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News Gram™ July 2006

June 2006 ~ Volume 12, No. 12

Depression is one of the most common problems encountered in all of psychiatry and is of particular significance in a medical-legal setting. There are numerous manifestations of depressive disorders that range from a major depression to dysthymia to a depressive disorder not otherwise specified and mood disorder accompanying a general medical condition. Each of these syndromes have features peculiar to themselves but there are general features of depression common to all of the individual varieties that bear attention. Let’s take a look at these general aspects of the depressive spectrum.

Diffuse Representation: Perhaps the most important feature of any depressive disorder is that it involves the whole person. By this, we mean that every aspect of the person is affected to a greater or lesser extent by his or her own emotional state. To refer to depression as an affective disorder or a disruption of emotional regulation is, while not incorrect, hardly sufficient. Depressed individuals tend to move more slowly, eat less, lack motivation, find little pleasure in life, have diminished sex drives, and most commonly, seem to have moods that are depressed, dysphoric, or sad. The broad and diffuse aspect of depression tells us that people fully immersed in a depressive disorder are somehow changed with respect to their person. Such individuals think differently. They tend to be discouraged, regard themselves as inferior, bad, ugly, poor, and bereft of all positive traits. Aaron Beck, M.D., opens his famous book on depression with the observation that a banker will regard himself as impoverished, a beauty queen as hopelessly unattractive, and a musician as lacking in any musical ability at all. These negative self-attributions are particularly common in depression but are not found as uniformly in other kinds of psychiatric disorders. It is for this reason that people will describe themselves as lacking in self-esteem. What they are saying is they can’t help but think that other people see them as essentially worthless.

Distinctive Mood: There are a number of researchers who contend that a person suffering from a major depression is not merely unhappy, or sad, or troubled, or emotionally indisposed in some way. The depressed mood is not the same as sadness. In fact many patients will not even complain of feeling sad. Instead, they will describe their lack of motivation, their lack of interest in sex, or their decreased appetite. The mood they are in is one we refer to as depressed, inferred after first assessing what we refer to as the individual’s vegetative functions, i.e., those basic drives and states of the person that are related to his survival and what we may call his homeostasis. Thus, a depressed person will identify such areas as his decreased energy, decreased appetite and sleep, his diminished motivation and sex drive, and his general lack of interest in most things. An affected individual will see things around him as being grey in quality, as seeming lifeless to him and utterly without interest. People who are severely depressed will also experience the world as being diminished in size, which is, perhaps, an expression of decreased interest and investment in the things going on around him or her.

It is easy to see that what we refer to as a depressed mood is very different from a sad affect, and a visible set of behaviors such as tearfulness, a distressed facial expression, and expressions of disappointment, that everyone experiences from time to time. A depressed person has a depressed mood that infiltrates not just his emotional status but his thinking and behavior as well.

One of the most interesting and significant aspects of depression is the extent to which a depressed person experiences anhedonia, the inability to experience pleasure or gratification for one’s experiences. In many ways, this aspect of depression is most central, though it is often not referred to in routine psychiatric evaluations. It is one of the reasons that a person who is severely depressed will not report that he or she is sad. Rather, there is a lack of interest in one’s self, just as there is a withdrawal of interest from the rest of the world. What makes anhedonia so central is that it helps to explain the other vegetative signs that characterize depression. Decreased appetite and lessened sex drive are just two examples. Also, such a person would likely find going to the theater not particularly appealing even if he previously enjoyed such experiences. Whatever in the brain mediates the capacity for pleasure in general is likely the culprit in this aspect of depression. That is, there is a fundamental loss of ability to invest oneself in the world – and that investment includes ones self.

These three aspects of depression are central and are well to keep in mind when “evaluating” an evaluation. It is important to ask yourself whether the psychiatrist has addressed the whole person aspect of the depressive spectrum, whether he or she has promptly characterized the depth, expansiveness, and experiential uniqueness of depression vis-à-vis other emotional states such as sadness, disappointment or regret. And finally, has the psychiatrist adequately identified the anhedonic dimension of depression? Most commonly, psychiatrists who treat the DSM IV as a biblical reference work, fail to understand the status of anhedonia with respect to the entire set of difficulties manifest in depression. Without such an understanding, it is easy to commit diagnostic errors and fail to appreciate either the depth of depression or the fact that the patient being evaluated is not depressed at all. We have not mentioned suicide as a terminal event in depression, which we will do in a subsequent issue of NewsGram.

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