296.22 Major Depressive Disorder, single episode, with Atypical
Major Depressive Disorder according to the DSM-IV:
A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
(1) depressed mood most of the day, nearly every day, as indicated
by either subjective report (e.g., feels sad or empty) or
observations 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 made by others)
(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 gains.
(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
(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
(9) recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, a suicide attempt or a
specific plan for committing suicide
B. The symptoms do not meet the criteria for a Mixed Episode
C. The symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., hypothyroidism)
E. The symptoms are not better accounted for by Bereavement, i.e.,
after the loss of a loved one the symptoms persist for longer than
2 months or are characterized by marked functional impairment, morbid
preoccupation with worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
Major Depressive Disorder 296.xx - The numerical code for Major
Depressive Disorder starts with 296. It is then .2 if one episode, .3
if more. The next digit refers to severity: 1: mild, 2: moderate, 3:
severe without psychotic features, 4: severe with psychotic features
5 partial and 6 full remission, for example: 296.33 would indicate
that there had been more than one major depressive episode and that
the current depression was severe, without psychotic features. Also,
specify with Atypical Features. Chronic = at least 2 years criteria
300.4 Dysthymic Disorder
- chronically depressed mood
for most of the day more days than not for at least 2 years.
The differential diagnosis between Dysthymic Disorder and Major
Depressive Disorder is made particularly difficult by the facts that
the two disorders share similar symptoms and that the differences in
them in onset, duration, persistence, and severity are not easy to
evaluate retrospectively. Usually Major Depressive Disorder consists
of one of more discrete Major Depressive Episodes that can be
distinguished from the person's usual functioning, whereas Dysthmymic
Disorder is characterized by chronic, less severe depressive symptoms
that have been present for many years. When Dysthymic Disorder is of
many years' duration, the mood disturbance may not be easily
distinguished from the person's "usual" functioning. If the
initial onset of chronic depressive symptoms is of sufficient
severity and number to meet full critieria for a Major Depressive
Episode, the diagnosis would be Major Depressive Disorder, Chronic
(if the full criteria are still met), or Major Depressive Disorder,
In Partial Remission (if the full criteria are no longer
The DSM goes on to say that if Dysthymic Disorder was present, yet
there were no major depressive episodes during the first two years,
of symptoms, or there has been a full remission of major depressive
disorder (lasting at least 2 months) - I would have to say I was
depressed in the two years leading up to, but not sure it was
constant enough to fit dysthymic disorder. It all gets messy, and I
don't see how it's possible to 'totally get it right' in all cases,
but I would say that partly because that first unaddressed episode
was unaddressed, and had significant impact on my life, it could be
seen as major depression, however, since that time I have never been
free of even dysthymic symptoms for two months at a time - or at
least I don't think so.
My first major depressive episode occurred in the summer of 1981, at
age 15. I had asked to see a psychiatrist, went to see him a couple
of times, but felt more hopeless after trying. It is possible that
the reason I didn't think therapy would go anywhere was related to
lack of awareness at that time regarding eating disorders - or that
in order for something to be recognized as an eating disorder, the
patient had to be emaciated or admit to self-induced vomiting or
The reason I had sought as a psychiatrist was that I was looking for
a neutral observer to offer input. I was having trouble related to
disappointing my mother, who wanted me to put in the effort to
control my weight. On the other side, while living with my father, I
had no limits whatsoever with regards to food, and even when I ate
unusual amounts, I was never questioned about it, and food was
constantly replaced. I felt out of control with my eating patterns.
When my effort to seek help didn't have promising results, it may
have triggered my first major depressive episode. I then spent at
least two weeks in bed, until school resumed.
Before the first major depressive episode, I was depressed in perhaps
a more general sense, and I was also experiencing symptoms of
anxiety. The depression and anxiety were partly related to an eating
disorder, but also related to my circumstances: cumulative effects
from many moves and upheavals within the family, the psychological
distress related to having an incurable medical condition
(ichthyosis) which was becoming more relevant as I became more
sexually mature, the addictions, unhappiness and behaviour patterns
of the adults in my life - to name a few.
In major depressive disorder, a person may avoid leaving the home
due to apathy, loss of energy or anhedonia. Later on in my life, it
was eventually assumed that I was agoraphobic, but I don't think it
is that simple, and think the original cause or diagnosis is closer
to an unresolved depression from way back.
My depression has (so far) been atypical, that is, that instead of
insomnia and loss of appetite, I tend to experience the opposite.
Also, there are usually some events or occurrences which can
momentarily lift my mood to some extent.
The DSM-IV-TR defines Atypical Depression
as a subtype
of depression or dysthymia, characterized by Atypical
A. Mood reactivity (i.e., mood brightens in response to actual or
potential positive events)
B. At least two of the following:
(1) Significant weight gain or increase in appetite ("comfort
(2) Hypersomnia (sleeping too much, as opposed to the insomnia
present in melancholic depression)
(3) Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
(4) Long-standing pattern of sensitivity to interpersonal rejection
(not limited to episodes of mood disturbance; fits of rage, hysteria,
aggression and irrational reactions) that results in significant
social or occupational impairment
C. Criteria are not met for melancholic depression or catatonic
depression during the same episode.
Atypical depression is the most common kind, and it seems to me that
my depression fits this category. For more than 20 years, I have
wished for death on a daily basis. Life to me is something which is
endured rather than enjoyed. I can appreciate things intellectually,
but actual pleasure is difficult to experience, although my mood may
brighten somewhat in response to certain occurrences.
...If depression is about loss of attachments, and I suggest that it
is, then the events that precipitate depression tend to be about
interpersonal loss. If we have one half of the human race that's
more preprogrammed for attachment, then that's the half that's going
to be more vulnerable...
...In depression, the limbic system becomes unresponsive and
lethargic. The researchers speculated that perhaps the intense female
response is sometimes too much, that it wears out the neural
circuits. The result is a collapse into numbness which may, if
contained, allow recovery...
Ellen Frank, quoted by Deborah Blum in Sex on the Brain - The
Biological Differences Between Men and Women
Some of the symptoms listed in personality and other disorders (e.g.,
apparent emotional numbness or detachment) may be the result of lost
attachments and/or a fried limbic system. Some people may experience
continued traumas or losses that do not allow time for
recovery. Symptoms of depression might be mistaken for coldness or
lack of affect associated with personality disorders.
If my chronology is examined, I have experienced no small amount of
trauma, upheaval and loss. At times during my childhood and
adolescence, I experienced many such events during very short periods
of time. People tend to focus in modern times on sexual abuse or
physical abuse, and over the years many people I have talked to,
including therapists, have seemed to dismiss my experiences as not
all that bad compared to those of other kids they have encountered,
and yet for sheer volume of events, ongoing erratic parenting,
chaotic living arrangements, I think there was potentially a lot that
could have eventually affected my functioning, even if at first I
seemed to handle the shocks adequately.
As mentioned in evolutionary
, there are evolutionary biologists who think that
depression, rather than signifying dysfunction, is actually an
I think that my depression is unipolar. Below I have addressed issues
that may have to do with questions about whether I have experienced
manic episodes, such that I might be bipolar rather than unipolar.
I have not thought myself manic, but some things such as drastically
changing one's appearance, or having a lot of sexual encounters,
passing out money on the street, occasionally dancing wildly, having
'creative periods', etc, may be interpreted as manic behaviours. When
it comes to appearance, for me that was more consciously about taking
a stand, making an effort to express outwardly that I felt abnormal
on the inside. As for sexual encounters, when more of them occurred,
it was more likely during times when I was both slimmer, fitter and
tanned - so as to take advantage of a time when I was actually able
to attract someone. I am not sure that counts as manic, as it did not
occur at random times. And, when it came to passing out money, often
that was about removing temptation to spend it on food myself, such
that I'd go on an enforced fast - which was related to my eating
disorder and perception of my appearance, as well as my feeling of
lack of control, stability.
For the most part, my mood was usually stable. (Depressed).
Irritability was sometimes noticeable in my mid-30s, and may have
been the result of unconscious resentment coming to the surface,
through years of studying my own details - in other words, I may
actually have been making progress in getting in touch with my anger.
Previous boyfriends had sometimes found it strange or thought
it meant I didn't care when I refused to get all riled up, preferring
to discuss any situation calmly and rationally.
For elaboration regarding the upheavals I have spoken of, see: chronology
, and also Holmes and Rahe stress
For the reasons I ruled out the idea that I had adjustment issues
with mixed depressive and anxiety symptoms, see: adjustment disorder,