The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of important updates and changes made to major depression (also known as clinical depression) and depressive disorders. This article outlines some of the major changes to these conditions, including the introduction of two new disorders: disruptive mood dysregulation disorder and premenstrual dysphoric disorder.
Dysthymia is gone, replaced with something called “persistent depressive disorder.” The new condition includes both chronic major depressive disorder and the previous dysthymic disorder. Why this change? “An inability to find scientifically meaningful differences between these two conditions led to their combination with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.”
Disruptive Mood Dysregulation Disorder
Disruptive Mood Dysregulation disorder is a new condition introduced in the DSM-5 to address symptoms that had been labeled as “childhood bipolar disorder” before the DSM-5’s publication. This new disorder can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme, out-of-control behavior.
Premenstrual Dysphoric Disorder
Premenstrual Dysphoric Disorder is now an official diagnosis in the DSM-5. It’s like the symptom criteria are similar to those in the draft revision of the DSM-5:
In most menstrual cycles during the past year, five (or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):
(1) marked affective liability (e.g., mood swings; feeling suddenly sad or teaful or increased sensitivity to rejection)
(2) marked irritability or anger or increased interpersonal conflicts
(3) markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
(4) marked anxiety, tension, feelings of being “keyed up” or “on edge”
(5) decreased interest in usual activities (e.g., work, school, friends, hobbies)
(6) subjective sense of difficulty in concentration
(7) lethargy, easy fatigability, or marked lack of energy
(8) marked change in appetite, overeating, or specific food cravings
(9) hypersomnia or insomnia
(10) a subjective sense of being overwhelmed or out of control
(11) other physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, weight gain
Major Depressive Disorder
Given that clinical depression — or as the DSM has long referred to it, major depressive disorder — is so commonly diagnosed, it would be wise to limit changes to this popular diagnosis. And so the APA has shown wisdom by not changing any of the core criteria of symptoms for major depression, nor the requisite 2 week time period needed before it can be diagnosed.
“The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier with mixed features.
“The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained,” notes the APA.
Much ado has been made about the removal of the “bereavement exclusion” from the diagnosis of major depression, but in reality, little will change for most clinicians. This exclusion was only in effect if a person presented with major depressive symptoms within the first 2 months after the death of a loved one.
This exclusion was omitted in DSM-5 for several reasons:
The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 12 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III.
Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as nonbereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as nonbereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction be-tween the symptoms characteristic of bereavement and those of a major depressive episode. Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.
The DSM-5 change allows the clinician to now exercise their professional judgment as to whether someone with symptoms of major depression and who is in grief should be diagnosed with depression. In many cases, I suspect professionals will continue to refrain from diagnosing depression if the symptoms do not warrant it — or if doing so will result in little change to the treatment options or choices of the patient.
Specifiers for Depressive Disorders
People who are suicidal remain a concern public mental health concern. A new specifier is available that helps shed light on suicidality factors in someone who is depressed. These factors include suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual.
“A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar depression,” notes the APA.
“A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making,” concludes the APA. “The with anxious distress specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.”