To the best of my knowledge the jury is still out on what causes depression. In David Burn's book "Feeling Good", Chapter 17, he discusses this subject at some length, he writes:
At least two major arguments have been advanced to support the notion that some type of chemical imbalance or brain abnormality may play a role in clinical depression. First, the physical (somatic) symptoms of severe depression support the notion that organic changes might be involved. These physical symptoms include agitation (increased nervous activity such as pacing or hand-wringing) or enormous fatigue (motionless apathy- you feel like a ton of bricks and do nothing). You also may experience a "diurnal" variation in your mood. This refers to a worsening of the symptoms of depression in the morning and an improvement toward the end of the day. Other physical symptoms of depression include disturbed sleep patterns (insomnia is the most common), constipation, changes in appetite (usually decreased, sometimes increased), trouble concentrating, and a loss of interest in sex. Because these symptoms of depression "feel" quite physical, there is a tendency to think that the causes of depression are physical.
A second argument for a physiologic cause for depression is that at least some mood disorders seem to run in families, suggesting a role for genetic factors. If there is an inherited abnormality that predisposes some individuals to depression, it could be in the form of a disturbance in body chemistry, as with so many genetic diseases.
The genetic argument is interesting but the data are inconclusive. The evidence for genetic influences in bipolar manic-depressive illness is much stronger than the evidence for genetic influences in the more common forms of depression that afflict most people. In addition, lots of things that do not have genetic causes run in families. For example, families in the United States nearly always speak English, and families in Mexico nearly always speak Spanish. We can say that the tendency to speak a certain language also runs in families, but the language you speak is learned and not inherited.
I don't mean to discount the importance of genetic factors. Recent studies of identical twins who were separated at birth and raised in different families show that many traits we think of as being learned are actually inherited. Even such personality traits as a tendency towards shyness or sociability appear to be partly inherited. Personal preferences, such as liking a particular flavor of ice cream, may also be strongly influenced by our genes. It seems plausible that we may also inherit a tendency to look at things either in a positive, optimistic way or in a negative, gloomy way. Much more research will be needed to sort out this possibility.
I had many of the symptoms described by Dr. Burns when I was very unwell including: feeling like a ton of bricks and doing nothing, a worsening of the symptoms of depression in the morning and an improvement toward the end of the day, disturbed sleep patterns, loss of appetite and most bothersome to me, trouble concentrating. I was a university student when I was first diagnosed with depression and there were spans of months that dragged into years when I was completely unable to concentrate. I had been reduced from an active student achieving good grades to a tired out blob only capable of concentrating on daytime television shows. I watched a lot of gossip based talk shows like Jerry Springer, Maury Povich and Montel Williams while depressed, and slept for most of the rest of the day.
These physical symptoms were part of what convinced me that my brain was not functioning correctly, and the problem was either chemical, genetic or structural. It never occurred to me that anything other than pills or brain surgery might be the correct cure. Since my initial luck with medication hadn't been good and I figured brain surgery wasn't a realistic option I thought my case was hopeless.
Before attending Recovery meetings I spent 10 years talking to a psychiatrist. In my conversations with him I picked up the idea that depression was nothing to be ashamed about. He certainly thought that a genetically influenced chemical imbalance was the most likely explanation for me. With this "physical" diagnosis, I felt relatively at ease that my depression was not my fault, and reassured that something could be done.
At a recent Recovery meeting we were discussing stigma and shame associated with mental health issues and to what extent people needed to be convinced that they are suffering from depression or anxiety versus some physical ailment. I was surprised to learn that many of our members initially thought they had a physical illness, not a nervous condition.
While some of our members were aware of the idea that a chemical imbalance might cause depression, their initial concern was that their nervous symptoms were caused by a weak heart, a stomach ulcer, or some other physically diagnosable illness. In Recovery we discuss symptoms a great deal, and we encourage members who suffer from physical symptoms to see a medical practitioner to rule out as many causes as possible.
My belief in this idea that there was a physical cause to my emotionally troubled landscape has changed as I've learned cognitive behavioral techniques. In Recovery meetings we do not talk about what the true cause of your depressive symptoms are. It is not our job to diagnose one another. However, we do acknowledge that nervous persons suffer from a variety of sometimes very intense physical symptoms that are a result of their thoughts and feelings. The notion that physical symptoms are tied to your thoughts in a complex fashion is something that we focus on. This is a new idea to some people. In MHTWT, the chapter "The Myth of 'Nervous Fatigue'", Dr. Low as (E)xaminer reports an exchange with a (P)atient:
P: I don't know what to say. The fact is that I am all in no matter how well I slept. If you call that a subjective feeling you must think it is mental. But I didn't even have time to think about it. It is there the moment I wake up.
E: I do not know what precisely you mean when you use the word "mental." Presumably you refer to the possibility that you may have the thought of fatigue in your mind and instantly feel the fatigue in your muscles. This instantaneous response of the muscles to a thought seems to puzzle you. I do not see why it should. You have certainly gone through similar experiences hundreds of times. Remember the occasion, for instance, when you were at a meeting and were called upon to make a speech. Instantly, your heart began to palpitate, your face reddened, your abdomen trembled and the knees shook. To use your own words, you "didn't even have time to think" of the speech; you merely heard your name called, and the muscles of your heart, abdomen and legs were thrown into violent tremors "in no time." In the instance which I quoted the thought in your mind which caused your muscles to shake was the fear of not being able to deliver a well constructed address. It was a fear, or you may call it a fear idea, or the idea of danger. Do you understand now that if an idea strikes or occupies your mind the muscles may respond with a violent reaction in a fraction of a second?
P: I understand that. But when I get up in the morning there is no idea of danger in my head.
E: The question is what you mean by danger. If you wish to indicate that, in the morning, you are not trembling with the fear of being killed or trapped or burned I shall fully agree with you that no such idea may occupy your brain immediately after awakening. But there are subtler forms of fears and dangers. These subtle anxieties and apprehensions go by the name of preoccupations. I happen to know from your own account how readily you fall victim to such preoccupations. Let me remind you, for instance, of the anguish you experience whenever you expect visitors for the afternoon or the evening. You fret and worry days in advance, anticipating some bungling or clumsiness while performing the part of the hostess. You know that when finally the much dreaded day arrives you feel troubled and helpless "the very minute" you awaken. The day stares you in the face as a threat, as an event fraught with heavy responsibilities. You are without pep or zest. Your vitality is at a low ebb. A heaviness seems to descend on your limbs. Everything is done with effort. You have to drag yourself, feel "all in," exhausted, lifeless, fatigued. Do you understand that all of this is caused by your preoccupation, and that the preoccupation is based on the idea of danger?
Both at work today, and as a student years ago, I have given many presentations. These are often stressful. I always suffer from some physical symptoms prior to giving a talk to a difficult audience. Sometimes I'd also have a similar response when I was meeting with my boss and had to discuss a difficult subject, or even before what should be a pleasant social engagement. I have experienced a dry mouth, shaking legs, stuttering in my speech, an upset stomach, and a racing heart for example. To me it was usually obvious that these physical symptoms were caused by an event, the difficult meeting or presentation.
In Recovery we talk about generalizing this experience and understanding that many of our physical depressive or anxious symptoms are caused by subtle experiences and daily thoughts. These symptoms can seem to have no obvious cause in part because they are a reflection of our habitual thoughts and attitudes. The example where we are fully aware of the cause, feeling wobbly while giving the talk, may be the same experience you have when you simply "get-up" in the morning and still feel tired out. When I was unwell, I was extremely upset when I awoke in the morning, I never felt awake, and often went back to sleep for a large part of the day.
A big part of what made me believe that my depression was rooted in a chemical imbalance was the intensity and persistence of the physical symptoms that I had on a day-to-day basis. While there still may be some truth to the idea that a chemical imbalance was at work, there is also clear truth in the idea that an emotional upset will also result in physical symptoms. My worry about the collapse of my life after quitting school was a real cause of my exhaustion in the morning, although that was not obvious to me.
In Recovery meetings we talk about these less obvious symptoms. Being tired out as soon as someone starts talking about bills is a signal that you are going into temper, possibly anger that you are being asked to pay more than your share. A feeling that you are having an upset stomach when you run into an old boyfriend or girlfriend may be connected to a fear about whether they will hurt you with some news of how well they are doing without you. An inability to think clearly when going to work or school may be related to your disgust or frustration with the job. Tunnel vision experienced during a discussion or the inability to hear or understand what someone is saying may be a result of your intense worry about what might be said.
In meetings attendees give examples of the use of Recovery tools. We use a four part example template where attendees:
1. Give a summary report of a situation involving temper.
2. Report both the physical and mental symptoms experienced.
3. Talk about the tools used to address the situation.
4. Describe how they have improved.
The second step of the four part example process includes reporting the observation of both physical and mental symptoms. We recognize physical symptoms as warning signs, indicators that a person is going into temper. Usually attendees have no trouble connecting angry or fearful thoughts with a difficult situation, but of equal importance is recognizing the physical symptoms that occur. People don't always connect physical symptoms with their thoughts and feelings; we encourage each other to try to make this connection.
Observing physical symptoms helps us to know that we are in a situation where we are likely to respond impulsively. Recognizing the pattern of our symptoms also helps us to reduce the impact of the vicious cycle. I know that I tend to get an upset stomach before a meeting or social engagement. I try not to worry about the symptom itself, and instead just acknowledge that it is something that I often experience in these situations. Instead of multiplying my problem by saying, I have both a social engagement that I'm worried about and a terrible upset stomach which might be the flue, I recognize that they are both the same worry. I know that if I can be realistic about the social engagement that the physical symptom of the upset stomach will usually resolve itself.
From past experience I know that the symptom only gets out of control if I let it. I also know that some physical symptoms are subtle and less obvious. Headaches, tiredness, irritability, small aches and pains, a sore throat, all of these physical symptoms may be connected to frustration, fear, upset or anger. In the past I might have dismissed them as a cold coming on, or perhaps lack of sleep the night before. Today I recognize these minor aches and pains as a signal that I'm feeling pressured and upset by what is going on around me, and that I need to be aware of how I respond to my situation.
We don't know why some people get depressed and why others seem resilient in the same situation. If we did that might help facilitate a cure. We do know that physical symptoms are tightly linked to both fearful temper and angry temper. We also know that regardless of the cause of your anxiety or your depression there are ways you can change your behavior and your thinking to reduce the intensity of your physical symptoms.
We regularly remind attendees to consult with a physician if they are having serious physical symptoms. If you experience heart palpitations you may have some sort of heart condition and you should go and see a doctor if you believe you are at risk. However, if you think you are experiencing depression or anxiety and your doctor has given you a clean bill of physical health, you should consider that your physical symptoms might be associated with a nervous condition. You may be able to experience relief from those symptoms by learning about the Recovery tools.
Meetings: Activities and Key Concepts
Insomnia, Anxiety and Depression
Feelings are not Facts