Reflection on Depression

Terrorism and the Helplessness Hypothesis

I don't rejoice in the death of another human being, and I'm agnostic as to whether we should respond to killing with more killing.  Even so, I was elated to find out that Osama bin Laden is dead.  It wasn't a joyful elated, but rather a relieved elated -- a little like finishing the last exam of a grueling semester but orders of magnitude more significant. 

Terrorism is uniquely calibrated to instill a sense of powerlessness in its victims. It is unpredictable, and seemingly unpreventable. The measures we took over the past decade -- confiscating water bottles at the airport, a terror alert system that remained on "orange" for years at a time, and two frustrating wars -- didn't go far in restoring our collective sense of self-efficacy.

A psychological theory of depression called "Learned Helplessness" posits that a perceived loss of control over adverse events can induce depressive behavior. The theory resulted from a 1960s experiment in which two groups of dogs received electric shocks. The dogs in group 1 could stop the shocks by pressing a lever--they had some degree of control. The dogs in group 2 received the same shocks but seemingly at random--they had no control. Dogs in group 2 recovered from the trauma much more slowly than dogs in group 1.

In the second part of the experiment both groups of dogs received shocks again, but this time they could escape by jumping over a small partition. While the dogs from group 1 jumped over the partition, most of the dogs from group 2 didn't even try, lying down and acting helpless--depressive behavior. (Notably, roughly one third of the dogs in group 2 appeared "resilient" and did jump over the partition.)   

The lack of control the group 2 dogs experienced is a little like what people go through when they are subjected to unexpected trauma or sustained abuse. On September 11, 2001, the nation experienced a collective trauma that highlighted our vulnerablity. In this case, reclaiming our power--asserting ourselves against our abuser--has been healing, lifting our collective depression.

The elation I felt when bin Laden died reminded me of the relief I experienced a few years ago when a jury returned a guilty verdict against the man who raped my sister. When the verdict came back I felt sad that a young man had thrown his life away, and ambivalent about the 57 year prison sentence, but my sense of strength and effectiveness was restored.

As a child, my father used to advise "Don't fight back" if another family member was upset at me.  He reasoned (correctly) that the unpleasantness would be over sooner if I "just let it happen," even when I wasn't at fault. It felt good, however, to fight back. It showed that I didn't condone unjustified emotional outbursts, and that I wouldn't be subjected to them. (In all fairness, I did my share of instigating fights and emotional outbursts as well.)

Although "turn the other cheek" may be the Christian thing to do, and "don't fight back" may be the most practical course of action, sometimes the healthiest thing to do is to strike back--to demonstrate an ability to defend oneself and to reclaim power that has been lost.

The healthiest thing to do is not necessarily in line with ethics of the highest order. Maybe that's why the most ethical decisions are sometimes difficult and self-sacrificing. While I admire the folks who can turn the other cheek in response to bin Laden's attacks, I also understand the healthy impulses behind our retaliation, and why that retaliation is cathartic.

Gifts for doctors

A few years ago I was was seen by a medical resident at Stanford's student health center while in the midst of an acute depression. The arrangement was temporary--I was new to her practice and still in the process of finding a permanent doctor; she was in the infancy of her career, completing her residency.  

Despite my transience and her inexperience, she rose to the occasion, alleviating my worst depression in fifteen years.  To show my appreciation I brought a small thank-you gift to our penultimate session. After all, I'm from the South, where appreciation often manifests as a tin of brownies and a thank you note, and where the waiting room of my North Carolina psychiatrist is filled with decorative items from grateful patients.

The gift to my psychiatrist at Stanford was not as well-received. Her awkward acceptance caught me off guard. Had I made a social misstep? Violated the bounds of the doctor-patient relationship?  Come off as desperate and needy? 

I felt a little bit like Keri Russel in The Waitress when her character "Jenna" brings a pie to her longtime doctor, but discovers that the doctor has retired and handed over her patient load to a new out-of-towner. An awkward moment ensues (although most of the doctor-patient awkwardness doesn't arise until Jenna and the new doctor begin a hot affair). 

I told my roommate about the gift-giving misstep with the Stanford pscyhiatrist. My roommate explained that the gift could be perceived as evidence of a psychiatric problem, possibly an attachment disorder or emotional neediness. Forget that cancer patients routinely thank their oncologist with sentimental presents--outside the South, thanking a psychiatrist with any degree of emotion is symptomatic of a mental disorder.

Her comments made me consider the role that culture plays in assessing behavior. Where do we draw the line between cultural eccentricities and medical symptoms? Seeing through the glaze of culture, I imagine, is difficult for doctors who only see patients for a short time. 

Misreading cultural cues creates a danger that we will pathologize benign (even beneficial) differences. This is the concern at the heart of the stringent civil liberties that guard against forced treatment in all but the most extreme circumstances. In such a diverse nation, these safeguards may be necessary to protect our democracy.

After all, if I were a doctor I'd be tempted to characterize terse New Englanders as antisocial; counter-culture hippies in San Francisco as having an adjustment disorder; and "tiger moms" as authoritarian personalities.  How would others perceive me? As perfectly normal, of course . . . if they're a southern, suburban professional :).

Along these lines, the MCAT may soon place more emphasis on the social and behavioral sciences in order to improve the cultural competency of doctors.  Changes to the MCAT

**Unfortunately, I haven't been able to write as  frequenly as I would like. I've been staffed on several demanding merger cases. Merger cases are my most intense. Since there are only only 6-8 weeks between the announcement of a merger and the shareholder vote, all of discovery and briefing must occur on an expedited schedule. It's a crazy schedule, but also adrenaline pumping and addictive. I finally understand why some people become workaholics.

Previously Depressed Patients: An Untapped Resource

I suspect that it's hard for mental health professionals to assess a patient's level of discomfort. After all, there are no psychological x-rays to reveal the extent of mental pain, and the piercing cacophony of morbid thoughts in a patient's head may only come across as a whisper to the world outside. 

William Stryon alluded to the limitations of clinicians in his memoir of depression, Darkness Visible. In it, he recounts a time when his psychiatrist was painfully out of touch with the severity of Styron's condition:

"Further, Dr. Gold said with a straight face, the pill at optimum dosage could have the side effect of impotence. Until that moment, although I'd had some trouble with his personality, I had not thought him totally lacking in perspicacity; now I was not at all sure. Putting myself in Dr. Gold's shoes, I wondered if he seriously thought that this juiceless and ravaged semi-invalid with the shuffle and the ancient wheeze woke up each morning from his Halcion sleep eager for carnal fun." 

Styron might have found better comprehension in another patient. People who have suffered from depression understand the havoc it wreaks. They understand the internal logic that seems incomprehensible to others and the syntax of mental illness--the supercharged feelings that compel strange thoughts and behaviors, and make normal ones impossible.

Co-sufferors can't provide medication, therapy, or family support, but they can provide understanding that no one else can. Someone who has walked the same road and reached a place of respite knows the scenery.  

I went to DBSA meetings (Depression and Bipolar Support Alliance) for awhile and found them very helpful. Support groups are sometimes a bizarre mix of people from all walks of life who have little in common except an ailment. But those differences can be clarifying, making the illness stand out in relief against the background of very different lives.

It was a relief to be around people who knew how I felt. It was like communicating with people in my native tongue; the layer of extra effort normally required to explain the inexplicable pain of depression was no longer required. I didn't feel so weird and defective for feeling the way I did and began to recognize that the effects of depression were symptoms, not my own personal flaws. Meetings are definitely worth checking out!

 Click DBSA for their main website, and then you can look up your local chapter.

And see here for more information about talking to others with depression:  http://www.lawyerswithdepression.com/previously_depressed.asp 

Is Charlie Sheen acting manic, or just acting?

Charlie Sheen's recent shenanigans have eclipsed, in sheer eccentricity, other celebrities' outrageous antics--even Tom Cruise's overzealous couch jumping and Mel Gibson's disturbing public tirades again Jewish people and women. In the words of Shrek, The Musical, Cruise and Gibson let their freak flags fly. Sheen, on the other hand, may think he can fly.

Whether it's real or contrived, Sheen's fall from grace is a good example of what mania can look like. His statements border on the bizarre (he has "Adonis DNA" and "can cure addiction with his mind"), his speech is pressured, and he connects words that sound alike but don't mean the same thing (speaking of his studio execs he noted "They continue to be in breach, like so many whales."). Most tellingly, he has a preoccupation with "winning"--a grandiose idea that is unsupported by the evidence (which, by all measures, indicates that he is losing everything). 

I find it interesting that his thoughts (to the extent they are reflected in his public statements) are the mirror image of the thoughts I had in the most extreme depths of my depression. Like Sheen, my thoughts were rooted more in irrational emotion than reality. I felt things so strongly that my mind began to fabricate reasons why those feelings were justified. I was convinced I was a horrible person--worse and more pathetic than even a serial killer or child abuser--despite having done nothing that would rank among those horrific wrongs. Sheen, on the other hand, has an obsessive and unsupported focus on his greatness.  

I was never floridly psychotic. Nor, it appears, is Sheen. When pressed, I conceded that my thoughts didn't conform to the evidence; that the things I thought weren't (or at least probably weren't) true. But they still felt so real. If Sheen is experiencing hypomania (short of full blown mania) he may have the same tenuous grip on reality--an intellectual understanding that what he is saying is not reflective of his situation, but the perception that is it.

If manic, Sheen's mental state could either deteriorate into psychosis or flip into suicidal depression and self-medication; or we could find out that this whole episode has been a hoax, a la Joaquin Phoenix. Regardless of what happens, his behavior is an instructive presentation of mania that has familiarized the public with symptoms that people now may recognize in friends or family. Hopefully it has also acquainted us with the importance of getting treatment.

Immediate mood booster - humor

I highly recommend viewing addictive internet memes, bromance comedies, and hilarious photos of badly dressed people at Walmart as a form of complementary medicine. It sounds obvious, but humor is a treatment I didn't consciously embrace until recently. 

I've always loved being around funny people, but now that I'm a lawyer my day is fairly solitary. It turns out that internet humor is just the seasoning I need to prevent my good mood from withering during an emotionally bland day. After an hour or two of reading cases, 10 minutes reading lamebook or epic fail provides a nice mental break and emotional refresher. It's really hard not to smile when seeing the crazy stuff that people do.

I don't want to make anyone who is so depressed that they can't read or watch TV feel guilty for not being able to appreciate a joke. Like exercise, humor isn't effective when morbidly depressed. But if you're doing pretty well, then reading the funnies may help keep your spirits up.

I feel a small pang of guilt whenever I use humor that comes at someone else's expense. I'm pretty sure viewing "People of Walmart" everyday will land me in hell, but at least I'll be laughing all the way there. Plus, I try to laugh at myself just as much -- this week during my training session I did a bunch of lunges, and then tried (unsuccessfully) to jog up a set of stairs.  The lunges worked my legs so hard that when my brain signaled my leg muscles to move up the stairs, the muscles didn't respond. My upper body, on the other hand, got the message and lurched forward without its bottom half.  I ended up landing on my face while my legs buckled underneath me. Confused, I pulled myself up by the railing and tried a second time to run up the stairs.  And I fell on my face, again. It was pretty funny and would have made a hilarious clip titled "Going Upstairs--FAIL".

How thoughtful!

Starbucks' non-fat miso is my favorite morning beverage (I have no idea why it's called a miso--it has nothing to do with miso soup. Plus, everywhere else the drink is called a cafe au lait).  [Jan. 5 update:  someone explained that it's actually called a "misto," the Italian word for "mixed".]

Anyway, I overheard a barista talking with another customer while I waited for my misto on New Year's Eve.  The customer commented that she came to Starbucks on Christmas day and was surprised the store had been so busy.  "Maybe it's because there are so many people here from other cultures--cultures that don't celebrate Christmas."  (Not that there's anything wrong to going to Starbucks on Christmas even if you do celebrate it--I did :) ). 

The Barista agreed and added "It's good people come in. You know, there're a lot of suicides around the holidays. It's better people come here than stay at home." 

Next he called my name because my drink was ready. And as I approached the counter to grab my miso he looked into my eyes and said "Happy New Year. Have a great day."  He said it in a way that was more engaging that the normal exchange between employees and customers. His eyes said he cared and they gave me the impression that I could remain and talk to him if I needed someone to listen. His friendliness wasn't over the top or creepy. It was genuine and uplifting.

I got the impression that his behavior was tied to his prior comment about suicide--he wanted to touch every life and every path he crossed during the holidays. He was attuned to the pain that the holidays bring to some people, but still able to spread the joy that's at the heart of the season. Most of all, he was aware of the impact he could have on his customers. And he knew that, in rare instances, his kindness could be lifesaving.

To someone suffering from depression, that outreach, resulting in a very real and genuine positive interaction, is a much needed moment of recognition that warms the soul enough to survive the cold and sometimes unrelenting loneliness of the winter holidays. 

This man epitomized the holiday spirit. He didn't have much--being a barista is a pretty low-paying job--but he offered his customers what he could, and it was no doubt more valuable than money to some.

DSM V - FAIL

I have issues with the DSM-IV, and it looks like they aren't going away when the new DSM-V is published in 2013.  The DSM (Diagnostic and Statistical Manual of Mental Disorders) is a sort of pseudo-scientific classification of behavioral and mental disorders based on clinical presentation (not based on well-understood underlying etiology).  Obviously, coming to some kind of agreement on what constitutes a particular disorder like depression is a challenge when we don't really know what depression actually is.  It's probably a heterogeneous set of disorders, and not a single disorder on a continuum from mild to severe as the DSM posits.

I appreciate the work of the clinicians and academics who are trying to formulate a workable and accurate classification system based on poorly understood phenomena.  It has to be a thankless task.  At best, the results will be mediocre (since the results can hardly exceed our limited understanding of mental disorders) but the work is still necessary--it's presumably better than nothing.  After all, how would we carry out research that can be disseminated and compared without any standard classification system?

That said, the current revisions that will lead to the DMS - V are proceeding in a particularly contentious manner. Cloaked in secrecy, criticized openly by some participants, and behind schedule, the validity of the new DSM is already an open question.

See this article about missed deadlines and shoddy work product for a quick rundown of some of the problems the DSM-V writers face.

 

Depression and Creativity

Ugh . . . if I hear it one more time I'm going to scream: "mental illness is linked to creativity."  Major selection bias propels this myth. Whenever someone notes the correlation of artistic talent and depression, I point out that for every one Van Gogh there are thousands upon thousands of totally uncreative depressives--accountants, lawyers, doctors, bus drivers, stay-at-home moms, and even mental health workers--who go about their lives without utilizing much creative talent (in some cases, because they have none).  There are legions of depressives whose only foray into the visual arts occurred during grade school, or in a required in-patient "art therapy" class.

Sure, depression can serve as inspiration for art.  But so can any major life event or profound emotional experience.  The people propelled to artistic triumph by depression are those who already possess talent.  If not for their depression, they would likely produce great works inspired by less morbid, less soul-sucking life experiences.  Their art would be even more profound, since depression, in my opinion, narrows rather than expands life experience.

The silver lining that comes in the form of artistic expression is not worth the ruined lives that depression more frequently leaves in its wake.  So to every accountant, lawyer, and schoolteacher out there without a creative bone in your body . . . you shouldn't have to suffer so the rest of the world can enjoy Van Gogh.

Jackson Hole Vacation with Family

I've spent the last couple of days in Wyoming, visiting Yellowstone and Grand Teton national parks. The views have been amazing, and we've seen a ton of wildlife--elk, moose, and even a grizzly bear. 

I love the West because it's such a healing place. There's something about the wide open spaces, whether they be deserts or alpine mountains, that feels big enough to swallow any pain or sorrow I am feeling. I see why so many recovery centers are out here. 

I loved this vacation and everything we did, as well as having time to relax. Sleep and relaxation is so important to staying well!

 (me, my cousin, and my sister)

My third Project Happiness podcast

 

My third Project Happiness podcast was posted recently. In this one I discuss how the wellness techniques that Project Happiness teaches can help people prevent and recover from clinical depression. Project Happiness is a fabulous organization that is spreading knowledge of emotional wellness techniques to school-age children (and others) around the country.