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Depression (Unipolar) - The Biochemical-Psychosexual Revolution: Getting Up and Close while Being Down and Out
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The Biochemical-Psychosexual Revolution: Getting Up and Close while Being Down and Out
Mark Gorkin, LICSW, "The Stress Doc"

A recent email plugged a hole in my curiosity zone. I believe the original series on my depression struggles and meds trials noted how reduced sex drive - whether capacity for erection or for orgasm - was a not too uncommon side effect of the new antidepressant SSRI medications. Around this time, another one word pharmaceutical product was stirring the next medical-psychosocial revolutionProzac meet Viagra! And the inevitable question: which is greater, the immovable object or the irresistible force? Or is it the irresistible object and the immovable force? Careful, Doc, you're bordering on the psychosexually incorrect. More to the point, could Viagra counter the libido inhibiting tendencies of the new wave of antidepressants? And the first return isWell, good news and bad news.

Prozac and its SSRI cousins often have a variety of side effects, for example, increasing general energy levels (though also inducing periods of drowsiness) and, for some, seemingly stimulating aggressive energy displays. These meds also help diminish levels of agitation and obsession. Yet, as noted, Prozac also dampens sex drive. (Of course, depression when serious enough can totally shut down interest in sex; mild-moderate depression, however, has been known to turn some folks loose sexually, albeit, dysfunctionally.)

As for Viagra, it has an arousing effect by directing blood flow to the male sexual organ. A guy gets pumped up, you might say. Some degree of sensitivity, along with erectile capacity, are enhanced. So...what's the resulting interaction -- is there any "chemistry" -- when Mr. P meets Ms. V? And the practical question: should a male consider using Viagra routinely when experiencing SSRI-induced sexual functioning side effects?

First Hand Account

Clearly, a male should consult his or her physician when pondering this issue. But for right now, here is a reader's online/frontline report (the first I've received) on the effects -- primary and side -- from mixing Prozac and Viagra:

"I don't even try to masturbate anymore, as it just doesn't work. (Our protagonist is on 20mg of Prozac. He's overseas, wife's in the states.) I was VERY glad though that when she visited me recently I had my first opportunity to test things out - taking Viagra during her time here. When I took the Viagra I was able to achieve good erection. However, I still couldn't climax - which was a real drag after enough time went by!! So this side effect is definitely one I don't care for! The only good aspect is I do maintain longer - just no pot of gold at the end of the rainbow. :( " (Of course, one suspects his wife is not complaining too vociferously. ;-)

Well Mr. Good News/Bad News some consoling words, if as the say, "Misery doesn't just like company but, actually, likes miserable company." More than one puzzled "e-male" correspondent has bemoaned the absolute or relative loss of a capacity to ejaculate on SSRIs. Other readers have also given up on masturbationGee, talk about being disconnected from one's consoling inner adolescent; from being deprived of momentary stress relief in the palm of your hand, as it were.

Then again, sometimes there's an upside to being dammed (not damned) auto-erotically. When practiced compulsively, masturbation may also reflect a need to self-medicate (or to numb oneself) when feeling overwhelmed by depression, rage or panic. And when regularly combined with pornography, auto-eroticism may distort the ability to be emotionally intimate with a real partner. Also, I believe the latest statistics indicate that as many as 200,000 folks (mostly male, I suspect) are likely addicted to online pornography of some kind.

Of course, some men are hypercharged by agitation, an aggressive power status or drive and/or "The Big Dipper"-like testosterone levels. (For example, think of certain bipartisan residents of Washington, DC.) But for mere mortals, as a man ages and matures (or, at least, as some do) there often needs to be more than just a physical turn on for achieving satisfying sexual performance. And for genuine sexual and emotional intimacy...well, better living and relating takes more than just chemistry!

So today, let's grapple with how depression impacts the ability to healthfully and passionately unite sexuality and intimacy. (I'm as curious as you to discover what we uncover.)

1. Depression as a Biochemical Catalyst for Thrill-Seeking. If the depression state isn't completely overwhelming or paralyzing it can easily fuel risk-taking and addictive behavior. For example, one study found a relationship between mood disorder and compulsive gambling. The gambler needed to create excitement for temporarily escaping his moodiness. Of course, this usually produced a self-defeating and even more depressing outcome.

In addition to abusing substances like food and drugs, to compensate for diminished levels of mood regulating serotonin and dopamine, a person may self-medicate naturally through relentless aerobic-endorphin producing exercise or through sexual obsession and predatory activity. (Now some folks combine both, though it usually takes a very good male for sexual activity to rise to and to sustain aerobic levels. ;-)

So adrenaline and testosterone are often working overtime to fill the biochemical and hormonal gaps. And a variety of chronic stress conditions may result, including high blood pressure. Not just your hormones but your heart is at risk with unrecognized or untreated depression.

2. Depression as a Psychphysiological Catalyst for Diminished Energy. While depression often induces exhaustion, the prevalent image of a person cowering under covers or retreating to a bedroom for days and weeks doesn't do justice to the mind-body complexity. For example, let's look at agitated depression. A restless night, an inability to fall back to sleep, easily induces grogginess and fatigue. However, the same agitated component can have the depressed individual jumping out of bed at first morning light. For example, a hyper-depressed trait had me at a writer's desk two minutes after waking, without coffee. However, I could not sustain the intensity and concentration for long and would invariably crash. And it takes energy to preserve and recognize healthy boundaries

3. Depression as a Catalyst for Low Self-Esteem. Clearly, if you can't fully control and predict your own energy level, your ability to focus or to start and sustain tasks and achieve goals then seeds of self-doubt, unworthiness and inadequacy are being sowed. Dreams too are abandoned. Why is it that other's can be more disciplined, motivated and successful? And, of course, it's a short step from unfavorable social comparison to two distinct yet complementary "survival" patterns: a) avoiding others one finds ego deflating or intimidating or b) anxiously needing and soliciting the approval of others. Clearly, we are talking dysfunctional, often depression-inducing codependency.

4. Depression as a Catalyst for Psychosexual Fusion. A common experience for the clinically depressed individual is a profound sense of emptiness. A body aching yet, paradoxically, hollow inner feeling. Ones inner foundation and scaffolding is fragile at best. For example, at nineteen, when my parents unexpectedly announced their separation, with my father moving out, I instantaneously burst into anguished crying. Not only was my family structure crumbling, but my personal facade was cracking: my inner hollowness was exposed. The game that a family and a child can cruise along blindly and self-deceivingly was being shattered. Yet, as the artistic giant, (though, perhaps, relationship pygmy) Pablo Picasso noted, "Every act of creation is first of all an act of destruction." Thankfully, the dissolution trauma was the beginning of a long and painful recovery process:

What made him break
From our mistake
Perhaps well never know.

But in the wake
Of psychic quake
The formula to grow.

The silence cracks
Each spouse attacks
The couple hardly known.

But on these tracks
Of broken backs
Emancipation sown.

However, at the time and for a seemingly interminable future, profound self-doubt lurked and stalked in the background and foreground.

And one way to shut down this chaotic Intimate FOE: Fear of Emptiness/Fear of Exposurebecome symbiotically attached to a partner. And the more intense the sexual relationship the more potent the anesthetic. Theres the illusion of plugging the black hole of depression. With this desperate attachment, the depressed individual seemingly feeds intravenously off a partner, ravenously sucking away energy nutrients and ego needs. Or one can project feelings of inadequacy through hostile attack. And, surely, aggression and sex can also feed off, if not fuel, each other. And now those sexual hormones are percolating and pumping throughout the system. Alas, what goes up fast and over the intensity edge usually comes down fast and painful. Fuse harddie hard!

5. Depression as a Barrier to Quietness and Separateness. The flip side of needing to numb and fuse is a profound difficulty living and relating in a state of quiet. We extol human doing not just being with another. First, with all the turbulence underneath the heavy depressive cover theres a fear, if not terror, of stillness and quiet. Stillness, for the depressive, borders on emptiness which can so easily morph into another "bottom of the dark and dank pit" free fall mood cycle.

Conversely, some of us use a manic-like, Type A achievement frenetic mode to defuse the depressive demons and impress a potential partner. Letting go of talking about work, especially of the high of ones most potent sources of identification and pride (for example, children, creative achievement, etc.) robs the emperor or princess of his or her clothes, that is, ones persona or psychic cover-up.

Now suddenly, one is vulnerable, shamefully flawed. Who would want to get close to this wounded, needy, spineless, bottom of the barrel creature. As Simon and Garfunkel observed decades ago, the "Sounds of Silence" can be fearfully deafening.

6. Depression as a Catalyst for the Separation-Attachment Catch-22. The eternal bind for the depressed individual is a need to numb the "chasmotic" inner dead and dread. (Chasmotic is my newly minted term uniting chasm (or disconnection and emptiness) and the chaotic. The depressive longs for and urgently seeks a sheltering partner from the storm. But as the storm is primarily inner, three possibilities likely unfold, especially as one gets increasingly intimate, physically and emotionally:

a) a fear of psychological abandonment, that is, "something always goes wrong," "this good feeling cant last," "the person will eventually leave me" (or whats wrong with her for wanting me, anyway?"),
b) a bailing out strategy "Ill reject you before you reject me," and
c) a tendency to find fault as the infatuation and hormone levels dim with an increasingly "obvious" imperfect mate. Yet, when the depressive isnt self-isolating he or she often will do almost anything not to be left alone or left out. The person too often lingers in a dysfunctional, ever critical and dissatisfied dance. Of course, if playing the role of the depressives moody target, you are inviting your own "sympathetic," codependent mood disorder.

So the depressive wildly swings between what pioneering psychoanalyst Otto Rank called "The Life Fear and the Death Fear": The life fear occurs when the individual is afraid to separate from another for fear of isolation and emptiness. The death fear prevents closeness; its the terror of being swallowed up, of losing ones sense of self in a too entangled, too smothering or, even, too intimate bond.

7. Depression as a Barrier to Trusting and Saying, "I Love You." If the depressive is forever caught in approach-avoidance mood shifts, chasing then running from commitment traps or clinging to codependent fusion one condition is obvious: theres no sense of a solid center, no clear sense of integrity. To be able to trust, openly not blindly, in a give and take adult relationship requires an ability to declare: "This is who I really am" (no matter what you may think or feel, or what I believe you think or feel). "This is whats happening to me in relation to you" (whether you think its right or wrong, good or bad. And you are free to disagree.) "I have these thoughts and feelings I need to express constructively -- firmly, or tentatively, passionately or rationally" (whether you decide to stay or withdraw).

One must build trust, not simply declare it. Like commitment, trust evolves or erodes over time and space. And, of course, for the on the edge, untreated depressive frustration tolerance and patience, capacity for risk and for closeness are qualities often dangerously low in supply.

Clearly, theres a powerful interaction when mixing depression, sexuality and the quality of relating. As the German philosopher Friedrich Nietzshe observed in Beyond Good and Evil over a hundred years ago: "Sensuality often forces the growth of love too much; so that its root remains weak, and is easily torn up." Nietzshe, a brooding genius, understood that a dark mood unchecked while seemingly cultivating the ambiance for romance, more likely yields a "romantasy" fungus. Craven sensuality and unchecked clinical depression erodes or suffocates the foundation of genuine friendship and the potential for a loving, sexually intimate partnership. This volatile mix makes an endangered species of "Four C-ing Love," a love based on: Chemistry, Caring, Cosciousness and Commitment. As that other, more contemporary yet no less soulful philosopher, Diana Ross, succinctly noted: "You cant hurry love."

For a future edition, thoughts on my ongoing learning curve about slow growth intimacy. For now, heres to a psychological and, if necessary, a biochemical process of doing and being that transforms depression and romantic addiction into patiently assertive and quietly playful exploration. It's a mutual sharing that also allows us toPractice Safe Stress!