Symptoms of depression
The primary symptom in depression is the change in mood, yet this is often not the principal complaint of the patient, who may present a whole range of symptoms suggesting physical illness rather than a mental disorder. The patient may be ashamed of feeling depressed, as if it is a sign of weakness on his part, and therefore he must offer the doctor a more respectable sort of illness. People of obsessional personality who set themselves high standards of behaviour are particularly prone to present in this way. Other patients are very aware of the secondary physical features of their illness and may hardly realise that their mood is one of depression, so they complain of insomnia, constipation, tiredness, loss of energy, and the like, rather than feeling of hopelessness and misery. The diagnosis of a depressive illness is often only made as a result of careful inquiries into whether the patient has certain symptoms apart from those of which they spontaneously complain.
Clinically, it is possible to divide depressive illness into two main groups, but in practice it is often very difficult to decide in which group an individual patient should be placed. These two groups are called reactive and endogenous depression.
As its name implies, reactive depression is a change in mood arising from events happening to the individual, and the features of the illness are similar to the normal grief reaction we all experience as a result of the loss of someone, or something, for whom we have strong feelings of love or affection. Thus, the patient can usually understand and explain why he feels as he does, and will date the onset of his illness from a particular event. He feels sad and fearful, and may derive benefit from crying.
He is preoccupied with thoughts concerning his loss, and there is often an underlying anger and resentment, usually directed at other people rather than at himself, with a tendency to blame them for his loss. He feels worse towards evening, and may find it difficult to get off to sleep, but usually once asleep, he will remain so for the whole night. He can usually be cheered up at least for a time, and be able to respond to company. While he may lose his appetite, and become constipated, the physiological changes are usually slight.
Endogenous depression (arising from within)
While the illness may be precipitated by some external event, it can arise without any obvious cause, so that patients often say, I’ve nothing to be depressed about. The feeling of sadness seems to differ in some way from the normal response to unhappy events, and it is almost always accompanied by a number of physiological changes. Patients may weep, but frequently they complain that crying doesn’t help, or I’ve gone beyond tears. Not only does the patient feel low in spirit, but there is a general lowering of interest in, and desire for, almost all former interests. Thus, food longer holds any pleasure and may become actively disliked. Hobbies and pastimes are neglected, and even reading a newspaper or watching a television programme becomes too much of an effort.
They are unable to concentrate and may find it difficult to make even quite simple decisions. While they remain at work the difficulties make it impossible for them to get through their normal amount of work. This, in return leads to the work accumulating, which increases their sense of guilt and hopelessness, so that they become even more depressed. They, and their families, often feel that it was overwork that caused the illness, but almost always the true course of events in the one just outlined.
The patient may complain that his mid keeps on turning over the same problem or morbid thought, and that he cannot concentrate because of these fixed ideas, which are often concerned with death. He may ponder on the death of friends or relatives, and may wish that he, too was dead. This state of being half in love with easeful death may progress to the actual wish to commit suicide, and the patient may make plans for so doing, or carry out an attempt. He may become so preoccupied with morbid thoughts, and find life so unrewarding that he becomes withdrawn to an extent that he merely sits, unspeaking and almost unmoving. In extreme cases the patient may pass into a state of depressive stupor, which clinically is very similar to the condition that occurs in some patients with catatonic schizophrenia.
Not all patients show this reduction in activity or motor retardation as it is called; some show the opposite state in which, while their mood is depressed and their appetites diminished, they become physically over-active and restless and extremely agitated. This type of depression is quite often seen in people who have their first attack of depression in middle age, and who have a rather rigid and obsessional personality prior to their illness. This type of depression is sometimes called involutional because of the time life at which it occurs. Many patients with this type of illness express delusional ideas, which arise from the feelings of hopelessness and misery and in some ways represent the patients attempt to explain to themselves why they feel so awful and life seems so horrible.