Posts Tagged ‘depression’
Posted on October 8, 2010 - by David
Diseases of the Will: Schizophrenia and MDI as One Illness
I am working directly from the unpublished text of Liah Greenfeld’s forthcoming book, Mind, Madness, and Modernity: The Impact of Culture on Human Experience. All the original ideas, and all interpretations and analysis of primary and secondary source materials used to support the ideas are attributable to Liah Greenfeld. Read the introduction to the exposition here.
part 1 – Doing Away With Dualism: A Solution to the Mind/Body Problem
part 2 – A Symbolic Reality: The Emergence of Culture and the Mind
part 3 – Madness: A Modern Phenomenon
part 4 – Schizophrenia and Manic-depressive Illness: What do we Know?
In this last installment, we consider how Greenfeld’s theory of the mind makes it possible to see schizophrenia and manic-depressive illness (that is, major depression and bipolar disorder), which are usually considered distinct disorders, as diseases of the will, existing on a continuum of complexity of the will-impairment experienced.
Culture – the symbolic transmission of human ways of life- is an emergent phenomenon, a new reality with its own rules, that nonetheless operates within the boundary conditions of life. This symbolic reality is only alive, (the process can only occur), in individual brains, hence the understanding of the mind as “culture in the brain,” or “individualized culture.” As described in part 2, three important “structures” of the mind – (patterned and systematic symbolic processes which must be supported by corresponding patterned and systematic processes in the brain) – are identity, will, and the thinking self.
Identity - the relationally constituted self – is always a reflection of a particular cultural environment. Greenfeld hypothesizes that the lack of direction given by modern culture makes the once relatively simple process of identity formation much more complicated. A well formed identity is able to subjectively rank the choices present at any moment, giving the will, (or acting self), a basis for decision-making. It follows then that problems with identity formation lead to problems with the will. Malformation of identity and impairment of the will necessarily affect the functioning of the thinking self (the “I of self-consciousness”) – the part of the mind which is explicitly symbolic in the sense that it operates with formal symbols – above all, language. The thinking self may become fixed on questions of identity; it may have to stand in for the will, when a person has to talk him/herself into acting in situations which normally wouldn’t require self-conscious reflection (e.g going to the bathroom, eating, getting out of bed); or in the most severe cases, the thinking self may become completely disconnected from individualized culture, in which case all the cultural resources of the mind range free, without direction from identity and will.
The experiences of those who suffer from mental illness begin to make sense within this framework. In major depression, the will is impaired in its motivating function – the ability to force oneself to act or think as one would like to, or as would seem appropriate, is severely lessened. The mind at this stage remains individualized and one has a definite, though distorted and painful, sense of self. The thinking self becomes negatively obsessed with identity, and an incredible dialogue of self-loathing thoughts takes hold. It is insufferable to be oneself, and death naturally suggests itself as the only possibility of escape. Though tragically, as we all know, many depressed people do take their lives, for many even the will to take this action is not present. In bipolar disorder, the impairment of the motivating function of the will in depression mixes with the impairment of its restraining capacity in mania. One can neither move oneself in the desired direction nor restrain one’s thoughts and actions from running in every direction. The negative self-obsession of depression (which can still be justifiably considered delusional) alternates with (the often more noticeable to the outside observer) grandiose and exalted self-image and beliefs. Mania can either cycle back to depression or, through delusional tension, develop into acute psychosis.
The most characteristic symptoms of schizophrenia – hallucinations and elaborate delusions – are usually preceded by a prodrome which bears significant resemblance to certain aspects of depression and mania. This is often a period of social withdrawal, when the experience of the outside world seems to move from a sense of unreality to a sense of the profound yet ambiguous meaningfulness of all things. In healthy minds, identity provides a relatively stable image of the cultural world and the individual’s place in it, and thus the will directs thought and action towards relevant goals. Naturally, at each moment much of the environment is overlooked so that attention can be focused where it should be. In the prodrome, however, the thinking self becomes fixated on mundane aspects of reality, and things in the environment which are usually taken for granted become alternately senseless or imbued with special significance. This experience of the world as incomprehensible and inconsistent suggests a serious problem with identity. The will, (which in healthy cases is a largely unconscious process directed by identity), gets put on the shelf, so to speak, and the thinking self takes on the task of trying to piece together this unreal or hyperreal outside world.
The prodrome is usually only identified after the fact, since it is the appearance of hallucinations and delusions which allows the illness to be diagnosed as schizophrenia. Delusions, (often also present in patients diagnosed with bipolar), are the best known feature of schizophrenia. We can understand delusion as the inability to separate between subjective and objective realities, or put another way, the inability to distinguish between the cultural process on the individual level (the mind) and culture on the collective level. Thus internally-generated experiences are mistakenly thought to have originated outside. The elaborate delusions described by schizophrenic patients can be seen as a kind of rationalization of the experience of acute psychosis. It is important to distinguish between delusional accounts of the acutely psychotic phase, given after the fact in moments of relative self-possession, and the experience itself. In the midst of acute psychosis, a person is almost always incommunicative. Descriptions of this stage often mention the loss of the sense of self, as well as the sense of being watched by an external observer. The mental process, no longer individualized, is beyond willed control. Schneider’s first-rank symptoms, such as the belief that thoughts are extracted or implanted and that physical sensations and actions are controlled by an external force, clearly point to the experienced loss of will which runs underneath so many schizophrenic delusions. The sense of an alien presence is explained by the continued processing of the thinking self even after identity and will have (if only temporarily) disintegrated. Lacking this individualized direction, the “I of self-consciousness” becomes the “eye of unwilled self-consciousness,” – the defenseless sufferer necessarily experiences this free-ranging cultural process as foreign, and quite possibly terrifying, because it is beyond his control.
The formal abnormalities of thought which were so important to Eugen Bleuler’s diagnosis of schizophrenia also fit into the cultural framework. Schizophrenics are often unable to privilege conventional, socially-accepted associations in thought. Most of the time in our modern societies, normal associations follow the rules of logic, (in the strict sense of Aristotelian logic based on the principle of no contradiction). (However, it must be noted that logic is an historical, thus cultural phenomenon, so the inability to think logically should not be taken as evidence of brain malfunction). Of course, depending on the context, some other logic may be culturally appropriate, and arbitrating between contextual logics is one of the primary ways that the will directs thought. In schizophrenia, though, with the will impaired, thought is unanchored to any of these logics, and seems to jump from one to another at random. This becomes most evident in the use of language, which seems to speak itself, flowing without direction and often tied together by the sonic qualities of words or connections in meaning which would usually be overlooked as irrelevant. While the use of language will necessarily depend on the particular cultural resources present in the individual’s mind, it is impersonal in the sense that it draws it life from the associations inherent in language itself, rather than associations pertinent to individual identity or the objective cultural context.
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Not only does Greenfeld’s continuum model better account for the huge overlap between the illnesses as currently defined, it also allows us to pay closer attention to movement along this continuum throughout the course of an individual’s illness. While anomie is presumed to be the initial cause of mental illness early in life through interference with identity formation, the various swings on the spectrum may become more comprehensible when we consider what is happening to the individual at the time when the change in symptoms occurs. It is possible that specifically anomic situations may lead to shifts in the already existing illness. (These considerations are explored in Greenfeld’s analyses of the well-publicized cases of John Nash, ( Nobel prize winner in economics), and Kay Redfield Jamison, co-author of the authoritative book on manic-depressive illness.)
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The focus on the symbolic, mental processes at work in these “diseases of the will” should not be misunderstood as in any way taking away from the biological reality of major mental illness. Just as the activity of healthy minds corresponds to certain brain activity, so the abnormal processes of a sick mind would be expected to correspond to atypical patterns of brain function. Neither does the hypothesis that mental illness has a cultural rather than biological cause ignore potential genetic conditions that might make certain individuals more vulnerable than others. In fact, it is possible that mechanisms of interaction between culture and genes may become known with continued research in epigenetics – the study of changes in gene expression not caused by changes to the underlying DNA sequence. Some have already hypothesized that gene-environment interaction may lead to epigenetic changes that are central to the expression of mental illness. Of course, unless epigenetic research is specifically designed to take the symbolic nature of the environment into account, it will probably do little to help us to better understand mental disease and the mental process in general.
Summary/Commentary
Part 1 of the exposition looks at the the mind/body problem which has stood at the center of Western Philosophy for over 2000 years, and considers Greenfeld’s proposed resolution – a 3 layer view of reality (matter, life, and culture/mind) in which the top 2 are emergent phenomenon. Greenfeld credits Charles Darwin with making it possible to view the world in terms of emergent phenomenon, which in turn makes possible her theory of culture and the mind which can put the mind/body question to rest. At the same time, she exposes the historical roots of the dogmatic bias of science (as it is normally practiced) towards materialism, and dismisses the notion that science has (or can) in any way empirically prove this position, thereby maintaining that there is no inherent conflict between faith and rigorous empirical study.
In part 2, the proposed solution to the dualist problem is developed – culture is a symbolic process emergent from biological phenomena and operating within the boundary conditions of life, yet fundamentally autonomous and governed by different set of rules. As life organizes the matter out of which it is composed into unlikely patterns, so the symbolic process of culture organizes the brain, (which at all times both supports and provides the boundary conditions for the process) to suit its own needs. Greenfeld logically deduces that the point of emergence for culture and the mind must have been the moment vocal signs were first intentionally articulated, and became symbols. The internalization of this intention creates the mental structure of the will. Yes, this means that in a single moment, culture, the mind, and “free will” as we know it appear together, forever separating homo sapiens from all other animal species and making humanity a reality of its own kind. This view of culture, as a symbolic process which not only structures social life but individual minds, has radical implications for the many disciplines which study the various aspects of humanity. This view also demands the attention of neuroscience, which will remain purely descriptive and not gain any ground in the attempt to understand and explain “consciousness” until it takes into account the symbolic reality – by far the most important aspect of the human environment.
Part 3 reiterates the ideas about nationalism developed in Greenfeld’s first two book and takes things a step further. She identifies nationalism, a fundamentally secular consciousness based on the principles of popular sovereignty and egalitarianism, as the defining element of modernity, responsible for massive changes in the nature of human experience. More specifically here, she claims that love, ambition, and madness as we know them today emerged out of this new consciousness in 16th century England and spread from there to other societies that adopted and adapted the nationalist culture.
Part 4 challenges the current psychiatric dogma that manic-depressive illness and schizophrenia are distinct illnesses with biological causes. The need to rethink this distinction is evidenced by the high degree of overlap in symptoms between two conditions and the failure to find consistent functional or structural brain abnormalities which would allow for accurate differential diagnosis. Not only have genetic researchers been unable to find individual genes that cause schizophrenia or mdi, their best work suggests a shared vulnerability to both illnesses. Epidemiological data seems to show that mental illness occurs at greater rates in modern nations with Western-derived culture, and studies within these nations suggest that the upper classes (i.e those individuals who fully experience the openness of society and have the greatest number of choices) are particularly affected. Both of these findings are consistent with Greenfeld’s hypothesis that anomie causes mental illness. Nevertheless, this data is consistently ignored or rejected as flawed, since it flies in the face of the currently accepted notion of mental illness as biologically caused and uniformly spread across cultures and throughout history. Likewise, the fact that no genetic cause of mdi or schizophrenia has been found has done little to dhake the faith that such a cause will one day be found. Unfortunately, this systemic materialist bias can only continue to impede progress in the understanding of these fatal conditions.
The theoretical view of mental illness as ultimately stemming from problems with the formation of identity is a new one, and thus it does not come packaged with some ingenious cure. However, the clear implication is that something must be done to help individuals in anomic modern societies to create well formed identities. Since this process begins very early in childhood, the intervention must begin then as well. Educating children about the multitude of choices they will face in their extremely open environment, and alerting them to the presence of the many competing and often contradictory cultural voices vying for their attention would become priorities. We should also be cautious (as the recent work of people like Ethan Watters suggests) of the potential side effects of exporting our culture to other societies.
While this exposition is in some sense finished, there is much more to say, and I will continue exploring these ideas and comparing them with other perspectives in my future posts. I realize this work is controversial, and can be difficult to take in all at once. Please, if any part (of the whole) of this seems unclear, unsupported, or simply outrageous, ask a question or give your critique. I’m eager to hear what others have to say.
Posted on March 2, 2010 - by David
‘Analytical Rumination’:Depression as an Adaptive Response?
I read an article last week in the New York Times Magazine by Jonah Lehrer called Depression’s Upside, exploring the possibility that depression is an adaptive, evolved response which helps people focus cognitive resources on solving complex problems. The idea comes from a paper by Paul W. Andrews and J. Anderson Thomson, Jr. published in July of 2009 in the Psychological Review, titled The Bright Side of Being Blue: Depression as an Adaptation for Analyzing Complex Problems. Lehrer’s clever lede uses a description of Darwin’s own mental anguish to slide into yet another evolutionary explanation for the workings of the mind. The following paragraph describes the theoretical view from which the work springs:
In the late 1990s, Thomson became interested in evolutionary psychology, which tries to explain the features of the human mind in terms of natural selection. The starting premise of the field is that the brain has a vast evolutionary history, and that this history shapes human nature. We are not a blank slate but a byproduct of imperfect adaptations, stuck with a mind that was designed to meet the needs of Pleistocene hunter-gatherers on the African savanna. While the specifics of evolutionary psychology remain controversial — it’s never easy proving theories about the distant past — its underlying assumption is largely accepted by mainstream scientists. There is no longer much debate over whether evolution sculptured the fleshy machine inside our head. Instead, researchers have moved on to new questions like when and how this sculpturing happened and which of our mental traits are adaptations and which are accidents.
As Lehrer points out earlier in his article, the prevalence of depression poses a problem for those who are “trying to explain the features of the human mind in terms of natural selection.” The only solution for them seems to be to demonstrate that depression actually has evolutionary benefits. Meanwhile a disorder like schizophrenia is rare enough, and a case for its adaptive benefits would be so difficult to make, that I guess it’s easier for them to chalk it up to a kind of glitch in the system.
My first problem is that this point of view fundamentally disregards the symbolic reality of culture. Once again, I’ll quote from Liah Greenfeld’s essay, Nationalism and the Mind, to give background on the view of culture as an emergent phenomenon:
On the most general level, culture is the process of transmission of historical ways of life and forms of human association across generations and distances… In distinction to other animal species, such transmission of ways of life and social organization, in the case of humanity, is not genetic, but symbolic. Humans are the only biological species, the continuation of whose existence is dependent on symbolic transmission.
The products of this cultural process are stored in the environment within which our biological life takes place, but the process itself goes on inside us. In other words, culture exists dynamically, develops, regenerates, transforms only by means of our minds – which makes culture a mental process. Let me reiterate: culture is a symbolic and a mental process. The fact that it is a mental process means that it occurs by means of the mechanisms of the brain. The fact that it is a symbolic process means that its logic cannot be reduced to the logic of the brain mechanisms, that it is an emergent phenomenon and a reality sui generis. In other words: the neural processes by means of which the cultural process occurs serve only as boundary conditions outside of which it cannot occur, but are powerless to shape the nature and direction of the cultural process. In contrast, culture itself consistently directs the brain, by means of which it occurs, forcing brain mechanisms into patterns of organization and operation which (though, obviously, not impossible) are most improbable given all that we may know of the biological functioning of the brain. (15-16)
The idea of culture as an emergent phenomenon leads to a view of the human mind as the individualized process of culture, and this obviously clashes with the argument made by Andrews and Thomson which seeks to explain the human mind as a product of biological evolution. Nevertheless, their argument is based upon an implicit acceptance of the idea that problems in the cultural environment affect the function of the brain.
I think it’s best now to look at the paper itself. On page 6, they describe the theory one claim at a time:
“In summary, we hypothesize that depression is a stress response mechanism: (1) that is triggered by analytically difficult problems that influence important fitness-related goals; (2) that coordinates changes in body systems to promote sustained analysis of the triggering problem, otherwise known as depressive rumination; (3) that helps people generate and evaluate potential solutions to the triggering problem; and (4) that makes tradeoffs with other goals in order to promote analysis of the triggering problem, including reduced accuracy on laboratory tasks. Collectively, we refer to this suite of claims as the analytical rumination (AR) hypothesis.”
By calling depression “a stress response mechanism,” they make it analogous to any animal’s response to a problem (such as the presence of predator) in the physical environment. On page 4, they write that “negative emotions are stress response mechanisms – they are involuntary response to environmental challenges with important fitness consequences, and they evolved to coordinate changes in physiology, immune function, attention and cognition, physical activity and other body systems to meet those challenges.” This view both cuts out the cultural (therefore symbolic) aspect of emotion and fails to acknowledge that “environmental challenges” are cultural challenges – for humans, the most important and challenging terrain that must be navigated is not the physical but the cultural world. When they write that “different environmental stressors trigger different emotions…” the only way to make sense of this is to read “environmental stressors” as “cultural stressors. The “stressor” may be present in the physical environment – a boss, an ex-wife, a place of work – but it is the cultural significance attached to these things which can “trigger different emotions.” I think we can safely assume that the “stress response” of a rabbit exposed to a wolf has never been based on symbolic reality and has probably been consistent over thousands of years. But for humans, both what constitutes a complex problem, and responses to such complex problems, has not been consistent over time and between places.
The authors focus on social dilemmas as the classic example of a complex problem that triggers depression. But you can’t talk about social dilemmas just in terms of evolution, cutting out the symbolic process of culture. Otherwise, each culture and its particularities must represent a separate human evolution. They use sexual infidelity as an example of an evolutionary fitness-related social dilemma, but it doesn’t take an anthropologist or an historian to figure out that such a situation differs widely over time and from culture to culture. It’s like they’re moving between descriptions of humans as just another species of animals and humans as cultural beings without ever acknowledging the difference. On the one hand they write “if his wife gets pregnant…” and then they mention “access to mates.” So are we cultural beings with institutions like marriage or just animals who need mates? They are speculating about the social dilemmas of hunter-gatherer groups and trying to relate this to the depression of modern people who live in a radically different cultural environment, but they don’t seem to see the disconnect.
The core of their theory is the claim that depression can be seen as adaptive rather than a disorder, because the analytical rumination characteristic of depression actually leads people to solutions for their complex problems. I’d like to consider this view in relation to the view of Allan Horwitz and Jerome Wakefield as described in the Loss of Sadness. Horwitz and Wakefield believe that certain symptoms of depression are normal reactions to difficult life events, and can even lead to personal growth of some kind, but they don’t consider these reactions to be true cases of depression. They consider true depression to have no apparent cause or context, or to last longer and have more severe symptoms than “normal sorrow.” Andrews and Thomson, on the other hand, see no qualitative difference between major depression and subclinical depression, claiming that “…depressive symptoms are better characterized on a single continuum of severity, duration, and liability” (7). While there may be good reasons for the continuum view, I believe this allows Andrews and Thomson to make their adaptive response argument for depression on the basis of evidence drawn mostly from subclinical cases and even from subjects in which “depressed affect” was induced by sad music or film clips. I don’t doubt that for some people, rumination may lead to a better understanding of their problems which could in turn lead to resolution or avoidance of future problems, but critics are quick to point out that this is probably not the way it works for severely depressed people. Lehrer quotes Peter Kramer, Brown University professor of psychiatry and human behavior and author of Listening to Prozac, who wrote, “this study says nothing about chronic depression and the sort of self-hating, paralyzing, hopeless, circular rumination it inspires.”
Andrews and Thomson are clearly interested in proposing new methods of treatment for depression, and believe that therapies which facilitate the process of rumination may be effective in dealing with the underlying problems causing depression. They describe a method which involves “having patients write about their strongest thoughts and feelings about their depressive episode in a journal (25). Journal entries were later examined and coded for “avoidance and processing.” The study found that:
“…the peak in processing was also associated with a spike in depressive symptomatology. Thus, the authors viewed the temporary spike in depression as a positive sign of growth and insight during treatment. This suggests that depression may enhance processing that promotes growth and insight into problems and may facilitate the resolution of the episode. “ (26)
I simply don’t see what leads them to conclude that “depression may enhance processing,” except that this view fits with their hypothesis. It would seem more logical to me to conclude that the increase in processing of negative thoughts and emotions caused the “temporary spike in depression.” They also fail to acknowledge the huge difference between depressive rumination in isolation, and carefully facilitated processing which occurs in the context of therapy. “Analytical rumination” may very well be a common feature of depression, but there is no reason this has to be seen as an evolutionary adaptation, and I doubt that it often leads to the resolution of complex problems without some form of outside help that can orient this rumination towards action.
As their paper draws to a close, Andrews and Thomson restate their claims and review the evidence they’ve used to try to demonstrate that “depression evolved by natural selection, probably because it helped people analyze and solve the problems they were ruminating about.” (41) I have to say, I was extremely frustrated by the number of times that “social dilemmas” and “complex problems” were mentioned, without any real examination of what this means for a depressed person today, or any apparent consideration of differences between cultures and over time. Then, I read this little paragraph:
A design analysis does not require depressive rumination to be currently adaptive because modern and evolutionary environments may differ in important ways (Thornhill 1990, 1997). All that is required is that, on average, depressive rumination helped people analyze and solve the problems they were ruminating about in ancestral environments. Still, strong, replicable evidence that depression rumination currently helps people analyze and solve the problems they ruminate about would support the evolutionary argument, and more research is needed here. (41)
Wow. Now they say something about this? So how do these environments differ, and why? They move between their ideas of the evolutionary past and today without blinking an eye, implying continuity and giving the appearance that they are in fact arguing that depressive rumination is “currently adaptive,” and then with only a few pages left to go in the paper they throw this in? So what has the point of all this been?
In looking at ‘now and then,’ so to speak, they suggest that today, compared to the “ancestral environment,” there are more ways to distract oneself from depression and the “complex problems” which trigger it, meaning that we are robbed of the potential benefit of depressive rumination. However, nowhere do they consider the obvious possibility- that the problems that individuals in modern societies face are of a much different nature than those of the “evolutionary past.” In the end, they seem to be saying the same thing Horwitz and Wakefield say, only they take a much more circuitous and frustrating path to arrive at their final statement:
Depression is the primary emotional condition for which people seek help. The current therapeutic emphasis on antidepressant medications taps into the evolved desire to find quick fixes for pain. But learning how to endure and utilize emotional pain may be part of the evolutionary heritage of depression, which may explain venerable philosophical traditions that view emotional pain as the impetus for growth and insight into oneself and the problems of life. (43-44)
I guess by this point, I shouldn’t be surprised when our “venerable philosophical traditions” get reduced to byproducts of evolution, but it still leaves me shaking my head.
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.
Posted on February 9, 2010 - by David
Allan Horwitz on the Medicalization of Depression
A few weeks ago a friend of mine sent me a link to a podcast interview with sociologist Allan Horwitz, author of a book called The Loss of Sadness which looks at the medicalization of depression. If you’re going to listen to the podcast, skip ahead to 4:51, where the interview (which lasts about 20 minutes) actually begins.
at 6:50 into the podcast, Horwitz says:
… In the current environment, genetic explanations are, one, given tremendous credibility, so if you can link things to genes that somehow makes it more important explanation than linking them to life histories or linking them to social circumstances… and that’s a cultural phenomenon, [there’s] no reality that they’re more important… And the second important phenomenon, which I also think is purely social, is that if phenomena are linked to gene it makes them seem as if they’re disorders whereas in fact there’s genes for perfectly normal personality dispositions or there’s probably genes that make us grieve when somebody close to us dies, certainly doesn’t mean bereavement is a disorder, but that the cultural valence of genes associates them with mental disorders..
At first, I was happy to hear someone point out that the prominence of genetic explanations of mental illness is a cultural phenomenon, not a reflection that they are actually more important than other perspectives. However, I got more and more confused as I considered what Horwitz actually says in this interview. Let’s just look at the above statement piece by piece.
1. It is a cultural phenomenon that genetic explanations of mental illness are given such prominence. Ok, check, I follow.
2. Linking phenomena to genes makes it seem as if they are disorders. Ok, I think I’m still with you, but are you telling me they have succesfully linked specific genes to mental disorders?
3. There are genes for behavior which we would consider normal, such as expressing grief when someone close to us dies. Wait, so are you saying there’s a gene for everything I do? Have they even linked sarcasm in blog posts to genes?
Let’s look at another piece of the interview, at 12:36
Horwitz: Depression is probably one of the very few psychiatric illnesses that’s been recognized for thousands of years, so it’s certainly not something that’s a new condition. From the ancient Greek philosophers, through the renaissance period, through the early psychiatrists, even through Sigmund Freud and the DSM I and the DSM II – it had always been a contextualized illness so that the people who become sad or even intensely sad in contexts where we would expect people to be sad – the loss of intimates, diagnoses of a serious physical condition, serious economic difficulties- these sorts of things were always clearly distinguished from the mental illness of depression, which either arises with no context or persists longer than the original context in which it arose or features extremely severe symptoms- vegetative symptoms, hallucinations and delusions, these sorts of things.
Interviewer: So you’re saying that there’s been this historical legacy of seeing depression as a pathology only when it doesn’t fit the context, when it doesn’t fit the situation.
Horwitz: Precisely, the symptoms are identical but one is contextually appropriate and the other is without cause or without reason.
Now I guess I’ll have to read his book to see if he gives evidence for his claim that depression has been recognized for thousands of years and has “always been clearly distinguished” from normal, “contextually appropriate” sadness. (I will point out that all the examples he rattles off are clearly part of Western culture). It’s a bit confusing that he says the symptoms of “the mental illness of depression” are more severe than expressions of normal sadness, and then later says “the symptoms are identical” but in some cases they are not contextually appropriate. I do get the point he is trying to argue- that social and other contexts should be taken into consideration when making a diagnosis of depression- but I’m don’t think he’s being very clear or convincing.
He is critical of the emphasis on genetic explanations of mental illness because it confuses normal reactions to life with disorders, but at the same time he claims that the “the mental illness of depression,” where the symptoms are severe and not contextually appropriate, has been recognized for thousands of years. So his argument basically amounts to a claim that the prevalence of depression is greatly overestimated because context is no longer considered when diagnoses are made. But where does this leave us with regards to the real, true cases of depression? Apparently, context can help explain why some reactions aren’t disorders, but Horwitz says nothing about how cultural context can account for the phenomena which actually are disorders. In fact, Horwitz seems to inadvertently reaffirm the prominence of the biomedical/genetic account of mental illness. By essentially suggesting that phenomena which can be explained by social and cultural contexts are not actually disorders, he places the true, severe, undeniable forms of mental illness in a category which only biology and medicine can touch.
Posted on January 28, 2010 - by David
Crazy Like Us, Part 4: Depression in Japan
Chapter 4 – The Mega-Marketing of Depression in Japan
One of the main ideas in Ethan Watters’ book, Crazy Like Us: The Globalization of the American Psyche is obviously that the active exportation of Western conceptions of mental illness has had a largely negative effect of the expression of these illnesses in other cultures. Nowhere is his criticism of this process more evident than in the final chapter on depression in Japan. Watters shows how drug companies went about actively creating a market for their products by both determining effective, culturally specific messages and ghostwriting research studies which would give credence to their claims of the need for, and efficacy of the SSRI anti-depressants. But what I’m most interested in looking at in this chapter is the evidence that depression as we know it is still missing from Japan.
At the end of the chapter, Watters concludes that the “mega-marketing” scheme seems to have worked in terms of profit. In its debut year in Japan , sales GlaxoSmithKline’s Paxil (the main drug discussed in the chapter) brought in over a hundred million dollars. By 2008, less than ten years after it was introduced, sales had grown to over a billion. This kind of gives the impression that depression, or at least its treatment, is now nearly the same in Japan as in the U.S. However the results of one small, impromptu survey I’ve been a part of twice suggest that the prevalence of depression in Japan is still nothing compared to America. Once a few years ago, and again this past November, I was present in Liah Greenfeld’s modernity seminar at Boston University when professor Chikako Takeishi of Chuo University in Tokyo brought a group of her students to class as part of larger U.S visit to cultural sites and institutions. Greenfeld asked her American students if they were friends with someone who had been depressed, and every hand went up. She then asked how many of us had been depressed ourselves, and I’d say a third, if not more of us, (including myself), raised our hands again. The responses of the Japanese students were strikingly different. Out of about 20 students, I believe no more than 3 said they had friends who had been depressed, and none of them had been depressed themselves. These were our Japanese counterparts – university students from an industrialized and technologically advanced nation under as much, if not more, pressure to succeed than we were. Of course, a number of objections could be made regarding the methodology of our little study, but Watters book makes one thing clear: thanks in large part to the efforts of companies like GlaxoSmithKline, it was no longer possible for these students to be ignorant of what we were talking about when we used the word “depression.” They knew conceptually, but none of them knew intuitively, experientially, like we did, what it was to suffer from this illness.
One of the reasons depression might appear to be a problem in Japan is the cultural prominence of the melancholic personality type. While in the West, we associate melancholy with depression to such a degree that the two are almost synonymous, this is not so in Japan. The typus melancholicus was adapted into Japanese psychiatry in the 1960’s from a German professor named Hubert Tellenbach. It seems the idea caught on not as a result of any forceful marketing but because the description of this personality type corresponded to certain highly valued characteristics. As Watters writes, “its association with such prized Japanese traits as orderliness and high achievement meant that having such a sadness-prone personality was something not to be feared but aspired to” (208). Some have identified the importance of Buddhist beliefs about suffering as an explanation for the value placed on sadness in Japanese culture. So while on the outside, Japanese sadness may look like our depression, the difference seems to be that, for the most part, the Japanese experience is not maladaptive to the culture or a cause of dysfunction. Watters quotes professor Margaret Lock of McGill University, who believes that some experiences which we see as negative symptoms may actual serve to strengthen social ties among the Japanese:
Feeling sad and reacting sensitively to losses, particularly of loved ones, is an idea that has singular appeal in Japanese. The theater, a range of literature and indigenous popular songs, traditional and modern, positively wallow in nostalgia, sensation of grief and loss, and a sense of the impermanence of things. People cry freely (by North American and northern European standards) about separation and lost loved ones, but at the same time they seem to draw strength from these experiences, to tighten their bonds with those who remain living, and to reaffirm group solidarity (212)
While this tendency towards melancholy may account for some of the confusion, there is an even greater reason why many see the Japanese as a deeply depressed culture: the astounding suicide rate. I agree with Watters, who writes that “most Americans would certainly assume that suicidal acts are nearly always caused by mental illness, most commonly depression” (218). The Japanese, though, have a long cultural history of suicide for reasons other than what we might expect. Watters references psychiatrist Masao Miyamoto, who has argued against the notion that the rise in suicide is related to depression. “A peculiarity of the Japanese is that they often die for the sake of the group,… They die for shame” (219)
In his classic study on suicide, sociologist Emile Durkheim identified altruistic suicide as one of three definitive types of suicide. In contrast to egoistic suicide, which results when society is not well-integrated and is unable to hold the individual members together, altruistic suicide occurs when the individual is so totally absorbed in the group that his own life loses value. A suicide “for the sake of the group” falls into the altruistic category. We can see in the story of young Oshima Ichiro, (featured prominently in this chapter), how excessive social integration and lack of individual identity can lead to suicide. In 1990, Ichiro, 24, joined the Dentsu advertising agency, which Watters describes as “the largest company of its kind in the world” (214). The Japanese market was in the midst of a dramatic economic downturn, while only a few months earlier it had been the envy of the world. By Watters’ description, Ichiro pretty much handed his life over to the company. Apparently, he was working an average of 47 overtime hours a week, though interestingly, based on his time sheets he only averaged 12 to 20 hours overtime. This suggests to me that he saw it as his duty to put in the time necessary to help his company succeed without demanding excessive compensation. Also, it seems the treatment he received at work was by American standards far below acceptable. Watters writes:
At one late-night drinking binge at the office, Oshima’s boss poured beer into his own shoe and demaned that Oshima drink it down. When he momentarily refused the request, his boss beat him. (216)
Also striking is the fact that an hour before his family found him hanging in the bathroom, Ichiro called the office to tell them he was sick and wouldn’t be making it in. Obviously his identity had been completely absorbed by the Dentsu advertising agency. Even in the moments before his death he could not forgo his duty to at least notify the company that he would be absent that day. While many American identities are wrapped up in work, Oshima Ichiro’s identity belonged to the company that employed him, and I believe this is an important difference. Perhaps the most typical question asked when two Americans meet for the first time is ‘what do you do?’ , and we all understand that this means ‘what do you, as an individual, do for work?’ While our identities are linked to our individually chosen pursuits, it seems for the Japanese, identity is much more about who you are connected to. For Ichiro, failure would not be merely personal, it would mean letting all the other members of his company down, as well as his family and society as a whole.
While I’ve tried to show that suicide in Japan is not necessarily the result of depression, there are ways in which it may be related to modern societal changes. The third type of suicide which Durkheim mentions, anomic suicide, is caused by a lack of regulation in society. While this type is closely related to egoistic suicide, (and Greenfeld’s definition of anomie goes a long way towards reconciling the two into one), Durkheim focuses much of his discussion of anomic suicide specifically on lack of economic regulation. It seems likely that the huge economic swings related to competition in the global marketplace introduced a new level of stress to the Japanese workforce, further augmenting the cultural tendency towards suicide. For centuries, the Japanese have been dying for shame and the sake of the group, and their marriage to the modern economy seems to be a deadly union.
These two articles from the New York Times archives give some relevant background information on the topic of depression in Japan, as well as introduce what I see as one of the major problems with the whole discussion of depression in general. The first I believe is representative of the “depression is a serious brain disease” camp, while the second tends towards the “we have medicalized sadness” stance. For some reason, it seems that the implied middle view- the possibility that something is indeed seriously wrong, but the root causes of the problem are not simply biological or genetic- hardly even exists in the discussion. I guess I’m trying to do what little I can to change that.
Exploring modern culture and its effects on the mind