194 CHAPTER 6
CASE 6.1 • FROM THE INSIDE: Major Depressive Episode
Another experience of depression was captured by the writer William Styron in his
memoir, Darkness Visible.
In depression this faith in deliverance, in ultimate restoration, is absent. The pain is unre-
lenting, and what makes the condition intolerable is the foreknowledge that no remedy will
come—not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is
only temporary; more pain will follow. It is hopelessness even more than pain that crushes the
soul. So the decision-making of daily life involves not, as in normal affairs, shifting from one
annoying situation to another less annoying—or from discomfort to relative comfort, or from
boredom to activity—but moving from pain to pain. One does not abandon, even briefl y, one’s
bed of nails, but is attached to it wherever one goes.
(Styron, 1990, p. 62)Hypersomnia
Sleeping more hours each day than normal.
Prodrome
Early symptoms of a disorder.
Premorbid
Referring to the period of time prior to a
patient’s illness.
Major depressive disorder (MDD)
The mood disorder marked by fi ve or more
symptoms of an MDE lasting more than
2 weeks.
Age cohort
A group of people born in a particular range
of years.
insomnia or, less commonly, hypersomnia, which is sleeping more hours each day
than normal. In addition, people who are depressed may feel less energetic than
usual or feel tired or fatigued even when they don’t physically exert themselves.
In fact, many people who are depressed had sleep disturbances up to a month
before the depression began, which suggests that sleep irregularities may be a
harbinger of a depressive episode (Perlis et al., 1997; Perlis, Smith, et al., 2006).
Sleep irregularities in depressed people are particularly notable during the phase
when dreams primarily take place, known as rapid eye movement sleep (REM
sleep) (Rao et al., 2002); REM sleep is involved in processing emotional memories
(Marano, 2003).
In order to meet the diagnostic criteria, the vegetative signs should be observ-
able by others, not just reported as subjective experiences. For instance, if a new
patient reported diffi culty getting to sleep, poor appetite, and feeling agitated, the
clinician would ask the patient for more details before determining that these were
vegetative signs of depression: How long does it actually take the patient to get
to sleep? Has the patient’s weight changed? The clinician would also observe the
patient for signs of psychomotor agitation, such as a leg constantly bobbing up and
down or fi ngers tapping on the armrest.Cognitive Symptoms of Depression
When in the grip of depression, people often feel worthless or guilt-ridden, may
evaluate themselves negatively for no objective reason, and tend to ruminate over
their past failings (which they may exaggerate). They may misinterpret ambiguous
statements made by other people as evidence of their worthlessness. For instance,
a depressed man, Tyrone, might hear a colleague’s question “How are you?” as
an indication that he is incompetent and infer that the colleague is asking the
question because Tyrone’s incompetence is so obvious. Depressed patients can
also feel unwarranted responsibility for negative events, to the point of hav-
ing delusions that revolve around a strong sense of guilt, deserved punishment,
worthlessness, or personal responsibility for problems in the world. They blame
themselves for their depression and for the fact that they cannot function well.
During a depressive episode, people may also report diffi culty thinking, remem-
bering, concentrating, and making decisions, as author William Styron describes,
in Case 6.1. To others, the depressed person may appear distracted. Note, how-
ever, that depression is heterogeneous, which means that people with depression
experience these symptoms in different combinations. No single set of symptoms
is shared by all people with depression (Hasler et al., 2004).The symptoms of MDE develop over days and weeks. The prodromeis
the early symptoms of the disorder, and the prodrome of an MDE may include
anxiety or mild depressive symptoms that last for weeks to months before fully