Depression and Bipolar Disorder (a.k.a. Manic Depression)
One of the difficulties in understanding whether "depression" arises from a medical condition or circumstantial sadness arises from the fact depression is such a non-specific word. That is, "depression" generally suggests sadness, and we all use it to describe that feeling. But the term does not provide information about its cause. There are times when it is quite natural for us to be depressed in a non-medical way, and this is by far the most common type of "depression." For example, disease does not account for our profound "depression" when we lose something or someone dear to us. However, "depression" that may occur independent of life circumstances may be caused by diseases such as Major Depressive Disorder. So, since our language does not help us distinguish between the two types of depression, how do we do so?
As suggested above, one form of "depression" a normal mood state that is most often associated with one's circumstances at the time. The other is characterized by a depressed or altered mood with additional signs and symptoms, none of which are necessarily dependent on one's life circumstances. Thus non-medical “depression” tends to describe a transient, reactive mood state. We generally use it to describe sadness, loneliness, or disappointment. It is most commonly tied to difficult life experiences that arise from ongoing or recent events. Sometimes it may be a case of the "blues" of short duration which all of us experience from time to time.
In contrast, depression as a medical condition (which for simplicity we will distinguish using the capital letter D) is the result of medical diseases. These diseases are almost always Major Depressive Disorder or Bipolar Affective Disorder. In this form, Depression is characterized by a more comprehensive collection of symptoms that can have more pervasive and debilitating effects. This is not to say that natural depression cannot be terrible, overwhelming, or debilitating. However, in its medical form, Depression involves additional physical and emotional changes that may compromise our daily experience by more comprehensive or pervasive impairments.
So, as mentioned, the difference between depression and Depression is not measured by how sad or upset a Depressed individual becomes. It is more the extent to which Depression's poisonous tentacles insinuate themselves into so many aspects of our lives. Worse, the duration of Depression tends to be much longer. A Depressive episode can last from weeks to years.
Because of the level of impairment and extended duration of Depression, it can disrupt profoundly one's expected life trajectory. For example, let's say we can observe the life course of a hypothetical patient (Joe) in two parallel worlds (A and B). Let us imagine in World A that Joe begins a Depressive episode on his 29th birthday and it resolves after 1 year. Let us imagine that in World B, Joe's life has been exactly the same until his 29th birthday when he instead never develops a Depressive episode. At the end of the year, each Joe will now have very different lives. Joe A may not live in the same place; he may have lost or or developed new, unhealthy relationships; he may have begun to overindulge in harmful substances or behaviors; he has almost certainly neglected his health; he may have dropped out of school or lost a job; he may have made poor employment choices; or he may have created legal problems or financial crises. Whatever the changes, it is a certainty that the richness and satisfaction of the last year for Joe A will wane in comparison to Joe B's.
Perhaps the consequences of Depression can be seen most clearly in children and adolescents. Because we are able to observe them closely, we are necessarily more involved in their lives, and their lives have more predictable (but no less profound) complications, we can see more clearly the resulting changes. Frequently, when children and adolescents develop Depression, they may unexpectedly drop out of favorite activities or sports, change friend groups, make uncharacteristically bad decisions, engage in self-destructive behaviors, and/or suffer a downturn in academic performance.
The specific signs and symptoms of Depression include both physical and "mental" changes. There are several possible physical manifestations of Depression. These may include a significant loss of energy. The individual will feel tired most of the time. There are usually sleep and appetite disruptions. Often there is physical pain or an amplification of preexisting pain. New pain is often described vaguely and difficult to localize. This can create difficulty in finding the source, and frustration may develop in the Depressed person and their caregivers -- be they friends, family, or healthcare professionals. Pain from Depression becomes more common with advancing age.
There may be increased sensitivity to noise or other forms of stimulation generally. Almost always, there is a slowdown in thinking and movement. A depressed individual may walk, talk and move more slowly or with greater hesitancy. A slowing of the functioning and clarity of the mind may present, and sometimes people can become so slowed down that they barely move at all and become mute for the Depression's duration. This may be referred to as catatonia.
There are also symptoms that do not present with purely physical manifestations. There are fundamental disturbances of core beliefs and perceptions. Beliefs about our own value or the value of life generally become distorted. We may believe we are a burden to others, inadequate, inferior, worthless, or simply a failure. Life may seem more meaningless or cruel. Often there is a perception that no one cares. With this cluster of symptoms (and others), sometimes people will develop existential crises or crises of faith.
We may experience also a shift in how we perceive and interact with the world. Almost always, there is a prominent loss of interest in much of anything. Activities that were generally fun or pleasurable for the individual when well do not bring the same joy or fulfillment. The same activities may seem pointless or even irritating to a person when in this state. The person will often feel so tired and discouraged that these activities seem like a chore.
Due to this disinterest and dwindling energy, affected individuals struggle to find enthusiasm for most if not all aspects of their lives. There may be a strong desire to isolate and not participate socially. Most of one's time will be spent alone in the bedroom hoping to sleep and escape Depression. Difficulty getting out of bed or attending to important functions is common. Straightening up the living space, keeping up with laundry, attending to the dishes or trash, or bathing and grooming may become overwhelming or almost impossible. Outside activities or responsibilities are frequently avoided, family interactions minimized, and invitations to spend time with others will be rejected. Involvement in group projects, sports, or clubs will be avoided or left altogether. Adolescents may decide to quit a team or club about which they were previously quite enthusiastic. At all age levels there may be atypical absences from work or school, poor grades, jobs lost or left, and relationships neglected to the point of lost friends or partners.
Unfortunately, others may misinterpret the behavior as laziness, lack of ambition/willpower, attention seeking/selfishness, weakness, incompetence, thoughtlessness, or passive aggressive behavior. There may be hurt or anger felt by others if they (understandably) misinterpret the Depressed person's behavior as disinterest and avoidance. To make matters worse, others may become still more negative because Depressed persons frequently answer questions vaguely or with a simple "I don't know." The impression may be that the vagueness reflects evasion or avoidance of accountability. In fact, the vagueness reflects impaired concentration and mental slowing caused by the Depression.
With regard to mood changes, they are substantial; however, "depression" is not may or may not be the predominant mood. There may be irritability, anxiety, or a loss of a mood altogether. There is often a sense of guilt or shame. Often the experience is likened to feeling as if one is trapped in a dark cave or hole from which there is no escape. There may be sense that the entire human experience has lost any vibrancy. There may be sense that the world - colors, tastes, emotions - have become blunted or grey.
People may become tearful at “the drop of a hat.” A commercial, song, or photo may trigger tears. Not everyone becomes tearful, but this symptom is commonly present. Possibly the most distressing mood or attitudinal change is the deterioration of hope. Hopelessness might be the most destructive symptom of depression; certainly it is a hallmark of deepening depression and despair.
As noted above, there are prominent changes in the mind's ability to process information or more broadly"cogitation." Without fail, Depression diminishes concentration. Poor concentration has pervasive, negative consequences on our ability to manipulate information. With poor concentration, one's ability to attend to important information deteriorates. People will have trouble following conversation or absorbing written material. A Depressed individually sometimes describes the need to read and reread written information. The problem is two-fold. It is more passages to understand and store material. addition to the slowness of thinking described above, concentration decreases. There will be an impairment in memory. Things will be forgotten and commitments overlooked. Some may misinterpret the changes as symptoms of new onset dementia.
Depression and Psychosis
Up to 10% of persons who are in the midst of a depressive episode will develop a more significant shift in perceptions and beliefs. The perceptions will no longer be rooted in reality. They are what define "psychosis." For the purposes of our discussion, psychosis means delusions and/or hallucinations.
Hallucinations are distortions of our five senses. Common hallucinations present as voices that one perceives when no one is there. Sometimes the speaker is recognizable to the person, but sometimes the source may be perceived as strangers or evil entities. It might be a a sound such as a knife sharpening, a match lighting, scratches form something that seems to be in the walls or attic, or knocking on the wall or door. When voices are involved, they almost always say very negative things and encourage mistrust, disgust with oneself, or self-destructive behavior. There may be strong encouragement or demands to hurt oneself or others.
There may be unusual odors such as burning. Sometimes it's an odor that may be described as sewer gas, sulphuric or like brimstone. There may be strange visual experiences -- seeing people, monsters, animals, or demons that will often speak cruel things like those listed above.
It may be helpful to note these are not recollections of past experiences. In this context, a hallucinated voice is not the same as hearing your mother's voice when you make a mistake. A visual hallucination is not the same as seeing or remember something "in my mind's eye." Hallucinations are new, unique sensory experiences that occur in real time. Most individuals will seek out the source of an auditory hallucination the first few times it occurs. Also, the individual may ask others whether they also heard the voice or sound.
There may be frightening new beliefs that are not related to a person's five senses. These are called delusions. What is distinctive about delusions is that they are false beliefs but they are believed to an absolute certainty by the delusional individual. By definition, a delusion is a fixed, false belief that isn't part of a common cultural belief. The falsehood is accepted with 100% certainty. Once a belief becomes a delusion, the delusional person rarely, if ever, tolerates evidence or any discussion that contradicts the belief. This occurs even if on their face, the delusions are clearly and demonstrably impossible. For example, a male may believe he is pregnant with the devil's child without any acknowledgment or concern for the impossibility of his being or becoming pregnant. Common delusions include a belief one is damned irreversibly for having committed an "unforgivable act" (that may or may not have occurred); there may be certainty of a fatal, incurable disease despite a number of tests that disprove this; or there may a belief that the individual is already and irrefutably existing in hell.
It is important to understand that these aren't metaphorical or clever statements to demonstrate a point. We may dismiss or overlook these statements because they might be something a "depressed" person might say. We may dismiss them as well because they are often outrageous, and it is our experience that the speaker is an otherwise rational person.
However, a delusion is fixed and unmovable. So, trying to convince a delusional individual that they are wrong is as futile as trying to convince a person that 2+2 is 5 or that the moon is made of cheese. Therefore, one can understand that when someone contradicts a delusional belief, it can be perceived as a provocation and an insult the delusional person's intelligence or integrity. Worse, if paranoia is part of the delusion, then the delusional person may suspect the person arguing with them is actually part of the problem and in on "the plot."
Psychosis can be frightening to the person trying to support the Depressed individual, but it is equally frightening to the individual who has psychosis. Patients are often afraid to discuss these experiences with their healthcare provider for fear they appear “crazy.” This is unfortunate because these experiences are fairly common. They are caused by and are symptoms of the depression itself. Most people believe that only schizophrenia generates psychosis. In fact several diseases can generate psychosis. For example, Depression, Bipolar Disorder, Schizophrenia, dementia, intoxication, drug withdrawal can all cause psychosis.
Finally, sometimes the trouble we have distinguishing depression from Depression can cause us to say things that may paradoxically worsen the Depression. We may offer advice that is helpful to the dispirited person who is depressed but may be hurtful to a person who is experiencing a flare of Depression. We may encourage them to "get out there and exercise" or "be with other people." We may exhort them to “cheer up,” “look at the bright side of things” or “stop being so negative." We may tell them how good their life is, and that they should be happy and appreciate this fact. These interventions are often useful to help others and ourselves when there is normal depression.
Unfortunately these statements can be hurtful to people who are Depressed. This is because these statements may be interpreted as a way of blaming the person for the Depression. Therefore, the person with Depression doesn't necessarily benefit from the advice; in fact they may feel worse and misunderstood. They have almost certainly thought of or tried those things already.
In summary, depressive symptoms can create great confusion and frustration for the person who is Depressed and for their loved ones who want desperately to help. However, being able to distinguish natural depression and "medical" Depression can allow patients and caregivers to feel more in control of the problem. We gift ourselves a better sense of competence and more options to act positively to ameliorate of depression in all of its forms.