"Make an effort!" Or again: "If you do not try to shake yourself a bit, how do you get out of it?" Such recommendations are made daily to people with depression and come in many forms. Even if they start from a good intention, they are often useless and even counterproductive because they feel guilty.
by Fabien Vinckier, psychiatrist, medical researcher at Paris-Descartes University, postdoctoral fellow, Institute of Brain and Spinal Cord (ICM), originally published on The Conversation
"Shake," " Move "or" Make an effort! "... This type of exchange with the entourage is reported so often by the patients that the psychiatrists ended up giving him a small name. They call it the "orangina syndrome", referring to the brand's soft drink slogan, "Shake me - otherwise the pulp stays down".
These short sentences are most often spoken with kindness and empathy, with the intention of helping. Sometimes, they come out under the spell of exasperation, or because of the pain that can arouse in us the apathy of a relative, or a colleague. Yet, they rarely seem to bear fruit. Worse, these same patients explain very well how these counsels and injunctions can be guilty and ultimately counterproductive.
Today, neuroscience makes it easier to understand why. And should encourage those around to look for other ways to help a loved one affected by depression.
Depression, a state of sadness, but not only
It is difficult for a non-patient to picture depression. When we try to do it, the images that come naturally are those of sadness. We draw from our personal history painful memories and try - which is sometimes difficult - to remember our state then. The picture of depression includes indeed the anxieties, the state of sadness, in other words - probably closer to the reality experienced by the patient - psychic suffering and moral pain.
With suicidal thoughts, this suffering is the most visible part of depression and probably the most "understandable" for those around you. In the same way that we sympathize with the sight of a physical injury, we suffer with our loved ones experiencing a moral pain, even when we do not understand the cause.
But depression is not only translated by this excess of so-called negative affects. It is also manifested by another facet, just as frequent and equally serious: the lack of positive affects. Psychiatrists have varied jargon to describe the various symptoms: anhedonia or inability to experience pleasure, abulia or abolition of will, apragmatism, or inability to undertake actions or athymhormy, the loss of vital momentum.
The "blow of slack" is transient, not the depression
When we try to figure out these symptoms, we can remember "slack shots", periods of slump. These conditions may have resulted in us from an infection, an excess of work or following a painful news. Fortunately, they have been transient.
In fact, when a few days of rest were not enough to get out of this state, our relatives were there to "shake" us, push us to act or "change our minds". But during the depression, the ideas do not change on demand, under the effect of a simple distraction or an injunction ... or even spontaneously. The term rumination, one of the symptoms of depression, defines precisely this inability to "change ideas", this propensity to remain fixed again and again on the same negative thoughts, to accuse oneself of the same evils. Most often, the patient with depression is fully aware of his condition. He suffers, but seems unable to change perspective.
This second component of depression, the lack of positive affects, is not necessarily well treated by current therapies. Conventional antidepressants (including selective serotonin reuptake inhibitors) seem to be more effective in targeting the first component, the excess of negative affects, according to the scientific literature.
A disease affecting the networks of the brain involved in motivation
The most recent knowledge in neuroscience suggests that it is a disease of motivation, that is to say affecting the networks of the brain involved in motivation. If these patients with depression could want, if they could "make an effort", it would mean ... they are no longer depressed.
In the same way that it would be absurd to require a patient with diabetes to ask his pancreas to "make an effort", or to have another broken leg to have less wrong or running, it is absurd to require a "patient of motivation" to be a little more voluntary.
There are many ways for a researcher to address the mechanisms of motivation. Thus, it is possible to ask the question of its determinants related to genetics or the environment, its neurobiological foundations (at the microscopic scale of a cell and its receptors, neurotransmitters), its brain bases. (Visible by studies in imaging, on the scale of a brain area and therefore the centimeter) or its cognitive mechanisms (related to the functioning of thought).
Our cognitive neuroscience team, the Brain Motivation and Behavior Team at the Brain and Spine Institute (CMI), is studying these different aspects in patients.In particular, we use functional MRI or electrophysiology, taking into account prescribed drugs.
In this approach, motivation can be defined as the set of factors that determine the behavior of an individual; in terms of direction: he chooses one action over another - for example, to make himself a dinner, rather than order a pizza; either in terms of intensity: it determines the amount of resources that it allocates to an action, that is to say the effort it will provide or the time it will devote to it.
A confrontation between benefits and costs
When we have to choose between several actions or decide to make an effort, our decision is based on the confrontation between two opposing elements: on the one hand the benefits, on the other hand ie the reward we can get - but also the losses we can avoid - and on the other side, the costs, including the energy expended or effort required.
In this context, the notion of reward can mean a material good, for example an object, food and even money or, conversely, an intangible good, such as the pleasure of immersing oneself in a book or the esteem of his relatives. Similarly, costs can be physical as well as mental.
This division of the determinants of our actions into two categories is probably reductive or even simplistic. But it can point to the origin of a motivation disorder as falling under one of these two major axes: either a decrease in the sensitivity to the rewards or the sensitivity to the losses (to the "carrot" or to the " stick "to take this classic image), an increase in sensitivity to effort. These two mechanisms can probably coexist in the same patient, to greater or lesser degrees.
Take the example of a person who is faced with the opportunity to go out to meet his friends at the restaurant. A patient suffering from depression may be unable to do so either because the prospect of reward (the pleasure of being with his family) is abolished, or because the cost of each of the actions necessary to join his friends is multiplied at home - in other words, the effort involved in making a decision, getting dressed, combing and walking the distance to the restaurant is increased.
Every decision becomes a mountain to climb
Many patients express precisely their difficulties in these terms: the least decision, the slightest action become so many mountains to climb. In fact, every time we ask a depressed loved one "to try a little", to make an effort that seems minimal, we ask him in fact to achieve a phenomenal ascent ... while it will not necessarily be in state to enjoy the view once reached the summit, could we add to spin the metaphor.
In recent years, several teams around the world have sought to measure these two facets of motivation, in the general population or in patients with a motivation disorder, such as depression.
The stakes are all the more important because a bundle of arguments seems to indicate that the cerebral and chemical bases of each are different. When we calculate the value of the reward or the cost of the effort, it is not the same brain regions and probably not the same neurotransmitters, these chemical messengers between neurons, which are at work.
However, there is currently no validated way for psychiatrists to be able to measure the respective weight of these two mechanisms in a patient's daily practice. For the moment, such assessments are limited to patients who have adhered to a research protocol and are only valid at the group level.
Yet, it's a safe bet that these two major types of motivational disorders may require different therapeutic interventions - be they drugs, brain stimulation such as transcranial magnetic stimulation or electroconvulsive therapy, or of psychotherapies. In the future, it will undoubtedly be possible to distinguish, in a loved one suffering from depression, which of the two mechanisms is involved. In the meantime, let us abstain, already, from overwhelming him with a "if you will, we can".
To go further
==> 5 misconceptions about depression
Unclear or almost invisible, the depression concerns more than 3 million French people. The absence of physical signs of this disease leaves room for innumerable misconceptions. Not always wrong, they are too simple answers to complex questions. Marie-Claude Gavard is a psychiatrist, psychotherapist and psychoanalyst, and makes the fight against ideas heralded.