Atypical depression

A woman in her 30s comes to a clinic and says that for several months she has been feeling sad and hopeless and too anxious to concentrate on her work. She is afraid she may lose her job and occasionally has thoughts of suicide. She has gained 15 pounds and feels tired all the time. She has trouble falling asleep and then sleeps through her alarm. Often she finds herself bursting into tears, with her heart pounding. The symptoms began after the breakup of a romance. Her self-esteem has always been low, she says, and she has had previous episodes of depression, usually brought on by a disappointment in love. At times she has taken diet pills and been a heavy drinker, but now she is avoiding drugs and alcohol. She does not improve when given the tricyclic antidepressant imipramine, but most of her symptoms go away in a few weeks when she is switched to phenelzine, a monoamine oxidase inhibitor (MAOI).

Although most people would not find anything unusual or remarkable about this condition, it has been called "atypical depression." Why?

The term came into use in the late 1950s when psychiatrists noticed that for some depressed patients, tricyclic antidepressants were not effective but MAOIs (at that time the only alternative) were. These patients seem to have certain other characteristics in common. They complained of many physical symptoms, one of which, often, was a feeling of heaviness in the arms and legs. They had a tendency to oversleep and overeat. They felt worse in the evening. They were not sad all the time but able to cheer up at least momentarily in response to sympathy, compliments, or a visit from a child. They were highly sensitive to what they regarded as rejection by lovers and others. Many had phobias, panic attacks, or severe premenstrual symptoms. This picture is atypical because most depressed patients are more constantly sad, wake up early rather than oversleep, feel worse in the morning rather than the evening, and eat less rather than more than average.

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