Depression is one of the common psychiatric disorders, and according to epidemiological data, it accounts for about 3% of the total population. The prevalence of depression is gradually increasing with the socio-economic development and the increasing work pressure. The typical symptoms of depression are depressed mood, decreased interest and reduced verbal activity, which are known as the “three lows”.
However, many patients with depression do not show typical symptoms, the so-called “atypical” depression, that is, in addition to the above typical psychosocial symptoms, these patients also show many physical symptoms such as pain, panic, loss of appetite, frequent urination, etc., and many patients do not think that these symptoms are the manifestation of mental illness, and first go to the general hospital. After many tests and detours, they finally go to psychological clinics or psychiatric departments, delaying the diagnosis and treatment, which needs the attention of the people and the medical workers.
”Atypical” symptoms.
Sleep disturbance: Sleep disturbance is the most common concomitant symptom of depressive state disorder patients, and it is also the most common complaint of many patients visiting hospitals. Sleep disturbances in depressed patients are diverse: difficulty falling asleep, poor sleep and wakefulness, excessive nightmares, early awakening and lack of sleep perception. Among them, difficulty in falling asleep is the most common, patients often sleep for a long time after being bedridden, and in severe cases, they even stay up all night for several days.
Early awakening refers to patients waking up 1~2 hours earlier than usual, and it is difficult to fall asleep after waking up. Patients with sleep deprivation have a good amount of sleep and seem to be sleeping heavily to others, but the next day they feel little sleep or even stay up all night. Some “atypical” patients can also be sleepy.
Pain: Pain symptoms are more common in depressed patients. Foreign studies have found that more than one-third of patients complaining of various types of pain symptoms may have depression. Headache, neck and shoulder pain, and anterior chest pain are some of the more common types of pain in depressed patients with complaints of somatic symptoms. The causal relationship between pain and depression varies in different populations. In particular, there is a significant correlation between chronic pain and depression in the elderly, and the study found that the number of chronic pain complaints with depressive symptoms was significantly higher in the elderly group, and the incidence of depressed patients complaining of pain and discomfort was also significantly higher than in other groups.
Heartburn and chest tightness: Cardiovascular and respiratory symptoms such as heartburn and palpitations, chest tightness and shortness of breath, chest pain, breath-holding and even dyspnea are also common complaints of depressed patients, among which heartburn and chest tightness are the most common. Some patients may have an accelerated heart rate and a pulse rate of about 100 beats per minute, but more often the heart rate is not significantly accelerated, and some patients may behave very much like an angina attack, but the electrocardiogram and 24-hour ambulatory ECG monitoring are not abnormal, and some patients even undergo invasive tests such as coronary angiography, but often Some patients even undergo invasive coronary angiography, but often to no avail. In short, patients have no obvious or only minor ancillary findings, which are clearly inconsistent with the severity of their subjective experience.
Fatigue and lethargy: Another frequent symptom of depression is a feeling of fatigue and lethargy, even when not engaged in any physical activity. The routine work and household chores become difficult, and the patient is too lethargic and tired to perform daily activities such as living and working, and is reluctant to meet people and even to take care of personal hygiene, which has become a difficult task. This feeling of fatigue and lethargy makes patients worry about the quality of completion of school, work and household chores, etc., which in turn leads to a vicious circle of pessimism, lack of self-confidence, and lack of pleasure to strengthen the symptoms.
Memory loss: There are also many depressed patients who experience memory loss, especially in older patients. Memory loss is very prominent in some older depressed patients, and some patients may even show dementia-like symptoms, where these patients feel that their brains are dumb and their thinking is slow. When depression is severe, the thinking activity will be fully inhibited, giving an impression of “dementia”, which we call “pseudo-dementia”. Some patients with depression also have a reduced ability to think, their attention is easily distracted, and they are unable to make conclusions or decisions as the analysis process continues.
Gastrointestinal and genitourinary symptoms: The main symptoms of depression in the digestive tract are loss of appetite and weight loss. Some patients may also have GI symptoms such as nausea, dry stools, constipation or diarrhea. The most common GI symptom in depressed patients is loss of appetite, the incidence of which is reported to be as high as about 70%.
Patients with mild appetite loss do not necessarily have a significant reduction in the amount of food they eat, and their weight may not drop significantly for a period of time; patients with severe depression may have a significant loss of appetite, or even refusal to eat, leading to significant weight loss and eventual malnutrition. Some patients with “atypical” depression may also experience hyperphagia and weight gain. Many depressed patients may also have genitourinary symptoms such as frequent, urgent, and painful urination, and some patients may also show reduced sexual function.
Diagnostic criteria
Patients with “atypical” depression usually have the above non-specific physical symptoms, and because the physical symptoms are very obvious, patients tend to pay attention to the physical symptoms and ignore the emotional problems, so that they only report the physical symptoms without mentioning the emotional symptoms, as if the physical symptoms cover up the depressed mood or the depressed mood is hidden. These atypical symptoms often play a “confusing” role in the diagnosis of depression and can easily be misdiagnosed by doctors without psychiatric training.
Therefore, when a patient presents with non-specific somatic symptoms, especially when the symptoms are related to multiple organs and systems, the possibility of depression should be considered after no positive findings on basic ancillary tests. The doctor should pay attention to the psychological and social symptoms such as mood, thinking activities, and changes in daily abilities of the patient, and if necessary, promptly suggest to the patient to visit a psychological clinic or psychiatric department so that the patient can receive the correct diagnosis and treatment as early as possible.
In cases where there is insufficient evidence of clinical manifestations, performing a large number of, especially large and invasive, ancillary tests just to exclude the diagnosis of certain somatic diseases will not only unnecessarily increase the financial burden of the patient, but may also further delay the patient’s condition and increase the risk of the patient eventually developing chronic prolongation of the disease.
According to the diagnostic and classification criteria for mental disorders in China, the diagnostic criteria for depression are listed below.
1. loss of interest and unpleasantness.
2. loss of energy or a sense of fatigue
3. psychomotor retardation or agitation.
4, low self-esteem, self-blame, or feelings of guilt.
5. difficulty in association or reduced ability to think for oneself.
6. recurrent thoughts of death or suicidal or self-injurious behavior.
7. sleep disorders, such as insomnia, early awakening, or excessive sleep.
8.Decreased appetite or significant weight loss.
9.Decreased sexual desire.
The presence of depressive symptoms can be determined if a person presents with depressed mood along with four or more of the above symptoms. Depression can be diagnosed if the depressive symptoms have lasted for more than 2 weeks and have caused impaired social functioning, pain or adverse consequences for the patient, and if depressive episodes caused by other diseases such as heart disease and endocrine metabolic diseases can be excluded.
Principles of treatment
The “atypical” symptoms of these depressed patients are closely related to the severity of their depression, and once their depression is effectively relieved, their physical symptoms will naturally improve. Therefore, these “atypical” depressed patients should also receive systematic antidepressant treatment in psychiatric clinics or psychiatry departments. There are many treatment methods for depression, such as medication, psychotherapy, sleep deprivation therapy and electroconvulsive therapy, etc. Currently, the treatment is mainly medication, and new antidepressants are generally preferred, such as fluoxetine, paroxetine and other selective 5-hydroxytryptamine reuptake inhibitors.
These drugs have precise efficacy, generally have few side effects, are easy to use, and only need to be taken once a day. Cognitive-behavioral and interpersonal psychotherapy are also effective for depression. During psychotherapy, doctors help patients change the behaviors and ways of thinking that lead to the occurrence of symptoms, and help patients change the behaviors that lead to depression in interpersonal interactions, so as to achieve the goal of treating depression.
Most patients have good results after receiving timely and systematic antidepressant treatment, and generally the physical and emotional symptoms of patients will be reduced in about 4 weeks. After systematic antidepressant treatment, a small number of patients may still have the above atypical somatic symptoms. Generally, these patients have a higher risk of relapse and should be maintained for a longer period of time, with regular follow-up to prevent or prevent the recurrence of symptoms.