There are three levels of symptoms to watch for: somatic symptoms, strategies to relieve discomfort, and social withdrawal.
Somatic Symptoms
The primary somatic symptom of early depression is insomnia. Soon afterwards loss of energy, easy fatigability and lack of staying power are reported. Vague gastrointestinal complaints are commonplace — anorexia with upper gastric pain not necessarily meal-related, loose stools, gas, etc. The patient’s record may indicate several visits to the doctor’s office within the span of a few weeks with vague and changeable somatic discomforts. Early to appear, but late to be revealed, is relative loss of libido.
Strategies for Relieving Discomfort
In response to his awareness that he is unwell, that life has lost its savor, a depressed person will develop defenses against increasing anxiety and mood change. An increase in the consumption of alcohol and tobacco comes early, together with other non-prescription chemical supports. The patient’s job will suffer from ineffective use of time and frequent absences, accompanied by self-blaming ruminative thoughts; also a lessened participation in family life will be evident. The cumulative effect of these deficiencies will be a self-evaluation that “I can’t cope”. The subsequent experience of diminishing self-confidence is often catastrophic.
Social Withdrawal
Up to this point the symptom pattern may be a private one; however, the next step brings outward manifestations of depression that the informed observer cannot ignore. Friends report finding the patient “different”. It becomes obvious that he or she is withdrawing from usual social contacts. There may be difficulty with emotional control. The patient is seen to be inattentive, to lack spontaneity, to avoid meeting a direct gaze. He may be self-deprecating in his talk, untidy and losing poise in his demeanor. Direct and indirect appeals for help are made to those with ears to hear.
A Complex Dislocation Of a Person’s Life
Depression can be understood in terms of three main factors.
First, it is a medical disorder causing pain and loss of energy. Many body systems are involved, but in particular there is gastrointestinal disturbance, often with upper gastric pain associated with anorexia or constipation. There is also musculoskeletal tension and pain experienced in the head or in the back. Symptoms of endocrine disturbance are commonplace, with amenorrhea in the female patient, evidence of low thryroid function and a blood sugar disturbance. Depression is also an inhibition and release disorder, sometimes with slowness of movement and speech, sometimes with restlessness and agitation.
Second, there is reaction to a situational stress. This stress often involves loss (infrequently by death or other personal disaster), the net effect of which is ego depletion. There is loss of self-confidence and a loss in capacity to cope. The patient often feels at the mercy of other people and of himself. He is hypersensitive, both to criticism from without and to self-criticism.
Third, there is a posture which expresses his predicament. The behavior may be an endeavor to secure secondary gains, but other appeals for intervention can be made, such as the petition for magical healing through a new medication or treatment procedure, or through a religious experience. The posture tells of a power struggle in which the person feels status has been lost and he feels disadvantaged in negotiations with key family members.
Depression and Suffering
The depressed person is hurting. His attention is focused inward on the hurt. Responsiveness is slow, movements are diminished, intellectual acuity is reduced, attention and concentration. are brief. He appears sad, dejected and lonely, but may not accept the designation of “depressed”. He feels “low”, “not himself, “off-color”, “peevish”, “dissatisfied”. He is aware of a loss of coping ability. He has an uncomfortable self-consciousness, nothing is funny anymore, the future looks bleak. The sense of proportion is lost and with that he gains intense sensitivity to losing face. He loses his capacity to help himself and in his performance nothing works, nothing seems right.
A severe catastrophic event as an initiator to depression is not the rule; rather, there is the accumulation of ego-depleting experiences. Candidates for reactive depression as a syndrome are people with a poor self-image, who have difficulty reconciling inner demands for self-assertive or sexual satisfaction with social controls that they perceive as authoritarian, restricting, judging. They feel people are ready to punish them by withholding approval. “I can’t please anyone”, or “People just put up with me” are frequent complaints. Concern is expressed over the burden of life’s obligations, that there is no right to have an opinion, that life presents a series of experiences of being used or exploited. The depressed person compares himself unfavorably with others and doesn’t measure up to the expectations he places on himself. Anger toward himself and other people is thinly veiled—if disguised at all.
Judgmental attitudes, scatter-gun criticism, self-deprecatory and self-destructive comments and behavior are manifest.
In the face of crisis he lacks the capacity to take credit for his strengths and capabilities and becomes intolerant of his dependency on other people. His support system, both within his own adaptive capacity and on outside friends and relatives is insufficient for his needs. “Since no one believes in me how can I believe in myself?” becomes his credo.
As a secondary effect of his vulnerability, the depressive learns to be compliant, to give in, to accept “peace at any price”, not to * ‘rock the boat”. To challenge this posture he may have to accumulate such a volume of grievances that he overreacts in sexual or food indulgences or in aggressive or delinquent excursions which are guilt-inducing and push him further into a depression. This phenomenon is usually repeated as if in response to a well-rehearsed script, to the dismay of the principal participants; i.e., the patient and his family, who are sorrowfully aware of the destructive by-products of this cycle. There are many alternate non-satisfying behavior sequences which further diminish self-image. Grooming may be drab, self-representation careless. Goals are not set, because defeat is anticipated, and this expectation becomes self-fulfilling. He sets up “no win” situations. His self-worth is further diminished as he becomes a target of unasked-for advice. He learns that instead of legitimate accomplishments, some of his needs can be appeased by the secondary gains of accepting the sick role, of being a martyr. Other possibilities are accident-proneness and acting out in some socially unacceptable way that invites retaliation or control.
Treatment Strategy
It is important to know who stands by, who is supportive, who can be counted on in the patient’s hour of need. He will need encouragement from a variety of resources and he may, in addition, require support and protection. Reduction of responsibility should be undertaken and opportunities for nurturing should be provided.
Opportunities for rest and sleep should be attended to, to give the patient opportunity to regain his perspective and his sense of proportion. A review should be made of self-help techniques that will give him opportunity to reclaim his self-image. He needs to undertake an honest evaluation of his attributes and set limited goals for himself, though feeling handicapped, in order to balance the inevitable inclination to focus on his deficiencies.
The patient can be taught about the place of tricyclic medication in treatment so that he can realize, according to his own lights, that there is a relationship between mind and body and that his distressed feelings can be relieved by chemical means until such time as his body balance is restored. In this frame of reference the patient feels less stigma and shows better medication compliance.
Attention should be paid to ineffective techniques the patient may be using in his interpersonal relationships, such as blaming and having unreasonable expectations of himself. He needs also to learn to fend off well-meant advice, exhortations and platitudes.
Résumé
(French Language)
Pour comprendre les effets de la dépression sur la vie d’un patient, le médecin doit connaître les manifestations de la dépression. La tension somatique, les stratégies pour soulager le malaise et le retrait social doivent être envisagés comme des symptômes de dépression. La connaissance des situations de vie qui peuvent donner naissance à ces symptômes de même que l’effet des réactions mêmes du médecin à la dépression du patient.