By Stephen J. Johnson, Ph.D.
In this first part of my threepart series on depression titled, When Depression Turns Deadly: The Mask Men Wear , I focus more specifically on the hidden depression in men and how to recognize it before it ravages your life. The tragic loss of a loved one by suicide is often the end result of a life long battle with unremitting depression. Learn how to recognize the signs and treat the problem before it’s too late. In Part II, Depression in Men and Women: Recognizing and Understanding the Condition , I discuss the two main forms of depression, the causes and common symptoms of Major Depressive Disorder as distinguished from Persistent Depressive Disorder (Dysthymia), its occurrence in men and women, how depression can turn violent and what needs to be done to weatherproof your life as a hedge against the condition. In the third part of the series, I provide information on childhood Disruptive Mood Dysregulation Disorder, Bipolar and Cyclothymic Disorders, a selfevaluation depression checklist, standard medical and alternative treatment modalities, and how to help yourself and others heal from the condition.
With an intention to provide some of the salient features of depression to help the reader to more readily recognize and distinguish the condition, I am synthesizing in some information from the Diagnostic and Statistical Manual of Mental Disorders (DSM) that is essentially the clinical bible that mental health practitioners utilize. The fifth edition of the DSM was published in 2013 and is a vital resource for understanding and diagnosing mental disorders. Since it is not my intention to provide a complete clinical analysis of the conditions mentioned herewith I recommend that for further and more in depth clinical information please refer to the DSM5.
Are You Feeling Overwhelmed?
If so, you’re not alone! “ Overwhelmed ” is the word I hear echoed by people more often these days than in past years. Is that your experience? Consider for a moment what word sums up what you want most these days? If you said “ Relief, ” you’ve landed on the word that expresses what many people need more of and yet find most lacking.
It’s fairly evident that stress is increasing in our lives in dramatic proportion to the more calm and serene states that allow for rest, relaxation and peace of mind. In many ways the world has become safer; but in many ways it doesn’t feel safer. And, the imminent threat of some impending calamity causes a pervasive state of agitation. We are living in the age of anxiety.
In addition to what causes our personal stresses, we carry in the back of our minds the worrisome concerns about when the big earthquake will occur; or whether our plane flight will get us to our destination in one piece; or whether our children will be safe in school today; or whether I may encounter some irate guy brandishing an AK-47 assault rifle while I’m out and about; or whether the worldwide threat of savage terrorism will once again impact our homeland.
Marc Schoen, Ph.D. in his book, Your Survival Instinct is Killing You, refers to a pervasive state of underlying uneasiness he calls “Agitance, a chronic state of misalignment in which we feel flustered, on edge, unstrung, unnerved, tense, and unable to relax.”
Unremitting stress undoubtedly fuels the epidemic of anxiety and depression that has become endemic to our society in modern times. Jed Diamond, Ph.D., author of Stress Relief for Men: How to Use the Revolutionary Tools of Energy Healing to Live Well, states that, “Depression is one of the most serious and controversial topics in health today. By the year 2020, depression will be the 2nd most common health problem in the world after heart disease and studies show depression is a contributory factor to fatal coronary disease. Billions of dollars are spent every year on antidepressants yet the rates of depression keep increasing.”
Are you Depressed?
I heard it once said: Man goes to doctor.
Says he’s depressed. Says life is harsh and cruel.
Say he feels all alone in a threatening world.
Doctor says, “Treatment is simple.
The great clown Pagliacci is in town tonight.
Go see him. That should pick you up.
Man bursts into tears.
He says, “But doctor . . . I am Pagliacci.”
Robin Williams (19512014)
The tragic death by suicide of the iconic Robin Williams has brought depression out of the shadows and into the light of day. According to depression statistics from the Centers for Disease Control and Prevention (CDC), about 9 percent of adult Americans have feelings of hopelessness, despondency, and/or guilt that generate a diagnosis of depression.
At any given time, about 3 percent of adults have major depression, also known as major depressive disorder (MDD), a longlasting and severe form of depression. In fact, major depression is the leading cause of disability for Americans between the ages of 15 and 44, according to the CDC. Understanding these very real depression statistics helps paint a fuller picture of the impact of depression in America.
Generally speaking, depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. This is referred to as Exogenous Depression. But when it becomes more acute and returns with increasing vengeance throughout one’s life it can turn deadly. This form of the condition is called Endogenous or Clinical Depression.
In this case, depression must be considered a serious medical illness that involves the brain. When it’s pervasive It’s more than just a feeling of being “down in the dumps” or “blue” for a few days. If you are one of the more than 20 million people in the United States who have clinical depression, the feelings do not go away. They persist and interfere with your everyday life. Symptoms can include
● Loss of interest or pleasure in activities you used to enjoy
● Change in weight
● Difficulty sleeping or oversleeping
● Energy loss
● Feelings of worthlessness
● Thoughts of death or suicide.
It is estimated that there are about 39,000 suicides a year in America. Among Americans age 3464, the suicide rate has increased almost 30% since 2000, and it has been trending upwards for American women as well. In the U.S. the suicide rate for males is 4 to 18 times higher than it is for females, increasing dramatically with age. Men between the ages of 65 and 85 kill themselves almost 10 times more frequently than do women of the same age, especially following a divorce. Veterans now commit suicide at a rate of 22 a day; that’s almost 1 per hour.
In Britain, suicide is the leading cause of death among males. “There are more than one million people who die by suicide each year in the world, which is more people than those who die from war, terrorist attacks and homicides every year. So more people kill themselves than are killed by other people,” says Lanny Berman, Ph.D., president of the International Association for Suicide Prevention (IASP). Further, worldwide, males kill themselves 4 times more often than females.
The Depression Myth
Men’s willingness to downplay weakness and pain is so great that it has been named as a factor in their shorter life span. The ten years of difference in longevity between men and women turns out to have little to do with genes. Men die early because they do not take care of themselves. Men wait too long to acknowledge that they are sick, take longer to get help, and once they get treatment do not comply with it as well as women do.It is commonly taught that depression is predominantly a woman’s disease and that the rate of depression is somewhere between two to four times higher for women than for men. One of the ironies about men’s depression is that the very forces that help create it keep us from seeing it. Men are not supposed to be vulnerable. Pain is something we are to rise above. He who has been brought down by it will most likely see himself as shameful. It is the secret pain that lies at the heart of many of the difficulties in men’s lives. It comes down to that we tend not to recognize depression in men because the disorder itself is seen as unmanly. Depression carries, for many, a double stain the stigma of mental illness and also the stigma of “feminine” emotionality. Men are supposed to be like “sturdy oaks” that stand tall and invincible in the face of all incursions that might challenge them.
Another factor mitigating against the recognition of depression in men is that mental health professionals, no less than anyone else, tend to look for what they expect to find. The conventional wisdom that women are depressed, while men are not, leads some therapists away from an accurate diagnostic assessment.
The Mask Men Wear
Depression in men is often hidden from those around the individual, and it is largely hidden from his own conscious awareness. Masked depression is one of the most prevalent disorders in modern American society, yet it is perhaps the most neglected category in psychiatric literature.
Thoreau once wrote: “The mass of men lead lives of quiet desperation.” When we think of depression however, our thoughts typically turn to symptoms that are not so quiet. Acute and dramatic, the pain inflicted by depression can loom largely. When the symptoms of depression are more visible and recognized for what they are, we may consider this state of the condition as overt. If overt depression in men tends to be overlooked, masked or covert depression is rendered all but invisible.
In his book I Don’t Want To Talk About It, Terrence Real characterises covert depression in men as “the hidden depression that drives several of the problems we think of as typically male—alcoholism, drug abuse, selfmedicating with sex, gambling, domestic violence, workaholism, antisocial behaviors and conduct disorder.”
Dr. Real sounds the alarm that, “There is a terrible collusion in our society, a cultural coverup about depression in men.” He goes on to say that, “Traditional gender socialization in our culture asks both boys and girls to “halve themselves.” Girls are allowed to maintain emotional expressiveness and cultivate connection. But they are systematically discouraged from fully developing and exercising their public, assertive selves their “voice,” as it is often called. Boys, by contrast, are greatly encouraged to develop their public, assertive selves, but they are systematically pushed away from the full exercise of emotional expressiveness and the skills for making and appreciating deep connection.” Girls, and later women, tend to internalize pain. They blame themselves and draw distress into themselves. Boys, and later men, tend to externalize pain; they are more likely to feel victimized by others and to discharge distress through action. Hospitalised male psychiatric patients far outnumber female patients in their rate of violent incidents; women outnumber men in selfmutilation.
Too often, a wounded boy grows up to be a wounding man, inflicting upon those closest to him the very distress he refused to acknowledge and has gone unhealed within himself. Depression in men, unless it is dealt with, tends to be passed along.
Research shows that one distinguishing characteristic of battering men is a markedly increased sensitivity to feelings of abandonment, which can often translate into love addiction. Dr. Real indicates that, “Without knowing it covertly depressed males use their connection to their sexual partners to help medicate their pain. When their partners ‘fail’ them, they are flooded by depression and shame. Rage psychologically and physiologically ‘medicates’ their dip into the experience of depression. Helpless feelings vanish with the illusion of inordinate power. the grandiose entitlement to lash out at another human being rights their floundering sense of selfworth and they strike.”
Like the Trojan Horse Invasion
Current research makes it clear that a vulnerability to depression is most probably an inherited biological condition. Anyone, male or female, given the right mix of chromosomes, will have a susceptibility to this disease. But in the majority of cases, biological vulnerability alone is not enough to bring about the disorder. It is the collision of inherited vulnerability with psychological injury that produces depression.
If you are experiencing an imbalance of neurotransmitters you are likely to get depressed. For example when one is not producing enough serotonin, a neurotransmitter that allows one to be calm, focused and moodstabilized, one tends to feel depressed, irritable, anxious and agitated. Like those rare conditions which causes a person’s own immune system to assault itself, depression is a disorder wherein the self attacks the self. It’s like the “trojan horse invasion” in which the attack sneaks place within the sacred fortress while one’s forces are unprepared and unsuspecting. The man attempts to ward it off, exhausting all of his resources, while endeavoring to maintain the appearance of impenetrability and invincibility.
While many of the men treated report the classic symptoms of overt depression, feelings of hopelessness, helplessness, and despair, many more experience depression as a state of numbness, which is known in psychiatry as A lexithymia. This experience of depression is not about feeling bad so much as about losing the capacity to feel at all.
In covert depression, a man desperately defends against such an onslaught while trying one perceived remedy after another only to come away empty handed and shamefully deflated. Dr. Real states that, “A common defense against the painful experience of deflated value is inflated value; and a common compensation for shame, of feeling less than, is a subtle or flagrant flight into grandiosity, of feeling better than. Quite a number of theorists have noted the ‘narcissistic defense’ of using the mask of grandiosity to ward off shame. The flight from shame into grandiosity lies at the heart of male covert depression.”
While the covertly depressed man must consume something or do something to shift the state of his selfesteem, a man with bipolar manicdepressive illness flips back and forth between grandiosity in the manic phase and shame in the depressed phase at the seeming whim of the disease. The manic phase of the condition is simply a more extreme version of elevation that relies on the rush of inflated selfesteem to ward off depression.
Some individuals use rage to physiologically pump up their sense of deflation. Research shows that rage simultaneously releases adrenaline, which speeds up the autonomic nervous system, and endorphins, which act as the body’s own opioids. This is a powerful internal cocktail, which tragically, like any other form of intoxication, can offer short-lived relief from the pain of depression.
Dr. Real goes on to say that, “When a covertly depressed man’s connection to the object of his addiction is undisturbed, he feels good about himself. But when connection to that object is disrupted when the cocaine runs out, the credit cards reach their limit, the affair ends his sense of selfworth plummets, and his hidden depression begins to unfold.”
Out of the Shadows and Into the Light
There is a tendency to selfmedicate when one feels anxious and depressed. This typically leads to dependency on the substance that one uses to ease the pain and suffering. An addict’s choice of drug may rest on that drug’s particular medicating properties. Alcohol, for example, relieves a sense of inner emptiness and coldness by warming and disinhibiting, often making one more sociable. By contrast, opioids, like heroin, do not warm one up so much as calm one down, tranquilizing the ferocity of depression, the agitation and selfhatred. Cocaine brightens a person, giving him energy; it breaks through the numb, dead feeling of Alexithymia.
The doubleedged approach of stopping the addictive cycle while dealing with the emergent depression, calls for the “dual diagnosis” of both depression and addiction. Covertly depressed men who selfmedicate with substances have the greatest chance of correct diagnosis and of receiving effective treatment for both aspects of their disorder.
Dr. Real cautions that, “The covertly depressed person cannot merely vault over the avoided pain directly into wholeness, as hard as he may try. The only real cure for covert depression is overt depression.” In other words, the mask of depression must be removed bringing the hidden condition out of the shadows and into the light of day. Novelist William Styron describes a relationship between alcohol and depression that, for him, stretched across decades:
“Alcohol was a central factor, to the best of my knowledge, in my depression. I believe that many people who are by nature depressive, or have a depressive bent, use alcohol
throughout most of their lives to, paradoxically, alleviate the depression … You use alcohol as a kind of medication to keep your demons at arm’s length. But all of a sudden I was unable to drink. I developed a severe intolerance to alcohol. .. ln the absence of this mood bath, as I call it, that I would have every day in the evening, now I had a new experience of not having alcohol there to give me that sensation of euphoria. And that allowed the depression to crowd in.
First, the covertly depressed man must walk through the fire from which he has run. He must allow the pain to surface. Then, he may resolve his hidden depression by learning about selfcare and healthy esteem.
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