able or considered appropriate to the loss, the presence of a major depressive episode in
addition to the normal response to a significant loss should also be carefully considered. This
decision inevitably requires the ex ercise of clinical judgment ba sed on the individual’s history
and the cultural norms for the expression of distress in the context of loss.1
D. The occurrence of the major depressive episode is not better explained by schizoaf-
fective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or
other specified and unspecified schizophrenia s pectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note:  This exclusion does not apply if all of the manic-like or hypomanic-like episodes
are substance-induced or are attributable to  the physiological effects of another med-
ical condition.
1In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in
grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent
depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is
likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of
grief. These waves tend to be associated with thoughts or reminders of the deceased. The
depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations.
The pain of grief may be accompanied by positi ve emotions and humor th at are uncharacteristic
of the pervasive unhappiness and misery characteristic of MDE. The thought content associated
with grief generally features a preoccupation with thoughts and memories of the deceased,
rather than the self-critical or pessimistic ruminati ons seen in MDE. In grief, self-esteem is gener-