A cruel trick: diurnal variation
Persistent diurnal variation of mood is one of the more reliable markers of a biological depression. However, something I have observed over the years, which does not seem to crop up in the literature, is this: the improvement of mood that occurs in the afternoons and evenings, and the return of severe symptoms on waking next morning, is something that can gradually get less noticeable if the illnesses becomes more severe and has been present for some time. In other words, as the illness is developing, diurnal variation is most noticeable; if-and-when the illness reaches a severe degree, then diurnal variation becomes less noticeable. People just feel like ‘death-warmed-up’ the whole time.
The converse is also true. As more severe illnesses start to improve and respond to treatment, the early improvement is usually most noticeable in the afternoons and evenings, but then, when people wake up next morning, they feel as bad as ever. If you ask someone with severe illness ‘what is your first thought about the day ahead when you awake’, the answer is frequently ‘OMGAD’ (Many suffers guess that immediately, I spell out that acronym below***). Hence the heading of this piece, ‘A cruel trick’. I am sure that this phenomenon has been responsible for many people giving up on treatment, or despairing of improvement, because they feel better in the afternoon and think the illness is improving, only to wake up as-bad-as-ever the next morning. If no one has provided the above explanation that phenomenon is a profoundly discouraging experience.
Remember the ‘waves on the beach’ analogy above, remember to compare like with like, i.e. afternoons with afternoons, or mornings with mornings, and remember to compare averages of several days, with a gap of a few days in between, to judge change. Also, as I sometimes commented to patients ‘I do not care how you feel’. That made people stop and listen! Instead I want to know what you have done, compared to before. This point was illustrated only a few days ago, in another skype ‘consultation’: ‘How are you going’? ‘I am more anxious …’. This person felt they were not improving. But a couple of brief questions made things clear. They had in fact managed to go shopping, alone, twice in that week, in order to get the ingredients to cook a meal (for the first time in a while) and also been to a drinks party and ‘coped quite well and enjoyed it, a bit’. And there was more! No wonder anxiety had increased. In relation to this remember ‘Salami tactics’ above, and the aphorisms, ‘Slow and steady wins the race’, ‘Do not try to run before you can walk’, and ‘Do not bite off more than you can chew’.
If people are doing more activities that is strong evidence that they have more drive and energy: if that core symptom is improving one can be quite sure they are getting better. As president Nixon is quoted as saying, ‘When you’ve got them by the balls, their hearts and minds are sure to follow’.
Enough said. *** The acronym OMGAD: ‘Oh my god, another day’.