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==Differentiating Clinical depression from other Diseases==
==Overview==


===Anxiety===
[[Major depressive disorder]] must be differentiated from other causes of depressive symptoms.
The different types of depression and [[anxiety]] are classified separately by the DSM-IV-TR, with the exception of hypomania, which is included in the bipolar disorder category. Despite the different categories, depression and anxiety can indeed be co-occurring (occurring together), independently (without [[mood congruence]]), or [[comorbid]] (occurring together, with overlapping symptoms, and with mood congruence). In an effort to bridge the gap between the [[DSM-IV-TR]] categories and what clinicians actually encounter, experts such as Herman Van Praag of Maastricht University have proposed ideas such as anxiety/aggression-driven depression.<ref>{{cite journal | last = van Praag | first = HM | title = Can Stress Cause Depression? | journal = World J Biol Psychiatry | volume = 6 Suppl | pages = 5-22 |date=2005 | url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16166019 | doi = 10.1080/15622970510030018 <!--Retrieved from URL by DOI bot-->}}</ref>  This idea refers to an anxiety/depression spectrum for these two disorders, which differs from the mainstream perspective of discrete diagnostic categories.


Although there is no specific diagnostic category for the comorbidity of depression and anxiety in the DSM or ICD, the National Comorbidity Survey (US) reports that 58 percent of those with major depression also suffer from lifetime anxiety.  Supporting this finding, two widely accepted clinical colloquialisms include
==Differential Diagnosis==


:*Agitated depression - a state of depression that presents as anxiety and includes [[akathisia]] (heightened restlessness), suicide, insomnia (not early morning wakefulness), nonclinical (meaning "doesn't meet the standard for formal diagnosis") and nonspecific panic, and a general sense of dread.
*[[Major depressive disorder]] is characterized by one or more episodes of depressed [[mood]] or diminished interest or pleasure ([[anhedonia]]) that last at least 2 weeks and are accompanied by 4 or more of the characteristic associated symptoms (including changes in [[sleep]], [[appetite]], or activity level); energy loss and [[fatigue]]; difficulty concentrating; excessive [[guilt]] or feelings of [[worthlessness]]; [[suicidal ideation]] or behavior). <ref>{{cite book | last = LastName | first = FirstName | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association,American Psychiatric Association | location = Arlington, VA Washington, D.C | year = 2013 | isbn = 978-0-89042-554-1 }}</ref>
*Major depressive disorder must be differentiated from other causes of depressive symptoms: <ref>{{cite book | last = LastName | first = FirstName | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association,American Psychiatric Association | location = Arlington, VA Washington, D.C | year = 2013 | isbn = 978-0-89042-554-1 }}</ref> <ref>{{cite book | last = First | first = Michael | title = DSM-5 handbook of differential diagnosis | publisher = American Psychiatric Publishing, a division of American Psychiatric Association | location = Washington, DC | year = 2014 | isbn = 9781585624621 }}</ref>


:*Akathitic depression - a state of depression that presents as anxiety or suicidality and includes [[akathisia]], but does not include symptoms of panic. Some consider it a form of [[mixed state (psychiatry)|mixed state]].<ref>http://stevens_mom.tripod.com/id36.html</ref>
{| class="wikitable"
| colspan="2" align="center" style="background: #4479BA; color: #FFFFFF " |'''Differential diagnosis for Major Depressive Disorder'''
|-
| align="center" |'''Depressive disorder'''
| align="center" |'''Distinguishing feature from [[Major depressive Disorder]]'''
|-
|'''[[Bipolar I]] or [[Bipolar II disorder]]'''
|
*One or more [[manic]] or [[hypomanic]] episodes are required for diagnosis.
*If [[manic]] or [[hypomanic]] episodes have ever been present, the patient cannot be diagnosed with [[major depressive disorder]].  
*If patients with major depressive symptoms have some manic or hypomanic symptoms that are not enough for diagnosis of mania and hypomania episode (i.e. fewer symptoms or shorter duration), they are specified as "major depressive disorder with mixed features".


Even mild anxiety symptoms can have a major impact on the course of a depressive illness, and the commingling of any anxiety symptoms with the primary depression is important to consider. A pilot study by Ellen Frank et al., at the [[University of Pittsburgh]], found that depressed or bipolar patients with lifetime panic symptoms experienced significant delays in their remission.<ref>http://archpsyc.ama-assn.org/cgi/content/abstract/48/9/851</ref> These patients also had higher levels of residual impairment, or the ability to get back into the swing of things.  On a similar note, Robert Sapolsky of Stanford University argues that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically.<ref>{{cite book | first = Robert M., Ph.D. | last = Sapolsky | year = 2004 | title = Why Zebras Don't Get Ulcers | chapter =  | editor =  | pages = 291-298 | publisher = Henry Holt and Company, LLC|id = ISBN 0-8050-7369-8 }}</ref> To that point, a<ref>{{cite journal |author=Heim C., Newport D., Heit S., Graham Y., Wilcox M., Bonsall R., Miller A., Nemeroff C. |title=Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood |journal=JAMA |volume=284 |issue=5 |pages=592-7 |year=2000 |pmid=10918705}}</ref> study by Heim and Nemeroff et al., of Emory University, found that depressed and anxious women with a history of [[child abuse]] recorded higher heart rates and the [[stress hormone]] [[ACTH]] when subjected to stressful situations.
|-
|'''[[Depressive disorder due to another medical condition]]'''
|
*Diagnosis of Depressive disorder due to another medical condition requires the presence of a medical condition as the etiology of depressive symptoms.  
*In Fact, Major depressive Disorder is not diagnosed if depressive symptoms are due to the direct physiologic effects of a medical condition.  


===Hypomania===
|-
[[Hypomania]], as the name suggests, is a state of mind or behavior that is "below" (''hypo'') mania.  In other words, a person in a hypomanic state often displays behavior that has all the hallmarks of a full-blown mania (e.g., marked elevation of mood that is characterized by euphoria, overactivity, disinhibition, impulsivity, a decreased need for sleep, hypersexuality), but these symptoms, though disruptive and seemingly out of character, are not so pronounced as to be considered a diagnosably manic episode. In a psychiatric context, it is important to identify the possible presence and characteristics of manic and hypomanic episodes, since these may lead to a diagnosis of [[bipolar disorder]], which is medically treated differently from depression.
|'''[[Substance/medication-induced depressive disorder]]'''
|
*Substance/medication-induced depressive disorder is diagnosed when depressive symptoms are due to direct physiologic effects of a substance or medication.  
*In Fact, a diagnosis of Major Depressive Disorder cannot be made when depressive symptoms are due to the direct physiologic effects of a substance or medication.  


Another important point is that hypomania is a diagnostic category that includes both anxiety and depression. It often presents as a state of anxiety that occurs in the context of a clinical depression. Patients in a hypomanic state often describe a sense of extreme generalized or specific anxiety, recurring panic attacks, night terrors, guilt, and [[Agency (philosophy)|agency]] (as it pertains to [[codependence]] and counterdependence). All of this happens while they are in a state of retarded or somnolent depression. This is the type of depression in which a person is lethargic and unable to move through life. The terms retarded and somnolent are shorthand for states of depression that include lethargy, [[hypersomnia]], a lack of motivation, a collapse of ADLs (activities of daily living), and social withdrawal. This is similar to the shorthand used to describe an "agitated" or "[[akathisia|akathitic]]" depression.
|-
|'''[[Persistent depressive disorder]] ([[Dysthymia]])'''
|
*Persistent depressive disorder is characterized by a depressed mood, on most days, for at least 2 years.
*Of note, a patient can be diagnosed with both Major Depressive Disorder and Persistent Depressive Disorder if the diagnostic criteria are met for both disorders.  


In considering the hypomania-depression connection, a distinction should be made between anxiety, [[panic]], and [[Stress (medicine)|stress]]. Anxiety is a [[physiology|physiological]] state that is caused by the [[sympathetic nervous system]]. Anxiety does not need an outside influence to occur. Panic is related to the [[fight or flight|"fight or flight"]] mechanism.  It is a reaction, induced by an outside stimulus, and is a product of the [[sympathetic nervous system]] and the [[cerebral cortex]]. More plainly, panic is an anxiety state that we are thinking about. Finally, stress is a [[psychosocial]] reaction, influenced by how a person filters nonthreatening external events. This filtering is based on one's own ideas, assumptions, and expectations.
|-
|'''[[Premenestrual dysphoric disorder]]'''
|
*[[Premenstrual dysphoric disorder]] is characterized by the presence of dysphoric mood in the few days before the onset of menses that improves within a few days after the onset of menses.  
*In contrast, no temporal connection is present between the depressive symptoms in Major Depressive Disorder and the menstrual cycles.
 
|-
|'''[[Disruptive mood dysregulation disorder]]'''
|
*Disruptive mood dysregulation disorder is characterized by severe, recurrent temper outbursts (verbally and/or behaviorally). In between the outbursts, persistently irritable or angry mood, most of the day, almost every day, is present.
*In contrast, in major depressive disorder, irritability is present only during depressive episodes.
 
|-
|'''[[Schizoaffective disorder]]'''
|
*[[Schizoaffective disorder]]is characterized by major depressive episodes with concurrent active-phase symptoms of schizophrenia, AND presence of hallucinations or delusions for two or more weeks in the absence of a major mood episode, AND major depressive episodes are present for the majority of the total duration of illness.
*If psychotic symptoms are present exclusively during major depressive episodes, the diagnosis of "Major depressive disorder with psychotic features" is made.
 
|-
|'''[[Adjustment disorder with depressed mood]]'''
|
*It is characterized by depressive symptoms occurring within 3 months of an identifiable psychological stressor that last <6 months after the stressor has ended.
* Symptoms should not meet the criteria for a major depressive episode.
 
|-
|'''[[Bereavement]]'''
|
*Bereavement occurs in response to the loss of a loved one. The symptoms are generally milder than a major depressive episode. Feelings of emptiness and loss are the predominant affects in bereavement, in contrast to depressed mood and inability to experience pleasure (anhedonia) in major depressive episodes.  
*The dysphoric mood in grief usually decreases in intensity over days to weeks, occurs in wanes, and tend to be associated with thoughts and reminders of the deceased, whereas the depressed mood in major depressive episode that is more persistent and not related to particular thoughts or preoccupations.
 
|-
|'''[[Sadness]]'''
|
*Nonpathological periods of sadness are characterized by the short duration of few depressive symptoms that are not associated with significant functional impairment or distress.  
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 12:32, 24 May 2021

Clinical Depression Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Major depressive disorder must be differentiated from other causes of depressive symptoms.

Differential Diagnosis

  • Major depressive disorder is characterized by one or more episodes of depressed mood or diminished interest or pleasure (anhedonia) that last at least 2 weeks and are accompanied by 4 or more of the characteristic associated symptoms (including changes in sleep, appetite, or activity level); energy loss and fatigue; difficulty concentrating; excessive guilt or feelings of worthlessness; suicidal ideation or behavior). [1]
  • Major depressive disorder must be differentiated from other causes of depressive symptoms: [2] [3]
Differential diagnosis for Major Depressive Disorder
Depressive disorder Distinguishing feature from Major depressive Disorder
Bipolar I or Bipolar II disorder
  • One or more manic or hypomanic episodes are required for diagnosis.
  • If manic or hypomanic episodes have ever been present, the patient cannot be diagnosed with major depressive disorder.
  • If patients with major depressive symptoms have some manic or hypomanic symptoms that are not enough for diagnosis of mania and hypomania episode (i.e. fewer symptoms or shorter duration), they are specified as "major depressive disorder with mixed features".
Depressive disorder due to another medical condition
  • Diagnosis of Depressive disorder due to another medical condition requires the presence of a medical condition as the etiology of depressive symptoms.
  • In Fact, Major depressive Disorder is not diagnosed if depressive symptoms are due to the direct physiologic effects of a medical condition.
Substance/medication-induced depressive disorder
  • Substance/medication-induced depressive disorder is diagnosed when depressive symptoms are due to direct physiologic effects of a substance or medication.
  • In Fact, a diagnosis of Major Depressive Disorder cannot be made when depressive symptoms are due to the direct physiologic effects of a substance or medication.
Persistent depressive disorder (Dysthymia)
  • Persistent depressive disorder is characterized by a depressed mood, on most days, for at least 2 years.
  • Of note, a patient can be diagnosed with both Major Depressive Disorder and Persistent Depressive Disorder if the diagnostic criteria are met for both disorders.
Premenestrual dysphoric disorder
  • Premenstrual dysphoric disorder is characterized by the presence of dysphoric mood in the few days before the onset of menses that improves within a few days after the onset of menses.
  • In contrast, no temporal connection is present between the depressive symptoms in Major Depressive Disorder and the menstrual cycles.
Disruptive mood dysregulation disorder
  • Disruptive mood dysregulation disorder is characterized by severe, recurrent temper outbursts (verbally and/or behaviorally). In between the outbursts, persistently irritable or angry mood, most of the day, almost every day, is present.
  • In contrast, in major depressive disorder, irritability is present only during depressive episodes.
Schizoaffective disorder
  • Schizoaffective disorderis characterized by major depressive episodes with concurrent active-phase symptoms of schizophrenia, AND presence of hallucinations or delusions for two or more weeks in the absence of a major mood episode, AND major depressive episodes are present for the majority of the total duration of illness.
  • If psychotic symptoms are present exclusively during major depressive episodes, the diagnosis of "Major depressive disorder with psychotic features" is made.
Adjustment disorder with depressed mood
  • It is characterized by depressive symptoms occurring within 3 months of an identifiable psychological stressor that last <6 months after the stressor has ended.
  • Symptoms should not meet the criteria for a major depressive episode.
Bereavement
  • Bereavement occurs in response to the loss of a loved one. The symptoms are generally milder than a major depressive episode. Feelings of emptiness and loss are the predominant affects in bereavement, in contrast to depressed mood and inability to experience pleasure (anhedonia) in major depressive episodes.
  • The dysphoric mood in grief usually decreases in intensity over days to weeks, occurs in wanes, and tend to be associated with thoughts and reminders of the deceased, whereas the depressed mood in major depressive episode that is more persistent and not related to particular thoughts or preoccupations.
Sadness
  • Nonpathological periods of sadness are characterized by the short duration of few depressive symptoms that are not associated with significant functional impairment or distress.

References

  1. ↑ LastName, FirstName (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Arlington, VA Washington, D.C: American Psychiatric Association,American Psychiatric Association. ISBN 978-0-89042-554-1.
  2. ↑ LastName, FirstName (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Arlington, VA Washington, D.C: American Psychiatric Association,American Psychiatric Association. ISBN 978-0-89042-554-1.
  3. ↑ First, Michael (2014). DSM-5 handbook of differential diagnosis. Washington, DC: American Psychiatric Publishing, a division of American Psychiatric Association. ISBN 9781585624621.

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