Depression can be experienced in many different ways, reflecting the individual’s personality, coping repertoires and mood state, as well as the type of depression. As there are no absolute rules, definitions of ‘the experience’ can only be imprecise markers of depressive sub-types.
For someone experiencing depression, their general mood state will be negative and marked by pessimism, lowered self-confidence, and a sense of helplessness and hopelessness. They may want to ‘walk away from things’ (for example, leave a difficult job or marriage), thus risking a drop in the social hierarchy. These features are generally more severe and pervasive in melancholic and psychotic depression. By contrast, in ‘normal’ and ‘non-melancholic’ depression, individuals may be able to ‘bounce out’ of the mood state, perhaps in response to support from others, or to something pleasant occurring in their life.
Some people may detect certain ‘gains’ from experiencing depression. For example, somebody who has constantly ‘won’ in life and who has taken things for granted may, for the first time, appreciate others and re-evaluate life’s basic priorities. It has been argued that, in such instances, the ‘rosy glow’ that non-depressed people can adopt to handle life’s difficulties may be lost, thus ensuring issues are seen in a more objective way.
✰ Coping repertoires in ‘normal’ and non-melancholic depression
It is interesting to consider the coping repertoires used in dealing with or trying to overcome the depression. For example, normal or non-melancholic depression may make some people feel ‘cold’, and they might need to warm themselves up, perhaps by sitting in a warm bath or by sitting next to a window taking in the sun on a winter’s day.
Some people may engage in self-consolatory behaviours, such as going shopping or ‘pigging out’ on certain foods, such as chocolate. Such behaviour can reflect complex psychological processes—‘He no longer cares for me. I will therefore care for myself. I will eat something I can really enjoy’.
Others may become reckless and impulsive, and perhaps throw or smash things or drive dangerously. While recklessness is more likely in men, women may also show such behavioural patterns, perhaps through socialising or relating to men in ‘at-risk’ ways.
Some women may become careless and ‘forget’ about contraception, particularly after a break-up in a relationship. Reasons for doing so may include an attempt to re-start the relationship, or to ‘keep part of him’.
A more common behaviour is to seek ‘re-attachment’. Many people seek help from friends and professionals, or in less direct ways such as praying. Some seek to distract themselves from the depressive thoughts either by working harder or more repetitively, or by developing a ‘depressive habit’ such as painting the kitchen during each episode. Others will actively seek passivity and attempt to block things out by drinking to excess, taking anxiety-relieving or sleeping tablets, or just going to bed ‘to escape’. Suicidal thoughts and actions may occur even in non-melancholic disorders, but are more likely to be countered by notions such as ‘I wouldn’t want to hurt my children’.
Those who have an ‘internalising’ personality style may retreat to their room to brood and ruminate about their hurt. They may believe themselves to be more inadequate than they actually are, ignoring their usual strengths.
Those with an ‘externalising’ style may be irritable and angry with those around them and start yelling and throwing or smashing things such as dinner sets or glassware.
Thus, in ‘normal’ or ‘non-melancholic’ depression, we see people using their inherent coping repertoires and revealing aspects of their personality as they try to cope with their mood state.
✰ Coping repertoires in melancholic depression
The mood state in melancholic depression is more dominant than in non-melancholic depression. The individual’s personality style is less evident and may be ‘trumped’ by the mood dominated picture. The mood state is both more severe and certainly more pervasive (there is nothing to look forward to, there is no pleasure to be found in the usual pleasurable events, interest cannot be maintained in activities) and will be present throughout the day, although it may be particularly severe in the morning. Concentration and memory function are commonly impaired. There is also an increased risk of suicide.
Observable PMD means that somebody suffering from melancholic depression can appear either ‘retarded’ or ‘agitated’, or even alternate between each state. Agitation may increase the suicide risk, while severe retardation may reduce the risk. Unfortunately, as treatment progresses and retardation decreases, those suffering melancholic depression can be at greater risk of suicide even though by all appearances they are recovering.
In ‘retarded’ melancholic depression, actions slow down— those suffering from this disorder may walk or talk slowly, pause before moving or talking, use briefer sentences with reduced conversational richness, and are not able to brighten (at all, superficially or temporarily) at the introduction of pleasant topics. The normal ‘light in the eyes’ is diminished or lost, facial movements are less mobile, hair may become brittle and skin pale and even pasty.
The novelist William Styron, in Darkness Visible, captures the elements of this mood state: ‘. . . my speech, emulating my way of walking, had slowed to the vocal equivalent of a shuffle . . . I’d feel the horror, like some poisonous fog bank, roll in upon my mind, forcing me into bed. There I would lie for as long as six hours, stuporous and virtually paralyzed’.
A description of Spike Milligan, while he was experiencing an episode, also captures aspects of retardation: ‘He is markedly lacking in spontaneity, sitting quietly, responding to questions but initiating little conversation. There is a noticeable lack of facial expression and little extraneous movement.’ And Milligan’s own description: ‘. . . this vital spark has stopped burning . . . I go to dinner . . . and don’t say a word, just sit like a dodo. It must be a bit unbalanced at the table with me sitting there dead-silent . . . It is like a light switch. I feel suddenly turned off. There is a tiredness, a feeling of complete lethargy’.
Those suffering ‘agitated’ melancholic depression appear preoccupied with what are usually quite mundane things— which are blown out of proportion—and show considerable ‘mental anxiety’. They may pace up and down, wringing their hands, or even make little picking movements. Speech is rapid but superficial, and without the usual richness—again dominated by mundane concerns. Sufferers may look apprehensive or even fearful, and their mental anguish is often visible to others.
In An Unquiet Mind, Kay Jamison describes one experience of agitation: ‘. . . I became exceedingly restless, angry, and irritable, and the only way I could dilute the agitation was to run along the beach or pace back and forth across my room like a polar bear at the zoo.’
Such stereotypical presentations (of observable retardation and agitation) are usually independent of the individual’s personality, and suggest to the professional observer a biological disruption or disease process. In younger people, psychomotor disturbance may be less evident. On questioning, however, they will usually describe experiencing motor changes and, in particular, effects on thinking and concentration, perhaps finding it quite impossible to study or to concentrate on reading.
The simple term ‘depression’ has been rejected by a number of writers as it is not capable of capturing the import of melancholic depression. William Styron suggested the term ‘brainstorm’ to describe ‘a veritable howling tempest in the brain’. The broadcaster Helen Razor felt bombarded by a ‘broken head’ and felt ‘plagued . . . by the suspicion that my synapses were exploding . . . of phrenic crashing . . . I became immobilised by these potent little shocks . . . I would imagine that my poor battered lobes were rolling about yolklike in my feckless eggshell head’.
✰ Coping repertoires in psychotic melancholia
In psychotic melancholia, the depressed mood is either extremely severe or, at times, even denied. Where depression is denied, the individual may instead describe states of nothingness, of profound enervation, or even of the disturbance being felt at the physical level (with flu-like symptoms, physical agitation or pain). Such a mood state persists across and over the days, and lacks the late in the day lift experienced by many with melancholic depression.
PMD (whether retardation or agitation) is even more severe in psychotic melancholia than in melancholia, so that in the ‘retarded’ state the individual’s appearance may resemble that of someone with dementia. Concentration, attention and memory are generally impaired. In agitated psychotic depression, the individual is rarely still except when asleep. A common speech pattern is that of repeated questions; for example, ‘What is going to become of me?’.
Delusions are far more common than hallucinations (unless the individual has profound PMD), and many people suffer from ‘mood-congruent’ themes (for example, ‘I am so worthless that I deserve to be put in jail or punished in some other way.’). Minor indiscretions of the past may serve as a focus for such delusional thinking and are generally blown out of proportion. Thus, someone who did not disclose two dollars on their tax return twenty years before may genuinely believe that they will be jailed for this minor indiscretion.
A percentage of people with psychotic melancholia will experience ‘mood-incongruent’ delusions (for example, that their home is being gassed, or that their food is being poisoned). Some delusions effectively ‘build in’ physical features that emerge during the episode. For example, psychotic melancholic people with constipation may believe that their bowels have turned to cement or that they have a bowel cancer. Many with psychotic melancholia have ‘over-valued ideas’ that are just short of being delusional, usually associated with preoccupations of guilt, and which cannot be relieved by reassurance.
Hallucinations can be brought on by noises, smells or tastes. Hearing may become highly acute with some people hearing distant traffic noise not heard by others. Helen Razor captures such nuances in her book Gas Smells Awful: ‘The tiniest sound can make you start. Music is deafening . . . Taste is repugnant. Mildly offensive smells work your gut into a frenzy. Everything appears to have hideously sharp edges . . . you can smell colour, savour sound, feel invisible objects.’
In such severe states of depression, many people feel a ‘burden’ on others and may seek to kill themselves or, if they feel that ‘the whole world is a burden’, may kill others to protect them. This explains the rare but tragic situation of a post-natal ‘puerperal psychosis’, where a caring mother may kill or harm her baby.
✰ Coping repertoires in bipolar disorder
“. . . an illness that is biological in its origins, yet one feels psychological in the experience of it. “ Kay Jamison, An Unquiet Mind
People with bipolar disorder generally get both ‘highs’ and ‘lows’ (although a small number get only ‘highs’). The ‘lows’ are almost always of the melancholic depressive ‘type’.
During the ‘high’, the individual feels terrific and is very confident. Talk is increased and is so much faster than usual that others seem unable to keep up. The mind races with ideas, and creativity is distinctly increased—certainly in the mind of the individual, but often in reality too. People with bipolar disorder have lots of energy and need less sleep than usual— perhaps getting up in the middle of the night to do housework, or write ‘The Great Australian Novel’! Sexual interest (and activity) commonly increase. Dressing is often more colourful, and singing more common. The world looks brighter and more attractive (trees are greener, water more sparkling). However, as the world is seen through ‘rose-coloured glasses’ judgment may be poor. Purchases, loans, affairs and other commitments can be undertaken without due regard for the consequences.
While those with depression risk dropping in the social hierarchy, those in a manic or hypomanic mood may rise in the hierarchy. For instance, the shy schoolgirl may ask the captain of the rugby team to take her to the school dance and behave that night with complete self-confidence. Others may persuasively ask for a salary rise, or propose to ‘Miss Impossible’ and, at times, succeed.
Although highs can make most people feel happy, friendly and amusing, as with alcohol, others can become irritable and aggressive. Experiencing bipolar disorder is as if your brakes have failed; whatever direction you are going in—whether gambling, shopping, driving, having sex, drinking, taking drugs or showing off—you are going too far and too fast. Kay Jamison has described her high:
“ . . . everything seemed so easy. I raced about like a crazed weasel, bubbling with plans and enthusiasms . . . I felt great. Not just great, I felt really great. I felt I could do anything, that no task was too difficult . . . not only did everything make perfect sense, but it all began to fit into a marvellous kind of cosmic relatedness.”
Of course, there are some advantages in experiencing a high and a lot may be achieved as a result. Many of the world’s top creative people have suffered bipolar disorder. But it is an ‘asset’ with liabilities. If most people were said to have four cylinder brains, people with bipolar disorder have V8s. Unfortunately, they also have cheap drum brakes. Quite a dangerous combination!
(extracted from) Dealing with Depression: A Commonsense Approach to Mood Disorders y Gordon Parker, published by Allen & Unwin