Mimicking Depression

There are two medical conditions that frequently show up in psychologists’ office as depression. These medical disorders outwardly mimic depression (and may even cause depression), but have distinctly different causes, and, untreated, can endanger a person’s health. If you are experiencing depression symptoms, you may want to consider seeing a physician, not for antidepressant medications, but rather to be checked for other problems that may mimic depression.

When I was in graduate school we were frequently reminded to consider hypothyroidism (insufficient release of thyroid hormone) in women who presented with depression. Both cause lethargy/fatigue and hypersomnia (sleepiness), are associated with physical pain in the joints and muscles, and involve lack of motivation, anhedonia (loss of enjoyment in things which use to be enjoyable), negative mood states (e.g., sadness, regret, or anger), mood swings, and weight gain. Many of the symptoms of hypothyroidism mimic depression and it is consequently frequently under-diagnosed, or misdiagnosed as depression.

No amount of anti-depressant medication will make the symptoms of hypothyroidism go away. Thyroid hormone affects many other bodily functions and low levels can negatively affect multiple organ systems. Untreated hypothyroidism can lead to goiter and heart problems and can even cause birth defects if a pregnant woman has hypothyroidism, so proper diagnosis is very important. More women than men present with depression symptoms, so awareness of this mimicking phenomenon is drilled into psychologists in grad school. However, it is also important that women be aware of the similarity so that they know to consult a physician (perhaps in addition to a psychologist) if they experience symptoms of depression.

Perhaps because men present for depression less frequently than women, being able to distinguish medical disorders from mental disorders is less emphasized in grad school. If a man presents with difficulty attaining or maintaining an erection, lack of sex drive, irritability, mood swings, negative mood states (e.g., sadness, regret, or anger), difficulty concentrating, lethargy/fatigue, a lack of motivation, and weight gain the psychologist is likely to diagnose depression, whereas the medical doctor will probably evaluate testosterone levels. These symptoms are common to both disorders and both would be reasonable diagnoses given the respective experts’ fields.

Many of the symptoms that might allow for differential diagnosis are not likely to be mentioned by men over 35 to either a psychologist or a physician. Hair loss is normal as a man ages, but is also accelerated by low testosterone. The development of fatty tissue in the breast/chest area probably also isn’t going to have attention called to it when presenting to a health professional—either because it is embarrassing or because it won’t even be noticed with the rest of the weight gain. But these are some of the things that can be used to assess if a man is suffering depression or low testosterone. Sometimes, though increasingly less so, male clients will not tell their psychotherapist or counselor about sexual dysfunction either. Even in the absence of these symptoms I have encouraged some of my male clients to have their testosterone levels checked.

Decreased testosterone is normal for a man over 40, but sometimes there is a precipitous drop in testosterone levels and that will lead to depression-type symptoms, along with health risks. Low testosterone is associated with heart problems and even susceptibility to broken bones. And, like hypothyroidism, anti-depressant medication will not address the symptoms, not even the mood symptoms, effectively.

Along with the normal drop in testosterone, there is a natural drop in sexual function and energy, which may be perceived as the normal part of aging—and for many it is—but even many physicians are not trained to ask about the effects of lessened testosterone in a way which would indicate lower-than-normal-for-age testosterone levels. It is important that men be aware of the symptoms and question the severity of the drop (and the mood features associated with low testosterone) in order to take care of themselves.

There is some controversy whether hypothyroidism and low testosterone mimic or actually cause depression. To me the distinction might be irrelevant. If after taking the medication the depressive symptoms do not go away after a few weeks, you might want to see a therapist to address whatever depression may have followed the body chemistry problems from the physical disorder. If the depressive symptoms go away from treating the primary physical problem, then the depression has gone anyway. But the main point is that, like with so many physical disorders, it is important to know to consider with the medical or mental health professionals all of the possibilities.

Doling Out Your Crazy

When we meet someone for the first time, especially someone with whom we want to get intimate, we want to make a good impression. Part of making a good impression is being yourself with someone. People are pretty good at detecting insincerity; people do not respond well to partial presentations. But people also don’t tend to want to associate with people who present as a “mess.”

I encourage my clients to dole out their crazy a little at a time when developing a relationship. There is a pace at which it feels healthy and appropriate to share one’s uncertainties and idiosyncrasies. It is sort of like testing the waters. Trying to see how much of our own craziness the person is ready to handle. This is partially determined by how much quality is perceived in the person—in other words: “Does the person have enough good stuff to put up with the crazy?” By the way, we all have a little craziness.

The craziness may be some odd superstitious ritual or fear that is not grounded in any rationality, but is grounded in the perception of our own experiences. We all have some strange ideas about the world and frequently our own un-founded insecurities (e.g., I have a faux paranoia about ebola). No one is really quite “normal,” while they might be mentally quite healthy. These are the quirks that make us who we are—often the parts that people find endearing after they get to know us.

However, emphasis on “after they get to know us” is worth highlighting. Too much intimacy—crazy or not—too soon is usually off-putting. We enjoy the process of getting to know someone; the process of discovery is engaging. Knowing everything at once can feel overwhelming—there is no context for the details, no sense of nuance or flavor. It can feel too raw. Additionally, I think there is something to feeling special because an intimate aspect of someone was shared with us. Aspects of oneself shared too easily do not feel like intimacy.

We also take as a cue how much we will share (or are expected to) based on how much another shares, and therefore someone sharing too much too quickly may feel threatening. Most of us want to control the rate at which someone knows our quirks and insecurities—there is vulnerability in it. When someone blurts out all of his or her idiosyncrasies, we don’t feel safe sharing with him or her our personal thoughts. Furthermore, the expectation to match the pace of sharing can make us want to back away (and protect our privacy).

I do not mean to discourage sharing, of course. Exposing our true selves actually tends to open us up to greater connection and happiness. However, when trying to decide to share one’s quirkiness think about the purpose of the sharing—what are you trying to achieve by it? Are you trying to provide insight? Are you trying to explain a particular behavior or tendency? Are you trying to be funny? Or is it just coming out of you uncontrollably? That last one is the one to watch out for—it will drive people away (or to stare).

The Five Love Languages

Gary Chapman came up with the theory of the five love languages. It is an idea I use with clients frequently. It addresses the idea that demonstrations of love often go unnoticed (or unappreciated) by a partner. Chapman discovered that people engage in and recognize demonstrations of love differently. He categorized these disparate actions into the categories, or languages: words of affirmation, quality time, receiving gifts, acts of service, and physical touch.

Saying “I love you” is important and can be powerful in its own right. However, in our culture the word “love” has lost some of its strength because of how loosely it is used (“Oh, I love those shoes”). “I love you” can also feel obligatory and insincere sometimes. I encourage clients to share what about their partner(s) they love. Those are true words of affirmation. I do caution people not to use them as blackmail though, don’t turn them into “I love it when you…” in order to get someone to do something, but rather only as sincere appreciation for their having done it.

One of the most valuable and overlooked things that we can offer a partner is our time. Companionship is essential for a relationship (of any kind). Doing things together can function as a bonding experience. It is important to find shared interests and it is important to be curious about your partner(s) interests, even when it is not a shared interest. Work on enjoying your partner’s company when you do things with them that you don’t necessarily enjoy doing yourself—make enjoying their company what you get out of it rather than the joy of the activity itself. Another aspect of quality time that is frequently overlooked is that just sitting with someone who is suffering, enduring what they are going through—without an agenda of your own—is one of the greatest gifts you can give someone.

Meaningful trinkets can in fact be very meaningful. A few years ago my BF was putting in some glass doors, to open the house up to the backyard. I appreciated what he was doing (and his concern that it was temporarily inconveniencing us) so I purchased and wrapped a DVD of a movie I knew liked and stuck in conspicuous place in the jobsite one night so that he found it the next day when he went back to the project. Flowers are the gold standard of trinket gifts, but occasionally spontaneously providing something that your partner has casually mentioned wanting is a great way of saying “I care about and attend to you.”

Doing non-chore household tasks, especially without being asked can be a powerful statement of “we are in this together.” Noticing things that your partner does not like or is incapable of doing and doing those things for him or her is another way of showing you are attending and care. If you can notice something you can do to improve a process of your partner’s or can create something to facilitate the ease of his or her process, you are likely to be appreciated. Even helping out in mundane ways tends to be felt as cared for. My boyfriend cooks most of the dinners in our home and I recognize his doing so is at least partially an act of appreciation for having me in his life.

Touch can be incredibly powerful. There is research that chemicals are released in our brains by just watching another person be tenderly touched. Research has even shown that a comforting touch can be desirable than sustenance. A simple caress or reaching for a partner’s hand while watching TV says “I value you.” While sexual groping can be a great way of saying “I find you sexy,” a non-sexual touch can say “I appreciate you beyond the great sex” (and might even lead to great sex!). Even people who are not touchy-feely can appreciate an occasional touch.

But the important thing to remember is that you may be saying “I love you” all of the time, but if you are speaking a different love language than you partner, the message may not be getting through. It is important to learn the language that your partner comprehends and speak that language. It may even be a good idea to let your partner know what language you hear. An issue that I have not seen Chapman address is that some people speak and hear different love languages themselves. So you cannot always count on getting your love message heard simply by speaking the same language your partner speaks. It is also worth learning what love language your partner speaks, so that you can become better aware of when he or she is saying “I love you” in a language that you don’t hear. Ideally you won’t send messages that are not received, but nor will you miss the messages that are sent in a foreign love tongue.