Introduction

In this chapter, we will search for a more sophisticated understanding of how a mood disorder is experienced by a patient in each wing of the patient’s matrix as first described in Chapter 7 on treatment planning. For the sake of conciseness we will collapse the matrix into the following five wings: biological, psychological, dyadic, familial/societal, and worldview (as reflected in the patient’s spirituality and framework for meaning). We will begin with the very smallest system of interaction – biological – and move outwards through progressively larger systems. We will see how these disorders create damage, and trigger core pains, throughout the wings of the patient’s matrix from biological and psychological disruptions to the damage done to the patient’s family, friends, workplace, spirituality, and worldview.

Because there is no time to explore all of the mood disorders, we will focus, specifically, upon the symptoms of depression, using depressive symptoms as a prototype through which we might better understand these damaging matrix effects in other mood disorders, indeed, in all psychiatric disorders. We will see how each depressive symptom is experienced uniquely by the person beneath the diagnosis, for every depression is a unique one.

I also believe that in order to effectively uncover psychiatric symptoms, it is critical to understand how patients experience these symptoms personally, in a phenomenological sense. As we shall soon see, this empathic familiarity on the part of the interviewer, if present, is quickly recognized by patients, resulting in a markedly more pronounced sense of safety. From the clinician’s questioning, it becomes clear to the patient that this interviewer has seen these symptoms before, often many times, and respects their complexity and nuance.

The more an interviewer understands the concepts explored in this chapter, the more open the interviewer will be to the subtle clues suggesting depression in an initial encounter, thus decreasing the likelihood that a depressive state will be missed or its severity underestimated. Simultaneously, this understanding helps the clinician to better phrase his or her questions in a fashion that empathically resonates with the patient, enabling the patient to share the intimate details of their pain more readily, including suicidal ideation and the other harsh realities left in a depression’s wake. From this understanding, interviewers enhance their sensitivity, their clinical acumen, and their ultimate engagement with patients. The interview is, at once, both more human and more clarifying.

At another level, our more sophisticated understanding of the human matrix will emphasize the sometimes-overlooked fact that interviewers – whether they want to or not – will, by their very presence, become a subsystem touched by the patient’s depression. The interviewer will both affect and be affected by the depressive processes being explored. Awareness of this fact can lead to important insights in intervention. Blindness to this fact can lead to short-sighted conclusions and misplaced interventions. With these ideas in mind, our exploration begins. At its conclusion, hopefully we will have a truer understanding of what it is like to be at a place where:

… all the wide horizon’s line is hid

By a black day sadder than any night.

As one enters the room occupied by a person experiencing depression, the physiologic ravages of the process are often disturbingly apparent. In a severely depressed person the initial glance may reveal unkempt hair, ragged or mismatched clothes, dirty nails, untied shoes, and a vacant look to the eyes. More striking may be the slowness of movement and the person’s lack of responsiveness. It may take a few seconds or longer for the depressed person to acknowledge the interviewer, if such acknowledgment occurs at all. In a similar manner, more subtle decrements in responsiveness may be the first clues of a milder depressive state. Thus, the interview begins with the first look, before any words are uttered.

The slowness of movement probably parallels the disquieting sensation of heaviness often reported by depressed people. Depression, as Baudelaire suggested with his line, “When the low heavy sky weighs like a lid …”, often feels like a heavy shawl weighing down upon the patient’s shoulders. As noted in the last chapter, the arms and limbs of the patient may feel weighted down, a sensation called “leaden paralysis” in the DSM-5. This abnormal sensation may be related to the powerfully intense sense of inertia that can accompany depression. It becomes distressing for the depressed person to initiate movement; it seems so much easier to simply rest. A young woman with a depressive disorder vividly describes this phenomenon:

It is so strange. Depression is exhausting in a physical sense. You know, most people have chores they have to do just to keep their lives going. And if the chores are waiting for you, and you sit there and look at them, they just seem overwhelming. And I could easily sit for 2 hours in a chair just looking at some clothes I left on the bedroom floor and not be able to motivate myself to pick them up. My body just feels heavy, as if it wouldn’t want to respond unless I absolutely forced it to … Hmm … You know it is actually almost as if your brain lost half of its ability to control your body in the sense that even making a decision to pick something up required so much energy that you don’t want to make it. You feel like it couldn’t possibly be worth it. I just want to vegetate.

This sensitive excerpt brings up another important point with the opening comment, “It is so strange.” Depressed patients, at times, present a peculiar dichotomy in the manner in which they cognitively and affectively experience their profound condition. On a cognitive level, they often feel they are the root of their problem, their speech becoming an entangled web of self-recrimination and belittlement. They cognitively experience their depression as being actively caused by their own flaws. Simultaneously, they emotionally experience the depression as coming on them or over them from an outside source. In a sense, they feel invaded and violated. They feel they are the passive recipients of a phenomenon that they do not understand or control. This incipient “loss of control” presents a terrifying threat to their sense of ideal self. Jaspers, with a single word, captures the pith of this process when he describes depressed patients as experiencing a physical and emotional “ossification.”²

At present, the etiologic meaning of such radical changes in movement and body perception in the patient’s biological wing remains unclear. Such changes may represent a variety of damaging inter-wing matrix effects: psychological defenses to withdraw the patient from painful external circumstances, social indicators that the person needs help, cultural attempts to withdraw a malfunctioning person from a potentially dangerous environment, or spiritual angst revealing itself as the need to withdraw from a meaningless world. Or they may be caused by a direct intra-wing matrix effect being the direct results of a primary biochemical imbalance. Any combination of the preceding factors is possible. No matter what the etiology of these phenomena, they create frightening experiences for anyone suffering from a depression. In essence, even patients’ bodies become strangers to them – one more step toward their intense sense of isolation.

The other neurovegetative symptoms also represent an array of biological markers of depression. Baseline energy withers. Appetite and libido dry up as if parched by the intensity of the process. These feelings of altered functioning can become immensely disturbing to patients, sometimes being perceived as further evidence of their personal failure. With these phenomena in mind, questions such as the following may add depth to the interview:

As well as allowing patients the chance to ventilate, these questions emphasize that the interviewer is interested in them as unique people whose depression they alone can explain.

Before leaving the biological field, I would like to briefly describe some of the biologic ramifications of an agitated depression. Here too there exists a peculiar dichotomy, as described by an elderly male patient in response to a question about losing energy, “I don’t know exactly what you mean, but yeah, I’ve got energy all over the place, driving me constantly, but no, I don’t have any sustained energy to do anything.” The result in an agitated depression is often an inability to begin tasks, the patient being disabled by the frenzy of his or her own agitation.

Note the difference between the disorganized energy seen in an agitated depressive episode when compared to the organized energy frequently seen in a patient experiencing a dysphoric mania as described in the last chapter. Although the patient with a dysphoric mania may not successfully complete many tasks, they are compelled to try them and initially may approach them with a remarkably well-organized drive. As opposed to the almost frantic inertia seen in a patient suffering from an agitated depression, a patient with a dysphoric mania may develop and initiate surprisingly intricate and well-developed plans of action with regards to self-harm, suicide, and violence to others.

Returning to depression, in an agitated depressive state there exists a nagging need to move. The energy is unbridled and disobedient. Consequently, the body tends to assume an incessant display of “bad nerves.” Hands wring each other in a frenzy of confusion. Fingers pick at the body or pluck the clothes. Sitting becomes an act of will power. From deep inside the legs there erupts a need to move. Pacing becomes a necessary method of release as natural as breathing. Especially when the patient is experiencing a depressive episode marked by melancholia, this agitated state may appear worse in the morning. In the interview it can be revealing to ask, “What part of the day seems worse to you?” It is important to remind oneself that a relatively calm patient interviewed at 4:00 P.M. may have looked remarkably more agitated at 8:00 A.M. Depression nags the body with an intermittent voice.

The Psychological Wing of the Matrix

Depression has a calling card. This calling card consists of a distinct set of changes that occur within the mind of those experiencing the depression. Not all depressed people experience these feelings, but many do in one combination or another. Four broad areas are touched by depression and will be the focus of this discussion: (1) perception of the world, (2) cognitive processes, (3) thought content, and (4) psychodynamic defenses. An understanding of the above processes can increase the ability of the interviewer to recognize the subtle clues of depression and can increase empathic abilities, as well.

1. Depressive Changes in How the World Is Perceived

Concerning the perception of the world, depression alters both the sense of time and the size of the world actively engaged. In a person experiencing a severe major depressive episode, the concept of current or future change frequently appears conspicuously absent. A mantle of flatness suffocates spontaneity. Moment-by-moment existence seems void of any chance of alteration. Without this feeling of possible change, time passes arrogantly slowly. In a literal sense, time passes painfully.

Such a state of psychic monotony can have a curious effect on the interviewee’s perception of the future. In effect, if change does not exist, then the future is essentially meaningless. All days are merely replicas. Our sense of the future is partially dependent upon our sense that the future may be different. To the depressed interviewee, the future is draped in a radically bland light. This perception may be one reason why depressed people often appear unmotivated. Without a perceived future why should they attempt change? This phenomenon has been described by the phenomenologist Eugene Minkowski as a “blocking of the future.”³

The second alteration in world perception does not involve time. It revolves about space. The “active world” of the depressed person undergoes a profound alteration. By “active world” I refer to that part of a person’s environment that he or she remains interested in engaging. In depression, the active world shrinks. The patient’s sense of space gradually vanishes creating a “cataract of the mind.” This shrinking of the active world can powerfully short circuit environmental reinforcement and reward. The depressed person becomes a behavioral isolate. The woman quoted before elegantly depicts this process.

I’m so focused inward … When I feel depressed it is such a great pain, and I am paying so much attention to it trying to control it, that I walk down the street and really don’t see much at all … I screen out other people because I don’t want to interact with others … I probably miss a lot. Even in the sense that I can walk down the street where I work and there can be roses blooming. And if I am really depressed, I don’t even see them. And I love roses. Whereas, if I am feeling better, even despite the smell of the buses running around, I will still smell the roses. And I will admire them …

It can come as quite a shock to the interviewer to realize that the interviewer may not be a feature of the interviewee’s active world. To engage such patients, the clinician needs to enter their world as best as possible. Consequently, the interview with a severely depressed patient may require a change in style. At times, the clinician must be more active while also accepting, with patience, the interviewee’s difficulty in responding.

The Window Shade Response

In an even more striking example of the patient’s need to consciously shut out the world, there is a specific sensation that sometimes plays a role in the shrinking of the patient’s world. To me, the phenomenon appears to be fairly unique to withdrawn depressive states, and it is not reported by patients with agitated depressions or anxiety disorders. I have found it to be a surprisingly reliable marker of the presence of a moderate to severe depressive episode.

It is a phenomenon perhaps related to the well-documented tendency of depressed patients to withdraw to their beds for much of the day. When patients seek out their beds, if they sleep, it is a fitful sleep at best. In point of fact, I find that they are seldom returning to their beds primarily to sleep. Instead, they are returning to their beds because they can shut their eyes while in their beds, for it is the natural place in our culture where it is acceptable to shut one’s eyes. With the closing of their eyes, they have effectively shut out the stresses of their world. The result is a desperately needed and immediate sense of relief. Sometimes severely depressed patients will actually draw their bed sheets over their head, an action often paralleled beforehand by the pulling down of the window shades so as to darken the room and further isolate themselves from the outside world.

And here we can see the connection with the uniquely depressive phenomenon that I hinted at above. Specifically, patients coping with depression not infrequently feel a need to shut their eyes, even while standing or walking about. It is as if the depressed patient is escaping the world by pulling down the ultimate window shade – their own eyes. Sometimes this need to shut the eyes is almost overpowering.

This “window shade response” was poignantly described by a particularly articulate lawyer, who first introduced me to the phenomenon. I have since found it to be common in moderate to severely depressed patients. He described it as follows. Note that he too, as with the patient above, emphasizes the “overwhelming” sensation experienced when depressed:

Sometimes the world is so overwhelming to me. It is mind-boggling how overwhelming the simplest of things is … I don’t want to see or talk to anyone. It is almost painful, and yet it sounds so silly. I’ll tell you another thing that is really interesting, it’s almost weird. When I’m depressed, I will find myself almost compelled to shut my eyes.

It is so odd. It is not a desire to rest or sleep, it’s not sleepiness. I just want to shut everything out. As soon as I shut my eyes, I feel some relief. And I just don’t want to open them and face the world again … It really feels like I’m driven to do it, because the relief feels so good … It can come over me, and that’s exactly what it feels like, like the urge to shut my eyes is somehow coming over me, almost against my will, almost any time when I’m really depressed.

During this last depression, I forced myself to keep up with my morning walks before work, which I’m really proud I did. It was tough to do, but I’m glad I did it. But here’s the strange thing. I’d be walking on the old dirt road up behind my house through a beautiful woodland and I would feel compelled to close my eyes while I was walking. And I did! I would do it for several paces intermittently. I didn’t even want to see the woods around me. I didn’t want to see anything. It’s hard to believe that several hours later, I’d be in court trying to do my best for my client. If they only knew what I looked like just 3 hours earlier.

To uncover the “window shade response” I have found the following question to be useful:

“When you’re really depressed, do you sometimes have an intense desire to just shut your eyes? It seems almost odd to you how strongly you want to shut your eyes, to just shut the world out?”

I think you will find the presence of the window shade response to be a surprisingly reliable marker of a moderate to severe depressive state in the interviewee. As I noted above, in my experience, it does not appear to be present in patients experiencing a pure anxiety disorder such as a generalized anxiety disorder or obsessive–compulsive disorder. In addition, it is very engaging to inquire about the phenomenon, for depressed patients are often surprised that you are familiar with the sensation.

2. Cognitive Changes Caused by Depression

Changes in the Flow of Thought and Ideational Caging

A second broad area of alteration concerns changes in the cognitive processes of the depressed person. In a melancholic depression, the thought process slows, as if the stream of thought were frozen by an unexpected drop in temperature. In contrast, in an agitated depression thought races, as if the same stream had sustained a turbulent boil. In both cases, the thought process becomes disjointed. Concentration becomes annoyingly elusive.

Besides these alterations in the speed and flow of thought, depression creates an ideational caging. The term “caging” suggests that the mind becomes trapped within a small network of limiting themes. Such depressive rumination can lock the depressed person into worries about the past, the present, or the future. Once within the cage, the depressed patient has great difficulty attending to new and perhaps therapeutic influences. In the interview, caging may demonstrate itself as a frustrating tendency for the patient to return to a specific topic. Or, alternatively, the patient may repeatedly ask the same question, despite the interviewer’s reasonable reassurances.

Such caging can seriously block an interview. One method of trying to circumvent it consists of attempting to acknowledge it while simultaneously refocusing the patient, as illustrated below. This strategy may look familiar, for it is one of the strategies that we examined in Chapter 3 for effectively transforming “wandering interviews.” In this interview, the clinician had done an excellent and sensitive job of providing the patient a chance to ventilate and describe her financial concerns. When an effort was made to learn more about her depressive symptoms, the patient would not move on.

Clin.: Mrs. Jones, can you tell me a little bit about the effect of all these troubles on your sleep?

Pt.: Sleep, can’t sleep … (pause) can’t sleep because of the bills. I just know we won’t be able to pay the bills. Oh God, my children, we’ll be ruined.

Clin.: No question about it, the money situation needs to be addressed. I’m also trying to figure out more about your depression too, it’s also a big problem for you right now. It might be even making it harder to fix the money situation. The reason I’m trying to learn more about your sleep is that it will help me to understand more about your depression and what type of medications might help you the most, that’s why I’m asking you about it. For instance, how long has it been taking you to fall asleep?

Pt.: I don’t know, all I think about are the bills. I know that somehow I’m to blame. What will we do? What will we do! Somebody has got to help.

Clin.: Mrs. Jones, I know it can be really hard to not talk about your financial concerns, and we’ll spend a lot more time doing so later; but, you know, in order to help you, I think I need to learn more about what your depression has done to you and what it feels like to you. To help us stay focused, I’m going to ask you some important questions, and if we get sidetracked I will pull us back to the question. It will help us figure out which of your symptoms we can help you with as fast as possible. Once again think carefully, how long is it taking you to fall asleep? (the preceding is said with a calm but firmer tone)

Pt.: It’s bad, real bad, maybe 2 or 3 hours; I just can’t fall asleep. My nerves are shot.

Clin.: Can you stay asleep or do you keep waking up?

Pt.: Stay asleep! I wish. God knows. I can’t ever get a good night’s sleep. Ever. Ever.

With proper timing, such an intervention may open a cage. At other times, the caging of the patient will not yield despite the interviewer’s best intentions.

Cognitive Distortions as Conceptualized by Aaron Beck

Aaron Beck, one of the founders of cognitive psychotherapy, has delineated many specific cognitive impairments in depression. Beck has pointed out that depressed patients may over-generalize, with statements such as “Everything has fallen apart” or “No one cares about me.” They can exaggerate, in essence creating the proverbial mountain out of a molehill with a statement such as, “My boss Mr. Henry looked angry. He’s dissatisfied with me. I’m sure it is only a matter of time until I’m fired.”

They also have a tendency to ignore the positive. For instance, a businesswoman confused me with the following statement, which illustrates this principle: “It’s the best Christmas season we’ve ever had. We’re really selling books all over the place. But I set myself a remarkably high quota. If we don’t meet it, I will have failed miserably as a manager.”

Beck has also described a trio of distortions – the cognitive triad – that frequently appears in depression: (1) negative view of the world, (2) negative concept of the self, and (3) a negative appraisal of the future.⁴

First Distortion in Beck’s Triad: Negative View of the World

This negative view of the world is partially generated by the tendency of the depressed patient to continually validate his or her depression. The patient speaks as if he or she had placed a negative filter over his or her eyes, as witnessed by the following taped comments:

When I’m really depressed every negative, every unpleasant thing that I could possibly think of that might be happening to another person like someone being hit by a car or someone getting cancer or a dog being injured will trigger personal fear and worry that the world is bad. And so the depression has no justification to ever lift because everything about life is horrible. It’s all just proof that depression is reality just looking itself in the face …

Second Distortion in Beck’s Triad: Negative Self-Concept

With regard to negative self-concept, the tendency to assume self-blame may be a major contributing factor. I do not think I have ever seen this quality as strikingly portrayed as in The Bob Newhart Show, a show whose re-runs are still quite popular with mental health professionals. In this show, Newhart plays a psychologist with a client named Mr. Herd who epitomizes the self-blamer. A typical exchange might be as follows:

Dr. Newhart: (after entering the office) I can’t believe it, I left my wallet at home.

Mr. Herd: I did it … You were worried about me and forgot your wallet over me … I’m sorry, I’m really sorry. I won’t let it happen again.

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