The Depressive Disorders

Symptoms

The depressive disorders can take many different forms. Alongside the main symptoms listed in the International Statistical Classification of Diseases (ICD-10) of “lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced” (2), there are in addition many different accompanying symptoms which derive from the main symptoms or supplement them. But such addition of symptoms does not result in a real clinical picture in which something of the nature of depression (5, 6, 7, p. 370-387) could be expressed. This requires a phenomenological view of depressive phenomena which can be classified into different levels from the perspectives of anthroposophical psychiatry (7, p. 379 ff):

1. Physical (organic functional) level
2. Mental level: primarily into thinking life, emotional life and life of the will.
3. Relationship level (psychosocial level)
4. Biographical spiritual level

1. The physical level: The depressive disorders are not limited in their symptoms to the psyche alone. On the contrary, depressive disorders always also manifest in physical experience, often also in organic functional impairments. In general, these often manifest as a feeling of heaviness, lassitude, tiredness, lack of strength and exhaustion, in slowing down and tension, in pain, stagnation and torpor, in loss of appetite and constipation, in sleep disorders and reduced libido and vitality. Organic functional disorders can affect the head, respiration and circulation, digestion, back muscles and limbs.

2. The mental level: The actual and essential mental symptoms can be differentiated into the three basic abilities of the soul:

• Thought life: Thinking manifests a slowing down, inability to switch off and brooding, fixation on negative, pessimistic thoughts, thoughts of hopelessness, self-contempt and futility.
• Emotional life: Feelings and moods manifest joylessness and listlessness, often sad and depressed moods for no reason, a “feeling of numbness”, fears, worries and phobias, feelings of guilt, fear of failure and despair.
• Life of the will: In volition and action/behaviour, it is strikingly apparent that those affected find everything more difficult than before. It starts with getting up in the morning, betrays itself with every pending decision, shows itself in all activities, leads to an inability to make decisions, listlessness and finally lethargy extending as far as stupor. Willpower is paralysed.

3. The relationship level: It is noticeable in depressive patients that their relationship life, their psychosocial contacts are characterised by social withdrawal, the fear of encounters and relationships, the worry of being a burden, the feeling of not being understood, the experience of being useless and therefore wanting to “disappear”. New encounters are avoided, old relationships are no longer cultivated. A withdrawal into loneliness and a feeling of not being understood develops.

4. The biographical spiritual level: This is the level in which the spiritual I of the human being expresses and realises itself – in lifestyle and way of life, in inner attitude (see also 8, p. 161-195) and individual possibilities of coping, in personal biography, in destiny. Here we experience in depressive patients severe self-esteem problems, self-doubt, fear and doubts about coping with life, questions about the meaning of life and the disorder, despair of destiny, tiredness of life and suicidal tendencies. Often a devastating and abysmal questioning of the value and meaning of life and life’s achievements can occur which in the context of severe depressive disorders can lead to weariness of life and suicidal tendencies out of despair. 

Pathogenesis

Psychiatry today no longer classifies depressive disorders according to cause but according to severity and course (2). Anthroposophical psychiatry strives to understand the nature of depression. It tries to move from the pathology to an understanding of the pathogenesis: how and through what does the clinical picture arise?
What do the symptoms express in the four levels, what processes can be identified in them? How can a therapy be derived from this? 

Pathogenesis describes the way in which the clinical picture develops in a person. Aetiology describes the causes or reasons that trigger pathogenesis. These reasons can be very different. In the case of depressive disorders, it can for example be disappointments or excessive demands, experiences of loss or trauma, conflicts or changes, but also the experience of the unattainability of an imagined and aspired perfectionism. Most reasons lie outside the human being, but it is always the human being with their constitution that responds or reacts to the reasons. Pathogenesis is a process of the response of the human organism as a whole – consisting of body, soul and I – to reasons in life. The clinical picture that then develops can be understood as an expression of an inappropriate response or an as yet unsuccessful way of coping. In this respect it is on the one hand a sign of (temporary) incapability, but on the other hand also a sign of therapeutic need.

The nature of depression

What happens in the pathogenesis of a depressive disorder, what forces or processes lead to the typical depressive symptoms? The above symptoms on the physical, mental, psychosocial and spiritual/biographical levels speak a clear language, they express the process which forms them.

In the main symptoms, as also mentioned in the ICD-10 (2) – lowering (depression) of mood, reduction in the capacity for interest or enjoyment, reduction in energy or increased tiredness – as well as in the facultative symptoms – loss of self-esteem, feelings of guilt, suicidal thoughts, difficulty concentrating and indecisiveness, psychomotor agitation or retardation, sleep disorders and loss of appetite – and also in other depressive symptoms such as those mentioned above, there is typically a tendency towards retardation, being burdened or weighed down and slowing down. We can recognise in this the effect of heaviness as a depressive “archetypal phenomenon”. All of the depressive symptoms mentioned can be attributed to the consequences of the excessive action of heaviness: on the body, in the soul – in thinking, feeling, in moods and in volition and action – as well as in psychosocial relationships and in shaping and coping with our own respective biography. The experience of heaviness in body and soul expresses itself in the manifold symptoms of depressive illness.

Heaviness is the constitutive, the determining element of being depressed (9, 10, 7, p. 370 ff); it is “the nature of burdensome heaviness” that leads to the typical depressive symptoms (9, 10, 7, p. 370 ff). Such heaviness is an expression of primarily physical forces which can be varied in many ways in the further differentiated development of an individual depressive clinical picture by triggering experiences on the one hand, and by inner organ forces on the other.

From this suggested understanding of depression (7, p. 370-387) as a dominance of the experience of heaviness in the body and the mind, a therapeutic need can be identified: overcoming the heaviness and the resulting retardation; brightening and easing experience and mood. Heaviness is always also associated with darkness, burden and threat. These therapeutic principles are realised in anthroposophical psychiatry at different levels.

“Apart from the causes of depression, which are generally both biophysical and psychosocial in nature, one specific aspect often forms a major problem in treatment: many depressed patients do not recognise that they are suffering from depression. They feel down, in despair, inferior, guilty, bad or lost without realising that their feelings are caused by an illness: depression.” (11)

In accordance with the holistic view of the human being and the understanding of illness in anthroposophical medicine and psychiatry, the therapeutic opportunities and provisions are also holistic and related to the different levels of being human. Here a somewhat different emphasis must be placed in comparison to the above description of the four levels, as the aspect of therapy that has been set out requires a different weighting from the earlier aspect of the phenomena of the disorder. This is why levels 2 and 3 are different – for therapy, the functional level gains a special significance through various therapeutic opportunities. Whereas here the mental and psychosocial levels can be combined and treated together.

1. The physical/bodily level: physiological and body-related therapies
2. The functional level: medicinal treatment
3. The mental and psychosocial level: art and creative therapies, psychosocial support, group therapies, self-help groups
4. The biographical and spiritual level: psychotherapy, therapeutic conversation with biographical aspects, spiritual therapies, anthroposophic psychotherapy

Regarding I. Physiological and body-related therapies

This includes many and various therapeutic interventions and provisions: from morning runs, getting up early, movement therapies, swimming, baths, compresses and organ Einreibung, dietary recommendations, light therapy for seasonal depression, to “therapeutic sleep deprivation” (wake therapy). The therapeutic idea underlying all these measures is that of support or stimulation to overcome heaviness, the experience of heaviness as inertia, retardation, stagnation and darkness in body and soul. Lastly, the support of the life rhythms is of therapeutic importance.

Regarding II. Medicinal treatment

Drug therapy with allopathic antidepressants will not be discussed here but specific references to anthroposophic medicines will be given. The therapeutic goal is stimulation, brightening – it is not by accident that antidepressants are called “mood elevators” – and relief of both physical and mental experience in terms of heaviness, slowing down and stagnation. In this sense the following are effective (12, 13):

For depressive symptoms related to the heart, such as a morning low as a typically heavy, depressed mood with anxiety about the day, self-reproach, guilt, existential anxiety, despair, death wishes, suicidal tendencies:

• Aurum metallicum praep. in higher potencies (D12, D15, D20 to D30) trit, amp WELEDA: 1 saltsp preferably orally in the morning as a trituration or as SC injection
• Hypericum, Hypericum Auro cult. Rh D3 WELEDA: 10 – 20 gtt 3 x/d.

For functional heart trouble and anxieties:

• Aurum/Lavandula Rosae aeth. comp. ointment WELEDA : apply to the area around the heart, preferably in the evening, but also in the morning in case of corresponding conditions.

For depressive symptoms related to the lungs, such as phobic anxieties, obsessive fears, anankastic behaviour, melancholic-compulsive-withdrawn perfectionist traits:

• Ferrum sidereum D20 tab WELEDA: 1 tab in the morning 
• Mercurius vivus nat. D12 trit, amp WELEDA: 1 saltsp in the morning or 1 s.c. injection

Especially for phobic anxieties:

• Skorodit D10 trit WELEDA together with  
• Quartz D20 trit WELEDA: 1 saltsp in the morning.

For depressive symptoms related to the liver, such as waking early in the morning between two and four o’clock, a morning low, as well as lack of strength, exhaustion, tiredness, lassitude, lack of energy, apathy, indecision, listlessness, weakness of will, tiredness of life:

• Hepar-Magnesium D4 amp WELEDA: depending on severity 1 amp as s.c. injection 1 x/d to 3 x/wk in the evening.
• Hepar-Stannum D4 amp WELEDA: 1 amp s.c. 3 x/wk in the evening.
• Cichorium D3 or Chelidonium D3 or
• Chelidonium Ferro cultum Rh D3 dil WELEDA or
• Choleodoron® drops WELEDA: 10 – 20 gtt 3 x/d.
• Hepatodoron® tab WELEDA: 2 tab in the evening. 
• Liver compress with yarrow or oxalis .
  For instructions see https://www.pflege-vademecum.de/schafgarben_leberwickel.php  

For depressive symptoms related to the kidneys, such as inner tension, restlessness, agitation, arousal or stuporous states, aggressiveness and hypochondriacal symptoms:

• Cuprum metallicum praep. D6 amp WELEDA or
• Chamomilla Cupro culta, Radix Rh D3 liquid dilution WELEDA or
• Melissa Cupro culta Rh D3 liquid dilution WELEDA: depending on severity of the symptoms 10 – 20 gtt 2 – 3 x/d.
• Ginger kidney compress.
  For instructions see https://www.pflege-vademecum.de/inw.php  
• As mood-elevating medicine Hypericum in high dosage: 900 mg/d in 1 or 2 administrations for mental stabilisation.

For mood changes and mood instability:

• Aurum/Stibium/Hyoscyamus pillules velati, amp WALA: 10 – 20 pillules or gtt 3 x/d or 1 amp/d – 3 x/wk s.c.

For sleep disorders and for better awakening:

• Phosphorus D6 : 5 – 7 gtt in the morning and Phosphorus D25/Malva 5% dil WELEDA: 20 gtt in the evening.

For inner brightening: 

• Phosphorus D10: 10 gtt in the morning.

For the stimulation of intrinsic forces:

• Argentit D6 trit WELEDA: 1 saltsp in the morning and evening

Against exhaustion and feelings of futility:

• Ferrum sidereum D20 trit amp WELEDA: 1 saltsp or 1 amp s.c. in the morning.

Composition of the medicines listed: Aurum/Lavandula Rosae aeth. comp. Ointment: Aurum metallicum praeparatum dil D4 1g, Lavandulae aetheroleum 0.03g, Aetheroleum extractum e floribus recentibus Rosae damascenae et centifoliae. Hepar-Magnesium D4: Hepar bovis – Magnesium hydroxydatum (6:4) dil D4. Hepar-Stannum D4: Hepar bovis – Stannum hydroxydatum (8:2) dil D4. Choleodoron®: Chelidonium majus Ø, Curcuma xanthorrhiza, ethanol. Decoctum Ø (=D1). Hepatodoron®: Fragaria vesca, Folium sicc. / Vitis vinifera, Folium sicc. Aurum/Stibium/Hyoscyamus amp: Aurum metallicum dil D9; Hyoscyamus niger ex herba ferm 33d dil D4 (HAB, Vs. 33d), Stibium metallicum dil D7, Sodium chloride, Sodium hydrogen carbonate, water for injection purposes.

The listed anthroposophical medicines represent a small selection from the experience gained in the clinical and outpatient treatment of depressed people, they are not a complete list. The indication for the use of the various preparations is made in accordance with the symptoms experienced in those affected, which must be seen in connection with the organic forces working into the psyche (described in detail in 8, p. 67-76, 7, p. 255-271 and p. 370-387, 12, p. 854-964, 13). Here the action on the psyche of the heart and lungs, liver and kidneys are particularly to be considered (in the sense of a psychology of the organs (8, pp. 67-76, 7, pp. 255-271), which is why the information here is structured accordingly. The connections between depressive symptoms, the action of the organs and medication can be found in the literature mentioned (9, 14, 15, 16, 17, 18) and will not be discussed further here. The depiction of the depressive symptoms makes clear that a depressive disorder is rarely associated with only one organ. Mostly it is several of the four main organs mentioned that interact in the sense of a psycho-organic complex of forces (14) and define the mental symptomatology of a depressive clinical picture (in a differentiation of the underlying effect of heaviness).

Regarding III. The art and creative therapies

Art therapy and creative methods such as therapeutic sculpting in clay, stone or wood, therapeutic drawing, painting therapy, music therapy, therapeutic speech, drama therapy, eurythmy therapy, dance therapy and other therapeutic artistic practices have today proved their worth in the complementary treatment of depressive patients in the sense of an activating and exercising therapy, often also in the sense of non-verbal psychotherapeutic methods. They complement the above therapies by directly addressing the mental experience and the mental self-activity of the patients. Through the two factors at work in art therapy of expression and impression (7, p. 468-479), those affected experience relief, unburdening and distancing through the opportunity of expressing their experience in an artistic medium. Through the factor of impression, they are offered a way of coping with their experience such as is possible in the artistic medium as well as positive self-experience, an expansion of the possibilities of dealing with and integrating heaviness, stress and suffering as well as activating resources of strength in their I.

In principle, all art therapies can be used with depressive patients. The differential indication is guided more by the ill persons and their access to an art than by the symptoms. The latter are taken into account in the choice of therapeutic measure in an art and in special art therapy interventions.

In the art therapies, the therapeutic goals can be described as mental activation, brightening and coping. 

Regarding IV. Anthroposophical psychotherapy

In the treatment of depressive patients, psychotherapeutic procedures are now generally recognised not only as a supplement to pharmacotherapeutic treatment, but as an appropriate and necessary therapy. Various psychotherapeutic methods can be used. In the past decades, methods of depth psychology and psychoanalysis were used in particular, then increasingly cognitive behavioural – today also schema therapy – and mindfulness-based methods such as mindfulness-based cognitive therapy (MBCT).

Specific aspects of anthroposophic psychotherapy are outlined below (15). Essential for any psychotherapy is a trusting and supportive therapeutic relationship (8, p. 126 ff).

In general, the psychotherapeutic treatment of depressive patients can pursue three goals: first, alleviation of the depressive symptoms; second, working on the triggering situation such as an affront, conflict, trauma, loss, overload; third, reflection and work on the psychological personality structure that predisposes to a depressive disorder (16, p. 309-325).

In anthroposophic psychotherapy we can also pursue the first two goals in a varied form. Then decisive new aspects additionally arise.

Overall, we can pursue four goals in anthroposophic psychotherapy:
First, an alleviation of the depressive symptoms. Second, working on the triggering situation such as an affront, conflict, trauma, loss, overload. Third, specific consideration of the depressive symptoms as an expression of organ effects in mental experience and behaviour. To this end appropriate psychotherapeutic interventions in therapeutic conversation can lead to a new understanding of the depressive symptoms, whereby the patient can develop a conscious distancing from the symptoms and a new attitude towards the disorder. These psychotherapeutic steps supplement external treatments, anthroposophical medicines and art therapies, and eurythmy therapy which can also be used with these perspectives in mind. Fourth, a reflection on the individual constitution of body, soul and spirit, the “personality structure” in a greater sense, especially soul development and the biographical situation that has produced a depressive disorder in response to certain experiences. This constitution is expressed psychologically in the inner attitude of the patients which they can develop towards the disorder, its triggering situation, the ability to cope or the suffering from the inability to cope, and their own biography.

Goals 3 and 4 are complementary to goals 1 and 2: here it is not about experiencing the symptoms of those affected, not about coming to terms with what has been experienced, but about the overall personality and the inner attitude of the person towards the disorder and their destiny. The inner attitude (8, p. 161-197) of a person is the result of the I working in the soul.  It allows us, consciously or unconsciously, to evaluate, judge and give (individual) meaning to everything we experience. Ultimately, our evaluation of the experience and our giving of meaning (16, p. 309-325) leads to the personal mental experience, to the feelings that can then either appear as a mental disorder – e.g. anxiety, depression, overload, compulsions – or enable us to cope with the experience. In this respect, a psychotherapeutic approach to the inner attitude of the patient as we have presented it in Anthroposophy-based Psychotherapy® (8, p. 161-197, 291-314) is a specifically anthroposophical approach that deliberately addresses, reflects and supports the efficacy of the I in the soul in order to enable acceptance, re-evaluation and management of the disorder in this way.

There are different psychotherapeutic ways to be able to work on and achieve the therapeutic goals. Anthroposophy-based Psychotherapy® has developed special approaches, methods, psychotherapeutic interventions and exercises for this purpose (8, chap. VII and IX).

The psychotherapeutic goals in consideration of the constituent element of heaviness can be characterised as illumination (working on meaningfulness), (inward) movement, the capacity to withstand and, lastly, overcoming.

Summary

In order to be able to treat people with depressive disorders appropriately, it is necessary not only to see depressive symptoms and want to treat those but to recognise the nature of the depressive disorders and to take into account their meaning in the biography of the person affected. The occurrence of heaviness in a person’s life always has meaning and significance.

The therapeutic goals of overcoming heaviness can be achieved in the therapies mentioned through activation and movement, through brightening and clarity, through stimulation and support on a physical and functional level, as well as on a mental and biographical-spiritual level. Supporting factors here are the therapeutic relationship, the therapeutic stance (8, p. 151 ff., 17) as well as an understanding of the disorder and the therapy goals to be aimed for that are found jointly between the patient and therapist.

Depression is a serious disorder, not a meaningless or random event in life. Depression has a meaning and it gives meaning. Through its occurrence in life, through the experience of heaviness, it often poses the question of meaning to those affected – and it can allow us the experience of a meaningful answer. Good therapy should pave the way for this. Anthroposophy-based Psychotherapy offers the methodological path in psychotherapeutic work on the inner attitude of the patient to deal with meaningfulness in an experiential and cognising way.

1. Styron W. Darkness Visible. A Memoir of Madness London: Vintage 2004. 
2. International Statistical Classification of Diseases and Related Health Problems. 10th Revision. F32 Depressive episode; F33 Recurrent depressive disorder; F34 Persistent mood [affective] disorders. https://icd.who.int/browse10/2019/en
3. World Health Organization. Depression and Other Common Mental Disorders. Available at https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf (30.11.2021). 
4. Available at www.äerzteblatt.de/archive.  
5. Treichler M. Wenn die Seele Trauer trägt. Depressionen mitfühlen, erkennen, verstehen, behandeln. Esslingen: Gesundheitspflege initiativ; 2010.
6. Treichler M. Sprechstunde Psychotherapie. Stuttgart: Urachhaus; 2007: 278-318.
7. Fintelmann V, Treichler M. Seele & Leib in Gesundheit und Krankheit. Frankfurt: Info3 Verlag; 2019.
8. Treichler M. Reiner J. Anthroposophie-basierte Psychotherapie. Salumed Verlag Berlin 2019.
9. Cf. also Kraus A. Sozialverhalten und Psychose Manisch-Depressiver. Stuttgart: Enke Verlag; 1977.
10. Cf. also Tellenbach H. Melancholie. Berlin, Heidelberg: Springer Verlag; 1983: 117-120.
11. Kuiper PC. Seelenfinsternis. Die Depression eines Psychiaters. Frankfurt: Fischer Taschenbuch Verlag; 1995: 9.
12. Only a very small selection of medicines is presented here. For more information on medicines, see Treichler R. Grundzüge einer geisteswissenschaftlich orientierten Psychiatrie. In: Husemann F,  Wolff O (ed.) Das Bild des Menschen als Grundlage der Heilkunst. Vol. II. Stuttgart: Freies Geistesleben; 1978: 854-964.
13. See also Rißmann W. Depressive Störungen: Menschenkundliches Verständnis und Therapie mit anthroposophischen Heilmitteln und äußeren Anwendungen. Der Merkurstab 2006;59(5):407-413. DOI: https://doi.org/10.14271/DMS-18956-DE.
14. Steiner R. Aspects of Psychiatry. In: Physiology and Healing. Treatment Therapy and Hygiene. CW 314. Forest Row: Rudolf Steiner Press; 2013: 212-221.
15. Somewhat different perspectives on psychotherapy are represented in: Roediger E. Anthroposophische Aspekte zur Psychotherapie der Depression. Der Merkurstab 2006;59(5):395-402. DOI: https://doi.org/10.14271/DMS-18954-DE.
16. Lang H. Wirkfaktoren der Psychotherapie depressiver Erkrankungen. In: Lang H (ed.) Wirkfaktoren der Psychotherapie. Würzburg: Verlag Königshausen & Neumann; 1994.
17. Treichler M. Von der therapeutischen Haltung. Der Merkurstab 2012;65(6):528-533. DOI: https://doi.org/10.14271/DMS-20053-DE.