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Individuals with PTSD often experience cooccurring depres-sive disorders, anxiety disorders and substance use disorders. The range of reported rates of concurrent depressive disorder in patients with PTSD is 30 to 50%. Many of the symptoms of PTSD overlap with signs and symptoms of depression such that both PTSD and MDD can be considered to be the result of traumatic events. In addition, depressive disorder may be as-sociated with worse outcome in individuals with cooccurring PTSD.
It is common for patients with MDD to experience somatic symp-toms including pain, although the intensity and frequency of the somatic complaints and the range of body systems affected do not usually meet criteria for somatization disorder. Patients who have mood symptoms that meet criteria for MDD evidence more com-plaints of pain, experience more physical, interpersonal and oc-cupational limitations, and perceive their overall health as worse than patients with chronic medical illness. The clinician should carefully evaluate for the presence of MDD in cases where the patient reports unexplained pain. Typically, pain complaints are relieved upon successful treatment of the MDD. However, somatoform disorders, as outlined in DSM-IV, may be associated with demoralization and depression.
There are little data available regarding prevalence of eating dis-orders in patients with MDD. However, 33 to 50% of patients with anorexia nervosa or bulimia nervosa experience a comorbid mood disorder. Between 50 and 75% of patients with an eating disorder have a history of a MDD over a lifetime. Initial treat-ment is aimed at the eating disorder. If depression continues after proper nourishment has been re-established in anorexia nervosa, treatment is directed at the primary mood disorder.
High rates of personality disorders are found in depressed inpa-tients and outpatients. Most studies report a rate of cooccurrence between 30 and 40% in outpatients and 50 to 60% in inpatient samples. Sixty-three percent of our sample of acutely ill patients (mostly inpatients) with a MDD were assigned at least one Axis II diagnosis on the basis of a semistructured diagnostic instrument (Gruenberg et al., 1993). Several studies have found that patients with comorbid MDD and personality disorder evidence an earlier age of onset for the first episode of depression, increased sever-ity of depressive symptoms, more episodes, longer duration of episodes, poorer response to both pharmacotherapy and psycho-therapy, and increased risk for self-injury.
A particular relationship is noted for comorbid MDD and borderline personality disorder (BPD). In a general psychiatric population, depressed patients show an estimated rate of 6% for cooccurring BPD. The link between BPD and MDD remains con-troversial. Anecdotally, there appear to be significant levels of depression accompanying PTSD in those women who have been sexually abused. Herman (1997) has made a cogent argument for conceptualizing these women as suffering from complex PTSD rather than BPD.
Depressive symptoms associated with normal grieving usually begin within 2 to 3 weeks of the loss and resolve spontaneously over 6 to 8 weeks. If full symptom criteria for MDD persist for more than 2 months beyond the death of a loved one, then an episode of MDD can be diagnosed. Specific treatment for a major depressive episode such as short-term psychotherapy focusing on unresolved grief or pharmacotherapy is indicated
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