Motivation is a purposeful need addressed to objects in the external environment. Motivation is born from needs. F.M. Dostoevsky figuratively defined the basic human needs as “the need for bread, education and worldwide connection.” Needs are congenital and acquired, some are of a primary biological nature, for example, the need for food, procreation, sleep, etc., others are of a more complex nature. The highest needs include the need to learn, to occupy a position in society, the need for self-realization. The needs existing in the subconscious sphere are transformed into motivation (attraction), which forms human behavior, namely, an externally observable form of activity.
With depression, almost all areas are affected – emotional, intellectual, strong-willed and necessarily motivational, which manifests itself both subjectively in the patient’s complaints and objectively in changing behavior. A persistent decrease in mood during depression is combined with a loss of interest in what was previously perceived by the patient as attractive, bringing satisfaction or joy – various forms of leisure, communication, reading books, hobbies, professional activities, sex life, etc. Not only will the feeling of satisfaction disappear as a result In such an activity, a patient suffering from depression has no motivation, there is no desire to start this activity, and interest in the activity itself is replaced by indifference and irritation. These disorders constitute one of the main diagnostic signs of depression, which is referred to in ICD-10 as “loss of interest and pleasure”. With all types of depressive state, primary biological motivations also suffer – food, appetite and sexual function are disturbed, sleep is disturbed. The degree of these disorders usually depends on the severity of the depressive state.
The connection between motivational disorders and depression is not accidental and has a certain biochemical basis: these disorders are caused by a violation of the metabolism of brain monoamines – serotonin, dopamine, norepinephrine.
Violation of food motivation
Human eating behavior – taste preferences, diet, diet, depend on cultural, social, family, emotional-affective and biological factors. Numerous works have shown that with the easy availability of food (as soon as you open the refrigerator door), psycho-social, and not energy (biological) factors become the most significant. The prevailing notions of beauty, especially of women, have a strong influence on eating behavior. In underdeveloped countries, a woman’s dignity is fullness. In developed countries, however, there is a fashion for a slim figure, which makes many, especially young women, “go on a diet” in order to lose weight and become slimmer. These self-restraints are usually not indicative of true eating disorders. True eating disorders are much less common and are caused not only by concern for the figure, but by a number of psychopathological conditions, including depression.
With depression, a decrease in appetite is more often observed, which is accompanied by a decrease in body weight. Anorexia and exhaustion so often accompany depression that they are considered one of its obligatory signs and are included as criteria for diagnosing depression in almost all known questionnaires. Anorectic reactions in depression have a number of distinctive features. As a rule, there is not only a decrease in appetite or lack of it, but often food becomes tasteless or begins to cause disgust. Even the smell or sight of food can cause disgust. Such patients may experience a feeling of nausea, less often vomiting. Eating is not accompanied by pleasure, such patients eat because they need to eat or they are forced to eat. The loss of pleasure from eating is often combined with increased satiety, when the patient, after taking small amounts of food, feels a full stomach, a feeling of unpleasant heaviness, satiety, and nausea. Anorexia leads to a sharp reduction in the amount of food and weight loss. Anorectic manifestations are closely related to the intensification of other manifestations of depression and are most pronounced in the morning. In some cases, they can be presented vividly and occupy a leading place in the clinical picture of the disease. In such patients, there is a need for differential diagnosis with anorexia nervosa.
Anorexia nervosa mostly affects girls. The peak incidence occurs in adolescence and adolescence. The main signs of the disease are a decrease in body weight by more than 15% of the initial, painful conviction of one’s own fullness, even despite a low weight, amenorrhea. At the heart of the disease is the desire to lose weight, which patients realize through diet, exhausting exercise, and often enemas, laxatives and vomiting. About half of people with anorexia nervosa have bouts of binge eating followed by unloading. The patients themselves do not pay attention to weight loss and fatigue. Concerned relatives bring them to the doctor. The causes of anorexia nervosa are still little known; an important role, apparently, is played by hereditary factors, family traditions, personality traits, including psychopathy.
Psychotherapy is widely used to treat anorexia in depressed patients. For pharmacological correction, antidepressants are used, in particular, it is known that TCAs are capable of causing an increase in body weight, apparently due to increased appetite. At the same time, in the case of eating disorders of the type of emotionogenic eating (see below), these drugs often, on the contrary, reduce appetite. A decrease in food motivation followed by a decrease in body weight are secondary to depression and in most cases go away on their own as depressive manifestations decrease. With depression, there is rarely a significant deficit in body weight, as in anorexia nervosa, and concomitant metabolic, severe endocrine, cardiovascular and other disorders that require special correction.
An increase in appetite or bulimia can also accompany depressive conditions, although this is less common. Typically, bulimia is associated with a lack or decreased feeling of satiety and leads to weight gain and obesity. Overeating in depressed patients is not based on hunger, but on emotional discomfort. Patients eat in order to relieve a bad mood, get rid of melancholy, apathy, anxiety, and feelings of loneliness. This type of bulimia is called compulsive bulimia, bulimia without unloading, hyperphagic reaction to stress, emotiogenic eating behavior, food drinking.
In depression, food intake is often the only form of behavior that brings the patient positive emotions and reduces the symptoms of depression. Often bulimia with depression is accompanied by drowsiness and hypersomnia.
The severity of emotiogenic eating behavior can lead to a significant increase in body weight. Research by T.G. Voznesenskaya showed that 60% of obese patients have emotiogenic food, which in such patients is the main mechanism for gaining body weight. Emotional eating behavior is closely associated with depression and increased levels of anxiety.
Night eating is a special type of emotiogenic eating behavior. Such patients wake up in the middle of the night, usually in the early morning hours (3-4 hours), and cannot fall asleep without a snack. An increase in appetite in such cases is not at all associated with the amount of food eaten before bedtime and the feeling of hunger, but plays the role of a sedative, sleeping pill. Such patients, as a rule, have sleep disturbances characteristic of depression (see below), overweight.
Biochemical studies carried out by J. Fernstrom, R. Wurtman (1971) made it possible to understand and explain why a number of foods can serve as a kind of cure for depression. In emotiogenic eating behavior, when patients eat in order to improve mood, reduce feelings of depression and apathy, they prefer digestible carbohydrate foods. An increased intake of carbohydrates leads to hyperglycemia and, consequently, to hyperinsulinemia. In a state of hyperinsulinemia, the permeability of the blood-brain barrier for the amino acid tryptophan changes. Tryptophan is a precursor of serotonin, therefore, following an increase in tryptophan content in the central nervous system, serotonin synthesis increases. Food intake can be a kind of modulator of the level of serotonin in the central nervous system; an increase in its synthesis associated with the absorption of carbohydrate food leads to an increase in the feeling of satiety and a decrease in depressive manifestations. Thus, it was clearly shown that bulimia and depression have common biochemical pathogenetic mechanisms – serotonin deficiency.
The results of these studies were the basis for the use of selective serotonergic antidepressants for the treatment of depression accompanied by bulimia and obesity with disturbed eating behavior. The leader among SSRIs is fluoxetine, or Prozac, which belongs to both antidepressants and anorexigenic drugs (S. Wise, 1992; L. Levine, 1989). The indications for its appointment in obesity is a combination with emotiogenic eating behavior, depression, chronic pain syndromes, panic attacks (T.G. Voznesenskaya, 1998).
Sexual function has an important biological and social significance, since it not only ensures the continuation of the race and the receipt of specific sexual sensations, but also opens up the possibility of creating a family, eliminating loneliness. It affects the social status of a person, her self-affirmation and self-esteem.
A fairly common symptom of depression is a violation of sexual function: a decrease in libido, impotence and frigidity, a decrease in the intensity of orgasm or anorgasmia. Many patients refuse sexual relations, as they do not experience pleasure; after intercourse, there may be an increase in depressive symptoms.
Sexual dysfunctions in men in most cases (up to 90%) are of a psychogenic nature. They make a man unable to provide sexual satisfaction to a woman, disrupt family relationships, often lead to her disintegration, which in turn aggravates the severity of mental disorders. Periodic fluctuations in sexual activity, in particular a sharp decrease in it, in combination with an increase in depressive symptoms can be observed in patients with cyclothymic mood swings.
In women, in contrast to men, sexual dysfunctions in the vast majority of cases do not hinder the creation of a family, do not deprive the spouse of the opportunity to provide sexual satisfaction. Active complaints of violations in the sexual sphere are much less common.
In young women, depression can lead to various menstrual irregularities: dysmenorrhea, amenorrhea, anovulatory cycles, and ultimately even infertility. With a detailed gynecological and endocrinological examination of such women, as a rule, no convincing reasons for menstrual dysfunction are found. In these cases, it is necessary to think about the possibility of depression and conduct appropriate research. The study of menstrual function in patients with various emotional-affective disorders, including depression, observed in the clinic of nervous diseases, showed that the frequency of menstrual irregularities reaches 70% or more (IV Kucherova, 1989). These violations are obligatory accompanied by a violation of sexual desire and frigidity. The use of hormonal drugs to restore menstrual function is not required. After antidepressant therapy, not only the mental state is normalized, but also the function of the gonads; sexual disorders go away.
Psychogenic amenorrhea is not necessarily a marker of depression. With amenorrhea with a marked decrease in body weight, especially in young women, it is necessary to exclude anorexia nervosa as an independent disease (MA Korkina and MA Tsivilko, 1986). The criteria for diagnosing anorexia nervosa have already been discussed above; if this disease is suspected, a psychiatrist’s consultation is necessary.
A syndrome that demonstrates a special relationship between motivational and affective disorders and the function of the gonads is premenstrual tension syndrome. It occurs in its pronounced form in about 25% of women and has a number of synonyms – premenstrual dysphoric disease or late luteal dysphoric phase.
Clinical symptoms usually appear 7 to 10 days before the onset of the next menstruation and disappear with its onset. Depressed mood, irritability, increased fatigue, decreased performance, resentment, aggressiveness, hostility are noted. It seems to women that their life has lost its meaning, there is a feeling of their own helplessness and uselessness, some have a fear of going crazy. Along with this, vegetative disorders, headaches, pains and discomfort in the lower abdomen appear. Appetite may increase, and there is a craving for sugary, high-carbohydrate foods, this is the reason for the increase in body weight in the premenstrual days. Sleep disturbances may appear in the form of daytime sleepiness and increased sleep duration, while sleep is intermittent, restless and does not bring a sense of rest. Peripheral edema may appear, and the mammary glands become swollen and painful. The symptom complex described in the premenstrual tension syndrome (depression, hypersomnia, bulimia, weight gain, premenstrual tension) is similar to the clinical picture of seasonal affective disorders (SAD). With SAR, the onset of all clinical symptoms is associated with the dark season, in our geographic zone it is from late October to early March.
The main role in the pathogenesis of premenstrual tension syndrome is played by sex hormones: estrogens, progesterone, and serotonin. They have a modulating effect on the functioning of the central nervous system; it is with serotonin deficiency and a violation of the ratio of estrogens and progesterone in the luteal phase of the cycle that the appearance of clinical symptoms in premenstrual tension syndrome is associated. The main method of treatment for premenstrual tension syndrome is SSRI antidepressants (G. Solomon, 1990; R. Fuller, 1995; M. Steiner, 1995,1997). When applied, both mental and somatic disorders regress.
A depressive state has a close connection with menopause, and their relationship is ambiguous: in some cases, depression can lead to an early or pathological menopause, in others, signs of depression can appear or worsen against the background of hormonal changes in the female body, and successfully carried out hormonal therapy can lead to a decrease in the severity of mental disorders.
The old authors called pronounced affective, autonomic and other disorders that occur in women during menopause, climacteric neurosis. They described climacteric neurosis with a preserved rhythm of menstruation (in the premenopausal period), with various irregularities in the cycle, more often the type of opsomenorrhea, and also at various times after the onset of menopause (postmenopausal period). Mental manifestations in menopause are observed in about half of women, are depressive or anxious-depressive in nature and have varying degrees of severity. Changes in the mental state are combined with autonomic disorders: the most common are hot flashes, sweating, palpitations, dizziness, noise in the head and ears, paresthesia in the limbs. A number of women have panic attacks against this background. The presence of chronic pain syndromes is characteristic: chronic tension headache, cardialgia. Disorders of night sleep are often noted, and vegetative and pain disorders, which often occur in this contingent at night, aggravate insomnia.
In the climacteric period, changes in the hormonal status of a woman are of significant importance in the deterioration of the emotional state, since hormones affect mental processes, the functional state of the brain, and change interhemispheric relationships. However, one should not forget about the attitude of many women to the cessation of menstruation. Some people perceive this as a disaster, the onset of old age, believe that they are becoming less attractive to a partner. Involutionary atrophic changes in the genitals in the climacteric period do not play a dominant role in the occurrence of sexual disorders, the psychological state of a woman is more important (A.M. Svyadosch, 1982). An inappropriate attitude towards the natural age period often leads to depression. It is the depressive state that can determine the pathological course of menopause. The main task of the doctor during this period is psychotherapeutic correction, the purpose of which is to normalize a woman’s self-perception, to reduce the level of stress. For the treatment of pathologically proceeding menopause, hormonal therapy is used in combination with antidepressants (S. Takagi and Y. Yanagisawa, 1996), it is such a complex therapy that helps most effectively eliminate depressive, vegetative, algic and other manifestations in the climacteric period.
Sleep disorders are observed in 83 – 99% of patients with depression. In some patients, they are the leading complaint, while in others they are noted along with other clinical symptoms characteristic of depression. One way or another, they are one of the criteria for diagnosing depression. The relationship between sleep disorders and depression is extremely close: the presence of persistent sleep disorders always serves as a basis for excluding latent, larvae depression, which manifests itself under the guise of these disorders.
The clinical manifestations of sleep disorders in depression have a number of characteristics. As a rule, post-somnic disorders are noted. These patients say that they fall asleep more or less satisfactorily, but wake up early. In the morning they can no longer sleep. The morning hours are difficult hours for patients with depression, it is at this time that the symptoms become aggravated, and by the evening the condition of the patients improves. However, this is not an absolute rule, as there are various forms of depression. Patients who complain of early morning awakening with the inability to fall asleep again often suffer from melancholy depression. In patients with anxious or agitated depression, falling asleep is often disturbed, and even the opposite phenomenon is noted – a compensatory lengthening of morning sleep.
A large number of electrophysiological studies of night sleep in depression have been carried out. Already in the first studies, it was shown that the subjective assessment of sleep by patients is often very inaccurate. For example, the patient claims that he spent the whole night without sleep, and the thoughts that crossed his mind at night were born in a state of wakefulness, and during the polygraphic recording at this time, the dream was objectively recorded. Therefore, for an objective assessment of night sleep, one should resort to special research, and not rely on the patient’s story.
Changes in the structure of nocturnal sleep during depression are diverse and are both nonspecific and relatively specific, i.e. are observed more often than with other forms of sleep disorders. Many sleep disorders that arise for various reasons are characterized by a decrease in the duration of sleep, a longer wakefulness during the hours when a person usually sleeps, an increase in motor activity during sleep, an increase in the latent periods of the onset of various sleep phases, an increase in the representation of superficial and a reduction in deep sleep stages. … Relatively specific for depression include a reduction in the deepest stage of REM sleep: the fourth stage, as well as an earlier onset of REM sleep.
A very interesting phenomenon of the so-called alpha-delta sleep has been found in patients with depression. It can take up to 20% of the total sleep duration and is manifested by a combination of delta waves, i.e. slow waves characteristic of the deep stages of sleep with alpha waves, which are one or two oscillations less frequent in frequency than in the waking state. At the same time, the dream turned out to be deep enough. The presence of alpha-delta sleep may indicate a link between deep sleep and depression. This question is especially interesting in connection with the developing ideas about the role of the serotonin factor in the initiation of slow wave sleep, as well as the role of disorders of serotonin metabolism in the pathogenesis of depression. It can be assumed that both sleep disorders and depression are based on the same biochemical mechanisms.
In 1996 Shute noted that sleep deprivation (deprivation) reduces the manifestations of depression and is especially effective in melancholy depression, and then R.G. Airapetov carried out special studies. However, sleep deprivation occupies a special place in the treatment of depressive states, which confirms the close connection between the mechanisms involved in the organization of sleep and the pathogenesis of depression.
It is obvious that depression manifests itself primarily in insomnia. However, with depression it is possible to observe some forms of hypersomnia. First of all, this is the syndrome of idiopathic hypersomnia, which is manifested by deep sleep, difficult morning awakening (“sleepy intoxication”), daytime sleepiness. Another manifestation of hypersomnia is periodic hibernation, which is observed in young people, who have a period of insurmountable drowsiness for 7 to 9 days, when they get up, eat, send their physiological needs, but spend most of the day sleeping. Then this state completely disappears for a while. Such episodes of hibernation are equivalent to a depressive state and are successfully treated with prophylactic antidepressant courses.
Sleeping pills cannot solve the problem of sleep disorders in depressed patients and are only symptomatic. They should be prescribed for a period of no more than 2 – 3 weeks, i.e. for the time required to clarify the depressive nature of insomnic or hypersomnic disorders. The method of choice is the course of treatment with antidepressants.