Depression is not normally a condition that is associated with pain. When we think of pain, we might think of the acute pain of stubbing your toe, the more sustained and intense pain of breaking a bone, or the chronic pain of a physical disease or condition. But depression is painful. It’s just a difficult task to describe the pain in a way that is understandable and relatable. Firstly, I believe it’s critical to point out that depression can be physically painful – a host of physical complaints are often reported by depressives, although I would not say these symptoms are what make the condition unbearable. The more exasperating, overwhelming form of pain is in the emotional and psychological side of depression.
It’s my belief that it’s in the interest of the individual with depression, those who care for the individual, and society at large, to bring the nature of this pain to the surface – and that means allowing patients to recount their pain as fully as possible, until their descriptions are congruent with their experiences, as this will help to foster true compassion. Too often depression is misconstrued and this is why responses to depression, albeit well-intentioned, can miss the mark and be unhelpful.
I would like, then, to try to utilise certain comparisons, metaphors, and thought experiments in an attempt to reify the pain of depression. After all, the pain of depression is not manufactured. Complaints of pain are not melodramatic or a sign of a soft or weak constitution. The pain is as real as any other kind of pain we can imagine.
The Emotional Pain of Depression
Depression is emotionally painful. If you doubt that one’s emotions can be a source of pain, then you need only consider the pain that you feel in a state of grief or heartbreak. Both subjective firsthand accounts and scientific research highlights the fact that these experiences are painful. For instance, one study found that the brain interprets the emotional pain of heartbreak in the same way as physical pain. On this note, I would draw a comparison between the painful nature of grief and heartbreak and the pain of depression. The pain cannot be considered equal or the same since the experiences are of a different kind and highly individual; yet, I would say that grief and heartbreak share some similarities with depression. As a case in point, psychological pain, which features in major depression, is – like grief – registered by the brain in ways similar to physical distress. Emotional pain and physical pain also involve common neurotransmitters. The difference between depression and grief, though, is that grief has an obvious cause of pain, whereas, for some depressed patients, the cause of the pain may be much more convoluted and multifaceted.
In the midst of a depressive episode, there may also be a feeling of painful loss, which we see in grief and heartbreak. But in depression, there might not be a clear loss as such, only the pain of something akin to grief or heartbreak, without an object of pain (the person you have lost from your life). In many cases, nevertheless, I would posit that the feeling of painful grieving or heartbreak in depression comes from the loss of various important aspects of a person’s life, such as one’s vitality, identity, hope, meaning, connection, and ability to experience pleasure and joy in life.
The Tortured Mind of a Depressive
Another way to imagine the pain of depression is to think of the ways in which we can experience mental torture. Experiencing a ‘bad trip’ on psychedelics would be one example. Anyone who has had a particularly distressing or difficult experience with a substance like LSD or magic mushrooms knows that it can be like mental torture. It can involve getting stuck in ‘thought loops’, being overwhelmed by disturbing or racing thoughts, or experiencing severe paranoia, suspiciousness, despair, anxiety, or panic.
This isn’t to say that a depressive episode is the same as a bad psychedelic trip, but it can, similarly, involve a kind of mental torture. In depression, you may also experience emotional and psychological states that are distressing due to their severe and uncontrollable nature. You can also be tormented by dark inner voices and feel so trapped by the pain and the experience that you become overwhelmed. What sets apart depression from a bad trip, however, is that the former can continue unabated. Depression is like a prolonged bad trip.
If we include this kind of psychological distress under the umbrella of human pain, then this would make it easier to understand the pain of depression. We may also be able to draw some comparison between physical torture and psychological torture, the latter of which can cause as much mental anguish as the former. It would be imprudent to say that the mental torture that depressed patients report is the same as that caused by methods of psychological torture, such as sham executions, witnessing the torture of loved ones, or threats against loved ones, but we can still picture a quality of psychological torture experienced by the depressive.
In depression, one’s own mind becomes a torture chamber, with a persecuting and intimidating voice never letting up, hurling abuse and insults, and even making threatening demands for self-destructive behaviours, such as self-harm and suicide. This is a form of torture for many people living with depression. Unfortunately, the pain cannot be put to an end by disclosing information or paying a ransom, as might happen with traditional torture. It can take a lot of a work and a long time to turn the prison cell of the mind into a safe haven, to transform the torturer into an ally.
The Pain of Isolation
As inherently social creatures, it is clear that solitary confinement causes severe psychological distress to us – that’s why it is so often implemented as a form of punishment. It’s up for debate whether solitary confinement should be classed as torture. We do, however, see widespread recognition (from human rights organisations to the United Nations) that prolonged solitary confinement is a form of torture. Regardless, it is clear from subjective accounts of this punishment that it can involve a high degree of psychological pain, due to our human need for social interaction.
I bring up the topic of solitary confinement, as I believe it acts as a somewhat useful metaphor in describing the quality of isolation found in depression and the concomitant pain. In a depressive state, the isolation doesn’t just result because one has a proclivity to physically isolate oneself from others and withdraw from the world. The isolation and loneliness is also a subjective feeling that doesn’t necessarily dissipate when interacting with or being around others. As with the previous discussion on torture, I won’t try to draw an equal comparison between solitary confinement and the isolating nature of depression – my only reason for making some comparison between the two is to underscore that it is possible to imagine how isolation can be psychologically painful. It is possible for the mind to go to a place where it is cut off from others, where you feel utterly alone and stranded, even if physically you are not being confined in a cell and unable to engage in social interaction.
As already touched upon, a classic sign of depression is the wish to withdraw from others. This symptom is not innocuous or a sign that someone is just being a bit distant and needs some time alone. Research has revealed that loneliness causes observable, deleterious changes to our organs (including our brain), affecting our overall health (both mental and physical). Loneliness is also associated with activation of the same brain regions involves in the processing of physical pain. Social disconnection is, for all intents and purposes, painful. When you are socially isolated or feeling lonely, you may not be able to locate an area of yourself that is in pain, but you do have a sense of being in pain. The evolutionary reason for this is that social isolation was extremely disadvantageous for our hunter-gatherer ancestors who achieved evolutionary success by banding together in tribes and acting in a cooperative manner. Those who lost contact with their tribe could have very easily lost their lives. The pain of loneliness, like the pain of physical injury, is a signal to avoid danger or doing some action (i.e. remaining isolated).
The unfortunate nature of depression, though, is that it causes you to act against your best interests. The evolutionary psychiatrist Randolph Nesse has written extensively on why mental illnesses like depression may have evolved (including in his latest book Good Reasons for Bad Feelings). After all, depression does not seem to benefit us, so it is curious as to how a condition like this was not eliminated by natural selection. According to Nesse, depression is an offshoot of normal emotions (low mood) that can be advantageous in some situations. He argues, for instance, that low mood can help us conserve energy and focus our attention and energy on what’s most important. Evolution is not a perfect system, so clinical depression may be a maladaptive byproduct of an adaptive mechanism or the extreme version of beneficial emotions. However, what could the possible benefit be of an urge to withdraw socially? In one paper he notes:
At first glance, it seems impossible that there could be any benefit from lacking energy, being fearful, and withdrawing from social life, to say nothing of the problems caused by not eating or sleeping. Any discussion of depression must start by acknowledging that it often is a pathological condition with no adaptive value. However, what about more mild variation in states of motivation?
Nesse points to researchers who “see some depressions as states of withdrawal in which the individual regroups to emerge with alternative strategies.” Regardless of how we delineate the benefit of having some tendency to socially withdraw and in what scenarios this could prove useful, it is clear that social isolation and loneliness – which can be especially acute and prolonged in depression – is psychologically painful. Moreover, it’s crucial to make a distinction between social isolation and loneliness. The latter is a subjective experience and – as alluded to earlier – can be experienced by a depressive (or anyone, for that matter) who still, nonetheless, has social connections. Modern society itself is alienating in all sorts of ways and this undoubtedly contributes to the high rates of depression we see. The loneliness epidemic and depression epidemic go hand in hand.
In terms of the intense, subjective feeling of loneliness in depression, I do wonder whether the brain registers this as painful in the same way as physical social isolation. I wouldn’t be surprised of course, not just because of how painful this loneliness feels from the first-person point of view, but also based on the assumption that the brain can become perturbed and disordered, with certain painful states of mind arising that may not seem to correspond with reality (such as feeling isolated despite being surrounded by loved ones). On the other hand, there are often reasons that you may feel lonely while having plenty of friends, such as not deeply connecting with others (social media doesn’t help in this respect), not being authentic, and not trusting others. Depression can both contribute to these issues and be a consequence of them. Yet whichever the direction of causality and however loneliness manifests in depression, the feeling of being completely alone is, unquestionably, painful. This sense of loneliness is also usually exacerbated by the difficulty of the depressive in communicating their pain to others and having it understood. This is why therapy and mental health support groups can be ameliorative. They often reduce feelings of loneliness.
Physical Pain in Depression
Depression is painful for many other reasons. For instance, depression results in a greater sensitivity to pain (known as hyperalgesia). This is because depression is commonly triggered by chronic stress and prolonged stress, unlike acute stress, makes us more sensitive to pain. For this reason, the hyperalgesia in depression can make you notice minor pains that you would otherwise ignore. Furthermore, since depression is often accompanied by a decrease in physical activity and sleep problems, this may also lead to an exacerbation of pain, as we know that both exercise and restful and adequate sleep involve the release of endorphins (pain-relieving chemicals). Studies have shown that poor sleep, which many depressives suffer from on a long-term basis, results in more pain sensitivity the next day. Other signs of depression that people may not normally associate with the condition include aches and pains. For many people, depression can feature back pain, stomach pain, chest pain, joint pain, muscle ache, and headaches.
Thus, it is misguided to say that depression is “all in your head”. Even if we discount all the physical pain linked to depression and the other ways it affects the body (e.g. fatigue, lack of energy, changes in appetite, vision problems, and sleep problems), to tell someone who is depressed that their psychological pain is all in their head is to invalidate them. This would be similar to telling someone grieving that their pain is just self-created and they need to change their attitude. When the author Johann Hari first went to visit his doctor for his depression as a teenager, he said “I had this feeling, like pain was leaking out of me,” and he couldn’t control it. We must take these reports of pain seriously and endeavour to treat them with the same compassion that we afford to every other kind of pain. This is central to the effort of reducing and eliminating mental health stigma.