Major Depressive Disorder (MDD)

MDD is characterized by one or more major depressive episodes & no history of manic, hypomanic or mixed episodes.  MDD can begin at any age but most often onsets in the mid-20s.  The course can be quite variable.  Some people may have isolated episodes of depression with remissions of many years; others may have clusters of episodes with brief remissions.  You can use specifiers to indicate the course of the disorder, such as the specifier “With Full Interepisode Recovery” or “Without Full Interepisode Recovery.”

The criteria:

• Presence of a single major depressive episode (see previous post)
• Episode is not better accounted for by schizoaffective disorder & is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
• There has never been a manic, mixed or hypomanic episode unless that episode is substance or treatment induced or due to a general medical condition.

• If the full criteria are met at the current time for a major depressive episode, specify its current clinical status and/or features:
• Mild (with 5 – 6 symptoms of a major depressive episode), moderate (between mild & severe), severe with psychotic features (with most symptoms of a depressive episode and psychosis) or severe without psychotic features (with most of the symptoms & no psychosis)
• Chronic – full criteria have been met for a major depressive episode for at least the previous 2 years
• With catatonic features – with 2 of the following
• Motor immobility as evidenced by muscular rigidity or stupor
• Excessive motor activity that serves no evident purpose & is not influenced by external stimuli
• Extreme negativism (resistance to instructions with no evident motive or maintenance of a rigid posture against attempts to be moved) or mutism
• Peculiarities of voluntary movement such as posturing (assuming bizarre or inappropriate postures), stereotyped movements, prominent mannerisms or prominent grimacing
• Echolalia (repeating what you say) or echopraxia (imitating your physical movements)
• With melancholic features – defined by
• Either loss of pleasure in nearly all activities or lack of reactivity to usually pleasurable stimuli at the most severe point of the episode.
• Three or more of the following symptoms:
• Distinct quality of depressed mood
• Depression regularly worse in the morning
• Early morning awakening (at least 2 hours before usual time of awakening)
• Marked psychomotor retardation or agitation
• Significant anorexia or weight loss
• Excessive or inappropriate guilt
• With atypical features
• Mood reactivity – mood improves in response to positive events
• Two or more of the following:
• Significant weight gain/increased appetite
• Hypersomnia
• Leaden paralysis – a heavy, leaden feeling in extremities
• Long standing pattern of sensitivity to interpersonal rejection that results in significant social/occupational impairment
• Criteria are not met for melancholic or catatonic features during the same episode
• With postpartum onset – episode onsets within 4 weeks postpartum

Mood Disorders & Mood Episodes

Mood disorders are characterized by having mood episodes.  I will here define the types of mood episodes: major depressive episode, manic episode, mixed episode and hypomanic episode.  The presence of these mood episodes will define mood disorders, which will be covered in subsequent posts.

Major Depressive Episode

• 5 or more of the following symptoms during the same 2 week period; must have either depressed mood or loss of interest/pleasure.
• Depressed mood for most of the day, nearly every day, as indicated by either self report or observation made by others. (In children/adolescents, mood by be irritable, rather than classically depressed.)
• Diminished pleasure in all or nearly all activities for most of the day nearly every day.  Again, this may be indicated by self report or observation made by others.
• Weight loss or gain (more than 5% in a month), or increase or decrease in appetite nearly every day.  (In children/adolescents, look for the child not to gain weight as expected.
• Insomnia/hypersomnia nearly every day.
• Psychomotor agitation/retardation nearly every day (must be observable by others; not just feelings of restlessness or being slowed down).
• Fatigue/loss of energy nearly every day.
• Feelings of worthlessness/excessive or inappropriate guilt nearly every day.  Guilt may be delusional & must be more than just self-reproach about being sick.
• Diminished ability to think, concentrate or make decisions nearly every day, indicated by either self report or observations of others.
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or suicide plan.
• Symptoms do not meet the criteria for a mixed episode.
• Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.
• Symptoms are not due to the direct physiological effects of a substance or a general medical condition.
• Symptoms are not better accounted for by bereavement.  Diagnosis may be made if the symptoms persist for longer than two months, or are characterized by marked functional impairment.

Manic Episode

• Period of abnormally & persistently elevated, expansive or irritable mood, lasting at least one week (or less if hospitalization is required).
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feeling rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees, gambling, risky investments).
• The symptoms do not meet the criteria for a mixed episode.
• The mood disturbance causes marked impairment in social or occupational functioning.  If there is psychosis, this criterion is considered to have been met.
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.

Mixed Episode

Mixed episodes may evolve out of a manic or major depressive episode, or can arise on their own.  A mixed episode can turn into a major depressive episode, or may remit to an asymptomatic period.  It is unusual for a mixed episode to turn into a manic episode.  Mixed episodes, by definition, must last longer than one week.

• The criteria are met both for a manic & a major depressive episode (except for duration) for at least one week.
• The symptoms must cause impairment in social or occupational functioning, require hospitalization, or have psychotic features.
• The symptoms are not caused by the direct physiological effects of a substance or a general medical condition.

Hypomanic Episode

Hypomanic episodes are essentially manic episodes that do not cause impairment in functioning.  The criteria are below, and you will find that the criteria are identical to the criteria for a manic episode except for the difference noted above & shorter duration.

• Period of persistently elevated, expansive or irritable mood, lasting at least 4 days & is clearly different from the normal nondepressed mood.
• During the period, three or more of the following symptoms have persisted (four if the mood is only irritable), and the symptoms have been present to a significant degree:
• Inflated self esteem/grandiosity
• Decreased need for sleep (feels rested after only a few hours)
• More talkative than usual/pressure to keep talking
• Flight of ideas or report of racing thoughts
• Distractibility
• Increase in goal-directed activity in any life sphere or psychomotor agitation
• Excessive involvement in pleasurable activities that have a potential for danger or harm (shopping sprees).
• The episode is associated with an unequivocal change in functioning that is not typical of the person when they are not having symptoms.
• The disturbance is observable by others.
• The mood disturbance does not cause marked impairment in social or occupational functioning. 
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition.