Diagnosis- Major Depressive Disorder
feature of Major Depressive Disorder is a clinical course that is characterized
by one or more Major Depressive Episodes (see p. 349) without a history of Manic,
Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance Induced
Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication,
or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not
count toward a diagnosis of Major Depressive Disorder. In addition, the episodes
must not be better accounted for by Schizoaffective Disorder and are not superimposed
on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic
Disorder Not Otherwise Specified (Criterion B).
The fourth digit in the
diagnostic code for Major Depressive Disorder indicates whether it is a Single
Episode (used only for first episodes) or Recurrent. It is sometimes difficult
to distinguish between a single episode with waxing and waning symptoms and two
separate episodes. For purposes of this manual, an episode is considered to have
ended when the full criteria for the Major Depressive Episode have not been met
for at least 2 consecutive months. During this 2-month period, there is either
complete resolution of symptoms or the presence of depressive symptoms that no
longer meet the full criteria for a Major Depressive Episode (In Partial Remission).
fifth digit in the diagnostic code for Major Depressive Disorder indicates the
current state of the disturbance. If the criteria for a Major Depressive Episode
are met, the severity of the episode is noted as Mild, Moderate, Severe Without
Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major
Depressive Episode are not currently met, the fifth digit is used to indicate
whether the disorder is In Partial Remission or In Full Remission (see p. 412).
Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive
Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or
hypomanic symptoms occur as a direct effect of antidepressant treatment, use of
other medications, substance use, or toxin exposure, the diagnosis of Major Depressive
Disorder remains appropriate and an additional diagnosis of Substance-Induced
Mood Disorder, With Manic Features (or With Mixed Features), should be noted.
Similarly, if manic or hypomanic symptoms occur as a direct effect of a general
medical condition, the diagnosis of Major Depressive Disorder remains appropriate
and an additional diagnosis of Mood Disorder Due to a General Medical Condition,
With Manic Features (or With Mixed Features), should be noted.
the full criteria are currently met for a Major Depressive Episode, the following
specifiers may be used to describe the current clinical status of the episode
and to describe features of the current episode:
Mild, Moderate, Severe
Without Psychotic Features, Severe With Psychotic Features (see p. 411)
(see p. 417)
With Catatonic Features (see p. 417)
With Melancholic Features
(see p. 419)
With Atypical Features (see p. 420)
With Postpartum Onset (see
If the full criteria are not currently met for a Major
Depressive Episode, the following specifiers may be used to describe the current
clinical status of the Major Depressive Disorder and to describe features of the
most recent episode:
In Partial Remission, In Full Remission (see p. 411)
(see p. 417)
With Catatonic Features (see p. 417)
With Melancholic Features
(see p. 419)
With Atypical Features (see p. 420)
With Postpartum Onset (see
The following specifiers may be used to indicate the
pattern of the episodes and the presence of interepisode symptoms for Major Depressive
Longitudinal Course Specifiers (With and Without Full
Interepisode Recovery) (see p. 424)
With Seasonal Pattern (see p. 425)
The diagnostic codes for Major Depressive Disorder are selected
1. The first three digits are 296.
2. The fourth digit is either
2 (if there is only a single Major Depressive Episode) or 3 (if there are recurrent
Major Depressive Episodes).
3. If the full criteria are currently met for a
Major Depressive Episode, the fifth digit indicates the current severity as follows:
1 for Mild severity, 2 for Moderate severity, 3 for Severe Without Psychotic Features,
4 for Severe With Psychotic Features. If the full criteria are not currently met
for a Major Depressive Episode, the fifth digit indicates the current clinical
status of the Major Depressive Disorder as follows: 5 for In Partial Remission,
6 for In Full Remission. If the severity of the current episode or the current
remission status of the disorder is unspecified, then the fifth digit is 0. Other
specifiers for Major Depressive Disorder cannot be coded.
recording the name of a diagnosis, terms should be listed in the following order:
Depressive Disorder, specifiers coded in the fourth digit (e.g., Recurrent), specifiers
coded in the fifth digit (e.g., Mild, Severe With Psychotic Features, In Partial
Remission), as many specifiers (without codes) as apply to the current or most
recent episode (e.g., With Melancholic Features, With Postpartum Onset), and as
many specifiers (without codes) as apply to the course of episodes (e.g., With
Full Interepisode Recovery); for example, 296.32 Major Depressive Disorder, Recurrent,
Moderate, With Atypical Features, With Seasonal Pattern, With Full Interepisode
Associated Features and Disorders
features and mental disorders. Major Depressive Disorder is associated with high
mortality. Up to 15% of individuals with severe Major Depressive Disorder die
by suicide. Epidemiological evidence also suggests that there is a fourfold increase
in death rates in individuals with Major Depressive Disorder who are over age
55 years. Individuals with Major Depressive Disorder admitted to nursing homes
may have a markedly increased likeithood of death in the first year. Among individuals
seen in general medical settings, those with Major Depressive Disorder have more
pain and physical illness and decreased physical, social, and role functioning.
Depressive Disorder may be preceded by Dysthymic Disorder (10% in epidemiological
samples and 15%-25% in clinical samples). It is also estimated that each year
approximately 10% of individuals with Dysthymic Disorder alone will go on to have
a first Major Depressive Episode. Other mental disorders frequently co-occur with
Major Depressive Disorder (e.g., Substance-Related Disorders, Panic Disorder,
Obsessive-Compulsive Disorder, Anorexia Nervosa, Bulimia Nervosa, Borderline Personality
Associated laboratory findings. The laboratory
abnormalities that are associated with Major Depressive Disorder are those associated
with Major Depressive Episode (see p. 352). None of these findings are diagnostic
of Major Depressive Disorder, but they have been noted to be abnormal in groups
of individuals with Major Depressive Disorder compared with control subjects.
Neurobiological disturbances such as elevated glucocorticoid levels and EEG sleep
alterations are more prevalent among individuals with Psychotic Features and those
with more severe episodes or with Melancholic Features. Most laboratory abnormalities
are state dependent (i.e., are present only when depressive symptoms are present).
However, evidence suggests that some sleep EEC abnormalities persist into clinical
remission or may precede the onset of the Major Depressive Episode.
physical examination findings and general medical conditions. Individuals
with chronic or severe general medical conditions are at increased risk to develop
Major Depressive Disorder. Up to 20%-25% of individuals with certain general medical
conditions (e.g., diabetes, myocardial infarction, carcinomas, stroke) will develop
Major Depressive Disorder during the course of their general medical condition.
The management of the general medical condition is more complex and the prognosis
is less favorable if Major Depressive Disorder is present. In addition, the prognosis
of Major Depressive Disorder is adversely affected (e.g., longer episodes or poorer
responses to treatment) by concomitant chronic general medical conditions.
American Psychological Association, "Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision", American Psychiatric Association:
matter how hard I try, my boss will never be satisfied with my work."
no use. If I tell my spouse how I feel, we'll only end up in an argument."
just know I'm going to say something stupid and embarrass myself."
can't do that. I don't have what it takes."
These are just a few examples
of the final type of unproductive thinking that often plagues DD sufferers. When
you anticipate or predict the future you may:
Expect the worst.
Whether you are about to interview for a job, give a speech, go to a party, or
ask a friend to do you a favor, you conjure up worst-case scenarios, imagining
everything that could possibly go wrong and often dwelling on the most anxiety-provoking
item on your list. Joel did this whenever he thought about approaching attractive
women at social gatherings. They would turn away from him as if he were invisible,
he thought. Judy did this before her co-worker's birthday party, picturing herself
"standing alone in the corner like some stupid wallflower."
the impossible. The flip side of expecting the worst, conjuring up best possible
fantasies also takes an emotional toll on you. Imagining that your new job will
be absolutely perfect, assuming that you and your lover will never disagree, expecting
your children to be well behaved and appreciative of everything you do for them
sets you up for disappointment. Reality rarely lives up to your grandiose ideals,
and you feel cheated. Best-case scenarios sometimes stir up as much anxiety as
their negative counterparts. For instance, while Joel was having a drink and mustering
up the courage to approach an attractive woman, he would fantasize about how terrific
it would be if she was "the real thing," the woman who was his perfect
match. He visualized their future together and, by the time he finished his drink,
had them married and living in suburbia with their two adorable kids. Suddenly
the prospect of being rejected by this woman was much more frightening. After
all, she wasn't a stranger anymore but his future wife and the mother of his children.
yourself that you "can't." Instead of tackling a task and doing it to
the best of your ability, you use your time and energy to tell yourself why you
are incapable of tackling it. This line of thinking frequently follows a "should"
(I should be able to get my paperwork done on time, but I can't get organized);
a comparison (other people enjoy these parties, but I can't think of anything
interesting to say to anybody); or a run-through of the long list of things you
feel obligated to do. Naturally, your "I can't's reinforce your sense of
inadequacy and powerlessness. They also leave you feeling overwhelmed and worried
that your entire life might be getting out of control.
three forms of anticipating and predicting the future stir up a maelstrom of unsettling
emotions and all too often become self-fulfilling prophecies. For instance, Joel
believed his prediction that attractive women would reject him and therefore did
not approach them. He could not get what he wanted and went home believing he
never would. Similarly, Judy's mind was often so preoccupied with worries about
what to say to people that she barely said anything at all. The resulting one-way
conversations made the other people uncomfortable, and they eventually drifted
away, leaving Judy to think, "See, I really am dull and boring." Whatever
it may be, the dreaded result comes to pass as predicted. You get to be right
but certainly not happy.
Likewise, anything you are convinced
you cannot do, you generally do not attempt or you leave half-finished because
you cannot do it as well as you wish you could. Your pattern of not doing leads
to getting nothing done, reinforcing your negative opinion of yourself and keeping
you down in the dumps.
"Looking at the Whole Spectrum"
Exercise. Like jumping to conclusions, when you anticipate or predict the future
you grab on to one idea and run with it. Usually settling upon the prophesized
outcome you fear most, you assume that your forecast will come true and act accordingly-more
often than not, attempting to avoid the situation that might produce the disaster
you have envisioned. As mentioned earlier, avoidance, especially when undertaken
without considering alternatives, is invariably self-defeating. It prevents you
from discovering that outcomes other than the ones you fear frequently occur and
that even if what you predicted comes to pass, it is rarely, if ever, as terrible
as you imagined it would be. What is more, you miss out on opportunities to handle
stressful situations, if not perfectly, at least adequately, which would counteract
all those self-defeating ideas about being a hopeless failure or a powerless victim.
To overcome this debilitating obstacle of beating the blues, you must learn to
look at the whole spectrum of possible outcomes, from the best to the worst, but
most important, everything in between. The following exercise will help you visualize
1. Open your notebook to a clean page. At the top
of it, write down an upcoming event that is creating anxiety or dread. If you
cannot think of a specific event, use a situation that typically prompts you to
anticipate or predict the future.
2. Divide the rest of the page into three
sections, labeling the top third Worst Cases, the bottom third Best Cases, and
the middle Everything Else.
3. Write down your catastrophic predictions in
the Worst Cases section of the page. Ask yourself what could possibly go wrong
and come up with some senarios for the event in question. Feel free to give vent
to your most ghastly fantasies.
4. Write your perfect fantasies in the Best
Cases section. Ask yourself what the best possible outcome would be. If you could
write the perfect script for the upcoming event, what would it say?
in the middle ground. Include less than optimal results that are not as catastrophic
as your worst-case scenarios, positive outcomes that are realistic rather than
fantasies, and neutral occurrences that would represent a respectable showing
although not necessarily anything spectacular.
6. Finally, rate the odds for
each outcome. Perhaps you found yourself chuckling at some of your own ideas.
When looked at realistically, both your best- and worst-case scenarios can be
amusing. Chances are that nothing you have written down thus far will ever come
to pass. Real outcomes of real situations tend to fall between the two extremes
to which you have been devoting so much of your time and energy.
of your outcomes are long shots (LS), so unlikely to occur that no experienced
gambler would bet on them? Which have even odds (EO), a 50-50 chance of coming
to pass? Which seem to be sure things (ST), the results you are most likely to
encounter? Mark each scenario with the initials that describe them.
give you an idea of what to expect from this strategy, here is a page from Joel's
Upcoming Event: Dinner meeting with Linda (a woman
Joel met after he began working as a volunteer on a congressman's reelection campaign.
She is the campaign manager and he finds her attractive.)
1. I bring flowers to let her know I'm interested in more than a working
relationship. She brings along her live-in boyfriend. (LS. She might have a boyfriend,
but she wouldn't bring him along.)
2. I drop silverware, spill the wine, drool,
and inadvertently make a snide comment about her favorite writer. She makes an
excuse to leave before dessert. (LS)
3. She tells me I'm a detriment to the
congressman's campaign and suggests that I should stay behind the scenes, perhaps
stuffing envelopes. (LS)
1. I don't do anything
to embarrass myself; Linda and I have a good time. (EO)
2. I figure out she
already has a boyfriend and feel disappointed. (EO)
3. She doesn't have a
boyfriend. I ask her out, she says no, I feel rejected and embarrassed. (EO)
She doesn't have a boyfriend. I ask her out, she says yes, I feel great. (EO)
I'm still not sure if she is interested in me socially, but I suggest that she
book my jazz group for a campaign fund-raiser and invite her to come hear us play.
She does and we get to know each other better. (EO)
6. I continue to work on
the congressman's campaign, take on more responsibility (feeling good about it).
I also make an effort to get to know Linda better and if all goes well, ask her
1. The congressman saw the position
paper I wrote and asked Linda to offer me a full-time job with a six-figure salary.
2. Linda seduces me. (LS)
3. I seduce Linda. (EO, but I probably won't
have the nerve.)
4. I get into politics, marry Linda, and with her by my side
eventually become governor. (LS)
As Joel did, you are apt to discover that
the outcomes most likely to come to pass (EOs and STs) rarely involve the horrific
consequences you have been envisioning. What actually happens may not elate you,
but it will not devastate you either. With that knowledge you may be able to move
forward in a more relaxed and confident manner. If there is still even the slightest
hint of potential discomfort attached to the event, however, you may remain paralyzed.
This generally means that you are still blowing at least one possible consequence
out of proportion and need to do a quick reality check.
problem with negative predictions goes beyond the prediction itself and often
lies in the notion that should your fear be realized, it would be catastrophic.
Even after you expand your view of the potential outcomes, this feeling that the
event will bring about consequences that cause permanent and irreversible damage
to you or your relationships may persist. In reality such catastrophes are almost
never the case, but you need not take my word for it. The next time you anticipate
disaster, ask yourself if anything that might happen will literally kill you,
truly ruin your career and all of your plans for the future, prompt your spouse
to divorce you or your family to disown you, or still be causing you pain a year
from now. If your answer is no (and 99.9 percent of the time it will be), then
it is safe to move forward. It is also more beneficial than staying where you
are-stuck on the blue mood merry-go-round.
- Hirschfeld, Robert, & Susan
Meltsner. When the Blues Won't Go Away: New Approaches to Dysthymic Disorder and
Other Forms of Chronic Low-Grade Depression., Philip Lief Group, Inc.: New York.
Personal Reflection Exercise Explanation
Goal of this Home Study Course is to create a learning experience that enhances
your clinical skills. We encourage you to discuss the Personal Reflection
Journaling Activities, found at the end of each Section, with your colleagues.
Thus, you are provided with an opportunity for a Group Discussion experience.
Case Study examples might include: family background, socio-economic status, education,
occupation, social/emotional issues, legal/financial issues, death/dying/health,
home management, parenting, etc. as you deem appropriate. A Case Study is to be
approximately 150 words in length. However, since the content of these Personal
Reflection Journaling Exercises is intended for your future reference, they
may contain confidential information and are to be applied as a work in
progress. You will not
be required to provide us with these Journaling Activities.
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #1
The preceding section contained information
about negative predictions. Write three case study examples regarding how you
might use the content of this section in your practice.
Online Continuing Education QUESTION
The problem with negative predictions goes beyond the prediction itself
and often lies in what? Record the letter of the correct answer the .