Depression affects the whole being of a person – negative (thoughts) about self, (emotional) pains and loss of pleasure (behaviours) with most things.
The fact is people inherit a vulnerability to depression but they do not inherit depression itself and that explains why depression is episodic. All depressions are biochemical events. Medication and the label attached to this illness may help combat shame. Stressful life events (e.g. breakup) are strongly related to onset. They are psychosocial causes of depression.
Anger has a role to play in depression but it is not the sole cause. Depression almost always has more than one cause. Low self-esteem and fear of expressing anger are risk factors for depression. Each painful depressive episode has the potential for personal growth. The depressed person may need to ‘think about what they are thinking about’ – psychological-minded or aware of self. He needs to instill change in himself. The goal is to progress or move forward while retaining the good. The best approach to battling depression is to use multiple approaches to change such as behavioural, cognitive, and interpersonal.
The key symptoms of Major Depressive Episode (MDE) can be clustered into 5 areas:
Behaviour - Inactivity due to loss of interests, poor self-care, self-defeating behaviour, restlessness (do lots but achieve little), light and noise avoidance, alcohol and drug use, crying & inability to cry (in itself does not worsen depression), self-harming behaviours.
Emotional - Depressed mood, loss of interest or pleasure, guilt and shame, anxiety, anger and despair. (Emotional bankruptcy).
Thoughts – Poor concentration, poor memory, difficulty making decisions, negative beliefs about self, the world and the future. Biased memory of the past, ruminations, being easily overwhelmed, racing thoughts, acute sensitivity to rejection, a belief of being punished, paranoia, delusions and hallucinations and thoughts of death.
Physiological - Weight loss, weight gain, insomnia, hypersomnia, agitation, psychomotor slowing, fatigue, reduced sex drive, pre-occupation with bodily symptoms.
Social - Isolation, decreased assertiveness, irritability, disconnection, difficulty tracking conversations, friends asking what’s wrong and friends drift away.
Dr Theiler presented two Personality Subtypes of Depression – The Socially Autonomous style (Type A) and the Socially Dependent type.
I was reminded of my client Grace who fell into the latter type. She has a strong desire for help and always comes to session with a plethora of material. The trouble is she often saves the most important problem to the end and thereby extends the length of the session. She wants the therapist to solve problems and I expect her to return even when she can handle the problems. From her sharing of presenting issues, it was clear she has been over-dependent on her spouse. She expects her spouse to make nearly all decisions by giving up control to spouse. Her spouse finds her too intimidating as she overreacts to crises and wants to share all her feelings with him.
It was interesting to note too some spouses or family members who were called to the session upon requests of clients fell into the Autonomous Type. They were indifferent to therapy and believed they should solve own problems. They too showed lack of trust for the clients’ ability to control and tend to make decisions on their own by covering up their reactions to crises. Some of my teenage clients fall into this category too.
Treatment of Depression
Pharmacology (AntiDepressants Medications – work for approx 50%)
ECT (ElectroConvulsive Therapy) – benefit 50% of those not responding to ADM
Both ADM and ECT may be required for severe MDD
Psychological treatment for mood disorders –
Psychodynamic Long-term and Brief
Cognitive-Behavioural Therapy (Beck et al.) which is evidence-based.
In CBT, the automatic thoughts are being examined. Such thoughts are short, specific and idiosyncratic. They seem to occur reflexively and involuntarily. People’s thoughts are negative most of the time. They involve evaluative distortions of reality. (Even highly intellectual people are not spared.)
Some patterns of distorted cognitive processes (it is refreshing to go through them again):
Filtering (out of positive) by magnifying the negative details.
Polarised thinking – Things are either good or bad. There is no middle ground.
Overgeneralisation - Come to a general conclusion based on a single piece of evidence.
Mind-reading – Without others saying so, I know what people are feeling and why they behave the way they do.
Catastrophising - ‘What if it happens to me?’
Personalisation - Thinking that everything people do or say is some kind of reaction to me.
Control fallacies - If I feel externally controlled, I see myself as helpless, a victim of fate. The fallacy of internal control makes me feel responsible for the pain and happiness of everyone around me.
Blaming - I hold other people responsible for my pain or blame myself for every problem.
Shoulds - I hold a list of ironclad rules about how I and other people should act. People who break the rules anger me and I feel guilty if I violate the rules.
Emotional reasoning - I believe that what I feel must be true – automatically. Eg. If I feel stupid and boring, then I must be stupid and boring.
Fallacy of change - I expect other people will change to suit me if I just pressure or cajole them enough. I need to change people because my hopes for happiness seem to depend entirely on them.
Global labeling - I generalize one or two qualities into a negative global judgment.
Being right - I am continually on trial to prove that my opinions and actions are correct. Being wrong is unthinkable and I will go to any lengths to demonstrate my rightness.
Heaven’s reward - I expect all my sacrifice and self-denial to pay off, as if there were someone keeping score. I feel bitter when the reward does not come.
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