The turbulence model of depression fits the endogenous type. I’m depressed because my body is out of whack. I’m depressed because my neurochemistry is not functioning correctly so that I am am happy and content with living.
As noted in the above picture, depression is when there is brain neurotransmitter dysregulation. Science likes to put this process under a microscope and identify every single step and molecule of movement. Why? Because if you know the process, you can eventually find a treatment. Simple cause and effect. Take a pill, you feel better. Sometimes this works. This was Ellen’s outcome in the previous post.
But what if depression is caused by circumstances or situations that involve others. There are many cases of this kind of depression. Psychologists have even coined terms and phrases to label this such as “oppression”. For example, “learned helplessness.” Earlier I said babies weren’t born with depression, maybe not. But, it doesn’t take long, under some circumstances, until a child is growing up experiencing a personal full-blown depressive episode.
To distinguish this kind of depression from “endogenous” depression, the word “exogenous” has been used.
Exogenous means: Medical Dictionary #1: “1 : growing from or on the outside exogenous spores. 2 : caused by factors (as food or a traumatic event) or an agent (as a disease-producing organism) from outside the organism or system exogenous obesity exogenous depression.”
Sometimes, exogenous depression is termed “Reactive” because the cause can be traced back to some external factor.
Steve was a client I saw recently who was in his late 50s, married, three children, was an accountant at a mid-level accounting firm.
“Doctor, I was a happy child, I had a good family, I was a good student and I enjoyed school. I selected a career that was fulfilling to me, but then I encountered my current boss, Roger. Roger was a transfer from a large CPA firm in the Midwest. Shortly after he first arrived over a year ago, Roger started belittling me on a daily basis. I hate the guy. I’ve had panic attacks at home when I think about him. He is ruining my life. I know you can’t do anything about Roger, but I think he caused my depression. I’m not sleeping, I’m losing weight, I feel like the future is hopeless, I feel worthless now, most of the time. I think I’m getting an ulcer. In fact, my Primary Care doctor said that she wanted to start me on an anti-depressant drug. I think she said it was Duloxetine. I tried it and it had some bad side effects like urinary retention. I won’t take it anymore. I’m not depressed, I’ve never been depressed. This is all Roger’s fault, [client starts sobbing uncontrollably]. Let me get ahold of myself. Doctor, this is what my day is like. It’s Roger, day in and day out, even on the weekend. I wish Roger would just die! I can’t sit in this chair any longer. I feel like I want to go home and go to bed, just sleep it all away. I was so happy as a child.”
This is a textbook case of endogenous or reactive depression. They say that depression affects about 5% of the adult population, maybe more. But, if you think about situations which might create a depressive state, such as a bad boss, losing a job, a divorce, an auto accident, a traffic ticket, an unexpected tax bill, even a water leak in the basement. All these hassles, setbacks, accidents, traumas have the potential to cause exogenous depression. Looked at this way, well over 50% of the adult population would be subject to bouts of exogenous depression.
Either way, all these people find their way to my office. My waitlist is long, partly because there are so many situations that can cause a depressive episode. This is why I take a careful history of a person’s life. In a history, I’m looking for situations or persons where there was trauma or harm done to the client. Circumstances when the client was vulnerable: early childhood, adolescence, when the client was ill, starting a new job, moving to a new home, habits that a person has picked up along the way, bad and good, husbands or wives, partners or companions of all types, sicknesses. It takes many sessions to get a complete history that will speak to me about sources or circumstances that created discomfort, trauma, fear, discouragement, entrapment of all kinds.
A history also helps the client get some perspective over her or his life. Verbally rehearsing one’s own life history is not easy to do alone. It is especially difficult to find meaning even when writing one’s own history. So, in the process of taking a history I’m providing perspective to a client about her or his life, what happened and what it means for the present and the future.
To be sure, the brain as a biological organism responds to life difficulties, judged as threatening, in specific ways, sometimes re-writing its whole neurology in response to an oppressive situation. When this happens even when you remove the problem. Say, for instance, Roger leaves and is no longer the above patient’s boss, the patient may still experience the same emotions and feelings even when the stimulus (Roger) is no longer there. This can create its own source of difficult because the client becomes frightened that “Roger” has changed him for good.
This is when exogenous depression migrates to endogenous depression. This is the topic of my next entry. The most commonly seen kind of depression is the interaction of endogenous and exogenous forms.