Clinical features
- Biological symptoms
- Appearance
- Speech
- Mood
- Morbid/pessimistic thoughts
- Poverty of thought
- Intellect and memory
- Sleep disturbance
- Change in appetite
- Change in weight
- Change in psychomotor activity
- Diurnal variation of mood
- Anhedonia
- Reduced energy and drive
- Loss of libido [sexual drive]
- Change in bowel habit
- Change in menstrual cycle
- Physical symptoms
- Psychotic features
- Other psychiatric symptoms
People with depressive illness may exhibit a number of features. The features present in any individual patient are determined by the severity of the illness. Doctors are able to assess the severity of the illness by means of eliciting a history combined with a structured “mental state examination.”
Biological symptoms
The following are often referred to as biological symptoms or “biological features.” They are features of moderate and severe depressive illness.
- Sleep disturbance.
- Diurnal variation of mood [worse in the morning].
- Loss of appetite.
- Loss of weight.
- Constipation.
- Loss of libido [sexual drive].
- Amenorrhoea [cessation of periods].
People with depressive illness may demonstrate any of the following, depending upon the severity of the illness:
Appearance
- Unkempt.
- Neglected dress and grooming.
- Poor self-care and personal hygiene – often dirty clothing.
- Depressed facial appearance, perhaps with turning down of the corners of the mouth.
- Tearfulness.
- “Knitted brow” – furrowing of the centre of the forehead, between the eyebrows.
- Downward gaze – poor eye contact and reduced rate of blinking. But some people may maintain a smiling exterior while depressed. These people are often referred to as “smiling or masked depressives”
- Weight loss.
- Reduced gestures.
- Shoulders bent and head inclined forwards.
Speech
- Poverty [lack] of speech and/or speaking in a monotone.
- Slow and hesitant – long delay before questions are answered.
Mood
- Low and sad – often one of misery.
- “Autonomous” – i.e. mood does not react in response to circumstance.
- Anxiety, irritability and agitation may occur.
Morbid / pessimistic thoughts
- Concerned with the past – often taking the form of unreasonable guilt and self-blame about minor matters, e.g. feeling guilty about past trivial acts of dishonesty [such as taking home an office pencil many years ago]. Such minor misdemeanours may be exaggerated out of all proportion and used as “proof” that the patient is “evil” and does not deserve his current status in life.
- Concerned with the present.
- Pessimism – the patient sees the unhappy side of every event. He thinks he is failing in everything he does and that other people see him as a failure.
- Low self-esteem - he no longer feels confident, and discounts any success as a chance happening for which he can take no credit.
- Concerned with the future [which seems bleak].
- Ideas of hopelessness and helplessness – the patient expects the worst.
- Often accompanied by the thought that life is no longer worth living for and that death would come as a welcome release.
- May progress to thoughts of, and plans for, suicide.
- Homicidal thoughts may occasionally occur – e.g. a depressed mother may decide the future is equally bleak for her children and plan to kill them before committing suicide; or a depressed elderly man may persuade his wife to enter into a suicide pact.
Poverty of thought
- Few thoughts – these lack variety and richness, and seem to move slowly through the mind.
Intellect and memory
- Impaired attention and concentration.
- Poor memory – not permanent, as is often feared by the patient.
- In the elderly, depressive pseudo-dementia may occur i.e. the patient exhibits the features of dementia, but this is due to the depressive illness.
Sleep disturbance
- Early morning wakening 2-3 hours before the patient’s usual time. Often occurs in more severe depressive illness.
- Initial insomnia – difficulty and delay in falling asleep. May occur in less severe depressive illness.
- Some young depressed people sleep excessively – but still feel unrefreshed on waking. Intractable sleep disturbance is common in the elderly.
Change in appetite
- Characteristically loss of appetite, less commonly increased appetite.
Change in weight
- Characteristically loss of body weight [at least 5% in a month], less commonly increased weight.
Change in psychomotor activity
- Common in the elderly.
- Characteristically psychomotor retardation [slowed up]. Sometimes agitation.
Diurnal variation of mood
- Characteristically worse in the morning – people wake up feeling very depressed and possibly suicidal. Their mood gradually lifts during the day, but is sometimes worse again in the evening. Some people, often with less severe depressive illness, may not feel depressed on waking but may become more depressed as the day progresses.
Anhedonia
- Total lack of interest in and enjoyment of hobbies / pleasure activities.
Reduced energy and drive
- Causing fatigue / tiredness and reduced activity.
Loss of [or markedly reduced] libido [sexual drive]
Change in bowel habit
- The patient may complain of constipation.
Change in menstrual cycle
- Amenorrhoea may occur in females i.e. periods cease.
Physical symptoms
- These are more common in the elderly. Aching and/or discomfort anywhere in the body. Increased complaints about any pre-existing physical disorder.
Psychotic features
- Delusions [False beliefs that are unshakeable].
- Concerning themes of worthlessness, guilt, ill health [especially cancer] or poverty.
- Concerning persecution [e.g. that others are going to take revenge on him]; the supposed persecution is often accepted as having been brought on himself.
- Hallucinations.
- Usually compatible with depressed mood i.e., derogatory auditory hallucinations – voices addressing repetitive words and phrases to the patient, confirming his ideas of worthlessness [e.g. “You are an evil sinful man; you should die”], making derisive comments or urging suicide.
- A few people experience visual hallucinations, such as scenes of death and destruction.
Other psychiatric symptoms
May include:
- Anxiety.
- Hypochondriasis– these [and other somatic complaints] are common in old age.
- Depersonalisation i.e. person feels unreal and detached from their own experience.
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