Major Depressive Disorder based on Diagnostic Statistical Manual 5

MOOD DISORDERS: AN OVERVIEW
2 Key Moods involved in Mood Disorders:
Mania characterized by intense and unrealistic feelings of excitement and euphoria.

Depression involves feelings of extraordinary sadness and dejection.
Types of Mood Disorders
Unipolar Depressive Disorders the person experiences only depressive episodes

Bipolar and related disorders the person experiences both manic and depressive
episodes
MOOD DISORDERS GROUP 5 (BS PSYCHOLOGY 3-4)
Page 1
MAJOR DEPRESSIVE DISORDER
HISTORY
he Old Testament story of King Saul describes a depressive syndrome, as does the
story of Ajax's suicide in Homer's Iliad. About 400 BCE, Hippocrates used the
terms mania and melancholia to describe mental disturbances. Around 30 AD, the
Roman physician Celsus described melancholia (from Greek melan ["black"] and chole
["bile"]) in his work De re medicina as a depression caused by black bile. The first English
text (Fig. 8 . 1 - 1 ) entirely related to depression was Robert Burton's Anatomy of
Melancholy, published in 1 62 1 . In 1 854, Jules Falret described a condition called Jolie
circulaire, in which patients experience alternating moods of depression and mania. In 1 882,
the German psychiatrist Karl Kahlbaum, using the term cyclothymia, described mania and
depression as stages of the same illness. In 1 899, Emil Kraepelin, building on the knowledge
of previous French and German psychiatrists, described manic-depressive psychosis using
most of the criteria that psychiatrists now use to establish a diagnosis of bipolar I disorder.
According to Kraepelin, the absence of a dementing and deteriorating course in manic
depressive psychosis differentiated it from dementia precox (as schizophrenia was then
called). Kraepelin also described a depression that came to be known as involutional
melancholia, which has since come to be viewed as a severe form of mood disorder that
begins in late adulthood. (Kaplan and Sadock, 2015: 347)
What is Major Depressive Disorder?
Major depressive disorder occurs without a history of a manic, mixed or hypomanic
episode. An affected person must experience either markedly depressed moods or marked
loss of interest in pleasurable activities most of every day, nearly every day, for at least two
consecutive weeks.
These Major Depressive Episodes are not due to a medical condition, medication,
abused substance, or Psychosis. If Manic, Mixed, or Hypomanic Episodes develop, the
diagnosis is changed to Bipolar Disorder.
Page 2
In typical depressive episodes, the person experiences depressed mood,

loss of interest and enjoyment, and reduced energy leading to diminished activity
for at least 2 weeks. Many people with depression also suffer from anxiety
symptoms and medically unexplained somatic symptoms.
A person with moderate or severe major depressive disorder has
difficulties carrying out his or her usual work, school, domestic or social activities
due to symptoms of depression.
When facing adversity, many people develop depressive symptoms, but
lack impairment in their usual activites - hence would not be diagnosed as having
major depressive disorder. The diagnosis of major depressive disorder requires
that the person not only has depressive symptoms, but also has difficulties in dayto-day functioning due to these symptoms.
DIAGNOSTIC CRITERIA
An individual diagnosed with major depressive disorder needs to meet all of the
following criteria:
A.Five (or more) of the following symptoms have been present during the same 2week 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 attibutable 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).
Major Depressive
Major Depressive
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previous
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has at least 5 of the
has at least 5 of the
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following 9
symptoms: (1)
symptoms: (1)
depressed mood,
depressed mood,
(2) loss of interest
(2) loss of interest
or pleasure, (3)
or pleasure, (3)
significant change
significant change
in appetite/weight,
in appetite/weight,
(4)
(4)
insomnia/hyperso
insomnia/hyperso
mnia, (5)
mnia, (5)
psychomotor
psychomotor
agitation/slowing,
agitation/slowing,
(6) fatigue/loss of
(6) fatigue/loss of
energy, (7)
energy, (7)
feelings of
feelings of
worthlessness/inap
worthlessness/inap
propriate guilt, (8)
propriate guilt, (8)
inability to
inability to
concentrate/indecis
concentrate/indecis
iveness, (9)
iveness, (9)
recurrent thoughts
recurrent thoughts
of death/suicide.
of death/suicide.
(Note: do not
(Note: do not
include symptoms
include symptoms
that are clearly
that are clearly
attibutable to
attibutable to
another medical
another medical
condition.)
condition.)
Page 3
Comorbidity
Problems
When Severe
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 without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
Comorbidity
Problems
When Severe
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Page 4
GRIEF vs. DEPRESSION

disability) may include the feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in the above criteria, which may resemble a depressive
episode.
Although such symptoms may be understandable 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.
Predominant affect is feelings of emptiness and loss
GRIEF
The dysphoria is likely to decrease in intensity over days to weeks and

occurs in waves, the so called pangs of grief
The pain may be accompanied by positive emotions and humor
Pre occupation with thoughts and memories of the deceased
Self-esteem is usually preserved
If self-derogatory ideation is present, it typically involves perceived failings
Page 5
Thoughts of death are typically related to wanting to be reunited with the deceased
loved one
DEPRESSI
ON
Predominant affect is depressed mood
The depressed mood is more persistent and not tied to specific thoughts or
preoccupations
Self-critical or pessimistic ruminations
Persistent depressed mood and the Inability to anticipate happiness or pleasure
Self-critical or pessimistic ruminations
Prolonged and marked functional impairment
Persistent isolation from others and self
Fixed emotions and feeling stuck
Has generalized feelings of guilt
Feelings of worthlessness and self-loathing are common clouds esteem
Thoughts of death related to feeling worthless, undeserving of life or unable to cope

with the pain
Page 6
SOCIAL PROBLEMS
Lack Of Social Skills During Major Depressive Disorder

There are social skills that are essential for healthy social functioning. During major
depressive
disorder,
individuals
lack
the
essential
social
skills
of self
confidence, optimism, belonging, and sociability. These are the same social skills that are
lacking in individuals with persistent depressive disorder, avoidant personality disorder and
social anxiety disorder.
SOCIAL
SKILL
SelfConfidence
Optimism
Belonging
Sociability
MAJOR
DEPRESSION
NORMAL
Having a good opinion of one's self and abilities; socially

confident and out-going
Pessimism or expecting Having a positive outlook on life; expecting a good
the worst
outcome; hopeful
Fearing rejection by
Feeling liked and accepted by friends, and included in their
others
group; not fearing rejection
Feeling inferior or shy
Social withdrawal
Friendly; interested in social contacts and activities
Which Dimensions of Human Behavior are Impaired in Major Depressive

Disorder?
ANCIENT
GREEK
CONCEPT
"BIG 5"
PERSONALITY
DIMENSIONS
Cooperation
Agreeableness
Sympathetic, Warm vs. Critical, Quarrelsome
Justice
Conscientiousness
Dependable, Self-Disciplined vs. Disorganized, Careless
DESCRIPTION
Page 7
Wisdom
Intellect (also termed

Open to New Experiences, Creative vs. Conventional,
Openness)
Uncreative
Self-Control
Extraversion
Sociable, Enthusiastic vs. Reserved, Quiet
Courage
Emotional Stability
Calm, Emotionally Stable vs. Anxious, Easily Upset
So What Causes Major Depressive Disorder?

This disorder can be triggered by exposure to any major physical, psychological, or
social adversity. So depression can be triggered by a physical illness or stress, an addiction
to alcohol or drugs, or a significant psychological or social stress. It appears that
depression is nature's way of shutting down the body (similar to hibernation).
Stressors may play a more significant role in the precipitation of the first or second
episode of this disorder and play less of a role in the onset of subsequent episodes. Chronic
medical conditions and Substance Use Disorders (particularly Alcohol or Cocaine
Dependence) may contribute to the onset or exacerbation of this disorder. The presence or
absence of stressful life events does not appear to provide a useful guide to prognosis or
treatment selection.
Recent stressful events are the most powerful predictors of the onset of a depressive
episode. From a psychodynamic perspective, the clinician is always interested in the meaning
of the stressor. Research has demonstrated that stressors that the patient experiences as
reflecting negatively on his or her self-esteem are more likely to produce depression.
Moreover, what may seem to be a relatively mild stressor to outsiders may be devastating to
the patient because of particular idiosyncratic meanings attached to the event.
First-degree biological relatives of individuals with this disorder are 2-4 times more
likely to develop Major Depressive Disorder. They also have an increased risk of having
Alcohol Dependence, Anxiety Disorder (e.g., Panic Disorder, Social Anxiety Disorder), and
Attention-Deficit/Hyperactivity Disorder compared with the general population. Heritability
is approximately 40%, and the personality trait neuroticism accounts for a substantial portion
of this genetic liability.
Personality Factors. No Single personality trait or type uniquely predisposes a
person to depression; all humans, of whatever personality pattern, can and do become
depressed under appropriate circumstances. Persons with certain personality disorders- OCD,
Page 8
histrionic and borderline may be at greater risk for depression than persons with antisocial pr
paranoid personality disorder
Psychodynamic Factors in Depression.
The psychodynamic understanding of depression
defined by Sigmund Freud and expanded by Karl
Abraham is known as the classic view of depression.
That theory involves four key points: (1) disturbances
in the infant-mother relationship during the oral phase
(the first 10 to 18 months of life) predispose to subsequent vulnerability to depression.; (2)
depression can be linked to real or imagined object loss; (3) introjections of the departed
objects is a defense mechanism invoked to deal with the distress connected with the objects
loss; and (4) because the lost object is regarded with a mixture of love and hate, feelings of
anger are directed inward at the self.
Cognitive Theory. According to cognitive theory, depression results from specific
cognitive distortions present in persons susceptible to depression. These distortions, referred
to as depressogenic schemata, are cognitive templates that perceive both internal and external
data in ways that are altered by early experiences. Aaron Beck postulated a cognitive triad of
depression that consists of (1) views about the self-a negative self-precept, (2) about the
environment--a tendency to experience the world as hostile and demanding, and (3) about the
future-- the expectation of suffering and failure. Therapy consists of modifying these
distortions.
Learned Helplessness. The learned helplessness theory of depression connects
depressive phenomena to the experience of uncontrollable events. For example, when dogs in
a laboratory were exposed to electrical shocks from which they could not escape, they
showed behaviors that differentiated them from dogs that had not been exposed to such
uncontrollable events. The dogs exposed to the shocks would not cross a barrier to stop the
flow of electric shock when put in a new learning situation. They remained passive and did
not move. According to the learned helplessness theory, the shocked dogs learned that
outcomes were independent of responses, so they had both cognitive motivational deficit
(i.e., they would not attempt to escape the shock) and emotional deficit (indicating
decreased reactivity to the shock). In the
reformulated view of learned helplessness as
Page 9
applied to human depression, internal causal

explanations are thought to produce a loss of
self-esteem after adverse external events.
Behaviorists who subscribe to the theory stress that
improvement of depression is contingent on the patient's learning a sense of control and
mastery of the environment.
CLI N ICAL FEATU RES
Patients often describe the symptom of depression as one of agonizing emotional
pain and sometimes complain about being unable to cry, a symptom that resolves as they
improve. About two-thirds of all depressed patients contemplate suicide, and 1 0 to 1 5
percent commit suicide. Those recently hospitalized with a suicide attempt or suicidal
ideation have a higher lifetime risk of successful suicide than those never hospitalized for
suicidal ideation. Some depressed patients sometimes seem unaware of their depression and
do not complain of a mood disturbance even though they exhibit withdrawal from family,
friends, and activities that previously interested them. Almost all depressed patients (97
percent) complain about reduced energy; they have difficulty finishing tasks, are impaired at
school and work, and have less motivation to undertake new projects. About 80 percent of
patients complain of trouble sleeping, especially early morning awakening (i.e., terminal
insomnia) and multiple awakenings at night, during which they ruminate about their
problems. Many patients have decreased appetite and weight loss, but others experience
increased appetite and weight gain and sleep longer than usual. These patients are classified
as having atypical features. Anxiety, a common symptom of depression, affects as many as 90
percent of all depressed patients. The various changes in food intake and rest can aggravate
coexisting medical illnesses such as diabetes, hypertension, chronic obstructive lung disease,
and heart disease. Other vegetative symptoms include abnormal menses and decreased
interest and performance in sexual activities. Sexual problems can sometimes lead to
inappropriate referrals, such as to marital counseling and sex therapy, when clinicians fail to
recognize the underlying depressive disorder. Anxiety (including panic attacks), alcohol
abuse, and somatic complaints (e.g., constipation and headaches) often complicate the
treatment of depression. About 50 percent of all patients describe a diurnal variation in their
symptoms, with increased severity in the morning and lessening of symptoms by evening.
Cognitive symptoms include subjective reports of an inability to concentrate (84 percent of
patients in one study) and impairments in thinking (67 percent of patients in another study).
Depression in Children and Adolescents.
School phobia and excessive clinging to parents
may be symptoms of depression in children. Poor
academic performance, substance abuse, antisocial
behavior, sexual promiscuity, truancy, and running
away may be symptoms of depression in adolescents.
Page 10
Depression in Older People.

Depression is more common in older persons than it is in the general population.
Various studies have reported prevalence rates ranging from 25 to almost 50 percent,
although the percentage of these cases that are caused by major depressive disorder is
uncertain. Several studies indicate that depression in older persons may be correlated with
low socioeconomic status, the loss of a spouse, a concurrent physical illness, and social
isolation. Other studies have indicated that depression in older persons is underdiagnosed and
undertreated, perhaps particularly by general practitioners. The underrecognition of
depression in older persons may occur because the disorder appears more often with somatic
complaints in older, than in younger, age groups. Further, ageism may influence and cause
clinicians to accept depressive symptoms as normal in older patients.
MENTAL STATUS EXAMINATION
General Description
Generalized psychomotor retardation is the most common symptom of depression,
although psychomotor agitation is also seen, especially in older patients. Hand wringing and
hair pulling are the most common symptoms of agitation. Classically, a depressed patient has
a stooped posture; no spontaneous movements; and a downcast, averted gaze (Figs. 8 . 1 -4
and 8 . 1 -5). On clinical examination, depressed patients exhibiting gross symptoms of
psychomotor retardation may appear identical to patients with catatonic schizophrenia.
Ms. A, a 34-year-old literature professor, presented
to a mood clinic with the following complaint: "I am in a
daze, confused, disoriented, staring. My thoughts do not
flow, my mind is arrested . . . . I seem to lack any sense of
direction, purpose . . . . I have such an inertia, I cannot
assert myself. I cannot fight; I have no will."
Mood, Affect, and Feelings
Depression is the key symptom, although about 50 percent of patients deny
depressive feelings and do not appear to be particularly depressed. Family members or
employers often bring or send these patients for treatment because of social withdrawal and
generally decreased activity.
Speech
Many depressed patients have decreased rate and volume of speech; they respond to
questions with single words and exhibit delayed responses to questions. The examiner may
literally have to wait 2 or 3 minutes for a response to a question.
Perceptual Disturbances
Page 11
Depressed patients with delusions or hallucinations are said to have a major

depressive episode with psychotic features. Even in the absence of delusions or
hallucinations, some clinicians use the term psychotic depression for grossly regressed
depressed patients-mute, not bathing, soiling. Such patients are probably better described as
having catatonic features. Delusions and hallucinations that are consistent with a depressed
mood are said to be mood congruent. Mood-congruent delusions in a depressed person
include those of guilt, sinfulness, worthlessness, poverty, failure, persecution, and terminal
somatic illnesses (such as cancer and a "rotting" brain). The content of mood-incongruent
delusions or hallucinations is not consistent with a depressed mood. For example, a moodincongruent delusion in a depressed person might involve grandiose themes of exaggerated
power, knowledge, and worth. When that occurs, a schizophrenic disorder should be
considered.
Thought
Depressed patients customarily have negative views of the world and of themselves.
Their thought content often includes nondelusional ruminations about loss, guilt, suicide, and
death. About 1 0 percent of all depressed patients have marked symptoms of a thought
disorder, usually thought blocking and profound poverty of content.
Sensorium and Cognition
Orientation. Most depressed patients are oriented to person, place, and time, although some
may not have sufficient energy or interest to answer questions about these subjects during an
interview.
Memory. About 50 to 75 percent of all depressed patients have a cognitive impairment,
sometimes referred to as depressive pseudodementia. Such patients commonly complain of
impaired concentration and forgetfulness.
Impulse Control
About 1 0 to 1 5 percent of all depressed patients commit suicide, and about twothirds have suicidal ideation. Depressed patients with psychotic features occasionally
consider killing a person as a result of their delusional systems, but the most severely
depressed patients often lack the motivation or the energy to act in an impulsive or violent
way. Patients with depressive disorders are at increased risk of suicide as they begin to
improve and regain the energy needed to plan and carry out a suicide (paradoxical suicide). It
is usually clinically unwise to give a depressed patient a large prescription for a large number
of antidepressants, especially tricyclic drugs, at the time of their discharge from the hospital.
Similarly, drugs that may be activating, such as fluoxetine, may be prescribed in such a way
that the energizing qualities are minimized (e.g., be given a benzodiazepine at the same time).
Judgment and Insight
Judgment is best assessed by reviewing patients' actions in the recent past and their
behavior during the interview. Depressed patients' descriptions of their disorder are often
Page 12
hyperbolic; they overemphasize their symptoms, their disorder, and their life problems. It is
difficult to convince such patients that improvement is possible.
Reliability
In interviews and conversations, depressed patients overemphasize the bad and minimize
the good. A common clinical mistake is to unquestioningly believe a depressed patient who
states that a previous trial of antidepressant medications did not work. Such statements may
be false, and they require confirmation from another source. Psychiatrists should not view
patients' misinformation as an intentional fabrication; the admission of any hopeful
information may be impossible for a person in a depressed state of mind.
TREATMENT GOALS:
Goal: prevent her depressed mood
If this problem persists: She will feel sad,
hopeless, discouraged, "down in the dumps",
or "blah". She may emphasize somatic
complaints (e.g., bodily aches and pains) rather
than reporting feelings of sadness. She may
exhibit increased irritability (e.g., persistent
anger, a tendency to respond to
events with angry outbursts or blamingothers, or an exaggerated sense of frustration over
minor matters).
Goal: prevent her loss of interest or pleasure.
If this problem persists: She will feel less interested in hobbies, "not caring
anymore," or not feeling any enjoyment in activities that were previously considered
pleasurable. There may be a significant reduction in her sexual interest or desire.
Goal: prevent her appetite or weight disturbance.
If this problem persists: She will have either abnormally decreased or increased
appetite. This may progress to significant loss or gain in weight.
Goal: prevent her insomnia or hypersomnia.
If this problem persists: She will sleep too little or too much. Typically she will have
middle insomnia (i.e., waking up during the night and having difficulty returning to
sleep) or terminal insomnia (i.e., waking too early and being unable to sleep). Initial
insomnia (i.e., difficulty falling asleep) may also occur. Less frequently, she may
have oversleeping (hypersomnia).
Goal: prevent her psychomotor agitation or slowing.
If this problem persists: She will have agitation (e.g., the inability to sit still, pacing,
hand-wringing; or pulling or rubbing of the skin, clothing, or other objects) or
psychomotor 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).
Goal: prevent her fatigue or loss of energy.
If this problem persists: She will experience decreased energy, tiredness, and fatigue.
Page 13
Eventually, even the smallest tasks will seem to require substantial effort. She may
find that washing and dressing in the morning are exhausting and take twice as long
as usual.
Goal: prevent her inappropriate self-reproach or guilt.
If this problem persists: She will have unrealistic negative evaluations of her worth
or guilty preoccupations or ruminations over minor failings. She may often
misinterpret neutral or trivial day-to-day events as evidence of her defects and have
an exaggerated sense of responsibility for untoward events. This may progress to
delusional proportions.
Goal: prevent her poor concentration or indecisiveness.
If this problem persists: She will have an impaired ability to think, concentrate, or
make decisions.
Goal: prevent her recurrent thoughts of death or suicide.
If this problem persists: She will be at risk of suicide. Many studies have shown that
it is not possible to predict accurately whether or when a particular individual with
depression will attempt suicide. Motivations for suicide may include a desire to give
up in the face of perceived insurmountable obstacles or an intense wish to end an
excruciatingly painful emotional state that is perceived by the person to be without
end.
TREATMENTS
Treatment of patients with mood disorders should be directed toward several goals.
First, the patients safety must be guaranteed. Second, a complete diagnostic evaluation of
the patient is necessary. Third, a treatment plan that addresses not only the immediate
symptoms but also the patients prospective well-being should be iniated.
Psychotherapy and Psychosocial Therapy
The major psychological treatments for depression
[cognitive behavior therapy (CBT), mindfulness-based
cognitive therapy (MBCT), interpersonal therapy (IPT),
short-term psychodynamic psychotherapy(STPP)]
when compared to each other are equally effective.
Cognitive-Behavioral Therapy. It is relatively form of
treatment that focuses on here-and-now problems
rather than on the more remote causal issues that
psychodynamic psychotherapy often addresses.
Cognitive therapy relies heavily on an empirical approach in that patients are taught to treat
their beliefs as hypotheses that can be tested through the use of behavioral experiments.
Another variant on cognitive therapy, called mindfulness-based cognitive therapy, has been
developed in recent years to be used with people with highly recurrent depression.
Behavioral Activation Treatment. This treatment approach focuses intensively on getting
patients to become more active and engaged with their environment and with their
interpersonal relationships. This focuses on changing the behavior.
Page 14
Interpersonal Therapy. This ITP approach focuses on current relationship issues, trying to
help the person understand and change maladaptive interaction patterns.
One large NIMH study on major depressive disorder found that the remission rate (after 16
weeks of treatment, at 18-month followup) did not differ significantly among four treatments:
30% for cognitive behavior therapy, 26% for interpersonal therapy, 19% for imipramine plus
clinical management, and 20% for placebo plus clinical management. Among patients who
had recovered, rates of relapse back into depression (at 18-month followup) were 36% for
cognitive behavior therapy, 33% for interpersonal therapy, 50% for imipramine plus clinical
management, and 33% for placebo plus clinical management.
Psychoanalytically Oriented Therapy. The goal of psychoanalytic psychotherapy is to
effect a change in patients personality structure or character, not simply to alleviate
symptoms.
Family Therapy. It examines the role of the mood-disordered member in the overall
psychological well-being of the whole family; it also examines the role of the entire family in
the maintenance of the patients symptoms.
A second study on moderate to severe major depressive disorder found (at 12-month
followup) a 31% relapse rate back into depression for cognitive behavioral therapy, and a
47% relapse rate for patients who kept taking medication. A third study on moderate to severe
major depressive disorder found that (after 16 weeks of therapy) there was a 46% remission
rate for medication, and a 40% remission rate for cognitive therapy.
The addition of psychological treatment (CBT, MBCT, IPT, STTP) to antidepressant
medication results in an improvement in outcome. St John's wort and regular exercise appear
mildly effective in the treatment of depression (but their effect size is small).
Pharmacotherapy
After a diagnosis has been established,
a pharmacological treatment strategy can be formulated.
The objective of pharmacologic treatment is symptom
remission, not just symptom reduction. Research
on antidepressant medication has made startling
findings: (1) all second-generation antidepressant
medications are equally effective, (2) treatment with acombination of antidepressant
medications (especially TCA + SSRI) is much more effective than treatment with a single
antidepressant medication, (3) only 60% of individuals with major depression respond to
antidepressant medication, and (4) antidepressant medications have relatively modest effects
when compared with an active placebo - such as patients seeing their GP for brief
counselling.
The active placebo effect causes three-quarters of the remission from major depression.
When compared to the40% remission rate on active placebo, the remission rate on
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antidepressant medication is 45% for mild depression,52% for moderate depression,

and 56% for severe depression.
Since antidepressant medication is no more effective than active placebo for the treatment
of mild major depressive disorder; antidepressant medication has proven benefit only in the
treatment of moderate to severe major depressive disorder. However, for those whose
depression causes marked distress or disability; antidepressant medication dramatically
reduces the risk of suicide, and returns the individual back to health, months sooner than
would have been the case without treatment.
It should be remembered that, even without treatment, the median duration of major
depressive disorder is 6 months. Treatment refractory depressionsmay respond to a
combination of an antidepressant plus lithium or electroconvulsive therapy (ECT). In terms
of symptom reduction, some atypical antipsychotic medications added to antidepressant
medications result in a small benefit[aripiprazole (NNT= 7), risperidone (NNT= 8)]; whereas
others are ineffective [quetiapine (NNT= 10), and olanzapine/fluoxetine combination (NNT=
19)]. (Note: A treatment with a Number Needed To Treat (NNT) >8 is generally considered
clinically insignificant.) The only antidepressants approved for use in depressed children in
the U.S. are fluoxetine and escitalopram.
Electroconvulsive Therapy (ECT)
When given ECT, 55% of individuals with major depressive disorder will go into
remission. Unfortunately, there is a very high relapse rate 6 months after ECT. Of those going
into remission with ECT, at 6 months posttreatment: (1) on placebo 84% relapse, and (2) on
antidepressant medication plus lithium 39% relapse. Thus ECT is effective during the acute
treatment phase in hospital, but steadily loses its benefit after hospital discharge. The
effectiveness of ECT vs sham ECT at oneor more months posttreatment is still controversial.
Hospitalization
Clear indications for hospitalization are the risk of suicide or homicide, a patients
grossly reduced ability to get food and shelter, and the need for diagnostic procedures.
Ineffective Therapies
Vitamins, dietary supplements, and acupuncture are all ineffective for depression.
CASE
STUDY
Janet called the mental-health center to ask if
someone could help her 5-year-old son, Adam.
He had been having trouble sleeping for the past
several weeks, and Janet was becoming
concerned about his health. Adam refused to go
Page 16
to sleep at his regular bedtime and also woke up at irregular intervals throughout thenight.
Whenever he woke up, Adam would come downstairs to be with Janet. Her initial reaction
had been sympathetic, but as the cycle came to repeat itself night after night, Janets tolerance
grew thin, and she became more argumentative. She found herself engaged in repeated battles
that usually ended when she agreed to let him sleep in her room. Janet felt guilty about giving
in to a 5-yearolds demands, but it seemed like the only way they would ever get any sleep.
The family physician was unable to identify a physical explanation for Adams problem; he
suggested that Janet contact a psychologist. This advice led Janet to inquire about the mentalhealth centers series of parent-training groups.
Applicants for the groups were routinely screened during an individual intake
interview. The therapist began by asking several questions about Janet and her family. Janet
was 30 years old and had been divorced from her husband, David, for a little more than a
year. Adam was the youngest of Janets three children; Jennifer was 10, and Claire was 8.
Janet had resumed her college education on a part-time basis when Adam was 2 years old.
She had hoped to finish her bachelors degree at the end of the next semester and enter law
school in the fall. Unfortunately, she had withdrawn from classes 1 month prior to her
appointment at the mental-health center. Her current plans were indefi nite. She spent almost
all of her time at home with Adam.
Janet and the children lived in a large, comfortable house that she had received as
part of her divorce settlement. Finances were a major concern to Janet, but she managed to
make ends meet through the combination of student loans, a grant-in-aid from the university,
and child-support payments from David. David lived in a nearby town with a younger woman
whom he had married shortly after the divorce. He visited Janet and the children once or
twice every month and took the children to spend weekends with him once a month.
Having collected the necessary background information, the therapist asked for a
description of Adams sleep diffi culties. This discussion covered the sequence of a typical
evenings events. It was clear during this discussion that Janet felt completely overwhelmed.
At several points during the interview, Janet was on the verge of tears. Her eyes were watery,
and her voice broke as they discussed her response to Davids occasional visits. The therapist,
therefore, suggested that they put off a further analysis of Adams problems and spend some
time discussing Janets situation in a broader perspective.
Janets mood had been depressed since her husband had asked for a divorce. She felt
sad, discouraged, and lonely. This feeling had become even more severe just prior to her
withdrawal from classes at the university (1 year after Davids departure). When David left,
she remembered feeling down in the dumps, but she could usually cheer herself up by
playing with the children or going for a walk. Now she was nearing desperation. She cried
frequently and for long periods of time. Nothing seemed to cheer her up. She had lost interest
in her friends, and the children seemed to be more of a burden than ever. Her depression was
somewhat worse in the morning, when it seemed that she would never be able to make it
through the day.
Janet was preoccupied with her divorce from David and spent hours each day
brooding about the events that led to their separation. These worries interfered considerably
with her ability to concentrate and seemed directly related to her withdrawal from the
university. She had been totally unable to study assigned readings or concentrate on lectures.
Page 17
Withdrawing from school precipitated further problems. She was no longer eligible for
student aid and would have to begin paying back her loans within a few months. In short, one
problem led to another, and her attitude became increasingly pessimistic.
Janet blamed herself for the divorce, although she also harbored considerable
resentment toward David and his new wife. She believed that her return to school had placed
additional strain on an already problematic relationship, and she wondered whether she had
acted selfi shly. The therapist noted that Janets reasoning about her marriage often seemed
vague and illogical. She argued that she had been a poor marital partner and cited several
examples of her own misconduct. These included events and circumstances that struck the
therapist as being very common and perhaps expected differences between men and women.
For example, Janet spent more money than he did on clothes, did not share his enthusiasm for
sports, and frequently tried to engage David in discussions about his personal habits that
annoyed her and the imperfections of their relationship. Of course, one could easily argue that
David had not been sufficiently concernedabout his own appearance (spending too little effort
on his own wardrobe), that he had been too preoccupied with sports, and that he had avoided
her sincere efforts to work on their marital diffi culties. But Janet blamed herself. Rather than
viewing these things as simple differences in their interests and personalities, Janet saw them
as evidence of her own failures. She blew these matters totally out of proportion until they
appeared to her to be terrible sins. Janet also generalized from her marriage to other
relationships in her life. If her first marriage had failed, how could she ever expect to develop
a satisfactory relationship with another man? Furthermore, Janet had begun to question her
value as a friend and parent. The collapse of her marriage seemed to affect the manner in
which she viewed all of her social relationships.
The future looked bleak from her current perspective, but she had not given up all
hope. Her interest in solving Adams problem, for example, was an encouraging sign.
Although she was not optimistic about the chances of success, she was willing to try to
become a more effective parent.
Specifiers for Depressive

Disorders
Diagnostic Criteria
Specify if:
With anxious distress: Anxious distress is defined as the presence of at least two of
the following symptoms during the majority of days of a major depressive episode or
persistent depressive disorder (dysthymia):
1. Feeling keyed up or tense.
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2. Feeling unusually restless.

3. Difficulty concentrating because of worry.
4. Fear that something awful may happen.
5. Feeling that the individual might lose control of himself or herself.
Specify current severity:
Mild: Two symptoms.
Moderate: Three symptoms.
Moderate-severe: Four or five symptoms.
Severe: Four or five symptoms and with motor agitation.
Note: Anxious distress has been noted as a prominent feature of both bipolar and major
depressive disorder in both primary care and specialty mental health settings. High levels of
anxiety have been associated with higher suicide risk, longer duration of illness, and greater
likelihood of treatment nonresponse. As a result, it is clinically useful to specify accurately
the presence and severity levels of anxious distress for treatment planning and monitoring of
response to treatment.
With mixed features:
A. At least three of the following manic/hypomanic symptoms are present nearly every day
during the majority of days of a major depressive episode:
1. Elevated, expansive mood.
2. Inflated self-esteem or grandiosity.
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Increase in energy or goal-directed activity (either socially, at work or school, or
sexually).
6. Increased or excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, foolish
business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be
contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the persons usual
behavior.
C. For individuals whose symptoms meet full criteria for either mania or hypomania, the
diagnosis should be bipolar I or bipolar II disorder.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication or other treatment).
Note: Mixed features associated with a major depressive episode have been found to be a
significant risk factor for the development of bipolar I or bipolar II disorder. As a result, it is
clinically useful to note the presence of this specifier for treatment planning and monitoring
of response to treatment.
With melancholic features:
A. One of the following is present during the most severe period of the current episode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even
temporarily, when something good happens).
B. Three (or more) of the following;
1. A distinct quality of depressed mood characterized by profound despondency, despair,
and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
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4. Marked psychomotor agitation or retardation.

5. Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note: The specifier with melancholic features is applied if these features are present at the
most severe stage of the episode. There is a near-complete absence of the capacity for
pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is
that even highly desired events are not associated with marked brightening of mood. Either
mood does not brighten at all, or it brightens only partially (e.g., up to 20%-40% of normal
for only minutes at a time). The distinct quality of mood that is characteristic of the with
melancholic features specifier is experienced as qualitatively different from that during a
nonmelancholic depressive episode. A depressed mood that is described as merely more
severe, longer lasting, or present without a reason
is not considered distinct in quality. Psychomotor changes are nearly always present and are
observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes in the same
individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to
occur in milder than in more severe major depressive episodes; and are more likely to occur
in those with psychotic features.
With atypical features: This specifier can be applied when these features predominate
during the majority of days of the current or most recent major depressive episode or
persistent depressive disorder.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of
mood disturbance) that results in significant social or occupational impairment.
C. Criteria are not met for with melancholic features or with catatonia during the same
episode.
Note: Atypical depression has historical significance (i.e., atypical in contradistinction to
the more classical agitated, endogenous presentations of depression that were the norm
when depression was rarely diagnosed in outpatients and almost never in adolescents or
younger adults) and today does not connote an uncommon or unusual clinical presentation as
the term might imply.
Mood reactivity is the capacity to be cheered up when presented with positive events (e.g.,
a visit from children, compliments from others). Mood may become euthymic (not sad) even
for extended periods of time if the external circumstances remain favorable. Increased
appetite may be manifested by an obvious increase in food intake or by weight gain.
Hypersomnia may include either an extended period of nighttime sleep or daytime napping
that totals at least 10 hours of sleep per day (or at least 2 hours more than when not
depressed). Leaden paralysis is defined as feeling heavy, leaden, or weighted down, usually
in the arms or legs. This sensation is generally present for at least an hour a day but often
lasts for many hours at a time. Unlike the other atypical features, pathological sensitivity to
perceived interpersonal rejection is a trait that has an early onset and persists throughout most
of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though
it may be exacerbated during depressive periods.
With psychotic features: Delusions and/or hallucinations are present.
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With mood-congruent psychotic features: The content of all delusions and

hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt,
disease, death, nihilism, or deserved punishment.
With mood-incongruent psychotic features: The content of the delusions or
hallucinations does not involve typical depressive themes of personal inadequacy, guilt,
disease, death, nihilism, or deserved punishment, or the content is a mixture of moodincongruent and mood-congruent themes.
With catatonia: The catatonia specifier can apply to an episode of depression if catatonic
features are present during most of the episode. See criteria for catatonia associated with a
mental disorder (for a description of catatonia, see the chapter Schizophrenia Spectrum and
Other Psychotic Disorders).
With peripartum onset: This specifier can be applied to the current or, if full criteria are not
currently met for a major depressive episode, most recent episode of major depression if
onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery.
Note: Mood episodes can have their onset either during pregnancy or postpartum.
Although the estimates differ according to the period of follow-up after delivery, between 3%
and 6% of women will experience the onset of a major depressive episode during pregnancy
or in the weeks or months following delivery. Fifty percent of postpartum major depressive
episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as
peripartum episodes. Women with peripartum major depressive episodes often have severe
anxiety and even panic attacks. Prospective studies have demonstrated that mood and anxiety
symptoms during pregnancy, as well as the baby blues, increase the risk for a postpartum
major depressive episode.
Peripartum-onset mood episodes can present either with or without psychotic features.
Infanticide is most often associated with postpartum psychotic episodes that are characterized
by command hallucinations to kill the infant or delusions that the infant is possessed, but
psychotic symptoms can also occur in severe postpartum mood episodes without such
specific delusions or hallucinations.
Postpartum mood (major depressive or manic) episodes with psychotic features appear to
occur in from 1 in 500 to 1 in 1,000 deliveries and may be more common in primiparous
women. The risk of postpartum episodes with psychotic features is particularly increased for
women with prior postpartum mood episodes but is also elevated for those with a prior
history of a depressive or bipolar disorder (especially bipolar I disorder) and those with a
family history of bipolar disorders.
Once a woman has had a postpartum episode with psychotic features, the risk of
recurrence with each subsequent delivery is between 30% and 50%. Postpartum episodes
must be differentiated from delirium occurring in the postpartum period, which is
distinguished by a fluctuating level of awareness or attention. The postpartum period is
unique with respect to the degree of neuroendocrine alterations and psychosocial adjustments,
the potential impact of breast-feeding on treatment planning, and the long-term implications
of a history of postpartum mood disorder on subsequent family planning.
With seasonal pattern: This specifier applies to recurrent major depressive disorder.
Page 21
A. There has been a regular temporal relationship between the onset of major depressive
episodes in major depressive disorder and a particular time of the year (e.g., in the fall or
winter).
Note: Do not include cases in which there is an obvious effect of seasonally related
psychosocial stressors (e.g., regularly being unemployed every winter).
B. Full remissions (or a change from major depression to mania or hypomania) also occur at
a characteristic time of the year (e.g., depression disappears in the spring).
C. In the last 2 years, two major depressive episodes have occurred that demonstrate the
temporal seasonal relationships defined above and no nonseasonal major depressive episodes
have occurred during that same period.
D. Seasonal major depressive episodes (as described above) substantially outnumber the
nonseasonal major depressive episodes that may have occurred over the individuals lifetime
.
Note: The specifier with seasonal pattern can be applied to the pattern of major
depressive episodes in major depressive disorder, recurrent. The essential feature is the onset
and remission of major depressive episodes at characteristic times of the year. In most cases,
the episodes begin in fall or winter and remit in spring. Less commonly, there may be
recurrent summer depressive episodes. This pattern of onset and remission of episodes must
have occurred during at least a 2-year period, without any nonseasonal episodes occurring
during this period. In addition, the seasonal depressive episodes must substantially outnumber
any nonseasonal depressive episodes over the individuals lifetime.
This specifier does not apply to those situations in which the pattern is better explained by
seasonally linked psychosocial stressors (e.g., seasonal unemployment or school schedule).
Major depressive episodes that occur in a seasonal pattern are often characterized by
prominent energy, hypersomnia, overeating, weight gain, and a craving for carbohydrates. It
is unclear whether a seasonal pattern is more likely in recurrent major depressive disorder or
in bipolar disorders. However, within the bipolar disorders group, a seasonal pattern appears
to be more likely in bipolar II disorder than in bipolar I disorder. In some individuals, the
onset of manic or hypomanie episodes may also be linked to a particular season. The
prevalence of winter-type seasonal pattern appears to vary with latitude, age, and sex.
Prevalence increases with higher latitudes. Age is also a strong predictor of seasonality, with
younger persons at higher risk for winter depressive episodes.
Specify if:
In partial remission: Symptoms of the immediately previous major depressive episode
are present, but full criteria are not met, or there is a period lasting less than 2 months without
any significant symptoms of a major depressive episode following the end of such an
episode.
In full remission: During the past 2 months, no significant signs or symptoms of the
disturbance were present.
Specify current severity:
Severity is based on the number of criterion symptoms, the severity of those symptoms, and
the degree of functional disability.
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present,
the intensity of the symptoms is distressing but manageable, and the symptoms result in
minor impairment in social or occupational functioning.
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Moderate: The number of symptoms, intensity of symptoms, and/or functional

impairment are between those specified for mild and severe.
Severe: The number of symptoms is substantially in excess of that required to make the
diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the
symptoms markedly interfere with social and occupational functioning.
Unspecified Depressive Disorder 311 (F32.9)

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. The unspecified depressive disorder
category is used in situations in which the clinician chooses not to specify the reason that the
criteria are not met for a specific depressive disorder, and includes presentations for which
there is insufficient information to make a more specific diagnosis (e.g., in emergency room
settings).
Disruptive Mood Dysregulation

Disorder
What is DMDD?
It is a childhood condition of Extreme irritability, anger, and frequent, intense temper
outbursts.
History
In the late 1990s and continuing on into the past decade, bipolar disorder started being
diagnosed more and more in children. This became a problem only because the criteria for
bipolar disorder in children have never been firmly established. Researchers developed their
own set of criteria which contradicted the official diagnostic criteria for the disorder. The
research criteria basically did away with the need for a manic or hypomanic episode, and
instead replaced it with irritability and anger.
Coincidentally, a few pharmaceutical companies also released a set of medications called
atypical antipsychotics which can be used to treat certain symptoms of bipolar disorder.
Doctors started diagnosing bipolar disorder in children with a looser set of criteria, and felt
more at ease prescribing a treatment for it because these new medications had become
available.
This set of circumstances led to a reported 40-fold increase in the past decade of bipolar
disorder diagnoses in children. This suggests a pretty obvious problem in the diagnostic
criteria, since nothing has changed so much in the past decade to offer a reasonable
explanation for this sort of increase.
This issue has gotten more attention as of late because of the DSM-5 revision process. This is
the perfect time, after all, to ensure the research criteria match the official diagnostic criteria.
Page 23
Such an effort can put a halt to too-liberal diagnosing of childrens simple bad behavior as a
disorder.
The result?
A new proposed diagnosis called Disruptive Mood Dysregulation Disorder.
Diagnostic Criteria
1. 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.
2. The temper outbursts are inconsistent with developmental level (e.g., the child is older than
you would expect to be having a temper tantrum).
3. The temper outbursts occur, on average, three or more times per week.
4. 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, friends).
5. The above criteria have been present for 1 year or more, without a relief period of longer
than 3 months. The above criteria must also be present in two or more settings (e.g., at home
and school), and are severe in at least one of these settings.
6. The diagnosis should not be made for the first time before age 6 years or after age 18. Age
of onset of these symptoms must be before 10 years old.
7. 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.
8. The behaviors do not occur exclusively during an episode of major depressive disorder and
are not better explained by another mental disorder.
As with all child mental disorders, the symptoms also can not be attributable to the
physiological effects of a substance or to another medical or neurological condition.
Causes
There is still NO concluded exact cause of Disruptive Mood Dysregulation Disorder.
1. Family Problems (Divorces, Death in the family)
2. Psychological Trauma or emotional, sexual, or physical abuse in early ages.
3. Alcohol and Drug abuse during pregnancy.
4. Neurological problems (e.g. Migraine)
5. Poor diet (Vitamin defiency, Malnutrition)
Page 24
Risk Factor
Children with a history of chronic irritability are more likely to be diagnosed with disruptive
mood dysregulation disorder.
Treatment
1. Medication
Stimulants
Stimulants are medications that are commonly used to treat ADHD. There is
evidence that, in children with irritability and ADHD, stimulant medications also
decrease irritability.
Stimulants should not be used in individuals with serious heart problems. According to
the FDA , people on stimulant medications should be periodically monitored for change in
heart rate and blood pressure.
Antidepressants
Antidepressant medication is sometimes used to treat the irritability and mood
problems associated with DMDD. Ongoing studies are testing whether these medicines are
effective for this problem. It is important to note that, although antidepressants are safe and
effective for many people, they carry a risk of suicidal thoughts and behavior in children and
teens. A black box warningthe most serious type of warning that a prescription can carry
has been added to the labels of these medications to alert parents and patients to this risk.
For this reason, a child taking an antidepressant should be monitored closely, especially when
they first start taking the medication.
Atypical Antipsychotic
An atypical antipsychotic medication may be prescribed for children with very severe temper
outbursts that involve physical aggression toward people or
property. Risperidone and aripiprazole are FDA-approved for the treatment of irritability
associated with autism and are sometimes used to treat DMDD. Atypical antipsychotic
medications are associated with many significant side-effects, including suicidal
ideation/behaviors, weight gain, metabolic abnormalities, sedation, movement disorders,
hormone changes, and others.
2. Psychological treatments
Psychotherapy
Cognitive-behavioral therapy, a type of psychotherapy, is commonly used to teach
children and teens how to deal with thoughts and feelings that contribute to their feeling
depressed or anxious. Clinicians can use similar techniques to teach children to more
effectively regulate their mood and to increase their tolerance for frustration. The therapy also
Page 25
teaches coping skills for regulating anger and ways to identify and re-label the distorted
perceptions that contribute to outbursts.
Parent Training
Parent training aims to help parents interact with a child in a way that will reduce aggression
and irritable behavior and improve the parent-child relationship. Multiple studies show that
such interventions can be effective. Specifically, parent training teaches parents more
effective ways to respond to irritable behavior, such as anticipating events that might lead a
child to have a temper outburst and working ahead to avert the outburst. Training also focuses
on the importance of predictability, being consistent with children, and rewarding positive
behavior.
Computer-based training
Evidence suggests that irritable youth with DMDD may be prone to
misperceiving ambiguous facial expressions as angry. There is preliminary evidence that
computer-based training designed to correct this problem may help youth with DMDD or
severe irritability
Case Study
An 8-year-old boy with frequent temper outbursts is evaluated. Dillon, an 8-year-old boy
living with his parents and his younger brother, was evaluated because his parents were at
their wits end regarding how to handle his explosive outbursts, which were occurring
several times a day. Ms. A, Dillons mother, stated, It has gotten to the point where I dislike
my child.
At the time of the evaluation, Dillon was exhibiting temper outbursts several times a day that
lasted approximately 10 minutes, and more intense 30-minute outbursts multiple times a
week, during which he became physically aggressive.
For example, during a recent tantrum, Dillon kicked and punched holes in his bedroom door,
causing destruction that warranted the doors removal. Additionally, Ms. A. reported that she
always had bruises on her arms from blocking Dillons strikes. Dillons parents described him
as irritable and cranky for the better part of the day on most days. When irritable, Dillon
appeared agitated and restless and often expressed that he wanted to be left alone. Attempts
to cheer him up were typically unsuccessful and sometimes worsened his irritability.
Dillon was in the second grade in a restrictive classroom environment, classified under
special education as emotionally disturbed. In the past school year, Dillon had been
suspended three timesfor physical aggression toward school personnel, for throwing a chair
in the classroom, and for knocking over a bookcase. Despite his average to superior cognitive
abilities, Dillon struggled academically, partly because of the large amount of time he spent
out of the classroom because of disruptive behavior. Teachers noted that Dillon often
appeared to be in an irritable, agitated mood and that he rarely smiled or appeared happy.
They often felt they were walking on eggshells to avoid his rageful outbursts
Page 26
Persistent Depressive Disorder

(Dysthymia)
What is Persistent Depressive Disorder (Dysthymia)?
Dysthymia = ILL HUMORED
Presence of depressed mood that last most of the day and is present almost continuously .
It is a serious and disabling disorder that shares many symptoms with other forms of clinical
depression.
It is generally experienced as less severe but more chronic form of Major depression.
Core Concept of PDD (Dysthymia)
Sub-affective or subclinical depressive disorder with:
1. Low grade chronicity for atleast 2 years
2. Insidious Onset (w/ origin often childhood & adolescence)
3. Persistent or intermittent course
History
Introduced in 1980
It was before classified as having depressive Neurosis (Neurotic Depression)
Associated Feelings
- Inadequacy, Guilt, Irritability, Anger, Withdrawal from society, Loss of
interest, Inactivity, Lack of productivity
Diagnostic Criteria
This disorder represents a consolidation of DSM-lV-defined chronic major depressive

disorder and dysthymic disorder.
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.
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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.
Note: Because the criteria for a major depressive episode include four symptoms that are
absent from the symptom list for persistent depressive disorder (dysthymia), a very limited
number of individuals will have depressive symptoms that have persisted longer than 2 years
but will not meet criteria for persistent depressive disorder. If full criteria for a major
depressive episode have been met at some point during the current episode of illness, they
should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other
specified depressive disorder or unspecified depressive disorder is warranted.
Symptoms
Main symptoms:
Low, dark, sad mood nearly everyday for atleast 2 years.
Other symptoms:
Insomia or excessive sleep
Low energy or fatigue
Low self-esteem
Poor appetite or over eating
Poor concentration or indecisiveness
Feelings of hopelessness
Risk Factors
Having 1st degree relative with Major depressive disorders
Traumatic / Stressful life events
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Personality traits that include negativity (Low self-esteem, being too dependent, and
self-critical/ pessimistic)
Causes
The Exact Cause of PDD is still UNKNOWN.
Other Causes:
Genetic
Biochemical
Environmental
Psychological factors
Chronic stress and trauma
Treatment
1.
-
Psychotherapy
Cognitive therapy
Insight oriented (psychoanalytic)
Interpersonal therapy
Family & group therapies
2. Pharmacotherapy (Antidepressants)
- SSRIs (Venlafaxine & Bupropion)
Other treatments:
exercising at least three times per week
eating a diet that largely consists of natural foods, such as fruits and vegetables
avoiding drugs and alcohol
seeing an acupuncturist
taking certain supplements, including St. Johns wort and fish oil
practicing yoga, tai chi, or meditation
writing in a journal
Substance/Medication-Induced
Depressive Disorder
Depressions can be caused by medicines or substances that are being induced and
lead to depressive disorders.
Diagnostic Criteria
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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 a medication.
2. The involved substance/medication is capable of producing the symptoms in
Criterion A.
C. The disturbance is not better explained by a depressive disorder that is not substance/
medication-induced. Such evidence of an independent depressive disorder could include the
following:
The symptoms preceded the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence suggesting the
existence of an independent non-substance/medication-induced depressive disorder
(e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.
Specify if
With onset during intoxication: If criteria are met for intoxication with the substance and
the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance and the
symptoms develop during, or shortly after, withdrawal.
Recording Procedures
ICD-9-CM. The name of the substance/medication-induced depressive disorder begins with
the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing the
depressive symptoms. The diagnostic code is selected from the table included in the criteria
set, which is based on the drug class. For substances that do not fit into any of the classes
(e.g., dexamethasone), the code for ''other substance" should be used; and in cases in which a
substance is judged to be an etiological factor but the specific class of substance is unknown,
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the category "unknown substance" should be used. The name of the disorder is followed by
the specification of onset (i.e., onset during intoxication, onset during withdrawal). Unlike the
recording procedures for ICD-IO-CM, which combine the substance-induced disorder and
substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is given
for the substance use disorder. For example, in the case of depressive symptoms occurring
during withdrawal in a man with a severe cocaine use disorder, the diagnosis is 292.84
cocaine-induced depressive disorder, with onset during withdrawal. An additional diagnosis
of 304.20 severe cocaine use disorder is also given. When more than one substance is judged
to play a significant role in the development of depressive mood symptoms, each should be
listed separately (e.g., 292.84 methylphenidate-induced depressive disorder, with onset
during withdrawal; 292.84 dexamethasone-induced depressive disorder, with onset during
intoxication).
Diagnostic Features
The diagnostic features of substance/medication-induced depressive disorder include the
symptoms of a depressive disorder, such as major depressive disorder; however, the
depressive symptoms are associated with the ingestion, injection, or inhalation of a substance
(e.g., drug of abuse, toxin, psychotropic medication, other medication), and the depressive
symptoms persist beyond the expected length of physiological effects, intoxication, or
withdrawal period. As evidenced by clinical history, physical examination, or laboratory
findings, the relevant depressive disorder should have developed during or within 1 month
after use of a substance that is capable of producing the depressive disorder (Criterion Bl). In
addition, the diagnosis is not better explained by an independent depressive disorder.
Evidence of an independent depressive disorder includes the depressive disorder preceded the
onset of ingestion or withdrawal from the substance; the depressive disorder persists beyond
a substantial period of time after the cessation of substance
use; or other evidence suggests the existence of an independent non-substance/ medicationinduced depressive disorder (Criterion C). This diagnosis should not be made when
symptoms occur exclusively during the course of a delirium (Criterion D). The depressive
disorder associated with the substance use, intoxication, or withdrawal must cause clinically
significant distress or impairment in social, occupational, or other important areas of
functioning to qualify for this diagnosis (Criterion E).
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Some medications (e.g., stimulants, steroids, L-dopa, antibiotics, central nervous system
drugs, dermatological agents, chemotherapeutic drugs, immunological agents) can induce
depressive mood disturbances. Clinical judgment is essential to determine whether the
medication is truly associated with inducing the depressive disorder or whether a primary
depressive disorder happened to have its onset while the person was receiving the treatment.
For example, a depressive episode that developed within the first several weeks of beginning
alpha-methyldopa (an antihypertensive agent) in an individual with no history of major
depressive disorder would qualify for the diagnosis of medication- induced depressive
disorder. In some cases, a previously established condition (e.g., major depressive disorder,
recurrent) can recur while the individual is coincidentally taking a medication that has the
capacity to cause depressive symptoms (e.g., L-dopa, oral contraceptives). In such cases, the
clinician must make a judgment as to whether the medication is causative in this particular
situation.
A substance/medication-induced depressive disorder is distinguished from a primary
depressive disorder by considering the onset, course, and other factors associated with the
substance use. There must be evidence from the history, physical examination, or laboratory
findings of substance use, abuse, intoxication, or withdrawal prior to the onset of the
depressive disorder. The withdrawal state for some substances can be relatively protracted,
and thus intense depressive symptoms can last for a long period after the cessation of
substance use.
Risk and Prognostic Factors
Temperamental. Factors that appear to increase the risk of substance/medication induced
depressive disorder can be conceptualized as pertaining to the specific type of drug or to a
group of individuals with underlying alcohol or drug use disorders. Risk factors common to
all drugs include history of major depressive disorder, history of drug induced depression,
and psychosocial stressors.
Environmental. There are also risks factors pertaining to a specific type of medication (e.g.,
increased immune activation prior to treatment for hepatitis C associated with interferonalfa-induced depression); high doses (greater than 80 mg/day prednisone-equivalents) of
corticosteroids or high plasma concentrations of efavirenz; and high estrogen/ progesterone
content in oral contraceptives.
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Depressive Disorder Due to Another

Medical Condition
Diagnostic Criteria
A. A prominent and persistent period of depressed mood or markedly diminished interest or

pleasure in all, or almost all, activities that predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder (e.g., adjustment
disorder, with depressed mood, in which the stressor is a serious medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
Diagnostic Features
The essential feature of depressive disorder due to another medical condition is a prominent
and persistent period of depressed mood or markedly diminished interest or pleasure in all, or
almost all, activities that predominates in the clinical picture (Criterion A) and that is thought
to be related to the direct physiological effects of another medical condition (Criterion B). In
determining whether the mood disturbance is due to a general medical condition, the clinician
must first establish the presence of a general medical condition. Further, the clinician must
establish that the mood disturbance is etiologically related to the general medical condition
through a physiological mechanism. A careful and comprehensive assessment of multiple
factors is necessary to make this judgment. Although there are no infallible guidelines for
determining whether the relationship between the mood disturbance and the general medical
condition is etiological, several considerations provide some guidance in this area. One
consideration is the presence of a temporal association between the onset, exacerbation, or
remission of the general medical condition and that of the mood disturbance. A second
consideration is the presence of features that are atypical of primary Mood Disorders (e.g.,
atypical age at onset or course or absence of family history). Evidence from the literature that
suggests that there can be a direct association between the general medical condition in
question and the development of mood symptoms can provide a useful context in the
assessment of a particular situation.
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Functional Consequences of Depressive Disorder Due to Another Medical

Condition
Functional consequences pertain to those associated with the medical condition. In general, it
is believed, but not established, that a major depressive episode induced by Cushing's disease
will not recur if the Cushing's disease is cured or arrested. However, it is also suggested, but
not established, that mood syndromes, including depressive and manic/ hypomanic ones, may
be episodic (i.e., recurring) in some individuals with static brain injuries and other central
nervous system diseases.
Differential Diagnosis
Depressive disorders not due to another medical condition. Determination of whether a

medical condition accompanying a depressive disorder is causing the disorder depends on a)
the absence of an episode(s) of depressive episodes prior to the onset of the medical
condition, b) the probability that the associated medical condition has a potential to promote
or cause a depressive disorder, and c) a course of the depressive symptoms shortly after the
onset of worsening of the medical condition, especially if the depressive symptoms remit near
the time that the medical disorder is effectively treated or remits.
Medication-induced depressive disorder. An important caveat is that some medical
conditions are treated with medications (e.g., steroids or alpha-interferon) that can induce
depressive or manic symptoms. In these cases, clinical judgment, based on all the evidence in
hand, is the best way to try to separate the most likely and/or the most important of two
etiological factors (i.e., association with the medical condition vs. a substance-induced
syndrome).
Adjustment disorders. It is important to differentiate a depressive episode from an
adjustment disorder, as the onset of the medical condition is in itself a life stressor that could
bring on either an adjustment disorder or an episode of major depression. The major
differentiating elements are the pervasiveness the depressive picture and the number and
quality of the depressive symptoms that the patient reports or demonstrates on the mental
status examination. The differential diagnosis of the associated medical conditions is relevant
but largely beyond the scope of the present manual.
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Other Specified Depressive Disorder

311 (F32.8)
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. The other specified depressive
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific depressive
disorder. This is done by recording other specified depressive disorder followed by the
specific reason (e.g., short-duration depressive episode).
Examples of presentations that can be specified using the other specified designation
include the following:
1. 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 in an individual whose presentation has
never met criteria for any other depressive or bipolar disorder and does not currently meet
active or residual criteria for any psychotic disorder.
2. 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, in an
individual whose presentation has never met criteria for any other depressive or bipolar
disorder, does not currently meet active or residual criteria for any psychotic disorder, and
does not meet criteria for recurrent brief depression.
3. 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, does not currently meet active
or residual criteria for any psychotic disorder, and does not meet criteria for mixed anxiety
and depressive disorder symptoms.
BIPOLAR I
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WHAT IS BIPOLAR 1 DISORDER?

Bipolar I disorder
- also known as manic-depressive disorder or manic depression
- a form of mental illness
- A person affected by bipolar I disorder has had at least one manic episode in his or
her life.
WHO IS AT RISK?
Men and women both get bipolar disorder. In most cases, symptoms usually start in
people who are 15-30 years old. More rarely, it can begin in childhood. The condition can
sometimes run in families, but not everyone in a family may have it.
THERAPY FOR BIPOLAR DISORDER
Talk Therapy for Bipolar Disorder:
Cognitive behavioral therapy - focuses on changing thoughts and behaviors that

accompany mood swings.
Interpersonal therapy - aims to ease the strain bipolar disorder puts on personal
relationships.
Social rhythm therapy - helps people develop and maintain daily routines.
Electroconvulsive Therapy (ECT)

This treatment, done while you are asleep under general anesthesia, can rapidly
improve mood symptoms of bipolar disorder. It uses an electric current to cause a seizure in
the brain. Its one of the fastest ways to ease severe symptoms. ECT is often a safe and
effective treatment option for severe mood episodes when medications have not led to
meaningful symptom improvement. Its a safe and highly effective treatment.
WHAT IS MANIC EPISODE?
Manic episode is a period of abnormally elevated mood and high energy,
accompanied by abnormal behavior that disrupts life.
DIAGNOSTIC CRITERIA FOR MANIC EPISODE
A. A distinct period of abnormally elevated or irritable mood and abnormally increased goaldirected activity or energy, lasting at least 1 week and present most of the day.
B. During the period of mood disturbance and increased activity or energy, 3 or more of the
ff. symptoms are present, and represent a noticeable change from usual behavior:
1. Inflated self-esteem.
2. Decreased need for sleep.
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3. More talkative than usual.

4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility, as reported or observed.
6. Increase in goal-directed activity.
7. Excessive involvement in activities that have a high potential for painful
consequences.
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or others, or
there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required
for the diagnosis of bipolar I disorder.
WHAT IS HYPOMANIC EPISODE?
Hypomanic episode, in milder forms, is a period of abnormally elevated, or irritable
mood for at least 4 days.
WHAT IS MAJOR DEPRESSIVE EPISODE?
Major Depressive Episode
- also known as unipolar major depression.
- occur only in major depressive disorder (MDD)
- women > men (2:1)
DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE EPISODE
A. At least 5 of the ff. symptoms present during a two-week period nearly every day; at least
one symptom is either depressed mood or loss of interest/pleasure:
depressed mood most of the day
diminished interest in nearly all activities most of the day
significant change in weight or appetite
insomnia or hypersomnia
psychomotor agitation or retardation
fatigue or decreased energy
inappropriate guilt or feelings of worthlessness
difficulty concentrating or making decisions
recurrent thoughts of death, suicidal thoughts, plans, or attempts
B. Symptoms don't meet criteria for a Mixed Episode.
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C. Symptoms cause significant social/occupational impairment or distress.

D. Symptoms are not due to a substance or medical condition.
E.Symptoms are not better accounted for by Bereavement.
WHAT THE DEPRESSION PHASE IS LIKE
Without treatment, a person with bipolar disorder may have intense episodes of
depression. Symptoms include sadness, anxiety, loss of energy, hopelessness, and trouble
concentrating. They may lose interest in activities that they used to enjoy. Its also common to
gain or lose weight, sleep too much or too little, and even think about suicide.
WHATS A "MIXED EPISODE"?
Mixed Episode - When people with bipolar disorder have depression and mania
symptoms at the same time, or very close together.
This can lead to unpredictable behavior, such as taking dangerous risks when
feeling hopeless and suicidal but energized and agitated. Mood episodes involving mixed
features may be somewhat more common in women and in people who develop bipolar
disorder at a young age.
CYCLOTHYMIC DISORDER
Cyclothymic Disorder a less serious version of full-blown bipolar disorder because
it lacks certain extreme symptoms and psychotic features such as delusions and the marked
impairment caused by full-blown manic or major depressive episodes.
DIAGNOSTIC CRITERIA FOR CYCLOTHYMIC DISORDER
A. For at least 2 years (at least 1 year in children
and adolescents) there have been numerous periods
with hypomanic symptoms that do not meet criteria
for a hypomanic episode and numerous periods
with depressive symptoms that do not meet the
criteria for a major depressive episode.
B. During the above 2-year period (1 year in
children and adolescents), the hypomanic and
depressive periods have been present for at least
half the time and the individual has not been
without the symptoms for more than 2 months at
a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder,
schizophrenia, schizophreni-form disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
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E. The symptoms are not attributable to the physiological effects of a substance or another
medical condition.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
BIPOLAR II DISORDER
WHAT IS BIPOLAR II DISORDER?
Bipolar II disorder is a form of mental illness. Similar to bipolar I disorder,
individuals diagnosed with bipolar II disorder generally experience mood shifts that cycle
over a period of time. Unlike bipolar I disorder, however, those suffering from bipolar II
disorder never experience mood elevations that reach full-on mania. People with bipolar II
disorder will experience at least one hypomanic episode at some point in their lives, but
often the real battle is with episodes of major depression.
It is characterized by at least one episode of hypomania and at least one episode of
major depression. Diagnosis for bipolar II disorder requires that the individual must never
have experienced a full manic episode (unless it was caused by an antidepressant medication;
otherwise one manic episode meets the criteria for bipolar I disorder). The depression
experienced by sufferers of bipolar disorder is equally severe for people with bipolar I as for
people with bipolar II. Some recent studies have reported that depression can be both more
frequent and more chronic in the case of people with bipolar II than with bipolar I. In fact, it
tends to be more chronic than bipolar I, and can cause long periods of depression and
instability of mood, which in turn can lead to problems at work, in social situations and in
ones home life.
What is the difference between Bipolar 1 and Bipolar Type 2? Lets look at some
definitions:
Bipolar 1: Where the individual has experienced episode(s) of mania, with or without a
history of depressive disorders.
Bipolar 2: Where the individual has experienced episode(s) of both hypomania and
depression (and has never experienced an episode of mania or had psychotic episodes).
This is why Bipolar II is sometimes known as soft bipolar. Depression is present, but
instead of mania, the person suffers from hypomania a milder form of mania. One way of
understanding the differences between hard and soft bipolar, or Type I Bipolar and Type II
Bipolar, is to understand the differences between MANIA and HYPOMANIA.
Mania is a high mood that is of distinct severity and where the individual is often
psychotic in the sense of having delusions and/or hallucinations.
Hypomania comes from the Greek and means less than mania. It describes a high that is
less severe than a manic episode and without any psychotic features such as misinterpretation
of events.
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Bipolar Disorder I is more severe, and the longer and more serious highs, which may
involve psychosis, are far more likely to lead to hospitalization.
Bipolar Type I is quite different from the much shorter and less dramatic highs in Bipolar
Type II disorder. Bipolar 2 does NOT involve any psychotic experiences.
HISTORY
In 19th century psychiatry, mania had a broad meaning of craziness, and hypomania
was equated by some to concepts of 'partial insanity' or monomania. A more specific usage
was advanced by the German neuro-psychiatrist Emanuel Ernst Mendel in 1881, who wrote
"I recommend to name those types of mania that show a less severe phenomenological
picture, 'hypomania'".
The first diagnostic distinction to be made between manic-depression involving

mania, and that involving hypomania, came from Carl Gustav Jung in 1903. In his paper,
Jung introduced the non-psychotic version of the illness where "it is not a question of real
mania at all but of a hypomanic state which cannot be regarded as psychotic." Jung illustrated
the hypomanic variation with five case histories, each involving hypomanic behavior,
occasional bouts of depression, and mixed mood states, which involved personal and
interpersonal upheaval for each patient. In 1975, Jung's original distinction between mania
and hypomania gained support. . Fieve and Dunner published an article recognizing that only
individuals in a manic state require hospitalization.
Empirical evidence, combined with treatment considerations, led the DSM-IV Mood
Disorders Work Group to add bipolar II disorder as its own entity in the 1994 publication.
The first expected change will reduce the required duration of a hypomanic state from four to
two days. The second change will allow hypomania to be diagnosed without the
manifestation of elevated mood; that is, increased energy/activity will be sufficient. The
rationale behind the latter revision that some individuals with Bipolar II manifest only visible
changes in energy. Without presenting elevated mood, these individuals are commonly
misdiagnosed with major depressive disorder. Consequently, they receive prescriptions for
antidepressants, which unaccompanied by mood stabilizers, may induce rapid cycling or
mixed states.
DIAGNOSTIC CRITERIA
For a diagnosis of bipolar II, it is necessary to meet the following criteria for a current
or past hypomanic episode and the following criteria for a current or past major depressive
episode:
Hypomanic Episode
A. A distinct period of abnormally and persistently elevated, expansive or irritable mood
and abnormally and persistently increased activity or energy, lasting at least 4
consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or
more) of the following symptoms have persisted (four of the moods is only irritable),
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represent a noticeable change from usual behavior, and have present to a significant
degree:
1. Inflated self-esteem or grandiosity
2.
Decreased need for sleep (for example, you feel rested after only three hours of sleep)
3.
Unusual talkativeness
4.
Flight of ideas or subjective experience that thoughts are racing
5.
Distractibility (i.e. attention too easily drawn to unimportant or external stimuli), as

reported or observed.
6.
Increased goal-directed activity (either socially, at work or school, or sexually) or

psychomotor agitation.
7.
Excessive involvement in activities that have a high potential for painful

consequences for example, unrestrained buying sprees, sexual indiscretions or
foolish business investments
C. The episode is associated with an unequivocal change in functioning that is

uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or
occupational functioning or to necessitate hospitalization. If there are psychotic
features, the episode is, bby definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication or other treatment)
Bipolar II Disorder
A. Criteria have been met for at least one hypomanic episode and at least one major
depressive episode.
B. There has never been a manic episode.
C. The occurrence of the hypomanic episodes and the major depressive episodes is not
better explained by schizoaffective disorder, schizophrenia, schizopherniaform
disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum
and other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternative
between periods of depression and hypomania causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
SYMPTOMS
Symptoms of a depressive episode include:
Depressed mood or sadness daily
Difficulty concentrating, remembering, or making decisions
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Loss of pleasure in activities once found enjoyable

Pulling away from friends
Eating problems loss of appetite or weight loss, or overeating and weight gain
Trouble getting to sleep, or sleeping too much
Feeling guilty, worthless, or hopeless
Low energy
Loss of self-esteem
Thoughts of suicide and death
Abuse of alcohol or substances, which may make the symptoms as well as suicide risk worse
Symptoms of a hypomanic episode include:
A noticeable increase in energy, with hyperactivity and a decreased need for sleep
Rushing from one activity or task to another, possibly without finishing one before going on
to another
Talking in a rapid, pressured, or loud manner
Left untreated, an episode of hypomania can last from a few days to several months.
CAUSES
There have been very few studies conducted to examine the possible causes of
Bipolar II. Those that have been done have not considered Bipolar I and Bipolar II separately
and have had inconclusive results. Researchers have found that patients with either Bipolar I
or II may have increased levels of blood calcium concentrations, but the results are
inconclusive. The studies that have been conducted did not find a significant difference
between those with Bipolar I or Bipolar II. There has been a study looking at genetics of
Bipolar II disorder and the results are inconclusive; however, scientists did find that relatives
of people with Bipolar II are more likely to develop the same bipolar disorder or major
depression rather than developing Bipolar I disorder.
RISK FACTORS
Most people are in their teens or early 20s when symptoms of bipolar disorder first
start. Nearly everyone with bipolar II disorder develops it before age 50. People with an
immediate family member who has bipolar are at higher risk.
TREATMENT
Psychotherapy
Therapy is critical for managing symptoms of bipolar II disorder. The most effective
therapies are cognitive-behavioral therapy, family-focused therapy and interpersonal therapy.
Through regular sessions with an experienced therapist, people with bipolar II can better
understand their illness, develop essential coping skills, solve day-to-day problems, regulate
moods, rebuild their relationships, and manage difficult thoughts and emotions. Therapists
may also recommend important self-care measures, such as exercising regularly, eating
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nutritious foods, and getting enough sleep, as well as alternative bipolar treatments like
acupuncture, yoga, and mindfulness meditation.
Medications
A number of medications can help with bipolar II disorder, including mood stabilizers and
antidepressants.
Among the mood stabilizers:
Lithium is considered highly effective in controlling mood swings, particularly the highs.
Lithium has been used for more than 60 years in the treatment of bipolar disorder. It can take
a while for lithium to work, so its better used for long-term treatment than to treat acute
hypomanic episodes. In addition, periodic monitoring is required of the lithium level in the
blood and other laboratory tests of kidney and thyroid functioning in order to avoid side
effects.
Lamictal, approved by the FDA for maintenance treatment of bipolar disorder in adults,
helps delay bouts of depression and hypomania, as well as mixed episodes in people being
treated with standard therapy. It is considered to be stronger for the prevention of relapses
than for treatment of acute episodes of bipolar depression.
Depakote, an anti-seizure drug, works to level out moods. It works more rapidly than lithium
and can also be used for prevention.
Other anti-seizure medications sometimes prescribed include Trileptal and Tegretol.
Benzodiazepines, including Ativan, Xanax and Valium, are tranquilizers used for the shortterm control of acute symptoms common with hypomania, such as agitation or insomnia.
Although the hypomanic episodes in bipolar II disorder do not interfere with functioning and
do not involve psychosis, sometimes antipsychotic drugs, including Abilify, Risperdal,
Seroquel, and others, are used to treat hypomania.
Seroquel and antidepressants such as Paxil, Prozac and Zoloft are sometimes used to treat
bipolar II depression.
Family Treatment and Support Programs and Services
Family treatment programs that combine support and education about bipolar II disorder can
help family members cope and help reduce the likelihood of some symptoms recurring. For
individuals suffering from bipolar II disorder who do not have family and social support,
community support and outreach service can be invaluable.
Heres what family treatment and support programs and services do:
Help family members cope with symptoms that are present even when medications
are taken.
Help family members stay on top of the individual with bipolar II disorder, reminding
him or her to take the medications as the doctor prescribed and helping the individual to learn
how to manage any side effects.
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Helping family members recognize that it is crucial that the individual with bipolar II
disorder gets adequate sleep each night.
Informing the family members that encouraging the person with bipolar II disorder to
live a healthy lifestyle and stay away from recreational drugs is important in their overall
recovery.
The person suffering from bipolar II disorder may not recognize or be able to tell a therapist
or doctor about his or her symptoms, so having family members who know what to watch out
for can be helpful. Support groups can help family members during stressful episodes.
Substance abuse is very common among people with bipolar disorder, according to the
National Institute of Mental Health. Some individuals turn to alcohol or drugs to lessen their
symptoms, but substance abuse can actually trigger or prolong bipolar II symptoms.
Other disorders that often co-occur with bipolar II disorder include post-traumatic stress
disorder, social phobia and attention deficit hyperactivity disorder.
Bottom line: Episodes of hypomania and depression are warning signs that someone may
need treatment. If you think or suspect that you, a member of your family, or a close friend or
co-worker has bipolar II disorder, the best recommendation is to get that person to a doctor
for a thorough evaluation
SPECIFIERS FOR MOOD DISORDERS

Specifiers are extensions to a diagnosis that further clarify the course, severity or special
features of a disorder or illness. The Diagnostic & Statistical Manual of Mental
Disorders (DSM-5) uses specifiers extensively in the diagnosis of mood disorders. Any
number of applicable specifiers can be used for the same episode. For bipolar disorder, there
are two categories of specifiers: Those for defining the current or most recent mood episode
and those concerning the course of recurrent, or repeating, mood episodes. The first category,
defining current or recent episodes, includes mixed features,anxious distress, melancholic
features, atypical features, psychotic features andcatatonic features. The second category,
defining recurrent episodes, includes rapid cycling, peripartum onset and seasonal pattern.
Mixed Features Specifier. Bipolar disorder with mixed features means that you have both
manic/hypomanic symptoms and depressive symptoms in the same mood episode, rather than
one or the other. To be diagnosed with this specifier, your mood episodes, whether defined as
manic, hypomanic or depressive, must meet all the criteria for that particular episode AND
have at least three symptoms that belong to the opposite type. So, for instance, if you have a
mood episode that meets all the criteria for a manic/hypomanic episode, yet also has at least
three symptoms of a depressive episode, this specifier would fit you.
Anxious Distress Specifier. Bipolar disorder with anxious distress is specified if your mood
episode includes at least two symptoms of anxiety. These symptoms can be restlessness, lack
of concentration, worry, feeling tense and fear of losing control.
Melancholic Features Specifier. Bipolar with melancholic features usually happens if you
have severe depressive symptoms. It's defined as severe depression that includes symptoms
Page 44
like feeling significantly worse in the morning, weight loss and/or not wanting to eat, losing
pleasure in activities you used to enjoy, waking up early and excessive guilt.
Atypical Features Specifier . Bipolar disorder with atypical features means that you have
the atypical symptoms of sleeping too much, increased appetite, feeling like your arms and
legs are heavy, being overly sensitive to rejection and the ability to feel at least somewhat
better when you experience something positive.
Psychotic Features Specifier . Bipolar disorder with psychotic features can include moodcongruent
or
mood-incongruent features.
Psychotic
features
involve hallucinations and/or delusions.
Catatonic Features Specifier. Bipolar with catatonic features is diagnosed if you
experience catatonia along with your mood episodes. Catatonia symptoms can include not
responding to anything, not being able and/or willing to talk, rigid muscles, repeating what
someone just said, grimacing, moving around with no purpose and resisting movement.
Rapid Cycling Specifier. The rapid cycling specifier means that your mood episodes have
occurred a minimum of four times in the past year. In between mood episodes, you must have
had a stable mood or switched completely to the opposite kind of mood episodes, i.e., from
hypomanic to depressive.
Seasonal Pattern Specifier . The seasonal pattern specifier is indicated if your mood
episodes only occur at certain times of the year, usually fall and/or winter. This can happen
because of light depravation.
Peripartum Onset Specifier. Peripartum onset can be diagnosed if your mood episode,
usually depressive, occurs during your pregnancy or up to four weeks after you give birth.
These episodes can be accompanied by anxiety or panic attacks.
Page 45

Major Depressive Disorder based on Diagnostic Statistical Manual 5

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MOOD DISORDERS: AN OVERVIEW

2 Key Moods involved in Mood Disorders:

Mania characterized by intense and unrealistic feelings of excitement and euphoria.

Types of Mood Disorders

Unipolar Depressive Disorders the person experiences only depressive episodes

MOOD DISORDERS GROUP 5 (BS PSYCHOLOGY 3-4)