Depression

DEPRESSION (from Latin deprimere - to press down), psychic depression, a symptom complex characterized by a depressed, gloomy mood, slowed movements, and difficulty thinking. Although occurring episodically in almost all psychic diseases, D. has independent clinical significance in the following cases: 1) as a phase of manic-depressive psychosis - endogenous D., 2) as a constant property of personality characterizing a certain group of psychopathies - constitutional D., 3) as one form of psychic reactions to traumatic experiences - reactive D., and 4) as one form of pre-senile psychoses - presenile melancholia. Endogenous D. either develops without any external cause or is added to some psychic trauma, physical illness, etc.; in some cases it directly follows the manic phase of psychosis. Its phenomena usually develop gradually. At the beginning of the illness, the most noticeable feature is the decline in mood and initiative. As if a shadow falls "over the whole world, what happens around is perceived in the light of gloomy premonitions, consciousness fills with anxiety, manifestations of joy in other people are irritating, a feeling of deep sorrow grows. Unfounded indecisiveness seizes the patient, the desire to work disappears, endless fatigue increases, so that there is not enough strength even for the simplest actions. Thinking becomes difficult, thoughts become poor and monotonous, there is a feeling of inability to complete even the simplest mental operations. Patients note in themselves a blunting of perception sharpness, weakening of memory, etc. Complaints are common that impressions acquire an unreal, ghostly character, as if reaching the patient from afar. Time seems to move infinitely slowly, and at the same time with each passing moment an inescapable thought about the inevitable approach of death is imposed. Some patients complain of being unable to imagine anything in their minds except what they have just seen. Sometimes a tormenting sensation of spiritual emptiness, apathy, and numbness (anaesthesia dolorosa) is created. On the other hand, consciousness of guilt and fear of punishment arise extremely often. The movements of patients become weak and slow, speech - quiet, facial expression - frozen in an expression of suffering. Posture, gestures, manner of expressing oneself express on the one hand desolation, and on the other - a desire to escape the attention of others, to close in on oneself. In some patients, an extremely characteristic symptom can be noted - crying without tears - the facial expression of sobbing with dry eyes. To the described phenomena, which are very easily united under the concept of psychomotor inhibition, there almost always corresponds a clearly expressed metabolic disorder, manifested by a sharp drop in weight, loss of appetite, constipation, and other dyspeptic phenomena (apparently often connected with a decrease in the secretory function of the digestive glands), sometimes various circulatory disorders, etc. Patients complain of insomnia at night and drowsiness during the day. Numerous painful sensations in various parts of the body often appear: headaches, pressure in the chest, a feeling of heaviness in the abdominal area, etc. Many develop suspiciousness and hypochondriacal thoughts. Fluctuations in condition during the day are characteristic: patients feel worst in the morning, immediately after awakening, when they are completely under the power of physically felt sorrow. During the day it is sometimes possible to gain some control over oneself, although the general condition remains heavy; most patients feel best in the evening, when a certain lightening of mood and decrease in inhibition occurs. As long as the described disorders have not reached excessive intensity, patients in many cases show considerable ability to cope with their condition, sometimes very skillfully masking their gloomy mood. Some with mild forms of D. do not stop their usual work for a single day, no matter how subjectively heavy it may be for them (cyclothymic forms). However, the feeling of illness is often so strongly expressed, and the condition of patients reaches such acuteness so quickly, that it makes not only continuation of work impossible, but even keeping them in a home environment necessary. Hospitalization of patients is necessary 1) in cases where phenomena of motor inhibition develop to extreme limits (all impulses to action fade, patients almost completely freeze, stop speaking and only sometimes betray their experiences by the expression of their eyes); 2) in cases where such extreme inhibition does not occur, but the condition of patients is aggravated by an increase in the affect of sorrow to such a degree of spiritual pain that excludes the possibility of self-control - patients continuously cry, tear their hands, frantically run around the room, bang their heads against the wall; in many an irresistible urge to suicide arises; 3) at the height of the illness, when thoughts of one's own guilt and impending retribution often take the form of actual delusions, accompanied by the development of a sharply expressed affect of fear: the patient accuses himself of all sorts of sins and crimes and expects as their consequence the most terrible misfortunes for close people and punishment for himself. In some cases, consciousness is disturbed and complete confusion occurs: patients become disoriented, lose understanding of what is happening around them, people around them seem to them to be victims of their crimes or, conversely, executioners, all sorts of horrors seem to be everywhere; if hallucinations are added, a typical picture of delirium may also develop (see Delusion). The elimination of D. phenomena occurs most often as gradually as the initial increase. First, weight increases and inhibition weakens: patients become more mobile and sociable. Often this very period, when disinhibition occurs while strong gloominess is still preserved, turns out to be the most dangerous, as it is precisely during this period that a significant number of successful suicide attempts occur. Affective instability, anxiety, and easy irritability are symptoms that disappear at the very end of the illness. Sometimes a depressive attack ends with a slight hypomanic excitement, which, gradually subsiding, leads to the establishment of mental equilibrium. True endogenous depression always ends with complete recovery and restoration of the basic properties of the prepsychotic personality, which emerges from the disease without any defects. The question of the psychological structure of depressive states remains little clarified. Kurt Schneider (K. Schneider) believes that in endogenous D. the layer of affectivity is affected, which is most connected with general organic, and not only nervous, physiological processes, namely - the area of so-called vital feelings. In connection with this assumption, he connects the abundance of patients' complaints about the most varied painful sensations in the body and the very poor motivation of the gloominess they experience. Psychopathologists who come from the psychoanalytic school or are close to it (Freud, Adler, more recently Kant, Fridman) seek to find in D., under the mask of passivity, aggressive-destructive tendencies. (Adler speaks of "the impulse of revenge arising from powerless rage", while Freud speaks of the direction of destructive tendencies toward the lost object of love, with which the patient somehow identifies his own personality.) The physiological basis of endogenous D. has also not yet been established; one can only assume that its source is a violation of metabolic regulation in the body by centers of the autonomic nervous system, which can easily be caused on the soil of constitutional instability of the latter, both by endogenous periodic fluctuations of its general tone and by various external factors. Some authors, however, tend to attribute the greatest importance in the pathogenesis of attacks of endogenous D. to the influence of disorders in the activity of some glands of internal secretion (adrenal glands). Therapy - symptomatic: warm baths, opiates, care for nutrition and strengthening of the general condition; most important - careful observation of the patient and care to prevent possible suicide attempts. Constitutional D. - a name given to cases where traits of psychic depression constitute an inalienable sign of a psychopathic personality, firmly characterizing its psychic appearance and accompanying it until the grave. This is its main difference from "endogenous" D., which represents only one of the alternating phases of manic-depressive psychosis (a disease, as is known, also classified as constitutional). Thus, there is no fundamental boundary between constitutional and endogenous D. Individual attacks of the latter sometimes develop as exacerbations against the background of a constantly depressed state characterizing the first. Depressive psychopaths are persons with a predominating depressed shade of mood, who in their youth firmly adopted a pessimistic attitude toward life, incapable of joy, viewing everything in a gloomy light and heavily experiencing any difficulties and unpleasantnesses.

They can naturally be divided into several groups, the most important of which should be considered: 1) mild, immobile, tender and timid melancholics, most often weak-willed, indecisive, easily losing courage and falling into despair, and 2) unsociable, eternally dissatisfied with everything, irritable and even malicious pessimists, vehemently denying any meaning in life and seeing only evil in people. Within this second group, a subgroup of paranoid individuals can be distinguished: distrustful, prone to suspect that others wish to harm them. One of the characteristic features of some depressive psychopaths is a special restlessness and tendency to change places, undertaken as if to escape from the oppressive melancholy that weighs on them. Not all people suffering from constitutional D. can be recognized at first glance: many of them quite successfully mask the joyless tone of their inner experiences with jester-like behavior or an increased striving for activity, in which they, as in changing their place, seek oblivion. It should be noted that on the basis of this psychopathy, a tendency to habitual use of narcotic substances (morphine, cocaine, alcohol, etc.) also easily develops. Reactive D. is a psychic condition that develops after severe experiences, most often after the loss of loved ones, love failures, etc. From the states of depression caused by such experiences that occur in normal people, reactive D. differs in its prolonged nature, excessive depth, and sometimes in the addition to the affect of melancholy of general phenomena of inhibition and delusional thoughts. Almost always with reactive D., there is an inability to detach oneself from the constant mental return to the experience that caused the D. Schneider sees the main difference between reactive D. and endogenous D. in that, while in the latter the sphere of vital feelings is affected, here the 'psychic' affective sphere ('seelische Gefuhle'), connected mainly with the apparatus of the higher nervous activity, is changed. Recently, Lange (J. Lange) made an attempt to divide pathological depressive states arising after psychic traumas into several groups. 1. In relation to cases where such D. develop in persons not belonging to the circle of constitutions related to manic-depressive psychosis, Lange proposes to use the term 'psychogenic' (and not 'reactive') D. Here the phenomena of melancholy recede to the background in favor of withdrawal into oneself, combined with some bitterness and a hostile attitude toward others, and the place of inhibition is taken by the inability to do anything other than constantly picking at one's emotional wound. Accordingly, patients are aggressive, egoistic, insincere, and their self-accusations often betray a secret desire to achieve rehabilitation from their interlocutor. 2. D. caused by psychic traumas in cycloids, Lange calls reactive melancholies. In their course, the latter are very close to endogenous D., but their distinguishing feature, according to Lange, is the persistent throughout the illness close connection of the patient's psychic state with the initial traumatic experience. Finally, D. caused by severe psychic traumas in circular patients, who have often already undergone several attacks of manic-depressive psychosis (psychically-provoked melancholies according to Lange), differ in their picture in no way from endogenous D., and even the connection with the initial experience, as the illness develops, usually becomes less and less distinct until it completely disappears. Lange's classification is of considerable interest as the first serious attempt to sort out the diversity of pictures that previously went under the common designation of reactive D., however, it cannot yet be considered universally accepted. Presenile melancholy - see Melancholia.