Wednesday, October 11, 2006

Depression Feeds on Itself

Something about this time of year, mid-October, first harbingers of autumn, first nip in the air. People are coming in depressed.

Sure, it's random. I know. But if there were a theme for the week so far it would surely be, "I'm so blanking depressed, Doc. Can't seem to shake it."

When my daughter-in-law, a future therapydoc, was in town over the weekend, we talked a lot about shaking it up. I said, "Shake it up has to be our theme song," theme something, can't remember exactly what I said.

If you watch the cable cooking show EMERYL you know his motto is Kick it Up, meaning add a lot of garlic or Worchester sauce. So shake it up is on that order.

What AM I talking about?

First the quick and dirty on depression. Forget genetics for a second, forget drugs, forget trauma. Let's just run through what happens when a person is depressed.

The mind shuts down, can't think, and the body crashes, too. The neurons of the brain have locked up endorphins (feel good neurotransmitters) in brain cell walls so that there's no zipping around up there.

Endorphin lock-down in the brain is the enemy, of course. Anti-depressants kick locked up serotonin out of the walls of the neurons. When serotonin is zipping around again, people feel better.

So that's one way to shake it up. Use meds. I highly recommend this, but don't leave out the psychotherapy. The psychotherapy can be behavioral (like you'll get in this post). Talk therapy is actually behavioral, too. It's cognitive, thoughtful. But talking is a behavior. So talk therapy IS the original behavioral therapy.

Let's look at what depressed people actually go through.

When you're depressed you feel like your brain is running too slow. Everything is less intelligible, everything is hard. A person feels physically fatigued, worn out, lethargic, heavy. Real depression makes it hard to get out of bed, hard to get up in the morning, hard to do the simplest of tasks.

People with well-developed super-egos, who have many "shoulds" that rule their lives, think they're being lazy when they're depressed. They get angry at themselves for being unable to fold the laundry, take in the mail, change the cat litter.

Mundane tasks seem so hard, but do-ers who get depressed know that someone has to do them, only they just don't care. They're not themselves. They know it and it makes them MORE depressed.

People who don't mind underfunctioning are still going to feel terrible when they're clinically depressed. Depression also brings on tears and the feeling that there is indeed a cloud directly OVER one's head.

Clinical depression, you probably know, means that your appetites are virtually gone: you don't feel like eating, you can't sleep, and sex is the last thing on your mind.

Then there's the problem of communicating. If you're depressed, when other people talk to you, you tend to space out, can't follow, lose track, can't concentrate. You forget everything, even writing things down is a chore. You forget to make lists, forget to write things down, can't find a pen.

This cognitive dysfunction is humiliating and depressing. Again, the very symptoms of depression can actually make a person more depressed.

(Novice docs who try to do cognitive therapy, as in, challenging negative thoughts, before good cognition is possible only frustrate their patients. Analyzing one's negative thoughts really can wait until a person feels just a little better. Next post maybe.)

And of course, depressed people stay at home (no energy); they don't go to parties. They don't visit, gossip. In fact, they avoid people, too mentally fatigued to want to put forth the effort of socializing. Even the easiest social interaction, say going to a movie with someone, can feel like drudgery, work. Then there's that problem with concentration.

Basically? The senses are dulled, the mind drawn inward, attention is only upon the self and thoughts tend to be negative, the negative thoughts paralyzing creativity.

There's no thought of garlic. None.

How DO we slip in the garlic?

It takes work.

If you were in a hospital for depression, the staff would have you out of bed and hitting the showers at 6:30 a.m. Showers are stimulating. You'd be in group therapy by 7:00 and have breakfast at 8:00. By 9:00 you'd be seeing a doc, by 10:00 shooting baskets or playing ping pong.

The day would be busy. The hospital program essentially works to get that brain/body functioning again. The stimulation isn't only talk therapy, it's also physical, and psycho- pharmacological, of course. They use meds in hospitals, and work to get them right.

If you're treated as an out-patient, seeing someone like me, then your doc probably won't make you get up at 6:30, but you might have to agree to try to force your way out of bed at some point.

The idea is that you don't want to sleep your life away. Meds work here, too.
But once you're on meds you might sleep too long, and until you take them you may not sleep well, if at all. Oh, and did I mention that everyone's different?

In some cases sleeping the entire depressive episode IS necessary and has to happen. Especially in bi-polar disorder, where the highs are very high and the lows very low, there may be no alternative to sleep than to sleep.

Which is fine. But it's worth testing it out, trying to see if sensory stimulation won't help waken a sleeping brain. It often does.

What's sensory stimulation? It's something that the brain can use to kick those endorphins out of the cell walls by tickling perceptors. Imagination can do it, too, believe it or not, thinking new, more exciting thoughts. Good psychotherapy functions like that. Events can do it, like winning the lottery. The brain likes things new.

But assuming you won't win the lottery, I'm actually suggesting that if you haven't bought yourself anything new to wear for a year, this might be the time to pop for a couple of affordable new things. New clothes FEEL good.

New things don't have to be material, however. They don't have to be things you buy.

The brain likes any stimulation, anything new. Like the smell of a rose, or baby oil on the skin. Fresh baked bread. A manicure.

I push people to work the tasks of the five senses: seeing, hearing, smelling, tasting, and feeling. These are your gateways to worldly pleasures. We perceive the world around us with our eyes, ears, nose, mouth, and skin.


I'll tell my patients, even those on disability who can't work,

You had blank well better get outside today and look up at the sky. I want to know the colors you see. I want to know what birds are out there. I want to know how it feels to let the raindrops wet your skin. I want you to walk around in the rain, hear the crackle of leaves beneath your feet.

If you only walk to the sidewalk, that's fine. Do it ten times a day.

Dr. Domeena Renshaw, one of my mentors, said in 1981 before we even had half the great drugs we have today: If I have to have a single terrible illness, MAKE IT DEPRESSION. I KNOW I'LL GET WELL. It might take a year, but it'll pass.

There's such a thing as trying to speed things along, though. Not always, not in EVERY case, but in most, there's the pro-active piece of jogging depression.

If you don't shake it up, depression really might feed on itself and get worse. You might go from staying home, to losing weight, to sleeplessness, hopelessness, and helplessness. The perfectly fabulous person you are might feel like a loser and think life not worthwhile.

You do have to work at getting better.

The alternative's unacceptable peeps. Not on my watch. Shake it up.

Copyright 2006, TherapyDoc


Anonymous said...

This is awesome. Wow. Legitimizing. I always feel like I'm a lazy shit even though when i was younger I was an overachieving kid. Stimulation - for me that's beer and cigarettes. recklessness. not sleeping - is being sleepy an excuse for being suicidal?

"not on your watch."
somebody needs to promote you. i'm not adequate though, too depressed. ha.

therapydoc said...

Hold on, Legitimizing what? Not the beer and cigs, dear. Google the words to Rainbow connection. I was going to have to tell someone that today.

Anyway, you gotta' love yourself, and more'n likely you can and do. (your writing's fab, fren, what more do you want?)

No reason's a reason to be suicidal. Permanent solution to a temporary problem.

Happy is better.

Rivka said...

Thank you for posting this. I just found your blog today through Haveil Havalim and this post caught my eye.

Every once in a while, when I really truly need it, I give myself permission to spend the day sleeping or reading a good book (distraction, escape).

The rest of the time, even when I'm having my bad days, I require of myself that I get up, shower (always helpful when feeling low even though it's so incredibly overwhelming just to shower), get dressed, comb my hair, eat something, and take care of dirty dishes. Even if that's all I do, experience has taught me that much helps.

And if I can do that, I can usually convince myself to spend a little time davening, which helps me.

Sometimes it's just focusing on the little things that help me get through the day.

Thanks for blogging from your perspective. I think a lot of people will find it helpful and interesting.

therapydoc said...

Rivka, if you can do all of that, you're in the right place. There's a certain amount of just feeling terrible that's programmed into everyone's physiology. Our biggest problem is that we live in a feel good, live for the moment culture and if we don't feel good we automatically assume that there's something really wrong with us.

That's just not the case. You know the warning signals to get help, though right? Suicidal thoughts, self-destructive behavior, primarily.

Rivka said...

Thank you. Yes, I keep pretty careful watch when things get particularly low, or even the highs (if you can call them that - your description of hypomania is right on) when I need to stay away from anything involving spending money. I've been hospitalized enough times I never care to repeat the experience. Baruch Hashem the last time was over 10 years ago, and so long as I remain vigilant and on-task with meds and therapy, I hope to never go back.

There are times of true joy and contentment in my life and those are the times I hold onto and look forward to again. said...

Thank you so much for posting this. I've tried for years to explain/illustrate/SHOW what depression's like. The Black Hole is the best I've ever been able to do. And I'm a writer.

Those days I can't even manage a shower there's a part of me that's watching and noting that things are not "good," and it's probably time for a med check. Or to at least open the front door and stand out on the front porch for a few moments.

One afternoon several years ago, when none of the meds were working, and I was zombied out on the couch -- a friend dropped by unannounced. I could recognize by the look on her face how bad I was. She calmly suggested we go at once to get an ice cream at a store a few blocks away. She hauled me up off that couch and we walked to the store.

That's all it took that day. Getting up, getting outside, and walking a block or two. And a good friend.

But god, it's so hard to remember that when you're in the bottom of the Hole. I'm so thankful for that little part of my mind/soul that keeps watch for me, no matter how bad the depression gets.

therapydoc said...

Glad you got to read it, BP.