Implications of the DSM's emphasis on sadness and anhedonia in major depressive disorder

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Abstract

At least five symptoms must occur for a DSM diagnosis of major depressive disorder (MDD), one of which must be sadness or anhedonia. The present study is the first known investigation of the implications of the presence or absence of these prioritized symptoms on symptom expression and clinical characteristics among 564 young adults with MDD. Differences in symptom expression and clinical characteristics occurred among MDD participants with sadness relative to those without sadness as well as among MDD participants with anhedonia relative to those without anhedonia. Differential symptom expression could have important implications for the etiology, prevention, and treatment of MDD.

Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000), at least five symptoms must occur for a diagnosis of major depressive disorder (MDD), one of which must be either sadness or anhedonia. Given that these two symptoms are prioritized by the DSM, the question arises as to what are the implications of presence or absence of these symptoms in individuals with MDD. In other words, do patients with anhedonia have a different pattern of symptoms than patients without anhedonia and do patients with sadness have a different pattern of symptoms than patients without sadness? Such differential symptom expression could have important implications for understanding the etiology, prevention, and treatment of MDD. For example, perhaps the emphasis on these two depressive symptoms at least partially explains the heterogeneity of symptom expression among individuals with MDD, such as why some individuals with MDD experience increased appetite while others experience decreased appetite. However, to our knowledge, this question has not been empirically examined.

There is some evidence to suggest that differential symptom patterns may exist. MDD individuals with anhedonia have been found to demonstrate greater social impairment, have higher scores on measures of depression and hopelessness, be less neurotic, be younger, and to be more often female when compared with MDD individuals without anhedonia (Fawcett et al., 1983). There is also evidence to suggest a correlation between anhedonia and psychomotor retardation among adults with MDD (e.g., Lemke et al., 1999). Depression with melancholia (a defining characteristic of which is loss of interest or pleasure in nearly all activities) has been found to be associated with loss of appetite (e.g., Kazes et al., 1993). Additionally, negative emotions such as sadness have been linked to increased eating in some individuals (e.g., Geliebter and Aversa, 2003).

The present study serves as the first known comprehensive attempt to examine the effects of the presence or absence of sadness and anhedonia on the remaining DSM symptoms of MDD among young adults. The present study also examined the effects of the presence or absence of sadness and anhedonia on both DSM criteria as well as clinical characteristics of MDD. Clinical characteristics were examined to investigate a wider range of the implications of the prioritization of sadness and anhedonia on the expression of MDD. It was hypothesized that different symptoms would be correlated with the presence of anhedonia than the absence of anhedonia and that different symptoms would be correlated with the presence of sadness than the absence of sadness. We specifically expected that the presence of anhedonia would be associated with indicators of impaired hedonics (e.g., decreased appetite, decreased desire to socialize). Gender differences were also analyzed to determine if males and females differ with regard to how the presence or absence of sadness and anhedonia influenced overall symptom expression.

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Participants and procedures

The sample was drawn from the Oregon Adolescent Depression Project. Participants were randomly selected from nine senior high schools representative of urban and rural districts in western Oregon. A total of 1709 adolescents completed the initial (T1) assessments, with an overall participation rate of 61%. Specific comparisons were made to determine the representativeness of this sample (see also Lewinsohn et al., 1997, Lewinsohn et al., 2001). First, demographic characteristics of participants

Results

Of 564 participants (371 females) who experienced an MDD episode, 46 (8%) did not experience anhedonia. The mean symptom count was 17.2 (S.D. = 4.3; range = 6–32) out of a total of 35 symptoms assessed.

The associations of sadness and anhedonia with other symptoms were assessed by conducting two one-way multiple analyses of variance (MANOVAs). In both MANOVAs, symptoms were entered as dependent variables (DVs), excluding the one symptom (i.e., sadness or anhedonia) entered as the independent

Discussion

To our knowledge, this is the first study to comprehensively examine differential patterns of depressive symptoms in the presence and absence of the two symptoms prioritized by the DSM for MDD, sadness and anhedonia. These results indicate that there are differences in symptom patterns among participants with sadness versus participants without sadness and that there are different symptom patterns among participants with anhedonia versus those without anhedonia. When compared with participants

Acknowledgements

This research was supported in part by NIMH awards MH40501 and MH50522, and by the John Simon Guggenheim Foundation awarded to Dr. Peter M. Lewinsohn. This research was also supported in part by a National Research Service Award from the National Institute of Drug Abuse (F31 DA021457) awarded to Julia D. Buckner.

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