There are two broad ways in which the patient may present, depending on the relative influence of psychomotor retardation and agitation. When retardation is extreme the patient is in a stupor, mute and in need of constant nursing care; when less severe the patient performs slowly and the increased sense of effort is obvious. The agitated patient is restless, unable to sit or settle and indulges in continuous purposeless activity. The retarded patient speaks slowly with obvious effort and has difficulty in self-expression; the agitated patient, on the other hand, may be voluble perhaps to the point on incoherence.
The content of the patient's conversation displays his restriction of interests and his preoccupation with his illness. Depressive ideas of guilt, self-reproach and unworthiness are common and over-concern with personal idiosyncrasies, spiritual matters, or with physical or psychological problems may form the basis of delusionary beliefs. These sometimes take on a markedly paranoid colouring. Sleep is almost always disturbed, the patient typically waking early; initial insomnia and broken sleep are also common. An occasional patient will experience hyper-somnia.
Even though the word depression may not be used by the patient and he may complain of apathy and loss of feeling, observation alone in these severe cases confirms his despondency, sadness or despair. In many patients, the depression shows a clear daily variation, being at its worst in the morning and improving later in the day, so that the evenings may be more or less tolerable. The depression may show some reaction to the surroundings, but commonly it is relatively unaffected by environmental events. In the agitated patient, anxiety symptoms may dominate the clinical picture; unremitting feelings of tension with their usual physical concomitants such as palpitations, headaches and loss of appetite are common, but the anxiety may be expressed in episodic form, including panic attacks and phobias. Weariness and fatigue are almost invariable. Amenorrhoea is frequent and sexual desire is commonly diminished. Fears of disease are common, particularly when somatic anxiety manifestations are prominent and hypchondriacal preoccupations with aches and pains and bowel or menstrual function may lead to the conviction on the part of the patient that he or she is suffering from cancer, heart disease, or hypertension. Other patients express fears of insanity or intellectual deterioration. Secondly, hysterical features may occur in association with hypochondriasis, leading to an invalid reaction.
In depressive illness there are, of course, no cognitive or intellectual changes, though these may be suspected because a patient emphasizes difficulty in concentration and consequent failure of recent memory. In many of these patients there will be a history of similar or previous episodes coming on without reason and terminating either spontaneously or in response to anti-depressant treatment. In perhaps 5 percent, there will be a history of depression or one or more attacks of mania.
Many mild cases of endogenous depression never seek medical help - many indeed never appreciate that they are ill. For the period of the illness, the sufferer continues to go about his daily existence, with a decreased sense of enjoyment, an increased sense of effort and perhaps some reduction in efficiency.
Michael Russell
Your Independent guide to Depression
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