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Partial Validation of the Atypical Features Subtype of Major Depressive Disorder

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Partial Validation of the Atypical Features Subtype of Major Depressive Disorder ORIGINAL ARTICLE Partial Validation of the Atypical Features Subtype of Major Depressive Disorder Michael A. Posternak, MD; Mark Zimmerman, MD Background: Symptoms of the atypical features sub- semistructured interviews. Using the available litera- type of major depressive disorder include mood reactiv- ture, we made a series of a priori hypotheses regarding ity, hypersomnia, hyperphagia, leaden paralysis, and re- how depressed patients with atypical features (n=130) jection sensitivity. This subtype was introduced into the would differ from those without atypical features (n=449). mood disorders section of the DSM-IV following a series In addition, we tested the strength of the associations be- of antidepressant trials showing that such patients re- tween each of the 5 atypical symptoms. sponded preferentially to monoamine oxidase inhibi- tors. Studies aimed at validating the atypical features sub- Results: Although many of the predicted hypotheses were type have yielded inconsistent results. Our study sought substantiated, an equal number were not. Correlation to reevaluate the validity of atypical depression by ex- analyses revealed modest associations between several of amining the demographic and clinical features of a large the atypical symptoms, but mood reactivity was not as- cohort of depressed patients who met DSM-IV criteria for sociated with any of the other symptom criteria. atypical features. Conclusion: Our results provide partial support for the Methods: We evaluated 579 psychiatric outpatients with validity of the atypical features subtype of major depres- a current diagnosis of major depressive disorder for the sive disorder. presence of atypical features. Detailed demographic and clinical information was obtained for each patient through Arch Gen Psychiatry. 2002;59:70-76 TYPICAL depression stands included patients with panic disorder; the alone among the DSM-IV1 other, patients with hysteroid dysphoria. mood disorder subtypes The latter syndrome was characteristic of as being born out of the histrionic patients, whose mood was de- modern psychopharmaco- scribed as “shallow” and excessively sensi- Alogic revolution. West and Dally2 first used tive to both admiration (mood reactive) and the qualifier atypical to characterize a co- rejection (rejection sensitive). When de- hort of depressed patients who appeared pressed, such patients purportedly dis- phobic, “overreactive,” and “hysterical” played a propensity to oversleep and over- and exhibited prominent fatigue, re- eat. Although the validity of hysteroid versed diurnal variation, initial insom- dysphoria was questioned by some,5,6 it was nia, and an absence of decreased appe- ultimately incorporated into the DSM-IV as tite. Sargant3 added that such patients also a depressive subtype by virtue of the pref- tended to complain of severe lethargy, hy- erential response such patients showed for persomnia, and irritability. Both sets of in- MAOIs rather than tricyclic antidepres- vestigators believed that these patients had sants. In its current form, the atypical sub- good premorbid personalities but were type includes 5 features: mood reactivity now experiencing a chronic form of de- plus at least 2 of the following 4 symptoms pression. They also noted that such pa- (hereafter referred to as atypical B symp- tients responded particularly well to mono- toms): hypersomnia, hyperphagia, severe amine oxidase inhibitors (MAOIs) and less lethargy (often described as a feeling of From the Department of well to tricyclic antidepressants and elec- “leaden paralysis”), and a pathological sen- Psychiatry and Human troconvulsive therapy. sitivity to rejection and criticism. 4 Behavior, Brown University Quitkin et al subsequently argued that The decision to include the atypical School of Medicine, Rhode these early investigators were actually de- features subtype in the DSM-IV was con- Island Hospital, Providence. scribing 2 distinct subtypes. One subtype troversial,7 in part because studies that have (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 59, JAN 2002 WWW.ARCHGENPSYCHIATRY.COM 70 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 SUBJECTS AND METHODS 0.78; and rejection sensitivity, 0.75, indicating excellent in- terrater reliability. The SCID was supplemented with questions from the SUBJECTS Schedule for Affective Disorders and Schizophrenia (SADS)37 to assess the severity of symptoms during the week prior to All subjects in our study were recruited from the Rhode the evaluation. From this, we were able to obtain extracted Island Hospital (Providence) Department of Psychiatry’s 21-item Hamilton Depression Rating Scale (HAM-D) scores outpatient practice. During their initial telephone screen, following the algorithm developed by Endicott et al.38 Cur- all patients were invited to participate in an in-depth di- rent social-functioning ratings were obtained using the SADS agnostic evaluation prior to meeting with their treating cli- item that rates the highest level of social relations during nician (psychiatrist, psychologist, or social worker). Only the last 5 years. Baseline Clinical Global Impression– non-English-speaking patients and those with evidence of Severity (CGI-S)39 ratings and current Global Assessment of cognitive impairment were excluded from the study. To date, Functioning (GAF)40 scores were also obtained for each pa- 1130 patients have been evaluated. Of these, 579 (51.2%) tient by the diagnostic interviewer. Personality disorder as- were diagnosed as having a current major depressive dis- sessments were incorporated into the protocol for only the order and form the cohort of interest for the study. The last 530 patients; the first 600 patients did not undergo an Rhode Island Hospital institutional review board ap- Axis II diagnostic evaluation. Thus, PD diagnoses were avail- proved the research protocol, and all patients provided in- able for only 262 (45.3%) of the 579 patients with major formed written consent. depression. Personality disorders were assessed using the Structured Interview for DSM-IV Personality.41 METHODS All diagnoses were made according to DSM-IV crite- ria. Our analyses comparing depressed patients with and Consenting patients were interviewed at baseline using the without atypical features are based on current rather than Structured Clinical Interview for DSM-IV (SCID).35 Diag- lifetime diagnoses of affective disorders. In comparing co- nostic raters were PhD psychologists or college graduate morbidity rates, however, we used lifetime diagnoses. Psy- research assistants who had undergone extensive train- chomotor retardation was rated by interviewer observa- ing, as described elsewhere.36 tion rather than patient report. Prior suicidal behavior was Mood reactivity was assessed according to the SCID by analyzed based on the most serious lifetime attempt. The asking patients whether they felt better, even temporarily, determination of seriousness was made after assessing the when something good happened. Hyperphagia was defined method and purpose of the attempt, the likelihood of res- as increased appetite nearly every day for at least 2 weeks or cue, and the seriousness of injury. an increase in body weight of 5% or more. Hypersomnia was defined as sleeping significantly more than usual. Leaden pa- STATISTICAL ANALYSES ralysis was considered to be present when a patient acknowl- edged often having a heavy, leaden feeling in the arms or legs. We performed ␹2 and t tests to analyze all categorical and Rejection sensitivity was defined as a long-standing pattern continuous variables, respectively. Correlation coeffi- of interpersonal sensitivity (not limited to episodes of mood cients were obtained using the Spearman ␳ because all vari- disturbance) that caused significant social or occupational im- ables tested were dichotomous. For all hypothesized com- pairment. All 5 symptoms were rated as being either pre- parisons, statistical significance was set at PϽ.05, and all sent, absent, or subthreshold, and only the first rating counted tests were 2-tailed. In addition, 34 tests were performed with- as being present. Reliability ratings for each of the atypical out an a priori hypothesis. For these tests, the Bonferroni symptoms were obtained from 24 joint interviews. ␬ Values correction was used to adjust for chance positive findings. for the atypical symptoms were as follows: mood reactivity, Statistical significance in these analyses was set at PϽ.05 0.83; hyperphagia, 1.0; hypersomnia, 0.90; leaden paralysis, divided by 34, or PϽ.0015. examined the demographic and clinical features of pa- In our study, we sought to assess and reevaluate the tients with atypical depression have frequently yielded con- validity of the atypical subtype by comparing the demo- tradictory results. For example, the atypical features sub- graphic and clinical features of depressed patients with type has been associated with female sex by some and without atypical features. Our analyses are based on investigators8-11 but not others,12-14 younger age by some9,12,15 data collected from the Rhode Island Methods to Im- but not others,8,13,14,16 bipolarity by some17,18 but not oth- prove Diagnostic Assessment and Services (MIDAS) ers,13 greater anxiety by some9,12,19-21 but not oth- project,27 which has overcome many of the limitations ers,11,14,16,22 less severity by some11,22 but not others,8,13,23,24 of previous studies by (1) evaluating a large cohort of un- a longer duration of illness by
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