Questions and Answers
Question # 38
Are persons with NLD prone to develop Depression?
If so, what may account for this?
How about Bipolar Disorder?
Overview. It should be clear that persons with NLD are particularly prone to the development of Depression as part of a "package" of internalized psychopathology that often appears in late childhood and throughout adolescence (see Content and Dynamics; Question #18).
The development of Depression in persons with NLD appears to result from a combination of factors that lead to fairly consistent experiences of failure, especially in social relating, and even ostracism by valued others and peers. The child/adolescent with NLD finds that he is not invited to birthday parties, not chosen on teams, not sought out for companionship and conversation, and the like. Because of his gullibility, he may also be led into compromising, even abusive, situations that result in much grief and anxiety.
Developmental Dynamics. Like many young children, individuals with NLD do not initially see the inherent value of social relationships beyond the pragmatic level of ensuring one's needs are met. For individuals with NLD, this may last longer, possibly well into early adolescence. As the young adolescent becomes more aware of the value of social relationships, this reflects improved "insight." This is a positive development, but one that can be quickly overshadowed by the personal recognition (another "insight") of not having a social network to enhance one's enjoyment of life. At this stage, one might observe increased agitation, or increased withdrawal, symptoms which should not be ignored or dismissed as simply a part of the NLD syndrome.
This combination of social failures, ostracism, and/or abuse quite "naturally" leads to withdrawal from the situations in which these psychologically painful experiences usually occur. The adolescent with NLD may gravitate more and more to solitary activities and/or to those social encounters that involve much younger persons or adults. This almost certainly leads to problems in identity formation through a lack of opportunities for imitation and experimentation resulting from a lack of contact with age-mates who exhibit such roles. Instead, the adolescent with NLD is very likely to be drawn toward the kind of interactions mentioned above, that tend to be quite unexciting and dull. The fact that many adolescents with NLD are described as drab, unemotional (flat affect), even sullen, is probably at least a partial reflection of this dull, prosaic world wherein they feel relatively safe, and the underlying Depression that is developing as a reaction to continued interactions with it. The absence of growth-engendering psychosocial experiences with age-mates only exaggerates and exacerbates these problems.
Some Clinical Implications. It is important to bear in mind the following: The prudent clinician will not attribute all symptoms of muted emotional presentation, in the individual case, to the neurodynamics of NLD. Conversely, she/he will not automatically attribute all symptoms of muted emotional presentations in a person with NLD to Depression.
These are extremely important, though not the only, "interactions" of Depression and NLD that can be quite complex. Hence, efficacious treatment planning for persons who exhibit both NLD and Depression can be tricky, especially for therapists who have a limited knowledge of NLD, Depression and/or the neurodevelopmental dynamics of NLD that "lead to" Depression. Astute clinicians in the area would agree that mistakes can be made, as it were, "on both sides of the fence."
Being aware of this is the first step toward the formulation of dynamics and potentially efficacious treatment plans in the individual case.
My impression is that this is not any more prevalent in persons with NLD than in the larger population. Indeed, there is no basis in the hypothesized neurodevelopmental dynamics of NLD for this presentation to be seen as probable. I have also consulted with a number of knowledgeable psychological and psychiatric colleagues who concur with my view regarding incidence. This is not to suggest that persons with NLD are immune from Bipolar Disorder. Indeed, some appear to suffer therefrom. But, the etiology of their Bipolar Disorder is, in all probability, quite distinct from the neurodevelopmental dynamics of their NLD and the Depression that often develops therefrom. In a word, this is another example of "measles (NLD) and a broken leg (Bipolar Disorder)." See Questions 7 and 34 for other examples of this.
Effective therapy for the Depression that persons with NLD come to exhibit is probably quite different than that for Bipolar Disorder. For one thing, it is almost certain that therapy for Bipolar Disorder will involve medications that have been shown to be particularly efficacious for this disorder. Effective therapy for the Depression exhibited by persons with NLD would, at the very least, involve cognitive-behavioural interventions that aim to develop skill-building and other behaviours that are expected to render the person more resilient and resistant to Depression. Medications may also be helpful. At this juncture, it would not appear fruitful to go much beyond these broad generalizations. Doing so would entail very complex considerations well beyond those that this website was designed to accommodate.