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Depression
Atypical Depression: A Typical Illness in Women
This common condition is still under-diagnosed and under-treated.
Posted September 14, 2022 Reviewed by Davia Sills
Key points
- Atypical depression is not atypical at all.
- It is especially common among women but is easily misdiagnosed.
- Effective treatment is often delayed due to the distractions of some atypical depression symptoms.
Psychiatry has a naming problem. Obsessive-compulsive disorder and obsessive-compulsive personality disorder are assumed to be cousins but, in fact, are barely related. The “schizo” in schizophrenia implies a split in the mind—but no such split takes place. And so it is with atypical depression, a form of depression that, in women, is actually common and typical. It is the entryway for many young women into mental health care but is often not diagnosed due to its multiple distracting features. It also acts as a mirror, reflecting psychiatric and social biases towards women. Despite its prevalence, misdiagnosis and under-treatment remain commonplace.
Atypical depression may represent up to one-third of all instances of depression. As almost all cases occur in women, I will discuss the illness from a woman’s perspective. They also occur earlier in life and may be associated with numerous other mental health issues. What exactly makes atypical depression appear atypical is at the center of the diagnosis and the problems it entails.
What, then, is not typical here? To answer, we first need to understand what is considered typical. The first descriptions of depression, dating back to 400 BCE, became known as melancholia, a diagnosis still in use. Our current description of melancholia depicts a patient who sits and barely moves a muscle, except possibly for wringing their hands. They appear flat, worried, and unhappy. The essence of this picture is the lack of movement or response. We have a name for what is missing: reactivity.
Reactivity is the key to diagnosis
Reactivity—the degree to which we respond physically and emotionally to things around us—is almost always decreased in typical depression. Depressed people move their bodies, change their expressions, and even adjust their tone of voice less than others do. In practice, I would take note of a patient’s voice the moment they began to speak. Often, I could tell if they had improved after just a few sentences.
In melancholia, reactivity is profoundly diminished. In severe cases, a patient may look like a statue. If told they had won the lottery, a patient would respond with a barely audible, emotionless acknowledgment, hardly moving a muscle. In atypical depression, this dimension is completely different. People retain their reactivity—in some cases, excessively so. This normal reactivity—laughing at jokes, appearing interested in something new, and having normal body movement—can make this type of depression difficult to spot.
Melancholia and atypical depression are two ends of a spectrum of illness. Atypical depression is common; pure melancholia much less so. Most depressions lie somewhere in the middle with comparatively decreased reactivity.
Further diagnosis
In atypical depression, we often find not only a preservation of reactivity but also amplified responsiveness. A perceived rejection or insult may bring about an explosive emotional response. Note that this is a “perceived” rejection or insult. It may not seem so to onlookers. This reaction is so important to the psychology of atypical depression that it has a label: rejection sensitivity. In fact, a person suffering from atypical depression can get extremely upset, either sad or angry, at minor interpersonal experiences that to them convey painful insults or outright rejection.
Negative feelings (sad, angry, blah) come quite easily to these unfortunate individuals. This may put them in perpetual conflict with those around them. This tendency towards difficult relationships is responsible for the commonly mistaken diagnosis of a personality disorder (usually borderline personality) or the more pejorative labels of "difficult" or "manipulative."
Another common observation and source of misdiagnosis is that the mood reactivity (which may be in response to positive things as well as negative) may be so dramatic as to be seen as severe mood lability. Lability is different from reactivity in that mood changes have lost their connection to what is happening around the individual. The person’s mood shifts quickly and substantially from good to bad and back again. This, in turn, is mistakenly believed to be bipolar disorder. While patients suffering from bipolar mania may act this way, mood lability is not diagnostic of this illness.
In addition to a depressed mood with preserved or exaggerated reactivity, there are other symptoms that are considered atypical. These include “reversed” neuro-vegetative symptoms: Instead of sleeping and eating less, they do more of both. I have seen this in practice, but it is not present in every case. As a result, I do not consider it essential to make the diagnosis.
What is very common, however, is that anxiety is a prominent part of this depressive syndrome. Many people experience significant anxiety when they develop their first depression, atypical or otherwise. In atypical depression, the levels of anxiety are quite high and are often the reason the person seeks help.
In my opinion, the diagnosis should be made when there is excessive reactivity around interpersonal tensions; rapid, sudden mood changes (all of these changes are predominantly negative emotions); heightened anxiety; and, frequently, a significant increase in symptoms in women before their menses. Other changes, such as eating, sleeping, energy, and suicidal thinking, may, of course, be present.
PMS is not a hormonal problem
It is important to note that the increase in symptoms in the premenstrual phase is not a hormonal problem. It is how depression reacts to normal changes in the female menstrual cycle. Hormonal medication does not work, may make their mood worse, and exposes the woman to unnecessary medical risks. (Some oral contraceptives shorten menses, and thus the time of being symptomatic.)
The changes around the premenstrual phase lead to yet another source of bias and misdiagnosis. As atypical depression often begins in adolescence, clinicians and family members are led to assume that this is the storm of emotions of normal teenage life, especially a female one. To correct these misconceptions, I must make two points: First, adolescence does indeed entail emotional change as well as high and low points. However, the teen years are not inherently a storm of emotional turmoil as commonly believed. And second, women, especially young women, are not inherently overly emotional.
Helping the struggling teenage girl
Atypical depression is important to recognize as it is commonly what is wrong with the “troubled teenage girl.” In addition, as with any emotional problems in adolescents, behavioral problems such as wrist cutting, sexually acting out, or new-onset substance use may take up all the therapeutic limelight. This can easily deflect appropriate attention given to possible mood disorders.
The diagnosis of atypical depression was established in the 1960s when it was found that some people needed MAOI antidepressants to recover instead of the usual tricyclic drugs. The use of the complicated (but still highly effective) MAOI antidepressants has been eclipsed by SSRIs and their cousins, the SNRIs.
A usual dose of an SSRI (e.g., Prozac or Lexapro) or course of psychotherapy generally does not help. In my experience, patients require either a higher dose of a common antidepressant or, better yet, a full therapeutic dose of an SNRI (Effexor or Pristiq). Once their moods become more stable, therapy around interpersonal relationships and the handling of strong emotions is an extremely valuable addition.
Sadly, this is not the usual course of things. Understandable attention focused on the behaviors mentioned above or toward an incorrect diagnosis may detour the patient into years of struggle instead of helpful treatment. For younger patients, this also may derail important areas of development. Relationships become a minefield of untamable emotions, making the formation of stable relationships extremely difficult.
Treatment of atypical depression may not right the listing course of a young woman’s life in every case. But it usually makes change possible where before it was unapproachable.
