Depressive Reactions
There are few persons who do not experience periods of discouragement and dispair. As with nervousness, irritability, and anxiety, depression of mood that is appropriate to a given situation in life (e.g., grife reaction) is seldom the basis of medical concern. Persons in these situations tend to seek help only when their grief or unhapiness is persistent and beyond control. However, there are numerous instances in which the symptoms of depression assert themselves for reasons that are not apparent. Often the symptoms are interpreted as a medical illness, bringing the patient first to the internist or neurologist. Sometimes another disease is found (such as chronic hepatitis or other infection or postinfectious asthenia) in which chronic fatigue is confused with depression; more often the opposite pertains, i.e., an endogenous depression is the essential problem even when there has been evidence earlier of a viral or bacterial infection. Since the risk of suicide is not inconsiderable in the depressed patient, an error in diagnosis may be life-threatening.
From the patient and the family it is leanred that the patient has been "feeling unwell," "low in spirits," "blue", "glum," "unhappy," or "morbid." There has been a change in his emotional reactions of which the patient may not be fully aware. Activities that he formerly found pleasureable are no longer so. Often, however, change in mood is less conspicuous then reduction in psychic and physicial energy, and it is this type of case that is so often misdiagnosed by internists and neurologists. A complaint of fatigue is almost invariable; not uncommonly, it is worse in the morning after a night of restless sleep. The patient complains of a "loss of pep," "weakness," "tiredness," "having no energy," and/or that his job has become more difficult. His outlook is pessimistic. The patient is irritable and preoccupied with uncontrollable worry over trivialities. With excessive worry, the ability to think with accostumed efficiency is reduced; the patient complains that his mind is not functioning properly and he is forgetful and unable to concentrate. If the patient is naturally of suspicious nature, paranoid tendencies may assert themselves.
Particularly troublesome is the patient's tendency to hypochondriasis. Indeed, the most cases formerly diagnosed as hypochorriasis are now regarded as depression. Pain from whatever cause--a stiff joint, a toothache, fleeting chest or abdomical pains, muscle cramps, or other disturbances such as constipation, frequency of urination, insomnia, pruritius, burning tongue, weight loss--may lead to obsessive complaints. The patients passes from doctor to doctor seeking relief from symptoms that would not trouble the normal person, and no amount of reassurance relieves his state of mind. The anxiety and depressed mood of these persons may be obscured by their preoccupation with visceral functions.
When the patient is examined, his facial expression is often plaintive, throubled, pained, or anguished. The patient's attitude and manner betray a prevailing mood of depression, hopelessness, and despondency. Sighing is a frequent sign. In other words, the affect, which is the outward expression of feeling, is consistent with the depressed mood. During the interview the patient may sigh frequently or be tearful and may cry openly. In some there is a kind of immobility of the face that mimicks parkinsonism, though others are restless and agitated (pacing, wringing their hands, etc.). Occasionally the patient will smile, but the smil impresses one as more a social gesture than a genuine expression of feeling.
The stream of speech is slow. There may be long pauses between questions and answers. The latter are brief and may be monosyllabic. There is a paucity of ideas. The retardation extends to all topics of conversation and affects movement of the limbs as well (anergic depression). The most extreme forms of decreased motor activity, rarely seen in the office or clinic, border on muteness and stupor Conversation is replete with pesimistic thoughts, fears, and expressions of unworthiness, inadequacy, inferiority, hopelessness, and sometimes guilt. In sever depressions, bizarre ideas and bodily delusions ("blood drying up," "bowels are blocked with cement,"I am half dead", may be expressed.
Three theories have emerged concerning the cause of the patholigic depressive state. (1) that the endogenous form is hereditary, (2) that a biochemical abnormality resutls in a periodic depletion in the brain of serotonin and norepinephrine, and (3) hat a basic fault in character developments exists. These theories are elaborated in Chap. 57.
It is the authors' belief that depressive states are among the most commonly overlooked diagnoses in clinical medicine. Part of the trouble is with the word itself, which implies being happy about something. Endogenous depression should be suspected in all states of chronic ill health, hypochrondriasis, disablity that exceeds manifest signs of medical disease, neurasthenia and ongoing fatigue, chronic pain sydromes--all of which may be termed "masked depressions." Inasmuch as recovery is the rule, suicide is a tragedy for which the medical profession must often share responsibility. Depressive illness and theories of their causation and management are considered further in Chap. 57. -Principles of Neurology, by Maurice Victor and Allen H. Ropper
