DSM-III

Diagnostic Criteria

A. Dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. The dysphoric mood is characterized by symptoms such as the following: depressed, sad, blue, hopeless, low, down in the dumps, irritable. The mood disturbance must be prominent and relatively persistent, but not necessarily the most dominant symptom, and does not include momentary shifts from one dysphoric mood to another dysphoric mood, e.g., anxiety to depression to anger, such as are seen in states of acute psychotic turmoil. (For children under six, dysphoric mood may have to be inferred from a persistently sad facial expression.)

B. At least four of the following symptoms have each been present nearly every day for a period of at least two weeks (in children under six, at least three of the first four).

  1. poor appetite or significant weight loss (when not dieting) or increased appetite or significant weight gain (in children under six, consider failure to make expected weight gains)
  2. insomnia or hypersomnia
  3. psychomotor agitation or retardation (but not merely subjective feelings of restlessness or being slowed down) (in children under six, hypoactivity)
  4. loss of interest or pleasure in usual activities, or decrease in sexual drive not limited to a period when delusional or hallucinating (in children under six, signs of apathy)
  5. loss of energy; fatigue
  6. feelings of worthlessness, self-reproach, or excessive or inappropriate guilt (either may be delusional)
  7. complaints or evidence of diminished ability to think or concentrate, such as slowed thinking, or indecisiveness not associated with marked loosening of associations or incoherence
  8. recurrent thoughts of death, suicidal ideation, wishes to be dead, or suicide attempt

C. Neither of the following dominate the clinical picture when an affective syndrome is absent (i.e., symptoms in criteria A and B above):

  1. preoccupation with a mood-incongruent delusion or hallucination (see definition below)
  2. bizarre behavior

D. Not superimposed on either Schizophrenia, Schizophreniform Disorder, or a Paranoid Disorder.

E. Not due to any Organic Mental Disorder or Uncomplicated Bereavement.

Criteria for subclassification of major depressive episode

In Remission

This category should be used when in the past the individual met the full criteria for a major depressive episode but now is essentially free of depressive symptoms or has some signs of the disorder but does not meet the full criteria.

With Psychotic Features

This category should be used when there apparently is gross impairment in reality testing, as when there are delusions or hallucinations, or depressive stupor (the individual is mute and unresponsive). When possible, specify whether the psychotic features are mood-congruent or mood-incongruent.

Mood-congruent Psychotic Features

Delusions or hallucinations whose content is entirely consistent with the themes of either personal inadequacy, guilt, disease, death, nihilism, or deserved punishment; depressive stupor (the individual is mute and unresponsive).

Mood-incongruent Psychotic Features

Delusions or hallucinations whose content does not involve themes of either personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included here are such symptoms as persecutory delusions, thought insertion, thought broadcasting, and delusions of control, whose content has no apparent relationship to any of the themes noted above.

With Melancholia

Loss of pleasure in all or almost all activities, lack of reactivity to usually pleasurable stimuli (doesn't feel much better, even temporarily, when something good happens), and at least three of the following:

  • a. distinct quality of depressed mood, i.e., the depressed mood is perceived as distinctly different from the kind of feeling experienced following the death of a loved one
  • b. the depression is regularly worse in the morning
  • c. early morning awakening (at least two hours before usual time of awakening)
  • d. marked psychomotor retardation or agitation
  • e. significant anorexia or weight loss
  • f. excessive or inappropriate guilt

Differential Diagnosis

Organic Affective Syndrome

An Organic Affective Syndrome with depression may be due to substances such as reserpine, to infectious diseases such as influenza, or to hypothyroidism. Only by excluding organic etiology can one make the diagnosis of a major depressive episode.

Dementia

Primary-Degenerative Dementia or Multi-infarct Dementia, because of the presence of disorientation, apathy, and complaints of difficulty, concentrating or or memory loss, may be difficult to distinguish from a major depressive episode occurring in the elderly. If the features suggesting a major depressive episode are at least as prominent as those suggesting Dementia, it is best to diagnosis a major depressive episode and assume that the features suggestion Dementia represent a pseudo-dementia that is a manifestation of the major depressive episode. In such cases the successful treatment of the major depressive episode often result in the disappearance of the symptoms suggesting Dementia. If the features suggesting Dementia are more prominent than the depressive features, the diagnosis should be the appropriate form of Dementia, but the presence of depressive features should be noted.

Psychological reaction to physical illness

If a psychological reaction to the functional impairment associated with a physical illness that does not involve the central nervous system causes a depression that meets the full criteria for a major depressive episode, the Major Depression should be recorded, along with the physical disorder, and the severity of the psychosocial stressor. Examples would include the psychological reaction to the amputation of a leg or to the development of a life-threatening or incapacitating illness.

Schizophrenia

In Schizophrenia there is usually considerable depressive symptomatology. If an episode of depression follows an episode of Schizophrenia and is superimposed upon the residual phase of Schizophrenia, the additional diagnosis of either Atypical Depression or Adjustment Disorder with Depressed Mood may be made, but not Major Depression. An individual with a major depressive episode may have psychotic symptoms; however, the diagnosis of Schizophrenia is made in the presence of a full depressive syndrome only if the affective symptoms follow the psychotic symptoms or are brief relative to the duration of the psychotic symptoms. An individual with Schizophrenia, Catatonic Type, may appear to be withdrawn and depressed, and it may be difficult to distinguish this condition from Major Depression with psychomotor retardation. In such instances it may be necessary to rely on features that on a statistical basis are associated differently with the two disorders. For example, the diagnosis of a major depressive episode is more likely if there is a family history of Affective Disorder, good premorbid adjustment, and a previous episode of affective disturbance from which there was complete recovery.

Schizoaffective Disorder

The diagnosis of Schizoaffective Disorder can be made whenever the clinician is unable to make a differential diagnosis between a major depressive episode and Schizophrenia.

Dysthymic and Cyclothymic Disorders

In Dysthymic and Cyclothymic Disorders there are features of the depressive syndrome, but they are not of sufficient severity and duration to meet the criteria for a major depressive episode. However, in some instances, a major depressive episode is superimposed on one of these disorders. In such cases both diagnoses should be recorded, since it is likely that after recovering from the major depressive episode, either a Dysthymic or a Cyclothymic Disorder will persist.

Chronic mental disorders

Chronic mental disorders, such as Obsessive Compulsive Disorder or Alcohol Dependence, when associated with depressive symptoms, may suggest a Major Depression. The additional diagnosis of Major Depression should be made only if the full depressive syndrome is present and persistent. In such instances both the chronic mental disorder and the superimposed Major Depression should be recorded.

Separation Anxiety Disorder

In Separation Anxiety Disorder, depressive symptoms are common, but if the full depressive syndrome is not present, only Separation Anxiety Disorder should be diagnosed. On the other hand, children with Separation Anxiety Disorder may develop a superimposed major depressive episode, in which case both diagnoses should be made.

Uncomplicated Bereavement

Uncomplicated Bereavement is distinguished from a major depressive episode and is not considered a mental disorder even when associated with the full depressive syndrome. However, if bereavement is unduly severe or prolonged, the diagnosis may be changed to Major Depression.

DSM-IV

Diagnostic Criteria

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.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

  1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feel sad or empty) or observation 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, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet 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.

Specifiers

Severity/Psychotic/Remission Specifiers

These specifiers apply to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode. If criteria are currently met for the Major Depressive Episode, it can be classified as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria are no longer met, the specifier indicates whether the episode is in partial or full remission.

Criteria

Note: Can be applied to the most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

  • Mild: Few, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.
  • Moderate: Symptoms or functional impairment between "mild" and "severe."
  • Severe Without Psychotic Features: Several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.
  • Severe With Psychotic Features: Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:
    • Mood-Congruent Psychotic Features: Delusions or hallucinations whose content is entirely consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.
    • Mood-Incongruent Psychotic Features: Delusions or hallcuinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions (not directly related to depressive themes), thought insertion, thought broadcasting, and delusions of control.
  • In Partial Remission: Symptoms of a Major Depressive Episode are present but full criteria are not met, or there is a period without any significant symptoms of a Major Depressive Episode lasting less than 2 months following the end of the Major Depressive Episode. (If the Major Depressive Episode was superimposed on Dysthymic Disorder, the diagnosis of Dysthymic Disorder alone is given once the full criteria for a Major Depressive Episode are no longer met.)
  • In Full Remission: During the past 2 months, no significant signs or symptoms of the disturbance were present.
  • Unspecified
Mild, Moderate, Severe Without Psychotic Features

Severity is judged to be mild, moderate, or severe based on the number of criteria symptoms, the severity of the symptoms, and the degree of functional disability and distress. Mild episodes are characterized by the presence of only five or six depressed symptoms and either mild disability or the capacity to function normally but with substantial and unusual effert. Episodes that are Severe Without Psychotic Features are characterized by the presence of most of the criteria symptoms and clear-cut observable disability (e.g., inability to work or care for children). Moderate episodes have a severity that is intermediate between mild and severe.

Severe With Psychotic Features

This specifier indicates the presence of either delusions or hallucinations (typically auditory). Most commonly, the content of the delusions or hallucinations is consistent with the depressive themes. Such mood-congruent psychotic features include delusions of guilt (e.g., of being responsible for illness in a loved one), delusions of deserved punishment (e.g., of being punished because of a moral transgression or some personal inadequacy), nihilistic delusions (e.g., of world or personal destruction), somatic delusions (e.g., of cancer or one's body "rotting away"), or delusions of poverty (e.g., of being bankrupt). Hallucinations, when present, are usually transient and not elaborate and may involve voices that berate the person for shortcomings or sins.

Less commonly, the content of the hallucinations or delusions has no apparent relationship to depressive themes. Such mood-incongruent psychotic features include persecutory delusions (without depressive themes that the individual deserves to be persecuted), delusions of thought insertion (i.e., one's thoughts are not one's own), delusions of thought broadcasting (i.e., others can hear one's thoughts) and delusions of control (i.e., one's actions are under outside control). These features are associated with a poorer prognosis. The clinician can indicate the nature of the psychotic features by specifying With Mood-Congruent Features or With Mood-Incongruent Features.

In Partial Remission, In Full Remission

Full Remission requires a period of at least 2 months in which there are no significant symptoms of depression. There are two ways for the episode to be In Partial Remission: 1) some symptoms of a Major Depressive Episode are still present, but full criteria are no longer met; or 2) there are no longer any significant symptoms of a Major Depressive Episode, but the period of remission has been less than 2 months. If the Major Depressive Episode has been superimposed on Dysthymic Disorder, the diagnosis of Major Depressive Disorder, In Partial Remission, is not given once the full criteria for a Major Depressive Disorder are no longer met; instead, the diagnosis is Dysthymic Disorder and Major Depressive Disorder, Prior History.

Chronic Specifier

This specifier indicates the chronic nature of a Major Depressive Episode. This specifier applies to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it is the most recent type of mood episode.

Criteria

Can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode.

Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.

Differential Diagnosis

Mood Disorder Due to a General Medical Condition

A Major Depressive Episode must be distinguished from a Mood Disorder Due to a General Medical Condition. The appropriate diagnosis would be Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condition (e.g., multiple sclerosis, stroke, hypothyroidism). This determination is based on the history, laboratory findings, or physical examination. If both a Major Depressive Episode and a general medical condition are present but it is judged that the depressive symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded (e.g., Major Depressive Disorder) and the general medical condition is recorded separately (e.g., myocardial infarction). This would be the case, for example, if the Major Depressive Episode is considered to be the psychological consequence of having the general medical condition or if there is no etiological relationship between the Major Depressive Episode and the general medi cal condition.

Substance-Induced Mood Disorder

A Substance-Induced Mood Disorder is distinguished from a Major Depressive Episode by the fact that a substance (e.g., a drug of abuse, a medication, or a toxin) is judged to be etiologically related to the mood disturbance. For example, depressed mood that occurs only in the context of withdrawal from cocaine would be diagnosed as Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal.

Dementia

In elderly persons, it is often difficult to determine whether cognitive symptoms (e.g., disorientation, apathy, difficulty concentrating, memory loss) are better accounted for by a dementia or by a Major Depressive Episode. A thorough medical evaluation and an evaluation of the onset of the disturbance, temporal sequencing of depressive and cognitive symptoms, course of illness, and treatment response are helpful in making this determination. The premorbid state of the individual may help to differentiate a Major Depressive Episode from a dementia. In a dementia, there is usually a premorbid history of declining cognitive function, whereas the individual with a Major Depressive Episode is much more likely to have a relatively normal premorbid state and abrupt cognitive decline associated with the depression.

Other Mood Episodes

Major Depressive Episodes with prominent irritable mood may be difficult to distinguish from Manic Episodes with irritable mood or from Mixed Episodes. This distinction requires a careful clinical evaluation of the presence of manic symptoms. If criteria are met for both a Manic Episode and a Major Depressive Episode (except for the 2-week duration) nearly every day for at least a 1-week period, this would constitute a Mixed Episode.

Attention-Deficit/Hyperactivity Disorder

Distractibility and low frustration tolerance can occur in both Attention-Deficit/Hyperactivity Disorder and a Major Depressive Episode; if the criteria are met for both, Attention-Deficit/Hyperactivity Disorder may be diagnosed in addition to the Mood Disorder. However, the clinician must be cautious not to overdiagnose a Major Depressive Episode in children with Attention-Deficit/Hyperactivity Disorder whose disturbance in mood is characterized by irritability rather than by sadness or loss of interest.

Adjustment Disorder and Bereavement

A Major Depressive Episode that occurs in response to a psychosocial stressor is distinguished from Adjustment Disorder With Depressed Mood by the fact that the full criteria for a Major Depressive Episode are not met in Adjustment Disorder. After the loss of a loved one, even if depressive symptoms are of sufficient duration and number to meet criteria for a Major Depressive Episode, they should be attributed to Bereavement rather than to a Major Depressive Episode, unless they persist for more than 2 months or include marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Normal sadness and Depressive Disorder Not Otherwise Specified

Periods of sadness are inherent aspects of the human experience. These periods should not be diagnosed as a Major Depressive Episode unless criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly every day for at least 2 weeks), and clinically significant distress or impairment. The diagnosis Depressive Disorder Not Otherwise Specified may be appropriate for presentations of depressed mood with clinically significant impairment that do not meet criteria for duration or severity.

DSM-5

Diagnostic Criteria

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. (Note: Do not include symptoms that are clearly attributable to another medical condition.)

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation 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).
  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 gain.)
  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, or a suicide attempt or a specific plan for committing suicide.

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

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

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