CHAPTER
18

Affective Disorders

In This Chapter

“I’m afraid the black dog has really got me …. It crouches in the corner of the room, waits for me to make a move. Or lies at the foot of the bed, like a shadow, until I try to get up ….”

So begins the prologue of Cathy Kronkite’s candid book On the Edge of Darkness: Conversations About Conquering Depression, in which she talks about her own experience with depression and shares stories of other celebrities who’ve had similar experiences. They’re not hard to find: Queen Elizabeth, Elton John, Patti Duke, Tipper Gore—not to mention one out of every 20 of us regular folks.

In this chapter, we explore affective disorders, a family of illnesses in which the main symptom is a disturbance of mood; anxiety and depression are two examples. You’ll discover the difference between a bad mood, major depression, and low-level sadness, and explore the mood swings of bipolar disorder and its gentler cousin, cyclothymia. You’ll also meet the four anxiety disorders, discover what “panicking” really means, and learn what to do when obsessive thoughts won’t go away.

Bad Mood or Big Time Trouble?

From a clinical point of view, you are not depressed when you have a bad day, are in a funk, or are feeling blue. We commonly use the word depression to describe everything from a passing mood to a chronic illness, but this creates confusion for all of us. As long as we use the terms interchangeably, it’s easy to respond to a depressed friend or colleague with, “So what? I was depressed yesterday, too, and I snapped out of it.” Not if you were experiencing a major depression. Clinical depression typically will last several months and invade every part of your life. Left untreated, it can be very dangerous.

What Depression Feels Like

You don’t feel hopeful or happy about anything in your life. You feel like you’re moving in slow motion. Nothing tastes good. Getting up in the morning requires tremendous effort. You find yourself crying over nothing, or at something that wouldn’t normally bother you; maybe you can’t cry at all any more, even if you want to. These are the faces of clinical depression.

Major depression affects 1 in 20 Americans every year, about twice as many women as men.
It’s an equal opportunity illness, hitting people of all socioeconomic levels and ethnic backgrounds. It can creep up on you or grab you by the throat. Major depression is debilitating and dangerous—an overwhelming sadness that lasts at least two weeks and is severe enough to interfere with a person’s life.

PSYCHOBABBLE

A 2013 study found that over 60 percent of patients who had been prescribed antidepressants didn’t meet the clinical criteria for a major depression. If help is necessary, make sure you’re evaluated by a psychiatrist with knowledge and experience treating mood disorders.

When mental health professionals assess someone for depression, they look for five or more of the following symptoms:

The depression must have lasted at least two weeks and it must cause significant emotional distress or disrupt your daily life. Of course, a list of clinical symptoms can’t capture the personal experience of living with depression. Here are some real examples of what a depressed person might say:

“I just don’t want to be around anyone. I keep making excuses to my friends. I know I’m hurting their feelings, but I don’t want to be a downer to them, and I just can’t pretend anymore that I’m up.”

“I can’t remember the last time I laughed. I have so much to be thankful for, so why can’t I just snap out of it?”

“It takes me a week to do what I used to do in a day. Some days I don’t get out of bed until noon.”

“I feel so bad that sometimes I wish I were dead. Yeah, I guess I’ve had thoughts of killing myself; anything would be better than this.”

As you can see, these thoughts and feelings are not typical of ordinary sadness. You might want to pull the covers up over your head when you’re in a bad mood, but you don’t think about suicide.

Let’s take a look at what causes depression and who’s likely to get it.

Why Me?

Depression often runs in families. However, depression can also occur in people with no family history and, if our life circumstances get bad enough, any of us can develop a clinical case of the blues.

How our genes and environment interact to predict—or protect us from—a mood disorder is becoming clearer. Research has found that 21 percent of us have the genotype that predisposes us to depression; 26 percent have the genotype with resilience to depression; and 53 percent have a mix of the two.

Researchers followed a group of 127 people for over 25 years. They found that individuals with a genetic predisposition for depression had an 80 percent chance of becoming depressed if they experienced three or more negative life events in a year.

Apparently, three is the magic number at which most genetically vulnerable individuals are knocked over, particularly when they are exposed to a series of difficult life events in a relatively short time period.

INSIGHT

Many physical illnesses can mimic psychological problems. If you suddenly find yourself feeling depressed or experiencing unusual emotional symptoms, it’s critical that you get a medical check-up. It can save your life.

Those Good Genes Can Help

Some of us, however, are blessed with genes that buffer us from mood disorders. A variation on one gene affects how much of the brain chemical serotonin is available to brain cells. This variation raises the risk of depression in people who carry it. But NIMH scientists found that a variation in another gene that produces a substance that enables the growth and health of brain cells appears to prevent or offset the changes generated by the depression-fostering one.

Our genes also set the stage for how we respond to difficult or traumatic events. The stress hormone CRH (corticotropin-releasing hormone) regulates the chemical messages through which our brain cells communicate with each other. Childhood trauma such as abuse tends to overactivate the system, increasing the risk of depression in adulthood. Of the people in the study who had a history of child abuse, those with certain genetic variations had only half the symptoms of moderate to severe depression of those who had more common variations in the same gene.

As you can see, either physical or psychological events can trigger—or prevent—clinical depression. Most commonly, both seem to be involved. But however it begins, depression can quickly develop into a set of physical and psychological problems that feed on each other and grow.

INSIGHT

You might think a person would know if he was depressed, but that often isn’t true. A person may gradually slip into a clinical depression without fully realizing how far down he’s fallen. If you’ve ever had a cold that gradually turned into bronchitis or pneumonia, you’ve experienced the physical version of this phenomenon. In fact, you may not have appreciated exactly how bad you felt until you felt better. Depression can be like that, too.

Bad Mood Busters

Whether you’re in a really bad mood or a major depression, you can do some things to help ride the situation out. Use these 10 depression buffers as a bad-mood buster or as add-ons to professional help.

INSIGHT

Sadly, no one can “cure” someone else’s depression, but you can say and do things that will help. Make sure they know you care, and that they’re not alone.

Avoid dismissing comments like, “It’s all in your head,” or, “Pull yourself together.” And don’t tell them you know just how they feel unless you, too, have really suffered from clinical depression.

Low-Level Sadness

When I was 25, I started feeling more and more fatigued over a period of six weeks. When I finally saw the doctor, she took one look in my ears and diagnosed an ear infection; after a few days of antibiotics, I was back to my energetic self. Dysthymia is like having a low-grade emotional “infection” that saps your mood, drains your energy, and can take away the pleasure of living.

Dysthymic disorder, or dysthymia, is a mild to moderate level of depression that lasts at least two years. It often causes changes in appetite and sleep, low energy, fatigue, and feelings of hopelessness. Even though this type of depression is mild, it’s like carrying around a ball and chain; you’re still able to do what you have to, but it sure makes it harder.

Up to 3 percent of the population in the United States suffers from dysthymia, which can begin at any age and seems to affect more women than men. Although the cause is unknown, there may be changes in the brain that involve the neurotransmitter serotonin. In addition, personality problems, medical problems, and chronic life stressors may also play a role.

The Post-Baby Plummet

Up to 70 percent of new mothers experience mood swings, tearfulness, and irritability for a few days to a few weeks after birth. However, as many as one in five women in the United States suffer from something much worse—postpartum depression.

Symptoms of postpartum depression, which typically occur within two weeks after birth but can occur at any time during the first year, include extreme fatigue, loss of pleasure in daily life, sleeplessness, sadness, tearfulness, anxiety, hopelessness, feelings of worthlessness and guilt, irritability, appetite change, and poor concentration. In addition, many postpartum depression sufferers describe difficulty bonding with their new baby and may develop fears of harming their infant.

The cause of postpartum depression is unclear and is likely the result of a combination of factors—hormonal vulnerability, lack of sleep, genetic susceptibility, and situational stressors. Some new moms are more at risk than others—women with a low income, young mothers, women with poor social support, and new moms with a prior history of depression. Babies contribute their own two cents; up to one third of new moms with a fussy baby report significant feelings of depression.

PSYCHOBABBLE

Between 3 and 8 percent of menstruating women suffer from premenstrual dysphoric disorder, a debilitating combination of depression, irritability, and tension that occurs between 5 and 10 days prior to the onset of menstruation each month.

Riding the Mood Roller Coaster

Bipolar disorder, commonly called manic depression, is a psychological disorder that affects about 1 percent of the population of every country in the world. And unlike major depression, men and women are equally likely to get it.

While all of us have “up” days and “down” days, individuals with bipolar disorder will be severely up sometimes, severely down sometimes, and in the middle some or most of the time. The hallmark of the disorder is the alternation between periods of mania and periods of depression.

INSIGHT

Check out Terri Chaney’s Manic: A Memoir, a fascinating look at the secret and horrifying illness that almost took her life.

The depressive end of bipolar disorder looks a lot like major depression. For this reason, the manic part of bipolar disorder determines the diagnosis. And when it first starts, it can be productive and fun. Imagine being in a great mood, full of energy and inspiration. The problem is, of course, the person can’t stay at that level forever. In a full-blown manic episode, the person may …

Cyclothymia is also characterized by mood swings from mania to depression. However, a person with cyclothymia experiences symptoms of hypomania but never a full-blown manic episode. Hypomanic symptoms are the same as the symptoms of a manic episode, but milder. A hypomanic episode doesn’t disrupt the person’s ability to function, doesn’t require hospitalization, and doesn’t include hallucinations or delusions.

Likewise, although depression is a part of cyclothymia, the symptoms never reach a clinically depressed level. For cyclothymia to be diagnosed, hypomanic and depressive symptoms must alternate for at least two years. Treatment depends upon the severity of the disorder—mild symptoms may respond to psychotherapy and more severe mood problems may require medications such as lithium or other mood stabilizers.

Moody Children and Terrible Teens

Childhood should be the happiest time of a person’s life. However, increasing evidence shows that mood disorders can develop in children, and occur more often in teenagers than the mental health community once thought. In fact, 7 to 14 percent of children will experience an episode of major depression before age 15; 20 to 30 percent of adults with bipolar disorder have their first episode before age 20, and an estimated 2,000 teenagers commit suicide each year.

INSIGHT

A teenager who isolates himself in his room and has deteriorating grades and few friends is not just going through a stage; he may be clinically depressed.

The major symptoms of mood disorders are the same in children and adults. Depressed children may be frequently tearful or irritable far beyond normal mood changes. They may seem unusually serious and lack the enthusiasm of their peers. And of most concern, they may make frequent negative self-statements (“I hate myself”; “I wish I were dead”) and do things that are self-destructive (such as hitting themselves).

However, children may also express their symptoms differently than adults. Because children don’t always have the words to accurately describe how they feel, they’re more likely to show you their suffering—via behavior problems—than talk about it.

Puberty may be a particular period of vulnerability for at-risk children; certain developmental brain changes may be biomarkers—specific traits—that make the brain more vulnerable to severe mood swings. While most of us think of moodiness and adolescence as two peas in a pod, some teens are not just going through “a stage.” A teenager who isolates himself in his room and has deteriorating grades and few friends may be clinically depressed.

BRAIN BUSTER

Most people who commit suicide talk about it first. Talking or joking about suicide, acting in a reckless or dangerous manner, giving away possessions, or expressing feelings of hopelessness are common signs of suicidal thoughts.

Getting the Best Treatment

The treatment of choice for depression depends on its type and severity. For major depression, two options, independently, work about equally well: a type of psychotherapy called cognitive-behavioral therapy (CBT) and an antidepressant medication. Together, CBT and antidepressants are the most effective weapon in the battle against major depression; they work for 80 to 90 percent of the clients who use them.

CBT is a type of therapy that focuses on the thinking that affects mood. CBT helps individuals with depression challenge the self-defeating thoughts (I’m worthless; I’ll never feel better; there’s nothing I can do about my situation) that either contribute to, or cause, their depressed mood.

In general, the more severe the depression, the more likely medication will help. Medications most often involve the commonly used selective serotonin reuptake inhibitors or SSRIs, such as Prozac, Paxil, and Zoloft. (The good news is these are almost impossible to overdose. The bad news is they often cause negative sexual side effects.) There are the tricyclic antidepressants—Elavil, Pamelor, and similar meds—which are cheaper but tend to have worse side effects, take longer to kick in, and can be overdosed.

Mood stabilizers are the treatment of choice for bipolar disorder, a.k.a. manic depression. Newer medications, especially anticonvulsants like Depakote or Tegretol, are showing promising results but are still used primarily when lithium isn’t effective.

INSIGHT

Moderate exercise (20 to 30 minutes a day) is increasingly being recognized as an effective tool to treat depression and also to prevent future episodes.

Feeling Anxious About Everything

Everyone experiences anxiety or fear in certain life situations, but 15 percent of the population has, at some point in their lives, experienced so much anxiety it disrupted their lives. When a person feels anxious or worried most of the time for a period of at least six months, she is suffering from generalized anxiety disorder. The anxiety might focus on a specific circumstance, such as unrealistic money worries or an inexplicable fear that a loved one will die or be injured. Or it might be a general apprehension that something bad is about to happen. For example, a person suffering from generalized anxiety disorder might start calling the emergency rooms if her spouse was late coming home from work.

In addition to the emotional discomfort, a person with generalized anxiety disorder is often tense, is easily startled, is unusually attentive to the cause or source of the anxiety, and may lie awake at night worrying. Over time, people who suffer from generalized anxiety disorder report fatigue and tiredness; they literally wear themselves out with worry.

INSIGHT

New research suggests that difficulty identifying and managing emotions may contribute to a person’s ongoing vulnerability to panic attacks.

Hit-and-Run Fear

People who’ve had panic attacks often say it feels like a train is bearing down on them at top speed and they can’t move out of the way. They know there’s no train, but their body responds as if there is; their hearts race, their mouths get dry, their blood pressure rises, and they feel as if something really bad is going to happen to them—or even that they’re going to die. These recurrent episodes of intense anxiety and physical arousal can last up to 10 minutes and often occur several times a month.

PSYCHOBABBLE

Although suicide is most commonly associated with depression, studies show that severe anxiety, especially when accompanied by panic attacks, often leads to suicidal thoughts.

Sufferers of panic disorder experience unexpected but severe bouts of anxiety, from out of the blue, at least several times a month. They can happen anywhere—during a romantic dinner with your spouse, at the grocery store, or in the middle of an aerobics class. And wham! There you go again.

Panic-Attack Pileup

As you might imagine, it wouldn’t take too many of these emotional whacks upside the head before you started worrying about when the next one will happen. One coping strategy is to avoid any place where they’ve had an attack, in hopes that this will reduce the odds of having another one. But that can lead to an even worse problem—agoraphobia.

INSIGHT

Panic disorder has a strong biological component and tends to run in families. For some reason, during a panic attack, the normal “fight-or-flight” response begins misfiring. Once it starts, the frightening physical symptoms snowball into a psychological nightmare, characterized by constant worry (“When will it happen again?”), catastrophic thinking (“What if I lose my mind?”), and self-doubt (“I can’t handle another attack”).

Shut in the House All Day

Individuals with agoraphobia experience anxiety in public places where escape might be difficult or embarrassing. They are controlled by the fear that if they panic or become frightened outside the home, they’ll either embarrass themselves or become paralyzed with their fear. As a result, they may gradually narrow their world until they literally become prisoners in their own homes.

Agoraphobia often starts out with random panic attacks. Maybe someone is shopping at the mall and has a panic attack. She leaves immediately and feels better. But the next time she needs to go to the mall for something, she starts to feel a little anxious. “What if it happens again?” a little voice whispers. Maybe she decides to go to a different mall, just in case. Everything is fine, but a few weeks later she has a panic attack there, too.

Over time, you can see how a person might become more and more afraid to venture out. After all, if a panic attack could happen anywhere, no place is 100 percent safe. At least at home no one will see it happen.

INSIGHT

Social phobia is a pervasive and ongoing fear of social or performance situations in which the person might either be under scrutiny from others (public speaking, speaking to authority figures) or around strangers (going to parties, striking up conversations, dating). The fear of embarrassment and humiliation can lead him to avoid having to face such situations.

Meet the Phobia Family

If your house is on fire or you’re being mugged, fear is a rational reaction. In contrast, a person with a phobia suffers from an extreme, irrational fear of something that creates a compelling desire to avoid it.

The five most common phobias are:

Approximately one out of eight Americans will develop a phobia at some point in their life. Some of those phobias gradually go away by themselves, and some of us just live with them unless they begin to disrupt our lives. For example, if you were considering a run for public office or were up for a promotion that involved giving presentations, a fear of public speaking—one form of social phobia—would be a real drag. On the other hand, if you’re a computer programmer, the fear of public speaking might be annoying but it wouldn’t necessarily kill your career.

Obsessive and Compulsive

You’ve just locked the door and gotten into your car to head to a movie. You’re running late, and you don’t want to miss the beginning. But just as you’re backing out of the driveway, a thought pops up. Did I turn off the stove? You mentally retrace your movements, and you’re 95 percent sure you did. But horrible images of your house in flames still dance through your head. Are you sure? What if your house burns down while you’re gone? So you run back into the house to check—or spend much of the movie wishing you had. If this kind of anxiety becomes excessive and leads to repetitive patterns of behavior, it might be a form of obsessive compulsive disorder.

DEFINITION

Obsessive compulsive disorder is an illness that traps people in endless cycles of repetitive thoughts (obsessions) and behaviors (compulsions) This could mean checking repeatedly to make sure the stove is off before leaving for work or washing your hands over and over after using a public toilet because of a profound fear of germs.

Kicked Out of the Club

OCD has a lot in common with the other anxieties—unpleasant feelings coupled with maladaptive and/or ritualistic coping strategies; however, it also shares many features of other disorders that are characterized by uncontrollable urges, such as hoarding disorder, trichotillomania (hair pulling), and excoriation (skin picking). As a result, with the release of the DSM-5, OCD is no longer classified as an anxiety disorder but obtained its own classification.

Let’s Stay Together

Stomachaches before going to school. A refusal to go to sleep without a caretaker within arm’s reach. Nightmares about being separated from a caretaker. While most parents deal with a clingy child from time to time, for parents with children suffering from separation anxiety disorder, the child is literally unable—or unwilling—to be out of a parent’s sight.

DEFINITION

Separation anxiety disorder, most commonly seen in children age 12 and younger, is a psychological condition in which the person experiences excessive anxiety when away from home or separated from people with whom the person has a strong emotional bond. It often starts after a traumatic event such as a move, death in the family, or hospital stay.

For the first time, in 2013 mental health professionals recognized that adults experience separation anxiety as well and it can be equally debilitating in terms of their occupational and social functioning. Like children, adults with separation anxiety disorder are often terrified that, in their absence, something bad will happen to a loved one. Unlike children, however, this can manifest itself in more sophisticated coping strategies. For example, partners of adult separation anxiety disorder may report that the sufferer is extremely jealous or demands excessive or constant reassurance from them. They may also structure their lives so as to avoid separation, something children can rarely do.

Overcoming Anxiety

Simple phobias are the easiest fears to treat. With generalized anxiety disorder, agoraphobia, and panic attacks, cognitive-behavioral therapy and medication are the first lines of defense. In addition to CBT, self-calming talk can be particularly effective with panic attacks, while behavior therapy aimed at gradually exposing the adult to separation from their loved one can be really helpful for separation anxiety disorder. Relaxation training is useful with all anxiety disorders.

The SSRI drugs are often used with OCD, but so are medications like Anafranil. Benzodiazapines like Klonopin and Xanax will help treat anxiety in the short run, but in the long run they can be dangerously addictive. Generally, they are used in conjunction with psychotherapy.

For simple phobias, chances of improvement are almost 100 percent if you stick with the treatment. The success rate for anxiety disorders is about 80 to 90 percent with full treatment. Because our awareness of adult separation anxiety disorder is so new, there are no good statistics on treatment effectiveness; between 50 and 75 percent of children with separation anxiety disorder see improvement after 10 to 20 sessions of CBT. Of course, these impressive therapy statistics are meaningless unless a person stays the course when the going gets tough!

INSIGHT

Helping fearful children face their individual fears may be the most effective strategy for reducing their overall anxiety. And for children who already have an anxiety disorder, cognitive behavioral treatment combined with antidepressant medication is most likely to help children with anxiety disorders, but each of the treatments alone is also effective.

I Can’t Throw It Away!

Three to six million Americans suffer from the overwhelming desire to acquire, save, and compulsively collect so much stuff that it literally takes over their lives. Compulsive hoarders are different from die-hard collectors or “clutter bugs” in that they can’t stop acquiring things or make themselves throw anything away.

PET scans of hoarders were found to have lower activity in a specific part of the brain that’s involved in decision-making, focused attention, and the regulation of emotion. These findings may pave the way for future studies on medication and other treatments that can increase the activity in this particular part of the brain and regulate the impulses that make hoarders save and acquire excessively. In the meantime, therapy offers hope on another front. Following 7 to 12 months of treatment, 50 percent of compulsive hoarders were well on their way to recovery.

While most of us haven’t been clinically depressed or anxious, we all know what it feels like to have the blues or to feel nervous, so we can relate to mood disorders. But in the next chapter, we’ll take a look at a mental illness whose symptoms—hallucinations, disorganization, delusions—most of us will never experience as we explore the fascinating, complex, and misunderstood condition known as schizophrenia.

The Least You Need to Know