Sunday, May 10, 2009

Depression and the Shackles of Shame

There is no blood test for depression, no x-ray nor sonagram.  Depression is the label that is given to a constellation of symptoms.  There are theories about the cause of the symptoms.  But the diagnosis is more like tea leaves. 

Depression Diagnostic Criteria 

· Lasting sad, anxious, or empty mood
· Loss of interest or pleasure in activities once enjoyed, including sex

· Feelings of hopelessness or pessimism
· Feelings of guilt, worthlessness, or helplessness
· Decreased energy, a feeling of fatigue or of being “slowed down”
· Difficulty concentrating, remembering, making decisions
· Restlessness or irritability
· Sleeping too much, or can’t sleep
· Change in appetite and/or unintended weight loss or gain
· Chronic pain or other persistent bodily symptoms without physical cause
· Thoughts of death or suicide, or suicide attempts

If you have five of the above, including one of the first two, for more than two weeks, and without appropriate reason (like, your mother died) then that's depression. You've got the Grim at the bottom of your teacup. 


I have done enough intake interviews that I recognize the differential diagnostic tree when it's coming at me. I used to get nervous when they asked about guilt. No, I don't actually feel guilt, except appropriate guilt for recent misbehavior, not the horrible self-judgment for imagined offenses. I don't feel guilty for my depression. I am not the offender but the offended.


No, what I feel about my depression, and events that are related, is shame.  And what I really feel shame about is feeling shame.

We don't do shame in this country.  I have heard there are guilt cultures and shame cultures, and that the United States is a guilt culture.  Places like Japan and Iran are shame cultures.  "You should be ashamed of yourself" -- people aren't supposed to say that here, because shame is bad, and making people feel ashamed is bad.

Yes, it is bad. I know, because I do feel shame, and it's not pretty.  I know it's not logical.  "You shouldn't feel ashamed" -- that's something else people say.  So I do something that I shouldn't, feel ashamed, which is why I am ashamed of my shame.

Research On Shame In Depression

And I get nervous when my shame is at risk of being discovered, like in an intake interview. I get nervous, but I needn't.  They never ask.  They don't ask, because it is not part of the diagnostic criteria for depression.  It's over in another branch of the tree that we aren't exploring.

So I was curious to discover a study about shame, guilt and childhood psychological mistreatment that says:

1) Shame and guilt together are positively associated with depression.
2) Guilt without shame is not positively correlated with depression.
3) There are other studies that indicate shame is associated with poor psychological functioning, but guilt isn't.

Huh?  Then why is guilt one of the diagnostic criteria? And why isn't shame?

Actually, I am glad that it isn't, because I don't want to talk about it.

Which brings me to another article about shame, reporting a review of the literature by A. Hook and B. Andrews, which includes:

1) Shame is associated with the onset and course of depression, especially recurrent and chronic depression.
2) Shame is a major reason why clients withhold information in therapy(nearly 75% of the time).
3) Withholding information, especially about symptoms, is associated with poorer outcomes in therapy.

All of which seems perfectly obvious.  What is not obvious is why shame is not one of the symptoms of depression.  Actually, I am glad that it isn't, because I don't want to talk about it.
photo in public domain and modified
reformatted 11/27/10

Saturday, May 2, 2009

Thank You For Being My Friends

Try this experiment on yourself.  Imagine that you are standing at the base of the hill.  What do you see, smell, hear?  Put yourself in this picture.  Are you with anybody?  If so, who is it?  What is your relationship like? 

Now, tell me. How steep is the hill?  Really steep?  Sort of steep?  Not so steep? 

Friends And The Perception Of Difficulty 

Researchers at Plymouth University in the United Kingdom and the University of Virginia in the United States conducted similar experiments with college students, examining the effect of various factors on the perception of obstacles.  They asked participants to estimate the degree of the incline, (a more precise measurement than I asked from you.)  Those who had a friend standing nearby, or imagining a friend estimated the slant to be lower than those who had a neutral person or enemy nearby.  Current mood and physical condition, by the way, had no influence on their estimates.

These findings are reported in the April 21, 2009 New York Times article, "What Are Friends For? A Longer Life"  The physical benefits of friendship have been documented among breast cancer and heart patients.  Friends increase longevity and brain health, even decrease your incidence of colds.  A regular reader of Prozac Monologues, a friend of mine, brought the article to my attention.  And I am pleased to bring it to yours.

Recovery, Not Remission 

I used to pursue remission of my depression.  With each relapse I felt like a failure and was terrified of a return to the scariest symptoms.  Recently I have been learning about NAMI, the National Alliance on Mental Illness.  NAMI focuses on recovery, by which they mean management of symptoms, a process of moving beyond the limitations of the disability. 

Recovery is different from the medical focus on remission, the elimination of symptoms.  In my case, we can't find a medication that eliminates my symptoms without intolerable side effects.  The psychiatrists predict that without enough medication to eliminate symptoms, I have a 90% or better chance of relapse, and that episodes will continue to get worse.  So the goal of remission was the course of despair.

But recovery, I can manage recovery.  Now I am focusing on the resources I have to deal with my depression.  If I look at my non-medical resources, they are many.  They include my friends.

I have lots of friends.  My friends make this hill of mine a lot less steep.

What about you?  What were your results from the mind experiment?  What are your thoughts about friendship?
photo in the public domain

reformatted 11/26/10