Test 2 Depression DSM-5 Self Exam Questions

A 12-year-old boy begins to have new episodes of temper outbursts that are out of proportion to the situation. Which of the following is not a diagnostic possibility for this patient? A. Disruptive mood dysregulation disorder. B. Bipolar disorder. C. Oppositional defiant disorder. D. Conduct disorder. E. Attention-deficit/hyperactivity disorder.

Ans: A. Disruptive mood dysregulation disorder. Explanation: Criteria G and H of disruptive mood dysregulation disorder state that the chronological age at onset is at least 6 years (or equivalent develop-mental level) and the onset is before 10 years.

Which of the following symptoms must be present for a woman to meet criteria for premenstrual dysphoric disorder? A. Marked affective lability. B. Decreased interest in usual activities. C. Physical symptoms such as breast tenderness. D. Marked change in appetite. E. A sense of feeling overwhelmed or out of control.

Ans: A. Marked affective lability. Explanation: Of the 11 symptoms in the premenstrual dysphoric disorder di-agnostic criteria, patients must have a total of at least 5 symptoms. One of the 5 must be one of the following symptoms: 1) marked affective lability; 2) marked irritability or anger or increased interpersonal conflicts; 3) marked depressed mood, feelings of hopelessness, or self-deprecating thoughts; 4) marked anxiety, tension, and/or feelings of being keyed up or on edge.

Which of the following statements about diagnostic markers for major depressive disorder (MDD) is true? A. No laboratory test has demonstrated sufficient sensitivity and specificity to be used as a diagnostic tool for MDD. B. Several diagnostic laboratory tests exist, but no commercial enterprise will offer them to the public. C. Diagnostic laboratory tests have been withheld for fear that people testing positive for MDD may attempt suicide. D. Tests that exist are adequate diagnostically but are not covered by health in-surance. E. Only functional magnetic resonance imaging (fMRI) provides absolute di-agnostic reliability for MDD.

Ans: A. No laboratory test has demonstrated sufficient sensitivity and specificity to be used as a diagnostic tool for MDD. Explanation: Although an extensive literature exists describing neuroanatomical, neuroendocrinological, and neurophysiological correlates of MDD, no laboratory test has yielded results of sufficient sensitivity and specificity to be used as a diagnostic tool for this disorder. Until recently, hypothalamic-pituitary-adrenal axis hyperactivity had been the most extensively investigated ab-normality associated with major depressive episodes, and it appears to be associated with melancholia, psychotic features, and risks for eventual suicide. Molecular studies have also implicated peripheral factors, including genetic variants in neurotrophic factors and pro-inflammatory cytokines. Addition-ally, fMRI studies provide evidence for functional abnormalities in specific neural systems supporting emotion processing, reward seeking, and emotion regulation in adults with major depression.

A 45-year-old man with classic features of schizophrenia has always experienced co-occurring symptoms of depression—including feeling "down in the dumps," having a poor appetite, feeling hopeless, and suffering from insomnia—during his episodes of active psychosis. These depressive symptoms occurred only during his psychotic episodes and only during the 2-year period when the patient was experiencing active symptoms of schizophrenia. After his psychotic episodes were successfully controlled by medication, no further symptoms of depression were present. The patient has never met full criteria for major depressive disorder at any time. What is the appropriate DSM-5 diagnosis? A. Schizophrenia. B. Schizoaffective disorder. C. Persistent depressive disorder (dysthymia). D. Schizophrenia and persistent depressive disorder (dysthymia). E. Unspecified schizophrenia spectrum and other psychotic disorder.

Ans: A. Schizophrenia. Explanation: Depressive symptoms are a common associated feature of chronic psychotic disorders (e.g., schizoaffective disorder, schizophrenia, delusional disorder). A separate diagnosis of persistent depressive disorder is not made if the symptoms occur only during the course of the psychotic disorder (including residual phases).

The diagnostic criteria for disruptive mood dysregulation disorder (DMDD) state that the diagnosis should not be made for the first time before age 6 years or after 18 years (Criterion G). Which of the following statements best describes the rationale for this age range restriction? A. Validity of the diagnosis has been established only in the age group 7-18 years. B. The restriction represents an attempt to differentiate DMDD from bipolar disorder. C. The restriction is based on existing genetic data. D. The restriction represents an attempt to differentiate DMDD from intermit-tent explosive disorder. E. The restriction represents an attempt to differentiate DMDD from autism spectrum disorder.

Ans: A. Validity of the diagnosis has been established only in the age group 7-18 years. Explanation: By definition, the onset of DMDD (by history or observation) must be before age 10 years (Criterion H), and the diagnosis should not be ap-plied to children with a developmental age of less than 6 years. It is unknown whether the condition presents only in this age-delimited fashion. Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (7-18 years). Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later. Rates of conversion from severe, non-episodic irritability to bipolar disorder are very low. Instead, children with chronic irritability are at risk to develop unipolar depressive and/or anxiety disorders in adulthood.

What are the new depressive disorder diagnoses in DSM-5? A. Subsyndromal depressive disorder, premenstrual dysphoric disorder, and mixed anxiety and depressive disorder. B. Disruptive mood dysregulation disorder, premenstrual dysphoric disorder, and persistent depressive disorder (dysthymia). C. Disruptive mood dysregulation disorder, premenstrual dysphoric disorder, and subsyndromal depressive disorder. D. Disruptive mood dysregulation disorder, postmenopausal dysphoric disor-der, and persistent depressive disorder (dysthymia). E. Mixed anxiety and depressive disorder, bereavement-induced major de-pressive disorder, and postmenopausal dysphoric disorder.

Ans: B. Disruptive mood dysregulation disorder, premenstrual dysphoric disorder, and persistent depressive disorder (dysthymia). Explanation: Several new diagnoses appear in the DSM-5 "Depressive Disorders" chapter. After careful scientific review of the evidence, premenstrual dysphoric disorder (PMDD) has been moved from Appendix B ("Criteria Sets and Axes Provided for Further Study") of DSM-IV to Section II of DSM-5. Al-most 20 years of additional research on this condition has confirmed a specific and treatment-responsive form of depressive disorder that begins sometime following ovulation and remits within a few days of menses and has a marked impact on functioning. In order to address concerns about the potential for the overdiagnosis of and treatment for bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder (DMDD), referring to the presentation of children with persistent irritability and frequent episodes of extreme behavioral dyscontrol, is added to the depressive disorders for children up to 12 years of age. Its placement in this chapter reflects the finding that children with this symptom pattern typically develop unipolar depressive disorders or anxiety disorders, rather than bipolar disorders, as they mature into adolescence and adulthood. A more chronic form of depression, persistent depressive disorder (dysthymia), can be diagnosed when the mood disturbance continues for at least 2 years in adults or 1 year in children. This diagnosis, new in DSM-5, includes the DSM-IV diagnostic categories of chronic major depression and dysthymia.

Children with disruptive mood dysregulation disorder (DMDD) often meet criteria for what additional DSM-5 diagnosis? A. Pediatric bipolar disorder. B. Oppositional defiant disorder. C. Schizophrenia. D. Intermittent explosive disorder. E. Major depressive disorder.

Ans: B. Oppositional defiant disorder. Explanation: Because chronically irritable children and adolescents typically present with complex histories, the diagnosis of DMDD must be made while considering the presence or absence of multiple other conditions. The differential diagnosis of DMDD from both bipolar disorder and oppositional defiant disorder requires careful consideration. DMDD differs from bipolar disorder in that the former is chronic, whereas the latter is episodic. DMDD differs from oppositional defiant disorder in that very severe irritability is required in the former but not the latter. For this reason, while most children who meet criteria for DMDD will also meet criteria for oppositional defiant disorder, the reverse is not the case.

A 30-year-old woman reports 2 years of persistently depressed mood, accompanied by loss of pleasure in all activities, ruminations that she would be better off dead, feelings of guilt about "bad things" she has done, and thoughts about quitting work because of her inability to make decisions. Although she has never been treated for depression, she feels so distressed at times that she wonders if she should be hospitalized. She experiences an increased need for sleep but still feels fatigued during the day. Her overeating has led to a 12-kg weight gain. She denies drug or alcohol use, and her medical workup is completely normal, including laboratory tests for vitamins. The consultation was prompted by her worsened mood for the past several weeks. What is the most appropriate diagnosis? A. Major depressive disorder (MDD). B. Persistent depressive disorder (dysthymia), with persistent major depres-sive episode. C. Cyclothymia. D. Bipolar II disorder. E. MDD, with melancholic features.

Ans: B. Persistent depressive disorder (dysthymia), with persistent major depressive episode. Explanation: The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years. This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. Major de-pression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive dis-order. If there is a depressed mood plus two or more symptoms meeting criteria for a persistent depressive episode for 2 years or more, then the diagnosis of persistent depressive disorder is made. The diagnosis depends on the 2-year duration, which distinguishes it from episodes of depression that do not last 2 years. If the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this period, then the diagnosis of major depression should be noted, but it is coded not as a separate diagnosis but rather as a specifier with the diagnosis of persistent depressive disorder. If the individual's symptoms currently meet full criteria for a major depressive episode, then the specifier "with intermittent major depressive episodes, with current episode" would be applied. If—as in the patient described in the above vignette—the major depressive episode has persisted for at least a 2-year duration and remains present, then the specifier "with persistent major depressive episode" is used. When full major depressive episode criteria are not currently met but there has been at least one previous episode of major depression in the context of at least 2 years of persistent depressive symptoms, then the specifier "with intermittent major depressive episodes, without current episode" is used. If the individual has not experienced an episode of major depression in the past 2 years, then the specifier "with pure dysthymic syndrome" is used.

Which of the following statements about the heritability of major depressive disorder (MDD) is true? A. Nearly 100% of people with genetic liability can be accounted for by the personality trait of dogmatism. B. The heritability is approximately 40%, and the personality trait of neuroticism accounts for a substantial portion of this genetic liability. C. Less than 10% of people with genetic liability can be accounted for by the personality trait of perfectionism. D. Nearly 50% of people with genetic liability can be accounted for by the per-sonality trait of aggressiveness. E. The heritability of MDD depends on whether the individual's mother or father had MDD.

Ans: B. The heritability is approximately 40%, and the personality trait of neuroticism accounts for a substantial portion of this genetic liability. Explanation: First-degree family members of individuals with major depressive disorder have a risk of major depressive disorder two- to fourfold higher than that of the general population. Relative risks appear to be higher for early-onset and recurrent forms. Heritability is approximately 40%, and the personality trait neuroticism accounts for a substantial portion of this genetic liability. Neuroticism (negative affectivity) is a well-established risk factor for the onset of major depressive disorder, and high levels appear to render individuals more likely to develop depressive episodes in response to stressful life events.

A 45-year-old woman with multiple sclerosis was treated with interferon beta-1a a year ago, which resolved her physical symptoms. She now presents with depressed mood (experienced daily for the past several months), middle insomnia (of recent onset), poor appetite, trouble concentrating, and lack of interest in sex. Although she has no physical symptoms, she is frequently absent from work. She denies any active plans to commit suicide but admits that she often thinks about it, as her mood has worsened. What is the most likely diagnosis? A. Major depressive disorder. B. Persistent depressive disorder (dysthymia). C. Depressive disorder due to another medical condition. D. Substance/medication-induced depressive disorder. E. Persistent depressive disorder (dysthymia) and multiple sclerosis.

Ans: C. Depressive disorder due to another medical condition. Explanation: The essential feature of depressive disorder due to another medical condition is a prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all, or almost all, activities that predominates in the clinical picture and that is thought to be related to the direct physiological effects of another medical condition. In determining whether the mood disturbance is due to another medical condition, the clinician must first establish the presence of such a condition. Furthermore, the clinician must establish that the mood disturbance is etiologically related to the other medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment.

A 29-year-old woman complains of sad mood every month in anticipation of her very painful menses. The pain begins with the start of her flow and continues for several days. She does not experience pain during other times of the month. She has tried a variety of treatments, none of which have given her relief. What is the appropriate diagnosis? A. Premenstrual dysphoric disorder. B. Premenstrual syndrome. C. Dysmenorrhea. D. Factitious disorder. E. Persistent depressive disorder (dysthymia).

Ans: C. Dysmenorrhea. Explanation: Dysmenorrhea is a syndrome of painful menses, but this is distinct from a syndrome characterized by affective changes. Symptoms of dysmenorrhea begin with the onset of menses, whereas symptoms of premenstrual dysphoric disorder, by definition, begin before the onset of menses, even if they linger into the first few days of menses.

A 45-year-old man is admitted to the hospital with profound hypothyroidism. He is depressed but does not meet full criteria for major depressive disorder (MDD), the diagnosis given to him by his internist. The patient has no prior history of a mood disorder, and all of the depressive symptoms are temporally related to the hypothyroidism. Based on this information, you determine that a change in diagnosis—to depressive disorder due to another medical condition—is warranted, as well as a specifier to indicate that full criteria for MDD are not met. How would the full diagnosis be recorded? A. Hypothyroidism would be coded on Axis III in DSM-5. B. There is no special coding procedure in DSM-5. C. Hypothyroidism would be recorded as the name of the "other medical con-dition" in the DSM-5 diagnosis. D. Medical disorders are not coded as part of a mental disorder diagnosis in DSM-5. E. A revision to DSM-5 is planned to deal with this issue.

Ans: C. Hypothyroidism would be recorded as the name of the "other medical condition" in the DSM-5 diagnosis. Explanation: In recording a diagnosis of depressive disorder due to another medical condition, the name of the other medical condition is inserted in the mental disorder diagnosis (i.e., "depressive disorder due to hypothyroidism"). In addition, the other medical condition should be coded and listed separately immediately before the depressive disorder due to the medical condition. In this vignette, the full coding would be "244.9 [E03.9] hypothyroidism; 293.83 [F06.31] depressive disorder due to hypothyroidism, with depressive features." (The "with depressive features" specifier denotes that full criteria are not met for a major depressive episode.) There is no longer an Axis III in DSM-5.

A depressed patient reports that he experiences no pleasure from his normally enjoyable activities. Which of the following additional symptoms would be re-quired for this patient to qualify for a diagnosis of major depressive disorder with melancholic features? A. Despondency, depression that is worse in the morning, and inability to fall asleep. B. Depression that is worse in the evening, psychomotor agitation, and signif-icant weight loss. C. Inappropriate guilt, depression that is worse in the morning, and early-morning awakening. D. Significant weight gain, depression that is worse in the evening, and exces-sive guilt. E. Despondency, significant weight gain, and psychomotor retardation.

Ans: C. Inappropriate guilt, depression that is worse in the morning, and early-morning awakening. Explanation: Two criteria must be met to qualify for the specifier "with melancholic features" for major depressive disorder. Criterion A specifies that one of the following must be present during the most severe period of the current episode: 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). Criterion B specifies that three (or more) of the following must be present: 1) a distinct quality of depressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood; 2) depression that is regularly worse in the morning; 3) early-morning awakening (i.e., at least 2 hours before usual awakening); 4) marked psycho-motor agitation or retardation; 5) significant anorexia or weight loss; 6) excessive or inappropriate guilt. The specifier "with melancholic features" can be applied to the current (or, if the full criteria are not currently met for major de-pressive episode, to the most recent) major depressive episode in major depressive disorder or in bipolar I or II disorder only if it is the most recent type of mood episode.

A 9-year-old boy is brought in for evaluation because of explosive outbursts when he is frustrated with schoolwork. The parents report that their son is well behaved and pleasant at other times. Which diagnosis best fits this clinical picture? A. Disruptive mood dysregulation disorder. B. Pediatric bipolar disorder. C. Intermittent explosive disorder. D. Major depressive disorder. E. Persistent depressive disorder (dysthymia).

Ans: C. Intermittent explosive disorder. Explanation: Children with intermittent explosive disorder present with in-stances of severe temper outbursts much like those in children with disruptive mood dysregulation disorder. However, unlike children with disruptive mood dysregulation disorder, children with intermittent explosive disorder do not exhibit persistent disruption in mood between outbursts. Thus, the two diagnoses are mutually exclusive and cannot be made in the same child. For children with outbursts and intercurrent, persistent irritability, the diagnosis of disruptive mood dysregulation disorder should be made. For children with outbursts but no such irritability, the diagnosis of intermittent explosive disorder should be made.

A 39-year-old woman reports that she became quite depressed in the winter last year when her company closed for the season, but she felt completely nor-mal in the spring. She recalls experiencing several other episodes of depression over the past 5 years (for which she cannot identify a seasonal pattern) that would have met criteria for major depressive disorder. Which of the following correctly summarizes this patient's eligibility for a diagnosis of "major depressive disorder, with seasonal pattern"? A. She does not qualify for this diagnosis: the episode must start in the fall, and the patient must have no episodes that do not have a seasonal pattern. B. She does qualify for this diagnosis: the single episode described started in the winter and ended in the spring. C. She does not qualify for this diagnosis: the patient must have had two epi-sodes with a seasonal relationship in the past 2 years and no nonseasonal episodes during that period. D. She does qualify for this diagnosis: the symptoms described are related to psychosocial stressors. E. She does qualify for this diagnosis: the symptoms are not related to bipolar I or bipolar II disorder.

Ans: C. She does not qualify for this diagnosis: the patient must have had two episodes with a seasonal relationship in the past 2 years and no nonseasonal episodes during that period. Explanation: The "with seasonal pattern" specifier requires a regular temporal relationship between the onset of major depressive episodes (MDEs) in major depressive disorder or in bipolar I or bipolar II disorder and a particular time of the year (e.g., in the fall or winter). The diagnosis excludes cases in which there is an obvious effect of seasonal-related psychosocial stressors (e.g., regularly being unemployed every winter). Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring). In the past 2 years, two MDEs must have occurred that demonstrate the temporal seasonal relationships de-fined above, and no nonseasonal MDEs must have occurred during that same period. Seasonal MDEs must substantially outnumber the nonseasonal MDEs that may have occurred over the individual's lifetime. The specifier "with seasonal pattern" can be applied to the pattern of MDEs in bipolar I disorder, bi-polar II disorder, or major depressive disorder, recurrent.

An 18-year-old college student, recently arrived in the United States from Beijing, complains to her gynecologist of irritability, problems with her room-mates, increased appetite, feeling bloated, and feeling depressed for 3-4 days prior to the onset of menses. She reports that these symptoms have been present since she reached menarche at age 12 (although she has never kept a mood log). The gynecologist calls you for a consultation about the correct diagnosis, because she is as yet unfamiliar with the new DSM-5 diagnostic criteria. What is your response? A. The patient has premenstrual syndrome because she does not meet criteria for premenstrual dysphoric disorder. B. The patient would qualify for a provisional diagnosis of premenstrual dys-phoric disorder; however, the diagnosis does not exist in DSM-5. C. The patient would qualify for a provisional diagnosis of premenstrual dysphoric disorder. D. The patient would qualify for a provisional diagnosis of premenstrual dysphoric disorder if the diagnosis had been validated in Asian women. E. The patient has no DSM-5 diagnosis.

Ans: C. The patient would qualify for a provisional diagnosis of premenstrual dysphoric disorder. Explanation: Premenstrual dysphoric disorder is not a culture-bound syn-drome and has been observed in individuals in the United States, Europe, India, and Asia. It is unclear as to whether rates differ by race. The essential features of premenstrual dysphoric disorder are the expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter. These symptoms may be accompanied by behavioral and physical symptoms. Symptoms must have occurred in most of the menstrual cycles during the past year and must have an adverse effect on work or social functioning. Typically, symptoms peak around the time of the onset of menses. While the core symptoms include mood and anxiety symptoms, behavioral and somatic symptoms commonly also occur. In order to confirm a provisional diagnosis, daily prospective symptom ratings are required for at least two symptomatic cycles.

How do individuals with substance/medication-induced depressive disorder differ from individuals with major depressive disorder who do not have a sub-stance use disorder? A. They are more likely to be female. B. They are more likely to have graduate school education. C. They are more likely to be male. D. They are more likely to be white. E. They are less likely to report suicidal thoughts/attempts.

Ans: C. They are more likely to be male. Explanation: In a representative U.S. adult population, compared with individuals with major depressive disorder who did not have a substance use dis-order, individuals with substance-induced depressive disorder were more likely to be male, to be black, to have at most a high school diploma, to lack insurance, and to have lower family income. They were also more likely to report higher family history of substance use disorders and antisocial behavior, higher 12-month history of stressful life events, a greater number of DSM-IV major depressive disorder criteria, and feelings of worthlessness, insomnia/hypersomnia, and thoughts of death and suicide attempts.

Which of the following features distinguishes disruptive mood dysregulation disorder (DMDD) from bipolar disorder in children? A. Age at onset. B. Gender of the child. C. Irritability. D. Chronicity. E. Severity.

Ans: D. Chronicity. Explanation: The core feature of DMDD is chronic, severe, persistent irritability. This severe irritability has two prominent clinical manifestations, the first of which is frequent temper outbursts. These outbursts typically occur in response to frustration and can be verbal or behavioral (the latter in the form of aggression against property, self, or others). The clinical presentation of DMDD must be carefully distinguished from presentations of other, related conditions, particularly pediatric bipolar disorder. DMDD was added to DSM-5 to address the considerable concern about the appropriate classification and treatment of children who present with chronic, persistent irritability relative to children who present with classic (i.e., episodic) bipolar disorder. In DSM-5, the term bipolar disorder is explicitly reserved for episodic presentations of bipolar symptoms. DSM-IV did not include a diagnosis designed to capture youths whose hallmark symptoms consisted of very severe, nonepisodic irritability, whereas DSM-5, with the inclusion of DMDD, provides a dis-tinct category for such presentations.

What DSM-5 diagnostic provision is made for depressive symptoms following the death of a loved one? A. Depressive symptoms lasting less than 2 months after the loss of a loved one are excluded from receiving a diagnosis of major depressive episode. B. To qualify for a diagnosis of major depressive episode, the depression must start no less than 12 weeks following the loss. C. To qualify for a diagnosis of major depressive episode, the depressive symptoms in such individuals must include suicidal ideation. D. Depressive symptoms following the loss of a loved one are not excluded from receiving a major depressive episode diagnosis if the symptoms oth-erwise fulfill the diagnostic criteria. E. Depressive symptoms following the loss of a loved one are excluded from receiving a major depressive episode diagnosis; however, a proposed diagnostic category for post bereavement depression is included in "Conditions for Further Study" (DSM-5 Appendix) pending further research.

Ans: D. Depressive symptoms following the loss of a loved one are not excluded from receiving a major depressive episode diagnosis if the symptoms otherwise fulfill the diagnostic criteria. Explanation: In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk of suffering, feelings of worthless-ness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physicians and grief counselors recognize that the duration is more commonly 1-2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder.

Which of the following statements about how grief differs from a major depressive episode (MDE) is false? A. In grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. B. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. C. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. D. In grief, feelings of worthlessness and self-loathing are common; in MDE, self-esteem is generally preserved. E. If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the de-ceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

Ans: D. In grief, feelings of worthlessness and self-loathing are common; in MDE, self-esteem is generally preserved. Explanation: In distinguishing grief from an MDE, it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and hu-mor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about "joining" the deceased, whereas in MDE such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of de-pression.

A 50-year-old man presents with persistently depressed mood for several weeks that interferes with his ability to work. He has insomnia and fatigue, feels guilty, has thoughts he would be better off dead, and has thought about how he could die without anyone knowing it was a suicide. His wife informs you that he requests sex several times a day and that she thinks he may be going to "massage parlors" regularly, both of which are changes from his typical behavior. He has told her he has ideas for a "better Internet," and he has in-vested thousands of dollars in software programs that he cannot use. She notes that he complains of fatigue but sleeps only 1 or 2 hours each night and seems to have tremendous energy during the day. Which diagnosis best fits this patient? A. Manic episode. B. Hypomanic episode. C. Major depressive episode. D. Major depressive episode, with mixed features. E. Major depressive episode, with atypical features.

Ans: D. Major depressive episode, with mixed features. Explanation: The specifier "with mixed features" now denotes the coexistence of at least three manic symptoms insufficient to satisfy criteria for a manic episode, within a major depressive episode. This change is based on findings from studies of family history and diagnostic stability showing that the presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum. This likelihood was judged insufficient to assign such individuals a diagnosis of bipolar disorder. The presence of a full manic syndrome within a depressive episode will continue to be an exclusion criterion for a depressive disorder diagnosis, and individuals with this pattern will be considered to have a manic episode.

A 14-year-old boy describes himself as feeling "down" all of the time for the past year. He remembers feeling better while he was at camp for 4 weeks during the summer; however, the depressed mood returned when he came home. He reports poor concentration, feelings of hopelessness, and low self-esteem but denies suicidal ideation or changes in his appetite or sleep. What is the most likely diagnosis? A. Major depressive disorder. B. Disruptive mood dysregulation disorder. C. Depressive episodes with short-duration hypomania. D. Persistent depressive disorder (dysthymia), with early onset. E. Schizoaffective disorder.

Ans: D. Persistent depressive disorder (dysthymia), with early onset. Explanation: The essential feature of persistent depressive disorder (dysthymia) is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year for children and adolescents (Criterion A). This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. Major depression may precede persistent depressive disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persis-tent depressive disorder as well as major depressive disorder. Individuals with persistent depressive disorder describe their mood as sad or "down in the dumps." During periods of depressed mood, at least two of the six symptoms from Criterion B are present. Because these symptoms have become a part of the individual's day-to-day experience, particularly in the case of early onset (e.g., "I've always been this way"), they may not be reported unless the individual is directly prompted. During the 2-year period (1 year for children or adolescents), any symptom-free intervals last no longer than 2 months (Criterion C).

A 23-year-old woman reports that during every menstrual cycle she experiences breast swelling, bloating, hypersomnia, an increased craving for sweets, poor concentration, and a feeling that she cannot handle her normal responsibilities. She notes that she also feels somewhat more sensitive emotionally and may become tearful when hearing a sad story. She takes no oral medication but does use a drospirenone/ethinyl estradiol patch. What diagnosis best fits this clinical picture? A. Premenstrual dysphoric disorder (PMDD). B. Dysthymia. C. Dysmenorrhea. D. Premenstrual syndrome. E. Substance/medication-induced depressive disorder.

Ans: D. Premenstrual syndrome. Explanation: Premenstrual syndrome differs from PMDD in that a minimum of five symptoms is not required and there is no stipulation of affective symptoms for individuals who suffer from premenstrual syndrome. This condition may be more common than PMDD, although the estimated prevalence of pre-menstrual syndrome varies. Premenstrual syndrome shares with PMDD the feature of symptom expression during the premenstrual phase of the menstrual cycle, but it is generally considered to be less severe than PMDD. Individuals who experience physical or behavioral symptoms in the pre-menstrum, with-out the required affective symptoms, likely meet criteria for premenstrual syn-drome and not for PMDD.

A 31-year-old woman with no history of mood symptoms reports that she experiences distressing mood lability and irritability starting about 4 days before the onset of menses. She feels "on edge," cannot concentrate, has little enjoyment from any of her activities, and experiences bloating and swelling of her breasts. The patient reports that these symptoms started 6 months ago when she began taking oral contraceptives for the first time. If she stops the oral contraceptives and her symptoms remit, what would the diagnosis be? A. Premenstrual dysphoric disorder. B. Dysthymia. C. Major depressive episode. D. Substance/medication-induced depressive disorder. E. Premenstrual syndrome.

Ans: D. Substance/medication-induced depressive disorder. Explanation: If the woman stops the hormones and her symptoms disappear, this is consistent with substance/medication-induced depressive disorder. Some women who present with moderate to severe premenstrual symptoms may be using hormonal contraceptives. If such symptoms occur after initiation of exogenous hormone use, the symptoms may be due to the use of hormones rather than the underlying condition of premenstrual dysphoric disorder.

An irritable 8-year-old child has a history of temper outbursts both at home and at school. What characteristic mood feature must be also present to qualify him for a diagnosis of disruptive mood dysregulation disorder? A. The child's mood between outbursts is typically euthymic. B. The child's mood between outbursts is typically hypomanic. C. The child's mood between outbursts is typically depressed. D. The child's mood between outbursts is typically irritable or angry. E. The mood symptoms and temper outbursts must not have persisted for more than 6 months.

Ans: D. The child's mood between outbursts is typically irritable or angry. Explanation: Criterion D of disruptive mood dysregulation disorder requires that the child's mood between temper outbursts be persistently irritable or an-gry most of the day, nearly every day, and observable by others (e.g., parents, teachers, peers).

Which of the following statements about the prevalence of major depressive disorder in the United States is true? A. The 12-month prevalence is 17%. B. Females and males have equal prevalence at all ages. C. Females have increased prevalence at all ages. D. The prevalence in 18- to 29-year-olds is three times higher than that in 60- year-olds. E. The prevalence in 60-year-olds is three times higher than that in 18- to 29- year-olds.

Ans: D. The prevalence in 18- to 29-year-olds is three times higher than that in 60-year-olds. Explanation: The 12-month prevalence of major depressive disorder in the United States is 7%, with marked differences by age group such that the prevalence in 18- to 29-year-old individuals is threefold higher than the prevalence in individuals age 60 years or older. Females experience 1.5- to 3-fold higher rates than males beginning in early adolescence.

What is the appropriate method of confirming a diagnosis of premenstrual dysphoric disorder? A. Laboratory tests. B. Family history. C. Neuropsychological testing. D. Two or more months of prospective symptom ratings on validated scales. E. One month of scoring high on the Daily Rating of Severity of Problems or 1 month of scoring high on the Visual Analogue Scales for Premenstrual Mood Symptoms.

Ans: D. Two or more months of prospective symptom ratings on validated scales. Explanation: The diagnosis of premenstrual dysphoric disorder is appropriately confirmed by 2 months of prospective symptom ratings. (Note: The diagnosis may be made provisionally prior to this confirmation.) A number of scales, including the Daily Rating of Severity of Problems and the Visual Analogue Scales for Premenstrual Mood Symptoms, have undergone validation and are commonly used in clinical trials for premenstrual dysphoric disorder. The Premenstrual Tension Syndrome Rating Scale has a self-report and an ob-server version, both of which have been validated and used widely to measure illness severity in women who have premenstrual dysphoric disorder.

Which of the following statements about gender differences in suicide risk and suicide rates in major depressive disorder (MDD) is true? A. The risk of suicide attempts and completions is higher for women. B. The risk of suicide attempts and completions is higher for men. C. The risk of suicide attempts and completions is equal for men and women. D. The disparity in suicide rate by gender is much greater in individuals with MDD than in the general population. E. The risk of suicide attempts is higher for women, but the risk of suicide completions is lower.

Ans: E. The risk of suicide attempts is higher for women, but the risk of suicide completions is lower. Explanation: In women, the risk of suicide attempts is higher, and the risk of suicide completions is lower. The disparity in suicide rate by gender is not as great among those with depressive disorders as it is in the population as a whole.

Children with disruptive mood dysregulation disorder are most likely to develop which of the following disorders in adulthood? A. Bipolar I disorder. B. Schizophrenia. C. Bipolar II disorder. D. Borderline personality disorder. E. Unipolar depressive disorders.

Ans: E. Unipolar depressive disorders. Explanation: Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later. Rates of conversion from severe, non-episodic irritability to bipolar disorder are very low. Instead, children with chronic irritability are at risk to develop unipolar depressive and/or anxiety disorders in adulthood.