Descriptive Psychopathology: The Signs and Symptoms of ...

380 Section 4: Evidence-based classificationThese patients had many melancholic features and were suicidal, clinically meetingcriteria for melancholia as well as abnormal bereavement. 68 Abnormal bereavementshould be eliminated from the classification. The death of a loved one does not elicita unique depressive illness.Bipolar and unipolar categoriesSyndrome delineationWhen depression is divided into melancholia and non-melancholia classes,the distinction between the bipolar and unipolar categories changes. Unipolardisorder becomes non-melancholia depressive disorder. Bipolar disorder is melancholiawith associated mania or hypomania. What appears to be recurrentmelancholia only and melancholia associated with mania or hypomania areaspects of one disease as formulated by Kraepelin, manic-depressive illness. Nonmelancholicdisorder consists of different depressive illnesses and some anxietydisorders, while melancholic disorder consists of patients all of whom experiencemelancholic depression and many who also experience mania or hypomania.Others have also reached this conclusion. 69The challenges to the present bipolar/unipolar dichotomy are substantial, but thecontroversy can be resolved with the melancholia/non-melancholia separation. Thedelineation of manic-depressive illness into unipolar and bipolar distinctions wasinitially supported by family history studies. 70 The dichotomy was challenged, firstin literature reviews and then in prospective studies. 71 Family illness patterns arenot clearly dichotomous. The most common mood disorder in the first-degreerelatives of patients with bipolar disorder is recurrent depressive illness (“unipolardisorder”). The morbid risk (age-corrected prevalence) for unipolar disorder in thefamilies of the bipolar patients is greater than the morbid risks for unipolardepression in the families of unipolar patients. The risk for manic-depressive illnessis modestly elevated in the relatives of patients with recurrent depression. 72 Severalinvestigators concluded that they could not distinguish unipolar and bipolarpatients by family data as long as depression was defined as melancholia. 73 However,in a large family study, Winokur et al. (1995) reported that there was little familialoverlap between bipolar and unipolar conditions. But an examination of their datashows that the families of patients with psychotic depression were similar to thoseof patients with manic-depression. Psychotic depression is melancholia.Twin studies also show the overlap. 74 In the analysis of 30 monozygotic and37 dizygotic twin pairs the proband-concordance was higher for monozygoticthan for dizygotic twins, with heritability estimated at 89%. In almost 29% of themonozygotic pairs, one twin had both manic and depressive episodes while theother had recurrent depressive illness. Among dizygotic pairs, 13.5% had a mixed