Changes in volitional activity in depression
Depressive syndrome belongs to productive psychopathological symptoms, accompanied by vivid emotional experiences (anxiety, dysphoria) and sometimes delusions. As a rule, this is a prolonged, but always reversible condition (prior to the active introduction of antidepressants and electroconvulsive therapy, patients could recover from it spontaneously).
By origin, they are distinguished into:
- Endogenous depression: occurs without obvious external causes. It accompanies schizophrenia, organic brain damage, endocrine disorders, and manic-depressive psychosis (MDP).
- Reactive depression: develops in response to severe psychological trauma. With a prolonged course, endogenization is possible—a process in which painful experiences lose their connection to the initial traumatic situation and persist even with favorable life changes.
In typical cases, volitional disorders manifest as severe apathy (the patient literally "cannot force themselves" to do anything), anhedonia, complete refusal of medical examinations due to the fear of learning "the worst," and the loss of basic self-care skills. Suicidal thoughts frequently join the clinical picture.
Somatic manifestations and masked depression
Changes in volitional and emotional activity in depression are closely linked to autonomic and somatic shifts.
- Cardiovascular system: sympathicotonia is observed (tachycardia, tendency toward elevated blood pressure), indicating the body's active response to stress.
- Gastrointestinal tract and metabolism: characterized by constipation, a sharp deterioration in digestion, and pronounced weight loss (up to 10 kg in a single month).
- Pain syndrome: patients may complain of various atypical pains—in the abdomen, joints, behind the sternum, and headaches.
Particular attention is required for masked (larvated) depression, especially during the first episode. In this condition, an abundance of somatic complaints completely conceals the true psychiatric picture. As a result, patients undergo futile treatments by internists for a long time. They are frequently misdiagnosed with coronary artery disease (CAD), hypertension, vegetative-vascular dystonia (VVD), or biliary dyskinesia.
Clinical variants of depressive syndromes
In addition to the classical psychotic variant (as well as the mitigated neurotic subdepression), there are forms where volitional disorders have specific features:
- Apathetic depression: dysphoria and total inactivity become the leading symptoms. Patients lose interest in the future, make no complaints, and their only desire is to be left alone. It is most often seen in schizophrenia. An important distinction from the apathetic-abulic syndrome is the instability and reversibility of the condition.
- Anxious (agitated) depression: proceeds without typical passivity and motor inhibition (often seen in individuals of involutional age). The sthenic affect of anxiety drives patients to bustle, suffer from severe insomnia, and experience a sense of impending doom. They may persistently ask for help to end their lives or attempt public suicide. The extreme degree of such agitation is called melancholic raptus (raptus melancholicus)—patients bang their heads against walls, scream, and tear off their clothes.
- Depressive-delusional syndrome: dysphoria is accompanied by delusions whose plot is not directly related to lowered mood (delusions of staging, passivity, or persecution are encountered). Patients are restless and convinced that their relatives will be severely punished for their misdeeds. Such a clinical picture is uncharacteristic of MDP and points to an acute attack of schizophrenia (schizoaffective psychosis).
Manic syndrome: disinhibition of will and drives
Mania is a sign of acute psychosis (most commonly within the framework of MDP or schizophrenia), the duration of which is usually shorter than depressive phases. The presence of prominent productive symptoms is a prognostically favorable sign, allowing one to expect a quality remission.
A typical manic picture is described by the triad:
- Hyperthymia (elevated mood): persistent optimism, denial of illness, and ignoring problems.
- Accelerated thinking: rapid, leaping speech due to heightened distractibility. In severe mania, speech disorganizes into a "word salad," patients lose their voice, and foam gathers at the mouth.
- Psychomotor agitation: chaotic and unproductive activity. Patients strive to leave home or the hospital and cannot sit still.
Volitional disorders in mania are expressed as a sharp enhancement of basic drives. Appetite increases (however, due to pronounced agitation, patients may lose weight despite a "wolfish" hunger), hypersexuality arises (indecent proposals, declarations of love), along with a tendency toward periods of alcohol abuse (dipsomania). Sleep is drastically reduced, yet patients do not feel tired.
Social boundaries break down: patients intrusively seek communication, are overly familiar with doctors, and show altruism toward strangers to the detriment of their own family. They make impulsive purchases, fail to finish tasks, and enter into ill-considered marriages. Appearance changes: men decorate themselves with pins and badges, while women use overtly sexual clothing and bright makeup. At the height of the syndrome, delusions of grandeur develop. Attempts to restrict the patient's activity may provoke a reaction of fierce indignation (angry mania).
Atypical mania and hypomania
In addition to fully developed mania, the following are distinguished:
- Hypomania: a mild subpsychotic elevation of mood. Delusions do not occur, and partial insight into one's condition may be preserved. Patients appear witty, but marked distractibility destroys their working capacity.
- Manic-delusional syndrome: the affect of happiness is combined with megalomaniacal delusions of grandeur and ideas of staging (acute paraphrenia). Patients declare a mission to "save the world." This syndrome does not occur in MDP; it is characteristic of schizoaffective disorder and at the height of an attack can be complicated by oneyroid clouding of consciousness.
Briefly: answers to topical questions
What clinical variants of atypical depressions exist, apart from apathetic and anxious?
In addition to apathetic and anxious (agitated) depressions, the following clinical variants are distinguished:
- Subdepression — mild forms of depression at the neurotic level.
- Depressive-delusional syndrome — a combination of dysphoria with delusions.
- Anesthetic — agonizing numbness, the experience of inner emptiness, and loss of feelings for loved ones.
- Asthenic — pronounced asthenia, mental and physical exhaustion, hyperesthesia.
- Retarded — marked motor inhibition and slowed thinking.
- Ironic — a sorrowful smile combined with bitter irony regarding one's condition.
- Masked — an abundance of somatic complaints conceals the true diagnosis.
What psychopathological symptoms are included in the structure of acute paraphrenia syndrome?
The structure of acute paraphrenia syndrome includes the following psychopathological symptoms:
- Affective disorders — affect of happiness, complacent or elevated mood.
- Delusional ideas — unsystematized delusions of persecution and staging, megalomaniacal delusions of grandeur, as well as delusions of control.
- Hallucinations — verbal pseudohallucinations.
- Psychic automatism — a sense of being made, with tolerance toward the perceived influence.
- Paramnesias — fictitious memories (confabulatorial delusions) and fantastic interpretation of the present time.
Against the background of these symptoms, patients frequently declare incredible abilities and a mission to save the world.
Class and exam questions
How does apathetic depression differ from apathetic-abulic syndrome?
The decrease in volitional activity, dysphoria, and inactivity in apathetic depression are unstable and completely reversible states, whereas the apathetic-abulic syndrome represents a persistent process defect.
How to distinguish healthy grief from depression?
In normal grief, a person can be distracted when surrounded by loved ones, is grateful for support, and the intensity of experiences decreases within 1–2 months. In depression, the patient avoids communication, is irritated by others' joy, and experiences delusional self-blame and suicidal thoughts.
Why the Beck and Hamilton scales should not be used for the initial diagnosis of depression?
These psychometric scales are designed to assess the severity of an already confirmed disorder and treatment dynamics. During initial assessment, their results can be false-positive, as high scores are often obtained by somatic patients or healthy people experiencing grief.
What else to study on this topic
- Acute paraphrenia and oneiric clouding of consciousness
- Mechanisms of endogenization in reactive depression
- Sympathicotonia and somatic masks of depressive phases
- Differential diagnosis of schizoaffective psychosis and manic-depressive psychosis
- Irate mania and dipsomania in the structure of affective disorders
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Other topics in "Chapter 12. Disorders of the Emotional-Volitional Sphere"
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