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Gift From Within - Questions & Answers with Frank Ochberg on PTSD
|PTSD Symptoms: Depression.
Q: Dear Frank, In your recent program, Surviving Trauma & Tragedy: Lessons For Future Physicians you discuss that major depression is more likely to take place than PTSD. The panel members courageously discussed their traumatic events like Linda, who was pregnant and assaulted at gunpoint while shopping for her family, and a couple whose 20 year old son was a victim of homicide. Can you talk more about major depression and why this is something health professionals and survivors should be aware of? What are the major differences?
A: Dear Joyce, Depression is often confused with sadness and grief. Who would not be sad when robbed of dignity, integrity or a loved one by a rapist or a murderer? Who would not grieve the loss, with an aching sense of degradation or loneliness? The emotion of sadness is normal, even when it is profound sadness, proportional to the circumstance. The condition of bereavement or grief is also normal, and is always associated with loss. But depression is different. In a depressed state, a person feels hopeless and helpless and worthless. In addition, they have a specific type of lethargy that stops them from doing what they have been put on Earth to do. The cook cannot prepare a meal; the seamstress cannot sew; the writer cannot summon the energy to compose a sentence. Each of these people could climb a flight of stairs. They are not like the anemic or the heart patient without stamina and strength; they simply lack the energy to do what they usually do to be productive and to feel alive. Worthlessness is particularly important. If your spouse is killed and your life is suddenly changed forever, you would be expected to feel helpless and, for a while, without hope. But feeling worthless is a sign of depression. You shouldn't feel worthless during "normal grief."
When I was a psychiatric resident in the late '60s we were taught to consider two different types of depression. Exogenous depression, or depression from the outside, was a reaction to stressful life events. We thought of it as "situational" rather than "biological." If drugs were to be prescribed, we used minor tranquilizers like Librium and Valium. We expected the depression to improve as life conditions improved. Endogenous depression, or depression from within, was thought of as a genetic disorder with episodes lasting weeks or months, best treated with antidepressants like Tofranil or Elavil. Endogenous depression could come out of the blue, and was not thought to be caused by stress or loss. Now we know that endogenous depression often appears after extreme stress. In other words, a trauma can cause an episode of the type of depression that looks "biological."
Think of it as having your mood thermostat impaired. While it is medically normal to be sad when life is miserable, the brain's mood thermostat allows you to feel good when life improves. But if you are stuck in sadness, and the sadness includes feeling worthless and unable to summon the energy to do what you used to thrive on doing, you are depressed. And you need therapy for depression.
Therapy for depression is relatively straight-forward. There are ways to learn to correct self-defeating thoughts and there are medicines that repair the brain's broken mood thermostat. Both approaches, used together, give the best chance of recovery.
Often, working with extreme trauma, I'll find a combination of depression and PTSD. Both can be treated together. The numbness and avoidance that is part of the definition of PTSD may feel like depression. But people who spend the day in bed feeling worthless are beyond PTSD. They are not just numb and avoidant. They have broken mood thermostats and they cannot experience normal feelings until those pathways are restored. It helps to have the diagnosis of depression and the treatments that go with that diagnosis.
When journalists cover war they are vulnerable to PTSD and depression. Because of the strict criteria for giving the PTSD diagnosis, not every shell-shocked reporter qualifies for the PTSD diagnosis. So research suggests that depression is slightly more common than PTSD in this group. When I say that depression is often more common than PTSD after trauma, I am not minimizing the occurrence of PTSD. I'm just alerting survivors, doctors and government officials to the problem. Let's not ignore post-traumatic depression. It is a significant problem - but it is a treatable problem, particularly when friends and loved ones know enough to help.
Webcast: PTSD & Depression: Who is on your Board Of Directors
In this webcast Dr. Frank Ochberg discusses how he helps his PTSD and
depressed patients. Dr. Ochberg explains a therapeutic tool he calls "your
board of directors." Replacing the negative people on your board of directors
with those who are supportive
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