Depressive Disorder According to the DSM --

¶ … Depressive Disorder

According to the DSM -- IV -- TR (2000), Major Depressive Disorder is classified by the number of Major Depressive Episodes -- although only one is needed in order to diagnose Major Depressive Disorder -- and according to the severity, ranging from mild, moderate, severe without psychotic features, or severe with psychotic features (347). This means that, in practice, the signs or symptoms of Major Depressive Disorder are those of a Major Depressive Episode: the clinician is required to diagnose the Episode before the larger diagnosis of the Disorder is indicated. In order to diagnose a Major Depressive Episode, there must be present a mood which is obviously depressed, which can also be observed as simply the loss of interest in nearly all activities, or the absence of accustomed pleasure -- sometimes known by the more clinical term "anhedonia" -- in familiar activities (349). However, the DSM-IV-TR specifies that the length of time of this mood must be "a period of at least 2 weeks" (349). This is the most salient feature of the condition, and without this no further attempt at diagnosis should proceed. However, this clearly fits under the heading of common sense: the patient must exhibit a depressed mood, or at the very least a mood in which interest and pleasure in "nearly all activities" have vanished (349).

Having identified an overall depressed mood in the patient according to these criteria, however, the clinician is then required to measure the patient against a checklist, in which "at least four additional symptoms" must be present for the situation to qualify as a Major Depressive Episode (349). The first and second of the listed symptoms are what has already been described, one of which is necessary for the diagnosis. The first is the depressed mood, which may or may not be acknowledged by the patient. The patient's subjective description can take a number of forms, describing the mood as "depressed, sad, hopeless, discouraged, or 'down in the dumps'." (349). But the patient is also in some cases likely to deny the mood, in which case the clinician might attempt to gain an admission by interview or infer the mood "from the person's facial expression and demanor" (349). It is also worth noting that some patients will either report or demonstrate a mood which appears "irritable or cranky" -- this is particularly noteworthy in children and adolescents, where Major Depressive Disorder will often present this type of mood, although it must not be confused with the sort of irritability a child or adolescent might demonstrate when merely frustrated (349). The second of the two necessary diagnostic criteria is the anhedonia, or "loss of interest or pleasure" in daily activities -- this is, in some way, "nearly always present" (349). As a result, one of these first two criteria on the diagnostic list is necessary to make the further diagnosis.

Of the subsequent symptoms on the diagnostic list, it is necessary for the patient to exhibit at least four out of the remaining seven in order to warrant a diagnosis of Major Depressive Episode. We can examine these symptoms in the order they appear on the diagnostic list. The third symptom, Criterion A3, is related to weight or appetite: the clinician is instructed to look for noticeable weight loss (when the patient is not on a diet) or weight gain, or else a daily increase or decrease in appetite (350). The DSM notes that, in practice, the "appetite is usually reduced" (349). But obviously the noticeable weight gain or loss is generally related to the change in appetite, although relying upon weight as the diagnostic criterion here may relate to the occasional unwillingness of patients having a Major Depressive Episode to acknowledge or share their subjective experiences.

The fourth symptom, Criterion A4, can be generally termed as "sleep disturbance" (350). This means the presence of either insomnia or hypersomnia (excessive sleep) almost every day. But in terms of how commonly this symptom may present itself, it is worth noting that insomnia is the "most common sleep disturbance associated with a Major Depressive Episode" (350). Most often the type of insomnia is "middle" or "terminal" -- i.e., the patient wakes up in the middle of the night and has difficulty getting back to sleep, or the patient wakes up too early and is unable to return to sleep at all -- although less commonly patients may complain of "initial" insomnia, i.e., a difficulty in falling asleep (350). Hypersomnia is less common, but can also be a valid symptom. The sleep disturbance is crucial because, once again, given the frequent unwillingness of patients with a Major Depressive Episode to acknowledge their symptoms, the clinician will sometimes find that the stated reason for seeking treatment is the sleep disturbance, rather than a more obvious acknowledgement of depression.

The fifth symptom on the list, Criterion A5, is a change in psychomotor activity -- either retardation (slowing down) or agitation (feelings of restlessness). The restlessness can take many forms -- "inability to sit still, pacing, hand-wringing; or pulling or rubbing of the skin, clothing, or other objects" (350). The retardation can be observed as a slowing down of speech, thought, or movement, or various other changes in speech pattern, ranging from "increased pauses" to complete "muteness" (350). The crucial thing about this particular diagnostic criterion is that, in this case, the clinician cannot rely on the patient's "subjective feelings," but the agitation or retardation must be significant enough to be "observable by others" (350). However, it is possible for there to be a certain amount of diagnostic overlap with the retardation component of Criterion A5 and the overall substance of the next symptom, Criterion A6, which specifies fatigue or loss of energy nearly every day. Again, this has to be significant and observable, with the patient reporting "sustained fatigue without physical exertion" (350). The specific example offered by the DSM for this criterion is a patient who complains that "washing and dressing in the morning are exhausting and take twice as long as usual" (350). In this case, the element of duration -- in which these simple activities seem to take twice as long to accomplish -- can possibly give the clinician an indicator for the previous criterion of psychomotor retardation. But the patient's sense that even simple activities cause fatigue is the clear sign of this criterion -- which, as with all of these symptoms, must be present (and present more or less every day) for at least a 2-week period before the examination in order to qualify as a Major Depressive Episode.

The final three criteria are all cognitive in character. The seventh diagnostic criterion, A7, specifies a "sense of worthlessness or guilt," which can for example take the form "unrealistic negative evaluations of one's worth or guilty preoccupations or ruminations over minor past failings" (350). It is also worth noting that this particular symptom can, in fact, take on "delusional proportions" -- in other words, a patient is convinced that "he or she is personally responsible for world poverty" (350). But in terms of evaluating the patient for this particular criterion, the DSM-IV-TR also specifies that it is not sufficient that the patient blames himself or herself for the illness and for failure to meet job-related or personal responsibilities as a result of the illness -- this is such a common response to the illness itself that it should be regarded as a standard element of the first criterion, of the generalized depressed mood. The next of the cognitive diagnostic criteria, A8, is a diminished ability to think or concentrate, or indecisiveness, observed on a daily basis. As with other criteria for a Major Depressive Episode, the patient's unwillingness to admit to various aspects of thought or behavior means that this can be diagnosed by the observations of others, even if the patient fails to admit it. This impaired ability to think can frequently take the form of "memory difficulties" or "concentration problems" -- in children, it may be reflected by poor academic performance, and in elderly patients it very frequently takes the form of memory problems where the clinician must be careful not to mistake it for dementia (350). In fact, depression-related memory problems in the elderly can, by the frequency of occurrence, be labeled as "pseudo-dementia" because, when the patient is properly treated for depression, the "memory problems often fully abate" (350). And the final cognitive criterion, A9, relates to "recurrent thoughts of death" or suicide, and various forms of suicidal ideation or behavior. The clinician is warned, however, that "the frequency, intensity and lethality of these thoughts can be quite variable" (351). In other words, the thoughts of death can be transient ideation, once or twice a week, or they can be part of an actual plan (including the requisite materials) with a constant recurrent fixation on the idea of self-harm or death.

These 9 criteria are the first step in diagnosing a Major Depressive Episode or Disorder, where either A1 or A2 is necessary for diagnosis, and then at least four of the remaining seven criteria is additionally necessary. The remaining criteria for diagnosis are relatively simple. Criterion B. states that the clinician must be certain that the symptoms presented by the patient do not instead qualify as a "Mixed Episode" -- in other words, it must not additionally include the symptoms of a Manic Episode in addition to those nine criteria outlined for Major Depressive Episode. This requires care in some specifics: irritability can be seen as an aspect of A2, but it can also be present in the elevated mood states of mania. Insomnia is a characteristic of depression, but mania instead demonstrates a decreased need for sleep, where the patient feels well-rested on very little sleep. And the cognitive impairments seen in depression are different from the racing thoughts and distractibility of mania. But otherwise it is relatively simple to distinguish between the bipolar symptoms that would warrant a diagnosis of Mixed Episode rather than a Major Depressive Episode. Meanwhile Criterion C. evaluates the level of distress or impairment caused: this requires the clinician to evaluate the patient's functionality, in which the patient's "ability to function socially or occupationally" must be impaired. And the final two criteria are used to rule out situations which might, in many ways, mimic the symptoms of a Major Depressive Episode -- Criterion D. specifies that the patient's symptoms are not in some way caused physiologically by a substance (whether through drug abuse or medication), and Criterion E. specifies that the patient's circumstance is not best described as Bereavement from the loss of a loved one. Obviously the normal process of grief can resemble in many ways the features of a Major Depressive Episode, but Bereavement is itself a separate diagnosis, and does not cross the line into a Major Depressive Episode unless it is "associated with marked functional impairment or include[s] morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation" (352).

In terms of etiology, the DSM-IV-TR specifies that the symptoms of a Major Depressive Episode "usually develop over days to weeks" which may include a "prodromal period" of mild depressive symptoms and anxiety symptoms that can last for weeks or months before the onset of the actual Major Depressive Episode (354). It is also worth noting that there are "no laboratory findings that are diagnostic of a Major Depressive Episode [that] have been identified" (352). While there are alterations in neurotransmitter systems, neuropeptides, and sometimes hormonal disturbances, and while some studies have noted alterations in blood flow and metabolism within the brain, it is worth noting that "none of these changes are present in all individuals in a Major Depressive Episode…nor is any particular disturbance specific to depression" (353). In other words, the etiology is in many ways poorly understood, even if the disease itself is readily diagnosed, and the prognosis is usually quite good, where "in a majority of cases there is a complete remission of symptoms, and functioning returns to the premorbid level" (354). In terms of epidemiology, it is worth noting that Major Depressive Episodes "occur twice as frequently in women as in men," with the increased risk beginning in adolescence, and possibly to be identified with the onset of puberty (354). The DSM-IV-TR otherwise notes that, in terms of epidemiology, the reported symptoms can vary culturally, where some cultures are more likely to describe or experience the Disorder "largely in somatic terms" (nerves, headaches, "imabalance") rather than in terms of feelings of sadness or guilt (353).

In terms of treatment, the pharmacological approach is recommended for all types of Major Depressive Episode, no matter the severity. However, psychotherapy is contraindicated in the severe forms, with or without the presence of psychotic features. This merely places the severe forms of a Major Depressive Episode in the category of psychiatric illness (such as anorexia nervosa or gender-identity disorder) where the patient is likely to be unresponsive or resistant to the methods of talk therapy -- considering that criterion A5 of Major Depressive Disorder can extend as far as total muteness in conversation, it is not hard to imagine why in the more severe manifestations of this condition, psychotherapy is contraindicated. However, in terms of the theory and practice of psychotherapy for treatment of Major Depressive Disorder, many of the salient points are capable of being extrapolated from the observed facts of the disease, as mentioned in the diagnostic criteria and outlined in the DSM-IV-TR. These include the frequent reluctance of patients to admit or own up to certain elements of the condition, including the emotional and cognitive effects. As the DSM-IV-TR specifies, in many cases this reluctance can be ascribed to cultural factors, such as belonging to an ethnicity in which mental disorders overall are downplayed or ascribed to physical symptoms, leading the patient to describe the condition purely in terms of physical symptoms. The practitioner, however, is generally able to identify the actual symptoms through interview, or even merely by observation.

In dealing with Major Depressive Disorder through traditional psychotherapy, however, practitioners have often depended upon the psychoanalytic theory of mind first set forth by Sigmund Freud. To a certain degree, we can again see how the basic symptomatology of Major Depressive Disorder as outlined in the DSM-IV-TR gave rise to this theory of mind, and extended its use throughout clinical practice. The frequently observable unwillingness of patients to own up to certain features of their condition led the psychoanalytic model to posit that Major Depressive Disorder was caused by a phenomenon of introjection -- in other words, the Major Depressive Episode began with a redirection of more primal and aggressive feelings and energies, turning them inward and making their object the self. We can observe the workings of this model in examining, for example, a case of extreme Bereavement, which in terms of symptomatology is acknowledged to be more or less identical with Major Depressive Disorder save for the fact that it has an identifiable cause (and frequently alleviates with time, without the need for any specific clinical intervention). According to the psychoanalytic perspective, a bereaved spouse, whose husband has just died at a relatively young age, will express extreme feelings of lack of self-worth and hopelessness in part because of the loss, but what pathologizes the situation for psychoanalysts is that the excessiveness of the feeling is due to a redirection of anger at the deceased spouse -- anger which cannot be rationally directed at an absent person, and which may in fact be deemed inexpressible on some level by the patient. As a result, the goal of psychoanalysis -- in which the patient is merely encouraged to talk to the analyst, until such a point at which the patient is more or less capable of catching herself in the act of thinking irrationally -- is to unpack the aggressive impulse, or the emotion that cannot be acknowledged, concealed within the depressive ideation.