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Jul 17 2014

A Primer On Atypical Depression

At CONvergence two weeks ago, I and a few other people did a panel on myths about mental illness. It was really great, and I hope that there will be a video of it up eventually. At one point, I tangentially mentioned atypical depression, a type of depression that is sometimes contrasted with melancholic depression, or the “typical” kind.

Atypical depression is the type that I have, and that might be part of the reason it took me something like seven years to realize that I had depression at all. A few people have since told me that they didn’t even realize atypical depression was a thing. So I decided to write a brief overview of it in the hopes that more people who don’t have a name for what they’re going through might find a name for it.

There are some “classic” depression symptoms that most people think of when they think of depression: being numb or sad most of the time, being unable to take joy in things you used to like, insomnia, and loss of appetite and weight. You think of the person lying in bed unable to care about or take pleasure in anything.

Atypical depression has a rather different set of features. Instead of insomnia, you may have hypersomnia (oversleeping). People with atypical depression might regularly need to sleep 10 or 12 or even more hours. Instead of loss of appetite, you may overeat and/or gain weight. Instead of being numb or just uniformly sad, you have high mood reactivity, or mood swings. You may find that you’re able to enjoy things and feel happy when things are going very well, but as soon as things are neutral or even just a little bit bad, you feel horrible again. There are two other symptoms that are sometimes present: leaden paralysis, or the feeling that your limbs are very heavy and difficult to move, and high rejection sensitivity, which means being overly concerned about people not liking you or rejecting you, to the point that it impairs your social functioning.

Unsurprisingly, these different sets of symptoms mean that different types of antidepressants may work best for each type. I will quote Wikipedia here, since it’s sourced and there’s no good reason to rephrase it:

Medication response differs between chronic atypical depression and acute melancholic depression. Some studies[4] suggest that the older class of antidepressants, monoamine oxidase inhibitors (MAOIs), may be more effective at treating atypical depression. While the more modern SSRIs and SNRIs are usually quite effective in this illness, the tricyclic antidepressants typically are not.[1] The wakefulness-promoting agent Modafinil has shown considerable effect in combating atypical depression, maintaining this effect even after discontinuation of treatment. [5]

I don’t know how useful this information is to you if you think you may have atypical depression, but at least now you know that if your symptoms fit this pattern but your psychiatrist prescribes you a tricyclic antidepressant without further explanation, it might be worth bringing up this research. In addition, if SSRIs haven’t been working for you, you might ask your psychiatrist about trying MAOIs rather than a different SSRI or a higher dose of the same one.

In terms of therapy, I can’t seem to find any studies on the effectiveness of different types of therapy on the different types of depression (that may be because Google Scholar is actually a terrible search engine), but my educated guess would be that dialectical behavior therapy (DBT) would be extra helpful for atypical depression as opposed to melancholic depression. DBT is a type of therapy developed specifically to treat borderline personality disorder, which involves lots of mood swings, rejection sensitivity, and general troubles with managing emotions. DBT contains a lot of the same techniques as cognitive-behavioral therapy (CBT; the standard of evidence-based treatment), but it also emphasizes mindfulness and learning to cope with strong emotions. Atypical depression, with its mood swings and interpersonal issues, might be especially amenable to it.

To the extent that psychodynamic therapy is effective (actually, plenty of studies suggest that it might be), it might also be more effective on atypical depression than other approaches. Atypical depression tends to have an earlier onset, and people may experience it as an aspect of their personality that is rooted deeply in their life experiences. When practiced well, psychodynamic therapy may be useful for resolving these issues. But none of this is to say that standard CBT should not be tried.

During my senior year of college, I asked a professor who studies the neuropsychology of mood disorders whether or not he knew of any research on neurological differences between atypical and melancholic depression. After all, there’s been plenty of research on how depression affects the brain–in terms of active brain regions, neurogenesis (growth of new neurons) in various regions, and so on. Were all these studies really done using patients who might’ve had what looks like two nearly-completely different illnesses? Apparently. My professor wasn’t aware of any such studies, and I’ve only found one myself: some research that examined which hemisphere of the brain responds more to a particular face test, and in atypical depression patients, the right hemisphere was much more active than it was in melancholic depression patients and in non-depressed controls. The authors write, “This is further evidence that atypical depression is a biologically distinct subtype and underscores the importance of this diagnostic distinction for neurophysiologic studies.”

There also seems to be some evidence that atypical depression in particular is linked to thyroid dysfunction, which may explain some of the physical symptoms. However, the results seem to be rather complicated and confusing, and it’s definitely not a simple causative link.

Although the diagnostic criteria for depression contain both sets of symptom patterns and there’s even a special indicator for “atypical features,” the popular conception of depression is of the melancholic type, not the atypical type. This means that many people, believing that depression necessarily means “being completely miserable all of the time always,” may not realize that they might have depression and can benefit from treatment.

Atypical depression presents a classic boiling-frog problem. Because you are in fact capable of feeling happy for short or medium stretches of time, it can take a serious increase in symptom severity to realize that there’s anything wrong. Incidentally, as I mentioned, atypical depression also tends to have an earlier onset than melancholic depression, which means that you may spend your entire post-childhood life that way. For some people, certainly for me, it felt like it was “just my personality.” To make things even more confusing, the rejection sensitivity tends to be present even during periods of time when the rest of the symptoms are in remission. But when it comes to mental health, nothing is ever really “just your personality” if you don’t want it to be.

Hopefully, this overview will help people–at least the people who read this blog–broaden their awareness of what depression is. If there’s anything I missed in terms of research, by the way, please let me know. As I mentioned, my Google Scholar-fu is much worse than my Google-fu.

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  1. 1
    Improbable Joe, bearer of the Official SpokesGuitar

    Depression is a sneaky demon, as a friend of mine told me a few days ago. I’ve got characteristics of major depression and atypical depression… and I’m guessing it is harder to deal with than the “pure” major depression. People expect you to feel down all the time, and when you feel OK they think you’re “done being depressed”.

  2. 2
    knopfspiel

    Whoa… I totally find myself in this.
    I may have had atypical depression for the last eight years. I only recently realised that there must be something wrong, but then I looked at the symptoms of depression: “Oh – insomnia. Well I definitly don’t have this, I sleep much too long all the time.”

    Thank you vERY much for this posting. You may have reduced the time I still need (doing needless worrying and procrastinating) before I go to a therapy by a factor of five. :-)

  3. 3
    Beatrice, an amateur cynic looking for a happy thought

    Interesting.
    After years or being accused I’m always in a bad mood (alternating between numb and angry, mostly), of feeling overwhelmingly sad and sometimes having thougths about suicide, I only realized that I’m probably depressed when I started hanging around Pharyngula. People talked openly about their depression, or other issues, and I figured that what I was feeling wasn’t just “something” about me, but depression.

    My life recently took a great turn, and miraculously, I’m feeling good a lot of the time. It’s pretty unbelievable, my friends noticed that this is the first time in a long time that I look happy.
    But what about the depression?
    Thoughts about suicide still sometimes come and go. I deal with them with almost something like relief. If things get bad, that’s a way out. I’m ok having that “safety line”, and I can usually not linger on these thoughts for long.

    Since I’m better, does that mean I actually was never depressed, just very sad?

    It’s difficult to believe, when I look back at my childhood and early twenties. Yes, some things in my life were bad, and I had good reasons to feel sad, but I don’t think that was all. People get sad, but that shouldn’t last for years (not counting short periods of being “kinda ok” or at least not feeling like the world is crashign on you).
    The bad times still sometimes emerge, they are just not as bad as they used to be.

    What you write about atypical depression sounds very much like me.
    I dunno.
    Maybe it’s just confirmation bias, since this fits my fears of depression (deep sadness?) comming back when I least expect.

    I still can’t say I’m happy. I’m not sure I know how to be happy or even what happy is. But I’m content. It’s probably the best I’ve ever been. Again, can see this as a symptom or just my character? It’s really confusing.

    Sorry, just throwing my thoughts out here, since your post resonated so much with the things I’m trying to find answers to.

  4. 4
    J B

    This seems like a sort of combination of depression and anxiety. I can chase diagnoses till the cows come home personally, and could get merit badges for PTSD, ADD (without the H), and anxiety if I wanted to. It gets rather frustrating dealing with the interactions of all these things and trying to get effective treatment.

    That said, I really appreciate your transparency here–I think it’s having a good effect on my own struggle, and I plan to share this well thought-out piece with my therapist. Thanks!

  5. 5
    asa

    I can really identify with the sense that my depression was a part of my personality. I got dysthymia first and it was undiagnosed until I was 21. I actually thought that that was just what happened when people went through puberty, that I was no longer able to think like I did when I was a kid, and that was it, I was just a sad, lazy person who didn’t really like things. When my medication started working the first time, i was really angry, because there was the sense that I had wasted 10 years of my life being this way. I’m also very good at “acting normal” maybe because of the social anxiety, people mistake the depression for aloofness and stoicism, and i evaded diagnosis by several therapists.

    I’ve got a really odd type of depression that seems to be half between atypical and melancholic and it baffles both my therapist and my psychiatrist. I get the oversleeping but with no appetite, rejection sensitivity but that could be due to social anxiety, and my mood improves but sporadically for specific things. The modafinil thing is interesting – i take a caffeine pill to get my meds working, interesting that it’s also helpful for depersonalization disorder as ive got that too. Its really unfortunate that most depression meds put you to sleep, I do not need to be doing more of that.

  6. 6
    highlyeccentric

    Huh. Does the mood reactivity result in difficulty differentiating between atypical depression and bipolar II? I know my mood patterns keep causing doctors to screen me more carefully for bipolar (i always come up clear), but I’ve never seen a description of atypical depression before.

    Can I ask what your source for the diagnostic ‘atypical depression’ is? Is it a separate DSM entry? I’ve only seen the breakdowns melancholic/non-melancholic/psychotic before. (Oooh. Looks like The Black Dog have added atypical since last I checked.)

    1. 6.1
      Miri, Professional Fun-Ruiner

      I’ve actually heard from a therapist that clinicians making diagnoses are likely to miss bipolar II, but I’m sure false positives happen too. That said, the criteria for bipolar II are pretty specific and most clinicians would probably stay away from calling normal mood improvement “mania.” Mood reactivity doesn’t necessarily mean abnormally high/energetic moods; it just means that moods change very quickly in response to very little. For instance, I can very quickly become happy like a normal person might be in response to something fun or pleasant.

      I can’t link to the DSM itself since it isn’t publicly available, but here’s a description of the different depression specifiers, including atypical. When writing a diagnosis, a clinician might say something like “major depressive disorder, with atypical features.”

  7. 7
    Dee Emarr

    Wow. Thank you for posting this. I’ve known I had depression, but that list of qualities/symptoms fits me to a tee. I’ve been on an SSRI for almost a year, and it hasn’t helped much. Or rather, it petered out very quickly. And sometimes I feel okay for a day or two, but then i forget to do some tiny simple task at work that has like no repercussions and suddenly everything is wrong. I was beginning to think it was just me. God, I’m basically just repeating what you said, but… Jesus. Thank you. Just… Thank you.

  1. 8
    Monday Miscellany: Playgrounds, Primers, Pleiades | Gruntled & Hinged

    […] 3. Look, a linkdump on excellent depression writing. First, a primer on atypical depression. […]

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