The Bottom-line: Endogenous vs. Exogenous Depression
CLASSIFYING DEPRESSION
Depression of all kinds produces mood, thought, motivational, and physical
deficits. What kinds of depression exist? DSM-4 has adopted the most reliable
and basic distinction in depression: the unipolar-bipolar distinction,
which we defined above. In addition to the bipolar-unipolar distinction,
however, DSM-4 also distinguishes between episodic and chronic depressions.
In a chronic depression, the individual has been depressed for at least
two solid years without having had a remission to normality of at least two
months in duration. An episodic depression, which is much more common,
is of less than two years' duration and has a clear onset which distinguishes it
from previous non-depressed functioning.
Endogenous vs. Exogenous Depression
The endogenous vs. exogenous distinction in depression, called by DSM-4
depression with melancholia vs. depression without melancholia, is an attempt
to separate biologically based from psychologically based depressions.
The word endogenous (biological-with melancholia) means
"coming from within the body," and exogenous (psychological-without
melancholia) means "coming from outside the body"; the implication of
these terms is that an exogenous depression is precipitated by a life stressor,
while an endogenous depression arises from a disordered biology.
This distinction is associated with two fairly reliable symptom clusters: endogenous
depressions involve psycho-motor retardation, more severe symptoms, the
lack of reaction to environmental changes during the depression, loss of interest
in life, and somatic symptoms, while exogenous depressions show
fewer of these characteristics. In addition, early morning awakening, guilt,
and suicidal behavior may be more associated with endogenous than exogenous
depressions (Mendels and Cochran, 1968).
The usefulness of the endogenous-exogenous distinction is compromised,
however, by a lack of difference in precipitating events. Endogenous depressions
have been found to have no fewer precipitating events than exogenous
depressions (Paykel, Meyers, Dienelt, Klerman, Lindenthal, and
Pfeffer, 1969; Leff Roatch, and Bunney, 1970).
But while there is no difference in precipitating events, there may be different treatment implications:
Endogenous depressions, identified by the endogenous symptom cluster
may respond better to antidepressant drugs and electro-convulsive shock,
while exogenous depressions may fare better with psychotherapy alone. The
results of differential treatment studies have not been uniform, however,
and the distinction must be viewed with caution (Fowles and Gersh, 1979).
Finally, there is also a good possibility that the distinction between mild
and severe may be the basis of the endogenous-exogenous continuum, with
the endogenous depressions merely being more severe. This would mean
that there is only one type of unipolar depression but that there are important
differences in intensity.
We will distinguish below only between unipolar and bipolar depression.
We now turn to the question of who is particularly vulnerable to unipolar
depression.
VULNERABILITY TO DEPRESSION
How specific can we be about this "common cold of mental illness"? At the
very moment about one out of fifteen Americans is moderately or severely
depressed, and chances are one in three of having a depressive episode of
clinical proportions at least once in your lifetime (Weissman and Myers,
1978). Depression has always been with us. Early Greek and Roman tracts
describe the disorder in terms that still ring true. The Roman historian Plutarch
in the second century, A.D., described melancholia as follows:
He looks on himself as a man whom the gods hate and pursue with their anger. A far worse lot is before him; he does not employ any means of averting or of remedying the evil, les the be found fighting against the gods. The physician, the consoling friend, are driven away. "Leave me," says the wretched man. "Me, the impious, the accursed, hated of the gods, to suffer my punishment."He sits out of doors wrapped in sackcloth or in filthy rags. Ever and alone, he rolls himself, naked, in the dirt confessing about this and that sin. (Zilboorg, 1941)
Who is vulnerable to depression? Everyone. No group-not blacks or
whites, not women or men, not young or old, not rich or poor-is wholly
spared. While depression is found among all segments of mankind, some
groups, however, are more susceptible than others.
Sex Differences in Depression
Women seem to be rather more vulnerable to depression than men. About
twice as many women as men are treated for depression. Moreover, a similar
ratio is found when door-to-door surveys are taken of men and women
in urban communities, indicating that the ratio is not a result of women's
greater willingness than mens to seek treatment. The 2-1 ratio applies
across cultures, holding both in Europe and the United States, as well as in
two small villages in Uganda (Orley and Wing, 1979). When an investigator
matched large numbers of women and men for such influences as income,
employment, age, marital status, head of household, and others, she found
that in every category save two, greater numbers of women reported more
depression than men. For example, among women and men earning the
same amount of money, depression was more frequent in women. Only
among single heads of household and among groups of those over sixty-five
was the frequency of depression the same for men and women (Radloff and Rae, 1979).
Several hypotheses have been advanced to account for the sex difference
in depression. First, women may be more willing to
express depressive symptoms than men are in our society. When they confront loss, women are
more reinforced for passivity and crying, while men are more reinforced for
anger or indifference (Weissman and Paykel, 1974).
Second, biological hypotheses suggest
that chemical enzyme activity, genetic proneness, and a
monthly bout of premenstrual depression influence vulnerability in
women. Also there is the possibility that female carriers of a depressive gene
become depressed, whereas male carriers of the same gene become alcoholic
(Robinson, Davis, Nics, Ravaris, and Sylvester, 1971; Winokur, 1972.) A
third hypothesis grows out of the learned helplessness theory of depression.
If depression is related to helplessness, then to the extent
that women learn to be more helpless than men, depression will appear
more frequently in women than in men. A society that rewards women for
becoming passive in the face of loss while rewarding men for active coping
attempts may pay a heavy price in later female depression (Radloff, 1975).
Note: Infants between the ages of six
and eighteen months who are
separated from their mothers for
prolonged periods may develop
symptoms of 'anaclitic' depression.
Depression of all kinds produces mood, thought, motivational, and physical
deficits. What kinds of depression exist? DSM-4 has adopted the most reliable
and basic distinction in depression: the unipolar-bipolar distinction,
which we defined above. In addition to the bipolar-unipolar distinction,
however, DSM-4 also distinguishes between episodic and chronic depressions.
In a chronic depression, the individual has been depressed for at least
two solid years without having had a remission to normality of at least two
months in duration. An episodic depression, which is much more common,
is of less than two years' duration and has a clear onset which distinguishes it
from previous non-depressed functioning.
Endogenous vs. Exogenous Depression
The endogenous vs. exogenous distinction in depression, called by DSM-4
depression with melancholia vs. depression without melancholia, is an attempt
to separate biologically based from psychologically based depressions.
The word endogenous (biological-with melancholia) means
"coming from within the body," and exogenous (psychological-without
melancholia) means "coming from outside the body"; the implication of
these terms is that an exogenous depression is precipitated by a life stressor,
while an endogenous depression arises from a disordered biology.
This distinction is associated with two fairly reliable symptom clusters: endogenous
depressions involve psycho-motor retardation, more severe symptoms, the
lack of reaction to environmental changes during the depression, loss of interest
in life, and somatic symptoms, while exogenous depressions show
fewer of these characteristics. In addition, early morning awakening, guilt,
and suicidal behavior may be more associated with endogenous than exogenous
depressions (Mendels and Cochran, 1968).
The usefulness of the endogenous-exogenous distinction is compromised,
however, by a lack of difference in precipitating events. Endogenous depressions
have been found to have no fewer precipitating events than exogenous
depressions (Paykel, Meyers, Dienelt, Klerman, Lindenthal, and
Pfeffer, 1969; Leff Roatch, and Bunney, 1970).
But while there is no difference in precipitating events, there may be different treatment implications:
Endogenous depressions, identified by the endogenous symptom cluster
may respond better to antidepressant drugs and electro-convulsive shock,
while exogenous depressions may fare better with psychotherapy alone. The
results of differential treatment studies have not been uniform, however,
and the distinction must be viewed with caution (Fowles and Gersh, 1979).
Finally, there is also a good possibility that the distinction between mild
and severe may be the basis of the endogenous-exogenous continuum, with
the endogenous depressions merely being more severe. This would mean
that there is only one type of unipolar depression but that there are important
differences in intensity.
We will distinguish below only between unipolar and bipolar depression.
We now turn to the question of who is particularly vulnerable to unipolar
depression.
VULNERABILITY TO DEPRESSION
How specific can we be about this "common cold of mental illness"? At the
very moment about one out of fifteen Americans is moderately or severely
depressed, and chances are one in three of having a depressive episode of
clinical proportions at least once in your lifetime (Weissman and Myers,
1978). Depression has always been with us. Early Greek and Roman tracts
describe the disorder in terms that still ring true. The Roman historian Plutarch
in the second century, A.D., described melancholia as follows:
He looks on himself as a man whom the gods hate and pursue with their anger. A far worse lot is before him; he does not employ any means of averting or of remedying the evil, les the be found fighting against the gods. The physician, the consoling friend, are driven away. "Leave me," says the wretched man. "Me, the impious, the accursed, hated of the gods, to suffer my punishment."He sits out of doors wrapped in sackcloth or in filthy rags. Ever and alone, he rolls himself, naked, in the dirt confessing about this and that sin. (Zilboorg, 1941)
Who is vulnerable to depression? Everyone. No group-not blacks or
whites, not women or men, not young or old, not rich or poor-is wholly
spared. While depression is found among all segments of mankind, some
groups, however, are more susceptible than others.
Sex Differences in Depression
Women seem to be rather more vulnerable to depression than men. About
twice as many women as men are treated for depression. Moreover, a similar
ratio is found when door-to-door surveys are taken of men and women
in urban communities, indicating that the ratio is not a result of women's
greater willingness than mens to seek treatment. The 2-1 ratio applies
across cultures, holding both in Europe and the United States, as well as in
two small villages in Uganda (Orley and Wing, 1979). When an investigator
matched large numbers of women and men for such influences as income,
employment, age, marital status, head of household, and others, she found
that in every category save two, greater numbers of women reported more
depression than men. For example, among women and men earning the
same amount of money, depression was more frequent in women. Only
among single heads of household and among groups of those over sixty-five
was the frequency of depression the same for men and women (Radloff and Rae, 1979).
Several hypotheses have been advanced to account for the sex difference
in depression. First, women may be more willing to
express depressive symptoms than men are in our society. When they confront loss, women are
more reinforced for passivity and crying, while men are more reinforced for
anger or indifference (Weissman and Paykel, 1974).
Second, biological hypotheses suggest
that chemical enzyme activity, genetic proneness, and a
monthly bout of premenstrual depression influence vulnerability in
women. Also there is the possibility that female carriers of a depressive gene
become depressed, whereas male carriers of the same gene become alcoholic
(Robinson, Davis, Nics, Ravaris, and Sylvester, 1971; Winokur, 1972.) A
third hypothesis grows out of the learned helplessness theory of depression.
If depression is related to helplessness, then to the extent
that women learn to be more helpless than men, depression will appear
more frequently in women than in men. A society that rewards women for
becoming passive in the face of loss while rewarding men for active coping
attempts may pay a heavy price in later female depression (Radloff, 1975).
Note: Infants between the ages of six
and eighteen months who are
separated from their mothers for
prolonged periods may develop
symptoms of 'anaclitic' depression.
Depression and Suicide
Post-Traumatic Stress Disorder (PTSD)
Social Anxiety
Generalized Anxiety
Panic Disorder
Major Depression Disorder
Agoraphobia
For the Therapy I recommend click here:
The Liberator Method
Post-Traumatic Stress Disorder (PTSD)
Social Anxiety
Generalized Anxiety
Panic Disorder
Major Depression Disorder
Agoraphobia
For the Therapy I recommend click here:
The Liberator Method