Depression or Sadness

In beginning a new month, I thought we would begin a new topical series on psychological disorders beginning with the one that affects more North Americans than the others…Depression.

In my professional opinion depression is a term over-used and over-diagnosed in numerous cases where it is clearly not applicable. We have become a society whereby sadness is often stated to be depression, which prevents some from a normal life experience. Experiencing sadness is not a bad thing; it should be part of every human beings emotional repertoire. Without sadness, we cannot fully comprehend joy. As psychologists and psychiatrists, I believe we have over-diagnosed normality of experience at times. There are numerous events in life that will create the emotion of sadness—these events do not require psychotherapeutic interventions, medications, and/or disability leaves from the workplace.

These sorrowful events require…

  • good support from family and friends,
  • our willingness to not always feel good,
  • and our initiatives to experience, press beyond, and come out the other side having conquered and overcome.

Similar to the use of the word “stressed” in the 80’s we are now a society that is “depressed”. Through the 80’s and 90’s everyone was “stressed” and needing a break. Many used this term to take weeks if not months off from work. What became evident through research was that stress is not a bad thing; we all need some degree of stress in our lives to function at optimal levels—we simply need to know how to manage stressful events and situations to ensure this does not become a greater concern. Additionally, insurance carriers and others stopped accepting the term “stress” as a rationale for a leave from work, which initiated the diagnosis of depression as this, is a qualified diagnostic that allows for a leave from work. The problem with this…it filtered beyond the medical and psychological offices into day-to-day linguistics and has become the new “stressed”.

Depression is a reality for many…I clearly believe that this disorder exists and it is devastating for those experiencing it and for their friends and family members. However, it needs to be properly diagnosed and properly treated through either psychopharmaceuticals and/or psychotherapeutic interventions. However, the rate of depressive diagnostics has skyrocketed over the past 15 years and albeit that there are some rationales for an increase in the number of cases this does not account for the numbers we are seeing as a society.

This week we will explore the many faucets of depression from what it “really” is, how it is diagnosed, what are the different treatment options (including specific methods and suggestions for healing oneself), to when should you seek professional supports.

Before I end today’s blog, I will describe one of my favorite “stress/depression” episodes. An individual came to see me to provide me with a medical note indicating a leave from work for “stress/depressive” symptomologies. Everything about this looked to be normal for this type of case except that there was no treatment plan whatsoever which in and of itself is not that unusual either (unfortunately) but this person seemed “scripted” in their description of symptoms. In any event, they were also surprised and actually appalled that I was going to be giving them a prescribed course of psychotherapy. Most individuals that are depressed are happy to finally be shown a light at the end of the tunnel; this person saw it only as a train getting in their way. At the time, I was proving EAP services to organizations, which meant that I worked with all the employees of specific companies… so if colleagues needed supports they would come to me too. Well in short order another employee from this same company came to see me with the same set of symptoms (almost the same script) and the same disdain for the prescribed course of treatment. Then another came into my offices. This was beginning to look very unusual to the point that I was curious as to the working environment these individuals were being exposed to that all would have the same symptoms of stresses. I then received a call from the insurance carrier that was handling all of these “disability” claims to discover that the notes were also all written from the same physician. The insurance carrier decided to investigate only to find that these individuals were all looking to take extra time off as a means of having extended vacations. Apparently, they even spoke to their co-workers about this new found scam and all of them ended up getting sort of what they wanted—unlimited time off from work; for them it was no longer disability though, it was termination.


Diagnosing Depression

Today we will explore how one comes to the diagnosis of depression. Before exploring the area I wanted to note that there is an additional piece of information on Depression in the Newsletter Section.

Depression as a diagnosis is often based upon the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). To ensure a higher accuracy of diagnosis it is important to receive a full medical evaluation, as there are a number of medical conditions that can mirror depressive symptomology. I prefer to rule out other medical rationales for depression before seeking psychological diagnostics.

A person is classified as having a major depressive disorder if the meet the below listed conditions…

• Presence of a major depressive episode
• The depressive episode is not accounted for by some other disorder
• There has never been a manic episode, mixed episode, or hypomanic episode (there are some exclusions to this)

If someone is deemed to have a major depressive disorder, it is then classed on its severity and its status. So then, what is a major depressive episode? This is a little more detailed but I will endeavor to provide a basic overview…

To have a major depressive episode a person needs to experiencefive or more of the following symptoms for at least a two-week period and that these symptoms occur almost every day and one of the symptoms has to be either a depressed mood or loss of interest/pleasure.

• Depressed mood most of the day
• Significant decline in interests or pleasures
• Significant weight loss when not dieting
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or energy loss
• Feelings of worthlessness or excessive guilt
• Diminished ability to focus or concentrate
• Recurrent thoughts of death, suicide, or planning or attempts of suicide

As a society, many individuals simply focus on their mood as a sole indicator of depression; as you can see there needs to be a lot more occurring for someone to be clinically depressed.

One of my more extreme examples of misdiagnosis in this area came many years ago when a woman was referred to me for depression therapy. I believe I was her third or fourth psychologist all of whom worked with her on stress/depression management skills and got nowhere…they asked if I would be willing to explore this case. When I explored her medical evaluations prior to the referral, I discovered that she had not yet been seen beyond a family GP for assistance or assessment. She was also adamant that she was not depressed!

She had met the criteria for a depressive disorder; depressed mood, decline in interests, weight loss, fatigue and energy loss, difficulties with concentration, and sleep disturbances. When I spoke to her, I discovered that she was experiencing major gastrointestinal problems that contributed and accounted for a portion if not all of the symptoms she was experiencing. The way it was diagnosed was in reverse; if she dealt with the depression, she would not have the gastrointestinal issues. In fact, once seen by a GI specialist it was discovered that she had a rare gastrointestinal disorder and once treated she was able to retain food in her system, gain weight, not experience stomach cramps, which now permitted her to sleep which in turn contributed to better energy levels and concentration skills. This is why medical evaluations and listening to a patient are key features to care.


Treating Depression

Treating depression begins with a qualified assessment to ensure that a depression exists and that it is not accounted for by some other medical or psychological rationale. As mentioned in previous blogs so many people are either misdiagnosed or treated for depression when in fact they have a rationale for experiencing a suppressed mood. One… Read more »

Personality Change

The final aspect to exploring personality is changing personality versus altering personas. Personas are the masks we wear in differing situations; these we change without thought and without effort. Personality is often defined as the more core related characteristics or traits that cut across personas; some theorists believe that these traits are unalterable once formed others believe that through extensive work or meaningful impact even these traits can become altered. Having seen the later occur, I am more of the mindset that some personality traits are alterable under extreme circumstance.

Personality traits can be seen as existing along a continuum whereby transfer from one side to the other is easier and more readily available the closer one is to the center of the continuum and extremes in the continuum are often problematic;

  • Warmth vs. Detached
  • Introverted vs. Extroverted
  • Internalized vs. Externalized
  • Depressed vs. Happy
  • Anxious vs. Serene
  • Dominant vs. Passive
  • Altruistic vs. Egocentric
  • Conscientious vs. Expedient
  • Insecurity vs. Confidence
  • Self-Sufficient vs. Other-Controlled
  • Restrained vs. Unrestrained

Circumstances where I have seen personality alteration occur include recovery from addiction, divorce, experiencing a major trauma (loss of life), death of a loved one, survival from suicidal attempt, and others. For many of these individuals there was also a meaningful spiritual experience or conversion type experience.

William James speaks of two differing types of conversion processes. One is the volitional type, which is a building up a new set of spiritual principles and morals, while the other is the type by self-surrender. The volitional type is perceived as holding the properties of partial self-surrender, with reliance on other “forces” for progress. The self-surrender type alone is often an awareness of incompleteness followed by a longing for the ideal with the complete surrender of self-resources to achieve this reality.

For some, this self-surrender comes in a moment of complete exhaustion and they concede, only to find the self-will slip away and the spirit to reside. Conversion experiences are what have been referred to as not a claim that “I have changed” but more an “openness to being changed”. What ensue are a personality alteration, a transformation, and a new state of consciousness and being.

An example of this is the many addicts that I have seen alter from being detached, internalized, egocentric, and expedient individuals that went on through volitional type conversion to become warmer, self-revealing, other-centered, rule bound contributors to society—traits that were not present prior to the addiction beginning.