Us depressives must learn to listen to and take care of our bodies. Divorced from feelings, we tend to see ourselves divorced from our bodies as well. But our “true self” is not only in our head, it is our whole being, body, mind, and spirit. Ignoring body messages like pain, fatigue, and psychophysiological symptoms just sends us off for unnecessary medical care—depressives dramatically overuse physical medicine—and makes us feel more depressed because the medical care doesn’t touch the real problem.
Positive thinking is good for the body: people who believe in positive myths about themselves live longer, have fewer heart attacks, and require less anesthesia during surgery. Optimists' wounds heal more quickly than those of pessimists. Being a pessimist can shorten your lifespan. Being depressed is even worse. New research is showing us more and more evidence that depression damages health. A whole new science, psychoneuroimmunology, has developed over the past 25 years to explore the sometimes mystifying connections between mind, body, and health—for instance, the finding that stressful experiences in childhood cause changes in the brain that seem to make you more vulnerable to autoimmune diseases in adulthood like lupus, to chronic pain conditions, to not-yet-understood illnesses like fibromyalgia, and to heart disease, diabetes, stroke, and fractures. In fact, it seems that the immune system is shaped by our earliest emotional experiences as infants learning to cope with stress. Many have reached the conclusion that it’s best to eliminate the distinction between mind and body. Much of the mind is in the body, in complex nerve centers in the heart, gut, and immune systems that function like auxiliary brains, in receptor systems in the muscles, bones, blood, and lymph that are tied intimately into the traditional brains in our heads.
For instance, people with depression usually have elevated levels of cortisol and adrenaline, the fight-or-flight hormones that wear out so many body and brain systems. These chemical messengers are very efficient at preparing the body for danger. When we first see a threat, the body suddenly releases electrical and chemical signals that increase heart rate, redirect energy to the muscular and sensory systems, shut down digestion and reproduction, send immune cells into storage depots, and deploy steroids to help us heal from wounds. We can see, hear, and smell better; we are more alert and can concentrate better; our skin tightens and our hair stands on end. This is the fight-or-flight response; everything going on within us is designed to help us deal with danger more effectively. Once we feel safe, systems return to normal. Heart rate slows, and we once again get interested in things like food, sex, and comfort, items that were low priorities while danger loomed. But when we feel in constant danger, as we do with depression and other stress-related diseases, we keep on pumping out stress hormones. This can lead to exhaustion, cardiac strain, kidney damage, muscle fatigue, damage to the digestive and circulatory system, loss of appetite and the ability to absorb nutrients, damage to the immune system so we’ll be more vulnerable to infection, loss of interest in sex, and the constant subjective feeling of tension and fear. Part of the problem is that our bodies haven’t changed much in 160,000 years, since the first human appeared. In those days, it was useful to constantly be on guard, and there wasn’t any evolutionary pressure to reduce the long-term effects of stress, because no one lived past 35 anyway. Now, once we pass 35, we start to experience what constant vigilance does to our bodies—and for some us it happens much younger because we live with a new kind of stress.
Some effects of all this: In one four-year study of nursing home residents, those who were assessed as most depressed at the outset had the greatest impairment of the immune response as time went on. Depression is a significant risk factor for heart attack. Depression shortens the lifespan, even if the sufferer doesn't commit suicide, and increases the risk of other medical problems. Depression leads to higher death rates following heart attack, for both men and women, controlling for all other health and social variables. Depression means increased risk of death for the general hospital population, no matter what the diagnosis, not only cardiac cases. Patients with depression visit their doctors more often, have more operations, and go to the ER (nonpsychiatric) more often than the general population. Depression is highly intertwined with nonspecific illness: one survey of almost 20,000 individuals found that 17 percent reported chronic pain and 4 percent reported major depression; but of those with depression, 40 percent also had chronic pain. Chronic pain, digestive and gut problems, migraine headaches, menstrual pain and dysphoria, weight control problems, all will add their own suffering to that of depression. They also compound the effects of depression, further restricting activity, nutrition, and self-care, and reinforcing the depressive's idea of himself as out of control, bad, or weak. In the end, people with depression experience that strange euphemism used by statisticians: “excess mortality.” They die earlier than they should.
The famous “Nuns of Mankato” study compared the essays written by a group of nuns in their twenties when they were entering the order, with their health and life expectancy some sixty years later. The researchers coded all the emotion-laden words in the essays and grouped them into positive, negative, and neutral. The sisters were a wonderful group to study because all of them had had basically the same experiences during their lifetimes, unlike virtually any other group where factors like marriage and divorce, motherhood, stress, alcohol abuse, wealth or educational achievement, would have been intervening variables, confounding the research so that you couldn’t be certain it was the way they expressed feelings that was the only factor at work. In the end, the researchers found that the more positive feelings the nuns had expressed in their essays in early adulthood, the longer they were likely to live. Now science is trying to explain why this is so.
Depression also affects the brain directly. We stop producing dopamine, the chief neurotransmitter of pleasure circuitry in the brain. The receptor sites for endorphins, the happy hormones, get "pruned" like a tiny little apple orchard, so that pleasant events no longer result in pleasant feelings.
One of my patients, an interior designer, tells me that when her depression is very bad, she has a lot of trouble with balance and coordination, and her ability to visualize a room or a tableau spatially is reduced. It all just seems like different unconnected parts. More urgently, she feels very dizzy on a stepladder. Her coworkers, who are supportive, can tell that she’s gotten clumsy and dizzy. This is a very distinct change from her normal functioning. How much worse would this be if you had to work on something taller than a stepladder?
The subject of somatization casts the whole field of mind-body medicine, especially depression, into confusion. Somatization, formally, is a psychological defense mechanism referring to the use of the body to convey an emotional or interpersonal message. People with some conditions that are seen by others as perhaps not really real, like fibromyalgia or chronic fatigue syndrome, get extremely defensive about the concept of somatization, especially when the dreaded word “psychosomatic” is used. “Psychosomatic” simply means having to do both with the mind and the body, but in popular use we mean someone has an imaginary illness and should know better; or they are perhaps faking the whole thing.
This is unfair both to the sufferers of such illnesses and to those who are trying to understand them. As we have been seeing, the mind-body connection is very close and we don’t understand it very well yet. We realize now that it’s quite naïve to think of the body as a machine to carry around the brain or to imagine that our “self” is located up in the skull behind our eyes—the mind and the body are one thing. People with stress-related diseases, including chronic pain sufferers, damaged immune systems and autoimmune diseases, and such 21st-century diseases as fibromyalgia, chronic fatigue, and multiple allergies, often seem to have been made vulnerable by childhood experiences, particularly of sexual abuse or having parents with very inappropriate boundaries. If you have one of these conditions, I strongly urge you to consider that you might be depressed, and that treating the depression might be the shortest route to relieving the physical symptoms.
So somatization is not merely a psychological defense mechanism—use of the body to speak for the mind—because complex physical changes do occur. Still, we rely on our bodies to communicate interpersonal messages all the time. The fact is that any illness, no matter how “real” it is, can be used by the patient to express himself emotionally and interpersonally. I have heard from my patients about many mothers and fathers who use their cancer, diabetes, or handicap as fuel for guilt-tripping the patient, as an excuse for emotional withdrawal, or a means of manipulation. Then there are some illnesses that are not quite real but are used for the same reason—for instance, a pain condition or “diabetes” or “heart condition” that never gets pinned down. The patient can never seem to get to doctor’s appointments and when he does, emerges with confusing or conflicting advice. Family members are left mystified about the reality of the illness.
But some people with depression are especially prone to somatization.
Stephanie was a survivor of childhood incest, who lived with an alcoholic and abusive husband and felt unable to escape her marriage because of the children
.. She was a caretaker, always putting the needs of others first, unable to stand up for her rights. Antidepressants didn’t seem to do much for her. Physically, she suffered from frequent debilitating migraines and a great deal of fatigue. Her family doctor had referred her to a rheumatologist, who told her she had fibromyalgia and chronic fatigue syndrome, and perhaps chronic Lyme disease. Stephanie was intelligent but unsophisticated about depression and health. She assumed that these were all separate physical illnesses not connected to her depression. But I thought it made a lot of sense: that if I walked around for thirty years as tense as Stephanie, always afraid, always hypervigilant, unable to relax, my joints and muscles would ache too, and I would always be on the edge of exhaustion. I watched over the next few years as Stephanie became a guinea pig for medication: antidepressants, stimulants, relaxants, antibiotics, hormones, painkillers, steroids. She went through hot flashes, cold sweats, deep depression, hypomanic highs, disfiguring skin eruptions, severe weight loss and then gain, insomnia, nightmares, sleeping too much, severely impaired concentration, crippling anxiety, the fear of losing her mind, a psychiatric hospitalization—almost all of which I felt was due to the medications she was taking.
I think that Stephanie was expressing some of the rage she had repressed from her abuse experiences. She was reliving them, in a way, with the doctors as the abusers. She was also saying to her therapist, You can’t help me. What good is your empathy? Where were you when I needed you?
Somatization may be a form of introjection—we make the bad parent or the abuser part of ourselves, twisting our backs, giving us splitting headaches, pain in the heart, crippling menstrual cramps. In this way we relive traumatic experiences. Remember Jane, whose son shot himself in the head, and her crippling headaches?
If you spend a lot of time and money pursuing solutions to physical complaints and not getting much relief—especially if you are an abuse victim—my advice is to find one internist, GP, or gynecologist who is enlightened about and interested in mind-body relationships (your therapist or psychiatrist should be able to help you find one), and make develop a good relationship with him or her. Tell the doctor about your condition, but go into detail about your history and your current stresses. Make it clear you will be needing his help in getting symptomatic relief while accepting the limits of physical medicine to address mind-body problems. Exercise, go to spas, get massages. Even if your symptoms are exclusively physical, consider the idea of trying an antidepressant and getting some psychotherapy. No one is accusing you of faking an illness; rather just trying to get you good help for the effects of stress and trauma.
(References for all the research cited here can be found in Undoing Depression, 2nd ed., © 2010 Little, Brown & Co.)
 There were reasons I can’t describe here why I couldn’t intervene more directly with Stephanie.
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