Symptoms of endogenous depression
The usual list of symptoms occurring with endogenous depression includes depressive (melancholy) mood, motor and mental retardation, decreased interests and level of impulses, ideas of value, suicidal tendencies, anxiety, auto-and somatopsy depersonalization, sleep disturbance, loss of appetite and a number of other vegetomatic manifestations. One of the leading psychopathological signs of endogenous depression is a painfully depressed mood, which patients characterize as heaviness in the soul, depression, hopelessness, etc.
As a rule, when interviewing patients note that this longing is different from the usual, situationally caused grief or sadness, but what exactly - they can not explain. Pleasant news or events do not significantly change the mood. It is this component of vitality that distinguishes endogenous depression from situationally conditioned.
In the psychopathological picture of endogenous depression, anxiety can manifest itself with a wide range of symptoms: in severe cases, agitation or "disturbing numbness", up to complete stupor, panic sensation of impending catastrophe, death, painful compression in the chest, feeling of suffocation (it is characteristic that patients with anxiety complain of heaviness, compression, pain in the chest, and with the prevalence of longing - in the region of the heart.
The distinction between anxiety and melancholy often presents great difficulties not only for the patient, but also for the doctor, especially since the "pure anxiety" that arises outside the framework of affective psychosis is always accompanied by a depressed mood.
In contrast to the normal, painfully altered mood, in particular depressive, is determined by congestive pathological affects. Therefore, external influences can not change the sign (character) mood, and only sometimes they can to some extent strengthen or weaken it. And, just as a normal mood can be caused by a complex of several emotions, and a pathological one by several coexisting affects.
A distinctive feature of mood in endogenous depression is daily fluctuations, when in the first morning hours there is a particularly intense longing, and late in the evening it softens somewhat.
Sometimes patients try to give this psychological explanation. "By evening, it becomes easier because you realize that another agonizing day is over, you can even be forgotten for a while in a dream."
The absence of daily fluctuations, as a rule, occurs in severe conditions. Sometimes a perverted diurnal rhythm is noted, but if it occurs in patients with endogenous depression, upon careful questioning, it turns out that the deterioration in the evening is not due to the deepening of longing, but to an increase in obsessions, anxious feelings and doubts.
Sometimes perverted daily rhythm is observed in patients with depressive depersonalization syndrome.
An important symptom of endogenous depression included by Kraepelin in the triad of leading signs is mental retardation, which manifests itself in the form of a slowdown in the rate of thinking and speech. Patients do not immediately comprehend the questions, answer them with a long delay, hardly select the right words and wording. They note that thoughts are made slow, cumbersome, they seem to "not hook on each other." Even a slight slowdown in the rate of thinking of people of intellectual labor notice especially quickly.
True depressive inhibition of thinking is sometimes difficult to distinguish from the manifestations of asthenia. In the first case, the tempo of thinking is equally slowed down at the beginning and at the end of the conversation, while in the second, it decreases in the process of conversation as the patient is exhausted.
It is very important for assessing the condition and the choice of therapy to differentiate the slowing of the pace of thinking due to depression from inhibition, often arising from intense anxiety and tension. Despite the fact that such anxious patients can slow down the rate of speech to the degree of mutism, they can be distinguished by a number of external signs: by a tense, brilliant look, frozen tense facial expressions, but without severe grief, etc. If such a patient still says a few words, they are pulled out with effort, as if overcoming an obstacle, while with depressive inhibition each word is pronounced slowly, monotonously.
Sometimes mental retardation is disproportionately pronounced in comparison with other components of the depressive syndrome, including motor retardation. Recognition of depression in these patients is difficult. They give the impression of being confused, they are not able to get descriptions of their painful experiences, including complaints of low mood. In some cases, they are somewhat reminiscent of pseudodement patients. Only after the end of the depressive phase, they say that their mood was low, but that they could not explain anything because of the almost complete lack of thoughts in their heads. In some cases, they amnesize some periods of depression.
In relation to elderly patients with such symptoms, there is an assumption about the presence of a coarse organic (vascular) disease of the brain, against the background of which depression has developed. However, in the majority of such patients, organic symptoms during the intermission period cannot be detected.
Motor inhibition is most often correlated with mental. In rare cases, it can reach the degree of complete immobility. Usually, it manifests itself in varying degrees of slowing down the speed of movements, gait. Motor retardation also needs to be distinguished from the lethargy inherent in anergic and asthenic conditions, and from an "alarming stupor," sometimes reaching a degree of stupor. Often patients with psychomotor retardation hardly get out of bed in the first half of the day.
Endogenous depression is characterized by a general decrease in mental tone. The level of interests falls sharply; events that previously occupied the patient seem "bland", empty, unnecessary, the patient tries to avoid communication with others. The desire to avoid all kinds of contacts and activities is also due to the fact that everyday everyday tasks and issues that are solved in a healthy state almost automatically become depressed as complex, painful, intractable problems. Therefore, along with the general decline in the range of interests, some, often minor, questions and events completely absorb attention and thoughts, becoming the object of constant painful experiences.
People whose work proceeds in a strictly limited, stereotypical framework continue to cope with it for a relatively long time, despite the fact that in other areas the disease has already led to decompensation.
The feeling of helplessness, powerlessness, weakness becomes the ground for the emergence of ideas of low value, and sometimes suicidal intentions.
These experiences are even more exacerbated by the inherent personal characteristics of a significant proportion of TIR patients.
They are characterized by good faith, a high sense of duty, responsibility, in the service they are known as people who can be relied upon. They, as a rule, are soft, conscientious, comfortable in a hostel, tend not to offend anyone, not to offend. They have a tendency to increase their social and educational level: many of them attend various courses, clubs, evening schools.
In general, these people have a certain feeling of dissatisfaction with themselves and their position. Similar features have recently been considered typical for premorbid patients with endogenous depression. Obviously, these traits are based on heightened anxiety, uncertainty, a tendency to doubt, difficulty in making decisions, and sensitivity.
These features are expressed in varying degrees and in some cases reach a level that makes it possible to qualify these people as anxious and suspicious individuals. In other cases, they are weakly expressed, especially in adolescence, and manifest only in certain situations (illness of relatives, examinations, a dramatic change in the situation, the need to make responsible decisions, especially when there are alternative options).
Often, anxiety and insecurity are not noticed either by others or by themselves until such a situation arises. They, as well as their loved ones, characterize themselves in the past as cheerful, energetic, quite decisive, but somewhat impressionable and unnecessarily experiencing trouble.
With age, the features of anxiety and insecurity begin to gradually increase. In many women, they are clearly manifested after childbirth in the form of excessive fear for the child, an increased concern for his health. Sometimes they are found in the period of fatigue after suffering a serious illness. In the future, in the case of an unsuccessfully established life, the uncertainty and anxiety manifest themselves more strongly and may significantly worsen, especially among women during the involution period.
With a certain predisposition and a sufficiently high level of anxiety, obsessions arise, and with a further increase in anxiety, they can acquire the character of phobias.
The presence of obsessions in the premorbid of patients with involutional depression or other criteria - late monopolar endogenous depression - was noted by many researchers. In some patients of this group, certain patterns of personality development can be traced during the pre-suppressive period.
One of the possible ways goes according to the type of hyper-socialization: the circle of duties and interests assigned to them gradually continues to increase, although it is becoming more and more difficult for patients to cope with them, they increasingly have to choose between what needs to be done and what can be postponed. However, it is the necessity of choice that creates a stressful situation for these people. They begin to rush between unresolved problems, tormented by remorse of conscience, and more and more entangled in the situation created by them. During this period, neurasthenic complaints, sleep disorders, and autonomic shifts often appear. An accidental additional traumatic factor can trigger depression.
A similar picture of anxiety increase is also observed in people who, because of their inherent insecurity, tend to constant self-assertion: setting themselves new tasks, spurring themselves, they create a situation of chronic stress, which ultimately leads to asthenization. Fatigue, reduced performance increase their disbelief in their strength and make them even harder to try to achieve their goals. Thus, a kind of vicious circle is created, leading to the gradual development of anxiety.
For another, opposite to the first, variant of development, a tendency towards a kind of "encapsulation" is characteristic. Often it is observed in people whose life before the onset of depression took shape according to external signs quite well. A distinctive feature of the development of their personality is the constant narrowing of the range of interests, switching to any one task, which is the main goal and interest of their life. In this narrow area, the features of anxiety suspiciousness inherent in them and growing with age almost do not manifest themselves, while in other areas of activity the uncertainty and anxiety increase noticeably with age.
Thus, narrowing the scope of their interests with a subconscious goal to protect themselves from everyday anxieties, these people themselves create the prerequisites for severe decompensation in an adverse turn of events. As our observations indicate, such decompensation can lead to depression (Vasilyev V.Z., Nuller K. L., 1976). On the other hand, chronic anxiety (stress) creates conditions for the depletion of brain monoamines and, ultimately, can lead to their deficiency, especially in the case when there is a genetically determined weakness of certain parts of their metabolism.
The disturbance of concentration observed during depression probably depends on a number of reasons: a decrease in mental tone, ideological retardation, anxiety, and chaining to emotionally significant depressive thoughts. The same reasons are due to complaints of patients to memory impairment.
In addition to this core, the symptomatology of depression includes a number of other manifestations associated with the pathophysiological mechanisms of the disease. These are often depersonalization disorders. More extensive depersonalization symptoms occur in depressive depersonalizing anion syndrome.
Depression is characterized by sleep disturbances, most often in the form of early awakening, which are painful for the patient due to the fact that it is at this time that the depressed mood and painful thoughts and experiences are especially intense.
The above-described "nuclear" symptoms of depression, directly caused by impaired brain function, create the basis for a "depressive attitude". First of all, it refers to anguish.
Thus, anguish and anxiety determine the affective structure of the depressive syndrome. This affective core of the syndrome, along with impaired psychomotor activity, constitutes the main core of the psychopathological symptoms of depression.
Obviously, a "depressed world outlook" leads to the formation of some symptoms, which, to a large extent, depend on the personal, cultural and social characteristics of the patient. These symptoms primarily include suicidal tendencies and ideas of low value.
When assessing the risk of a suicidal attempt, it can be represented as a resultant of two oppositely directed factors: the intensity of suicidal motives and the psychological barrier that impedes their realization. The intensity of suicidal impulses is determined by the severity of anguish, the degree of anxiety and affective tension, as well as the severity of the other manifestations of depression listed above.
Suicides are relatively frequent in patients with prolonged depressions with severe somatic, hypochondriac, and depersonalization symptomatology. The absence of relief leads them to think of an unrecognized and incurable disease and, in order to get rid of their torment, such patients try to commit suicide. The most serious and most often viewed are suicidal attempts in patients with depressive depersonalization syndrome. Suicidal attempts in these patients are well thought out. The absence of significant psychomotor inhibition facilitates the implementation of suicide. In addition, analgesia often noted in severe depersonalization allows the patient to perform extremely cruel actions.
For example, one patient with depressive depersonalization syndrome was broken from a pencil under a blanket and slowly pierced his skin, intercostal muscles, and reached the pericardium. In terms of facial expressions, no one around was able to suspect anything, and only when the patient turned pale due to blood loss did a suicide attempt be detected.
The danger of seeing suicidal tendencies, and sometimes depression itself, in such patients is also aggravated by the fact that their facial expression is often not mournful, but indifferent, there is no pronounced inhibition, and sometimes they even smile with an inexpressive polite smile that misleads the doctor. Such smiling depressions are extremely dangerous with regard to misdiagnosis.
However, in some cases, on the background of a shallow endogenous depression, reactive situations arise or endogenous depression is "masked" by reactive symptoms. Details of these forms of depression are described below.
As you know, depressive ideas belong to the group of affective (golodimnyh) and are largely determined by the intensity of affect: with less affective tension, they are presented as overvalued ideas; as the intensity of passion increases, the ability to criticize disappears, and the ideas on the plot are presented more in the form of delusions, which, as they intensify, increasingly determine the behavior of the patient. As the severity of affect decreases, the opposite dynamics is observed.
The plot of depressive ideas is largely determined by the personal characteristics of the patient, his cultural level, profession, etc. Thus, on the basis of the analysis of depressive ideas, one can judge the intensity and structure of affect.
Another symptom, also reflecting the affective structure of the depressive state, is obsession. As a rule, they occur during the depressive phase in people with obsessive constitution in premorbid. The nature of obsessions is also largely determined by the affective structure of the depressive state. So, with anergic depression that occurs without noticeable tension and anxiety, obsessions are more common with regard to indifferent content: obsessive doubts, counts, etc. When expressed, they may be blasphemous thoughts, obsessive thoughts about suicide (often about one way). The subtext of these obsessional experiences is to think or do something sinful, unacceptable, contrary to moral norms.
When anxious depression obsessiveness manifested in the form of phobias.
Somatic symptoms of depression
Endogenous depression is characterized by a number of somatic disorders, which are of great importance in the diagnosis of this disease. First of all, the very appearance of the patient with rather severe depression draws attention: the mimicry is not only mournful, but also frozen, the expression of grief is aggravated by the Veragutta fold; posture bent, walking legs dragging; voice is quiet, deaf with weak modulations or not modulated at all.
One of the most important and persistent somatic symptoms of depression are loss of appetite and weight loss. Severe depressive patients, in addition to emaciation, are distinguished by a "hungry smell" from the mouth, furred tongue and pharynx. Constipation is a constant and sometimes very unpleasant and painful for patients with somatic manifestations of depression.
Disturbances in the sexual sphere are common: a decrease in libido, temporary frigidity in women and cessation of menstruation, in men a decrease in potency. Some pain, neurological and muscular disorders are less frequently observed during depression.
A number of unpleasant and painful sensations arising from depression are associated with impaired tonus of smooth and skeletal muscles. These disorders include: unpleasant, nagging pain in the neck and neck. Similar sensations sometimes occur between the shoulder blades, in the shoulder girdle, in the lower limbs, in the area of the knees, shins. Spastic phenomena are not rare: the calf muscles are often cramped, often at night, and to such an extent that in the morning patients continue to feel severe pain, hardening in the calves. When depression often occur attacks of the sacrospinal radiculitis.
There are headaches squeezing the back of the head, temples, forehead and extending to the neck, pains that resemble migraine, and pains that resemble facial nerve neuralgia. In depressions, an algic syndrome is sometimes described, apparently due to a reduction in pain sensitivity.
A significant part of somatic disorders are more often observed at the beginning of an attack of depression or precede it, and are also observed in case of anxiety (this is especially true for muscle and pain symptoms).