Posted on February 24, 2010 - by David

A response to Dr. Sally Satel’s review of ‘The Loss of Sadness’

I was happy to see that Dr. Sally Satel commented on Monday’s post which linked to her WSJ article about the proposed revisions for the DSM-V. She posted a link to this article, written two years ago, which is actually a review of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, by Allan Horwitz and Jerome Wakefield. Written from the perspective of a psychiatrist critical of the direction the field is moving in, it’s plenty more than a book review. Dr. Satel incorporates her own knowledge of the history of psychiatry and the difficulties of diagnosis and treatment as she considers the book’s contributions and shortcomings.

I realize that some of my criticisms are really directed at Horwitz and Wakefield, and I may be repeating some of things I wrote in my post on the Horwitz interview, but here goes anyway:

Satel gives some valuable history on the state of affairs in psychiatry during the 60’s and 70’s leading up to the publication of DSM-III. I’ll just say that Horwitz and Wakefield identify the publication of the DSM-III in 1980 with a shift towards symptom-based diagnosis which effectively eliminated considerations of context. The biggest problem they see resulting from this, (as the title of their book implies), is that the normal expression of sorrow in the wake of difficult life events is being diagnosed as depression. They believe this leads to unnecessary prescription of medication, inflated rates of mental illness, and a culture-wide loss of the ability to integrate hardship and sadness into a normal, healthy life.

The book seems to argue (as Horwitz stated in the contexts interview) that there are two types of real depression. 1. Depression that appears without cause or context, and 2. Depression which begins with an apparent cause or context but persists longer than appropriate with more severe symptoms than normal.

From Satel’s article:

In the classic form of uncaused depression — referred to in the pre-DSM-III days as endogenous depression or melancholia — symptoms arise mysteriously out of the blue when life is otherwise good. It seems clear that whatever biological mechanism that regulates mood has gone badly awry.

Yet clinical depression need not always have a spontaneous onset; it can also arise in the aftermath of loss. The important distinction between normal sorrow and major depression, the authors say, is that in the latter the symptoms triggered by circumstances eventually lose their contextual moorings. Either they persist long beyond the resolution of the stressful situation, or the point at which an otherwise healthy person would have adapted to a new condition; or they mutate into overt psychosis, suicidal impulses or actions, or physical immobilization. A patient in the pathological realm is beset by self-reproach and ruminations. He does not brighten when, say, a beloved grandchild visits, and he cannot imagine anything ever making him happy again.

While I would agree that this idea makes sense on the surface, I see a real problem. When someone reacts too strongly for too long to some loss or crisis, we might say something went wrong to make this person overly-sensitive to either loss in general, or the particular loss that was suffered. But this is still much different from depression which arises “mysteriously out of the blue when life is otherwise good.” Perhaps the way we look at context or what we consider “context” to mean  leads us to see symptoms arising from nowhere which actually do have an explanation outside of a brain malfunction.

The argument presented in The Loss of Sadness seems to rest on the claim that real depression is the same today as it was over 2000 years ago – that culture has changed our understanding of mental illness but mental illness itself (assumed to be biologically caused) has not changed. To me, this implies that “normal sorrow” should look similar between cultures and over time, with some differences that can be accounted for by cultural and historical context.

I believe this view obscures the dramatic cultural change that modernity brings. We may take it for granted that a certain type of loss is difficult and a cause for deep sadness, but to extend this response to all of history and humanity is ignorant.  (I think Ethan Watters chapter on PTSD in Sri Lanka is helpful in looking at cultural differences in response to tragedy). Sure, some depression might be easier for us (as modern people) to understand given the context or spark. But if our “normal responses” to loss closely resemble pathological states, perhaps Horwitz’s conclusion isn’t the only one that can be drawn.  The authors are saying we have pathologized normal human emotions, but perhaps our responses to “normal life events” have actually become more pathological. Of course, if the broad cultural changes that accompany the rise of modernity are not considered important and human emotions and attitudes (or even Western emotions and attitudes) are seen as historically consistent, then this second possibility doesn’t even show up on the radar.

The principles inherent in nationalism provide the basis for modern culture – the only form of consciousness most people reading this blog have ever known. As defined by Liah Greenfeld, “nationalism is a fundamentally secular and humanistic consciousness based on the principles of popular sovereignty and egalitarianism.” For this discussion, it is important to recognize two aspects of modern culture: 1. It’s openness gives individuals great freedom, but very little guidance in forming identity 2. It changes what we hope for and what we expect out of life, therefore changing the nature of what constitutes “loss” and interfering with our ability to accept loss. Consider the following from Greenfeld’s essay, Nationalism and the Mind:

The focus on the life in this world dramatically increases the value of this life to the individual and inevitably leads to the insistence on a good life, however defined. One is no longer expected to submit to suffering or deprivation, unless one has special reasons to do so, for the general reasons for such submission – the expectation of rewards in the beyond, transmutation and migration of the souls, the duty to serve witness to the glory of God wherever one is called, or the sheer impossibility to change one’s condition – no longer apply.

Moreover, in a self-sufficient world, changeable and shaped by people, suffering is generally believed to be man-made. Even natural disasters are likely to be so interpreted: a famine, an earthquake, or an epidemic are as often as not attributed to some human agent’s withholding of the needed but available resources or negligence; personal misfortunes, such as debilitating, life-threatening, and incurable illnesses are blamed on artificially-created environmental conditions (second-hand smoke, lead paint, etc.) or on doctors’ incompetence. None of these natural disasters, it is said, “have to happen”: they are no longer believed to be in the nature of things. Of course, the right to a life free of suffering is most clearly asserted when suffering is caused – as it is mostly, in modern societies — by social evils: war, economic or political conditions, competition for precedence, and so forth. Humiliation, rejection, thwarted ambition are felt as unjust – as contrary to expectations and thus resulting from illegitimate intervention of malicious others.

Greenfeld’s argument is that modern culture causes problems with identity formation which can lead to “biologically real” mental illness. She is therefore arguing that diseases like schizophrenia, bipolar, and depression are not as old as humanity, but really began appearing about 500 years ago with the rise of nationalism.

Her work proceeds from the view that culture- the symbolic process by which human ways of life are transmitted historically, is an emergent phenomenon, logically consistent with the laws of physics and biology, but nonetheless autonomous. This is absolutely critical. It is this first view which distinguishes Greenfeld from the many biologists and anthropologists who see human culture as dictated by biologically evolved brain mechanisms and natural selection.

For Greenfeld, the mind is the individualized cultural process, or “culture in the brain.” The individualized cultural process is therefore dependent upon, but not determined by, the biological functions of the brain. Just as organic brain damage can cause symptoms of mental illness- problems with thought, mood, and speech for example – Greenfeld believes that problems with the mind (problems with culture, that is) can lead to problems with brain function.

Obviously, all I can do here is prevent a bare-bones, unsupported version of Greenfeld’s theory and set in against the dominant view of the day. She is well along in the process of writing a book on this very subject and I look forward to its publication. Her work is not meant to go against, but to complement and elucidate research on the biology and genetics of mental illness. Genetic susceptibility probably goes a long way in explaining why only certain individuals experience mental illness, but it is important to acknowledge, (as Dr. Satel’ article does) that the extensive research to date hasn’t revealed a genetic cause of mental illness:

Psychiatry, alas, has a long way to go. “Although the past two decades have produced a great deal of progress in neurobiological investigations,” notes a recent paper written to guide preparation of the forthcoming DSM-V, “the field has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder or for predicting response to psychopharmacological treatment.” Indeed, almost all of the recent genetic findings are not specific. A particular gene associated with bipolar illness was later discovered to occur in people with schizophrenia. The same goes for almost every other major finding — leading to the current hypothesis that these various genes confer risk for psychopathology, but not for any specific kind.

Nevertheless, the dogmatic view that true, serious mental illnesses are caused by a problem in the brain hasn’t lost any steam. Satel writes:

As brain-based etiologies of classic serious mental illnesses, such as schizophrenia and bipolar illness, are uncovered, psychiatry will probably lose those diagnoses to neurology. Perhaps one day psychiatry will cater only to patients suffering from existential crises. But not anytime soon.

Dr. Satel seems to feel that as a psychiatrist, her job is not to figure out the exact nature and cause of mental illness, but to provide the best patient-care possible, and I guess I can’t argue with this.

… in his essay the weary Dr. Spitzer admitted that, “I doubt that clinicians will ever be very concerned with what illness itself is…. Concerns with defining medical or psychiatric illness or disorder are generally left to sociologists, psychologists, philosophers of science, and members of the legal profession.” This is deeply true. Front-line clinicians will not be joining the fray anytime soon. The academic debate over the evolutionary history of their patients’ woes is irrelevant to everyday practice.

I suppose that so far, academic attempts to define mental illness have been “irrelevant to everyday practice” because they haven’t resulted in any understanding of etiology or pathogenesis that could be translated into treatment and prevention strategies. But just because nothing has been solved so far, doesn’t mean a radical new approach might not prove to be more than added noise in the “academic debate.”

Satel concludes that “in the end, the most we can say about mental illnesses is that they are the result of various interrelated causes unfolding at different levels of explanation: biological (genetic or cellular), cognitive (information processing), and psychological (the generation of meanings in contexts).” I believe Greenfeld’s view of the mind as the individualized cultural process can help put together this causal puzzle that Dr. Satel describes. But this can only begin if we allow for the possibility that human experience is not determined by our biology. If we persist in the hope, (which I believe Satel holds), that we will one day grasp “how those swirling galaxies of neurons and molecules make us who we are, both in sickness and in mental health,” we will never stop “struggling in the dark.”

Thanks again to Dr. Sally Satel for the comment that sparked this post. You can read more of her writing here.