296.22 Major Depressive Disorder, single episode, with Atypical Features

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 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, 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 met.

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 met).

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 laxative abuse.

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 Features:

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 eating")
(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 factors, there are evolutionary biologists who think that depression, rather than signifying dysfunction, is actually an adaptation.

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 scale.

For the reasons I ruled out the idea that I had adjustment issues with mixed depressive and anxiety symptoms, see: adjustment disorder, mixed















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