Warning: this post contains detailed descriptions of suicidal thoughts and feelings
1 The branch of linguistics and logic concerned with meaning
1.1 The meaning of a word, phrase, or text:
such quibbling over semantics may seem petty stuff’ (Oxford Dictionaries )
“I will always have an abnormal level of anxiety, but it isn’t all bad,” tweeted author Matt Haig a few days ago. “It keeps a mind sharp. Sometimes it feels like a superpower.”
There was an intake of online breath from anxiety sufferers. A superpower. A superpower?Yes – “those moments when you rise up, out of panic but massively alert, feel very empowering.”
Haig, who often appears mildly baffled by reactions to his views on mental health, offered clarification. “The main thing is: no two experiences of life or illness are the same. To me anxiety can sometimes tip upwards into an intense excitement.”
Of course he’s right that no two experiences of any illness can be the same. But I was among those wondering whether something that felt like a superpower, that was a kind of excitement, that had anything at all positive going for it, could match my personal understanding of anxiety. There was a flurry of tweets as people rushed to explain why the debilitating nature of their anxiety made the suggestion offensive, and a flurry of counter-tweets validating Haig’s right to describe his anxiety any way he likes. Now I’m left chewing on the question: when you say you have a condition, and I say I have that condition, how do we ever know that we are referring to the same thing?
Let’s take a look at the criteria for a diagnosis of depression:
Reduced pleasure in activities 🔹 Feeling down, depressed or hopeless 🔹 Trouble falling or staying asleep, or sleeping too much 🔹 Feeling tired or having little energy 🔹 A poor appetite or overeating 🔹 Feeling that you’re a failure or let yourself or your family down 🔹 Trouble concentrating on things like reading the paper or watching TV 🔹 Moving or speaking slowly, or being very fidgety, so that other people can notice 🔹 Thinking that you’d be better off dead or hurting yourself in some way
“But wait a minute!” people cry when I get to this point on training courses. “Sleeping too little and sleeping too much are both on there! Are you saying someone might have depression if they are eating too much or too little? If they are unusually fast or slow? How can two opposites lead to the same diagnosis?” Well…
Clinical criteria impact on how people with mental health problems describe their own symptoms. I’m bipolar, that’s my diagnosis, and it resonates. And that diagnosis means that I swing between two opposites, yes? So if one of the poles is elevated, high mood, then the other must be low mood. And low mood = depression. I mean, that’s what it must be, it says so in the manuals. Manic depression, (hypo)manic mood alternating with depressed mood. Right?
Except what if it isn’t? What my experience at the low pole isn’t depression as other people understand it?
I sometimes hear people speak of their depression and/or suicidality as an emptiness or numbness. I have no means of relating to this. It’s like we are speaking a different language. I have no reason to disbelieve them, yet when comparing their description with my own experience I hit a total block. I cannot imagine not feeling. It seems implausible. And if I did, I wouldn’t see that as depression.
Because depression, to me, means pain. Active, urgent pain, the kind of pain that must be stopped. Ultimately the only certain way to do this is by suicide, so even when the pain fades for a while the fear of it coming back means I never really rule out killing myself as an option.
Right now I am somewhat depressed. There is a hole in my soul and the cold is creeping slowly in. This edge of pain is bearable, but if it progresses to severe depression, it won’t be. That hole, somewhere around my solar plexus, will expand and I will find myself hunched cover, my body curving around the void until my spine aches. The muscles around my mouth will ache too from the twist of something beyond crying, something more like keening, forced out of me by the anguish.
By the time I get into crisis the emotional pain is such that I sometimes cannot stand. I promise I’m not making this up. I end up on the floor, or leaning over the kitchen counter, as if someone has just punched me in the stomach. The whole time my mind runs over the same refrain: I can’t stand this agony, I can’t live in such acute distress, please let me die, please don’t try to stop me, if you knew, if you knew how much pain I am in and you really loved me you would not try to stop me, you would give me the pills yourself, you would take me to a Belgian clinic, you would sit beside me and hold my hand and stroke my hair until I was finally released.
Is that what other people mean by depression? How can I know? If it’s not your depression, if there is a massive gulf between our experiences, then how much use is the word?
I am emphatically not saying that my depression is more important or of more value than the depression of someone who experiences an absence of feeling. Objectively, that sounds horrible, not being able to connect with any feelings at all. It sounds like it would be hard to feel like a human. And yet as I curl up on the floor in the corner by the door, I feel that I would happily ditch my humanity if I could trade my despair for numbness. I am sure that if I got my wish I would regret it in a heartbeat. But sometimes, just a little, I envy those who are cut off the from the feelings that I am unable to bear.
I suppose for medicine and public health there is the issue of outcomes. Intolerable numbness and intolerable pain may both in the end lead to attempted or completed suicide. They are both incapacitating, interfering with partnerships, friendships, work, ability to enjoy what life has to offer. But the focus on the observable tells us nothing about the inner experience. Stroke and dementia can both cause loss of speech, but we would not expect the internal worlds of the stroke survivor and the person with dementia to be the same.
Maybe we need a new vocabulary, although I’ve no idea how this would be achieved. Cultures that end up with numerous words for what we might perceive at the same thing do so through shared consensus about things that everyone can see. It’s just not feasible for largely subjective experiences.
Perhaps it’s more realistic to recognise and acknowledge that it’s not just the diagnoses attached to a person that may be problematic. The personal meaning that those with mental health problems bring may be radically misunderstood by professionals and indeed peers. Perhaps we need to move away from simply asking whether service users tick enough boxes to merit a diagnosis, to a focus on the quality of the experience. What does “down, depressed or hopeless” mean to that person? What does it feel like? If they struggle with the idea that they would be “better off dead” what emotional resonance, if any, does that idea have? In order to help helpers to understand, should we be offering a range of adjectives (including numb, empty, detached) to pick from, instead of a menu of recent thoughts and behaviours?
I have no idea how to answer my own questions, or indeed if any work is being done in this area. But if we don’t try to cut through limiting language and our personal assumptions, we may never really be in a position to connect.
Thanks for this, Charlotte it’s helpful and something I struggle with. In general practice this issue is especially tricky as we see undifferentiated suffering (whereas in psychiatry they see the tip of the mental health iceberg, where symptoms are more severe). Deciding whether a patient’s symptoms and experiences are sufficient for a diagnosis of depression can be very difficult, especially in the context of a life lived under stressful circumstances. From research perspectives, GPs are always told that we over and under diagnose depression and your thoughts here help illuminate our difficulties.
I have particular difficulties with bipolar subtypes: some patients are regularly sectioned with psychosis and cannot manage continuous employment and others are never psychotic and seem to be very successful. I’m sure you’ve covered this elsewhere.
I’ll share your blog with my students and trainees to get them thinking, thanks again, jonathon
My depression is an active, brutal, torrent of mental pain, a storm of self-loathing knives piercing my brain. I cannot catch my breath, or a thought process, there is no quiet, and it converts into physical pain. It’s aggressive and exhausting and terrifying. I want to cease being, because it is the only available escape.There is an absence of hope and inability to feel joy underlying it, but I am not numb or without emotion. So yep I get what you are saying – people have pointed me to “cartoons” saying it absolutely describes their depression – and it’s unrecognisable to me. I don’t think there’s a lot of maturity in the diagnosis of mental health issues: the depression scales used to “quantify” depression are laughable. I’m lucky, I respond very well to medication, but I wonder if this is why some people don’t: they have a completely different condition to me, or casue of that condition, all lumped in under the same broad umbrella.