Atypical Depression: Symptoms, Causes, and Treatments

Compared to other forms of depression, people with atypical depression may feel sleepier, hungrier, and more responsive to positive events.

Do you experience depression but still get a mood boost when good things happen? Is it easy for you to oversleep and overeat? Are you always afraid that people won’t like you?

These are some of the symptoms of ‘atypical depression’.

Although the name makes it sound rare, atypical depression is actually quite common and occurs approximately 18% to 36% of people with depression.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), atypical depression — also called “depression with atypical features” — is a “specification” that mental health professionals can add to the following disorders:

A specification adds new information to the primary diagnosis. For example, if you were diagnosed with major depression with atypical features, you first met the criteria for MDD and then atypical features were added to further clarify your condition.

To be diagnosed with atypical depression, you must exhibit “mood reactivity,” meaning your mood can improve when something good happens.

In addition to mood reactivity, there must be at least two of the following symptoms for a diagnosis of atypical depression:

  • significant increase in appetite
  • oversleeping (hypersomnia)
  • lead paralysis, where your arms and legs feel heavy
  • a long-lasting pattern of rejection sensitivity, when you interpret common or mildly negative social cues as rejection

Importantly, atypical depression is not always persistent. For example, a person diagnosed with atypical features may begin to experience symptoms of melancholy, which is another depression specification. People with depression with melancholic features have anhedonia (an inability to feel pleasure) and show no signs of mood reactivity.

In fact, research shows that diagnoses of depression subtypes are only stable 22% to 29% of the time. It is more common for people to experience fluctuations between atypical and melancholic episodes than to have one type over time.

In general, it is important that people with atypical symptoms receive a thorough evaluation before being diagnosed.

Atypical depression can be misdiagnosed as borderline personality disorder because of the overlap in symptoms, such as extreme sensitivity to rejection.

The exact cause of atypical depression is unknown, but there are a few theories. The causes of depression are likely similar for different subtypes of depression – a mixture of genetic and environmental factors.

A 2017 review notes the following specific differences that may contribute to atypical depression:

  • Differences in the stress response system† The stress response system, called the hypothalamic-pituitary-adrenal (HPA) axis, may act differently in depression with atypical versus melancholic features. It appears to be overactive in people with melancholic depression and underactive in people with atypical depression.
  • Inflammatory markers† Inflammation appears to be much greater in people with atypical depression compared to other forms of depression and healthy controls. Atypical depression also has different inflammatory patterns than melancholic depression.
  • Leptin system (a hormone secreted by fat cells). Leptin regulation (resistance) may be an underlying mechanism linking obesity and depression. The concentration of this mood-regulating hormone has been significantly associated with clinical symptoms of atypical depression, such as excessive appetite, weight gain and lead paralysis.
  • Brain structure or activity† People with atypical depression may have increased blood flow in the frontal, temporal, and parietal lobes of the brain and decreased blood flow in the occipital lobe.

Atypical depression is more common in people with bipolar disorder. A population survey in the United States published in: 2011 found that people with atypical depression had significantly higher rates of bipolar I disorder than people without atypical features.

In addition, atypical depression can co-occur with other mental health disorders, such as:

Compared to melancholic depression, people with atypical depression often have a earlier start and a more chronic course of the disease. They are also more likely to have family members with chronic depression.

Some proof also suggests that atypical depression may be related to seasonal depression and obesity.

Atypical depression is often treated with psychotherapy, medication, or both.

Psychotherapy

Psychotherapy, especially cognitive behavioral therapy (CBT), is a common treatment for most types of depression, including atypical depression. CBT teaches clients to identify and change any negative or useless belief patterns.

In a 2013 study, participants with depression received either a 16-week course of the antidepressant paroxetine or a course of CBT. Both treatments reduced cognitive and suicidal symptoms; However, CBT was more effective at reducing certain atypical symptoms, such as overeating and oversleeping.

medication

Guidelines for the treatment of atypical depression are lacking, but historically monoamine oxidase inhibitors (MAOIs) have been the most effective.

MAOIs are not widely used today due to potential side effects, but clinicians can prescribe them with caution to people with atypical depression. They may also prescribe selective serotonin reuptake inhibitors (SSRIs).

Starting too late the fiftiesresearchers noted that people with certain features of depression (now considered atypical features) responded very well to treatment with iproniazide, the original MAOI.

Then, a 2006 analysis looked at studies comparing MAOIs to both tricyclic antidepressants and SSRIs. The researchers found MAO inhibitors to be remarkably more effective than tricyclics, and they found little difference between MAO inhibitors and SSRIs. According to the researchers, the available data was insufficient.

Wellbutrin (bupropion), a norepinephrine-dopamine reuptake inhibitor (NDRI), may also be effective in improving oversleeping and fatigue, which are symptoms of atypical depression.

If you’re living with atypical depression, there are several things you can do to help with your treatment. These include exercise, a healthy diet, and seeking support.

Excercise

Exercise may be the last thing on your mind when dealing with the fatigue and heaviness of atypical depression.

But 2016 research shows that people with MDD with atypical features have better treatment outcomes if they do aerobic exercise. The authors also report that people with hypersomnia and an elevated BMI (symptoms of atypical depression) may have a greater response to exercise.

healthy diet

Several studies over the years have suggested that a healthy diet may play a role in reducing certain types of depression. Likewise, a poor diet, including a diet full of sweets, processed foods, and refined grains, can contribute to the risk of depression.

A review 2018 of 41 studies found that consistently eating a healthy diet — particularly a traditional Mediterranean diet, or at the very least avoiding an anti-inflammatory diet — appears to provide some protection against depression.

The Mediterranean diet is characterized by vegetables, fruits, nuts, fish, olive oil and whole grains.

Researchers suggest that diet may influence depression risk through the following pathways:

  • inflammation
  • gut microbiome
  • oxidative stress (too many free radicals in the body)
  • neuroplasticity (the brain’s ability to adapt)
  • mitochondrial function (cell metabolism)

Eating healthy can be especially challenging when you have depression, especially with the increased appetite often seen with atypical depression — but you can start small.

Consider aligning your cravings with healthier choices. For example, grab a handful of dates or strawberries instead of snacking on candy. If you’re craving heavy carbs, opt for whole-wheat bread instead of refined bread or crackers.

Join a support group

The simple act of giving and receiving support from others going through similar challenges can be very healing. Consider joining a support group for people with depression.

To read about some options, check out the Psych Central Guide to Online Depression Support Groups.

Living with atypical depression is not easy, but know that you are not alone and that the condition is highly treatable.

If you think you may have the symptoms of atypical depression, don’t hesitate to contact a mental health professional. Together, you and your mental health professional can discuss treatment options to begin your journey to wellness.

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