DEPRESSION – looking for a definition
The history of depression is the history of mankind, however, the term connoting depression as a psychiatric syndrome was only introduced in the 1920s, by the German psychiatrist Meyer.
Depression is a universal, emotional experience which is innate to mankind (it was once said that you are not a man until you
have experienced depression). Depression is one of the emotional means mankind
has to relate to the world and it allows us to overcome frustrations, delusions
and losses. Every change is, as such, a loss of something known and an adventure
of the unknown, thus it brings with it feelings of depression, for the loss we
experience, and the anxiety we feel for the unknown. Living means continually
facing changes and therefore the risk of physiological depression turning into
pathological depression is always there.
Depression hovers between normality and illness: it may be the result of mourning, for example, (a normal reaction to the loss of a loved one or a serious frustration) or it can be an illness (this differs from mourning mainly in terms of how long it lasts, the quantity of it and the disproportion with respect to the trigger). Mourning allows us to break the bonds we have with a lost person or idea and it becomes a nice memory and it allows us to make new relationship. The function of mourning is the same as that of depression: the object we have lost is kept alive inside of us however reality takes over, thus we are able to look forward once again. When there is no trigger for depression however, and we see signs of it which persist over time, we lose some of our self-esteem and the sense of time and space changes and we start to think it is impossible to get out of this situation, thus it becomes an illness.
This illness has been recognised since ancient times and it has always been described as an anomaly compared to normality.
|The first description of depression may well be that written by Homer about Bellerophon in Illiad: ....but when Bellerophon came to be hated by all the gods, he wandered all desolate and dismayed upon the Alean plain and with the abandonment of the Gods, he no longer had the courage or strength to live and so it was in absolute emptiness and all-consuming sadness that the hero struggled and wasted away.|
The artists who were able to best capture and represent the suffering and anxieties of mankind and their descriptions, were those who illustrated depression. Here are some examples:
Works of art have also captured how depression affects us: Melencolia I by Durer exemplifies the paralysing pain of depression and The Scream by Munch communicates the crushing anxiety of depression.
Here is a description that was made by the psychiatrist Esquirol (1772-1840) to close this brief overview:
|a heaviness of the head which prevents thought and of a torpor and general lassitude which render effort impossible [...] They abandon their ordinary occupations, neglect their domestic duties and are indifferent to the objects of their former affections [...] they entertain gloomy meditations and at length in despair on account of their real or pretended worthlessness, which they believe can never be surmounted, they desire death call for it and sometimes devote themselves to it wishing...|
Looking for a definition
Melancholy has been discussed over centuries, followed by endogenous, major and reactive depression and dysthymic disorder or neurotic depression and chronic, masked, senile, organic and, finally, cyclothymic or bipolar, atypical depression.
Melancholy or endogenous depression or more (Freud): deep and dark discouragement, becoming less interested in the world, losing the ability to love, inhibitions about everything, humiliation about your own feelings, self-punishment and self-abuse and this culminates in a great sense of guilt and a delirious wait for punishment.
Reactive depression (Breuler): having alleviated the painful desperation about your disgrace, and having wiped away the tears again, when the worst seems to be behind you, you find yourself petrified, you no longer have the interests you once had, nothing cheers or enthrals you, friends are indifferent, life has lost its attraction and perceptions has lost importance and expressivity
Chronic or residual depression: the symptoms of the acute phase remain, especially social isolation, apathy and pessimism. The patient is not able to overcome the loss of something and continues to try and regret, blaming the people he/she comes into contact with as the patient does not consider them to be as good as the lost (or not achieved) ‘thing’.
Masked depression: psychical somatic symptoms prevail in this case.
Senile depression: there may be signs of paranoia, marked hypochondria and sometimes confusion. Some explanations must be differentiated from dementia.
Organic depression: this occurs after taking hallucinogenic medication or it can be the result of other illnesses (infectious diseases, cancer of the pancreas and hypothyroidism).
Nowadays, it is thought that we should not talk about different and separate diseases, but rather we should talk about a continuum between one form and another that varies depending on the structure of the patient’s personality, his/her life events, the personal events and relationship experiences had during childhood or, taking another approach, the quality and quantity of the deficit of neurotransmitters.
The key to depression is loss of affection: a depressed person feels that he/she, his/her life and the surrounding reality are completely unpleasant and painful. This person’s existence loses its meaning and interest and, since the depressed person lives a life of solitude, death looks like a liberator. He/she changes the way he/she relates to the world, especially regarding time and space: there is a sort of paralysis of becoming, the weight of the past grows, only a few acts of the past end up characterising the patient's personal history and he/she is full of negativity. The past no longer has pleasurable memories, nostalgia is painful, the future is inaccessible and blocked, there is no more planning and the present shrinks and becomes unchangeable. Space is limited, narrow, closed, motionless and empty and objects become unreachable: the depressed person feels distant from him/herself inside.
The scientific description usually accepted nowadays is provided by the American Psychiatric Association in the Diagnostic and Statistic Manual of Mental Disorders: the DSM IV of Major Depressive Episodes.
Major Depressive Episodes
5 or more of the following symptoms must be present during a two week period and they must represent a change from previous behaviour. At least one of the symptoms must be a depressed mood or loss of interest or pleasure.
As can be seen in the DSM IV definition, the psychical, psychomotor and psychosomatic symptoms present in cases of depression, and which are found in big or small amounts, are:
Clarifying the definition of depression is absolutely necessary for its diagnosis.
It is necessary to highlight that the moment in which a diagnosis is made does not signal the end of the doctor-patient relationship. Besides the diagnosis, which helps the physician to provide the right prescription of drugs or psychiatric treatment, it is essential that there is a good relationship between doctor and patient: never underestimate the relationship that allows us to understand the meaning and depth of suffering. As Balint wrote:
|The doctor’s work is to know how to administer himself and medicine.|
The doctor must be able to accept that he/she will suffer with the patient, and he/she must share that sense of emptiness and the paralysing aggression
that, although in different ways, are always present in relationships with the
depressed patient. The physician will also have to inform family members that
depression is not a lack of will, or that the patient wants to suffer pain and
that he/she does not work because he/she does not want to, but because the patient
is not able to not suffer and can not do his/her work properly. A pat on the shoulder
and telling him/her to react and deal with their own responsibilities are not
enough: this attitude sometimes only serves to further blame the depressed person.
The depressed patient must be respected as deeply as the depth of his/her suffering is. Sometimes the patient can be healed with firmness, and reminding him/her of the reality of things, but this must always be done with the intention of helping to heal and with the full knowledge that today it is possible, thanks to medicine and psychotherapeutic approaches, to heal, improve or at least obtain a better quality of life.
|The contemporary author Paulo Coelho, who lived in a mental asylum for three years, tells us how, sometimes, depression, including the darkest or more neutral types of depression, can be a maturing experience and can represent a dark, black and painful tunnel which opens up into a large field of hope and freedom. In Veronika decides to die, Veronika, through meaningful relationships and awareness of death, surprisingly becomes aware of life, even being aware of the ability to live every day like it is a miracle, like an exciting discovery, contradicting the poet Ungaretti when he wrote that living discounts death.|
The miraculous gift of serenity can be obtained in any place, even in places which appear improbable, and in the saddest of situations. And if not completely, at least a little.