Shirah Vollmer MD

The Musings of Dr. Vollmer

Just What Is Depression?

Posted by Dr. Vollmer on November 7, 2014

Mood Disorders is the topic of my next class at the psychoanalytic institute, and yet, despite my readings, my 25 years in clinical practice, and my unending discussion with colleagues, I cannot define or pretend to understand depression. The word, as I hear it, is vague and unhelpful. I understand the words above, using the acronym FINE, as I understand the “self-deficit” feeling, but this strikes me as more of an “ego problem” then a “depression” problem. It is not that I do not understand moods. I appreciate that feeling states change from moment to moment, and a sense of optimism/pessimism, enthusiasm/apathy, and joy/boredom, are all different experiences throughout a day. I can see that the persistence of the negative feeling states can cause someone to be labeled “depressed” but I would prefer to elaborate the negative feeling state, rather than use the word “depressed”. I, by order of personal decree, therefore, change the nomenclature from “Major Depression” to “Persistent Negative Feeling State.”

Miley, my fictitious patient, from the previous blog, who in her 60s feels burdened and negative that she “has to” take care of her elderly parents on a daily basis, is a good example of a “persistent negative feeling state,” which describes her situation better than “depression.” Miley gets up every morning, showers, eats well and exercises. Her daily routine and self-care are intact. However, in her mind, the world is a terrible place to live and she is filled with dread and negativity when she is faced with her day. She constantly feels that others have easier lives and she constantly feels confused as to why her life is so hard. This way of being, she would say, has been true for over forty years. Is she, as psychiatrists might say, “dysthymic”? If dysthymic means that she leads a life in which she is mostly bitter and angry, then “dysthymic” might fit, but when we understand that she is bitter and angry because in her mind she has “no choice” but to devote her emotional life to the care of her parents. Friends, and other members of her family, tell her the opposite, that she does have choices, but she cannot hear this. She has convinced herself that there is only one way to live her life and that one way makes her feel irritable all of the time. The dynamic psychotherapeutic model suggests that with intensive psychotherapy, Miley can begin to see how choices lead to feeling states, and as such, her life can be changed by making more conscious choices. Yes, Miley has responsibilities towards her parents, but this does not have to translate into daily contact, or to severe emotional drainage. Miley has control over how she interprets her responsibility towards her parents, and within this context, she can open herself to new feeling states. Depression, the word, does not tell us how to help Miley, but “persistent negative feeling state” gives us a path to hope and expansion. Nomenclature is important. DSM 6, can you hear me?

7 Responses to “Just What Is Depression?”

  1. Ashana M said

    Depression is the overwhelming, intense, usually unexplained desire to sit down or to lie down or to generally do nothing. Different people react to the feeling in different ways. They have different thoughts about it and because of it. Some people take revenge on themselves for it and assault themselves with negative thoughts, which usually makes the depression last longer. Some people extend the feeling to thoughts about the future and decide it is all hopeless and impossible and can’t be done. For some people it creates ego problems: wanting to sit down all the time makes it difficult to cope with life, to feel competent. It makes it difficult to maintain supportive relationships.

    But the thoughts and the reaction can be separated from the felt emotion. The emotion can be experienced without those thoughts: they aren’t necessary to one another. How to help depends in part on the reaction. Like having a broken leg and needing to work out how to walk on crutches, you also need to work out how to live life when you are constantly overwhelmed by the urge to sit down. If you typically react with thoughts that intensify the depression, you need to work with that. And you can also help by the addressing the emotion itself. Depressed people spend all of their time and energy fighting the emotion, but the depression must also be felt. There must be a space in which to do it, where feeling it intensely won’t have any consequences. It won’t lead to neglecting the children, to problems at work, or to poor health.You can also help by working out why the depression occurs, but that seems to be the easy part.

    Depression I know very well.

  2. Shelly said

    I don’t like the word “depression”. It has stigma attached to it, the same as the word “bipolar,” “manic,” ” schizophrenic” or any other mood or major mental disorders. I do understand a “Persistent Negative Feeling State” and can sympathize with Miley’s predicament. She feels that she needs to take care of her elderly parents even though it is stifling. While you say that she has choices, like NOT taking care of them, that is not really a choice, because abandonment and living with the guilt of it isn’t really a decision.

    • There is a middle ground between abandonment and taking care of her parents, which Miley, with thought and reflection, can go to, rather than surrendering her life to the care of her parents. Balance is the short answer, but you are right that guilt is the inhibiting factor, and so working with that guilt is the challenge of our work. Thanks.

  3. Eleanor said

    I’m probably going out on a limb here but I’m going to mention the name and work of a Stanford neuroscientist….Robert Sapolsky, PhD. As always I speak from my personal experiences and views ONLY and I realize others most likely will have different viewpoints and experiences. Dr. Sapolsky has given a lecture (available to watch online) on Major Depressive Disorder and directed so lay people can have some understanding this extremely complex and devastating disease. My much loved mother developed crippling episodes of this illness in her later years. I have listened to Dr. Sapolsk’s hour lecture several times and it comes closest to describing the experience with the disease my mom had. He covers the complex interplay involving details of neurochemistry in the brain along with massive effects on the entire body (somatic influences) along with the effects of genetics and early childhood traumatic experiences. (In my mom’s case, the horrible loss of her only sibling who was killed by a horse drawn milk cart during childhood) to the traumatic loss of her mother a few years later to uterine cancer. Perhaps there should be a subcategory when referring to depression as “persistent negative feeling state” ….maybe “Major Depressive Disorder” as it is at present. In my experience with a loved one, true major depression is a “biological illness” as much so as Juvenile Diabetes or Cancer (along with major psychological and genetic components of course). To repeat, I am talking depression that has strong genetic components, early family trauma, extreme biochemical components, the need for hospitalization accompanied by ECT treatment, etc. This type of depressive illness goes beyond Shirah’s description of Miley, yet it can happen to “good, intelligent, every day people”, given the right unfortunate circumstances (as with my mother). I’ve seen it happen and I lived it with her.

    One final comment, to this day I am convinced that had my mom had early intervention with psychoanalysis by a skilled physician, her later Major Depression could have been avoided. Again, I only speak from my experiences.

    • Thanks, Eleanor. It seems to me that your mom’s experience is a result of early trauma, and as such, I agree that early intervention could have prevented a late-life depression. Having said that, the effect of trauma is not emphasized enough. I suspect that trauma does combine with genetic neurochemistry, but I also lean more towards the trauma as the culprit to many mood issues. Thanks.

      • Eleanor said

        I agree Shirah. I seemed to be the only person (psychiatrists included) that felt this major depression was , at least in part, the result of these early traumatic losses. Too many psychiatrists want to hand out prescription after presciption which in the end can complicate the depression enormously, adding symptoms on top of symptoms. My layperson’s philosophy has always been the mind and body are connected and have heard the scientific community say “the human brain is the most complex thing in our known universe that we know of…….so far”. Amidst all our neurochemistry and neural connections (biology) is a human being…a human soul…with feelings, emotions, sadness and so on. For the psychiatric community, at least in part, to deaden our humanness with huge doses of medications is, my my laypersons opinion, unacceptable.

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