Depressed mood for most of the day, for more days than not, as
indicated either by 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.
Presence, while
depressed, of two (or more) 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.
Psychomotor
agitation or retardation nearly every day.
During the 2-year period (1 year for children or adolescents)
of the disturbance, the person has never been without the symptoms
in Criteria A and B for more than 2 months at a time.
No Major
Depressive Episode has been present during the first 2 years
of the disturbance (1 year for children and adolescents); i.e.,
the disturbance is not better accounted for by chronic Major Depressive
Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive
Episode provided there was a full remission (no significant signs
or symptoms for 2 months) before development of the Dysthymic
Disorder. In addition, after the initial 2 years (1 year in children
or adolescents) of Dysthymic Disorder, there may be superimposed
episodes of Major Depressive Disorder, in which case both diagnoses
may be given when the criteria are met for a Major
Depressive Episode.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode, and criteria have never been met for Cyclothymic
Disorder.
The disturbance
does not occur exclusively during the course of a chronic Psychotic
Disorder, such as Schizophrenia
or Delusional Disorder.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug
of abuse, a medication) or a general medical condition (e.g.,
hypothyroidism).
The symptoms cause
clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Major
Depressive Episode:
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.
Note:
Do not include symptoms that are clearly due to a general medical
condition, or mood-incongruent delusions or hallucinations.
Depressed
mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation
made by others (e.g., appears tearful). Note: In children and
adolescents, can be irritable mood.
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 made by others).
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 gains.
Insomnia
or hypersomnia nearly every day.
Psychomotor
agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed
down).
Fatigue
or loss of energy nearly every day.
Feelings
of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach
or guilt about being sick).
Diminished
ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
Recurrent
thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide.
The symptoms do not meet criteria for a Mixed Episode
The symptoms cause
clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition
(e.g., hypothyroidism).
The symptoms are
not better accounted for by Bereavement, i.e., after the loss
of a loved one, the symptoms persist for longer than 2 months
or are characterized by marked functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation.
Manic
Episode:
A distinct period of abnormally and persistently elevated, expansive,
or irritable mood, lasting at least 1 week (or any duration if
hospitalization is necessary).
During the period
of mood disturbance, three (or more) of the following symptoms
have persisted (four if the mood is only irritable) and have been
present to a significant degree:
Inflated
self-esteem or grandiosity.
Decreased
need for sleep (e.g., feels rested after only 3 hours of sleep).
More
talkative than usual or pressure to keep talking.
Insomnia
or hypersomnia nearly every day.
Psychomotor
agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed
down).
Flight
of ideas or subjective experience that thoughts are racing.
Distractibility
(i.e., attention too easily drawn to unimportant or irrelevant
external stimuli).
Increase
in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation.
Excessive
involvement in pleasurable activities that have a high potential
for painful consequences (e.g., engaging in unrestrained buying
sprees, sexual indiscretions, or foolish business investments)
The symptoms do not meet criteria for a Mixed Episode
The mood disturbance
is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with
others, or to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other treatment) or a general
medical condition (e.g., hyperthyroidism).
Mixed
Episode:
The criteria are met both for a Manic Episode and for a Major
Depressive Episode (except for duration) nearly every day during
at least a 1-week period.
The mood disturbance
is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with
others, or to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other treatment) or a general
medical condition (e.g., hyperthyroidism).
Hypomanic
Episode:
A distinct period of persistently elevated, expansive, or irritable
mood, lasting throughout at least 4 days, that is clearly different
from the usual nondepressed mood.
During the period
of mood disturbance, three (or more) of the following symptoms
have persisted (four if the mood is only irritable) and have been
present to a significant degree:
Inflated
self-esteem or grandiosity.
Decreased
need for sleep (e.g., feels rested after only 3 hours of sleep).
More
talkative than usual or pressure to keep talking.
Flight
of ideas or subjective experience that thoughts are racing.
Distractibility
(i.e., attention too easily drawn to unimportant or irrelevant
external stimuli).
Increase
in goal-directed activity (either socially, at work or school,
or sexually) or psychomotor agitation.
Excessive
involvement in pleasurable activities that have a high potential
for painful consequences (e.g., the person engages in unrestrained
buying sprees, sexual indiscretions, or foolish business investments).
The episode is associated with an unequivocal change in functioning
that is
uncharacteristic of the person
when not symptomatic.
The disturbance
in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in
social or occupational functioning, or to necessitate hospitalization,
and there are no psychotic features.
The symptoms are
not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication, or other treatment) or a general
medical condition (e.g., hyperthyroidism).
Associated
Features
Depressed
Mood
Somatic
or Sexual
Dysfunction
Guilt or Obsession
Addiction
Anxious or Fearful or Dependent
Personality
Dramatic or Erratic or Antisocial
Personality
Differential
Diagnosis
Some disorders have similar or even overlapping symptoms. The
clinician, therefore, in his diagnostic attempt has to differentiate
against the following disorders which need to be ruled out to
establish a precise diagnosis.
Psychiatric:
Manic, Mixed, or Hypomanic Episode; Mood Disorder Due to a General
Medical Condition; Substance-Induced Mood Disorder; Schizoaffective
Disorder; Schizophrenia;
Delusional Disorder; Psychotic
Disorder Not Otherwise Specified; Dementia;
Major Depressive Disorder; chronic Psychotic Disorders; coexisting
personality disturbance.
Medical:
Organic Mood Syndromes caused by: Acquired Immune Deficiency Syndrome
(AIDS), Adrenal (Cushing's or Addison's Diseases), Cancer (especially
pancreatic and other GI), Cardiopulmonary disease, Dementias
(including Alzheimer's Disease);
Epilepsy, Fahr's Syndrome, Huntington's
Disease, Hydrocephalus, Hyperaldosteronism,
Infections (including HIV and neurosyphilis), Migraines, Mononucleosis,
Multiple Sclerosis, Narcolepsy, Neoplasms,
Parathyroid Disorders (hyper- and hypo-), Parkinson's
Disease, Pneumonia (viral and bacterial), Porphyria, Postpartum,
Premenstrual Syndrome, Progressive Supranuclear Palsy, Rheumatoid
Arthritis, Sjogren's Arteritis, Sleep
Apnea, Stroke, Systemic Lupus Erythematosus, Temporal Arteritis,
Trauma, Thyroid Disorders (hypothyroid and "apathetic"
hyperthyroidism), Tuberculosis, Uremia (and other renal diseases),
Vitamin Deficiencies (B12, C, folate, niacin, thiamine), Wilson's
Disease.
Drugs:
Acetazolamine, Alphamethyldopa, Amantadine, Amphetamines, Ampicillin,
Azathioprine (AZT), 6-Azauridine, Baclofen, Beta Blockers, Bethanidine,
Bleomycin, Bromocriptine, C-Asparaginase, Carbamazepine, Choline,
Cimetidine, Clonidine, Clycloserin, Cocaine, Corticosteroids (including
ACTH), Cyproheptadine, Danazol, Digitalis, Diphenoxylate, Disulfiram,
Ethionamide, Fenfluramine, Griseofulvin, Guanethidine, Hydralazine,
Ibuprofen, Indomethacin, Lidocaine, Levodopa, Methoserpidine,
Methysergide, Metronidazole, Nalidixic Acid, Neuroleptics (butyrophenones,
phenothiazines, oxyindoles), Nitrofurantoin, Opiates, Oral Contraceptives,
Phenacetin, Phenytoin, Prazosin, Prednisone, Procainamide, Procyclidine,
Quanabenzacetate, Rescinnamine, Reserpine, Sedative/Hypnotics
(barbiturates, benzodiazepines, chloral hydrate), Streptomycin,
Sulfamethoxazole, Sulfonamides, Tetrabenazine, Tetracycline, Triamcinolone,
Trimethoprim, Veratrum, Vincristine.
