The influence of anxiety as a risk to early onset major depression.

OBJECTIVE: we seek to identify and quantify any risk provided by several expressions of "anxiety" to major depression overall, and to separate melancholic and non-melancholic sub-types. METHOD: a sample of 269 patients with a current major depressive episode was assessed for rates of separate formalised anxiety disorders, both for lifetime and prior to the initial depressive episode. We also sought for evidence of familial anxiety and, early childhood expression of anxiety forerunners, measured both state and trait anxiety levels as well as anxiety at a "personality" level, and assessed use of anxiolytic medications. Depressive sub-typing was undertaken using DSM-IV criteria, while "early onset" (EO) depression was defined as an initial onset at 25 years or less, and subsequently re-examined with a cut-off age of 20 years or less. RESULTS: overall. 42% of our sample were assigned as having EO depression, with there being a higher representation of non-melancholic than melancholic EO subjects (i.e., 51% vs. 29%), arguing for sub-type status being respected in the analyses. For both melancholic and non-melancholic subjects two trait anxiety items ("tense"; "keyed up/on edge") were over-represented, suggesting that such a tense anxiety style may provide an antecedent risk to depression (of either sub-type) or be a consequence of depression. Specificity was most evident in the non-melancholic sub-sample, where EO depression was associated with a family history of anxiety, early childhood expressions of anxiety and with two lifetime anxiety disorders (social phobia and obsessive-compulsive disorder). Broadly similar results were returned when "EO" definition was reduced to 20 years or less. CONCLUSIONS: our study is consistent with previous research in identifying anxiety in the form of social inhibition or social avoidance as being particularly likely to precede and perhaps be a conduit to early onset non-melancholic major depression. This conclusion both sharpens risk factor research and indicates an important fulcrum that could be used to assist primary prevention of the depressive disorders.

Qualitative and quantitative analyses of a 'lock and key' hypothesis of depression.

BACKGROUND: We examine a 'lock and key' ('L-K') hypothesis to depression which posits that early adverse experiences establish locks that are activated by keys mirroring the earlier adverse experience to induce depression. METHODS: Two-hundred and seventy clinically depressed patients were examined with open-ended and pre-coded interview questions to ascertain both early adverse experiences and precipitating life events. Qualitative and quantitative data analyses examined for any associations between developmental 'locks' and precipitating 'keys'. RESULTS: Qualitative assessment suggested 'L-K' links in almost one-third of the sample, and examples are provided. While quantitative analyses indicated significant associations between several identical 'lock' and 'key' constructs, evidence of specificity was rare. When individual 'locks' and 'keys' were consolidated into three higher-order constructs, variable models were suggested, including a non-specific link, a specific link and absence of any link. 'L-K' links appeared more likely in those with 'non-melancholic' (versus 'melancholic') depression, with the seemingly greater relevance to 'reactive' (versus 'neurotic') depression in the quantitative analyses inviting speculation that that 'disorder' may be more a reaction to a salient rather than a severe stressor. CONCLUSIONS: This exploratory study suggests that early adverse experiences may variably establish specific and non-specific patterns of vulnerability to having depression triggered by exposure to salient mirroring life event stressors.

On modelling personality disorders: are personality style and disordered functioning independent or interdependent constructs?

Current descriptors of personality disorder (PD) are an amalgam of two constructs, personality style and/or disorder. We seek to determine whether their intrinsic personality style descriptors are proxy measures of, or independent of, disordered personality functioning. In a sample of depressed patients, psychiatrists rated 16 differing PD personality style vignettes and assessed eight differing manifestations of disordered functioning. When "personality" vignettes and identified personality clusters were intercorrelated with "disorder" variables, interdependence was generally evident, suggesting that the personality descriptors underpinning current definition of the PDs actually act as proxy criteria for assessing disorder because they are, in and of themselves, descriptors of pathological functioning. The obsessional personality vignette provided an exception, seeming to be independent of disordered function. Such results assist consideration of how best to model, define and measure the personality disorders.

Non-melancholic depression: the contribution of personality, anxiety and life events to subclassification.

BACKGROUND: We sought to develop a clinically useful subtyping system for the non-melancholic depressive disorders, and here we assess one weighted to central aetiological factors. METHODS: We studied 185 patients meeting DSM-III-R and/or clinical criteria for non-melancholic depression. Data were obtained by self-report, interview of patients and from corroborative witnesses. We developed a set of variables for class definition, assessing: (i) 'P', disordered personality as a vulnerability factor; (ii) 'A', meeting criteria for a lifetime anxiety disorder or positive on probe questions about trait anxiety characteristics, so assessing anxiety as a vulnerability factor; and (iii) 'L', psychiatrist and consensually-rated life event stress prior to depression onset. RESULTS: A latent class analysis generated a four-class solution for the P-A-L variables. Life event stressors had similar item probabilities across all four classes, and did not influence the four-class 'P-A' solution when deleted from the analysis, suggesting that life event stress may act more as a general provoking agent, rather than constituting any distinct 'reactive' or 'situational' depression class. Three classes generated clinically meaningful groupings, reflecting varying contributions of anxiety and disordered personality functioning, and with evidence of differential outcome over the following 12 months. CONCLUSIONS: We suggest that a refined aetiologically-weighted model may assist definition of the non-melancholic depressive disorders, and provide the logic for exploring the comparative utility of differing treatments to identified vulnerability-based classes.

Disordered personality style: higher rates in non-melancholic compared to melancholic depression.

OBJECTIVE: We test whether there is differential representation of disordered personality function across melancholic and non-melancholic depressive sub-types, with levels of differentiation examined against differing sub-typing measures. METHOD: In a sample of 245 subjects meeting criteria for a non-psychotic major depressive episode lasting less than 2 years, we examine for differential rates of disordered personality style across melancholic and non-melancholic depression, using four differing sub-typing measures (i.e., DSM-III-R and DSM-IV criteria, Newcastle Index, and the CORE measure). Disordered personality was assessed by psychiatrist ratings of 15 differing personality styles underpinning disorder classes, and several parameters and domains that reflect the arenas whereby disordered personality may be manifested. RESULTS: However defined, those with non-melancholic depression were distinctly more likely to rate as showing disordered personality function, with over-representation to an avoidant personality disorder style being the most consistently and strongly identified personality disorder class. Because of limitations to several of the sub-typing measures, we focus on the DSM-IV system. Discriminant function analyses indicated that those so identified as having non-melancholic depression were significantly more likely to rate as having avoidant and schizoid personality styles. A principal components analysis of our 15 differing personality disorder classes identified three molar classes corresponding to the three-cluster DSM system. Again, non-melancholic (compared to melancholic) subjects were more likely to return higher scores: in order, an 'anxious and fearful' (Cluster C) personality style, then an 'eccentric' Cluster A, and somewhat less clearly, a 'dramatic' Cluster B personality disorder style. Specificity to the non-melancholic depressive class was again suggested in relation to a large number of the parameters and domains measuring disordered personality function. CONCLUSIONS: Disordered personality function appears distinctly more likely in non-melancholic, compared to melancholic depression.

The development of a refined measure of dysfunctional parenting and assessment of its relevance in patients with affective disorders.

BACKGROUND: The Parental Bonding Instrument (PBI) measures fundamental parenting dimensions (care and over-protection), but does not directly assess abusive parenting. METHODS: We describe the development of the Measure of Parenting Style (the MOPS), comprising refined PBI scales assessing parental indifference and over-control, as well as a scale assessing parental abuse. RESULTS: We examine psychometric properties of the MOPS, while several analyses build to the concurrent validity of the abuse scale as an experimental measure. We examine the extent to which both the PBI and the MOPS scales showed specificity of dysfunctional parenting to the non-melancholic depressive subtype, and across a range of anxiety disorders. Non-melancholic depressed patients returned anomalous parenting scale scores (compared to melancholic subjects), but only when such subtyping decisions were clinician-generated. Those receiving DSM-III-R lifetime anxiety diagnoses of panic disorder and of social phobia returned higher PBI protection and MOPS over-control scores than non-anxious subjects, while differences were not established for those with generalized anxiety disorder or obsessive compulsive disorder. CONCLUSIONS: We consider the likely utility of the MOPS scale and note the module capacity of separate MOPS and PBI scales, which allow a set of options for assessing perceived parenting characteristics.

How distinct is 'distinct quality' of mood?

BACKGROUND: The DSM-IV criteria for melancholia include the clinical feature 'distinct quality', defined as a mood state differing from that experienced in bereavement. Both propositions-its specificity to melancholia and its definition- remain problematical. METHODS: We examine both propositions by analysing an adjective checklist completed by melancholic and non-melancholic depressed subjects, as well as by a bereaved sample. The checklist was refined by a principal components analysis to four scales-one assessing a general 'mood' severity or dysphoric dimension, and the other three assessing dimensions of 'fatigue', 'numbness' and 'guilt'. RESULTS: If the concept of "distinct quality' has validity, we would require specificity of the refined qualitative constructs to melancholic depression. The 'numbness' component met that requirement, but only to a degree. While bereaved subjects did differ from those with melancholic depression on a number of our refined qualitative mood domains, such differences appeared more related to lower levels of depression in the bereaved sample. CONCLUSIONS: We argue for deleting the 'distinct quality' criterion from diagnostic checklists of melancholia until its definition has been improved, its utility demonstrated and its specificity to any depressive subtype established as having clinical significance.

Distinguishing psychotic depression from melancholia.

We contrast 25 patients with "psychotic depression" (PD) against two age- and sex-matched groups of melancholic depressed patients. In terms of clinical features, specificity of PD was suggested for several features, including delusions, morbid cognitions (involving guilt and a sense of deserving punishment), hallucinations and constipation. In addition, the PDs had significantly higher levels of behaviourally rated psychomotor disturbance. A comprehensive list of risk factors to depression (e.g., socio-demographic, family history, parental influences, medical disorders, anxiety, stressors and personality style) were examined, without clear differentiation between the comparison groups apart from the suggestion that being a "worrier" and having tenuous stability under stress was over-represented in the PDs. Findings favour the view that psychotic depression is a sub-type of melancholic depression (accounting for the similar expression of the majority of clinical and possible aetiological variables across our contrasted "types'). Findings also suggest possible benefits from future phenomenological studies of psychotic depression relying more on observer-based rather than self-report or symptom data sets. Aetiological studies would benefit from focussing on those features identified as distinguishing the condition from melancholic depression.

Plumbing the depths: some problems in quantifying depression severity.

We first report further studies of the psychometric properties of the AUSSI), a brief (11-item) self-report depression measure assessing mood state severity and disability in a sample of 270 subjects. Total scores (combining mood state and disability) correlated well with another self-report measure of depression severity, the Beck, but minimally with both Hamilton and DSM-III-R Global Assessment of Function (GAF) scores. For a sub-sample where we had complete data sets (including a corroborative witness [CW] form of the AUSSI), we established moderate levels of agreement between self-report and CW AUSSI scores, important in supporting validity of its disability sub-scale. Against expectation, neither mood nor disability AUSSI scale scores differed across clinically meaningful depressive sub-types, while differentiation was demonstrated for the Hamilton and GAF measures. Differentiation for the Hamilton measure was clearly driven by several type-specific component clinical features, but also presumably contributed to by the clinician-rater format. Our study raises questions about the varying reference bases and semantics used by patients, corroborative witnesses and clinicians in rating depression severity, and which may generate similar or contrasting severity estimates across varying depressive sub-types.

Supernumerary lacrimal canaliculi.

Supernumerary extopic canaliculi in a 12-year-old white male patient are presented. Their external openings (puncti) were located on the lateral surface of the nose, 1 cm from the inner canthus, and were reaching the lacrimal sac directly. The anomaly was surgically corrected and 2 years after the operation the patient is free of symptoms.