When Depression Turns Deadly: The Mask Men Wear – Part 1

By Stephen J. Johnson, Ph.D.


In  this  first  part  of  my  three­part  series  on  depression  titled,  ​When  Depression  Turns Deadly:  The  Mask  Men  Wear​ ,  I  focus  more  specifically  on  the  hidden  depression  in men  and how  to  recognize it before  it  ravages  your  life.  The tragic loss  of a loved one by suicide is  often the  end result of a life long battle with unremitting depression.  Learn how  to  recognize  the  signs  and  treat  the  problem  before  it’s  too  late.  In  Part  II, Depression  in  Men   and  Women:  Recognizing  and  Understanding  the  Condition​ ,  I discuss  the two  main  forms  of  depression,  the causes and common symptoms of Major Depressive  Disorder as  distinguished from Persistent Depressive Disorder (Dysthymia), its  occurrence  in men and  women,  how depression  can turn  violent and  what  needs to be done  to weatherproof  your  life as a  hedge  against the condition.  In the third  part of the  series,  I  provide  information  on  childhood Disruptive Mood Dysregulation Disorder, Bipolar  and   Cyclothymic  Disorders,  a  self­evaluation  depression  check­list,  standard medical  and alternative treatment  modalities, and  how to  help  yourself  and  others heal from the condition.

With  an  intention  to  provide  some  of  the  salient  features  of  depression   to  help  the reader  to  more  readily  recognize  and  distinguish  the  condition,  I  am  synthesizing  in some  information  from  the  Diagnostic and Statistical Manual of Mental Disorders (DSM) that  is  essentially  the  clinical  bible  that  mental  health  practitioners  utilize.  The  fifth edition  of  the DSM  was published  in 2013  and  is a vital resource for understanding and diagnosing  mental  disorders.  Since it is  not  my intention  to provide  a  complete  clinical analysis of  the  conditions  mentioned  herewith I  recommend that  for further and more in depth clinical information please refer to the DSM­5.

Are You Feeling Overwhelmed?

If so,  you’re not  alone!  “​ Overwhelmed​ ”  is the word I hear echoed by people more often these  days  than  in  past  years.  Is that  your experience?  Consider for  a  moment  what word sums up what  you  want  most these days?  If  you  said “​ Relief,​ ”  you’ve landed on the word that expresses what many people need more of and yet find most lacking.

It’s  fairly  evident that  stress  is increasing in  our  lives  in dramatic  proportion to the more calm and  serene  states  that allow  for rest, relaxation and peace of mind.  In many ways the  world  has  become  safer;  but  in many  ways  it  doesn’t  feel safer.  And, the imminent threat of  some  impending  calamity causes a  pervasive  state of  agitation.  We are living in ​the age of anxiety​.

In  addition  to what causes  our  personal stresses, we  carry in  the back of our minds the worrisome  concerns  about  when  the  big  earthquake  will  occur;  or  whether  our  plane flight  will  get  us  to   our  destination  in  one  piece; or  whether  our  children  will  be  safe  in school  today; or  whether  I  may encounter some irate guy brandishing an AK-47 assault rifle  while  I’m  out  and   about;  or  whether  the  world­wide threat of  savage terrorism will once again impact our homeland.

Marc  Schoen,  Ph.D.  in  his  book,  ​ Your  Survival  Instinct  is  Killing  You,  refers  to  a pervasive  state  of   underlying  uneasiness  he  calls  “​Agitance​,  a  chronic  state  of misalignment  in  which  we  feel  flustered,  on  edge,   unstrung,  unnerved,  tense,  and unable to relax.”

Unremitting  stress  undoubtedly  fuels  the  epidemic  of  anxiety  and  depression  that  has become endemic  to our society in modern times. Jed Diamond, Ph.D., author of ​Stress Relief  for  Men:  How  to   Use  the  Revolutionary  Tools  of  Energy  Healing  to  Live  Well​, states  that,  “Depression  is  one  of  the  most  serious  and  controversial  topics  in  health today. By  the  year 2020, depression will be the 2nd most common health  problem in the world  after  heart  disease  and  studies  show  depression  is  a  contributory  factor  to  fatal coronary  disease.  Billions  of  dollars  are  spent  every  year  on  antidepressants  yet  the rates of depression keep increasing.”

Are you Depressed?

I heard it once said: Man goes to doctor.

Says he’s depressed. Says life is harsh and cruel.

Say he feels all alone in a threatening world.

Doctor says, “Treatment is simple.

The great clown Pagliacci is in town tonight.

Go see him. That should pick you up.

Man bursts into tears.

He says, “But doctor . . .  I am Pagliacci.”

Robin Williams (1951­2014)

The  tragic  death by suicide  of the  iconic  Robin Williams  has  brought  depression out of the  shadows  and  into  the  light  of  day.  According  to  depression  statistics  from  the Centers  for Disease  Control  and Prevention  (CDC),  about 9 percent of adult Americans have  feelings  of  hopelessness,  despondency,  and/or  guilt that  generate a diagnosis  of depression.

At  any  given  time,  about  3  percent  of  adults  have  major  depression,  also  known  as major  depressive  disorder  (MDD), a long­lasting  and severe form of  depression. In fact, major  depression  is  the  leading  cause  of  disability  for Americans  between the  ages of 15  and  44,  according  to  the  CDC.  Understanding  these  very  real depression  statistics helps paint a fuller picture of the impact of depression in America.

Generally  speaking,  depression  may  be  described  as  feeling  sad,  blue,  unhappy, miserable,  or  down  in  the  dumps.  Most  of  us  feel  this  way   at  one  time  or  another  for short  periods.  This  is  referred  to  as  ​Exogenous  Depression​.  But  when  it  becomes more  acute  and  returns  with  increasing  vengeance  throughout  one’s   life  it  can  turn deadly.  This form of the condition is called ​Endogenous or Clinical Depression​.

In  this  case,  depression must  be  considered  a  serious  medical  illness that  involves  the brain.  When it’s  pervasive It’s more  than  just  a  feeling  of being “down in  the  dumps” or “blue”  for  a  few  days.  If  you  are  one  of  the  more  than  20 million  people  in the United States  who  have  clinical  depression,  the  feelings  do  not  go  away.  They  persist  and interfere with your everyday life. Symptoms can include
● Sadness
● Loss of interest or pleasure in activities you used to enjoy
● Change in weight
● Difficulty sleeping or oversleeping
● Energy loss
● Feelings of worthlessness
● Thoughts of death or suicide.

It  is  estimated  that   there  are  about  39,000  suicides  a  year  in  America.  Among Americans age  34­64, the suicide rate has increased almost 30% since 2000, and it has been  trending  upwards  for  American  women  as  well.   ​In  the  U.S.  the  suicide  rate  for males  is  4  to  18  times   higher  than  it  is  for  females,  increasing  dramatically  with  age. Men  between  the  ages  of  65  and  85  kill  themselves  almost  10  times  more  frequently than  do  women  of the  same  age,  especially following a divorce.  Veterans now commit suicide at a rate of 22 a day; that’s almost 1 per hour.

In  Britain,  suicide  is   the  leading  cause  of  death  among  males.    “There  are  more than one million  people  who  die by suicide each year in the world, which is more people than those  who  die from war,  terrorist  attacks  and homicides every year. So more people kill themselves than are killed by other people,” says Lanny Berman, Ph.D., president of the International  Association  for  Suicide  Prevention  (IASP).  Further,  worldwide, males  kill themselves 4 times more often than females.

The Depression Myth

Men’s willingness to downplay weakness and pain is so great  that it has been named  as a factor in  their  shorter  life span. The  ten years of  difference  in longevity  between men and women  turns out  to  have  little to do with  genes. Men die early because they do not take  care  of  themselves.  Men  wait  too  long  to  acknowledge  that  they  are  sick,  take longer  to get  help, and  once  they  get treatment  do  not  comply  with it as well as women do.It  is commonly taught  that depression is predominantly  a  woman’s disease and  that the  rate of  depression  is  somewhere between  two  to  four  times higher for women than for  men.  One  of  the  ironies  about  men’s   depression  is  that  the  very  forces  that  help create  it  keep  us  from  seeing  it.  Men  are  not  supposed  to  be  vulnerable.  Pain  is something  we  are  to  rise  above.  He  who  has  been  brought  down  by  it  will  most  likely see  himself  as  shameful.  It  is  the  secret  pain  that  lies  at  the  heart  of  many  of  the difficulties in men’s lives. It comes  down  to that we tend not to recognize depression in men because the disorder itself  is  seen  as  unmanly.  Depression  carries,  for  many, a  double stain  ­ the stigma  of mental  illness  and  also the stigma of  “feminine”  emotionality.  Men  are  supposed to be like  “sturdy  oaks”  that  stand  tall  and  invincible  in  the   face  of  all  incursions  that  might challenge them.

Another  factor  mitigating  against  the  recognition  of  depression  in  men  is  that  mental health professionals,  no  less than anyone else, tend to look for what they expect to find. The  conventional  wisdom  that  women  are  depressed,  while  men  are  not,  leads some therapists away from an accurate diagnostic assessment.

The Mask Men Wear

Depression  in  men   is  often  hidden  from  those  around  the  individual,  and  it  is  largely hidden  from  his   own  conscious  awareness.  Masked  depression  is  one  of  the  most prevalent  disorders  in  modern  American  society,  yet  it  is  perhaps  the  most  neglected category in psychiatric literature.

Thoreau once  wrote: “The  mass of men lead lives of quiet desperation.” When we think of  depression  however,  our  thoughts  typically  turn  to  symptoms  that  are  not  so  quiet. Acute  and  dramatic,  the  pain  inflicted  by  depression  can  loom  largely.  When  the symptoms  of  depression   are  more  visible  and  recognized  for  what  they  are,  we  may consider  this  state  of  the  condition  as  overt.  If   ​ overt  depression  in  men  tends  to  be overlooked, masked or ​ covert depression​ is rendered all but invisible.

In  his  book  ​I  Don’t  Want  To  Talk  About  It​,  Terrence  Real  characterises  covert depression  in  men  as  “the  hidden  depression  that  drives  several  of  the  problems  we think  of  as  typically  male—alcoholism, drug abuse, self­medicating  with sex,  gambling, domestic violence, workaholism, antisocial behaviors and conduct disorder.”

Dr.  Real  sounds  the  alarm  that,  “​There  is  a  terrible  collusion  in  our  society,  a cultural cover­up  about  depression  in  men.”  He  goes  on  to  say  that,  “​Traditional  gender socialization  in  our  culture  asks  both  boys  and  girls  to  “halve  themselves.”  Girls  are allowed  to  maintain  emotional  expressiveness  and  cultivate  connection.  But  they  are systematically  discouraged  from  fully  developing  and  exercising  their  public,  assertive selves  ­ their “voice,”  as it is  often  called.  Boys,  by contrast, are greatly encouraged  to develop  their  public,  assertive  selves, but they are systematically pushed away from the full  exercise  of  emotional  expressiveness  and  the  skills  for  making  and  appreciating deep connection.” Girls,  and  later  women,  tend  to  internalize  pain.  They  blame  themselves  and  draw distress  into  themselves.  Boys,  and  later  men,  tend to  externalize pain;  they  are more likely to feel victimized  by others  and to discharge distress through action.  Hospitalised male psychiatric  patients  far outnumber  female  patients in their rate of violent incidents; women outnumber men in self­mutilation.

Too often, a wounded boy grows up to be a wounding man, inflicting upon those closest to  him  the  very  distress  he   refused  to  acknowledge  and  has  gone  unhealed  within himself. Depression in men, unless it is dealt with, tends to be passed along.

Research  shows  that   one  distinguishing  characteristic  of  battering  men  is  a  markedly increased  sensitivity  to  feelings  of  abandonment,  which  can  often  translate  into  love addiction.  Dr.  Real  indicates  that,  “Without  knowing  it  covertly  depressed  males  use their  connection to their sexual partners to help medicate their pain. When their partners ‘fail’  them,  they  are  flooded  by  depression  and  shame.  Rage  psychologically  and physiologically  ‘medicates’  their  dip into the experience of depression. Helpless feelings vanish  with  the  illusion  of  inordinate  power.   the  grandiose  entitlement  to  lash  out  at another human being rights their floundering sense of self­worth ­ and they strike.”

Like the Trojan Horse Invasion

Current  research  makes  it  clear  that  a  vulnerability  to  depression  is most  probably an inherited  biological  condition.  Anyone,  male  or  female,  given  the  right  mix  of chromosomes,  will  have  a  susceptibility  to  this  disease.  But  in  the  majority  of  cases, biological vulnerability  alone  is not  enough to bring  about  the disorder.  It is the collision of inherited vulnerability with psychological injury that produces depression.

If  you  are  experiencing  an  imbalance  of  neurotransmitters  you  are  likely  to  get depressed.  For  example  when  one  is  not  producing  enough  serotonin,  a neurotransmitter  that  allows one  to be calm, focused and mood­stabilized, one tends to feel depressed, irritable, anxious and agitated. Like  those  rare  conditions  which  causes  a  person’s  own  immune  system  to  assault itself,  depression is a disorder wherein the self attacks the self.  It’s like the “trojan horse invasion”  in  which  the attack  sneaks  place  within  the  sacred  fortress while  one’s forces are  unprepared  and  unsuspecting.  The  man  attempts  to ward  it  off, exhausting  all  of his  resources,  while  endeavoring  to  maintain   the  appearance  of  impenetrability  and invincibility.

While  many  of  the  men  treated  report  the  classic  symptoms  of  overt   depression, feelings of hopelessness, helplessness, and despair, many more experience depression as a state of numbness, which is known in psychiatry as A​ lexithymia. ​This experience of depression is not about feeling bad so much as about losing the capacity to feel at all.

In covert depression, a man desperately defends against such an  onslaught while trying one  perceived  remedy  after  another only  to  come away empty  handed and shamefully deflated.  Dr.  Real  states  that,  “A  common  defense  against  the painful experience  of deflated  value  is inflated  value;  and a common compensation for shame, of feeling less than, is  a  subtle or  flagrant  flight  into grandiosity, of  feeling  better than. Quite a number of  theorists  have   noted  the  ‘narcissistic  defense’  of  using  the  mask  of  grandiosity  to ward  off  shame.  The   flight  from  shame  into  grandiosity  lies  at the  heart of male covert depression.”

While  the  covertly  depressed  man  must  consume  something  or  do  something  to  shift the  state  of  his self­esteem, a man with bi­polar manic­depressive illness flips back and forth  between  grandiosity in  the manic phase and shame in the depressed phase at the seeming  whim  of  the  disease.  The  manic  phase  of  the  condition  is simply  a  more extreme  version  of  elevation  that  relies  on  the  rush  of  inflated  self­esteem  to ward  off depression.

Some individuals use rage to physiologically pump up their sense of deflation. Research shows  that  rage  simultaneously  releases  adrenaline,  which  speeds  up  the  autonomic nervous  system,  and  endorphins,  which  act  as   the  body’s  own  opioids.  This  is  a powerful  internal  cocktail,  which  tragically,  like  any  other  form  of intoxication,  can  offer short-lived relief from the pain of depression.

Dr.  Real  goes  on  to  say  that,  “When  a  covertly  depressed  man’s  connection  to  the object of  his  addiction is undisturbed, he feels good about himself.  But when connection to  that  object is  disrupted  ­  when the cocaine runs out, the credit cards reach their limit, the  affair ends  ­ his  sense  of  self­worth plummets,  and  his hidden depression begins to unfold.”

Out of the Shadows and Into the Light

There  is  a  tendency  to  self­medicate  when  one  feels  anxious  and  depressed.  This typically  leads  to    dependency  on  the  substance  that  one  uses  to  ease  the  pain  and suffering.  An  addict’s  choice  of  drug  may  rest  on  that  drug’s  particular  medicating properties.  Alcohol,   for  example,  relieves  a  sense  of  inner emptiness and  coldness by warming  and  disinhibiting,  often  making  one  more  sociable.  By  contrast,  opioids,  like heroin,  do  not  warm  one  up  so  much  as  calm  one  down,  tranquilizing  the  ferocity  of depression,  the  agitation  and  self­hatred.  Cocaine  brightens  a  person,  giving  him energy; it breaks through the numb, dead feeling of Alexithymia.

The  double­edged  approach  of   stopping  the  addictive  cycle  while  dealing  with  the emergent  depression,  calls  for  the  “dual  diagnosis”  of  both  depression  and  addiction. Covertly  depressed  men  who  self­medicate  with  substances  have  the  greatest  chance of  correct  diagnosis  and  of  receiving  effective   treatment  for  both  aspects  of  their disorder.

Dr.  Real  cautions  that,  “The  covertly  depressed  person  cannot  merely  vault  over  the avoided  pain  directly  into  wholeness,  as  hard  as  he  may  try.  The  only  real  cure  for covert depression is  overt depression.”  In other words, the mask of depression must be removed  bringing  the  hidden  condition   out  of  the  shadows  and  into  the  light  of  day. Novelist  William  Styron  describes  a  relationship  between  alcohol  and depression  that, for him, stretched across decades:

“Alcohol  was a  central factor,  to  the best of  my  knowledge,  in my  depression.  I  believe that many people who  are by nature depressive, or have a depressive bent, use alcohol
throughout   most  of  their  lives  to,  paradoxically,  alleviate  the  depression  …  You  use alcohol as a  kind of medication to keep your demons at arm’s length. But all of a sudden I  was  unable  to  drink.  I developed a severe intolerance to alcohol.  ..  ln the  absence  of this mood bath,  as  I call it,  that I would have every day in the evening, now I had a new experience  of  not  having  alcohol there  to give me  that sensation  of euphoria.  And that allowed the depression to crowd in.

First, the covertly depressed man must walk through the fire from which he has run. He must allow the pain to surface. Then, he may resolve his hidden depression by learning about self­care and healthy esteem.

This article, or parts of it, may be quoted or reproduced with permission.  Please contact the author at:  DrJ@DrStephenJohnson.com


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