A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of rest or pleasure. (Note: Do not include symptoms that are clearly attributable another medical condition)
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 % of body weight i a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. he symptoms cause clinically significant distress or impairment in social, occupational, or other important as of functioning
C. he episode is not attributable to the physiological effects of a substance or to another medical condition
Note: Must meet Criteria A–C to represent a major depressive episode
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for expression of distress in the context of loss. In distinguishing grief from a major depressive episode (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 humor 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 deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such though are generally focused on the deceased and possibly about “joining” the deceased, whereas in MDE such thoughts focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the n of depression
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders
E. There has never been a manic episode or a hypomanic episode. (Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.)
Major Depressive Disorder
Major depressive disorder is the most common depressive disorder. Table 3.1 lists the DSM-5 criteria for the diagnosis of MDD [9].
The DSM-5 includes the following new specifiers for MDD: “with anxious distress” and “with mixed features.” These specifiers allow for the characterization of additional symptoms. In addition, the DSM-5 expands the specifier “postnatal onset” to include onset during pregnancy by substituting “postnatal onset” with “perinatal onset.”
The following is a complete list of the DSM-5 specifiers for MDD [9]:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern
When considering a diagnosis of depression, it is of utmost importance to screen for symptoms of current or past mania. Manic symptoms include: decreased sleep, racing thoughts, pressured speech, distractibility, increased risky behavior, and inflated self-esteem or sense of grandiosity. In order to be considered a manic episode, the patient must have noticeable difficulty keeping his social and work responsibilities, need hospitalization, or suffer from delusions. A floridly manic patient should be taken to the Emergency Room for evaluation. SSRI’s should not be prescribed in patients with a history of mania or hypomania as they may precipitate a manic episode.
A thorough assessment of suicidality must be undertaken in any patient suspected of being depressed. This evaluation includes an assessment of ideation, plan, and intent. We recommend the following screening questions:
Ideation: It seems like thing have been difficult recently, has it ever gotten so bad that you have thought of taking your life?
Plan: Have you thought about how you would kill yourself? Have you made any plans? Do you have access to firearms or weapons?
Intent: Do you think you would carry out these plans? Have you ever tried to kill yourself in the past?
Patients at risk for suicide must be taken to the nearest Emergency Room for evaluation.
Treatment of Depressive Disorders
Overview
The goal of depression treatment is remission, or return to baseline. The initial treatment for unipolar depression consists of pharmacotherapy, psychotherapy, or both. Evidence suggests that the combination of pharmacotherapy and psychotherapy is more effective than either therapy alone [11, 12]. Given issues of patient openness to psychotherapy referrals as well as limited availability of psychotherapy providers in some areas, it may also be helpful to encourage patients to seek support or counseling as is appropriate and available in their social context.
Pharmacology
SSRIs, a type of second-generation anti-depressant, are the most commonly prescribed antidepressants given their efficacy and tolerability. Table 3.2 details the doses and most common side effects of SSRIs. Since their efficacy is comparable, choosing among this list of antidepressants is usually based on factors like side effects, safety, patient preference, cost, and comorbidities. The most common side effects include: diarrhea, nausea, vomiting, and sexual dysfunction.
Table 3.2
SSRI antidepressant medications
Antidepressant name (trade name) | Starting dose | Target daily dose |
|---|---|---|
Citalopram (Celexa) | 10 | 20–40 |
Escitalopram (Lexapro) | 5 | 10–20 |
Fluoxetine (Prozac) | 10 | 20–60 |
Paroxetine CR (Paxil CR) | 12.5 | 25–50 |
Sertraline (Zoloft) | 25 | 50–200 |
Psychotherapy
The most commonly used therapies for depression include cognitive behavioral therapy (CBT), interpersonal therapy (IPT), psychodynamic psychotherapy, and supportive therapy.
CBT is a skill-oriented and time-limited psychotherapy where the therapist helps patients change the relationship that they have with their thoughts and identify cognitive distortions. CBT also teaches participants to recognize maladaptive thoughts or behaviors and substitute them with adaptive ones.
IPT is also a time-limited psychotherapy that focuses on interpersonal relationships. This therapy rests on the theory that there is a relationship between a person’s mental health and how they interact with people.
Unlike CBT and IPT, psychodynamic psychotherapy focuses on the unconscious and is based on the idea that events in the past affect how we experience the present through our unconscious.
Supportive psychotherapy is a type of listening therapy where the therapist’s main role is to form an alliance with the patient and provide support.
Depressive Disorders Subsection Take Home Points
Main Changes introduced in DSM-5:
The following disorders were added: Disruptive mood dysregulation and premenstrual dysphoric disorder.
Dysthymia was eliminated and is now included under the diagnosis of persistent depressive disorder.
Specifiers ‘with mixed features’ and ‘with anxious distress’ were added to MDD.
The bereavement exclusion was eliminated
Major Depressive Disorder is the most common depressive disorder and can be treated with psychopharmacology and/or psychotherapy. Clinicians should assess suicidality when considering a diagnosis of MDD.
Anxiety Disorders
Overview and Epidemiology of Anxiety Disorders
Anxiety and fear can be normal and adaptive human emotions. Anxiety often manifests itself as uneasiness towards anticipated and imagined dangers, whereas fear is triggered by a real and present danger and is usually associated with the stress response, that is to say, the body’s response to a real or perceived threat. When these normal stress responses become unmanageable symptoms, an anxiety disorder or medical condition exacerbated by anxiety should be considered.
Anxiety disorders are characterized by a chronic state of persistent, excessive, and debilitating anxiety and/or fear that is often accompanied by avoidance behaviors. Anxiety disorders are the most common mental health disorder worldwide [14] and their lifetime prevalence is over 25 % in the US [15]. High risk groups include those with a history of childhood adversity or trauma, low-income women, as well as middle-aged widowed, separated, or divorced individuals [16, 17].
Anxiety Disorders and the DSM
The following anxiety disorders are described in the DSM-5 [9]: Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphonia, Generalized Anxiety Disorder, Substance/Medication-Induced Anxiety Disorder, Anxiety Disorder due to Another Medical Condition, Other Specified Anxiety Disorder, and Unspecified Anxiety Disorder.
The main anxiety disorders-related DSM-5 changes include the following [10]:
Anxiety disorders are listed in a separate chapter and no longer include obsessive-compulsive disorders or post-traumatic stress disorder.
Individuals over 18 no longer need to recognize that their fear is excessive in order to be diagnosed with agoraphobia, social anxiety disorder, or specific phobia
The minimum 6-month duration for the diagnosis of agoraphobia, social anxiety disorder, and specific phobia was extended to all ages (in the DSM-IV the 6 month duration minimum was limited to individuals under 18 years of age).
Different types of panic attacks are now described as expected or unexpected.
Panic disorder and agoraphobia are two separate diagnoses whereas in the DSM-IV one could diagnose panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder.
Social phobia is now called social anxiety disorder and the “generalized” specifier was eliminated and replaced by “performance only.”
Separation Anxiety Disorder and Selective Mutism are now classified as anxiety disorders, whereas in the DSM-IV they were under the subsection “Disorders usually first diagnosed in infancy, childhood or adolescence.”
The criteria for diagnosis of Separation Anxiety Disorder no longer include an age of onset before 18 years of age.
We will focus on Generalized Anxiety Disorder, as it is the anxiety disorder that we have observed to most often complicate the treatment of dermatological patients.
Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) is a chronic condition characterized by excessive and uncontrollable worry over numerous aspects of ones life that often interferes with functioning and is accompanied by behavioral changes and somatic symptoms. In order to diagnose GAD, symptoms must be present for at least 6 months. Table 3.3 details the complete DSM-5 criteria for the diagnosis of GAD [9].
Table 3.3
DSM-5 criteria for diagnosis of generalized anxiety disorder
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) |
B. The individual finds it difficult to control the worry |
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): |
Note: Only one item is required in children |
1. Restlessness or feeling keyed up or on edge |
2. Being easily fatigued |
3. Difficulty concentrating or mind going blank |
4. Irritability |
5. Muscle tension |
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) |
B. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning |
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism) |
D. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder) |
GAD is highly prevalent in primary care settings and has a 12-month prevalence of approximately 2 % [16, 18]. Its age of onset is generally late adolescence or early adulthood and risk factors for its development are similar to the risk factors for the development of depressive disorders. GAD is two times more common in women compared to men and is often comorbid with other psychiatric disorders; the lifetime comorbidity with other disorders has been reported to be as high as 90 % [17].
GAD first appeared in the DSM in its third edition. Since then, the diagnostic criteria have changed significantly [16]. Before the DSM-III, GAD was considered a residual condition. As such, it wasn’t until after 1980 that clinicians started understanding and diagnosing GAD as a separate diagnosis. Even then, the DSM-III prohibited the diagnosis of GAD when there were other psychiatric diagnoses. With the DSM-IIIR, GAD could be diagnosed with other psychiatric conditions. There have not been any significant changes in the diagnostic criteria for GAD between the DSM-IV and DSM-5 [10].
When considering a diagnosis of GAD, careful attention must be paid to other medical or psychiatric conditions that could be primary or comorbid. If an older patient presents with excessive worrying, weight loss and cognitive changes, consider other medical causes to explain these changes. It is also important to gather a complete social, substance use, and family psychiatric history when considering a diagnosis of GAD. Of note, GAD can be diagnosed with or without panic attacks, which are characterized by discrete periods of intense fear accompanied by bodily symptoms like heart palpitations, dizziness, chest pain, or shortness of breath. The occurrence of panic attacks is not sufficient for the diagnosis of panic disorder, which is outside the scope of this chapter.
Treatment of Generalized Anxiety Disorder
Traditionally the goal of GAD treatment had been treatment response, however the field has been moving towards considering remission, or >70 % improvement from baseline, to be the new treatment goal [13]. Like MDD, GAD can be treated with psychopharmacology and/or psychotherapy. Because all of the psychotherapies delineated in the MDD section are applicable to the treatment of GAD, this subsection will focus on psychopharmacology. It should be noted, however, that psychotherapy is a critical component in the treatment of anxiety disorders. Please refer to the psychotherapies for MDD section for more detail.
Psychopharmacology Treatments
Selective Serotonin Reuptake Inhibitors
SSRIs are the first-line treatment of GAD. Because the anxiolytic effects of SSRIs are quite similar across the different drugs, factors that guide selection of specific SSRIs include side-effect profile, family history (first degree relatives with a response to a particular agent), cost/availability, and patient preference. Table 3.2 details the SSRI doses used in MDD, which are similar to those used in GAD. Note that the starting dose for GAD is often lower to avoid initial exacerbation of symptoms and the target dose is often higher to treat anxiety disorders. Additionally, the titration schedule is often slower in an effort to avoid exacerbation of somatic symptoms in anxious, vigilant patients. Patients with GAD may show some early response to SSRIs within 4 weeks, but often require 6–8 weeks to see the full benefit. Patients should be counseled about this timeline to set expectations appropriately. It should also be noted that any side effects that emerge are most likely to be experienced within the first 6–8 weeks and often dissipate after that time. If the patient shows only partial improvement, the SSRI dose can be increased after this timeframe. A different medication trial is recommended if the patient does not show any response after a 6–8 week trial. A trial of a second SSRI is recommended before moving on to an agent in another class (most often an SNRI). When switching SSRIs, the clinician can choose between a cross-taper or a full switch. Since SSRIs have the same mechanism of action, switching SSRIs with equivalent doses is generally well tolerated by patients and is probably the simplest choice. Clinicians must remember that, upon discontinuation, antidepressants need to be tapered at a rate of about 25 % reduction per week given the risk for discontinuation syndrome. While not physiologically dangerous, antidepressant discontinuation syndrome can be quite uncomfortable for patients and includes anxiety, irritability, nausea, dizziness, fatigue, and muscle aches. Paroxetine is notorious for its discontinuation syndrome and utmost care must be taken when tapering this antidepressant.
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