Posted by: thealienist | October 13, 2014

The Depression Trap

Just as in anxiety and bipolar disorders (see previous posts), major depression has its own traps.  If seen far enough in advance, they are usually easily avoidable.  Unfortunately, many patients do not recognize these traps until they are neck-deep in them.  Let’s examine them in more detail.

The first trap is one that is based on the nature of depression itself.  As depression takes hold of your thoughts and emotions, it begins to leach away the positive emotions that give every day activities their feelings of satisfaction and significance.  As the depression worsens, more positive emotions are stolen, but this is made even worse by loss of energy, difficulty concentrating, and poor self-care (often recognized more easily in changes in appetite and sleep).  In the face of loss of motivating emotions (and especially with an uncooperative body), thoughts become twisted toward fatalism, pessimism, impotence, and existential emptiness.  Where we once had thoughts, emotions, and physical health united in rewarding and meaningful activities, now we have a mind polluted with memories construed as evidence of failure and expectations that the future holds only more futility and failure.  We have a self-image that ignores any past success and any realistic appreciation of ability — instead seeing only vanity and uselessness.  These are accompanied by emotions that only see past pleasures as irretrievably gone and miseries as ever-present.  Under the burden of these thoughts and feelings, the body refuses to mount even the least resistance.

The bait for this trap is the thought, “If only I could get some rest,” “If only I could get rid of some of this stress,” or “I’ll do better is I just let a few things go.”  With this, the patient with depression sheds the “meaningless” and “burdensome” things in his life.  He isolates from his family, who up to now has been a source of joy for him.  He takes sick leave from work, which used to be an important source of accomplishment for him and gave him his identity as provider for the family.  He shuns friends, telling himself that they are better of without him bringing them down.  He stays in bed thinking that one of these days the rest will pay off.  Instead, he neglects his hygiene; he eats poorly; he gets little exercise; and his physical health wastes away.

Finally, his family insists that he goes to see a therapist or a doctor.  He is diagnosed with major depressive disorder and offered treatment.  Perhaps he is started on an antidepressant.  He succumbs to family pressure (he calls it nagging) and takes his pill every day when it is brought to him.  After several weeks, he and his doctor have this conversation:

Patient:  “Doc, I don’t feel any better.”

Doctor:  “What have you been doing?”

Patient:  “I’ve been taking my pill every day, but it’s not making me happy.”

Doctor:  “O.K.  Have you been exercising every day?”

Patient:  “No.”

Doctor:  “O.K.  Have you been keeping up with your basic hygiene?  Brushing your teeth?  Showering?  Combing your hair?”

Patient:  “No.”

Doctor:  “Hmmm.  Have you been spending time with your family and participating in family activities?”

Patient:  “No.”

Doctor:  “Have you been looking for things to do that used to be a source of pleasure for you or that have been meaningful for you?”

Patient:  “No.”

Doctor:  “No reading?  No t.v.?  No movies?  No conversations with friends?”

Patient:  “Oh, I watch re-runs of Gunsmoke.”

Doctor:  “O.K.  Do you enjoy that?”

Patient:  “No.  It’s just for background noise.  I’m just so frustrated that I’m not happy.”

Doctor:  “Well, it seems to me that considering how you hide from every possible source of happiness, unhappiness is the expected result.”

It is a dark, dank, miserable trap.

Now, how does one avoid this trap?  Most of my patients will avoid this trap best if they use their intellect (which is relatively spared during depression) to counter their unhelpful emotions and physical symptoms.  When the temptation arises to give up parts of your life as meaningless burdens, you ask yourself, “Is this really only a burden?  Does this really have no meaning?  My emotions may say so, but my intellect says that this is a lie.”  You realize that your family and their activities may not feel important to you, but you know that their importance is not measures by feeling.  You have decided that they are important to you.  Your emotions may not say that your job is important, but you decided that the resources you could bring to your life and to your family were important.  Your emotions say that it is futile to exercise and exert yourself, but you decided long before that taking care of yourself was worthwhile.  You refuse to cast off parts of your life simply because your fickle emotions have rebelled for the moment.  And when you have filled your life with the things you know are meaningful, significant, important, and satisfying and your emotions still rebel, then you know the antidepressant is not working.  Funny thing, though.  You are more likely to find that you are better.

The second trap is one that is very hard to manage.  It generally takes vigorous cooperation between the patient, a mental health care provider, and a pain manager.  One of the things we know about depression and pain is that each worsens the other.  When a patient has both major depressive disorder and chronic pain, it is very difficult to extract them from this trap.  Pain makes it hard for patients to engage in their usual daily activities.  This makes depression harder to manage.  Depression often saps the energy and motivation needed to engage in activities that treat chronic pain.  It can become a “chicken-and-egg” problem.  How does one avoid or escape this trap?  Recognize it early.  If available, seek treatment from a multidisciplinary pain clinic so that the psychological effects of chronic pain are well-recognized.  And finally, don’t wait for one problem to be solved before the other is addressed.  The mental health care and the chronic pain treatment will almost always need to be addressed simultaneously.

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Responses

  1. The biggest problem is the underlying conclusion that, for instance, I, as a covert narcissist, am junk. Everything, from exercise to get-togethers to vacations, is weighed against the junk. See a couple in love? Hello, junk. Watch the Oscars? Junk reporting, sir! Even when I feel good it only feels like a delusional reprieve from the junk.

    Like

    • Yep. That’s the way that depressed people think. The junk is overestimated and the non-junk is underestimated. You summarized it well. Thanks for contributing.

      John

      Like


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