Diagnosis

Of course, it is very easy and very tempting to take pot-shots at classification and diagnosis in psychiatry. From a sceptical viewpoint, it appears to the outside that every few years a bunch of experts sit around and "horse-trade" their favourite, often self-promoting diagnoses. The history of the classification and diagnosis of depression has witnessed, for example, a varying set of categories such as neurotic-endogenous, reactive-endogenous, and neurotic-psychotic. As Bebbington (Chapter 1) summarises, these and other distinctions appear to reflect a dimension of severity of depression, in which rarer symptoms (for example, delusions of guilt) appear in only the most extreme variants.

The problem for classification and diagnosis in depression—indeed, for all psychological disorders—is that there is no theoretical basis for the systems in use. Indeed, the systems such as DSM are explicitly atheoretical. Imagine that Mendeleev had approached the periodic table of the chemical elements in the same way; there are clearly substances that are "shiny, silver ones" (such as aluminium, silver, and iron), while there is another group that are "shiny, golden ones" (such as copper and gold). Another distinction could be made between "soft, malleable" substances that explode (such as potassium, sodium, and phosphorus) and "hard, non-explosive" substances (such as zinc, tin, and silicon). These distinctions would have some value, at least for a while, but because they are not theoretically based, they will be inconsistent, contradictory, and change with fashion.

So what is the answer for classification and diagnosis in depression? The first step, and one that many chapters in this book argue explicitly for, is that there needs to be a dimensional approach, in which the severity of the disorder ranges from minimal to maximal. But how should this dimension be conceptualised? Indeed, should there be only one dimension considered? These two questions are significant, first, because we need to know whether the opposite to "very depressed" on the severity dimension is "not depressed", or whether it is the bipolar opposite of depression, "very happy". The traditional approach to the manic state in bipolar disorders might suggest this latter option; namely, that the "opposite" state to depression is a state of elation. However, this traditional account fails to explain why recent empirical studies of the manic and hypomanic states show that elation may not be the most highly characteristic aspect, but that "mixed states" and mood lability may be more accurate conceptualisations (Cassidy et al., 1998; Cavanagh et al., submitted). This issue certainly demands a broader approach to the assessment of depression than the current reliance on self-report and on clinical interviews, as Peck has cogently argued (Chapter 17).

The second question is, if there is more than one dimension, what should these other dimensions be? A starting point may be that there are two possible dimensions, both capturing severity, but one relating to genetic/biological factors and one relating to psychological/social factors. Of course, such factors are aetiological rather than merely symptom-based, and are generally avoided in DSM-type classification systems, with the one exception of post-traumatic stress disorder, in which the stressor is both aetiological and nosological. The dimensions have the advantage that they provide a dimensional classification system within which both the unipolar and bipolar disorders can be placed according to their putative aetiology, while acknowledging that the majority of depressions have a contribution from both. Such an approach would also allow the incorporation of some of the recent problems highlighted with bipolar disorders, in which the initial diagnosis is almost always wrong if the first episode is a depressed one, given that the diagnostician can really be certain only after further episodes whether or not these are manic/hypomanic ones. Recently, there have been suggestions that very short periods of "highs" might be predictive of later manic episodes, and that short "highs" in reaction to antidepressant treatment might be similarly indicative (e.g., Perugi et al., 1997).

A two-dimensional approach might provide a starting point for the nosology of depression, but it still may not go far enough in overcoming the consensus-driven versus theory-driven approaches. Even the proposal mentioned above that all depressions should be treated as bipolar until proven otherwise, and that there may be further bipolar 1, 2, 3, 4, etc., subtypes may simply amount to further atheoretical, descriptive game-playing, however useful the distinctions might be. A more radical approach to depression and its classification might be to get a theory! To return to the periodic table, by analogy, the best theory cannot simply be a theory of just the alkaline metals but has to place depression in the context of other psychological disorders, especially given the high rates of comorbidity with other disorders such as anxiety (see Chapter 1). There can be no accusations of modesty for the following speculations, but they are provided as an illustration of how one might go about developing a theoretically based classification; they are not being presented as the correct one.

The basic-emotions approach has a long and distinguished history that includes Descartes and Darwin, and recent exponents such as Ekman, Plutchik, Izzard, and Tomkins. The approach was extended by Oatley and Johnson-Laird (1987) in their functional account of emotion, which assumed that a set of five basic emotions could be used to derive all the other more complex emotions. Power and Dalgleish (1997) further extended this proposal and argued that emotional disorders might also be explicable in such a system with certain additional theoretical assumptions, such as the idea of "coupling" or "blending" of emotions (cf. Plutchik, 1980). The preliminary conceptual analysis suggested that, from a basic-emotions point of view, many emotional disorders could be viewed as the coupling of two or more basic emotions, and that many supposedly "unitary" disorders, such as obsessional compulsive disorders and phobias, might be more appropriately derived from different basic emotions. In relation to depression, there are a number of possible combinations of coupled emotions. If sadness is taken as the commonest emotion in depression, when it is combined with disgust, especially in the form of self-disgust (that is, as self-loathing, shame, and guilt, which are complex emotions derived from the basic emotion of disgust; see Power, 1999; Power & Dalgleish, 1997), the coupling provides for one subtype of depression together with some inhibition of happiness. However, other combinations are also possible; for example, anxious depression could occur from the coupling of sadness and anxiety, perhaps with some disgust plus some happiness inhibition. Agitated or irritable depression is likely to be a coupling of sadness and anger, and again some increased disgust and inhibited happiness. When happiness is increased rather than inhibited, the mixed states occur, especially in the dysphoric mania category, where both increased happiness and increased anxiety occur. Combinations such as sadness and anger, but without increased disgust, are more likely to be seen in examples of extreme or "pathological grief"; for example, after the sudden and unexpected loss of a loved one (see Power & Dalgleish, 1997).

Although we are yet to obtain solid and replicated data for the full range of this basic-emotions analysis of the emotional disorders, in a recent study (Power & Tarsia, submitted) we compared basic-emotion profiles across groups of normal controls, depressed, anxious, and mixed anxiety depression (not, however, the subclinical category appendixed in DSM-IV, but rather a group of patients who met DSM criteria for both major depression and one of the anxiety disorders, such as Generalised Anxiety Disorder (GAD) or phobia). The basic-emotion profiles, obtained with the Basic Emotions Scale (Power, submitted) showed no elevation of anger, but the sadness and the disgust levels were significantly higher in the depressed and the mixed groups than in the anxiety and control groups. The anxiety levels were elevated in all of the clinical groups in comparison to the controls, but the clinical groups did not differ significantly from each other. Whether this reflects the fact that the patients were primarily an outpatient group, or that the findings will be replicated in larger, more extensive studies remains to be seen. Finally, the happiness levels were highest in the control, intermediate in the anxious, and lowest in the mixed and depressed groups. In sum, the Basic Emotions Scale showed that different profiles of basic emotions are found across different emotional disorders, though whether or not such profiles could ever provide a theoretical basis for the classification and diagnosis of the emotional disorders remains to be seen.

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