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.

HoboJacket’s Casual Classism: Ethical Humor and Objectifying the Homeless

Elite college students being snobby and idiotic isn’t really newsworthy, but a group of MIT students went above and beyond the standard this past week.

The students thought it’d be funny to give local homeless people jackets from Caltech, MIT’s rival, in order to “show the true value of a Caltech degree.” And then, to practice their coding skills, they actually made a website called HoboJacket where you can donate to do just that.

In a way, it’s a brilliant idea. The students get to practice valuable skills and diss a rival school while simultaneously performing a nominally charitable act. And then, just as Tucker Max did with his solipsistic Planned Parenthood donation, they and their defenders can claim that anyone who disagrees with any part of their methods doesn’t really care about the homeless, puts ideology before practicality, and, worst of all, can’t take a joke.

The criticism, of course, was plentiful. The students literally used homeless people as props to make a (fairly inane and classist) point, and while the joke was supposed to be at Caltech students’ expense, what it really accomplishes is objectifying homeless people. As Laura Beck at Jezebel wrote, “Being homeless already carries enough social shame, it doesn’t need your help. The barb at the end of the particular stick you’ve built is that homeless people are gross and dirty and making them wear clothes with rivals logos somehow degrades the logo.”

This, of course, is where a certain type of liberal comes out and protests that “Yeah well at least it’s getting them jackets/what are you complaining about/would you rather they went without clothes/if that’s what it takes to get people to donate then that’s just how it works.”

Raising money is hard. Duh. Sometimes gimmicks are necessary. Sometimes these gimmicks will be controversial. However, I believe that ethical humor is humor that punches up, not down, and I believe that if you can’t do something ethically, you shouldn’t be doing it. Leave it to someone who can.

And nevertheless, many non-profits and charities are able to solicit donations without exploiting existing social inequalities. If you really believe that you need to use marginalized people as props to attract attention to your cause because “that’s just how it works,” that probably says more about you than it does about the psychology of charitable giving.

It is not an exaggeration to suggest that we objectify and dehumanize the homeless. A research study that I was coincidentally assigned to present in one of my neuroscience classes yesterday comes to this conclusion*. The researchers scanned people’s brains with an fMRI machine as they looked at photos of different types of people–the elderly, the rich, the disabled, the homeless. Only for homeless people and drug addicts did the medial prefrontal cortex–a part of the brain that activates when analyzing people as opposed to objects–fail to activate.

Before you rush to give this some sort of evolutionary explanation, remember the way our brain functions is not set in stone by genetics and biology. We are probably not born viewing homeless people as any different from other kinds of people. That’s something we learn, and that’s something to which the brain adapts. And even if we were born that way, the cool thing about being a sentient being is that you can choose to override the signals your brain sends you. That’s why people can choose to be celibate, go on hunger strikes, become doctors and treat sick people, and overcome “natural” fears like snakes and heights.

My point in discussing this study is not to excuse the MIT students’ actions by claiming that they were compelled to do what they did because that’s the way their brains function. Rather, it’s to show that this is not an “isolated incident,” as people love to claim when someone does something insensitive and awful. The objectification of homeless people is real and supported by evidence, so casting this as a silly college prank is inaccurate and socially irresponsible.

Although the students initially dismissed criticism of their project by comparing it to Facebook’s origins as a tool to objectify women (an overly ambitious comparison, I’d say), they eventually understood what they did wrong, apologized, and took the site down. Honestly, that’s great, and they deserve credit for listening to their critics.

But I still wanted to write about this because, as I mentioned, it’s not an isolated incident. This particular type of prank might be, but the prejudice inherent in it is not. It’s worth discussing. It sheds light on how we view the homeless, which should in turn inform how we attempt to help them.

Of course, in my view, donating clothing to homeless people is kind and important but does not address the roots of the problem. The problem, unfortunately, is structural, and we can’t really talk about homelessness without talking about the pervasive economic inequality that our society has.

*Harris, L.T. & Fiske, S.T. (2006). Dehumanizing the lowest of the low: Neuroimaging responses to extreme out-groups. Psychological Science, 17(10), 847-53.