Depression: illness or symptom?

A while ago I posted a short piece on depression, and in it I touched on a number of issues which I thought were particularly important to bear in mind when thinking about, and treating, this condition. 1   Using an imaginary case study, I suggested that depression is a symptom, not a cause (i.e. an illness); and that that it is specifically a symptom of loss. This position is some what at odds with that of mainstream psychiatry and clinical psychology, which tends to focus on treating the symptoms of depression. This in turn raises the question of what we mean by the term ‘symptom’ in the first place.

In this and subsequent posts I want to explore some of these issues in more detail, and discuss what they mean in terms of developing a treatment for depression.

I stated in the introduction that depression could be regarded as a symptom not a cause. I also said this view was not one shared by mainstream psychiatry and clinical psychology. Before exploring the reason for this difference in viewpoint it would be helpful to understand what we mean by the term ‘symptom’.

If we stick with the medical definition of ‘symptom’, there are a range of definitions. For example:

A physical or mental feature with in regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient.2

Any subjective evidence of disease or of a patient’s condition, i.e., such evidence as perceived by the patient; a change in a patient’s condition indicative of some bodily or mental state….A subjective indication of a disease or a change in condition as perceived by the patient. For example, the halo symptom of glaucoma is seen by the patient as colored rings around a single light source.3

With the second two definitions it is interesting to note the emphasis on the term subjective. In other words, a symptom is how the individual experiences their illness, and, by implication, may have very little to do with the objective, e.g., biological, condition of the illness. This emphasis on the subjective is rather peculiar if we look at the etymology of the word ‘symptom’, which derives from the Greek ‘to befall’, i.e. to happen. In other words, a symptom refers to something which happens to the subject. Of course, this is not how the term symptom is commonly used nowadays, even outside of the medical profession. Rather, it is used to mean ‘indicative of something’. In other words, symptoms refer to something which is not immediately obvious.

The psychiatric profession places a great deal of emphasis on symptoms as indicators – both in terms of their classification and their treatment. In fact, the ‘bible’ of American (and, in many cases, British) psychiatry, the DSM, is essentially a dictionary of symptoms. The current version, due to be replaced in May 2013, is DSM IV TR, and it uses the umbrella term ‘mood disorder’ to classify a number of depressive illnesses. For each illness (or ‘disorder’ to use the DSM’s preferred terminology) it identifies a number of symptoms (indicators).

So, with regards to what the DSM IV defines as Major Depressive Episode, we see the following entry:

Major Depressive EpisodeA. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.Note:  Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. The symptoms do not meet criteria for a Mixed Episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. 4

In one sense this all looks perfectly straightforward: if you are exhibiting five or more of these symptoms (indicators) for more than two weeks it is quite likely that you are suffering a major depressive episode.

However, there are number of problems here. To start with, some of these ‘symptoms’ do not fit the medical definition of ‘symptom’ in the first place. For example, take ‘symptom’ number 3: significant weight loss when not dieting or weight gain; or number 4: insomnia or hypersomnia nearly every day. These are not ‘subjective indications of a disease’: they are totally objective and measurable.

There is a more fundamental problem: it is not clear how the ‘diagnosis’ of major depressive episode is derived from a particular ‘cluster’ of symptoms, such as those described above. If we are to take the medical definition of ‘symptom’ seriously we must assume that behind these symptoms (both ‘subjective’ and ‘objective’ in this case) there lies an underlying ‘condition’ or ‘disorder’ called a ‘major depressive episode’. In fact, though, this is utter nonsense: what we have instead is a set of behavioural characteristics which are lumped together as ‘major depressive episode’. In other words, a ‘major depressive episode’ is a linguistic construction rather than some underlying, real, entity.

What about the psychoanalytic approach to symptoms?  How does this differ from the medical (and in many ways, common sense) view of the symptom?  As Dylan Evans, in his Dictionary of Lacanian Psychoanalysis, points out, the medical concept of symptoms is:

….predicated on a basic distinction between surface and depth, between phenomena (objects which can be directly experienced) and the hidden causes of those phenomena which cannot be experienced but must be inferred. 5

Evans goes on to explain that there is also a distinction in Lacan’s work between symptoms and structures. However, this is not a distinction between surface and depth, as is the case in the medical conception of symptom, because clinical structures, i.e. neurosis, perversion and psychosis, as much on the surface as are the symptoms themselves. Furthermore, as Dylan points out, in Lacan’s work the term symptom usually refers to neurotic symptoms; strictly speaking, the psychotic subject, for example, experiences psychotic phenomena rather than symptoms, although in the later Lacan a modified version of the symptom (the sinthome) moves psychosis centre stage.

Both Freud and Lacan argued that symptoms are formations of the unconscious and ‘that they are always a compromise between two conflicting desires’.6  One of the interesting consequences of such a definitions is that dreams can be regarded as symptoms. A more general point is that symptoms are understood by Lacan, at least in his earlier work, in linguistic terms, and therefore an analysis of symptoms is an analysis of language.

As Lacan noted, the medical approach to the symptom regards it as an index, in the sense that it points somewhere else (to the underlying illness). This is not the case with the symptom as a linguistic construction. The early Lacan regarded the symptom as a signifier, and one which was product of the subject’s unique history. Furthermore:

Despite their apparent similarities, all neurotic symptoms are unique. Another consequence is that there is no fixed one-to-one link between neurotic symptoms and the underlying neurotic structure; no neurotic symptom is in itself hysterical or obsessional. This means that whereas a doctor can arrive at a diagnosis on the basis of the symptoms presented by the patient, a Lacanian analyst cannot determine whether a neurotic patient is a hysteric or an obsessional simply on the basis of his symptoms.7

In the later Lacan, and particularly in his work in the 1970s, the concept of the sinthome replaces that of the symptom. This relates to a more formalised and mathematical conception of the three registers of the Real, Symbolic and Imaginary (RSI), with the introduction of the Borromean Knot. The sinthome adds an additional ‘ring’ to the existing three ‘rings’ of the RSI, and, Lacan argues, is what keeps the Real, Symbolic and Imaginary from breaking away from one another, which is essentially the condition of the psychotic.

Where does all this leave depression? Can we still argue that it is a symptom rather than the underlying illness? At this point we need to distinguish between illness and disease. If you recall, the medical definitions of symptom quoted earlier referred to disease rather than illness. Even though these terms are often used interchangeably, it’s probably more helpful to think of disease in terms of some biological malfunction of the organism, whereas the illness is how such a biological malfunction is experienced by the subject. Furthermore, it is quite possible for the subject to have a disease without being ill, i.e. not to be aware of any underlying abnormality; and also possible for someone to be ill without there being any underlying (biological) problem. Psychoanalysts are particularly familiar with the latter situation.

From this perspective, we might argue that illness is on the side of the symptom, in its common, medical use. In other words, when someone says that they feel ill, they often mean they are experiencing a particular set of symptoms, for example sickness, tiredness, headaches – which may or may not relate to some underlying malfunction of the organism.

When it comes to depression, things start to get even more tricky. As we have seen, the DSM treats depression in terms of clusters of symptoms; in fact, the DSM does not recognise depression per say, but rather a range of mood disorders, which all have their own particular symptom cluster. The question is, however, is do these symptoms indicate an underlying, biological (or neurobiological) malfunction?

Strictly speaking, the answer to this question should be yes and no. Yes, to the extent that there are often measurable changes in neurochemistry in a person who is exhibiting those particular symptoms that are associated with a particular mood disorder (to use the language of the DSM). No, to the extent that these changes in neurobiology may not necessarily be a malfunction, but rather simply the brain’s response to a particular situation – for example, the person may be in a state of grief following the death of a loved one. Perhaps at this point it is worth noting that in the new version of the DSM, DSM V, such grief reactions are to be considered pathological if they continue for more than two weeks!

In other words, the fact that there can be correlations between a person’s neurobiological state and a particular set of symptoms does not mean that we can say depression is a disease. After all, how do we decide which particular neurobiological state is ‘normal’ and which is ‘pathological’? These may seem rather philosophical questions, but in fact they have very practical, and sometimes dire consequences, especially when in comes to decisions regarding medication.

And there is another problem when in comes to depression as a particular neurobiological state: that of causality. In other words, is the neurobiological state the cause or the effect? In the example of grief cited earlier, we might suspect the neurobiological changes, assuming there are any, are the effect not the cause.

When it comes to the psychoanalytic notion of the symptom then I think we have to say that, strictly speaking, depression is neither symptom or illness (disease). Rather, it is an affect which accompanies a range of human conditions. In fact, Melanie Klein talked about the depressive position, rather than depression as a symptom or underlying disease.

However, this is not to say that psychoanalysis has no interest in depression; on the contrary, it has a great deal to say about it. The important point to note, however, is that the focus here is on depression in relation to loss…

Notes and references

  1. http://www.therapeia.org.uk/wp/touching-the-real-2/psychotherapist-in-godalming-and-aldershot-understanding-depression/ []
  2. The New Oxford Dictionary of English []
  3. http://medical-dictionary.thefreedictionary.com/symptom []
  4. http://www.mental-health-today.com/dep/dsm.htm []
  5. Evans, D. (1996) An Introductory Dictionary of Lacanian Psychoanalysis. London, Routledge, p. 205 []
  6. ibid []
  7. ibid []

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