SHUTDOWN: WHY PEOPLE WITH DEPRESSION FEEL SO NEGATIVE

Depression is a state of shutdown in which an individual’s psychological system shifts toward negative feeling states and diminishes the positive feeling states. The hallmark features of a depressive episode is a high negative mood state (characterized primarily in terms of depressed/demoralized/defeated/despairing feelings and secondarily in terms of anxiety, irritability/defensive hostility, and guilt/shame) and a diminished positive mood state (loss of interest, pleasure, energy, desire, and excitement).

Why do people get depressed? The primary reason people enter depressive shutdowns because they cannot obtain the necessary psychological nourishment needed to energize their behavioral investment system. Think of it as being akin to a state of starvation, only instead of physiological nutrition, the individual is lacking psychological nutrition. What is psychological nutrition? The fundamental principle that underlies psychological organization is that of behavioral investment. The psychological system is organized to direct mental energy and action toward investments that offer a return on those expenditures. When one is a getting a good return on one’s investments, then one feels fulfilled, energized and engaged. However, when one is not getting a good return, one begins to feel frustrated, anxious, irritable, or disappointed. If one cannot find an effective pathway for getting one’s needs met, one begins to enter into a state of psychological shutdown called depression.

So what are the core psychological needs that people have that need to be nourished? There are many different possible classification systems of needs (and motives and goals that people seek fulfillment around, see, e.g., here). I offer five categories here that overlap loosely with Maslow’s classic hierarchy of needs.

Safety and Security Needs. First and foremost, the psychological investment system is concerned with basic safety and survival. If one’s physical safety is chronically threatened, if one is in constant pain, if one is chronically hungry, and so forth, the attention of the system will largely be focused here.

The Base Pleasures. Good sex, tasty food, relaxing on a warm summer day on the beach after working hard. The “hedonic” pleasures serve as a fundamental reward and signal positive investments (at least in the short term). Good investment systems are generally characterized by meaningful effort and hard work toward a productive goal, followed by short periods of relaxing and enjoying the base pleasures.

Relational Needs. Our core psychosocial need is to be known and valued by important others. Most notably, this includes being known and valued by members of our family of origin, friends/peers, romantic partners, and community. Needs for relational value are reflective of one’s degree of social influence. And folks go about achieving social influence and relational value in different ways. For example, see here for power and achievement needs relative to belonging and intimacy needs.

Developmental Growth Needs. We can think about an individual’s psychological system as being akin to an investor’s portfolio. An investor has resources that have the potential for growth and loss. An investor with a diverse portfolio whose investments are growing in a way that is exceeding expectation is flourishing. The same is true for an individual. Each individual will have “personal projects” that are engagements they are involved in that afford opportunities for growth (hobbies, interests, creative and playful endeavors, meaningful work projects, etc.). If an individual is chronically stuck and not growing or is largely cutoff from their growth pathways, or is frequently failing to meet expectations, or is deeply investing in pathways based on extrinsic reasons that are not consistent with their underlying emotional/motivational needs (or intuitive sense of potential), then the investment system is vulnerable.

Existential/Transcendental/Virtuous Needs. Adult humans are meaning-making creatures that need to have a narrative for how their lives and personal projects make sense. As Victor Frankl notes in his timeless classic Man’s Search for Meaning, if they cannot place their suffering, personal projects, virtues and relationships in the context of a larger narrative that provides meaning, then they will be vulnerable to developing a nihilistic attitude, which is the belief that their lives or actions really don’t matter, because really nothing matters. A nihilistic narrative can undercut the emotional value that folks get from engaging in such projects, leading to existential crises or depressions.

Why do people have trouble getting their psychological needs met? Sometimes the answer is obvious. For example, consider the city of Aleppo in Syria. The people of that city have been completely brutalized and many folks there undoubtedly feel depressed. (As an interesting aside, it is worth noting that the field of psychiatry/clinical psychology is divided as to whether such individuals should be considered “clinically depressed”). In other obvious cases, folks get depressed because of chronic pain or illness, or death of a loved one or because they get addicted so substances that ruin their lives or because they are abused or isolated.

Other times the issue is much more complicated. Consider that there are many people that live in nice houses and seem to be surrounded by caring people and are achieving in their lives, yet they also get depressed. Indeed, despite the fact that we have more and more technology and more and more resources and control over our environment, we seem to be struggling more than ever with feelings of depression and anxiety. What is going on in these cases?

The short answer is that I think the modern, fast-paced society is placing many new, unusual stressors on our emotional system. And I don’t think people have been well-educated about how to appropriately process negative feelings. People have been given much more freedom to acknowledge negative feelings than in past generations (read this story to see what I mean), but there has not been good education on how to learn and grow from such feelings (see here or here). What I see in my clinic is that individuals try to avoid negative feelings, and wish everything would just be fine. They often try to act publicly like everything is fine, but they have no idea how to maturely process and learn from their negative feelings. Instead, they enter into an intra-psychic battle with their negative feelings, often working to banish them, or criticize themselves out of their feelings or try to “stay positive”. This creates a powerful “split” in their psychological systems. Namely, their feeling system is sending one signal, their internal narrator is in conflict with that signal, and they are trying to publicly present a totally different image than their inner conflict. All of this sets the stage for a “neurotic breakdown”.

In addition, I see many parents who value their kids, but who do not know how to guide their children in processing negative feelings. Instead, too many have been caught up in “self-esteem nation” and act in an overprotective way, essentially communicating both that their kids are fragile and that others are responsible for keeping you happy. Another group teaches their kids to repress and minimize their feelings. I am not blaming parents here. The modern world is complicated and psychologists and psychiatrists have generally not done a great job being clear about the nature of emotions and relational needs.

At the societal level, we need to recognize both the dramatic changes the information technological revolution has brought to our world and how many of the institutions that provided guidance for the good life are breaking down. Religious systems have lost much of their authority. The political system has broken down into a polarized way. I think our educational system is broken in the way it assesses performance and fails to teach character values. Science often seems to characterize the world as an amoral, meaningless physical system. In other words, in terms of our existential/transcendental understanding, there seems little that supports the deep-seated need that many people have for true meaning making. So, we live in a fast-paced, high-stress world in which we are overloaded with choice, we regularly observe massive amounts of inequity in power and resources, we give lip service to negative feelings but often characterize them as disease states and provide very little real education about human emotions and needs, and institutions that provided deep meaning making systems have lost their authority.

The bottom line is that depression arises, in most cases, when people do not receive the necessary psychological nourishment from their investments. This arises because of brutal environments and injury from traumas, diminished capacities to meet growth expectations, intrapsychic and interpersonal conflict with important others. Unable to find a path forward folks shutdown and, unfortunately, getting depressed in modern society likely creates more problems than it solves. So folks get trapped in neurotic depressive cycles.

There is clearly no easy fix, as depression is a massive health problem. But I do believe there is much that can be done. We need (and can achieve) a much better shared understanding of human psychological needs and nourishment. We also need a clear recognition from institutions like the World Health Organization that depression emerges as a function of psychological malnourishment, rather than being brain disease stemming from neurological malfunctions.

My ultimate vision is for the development of a holistic meaning-making system that harmonizes the natural sciences, the social sciences, and the humanities in a way that affords an understanding of our human natures such that we can have a more effective guide toward fulfillment during these rapidly changing times.

Gregg Henriques, Ph.D., author of A New Unified Theory of Psychology, directs the Combined Clinical and School Psychology Doctoral Program at James Madison University. He is a licensed clinical psychologist with expertise in depressionsuicide, and the personality disorders. He has developed a new meta-theoretical system for psychology articulated in many professional journals and is now applying that system to researching well-being, personality, and social motivation, and he and his students are working on the development of a general system of psychotherapy. Henriques received his M.A. in Clinical/Community Psychology from UNC-Charlotte and his Ph.D. in clinical psychology from the University of Vermont. He also completed several years of post-doctoral training at the University of Pennsylvania under Aaron T. Beck exploring the effectiveness of various cognitive psychotherapy interventions for suicide and psychosis. Henriques teaches courses in personality theory, personality assessment, social psychology and integrative adult psychotherapy.

 

Am I Depressed Because I’m a Lawyer?

Patrick Krill, a lawyer turned mental health counselor and consultant to law firms about lawyer mental health issues tries to answer the question: “A predicate to all of this, however, is the need to determine if you are actually depressed. Maybe you just hate your job, end of story. Moving on to a different practice or firm could be the change you need.  Or, maybe you have an underlying medical condition that is masquerading as or causing a depressed feeling.”  Read the rest of his blog here.

The Creativity Cure for Depression: An Interview with Dr. Carrie Barron

Today’s guest is Dr. Carrie Barron, a board-certified psychiatrist/psychoanalyst on the clinical faculty of the Columbia College of Physicians and Surgeons who also has a private practice in New York City.  She has published in peer-reviewed journals, won several academic awards, and presented original works related to creativity and self-expression at national meetings of the American Psychoanalytic Association. Along with her husband, Alton Barron, M.D., a hand and shoulder surgeon, she co-authored the book, The Creativity Cure: How to Build Happiness with Your Own Two Hands.

Dan:

Why is depression such a problem in our culture?

Carrie:

I think the level of stress has gone up enormously because we have so much to do and we’re on twenty-four hours a day. So I think because of technology, which offers us so many great things, but gives us much to do. I think that’s part of it. I also think, especially for children, we’re in a striving, ambitious, be productive all the time mentality – for children and adults. We need to play, we need to hangout, we need to have spontaneous time. I think spontaneous thought does a lot for alleviating depression and anxiety.

Dan:

We have so many different words in our culture for unpleasant experiences. We might say things like, “I’m sad,” “I’m burnt-out,” “I’m stressed-out,” or “I’m depressed.”  But what is the difference in your mind, as a clinician, between sadness, say, and depression?

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Carrie:

Sadness is a normal emotion. We don’t have to treat everything and be afraid of sadness. We don’t have to pathologize everything. There is a range. I mean, life can be very hard and it’s appropriate not only to have it, but let yourself have it. Sometimes it is actually moving towards the authentic feeling, rather than running away from it, that actually makes it go away. You first have to experience it, and then when you understand it, and you’re in it, it runs its course. Now, this is separate from a true major depression where you can’t get up in the morning. That’s another story. But sadness is a normal part of life.

Dan:

In your clinical practice, how often would you say depression has played a role in why people have come to see you?

Carrie:

I think it plays a role often. The categories that we have in the DSM-5, I think they’re useful so that clinicians can communicate with others. But nobody is fully described by a category or diagnosis. There’s a lot of overlap. When people are depressed, they’re also often anxious and also stressed, and sometimes it’s more one than the other. But depression does come up a lot for people and it’s very painful. I think not being able to get up in the morning, not feeling like doing anything, not being able to enjoy the sunny day or the view of the water, or whatever else people are getting into, it makes you feel very separate and alone when you are depressed and other people around you are not.  So it has, kind of, a trickle-down effect, too.

Dan:

Why did you write the book, The Creativity Cure? I found it such an interesting book, a fascinating read. You wrote it with your husband who is a surgeon. Can you tell our audience why you wrote it?

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Carrie:

There are two things.  I talk about this now, I didn’t talk about this in the book, when I was a kid, I had some problems. I was depressed. I was anxious. We weren’t taking meds at that time. There was some chaos in my world.  I really had to find a way to survive. When I look back on it now, all those things that I recommend in my book are things I was doing, or trying to do, like using my hands. I would cook a lot. I would take long walks.  Then, later in my practice, maybe ten years ago, patients were saying, “You know, I went home and I fixed my sink and I became euphoric! I felt great!” I started to realize that meaningful hand use has a lot to do with happiness. And yet, because so much of what we do now is accomplished with a click on a device, we’re deprived of the process. And process, being deeply immersed in making, or making music, brings with it the possibility for euphoria, and satisfaction, and feeling good about living. So creativity is really about a way to have an optimal life. How you define creativity is another matter.

Dan:

What’s going on in the body, in particular, the brain when someone is struggling with depression? And how does creative action interact with that?

Carrie:

I think a lot of studies have been done, and serotonin and neurotransmitters, there’s a depleted state, and that we need to boost it up with medication or activities that do the same. Vigorous exercise can create the same biological state that antidepressants can. I want to qualify this and say that one must see their physician and make an informed decision, but certainly exercise can help a lot. Also, meaningful hand use has been shown to boost mood. Dr. Kelly Lambert wrote a book, Lifting Depression: A Neuroscientist’s Hands-On Approach to Activating Your Brain’s Healing Power, and she was the one who talked a lot about how purposeful hand use can affect brain chemistry and make people feel happier.

Dan:

What would be some examples of using your hands? When we think of creativity, many people might think of painting, for example. They might say to themselves, “Well, I’m not a good painter,” or “I don’t play an instrument.” But creativity isn’t really limited to that. Can you expand on that?

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Carrie:

Sure. I am so glad you asked that. I think this is the crucial question. And I think you hit the nail on the head. A lot of people say, “I’m not creative.” Well, first of all, I think we’re all born creative. It’s a matter of finding what you can do. It can be applied to business. You can be amazing. You could be a genius at figuring out what the team needs to be. That’s very creative. You could be an amazing cook. You could have a tremendous talent for decorating. Gardening, the design of a garden. It doesn’t have to be on a professional level. It’s really a matter of figuring out what you can get into. You may find that if you put some time into mastering a skill that you find a certain pleasure and freedom with it. That could be something like painting, but it doesn’t have to be. Knitting, crafting, it could even be fixing things. All of that involves meaningful hand use.

There are many definitions of creativity.  My definition of it is allowing most natural self to emerge to make a positive contribution. It’s allowing you a freedom, a spontaneity in the way that you live, a feeling of safety that allows you to do that so you’ll throw out an idea, you’ll say something funny in conversation, so that you are just yourself and it works. That’s really optimal living.

Dan:

You talked earlier about when you were younger and growing up having some difficult childhood experiences and learning some creative coping skills.  Myself, when I think about this, I had a very difficult childhood as well with an alcoholic, abusive father. Over time, I didn’t have what I would now think of as depression as a young adult. It developed more at midlife when I turned forty.  It seems that there’s a lot of research that suggests that when people in their childhoods have difficult experiences, either emotional abuse, or physical abuse, or deprivation, there’s some kind of linkup with adult-onset depression. Have you found you found that in your experience?

Carrie:

Yea, I think so. I think because in certain ways when you’re in your twenties and your thirties and you’re striving, and you’re distracted and you have a strong goal, that, in and of itself, that kind of commitment to a goal or emotion can stave off certain aspects of your memory or your inner life and it might get triggered in your forties.  Maybe when you have a little bit more time to contemplate or think back. I will say that there are certainly ways, I just like to not be falsely optimistic, but be really optimistic and really encourage people to understand that there are ways to look into your particular history, your particular form of depression, and work with it to get to a much better place at any age.

Dan:

In your book, you talk specifically about not only being creatively engaged, but the use of one’s hands, a physical activity, and how that somehow connects to creativity, no matter your history, or the causes of your depression. This seems to work for just about anybody with depression or unhappiness. Would you say that’s the case?

Carrie:

I do. I think it’s mild or moderate depression. I think if you have a very severe depression, you might need some medical intervention or an intense therapy. But what I like to say is that if you develop a creative habit, it’s very useful to fall back on it when you are depressed. You may not be able to master a new habit when you’re severely depressed, but if you’re mild to moderate, and you work on your knitting, or you work on your painting, or you go into the kitchen and you are inventive about your cooking, it really can shift mood, but not if you’re in a very crippled state. In a crippled state, you need to get to, sort of, a better place, and then use the creativity after that.

Dan:

You’re living in New York City, but you’re soon to be on the move. Tell us a little bit about that.

Carrie:

I’m very excited because I am going to be moving to Austin, Texas soon.  I’m going to be involved in, and working with the great people to try to develop a creativity/wellness program together. I’m not sure exactly, I haven’t submitted a proposal to them about human flourishing and aspects of human flourishing, but from my research, I outline 10 principles that are based on scientific research, but also on ancient philosophies that really help people with optimal living. Most of those are, actually, linked to creativity and linked to better health. So I’m really excited to get to work with people there.

Dan:

You actually have a website. Where can our podcast listeners and readers find you?

Carrie:

At carriebarronmd.com and we have a pretty active Facebook page has a wide following. People make lots of comments and have lots of pretty interesting things to say on that.  So that might be a place to look. And I do have an active Psychology Today blog. I try to keep it lighter for Facebook, kind of short for my website. On Psychology Today, I try to deal with deeper, more complicated issues, but try to be useful.

Dan:

Carrie, it’s been a real pleasure speaking with you today on this very important topic of depression and what we can do about it with creativity.  And we look forward to following your future work.  I hope everybody follows Carrie on her website and reads her blogs. This is Dan Lukasik from Lawyers with Depression. Join us next week for another interesting interview.

Finding Motivation Even Through the Apathy of Depression

From Esperanza magazine, blogger Margaret Lanning writes, “Lack of motivation is probably the most difficult part of depression I continue to wrestle with. Trying to figure out how to get up and get moving is extremely challenging. It can make or break a day. When I feel apathetic, my senseless thought cycle starts with the notion that I need to choose to do something (clean the kitchen). Then comes immediate resistance (I don’t want to clean the kitchen), then the guilt trip (good mothers clean kitchens so the family can be healthy), then the compromise (I can have a bite of chocolate if I clean the kitchen), then the shut-down (but I still don’t want to clean, and I’ll probably eat the whole chocolate bar), then the self-punishment (I am a bad person because I’m still sitting here).” Read the blog.

Inside the Los Angeles Clinic That Uses Ketamine to Treat Depression

From LA Magazine. Advocates are hailing ketamine therapy and its attendant hallucinations as the ultimate brain hack. Prominent doctors and even the stodgy National Institute of Mental Health have championed the treatment as a powerful weapon in the battle against depression, one that could potentially prevent people from taking their own lives. Read the article.

Depression Undercover: A Trial Lawyer’s Secret

Once upon a time, I was a trial attorney at a personal injury defense firm. I was good at it.  I always pushed hard; always did the best job possible.  I won a good share of cases, and, of course, lost a few as well.  I was valued highly enough to be made a partner shortly after joining the firm.

But I had a dirty little secret.  I had bipolar disorder, which was well-controlled through a close partnership with a good psychiatrist.  Still, in my mind, if word ever got out, my employers would see me as weak, a liability.  To a degree, I understood.  If the insurance companies that paid the bills learned that one of the firm’s trial attorneys had such a condition, their mandate would be clear: if you want our business, get rid of him. That is what I assumed.

Throughout my career, colleagues would make offhanded remarks about someone “not taking his medication.” I would grit my teeth and ignore it.

Instead, I was able to construct an alter-ego, the “happy warrior.”  I had a smile on my face and a sardonic remark ready on cue. But I went about my daily business feeling like a secret agent in a Cold War spy movie.  If my cover was ever blown, I was certain that my career would be at an end.

Over time, maintaining this secret identity while dealing with the usual strains of trial practice gave rise to a growing depression.  Yet I still performed at a high level and still got results.

Although I had a close friend at the firm, another partner, he would deflect when I tried to talk to him about my depression, so I stopped.  I began to worry that others at the firm might know about me.

Fear and the sense of isolation only fed upon themselves in a continuous cycle.  I finally experienced a severe episode of depression that led to a period of disability.  When I told my boss what was going on, he expressed genuine surprise that I was suffering from depression at all.

When I returned to work, I felt better, but I remained wary.  Instead of engaging in a conversation about what had happened, we all acted as though nothing had occurred.  The computer was rebooted, and business continued on as usual.  I went back undercover, and no one seemed to mind.

Simply due to scheduling conflicts and adjournments, it was some time before I tried another case.  I admit that I was a little nervous, but I was having no trouble handling my case load.  I was puzzled when my boss came into my office one afternoon as I was preparing for the trial.  He asked me if I felt good to go.  He had never done that before.  I said, “yes,” because I felt perfectly up to the task.  I never asked myself, “If he is worried about my performance, why is he even letting me try the case?”

At trial, the insurance company sent an adjuster to audit the proceedings, a routine procedure.  I knew him well, and he had an excellent grasp of the case, even though he had not been involved before trial.  We had constant discussions about what was going on, and we seemed to be in sync.  Suddenly, the insurance company pulled my old friend off the case and replaced him with a mid-level manager who consistently praised my performance.

The case went to verdict, and the jury awarded somewhat less than what the insurance company had offered settle for.  To preclude the possibility of an appeal, the insurance company threw in a few more dollars.  Case closed, on to the next one.  To me, that was a pretty good result.

Was I in for a big surprise.

Shortly after the trial, year-end reviews were scheduled.  I was getting ready for another trial, and I was very excited about it, so I wasn’t really paying attention to what was going on in the office.  Other attorneys were getting their reviews – important because raises would be discussed – but I was never called in.

Ultimately, my case settled after much hard work on all sides, and the usual time for reviews was long past.  I did start to worry then.  I even made a remark to my secretary about it.

The call finally came.  When I stepped into the conference room and saw every equity partner in the firm waiting for me, I knew.  The spy had been caught, but what would happen?

My boss said that they waited to speak with me because they did not want to put pressure on me while I was preparing for another trial.  He asked me if I felt capable of trying cases.  I paused and then broke under the years of strain.  I wept, and answered, “No.”  Whether that “No” was true then or true now or was ever true, it was the most humiliating moment of a 20-year career.

My boss started to dissect my prior trial, telling me that the insurance company’s representative was reporting that I was doing a bad job.  He even told me that the supervisor at the insurance company knew that I had depression.  After the expected awkward silence, another partner suggested that “we find a creative solution” to keep me at the firm.  I made some suggestions over the next few months.  No replies were forthcoming.  I was quietly being swept out the door.  It wasn’t hard to get the message. I found another job and moved on.

The whole experience seemed to confirm everything I feared about being a lawyer with depression.  Currently, I am not practicing, and am seeking other opportunities.

But if the story ends there, what is the point?  Can I offer my account as a teaching opportunity?  At the very heart of the tale lies the sad truth that we, as lawyers, trained to be superlative communicators, can utterly fail to make each other understood when it comes to depression.  Should I have been more candid about my condition?  My employers never told me what concerns they had or what they knew.  Could all of us have been proactive for our mutual benefit, especially after I returned to work?  I believe that there had been an opportunity to open a constructive dialogue, but my fear told me to keep my mouth shut.  I cannot speak for my former employers, although I highly doubt that they held any malice.  I doubt that they thought much about it at all until some critical pressure was brought to bear, whether from within or outside of the firm.  Unfortunately, by the time everyone was talking, my job at a firm I loved was gone.

I miss working there.  I still have close friends there.  I see them when I can, which is not often enough.  Just recently, I ran into my secretary, and we briefly chatted about my plans for the future.  And then she said something that cut me to the quick: “You were a good lawyer.”

— Anonymous guest blog

My Family, My Depression

“If you look deeply into the palm of your hand, you will see your parents and all generations of your ancestors. All of them are alive in the moment. Each is present in your body. You are the continuation of each of these people” – Thich Nhat Hanh

Like all parents, my Mom and Dad were flawed people – as I am. Yet, they were something more than that.

I’ve struggled to understand them much of my adult life; maybe more so now that they’re both gone. Here’s a picture of them from 1946 cleaning up the reception hall after a two-day celebration.

The nineteenth-century German philosopher Arthur Schopenhauer once wrote:

The Neuroscience of Depression: An Interview with Dr. Alex Korb

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The following is an edited transcript of the podcast recorded interview with Dr. Alex Korb.  This transcript has not been reviewed and is not a word-by-word rendering of the entire interview.

Hi, I’m Dan Lukasik from lawyerswithdepression.com. Today’s guest is Dr. Alex Korb.  Dr. Korb is a neuroscientist, writer, and coach.  He’s studied the brain for over fifteen years, attending Brown University as an undergraduate and earning his Ph.D. in neuroscience from UCLA. He has over a dozen peer-reviewed journal articles on depression and is also the author of the book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time. Interesting, he’s also coached the UCLA Women’s Ultimate Freesbie team for twelve seasons and is a three-time winner for Ultimate Coach of the Year.  His expertise extends into leadership and motivation, stress and anxiety, mindfulness, physical fitness, and even standup comedy. Welcome to the show.

Dr. Korb:

Thank you, great to be here.

Dan:

Let’s begin for our audience.  You’re a neuroscientist. What is neuroscience?

Dr. Korb:

Neuroscience is simply the study of the brain and nervous system. It’s a branch of biology, but it also incorporates aspects of psychology, psychiatry, and neurobiology.  It’s anything that’s going on in the brain and nervous system all under the purview of neuroscience.

Dan:

You’ve studied depression as a neuroscientist?

Dr. Korb:

Yes, that’s what I wrote my dissertation on. The aspect of neuroscience that I’m most interested in is what underlies the neural basis for our moods and emotions, behaviors, and psychiatric illnesses. Some peer-reviewed articles look at schizophrenia as well as other psychiatric disorders like depression which have a lot of basis in neuroscience and we just don’t fully understand what is happening in the brain.

Dan:

Based on your research, can you tell us what’s going on in the brain when someone is suffering from depression?

Dr. Korb:

The best way to describe it is a dysfunction in frontal-limbic communication. To simplify it, there’s a problem with the way the thinking, feeling, and action circuits in the brain are communicating with each other.  Those all have different regions of the brain that are more dedicated to each aspect of thoughts, feelings, and actions. But, normally, there’s a dynamic of how these regions are supposed to communicate with each other, and there’s something with depression that’s a little bit off.

Dan:

Can the same be said for anxiety as far as what’s going on in the brain?

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Dr. Korb:

Yes, anxiety and depression have a lot of overlap regarding the neuroscience and neurobiology behind them.  A lot of the same brain regions are involved. For example, the amygdala, which is often called the fear center of the brain, but is involved in a lot of emotional expressions, that’s one of the core emotion regions in the brain, and it plays a role in both depression and anxiety.  And there’s just a lot of overlap in brain regions, and neurochemistry that underlies these disorders and it’s one of the reasons why anxiety is one of the most common features of depression and they often co-occur together.

Dan:

When I’ve tried to explain what I was suffering from, and my symptoms and I called it “depression,” most people didn’t have any frame of reference for that. They usually thought of it as “sadness.” With respect to sadness and depression, are there different areas of the brain that pertain to sadness that are different from clinical depression?

Dr. Korb:

There’s a lot of overlap between sadness and depression, but a lot of the misunderstanding that people have is that we use the term depression and sadness, “I’m feeling depressed” or, “I’m feeling sad,” we use those colloquially, very interchangeably.

But medically, or neuroscientifically, they’re very different.

Depression and the diagnosis of depression are a lot more than simple sadness.  In fact, a lot of people who suffer from depression don’t feel sad per se. They can often feel an emptiness where emotion should be.  They have a lot of other symptoms such as hopelessness and feelings of helplessness, guilt and shame, isolation, and anxiety can be a part of it.

They can have fatigue, problems falling asleep or staying asleep or even sleeping too much and, generally, the things that they used to find enjoyable they no longer find enjoyable. Everything just feels very difficult.

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It’s hard to explain to someone why it’s difficult because it seems like it shouldn’t be. It’s a much deeper feeling of being stuck than most people experience.  I think the average person if you can think of how you felt after the week of your greatest heartbreak, that sort of touches the edge of what it means to be depressed. It’s not the depth of how badly you feel, but that you can’t escape it. For example, I like to think of depression as a traffic jam.  When you enter a traffic jam, sometimes there’s an accident. The cars are stopped, and you sit there and wait.  And you don’t know how long the traffic jam is going to be. But for most people, it was just a little stoppage on their way. But for people with depression, it’s something that their brain just can’t quite escape. They can try and try, but their brain is stuck in the pattern of activity that just drags along, and the traffic jam just continues.

Dan:

That’s a great explanation of the experience of depression. Both what’s going on in the brain and psychologically. I think people want to know what are some of the causes of depression? Many people once they’ve often been diagnosed try to figure out for themselves, and people who care about them try to figure out?

Dr. Korb:

Depression can have a huge number of different causes. This is where the traffic jam analogy does a lot to help us understand depression. If you see a traffic jam, you can say, “Oh, what caused it?” Well, a traffic jam can come from any number of causes. There’s construction on the freeway, or there was an accident, there was heavy rain or fog, or it could just be that everyone decided to leave work at the same time, and there’s no specific “cause,” it’s just that the interaction – the dynamic interaction – of all those cars just reaches a tipping point.

With depression, it’s the same way. Often, it can be precipitated by a big life event such as a divorce, or breakup, or death in the family. Or smaller life events such as a perceived emotional embarrassment or you didn’t get that promotion.  But, often it’s not “caused” by anything.  It’s just the dynamic interaction of your brain circuits with each other, combined with the sum of your current life circumstances, which causes the brain to get stuck in a certain pattern of activity and reactivity.

That’s much more likely to happen for some people than others because some people’s brains are just more at risk for falling into that pattern. This can be based on the genes you got from your parents, and your early childhood experiences and the coping patterns you’ve been doing your whole life shaped the neurocircuitry and neurochemistry of your particular brain.  So, it’s not always a specifically, identifiable cause.  I think that’s one of the reasons why people, sometimes, don’t quite believe that it’s real or don’t think they should be suffering it. But, it’s very similar to that traffic analogy where it just “sort of happened” for seemingly no reason. It’s just caused by the fact that is vague, nonlinear, dynamic system.

Dan:

Why did you write the book, The Upward Spiral? There are plenty of scientists out there who study depression, but not many of them write a book for the general public on the topic.  What is it that led you to write this kind of book?

Dr. Korb:

I just realized that there was so much useful neuroscience out there that wasn’t being effectively delivered to the people who needed it most. One of the things that made me realize that is from when I was coaching Ultimate Freesbie. After a few months, one of the girls on the team revealed to me that she had been suffering from major depression and that she’d been suffering for years, and, tragically, many months later she ended up committing suicide. It was a devastating event in my life. This was back when I was still studying neuroscience, but before I had decided to go to grad school and study depression. That event led me to want to understand exactly what was going on in her brain that could lead her to do something like that. How could the brain get stuck in a disease like this?

That lead me to going to grad school and doing my dissertation on depression to try and understand and share some of these things with other people. As I was doing my dissertation, I realized that, yes, it’s good to advance the science, but there was already so much good science out there that was so beneficial. I didn’t think that anyone was doing a good enough job communicating clearly exactly about what was happening in the brain in depression and about all the little life changes that you can make that have measurable effects on brain activity and brain chemistry.

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Dan:

The second part of your book is devoted to eight specific things you can do to alleviate depression. Quickly, they exercise your brain, set goals and make decisions, give your brain a rest, develop positive habits, biofeedback, develop the ‘gratitude circuit,’ the power of others, and your brain in therapy. We don’t have enough time to focus on all eight, so why don’t we focus in on one or two. What I thought was fascinating is that you give the backdrop for what is going on in the brain when you do these things.  A few things that popped into my mind were gratitude and your brain in therapy. What about gratitude? How can it help depression?

Dr. Korb:

Gratitude can have a lot of powerful effects on the brain. And one of the reasons going back to why I wrote this book, is that there are tons of books out there that will tell you different life changes that you can make that will help with depression, but I’ve found that a lot of them are unsatisfying because they don’t explain, why. Therefore, it’s not as convincing, and it’s very easy for people to dismiss.

So when I talk about gratitude and how practicing gratitude can be so powerful in overcoming depression, a lot of people can resist that idea because it sounds so hokey.  But if I can point to specific neuroscience studies that show that it has measurable effects in changing brain activity and brain chemistry, then you’re much more likely to do it and it gives you a much better understanding of what’s going on. Gratitude has been shown to, if people who keep a gratitude journal, improve the quality of their sleep, and sleep symptoms of depression are one of the causes of depression. The reason why I called my book, The Upward Spiral because depression can sort of be seen as a “downward spiral” where one symptom or one event can lead to seemingly to a whole cascade of events that keep you stuck. So, gratitude can help break the downward spiral that’s coming from sleep problems that are leading to difficulty in concentration, and that’s one place to break the loop.

Dan:

After reading the chapter on gratitude, I picked up a spiral notebook and started a gratitude list. It was more of a lifetime gratitude list. It’s amazing. I came up with eighty things. I was surprised. So often my experience with depression is that we ruminate about negative things. We just don’t take the time, or don’t have the skill to savor and reflect on the good things in our lives.  It seems what you’re saying is that this practice has effects in the brain.

Dr. Korb:

Yes, when you’re in a depressed state it’s much harder to see the positive aspects of your life. But that’s why it’s all the more important to build a habit of looking for those positive things because often the most important feature of gratitude is not finding something to be grateful for. It’s remembering to look in the first place because that activates the prefrontal cortex which is the more thinking part of the brain which helps it to regulate the emotional regions of the brain that are going haywire in depression.

And gratitude increases activity in the key region of the brain called the cingulate cortex that sits at the intersection between the emotional limbic system and the rational prefrontal cortex and helps modulate communication between those. Remembering things in your past that you are happy or grateful for actually increases the production of the neurotransmitter serotonin in that same brain region and serotonin is one of the most common targets for antidepressant medications.  Practicing gratitude is having effects in key brain regions that we know contribute to depression and in the neurotransmitter systems that are contributing to depression.

Dan:

I also found it interesting your chapter on our brains and therapy. What’s interesting is that many people who treat with a therapist find comfort and solace in going to therapy when they are struggling with depression. They walk out, and they often do feel better at times don’t’ always understand why they feel better.  Or, we know, there’s a recent study from National Institute of Mental Health, which concluded that as many as eighty percent of people in this country get no treatment for depression whether it be antidepressants or therapy.  So, why is it important, if at all, for people to go to therapy who struggle with depression?

Dr. Korb:

The chapter that I wrote on therapy encompasses not just psychotherapy – going to talk to someone – but it also includes medical therapy such as antidepressant medication or other forms of therapy like neuromodulation techniques. These have been demonstrated through rigorous, double-blind studies that show they have powerful effects on treating depression.  Going to see a professional if you think you are depressed is a hugely important step because they can put at your disposal all the advances of western medicine.

What’s interesting – and it’s the last chapter in the book – and it’s funny how many comments I get because they say, “You left antidepressants to the end because it’s not that important and there are other life changes people can do.” Another psychiatrist will say to me, “Why are you so dismissive of antidepressant medication? They are hugely important in the treatment of depression.”  It’s neither of those. I agree that antidepressants and psychotherapy are extremely important in the treatment of depression, and if you think you are suffering from depression, you should go to see a health professional whether it’s just your doctor or you go to see a psychotherapist.

I just don’t think antidepressants are the entire answer.

For some people, I would say about one-third of people suffering from depression; antidepressants are the answer. You can get over your depression completely simply be taking a pill. You don’t know if you might be one of those people. So, you might as well see a doctor and find out.

For the other half or two-thirds of people, antidepressant medication can still be a huge part of the answer, even if it’s not the entire answer. Taking antidepressants can also help you make these other small life changes such as increasing exercise, or changing your sleep habits, or practicing gratitude.  As you make the other small life changes, then things can start to spiral upward.

Dan:

It’s been an informative and very interesting interview with you Dr. Korb.  I want to thank you for being on the show and I highly recommend listeners to pick up and read his book, The Upward Spiral: Using Neuroscience to Reverse the Course of Depression One Small Change at a Time.  Join us next week for another interesting interview at Lawyerswithdepression.com.

I encourage everyone to check out Dr. Korb’s website at alexkorbphd.com.

 

Depression and Suicide: A Catholic Perspective

As a psychiatrist, I had been aware, prior to his death, that Robin Williams struggled with a severe mood disorder – major depression and bipolar disorder, depending on the source of the reporting – along with related problems and drug dependence.

The vast majority of suicides are associated with some form of clinical depression, which in its more serious forms can be a sort of madness that drives people to despair – leading to a profound and painful sense of hopelessness and even delusional thinking about oneself, the world and the future.

I knew all of this, and yet this death still shocked and surprised me, as it shocked and surprised so many others. Williams seemed to be the consummate humorist, the funny man who would be just so much fun to be around. Unlike some comedians who trade only on irony and cutting humor, Williams appeared to us as a warm, big-hearted, endlessly fun, brilliantly quick, incredibly talented man. Though he was a celebrity, he was the kind of person that people felt like they knew – like the cousin, everyone just adores and hopes will show up at the family reunion.  Williams was the kind of guy that people wanted to be friends with, the kind of person that one wanted to invite to the party.

This is not the typical stereotype of mental illness, which why the typical stereotype must be relinquished: Quite simply, it is false.

Mental illness can afflict anyone, of any temperament and personality. In the wake of his death, the strange truth gradually began to sink in: In spite of outward appearances, Williams’ mind was afflicted by a devastating disorder that proved every bit as deadly as a heart attack or cancer. He suffered in ways that are difficult for most people to imagine.

Why couldn’t Williams see himself as other saw him – as a person of immense gifts and talents, a man who stood at the pinnacle of achievement in the world of comedy and entertainment?

Why couldn’t he see himself as God saw him – as a beloved child, a human soul of immense worth, a person for whom Christ died?

This is the tragedy of depression, which is so often misunderstood by those who have not suffered its effects.

Novelist William Styron – whose memoir Darkness Visible represents one of the best first-person attempts to describe the experience of depression – complains that the very word “depression” is a pale and inadequate term for such a terrible affliction.  It is a pedestrian noun that typically represents a dip in the road or an economic downtown. Styron prefers the older term “melancholia,” which conjures images of a thick, black fog that descends on the mind and saps the body of all vitality.

Indeed, the title of his book – Darkness Visible – comes from John Milton’s description of hell in Paradise Lost. We’re not talking about hitting a rough patch in life or the everyday blues that we all experience from time to time. We are talking about a serious, potentially fatal, disorder of mind and brain.

Fortunately, in most cases, depression is amenable to treatment. Because the illness is complex – involving biological, psychological, social, relational and, in some cases, behavioral and spiritual factors – the treatment likewise can be complex. Medications may have a very important role, but so do psychotherapy, behavioral approaches, social support and spiritual direction.

In some cases, hospitalization may be necessary, especially when an afflicted individual is in the throes of suicidal thinking or when one’s functioning is so impaired from the illness that he or she has difficulty getting out of bed or engaging in daily activities. For the severely depressed, even brushing one’s teeth can seem like an almost impossibly difficult chore.

This level of impairment is often puzzling to outsiders – to the spouse or parent who is trying to help the loved one. Unlike cancer or a broken bone, the illness here is hidden from sight. But the functional impairments can be every bit as severe.

I recall one patient, a married Catholic woman with several children and grandchildren, who had suffered from both life-threatening breast cancer and from severe depression. She once told me that, if given the choice, she would choose cancer over the depression, since the depression caused her far more intense suffering. Though she had been cured of cancer, she tragically died by suicide a few years after she stopped seeing me for treatment.

Depression is neither laziness nor weakness of will, nor a manifestation of a character defect. It needs to be distinguished from spiritual states, such as what St. Ignatius described as spiritual desolation and what St. John of the Cross called the dark night of the soul.

Tragically, even with good efforts aimed at treatment, some cases of depression still lead to suicide – leaving devastated family members who struggle with loss, guilt, and confusion.

The Church teaches that suicide is a sin against love of God, love of oneself and love of neighbor.  On the other hand, the Church recognizes that an individual’s moral culpability for the act of suicide can be diminished by mental illness, as described in the Catechism: “Grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide.”

The Catechism goes on to say: “We should not despair of the eternal salvation of persons who have taken their lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.”

Robin Williams’ death – like the death of so many others by suicide who have suffered from severe mental illness – issued from an unsound mind afflicted by a devastating disorder. Depression affects not just a person’s moods and emotions; it also constricts a person’s thinking – often to the point where the person feels entirely trapped and cannot see any way out of his mental suffering. Depression can destroy a person’s capacity to reason clearly; it can severely impair his sound judgment, such that a person suffering in this way is liable to do things, which, when not depressed, he would never consider. Our Lord’s ministry was a ministry of healing, in imitation of Christ, we are called to be healers as well. Those who suffer from mental-health problems should not bear this cross alone. As Christians, we need to encounter them, to understand them and to bear their burdens with them.

We should begin with the premise that science and religion, reason and faith are in harmony. Our task is to integrate insights from all these sources – medicine, psychology, the Bible, and theology – in order to understand mental illness and to help others to recover from it. In cases where recovery proves difficult or impossible, we pray for the departed and never abandon those who still struggle.

Aaron Kheriaty, M.D., is associate professor of psychiatry and human behavior at the University of California-Irvine School of Medicine. He is the co-author with Msgr. John Cihak of The Catholic Guide to Depression.

Wiring of ‘Little Brain’ Linked to Multiple Forms of Mental Illness

Having a single mental illness like anxiety, depression or schizophrenia is hard enough on its own. But studies consistently show that up to half of people with one mental illness also experience one or more additional forms of mental illness at the same time.The high numbers of patients who suffer from multiple forms of mental illness has many researchers shifting focus away from studying individual disorders and instead hunting for common mechanisms or risk factors that might cause all types of mental disorders. Read the rest of the news here.

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