Anthony’s comment:
Daily activities may be stagnated. When a medical specialist met with me for an unrelated condition and asked about my daily routine, he noted that I must be depressed based on what I told him. I considered this very observant and insightful on the part of my endocrinologist. Depression is not always experienced by a person as strictly an emotional state. My behavior is consistent with depression, even if I am not always cognizant of it. Looking back at what has happened to me in the past couple months, and the pattern of my daily activities, it is clear to me that I have become depressed again.
Part of the misunderstanding that creates so much guilt and shame around clinical depression comes from the fact that many people mistake depression as a symptom for depression as a disease. It is perfectly normal for people to feel sad, to have the “blues,” or to feel in a “funk” at times. Life is filled with small and large disappointments and losses. These events are part of the inevitable course of everyone’s life history. Therefore because such feelings are normal, becoming incapacitated by them while others seem to bounce back and move on can inevitably lead one to feelings of guilt and shame for not being “strong enough” to handle seemingly everyday events. One might work extra hard to fight the incapacitating feelings and to avoid either admitting having them or giving into them. When one does, the shame can become so overwhelming that it leads to further denial, withdrawal, or, worse, suicidal acts.
There are many times then when the only thing to do is to simply deny feeling depressed. The denial of such feelings can become locked away in one’s unconscious to prevent perceived harm. Identifying how one feels sometimes becomes as difficult as describing the nose on one’s face without ever looking in a mirror. Thus family and friends may have a better sense of a person’s moods or behavior than the person who is depressed. The denial of feelings is not always unconscious. Sometimes people knowingly deny how they feel because they identify it as a sign of moral weakness rather than an illness, or people are so caught up in external events they have lost sight of how they feel about them.
In all these ways people are not always in touch with the way they feel or behave. However, clinical depression manifests itself regardless of whether people consciously deny it, are unconsciously unaware they are feeling sad or depressed, or are so caught up in events they have lost sight of their feelings. It is important to understand that clinical depression represents a constellation of symptoms that occur simultaneously and not by the simple fact that one feels sad. One should think of clinical depression in the more general physiologic or economic sense of a reduction in activity rather than a feeling of sadness.
These symptoms are attributed to a variety of physiologic states that are depressed (or slowed down). Thinking is slowed so that concentration and short-term memory are impacted. Interest in activities slows to a standstill, leading to a lack of motivation to do anything but the most basic tasks. Appetite is slowed so that people often lose their sense of hunger, taste, or interest in food. This can paradoxically lead to weight gain, because food is chosen that is the most immediately rewarding, usually high in fats and carbohydrates. Bowels slow, leading to indigestion and constipation. Energy slows, causing feelings of fatigue. Sleep slows, leading to disruption. All these physiologic states are reduced or depressed in a broad sense independently of whether one feels sad, although as a result the person will admit to a loss of interest in activities that he or she previously enjoyed.
Thus there are times when a doctor diagnoses depression in the absence of feeling sad or depressed. Some populations or age groups are more susceptible to depression in the absence of feeling sad. For example, some cultures do not have language to describe feelings, and, instead, feelings are identified somatically, through bodily complaints. As people age their ability to identify their feelings diminishes as well. Often, older people become so preoccupied with their bodily functions they lose sight of the impact that their physical complaints are having on them. Under these circumstances patients often come to see a psychiatrist as much out of frustration with their internist as clinical need.
They often report no feelings of depression whatsoever but com-plain bitterly about how their physical complaints are preventing them from doing all the activities that normally gave them pleasure in life. They often report they can no longer garden, golf, read, do crossword puzzles, or follow the news because they are so consumed with worry about their physical condition. These are situations in which depression may be diagnosed in the absence of subjective feelings of depression.