In my last post on depression, I stressed the key points differentiating a bipolar disorder from a depression. In this post, I will focus on the differences between mild and moderate symptom profiles, as well as normal mood swings and a Major Depression.
Moderate to severe Major Depressions are easy to differentiate from normal mood swings. The significant difference is titled “vegetative symptoms.” This may call to mind comatose people or someone drooling in a corner; however, the meaning is different. Vegetative symptoms of a depression are the physical symptoms that emerge when one declines from a mild to moderate level of depression. This is the stage where people seek treatment, or are pressured by others to do so. Please keep in mind that the diagnostic rules of Major Depression only differentiate mild from moderate levels of severity based on functional impairment. My contention is that this functional impairment is a direct consequence of the physical symptoms of depression. Often the physical symptoms are so unexpected and alarming that many people believe it is another disorder entirely.
The vegetative symptoms of depression occur in polar extremes; sleep is minimal or too much, appetite is reduced or hunger excessive, energy is decreased or a constant agitated fatigue sets in. It is difficult for people to believe that a psychological problem could cause such physical disruption. Often those who complain of chronic fatigue or general malaise are clinically depressed. Most people expect a depressed person to be very sad and tearful, but a moderate Major Depressive may not have a subjective (personal) sense of sadness, nor may they be tearful. Chronic irritation and general fatigue are often presenting complaints of the chronically depressed. Men are more apt to experience irritation/anger as the prominent feature of depression than women. In the mild phase of depression, a person may be aware of a lowered frustration tolerance, but it is able to be controlled. The moderate stage may reveal rage reactions or simple frustrations that quickly spin out of their control.
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Sleep disruption is almost always an important factor in moderate Major Depressions. Few people perceive increased sleep as a problem, yet the increased sleep engendered with a depression doesn’t increase sleep comfortably or effectively. The increased sleep tends to be debilitating. Please note that sleep may be reduced in a Major Depression, but I am focusing on the increased pole, at the moment. Missing work, missed children appointments and missing one’s own appointments are more common than not. Getting out of bed and into the washroom may feel to the afflicted like an epic journey. For example, the daughter of a close friend became moderately depressed. Her nine year old daughter came home each day from school to find her mother in bed. She no longer makes her daughter meals or takes her to school. Increasingly, the daughter takes care of her mother. This dynamic is often observed in families with substance abuse; the course of the treatment is different, but the danger to the family is similar.
As most of us wish for more sleep, we also desire less appetite for food. Supposedly, in excess of a trillion dollars is spent on global weight loss strategies annually. Weight loss secondary to depression is effective, though drastic, unpleasant and unhealthy. The loss of appetite from depression is often gradual, such that it’s cause is obscured over time. Often the sight and especially odors of food will make one feel nauseous. A useful clinical rule is that a ten percent drop in total body weight in one month spells medical trouble. As with sleep, please note that that appetite may also be increased by a Major Depression, but I am focusing on the decreased pole at the moment. Women are more apt than men to be pleased with the weight loss-initially. Others typically remark about the unhealthy appearance of this type of weight loss, decreasing the expected pleasure of hearing peers rave about the missing pounds. This depressive weight loss also entails lower strength and energy, as well as lowered attentional resources. There is little comfort or complements to be gained from depressive weight loss. As with reduced sleep, medications to treat the symptoms tend to prolong or exacerbate the problems. The only known way to combat the sleep and appetite disruption from depression is to treat the underlying depression. Please leave comments regarding this post in the space provided below.
Obsessive-compulsive Disorder is a well-named condition. The obsessions relate to our thoughts; specifically automatic repetitive thoughts that can’t be ignored for very long. Many disorders experience obsessive thoughts, but not as a primary feature of the illness. For example, schizophrenics are often obsessed with their paranoid or grandiose thoughts, but it is not a primary feature of the disorder. Schizophrenics are not aware of their thoughts being unusual or abnormal, while the person with OCD perceives their obsessions as abnormal. Obsessive thoughts for the OCD sufferer tend to center about particular behaviors; for example, hand washing, counting and touching. The obsession is typically paired with magical thoughts; such as the avoidance of something bad happening if the doorknob is touched exactly three times. Compulsion refers to the need of a person to perform a particular motor behavior. It is the realization of the obsessive thought. In the example above, uncontrolled thoughts of being dirty are the obsession, and the compulsion is the actual repetitive hand washing. Persons with OCD can voluntarily stop the compulsive behavior, but tension will increase until they perform the particular motor routine, complete with the expected magical outcome.
An excellent comment was left by “Nervous Nelly” as to what differentiates a “habit” from a “compulsion”. Neuropsychologically, there is no known concrete difference between a habit and a compulsion. Both words describe behaviors that are so well-learned that conscious control is not required. Both are performed in the absence of cues or prompts within the environment. Neither depends on some event in the environment to signal the start or stop of the behavior. So what is the difference?
There is increasing research evidence that compulsions are involved in a very tight feedback loop between two areas of the brain. Habits appear less tightly bound to this feedback loop; exhibiting more activation in other areas of the brain. There is increased evidence that a compulsion is a maladaptive subset of the behaviors we label as habits. Much of the common usage difference between a “habit” and a “compulsion” is in terms of functional outcome. Habits of going to work and taking out the garbage are not typically viewed as bad, but the sniffing of cocaine is uniformly considered a bad habit. Habits are labeled as good or bad, but compulsions are nearly always used in the context of being maladaptive and bad. Occasionally, people speak of an “artistic compulsion”, but even here it suggests a maladaptive love of art. It appears that a primary difference between habits and compulsions are societal values. Even murkier is the distinction between compulsions and “bad habits”, such as gambling and substance abuse. Compulsion fits these behaviors neatly, but not typically used in conjunction with these “bad habits”. To summarize, the main difference between a habit and a compulsion are cerebral localization and societal values.
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As with so many mental disorders, there is a huge gap between mild and severe sufferers. Mild sufferers with OCD are often successful people, detail oriented, who are perceived by others to be stuffy, cold and particular. This is close to what is termed an Obsessive-compulsive Personality Disorder. Those with severe OCD are completely debilitated. Immersion into the obsessions and compulsions is so complete that nearly all necessary adaptive behaviors are shoved aside by the illness. The degree to which they are bound to the compulsion is heart wrenching. Severe OCD sufferers are helpless in the face of their obsessive thoughts and compulsive behaviors.
What can be done for those afflicted with Obsessive-compulsive Disorder? Obsessive-compulsive Personality Disorder is rarely treated, as those afflicted are generally successful people. Often this group is brought in by a loved one who can’t cope with the bizarre behavior and cold attitude. Treatment of mild OCD entails the identification of maladaptive and irrational aspects of their behavior. These patients often fixate and obsess on the psychologist’s words, and the increased awareness into this tendency promotes increasingly flexible thinking. The psychologist will increasingly have the patient practice looking at the big picture; the global aspects of their environment. It will always be difficult for these mild sufferers to break from small details and scan the macro features of situations. Treatment of severe OCD is generally performed on an inpatient psychiatric unit. These unfortunate people require medication to stabilize their condition. There has been increased research into severe OCD as being primarily a psychotic disorder, and not a subset of anxiety disorders. Severe OCD may respond to major tranquilizers, whereas this class of medications is not effective for mild sufferers. Working my way through school as a psychiatric tech, I was shocked at the level of functional disability engendered by severe OCD. I would not be surprised if subsequent research proves that mild and severe OCD are two distinct disorders, sharing some symptom overlap, but with distinctly different treatment choices and outcomes.
Depression, Psychology | orlandopsychcom | 
May 24, 2010 2:15 pm | 
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