Indeed, it is very doubtful that these are strictly delineated categories. Furthermore, the nature of the putative "cause" or precipitating event is not a reliable predictor of where, on this emotional continuum, a given individual may end up. The loss of a loved one, for example, ordinarily provokes sorrow and a finite period of grief and mourning.
Most mourners do not develop a severe, intractable clinical depression. Indeed, in the Judaic tradition, it is expected that after the seven days of mourning known as shiva , the bereaved will generally be ready to resume some "everyday" activities while refraining, however, from any kind of celebration [ 5 ]. There are, of course, many exceptions to the generally self-limited course of mourning; in principle, there are as many kinds of mourning as there are mourners.
The great medieval philosopher, Moses ben Maimon Maimonides, — , appears to have developed a profound and prolonged depression, after the death of his beloved brother, David, in a shipwreck.
Maimonides writes, in a letter dated from ,. About eight years have since passed, but I am still mourning and unable to accept consolation Just as the English scholar, Robert Burton, was able to develop an "anatomy of melancholy", we can develop a rough anatomy of sorrow.
Burton himself recognized sorrow as related to, but distinct from , melancholy. Citing Hippocrates, Burton writes that sorrow is both " But though the boundaries between ordinary sorrow and significant depression are sometimes vague, there are experiential or "phenomenological" features that help us distinguish these conditions.
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For example, when we experience everyday sorrow, we generally feel—or at least are capable of feeling — intimately connected with others. Thus, Shakespeare has Romeo and Juliet parting in " In contrast, when we experience severe depression, we typically feel outcast and alone.
Sorrow, to use Martin Buber's terms, is an "I-Thou" or relational experience; clinical depression, a morbid preoccupation with "me".
Indeed, William Styron, in Darkness Visible , describes depressed individuals as having "their minds turned agonizingly inward" [ 8 ]. The sense of time is also different in sorrow and depression. When we experience sorrow, we have the sense that, someday, it will end. As Psalm 30 tells us, "Weeping may last for the night, but joy returns in the morning. Indeed, Dr. Nassir Ghaemi, drawing on the work of Leston Havens and Eugene Minkowski, has called attention to the sense of temporal distortion in depression; i.
Sorrow, unlike severe depression, is curiously ambivalent : sorrow has the capacity to contain joy within it, or at least to find solace within its own essence. Sorrow, in this sense, is dialectical: it generates an inward "conversation" between hopeful possibility and foreclosure of hope.
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Thus, when Martin Luther was confronted with the imminent death of his beloved daughter, Magdalena, he is said to have uttered these words to the girl, as she lay in his arms:. I am happy in the spirit, but in the flesh I am very sorrowful. Another experiential difference between sorrow and depression is brought home in an anecdote concerning the writer James Joyce, and his daughter, Lucia, who was eventually diagnosed with schizophrenia.
Although apparently apocryphal [ 14 ], the vignette makes an important existential distinction. Supposedly Joyce had brought Lucia to the eminent psychoanalyst, Dr. Carl Jung.
Joyce was perplexed, regarding the difference between his own idiosyncratic thinking, and the convoluted thought processes of his daughter. Jung is said to have replied: "She falls. You leap. Indeed, we might say that depression is to sorrow as falling is to leaping. Put another way: we are overtaken by depression, but give ourselves over to sorrow. There is, in short, an intentional dimension to sorrow. Sorrow, a gift? This counter-intuitive perspective is nicely elucidated by the psychotherapist and former Catholic monk Thomas Moore:. When you are going through a period of extreme loss or pain, you reflect on the people who mean the most to you instead of on personal success; and the deep design of your life, instead of distracting gadgets and entertainments.
You may be more open to the beauty of your world as a relief from distress. Beauty is always present, but ordinarily you may not notice it because of your priorities or your absorption in other things. In contrast, it is very rare, though not unheard of, that severely depressed individuals consider their depression per se a "gift". Some, however, have found spiritual meaning or sources of creativity in their depression.
Kay Redfield Jamison, a psychologist who suffers from bipolar disorder, has observed that. Even more important, however, it can derive great strength from the struggle to come to terms with such emotional extremes and from the attempt to derive from them some redemptive value. Nevertheless, the well-known association between bipolar disorder and creativity 16 does not mean that severe depression per se is a period of creativity. More typical of the depressive period and its effect on creativity is this description from essayist Virginia Heffernan:.
Contemporary poets who are alive and can tell us about their experience with depression are consistent in reporting that it was only after effective psychiatric treatment that they were able to create at their highest levels. We have so far adumbrated four experiential dimensions that help differentiate clinical depression from sorrow; i. But this analysis is hardly exhaustive; indeed, we can hypothesize other phenomenological dimensions that may help distinguish clinical depression from ordinary sorrow. For example, do these states differ in the realm of personhood? As Berlin points out, severe depression interferes with realistic self-assessment [ 19 ].
For example, the severely depressed individual may describe herself as "a total nothing," "a complete failure," or "a big zero. Another though perhaps related phenomenological difference between sorrow and clinical depression may involve what I call mortal vulnerability — the sense, in severe depression, of being at the mercy of a hostile universe.
This is wonderfully expressed in these lines from a poem entitled, "Depressive", by J. In summary, the sorrowful and the severely depressed inhabit two quite different phenomenological worlds, though the two "universes" intersect in certain experiential respects; for example, both the sorrowful and the depressed person will describe feelings of sadness and loss. The severely depressed person, however, endures a unique kind of suffering.
Even though, as Paul Genova MD has observed, suffering may be beneficially "transformative" in some patients [ 21 ], others will simply be crushed by their suffering. Indeed, it is hard to find a better phenomenological description of such soul-killing suffering than in William Styron's account of his severe and intractable depression, in Darkness Visible :. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain And because no breeze stirs this caldron, because there is no escape from the smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion In depression the faith in deliverance, in ultimate restoration, is absent A recent and very influential book, The Loss of Sadness , has argued that psychiatrists, over the last few decades, have "medicalized" sadness—in effect, lumping normal, adaptive sadness in with clinical depression, by failing to appreciate the emotional context in which depression takes place [ 22 ].
To be sure, the criteria for depressive disorders in DSM-IV are almost certainly too inclusive, and are undoubtedly in need of refinement. For example, current criteria conflate cases in which major depression has been present for only two weeks with those that have been present a year or more.
The categorical approach of the DSM system also tends to create "pigeon holes" and procrustean checklists of symptoms. Notwithstanding problems with the DSM system, psychiatrists have been in the forefront of distinguishing the subtle nuances of sorrow, grief, and depression, as well as calling upon us to appreciate the experiential aspects of the patient's mood states.
For example, Dr. Naomi Simon and her colleagues at Massachusetts General Hospital have described what they term "Complicated Grief" CG —sometimes referred to as "pathological" or "traumatic" grief [ 23 ]. The construct of traumatic grief dates from antiquity. Indeed, we find traumatic grief eloquently represented in Homer's Iliad , as psychiatrist Jonathan Shay has shown in his classic work, Achilles in Vietnam [ 24 ].
Curiously, Horwitz and Wakefield see Achilles' grief as a prototype of "normal sadness" [ 22 ].
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From the clinical standpoint, this hardly seems plausible. In the Iliad , we find this description of Achilles' grief, after the death of his beloved friend, Patroclus:. With both hands he scooped up soot and dust and poured it on his head, covering his handsome face with dirt, covering his sweet-smelling tunic with black ash. He lay sprawling—his mighty warrior's massive body collapsed and stretched out in the dust. With his hands, he tugged at his own hair, disfiguring himself.
Things go downhill from there: Achilles essentially goes "berserk" and commits atrocities against his enemies, the Trojans. When Achilles says to his mother, Thetis, "Then let me die, since I could not prevent the death of my companion Unlike ordinary mourning or bereavement, pathological mourning what Freud terms "melancholia" involves profound guilt and self-reproach. To oversimplify Freud's thesis considerably, the survivor blames himself , on some unconscious level, for the death of the loved one.
Simon and her colleagues have delineated a syndrome that bears a close resemblance to the historical notion of traumatic or pathological grief [ 23 ]. Complicated grief CG is understood as a set of symptoms lasting at least six months after the loss of a loved one, and consisting of :. Notice that the first three features are essentially phenomenological criteria; that is, they reflect, and must be elicited from, the patient's subjective experiential account.
Arguably, the "avoidance of painful reminders" might be inferred from the bereaved person's behavior. Similarly, Simon et al also note that many individuals with CG often report "anger and bitterness related to the death", and "feel estranged from other close friends and relatives". They "cannot find satisfaction in ongoing life" [ 23 ].
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While some of these features may remind us of Styron's severe major depression, only a little over half of Dr. Nonetheless, Simon and her colleagues find that severe CG can result in significant social and vocational impairment. Complicated grief might be regarded, in our present state of knowledge, as a kind conceptual bridge between ordinary bereavement and full-blown major depression. If sorrow, bereavement, pathological grief, and major depression are distinguishable clinically and phenomenologically, we might hypothesize that they also differ biologically.
This might be investigated from two perspectives.
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On the one hand, we might regard these mood states not as discrete categories, but as conditions along a continuum or spectrum of dysphoric mood and impaired function. Ghaemi, for example, posits a "unipolar depressive spectrum" that distinguishes acute from chronic major depression; and single from recurrent episodes of major depression [ 27 ]. The terms "continuum" and "spectrum" are often used interchangeably in the depression literature.
A spectrum denotes an ordered arrangement by a particular characteristic , such as a spectrum of visible color wavelengths. For our purposes, however, this distinction is not critical. Based on the spectrum-continuum model, we might hypothesize that mood states and disorders would yield subtle gradations of biological differentiae, rather than black-and-white distinctions.
On the other hand, we might posit a categorical separation of mood states. The now outmoded "reactive" exogenous versus "endogenous" distinction is one example of a categorical classification of depression though, in theory, one could envision subtle gradations of "endogenicity".