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March 2017
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DEPRESSION – looking for a definition  

    DEPRESSION



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.

Depression in literature and art 

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:

  • Plutarch, describing King Antiochus who was in love with his young stepmother: ...every little evil is magnified by the scaring spectres of his anxiety, he looks on himself as a man whom the gods hate. The physician, the consoling friend are driven away. He sits out of doors, wrapped in sackcloth. Ever and anon he rolls himself, naked, in the dirt, confessing aloud this and that sin. Asleep or awake, he is haunted alike by the spectres of his anxiety. Awake, he makes no use of his reason, asleep he enjoys no respite from his alarms. Nowhere can he find an escape from his imaginary terrors.
  • Seneca, in On the Tranquillity of Mind in response to Serenus Sammonicus:  And so we ought to understand that what we struggle with is the fault, not of the places, but of ourselves; when there is need of endurance, we are weak, and we cannot bear toil or pleasure or ourselves or anything very long.
  • Petrarch in Secretum: ...everything is bitter, gloomy, horrendous: desperation turns the day into hellish night and forces us to nourish ourselves with tears and pain with a certain something like pleasure, so much so as to reluctantly detract it.

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.

DSM IV

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.

    1. Depressed mood for most of the day, nearly every day, and it can be noted by the patient him/herself (feeling sad or empty) or it can be an observation made by others (the patient looks like he/she may cry). N.B. irritability can often be observed in children and adolescents.
    2. Obvious loss of interest or pleasure in all or almost all activities for most of the day, nearly every day (as indicated by both the patient him/herself or observed by others).
    3. Significant weight loss (when not dieting) or weight gain (for example, a change of more than 5% of body weight in a month), or decreases or increases in appetite nearly every day. N.B. failure to gain weight is normal in children.
    4. Insomnia or hypersomnia nearly every day.
    5. Agitation or psychomotor reduction nearly every day (observable by others, not merely by the patient who notices he/she cannot stay still or be stopped).
    6. Fatigue or loss of energy nearly every day.
    7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-punitive or about being ill).
    8. Diminished ability to think and concentrate, or indecisiveness, nearly every day (either noted by the patient or observed by others).
    9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal thoughts without a specific plan for suicide or suicide attempts or specific plans for suicide. 

  • The symptoms do not have to be included in the defined criteria for a mixed episode.
  • The symptoms cause clinically significant distress or feelings of inferiority in social life, work and other important areas.
  • The symptoms do not have to be due to psychological effects from a substance (for example, a drug, medication) or a general medical condition (for instance, hyperthyroidism).
  • The symptoms are not caused by a death, such as the loss of a loved one, but the symptoms persist for a period that is longer than two months, or they are characterised by noticeable functional impairment, morbid worry about being worthlessness, suicidal thoughts, psychotic symptoms or psychomotor reduction.

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:

  • Psychical: sadness, despair, indifference, not feeling anything, internal emptiness, apathy, indecisiveness, inhibitions, decreased ability to concentrate and memorise things, pessimism, ideas of death, thoughts of ruin, self-devaluation, worthlessness, guilt;
  • Psychomotor: slowing down, restlessness, hypomimia;
  • Psychosomatic: insomnia and hypersomnia, feelings of tension, decreased strength, dizziness, hypotension, dyspnea, constipation, colitis, loss of appetite, weight loss, feeling cold, palpitations, body aches.

Clarifying the definition of depression is absolutely necessary for its diagnosis.

After 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.

DEPRESSION

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