June 17, 2022 • 17 mins
Are you putting on weight? Sleeping too much? Feeling anxious? Most people don’t think of these as classic signs of depression—but they could be. Dr. Saltz looks at atypical depression—the unexpected symptoms, and effective ways to feel better.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Bees are challenging times, but you don't have to navigate
them alone. Welcome to How Can I Help? I'm Dr
Gail Salt. I'm a clinical Associate Professor of Psychiatry at
the New York Presbyterian Hospital, a psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:26):
hopefully with understanding, insight and advice. Most people know what
depression is, and they have heard that if someone is
sad most of the time, and they have trouble eating
or sleeping, don't enjoy anything, can't concentrate, and have no energy,
they are likely suffering from a clinical depression. But what
(00:49):
they may not know is that not all clinical depression
appears this way. Today, I am answering a question from
a listener that is wondering if what she's experiencing is
depression because it doesn't fit this pattern. There are actually
multiple forms of clinical depression. They can vary in terms
(01:10):
of severity, length of time they last, whether they occur
along with other types of symptoms, and actually what symptoms
they present with in the first place. Why does this
matter Because different forms of depression respond to different forms
of treatment, so it is important to know what you're
(01:31):
suffering with so that an appropriate psychotherapy and or medication,
if need be, can be selected and administered for you.
A typical depression is a subtype of major depression or
dysthymic disorder that involves several specific symptoms, including increased appetite
(01:54):
or weight gain, sleepiness or excessive sleep, marked fatigue or weakness,
moods that are strongly reactive to environmental circumstances, and feeling
extremely sensitive to rejection. A typical depression can be what
is called a specifier for either major depression or dyslimic disorder.
(02:20):
People with a typical depression have often experienced depression first
at an early age, like during their teenage years. A
person with classic major depression has at least five of
the following nine symptoms. Sadness or depressed mood most of
the day or almost every day. Loss of enjoyment in
(02:44):
things that were once pleasurable called antedonia, major change in
weight a gain or loss of more than five percent
of weight within a month, or appetite, insomnia or excessive
sleep almost every day. A state of physical restlessness or
being run down that is noticeable by others. Fatigue, or
(03:09):
loss of energy almost every day, feelings of hopelessness or
worthlessness or excessive guilt almost every day, problems with concentration.
We're making decisions almost every day, and reoccurring thoughts of
death or suicide, a suicide plan, or a suicide attempt.
(03:31):
You can see how atypical depression could fit within this
criteria or major depression. Dyslymic disorder, which is known as
persistent depressive disorder or chronic major depression, is a condition
involving the presence of a depressed mood more days than
(03:51):
not for at least a two year period in adults.
So this is different from major depression in the length
of time that at lasts it can be only one
year for children and adolescence, plus at least two of
the already mentioned symptoms that I gave that list, but
fewer than the five symptoms which define a major depressive episode.
(04:17):
Despite its name, a typical depression is actually very common.
It is contrasted with what is called melancholic depression, another
subtype of depression, which involves what most people hear about
the symptoms of insomnia rather than oversleeping, the symptom of
(04:37):
loss of appetite rather than increased appetite, a relative lack
of mood reactiveness to environmental circumstances, meaning whatever might come
along to try to cheer you up does not, and
a markedly diminished ability to feel pleasure in anything, even
things that used to bring you pleasure. But one of
(04:59):
the main care juristics of a typical depression that distinguishes
it from melancholic depression is mood reactivity. In other words,
the person with a typical depression will see their mood
improve if something positive happens. In melancholic depression, positive changes
will seldom bring on a change in mood. In addition,
(05:23):
diagnostic criteria call for at least two of the following
symptoms to accompany this mood reactivity in a typical depression,
sleeping too much, which is called hypersomnia, increased appetite or
weight gain, having a more intense reaction or increased sensitivity
(05:44):
to rejection or criticism resulting in problems with social and
work relationships. Having a feeling of being weighed down, paralyzed,
or feeling leaden in your arms and legs. These are
the features that really distinguish a typical depression from melancholic depression.
(06:08):
Depression is believed to be the result of impaired functioning
of brain circuits that regulate mood and that allow one
region of the brain to communicate with another nerve. Cells
contained within these circuits transmit signals through brain chemicals called neurotransmitters,
and in this case, dopamine, serotonin, and nor benefferent. While
(06:31):
the exact specific cause of depression is actually still unknown,
there are risk factors for depression, which include a family
history of depression it does run in families, a significant
loss from death, divorce, or separation that can trigger an
underlying vulnerability to depression, interpersonal conflicts and related emotions like guilt,
(06:57):
any type of abuse, physical, sexual, or emotional. Any type
of major life event such as moving, changing or losing
a job, graduating, retiring, or social isolation in people who
have a biological vulnerability to depression, Any type of serious
(07:19):
illness such as cancer, heart disease, stroke, or HIV, and
any drug or alcohol abuse. These are all risk factors.
Like other types of depression, a typical depression is a
serious illness that can cause major problems. It can result
(07:40):
in emotional, behavioral, and health problems that affect every area
of your life. For example, a typical depression can be
associated with weight gain due to increased appetite, personal and
work relationship problems due to being very sensitive to rejection
drug or alcohol use, due to trouble hoping, and other
(08:02):
mental health disorders such as anxiety, as well as suicide
from feelings of depression. So with that, right after the break,
we'll get to my listeners question. Welcome back. Let's get
(08:29):
to my listeners question and see how can I help,
Dear doctor Salts. I just broke up with my boyfriend,
and though we both felt it was the better way
to go, I am now really struggling. I have wondered
if I should talk to a therapist because I keep
thinking about the breakup and feeling so distraught about it.
(08:52):
I feel so hurt and cast aside, even though I
initiated the breakup, which I guess doesn't make a lot
of sense, but I feel that way anyway. I also
am finding it difficult to get out of bed. I'm
exhausted constantly and napping even though I've slept like twelve
hours at night. I am eating a lot as well,
(09:15):
constantly craving more sweets or more carbs. I've eaten so
much pasta, and I'm gaining weight I don't want, which
only makes me feel worse. I feel so unmotivated to
do anything. My sister says this can't be depression, because
she's had depression and she lost her appetite, she couldn't sleep,
(09:38):
and she felt agitated all the time. She also noticed
that sometimes I'm not miserable, which she definitely takes as
a sign I'm not depressed. But what could be going on?
Is this just how it feels to break up? Is
this something a therapist could help me with? Breaking off
(09:59):
an important relay reationship, even if you are the one
who initiated it, is a significant life loss, it's not
unusual to need time to grieve that loss, and sometimes
grief becomes so intense and more complicated such that what
ultimately emerges our feelings of depression. Typical melancholic depression would,
(10:24):
as your sister says, cause difficulty sleeping with early morning awakening,
a loss of appetite, sometimes with weight loss, and sadness
that is unchanged by doing something that used to be enjoyable.
So I can understand why you think that as bad
as this feels, it isn't depression, but actually there are
(10:48):
different ways that depression can present. And feeling very sad
a lot of the time, but with the ability to
have hours of the day where your mood is brightened
by something does not rule out clinical depression. The fact
that on top of this you find yourself very exhausted
and sleeping much more than is typical for you, that
(11:10):
you are craving carbohydrates and sugar and eating more such
that you are gaining weight are actually signs of clinical depression.
It's just that this is what is referred to as
a typical depression or depression with a typical features. This
type of depression can be set off by a traumatic
(11:31):
event in one's life, like a breakup, especially in a
person who has had a depression in the past and
one who is sensitive to rejection. This type of depression
needs treatment just as much as any other subtype. It
is important that you get an evaluation, preferably from someone
(11:52):
versed in treating depression, a psychiatrist or psychologist who treats
clinical depression. Treatment can be a psychotherapy, either psychodynamic psychotherapy
or a cognitive behavioral psychotherapy, and, if needed in terms
of severity, medication. Medication choice depends on your particular symptom cluster,
(12:16):
and actually atypical depression tends to respond to antidepressants that
are different from typical melancholic depression. The sooner you go,
the sooner you're start feeling better. Other things that can
help you help yourself is thirty minutes of aerobic exercise
three to four times per week, which may be hard
(12:38):
to get yourself to do as you're feeling, but really
can help you boost your mood. So try talking with
others about how you feel and getting support like your
sister or a friend, journaling how you are feeling, avoiding
alcohol or drug use as a means to feel better,
(12:58):
because actually it will make you feel worse. Getting out
to do things that do bring you pleasure, especially something
social psychotherapy is often especially helpful to people who tend
to develop a typical depression because even when they are
not having depression, they may struggle with feeling very sensitive
(13:20):
to rejection such that it makes them feel badly and
it disrupts other relationships, and psychotherapy can help you understand
this better and make strides in not over interpreting signs
of rejection and not emotionally feeling as vulnerable. A form
of therapy called dialectical behavior therapy can be especially useful
(13:45):
for this, helping to manage intense emotional states. If this
is an issue for you prior to this breakup, this
may be a great therapy choice for you to try now.
I hope that was helpful. As much as of depressions
(14:05):
are a typical, with women affected four times as often
as men, treatment can be different for a typical depression
due to the differences in clinical presentation between a typical
depression and melancholic depression. Studies were conducted in the nineteen
eighties and nineteen nineties to assess the therapeutic responsiveness of
(14:28):
those meds that were available at that time in these
two different subsets of patients at the time. Antidepressants that
existed were S sr eyes serotonin reuptake inhibitors a S
n our eyes serotonin nor epernepherin reuptake inhibitors and our
eyes and something called mertazepine, and they were considered the
(14:51):
best medications to treat a typical depression due to efficacy
and having fewer side effects than previous antidepressants, but actually
medications like bupropion, which is a nor epineffrine reuptake inhibitor,
turned out to perhaps be uniquely suited to treat the
atypical depression symptoms of lethargy and increased appetite in adults,
(15:15):
and modaphanel is sometimes used to treat as an off
label treatment option. Before the year two thousand, a group
of meds called monomine oxidase inhibitors or m A O
eyes were shown to be of superior efficacy compared to
other antidepressants for the treatment of a typical depression and
were used as first line treatments for this clinical presentation.
(15:40):
This class of medication has fallen in popularity with the
invention of selective agents like S sries because of dangerous
interactions with pyramine rich foods which come in age cheese,
certain types of wine, tap beer, and bava beanes causing
a hypertensive crisis, and some m aoies can be at
(16:03):
great risk when taken together with S S R eyes
as they can cause a serotonin reuptake crisis. Despite these concerns,
they are still used in treatment resistant cases when other
options have been exhausted, and usually show greater rates of
a remission compared to previous psychopharmacology. They are also generally
(16:25):
better tolerated by many patients. There are newer selective and
reversible m ao ees such as more globrimide, which carry
a much lower risk of tyremine potential action and have
fewer interactions with other drugs, so today's people with a
(16:45):
typical depression are often tried with that. However, tricyclic antidepressants,
which used to be used a lot before the year
two thousand, are turning out to be not as efficacious
as m a o ees and have fallen out of favor.
They have also a lot of side effects. But important
to keep in mind is that psychotherapies like CBT can
(17:08):
have equal efficacy to m a olies for a subset
of patients with a typical depression. So some patients do
well without medication but with psychotherapy alone, and this is
why it's important to discuss your specific symptoms and everything
available to you with your doctor. Do you have a
(17:31):
problem I can help with? If so, email me yet
how can I help? At Seneca women dot com, all
centers remain anonymous and listen every Friday too. How can
I help with me Dr Gail's salts
Bees are challenging times, but you don't have to navigate
them alone. Welcome to How Can I Help? I'm Dr
Gail Salt. I'm a clinical Associate Professor of Psychiatry at
the New York Presbyterian Hospital, a psychoanalyst, and best selling author,
and I'm here every week to answer your most pressing questions,
(00:26):
hopefully with understanding, insight and advice. Most people know what
depression is, and they have heard that if someone is
sad most of the time, and they have trouble eating
or sleeping, don't enjoy anything, can't concentrate, and have no energy,
they are likely suffering from a clinical depression. But what
(00:49):
they may not know is that not all clinical depression
appears this way. Today, I am answering a question from
a listener that is wondering if what she's experiencing is
depression because it doesn't fit this pattern. There are actually
multiple forms of clinical depression. They can vary in terms
(01:10):
of severity, length of time they last, whether they occur
along with other types of symptoms, and actually what symptoms
they present with in the first place. Why does this
matter Because different forms of depression respond to different forms
of treatment, so it is important to know what you're
(01:31):
suffering with so that an appropriate psychotherapy and or medication,
if need be, can be selected and administered for you.
A typical depression is a subtype of major depression or
dysthymic disorder that involves several specific symptoms, including increased appetite
(01:54):
or weight gain, sleepiness or excessive sleep, marked fatigue or weakness,
moods that are strongly reactive to environmental circumstances, and feeling
extremely sensitive to rejection. A typical depression can be what
is called a specifier for either major depression or dyslimic disorder.
(02:20):
People with a typical depression have often experienced depression first
at an early age, like during their teenage years. A
person with classic major depression has at least five of
the following nine symptoms. Sadness or depressed mood most of
the day or almost every day. Loss of enjoyment in
(02:44):
things that were once pleasurable called antedonia, major change in
weight a gain or loss of more than five percent
of weight within a month, or appetite, insomnia or excessive
sleep almost every day. A state of physical restlessness or
being run down that is noticeable by others. Fatigue, or
(03:09):
loss of energy almost every day, feelings of hopelessness or
worthlessness or excessive guilt almost every day, problems with concentration.
We're making decisions almost every day, and reoccurring thoughts of
death or suicide, a suicide plan, or a suicide attempt.
(03:31):
You can see how atypical depression could fit within this
criteria or major depression. Dyslymic disorder, which is known as
persistent depressive disorder or chronic major depression, is a condition
involving the presence of a depressed mood more days than
(03:51):
not for at least a two year period in adults.
So this is different from major depression in the length
of time that at lasts it can be only one
year for children and adolescence, plus at least two of
the already mentioned symptoms that I gave that list, but
fewer than the five symptoms which define a major depressive episode.
(04:17):
Despite its name, a typical depression is actually very common.
It is contrasted with what is called melancholic depression, another
subtype of depression, which involves what most people hear about
the symptoms of insomnia rather than oversleeping, the symptom of
(04:37):
loss of appetite rather than increased appetite, a relative lack
of mood reactiveness to environmental circumstances, meaning whatever might come
along to try to cheer you up does not, and
a markedly diminished ability to feel pleasure in anything, even
things that used to bring you pleasure. But one of
(04:59):
the main care juristics of a typical depression that distinguishes
it from melancholic depression is mood reactivity. In other words,
the person with a typical depression will see their mood
improve if something positive happens. In melancholic depression, positive changes
will seldom bring on a change in mood. In addition,
(05:23):
diagnostic criteria call for at least two of the following
symptoms to accompany this mood reactivity in a typical depression,
sleeping too much, which is called hypersomnia, increased appetite or
weight gain, having a more intense reaction or increased sensitivity
(05:44):
to rejection or criticism resulting in problems with social and
work relationships. Having a feeling of being weighed down, paralyzed,
or feeling leaden in your arms and legs. These are
the features that really distinguish a typical depression from melancholic depression.
(06:08):
Depression is believed to be the result of impaired functioning
of brain circuits that regulate mood and that allow one
region of the brain to communicate with another nerve. Cells
contained within these circuits transmit signals through brain chemicals called neurotransmitters,
and in this case, dopamine, serotonin, and nor benefferent. While
(06:31):
the exact specific cause of depression is actually still unknown,
there are risk factors for depression, which include a family
history of depression it does run in families, a significant
loss from death, divorce, or separation that can trigger an
underlying vulnerability to depression, interpersonal conflicts and related emotions like guilt,
(06:57):
any type of abuse, physical, sexual, or emotional. Any type
of major life event such as moving, changing or losing
a job, graduating, retiring, or social isolation in people who
have a biological vulnerability to depression, Any type of serious
(07:19):
illness such as cancer, heart disease, stroke, or HIV, and
any drug or alcohol abuse. These are all risk factors.
Like other types of depression, a typical depression is a
serious illness that can cause major problems. It can result
(07:40):
in emotional, behavioral, and health problems that affect every area
of your life. For example, a typical depression can be
associated with weight gain due to increased appetite, personal and
work relationship problems due to being very sensitive to rejection
drug or alcohol use, due to trouble hoping, and other
(08:02):
mental health disorders such as anxiety, as well as suicide
from feelings of depression. So with that, right after the break,
we'll get to my listeners question. Welcome back. Let's get
(08:29):
to my listeners question and see how can I help,
Dear doctor Salts. I just broke up with my boyfriend,
and though we both felt it was the better way
to go, I am now really struggling. I have wondered
if I should talk to a therapist because I keep
thinking about the breakup and feeling so distraught about it.
(08:52):
I feel so hurt and cast aside, even though I
initiated the breakup, which I guess doesn't make a lot
of sense, but I feel that way anyway. I also
am finding it difficult to get out of bed. I'm
exhausted constantly and napping even though I've slept like twelve
hours at night. I am eating a lot as well,
(09:15):
constantly craving more sweets or more carbs. I've eaten so
much pasta, and I'm gaining weight I don't want, which
only makes me feel worse. I feel so unmotivated to
do anything. My sister says this can't be depression, because
she's had depression and she lost her appetite, she couldn't sleep,
(09:38):
and she felt agitated all the time. She also noticed
that sometimes I'm not miserable, which she definitely takes as
a sign I'm not depressed. But what could be going on?
Is this just how it feels to break up? Is
this something a therapist could help me with? Breaking off
(09:59):
an important relay reationship, even if you are the one
who initiated it, is a significant life loss, it's not
unusual to need time to grieve that loss, and sometimes
grief becomes so intense and more complicated such that what
ultimately emerges our feelings of depression. Typical melancholic depression would,
(10:24):
as your sister says, cause difficulty sleeping with early morning awakening,
a loss of appetite, sometimes with weight loss, and sadness
that is unchanged by doing something that used to be enjoyable.
So I can understand why you think that as bad
as this feels, it isn't depression, but actually there are
(10:48):
different ways that depression can present. And feeling very sad
a lot of the time, but with the ability to
have hours of the day where your mood is brightened
by something does not rule out clinical depression. The fact
that on top of this you find yourself very exhausted
and sleeping much more than is typical for you, that
(11:10):
you are craving carbohydrates and sugar and eating more such
that you are gaining weight are actually signs of clinical depression.
It's just that this is what is referred to as
a typical depression or depression with a typical features. This
type of depression can be set off by a traumatic
(11:31):
event in one's life, like a breakup, especially in a
person who has had a depression in the past and
one who is sensitive to rejection. This type of depression
needs treatment just as much as any other subtype. It
is important that you get an evaluation, preferably from someone
(11:52):
versed in treating depression, a psychiatrist or psychologist who treats
clinical depression. Treatment can be a psychotherapy, either psychodynamic psychotherapy
or a cognitive behavioral psychotherapy, and, if needed in terms
of severity, medication. Medication choice depends on your particular symptom cluster,
(12:16):
and actually atypical depression tends to respond to antidepressants that
are different from typical melancholic depression. The sooner you go,
the sooner you're start feeling better. Other things that can
help you help yourself is thirty minutes of aerobic exercise
three to four times per week, which may be hard
(12:38):
to get yourself to do as you're feeling, but really
can help you boost your mood. So try talking with
others about how you feel and getting support like your
sister or a friend, journaling how you are feeling, avoiding
alcohol or drug use as a means to feel better,
(12:58):
because actually it will make you feel worse. Getting out
to do things that do bring you pleasure, especially something
social psychotherapy is often especially helpful to people who tend
to develop a typical depression because even when they are
not having depression, they may struggle with feeling very sensitive
(13:20):
to rejection such that it makes them feel badly and
it disrupts other relationships, and psychotherapy can help you understand
this better and make strides in not over interpreting signs
of rejection and not emotionally feeling as vulnerable. A form
of therapy called dialectical behavior therapy can be especially useful
(13:45):
for this, helping to manage intense emotional states. If this
is an issue for you prior to this breakup, this
may be a great therapy choice for you to try now.
I hope that was helpful. As much as of depressions
(14:05):
are a typical, with women affected four times as often
as men, treatment can be different for a typical depression
due to the differences in clinical presentation between a typical
depression and melancholic depression. Studies were conducted in the nineteen
eighties and nineteen nineties to assess the therapeutic responsiveness of
(14:28):
those meds that were available at that time in these
two different subsets of patients at the time. Antidepressants that
existed were S sr eyes serotonin reuptake inhibitors a S
n our eyes serotonin nor epernepherin reuptake inhibitors and our
eyes and something called mertazepine, and they were considered the
(14:51):
best medications to treat a typical depression due to efficacy
and having fewer side effects than previous antidepressants, but actually
medications like bupropion, which is a nor epineffrine reuptake inhibitor,
turned out to perhaps be uniquely suited to treat the
atypical depression symptoms of lethargy and increased appetite in adults,
(15:15):
and modaphanel is sometimes used to treat as an off
label treatment option. Before the year two thousand, a group
of meds called monomine oxidase inhibitors or m A O
eyes were shown to be of superior efficacy compared to
other antidepressants for the treatment of a typical depression and
were used as first line treatments for this clinical presentation.
(15:40):
This class of medication has fallen in popularity with the
invention of selective agents like S sries because of dangerous
interactions with pyramine rich foods which come in age cheese,
certain types of wine, tap beer, and bava beanes causing
a hypertensive crisis, and some m aoies can be at
(16:03):
great risk when taken together with S S R eyes
as they can cause a serotonin reuptake crisis. Despite these concerns,
they are still used in treatment resistant cases when other
options have been exhausted, and usually show greater rates of
a remission compared to previous psychopharmacology. They are also generally
(16:25):
better tolerated by many patients. There are newer selective and
reversible m ao ees such as more globrimide, which carry
a much lower risk of tyremine potential action and have
fewer interactions with other drugs, so today's people with a
(16:45):
typical depression are often tried with that. However, tricyclic antidepressants,
which used to be used a lot before the year
two thousand, are turning out to be not as efficacious
as m a o ees and have fallen out of favor.
They have also a lot of side effects. But important
to keep in mind is that psychotherapies like CBT can
(17:08):
have equal efficacy to m a olies for a subset
of patients with a typical depression. So some patients do
well without medication but with psychotherapy alone, and this is
why it's important to discuss your specific symptoms and everything
available to you with your doctor. Do you have a
(17:31):
problem I can help with? If so, email me yet
how can I help? At Seneca women dot com, all
centers remain anonymous and listen every Friday too. How can
I help with me Dr Gail's salts
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