To feel calm, at peace, content, to be in a state of balance, serene.
These are words and phrases that connote the absence of rapidly shifting of mood. Even though a person feels stuck when they report being depressed, they are not in reality, stuck (or frozen). In fact, they are in a dynamic flux of push and pull with conflicting emotions and thought.
Depression is not a calm or a stable state. I have never encountered a person who believes that she or he was born depressed. Depression is acquired, or it manifests itself during the life course. There are babies who are neglected or abused, but it is unknown whether the immediate consequence of such trauma is depression.
Even though we were not likely born with depression, our human biological processes, particularly as they interact with a 21st Century high-technology, knowledge-intensive world, where thought and thinking dominates our every-day living routines and controlling, constraining, disciplining our thoughts are essential for adaptation, our biology is such that we are prone to conditions of the mind and thought like depression and to a lesser extent anxiety.
It is difficult to sort out depressive thoughts. For example, What is the difference between depression and discouragement? How long will a typical depressive episode last? Why can’t people just snap out of a given depressive state?
It is difficult to sort out depression because depression is probably not a single state, but it is more likely a process of thinking. It is when our reasoning has gone awry. There are lots of things within our biology that can cause this. Depression can be created by our environment (depression and oppression are highly related words) or depression can emerge from the interaction between biology and environment.
Depression, as I encounter it, is bound up in language. People use words to describe their depressed state. “Doctor, I feel sad, I feel hopeless, I feel helpless, I am worthless.”
But, if a person could not talk or express themselves verbally would they still experience depression? Your guess is as good as mine.
In psychotherapy, a person conveys inner feelings through words. I imagine that when a person feels depressed they are in a turbulent state. Shifting from negative to very negative mood like the sound wave pattern below:
Where the middle is negative mood, that shifts from mild negativity to extreme states of low mood and back. Not only is the person dealing with negative mood, but mood is changing rapidly and it is impossible to adapt when change is occurring at such a rapid rate. The psychiatric profession has a label for this phenomenon. They call it “cycling.”
From Medscape, Saturday, February 20, 2021.
“…rapid cycling pattern…was first noted by Kraepelin in the early 1900s… rapid cycling as a specific entity…could quite possibly predict nonresponse to treatment…Many independent studies confirmed the existence of rapid cycling…”
Ellen was referred to me by a psychiatrist because he thought she might respond to talk therapy. When I visited with Ellen I conducted a brief history. She grew up in a nurturing home, attended school and was a popular child, she learned easily, and she enjoyed social interaction, had many friends. After high school she went to college and was busy in extra-curricular activities. She was a good student. She liked politics and studied political science. She had a few boyfriends in college, but she avoided committing herself to a relationship because she wanted to follow a focused career track as a political analyst. In her senior year in college, just prior to graduation she started feeling sad for no apparent reason. She began ruminating about the meaning of life, and began to feel that life had no purpose. This feeling grew until it began to dominate her day-to-day life. It became a struggle for her to get up in the morning, she lost her motivation to work, and she was in a very demanding internship program. Soon, she dropped out of the internship and returned home. She had developed the idea that if she could not find any purpose or meaning to life it would be better if she were dead.
This is when I encountered Ellen, a 42 year old, White, married female. She wanted to feel better, and on closer examination of her mood state, she did have periods of time when she felt OK. But, her mood stated was never predictable, sometimes it was good for a day, sometime only a few hours, but when it went in the positive direction it wasn’t long until it all seemed to evaporate, she wanted to feel better, but she could not shake the profound sense that her situation was hopeless, and she was helpless to change it, and she was worthless to everyone around her.
The psychiatrist had tried a number of medications, but she didn’t like the side effects, so she was changing to different medicines almost monthly. We decided that it might make sense for her to start a medication and stick with it for at least 6-months even with the side effects, and we chose a potent selective Serotonin re-uptake inhibitor (SSRI), starting at a low does with a very progressive regimen to increase the dosage. We tracked her depressed mood, which we discovered was quite variable. It cycled rapidly, but the cycling was between low and very low mood. We doubled the dose with no effect, several weeks later we doubled it again, with no effect, we doubled it again, still no effect. At this point, Ellen was becoming despondent and the psychiatrist was beginning to talk with her about Electroconvulsive Therapy. We doubled it again. At this point she had been on this same drug for five months and she was on a very high dose of the drug. Then, all of a sudden, her mood lifted. She began to talk and think differently. She started to laugh during therapy, find irony in life. She started talking about being bored and needing to get out and do new things. I suggested she try exercising since her energy seemed to be returning. It was when we doubled the dose once more, combined with what had become a vigorous 5-day a week exercise regimen that she felt this dark swirling that seemed to follow her everywhere, just lift. A weight had been removed from her shoulders. She began re-connecting with friends, showed signs that she wanted to begin to pursue her career again.
What happened here?
As I reflect over this case, it is clear that Ellen was suffering from a variant of depression known as: Endogenous Depression.
“Endogenous Depression is a biological variant of the depression diagnosis. When the symptoms of depression appear without any apparent cause. Endogenouse depression could be genetically determined, symptoms of this type of depression start frequently with a drop in psychological energy…people find it difficult to complete tasks or finish activities they start especially if there is difficult associated with the activity…This type of depression is likely due to a chemical imbalance…sleep becomes unrefreshing even through a patient might sleep around the clock…Anxiety is often associated with endogenous depression…in the extreme endogenous depression has been linked to severe agitation…In endogenous depression the swing of affect is conspicuous, but the swing is often missed because mood swings from low to very low to extremely low and back again…
The concept of emotional turbulence fits endogenous depression . Because of its biochemical basis, endogenous depression impacts features of a person that would not normally change (temperament, emotional lability, psychological Energy). Ellen was challenging for me to understand because the depression had overwhelmed her normal nature, her normal way of relating to others. Her anxiety was “fear of cycling” (recall the circle). She was cycling again, and again, and again. She was on a rollercoaster of turbulence.
When she found a way to bring some stability to her biological upheaval, her real character started to re-emerge. She could begin to focus on life. In a small way, Ellen found a strategy to get her life back under her control.