Which of the following symptoms are present when a person has a diagnosis of major depressive disorder with atypical features?

Atypical Depression (also known as Major Depressive Disorder with atypical features in the DSM-5) is a subtype of depression characterized by mood reactivity (moods that are strongly reactive to environmental circumstances, and feeling extremely sensitive - this is a must have feature), hypersomnia, carbohydrate craving/increased appetite, leaden paralysis (profound fatigue), and chronic rejection sensitivity. Atypical depression results in more disability than melancholic depression, because individuals often have more interpersonal difficulties.

In addition to meeting the criteria for major depressive disorder, the following specifier criteria are required to make the diagnosis of atypical depression:

This specifier can be applied when these features predominate during the majority of days of the current or most recent major depressive episode or persistent depressive disorder.

The mnemonic RAILS can be used to remember the features of atypical depression.

The common feature in all these diagnoses are emotional dysregulation and mood reactivity. The research hints that these disorders may all exist on a continuum.[4][5][6] Clinically, it can be challenging to distinguish between these disorders.

2) Levitan, R. D., Parikh, S. V., Lesage, A. D., Hegadoren, K. M., Adams, M., Kennedy, S. H., & Goering, P. N. (1998). Major depression in individuals with a history of childhood physical or sexual abuse: relationship to neurovegetative features, mania, and gender. American Journal of Psychiatry, 155(12), 1746-1752.

6) Chopra, K. K., Bagby, R. M., Dickens, S., Kennedy, S. H., Ravindran, A., & Levitan, R. D. (2005). A dimensional approach to personality in atypical depression. Psychiatry research, 134(2), 161-167.

7) Liebowitz, M. R., Quitkin, F. M., Stewart, J. W., McGrath, P. J., Harrison, W. M., Markowitz, J. S., ... & Klein, D. F. (1988). Antidepressant specificity in atypical depression. Archives of General Psychiatry, 45(2), 129-137.

8) Chiuccariello, L., Houle, S., Miler, L., Cooke, R. G., Rusjan, P. M., Rajkowska, G., ... & Wilson, A. A. (2014). Elevated monoamine oxidase a binding during major depressive episodes is associated with greater severity and reversed neurovegetative symptoms. Neuropsychopharmacology, 39(4), 973-980.

Depression is a condition that causes people to feel ongoing sadness and lose interest in activities they once enjoyed. Additional symptoms can include social isolation, feelings of hopeless and worthlessness, insomnia (difficulty falling and/or staying asleep), decreased appetite with weight loss, fatigue, difficulty concentrating and thoughts of death or suicide. Depression can interfere with one’s ability to perform daily tasks. It can also contribute to a wide range of physical problems and negatively impact one’s relationships.

What is atypical depression?

Atypical depression (also called major depression with atypical features) is a specific type of depression in which the symptoms vary from the traditional criteria. One symptom specific to atypical depression is a temporary mood improvement in response to actual or potential positive events. This is known as mood reactivity.

How common is atypical depression?

Depression is quite prevalent, affecting approximately 121 million people worldwide. Despite its name, atypical depression is actually quite common affecting 18 to 36% of people with a depressive disorder.

Atypical depression is at least twice more likely to affect women than men. In addition, atypical depression tends to begin at an earlier age (teen years and early 20s) and last longer (often becoming a chronic condition) than typical depression.

In addition to mood reactivity (described under “what is atypical depression”), people with atypical depression have at least two of the following symptoms:

  • Increase in appetite and/or significant weight gain
  • Excessive sleepiness (hypersomnia)
  • Heavy feeling in the arms or legs (also called leaden paralysis)
  • Intense reaction and increased sensitivity to criticism or rejection, which results in significant social and work impairment

These symptoms differ from typical depression symptoms, which often include a loss of appetite and insomnia (difficulty falling and/or staying asleep). In addition, the mood of people with typical depression usually does not improve, even when good things happen.

What causes atypical depression?

Doctors do not know exactly why some people experience depression or atypical depression. However, theories include:

  • Impaired functioning of neurotransmitters (chemicals that carry brain signals to other parts of the body) and/or neuroreceptors (the “receivers” of the signals)
  • Genetics (having a family member with mood disorders including bipolar disorder and dysthymia [long-term depression] may also contribute to the development of atypical depression
  • Trauma
  • Stress

Additional risk factors for the development of atypical depression include:

  • Negative childhood experiences
  • Emotional, physical or sexual abuse
  • Significant illness
  • Grief following a significant loss
  • History of substance abuse

Diagnosis of atypical depression is made based upon an evaluation of your symptoms. A doctor will perform a physical exam to rule out physical causes of depressive symptoms such as a thyroid disorder. He or she will ask if you have a family history of mental health issues or depression. Your doctor will also ask about your behaviors and feelings and may refer you to a behavioral health specialist (psychologist or psychiatrist) for diagnosis and treatment.

Atypical depression often responds well to treatment. Your treatment may vary depending on the condition’s severity. Treatments for atypical depression include:

  • Antidepressant medications to help regulate your brain chemistry
  • Lifestyle changes such as exercising or quitting alcohol or recreational drug use
  • Psychotherapy (talking with a mental health professional) to:
    • Learn coping strategies for negative or unhealthy thoughts
    • Improve interpersonal relationships
    • Resolve trauma

Some of the medications used to treat atypical depression can have side effects. Side effects can include:

  • Nausea/diarrhea
  • Loss of appetite
  • Headaches
  • Insomnia
  • Loss of sex drive

Side effects usually improve as your body adjusts to the medication. If side effects don’t lessen, your doctor can help you by suggesting different types of medications that may work better for you.

What are the complications associated with atypical depression?

People with atypical depression may experience complications and other mental health disorders including:

  • Alcohol or drug use as a coping method
  • Binge eating and weight gain due to increased appetite
  • Increase in anxiety
  • Relationship conflict
  • Thoughts of suicide (suicidal ideation)

Atypical depression is not always preventable. Steps you can take to reduce your risk of the disorder include:

  • Manage stress
  • Seek medical help at the first sign of depression
  • Talk about your feelings with someone you trust

Depression is a serious medical condition with serious potential outcomes if left untreated including:

  • Increased risk of suicide
  • Worsening of medical illness
  • Increased conflict in relationships
  • Increased risk of substance abuse
  • Increased missed time and loss of effort at work

However, with appropriate treatment, 70 to 80% of individuals with a major depressive disorder can greatly improve their symptoms, although as many as 50% of patients may not respond to the initial treatment trial.

Seek emergency medical help if you have thoughts of harming yourself or suicide. If you are experiencing sad mood or a loss of interest in previously enjoyed activities for a period of 2 weeks, make an appointment with your healthcare provider or talk to someone you trust such as a friend, family member or faith leader.

What questions should I ask my doctor?

If you have atypical depression, you may want to ask your doctor:

  • What is the cause of my atypical depression?
  • What is the best treatment for this type of depression?
  • What signs of complications should I look out for?
  • Should I follow up with a different kind of doctor?
  • What support resources are available to me?

A variety of organizations offer resources to help educate and empower people with Depression and Atypical Depression. Here are some useful resources for more information and support.

Last reviewed by a Cleveland Clinic medical professional on 09/17/2019.


  • American Psychiatric Association. Specifiers for Depressive Disorders: With Atypical Features. (https://books.google.com/books?hl=en&lr=&id=-JivBAAAQBAJ&oi=fnd&pg=PT18&dq=DSM+V&ots=ceTS71JMuc&sig=-1Swzzp616IhmZRxIhQ5F2b7KVw#v=onepage&q&f=false) Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. 2013. Accessed 9/17/2019.
  • Lojko D, Rybakowski JK. Atypical Depression: Current Perspectives. (https://www.dovepress.com/atypical-depression-current-perspectives-peer-reviewed-article-NDT) Neuropsychiatr Dis Treat 2017;13:2447-2456. Accessed 9/17/2019.
  • Singh T, Williams K. Atypical Depression. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990566/) Psychiatry (Edgmont). 2006 Apr; 3(4): 33–39. Accessed 9/17/2019.
  • Merck Manual. Depression. (https://www.merckmanuals.com/home/mental-health-disorders/mood-disorders/depression) Accessed 9/17/2019.
  • National Institute of Mental Health. Mental Health Medications. (https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml) Accessed 9/17/2019.
  • American Psychiatric Association. What is Depression? (https://www.psychiatry.org/patients-families/depression/what-is-depression) Accessed 9/17/2019.

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