Psychosomatic relationships in depression in patients with somatic diseases

Among mental disorders in patients with somatic diseases, depressions are second only in frequency to the disorders observed in the somnology clinic. If, according to epidemiological data, among people aged 14 and older, the incidence of insomnia reaches 21-45% (A.M. Wayne, 1995), then depression is registered in the population in 4.8-7.4%, in the general outpatient network – in 10% (T. Ustun, N. Sartorius, 1995), and among patients with verified somatic diseases this indicator rises to 22-33% and exceeds the frequency of such a widespread pathology as arterial hypertension (W. Katon, M. Sulliven, 1990 )
Depression is assessed as a disease that places a heavy burden on the patient, his family, society as a whole and, to a greater extent than chronic somatic diseases, interferes with full life. Unlike other mental illnesses, depression is given “exceptional social significance” (HK Rose, 1999). With a combination of depression and somatic disease, the situation is aggravated by the fact that this combination is one of the adverse factors complicating the process of diagnosis, therapy and medical care of this population, on the one hand, and on the other, negatively affecting the course and prognosis of both mental and somatic diseases.
Depression can provoke a somatic disease (e.g., coronary heart disease, arterial hypertension), and can be a deteriorating factor in the prognosis of diseases such as parkinsonism, diabetes, malignant neoplasms, AIDS, etc. (DL Evans et al., 1997). Clinically defined depression in somatic patients, according to A.B. Smulevich et al. (1999, 2000), obtained by examining the contingent of a multidisciplinary hospital, significantly more often leads to disability than a single somatic disease. Depression also increases the risk of death of somatic disease (BW Rovner, PS German et al., 1991). So, the probability of death within 6 months after myocardial infarction with the onset of depression increases 3-4 times (N. Frasure-Smith, F. Lasperance et al., 1993). Along with an increase in mortality from bodily illness, the cause of death in patients with somatic illness accompanied by depression often becomes suicide, and the suicidal risk is higher than in cases of “uncomplicated” depression. The consequences of incomplete suicides in such cases are exacerbation of the existing and / or accession of additional somatic pathology (fractures, brain damage; anemia due to artificially caused bleeding or deliberate refusal to eat; intoxication associated with poisoning, aspiration or hypostatic pneumonia, etc.).
In turn, a somatic disease can complicate the diagnosis of depression, increase its severity, contribute to chronicity (SR Kisely, DP Goldberg, 1993), and alter the body’s response to therapy (A.B.Smulevich et al., 1997).
Every doctor needs knowledge of the psychosomatic relationships in depression, since the interaction of mental and somatic processes is most clearly manifested in the clinic of affective pathology. Even depressive conditions arising outside the context of somatic illness are, by their symptoms, the most somatized mental disorders. In the patient’s perception, somatic phenomena can so clearly come to the fore that mental disorders are completely switched to the somatic level. Somatic complaints and dysfunctions of internal organs and systems can become so important in the clinical picture of depression that there is a tendency to consider all psychosomatic complaints of patients (or most of them) as a manifestation of depression (V. Breitigam, P. Christian, M. Rad, 1999).
Obviously, the modern official classification ICD-10, intended for a generalized standardized description of syndromic clinical categories, necessary to achieve reproducibility of diagnostic assessments and solving statistical problems, does not allow differentiating psychosomatic manifestations in the structure of depression. A binary (two-level) typological model presents this possibility (A.B.Smulevich et al., 1997; A.B.Smulevich, E.B.Dubnitskaya, 1999), according to which psychopathologically polymorphic manifestations of depression are divided into positive and negative affectivity .
Positive (pathologically productive) affectiveness is represented in the structure of depression by the phenomena of the circle of depressive hyperesthesia (W. Griesenger, 1866). The dominant melancholy affect is recognized as a painful mental disorder, has a special, protopathic character, is accompanied by ideative and motor inhibition with the formation of a meaningful depression complex – ideas of low value, self-humiliation and / or hypochondriacal interpretations with alarming fears for one’s health that are not related to actual somatic disease, or addressed to an imaginary disease.
Negative affectiveness (D. Watson, A. Clark, 1984) is manifested by the phenomena of devitalization, mental exclusion with a lack of motivation, loss of vitality, lethargy, inability to experience pleasure (anhedonia), indifference to everything around, awareness of the change in one’s life, deep dysfunction.
Correspondingly, depressions are ranked in a continuum in which vital (melancholy) depression (K. Schneider, 1959), in which the signs of positive affectiveness are extremely pronounced, is opposed to apathetic (O.P. Vertogradova, 1980) with the dominance of the phenomena of negative affectivity. The central position is occupied by anesthetic (depersonalization) depression (A. Schafer, 1880), which includes polar manifestations of positive and negative affectiveness and proceeds with a picture of painful insensibility – anaesthesia psychica dolorosa (painful consciousness of loss of emotions, inability to perceive nature, to experience love, hatred, compassion, anger, lack of emotional response to what is happening around) and / or apperceptive anesthesia (N.A. Ilyina, 1999) – a painful consciousness of the loss of the ability to logical thinking, the establishment of the elementary meaning of things, the extinction of imagination, loss of intuition.
Given the “resolution” of this model, the relationship between depression and somatic pathology is discussed further in two aspects: in terms of chronological and pathogenetic comorbidity.
With chronological comorbidity, we are talking about a coincidence in time of affective disorders that develop out of direct connection with the pathology of internal organs, somatic disease. Within this ratio, depressions independent of somatic disease are formed (cyclotymic – vital, apathetic, anesthetic; dysthymic – characterological, somatized dysthymia; reactive – anxious, hypochondriacal, hysterical).
With pathogenetic comorbidity in the mechanisms of development of depression, somatic disease plays the role of a stressful event that realizes either a special form of psychogenic reactions – nosogenic depression (A.B.Smulevich et al., 1992) 2, or somatogeny proper, reflecting the central nervous system response to pathological processes in the body – organic (associated with structural changes in the brain) and symptomatic (associated with intoxication, metabolic disorders) depression.
When recognizing an affective pathology that develops independently of a somatic disease (cyclotymic, dysthymic, reactive depression), the greatest difficulties are associated with the fact that the clinical picture includes a number of somatovegetative symptom complexes that are characteristic of both affective pathology and somatic suffering (general symptoms).
Among these symptoms, with the prevalence of positive affect phenomena in the depression picture, a general decline with constant fatigue, lack of a sense of rest after sleep, lack of sleep and lack of sleep, lack of appetite and constipation, a feeling of a “lead” head, and heaviness (a hundred-kilogram stone) can be highlighted. ) in the chest or abdomen, sensations of compression of the neck, anxiety in the chest, abdomen, less often in the head, disorders of the menstrual cycle, libido, potency, abnormal circadian rhythm. According to V. Breitigam, P. Christian and M. Rad (1999), the most frequent somatic manifestations of such depressions can be arranged in decreasing order of frequency as follows:
* headache, sensation of pressure in the head;
* a feeling of pressure and pain in the epigastrium;
* pain and tension in the limbs;
* a feeling of pressure in the heart, heart fear;
* difficulty breathing;
* A feeling of pressure in the throat and the urge to vomit.
Dramatic, having a touch of deliberation and caricature, the manifestations of hysterical depression are accompanied by massive conversion symptoms (“globus hystericus”, functional hyperkinesis, tremor, anesthesia, paresis, astasia-abasia, narrowing of the field of visual perception, psychogenic aphonia, etc.); in the picture of anxiety depressions, somatic anxiety phenomena (sweating, tachycardia, tachypnea, dizziness, gastrointestinal symptoms, dry mouth, etc.) often come to the fore; in hypochondria depressions, the affective somatovegetative symptom complex includes somatoform disorders (multiple pathological bodily sensations associated with the fear of a severe bodily illness or with the conviction of its presence) .3
“Common to physical” symptoms of depression and somatic disease (R. Tölle, 1999) with a predominance phenomena of negative affectivity, along with the subjective manifestations of the “loss syndrome” (impotence, joylessness, insensibility, and, when the disorder is aggravated, “fossil” and “emptiness”) are expressed by a feeling of weakness with special muscular lethargy (violation of the general feeling of the body) , anesthesia of somatic functions (lack of a feeling of sleep, hunger, satiety, thirst, etc.) or signs of alienation of catastrophic drives (loss of need for sleep, depressive anorexia with a feeling of aversion to food, etc.).
A special place among depressions that develop independently of somatic illness (and especially in patients with a general medical network where erased, atypical forms predominate) belongs to somatized depressions, in which the main manifestations of affective disorder (hypotension, psychomotor disturbances, ideas of guilt, etc.) poorly expressed (“subsyndromal depressions” (L. Judd et al., 1994). When these conditions predominate in disorders of the autonomic nervous system, they speak of “vegetative depressions” (G. Lemke, 1974), depressions with a dominance of pain are indicated by the term “ algichesky “(N. Petrilowitch, 1960), etc.
Asthenic depression (L. Gayral, 1972);” depression of exhaustion “(P. Kielholz, 1973.) The hyperesthetic (initial) stage of the disorder is characterized by the phenomena of positive affectivity: fatigue, tearfulness, increased sensitivity to sensory stimuli (loud sounds, bright light, etc.), disproportionate sensations, accompanying their physiological processes. Signs of negative affectiveness (hyperesthetic asthenia with the alienation of one’s own activity and general feeling of the body) may form in the picture of unfolded depression.
A similar stereotype of development is also inherent in somatized (catesthetic) dysthymia (E.V. Kolyutskaya, 1993), characterized at the stages of formation and complete psychopathological completeness of the syndrome by the prevalence of positive affectivity phenomena that are inseparable from hypotension proper, which has a physical connotation (burning in the chest or larynx, “Icy cold” under the spoon, etc.), somatoform disorders (weakness, palpitations, shortness of breath, etc.). As the condition becomes chronic, the phenomena of hypesthetic asthenia and a tendency to hypochondriacal self-observation may come to the fore.
In depressions that occur under somatic “masks” (“hidden”, “larvated”, “alexithymic depressions”, “thymopathic (depressive) equivalents” (JJ Lopez-Ibor, 1973) 4, patients are not only unaware of the depressive disorder, but they are convinced they have any rare and difficult to diagnose disease, insist on numerous examinations, in which cases the “center of gravity” of the disease shifts in the direction of psychosomatic disorders, and patients, in the words of HK Rose (1999), “become victims of somatomedical overdiagnosis, excessive therapeutic measures and polypharmacy as a consequence of therapeutic helplessness. ”The
diagnosis of somatized depression is based on the following criteria:
– the gap between the polymorphism of somatovegetative manifestations, the need for medical care, on the one hand, and the absence of objectively detectable signs of somatic disease, on the other;
– the subordination of somatized and others positive manifestations daily rhythm affectiveness (improvement in the evening, less often in the morning);
– joining in the opening or as the dynamics of the disorder show signs of negative affectivity;
– the frequency (seasonality) of the manifestation of painful symptoms, remitting course;
– persistent seeking medical help, despite the apparent lack of treatment results;
– improvement with antidepressants.
Somatogenic (organic and symptomatic) depressions complicate severe neurological and somatic diseases.
One of the common features of such states (in contrast to the ones already considered) is that, in general, psychosomatic relationships obey in these cases the laws of dynamics of the exogenous type of reactions (K. Bonhoeffer, 1912) – the response to external harmfulness includes a successive change of stages in accordance with the severity and nature of the somatic disease: asthenia, affective disorders, impaired consciousness (delirium, etc.), dementia 5.
Another general characteristic of organic and somatogenic depressions is the correspondence of the dynamics of an affective disorder to the course of a somatic disease: with an aggravation of the condition due to an exacerbation of a bodily ailment, depression is aggravated, when it is relieved, it takes a sub-syndromic form or reduces.
Organic depressions are more often formed in the framework of the following neurological diseases: in organic processes with a predominant lesion of the extrapyramidal system (parkinsonism, Huntington’s chorea, hepatocerebral dystrophy); demyelinating diseases (multiple sclerosis); cerebrovascular diseases (cerebral arteriosclerosis, acute cerebrovascular accident, residual effects after acute cerebrovascular accident, discirculatory encephalopathy); traumatic brain injuries (traumatic encephalopathy); brain tumors (usually the temporal or frontal lobe).
With some organic lesions of the central nervous system (parkinsonism, Huntington’s chorea, multiple sclerosis, tumors of the frontal lobe of the brain), depression at the initial stages of the pathological process can act as one of the early symptoms that mask the manifestations of the underlying disease. Affective manifestations in these cases are distinguished by rudimentarity, incompleteness (despondency, tearfulness, periodically arising anxiety, sleep disturbances).
The clinical picture of more pronounced organic depressions, as a rule, is dominated by signs of negative affectiveness – adynamia, spontaneity, akinesia, asthenia, dysphoria. So, for affective disorders in parkinsonism, a predominance of violations of the asthenic pole is characteristic (V.L. Golubev, 1998). Moreover, hypotension can be accompanied not only by “pseudo-neurotic” complaints (E. Ya. Sternberg, 1983) (lethargy, general weakness, fatigue, lack of strength), but also by dysphoria with irritability, anxiety, pessimistic assessment of the future, suicidal thoughts, but without ideas sinfulness and self-incrimination. Dysphoric depression is also observed in the distant period of traumatic brain injury (M.O. Gurevich, 1948). Another dominant manifestation of negative affectivity in these cases is anhedonia with monotony of affect. Vascular depression is characterized by an abundance of somatic and hypochondriacal complaints, the uniformity and importunity of behavior – “complaining”, “aching” depression (E. Ya. Sternberg, 1983). In the acute post-stroke period, a complication of the picture of depression with pathological (violent) crying is possible; outbreaks of anxious and timid arousal and night delirious episodes are possible.
The prevalence of positive affectiveness in the picture of organic depressions is less common, for example, tumors of the left temporal lobe may be accompanied by an acute feeling of longing, anxiety, and suicidal tendencies (T.A. Dobrokhotova, 1974).
Symptomatic depression is a common disorder seen in many severe somatic diseases. Their formation may be associated with pathology of the cardiovascular, pulmonary and digestive systems, kidney damage with the phenomena of uremia, cirrhosis of the liver, systemic lupus erythematosus, and oncological diseases. In a series of endocrine disorders, depression is more likely to occur with hyperparathyroidism, hypothyroidism, and diabetes. Affective disorders also occur with vitamin deficiencies, iron and vitamin B12-deficient anemia.
Symptomatic depressions are formed according to the same patterns as organic ones: they debut with increasing severity and decrease as the symptoms of somatic disease reverse. The clinical picture of somatogenesis complicating somatic disease often takes the form of asthenic depression with hyperesthesia, irritable weakness, increased exhaustion, weak-heartedness, and tearfulness. Along with this, anhedonia and psychomotor retardation, weak attention span with distraction, forgetfulness, inability to concentrate, as well as severe vegetovascular manifestations, complaints of noise and ringing in the ears, headaches, dizziness, can be observed.
So, in cases of chronic renal failure (CRF), depressive disorders are dominated by anhedonia, depression, depersonalization-anesthetic symptoms, asthenia, irritability, and lacrimation (NN Petrova, 1977). In a number of cases, anxiety prevails, for example, when CRF is aggravated by severe cardiovascular insufficiency, an increase in anxiety and psychomotor agitation can occur (M.A. Tsivilko, 1977) with outbursts of irritability (pickiness, excessive exactingness, moodiness), sometimes reaching the level of dysphoria. When the somatic state is aggravated, the clinical picture of depression increases adynamia, lethargy, and indifference to the environment.
In oncological diseases (especially pancreatic cancer), depression may be one of the earliest symptoms of underlying suffering (RT Joffe et al., 1986). The clinical picture in these cases is dominated by anxiety with a premonition of impending death (J. Fras, E. Litin, J. Pearson, 1967; B. Klatchko, J. Gorzynski, 1982). More often, depression occurs at the remote stages of the development of malignant neoplasms, their severity increases in proportion to the severity of the condition.
It should be emphasized that the psychosomatic relationship in depression is much more complicated than is presented in the above work scheme. This, in particular, is evidenced by the results of a study of depression associated with the generative cycle in women. In these cases, the normal physiological process (menstrual cycle, pregnancy, puerperal period, involution) most often plays the role of a trigger factor, revealing previously hidden susceptibility to endogenous depression, and acquires a pathogenic meaning. Less commonly, the erased manifestations of depression can be associated with an exacerbation of somatic disease (endocrine disorders, cancer, systemic lupus erythematosus, anemia, endometriosis, etc.).
No less complicated is the ratio of such etiological factors as organic brain damage, intoxication with vascular (myocardial infarction), cancer, infectious (AIDS) diseases with psychogenic effects associated with a high risk of death.
The fact that in the modern world 43% of patients with depression are treated by general practitioners, 46% are outpatient by psychiatrists and only 11% are placed in psychiatric clinics indicates the importance of the problem of providing medical care to this contingent in general institutions.
Therapy of depressive conditions in the general medical network (including neurosis rooms of territorial clinics) requires an integrated approach and a real partnership between internists and psychiatrists. The leading method of treatment is psychopharmacotherapy, the adequate application of which is impossible without knowledge of not only the spectrum of psychotropic activity of thymoanaleptics (antidepressants), but also the clinical properties of medicines used in general medicine.
A prerequisite for successful treatment is an integrative therapeutic plan, in which psychopharmacotherapy, psychotherapy and somatic therapy are used. The specific gravity of each of these types of treatment is related to the characteristic of the observed disorder.
There is a general rule for outpatient practice: treatment should be started with minimal doses due to the risk of unwanted side effects. The course of antidepressant therapy also stops gradually; its duration should be no less than the duration of untreated depression, since psychopharmacotherapy does not reduce the duration of the depressive phase, but only alleviates its symptoms. Therefore, with premature termination of therapy, exacerbation with the phenomena of drug resistance may develop. The chance that depression will “respond” to therapy is 60-70%.
In a community-acquired network, modern antidepressants related to first-line drugs are preferred (A.B.Smulevich, 2000). Drugs of this series have selective psychotropic activity (elective clinical effect), which provides them with an effective effect on the manifestations of positive and negative affectiveness.
In depression with a predominance of the phenomena of positive affectivity, the best results are given by pyrazidol, tianeptine (coaxyl). The effectiveness of tianeptine in depressive states with severe somatovegetative, asthenic, algic and conversion disorders exceeds 70%. Moreover, long-term therapy leads to a decrease in the frequency of exacerbations – up to 6% after 6 months and relapse of depression – up to 12% after 18 months (J. Dalery, V. Dagens-Lafant, de Badinat C., 1997).
Tianeptine is safe in the treatment of depression in patients with cardiovascular disease (Drobizhev M.Yu. et al., 1998); the drug has practically no effect on blood pressure, the number of heart contractions, does not cause clinically significant orthostatic hypotension, does not change blood sugar levels, hematological parameters.
When negative affectiveness dominates the clinical picture of depression, serotonergic antidepressants (SSRIs) are indicated.

2 This type of depression, in the origin of which the subjective significance of the pathology of internal organs and the semantics of the diagnosis play a paramount role, is considered in the work of A.B. Smulevich published in this issue.
3 Disorders of this circle are examined in detail in an article by A.B. Smulevich (see).
4 The main somatized “masks” of such conditions can manifest themselves in the form of vegetative, somatized, and endocrine disorders (vegetative-vascular dystonia syndrome, dizziness, functional disorders of the internal organs, neurodermatitis, skin itching, anorexia, bulimia, impotence, menstrual irregularities), algy (cephalgia, cardialgia, abdominalgia, fibromyalgia, neuralgia – trigeminal, facial nerves, intercostal neuralgia, lumbosacral radiculitis, spondylalgia, pseudo-rheumatic arthralgia), biological rhythm disturbances (insomnia, hypersomnia).
5 In some cases, mnestic-intellectual disorders are a sign of depressive pseudo-dementia and are reduced as affective disorders reverse.

Leave a Reply

Your email address will not be published. Required fields are marked *