Lesson 14

Depressive Disorders

Topic 63-69

Topic 63

Whenever we feel particularly unhappy, we are likely to describe ourselves as “depressed.” In all
likelihood, we are merely responding to sad events, fatigue, or unhappy thoughts. All of us
experience dejection from time to time, but only some experience a depressive disorder.
Depressive disorders bring severe and long-lasting psychological pain that may intensify as time
goes by. Those who suffer from such disorders may lose their will to carry out the simplest of
life’s activities; some even lose their will to live. Earlier known as mood/affective disorders and
mood disorders, depressive disorders are a wide range of disorders. Following disorders come
under umbrella of depressive disorders:

1. Disruptive Mood Dysregulation Disorder

2. Major Depressive Disorder
3. Persistent Depressive Disorders (Dysthymia)
4. Substance/Medication-Induced Depressive Disorders
5. Depressive Disorder Due to Another Medical Condition
6. Other Specified Depressive Disorders

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder is a disorder that starts in developmental phase, and is
characterized by a persistently irritable/angry mood and recurrent temper outbursts that are out of
proportion to the situation in hand and considerably more severe than the typical reaction of
same-aged peers in children and adolescents. This disorder is diagnosed when:

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or
behaviorally (e.g., physical aggression toward people or property) that are grossly out of
proportion in intensity or duration to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
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C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly
every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual
has not had a period lasting 3 or more consecutive months without all of the symptoms in
Criteria A-D.
F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with
peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full
symptom criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly
positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and
are not better explained by another mental disorder (e.g., autism spectrum disorder,
posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder
[dysthymia]).
K. The symptoms are not attributable to the physiological effects of a substance or to an-other
medical or neurological condition.

Topic 64: Major Depressive Disorder

Major depressive disorder, also known as clinical depression, is characterized of low mood and
intense feelings of sadness for extended period of time.

Following is the diagnostic criteria of MDD:

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.

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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, 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 with out
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 to another
medical condition.

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D. The occurrence of the major depressive episode is not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified
and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are
substance-induced or are attributable to the physiological effects of another medical condition.

If five (or more) symptoms of the symptoms persist for 2-weeks period

1. At least one of the symptoms is either

• Depressed mood or
• Loss of interest or pleasure
2. Significant weight loss or weight gain
3. Insomnia or hypersomnia
4. Psychomotor agitation or retardation
5. Fatigue or loss of energy
6. Diminished ability to think or concentrate
7. Recurrent suicidal ideation

MDD will be diagnosed if the symptoms cause clinically significant distress or impairment in
different areas of functioning. The diagnosis is not attributable to the physiological effects of a
substance or to another medical condition. The symptoms are not better explained by another
mental disorder (Psychotic, Manic etc.)

Specifiers:

Course: We need to specify if it is Single episode or Recurrent episode

We also need to specify the severity on the followings with the help of different diagnostic scales
as well as clinical observation:

• Mild
• Moderate

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 • Severe
• With psychotic features
• In partial / Full remission
• Unspecified

Topic 65: Persistent Depressive Disorders (Dysthemia)

Persistent Depressive Disorders is very much like major depressive disorders but with slight
differences. As the name indicates that problems remain for the longer period of time i.e.
depressed mood present for at least 2 years. In addition to that in children and adolescents, mood
can be irritable instead of being low and duration must be at least 1 year.

Diagnostic Criteria:

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.

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E. There has never been a manic episode or a hypomanie episode, and criteria have never been
met for cyclothymic disorder.
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.

Note: Because the criteria for a major depressive episode include four symptoms that are absent
from the symptom list for persistent depressive disorder (dysthymia), a very limited number of
individuals will have depressive symptoms that have persisted longer than 2 years but will 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, they should be given a
diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive
disorder or unspecified depressive disorder is warranted.

Severity:

We also need to specify the current severity of the disorder on the following:

• Mild
• Moderate
• Severe

Topic 66: Substance/Medication-Induced Depressive Disorders

In Substance/Medication-Induced Depressive Disorders the symptoms start during or soon after

a certain substance/medication has been taken.

Following is the diagnostic criteria of Substance/Medication-Induced Depressive Disorders:

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A. A prominent and persistent disturbance in mood that predominates in the clinical picture and
is characterized by depressed mood or markedly diminished interest or pleasure in all, or
almost all, activities.
B. There is evidence from the history, physical examination, or laboratory findings of both (1)
and (2):

1. The symptoms in Criterion A developed during or soon after substance intoxication or

withdrawal or after exposure to a medication.

2. The involved substance/medication is capable of producing the symptoms in Criterion

A.

C. The disturbance is not better explained by a depressive disorder that is not

substance/medication-induced. Such evidence of an independent depressive disorder could
include the following:
The symptoms preceded the onset of the substance/medication use; the symptoms persist for
a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or
severe intoxication; or there is other evidence suggesting the existence of an independent
non-substance/medication-induced depressive disorder (e.g., a history of recurrent non
substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.

Specifiers:

While diagnosing Substance/Medication-Induced Depressive Disorders we need to specify if the

onset is during:

• intoxication
• withdrawal

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Topic 67: Depressive Disorder Due to Another Medical Condition

Depression can be caused by general medical conditions that affect the body's systems or from
long-term illnesses that cause ongoing pain. Although the symptoms are similar to those of
depressive disorders, it is important to determine if the person has a non-neuropsychiatric
medical condition.

Depressive Disorder Due to Another Medical Condition is diagnosed when there is:

A. A prominent and persistent period of depressed mood or markedly diminished interest or

pleasure in all, or almost all, activities that predominates in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder (e.g., adjustment disorder,
with depressed mood, in which the stressor is a serious medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.

Specifiers:

While diagnosing Depressive Disorder Due to Another Medical Condition, it needs to be

specified if it is:

• With depressive features

• With major depressive-like episode
• With mixed feature

Other Specified Depressive Disorders

These disorders are diagnosed when symptoms of depressive disorder that cause clinically
significant distress or impairment predominate but do not meet the full criteria for any of the
disorders in the depressive disorders diagnostic class. This category is used in situations in which

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the clinician chooses to communicate the specific reason that the presentation does not meet the
criteria for any specific depressive disorder.

Examples of presentations that can be specified using the “other specified” designation include
the following:

• Recurrent brief depression

• Short-duration depressive episode
• Depressive episode with insufficient symptoms

Topic 68: Etiology of Depressive Disorders

There are multiple factors which can be attributed to the development of depressive disorders.

Neurobiological Factors:

• Monozygotic twins (identical) and Dizygotic (fraternal) twins yield heritability. Studies
have found that there is higher concordance in Monozygotic than dizygotic twins for
developing major depressive disorder
• Genetic vulnerabilities express themselves more when there the certain environmental
factors facilitate them. These environmental such as deprived environment, abusive
surroundings or stressful situations, influence expression of genetic vulnerabilities
• Adoption studies also support the modest heritability of depressive disorder.
• There are certain neuro-chemical changes in brain. In this regard, neurotransmitters have
been studied the most in terms of their possible role in mood disorders: norepinephrine,
dopamine, and serotonin. Each of these neurotransmitters is present in many different
areas of the brain.
• Depressive disorders have also been associated with changes in many of the brain areas
involved in experiencing and regulating emotion: the subgenual anterior cingulate; the
hippocampus, and the dorsolateral prefrontal cortex.

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Social Factors:

• Those who experience stressful life events involving loss i.e. financial loss or of
significant others’, and humiliation, may develop depression.
• Diathesis–Stress Model considers both preexisting vulnerabilities (diatheses) and
stressors. We all have vulnerabilities, and this vulnerability causes us to get stressed
when faced with any stressor.
• Diatheses (preexisting vulnerabilities) could be biological, social, or psychological.
• Low social support is another very important social factor which may lessen a person’s
ability to handle stressful life events.
• Relapse of depression is more common in patients who have family members with high
expressed emotions i.e. a family member’s critical or hostile comments toward
personality and disorder related behavior of patient or emotional over involvement with
the person to trigger depression.
• Interpersonal problems can trigger the onset of depressive symptoms and vice versa.

Topic 69: Etiology of Depressive Disorders

Psychological Factors

Neuroticism is a personality trait that refers to a person who is anxiety prone. Neuroticism is a
vulnerability factor and predicts the onset of depression. Several longitudinal studies suggest that
neuroticism, a personality trait that involves the tendency to react to events with greater-than-
average negative affect, predicts the onset of depression

Cognitive Biases:

In cognitive theories, negative thoughts and beliefs are seen as major causes of depression.
Pessimistic and self-critical thoughts can torture the person with depression. According to Aron
Beck, cognitive bias is very common among patients of depression. He postulated that:

• People with depression are overly attentive to negative feedback about themselves.
• They hold biased view of others as they focus more on negative aspects filtering the
positive ones.

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 • Selective perception

Negative Triad:

Aaron Beck (1967) argued that depression is associated with a negative triad: negative views of
the self, the world, and the future. The “world” part of the depressive triad refers to the person’s
own corner of the world the situations he or she faces. For example, people might think “I cannot
possibly cope with all these demands and responsibilities” as opposed to worrying about
problems in the broader world outside of their life.

According to this model, in childhood, people with depression acquired negative schema through
experiences such as loss of a parent, the social rejection of peers, or the depressive attitude of a
parent. Schemas are different from conscious thoughts they are an underlying set of beliefs that
operate outside of a person’s awareness to shape the way a person makes sense of his or her
experiences. The negative schema is activated whenever the person encounters situations similar
to those that originally caused the schema to form. Once activated, negative schemas are
believed to cause cognitive biases, or tendencies to process information in certain negative ways.
That is, Beck suggested that people with depression might be overly attentive to negative
feedback about themselves.

Rumination

While Beck’s theory and the hopelessness model tend to focus on the nature of negative
thoughts, Susan Nolen-Hoeksema (1991) has suggested that a specific way of thinking called
rumination may increase the risk of depression. Rumination is defined as a tendency to
repetitively dwell on sad experiences and thoughts, or to chew on material again and again. The
most detrimental form of rumination may be a tendency to brood or to regretfully ponder why an
episode happened.

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