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Behavioral techniques (see above) are most frequently used in therapeutic settings such as day treatment centers, but there is no reason why they cannot be incorporated into family situations or any therapeutic setting Many behavioral techniques (eg, positive reinforcement whether it be a word of praise or an approving nod after some positive behavior), can be a powerful instrument for helping a person learn behaviors that will facilitate social acceptance Music from portable digital players with earphones is one of many ways to divert the patient s attention from auditory hallucinations
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Present in some severe depressions:
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Psychomotor retardation or agitation Delusions of a hypochondriacal or persecutory nature Withdrawal from activities Physical symptoms of major severity, eg, anorexia, insomnia, reduced sexual drive, weight loss, and various somatic complaints Suicidal ideation
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920 Present in mania:
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dysfunction, anxiety, chronic fatigue, feelings of worthlessness, somatic complaints (unidentifiable somatic complaints frequently indicate depression), loss of sexual drive, and thoughts of death Diurnal variation with improvement as the day progresses is common Vegetative signs that frequently occur are insomnia, anorexia with weight loss, and constipation Occasionally, severe agitation and psychotic ideation (paranoid thinking, somatic delusions) are present These symptoms are more common in depressed persons who are older than 50 years Paranoid symptoms may range from general suspiciousness to ideas of reference with delusions The somatic delusions frequently revolve around feelings of impending annihilation or hypochondriacal beliefs (eg, that the body is rotting away with cancer) Hallucinations are uncommon Subcategories include major depression with atypical features characterized by hypersomnia, overeating, lethargy, and rejection sensitivity Major depression with a seasonal onset (seasonal affective disorder) is a dysfunction of circadian rhythms that occurs more commonly in the winter months and is believed to be due to decreased exposure to full-spectrum light Common symptoms include carbohydrate craving, lethargy, hyperphagia, and hypersomnia Major depression with postpartum onset usually occurs 2 weeks to 6 months postpartum Most women (up to 80%) experience some mild letdown of mood in the postpartum period For some of these (10 15%), the symptoms are more severe and similar to those usually seen in serious depression, with an increased emphasis on concerns related to the baby (obsessive thoughts about harming it or inability to care for it) When psychotic symptoms occur, there is frequently associated sleep deprivation, volatility of behavior, and manic-like symptoms Postpartum psychosis is much less common (< 2%), often occurs within the first 2 weeks, and requires early and aggressive management Biologic vulnerability with hormonal changes and psychosocial stressors all play a role The chances of a second episode are about 25% and may be reduced with prophylactic treatment 2 Dysthymia Dysthymia is a chronic depressive disturbance Sadness, loss of interest, and withdrawal from activities over a period of 2 or more years with a relatively persistent course is necessary for this diagnosis Generally, the symptoms are milder but longer-lasting than those in a major depressive episode 3 Premenstrual dysphoric disorder Depressive symptoms occur during the late luteal phase (last 2 weeks) of the menstrual cycle
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Mood ranging from euphoria to irritability Sleep disruption Hyperactivity Racing thoughts Grandiosity Variable psychotic symptoms
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Depression is extremely common, with up to 30% of primary care patients having depressive symptoms Depression may be the final expression of (1) genetic factors (neurotransmitter dysfunction), (2) developmental problems (personality problems, childhood events), or (3) psychosocial stresses (divorce, unemployment) It frequently presents in the form of somatic complaints with negative medical workups Although sadness and grief are normal responses to loss, depression is not Patients experiencing normal grief tend to produce sympathy and sadness in the clinician caregiver; depression often produces frustration and irritation in the clinician Grief is usually accompanied by intact self-esteem, whereas depression is marked by a sense of guilt and worthlessness Mania is often combined with depression and may occur alone, together with mania in a mixed episode, or in cyclic fashion with depression
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