The Case of Susan:
CASE: 142XXX:
Presenting Issue: Dr., I’m at my wit’s end. I never feel good. I’m plagued by negative, irrational thoughts day in and day out. I can’t sleep; I have no motivation. I can barely get through a day and don’t have hope for the future. I feel like I’m under a cold, wet, heavy blanket, and this damp cold is sucking the life from me. I’ve tried everything: drugs, cognitive behavioral therapy, and group therapy with other depressed people. Honestly, depressed people just depress me more. I can’t exercise; I don’t feel like going out. My spouse is patient and concerned but has no idea what I’m going through, always asking if “I’m OK” (which I’m not, and he knows it), and when he comes home, “How are you feeling?” which is terrible (and he knows it).
He cooks dinner and makes food for me during the day while he’s gone, but I don’t have an appetite; I think I’m losing weight; I have no interest in weighing myself. I’ve lost all my friends because they never call, and my adult children avoid me because “Mom doesn’t want to be around people.” That’s not true, but when I’m around people, I get jealous that they feel good because I feel so bad. I need to change this, but I don’t know how to, where to go, or what to do.
Susan can be a PCP’s nightmare. Reassure her and prescribe medication, sure, but seeing Susan at only 3- or 6-month intervals will do little to address her concerns.
Excerpts from my clinical notes describe the struggle with chronic depression. Such a client rarely calls me directly; instead, Susan might be referred by her psychiatrist or a family physician. If a PCP perceives Susan is not making progress, a referral to specialized care is next. Usually to a knowledgeable therapist who’s been in the business for a while. Susan’s diagnosis might be:
ICD 10: F33.1, Major Depressive Disorder, Moderate, Intractable.
For the prerequisite reading, see the entry Clinical Depression (Part 1 of 3).
Susan is experiencing an internal dynamic. Diffuse, generalized, variable in intensity, psychic in origin. Labeled, dysphoria, which is a common word for the expressed symptoms of a presumed depressive episode.
Dysphoria is (Cambridge Dictionary) severe unhappiness, especially a person's feeling of being uncomfortable in their body or of being in the wrong body:
Dysphoria is a “state of mind,” a “sensation,” or a “self-perception.” The Cambridge Dictionary definition identifies the physical body (“in their body or of being in the wrong body”).
The American Psychological Association Dictionary Definition elaborates Dysphoria as (n): a mood characterized by generalized discontent and agitation. Dysphoria is a “state of mind.” or a psychic phenomenon.
Dysphoria can vary in intensity, frequency, and length (for example, low grade, variable up & down, long duration dysphoria).
In physiological conditions like the flu, dysphoria manifests as a panoply of uncomfortable feeling states (physical, psychic, and even social discomfort). Still, self-prediction of dysphoria’s course for the flu is predictable. It lessens as the physical disease remits. Aches and pains, sweating, shivering, feeling cold and then hot, headaches, runny nose, etc., diminish as the “flu” remits. Dysphoria, in this case, is “a temporary sensation” of feeling unwell as a bodily response to a disease. Dysphoria might be a sign the body/brain is resisting a virus (bacteria, infection, etc.). The immune system is attacking the pathogen and, in short order, will address the concern. There are emotional rewards to “feeling better,” even though one may still be sick. Decreasing dysphoria in physical illness like the flu is a gauge to health.
Sometimes, as, for example, in syphilis, dysphoria might diminish even though the disease is still active, in a dormant stage. A sufferer might be lulled into believing “health” is returning when, in fact, the disease is quietly progressing to a more virulent stage.
ESSENTIAL POINT #1: DYSPHORIA IS A SYMPTOM OF PHYSICAL ILLNESS, IT IS THE MAIN SHOW IN DEPRESSION.
Doctors say you are chronically depressed. Why do they say this? Because you tell them you are depressed (no other reason). So, they say, treat the depression, which means doctors treat the brain, which means treat brain neurochemistry, which means alter, at a molecular level, cell metabolism, which means remediate neuronal communication. And so it goes… Doctors say your brain is not regulating your neurochemistry. Why? Because you tell the doctor you are depressed. You are not just sad, you aren’t getting better, so the doctor conjectures something is wrong with your brain. There is no physiological test for “depression” per se.
This approach to evaluation leads to a kind of treatment:
Pharmacology (anti-depressant medications or antipsychotics or other psychoactive drugs).
Transcranial treatments (Transcranial magnetic stimulation (TMS) with electric impulses and/or infrared lights, etc.)
Electroconvulsive therapy or ECT (to trigger seizures with electricity)
Hospitalization (to regulate medications and all aspects of every-day function and disrupt life routines that may be contributing to a depressed state)
In all cases, the approach assumes “getting well” involves:
Applying treatment (take drug or intervention).
The brain responds (things happen via drug effects).
Dysphoria diminishes (feeling better!).
Brain function re-stabilizes. You no longer feel dysphoric.
“Tweak” treatment to stay better.
You feel better with treatment.
OR
Treatment is related to the brain (magically) adjusting back to normality: “No dysphoria!”
Brain function re-stabilizes. You no longer feel dysphoric.
The treatment ends (I’m cured!)
ESSENTIAL POINT #2: DEPRESSION IS A STATE OF MIND.
Physical disease is a bodily state. You break your leg, you scream out in pain (State of Mind). See your bone poking through the skin (observing a body abnormality due to accident), at the sight, you experience a panic attack (State of Mind).
Mental instability like depression is A STATE OF MIND. A state of mind that might be amenable to change with the application of drugs (think psychedelics like LSD or electric shock, but the fact is: IT IS STILL A STATE OF MIND.
Medical Doctors have begrudgingly acknowledged the importance of dysphoria in depressive disorder (Dysthymic Disorder). Also referred to as “Dysthymia.” Unfortunately, dysthymia is so tightly linked to clinical depression its value in guiding psychological treatments (or for that matter, medical treatments) is limited. In short, dysthymia, a mild form of MDD (Major Depressive Disorder, Mild) as described by DSM5.
Dysthymia is Defined (Merriam-Webster) as: a mood disorder characterized by chronic mildly depressed or irritable mood often accompanied by other symptoms (as eating and sleeping disturbances, fatigue, and poor self-esteem)…called also dysthymic disorder.
When people experience what is commonly referred to as “clinical depression,” variations are (as the picture - taken from The Lancet highlights above):
Severity of Symptoms
Chronicity of Symptoms
Dysphoria, I believe, is not simply dysthymia or a covarying facet of depression but a somewhat independent (and amenable to intervention) feature of depressed phenomenology. Why not treat, directly, the dysphoria. So, it may be you treat the body, but the body is relatively intact - with one exception - “State-of-Mind”.
REGULATORY PROCESSES
Yes, Depression and Anxiety; if linked to any bodily condition, is all about “REGULATION.” It is OK to call depression “a physical disease” if we define “disease” as it is found in the dictionary:
Disease (Merriam-Webster): a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms (for example, Depression, a disease of the mind).
ESSENTIAL POINT #2a: DEPRESSION IS A REGULATORY DISEASE STATE OF BRAIN.
How do you treat a regulatory brain disease?
A regulatory brain disease responds to changing conditions and circumstances.
Think about it: Why is “aerobic exercise” helpful in depression? Most scholars and medical practitioners of depression believe that activity (aerobic and non-aerobic) has a specific neuro-communication brain pathway that impacts the brain by reducing inflammation or promoting through neuronal upregulation more precise connection signals between brain and body. Dysregulated connections/communication is associated with dysphoria or a “State of Mind” (perceived dysphoria increases when the regulation is consistent versus erratic).
Below is a brief - but complex - description of how brain processes are influenced by an active (versus a passive physical condition):
…molecular changes that swerve [or turn] from a chronic pro-inflammatory state to an anti-inflammatory state in both the periphery and central nervous system. The changes caused by physical exercise include an increase in PGC1α gene expression, a transcriptional co-activator involved in reducing the synthesis and release of pro-inflammatory cytokines, and…increase in anti-inflammatory cytokines. PGC1α changes the metabolism of kynurenine, and, in turn, it reduces glutamatergic neurotoxicity and promotes alterations in the circuitry of monoaminergic neurotransmission…through…release of proinflammatory cytokines.
(see; Ignacio et al. Physical exercise and neuroinflammation in major depressive disorder, Molecular Neurobiology, 2019, Vol 56, 8323-8335.
The afore paragraph is not really readable for the layperson. Still, the point is that countless “bench” research studies indicate that “dysphoria in Depression is due to altered REGULATORY PROCESSES.”
We think we KNOW this!
We also think we KNOW:
Depression, as experienced by the sufferer, IS dysphoria.
Therefore:
ESSENTIAL POINT #3: TREAT DYSPHORIA AS THE TARGET CONCERN, NOT AS THE SYMPTOM!
ESSENTIAL POINT #3a: DYSPHORIA MIGHT BE CAUSATIVE OF DEPRESSION RATHER THAN SIMPLY A SYMPTOM!
This is a critical point to remember when working with someone in a depressed state. It is essential to understand for someone experiencing depression; that is, doctors might intervene with the body/brain (drugs/ECT/transcranial therapies), but the goal of treatment is diminishing dysphoria. Even if, say, the mind/brain is dysregulated (maybe even from birth), if dysphoria is not present, this could be OK.
Stated another way, Dysphoria may be stimulating or causing a depressive episode. Think about it: In Anxiety, “Catastrophic Thinking” may cause or initiate an anxiety attack or a panic attack. A person might have a troubled Trauma Memory that is triggered, causing a physiological dysregulation of the person’s entire bodily system. The dysregulation, in this case, came from a thought (a trauma memory). Might this also be the case for an episode of clinical depression. Mentally initiating a dysphoric state or dysphoric memory might stimulate a full-blown dysregulated clinical depressive episode! (I will develop this idea further in my next entry).
Think about “Gender Dysphoria”
Is dysphoria, in the sense of a realization of Gender Incompatibility, a mental illness or simply a state of “conflict” that then creates dysphoria, and the dysphoria persists. Now, a person feels clinically depressed, NOT because of a brain disease, but because of a deep and central conflict with who one is (core identity) and that one’s current gender (a feature of core identity) is incompatible with how one feels and relates to the world.
Would this person be a candidate for “anti-depressant medication therapy”?
TREATING DYSPHORIA
What are the essential elements of dysphoria, a partial listing:
Perceived psychic pain.
Poor future outlook (or restricted outlook due to dysphoric state)
Lack of motivation to do anything except sit there in pain.
Desire to sleep to remove the dysphoria (While sleeping, dysphoria is not present).
Slanted view of the past with a negative bias. (“I wish I felt like I did five years ago.”).
These are mental states. (Recall Essential Point #1). They may be mentally reactive states to a brain disease. (Fair Enough). If a person feels nauseated due to food poisoning, that person won’t feel motivated to do anything. If the person, say, is in a light state of nausea and goes to work, is distracted at work, it is sometimes the case that the distraction diminishes attention to the nausea and the person feels better while at work. People get motivated to see a doctor if they “think” (outlook) they will feel better. Motivation is a mental state. Mental states are always amenable to modification, particularly through psychic intervention.
ESSENTIAL POINT #4: ALTERING MENTAL STATE WILL ALTER DYSPHORIA, REGARDLESS OF THE SITUATION OR CIRCUMSTANCE.
If a person is depressed and also highly hypnotizable (by objective measures and sufficient pre-testing), then it is likely that the person can be hypnotized and, during the process, experience an alleviation of depressive symptoms. I’ve done this many times in my office, sometimes with dramatic, short-term results. Almost in every case, when the person goes home, dysphoria returns.
Hypnosis is not my first line of treatment with a person suffering from intractable depression, but it can (and is) predictably useful during acute depressive episodes (and there are no side effects!). The hypnotic effect is like ECT, rapid and at times impressive, but ultimately short-lived reduction in dysphoria.
Define Intractable Depression: Intractable Depression (also known as Treatment Resistant Depression or TRD) is non-response to attempts at treatment with an adequate dose time of two or more anti-depressants and following a complete psychiatric assessment.
The reason is twofold:
Not that many individuals are this hypnotizable.
Even for hypnotizable people, the effects are short-duration, usually within the session, including with post-hypnotic suggestions. These simply don’t have the sustaining power.
But, the fact that hypnosis is potent in treating, at times, a depressed state suggests that State of Mind is at least in the dysphoria feature of a depressed state, is modifiable. Either way, my view is Dysphoria is an actual (perhaps the focal) target we should treat.
There are other potent approaches to treating “STATE OF MIND” whether in or (not in) the presence of an ongoing diagnosed clinical depressed condition or brain disease. Nothing, of course, works every time; dysphoria is an elusive phenomenon. It is possible to change the state of mind even when a person is complaining only of dysphoria.
This topic requires another entry because my space has been exceeded. I look forward to writing next: Treating Depression as a State of Mind (Part IIb)