A social worker is conducting an initial assessment with a 35-year-old client who reports experiencing a persistently low mood, loss of interest in hobbies, and feelings of guilt and worthlessness...

You can study the depths of the DSM as you prepare for the social work licensing exam. That may or may not help you on ASWB exam questions. But don’t skip understanding the DSM essentials. Any list of crucial diagnoses to become familiar with is going to include the depressive disorders. You know the ones. They cover persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities. Let's explore those in some depth. It's likely to pay off on the the big test. It will definitely help with the practice question included at the bottom of the post. 

Diagnoses

Major Depressive Disorder (MDD) Characterized by a persistent low mood and loss of interest or pleasure in most activities. Other symptoms may include changes in appetite or weight, sleep disturbances, fatigue, feelings of worthlessness or guilt, and difficulty concentrating. To meet the criteria for MDD, these symptoms must persist for at least two weeks.

Persistent Depressive Disorder (Dysthymia) A chronic form of depression lasting for at least two years (or one year in children and adolescents). It involves a low mood that persists most days, along with additional depressive symptoms.

Disruptive Mood Dysregulation Disorder (DMDD) Primarily used for children and adolescents who exhibit severe temper outbursts that are out of proportion to the situation. These mood disruptions must be present for at least one year.

Premenstrual Dysphoric Disorder (PMDD) PMDD is a severe form of premenstrual syndrome (PMS) characterized by severe mood disturbances, irritability, and physical symptoms in the days before menstruation.

Substance/Medication-Induced Depressive Disorder Diagnosed when the symptoms of depression are due to substance abuse or withdrawal from a substance.

Depressive Disorder Due to Another Medical Condition If depressive symptoms are primarily caused by a medical condition (e.g., a neurological disorder or hormonal imbalance), this diagnosis may be given.

Other Specified Depressive Disorder Depressive disorders that don't fit the criteria for the above diagnoses but still cause significant distress or impairment.

Unspecified Depressive Disorder Used when the symptoms of depression don't fit any of the specific categories mentioned above.

Differentials

MDD vs PDD

A key differential to be acquainted with: Major Depressive Disorder (MDD) vs. Persistent Depressive Disorder (PDD).

  • Duration:
    • MDD: Symptoms last for at least two weeks during a major depressive episode.
    • PDD: Symptoms persist for at least two years (or one year in children and adolescents).
  • Severity:
    • MDD: Involves severe symptoms during episodes.
    • PDD: Symptoms are chronic but typically milder.
  • Course:
    • MDD: Follows an episodic pattern with distinct episodes of depression.
    • PDD: Chronic and lacks distinct episodes.
  • Impairment:
    • MDD: Often leads to significant impairment in daily functioning.
    • PDD: Causes impairment but is generally less severe.

In essence, MDD involves severe, episodic depression, while PDD is a chronic, milder form of depression.

MDD vs. Bipolar D/O

Major Depressive Disorder (MDD):

  • Involves persistent low mood, loss of interest in activities, and depressive symptoms.
  • No manic or hypomanic episodes.
  • Consistent and enduring periods of depression.
  • Treatment with therapy and/or antidepressants.

Bipolar Disorder:

  • Involves both depressive episodes (similar to MDD) and manic/hypomanic episodes.
  • Mood fluctuations between extreme highs (mania or hypomania) and lows (depression).
  • Manic or hypomanic episodes with elevated mood and increased energy.
  • Treatment with mood stabilizers, other medications, and therapy.

Essential Criteria

Sometimes, it's good to have more than a general sense of a diagnosis. Some key criteria follow.

Major Depressive Disorder (MDD)

To be diagnosed with MDD, a person must exhibit the following criteria:

  • Depressed Mood: The individual must experience a persistent low mood or a markedly diminished interest or pleasure in most activities for most of the day, nearly every day, over at least a two-week period.
  • Additional Symptoms: In addition to the depressed mood, the individual must experience at least five of the following symptoms during the same two-week period. These symptoms should represent a change from the person's previous functioning and should include either a depressed mood or loss of interest/pleasure:
    • Significant weight loss or gain (without trying).
    • Insomnia or hypersomnia (excessive sleep).
    • Psychomotor agitation or retardation (observable restlessness or sluggishness).
    • Fatigue or loss of energy.
    • Feelings of worthlessness or excessive guilt.
    • Diminished ability to think or concentrate, or indecisiveness.
    • Recurrent thoughts of death, suicidal ideation, or a suicide attempt.
  • Duration and Impairment: The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.
  • Exclusion of Other Causes: The symptoms should not be due to the direct physiological effects of a substance (e.g., drugs or medications) or a general medical condition (e.g., hypothyroidism).
  • Not Better Explained: The symptoms should not be better explained by another mental disorder, such as bipolar disorder.

Premenstrual Dysphoric Disorder 

PMDD shares a lot with PMS. Don’t get tricked!

  • In most menstrual cycles, at least five of the following symptoms must be present in the final week before the onset of menstruation (the week known as the luteal phase), start to improve within a few days after the onset of menstruation, and become minimal or absent in the week post-menses:
    • Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection).
    • Marked irritability or anger or increased interpersonal conflicts.
    • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
    • Marked anxiety, tension, and/or feelings of being on edge.
    • Decreased interest in usual activities.
    • Subjective sense of difficulty in concentrating.
    • Fatigue, lack of energy.
    • Change in appetite, overeating, or specific food cravings.
    • Hypersomnia or insomnia.
    • A sense of being overwhelmed or out of control.
    • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating," or weight gain.
  • These symptoms must be severe enough to interfere with work, school, usual social activities, or relationships.
  • The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder or panic disorder, and there is evidence from the timing of the symptoms that they are associated with the menstrual cycle.
  • The symptoms are not exclusively attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition (e.g., hyperthyroidism).

Treatment options for PMDD may include lifestyle changes, psychotherapy, and medications to alleviate symptoms and improve quality of life during the premenstrual period.

Disruptive Mood Dysregulation Disorder (DMDD)

Again, typically applied to children and adolescents who exhibit severe temper outbursts that are out of proportion to the situation. Here are the criteria:

  • Severe temper outbursts that are out of proportion to the situation, occurring frequently (three or more times per week), and observable by others.
  • Mood between temper outbursts is persistently irritable or angry, observable by others and has been present for most of the day, nearly every day, and for at least 12 months (or, if the individual is younger than 6 years, most of the day, nearly every day, for at least 6 months).
  • The individual has displayed the symptoms in Criteria A and B in at least two of three settings (e.g., at home, at school, with peers) and is severe in at least one of these settings.
  • The diagnosis should not be made for the first time before age 6 years or after age 18 years.
  • By history or observation, the age at onset of Criteria A, B, and C is before 10 years.
  • There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
  • The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder).

DMDD is a relatively new diagnosis and was introduced to provide a more accurate characterization of severe temper outbursts in children and adolescents who did not fit the criteria for other mood disorders like bipolar disorder.  Treatment for DMDD may involve therapy and sometimes medication to help manage symptoms and improve functioning.

Practice Question

A social worker is conducting an initial assessment with a 35-year-old client who reports experiencing a persistently low mood, loss of interest in hobbies, and feelings of guilt and worthlessness. These symptoms have been present for the past four weeks. The client also mentions difficulty concentrating and feeling physically fatigued. Which of the following is the most likely diagnosis based on the information provided?

A) Unspecified Depressive Disorder

B) Major Depressive Disorder

C) Cyclothymic Disorder

D) Persistent Depressive Disorder

Have your answer?

There is enough specificity here to skip Unspecified Depressive Disorder. Cyclothymic Disorder is characterized by mood swings but does not include the prolonged and severe symptoms described. Persistent Depressive Disorder (Dysthymia) is a chronic form of depression lasting for at least two years--the client's symptoms do not meet this duration requirement.

The client's presentation of persistently low mood, loss of interest in hobbies, feelings of guilt and worthlessness, difficulty concentrating, and physical fatigue for the past four weeks is indicative of Major Depressive Disorder (MDD). To meet the criteria for MDD, these symptoms must persist for at least two weeks.

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August 28, 2023
Categories : 
  DSM  
  practice  
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