Many people wonder, "What are the criteria for Major Depression?" In this article we will discuss the formal 'symptom cluster' we commonly refer to as Major Depressive Disorder. This is taken from the 'dictionary' many use called the DSM V.
Recognizing the Signs of Major Depressive Disorder
Five or more of the following symptoms have to have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms representing the emotional centers must be present either depressed mood or loss of interest or pleasure (anhedonia).
- Depressed mood, most of the day, nearly every day, as indicated by how a person report that they feel or observations made by others. The emotional centers that help us measure the ‘biological relevance’ of everything in our life is hyper metabolic (overactive) and reading everything with a negative valence.
- Markedly diminished interest or pleasure in all, or almost all, activities of the day, nearly every day. This is a part of the reason a person’s life tends to collapse as motivation to do anything wanes.
- Significant weight loss when not dieting or weight gain, or decreased or increased appetite nearly every day. Usually, people will have this predilection one way or another when they are under stress.
- Insomnia or hypersomnia nearly every day. Either way, when people awake they never feel rested. Often, they can get to sleep but wake every 90 minutes or so worrying. It then usually takes at least 30 minutes to get back to sleep. Another sleep pattern is to wake up early and be unable to get back to sleep. We need to carefully assess for snoring, waking short of breath and reports of intermittently not breathing while asleep. This would represent a separate problem called sleep apnea and require further assessment with a sleep study.
- Psychomotor agitation or retardation nearly every day. If either of these is severe, we need to carefully assess for the possibility of Bipolar Disorder (See information available under this title.)
- Fatigue or loss of energy nearly every day. The more profound the fatigue, the more we should consider a medical diagnosis and more extensive biological testing. Hypothyroidism, rheumatological conditions, vitamin deficiencies, hormonal imbalances, chronic infections, toxic exposures and certain types of cancer need to be considered.
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day. Both of these set the groundwork for suicidal idealization. They also steal from the person’s limited energy reserves and makes involvement in healthy activities difficult. When chronic, one might consider slowly ‘stacking’ healthy daily activities one at a time. First consider working on getting up in the morning at a specific time (Of course, this will require you going to sleep at a specific time! No late night TV!), going for a walk (With plenty of heart thumping music) and reviewing your 90 goals preferably with a partner to see how you can forward each of them by 1% that day. Then, as time goes, by adding other healthy habits as you deem appropriate. Picking up habits you use to have or are somehow related to previous interests will be the easiest to pick up. (See ‘Daily Rituals’ under the tab ‘Life Applications’ on the bottom of the home page.)
- Diminished ability to think, concentrate, or indecisiveness, nearly every day. When this symptom predominates consider the diagnosis of ADHD, particularly when an antidepressant of the SSRI class seems to make this worse. Serotonin can lower other neuro hormones that are necessary to maintain energy and concentration. Please also remember to keep in mind that a variable response to antidepressants is also a hallmark of Bipolar Disorder and requires treatment with mood stabilizers. In either case, a careful history including early life and family history is often helpful. In ADHD one usually sees traits that begin in elementary school, in Bipolar Disorder traits usually become more evident in junior high school as our brain matures and our highest mind becomes fully activated.
- Recurrent thoughts of death, recurrent suicidal idealization without a specific plan, or suicide attempt or a specific plan for committing suicide. This is an emergency. Please do not be afraid of asking for help. It really helps someone to be able to admit and talk about this. We don’t want anyone feeling alone with these thoughts. Be there, offer support, ask what might help them when they feel this way and always tell members of your treatment team about where you are with these types of thoughts. Including such thoughts as, “sometimes I just wish I wouldn’t wake up.” If you feel this way and no one is available please call the local suicide hotline or emergency room.
- The symptoms cause clinically significant distress or impairment in social, occupational or important areas of functioning. This is what turns passing traits into symptoms. This is what turns all of the ‘shoulds’ into ‘musts’. This is when you get help, look for patterns, develop a plan that optimizes goals and make sure you have support for follow through.
- The episode is not attributable to the physiological effects of a substance or to another medical condition. Even if you are a casual drinker/’user’ now is the time to clean up any behavior that might be keeping you from living the life you dream of. Also, make sure you go to your family doctor to check for a whole host of potential medical issues. You don’t want to be spending a year in psychotherapy or taking an antidepressant while a medical problem like hypothyroidism goes unchecked. Additionally, the thyroid problem will likely distort any positive effect the therapy or medication might have had.
- The occurrence of the major depression episode is not better explained by a psychotic disorder. There are other disorders that cause a person to not only ‘misinterpret information’ but to create visual, auditory or thought information that has absolutely no basis in reality. When this is a consideration, please see a psychiatrist.
- There has never been a manic episode or a hypomanic episode. In this case it would be called Bipolar Disorder which is a separate illness. Bipolar disorder usually starts with a depressive episode and so can be difficult to discern from Major Depression. Please believe me when I tell you, they are very different with different treatments both medically and psychologically. Again, if you are being treated for Major Depression when you really have Bipolar Disorder, your Disorder is likely going unchecked and will likely be more difficult to treat down the line. (Please see the discussion on Bipolar Disorder in this section)
- Depression, like bipolar disorder, is highly variable and has a number of specifiers which can help to further communicate what a person is going through. One of the main reasons for these diagnostic criteria is to help everyone understand and therefore better support those involved. Different tendencies will need to be included in any treatment plan to optimize your life.
- with anxious distress. This would include at least two of the following five symptoms. Feeling keyed up or tense, unusually restless, having difficulty concentrating because of worry, fear that something awful might happen, feeling that an individual might lose control of himself or herself.
- with mixed features. This specifier could be added to either a manic or hypomanic episode and include at least three of the following symptoms. Predominant dysphoria or depressed mood as indicated by either objective report or observation made by others, diminished interest or pleasure in all, or almost all, activities, psychomotor retardation nearly every day, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, or recurrent thoughts of death. If all the depressive and manic symptom criteria are met the diagnosis 'manic episode with mixed features' should be made.
- with rapid cycling. The presence of at least four mood episodes in the previous 12 months that met criteria for major depressive episode (not manic or hypomanic as this would be bipolar disorder).
- with melancholic features. When one of the following is present during the most severe part of the current episode. Loss of pleasure in all or almost all activities, or lack of reactivity to pleasurable stimuli. Additionally, there needs to be three or more of the following criteria. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or so-called empty mood. Depression that is regularly worse in the morning, early morning awakening, marked psychomotor agitation or retardation, significant anorexia or weight loss, or excessive or inappropriate guilt.
- with atypical features. This specifier can be applied when the following features predominate during the majority of the days of the current or most recent depressive mood. Mood reactivity and two or more of the following: Significant weight gain or increased appetite, hypersomnia, leaden paralysis, a long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment.
- with mood congruent psychotic features. During the manic episode, the content of all delusions and hallucinations is consistent with typical manic themes.
- with mood incongruent psychotic features. The content of the delusions and hallucinations is inconsistent with the episode polarity themes as described.
- with catatonia. This specifier can apply to an episode of mania or depression if catatonic features are present during most of the episode. Catatonia includes lack of psychomotor activity, passive maintenance of posture held against gravity, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypic, agitation, grimacing, echolalia, and echopraxia. Echopraxia is the mimicking of another's movements.
- with peripartum onset. This specifier can be applied to the current episode if symptoms occur during pregnancy or in the four weeks following delivery.
- with seasonal pattern. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episode at a particular time of year. Full remissions also express at a characteristic time of year. In the last two years the individual's mood fluctuations have demonstrated a temporal seasonal relationship. Seasonal mood events substantially outnumber any non-seasonal mood events.