On the other side of the mood spectrum, or pole, from mania and hypomania is depression and a long-lasting depressed state called dysthymia. Unlike the passing blues we all get, an episode of depression is a sustained sad or unhappy mood. To be classified as clinical depression, it must persist for at least two weeks and have at least five of the following symptoms, you may find it useful to use a mnemonic (memory aid) taught in medical school, “sig e caps.”
• Sleep. People who are depressed will often experience unwanted changes in their sleep pattern. This will range from difficulty falling asleep and middle-of-the-night-arousals to waking up earlier and earlier. In some types of depression, instead of sleeping less, some people will sleep excessively and feel constantly tired. In the depression associated with bipolar disorder, this increased tiredness is common.
• Interest. When depressed, people lose interest in things they usually enjoy. This can progress to a total lack of pleasure referred to as “anhedonia.”
• Guilt. Here we’re talking about guilt that is excessive and out of proportion to the situation. In some depressions this can actually assume delusional (psychotic) proportions: For example, someone who always pays her taxes on time and never cheats becomes consumed by the belief that the IRS is coming after her. More typically, a depressed person will ruminate about everything wrong they’ve ever done. Their self esteem is at rock bottom, and they can feel worthless. You may hear them say things like: “It’s all my fault” and “I can’t do anything right.”
• Energy. This is usually decreased. People feel run down, drained, tired. For some, depression has additional physical complaints that include generalized aches and an increased focus on medical concerns.
• Concentration. People with depression may have trouble focusing. They are easily distracted, and everyday tasks become increasingly difficult. As the depression worsens, even focusing on a television show or reading a short newspaper article may become too much.
• Appetite. Most commonly, people with depression lose their appetite, along with quite a bit of weight. Some, however, eat constantly and gain weight.
• Psychomotor agitation or slowing. This refers to how the person looks and feels. Sometimes people with depression can be markedly slowed, their speech diminished to one or two word answers and the expression on their face flat and unchanging. Or, they could be visibly anxious, worried, and jumpy, this could be called the ‘hand-wringing’ depression.
• Suicide. People who are in unbearable psychological pain often think of suicide as a way out. We’ll talk more about suicide later in this book, but one of the key points to remember is that if someone says he has lost hope and no longer sees a future for himself, it’s a serious red flag that he may be actively planning to kill himself. Expressed thoughts of suicide should always be taken seriously, as most people who kill themselves (over 90 percent) have told someone that they were thinking about it.
The following internal monologue illustrates many symptoms of depression.
It’s so hard to find words. Everything inside of me feels dead. I don’t want to write this, or think. I’d like to go away and be done with everything. I’m so sorry. I’ve screwed up everything. I don’t want to do this to Peg or the kids, I can’t shake this, and I know that they’ll be better off in the long run.
I’m supposed to be looking for a job. John told me the layoff wasn’t anything to do with my performance. Others got laid off, I know this, but how do you not take it personally? I’m such a total loser, failure. Like everything I’ve worked for all of these years didn’t matter. You’re with a company for twenty years and they tell you it’s not personal, when you have two weeks to say goodbye, clean out your desk, and go for job counseling. What a joke that was.
I can’t sleep. I lay there, the same thoughts over and over through my head, everything is coming undone. Two months of not paying the mortgage. I don’t have the money for the taxes. No one’s going to hire me, not for anything close to what I was making. I’m almost fifty. My whole life is unraveling and there’s nothing I can do to stop it. I get up and even the television is too much. I can’t focus. I hear Leno tell a joke, I used to think he was hysterical; it’s not funny, even though I hear the audience laugh. I used to laugh all the time. People would come up to me and tell me what a happy person I must be because I’m always smiling.
Every day, every hour I think about the car in the garage and how easy it would be to do this. The weird part is that thinking about killing myself, of just turning the key and letting it run, doesn’t feel bad, more like a relief, just be done with it. I think that’s what I’ll do. I’ll do it in the morning.