Treatment consists of convincing the bearer of the tank to use its
fuel wisely
... working within its limits, not squeezing every drop of energy to the point
of emptiness, which brings on a debilitating depression that forces the bearer
to go into a state of hibernation for a period of time, until there is some
degree of regeneration of fuel, permitting the bearer to awake from this state
and become active again. However, if the bearer becomes too active too
quickly, he will quickly use up the small amount of regenerated fuel and relapse
into the depressive state again. This is why relapse is highest in the
early stages of recovery and gradually returns to baseline as time from initial
remission increases; it takes at least six months to return to baseline
relapse risk. The best way of preventing relapse is to avoid being
overactive shortly after remission, but to 'work' within the narrow limits of
the partially refilled fuel tank, which is slowly refilling. In other
words, it will take time for the tank to refill to a capacity that will permit
'normal' activity levels. By activity levels, I mean exposure to stress
levels, including physiological or internally-generated stress.
Medication
can be seen as a mechanism of encouraging the refilling of the fuel tank, such
as a petrol station. It also prevents excessive or rapid loss of fuel from
the tank, improving the efficiency of the fuel consumption, such as a fuel
additive.
Past
traumatic issues occurring in the construction yard can create baggage that
the ship takes along with it on its voyage, weighing it down, but not so
much as to sink it.
Sinkage
may be threatened by extra baggage that is accumulated along the voyage, or
rough waters, such as a torrential storm, tidal wave, or tsunami that the
ship confronts during the voyage, spilling water over the sides into the
ship adding extra strain and weight. Panic may ensue as the ship
falters.
Management
to prevent sinkage:
The
water needs to be pumped out with buckets. Assistance may need to be
recruited ... from deck hands. Or from outside the ship, from other
ships. A mechanical pump may be necessary and should be installed by a
professional.
The
ship needs to keep moving along, to pass through the rough waters.
Assistance may be needed to help guide the panicking ship into calmer
waters.
The
baggage may need to be sorted through, reorganised, redistributed through the
ship, important elements brought up to the deck for examination in the light of
day and selectively discarded. Professional assistance may be necessary to
complete this task.
The
ship might need to deviate from the course it was on, to the closest shipyard
for maintenance.
Being
trapped in a depressive disorder is like walking waist-high against the current
of a flowing river. To make it past the difficult length of the river to a
more manageable stream, the river walker must maintain a pace that does not
cause exhaustion. The walker must conserve energy but continue walking
such that there is some energy left over in case there are any snags further
along the way to manage, before arrival at the calm waters ahead. 
Assistance
may be required, especially if a ridge is encountered that the walker cannot
bypass.
Depression
can feel like being walled in, without any way of getting through.
Changing the wall into a picket fence makes the barrier more
penetrable. Building a gate in the fence allows a way out.
Assistance in the form of building tools and a carpenter will be required to
assist with the reconstruction and rebuilding.
Being
in a state of clinical depression is like feeling stuck on the edge of a
cliff face.
High levels of
temperament anxiety (neuroticism) predispose to depressive episodes (70% of anxiety in an
individual is genetic/inherited and 30% is dependent on
environment/experience).
This type of
depressive disorder often progresses from childhood or adolescence as part of a
slow, insidious disorder known as dysthymia, a low-grade depressive
state. It may evolve into a frank depressive disorder - a much lower
ability to function due to more severe symptoms, often occurring in the sufferer
in their 20s or 30s.
Alternatively
(probably more commonly), the very anxious, highly strung individual may
function quite well up until their 20s, 30s or 40s (without dysthymia), only to
develop recurrent depressive 
episodes following some significant stressor
occurring (which may be the last of a number i.e. the
straw that broke the camel's back - a good metaphor). This
pushes them over the edge, leading to their losing emotional reserve (the
levels of which may be chronically low anyway due to the chronic anxiety state
always diverting some emotional energy to 'contain' things). They then
become even more vulnerable to develop further episodes, triggered even by
stressors of much lower severity than the original one (due to the lower levels
of reserve). This is known as kindling.
This
metaphor is useful in describing how adverse experience can significantly
influence feelings and behaviour.
If
an individual has experienced a childhood of bumps, ditches, hills, pits and
potholes, their nervous system will adapt by turning into a perpetually
withdrawn, cautious and anxious state to evade threats and promote survival.
Being perpetually anxious is unpleasant but it may keep the individual alive
through hyperarousal, a state that prepares the individual for the next road
hazard.
If
the vehicle had been crushed, unexpectedly having hit a wall, or collided
with someone else or dropped into a deep dark pit, the shock might have been
enough to lead to a dramatic re-evaluation of the best current
design. Such a restructuring process may, similarly, lead to the
gearstick being limited to gears one and two only to improve safety.
If it doesn't move far from the garage, it won't get damaged again.
Speed
may be capped low or the driver may race frantically to as remote and safe a
distance from everyone else as possible. The car may be driven at as
far a distance from everyone else on the road as possible to avoid potential
conflict.
Confidence
may be shattered. The driver may insist that the vehicle be towed by
someone who he knows to be reliable, as his dependency needs have spiralled.
There
can be no room for mistakes. Better the car over-revs than stalls,
becoming vulnerable to attack or to going backwards, sliding downhill.
For this reason, the car only has gears one and two; gears three to five
have not been incorporated as there is no expectation of a smooth ride along
a fast securely grounded freeway. The car has been designed for rough
rocky uphill terrain only. The driver’s concentration may be limited
to observing the immediately approaching terrain for hazards, his
perspective constricted to the present only. Or ruminations about the
past, constantly reminding him how dangerous the road can be.
In
this limited range, the driver might over-rev the car too easily and even
the slightest bump in the road is experienced as a big mound, as the car is
driving slowly at a high number of RPMs and a bumpy road will throw the
occupants all over the place. They will constantly be securing and
checking the seatbelt, tightly gripping the steering wheel and vigilantly
examining the road ahead to minimise the turbulence and revving. Other cars
will constantly be overtaking and so the driver will be frantically darting
to the rear-vision and side mirrors to watch for upcoming vehicles that
might trample the battered buggy.
This
high anxiety state is often exhausting and the car becomes fatigued and
weary. When the state goes on for long enough, the car may lose focus
and merely drive on arbitrarily. If the car gets stuck in first gear,
it cannot go very far without stammering, spluttering and hesitating.
It will be a whirl of confusion, anxiety and disorientation.
In
such a scenario, it is likely that the engine was not tuned optimally to
begin with and the traumas experienced tipped it into a more severely
unstable state. These engines were tuned with low anxiety curve
thresholds, so that they started out with tendencies to be sensitive.
They may have performed particularly well on lined, well-sealed, sleek
smooth roads that do not have too many hazards or twists. But on a
hazardous path, especially if near their tender beginnings on the factory
line when they needed to be lovingly polished and painted, they become
unroadworthy downtrack.
These
engines need to be taken off the hazardous road and permitted to run in the
transit lane for a while, until they have recovered sufficiently to join the
race again through the busy downtown streets. They need regular pit
stops. They need a tune-up. They may need lubricating oil to
loosen up the gearstick to enable more easy gear changes to the higher
gears. They may need to practice city runs by doing a course of longer
and longer runs in preparation. They may need to do another driver’s
course to relearn the rules and alter the improvised rules that may have
been self-taught from bad habits.
Manual
car drivers are well aware that 'low' gears (one and two) are designed for
parking, starting the car from park, going up hill, through city traffic or over
rough terrain. The 'high' gears are for cruising, flying down the highway
and enjoying a country road ride with minimal engine noise.
What
would happen if the gearstick got 'stuck' in one or two? In two, it would
be a very uncomfortable ride if you wanted to go cruising down a country
lane. The car would be over-revving and if you hit a pothole, even worse,
possibly with shaking and engine whining. If you were stuck in one, you
would pretty much be at standstill, with only brief excursions from the side of
the road, or awful stop-starting and jarring and angst, if trying to go any
length of distance.
Severe
depression where the patient is 'psychomotor retarded' (literally physically and
mentally paralysed) or 'psychomotor agitated' (restless) is akin to being stuck
in gear one. Moderate depression is like being limited to using the first
two gears only, being unable to get into three, four or five except for brief
periods. Patients often speak about having good days and bad days (more
bad, when in a depressive disorder), which is like moving between gears one/two
and three/four but constantly tending to getting re-stuck back in gears
one/two.
What
is required to escape from this scenario is for the car to gradually increase
its time on the open road, out of traffic and away from potholes and sand and
oil slicks. Spending increasing periods of time cruising gets the
gearstick 'used' to being comfortable in gears three upwards, again. Its
like exercising a muscle: you need to gradually lift heavier and heavier weights
to develop a strong muscle again. And if its atrophied from under-use,
then the weights and the time lifting needs to be reflective of this initially
to ensure the goals are surmountable. It is crucial to set the drive up to
win. Setting tasks that are not achievable for that particular scenario
will only worsen things. The route needs to be considered and prepared
such that the drive will be a straight, smooth and comfortable one.
Gradually, as the distances are increased, turns can be introduced and
eventually rises and dips.
Sometimes,
a lubricant is required. Something that will promote the gearstick
shifting out of gears one and two more easily, especially if they are firmly
stuck in these gears. Different lubricants will work for different
gearsticks. Sometimes experimentation is required to find the right one
that will work. Remember, the lubricant is not forcing the gearstick out
of one or two, it is catalysing the change of gear, making it easier to shift
and to stay in the higher gear. That's how antidepressants work.
They don't induce an 'artificial high', like stimulants or alcohol. They
don't make someone 'happier' if they're already smooth sailing in gear
five.
Many
people need the lubricant on board for a period of time, then once they've been
'stabilised' and their gearbox is re-calibrated, the momentum of being on the
open road regularly (as well as heavy traffic and bad roads) will keep the gears
running smoothly. How long before the system is unlikely to fall back into
low gear? At least 6 months after a first depressive episode.
So stopping the lubricant the moment the car is smooth sailing is risking
quickly falling into low gear again the moment a small hill is
encountered. At least 6-18 months PLUS the amount of time the patient has
been consistently in low gear, if the episode was severe or
repeated.
Problem
is, some people need the lubricant on board constantly or they fall back into
low gears without it. Perhaps indefinitely if the episode was so severe
that the person posed a risk to themself or others or had psychotic
symptoms.
Falling
into depression can feel like getting stuck in quicksand, where the more you
struggle, the more this promotes sinkage. A more effective strategy
is to desist any frantic movements and cautiously determine an escape
strategy. Calling out for assistance (for a rope to be thrown or branch to
be extended) is the obvious first thing to do. Trying to maintain one
position and spreading the arms apart may assist to keep afloat, whilst waiting
for help.
When
the onset of major depressive disorder coincides with the death, or an
anniversary event related to the death, of a significant other, the grieving has
become a complicated bereavement. It often occurs where idealisation or
ambivalence had been present regarding the lost other. Even major
depression unrelated to the death of loss of a loved one, is often triggered by
the loss of a romantic relationship or separation from loved ones, such as
occurs in migration or relocation, or other transitions.
It is
like the
infant duckling, dependent on its mother, who gets lost and behaves in such a
manner that will maximise its chances of survival, which it believes
requires reunification with mother:
It
stays in one spot, wildly flapping its wings and quacking, to draw attention
from mother or its brace (flock of ducks). This is akin to the grief, dysphoria,
psychomotor agitation and retardation of some types of major depression.
It
does not sleep, as doing so might lead it to lose the opportunity to attract its
mother's or brace's attention should she/they wander nearby. This is akin to the
insomnia of some forms of major depression.
It
does not search around for food, as doing so might lead it to move further away from
the location where potential assistance can occur. This is akin to anorexia and weight loss
of most forms of major depression. It is well known that if you get lost, you have
a better chance of being found if you stay put.
Some
forms of depressive disorder manifest in the form of waves of depression passing
through the afflicted individual, causing a period of symptomatic distress
lasting hours or days, usually with anxiety, dysphoria, agitation, hopelessness
and thoughts of self-harm. This pattern occurs most often when depression
develops in an individual with a pre-existing tendency towards mood swings: mood
instability, mood lability, a tendency towards experiencing highs and lows,
& rejection sensitivity. i.e. on the bipolarity spectrum / borderline
personality spectrum. In other words, those with a form of bipolar
disorder (especially type II) or borderline personality traits/disorder, are
particularly prone to this type of depressive experience.
When waves of depression
pass
through the afflicted individual, these
episodes must be survived. Methods of coping with the distress must be
found. Dialectical behaviour therapy may well assist to teach strategies
to manage the experience, such as distress tolerance, visualisations,
self-reassurance, distraction, breathing exercises and reaching out for support
if necessary.
When
experiencing a depressive wave, the sufferer should remind themselves that it is a wave passing through them,
which will pass through and then begone. Any self-harm for tension
release or self-medication with substances such as alcohol or illicit
drugs may help in the short-run, but make things worse in the longer run by
increasing the frequency and amplitude of the waves, at worst, and just mask the
disorder at the least.
Medication
acts like a sand-bar, buffering the waves, and hopefully re-sculpting the beach
head
to reduce the frequency and amplitude of the waves hitting the shore.
Also
see:
The
reign yourself in to avoid burning out metaphor
The
trigger that throws you off track metaphor
The
throw the lifejacket to the drowning person metaphor
The
ball & chain around the ankle metaphor
The
riding the rapids metaphor
There
is no
time to think, the focus is surviving each moment, with high levels of arousal
& vigilance. If this goes on too long, you become exhausted and
eventually give up battling to stay afloat, and being dragged under may seem
like an escape from the fear and apprehension.
The
emotional minefields metaphor
The
putting all the eggs in one basket metaphor
The
keeping on track metaphor
Medications
are barriers on the side of the track nudging the vehicle back on track.
The
going into a shell metaphor
The
playing dead metaphor
The reduced concentration that frequently occurs during a depressive episode
is like "playing dead".
The
wheels spinning on sand metaphor
The
shades of grey metaphor
Moods
come in different shades between black and grey.
The
hard disk corrupt sector metaphor
The
hard disk keeps spinning if it comes across a bad sector to attempt to get past
it.
The being weighed
down by low self esteem metaphor
Low
self-worth leads already weighs you down. Assuming others devalue you
(sometimes without acknowledging how badly you feel about yourself and perceive
yourself) exacerbates the feelings of sadness, anxiety and anger already
there. Defensivess leads to others withdrawing. Rejection feels like
death. Depression is a loss of self-love.
Illness
spectrum of mental disorders
There
are some types of depressive disorder that are part of an illness spectrum,
which are probably largely influenced by person's genetic predisposition
reacting with environment. In other words, experience probably
activates and greatly modifies the illness course (this is called
pathoplasticity) of an otherwise very internally driven disorder, meaning
that the internal chemistry is the major contributor and propagator and
determiner of the symptoms and course of the disorder.
This
is dualistic thinking, of course, and in reality every patient probably has
a combination of externally induced chemical change and genetically driven
internal state. It is useful purely from a conceptual perspective to
think of dualities such as:
Perhaps
the illness spectrum (see diagram) is a more
helpful paradigm. Therefore, DSM's categories refer to an ideal, pure,
purely hypothetical model of the disorder than is helpful when communicating
about disorders, researching them and working out how to treat them, rather than
some actual entity in themselves. The only actual entities are the
symptoms and symptom clusters that your patients present with. 
Environmental triggers in childhood
(psychosocial stressors) and personality attributes (temperamental and coping strategies) that increase
the vulnerability to develop depressive disorder do so by reducing emotional
reserve - the trigger threshold that a significant downstream stressor
(psychosocial or internal/physiological) that may trigger depressive symptoms.
This emotional reserve is like an emotional fuel tank.
A fuel tank that has a capacity that has been shrunk by early life experiences,
but which has the capacity to gradually expand ... if excessive demands are not
made on the tank, constantly bleeding it dry of its energy. 