Mimicking Depression

There are two medical conditions that frequently show up in psychologists’ office as depression. These medical disorders outwardly mimic depression (and may even cause depression), but have distinctly different causes, and, untreated, can endanger a person’s health. If you are experiencing depression symptoms, you may want to consider seeing a physician, not for antidepressant medications, but rather to be checked for other problems that may mimic depression.

When I was in graduate school we were frequently reminded to consider hypothyroidism (insufficient release of thyroid hormone) in women who presented with depression. Both cause lethargy/fatigue and hypersomnia (sleepiness), are associated with physical pain in the joints and muscles, and involve lack of motivation, anhedonia (loss of enjoyment in things which use to be enjoyable), negative mood states (e.g., sadness, regret, or anger), mood swings, and weight gain. Many of the symptoms of hypothyroidism mimic depression and it is consequently frequently under-diagnosed, or misdiagnosed as depression.

No amount of anti-depressant medication will make the symptoms of hypothyroidism go away. Thyroid hormone affects many other bodily functions and low levels can negatively affect multiple organ systems. Untreated hypothyroidism can lead to goiter and heart problems and can even cause birth defects if a pregnant woman has hypothyroidism, so proper diagnosis is very important. More women than men present with depression symptoms, so awareness of this mimicking phenomenon is drilled into psychologists in grad school. However, it is also important that women be aware of the similarity so that they know to consult a physician (perhaps in addition to a psychologist) if they experience symptoms of depression.

Perhaps because men present for depression less frequently than women, being able to distinguish medical disorders from mental disorders is less emphasized in grad school. If a man presents with difficulty attaining or maintaining an erection, lack of sex drive, irritability, mood swings, negative mood states (e.g., sadness, regret, or anger), difficulty concentrating, lethargy/fatigue, a lack of motivation, and weight gain the psychologist is likely to diagnose depression, whereas the medical doctor will probably evaluate testosterone levels. These symptoms are common to both disorders and both would be reasonable diagnoses given the respective experts’ fields.

Many of the symptoms that might allow for differential diagnosis are not likely to be mentioned by men over 35 to either a psychologist or a physician. Hair loss is normal as a man ages, but is also accelerated by low testosterone. The development of fatty tissue in the breast/chest area probably also isn’t going to have attention called to it when presenting to a health professional—either because it is embarrassing or because it won’t even be noticed with the rest of the weight gain. But these are some of the things that can be used to assess if a man is suffering depression or low testosterone. Sometimes, though increasingly less so, male clients will not tell their psychotherapist or counselor about sexual dysfunction either. Even in the absence of these symptoms I have encouraged some of my male clients to have their testosterone levels checked.

Decreased testosterone is normal for a man over 40, but sometimes there is a precipitous drop in testosterone levels and that will lead to depression-type symptoms, along with health risks. Low testosterone is associated with heart problems and even susceptibility to broken bones. And, like hypothyroidism, anti-depressant medication will not address the symptoms, not even the mood symptoms, effectively.

Along with the normal drop in testosterone, there is a natural drop in sexual function and energy, which may be perceived as the normal part of aging—and for many it is—but even many physicians are not trained to ask about the effects of lessened testosterone in a way which would indicate lower-than-normal-for-age testosterone levels. It is important that men be aware of the symptoms and question the severity of the drop (and the mood features associated with low testosterone) in order to take care of themselves.

There is some controversy whether hypothyroidism and low testosterone mimic or actually cause depression. To me the distinction might be irrelevant. If after taking the medication the depressive symptoms do not go away after a few weeks, you might want to see a therapist to address whatever depression may have followed the body chemistry problems from the physical disorder. If the depressive symptoms go away from treating the primary physical problem, then the depression has gone anyway. But the main point is that, like with so many physical disorders, it is important to know to consider with the medical or mental health professionals all of the possibilities.

Doling Out Your Crazy

When we meet someone for the first time, especially someone with whom we want to get intimate, we want to make a good impression. Part of making a good impression is being yourself with someone. People are pretty good at detecting insincerity; people do not respond well to partial presentations. But people also don’t tend to want to associate with people who present as a “mess.”

I encourage my clients to dole out their crazy a little at a time when developing a relationship. There is a pace at which it feels healthy and appropriate to share one’s uncertainties and idiosyncrasies. It is sort of like testing the waters. Trying to see how much of our own craziness the person is ready to handle. This is partially determined by how much quality is perceived in the person—in other words: “Does the person have enough good stuff to put up with the crazy?” By the way, we all have a little craziness.

The craziness may be some odd superstitious ritual or fear that is not grounded in any rationality, but is grounded in the perception of our own experiences. We all have some strange ideas about the world and frequently our own un-founded insecurities (e.g., I have a faux paranoia about ebola). No one is really quite “normal,” while they might be mentally quite healthy. These are the quirks that make us who we are—often the parts that people find endearing after they get to know us.

However, emphasis on “after they get to know us” is worth highlighting. Too much intimacy—crazy or not—too soon is usually off-putting. We enjoy the process of getting to know someone; the process of discovery is engaging. Knowing everything at once can feel overwhelming—there is no context for the details, no sense of nuance or flavor. It can feel too raw. Additionally, I think there is something to feeling special because an intimate aspect of someone was shared with us. Aspects of oneself shared too easily do not feel like intimacy.

We also take as a cue how much we will share (or are expected to) based on how much another shares, and therefore someone sharing too much too quickly may feel threatening. Most of us want to control the rate at which someone knows our quirks and insecurities—there is vulnerability in it. When someone blurts out all of his or her idiosyncrasies, we don’t feel safe sharing with him or her our personal thoughts. Furthermore, the expectation to match the pace of sharing can make us want to back away (and protect our privacy).

I do not mean to discourage sharing, of course. Exposing our true selves actually tends to open us up to greater connection and happiness. However, when trying to decide to share one’s quirkiness think about the purpose of the sharing—what are you trying to achieve by it? Are you trying to provide insight? Are you trying to explain a particular behavior or tendency? Are you trying to be funny? Or is it just coming out of you uncontrollably? That last one is the one to watch out for—it will drive people away (or to stare).

The Five Love Languages

Gary Chapman came up with the theory of the five love languages. It is an idea I use with clients frequently. It addresses the idea that demonstrations of love often go unnoticed (or unappreciated) by a partner. Chapman discovered that people engage in and recognize demonstrations of love differently. He categorized these disparate actions into the categories, or languages: words of affirmation, quality time, receiving gifts, acts of service, and physical touch.

Saying “I love you” is important and can be powerful in its own right. However, in our culture the word “love” has lost some of its strength because of how loosely it is used (“Oh, I love those shoes”). “I love you” can also feel obligatory and insincere sometimes. I encourage clients to share what about their partner(s) they love. Those are true words of affirmation. I do caution people not to use them as blackmail though, don’t turn them into “I love it when you...” in order to get someone to do something, but rather only as sincere appreciation for their having done it.

One of the most valuable and overlooked things that we can offer a partner is our time. Companionship is essential for a relationship (of any kind). Doing things together can function as a bonding experience. It is important to find shared interests and it is important to be curious about your partner(s) interests, even when it is not a shared interest. Work on enjoying your partner’s company when you do things with them that you don’t necessarily enjoy doing yourself—make enjoying their company what you get out of it rather than the joy of the activity itself. Another aspect of quality time that is frequently overlooked is that just sitting with someone who is suffering, enduring what they are going through—without an agenda of your own—is one of the greatest gifts you can give someone.

Meaningful trinkets can in fact be very meaningful. A few years ago my BF was putting in some glass doors, to open the house up to the backyard. I appreciated what he was doing (and his concern that it was temporarily inconveniencing us) so I purchased and wrapped a DVD of a movie I knew liked and stuck in conspicuous place in the jobsite one night so that he found it the next day when he went back to the project. Flowers are the gold standard of trinket gifts, but occasionally spontaneously providing something that your partner has casually mentioned wanting is a great way of saying “I care about and attend to you.”

Doing non-chore household tasks, especially without being asked can be a powerful statement of “we are in this together.” Noticing things that your partner does not like or is incapable of doing and doing those things for him or her is another way of showing you are attending and care. If you can notice something you can do to improve a process of your partner’s or can create something to facilitate the ease of his or her process, you are likely to be appreciated. Even helping out in mundane ways tends to be felt as cared for. My boyfriend cooks most of the dinners in our home and I recognize his doing so is at least partially an act of appreciation for having me in his life.

Touch can be incredibly powerful. There is research that chemicals are released in our brains by just watching another person be tenderly touched. Research has even shown that a comforting touch can be desirable than sustenance. A simple caress or reaching for a partner’s hand while watching TV says “I value you.” While sexual groping can be a great way of saying “I find you sexy,” a non-sexual touch can say “I appreciate you beyond the great sex” (and might even lead to great sex!). Even people who are not touchy-feely can appreciate an occasional touch.

But the important thing to remember is that you may be saying “I love you” all of the time, but if you are speaking a different love language than you partner, the message may not be getting through. It is important to learn the language that your partner comprehends and speak that language. It may even be a good idea to let your partner know what language you hear. An issue that I have not seen Chapman address is that some people speak and hear different love languages themselves. So you cannot always count on getting your love message heard simply by speaking the same language your partner speaks. It is also worth learning what love language your partner speaks, so that you can become better aware of when he or she is saying “I love you” in a language that you don’t hear. Ideally you won’t send messages that are not received, but nor will you miss the messages that are sent in a foreign love tongue.

Misdirected (Dis)Respect

I recently had a client tell me about a guy with whom he was maybe, sort of, kind of, possibly beginning to start a relationship. And the client shared with me that one of his hesitations about starting the relationship was that “the guy deserved better.” The statement stopped me.

The idea that someone deserves better than oneself is a notion that has never made sense to me. Unless you know that you are going to do harm to someone or are being duplicitous, then I don’t know from where anyone gets the idea that he or she has the authority to decide whether one is good enough for another. I asked my client on what basis was he making the decision for his potential love interest and my client was unable to produce a coherent, rational argument. It seemed to be more of a feeling. In this case, it was a feeling of personal inadequacy of my client’s.

It strikes me as very presumptive that someone would feel he or she was in a better position to decide what would be rewarding to a (potential) partner than the partner himself or herself. On what basis does one make such a claim? Are you thinking of dating someone with poor judgment?—if that is the case, then the person probably does not deserve better than you. The assertion strikes me as rather self-centered actually.

I think the statement is made out of respect for the (potential) partner, but is actually an act of disrespect. It is grounded on the person either not being able to make good decisions or not knowing what would be good for himself or herself or that the person cannot adequately assess others. Those aren’t very respectful claims to make about another. In fact, they pretty well disregard the other person’s ability to decide or determine what he or she would most enjoy or benefit from in a partner. It pretty much is the same as saying “I know what would be good for you better than you do.”

But the aspect that I think makes it the most self-centered is that it is really about the person making the statement’s self-image than the person about whom the statement is being made. As with my client, it is more often a statement of one’s own sense of inadequacy. It seems it would a healthier and more productive approach to acknowledge and explore how the qualities you see in yours love interest make you feel, rather than write off the compatibility. Heck, you may even want to be honest with your partner. But I would strongly encourage you to be open to what your partner might see in you of value that you do not recognize in yourself.

I really don’t think we are in a position to decide if we are worthy of or good enough for another. I think we are not the best judges of that. I think that we grant a (potential) partner more autonomy and more respect by being honest about who we are (with our concerns about compatibility and being open to his or her perspective). Respect for your (potential) partner’s ability to make a good decision as much as you respect the qualities that make you feel unworthy.

Put Your Oxygen mask on First before Assisting Others

This piece of advice from flight attendants is a useful metaphor for the rest of one’s life. Many people end up putting others before themselves, end up assisting others before taking care of themselves. And, in a sense, the same consequence occurs as might if you waited to put your oxygen mask on until all those around you had been taken care of—they spiritually or emotionally pass out. Perhaps more accurately, they end up being less functional because they have averted too many of their resources towards others. This is perhaps a particular concern for the submissive members of the BDSM community.

When I was in graduate school the faculty emphasized the importance of taking care of oneself in order to be available to give one’s best in taking care of another. Being in a profession that is highly susceptible to “compassion fatigue,” this was frequently repeated in all of my training experiences. However, for people for whom compassion and service toward others is their nature but are not in a “compassion profession” they are rarely taught the importance of self-care.

One of the barriers to awareness about self-care is the blurring of self-preservation or even self-interest and selfishness. I addressed this previously on this blog, but it is common enough of a phenomenon that it is worth repeating. Self-care is more akin to being responsible, than being selfish. Self-care (or equally self-preservation or self-interest) can as reasonably be seen as maintenance. The best service is offered by the best maintained machines. This is also true of people; we operate best when we take care of ourselves (first).

When we haven’t taken care of ourselves first, then we are prone to the effects of stress. We are more likely to get distracted, more likely to forget things, more likely to make bad decisions, and more likely to become irritable, rather than act in a loving manner. Taking care of others can actually increase one’s happiness. However, this is much less likely if the care feels like a burden rather than an act of kindness. If one is worn out or unfulfilled in his or her own life, then the care that is given—to a child, parent, partner, or friend—is more likely to generate feelings of resentment. This will in turn undermine both the relationship and the reward of the relationship. Subsequently, the quality of the care provided will suffer.

I do not want to promote selfishness under the guise of self-care, but I too often see people neglect themselves under the guise of caring for others. This actually seems more insidious than selfishness to me. I suppose what I would truly advocate is greater awareness in taking care of oneself, rather than putting others first. I would even suggest that to my sub (slave/boy) friends and clients—a good Dom/Master/Daddy needs to be aware of when his/her sub needs to care for himself/herself as well. So, if you find yourself providing a lot of service or care to another or others, check with yourself to make sure that your needs are being met too. You will be able to provide better care and service if you do.

Friendship is Not an a la Carte Option

I recently received an email from a client that asked “why should I continue to try to be friends with people, when people will invariably disappoint me?”

Generally, from what I see with my clients, isolation and loneliness are more damaging and more painful than disappointment. One of our core needs is the need to be accepted, to belong. When we isolate ourselves from others because we find it difficult to tolerate disappointment, then we deny ourselves getting this need met. Without this need we are not whole. Belongingness and acceptance are not things we can provide for ourselves, and are only truly available from others. In fact, former head of the American Psychological Association Abraham Maslow argued that our self-acceptance is grounded on feeling a sense of acceptance by others.

If we refuse to allow others to occasionally disappoint us (because of earlier experiences in which disappointment was associated with real needs—like food, shelter, affection), then we insure that some of our needs will go unmet. We may become so starved for belongingness and acceptance that we perceive the disappointment as rejection—being valued is seen in rather all-or-nothing terms. Sometimes our friends really do care about us but do not know how to show it in a way that we can perceive. Sometimes we have to lovingly invite a conversation about it how feels when we are disappointed.

Sometimes our friends seem unable to change the behavior that disappoints us. Then we have a choice. We have to decide if the behavior that offends weighs more than the value that the friendship offers. Often times a big part of what makes the behavior offensive is that we cannot understand it. Developing compassion for why our friends are unable to change their behavior (right now)—or at least what motivates the behavior—may make the offending behavior easier to tolerate. It may also be worth recognizing that the behavior does not mean the same thing to the friend as it does to you. Sometimes the behavior is just a quirk. It might also be worth remembering that we disappoint our friends too—hey, nobody’s perfect.

There are also times when we experience a friend’s behavior as genuinely intolerable. Sometimes our friends’ behavior is damaging or exploitive to us. Even if their friendship offers us something good, we may need to sever the friendship. It is important to balance self-preservation and growing to be more compassionate of others. There is no simple answer here.

The psychological reward from friendships is in the sense of companionship and having a confidant. Friendships should make us feel better about ourselves. Friendships have been shown to improve one’s mental health, physical health, and longevity. If what you have a is a real friendship, then the disappointing parts are probably worth finding a way to not be bothered by them, but if the “friendship” does not build you up and make you feel more sure of yourself, then it might be time to move on. Either way, we cannot get the good without the bad.

Self–Esteem vs. self-esteem

"I'm good enough. I'm smart enough. And doggone it,
people like me."

Stuart Smalley

In the last few decades there has been a movement toward an “everyone is great” attitude. This idea was (not so?) subtly addressed in the move The Incredibles. Syndrome points out the problem with this position when he says that “when everyone is super, no one will be.” This idea is repeated when Dash is graduating from the 4th to 5th grade and Mr. Incredible says “It's psychotic! They keep creating new ways to celebrate mediocrity.” After a while Self-Esteem becomes grounded in nothing, and consequently also becomes meaningless.

The claim that one is special becomes as empty as Stuart Smalley’s affirmations. Affirmations have been shown to be an effective tool to change one’s thinking—BUT ONLY when the person can actually believe the affirmation. Otherwise, affirmations are as likely to reinforce the idea that one falls short of the very thing he or she is trying to believe or achieve. This is what happens when we build up Self-Esteem in the absence of any foundation for it. In fact, telling people that they great in the absence of a basis (e.g., actual achievement) has been shown to be detrimental to both performance and emotional wellbeing. Martin Seligman, one of the leading researchers on happiness, has claimed that the increased interest on Self-Esteem has actually led to increased occurrence of depression. However, high Self-Esteem has been correlated with better performance, initiative, and happiness. People with high Self-Esteem tend to be more comfortable in social interactions. Consequently, Self-Esteem as a psychological phenomenon has become rather controversial.

When I talk about self-esteem with clients I talk about it terms of what do they actually value about themselves, or what do they feel that they have that they can contribute or that will draw people toward them. Self-esteem gives one a sense that he or she will be accepted (or is acceptable); this is essential to one of our fundamental needs—belongingness. It allows us to take risks, both a good and bad thing, because we less fear rejection. In my experience, valuing something specific about oneself makes a difference. Few of us believe claims (especially about ourselves) in the absence of evidence.

I see many clients who are anxious or depressed because they lack initiative or confidence and socially isolate themselves specifically because they do not recognize what they have to offer. I try to get them to list the traits they perceive in themselves and then help them recognize how some of those traits may be valuable to others. I ask them what they like about themselves. Sometimes I have them ask important others in their lives what those people like about them. This sometimes helps the client see that a trait he or she did not recognize as valuable is in fact valuable to others—and will consequently promote acceptance and belongingness.

This is a technique that many of us could benefit from. Make a list of what about you is valuable and keep it around for those times when you become less certain about how likable you might be. Just make sure these are traits that you believe (a) are valuable to others, and (b) that you actually have. It can be good to proud of oneself, as long as one is proud of something about oneself. That makes for healthy, beneficial self-esteem.