Kyle: Are introverts more susceptible to depression?
Dr. Ramani: Yes they are, but only because they’re higher in a trait called neuroticism. And neuroticism is a trait that is a risk factor for depression. Does that make sense?
Kyle: Yes.
Dr. Ramani: So it’s simply by having that trait that they’re more vulnerable.
The introversion is not a direct path to depression. It’s mediated by this thing called neuroticism.
Kyle: Introversion to neuroticism, to depression. And only slightly more likely?
Dr. Ramani: Yeah. It’s all gonna be dictated by the presence of the neuroticism, not the introversion.
Kyle: Got it.
Dr. Ramani: So they’re more likely to hold this thing called neuroticism. If you’re an introvert and you’re not high in neuroticism, you won’t be at any more significant elevated risk for depression.
Kyle: Got it. Alright. Let’s look at the diagnostic criteria then for depression.
Dr. Ramani: Yep.
Kyle: What is it?
Dr. Ramani: So the diagnostic criteria for depression is the presence of either sad or depressed or irritable mood or something we call anhedonia – a loss of pleasure and activities that usually give a person pleasure most days or nearly every day for two weeks orr longer, and that these mood shifts, this change into depressed mood is associated with significant social and occupational impairment or problems in your relationships and work.
Beyond that, we look for things like significant changes in sleep. Either they can’t fall asleep, stay asleep, or they oversleep, they sleep too much, changes in appetite, and that can either be an increase in appetite or a decrease in appetite which results in weight gain or weight loss.
Changes in concentration and difficulty paying attention. Changes in energy like lower energy and fatigue, getting fatigue easily, having suicidal thoughts or intentions or gestures. Feelings of worthlessness, feelings of guilt. And either what we call psychomotor agitation or retardation.
Psychomotor agitation is almost like the sense of physical restlessness. Doesn’t mean you’re moving quickly. It means it’s just like you can’t sit still to the point where it’s somewhat uncomfortable. What’s probably more commonly seen is a pattern called psychomotor retardation, which is slowing, everything is slowing.
Putting on your pants is slower. Walking into the car is slower. Just slower. So it’s all of those things together.
I think you need to have at least four from that long list I gave you, plus either depressed mood or mood that is characterized by that loss of pleasure.
We also look for other patterns like apathy, a lack of interest in doing anything and lower than usual levels of motivation, a lack of desire to get up and do anything.
Kyle: I want to go back to, you said thoughts of suicide. I think a lot of people think that if you have thoughts of suicide, then you are depressed and in order to be depressed, you have to have thoughts of suicide.
Dr. Ramani: Not at all. The psychiatric diagnosis associated with the highest rate of people who actually end their lives through suicide is borderline personality disorder, and we certainly see a greater prevalence of those kinds of distress – suicidal thoughts, suicidal intentions, suicidal gestures, and suicide in people with borderline personality.
Obviously, we’re always gonna make this clear to every MedCircle viewer. If there are thoughts of suicide, you must get mental health intervention immediately to get ahead of that. It may be the kind of thing just simply talking to someone is gonna help.
But call whomever you need to get that assistance. But it’s not a marker for depression by any means. It’s associated with numerous disorders – eating disorders, depression, bipolar disorder, a variety of personality disorders, substance use disorders. I mean that idea that suicide belongs to depression couldn’t be farther from the truth.
And it means we often miss suicidal risk because we’re not looking for it in other disorders. Oh, really? Excellent points.
Kyle: Oh, really excellent points. Thank you for bringing that up.
Before we talk about the diagnostic criteria for anxiety, are there cases where someone’s diagnosed with depression but not anxiety?
Dr. Ramani: Oh, absolutely. Absolutely. Just because depression and anxiety are highly comorbid doesn’t mean that both are diagnosed at the same time. It doesn’t mean that’s always the case. There can be a fair amount of anxiety in depression, but that doesn’t mean that the person has a full-blown anxiety disorder.
In fact, there are some people who believe that anxiety and depression are actually quite similar at the level of the central nervous system – in terms of neurotransmitters and the areas of the brain that are affected – and maybe variations on a theme that some people experiencing that same kind of brain chemistry, some of them may be endorsing more anxiety, some may describe it more as depression, but it’s a sort of similar involvement.
But we do know, for example, people with depression are very prone to something we call rumination, which is they get a thought in their head and they can’t let it go. Can’t let it go. Can’t let it go. That is also a pattern we see in anxiety.
So there’s a lot of overlap in the patterns, but in terms of having two distinct disorders…for example, having a diagnosis of major depressive disorder as well as a specific anxiety disorder diagnosis, that requires that person as having all separate symptoms, so they cover both diagnoses at the same time.
But anxiety and depression, the presence of anxiety and depression is very prevalent.
Kyle: I know that we don’t want to get into the error of just looking for little boxes to fit us all in. But in the five psychiatrists I’ve seen in my life, maybe five or six, they all would diagnose me with depression and anxiety.
But when I would work through my therapy – the talk therapy – we really just focused on the depression point. Even though I had this diagnosis with anxiety and I always thought, why do I have this diagnosis with anxiety? It’s never addressed it. I never even feel like it’s that big of a problem.
I probably have normal, healthy levels of anxiety. But I always got that diagnosis with the depression, so I had created this story in my head that if you get a diagnosis with depression, you’re gonna get the diagnosis with anxiety.
Dr. Ramani: There’s a mixed anxiety-depression disorder. It’s actually a mixed type of depression that has both types of mood – depressed mood and anxious mood are highly prominent. Like I said, they go together.
They live together, they hang together. Have I ever worked with a depressed client who didn’t have a significant prominence of anxiety? No.
And vice versa. I’ve worked with anxious clients and there’s some kind of undercurrent of some depressive symptoms, maybe not sad mood, but definitely some loss of pleasure and activity, some irritability, loss of energy. So again, they’re very over overlapping situations and a lot of the techniques we use to manage them are similar.
Cognitive behavioral techniques. Mindfulness problem solving, similar coping styles, skills we give them. It’s very similar how we approach it, but it’s, again, obviously it impacts life in different ways.
Kyle: What is the diagnostic criteria for anxiety?
Dr. Ramani: Anxiety is a family of disorders. Okay?
Anxiety disorders are family disorders, and that includes things like – phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. So each of these specific anxiety disorders has a slightly different presentation.
And if we were to go through them all, the key elements that unite all of the anxiety disorders is a significant presence of anxiety that’s resulting in avoidance of whatever that thing that is making them anxious, significant symptoms of arousal, racing heartbeat, muscle tension, hyperventilation, dizziness, like all the stuff that goes with feeling anxious. A greater likelihood to worry. A greater likelihood to ruminate.
But in a phobia, for example, all that worry is coalesced around a single object or a situation like being afraid of flying in an airplane, being afraid of a clown. Like all of that, all those anxiety symptoms are all isolated on that one thing. You are afraid.
And panic disorder, it’s anxiety gone completely full tilt. So now the person is having these catastrophic panic attacks where they feel like they’re having a heart attack. They feel like they’re dying. They’re having all kinds of physiological symptoms, but there’s no biological basis. They’re not actually having a heart attack, but panic attacks.
If they happen repeatedly and the person doesn’t expect them to come out of the blue, that’s often paired with something we call agoraphobia. And agoraphobia is a fear of being in a place, in a space in which help won’t be readily available – Coachella, like a big music festival or a like a grocery store or an amusement park, classroom.
And that fear of embarrassment that could happen if they had a panic attack in that kind of place. So they don’t leave the house. And I know what you’re thinking – they don’t leave the house. Is that introversion? No, the person with agoraphobia is not leaving the house because they’re most likely afraid they’re going to have a panic attack and help won’t be readily available.
A person who is introverted by nature wants to be home and do the things at home and home gives them pleasure. Whatever it is they’re doing.
Kyle: They’re not avoiding getting attacked, they’re not avoiding something.
Dr. Ramani: Yeah. And generalized anxiety is like a generalized anxiety about a variety of situations, but the same thing – the worry, the rumination, the arousal symptoms, all of that.
Kyle: Could you have all of that?
Dr. Ramani: I have to tell you this. I don’t think you’d have all of it. Yeah, no. Even as I teach it, I think that these phenomenologies are quite separate. I think you can have a big messy ball of, anxiety, but then that tends to fall more into generalized anxiety disorder.
Is it possible that a person could have a phobia, for example? I don’t know. A public speaking phobia, for example, is actually social anxiety disorder. Can that social anxiety disordered person also have a worry about a whole variety of other things? Can they pay their taxes? Is their mother okay? Are they sick and all that?
Then they might have generalized anxiety disorder and social anxiety disorder, but would you have all of them? Probably not. Actually, interestingly phobias are one of the most common forms of mental illness that we see in the United States. Because of that the social anxiety disorder piece falls into the phobias.
Kyle: Yeah. Okay. For people who are watching this, I imagine they are either introverted and facing depression or anxiety, or know somebody who is introverted facing depression and anxiety.
How would the person who needs help seek it out in the first place?
Dr. Ramani: Here’s where again I think that introvert / extrovert, it’s difficult when a person is struggling with anxiety to get help because you often feel a sense of the immobilization, that amotivation, the anhedonia, the apathy.
It feels like, “Oh my gosh, it feels so difficult. I don’t know a therapist, what am I supposed to do?”
And sometimes many people enter the mental health system through their primary care physician. So they may not be feeling well, sick or getting a physical exam. If they are fortunate, their primary care physician might ask them how their mood is. They might say it’s not been good, and that might be their portal into therapy.
I’m not convinced that an introverted person might have that much more trouble asking to get therapy than an extroverted person because remember, introverted people do have people who are close to them in their lives. Extroverted people may simply have more people in their life.
In fact, I might even try the hypothesis that an extroverted person might have a greater sense of shame or concern about being depressed because they don’t wanna look bad to their many stakeholders. Where an introverted person may have more deeply felt relationships with a smaller group of people, and may be more willing to be a bit more vulnerable in that group to get the help they need.
So that’s also a possibility. This idea that an introvert is gonna be so socially isolated, I’m not so sure. Because they’re not isolated. The isolation is the depression. But that would be seen in an extroverted person with depression too.
Kyle: I loved your choice of words – the stakeholders. That was another word for friends.
But I know people in their lives who view their friends as stakeholders. And to me that could be very unhealthy when you’re trying to impress everybody at the detriment of your own health.
Dr. Ramani: Yeah, with an extroverted person. Listen, when you have so many more people in your life, you’re not gonna be able to give them the same amount of attention.
You just can’t. It’s a numbers game, right? So it could very well be, though, that extroverts may care more about what other people think about them. For example, extroversion is correlated with narcissism. Higher extroversion is seen in people who are narcissistic, so they care what other people think.
Kyle: So if we polled a room full of narcissists or people who have narcissistic personality disorder, there would be more extroverts in that group than introverts?
Dr. Ramani: Yeah. Except in the covert narcissists who tend to be more introverted.
Kyle: Yeah. Good point. Okay. So the seeking process for an introvert would be relatively the same as anybody else?
Dr. Ramani: I think so. Yeah.
Kyle: And then they have those close friends that they can call upon.
Dr. Ramani: Yep.
Kyle: When I’ve been at the depths of my depression as an introvert, it becomes daunting to even put out the effort to make an appointment with a therapist. That becomes a mountain I cannot climb.
Dr. Ramani: That would be daunting for an extrovert or an introvert extrovert.
Because you’re depressed. Does that make sense? You’ve got to put the lens in the right place – on the depression.
Kyle: Yes. You’re gonna have to redirect me a few times. That’s such a good point.
Dr. Ramani: It’s about the depression.
Kyle: What tips can you give for somebody who’s maybe watching this or their friend gave them access to MedCircle and they’re just sitting here and they’re going – “I know. Okay. I am hearing you and I know I should, but I just can’t imagine calling the receptionist and getting put on hold and not having availability for three months and finding out what insurance takes.”
What do you tell those people?
Dr. Ramani: First of all, you offer to help. You say, “How can I help with this? Or can I help with this??
Kyle: But if someone needs the help, they need to reach out?
Dr. Ramani: Yes, they do need to reach out.
So you’re the person who needs the help. You might even say I don’t know how to do this. And then to the people who are their supporters…to step in there and say, what can I do? Can I help? Can I drive you to that first appointment? Can I stay on hold for you?
Here’s the thing though, I have to tell listeners, you can’t make an appointment with a mental health practitioner for another adult.
So if somebody calls my office and says, “Hey, I’m making an appointment for my wife.” Your wife has to be the one who’s consenting for treatment.
And I’ve had people sometimes bring people into a therapy office under false pretenses. I don’t do court ordered sessions, so I only bring in voluntary clients.
So somebody says, “Hey, my wife needs therapy. I wanna make an appointment.” I said, “I can hold an appointment, but she’s gotta be the one. Ultimately you can hand the phone over to her. You can even call me another time, but it has to be her making the appointment.”
Kyle: I did not know that. Is that pretty standard?
Dr. Ramani: I think it is. Unless you’re going to a clinic, but ultimately then that person has to come in and sign consent. But I can’t count on both hands the number of times I was like, okay sure. And then that person said, this is not what I signed up for. And so I do think it’s important that you get that buy-in.
Otherwise it may feel coercive. And it might foster a greater sense of helplessness in that person. It may even undercut the trust that they could form with a therapist.
Kyle: Absolutely. because now your husband just tricked you into going into therapy.
Dr. Ramani: Kind of, yeah. It may, and I’m not saying that our supporters watching this are intending to trick anyone.
Kyle: No, of course not.
Dr. Ramani: But I think it’s that you have them in the room with you and you make the call when you finally get the person on the phone and say, “They have the time you want. Can you just go ahead and get on the phone with them?” And then, say, “I’m making this appointment for myself.”
Kyle: Got it. Really great advice.
Dr. Ramani: This may not be something that all therapists agree with. I really do, because ultimately therapy is consented to an adult by the adult who’s in the office.
This is obviously entirely different with anyone under the age of 18. Then obviously a parent will be the one reaching out to make that appointment. Kyle: Yes. Yeah. Wonderful.
