PERIPHERALIA

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“We have a preponderance of psychiatric treatments that 
now ignore the heart and soul of what it is to be human” 

Robert A Berezin 

In general practice we often see the classical features of 
depression in our patients. These are the ones laid out in the 
box that has been promulgated by the DSM V. We know that 
not everyone fits into these boxes for classification and there 
is a penumbra of feelings and emotions that occur around 
the classic features. They are the shadows of the shadows 
and the more indistinct symptoms that surround the core of 
central darkness.  

The DSM V correctly lays down the criteria for depression, 
which include, amongst others, too much or too little sleep 
with early morning awakening, too much or too little appetite 
and too much or too little psychomotor activity. There is also 
loss of interest in life, concentration and fatigue. 

But this can never be, as we know, the whole picture when 
treating individuals. There are nebulae of less well defined 
feelings and emotions that may surround the main picture or 
may assume more prominent features in a specific patient’s 
life.

These include withdrawal, a sense of failure, indecision, a loss 
of confidence, a sense of apprehension, a feeling of exposure 
and a distrust of others and institutions. In the last decade or 
two there is also an old Greek word that has been resurrected, 
anhedonia, meaning the inability to experience pleasure. It is 
the absence of joy or appreciation of life lived to its fullest.  

There are also other issues beyond these experiences such as 
the seeking for the reasons for our life conditions especially 
when we have to face events for which there is no rational 
explanation. We often need to confirm that life has a purpose 
or telos and negotiate the religious and moral reasons for 
illness.

In the middle ages an interesting form of depression 
involving the spirit or soul was called Acedia (or Accidie). It was 
described as a form of spiritual alienation found in monks in 
monasteries, who had had a crisis of faith. Along the same lines, 
in 1967, the psychologist Maddi proposed the concept of the 
existential neurosis of modern life that alienates patients from 
both themselves and society. The condition is characterised 
by chronic meaningless, apathy and aimlessness. It is partly 
caused by the breakdown of the discipline and coherence of 
modern civil society and family life.

I have in the past encountered patients, usually devout 
Christians, who have presented with this crisis of belief. On 

further enquiry they have partially fulfilled the criteria for 
clinical depression but whether the loss of faith has caused 
the depression or is a manifestation of the depression itself 
was never clear. Many patients are on spirit quests especially 
rural and indigenous peoples of Africa, the Americas and 
Australasia. Spiritual quests are often conducted through 
meditative practices such as mindfulness, transcendental 
meditation, Koranic recitations, Zazen in Zen Bhuddism, as 
well as Yogic meditation, Christian contemplative prayer, 
Sufi meditation and the ethical meditation of Confucian 
philosophy. 

In recent years I seem to have concentrated on biomedical 
explanations for depression on the basis of chemical 
imbalances. In the rush of general practice this is often the 
easy way out and the spiritual and cultural constructions of 
depression have taken a back seat. 

We like to confine patients to diagnostic boxes because 
it is easier for us to visualise them but now we are seeing 
complex mixed forms of depression and anxiety interwoven 
with the problems of living, such as unemployment, poverty, 
chronic illness, divorce, violence and family conflict. Beyond 
the boxes and the classifications lies the spirit or soul mostly 
unacknowledged by the medical gaze. The soul, like ultimate 
reality, is difficult to understand or describe from a medical 
aspect. It is “beginningless, beyond what is and beyond what 
is not, incomprehensible, unlimited, not to be reasoned 
about, unthinkable” (Maitri Upanishad, 1.4.6). The philosopher 
Plato thought that a man’s soul is the very essence of his 
being and was God immanent (God-within-him). The purpose 
of good and just men and women was, he said, to educate 
and nurture the soul in other men and women.

The pastoral aspects of medical practice has, over the 
years, often been replaced by the modern medications and 
technology now available to us. How does one address the 
soul which is not available for scrutiny in a laboratory or in 
the physiology of the prefrontal cerebral cortex? It is not 
something that one can “treat”. It needs to be understood 
as a personal individual reality. It is in this way that medical 
practice can be widened into the three duties described 
by Marcus Aurelius. These three duties were: to this bodily 
shell that envelopes us, to the divine, which is the source of 
everything in all things and to our fellow-mortals around us.  

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

Email: cristobalellis@gmail.com

The spiritual construction of depression