Understanding Your Bad Headspace
So you’re in a bad head space, aka depressed. What exactly does that mean? Sure you may be feeling down, but you’re not like your 30-year old cousin who can’t hold down a job and never steps out of his room, and your aunt says he’s depressed. And you’re definitely not like your best friend’s girlfriend, who’s fine one minute, and crying the next, and he keeps explaining that she’s depressed. No, you’re just garden-variety down, but can still function and go to work every day. So how can you all be depressed if depressed looks different for each of you?
Types of Depression
Actually, depression can be genetic or environmental, or a combination of both. It can be cause (depression leading to, or presenting alongside, other ailments), or effect (depression caused by hopelessness and despair over physical or environmental issues, including trauma), or organic (a symptom of another physical disease). And that only describes what depression looks like, but neither the severity, frequency, nor duration of depressive episodes. Let’s look at some of the ways depression presents, and the treatment implications for each.
Case Studies*
Pete, Stacy, and Amanda are all depressed, but for different reasons, so their cases look different as well. And while their treatment should include therapy and medication for best results**, the unique circumstances of each case will determine the direction their therapy will take, as well as the choice of medications they are prescribed.
Pete
Pete’s feeling down. He’s dealing with a guilt- and shame-inducing break-up, the country’s in a state of COVID-fueled chaos, and he didn’t qualify for an SBE for his small business and may have to declare bankruptcy. He feels edgy, can’t eat or think, has no energy, barely socializes, and would sleep all day, if he could.
Stacy
Stacy was diagnosed with Crohn’s Disease 8 months ago. Since then, she’s had two surgeries to deal with complications caused by inflammation in her digestive tract, battles gastrointestinal symptoms daily, and isn’t in remission yet. Between bouts of extreme discomfort, Stacy’s all but given up talking to her friends, cries constantly, and no longer wants to listen to music, or play with her cat, activities she’s previously enjoyed.
Amanda
Amanda was diagnosed with Borderline Personality Disorder several years ago. She experiences either emotional emptiness or intense reactivity, says she can’t trust her feelings or decisions because of past mistakes and childhood trauma, and when she’s really desperate, has also been suicidal, or made suicidal gestures. Amanda’s been in and out of therapy for years, tried every medication in the book, and often feels like she’s going crazy. To regulate her emotions in the only way she knows how, Amanda has self-harmed, binge-purged, and exercised obsessively. Needless to say, she’s self-loathing and depressed, and often wonders whether she can ever feel normal.
Now that you’ve met this group of characters, and have a sense of what their respective cases look like, let’s see what the treatment implications are for each of them.
Pete’s Treatment Plan
Pete suffers symptoms of clinical depression so debilitating that sometimes he can’t function. Pete’s father was prone to bouts of depression, and his mother had frequent panic attacks, so there’s clearly a genetic component to Pete’s depression. And his genetic predisposition appears to have collided with circumstances in his personal and professional environment, to make Pete feel trapped, hopeless, and ashamed. He’s had a recent break-up, which he attributes to his own bad temper, hence the shame and guilt -particularly when he recalls that that growing up, his father had a temper too, intimidated the whole family, and Pete himself had repeatedly sworn he’d never be like him. Pete’s professional life is in peril due to the toll taken by the pandemic, and he’s dealing with existential fear of catching COVID himself. Each of these issues by itself would be enough to cause depression. The catastrophic cluster effect of genetic and environmental factors, however, overwhelms Pete’s ability to be resilient and move on. He will need a combination of anti-depressants and therapy to start feeling better. The anti-depressants should mitigate the severity of Pete’s depressive symptoms, so that in therapy, Pete can actually look at the events of the past few months, make connections between his father’s angry displays and Pete’s own outbursts, and realize why his break-up and the additional stressors impacted him to this extent. Together, medication management and therapeutic insight should strengthen Pete’s resilience to the point where he actually wants to emerge from his painful - but surprisingly comfortable, because familiar - depression swamp.
Stacy’s Treatment Plan
Stacy’s depression is the result of despair over her diagnosis and symptoms. She’s mentally exhausted with trying to respond effectively to the series of medical obstacles her body’s been plagued with, and is close to giving up hope. Naturally her state of mind has weakened her resilience, thereby compromising her immune system, which unfortunately exacerbates her physical condition. Treatment for Stacy will include medication for her physical illness, and possibly, medication to combat her depression, Treatment should definitely include therapy as well, so Stacy can learn to come to terms with her diagnosis, understand the close relationship between her mental health and physical condition, and learn ways to regulate her emotions, including meditation and grounding to soothe the panic and catastrophic thinking that have made her feel so much worse, thereby easing the inflammation that has kept her symptomatic.
Amanda’s Treatment Plan
Amanda has borderline personality disorder, or BPD. Personality disorders, in general, are notoriously resistant to change. The combination of childhood trauma, subsequent poor decision-making, and risky behavior, have resulted in an adolescence and adulthood rife with further traumatic incidents. Changes in Amanda’s nervous system caused by repeated sudden escalations of violence followed by an uneasy calm, and a slow build-up to further violence, have led to Amanda seeking out situations and people with whom she can repeat this dynamic, as she no longer knows what “normal” life really feels like, and confuses it with an emptiness so vast, that escalations of excitement, violence, and risk seem preferable. The results are predictably destructive, personally, professionally, and physically, leading to depression and anxiety because of the hopelessness of it all. Treatment for Amanda, again, will include medication and therapy. This time, however, her psychiatrist may add a mood stabilizer to her anti-depressant medication to balance out her mood fluctuations, which range from calm to distraught to angry to happy. Amanda might be referred to a specialized in- or out-patient program specializing in Dialectical Behavior Therapy (DBT), which is one of the trauma treatments of choice for BPD, focusing on emotion regulation, mindfulness, interpersonal effectiveness, and crisis management. The program might last up to a month, after which Amanda would be referred back to her regular therapist for continued reinforcement of DBT principles, particularly emotion regulation, along with other kinds trauma modalities, like EMDR. The combination of medication and in- and out-patient therapy will help stabilize Amanda’s emotions, so she can start managing her moods more effectively and consequently, create order and consistency in her life, all of which should alleviate her depression and anxiety.
For further information and useful resources relating to depression, please see the links below.
References
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed.): DSM-5. Washington, DC: American Psychiatric Association Task Force on DSM-5.
Kramlinger K, Mayo Clinic. Mayo Clinic on depression. Rochester, Minn.: Mayo Clinic; 2001.
Luborsky L, Singer B, Luborsky L. Comparative studies of psychotherapies. Is it true that “everywon has one and all must have prizes” Arch Gen Psychiatry. 1975;32:995-1008.
*The case studies presented are for learning purposes only, and are fictitious.
**In a 1975 meta-analysis in the Archives of General Psychiatry, Luborsky and Singer found that combined treatment with psychotherapy and medication produced notably superior results to either treatment alone.
