Masked depression: how to distinguish it from other diseases and get rid of it

You can love your family and friends, but not feel joy in being with them. Having an ideal job, but not feeling satisfied with it. Being bedridden, despite apparent physical health. The reason for this is depression.

In everyday life, the concept of “depression” is vague. This word is used to describe bad mood, sadness, depression, and reluctance to do something. All of the above may be symptoms of depression, but they are not. Sadness gradually goes away on its own and does not interfere with functioning in society - depression deprives a person of a full life.

What is depression

Depression is a mental disorder in which a person's activity and interest in life decrease.

According to the World Health Organization (WHO), depression affects approximately 350 million people worldwide. Less than 50% of them receive treatment, and in some countries less than 10%. Many patients do not seek help, unaware of the presence of the disease and blaming themselves for laziness or bad character.

What happens in the body during depression

With depression, the limbic system of the brain works differently - it is responsible for emotions, memory, sleep and other processes in the body.

Normally, the prefrontal cortex processes information received from the hippocampus and “slows down” the fear and anxiety that the amygdala activates.

Prefrontal cortex

Processes information Inhibits excessive activity of the amygdala Influences motivation and decision-making, regulates behavior
Hippocampus
Participates in the formation of emotions, the transition of short-term memory to long-term memory, as well as in maintaining attention

Amygdala (amygdala)

Activated when fear or anxiety occurs. Responsible for the formation of autobiographical memories associated with emotional outbursts.

During depression, the number of neurons and contacts between nerve cells decreases, the volume of the hippocampus and prefrontal cortex decreases, and the size of the amygdala changes up or down. Therefore, the prefrontal cortex cannot fully inhibit the activity of the amygdala and process information from the hippocampus - hence uncontrollable anxiety, depressed mood and lack of positive thoughts.

Prefrontal cortex

Information is processed incorrectly The activity of the amygdala is not inhibited => Motivation decreases, behavior changes, anxiety appears
Hippocampus
Volume decreases => Mood and memory worsen, concentration decreases

Amygdala (amygdala)

The size changes => Fear and anxiety are triggered; mental disorder develops

Depression is characterized by a deficiency of neurotransmitters - chemicals that transmit excitation from one nerve cell to another through networks of neurons. There is mainly a shortage of three mediators:

1. Norepinephrine
   - is involved in the inhibition of sleep centers in the central nervous system, is responsible for concentration, memory and motivation, and general motor activity. Affects how we react to stress and show emotions.
2. Serotonin
   is responsible for sleep, mood, control of aggression, regulation of appetite, sensitivity to pain.
3. Dopamine
   is responsible for feelings of satisfaction, love and affection, is involved in the process of learning and switching attention.

The production of endorphins is also reduced. They are responsible for “pain relief”, reducing the pain signal to a tolerable level - both during physical injuries and in a stressful situation. This explains the poor tolerance to stress and pain in people suffering from depression.

How does a person feel when depressed?

Depression is characterized by cognitive distortions—thought errors that prevent you from thinking rationally. “Nobody understands how much it hurts me”, “everything is bad”, “nobody needs me”, “everything around me is falling apart”, “I don’t deserve to live” - a feeling of loneliness and alienation accompanies everywhere, even if a person realizes that the facts do not support these destructive thoughts.

Any daily activity requires a lot of effort. Getting out of bed, meeting a friend, preparing dinner - a person with depression puts as much effort into these simple actions as a healthy person would into climbing Everest.

Previous interests, aspirations, desires lose their meaning. Food loses its former taste. Thoughts become confused, attention becomes scattered, mental acuity turns into lethargy. Appetite decreases or, conversely, increases if there is a habit of “eating” negative experiences. Insomnia or excessive sleepiness begins.

We invite you to take a look at the video, which shows the feelings characteristic of people with depression. Symptoms, feelings, and thoughts vary depending on the type of disorder and individual characteristics.

"Living with Depression" short film on Youtube. There are Russian subtitles.

Causes of masked depression

Experts have long noted that physical symptoms are closely related to the mental state, or rather, to emotional reactions. This psychosomatic connection plays a big role in the development of masked depression. In a normal state, a person does not associate experienced emotions with body reactions, but during mental illness, all sensations become vivid and remain in memory.

The occurrence of such pathology of the nervous system is influenced by reduced levels of serotonin, norepinephrine and dopamine. These hormones are necessary to carry impulses from the senses to the brain. When a sufficient amount of these components is present in the body, a person is more often in a good mood, feels cheerful and has a surge of strength. If there is a deficiency of certain hormones, then the patient’s joyful emotions are less frequent, and he ceases to feel pleasure from any events. The days become gray, monotonous and boring, it seems that nothing interesting is happening in life.

Disruptions in the hormonal system may have genetic roots.

The following diseases or periods of life may also be the cause:

• diseases of the endocrine system, for example, hypothyroidism, diabetes mellitus, Addison's disease, Itsenko-Cushing's disease;
• chronic nervous overstrain;
• long-term use of various medications - these are hormonal drugs, cardiac glycosides, antihypertensive and antibacterial agents, adrenergic blockers, some analgesics, barbiturates and tranquilizers;
• puberty, pregnancy or menopause;
• destruction of neural connections responsible for the expression of emotions, which leads to mood swings and decreased cognitive function (the cause may be multiple sclerosis, stroke, brain tumors, injuries or other disorders);
• neurotransmitter changes that occur due to cancer;
• a sharp decrease in immune defense after treatment with antibiotics.

Masked depression of a neurotic nature can appear as a result of a deficiency of vitamins and microelements obtained from food, chronic fatigue, physical inactivity, decreased sleep time, and lack of sunlight. All body systems, including the nervous system, gradually weaken, lose the ability to cope with stress, and then this process leads to the emergence and development of this type of pathology.

A person’s life is not complete without stressful situations associated with strong feelings: loss of loved ones, layoffs, accidents and tragedies. If the body’s strength is not enough to survive an emotional shock, then internal protection is activated. A person can withdraw into himself and cease to be interested in what and who surrounds him (work, family, any activity). This is fertile ground for the occurrence of a nervous disorder. If you do not receive support during this period and completely plunge into a gloomy state, then bodily illnesses are inevitable, which are only a cover for masked depression.

Types of depression

There are many classifications of depressive disorders. Some are no longer relevant, some are controversial. We tried to combine the main types of depression into subgroups, which are identified by ICD-10, the World Psychiatric Organization and some researchers (D. Hell, V. A. Torchilov, V. L. Minutko).

By severity

• Light
  - difficult to distinguish from sadness and melancholy. The range of symptoms and their severity do not yet allow a clear diagnosis of depressive disorder, but with a high degree of probability a person will experience depression in the future. This condition is also called subdepressive or subsyndromal (minor) depression.
• Moderate
  - the clinical picture is clear, but the person is able to fully (or almost fully) function in society.
• Severe
  - pronounced symptoms up to loss of functionality, delusions or hallucinations.

By origin

• Endogenous
  - does not depend on external influences, only on internal reasons - for example, due to heredity.
• Reactive (exogenous, psychogenic)
  - develops under the influence of external stress: death of a loved one, workload, breakup, etc.

It is often difficult to attribute depression only to endogenous or only to reactive - the disorder in most cases is caused by both external and internal factors.

• Primary
  - depression is not preceded by other mental illnesses and is not caused by taking any chemical substances.
• Secondary
  - caused by other disorders and diseases (schizophrenia, alcoholism, brain pathologies) or taking drugs/medicines. Depression caused by somatic (“bodily”) causes is also called somatogenic.

By type of phase flow

• Unipolar (monopolar)
  - the depressive state is stable throughout the entire illness.
• Bipolar disorder (manic-depressive psychosis)
  - the depression phase is periodically replaced by a mania phase - agitation, hyperactivity, elevated mood, outbursts of anger, etc.
• Dysthymia
  is chronic depressed mood for two or more years without severe symptoms.
• Cyclothymia
  is a “mild” form of bipolar disorder in which the mood constantly changes from elated and excited to depressed and vice versa. Mood changes are irregular and last several days.

According to seasonality

• Seasonal Affective Disorder
  - Occurs depending on the season, usually in the fall or winter.
• Non-seasonal disorder
  - manifests itself regardless of the time of year.

By leading affect

• Anxious
  - anxiety, concern, panic attacks predominate.
• Melancholy
  - there is a sad, melancholic mood, tearfulness.
• Apathetic
  - characterized by apathy, lack of interest in anything, dullness of feelings.
• Undifferentiated
  - it is impossible to single out any of the affects as leading.

By type of disorder in the motor or ideational sphere

• Inhibited (adynamic)
  - characterized by impaired concentration, increased fatigue, memory impairment, and cases of inability to move and perform even simple actions.
• Agitated
  - symptoms include motor restlessness, a feeling of fear, rapid heartbeat, and strong emotional arousal.
• Mixed
  - combining signs of inhibition and agitation.
• Dissociated
  - without violations in these areas.

Disorders not included in subgroups

• Adjustment disorder
  is an emotional disorder under the influence of severe stress that occurs during the period of adaptation to changes and interferes with a full life.
• Atypical depression
  - symptoms include specific signs: increased emotional reaction, weight gain, drowsiness, avoidance of interpersonal contacts.
• Resistant depression
  - refractory to treatment with antidepressants for at least two consecutive courses of 3-4 weeks.
• Anxiety-depressive disorder
  combines features of anxiety disorder and depression, and it is difficult to single out one as primary.
• Postpartum (postnatal) depression.

The problem of larval depression is one of the most complex and theoretically and practically relevant issues of modern psychiatry.

Larviroral, masked, hidden or, as they are often called nowadays, somatized depression include conditions in which the manifestations of depression are hidden behind a “façade” of various somatovegetative symptoms. Timely diagnosis of these conditions is significantly difficult, since the impression of the presence of a somatic disease is often created. Patients usually turn not to a psychiatrist, but to other specialists, are unsuccessfully examined for a long time and treated in appropriate institutions, where various types of serious interventions are sometimes undertaken. At the same time, general practitioners do not pay due attention to the low mood of patients, their statements about the severity of somatic loss and the failure of therapy, and in some cases about their reluctance to live; Moreover, doctors usually associate these complaints with the severity of the underlying disease. At the same time, the suicidal danger of such depression is very high. Difficulties in diagnosis are due to the fact that the period of treatment by various specialists can stretch for a long time, sometimes reaching 5-8 years, and the intensity of depression during this time, as a rule, increases significantly. As Lopez Ibor (1972, 1973) and Kielholz (1982) noted, currently suicide attempts are made in non-psychiatric hospitals much more often than in psychiatric ones. Subsequent study of case histories shows that the patients had severe depression. Their untimely diagnosis is primarily due to the fact that doctors of various specialties are not sufficiently familiar with the clinic of larval depression. In this regard, there was a need to include issues of clinical psychiatry (including clinics for generalized depression) in the advanced training course for internists. Difficulties in diagnosing larval depression are also associated with the fact that patients usually do not complain of depressed mood, but complain of various types of somatic manifestations. They are reluctant to turn to psychiatrists even when there is an assumption that they have a mental illness. In some cases, psychiatrists cannot exclude the presence of a somatic disease or are inclined to give a purely psychological explanation to the depressed mood of patients, linking it with the difficulty of diagnosing and treating the alleged somatic disease.

Larval depressive states were described back in the last century. Falret (1878, 1879) considered them a milder form of circular psychosis. Kahlbaum (1889) classified these rudimentary forms of circular psychosis as cyclothymia. Pinel and Esquirol indicated somatic symptoms in patients with mania and melancholia. Y.A. Anfimov (1899) called larval depressive states periodic laziness. S.V. Kannabikh (1914) classified these conditions as cyclothymia, designating them as “equivalents of a depressive attack.” Therapist D.D. Pletnev (1927), describing patients with periodically occurring obesity, pointed out that obesity is not a concomitant, but the main manifestation of depression. He designated these conditions as somatic cyclothymia. In the literature you can find other names for larval depression: cyclosomia (E.E. Krasnushkin, 1960), affective-depressive equivalent (Yu.V. Kannabikh, 1914), somatic equivalent (T.A. Nevzorova, 1962,1965), affective equivalent, depression without depression, thymopathic equivalent, psychovegetative syndrome, etc.

In recent years, the number of studies devoted to the study of larval depression has increased significantly. There is a tendency to expand the range of disorders described as so-called “facade” symptoms. In addition to somatovegetative manifestations, they also include various drive disorders and behavioral anomalies (V.F. Desyatnikov, 1965, 1981, etc.). Kielholz (1972,1973) only limits the range of these depressions to conditions where somatic symptoms come to the fore. A.K. Anufriev (1978) also adheres to a similar point of view.

Manic depressions are extremely polymorphic, which refers both to the manifestations of the somatovegetative “facade” and to the affective radical, expressed by subdepressions of various structures. As somatovegetative manifestations, they may experience sleep disorders, changes in body weight, unpleasant sensations in the head, headaches, migraines, Meniere-like syndrome, neuralgia and myositis, lumbago, brachialgia, femoralgia, trigeminal pain, a feeling of numbness and coldness in some part body, pain or discomfort in the heart area, various arrhythmias, changes in blood pressure with the development in some cases of vascular crises, as well as various visual disturbances - flickering before the eyes, luminous circles, colored sparks, transient nystagmus or diplopia, blepharospasm, deterioration of vision that cannot be easily corrected, and various types of allergic manifestations, including dermatitis, eczema and even, according to some descriptions, attacks of bronchial asthma. Morning and daytime vomiting, akathisia, dry mouth, noise and ringing in the ears, various pains and discomfort in the abdominal cavity, colitis and gastritis, and impotence are also described as so-called “facade” symptoms. As this rather extensive, but far from complete (exhaustive) listing shows, the “masks” of larval depression can be infinitely varied.

The variety of symptoms indicates that patients with severe depressive states can be encountered in the practice of doctors of many specialties (Peters, Halzel 1971). Patients may contact pediatricians 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 heartbeat, tachycardia, and a feeling 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, and pseudothyrotoxic conditions. Patients may contact surgeons with complaints of pain and unpleasant sensations in the abdominal cavity. In some cases, the picture of an “acute abdomen” is almost completely imitated, which can lead to unjustified surgical interventions. Pseudothyrotoxic conditions, sometimes with a slight enlargement of the thyroid gland and an increase in basal metabolism, are encountered in the practice of surgeons and can also serve as a reason for surgical interventions. Patients with various types of dysmenorrhea and pain in the appendage area turn to gynecologists, and dermatologists with eczema and dermatoses. Patients with larval depression who turn to otorhinolaryngologists complain of pain in the ears or sensations of “stuffing,” difficulty swallowing, hoarseness or sensations of a “lump in the throat,” vague neuralgia 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.

This list, which is far from complete, clearly demonstrates both the diversity of depressive “masks” and the difficulties that arise in diagnosing them.

For psychiatrists, it is important that a number of authors indicate that suspicion of larval depression should be caused by all types of drug addictions, periodically occurring neurotic disorders, and various types of behavioral disorders in childhood and adolescence (Fonseca, 1963, etc.).

The pronounced polymorphism of larval depressions extremely complicates attempts to create their classification. In the domestic literature, the works of T.A. Nevzorova (1962, 1964, 1965), T.A. are devoted to the classification of larval depressions. Khvilivitsky (1957, 1965), A.K. Anufriev (1968), V.F. Desyatnikov (1965, 1981), T.A. Nevzorova and Yu.Z. Drobizhev (1962). However, to date, there is no unified classification of larval depression, which is largely due to the heterogeneity of the approach to its creation.

An important feature of larval depression, which usually helps in making a diagnosis, is that the manifestations of the somatovegetative “facade” usually do not fit completely within the framework of the disease that they imitate, and doctors of non-psychiatric specialties, as a rule, note this fact, and also pay attention to failure to treat suspected somatic suffering. Particular attention should be paid to this fact, since it usually makes one suspect the presence of larval depression.

The main difficulties in diagnosing latent depression lie primarily in detecting affective disorders themselves. A psychiatrist must be able to identify various signs of hypothymia present in the structure of the condition. You should pay attention to mild depression, inability to enjoy life, difficulties in communicating with others, desire for solitude, limited contacts, decrease in previous energy and activity, difficulty in making decisions, anxiety, “nervousness” (sometimes with a feeling of fear), an abundance of various somato-vegetative complaints that do not fit into the framework of a specific disease, disorders of vital functions - sleep disturbance (in the form of reduced duration or early awakening), decreased appetite, potency, weight loss, menstrual irregularities, as well as daily fluctuations in affect and somatovegetative disorders (worsening more often in the evening).

When studying the course of the disease, diagnostic criteria may include the frequency of occurrence of somatovegetative and mental disorders, the presence of a history of unclear somatic disorders, erased, classic depressive or manic phases, the spontaneity of the onset and disappearance of attacks of the disease, the seasonal occurrence of attacks of the disease.

When diagnosing larval depression, data on the lack of effect of somatic therapy and a positive reaction to antidepressant therapy can be of great help. Regarding the question of the nosological affiliation of larval depressions, it is worth recalling the previously published works of authors attributing these cases to periodic melancholia or cyclothymia. Currently, larval depressions are described within the framework of endogenous affective pathology. There is a point of view that these conditions can be classified as a group of neuroses (V.N. Myasishchev, 1960, 1963). A.K. Anufriev (1978) believes that Lemke's vegetative depression, Weitbrecht's endoreactive dysthymia and the early stages of Kielholz's exhaustion depression are larved depressive states. All these variants of larval depression should be classified as endogenous psychoses that occur in phases.

With cyclothymia, larval depressions more often occur within the framework of a unipolar depressive type of course. In these cases, larvated depressions can be repeated in a “cliché” type, with a certain seasonal interest. There are cases when, with cyclothymia, phases alternate in the form of larval depressions with phases that occur as ordinary subdepressive states. With a cyclothymic course, larval depressive states can also occur as part of a bipolar course, although these cases are observed somewhat less frequently.

In more severe, so-called “psychotic” variants of manic-depressive psychosis, larval depressive states can be combined with phases in which depression passes from larval subdepressions to massive vital ones with an affect of melancholy, ideas of self-blame, and suicidal thoughts.

In schizoaffective psychoses and schizophrenia, the course of the disease may combine milder paroxysmal states that occur with a picture of larval depression with attacks in the form of massive depression or affective-delusional states. A feature of the somatovegetative “facade” in these cases is a significant proportion of senestopathies, and such conditions are possible with Cotard’s nihilistic delirium (A.K. Anufriev, 1978).

As already mentioned above, a characteristic feature of larval depressions is their protracted course. Within one phase or attack, these conditions may not undergo significant dynamics, remaining at the level of larval subdepression. Quite often there is a gradual deepening of the affective radical state with the appearance of feelings of melancholy and anxiety, an affect of despair, suicidal thoughts and attempts. With an increase in the intensity of depression, in some cases it is “cleansed” from the somatovegetative “facade”, but more typical is the simultaneous increase in the intensity of somatovegetative and affective manifestations. In this case, a modification of the psychopathological structure of both the somatovegetative and affective components of the state occurs. The issues of the dynamics of larval depressions can be found in the work of A.K. Anufriev (1978); The scope of this lecture does not allow us to cover this issue in detail.

It is difficult to provide comprehensive recommendations regarding the treatment of larval depression. Typically, various combinations of antidepressants with antipsychotics, and in some cases with tranquilizers, are used. The best drug from the group of antipsychotics that can be recommended for the treatment of larval depression is teralen, but its use is currently sharply limited due to the lack or absence of the drug. The doses of the agents used and the methods of their administration should vary taking into account the characteristics of specific cases. Taking into account the tendency of larval depression to have a protracted course, measures should be taken, if possible, to overcome emerging resistance to therapy. Unfortunately, it is difficult to give definite therapeutic recommendations in this regard. When monitoring a patient with larval depression and treating them, one should take into account the possibility of a gradual or acute increase in the intensity of the depressive radical, the appearance of suicidal thoughts and raptoid states. If such conditions occur, patients should be immediately sent to the hospital.

In the vast majority of cases, patients with larvated depression are treated on an outpatient basis and, as noted above, are observed for a long time in non-psychiatric institutions. In this regard, the introduction of a full-time psychiatrist position in non-psychiatric hospitals and clinics should be recognized as an important organizational measure that can provide adequate treatment for a larger contingent of patients with chronic depression and lead to a reduction in the suicidal risk of these conditions.

Bibliography

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Seasonal depression

The reason for the autumn blues is clear: sunny days are shortening, the air temperature is dropping - hence drowsiness, worsening mood and lack of energy. But “autumn depression” is not just melancholy. It cannot be cured by watching comedy series.

Experts use the term “seasonal affective (depressive) disorder.” Symptoms are similar to regular depression: loss of interest, irritability, poor concentration, changes in sleep patterns and appetite. More often than with other types of depression, overeating and excessive sleep occur.

Seasonal affective disorder occurs in the fall or winter. This diagnosis can be made if symptoms are observed at least twice during the cold season and not at any other time for two years or more.

While figuring out how to get rid of the autumn blues and depression, scientists suggested that the disorder is caused by a decrease in the level of sunlight. This affects the hypothalamus, which helps with the functioning of the nervous and endocrine systems.

Seasonal disorder also causes the brain to produce increased amounts of melatonin, a hormone that controls sleep-wake cycles. This leads to sleep problems, unexplained fatigue and apathy. At the same time, decreased levels of sunlight cause a decrease in the production of serotonin, which affects our mood, appetite and sleep.

How to cope with autumn depression? Doctors advise getting as much sunlight as possible during the day: going outside more often, sitting near windows and in well-lit rooms.

When thinking about how to get rid of autumn depression, you should make sure that it is not associated with stress, somatic causes or heredity. This can be clarified at an appointment with a specialist.

Other mood changes and symptoms

Depression is closely linked to a number of other psychological and behavioral disorders.

Anxiety, suspiciousness, eating disorders, and blues can arise due to parallel health problems.

Be sure to pay attention to your worldview and how it changes under the influence of various factors.

Depression in women

According to statistics, there are 2 times more documented cases of depression in women than in men (Tyuvina et al., “Gender characteristics of depressive disorders in women”). The cause of depression in women can be hormonal changes: changes in the menstrual cycle, pregnancy, miscarriages, the postpartum or premenopausal period, menopause.

Also, depressive disorders may include premenstrual dysphoric disorder, when a woman becomes depressed before the start of her cycle - more pronounced than with typical premenstrual syndrome (PMS).

A separate form is postpartum depression, which affects 13% of mothers. 50% of them had depressive tendencies even before pregnancy.

Young mothers spend enormous energy caring for their children, and therefore forget about themselves and their mental state. This is fraught with eating disorders, sleep disorders and other symptoms.

Before a woman fights depression on her own, it is recommended to consult a specialist. Maternal depressive disorder leads to disruption of the interaction between mother and child, which can lead to deviations in mental, emotional and physical development.

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!

Depression in men

Perhaps the low number of reported cases of depression in men is associated with the stigmatization of this disorder in men (stereotypes such as “a man should be strong”, “a man should not worry about problems, but solve them”, etc.). This makes it more difficult for men to understand how to deal with depression and admit to having an emotion-related illness.

In some cases, depression is unconsciously masked by irritability and aggression, immersion in work and career, alcoholism and other addictions.

Symptoms

As already mentioned, there are a lot of symptoms behind which this pathology is hidden. It is very difficult to guess which of them is false and which indicates a real problem and the possibility of physical illness. This “masked” type of depression is very easy to confuse with any disease of any body system.

Scientists, having studied somatized depression and its manifestations in patients for a long time, came to the conclusion that the symptoms of this mental disorder are as follows:

• nausea, pain and tingling in the abdominal area;
• aching pain in the muscles of the legs and arms;
• back and joint pain;
• pain when urinating;
• migraine and frequent headaches;
• shortness of breath;
• memory loss;
• difficulty swallowing;
• general weakness of the body;
• lack of sexual desire;
• pain during intercourse;
• severe pain during menstruation;
• heavy bleeding during menstruation.

Due to a lack of understanding of what is happening and complete confidence that a person is sick with a physical illness, the patient visits various doctors and spends an incredible amount of time, effort and money on treating a non-existent disease. Such patients are very impulsive, irritable and unpredictable, and also deny any diagnoses related to the nervous system.

Depression in children and adolescents

Undesirable behavior of a child can be attributed to laziness or whims, but often there is a serious reason behind the reluctance to study, eat or sleep.

Even young children develop depression. The younger the child is, the more somatic symptoms he has: colic, pain, insomnia, constant crying. As the child's awareness increases, other signs appear: he loses the desire to get up in the morning, interest in toys and learning new things; attacks of fear and sudden mood swings appear. If symptoms persist for two weeks or more, you should meet with a psychologist who specializes in working with children.

Therapy

When the diagnosis is confirmed, the doctor will tell you exactly how this depression should be treated. It is important to understand that the success of therapy directly depends on an integrated approach, including the use of certain types of medications, as well as psychotherapy.

1. Taking antidepressants. Anafranil is often prescribed. If there is a violation of mental or motor function, Melipramine may be prescribed.
2. Nootropics and tranquilizers. If the patient has increased anxiety, then he is prescribed these drugs. They also strengthen the nervous system. This is how Phenibut or Phenazepam are prescribed, for example.
3. Sedatives. Special medications that help counter nervousness, irritability, and excessive aggression. They also have a beneficial effect on the functioning of the heart and improve sleep.
4. Vitamin and mineral complex. Helps maintain the nervous system and reduce the negative effects of stress factors.
5. Psychotherapy. The psychotherapist will teach you how to understand yourself, get rid of negative thoughts, and solve accumulated problems. The use of special techniques that will allow you to get rid of depression, as well as change your life for the better.

In just a couple of weeks, positive dynamics will become noticeable. It usually takes about a month to completely get rid of this depression. However, the patient should not stop there if the doctor has prescribed a course of treatment lasting three months; in special cases, this period can be extended to six. Since premature cessation of treatment may increase the risk of relapse.

Use of drugs

The “gold standard” in the treatment of masked depression is the use of antidepressants. This group of drugs normalizes the functioning of neurotransmitter systems in the brain and eliminates the clinical manifestations of pathology. When choosing drugs, you should take into account existing somatic diseases, which may be contraindications to their use.

The main antidepressant drugs used in the treatment of masked depression

Treatment of masked depression is carried out in three stages, each of which is mandatory for all patients.

The first stage is relief therapy aimed at eliminating acute symptoms and achieving remission. The average duration of treatment varies from 1 to 3 months, depending on the severity of symptoms. It is recommended to use antidepressants from the group of selective serotonin reuptake inhibitors, which show the greatest effectiveness and safety when taken long-term. The main drugs: Paroxetine, Fluoxetine, Escitalopram, Sertraline, Maprotiline and Venlafaxine. Additionally, low doses of tranquilizers (Phenazepam, Afobazol, etc.) are selected. At the beginning of therapy, the dosage of drugs is minimal. It increases gradually during treatment until the symptoms of the pathology disappear. If the patient has severe autonomic disorders, then it is possible to use antipsychotics such as Sulpiride or Teraligen.

At the end of the relief treatment, they move on to stabilizing therapy. Its goal is to eliminate the residual effects of depressive disorder. Treatment lasts from 3 to 9 months. The patient uses similar antidepressants in low dosages. It is recommended to use drugs used at the stage of relief therapy. Atypical antipsychotics remain highly effective.

Preventive treatment lasts from 1 year and is aimed at preventing relapses of depressive disorder. Antidepressants, low dosages of carbamazepine and lithium salts are used in therapy.

Psychotherapeutic assistance

Subdepressive state or masked depression is a mental disorder that requires psychotherapeutic help. In this regard, clinical recommendations for the treatment of the disease necessarily include psychotherapy. It is possible to use its various directions: cognitive-behavioral, psychoanalysis, positive approach, etc.

At the initial stages of treatment, individual psychotherapy is recommended. This allows you to reduce the severity of symptoms and ensure high effectiveness of drug therapy. The specialist teaches the patient how to correctly work with existing symptoms and sensations, accept and adapt them for normal life. Much attention is paid to the patient’s social life to restore contacts with loved ones and friends.

During the preventative therapy stage, it is possible to attend group or family psychotherapy sessions. At the same time, there is an improvement in the socialization of the patient and a reduction in the risk of relapse of a mental disorder in the future.

It is important to note that psychotherapy should not be considered the only method of treatment. All patients with symptoms of depression require the use of antidepressants to quickly restore the normal functioning of neurotransmitter systems in the central nervous system.

Non-drug approaches

Meditation, sleep deprivation and physiotherapy sessions can be used as additional therapy methods. Long-term breathing meditation can improve the balance of neurotransmitters in the brain and stabilize mood. Physiotherapy (electric sleep, galvanization, etc.) has a general strengthening effect on the body.

Sleep deprivation is carried out only in cases of severe depressive disorder and low effectiveness of medications. The method is performed in a medical institution with constant medical supervision of the patient.

The following changes are used as criteria for the effectiveness of complex treatment for latent depression:

• persistent improvement in everyday mood, determined during a survey and using specialized psychological tests (Beck Depression Scale, etc.);
• absence of somatic and vegetative symptoms;
• returning to past hobbies, restoring social contacts;
• improving the standard of living.

When these criteria are reached, the patient is transferred to supportive psychotherapy.

Causes of depression

Several factors contribute to depression:

• Biochemistry.
  With depression, brain activity and neurotransmitters change.
• Genetics.
  The influence of heredity on the development of depression was studied using the example of bipolar disorder. Direct relatives of bipolar patients are 15 times more likely to develop depression than relatives of healthy people. If one parent has the disorder, children experience depression in 25% of cases; if both parents - in 75% (Minutko V.L., “Depression”).
• Personal characteristics.
  People with low self-esteem may think that they are not worthy of love and recognition. With pronounced perfectionism, all energy is aimed at achieving an ideal result - burnout occurs. Individuals prone to dependence in relationships and living their lives through another person are also prone to depression: losing awareness of themselves as a separate unit and not leaving themselves personal space, when parting, they experience the loss of a loved one as the loss of themselves.
• External factors.
  Low standards of living and security in the country, social characteristics of the state (for example, oppression of minorities), incidents of violence (both physical and psychological), and the loss of a loved one can make a person more vulnerable to depression if he was initially predisposed to affective disorders.

Diagnostics

The issue of diagnosis should be handled by a psychotherapist or psychiatrist. When depression occurs in a hidden form, a person may not even suspect a problem of this nature. Often he goes to see a doctor who is not even close to the real problem. In such a situation, a person is faced with the fact that he is sent for various studies and tests in order to confirm a particular disease. At the same time, time and money are wasted, and the problem is never solved.

If, nevertheless, the individual was sent to see a psychotherapist, then the search for the true reason will begin with a survey. There will be questions about:

• personal problems;
• well-being;
• plans for the future;
• interests;
• habits and attitudes;
• features of the work;
• communicating with people.

After conducting this questionnaire, the presence of low self-esteem is often revealed, which entails the development of hidden depression and negative outlooks on life.

Symptoms of depression

Depression is diagnosed by a clinical psychologist, psychotherapist or psychiatrist. But you can determine the presence of depressive tendencies yourself. For this purpose, tests created by professors of psychiatry are used - the Zang (Tsung) scale or the Beck scale.

Main symptoms of depression:

• Persistent feelings of depression, anxiety, hopelessness, emptiness
• The desire for self-isolation, limiting contacts with loved ones, the desire to stay at home all the time
• Feelings of guilt, worthlessness, helplessness
• Tearfulness
• Feeling lonely
• Loss of strength, lethargy
• Problems with memory, concentration
• Vulnerability: a person with depression is easier to hurt and offend
• The feeling that no one understands, sympathizes, or loves
• Feelings of inferiority compared to other people
• Sleep disorders: insomnia, interrupted sleep or high duration of sleep, constant drowsiness
• Difficulty making decisions
• Feeling like thoughts are slipping away or getting lost
• Excessive overeating or lack of appetite
• Feeling that it takes a lot of effort to do simple things
• Loss of interest in activities and hobbies that previously brought pleasure
• Thoughts of death or suicide, suicide attempts, self-harm, desire to harm oneself, to “punish” oneself
• Symptoms of poor physical health that cannot be treated: headaches, digestive disorders, nervous tics, heaviness in the chest, heart pain, etc.

If you observe several symptoms simultaneously for 2 weeks or more, this is a reason to consult a specialist.

Classification of pathology

In the International Classification of Diseases, 10th revision (ICD-10), there is no separate section for masked depression. However, such a diagnosis is common in psychiatry, and the incidence of the disease in the population is growing. Experts divide all cases of latent depressive disorder into two types:

1. Psychopathological - manifested by fatigue, anxiety and reluctance to communicate with other people (the patient notes a feeling of inferiority).
2. Psychosomatic - health complaints predominate, but when examined, diseases of the internal organs are absent. This group of patients is characterized by pain, numbness in the arms or legs, insomnia and decreased libido.

Depending on the prevailing symptoms and characteristics of the course, clinical forms of latent depression are distinguished:

• Agripnica - with a predominance of sleep disorders. The patient has difficulty falling asleep and often wakes up at night and early in the morning. Falling back to sleep is impossible. As a result, he feels tired during the day and rests often.
• Vegetative-visceral - similar to the manifestations of neurocirculatory dystonia, which is called VSD. During the day, patients experience changes in blood pressure, heart rate, body temperature, and may experience increased sweating. A characteristic symptom is dyspeptic disorders in the form of nausea, discomfort and bloating.
• Algic-senestopathic - the patient feels painful tingling and discomfort throughout the body. Their localization is constantly changing, which excludes the organic nature of the pathology.
• Drug addiction - associated with the occurrence of symptoms against the background of prolonged use of alcoholic beverages or drugs. At the same time, a person tries to reduce the manifestations of depression with their help, which aggravates the symptoms.
• Psychopathic-like - more often detected in adolescents. Patients suffer from mood lability and have a negative attitude towards any requests. Positive events do not lead to joy.
• Asexual - with a predominant decrease in libido.

Diagnosis and treatment of depression

A clinical psychologist, psychotherapist or psychiatrist conducts a conversation with the patient, asks leading questions: how the symptoms manifest themselves, for how long, whether there has been a deterioration or improvement in well-being. Tests and questionnaires can be used for diagnosis. In some cases, the doctor will refer you to other specialists (for example, to a cardiologist if your heart is bothering you) to rule out physical causes of this condition.

Patients with depression are hospitalized in exceptional cases - for example, if there is a real threat of suicide or delusions and hallucinations appear.

The approach to treating depression depends on the cause of its occurrence:

• Depression is endogenous, that is, it does not depend on external circumstances.
  The main method of treatment is pharmacotherapy. For anxiety and restlessness, sedative antidepressants are prescribed, and for apathy and melancholy - stimulating drugs. If symptoms of both groups are present, drugs of balanced action are used.
• The disorder arose against a background of stress.
  It is necessary to work out the causes of stress in psychotherapy. Together with a specialist, you will understand what mechanisms your psyche triggers and how to rebuild them in order to feel better. Such depression can be treated without medication, but if the symptoms are severe and the patient feels unbearable, the doctor may prescribe a course of antidepressants.
• Depression is a reaction to somatic illnesses.
  It is necessary to treat the root cause of depressive disorder and only then resort to symptomatic pharmacotherapy and psychotherapy.

Antidepressants have side effects: They should be taken only as prescribed by a doctor. If you feel that the drug has a strange effect on your mood and condition, be sure to contact a specialist again - he will adjust the dosage or select another treatment.

Definition and types

Masked depression is a type of mental disorder that is subdepressive in nature.
This condition is often difficult to detect, since it is often disguised as manifestations of addiction or a certain disease, and bad mood and depression are not particularly noticeable. Knowledge about its main features, as well as what symptoms characterize it, helps to identify this disorder in a timely manner. This type of depression can occur in two forms.

1. Psychosomatic. A person makes many complaints indicating various diseases. However, they are not enough to suggest a specific disease. For example, there may be tingling in the limbs, sensations of pain, problems in sexual life.
2. Psychopathological. The person is in a depressed state. He feels excessive fatigue, increased anxiety, a feeling of loneliness does not leave him, there is no desire to communicate with other people or enjoy life, there is a feeling of inferiority.

Depending on the characteristics of the disorder and its symptoms, there are several variants of this type of depression.

1. Agripnic. Characterized by sleep disturbance. It is difficult for an individual to fall asleep, sleep is intermittent and superficial. Often a person wakes up earlier than expected, but is unable to fall asleep. At the same time, he does not feel rested.
2. Algic-senestopathic. A person experiences strange sensations spreading throughout his body, often accompanied by pain. There may be a concentration of pain in a certain area of ​​the body, and migration to various organs is also possible.
3. Vegetative-visceral. Manifestations are characteristic of vegetative-vascular dystonia, accompanied by unstable blood pressure, respiratory rate, and heart rate. There is also increased sweating and increased temperature. Flatulence and abdominal discomfort may occur.
4. Drug addict. Develops against the background of drug addiction and alcoholism. By resorting to alcohol or drugs, a person tries to escape from a subdepressive state.
5. Psychopathic. Occurs in adolescence, and can also occur in adolescence. The teenager is often in no mood, is lazy to do anything, perceives demands and requests very negatively, and almost never experiences joy. But parents should know that such manifestations do not always indicate that the teenager has masked depression of a neurotic nature. This behavior may be an age-related feature of the psyche.
6. Asexual. A person loses interest in representatives of the opposite sex, and there are no positive emotions from communication. In men it manifests itself as impotence, in women - frigidity.

It is important to know that in special cases different types of masked depression can be combined. This phenomenon makes it much more difficult to identify the root cause of the disease.

Masks of depressive disorder

Masked depression is divided into masks (types) depending on which symptoms predominate.

1. Psychopathological disorders: obsessive-compulsive, anxiety-phobic, hypochondriacal, neurasthenic.
2. Biological clock disorders: nightmares, insomnia, hypersomnia;
3. Masks in the form of algia: pain in the abdomen, heart, spine, head, joints, pseudorheumatic arthralgia, neuralgia.
4. Endocrine and somatized autonomic disorders: VSD syndrome, itchy skin, bulimia or anorexia, neurodermatitis, disorder of internal organs of a functional nature, in particular, irritable bowel and stomach syndrome, cardioneurosis.
5. Behavioral disorders: the formation of addictions, in particular drug addiction and alcoholism, hysteria, antisocial behavior.

How to deal with apathy and depression on your own

The best ways to combat depression are psychotherapy and treatment as prescribed by your doctor. However, there are several ways to deal with stress and depression on your own.

Any work, including psychological work, is not easy when you are depressed, but taking care of yourself will significantly speed up recovery.

Record your condition

A person prone to depression is not always able to express his feelings in words. In this regard, problems may arise in communicating with loved ones (when you want to share your problems, but they do not understand you) and in understanding yourself.

An exercise with a 10-point scale will help you understand what happens to you when you are depressed.

Idea taken from Learning Solution-Focused Therapy by Anne Bodmer Lutz.

Draw a line and mark it with divisions from 0 to 10. This will be a scale of your state, where 0 is the worst feeling, and 10 is the best possible feeling, a state of absolute happiness. Assign each division a list of “symptoms,” feelings, and thoughts. You can use metaphors and images that are close to you personally. Here's an example:

When you feel changes in your condition, ask yourself questions:

1. How am I feeling now? Where am I now on a scale of 10?
2. Is there something that could cause me to move left on the scale? What should I be afraid of? Can I protect myself from this shift?
3. Is there anything that will allow me to move up the scale by at least one point? How about two points?

There is a difference between “I feel terrible” and “I feel 2/10 bad.” By rationalizing your condition, you increase the chances of its improvement. The scale will tell you what to do if depression does not go away.

Remember what makes you feel better

If something makes you feel even a little better, write down the reason. You liked the taste of food, listened to a friend, watched a funny video with cats - any event that brought a smile or smoothed out the feeling of pain and emptiness deserves attention. You can record how many points the improvement occurred after each event. Even if it is only one tenth, any positive change is worth recording.

During depressive episodes, you should turn to the list of positive things you have created and try to implement any of them.

Track your needs

Usually when you're depressed you don't want anything. It is all the more important not to miss the moment when the desire to do something does appear. Suddenly felt like you wanted to go for a walk? Go outside. Want to chat with friends? Call them.

If you just want to lie on the couch, allow yourself that too. By coming into conflict with yourself over procrastination, you only waste your internal resources, which are already scarce in depression. Try to put things aside and allow yourself to rest without remorse.

Process destructive thoughts

Depression is characterized by destructive automatic thoughts. These are judgments that arise fleetingly and most often are not based on specific facts (“nobody loves me,” “I’m worthless,” “I’m all alone”). Often a person is not aware of these thoughts, but he feels the emotions that arise as a result of them.

Information and exercise taken from the book “Mood Management. Methods and exercises” by D. Greenberger and K. Padesky.

According to cognitive behavioral therapy, you can learn to catch such thoughts and reduce the intensity of negative emotions. The easiest way to do this is using a table.

1. When you feel a strong emotion, write it down and rate the intensity on a scale of 100. If you can’t determine what these feelings are, find a list of emotions on the Internet and listen to yourself, going through the concepts: which word resonates with you more strongly than others?
2. Write down the situation in which this emotion arose. Where were you at this moment? Was there anyone else nearby?
3. Try to isolate the thought (or several thoughts) that led you to the emotion.
4. Try to use cold calculation: write down objective evidence that supports this idea, and facts that contradict it.
5. Based on contradictory facts, formulate a new thought, more balanced and thoughtful. Rate how confident you are in her.
6. Rate the intensity of the original emotion after formulating an alternative thought. Has the emotion weakened? Has it become easier?

Try to confirm your thoughts in practice, conduct experiments. If you feel like no one loves you, conduct a survey among your friends and family and write down the results. If you are afraid that you are performing poorly and will soon be fired, ask for feedback from your superiors. By receiving “applied” confirmation of alternative thoughts, the brain consolidates the new experience as positive, and the intensity of previous negative feelings decreases.

It is unlikely that after completing the exercise you will stop experiencing negative emotions. Perhaps their intensity will decrease by only 5–10 points out of 100 or not at all. But by filling out the table every day for several months, you will learn to replace destructive thoughts with more thoughtful ones and manage your feelings.

Here is a table with an example typical for a depressive state:

Don't be shy to ask for support

The idea of ​​asking for help is often accompanied by fear: what if the person refuses, laughs, or devalues ​​the experience? Therefore, when dealing with depression, it is important to protect yourself and ask for support correctly.

1. Try to determine what support is needed.
   For some, these are supportive words (and you should immediately determine which ones), for others - a hug, joint leisure, just being nearby.
2. Identify people you can reach out to.
   People whom we consider close are not always ready to provide support. Analyze your experience of communicating with a person: were there any cases when he ignored you or joked inappropriately? If yes, don't risk it. At the same time, it is not necessary to ask for support from relatives or close friends. Strangers, friends or colleagues can also support (pat you on the shoulder, listen, say kind words).
3. Request support.
   People don’t know how to read minds, they may not know that you are feeling bad right now, and they may not understand what kind of support you need. Also, a person may be busy or immersed in his own experiences, so it is important to clearly formulate the request without pushing personal boundaries. For example: “I feel bad now and want to talk, can you listen to me, please?”

If asking for help is scary and uncomfortable, ask yourself: would I support this person if he turned to me? If yes, then why shouldn’t he support you?