Depressive disorders

What are the DSM-5-TR requirements for Major depressive disorder?

5 or more of the following symptoms present during the same 2 week period.

1) Depressed mood most of the day, every day

2) diminished interest, anhedonia

3) weight loss or weight gain

4) insomnia or hypersomnia

5) Psychomotor agitation or retardation

6) Fatigue, energy loss

7) Feeling worthless, inappropriate guilt

8) Diminished concentration or indecisiveness

9) SI, with or w/out plans, with or w/out attempt, thoughts of death

What symptom is required for a diagnosis of major depressive disorder?

Either:

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).

What is the DSM-5-TR criteria for Major Depressive Disorder with anxious distress?

With anxious distress: Anxious distress is defined as the presence of at least two of the following symptoms during the majority of days of the current major depressive episode (or the most recent major depressive episode if major depressive disorder is currently in partial or full remission) or current persistent depressive disorder:

1. Feeling keyed up or tense.

2. Feeling unusually restless.

3. Difficulty concentrating because of worry.

4. Fear that something awful may happen.

5. Feeling that the individual might lose control of himself or herself.

Specify current severity:

Mild: Two symptoms.

Moderate: Three symptoms.

Moderate-severe: Four or five symptoms.

Severe: Four or five symptoms and with motor agitation.

An individual diagnosed with major depressive disorder is experiencing feeling keyed up, difficulty concentrating because of worry, and fear that something awful may happen. Which severity level of anxious distress would best describe this individual's symptoms?

A) Mild

B) Moderate

C) Moderate-severe

D) Severe

Ans: B

During the majority of days of the current major depressive episode, an individual reports feeling unusually restless, difficulty concentrating because of worry, fear that something awful may happen, and feeling that they might lose control of themselves. What is the current severity level of their anxious distress?

A) Mild

B) Moderate

C) Moderate-severe

D) Severe

Ans: C

Which of the following symptoms is NOT part of the criteria for anxious distress in major depressive disorder?

A) Feeling keyed up or tense

B) Feeling unusually restless

C) Difficulty concentrating because of worry

D) Fear of social situations

Ans: D

A patient with major depressive disorder presents with feeling keyed up or tense, feeling unusually restless, difficulty concentrating because of worry, and fear that something awful may happen. Additionally, the patient exhibits motor agitation. What is the current severity level of their anxious distress?

A) Mild

B) Moderate

C) Moderate-severe

D) Severe

Ans: D

In major depressive disorder with anxious distress, motor agitation is associated with which level of severity?

A) Mild

B) Moderate

C) Moderate-severe

D) Severe

Ans: D

Mary is a 35-year-old woman who has been struggling with persistent feelings of sadness and low mood for the past several months. She finds it difficult to enjoy activities that she used to find pleasurable and has been experiencing changes in appetite and sleep patterns. Mary has also been feeling keyed up and tense lately, often worrying excessively about various aspects of her life, such as her job and relationships and has difficulty concentrating on tasks due to her worry.

Which of the following diagnosis best fits Mary's symptoms?

A) Major depressive disorder, with mixed features

B) Major depressive disorder, with anxious distress, mild

C) Major depressive disorder, with atypical features

D) Major depressive disorder, with melancholic features

Ans: B

SIGECAPS

Sleep

Interest

Guilt

Energy

Concentration

Appetite

Psychomotor disturbances

Suicide

What is the DSM-5-TR criteria for Major Depressive Disorder in children

5 or more of the following symptoms during the same 2 week period. MUST have #1 or #2

1) Depressed mood; For children & adolescents, this can also be an irritable mood

2) diminished interest, anhedonia

3) weight loss or weight gain; For children, this can be failure to achieve expected weight gain

4) insomnia or hypersomnia

5) Psychomotor agitation or retardation

6) Fatigue, energy loss

7) Feeling worthless, inappropriate guilt

8) Diminished concentration or indecisiveness

9) SI, with or w/out plans, with or w/out attempt, thoughts of death

What is the DSM-5-TR criteria for Persistent Depressive Disorder?

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.

What is the DSM-5-TR criteria for Premenstrual Dysphoric Disorder?

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

B. One (or more) of the following symptoms must be present:

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or in-creased sensitivity to rejection).

2. Marked irritability or anger or increased interpersonal conflicts.

3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).

2. Subjective difficulty in concentration.

3. Lethargy, easy fatigability, or marked lack of energy.

4. Marked change in appetite; overeating; or specific food cravings.

5. Hypersomnia or insomnia. 6. A sense of being overwhelmed or out of control.

7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," or weight gain.

Note: The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year.

Emily is a 28-year-old woman who has been experiencing significant emotional and physical changes in the week before her menstrual period for the past several months. During this time, she becomes irritable, moody, and feels extremely sad. She notices a significant loss of interest in activities she once enjoyed and struggles with feelings of hopelessness. Emily also experiences marked anxiety, feeling on edge and highly sensitive to any perceived criticism or rejection. She often finds it challenging to concentrate and experiences fatigue and low energy levels. Additionally, she has difficulty controlling her appetite, often craving certain foods and experiencing significant weight gain. Which of the following diagnoses fit Emily's symptoms?

A. Premenstrual syndrome

B. Dysmenorrhea

C. Premenstrual dysphoric disorder

D. Use of hormonal treatments

Ans: C

What is the DSM-5-TR criteria for a depressive disorder with mixed features?

At least three of the following manic/hypomanic symptoms are present during the majority of days of the current major depressive episode (or the most recent major depressive episode if major depressive disorder is currently in partial or full remis-sion): 1. Elevated, expansive mood. 2. Inflated self-esteem or grandiosity. 3. More talkative than usual or pressure to keep talking. 4. Flight of ideas or subjective experience that thoughts are racing. 5. Increase in energy or goal-directed activity (either socially, at work or school, or sexually).

6. Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual in-discretions, or foolish business investments).

7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).

What is the DSM-5-TR criteria for depressive disorder with melancholic features?

One of the following is present during the most severe period of the current major depressive episode (or the most recent major depressive episode if major depressive disorder is currently in partial or full remission):

1. Loss of pleasure in all, or almost all, activities. 2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).

B. Three (or more) of the following: 1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.

2. Depression that is regularly worse in the morning. 3. Early-morning awakening (i.e., at least 2 hours before usual awakening). 4. Marked psychomotor agitation or retardation. 5. Significant anorexia or weight loss. 6. Excessive or inappropriate guilt.

Note: The specifier "with melancholic features" is applied if these features are present at the most severe stage of the episode.

What is the DSM-5-TR criteria for depressive disorder with atypical features?

This specifier is applied when these features predominate during the majority of days of the current major depressive episode (or the most recent major depressive episode if major depressive disorder is currently in partial or full remission) or current persistent depressive disorder. A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).

B. Two (or more) of the following:

1. Significant weight gain or increase in appetite.

2. Hypersomnia.

3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).

4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment.

C. Criteria are not met for "with melancholic features" or "with catatonia" during the same episode.

What is the DSM-5-TR criteria for depressive disorder with psychotic features?

Delusions and/or hallucinations are present at any time in the current major depressive episode (or the most recent major depressive episode if major depressive disorder is currently in partial or full remission). If psychotic features are present, specify if mood-congruent or mood-incongruent:

What does mood-congruent psychotic features mean?

The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment.

What does mood-incongruent psychotic features mean?

The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes.

John, a 40-year-old who was recently diagnosed with major depressive disorder, is experiencing low mood, heightened energy, restlessness, and irritability. He denies that his depression is worse in the morning and reports it feels about the same throughout the day. He engages in impulsive behaviors, struggles with sleep, and experiences changes in appetite. He also reports feelings of worthlessness and guilt, and racing thoughts making it difficult to concentrate or make decisions.

Which of the following diagnoses fits John's symptoms?

A. Major depressive disorder with atypical features

B. Major depressive disorder with mixed features

C. Major depressive disorder with anxious distress, moderate

D. Major depressive disorder with melancholic features

Ans: B

Choice A is incorrect because John's mood does not brighten in response to an actual or potential positive event.

Choice C is incorrect because although John has feelings of restlessness and difficulty concentrating; in order to meet MDD w/ anxious distress, moderate John must meet at least 3 symptoms in the criteria for anxious distress.

Choice D is incorrect because John denies that his depression is worse in the morning.

Ann, a 35-year-old woman, has been feeling sad when she wakes up, and she hasn't wanted to do anything but stay in bed after work and on her days off for the last few months. Her daughter's birthday party was last week and she had a difficult time trying to stop herself from having crying spells. She has trouble getting back to sleep after waking up 3 hours before her alarm goes off and feels tired throughout the day. She reports that she feels worse in the mornings and her mood gets better after lunch but she still feels sad and depressed throughout the day. She reports she has had difficulty concentrating on her daily work tasks lately and has been getting in trouble with her boss over not completing assignments on time. She feels bad and like she has no value. She can't sit still and is often seen walking around, rubbing her hands, or squirming.

Which of the following diagnoses fits Ann's symptoms?

A. Major depressive disorder with atypical features

B. Major depressive disorder with mixed features

C. Major depressive disorder with anxious distress, moderate

D. Major depressive disorder with melancholic features

Ans: D

With melancholic features: A. One of the following is present throughout the most severe time of the current major depressive episode (or the most recent if the condition is in partial or complete remission):

1. Disinterest in all activities.

2. Lack of reaction to typically enjoyable stimuli (does not feel better, even momentarily, when something wonderful occurs).

B. Three or more:

1. A unique melancholy mood marked by intense sorrow, despair, and/or moroseness or empty mood.

2. Morning-worse depression.

3. Early-morning wakeup at least two hours before normal.

4. Psychomotor agitation/retardation.

5. significant anorexia/wt loss.

6. Excessive or improper guilt.

Note: "With melancholic features" is used when the episode is at its worst.

- Pleasure is almost nonexistent.

- Even highly wanted occurrences do not significantly enhance mood.

- Mood either does not improve or improves just briefly (e.g., 20%-40% of usual for minutes).

- "With melancholic features" depressive episodes have a "distinct quality" of mood that differs from nonmelancholic depressive episodes.

- Depressed moods that are more intense, longer-lasting, or unmotivated are not separate.

- Psychomotor alterations are usually noticeable.

- Melancholic traits seldom reoccur in the same person.

- They are more common in inpatients than outpatients, less prevalent in milder major depressive episodes, and more likely in psychotic patients.

Jessica, a 28-year-old stay at home mom, has felt sad and lost almost every day for the past month. Her sadness is marked by mood swings, and when something good happens or she hears good news, she sometimes feels better. Jessica's increased hunger, especially for carbs, has caused her to gain weight and make her hungry more often. She has been going to bed anywhere from 7 pm to 8 pm and waking up at 6 am, which causes her to feel overly exhausted and makes it difficult for her to get out of bed in the morning. She also has trouble staying awake and has to take many naps during the day making it difficult to think about what she needs to do for her daily household chores.

Jessica is also very sensitive to rejection or criticism from other people. Even small comments or what she thinks are slights can have a big effect on her mood. She gets upset quickly, feeling ignored, worthless, and not good enough.

Which of the following diagnoses fit's Jessica's symptoms?

A. Major depressive disorder with atypical features

B. Major depressive disorder with mixed features

C. Major depressive disorder with anxious distress, moderate

D. Major depressive disorder with melancholic features

Ans: A

In Major Depressive Disorder with Atypical Features, the presence of mood reactivity, increased appetite, weight gain, hypersomnia, and interpersonal sensitivity are key distinguishing features.

35-year-old John has been feeling intensely sad and down for the past six months. He no longer enjoys basketball and socializing with close friends. John struggles to find pleasure in anything and often feels empty and hopeless. He has problems falling asleep and wakes up multiple times during the night. He has dropped weight inadvertently due to a lack of hunger. John's fatigue makes even basic chores difficult. John often feels exhausted and lacks energy, which makes it difficult for him to complete even simple tasks and he feels worthless and guilt. He continually criticizes himself and feels like a burden to others. John's symptoms have impacted his life and relationships for a long time. Work performance has declined due to his inability to focus.

Which of the following diagnoses best fit's John's diagnosis?

A. Persistent depressive disorder

B. Adjustment disorder with depressed mood

C. Major depressive disorder

D. Disruptive mood dysregulation disorder

Ans: C

Based on this scenario, John meets the criteria for Major Depressive Disorder as he experiences depressed mood, loss of interest, sleep disturbances, appetite changes, fatigue, feelings of worthlessness and guilt, difficulty concentrating, and recurrent thoughts of death. His symptoms have persisted for an extended period and significantly impact his functioning and well-being.

George, 45, has been suffering from chronic low mood for the last five years, leading him to battle with emotions of despair, hopelessness, and a lack of enthusiasm in life. His energy levels are frequently low, making everyday tasks tough for him. His self-esteem is poor, and he regularly criticizes himself, feeling that he is unworthy of pleasure or success. Because of his low self-perception, he avoids social relationships out of fear of rejection and criticism. Even on comparatively good days, he finds it difficult to feel joy or excitement. George also has problems with his appetite which has led to a 15 lb weight loss. His has difficulty sleeping at night, which typically results in fatigue and difficulty concentrating while a work.

Which of the following diagnoses best fits George's symptoms?

A. Persistent depressive disorder

B. Adjustment disorder with depressed mood

C. Major depressive disorder

D. Disruptive mood dysregulation disorder

Ans: A

Based on this scenario, George meets the criteria for Persistent Depressive Disorder as he has experienced a chronically low mood for the past five years, with periods of temporary relief but never a complete absence of depressive symptoms. He exhibits low energy, low self-esteem, difficulty concentrating, and feelings of hopelessness. His symptoms have caused significant distress and impairment in his daily life.

Jake, a 32-year-old man, experienced a significant life change when he was laid off from his job due to company downsizing. He has been experiencing a persistent sense of sadness and hopelessness since the layoff. Jake struggles to engage in his usual activities and has lost interest in things he used to enjoy. Jake constantly ruminates on the unfairness of losing his job and the fear of finding another one.

Sleep patterns have also changed, with Jake struggling with falling asleep and often waking up early in the morning, feeling restless and unable to sleep. He struggles to maintain a healthy eating routine and often has to force himself to eat even small meals. This leads to fatigue and lack of energy for daily tasks.

Which of the following diagnoses best fits Jake's symptoms?

A. Persistent depressive disorder

B. Adjustment disorder with depressed mood

C. Major depressive disorder

D. Disruptive mood dysregulation disorder

Ans: B

Based on this scenario, Jake meets the criteria for Adjustment Disorder with Depressed Mood. His depressive symptoms, such as persistent sadness, loss of interest, negative thoughts, changes in sleep and appetite, and feelings of hopelessness, have emerged in response to the stressor of losing his job. These symptoms have persisted for more than two weeks and have caused significant distress and impairment in his daily life.

Ariana, a 8-year-old girl, has been irritable and has frequent angry outburst for the past year and a half. Her parents say she is often annoyed by little things. Her mood is irritable at least three times a week, even in situations that would not ordinarily cause such a strong emotional response. Her parents and teachers report she has trouble managing her emotions and overreacts to minor frustrations. Ariana is always grumpy and it takes a lot to put her in a good mood. Even in ordinary situations, she complains of feeling irritated or dissatisfied. Her schoolwork has suffered due to her irritation. Her parents concerned about her behavioral troubles affecting her health, so they sought help.

Which of the following diagnoses best fits Ariana's symptoms?

A. Persistent depressive disorder

B. Adjustment disorder with depressed mood

C. Major depressive disorder

D. Disruptive mood dysregulation disorder

Ans: D

Ariana meets the criteria for Disruptive Mood Dysregulation Disorder. Her chronic irritability, frequent temper outbursts, and difficulty regulating her emotions are persistent and severe, significantly impacting her daily functioning and relationships. The symptoms have been present for more than two years, and her behavior is inconsistent with what is expected for her age.

A score of ___________ on the PHQ-9 indicates no depression to minimal depression.

0-4

A score of ___________ on the PHQ-9 indicates mild depression.

5-9

A score of ___________ on the PHQ-9 indicates moderate depression.

10-14

A score of ___________ on the PHQ-9 indicates moderately severe depression.

15-19

A score of ____________ on the PHQ-9 indicates severe depression.

20-27

A patient scores a 3 on the PHQ-9, what is the proposed treatment action?

None

A patient scores an 8 on the PHQ-9, what is the proposed treatment action?

Watchful waiting; repeat PHQ-9 at follow-up

A patient scores a 14 on the PHQ-9, what is the proposed treatment action?

Treatment plan, consider counseling, follow-up and/or pharmacotherapy

A patient scores a 16 on the PHQ-9, what is the proposed treatment action?

Active treatment with pharmacotherapy and psychotherapy

A patient scores a 27 on the PHQ-9, what is the proposed treatment action?

Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited to a mental health specialist for psychotherapy and/or collaborative management.

What is the minimum duration of the symptoms to meet criteria for major depressive disorder?

The minimum duration of the symptoms is 2 weeks to meet criteria for major

depressive disorder.

What is the minimum duration of symptoms for adults to meet criteria for persistent

depressive disorder?

The minimum duration of the symptoms is 2 weeks to meet criteria for major

depressive disorder.

What is the minimum duration of symptoms for children and adolescents to meet criteria for persistent depressive disorder?

One year is the minimum duration of symptoms for children and adolescents

to meet criteria for persistent depressive disorder.

Define early onset and late onset for persistent depressive disorder.

In persistent depressive disorder, early onset occurs before age 21 and late onset occurs at age 21 or older.

What is the fewest number of symptoms necessary for a diagnosis of persistent

depressive disorder?

At least three symptoms are necessary for a diagnosis of persistent depressive

disorder.

In disruptive mood dysregulation disorder, onset must be before what age in a

child?

Onset of disruptive mood dysregulation disorder must be before age 10 years.

How frequent must temper outbursts be to meet criteria for disruptive mood

dysregulation disorder?

Temper outbursts must occur an average of three or more times weekly to meet criteria for disruptive mood dysregulation disorder.

How long must temper outbursts have been present to meet criteria for disruptive

mood dysregulation disorder?

Temper outbursts must have been present for at least 12 months to meet criteria

for disruptive mood dysregulation disorder.

Name the four hallmark symptoms of premenstrual dysphoric disorder; that is,

the four symptoms of which at least one must be present to meet criteria for the

diagnosis.

Mood lability, irritability, dysphoria, and anxiety are the hallmark symptoms

of premenstrual dysphoric disorder.

Describe the course of key symptoms of premenstrual dysphoric disorder during

the menstrual cycle.

In premenstrual dysphoric disorder, symptoms manifest in the final week before the onset of menses, improve after the onset of menses, and are minimal

or absent in the week postmenses.

A 56 year old woman is seen by the psychiatric nurse practitioner in the outpatient clinic because she reports that she is "not able to function". She reports feeling rejected all of the time with a depressed mood. She also complains of lack of appetite and a feeling of heaviness in her arms and legs. She reports sleeping up to 15 hours a day for the past three weeks and not feeling rested when she awakens. The most appropriate diagnosis is:

A. Dysthymia

B. Generalized anxiety disorder

C. Borderline personality disorder

D. Major depressive disorder with atypical features

Ans: D

Major depression is characterized by which of the following?

A. Mania

B. Anhedonia or sadness

C. Significant impairment lasting four weeks or more

D. Hallucinations and delusions

Ans: B

A 35-year-old female has just been diagnosed with major depressive disorder. For the past eight months, she has suffered from depressed mood, decreased energy and concentration, and anhedonia. Although she has never attempted suicide, she acknowledges that she would probably jump off of a local bridge if she ever had a chance. She denies a history of excessively elevated moods. You decide to start her on antidepressant therapy. Two weeks later this patient is at greatest risk for:

A. Suicide completion

B. Medication non-compliance

C. Manic episode

D. Hypomanic episode

Ans: A

Features of anhedonia may include all of the following except:

A. Reduced speech amplitude and flow

B. Paucity of spontaneous movement

C. Restlessness

D. Indecisiveness

Ans: C

A 70-year-old women presents to her psychiatric nurse practitioner's office complaining of severe sadness since the death of her husband three months ago. She reports insomnia, poor appetite, a 20 pound weight loss, anhedonia, and severe preoccupation with guilt and worthlessness. She reports that she just 'knows' that she caused her husband's death, although health care professionals have told her that he died of natural causes. She says she hears a strange voice telling her that she is evil for killing her husband. Given this history, which one of the following is her most likely diagnosis for her symptoms?

A. Brief psychotic disorder with marked stressor

B. Bereavement

C. Adjustment disorder with depressed mood

D. Major depressive episode with psychotic symptoms

Ans: D

A 32-year-old man is being treated for a severe major depression. Which of the following symptoms, if present, is one of the most accurate indicators of long-term suicidal risk?

A. Revenge fantasies

B. Presence of rage in the patient

C. Hopelessness

D. Presence of guilt

Ans: C