”He told me it's all in my head." She wept silently, eyes down. "Maybe he's right."
Her state was familiar, one I had seen many times before.
But “he” wasn't right.
Depression is a highly physical condition, a state of the brain and body informed by genetics, gestational environment, early learning and later relationships, all of which lead to specific changes within the brain and the body itself through a complex interaction of chemicals.
Depression is not a simple mind over matter issue. Those who suffer don't have the ability to just wake up one day and make it go away.
And if it could be chosen, no one would fucking choose that shit. No one. Certainly not the near ten percent of the population affected by it.
People around you owe you more than, "It's all in your head." Because that simply isn't true.
It’s a system. It's physical. And once you understand what it is and what causes it, you may be better equipped to explore your options.
There is hope. There is help. Let’s get into this.
What Does Depression Feel Like?
To qualify as a major depressive episode, symptoms must impair your functioning and last a minimum of two weeks. You must have at least five of the following symptoms, including the first two.
The Official Symptoms of Major Depression:
- Depressed mood
- Trouble with pleasure (anhedonia)
- Lack of energy/tiredness
- Too little or too much sleep
- Changes in appetite
- Changes in mental or physical processes (slowing or increasing)
- Trouble concentrating
- Suicidal thoughts or attempts
While the above embody the clinical definition, there are a few more traits that are very common in those with major depression, even when they are not in the throes of a depressive episode:
- Vulnerability to emotional issues when stressed
- High sensitivity to events, particularly losses and relationship issues: In Against Depression, Peter Kramer notes that because women tend to (but not always) have deeper feelings surrounding relationships, they may set themselves up for additional losses inadvertently, which may partially explain the higher rates of depression in women1.
- Slow recovery from slights or failures at bouncing back, often due to specific changes in the brain. Because resilience is often a matter of physical process, a slow recovery can indicate depression for this reason.
- Trouble accepting compliments
- Trouble recalling good events in the past, or seeing positives in the present (I once heard it referred to as, "Looking at the world through shit-colored glasses.")
- Withdrawal from others or isolation
- Slow motion, lethargy and “Low Spirits”: In The Expression of the Emotions in Man and Animals, Charles Darwin identified this set of emotions he called "low spirits" that came with grief, dejection, anxiety and despair, all of which included motionlessness so common in depressive disorders2.
- Pessimism: Kramer notes that depressives may actually have more realistic views of the world, for example understanding that they aren’t likely to win the lottery or a poker game. However, they are actually less likely to listen to those instincts which leads to a self-fulfilling prophecy of doom and reinforcement.:“I shouldn't bet on that because I'm likely to lose, but screw it, I'm doomed anyway…oh shit, lost again. I suck.”
- Neuroticism, or history of other mental health issues including anxiety, moodiness, irritability, and high sensitivity. Kramer identifies this trait as one that predicts depression and shares 60% of genetic vulnerability with clinical depression.
"But you said it's a physical illness. Those sound like emotional problems."
Perhaps. But maybe not. Because in the depressed population the emotional symptoms and the physical are intertwined in a way that causes both systems to get worse over time without intervention. So where does it start?
What Causes Depression?
There are many things that can trigger depression, from the loss of a relationship, to job loss to shame from peers. But what would make one person slip into months of major depression while another cries for a week and moves on?
Models of Depression and Kindling (Sensitization):
In Against Depression, Kramer explains the tendency to become depressed using the term “kindling"1. Kindling is essentially sensitization, the idea that, at first, a person requires a trigger to go into a depressive state. But, because of the damage to brain structures from that episode, the next episode may not be as hard to trigger, a process which gets progressively worse until it takes little (if anything) to trigger another bout of depression.
It’s like a glass of water that starts out empty but fills with stress from the environment. Once it hits a certain level, it will overflow into depression. But just because it overflows doesn’t mean the rest of the water disappears; it’s still full and will overflow again with much less being added.
This partially explains why most of those who have one event will experience another, and each depressive episode tends to be worse than the one before. This may also explain why some people tend to show increased sensitivity to things like scary movies and books over time. The horror flick that excited you in your teens may now incite full blown panic as your brain becomes more responsive to those stressors.
In addition, Kramer notes that those with high levels of sensitization or “kindling” may be prone to see slights where none actually exist because of an already stressed system, or they may perceive slights that others wouldn't notice because of their hyper-vigilance. In the latter case, the judgment of a depressed individual may be accurate, and yet due to self doubt they may degenerate further by thinking that they are “crazy” or “overemotional”.
Being more susceptible to slights can also up your potential for guilt considerably. If you know something would bother you, it makes sense to assume it would bother others. But feeling badly for days, worried that “So-and-so will think that I am being terrible to her for not calling yesterday,” often has little merit. Not only are others not looking for those slights, but they are not as sensitive to them when they actually happen. This means that the guilt many “kindled” individuals feel is unfounded.
So, where does kindling start?
What Causes Initial Kindling? What are the Early Risk Factors for Depression?
Kindling usually starts early in life. The four most common risk factors are:
- Childhood parent loss
- Childhood sexual abuse
- Disturbed family environment including lack of secure attachment (attachment is the way young children learn to regulate their feelings)
- Genetic markers
These four risk factors up the likelihood of later depressive episodes by triggering a cycle of too many stress hormones and too few coping skills. Depression results when those early risk factors lead to an inability to regulate the emotions caused by those stress chemicals, which leads to more stress hormones being produced.
And there's more. According to Kramer, the way depression plays out in the brain triggers specific personality traits which may make it more difficult to find stable, supportive relationships that would allow healing. Kramer notes that issues like low self worth, conduct disorders, anxiety and overall neuroticism--all common in the face of the above risk factors--can signal vulnerability to others which makes the risk for future abuse higher, even before the depression itself shows up.
So, if you come out neurotic due to genetics or early womb environment, you have a higher chance of being depressed due to the social ramifications of the traits themselves.
One oversimplified interpretation of Kramer's theory:
Say I'm a child born to a mother who says things like, “Get over it,” or “Stop being a sissy,” instead of teaching me how to handle my emotions by attaching securely. Early on, I show anxiety and overall moodiness and have trouble sleeping. I do well in school, but I withdraw when I get upset. In addition, my mother's history of depression and lack of appropriate coping skills attracts men who prey on this vulnerability, namely my step father. While he's a douchebag who has no issue with raping small children, he has no interest in going to jail, so when it comes time to choose between myself and my sister (who is more self-confident and more vocal), he picks me to abuse. This cycle reinforces my vulnerability, my withdrawal and deepens a sense of impending doom that follows me, though I have trouble identifying this in a meaningful way. When my high school drop-out friends--the only ones who want to deal with my moodiness--tease me about my dropping grades, the grades themselves become another source of sadness and self-loathing, and become another trigger for withdrawal, which reinforces the cycle further. And on, and on, and on.
"I'm still not sold on the 'depression is a physical disease argument,'" you say. "These are environmental issues," you say.
Maybe so, but all those seemingly emotional and environmental circumstances are wreaking havoc on the brain, and some of them can be hard to alter once they progress into physical brain changes. Regardless of how the cycle starts, it does not remain purely environmental or emotional for long. Find out more in part two of this series: Is Depression A Physical Illness? The Link Between Depressive Symptoms and Brain Changes.
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