By Rajnish Mago, MD (bio)
Depressive episodes in depressive disorders or bipolar disorders can be associated with what are called “atypical features.” What exactly are these atypical features and when should we diagnose a mood episode as being “With atypical features”?
Two clarifications
In the DSM-5, the phrase “With atypical features” is a “specifier” that can be added to a diagnosis when the atypical clinical features discussed below predominate during the majority of days of the current or most recent episode.
It is a misunderstanding to think that the “with atypical features” specifier can apply only to major depressive disorder. It can also be used with diagnoses of persistent depressive disorder or bipolar depression.
Diagnostic criteria for atypical features
The “with atypical features” specifier in DSM-5 applies if there is mood reactivity AND at least two more of the symptoms below.
Mood reactivity is said to be present when the person’s mood typically improves when something good happens or there is an anticipation that something good is going to happen. Notice that mood reactivity is not a bad thing; absence of mood reactivity is something undesirable.
Other symptoms of which at least two must be present:
1. Significant increase in appetite or weight gain
2. Hypersomnia. This is said to be present when the total amount of sleep in a 24 hour period exceeds 10 hours OR is at least 2 hours more than the amount of sleep the person typically gets when euthymic.
3. A heavy, leaden feeling in the limbs (also called “Leaden paralysis”)
4. A pattern of clinically significant interpersonal rejection sensitivity that is long-standing and is not limited to the mood episodes. We should note that this is an unusual diagnostic feature. It is a key diagnostic symptom but is unusual because it occurs well before the mood episode occurs.
Not so atypical
The term “atypical features” is a misnomer. It was originally used because in the past there was a focus on diagnosing clinical depression with features of lack of reactivity, decreased appetite, decreased sleep, etc. We should not conclude that “atypical” clinical features are uncommon in depressive episodes.
Low on the totem pole
There is another diagnostic note that we must make. Some of the specifiers are arranged hierarchically. The “with atypical features” specifier can only be used if the specifiers “with melancholic features” and “with catatonia” do not apply during the same mood episode.
An important clinical question is: How should depressive episodes with atypical features be evaluated and managed differently from those without atypical features? For our practical guidance on this, please see the articles linked to below:
How to assess patients with depressive episodes with atypical features
How to manage atypical features in depressive and bipolar disorders
Related Pages
How to assess patients with depressive episodes with atypical features
How to manage atypical features in depressive and bipolar disorders
“Specifiers” for mood disorders
Anxious distress (in depressive episodes)
Cognitive dysfunction in major depressive disorder
A Deeper Understanding of the DSM-5 Criteria for Major Depressive Disorder
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing. 2013.
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I have one confusion. Some researchers have proposed not using mood reactivity as a necessary criterion. In clinical practice, as the depressive symptoms increase in severity, mood reactivity diminishes—hence, it loses its diagnostic utility.