In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is atypical depression.
“Atypical features” is a specifier that describes individual depressive episodes. While the name suggests it’s not particularly common, that’s not actually the case. The atypical name comes because of the way it differs from depression with melancholic features.
Symptoms of atypical depression
In addition to meeting the criteria for a major depressive episode, the atypical features specifier requires the first of the following symptoms as well as at least two others:
- mood reactivity to pleasurable stimuli or positive events
- increased appetite or significant weight gain (as opposed to decreased appetite and weight loss in melancholic features)
- increased sleep (as opposed to early morning awakening in melancholic features)
- feeling of heaviness in the limbs that has a significant impact on functioning (aka leaden paralysis)
- a pattern of longstanding sensitivity to interpersonal rejection
In the world of psychiatry, the term “neurovegetative symptoms” refers to depression’s impact on sleep, appetite, and weight. The increased sleep and appetite with atypical features is sometimes referred to as reversed neurovegetative symptoms (i.e. a reversed pattern from melancholic features).
Atypical features first showed up in the DSM with the release of the DSM-IV back in 1994. There’s been a fair bit of debate around the criteria and whether it constitutes a distinct illness from melancholic depression. While the DSM requires mood reactivity for an atypical features diagnosis, some researchers have argued against that.
Other characteristics
One figure I came across said that between 15-29% of patients with depression have atypical features. It’s particularly common in people with bipolar II disorder and persistent depressive disorder (formerly known as dysthymia). Atypical features are more common in females, and the age of onset tends to be younger than in people with other presentations of depression. Almost 2/3 of people who have atypical features in a given depressive episode have a repeat of atypical features in their next episode.
People with atypical features are more likely to have a history of sexual abuse or neglect (research results are less clear re. physical abuse) versus those with non-atypical features. They’re also more likely to experience suicidal thinking and suicide attempts, as well as greater functional disability.
People with atypical features are more likely to have comorbid conditions, and in particular panic disorder, social anxiety disorder, or bulimia, compared to people with non-atypical depression. Rates of substance abuse are also higher.
While melancholic depression often involves a hyperactive stress hormone system (the hypothalamic-pituitary-adrenal axis), that’s not the case in atypical depression, and an underactive HPA axis has been observed in some patients with reversed neurovegetative symptoms. Differences in blood perfusion to certain areas of the brain have been observed in atypical vs non-atypical depression.
Treatment
Treatment specific to atypical features hasn’t been as well researched as treatment of melancholic features. Monoamine oxidase inhibitor (MAOI) antidepressants are about twice as effective as tricyclic antidepressants (TCAs) in this patient population. However, MAOIs are more likely to cause side effects and require limiting dietary tyramine intake, so they’re not generally used as a first-line treatment. Fluoxetine has shown positive results in some fairly small studies. Bupropion (Wellbutrin) may be a good first-line choice; it affects the neurotransmitters norepinephrine and dopamine rather than serotonin and tends to be more activating than SSRIs.
People with atypical features don’t appear to respond as well to electroconvulsive therapy (ECT) as people with melancholic depression. In terms of psychotherapy, cognitive behavioural therapy (CBT) has been found to be effective.
I’ve always tended toward melancholic features, and I’ve never had atypical features with my own depression. When my sleep and appetite are affected, they’re always decreased rather than increased.
Is atypical depression something that you’ve ever experienced?
References
- Cristancho, M. A., O’reardon, J. P., & Thase, M. E. (2011). Atypical depression in the 21st century: Diagnostic and treatment issues. Psychiatric Times, 28(1), 42-47.
- Łojko, D., & Rybakowski, J. K. (2017). Atypical depression: Current perspectives. Neuropsychiatric Disease and Treatment, 2017(13), 2447-2456.
- Matza, L. S., Revicki, D. A., Davidson, J. R., & Stewart, J. W. (2003). Depression with atypical features in the National Comorbidity Survey: Classification, description, and consequences. Archives of General Psychiatry, 60(8), 817-826.
- Nelson, E. B., & McElroy, S. L. (2003). Atypical depression Puzzled? How to piece together symptoms and treatments. Current Psychiatry, 2(4), 13.
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
Your articles are always so informative! Thank you.
Thank you!
Actually, I have experienced some of those symptoms when depressed, especially sleeping more…
🙁
I experienced atypical-type depression, although now it’s not clear how much was actually depression and how much was autistic burnout.
I can see that being hard to distinguish.
I have bipolar 1, and my last three depressions were atypical; I have found CBT to be effective.
I’m glad it’s helped!
Interesting to learn more about this kind of depression. I didn’t know it was a type all its own in the DSM!
🙂
Is atypical depression something that you’ve ever experienced? Yeah. Onset (although undiagnosed) at age 13 or 14, exacerbated in my 20s, have struggled with atypical depression my entire adult life. I have an antidepressant that works wonderfully, while most of the others tend to make me jittery or comatose. I take another at night for help with insomnia and sleeping troubles. I have one suicide attempt, and have suicidal ideations quite a lot, but no impetus to act on those any more. They stuck various labels on me on this long journey through mental illness and one of them was dysthymia, another was chronic depressive, another still was long-term depressive. All come down to the same thing though. Well in my opinion.
Yeah, depression is shitty, no matter what label is attached to it.
What if someone has characteristics of both melancholic depression and atypical depression?
Somewhat related: Quite a significant subset of folks with treatment resistant depression have a high dissociation / a possible comorbid dissociative disorder. A psychiatrist expert in dissociative disorders (Vedat Sar) has written about how perhaps it’s important to bring back depression subtypes again.
Makes interesting reading.
If someone had a mix of symptoms they just wouldn’t be given a features specifier.
I wasn’t familiar with Dr. Sar’s work. Interesting stuff.
Ooh, that’s cool to know! I think I was diagnosed with “persistent depressive disorder” (formerly dysthtmia) though I honestly feel I’ve met MDD criteria plenty of times despite medication.
I guess I didn’t actually realise that persistent depressive disorder/dysthymia can also be classified as having melancholic or atypical features, which seems to be the case given what you say about a lot of folks with PDD and bipolar having atypical features. It’s actually quite logical that it could also be classified like that because it’s still depression like MDD, but for some reason it had never occurred to me before.
I don’t really know which one I have, I guess it’s a very mixed bag and it depends largely on the intensity of the symptoms. Mood reactivity definitely is there most of the time at least to some degree, which I feel really lucky about because I’ve experienced anhedonia at times as well and it stinks like a giant skunk.
While I do sometimes have phases where I’ll try to make myself feel better with food, generally the shittier I feel (be it stressed or depressed or AVPD or whatever else) the less I eat. Maybe not even because my appetite has physically decreased but I just can’t be bothered to think about food or I’m physically hungry but mentally just not into it one bit until I can’t ignore the hungry feeling any longer.
With sleep I think it gets complicated by my weird shifting sleep patterns. I do really like to escape into Sleepland for as long as possible when my depression gets worse and then it’s often possible for me to spend loads of time in there, but there are also times when I just can’t sleep much at all when I’m particularly depressed or it’s very broken sleep. Early morning or middle of the night awakenings can be a thing too but I don’t think they correlate with my mood in some specific way, it’s just a feature of my moody circadian rhythm. They’re just a lot more frustrating when I feel particularly depressed because it feels like you have loads and loads of time with nothing to do with it, whereas when I’m more or less around my baseline or higher I don’t mind it.
When I had my major depressive episodes, I felt freakishly fatigued and weary all the time in each of them, yet had real trouble falling asleep pretty much every night so I really hated night time. But once/if I’d manage to fall asleep I don’t recall waking up a lot or super early, actually I remember with the second one it was kind of weird because my sleep cycle became oddly predictable then compared to what it normally is like and most of the time I’d fall asleep sometime around 3 AM and wake up around 10 AM if I didn’t have to wake up earlier for school or something, but it was super impractical as a regular sleep-wake schedule.
So yeah, I think it’s quite mixed for me and I wouldn’t be surprised if this was a very common thing for people to just have a mixed bag like that.
Yeah, a mixed bag of symptoms is common, and a lot of people aren’t given a particular features specifier.
That combination of fatigue yet difficulty getting to sleep is such a weird feeling.
The depression I experience is considered atypical. Increased appetite, weight gain, etc.
Not fun.
I honestly am not sure what type of depression I experience with the bipolar. I do have increased sleep and some weight gain. But my doc has never categorized the depression side of the bipolar as atypical or non-atypical. Meds that work for me include: clozapine, clonazepam and oxcarbazepine.
A lot of times people aren’t given a features specifier for their depression.
Also to add to the above, I am not a good candidate for the typical anti-depressant. The anti-depressant bumps me into mania/hypomania.
That’s definitely a risk with antidepressants in bipolar, and they also don’t work as well as they do for unipolar depression.
Yes. It was a really bad problem for me with the post partum depression just after my daughter was born 18 years ago. I kept getting prescribed an anti-depressant (different ones) and kept landing in the hospital every few months. I think it is more widely accepted now (18 years later) that antidepressants present a risk for people with bipolar.
Interesting categorization to think about. I think I mostly experience typical episodes with the exception of sleep. I used have insomnia at night (regardless of napping or not napping) but could sleep excessively during the day, which I totally used as an escape. Now, though, things seem to have transitioned into just insomnia. I somewhat blame my MAOI and TMS for that, but I think it’s partly just the progression of things for me.
There’s been many times when I wished I could just sleep all day…
It is pretty frustrating not being able to. Of course, it also gets in the way of life when you can’t seem to stop, so I guess it’s not the ideal strategy – unfortunately.
I absolutely have depression with atypical features. This whole article was written about me. I have Bipolar I though. The heaviness in the limbs is a really terrible thing. I feel like I’m dragging around anvils so I
stay in bed and sleep. I attempted suicide for the 2nd time in my life in 2019 and recovered mentally just in time for COVID lockdowns. I am finally doing well enough with CBT that a few of my coping skills are kicking in here and there making some things a little easier. It’s a hard road but I’m finding the bit about the coping skills quite pleasing.
I’m glad things have gotten a little easier. The limb heaviness thing sounds really hard.