Let me be blunt. Depression, as most people know it, and suffering from Major Depressive Disorder, isn’t the same thing. There’s a magnitude of difference. One is a general feeling of sadness experienced by all, while the other is a recognized illness experienced by some.
But what exactly is Major Depressive Disorder? In this post, I begin a series that I hope will answer that question.
I’ll begin my discussion of this illness by sharing its definition as found in the Diagnostic and Statistical Manual of Mental Disorders (DSM). I’ll then share my history and explore how those definitions apply to me.
Please be aware that some of the series will be quite dry and for that, I apologize. Remember, though, that I’m doing this because it’s important to define exactly what depression is and what it is not. Far too many use the word depression loosely.
A Few Words About Me and My Experience With Depression
By way of background, I attempted suicide in 2014 and was subsequently diagnosed as suffering from Major Depressive Disorder (depression) that same year. I was then diagnosed as suffering from Bipolar II Disorder (bipolar II) in 2019. While I haven’t been diagnosed with Generalized Anxiety Disorder (anxiety), like many people who experience depression I exhibit clear signs of anxiety. I’ve no doubt that I’ve suffered from each illness since at least my early teens.
Despite this life experience, I’m not an expert on these illnesses. Far from it. I understand that even though sufferers share common symptomology, just how those symptoms are experienced varies from one individual to another. So what is true for me might not be true for someone else.
So, let’s begin our look at depression by considering the formal definition of Major Depressive Disorder.
Where Psychiatrists Begin: The DSM
When diagnosing a mental disorder North American mental health professionals refer to a standard classification system called The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. The most recent version is DSM-5. For Major Depressive Disorder, the definition provides:
A. 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 attributable to another medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) 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).
- 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 gain.)
- 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.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. (*)
The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
(*) In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “joining” the deceased, whereas in MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
This definition is like many of the definitions in the DSM, seemingly vague. Nonetheless, there are key elements that require our attention:
- impairment in functioning over the entire duration;
- a lack of a physiological or general medical cause;
- clear physical affects that are more than mood;
- the presence of five (or more) affects throughout the entire duration which must include either depressed mood or loss of interest or pleasure; and
- suicidal thoughts with or without a plan.
Please keep these in mind as we continue with this series.
In my next post, I’ll begin to interpret and apply this definition by sharing the structure of my patient interview.
I remind you that I’m not a mental health professional. I live with Major Depressive Disorder and, from time to time, I experience depressive episodes. The most severe episode resulted in a suicide attempt. It subsequently prompted my reaching out for help. My own research, the guidance and lessons shared by fellow sufferers, the compassion of therapists, and so much more, have all inspired me to share what I’ve learned with you. It’s information, not a diagnosis.
If you believe that you’re in need of help, I urge you to speak to your family doctor. If you’re experiencing suicidal thoughts SEEK HELP IMMEDIATELY BY DIALING 911 OR VISITING YOUR LOCAL HOSPITAL EMERGENCY ROOM.
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