The Many Faces of Depression

Depression – it’s one word to describe so many different things. The many faces of depression means that no one person’s experience can ever capture what depression is. It’s a simple word for a complex illness, so let’s chat a bit about what that complexity can look like.

Major depressive episode symptoms

The possible symptoms of a major depressive episode are the same whether it occurs in major depressive disorder, bipolar disorder, schizoaffective disorder, or any other depressive. These include:

• depressed mood, including feeling sad, hopeless, or irritable
• lack of interest/pleasure (anhedonia)
• decreased or increased appetite, with weight loss or gain
• insomnia or hypersomnia (sleeping excessively)
• psychomotor retardation or agitation
• fatigue
• feeling worthless/guilty
• decreased concentration
• suicidal ideation

Melancholic features

There are a few different subtype specifiers for depression that may apply if the depressive symptoms follow a particular pattern. One of these is melancholic features, which tends to involve these symptoms, although not necessarily all of them:

• anhedonia
• lack of mood reactivity to positive events
• depressed mood feels subjectively different from grief/loss
• decreased appetite
• psychomotor agitation or retardation
• early morning awakening
• excessive guilt
• mood worse in the morning

Atypical features

Depression with atypical features involves these symptoms:

• mood reactivity, i.e. mood brightens in response to positive events
• increased appetite
• hypersomnia
• leaden paralysis (feeling heavily weighed down by fatigue)
• longstanding pattern of interpersonal rejection sensitivity

Atypical depression doesn’t get that name because it’s uncommon; it’s because the mood reactivity, appetite, and sleep are opposite from what’s typically seen in melancholic depression.

Different people, different patterns

There are also assorted other depressive diagnoses and features, like persistent depressive disorder (previously known as dysthymia), premenstrual dysphoric disorder (PMDD), seasonal features (seasonal affective disorder), peripartum onset, etc. It’s quite the diverse set of options, with room for a lot of different faces of depression for different people.

How much overlap is there biologically? That’s still not clear. There’s been some debate about whether melancholic and atypical depression are different illnesses from one another, but given that the DSM is categorical in nature rather than being aligned with specific biological processes, it probably doesn’t really matter one way or the other.

While different people can have very different patterns of symptoms that they experience, I think there’s still a lot of commonality in having a mind that doesn’t behave the way we’d like it to.

Same person, different patterns

For the same person, the pattern of symptoms may vary over time, and certain symptoms may respond differently to different medications. Same person, different faces of depression.

I’ve generally tended towards melancholic features. The anhedonia and psychomotor retardation have become quite treatment-resistant over the last few years, and the psychomotor symptoms have had a huge impact on my level of functioning, but meds mostly keep my other symptoms reasonably reined in.

Not always, though. Late August through September tends to be a bad time for me, and this year, my sleep and appetite were bad, and I was irritable, crying a lot, and having guilt try to poke its way into my head. Fuck off, guilt, I don’t want you in my head!

Irritability flares up periodically when I’m depressed. It doesn’t happen that often, but when it does, I don’t have much control over it. Anhedonia is the most consistent mood feature. I suppose I have the melancholic depressed mood that’s subjectively different from grief. Sadness doesn’t tend to play a big role in my depression; I would describe it more as a sense of the mental version of physical pain. Being without hope has become pretty much a constant, but more active feelings of hopelessness don’t intrude too much as long as I’m well-medicated.

I’m naturally a morning person, so the worsening of mood in the morning that’s often a part of melancholic depression only tends to happen when I’m unmedicated or really under-medicated.

I’ve never had atypical features; when my sleep and appetite are affected, they’re decreased.

Making room for diverse faces of depression

Sometimes I see bloggers write that they’re not sure if they should share their experiences because there are already so many people writing about mental health. I think the diversity of mental illness experiences makes it extra important that as many people share their stories as possible. The more people that are talking, the more likely it easy that everyone will be able to find someone who’s going through something similar.

If you’ve experienced depression, have you noticed changes in your pattern of symptoms over time? What faces does your depression wear?