Smiling But Sad: Decoding Persistent Depressive Disorder, Dysthymia, “Eeyore Syndrome” w/BONUS Medication Analogy and Thanksgiving Talk Topics

okay, let's be honest, sometimes the world of mental health feels a little bit like trying to crack a code of an overly complicated spy novel because you will walk into your therapist's office and you're thinking, I think I'm a little sad. And then suddenly you are navigating through PDD, which surprise is not PMDD. One is a persistent drizzle of sadness and the other is an emotional thunderstorm that happens to be synced to a lunar calendar.

And then somebody throws in ODD, not the odd that you're thinking, but we're talking oppositional defiant disorder. So now you're wondering if your toddler might be staging a coup. And don't even get me started on OCD, DID, NPD, and BPD, because if you say them all together, they start to not really sound like diagnoses, or you suddenly just realize that you're being invited into some sort of secret society.

And I am sorry, but If you are a child of the 90s or maybe in your early 20s in the 90s like myself, most likely your brain just screamed, are you down with OPP? And don't even dare look that up, what that means now that you have the internet or else you will D. I. E. thinking that you were singing that out loud, maybe with the kids in the car, because I guarantee that you did not know. That that was what it meant.

And before you know it, you're starting to spell out H E L P in metaphorical Morse code , because all you really wanted was to feel G O O D. But, at least you know one thing is for sure, the DSM, or the Bible of Mental Health Diagnoses must stand for definitely so many meanings. And that is where we come in. To untangle this alphabet soup one letter at a time. You're not crazy, you're just stuck in the middle of a very confusing game of Scrabble.

Or words with friends for the modern day audience. And since this is a mental health related podcast, yes.

People I played with several years ago, there is an app that helps you come up with words based on your letters and sure, maybe I used it just a time or two, or actually a lot, which this confession, because the very need for it came from a little bit of an intrusive thought, would technically qualify as a form of OCD, or P OCD, or pure OCD, but the confession itself seems a little bit more like scrupulosity, which does sound like a fun board game.

Hey everybody, we're heading to the cabin this weekend. Somebody make sure and grab the scrupulosity. I've always wanted to play. And that tangent, my friends, is definitely a form of my own very lovable ADHD.

Hey everybody, welcome to episode 432 of The Virtual Couch. Hey everybody, I am your host, Tony Overbay. I'm a licensed marriage and family therapist and host of a few other podcasts. I would highly recommend you go check out Waking Up to Narcissism.

Especially the, the episode that I did last week, and I will include that in the show notes, and I will just leave it at that, a little bit of a mystery there, but a funny thing is when I first started writing down notes for this episode, it was quite a while ago, a long time ago, and what I was really thinking I would be talking about is a condition called dysthymia. And it's something that isn't mentioned a lot.

It's it's in the world of depression, but it's a very, persistent, consistent, sad or depressed feeling. But then when I finally sat down to write some notes to cover in this episode, I learned that all the way back in 2013, dysthymia was changed to persistent depressive disorder or PDD. And that was with the release of the DSM 5.

And today's episode, We're going to cover some different takes on depression and , I think could really help anybody listening who maybe has felt down or sad or lacks motivation or, Maybe more significantly has for quite some time, or this might help you understand somebody that you care about a bit more, which might provide you with more opportunities to connect or empathize.

And if I'm being honest, this one goes out a little bit to the psychology or therapy nerds, especially heading into what in the U. S. is Thanksgiving, where you will be around a lot of extended family. And right now there might be some challenges talking about a lot of things coming off. What was a pretty pretty intense election cycle. Think of this as my gift to you. Some fun facts that you can share around the Thanksgiving table as well.

So we will talk about those feelings of melancholy that you might have been experiencing for a long period of time, what to do about it, but stay tuned as well, because I want to talk a bit more about how medications work in the brain. And I am not a doctor, although people have written it on, checks when I used to get more checks, but I am going to explain things the way that I understand them.

Fact checked, of course, by the internet because what actually is a serotonin reuptake inhibitor and why this constant need to reuptake things in the first place. And while dopamine and serotonin definitely have better PR teams on their side, how about this this norepinephrine how does that come into play?

And one more thing that I think is really fascinating The time when this type of depression was viewed as a personality disorder and then how significant it was when it was suddenly changed to a mood disorder because those are two very, very different things.

So first, let's go back to this DSM just in case you've never heard about it. So the DSM, it stands for the Diagnostic and Statistical Manual of Mental Disorders. And that is a comprehensive guide. It's published by the American Psychiatric Association or the APA. And it outlines standardized criteria for diagnosing mental health conditions. It was something that I was supposed to get to know. Oh, so well back in grad school.

And I did own one kind of put a period there, but the latest edition was the DSM T R the text revision, and it was released in March of 2022. And I did a little bit of research on when is this DSM six going to come out? And who knows, because it takes a long time to put together all the information, but it's significant because with each release of a diagnostic and statistical manual of mental health disorders, then , the names change, the diagnoses change, the criteria change.

And as somebody who works a lot in the world of narcissistic traits and tendencies and emotional immaturity, there is a part of me that really anticipates some changes there where we're going to talk a lot more about emotional immaturity and what that looks like maybe on a spectrum. But you've got the DSM, and then this isn't to be confused with another diagnostic tool, which is the International Classification of Diseases, the ICD. And that is a global diagnostic tool.

It's developed by the World Health Organization, and that one covers all health conditions, both physical and mental. So the ICD 11, that's the latest edition, and that was adopted by the World Health Organization member states in May of 2019. And then it came into effect on January 1st, 2022. And if you are keeping notes, it beat the latest revision of the DSM by a mere two months.

So I can only imagine someday we'll see a harrowing lifetime movie on the intense few months that led up to who can get this revision out sooner so that, I don't know, so they can release it sooner. But in the mental health field, do you DSM or do you ICD? And to me, it definitely feels a bit like the mental health world's version of things like the metric versus the imperial system debate.

You know, in the U. S., we proudly cling to the DSM, the Diagnostic and Statistical Manual, to diagnose these mental health conditions. And meanwhile, the rest of the world is out there using the ICD, or the International Classification of Diseases, because again, it covers everything, physical and mental health alike. And I think that explaining the difference is important. Like Trying to describe distance to somebody who uses kilometers while you're stuck in miles.

And I feel that I have an advantage just as a runner because I've run enough five and 10 Ks and even 50 and a hundred Ks to convert the kilometers to miles, and I did once learn that to get to Fahrenheit, you basically double whatever the temperature is in Celsius and you add 30 and it's actually pretty close. But you can't quite do the same thing when it comes to trying to explain mental health diagnosis.

So when it comes to the DSM versus the ICD, it isn't so straightforward because you might tell somebody that they've got generalized anxiety disorder in DSM lingo, and they'll nod until they realize that their ICD using doctor or mental health professional calls it F41. 1. Same condition, different branding, kind of like yards and meters or inches and centimeters. Both systems get you to the finish line, but the conversion can leave your brain kind of sprinting in circles.

And like the metric system, the ICD is a global standardized and frankly it does make a fair amount of sense. But here in the U S we stick to our DSM because well why not make mental health a little more uniquely American, right? So back to today's topic of dysthymia. Or also known as Persistent Depressive Disorder.

So the goal of the change, as much as I could tell, was hopefully to simplify and clarify diagnostic criteria, but also to do a little bit of diagnostic housecleaning by combining two of these previously very distinct diagnoses. So the first was this Dysthymic Disorder. So this was chronic, low grade depression, lasting at least two years. Or one year for kids and adolescents and then chronic major depressive

disorder, . So the hope is that by merging both of these conditions into this persistent depressive disorder, the DSM five would start to emphasize that. really the chronic nature of the symptoms instead of the severity or the intensity at any given moment. And then this update also hope to reduce confusion and then provide more of a cohesive framework for treatment and for diagnosis.

And I think that's really helpful because you first need to really try to understand what is going on in order for you to start looking at treatment options, but I'll be honest, I'm still stuck in this world of dysthymia. And I think it's largely because of the population I tend to work with. And maybe it's also because I don't take insurance. So the need for an official diagnosis hasn't really been as pressing.

And as a big acceptance and commitment therapy guy I found that a lot of the people that I work with that, although definitely not all feel a little bit more judged when they're given a diagnosis. And that judgment often leads to shame and there is no place for shame in my dojo. It might walk in, but it is not going to be walking out on its own two legs.

But with that said, I've also worked with plenty of people who feel that receiving a diagnosis has been incredibly validating and it's helped them feel less crazy and more understood and less alone. And it's given them more of a sense of being seen as something that they can tangibly Google to learn about and process and to begin to navigate.

And. With that concept in mind, I do have to say, I think it's really fascinating when I hear the number of people that I'm working with that have worked with other therapists or a doctor, and then , they talk about experiences where they've gone in and they have turned to Dr. Google, sure, and they bring that into the therapy office and how some therapists are very offended and they're saying, well, let me try to understand

where you're at and then I'll be the one that can make this diagnosis where in reality, it's the world that we live in. If that person has never doctor Googled anything, I don't know. I don't know if I believe that person or not. That's a me thing. Sure. But. I think it's one of the best things that you can do is if you're walking into your mental health professional, even your doctor and you're saying, of course, I've been looking this up and this is what I found because now here's our muse.

Can you help me make sense of this? Maybe calm down from it, or maybe this is a place to start because you will understand that that is where that person . Is that in their mind? So I just think that's a really fascinating concept. So if you are looking things up because you're the only one that knows what it feels like to be you, well done. Yeah. And then take that in to your mental health professional and, be open and honest.

The therapist hopefully is trying to provide a safe place for you to be open and honest, but I also want to talk about the origin story of dysthymia because we can explore whether the rebranding in 2013 was a win for visibility or understanding or whether the new PR department did it. Basically a disservice because either way, we'll look at how this change might have helped people get the help they need and more importantly, the help that they deserve.

So I first want to go to this Encyclopedia Britannica website and having just turned 55 just a couple of days ago, when I think of encyclopedias, I'm literally thinking of the physical, hardbound books that every family had a set of, that had a letter on the spine and within that book, you could read. It held everything that you ever wanted to know about things that begin with the letter. I know, well, you name it. And now, warning. This is purely for conversation around the Thanksgiving table.

Because if you are under 30, ask which set of encyclopedias your parents or your grandparents own. Because back in the 80s, owning a set of encyclopedias was more than just a practical decision. This thing was a statement. Because having a full collection of world book or encyclopedia Britannicas on your shelf was kind of like telling the world, or at least your neighbors for sure, we are a family of intellectuals. Thank you very much because they were status symbols.

I mean, you probably displayed them in the living room like a trophy of academic ambition. Now, they might take a look at the kids then and say, I guess it's not just the books themselves. And I believe we were world book folk. I think the rich people had the encyclopedia Britannicus, but I don't know. Encyclopedias were expensive.

A full set could cost several hundred dollars, which I looked up that that is easily the equivalent of a few thousand dollars today, but thankfully they had installment plans. They had door to door encyclopedia salesmen. That is a true thing, but that made it possible for middle class and even some lower class families to afford this investment. And they were looking at like an investment in their children's education, but they weren't just books. Because they were essential for learning.

Teachers leaned on them as trusted sources. Because if you had to write a book report, and you couldn't get to a library, or didn't have one anywhere close, you were turning to the encyclopedia. It's such a trip to think about that. So they would assign reports and projects that sent students running through their volumes for facts and figures. But then also, it was a little bit easy to get caught for plagiarism. Theoretically. Not that that ever happened to me.

Writing one, I think about a Fox or something when I was in middle school, but for kids, the encyclopedia was basically an analog Google, except it weighed a lot and it required you to actually flip pages, meticulously crafted and they had these durable bindings and then the high quality glossy paper, and they were designed to stand the test of time because I think it's so interesting. Again, who knew that the internet was on its way here.

Many families pass down their encyclopedias, like heirlooms, ensuring that the next generation had access to this amazing treasure trove of knowledge, which would now be outdated and still 50 pounds. But let's get back to today's topic of dysthymia are also now persistent depressive disorder or PDD. . Because the condition's a bit like depression's quieter, longer lasting cousin who never, ever, ever really leaves the party and just keeps kind of making really sad comments.

Because PDD is defined as having symptoms of depression that stick around for at least two years, or again, just one if you're a child or a teen. And while the name Persistent Depressive Disorder might feel new, it officially made its debut in 2010. 2013, but the condition has been hanging out in the human psyche for a very, very long time. So let's take a brief stroll through history because long before modern psychiatry, the ancient Greeks had their eye on this condition of dysthymia.

So you have a Pocrates who is one of the OGs of medicine, but he described it as a melancholic temperament. And this was as far back as 460 BCE, and that's where he used the Greek word dysthymia, which meant despondency. So you've got somebody that just looks like they are just checked out, despondent.

Now you fast forward to the 19th century, and you've got a German psychiatrist named Carl Friedrich Fleming, and he then dusted off the word dysthymia, and in 1844, he used it to make a distinction between mood disorders, And then other mental health conditions. And you've got 1863, Carl Ludwig Kahlbaum took it a step further and he described dysthymia as a chronic form of melancholia. So basically it is this long haul version of feeling down.

So by the time that the DSM II rolled around in 1968, Now, you've got long term depression and that was labeled as neurotic depression, which is such a trip because I think if you hear the word neurotic now, I would imagine it comes with some baggage, some real negative implications, but here's the thing, neurotic depression was considered more of a personality disorder. Then a condition with treatable symptoms.

So when things shifted with the DSM three in 1980, when chronic depression got a bit of a glow up and became dysthymic disorder, a term that acknowledged the condition as a disease was the way it was viewed, rather than this intrinsic flaw in your personality, a disorder, a personality disorder. And then in 2013, the DSM combines the stomach disorder with another diagnosis. Chronic major depression, and that gives us that persistent depressive disorder.

So here's where it gets really interesting, . What

is a personality disorder? Because I work with people that are, trying to determine if they or their spouse has things like narcissistic personality disorder or borderline personality disorder. Or antisocial personality disorder. So personality disorder is a mental health condition that affects the way a person thinks, feels, and behaves.

But it's not about having a bad personality, but it's rather, it's about the patterns of thinking and acting that do cause these problems in relationships or in your work or in your daily life, because those patterns are typically long term. They are ingrained, they're factory settings, and they don't typically change much over time.

Even if they create challenges, . They're different from temporary struggles like stress or sadness, and they're more deeply rooted and they're consistent over time. So people with a personality disorder probably don't even realize that their patterns are causing problems because that it feels normal to them. So I I came up with a, Couple of narratives. So what is it? What is it not? Meet Alex. So Alex has always had trouble keeping friendships.

Alex often feels that people really don't care about him. So they push people away before they can get hurt. So that pattern has been with Alex since they were a teenager. They find it hard to trust others. They often feel angry or misunderstood. Alex has been told that they're too sensitive or they're difficult, but they don't really understand. They don't see what's wrong. Because this is just how they've always been.

And they start to feel like, I just don't understand why nobody really understands me. So one day, Alex is talking to a therapist who helps them understand their consistent fear of being hurt or abandoned and how that might be something deeper, a personality disorder. So this therapist is going to try to explain that these patterns can be worked on with help, but it takes time and self awareness. But the problem is that if that is the case, it is just, it is what it feels like to be Alex.

It's not this thing that comes and goes, or something that Alex is aware of and tries to work on. It's this continual feeling of not really understanding. Because when I go into this world of emotional immaturity, or even on this spectrum of narcissistic traits and tendencies, that narcissistic person, or that incredibly emotionally immature person, Will not and cannot take ownership for anything that they have done that they view as wrong because then they immediately go to this.

If I admit this, my whole world falls apart and then you will leave me. So I didn't do it. You did it. Or, well, if I did do it, it's because you told me to do it and you may not remember it. But in that real time, that narcissistic person, that emotionally mature person is creating that new narrative in real time because it cannot be that they did anything wrong or you will abandon them.

There's our personality disorder because it does not matter what you say or do, they will not have that aha moment or that epiphany and you will drive yourself crazy trying to explain to them that but it's okay, it is okay that you did that, but they're saying, but I didn't. And I think that's why the significance of moving something that is this chronic long term depression away from it is a personality disorder into it's a mood disorder back to Alex.

, Alex's struggles are not about being mean or bad. It is about long term patterns and how they see the world, how they interact with others. And those patterns have made life harder for Alex in this scenario, now, what Alex's situation isn't. Alex doesn't just have a bad day or a personality quirk. For example, somebody having a bad day might snap at a friend, but they usually apologize and they move on.

A personality disorder on the other hand involves patterns that are so deeply ingrained and don't change easily, even when they cause problems. That personality disorder vibe is not about being a bad person. It's not about choosing to act a certain way. It's about patterns that have been shaped over time. So it just becomes reactionary, involuntary, and it often starts in childhood.

Or it becomes unpacked in the early teenage years, now with awareness and support, though, people like Alex can work on patterns and try to find healthier ways to cope. But the challenge there is that. They may just be learning how to interact with the world, but still not understanding why the world can be so difficult versus wanting to get rid of this discomfort, this pain, and just not really understanding why. When you get somebody in your office that really does want those tools.

Then they will often still have a fair amount of the, yeah, but we have, you don't understand, but at some point when it clicks, they just want to read everything, do everything. They just want to be better. They want to be the very best versions of them that they can be. And often I find that if people are incredibly emotionally immature, or even on that narcissistic trait and tendency scale, they're coming into therapy because they just want validation.

They want you to tell them that, well, it sounds like that's all you can do and you're doing everything you can. And what is so fascinating about that.

As a practicing therapist, is you're aware of somebody that's coming in saying, , tell me what I don't know that I don't even know, and I'll still admit that it's going to be difficult, and I may not follow through on the homework, and I'm going to come back in, and I'm going to assume that you are disappointed in me, Mr. Therapist, because I'm not getting better. Give me that person all day long, because we're going to figure this out.

Or it's the person that comes in and they're continually telling you about their struggles, their challenges, but how, no, I already did that. No, that's, I do. I do all the meditation. No, I've read that book. I am familiar with that. Because at that point then, anything that you're providing because they're not truly being curious becomes this attack surface. And at that point, Then what they're really looking for is validation. And that is often what comes from a session like that.

And people will say, but you need to push them more. Well, have you tried that? Have you sat in there in a therapy office and listen to this person and really tried to understand and get to know them and hear their familial patterns and see where they are struggling in their relationships in their life and want to help so desperately, which is a me thing as a therapist, but then that person is going to continually, you don't understand. I did. I've done that. You don't get it.

So at some point, it really is a man that does sound like, then it sounds like you've done everything you can do. And if the person really is very insecure, very immature, and they just are looking for validation, then what do they do? They walk out of that scenario, they walk out of that session, and now they feel validated. And so they feel like, okay, it, I am doing everything I can do, and it is everybody else's fault. And even the therapist agrees.

But I think what's so interesting is the therapist didn't agree. The therapist tried to bring awareness, tried to help with new tools, but when they were, yeah, budded for a consistent pattern of time. Now at that moment, then you start to realize that to the personality disordered person or the person who's incredibly emotionally immature, insecure, then they're not being open about the possibility that they could change.

And so then when you finally say, it sounds like you've done, you're doing everything you can do. You are no longer telling them what they're doing is wrong in their mind, because that is that version of emotional immaturity. It's this zero sum game. It's right or it's wrong. It's black or white, all or nothing. And it feels so much better for them to not be argued with or told they're wrong. So then when, when they hear This validation, it feels like agreeance.

So now they do feel like, well, the therapist agreed. Now the therapist realized that you are, they are looking for validation. It's so fascinating, but back to this persistent depressive disorder.

What does it even look like? So according to the DSM, it starts with a depressed mood that lingers for at least two years. Let's go with a rain analogy, it is a persistent emotional drizzle rather than a full on thunderstorm, but those skies are cloudy all day. And then kids and teens, they get a bit of a time break requiring only a year of mood changes. Though, if we're being honest, I think a lot of parents would swear that one year in kid time probably feels like two or three.

And then along with the constant low mood, at least two of these symptoms have to join the party. So you've got changes in appetite. What can be really interesting, it can be either eating everything or barely anything. Sleep troubles, too much or too little. Low energy or chronic fatigue, struggling with self esteem. Difficulty concentrating or making decisions, feelings of hopelessness. But wait, there's more.

So PDD often comes with bonus features like guilt and worry and avoiding social activities, which is so unfortunate because those are the very things that can cause someone to get a dose of vitamin C. Aka connection, but basically it can make the idea of even anything fun that the person wants to do feel pretty exhausting, which is one of those major signs of depression. Now, how it stands out from major depressive disorder.

So PDD is going to share a lot of symptoms with major depressive disorder or MDD. But the two just aren't quite the same because if you think of MDD as a sudden intense storm that shakes everything up for at least a couple of weeks. , whereas PDD is that dreary overcast weather that just lingers, but for years. So people with PDD might not hit the severity markers for MDD, but the duration of their symptoms is what really makes the diagnosis unique.

But that said, the two conditions aren't exclusive because somebody who has persistent depressive disorder can experience major depressive episodes on top of that chronic symptoms. So it's, it's like you've got this drizzle constantly, these gray skies, and every now and again, you've got a week or two of just a downpour. So that already pretty, pretty crummy weather and.

Persistent depressive disorder might not have the dramatic flair of some of the mental health conditions and I think that's one of the reasons I wanted to just bring awareness to it because it's just so low grade, it's so consistent and it, and the duration is so long, but that impact then can be profound because whether you know it is dysthymia or neurotic depression or the current DSM name, it is a reminder that chronic emotional struggles, they are just as

important to address as the acute ones. Because sometimes you're just that low grade buzz in the background of other people's experience or existence, and then they do start to just take you for granted. And it's hard because if you're experiencing this persistent depressive disorder, then you may not even have the energy or the awareness or the ability to then really speak up about what you need.

And then whether PDD's 2013 rebranding helped or hurt its public image, I think the goal is still the same, to help people understand what they're experiencing and to get the support they need to feel better, no matter how long their emotional forecast has been cloudy.

Let's look at some of the things that might cause persistent depressive disorder, and more importantly how do you treat and manage it? And spoiler alert, like most things in mental health, it is not as simple as pointing to one thing and saying, this is it.

Instead, I think it's important to note that depression in all its forms, including PDD, is like this stew, I was going to say tasty stew, probably not very tasty, Made up of a whole mix of biological and social and psychological ingredients. And nobody is quite sure of the exact recipe. I think that's the most important thing to recognize. But researchers have identified some key factors that seem to make the pot boil a little bit more.

For starters, depression of any kind tends to be a team effort between brain chemistry, genetics, life stressors. I think so much of it goes into the things that you were mapped with your, in your childhood. So it really does fall into the nature and nurture. Birth order and DNA abandonment and rejection, hopes and dreams, fears, the things that you've always wanted to do or not.

If you've had those opportunities to, if you have had a secure attachment with your kids, if you had a secure attachment with your caregiver, if you've generally had opportunities to, to do things throughout your life at school activities, who your friends have been and studies estimate that around 3 percent of people in Western countries at least will experience PDD at some point in their lives.

So that actually is pretty significant because that means that that percentage of people will go through this for at least a couple of years at some point in their lives and women are about twice as likely to be affected as men. And I, there's some belief that that has to do with everything from hormones and social pressures that those start to play into the mix here as well.

So biologically, there's, evidence that imbalances and neurotransmitters like serotonin, that those play a role in depression generally. And though the research specific to PDD is still limited. What we do know is that genetics seem to loom very large in PDD. So if your family tree has some PDD branches, your chances of developing it are higher than if we were talking about major depressive disorder. And I think what's really fascinating is the more we learn about the concepts of epigenetics.

And again, I will say probably a few more times, I'm not a doctor. I have a master's degree in counseling. I've been doing this for 20 years and I'm a human being. And I love the work that I do. And I have a lot of in the chair experience. Again, see the aforementioned 20 years. Some of these things will just be my opinion. And this is why I love acceptance and commitment therapy so much.

Because since you are the only version of you that's ever walked the face of the earth, you are going to think and feel the way you do because you do. And when someone else is telling you, well, this is what you should think and should feel. A, nobody likes to be shit on. And B. I forgot what B was, but I think it's probably something like you're going through life for the very first time. And so ultimately it is ideal for you to be able to figure out the things that matter to you.

But often we do need a little bit of a shove out of the nest. We do need a muse to interact with.

If we don't know if we even like playing sports, then it would be wonderful if we had this opportunity to try a sport and that might even cause us to realize that we want to be the coach or we want to be a cheerleader, want to be a, an equipment manager, or we see the guy who's sweeping the floor and all of a sudden we think, I really like things clean, but you, have to be able to do things in order to really learn more about yourself.

But on top of biology and genetics, certain personality traits like neuroticism, which is a tendency to worry or be overly emotional and chronic states of high anxiety can increase the risk.

And then, let us not forget stress. That is the unsung villain in so many mental health stories. Because when, when life keeps piling it on, the weight of it all can make PDD more likely to stick around.

And that's where we'll get into the world of acceptance and commitment therapy and even this concept of acceptance that at times I might have to accept the fact that there's a lot going on in my life. And that means I'm going to welcome all those things in without defense in their entirety, because if I'm continually trying to avoid things, then that could lead to more of these feelings of feeling stuck or feeling hopeless or feeling depressed.

I get to sit with people often that say, I don't know what's wrong with me. And I don't understand why I'm feeling the way I feel. , well, let's start from a place of, because it's the first time that it's you going through life as you. So check that out. And you're thinking and feeling the way you are because you are, you're not broken, you're human, and this is, how you are feeling.

But then when we review the game film and we go back a week or two or a few months, there's a lot that might be going on in your life. So then, of course, this is how you're feeling. There, there is nothing wrong. So you can step back and look at that in the context of all the stuff that's going on. Maybe there was a job loss. Maybe there's been some financial struggles or of our car crash, or is someone in your family that's close to you recently passed away.

So those things are going to cause us to feel. And when you have things that just stack up, then you can start to recognize that, okay, this is the first time I'm going through life as me. And that is a lot going on. And so I am feeling the way I am. And that's an amazing place to start from.

So how do we treat persistent depressive disorder? Thankfully, the toolbox for managing PDD is getting pretty well stocked. And the two heavy hitters are psychotherapy and medication. The psychotherapy piece, , is what I'm talking about now, which I'm a big fan of acceptance and commitment therapy.

And if anything, . If you're listening to this, if somebody forwarded this to you, or if you are starting to listen to podcasts or reading books or anything, articles online about, about depression, and this resonates with you a bit, then just start to go on that, train of thought.

And if you're open to seeing a therapist, then by all means, that is a wonderful place to start and you can bring them this information and say, this is maybe resonated with me, but I want to talk about the brain a little bit more. And I want to talk about medication. This is something I've wanted to talk about for a long time, and it's because I wanted to understand this more. So I'm going to, tell you a little bit of the way that I understand a lot of the ways that the medications work.

And I will continually say that while people have written the initials. when writing a check to me a time or two back in the day, I may have even photocopied a couple of them. I am not a doctor. So please consult your doctor for more information.

I reserve the right to absolutely be wrong, but let's, let's take a little journey into the brains, emotional chemistry lab where feel good chemicals like dopamine and serotonin and norepinephrine, those are the star players. And these are neurotransmitters and what neurotransmitters. are, they act as tiny little messengers and they take, they ferry these signals between brain cells and these neurotransmitters play a huge role in regulating your mood and your energy and your focus.

But when things get out of balance, it's like the lab goes on strike and then that's where depression or anxiety can sneak in. We talk about neurotransmitters, I think so often in the world of mental health and people just nod. Oh yeah, dopamine, serotonin, neurotransmitters, brain. Those are all words I know. But what are they? I mean, what does that even mean? How do these tiny messengers work to regulate mood and energy and focus?

Neurotransmitters they're chemical substances in the brain that help the neurons. And I think it's so important in my mind to picture the neurons in these little nerve cells, and they are communicating with each other, these little signals. They're like the brain's little postal service and they deliver messages from one neuron to another, and that keeps everything running. Hopefully. Smoothly. So the way the process works is there's a signal that's sent.

So a neuron, the sender, then it gets an electrical signal and it releases a neurotransmitter into the synapse, the tiny gap between the two neurons. You've probably seen the little pictures about that. And then the message is delivered. The neurotransmitter travels across the synapse. And it binds to these receptors on the next neuron, the receiver, and it's kind of like a little key fitting into a lock. And this tells the receiving neuron what to do next.

Send another signal, suppress an action, trigger a response. And then once that message is delivered, then that neurotransmitter is either broken down by enzymes or it's reabsorbed by the sender. And that is a process called reuptake. And if you are a psychology nerd or a therapy fan, you've probably heard about your antidepressants or selective serotonin reuptake inhibitors. There's that word reuptake and all of that's done to keep your brain system efficient.

Here's something that to me was a bit of a game changer and it helps me understand this part. So you hear this phrase reuptake inhibitor, but what does that even mean? This is a simple metaphor that I once heard and then I've, expanded on. And then we'll talk more about the chemicals and how they work. I promise, but this will help you understand what the heck is going on in your brain.

Think of it like watering a plant, because if you were to pour water into the soil and then immediately take a sponge or a syringe or something and suck that water back up, That would be like you were reuptaking the water. So the plant would not get enough time to absorb the moisture that it needed to grow. I currently travel between offices in California and Arizona, and I have a couple of plants in my California office and they have been around for quite a while. It's mind blowing to me.

And when I returned to California, the soil of one of my favorite plants is dry. . So if I immediately dump a ton of water into the soil, which I've done it, it goes right through it and it ends up in the, I guess I don't know if the plant world exactly what it's called, kind of looks like a drip pan in the bottom of the pot, but then I flooded the plant with too much of what it needs to thrive.

But now if I poured even the right amount of water, what that would be, but then if I immediately remove that water from the soil before I had a chance to get into the cells of the plant. A, I'm kind of a jerk. B, I kind of do think that plants low key know things and they probably haunt my dreams. But C, the plant would not continue to thrive and it would begin to atrophy and eventually it would die. And then it also would haunt me.

C, part B. But medications can act like removing the sponge trying to soak back up the water for a while so that the water can sink in and nourish the plant properly. And then there are these other types of medications that control the rate at which the water is distributed to the plant, ensuring that the plant won't be flooded with too much of the very thing that actually could provide it life. Let's go back to this concept of reuptake.

So imagine your brain is a big group chat, and the neurons, or the brain cells, are texting each other. So the neurotransmitters, like serotonin norepinephrine, those are the messages being sent. And when one neuron sends a neurotransmitter, it releases it into that tiny space between the two neurons called the synapse, kind of like hitting the send on a text. But now once the message has been delivered to the next neuron, the receiver, the first neuron now has a decision to make.

Do we let the message hang out in the synapse for a bit so it can be read and digested and understood, or we better unsend it? Take it back because we have to save it for later. You know what I mean? And sometimes your brain is a little bit of a jerk in itself and that it's like showing you this letter and it's like saying no, no. Go ahead and read this letter because it's awesome. It has a lot of great information on how to save your life.

And then you start reading it and you're starting to get excited. I'm like, Oh, this kind of makes sense. And then it pulls the letter away. And you say, I wasn't done reading it, but it was really good, but your brain, it doesn't even think it's being a jerk. And it thinks that it has this time limit it has to limit the amount of time that it shares the letter or the letter might suddenly disappear. So there's this game of kind of push and pull.

I'd really like to see more of the secrets to life that that letter seemed to, to have please. And part of our brain is saying, totally, I want you to have more of that because I am part of you after all. So here, Okay. Take another quick peek, but I need to ration how much of the letter that you see and it thinks it's right and you think you're right, but unfortunately, the part of you that saw the secrets of the universe on that letter can't get enough of the info on the letter.

So, what do you do? Start looking for it elsewhere, like in unhealthy ways, like overindulging in things like addictive substances, like corn, which I now understand this is one of the reasons why my videos are not as popular on YouTube because I have not said corn or corn ography. But on that note here's today's advertisement waiting until almost the end.

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Okay. And also follow me on social media at virtual couch on Instagram or at virtual couch on tick tock, or please, if you're listening to this, go find the YouTube channel, watch it there and then subscribe. I would be forever grateful. Okay. Back to the narrative. So there might be times or conditions where your brain says, okay, fine. You want to read this letter then? Yeah. You like the letter. Here, read it while I plaster it right on top of your face. How do you like that?

Or how about this? You can read the letter from the back of your throat as it crumples up the letter and it just shoves it down the old windpipe. So back to the text analogy. Reuptake is the unsending process, but bless your brain's heart, it thinks it's doing you a solid. So sometimes you might need some medication that will lovingly force your brain to let you read the text. All of the letter long enough that you can now have the information you need, these secrets of life.

Now, you still need to do something good with the information. I've long said that when my ADHD medication kicks in, it feels like hope. And then what do I do with that hope? Do I write a podcast script about medication or do I play the crap out of online bingo or watch YouTube or TikTok videos with such intense focus and pure joy? That it makes my morning. Or both. But let's also get a little bit more science y. Why is reuptake important?

Reuptake is a normal and necessary part of how the brain works. Because without it, neurotransmitters could build up in the synapse and it will flood the whole system, and that would be chaotic. So reuptake makes sure that the brain doesn't waste neurotransmitters and it keeps everything running smoothly by recycling them when they're no longer needed. Here's the catch.

Sometimes the brain pulls back neurotransmitters too quickly, and that will mean there's not enough serotonin left in the synapse to regulate your mood. Or there's too little dopamine to spark motivation. So when reuptake happens too fast or too often, it's like cutting off a conversation before the other person has time to respond. The message doesn't have enough time to do its job, which can lead to symptoms of depression, anxiety, low energy.

And so why then are so many of these medications reuptake inhibitors? This is where the medication comes into play because you've got a reuptake inhibitor like a SSRI, selective serotonin reuptake inhibitor, or you've got a SNRI, a selective norepinephrine reuptake inhibitor, and so they'll act like a pause button on the reuptake. They slow the process down so that gives the neurotransmitters more time to stay in the synapse and deliver their message.

So serotonin reuptake inhibitors, they're going to leave a little more serotonin in the synapse. So that will give you a better chance to improve your mood. Norepinephrine reuptake inhibitors, they help boost energy and focus. Dopamine reuptake inhibitors, they increase motivation and the ability to experience pleasure.

So in really simple terms, a reuptake inhibitor, it makes sure your brain doesn't snatch back the feel good chemicals too quickly and it allows them to do their job and then really help you feel better. Because the concept of like reuptake itself is normal. It's how your brain regulates neurotransmitters, but that issue arises when it happens too fast or it's too often.

And that's when we can talk about things like, our chemicals in our brain are off and that can throw off the balance of all the chemicals. And so medications can help restore that balance by slowing the whole reuptake process just enough to let those neurotransmitters in your brain work their magic. So if I go back to, I'll even simplify that metaphor more. Think of it like watering a plant.

If you pour water into the soil and immediately suck it all back up with a sponge, reuptake, then the plant doesn't get enough time to absorb the moisture that it needs to grow. And so medications act like removing the sponge for a while so the water can sink in and it'll nourish the plant properly. Reuptake is part of a normal healthy brain system, but if it's too efficient or it happens too quickly, then it can cause some challenges.

And so those reuptake inhibitors, those medications, they do slow things down, give your brain the time it needs to use the neurotransmitters to regulate your mood and give you energy and focus. And it's it's like your brain's messaging system gets a chance to catch his breath. And and what is so amazing about this whole concept is how cool your body is that, yeah, it might not be perfectly handling the system of. Of moving these neurotransmitters around.

But just think about the miracle of that, that intricate signaling system. I mean, that's the foundation of the way the brain and by extension, your whole body operates. So when the neurotransmitters are working well, you feel pretty emotionally stable and you're resilient and you have the energy and the motivation to tackle like daily tasks and you can focus on what's important without maybe feeling as overwhelmed or distracted and understanding that process.

I think also helps explain why treatments like medication or therapy or lifestyle changes are aimed at improving communication in the brain. It's not. about fixing a broken brain, but it's given it the tools to communicate better. So you can feel more like yourself. So you got serotonin and I think it's just interesting. It's more of a mood stabilizer. If you think about it, serotonin, it's like the brain's chill pill helps regulate mood and sleep, appetite, digestion.

It plays a big role in feelings of happiness and emotional stability. And then Low serotonin levels are often linked to depression and anxiety and irritability. So it's like the volume on your emotional resilience gets turned way down. Or you got dopamine, which is the one I think we hear a lot about. I don't know, dopamine or serotonin, one and two in the leaderboard. More, but dopamine is more like this motivation or focus molecule. It's all about reward and motivations. What gives you that?

I did it feeling, you know, when you check off the to do list, which I've heard about doing before, but if you crush a workout or you, accomplish something. So low dopamine can lead to feelings of apathy, low energy, even difficulty experiencing any pleasure, the symptom called anhedonia. And it's like the brain's reward system that goes offline. And so then certain medications can increase the amount of dopamine, helping you restore motivation and energy.

And then you got this norepinephrine, which I think is the one that needs a new PR team, but that's kind of like adrenaline is calmer sibling. So it helps with focus and alertness and responding to stress. And some of the newer, I believe ADHD medications are looking more at norepinephrine, but low levels can lead to fatigue, lack of concentration, general sense of the kind of the blahs. But then too much norepinephrine can heighten your anxiety, make you feel a little bit jumpy and on edge.

But there's a couple other neurotransmitters that don't get much play at all. One's called GABA. And it's viewed a little bit as a calming agent. It's like the brain's natural tranquilizer. It kind of helps calm the nervous system down. It can reduce anxiety. And then you've got one called glutamate and that's the, accelerator glutamate. It's this excitatory neurotransmitter and it helps with learning and memory. And then, so imbalances in glutamate will often.

Also contribute to depression, particularly when the brain's stuck in this low energy state. And then now you can look at all of these things and it's, it's a symphony, serotonin, setting the tone, keeping things balanced and stable. You got dopamine, adding a little flare driving rewards and excitement, norepinephrine keeps the rhythm at the focus, the energy. Then you got a GABA and glutamate. They're ensuring the tempo, make sure that it doesn't get too slow or too fast.

So when one section is out of tune, it can throw the whole performance off. So things like medications, they can aim to restore harmony and they can either increase certain neurotransmitters or adjust their activity or help the brain use them more efficiently. And I want to take the chance here again to say, call upon my emotional baseline theory.

And when people feel so down, so low that they feel like they don't even know how to access the tools that they may be aware of, they might be even going to therapy, but they just can't do the things that they believe they should do. Your emotional baseline may be so low that taking medication might help bump that baseline up just enough to access the tools and then the tools might be, it might be meditation. It might be reaching out and connecting with friends.

It might be going on a walk, getting to the gym. And then once you start doing those things, then you're going to continue to raise your emotional baseline. And at that point, you may want to then say, all right, maybe I don't want to keep taking the medication or taking a medication, got you to the place where you could access the tools.

But I do want to say for those who are reluctant to take medication, if meds aren't your jam, there are plenty of ways that are believed to naturally encourage better brain chemistry, exercise, regular physical activity, boost dopamine, serotonin, norepinephrine, and then it reduces stress hormones like cortisol. So exercise is a full brain workout. Even a 20 minute walk can make a difference.

And then sleep rest is so essential for neurotransmitter production and regulation, and it clears all the gunk out of your brain as well. So you really. Would help if you aim for consistent sleep patterns and get enough hours to recharge and diet, I don't want to mention that one. You can boost it with foods that are rich. And it's funny, we're hitting Thanksgiving tryptophan, turkey, eggs, salmon, dopamine, you can eat protein, rich foods.

Chicken, beans, nuts, you got omega threes found in fatty fish, flax seeds, those support brain health. And then you got mindfulness and meditation. There's a belief those practices can even increase GABA and reduce anxiety and help calm the brain's alarm system. But again, I am not a doctor, but I do believe social connection sure helps. Spending time with loved ones or even pets can boost your oxytocin, that cuddle hormone, the bonding hormone, and help you regulate your mood.

And then therapy, especially acceptance and commitment therapy, can help you change the relationship you have with your thoughts and over time help you change your interior landscape of your mind or what it feels like to be you. And sunlight and nature. Exposure to sunlight increases serotonin. Being in nature has been shown to reduce stress and improve your mood.

Back to dysthymia. So we've got dysthymia, officially referred to as persistent depressive disorder, and I thought there were a couple of things that were interesting to share and then we'll wrap things up. . So dysthymia, I think it's just important to note that it does tend to be less intense.

But as we mentioned last longer, often two years or more in adults, some people view it almost as a high functioning depression because a lot of people with dysthymia appear to be functioning well in their daily lives, but they're just carrying this constant low grade emotional heaviness that affects their quality of life. And some of the things I think are just interesting to share while we're here is there's a concept called the Eeyore syndrome.

Because a lot of people with dysthymia might feel like they, they've always just been a little down or they're naturally pessimistic. They often assume it's just their personality rather than recognizing that it is a treatable mental health condition.

And so the hidden struggles I think that come with this is people that, that do experience dysthymia again or persistent depressive disorder can feel overlooked or invalidated because their symptoms don't appear as acute or as intense as somebody With major depression and it's interesting because it's almost like their perseverance of continuing to do and be, even though they feel so down often masks the whole severity of their emotional pain.

So that'll lead to misconceptions about how hard the struggle actually is. So it almost becomes this burden of. of this chronicity of it being chronic. Dysthymia, I heard it once mentioned that it's this emotional erosion because it's this persistent undercurrent of sadness and hopelessness and fatigue that can wear people down over time. And so then people might start to develop coping mechanisms that reinforce the disorder, like avoiding deep connections to avoid emotional vulnerability.

And then it has a pretty high rate of what's called comorbidity. Where it can also be found with other things like anxiety disorders, substance abuse there are personality traits that are tied to perfectionism or self criticism. So a lot of people with dysthymia experience what some people call double depression where they might have bouts of major depression on top of this just chronic low mood.

And it breaks my heart because I think what a lot of people they just don't understand when somebody has something like dysthymia that some cultures they do, they, they normalize chronic sadness, they just say it's life stress resilience rather than recognizing it as something that is a mental health condition. It's also sometimes known as smiling depression. It's a common phenomenon where people appear outwardly. Okay. But they're battling like this inner turmoil, these inner demons.

And one of the hallmarks of dysthymia is irritability or emotional detachment and that can strain relationships because partners or friends might interpret these, the behaviors as a lack of interest rather than symptoms of the condition. It, it is believed that it's most likely tied to an overactive stress response. And then that leads to these physical symptoms like headaches and digestive issues and poor sleep.

And. And then we want to address this because when you start to look at the neurons that fire together, wire together, there's some thoughts that maybe chronic low grade depression starts to lead to structural brain changes, like, reduced hippocampus volume, which underscores like this importance of treating it and it's never too late. People who live with dysthymia, they learn to adapt. They often become incredibly resourceful in managing their symptoms.

They develop habits that allow them to keep going despite these emotional struggles. But this is where I think the concepts of things like radical acceptance or how people embrace their condition as part of their identity, and they can over time use it to be a motivator for personal growth.

I really think acceptance and commitment therapy is Probably the most helpful modality for dysthymia because it fosters a sense of meaning and then values driven action, even though you're uncomfortable because you're accepting the fact that I am currently uncomfortable. So the fact that I'm not trying to avoid the discomfort because it's there because this has been persistent and going on for a long time.

And so now the job is for me to, now that I've accepted it, let me figure out what my values are. Let me start to find that sense of purpose and then take action on it. And yes, it's going to be, it's going to be a bit of a journey. We'll call it.

But I think that it would be really helpful if this ring true to you in any way, no, hear me, hear me, you are the only version of you, it's ever walked the face of the earth. You're okay. You really are. You didn't know what you didn't know. And so the more that you are understanding and knowing, it's still probably going to feel pretty overwhelming. And that's actually perfectly normal because when we go from, we didn't know what we didn't know.

And now we're starting to understand or starting to feel like maybe I'm. I have an idea of something I might be struggling with that I can feel pretty overwhelming too, because now you know, you're not really sure what to do. And that's one of the longest places to, to live in is this area of, I'm just not exactly sure what to do. Sometimes I will do things, they'll feel better, but a lot of times I don't. And that's normal.

And you'll eventually move into this category of, you know, I'm actually doing things more than I used to, and there are times where I feel good. And eventually, I'll just move into this place of I have just, I've changed. I've become some, someone new, someone who has now taken this dysthymia, this persistent depressive disorder. And then it has been the thing that has caused me to finally say, I gotta do something.

And that does become a journey, but I guarantee if you stay on the journey that you will find a completely new version of yourself on the other end. And sure, there will be times where you'll wish you would have figured this out sooner, but then there, you're there and you're, starting to be more present. Enjoy more things about life. Sure, there will be moments where you'll still feel the old pang of this persistent depressive disorder.

This. familiar feeling, but then that very feeling is the thing that will cue you in on turning to some value based activity or goal. If you have questions, please reach out. Please Google low cost counseling near you. If you can't afford a therapist and but you definitely deserve to be the very best version of you. If you're hearing this before Thanksgiving, I hope you have a very happy Thanksgiving. And if you're hearing it after, I hope it was great. And I appreciate you being here.

I will see you next time on the virtual couch, taking us out per usual, the wonderful, the talented Aurora Florence with her song, it's wonderful. Have a great week and we'll see you next time on the virtual couch.