About Specific Symptoms
A mental health professional will carefully evaluate a person's symptoms to determine whether the symptoms meet the criteria for a diagnosis of a mood disorder. This section describes some of these symptoms in more detail.
At least one of two essential features of clinical depression must be present in order to suspect a diagnosis of major depressive disorder. One of these is depressed mood, and the other is a loss of interest or pleasure in activities. A mental health professional will evaluate whether a person has depressed mood in any of several ways. A person may simply state that he or she has been feeling sad, depressed, blue, empty, "down in the dumps," hopeless, etc. If a person denies such feelings, but either appears to be on the edge of tearfulness, shows a depressed facial expression and disposition, or appears to be overly irritable, then these may also indicate the presence of depressed mood. Children and adolescents may display mood that is cranky or irritable rather than mood that appears sad or despondent. This, of course, would be different than "spoiled child" behaviors.
Additionally, some people may be more likely to report physical complaints (i.e., aches, pains, headaches) rather than depressed mood. This may be because some people more easily recognize physical than emotional symptoms, they experience their mood in physical terms, or it may be more socially acceptable to report physical symptoms. Nevertheless, such physical symptoms can sometimes suggest the presence of depressed mood.
For the symptom to meet the criteria towards a diagnosis of major depression, a person must have had a depressed mood for most of the day, nearly every day for a two-week period of time.
Feelings of Hopelessness, Helplessness
Feelings of hopeless and/or helplessness are common in those who are clinically depressed. They are also some of the most frustrating feelings that depressed individuals experience. Research on the cognitive theory of depression has shown that people who are depressed struggle with feelings of hopelessness and helplessness more so than people who are not depressed (Sacco & Beck, 1995). A sense of hopelessness reflects a negative view of the future. This includes expectations of personal dissatisfaction, failure, and a continuation of pain and difficulty-- a belief that nothing will get better. Feelings of helplessness reflect a negative view of the self. Depressed individuals view themselves more negatively, their self-esteem suffers, and they have little or no self-confidence. They do not believe they have any control or that they can help themselves to feel better. They may have an urge to give up and think, "what's the use?"
Research has also indicated that severe hopelessness may be a predictor of suicide (Beck, 1987; Fawcett, 1990). Now, this does not mean that if a person feels hopeless that he or she will attempt to commit suicide. This is a common symptom of clinical depression. What it does tell us, however, is that depressed individuals who struggle with strong feelings of hopelessness may be at a higher risk for self-harm. They should receive treatment from a trained medical or mental health professional.
Cognitive therapy or Cognitive-Behavioral therapy often address feelings of hopelessness and helplessness in a direct manner.
Loss of Interest or Pleasure
At least one of two essential features of clinical depression must be present in order to suspect a diagnosis of major depressive disorder. One of these is loss of interest or pleasure, and the other is depressed mood. People who become depressed tend to lose interest in things they once found enjoyable. Activities such as going out to dinner or a movie, visiting with friends, working, or doing hobbies are just not as interesting or enjoyable as they once were. This includes losing interest or desire in having sex. People who are depressed may say such things as, "I just don't care anymore," or "nothing matters anymore." Friends and family of the depressed person may notice that he/she has withdrawn from friends, or has neglected or quit doing activities that were once a source of enjoyment.
This loss of interest or pleasure in activities includes a loss of interest in sex. Some people who have had more than one bout with depression may recognize their diminished interest in sex as an early warning sign of the return of their illness. For a person who is depressed, sex may seem like too much trouble. It may even be hard to remember why sex was ever enjoyable at all. Attempts to have sex may only result in problems with achieving an erection or orgasm. Negative thoughts about oneself can also feed into a lack of interest in sex. Depressed people tend to have problems with self-esteem and may believe that no one, not even a spouse or partner, find them attractive.
For the symptom to meet the criteria towards a diagnosis of major depression, a person must have had a significant reduction in level of interest of pleasure in most activities, nearly every day for a two-week period of time.
Appetite and Weight Changes
People who develop clinical depression often have changes in their appetite. On the one hand, some people never feel very hungry. They can go long periods of time without wanting to eat anything. They may forget to eat, or if they do eat just a few bites may fill them up. They may even feel that they have to force themselves to eat. For some people, the thought of eating is unpleasant, and having to prepare a meal seems to require too much energy. In such cases, a depressed person may lose a significant amount of weight. Depressed children may not meet weight gains that are expected for their age. A reduction in weight is often associated with a melancholic type of depression.
On the other hand, some people who become depressed tend to have an increase in their appetite and may gain significant amounts of weight. They may even find that they crave certain types of food such as sweets or carbohydrates. People with seasonal affective disorder (SAD) often crave foods that are high in carbohydrates such as pasta, bread, and potatoes. Weight gain is often associated with an atypical type of depression.
In terms of a diagnostic evaluation of this symptom, a mental health professional will consider either of two things. One is whether a person has had a change of more than 5% in weight within a month. The other is whether there has been a decrease or increase from usual appetite patterns nearly every day within a two-week period of time.
Not being able to get enough sleep at night is the most common type of sleep disturbance for people who are clinically depressed. Sometimes people will wake up during the middle of the night and then find it difficult to fall asleep (called "middle insomnia"). Others might wake up too early in the morning and cannot fall back asleep (known as "terminal insomnia"). And still others might have general difficulty falling asleep at night (insomnia). These types of sleeping problems are often associated with a melancholic type of depression.
Alternatively, a less common sleeping problem is when a person tends to oversleep (called "hypersomnia"). This may be in the form of sleeping for prolonged periods of time at night or increased sleeping during the daytime. Even with excess sleep, a person may still feel tired and sluggish during the day. People with seasonal affective disorder (SAD) may sleep longer during the winter months. Hypersomnia is often associated with an atypical type of depression.
For diagnostic purposes, a mental health professional will evaluate whether such problems with sleep have occurred nearly every day within a two-week period of time.
Feeling Agitated or Slowed Down
People who are depressed may appear to be either quite agitated, or alternatively, very slowed down in their mannerisms and behavior. If a person is agitated (also known as psychomotor agitation), he or she may find it difficult to sit still. An agitated person may pace the room, wring his/her hands, or fidget with clothes or objects. Older people with depression are more likely to appear restless and agitated than those who are younger.
On the other hand, someone who is slowed down in his or her behavior (also known as psychomotor retardation) will tend to have movements that are very sluggish. A person may move across a room very slowly, avert his/her eyes, and sit slumped in a chair. When speaking, he or she will do so slowly, say few words, and may pause before responding to questions. There may also be a reduction in volume in tone of speech, inflection, and content of what is said. It is also not uncommon for a person's ability to think to be slower than usual.
In terms of diagnosis, the agitation or slowing down of one's demeanor must be to the degree that it can be observed by others. It should be more than just experiences or feelings that a person reports to have.
Decreased energy and feeling tired and fatigued are very common symptoms for those who are clinically depressed. A person may feel quite tired even without having engaged in any physical activity. Simple day-to-day tasks are no longer simple. Even such things as getting washed and dressed in the morning can seem overwhelming and may even take twice as long to accomplish than usual. When a person is able to do things around the house or at work, he or she may become very exhausted or tire quickly. As a result of feeling fatigued, people often find that their work at home, school, or job suffers.
Towards making a diagnosis, this is not a symptom that is necessarily observable by others. Instead the person reports that he or she is experiencing a loss of energy or feeling more fatigued than usual.
Feeling Worthless or Guilty
People who are depressed may tend to think of themselves in very negative unrealistic ways. They may become preoccupied with past "failures," personalize trivial events, or believe that minor mistakes are proof of their inadequacy. They also may have an unrealistic sense of personal responsibility and see many things as being their own fault. For example, a car salesperson may spend a great deal of time blaming himself/herself for not meeting certain sales quotas even when the overall sales of cars in the area is down and other salespeople are having similar difficulty. Sometimes this belief of personal responsibility can become delusional. For instance, a person may begin to believe that he or she is to blame for civil unrest in other parts of the world.
Self-loathing is common in clinical depression. This can be a downward spiral when combined with other symptoms such as lack of energy and difficulty with concentration. For instance, if a person has been unable to keep the house clean or finish assignments at work, he or she may look to that as proof that he or she is a bad person. The more things do not get done at home or work, the worse a person feels about him or herself. In reality, the person has problems at home and work because of the effects of a depressive illness, not because he or she is a "bad person."
Diagnostically, a person would experience feelings of worthlessness or excessive guilt almost every day for a period of two weeks in order to meet criteria for major depression. However, beliefs or thoughts that do not meet the criteria for major depression include feeling blame for being ill and not meeting personal responsibilities as a result of clinical depression.
Thoughts and emotions are powerfully affected by clinical depression. A person's thoughts are frequently very negative and pessimistic. It becomes difficult for a person to believe that he or she can be helped or ever feel well again.
Those who are clinically depressed often find that they their ability to think, concentrate, or make decisions becomes impaired. A person may report having problems with his or her memory, or that he or she is easily distracted. This problem can be especially pronounced and cause great difficulty in functioning for those who are involved in intellectually demanding activities such as professors, computer programmers, and doctors.
For children and teenagers, an unusual drop in school grades can indicate a problem with thinking and concentration. For those who are elderly, the initial complaint may be with problems in memory and can be misdiagnosed as being some early signs of dementia. For some elderly individuals, after the clinical depression is treated their problems with memory often disappear. For others, major depression may be a precursor to inevitable dementia.
For diagnostic purposes, a person may experience difficulty in thinking, concentration, or decision making almost every day for a period of two weeks or more. This can be through subjective report of the person or by observations of others.
Suicidal Thoughts, Plans, or Attempts
Thoughts of death, suicide, or even suicide attempts can be common for those who are clinically depressed. The frequency and intensity of thoughts about suicide can be wide-ranging from believing that friends and family would be better off if he or she were dead, to frequent thoughts about committing suicide, to detailed plans about how he or she would actually carry out the act of suicide. People who are less severely suicidal may have short, but regular (a few times a week) thoughts of suicide. A person who is more severely suicidal may have made specific plans, collected materials (i.e., pills, gun, rope), and decided upon a day and location for the suicide attempt.
The motivation for a person to want to kill him- or herself may not be for the desire to actually die. It may be due to the wish to give up in the face of what seems for the person to be overwhelming obstacles, or the desire to end the emotional pain that seems to have no end.
Those who are severely depressed are at a lower risk for suicide since they lack the energy or motivation to carry it out. However, the risk can increase when a depression begins to lift and their energy begins to return. Those who "have a reason to live" such as the need to raise children may be at a lower risk for attempting suicide. At high risk are those individuals who have made plans to kill themselves and who seem to have a brighter mood after deciding to do so. People who think and behave this way must often be hospitalized to keep them from harming themselves. If you have been thinking about suicide, you should seek appropriate help for yourself by speaking with your doctor, clergy, or a mental health professional. Please do not keep these thoughts to yourself, but speak to others who can aid you in getting the help that you need.
Towards a diagnosis of major depression, a mental health professional will evaluate whether a person has repeated thoughts of death, suicidal thoughts with or without a specific plan, or previous suicide attempt.
Delusions and/or Hallucinations
Psychotic features that may accompany depressive, manic, or mixed episodes include the presence of delusions and/or hallucinations. Delusions are firmly held beliefs that persist despite strong evidence to the contrary. Hallucinations are sensory experiences that appear real to the person experiencing them, but there is no actual physical stimulus for the perception. Most commonly hallucinations include a person hearing voices or seeing things that are not there.
Psychoses may develop in about 15% of those with major depressive disorder. The presence of delusions and hallucinations often interfere with a person's ability to make sound judgments about consequences of their actions and this may put them at risk for harming themselves. Psychotic symptoms are serious and a person in this condition needs immediate medical attention and possibly hospitalization.
Physical Aches and Pains
It often happens that people who are depressed first seek help from their family doctors with complaints of physical symptoms rather than depressed mood. Many people do not even report to their doctors that they feel depressed or that they have been experiencing other problems related to their despondent mood. The physical symptoms people feel are real, but they are caused by the illness of clinical depression rather than by another physical illness.
Frequently, those who are depressed have chronic aches and pains. Headaches, stomachaches, and back and joint pain are common physical complaints. Others may have gastrointestinal problems such as indigestion, constipation and irritable bowel syndrome. Some women contend with painful or irregular menstrual periods.