Specifiers for Depressive Disorders 185
6. Increased or excessive involvement in activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual in-
discretions, foolish business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be
contrasted with insomnia).
B. Mixed symptoms are observable by others and represent a change from the per-
son’s usual behavior.
C. For individuals whose symptoms meet full criteria for either mania or hypomania,
the diagnosis should be bipolar I or bipolar II disorder.
D. The mixed symptoms are not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication or other treatment).
Note:  Mixed features associated with a major depressive episode have been found
to be a significant risk factor for the development of bipolar I or bipolar II disorder.
As a result, it is clinically useful to note the presence of this specifier for treatment
planning and monitoring of response to treatment.
With melancholic features:
A. One of the following is present during the most severe period of the current epi-
sode:
1. Loss of pleasure in all, or almost all, activities.
2. Lack of reactivity to usually pleasurable stimuli (does not feel much better, even
temporarily, when something good happens).
B. Three (or more) of the following:
1. A distinct quality of depressed mood characterized by profound despondency,
despair, and/or moroseness or by so-called empty mood.
2. Depression that is regularly worse in the morning.
3. Early-morning awakening (i.e., at least 2 hours before usual awakening).
4. Marked psychomotor agitation or retardation.
5. Significant anorexia or weight loss.