Introduction
In the early 1800s as Blake wandered the drab lanes of London, his eyes met the face of depression at every corner. Depression stalked among merchants, seamen, and prostitutes alike, because depression impolitely ignored the proper boundaries of social class. Today, whether on Fifth Avenue in New York or at a community mental health center in rural Nebraska, mental health professionals encounter faces strongly reminiscent of those that William Blake described centuries ago. As in Blake’s time, depression masquerades in many costumes and clinical presentations.
As an illustration of this diversity, I remember working with a woman of about 40, who had been a successful interior designer. In the midst of a severe economic downturn, she found herself jobless. Her confidence and self-esteem were affronted with each passing day. Her belief in herself insidiously weakened as if she were an invalid who decided that there was no hope. Anxiety attacks punctuated her daily routine. Despite her pain she continued her frantic job search, terrified by each job interview. Her days became compacted cells of anxiety neatly delineated by bars of self-doubt.
How different this woman’s presentation appears when contrasted with a strikingly white-haired woman I met in North Carolina. Although only 50 years old, this woman’s face was branded by thick wrinkles. She had been extremely dependent on her father, a caricature of “Daddy’s little girl.” Following his death 4 months earlier, she had felt as if her skin had emptied. She was no longer whole. The sight of his face could not comfort her. His touch could not reassure her. She was brought into the hospital on an involuntary commitment. According to the police she had been found wandering a local cemetery with a butcher knife in hand. She related that her father’s voice was pleading with her to join him.
These people were obviously experiencing life very differently, yet both were suffering from depressive symptoms. I highlight this diversity of presentation to emphasize that depression, as well as bipolar disorder and other disturbances in mood, are not “things.” They are constantly evolving processes. Being processes, mood disorders become a way of living. They are unique for each individual and create damaging effects throughout the wings of each individual’s matrix.
Nevertheless, there are many similarities in the presentations of mood disorders that enable the clinician to recognize them despite atypical patterns. This dual capacity of mood disorders to appear both foreign and familiar provides the interviewer with the first inkling that sensitively uncovering mood disorders requires many levels of understanding.
As we have already noted, gifted intentional interviewers integrate the process of differential diagnosis with the continuous art of understanding, incessantly searching for the person beneath the diagnosis. Only when a patient feels the intensity of his or her clinician’s drive for such an understanding is it likely that the clinician’s help will be accepted, whether it exists in the form of psychotherapy, medication, or other interventions within the patient’s matrix.
To this end, in this chapter we will explore interviewing tips and strategies that will allow us to more deftly and sensitively perform a differential diagnosis regarding mood disorders. At the same time it will provide a sound introduction to the psychopathology and symptoms of these disorders.
In addition, by learning how to sensitively explore depressive and manic symptoms, you will be learning interviewing principles and diagnostic strategies that you can generalize to the differential diagnosis of other major psychiatric disorders (such as anxiety disorders, substance abuse disorders, eating disorders, and trauma disorders, which are not included in this book due to size limitations). Indeed, in the video modules at the end of this chapter, you will have an opportunity, if you so choose, to not only watch me utilize the interviewing techniques described in this chapter for exploring a major depressive disorder, but to also watch me utilize the same interviewing techniques to explore other disorders not addressed in this text (such as panic disorder and adult attention-deficit disorder).
This chapter on differential diagnosis will also provide us with yet another bonus of sorts, for as we explore the nuances of the psychopathology and the differential diagnosis of mood disorders, our explorations will bring us face-to-face with several complex everyday interviewing tasks (such as delineating an accurate history of the presenting disorder, taking a past psychiatric history, and uncovering a family history) that are of practical use in all initial assessments. We will also get a chance to address important cross-cultural issues inherent in the understanding of the differential diagnosis of mood disorders.
But before we can begin our exploration of differential diagnosis in this chapter, it is important that we first examine a topic that will be critical for our understanding of all of the diagnostic entities discussed, not only in this chapter but in the rest of Part II of this book. Specifically, we need to briefly address the principles of how diagnostic systems are designed, for how they are designed can create limitations in how effectively you and I can use them.
To understand these practical and clinical limitations – and the design elements that created them – we must focus our attention on some of the principles and terminologies that describe diagnostic design itself. I must admit that when I first encountered these concepts and terms (such as face validity, inter-rater reliability, categorical versus dimensional design) I found them to be somewhat abstract and off-putting. My goal in the following few pages is to create a quite different initial experience for you. I want to provide you with a simple, brief, easily understood, and enjoyable introduction to these pivotal concepts – an introduction that was not available to me. At the same time, I hope to do so with the appropriate level of sophistication that befits a well-trained mental health professional.
In the last analysis, our ability to do differential diagnosis sensitively and effectively will be directly related to the sophistication that we possess regarding the limitations of whatever diagnostic system we have chosen to utilize. A diagnostic system employed without a knowledge of its limitations is a diagnostic system that has the potential to do harm. By the end of the next few pages, I believe we will have the sophisticated knowledge that we need to avoid this trap. We will then be able to effectively use differential diagnosis to help kick-start the healing process.
Diagnostic Systems: There Has Never Been a Perfect One and There Never Will Be
The human brain craves understanding. It cannot understand without simplifying, that is, without reducing things to a common element. However, all simplifications are arbitrary and lead us to drift insensibly away from reality.
Lecomte du Nouy
Biologist, and author of Human Destiny
The Nature of the Dilemma for Front-Line Clinicians
Validity Versus Reliability
At its simplest, the “validity” of a diagnostic system is its ability to describe accurately the person or phenomenon it is delineating. Designers of diagnostic systems feel that highly valid systems are often the most useful in helping patients, for such diagnostic systems accurately capture the symptoms and problems that a patient is experiencing. Such an understanding can provide a sound framework for collaborative treatment planning and intervention.
At first glance, one would think that it would be best to always design a diagnostic system that is maximally valid. But there is a catch. Diagnostic systems that are extremely valid are not necessarily easy to use or even capable of being effectively employed in the real world of clinical practice, because they may require too much time to perform or be so complex as to hinder their acceptance by clinicians.
From this practical perspective, it is essential that a diagnostic system be constructed in such a fashion that different interviewers who interview the same patient will arrive at the same diagnosis, and in a timely fashion, a characteristic called inter-rater “reliability.” Without reliability, a diagnostic system is essentially useless in a clinical setting. Without reliability, a single patient could be given radically different diagnoses by different clinicians, either because the clinicians were confused by the too-numerous criteria or were not able to explore the criteria within the tight time constraints of everyday practice. Furthermore, with such difficulties in terms of definitions and diagnoses, clinicians could not effectively communicate with one another and research would also grind to a halt.
An ideal diagnostic system would exhibit extremely high validity and extremely high reliability, while simultaneously being easily completed in an initial interview and easy to learn. The problem lies in the fact that the requirements for validity and reliability are often conflicting and require different approaches. Specifically, they often demand an intentional change in interviewing technique.
Consequently, all diagnostic systems experience a tension between these two desirable traits. The more reliable a system, often the harder it is for it to be valid, and vice versa. An old metaphor may be helpful here: You don’t want to miss the forest for the trees. To use this analogy, the tension in designing diagnostic systems is often between gaining accuracy on all the trees (validity) versus simply and quickly identifying the overall nature of the forest (reliability). Truth be told, both are very important, yet neither can be completely maximized in any given diagnostic system.
Thus, whether one is using the DSM-5 (or a future variant) or the ICD-10 (or upcoming ICD-11), one is never using a perfect tool. But the designers of both of these systems have done their best to arrive at a compromise that can help guide collaborative treatment planning with the goal of relieving the greatest amount of pain in our patients in the fastest way possible.
Construct Validity, Face Validity, and Descriptive Essence
Validity, itself, is comprised of subtypes. For instance “construct validity” defines whether a diagnostic system appears to be constructed upon previously delineated clinical/design principles that are viewed as being useful by experts and clinicians and logically follow one from the other. A system with high construct validity should adhere to the best evidence base available at the time of development.
“Face validity” describes the degree to which a diagnostic system, or a specific diagnosis within a system, appears “on the face of it” to make sense. Do the diagnostic categories and their criteria fit with how patients with these disorders actually present in the real world of clinical experience?
It is to a special aspect of face validity that I want to now draw our attention, for it has direct ramifications as to whether a diagnostic system will be of immediate use to us during the interview itself. This aspect is a concept I call “descriptive essence.” A diagnosis will have high descriptive essence if:
1. As a clinician reviews the diagnostic criteria, the key characteristics of the diagnosis that delineate it from other diagnoses are immediately apparent. (In less technical terms: Do the real-life hallmarks of this disorder jump out at the reader as the diagnostic criteria are scanned?)
2. When an interviewer reads or hears the name of the disorder, the diagnostic label clearly suggests the essence of the disorder. (In less technical terms: Does this diagnostic tag seem to resonate with the symptoms of a typical patient presenting with this disorder?)
From a practical standpoint – and so from the viewpoint of an everyday clinician – descriptive essence is of immense importance. There are a great number of diagnoses and diagnostic criteria in both the DSM-5 and the ICD-10. It is critical that they are as easy to remember as possible. If the criteria seem to fit the fashion in which a clinician pictures people presenting with the diagnosis in question (the diagnosis possesses high descriptive essence), then it is much easier for the interviewer to remember what questions to ask.
Categorical Diagnostic Systems Versus Dimensional Diagnostic Systems
Categorical Diagnostic Systems
In a categorical diagnostic system, the items, phenomena, or behaviors to be classified are placed into discrete categories as one might expect from the name. Thus, the resulting disorders are qualitatively different from one another. In the DSM-5, for example, a patient’s behaviors and experiences are ultimately classified into discrete diagnostic categories (such as Schizophrenia Spectrum and Other Psychotic Disorders, Bipolar and Related Disorders, Depressive Disorders, Anxiety Disorders, and Personality Disorders).
Each diagnosis within a categorical system contains a set of criteria or an overall cluster of attributes that must be present for the diagnosis to be made. For instance, in the DSM-5 there are nine criteria for satisfying the diagnosis of a major depressive disorder (such as depressed mood, loss of interest or pleasure, and insomnia) of which five or more of the symptoms must be present for the diagnosis to be made.
Generally speaking, with a categorical system, if it is well designed the criteria have excellent descriptive essence, making them relatively easy to remember. Because the criteria are specific and easily recalled, the diagnoses can frequently be made relatively quickly. In addition, the more specific the criteria, the easier it is for different clinicians to arrive at the same diagnosis when interviewing the same patient. Thus, categorical diagnostic systems tend to have relatively high reliability, ease of use, and practicality in everyday clinical situations. If designed well, they will also show good validity. On the down side, it can be hard to design them well, and it is the validity that suffers.
Dimensional Diagnostic Systems
In contrast, dimensional diagnostic systems view phenomena, symptoms, and experiences as not being easily placed into discrete, unrelated categories. Dimensional systems take into account the difficulty of fitting shifting processes such as symptoms and behaviors – that do not have discrete borders – into tightly delineated diagnostic labels (as might occur in a categorical diagnostic system) and that doing so is inherently artificial in nature.
From this perspective, the complexity of a human behavior, personality, and psychopathology cannot be accurately portrayed by fitting it into a box of characteristics that are present or not present. Instead, it is more accurate (increased validity) to look at all of the individual behaviors, symptoms, and traits of a person, ascertain which characteristics are present, and subsequently determine how intense and frequent the characteristics may be. Dimensional systems even speculate that characteristics may vary over time and situation.
In a purely dimensional system, it is not so much that a person has (meets the criteria for having) such and such a symptom, experience, or trait, it is more that people vary on how much they display symptoms, experiences, and traits that are shared by most, if not all, people but not to the same degree. Thus, from the perspective of a classic dimensional system, all people can show anger, but this can range from appropriate anger to inappropriate rage and aggression as seen in an episode of dysphoric mania.
Dimensional systems often require an interviewer to survey a large number of experiences, behaviors, symptoms, and traits in great detail. Often these characteristics are ranked by number (or a severity level) as to how problematic they might be. Generally speaking, the more experiences, behaviors, symptoms, and traits a dimensional system delineates, the more accurate the resulting picture of the person will be (increased validity).
In my opinion, there is no doubt that a well-designed dimensional diagnostic system can result in a highly accurate portrait of a patient, more accurate than a comparable categorical diagnostic system can produce. There is also no doubt that, depending upon the number of characteristics a clinician is expected to explore and the extent to which the interviewer is expected to explore them, a dimensional system can be unwieldy and impractical.
A Pivotal Step Forward in the DSM-5
The DSM-5 remains a diagnostic system that is primarily categorical in nature for ease of use, but it is a system that has added important dimensional qualities. The addition of these dimensional qualities, in my opinion, is one of the most significant advances of the DSM-5 from its predecessor, the DSM-IV-TR. In essence, the DSM-5 has maintained the ease of use of a categorical system and yet has increased validity through the use of judicious dimensional criteria. The DSM-5 even offers an alternative, hybrid categorical/dimensional system (which emphasizes dimensionality) for delineating personality disorders that can be officially used in everyday practice if the clinician prefers a more dimensional approach to personality differential diagnosis.
Dimensional diagnostic characteristics allow one to paint a more individualized picture of a given patient’s experiences that better captures both the pain of the patient and the immediate impact of the symptoms on the patient and his or her functioning. The DSM-5 has accomplished this advance by expanding the “specifiers” that one can add to any specific diagnosis.
For instance, experienced clinicians know all too well that some people afflicted with obsessive–compulsive disorder (OCD) can develop obsessions that truly reach psychotic proportions (i.e., the patient is absolutely convinced that they have dangerous germs all over his or her hands and will die if hand washing is not done). This is, indeed, a very different individual to a patient with OCD who feels his or her fear of germs is not normal and wishes that he or she could stop the incessant hand washing for it is not necessary. In the DSM-IV-TR there was no way to paint this description accurately; in the DSM-5 the clinician can note whether the patient has one of three levels of insight: (1) good or fair, (2) poor, or (3) absent or delusional in nature. Naturally, the presence or absence of insight may have significant implications for both treatment and, equally important, methods for securing the patient’s interest in that treatment.
With regard to mood disorders, many specifiers can be utilized. It is beyond the scope of this book to review these in detail, but I urge the reader to become familiar with them, for they can help one to more accurately uncover the phenomena being experienced by the patient and communicate that distress more accurately to fellow clinicians.
By way of example, in the DSM-5, Depressive Disorders have the following specifiers: (1) with anxious distress (including a severity dimension from mild to severe), (2) with mixed features (allows one to include manic symptoms being concurrently experienced by the patient), (3) melancholic features, (4) atypical features, (5) psychotic features, (6) the presence of catatonia, (7) with peripartum onset (if the symptoms emerge during pregnancy or 4 weeks postpartum), (8) seasonal patterns, (9) the presence of remissions, and (10) severity (from mild to severe). In my opinion, the added dimensionality of the DSM-5 has given it an even higher “descriptive essence” than previous DSM systems.
Throughout the chapters on differential diagnosis in Part II of this book, the role of dimensionality will be addressed in those aspects where it can help us to provide better care through better diagnostic acumen. We will soon see that it can play a critical role in achieving a better understanding, recognition, and treatment of bipolar disorder in particular for, I assure you, not all people who have manic episodes experience them in the same fashion.
First Steps in the Differential Diagnosis of Mood Disorders
For the sake of discussion, let us assume that the material described in the following clinical presentations has been elicited after roughly the first 40 minutes of an initial interview. As the reader reviews this material, two points will become obvious: (1) all of these people are in significant psychological pain, and (2) all of them appear depressed. The next question facing the clinician is whether all of these people should be diagnosed as having a true major depressive disorder or some other mood disorder such as bipolar disorder or persistent depressive disorder (dysthymia). The following clinical illustrations will focus on the various lines of questioning that an interviewer might use to sort out this sometimes-difficult differential diagnosis.
In the first place, in order to diagnose accurately the clinician needs to be thoroughly familiar with the basic criteria of DSM-5. This familiarization does not mean that the clinician should obsessively memorize hundreds of criteria. On the contrary, this suggests a working knowledge of what material is necessary to clarify the major diagnoses. This diagnostic familiarization allows the clinician to focus on the art of eliciting the necessary material while successfully engaging the interviewee. The establishment of a sound therapeutic alliance, as usual, remains of paramount importance.
The diagnostic criteria for two of the most common depressive mood disorders in the DSM-5 are reviewed below.2,3 Later in the chapter we will be addressing DSM-5 criteria for other common mood disorders, such as bipolar I disorder, bipolar II disorder, and cyclothymic disorder. The DSM-5 defines major depressive disorder and persistent depressive disorder as shown below.
For the novice clinician, after reviewing the above criteria, the first step is to ensure that one can readily recall them during the interview itself, a task that can appear a bit daunting at first glance. Cary Gross at Massachusetts General Hospital coined a mnemonic for easily remembering the symptoms of depression, which was popularized by Danny Carlat in his outstanding primer on clinical interviewing.4 The mnemonic is based upon a well-known Latin abbreviation (“SIG”) found on all prescription pads for medication (prescribers write how the medication is to be taken, as with once a day or twice a day directly after the Latin word “SIG”). The idea is that the mnemonic represents a “prescription” for recalling the symptoms of depression. The mnemonic is as follows – SIG: Energy CAPSules. I find that for many prescribing clinicians, the acronym is easy to remember because of their familiarity with this abbreviation. Interestingly, for many non-prescribing clinicians it is equally easy to remember for the exact opposite reason, its oddness. See what you think. Each letter represents one of the classic symptoms of a major depression as follows:
Sleep disorder (either increased or decreased)
Guilt (worthlessness, hopelessness, regret)
Appetite disorder (either decreased or increased)
Psychomotor retardation or agitation
Let us now proceed to our clinical presentations, for no one can better teach the nuances of depression and bipolar disorder than the people experiencing their destructive power. Note that, as in the rest of this book, all patient names are fictitious.
Clinical Presentations and Discussions
Clinical Presentation #1: Mr. Evans
Mr. Evans is a 61-year-old White single man who retired from a prestigious administrative job at the police department 1 year ago. He is accompanied by his fiancée. With her help he hopes to open a bar in the next 6 months if they can get a liquor license. Mr. Evans is well groomed and dressed in a simple flannel work shirt and corduroy trousers. He appears very sad and relates, “It seems strange, but I can’t really cry.” He speaks softly and slowly, taking a while before answering questions as if the act of thought required immense effort. On occasion, he tries to manage a smile. His eyes study the floor, seldom meeting the eyes of the interviewer. His fiancée chimes in, “Nothing cheers him up. Lord knows, I try. But nothing.” Mr. Evans complains of severe depression, of not being able to enjoy anything, sleep disturbance, loss of appetite and libido, and severe loss of energy. In the past 3 weeks he had held a loaded revolver to his head on several occasions. He spontaneously reports seeing no future. Before she left the room, his fiancée, although obviously concerned, appeared to be somewhat irritated and commented to the interviewer. “He just won’t help himself no matter how much I try to help him. Now I’ve got to meet with the Liquor Control Board agent alone next week.”
Discussion of Mr. Evans
The Painful World of Anhedonia: Its Role in Diagnosis
Major depressive disorders are common. In any given year in the United States about 7% of the population will meet the criteria for a major depressive disorder. Generally speaking, beginning in adolescence, females experience a 1.5- to 3-fold higher rate of depression. Interestingly, there is also a marked increase in prevalence in adolescence and young adulthood, with 18–29 year olds having a threefold higher rate of major depressive disorder compared to individuals 60 years and older.5 It is a disorder not to be taken lightly, for up to 15% of patients with this disorder die by suicide.6
Mr. Evans demonstrates many of the classic symptoms of a major depression. In the first place, Mr. Evans states clearly that he has a persistently depressed mood, thus fulfilling one of the first two symptoms of criterion A needed for a diagnosis of major depression in the DSM-5. It is important to note that one does not need to feel “depressed” to fulfill criterion A, because one needs the presence of either Symptom A-1 or Symptom A-2 for making a diagnosis of a major depressive disorder.
You will recall that Symptom A-2 reads “Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.” Symptom A-2 is essentially an undeclared definition of anhedonia. The word “anhedonia” is a derivative of the Greek word “hēdonē,” referring to pleasure, as also seen in the English word “hedonism.” In anhedonia, one demonstrates a decreased ability to experience or to anticipate pleasure or to develop interest. This alteration in the experience of pleasure is a common symptom of depression warranting a careful search in the initial interview.
One of the ways in which to sensitively explore anhedonia is to discover first what types of activities the interviewee enjoys in general, as we saw in our discussion of the “wellness triad” from Chapter 6. Questions such as the following may be fruitful for setting up such an exploration:
a. “What kinds of things do you like to do when you’re away from work?”
b. “In the past, have you generally enjoyed your work?”
c. “Do you have any types of hobbies or sports you enjoy?”
d. “Do you enjoy reading or watching TV?”
e. “Do you like surfing the web, looking at YouTube or online gaming or shopping?”
f. “How much time do you spend on social media like Facebook or Twitter?”
Often I will spend considerable time exploring these interests further, because they can provide important insights to the clinician about the person’s viewpoints and psychological integration, as seen, for instance, in the following:
Clin.: Do you enjoy reading or listening to music?
Pt.: I used to enjoy reading quite a bit … sort of odd stuff … (tiny smile) … like St. Augustine, Thomas Aquinas, and other theological books.
Clin.: Sounds like pretty heavy reading?
Pt.: Yeah, it is. But I used to enjoy it. (pause) … I used to be fairly religious … used to be (said with a trailing off of the voice).
From this dialogue it appears that religious themes may be important issues for this patient, perhaps contributing to his depressive anxiety or perhaps offering potential resources for healing. This questioning has not only laid the groundwork for the exploration of possible anhedonia, but it has also served the dual function of gathering pertinent intrapsychic material about the spiritual wing of the patient’s matrix, while further engaging the patient. At this point one may continue the search for anhedonia with questions referring to the groundwork laid above.
a. “Over the past several weeks have you felt like doing these activities?”
b. “Do you find it as enjoyable to do these things as you used to or has there been a change?”
c. “Have you been feeling interested in your hobbies over the past several weeks?”
At times, interpersonal questions can uncover anhedonic complaints, as evidenced by the following:
Clin.: You mentioned your grandchildren. Do you have a good time when you’re around them now?
Pt.: (sigh) Sort of … Don’t get me wrong, I love my grandchildren, but I just can’t seem to enjoy anything anymore, even them.
Uncovering the Neurovegetative Symptoms of Depression
What Are the Neurovegetative Symptoms of Depression?
Mr. Evans appears to be suffering from many of the neurovegetative symptoms of depression. Although it is difficult to find a standard definition of neurovegetative symptoms, I view them as symptoms suggesting that basic regulatory physiology has been disturbed. With such a definition in mind, in addition to anhedonia, the neurovegetative symptoms can be listed as follows: change in appetite, change in weight, sleep disturbance, change in energy, change in libido, altered concentration, and retarded or agitated motor activity. Although not always labeled as neurovegetative symptoms, other common physiologic correlates of depression exist including constipation, dry mouth, and cold extremities.
The neurovegetative symptoms are classic hallmarks of a major depressive disorder, fulfilling many of the symptoms in Criterion A for this disorder in the DSM-5. If they are not elicited spontaneously, they should always be actively sought. When done properly, such questioning powerfully engages the interviewee. It shows the interviewee two reassuring characteristics: (1) that the interviewer is interested in the individual as a person whose depression affects every aspect of his or her life, and (2) that the interviewer is knowledgeable, as witnessed by the fact that the questions seem right on the mark.
Tips for Exploring Early Morning Awakening and Other Sleep Disturbances
Sleep disturbance warrants a thorough discussion. Part of the lore of psychiatry has been that people suffering from major depressions often display early morning awakening. The exact frequency of this phenomenon is not entirely clear, although there is good evidence that both feeling worse in the morning and early morning awakening are frequently present in depressive episodes. As we shall see later, in one type of severe depression, melancholic depression, both of these symptoms are quite common and quite severe.
However, in my experience, early morning awakening of a milder, yet still disturbing nature, is common in major depressive disorders of even a mild to moderate severity. The symptom of early morning awakening often has a distinctive phenomenology.
It is not just that patients awaken earlier than they would like. It is that patients feel as if they are abruptly awakened by a steady stream of unpleasant worries. They find it extremely hard to shake these frets. Once one fret is gone, a new one appears. The worries are often accompanied by a growing feeling that the prospective problems of the day are insurmountable. It is very difficult to fall back to sleep, despite staying in bed. One of my patients, a physician, elegantly captured the pain as follows:
It’s literally one worry after another. Frankly, the sensation is almost more like fear than worry. You just know you can’t cope with everything you’re supposed to do that day. It’s simply overwhelming (patient tears up). You just lay there and toss and turn. You absolutely do not want to get up, because then you know that you have to start the day. On the other hand, you’re miserable lying there in the bed (he pauses). What a horrible feeling, what a mess. I wouldn’t wish it on anyone. And, you know, the really funny thing about it is that it usually gets better as the morning goes on once I get up. I don’t know why I just don’t make myself get out of the bed because there is no way I’m going to get back to sleep.
I have found the following questions to be useful in spotting early morning awakening:
“Do you find yourself sort of jolted out of your sleep in the mornings by worries and frets, and you can’t get back to sleep?”
“Do you find yourself waking up earlier than you want to and your mind is filled with worries and you just dread getting up, you just don’t feel you can face the day?”
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