A. At least three of the following manic/hypomanic symptoms are present nearly every day during the majority of days of a major depressive episode: 1. Elevated, expansive mood.
Inflated self-esteem or grandiosity.
More talkative than usual or pressure to keep talking.
Flight of ideas or subjective experience that thoughts are racing.
Increase in energy or goal-directed activity (either socially, at work or school. or sexually).
6. Increased or excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees. sexual in- discretions, foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the per- son’s usual behavior.
C. For individuals whose symptoms meet full criteria for either mania or hypomania, the diagnosis should be bipolar | or bipolar II disorder.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment).
Note: Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to treatment.
With melancholic features:
A. One of the following is present during the most severe period of the current epi- sode: 1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
B. Three (or more) of the following: 1. A distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
Depression that is regularly worse in the morning.
EarIy-morning awakening (i.e., at least 2 hours before usual awakening).
Marked psychomotor agitation or retardation.
Significant anorexia or weight loss.
6. Excessive or inappropriate guilt.
Note: The specifier “with melancholic features" is applied if these features are present at the most severe stage of the episode. There is a near-complete absence of the ca- pacity for pleasure, not merely a diminution. A guideline for evaluating the lack of reac- tivity of mood is that even highly desired events are not associated with marked brightening of mood. Either mood does not brighten at all, or it brightens only partially (e.g., up to 20%—40% of normal for only minutes at a time). The “distinct quality‘ of mood that is characteristic of the “with melancholic features" specifier is experienced as qual- itatively different from that during a nonmelancholic depressive episode. A depressed mood that is described as merely more severe, longer lasting, or present without a rea- son is not considered distinct in quality. Psychomotor changes are nearly always pres- ent and are observable by others.
Melancholic features exhibit only a modest tendency to repeat across episodes in the same individual. They are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.
With atypical features: This specifier can be applied when these features predomi- nate during the majority of days of the current or most recent major depressive episode or persistent depressive disorder.
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A. Mood reactivity (i.e., mood brightens in response to actual or potential positive events).
B. Two (or more) of the following: 1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).