Phenomenology of Major Depression

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Phenomenology of Major Depression

• C. Robert Cloninger, MD
• Washington University in St. Louis

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Outline

• Basic Questions
• How do we recognize that a person has Major
  Depressive Disorder?
• What does it mean to say a person has MDD?
• What are the criteria for diagnosing MDD?
• What other conditions resemble MDD and need to be
  distinguished?
• Are there more specific subtypes of MDD?
• What is the range of features and functions of
  depressive disorders?
• What are the observable vulnerability factors
  underlying MDD?
• Are there ways to recognize the causes of
  depression rather than just categorizing or
  quantifying its symptoms?

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How is Major Depression recognized?

• Set of observable phenomena summarized as
  diagnostic criteria for MDD
• May also be recognized as a felt experience of
  inter-subjectivity
• May be inferred as masked or latent
  depression to explain suicidal and other
  depression-related behaviors even when denied
  (e.g., alcoholic men may be etiologically
  comparable to depressive women in some disease
  spectrum models)

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Types of Phenomenological Models

• Categorical Models diseases with subtypes or
  disease spectra
• Dimensional Models configurations of traits or
  factors
• Functional Models psychodynamic processes,
  complex adaptive systems

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Categorical Model - DSM-IV Inclusion criteria of
MDD

• Presence of one or more Major Depressive Episodes
• Two or more weeks with FIVE or more symptoms
  including depressed mood or loss of interest or
  pleasure
• Depressed mood
• Loss of interest or pleasure in most activities
• Loss or gain in weight or appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Worthlessness or guilt
• Poor concentration or indecision
• Recurrent thoughts of death or suicidal ideation
• Significant distress or impairment in social,
  occupational or other important areas of
  functioning

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Exclusion Criteria for DSM-IV MDD

• Not better accounted for by Schizoaffective
  Disorder and not superimposed on Schizophrenia,
  Schizophreniform Disorder, Delusional Disorder,
  or Psychotic disorder NOS
• Never had a manic episode, mixed episode, or a
  hypomanic episode
• Not due to direct physiological effects of a
  substance (medication or drugs of abuse) or a
  general medical condition (e.g., hypothyroidism)
• Not better accounted for by Bereavement (i.e.,
  persist more than two months after death or
  characterized by major impairment or
  worthlessness, suicidal ideation, psychotic
  symptoms, or psychomotor retardation)

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Specifiers for subtyping DSM-IV MDD

• Can specify status and/or features as
• Mild, moderate, severe with or without psychotic
  features
• Chronic (2 or more years)
• With Catatonic Features (stupor or stereotypy)
• With Melancholic Features (anhedonia worse in
  am, guilt, agitation/retarded)
• With Atypical Features (reactive weight gain,
  hypersomnia, reject sensitive)
• With Postpartum Onset
• With or without inter-episode recovery
• With Seasonal Pattern (e.g. fall onset, spring
  remission)

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Examples of Masked Depressive Disorders

• Studies of individuals and families reveal that
  MDD is often comorbid with other mental disorders
  including personality disorders, substance abuse,
  anxiety disorders, and eating disorders in
  particular
• Individuals with only primary major depression
  by definition have no antecedent psychiatric
  disorder and they have a DEFICIT of personality
  disorders and other psychopathology in their
  relatives (Maser Cloninger , 1990)
• Depressive Spectrum Disorder is characterized by
  major depression in women and by alcoholism and
  antisocial personality disorder in male relatives
  (Winokur)
• Men with alcoholism and antisocial PD have
  increased risk of suicide and suicide attempts so
  recognition of this depressive behavior
  requires screening for substance dependence and
  personality maturity, even though the men may
  have a gender-role or sociocultural bias against
  disclosure of subjective depressive symptoms

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Dimensional Models of Mood State

• Dimensional analysis shows that positive and
  negative emotions are distinct traits with
  dissociable causes and consequences (Tellegan,
  Watson See Positive and Negative Affect Scale)
• Positive Emotions include feeling happy, joyful,
  optimistic, enthusiastic
• Negative Emotions include feeling sad, anxious,
  pessimistic, discouraged
• Major Depressive Criteria confound the presence
  of negative emotions and the absence of positive
  emotions whereas these are distinct processes
  genetically, biologically, and cognitively
• Double Depression Dysthymia (mild chronic
  depression) plus MDD can also be described in
  terms of personality traits high Harm Avoidance
  and/or low Self-directedness plus major
  depression under stress)
• How do the categorical and dimensional models
  account for episodic course? They both try to
  exclude external causes from environment or
  internal physiology. They deal with symptoms, not
  causes.

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Identifying causes -- Personality in depressives,
sibs of depressives, controls (Farmer et al.,
2002)
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The Psychobiological Model of Personality
(Cloninger 1993)
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The Temperament Cube (Cloninger 1987)
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The Character Cube (Cloninger 1993)
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(1) Definition of Mental Health WHO 2001

• A state of well-being in which the person
• Realizes and uses his or her own abilities
• Can cope with the normal stresses of life
• Can work productively and fruitfully
• Is able to contribute to his or her community
• Indivisible from physical health
• More than the absence of disease

WHO (2001)Herrman H et al (2005)
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How is Well-Being measured?

• Emotions presence of positive emotions and
  absence of negative emotions, as in the Watsons
  PANAS
• Personality maturity and integration of
  character traits, as in the Temperament and
  Character Inventory (TCI), Antonofskys measures
  of coherence, or Ryffs measures of eudaimonic
  well-being
• Life Satisfaction reliable subjective rating, as
  in Dieners SWBS or WHOs measures of Quality of
  Life
• Virtues prototypical character traits like
  courage, justice, moderation, honor, wisdom,
  patience, love, hope, and faith, as in Peterson
  and Seligmans Character Strengths and Virtues
  inventory

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Higher Cognitive Functions Mental Self-Government

• Executive Functions (Self-directedness)
• responsible, purposeful, resourceful
• Legislative Functions (Cooperativeness)
• flexible, helpful, compassionate
• Judicial Functions (Self-transcendence)
• judicious, insightful, intuitive

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Happiness and Sadness depend on all 3 TCI
character dimensions
Facts - Character and Hedonic Well-Being
Cloninger, Feeling Good The Science of
Well-Being, 2004
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Emotional, Physical, and Social Well-being depend
on Character Profiles
Zohar Cloninger, 2009
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Summary

• Major Depressive Disorders can be understood
  phenomenologically from several perspectives with
  fundamentally different assumptions
• Major Depressive Disorders are a combination of
  the presence of negative emotions (depression,
  anxiety, guilt, worthlessness), absence of
  positive emotions (diminished interest,
  happiness, joy, hope), disturbance of appetite,
  energy, concentration, and dysfunctional
  attitudes/perceptions
• Vulnerability factors are present in relatives
  and prior to onset
• Onset of illness is related to bio-psycho-social
  sources of stress, representing lack of
  resilience or ability to adapt to loss,
  non-support, blows to self-image and hope
• Focus on depression as a discrete disease is
  inadequate generally but provides a way to focus
  on a moderately distinct group of people
• The variability in phenomenological features
  corresponds to variability in etiological
  features offering hope for functional and causal
  understanding of MDD as a complex adaptive system
  that is more realistic than categorical or
  dimensional models

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Any Questions ?
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