Depressive Disorders Outline

Sunday, 1 October 2023 7:09 pm

Understanding and Defining Mood Disorders

Mood disorders involve profound disturbances in emotion—from the deep sadness and
disengagement of depression to the extreme elation and irritability of mania. The DSM-5 recognizes
two broad types of mood disorders: those that involve only depressive symptoms (unipolar
depressive disorders) and those that involve manic symptoms (bipolar disorders).

Depressive Disorders
• Major depressive disorder
• Persistent depressive disorder
• Premenstrual dysphoric disorder
• Disruptive mood dysregulation disorder
• Substance/medication-induced depressive disorder
• Depressive disorder due to another medical condition
• Other specified depressive disorders

The common feature of all of these disorders is the presence of sad, empty, or irritable mood,
accompanied by related changes that significantly affect the individual’s capacity to function (e.g.,
somatic and cognitive changes in major depressive disorder and persistent depressive disorder).
What differs among them are issues of duration, timing, or presumed etiology.

DSM-5 DIAGNOSES MAJOR FEATURES

Major depressive disorder Five or more depressive symptoms, including sad mood or
anhedonia, for 2 weeks
Persistent depressive disorder Low mood and at least two other symptoms of depression at least
half of the time for 2 years
Premenstrual dysphoric Mood symptoms in the week before menses
disorder
Disruptive mood Severe recurrent temper outbursts and persistent negative mood
dysregulation disorder for at least 1 year

Cardinal symptoms of depression

• Depressed mood/profound sadness
• Inability to experience pleasure (anhedonia)

Major depressive disorder

• Five or more depressive symptoms, including depressed mood or anhedonia, for 2 weeks
• The episode must be accompanied by clinically significant distress or impairment in social,
occupational, or other important areas of functioning
• Major depressive episodes often recur—once a given episode clears, a person is likely to
experience another episode

Diagnostic Criteria (A)

1. Depressed mood most of the day, nearly every day
2. Marked diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day
3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite
nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day

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 6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
9. Recurrent thoughts of death

Persistent depressive disorder

• People with persistent depressive disorder are chronically depressed— more than half of the
time for at least 2 years, they feel blue or obtain little pleasure from activities and pastimes
○ Patient cannot be symptom free for more than 2 months at a time
• Persistent depressive disorder differs from a major depressive disorder in the number of
symptoms required, but mostly in its chronicity

Diagnostic Criteria
Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness

Premenstrual Dysphoric Disorder

• Expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly
during the premenstrual phase of the cycle and remit around the onset of menses or shortly
thereafter.
• Symptoms must have occurred in most of the menstrual cycles during the past year and must
have an adverse effect on work or social functioning.
• One or more symptoms from diagnostic criteria B and one or more symptoms from diagnostic
criteria C to reach a total of five symptoms

Diagnostic Criteria (B)

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased
sensitivity to rejection).
2. Marked irritability or anger or increased interpersonal conflicts.
3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

Diagnostic Criteria ©
1. Decreased interest in usual activities
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite
5. Hypersomnia or insomnia.
6. A sense of being overwhelmed or out of control
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of
“bloating,” or weight gain

Disruptive Mood Dysregulation Disorder

• Disruptive mood dysregulation disorder was added to DSM-5 to address the considerable
concern about the appropriate classification and treatment of children who present with
chronic, persistent irritability relative to children who present with classic (i.e., episodic)
bipolar disorder.
• Severe recurrent temper outbursts and persistent negative mood for at least 1 year beginning
before age 10
• Included to address the growing number of children and adolescents who are seen by
clinicians due to severe mood changes and irritability as well as some of the symptoms of
mania. Many of these youth do not meet the full criteria for mania (the defining feature of

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 mania. Many of these youth do not meet the full criteria for mania (the defining feature of
bipolar disorder) but were often falsely labeled with bipolar disorder because no other
category seemed to fit their symptoms.
• A young person must show severe temper outbursts that are grossly out of proportion in
intensity and duration to a situation and inconsistent with developmental level

Diagnostic Criteria
A. Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly
out of proportion in intensity or duration to the situation or provocation
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly
every day, and is observable by others
E. Criteria A–D have been present for 12 or more months.
F. Criteria A and D are present in at least 2 to 3 settings

Substance/Medication-Induced Depressive Disorder

• A prominent and persistent disturbance in mood that predominates in the
clinical picture and is characterized by depressed mood or markedly diminished interest or
pleasure in all, or almost all, activities that is due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or a toxin exposure)
• The depressive symptoms must have developed during or soon after substance intoxication or
withdrawal or after exposure to or withdrawal from a medication, and the involved
substance/medication must be capable of producing the depressive symptoms

Diagnostic Criteria
A. A prominent and persistent disturbance in mood that predominates in the clinical picture and
is characterized by depressed mood or markedly diminished interest or pleasure in all, or
almost all, activities.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and
(2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to or withdrawal from a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

Substances/medications most likely to cause substance/medication-induced depressive

disorder
• Depressants
○ Intoxication with alcohol
○ Benzodiazepines
• Stimulants
○ Cocaine
○ Withdrawal from amphetamine-type substances
• Opioids
• Medications
○ Steroids
○ Antihypertensive-type substances
○ Antibiotics
○ Antiviral agents
○ Cardiovascular agents
○ Hormonal agents

Depressive Disorder Due to Another Medical Condition

• Depressed mood or markedly diminished interest or pleasure in all, or almost all activities and
that is thought to be due to the physiological effects of another medical condition
• There is evidence from the history, physical examination, or laboratory findings that the

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 • There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.

Medical conditions associated with depression

A. Neurological illnesses
1. Cerebrovascular accident (CVA)
2. Huntington’s disease
3. Parkinson’s disease
4. Traumatic brain injury (TBI)
B. Neuroendocrine conditions
1. Cushing’s syndrome
2. Hypothyroidism

Other Specified Depressive Disorder

• This category applies to presentations in which symptoms characteristic of a depressive
disorder that cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the depressive disorders diagnostic class

Recurrent brief depression

○ Concurrent presence of depressed mood and at least four other symptoms of
depression for 2–13 days at least once per month (not associated with the menstrual
cycle) for at least 12 consecutive months
Short-duration depressive episode (4-13 days):
○ Depressed affect and at least four of the other eight symptoms of a major depressive
episode associated with clinically significant distress or impairment that persists for
more than 4 days, but less than 14 days
Depressive episode with insufficient symptoms
○ Depressed affect and at least one of the other eight symptoms of a major depressive
episode associated with clinically significant distress or impairment that persist for at
least 2 weeks in an individual whose presentation has never met criteria for any other
depressive or bipolar disorder
Major depressive episode superimposed on schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorder.

Specifiers for Depressive Disorders

1. Psychotic features specifiers
○ Psychotic symptoms, specifically hallucinations and delusions
○ Mood incongruent - psychotic symptoms does not involve typical depressive themes of
personal inadequacy, guilt, disease, death, nihilism, or deserved punishment
○ Mood congruent - psychotic symptoms are consistent with the typical depressive
themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
2. Anxious distress specifiers
○ The presence and severity of accompanying anxiety
○ High levels of anxiety have been associated with higher suicide risk, longer duration of
illness, and greater likelihood of treatment nonresponse
3. Mixed features specifier
○ Predominantly depressive episodes that have at least three symptoms of
mania/hypomania
4. Melancholic features
○ Inability to experience pleasure, distinct depressed mood, depression regularly worse in
morning, early morning awakening, marked psychomotor retardation or agitation,
significant anorexia or weight loss, excessive guilt
5. Catatonic features specifier
○ Extreme physical immobility or excessive peculiar physical movement
6. Atypical features specifier

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 6. Atypical features specifier
○ Positive mood reactions to some events, significant weight gain or increase in appetite,
hypersomnia, heavy or leaden feelings in arms or legs, long-standing pattern of
sensitivity to interpersonal rejection
7. Peripartum onset specifier
○ Peri means “surrounding,” in this case the period of time just before and just after the
birth
○ Onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery
8. Seasonal pattern specifier
○ Accompanies episodes that occur during certain seasons or particular time of the year
○ Seasonal affective disorder (SAD)

Suicide
Death from self-injury

Key terms
• Suicidal ideation - thinking seriously about suicide
• Suicidal plans - the formulation of a specific method for killing oneself
• Suicidal attempts - the person survives
• Non-suicidal self-injury

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