Seasonal Affective Disorder DSM 5 Criteria

What is seasonal affective disorder?

Seasonal Affective Disorders (SAD) are a type of major depression that occurs at a specific time of the year, usually during the fall and winter months when there is less natural sunlight. It is sometimes called "winter depression" or "winter blues." The exact cause of winter seasonal affective disorder (SAD) is not fully understood, but it is believed to be related to the reduced level of sunlight in fall and winter, which can disrupt your body's internal clock and lead to feelings of depression.

The concept of SAD was first introduced in the 1980s by Dr. Norman Rosenthal and his colleagues at the National Institute of Mental Health. They noticed that some patients experienced depressive episodes during specific seasons, which led to the identification of this seasonal pattern of depression.

The scientific basis for SAD includes disruptions to the body's circadian rhythms, changes in serotonin and melatonin levels, and the influence of genetics. Research has shown that light therapy, which mimics natural sunlight, can help regulate these biological factors and improve symptoms of SAD (Melrose, 2015).

Seasonal affective disorder symptoms

Signs and symptoms of SAD may include depressive symptoms such as:

• Feelings of depression most of the day, nearly every day
• Loss of interest in activities you once enjoyed
• Low energy and lethargy
• Sleep disturbances (oversleeping or insomnia)
• Changes in appetite or weight (particularly cravings for carbohydrates and weight gain)
• Difficulty concentrating
• Feelings of hopelessness or worthlessness
• Social withdrawal

It's important to note that not everyone with SAD experiences all of these symptoms, and the severity can vary from person to person. These can be assessed by tools such as the seasonal pattern assessment questionnaire.

Risk factors and causes of seasonal affective disorder

While the exact cause of SAD is unknown, several factors may increase the risk of developing the condition:

• Geography: SAD is more common in regions farther from the equator, with shorter daylight hours in the winter.
• Family history: Individuals with a family history of SAD or other forms of depression are at a higher risk.
• Biological factors: Disruptions in the body's circadian rhythms and imbalances in serotonin and melatonin levels are believed to play a role.
• Gender: SAD is more commonly diagnosed in women than in men.

Understanding these risk factors can help individuals and healthcare professionals identify and manage SAD more effectively.

How is this different from other types of depression?

Seasonal Affective Disorder (SAD) is a subtype of major depressive disorder (MDD) with a distinct seasonal pattern. While it shares many symptoms with other forms of depression, there are key differences that set it apart:

• Seasonal pattern: The most distinguishing feature of SAD is its recurrent seasonal pattern. Symptoms typically begin in the fall or winter and subside in the spring or summer. This pattern must occur for at least two consecutive years for a diagnosis of SAD.
• Symptom variation: The symptoms of SAD often include hypersomnia (oversleeping), increased appetite with carbohydrate cravings, weight gain, and a heavy sensation in the arms and legs. These symptoms are less common in non-seasonal depression.
• Light sensitivity: People with SAD may be more sensitive to changes in natural light and may experience a significant improvement in mood and energy levels on bright sunny days or when exposed to artificial light therapy.
• Cause: While the exact cause of SAD is unknown, it is believed to be related to reduced exposure to sunlight during the shorter days of fall and winter. This is in contrast to other types of depression, where factors such as genetics, brain chemistry, and life events play a more prominent role.

It's important to note that while SAD is a type of depression, not all depression that occurs in the winter months is considered SAD. A thorough evaluation by a mental health professional is necessary to determine the correct diagnosis and appropriate treatment.

What is the DSM 5?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is a comprehensive classification system for mental disorders. Published by the American Psychiatric Association (APA), the DSM-5 is used by mental health professionals worldwide as a standardized tool for diagnosing and treating mental health conditions.

The DSM-5 provides clear descriptions, diagnostic criteria, and codes for each disorder, ensuring consistency and accuracy in diagnosis. It covers a wide range of mental health conditions, from mood disorders like depression and bipolar disorder to anxiety disorders, psychotic disorders, and more.

One of the key features of the DSM-5 is its emphasis on dimensional assessment, which considers the severity and frequency of symptoms along a continuum rather than a categorical approach. This allows for a more nuanced understanding of a person's mental health condition.

The DSM-5 is considered a reliable resource for mental health professionals, but it is not without controversy. Some critics argue that it can lead to overdiagnosis or that certain criteria may not capture the full complexity of an individual's experience. Despite these debates, the DSM-5 remains a cornerstone in the field of mental health for guiding clinical practice and research.

DSM 5 criteria for seasonal affective disorder

The DSM-5 outlines specific criteria for diagnosing Seasonal Affective Disorder (SAD) as a subtype of major depressive disorder or bipolar disorder with a seasonal pattern. The criteria include:

• Criterion A: A regular temporal relationship between the onset of major depressive episodes and a specific time of the year (e.g., fall or winter).
• Criterion B: Full remissions or a change in mood (from depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression lifts in the spring).
• Criterion C: In the past two years, the individual has experienced seasonal depressive episodes, with no non-seasonal episodes during that period.
• Criterion D: Seasonal depressive episodes substantially outnumber any non-seasonal episodes over the individual's lifetime.

Are there differences between the DSM 4 and DSM 5 criteria for this?

The transition from DSM-IV to DSM-5 brought about significant changes in the classification and diagnosis of Seasonal Affective Disorder (SAD).

In DSM-IV, SAD was not considered a standalone mood disorder but rather a seasonal pattern specifier for major depressive episodes. In contrast, DSM-5 recognizes SAD as a subtype of depression, specifically Major Depressive Disorder with a seasonal pattern. This shift acknowledges SAD as a distinct form of depression with unique characteristics.

Moreover, in DSM-IV, SAD could be diagnosed as a modifier for mood disorders, allowing for comorbid diagnoses such as bipolar disorder with a seasonal pattern. However, in DSM-5, SAD is identified as a specific subtype of depression, separating it from other mood disorders and highlighting its unique seasonal pattern.

Lastly, the criteria for diagnosing SAD have been refined in DSM-5. The essential feature is a regular seasonal pattern of mood episodes (mania, hypomania, or depression) with full remissions or a change in the type of episode occurring at a characteristic time of year. The criteria in DSM-5 emphasize the temporal relationship between mood episodes and specific seasons, requiring a consistent pattern over the last two years without non-seasonal episodes of the same polarity during that period.

These changes reflect a more nuanced understanding of SAD and its distinct features compared to other forms of depression, providing a clearer framework for diagnosis and treatment.

Seasonal affective disorder treatments

Effective treatment for Seasonal Affective Disorder (SAD) involves a combination of therapeutic interventions tailored to the individual's symptoms and needs. Here are some commonly used treatments:

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant that can help alleviate the symptoms of SAD by increasing the levels of serotonin in the brain. Serotonin is a neurotransmitter associated with mood regulation, and its imbalance is often linked to depression. Common SSRIs used to treat SAD include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). While effective, these medications may come with side effects such as nausea, insomnia, and sexual dysfunction.

Second generation antidepressants

In addition to SSRIs, second-generation antidepressants like bupropion (Wellbutrin) are also used to treat SAD. Bupropion is particularly interesting because it not only acts as an antidepressant but also as a smoking cessation aid. It works by inhibiting the reuptake of dopamine and norepinephrine, another two neurotransmitters involved in mood regulation. Bupropion is often prescribed for SAD patients who don't respond well to SSRIs.

Cognitive behavioral therapy (CBT)

CBT is a form of psychotherapy that helps patients identify and change negative thought patterns and behaviors that contribute to their depression. For SAD, CBT focuses on coping strategies for dealing with the winter months and can include techniques like light exposure, scheduling pleasant activities, and maintaining a regular routine. CBT has been shown to be effective in reducing SAD symptoms and can have long-lasting benefits.

Bright light therapy

Bright light therapy is one of the most well-established treatments for SAD. It involves exposure to a lightbox that emits bright light, mimicking natural sunlight. Patients are typically advised to use the lightbox for about 30 minutes to an hour each morning during the fall and winter months. This therapy is thought to help reset the body's circadian rhythms and stimulate the production of serotonin.

Vitamin D supplementation

Some studies suggest that low levels of vitamin D may be linked to SAD. Taking vitamin D supplements may help improve mood in individuals with SAD, especially if they have a vitamin D deficiency. However, more research is needed in this area.

Psychoeducation and lifestyle changes

Psychoeducation involves learning about SAD, its causes, symptoms, and treatment options. Understanding the disorder is the first step; after that comes getting regular exercise, maintaining a healthy diet, and establishing a consistent sleep schedule. These all contribute to improved mood and overall well-being in individuals with SAD.

Research on seasonal affective disorder

Seasonal Affective Disorder (SAD) has been the subject of numerous studies aimed at understanding its underlying mechanisms and finding effective treatments. Two notable studies shed light on the neural effects of bright light therapy and the complexities of hypersomnolence in SAD.

A study published by Costello et al in the Annals of Medicine in 2023 explored how bright light therapy (BLT) might work for SAD. Researchers found that BLT affects certain markers in the brain related to inflammation and brain cell health, known as neuroinflammation and neuroplasticity. These changes were observed in different brain areas and varied between males and females. The findings suggest that BLT's benefits for mood, sleep, and thinking might be due to its impact on these brain markers.

Another study by Wescott and colleagues in Psychological Medicine last year looked at sleep patterns in people with SAD compared to those without seasonal depression. Despite SAD sufferers reporting longer sleep and more daytime sleepiness in winter, actual sleep time didn't differ much between seasons or groups. This suggests that feeling overly sleepy in SAD might not just be about sleeping more. Researchers recommend thoroughly assessing sleep issues in mood disorders before considering treatments for sleep.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th ed.). American Psychiatric Association Publishing. https://www.migna.ir/images/docs/files/000058/nf00058253-2.pdf

Costello, A., Linning-Duffy, K., Vandenbrook, C., Lonstein, J. S., & Yan, L. (2023). Effects of bright light therapy on neuroinflammatory and neuroplasticity markers in a diurnal rodent model of seasonal affective disorder. Annals of Medicine, 55(2). https://doi.org/10.1080/07853890.2023.2249015

Melrose, S. (2015). Seasonal affective disorder: An overview of assessment and treatment approaches. Depression Research and Treatment, 2015, 1–6. https://doi.org/10.1155/2015/178564

Nevarez-Flores, A. G., Bostock, E. C. S., & Neil, A. L. (2023). The underexplored presence of seasonal affective disorder in the southern hemisphere: A narrative review of the Australian literature. Journal of Psychiatric Research, 162, 170–179. https://doi.org/10.1016/j.jpsychires.2023.05.003

Wescott, D. L., Franzen, P. L., Hasler, B. P., Miller, M. A., Soehner, A. M., Smagula, S. F., Wallace, M. L., Hall, M. H., & Roecklein, K. A. (2021). Elusive hypersomnolence in seasonal affective disorder: Actigraphic and self-reported sleep in and out of depressive episodes. Psychological Medicine, 53(4), 1–10. https://doi.org/10.1017/s003329172100283x