Second edition

06.qxd 3/10/08 9:34 AM Page 208
Syndromes of disturbances of mood and affect
6.1 Depression 208
6.2 Apathy 214
6.3 Mania 215
6.1 DEPRESSION
Depression, as conceived of here, is a syndrome that may
result from any one of a large number of underlying
causes. Although the most common cause of depression is
major depressive disorder, it is critical to subject each
depressed patient to a thorough diagnostic evaluation
before concluding that major depressive disorder, or perhaps
one of the other idiopathic disorders discussed below,
is the cause.
Clinical features
The syndrome of depression, in its fully developed form,
includes not only a depressed or irritable mood, but also
other symptoms, as listed in Table 6.1; each one of these is
considered in turn.
Mood is depressed or sometimes irritable; some, in addition
to these symptoms, may also complain of anxiety. At
times patients may deny a depressed mood, but rather complain
of a sense of discouragement, or perhaps lassitude and
a sense of being weighted down. The patient’s affect generally
mirrors the mood, and there may be copious tears.
At times, and especially in those with anxiety, there may
be a ‘pained’ facial expression. Occasionally, patients may
attempt to hide their depressed mood by feigning a ‘happy’
affect, thus creating a ‘smiling depression’.
Self-esteem typically sinks during depression, and the
workings of conscience may become so prominent as to
create an almost insupportable burden of guilt: patients
may see their sins multiply in front of them, and in reviewing
their past may be blind to their accomplishments and
see only their misdeeds. Pessimism settles in and patients
see no hope for themselves, either now or in the future.
Suicidal ideation is typically present, and may be either
passive or active. Patients may say that they would not mind
if they were in a fatal accident or died of some disease.
6
6.4 Agitation 222
6.5 Anxiety 225
References 227
Others may actively seek death, perhaps by hanging, shooting,
jumping from bridges, or taking overdoses.
Difficulty with concentration may be profound. Patients
may complain that it is as if a ‘fog’ had settled in, and that
they feel dull and heavy headed. Memory seems to fail, and
patients may be unable to recall where they put things or
what was said. Attempts at cognitive activities often end in
failure: patients, in trying to read a book, may read the same
paragraph again and again, and find themselves unable to
absorb or understand what they have read. Things seem too
complex and making decisions may be impossible.
The remaining symptoms, namely anhedonia, anergia,
sleep disturbance, appetite change, and psychomotor change,
are often referred to, collectively, as the ‘vegetative’ symptoms
of depression, in that they represent disturbances in
the basic vegetative functions critical for survival.
Anhedonia represents an inability to take pleasure in
things, and patients may complain that nothing arouses or
attracts them. Thus unable to experience pleasure, patients
lose interest in formerly pleasurable activities and must
force themselves to get through their days, which, to them,
seem desolate and lifeless. Libido is especially lost, and
patients may withdraw entirely from any sexual activities.
Anergia, or a dearth of energy, may leave patients complaining
of fatigue, tiredness, and exhaustion, or of being
‘drained’. The anergia may be so extreme that patients are
unable to complete routine tasks; some may even be
unable to find the energy to get dressed.
Sleep disturbance may manifest with either insomnia or
hypersomnia. Insomnia is more common, and may be a
particular torment to the patient. Although some complain
of what is technically known as ‘initial’ insomnia, that is to
say trouble initiating or falling asleep, a more characteristic
complaint is ‘middle’ insomnia, wherein patients awaken in
the middle of the night, and have great difficulty in falling
back asleep; some complain that their ‘mind’ simply won’t
‘shut off’. Some may also experience ‘terminal’ insomnia, or,
as it is also known, ‘early morning awakening’, wherein they