Depressive Disorders

What is a depressive disorder? 

Depression is a mental health disorder characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. It can affect thoughts, feelings, and behavior, and can lead to a variety of emotional and physical problems.

Depressive disorders are characterized by the presence of sad, empty or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. These disorders  differ from one another in the frequency and severity with which depressive symptoms occur and the course of the symptoms (chronic/non-chronic). 

Treatments:

Cognitive-Behavioral Therapy- correcting cognitive errors and substituting less depressing and more realistic thoughts and appraisals. 

Interpersonal Psychotherapy- focusing on resolving problems in existing relationships and learning to form important new interpersonal relationships. 

Below you will find a list of different depressive Disorders:

1. Disruptive Mood Dysregulation Disorder (DMDD) 

Diagnostic Criteria:

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g.. physical aggression toward people or property) 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.g., parents, teachers, peers).

E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D.

F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.

G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.

H. By history or observation, the age at onset of Criteria A-E is before 10 years.

I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

    Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).

    Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent ex- plosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Prevalence:

6 months to 1-year prevalence of children & adolescents: 2% to 5% 

Higher in males & school-aged children

Development and Course:

Age of onset- before 10 years of age

Etiology:

Temperamental- exhibit complicated psychiatric histories, have symptoms that also meet criteria for ADHD. 

2. Major Depressive Disorder (MDD) 

Major Depressive Episode it is persistent depressed mood and the inability to anticipate happiness or pleasure. In MDE feelings of worthlessness and self-loathing are common.

Diagnostic Criteria:

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

    Note: Do not include symptoms that are clearly attributable to another medical condition.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g. appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with- out a specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

    Note: Criteria A-C represent a major depressive episode.

    Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sad- ness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understand- able or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

    Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

In recording the name of a diagnosis, terms should be listed in the following order: major depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers, followed by as many of the following specifiers without codes that apply to the current episode.

    Specify:

• With anxious distress (p. 184)
• With mixed features (pp. 184-185)
• With melancholic features (p. 185)
• With atypical features (pp. 185-186)
• With mood-congruent psychotic features (p. 186)
• With mood-incongruent psychotic features (p. 186)
• With catatonia (p. 186). Coding note: Use additional code 293.89 (F06.1).
• With peripartum onset (pp. 186-187)
• With seasonal pattern (recurrent episode only) (pp. 187-188)

Diagnostic features: 

1. Some individuals emphasize somatic complaints (e.g., bodily aches and pains) rather than reporting feelings of sadness. 

2. Many individuals report or exhibit increased irritability (e.g., persistent anger, a tendency to respond to events with angry outbursts or blaming others, an exaggerated sense of frustration over minor matters).

3. In children and adolescents, an irritable or cranky mood may develop rather than a sad or dejected mood.

4. In some individuals, there is a significant reduction from previous levels of sexual interest or desire.

5. Insomnia:

• Middle insomnia- waking up during the night and then having difficulty returning to sleep.
• Terminal insomnia- waking too early and being unable to return to sleep. 
• Initial insomnia- difficulty falling asleep.  
• Hypersomnia- prolonged sleep episodes at night or increased daytime sleep. 

6. Psychomotor changes include agitation (e.g., the inability to sit still, pacing, hand- wringing; or pulling or rubbing of the skin, clothing, or other objects) or retardation (e.g. slowed speech, thinking, and body movements; increased pauses before answering; speech that is decreased in volume, inflection, amount, or variety of content, or muteness).

7. Children- drop in grades; Elderly individuals- memory difficulties

8. Increased likelihood of death in the first year. 

Prevalence:

1-year prevalence of children & adolescents: 7% 

18-29 year old- three fold higher prevalence than individuals 60 years or older. 

Development and Course:

Age of onset- puberty, peaks in 20s.

Etiology:

Temperamental- Neuroticism 

Environmental- Adverse childhood experiences, stressful life events. 

Genetic & Physiological- 2-4 fold higher in individuals with major depressive disorder first-degree family members. Heritability: 40%

3. Persistent Depressive Disorder (Dysthymia) 

Diagnostic Criteria:

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

    Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. 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.

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder. schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Development and Course:

Age of onset- early and insidious onset

Chronic course 

Etiology:

Temperamental- Neuroticism, greater symptom severity, poorer global functioning, presence of anxiety disorders or conduct disorder.

Environmental- Parental loss or separation 

Genetic & Physiological- higher chance if the first degree relatives also have this disorder. 

4. Premenstrual Dysphoric Disorder  

Diagnostic Criteria:

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

B. One (or more) of the following symptoms must be present:

Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection).

1. Marked irritability or anger or increased interpersonal conflicts.
2. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
3. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).
2. Subjective difficulty in concentration.
3. Lethargy, easy fatigability, or marked lack of energy.
4. Marked change in appetite; overeating; or specific food cravings.
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.

    Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.

D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). 

E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

Diagnostic features: 

1. Essential features- expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the pre menstrual phase of the cycle and remit around the onset of menses or shortly thereafter.

2. Symptoms must have occurred in most of the menstrual cycles during the past year.

3. Symptoms peak around the time of the onset of menses.

4. Symptom-free period in the follicular phase after the menstrual period begins.

5. Delusions and hallucinations in late luteal phase. (RARE)

Prevalence:

1.8% and 5.8% of menstruating women

Development and Course:

Age of onset- any point after menarche

Etiology:

Temperamental- history of interpersonal trauma, seasonal changes, sociocultural aspects of female sexual behavior in general and female gender role in particular.