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The New Therapist
with Anthony D. Smith, LMHC

Signs of Major Depression Subtypes: Atypical Features

In the previous segment it was mentioned how Melancholia was historically-known as “typical” depression. Today, we’ll examine its nemesis: Atypical Features. You’re probably wondering why the smiling woman in a series on depression? Well, in contrast to the chronic misery of Melancholic Features, someone with Atypical depression can experience some good feeling in reaction to things. Despite this, Atypical  should not be thought of as a pleasant experience. Let’s take a look…

Atypical features does not indicate it is uncommon; the term was originally meant to note that symptoms were not Melancholic in nature. In essence, that the patient can have periods of feeling better in response to positive experiences, unlike the unrelenting torment of Melancholia. It is also atypical in that most people who get depressed have insomnia and appetite loss; it’s just the opposite with this one. Like Melancholia, current prevalence rates are hard to come by. There is minimal recent data on prevalence, but Atypical Features is believed to account for up to 36% of MDD cases (Łojko & Rybakowski, 2017). It also seems to first appear in the teens and early 20s, earlier than other MDD forms; be more chronic, and more prevalent in women (Barlow & Durand, 2015; Singh & Williams, 2006), and be the kind of depression most associated with Bipolar Disorder.

The Presentation:

Atypical Features is an interesting MDD subtype in that, aside from the ability to experience some level of a good mood, we also encounter the unusual symptom of leaden paralysis, like Barbara:

Barbara, a working mother of two and devoted wife, was no stranger to depression.  She adored her family and enjoyed her part-time work at the library. Barbara knew when a depressive episode was coming on when she began feeling drained at the thought of having to work, never mind that plus caring for the kids after daycare until her husband, Jack, got home. It never failed that her down-in-the-dumps feeling led to eating a lot of comfort foods. She’d berate herself as she ate a second bacon and egg sandwich many mornings, but she was simply feeling like eating more. At dinner, Barbara plowed through extra helpings of dinner and desserts. Within a week, Barbara was frowning in the mirror, checking if the weight gain she was starting to feel was observable. Soon, she was not only bedraggled by tiredness, but could go for hours feeling as if she wore weighted clothing. It was impossible to drive to the library and work for four hours each day, never mind chase the kids around. Thankfully, Jack had an understanding boss, and he could work from home on those days. Despite her feeling down, Barbara would maintain a level of brightness when Jack was home during these periods.

The official criteria for Atypical Features, according to the DSM-5, is as follows:

  • Mood reactivity must be present

Coupled with at least two of the following:

  • Excessive appetite/weight gain
  • Excessive sleep
  • Leaden paralysis, especially felt in the extremities.
  • A sense of interpersonal rejection that is present even when the person is not in a depressive episode

Can you identify the Atypical Features of Barbara’s depression? Feel free to share in the Comments!

Treatment Implications:

As with Melancholia and Anxious Distress, Atypical Features has its special considerations. First, given Atypical Features is highly associated with Bipolar Disorder, we should become vigilant for any manic/hypomanic symptoms as we get to know the patient. As you’re probably aware, Bipolar Disorders are genetic conditions that require pharmacological intervention to stabilize well, and the sooner the intervention the better. Manic episodes are prone to kindling effects, meaning that the more episodes someone has, the longer and more severe subsequent episodes may become.

Next, Atypical depression is correlated with higher rates of suicide attempts and completions. This is likely due to there generally being more depressive symptoms present overall and the symptoms tending to be more severe. Also, people with Atypical depression are more apt to have co-occurring anxiety disorders, compounding their misery. Imagine feeling but also weighted down to the point it is hard to move, as weight piles on from overeating, further sinking your self-esteem. Add to this feeling no good to the point you believe the world is rejecting you, coupled with a co-occurring baseline anxiety condition! Assessing for risk of suicide is very important in the presence of Atypical depression.

As with the other MDD subtypes thus far, referral to psychiatry is exceptionally important here. Like Melancholia, Atypical Features researchers have written much on a heavy  biological influence. Thus, it often responds well to medication, especially the fatigue and appetite symptoms. Getting a patient to have the energy to attend therapy is a big step. Curbing the appetite will help with issues of self-esteem, and managing the sugar spikes and crashes many seem to experience from indulging in comfort foods, which surely doesn’t help the moodiness. You may have heard of MAOI’s or monoamine oxidase inhibitors, the earliest of anti-depressants. Interestingly, these were discovered as antidepressants while used in tuberculosis wards during the middle of last century (Mendelson, 2020). These are not used much nowadays except as a last resort, because they don’t interact well with other medications and can cause serious complications if certain foods are eaten (Culpepper, 2013). Other more modern antidepressants, sometimes in combination, are often prescribed that can also help with quickly curbing appetite and increasing energy.

Working with patients with Atypical depression again presents a significant challenge to therapists. However, given their ability to experience windows of more positive demeanor despite the depression can also make therapy less of a chore. Ultimately, Atypically-depressed patients can meet with success while working closely with a therapist and psychiatrist, who are also keeping vigilant for suicide and emerging Bipolar Disorders.

Speaking of curious MDD presentations, up next we’ll investigate the strange world of Catatonic Features…

References:

Barlow, D.H. and Durand, V.M. (2015). Abnormal psychology: an integrative approach. Cengage.

Culpepper L. (2013). Reducing the Burden of Difficult-to-Treat Major Depressive Disorder: Revisiting Monoamine Oxidase Inhibitor Therapy. The primary care companion for CNS disorders15(5), PCC.13r01515. https://doi.org/10.4088/PCC.13r01515

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Łojko, D., & Rybakowski, J. K. (2017). Atypical depression: current perspectives. Neuropsychiatric disease and treatment13, 2447–2456. https://doi.org/10.2147/NDT.S147317

Mendelson, W.B. (2020). The curious history of medicines in psychiatry. Pythagoras Press.

Singh, T., & Williams, K. (2006). Atypical depression. Psychiatry (Edgmont (Pa. : Township)3(4), 33–39.

 

Signs of Major Depression Subtypes: Atypical Features


Anthony

Anthony Smith is a licensed mental health counselor in Massachusetts with 20 years of experience. He has worked in facilities and in private practice performing therapy and diagnostic evaluations across a wide array of populations both demographically and clinically. This includes 17 years in the forensic arena, where he currently provides assessments for the juvenile courts. Aside from interest in the intersection of psychology and law, Anthony is particularly in interested differential diagnosis and supervision of new practitioners. He regularly teaches abnormal psychology and creates courses on the lived experience of people with mental illness, along with supervising graduate student counselling practicums at a local university. When not providing clinical services, teaching or blogging, Anthony can be found hiking and fly-fishing around the Northeast and American West.

 


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APA Reference
Smith, A. (2020). Signs of Major Depression Subtypes: Atypical Features. Psych Central. Retrieved on August 10, 2020, from https://pro.psychcentral.com/new-therapist/2020/07/signs-of-major-depression-subtypes-atypical-features/