The (Hidden) Symptoms of Depression

A new series

Clinical depression presents with a variety of manifestations which, taken together, can be used to make a diagnosis. But in addition to the commonly-cited experiences, there are many more subtle symptoms of depression that can be a part of the picture.

In this series of posts let’s examine some of these less-discussed aspects of depressive experience. But first …

How do we diagnose depression? 

The same way we diagnose any other disorder: with a list of signs and symptoms.

The list appears in the Diagnostic and Statistical Manual, the much (and somewhat justly) maligned guide to psychiatric disorders, soon to be even more reviled with the contentious release of the fifth edition, DSM-5.

Although I’ve been critical of the DSM system in past posts, the diagnostic criteria for major depression are reasonably useful, and (in their current form, at least) set the mark far enough from everyday experience that calling it a disorder isn’t entirely out of line.

The list of criteria can be found all over the web, so I’ve considered not repeating it here. But how can we talk about the other symptoms without at least mentioning the more widely known ones? To that end, then, let’s recite the list.

The DSM-IV criteria for Major Depressive Episode

The person must have five or more of the following nine symptoms at the same time for at least a two-week period. (Usually depressive episodes last much longer than two weeks, but two weeks is the traditional line in the sand beyond which we call the problem depression.) The person must have at one or both of the first two symptoms in the list (depressed mood or diminished interest). There are some provisos for children, but I’ll ignore these for now.

1. Depressed mood.  Most of the day, nearly every day.  No significant breaks.
2. Markedly diminished interest or pleasure in all, or almost all, activities. Again, most of the day, nearly every day. This is what is often called anhedonia.
3. Significant weight loss (without the attempt to diet) or weight gain. A change of more than 5% body weight in a month is the traditional marker. Alternatively, a marked decrease or increase in appetite nearly every day. Obviously the weight change usually goes along with the change in appetite, but technically you only need one or the other. 
4. Insomnia or hypersomnia (sleeping much more than usual) nearly every day. 
5. Psychomotor agitation or retardation to the point that others can observe them, nearly every day. Of the entire list, this is the least commonly observed in milder cases.
6. Fatigue or loss of energy, nearly every day. This one is so common it is almost a requirement. Not just sleepiness because of the insomnia. People routinely report that it seems to take much more energy to do anything (e.g., walk up a flight of stairs).
7. Feelings of worthlessness or excessive or inappropriate guilt, nearly every day. Guilt or self-criticism about being depressed doesn’t count; this has to involve other issues as well.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day. Also common, this problem can be so pronounced that people suspect they are dementing.
9. Recurrent thoughts of death, or suicidal thoughts with or without a plan. A fear of death does not count. 

There are some other criteria as well:

• The symptoms must not meet the criteria for a Mixed Episode, in which the person has some manic characteristics as well.
• The symptoms must cause clinically significant distress, or must impair social, occupational, or other important areas of functioning. If a person truly has five or more of the above nine symptoms, it is not difficult to clear this hurdle as well.
• The symptoms must not be due to the direct physiological effects of a substance (such as a prescription medication or a drug of abuse) or to a medical condition (such as hypothyroidism).
• The symptoms are not better accounted for by bereavement. Oddly enough, experiencing more than two months of symptoms of bereavement is considered sufficient to begin talking about depression again. This causes some eye-rolling amongst clinicians, who argue that depending on the loss, normal bereavement often goes on longer.

So that’s the list …

… and when people write about depression these symptoms are often all that are discussed. But there are others that are just as common, and that also cause problems. One of the challenges is that because people don’t hear about them, they worry that these phenomena might signal some other problem. And because they are often ignored, people don’t know what to do when they have them.

So let’s take some time talking about the additional symptoms of depression that typically get less attention. 

Next up:  The plexiglass wall.