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- Category: A Study Of Psychopathology
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In addition to the 17 males and 38 females diagnosed as reactive depressions, significant depressive features were also found in a large percentage of the rest of the patients. Anxiety reactions alternated with depression. Obsessive-compulsive mechanisms were desperate struggles against being overrun with depression. About a third of the psychophysiologic reactions in each group of men and women were body expressions of a depression so severe that I often wondered if the body were not being used as a safety valve to stave off a more malignant psychological process.
Many of those diagnosed as adjustment reactions of adolescents and adults revealed difficult situations which were gradually bringing the patient, had resolution not been reached, towards a depression. Because depression is a subjective symptom, the burden of proof rests on whoever declares its presence. This task proves difficult in patients whose type of depression is of non-psychotic proportions. Psychotic depression, with its classical signs and symptoms, is unmistakable anywhere. Reactive depression, which finds the patient still reality-oriented, with some capacity left to react, communicate, and function even if to a greatly reduced degree, is more difficult to detect.
There is a particular cultural tendency among Filipinos to deny the presence of depression. A patient in this study, for instance, employed an array of defenses to deny his depression. The people around him also helped to reinforce this denial. They mislabeled him as merely sad-looking, lonely, disappointed or feeling low because of his physical illness.
From the accounts of patients, insomnia is nearly always the first sign of depression. Furthermore, each depressed patient sooner or later mentioned insomnia as a serious symptom. He might recall that months before, he had had occasional bouts of insomnia which were not too upsetting. Some even mentioned over-sleeping at the beginning of the illness. Women, especially, cited a fondness for overstaying in bed, which at the time they had interpreted as laziness or not feeling well. Actually they wanted to sleep most of the day because their sleep at night was not restful enough. As the weeks or months went by, the early morning awakening became gradually more pronounced. Depressed patients soon reported that sleep became impossible at around three o’clock in the morning.
Even more common than early morning awakening was difficulty in falling asleep. One patient described struggling with himself to initiate sleep, debating with himself for hours whether to take pills or not, to walk actively or not; the harder he tried to put his thoughts aside, the more active they became. Finally just when he would be exhausted and on the brink of falling asleep, he would wake up with a jolt and start the struggle all over again. From numerous accounts similar to this, it was clear that the patient unconsciously resisted going to sleep.
Diurnal changes in mood did not always follow textbook- like patterns. Many felt low in the morning because there were so many things to look forward to but for which they could not seem to summon energy or enthusiasm. Others felt worse at night because it meant wrestling with the sleep problem again. The loss of interest in one’s surroundings as well as the decline of energy to carry out the usual activities came on so gradually that the patient hardly recognized what was happening until it was fairly obvious. What they did recall in retrospect was irritability, frequent arguments at the office or with the maids, or short-temperedness with the children. A few men resorted to drinking for a while. Some decided to take short trips or vacations but these failed to bring about an improvement of spirits.
As the depression progressed, psychologically-based somatic disturbance entered the clinical picture. Sometimes, an organic ailment came along, whose timing seemed perfect for it to be utilized by the depression in full force. Thus after a gall bladder operation, the discovery of a duodenal ulcer, a urinary infection, a miscarriage, etc., the patient’s depression raged worse than ever and became impossible to ignore. The somatic ailment, fact or fantasy, became an obsessional concern; the patient by then was convinced that the illness surely meant the beginning of his end.
This was the usual point in the illness when psychiatric help was then sought. The patient, pessimistic and cheerless, reported frequent dreams of death, of being buried alive, of departed loved ones, funerals, coffins, cemeteries, and other situations pertaining to death. Losing a tooth in dreams was mentioned by a few. There were periods of staring blankly into space. During the day, relentless rumination about the fantasized tragedy-to-come followed the patient in whatever he did, even as he tried to pursue his usual activities. One woman described it very aptly: “This terrible feeling clings to me like a black garment.”
At work or at play, the patient bravely tried to maintain a front in spite of the depressive burden. Female patients, probably because of the premium the culture places on endurance and silent suffering, would often ask the doctor to help them get used to it and not necessarily be relieved of it. Indeed, the history of their illness was often that of silently tolerating the depressed feeling for a long time, or simply ignoring it. To fight it would be to acknowledge its presence. Thus, these women were in a state of chronic depression for some time when added stress came along and forced the issue into the open.
Depression is an acutely painful affective state. These patients were in no way different from similar patients described in other cultures. One heard such statements as: “If a man ravaged my life, killed my children, stole all my worldly goods, I would not wish upon him as punishment the state of depression I am now in”; “I would give anything to get my spirits back; I would gladly go barefoot and eat rice and bagoong again rather than be in this state,” from a man whose life was centered on acquisitiveness for material things. “It would be better to lose one’s mind completely than to be depressed like this”; “I cannot feel even the simplest joys which I have been used to before: a plate of pancit, a good movie, listening to the radio, watching my children play.”
For male patients, this terrible and painful state was compounded when sexual potency was impaired. They did not perceive it as part of the general reduction of energy and interest occasioned by the depression. Rather they saw it as the ultimate punishment, the long-dreaded and anticipated catastrophe, finally descending on them. One patient who had his depressive illness at the time of the U.S.-Cuban crisis in 1962 remarked. “What does it matter if another world war breaks out? If I cannot perform sexual intercourse, I might as well be dead.” Impotence seemed to be the last thing that the male patient was willing to sacrifice to the illness. In much the same way, a depressed female patient heaped all kinds of criticism upon herself but would save as her last source of narcissism and strength her virtues as a mother.
At the height of a patient’s depression, guilt feelings and suicidal thoughts were given abundant expression. The guilt feelings in men had to do with “impure thoughts,” sexual excesses,” greediness with money,” not being a good son,” pr “making the wrong decisions at the job.” In women, the guilt centered around “failure to serve parents,” wanting too much,” being too ambitious,” not being devout enough in prayers.” Guilt feelings, like suicidal thoughts, seemed sufficiently excruciating and frightening so that patients employed various means to escape a continuous siege of self-blame. Suicidal thoughts were denied vehemently, even as the patient noted that death seemed to be on his mind all the time. Women clung to concern for their children to dispel self-an nihilistic thoughts.
Women lapsed back and forth in prayer, sometimes alarmed at their inability to feel fervent but retaining hope that God will eventually effect some rescue. There was much bargaining with God, protesting that one hail suffered enough, importuning Him to stop the suffering because the mind might break. Men and women tended to exonerate themselves and blame others, including the doctor who failed to identify the physical illness. Women, in particular, carried the fight to family conflicts so that eventually the issue of self-guilt was beclouded by other issues.
Shame was also substituted for guilt quite literally, so that instead of feeling guilty the depressed patient now felt ashamed. This often helped to alleviate, to some extent, the painful affective state. Shame involves other factors, other situations, other people, whereas guilt is a lonely battle between the individual and himself. Thus, a young girl jilted by the boy she was going steady with felt intense shame in the eyes of her town mates and friends. She felt as if they were laughing at her and criticizing her for being too “free” in giving her affection to a boy. Actually, she felt very guilty and depressed about her sexual impulses and saw the boy’s rejection as logical punishment for disobeying parental edicts about sex. She considered herself a “bad girl.” Shifting the feeling of guilt to shame served the purpose of focusing her energies on fighting the townmates” opinion of her and eventually proving them wrong.
Although patients had a repertoire of psychological defenses and maneuvers to cope with the onslaught of guilt, regressive behavior with its primary and secondary gains seemed to be the most effective factor in stemming the tide. By this time the family had become quite active and generous in giving the patient all the emotional support he needed. He was allowed to release himself from pressing responsibilities. A young boy or girl was allowed to give up his or her studies in the meantime. Loss of one’s job was tolerated by the family; the married woman, if she wished or if it was possible, took a brief vacation with her parents.
The women were given more leeway to indulge in self-pity than the men. Their crying spells were well tolerated. One woman who said she had not cried since she got married found that she could not seem to stop weeping. Filipino men are allowed occasional tears by the culture but in general, as other cultures, crying lit men is taken as a sign of weakness. Women, on the other hand, are inordinately prone to tears. Female patients did not feel embarrassed about crying and felt it was part of their nature: “I am like the papaya, a little scratch and I cry right away.” Or in Tagalog, “Mababaw ang luha ko.” Crying serves many purposes, from release of unexpressed aggression to creating guilt in others. It is especially useful as a self-nurturing device. By feeding on the depression, as it were, the patient derives some strength.
An interesting symptom, reported by three male patients, consisted of apparently sudden and unprovoked crying spells, unrelated to what each was doing or thinking about at the time. One said it usually hit him on waking up. He would find himself sobbing loudly, then crying. He did not know what to make of it. Another said he would suddenly cry for no apparent reason at unpredictable times, e.g. while waiting for his wife so they could go to the grocery, while feeding the dog, or after playing basketball with his sons. The third patient had crying spells usually after leaving the office at five o’clock in the afternoon. Each treated the symptom as ego-alien and all were quite puzzled and perplexed at the loss of control over one’s tears.
Clinically, the equivocation with which a Filipino patient is diagnosed as a case of depression stems from two factors, namely, his various ways of disguising the depression, as mentioned above, and the consequent absence of a prolonged siege of guilt feelings and self-castigation which one encounters in other depressions, particularly in Western culture. In the reactive depression cases in this study, the patient spoke not so much of feeling guilty, but of having committed a “sin.” The “sin” was not in a religious context but a moral one. Sin and punishment or penance goes together, and the patient behaved as though his illness were already part of the punishment. He had been adjudged guilty as it were, and had begun serving his sentence, although the worst was yet to come. In depressions occurring in Western culture, the vicious barrage of guilt still awaits judgment and punishment, fantasized as mutilation or castration. The illness is like a bribe to one’s conscience or super-ego, pleading leniency on the ground that depression has caused enough suffering. Depression in a Filipino patient is usually combined with ways and means to help him avoid self-anticlastic attitudes. Nonetheless, the patient feels just as wretched and just as rent with ambivalence as his Western counterpart, and with his regressive devices, sometimes ends up paying a higher price for recovery.