Grief in disguise: masked or disguised depression

Living example

To make it clearer what we are talking about, I will immediately present a life picture. A typical case from my own practice. For several years, the patient, a young woman, complained to doctors of various specialties in our clinic. To the gastroenterologist she complained of pain in the pit of the stomach, heartburn, and abdominal cramps. An objective examination—FGS, X-ray, ultrasound—could not identify the disease. After this, as if by magic, the digestive problems disappeared, giving way to cardiological complaints. The patient visited a cardiologist, reporting pain in the left side of the chest, palpitations and surges in blood pressure. Since the ECG and ultrasound of the heart also showed normal results, the doctor began to doubt the origin of the complaints. Cardiologists and therapists are well aware of exactly where pain in angina pectoris is usually localized and what symptoms it is accompanied by. The cardiologist suggested that the lady visit a psychiatrist, but she indignantly refused. Heart problems (apparently from “righteous” anger) disappeared, and the patient attacked the gynecologists. Another leisurely process of examination and treatment began, and (surprise, surprise!) - just as unsuccessful as the previous ones. And then a urologist, an endocrinologist, a neurologist fell victim to a “complicated” patient... And the “moment of truth” came when each of them uttered the mantra: “Girl, you should see a psychiatrist!..”

Masked depression (or larvated, somatized depression - from the Latin larva, that is, “larva”, “embryo”) is a type of depressive state in which low mood is masked by somatic and vegetative symptoms predominant in the clinical picture, as well as psychopathological signs of another, not of a depressive nature (obsessiveness, drug addiction attacks). In this case, the actual affective depressive symptoms are relegated to the background, which creates serious difficulties in diagnosing larval depression.

Bleikher V. M., Kruk I. V. Explanatory dictionary of psychiatric terms. Voronezh: NPO "MODEK", 1995

And so the patient appeared in my office to bring down the accumulated health complaints on my head, and at the same time on the careless physicians, helpless in the face of the sufferer’s ailments. Her anger was righteous, and her determination to restore her reputation was great... Well, in the end, a banal thing turned out to be true. The patient's husband drank. And he cheated. He ignored his wife in every possible way. And at work there was no career growth, but only a picky boss and “thieves” colleagues. It became obvious that the castles in the air built in youth were dissolving into thin air, while youth was being eaten up by work, everyday life and empty hassle. And my mood began to decline... Anxiety, tension, insomnia, fatigue, and irritability appeared. And then the pain came...

The patient was helped. A month later she confidently began to recover. But the most difficult thing in such a situation is not eliminating the manifestations of the disease, but fighting their causes, the fundamental principle that launched the process of the disease. And doctors, as a rule, are unable to help with this. A person must determine his own life priorities and change taking into account the circumstances of his destiny.

From 1/3 to 2/3 of all patients seen by general practitioners, as well as by specialists, suffer from depression, masked hypochondriacal symptoms or complaints of physical malaise. For these disorders, women are 2–3 times more likely than men to seek help from a primary care physician.

(Smulevich A.V., Syrkin A.L., Rapoport S.I. et al. Organ neuroses as a psychosomatic problem // Journal of neurology and psychiatry. 2000. No. 12. P. 4–12).

In a situation of larval depression, classic symptoms and depressive manifestations (low emotional background, apathy, withdrawal from contacts with the outside world) may be insignificant or even completely absent. Although this is a controversial issue, in some cases associated with the doctor’s insufficient attention to the patient’s complaints or behavior. The patient is often unaware of the depressive disorder. He may be convinced that he has some rare and difficult to diagnose disease of the internal organs, or he draws the attention of his and the doctors to some neurotic symptoms, biological rhythm disorders, insomnia. In my practice, for example, the bulk of such patients are delivered by colleagues - cardiologists and gastroenterologists, and the neurologist and therapists are not far behind. A simple fact is obvious: the more experienced and qualified the internist, the more often he suspects that fate has brought him together with a psychiatrist’s client. And, as experience shows, attentive doctors rarely make mistakes!

Hidden depression

Hidden depression (dull, erased, latent, depression without depression, somatized, pseudopsychosomatic form of atypical mental depression, missed, foggy, etc.) is a special variant of the depressive state, expressed by the predominance in the clinical picture of “somatic equivalents” of depressed mood in the form of functional organ disorders and the autonomic system, while the actual affective disorders, hidden by somatic symptoms, remain in the background and can only be identified with appropriate research. D.D. Pletnev described similar conditions in 1927 under the name of somatic cyclothymia, and E.I. Krasnushkin in 1947 - cyclosomia.

Among somatized mental disorders, senestopathic phenomena occupy a prominent place - various pains, paresthesias, burning sensations localized in various parts of the body. Autonomic disorders play an equally important role: dizziness, tachycardia, palpitations, dry oral mucosa, anorexia, biliary dyskinesia, constipation, weight loss, bladder hyperesthesia, hyperhidrosis, etc. Along with this, hypochondriacal readiness, fears, obsessions, and others are observed. neurosis-like disorders - “mental equivalents of depression”, a tendency to abuse alcohol and drugs - “toxicomanic equivalent of depression”, sleep disorders, decreased activity, sexual disorders and other disorders of the vital functions of the body. V.F. Desyatnikov (1978) distinguishes the following subsyndromes of latent depression: drug addiction, obsessive-phobic, agripnic (with persistent insomnia), hypothalamic (vegetovisceral, vasomotor-allergic, pseudoasthmatic), as well as algic-senestopatic with a number of variants of the latter - abdominal, cardialgic, cephalgic, panalgic. The above classification does not reflect the full variety of manifestations of latent depression. In particular, sexual disorders and the phenomenon of hypersomnia, which sometimes occur in the clinical structure of depression, are not taken into account; anorexia, as well as rare, but possible with depression, bulimia; persistent constipation, amenorrhea, etc. In addition, there is no clear distinction between somatized and atypical forms of depression.

Patients with latent depression are mostly observed by internists, mainly therapists and neurologists. However, their appearance among “narrow” specialists is not uncommon. Thus, one of the patients we observed repeatedly turned to the ophthalmologist with complaints about the disappearance of tears. Of the diagnoses established for such patients by somatic doctors, “osteochondrosis”, “neuropathy”, “vegetodystonia”, “neurosis”, “neurodermatitis”, “bronchial asthma, asthmatoid bronchitis”, “rheumatic arthritis”, “gastritis” especially often appear. Sometimes faking the disease is suspected.

Crucial for the diagnosis of latent depression is the identification of actual affective disorders. They boil down to a mildly expressed decrease in mood with a predominance of joylessness (unlust-type mood), anhedonia, loss of pleasure from life, pessimism, and a feeling of hopelessness. Anxiety, irritability, tearfulness, symptoms of painful mental anesthesia, increased impressionability, vulnerability, and excessive suspiciousness are also observed. A special attitude towards the disease is formed, and there is an increased lability of the manifestations of the disease under the influence of psychogenic influences. More than half of the patients have suicidal thoughts and attempts, much less often - the desire to use the secondary benefit of disorders.

As a rule, complaints are made about deterioration of attention, memory, dulling of mental activity (absent-mindedness, lack of concentration, inability to carry on a conversation, think well and freely express thoughts, etc.). Reproductive memory decreases - patients note that they cannot remember information well known to them at the right time.

They also note a weakening of motivations, loss of interests in various areas of life and activity, impoverishment of emotional life, and for the most part consider this as signs of illness. Symptoms of depersonalization and derealization, individual deceptions of perception, in particular hallucinoids, may occur.

In general, recognition of hidden depression is based on the following signs:

• the onset of the disease is often not associated with the influence of psychogenic, somatogenic and exogenous-organic factors;
• phase flow. In the anamnesis, one can find indications of the recurrence of periods of malaise, weakness, nervousness, low mood, severe sleep disturbances and other disorders characteristic of this type of depression. The duration of the phases is months and years. Episodes of mild hypomania may occur;
• hereditary burden of affective psychoses. The symptoms of the proband's disease may have significant similarities with painful disorders observed in close relatives;
• a vital shade of low mood (“heaviness in the soul, the heart aches, aches, squeezes...”) with persistent sleep disturbances, anorexia, decreased libido, a feeling of loss of strength;
• daily fluctuations in mood and well-being (worsening in the morning, in the first half of the day, with spontaneous improvement in the afternoon, towards night - “evening intervals”);
• the presence in the mental state of indications of the phenomena of ideational and psychomotor inhibition, reproductive memory disorders, symptoms of painful mental anesthesia, depersonalization, derealization;
• presence of suicidal readiness;
• general somatic and autonomic disorders in latent depression do not fit into the clinical picture of any specific somatic disease. Nevertheless, there are forms of hidden depression that show significant similarities with the manifestations of somatic diseases. The term “masked depression (larvated, masked depression)” is adequate specifically for these forms.

Their genesis remains unclear; at least three mechanisms can be considered as a hypothesis:

1. latent depression reveals subclinical somatic and neurological pathology , that is, it serves as the cause of its decompensation, manifestation;
2. hidden depression is combined with real somatic syndromes (bronchial asthma, neurodermatitis, allergic phenomena, joint diseases), pathogenetically associated with a depressive state. Effective treatment of depression can result in the complete elimination of psychosomatic syndromes and compensation of overt and subclinical somatic pathology. In both cases, we are talking about complex etiopathogenetic dependencies and the need to maintain broad approaches in the interpretation of real pathology;
3. hidden depression imitates somatic disorders due to the uniqueness of the internal picture of the disease . Patients who have been ill for a long time, reflecting on their well-being and reading specialized literature, sooner or later find analogies of their own condition with some physical disease. Subsequently, they distort their complaints in accordance with their accepted model of the disease and thereby establish similarities with it. In this case, we should obviously talk not about hidden depression, but about hypochondriacal depression. Therapy with antidepressants can improve the condition of patients, especially in that part where it does not affect hypochondriacal interpretations and those disorders that approach conversion (with hysterical depression), that is, arising from painful expectations; positive reaction to antidepressants (diagnosis ex juvantibus).

In order to identify hidden depression in patients who present only somatic complaints, Kilchholtz offers internists a short questionnaire. Most affirmative answers suggest depression. These questions may also be useful for a psychiatrist starting to practice:

1. Do you enjoy life as much as before?
2. Is it difficult for you to make decisions?
3. Has your range of interests narrowed recently?
4. Have you started thinking more about unpleasant things lately?
5. Don't you think now that life has become meaningless and useless?
6. Do you feel more tired and/or less energetic than usual?
7. Has your night sleep been disturbed?
8. Have you lost your appetite or lost weight?
9. Do you feel pain in your body or heaviness in your chest?
10. Is your intimate life upset?

Latent depression is an affective syndrome observed in the clinic of circular psychosis, periodically and in continuous forms of schizophrenia. The question of whether it can occur in psychogenic and exogenous-organic diseases has not been completely resolved.

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Why are “saboteurs” dangerous?

In these states, the manifestations of depression are hidden behind a “façade” of various somatovegetative symptoms, so the doctor initially gets the impression that there is a somatic disease. Patients turn not to a psychiatrist, but to other specialists, are examined for a long time without success and treated in hospitals, where sometimes even serious interventions are undertaken. At the same time, doctors do not always pay attention to the low mood of patients, their statements about the severity of their physical condition and the failure of therapy, and in some cases about their reluctance to live. These complaints are often associated with the severity of the underlying disease. At the same time, the danger of suicide in masked depression, as in classic depression, is great.

Such patients are reluctant to go to psychiatrists even when there is a suspicion of a mental disorder. The period of treatment by various specialists can stretch for a long time, sometimes reaching 5–8 years, and the severity of depression usually increases. Suicidal attempts in general somatic hospitals are not uncommon, and a study of the medical histories of such suicides shows the presence of unrecognized, delayed depression. Medical staff and internists are often not prepared for such a turn of events, unlike psychiatric workers who are “always on guard.”

In some cases, psychiatrists cannot exclude the presence of a somatic illness, or they associate a depressed mood with the difficulty of diagnosing and treating a supposed “internal” illness.

Causes

According to statistics, signs of latent depressive syndrome appear more often in women. Sometimes mental deviation is complicated by real diseases of any body system.

The causes of masked depression include:

• disruption of hormonal levels due to endocrine diseases (diabetes mellitus, hypothyroidism);
• nervous overstrain that has become chronic;
• long-term use of medications (analgesics, tranquilizers, glycosides, hormonal drugs);
• pregnancy, menopause, puberty in adolescence;
• development of malignant tumors;
• disruptions in the functioning of the immune system after infectious diseases;
• severe stress (occurs in difficult life situations).

Masked depression is caused by the body’s inability to fully resist health-threatening factors. This is caused by lack of sleep, lack of useful microelements and vitamins in food, and chronic fatigue.

Reconnaissance in force

Patients with masked depression are encountered in the practice of doctors of many specialties. Pediatricians may be contacted with complaints of headaches and abdominal pain. At the same time, children sometimes complain of feeling tired, poor sleep, loss of the ability to enjoy life, deterioration in academic performance, and difficulties in making decisions (if we are talking about older children). A diagnosis of a somatic disease that could explain such complaints is usually not possible to make.

Neurologists and neurosurgeons see patients suffering from headaches, which sometimes raise suspicion of a brain tumor, as well as complaints of pain in the face, spine, and limbs.

Patients turn to therapists with complaints of cardiac dysfunction with the appearance of pain, increased or rapid heartbeat, and feelings of tightness in the chest, and they may experience changes in the ECG that disappear after treatment with antidepressants. In the practice of therapists, “masks” may occur in the form of attacks of bronchial asthma, colitis, gastritis, and peptic ulcers.

Patients turn to surgeons with complaints of pain and discomfort in the abdominal cavity. In some cases, the picture of an “acute abdomen” is almost completely imitated, which can lead to unjustified surgical interventions.

Patients come to gynecologists with various kinds of dysmenorrhea and pain in the appendage area, and to dermatologists with eczema and dermatoses.

Patients with larvic depression, whom otorhinolaryngologists meet, complain of pain in the ears or sensations of “stuffing”, difficulty swallowing, hoarseness or sensations of a “lump in the throat”, vague pain in the mouth and pharynx.

Patients with a feeling of blurred vision and the appearance of blepharospasm are referred to ophthalmologists. Dentists see patients with larvic depression, suffering from neuralgic pain, which can lead to tooth extraction, after which the pain does not disappear.

Psychiatrists should suspect larval depression from all types of drug addictions, periodically occurring neurotic disorders, and various types of behavioral disorders in childhood and adolescence.

Physical pain and health disorders

Depression is a mental health condition, but it can also have physical consequences. In addition to weight changes and fatigue, other physical symptoms of hidden depression to watch for include:

• backache
• chronic pain conditions
• digestive problems
• headache

Research also shows that people with severe depression are more likely to develop these conditions:

• arthritis
• autoimmune diseases
• cancer
• heart diseases
• type 2 diabetes

How to recognize the enemy?

I must immediately make a reservation that there are no clear criteria for diagnosing masked depression. It helps to establish a diagnosis that somatovegetative symptoms usually do not fit completely within the framework of the disease that they mimic, and doctors of non-psychiatric specialties, as a rule, notice this, and also pay attention to the failure of treatment of the suspected somatic disease.

The most difficult thing to detect is the actual disturbed mood. The doctor must be able to identify the various signs of depression present in the clinic of such an illness.

They suggest the idea of ​​masked depression - the frequency of appearance of somatovegetative and mental disorders, the presence of a history of unclear somatic disorders, erased, classic depressive or manic phases, the suddenness of the onset and disappearance of attacks of the disease, the seasonal occurrence of attacks of the disease - mainly in the autumn-spring period, which is typical and other classic types of depression. Data on the lack of effect from somatic therapy and a positive reaction to treatment with antidepressants can be of great help in diagnosis.

Less optimistic than others

Research shows that people with depression may have pessimistic tendencies. There is a theory that people with depression may exhibit a trait called "depressive realism", which means they may be "more accurate" in their view of events and control over those events than people without depression. People with depression may also be more pessimistic. Research shows that people with major depressive disorder often have a negative outlook on the future. Being more realistic or pessimistic than others can be a sign of depression, especially if a person has other possible symptoms of depression.

Masked depression: symptoms, prognosis and treatment

Typically a protracted course with slight fluctuations in low mood within one attack. Often there is a gradual deepening of the depressive state with the appearance of feelings of melancholy and anxiety, despair, suicidal thoughts and attempts. As the severity of depression increases, in some cases it is “cleansed” from the somatovegetative “façade”, but more typical is the simultaneous increase in somatovegetative and emotional manifestations.

Typically, patients begin to be treated on an outpatient basis, using various combinations of antidepressants with antipsychotics, and in some cases with tranquilizers. Doses and methods of their administration differ depending on the characteristics of specific cases. Given the propensity of masked depression to be protracted, measures must be taken to overcome emerging resistance to therapy. If the depth of depression increases or suicidal thoughts appear, patients should be immediately sent to a hospital.

The introduction of a full-time psychiatrist position in non-psychiatric hospitals and clinics will provide adequate treatment for a larger number of patients with latent depression and will lead to a reduction in the risk of suicide in these conditions. And, of course, it is necessary to include issues of clinical psychiatry (including clinical depression clinics) in the advanced training course for internists.

Treatment

The main therapy for masked depression is drug treatment with antidepressants, tranquilizers (short-term) and sedatives.

Among antidepressants, the first choice drugs are the group of serotonin and norepinephrine reuptake inhibitors (for example: Venlafaxine, Duloxetine). In case of intense anxiety, tranquilizers are prescribed - benzodiazepine derivatives (for example: Phenazepam). For severe sleep disorders, modern classes of drugs are used: cyclopyrrolone derivatives (for example: Zopiclone). If the patient has predominant mental and motor retardation, antidepressants that have a stimulating effect on the central nervous system and contain imipramine are used.

Therapy for masked depression shows good therapeutic results in a relatively short period of time. Often the symptoms of the disease completely disappear after a month after starting treatment. However, it is recommended to continue drug treatment for at least 3-6 months.

Psychotherapy sessions are aimed at identifying the psychological causes of the disease, developing correct self-esteem and motivation, and teaching relaxation and self-control skills.