Diagnosis and course of affective psychoses: was Kraepelin right?

Kraepelin's basic attitude to the classification of psychoses was data-oriented and flexible. In his latter years he was close to revising his own celebrated dichotomy between manic-depressive insanity and dementia praecox in order to take account of a large group of intermediate psychoses, which today are called schizo-affective. His concept of a continuum from healthy to ill has stood the test of time and corresponds to modern epidemiological findings. Kraepelin's unitarian concept of manic-depressive insanity did not survive. It was differentiated and broken down into several subgroups, and a proportional diagnostic spectrum with a continuum from mania via bipolar disorders to depression has recently even been proposed. Bipolar disorders would in that case be comorbid disorders of mania plus depression. In contrast to Kraepelin's unitarian view the long-term prognosis of subgroups of mood disorders varies considerably. Overall it is nevertheless astonishing how much of Kraepelin's legacy has survive

Concurrent psychiatric comorbidity and multimorbidity in a community study: gender differences and quality of life

This study analysis of a community cohort at the age of 35 focused on the effects of gender and multimorbidity on quality of life and subjective distress. Consistent with an earlier analysis, quality of life decreased with increasing numbers of concurrent psychiatric diagnoses. Women generally reported lower quality of life and higher distress than men. Relative to men, well-being in women was subject to more diagnostic (alcohol abuse/dependence, depression, generalized anxiety disorder, bulimia) and social influences (partner, promotion). The same factors predicted women's psychological and physical well-being, indicating a more holistic experience in women. Men's physical well-being did not correlate with any of the diagnostic or social variables measure

The spectra of neurasthenia and depression: course, stability and transitions

Background: Neurasthenia has had a chequered history, receiving changing labels such as chronic fatigue or Gulf war syndrome. Neurasthenia is recognized by ICD-10, but not by DSM-IV. Its course, longitudinal stability and relationship to depression is not well understood. Methods: In a stratified community sample (n=591), representative of 2600 persons of the canton of Zurich, Switzerland, neurasthenia and depression were assessed in six structured interviews between ages 20 and 41. Course, stability and comorbidity were examined. A severity spectrum of neurasthenia and depression from symptoms to diagnosis was taken into account. Results: The annual prevalence of a neurasthenia diagnosis increased from 0.7% to 3.8% from age 22-41, while mere symptoms became less prevalent. Intraindividual courses improved in 40% and deteriorated in about 30% of symptomatic cases. The most frequent symptoms overall, besides criterial exhaustion, were increased need for sleep, over-sensitivity, nervousness and difficulty concentrating. Cross-sectional associations and overlap with depression were strong. Longitudinal stability of ICD-neurasthenia was low. Conclusions: Neurasthenia is intermittent, overlaps significantly with depression, and shows improvement and deterioration over time to roughly equal measure

Childhood adversity and chronicity of mood disorders

To evaluate the potential impact of early childhood problems on the chronicity of mood disorders. A representative cohort from the population was prospectively studied from ages 19/20 to 39/40. Unipolar (UP) and bipolar disorders (BP) were operationally defined applying broad Zurich criteria for bipolarity. Chronicity required the presence of symptoms for more days than not over 2years prior to an interview, or almost daily occurrence for 1year. A family history and a history of childhood problems were taken at ages 27/28 and 29/30. Data include the first of multiple self-assessments with the Symptom-Checklist-90 R at age 19/20, and mastery and self-esteem assessed 1year later. A factor analysis of childhood problems yielded two factors: family problems and conduct problems. Sexual trauma, which did not load on either factor, and conduct problems were unrelated to chronicity of UP or BP or both together. In contrast, childhood family problems increased the risk of chronicity by a factor of 1.7. An anxious personality in childhood and low self-esteem and mastery in early adulthood were also associated with chronicity. Childhood family problems are strong risk factors for the chronicity of mood disorders (UP and BP). The risk may be mediated partly by anxious personality traits, poor coping and low self-estee

Does psychomotor agitation in major depressive episodes indicate bipolarity?: Evidence from the Zurich Study

Background: Kraepelin's partial interpretation of agitated depression as a mixed state of "manic-depressive insanity” (including the current concept of bipolar disorder) has recently been the focus of much research. This paper tested whether, how, and to what extent both psychomotor symptoms, agitation and retardation in depression are related to bipolarity and anxiety. Method: The prospective Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults (N=591) (aged 20 at first interview) by six interviews over 20years (1979-1999). Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 (five interviews) on the basis of the observed and reported behaviour within the interview section on depression. Psychiatric diagnoses were strictly operationalised and, in the case of bipolar-II disorder, were broader than proposed by DSM-IV-TR and ICD-10. As indicators of bipolarity, the association with bipolar disorder, a family history of mania/hypomania/cyclothymia, together with hypomanic and cyclothymic temperament as assessed by the general behavior inventory (GBI) [15], and mood lability (an element of cyclothymic temperament) were used. Results: Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety. Longitudinally, agitation and retardation were significantly associated with each other (OR=1.8, 95% CI=1.0-3.2), and this combined group of major depressives showed stronger associations with bipolarity, with both hypomanic/cyclothymic and depressive temperamental traits, and with anxiety. Among agitated, non-retarded depressives, unipolar mood disorder was even twice as common as bipolar mood disorder. Conclusion: Combined agitated and retarded major depressive states are more often bipolar than unipolar, but, in general, agitated depression (with or without retardation) is not more frequently bipolar than retarded depression (with or without agitation), and pure agitated depression is even much less frequently bipolar than unipolar. The findings do not support the hypothesis that agitated depressive syndromes are mixed states. Limitations: The results are limited to a population up to the age of 40; bipolar-I disorders could not be analysed (small N

Is bipolar I disorder heterogeneous?

Abstract. : Objectives: : The question whether bipolar I disorder should be subdivided into a preponderantly manic group (M) with no depression or only mild depression (Md) and a nuclear manic-depressive group (MD) has been rarely studied although the problem was raised more than 50 years ago. This paper seeks to elucidate this question by contributing further data. Methods: : 406 patients with mood disorders hospitalised at some time during the period 1959-1963 were followed-up every five years until 1985; mortality data were collected up to 1997. Data on episodes, outcome, suicides and attempted suicides, alcohol and substance abuse/dependence and long-term medication, as well as on personality (melancholic and manic type) were collected. Major mood disorders were subclassified according to their hospitalisation for depression (D) and/or mania (M). Results: : 30 manic patients (M/Md), 130 bipolar I (MD), 60 bipolar II patients (Dm) and 186 major depressive patients (D) were compared. The manic group differed from the bipolar I group in several variables: better school achievement, milder course of the illness (fewer recurrences), significantly less suicidality and a trend to less chronicity and more recovery. Manic patients required less long-term medication than bipolars and they differed in personality types from bipolars, the personality of manic patients being more often of the manic rather than the melancholic type, they were also more aggressive than bipolars. The family history data showed that the overall morbidity risk of first degree relatives of manic patients was significantly lower than that of bipolar patients. Conclusions: : In accord with several other studies our data point to the existence of a more manic (M/Md) group of bipolar subjects. The diagnosis predicts a better course, lower suicidality and fewer and different treatment needs than does nuclear bipolar I (MD) disorder. The M/Md groups, as clinically interesting subgroups of the mood spectrum, should become a target of further researc

The spectra of neurasthenia and depression: course, stability and transitions

Background: Neurasthenia has had a chequered history, receiving changing labels such as chronic fatigue or Gulf war syndrome. Neurasthenia is recognized by ICD-10, but not by DSM-IV. Its course, longitudinal stability and relationship to depression is not well understood. Methods: In a stratified community sample (n=591), representative of 2600 persons of the canton of Zurich, Switzerland, neurasthenia and depression were assessed in six structured interviews between ages 20 and 41. Course, stability and comorbidity were examined. A severity spectrum of neurasthenia and depression from symptoms to diagnosis was taken into account. Results: The annual prevalence of a neurasthenia diagnosis increased from 0.7% to 3.8% from age 22-41, while mere symptoms became less prevalent. Intraindividual courses improved in 40% and deteriorated in about 30% of symptomatic cases. The most frequent symptoms overall, besides criterial exhaustion, were increased need for sleep, over-sensitivity, nervousness and difficulty concentrating. Cross-sectional associations and overlap with depression were strong. Longitudinal stability of ICD-neurasthenia was low. Conclusions: Neurasthenia is intermittent, overlaps significantly with depression, and shows improvement and deterioration over time to roughly equal measure

The generalized anxiety spectrum: prevalence, onset, course and outcome

Background: Generalized anxiety disorder (GAD) is generally considered to be a chronic condition, waxing and waning in severity; however prospective investigation of the course of GAD in community samples is lacking. This study seeks to fill that gap, by identifying the whole spectrum of generalized anxiety syndromes, sub-typing them according to their duration and frequency of occurrence, and evaluating their long-term course and outcome in the community. Method: The prospective Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults (N=591) (aged 20years at first interview) by six interviews over a period of 20years (1979-1999). GAD syndromes were defined by DSM-III symptom criteria without applying any exclusion criteria. A spectrum of generalized anxiety was defined by duration: 6months (DSM-IV), 1month (DSM-III), ≤2weeks (with weekly occurrence over one year), and anxiety symptoms. From 1978 (screening) to 1999 the annual presence of symptoms and treatment was assessed. Persistence of anxiety was defined by the almost daily presence of symptoms over the previous 12months. Results: The annual incidence of DSM-III GAD increased considerably between the ages of 20 and 40. The average age of onset of symptoms was 15.6years; in 75% of cases it occurred before the age of 20. 75 of 105 DSM-III GAD cases had at least one follow-up. At their individual last follow-up, 12 of those 75 subjects (16%) were re-diagnosed as having GAD, 22 (29%) manifested subthreshold syndromes or anxiety symptoms, while 39 cases, the majority, (52%) were symptom-free; 5 of the 12 re-diagnosed GAD cases were persistent (corresponding to 7% of all 75 initial GAD cases). In their twenties they were treated at some time in 6% of all years, but in their thirties this figure rose to 12%. At their individual last follow-up 26% of 6-month GAD subjects and 22% of 1-month GAD subjects were still being treated. Treated vs. non-treated subjects did not differ in terms of gender but did differ in severity, persistence and in comorbidity with bipolar-II disorder, social phobia, obsessive-compulsive syndromes and substance-use disorders. Limitations: Results are based on a relatively small sample and cannot be generalized to adults aged over 40years. Conclusions: The course of DSM-III-defined GAD may not be chronic, as previously suggested, but mainly recurrent with intervening symptom-free periods of recovery in about half of cases. Over a period of 20years there was more improvement than progression within the anxiety spectru