Depression is a common psychological disorder.
As of the end of August 2014, I have been a clinical psychologist for exactly seven years and have received more than 2,000 cases of visitors. Among them, depression accounted for about 30% of the patients, nearly 600 people. From the end of September 2010, when I started online consultation, to the middle and end of September 2014, a total of 4 years, I have answered exactly 5000 cases of online questions from visitors, and depression was also around 30% of the problems.
Among these 2000+ cases (face-to-face + online consultation) of depressed visitors, the common concerns can be roughly grouped into 4 categories as follows
1.What is my current performance, is it depression?
2. Why do I have depression? Is depression hereditary?
3. How to treat it? Is medication or psychotherapy better? Are there any side effects of medication? Will there be dependence? How is psychotherapy treated? Do you know hypnosis?
4. What is the prognosis for the future? Can it be cured? Will there be relapse?
Because there are a lot of popular science articles about depression on the Internet (there is an article “Depression: Who Stole Your Happiness” in the “Science People” section on the web, which I respect, and those who are interested can search and read it), I would like to focus on the clinical manifestations of depression and psychological analysis of these two problems.
First, what are the symptoms of depression?
The American Diagnostic and Statistical Manual of Mental Disorders is an important guide for psychiatrists in clinical practice. In its new fifth edition (DSM-5) [1], depressive disorders are classified into 8 categories: disruptive dysregulation disorder, major depressive disorder, persistent depressive disorder, premenstrual irritability disorder, substance/medication-induced depressive disorder, depressive disorder due to other somatic disorders, other specified depressive disorder, and unspecified depressive disorder.
Since the first 3 types of depressive disorders are more prevalent and have more typical clinical presentations, I will list the diagnostic criteria for the first 3 in detail [1].
(A) Disruptive mood disorder disorder
A: Severe recurrent temper outbursts, manifested by verbal (e.g., verbal violence) and/or behavioral (e.g., physically attacking others or property) outbursts of an intensity or duration that is completely disproportionate to the situation or provocation to which they are subjected.
B: Temper outbursts are not consistent with their developmental stage.
C: Temper outbursts average 3 or more times per week.
D: Almost daily and most of the day, the state of mind between temper outbursts is persistently irritable or angry and can be observed by others (e.g., parents, teachers, peers).
E: Symptoms of diagnostic criteria A-D have persisted for 12 months or longer, during which time the individual has never been free of all of the symptoms in diagnostic criteria A-D for 3 consecutive months or longer.
F: Diagnostic criteria A and D are present in at least two of the following three (i.e., at home, at school, and with peers) scenarios and are severe in at least one of these scenarios.
G: The first diagnosis cannot be made before age 6 or after age 18.
H: Based on history or observation, the age of onset of symptoms for diagnostic criteria A-E is before 10 years of age.
I: There has never been a special period lasting 1 day during which all diagnostic criteria for a manic or hypomanic episode were met, except for duration.
Note: Mood elevation consistent with developmental stage, such as encountering or anticipating a very positive event, is not considered a symptom of mania or hypomania.
J: These behaviors do not only occur during episodes of major depressive disorder and cannot be better explained by other psychiatric disorders (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysphoric state of mind])
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent rage disorder, or bipolar disorder, but can coexist with other psychiatric disorders, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorder. If an individual’s symptoms meet the diagnostic criteria for both disruptive dysregulation disorder and oppositional defiant disorder, only disruptive dysregulation disorder will be diagnosed. If the individual has had a manic or hypomanic episode, the diagnosis of disruptive mood disorder can no longer be made.
K: These symptoms cannot be attributed to the physiological effects of a substance, or to other somatic or neurological disorders.
(II) Major depressive disorder
A: More than 5 of the following symptoms occurring within the same 2-week period, showing a change from previous functioning, at least 1 of which is depressed mood or loss of interest or pleasure.
Note: Excluding those symptoms that can be clearly attributed to other physical illnesses.
1. Depressed mood almost every day or most of the day, either as a subjective report (e.g., feeling sad, empty, hopeless) or as observed by others (e.g., exhibiting tearfulness) (Note: Children and adolescents, may exhibit irritable mood).
2. Significantly less interest or pleasure in all or almost all activities for almost every day or most of the day (either subjectively experienced or observed).
3. Significant weight loss without dieting, or weight gain (e.g., a change in weight of more than 5% of the original weight in a month), or loss or gain almost every day (note: children may show that they have not reached the weight they should have gained).
4. Insomnia or excessive sleep almost every day.
5. Psychomotor agitation or retardation (observed by others, not just subjectively experienced as fidgeting or sluggishness) almost every day.
6. Fatigue or low energy almost every day.
7. Feeling worthless almost every day, or excessive and inappropriate guilt (which can reach the level of delusion), (and not just self-blame or guilt because of illness).
8. Almost daily presence of diminished ability to think or concentrate or indecision (can be both a subjective experience and an observation by others).
9. Recurrent thoughts of death (rather than just fear of death), recurrent suicidal ideation without a specific plan, or some kind of suicide attempt, or some specific plan to carry out suicide.
B: These symptoms cause clinically significant distress or lead to impairment in social, occupational, or other important functioning.
C: These symptoms cannot be attributed to the physiological effects of a substance, or other physical illness.
Note: Diagnostic criteria A-C constitute a major depressive episode.
Note: Reactions to significant loss (e.g., bereavement, financial ruin, loss from a natural disaster, serious physical illness or disability) may include the symptoms listed in diagnostic criterion A: such as intense sadness, immersion in loss, insomnia, lack of appetite, and weight loss, which can resemble depressive episodes. Although such symptoms are understandable or appropriate responses to loss, the possibility of a major depressive episode should be carefully considered in addition to the normal response to a significant loss. This decision must be based on a personal history and cultural norms for expressing distress in the context of loss to make a clinical judgment.
D: The presence of such major depressive episodes cannot be better explained by schizoaffective disorder, schizoaffective disorder, schizophrenia-like disorder, delusional disorder, or other specific or unspecified schizophrenia spectrum and other psychotic disorders.
E: From the absence of manic episodes or hypomanic episodes.
Note: This exclusion does not apply if all manic-like or hypomanic episodes are due to substance abuse or are attributable to the physiological effects of other somatic disorders.
(iii) Persistent depressive disorder (poor mood)
This disorder results from the combination of chronic major depressive disorder and dysphoric disorder as defined by DSM-IV.
A: Depressed state of mind for most days of the day for at least 2 years, either as a subjective experience or as observed by others.
Note: The state of mind in children and adolescents can manifest as irritability and persist for at least 1 year.
B: Depressive state when 2 (or more) of the following are present.
1. Loss of appetite or excessive eating.
2.Insomnia or excessive sleep.
3.Lack of energy or fatigue.
4.Low self-esteem.
5.Lack of concentration or indecision.
6.Feeling hopeless.
C: During the 2-year course of the illness (1 year for children or adolescents), the individual has never had a single episode without symptoms of diagnostic criteria A or B for more than 2 months.
D: The diagnosis of major depressive disorder can exist continuously for 2 years.
E: Never had a manic or hypomanic episode and never met the diagnostic criteria for cyclothymic disorder.
F: The disorder cannot be better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, other specific or unspecified schizophrenia spectrum and other psychotic disorders.
G: These symptoms cannot be attributed to the physiological effects of a substance (e.g., drugs of abuse, medications), or other somatic disorders (e.g., hypothyroidism).
H: These symptoms cause clinically significant distress or lead to impairment in social, occupational, or other important functions.
Note: Because the list of symptoms of persistent depressive disorder (poor mood) lacks the four symptoms included in the diagnostic criteria for a major depressive episode, only a very small number of individuals have persistent depressive symptoms for more than 2 years without meeting the diagnostic criteria for persistent depressive disorder. If all diagnostic criteria for a major depressive episode are met at some point during the course of the current episode, a diagnosis of major depressive disorder should be given. Otherwise, a diagnosis of other specific depressive disorder or unspecified depressive disorder is warranted.
A discerning person with a little medical knowledge can see from these symptom descriptions that the next corresponding diagnosis requires symptom criteria (what manifestations are present), duration criteria (how long), exclusion criteria (which ones with the same manifestations cannot be classified as depressive disorders) and severity criteria (the degree of impact on social life).
II. Psychological analysis of depression
From my clinical experience, the occurrence of these 3 depressive disorders is related to self-perception (or called self-concept, self-image).
Although many psychologists emphasize that a correct understanding of the self is a prerequisite for mental health, studies have now demonstrated that people who are often in a happy state of mind often have a moderately positive illusion of self-perception (i.e., feeling better than others, exaggerating their sense of control over reality, and viewing the future overly positively), whereas depressed people are often pessimistic and realistic [2-6]. This is actually consistent with our daily life experiences. In general, we are in a happy mood when feeling superior to others, and we are depressed when feeling inferior to others. If this feeling of inferiority lasts for a longer period of time, our state of mind will also remain low for a longer period of time.
To clarify this point, we need to look at the motivation and source of self-awareness.
Similar to the three groups of self-object empathy (idealized empathy, mirror empathy, twin or alter ego empathy) defined by Kohut in autopsychology [7], there are three motivations for our self-knowledge.
1. the need for self-improvement, i.e., the desire to feel good about ourselves and to avoid feeling bad…
2. the need for accuracy, i.e. the need to know what we are really like.
3. the need for consistency, i.e., the need to keep our self-concept consistent and to prevent changes from occurring.
Of these three motivations, the motivation of self-improvement dominates, even for someone with low self-esteem.
And our self-perceptions often originate from so many sources.
1. the objective physical world. In the process of living with nature, or transforming nature, we gain knowledge of our self, and also enhance our sense of self-worth. For example, “The Old Man and the Sea” and “Robinson Crusoe” in the main character’s experience of struggling with nature is a literary description of this feeling.
2. Social comparison. We obtain the feeling of our self-image through comparison with other people, especially with our peers.
3. Reflexive evaluation. That is, seeing ourselves through the eyes of others and liking ourselves because of others’ liking. For example, children feel good about themselves because their parents and teachers praise them.
4, introspection. Similar to what the ancients called “three times a day” or “see the wise, see the unwise, then introspection”. This introspection is difficult for ordinary people to do, but excessive is not good, will affect the power of action and judgment.
5, self-knowledge and attribution. By observing my own behavior to determine what I am like.
Among these five sources, the sources that are closely related to self-knowledge (or self-concept) are social comparison and reflexive evaluation, which is the main meaning of what I often say, “self-confidence comes from other people’s beliefs, self-esteem comes from other people’s respect.
Because of the importance of these two sources, people generally react more strongly when they lose their inherent place in social comparison or when they lose their source of affirmative reflexive evaluation, especially for those individuals who have previously relied strongly on social comparison and reflexive evaluation.
Depending on the degree of damage or fragmentation of the self-concept or self-image, I have classified the psychological causes of depressive disorders into four categories as follows.
(i) Wear and tear of the ego This is a feeling of mediocrity among excellence, where the previous excellence is no longer 100%, and the patient feels lost, as if he or she has lost some part, a tiny part of himself or herself, but not fatally. This type of depressive disorder often manifests itself as a poor state of mind type, which is abrasive rather than ruptured in terms of damage to the self-concept. For example, in a chronically competitive and stressful environment, the patient loses his or her former one-horse dominant position, but remains in a more advanced position.
（This is a feeling of “I will not be me” (similar to disfigurement) and the patient feels great distress. This type of depressive disorder can be divided into two categories, either destructive dysregulation disorder or major depressive disorder. The causes, both of which are related to a shattered self-concept rather than a worn out self-image. Its destructive dysregulation, which is a frequent denial struggle because of refusal to accept the shattered self-concept, generally often occurs in the early stages of self-concept shattering. As time lengthens, patients manifest major depressive disorder when they realize that this fragmentation cannot be changed and only choose to acknowledge the established facts. For example, a provincial high achiever who goes to Peking University and Tsinghua University, or a secondary school student whose ranking slips after a midterm exam, both have the potential for this non-ego despair to occur.
(iii) Punishment of the ego This type of depression, although it gives the impression of a punishment of the ego, is actually a protection of the ego deep down, similar to the guilt of a survivor or a successful person. For example, the company commander “Gu Zi Di” in “The Gathering”.
(iv) Punishment of others This type of depression is also a protection of the self, but its psychological mechanism is more complex. For example, a beautiful goddess, after 30 years of marrying a Pan Kou Xiao in the midst of all the opposition, finds that Pan Kou cores and polycarbonates are very important to her. The company’s main business is to provide a wide range of products and services to the public. Hydrazinium is a very important tool for the treatment of the family.
Third, treatment
In my opinion, the treatment of depressive disorder must be a combination of psychotherapy and medication, and it must be mainly psychotherapy and supplemented by medication (but do not use it).
I think the essence of psychotherapy for depression disorder is to help the patient to achieve “two acknowledgments”: acknowledgement and recognition.
To admit to oneself is to acknowledge one’s ordinariness, mediocrity, and even disability.
Recognition is to get the approval of others, especially important others.
These “two acknowledgments” are complementary, a double helix structure of one’s spiritual DNA, and one cannot be separated from the other.
How to help a visitor achieve these “two recognitions” is the art of psychotherapy, and it is also what distinguishes a psychiatrist from the usual chicken soup for the soul.
Relapse and Prognosis
Clinically, there is a saying that the relapse rate for patients with one attack is 30%-50%; for patients with two attacks, the relapse rate is 50%-70%; and for patients with three or more attacks, the relapse rate is as high as 90%. Therefore, lifelong medication is recommended for those who have had three or more episodes.
However, from my experience, I believe that there is a possibility of cure for depressive disorders. Just like the immunity to tuberculosis after BCG vaccination, as long as the visitor can adjust his personality and perception, accept the admission and also receive the recognition, the visitor is also immune to the wear and tear or shattering of self-concept, and the possibility of suffering from depressive disorder again is minimal.
The above statement is just my family’s opinion. After all, I have only seen more than 2,000 cases of depression! More medical practice is needed to verify my philosophy.