Madness Explained
Page 28
It remains unclear why some psychotic patients experience this difficulty. In a study reported by Meredith Mayer, Murray Alpert and their colleagues it was found that flat affect was associated with severe side effects of neuroleptic medication, length of hospitalization, and poor performance on neuropsychological tests designed to assess the functioning of the right half of the cerebral cortex.60 As the right cerebral hemisphere is believed to be involved in the regulation of emotional expression, this last finding might seem unsurprising. Unfortunately, later researchers, using more sophisticated right hemisphere tests, have not been able to replicate these results.61
Intriguingly, whether or not flat affect is associated with poor functioning of particular brain regions, it may most accurately be described as a problem of social communication. Heiner Ellgring, a psychologist at the University of Würzburg in Germany, studied the facial expressions of schizophrenia patients as they watched emotion-provoking films and, like the American researchers, found that they were under-expressive. However, she found that the patients showed reduced activity specifically in those muscles of the upper face that are normally active when we are talking to other people (for example, when we raise our eyebrows in response to a juicy piece of gossip). In another study, she calculated the rate at which facial expressions occurred while speaking and when not engaged in conversation. Ordinary people are most expressive when talking to others. However, in the case of the schizophrenia patients studied by Ellgring, no differences were observed in the rates at which expressions were generated while speaking and not speaking. Ellgring argues that these findings show that, in schizophrenia patients, facial expressions have become dissociated from their communicative function. Clearly, this could be caused by some kind of damage to the social brain. Equally, it is possible that the long periods of social isolation often experienced by schizophrenia patients might cause them to lose the skill of expressing their emotions to other people.62
Anhedonia
Like affective blunting, the inability to experience pleasure has long been regarded as an important feature of schizophrenia. In the mid-1950s, the Hungarian-born psychoanalyst Sandor Rado, who had joined the great European exodus of intellectuals to America in the years preceding the Second World War, argued that anhedonia was not merely a symptom of the disorder, but a core deficit that led to loss of motivation, a vulnerability to irrational fears, an incoherent sense of self, and an inability to form adequate relationships.63 This idea was developed further in Paul Meehl’s speculative 1962 paper on the relationship between schizophrenia and personality.64 Meehl suggested that anhedonia might be a primary cause of the disorder, present before the onset of illness, and responsible for patients’ social isolation and aberrant interpersonal behaviour. One problem with this idea is that anhedonia is not restricted to schizophrenia patients. Martin Harrow and his colleagues in Chicago interviewed psychiatric patients about their experiences of joy and pleasure, and found that, although anhedonia was most often reported by schizophrenia patients, it was also frequently reported by patients with other diag-noses.65 Similarly, Joanna Katsanis and colleagues at the University of Minnesota studied patients who were experiencing their first episode of psychosis, and found that high levels of anhedonia were reported, not only by those diagnosed as suffering from schizophrenia, but also by patients diagnosed as suffering from schizoaffective disorder, depression or bipolar disorder.66
This last observation may seem particularly surprising, as bipolar patients are said to experience both extreme positive and negative emotions. For this reason, American psychologists Jack Blanchard, Alan Bellack and Kim Mueser examined levels of anhedonia in schizophrenia and bipolar patients more carefully. They found that high levels of anhedonia were reported by depressed bipolar patients but not by those who had recently suffered from an episode of mania. Therefore, whereas anhedonia may be a stable or trait-like characteristic of some schizophrenia patients, it appears to vary with time in patients with a bipolar diagnosis.67 Consistent with this hypothesis, Katsanis and her colleagues found that anhedonia correlated with premorbid social functioning in schizophrenia patients (those who functioned poorly prior to illness showed high levels of anhedonia when ill) but not in patients with other diagnoses.68
These findings tell us very little about the emotional life of anhedonic patients. Again, the circumplex model of emotion provides a useful framework. In a recent study, Blanchard, Mueser and Bellack measured physical and social anhedonia, as well as positive and negative affect, in schizophrenia patients and normal controls. As expected, the schizophrenia patients reported higher levels of anhedonia and lower levels of positive emotion in comparison to the controls. However, they also reported high levels of negative emotion and social anxiety. These differences remained when the participants were retested three months later. When the anhedonia scores of the schizophrenia patients were examined, it was found that they were negatively correlated with positive emotion. Social anhedonia scores, but not physical anhedonia scores, were positively correlated with negative emotion. It therefore appears that anhedonic patients suffer not only from a deficiency of positive emotion, but also from a surfeit of negative emotion.69
Disorders of affect-logic
Negative symptoms are among the least researched facets of psychosis. As we will see in later chapters, much more effort has been directed towards understanding the psychological mechanisms involved in more flamboyant symptoms, such as delusions, hallucinations and unusual forms of speech. Perhaps because they have been ignored, negative symptoms have appeared all the more mysterious, or have simply been dismissed as reflecting the impoverished output of a wounded brain. However, we have seen that, when some of these symptoms are examined in the context of what is known about normal emotions, the picture of a type of madness in which the individual is aloof or indifferent to the social world is revealed as largely myth. The negative symptoms become more understandable, if as yet not completely explained.
The misleading view that negative symptoms reflect a lack of emotion has underpinned the assumption that schizophrenia is an intellectual disorder whereas manic depression is a disorder of affect.
Objecting to this assumption, the Swiss psychiatrist Luc Ciompi has suggested70 that all psychotic illnesses are disorders of affect-logic, a term which he uses to highlight the inseparable relationship between cognition and emotion.* In the next part of this book, in which we consider the most commonly reported symptoms of psychosis, we will see that this principle holds for delusions, mania, hallucinations and disordered speech.
The term affect-logic is not an entirely satisfactory translation of an appropriated German neologism meaning, simultaneously, ‘the logic of affectivity’ and ‘the affectivity of logic’. It points to the central conceptual basis of the model, which postulates that in all normal and most pathological mental functions, emotions and cognitions – or affective and cognitive functions, feeling and thinking, affectivity and logic – are inseperably connected and interact in regular but not yet sufficiently well understood ways.
Ciompi’s theory is a complex blend of Piagetian developmental psychology, biological studies of emotion and non-linear dynamics. There is clearly considerable overlap between his approach and the approach taken in this book. The main difference is that Ciompi has paid less attention to the psychological processes involved in specific symptoms.
Part Three
Some Madnesses Explained
10
Depression and the Pathology of Self
O God, I could be bounded in a nutshell and count myself a king of infinite space, were it not that I have bad dreams.
Shakespeare, Hamlet
I can vividly remember beginning the first draft of this chapter on a cold February morning in 1999. My wife Aisling sat nearby on a sofa, cuddling our children, Keeva and Fintan, who had been born a few weeks earlier. Although they were breast-fed in the daytime, at night we gave them bottles so that we could share the burden impose
d by their arrival. The night before, we had fed them at two o’clock and again at half past four. On the second of these occasions, I had stared at Keeva while in the semi-psychotic state that lies at the boundary between wakefulness and dreaming, and it had occurred to me that she might really be an angel. It would not have surprised me if, at that moment, fluffy wings had unfurled from behind her back.
In many ways, the period immediately following the birth of the twins was extremely stressful. Aisling and I survived on vanishingly small amounts of sleep. Naturally, my academic productivity was affected (later, I calculated that the year 2000 saw my lowest number of publications since the mid-1980s). Yet, I was probably as contented as I have ever been.
My life had not always been so happy. The years that followed my twenty-ninth birthday were especially difficult. Looking ahead a year or two earlier, the omens had seemed good. In short order, I had married my first wife, obtained my doctorate in experimental psychology, qualified as a clinical psychologist, and secured my first job in the National Health Service. And yet, in the few years that followed, my father died in a road accident, my brother committed suicide, and I walked out of my marriage in favour of an old girlfriend who immediately disowned me. When I struggled to make sense of these events, they seemed to be inexplicably connected, as if fruits of some kind of curse.
Leaving my small house in Chester, I found myself homeless. For almost twelve months I lived from a suitcase and drifted between friends. At my worst during the year of 1986, I probably met the DSM-IV criteria for major depression. However, I cannot remember a point at which I thought of myself as ‘ill’ or a specific moment when I seemed to have become ‘better’. Instead, my feelings seemed appropriate to the dismal sequence of events that had befallen me. I saw myself drinking from a well of emotion that I shared with others suffering similar difficulties, a common reservoir of misery which is part of my species’ collective experience. Many of us, when confronted by these kinds of events, pick ourselves up and struggle onwards. In my own case, I was helped by a good psychotherapist, to whom I was referred by a colleague who could see that I was not coping.
Although it is not usually included among the symptoms of psychosis, there are several good reasons for beginning our detailed examination of psychotic phenomena with depression. First, as American psychologists David Rosenhan and Martin Seligman have observed, depression is ‘the common cold of mental illness’.1 The very familiarity of negative mood will make it more understandable to most readers than some of the other symptoms that we will encounter later. Second, depression is very commonly experienced by schizophrenia patients, both during acute episodes and also during the prodromal phase that precedes the appearance of positive symptoms. Third, it is also an important facet of manic depression as described by Klaus Leonhard, who observed that mania rarely occurs in its absence. Moreover, unipolar depression can, in its own right, become psychotic, which is to say that it can be accompanied by other psychotic symptoms such as delusions and hallucinations. And finally, many of the concepts that we will explore when attempting to explain depression will serve us well in later chapters, when we attempt to get to grips with other types of symptoms.
Before we can begin, we must first address a complication. I have thus far talked about ‘depression’ as if what I mean by this term is self-evident. Indeed, most of us accept the idea of depression as if it can be easily differentiated from other types of unpleasant feelings. However, as we saw in the last chapter, the landscape of emotion is not so easily charted. To take my own experiences fifteen years ago, I suffered not only deep feelings of dysphoria, but I also had a very low opinion of myself and felt very pessimistic about the future. I had difficulty sleeping, and would ruminate in the dark hours about how other people saw my change of circumstances. During the daytime I felt tired and lacking in energy. So preoccupied was I with my own difficulties that my capacity to empathize with my patients was severely blunted. (With the benefit of hindsight I can now see that I should have given up clinical work for the duration.)
People diagnosed as depressed often have experiences such as these, but suffer them to varying degrees. At its worst, the pessimism associated with depression can be so severe that the person does not believe that there is any point to getting up, and may languish in bed for days on end. Other symptoms are also commonly reported. The first depressed patient I was asked to treat when I was a trainee clinical psychologist was a recently divorced and lonely middle-aged woman whom I will call Clare.* Consistent with my own experience, she felt severely demoralized and made gloomy predictions about what would happen to her in the years ahead. However, in contrast to many patients who complain of anhedonia, her interest in food and sex were heightened, making the lack of a partner even more difficult to bear. In common with many other patients, she felt very tense. However, less commonly, she found that she could relieve her tension by taking a knife and making shallow cuts across her breasts and arms.
In psychotic depression, the content of the accompanying symptoms is usually congruent with the patient’s mood, so that hallucinations make derogatory remarks, and the patient feels guilty of improbable crimes, or becomes convinced that he is doomed to some kind of horrific fate. George, an extremely successful engineer, could survive with equanimity the stresses of his demanding job, but became severely dysphoric after travelling abroad (a fact that did not deter him from taking his family on regular foreign holidays). During these episodes, which sometimes lasted for several months, he would develop the delusion that his employers were about to sack him and reclaim his salary from the preceding years (in fact, they were amazingly tolerant of his long absences). He also believed that he had somehow mislaid the very substantial savings that he had accumulated, and that his family were about to be evicted from their home and would eventually starve. Efforts to reassure him, for example by showing him his bank statements and building society accounts, were all to no avail. For weeks, he would avoid brushing his teeth, in order to ‘conserve energy’, and would spend his time sitting around his house in his pyjamas, remaining as motionless as possible.
Investigators studying cross-cultural differences in depression have noted that cognitive symptoms – especially guilt and low self-esteem – are less evident in developing countries than in the West. In contrast, patients in developing countries tend to complain more of somatic symptoms, such as fatigue, loss of weight, or headaches and dizziness. Not surprisingly, beliefs about the nature and causes of these symptoms also vary between cultures. In a vivid example of this kind of difference, Arthur Kleinman has described the case of Mrs Lin, a 28-year-old primary school teacher he met at Hunan Medical College in south central China in 1980:2
Mrs Lin, who has suffered from chronic head-aches for the past six years, is telling me about her other symptoms: dizziness, tiredness, easy fatigue, weakness, and a ringing sound in her ears. She has been under the treatment of doctors in the internal medicine clinic… for more than half a year with increasing symptoms. They have referred her to the psychiatric clinic, though against her objections, with the diagnosis of neurasthenia. Gently, sensing a deep disquiet behind the tight lips and mask-like squint, I ask Mrs Lin if she feels depressed. ‘Yes, I am unhappy,’ she replies. ‘My life has been difficult,’ she adds quickly as a justification. At this point Mrs Lin looks away. Her thin lips tremble. The brave mask dissolves into tears. For several minutes she continues sobbing; the deep inhalations reverberate as a low wail.
Further inquiry revealed that Mrs Lin’s parents had been killed during the Cultural Revolution. A teenager at the time, she and her four siblings had been dispersed to different rural areas. She had difficulty adapting to her new environment, which was much harsher than the city in which she had been raised. During the following years, she felt cold and hungry and had only one friend. She later learned that one of her sisters had committed suicide and that her brother had been paralysed in a tractor accident. Unable to pass the entrance exam to her chos
en university, she agreed to an arranged marriage. Her husband and mother-in-law later subjected her to physical and psychological abuse following the stillbirth of a nearly full-term foetus. Kleinman remarks:
For a North American psychiatrist, Mrs Lin meets the official diagnostic criteria for a major depressive disorder. The Chinese psychiatrists who interviewed her with me did not agree with this diagnosis. They did not deny that she was depressed, but they regarded the depression as a manifestation of neurasthenia, and Mrs Lin shared this viewpoint. Neurasthenia – a syndrome of exhaustion, weakness, and diffuse bodily complaints believed to be caused by inadequate physical energy in the central nervous system – is an official diagnosis in China; but it is not a diagnosis in the American Psychiatric Association’s latest nosology.
Kleinman’s view is that Western depression and Chinese neurasthenia are the same condition, which is expressed in different ways in response to local cultural influences. Chinese neurasthenia is therefore somatized depression. However, as Richard Shweder of the University of Chicago has pointed out, we might just as well describe North American depression as emotionalized neurasthenia.3 The solution to this cross-cultural conundrum is to recognize that Western depression and Chinese neurasthenia are different but overlapping clusters of symptoms. There is no need to think of an underlying disease entity that is the ‘middle man’, or to give primacy to one diagnosis or the other.4