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1 The Diagnostic Criteria of Depression

1 The Diagnostic Criteria of Depression

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9.1



171



The Diagnostic Criteria of Depression



their actual mood. Their descriptions fell in several categories: the commonest

description was the experience of lethargy and inability to do things. The next most

common was a sense of detachment from the environment (the inability to interact

with others and even perceptual changes of the environment); then a physical feeling of “viral illness,” aches, and pains; and cenesthesia-like sensation of a tight

bands around the head or of inflation of the head. The patients were then asked to

choose adjectives from a list describing their state, excluding the usual words for

describing depression (e.g., sad). They came up with words like dispirited, sluggish,

empty, and washed out, suggesting a state different from sadness.

However, mood is not only an inner mental state (Parnas 2012) but an atmospheric experience of the world. “[M]oods constitute a sense of being part of a

world that is pre-subjective and pre-objective. All ‘states of mind’ and all perceptions and cognitions of ‘external’ things presuppose this background sense of

belonging to a world.” (Ratcliffe 2013). Mood is not directed toward any object,

although some depressive patients may express delusional pseudo-explanations for

their present state: they have gone bankrupt, are going to be divorced, etc. Depressed

mood implies at least four further features: lack of vital drive, anhedonia, helplessness, and moral pain (Stanghellini and Rosfort 2013, p. 270). The core depressive

(melancholic) patient may feel lifeless or dead and expect the world to be doomed

and his/her children to have no future, as opposed to the patient in mourning who is

indeed miserable because of the loss she has suffered, but who recognizes her own

personal qualities and expects the rest of the world to go on unconcerned. The

depressive mood with its diurnal variation is impervious to environmental influences (loss of reactivity, Gillespie 1929), as opposed to affective reactivity and lability of personality disorders. Sedative drug effects hardly lighten depression either

(Schneider 1959, p. 139). DSM-5 offers simple and insufficient definitions of moods

and affects (p. 824): “In contrast to affect, which refers to more fluctuating changes

in emotional “weather,” mood refers to a pervasive and sustained emotional “climate.”” In fact, there are obvious qualitative differences: a mood is a background

“sense of being part of a world” unlike an affect, which is situational and directed to

a specific object (see the comparison in Table 9.1).

Table 9.1 A comparison of mood and affect

Mood

A background sense of being part of a world

Non-intentional

No semantic content

Often long-lasting

Prerequisite for affects

Examples of moods providing basis for affects:

Dysphoria →

Fearfulness →



Affect

A situational emotion in focus of

attention

Intentional: directed to an object

A situational theme

Situational, transient

On the background of a mood

Anger at…

Fear of…



172



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Varieties of Depressive-Like Mental States



The loss of interest or pleasure is named anhedonia (or hypohedonia). In melancholia, anhedonia is state-like, reflecting the depressive mood, and often part of the

loss of all feelings (Johnson 1935; Jaspers 1997, p. 111), also referred to as anesthesia dolorosa (von Krafft-Ebing 1905), in which the patient is conscious of his emotional loss and is painfully affected by it (as opposed to apathy, which is a total loss

of feelings accompanied by indifference). This inability to feel is expressed movingly by a melancholic patient:

I still continue to suffer constantly; I have not a moment of comfort and no human sensations. Surrounded by all that can render life happy and agreeable, still to me the faculty of

enjoyment and of feeling is wanting—both have become physical impossibilities. In everything, even in the most tender caresses of my children, I find only bitterness. I cover them

with kisses, but there is something between their lips and mine; and this horrid something

is between me and all the enjoyments of life. My existence is incomplete. The functions and

acts of ordinary life, it is true, still remain to me, but in every one of them there is something

wanting—to wit, the feeling which is proper to them and the pleasure which follows them.

. . . . Music has lost all charm for me, I used to love it dearly. My daughter plays very well,

but for me it is mere noise. That lively interest which a year ago made me hear a delicious

concert in the smallest air their fingers played—that thrill, that general vibration which

made me shed such tender tears—all that exists no more. (Quote from Brachet, in Johnson

1935)



Anhedonia is found in several psychiatric conditions in addition to depression: in

schizotypy and schizophrenia (Meehl 1962; Pelizza and Ferrari 2012), in organic

and in drug-related states. Its presence does not necessarily imply a depressive

mood. Patients with schizophrenia can often tell the two conditions apart, e.g., stating, “I am not depressed, I just cannot feel any pleasure.” In the schizophrenia spectrum, anhedonia is a trait-like disorder of self-awareness (Juckel et al. 2003). Meehl

(1962) considers anhedonia, the “marked, widespread, and refractory defect in pleasure capacity,” a “quasi-pathognomonic sign” of schizophrenia. It can be divided

into social anhedonia related to diminished presence, the feeling of being present in

the world and affected by it, and physical anhedonia, diminished ability to experience pleasure in relation to the immediate surrounding perceptual or intellectual

stimulation (Parnas et al. 2005).

The accessory diagnostic criteria of depression in DSM-5 and ICD-10 are mostly

nonspecific signs or symptoms (weight change, change in appetite, sleep and activity, diminished concentration, and in ICD-10: loss of confidence and self-esteem).

Thoughts of death or suicide are often supposed to be expressive of depression, but

they may, e.g., in schizophrenia be motivated by solitude with inability to participate in human interactions and feelings of inferiority, reflective of a more basic

self-alienation and incapacity for immersion in the shared world (Skodlar et al.

2008). Only two of the accessory criteria of depression have a specific melancholic

character: psychomotor agitation or retardation and guilt or worthlessness. In clinical practice, these features are nevertheless frequently misinterpreted.

Psychomotor retardation proper refers to retardation of all motor and mental

acts: the patient moves slowly, answers questions with a latency, speaks slowly,

shows few facial expressions, etc. (The expressivity of retardation is treated in



9.1



The Diagnostic Criteria of Depression



173



Sects. 5.1 and Sect. 9.4). In phenomenological psychiatry, it is seen closely related

to a change in the temporal organization in melancholia (see below). In schizophrenia, there are phases distinguished by deviations of motor activity. Gruhle (1932,

p. 203) speaks of hyper- and hypo-phases of spontaneity, the latter seen in stupor.

Benommenheit (Bleuler 1950, p. 221–223; see Sects. 5.1 and 7.5.1), found in certain

schizophrenic states, is a kind of motor retardation accompanied by perplexity but

in the absence of depressed mood. Hypomimia, and other signs of reduced spontaneous motor activity, is often alleged to be retardation, but is found even in nonaffective states like schizophrenia and dementia.

Guilt, with the predicates, “excessive” or “inappropriate”, is part of the diagnostic criteria for depression in DSM-5 and ICD-10, and its negation, lack of guilt, for

certain personality disorders, but the concept itself escapes definition in these diagnostic manuals. Feelings of guilt represent a variegated array of phenomena spanning from normal psychology to delusions. There are three different meanings of

the concept of guilt (Stoltz-Ingenlath and Frick 2006): (1) the juridical, a guilt of

action or inaction in the sense of making a mistake; (2) the ontological or existential

guilt, a kind of debt similar to “owing something to somebody” or in not fulfilling

one’s own potentials in life; and (3) tragic guilt in the sense of being the cause of an

evil which was neither consciously nor deliberately intended. All three categories

may be found in normal psychology as well as in depressive guilt. There is always

an interpersonal dimension to guilt, which occurs in a context of shared values and

of real or imaginary accusatory others (Brooke 1985). Pathological guilt is “inappropriate”: it is typically related to trifling faults in the past possessing exceptional

subjective weight (“petites fautes,” Tellenbach 1980, p. 180ff). Ratcliffe (2010) considers depressive guilt to involve a focus on past deeds whose effects are unchangeable, estrangement from others, in whose eyes one has done wrong, and anticipation

of being harmed or punished. Sometimes the patient does not feel guilty about anything particular, but about everything, as a guilty rumination. Guilt in melancholia

is “primary” (Tellenbach 1980, p. 177), an already premelancholic guilt of remaining in default to oneself. Guilt phenomena occur in other diagnostic areas than

depression. The schizophrenic patient may express an ontological essence of guilt,

e.g., feeling that his breathing is responsible for the famine in the Third World, dissimilar to the depressive guilt embedded in a personal statement without any

recourse to such a general concept of guilt (Bovet and Parnas 1993). Straus (2012)

expounds the obsessive-compulsive patient’s feelings of guilt more like “a sense of

horror about his being evil than about any particular evil deed. He is crushed by his

universal feeling of guilt before he has ever begun to act” (p. 232).

Self-reproach is not defined in DSM-5 either. We meet, in clinical practice, any

kind of self-criticism characterized as self-reproach, supposed to indicate depression. Pathological self-reproach is a self-punishment for having or not having done

something, bound up with the experience of moral responsibility, reciprocally

related to psychological responsibility (Shapiro 2006). Moral responsibility is

uncompromising, ignorant of reasons or psychology, whereas psychological responsibility is related to agency. The melancholic self-reproach (or even self-accusation),

related to guilt, is mostly relational, blaming oneself for hurting others. Depressive



174



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Varieties of Depressive-Like Mental States



self-reproach also differs from morbid regrets found in the schizophrenia spectrum

as a reflection of diminished sense of basic self (Minkowski 2002, p. 226ff; Parnas

et al. 2005). This latter may be related to the second meaning of guilt, but not necessarily as a relational phenomenon: a woman with schizophrenia complained in a

long letter titled, “All my self-reproaches”: “I can’t do anything, I am too old-fashioned, I sing wrong…”. Self-reproach should also be distinguished from regret in

personality disorder, e.g., facing the consequences of impulsive behavior, and in

paradepression (see below). Here, there will often be a touch of rationalization and

self-pity. True depressive self-reproach is consistent, i.e., not attended by self-pity

or blaming others. Obsessions (or pseudo-obsessions) with depressive themes of

harming others or going beyond the bounds are frequent in severe depressions (se

Sect. 10.4).

The Hamilton depression scale was devised for use only in patients already diagnosed as suffering from depression (Hamilton 1960). The scale is said to measure

the degree of depression but is not designed to make the diagnosis. In effect, the

scale covers more or less the same items as the diagnostic criteria of major depressive episode (DSM-5), which serves to show that the diagnosis can hardly be made

exclusively by these criteria either. The major difference between Hamilton and

DSM-5 is the depressive mood only appearing as a DSM-criterion. In any case, the

diagnosis of depression cannot be made validly from nonspecific criteria without a

prototypical recognition of depression.

Anxiety and agony, prominent features of depression, are absent from the diagnostic criteria and therefore lead to comorbid anxiety diagnoses in DSM-5 (not so

in ICD-10 due to the (implicit) diagnostic principle of hierarchy taking effect in

case of simultaneousness). The reason for the omission of these features from operational criteria is the intention to avoid criterial redundancy. Thus, anxiety has been

relegated to the anxiety diagnoses.



9.2



The Different Meanings of Depression



The contemporary usage of the term, depression, covers a whole array of clinical

states whose common denominator is some kind of distress, and statements like “I

feel depressed” may refer to an infinite range of distressing psychopathological phenomena (Parnas 2012). Neither DSM nor ICD distinguish between different qualities of (major) depression, and although they do mention various depressive

categories, such as organic depression, post-psychotic or post-schizophrenic depressions, they do not elaborate their qualitative differences. Even melancholia, seen by

many researchers as a specific nosological unit, is relegated to a specifier—the melancholic features specifier in DSM-5 and the somatic syndrome in ICD-10.

Maj considers different approaches to the question, “When does depression

become a mental disorder?” (2012). The first approach concerns the exclusion of

sadness proportional to a real loss. The difficulty here is, among other things, the

fact that most depressive patients report stressful life events previous to the onset of

depression and the fact that depression itself may cause such events (e.g., loss of



9.2



The Different Meanings of Depression



175



job). The second approach concerns the qualitative difference between true depression (at least the melancholic type) and sadness, which has been lost due to oversimplification of psychopathology. The third approach pertains to the boundary between

normality and depression. A pragmatic approach to this is the application of diagnostic thresholds (of duration, severity, etc.). However, Maj demonstrates that the

thresholds of DSM-IV major depression are arbitrary and lacking in empirical

support.

Schneider (1959, p. 116) distinguishes between (at least) four different modes of

depression with differing moods: (1) a reactive (motivated) mood, aroused by something external; (2) an irritable or gloomy mood, reactive on the background

(Hintergrund) of psychic tension or physical discomfort, such as migraine, menstruation, and toxic effects; (3) a depression of the psychic ground (Untergrunddepression),

the commonly experienced spontaneous onset of depressive feelings; and (4) the

vital cyclothymic [bipolar] depression, filling “the total canvas.” The notion of psychic ground (Untergrund) means the non-experienced basis of all mental processes.

Weitbrecht enlarges on Schneider’s “Untergrunddepression” (Weitbrecht 1973,

pp. 432–434): it is a mild causeless, i.e., spontaneously arising, depressive-like state

in normal or disordered personality, often of short duration, comparable with experience of “getting out of bed to the wrong side” or the state of premenstrual dysphoric

disorder. In contrast to what is seen in bipolar depression, the patient will try to

counteract this state with the aid of amusement or substance abuse. To these depressive modes by Schneider, Weitbrecht adds the endo-reactive dysthymia (p. 434ff),

supposed to be depression neither belonging to the abnormal reactions nor the endogenous (bipolar) depressions. Compared with the reactive states, these are more severe

and bodily related, e.g., with a hypochondriac tint. The phases of illness do not have

the causeless endogenous character of bipolar disorder, and mania is not seen. The

existence of such a subgroup of depression is, however, controversial.

In the following, the depressive states will be divided into three groups: nuclear

depression (melancholic, bipolar, and “endogenous” depression characterized by a

depressive mood and vegetative somatic symptoms—corresponding to Schneider’s

fourth mode), paradepression (a number of reactive and situational states with bad

temper and gloom, similar to Schneider’s first mode), and pseudo-depression

(depressive-like states in somatic or psychotic disorder).



9.2.1



Nuclear Depression



Until the early nineteenth century, melancholia was a “rag-bag of insanity states”

with few delusions (Berrios 1995, p. 385). The modern concept took shape in the

last decades of the century, and melancholia became related to the manic-depressive

insanity. The twentieth century melancholia prototype is a clinical state comprising

psychomotor retardation or agitation, late insomnia and early morning worsening

(related to the disruption of circadian rhythms), and ideas of guilt.

Phenomenological psychiatry has identified disturbances of the time structure to

be the generative disorder of melancholia. Time has several different meanings.



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