Persistent Depressive Disorder

Question 1

Diagnostic criteria of Persistent Depressive Disorder

Answer 1

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) 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. Feelings of hopelessness.

C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years.

E. There has never been a manic episode or a hypomanic episode.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 2

How do you diagnose when MDD + Persistent depressive disorder co-occurs?

Answer 2

If criteria are sufficient for a diagnosis of a major depressive episode at any time during the 2-year period of depressed mood, then a separate diagnosis of major depression should be made in addition to the diagnosis of persistent depressive disorder along with the relevant specifier (e.g., with intermittent major depressive episodes, with current episode).

Question 3

What are the specifiers of Persistent Depressive Disorder?

Answer 3

Course specifiers:

• In partial remission
• In full remission
• Early onset: If onset is before age 21 years.
• Late onset: If onset is at age 21 years or older.

Severity specifiers:

• Mild
• Moderate
• Severe

Extra specifiers 1:

• With anxious distress
• With atypical features

Extra specifiers 2:
- With pure dysthymic syndrome: Full criteria for a major depressive episode
have not been met in at least the preceding 2 years.

• With persistent major depressive episode: Full criteria for a major depressive episode have been met throughout the preceding 2-year period.
• With intermittent major depressive episodes, with current episode: Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode.
• With intermittent major depressive episodes, without current episode: Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years.

Question 4

What are the characteristics of the symptoms experienced in Persistent Depressive Disorder?

Answer 4

Because these symptoms have become a part of the individual’s day-to-day experience, particularly in the case of early onset (e.g., “I’ve always been this way”), they may not be reported unless the individual is directly prompted.

Question 5

Prevalence of Persistent Depressive Disorder

Answer 5

The 12-month prevalence in the United States is approximately 0.5% for dysthymic disorder and 1.5% for chronic major depressive disorder, with prevalence among women approximately 1.5 and 2 times higher than prevalence among men for each of these diagnoses, respectively.

Question 6

What was Persistent Depressive Disorder in DSM-IV?

Answer 6

Persistent depressive disorder is effectively an amalgam of DSM-IV dysthymic disorder and chronic major depressive episode.

Question 7

Development and course characteristics of Persistent Depressive Disorder

Answer 7

1. Persistent depressive disorder often has an early and insidious onset (i.e., in childhood, adolescence, or early adult life) and, by definition, a chronic course. Borderline personality disorder is a particularly robust risk factor for persistent depressive disorder.
2. Early onset (i.e., before age 21 years) is associated with a higher likelihood of comorbid personality disorders and substance use disorders.

Question 8

Risk and prognostic factors of Persistent Depressive Disorder

Answer 8

1. Temperamental: Factors predictive of poorer long-term outcome include higher levels of negative affectivity (neuroticism), greater symptom severity, poorer global functioning, and presence of anxiety disorders or conduct disorder.
2. Environmental: Childhood risk factors include parental loss or separation and childhood adversity.
3. Genetic and physiological: It is thus likely that individuals with persistent depressive disorder will have a higher proportion of first-degree relatives with persistent depressive disorder than do individuals with nonchronic major depressive disorder, and more depressive disorders in general.

Question 9

Culture-Related Diagnostic Issues (Persistent Depressive Disorder)

Answer 9

The perceived abnormality or tolerance of chronic depressive symptoms may vary across cultures, affecting symptom detection and treatment acceptability. For example, some social groups or age cohorts may consider long-standing depressive symptoms to be normal reactions to adversity.

Question 10

Association With Suicidal Thoughts or Behavior (Persistent Depressive Disorder)

Answer 10

Persistent depressive disorder is associated with elevated risk of suicidal outcomes and comparable levels of disability, whether the disorder occurs in high-, middle-, or low-income countries.

Question 11

Functional Consequences of Persistent Depressive Disorder

Answer 11

The degree to which persistent depressive disorder impacts social and occupational functioning is likely to vary widely, but effects can be as great as or greater than those of major depressive disorder.

Question 12

Differential diagnosis of Persistent Depressive Disorder

Answer 12

1. MDD
2. Other specified depressive disorder
3. BP I/II
4. Cyclothymic disorder
5. Psychotic disorders
6. Depressive/bipolar disorders/related disorders due to another medical condition
7. Substance/medication-induced depressive or bipolar and related disorder.
8. Personality disorders

Question 13

Comorbidity of Persistent Depressive Disorder

Answer 13

In comparison to individuals with major depressive disorder, those with persistent depressive disorder are at higher risk for psychiatric comorbidity in general, and for anxiety disorders, substance use disorders, and personality disorders in particular. Early-onset persistent depressive disorder is strongly associated with DSM-5 Cluster B and C personality disorders.

Question 14

When can you diagnose unspecified or other specified depressive disorder?

Answer 14

Because the criteria for a major depressive episode include symptoms (i.e., markedly diminished interest or pleasure in activities; psychomotor agitation or retardation; recurrent thoughts of death, suicidal ideation, suicide attempt or plan) that are absent from the symptom list for persistent depressive disorder (i.e., depressed mood and two out of six Criterion B symptoms), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but that do not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, a diagnosis of major depressive disorder would apply. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder should be given.