DSM Specifiers For Major Depression

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).
Comments
  • Anonymous-1

    This is true. I have been dealing with a major depressive epsiodes for about six years now. I at first believed i was going crazy, but then things got worse. I stopped eating, i grimace constantly, I cant sleep or when i do i sleep to much. Nothing seems to get me excited, I am in college now, and though i have gotten treatment, i am afraid that the symptoms will manifest themselves again. I am staritng to do somethings out of charcter. i am needing some help, but the profesionals dont seem to get it. They keep asking me, why i am depressed, what happend to make me depressed. I usually feel worse when i leave their office than i did coming in. I wont hurt myself like this agin, I cont go and live in a cave for the rest of my life. Is there a way for me to understand the major depressive disorders better.

  • Anonymous-2

    I have been experiencing depression for most of my life. Since I was a child suicide was always an option in my mind. I acted on it as a teenager and this brought on several stays in mental hospitals as well as trying several different brands of anti depressants. I have had periods in my life where I am ok and feel fine.

    Depression brought on poor decision making in my younger years and some of those decisions were life altering and continue to stress me years after. For example: marrying very young to someone who was not the best for me, having children at a young age.

    A lot of my depression stemmed from feeling a lack of love from my parents, my father specifically. I find that when I am feeling better and try to reach out to him in my adulthood and get rejected or ignored this helps onset my depression. I have decided not to contact him again.

    I have experienced poor choice in mates, retrospectively I found that some of these mates exhibited characteristics that remind me of my father. I have decided to also put a halt on searching for a mate until I can break this pattern.

    The feeling that I was not good enough has helped somehow in my career. I always have to do my best to "prove my worth" which led to promotions at work, the problem with that is that I feel overworked. The benefit is that I was able to increase my income and I am able to care for my household and children.

    I am currently taking an anti-depressant and I have found that it helps allevieate my symptoms.

    Usually, the onset of a unipolar episode with me begins with a gradual de-socialization on my part. I become more emotionally unavailable to friends, I avoid my phone.

    I know that I am in a deep depressive state when I begin to have nightmares every night and a feeling of doom develops. I found that trying to help others and reaching out helps me come out of my depression. Actively developing a grateful attitude helps. Mentally rehearsing the things that I am thankful for and take for granted helps. I also try not to lose my temper. I am ususally very patient and when feeling down I develop anxiety and impatience with other people's flaws. Being aware of this and not acting on it helps.

  • Sam Garner

    I have been depressed since I was 14 years old and I am 61 years old.

    When you suffer chronic deppression you do not exhibit good reasoning. You should avoid making major changes at all cost. If you are single and dating don't get married without a major reasoning session.

    I AM ALSO A SURVIVOR OF SUICIDE. my only child developed schizo-affectine disorder at age 14 and completed suicide December 14, 2002 age 17. My marriage ended 3 months later when my wife deserted me because she could not handle the grief. I am now divorced and live in Guam.

    I wish I could tell you somethins to cure your problem with your major depression.

    Professional treatment by a competant Psyciatrist with medication and pschotherapy with a social worker or psychologist is a large comoponent in you recovery efforts.

    I can tell you honestly, the pain never goes away completely, but you can learn to bear your cross in life and offer it up to Jesus as a part of his suffering on the Cross for us. It really works. Been there done that. One day at a time sometimes 1 hour at a time. Just force yourself to start with 1 hour of the day as a positive person. Build upon that and go out side and look at the beauty found in the natural world of which you are a part of. Then you realize we are in a wonderful beautiful place to live 1 hour ata time.

  • Worrybird

    OMG after reading the last persons entry I just had to write. I have also had a bad time with therapist, namely Psychiatrist. The first psychiatrist I saw kept asking me what was wrong, who else in my family experiences depression (no one that I am aware of) and she continued to with that depression is inherided and if no one else in my family suffers how could I. She kept getting my family facts mixed up. Most of our sessions were spent talking about her diabetes. On my last session with her she made a comment about myself that way in no way true ( an alcoholic) and I had no idea were she got this idea from. I was so frustrated and confused I started to cry and then she yelled at me for crying. Why should I be crying. I don't need this in my office, it will only stress me out more she said. All I could do was get up and walk out.

    If it was not for my insurance company I wo6/1uld never see another Psychiatrist again and would stay with the therapist, psychotherapist, I am with now but to them that is not good enough. I don't understand this but it is not up to me.

  • wes

    When i was 18 years old i took part in shock and awe {the initial invasion of iraq} by the time i was 19 i had killed my 14th person. im now alot older, and im a shut in, i dont speak to my parents anymore(the only ones who loved me) i abandoned my wife. im paranoid, and the paranoia leads to anxiety, and those two stacked up cause horrible panic attacks. almost kicked down a door because my palms were to sweaty to turn the knob.get light headed and find my self balling fists at people who talk to much. Ive seen a proffesional. And he had the audacity to tell me , all i have to do is find my way? I HAD A WAY! It was destroyeed. it left with my innocence, now all i want is clarity. What is wrong with me? if anyone knows, my email is forgottendog@aol.com

  • Dena

    This is in response to Wes (forgottendog). After reading this article and Wes' comments I realize for the first time just how Major my depression is and has been for several years. The suffering is unbearable. I have completely shut myself off from most all of the world and my friends and family. Without God in my life there would be little or no light.

    Wes, in no way can I say that I have been in your shoes, but I did serve 19 1/2 years in the military. There are, I'm sure, some things we may have in common having been part of our fighting forces and by providing safety and security for our national and the rest of the world around us. It is a huge undertaking in all the lives of our service men and women, regardless of what your job may be. We are all a part of it, and it can reek havoc in our lives.

    I know 'You Have A Way' now that is quite different from what you envisioned for yourself. You have so much to offer us. The things you have experienced cannot be learned in any other way than what you have been through. Therapists cannot do for you what I believe and know you need. Our Lord, Jesus Christ is the only one that can help you make sense of what the meaning of your life is. He knows this is a dark world, ruled by satan. God is light. He will save you from this world of darkness. Please, talk to Him and let His Holy Spirit into you heart. You will soon learn that you truly are NOT forgotten, but rather loved very much.

    Thank you for your service of protection. You will be a survivor. You had to do the hardest job anyone could be asked to do. You need to ask the Lord for forgiveness and then forgive yourself and begin a new life, a life with real purpose. Help others that have or are still wearing your shoes. Your true mission in this life is just now beginning. In our weakness we are made strong.

    For God so loved His only begotten Son, that whosoever believeth in Him shall not perish but have everlasting life. -John 3:16

    Blessings,

    Dena

  • Tina

    I really feel my life is not worth living anymore and why don't I just stop breathing that way I will be gone and nobody will have to deal with me anylonger. I am a 44 year old lesbian and please don't say it is my life style because that is only part of me I understand. I was once married to a man who I was not inlove with and we had 2 kids who I loved more then anything and when they got older I got out of the crap I had to deal with their father, thank God. I lost my daughter Sepy. 07, 2007 and she had a 3 year old daughter whom I had already had custody of. My daughter had just turned 19 on Aug. 22, 2007 and was the last time I saw her alive. I miss her and I feel I could have done something to have changed her way of life she was living at that time but I thought hey tough love was best but boy was I wrong. Now I have lost custody of my baby because of my son and his girlfriend was doing in a house where I was living with them at. I had moved out with my grandaughter before anything took place and I have proof of it but when it comes to DHR it does not matter. The blaim was all puy on me and they took my baby. Now I am going through hell to get her back. Nothing I do is good enough for anybody anymore. I tried to take my life back in 2000 and how I wish it had worked. I am with a woman now who I love but I am messing it all up. I don't feel she loves me and she says she does but I feel she don't. I feel nobody loves me or cares so what is the use of living a life that is not worth it. I hurt all the time and I have talked to my doctor but he acts like he don't care. I hurt from my neck which I have had 2 surgies and my lower back is messed up also. It is getting harder to walk and do things around the house. I have no job. I have been told to sign up for SSI but have not done that. Why should I? I know I will get turned down so why try? Why don't I fall off the face of this so called EARTH? And SOONER THE BETTER.

  • IhearMe

    Ironically I can relate to all of the fun depressive things in this article, so what do you call that? See here is where I get a little ticked. I understand that all these people posting are living in the crud we call depression, and they get it, and the docs who think they get it, only know what they know from books they've read or what they've been taught. Until they live it, they shouldn't be telling people what's what, instead they should be listening very carefully.

    I've seen spirits since a very young age, (2) to be exact. Seeing and hearing the spirits is all that's kept me from taking my own life time and time again, but yet, you tell a psychiatrist this and they amount it to "voices". Well I wouldn't want to be referred to as a voice if I died, so that's really offensive. If you tell someone it's dangerous cause you don't understand it, then some people tend to believe it(although it isn't true at all).

    Med treatments make the "so called voices" quiet down a bit, but being I don't trust another living soul cause most are liars just trying to survive themselves, I miss my spirit friends. Does that make me a danger to myself or others? No it does not, it's my way of coping with what I was dealt with in life. To shut them down would take away everything i know to be me(and it took a long time for me to figure that out), so now what?

    Yes I seclude myself from people, especially those who live in a facade and talk themselves into the fact that they are okay. We are all on this road together, and until docs can figure out that medications are just a mask for the real reason for our so called illnesses (which I call individualities), nothing is going to get better. Personally I was raped after my mother sold me to a man for a weekend trip at the age of 8, then I watched as my step father killed that guy. That still doesn't explain me calling the cops on spirit before this occurred, but I can tell you that what she did certainly did not help my situation at all, and if weren't for spirit I would have been dead after that rape. So to all the docs that want to take away the only people that have ever truly helped me, what do you say to this posting?

  • Anonymous-3

    been depressed all my life due to many facts of family. my feelings and mind set r this pain, stay in bed, no comunication, suicidal, dreams i kill my self, cant go out in public without feeling mad everybody staring at me. sets me off in fits of angry have to leave public place because of outburst and cant afford to to no doctor what next take this whole bottle of pills and tell everybody on here good bye my depression problem is now overwith

  • Person who cares.

    Dear Forgotten Dog

    After reading your story my heart went out to you and even though I do not know you personally, I do have an idea of what you are suffering from.

    Based only on the limited information you have given, it seems like that you are most likely suffering from Post Traumatic Stress Disorder (PTSD). This is a very real condition and can manifest itself in the way you have described your symptoms. You are not going mad but are having a 'normal' reaction to what were clearly 'abnormal events'. You did what you had to do to survive at the time and it is often the case that people who experience situations like you did go into survival mode and cope while in the situation. It is only later when in a safe environment that any emotions that were put on hold start to emerge. I am surprised that your therapist did not pick up these symptoms and am sorry you were let down by a person who should have known better. The sweaty palms, racing heartbeat and unexpected behaviour are all part of PTSD and it is possibl that you are having panic attacks. It is not unusual for people with PTSD to cut themselves off from people, especially for loved ones because to feel anything can be painful so avoiding any feelings such as the loving feelings normally held for those closest becomes impossible. Please don't give up because you had one bad epxerience with a therapist. There is a lot that can be done to help you get through this. I urge you to take a chance and seek out another therapist. Alternatively read up all you can about PTSD and about how to help yourself process everything you have been through. Writing about what happened can be very helpful because it takes the memories out of your head and puts them on paper. Well, its a start and only one of many things that you can do. Step one: Acknowledge that what you are going through is a very real thing. It is not just you imagining things. You can get through this and it will get better. I wish you well.