An Unusual, Overlooked Sign of Depression

Stimulation-seeking and missed diagnoses.

• Depression is deflating, but some sufferers learn to feel energized with risky thrills.

• The onset of theft, fighting, infidelity, and/or excessive gambling can signal depression.

• Evaluating for and treating depression could dissolve the problematic activity.

Thrills and depression are seemingly unlikely bedfellows, but they're more collegial than one might think. At first, readers might think this refers to depression arousing creative expressive energy. After all, centuries of musicians and writers, for example, have discovered silver linings to their affective plight when it engendered well-crafted songs or prose.

While indeed having created these works could buoy the spirits of the artists, there is another variety of more habituated, immediate thrills that become embedded in some patients that may make them seem more characterologically disturbed than depressed.

Not the Usual Suspects

It's not unusual for teens to be referred for intervention or become court-involved for theft, perhaps even kleptomaniacal activity, or fighting. Relationship therapists encounter infidelity, while family therapists may see parents concerned about their child sneaking out.

While all of these scenarios could be accounted for by things like misplaced anger, cluster B personality disorders, stimulation-seeking in severe ADHD, or even, to some degree, age-appropriate rebellion, it must be recognized that these concerning actions do not always occur within such expected confines. Consider the case of Aiden and Jenna (names disguised), a young, married couple I worked with early on.

Jenna called for an appointment because she was concerned about recently discovering Aiden’s online gambling and flirtation on pornographic chat rooms. Upon getting to know Aiden, it became clear the onset of these activities coincided with months-long worsening depression spurred by various unfortunate events.

His guilt and shame about engaging in these were palpable, and discussing the matters initially lowered his spirits even further. Jenna knew this "wasn't him" and remained understanding as we navigated the fallout of trust issues. What Aiden explained was that the risk-taking of gambling made him "feel alive," while gaining the attention of several women, albeit superficial, made him feel desirable amidst a horribly-low self-image.

As I matured in my career, similar scenarios played out across couples, families, genders, and ages. Mason (name disguised) was a college-aged male, referred for plunging academic performance at a prestigious institution.

Mason presented and described a classic dysthymic, or chronic, mild-moderate depressive, experience. In the second session, he offered, "I fight a lot." Given many depressed males' dysphoria is irritability instead of sadness, which can cause squabbling in relationships, I was ready to hear about a penchant for argumentativeness.

It was surprising to hear he meant he was essentially looking for fist fights. Mason confessed that after a sports event one weekend, an inadvertent brawl seemed to have been an outlet for his frustrated state of affairs. However, he described coming to chase "a charge" that came with the activity.

The fighting, which Mason discovered he had a knack for, sustained a sense of superiority and provided stimulation in an otherwise deflated existence. He realized it could eventually lead to legal problems and removal from school, which would create an existential crisis.

First Glance

It's easy to focus on the problematic activity, given that it led to the referral. However, jumping straight to pointedly trying to eliminate the gambling, stealing, etc. may only bring frustration to the patient and practitioner. Realizing these activities tend not to exist in a vacuum is an important part of treatment. Not unusually, the impetus stems from a bigger clinical complication; essentially, remove the fuel, and the fire subsides.

In 2002, Lejoyeux noted that patients with kleptomania and pyromania had significant numbers of depressive episodes. In fact, there's a body of research concerning gambling (e.g., Edgerton et al., 2018; Rogier et al., 2019), stealing (e.g., Fishbain,1987; McElroy et al.,1991; Talih, 2011), and fighting (e.g., Dutton & Karakanta, 2013; Krakowski & Nolan, 2017) being highly correlated with, and even encouraged by, depression.

Relationship experts such as David Ley, Ph.D., (2010) have written about how infidelity, for some, evolves as a remedy for depression. Like Aiden, the people Dr. Ley has dealt with reported excitement and higher self-esteem. Ley also explained how someone pursuing an affair is more apt to take care of themselves for appearance’s sake, and may take to exercise and better self-care, which in themselves may be antidotes to depression.

Evaluating If Depression is the Root Problem

People can, of course, have baseline habits of stealing, fighting, infidelity, fire-setting, or gambling, and experience superimposed depressive episodes. Perhaps the depression is even due to the pickles they find themselves in because of their unsavory activity. In those cases, it will be important to manage the activity of choice in order to curb the depression. It must be evaluated if the reverse is true, however, like in the aforementioned scenarios, as that will dictate a focus on depression to help dissolve the concerning behaviors.

The following considerations can help understand the nature of the relationship to depression in evaluating people presenting for impulse control matters, fighting, or infidelity.

Make sure the behavior does not coincide with a head injury or other physical complication or initiating a medication. Some SSRIs, for example, have been correlated to cases of onset of impulse control disorders (e.g., Kindler et al., 1997; Gupta, 2014).

Is this an occasional burst of behavior, or a long-standing, baseline problematic activity? If sporadic, that may be indicative of occurrence only during mood episodes. If the latter, it is more likely related to things like obtaining drugs or personality disorders.

After the above, evaluating for the presence of depression is the foremost consideration. If depression is extant, it is essential to survey if the periods of concerning activity coincide within the confines of the episode(s).

If depression is present, is it part of a mixed mood state, as written about in The Spinning World of Major Depression with Mixed Features? If so, referral to psychiatry for a mood stabilizer medication as used in bipolar illnesses may be helpful in controlling the matter, as the hypomanic or manic components would be the culprit.

Anthony D. Smith LMHC

References

Edgerton, J.D., Keough, M.T. & Roberts, L.W. (2018). Co-development of problem gambling and depression symptoms in emerging adults: A parallel-process latent class growth model. Journal of Gambling Studies, 34, 949–968.

Fishbain, D. (1987). Kleptomania as risk-taking behavior in response to depression. The American Journal of Psychotherapy, 41 (4), 598-603.

Dutton, D., and Karaktan, C. (2013). Depression as a risk marker for aggression: A critical review. Aggression and Violent Behavior, 18 (2), 310-319.

Gupta, P.R. (2014). Emergence of kleptomania during treatment for obsessive compulsive disorder with fluvoxamine. Indian Journal of Psychiatry, 56, 100‑101.

Kindler, S., Dannon P.N., Iancu I., Sasson. Y., & Zohar, J. (1997). Emergence of kleptomania during treatment for depression with serotonin selective reuptake inhibitors. Clinical Neuropharmacology, 20, 126‑129.

Krakowski, M. & Nolan, K. (2017, February 27). Depressive symptoms associated with aggression. Psychiatric Times, 34 (2).

Lejoyeux, M., Arbaretaz, M., McLoughlin,M., & Ades, J. (2002). Impulse control disorders and depression. The Journal of Nervous and Mental Disease, 190 (5), 310-314.

Ley, D. (2010, October 10). Can infidelity cure depression? Can extramartial sex self-medicate against the effects of depression? Psychology Today. https://bit.ly/3NCPNG7

McElroy, S., Hudson, J., Pope, H., & Keck, P. (1991). Kleptomania: Clinical characteristics and associated psychopathology. Psychological Medicine, 21 (1), 93-108. doi:10.1017/S0033291700014690

Rogier, G., Picci, G. & Velotti, P. (2019). Struggling with happiness: A pathway leading depression to gambling disorder. Journal of Gambling Studies 35, 293–305.

Talih F. R. (2011). Kleptomania and potential exacerbating factors: a review and case report. Innovations in Clinical Neuroscience, 8 (10), 35–39.