Psychosis, in its broadest definition, refers to any major derangement in mental function in which the individual’s ability to perceive and interact with the environment is impaired. Hallucinations are a frequent accompaniment but do not alone define this category of illness. From a neurologic perspective, there are four major categories of psychosis: (1) confusional-delirious states, (2) psychoses associated with focal or multifocal cerebral lesions, (3) affective disorders (bipolar and depressive psychoses), and (4) schizophrenia. The first two categories are discussed in Chaps. 20 and 22. The latter two are the subject of this and the following chapter.

Depression is perhaps the cause of more grief and misery than any other single disease to which humankind is subject. This view, expressed by Kline more than 40 years ago, is still shared by everyone in the field of mental health. The several forms of depression taken together are the most frequent of all psychiatric illnesses. In a general hospital, as indicated in the previous chapter, depression accounted for an estimated 50 percent of psychiatric consultations and 12 percent of all admissions. Although depression has been known for more than 2,000 years (melancholia is described in the writings of Hippocrates), there is still uncertainty as to its medical status as a disease state (kraepelinian concept) or as a type of psychologic reaction (meyerian concept). In other words, is it basically a biologic derangement or a response to psychosocial stress? An eclectic position is that both are correct—i.e., that there are two basic forms of depression: exogenous (an apparent cause) and endogenous (with no overt external cause), and that there may be both an interplay between them and biologic susceptibility to either one.

In respect to endogenous depression and the related condition of bipolar disease, genetic and neurochemical data cited further on support the kraepelinian view of a disease state. Nonetheless, a lay concept persists, perpetuated perhaps by some process-oriented psychiatrists, that events in one’s life, either distant or current, underlie all types of depressive illnesses. An unfortunate consequence of this view is the assumption that an inability to deal with these stresses represents a personal failure of sorts and this in turn may inhibit the acceptance of psychiatric help.

Of considerable consequence for clinical work, depressive states are often associated with obscure physical symptoms. For this reason they are likely to come first to the attention of general physicians than are other psychiatric entities. All fields of medical specialty, however, have depressive equivalents; the physical symptoms frequently are mistakenly attributed to anemia, low or high blood pressure, hypothyroidism, migraine, tension headaches, chronic pain syndrome, or chronic infection, or are casually attributed to emotional problems, worry, and stress. Neurologists are most likely to encounter depressed patients who complain of fatigue and weakness, chronic headache, and difficulty in thinking or remembering. Depression masquerading as a chronic pain or a fatigue state or some other medical condition had been called masked depression or depressive equivalent, terms we still find appropriate and useful in explaining certain symptoms to patients.

There are numerous reasons for separating the problem of endogenous depression from bipolar disease but the distinction clinically may be difficult because bipolar disease may be dominated by depressions, with manic or hypomanic episodes appearing as only a minor or background problem. Foremost among the reasons to consider them separately, however, are differences in response to treatment. In keeping with modern notions, endogenous depression and bipolar disorder are presented separately in this chapter but an understanding of either one is incomplete without knowledge of the other.

Another important reason why all physicians should be knowledgeable about depressive illness in all its forms is the danger of suicide, which may be attempted and successfully accomplished before the depression is recognized. Timely diagnosis may prevent such a tragedy—one that is all the more regrettable as most depressive illnesses can be successfully treated.

As remarked in Chap. 24, the term depression embraces more than a feeling of sadness and unhappiness. It stands for a complex of disturbed feelings (called mood, or affective, disorder)—which may include aspects of despair, hopelessness, sense of worthlessness, and thoughts of self-harm—associated with decreased energy and libido, loss of interest in personal affairs, impaired concentration, various abnormalities of behavior and appearance, and prominent physical complaints—the most important of which may include anxiety, insomnia, anorexia or overeating, headache, and various types of regional pain. At one extreme are depressive symptoms of psychotic proportions including paranoid or somatic delusions, which create chaos in the lives of the patient and those close to him. At the other extreme are the common feelings of unhappiness, anhedonia (loss of pleasurable responses), discouragement, and resentment that may occur in almost everyone as a reaction to the disappointments of everyday life such as loss of employment, failure to gain recognition, or unsuccessful sexual or social adjustment.

The place in this nosology of the special case of postpartum depression has not been clear, and it is discussed in this chapter as well in the in the next one, as it is sometimes difficult to differentiate it from postpartum psychosis, a more dramatic and well-defined disorder discussed in the next chapter. Some modern authors question the existence of a primary biologic depression that is tied to the postpartum period (see summary by Brockington) but this diverges markedly from the general experience, in which varying degrees of depression are quite common in the weeks after delivery and cannot simply be attributed to psychosocial factors or sleep deprivation.

As a purely phenomenological observation, an abnormally elevated mood, or mania, is about one-third as frequent as depression. It may develop as a relatively pure, recurrent clinical state, or more often may alternate or be intertwined with depression, in which case it was referred to as manic-depressive disease (now, bipolar disorder in the classification of the Diagnostic and Statistical Manual of Mental Disorders. Hypomania and cyclothymic disorder are the names given to milder forms of mania and bipolar disorder, respectively. The DSM classifications also acknowledge the existence of a mixed schizoaffective state in which attributes of depression and schizophrenia are combined. Distinguishing these various types of depressive illnesses is of therapeutic as well as theoretical importance insofar as a particular type may respond better to one form of treatment than to another. Finally, the neurologist should always bear in mind the possibility of an incipient dementia presenting as a depression, although the reverse, a masked depression causing difficulty with thinking and memory (pseudodementia) is more common.

Reactive Depressions and Depressions with Medical and Neurologic Diseases

Patients reacting to a medical or neurologic illness seldom express feelings of sadness or despair without mentioning physical accompaniments such as easy fatigability, anxiety, headaches, dizziness, loss of appetite, reduced interest in life and love, trouble in falling asleep, or premature awakening. It follows that whenever these symptoms become manifest in the course of medical disease, they should arouse suspicion of a depressive reaction (Table 52-1).

Chronic pain is a particularly frequent somatic manifestation of depression. The pain may be based on an attendant disease but is prolonged, disabling, sometimes vague in nature, and recalcitrant to straightforward medical and surgical approaches. Furthermore, depressed mood exacerbates and prolongs pain of any type. All patients with chronic pain syndromes should be evaluated psychiatrically, as pointed out in Chap. 8.

In a number of major medical illnesses depressive symptoms occur with such frequency as to become almost part of the disease. Contrariwise, in certain chronic and occult diseases, symptoms such as lassitude and fatigue may resemble and be mistaken for a depressive reaction. Hypothyroidism, infectious mononucleosis, hepatitis, lymphoma, myeloma, metastatic carcinoma, malnutrition, polymyalgia rheumatica, and frontal lobe tumors, especially meningiomas, may simulate depression for weeks or months before the diagnosis becomes evident. A special relationship to occult pancreatic or other abdominal cancers has been suggested but is difficult to understand. Sedative drugs, beta-adrenergic blocking agents, beta-interferons used for the treatment of multiple sclerosis and hepatitis, and the phenothiazines may also evoke a depressive reaction; corticosteroids can induce a peculiar psychiatric state in which confusion, insomnia, and either an elevation of mood or depression are combined, even to the point of psychoses. A depressed mood may also emerge during the tapering-off period of corticosteroid medication or during their initial use (a hypomanic state is more common).

Of particular significance is the reactive depression that occurs on learning of a serious medical or neurologic disease. Often such an emotional reaction, which the physician may tend to ignore, is the dominant manifestation of a disease that threatens the life pattern and independence of the patient. Recognition by the patient that he has suffered a stroke or that he has cancer, multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson disease, is almost always followed by some degree of reactive depression, often with an element of anxiety. A prime example is the depression that follows myocardial infarction (Wishnie et al). Usually it begins toward the end of the patient’s stay in the hospital and attracts little attention. Once the patient is home, fatigability that approaches exhaustion is the main complaint and interferes with accustomed activities and rehabilitation. It may be described as weakness and falsely attributed to heart failure. Symptoms of irritability, anxiety, and despondency are next in order of frequency, followed by insomnia and feelings of aimlessness and boredom. Although most of these patients ultimately recover without medical assistance the depression exacts a high toll in terms of mental suffering.

Depression Following Stroke and with Degenerative Neurologic Disease

An analogous depressive reaction occurs in some patients after a stroke. Some studies have indicated that patients with left anterior cerebral lesions, involving predominantly the lateral frontal cortex or basal ganglia, have a greater frequency and severity of depression than do patients with lesions in other locations (Starkstein et al, 1987; Robinson). According to these authors, lesions of the right hemisphere do not show this correlation with depression but have a higher association with pathologic cheerfulness or mania. However, House and colleagues, in a British community-based study of stroke survivors, failed to confirm these findings, perhaps because the infarcts were small in size (more than half the patients had never been admitted to hospital) and many patients were examined for the first time only at 6 and 12 months after their strokes. Our colleagues Levine and Finkelstein have reported the occurrence of psychotic depression with hallucinations and delusions in patients with right temporoparietal infarcts. Our own experience suggests an unsurprising relationship between the degree of motor and language disability and the severity of poststroke depression, but a less predictable relationship to the location of the lesion. The possible predisposing effects of minor previous episodes of depression, family history of depressive illness, and medications have not been studied systematically. These issues are also incorporated into Chap. 34.

With regard to emotional reactions in degenerative brain diseases, Parkinson disease is complicated by a depressive reaction in approximately one-quarter of cases. Weakness and fatigability, already aspects of the motor syndrome, are added to the principal psychologic manifestations and the resulting therapeutic problem becomes formidable. Another hazard in Parkinson and in Lewy-body disease is the tendency for L-dopa itself to provoke a depression in a limited number of patients, sometimes with suicidal tendencies, paranoid ideation, and psychotic episodes. Huntington chorea is quite often associated with depression, even before the movement disorder and dementia become conspicuous. In one series, 10 of 101 patients with Huntington disease either committed suicide or attempted it, and this outcome is commented on in almost all large series of that disease. Alzheimer disease may be accompanied by depressive symptoms, in which instance it is difficult or impossible early in the illness to evaluate the relative contributions of the mood disorder and the dementia. In later stages, the overt signs of depression usually abate.

Depression during and after Pregnancy

The main risk for depression during pregnancy is a history of previous depressions. Certain epidemiologic factors also come into play including a family history of depression, single motherhood, cigarette smoking, low income, youth, and domestic violence. The implications, however, of depression during pregnancy are great in that the fetus is at risk of suffering due to inadequate prenatal care and an increased rate of miscarriage. Several pieces of controversial evidence suggested that maternal depression may affect fetal growth and infant temperament. Furthermore, postpartum depression is also more common in women with prenatal depression and may lead to similar difficulties with infant care.

The treatment of depression during pregnancy has attracted considerable attention because of the potential risks to the fetus of the modern class of serotonin reuptake inhibitors. This is discussed in a later section. The clinical aspects of depression during pregnancy have been summarized by Stewart.

Clinical Presentation

Fully developed endogenous depression may evolve within a few days, or, more often, it emerges more gradually, on a background of vague prodromal symptoms that had been present for months. Chapter 24 provides a detailed description of the symptoms and signs of depression. Here it need only be repeated that the patient, when asked, or spontaneously expresses feelings of sadness, unhappiness, discouragement, hopelessness, and despondency, with loss of self-esteem. Reduced energy and activity, typically expressed as mental and physical exhaustion, is almost always present, to the point of catatonia in the most severe cases. Indeed, as emphasized in Chap. 24, the most common cause of symptoms relating to reduced psychic and physical energy and drive (conation) is depression. There is heightened irritability, usually reported by a spouse or friends, as well as a lack of interest in most activities that formerly were pleasurable.

According to DSM, the essential diagnostic criteria of endogenous depression (“major depressive syndrome”) consist of a dysphoric mood or loss of interest or pleasure in all usual activities (including sexual activity) in combination with at least four of the following seven symptoms: (1) disturbance of appetite and change in weight; (2) sleep disorder; (3) psychomotor retardation or agitation; (4) decreased energy and fatigue; (5) self-reproach, feelings of worthlessness or guilt; (6) indecisiveness, complaints of memory loss and difficulty in concentrating; and (7) thoughts of death or suicide or actual suicide attempts. In this diagnostic scheme, each of the four diagnostic symptoms should have been present for at least 2 weeks. This is a useful listing but simply recapitulates the well-described emotional, conative, and physical aspects of endogenous depression. The formalized diagnostic criteria have been devised for both screening and diagnosis of major depression (Table 52-2). These codify the clinical features discussed in previous paragraphs but separate major depression from bipolar disorder by requiring the absence of elements that suggest a manic or hypomanic episode and further exclude depression that is plausibly connected to personal distress or grieving due to a loss, or the effects of a drug or toxic substance.

The depressed patient tends to move slowly, sighing is frequent, and speech is reduced. The mental life of such an individual may narrow to a single-minded concern about physical or mental health. In dialogue, the patient’s responses become so stereotyped that the listener can soon predict exactly what is going to be said. There is a poverty of ideation and sometimes a notable absence of insight. Consciousness is clear, and although there is no evidence of a schizophrenic type of thought disorder, delusional ideas, and less often hallucinations, may be prominent in some patients, justifying the term depressive psychosis. The delusions are generally congruent with the patient’s mood and are not as fixed or bizarre as those of schizophrenia or paranoia. In our experience, delusions are more common in older patients and tend to appear only after weeks or months of more typical symptoms of depression. Hallucinations, when they occur, are usually transitory, vocal, and vaguely accusatory; their presence should always raise the possibility of an associated structural brain disease, drug intoxication, or alcoholic auditory hallucinosis.

Frequently, agitation or irritability rather than physical inactivity and mental slowness are the principal behavioral abnormalities. The source of the agitation appears usually to be an underlying anxiety state. Pacing the floor and wringing the hands, particularly in the early morning hours, are characteristic. Such patients tend to be overly talkative and vexed in their manner of expression, irritable, short-tempered, impatient, and intolerant of minor problems—changes noted mainly by family members. Attempts at reassurance may meet with initial success, only to be dispelled in the next rush of doubts. These patients remain impervious to reason and logic with respect to their symptoms, even though they are reasonable and logical in other areas of their lives. At its worst, the illness takes the form of a depressive stupor; the patient becomes mute, indifferent to nutritional needs, and neglectful even of bowel and bladder functions (anergic depression). The condition in this extreme form is a catatonic depression. Such patients must be fed and their other needs attended to until therapy (usually electroconvulsive therapy [ECT]) brings about improvement.

The most important concern in patients with mid- and late-life depression is suicide, a topic addressed again further on. Because many of these individuals have reputations for being sound, dependable, and stable and deny being depressed, one’s inclination is to doubt the possibility of self-destruction. Such patients should nonetheless be questioned forthrightly on this subject: Do they feel that life is not worthwhile? Have there been thoughts of suicide? Do they think themselves capable of committing suicide? Have they made such plans or made suicide attempts before? Is there a family history of suicide? Do they own a firearm? Are they fearful of dying? Do they have a strongly held religious view that proscribes suicide? These questions relate to features that have been shown to put depressed individuals at risk of suicide. If, from their answers, they are judged to carry an imminent risk of suicide, they should be directed to a psychiatrist and generally admitted to a hospital. In recent years, it has come to be appreciated that the elderly are increasingly prone to suicide and that older white men have the highest rates of completed suicides (mainly with firearms).

In some depressions, hypochondriacal preoccupation with bowel and digestive functions accounts for repeated visits to the physician. In one study, 21 of 120 such patients were subsequently diagnosed as being depressed. Persistent insomnia may be the major complaint of the depressed patient. Early awakening is typical, and the morning hours are then the worst period of the day for the low emotional state. Other patients have difficulty falling asleep, especially if there is an associated anxiety state. A complaint in the male of loss of libido and erectile dysfunction is another monosymptomatic presentation; only with probing inquiry about other disturbances common to depression will the diagnosis become evident.

Adherence to the aforementioned diagnostic criteria (see Table 52-1) undoubtedly facilitates diagnosis, but not infrequently a single one of these symptoms so dominates the clinical picture as to suggest the diagnosis of another disease state and obscure the presence of an underlying depression. As mentioned earlier, depressed patients who are referred to the neurologist tend to complain inordinately of physical and cognitive symptoms and to minimize or deny the purely affective ones. Complaints of fatigue, weakness, malaise, or widespread aches and pains, for example, suggest a variety of medical diseases, such as anemia, Addison disease, hypothyroidism, chronic infection, polymyositis, or early rheumatoid arthritis. Quite often the fatigue state is misinterpreted as muscular weakness, and this directs a medical search for neuromuscular disease. Similarly, complaints of persistent headache may suggest the presence of intracranial disease. Complaints of poor memory, inability to concentrate, and other cognitive impairments raise the question of a dementia until it is found, by careful examination, that mental competence belies the patient’s appraisal of his own defects.

A number of psychologic testing scales are used to detect and score the severity of depression. Although they are of value mainly for clinical studies, several of them can be helpful in clinical work since they are sensitive to one or another aspect of depression. They do not supplant the clinical examination in determining if an individual is depressed or suicidal but they may be helpful in differentiating depression from dementia and in detecting depression in cases where physical complaints are more prominent than psychic ones. The tests most familiar to neurologists are the Hamilton and the Beck scales, but several others are as valid and widely used.

Bipolar disease is a disorder of mood consisting of prolonged episodes of depression, interrupted by, or coexistent with episodes of mania. It was given the name manic-depressive disease by Kraepelin in 1896, and it was with him that our current clinical concept of this disorder originated. He viewed the manic and depressive attacks as opposite poles of the same underlying process and pointed out that, unlike dementia praecox (his name for schizophrenia), bipolar psychosis entails no intellectual deterioration with recurrent episodes. A traditional view of this disease was that of a periodic or cyclic condition in which one major mood swing was followed by an equal but opposite excursion. This is seldom the case, however. Episodes of depression are more than twice as frequent as manic ones, and according to current experts, the most common form of the illness is characterized by episodic depression alone and many patients have several episodes of depression before their first period of mania.

Recurrence of episodes of pure mania without interspersed episodes of depression is known but relatively uncommon. As a consequence, bipolar psychosis has been divided into two subtypes: the unipolar group, in which only an endogenous depressive illness occurs, and a bipolar group, in which one or more bouts of mania occur with or without depression. The bipolar variety occurs in approximately 10 percent of patients with affective disorder. The biologic accuracy of this classification has not been critically determined. There has been an arbitrary further subdivision of bipolar I to denote at least one episode of full mania, and bipolar II when the process entails an episode of hypomania.

In addition, there are mixed affective states, in which symptoms of both depression and mania occur within a single episode of the illness. A so-called “rapid-cycling” form of bipolar disease has also been recognized in which four or more circumscribed episodes occur in a year. Like other variants of the disease, it tends to have an aberrant or unpredictable response to medication. Still other patients with affective elements of depression present with atypical features; for example, instead of anorexia, weight loss, and insomnia, they sleep and eat excessively.

The prevalence of bipolar disease cannot be stated with precision, mainly because of varying criteria used for diagnosis. Certainly depression and depressive episodes are ubiquitous and mania is less common. The apparent increase of the disease in the past 50 years probably reflects a growing awareness of the condition among both physicians and the laity. Studies of large groups of patients from isolated areas of Iceland and the Danish islands of Bornholm and Samsø indicate that 5 percent of men and 9 percent of women will develop symptoms of major depression, mania, or both at some time during their lives (Goodwin and Guze). Some recent studies, such as the one conducted by the National Comorbidity Survey, report lifetime prevalence for bipolar disorder in the United States as 4.5% (Merikangas et al).

Bipolar disease occurs most frequently in middle and later adult years, with a peak age of onset between 55 and 65 for both sexes. However, a significant proportion of patients experience the first attack in childhood, adolescence, or early adult life. Depression is also a major problem in the elderly. Blazer and Williams, who studied 997 persons older than age 65 years in North Carolina, found symptoms of a major depressive illness in 3.7 percent. The disease was two or three times more frequent among women. There is no known explanation for this gender difference, but some have speculated that just as many men are depressed, only they deny it or turn to alcohol. Patients in the bipolar group have an earlier age of onset, more frequent and shorter cycles of illness, and a greater prevalence of affective disorder among their relatives than do patients with unipolar depression (Winokur).

Clinical Presentation

The manic state

Related posts:

Disorders of the Special Senses Chapter 20. Delirium and Other Acute Confusional States Chapter 24. Fatigue, Asthenia, Anxiety, and Depression Chapter 28. Normal Development and Deviations in Development of the Nervous System Chapter 50. The Myotonias, Periodic Paralyses, Cramps, Spasms, and States of Persistent Muscle Fiber Activity Chapter 38. Developmental Diseases of the Nervous System

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