Question 1 of 10

    Atypical Depression (Atypical Depressive Disorder)

    Atypical depression is a term used to refer to either depression followed by stress or anxiety, or depression accompanied by a symptomatology of increased appetite, weight gain or hypersomnia. It is a clinical entity that shares many of the symptoms of major depression, but in the case of atypical depression an individual remains reactive to the stimuli of their environment, in the sense that their mood is still affected by them, positively of negatively.

    The disease is the result of this process: mental.

    Presentation

    A characteristic feature of atypical depression is mood reactivity, namely the individual's ability to still respond positively to positive environmental stimuli. This characteristic is a factor that distinguishes atypical depression from a major depression or dysthymia. Patients affected by these conditions very rarely experience an elevated mood when something positive happens. Mood reactivity is termed "criterion A" for atypical depression.

    Other than that, in order to diagnose an episode of atypical depression, at least two of the following symptoms must be present alongside mood reactivity ("criterion B"):

    • Excessive need for sleep (hypersomnia)
    • Increased appetite/weight gain
    • Leaden paralysis: The feeling of being so heavy one is unable to move, as though burdened with lead.
    • Interpersonal rejection sensitivity which causes problems in personal life or work, reacting excessively when one feels that they are being rejected.

    Atypical depression is considered a "specifier" for major depression or dysthymic disorder, namely it is used to better evaluate the course of these conditions and characterize them. It is common for patients with atypical depression to have experienced at least one episode of major depression, usually at a young age.

    Entire body system
    Crying
    • Symptoms of Atypical Depression These are some of the common signs of atypical depression: Depression Irritability Lack of energy Insomnia or excessive sleep Feelings of hopelessness Loss of enjoyment in life Concentration problems Uncontrollable crying[gomentor.com]
    • Subsequently, they withdrew and ceased crying altogether, even if they were left alone or had gone without eating for many hours.[nature.com]
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  • neurologic
    Catatonia
    • Catatonic Depression Catatonia is a state where a person appears unresponsive and moves little, if at all.[healthline.com]
    • For example, according to a study published in the journal Psychiatry , the following are signs of atypical depression: Periodically improved mood based on positive experiences No experience of catatonia or melancholia Two or more of the following symptoms[dualdiagnosis.org]
    • A person with atypical depression must also experience an improvement in mood when positive events occur, and must lack symptoms of two mental states called catatonia and melancholia.[elementsbehavioralhealth.com]
    • DSM IV TR has also enlisted cross sectional specifiers of major depressive episode(catatonia, melancholic, atypical, postpartum),and longitudinal specifiers (chronic, seasonal, rapidly cycling).Depression has also been graded by DSM IV TR on the basis[priory.com]
    Hyperactivity
    • Indeed, it has been suggested that prolonged overproduction of glucocorticoids, whether as a result of ongoing stress or a genetic predisposition to HPA axis hyperactivity, damages brain structures (especially the hippocampus) essential for HPA axis restraint[scielo.br]
    • Theoretically, the prefrontal cortex could be disinhibited or primarily hyperactive.[nature.com]
    • A major source of inflammatory cytokines is hyperactivity of the stress response which is a known phenomenon in depression.[balancingbrainchemistry.co.uk]
    • Gold and Chrousos [ 15 ] have hypothesized that new onset FM is generally associated with a hyperactive HPA axis characterized by elevated levels of CRH and cortisol (a characteristic of MDE), and that, over time, persistent stress results in blunting[bmcmusculoskeletdisord.biomedcentral.com]
    • These behavioral signs include: Agitation Irritability Anxiety Panic attacks Insomnia Aggressiveness Impulsivity Hyperactivity in actions and speech Worsening of depression Increased thoughts of suicide The FDA’s guidelines for medication usage also recommend[nytimes.com]
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  • gastrointestinal
    Loss of Appetite
    • It is also possible that the loss of appetite/weight exhibited by people with typical depression also arises from endogenous distortions in neurotransmitters while the loss of appetite/weight reported by several people who exhibit atypical depression[hindawi.com]
    • […] of appetite weight loss or weight gain (5% in one month) over sleeping or lack of sleep fatigue or loss of energy every day interpersonal rejection sensitivity absence of catatonic features Treatments Psychotherapy - talk therapy medication - prescription[prezi.com]
    • Instead of loss of appetite, you may overeat and/or gain weight.[freethoughtblogs.com]
    • An important further distinction is that “typical” depression is commonly associated with loss of appetite and weight loss, whereas “atypical” depression typically involves increased appetite (comfort eating), often with significant weight gain.[drsharma.ca]
    • Unlike other types of major depression, such as melancholic depression, which is associated with oversleeping, loss of appetite, and lack of mood improvement even if a positive event happens, atypical depression sufferers often experience insomnia, increased[nutritionaloutlook.com]
    Overeating
    • "If only, if only," a piece of your over-ruminating prefrontal cortex may be chanting.[knowledgeisnecessity.blogspot.com]
    • […] or loss of appetite weight loss or weight gain (5% in one month) over sleeping or lack of sleep fatigue or loss of energy every day interpersonal rejection sensitivity absence of catatonic features Treatments Psychotherapy - talk therapy medication -[prezi.com]
    • And the ease of just rolling over in bed and going back to sleep is experienced without guilt of being irresponsible.[depressiond.com]
    • Fatigue When overeating is experienced, so is tiredness and fatigue.[sunsetmalibu.com]
    • Additionally, atypical depression is characterized by reversed vegetative symptoms , namely over-eating and over-sleeping.[depression.wikia.com]
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  • musculoskeletal
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  • psychiatrical
    Anger
    • Depression with anger attacks.[priory.com]
    • Examples of these shared traits include a tendency toward impulsive behavior, a relatively poor ability to think clearly, relatively easy provocation to anger, and a tendency toward anxiety, envy, and worry.[elementsbehavioralhealth.com]
    • Journaling, as part of your treatment, may improve your mood by allowing you to express pain, anger, fear or other emotions.[drugs.com]
    • Write down – as detailed as possible – how, how long and when you experienced your pain, fear, anger, emotions, etc.[anxiety-attack-panic-chronic-depression-bipolar-disorder.com]
    Anxiety Disorder
    • Similarly, patients with atypical depression are more likely to suffer from personality disorders and anxiety disorders such as borderline personality disorder, avoidant personality disorder, generalized anxiety disorder, obsessive-compulsive disorder[en.wikipedia.org]
    • Relationship between atypical depression and social anxiety disorder.[mayoclinic.org]
    • Atypical depression often occurs together with panic disorder (a common anxiety disorder) and can be accompanied by problems with drug or alcohol abuse.[workpsychcorp.com]
    • Sure, bipolar disorder is considerably more rare than major depressive disorder or anxiety disorder, but that does not mean the potential for other mental illnesses should be overlooked, especially with new research pouring out about detecting bipolar[blogs.psychcentral.com]
    Chronic Anxiety
    • Like other types and sub-types of depression, the overwhelming feeling of atypical depression is a sense of profound sadness, chronic anxiety, and a degree of hopelessness (ie: this is never going to improve).[depressiond.com]
    Compulsive Disorder
    • Similarly, patients with atypical depression are more likely to suffer from personality disorders and anxiety disorders such as borderline personality disorder, avoidant personality disorder, generalized anxiety disorder, obsessive-compulsive disorder[en.wikipedia.org]
    • There are a number of other disorders that share some of the symptomology with atypical depression, including bipolar disorder, obsessive-compulsive disorder, panic disorder and bulimia.[psyweb.com]
    • An increased likelihood of assuming other psychological syndromes, such as obsessive-compulsive disorder, panic attacks, avoidant personality disorder (even sometimes resulting in agoraphobia, or fear of open spaces), and related social phobias.[depressiond.com]
    • , as in melancholic depression. 2,5-6 In addition to melancholic depression, a spectrum of other conditions may be associated with increased and prolonged activation of the HPA axis, including anorexia nervosa with or without malnutrition, obsessive-compulsive[scielo.br]
    • An implantable deep brain stimulation device (Reclaim), similar to a pacemaker and devices used for treating movement disorders like Parkinson’s disease, has been approved for treatment of severe obsessive-compulsive disorder.[nytimes.com]
    Dysthymic Disorder
    • Atypical depression can be a "specifier" for either major depression or dysthymic disorder.[webmd.com]
    • […] rates are higher among women than men. 1,2 In the Diagnostic and Statistical Manual of Mental Disorders , 5th Edition (DSM-5), atypical depression is a specifier to major depressive disorder (MDD) and persistent depressive disorder (PDD; formerly called dysthymic[psychiatryadvisor.com]
    • “episode specifier” in DSM-IV. 10 DIAGNOSIS The DSM-IV specifier “with atypical features ” can be used to characterize the current or most recent depressive episode in patients with either unipolar or bipolar type mood disorder and in patients with dysthymic[psychiatrictimes.com]
    • Psychotherapy for dysthymic disorder.[priory.com]
    • Mood disorders: major depressive disorder and dysthymic disorder.[nytimes.com]
    Indecisiveness
    • Such or similar concentration problems and indecisiveness are possible symptoms of atypical depression . ____________________________________________ They constantly feel hopeless, helpless and particularly worthless for the people around them and they[anxiety-attack-panic-chronic-depression-bipolar-disorder.com]
    Low Self-Esteem
    • Atypical depression has many symptoms that are common to all depressions, e. g. pessimistic and negative thinking, low self-esteem or lack of confidence, suicidal ideas or impulses, loss of sex drive, diminished ability to experience vitality and a sense[sharecare.com]
    • Risk factors may include: History of bipolar disorder Abuse of alcohol or recreational drugs Physical or sexual abuse Traumatic childhood experiences Certain personality traits, such as low self-esteem or being overly dependent Serious illness, such as[drugs.com]
    • Prominent symptoms can be depress mood, low energy, low self esteem, feeling of hopelessness (2) In dysthymia, vegetative symptoms of depression like sleep and appetite disturbance are less common.[priory.com]
    • . ____________________________________________ Traumatic events People who have developed a low self-esteem over a longer time or who are extremely helpless and dependent from others, are likely to suffer from atypical depression symptoms in adulthood[anxiety-attack-panic-chronic-depression-bipolar-disorder.com]
    Suggestibility
    • Recent research suggests that young people are more likely to suffer from hypersomnia while older people are more likely to suffer from polyphagia.[en.wikipedia.org]
    • Findings from 4 studies showed that mood reactivity does not significantly correlate with the presence of criterion B features, which suggests that mood reactivity should not be considered an obligatory feature for the diagnosis of atypical depression[psychiatrictimes.com]
    • This is not to suggest that the criteria were simply wrong.[hindawi.com]
    • Some studies[5] suggest that an older class of drugs, the monoamine oxidase inhibitors (MAOIs), may be more effective at treating atypical depression.[wattpad.com]
    • Recent studies have suggested that there is a genetic propensity to suffer from chronic fatigue, with the concordance between monozygotic twins more than twice that of dizygotic twins. 55 Multivariate modeling suggests that part of this vulnerability[scielo.br]
    Suicidal Depression
    • Depression is the cause of up to two-thirds of all suicides.[nytimes.com]
    Suicidal Ideation
    • Additional exclusion criteria included a Beck Depression Inventory score greater than 31 (extreme depression), any medical disorder that altered the HPA axis, suicidal ideation, abnormal thyroid stimulating hormone levels (less than 0.28 uIU/ml or greater[bmcmusculoskeletdisord.biomedcentral.com]
    • Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials.[nytimes.com]
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  • Workup

    Any recent or present episode of dysthymia or bipolar disorder can be termed as "bearing atypical characteristics" according to DSM-IV [10]. In order to achieve a successful and accurate diagnosis, a doctor must bear in mind that the feature distinctly distinguishing atypical depression from other psychiatric disorders is mood reactivity. A person is considered to be reactive, when they experience a mood elevation of at least 50% when a positive event takes place (a compliment, a raise, a date, etc.).

    Laboratory

    Serum
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  • Imaging

    X-ray
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  • Treatment

    Monoamine oxidase inhibitors (MAOIs), specifically phenelzine, have proven to address atypical depression with great efficacy. In spite of the existence of several FDA-licensed MAOIs for the treatment of major depression, phenelzine is the only drug that has received a clear indication for the treatment of atypical depression. Nevertheless, doctors tend to refrain from widely using MAOIs as first-line treatment, due to their possible interaction with diet-acquired tyramine, it could result in a life-threatening hypertensive crisis. Furthermore, there is always the risk of drug-drug interactions, which could trigger a serotonin syndrome. For these reasons, various other antidepressants are implemented as first-line treatments for atypical depression [12]. 

    The use of MAOIs has assisted researchers in the so called psychopharmacological dissection of atypical depression, the classification of disease sub-categories based on the response to medication. A group of patients whose symptoms are aided by MAOIs in comparison to tricyclic antidepressants or electroconvulsive therapy has been a valid observation.

    The existence of randomized clinical trials suggesting the use of selective serotonin reuptake inhibitors for this subtype (fluoxetine vs phenelzine, fluoxetine vs moclobemide, fluoxetine vs imipramine, fluoxetine vs nortriptyline and sertraline vs moclobemide) has also broken new ground. Fluoxetine has been proven to be effective for atypical depression, with patients responding positively at a rate of 65% [13].

    Other types of medication that have shown effectiveness in the treatment of atypical depression according to open-label, randomized or controlled studies include hypericum, gepirone, modafinil, melatonin and GH. In addition to this, newer antidepressants like duloxetine, venlafaxine and mirtazapine may be used towards achieving a therapeutic result, but still remain an uninvestigated option.

    During the acute phase of an atypical depression episode, a patient may also benefit more from cognitive therapy in contradistinction to pharmacologic treatment.

    Prognosis

    Atypical depression needs early intervention, which can help an individual manage their symptoms and minimize suffering. Comorbidities include somatization disorder, substance abuse (drugs, medications, etc.), cluster B and C personality disorders and increased anxiety.

    Complications

    Obsessive-Compulsive Disorder
    • Similarly, patients with atypical depression are more likely to suffer from personality disorders and anxiety disorders such as borderline personality disorder, avoidant personality disorder, generalized anxiety disorder, obsessive-compulsive disorder[en.wikipedia.org]
    • There are a number of other disorders that share some of the symptomology with atypical depression, including bipolar disorder, obsessive-compulsive disorder, panic disorder and bulimia.[psyweb.com]
    • An increased likelihood of assuming other psychological syndromes, such as obsessive-compulsive disorder, panic attacks, avoidant personality disorder (even sometimes resulting in agoraphobia, or fear of open spaces), and related social phobias.[depressiond.com]
    • […] hypercortisolemia, as in melancholic depression. 2,5-6 In addition to melancholic depression, a spectrum of other conditions may be associated with increased and prolonged activation of the HPA axis, including anorexia nervosa with or without malnutrition, obsessive-compulsive[scielo.br]
    • An implantable deep brain stimulation device (Reclaim), similar to a pacemaker and devices used for treating movement disorders like Parkinson’s disease, has been approved for treatment of severe obsessive-compulsive disorder.[nytimes.com]
    Paralysis
    • The patient had reported some features of atypical depression (hypersomnia, hyperphagia, and mood reactivity) without leaden paralysis.[healio.com]
    • […] and in patients with dysthymic disorder. 10 As described in the Table , the DSM-IV specifier requires the presence of mood reactivity (criterion A) and at least 2 of 4 criterion B features (significant weight gain or hyperphagia, hypersomnia, leaden paralysis[psychiatrictimes.com]
    • […] used synonym for panic disorder. atypical depression Panic disorder , see there. atypical depression Abbreviation: AD A form of depression in which overeating and oversleeping are commonly observed, often but not exclusively in association with leaden paralysis[medical-dictionary.thefreedictionary.com]
    • For rejection sensitivity, Seemüller et al. used a measure of irritability and for leaden paralysis a measure of heaviness in legs.[hindawi.com]
    Suicide Attempt
    • From suicide attempts and possible death to the other physical and mental problems that can be brought on by clinical depression.[gomentor.com]
    • Attempt Survivors International Resources Coping with Loss Get Involved SAVE Events Join or Start a SAVE Charter Fundraise for SAVE Volunteer Donate Connect with SAVE Stories of Hope For Students Shop SAVE Learn More For Survivors Resources to help cope[save.org]
    • Attempts to commit suicide Unlike clinic or major depression, fewer symptoms take place when you have atypical depression.[undepress.net]
    • attempt Dysthymic disorder, now known in the psychiatric community as "persistent depressive disorder," is a condition involving the presence of a depressed mood more days than not for at least a two year period in adults (one year in children and adolescents[webmd.com]
    • Attempts to commit suicide With atypical depression fewer symptoms are manifested than with classic depression.[treat-depression.com]
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  • Etiology

    It is impossible to define the exact causes leading to atypical depression. Possible factors may involve:

    • Childhood trauma: Given the psychological sensitivity of a child, particularly in the early life, incidents such as the death of a parent or child abuse can lead to the individual being more prone to depression.
    • Incidents in adult life: Stress, financial issues, disease, dysfunctional interpersonal relationships or the death of a loved one can also trigger a depression.
    • Hereditary factors: Depression is more frequently observed in individuals whose blood relatives suffer from the same condition.
    • Biological factors: There has been a suggestion that depression may occur when neurotransmitters are dysfunctional.

    Epidemiology

    The characterization of "atypical" refers to the DSM criteria for other mood disorders. In this sense, atypical does not imply that a disorder is unusual or rare, but rather that it cannot be classified as an already existing mood disorder, even though they may share lots of common features. Atypical depression is, in reality, a common disorder [2].

    Atypical depression was found to be affecting a 4.5% of women and a 1.2% of men in a study conducted in Zurich, Switzerland. Another research indicated the lifetime prevalence of the disorder to be amounting to a 0.7% [6].

    Women are more frequently affected by this condition at a rate of 2:1 to 3:1 when compared to men. Some patients tend to display a chronic unmanageable course of major depression, rather than a typical depression [1]. Episodes start at a younger age [3] [4] and monozygotic twins usually both display the disorder, which suggests a possible genetic factor [5]. 

    Sex distribution
    Age distribution

    Pathophysiology

    The DSM-IV classification provides accurate characteristics and symptomatology for atypical depression, however, little is known about the actual mechanisms causing the condition. Therefore, data is limited to hypotheses.

    Biological hypothesis

    Hormonal axis

    One study used a group of patients meeting the full atypical depression criteria, a group displaying mood reactivity as the only atypical symptom and a control group with no atypical symptoms. Desipramine (selective NRI (noradrenaline reuptake inhibitor)) was administered to all three groups, with the patients exhibiting the full set of atypical symptoms showing an increased cortisole response when compared to the others. This led to the suggestion that in patients with atypical depression, the noradrenaline system is less affected [7]. Furthermore, patients with atypical depression have been found to be free of corticotropin releasing hormone (CRH) hypersecretion, in contradistinction to patients suffering of typical depression. In fact, the CRH levels of atypical patients have been found to be lower even in comparison to healthy individuals [8].

    Brain hemispheric bias

    Atypical depression is distinct from its typical counterpart in the means of the brain region they originate. Atypical depression favors the right parietal lobe, whereas typical depression the left parietal lobe [9]. With reference to perfusion, increased right frontal lobe perfusion is seen in patients with atypical depression and typical depression exhibits diminished perfusion in all regions but the occipital lobe [10].

    Psychological hypothesis

    Parker et al [11] have suggested that atypical depression may indeed be a spectrum disorder, although their propositions have yet to be proven. Personality and temper evaluation of patients with both typical and atypical depression was used to determine the primary psychological triggers of atypical depression. Conclusions that were drawn, pointed out to the importance of interpersonal rejection sensitivity as a primary cause. People that generally tended to overreact to real or imagined rejection also went on to exhibit increased anxiety, hypersomnia and increased appetite. [11]   

    Prevention

    Given that there is no known cause for depression, one can simply follow advice on how to lead a stress-free life in order to reduce the chances of getting depressed:

    • Try to control the levels of stress. Recognize the situations you can influence and those you cannot. Try to evaluate the severity of a situation with a clear head, before panicking. 
    • Talk, people are social beings. You will see that sharing a problem with close people helps you to deal with it.
    • If you think you are depressed, consult an expert. Getting professional help early prevents a depression from settling firmly.
    • Consider the possibility of getting long-term professional help to prevent symptoms from re-emerging.

    Summary

    The DSM-IV defines atypical depression as a disorder characterized by symptoms of increased appetite and weight gain, excessive need for sleep, interpersonal rejection sensitivity, "leaden" paralysis and a reactive mood [1]. Episodes exhibiting the aforementioned characteristics occur during the course of longitudinal mood disorders (bipolar disorder, dysthymia or major depression). Therefore, in order to decisively diagnose an episode of atypical depression, a patient needs first of all to accurately meet the DSM specified criteria for a longitudinal mood disorder, atypical symptoms alone do not suffice to diagnose such an episode [1]. Atypical depression is viewed as a vital specifier, helping to manage patients with longitudinal mood disorders and better characterize the course of their condition. 

    Given that such a disorder already exists, in order for an episode to be established as an atypical episode, the following criteria must be met [1]:

    • Mood reactivity to environmental stimuli and at least 2 other symptoms must dominate the most recent 2-week period of an episode related to major depression or bipolar disorder.
    • Mood reactivity to environmental stimuli and at least 2 other symptoms must be present in the most recent 2 years of a dysthymic disorder.

    Atypical depression was established as a clinical entity in 1994, it was then that it was classified as  an “episode specifier” in DSM-IV classification.

    Patient Information

    Atypical depression is a type of the depression that has some different characteristics from its typical "counterpart". Even though the term atypical might strike one as odd, rare or unusual, this disorder is actually a very common one. Because depression is a factor that may lower the quality of your life and prevent you from doing many things you would normally like to do, it is important that you keep in mind the following signs, should you ever experience one of them:

    • Increased hunger, leading to weight gain
    • A need to sleep too much, more than usual
    • A feeling that your legs are heavy as though made from lead, that makes it unpleasant or difficult for you to move
    • Difficulty maintaining balanced relationships with friends or coworkers, because you feel too rejected or insulted all the time
    • Sudden mood enhancement when good news crop up, which is then followed by depressed feelings again

    It is important to get professional help if you have the suspicion that you may have an atypical form of depression. It is nothing to be ashamed of, it is quite common, mostly among women, and it does not mean that you are faulty or irreparably damaged. Also, do keep in mind that such problems, if left untreated, may lead to complications that include:

    • Suicidal tendencies
    • Isolation
    • Phobias and panic disorder
    • Obesity and heart-related conditions or diabetes
    • Substance abuse
    • Dysfunctional relationships at work, in the family, at school which can further worsen the problems already present.

    There are also many treatment options for atypical depression. Depending on the severity, patients may need medication, counseling or a combination of these. Do not hesitate to reach out to a psychologist, psychiatrist or other mental health expert, early intervention can help you get life back on track and continue living your life to a full extent.

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    References

    1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
    2. Gillespie RD. The clinical differentiation of types of depression. Guy Hosp Rep. 1929;79: 306-344.
    3. Benazzi F. Testing DSM-IV definition of atypical depression. Ann Clin Psychiatry. 2003 Mar; 15 (1): 9-16
    4. Stewart JW, McGrath PJ, Quitkin FM. Do age of onset and course of illness predict different treatment outcome among DSM IV depressive disorders with atypical features? Neuropsychopharmacology. 2002 Feb; 26 (2): 237-45.
    5. Kendler KS, Eaves LJ, Walters EE, et al. The identifica-tion and validation of distinct depressive syndromes in a population-based sample of female twins. Arch Gen Psychiatry. 1996 May; 53 (5): 391-9.
    6. Horwath E, Johnson J, Weissman MM, et al. The validity of major depression with atypical features based on a com-munity study. J Affect Disord. 1992 Oct; 26 (2): 117-25
    7. McGinn LK, Asnis GM, Rubinson E. Biological and clinical validation of atypical depression. Psychiatry Res. 1996 Mar 29; 60 (2-3): 191-8
    8. Geracioti Jr TD, Loosen PT, Orth DN. Low cerebrospinal fluid corticotropin-releasing hormone concentrations in eucortisolemic depression. Biol Psychiatry. 1997 Aug 1; 42 (3): 165-74
    9. Bruder GE, Stewart JW, McGrath PJ, et al. Atypical de-pression: enhanced right hemispheric dominance for per-ceiving emotional chimeric faces. J Abnorm Psychology. 2002 Aug; 111 (3): 446-54
    10. Fountoulakis KN, Iacovides A, Gerasimou G, et al. The relationship of regional cerebral blood flow with subtypes of major depression. Prog Neuropsychopharmacology Biol Psychiatry. 2004 May; 28 (3): 537-46.
    11. Parker GB. Atypical depression: a valid subtype? J Clin Psychiatry. 2007; 68 Suppl. 3: 18-22
    12. Quitkin FM. Depression with atypical features: diagnostic validity, prevalence, and treatment. Prim Care Companion J Clin Psychiatry. 2002 Jun; 4 (3): 94-9
    13. Reimherr FW, Wood DR, Byerley B, et al. Characteristics of responde o fluoxetine. Psychopharmacol Bull. 1984; 20 (1): 70-2

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