DSM -1V
(Diagnostic and Statistical Manual of Mental Disorders)
Melancholic depression - Major depressive episode [1]
Criteria
The criteria below are based on the formal DSM-IV criteria for a Major Depressive Episode. A diagnosis of major depressive episode requires that the patient has—over a two-week period—experienced five or more of the symptoms below, and these must be outside the patient's normal behaviour. Either depressed mood or decreased interest or pleasure must be one of the five (although both are frequently concomitant).
Mood
- How many times a week do you report a depressed mood or appear depressed to others?
- Do you state that you have been feeling sad, depressed, blue, empty hopeless, etc.?
- You appear to be on the verge of tearfulness, manifests a depressed facial expression and disposition, or appears to be overly irritable?
- Do you report physical complaints (i.e., aches, pains, headaches) rather than depressed mood? Physical symptoms without physical cause are sometimes indicators of depression?
Anhedonia and loss of interest
- Do you feel nearly every day, interest or pleasure is markedly decreased in nearly all activities?
- Do you tend to lose interest in things they once found enjoyable?
- Activities are no longer enjoyable and there is often a loss of interest in or desire for sex, right? You are in deep love with some one?
- Did you ever say to yourself, "I just don't care anymore," or "nothing matters anymore?
- Did you ever feel that " Friends and family noticed that you have withdrawn from friends, or has neglected or quit doing activities that were once a source of enjoyment?
Change in eating, appetite, or weight
- Although you do not diet, there is a marked loss or gain of weight (such as 5% in one month) or appetite is markedly decreased or increased nearly every day, right?
- Did you ever check your weight or feel conscious of weight?
- Did you ever think that you never feel hungry, can go long periods without wanting to eat or may forget to eat?
- Did you eat a small amount of food and say it is sufficient? A reduction in weight is often associated with a melancholic type of depression.
- (In the second instance, some people tend toward an increase in appetite and may gain significant amounts of weight). Did you tend to crave certain types of food such as sweets or carbohydrates? People with seasonal affective disorder (SAD) often crave foods high in carbohydrates. Weight gain is often associated with atypical depression.
Sleep
- Nearly every day you sleep excessively, (known as hypersomnia), or not enough ( known as insomnia)?
- (Insomnia is the most common type of sleep disturbance for people who are clinically depressed). Do you have difficulty falling asleep at night? (is known as "initial" insomnia;)
- Did anyone ever tell you that you are waking in the middle of the night and being unable to go back to sleep? as "middle insomnia", and; waking too early as "terminal insomnia". Insomnia is often associated with a melancholic type of depression.
- A less frequent sleeping problem is oversleeping (called "hypersomnia"). This may occur in the form of sleeping for prolonged periods at night or increased sleeping during the daytime. Even with excess sleep, you may still feel tired and sluggish during the day? Do you?
- Do you feel like sleep more in the winter? Is the seasonal affective disorder (SAD) may sleep longer during the winter months. Hypersomnia is often associated with an atypical depression.
Motor activity
- Nearly every day others can see that your activity is agitated or slow?
- {People suffering from depression may be either quite agitated (psychomotor agitation), or very lethargic} (psychomotor retardation) in their mannerisms and behavior.
- In your agitation do you find it difficult to sit still?, may pace the room, wring his/her hands, or fidget with clothes or objects. Someone with psychomotor retardation tends to move sluggishly, may move across a room very slowly, avert his/her eyes, sit slumped in a chair and speak slowly, saying little.
- In terms of diagnosis, the agitation or slowing down of one's demeanor must be to the degree that it can be observed by others.
Fatigue
- Do you nearly every day experience extreme fatigue?
- (A decrease in energy and feeling fatigued are very common symptoms for those who are clinically depressed). Do you feel tired without having engaged in any physical activity, and day-to-day tasks become difficult, including getting washed and dressed in the morning?
- You desired for sex, and had it? And it was not comfortable? You felt that you were used and not respected your satisfaction?
- You long for sex but fear of being used not attending your need, right?
Self-worth
- Do you nearly every day the patient feels worthless or inappropriately guilty? {These feelings are not just about being depressed; they may be delusional}.
- Do you think of yourself in very negative, unrealistic ways such as manifesting a preoccupation with past "failures", personalisation of trivial events?
- Do you believe that minor mistakes prove their inadequacy? They also may have an unrealistic sense of personal responsibility and see things beyond their control as being their fault. Additionally, self-loathing is common in clinical depression, and can lead to a downward spiral when combined with other symptoms.
- Can you digest defeat, nearly be passive but suffer inside, right?
Concentration
- Did you ever feel or noted by others, that nearly every day you are indecisive or has trouble thinking or concentrating?
- A person with depression frequently experiences negative and pessimistic thoughts, and reports that his/her ability to think, concentrate, or make decisions becomes impaired. Memory and distraction problems are common. This problem can be notably pronounced, causing significant difficulty in functioning for those involved in intellectually demanding activities.
Thoughts of death
- Did you ever repeated thoughts about death (other than the fear of dying), suicide (with or without a plan) or has made a suicide attempt?
- The frequency and intensity of thoughts about suicide can range from believing that friends and family would be better off if one were dead, to frequent thoughts about committing suicide (generally related to wishing to stop the emotional pain), to detailed plans about how the suicide would be carried out. Less severely suicidal people may have regular thoughts of suicide, while those who are more severely suicidal may have made specific plans and decided upon a day and location for the suicide attempt.
- Thoughts of suicide occur mostly when triggered. Thoughts of suicide happen more frequently than normal.
Diagnostic Caveats
In diagnosing the symptoms, a trained therapist must take the following into account:
- These symptoms must cause clinically important distress, or impair work, social or personal functioning, and they should not fulfil the criteria for Mixed Episode.
- The symptoms are not due to the direct physiological effects of a substance. Other than in the case of severe symptoms (severely impaired functioning, severe preoccupation with worthlessness, ideas of suicide, delusions or hallucinations or psychomotor retardation), the episode should not have begun within two months of the loss of a loved one.
- If left untreated, a typical major depressive episode may last for about six months, while about 20% of these episodes can last two years or more, with 50% of depressive episodes ending spontaneously. However, even after the major depressive episode is over, 20% to 30% of patients have residual symptoms, which can be distressing and associated with disability.[2]
- Regarding the treatment of major depressive episodes of severe intensity (multiple symptoms, minimal mood reactivity, severe functional impairment), combined psychotherapy plus antidepressant medications is more effective than psychotherapy alone.
- Estimates of the numbers of people suffering from major depressive episodes and Major Depressive Disorder (MDD) vary significantly. Between 10% and 25% of women, and between 5% and 12% of men will suffer a major depressive episode.
- Fewer people, between 5% and 9% of women and between 2% and 3% of men, will have MDD, or full-blown depression. Depression occurs nearly twice as often in adolescent and adult females as in males, and the peak period of development is between the ages of 25 and 44 years.
- Onset of major depressive episodes or MDD often occurs to people in their mid-20s, and less often to those over 65. Prepubescent girls and boys are affected equally. Additionally, socio-economic or environmental factors do not appear to have any bearing on the incidence of a major depressive episode or MDD.
DSM – IV: Psychological Treatment
Phase I
Causes
Causes we cannot presume what causes what, but mostly of:
- Diurnal Mood Variation – feel depression in the morning but continues
- Likely to have something to do with biological circadition rhythms (body clock) and inherited biological symptoms
- Twice in adolescence, peak period of development from the age 25- 44
- Often occur in mid-20’s; less often over 65’s
- It can take a bit of time to get better from it and generally the longer the delay the worse it will be.
- Treatment
- Psychotherapy (CBT)
- Antidepressant medication
Psychological treatments used by psychologists and psychiatrists may not only help a person to recover, but can also help to prevent a recurrence of depression.
Cognitive Behaviour Therapy (CBT)
- One of the most effective psychological treatments is Cognitive Behaviour Therapy (CBT). CBT is a structured program which recognises that the way people think affects the way they feel. CBT teaches people to think rationally about common difficulties, helping a person to change their thought patterns and the way they react to certain situations.
- Negative thinking interferes with recovery and makes the person more vulnerable to depression in the future. It is important to recognise unhelpful thoughts and replace them with more realistic thoughts.
- As well as helping people manage negative thoughts, CBT also involves looking at behaviour. This includes helping people find new ways of going about their everyday life. This can include the way a person may react to certain people or situations and/or how a person might plan their day.
Learning these techniques can help recovery and prevent relapse.
Interpersonal Therapy (IPT)
People with depression may sometimes be easily upset by other people's comments. They may feel criticised when no criticism was intended. IPT helps people find new ways to get along with others.
Family Therapy
Family and close friends of a depressed person need to know more about the illness because their support and understanding is very important. Family Therapy helps family members and close friends learn about depression. It helps people find new ways to support and get along with the family member or friend who has depression.
Psychodynamic psychotherapy
This form of therapy is usually long term and looks at how past experiences affect people. It focuses on the way childhood and earlier life experiences affect how the person thinks and acts now. It has been found to be particularly helpful in treatment and management of Generalised Anxiety Disorder (GAD) and phobias, particularly those first experienced in childhood.
The work
- With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you to identify your individual patterns of thoughts, emotions, bodily feelings and actions.
- Together you will look at your thoughts, feelings and behaviours to work out: if they are unrealistic or unhelpful how they affect each other, and you.
- The therapist will then help you to work out how to change unhelpful thoughts and behaviours.
- It's easy to talk about doing something, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend 'homework' - you practise these changes in your everyday life. Depending on the situation, you might start to: question a self-critical or upsetting thought and replace it with a more helpful (and more realistic) one that you have developed in CBT recognise that you are about to do something that will make you feel worse and, instead, do something more helpful.
- At each meeting you discuss how you've got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don't seem to be helping.
- They will not ask you to do things you don't want to do - you decide the pace of the treatment and what you will and won't try. The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.
- motivated
- has an internal locus of control
- has the capacity for introspection
What Is Behavioural Activation?
- Behavioural activation is another goal of CBT that aims to help patients engage more often in enjoyable activities and develop or enhance problem-solving skills.
- Inertia is a major problem for people with depression. One major symptom of depression is loss of interest in things that were once found enjoyable. A person with depression stops doing things because he or she thinks it's not worth the effort. But this only deepens the depression.
- In CBT, the therapist helps the patient schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps.
- Patients are encouraged to keep a record of the experience, noting how he or she felt and what the specific circumstances were. If it didn't go as planned, the patient is encouraged to explore why and what might be done to change it. By taking action that moves toward a positive solution and goal, the patient moves farther from the paralyzing inaction that locks him or her inside the depression.
Is There a Standard Procedure for Therapy Sessions?
Mental health professionals who practice CBT receive special training and follow a manual in their own practice. Although actual sessions may vary, they typically follow this outline:
- The session begins with a check on the patient's mood and symptoms.
- Together, the patient and therapist set an agenda for the meeting.
- Once the agenda is set, they revisit the previous session so they can bridge to the new one.
- The therapist and patient review the homework assignment and discuss problems and successes.
- Next, they turn to the issues on the agenda, which may or may not all get addressed.
- New homework is set.
- The session ends with the therapist summarizing the session and getting feedback from the patient.
A typical session lasts 50 minutes to an hour.
DSM – IV: Psychological Treatment
Phase II
Joyful
- Would you please share with me a joyful moment that has occurred in your childhood days that begins from birth to age 5? – P, R, F, C, S.
- Would you please recall and tell me a joyful moment that has made you exuberant from age 5 to 10? - P, R, F, C, S.
- Would you please share with me an unforgettable event that happened in a few minutes in any year of the ager 10 to 15? - P, R, F, C, S.
- Would you please share with me a sweetest moment that you cherished in any time of the age from 15 to 20 willingly and regretted for having gone through after some time? - P, R, F, C, S.
- Would you please share with me the joyful moment that you enjoyed between you and the other in the day or night, in the whole of last year? - P, R, F, C, S.
- You, being the best partner what were the likes of your partner in the sex? L, V, G, S, H.
- What are the places that liked most during the sex? L, V, G, S, H.
Sadness:
- Would you like to recall any saddest event that made you cry bitterly in any time of the first five years? - P, R, F, C, S.
- Can I request you to recall any worst event that made you to shed tears in any time of the years from 5 to 10? - P, R, F, C, S.
- Is it possible for me to have your sharing of any saddened story that made you to say, Shit, what is this life, let me go away form it in any time of the years 10 – 15? - P, R, F, C, S.
- Would you please be kind in sharing with me any unintentional thing or action took place between you and other and you enjoyed for that moment and regretted afterwards in the years 15- 20? - P, R, F, C, S.
- Can I request you to recall for me the unexpected or prepared action that took place between you and other one in the day or night in the whole of last year – though it remains happy moment but it gives you pain today? - P, R, F, C, S.
- What are the places of agitations during the sex? L, V, G, S, H.
- What are the places that brought tears during the perceptions - L, V, G, S, H.
DSM – IV: Psychological Treatment
Phase III
Basing on the phase II
- Joyful situation: How it just began, agreement and disagreement in gestures, touches, looks, actions, ratum et consumatum.
- Sad situation: How it just began, agreement and disagreement in gestures, touches, looks, actions, ratum et consumatum
DSM – IV: Psychological Treatment
Phase IV
Patients engage more often in enjoyable activities and develop or enhance problem-solving skills.
- Schedule enjoyable experiences, often with other people who can reinforce the enjoyment. Part of the process is looking at obstacles to taking part in that experience and deciding how to get past those obstacles by breaking the process down into smaller steps.
