by Dean Burnett
How do we define a mental disorder? The brain is made up of billions of neurons forming trillions of connections producing thousands of functions derived from countless genetic processes and learned experiences. No two are exactly alike, so how do we determine whose brain is working normally and whose ‘isn’t’? Everyone has weird habits, quirks, tics or eccentricities, which are often incorporated into identity and personality. Synaesthesia, for instance, doesn’t seem to cause anyone any problems with functioning; many people don’t realise they have anything amiss until they get weird looks for saying they like the smell of purple.1
Mental disorders are generally described as patterns of behaviour or thinking that cause discomfort and suffering, or impaired ability to function in ‘normal’ society. That last bit is important; it means for a mental disorder to be recognised it has to be compared with what’s ‘normal’, and this can vary considerably over time. Only in 1973 did the American Psychiatric Association declassify homosexuality as a mental disorder.
Mental health practitioners are constantly revaluating the categorisation of mental disorders due to advances in understanding, new therapies and approaches, changes in dominant schools of thought, even the worrying influence of pharmaceutical companies, who like having new ailments to sell medications for. This is all possible because, up close, the line between ‘mental disorder’ and ‘mentally normal’ is incredibly fuzzy and indistinct, often relying on arbitrary decisions based on social norms.
Add to this the fact they’re so common (nearly 1 in 4 people experience some manifestation of mental disorder, according to the data2) and it’s easy to see why mental health problems are such a controversial issue. Even when they are recognised as a real thing (which is far from a given), the debilitating nature of mental disorders is often dismissed or ignored by those lucky enough not to be afflicted. There is also heated debate about how to classify mental disorders. For example, many say ‘mental illness’, but there are those who find this term misleading; it implies something that can be remedied, like the flu, or chickenpox. Mental disorders don’t work that way; there often isn’t a physical problem to be ‘fixed’, meaning a ‘cure’ is hard to identify.
Some even strongly object to the term ‘mental disorder’ as it makes them seem bad or damaging, when they can instead be seen as alternative ways of thinking and behaving. There’s a large swathe of the clinical psychology community who argue that talking and thinking of mental issues as illnesses or problems is itself harmful, and are pushing for more neutral and less loaded terms to be used when discussing them. There are growing objections to the dominance of the medical field and approaches to mental health, and given the arbitrary nature of establishing what’s ‘normal’ or not, this is understandable.
Despite these arguments, this chapter does stick more to the medical/psychiatric perspective – that’s my background and, for most of us, it’s the most familiar way of describing the subject matter. This is a brief overview of some more common examples of mental health issues while explaining how our brains let us down, both for those afflicted by the problem, and those of us around them who so often struggle to recognise and appreciate what’s going on.
Dealing with the black dog
(Depression and the misconceptions around it)
Depression, the clinical condition, could use a different name. ‘Depressed’ presently applies both to people who are a bit miserable and to those with a genuine debilitating mood disorder. This means people can dismiss depression as a minor concern. After all, everyone gets depressed now and again, right? We just get over it. We often have only our own experiences to base judgements on, and we’ve seen how our brains automatically big up and exaggerate our own experiences, or minimise our impression of other people’s experiences if they differ from our own.
This doesn’t make it right, though. Dismissing the concerns of a person with genuine depression because you’ve been miserable and got over it is like dismissing someone who’s had to have their arm amputated because you once had a papercut. Depression is a genuine debilitating condition, and being in ‘a bit of a funk’ isn’t. Depression can be so bad that those experiencing it end up concluding that ending their life is the only viable option.
It’s an indisputable fact that everyone dies eventually. But knowing it and directly experiencing it are two different things; you can ‘know’ that it hurts to get shot, but this doesn’t mean you know how getting shot feels. Similarly, we know that everyone close to us will expire eventually, but it’s still an emotional gut punch when it happens. We’ve seen how the brain has evolved to form strong and lasting relationships with people, but the down side is how much it hurts when those relationships come to an end. And there’s no ‘end’ more final than when someone dies.
As bad as this is, there’s an extra dose of awfulness when a loved one ends their own life. How and why someone ends up believing suicide is the only viable option is impossible for us to know for certain, but whatever the reasoning it’s devastating to those left behind. These people are the ones the rest of us get to see. As a result, it’s understandable why people often form negative opinions of the deceased – they might have successfully ended their own suffering, but they’ve caused it in many others.
As we saw in Chapter 7, the brain performs serious mental gymnastics to avoid feeling sorry for victims, and another possible manifestation of this is the labelling of those who end their own lives as ‘selfish’. It’s a bitterly ironic coincidence that one of the most common factors leading to suicide is clinical depression, as people with it are also regularly labelled as ‘selfish’, ‘lazy’ or with other disparaging adjectives. This may be the brain’s egocentric self-defence kicking in again; acknowledging a mood disorder so severe that ending it all is an acceptable solution technically means acknowledging, at some level, that it might happen to you. An unpleasant thought. But if someone’s just self-indulgent or callously selfish, that’s their problem. It won’t happen to you, and thus you get to feel better about yourself.
That’s one explanation. Another is that some people are just ignorant jerks.
Labelling those with depression and/or those who die by suicide as selfish is a bleakly common occurrence, most prominently seen when applied to someone even slightly famous. The sad passing of Robin Williams, international superstar and beloved actor and comedian, provides the most obvious recent example.
Amid the glowing and tearful tributes, the media and Internet were still awash with comments like, ‘Doing that to your family is just selfish’, or, ‘To commit suicide when you’ve got so much going for you is pure selfishness’, and so on. These comments weren’t restricted to anonymous online types; such sentiments came from high-profile celebrities and numerous news networks not exactly known for compassion, such as Fox News.
If you are someone who has expressed these views or similar, sorry – but you’re wrong. Quirks of the brain’s workings may explain part of it, but ignorance and misinformation can’t be ignored. Granted, our brains don’t like uncertainty and unpleasantness, but most mental disorders provide ample amounts of both. Depression is a genuine and serious problem that deserves empathy and respect, not dismissal and scorn.
Depression manifests in many different ways. It’s a mood disorder, so mood is affected, but how it’s affected varies. Some end up with unshakeable despair; others experience intense anxiety, resulting in feelings of impending doom and alarm. Other people have no mood to speak of, just feel empty and emotionless regardless of what’s happening. Some (mostly men) become constantly angry and restless.
This is part of why it’s proven difficult to establish an underlying cause of depression. For some time, the most widespread theory was the monoamine hypothesis.3 Many neurotransmitters used by the brain are types of monoamines, and people with depression seem to have reduced levels of them. This affects the brain’s activity, in a manner that may lead to depression. Most well-known antidepressants increase the availabilit
y of monoamines in the brain. The currently most widely used antidepressants are selective serotonin reuptake inhibitors (SSRI). Serotonin (a monoamine) is a neurotransmitter involved in processing anxiety, mood, sleep and so on. It’s also believed to help regulate other neurotransmitter systems, so altering its levels could have a ‘knock-on’ effect. SSRIs work by stopping the removal of serotonin from synapses after it’s released, increasing overall levels. Other antidepressants do similar things with monoamines such as dopamine or noradrenaline.
However, the monoamine hypothesis is meeting increasing criticism. It doesn’t really explain what’s happening; it’s like restoring an old painting and saying it ‘needs more green’; that might well be the case, but it’s not specific enough to tell you what you actually need to do.
Also, SSRIs raise serotonin levels immediately, but beneficial effects take weeks to be felt. Exactly why this is has yet to be established (although there are theories, as we’ll see), but it’s like filling your car’s empty tank with petrol and it working again only a month later; ‘no fuel’ may have been a problem, but it’s clearly not the only problem. Add to this the lack of evidence showing a specific monoamine system that’s impaired in depression, and that some effective antidepressants which don’t interact with monoamines at all, and clearly there’s more to depression than a simple chemical imbalance.
Other possibilities abound. Sleep and depression also seem interlinked4 – serotonin is a key neurotransmitter in regulating circadian rhythms, and depression causes disturbed sleep patterns. The first chapter showed sleep disruption is problematic; maybe depression is another consequence?
The anterior cingulate cortex has also been implicated in depression.5 It’s a part of the frontal lobe that seems to have many functions, from monitoring heart rate to anticipating reward, decision-making, empathy, controlling impulses and so on. It’s essentially a cerebral Swiss Army knife. It’s also been shown to be more active in depressed patients. One explanation is it’s responsible for cognitive experience of suffering. If it is responsible for anticipation of reward then it makes sense that it would be involved in perceiving pleasure or, more pertinently, a complete lack thereof.
The hypothalamic axis that regulates responses to stress is also a focus of study.6 But other theories suggest that the mechanism of depression is more of a widespread process than being isolated in specific brain areas. Neuroplasticity, the ability to form new physical connections between neurons, underpins learning and much of the brain’s general functioning, and has been shown to be impaired in people with depression.7 This arguably prevents the brain from responding or adapting to aversive stimuli and stress. Something bad happens, and the impaired plasticity means the brain is more ‘fixed’, like a cake left out too long, preventing moving on or escaping the negative mind-set. Thus, depression happens and endures. This might explain why depression is so persistent and pervasive; impaired neuroplasticity prevents a coping response. Antidepressants which increase neurotransmitters often increase neuroplasticity, too, so this may be actually why they work as they do, long after transmitter levels are raised. It’s not like refuelling a car, it’s more like fertilising plants; it takes time for the helpful elements to be absorbed into the system.
All of these theories may contribute to, or may be consequences rather than causes of, depression. Research is ongoing. What is clear is that it’s a very real, often extremely debilitating condition. Aside from cripplingly awful moods, depression also impairs cognitive ability. Many medical practitioners are taught how to differentiate between depression and dementia, as on cognitive tests serious memory problems and being genuinely unable to muster up any motivation to complete a test look the same, as far as the results are concerned. It’s important to differentiate; the treatment for depression and dementia vary considerably, although often a diagnosis of dementia leads to depression,8 which just complicates matters further.
Other tests show that people with depression pay more attention to negative stimuli.9 If shown a list of words, they’ll focus far more on those with unpleasant meanings (‘murder’, for example) than neutral ones (‘grass’). We’ve discussed the brain’s egocentric bias, meaning we focus on things that make us feel good about ourselves and ignore things that don’t. Depression flips this: anything positive is ignored or downplayed; anything negative is perceived as 100 per cent accurate. As a result, once depression occurs, it can be extremely hard to get rid of.
While some people do seem to develop depression ‘out of the blue’, for many it’s a consequence of too much time being hammered by life. Depression often occurs in conjunction with other serious conditions, including cancer, dementia and paralysis. There’s also the famous ‘downward spiral’, where people’s problems mount up over time. Losing your job is unpleasant, but if then your partner leaves you soon after, then a relative dies and you get mugged while heading home from the funeral, this can be just too much to deal with. The comfortable biases and assumptions our brains maintain to keep us motivated (that the world is fair, that nothing bad will happen to us) are shattered. We’ve no control over events, which makes matters worse. We stop seeing friends and pursuing interests, maybe turn to alcohol and drugs. All this, despite providing fleeting relief, taxes the brain further. The spiral continues.
These are risk factors for depression, which increase the likelihood of it occurring. Having a successful and public lifestyle, where money is no object and millions admire you, will have fewer risk factors than living in a deprived high-crime area, earning barely enough to survive and with no family support. If depression were like lightning, some people are indoors while others are struck outside near trees and flag-poles; the latter are more likely to get struck.
A successful lifestyle doesn’t provide immunity. If someone rich and famous admits they suffer from depression, saying, ‘How can they be depressed? They’ve got everything going for them’, makes no sense. Being a smoker means you’re more likely to develop lung cancer, but it doesn’t affect only smokers. The brain’s complexity mean many risk factors for depression aren’t linked to your situation. Some have personality traits (such as a tendency to be self-critical) or even genes (depression is known to have a heritable component10) that make depression more likely.
What if the constant struggle against depression is what spurred someone to be successful? Staving off and/or overcoming depression often requires considerable willpower and effort, which can be channelled in interesting directions. The ‘tears of a clown’ cliché about successful comics whose skills stem from fighting internal torment is a perfect example, as are many famous creatives who endured the condition (Van Gogh, for instance). Far from a preventative, success may result from depression.
Also, unless you’re born to it, achieving wealth and fame is hard work. Who knows what sacrifices a person made to obtain their success? And what if they eventually realise it wasn’t worth it? Achieving something you’ve worked for for years can rip the purpose and drive from your life, leaving you adrift. Or, if you’ve lost the people you value on your determined upward career path, this can eventually be seen as too high a price. Being successful in other people’s eyes is no defence. A healthy bank balance does not overrule the processes underlying depression. Even if it did, where’s the cut-off point? Who would be ‘too successful’ to be ill? If you can’t be depressed because you’re better off than others, logically only the most unfortunate person on earth should be depressed.
This isn’t to say many rich and successful people aren’t very happy; it’s just not a guarantee. The workings of your brain don’t drastically change because you have a film career.
Depression is not logical. Those describing suicide and depression as selfish apparently struggle with this concept, as if those with depression make a table or chart with the pros and cons of suicide and, despite there being more cons, selfishly opt for suicide anyway.
This is nonsensical. A big problem with depression, perhaps the problem, is
that it prevents you from behaving or thinking ‘normally’. A person with depression is not thinking like a non-sufferer, in the same way that someone who’s drowning is not ‘breathing air’ like someone on land. Everything we perceive and experience is processed and filtered through our brain, and if our brain has determined that everything is absolutely awful, that’ll impact on everything else in our lives. From a depressed person’s perspective, their self-worth may be so low, their outlook so bleak, that they genuinely believe their families/friends/fans would be better off without them in the world, that their suicide is actually an act of generosity. It’s a very upsetting conclusion, but not one arrived at by a mind that’s thinking ‘straight’.
Accusations of selfishness also often imply people with depression are somehow choosing their situation, that they could enjoy life and be happy but consider it more convenient not to? Exactly how or why they’d do this is rarely explained. In instances of suicide, you get people saying it’s the ‘easy way out’. There are many ways to describe the sort of suffering that overrides millions-of-years-old survival instincts, but ‘easy’ isn’t an obvious one. Perhaps none of it makes sense from a logical perspective, but insisting on logical thinking from someone in the grip of mental illness is like insisting that someone with a broken leg walks normally.
Depression isn’t visible or communicable like a typical illness, so it’s easier to deny that it’s a problem rather than to accept the harsh unpredictable reality. Denial reassures the observer that ‘it will never happen to me’, but depression is still affects millions of people regardless, and throwing accusations of selfishness or laziness at them purely to make yourself feel better can’t help. As a behaviour, that’s a much better example of selfishness.