The ICD-10 Classification of Mental and Behavioural
Disorders
World Health Organization, Geneva, 1992
Depressive Disorder
In typical depressive episodes of all three varieties described
below (mild, moderate, and severe), the individual usually suffers
from depressed mood, loss of interest and enjoyment, and reduced
energy leading to increased fatiguability and diminished activity.
Marked tiredness after only slight effort is common. Other common
symptoms are:
(a) reduced concentration and attention;
(b) reduced self-esteem and self-confidence;
(c) ideas of guilt and unworthiness (even in a mild type of
episode);
(d) bleak and pessimistic views of the future;
(e) ideas or acts of self-harm or suicide;
(f) disturbed sleep;
(g) diminished appetite.
The lowered mood varies little from day to day, and is often
unresponsive to circumstances, yet may show a characteristic
diurnal variation as the day goes on. As with manic episodes, the
clinical presentation shows marked individual variations, and
atypical presentations are particularly common in adolescence. In
some cases, anxiety, distress, and motor agitation may be more
prominent at times than the depression, and the mood change may
also be masked by added features such as irritability, excessive
consumption of alcohol, histrionic behaviour, and exacerbation of
pre-existing phobic or obsessional symptoms, or by hypochondriacal
preoccupations. For depressive episodes of all three grades of
severity, a duration of at least 2 weeks is usually required for
diagnosis, but shorter periods may be reasonable if symptoms are
unusually severe and of rapid onset.
Some of the above symptoms may be marked and develop
characteristic features that are widely regarded as having special
clinical significance. The most typical examples of these
"somatic" symptoms are: loss of interest or pleasure in
activities that are normally enjoyable; lack of emotional
reactivity to normally pleasurable surroundings and events; waking
in the morning 2 hours or more before the usual time; depression
worse in the morning; objective evidence of definite psychomotor
retardation or agitation (remarked on or reported by other
people); marked loss of appetite; weight loss (often defined as 5%
or more of body weight in the past month); marked loss of libido.
Usually, this somatic syndrome is not regarded as present unless
about four of these symptoms are definitely present.
The categories of mild, moderate and severe depressive episodes
described in more detail below should be used only for a single
(first) depressive episode. Further depressive episodes should be
classified under one of the subdivisions of recurrent depressive
disorder.
These grades of severity are specified to cover a wide range of
clinical states that are encountered in different types of
psychiatric practice. Individuals with mild depressive episodes
are common in primary care and general medical settings, whereas
psychiatric inpatient units deal largely with patients suffering
from the severe grades.
Acts of self-harm associated with mood (affective) disorders,
most commonly self-poisoning by prescribed medication, should be
recorded by means of an additional code from Chapter XX of ICD-10
(X60-X84). These codes do not involve differentiation between
attempted suicide and "parasuicide", since both are
included in the general category of self-harm.
Differentiation between mild, moderate, and severe depressive
episodes rests upon a complicated clinical judgement that involves
the number, type, and severity of symptoms present. The extent of
ordinary social and work activities is often a useful general
guide to the likely degree of severity of the episode, but
individual, social, and cultural influences that disrupt a smooth
relationship between severity of symptoms and social performance
are sufficiently common and powerful to make it unwise to include
social performance amongst the essential criteria of severity.
The presence of dementia or mental retardation does not rule
out the diagnosis of a treatable depressive episode, but
communication difficulties are likely to make it necessary to rely
more than usual for the diagnosis upon objectively observed
somatic symptoms, such as psychomotor retardation, loss of
appetite and weight, and sleep disturbance.
Includes:
* single episodes of depression (without psychotic symptoms),
psychogenic depression or reactive depression)
Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased
fatiguability are usually regarded as the most typical symptoms of
depression, and at least two of these, plus at least two of the
other symptoms described above should usually be present for a
definite diagnosis. None of the symptoms should be present to an
intense degree. Minimum duration of the whole episode is about 2
weeks.
An individual with a mild depressive episode is usually
distressed by the symptoms and has some difficulty in continuing
with ordinary work and social activities, but will probably not
cease to function completely.
A fifth character may be used to specify the presence of the
somatic syndrome:
F32.00 Without somatic symptoms
The criteria for mild depressive episode are fulfilled, and there
are few or none of the somatic symptoms present.
F32.01 With somatic symptoms
The criteria for mild depressive episode are fulfilled, and four
or more of the somatic symptoms are also present. (If only two or
three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
Diagnostic Guidelines
At least two of the three most typical symptoms noted for mild
depressive episode should be present, plus at least three (and
preferably four) of the other symptoms. Several symptoms are
likely to be present to a marked degree, but this is not essential
if a particularly wide variety of symptoms is present overall.
Minimum duration of the whole episode is about 2 weeks.
An individual with a moderately severe depressive episode will
usually have considerable difficulty in continuing with social,
work or domestic activities.
A fifth character may be used to specify the occurrence of
somatic symptoms:
F32.10 Without somatic symptoms
The criteria for moderate depressive episode are fulfilled, and
few if any of the somatic symptoms are present.
F32.11 With somatic symptoms
The criteria for moderate depressive episode are fulfilled, and
four or more or the somatic symptoms are present. (If only two or
three somatic symptoms are present but they are unusually severe,
use of this category may be justified.)
In a severe depressive episode, the sufferer usually shows
considerable distress or agitation, unless retardation is a marked
feature. Loss of self-esteem or feelings of uselessness or guilt
are likely to be prominent, and suicide is a distinct danger in
particularly severe cases. It is presumed here that the somatic
syndrome will almost always be present in a severe depressive
episode.
Diagnostic Guidelines
All three of the typical symptoms noted for mild and moderate
depressive episodes should be present, plus at least four other
symptoms, some of which should be of severe intensity. However, if
important symptoms such as agitation or retardation are marked,
the patient may be unwilling or unable to describe many symptoms
in detail. An overall grading of severe episode may still be
justified in such instances. The depressive episode should usually
last at least 2 weeks, but if the symptoms are particularly severe
and of very rapid onset, it may be justified to make this
diagnosis after less than 2 weeks.
During a severe depressive episode it is very unlikely that the
sufferer will be able to continue with social, work, or domestic
activities, except to a very limited extent.
This category should be used only for single episodes of severe
depression without psychotic symptoms; for further episodes, a
subcategory of recurrent depressive disorder should be used.
Includes:
* single episodes of agitated depression
* melancholia or vital depression without psychotic symptoms
Diagnostic Guidelines
A severe depressive episode which meets the criteria given for
severe depressive episode without psychotic symptoms and in which
delusions, hallucinations, or depressive stupor are present. The
delusions usually involve ideas of sin, poverty, or imminent
disasters, responsibility for which may be assumed by the patient.
Auditory or olfactory hallucinations are usually of defamatory or
accusatory voices or of rotting filth or decomposing flesh. Severe
psychomotor retardation may progress to stupor. If required,
delusions or hallucinations may be specified as mood-congruent or
mood-incongruent.
Differential Diagnosis
Depressive stupor must be differentiated from catatonic
schizophrenia, from dissociative stupor, and from organic forms of
stupor. This category should be used only for single episodes of
severe depression with psychotic symptoms; for further episodes a
subcategory of recurrent depressive disorder should be used.
Includes:
* single episodes of major depression with psychotic symptoms,
psychotic depression, psychogenic depressive psychosis, reactive
depressive psychosis
The disorder is characterized by repeated episodes of
depression as specified in depressive episode (mild, moderate, or
severe), without any history of independent episodes of mood
elevation and overactivity that fulfill the criteria of mania.
However, the category should still be used if there is evidence of
brief episodes of mild mood elevation and overactivity which
fulfill the criteria of hypomania immediately after a depressive
episode (sometimes apparently precipitated by treatment of a
depression). The age of onset and the severity, duration, and
frequency of the episodes of depression are all highly variable.
In general, the first episode occurs later than in bipolar
disorder, with a mean age of onset in the fifth decade. Individual
episodes also last between 3 and 12 months (median duration about
6 months) but recur less frequently. Recovery is usually complete
between episodes, but a minority of patients may develop a
persistent depression, mainly in old age (for which this category
should still be used). Individual episodes of any severity are
often precipitated by stressful life events; in many cultures,
both individual episodes and persistent depression are twice as
common in women as in men.
The risk that a patient with recurrent depressive disorder will
have an episode of mania never disappears completely, however many
depressive episodes he or she has experienced. If a manic episode
does occur, the diagnosis should change to bipolar affective
disorder.
Recurrent depressive episode may be subdivided, as below, by
specifying first the type of the current episode and then (if
sufficient information is available) the type that predominates in
all the episodes.
Includes:
* recurrent episodes of depressive reaction, psychogenic
depression, reactive depression, seasonal affective disorder
* recurrent episodes of endogenous depression, major depression,
manic depressive psychosis (depressed type), psychogenic or
reactive depressive psychosis, psychotic depression, vital
depression
Excludes:
* recurrent brief depressive episodes
ICD-10 copyright © 1992 by World
Health Organization.
AZ Psychiatry copyright
© (www.azpsychiatry.info)
by Dr. Manaan Kar Ray
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