Depression
When used as a descriptive word “depression” can mean low
mood, dejection, boredom, disappointment etc. These feeling
states are not an illness of depression, or a clinical depression
in a medical sense as described below, and are normal
feelings or reactions for everyone.
Dejection or low mood may be triggered by situations that
stimulate minor defects in one’s self esteem that everyone has
and that are not usually in conscious awareness. These might be
when ignored by peers, passed up at work for a good job,
rejection in romance, etc. These problems are usually mild and
self-limiting and not in need of any intervention such as
counseling unless the stress or sensitivity is really great.
Personality Disorder & Depression
Persons with deeper or a greater number of deficits in their
self identity (i.e., having core issues or mental schemas of
feeling unloved, unwanted, belittled, unvalidated, incompetent,
etc.), may have a more pervasive nature of low mood related to
these core issues or deficits in the “Self” or personality.
This low mood may be worsened by situations that stimulate these
deficits (like being ignored, rejected, etc.).
The dejection and low mood these persons feel is related to
faults in their identity or personality structure, like a
software problem, but they are not illnesses of the brain per se,
like a hardware problem. Persons whose personality is affected
to a significant degree may fit the criteria for a personality disorder.
Intensive psychotherapy aimed at personality
reorganization is the preferred treatment for these problems.
Usually a mixture of various approaches including
Psychodynamic Psychotherapy that uses a Core
Issue-Defense paradigm, or that based on Cognitive
Therapy will be helpful.
Clinical (Medical or Biologic) Depression
While Clinical Depression (also called major depression) is an
illness which has low mood as one of the major symptoms, the word
depression can be misleading because the person usually also has
many symptoms besides low mood that can be seen in their
behavior (slowness, lethargy), cognition (poor concentration,
paucity of thought, memory), social relations (avoidance, feeling
inferior to others), self esteem (low self-esteem may lead to
guilt, hopelessness and suicidal feelings), and physical symptoms
(often sleep and appetite disturbance and decreased libido; and
sometimes headache, ringing in the ears, dizziness, GI upset,
constipation, muscle aches, etc.). One of the main features of
depression is a lowering of enjoyment (lowered hedonic ability
called "anhedonia"). Another way to look at this is that the
threshold for enjoyment is raised which sometimes causes depressed persons to
engage in high-stimulation activities (excessive pornography viewing,
seeking or engaging in promiscuity, willingness to engage in destructive relationships, risk-taking sports, drug-abuse, etc.)
in an attempt just to feel normal.
A partial remission, or an improvement in some but not
all symptoms or degree of symptoms is quite common. In addition, the fact that there are so many symptoms besides depressed
mood often causes persons who have clinical depression
to conclude they don't have an “illness of depression”, and
also for partners of persons with depression to have difficulty
in accepting the depression if mood has lifted from treatment but
some of the other symptoms still remain (“why can’t my spouse
clean up the house or get a job” is a common complaint in this
situation). Anxiety
can also be a significant symptom of clinical depression;
please also refer to this page
regarding this topic.
The course of depression may be relatively sudden, especially
after a stress, however, it is more common to have a prodromal
period (a slowly progressive lead-in) over a number of weeks and
months. Some persons have clear cycles, and some persons have a
chronic waxing and waning course. Persons with cycles often feel
that because they come out of their depression they are not
really ill, but it is the cycling of depression itself that is the illness. If persons only have cycles of depression they are
said to have “unipolar depression”. As an analogy, consider angina, which is chest pain due to lack of blood supply to the heart (usually due to hardening of the coronary arteries). Angina is typically precipitated by exertion, but the person feels fine when they are at rest. It is obvious that these persons are quite ill even at the times they feel fine.
The more a depression is chronic or recurrent, if there is a family history of depression or other mood disorder, and if there was no discrete stressful event leading up to the depression, then the more likely the depression is a naturally occurring internal or "endogenous" illness for that person, and the more likely they will need to take medication over the long-haul (similar to diabetes or thyroid disease). If they were to stop their medications, then they will likely return to their depressed state. It is not because they take medications that they need them, it is that depression is their natural but ill state of being (diabetes is also natural). For example, if you get hit by a car and break your leg, you will need treatment for a broken bone, but once it heals you will not need ongoing bone treatment. If however, you have an inborn disorder of bone metabolism (like hypophosphatasia), then you will have recurrent bone fractures, and need bone treatment for life. The problem is that depression comes on later in life so it is hard to accept that the illness process had been there all the while, even though there were no symptoms. As an analogy, one's arteries may start to become hardened (called atherosclerosis) many years before there are symptoms of hypertension or heart disease, actual symptoms do not appear until the disease process progresses to a critical degree.
Many persons that otherwise have a normal upbringing start to feel depressed as a teenager. Of course being a teenager comes with stresses, but most teens do not have depression so that some of these persons may have harbored the gene(s) to become depressed which "turn-on" during puberty, especially if there is a family history of anxiety or depression (it is obvious that genes have an on-off switch because activation of gene expression is what makes the proteins necessary for the physical changes of puberty).
The lifetime risk of depression is 15% for women and 7% for
men. The average age of onset is in the mid-late 20’s. There is
a 60% risk of relapse if the depression spontaneously improves or
if treatment is stopped. Depression is twice as common in
first-degree relatives, suggesting some genetic input. Some
persons opine that because they have had a difficult or traumatic
upbringing that that is the cause of their depression, however,
the majority of persons with a traumatic or difficult upbringing
do not get depression as an illness.
One of the biggest issues in persons with depression is the
difficulty often seen in their accepting their illness of
depression. One factor is the chronicity of depression.
Depression is often mild to moderate and chronic. A chronic mild
depression is called dysthymia.
These persons tend to recalibrate themselves to conclude that a
mild amount of low mood, low energy etc. is normal, and they only
come in for help if they really go much lower below the line
which is called a “double depression” (also described in the
dysthymia link). Many persons are stoic and persevere through
many years of low mood until they fall farther down. Then they
may come for help, but they still may not easily accept their
illness. This is also related to not wanting to accept any
personal weakness, not an easy task when one is already
depressed.
Rationalization and denial
are common psychological defenses used in the service of avoiding the
acceptance of having depression.
Often persons are seen who have lots of talent, and because of
this high capacity they can still function well (though far below
their level)-sometimes deceiving themselves or even their
therapist that they do not have depression. This might be a
physicist who lost their ability to conduct their own research
and now proofreads other physicists' research papers; or a
successful M.B.A. who could not concentrate or handle the stress
at a company who now teaches English conversation, etc. Depressed
persons who also have episodes of mania
(see below) will often aggressively blame others for all their faults (a type of
projection).
We will now look at the causes of depression, describe some
other types of depressive and mood (also called “affective”)
disorders, and then finally the treatments for depression will be
discussed.
Go to depression page two.
Summary of Depression Links
Depression｜
Personality Disorder｜
Psychodynamic Psychotherapy｜
Core Issue-Defense｜
Cognitive Therapy ｜
Anxiety｜
Unipolar Depression｜
Dysthymia｜
Rationalization｜
Denial｜
Mania ｜
Pub Med｜
Hypothalamic-Pituitary-Adrenal Axis｜
Cytokines｜
Neurotrophic Factors｜
Serotonin Transporter Allele｜
Molecular Biology Studies｜
Recurrent Brief Depression｜
Circadian Rhythms｜
Projection｜
Atypical Depression｜
bipolar disorder (Manic Depression)｜
Mixed State｜
Diagnostic and Statistical Manual of Mental Disorders-IV｜
Bipolar II｜
Cyclothymia｜
Hypomania｜
Medication-Induced Mania｜
Post-Partum Depression ｜
Seasonal Depression｜
Premenstrual Dysphoric Disorder｜
Antidepressants ｜
Depression Treatment
