About Depression

gregorkowalnew

Dr Gregor Kowal
Senior Consultant
in Psychiatry and Psychotherapy,
German Board Certified,
Medical Director,
Clinic for Health and Medical Care
Phone: 00971-4-4574240

Depression is a state of psychic despondency and reduced vitality accompanied by physical (vegetative) symptoms such as loss of appetite, sleep disturbances, inner restlessness and anxieties. Depression is ranked amongst the affective psychic disorders in which the patient`s mood (the “emotional life”) is particularly affected. Depressions take place in phases which continue for weeks and months and, without treatment, even for years. Depending on the severity of the depression a great risk of suicide exists.

1. Signs and symptoms:

A particularly severe progressive form of depression is accompanied by more massive mood restrictions (loss of ability to be happy or sad, “the feeling of numbness”), loss of affective response (encouragement by friends and relatives are not able to illuminate the patient`s mood), complete loss of vitality (all incentive), slowdown of thought sequences (mental block), massive sleeplessness and sometimes restlessness (agitation).

When suffering such heavy depressive detuning the involved sufferers are so inhibited, that even the most simple activities i.e. leaving bed, performing simple everyday things such as shopping, keeping the home tidy, body care and all social interactions are not possible any more. Further symptoms are helplessness, social self-isolation, reduced concentration, senseless circular thoughts (compulsive thinking) and disorders in time conception. Sexual interest is diminished or completely extinct (loss of libido).

It has been observed that the misgivings of a person affected by depression, normally considered an exaggeration, usually refer to the following overview of themes:

1) “Spiritual salvation”
2) Their material- and
3) Health status.

The ill believe them to be inferior and often develop unreasonable feelings of guilt. In extreme cases they are convinced of being the biggest sinners (delusions of guilt), have exaggerated problems regarding the future, concerning their material situation. It is not unusual for very rich persons to claim that they have no money and are destitute (delusion of impoverishment), or feel ill without having any organic sicknesses (hypochondriacal delusion). Negative experiences are overestimated, pleasing experiences have no effect.

2. Cause/Causes:

Depression can have various causes. A so called “reactive depression” can occur as a reaction to death of a beloved person or in the consequence of personal or career failures and anybody can develop one.

There are also other forms of depressive upset which have been referred to as “endogenous” in the past because they had no concrete cause. People who are successful and lead active lives, have intact families and no obvious reasons for being sad unexpectedly became depressive. Frequently, haphazard genetic disposition can be a causative factor for this type of depression. In the family history of such persons massed depressive detuning can often also be found in the relatives. The risk of also becoming depressive themselves is 10-15 % higher for children with a parent who suffers from depression and if both parents suffer from depression 20-40 % higher. But studies on twins (comparison of disease frequency in monozygotic twins) also show that the genetic component is only to some extent a factor for the development of the illness. The twin of the depressive patient falls ill in less than half of the cases, even if the genetic features are identical. However, in the development of depression other factors also play an important role.

Therapy of depression consists of drug treatment accompanied by psychotherapy. Unfortunately social conventions (a falsely conceived ethos: always to be strong and cheerful) and well-meant but inappropriate advice from people associated with the depressive person often lead to seeking belated therapeutic help or no help at all. If depression is recognized in time and treated by experts the chances of being cured are very good.

3. Subtypes:

Current classification systems (such as ICD 10) classify depression triggering causes in miscellaneous severity codes (mild, moderate or severe) under the aspect of the intensity of depressive symptoms. This quantitative allocation however ignores triggering reasons.

Particular forms of depression are:

– Agitated depression, where the patients appear overactive on the outside must constantly move about but are at the same time irritable and fearsome but are still not capable of fulfilling daily duties. As a result they are irritable and anxious.

– Masked (hidden) depression (also called somatic depression) where depressive symptoms are not directly visible (they are hidden or masked) focus lies on physical discomforts, which have a psychogenic (mental) nature. These pains are quite real for the affected people. Psychogenic pains can occur in any region of the body and affect every organ system. These can become manifest as back pains, prickling of the skin, migraines, continuous headaches, chest pains, abdominal pains, etc.

– Delusional depression which is accompanied by losing touch with reality. This form of depression can easily be mixed up with a psychosis. As mentioned above this depression is tangent to the patient’s health-, material security- and mental status. It can correspondingly be accompanied by a hypochondriacal mania, a mania of sin or a mania of impoverishment.

– Organically caused depression, for example by internal diseases. For this reason complete diagnostics and therapeutic knowledge are basic prerequisites for the detection of depression, its differential diagnostic distinction from somatic (physical) illnesses and for adequate treatment thereof.

4. History:

Some notes in an ancient Egyptian document known as the Ebers papyrus dating to circa 1550 BC appear to describe disordered states of concentration and attention, and emotional distress in the mind. Some of these have been interpreted as indicating what would later be termed melancholy and in our times depression.

The term “melancholia”, the older description of the psychological condition now known as depression, derives from the Ancient Greek “melas”= “black”, and “kholé” = “bile”. In the 4th and 5th centuries B.C.E., a Greek philosopher and the father of the modern medicine, Hippocrates argued that mental illnesses had biological origins, denying the popular custom of attributing them to supernatural or magical sources. He described „melancholia” as a manifestation of a brain dysfunction. He agreed with the contemporary humoral theory, which stated that humans must have equilibrium of the four humors – blood, black bile, yellow bile, and phlegm – to have even temperaments. Excessive black bile was considered to be the cause of melancholia; excessive yellow bile was associated with mania.

Another Greek philosopher Plato believed that the mind was the cause of madness. He saw mental illness as being the result of a person`s ignorance of a psyche, which leads to the self-deception.

Those different opinions persist until our times.

The term “depression” itself was derived from the Latin verb “deprimere”, “to press down”.

The German psychiatrist Emil Kraeplin the founder of modern scientific psychiatry, systemised the mood disorders. He created the term called “manic depression” now seen as comprising a range of mood disorders such as recurrent major depression and bipolar disorder.

Sigmund Freud had linked in his essay, “Mourning and Melancholia” (1917) the state of melancholia to mourning. Although these states are often triggered by the same circumstances he discusses what conditions need to be present for the two states to progress along their varying paths. He theorised that the depressed individual has identified with the object of affection through an unconscious, narcissistic process. He wrote: “Mourning is regularly the reaction to the loss of a loved person or to the loss of some abstraction which had taken the place of one, such as one`s country, liberty, an ideal, and so on”.

Mourning is not associated with pathological issues because it is a normal reaction to events and generally is overcome with time. These same symptoms are present in melancholia, however, in mourning reality eventually wins out and slowly the person returns to their normal state. “In mourning it is the world which has become poor and empty; in melancholia it is the ego itself”.

He describes the internal work of mourning: “… each single one of the memories and situations of expectancy which demonstrates the libido`s attachment to the lost object is met by the verdict of reality that the object no longer exists; and the ego, confronted as it were with the question whether it shall share this fate, is persuaded by the sum of the narcissistic satisfactions it derives from being alive to sever its attachment to the object that has been abolished”.

Melancholic individuals may, in some cases, know that they have lost something, but they never know what they have lost, for the loss is inaccessible to consciousness. In morning the libido slowly withdraws from the lost object and finds a new one to replace it with. In melancholia, however, the libido withdraws into the ego and identifies itself with the lost object.

Karl Abraham, a German psychoanalyst and a collaborator of Sigmund Freud, noted the relationship between mourning and melancholia (depression). For him, the structure of melancholia is closer to that of obsessive neurosis on account of the intense hostility toward the outside world. In both illnesses, hostility considerably reduces the ability to love, and this reduction is responsible for the onset of the illness. But in melancholia, the projection of hostile drives is combined with their repression. He proposed (based on the Freudian theory) a psychopathological model of psychotic depression, in which libidinal hatred, projected onto the outside world, reverts back onto the subject in the form of depressed feelings of being detested and of guilt (the source of masochistic pleasure).

The immense progress in the neurosciences which starts in the mid-20th century, showed that depressed people has some chemical imbalance in neurotransmitters in their brain. Neurotransmitters allowed the nerve cells to communicate with each other. Depression is associated with changes in neurotransmitters. The levels of these neurotransmitters can be influenced by genetics, physical illnesses, hormonal changes, medications, social circumstances and so on. The antidepressant drugs help to restore the balance of neurotransmitters having a therapeutic effect to the mood of depressed patients.

5. Facts:

– Depression occurs in people of all cultures, all social classes and nationalities
– A persons affiliation to a race or an ethnic origin has no influence on the development of depression
– Currently there are mathematically 340 million cases of depression existing worldwide
– In Germany 20% of all German citizens develop depression once in their life. Worldwide figures vary between 8-20%.
– The average age of manifestation of a “major depression” lies between the ages of 20 – 40
– Whilst approximately 25% of adult women develop depression only about 10 % of all men affected
– Approximately half of all depressions are recognized and of that half stay untreated. This means that only every fourth Person suffering depression is treated.
– 10% -15% of all patients ill with depression commit suicide
– Statistically men commit suicide 3 times more frequently than women
– Depression is a genuine illness and not a sign of a “personality weakness”
– Depression is curable

Famous people who have been diagnosed with depression:

Abraham Lincoln
Theodore Roosevelt
Robert Schumann
Ludwig van Beethoven
Edgar Allan Poe
Mark Twain
Vincent van Gogh

References

1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 101–05. ISBN 978-0890425558.

2.ICD-10-CM 2015: The Complete Official Codebook, ISBN-13: 978-1622020751

3..Freud, S (1984). “Mourning and Melancholia”. In Richards A. 11.On Metapsychology: The Theory of Psycholoanalysis. Aylesbury, Bucks: Pelican. pp. 245–69. ISBN 0-14-021740-1

4.Krishnan V, Nestler EJ (October 2008). “The molecular neurobiology of depression”. Nature 455 (7215): 894–902. Bibcode:2008Natur.455..894K. doi:10.1038/nature07455. PMC 2721780. PMID

5.Duman RS, Heninger GR, Nestler EJ (1997). “A molecular and cellular theory of depression”. Archives of General Psychiatry 54 (7): 597–606. doi:10.1001/archpsyc.1997.01830190015002. PMID 9236543

6.Brown GW, Harris TO (2001) [1978]. Social Origins of Depression: A Study of Psychiatric Disorder in Women. Routledge. ISBN 0-415-20268-X

7.Kessler RC (1997). “The effects of stressful life events on depression”. Annual Review of Psychology 48: 191–214. doi:10.1146/annurev.psych.48.1.191. PMID 9046559

8.Panksepp J, Moskal JR, Panksepp JB, Kroes RA (2002). “Comparative approaches in evolutionary psychology: Molecular neuroscience meets the mind” (PDF). Neuroendocrinology Letters 23 (Supplement 4): 105–15. PMID 12496741