What’s the difference between mourning, depression, melancholia and mania?
Mourning, depression and melancholia are often confused with one another, and mania is, for the most part, quite unknown. The term bipolar disorder, meanwhile, has become prevalent in everyday language whereas its clinical frequency has not changed.
They are all linked to a feeling of loss and, apart from mourning ––which is an entirely normal process that isn’t pathological–– they all belong to what are called mood disorders, those that affect the individual’s affective state, either by lowering it or heightening it.
Since there have been many questions about the subject from people in Madrid, let’s review what the differences are briefly.
Mourning is characterised by a state of sadness and apathy, often accompanied by insomnia and fatigue, that follow a conscious emotional loss. A loss that can be that of a loved one, a place, an activity, or even certain intellectual ideals.
Someone who is in mourning is fully aware of what they have lost; the acknowledgment of the loss leads them to slowly give up all the satisfactions, wishes and hopes that were tied to what has been lost –– hence the feeling of an impoverished world, and profound sadness. An important source of vitality, motivation and interest in their life is gone.
Mourning is not linear: it can be very intense, then disappear, come back at an unexpected time, or be absent at a moment when one would expect it. Although mourning gradually fades with time, it is not unusual for it to last several years if the loss has been that of someone or something deeply meaningful to the person.
Someone in mourning does not need psychotherapy or medication, they need time to reorganise their inner emotional landscape, and to be surrounded by understanding people. If, however, there is no modification in the sadness and the apathy over time then we talk about pathological mourning, which is a form of depression.
Depression manifests by the same signs as mourning ––in this case we call them depressive symptoms–– except that the depressed person has no conscious awareness of what they’ve lost, even though they feel a lack of vitality and motivation.
The depressed person does not understand why they feel the way they feel; something is happening to them ––apparently without reason, or with a reason that doesn’t justify the intensity of their distress–– that invades their psyche, and in the face of which they are helpless. The person feels there is no “logic” to their depression.
Depression is as nonlinear as mourning: it can come and go without any apparent reason. What differentiates depression from mourning is that it does not fade with time. The depressed individual, since he is not aware of what is causing the depression, cannot undertake the long process of working through the feelings that eventually resolve mourning; as a result, depressions tend to become chronic if they are not treated.
The unconscious reasons that lead an individual to be depressed are so numerous that we cannot really talk about one common aetiology to all different depressions. Let us name, nevertheless, some of the most frequent ones: a feeling of inner powerlessness, wounded self-esteem, punitive moral sense, lack of relational interaction, and self-destructive behaviour often underlie depression. Each one of these situations is propped up by complex unconscious scenarios that immobilize them into closed feedback loops.
Experience shows that it is rare for depression to cure itself without treatment; depressed individuals may develop all sorts of strategies to escape from their depressive feelings ––addictive behaviour, flights into pseudo-progress, compulsively changing lifestyles, amongst others–– but sooner or later the symptoms reappear.
In order to resolve depressive disorders in the long term it is necessary to undertake psychanalytic or psychotherapeutic work that will allow the individual to unearth the unconscious conflicts, work through them, and free himself from the burden that he unwittingly carries.
In the case in which depressive symptoms are so incapacitating that they do not allow the individual to maintain a minimum quality of life (being severely and chronically unable to leave the home, to work, to take care of one’s children) some medication will be prescribed until the person recovers sufficiently, and will then be progressively reduced. It is important to note that medication only offers symptom relief, it does not offer long-term solutions.
Melancholia is a severe kind of depression, that shares with it everything that we have described here above, but is distinguished from it by the presence of violent and unjustified self-criticism that is mostly absent in non-melancholic depressions.
The individual that suffers from melancholia tortures himself with critical, denigrating and insulting thoughts, that have no justified reason to be, and that have a devastating effect on his self-esteem.
This last point is important because, as well as the depressive feelings present in all forms of depression, in melancholia there is also the aggravating factor of the destruction of self-worth which intensifies the depressive experience. Hence the risk of suicide is greater in melancholia and must be carefully assessed when the person seeks help.
Unlike non-melancholic depressions, whose origins can be extremely varied, we do have more indicators of what the aetiology of melancholia may be. It is not unusual that, during the treatment of a melancholic patient we come to have the impression that the violent criticism that the patient directs towards himself could, in fact, apply to what he felt towards another person who has been important in his life –– someone who has been fiercely loved and hated. This suggests that, at an unconscious level, there is fusion-confusion between the patient and this person of their past with which he has maintained such an ambivalent relationship –– from this we can understand that, in fact, the hate directed at himself is actually directed at another person confused with himself.
With regards to the treatment of melancholia, it is similar to depression. The psychotherapeutic work will aim to help the patient to become aware of the intensely ambivalent bond that he has had with that loved-hated person, and will assist him ––through deep emotional understanding–– to separate from that person in his mind. This implies a long process of working through separation-differentiation as well as finding more beneficial channels for unconscious aggression. As in the treatment of severe depressions, if need be, medication can be prescribed during a limited period of time.
Mania is the opposite of depression. It is characterized by a euphoric, grandiose, exalted mood, an excess of self-confidence, and non-stop activity that is often accompanied by logorrhoea. Insomnia and irritability are also often present.
In its more severe, psychotic, manifestations, it brings about a loss of the sense of reality that is expressed by delusions of grandeur that can lead the patient to undertake impossible projects, or spend enormous sums of money. There are also less severe forms of mania, called hypomanic states, where the sense of reality is preserved.
Mania in the clinical sense of the term has nothing to do with what in everyday language is called “being a maniac”, which refers to madness in general or having excessive enthusiasm for something. Someone who suffers from mania is manic, not a maniac.
Mania never presents itself as a solitary symptom, it is always accompanied, sooner or later, by a depressive or melancholic episode. Even certain hypomanic states that seem to have no end have a hidden depressive side that is not always observable from the outside. If there are depressions without mania, why then aren’t there manias without depression?
Because mania is a defence against depression, a very costly defence for the organism in terms of the amount of energy spent, and it is not possible to keep it up for a long time. It is a way of protecting oneself from depressive feelings by transforming them into the opposite ––a common defensive strategy, for that matter–– but that defence only works for a certain period of time before the organism is exhausted and reality re-establishes itself. Then comes the pendular movement towards depression, aggravated by the contrast with the previous manic state and the burnout that it has caused. This is the origin of manic-depressive states, now called bipolar disorders.
People who are suffering from a manic episode do not usually consult a mental healthcare professional during the episode –– the grandiosity that comes with mania protects them from feeling any sense of need of help. It’s when mania swings into depression that they become aware of a need of help.
In less severe cases, such as hypomania, intensive psychotherapy may be enough. In cases where there is a psychotic loss of a sense of reality it is highly recommendable to complement psychotherapy with mood-regulating medicine until the patient can regulate his own emotional states well enough.