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CASE 23.1

You are seeing a 48-year-old female who presents with a 3-month history of low mood, low energy, poor concentration, and irritability. She has lost interest in most things she had enjoyed and has also noticed a 20-lb weight gain. She has been having frequent headaches, has been short tempered, and has noticed that it is hard to wake up in the morning. She reports no thoughts of suicide but has wondered if death would be a relief. She says she has felt restless for a while and feels that she is a bad person. Her mother suffered from depression. She does not consume alcohol or any other substances. She is divorced and has no children.

You think that this patient may meet criteria for a depressive disorder.

Question 23.1.1 Which of the following is NOT a criterion for the diagnosis of major depressive disorder (MDD)?

A) Low mood

B) Presence of suicidal ideation

C) Decreased appetite

D) Anhedonia or loss of interest

E) Mood fluctuations

Answer 23.1.1 The correct answer is "E." The presence of mood fluctuation is not used to make the diagnosis. Low mood should be present nearly every day to make the diagnosis. All of the other options listed are part of the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Special emphasis is placed on the presence of depressed mood and decreased interest, one of which must be present in order to diagnose MDD. Instead of depressed mood, patients may report somatic complaints or irritability.

Criteria for Major Depression: Two weeks or more of depressed mood or loss of interest or anhedonia AND four of the following: (1) significant change in weight or appetite; (2) insomnia or hypersomnia; (3) psychomotor agitation or retardation; (4) fatigue or loss of energy; (5) feeling worthless or excessive guilt; (6) poor concentration; and (7) recurrent thoughts of death, suicidal ideation, attempt, or plan.


Several mnemonics have been developed to help clinicians remember the DSM-5 criteria and two of these are "SIG-ECAPS" and "SPACE DIGS." Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicidality.

Question 23.1.2 Which one of this patient's symptoms is considered an atypical symptom of "atypical depression" or MDD?

A) Hypersomnia

B) Low mood

C) Anhedonia

D) Psychomotor retardation

E) Irritability


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