What does it feel like?
As illustrated by this example, the sufferer’s dark inner world inevitably impacts on their nearest and dearest. Relationships can be sorely tested. Sometimes the depressed person is only too aware of this, feeling increasingly guilty and self-reproachful. They try hard to disguise their mood until the effort becomes unsustainable and they collapse, to the surprise of others who had never suspected. In tragic cases suicide may prove the only escape from that Herculean effort of putting a good face on things, and the only way to protect family and friends from their “being a burden”.
Depression is primarily a mood disturbance, rather than a thought or behaviour one. We all have mood signatures with which our friends and colleagues are familiar. Some even-tempered people’s mood over time might be represented by a straight line. Others’ moods could be drawn like a wave, rocking gently up and down. Still others are stormy, peaks and troughs in the wave, moving rapidly from optimism to pessimism, buoyant one minute, gloomy and despondent the next. These signatures vary almost as much as written ones on legal documents. So long as the mood signature of a person remains more or less constant, they may be said to be free of mood disorder. Should someone who usually swings in mood become flat as a straight line for a sustained period though, perhaps friends should worry rather than feel reassured that peace has broken out!
Depressed mood is something we all experience. According to the dictionary, one definition of depression is a “sunken hollow place” and on a bad day that’s just what our whole organism – body, mind, and soul – feels like! This is a normal if unpleasant mood variation, which can occur without any especial stimulus, though often sad news, a bad decision or an unhappy event precedes it. Sometimes it will be worse and bother us for longer than usual. All the same, it runs its course before fading away and our characteristic mood sequence returns. This kind of temporary negativism is what we colloquially call depression but is not the subject of this book. This is not to minimise its importance, but it isn’t what we are concerned with here. Colloquial depression is well within the bounds of normal mental health – we can’t be happy all the time. However, any so-called depression that fails to resolve itself – becomes protracted, adversely affects otherwise good relationships, or causes the person to not enjoy their usual pleasures and interests – I’m going to mark as “little ‘d’” from now on to make clear we are in new territory. The person knows something is going wrong; they are up against psychological distress beyond common unhappiness.
What about “big ‘D’” then? I will use this to cover all those Depressions that without question require medical intervention on top of any other help; they have to be defined as an illness, whatever other crises may be simultaneously occurring. They often recur on a regular or irregular basis so that the sufferer comes to know and better manage the warning signs. At the deepest point in the Depression there is serious suicidal risk and the person may lose the ability to be objective about their condition. Nevertheless, as with little ‘d’, there are degrees of severity and over the course of any Depressive episode mood can lift or sink from day to day, sometimes hour to hour or moment to moment. A grey area exists between little ‘d’ and big ‘D’ and when referring to this, or making a comment on all Depressions collectively, I will use the big ‘D’. I trust you’ll soon get used to this.
While we are talking about nomenclature, you will also be introduced to the idea of a Self (capital S). We all have a picture of the kind of person we would like to show to the world, beautiful and clever perhaps, or caring, or adventurous, creative or successful. At the end of each day, should we review how our actual Self performed, we may find ourselves happy with it or critical of it, disappointed in it or angry with it. We have a relationship with our Self that obviously impacts on mood if we are always at loggerheads with it. I will discuss Self Psychology in a later chapter.
A Depression of whatever sort describes a process – not an infection or a growth you have either “got” or not got, as my Tesco man seemed to think. An astute observer or an experienced sufferer can trace its course as it deepens, gets stuck a while, then gradually or suddenly lightens. People undergoing regular or intermittent Depressions, as well as their relatives, carers and counsellors, can benefit from identifying each step of the route toward illness and afterwards toward recovery. The terrain along the way may be ghastly but at least you know where you are and what to expect.
When does little ‘d’ become a medical matter?
At what point can we say someone is actually ill? Usually we deem a person sick when they can’t function well enough in their day to day relationships and job to ”keep the show on the road”. We call it a nervous breakdown. Our sympathies are mobilised. Depression is tricky however, because some sufferers inhabit two worlds at once. Shame, impossibly high standards, an over-developed sense of obligation or responsibility force some to carry on, whilst inside all is despair. From the outside they seem no different. So are they ill? Perhaps unhappiness becomes illness when a point is reached where pleasure in anything at all has become impossible (the text books call it anhedonia) and where hope has vanished from the horizon. Yet still some struggle on, keeping up appearances.
How it feels on the inside, not how it appears on the outside, is what in my view as a therapist defines the line that crosses into that domain where some kind of professional help is required. Many people who have to bear cyclical periods of this ailment, be this little or big ‘D’, know the oncoming signs so well (“Hello darkness my old friend” as the song goes) that they can identify the very second a lingering oppressive mood has become a Depression. One of my clients told me: “It’s like someone sticking a seat belt on you. There’s that noise in your head – clunk-click; you know with awful dread that you’re now strapped in, but it’s trapped in, really. No way out. You need help.”
From the point of view of family or friends there may no evidence to explain such a loss of vitality and the complete inability to fight it. Parading the sufferer’s achievements before them, listing the people who love them, urging them to think positive or look forward to their holiday is of no avail, for the mood state is now all-encompassing. The person can’t be cheered up or consoled, for whilst they are affected (Depressions do end!) there is no belief that optimistic ways to view the world are possible. This loss of the capacity for hope is the illness. This is what non sufferers find so hard to grasp. For them hope springs eternal, even in the direst circumstances. Hope is a survival mechanism so rooted in our make-up that we cling to it even when the game is clearly up. If you want to understand the Depressions, try to imagine what it must be like to lose this life-line.
There’s a huge discrepancy between how the sufferer sees the world now, and how they saw it when well. They may know that very well, but it makes not a jot of difference to them. Their negative perceptions feel like the truth to them, their previous “normality” an illusion. Arguing with them won’t get you anywhere. Reason makes no inroads into mood. Look at someone who has just fallen in love, is over the moon. You can prove beyond doubt that their lover is a crook, a cheat and a liar, but does it affect their buoyant mood? As with the Depressions, you need to bide your time.
If a Depressed person can be persuaded to describe accurately their interior experience, the listener may be shocked by its extremity, may feel the narrator must be lying or exaggerating. They are not. Part of their mind is “out of order” like a faulty washing machine stuck on only one setting. Their reason is perfectly intact, but their mood unalterable, their optimism button jammed. Is it any wonder partners and pals feel powerless to help, or become irritated and critical of the sufferer who sometimes looks as if they are stubbornly refusing to cheer up? They can’t cheer up. When the affected person’s state is at its lowest ebb, that negative mindset is experienced by them as a permanent, pitiless reality: what conceivable point is there in trying? This is not stubbornness, which after all requires some effort, but hopelessness, which renders effort impossible.
Signs and symptoms
Let’s
