Un análisis crítico de los debates acerca del duelo y el trastorno depresivo en la era del Manual Diagnóstico y Estadístico de los Trastornos Mentales / A critical analysis of debates on grief and depressive disorder in the age of the Diagnostic and Statistical Manual of Mental Disorders

RESUMEN Desde la incorporación del trastorno depresivo mayor en el Diagnostic and Statistical Manual of Mental Disorders (DSM-III) de 1980, hasta su actualización en el DSM-IV-TR, el sistema clasificatorio DSM consideró necesario incluir el criterio de "exclusión por duelo", con el objetivo de diferenciar la tristeza normal, vinculada a una pérdida, de un trastorno mental, como el trastorno depresivo mayor. En su última versión (DSM-5), esta excepción fue suprimida, dando lugar a una controversia que se extiende hasta nuestros días. El debate ha confrontado a quienes están a favor de mantener y extender la exclusión a otros estresores y aquellos que han querido erradicarla. Nuestra hipótesis es que estas posiciones darían cuenta de dos matrices clínicas y epistemológicas cualitativamente diversas ligadas a las trasformaciones mayores que han experimentado las ciencias de la salud y la psiquiatría. Mostramos que este debate involucró una renovación profunda del sentido de la práctica psiquiátrica, un cambio en la función del diagnóstico y el modo de concebir la etiología de la enfermedad mental, así como, una reformulación del estatuto del sufrimiento del paciente para el acto médico.

ABSTRACT Since the incorporation of the major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, and until its update in the DSM-IV-TR, the DSM classification system considered it necessary to include the criterion of "bereavement exclusion", with the aim of differentiating normal sadness linked to a loss, from a mental disorder, such as the major depressive disorder. In its latest version (DSM-5), this exception was removed, giving rise to a controversy that continues to this day. The debate has set those who are in favor of maintaining this exclusion and extending it to other stressors against those who have intended to eradicate it. Our hypothesis is that these positions account for two qualitatively diverse clinical and epistemological matrices, linked to major transformations in health sciences and in psychiatry. We show that this debate involved a profound renewal of the meaning of psychiatric practice, a change in the function of diagnosis and in the way of conceiving the etiology of mental disorders, as well as a reformulation of the patient's suffering status for the medical act.

The joint structure of major depression, anxiety disorders, and trait negative affect

Background: Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil. Methods: The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling. Results: Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect. Conclusions: This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology. .

Does Age at Onset of First Major Depressive Episode Indicate the Subtype of Major Depressive Disorder?: The Clinical Research Center for Depression Study

PURPOSE: The purpose of this study was to evaluate the effects of age at onset of the first major depressive episode on the clinical features of individuals with major depressive disorder (MDD) in a large cohort of Korean depressed patients. MATERIALS AND METHODS: We recruited 419 MDD patients of age over 18 years from the Clinical Research Center for Depression study in South Korea. At the start of the study, the onset age of the first major depressive episode was self-reported by the subjects. The subjects were divided into four age-at-onset subgroups: childhood and adolescent onset (ages <18), early adult onset (ages 18-44), middle adult onset (ages 45-59), and late onset (ages 60+). Using analysis of covariance (ANCOVA) and ordinal logistic regression analysis with adjusting the effect of age, the relationships between clinical features and age at onset of MDD were evaluated. RESULTS: There was an apparent, but inconsistent correlation between clinical features and age at onset. Earlier onset MDD was significantly associated with higher proportion of female gender [adjusted odds ratio (AOR)=0.570, p=0.022], more previous suicide attempts (AOR=0.635, p=0.038), greater number of previous depressive episodes (F=3.475, p=0.016) and higher scores on the brief psychiatric rating scale (F=3.254, p=0.022), its negative symptom subscale (F=6.082, p<0.0001), and the alcohol use disorder identification test (F=7.061, p<0.0001). CONCLUSION: Early age at onset may increase the likelihood of distinguishable MDD subtype, and age at onset of the first major depressive episode is a promising clinical indicator for the clinical presentation, course, and outcome of MDD.

Depressão maior suscita questionamento maior / Major depression invites major concerns

OBJETIVO: Revisar as limitações do conceito e do construto da depressão maior. MÉTODO: Os objetivos na conceitualização inicial da depressão maior são examinados em relação à sua subseqüente utilidade e relevância para os clínicos e pesquisadores. RESULTADOS: Afirma-se que, como definida, a depressão maior não diferencia bem a depressão clínica das expressões de depressão não clínica ou de tristeza; que seu conjunto de critérios não gera diagnósticos confiáveis; que um diagnóstico da depressão maior pouco significa por si só (na medida em que compreende efetivamente múltiplos tipos de depressão); e não nos informa sobre a causa, histórico natural ou resposta diferenciada ao tratamento. CONCLUSÃO: As limitações do conceito de depressão maior poderiam se beneficiar de uma avaliação mais ampla para impulsionar alterações no diagnóstico clínico dos subtipos depressivos.

OBJECTIVE: To overview limitations to the concept and construct of major depression. METHOD: The objectives in initially conceptualizing major depression are examined against its subsequent utility and relevance to clinicians and researchers. RESULTS: It is argued that, as defined, major depression does not differentiate clinical depression well from expressions of non-clinical depression or sadness, that its criteria set do not generate reliable diagnoses, that a diagnosis of major depression means little in and of itself (as it effectively comprises multiple types of depression) and that it fails to inform us about cause, natural history or differential treatment response. CONCLUSION: Limitations to the concept of major depression would benefit from wider appreciation to advance changes to the clinical diagnosis of depressive sub-types.

A study of Late Onset Schizophrenia Clinical Characteristics with Review of Literature.

That schizophrenia does manifest for the first time in old age, has been recognized for a long time. A number of recent epidemiological studies have also documented its onset in old age. It has remained controversial, however, if schizophrenia occurring for the first time in old age is different substantially from schizophrenia manifesting at younger age. A number of efforts have been going on in recent years in different parts of the world to document differences and similarity between two groups on parameters like clinical features, family history, psychopathology, treatment response, and prognosis and outcome. Many studies have appeared on neuroimaging and neurobiology of late onset schizophrenia. Some efforts have also been done in India on this entity. The present study is to examine clinical characteristics of late onset schizophrenia on number of standardized structured instruments. The study compares its results with some well known studies.

Understanding childhood depression.

Major depressive disorder in children is a severe and a chronically disabling disorder. This population appears to be a special group in terms of consequences of poor psychosocial and academic outcome and increased risk of substance abuse, and suicide. Studies have revealed several major findings in genetic, familial, psychological, and biological aspects of such depression, some of which have explored into the issue of its relationship with adult depression. Considerable advances have been made now in the area of childhood depression providing a better understanding of its nature. We review literature available on historical aspect, epidemiology, clinical characteristics, and aetiology of childhood depression.

Sintomas alucinatórios persistentes: uma discussäo nosológica e Psicopatológica / Persistent Hallucinatory Symptoms: a nosological and psochopathological discussion

Os autores apresentam um caso de psicose de evoluçäo cronica marcado por sintomas alucinatórios persistentes. Discutem a classificaçäo nosológica do caso fazendo referencias a quadros clínicos classicos. Finalmente, fazem breve revisäo sobre a psicopatologia das alucinaçöes

Controversias acerca de la nosología de los trastornos delirantes paranoides / Controversies about nosology of delusional paranoid disorders

La existencia de pacientes con ideas delirantes persistentes, no bizarras, no atribuibles a otro trastorno mental, plantea una serie de interrogantes. Kraepelin distinguió dos entidades dentro de este grupo, la paranoia y la parafrenia, incluyéndolas dentro de las psicosis endógenas. Desde entonces ha existido una permanente controversia acerca de la atribución nosológica. Algunos autores plantean que se trata de formas moderadas de esquizofrenia. Otros afirman que es un subtipo de enfermedad afectiva. Un tercer punto de vista, coincidente con Kraepelin, considera que se trata de psicosis independientes. Actualmente predomina la idea de que es una categoria separada, aunque los fundamentos derivan de un número limitado de estudios. El DSM-III-R y la CIE-10 incluyen estos cuadros dentro de una nueva categoría diagnóstica los trastornos delirantes (paranoides). No obstante, los criterios diagnósticos difieren entre ambos sistemas nosológicos y entre estos y sus predecesores, el DSM-III y la CIE-9. Se requieren más investigaciones rigurosas para establecer mejor la legitimidad y los límites de estas entidad o grupo de entidades nosológicas