Depressive Disorders

Question 1

Common feature of depressive disorders

Answer 1

Presence of sad, empty, or irritable mood, accompanied by related changes that significantly affect the individual’s capacity to function.

Question 2

Features of major depressive episodes that occur in the context of bereavement

Answer 2

More severe symptoms and functional impairment; tend to occur in individuals with other vulnerabilities for depressive disorders.

Question 3

Disruptive Mood Dysregulation Disorder Diagnostic Criteria

Answer 3

A. Severe recurrent temper outbursts (verbal or behavioural) that are grossly disproportionate to the trigger.
B. Outbursts are inconsistent for developmental level.
C. Avg. ≥3 outbursts/week.
D.Irritable mood between outbursts, most of the day, nearly every day, observable by others
E. A-D have been present for ≥12 months; no period of ≥3 months where A-D are not met
F. A-D present in at least 2 settings and severe in at least of the two settings
G. Diagnosis cannot be made before age 6 or after age 18.
H. Onset of A-E is before age 10.
I. No period of ≥1 day where full symptom criteria for manic/hypomanic episode have not been met.
J. Does not occur exclusively during a major depressive episode and is not better explained by another diagnosis (note: DMDD cannot coexist with an oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder diagnosis).
K. Symptoms not attributable to substances, medication, neurological condition.

Question 4

Common rule-outs for Disruptive Mood Dysregulation Disorder

Answer 4

Most Important (DMDD cannot coexist with):
* Bipolar Disorder: History of a manic or hypomanic episode is an automatic rule-out of DMDD
* ODD (if individuals meet criteria for both ODD and DMDD, DMDD takes precedence)

Others (DMDD can coexist with):
* MDD
* ADHD
* ASD
* PTSD
* Separation Anxiety Disorder
* PDD

Question 5

Differentiation Between DMDD and Bipolar

Answer 5

• History of manic or hypomanic episode = bipolar
• Discerete obserbvable mood epidodes, “markedly different from baseline” = bipolar
• During manic episodes, cognition, behaviour and distractability get markedly worse in bipolar
• Irritability in DMDD is more stable and persistent

Question 6

Differentiation between DMDD and ODD

Answer 6

• Persistent negative mood state between outbursts = DMDD
• Tend to be more mood symtpoms in DMDD than ODD
• Impariment in multiple settings = DMDD
• ODD-like presentations can occur in DMDD, but not vice-versa; if criteria for both are met, DMDD wins out

Question 7

Differentiation between DMDD and disorders like ADHD, MDD, Anxiety Disorders, and ASD

Answer 7

• Comorbid diagnoses can be given, but:
• If irritability only occurs in context of or as an exacerbation of core features of these diagnoses, then DMDD is ruled out

Question 8

Differentiation between DMDD and Intermittent Explosive Disorder

Answer 8

• Severe outburts are present in both, but persistent irritability between outbursts = DMDD
• In some cases, Intermittent Explosive Disorder diagnosis can be made after 3 months, whereas 12 is needed for DMDD

Question 9

Major Depressive Disorder Diagnostic Criteria

Answer 9

A. ≥5 of the following symptoms withing the same 2-week period, and at least 1 symptom is depressed mood or loss of interest/pleasure:
1. Depressed mood most of the day, nearly every day (subjective or observable)
2. Loss of pleasure/interest in most/all activities, most of the day, nearly every day (subjective or observable)
3. Significant changes in weight (≥5% of body weight, without dieting; failure to make expected weight gain in children) or appetite
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or inappropriate guilt nearly every day (may be delusional in magnitude)
8. Diminished ability to think or concentrate, indecisiveness, nearly every day (subjective or observable)
9. Recurrent thoughts of death, recurrent passive suicidal ideation, active suicidal ideation

B. Clinically significant distress or impairment in social, occupational or other important areas of functioning.
C. Not attributable to medication, substances or a neurological condition.
D. At least one MDE is not better explained by schizoaffective disorder, or superimposed on a psychosis-spectrum disorder.
E. There has never been a manic or hypomanic episode

Question 10

Differentiation between MDD and grief/bereavement

Answer 10

Grief:
* predominant affect is feelings of loss
* dysphoria is likely to come in waves of intensity, especially associated with reminders of the deceased
* pain in grief can be accompanied by happiness and humour, much less likely to be observed in MDD
* self-esteem is usually preserved (if not, is related to feelings of guilt about perceived failings toward the deceased)
* thoughts of death are about “joining” the deceased

MDE:
* predominant affect is depressed mood and inability to anticipate happiness or pleasure
* depressed mood tends to be more stable/independent of reminders
* positive emotions and humour much more rarely observed
* self-loathing and feelings of worthlessness are common
* thoughts of ending one’s life are because of feelings of worthlessness, undeserving of life, unable to cope with depression

Question 11

Differentiation between MDD and manic episodes with irritable mood/mixed features

Answer 11

• Presentation can look very similar between the two if MDD is with prominent irritability
• Distinction involves judgement of whether enough symptoms of a manic episode are present (3 if mood is manic; 4 if mood is irritable)

Question 12

Differentiation between MDD and bipolar disorders

Answer 12

• Any history of manic or hypomanic episode precludes MDD diagnosis
• Note that presentations of MDD can occur with hypomania if criteria for hypomanic episode not met –> these can be diagnosed as either other specified bipolar and related disorder or MDD, depending on clinician’s judgement

Question 13

Differentiation between MDD and PDD

Answer 13

PDD requires depressed mood, more days than not, for at least 2 years (and no period of ≥2 months without depressed mood). Both can be diagnosed if criteria are met.

Question 14

Persistent Depressive Disorder Diagnostic Criteria

Answer 14

A. Depressed mood for most of the day, for more days than not (subjective or observable; in children and teens, mood can be irritable and duration = 1 year)
B. Presence, while depressed, of ≥2 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. Feelins of hopelessness

C. During the 2 years, individual is never without A-B for ≥2 months at a time
D. MDD criteria may be continuously present for 2 years (in this case, MDD and PDD should be diagnosed)
E. No history of manic/hypomanic episode
F. Symptoms not better explained by psychosis-spectrum disorders
G. Symptoms not due to substances or medical condition
H. Symptoms cause clinically significant distress or impairment in social, occupational, or other important arears of functioning.

Question 15

PDD Specifiers

Answer 15

Other features:
* With anxious distress
* With atypical features

Remission status:
* In partial remission
* In full remission

Onset:
* Early onset: If onset before age 21
* Late onset: If onset at age ≥21

Type:
* With pure dysthymic syndrome: Full MDE criteria not met in the last 2 years
* With persistent MDE: Fule MDE criteria met throughout the last 2 years
* With intermittent depressive episodes, with current episode: Full MDE criteria currently met, but with periods of ≥8 weeks in the last 2 years when they have not been
* With intermittent depressive episodes, without current episode: Full MDE criteria not currently met but have been at least once in the last 2 years

Severity:
* Mild
* Moderate
* Severe

Question 16

MDD Specifiers

Answer 16

Other features:
* With anxious distress
* With mixed features
* With melancholic features
* With atypical features
* With mood-congruent psychotic features
* With mood-incongurent psychotic features
* With catatonia

Onset and course:
* With peripartum onset
* With seasonal pattern

Question 17

Differentiation between PDD and Other specified depressive disorder

Answer 17

• Some MDE symptoms are absent from the PDD symptom list
• Some individuals can have these symptoms for ≥2 years but not meet criteria for PDD
• In those cases, either a diagnosis of MDD or other specified/unspecified depressive disorder should be given, depending on whether criteria for an MDE were ever met

Question 18

Differentiation between PDD and bipolar disorders

Answer 18

• History of manic or hypomanic episodes precludes a PDD diagnosis
• History of manic episodes = bipolar I
• History of hypomanic episodes, with persistent depressive presentation, where MDE criteria have been met = biploar II
• History of hypomanic episodes, with persistent depressive presentation, where MDE criteria have NOT been met = other specified bipolar disorder

Question 19

Differentiation between PDD and cyclothymic disorder

Answer 19

Cyclothymic disorder precludes PDD diagnosis; diagnosis = cyclothymic disorder if:
* During the 2-year depressed mood state, there are numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode
* No symptom-free periods of ≥2 months
* Criteria for MDE, manic episode, or hypomanic episode, have never been met

Question 20

Premenstrual Dysphoric Disorder Diagnostic Criteria

Answer 20

A. In the majority of menstrual cycles, ≥5 total symptoms (from B-C) must be present in the final week before menses, improve within a few days of menses onset, become minimal or absent in the week postmenses.
B. ≥1 of the following symptoms:
1. Marked affective lability (e.g., mood swings, sudden sadness/tearfulness, increased sensitivity to rejection)
2. Marked irritability/anger or increased interpersonal conflicts
3. Martked depressed mood, hopelessness, or self-depracating thoughts
4. Marked anxiety, tension, and/or feelings of being keyed up/on edge

C. ≥1 of the following symptoms:
1. Decreased interest in usual activities
2. Subjective difficulty concentrating
3. Lethargy, easy fatigability, or marked lack of energy
4. Marked change in appetite; overeating; or specific food cravings
5. Hypersomnia or insomnia
6. A sense of being overwhelmed/out of control
7. Physical symptoms (e.g., breast tenderness/swelling, joint/muscle pain, bloating, weight gain)

D. Clinically important distress in important areas of functioning
E. Not an exacerbation of symptoms of another disorder (e.g., MDD, panic disorder, PDD, or personality disorder [although may occur with a PD]).
F. Criterion A confirmed by prospective daily ratings during ≥2 symptomatic cycles
G. Symptoms not due to a substance or other medical condition

Question 21

Differentiation of Premenstrual Dysphoric Disorder from presmenstual syndrome

Answer 21

• PMS does not require ≥5 symptoms, nor mood-related symptoms
• PMS is generally considered to be less severe

Question 22

Differentiation of Premenstrual Dysphoric Disorder from dysmenorrhea

Answer 22

• Dysmenorrhea is characterized by very physically painful menses, without affective symptoms
• Dysmenorrhea begins at menses onset, whereas premenstrual dysphoric disorder symptoms come on pre-menses

Question 23

Substance/Medication-Induced Depressive Disorder

Answer 23

A. A prominent and persistent disturbance in mood that predominates in the presentation, characterized by depressed mood or markedly diminished interest/pleasure
B. Evidence from history, examination, or lab findings of both 1 and 2:
1. Symptoms in A developed during or soon after medication/substance intoxication/withdrawawl
2. The involved substance is capable of producing symptoms in A

C. Not better explained by a depressive disorder that is not substance/medication-induced (e.g., symptoms preceeded substance/medication use)
D. Disturbance does not occur only in the context of delirium
E. Caused clinically significant distress or impairment
Note: this diagnosis should only be made instead of substance intoxication/withdrawal when A predominates the clinical picture and is sufficiently sever to warrant clinical attention.

Question 24

Substance/Medication-Induced Depressive Disorder specifiers

Answer 24

Onset:
* With onset during intoxication
* With onset during withdrawal
* With onset after medication use: If symptoms developed at initiation of medication, with change of medication use, or during withdrawal

Question 25

Differentiation of Substance/Medication-Induced Depressive Disorder from Depressive disorder due to another medical condition

Answer 25

Can often happen, because medications are taken for an illness
* Usually can be judged by history, looking at symptom-onset and how it correlates with dose changes
* Sometimes manipulating/discontinuing doses is most helpful for determining cause
* If both the illness and the medical condition are a cause, both diagnoses are given
* If there’s not enough evidence to determine whether the primary cause is the substance, the illness, or independent, other specified depressive disorder or unspecified depressive disorder is indicated

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Question 26

Depressive Disorder Due to Another Medical Condition Diagnostic Criteria

Answer 26

A. A prominent and persistent disturbance in mood that predominates in the presentation, characterized by depressed mood or markedly diminished interest/pleasure
B. Evidence from history, examination, or lab findings that the disturbance is a direct pathophysiological consequence of another medical condition
C. Not better explained by another mental disorder (e.g., adjustment disorder, with depressed mood, in which the stressor is a serious medical condition)
D. Does not occur exclusively in the context of delirium
E. Causes clinically significant distress or impairment
Note: Name of the associated medical condition should be included in the diagnosis (e.g., Depressive disorder due to hypothyroidism)

Question 27

Depressive Disorder Due to Another Medical Condition specifiers

Answer 27

Additional features:
* With depressive features: Full MDE criteria not met
* With major depressive-like episode: Full MDE criteria (except C) are met
* With mixed features: Symptoms of mania or hypomania are also present but do not predominate the clinical picture

Question 28

Other Specified/Unspecified Depressive Disorder Diagnosis

Answer 28

• Presence of depressive disorder symptoms that cause clinically significant distress or impairment
• Full criteria for any other depressive disorders not met
• “Other specified” category is used when the clinician chooses to communicate specifically why the criteria for something else aren’t met (e.g., “Other specified depressive disorder, short-duration depressive episode”)
• “Unspecified cateogry is used then whe clinician does not choose to communicate why criteria for something else aren’t met

Question 29

Unspecified Mood Disorder Diagnosis

Answer 29

• Presence of mood disorder symptoms (manic and/or depressive) that cause clinically significant distress/impairment
• Full criteria for a bipolar and/or depressive disorder not met
• It is difficult to choose between unspecified bipolar and related disorder and unspecified depressive disorder

Question 30

Severity Specifiers for Depressive Disorders

Answer 30

Based on the number of criterion symptoms, their severity, and degree of functional impairment:
* Mild: Few, if any, symptoms beyond those needed for the diagnosis; intensity is distressing but manageable; minor impairment in functioning
* Moderate: Number and intensity of symtpoms and functional impairment is between minor and severe
* Severe: Number of symptoms is substantially more than those needed for the diagnosis, seriously distressing and unmanageable symptoms, marked functional impairment

Question 31

“With anxious distress” specifier for Depressive Disorders

Answer 31

≥2 of the following symptoms, most days during current MDE (or most recent if in remission or PDD):
1. Feeling keyed up or tense
2. Feeling unusually restless
3. Difficulty concentrating because of worry
4. Fear that something awful may happen
5. Feeling that the individual may lose control of themselves

Specify current severity:
* Mild: 2 symptoms
* Moderate: 3 symptoms
* Moderate-severe: 4-5 symptoms
* Severe: 4-5 symptoms + motor agitation

Question 32

“With mixed features” specifier for Depressive Disorders

Answer 32

A. ≥3 of the following manic/hypomanic symptoms are present most during current MDE (or most recent if in remission or PDD):
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
6. Increased or excessive involvement in highly risky/painful consequences activities
7. Decreased need for sleep (not insomnia–feeling rested without sleep)

B. Mixed symptoms are observable by others and a change from baseline
C. Full criteria for mania or hypomania not met
D. Not attributable to substances

Question 33

“With melancholic features” specifier for Depressive Disorders

Answer 33

A. 1 of the following present during most severe period of current MDE (or most recent if in remission or PDD):
1. Loss of pleasure in all or almost all activities
2. Loss of reactivity to pleasurable stimuli (does not feel better, even temporarily, when something good happens)

Note: The above should be near-complete

B. ≥3 of the following:
1. Distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness/empty mood (qualitatively different from normal depressed mood)
2. Depression is regularly worse in the morning
3. Early-morning waking (≥2 hours before usual)
4. Marked psychomotor agitation or retardation
5. Significant anorexia or weight loss
6. Excessive or inappropriate guilt

Question 34

“With atypical features” specifier for Depressive Disorders

Answer 34

When the following features predominate during most days of current MDE (or most recent if in remission or PDD):
A. Mood reactivity (i.e., mood brightens in response to positive events)
B. ≥2 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. Long-standing pattern of rejection sensitvity (not limited to mood episodes) that results in significant social/occupational impairment
C. Criteria for “with melancholic features” or “with catatonia” not met in the same episode.

Question 35

“With psychotic features” specifier for Depressive Disorders

Answer 35

Delusions and/or hallucinations present at any time during the curent MDE (or most recent if in remission or PDD). Specify if mood-congruent:
* With mood-congurent psychotic features: Content of all delusions and hallucinations is consistent with depressive themes or inadequacy guilt, disease, death, nihilism, or deserved punishment.
* With mood-incongruent psychotic features: Content of delusions and hallucinations does not involve the above depressive theme, or content is a mixture of mood-congruent and -incongruent themes.

Question 36

“With catatonia” specifier for Depressive Disorders

Answer 36

If catatonic features present in current MDE (or most recent if in remission or PDD)

Question 37

“With peripartum onset” specifier for Depressive Disorders

Answer 37

If onset of mood symptoms in MDE occur during pregnancy or in the 4 weeks following delivery.
Note: should be distinguished from “maternity blues” (i.e., sudden changes in mood that do not cause functional impairment, occur in the absence of depression, and are likely the cause of physical changes following delivery; typically resolve within a week)

Question 38

“With seasonal pattern” specifier for Depressive Disorders

Answer 38

Applies to recurrent MDD:
A. Regular temporal relationship between MDE onset and a particular time of year (fall/winter)
B. Full remissions occur at a characteristic time of year (spring/summer)
C. In the last 2 years, 2 MDEs have occurred to demonstrate this pattern; no nonseaosnal MDEs have occurred
D. Seasonal MDEs substantially outnumber nonseasonal MDEs over the individual’s lifetime

Note: this specified does not apply if the pattern occurs because of stressors that are temporally linked to different times of the year (e.g., school/work)

Question 39

Remission specifiers for Depressive Episodes

Answer 39

Specify if:
* In partial remission: Symptoms of most recent MDE are present but full criteria not met anymore OR period of <2 months without significant MDE symptoms.
* In full remission: ≥2 months, no significant signs or symptoms present.