Positive feedback spirals escalate anxiety. Repeated exposure to danger indicates that the anxiety system is not providing sufficient protection, so the system adjusts to become more sensitive. This poses the risk of positive feedback. Daniel Nettle and Melissa Bateson, biologists at the University of Newcastle, have proposed a special version of the Smoke Detector Principle that describes this capacity for adjusting responses.35 As noted already, such self-adjusting systems are vulnerable to dysregulation. Monitoring for symptoms of panic makes it more likely that minor physiological changes will escalate to a full-blown panic attack.
Fearless individuals are often admired, but their challenges are small compared to the gritty resolve many anxiety patients demonstrate by giving a talk, going to the dentist, flying on a plane, leaving the house, or coming for anxiety treatment. Treatment can reduce their suffering, and evolutionarily informed treatment can do that faster. In the meanwhile, people with anxiety disorders deserve recognition for their courage and daily determination to live full lives despite their symptoms.
CHAPTER 6
LOW MOOD AND THE ART OF GIVING UP
Pain or suffering of any kind, if long continued, causes depression and lessens the power of action; yet is well adapted to make a creature guard itself against any great or sudden evil.
—Charles Darwin, On the Origin of Species, 18871
If at first you don’t succeed, try, try again. Then quit. No point in being a damned fool about it.
—Attributed to W. C. Fields
A young man came to our clinic for treatment of moderately severe depression. He had lost interest in most everything, was sleeping poorly and losing weight, and said he was a failure and that his future was hopeless. He attributed his failing grades in community college to his poor sleep and depression. His father was a mason; his mother was a teacher. There was no family history of depression, and he did not have problems with drugs, alcohol, or medical conditions. He easily qualified for a diagnosis of major depression. We started him on an antidepressant and cognitive behavioral therapy.
A month later the psychiatry resident treating him said there was no improvement and asked me to see him again. He said that he was about to be expelled from school but his girlfriend would leave him if that happened. I asked about his girlfriend. He said that she was beautiful and brilliant and he would do anything to stay with her. She was still in high school but would graduate soon. I asked about her future plans. “She’s going to go to this college out east, Vassar, maybe you have heard of it.” “Um, yes, I’ve heard of it.”
What a dilemma! He hated school but had to continue to keep his girlfriend. But he must have known, on some level, that the relationship was unlikely to continue after she left the state for an extremely high-status college. I asked, “What do you think will happen when she moves out east?” He said he had thought about that, and, though it might be difficult, he loved her and was committed to making the relationship work. I said that sometimes it was hard to have a relationship with someone who was far away. He became pensive and said he did not always feel like he fit in with her crowd, but they loved each other. Toward the end of the interview, I asked if he had previously dated other women or if he was thinking of dating other women. He said definitely not.
A few months later the resident asked me to see him again. He was transformed. From a somber, slouching, slow, and soft-speaking disheveled man looking at the floor, he now was enthusiastic and well groomed. He looked me in the eye and said he thought he didn’t need more treatment. We reviewed his symptoms; they were mostly gone. When asked what had happened to make the transformation, he said, “Maybe the drugs worked or something.” However, he had stopped his medications weeks previously. I then asked, “How is school?” “No problem now. I decided to go to work with my dad instead.” “How are things with your girlfriend?” “Great,” he said. “We have lots of fun, it’s really good.” It was now summer, so I asked, “Is she still headed off to Vassar in September?” He replied, “Oh, you mean that girlfriend! She was too uppity. My new girlfriend likes to do all the same kind of things I do. She’s great.”
The Missing Question
Mood disorders pose perhaps the most urgent and frustrating medical problem facing our species. Depression causes more years lived with disability than any other disease.2 Suicide is a leading cause of death, increasing by 24 percent from 1999 through 2014 in the United States.3 Prevention and treatment of heart disease and cancer are increasingly effective, but the rates of depression and suicide have stayed the same or increased, despite decades of intensive research and treatment efforts. Most of the efforts attack depression head-on. They define it, diagnose it, and try to find causes and cures. But the process of revising the DSM diagnosis of depression revealed deep disagreements about a fundamental question: How can pathological depression be distinguished from ordinary low mood?
Jerry Wakefield and his colleagues raised the question with their suggestion that the diagnosis of depression should be excluded not only in the two months after loss of a loved one, as specified in DSM-IV, but also after other equally devastating losses. As noted in chapter 3, the authors of DSM-5 not only failed to adopt the suggestion, they eliminated the exclusion for bereavement.4 So now someone who has five or more depression symptoms for more than two weeks can be diagnosed with major depression even if he or she is in a medical intensive care unit after an auto accident that killed a son or daughter. To most people, that seems ridiculous. Newspapers published impassioned editorials. The blogosphere exploded with opinions. Scientists addressed the problem by studying the differences and similarities among depression, grief, and responses to other losses. However, those studies did little to resolve the debate. Some emphasized the risks of failing to recognize and treat serious depression in the bereaved. Others saw the risk of medicalizing and overtreating ordinary grief. Between these positions is a major gap in our knowledge.
Everyone agrees that some symptoms of depression are normal for a time after a loss. Everyone also agrees that extreme symptoms of depression are obviously abnormal. But disagreement about how to distinguish normal low mood from abnormal depression is intense and enduring. When so many smart people disagree, something is usually missing. What is missing from debates about depression is knowledge about the origins, functions, and regulation of normal low mood.
Trying to understand pathological depression without recognizing the evolutionary origins and utility of normal low mood is like trying to understand chronic pain without recognizing the causes and utility of normal pain. Pain is useful. Physical pain protects against tissue damage. It gets organisms to escape from situations that are damaging tissues and avoid them in the future. Mental pain stops behaviors that are causing social damage or wasting energy. Mental and physical pain can be equally excruciating, even in situations where they are useful. But both are also prone to excess expression when they are not useful, causing chronic pain and pathological depression.
The challenge of deciding if depression symptoms are normal or abnormal is mirrored by the challenge of deciding if physical pain is a product of tissue pathology or an abnormality in the pain system. Pain from a broken leg or a tumor pressing on the spinal cord is obviously normal. However, when no specific cause can be found, doctors consider the possibility that the pain system is abnormal. As a consultation psychiatrist, I was asked to address the question for many medical and surgical patients.
For physical pain, such decisions can be difficult, but finding a tumor or a source of inflammation settles the issue. For mental pain, the challenge is vastly harder because the cause is in the motivational structure of a person’s inner life. Specific life events, such as loss of a loved one, are the closest we can get to a specific cause of pain of the sort that surgeons can find. But ongoing life situations also cause low mood and depression.
When is low mood normal, and when is it abnormal? No amount of knowledge about mood me
chanisms can answer the question. An answer requires understanding the origins and adaptive significance of mood. It requires knowing how the capacity for normal mood variation gives selective advantages, the situations in which high and low mood can be useful, and how mood is regulated. It requires recognizing that many mood changes are normal but not useful. This knowledge is the essential but mostly missing foundation for understanding mood disorders and for discovering why mood regulation mechanisms are so vulnerable to failure.
A Few Definitions
Much confusion arises because words describing mood states are used in different ways. Mood usually refers to a long-term pervasive state, akin to climate, while affect is the expression of a current emotional state, more like the weather. However, there is no sharp boundary among mood, affect, and emotion, and the terms mood disorders and affective disorders are used interchangeably. I will use the word mood here to refer to the dimension that ranges from depression to low mood to high mood to mania. The word depression is now so closely associated with pathology that I will use low mood to describe symptoms of mild depression, without any implication of pathology or normality.
High mood is a pleasurable state of enthusiasm, energy, and optimistic activity usually associated with situations where activity is likely to pay off grandly. It is closely related to joy, the short-term pleasure from getting what has been desired, and happiness, the enduring state that can persist if most desires can be satisfied. Low mood is the painful state characterized by demoralization, low energy, pessimism, risk avoidance, and social withdrawal that is aroused by certain situations, especially those in which efforts to reach a goal are failing. Sadness can feel very similar to low mood, but it results from specific losses; it often does not include the pervasive lack of motivation that can characterize low mood and depression. Grief is the special kind of sadness caused by death of a loved one or other major loss. Tomes have been written to distinguish these and other mood states, but because emotions are products of evolution, not design, they overlap in untidy ways that defy exact description.
LOW MOOD
HIGH MOOD
Pessimism
Optimism
Risk avoidance
Risk taking
Inhibition
Initiative
Low energy
High energy
Social withdrawal
Social engagement
Quiet
Talkative
Slow thinking
Fast thinking
Unimaginative
Creative
Submissive
Dominant
Lack of confidence
Confidence
Low self-esteem
High self-esteem
Analytic thinking
Subjective thinking
Expecting criticism
Expecting praise
How Can Low Mood Be Useful?
Much confusion about depression results from the human tendency to think that specific things must have specific functions. Things we make, such as spears and baskets, have specific functions. So do parts of the body such as the eye and the thumb. It therefore seems natural to ask “What is the function of low mood?” For emotions, however, that is the wrong question. A better question is “In what situations do low mood and high mood give selective advantages?” However, most ideas about the utility of mood have been framed as possible functions, so we must start there.
One possibility is that even ordinary mood variations are not useful. They could arise from glitches, having as little utility as epileptic seizures or tremors. There are good reasons for thinking that this is incorrect. Syndromes that arise from defects in the body, such as epilepsy or tremor, happen to only some people, but nearly everyone has the capacity for mood. We all have a system that adjusts mood up or down depending on what is happening. Such regulation systems can be shaped only for useful responses. Pain, fever, vomiting, anxiety, and low mood turn on when they are needed. This does not mean that every instance is useful; false alarms can be normal. But it does mean that such systems need to be understood in terms of how and when they are useful.
The London psychoanalyst John Bowlby was one of the first to propose evolutionary functions for low mood. Thanks to conversations with the German ethologist Konrad Lorenz and the English biologist Robert Hinde, he turned an evolutionary eye toward the behaviors of babies separated from their mothers.5 After a short separation, some reconnected with the mother quickly, others acted distant, and a few acted angry. A longer separation led to a reliable sequence: initial wails of protest, followed by silent rocking and huddling in a ball that looks for all the world like an adult in a state of despair.6,7
Bowlby saw that crying motivated mothers to retrieve their infants. He also saw that extended crying would waste energy and attract predators, so if the mother did not return soon, inconspicuous withdrawal would be more useful. These ideas developed into attachment theory,8 which provides the foundation for understanding mother-infant bonding and the pathologies that result when it goes awry. Bowlby deserves recognition as a founder of evolutionary psychiatry for his insight that attachment evolved because it increases the fitness of both mother and baby.
More explicitly evolutionary analyses in recent decades have challenged the idea that only secure attachment is normal. In some situations, babies who use avoidant or anxious attachment styles may motivate their mothers to provide more care.9,10,11 If regular smiling and cooing don’t work, it may work better to scream indefinitely when she leaves or to give her the cold shoulder when she returns.
George Engel, the psychiatrist at the University of Rochester who coined the term biopsychosocial model, proposed a function for depression that is related to attachment. He suggested that a lost young monkey could conserve calories and avoid attracting predators by staying quiet in one place. He called this “conservation-withdrawal,” noted its resemblance to depression, and emphasized the similarity of depression to hibernation.12,13
Aubrey Lewis, a founder of the Institute of Psychiatry in London, believed that depression could signal the need for help.14 The idea was advanced further by David Hamburg, the former chair of psychiatry at Stanford University.15 Some evolutionary psychologists give the idea a cynical twist by suggesting that depression symptoms, and especially suicide threats, are strategies to manipulate others into providing help. Edward Hagen has suggested that postpartum depression is a specific adaptation shaped to blackmail relatives into providing help.16,17 He views the symptoms as a passive threat to abandon the infant and finds support for this view in evidence that postpartum depression is more likely when the husband is unsupportive, resources are scarce, or the baby needs extra care. Depression and suicide threats certainly can be manipulations. However, there is little evidence that depression is a reliable response in most mothers in such situations, and it is not at all clear that those who express more depression get more help from otherwise unhelpful relatives. Also, the theory does not fit well with prior research by psychologist James Coyne showing that depression elicits caring, helpful responses only briefly from relatives; after that they tend to withdraw.18
The Canadian psychologist Denys deCatanzaro suggested the even more disturbing idea that suicide can benefit an individual’s genes.19 If an individual in a harsh environment has little chance of future reproduction, suicide could free up food and resources that relatives could use to
have children who would carry some of the individual’s genes into future generations. This would be the ultimate example of selection shaping a trait to benefit genes at the expense of the individual. But the idea, while creative, is almost certainly wrong. Even in harsh environments, suicide is by no means routine. Even sick elderly people who can’t reproduce are often desperate to live longer. Also, why bother killing yourself? Why not just wander off or stop eating?
British psychiatrist John Price recognized an important function of depression symptoms based on his close observations of chickens.20 Chickens that lose a fight and descend in the pecking order withdraw from social engagement and act submissive, thereby reducing further attacks by chickens higher in the hierarchy. Price went on to study the same phenomenon in vervet monkeys.21 They live in small groups containing a few males and a few females. The alpha male, who gets essentially all the matings, has bright blue testicles. Until, that is, he loses a fight with another male. Then he huddles into a ball, rocks, withdraws, and acts depressed as his testicles turn a dusky gray. Price interprets these changes as signals of “involuntary yielding.”22,23 By signaling that he is not a threat, the loser escapes attacks by the new dominant male. Better to yield, and signal yielding, than to be attacked.
Price worked with psychiatrists Leon Sloman and Russell Gardner to apply these ideas in the clinic.24 They observed that many depressive episodes are precipitated by failure to accept a loss in a status competition. They view low mood as a normal response to losing a competition and depression as the result of continuing useless status striving, a situation aptly described as “failure to yield.” Other researchers, especially the British psychologist Paul Gilbert and his colleagues, have developed these ideas further.25 They interpret diverse stressful life events as a loss of status, and they observe that many patients recover when they give up an unwinnable status competition.
Good Reasons for Bad Feelings Page 11