How Turbulence Works

People and Situations

To feel calm, at peace, content, to be in a state of balance.

Words and phrases that connote the absence of a shift in mood state. Even though a person may feel 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 thoughts.

Depression is not a calm or stable state. I have never encountered a person who believes that she or he was born depressed. Depression is acquired, or it manifests during the life course.

Some babies are neglected or abused at or near birth, but it is unknown whether the immediate consequence of such trauma is depression; instead, it shows up in “failure to thrive,” a learned apathy and helplessness. This is likely not depression, as we have defined it.

It is difficult to sort out depressive affect and thoughts.

For example, what is the difference between depression and discouragement? How long will a typical depressive episode last? Why can’t people snap out of a given depressive state?

Depression is not a single state but a process of thinking and feeling. Many factors within our biology can cause this. Our environment alone does not create depression. Depression is when our biology and environment interact to create a dynamic negative flux.

In psychotherapy, a person conveys inner feelings through words. I imagine that when a person feels depressed, that person is experiencing a turbulent psychic state. This dynamic state or shifting from a negative to a very negative mood probably feels like the wave pattern below:

The middle of this graph is a negative mood. In this case, mood shifts rapidly from mild negativity to extremely low mood and back again. Not only is the person dealing with a negative stable mood state, but the intensity of the negativity and shifting to positivity is changing rapidly, making it impossible to adapt. The psychiatric profession has labeled this shifting as “cycling.”

I call it “turbulence.”

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…”

The Case of Ellen

Ellen was referred to me by a psychiatrist because the psychiatrist thought Ellen might respond to talk therapy. I met with Ellen and conducted a brief history. She grew up in a nurturing home, attended school, was academically successful, and was a popular child. She enjoyed social interaction and had many friends. After high school, she went to college and was busy with extracurricular activities.

A good student in college, she was interested in politics and studied political science. She had a few boyfriends but avoided committing to any relationship because she wanted to follow a focused career track as a political analyst. In her senior year, just before graduation, Ellen started feeling sad for no apparent reason. She began ruminating about life's meaning and felt that life had no purpose.

This feeling grew stronger until it began to dominate her day-to-day life. She struggled to get up in the morning and lost her motivation to work. At the time, she was in a very demanding internship program. Soon, she dropped out of the internship and returned home.

She wanted to feel better, and on closer examination of her mood state, she did have periods when she felt OK. But her mood state was never predictable; sometimes it was suitable for a day or only a few hours before shifting back. When her mood improved, her worries seemed to evaporate, but then she worried that she might get depressed again (anxiety). This worry would be followed by a drop in her mood, and then her fears returned.

She wanted to stop this cycling up and down of her mood. Finding herself unable to do so, she developed a profound sense that her situation was hopeless, and that she was helpless to change these up and down mood shifts.

The psychiatrist had tried several medications, but Ellen didn’t like the side effects, so she got into the pattern of changing to different medicines almost monthly. This had the effect of worsening her mood shifting.

As a consequence of my review, we decided, under the psychiatrist's direction, to start a medication and stick with it for at least 6 months even with the side effects. We selected a potent selective Serotonin reuptake inhibitor (SSRI), starting at a low dose with a very slow and progressive regimen of dosage increases.

We tracked her depressed mood, which we discovered was quite variable when unmedicated. Her mood, by her report, cycled rapidly up and then down. The psychiatrist continued to increase the dose slowly. Her mood shifting seemed to persist. At this point, Ellen was becoming despondent, and the psychiatrist was beginning to talk with her about Electroconvulsive Therapy. We continued to increase the dose. At this point, she had been on this same drug for five months at a reasonably high dose.

Then, all of a sudden, her mood stabilized. It was still low, but the shifting began to diminish. It was then that she began to talk and think differently. She started to laugh during therapy and found some irony in life.

As her mood became more stable, Ellen also reported that it was slowly becoming more positive. 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. We slightly increased the dose once more, combined with a vigorous 5-day-a-week exercise regimen. It was then that she reported the depressive state fully lifting. She said it was like a weight that had been removed from her shoulders. She began reconnecting with friends and showed signs that she wanted to pursue her career again.

What happened?

It seems 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, endogenous 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 difficulty associated with the activity…This type of depression is likely due to a chemical imbalance…sleep becomes unrefreshing even though 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. Still, the swing is often missed because mood swings from low to very low to extremely low and back again are masked by the patient’s reports of overall severity.

The concept of emotional turbulence fits with endogenous depression. Why?

Because of its biochemical basis, endogenous depression impacts features of a person that would not usually change (temperament, emotional lability, psychological Energy). Ellen was challenging for me to understand because the depression had overwhelmed her normal nature, her usual way of relating to the world.

Her anxiety was associated with “fear of cycling.” She was cycling again, and again, and again. She was on a rollercoaster of turbulence. The turbulence was the key factor impacting her depressive state.

Emotional turbulence was at the core of this case of endogenous depression. It wasn’t the severity of depression that was making a recovery difficult; it was the rapid shifting into different mood states and the fear (or anxiety) that this shifting would continue, along with the unpredictability of the turbulent emotions.

I call this pattern Emotional Turbulence.