The Aword

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Signs of Depression

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  • Lack of facial expression
  • Lack of emotional reaction or excessively tearful
  • Irritable and restless or slowed up
  • Monotonous voice
  • Unwilling to engage in conversation
  • Weight loss
  • Tendency to isolate self
  • Poor attention to physical appearance
The Abyss of Depression

A list of symptoms conveys only a faint impression of the reality of depression. Those who have not experienced it find it hard to appreciate the depths of despair and the way in which depression leaches out all the colour in the world and dims the brightness of even the sunniest day.

People have described depression in various ways, but there tend to be common themes: darkness, often the colour black (Churchill's black dog is a famous example), sensations of being trapped, imprisoned, held down by depression, terrible isolation.

The following quotes give some idea of the baffling and overwhelming nature of depression:

"I only know that summer sang in me a little while, that in me sings no more." - Edna St. Vincent Millay (1892-1950)

"I'm collapsed in a pile of shoes on my closet floor. I have no memory of what it feels like to be happy. I sit with my knees pulled up to my chest. It's not that I want to be still. I am numb." - Marie Osmond  "Behind the Smile"

"I have secluded myself from society; and yet I never meant any such thing. I have made a captive of myself and put me into a dungeon, and now I cannot find the key to let myself out." - Nathaniel Hawthorne

"I didn't know what was the matter with me. All I knew was that I was feeling lower than a snake's belly...I remember we used to go to restaurants, and I'd say 'Everybody's pointing at me, the cheat, the fraud, the fake.' You really believe these things! Astonishing!" - Mike Wallace, On the Edge of Darkness

"I was much further out than you thought and not waving but drowning." - Stevie Smith

"He couldn't remember a depression as deep as the one which now enveloped him. He felt as if he were suffocating in it." Stephen King, Insomnia.

"When you're depressed, there's no calendar. There are no dates, there's no day, there's no night, there's no seconds, there's no minutes, there's nothing. You're just existing in this cold, murky, ever-heavy atmosphere, like they put you inside a vial of mercury." - Rod Steiger, On the Edge of Darkness

"I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would be not one cheerful face on earth. Whether I shall ever be better, I cannot tell. I awfully forebode I shall not. To remain as I am is impossible. I must die or be better it appears to me." - Abraham Lincoln

"It was not really alarming at first, since the change was subtle, but I did notice that my surroundings took on a different tone at certain times: the shadows of nightfall seemed more somber, my mornings were less buoyant, walks in the woods became less zestful, and there was a moment during my working hours in the late afternoon when a kind of panic and anxiety overtook me..." - William Styron, Darkness Visible

Anyone who would like to read more about other peoples' experiences with depression may wish to try the American NIMH website:

How It May Affect Your Life

"If you do not bring forth what is within you, what you do not bring forth will destroy you." The Gnostic Gospel of Thomas.

  • Your house may become a mess with washing, ironing and dirty dishes piled up, mail unopened, etc. (assuming you stay on top of these things at the best of times!).
  • You may find yourself always making excuses to friends and family why you can't meet up with them, because you just can't face putting on a fa?ade of cheerfulness 
  • You may not bothered too much about your appearance when normally you wouldn't be seen dead without makeup or in those baggy old clothes. You're likely to be wearing mostly dark colours and shapeless clothes.
  • You could start putting off things that need to be done more than usual: your car registration, taking a book back to the library, buying a birthday present for someone. It all seems too much trouble.
  • You may find that you can't remember the last time you laughed a real laugh.
  • There isn't anything you look forward to doing.
  • You don't feel as if you can handle your job or get through the day at home anymore, even though nothing has changed so far as increased workload, responsibility or stress.
  • You're drinking or using more than your prescribed medication dose to escape the emotional pain not just the physical pain.
  • You've been finding that your pain level is worse overall and it is getting to you much more, you are finding yourself thinking of it as unbearable, punishing and other emotive terms.
  • You wake up in the middle of the night, and can't go back to sleep, or early in the morning and lie awake feeling tense and anxious. During the day you try to sleep a lot to escape from your life.
  • You have no plans, no hopes for the future. It just looks grey and is something to be apprehensive about. 
  • You lose things, find it difficult to make decisions or concentrate and you can't always remember what day of the week it is.
  • You've lost your appetite, don't care what you eat or whether it tastes good.
  • Alternatively, you may be eating all the time because somehow food seems comforting and to fill that void inside you.
  • You've lost interest in sex or even physical affection. Hugging someone doesn't make you feel closer to him or her, any different from leaning against a wall.
  • You're reading escapist books (fantasy, sci-fi, romance, mystery) without too much trouble, but anything more demanding mentally is too much effort.
  • You're watching TV all the time to distract yourself from the constant feeling of gloom, but you're not laughing at the comedies, although you may be crying more at the ?weepy' films or find yourself being uncharacteristically and persistently upset by sad news items. 
  • You're avoiding talking to people if possible and even those you do talk to, you don't look at while you're talking to them.
  • You hope you don't run into anyone you know while you're out. Not only is maintaining a normal conversation difficult, but you are sure they'll notice something is wrong with you.

Also: wounds may take longer to heal if you are depressed. A study in Wales found that patients with anxiety or depression experienced delayed wound healing. Previous studies have already shown a connection between psychological factors and wound healing.

Cognitive errors and pain:

The term ?cognitive errors' refers to the biases or distortions made by people when interpreting information from the environment; the well-known psychologist Beck coined it in 1963. Other authors such as Jensen may also refer to negatively distorted beliefs about oneself and a given situation.

Psychologists suggest that depressed patients tend to commit a wide variety of cognitive errors, such as personalisation, selective abstraction, over-generalisation and catastrophising.

These errors can influence mood, perception of pain and behaviour. Given the known relationship between chronic pain and depression, it seems that these sorts of distortion might very well also affect pain patients.

In other words, one's mind can't always be trusted to be giving us the true picture; our interpretation of sensory information (including pain, especially pain such as allodynia, which is felt from non-painful stimulus) is not necessarily accurate.

With pain being such an atavistic sensation, giving rise to emotional response of fear, these conscious ideas are unsurprising, but also extremely unhelpful.

Indeed, studies have reported a high frequency of cognitive distortions in chronic pain patients, with those who scored highly on distorted thoughts also scoring highly on depressive indices.

The frequency of cognitive errors also appears to be related to the severity of pain reported, with a high frequency of negative automatic thoughts correlating with greater severity of pain and psychological unease.

The ability to control these negative thoughts was inversely related to degree of anxiety experienced.  

The types of negative thoughts that might be occurring include emotionally laden terms for pain (?awful', ?unbearable') and ?awfulising' (?this is the worst pain ever', ?it will never go away', ?there's no way I can cope with it').

Obviously repetitive thoughts like these are likely to be associated with a low mood and high level of anxiety, which can both impact adversely on perceived pain.


Those who lose hope, who feel totally helpless, have nothing left to sustain them.

Consider the following story:

An American army medical officer held in the Viet Cong for over 5 years survived the first couple of years in relatively good health.

He was told by his captors that if he co-operated with them, he would be released, and he became a model prisoner. However, as time went on, he came to realise that they had lied to him. Once this notion took hold of him, he took to his bed, refusing food, lying on his cot sucking his thumb. He died within a matter of weeks. His loss of hope was fatal.

Similarly, scientists have found that animals exhibit a trait known as ?learned helplessness' in which they fail to even attempt to stay alive when put in life-threatening circumstances.

This was shown with rats in the late 50s. A rat held tightly in the hand until it stopped struggling, and then dropped into water splashed around for a few minutes and then sank passively to the bottom of the tank, having ?given up', because it had been convinced its fate was hopeless even before it was released into the water.

For those who experience chronic pain, one of the most important factors in coping is a repeated perception of loss of control over one's life, which is associated with a feeling of helplessness and often depression.

Studies suggest that individuals who have a lesser sense of control over their situation are likely to report higher levels of pain and distress, with greater overall negative impact of the illness on their daily lives.

One of the pivotal points is that of aiming for total control over pain. This may not be feasible, even given the pharmacological armamentarium at doctors' disposal these days.

The idea that pain can be completely controlled is probably an illusion, and as such can be a dangerous one, because when reality falls short of expectations, a whole range of negative emotions results: anger, disappointment, fear, frustration etc., all of which can be contributory to the suffering the individual experiences.

In this situation, it is helpful to aim rather towards strategies for coping with pain can towards eradication of the pain.

This does, however, require a degree of acceptance of the difficulties in maintaining ongoing pain relief: which can in turn be related to the degree of trust in which the patient holds the medical personnel who may be encouraging this attitude.

Loss of trust is common (especially in arachnoiditis due to the relationship between the condition and previous medical intervention) and this can adversely affect the acceptance of what is, at best, a most unpalatable truth: that pain must be lived with, and that there is no magic wand.

Of course, in perceiving pain as uncontrollable, it is possible that the individual may come to consider him/herself as less able to cope in a general way with work or daily life and be more likely to avoid these activities.

In the 70s, psychologists coined the phrase, "self-efficacy" within a framework called the Social Learning Theory. In 1986, Bandura ([1]) defined self-efficacy as

"the belief in one's capabilities to organise and execute the sources of action required to manage prospective situations."

More recently, he has written([2]),

"Ordinary realities are strewn with impediments, adversities, setbacks, frustrations and inequities. People must, therefore, have a robust sense of efficacy to sustain the perseverant effort needed to succeed."

Expectations of self-efficacy correspond to beliefs in one's own capacity to carry out the behaviour necessary to obtain the desired results.

Bandura suggests that people with who feel optimistic (even to the extent to being a little unrealistic) about their capabilities are likely to have higher motivation,

"approach difficult tasks as challenges to be mastered rather than as threats to be avoided"

and will interpret the resultant physical and emotional arousal as a positive part of life rather than a sign something is wrong.

He also asserts that in fact ?normal' people are prone to distorting reality, or looking at life through rose-coloured spectacles.

People who lack belief in themselves, perhaps as result of failure in the past, tend to have low aspirations and limited commitment to endeavours they feel will have a negative outcome.

Facing hurdles, they are more likely to dwell on their personal shortcomings and limitations, the enormity of the obstacles in their path and the chance of adverse outcome than on the necessary steps to take to ensure success. They will experience greater stress and distress than their more optimistic counterparts.

He also contends that we learn this self-belief in a variety of ways, including looking at role models around us, our past experiences (triumph over adversity being a source of strength), social persuasion (morale boosting or demoralisation by close friends and family or healthcare personnel), and our interpretation of our physical (somatic) and psychological states (if we are feeling stressed and tense, we may view this as a sign of vulnerability and thus likelihood of failure rather than a natural consequence of being engaged in a challenging activity).

It is important to bear in mind that one of the main features of depression is a low sense of self-efficacy, but this is something of a chicken and egg situation. Low self-efficacy is also linked with high levels of anxiety.

Another type of expectation that has been particularly looked at in relation to chronic pain is expectation of results, which refers to beliefs that certain behaviour will produce certain consequences.

Expectations of results are related to how we perceive the credibility of any proposed treatment (whether or not we think it will work also affects the way in which we perceive the credibility of the person prescribing the treatment.)

This relates to chronic pain in the following way: whether or not a person undertakes a given behavioural strategy to prevent, reduce or cope with pain depends upon (a) belief in the effectiveness of this behaviour (expectation of results) and (b) self-belief in ability to carry out the behaviour successfully (expectations of self-efficacy).

These two types of expectation may influence behaviour independently or interactively, in which case, an individual will only undertake a certain course of action if he/she not only believes the consequences to be beneficial but also considers him/herself capable of carrying it out successfully.

Given that a positive end-point may impossible to visualise (sustained total pain relief being unlikely) and that mood disturbance (depression in particular) common in chronic illness may impact adversely upon self-confidence, then we can see how readily these aspects of coping with pain can be negatively affected.

In turn, this can impact upon the effects of advice from medical personnel, which may be perceived as uncaring, unrealistic and unhelpful. This, of course, has a profoundly deleterious effect upon the doctor-patient relationship.

Numerous studies have looked at the relationship between self-efficacy expectations and response to treatment of chronic pain, such as biofeedback. Many authors report that belief in one's capacity to carry out activities correlates with the level of activity subsequently achieved.

One of the first targets must therefore be developing a sense of self-worth and hence self-efficacy; these in turn help towards a feeling of regaining some control, not perhaps over pain itself, but over its impact upon life as a whole. This is something that we can work on controlling: our reaction to the pain.

In addition, it is vital for medical personnel to recognise the vulnerability of the chronic pain patient and the need for trust to be built up before results can be expected. 

[1] Cited in Wood, R. E., & Bandura, A. (1989). Social cognitive theory of organizational management. Academy of
Management Review, 14, 361-384.

[2] Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998).