Depressive Disorder
Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms must be present for at least two weeks.
Patients may appear miserable, with tearful eyes, furrowed brows, down-turned corners of the mouth, slumped posture, poor eye contact, lack of facial expression, little body movement, and speech changes (eg, soft voice, lack of prosody, use of monosyllabic words). Appearance may be confused with Parkinson disease. In some patients, depressed mood is so deep that tears dry up; they report that they are unable to experience usual emotions and feel that the world has become colorless and lifeless.
Nutrition may be severely impaired, requiring immediate intervention.
Some depressed patients neglect personal hygiene or even their children, other loved ones, or pets.
For diagnosis of major depression, ≥ 5 of the following must have been present nearly every day during the same 2-week period, and one of them must be depressed mood or loss of interest or pleasure:
· Depressed mood most of the day
· Markedly diminished interest or pleasure in all or almost all activities for most of the day
· Significant (> 5%) weight gain or loss or decreased or increased appetite
· Insomnia (often sleep-maintenance insomnia) or hypersomnia
· Psychomotor agitation or retardation observed by others (not self-reported)
· Fatigue or loss of energy
· Feelings of worthlessness or excessive or inappropriate guilt
· Diminished ability to think or concentrate or indecisiveness
· Recurrent thoughts of death or suicide, a suicide attempt, or a specific plan for committing suicide
Depressive symptoms that persist for ≥ 2 years without remission are classified as persistent depressive disorder (PDD), a category that consolidates disorders formerly termed chronic major depressive disorder and dysthymic disorder.
Symptoms typically begin insidiously during adolescence and may persist for many years or decades. The number of symptoms often fluctuates above and below the threshold for major depressive episode.
Affected patients may be habitually gloomy, pessimistic, humorless, passive, lethargic, introverted, hypercritical of self and others, and complaining. Patients with PDD are also more likely to have underlying anxiety disorders, substance use disorders, or personality (ie, borderline personality) disorders.
For diagnosis of persistent depressive disorder, patients must have had a depressed mood for most of the day for more days than not for ≥ 2 years plus ≥ 2 of the following:
· Poor appetite or overeating
· Insomnia or hypersomnia
· Low energy or fatigue
· Low self-esteem
· Poor concentration or difficulty making decisions
· Feelings of hopelessness
Premenstrual dysphoric disorder involves mood and anxiety symptoms that are clearly related to the menstrual cycle, with onset during the premenstrual phase and a symptom-free interval after menstruation. Symptoms must be present during most menstrual cycles during the past year.
Manifestations are similar to those of premenstrual syndrome but are more severe, causing clinically significant distress and/or marked impairment of social or occupational functioning. The disorder may begin any time after menarche; it may worsen as menopause approaches but ceases after menopause. Prevalence is estimated at 2 to 6% of menstruating women in a given 12-month interval.
For diagnosis of premenstrual dysphoric disorder, patients must have ≥ 5 symptoms during the week before menstruation. Symptoms must begin to remit within a few days after onset of menses and become minimal or absent in the week after menstruation. Symptoms must include ≥ 1 of the following:
· Marked mood swings (eg, suddenly feeling sad or tearful)
· Marked irritability or anger or increased interpersonal conflicts
· Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
· Marked anxiety, tension, or an on-edge feeling
In addition, ≥ 1 of the following must be present:
· Decreased interest in usual activities
· Difficulty concentrating
· Low energy or fatigue
· Marked change in appetite, overeating, or specific food cravings
· Hypersomnia or insomnia
· Feeling overwhelmed or out of control
· Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a feeling of being bloated, and weight gain
Prolonged grief is persistent sadness following the loss of a loved one. It is distinct from depression in that the sadness relates to the specific loss rather than the more general feelings of failure associated with depression. In contrast to normal grief this condition may be highly disabling and require therapy specifically designed for prolonged grief disorder.
Prolonged grief is considered present when the grief response (typified by persistent longing or yearning and/or preoccupation with the deceased) lasts a year or longer and is persistent, pervasive, and exceeding cultural norms. It also must be accompanied by ≥ 3 of the following for the last month to a degree that causes distress or disability:
· Disbelief
· Intense emotional pain
· Feeling of identity confusion
· Avoidance of reminders of the loss
· Feelings of numbness
· Intense loneliness
· Feelings of meaninglessness
· Difficulty engaging in ongoing life
Clusters of symptoms with characteristics of a depressive disorder that do not meet the full criteria for other depressive disorders but that cause clinically significant distress or impairment of functioning are classified as other depressive (specified or unspecified) disorder.
Included are recurrent periods of dysphoria with ≥ 4 other depressive symptoms that last < 2 weeks in people who have never met criteria for another mood disorder (eg, recurrent brief depression) and depressive periods that last longer but that include insufficient symptoms for diagnosis of another depressive disorder.
Major depression and persistent depressive disorder may include one or more specifiers that describe additional manifestations during a depressive episode:
· Anxious distress: Patients feel tense and unusually restless; they have difficulty concentrating because they worry or fear that something awful may happen, or they feel that they may lose control of themselves.
· Mixed features: Patients also have ≥ 3 manic or hypomanic symptoms (eg, elevated mood, grandiosity, greater talkativeness than usual, flight of ideas, decreased sleep). Patients who have this type of depression are at increased risk of developing bipolar disorder.
· Melancholic: Patients have lost pleasure in nearly all activities or do not respond to usually pleasurable stimuli. They may be despondent and despairing, feel excessive or inappropriate guilt, or have early morning awakenings, marked psychomotor retardation or agitation, and significant anorexia or weight loss.
· Atypical: Patients' mood temporarily brightens in response to positive events (eg, a visit from children). They also have ≥ 2 of the following: overreaction to perceived criticism or rejection, feelings of leaden paralysis (a heavy or weighted-down feeling, usually in the extremities), weight gain or increased appetite, and hypersomnia.
· Psychotic: Patients have delusions and/or hallucinations. Delusions often involve having committed unpardonable sins or crimes, harboring incurable or shameful disorders, or being persecuted. Hallucinations may be auditory (eg, hearing accusatory or condemning voices) or visual. If only voices are described, careful consideration should be given to whether the voices represent true hallucinations.
· Catatonic: Patients have severe psychomotor retardation, engage in excessive purposeless activity, and/or withdraw; some patients grimace and mimic speech (echolalia) or movement (echopraxia).
· Peripartum onset: Onset is during pregnancy or in the 4 weeks after delivery. Psychotic features may be present; infanticide is often associated with psychotic episodes involving command hallucinations to kill the infant or delusions that the infant is possessed.
· Seasonal pattern: Episodes occur at a particular time of year, most often fall or winter.
Some forms of depression are slightly different, or they may develop under unique circumstances, such as:
Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-5 include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and premenstrual dysphoric disorder (PMDD).
Symptoms
Although depression may occur only once during your life, people typically have multiple episodes. During these episodes, symptoms occur most of the day, nearly every day and may include:
· Feelings of sadness, tearfulness, emptiness or hopelessness
· Angry outbursts, irritability or frustration, even over small matters
· Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports
· Sleep disturbances, including insomnia or sleeping too much
· Tiredness and lack of energy, so even small tasks take extra effort
· Reduced appetite and weight loss or increased cravings for food and weight gain
· Anxiety, agitation or restlessness
· Slowed thinking, speaking or body movements
· Feelings of worthlessness or guilt, fixating on past failures or self-blame
· Trouble thinking, concentrating, making decisions and remembering things
· Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
· Unexplained physical problems, such as back pain or headaches
For many people with depression, symptoms usually are severe enough to cause noticeable problems in day-to-day activities, such as work, school, social activities or relationships with others. Some people may feel generally miserable or unhappy without really knowing why.
Depression symptoms in children and teens
Common signs and symptoms of depression in children and teenagers are similar to those of adults, but there can be some differences.
· In younger children, symptoms of depression may include sadness, irritability, clinginess, worry, aches and pains, refusing to go to school, or being underweight.
· In teens, symptoms may include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feeling misunderstood and extremely sensitive, using recreational drugs or alcohol, eating or sleeping too much, self-harm, loss of interest in normal activities, and avoidance of social interaction.
Depression symptoms in older adults
Depression is not a normal part of growing older, and it should never be taken lightly. Unfortunately, depression often goes undiagnosed and untreated in older adults, and they may feel reluctant to seek help. Symptoms of depression may be different or less obvious in older adults, such as:
· Memory difficulties or personality changes
· Physical aches or pain
· Fatigue, loss of appetite, sleep problems or loss of interest in sex — not caused by a medical condition or medication
· Often wanting to stay at home, rather than going out to socialize or doing new things
· Suicidal thinking or feelings, especially in older men
Causes
It's not known exactly what causes depression. As with many mental disorders, a variety of factors may be involved, such as:
· Biological differences. People with depression appear to have physical changes in their brains. The significance of these changes is still uncertain, but may eventually help pinpoint causes.
· Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that likely play a role in depression. Recent research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involved in maintaining mood stability may play a significant role in depression and its treatment.
· Hormones. Changes in the body's balance of hormones may be involved in causing or triggering depression. Hormone changes can result with pregnancy and during the weeks or months after delivery (postpartum) and from thyroid problems, menopause or a number of other conditions.
· Inherited traits. Depression is more common in people whose blood relatives also have this condition. Researchers are trying to find genes that may be involved in causing depression.