Read an Excerpt
Chapter 1
The Body Blues
Women's Number One Mood Problem
At any given time, tens of millions of women are troubled by a syndrome for which they have no name. One of the most common complaints is feeling tired and sluggish much of the time. To their dismay, the women don't have enough energy to be the patient moms, supportive partners, or fun-loving friends they would like to be. Although they know that exercise would help revive them, they rarely have both the time and the motivation.
Many women with this syndrome have sleep difficulties as well. They have trouble falling asleep or staying asleep--or they sleep too much. The common denominator is that they feel drowsy during the day, whether due to a lack of sleep or general drowsiness. Those times when they feel alert and energetic all day long are a welcome relief.
Difficulty concentrating is another telltale sign of this disorder, especially in women 35 and older. The women have trouble focusing on tasks, absorbing complex information, or finding just the right words to say when they talk. Verbal slips and difficulty remembering names--even the names of people they know really well--can be a source of embarrassment. Curiously, these mental lapses can come and go. For days at a time, they feel mentally sharp. Then, for some unknown reason, their thinking becomes fuzzy or scattered. It's as though their IQs had dropped 10 points overnight. Middle- aged women can be especially troubled by these mental symptoms because they fear they might have the early signs of Alzheimer's disease.
Many of the women also feel stressed and irritable. They can be annoyed by simple things such as the sound of construction from a neighbor's house, a partner's eating habits, or being put on hold on the phone. Even when the pressure is off, some women find it hard to relax. A drink or two is a fast way to unwind, but relying on alcohol to relax can lead to alcohol dependency. A more common way to relieve stress is to watch TV or read a book. These two remedies work reasonably well, but they take away from the little time women have to be creative or take on ambitious projects.
But the most common and vexing symptoms of this syndrome are overeating and weight gain. In the morning, most of the women have little trouble controlling their appetite. But sometime in the afternoon, they begin to snack. They also feel an urge to eat whenever they are feeling anxious, tired, or stressed. Women say that certain foods are more soothing than others, especially pasta, pizza, sweets, bread, and chocolate. In fact, a craving for sweets and starches is one of the defining characteristics of this syndrome.
The logical result of feeling too tired to exercise and eating too much is being overweight. Some women manage to keep the £ds off through rigorous dieting, but most plateau at a high weight or continue to gain weight year after year. One reason being overweight is so troubling to them is that they can't cover it up. If need be, they can disguise the fact that they're sleeping poorly, forgetting names, or feeling irritable. But they can't deny that they're overweight. It's the one visible sign of their distress.
There's another symptom that one might expect to find on this list--a depressed mood. But women who have this syndrome do not have serious mood problems. Unlike women with clinical depression, they do not feel sad or tearful all the time. They don't feel hopeless or think that the world would be a better place without them. When something good happens to them, they feel genuinely happy. Most of them perform well at work, even those with high-level, demanding jobs. Nonetheless, they can be very distressed by their fatigue, eating problems, irritability, confused thinking, or sleep difficulties. These symptoms interfere with their relationships, frustrate their ambitions, and rob them of the full enjoyment of life. It's as though their bodies were depressed, but not their minds. They have what I call the "Body Blues."
What Is the Body Blues?
The textbook term for the Body Blues is vegetative depressive symptoms.1 A woman with this condition has three or more of the symptoms listed below to such a degree that they diminish her enjoyment in life and sense of well- being.
. Eating too much and gaining weight
. Low energy
. Difficulty concentrating
. Sleep difficulties
. Irritability or tension
. Daytime drowsiness
. Decreased interest in sex
. Mild anxiety
. Mild depression
. Heightened sensitivity to rejection or criticism
A woman can have the Body Blues all by itself, or it can be a part of other disorders. For example, PMS could be viewed as the Body Blues plus bloating, cramps, or breast tenderness. Postpartum depression, or the "baby blues," could be seen as the Body Blues but with more severe mood problems. Menopausal symptoms could be characterized as the Body Blues plus hot flashes and physical signs of aging. Seasonal affective disorder (SAD), also known as winter depression, could be regarded as a seasonal siege of the Body Blues. Embedded in all these disorders is the same core group of symptoms listed above.
Men can have symptoms of the Body Blues as well, especially those 40 or older. But the syndrome is far more common in women. First of all, most of the disorders that include symptoms of the Body Blues, such as PMS and the baby blues, are exclusive to women. But even the unisex disorders, such as SAD, are three or more times as common in women as men. For reasons I will explore in more depth in chapter 2, the Body Blues seems to go hand in hand with being female.
Joanne: A Portrait of the Body Blues
In addition to being a professor and researcher at the University of Washington School of Nursing, I am a primary care provider for female patients at the university's Women's Health Care Clinic. Like most practitioners, I see a steady stream of women with the Body Blues. One of my patients (I'll call her "Joanne") has four of the most common symptoms-- fatigue, irritability, low sexual desire, and weight gain. Although these problems bother her a great deal, few people would sense that anything is wrong with her. To the casual observer, she appears to be a competent, confident woman who happens to be slightly overweight.
The primary reason that Joanne made the initial appointment is that she feels tired much of the time. On most nights, she gets 7 to 8 hours of sleep, but when she wakes up in the morning, she still does not feel refreshed. By early afternoon, she is overwhelmed by the need to take a nap. Because her office is in her home, she can lie down whenever she needs to, but she resents taking the time. Napping also makes her feel lazy. "I'm only 39," she told me, "I shouldn't have to take a nap! I feel like my grandmother! Before I had employees, I could nap and not feel guilty. Now I have to sneak around to get the rest that I need."
Joanne also feels stressed and irritable much of the time. "My family bears the brunt of it," she told me. "My employees and clients soak up most of my patience during the day. My son gets what's left. My husband--I'm much more critical of him than I want to be. And for about 5 years, I've had much less interest in sex. Once I get aroused, I enjoy sex. I say, 'Hey, Jim! That felt really good! Why don't we do this more often?' But when I'm not making love, I have little interest in sex at all. Most nights, I'd rather read a book."
Even though Joanne listed fatigue as her reason for making the appointment, I could see that she was even more concerned about her weight. At 5 feet 6 and 172 £ds, she is about 30 £ds overweight. "I have no problem controlling what I eat for breakfast and lunch," she told me during that first appointment, "but everything falls apart in the late afternoon. I eat before dinner, during dinner, and after dinner. It's like I'm on a diet for the first half of the day, then I blow it the second half. I do this day after day." The net result of her frequent snacking and low energy is that she has been gaining about a £d or two every month. Even though she is not obese, her weight troubles her a great deal. She is unhappy about how she looks and feels ashamed that she can't tame her appetite. "I know everything there is to know about losing weight," she said. "I've done it dozens of times. But I can't keep it off. When I've dieted myself out of my size 16 clothes, I've learned not to throw them away because I know I'll be needing them again in a few months. Right now, I'm back in my fat clothes."
Although Joanne did not seem to be seriously depressed, I asked her some general questions about her mood just to make sure. She said her mood wasn't great, but she didn't think she was depressed. "I have my ups and downs," she said. "But most of the time, I feel okay."
"How do you feel about yourself?" I continued. "Do you often feel worthless or inadequate?" Many women have low self-esteem, but it is very common in women with serious mood disorders. Joanne laughed. "My husband would say I have the opposite problem--grandiosity. Most of the time, I'm pretty high on myself." Then she paused. "Except for being so tired. And my weight. I can't seem to do anything about that. And the fact that I'm such a slob. My house is a mess. So is the car. I can haul four sacks of groceries into the house, but I don't go back that one last time to clean out the car. That bugs Jim to no end. When I drive his car, I clean it up. But I leave mine a mess."
As I listened to Joanne, it seemed that she had high self-esteem except when it came to the symptoms of the Body Blues. She thought she was overweight because she lacked willpower. She had a messy house because she was a "slob." I find some measure of self-blame in virtually all women with this syndrome. "Why can't I stick to a diet?" "I know I should exercise. Why don't I do it?" "Why can other women keep the weight off?" "My husband eats everything in the house, and he's not overweight." "Why am I so tired all the time?" "Why do I have so little interest in sex?" "Why can't I remember the names of my best friend's children?" In addition to being troubled by their vegetative symptoms, these women are weighed down by feelings of shame and blame. In some of my patients, the self-criticism seems just as burdensome as the symptoms themselves. Very few women realize that their eating problems and feelings of fatigue, stress, and irritability are due, in part, to their biology.
I asked Joanne if her symptoms got worse just before menstruation, and she said that they did. "But I don't feel great the rest of the month," she said. "It's just that I eat more and feel more tired and irritable just before my period." Normally, I would have asked if her symptoms were confined to the winter, indicating that she might have SAD. But this was the end of June, and she was still feeling sluggish and eating too much. People with SAD feel much better in the summer.
Finally, I asked her some questions about her diet, exercise habits, family relationships, and social support system. As a nurse practitioner, I've been trained to look at the whole person, not just her symptoms. I noted nothing in Joanne's responses that suggested she was in need of personal, marital, or family therapy. At the end of the appointment, I ordered some blood tests to make sure that she did not have any of the physical problems linked with fatigue such as an underactive thyroid, diabetes, mononucleosis, hepatitis, or anemia. A few days later, when all her tests came back negative, I was not surprised. As I had begun to suspect during her first appointment, Joanne is one of the millions of women with the Body Blues.
Why Is This Syndrome News?
The fact that women are prone to having this particular cluster of symptoms has been known for a long time. For example, in the 19th century, the Body Blues was called "neurotic" or "nervous" depression and was considered a "female problem." The Victorians blamed this disorder on a woman's fragile constitution, her childlike nature, or her willful deviation from traditional femininity. Women at highest risk were thought to be those who were too involved in intellectual matters.
The 19th-century cures for the Body Blues seem just as foreign from our modern point of view. When a woman had problems with fatigue, for example, she was said to be "off her feet" and could be sent to bed for weeks on end. While sequestered in her dark room, she was to avoid having company or stimulating her mind--a cure that was in reality a recipe for depression! If a woman ate too much, she was said to be "eating like a ploughman." To tame her appetite, she might be subjected to bloodletting or leeches. If that didn't work, then her ovaries might be removed. Women who felt irritable or displayed "cussedness" were treated with laudanum--an addictive elixir of opium, sherry wine, and herbs guaranteed to cure anyone's ills.
Today, the Victorian remedies for the Body Blues and the 19th-century terms for the disorder are safely tucked away in the history books. The psychiatric community has chosen the label vegetative depressive symptoms because people who have this disorder tend to feel slowed down, weighed down, and sleepy, and they eat too much. In other words, they seem to "vegetate." The modern slang term "to veg out" has many of these same connotations. By contrast, people with more "typical" symptoms of depression have little appetite and tend to lose weight--the opposite of the Body Blues.
Until the 1990s, however, vegetative symptoms of depression were given scant attention. They were regarded as just another variety of depression that happened to be more common in women than men. Few people were aware that these symptoms could plague women throughout their reproductive years-- first manifesting themselves as PMS, then as winter depression, followed by the baby blues, and then perimenopausal and menopausal symptoms. People were too busy focusing on each of these disorders as a separate entity to see what they all had in common.
The Prozac Phenomenon
