Angst

Angst is not a word often used in conversation, yet it lists very highly on web searches.  I could not find it indexed in the Diagnostic and Statistic Manual IV.  This book lists accepted mental disorders and the codes many insurance companies use for claims.  Two medical dictionaries and a prior DSM (III) did not list angst as well.  It’s an uncommon term for a common condition.

The nearest synonym is anxiety, though it does not capture the full meaning of the word.  There are typically feelings of dread and frustration in a fluctuating balance.  Perhaps many people using “angst” as a search word are trying to capture a state of being they experience.  Perhaps there is a perception of something lacking in their existence, and most English words do not capture the essence of their thoughts adequately.

The existential philosophers address the word “angst,” which is actually a German word for “anxiety” or “dread.”  The philosophical use of the term was coined by Kierkegaard to denote a state of anguish we feel as the responsibility or burden of freedom.  There is dread arising from a lack of purpose, meaning or concern in the universe.  We try to impose our values and meanings on an inherently absurd universe.  Their is a constant dialectical tension between the man searching for meaning, and the universe that is conceived as mute and uncaring.

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While a sense of meaning is important, a sense of purpose can truly keep people alive.  In my clinical practice with nursing home patients, a sense of purpose is the single most important factor in turning around many depressive episodes.  Most people do not theorize about the meaning of their lives until something dramatic happens.  A sense of purpose is nearly prerequisite in the average adult, and it has the advantage of being less abstract than the meaning of one’s existence.

The most clinically meaningful use of the term “angst” is anxiety and frustration with an absent or misguided purpose to one’s life.  What makes it clinically relevant is that it captures a broad swath of humanity, and avoids the perception of the universe as absurd.  A sense of meaningless absurdity to one’s existence is often a depressive perception, such that taking it as factual would not be helpful in mitigating a patient’s Major Depression or Adjustment Disorder.  The typical goal of psychotherapy is to adjust someone to their environment, such that a perception of one’s environment as absurd would render the goal absurd as well.

Angst is a handy word to describe something complicated.  A perception that one is on the wrong track in life, that the boat was missed is the precondition of my definition.  The ongoing sense of anxious dread serving out the sentence of one’s life is angst.  The discovering of an ego-syntonic purpose to one’s life is psychotherapy.  Please share your thoughts about this post in the “comments” section below.

Depression

If you have been to informational websites on depression, then you have a sense of what psychologists consider to be depressive disorders.  The typical symptoms are well known, and discussed all the time.  Depression actually falls within the general category of  “Mood Disorders.”  Anyone who has suffered with a bout of moderate Major Depression does not have to be convinced of its impact on work and family life.  Many have no doubt run across the term “Bipolar Disorder” and its older antiquated name “Manic-depression.”  I consider this diagnosis  at greater length in another category on the blog titled “Bipolar.”

The major difference between Major Depression and Bipolar Disorder is a cycle of mania or hypomania.  This is not a trivial distinction, whatsoever.  Even its milder variant, hypomania, is alarming to others over prolonged periods, and negatively affects occupational and social functioning.  Mania is alarming to others over rather brief periods.  It is the polar opposite of Major Depression.  Often those afflicted are not aware of their expansive mood, or consider it to be a blessing.  Depressive people are aware of their symptoms, and sometimes dwell on them excessively.  Chronically irritated depressives are often not aware they are depressed, but they are aware of their anger.  Consider asking a confidant about your symptoms, since they may provide a fresh prospective.  We only know ourselves through the eyes of others.

Bipolar Disorders are less common than Major Depression.  Bipolar Disorders are often more debilitating, and with less effective long-term treatment.  Severe Major Depression is a nightmare, but add the disorganized frenzy of mania, and it sums to a complete breakdown in functioning.  People who suffer with a severe Major Depression have a willingness to commit suicide, and may even experience psychotic symptoms.  The type of delusions experienced by people with Major Depression and Bipolar Disorder are quite different, though either disorder may become self-destructive.

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Most people using this site are more likely to have a mild form of  Major Depression than a Bipolar Disorder.  The Bipolar subcategory on this blog is more useful to significant others, than for those who suffer themselves.  This is not true for the hypomanic person, as they tend to maintain greater self-awareness than someone with mania.  It’s that the hypomanic tends to feel quite elated and energetic, such that a boring old computer blog is not their idea of entertainment.  Perhaps those suffering with acute mania are too frantic to web surf, and those with hypomania lack the awareness to consider their condition a problem.

Bipolar Disorder is often misdiagnosed.  Hypomania is mistaken for mania, and normal mood swings are taken for hypomania.  It is a very serious illness that has almost been reduced to a fad.  Twenty years ago, Borderline Personality Disorder was constantly diagnosed and questioned.  It is doubtful that Bipolar Disorder will be the last diagnostic fad in the fields of psychology and psychiatry.

Most people have had at least one bout of Major Depression in their lives.  Statistically, it’s almost deviant to avoid a Major Depressive Episode one’s whole life.  Whereas Bipolar Disorders are rarely aware of their problematic symptoms while manic, the chronic depressive knows they are depressed, but often under-appreciates the severity of their suffering.  The depression becomes a backdrop to their life, to the point good spirits seem strange and disconcerting.  Once the depression reaches the Moderate stage, it grabs one’s attention in a different way.  Physical symptoms rear their ugly heads.  Suddenly, you cannot sleep, or conversely, one can’t seem to rouse the whole day.  Your appetite is either nil or not capable of being appeased.  Chronic anxious rumination is not able to be suppressed.  It is not always easy to link all the cognitive symptoms of a depression together, in order for someone to realize they are depressed.  Most outpatients initially seek treatment in the moderate stage of a Major Depression, as the physical symptoms assert themselves.  It is likely that the moderate stage of depression inspires many web searches.

Generally, treatment is a combination of psychotherapy and medication.  The combined treatment is nearly four times as effective as either treatment used in isolation.  I believe this rule is most true for Moderate to Severe Major Depressions.  I recommend cognitive-behavioral or psychodynamic therapy for treatment of mild depression.  I am less concerned about attribution errors in more severe depressions than a milder depression.  For example, many of my patients are worried when antidepressant therapy is decreased or discontinued.  Often these patients had taken an antidepressant for years without positive results, or were placed on too low a dose of the antidepressant to be clinically effective.  Depressive patients often fail to give themselves credit for their hard work in psychotherapy.  This is an attribution error, and we all are prone to this sort of error.  Please share your comments regarding this post in the space provided below.