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Depression and Bipolar Disorder (a.k.a. Manic Depression)

One of the difficulties all of us have is understanding when depression is more serious than just being really sad.  Part of the confusion stems from the fact we all use the word “depressed” in a fairly non-specific way.  In the non-medical use of the term, we use “depressed” to describe our mood.  It may mean sadness, loneliness, or disappointment.  Often, some sort of a loss triggers this emotion. This form of depression clearly is within the normal range of human experience, and perhaps it is necessary even to help us better appreciate and experience “happiness” or “contentment.”


 To be sure, normal sadness can be terrible, overwhelming, debilitating, and almost unbearable. However, when we speak of depression in the medical sense of the word, we really aren’t describing just an emotion or mood.    This form of “Depression” is the result of the disease Major Depressive Disorder.  It refers to a much broader change in a person’s state of being that does not include just mood changes.  Other aspects of this form of Depression are listed below. 


Frequently there are persistent, impairing physical symptoms that become increasingly prominent as one becomes Depressed.  Symptoms may include pain, exhaustion, a sense of slowness and difficulty moving or thinking, or at times, restlessness.  


At the same time, a fundamental disturbance in our core beliefs and perceptions develops.  Our beliefs about our own value or the value of life generally become increasingly distorted.   We may believe we are a burden to others, inadequate, inferior, or simply a failure.  Sometimes people describe feeling worthless.  


We may also experience 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 do not bring joy or fulfillment.  They become pointless or 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 disinterest and dwindling energy or enthusiasm, the individual generally experiences a strong desire to isolate and not participate socially.  Most of one's time will be in his or her bedroom hoping  to sleep and escape the Depression.   Meals will be skipped, family interactions avoided, and invitations to spend time with friends will be rejected.  


If the person is involved in communal activities (particularly adolescents), he or she may withdraw from projects, sports, clubs, or outside activities. Grades (or, for adults, job performance) will almost always suffer.  Such activities seem pointless and overwhelming to the depressed person.  


Mood changes are substantial, and may include sadness, irritability, or the loss of a mood altogether.  There is often prominent anxiety.  There may be a sense of guilt or shame. People often describe becoming tearful at “the drop of a hat.”  A commercial, a song, or a photo may trigger tears.  Not everyone becomes tearful, but this symptom is commonly present.  The most distressing mood change may be a diminishment in the sense of hope.  Hopelessness is a terrible and debilitating distortion of thought and perception with Depression. 


Additional symptoms during a Depression flare may include a crisis of faith or an extreme existential crisis.  There may be excessive or diminished sleep, very poor (or occasionally increased) appetite, poor concentration and memory, a sense of being in a cave or dark hole, a disregard for grooming or self-care, an inability to get out of bed or attend to important functions, and a sense that the world - colors, tastes, emotions - have become blunted or dull.  One may feel so overwhelmed that accomplishing even basic tasks or making decisions becomes almost impossible.  

Finally, a good percentage of people will develop a significant shift in perceptions and beliefs.  For example, people may hear voices when no one is there.  Sometimes the speaker is recognizable to the person, but sometimes the voice(s) may be perceived as strangers or evil beings.  Most often the voices 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 smells such as burning – sometimes an odor that may be described as sulphuric and like brimstone.   There may be strange visual experiences -- seeing people, monsters, or demons that will often speak cruel things like those listed above.


Patients are often afraid to discuss these experiences for fear they appear “crazy.”  However, these experiences are fairly common, and they are caused by the depression itself.  We do not know why some people have these experiences when depressed and others not. 

Finally, there may be frightening new beliefs, or “delusions,” and the person may become completely certain they are true.  If the belief is a delusion, then the individual’s certainty becomes 100%.   At this point, and the sufferer rarely tolerates evidence or discussion contradicting the belief – even if on their face, the beliefs are clearly untrue.   Such beliefs may include a certainty of damnation and having committed an "unforgivable act."   There may be certainty of a fatal, uncurable disease despite a number of tests that disprove this.  There may be a fixed belief that the individual is uniquely beyond any help or intervention to return to mental or physical wellness. 

Loved ones may become frustrated because they cannot understand why the sufferer will not respond to reason or facts that contradict these beliefs. However, it is crucial to understand that these beliefs, called delusions, are by definition fixed and unchangeable.  To try to convince the suffering person of other ideas or 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.  No amount of persuasion or facts will affect the beliefs, (which are almost always negative or paranoid in nature).   


When we try to help loved ones who become Depressed, it is important to realize what is unique about Depression versus the normal depressed mood we all experience from time to time.  With Depression, a change in circumstances or fortune rarely have any impact on the state of Depression.  Even the most positive outcomes or circumstances become distorted through the lens of depression.   Frequently, well-intended people may wonder aloud how “someone who has all the things you do” could be depressed.  Others may accuse the person as being manipulative or “too sensitive.”  Often the individual is exhorted to “cheer up” or “look at the bright side of things” or “stop being so negative.”   


These sorts of comments aren’t necessarily mean-spirited.  Instead they illustrate the trouble we all have distinguishing the two “depressions.”  However, advice that may be helpful when our friends are just sad or blue, may be counter-productive when people have had a flare of their underlying disease leading to a “Depressed” state.   

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