Many of the signs of distress we have spoken about so far may equally be present in the absence of a true anxiety or depression disturbance. If, however, they are very numerous in a given patient, we may very rightfully suspect that he cannot simply classed as someone whose "nerves are a a bit on edge", and that there is something more in his case. Anxiety and depression are frequent, but often ignored in patients with a severe, long-standing headache, and must be investigated by anyone who sets out to cure him.
When their presence is assumed, therefore, the questions we have just explained must be accompanied by a discreet inquiry directed to other features characteristic of depression.
Moments of sadness, of course, are part of life's common pattern. Even so, importance must be duly attached to a patient's admission that he is sad all or most of the time, and has lost interest in things that once attracted his attention and served as a stimulus.
Equally important and for the same reasons are substantial weight gains or losses over a relatively short period, especially if this period coincides with single or repeated dramatic or in some way adverse events in the patient's life.
A person's attitude towards death is a significant factor on which a judgement may be based. Several attitudes may be encountered. There are those who have a true fear of death (the technical term is thanatophobia): "Let's not talk about that, doctor. It's a terrible thought that never leaves me alone". Other people are frequently and intensely disturbed by the thought of the possible death of their loved ones.
Yet the situation that must be handled with the maximum delicacy is one in which death is seen as desirable. I am sometimes faced with patients who admit that they have tried to commit suicide, even more than once.
It is strange that, especially on the part of women, the determination needed for such an act may be built up, as it were, by degrees: "I couldn't tell you whether I really wanted to die the first time. The second time, there was no doubt at all". It is not a matter of chance that the number of uncompleted attempts is much higher than for men.
I shall never forget a story of this kind recounted by one of my patients. When I first saw her, virtually all the usual psychosomatic symptoms were present: intestinal pains, insomnia, phobias, anxiety, tachycardia, sudden sweating episodes, constipation, prostration, etc. She had suffered from recurrent depression crises in the past, and stated that she was still frequently very sad.
It was evident that a depression disturbance persisted, and the almost cheerful way in which she told her story was no cause for surprise. This was certainly not the first time I had encountered a depressed woman with a pleasing appearance, affable and light-hearted.
In answer to my question whether her times of sadness were suddenly replaced by periods of happiness, she stated that her mood swings were both sudden and powerful. I than asked her whether she had ever contemplated suicide in one of her black moments. As I expected, the answer was in the affirmative:
"Yes, about a year ago I nearly threw myself out of the window. I thought I'd get it all over, and not suffer any more".
"Then, thank heavens, I changed my mind".
"Yes, at the very last moment I changed my mind, to be more precise I had a thought that prevented me from going through with it".
I wondered which of the many reasons that conventionally frustrate a suicide applied in her case. She was separated from her husband and lived with her ten-year-old daughter. Was it the idea of leaving her alone that stopped her, the thought of her elderly mother or her current companion, or simply the fear of death? So I decided to ask her.
"What was the thought that fortunately prevented you from killing yourself?" With a ghost of a smile she gave the following explanation.
"What I'm going to tell you will seem incredible, but things really happened this way. I'd already made up my mind and was on my way upstairs when I caught sight of myself in a mirror on the landing. 'Good Lord', I said, 'Just look at my clothes. I must change. I can't be found dressed like this'. Then I started to think what would be right for the occasion. My first choice was a cocktail dress of which I am very fond. 'Black, too', I said to myself, 'and in keeping'. But then I considered its plunging neckline. What would people think? Next came a dress with flowers, another of my favorites. But that was immediately discarded as quite inappropriate. The flowers were roses and daisies... had they at least been chrysanthemums! So instead of going to the window I turned into my bedroom, opened the wardrobe, and looked at all my clothes. Not one was any good. So I decided not to kill myself".
Bashfulness, however, often prevents patients from expressing their feelings on the subject of death during the initial stages of our meeting. At times, after a long discussion, I look a patient straight in the eyes and say with as perfectly natural tome of voice: "Have you ever tried to commit suicide?" And the answer is often a nodded "yes".
Usually, however, I put the question another way: "Have you ever thought of death as a desirable event? I'm not talking of planning or attempting suicide, but of considering that, after all, if the end came you would accept it without complaints or even as a liberation". The affirmative answers to this type of question are more frequent than might be supposed.