In order to better understand what major depression is, examining incorrect (and amateur psychologists’) assumptions may give it clarity. What major depressive disorder is not is the blues, grief, or a bad mood, although grief can be a trigger for clinical depression. In fact, there are hundreds of things that can set off a depressive episode, but if it’s not actual clinical depression, the mood of the moment should lift within a few days, or even less; major depressive disorder is defined as lasting at least two weeks, but some episodes comprise years.

Major depressive disorder may be hard to accurately diagnose at times, and elements of it can be elusive, but statistics can tell us a story of human consequences as they pertain to depression in modern times. Here is some factual data about clinical depression:

• The first occurrence often strikes between the ages of 20 and 30; there are two other peak periods for most sufferers, namely 40 to 50 and 50 to 60. It can also occur in the elderly, especially those enduring poverty or illness.
• The end of depression is suicide for 3.4% of sufferers; 60% of all suicides involve a person who is clinically or otherwise depressed.
• There is no formal or laboratory test that can prove a suspicion of major depression; a diagnosis depends upon observation of characteristics or behaviors, sometimes by the patient, or by a doctor (usually a psychiatrist) or those close to the patient.
• People with on-going clinical depression have a shorter life expectancy than the normal population; this may be due to suicide or to the associated illnesses that are inherent with this general morbidity.
• Women are twice as prone to major depression as men, but only 1% of depressed women commit suicide as compared to 7% of men.
• The majority of people with major depressive disorder also suffer from some degree of anxiety.
• Although depression does not cause or promote post-traumatic stress disorder (PTSD), they often occur in tandem; the likelihood is that PSTD has nudged the depression into existence.
• Most western nations have a depression rate of significantly less than the U.S.A.; the usual rate is 8-12% of the population, but the Japanese rate is 3%.

Most other information about clinical depression is less fixed and more open to medical and professional opinion, or supported by on-going case studies. One thing is sure, major depression is growing. Major depressive disorder is a leading cause of morbidity (a state of disease) world-wide. At this time the odds of Americans enduring a major depressive episode within the period of one year is about 9% for females and 4% for males. These figures are expected to increase.

Clinical Depression and the Stigma of Mental Illness

A lot has been done in recent years to bring mental illness, including major depression, out into the open, enabling it to be more talked about and less negative, especially for depressed people. Adding to the list of historic figures such as Sir Winston Churchill, Samuel Johnson, Abraham Lincoln, Tennessee Williams, Wolfgang Amadeus Mozart, Mark Twain, Virginia Woolf, and Edgar Allan Poe, contemporary famous folk have found the courage to declare that they have suffered (and some still do) from depression. The list is surprising and filled with comedians such as Jim Carrey, and successful superstars like Marie Osmond and Harry Potter author. J.K. Rowling, but there is something that jumps out: many, about 95%, of self-admitted major depressives are in the arts, the business of creativity in some form.

Doctors concede that there may be a link between creative types and depression. Some have argued that involvement in the arts with low income prospects and huge competition for superstar status may be the cause. But when you look at who is part of this list, you must beg to differ: Woody Allen, Halle Berry, Jon Bon Jovi, Janet Jackson, Britney Spears, James Taylor, Harrison Ford, Sheryl Crow, Princess Diana, Gwyneth Paltrow, Angelina Jolie and Beyoncé Knowles, to name a very few. What is positive about this is that when such highly admired stars step up and say, “I have clinical depression”, it paves the path for the rest of us. And it makes them human, not stigmatized, in our eyes.

What Does Major Depressive Disorder Feel Like?

Clinical depression is characterized by long periods of feeling low and sometimes emotionally fatigued. It also commonly involves low self-esteem, loss of interest in the basic pleasures of life, and the resultant inability to experience pleasure, but those are just a few of the commonalities. Key to knowing if your feelings are a passing case of the blues or major depression are that they last a minimum of 2 weeks and nothing external can lift them, not your favorite song or a trip to the beach; nothing.

For example, you might have normally been a meticulous dresser, but now you are neglecting your appearance and you just don’t care. Or something that would never bother you before has you ruminating about it now. Or you can’t sleep and feel lethargic for no obvious reason. These are signs. For more information about the symptoms and signs of clinical depression, please visit: Depression Symptoms.

What Can be Done About Major Depression?

There are three approaches to managing depression, but no one seems to be certain that is it curable, just controlled. The treatment depends somewhat on the severity (mild, medium, severe or psychotic), and frequency of episodes, plus the duration of each. The normal approach is to treat as early as possible in the patient’s depressed state, or even as a preventative means when someone is prone to repeated episodes. This is also applicable where there is a risk of someone sinking into a state of major depression as the result of a traumatic event, such as the unexpected death of a spouse, the diagnosis of a chronic or fatal illness, or a bad car accident.

Many cases of depression can be managed through psychotherapy. Working with a compassionate and sympathetic psychiatrist may be all a patient needs to keep episodes at bay or reduce their severity, but in other cases, a combination of anti-depressant medications and counseling is a must, at least to see the patient through the deepest part of the situation. It has become widely understood that certain anti-depressants in specific individuals can actually trigger suicidal thoughts, so, as with any other powerful medication, some trial and error may be involved. In the most serious cases of clinical depression, demonstrating delusions and hallucinations, and where drugs and talk-therapy have failed, electro-convulsive therapy is sometimes used as a last resort.

The Sub-Types of Major Depression

As if depression doesn’t cover a broad enough swath of the human mosaic, there are several sub-types that may be directly related to specific causative factors, influences and other medical conditions. The good news is that these are readily identifiable, by and large, and treatable thanks to their “contained” depressive aspects. In a nutshell, these are the five common sub-types of clinical depression and their characteristics:

• Atypical depression: three main components include over-sleeping (hypersomnia), deep fear of personal rejection and the tendency to emerge from the depressed state when something good happens.
• Melancholic depression: the inability to react positively to upbeat situations and things. This is commonly worst early in the morning and feels a bit like grief, but far deeper.
• Post-partum depression: the mixed emotions and depression felt intensely by women who have recently given birth.
• Seasonal Affective Disorder: with the appropriate acronym, SAD, this indicates depressive episodes that occur during the winter months; vitamin D has shown to help this form of depression, as well as light therapy and bouts of outdoor sunshine when possible.
• Catatonic depression: a severe and fortunately fairly rare form of depression, the symptoms include total lack of speaking, immobility, and visual fixation; this may indicate schizophrenia.

A test known as Major Depression Inventory, developed by the World Health Organization, is available in 7 languages on-line and can assist you in ascertaining whether your or a loved one’s depression is just a sad period or legitimate major depressive disorder. While the test may not take into account every possible variable, it can help people who need treatment come to understand that and seek it. It is not to be considered as a substitute for professional diagnosis, just a tool to help. When “the blues” have become disabling, and are affecting all aspects of your life, and are enduring despite all best efforts to “pull out of it”, you may have clinical depression. Help is at hand, so don’t let despair exacerbate the suffering.

Regardless of the level of major depression that you or someone you know may be dealing with, it’s not your fault; it may be hereditary, things like estrogen and other hormones may be making it worse, and external influences might have brought it on. Some people who have endured clinical depression episodes for most of their lives have learned to cope by being candid with those they live with (it helps family members to not feel guilty), learning what gives them comfort (some cite exercise and the feel-good endorphins, and some just need to be quiet and escape by reading a good book), but almost all indicate that they need to deeply experience the full impact of the depression before it can begin to lift. In the majority of cases the episodes will return from time to time, but as they become familiar, the symptoms and effects of major depressive disorder will no longer be feared or cause for embarrassment.

Of course, not all victims of abuse in childhood attempt suicide. In a 2008 report published in the British Journal of Psychiatry, Dr. Gustavo Turecki and his colleagues at McGill University in Montréal, Canada, found that the incidence of suicide attempts bears a correlation to the type of abuse and the identity of the abuser; generally, a first-line relative, such as a father or brother, will have far greater impact on an individual. Neglect appears to be the least traumatic of the forms of abuse in terms of predicting the likelihood of depression and/or suicide later in life. Sexual abuse appears to carry the highest risk, and then emotional and physical abuse; the combination of two or more can be especially lethal.

The purpose of these studies is to identify adults who might be at greater risk for depression (and other psychiatric problems) and, ultimately, suicide by opening up conversation and recognizing the propensity of abused children to have mental illness leading to self-inflicted death as adults. There is also a factor that plays a role in the odds of a childhood abuse victim suffering from depression: memory.

What You Don’t Remember Can’t Hurt You, Right?

There is a school of thought among psychiatric professionals that the brain of a child who suffers abuse finds a default mechanism to either switch off their ability to remember, and therefore dwell upon, abusive incidents, or to repress memories sufficiently that they are able to function in the aftermath of abuse. In both cases, the result is almost invariably depression. It is worthy to note that, statistically, 83.3% of childhood abuse occurs in the family home and between family members, not strangers. In a home where there is spousal abuse (more than just a typical argument between a couple), odds are close to 60% that there is also child abuse going on. In-home child abuse is seldom reported; the children involved usually live in fear and do not understand that they have options for recourse. As a result, episodes of depression frequently begin at a very young age, and are too often written off as childhood “moodiness”.

Dr. Thomas Verny, a practicing psychiatrist and author with a specialty in pre-natal psychology, knows that abuse can and sometimes does start before a child is even born, but the burden of it occurs once a child is functioning within the family unit. He has studied and counseled many childhood abuse victims, and says, “Repressed memories are a defense mechanism; it is an automatic process, not one that the victim thinks through.” He also believes that there is a distinct correlation between childhood abuse and depression, among other disorders, the worst of which, in his opinion, is borderline personality disorder, an incredibly complex mental illness. “Schizophrenia is actually easier to treat,” he says.

A Case Study

Joan is an only child, and now, in mid-life, an orphan; this is a fact in which she finds relief. Joan’s father was a patriarch with an iron fist, a bully. She was the couple’s only child and when her father’s day went poorly, Joan’s evening was hell. Her mother, also abused emotionally and physically, was paralyzed and did nothing to stop her husband’s tirades exacted upon their daughter. Joan could do no right by her father. If she brought home a near-perfect report card, he would pick holes in it until there was an excuse for battery. If she dressed in blue, she looked ugly; if she dressed in red she looked like a tart. Joan quit school at 17 and moved out; it probably saved her life, but the damage was done.

Joan has suffered from episodes of depression all her life, and there is nothing to suggest that because her father is dead now that these bouts will stop; they haven’t and he has been gone five years. Fortunately, when Joan attempted suicide for the second time when she was 21, she received excellent psychiatric care and knows how to cope with depression when it hits, to recognize the triggers and to nurture herself when the “darkness descends”, as she puts it. But Joan’s depression has a distinguishing feature to it: she instantly defaults to thoughts of suicide when the wall of depression consumes her. Because Joan knows this, she also understands that she is not truly suicidal any more, but this is how her brain copes, just as it chose repression of memory to withstand her childhood abuse.

Part of Joan’s strategy is to let the people who love her know as soon as she finds herself sliding into depression; that way, they do not bear the burden of guilt, and they know it’s nothing they have done. Thanks to this openness, Joan’s family does not have to fear she will take her own life. There is no way for Joan to make the abuse go away; it is part of her past and cannot be changed, so coping with its legacy is all she can do. Joan is able to rationalize her depression and three attempts at suicide, now that she is a mature adult and has received proper care, but she is 100% certain that the abuse she suffered as a child resulted in her depression and was the causative factor in her desire to end her life.

Saving Lives is the Goal of Research

Scientists like Dr. Turecki and his team are engaged in their studies with the intention of predicting those at risk for suicide and preventing them from taking their own lives. In some instances, that’s harder than it sounds because a physical, biological shift occurs, not just mental trauma, in many cases of childhood abuse. Dr. Turecki, in examining 60 brains of mostly adult males who committed suicide, 40% of whom had been abused in some form during their childhoods, saw something startling: “There was a change to certain critical genes that then lead to the development of certain behaviors, that in turn increased the risk of suicide.” What Dr. Turecki witnessed was the result of a change in DNA; this is very different from depression as an outcome of childhood abuse. Like Joan’s experience with her brain taking what is tantamount to “separate” action to protect her from the abuse and its terrible memories, Dr. Turecki has found that traumas suffered due to abuse in childhood may actually cause the brain to undergo physical alterations, some of which may lead to suicide.

Some may argue that the sheer embarrassment, terror and shame brought on by childhood abuse is sufficient to warrant suicidal thoughts, and they’d be correct. But there is an established link between childhood abuse, depression and ensuing suicide. The rate of clinical depression and major depressive disorder in people who were abused as children is significantly higher than the general population.

Initially, Dr. Turecki’s team was searching for one specific gene that formed the connection, but much to their surprise, they have, thus far, uncovered more than 100 such genes. “It is more complex than we thought at the beginning,” says Benoit Labonte, a member of the McGill Group for Suicide Studies and part of Dr. Turecki’s research crew. With the aim of developing a test that will single out those at risk for suicide, and to find treatments (not just for the mental aspects, but for the physical alterations in the brain) -Dr. Turecki adds, “We know already that we can modify these changes in cell models.” There is hope for what victims would see as hopeless.

Another study conducted at the Department of Epidemiology, Mailman School of Public Health, Columbia University in New York City, took a slightly different approach to the same problem and revealed similar results. The 34,653 subjects of the study were a mixture of males and females all with a history of childhood abuse, to varying degrees. The study, reported in the February 20102 issue of the British Journal of Psychiatry, and entitled, “Childhood maltreatment and the structure of common psychiatric disorders”, looked more at the link between childhood abuse and depression as opposed to, ultimately, suicide. It found that men showed “externalizing liability”, where women experienced “internalizing liability”. In simple terms, this is how they burdened the guilt from their youthful experiences.

The Columbia study concluded: “The association between childhood maltreatment and common psychiatric disorders operates through latent liabilities to experience internalising and externalising psychopathology, indicating that the prevention of maltreatment may have a wide range of benefits in reducing the prevalence of many common mental disorders. Different forms of abuse have gender-specific consequences…”

What both of these studies, among many others, suggest is that by identifying childhood abuse, even if we are failing to prevent it (which we, as a society, are), we can take action to grapple with the psycho-social outcome, to help victims manage the ensuing depression, and prevent a vital person from ending his or her life.

Key to understanding the complexity of schizophrenia and to knowing if you or someone you love may be at risk of developing it is recognizing and acknowledging that it is not a form of depression. Even though schizophrenics may become depressed and share some of the symptoms, especially the early ones, it should not be mistaken for depression. In fact, it is often those who are caregivers for schizophrenics that end up with clinical depression. It’s a painful role to play and is one of many reasons why schizophrenics are often placed in specialized group homes.

So, if it’s not a Split Personality, What is it?

According to the National Institute of Mental Health (NIMH), based in Maryland, there are, among thousands of unanswered questions about schizophrenia, at least a handful of facts:

• Schizophrenia affects about 1% of the American population over the age of 18.
• It seldom occurs in children, although children may exhibit certain behaviors that suggest they may be at risk of developing the disease in their teens or early adulthood. Research into childhood-onset schizophrenia is commanding greater attention these days.
• Men and women are affected in equal numbers, but males tend to exhibit symptoms at an earlier age.
• All ethnicities are equally liable to have members that become schizophrenic.
• After a person reaches age 45 it is highly unlikely they will develop schizophrenia.
• Two common symptoms of schizophrenia, namely hallucinations and delusions (both detailed later), tend to materialize between the ages of 16 and 30.
• Schizophrenics are not usually violent, but some of the symptoms they suffer are associated with violence upon them.
• Schizophrenics attempt suicide more often than the general population, even those with major depression; 10% of schizophrenics die as the result of suicide.
• People with schizophrenia are 3 times more likely than the general population to smoke cigarettes, and they suffer more addictions to drugs and alcohol.
• The disease runs in families. Although 1% of the population becomes schizophrenic, 10% of those with an immediate relative who has schizophrenia are apt to develop it. That figure leaps to 45-60% if an identical twin has it.
• Schizophrenia cannot be predicted with accuracy, but there are ways to tell and test if there might be a propensity toward it.
• Autopsies and brain scans have shown that a schizophrenic brain demonstrates differences to a “normal” brain, including having bigger ventricles (the fluid-filled cavities that rest at the center of the brain), less or more brain activity than is common, and less “gray matter”.
• Psychiatric treatments help, but for diagnosed schizophrenics, medications are virtually mandatory to control the symptoms.
• There is no known “cure” for schizophrenia. No one appears to have simply grown out of it.
• The greatest issue in treating schizophrenia is that the patients are often delusional (a common and widespread symptom), so when the medications start to work, they begin to believe that they are cured, and go off the drugs, frequently resulting in a serious relapse.

There is a tendency among mentally well people to distance themselves from schizophrenics, probably because they know few truths about the disease, are ignorant and therefore afraid, and don’t realize that these patients are not dangerous, by and large. Ironically, not many schizophrenics can manage without some form of human support, so they need others, badly in some cases, to assist them in overcoming their daily challenges of staying alive and coping with what can be terrifying emotional experiences. Always remember that schizophrenics are not necessarily in complete control, but they do not “do” this on purpose. There is no point in being frustrated by the behavior of a schizophrenic, and yet, they can be confounding and trying at times.

What Causes Schizophrenia?

Because the disease is so complex, there are arguably more theories than facts when it comes to documented causes of schizophrenia. Science still has a lot to learn about this illness.

Schizophrenia tends to become evident in the teen years and this can be very difficult to diagnose given that the teen years invoke some of the most bizarre behavior exhibited by humans during the course of their lives. Warning symptoms and signs such as suddenly changing friendships, school grades going down in an otherwise normally good student, general irritability, sleep problems (often hypersomnia or over-sleeping) and withdrawing from social activities may seem like normal teen angst and hormonal fluctuations.

In the diagnostic process, this is known as the “prodromal” period. If the normally shifting, erratic and confounding behaviors of teens also include an abnormal tendency to isolate themselves (staying in their room for days on end), a family history of psychosis or a diagnosis of schizophrenia in a first-line relative, unsubstantiated suspicions (such as a former friend who they believe is trying to hurt them or has betrayed them in a profound and implausible way), and strangely illogical thoughts, there is an estimated 80% change of that teenager being at risk for developing schizophrenia. A saliva test can help expose people who are seriously at risk.

Schizophrenia has been proven to run in families. Scientists believe that a multiple gene mutation, essential to the normal development of brain cells and chemicals, malfunctions and can trigger schizophrenia. The problem is that research has not yet been able to demonstrate all the gene variations that might be involved, hence the onslaught being hard to predict, even where there is a family history.

Most doctors agree; the schizophrenic brain looks different from other brains. So much is yet to be learned about this complex and devastating disease, but scientists and researchers are basing their studies on what they do know thus far, not what they don’t know; facts as we know them (and they are still evolving) as to the causes of schizophrenia are:

• There is likely an interaction between genetic make-up and environment and most experts agree that this is the primary cause.
• The combination of genetic predisposition and such physical factors as exposure to a virus either in-vitro or at birth, malnutrition of the mother prior to giving birth, and problems during the birthing process can be “to blame”.
• Brains that possess a different structure or chemistry, resulting in a degree of imbalance in the cerebral cortex, may affect neurotransmitters in the brain and prevent or limit their functional capacity.
• The inability of the brain’s neurotransmitters to deliver messages from cell to cell, causing a disconnection.
• The pre-natal period is emerging as a crucial time period in the development of risk for schizophrenia. Lack of sufficient nutrients in the womb (the result, usually, of the mother’s dietary intake) can predispose the unborn child to the possibility of certain disease, including schizophrenia. Scientists think the connection may be hormonal and the hormones just “go to sleep” until the individual hormones wake up at the time of puberty. This makes sense because most people diagnosed with schizophrenia began to exhibit some form of symptoms in their early teens.

The causes of schizophrenia have some certainty and a lot of mystery. Research continues apace, but it is of little comfort to those who suffer now from this debilitating disease.

Symptoms and Signs of Schizophrenia

Part of the reason schizophrenia is so complex and frustrating is the range of different symptoms and the varying ways that individuals may manifest them. The ultimate objective of therapy is to control the symptoms, rather than to mask them. Masking them can and almost always does make people, including the sufferer, believe they are cured. They go off their medications and the results can be awful.

Schizophrenia is regarded as a life sentence. Once it manifests, there is no known cure. Most people who are diagnosed with it live a compromised quality if life, but many can still lead a reasonably decent life if they stick with the treatment plan. If left untreated, schizophrenia will assuredly be a terrifying experience for the individual who has it; the voices that almost all schizophrenics hear are cruel, demeaning and can be life-threatening with their direct instructions for self-destruction. The symptoms and signs of schizophrenia are grouped into three general categories, addressed as follows:

Positive Symptoms

The term “positive” in this instance as akin to having “positive results” or “testing positive” for a certain condition; is it not the synonymous “happy” that you might think at first glance. The positive symptoms are known to wax and wane, sometimes suggesting the disease has been cured or vanished on its own; beware, for this is not the case. One positive symptom, being out of touch with reality, is a sensibility that a lot of people seem to suffer in this day and age, but it’s not necessarily a cue for schizophrenia; some doctors believe that the modern tendency to “plug in” to music or other distractions provided by personal electronic devices has removed people from reality. A positive symptom almost invariably involves a series of psychotic behaviors that are not present in people without schizophrenia. These symptoms include:

• Delusions. Imagining that your next-door neighbors are doing more than clipping off your prize roses at night, but plotting to enlist the aid of Russian spies to murder you the next time you are up a ladder pruning the crabapple tree is an example of a deluded thought. Delusions are abstract and extreme ideas and thoughts that bear no base in reality. Deluded individuals sometimes think they are close friends with famous people; some celebrity stalkers might fall into this profile. Others may believe that they are a famous person, or are the reincarnation of a well-known historical figure. Far and away the most prevalent form of delusions in schizophrenics is “delusions of persecution”, almost always precipitated by the mysterious voices that only the victim can hear. These voices suggest that others are trying to kill the schizophrenic individual, stalking or attempting to poison them, or harassing or cheating them. None of these suspicions is based in fact.
• Hallucinations. Most people regard hallucinations as just being images that are not, in fact, there, but hallucinations also involve other senses, such as touch, smell and even taste. The hearing of voices is the most common type of hallucination, and in fact one of the most common symptoms in general of schizophrenia. Some schizophrenics also visualize the embodiment of their voices, but no such individuals actually exist. Some catch the scent of odors, such as roses outdoors in the wintertime, that cannot possibly be there. Others may feel the sensation of someone touching them when there is no other person present.
• Disorderly Thinking. This is a broad-stroke category of symptoms, but means any form of abnormal thought processes, including “warped” ways of thinking such as extreme illogic, and disorganized thinking in which thoughts come in the wrong order, somewhat like putting the cart before the horse, or in disjointed fashion. In some cases, stories are made up, or the invention of words sworn to be in every dictionary are used in speech. Another example is the sudden stoppage of speech, often mid-sentence, for no explicable reason, and the inability to recall what was being said. Some schizophrenics speak in garbled sentences, and many deliver words in monotone structure. A few come up with their own language, and claim their voices also speak in this tongue.
• Uncontrolled Movement. A symptom, but one of the lesser ones, this can involve sudden movements of limbs that have no sense of control; many schizophrenics could be called “fidgets” as their body movements, such as tapping of fingers or toes, convey a sense of impatience. Motions are sometimes made as though there is a drumbeat giving them rhythm, and they may be repetitive, possibly for hours without variation. The opposite to this is being catatonic, and schizophrenics almost all experience at least occasional bouts of this, whereby they will sit still, potentially transfixed, for long periods of time without moving, not even to eat or use the bathroom. Fortunately, the catatonic state is one of the symptoms that is readily controlled by the drug therapies available today.

Negative Symptoms

Negative symptoms do not suggest an absence of diagnosis, but they are harder to detect and can be mistaken for other mental illnesses such as depression. And yes, if you are a schizophrenic and suffering from these, they impact your life negatively. The definition of negative symptoms as they relate directly to schizophrenia is: disruptions or extremes to what would be regarded as “normal” human emotions or behaviors. For example, it would be normal to cry at a funeral; a schizophrenic may laugh or just turn off their emotions completely. Some negative symptoms and signs of include:

• Neglect of personal care and hygiene; this is not just someone being lazy or slovenly about appearance.
• The inability to perform mundane tasks that are more like repetitive physical labor than jobs or chores requiring much thought.
• What is known as “flat effect” or the tendency to speak perhaps slowly, almost invariably in monotone, devoid of inflection, often with complete lack of facial expression.
• The inability to derive pleasure from life (this is very much akin to a symptom of clinical depression, hence the confusion in the interpretation of some negative symptoms).
• Silence and being unwilling to speak, even in social situations, is a classic example.
• Confusion or a sense of being overwhelmed at the prospect of having to plan ahead, and the inability to maintain such plans if they are put into place.

Cognitive Symptoms

This set of symptoms can be confusing because of the great variation in their subtle difference. Cognitive symptoms are frequently overlooked until a test is performed relative to any type of symptom altogether. Because of their understated nuances, cognitive symptoms may go undetected or be misconstrued; they may not appear to be a part of the schizophrenic profile. But they are the aspects of schizophrenia that can have a profound effect on lifestyle; these symptoms are often the elements that prevent a sufferer from being able to earn a living, and they are the root of emotional upheaval and deep distress. Cognitive symptoms include:

• Difficulty in getting and remaining focused on any task or even a thought.
• Not being able to pay attention to instructions or directions.
• Low “executive functioning”, which means the individual will have a twofold problem: 1. understanding information; and 2. acting upon that in order to make decisions.
• The inability to make choices when more than one option is presented.
• Trouble with a normal “working memory”, which involves the capacity to use information immediately after it has been presented and/or learned. This is very much like acute short-term memory loss.
• Emotional overreaction or complete lack of reaction to otherwise normal occurrences. An insect bite, for example, soars out of proportion in importance, but a car crash is just another incident in a day of incidents.

With emotions out of control and the inability to remember input and do anything with it, cognitive function is impaired and prospects for a normal life are comprised, sometimes to an extreme.

Treating Schizophrenia

The emphasis of treatment for schizophrenia is the eradication of symptoms, but that is a lofty ambition. Controlling them is probably the best aim, with the hope that some will diminish in severity to the point of seeming to not be there. Unlike most forms of mental illness that can be treated with psychotherapy alone, schizophrenia requires, almost without exception, drug intervention to stabilize patients’ symptoms before a psychiatrist can conduct psychotherapy. At least if the doctor and patient harbor any hope for a positive outcome.

Prior to the 1950s, there was little hope for a diagnosis of schizophrenia. Patients languished in mental hospitals or proved an endless challenge to their families. With the advent of the first round of “typical” anti-psychotic drugs in the mid-1950s, combined with psychosocial therapy, victims of schizophrenia began to have hope for some level of life, albeit compromised. Since then, a second generation of “atypical” anti-psychotics, released in the mid-1990s, has helped a broad swath of the schizophrenic mosaic attain a better life.

All anti-psychotic drugs are powerful and come with inherent side-effects. Doctors usually find it necessary to experiment with different potential prescriptions before they find the one that suits an individual patient’s symptoms and metabolism; occasionally they have to try various individual drugs or combinations of drugs, until the required benefits are produced. Most come in pill form, some in liquid and a few are administered through an injection. Results typically take a few days to begin, and by six weeks most patients feel relatively normal, but that frequently prompts the risk of them going off their drugs because they feel so much better.

Not only do anti-psychotic drugs have a long list of negative side-effects, they often don’t combine well with other medications, should the schizophrenic have secondary diseases, and their interaction with simple things like vitamin and mineral supplements can be seriously problematic. Even over-the-counter cold reliefs or headache remedies can mix badly with anti-psychotics.

Treatments for schizophrenia are classed in two categories, drug and psychosocial therapy. Here is the essential list of antipsychotic drugs, together with their brand names in parentheses:

Typical Anti-psychotics

• Chlorpromazine (Thorazine)
• Fluphenazine (Prolixin)
• Haloperidol (Haldol)
• Perphenazine (Etrafon and Trilafon)

Atypical Anti-psychotics

• Aripiprazole (Abilify)
• Olanzapine (Zyprexa)
• Poliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

Another anti-psychotic drug used in treating schizophrenia is riddled with problematic side-effects, rendering it a prescription recommended only after the others have been tried, and failed to produce results. The downside to Clozapine (Clozaril) is that it sometimes causes a condition known as “agranulocytosis”, the reduction or loss of the white blood cells that help us battle infections. While the drug is often effective, it is frequently held back as an end-of-the-line option due to its issues, and once it is prescribed, patients are subject to bi-weekly blood tests to check that their white cell count is not compromised. But its ability to corral hallucinations and problems with perception of reality make it worth a shot, especially where other drugs have failed to work.

The normal side-effects of typical anti-psychotics include: skin rashes and sensitivity to the sun; menstrual irregularity in females; drowsiness and dizziness; a rapid heartbeat; and issue with eye focus. The side-effects of atypical anti-psychotics are commonly regarded as a bit worse, but it’s a balancing act given that these newer drugs appear to be more effective, by and large. A major issue is significant weight gain, but they also cause a series of problems that affect body movement. Patients report complaints of rigidity, restlessness, tremors and muscle spasm. But it’s the long-term use (and since schizophrenia is not curable, these drugs tend to be ingested for the life of the patient) that is the real concern; it can lead to a condition called “tardive dyskinesia” that results in muscular movement that’s out of control.

It is crucial to remember that anti-psychotic drugs are strong and anti-social in that they react poorly with almost all other medications. Given that alcohol and other substance abuse is common in schizophrenics, it is a major factor in prescription drug safety, and the effectiveness of treatments is compromised by alcohol, cigarettes and marijuana use. While we should all quit smoking, it’s harder for a schizophrenic because the nicotine withdrawal can trigger or exacerbate psychotic episodes.

The psychosocial version of treatments is designed to help patients already stabilized by taking the anti-psychotic medicines. The concept is to teach skills that help patients manage the daily challenges that form the core of their lives as schizophrenics. What were once simple tasks become complex efforts for schizophrenics and the basic life skills we take for granted may have to be re-instilled. It also involves educating a patient’s family in living with and managing the disease, and the frequent occurrence of substance abuse that accompanies the already complicated world of the schizophrenic.

Case Studies

We followed the lives of two people with schizophrenia to get an insight into the reality of the disease. Once we have reported on these two cases, we’ll give you some tips in handling people you know or complete strangers that may be suffering from schizophrenia. Given that 1 in 100 people have schizophrenia, odds are you know one or two already.

Jamie’s Story

Jamie was 20 and enrolled at a prestigious university, getting top grades, but he was struggling with choosing a major. Caught between medicine and dramatic arts, which are significantly different paths, he knew he had the brains to get through medical school, but his free-spirit side longed to work in theater, to be creative and part of a collaborative process.

In his teens, he’d suffered from depression, with bouts of major depressive periods, but never what anyone would call a manic episode. His parents, both professionals, and his siblings knew him as a bit of a lone wolf, but never found anything startling about him. No one in his family had schizophrenia or, for that matter, depression. But Jamie had heard cruel voices since he was in his early teens. He was confused by them and not certain if they were voices or just weird dreams, and so he told no one.

As time passed, the voices (there were, he recalls, about 6 distinctly different ones, sometimes all shouting at once, and occasionally speaking to one another, not just to Jamie) got worse, shouting at him and telling him he was useless, stupid, a “waste of skin”. Then one night, alone in his dormitory room, unable to sleep for the cacophony in his head, Jamie tried to silence the sound by having a glass of whisky and a cigarette. It had the opposite results to what he had hoped for.

The voices became intense, threatening, and argumentative. They fought among themselves and then united in one vile scream instructing Jamie to kill himself. Luckily, his suicide attempt failed. Shortly after, Jamie was tested and then diagnosed with schizophrenia. He moved back home, gave up his university studies and began treatments. Medications greatly reduced Jamie’s symptoms. A sympathetic friend of his parents who owned a restaurant gave Jamie a part-time job as a dishwasher. For a while, things were calm, if not sadly reduced for a young man who once had such promise.

One day, Jamie overheard his parents complaining about the high cost of his numerous medications, and he simply figured he was better, so he quit his prescriptions, without mentioning it to anyone, and one night, a few days later, when he was at work, the voices came back. This time they told him to get the kitchen knives and kill himself right then and there. James growled back at them, under his breath, and was unable to continue operating the dishwashing machine.

An astute cook recognized that something was wrong with Jamie and attempted to find out what was troubling him. Jamie brandished a knife and began to scream. He was about to run out the back door of the building, still with the knife in his hand, when the kitchen staff tackled him, dropped him to the ground, and took the knife from his hands. The police were summoned. The owner knew right away what had happened and Jamie was taken to hospital, where his doctor placed him back on his medications and held him for observation until he stabilized.

This was a major lesson for Jamie, and while it may have been embarrassing for him, now that the restaurant staff know he has schizophrenia, they are all aware of what danger signs to look for. Jamie can’t drive because of his disease, so he rides his bike to work every day, and has made some friends among his fellow staff members. Awareness helped them better understand him and he feels safe; so do they because they know Jamie isn’t normally violent, just a good guy with a serious mental illness. Jamie is a chain-smoker, but on his doctor’s advice he gave up beer and all other forms of alcohol. He recently got a small apartment, and he’s one of the few schizophrenics that is coping with life on his own.

Jamie is almost 30 now. He also suffers from occasional depression (his doctor thinks that might be a side-effect of one of Jamie’s many prescription drugs, or the result of a combination of them) and is sometimes hard to talk to, even for his parents, friends and co-workers, but everyone understands and if Jamie is low, they try to be respectful and show kindness. Jamie is aware of himself to that degree, and is very thankful that people teat him so well. Jamie is one of the lucky ones.

Mary and Greg’s Story

Schizophrenia doesn’t just affect the victim. In fact, some people who suffer from schizophrenia are so out of touch with reality, they don’t comprehend the nuances of the disease or the fact that they have it (another reason why schizophrenics sometimes withdraw from taking their medications). The people who have a strong bond with the schizophrenic individual have their work cut out for them; this includes institutional care-givers, parents, spouses, friends, co-workers (such as is the case with Jamie), siblings and children.

Greg met Mary when he suffered an acute bout of depression and had to be hospitalized. At that time, nearly 20 years ago, Mary’s mother thought her daughter was depressed; she had no idea what schizophrenia looked like and suspected Mary was depressed. Greg and Mary became friends and then were romantically involved. Greg felt a deep bond because they shared the scourge of depression and were able to be fully empathetic with one another. Then Mary began to hear voices and Greg, a well-read, intelligent person, recognized this as a possible, if not likely, symptom of schizophrenia. And the descent began.

When Greg decided he had better learn all he could about schizophrenia, he discovered that symptoms are generally classified as “positive”, “negative” and “cognitive”; he found nothing positive about it and over the many years that he fought to keep Mary living at their mutual home, rather than in a group home, he watched her deteriorate as her doctors paraded her through the numerous prescriptions that are supposed to control the symptoms. The only one that worked, the “last ditch” effort, posed a danger to her white blood cells.

Luckily, Mary exhibited only very mild paranoia, a common symptom of schizophrenia; some schizophrenics demonstrate severe paranoia. On occasion Greg and Mary would watch a television program and then the next day, Mary would be found mimicking the behavior of a character on the show. She stopped bathing and he had to regulate a new routine of hygiene for her. She would, if she went unchecked, wear the same clothing day in and day out for weeks; she had a large wardrobe of outfits, but defaulted to the same sloppy set of sweats, and the same underwear, every day; Greg had to manage laundry, and help her dress every day to ensure she wore clean clothes.

Mary lost track of the passage of time; a day would pass and she would think it was an hour, or an hour would pass and she believed it was a year. She went from being gregarious to withdrawing from other people, even her sons, and when she did speak in social situations, her voice was flat and monotone. They stopped going out and having friends over. Trips to the doctor or hospital became their only outings; they even ordered grocery store items to be delivered. Greg’s friends and family hardly saw him; they were uncomfortable with Mary’s decline (she had also stopped wearing make-up, and would not even brush her hair unless Greg did it for her).

Two elements dominated Mary’s “behavior” (in quotation marks because the actions were not of her own free will, which had been consumed by schizophrenia): 1. the prevalence of voices; and 2. her removal from reality.

The hearing of voices is a very common symptom of schizophrenia, but each victim experiences something slightly different. In Mary’s case, it was a group of four individuals and she had names for each of them. It was unclear if they told her their names or if she named them. There were two men and two women, Sam and Carl, Ellen and Susan. Sitting alone on the patio, having a cigarette, Mary would hold court with her voices, sometimes being powerfully in charge of them and issuing orders, but mostly they told her what to do and when they did it was invariably meant to be destructive towards Mary, and sometimes towards Greg or their pet cat.

Mary’s voices urged her to kill herself, telling her she was useless and no good. They also directed her to do things that could damage the few people, like Greg, who still cared about her. He found such things as bleach in his glass of drinking water, old cat food in teacups, and bits of metal in his food; Mary’s voices were getting more creative. The day that Mary urinated on their bed and several piles of laundry, Greg was at wit’s end.

Mary’s removal from reality is also common in schizophrenics and doctors regard this as a type of defense mechanism. For example, if Mary had been negligent in the few household duties Greg assigned to her, she would not notice. A pile of rotting food scraps in the under-sink compost bin would be left until Greg couldn’t cope with the stench; Mary smelled nothing unusual. And it wasn’t just not embracing reality, it included grandiosity; she decided that she and the late Doors singer, Jim Morrison, were close friends. She became obsessed with every lyric of every Doors song and believed they were written for her.

Other symptoms either stealthily infiltrated their lives, or co-existed with the major ones, including: Mary always living in the immediate moment and being unable to plan ahead, not even a few minutes ahead; Mary seeing a form of halo composed of glittering diamonds surrounding the heads of people she knew or who were strangers passing by in a hospital hallway; hypersomnia in which there were periods that saw Mary sleep 12 to 16 hours a day for a week or so, and then return to the normal 8 hours; brief or long periods wherein Mary was catatonic (there are degrees of this in schizophrenics and Mary’s was not as acute as some) and would fixate on something, such as an object in a store window, and refuse to walk away from it until she became catatonic in staring; Mary would sometimes fixate on a person’s face, never altering her gaze, much to the chagrin of the person (most often a child) under her constant, steely stare; and her drifting off, perhaps in mid-conversation, to the point where Greg had to gently shake her and shout to bring her back around to the moment.

While Mary was the technical victim of schizophrenia, it was Greg that arguably suffered most; at least he was conscious of what was going on, and because Mary had a much less acute understanding of her world, Greg found that he had to watch her constantly. This affected his ability to work outside their home, and to take care of his own needs. As time passed, the clutter in their house accumulated, and the housework piled up. With less income, due to Greg not working, they couldn’t afford to pay someone to do housekeeping.

Finally, Greg decided that Mary had to be moved to a group home; he had virtually lost his own life in the necessity of caring for Mary. His depression had returned with a vengeance. She found something in her diseased mind to fight him all the way, registering as immense guilt for Greg. Unfortunately the group home where Mary was to live turned out to be less than well-managed. She lasted there 2 weeks and Greg brought her home. The cycle resumed and Greg’s mental health declined. At one point he declared that the only sane being in the house was the cat.

Greg sought counsel with his psychiatrist, and part of their discussion involved a provocative question that doctors treating schizophrenics must repeatedly ask themselves: is the behavior entirely the fault of the disease, or partly to do with the powerful medications being used to treat the symptoms? There is no easy answer. Over time, Mary’s behaviors grew worse and Greg’s friends sat him down to say, “What you have tried to do for Mary over the last 15 years is noble, but it’s killing you.” Greg enlisted Mary’s two sons, now adults, and insisted they take their turn at housing Mary for as long a Greg needed to regain his own mental and physical health (this gargantuan stress and responsibility had resulted in a heart condition and diabetes for Greg).

Mary moved in with one of her sons, theoretically on a temporary basis; Greg never saw her again. He heard that she had been moved into a group home, one that was supposed to have a great reputation. He wished her well, but had to forge his own way to recovery. As the caregiver to a schizophrenic, a large chunk of his life had been compromised. At 60 years old, Greg is starting over.

Controversial Approaches

In the early days of educating himself about schizophrenia, Greg came across a book called “How to Live with Schizophrenia” by Dr. Abram Hoffer and Dr. Humphrey Osmond (published in 1974 by Citadel Press and re-released with updates in 1992). The book addresses not just how to live with this disease if you have it yourself, but the effect it has on caregivers, families and friends, and society. What Greg learned from this somewhat controversial time is Dr. Hoffer advocates that schizophrenia can be prevented, and even cured if caught in its early stages of development.

Key to Dr. Hoffer’s approach is that there are signs of impending schizophrenia, and a number of risk factors that become evident in adolescence or early adulthood. As soon as these show themselves, huge doses of Vitamin B-3 (niacin) are supposed to effectively stop schizophrenia in its tracks. He believes that even if the disease has manifest to some degree, it can be stopped or assuaged by this massive vitamin therapy. Dr. Hoffer has also published a book on “curing” alcoholism, a radical concept, but also based on his theory that all alcoholics have a Vitamin B-3 deficiency.

In Greg’s situation (Mary’s case) it was too late once he learned about the potential curative and restorative properties of B-3, but he met some people through Mary’s many hospital visits, who swore by the therapy and said it had eliminated the development schizophrenia in them or their loved ones. The one thing that must not be overlooked about this extreme and controversial method of controlling schizophrenia is the toxicity of large doses of niacin; is the benefit worth the risk?

Things You Should Never Say to a Schizophrenic

Schizophrenics waver between being present and being “elsewhere”, and very few people, even those that live with schizophrenics, can tell at a quick glimpse what state they are in at any given moment. Therefore, always err on the side of caution and assume they are in the removed state, or in a state of mind that is full of classic symptoms. If they happen to be having an especially lucid or “normal” moment, or if their medications are working sufficiently well that they appear not to have the disease, still be cautious in your approach.

Here are things you should never say to someone that you know has schizophrenia, or even a stranger that you suspect may have it (now that you have learned what it “looks” like):

• 1. Who are you talking to?
• 2. You seem really nervous.
• 3. Cheer up; you look glum.
• 4. Hey, nobody’s going to hurt you, it’s all in your imagination.
• 5. You’re just depressed; you’ll get over it.
• 6. Why can’t you keep a job!
• 7. You’re not making sense; just put your thoughts in order.

It might seem insignificant that 1% of the population develops schizophrenia, but if you frame that within the population of the U.S.A., that’s an astonishing 3 million people! Many schizophrenics appear to be normal until something challenges their tightly, necessarily regimented world. The risks appear early enough that we can be prepared, and maybe even take steps to ward off what seems to be the inevitable, but once schizophrenia has sunk its claws into a human being, their lives, and those who care about them, will shift forever.

When you’re in the business of trying to help mentally ill people, including those with depressive disorders return to a state of good mental health, it’s a tough task. A doctor treating a patient with appendicitis can surgically remove the appendix, the patient heals and all is well; not so with mental illness.

Psychiatrists need more than just medical training, but enormous human insight to know when suicidal thoughts are simply part of the path in clinical depression, or when it is time to worry. The same applies to patients who experience suicidal thoughts. Are they real; does the concept instill fear or a sense of peace?

The integral difference between thoughts of suicide and suicide is some form of action, including planning steps or making a list of conditions or supplies required. Taking action in whatever degree of seriousness may seem obvious, but it is a fine line. Many people who suffer from depression have a tendency to default to suicidal thoughts the moment a depressive episode is upon them; it’s simply how their brain reacts to clinical depression, but they never act on it.

Signals That May Precipitate a Suicide Attempt

There is probably no way that a depressed person at risk of contemplating or attempting suicide can be sufficiently objective to analyze their own situation. If you are experiencing dark thoughts and engage in precise suicide planning, and are able to visualize clearly a world without you in it, get professional help immediately. Don’t second-guess whether or not you might actually go through with it, get help.

If your fear is that someone you know and/or love is on the verge of committing suicide, but you’ve heard them threaten that before and nothing came of it, there are things to look for that might indicate this time they are serious. The list that follows includes psychiatric observations and the direct experiences of people who wanted to end their lives, but survived. Here are some signs that suicidal thoughts have turned potentially lethal:

• In a person who is not normally very orderly or organized, or does not otherwise have an illness, such as terminal cancer, that might warrant it, the preparation of a will can be a subtle hint. While the making of will seems sensible and we should all do it, if it seems out of the ordinary for the person in question, that’s a reason to be concerned.
• A strangely calm demeanor or even euphoria in a person who generally exhibits neither emotion profoundly. The decision to end the misery of life, as perceived by a depressed individual, can give them a sense of relief and find a final moment of happiness in knowing what has hurt them will soon be over.
• A need to set everything in order, to tidy the house, and put everything away; again, this applies more so to those who are normally not fastidious about housekeeping.
• Stockpiling prescription drugs over a period of time. This is often accompanied by using less than the prescribed dose so that there are “leftovers”.
• Using a computer or library to research methods of suicide, such as poisons, drugs, access to firearms, etc.
• Purchasing a gun or other weapon; this is a clear indicator if the individual is normally anti-firearms.
• Wrapping up loose ends by sending overdue letters or notes, paying bills to current, dividing personal items and money, and giving them away to family friends (as though executing a will in advance), and saying good-byes that have a final ring about them.
• Increased risky behaviors, including sexual recklessness and experimenting with or heavier use of drugs and alcohol.
• Withdrawing from society and personal relationships; psychiatrists assert that this helps the individual remove himself or herself from the daily workings of life, a way of separating from the life her or she knew and is about to leave.
• A sudden and sometimes prolonged interest in violence, such as gratuitously violent films, and death or dying; this may manifest in things like solo walks frequenting graveyards, reading books on the subject, visiting palliate care wards in hospitals, even hanging around funeral homes.

The Mayo Clinic warns that people who may be about to commit suicide will openly talk about it, perhaps as directly as stating, “I am going to kill myself.” Because we glibly use language in modern society, it’s easy to assume such talk may be a turn of phrase rather than a genuine suicide threat. Psychiatrists tend to agree that the more subtle statements about ending one’s life are likely serious. Be alert to comments such as, “I wish I had never been born,” and “I’d rather be dead.”

Don’t Wait And Regret Inaction

The reason that suicide is such a shock to the family, friends, colleagues and associates of the victim is more than the extreme sense of helplessness (I could have done something… if only I had known!) and sudden absence of an otherwise vital person. An often-cited issue is that they didn’t see it coming. This may have been because they either did not see the signs, partially thanks to the more ambiguous victim statements as noted above, or they did not recognize them as serious or related to a direct commitment to end one’s life.

If you see one or any of these signs, get help. Talk to the individual and offer remedial assistance, or get them to a doctor. If you discover that a suicide is imminent, or worse, in progress, call 9-1-1. People who are considering suicide are not able to see hope. A psychiatrist, church minister or suicide prevention line may begin to help them see that there are other options than death. Knowing the signs and taking action can save a life that is, ultimately, worth living. Almost everyone has entertained, albeit briefly, suicidal thoughts at certain highly charged emotional times in their lives, but it’s time to worry when words translate into actions and a plan is put in place to carry out the act of suicide.

Diagnosing depression requires knowledge & understanding of the clinical features of depression, which are listed below. We examine these in detail later in this article.

Signs of depression may include, but are not limited to, what follows. Note that these are not required in order that you are diagnosed with depression; many other factors may also be involved (it is a complex diagnosis):

TYPICAL DEPRESSION SYMPTOMS & SIGNS

Behavioral signs of depression:

• Avoiding eye contact, moving eyes downwards or away, slow eye blinking rate (unless any of these could be considered normal behavior in any individual.
• Slow or increased body movement, again not regarded as the norm.
• Speaking slowly in monotonous voice or unusually rapid talk, or talking gibberish.*
• Prolonged low mood, a sense of hopelessness, feeling heavy, down or desperate, generally accompanied by suicidal ideations. This would be more than a simple reaction to an upsetting event or emotional upheaval, but an acute response that becomes a chronic problem.
• Restlessness, irritability, feeling of being on the edge, or inexplicable tension and stress when external stress loads are not significantly different from normal.
• Anger, sometimes appearing more like the heightened emotions experienced during the manic episode, but it is almost always present in a person with depression; it may, however, be quietly percolating within and not show violently on the outside, at least not initially. This is sometimes directed at the people you love most and can shock you when it comes out.
• Delayed response times. An individual will consume an unusual length of time in formulating a reply to a question, and may seem distracted, or too busy inside their head
• A developed practice of being distant or disengaged, uninvolved with things that usually matter, negligent towards loved ones.

Physical appearance signs:

• Degree of self-neglect can be seen in appearance, for example poor hygiene and personal grooming
• Slouched posture, staring at the ground
• Wearing the same clothes several days in a row, or never changing out of pajamas

Biological symptoms of depression: (also known as somatic, endogenous, melancholic)

• Sudden reduced or increased appetite**
• Rapid and significant weight increase or weight loss, typically over 5% of total body weight.
• Physical pain & exhaustion that is not caused by other physical medical conditions. Common complaints include, heaviness in the limbs, lack of energy, exhaustion, headaches; this pain is commonly unable to be isolated by medical examination and can be a figment of the depressed person’s imagination.
• Muscle tension, frequent use of bathroom, sweating, trembling, being easily startled. Headache and nausea are common complains from those experiencing a depressive episode. Seldom will something as simple as a pain reliever or stomach treatment cure the problem, it is so intrinsically connected to the depression.
• Early morning wakening, typically a few hours before usual waking time, & inability to resume sleep. Also difficulty falling asleep, even when you feel tired. This includes irregular sleep patterns, and oversleeping as well as insomnia
• Recurring variation of mood, also called diurnal. In extreme cases, this may be more correctly diagnosed as bipolar disorder or manic depression.
• Loss of emotions or decreased ability to experience emotions, usually results in anhedonia & decreased libido; the reverse can also be true with vastly increased expression of emotions and excessive crying.
• Inability to experience pleasure from formerly enjoyable activities & hobbies, also known as anhedonia.
• Reduced desire for sexual activity, sex drive, even abnormal abhorrence of the concept of sex.
• In women, menstrual irregularities, including early onset of what appears to be menopause (normal menstrual patterns may resume after depression is managed, especially in women under the age of 50)
• Constipation and/or diarrhea, without obvious cause.

*symptoms like unusually rapid speech, increased movement fall under reversed biological symptoms

**symptoms like unusually increased appetite, oversleeping fall under reversed biological vegetative symptoms, usually associated with atypical depression.

Key to all of these symptoms is that they exist outside of what is normal for you and that they have no clear source. Fr example, if you are suffering from disturbed sleep patterns, but have increased your caffeine intake to 10 cups from 2 cups a day, there’s a reason.

Other depression symptoms:

• Low self-esteem, feelings of being a failure, overly comparing oneself to others, and feelings of great inadequacy dominating what was once a balanced sense of self.
• Thoughts of suicide, fantasies of suicide, talk of suicide; this may manifest in a knee-jerk reaction to suicidal thoughts when a formerly normal reaction would be to find a solution to a problem.
• Impaired cognition, loss of concentration & memory, and the inability to perform simple tasks.
• Impaired judgment, difficulty in making decisions or making plans, inability to understand consequences of their actions (most commonly associated with sociopathic and psychopathic behaviors, but sometimes a part of overall depression), unrealistic, usually exaggerated view of problems, a sense of feeling overwhelmed.
• Excessive, ongoing tension and worry, including anxiety states where everything seems worse than it is, nothing looks like it will have a positive outcome and there is a sense of helplessness, that the victim cannot do a thing about it all.
• Abnormally obsessive thoughts & compulsive behavior.
• Delusions, mainly associated with psychotic depression, include guilt, worries of being struck by a serious decease or thoughts that they are already sick with one. In extreme cases depressed people may deny the existence of body parts, or even the world around them.

SIGNS OF DEPRESSION: GAZE, EYE CONTACT & GESTURES

Studies on gaze, eye contact & depression have no consistent results, though general consensus is that depression (more so endogenous & neurotic) leads to reduced amount of gaze. This is also dependent upon the typical behavior of the individual; shy people often find it difficult to make and maintain eye contact, but that would be regarded as “normal” behavior for them. It is when such activity is abnormal that it becomes suspect pertaining to a diagnosis of depression. For these patients the amount of gaze is likely to increase with advancement in treatment of depression, immediate changes are likely to be noticeable after starting to take medications. People with general depressive disorder are likely to avoid eye contact, mutual gaze or general social contact; conversely, others will hold a gaze too long, and almost seem desperate to maintain any level of inter-human contact. This behavior is likely to increase significantly when the subject of discussion or other type of interaction is personal, rather than neutral. Generally the end & start of utterance are the trigger points. Depressed patients are likely to look away at the end of utterance. Some other key body gestures are likely to occur at these triggering points due to difficulty of speech. Filled pauses in speech or prolonged silence with avoidance of eye contact have shown to be possible signs of depression.
This type of behavior is likely to be triggered by the need of discharge from high emotional arousal, lack of social skills or cognitive overload.
In diagnosing depression gaze is an insignificant, insufficient factor. As far as person’s ability to heal, gaze can be a good indicator of person’s willingness, ability or capacity to receive social information, unless, as aforementioned, shyness is an inherent character trait. It is not just eye movement that can slow in a depressed individual, all body movement may decrease. This may manifest in slower speech, movement (such as walking or writing), reaction times, and ability to connect thoughts. In short, it appears as lethargy. This usually comes in tandem with a feeling of weight, like the world rests on your shoulders. Every step feels arduous, every breath takes effort, hence the slowness.

SLOW OR UNUSUALLY RAPID SPEECH AS A SIGN OF DEPRESSION

Changes in speech are usually due to a general high arousal, cognitive overload or high emotional arousal, one or more of these can cause speech irregularities. For classical depression slowed or reduced amount of speech, prolonged pauses, frequent hesitation pauses, lax body gestures accompanying speech, prolonged reaction times, monotonous voice, short answers are some of the verbal signs of depression. For the depressed with higher anxiety levels however short latencies, long answers, fast speech rate are common. Negative, pessimistic, cynical, sarcastic, argumentative, excessively vulgar speech is likely to be in dialect of a depressed individual. Humor and sarcasm usually mask anger in a depressed person.  Absolute silence, or response involving only a blank stare or shrug of the shoulders, is a serious sign of depression in a person with otherwise normal verbal communication skills; the deeply depressed may find it impossible to articulate or even loathe the sound of their own voice. Data supports that a person’s sex doesn’t seem to affect these symptoms. Silence is also an inherent part of these speech abnormalities. Many people who are enduring a depressive episode cannot find it within themselves to speak, and oddly this often is directed (unwittingly) towards those they love the most. Spouses and children feel rejected as the victim withdraws into silence, sometimes for long periods. What is frustrating for loved ones is that the victim may be able to carry on what seems to be a normal conversation with others, but cannot seem to communicate with those closest to him or her. The best advice for the loved ones is to not take it personally, as hard as that may be.

SLEEP INTERRUPTIONS AS SYMPTOMS OF DEPRESSION: INSOMNIA AND OVERSLEEPING

Insomnia, sleep interruptions or oversleeping are some of the very common complaints from individuals who suffer from depression. Insomnia can be a reason for depression or a symptom of depression or both at the same time; the lack of sleep exacerbates depression, which in turn causes sleep problems. The fear of not being able to sleep creates another avenue of depression and complicates and already tenuous situation. Sleep is essential to human life; in ancient history, a torture that was certain to kill an individual was to deprive him of sleep. Sleep quantity and quality affect a person’s mental & physical well-being, thus long-term sleep interruptions caused by depression can develop new or worsen existing health problems. Depressed people usually feel unrested & tired despite of the time of the day or getting enough sleep, some studies show they usually have deficit in deeper levels of sleep & are irritable & restless in sleep. Chronic initial, middle or terminal insomnia is likely to cause cognitive impairment. Those with early morning waking & inability to fall back to sleep are likely to engage in negative thoughts upon wakening, of which those with diurnal variation of mood are likely to be at high suicide risk. Symptoms of decreased level of sleep with high energy levels my indicate possibility of bipolar disorder (manic depression). Fatigue in the morning with better energy levels later in the day can be a sign of major depression. Those with high anxiety levels are likely to experience decreased levels of sleep; complaints of inability to fall asleep due to endlessly spinning concerns in mind & restless thoughts are likely to come up. Some can only fall asleep with  “white noise” such as a fan or TV on in order to drown out their thoughts. Often the effort to fall asleep can result in frustration due to inability of falling asleep. A different type of sleep destruction is staying in bed too long or oversleeping, which again can be a symptom of depression as well as a contributor to depression. Oversleeping is usually a sign of atypical depression. Oversleeping causes disruptive sleep patterns & inability to maintain a regular sleeping routine. This leads to feeling tired, unmotivated, poor vigilance & motor tasks, sleep not seeming restful, being physically out of shape, gaining unnecessary weight and other problems. The Human Performance Institute, aimed at the optimum well-being of athletes, conducted tests in the mid-1990s geared at helping Formula 1 race card drivers combat the inevitability of jet lag as they travel between races as far apart as Europe and Australia. When subjects were placed in a windowless room without any clocks, their circadian rhythms, also knows as “body clocks” immediately began to adhere to a 25-hour day, falling asleep one hour later each day. Depression symptoms often reflect this natural tendency. It’s as though the individual with depression finds some innate comfort at allowing the natural circadian rhythm to overtake the logical one that supports a 24-hour pattern. • Nightmares are another sleep-related indicator of depression. Almost all of us have nightmares from time to time, but they tend to be frequent and repetitive when a period of depression engulfs. Interestingly, they can also become a diversion for the sufferer because interesting books that explain the symbols inherent in dreams are a form of entertainment, and when depression thrives, research into every possible cause becomes a virtual obsession.

EMOTIONAL DISTANCING AND/OR OVER-REACTING WHEN DEPRESSED

Depressed individuals can show extremes of emotion, even if they are not bipolar. In some cases, the distancing or lack of emotions is a practiced action intended to protect oneself from the pain of feeling anything in a depressed state. This sometimes appears in the form of apathy and indifference, and can be marked by a sudden lack of interest in, for example, world events. There’s a war everywhere, murders in each city, famines galore; nothing can be done, so why bother to care. It applies both on a larger scale, like those cited, or close to home in the framework of losing interest in your spouse or your children. By determinedly choosing the path of removal from emotions, the sense of anxiety and hopelessness rests at arm’s length. Sometimes this distancing triggers feelings of guilt, especially if a spouse or children are the recipients of the “cold shoulder” when they do not diverse it. Because the depression can cause a victim to withdraw from the normal routines of life, such as work, household responsibilities and family, a normally committed person will often feel guilt about not honoring his or her duties. This is a normal reaction to being slack, but can manifest in gargantuan proportions compared to the actual level of responsibility being ignored. Conversely, depressed persons may find themselves so emotionally involved, so extremely and acutely sensitive to everything, that they over-react to things that bear little genuine significance in their outcomes. Excessive worry fits into this category, too. Depression can become the root of over-reaction in normally level-headed people, leaving them stressed and anxious about things that would, under normal circumstances, be regarded as “just the small stuff”. Negligible issues can become mammoth in a depressive episode. Worry is essential to this equation, manifesting in chronic anxiety attacks and causing the dichotomy of literally worrying oneself to sickness, something else to worry about (if that makes sense). It hurts to feel things sometimes, and for the person in the depressive episode, all that felt glorious in the manic state is now false and to be avoided. This innate inability to feel anything is a protective device, but the fear of feeling is worse than the feeling itself. It is a destructive phase in the depressive mode. No wall of protection can stay in place forever. For some victims, it offers false comfort and the crash is resultantly deeper when emotions begin to surface again.

PHYSICAL APPEARANCE SUFFERS WHEN DEPRESSION HITS

Some people are naturally careless about their appearance, but most of us take at least some time every day to comb our hair, brush our teeth and put on a set of clean clothes. When a personal suddenly ceases to care about what they look or smell like, then personal neglect as a sign of depression may well be the culprit. It is an early sign and one of the most obvious. Because it connects several aspects of personal care, it shows in various ways. A reduction in personal grooming habits, modes of dress and personal hygiene are typical, as is disregard for weight. Some victims gain substantial weight, in part due to their lack of energy and subsequent activity, and in part due to their changed eating habits. A lack of interest in food can also result in a significant weight loss, and the resultant poor health. This also relates to the matter of personal neglect; those suffering from depression lack the ability to care about themselves. Weight issues associated with a depressive episode are not the same as daily weight-consciousness that demonstrate care of self; they are not about health, fitness and attractiveness, but about the inability to care for and nurture our bodies. The person in a depressed state cannot deal sensibly with such minutiae. Sufferers feel like it just doesn’t matter how they look because they feel so unacceptable within. It is an outward manifestation of the internal depression.

THE INABILITY TO CONTROL YOUR OWN FEELINGS IS A SIGN OF DEPRESSION

This is especially true when no matter what you do, your emotions do not respond, or may even worsen. Because of this, it’s nit just depression that is intrinsic to it, but also exasperation and frustration; those just serve to make the depression worse. The results can be devastating and involve, among many other overwhelming feelings, a sense of abject failure. This is the greatest de-motivator of the depressive person. It effectively stops those in this episode from making an effort toward recovery because they feel that they cannot succeed, regardless of how hard they try. So they don’t. They give up, leaving a feeling of utter hopelessness. This is the end of the road for most people who suffer serious clinical depression, be that part of bipolar disorder or not. Unless hope exists, even in minimal form, there is no reason to carry on. Psychiatrists regard this as the signal to take action that will prevent suicidal actions in a patient. The other emotion that empowers depression and helps it feel larger and more acutely real is anxiety. Once it grips the individual, it’s next-of-kin, despair, settles in and won’t let go. Frustration mounts and the spirits drops even further for those suffering this symptom. Part of the anxiety stems from a feeling that nothing can go right, rather than it actually happening. It’s like an imagined worst-case scenario with no other option. When these emotions seem untenable, it’s time to get help. A diagnosis of depression is almost a piffle; if your emotions are in this state, get immediate help.

• psychotherapy
• group therapy
• medications, generally antianxiety drugs & antidepressants
• eye movement desensitization and reprocessing (EMDR)

As a rule, treating PTSD at early stages has better chances for earlier & complete recovery. In addition it will decrease the overall negative impacts of the trauma. The best way to help someone affected by a trauma is to get them to a mental health specialist as soon as possible. Depending on the situation and the condition of the patient, a unique treatment plan is chosen for the specific situation.

Psychotherapy

Psychotherapy is generally an undivided part of treating mental disorders and PTSD is not an exception. Some therapy sessions can be necessary with family members or the partner. Types of psychotherapy that can be used for treating PTSD can include one or a combination of following:

• exposure therapy
• anxiety management
• cognitive therapy
• relaxation training
• trauma debriefing
• critical incident debriefing
• supportive psychotherapy
• hypnosis
• blogging or diary keeping
• creative arts

Only qualified specialists should attempt complex procedures like trauma debriefing or critical-incident stress debriefing, since these have the power to retraumatize the victim if they are not performed correctly & with utmost caution.

Generally, the goals of psychotherapy include helping the victim to engage with the trauma memory in a healthy way, assist the victim in correcting dysfunctional cognitions followed by the trauma, help them out of social isolation & ability to develop trust in other people.

Group Therapy

Group therapies for PTSD usually consist of a small group of people who went through a similar traumatic event. The victims share experiences with each other and share & learn techniques to cope with the trauma & symptoms. Generally group therapy for those suffering from PTSD proves to be very helpful.

Medication

Medications prescribed for PTSD are generally used to treat depression or anxiety. Major categories include:

• benzodiazepines
• serotonin receptor partial agonists
• selective serotonin reuptake inhibitors
• tricyclic antidepressants
• MAO inhibitors

Virtually every class of psychotropic agent is being used for PTSD treatment, due to biological abnormalities and other comorbid disorders associated with the post-traumatic stress disorder.

EMDR – Eye Movement Desensitization and Reprocessing

EMDR is a relatively new type of therapy used for PTSD. It combines many elements of other therapies & helps the victim in reprocessing of traumatic information and experience. The therapy involves specific eye movements while discussing & remembering the traumatic event. This activity develops a better response & ability to process the trauma in the victim. EMDR is performed by highly skilled professionals only & has drawn a lot of interest from researchers.

Post-traumatic stress disorder generally coexists with other mental health disorders. Most common disorders that co-occur with PTSD are:

• depressive disorders
• substance abuse disorders
• anxiety disorders

Symptoms of comorbid conditions are addressed during PTSD treatment as well.

PTSD is generally treated on an outpatient basis, however, in cases when the symptoms are severe, inpatient treatment can be necessary.

The reaction displayed by the victims of different type of overwhelming life events is surprisingly consistent, be it a consequence of war, experiences of rape, abuse in childhood, natural or other disaster. Common consequences include phasic re-experiencing & denial with alternating emotional constriction, pulling away from family obligations, depression, insomnia, nightmares, anxiety, social isolation, obsessive thoughts, anhedonia, sense of separation, impairment of memory, hyperreactivity, explosive outbursts, startle responses, tension, irritability, aggressive acts against others or self, sensation seeking, reenactment, drug & alcohol abuse, flashbacks. Traumatized people have low threshold for emotional & physiological arousal. Motoric discharge or social and/or emotional withdrawal is the usual response to stress by the people suffering from psychological trauma. In some cases re-experiencing can take the form of traumatophilia (seemingly voluntary reenactment) (ex., veterans enlist as mercenaries , victims of rape become prostitutes , physically abused children constantly expose themselves to danger). Freud thought the voluntary reenactment of trauma was an effort to gain mastery. Others may try to master the situation by avoiding & excluding everything that may remind them of the trauma. Often they avoid intimate relationships or other types of emotional connection.

Factors that contribute to the long-term traumatization:

• severity of the stressor
• genetic predisposition
• age
• social support system
• prior traumatization
• preexisting personality

A successful resolution is the ability to recall the trauma at will, while being in control to switch to other unrelated thoughts at will. Symptoms that originate mostly due to genetic predisposition are probably the most resistant to the recovery process. Those affected that develop emotional constriction, reenactment, sensation seeking, drug & alcohol abuse, face overwhelming problems since the mentioned consequences serve as a base for many other consequential problems & further impair the person’s ability to recover.

Signs and symptoms that are likely to occur, which are more likely to be caused by an interpersonal stressor (e.g.,physical or childhood sexual abuse, being taken hostage, domestic violence, incarceration like a prisoner of war or perhaps in a concentration camping and torture), are:

• impaired affect modulation;
• impulsive behavior;
• self-destructive behavior;
• dissociative symptoms;
• somatic complaints;
• feelings of shame;
• hopelessness or permanent feeling of despair;
• inactivity;
• complete loss of belief in previously sustained values;
• social withdrawal;
• hostility;
• impaired relationships;
• feelings of constant threat;
• changes in the personal characteristics of the individual;

There might be elevated chance of Panic Attacks, OCD, Agoraphobia, Social Fear, Major Despression Symptoms, Substance-Related Disorders, Impulse Control Disorders and Somatization Disorder.

The people with traumatic events frequently develop depression. There is a feeling of anxiety with no clear reason for it, the heart is racing, the argumentativeness is increasing, when the evening comes, you cannot sleep, haunted by bad dreams. The person starts arguments with the members of family, partner or friends, more commonly makes no sense whatsoever in their eyes, avoids certain situations or places, always struggling and fighting with those disturbing images that come to mind.  With time, this starts to affect the persons relationships, work life or ability to perform everyday tasks. Coping with the symptoms of post traumatic stress disorder deprives life of joy, leaves no room for having relationships and or just peace of mind. Studies show that depression will probably develop following a stressful life or a prolonged period of stress. Hormones which are related to stress are responsible for alterations in the brain’s chemical balance, which in turn becomes a cause for major depression. Shouldn’t come as a a surprise that these factors put those with post traumatic stress disorder at a greater risk for depression.

There is a common misconception that a depressed person is the one that is sad & crying most of the time. In reality a depressed person can display different set of symptoms, for instance irritability, indifference & numbness. Indifference & numbness are some of the classic symptoms of both post traumatic stress disorder and depression; ex. loss of interest in previously fun, enjoyable, or fulfilling activities, which in turn is likely to cause social isolation. Those who are depressed may also withdraw from social activities simply because they feel that they aren’t a good company. Some other symptoms of depression are difficulty in sleeping, alterations in eating habits and appetite, feeling tired (or sometimes irritated), having trouble in concentration, a loss of interest to have sex, and feelings of worthlessness or guilt.

A person suffering from hyperarousal symptoms may attempt to restrict you or other family members’ activities due to the extreme fear that there is danger waiting around the corner. Remind yourself not to be annoyed by this behavior, it will likely go away with treatment & time. You can react to your partner’s or family member’s actions to control the situation by saying something similar to, “It is nice to understand you care well enough to be really worried about me.”

Irritability & anger are also possible symptoms of hyperarousal. Generally they don’t result in violence & there is nothing to worry about. That said, in case you notice violent behavior, you should stay alert & in extreme cases take the appropriate measures to protect yourself & other family members.

Medications prescribed for hyperarousal symptoms:

General hyperarousal symptoms:

amitriptyline
phenelzine
nefazodone
sertraline (only for women)

Sleep disturbance symptoms & nightmares:

benzodiazepines
phenelzine
carbamazepine
trazodone
clonidine
zolpidem
nefazodone

Symptoms of irritability, impulsiveness, anger outbursts:

nefazodone
carbamazepine
valproic acid

Symptoms of anger:

buspirone
lithium
fluoxetine
trazodone

Symptoms of aggression:

risperidone

General autonomic hyperexcitability, exaggerated startle response;

propranolol
benzodiazepines
clonidine
valproic acid
buspirone
carbamazepine