Depression: Major Depression & Unipolar Varieties
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DSM Specifiers for Major Depression

Rashmi Nemade, Ph.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Once a diagnosis of a particular mood disorder is made, more detailed information about the person's condition can be provided in the form of "specifiers," which are additional standardized tags that can be appended to the primary diagnosis. Clinicians' careful application of diagnostic specifiers can help them narrow down which treatments may work best for a given patient. Specifiers may also be used to provide information about a person's anticipated disorder course and their prognosis (outcome). For example, the diagnosis of Major Depressive Disorder, Recurrent with Catatonic Features suggests that a person has experienced repeated Major Depressive Episodes with associated periods where they were immobile or demonstrated peculiar postures (see our discussion below). The diagnosis of Major Depressive Disorder, Recurrent, with a Seasonal Pattern provides information about a type of treatment that may be useful. Seasonal depressions are often responsive to light therapy, whereas other forms of depression may be less so. Thus, specifiers provide a means of establishing sub-categories or variations within the mood disorder diagnoses.

The following specifiers may be applied to the current or most recent Major Depressive Episode: 

  • Chronic - as mentioned previously, this specifier is used when a person meets the criteria for a Major Depressive Episode continuously for the past two years.
  • Catatonic Features - a person demonstrates one or many unusual movements and mannerisms, including: motoric immobility (periods during which they do not move) or excessive movement; extreme negativism (resisting instructions or maintaining a rigid posture against attempts to be moved); mutism (an inability to speak); posturing (taking up inappropriate or bizarre body positions and holding them for periods of time); stereotyped movements (repeating behaviors over and over); prominent grimacing; and/or the compulsive repetition of someone else's words or movements. For example, a person sitting on a park bench who seems unable to stop imitating gestures and words of passers-by might be suffering from Major Depression with catatonic features.
  • Melancholic Features - a person demonstrates one or more distinct qualities of depressed mood such as: mood that is regularly worse in the morning; early morning awakening (at least two hours before the usual time); marked psychomotor retardation (a generalized slowing of psychological and physical activity) or agitation (speeding up of physical activity); significant anorexia (loss of appetite) or unplanned weight loss; and excessive or inappropriate guilt. In addition, the person does not feel better (even temporarily), when something good happens. For example, someone's lack of excitement at being promoted might be a manifestation of Major Depression with melancholic features.
  • Atypical Features - this specifier is used for people who display the following "unusual" depressive symptoms: mood reactivity (a person's mood brightens in response to positive events); significant weight gain or increase in appetite; hypersomnia (sleeping excessively); leaden paralysis (a heavy, leaden feelings in arms or legs); and a long-standing pattern of being highly sensitive to interpersonal slights (not limited to episodes of mood disturbance) that results in significant social or occupational impairment. For example, people who seem happy to be included in office outings, but always feel excluded from inter-office jokes and rejected by their peers may be depressed with atypical features.
  • Postpartum Onset - this specifier is used if the onset of MDD occurs in close proximity (within 4 weeks) to childbirth. Common symptoms include mood fluctuations and excessive preoccupation with the infant's well-being. Obviously, it is quite normal for parents to be concerned about their new babies and their parenting skills. However, calling the pediatrician multiple times each day for weeks on end is atypical parenting behavior. Excessive worry about typical newborn behaviors, such as straining during a bowel movement, and treating these behaviors as a major medical event requiring immediate attention is also atypical. Postpartum depression can also include psychotic thinking with unshakable false beliefs (delusions). Delusional thoughts that include themes of harming the infant are particularly dangerous. For example, a mother may hallucinate that the baby or other people are telling her that she is a bad mother, hear voices that tell her to kill the baby, or think that her infant is possessed. Infanticide is most common with women who experience delusions or hallucinations; but women who are severely depressed without psychotic features have also killed their children. Once a woman has had a postpartum depressive episode with psychotic features, her risk of having a similar episode with each subsequent delivery is between 30-50%.
  • Seasonal Pattern - this specifier is used when at least two of a person's major depressive episodes occur regularly and coincide with a specific season of the year. For example, a person who has an increasingly difficult time getting out of bed and going to work every fall and winter may have a seasonal pattern of depression. This specifier is also known as Seasonal Affective Disorder (SAD) or winter depression (see our discussion of SAD below).