention and Interoception in Melancholia" (JAMA Psychiatry, 18 Feb 2015):
http://archpsyc.jamanetwork.com/article.aspx?articleid=2119327
Part of the resistance to reform of the DSM-5 typologies rests on scepticism as to whether melancholia is a distinct biological form of depression which ought be distinguished clinically from non-melancholic kinds.
The results of this recent research may have the effect of rendering such scepticism less presumptively cogent than it has hitherto been.
"Issues for DSM-5: Whither Melancholia? The Case for Its Classification as a Distinct Mood Disorder" Am J Psychiatry (2010) 167 (7):
http://www.ncbi.nlm.nih.gov/pubmed/20595426
What do interested people here think about the plausibility and desirability of classifying melancholia as a distinct nosological type and the consequences such classification may have on diagnosis, treatment, and in particular medication "algorithms"?
Professor Parker has been engaged in the broader project of melancholia research for decades. His important edited collection of papers on the topic can be partly read on google books.
"Melancholia: A Disorder of Movement and Mood
A Phenomenological and Neurobiological Review", Cambridge UP, 1996
Posted by SLS on February 21, 2015, at 7:51:55
In reply to Brain Signature for Melancholia Identified, posted by Robert_Burton_1621 on February 21, 2015, at 3:04:54
As per my personal experience, I think bipolar depression may be a hybrid between atypical and melancholic depressions.
I saw the most severe melancholic depression in a woman who was visiting her mother who lived down he block. It was excruciating to witness the magnitude of psychomotor retardation she displayed. It was like watching slow-motion. She committed suicide soon afterwards.
- Scott------------------------------------------
> http://newsroom.unsw.edu.au/news/health/disruption-brain-signals-sheds-new-light-melancholic-depression
>
> For anyone interested in the nosology of depressions and, in particular, the bearing which progress in nosology may have on the classifications authorised by DSM-5, Professor Gordon Parker and his team have just published research which is claimed to isolate (for the first time) an empirically identifiable form of neurobiological dysfunction which is specific to melancholic depression.
>
> "Disrupted Effective Connectivity of Cortical Systems Supporting Attention and Interoception in Melancholia" (JAMA Psychiatry, 18 Feb 2015):
>
> http://archpsyc.jamanetwork.com/article.aspx?articleid=2119327
>
> Part of the resistance to reform of the DSM-5 typologies rests on scepticism as to whether melancholia is a distinct biological form of depression which ought be distinguished clinically from non-melancholic kinds.
>
> The results of this recent research may have the effect of rendering such scepticism less presumptively cogent than it has hitherto been.
>
> "Issues for DSM-5: Whither Melancholia? The Case for Its Classification as a Distinct Mood Disorder" Am J Psychiatry (2010) 167 (7):
>
> http://www.ncbi.nlm.nih.gov/pubmed/20595426
>
> What do interested people here think about the plausibility and desirability of classifying melancholia as a distinct nosological type and the consequences such classification may have on diagnosis, treatment, and in particular medication "algorithms"?
>
> Professor Parker has been engaged in the broader project of melancholia research for decades. His important edited collection of papers on the topic can be partly read on google books.
>
> "Melancholia: A Disorder of Movement and Mood
> A Phenomenological and Neurobiological Review", Cambridge UP, 1996
>
> https://books.google.com.au/books?id=aQYJbOT4PCUC&printsec=frontcover&dq=Melancholia:+A+Disorder+of+Movement+and+Mood&hl=en&sa=X&ei=bUboVOaEEYrg8gWnsIDwAg&ved=0CB4Q6AEwAA#v=onepage&q=Melancholia%3A%20A%20Disorder%20of%20Movement%20and%20Mood&f=false
>
>
>
>
Posted by Robert_Burton_1621 on February 21, 2015, at 13:45:13
In reply to Re: Brain Signature for Melancholia Identified » Robert_Burton_1621, posted by SLS on February 21, 2015, at 7:51:55
> As per my personal experience, I think bipolar depression may be a hybrid between atypical and melancholic depressions.>
Scott, that's interesting. I note you restrict your speculation about potential hybridity to the depressive phases of bipolar disorder, rather than bipolar disorder generally. I understand that the profoundly anergic depressive phases of bipolar are melancholic; in what respects, in your experience, do you associate some of the symptoms with atypicality? Do you refer to the atypical symptoms of hypersomnolence and hyperphagia?
The other key symptom of atypical depression is reactivity. I have never quite grasped precisely what is involved in this notion. Does it involve mere signs of behavioural reactivity to stimuli or does it require a capacity to derive positive hedonic feedback from such stimuli, if only episodically? If the former, I think it would be difficult to distinguish such behavioural indicia from the capacity merely to *simulate*, mechanically, a degree of seemingly "active" response to direct stimuli. Melancholic depressives do, unless they are in the deepest catatonic state, sometimes have the capacity to perform "mechanical" actions, especially if others are reliant on them or other duties demand a degree of active engagement of them, and may be said, to this extent, to demonstrate "reactivity". If so, what is the clinical role which "reactivity" plays in distinguishing atypicality from melancholia?
> I saw the most severe melancholic depression in a woman who was visiting her mother who lived down he block. It was excruciating to witness the magnitude of psychomotor retardation she displayed. It was like watching slow-motion. She committed suicide soon afterwards.>This is a harrowing story, and confirms the uttery dehumanising effect of severe psychomotor retardation in melancholia. Apart from being biological systems, we are also meaning-making creatures; and our capacity to apprehend and express our being *as* human presupposes to a great degree, I think, the subtle, imperceptible, connective functionality which links volition, intention, and action (I would count "thinking" as an action): which constitutes, in short, the preconditions to our agency. The profoundly fragmenting and nauseating alienation which psychomotor retardation induces between the body conceived under the aspect of biological object and our *self* as active agent can be unbearable.
> ------------------------------------------> > For anyone interested in the nosology of depressions and, in particular, the bearing which progress in nosology may have on the classifications authorised by DSM-5, Professor Gordon Parker and his team have just published research which is claimed to isolate (for the first time) an empirically identifiable form of neurobiological dysfunction which is specific to melancholic depression.
> > "Disrupted Effective Connectivity of Cortical Systems Supporting Attention and Interoception in Melancholia" (JAMA Psychiatry, 18 Feb 2015):
> > http://archpsyc.jamanetwork.com/article.aspx?articleid=2119327
> > Part of the resistance to reform of the DSM-5 typologies rests on scepticism as to whether melancholia is a distinct biological form of depression which ought be distinguished clinically from non-melancholic kinds.
> > The results of this recent research may have the effect of rendering such scepticism less presumptively cogent than it has hitherto been.
> > "Issues for DSM-5: Whither Melancholia? The Case for Its Classification as a Distinct Mood Disorder" Am J Psychiatry (2010) 167 (7):
> > http://www.ncbi.nlm.nih.gov/pubmed/20595426
> > What do interested people here think about the plausibility and desirability of classifying melancholia as a distinct nosological type and the consequences such classification may have on diagnosis, treatment, and in particular medication "algorithms"?
> > Professor Parker has been engaged in the broader project of melancholia research for decades. His important edited collection of papers on the topic can be partly read on google books:
> > "Melancholia: A Disorder of Movement and Mood
A Phenomenological and Neurobiological Review", Cambridge UP, 1996
Posted by Robert_Burton_1621 on February 22, 2015, at 5:56:39
In reply to Re: Brain Signature for Melancholia Identified » Robert_Burton_1621, posted by SLS on February 21, 2015, at 7:51:55
This interview with Professor Parker, conducted in 2010, is worth watching for an "accessible" overview of his research:
Posted by ed_uk2010 on February 22, 2015, at 16:30:01
In reply to Brain Signature for Melancholia Identified, posted by Robert_Burton_1621 on February 21, 2015, at 3:04:54
>What do interested people here think about the plausibility and desirability of classifying melancholia as a distinct nosological type and the consequences such classification may have on diagnosis, treatment, and in particular medication "algorithms"?
I think classifying depression into varies categories may be of some use. It is important to bear in mind, however, that depression with melancholic features is not necessarily more severe than non-melancholic depression. Melancholic depression is not synonymous with severe depression.... Although melancholic depression is usually severe, other forms of depression can be equally severe in a different way. As an example, the mood changes seen in some forms of 'atypical' depression may result in people feeling OK briefly and then intensely suicidally depressed later. This type of illness can be very serious.
Posted by Robert_Burton_1621 on February 23, 2015, at 10:29:07
In reply to Re: Brain Signature for Melancholia Identified » Robert_Burton_1621, posted by ed_uk2010 on February 22, 2015, at 16:30:01
>It is important to bear in mind, however, that depression with melancholic features is not necessarily more severe than non-melancholic depression. Melancholic depression is not synonymous with severe depression.... Although melancholic depression is usually severe, other forms of depression can be equally severe in a different way. As an example, the mood changes seen in some forms of 'atypical' depression may result in people feeling OK briefly and then intensely suicidally depressed later. This type of illness can be very serious.
>Very good points; I entirely agree.
One of the purposes of defining depression by reference to identifiable types (to the extent that they are distinct and identifiable) is to counter the dominant paradigm according to which "depression" is a unitary clinical entity which differs only in respect of the extent of the severity with which it is experienced. When you think about it, this is a very odd way of thinking about disease. While psychiatry, because of its need to grapple with the subjective/phenomenological in addition to the neuro-organic and biochemical, raises complexities in nosology which are more and different than those faced by other specialties, I am not sure this rationally justifies psychiatry's quite unique approach to classifying the disorders, especially the depressive disorders, within its purview. An oncologist does not diagnose a particular type of cancer by reference *primarily* to its severity; rather, severity is a potential property of some types of cancer, whose nature is classified by reference to traits biologically internal to, and often distinctive of, that type. The DSM, however, takes severity as a primary diagnostic indicator, and posits a scale along which an essentially unitary disorder of "depression" is then plotted according to patient symptoms.
This is one reason why I think the recent research to which I pointed is so important.
One consequence of the DSM criteria is that a person who suffers chronic depression after a severe "melancholic" or MDD episode (i.e., whose "depression" has never resolved), is often diagnosed as suffering from "dysthymia" simply by virtue of the fact that his or her chronicity is not as severely experienced as that index episode.
This diagnostic choice can then have an immediate and direct influence on recommended treatments.
In regards to atypicality, my understanding is that it would fall on the side of the biological or autonomous depressions, along with psychotic depression and melancholia. The depressive phase of bi-polar disorder is, from my understanding, usually melancholic, though as SLS has hypothesised, its characteristic traits may indicate that it amounts to a hybrid type.
Posted by ed_uk2010 on February 23, 2015, at 13:43:54
In reply to Re: Brain Signature for Melancholia Identified » ed_uk2010, posted by Robert_Burton_1621 on February 23, 2015, at 10:29:07
>One of the purposes of defining depression by reference to identifiable types (to the extent that they are distinct and identifiable) is to counter the dominant paradigm according to which "depression" is a unitary clinical entity which differs only in respect of the extent of the severity with which it is experienced. When you think about it, this is a very odd way of thinking about disease.
It is certainly a poor way of conceptualising depression. Unfortunately....
Depression, as a diagnosis, is currently a clinical syndrome and not a specific disease entity ie. the diagnosis is almost entirely symptom-based. Inevitably then, there is much variation between different people classified as suffering from depression. I can only assume that there is as much heterogeneity in the underlying causes of depression and its pathology as there is in terms of the symptoms described.
The concept of 'atypical' depression is particularly confused in the literature. All of the listed symptoms are common, and it is unclear whether the emphasis should be on reverse vegetative symptoms (oversleeping, overeating), on mood reactivity....or even personality traits.
I don't think we will be very successful at all in trying to define the subtypes of depression until we see large advances in understanding of the neurobiological aspects of depression.
Posted by ed_uk2010 on February 23, 2015, at 13:48:14
In reply to Brain Signature for Melancholia Identified, posted by Robert_Burton_1621 on February 21, 2015, at 3:04:54
>Professor Gordon Parker and his team have just published research which is claimed to isolate (for the first time) an empirically identifiable form of neurobiological dysfunction which is specific to melancholic depression.
I think it's interesting. I'd like to see more studies looking at the relationship between specific neurological abnormalities and treatment response... rather the the usual symptoms vs treatment response.
Posted by Robert_Burton_1621 on February 24, 2015, at 11:06:31
In reply to Re: Brain Signature for Melancholia Identified, posted by ed_uk2010 on February 23, 2015, at 13:48:14
> I think it's interesting. I'd like to see more studies looking at the relationship between specific neurological abnormalities and treatment response... rather the the usual symptoms and treatment response.
>Yes, that seems like the logical next step. At the moment, the research team is recruiting subjects in order to test whether the initial results are replicable, and to obtain a greater degree of statistical significance. The authors also noted that, owing to ethical considerations which militated against very ill melancholic subjects being taken off their medication for the duration of their participation in the study, it's not entirely clear whether medication may not have had some clinically relevant influence on the neuro-psychiatric dysfunction that was identified in the melancholic cohort.
Do you think this is possible and, if so, is it possible to minimise its potentially distorting effect through methods which don't involve withdrawal from medication?
This is the end of the thread.
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