Depression has a range of meanings from a general sense of unhappiness and meaninglessness to persistent changes of mood and feelings, to psychosis (Hale & Davies, 2009). Depression is classed as an affective disorder involving a prolonged and fundamental disturbance of mood and emotions (Cross & McIlveen, 1996) which is associated with changes of behaviour and physical symptoms (somatisation) such as backache and headache (Hale & Davies, 2009). Whilst depression can have a deep impact on our lives, it can be helped with therapy.
Depression's core features are:
- pervasive low mood
loss of interest and enjoyment (anhedonia);
reduced energy and fatigue and diminished activity (withdrawal).
Other features include poor concentration attention and decision making, diminished or increased appetite, loss of libido, disturbed sleep (waking early or over sleeping), increased agitation (pacing about, complaining), ideas or acts of self-harm or suicide, low self-esteem and self-confidence, feelings of guilt and /or unworthiness, increased irritability (often presents in children and adolescents, or men), bleak or pessimistic view of the future and depersonalisation (I’m not me anymore). Some people may show multiple physical and behavioural symptoms in the absence of low mood (‘masked depression) (Hale & Davies, 2009).
Another feature of depression is a loss of reactivity, individuals will show a blunted or ‘flat’ affect to life events (Sims, 1995). They show a failure to express feelings either verbally or non-verbally, especially when talking about issues that would normally be expected to engage the emotions. The difference is in degree. The client himself is not aware of his deficiency but when pointed out to him, may agree that there is a lack of any sort of emotional reaction (Sims, 1995). This may be experienced as a feeling of a loss of feeling made worse by the client’s own questioning of himself, feeling guilty about the lack of feeling.
A depressive episode may be classed as mild, moderate or severe and diagnosis lies in skilled clinical judgement (WHO ICD 10), usually symptoms have to be present for at least two weeks. A diagnosis of mild depression requires that at least two of the core symptoms are present (low mood, anhedonia or fatigue) and at least two of the other symptoms. For more severe depression more of these symptoms are present.
The Hidden Side of Depression
Clients often come to therapy presenting the physical symptoms of depression: lack of energy; loss of libido; disturbed sleep; absence of periods; unexplained aches and pains; difficulty making decisions; low motivation and inability to start or complete things. However they may not call it depression.
In an intake conversation a client talked of many symptoms of depression but presented them as problems related to her ‘tiredness’: ‘when I get tired my default position is negative, like I’m useless and no one likes me’. This client was clearly preoccupied with her lack of motivation to go into work. Her fear of not being able to get into work, ‘I cannot afford not to go into work’.
Depression may also present itself as excessive alcohol consumption, this is perhaps more common in men (Rowe, 1983). Rowe (1983) observes that many men use alcohol to hide their weaknesses from others and to hide from themselves their own fear and despair. They drink excessively in social situations and also alone at home.
Anger and Depression
we all get angry
Many people learn early on in childhood that it is wrong to get angry. (Rowe, 1983). This may be through having seen too much anger expressed in parents’ relationships with each other or with the child and the child then ‘decides’ that to be angry is bad and so represses it.
Schiffer (1988) proposes that this leads to depression because when a young child’s needs are not being met they will protest loudly (raging tantrums), making them even more difficult for the parents to handle so that parents become threatening or unresponsive and eventually the child will become anxious (threatened) then ultimately defeated (depression) thereby establishing a limbic brain tendency towards depression. (Schiffer, 1988)
Freud and Abraham posit that depression is anger turned inward against self (Schiffer, 1988) when the child internalizes the parent figure and then attacks the parent inside. People often perceive depression as a failure or weakness and as humans we have an innate tendency to get angry with those that fail: this is why depressed people often attack themselves. In addition a tendency towards ‘identification’ with the persecutor means that sometimes when a person feels overpowered by someone else there is a desire to befriend them – the mind of an abused mistreated child seeks to befriend the abusing adult, but to join the tormentor the child’s troubled mind must take sides with the abuser and therefore turn to attack himself (Schiffer, 1988).
Exacerbating this for many clients is the critical parent that has been internalized in the child’s superego, and which will serve to torment the adult client with lifetime barrage of criticism and negative self-talk (Schiffer, 1988).
For MN anger was an alien emotion: he recognised that he rarely got angry and was proud to be a very placid man most of the time. He can remember two occasions when he did ‘lose it’ and he was shocked and scared at his reaction. This reinforced further repression of the emotion. In fact MN had a lifelong pattern of repression of emotions which meant that he was not in touch with emotions to be able to talk about or express them. It was clear to the therapist that he had unresolved anger, as well as sadness and guilt about his wife’s death: ‘I wasn’t brave enough to challenge them,’ and ‘why do bad things have to happen to good people?’
Repressing anger by burying it deeply , turning it inward, and denying that it exists, because of fear of rejection or that it may escalate out of control, may be a good coping strategy to survive childhood, but the trouble with this is that it is the coping strategy itself that becomes problematic in adulthood causing many of the somatic presentations. Another defence mechanism in dealing with anger is reaction formation where the unacceptable ‘bad’ feeling of anger is turned into its opposite extreme of needing others’ approval to feel good: people pleasing (Parker-Hall, 2009), putting others before self or needing excessive amounts of approval from others. External behaviour presents as trying to please others all the time, being the peacemaker, going out of one’s way to never offend others, or a preoccupation with what others think about you. (Rowe, 1983). These types of people often find it difficult to say no and get put upon alot and go to great lengths to avoid conflict.