From the author: Continuing the topic of depression, here is about diagnosis. The article is more for specialists working with depressed clients. And for clients who need to understand what is happening to them. How can you recognize depression by sight? What exactly are the markers that indicate the appearance of signs of this “popular” mental disorder of our time? How to assess the degree of development of a depressive state and where to address it? Continuing my topic about the causes of depression, I will try to clarify these questions in this article. Depression significantly changes the quality of life. It affects all those areas where a person’s mental activity is manifested: - emotions and feelings - thinking and motivation - behavior and physical health The very nature of depression is to influence a person’s thoughts and actions in such a way that he becomes unable to do anything to improve his condition . As if this is such a symbolic parasite that does everything to keep its owner alive, and is not interested in the quality of life of its owner. Those. depression can feed on itself, driving a person into a vicious circle from which it is difficult to break out. Why is this so? I will assume that depression is a kind of global psychological defense, consisting of several characteristic, specific subdefenses. A person needs such protection in certain circumstances. Perhaps it creates conditions of existence in which a person can survive some unbearable circumstances of his life. Outside of these conditions, it is unknown what would happen to a person, and how he would cope with the demands placed on him from the surrounding reality. Of course, if a person is inclined to react with depression to intolerable environmental conditions, then he will react in this way. Psychoanalysts classify such a personality as “depressive.” Nevertheless, it is very important to objectively assess the severity of the condition and determine the point after which a person himself cannot return to mental health. That transitional moment when the sanogenic (self-healing) properties of the psyche are already powerless in the fight against depression, and a person needs systematic help from a psychologist, and in more severe cases, a psychotherapist or psychiatrist. I would also like to note that depression is a rather insidious disease. It is not always easy to diagnose it, for example, if it is disguised as somatic symptoms. This kind of depression is called “masked”. Next, I will give a diagnostic classifier of various depressive states with links to ICD-10.[/url] The classification is taken from the book by V.P. Samokhvalov "Psychiatry". Chronic (affective) mood disorders (F34). These disorders are chronic and usually unstable. Individual episodes are not profound enough to qualify as hypomania or mild depression. They last for years, and sometimes throughout the patient’s life. Due to this, they resemble special personality disorders such as constitutional cycloids or constitutional depression. Life events and stress can deepen these conditions. Etiology and pathogenesis The etiology of chronic mood disorders is both constitutional and genetic and is caused by a special affective background in the family, for example, its orientation towards hedonism and optimism or a pessimistic perception of life. When faced with life events that none of us can escape, the personality reacts with a typical affective state, which initially seems quite adequate and psychologically understandable. This affective state, although it causes a reaction from others, seems adaptive to them.[/url] Cyclothymia (F34.0). Seasonal mood swings are often observed since childhood or adolescence. However, this diagnosis is considered adequate only in post-puberty, when unstable mood with periods of subdepression and hypomania lasts at least two years. The clinic itself is endogenously perceived only asa period of inspiration, rash actions or blues. Moderate and severe depressive and manic episodes are absent, but are sometimes described in the anamnesis. The period of depressive mood grows gradually and is perceived as a decrease in energy or activity, the disappearance of usual inspiration and creativity. This in turn leads to a decrease in self-confidence and a feeling of inferiority, as well as social isolation; isolation also manifests itself in reduced talkativeness. Insomnia appears, pessimism is a stable character trait. The past and future are assessed negatively or ambivalently. Patients sometimes complain of increased drowsiness and impaired attention, which prevents them from perceiving new information. An important symptom is anhedonia in relation to previously pleasant types of instinctual release (food, sex, travel) or pleasant activities. The decrease in activity activity is especially noticeable if it follows an elevated mood. However, there are no suicidal thoughts. An episode can be perceived as a period of idleness, existential emptiness, and if it lasts for a long time, it is assessed as a characterological trait. The opposite state can be stimulated endogenously and by external events and can also be tied to the season. When your mood is elevated, energy and activity increase, and the need for sleep decreases. Creative thinking is enhanced or sharpened, which leads to increased self-esteem. The patient tries to demonstrate intelligence, wit, sarcasm, and speed of associations. If the patient’s profession coincides with self-demonstration (actor, lecturer, scientist), then his results are assessed as “brilliant”, but with low intelligence, increased self-esteem is perceived as inadequate and ridiculous. Interest in sex increases and sexual activity increases, interest in other types of instinctive increases. activities (food, travel, over-involvement in the interests of one’s own children and relatives, increased interest in clothes and jewelry). The future is perceived optimistically, past achievements are overestimated. The psychological analogue of cyclothymia is the creative productivity of A.S. Pushkin, who, as is known, was distinguished by significant productivity in the fall and a decrease in the activity of inspiration in the spring. The same periods of creative productivity, covering a longer period, were characteristic of P. Picasso. The cyclical rhythms of mood clearly depend on the length of daylight hours and the latitude of the area; this is intuitively grasped by patients in their desire to migrate and travel. Diagnosis1. More than two years of unstable mood, including alternating periods of both subdepression and hypomania with or without intervening periods of normal mood.2. There have been no moderate or severe manifestations of affective episodes for two years. The observed affective episodes are lower in level than mild ones.3. Depression must include at least three of the following symptoms: - decreased energy or activity; - insomnia; - decreased self-confidence or feelings of inadequacy; - difficulty concentrating; - social withdrawal; - decreased interest or pleasure in sex or pleasurable activities. activity; - decreased talkativeness; - pessimistic attitude towards the future and negative assessment of the past.4. An increase in mood is accompanied by at least three of the following symptoms: - increased energy or activity; - decreased need for sleep; - increased self-esteem; - increased or unusual creative thinking; - increased sociability; - increased talkativeness or display of intelligence; - increased interest in sex. and an increase in sexual relations and other types of activities that bring pleasure; - over-optimism and overestimation of past achievements. Individual anti-disciplinary actions are possible, usually in a state of intoxication, which are assessed as “excessive fun”. Differential diagnosis Should be differentiated from mild onesdepressive and manic episodes, bipolar affective disorders, occurring with moderate and mild affective attacks, hypomanic states should also be distinguished from the onset of Pick's disease. In relation to mild depressive and manic episodes, this can usually be done on the basis of anamnesis, since unstable mood with cyclothymia should be determined for up to two years, cyclothymics are also not characterized by suicidal thoughts, and their periods of elevated mood are socially more harmonious. Cyclothymic episodes do not reach a psychotic level, this distinguishes them from affective bipolar disorders, in addition, cyclothymics have a unique anamnestic history, episodes of mood disorders are noted very early in puberty. Mood changes in Pick's disease are noted at a later age and are combined with more severe disorders social functioning.[/url] Dysthymia (F34.1). EtiologyThe types of individuals who experience dysthymia would be correctly called constitutionally depressed. These traits appear in childhood and puberty as a reaction to any difficulty, and later endogenously. Clinic They are whiny, thoughtful and not very sociable, pessimistic. Under the influence of minor stresses in post-puberty, for at least two years, they experience periods of constant or periodic depressive mood. Intermediate periods of normal mood rarely last longer than a few weeks; the entire mood of the individual is colored by subdepression. However, the level of depression is lower than in mild recurrent disorder. It is possible to identify the following symptoms of subdepression: - decreased energy or activity; - sleep disturbances and insomnia; - decreased self-confidence or feelings of inferiority; - difficulty concentrating, and hence a subjectively perceived decrease in memory; - frequent tearfulness and hypersensitivity; - decreased interest. or pleasure from sex, other previously pleasant and instinctive forms of activity; - feelings of hopelessness or despair due to the awareness of helplessness; - inability to cope with the routine responsibilities of everyday life; - pessimistic attitude towards the future and a negative assessment of the past; - social withdrawal; - decreased talkativeness and secondary deprivation. Diagnosis1. At least two years of persistent or recurrent depressive mood. Periods of normal mood rarely last more than a few weeks.2. The criteria do not meet a mild depressive episode because there are no suicidal thoughts.3. During periods of depression, at least three of the following symptoms must be present: decreased energy or activity; insomnia; decreased self-confidence or feelings of inferiority; difficulty concentrating; frequent tearfulness; decreased interest or pleasure in sex or other pleasurable activities; feelings of hopelessness or despair; inability to cope with routine responsibilities of daily life; pessimistic attitude towards the future and negative assessment of the past; social isolation; decreased need for communication. Differential diagnosis Should be differentiated from a mild depressive episode, the initial stage of Alzheimer's disease. With a mild depressive episode, suicidal thoughts and ideas are present. In the initial stages of Alzheimer's disease and other organic disorders, depression becomes protracted; organic disorders can be identified neuropsychologically and using other objective research methods.[/url] Other chronic (affective) mood disorders F34.8. Category for chronic mood disorders that are not sufficiently severe or continuous to meet criteria for cyclothymia or dysthymia, mild or moderate depressive episode. Some types of depression formerly called "neurotic" are included. These types of depression are closely related to stress and, together with dysthymia, organize the circle of endoreactive dysthymia.[/url] Depressiveepisode (F32). Risk factors Risk factors for the development of depression are age 20-40 years, lower social class, divorce in men, family history of suicide, loss of relatives after 11 years, personality traits with traits of anxiety, diligence and conscientiousness, stressful events, homosexuality, problems of sexual satisfaction, postpartum period, especially in single women. In the pathogenesis of depression, along with genetic factors that determine the level of neurotransmitter systems, the cultivation of helplessness in the family during times of stress, which forms the basis of depressive thinking, loss of social contacts, is important. Clinic The clinic consists of emotional, cognitive and somatic disorders, among additional symptoms there are also secondary ideas self-blame, depressive depersonalization and derealization. Depression manifests itself in decreased mood, loss of interests and pleasure, decreased energy, and as a result, increased fatigue and decreased activity. A depressive episode lasts for at least 2 weeks. Patients note a decreased ability to concentrate and pay attention, which is subjectively perceived as difficulty remembering and decreased success in learning. This is especially noticeable in adolescence and youth, as well as in people engaged in intellectual work. Physical activity is also reduced to the point of lethargy (even stupor), which can be perceived as laziness. In children and adolescents, depression can be accompanied by aggressiveness and conflict, which mask a kind of self-hatred. All depressive states can be roughly divided into syndromes with and without an anxiety component. The rhythm of mood changes is characterized by a typical improvement in well-being in the evening. Self-esteem and self-confidence decrease, which looks like specific neophobia. These same sensations distance the patient from others and increase his sense of inferiority. With long-term depression after the age of 50, this leads to deprivation and a clinical picture resembling dementia. Ideas of guilt and self-deprecation arise, the future is seen in gloomy and pessimistic tones. All this leads to the emergence of ideas and actions associated with auto-aggression (self-harm, suicide). The rhythm of sleep/wakefulness is disrupted, insomnia or lack of a sense of sleep is observed, and dark dreams predominate. In the morning the patient has difficulty getting out of bed. Appetite decreases, sometimes the patient prefers carbohydrate foods to protein foods, appetite may be restored in the evening. The perception of time changes, which seems endlessly long and painful. The patient stops paying attention to himself, he may have numerous hypochondriacal and senestopathic experiences, depressive depersonalization appears with a negative image of his own self and body. Depressive derealization is expressed in the perception of the world in cold and gray tones. Speech is usually slow with talking about one's own problems and past. Concentration of attention is difficult, and the formulation of ideas is slow. During examination, patients often look out the window or at a light source, gesticulation with an orientation towards their own body, pressing their hands to the chest, with anxious depression to the throat, a pose of submission, in facial expressions the Veragut fold, lowered corners of the mouth. In case of anxiety, accelerated gesture manipulation of objects. The voice is low, quiet, with long pauses between words and low directiveness. Endogenous affective component. Expressed in the presence of rhythm: symptoms intensify in the morning and are compensated in the evening, in the presence of criticism and a subjective feeling of the severity of one’s condition, the connection of severity with the season, a positive reaction to tricyclic antidepressants .Somatic syndrome is a complex of symptoms that indirectly indicates a depressive episode. The fifth character is used to designate it, but the presence of this syndrome is not specified for a severe depressive episode,since with this option it is always detected. To determine the somatic syndrome, four of the following symptoms must be present: 1. Decreased interest and/or decreased pleasure in activities that are usually enjoyable for the patient, for example, previously enjoyable creative work now seems meaningless.2. Lack of reaction to events and/or activities that normally cause it; for example, a woman was previously upset by the fact that her husband returned late from work; now she is indifferent to this.3. Waking up in the morning two or more hours before usual time; after such an awakening, the patient usually continues to remain in bed.4. Depression is worse in the morning and improves in the evening.5. Objective evidence of noticeable psychomotor retardation or agitation (noted or described by others) - patients prefer solitude or rush around in restlessness, often moaning.6. A noticeable decrease in appetite, sometimes there is selectivity in food preference with an emphasis on sweets and carbohydrate foods7. Weight loss (five percent or more of body weight in the past month).8. A noticeable decrease in libido. However, in traditional diagnosis, many symptoms may include somatic syndrome, such as dilated pupils, tachycardia, constipation, decreased skin turgor and increased fragility of nails and hair, accelerated involutive changes (the patient seems older than his age), as well as somatoform symptoms, such as: psychogenic shortness of breath, restless legs syndrome, dermatological hypochondria, cardiac and pseudorheumatic symptoms, psychogenic dysuria, somatoform disorders of the gastrointestinal tract. In addition, with depression, sometimes weight does not decrease, but increases due to cravings for carbohydrates; libido may also not decrease, but increase, since sexual satisfaction reduces anxiety levels. Other somatic symptoms include vague headaches, amenorrhea and dysmenorrhea, chest pain and, especially, a specific feeling of “a stone, a heaviness on the chest.” Diagnosis The most important signs are: - decreased ability to concentrate and attention; - decreased self-esteem and self-confidence ;—ideas of guilt and self-deprecation;—gloomy and pessimistic vision of the future;—ideas or actions leading to self-harm or suicide;—disturbed sleep;—decreased appetite. Differential diagnosis Depression should be differentiated from the initial symptoms of Alzheimer's disease. Depression can indeed be accompanied by the pseudodementia clinical picture described by Wernicke. In addition, long-term depression can lead to cognitive deficits as a result of secondary deprivation. Pseudo-dementia in chronic depression is referred to as Puna Van Winkle syndrome. For differentiation, anamnestic information and data from objective research methods are important. Depressed patients more often have characteristic diurnal mood swings and relative success in the evening; their attention is not so severely impaired. In the facial expressions of depressed patients, there is a Veragut fold, drooping corners of the mouth and there is no confused amazement and rare blinking characteristic of Alzheimer's disease. Gesture stereotypies are also not observed in depression. In depression, as in Alzheimer's disease, there is a progressive involution, including decreased skin turgor, dull eyes, increased fragility of nails and hair, but these disorders in brain atrophy are often ahead of psychopathological disorders, and in depression they are observed with a long duration of low mood . Weight loss in depression is accompanied by a decrease in appetite, and in Alzheimer's disease, appetite not only does not decrease, but may even increase. Patients with depression respond more clearly to antidepressants with an increase in activity, but in Alzheimer's disease they can increase spontaneity and asthenia, creating the impression of a busy patient. Data is still kingCT, EEG and neuropsychological examination.[/url] Mild depressive episode (F32.0). Clinic The clinical picture includes: decreased ability to concentrate and attention, decreased self-esteem and self-confidence, ideas of guilt and self-deprecation, a gloomy and pessimistic attitude towards the future, suicidal ideas and self-harm, sleep disturbances, decreased appetite. These general symptoms of a depressive episode must be combined with a level of depressed mood that is perceived by the patient as abnormal, and the mood is not episodic, but covers most of the day and is not dependent on reactive moments. The patient experiences a distinct decrease in energy and increased fatigue, although he can control his condition and often continues to work. Behavioral (facial, communicative, postural and gestural) signs of bad mood may be present, but are controlled by the patient. In particular, you can notice a sad smile, motor retardation, which is perceived as “thoughtfulness.” Sometimes the first complaints are loss of the meaning of existence, “existential depression.” Typically, when diagnosing, it is noted whether depression occurs without somatic symptoms or with somatic symptoms. Diagnosis 1. The diagnosis must include at least two of the following three symptoms: - depressed mood; - decreased interest or pleasure in activities that the patient previously enjoyed; - decreased energy and increased fatigue.2. Two of the additional symptoms: - decreased confidence and self-esteem; - unreasonable feelings of self-judgment and guilt; - recurrent thoughts of death or suicide; - complaints of decreased concentration, indecision; - sleep disturbance; - changes in appetite. Differential diagnosis Most often a mild depressive episode must be differentiated from an asthenic state as a result of overwork, organic asthenia, and decompensation of asthenic personality traits. With asthenia, suicidal thoughts are not typical, and low mood and fatigue intensify in the evening. With organic asthenia, dizziness, muscle weakness, and fatigue during physical activity are often observed. History of traumatic brain injury. With decompensation of personality traits, the psychasthenic core is noticeable in the anamnesis, subdepression is perceived by the individual as a natural and characteristic personality trait.[/url] Moderate depressive episode (F32.1). ClinicThe main difference between a moderate depressive episode is that changes in affect affect the level of social activity and interfere with the realization of personality. When anxiety is present, it is clearly manifested in complaints and behavior. In addition, depression with obsessive-phobic components and senestopathies are often found. The differences between mild and moderate episodes may also be purely quantitative. Diagnosis1. Two of the three symptoms of a mild depressive episode, that is, from the following list: - depressed mood; - decreased interest or pleasure in activities that the patient previously enjoyed; - decreased energy and increased fatigue; 2. Three or four other symptoms from the general criteria for depression: - decreased confidence and self-esteem; - unreasonable feelings of self-judgment and guilt; - repeated thoughts of death or suicide; - complaints of decreased concentration, indecisiveness; - sleep disturbance; - changes in appetite.3 . Minimum duration is about two weeks. Differential diagnosis Should be differentiated from post-schizophrenic depression, especially in the absence of a clear history. A moderate depressive episode is characterized by an endogenous affective component; there are no negative emotional-volitional disorders.[/url] Severe depressive episode without psychotic symptoms (F32.2). ClinicIn the clinic of a major depressive episode, all the symptoms of depression are present. Motor skills are agitated or significantly inhibited. Suicidal thoughts and behavior are constant and alwaysthere is a somatic syndrome. Social activity is subordinated only to the disease and is significantly reduced or even impossible. All cases require hospitalization due to the risk of suicide. If agitation and retardation are observed in the presence of other behavioral signs of depression, but additional verbal information about the patient's condition cannot be obtained, this episode also refers to severe depression. Diagnosis 1. All criteria for a mild to moderate depressive episode must be present, that is, the following are always present: - depressed mood; - decreased interest or pleasure in activities that the patient previously enjoyed; - decreased energy and increased fatigue.2. Additionally, four or more symptoms from the general criteria of a depressive episode must be determined, that is, from the list: - decreased confidence and self-esteem; - unreasonable feelings of self-condemnation and guilt; - repeated thoughts of death or suicide; - complaints of decreased concentration, indecisiveness; - sleep disturbance; - change in appetite. 3. Duration of at least two weeks. Differential diagnosis Should be differentiated from organic affective symptoms and the initial stages of dementia, especially in Alzheimer's disease. Organic affective symptoms can be excluded by additional neurological, neuropsychological studies, EEG and CG. The same methods are used in the differential diagnosis with the initial stages of Alzheimer's disease.[/url] Severe depressive episode with psychotic symptoms (F32.3). Clinic At the height of severe depression, delusional ideas of self-blame, hypochondriacal delusional ideas about infection with some incurable disease and fear (or conviction of infection) of infecting loved ones with this disease arise. The patient takes upon himself the sins of all humanity and believes that he must atone for them, sometimes at the cost of eternal life (Ahasfer syndrome). His thoughts can confirm auditory, olfactory deceptions. As a result of these experiences, lethargy and depressive stupor occur. Clinical example: Patient Ch., 50 years old, a general practitioner, works in a clinic. Lives with his 25-year-old daughter and mother. The onset of the disease coincides with menopause. Over the course of a month, isolation and decreased mood are noted. Appetite increases, anxiety and periods of agitation occur, when one begins to moan loudly “from mental pain.” He is being treated in a day hospital. Often on the street the moaning is so loud that passers-by turn around. When talking about your problems, moaning makes it difficult to even speak. He doesn’t sleep at night, but constantly walks so as not to disturb his loved ones, wanders around the city at night, returning only in the morning. She assures that she most likely has AIDS, which she contracted from one patient, “everything inside is rotten,” “the blood vessels are empty,” “there’s a mess in my head.” He also believes that he could have infected his daughter, who will now not be able to get married. Confirmation of this idea is her pallor and weakness. She doesn’t see the meaning of life, before hospitalization she tried to commit suicide: she took a lot of clonidine tablets, after changing into the most beautiful dress. Diagnosis1. Meets criteria for a major depressive episode.2. The following symptoms must be present: 1) delusions (depressive delusions, delusions of self-blame, delusions of hypochondriacal, nihilistic or persecutory content); 2) auditory (accusing and insulting voices) and olfactory (smells of rotting) hallucinations; 3) depressive stupor. When diagnosing, note: whether additional psychotic symptoms, including delusions of guilt, self-deprecation, physical illness, impending disaster, mocking or judgmental auditory hallucinations, are mood consistent or inconsistent. For example, are there persistent delusions or hallucinations without affective content? Differential diagnosis The main differential diagnosis is associated with the group of schizoaffective disorders. In fact, severe depressive episodes can be seen as manifestations of schizoaffective disorders.).