Depressive Disorders

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

Abstract

Depressive disorders belong to the group of affective, i.e. mood disorders.

Characterized by feelings of sadness, irritability, emptiness, or loss of pleasure, accompanied by other cognitive, behavioral, or psychovegetative symptoms and significantly affects a person's ability to function. An important feature of all depressive disorders is the absence of a history of Manic, Mixed, or Hypomanic episodes that would indicate the presence of Bipolar Disorder or Cyclothymia.

Psychogenic or exogenous depression arises under the influence of external crisis reasons, psychotraumas. The human condition is characterized by persistent bad mood throughout the day, irritability, resentment, tearfulness. There is no psychomotor retardation in behavior, there are difficulties with falling asleep, anxiety before going to bed. The person tries to cope with the condition, trying to distract himself.

The onset of endogenous depression due to internal factors, often against the background of complete external well-being. Accompanied by mood swings during the day, worse in the morning. Sleep disorders are manifested in the inability to fall asleep, severe early awakenings. Main experiences: guilt, anxiety, melancholy, apathy, a feeling of squeezing in the chest. Behavior may show significant psychomotor retardation. The level of severity of endogenous depression is higher, the predisposition is inherited.

Symptoms

According to the International Classification of Diseases (ICD 11) the simultaneous presence of at least five of the following characteristic symptoms that persist most of the day, almost every day, for at least 2 weeks indicates a depressive episode (at least one symptom / sign from the Affective Cluster must be present).

Affective cluster:

1. Depressed (that is, depressed or sad) mood according to the client's description or external signs (namely, tearfulness, depressed appearance). In children and adolescents, depressed mood can manifest as irritability.

2. A marked decrease in interest in or pleasure in the activities, especially those that would normally bring the client joy. The latter may include a decrease in sexual desire.

Cognitive-behavioral cluster:

1. Decreased ability to concentrate and maintain attention on tasks, or noticeable indecision.

2. Beliefs in their own worthlessness, excessive or unreasonable guilt, which may be clearly delusional (in these cases, it is necessary to use the list of Psychotic symptoms). This point should be disregarded if ideas of guilt and self-reproach arise only in the presence of depression.

3. Hopelessness about the future.

4. Recurrent thoughts of death (not only fear of death), recurrent suicidal thoughts (with or without specific plans), or evidence of attempted suicide.

Neurovegetative cluster:

1. Significant sleep disturbances (difficulty falling asleep, frequent nighttime awakenings or early awakening) or excessive sleep. Significant change in appetite (decrease or increase) or significant change in weight (gain or loss).

2. Signs of psychomotor agitation or inhibition (noticeable to others, and not just subjective sensations of motor restlessness or slowness).

3. Decreased energy, fatigue, or noticeable fatigue with minimal effort.

4. Affective disorders are quite pronounced, which leads to significant disorders in personal, family, social, academic, professional and other important areas of functioning.

5. Symptoms are not a manifestation of another medical condition (such as a brain tumor).

6. Symptoms are not due to central nervous system exposure to psychoactive substances or other drugs (eg benzodiazepines), including withdrawal symptoms (eg stimulant withdrawal syndrome).

7. Symptoms cannot be attributed to bereavement.

In ICD-11, the main importance is attached to the options for the course of the disorder, as well as its severity.

The current classification of depressive disorders includes:

A single episode of depressive disorder

Recurrent depressive disorder

Dysthymic disorder

Mixed depressive and anxiety disorder

1. A single episode of depressive disorder.

In mild, moderate, or severe depressive episodes, typical cases are depressed mood, decreased energy, and decreased activity. Reduced ability to rejoice, have fun, be interested, concentrate. Extreme fatigue is common, even after minimal effort. Sleep and appetite are usually disturbed. Self-esteem and self-confidence are almost always reduced, even in mild forms of depression. Often there are thoughts of their own guilt and worthlessness. Low mood, which changes little from day to day, does not depend on the circumstances and can be accompanied by so-called somatic symptoms, such as loss of interest in the environment and loss of sensations that give pleasure, waking up in the morning a few hours earlier than usual, increased depression in the morning, severe psychomotor retardation, anxiety, loss of appetite, weight loss and decreased libido. Depending on the number and severity of symptoms, a depressive episode can be classified as mild, moderate, or severe.

D. E. Light proceeds without psychotic symptoms. The person usually experiences distress due to symptoms, as well as some difficulty in functioning in personal, family, social, academic, professional, or other important areas of life.

Moderate D. E. characterized by the presence of several symptoms to a noticeable degree, or, in general, a large number of depressive symptoms with a lesser degree of severity are determined. A person, as a rule, experiences significant difficulties in functioning in important areas of life.

Under Heavy D. E. mMany or most symptoms are present to a noticeable degree, or fewer or fewer symptoms are present and pronounced. A person is unable to function in important areas of life, except for a very limited extent.

Psychotic symptoms (delusions, hallucinations) can accompany a depressive episode starting from a mild one. Often they are poorly expressed, the client may hide and the border between psychotic symptoms and persistent depressive rumination (mental gum) or constant concern is not clear.

In some individuals, the affective component may be manifested mainly in the form of irritability, or lack of emotion, "devastation", in the form of bodily symptoms. Clients with severe depressive symptoms may show a lack of desire to describe certain experiences (for example, psychotic symptoms) or an inability to do it in detail (for example, due to psychomotor agitation or lethargy). Depressive episodes can be associated with increased use of alcohol or other substances, with an exacerbation of pre-existing psychological symptoms (for example, fears or obsessions), or preoccupation with a physical condition.

2. Recurrent depressive disorder.

It is characterized by repeated episodes of depression, corresponding to the description of a depressive episode, without a history of independent episodes of mood elevation and a surge of energy (mania). However, there may be brief episodes of mild mood elevation and hyperactivity (hypomania) immediately following a depressive episode, sometimes caused by antidepressant treatment. The most severe forms of recurrent depressive disorder have much in common with older concepts such as manic-depressive depression, melancholy, vital depression, and endogenous depression. The first episode can occur at any age, from childhood to old age. Its onset can be acute or imperceptible, and its duration can be from several weeks to many months. The risk that a person with recurrent depressive disorder will not have a manic episode is never completely eliminated. If this happens, the diagnosis should be changed to bipolar disorder.

Recurrent panic attacks can be an indicator of greater severity, less responsiveness to treatment, and a greater risk of suicide. There is a greater risk of having a Solitary Episode of Depressive Disorder or Recurrent Depressive Disorder in individuals with a family history of these disorders.

Additional Clarification Criteria for Depressive Episodes

With severe symptoms of anxiety

A depressive episode is accompanied by severe anxiety symptoms (for example, feeling nervous, anxious, or "agitated"; inability to control anxious thoughts; fear that something terrible will happen; inability to relax; movement tension, vegetative symptoms).

With melancholy

The person is experiencing a current Depressive episode and this episode is characterized by several of the following symptoms: loss of interest or anhedonia, lack of emotional response to usually pleasant stimuli, terminal insomnia, i.e. waking up in the morning earlier than usual by two hours or more, depressive symptoms are more pronounced in the morning, noticeable psychomotor retardation or agitation, noticeable loss of appetite or weight loss.

Current perinatal episode

A depressive episode occurred during pregnancy or within a few months after childbirth. This criterion should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic criteria for a depressive episode and may occur soon after childbirth (called postpartum depression).

Seasonal manifestation

This criterion can only be applied to Recurrent Depressive Disorder if there has been a regular seasonal alternation of onset and remission of depressive episodes. The prevalence of depressive episodes corresponds to the seasonality. The seasonal nature of episodes must be distinguished from episodes that coincidentally coincide with the same season and are associated with regular seasonal psychological stress (for example, seasonal unemployment).

Borders with other disorders and the norm

Some depressed mood is a normal response to difficult life events and problems (such as divorce, job loss). A depressive episode differs from these common experiences in the severity, range, and duration of symptoms.

The client may show symptoms of a natural grief reaction, allowing for some degree of depressive symptoms, if they have suffered a bereavement in the past 6-12 months. Clients with no history of depressive disorder may experience symptoms of depression during bereavement, but this does not imply an increased risk of developing depressive disorder later. However, a depressive episode can overlap with the normal experience of grief.

A lingering grief response is a persistent and pervasive grief response to the death of a partner, parent, child, or other loved one that persists for an abnormally long period of time after the loss (at least 6 months) and is characterized by longing for the deceased or persistent thoughts about the deceased, accompanied by severe mental pain (for example, sadness, guilt, anger, denial, self-reproach, inability to come to terms with death, a sense of loss of part of oneself, inability to experience positive emotions, emotional insensitivity, difficulties involved in social and other activities). Some of the typical symptoms of Lingering Grief are similar to those seen with a Depressive Episode (eg, sadness, loss of interest in activities, social isolation, guilt, suicidal thoughts). However, Lingering Grief is different from a Depressive Episode in that symptoms are mainly related and confined to the bereavement of a loved one, while in a Depressive Episode, depressive thoughts and emotional reactions tend to span different areas of life.

Generalized Anxiety Disorder and Solitary Episode of Depressive Disorder or Recurrent Depressive Disorder can have several common manifestations, such as somatic symptoms of anxiety, difficulty concentrating, sleep disturbances, and feelings of fear associated with pessimistic thoughts. A single episode of depressive disorder or Recurrent Depressive Disorder is characterized by the presence of low mood or loss of enjoyment of loved ones before activities and other characteristic symptoms of Depressive Disorder (for example, changes in appetite, feelings of worthlessness, suicidal thoughts). In Generalized Anxiety Disorder, recurring thoughts or fears are focused on daily concerns (such as family, finances, work) rather than feelings of worthlessness or hopelessness. Obsessive-compulsive ruminations are often found in the context of a Solitary Episode of Depressive Disorder or Recurrent Depressive Disorder, but unlike those in Generalized Anxiety Disorder, they are usually not accompanied by obsessive anxiety and fears about everyday life events. Generalized Anxiety Disorder can coexist with a Solitary Episode of Depressive Disorder or Recurrent Depressive Disorder.

In Depressive Syndrome resulting from the use of psychoactive substances or the effects of other drugs on the central nervous system, including withdrawal syndrome, the presence of persistent mood disorders should be judged after the physiological effects of the relevant chemical have ended.

3. Dysthymic disorder.

In 70% of cases, it begins before the age of 21. The clinical picture is distinguished by spontaneity of onset, manifestation out of connection with any traumatic events, and chronic course. A combination of dysthymic affect with anxiety disorders (panic attacks, generalized anxiety, social phobia, etc.) is also possible. After the first 2 years, more pronounced depression may join dysthymia. Affective manifestations (depressed mood, low self-esteem, pessimism) are usually overlapped by somatoform or personality disorders. In accordance with this, there are two main types of dysthymia: somatized and characterological.

Constant low mood (for 2 years or more), which is noted most of the time, according to the patient's words (i.e. sadness, sadness) or according to external signs (i.e. tearfulness, dull look). In children, the diagnosis can be made within 1 year.

Additionally, all the characteristic symptoms of a depressive episode are present, but during the first 2 years of the disorder, the number and duration of symptoms do not meet the diagnostic requirements of a depressive episode.

Since the onset of the disease, there have never been long (i.e., several months) symptom-free periods.

Depressive symptoms lead to significant subjective distress or significant impairment in important areas of functioning.

Borders with other disorders and the norm

A slight decrease in mood is a normal reaction to difficult life events and problems. Dysthymic disorder differs from such common experiences in the severity, range, and duration of symptoms.

In Dysthymic Disorder, over a longer period of time, the number and duration of symptoms do not meet the diagnostic criteria for Solitary Episode of Depressive Disorder and Recurrent Depressive Disorder. Unlike Dysthymia, which is a chronic and persistent condition, Recurrent Depressive Disorder is episodic.

In Generalized Anxiety Disorder and Dysthymic Disorder, some common features may occur, such as somatic symptoms of anxiety, difficulty concentrating, sleep disturbances, and feelings of fear associated with pessimistic thoughts. Dysthymic disorder is characterized by the presence of low mood or loss of pleasure from previously enjoyable activities and other characteristic symptoms (for example, changes in appetite; feelings of inadequacy; repeated thoughts of death). In Generalized Anxiety Disorder, patients focus on potential negative consequences that may arise during various daily life events (for example, in the area of family, finances, work), rather than thoughts of worthlessness or hopelessness. Generalized Anxiety Disorder can coexist with Dysthymic Disorder.

Additional signs

Having any depressive disorder increases the risk of suicide. There is a greater risk of Dysthymic Disorder in individuals with a family history of Mood Disorders.

Depressive disorders are typically associated with mental and behavioral disorders such as: Anxiety and fear-related; Bodily distress; Obsessive-compulsive and related disorders; Oppositional defiant disorder; associated with the use of psychoactive substances; Eating and eating disorders; and Personality Disorders.

4. Signs of Mixed Depressive and Anxiety Disorder:

The presence of both depressive and anxiety symptoms, which are observed longer than absent, for 2 weeks or more. Neither depressive nor anxiety symptoms, considered in isolation, are severe, numerous, or prolonged enough to warrant a diagnosis of another Depressive Disorder or Anxiety and Fear-Related Disorder.

Depressive symptoms include depressed mood or a marked decrease in interest or pleasure in activities, especially those that are usually enjoyable. The presence of multiple anxiety symptoms (eg, feeling nervous, anxious, or "agitated"; inability to control disturbing thoughts; fear that something terrible will happen; inability to relax; movement tension, vegetative symptoms). Symptoms result in significant subjective distress or significant impairment in important areas of functioning.

If anxiety or over-concern is the only symptom of anxiety (i.e., there are no autonomic or other manifestations of anxiety), the diagnosis of Mixed Depressive Anxiety Disorder is not warranted.

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Heredity accounts for almost half of all cases of depressive disorders. Thus, depression is more common among relatives of the 1st line of patients with depression; concordance between identical twins is quite high.

Other theories focus on altering neurotransmitter levels, including the mechanisms of regulation of choline, catecholamine (noradrenergic or dopaminergic), glutamatergic and serotonergic neutrotransmission. Violation of the neuroendocrine system can play a large role, primarily in connection with possible disorders of 3 systems: hypothalamic-pituitary-adrenal, pituitary-adrenal and hypothalamic-pituitary.

Psychosocial factors may also be involved…. An episode of major depression is usually preceded by stress (especially marital divorce or the loss of a loved one), however, such events usually do not cause prolonged, severe depression in people not predisposed to mood disorders.

Persons who have had an episode of major depression have a high risk of relapse. People who are less resistant and / or prone to anxiety are more likely to develop depressive disorder. They, as a rule, do not take any active steps to cope with life's difficulties.

Women are at higher risk of developing depression, but a reasonable explanation for this fact has not yet been identified. Possible factors include the following:

Increased exposure to, or increased reaction to, daily stress. Higher levels of monoamine oxidase (an enzyme that breaks down neurotransmitters thought to be important for mood). Increased rates of thyroid dysfunction. Hormonal changes that occur during menstruation and during menopause.

Numerous controlled trials have shown that psychotherapy is effective for patients with depressive disorder, both in treating acute symptoms and in reducing the likelihood of relapse. Mild depression can be treated with tonics and psychotherapy. Treatment for moderate to severe depression includes medication and / or psychotherapy. Some people need a combination of drugs. This is:

Selective serotonin reuptake inhibitors (SSRIs)

Serotonin Modulators (5-HT2 Blockers)

Serotonin-norepinephrine reuptake inhibitors

Norepinephrine and Dopamine Reuptake Inhibitors

Heterocyclic antidepressants

Monoamine oxidase inhibitors (MAOIs)

Melatonergic antidepressant

The choice of drug may depend on the response to the previous course of antidepressants. On the other hand, SSRIs are often prescribed as first-line drugs. Although the various SSRIs are equally effective in typical cases, certain properties of the drugs make them more or less suitable for some patients.

People with pronounced suicidal ideation, especially with insufficient family supervision, need hospitalization, as do patients with psychotic symptoms or somatic disorders. Depressive symptoms in substance abusers often resolve within a few months after stopping use. The effectiveness of the use of antidepressants with continued abuse of harmful substances is significantly reduced.

Clients and their loved ones may be anxious or embarrassed to have a mental disorder. It is important to realize that depression is a serious illness caused by biological disorders and requires specific treatment, and the prognosis with treatment is favorable. Depressive disorder does not reflect changes in a person's character (for example, the development of laziness, weakness). The path to recovery is long and not constant, it is important to consciously prepare for long-term treatment and believe in yourself. The need to gradually expand daily and social activities (for example, walking, training) should be implemented unobtrusively and correlated with the desires of the client himself. In a state of depression, there is no person's fault. Dark thoughts are just part of this state, and they will pass.

Literature:

Smulevich A. B. ‹– Depression in General Medicine: A Guide for Physicians ››

ICD-11