Depression. Aaron T. Beck, M.D.

mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. (2) 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 made by others). (3) 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 gains. (4) insomnia or hypersomnia nearly every day. (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). (6) fatigue or loss of energy nearly every day. (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). (9) 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 do not meet criteria for Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

      Adapted from DSM-IV-TR.

Derivation of System of Classification

      In its original development, the DSM system of classification represented a composite of the ideas of three schools of thought: those of Emil Kraepelin, Adolph Meyer, and Sigmund Freud. The division of the various nosological categories, particularly of the psychoses, reflected the original boundaries drawn by Kraepelin. The major modification in the terminology reflected the Meyerian influence. Meyer rejected the Kraepelinian concept of disease entities and formulated in its place a theory of “reaction types.” The reaction types were conceived by him to be the result of the interaction between the specific hereditary endowment and the matrix of psychological and social forces impinging on the organism. The term reaction in the nomenclature reflected the Meyerian view.

TABLE 4-2. Criteria for Manic Episode

A.	A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B.	During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
	(1) inflated self-esteem or grandiosity; (2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep); (3) more talkative than usual or pressure to keep talking; (4) flight of ideas or subjective experience that thoughts are racing; (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli); (6) increase in goal-directed activity (either socially, at work or school, or sexual or psychomotor agitation; (7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C.	The symptoms do not meet criteria for Mixed Episode.
D.	The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E.	The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). Note: Maniclike episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not be counted toward a diagnosis of Bipolar I Disorder.

      Adapted from DSM-IV-TR.

      Freud’s influence was seen in the descriptions of the specific categories in the glossary section of the original APA manual.² Here the syndromes were outlined according to the psychoanalytic theories; the various affective disorders were presented in terms of the concepts of guilt, retroflected hostility, and defense against anxiety. More recently, Jerome Wakefield has contributed some important ideas on the concept of mental disorder as harmful dysfunction.^8,9,10

TABLE 4-3. Types of Mood Disorder

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Disorder	Characterizations
Depressive Disorders
Major Depressive Disorder	One or more Major Depressive Episodes (i.e., at least 2 weeks of depressed mood or loss of interest accompanied by at least four additional symptoms of depression)
Dysthymic Disorder	At least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode
Depressive Disorder Not Otherwise Specified	Included for coding disorders with depressive features that do not meet criteria for Major Depressive Disorder, Dysthymic Disorder, Adjustment Disorder with Depressed Mood, or Adjustment Disorder with Mixed Anxiety and Depressed Mood (or depressive symptoms about which there is inadequate or contradictory information)
Bipolar Disorders
Bipolar I Disorder	One or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes
Bipolar II Disorder	One or more Major Depressive Episodes accompanied by at least one Hypomanic Episode
Cyclothymic Disorder	At least 2 years of numerous periods of Hypomanic symptoms that do not meet criteria for a Manic Episode and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode
Bipolar Disorder Not Otherwise Specified	Included for coding disorders with bipolar features that do not meet criteria for any of the specific Bipolar Disorders defined in this section (or bipolar symptoms about which there is inadequate or contradictory information)
Other Mood Disorders
Mood disorder due to a general medical condition	A prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a general medical condition