If the full criteria are currently met for a Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the episode and to describe features of the current episode:
Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features
Chronic
Chronic Specifier for a Major Depressive Episode
Introduction
This specifier indicates the chronic nature of a Major Depressive Episode (i.e., that full criteria for a Major Depressive Episode have been continuously met for at least 2 years). This specifier applies to the current (or, if the full criteria are not currently met for a Major Depressive Episode, to the most recent) Major Depressive Episode in Major Depressive Disorder and to the current (or most recent) Major Depressive Episode in Bipolar I or Bipolar II Disorder only if it is the most recent type of mood episode.
Criteria for Chronic Specifier
With Catatonic Features
Catatonic Features Specifier
Introduction
The specifier With Catatonic Features can be applied to the current Major Depressive, Manic, or Mixed Episode in Major Depressive Disorder, Bipolar I Disorder, or Bipolar II Disorder. If full criteria are no longer met for a mood episode, the specifier applies to the most recent mood episode. The specifier With Catatonic Features is appropriate when the clinical picture is characterized by marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism, peculiarities of voluntary movement, echolalia, or echopraxia. Motoric immobility may be manifested by catalepsy (waxy flexibility) or stupor. The excessive motor activity is apparently purposeless and is not influenced by external stimuli. There may be extreme negativism that is manifested by the maintenance of a rigid posture against attempts to be moved or resistance to all instructions. Peculiarities of voluntary movement are manifested by the assumption of inappropriate or bizarre postures or by prominent grimacing. Echolalia (the pathological, parrotlike, and apparently senseless repetition of a word or phrase just spoken by another person) and echopraxia (the repetitive imitation of the movements of another person) are often present. Additional features may include stereotypies, mannerisms, and automatic obedience or mimicry. During severe catatonic stupor or excitement, the person may need careful supervision to avoid self-harm or harm to others. Potential consequences include malnutrition, exhaustion, hyperpyrexia, or self-inflicted injury.
Catatonic states have been found to occur in 5%-9% of inpatients. Among inpatients with catatonia, 25%-50% of cases occur in association with Mood Disorders, 10%-15% of cases occur in association with Schizophrenia (see Schizophrenia, Catatonic Type), and the remainder occur in association with other mental disorders (e.g., Obsessive-Compulsive Disorder, Personality Disorders, and Dissociative Disorders). It is important to note that catatonia can also occur in a wide variety of general medical conditions including, but not limited to, those due to infectious, metabolic, neurological conditions (see Catatonic Disorder Due to a General Medical Condition), or can be due to a side effect of a medication (e.g., a Medication-Induced Movement Disorder). Because of the seriousness of the complications, particular attention should be paid to the possibility that the catatonia is due to Neuroleptic Malignant Syndrome
Specify if:
Chronic (can be applied to the current or most recent Major Depressive Episode in Major Depressive Disorder and to a Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode)
Full criteria for a Major Depressive Episode have been met continuously for at least the past 2 years.
With Melancholic Features
Melancholic Features Specifier
Introduction
The specifier With Melancholic Features can be applied to the current (or, if the full criteria are not currently met for a Major Depressive Episode, to the most recent) Major Depressive Episode in Major Depressive Disorder and to the current (or most recent) Major Depressive Episode in Bipolar I or II Disorder only if it is the most recent type of mood episode. The essential feature of a Major Depressive Episode, With Melancholic Features, is loss of interest or pleasure in all, or almost all, activities or a lack of reactivity to usually pleasurable stimuli. The individual’s depressed mood does not improve, even temporarily, when something good happens (Criterion A). In addition, at least three of the following symptoms are present: a distinct quality of the depressed mood, depression that is regularly worse in the morning, early morning awakening, psychomotor retardation or agitation, significant anorexia or weight loss, or excessive or inappropriate guilt (Criterion B).
The specifier With Melancholic Features is applied if these features are present at the nadir of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reactivity of mood is that, even for very desired events, the depressed mood does not brighten at all or brightens only partially (e.g., up to 20%-40% of normal for only minutes at a time). The distinct quality of mood that is characteristic of the With Melancholic Features specifier is experienced by individuals as qualitatively different from the sadness experienced during bereavement or a nonmelancholic depressive episode. This may be elicited by asking the person to compare the quality of the current depressed mood with the mood experienced after the death of a loved one. A depressed mood that is described as merely more severe, longer-lasting, or present without a reason is not considered distinct in quality. Psychomotor changes are nearly always present and are observable by others. Individuals with melancholic features are less likely to have a premorbid Personality Disorder, to have a clear precipitant to the episode, and to respond to a trial of placebo medication. One consequence of a lower probability of response to placebo is a greater need for active antidepressant treatment.
These features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients, and are less likely to occur in milder than in more severe Major Depressive Episodes and are more likely to occur in those with psychotic features. Melancholic features are more frequently associated with laboratory findings of dexamethasone nonsuppression; elevated cortisol concentrations in plasma, urine, and saliva; alterations of sleep EEG profiles; abnormal tyramine challenge test; and an abnormal asymmetry on dichotic listening tasks.
With Atypical Features
With Postpartum Onset
If the full criteria are not currently met for a Major Depressive Episode, the following specifiers may be used to describe the current clinical status of the Major Depressive Disorder and to describe features of the most recent episode:
In Partial Remission, In Full Remission
Chronic
With Catatonic Features
With Melancholic Features
With Atypical Features
With Postpartum Onset
The following specifiers may be used to indicate the pattern of the episodes and the presence of interepisode symptoms for Major Depressive Disorder, Recurrent:
Longitudinal Course Specifiers (With and Without Full Interepisode Recovery)
With Seasonal Pattern