834747

research-article2019
JHPXXX10.1177/0022167819834747Journal of Humanistic PsychologyBerra

Special Issue: Rehumanizing Psychotherapy—Contemporary

Existential and Jungian Perspectives
Journal of Humanistic Psychology
1­–9
Existential Depression: © The Author(s) 2019
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DOI: 10.1177/0022167819834747
https://doi.org/10.1177/0022167819834747
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Approach

Lodovico Berra1

Abstract
Depression is not merely an inopportune “disease.” Sometimes it is an
opportunity that allows us a new and more authentic view of existence. In
this sense, a philosophical-existential therapeutic approach, which considers
the ultimate meanings of existence, may be more useful, efficacious, and
appropriate. In existential depression, the mood is oriented in a depressive
sense, at first glance in a similar way to other depressive disorders. However,
it is necessary to diagnostically differentiate this sort of depressive state from
others, as it requires a different type of intervention from those typically used
today in treating pathological depression, such as standard psychotherapy
and/or psychiatric drugs. This specific depressive condition originates from
particular reflections and considerations on life, and produces a profound
discomfort, highlighting how the depressive state can represent, at least in
some cases, a pivotal moment of existence. In this article, the author, a
psychiatrist and existential therapist, describes existential depression, its
phenomenology, genesis, and philosophical-existential treatment.

Keywords
depression, existential depression, meaning, meaning of life, phenomenology,
nihilism, suicide, death, existential therapy, philosophical counseling

1Istituto Superiore di Filosofia, Psicologia, Psichiatria, ISFiPP, Turin, Italy

Corresponding Author:
Lodovico Berra, Istituto Superiore di Filosofia, Psicologia, Psichiatria, ISFiPP, Corso Fiume 16,
10133 Turin, Italy.
Email: prof.berra@isfipp.org
2 Journal of Humanistic Psychology 00(0)

Introduction
Depression is one of the most widespread mental disorders, with more than
300 million people affected across the globe according to the World Health
Organization (www.who.int/mental_health/management/depression/en), and
can present itself in many forms. Often when we talk about depression, we
talk about it generically, not considering that there are many clinical pictures,
sometimes very different from each other. It is indeed appropriate to think of
depression as dimensional, with different states that vary in intensity and
severity, each sharing depressed mood as a common element. This continuum
includes “normal” states, such as sadness, “common unhappiness” (Freud,
1892-1895/1967), and the depressive character, up to profoundly pathologi-
cal states such as major depression, psychotic depression, postpartum depres-
sion, or bipolar disorder. On this broad depressive spectrum, there is also a
particular condition with primarily philosophical implications, defined here
as existential depression.
The current classifications used in psychiatry and psychology tend to ignore,
and therefore exclude, this specific condition, including it in the usual diagnos-
tic categories, with the clinical consequence of not properly understanding the
philosophical and existential essence of this depressive state and, thus, treating
it in an inappropriate way. Depression generally originates from different
causes, psychological or biological, or can be the expression of an innate, char-
acteristic individual predisposition. In this article, I want to propose the possi-
bility of a nonpathological depressive state, without any neurobiological causes
and independent of typical psychological dynamics, one that derives entirely
from an acute and disturbing awareness of our stark existential reality.
The term existential depression defines a condition in which the mood is
oriented in a depressive sense, and stems from particular reflections and con-
siderations on the nature of existence (Berra, 2018). In existential depression,
the mood is depressive in a similar way to other forms of clinical depression,
but there are not known biological causes (as in endogenous depression) nor
specific psychopathological dynamics (such as the reactive or neurotic type)
as seen in psychogenic depression. Therefore, we must consider existential
depression a non-pathological mental state, one which does not necessarily
benefit from the usual pharmacological or psychotherapeutic interventions.
Typically, this type of depression is pathologized by most clinicians, and con-
sidered to be a mental disorder. Not understanding its diversity and true exis-
tential meaning results in incorrectly categorizing it within conventional
psychopathological frameworks, but above all, to its inappropriate treatment.
It is therefore important to be able to define precisely the characteristics and
phenomenology of this not uncommon clinical entity, so that it can be recog-
nized, differentiated, and diagnosed correctly by clinicians.
Berra 3

This term existential depression was used the first time by Haefner (1954)
to describe a condition that has no clear relationship to previous psychologi-
cal traumas, but with the whole meaning of life, and which appears when the
subject feels a significant absence of goals and aspirations. The same term
was used some years later by W. T. Winkler (1957), considering the possi-
bilities of psychotherapeutic treatment of depression. Existential analyst
Ludwig Binswanger (1960) recognizes the difficulty of distinguishing sad-
ness as an “existential form” (Daseinsgestalt) from endogenous depression,
especially in particularly severe cases. We can consider this kind of existen-
tial depression to be the direct consequence of questioning the fundamental
meanings of life, and its subsequent emptying and nullification. It is fre-
quently connected to a general feeling of anguish, a troubling sense of mal-
aise from the loss of existential reference points (Berra, 2017). There is a
close link between existential depression and anguish because, in both cases,
there is a modification of the view and perception of existence, of oneself,
and the world. Indeed, a deep sense of anguish is often associated with
depressed mood. Anguish and depression have a close interrelationship,
overlapping and reinforcing each other.

The Genesis of Existential Depression

In life, there can be moments when deep reflections on existence and its
meaning, or lack thereof, lead to a crisis. Questions about the ultimate mean-
ing of life, about what we do, about why we do it, about what we are, about
our goals, about our duties, arise at least once in everyone’s existence. The
answers to these questions are never reliable and sure, but always insecure
and precarious, and only faith or trust in some theory or system can reassure
us. Often the solution taken to this dilemma is the assiduous avoidance or
denial of the questions themselves. But sometimes, there is no way to avoid
the unrelenting anxiety of doubt, and the issue painfully imposes itself with-
out choice.
The search for a definitive meaning in life, one which can express the
ultimate truth, is a basically hopeless enterprise. When a person suddenly
discovers that life has no intrinsic significance, the only possibility left to him
or her is some irrational act, such as religious faith or suicide. If reason wants
to impose itself, we have to face the inherent laws and limits of our human
mind. This existential crisis of the senses involves an excruciating state of
suspension in the void, in the total absence of any certainty. When every for-
merly held meaning comes to lose its strength or credibility, there is a painful
and perilous state of emptiness and suffering, not easily tolerable.
4 Journal of Humanistic Psychology 00(0)

Facing Death
Often the thought of death can induce such a depressive existential crisis. The
appearance of the possibility of dying, or instead the awareness of the inevi-
tability of this event, can catalyze the painful loss of meaning of existence.
What sense does it make to live if we must die? Why struggle vainly in a life
that then ultimately dissolves into nothingness? In the devastating perspec-
tive of death, every event loses its significance, and the person may find him
or herself empty, discouraged, and defeated, with no more motivation to live.
The human being is thrown into the possibility of dying from the first
moment of birth, as a constitutive fact of being in the world. However, the
awareness of death, which generates the existential crisis, must be in the
authentic mode, that is to say, the direct and real awareness of one’s own
inevitable death, of the actual and concrete possibility of no longer being.
Usually, in the inauthentic mode of existence, we escape this dreadful thought,
or consider it as something that does not belong directly to us. It is not our
own personal and real death, the effective and definitive termination of one’s
life, but something more vague, less relevant, that does not belong to us. It is
always the death of the Other, as some abstract entity, as a theoretical possi-
bility, which we can speak of and discuss, but always with a certain intellec-
tual detachment and distance. But, in the authentic mode, the understanding
of death, of the impossibility of existence, of nothingness, the pure and sim-
ple nullity of Being, is commonly accompanied by an intense affective state,
that for Heidegger (1927), is anguish.

Symptoms of Existential Depression

Existential depression has a series of characteristic symptoms. However, I do
not seek to determine specific criteria for a formal diagnosis here but try
rather to describe phenomenologically an existential mental condition that
should not be considered pathological.
The existential depressive is, above all, hopeless, that is to say, without
hope, deprived of the possibility of denying the absolute evidence of the
tragic existential facts of life. This hopelessness can be connected to the
concept of “depressive realism,” a condition characterized by studies sug-
gesting that mildly depressed or dysthymic people may have a clearer view
of some aspects of reality than normal or nondepressed people (Alloy &
Abramson, 1979; Feltham, 2017). Once one has become acutely aware of
the nothingness that envelops us, when the vertiginous lucidity has reached
one, there is no more possibility of going back. The process is irreversible.
The lie to oneself, the “bad faith” (mauvaise foi) described in detail by Sartre
Berra 5

(1938), is only another ephemeral attempt at salvation, a futile effort des-

tined for failure.
The loss of meaning of existence is then the consequence of the perception
of the relativity of everything, of the precariousness of every value, of the
awareness of the subtle and deceptive games of our human mind. When we
disclose the last enigmatic mystery of life, everything appears empty and
insignificant, having lost every sure reference. There is a crucial moment in
which every motivation to exist, to plan, to do, to create, can be lost. The
prospect of an inevitable, unpredictable, and looming death destroys all vital-
ity. The depressed person's elàn vital crashes painfully against the over-
whelming wall of death, apparently closing off every future possibility
forever. It is at this critical and dangerous moment that the idea of suicide
may arise, a seemingly thoughtful, rational suicide, subjectively seen as a
reasonable solution to life's absurdity and suffering.

The Nihilistic Attitude

Life’s unfairness, the constant struggle, loss, the pain, the infinite, the doubt,
the temporariness of everything, death, the evil that surrounds us. These are
real, indisputable, and undeniable existential truths, unlike the psychotic dis-
tortion of reality characteristic of pathological conditions. Nevertheless, this
nihilistic attitude can become, in some ways, excessively pessimistic, never
balanced by a positive view of existence. For this reason, we consider exis-
tential depression a phase, a pivotal point in the life of the individual, which
must be somehow overcome in existential psychotherapy. Remaining in this
painful condition with no psychological, philosophical, or spiritual evolution,
eventuates in a perilously pathological and profound form of depression.
Despite experiencing such existential anguish, the depressed person can
maintain a good, gratifying, even satisfying social and work life, without
pathological symptoms such as severe abulia and apathy, psychosomatic dis-
orders, or delusional ideas. Insomnia may appear in the initial phase, repre-
senting a sort of potentially positive existential catalyst, one in which
recurring and persistent thoughts about the nature of existence can eventually
lead to increasing awareness. The last typical symptom to consider here is the
frequent presence of a vague and heterogeneous feeling similar to that of
boredom. Boredom is a sense of malaise, ennui, and inertia, with an oppres-
sive monotony of deeds and thoughts. It is the expression of a subjective state
of suspension of time, of stopping the natural flow of life, of emptying exis-
tence. Boredom, says Kierkegaard (1844/2014), rests on nothingness, mean-
ders through existence, and its vertigo is similar to what one feels when
staring into the infinite abyss. For philosopher Martin Heidegger (1927),
6 Journal of Humanistic Psychology 00(0)

boredom is a potentially revealing feeling that allows us to better grasp the

totality of our being, thus becoming authentic boredom. He writes in Was ist
Metaphisik (Heidegger, 1929): “The deep boredom that, like a silent fog, col-
lects itself in the abyss of our being, unites us men and things, ourselves with
all that is around us, in a singular indifference” (p. 66).
Boredom is then an opportunity to deeply perceive the essence of our exis-
tence. “Boredom,” writes Cioran (1949), “is the echo that is in us of time that
tears, . . . the revelation of emptiness, the depletion of that delirium that sus-
tains—or invents—life” (p. 26). Somewhat differently, Schopenhauer, in the
World as Will and Representation (1819/2014), affirms that, “Life is a perpet-
ual oscillation, where as soon as misery and pain grant man a truce, boredom is
immediately present” (p. 412). Only humans, so far as we surmise, can feel
boredom. Boredom, when courageously and consciously related to, can be a
way to discover our authenticity, forcing us to face the nothingness of exis-
tence, and this expresses an important aspect of the psychological state of exis-
tential depression. As Sartre (1943) succinctly states, “Consciousness is being,
the nature of which is to be conscious of the nothingness of its being” (p. 86).

Treating Existential Depression

Once the big question about the meaning of life has come up, it is challenging
to give a firm answer authentically, while at the same time, not abandoning or
evading the issue. In fact, being in an authentic mode does not allow for escap-
ing the subject of the meaning of life. Returning to a dimension of ordinary
existence, or we could say inauthenticity, where the question does not arise, is
a difficult and often impossible undertaking (Berra, 2015). At the same time,
no proposed truth regarding the meaning of life has ever been without a doubt.
In this sense, as Sartre (1938) suggests, meaning is not so much found or dis-
covered, but must be constantly created anew by each of us.
The human mind has the peculiarity of asking questions as the outcome of
an intrinsic way of functioning. The awareness of the fact that often issues,
such as the one about meaning, are the result of specific mental mechanisms,
like the law of causality (Berra, 2006), and tend to diminish the value of the
question. “He who knows no longer believes in all the stories generated by
desire and thought, comes out of the current, no longer consenting to decep-
tion,” says the philosopher Emil Cioran (1969, p. 99). “Knowing” is here
tantamount to having revealed the self-deception that produces our thought.
Questions such as, “What is the meaning of life?” can never receive answers
free of uncertainty. There will always remain an unsurpassable quota of
doubt, because the question itself is a consequence and artifact of our human
psychology, which compels us to search for a purpose, a motive, a cause, a
meaning, without necessary correspondence in reality.
Berra 7

Albert Camus writes in the Myth of Sisyphus (1942), “the reflection on the
‘why’ brings the spirit to fall back on itself, and the understanding of the
world depends solely on the form given to it by the man himself” (pp. 19-20).
Therefore, principles, which are inherent to the structure of human thinking,
impose “whys,” or force us to postulate the existence of abstract and unreal
concepts, such as that of nothingness, the possible, and the absurd. Resolving
existential depression requires helping patients become more aware of the
relativity of their reflections, and the arbitrary consequences of our mental
functioning. The resulting “emptying” of truth leads us to the need to choose
to reformulate a path away from the comforting yet artificial claims of our
own elaborate theories. This painful yet insightful and potentially liberating
moment is indeed fundamental, and essential for patients to experience in the
effective treatment and evolution of an existential depression, which, if it
remains stuck and blocked in a darkly nihilistic vision, can lead only to an
increasingly pathological and disturbed state of mind, and possibly suicide in
some tragic cases.
Psychiatrist and philosopher Karl Jaspers, in the Psychology of the
Worldview (1919), identifies behind single existence a transcendental struc-
ture, defined as a “blank and naked reticulate” (pp. 38-39) that the individual
fills with meaning, thus determining his or her existence and vision of the
world. The human mind is originally an empty, vacuous container, a tabula
rasa, that can be filled with the most heterogeneous ingredients: values from
family or social culture, experiences, memories, beliefs, and myriad ideas.
Thus, progressively, the individual structures and gives meaning to his or her
life and Weltanschauung.
This is not a static and unchangeable way of relating to existence, but
rather a fluid and pliable condition concerning events and the will of the indi-
vidual (Berra, 2013a). The “emptying” of the value content, the nullification
of the essence of things in the world, does not imply the permanent irrevers-
ibility of this phenomenon. The “empty and naked reticulated” can be filled
up again, but now chosen with a full and conscious will, and this can be a
vital task in psychotherapy with these existentially depressed patients.

Conclusion
Existential psychotherapy (Berra, 2013b, 2014) emphasizes the philosophical,
humanistic value of individual existence and its relations with the world, try-
ing to avoid conditioning arising from preconceived interpretative theories,
models, diagnostic categories, or standardized intervention methods, and
operating without the presupposition that every sort of mental suffering must
be classified as pathological and cured. Existential therapy and philosophical
counseling represent an ideal approach for an inner rebuilding of meaning and
8 Journal of Humanistic Psychology 00(0)

identity, wherein a philosophical attitude becomes a central tool (Berra, 2016).

In fact, for me, the problem of existential depression is primarily philosophi-
cal, and philosophy, more than any other discipline, properly poses the ques-
tion regarding the meaning of life. It is, therefore, necessary to embark on a
path of philosophical re-elaboration and re-clarification, through which the
worldview of the individual’s sets of ideas, values, and meanings are existen-
tially analyzed, discussed in depth, and finally, freely and consciously chosen,
giving a new shape and vitality to life.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author received no financial support for the research, authorship, and/or publica-
tion of this article.

ORCID iD
Lodovico Berra https://orcid.org/0000-0002-4340-5513

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Author Biography
Lodovico Berra, MD, is a psychiatrist and existential psy-
chotherapist practicing in Turino, Italy. He is professor of
biological psychology at the Istituto Universitario
Salesiano Rebaudengo IUSTO Torino, president of Istituto
Superiore di Filosofia, Psicologia, Psichiatria, director of
the Italian School of Existential Psychotherapy and of the
master’s program in philosophical counseling, where he is
professor of psychopathology and clinical psychiatry. He
is an international fellow of the American Psychiatric
Association, and a member of the Society of Existential Analysis and the International
Federation of Daseinanalysis. He has authored many professional articles and books
such as “Angoscia esistenziale: Teoria e clinica” (Existential Anxiety: Theory and
Practice, 2017), and “La dimensione depressiva: Dalla depressione patologica alla
depressione esistenziale” (Depressive Dimension. From Pathological Depression to
Existential Depression, 2018). Lodovico is editor-in-chief of Dasein Journal, the offi-
cial magazine of the Italian Society of Existential Psychotherapy, and of Rivista
Italiana di Counseling Filosofico (Italian Journal of Philosophical Counseling).