Unipolar Stable Depressive Disorders Q and A
An Overview of Stable Depressive Disorders
How are mood disorders divided up or classified?
Mood Disorders are divided into the unstable Bipolar Disorder, and the stable Unipolar Depressions. Bipolar Disorder has two poles , the high energy pole which is the excitable angry elated Manic pole or phase, which cycles with the low energy pole, which symptomatically resembles the Unipolar depression, though medication responses indicate a biochemistry related to that of the Bipolar Disorder from which it evolves.
How will we understand the differences?
The symptom presentations of Unipolar and Bipolar depressions , can be very similar, yet in the Bipolar depression there can be great variability within an episode and from episode to episode, especially in children and younger teens. Also they share different histories, biochemical basis and very different medication approaches. Essential features and symptoms will be presented with special emphasis on contrasting the Unipolar stable presentation symptom by symptom with the unstable Bipolar depressions, or similar Atypical Mood Disorders to illustrate the similarities and differences. Bipolar and Unstable Mood Disorders
What are the “poles” you are talking about?
The Bipolar cycles sometimes quickly between two poles, the high energy, good feeling or irritable, angry , rageful pole and the low energy sad-no pleasure -depressive pole, where as the Unipolar Depressive for the most part remains in the depressed pole, with little relief from good moods or higher energy states. As the bipolar persons illness progresses and they get older they spend less and less time in the manic or high energy states, and more and more time in the depressed phase.
Why when you are discussing symptoms are you listing the Unipolar depressive symptoms first?
Because this is a discussion to help you to understand Unipolar stable depressive mood disorder, especially as it compares to Bipolar depressive pole. Another is often the first episode of a Bipolar Disorder is a Depressive Episode, very much resembling on the surface a Unipolar Depression. ProSymptomScreenExpanded, MoodAnxietyScreen. The patient and the evaluator may not initially realize that the good moods following brief yet intense episodes of depression are not recovery from the depression but the hypomanic, that is less than manic phases that is actually fueling the process. This fueling process in made worse when antidepressant medications are used. One warning sign is too rapid and too good of a response with an antidepressant that then “wears off too quickly”, requiring continued escalation of the doses.
Is the person with a depressed mood disorder just always depressed, sad and blue?
That is how most people think about it, and for some that is the main presentation. However this kind of depression or mood problem can show itself with not only the sad mood, but with perhaps with only diminished interest or pleasure in things previously that were enjoyable, or were necessary to do such as less than desirable activities at school, work, or in decreased interest leisure activities, or as related to relationships with other, who often the first to be the target of this depressive symptom, and the first to notice that the person “ is not his normal self, or something is just not right” Sometimes it shows itself with a “I don’t care attitude, I’m bored, nothing matters. ” Another presentation is mostly anger and irritability, but not of the pervasiveness and persistence and unpredictability and mood swings of the unstable Bipolar type, and for others there is a complex variation on these Unipolar depressive themes.
How many symptom clusters are involved in this kind of Unipolar stable depressive disorder?
There are nine major symptoms or problems associated with the stable Unipolar depressions, the depressed mood itself, diminished interest or pleasure, physical symptoms like changes in appetite, headache, bowel and stomach problems, sleep disturbance, lack of drive, motivation with a slow body and mind, though the both may be too fast, guilt -negative thinking -poor evaluation of self and others, and hopelessness-pessimism, which may proceed to suicidal thinking.
There seems to be a lot of overlap here, is that the rule?
Yes and no, no first -the basic symptom pattern must be there to make a diagnosis but there is much variation in expression outwardly and in internal experience. Each person’s presentation and internal experience depends on three basic factors, stresses from the environment, the underlying biology and its brain chemistry that cause some of the symptoms especially the ones most responsive to medications, and lastly is the role of the person’s mind. By this I mean their reaction, response, interpretation, conceptualization, and use of mental or psychological defense mechanism, all determining how the symptoms are dealt with, and expressed internally on the surface. The internal world of the person may be very different than what they are experiencing in their mind.
What determines these differences in the symptom picture and its internal vs. external presentation and experience?
For some people the primary driving force may be environmental stress such as a relationship, a job, school, money issues , legal difficulties, etc, for others the brain chemistry predominates without major stresses, yet in some the way their minds psychology processes input from the environment can trigger an the underlying vulnerable brain chemistry. The brain chemistry may at the beginning cause the symptoms, especially those that are medication responsive, these may be further aggravated by outside stresses, but a critical determing factor is the how the mind deals with these symptoms which can be helpful, or it may add more fuel to the fires of depression.
Do medication help regardless of the presentation?
They can help dramatically and relatively quickly with most of the symptoms depending on those three factors, any one of the three factors can be so powerful that they will determine the treatment success, the prognosis, and what complication may occur, including re-occurrence or relapses.
What determines how well a treatment will work?
Most of us can’t control the environment and its stresses, even we think we are or can, bad things still happen to good people, we are in sense dealt a good or bad hand with our brain chemistry, so there isn’t much we do about that, the thing we can do the most about and have the most say and control or input though in the pits of depression it is the input our mind gives the process, it cannot be neutral, it either is helpful or adds fuel to the fires of depression. Thinking mode non biological therapies help greatly as do medications but not for all or the deepest symptoms, for this another approach may be needed, that gets to root of the driving energies causing, maintaining and leading to relapses. What is caused by the mind must be reversed by the mind.
You are saying the mind our psychology can cause a relapse , even with the best use of medication and non biological thinking mode type therapies, is there another approach?
Yes I am , but there is an approach other than thinking mode therapies, such as psychoanalytical therapy or coginitive behavior therapy, for those who have the patience persistence and effort to learn and apply it. There is more and more evidence that re occurrences relapse, and the hanging on of “untreatable “ symptoms, that may in fact make relapse more likely can be changed, lessened and perhaps eliminated by what I call applied clinical mindfulness. Mindfulness uses the experiencing mode of the mind and doesn’t use thinking at all to change, lessen or eliminate symptoms. More about this is discussed elsewhere. Applied Clinical Mindfulness Q and A
Where do you want to start with the symptom presentation and comparing it to a unstable or Bipolar depression?
The depressed mood is a good start and the logical place to begin. This is the first of two possible essential features. A relatively stable and persistently sad or depressed mood, with no major mood swings, or cycling into an elated or feeling too good state, as occurs in bipolar mood swings. Especially in children and teens irritability may be the presenting mood, which again is persistent and stable. If there is anger it tends to be not out proportion to the provocation and is short lived when it occurs. In bipolar the anger and rage may be more dominant than either the swings into sad or elated moods, and last from minutes to hours, and can be the chief presenting complaint or problem. The Unipolar depressive evokes sympathy, and compassion, where as the Bipolar depressive is difficult to live with, like walking on egg shells, a Dr Jeckle & Mr. Hyde, and you want to avoid the person, rather than be with them and to help. The irritability and excitability of the depressive tends to be more inwardly directed toward self, whereas the bipolar tends to direct aggression equally if not more so outwardly towards the very people that are trying to be helpful. As the Bipolar person gets older the depressive episodes tend to get more and more frequent and the high energy states less and less, yet the quality often has more of the excitable , irritable, angry, nasty features.
What is the second essential presentation of a Unipolar depression?
Diminished Interest or Pleasure is the second possible essential feather and may predominate with or without a sad or irritable mood. For most activities nearly daily there is less pleasure, joy, interest in things that formerly gave pleasure, and new things just aren’t as interesting or pleasurable. Common statement are “ I’m bored, nothing -interests me,- nothing seems to be fun anymore.” There can be a general I don’t care attitude. The bipolar depressive feels the same but when they swing to the high energy elated manic state, everything becomes too interesting, and they get over involved in too many things that they find pleasurable with little regard for painful consequences. The will stop eating and sleeping to keep doing more and more goal directed activities.
What about physical symptoms ?
Many times the first presentation and the chief reason one sees a primary care provider is some somatic complaint and the depression is not diagnosed for years. Weight Gain or Loss and other Physical Symptoms or other mostly physical disorders may be present and may what is called the depressive equivalent, that is depression showing itself primarily as something like headaches, or bowel or stomach problems, anything that can be experienced by the brain the mind can make a depressive equivalent. When not dieting there can be sever weight gain or loss based on loss or increase of appetite. Many psychosomatic symptoms may be associated with depressions and many times the physical complaints may dominate the picture. Bipolar disorder is episodic so the physical symptoms, syndromes, disorders associated with it are also episodic in presentation. A good example is headaches, where a constant low grade muscular tension type of headache, with only mild waxing and waning may occur, perhaps with mini type migraine episodes occurring in Unipolar depression. In bipolar the headaches may be full blown migraines the occur after a peak of high energy excitement, and decreased sleep, and a good mood state, the put literally put the person in bed, forcing them to slow down, and in a sense represent the low energy depressed phase. This is especially common in children and younger teens and so dramatic that it is not thought of as a manifestation or an equivalent of depression. Many other physical ailments may follow a similar pattern such as bowel –intestinal symptoms, asthma, psoriasis, eczema, rashes, generalized aches and pains, allergies to name a few. Often when the right medication helps the depression these physical disorders also improve greatly.
Is sleep disturbance a significant symptom?
Sleep problems are common and often is what brings the person in for an evaluation. Typically Unipolar depressives feel like they sleep too much yet are tired and feel not rested, and Bipolar people sleep too little, yet feel rested and often have a hard time waking up. Waking up in the middle of the night and not being able to get back to sleep is typical of Unipolar depression, with difficulty falling asleep common in both with the bipolar person having a body and mind that just won’t shut down, and the Unipolar being tense, worrying in a negative obsessional fashion about everything.
What about problems with the body and the mind feeling too slow or fast?
This is called Psychomotor Retardation or Agitation:. Unipolar depressives feel their mind and body is slow, sometimes there is a split with slow body-fast mind, or vice versa. The bipolar person usually has too much mental and physical energy with racing thoughts, and physically are driven to do more and more, where as the Unipolar person lacks drive motivation, making it hard to do daily activities at home, school and work.
How does this slow mind fit in with fit lack of motivation and fatigue?
They are separate but interconnected symptoms, the persons thinking may be fast or slow usually slow but it either case it may or may not lead to a sense of decreased Mental Energy-Lack of drive or mental and perhaps physical Fatigue: Even when the Unipolar person gets enough sleep they are still often physically and mentally exhausted, where as the bipolar seems to have inexhaustible energy and never seems to get fatigued even with less and less sleep. When is the high energy phase there is increase goal directed activities doing more and more of emotionally charged pleasurable and sometimes risky things, with little to no remorse, regret shame, guilt that would afflict the Unipolar depressive doing something in a small way that may be similar, like spending money, gambling, increased sexual activities, dabbling in drugs or alcohol.
What about the poor self esteem associated with depression?
This is part of the Guilt-Worthlessness-Poor Self Evaluation complex found in depression. Self evaluation become progressively worse as the depression deepens, until one feel s worthless, useless, everything one does, seems wrong . In the manic or hypomanic phase the self is over evaluated, one feels on top of the world, there is need to be in charge, be the boss, big ideas take hold, too big, unrealistically big, the opposite of the depressed phase, where things seem unrealistically useless, bound to fail, everything can be an effort and then not good enough in the mind of depressive. How bad I am versus how great I am. I am doing everything right versus everything wrong. I am right and good of course, vs. I am wrong and bad.
People don’t usually think of thinking problems with depression do they?
They usually don’t and because of that they don’t think of the disorder, but Diminished Concentration which is one of the cardinal symptoms can greatly how one processes mentally especially if it leads to slow Thinking with a paucity of thoughts. In the depressive phase everything including thinking is hard, a struggle, slow, an effort, thought move slowly, too slowly, lose track of ideas get distracted by negative feelings and thoughts. When in the up mood phase thinking is effortless at first but then it may get too fast, and now distraction set in , too many thought, too emotional, get one side tracked and distracted.
What about the negativity of the depressed person?
Hopelessness-Negativity- Pessimism is a devastating cluster and can lead to suicide. In the depressive phase the 3 H’s take hold, one is hopeless, things will never get better, less and less light at the end of the tunnel, until there is no light, one is hapless, why am I so unlucky, why do bad things happen to me, over and over again, and helpless, no matter what I do, nothing gets better, I am helpless to get things better, what is the use? The past , the present , the future is colored by negativity and pessimism, all is getting blacker and blacker. In the high energy phase one is too optimistic even in the face of adversity, one is too hopeful that all will work out for the best, one only sees the positives and not the negative, in depression one sees the negatives and not the positives, until the only way out is maybe to die, growing thoughts of death, dying, taking one’s life grow as the depression grows. One would be better off dead, why live things won’t get better.
Any summary ideas about these two forms of depression especially as it may apply in children?
The Unipolar depressive stays in the depressed low energy pole, while the Bipolar goes back and forth some time weeks , months, years between the feeling good, and the feeling bad episodes. In children and people called ultra rapid cyclers this switch between poles can be hours or even minutes, but not for the child or teen with Unipolar depression. Unipolar depression occurs in younger people but may be harder to diagnosis, often presenting with poor school performance and a multitude of physical complaints. Sometimes it may be cause of school avoidance and refusal, which is often missed if it presents with mostly physical symptoms or anger, irritability and ODD or Oppositional Defiant Disorder type symptoms. This can get very complex and confusing and requires much time and history taking and many times multiple trials of differnt treatment to clarify the diagnosis. ODD,ADHD or Mood, Unstable Mood Scales Historical Markers, Treatment Scale, Symptom Picutre, Bipolar and Unstable Mood Disorders