Masked Depression, Sexuality and Sexual Dysfunction, Pt 1

The holiday season often brings unwelcome visitors in the form of stress and depression. There are three primary areas that can invite these unwanted killers into your life.

The first is relationships! According to the researchers at the Mayo clinic, “Relationships can cause turmoil, conflict or stress at any time, but tensions are often heightened during the holidays. Family misunderstandings and conflicts can intensify — especially if you're thrust together for several days. On the other hand, facing the holidays without a loved one can be tough and leave you feeling lonely and sad.”

The second area is finances. “With the added expenses of gifts, travel, food and entertainment, the holidays can put a strain on your budget — and your peace of mind. Not to mention that overspending now can mean financial worries for months to come.”

And lastly, the physical demands that accompany the holiday season. “Even die-hard holiday enthusiasts may find that the extra shopping and socializing can leave them wiped out. Being exhausted increases your stress, creating a vicious cycle. Exercise and sleep — good antidotes for stress and fatigue — may take a back seat to chores and errands. To top it off, burning the wick at both ends makes you more susceptible to colds and other unwelcome guests.” (www.mayoclinic.com)
Depression is a serious biologic disease that affects millions of people. It affects all ages, genders, races, and economic levels. However it seems to slightly discriminate. Women are at a significantly greater risk than men to develop major depression. Research shows that episodes of depression occur twice as frequently in women as it does in men.
Although anyone can develop depression, some types of depression, including major depression, seem to run in families and can be genetic. The disorder is directly associated with changes to levels of chemicals in the brain such as serotonin and norepinephrine.
Recent research conducted at Rockefeller University shows that in patients who suffer from depression. Their levels of serotonin p11 protein are decreased. This protein is related to serotonin transmission within the brain.
A decrease in Norepinephrine is also implicated in depression. Norepinephrine is both a hormone and a neurotransmitter. It is released when a host of physiological changes begin to occur in an individual as a result of a stressful event. Serotonin-norepinephrine inhibitors are, simply put, antidepressants. They work by increasing the amount of both of these hormones to postsynaptic cells in the brain.
Depression and other psychiatric disorders are associated with increases in the risk of suicide. Ironically, although antidepressants are used to treat the symptoms of depression, antidepressants can also increase the risk of suicidal thinking and behavior in children, adolescents and young adults. In adults, over 65, there is a substantial reduction in this risk. Unfortunately, it has been my clinical experience that many patients suffering from this illness have suicidal preoccupations of drives by the first time they are seen by a professional.
The term ‘Depression’ as commonly used by most people refers to a mood change such as: sadness, dejection, despair, gloominess, despondence or melancholy. If an individuals’ change of disposition is not overt most people do not consider them depressed. Minor depression is cunning and may hide behind numerous personality facades such as laughter, joviality, and humor. Sometimes even a professional therapist can be fooled.

Often, until a patient outwardly exhibits the symptoms of advanced depressive behavior and this conduct dominates the clinical landscape, even a trained clinical social worker, psychologist, psychotherapist or psychiatrist may not be aware that a serious, fundamental psychiatric disorder is at hand.

The depressive affect and even many depressive syndromes may be so masked that symptoms masking depression are not limited to hypochondrias (people who always act and think they are sick; claiming illness) or psychosomatic (mental illness) disorders.

It has become quite obvious to me in my 24 years of clinical work, that numerous behavioral patterns can mask even exceptionally severe underlying depressions. I have had many patients in whom severe depression was masked by alcoholism, drug addiction, latent or active homosexuality, rage responses, delinquency, bulimia, sexual problems such as erectile dysfunction, lack of sexual desire, dyspareunia, and learning disorders to name a few.

Another eye-opener is that masked depression is exceptionally common among very successful people such as top level executives. For most success does come with a high price beyond the outward trappings of success. It also represents a very serious ailment among junior executives. I am not implying that all successful people suffer from masked depression, but I am asserting that more often than one thinks depressive disorders of severe proportions are masked by what appears to be monetary or fulfilling success. Depression is one of the most common disorders seen here in the United States. Despite the frequency of its occurrence, masked depression is rarely diagnosed at or near its inception. Many years can past before it is recognized and acknowledged by the person who is suffering.

Depression may also be disguised by various types of “acting out” or behavioral disturbances. These behavior masks may take the form of impulsive sexual behavior, compulsive gambling, destructiveness, antisocial acts, temper outburst, sadistic or masochistic acts, compulsive work, behavior patterns, histrionic dramatizations, drug and alcohol addictions and more.

Probing behind psychosomatic disorders, hypochondriacal symptoms or various behavior patterns one will find a depressive core from which a depressive affect will eventually become overt. Over time the depressive core usually rises to the surface spontaneously with the passage of time, like an iceberg that may rise to the surface under certain climatic conditions. According to Stanley Lesse and Irving Bieger, MD, “The process of masking depression at this point through acting out is masking an active depression with the depressive core just beneath the surface, and can be readily uncovered by a perceptive therapist.”

A depression is not only a disturbance of affect; it is also complex with attitudinal and behavioral components. In overt depression both the patient and the therapist are very aware of the depression, and therapeutic decisions revolve around alleviating it. In a masked depression , the individual may be unaware that he or she are depressed; they may not feel depressed yet recognize signs and symptoms that have come to identify as depression; or the individual may feel depressed yet be able to conceal it from others. Masking may occur in any type of depression, acute or chronic.

According to Irving Bieber, depression is a reaction to loss or threatened loss of something. The common denominator of all depressions is the high value placed upon the loss. Two types of depressive reactions can occur. First, the individual believes in some way they are responsible for the loss whether conscious or unconscious; second is a grief reaction, associated with the loss of a love one where there is no harboring of guilt associated with participation in bringing about the loss. Pure grief is not accompanied by guilt or hostility toward the lost one. The loss of something of value is operant in all depressions.

Sigmund Freud once pointed out that love and work are the two basic elements of human existence. The sense of loss that presages depression can usually be found in either or both of these areas. Depression inhibits pleasure and individuals suffering from depression often have an inability to partake in fun or to enjoy oneself free of anxiety about doing so. When possible they may try to avoid situations in which others are enjoying themselves. Frequently there is change in sexual behavior. Both women and men can suffer from the lack of sexual desire. In addition, men can suffer from performance anxiety due to low libido. In part two of this article I will explore, in depth, sexual dysfunction and, for some, its roots in depression.