Thank God! The holidays are over. This is a common harangue at this time of the year. It seems ridiculous that a time of year intended to give thanks and count one’s blessings should lead to so much tension. Perhaps the unintended consequence is ridiculous, but the ill effects are not. There are many reasons why people become depressed at this time of year, and here are a few. First, the way the Christmas Holiday has been configured in America, it is maximized towards the desires of young children, as their gifts comprise the greatest slice of the economic picture. This echoes the direction of motion pictures to offer material enjoyed by the adolescent and young adult ticket purchasers. This is not an evil plan, to my knowledge, but the typical manifestation of a market to make the most of its opportunities. This does not mean that it will be welcomed by all members of our society, as is clearly the case. Listening to one’s children complain about the paucity or selection of the gifts can infuse the occasion with a sense of meaninglessness. If you are a middle-class American, it is likely you turned in the same performance as a child.
Second, the holidays tend to bring back memories of loved ones that are no longer around. Whether they are deceased or merely estranged is less important than the way we are affected by the distance. There may be an unfulfilled need for this person, or a desire to make amends and reestablish contact. Either way the affected person may be morose or even mildly depressed at a time when we are all supposed to be happy. The expectation that one should be particularly happy during this time of year makes thoughts of loss and longing especially burdensome.
Third, what of this social obligation to be happy during the holidays? Social demands form the core of culture, and we tend to experience feelings when we accomplish or ignore cultural demands. Even if a person is not particularly sad during the holidays, there is an expectation of being happier than usual. If we do not acquiesce to this social demand, we are apt to feel guilt at the lack of our responsiveness. Another perception is anger at being subtly told how to think and feel, even if the consequences of not conforming are nothing more than disapproving looks. The behavioral literature is bursting with examples of how controlling another person’s behavior tends to increase the pressure to resist. People do not like to be pushed into ways of thinking and feeling; unless they believe it was at their initiative.
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Fourth, and perhaps the least discussed, is the holidays bring us into contact with people we may not like. Many friends and patients describe the familial and work obligations that are less than enjoyable. Perhaps due to the social demand of being happy and friendly during the holidays, most people tend not to acknowledge this potentially unpleasant aspect of the season. Even in the closest of family and work relationships, there are people one would rather not see more than once per year-if that! To buck and bridle about visiting the besotted “Uncle Jimmy” runs the risk of being branded a “Scrooge.” See, there is even a special designation for those unfortunates who do not have the appropriate “Christmas spirit.”
What can one do to stem the tide of emotions that flood during the holidays? The first is an automatic response to most mental health issues. Wait. Most of the negative emotions dissipate rapidly after the holiday season. Watching the apparently unappreciative children enjoying their toys, and besotted Uncle Jimmy wearing your gift, tends to ameliorate the initial reaction. January is a “git back to work” month when few expect to be particularly happy. Nature obligingly provides cold cloudy days to accomplish all the accumulated work. It seems a bit natural to be down in January, such that the social expectation to be joyful nearly vanishes! As in my other posts on depression, the typical waiting period is three to six months. If your depressive symptoms do not lessen within this time frame, it is likely that a depressive disorder has caught hold and will require professional treatment. Fortunately for most, the negative aspects of this season fade from view as the more positive aspects take hold in one’s memory. Please leave comments regarding this post in the section below.
The term “stroke” is a fitting name for a sudden unexpected happenstance. In medicine the term “stroke” applies to the sudden onset of symptoms after circulatory problems arise in the brain. The movies typically portray the sudden devastation to one’s physical functioning; for example the paralyzed father in “Legends of the Fall.” The slow insidious onset of symptoms from circulatory problems is neither as dramatic or pictorial as the sudden manifestation, but it may cause as much or more functional impairment. The sudden classic middle cerebral artery stroke with left or right paralysis may be diagnosed by many non-professionals. The slow manifestation is often overlooked or misidentified by professionals.
Neuropsychological and medical training instills the belief that the former type of stroke is much more common than the latter; that the sudden “stroke” is much more common than the slowly evolving cerebral damage from altered circulation. Given the unique and dramatic symptoms of a stroke are much easier to diagnose than the slowly evolving, it is likely that the figures taught to doctors are less than accurate. Slowly evolving symptoms of stroke are directly related to uncontrolled high blood pressure. While one would think that a slowly evolving hemorrhagic stroke (leaking blood vessel) would be more common than a blockage, this does not appear to be the case. Most hemorrhagic strokes are of sudden onset, and are often difficult to differentiate from a blockage in a cerebral artery.
Most slowly evolving events related to blood pressure present with decreased attention, a decreased level of arousal, and an overall slowing of thoughts and actions. There may be signs often considered focal or localized; for example speech and visual deficits, but this is hardly universal. Family history often identifies a day or two where the patient had been inattentive or even partially paralyzed, but the symptoms tended to abate. I recently interviewed a man with many years of uncontrolled high blood pressure. The man had refused treatment for high blood pressure because he was convinced the issue was touted by physicians to increase their income. His family noticed a few days of poor attention and impaired speech a year or two back, but his apparent rapid recovery dissuaded them from seeking medical consultation. The symptoms returned and abated over a course of years, but the overall picture was of functional decline. Diagnostic imaging of the brain was not remarkable, yet his performance on neuropsychological tests was indicative of one or more strokes. As is often the case, one of his arms was significantly stronger than the other, but not affected to the point it was noticeable to the patient or his family. He lost the power to ambulate as both legs became progressively weaker; not just the one side typically associated with a blockage of a cerebral artery. Notice that not only were both sides effected, but the damage increased over time. This is at odds with what most people would consider a cerebral vascular accident.
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Another difficulty in the diagnosis of slowly evolving strokes is the overlap with other conditions. The sudden dramatic onset of focal paralysis is not present in any other physical condition known to this clinician. The clinician must differentiate between a stroke and a psychological conversion reaction producing the symptoms, and the latter is fortunately very rare. The slow onset of bilateral weakness in the legs, as in my patient above, may be secondary to a host of factors other than brain damage. The unfortunate person may have generalized weakness due to malnutrition, dehydration, anemia, a systemic infection or metabolic/endocrine disorders. Bilateral weakness in the legs may be secondary to damage in the spinal column, a muscular dystrophy, arthritis or even an unwillingness to walk. Regardless of age, failure to bear weight on one’s hips and legs quickly leads to muscular atrophy. The burden on the physician is much greater when the symptoms are not focal and slowly evolving. It is no wonder that statistics regarding different kinds of strokes may be unavoidably inaccurate.
Given these hurdles experienced by trained professionals, what is an educated layman to do? The most practical and effective measure is to watch one’s blood pressure. Over the course of my training and twenty years of practice, I have observed many medical “facts” and “breakthroughs” fall by the wayside for a lack of evidence and efficacy. The evidence favoring control of blood pressure and its positive effects on health and overall well-being has only increased over the years. Regardless of age, if you are a female smoker and use birth control, I suggest close monitoring of your blood pressure. If you are older than 50, I suggest checking your blood pressure regularly; especially important if one has episodes of feeling dizzy and flush. Please leave comments regarding this post in the space provided below.
Depression, Psychology | orlandopsychcom | 
January 3, 2011 11:05 am | 
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