164 Depressive Disorders
substantial effort. The efficiency with whic h tasks are accomplished may be reduced. For
example, an individual may complain that washing and dressing in the morning are ex-
hausting and take twice as long as usual.
The sense of worthlessness or guilt associated with a major depressive episode may in-
clude unrealistic negative evaluations of one’ s worth or guilty preoccupations or rumina-
tions over minor past failings (Criterion A7). Such individu als often misinterpret neutral
or trivial day-to-day events as  evidence of personal defects and have an exaggerated sense
of responsibility for untoward events. The sens e of worthlessness or guilt may be of delu-
sional proportions (e.g., an individual who is convinced that he or she is personally re-
sponsible for world poverty). Blaming oneself for being sick and for failing to meet
occupational or interpersonal responsibilities as  a result of the depression is very common
and, unless delusional, is not consider ed sufficient to meet this criterion.
Many individuals report impaired ability to  think, concentrate, or make even minor
decisions (Criterion A8). They may appear ea sily distracted or complain of memory diffi-
culties. Those engaged in cogn itively demanding pursuits are often unable to function. In
children, a precipitous drop in grades may reflect poor concentratio n. In elderly individ-
uals, memory difficulties may be the chief co mplaint and may be mistaken for early signs
of a dementia (“pseudodementia”). When th e major depressive ep isode is successfully
treated, the memory problems often fully abate. However, in some individuals, particu-
larly elderly persons, a major depressive ep isode may sometimes be the initial presenta-
tion of an irreve rsible dementia.