If we’re looking for something based solely upon what it usually looks like, we’re in for a long and frustrating hunt. And if a mood or anxiety disorder is at play, we’re so much farther away from an accurate diagnosis and treatment. Case in point, depression isn’t always “depression.” Dr. Mae Casanova dials us in on three types that might fly under the radar…
It is thought that morning depression could be related to circadian rhythm, being the result of a kink in someone’s sleep/wake cycle.
It’s guest post time again. Dr. Mae Casanova contacted me some time ago, asking if she could write for Chipur. Frankly, her request got past me, so she sent a friendly nudge last week. Her subject matter looked good, as did her website and qualifications – so here we are.
Dr. Casanova is a Licensed Clinical Psychologist practicing in San Diego. She’s involved in all sorts of great work; however, she considers herself a “thinking outside the box” therapist and growth coach first. Dr. Casavova wraps-up her “Get to Know…” page by saying, “But above all – I am human – just like you. Perfectly flawed, doing my best to connect, thrive and grow.”
All good, if you ask me. The floor’s yours, Dr. Casanova…
3 Types of Depression You Might Not Know About
Clinical depression or major depressive disorder is a clinical diagnosis and a serious mood disorder identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A licensed medical or mental health provider needs to give a patient the diagnosis after a thorough assessment. However, “That’s depressing.” or “I’m just depressed.” are used in today’s society as jargon or as a replacement for feeling sad or low – usually not accompanied by a clinical diagnosis.
It’s important to understand that there are some presentations of clinical depression that do not look exactly like the DSM-5 describes. The criteria may be met, but the presentation, onset of symptoms, and duration to meet the criteria for a diagnosis are different.
Reactive Depression
Dr. Mae Casanova
Reactive or situational depression is a depressive episode brought on by a specific event. Feeling depressed after grief or loss, losing your job, or a break-up are all examples of reactive depression.
In the case of a reactive depression generated by grief or loss, the symptoms are similar to that of what we know as grief, as many depressive symptoms are, but they last longer than the typical grieving process.
The symptoms can come in the form of sadness, feelings of hopelessness, irritability and agitation, feeling anxious or worried, loss of interest in pleasurable things, appetite and weight changes, as well as many more.
Smiling depression is a form of depression in which someone is struggling with depressive symptoms on the inside, but presenting as smiling, happy, or content on the outside. The pressure to keep an outward appearance is high these days, so it’s understandable that someone may feel the need or pressure to hide their depression and its symptoms.
It’s important to remember that even if things seem okay on the outside, there could be guilt, sadness, hopelessness, anxiety, and fear on the inside. Much more on smiling depression.
Morning Depression
Morning depression is a subset of clinical depression where the depressive symptoms are worse in the morning. For example, one may feel more sad, hopeless, irritable, or lack the motivation to get the day started. These symptoms may lessen as the day goes on, but they are severe and consistent enough in the morning to meet criteria for a major depressive disorder diagnosis.
It is thought that morning depression could be related to circadian rhythm, being the result of a kink in someone’s sleep/wake cycle. More information on morning depression.
Depression is one of the most common mood diagnoses and be can be the most serious. If left untreated, there is a higher risk for hopelessness and helplessness, which can lead to self-injurious behaviors or even suicide.
If you or a loved one is presenting any of the types of depression we talked about, it is important to realize you are not alone, and there is help.
That’s All, Folks
Thank you, Dr. Casanova. Appreciate your expertise and willingness to share.
Yep, depression isn’t always “depression.” Same with anxiety and bipolarity. And if we insist upon making decisions based solely upon what we believe something looks like, we’re in for a long and hard journey.
As we’ve seen, the mood and anxiety disorders frequently present outside the box. And so we must think…
Dr. Casanova’s website. If you’re in the San Diego area and looking to stay on top of your emotional and mental health, get in touch.
Anxiety is a tortuous, confounding, painful, and often unrelenting demon that I wouldn’t wish on the worst of souls. If you’ve had any exposure to it, I can cut the descriptors. Really, there’s only one question here: “How the heck do we manage it?” For my money it’s all about learning, because, believe me, what you don’t know will hurt you…
And when I crossed the threshold of acceptance I knew my only relief option was to continue to learn about why and how anxiety presents in me, and how to effectively manage it.
The more time and energy we spend on surviving our emotional and mental challenges, the more we lose track of what’s really going-on and what to do about it.
Understandably, over time we get so gummed-up by offsetting low self-regard, masking symptoms, ducking assorted punches, people pleasing, quick-fixes, and more. And before we know it, poof, finding reason – solutions – in the midst of the unreasonable becomes a lost cause.
It doesn’t have to be that way.
My gut told me it was time to do a piece on the fundamentals of anxiety. In fact, we’re going to make it a two-parter. Let’s handle the biological goodies this go-round and come back with how to manage next week.
Keep in mind, I know anxiety like the back of my hand. Okay, being a counselor helps, but more so wrestling with it for fifty-five years. And I’ll tell you something else. When my anxiety hit full-throttle in my late teens, having no clue as to what was going-on, all I wanted to do was learn about it and know I wasn’t some sort of psycho-freak. I figured I’d reason-out the relief factor after I had a decent grip on what I was dealing with.
State & Trait Anxiety: Why You Need to Know
Everyone experiences anxiety; however, exactly what kind – state or trait – is important to know. State anxiety is anxiety that’s generated by a particular situation. For instance, when someone gets the “yips” when speaking to a group, it’s very likely state anxiety.
Trait anxiety is more pervasive in that it can be considered a personal characteristic, shall we say a (non-defining) component of who one is. A trait anxiety would indicate said person is typically uneasy about unknown outcomes. Actually, our public speaker may really have trait anxiety.
Can you see why it’s important to know what type of anxiety you have? Here, given my first panic attack hit when I was nine, and anxiety remains a part of my life, there’s no doubt I have trait anxiety. That being the case, I long ago gave-up on the notion that my anxiety may go away. It won’t.
And when I crossed the threshold of acceptance I knew my only relief option was to continue to learn about why and how anxiety presents in me, and how to effectively manage it. Period.
What about you? State or trait?
The Stress Response System
How can any of us accept and manage our anxiety circumstances if we don’t know what’s biologically taking place? We can’t! So what say we dig-in and see what we can see…
Oh, my reference for what you’re about to read is a great article, “Understanding the stress response,” from Harvard Health Publishing. It’s a good read, so I’ve linked at the end.
If you’re enduring your share of anxiety, how well you know the manifestations of the fight/flight response. The Harvard crew refers to it as the stress response and it’s the dance floor when it comes to anxiety.
The stress response begins in the brain. When we’re confronted by what we may think is danger, our eyes, ears, or both send the scoop to our emotional processing center, the amygdala; which interprets the news. If it perceives danger (which doesn’t necessarily make it true), it immediately sends a distress signal to the hypothalamus, which serves as a command center.
Always ready to roll, the hypothalamus sends a dispatch to our adrenal glands directing them to activate the sympathetic nervous system. The adrenals begin to pump epinephrine (adrenaline) into the bloodstream, bringing on instantaneous and significant changes, such as increased heartbeat, blood pressure, and rate of breathing. Add to that extra oxygen being sent to the brain, blood being forced to the muscles and vital organs, and glucose and fat being released into the bloodstream from storage.
Whole lotta’ shakin’ goin’ on.
On to the HPA Axis
Well, the initial surge of epinephrine ultimately subsides, but if danger is still perceived the hypothalamus activates the second component of the stress response system, the HPA axis. The initials? Hypothalamus, pituitary gland, adrenal glands. And now it’s all about hormones, as the HPA axis puts the pedal to the metal on the sympathetic nervous system.
Here’s the flow: The hypothalamus releases corticotropin-releasing hormone (CRH), which zooms to the pituitary gland, triggering the release of adrenocorticotropic hormone (ACTH). ACTH flows to the adrenal glands, which release big, bad cortisol, the “stress hormone.” So now the body, at DEFCON 1, is fully amped-up – defended.
Where Does It All End?
When danger is perceived to be gone for good, down go cortisol levels. It’s then that our parasympathetic nervous system hits the brakes on the stress response.
Now, you may be thinking…
“But wait! Many of us endure chronic – trait – anxiety so it’s very much an ever-present demon. I mean, who’s to say a danger won’t be perceived thirty minutes later, again activating the stress response? And what happens to my body with all those chemicals, especially cortisol, polluting it 24/7?”
Precisely! That’s why we’re setting the table by learning about the biological foundation of anxiety. And next week we’re going to get into reasoned management.
In the meantime, review what you just read and see if you can spot some intervention points. Okay?
ach and every day in the US some 120 people die subsequent to an opioid overdose. If lives weren’t enough, the total economic burden of prescription opioid abuse is right at $80 billion a year. This is stunning crisis news that calls for action. And action has to include education. So how ’bout we hit the treatment neck of the woods…
As you likely know, opioid withdrawal isn’t deadly, but it sure is horribly uncomfortable. And most folk would struggle making it through even one day without medicine…
True, we work exclusively with the mood and anxiety disorders here on Chipur. However, an opioid crisis discussion is relevant. And that’s because m/a disorder sufferers are perfect candidates for opioid abuse and dependence, should we find ourselves trying to manage significant physical pain.
Why?
Certainly, we have our emotional, mental, and “stress-magnet” leanings. But let’s not forget that opioids can have an anti-depressant effect. In fact, modulation of our endogenous opiate system is at the heart of an antidepressant in the late stages of development (Alkermes: ALKS-5461).
The Opioid Very Basics
So if we’re going to discuss opioid abuse/dependence treatment, we’d better bone-up on some basics…
First, some terminology. “Opioids” include “opiates,” which are drugs derived from opium (e.g. codeine, morphine). The remaining opioids include semi-synthetic and synthetic drugs (hydrocodone, oxycodone, etc.) and endogenous peptides (endorphins, etc.). Bottom-line: “opiate” is typically limited to the natural alkaloids found in the resin of the opium poppy.
Okay, so how do opioids work? Simply, they bind to opioid receptors principally found in the central and peripheral nervous systems, as well as the gastrointestinal tract. Keep in mind, there are numerous receptor classes and the response differs by receptor.
Treatment Considerations
As we discuss treatment for opioid abuse/dependence, we need to keep the following forward and ongoing in our thinking…
Meds play a huge role, but shouldn’t fly solo
Psychosocial interventions are the best co-pilot
Co-occurring disorders (e.g. panic disorder + opioid dependence) are real and there will be trouble if the non-substance piece is ignored
Psychosocial Interventions
Seemed to be the best option to use the term “psychosocial interventions” instead of “therapy.” See, with the exception of co-occurring disorder situations, where, say, the depression or PTSD component require treatment, I’m not so sure formal psychotherapy is a fit. I mean, cognitive-behavioral therapy (CBT) alone in the treatment of opioid abuse/dependence isn’t especially effective.
That said, there’s still a ton of merit to face-to-face work when it addresses motivation, direction, education, frustrations, stress-reduction, family dynamics, and more.
Finally, the power of support groups looms large. After the initial stages of withdrawal, participation in a 12-step, or other, group is extremely helpful.
Medications
A variety of meds are available for the treatment of opioid abuse/dependence. And, of course, the purpose of all of them is to get one off of opioids and continue-on in recovery.
As you likely know, opioid withdrawal isn’t deadly, but it sure is horribly uncomfortable. And most folk would struggle making it through even one day without medicine. So in comes the med – substitute – and then it’s tapered-down.
Okay, here’s a non-all-inclusive list I constructed on drugs.com. I selected prescription meds, including off-label applications. The list is in order of popularity…
Suboxone: A brand name for the combo buprenorphine and naloxone (Narcan). Available in sublingual tablet and film. Details just below.
buprenorphine/naloxone (generic): Buprenorphine is an opioid receptor partial agonist that produces almost big-league opioid effects. Naloxone is an opioid receptor antagonist that blocks the effects of opioids.
buprenorphine: Details above.
Vivitrol: Extended-release naltrexone. Details just below.
naltrexone: An opioid receptor antagonist that may decrease the desire to use opioids over time and decreases overdose risk. It’s not a controlled substance.
Zubsolv: Buprenorphine/naloxone combo that works just about identically to Suboxone; however, it comes in a very small sublingual tablet. Its bioavailability is reported to be superior, which is important because quicker absorption equates to lower dose required to achieve optimal effects. And that means reduced risk of cross-addiction and unwanted side effects.
Bunavail: Buprenorphine/naloxone combo that works just about identically to Suboxone and Zubsolv; however, it delivers its dose via film through the buccal mucosa of the cheek. Same superior bioavailabilty details as Zubsolv.
Probuphine: Buprenorphine delivered via subdermal implant. It’s reported to provide non-fluctuating buprenorphine blood levels around the clock for six months after the treatment procedure.
Sublocade: Long-acting buprenorphine delivered by injection. Restricted to those who have initiated treatment with a transmucosal buprenorphine-containing product and have been stabilized on dose for more than seven days.
lofexidine: An adrenergic (adrenaline/epinephrine) receptor agonist used to reduce the physical symptoms of withdrawal. It’s not a controlled substance.
So there’s a list of med options for you. Of course, you’re encouraged to do your due diligence and openly chat with your doc.
And never, ever, ever forget, buprenorphine is an opioid. That means you can become dependent upon it, and if you get cute with dosing it can kill you.
Got it?
Let’s Wrap It Up
So, yes, the US is smack-dab in the middle of a stunningly deadly opioid crisis. No doubt we need to deal with cause. But at the same time, we have to continue to promote and teach treatment.
Hope you, or someone you know, can use these need-to-knows, and that they help. Please spread the word.
(FYI: The Zubsolv image is not an endorsement. Just thought it would be a good fit.)
Hey, hundreds of Chipur mood and anxiety disorder-related titles are standing-by. Why not dig in?
he number of times I relied upon learning and understanding cause to hold me over when I had no idea how to find relief. Can’t count. Lots of comfort in connecting dots, you know. As it applies to depression, consider this biology…
Child abuse and neglect can be perceived as agents for neurodevelopmental disruption and, depending on when it occurs, can cause serious neurological ‘scars’ in some structures…
Been there? You have no idea how to make those pounding headaches go bye-bye. But there you are on the internet comparing symptoms, desperately trying to at least figure out what’s causing them.
We all feel better (even though we really don’t) when we know what we have – and why it’s happening.
Here’s the biological scoop on one particular cause of depression. Perhaps it’ll hit home…
“Early life stress, HPA axis, and depression”
Came upon a research piece from the journal Psychology & Neuroscience. “Early life stress, HPA axis, and depression” was presented by a team from the Universidade de São Paulo.
The team get things started by pointing-out that adaptive physiological responses occur in our bodies in the midst of acute stress. One of these is increased adrenocorticol hormone secretion, primarily cortisol.
(Okay, stop. To get the most out of this article you have to become at least acquainted with something known as the HPA axis. This oldie but goodie Chipur article will handle the introduction.)
These adaptive responses alter our internal homeostasis – “balance.” And when that happens illness is the likely result. Of particular interest to the team was psychological stress and the interactions with the nervous, endocrine, and immune systems.
Early Life Stress to Mood and Anxiety Disorders
The team consider early life stress as assorted traumatic experiences that occur during childhood and adolescence, which may have repercussions in adulthood. Included are parental loss, separation from parents, childhood illness, family violence, physical/emotional/sexual abuse, and emotional and physical neglect.
The team note that considerable evidence from assorted studies suggests early adverse experiences play a starring role in the development of mood and anxiety disorders.
Their take…
Child abuse and neglect can be perceived as agents for neurodevelopmental disruption and, depending on when it occurs, can cause serious neurological ‘scars’ in some structures, which could make some individuals vulnerable to certain types of psychopathology, especially depression, posttraumatic stress disorder (PTSD), and substance abuse.
Enter the HPA Axis
HPA Axis
So the team submit that changes in homeostasis is a major illness trigger. Enter the HPA axis. Seems the response of the HPA axis is a vivid reflection of an individual’s stress response. To the core, when the HPA axis is activated during the developmental process it becomes permanently unstable, hyperstimulated, vulnerable, or dysfunctional. And that equates to a compromised ability to respond to stress, which for our discussion opens the gates to depression.
During depression, dysfunction of limbic structures, including the hypothalamus (the “H” in HPA axis) and hippocampus, results in hypersecretion of corticotropin-releasing factor (CRF) and other hormones, which determines HPA activation.
Any kink in this system caused by, say, excessive stress, social isolation, or chronic irritability and anger causes difficulty in adapting to stress. And that can predispose an individual to depression by impairing the transmission of serotonin in the hippocampus.
Fact is, hyperactivity of the HPA axis in major depression is one of the most consistent findings in psychiatry. Yep, a significant percentage of patients with major depression have been shown to exhibit increased concentrations of cortisol in plasma, urine, etc. And, go figure, these patients typically show an enlargement of the pituitary and adrenal glands.
The Bottom-Line
Okay, we reviewed what I believe to be a likely common cause of depression. And if you endured early life stress and find yourself wrestling with depression, you now have some connected dots.
And even though there isn’t a 100% “fix,” there’s at least a large measure of comfort in knowing and understanding what’s going-on. Again, that was always huge for me.
But we need to address one more reality. The dynamics we reviewed strongly suggest permanence. And as bitter a pill as that may be to swallow, acceptance (not acquiescence) of our circumstances is always the first step toward recovery.
Never forget, permanence and acceptance don’t equate to the absence of options and relief. I crossed that insight threshold a long time ago and have been so much all the better for it.
So a reasonable biological explanation for depression. Does it help?
Being a teen in America is a dicey proposition. Sure, those years have never been the easiest, but school mass shootings have taken the accepted teenage plight well beyond tolerance. So where have we gone wrong? Let’s talk about it…
God only knows what it’s doing to our children’s brains. Sean Parker, Facebook’s first president
Yes, there was a life-snuffing high school mass shooting at the hands of a teenager last week. But there was one three months before. And four more over the past 20 years.
It doesn’t take a social psychologist to tell us something is horribly wrong here – its causes and cures.
In my mind, it comes down to good old-fashioned common sense. But intelligentsia assigns it little credibility.
Now, unless you’ve been living under a rock, you’ve heard and read all sorts of calls to action – solutions, if you will. And the vast majority of them are gun-focused, including second amendment rights, armed guards in schools, metal detectors, etc.
Sadly, most of the lip-service is political posturing.
I’m telling you up-front, I’m not getting into a gun discussion here because it’ll serve no immediate purpose. Besides, “Where have we gone wrong?” runs so much deeper.
I believe American society is in so many ways “out-of-control.” How can it be denied? And, of course, this reality horribly impacts one of our most vulnerable populations – teenagers.
Am I prepared to put my money where my mouth is? Sure. But realize, I can’t include everything on my mind in just one article. So how ’bout these three biggies…
Social Media
Ever wonder if social media is causing problems for our teens? Late last year, Sean Parker, Facebook’s first president, had this to say…
I don’t know if I really understood the consequences of what I was saying, because of the unintended consequences of a network when it grows to a billion or 2 billion people and it literally changes your relationship with society, with each other.
God only knows what it’s doing to our children’s brains.
Not long after, Chamath Palihapitiya, former Facebook vice president for user growth, chimed-in with…
I think we have created tools that are ripping apart the social fabric of how society works.
The short-term, dopamine-driven feedback loops we’ve created are destroying how society works. No civil discourse, no cooperation; misinformation, mistruth. And it’s not an American problem – this is not about Russian ads. This is a global problem.
I feel tremendous guilt. I think we all knew in the back of our minds – even though we feigned this whole line of, like, there probably aren’t any bad unintended consequences. I think in the back, deep, deep recesses of, we kind of knew something bad could happen. But I think the way we defined it was not like this.
So we are in a really bad state of affairs right now, in my opinion. It is eroding the core foundation of how people behave by and between each other. And I don’t have a good solution. My solution is I just don’t use these tools anymore. I haven’t for years.
Palihapitiya went on to say he doesn’t use social media because he “innately didn’t want to get programmed.” Regarding his children? “They’re not allowed to use this shit.”
Obviously, I’ve picked-on Facebook. But you know as well as I there’s more where it came from.
Films, TV Shows, Video Games
Are you kidding me? The violent and sexual content easily accessible in films, TV shows, and video games are appalling and behaviorally triggering. And, believe me, I’m no prude.
No doubt, you can find all sorts of studies that will tell you such things have no negative influence on our teens, but really? Again, it’s good old-fashioned common sense versus intelligentsia. And, unfortunately, the latter most often carries the day.
How could fast and casual exposure to violent and sexual content in so many films, TV shows, and video games – immediately and over time – not have a tragically negative impact on our teens?
Zeitgeist
Zeitgeist: the general intellectual, moral, and cultural climate of an era.
I don’t know about you, but I think the current American zeitgeist is downright scary. And the two biggest contributors are an “anything goes” attitude and cold-hearted meanness.
Just consider the caustic rhetoric heaved-up by folk from any point along the political spectrum. And take a look at the comments on most any article, post, or forum thread. So much anger, cruelty, and disrespect.
The zeitgeist – the “spirit of the day.” In America, triggering fuel for our teens.
That’s It
You know, I’m sad for American teenagers. And that includes the victims and the perpetrators wrapped-up in this school mass shooting horror.
No doubt, being a teenager in America has always been difficult. But am I wrong in believing never like this? And let’s not forget, I’ve been around for almost 64 years.
Where have we gone wrong, people? And what are we going to do about it?
Time’s already run out.
As long as we’re on the subject of teens, these Chipur articles may hit home…
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A variety of meds are available for the treatment of opioid abuse/dependence. And, of course, the purpose of all of them is to get one off of opioids and continue-on in recovery.
