THE ROLE OF DEPRESSION IN TRAUMA – With Love from Dr. G
Often what we in the field teach patients to understand about trauma symptoms is that they are expected responses to unexpected life events. Immediately following a traumatic event, we EXPECT you to show some signs of having gone through trauma (refer to TRAUMA 411). Especially if you are in treatment, we hope that over time these acute trauma symptoms will subside and normal life will resume. However, what commonly occurs is that other underlying symptoms may become more apparent or problematic. To clarify, once the jumpiness and fear resolves, and irritability improves, and even sleep returns to baseline, you may feel like you’re falling into a slump. Something to consider is that perhaps those symptoms (i.e., sadness) were there all along, but simply being overshadowed or distracted by the more “outward” or externally- presenting symptoms like anger and anxiety. Here are some basic facts about trauma, PTSD, and some of the associated issues we often see following a traumatic experience.
Approximately 1 in 3 people in this country have been formally diagnosed with an anxiety disorder, and 1 in 4 people have been formally diagnosed with a mood disorder (like depression). Obviously, this is an underestimation of prevalence since we all know people who likely have mental illness but who have not sought help or been diagnosed. And keep in mind that if you had experienced trauma, anxiety, or depression at any point in your life prior to your recent trauma, then this placed you at higher risk for manifesting anxiety, mood, and trauma symptoms following the event. Posttraumatic Stress Disorder is a complex disorder that includes overlapping symptoms of anxiety and depression, as well as symptoms unique to trauma (refer to HOW PTSD DEVELOPS). Furthermore, distinct anxiety and mood disorders may coexist with PTSD as stand-alone diagnoses when we see specific symptom clusters persist. Depression is often experienced with PTSD.
It is not surprising to see all of these types of symptoms cluster together because the mechanism by which they develop and are maintained (from a Cognitive Behavioral standpoint) is all the same. When you experience trauma, you may start to notice hypervigilant behaviors (e.g., scanning people, looking for exit routes, preparing for action should a catastrophic event occur). These behaviors reinforce highly negative and anxiety-provoking thoughts that you are constantly in danger, people cannot be trusted, and the world is a terrible unsafe place. If you continue to feel this way, you will likely start avoiding more and more situations (refer to WHY AVOIDANCE MAKES IT WORSE). In sum, your behaviors and thoughts become a negative feedback loop that often becomes worse and worse over time.
Similarly, when you experience other types of anxiety (e.g., generalized, social, specific), you may notice that you start avoiding engaging in activities or situations in which you become highly aroused or anxiety (often manifesting as panic – refer to ANXIETY AND PANIC). This avoidance is the single most dangerous thing because it reinforces your fear, and ultimately this alone may perpetuate and sustain your anxiety. People who suffer from chronic anxiety inevitably develop depression too. Think about it – how would you expect to feel as your life becomes smaller and smaller, and increasingly limited, and you begin to lose or neglect things in your life (relationships, hobbies, activities of daily living). Depressed! In sum, your behaviors and thoughts become a negative feedback loop that often becomes worse and worse over time. Does this sound like something you just read?
What is DEPRESSION? Depression is not just feeling sad, it is actually a medical condition that affects how we think, how we feel, and our behaviors and interactions with other people. As depression progresses, you begin to lose interest in or a sense of enjoyment from activities that you previously enjoyed. Other things you may notice are excessive feelings of guilt or hopelessness and even suicidal thoughts (i.e., thoughts about dying, killing yourself, or being better off “not here”). Often people experience changes in their energy level, appetite, and sleep patterns. It is also common to have difficulty focusing or concentrating, and to feel slowed down or amped up. When all these symptoms last for at least two weeks or longer, then it may indicate that you are heading into a clinical depressive episode that could last significantly longer (especially if you do not seek treatment). When you become depressed, you may start to feel detached and unmotivated to do much of anything, and this may lead you to isolate yourself from others. In sum, your behaviors and thoughts become a negative feedback loop that often becomes worse and worse over time. Are you noticing the pattern now?
It is important to recognize that when we see chronic depression, anxiety, and/or trauma symptoms, we also see anatomical, physiological, and neurochemical changes in the brain. Some of the structures that play a role in depression are the amygdala, hippocampus, and thalamus (i.e., all parts of the limbic system in the brain – again think about all the little emotions running around in the headquarters of Inside Out). One significant change occurs in the hippocampus, which shrinks over time when depression is chronic. This is problematic because the hippocampus is involved in focus, concentration, and memory – specifically forming, organizing, and storing memories. Research in recent decades supports this by demonstrating visible changes on fMRI (functional magnetic resonance imaging) scans, PET (positron emission tomography), and SPECT (single-photon emission computed tomography). Fortunately, these changes are reversible and highly treatable with both pharmacotherapy (medication) and psychotherapy (counseling).
So, what can we do if we are experiencing depression? Well, the answer is simple (although not necessarily easy). We want to do exactly the same thing we would do to recover from any anxiety or trauma disorder. At the end of the day, whether you are avoiding or isolating, you are still missing out on activities or socializing. In order to be healthy we want to stay vigilant about sleep, nutrition, and physical activity, stay connected to our social support network, and stay engaged in pleasant activities (and doing them even when we do not feel like it – don’t forget Bucket Rule #5 of the Dr. Ghaed’s Rules). Isolation (i.e., isolating ourselves) is as damaging as avoidance (i.e., avoidance behaviors).
Whether you are depressed, or still experiencing significant anxiety or trauma symptoms, this is a critical time when you simply cannot afford to allow your feelings to dictate the decisions you make throughout the day! Feelings change. Feelings are fickle. Even if you don’t enjoy socializing for the moment, force yourself to continue doing it until you get your mojo back. Even without treatment depression typically resolves, however, it may take a LOT longer and cause a lot more damage to your life. It’s always a good idea to seek professional help if a depressive episode does not appear to be resolving after a month or two, and try not to catastrophize about your situation. We often believe that how we feel right now is how we will always feel, when in fact, research has shown that we are terrible at predicting our future cognitive or emotional state. Practice mindfulness and have faith that this moment of suffering will pass.