“The Curse of the Strong”
by Dr. Tim Cantopher, Consultant Psychiatrist, Priory Healthcare Services
We all feel depressed at times. I certainly do, particularly on Monday mornings. But, because we all know how the emotion of depression feels, we tend to assume we know how someone feels who is suffering from a depressive illness, or clinical depression. In truth though, we haven’t the first idea of what a victim of this illness is going through. At its worst, it is a glimpse of hell which the rest of us, thank goodness, will never come near to experiencing in our lifetimes.
There are many misunderstandings about clinical depression. One of the commonest is that people who get it are in some way weak. This is ironic as in fact the opposite is true. Stress induced clinical depression does not happen to weak people, but is an affliction of people who are too strong. There are several different causes of clinical depression, but by far the commonest and the one I will deal with here is stress. Life, sadly, is getting more stressful and as it does so an epidemic of depressive illness is underway – up to I in 3 consultations in general practice involve patients with the disease.
And yet it can be prevented, is not difficult to treat and can be prevented from recurring in those who are unfortunate enough to suffer an episode.
This illness nearly always happens to one particular type of person.
He or she is strong, reliable, and diligent, with a strong conscience and sense of responsibility. But he is also sensitive, easily hurt by criticism and has a self-esteem which, while it may look robust on the outside, is in fact quite vulnerable and easily dented.
This is the person to whom you would turn in times of need, and she would never let you down. When the going gets tough, this person gets going.
Why should this type of person be the one to get ill? The reason becomes clear when one understands what clinical depression is. Here is the key: clinical depression is not a psychological condition or a state of mind. It is a physical illness.
A depressive illness happens when one part of the brain, called the limbic system, malfunctions. The limbic system is a set of nerve fibres arranged in a circuit. Essentially this circuit acts like a complex thermostat which controls a number of systems and functions in the body. Probably the most important of these is the control of mood. It usually works well with mood returning to normal reasonably quickly after most of the day to day ups and downs of life. But like any other physical system, the limbic system has a limit and if it is stressed beyond this point it will break. When this happens, the part of the system that fails is the transmitter chemicals, serotonin and noradrenaline. These are the chemicals which allow the electrical impulse to pass from the end of one nerve fibre to the beginning of the next. In depressive illness their levels fall rapidly, resulting in the circuit coming to a. grinding halt.
So what happens if you put a whole lot of stresses on to someone who is weak, or cynical, or lazy? The answer is that he will immediately give up, so he will never get stressed enough to become ill. The strong person on the other hand, reacts to stress by redoubling his efforts, pushing himself way beyond the limits for which his body is designed. When he starts to get symptoms, because he is sensitive and fears criticism and failure, he still keeps going, with the inevitable result that eventually something must give way. What gives way is the limbic system. If you put 18 amps through a 13 amp fuse, there is only one possible result.
Stress related depressive illness is essentially a blown fuse.
The symptoms of clinical depression (you don’t have to have them all to have the illness) are depressed mood, feeling worst in the morning and better as the day goes on, and a host of “Loss-of’s”.
That is, loss of:
Energy and enthusiasm
Confidence and self-esteem
and almost anything else you can imagine; pretty much everything goes.
So you have identified that you have a depressive illness and you recognise that it is a physical illness. What do you do now?
Answer: exactly the same as you would with any other physical illness; rest and take the prescribed treatment.
The trouble is that on the whole the people who develop this condition have overcome every problem they have encountered in the past by extra effort. The concept of giving in to the illness is anathema. Yet you wouldn’t normally try to overcome pneumonia through only the exercise of your resourcefulness. Neither can you with clinical depression.
Beware family and loving friends. However well meaning they will often give you the benefit of their homespun wisdom: “Go on, pull yourself together, get more interests, get out more, get more friends, come and have a party, we’ll cheer you up”. If you take this advice you will probably get worse.
Rest, especially in the early stages is crucial. This doesn’t mean going to bed or sitting in a chair doing nothing, that would give you far too much time to ruminate. It does mean avoiding any unnecessary challenges and only, where possible, doing what is easy. If it is possible to take time off work, do so. If you can get someone to clean up, look after the kids and do other chores, do so. Cancel social events that you are not looking forward to. Watch more TV or do anything else that comes easily to you.
Another difficult issue is antidepressant medications. While there is no doubt that they are an important part of treatment, they have had a very mixed press and people hold strong views about them. Again, misunderstandings abound.
Maybe I can dispel a few. Antidepressants are not addictive, though if you come off them too quickly you can get withdrawal symptoms; withdraw them slowly by tapering the dose over several weeks at the appropriate time. They don’t work straight away, usually taking a few weeks to kick in properly. They don’t give you a false high, Or make you a better, more creative person, or turn you into a murdering psychopath. Prozac is a good antidepressant but doesn’t deserve either the cult following or the condemnation it has attracted. Above all, if an antidepressant helps you get better, don’t stop it as soon as you get well. It takes the limbic system several months to heal properly, even though the symptoms of clinical depression have gone. If you do keep the drug going for long enough, you are unlikely to relapse when you come off it, in the same way that, when a plaster cast is taken off a broken leg which has healed, you can walk without a return of pain.
Once recovery starts, things get more complicated. You need to start doing a little more, but how much? The truth is, I don’t know. But you do, because at every stage, your body will tell you. You can divide activity into three categories: mental, physical and social.
At your body’s physical limit at any point of recovery you will start to feel heavy and lethargic.
For mental activity, you will find you don’t take anything in.
At social events, you will start to find it difficult to talk sensibly.
At this stage, or before, stop. If you do you will continue to recover, if you don’t you will feel rotten for the next 36 hours or so. The harder you push recovery, the slower it goes. So take it gently and listen to your body.
Even following these instructions you will get ups and downs, but they will be minimised. At the beginning there aren’t many good days. In the middle Of recovery some days are nearly back to normal and others almost as bad as ever. Nearing full recovery the bad spells become shorter, further apart, less bad and eventually peter out.
Beware extremes of emotions during this period. Your first good day isn’t the end of your problems and the rotten day that follows it doesn’t mean you will never be well. Don’t overdo it on the good days and don’t despair on the bad ones; this is normal recovery, and in any case, the bad days are often a message
that what you did yesterday was a bit too much.
Once you are somewhere near full recovery, it is time to ask some basic questions, such as: What is it all for? Do I have to run my life this way? Can I say ” no” occasionally? What do I want from life? Why do I always have to be everything for everybody? etc., etc.
These are difficult questions and there are many more. They involve you identifying the choices you have in your life and making them. If you don’t think you have any choices, because of your commitments and responsibilities, you are wrong. However you may have to give up your image of yourself as the perfect mother/father/employee/friend etc. to find them. If you do, you can stay well.
It isn’t always possible to achieve this on your own. This is when a psychotherapist comes in. There are a great many different forms of psychotherapy, but mainly they can be divided into exploratory (or psychodynamic), cognitive and behavioral. I won’t go into these therapies here, as that is another article, but they all work for different people, depending on their particular route into the illness. The essential point though is that effective treatment isn’t a matter of drugs or change of lifestyle or psychotherapy, but is often a combination of all three.
After that it’s down to you. If you have changed the way you operate and maybe the way you think, you have a great chance of remaining not only well, but happy too!
TWELVE ESSENTIAL FACTS ABOUT DEPRESSIVE ILLNESS
It is primarily a physical not a mental illness
It happens to strong, not weak people
It is not the same as “feeling depressed and fed up”
You don’t know how a person suffering it feels unless you have had it yourself
You cannot pull yourself out of it
It gets better eventually, sooner or later
It gets better quickest if you rest
Anti-depressants are not addictive. Anti-depressants usually take a few weeks to work
Don’t stop your anti-depressants as soon as you feet better
When recovering, increase your activity slowly, as your body dictates
in order to stay well following recovery will need to make changes to the way you operate, and possibly the way you think.
article, source unknown read at Swanage Depression Support Group in May 2017
review of he book by Cantopher is on this site