Over the years, I've learned firsthand the psychological toll that psoriasis can take, and the lowered self-esteem that so often goes with it. Living with the unpredictability of psoriasis, in particular, can have an emotional impact that's even worse than the actual symptoms.
By Robert H. Reiner, Ph.D. (See bio below.)
Understanding depression
Determining if you suffer from depression is something you should do only with help from your doctor or a psychologist. You should, however, be aware of what depression is, and understand its origins. There are two main types of depression:
- Reactive depression can usually be traced to obvious stresses in a person's life. These can include divorce, losing your job, learning that someone you love is sick—or a severe outbreak of psoriasis. Just because depression is reactive (related to some stressful life event, like psoriasis) doesn't mean it's any less painful or debilitating. Some people who become depressed over life events feel so sad that they stop functioning. Fortunately, this kind of depression usually improves when the event that caused it improves.
- Endogenous depression can occur any time, for no apparent reason. Endogenous depression is seen as an imbalance in brain chemistry, and it's more likely to be passed along genetically. It often requires medication, together with therapy.
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Signs of depression
How can you tell if you are really depressed? True depression has definite signs. Naturally, the most common signal is when you feel lousy—tired, irritable, withdrawn, disinterested in things that used to make you happy. In severe cases "psychomotor retardation" can occur. The body feels like it has actually slowed down. You just don't feel that you have the energy to do anything. It literally "hurts to be."
- Three other common signs of depression are difficulty sleeping (including early morning awakening), change in appetite (either increase or decrease), and change in sex drive. If these last longer than 3 months, you may be suffering from depression.
The rule of thumb for any psychological problem is that the more it interferes with your functioning, the more severe it is. If you find that you're unable to work, or are avoiding social situations that might otherwise give you pleasure, you're probably depressed.
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Six steps you can take to help with depression
The next question is, if you are depressed, what can you do about it? All of the following techniques can help with depression. The most important thing you can do is consult a medical professional. If you think you may be depressed, talk with your doctor or a psychologist as soon as you can. They can help you decide if you need professional help.
- Examine your thoughts
- Don't act depressed
- Treat yourself like you're important
- Practice "long-term hedonism"
- Put yourself in control
- Prepare for a flare—rehearse
Examine your thoughts
The first thing I tell people when they're depressed is to try to step back and examine their thoughts before they take them too seriously. This is because depressed people do something we call catastrophizing—making things seem a lot worse than they really are. Their skin is never just bad, it's "awful!"
I always discourage people from making important decisions when they're depressed. They're not themselves; they're not thinking rationally.
Another thing I remind psoriasis patients about is the need to be realistic about themselves. I don't believe in the "power of positive thinking" to cure psoriasis, but people spend too much time focusing on their negatives, needlessly criticizing themselves. If people with psoriasis focus exclusively on their skin, it's going to have a depressing effect. That just increases anxiety and depression.
I tell people to stand in front of a mirror and actively remind themselves of all the things in their life they feel good about—their positive qualities and accomplishments. This serves to balance their thinking and their mood.
Don't act depressed
One of the best ways to fight depression is to act as if you're not depressed—even when that's how you feel. That sounds simplistic, but it's important for you to make the effort.
The way that you behave has a lot to do with your mood. Your brain is always watching what you're doing (self-monitoring). The brain will say: "If I'm acting this way, then I must really be depressed." When you withdraw or behave in a way that looks like depression, you are unconsciously confirming the lifestyle of someone who is depressed. This makes it more likely that you'll continue to act and feel depressed.
I frequently say to people, "Imagine someone is videotaping and watching your life for a whole week—all of your behaviors, all of the things you're doing." If you are alone all the time, just going to work, coming home, having dinner, flipping through the TV stations, hanging around, or reading the paper, and then going to sleep every night, how could you be anything else but depressed? If there is no pleasure coming in, depression is really the predictable response.
Treat yourself like you're important
How you treat yourself also affects your depression. People who treat themselves like they're not important, or they don't deserve pleasurable things, make themselves feel worse.
If you tell yourself that you look ugly today, or that you're no good, it naturally lowers your self-esteem. And that deepens your depression. But if you treat yourself like you're a worthy person, it improves both your self-esteem and your depression.
One of the simplest ways of doing this is to give yourself something nice once in a while. It doesn't have to be anything big. Treat yourself to a massage. Go to a movie. Buy a good bottle of wine or a new CD. Plan a get-together with friends. The message is, "I am a person worthy of these good things." And this certainly carries over to how you let other people treat you. If you allow people to treat you like you're a doormat, that's just how you'll feel! Insist that people treat you respectfully, and your self-esteem will inevitably rise.
Practice "long-term hedonism"
You can also help minimize depression by guiding your behavior toward what we call "long-term hedonism." The best way to explain this is with an example. One of the most useful ways to treat depression is with aerobic exercise. I'm convinced that aerobic exercise is more powerful than antidepressant medication. The problem is, when people are depressed, exercise is the last thing they want to do.
If you're a disciplined person—a long-term hedonist—you'll say, "I don't feel like jogging, but I know that it's in my best long-term interest. So I'm going to act against my desire to just sit here, and I'll go jogging anyway." In other words, you ignore your short-term wishes to do what's good for you in the long-term.
Doing things that are good for you enhances your sense of control. The more you are convinced that what you do really counts and will ultimately have positive effects, the better you'll feel.
Put yourself in control
Control is central to dealing with depression. Psychologists have a term–locus of control. This has to do with the areas of your life that you feel you have control over. I'm always trying to get people to separate their self-esteem from how they look, what they do, or how successful they are in their relationships—because those areas are external, and sometimes beyond their control.
To the extent that you believe you have a strong effect on what happens to you, or feel you can exert influence over your life, you're expressing internal locus of control. Stockbrokers whose self-esteem is tied directly to the performance of the stock market are expressing external locus of control. They are going through tough times these days. Thus, people who function with internal locus of control are less likely to get depressed.
Prepare for a flare—rehearse
Another way to gain control is to prepare yourself to deal with a psoriasis flare before it happens. I'll have my patients with psoriasis stand in front of a mirror on good days, rehearsing what it will feel like if they have a flare. Psychologists call this an "inoculation model," because it performs like a flu shot. It provides a small dose of a difficult situation, and you get used to dealing with it. Then, when the problem actually hits, you've had some prior experience defending against it. Your next flare is never going to be a positive experience, but being ready for it can make it a lot less negative.
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| Dr. Robert H. Reiner, Ph.D., is a licensed psychologist who has been practicing for 22 years. He is a faculty member in the Department of Psychiatry at NYU Medical Center, where he teaches cognitive behavioral therapy and behavioral medicine to psychiatric residents and psychology interns. Dr. Reiner is also the executive director of Behavioral Associates, a dual clinical and consulting firm that he founded in 1988. Located in the upper east side of Manhattan, the firm provides behavioral medicine, stress management, and cognitive behavioral psychotherapy programs.
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