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Gift From Within - PTSD Questions & Answers with Frank Ochberg, M.D.
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PTSD Symptoms: Depression
FAQ 1: The differences between every day Depression, Dysthemia and Major Depression.
Q: Dear Frank, I think it would be good for most people to understand the differences between every day Depression, Dysthemia and Major Depression.
PTSD Symptoms: Depression.
A: Dear Joyce, Depression does come in different shapes and sizes.
Our Gift From Within family shares the common ground of trauma, traumatic stress and the consequences of being badly hurt. But many of our survivors have depression rather than PTSD.
I think of depression as four feelings all at once: helplessness, hopelessness, worthlessness, and incredible lethargy. The lethargy is not like the low energy from anemia or heart disease or other physical disabilities. It is a profound lack of emotional stamina. You can climb a flight of stairs, but you can't do the tasks that you know you ought to do. The seamstress doesn't sew. The homemaker doesn't cook. The student doesn't crack a book. It isn't a matter of not caring, The "juice" just isn't there. And although we may lump feeling helpless, hopeless and worthless all together, each is different from the other deficit. Feeling helpless is a source of shame.
Feeling hopeless is a source of dread. And feeling worthless is a source of separation from others who might provide comfort. When these four factors combine, they may be lethal. Major depression is a medical diagnosis and it is dangerous. Suicide is often visualized. That is called suicidal ideation. It may be contemplated and planned. It may be attempted. In some cases the lethargy is life saving, stopping a person from having the energy to complete the act. But suicide isn't the only lethal danger.
Major depression includes increased risk for physical disease and it compounds existing diseases. Major depression leads to malnutrition. Major depression accompanies drug and alcohol dependence. We psychiatrists take a careful history of our depressed patients. We look for family members who share the diagnosis. We want to know if this is a single episode and if not, whether there have been any manic episodes in the past. We also want to know the quality of the current episode. Can you feel happy despite the helpless, hopeless, worthless sensations? Are you very sensitive to rejection? Are your limbs leaden - feeling heavy and hard to move? This pattern is called "atypical depression" and it doesn't respond as well to Prozac and Lexipro and other SSRIs. On the other hand, if you are relentlessly melancholic, unable to lighten up at all, and you never had a manic bout, you are a good candidate for a simple antidepressant. Being bipolar (formerly manic-depressive) means a different medicinal approach, since an antidepressant can cause mania and mania, right after depression, is a very dangerous affair.
I've been writing about major depression, not dysthymia and not ordinary sadness and grief. Major depression is almost always a medical condition. The brain is starved of neurotransmitters. It doesn't have the chemistry it needs to complete the circuits that let us feel alive, lively and normal. I have patients who prefer not to use drugs, but most are amenable to medication and "talking therapy" and the combination works well. It takes time. If the condition is severe, hospitalization helps. But hospitals aren't what they used to be and insurance seldom covers all the care that is needed. These major depressive episodes tend to last two weeks to a few months. They remit without treatment, but are so difficult to bear that treatment is really necessary.
There is a condition, a frequent condition, called "Major Depression, Recurrent." Over a lifetime, there will be many episodes. On the other hand, there is a common depressive pattern called "Dysthymia." It is pronounced dis- thigh-me-ah with the accent on "thigh." This is a low-grade depression lasting at least a year in youngsters and two years in adults. It may go on and on and on. Usually there are some tolerable days, but most days are unpleasant. The same four factors may be present - feeling helpless, hopeless, worthless and lethargic - but they are not as crushing and debilitating. You can get out of bed. You can get to work. But you do need professional help and you deserve it. I've treated dysthymia with medication. Sometimes that ends up being several pills - for depression, anxiety and sleep. Often the first combination doesn't do the job, so we keep looking for a diet of pills that work best. Of course, some people with dysthymia will become overmedicated, particularly when they change doctors or when their doctors and therapists are different people and they do not communicate effectively. But, by and large, dysthymia is a treatable condition and most mental health professionals are very familiar with it. Again - Major Depression, whether is it atypical, melancholic or part of a Bipolar pattern, is episodic and it usually is disabling when it hits.
Dysthymia is longer in duration and shorter in impact. And then there is non-psychiatric sadness and non-psychiatric grief. These are low moods that are proportional to the life situation. Sometimes they are called "situational depression." I look for worthlessness to distinguish "medical" depression from "situational" depression. After a profound loss (a partner, a beloved pet, a job) it is absolutely normal and healthy to experience sadness and grief, to cry, to sigh, to be preoccupied with the loss, to dread the next day, to feel unable to cope. But to feel worthless - that is a sign of depression and an indication that professional help may be needed. Since my days as a resident in the late 1960s, we have learned that extended "situational sadness" becomes medical depression. Antidepressants do help when the condition reaches this point.
The term "Dysthymia" is replaced in the latest diagnostic manual, DSM-5 with the term "Persistent Depressive Disorder" (http://www.mentalhealth.com/dis/p20-md04.html). But the concept and the treatment is, essentially, the same.
And people who live in war zones - be those literal war zones or families that fight to the point of degrading and humiliating family members - are more often depressed than suffering from PTSD. The combination of depression and PTSD is often seen in survivors of extensive abuse.
So we in the GFW family should be aware of depression and its different patterns. We should encourage education, compassion and inspiration. Being depressed, by definition, is avoiding the opportunity for social contact. So we offer that contact carefully, skillfully, and with appreciation that we may be rebuffed.
Eventually, a friend will appreciate that we care, and even more -- that we are there.
FAQ 2: Depression, Sadness and Grief
Q: Dear Frank, In your recent program, Surviving Trauma & Tragedy: Lessons For Future Physicians you discuss that major depression is more likely to take place than PTSD. The panel members courageously discussed their traumatic events like Linda, who was pregnant and assaulted at gunpoint while shopping for her family, and a couple whose 20 year old son was a victim of homicide. Can you talk more about major depression and why this is something health professionals and survivors should be aware of? What are the major differences?
A: Dear Joyce, Depression is often confused with sadness and grief. Who would not be sad when robbed of dignity, integrity or a loved one by a rapist or a murderer? Who would not grieve the loss, with an aching sense of degradation or loneliness? The emotion of sadness is normal, even when it is profound sadness, proportional to the circumstance. The condition of bereavement or grief is also normal, and is always associated with loss. But depression is different. In a depressed state, a person feels hopeless and helpless and worthless. In addition, they have a specific type of lethargy that stops them from doing what they have been put on Earth to do. The cook cannot prepare a meal; the seamstress cannot sew; the writer cannot summon the energy to compose a sentence. Each of these people could climb a flight of stairs. They are not like the anemic or the heart patient without stamina and strength; they simply lack the energy to do what they usually do to be productive and to feel alive. Worthlessness is particularly important. If your spouse is killed and your life is suddenly changed forever, you would be expected to feel helpless and, for a while, without hope. But feeling worthless is a sign of depression. You shouldn't feel worthless during "normal grief."
When I was a psychiatric resident in the late '60s we were taught to consider two different types of depression. Exogenous depression, or depression from the outside, was a reaction to stressful life events. We thought of it as "situational" rather than "biological." If drugs were to be prescribed, we used minor tranquilizers like Librium and Valium. We expected the depression to improve as life conditions improved. Endogenous depression, or depression from within, was thought of as a genetic disorder with episodes lasting weeks or months, best treated with antidepressants like Tofranil or Elavil. Endogenous depression could come out of the blue, and was not thought to be caused by stress or loss. Now we know that endogenous depression often appears after extreme stress. In other words, a trauma can cause an episode of the type of depression that looks "biological."
Think of it as having your mood thermostat impaired. While it is medically normal to be sad when life is miserable, the brain's mood thermostat allows you to feel good when life improves. But if you are stuck in sadness, and the sadness includes feeling worthless and unable to summon the energy to do what you used to thrive on doing, you are depressed. And you need therapy for depression.
Therapy for depression is relatively straight-forward. There are ways to learn to correct self-defeating thoughts and there are medicines that repair the brain's broken mood thermostat. Both approaches, used together, give the best chance of recovery.
Often, working with extreme trauma, I'll find a combination of depression and PTSD. Both can be treated together. The numbness and avoidance that is part of the definition of PTSD may feel like depression. But people who spend the day in bed feeling worthless are beyond PTSD. They are not just numb and avoidant. They have broken mood thermostats and they cannot experience normal feelings until those pathways are restored. It helps to have the diagnosis of depression and the treatments that go with that diagnosis.
When journalists cover war they are vulnerable to PTSD and depression. Because of the strict criteria for giving the PTSD diagnosis, not every shell-shocked reporter qualifies for the PTSD diagnosis. So research suggests that depression is slightly more common than PTSD in this group. When I say that depression is often more common than PTSD after trauma, I am not minimizing the occurrence of PTSD. I'm just alerting survivors, doctors and government officials to the problem. Let's not ignore post-traumatic depression. It is a significant problem - but it is a treatable problem, particularly when friends and loved ones know enough to help.
Webcast: PTSD & Depression: Who is on your Board Of Directors
In this webcast Dr. Frank Ochberg discusses how he helps his PTSD and
depressed patients. Dr. Ochberg explains a therapeutic tool he calls "your
board of directors." Replacing the negative people on your board of directors
with those who are supportive
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