First, two important factors are involved when describing Clinical Depression. These are:
- This condition causes physical symptoms, and on rare occasions has physical causes; however, while it is not a disease, it is often unpreventable except with medication.
- During a physical depressed state, other transitional stresses and issues can worsen a person’s physical state. These factors reduce the person’s ability to cope. Transitional periods plus environmental factors can confuse the client’s cognitive processing whereby they are unable to determine the difference between a period of clinical depression and a shifting change in mood.
Physical/behavioural symptoms include:
- Sleep disturbances – insomnia or hypersomnia
- Appetite – eating more or less than usual, and gaining or losing weight
- Pain – headaches, joint ache and muscle ache
- Affective/emotional symptoms include:
Feelings of sadness, hopelessness and despair:
- Variation in moods throughout the day – worse in the morning but improving later in the day; or vice-versa
- Loss of pleasure such as no longer enjoying activities or hobbies
Cognitive symptoms include:
- Experiencing persistent negative beliefs about themselves and their abilities
- Suicidal thoughts
- Slower thought processes – difficulty concentrating, remembering and making decisions
Social/motivational symptoms include:
- Lack of activity, for example, social withdrawal and/or loss of interest in closeness or intimacy
Depression could be caused by one or more of the following:
- Biological factors – there could be an increased chance of developing depression if a family member has it
- Biochemical factors – low levels of serotonin have been linked to depression
- Anxiety factors – as a result of living with an on-going anxiety disorder such as obsessive compulsive disorder (OCD)
- Psychological factors – depression can be triggered by an external factor, for instance, a bereavement, divorce, moving or other change in circumstances
- Behavioural factors – learned helplessness resulting from an external factor (bereavement, divorce) and the attention the depressed person has received due to this. In other words they learn to continue being depressed
- Cognitive factors – in terms of learned helplessness, the depressed person learns not to try to help themselves because they believe they will fail, thus they may see their failure as internal (their fault) or external (caused by something else) or global (applies to all situations); maybe specific (just applies to this situation) or stable (likely to continue) or unstable (could change, but possibly for the worst)
Early Warning Systems
“Early Warning Systems” are factors that can help a depressed person evaluate why they are feeling a particular way. For example, questioning why “Peter” feels in a low mood in the afternoon might suggest to him that a major depressive state is coming on, where in fact it might actually mean he had little sleep the night before. In terms of understanding and using the “early warning system” the person can be taught how to grasp the difference between feelings and facts, and in which to determine what it is that caused their mood change. As such, and in this example, Peter is taught how to question key factors such as:
- Environmental – was he exposed to a stimulus that had an adverse effect on him, for example, had he been somewhere where he was sensitive to loud noise, bright lights, too many people rushing around? Would it have helped if he’d moved away from this environment to help gather his thoughts and to put in some perspective?
- People – had he had a negative interaction with someone? Was he able to resolve this issue by modifying the relationship by questioning how he “sees” that person’s behaviours and looking for alternative perceptions? Perhaps he could consider making amends or asking the other person to help rectify the problem.
- Physical – did he miss a meal? How can he check his meal times in the future?
- Emotional – could the emotions be transitory or depression? For example, being exposed to a particular stimulus can trigger a negative response, such as experiencing intrusive thoughts related to OCD. Was he able to recognise this and check his resources to get through it, for example, talking it through with his therapist, friend, parent or partner or using CBT strategies learned in therapy?
- Negative lifestyle – could Peter have worsened his mood by using alcohol, caffeine, drugs, binge eating? Could he be taught to consider the impact that self-medication can cause, for example, too much alcohol may lift the mood for a while, giving brief respite, but dampens the mood in the long run, and for longer, which adds to the depression?
- Sustainable – has he lost a sense of balance and stability by doing too little, or too much? How could he strike a balance? Perhaps by defining an appropriate level of activity in relation to recreational, social, voluntary work or physical exercise? Would this help to maintain his emotional well-being?
- Medication and medical supervision – has he stopped taking his medication, or overdosed accidentally? Has he been keeping up with appointments for medical check-ups? Can he be taught that his compliance with taking medication and maintaining that is helpful; and that keeping up with medical check-ups is important for his overall well-being?
- Disillusionment – does he feel he has had enough of fighting depression and feel like giving up? Has he forgotten that not fighting is actually worse than “giving up”? If this is the case then his therapist and other professionals must work together, if possible, and with support networks and carers to help him “pick himself up” and try again.
Once the key to an early warning system is found, a depressed person can then consider how to manage their moods. So in the example above it becomes clear to Peter why his mood lowered in the afternoon – he realised he’d slept for only three hours the night before. When considering feelings and facts he was able to differentiate how sleeping little can cause someone to feel low, but that this does not mean their depression will worsen. Therefore, he learned that maintaining a good sleeping pattern means better moods and so he decided to work at doing extra motivational tasks to induce sleep. He also realised he drank coffee at night, and started to understand that this was what was probably making him restless, in which case he decided to have a soothing drink such as chamomile tea, hot milk or Horlicks before bed instead.
Obsessive Compulsive Disorder
There is a clear relationship between OCD and depression in terms of either people developing obsessions during a depressive episode, where symptoms can reduce dramatically when the depression lifts; or becoming depressed following the onset of OCD, which is noted as secondary depression. Although a distinction can be made between depression and OCD, there is however a continuum where a person experiences on the one end depression without obsessions and on the other end experiencing OCD without depression, while at the same time swinging in the middle of the continuum where they tend to suffer a combination of both. What should be noted in this instance is recognising the features that describe depression (see symptom list at the start of the article) and the relationship between the two disorders. When treating OCD it is important that the depression is treated first, usually with medication, and before cognitive behavioural therapy (CBT) is applied, or continued. This is because depressed moods often result in depressed thinking or clouds thinking, leading to depressed behaviours. When this alters, OCD can be treated while keeping a regular check on moods.
Journals, self-assessment scales, and other CBT forms can help people who are depressed backtrack early warning systems in terms of identifying triggers and helping them make sense of the their moods and to better manage them. Keeping records can also help with other problems such as acknowledging and accepting the concept that feelings are not facts. This can lead to improved moods and a healthier lifestyle.
Major Depressive Disorder
Major Depressive Disorder has all the signs of clinical depression but on a much higher scale. It can be caused by external factors such as when a loved one passes away, or it can be caused by internal factors – for example, neurological.
Occurrences in major depressive disorder continue throughout the person’s life to an extent they can become suicidal. Self-sabotage might occur when for instance a person falls into certain behaviours to reduce the symptoms of low mood. These might be comfort eating, self-medicating with alcohol, shopping, reassurance seeking and so on. These become problematic when comfort eating becomes bingeing, self-medication becomes addictive, shopping becomes an emotional high, and reassurance seeking becomes obsessive.
These behaviours might occur when the person feels they have no other choice but to escape their emotions. However, these activities can increase the depths of their already fixed emotional insecurities – worry about weight issues, relationships and/or work problems due to alcohol addiction or other escape behaviours, debt due to unnecessary shopping trips and doubts about self-esteem when reassurance isn’t helping anymore.
The worst scenario is when a person fails to respond to alternative methods that would otherwise improve their condition. As such, self-soothing behaviours often increase and can lead to ill-health. This worsens depression and in some cases may lead to self-harm and either suicidal thoughts, or suicide itself.
A therapist’s role is much the same as with those with clinical depression. However, it is important that the therapist ensures the person attends regular medical supervision and encourages them to take the advice of their medical doctor and specialist. The therapist will also (or should) encourage the person to take and maintain prescribed medication, support him or her in following through with other support and safety mechanisms, for example “early warning systems” (see above), self-assessment scales, TLC and emergency contacts.
A therapist’s level of competence
There are times when additional supervision is needed. For instance, self-medication is a crucial issue since this can add to an already serious low mood, as noted earlier. The person’s general practitioner should monitor, for example, appropriate reduction in terms of withdrawal methods to help guard against the client tipping over the edge. While minor health issues can be complemented by health therapists to help manage client cases, severe mental health issues differ in that these go beyond a therapist’s level of competence.
Therefore in the first instance, it is the therapist’s job to support the client during medical supervision only, and to stick to the plan implemented by the medical specialists (since appropriate implementation is extremely hazardous and therefore should not be attempted by the therapist). In the second instance the therapist’s role is to only complement and assist with the consent and knowledge of a specialist, psychiatrist, community health team or mental health social worker, who coordinates and manages the patient.
“Early Warning Systems” are factors that can help a clinically depressed person evaluate why their moods are low. Additional supervision is required for people with more severe cases of depression as in the case with major depressive disorder. Subsequently, the person can then be helped to manage and monitor their moods and overlapping problems such as OCD, anxiety, GAD etc.
Carol Edwards © 2016. Updated Dec. 2017
Disclaimer: this document is information-based only; therefore if you are experiencing any of the symptoms discussed in this article please consult with your medical practitioner for their advice, and before going ahead with suggested strategies.
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