Madness Explained

by Richard P. Bental

  Given this degree of variation – both within and between cultures – between people who are all said to suffer from the same condition, it is not surprising that some psychologists and psychiatrists have suggested that the concept of depression has outlived its usefulness.5 As I agree with this conclusion, writing this chapter has presented me with a series of dilemmas. First, although I would like to focus specifically on dysphoric mood, I am hampered by the fact that nearly all the relevant research has been conducted on individuals from developed countries who are described as depressed rather than dysphoric. To some extent I will be able to get around this problem by making the dangerous assumption that negative mood is the common symptom experienced by these individuals. Unfortunately, there is not much that I can do about the cultural biases inherent in the research (although I will speculate a little about cross-cultural differences wherever this seems appropriate).

  Second, most of the published research on depression has been carried out either with ordinary people (typically university students) who are temporarily distressed, or with patients who are diagnosed as suffering from non-psychotic depression. Fortunately, there are good reasons to believe that the findings obtained can be generalized to psychotic patients. When experiments have been carried out both on ordinary people and on psychiatric patients, comparable results have usually been obtained. In the case of patients who are diagnosed as suffering from unipolar depression, the main difference between those who are psychotic and those who are not (other than the presence of hallucinations and delusions) seems to be the severity of their negative mood, those patients who are most dysphoric being most likely to experience delusions and hallucinations.6 When bipolar depression has been compared with unipolar depression, the results again reassure us that we are not dealing with fundamentally different phenomena.7

  There is one final caveat I must offer before proceeding with my account of the psychology of depression. As the term ‘depression’ applies to a loosely connected group of symptoms, of which dysphoria is the most obvious, it is unlikely the experiences of every depressed patient can be explained in the same way. We should therefore expect to find that depressive symptoms are influenced by a network of interacting psychological mechanisms, which play more or less decisive roles in different individuals. It follows that there may be several different pathways to depression. In this chapter, I will attempt to identify two such pathways (there may well be others), taking the reader step by step through the evidence that is relevant to each.

  From Appraisal to Distress

  Anyone who has failed to avoid the ordinary tragedies of life will recognize that many events can provoke a dysphoric mood – the death of a loved one, the collapse of a relationship, humiliation in the eyes of one’s peers, or the failure to achieve a cherished ambition. However, it is equally obvious that individuals react to these experiences in different ways. Some shrug them off after a few days of emotional discomfort while others plummet into an extended period of despair. These differences reflect the role of appraisals in modulating emotional reactions. A relatively positive interpretation of the death of a loved one (‘He had a good innings; he was loved by his family until the end; at least he is no longer suffering’) is likely to lead to better emotional adjustment to the loss than a negative appraisal (‘He never had a chance to fulfil his potential; I did not love him as much as I should have; he died a painful and lonely death’). Of course, appraisals are partly determined by the facts of the situation – a loved one might really have died a lonely and painful death – but, in most situations, there is usually some degree of freedom in the kind of interpretation that can be offered.

  There have been many attempts to define the kinds of appraisals that lead to dysphoria, but most have assumed that they involve some kind of pessimistic interpretation of events. Psychiatrist Aaron Beck of the University of Pennsylvania (who is best known for his pioneering efforts to develop effective psychological treatments for psychiatric patients) has observed that the thinking of depressed people is dominated by a negative view of the self, the world and the future. Beck refers to this cluster of attitudes as ‘the negative cognitive triad’. According to Beck, automatic or unbidden thoughts that reflect these themes are the immediate precursors of dysphoric mood.8 These thoughts are presumably part of the stream of inner speech, which, we saw in Chapter 7, tends to be evoked whenever we are emotionally aroused.

  Although Beck’s theory has enormously influenced clinical practice, most research on the appraisals of depressed patients has focused on a slightly different but not incompatible theory developed by American psychologists Martin Seligman, Lyn Abramson, Lauren Alloy and various collaborators. In a landmark paper, Abramson and Seligman, together with British psychologist John Teasdale, noted that we usually experience negative emotions when we are exposed to unpleasant events that are beyond our control.9 However, they argued that full-blown depression only develops when we hold certain beliefs about the causes of those events.*

  The theory developed by Seligman and his colleagues built on an observation, made some years earlier by the social psychologist Fritz Heider, that human beings act for much of the time like intuitive scientists.10 As we navigate our way through the challenges of everyday life, we usually attempt to find explanations for noteworthy events, particularly those that involve other people. An unpleasant disagreement with a friend might be attributed to some characteristic of the friend (‘She’s bad tempered and argumentative’), the situation (‘We’ve both been under stress lately’), oneself (‘It’s because I offended her when we met last week’), or some combination of these causes. In the jargon of social psychology, these kinds of causal statements (made to other people or to ourselves while thinking) are known as attributions (because they involve us attributing events to particular causes). So readily do we generate attributions that they might be thought of as one of the defining characteristics of our species – Seligman and his colleagues have estimated that most people make at least one causal statement (a sentence including or implying the word ‘because’) in every few hundred words of ordinary speech.11

  To understand how attributions are involved in the experience of negative mood, imagine that you have failed an exam. (Young readers will not find this too difficult. Readers who are as old as myself may have to think back a few years.) You might explain your performance in a number of ways. For example, you might say to yourself: ‘It’s because I didn’t work hard enough’, ‘I had bad luck’, or ‘The examination was unfair.’ According to Abramson, Seligman and Teasdale, your failure will only lead to lasting distress if you attribute it to a cause that is internal, global and stable.

  An internal cause is something to do with you, whereas its opposite, an external cause, is something to do with other people or circumstances. A global cause is something that will affect all areas of your life, as opposed to a specific cause, which will have an effect only on specific kinds of events. A stable cause is something you cannot change and which will be present in the future, whereas an unstable cause is something that is only likely to have an impact at this particular point in time. According to Abramson, Seligman and Teasdale’s recipe for depression, if you fail an exam the best way of ensuring enduring misery is to say or think to yourself, ‘It’s because I’m stupid.’ This attribution is internal (it locates the fault within yourself), global (it will adversely affect not only your performance in this exam but also your performance in others and, ultimately, your ability to earn a good living) and stable (there is not much you can do about being stupid; if you are stupid today the chances are that you will be stupid in the future). If you make any other kind of attribution you may still be miserable, but your misery will be short-lived.

  The attributional theory of depression is a type of stress-vulnerability model. According to Seligman, we each have an individual attributional style that remains relatively fixed throughout our adult lives. Individuals with a pessimistic style (those who usually explain
negative events in terms of causes that are internal, global and stable) may go for many years without experiencing depression. It is only when they encounter a severe negative event, and explain it pessimistically, that they become markedly dysphoric.

  Unfortunately, the measurement of attributional style has not been devoid of problems. With Christopher Petersen at the University of Michigan, Seligman developed a questionnaire for this purpose, known as the Attributional Style Questionnaire (ASQ, see Table 10.1). People completing the ASQ are asked to imagine a range of positive and negative events and are asked to write down their most likely cause. It is assumed that the kinds of attributions people make about these hypothetical scenarios are indicative of the kinds of attributions they make in everyday life. After writing down each cause, they are

  Table 10.1 An item from the Attributional Style Questionnaire (C. Peterson, A. Semmel, C. von Bayer, L. Abramson, G. I. Metalsky and M. E. P. Seligman (1982) ‘The Attributional Style Questionnaire’, Cognitive Therapy and Research, 3: 287–300).

  You meet a friend who acts hostilely toward you.

  1. Write down one possible cause of this event

  _________________________________________________

  2. Is the cause of your friend acting hostilely toward you due to something about you or something about other people or circumstances?

  Totally due to other people or circumstances

  Totally due to me

  1 2 3 4 5 6 7

  (circle one number)

  3. In the future, when interacting with friends, will this cause again be present?

  Will never again be present

  Will always be present

  1 2 3 4 5 6 7

  (circle one number)

  4. Is the cause something that just influences interacting with friends or does it also influence other areas of your life?

  Influences just this particular area

  Influences all situations in my life

  1 2 3 4 5 6 7

  (circle one number)

  asked to rate it on seven-point scales of internality–externality, globalness–specificity and stability–instability. These characteristics of attributions are therefore viewed as dimensions rather than categories.

  Although widely used in research, the ASQ suffers from a number of shortcomings,12 some of which we will consider when we think about delusions in a later chapter. For this reason a number of alternative approaches have been proposed. One strategy involves using judges to score attributions recorded from samples of everyday speech (a technique that Seligman calls the Content Analysis of Verbal Explanations, or CAVEing). Seligman and his colleagues have imaginatively employed this strategy to analyse patients’ mood changes during psychotherapy (less pessimistic attributions precede positive changes in mood),13 voter-preferences in elections (Americans, it seems, prefer to elect presidential candidates who make optimistic election speeches)14 and even political decision-making (optimistic shifts in Lyndon Johnson’s press statements preceded bold decisions in the Vietnam War).15

  Does attributional style predict future dysphoria in the way suggested by Seligman? It has turned out to be surprisingly difficult to answer this question. To begin with, there can be no doubt that depressed patients make excessively internal, global and stable attributions for negative events as predicted by the Abramson, Seligman and Teasdale theory. As early as 1986, psychologist Paul Sweeny and his colleagues at Indiana University were able to summarize the results of no less than 106 studies, most of which provided evidence that was consistent with the theory.16 Subsequent research has mostly replicated these findings.17 Although most of these studies have involved non-psychotic people, with Helen Lyon and Mike Startup at the University College of Wales in Bangor I have looked at the attributions of patients diagnosed as suffering from bipolar disorder.18 The scores of four participants, shown in Figure 10.1, illustrate some general points about attributional style.

  The panel on the left of the figure shows internality scores. High scores indicate that attributions are relatively internal (self-blaming) and low scores indicate that they are relatively external (blame is attributed to others or to circumstances). Average scores are given separately for hypothetical positive events (for example, being awarded a pay rise) and negative events (for example, going on a date that turns out badly). Note, first, that the scores of ordinary individuals (people without psychiatric problems) who took part in the study are not exactly fair-minded. Although the reader might expect that we tend to blame ourselves equally for positive and negative events, in fact we usually take more credit for things that turn out well than for things that turn out badly (if I fail an exam it’s probably because I’ve been handicapped by various problems beyond my control; if I pass it’s because I am a genius). This attributional distortion, which social psychologists call the self-serving bias, and which has been documented

  Figure 10.1 Internality, stability and globalness data for bipolar-manic, bipolar-depressed and normal participants (from Lyon et al., 1999).

  in numerous experiments,19 was accurately described by William Shakespeare in King Lear nearly four centuries ago:

  This is the excellent foppery of the world, that, when we are sick in fortune, – often the surfeit of our own behaviour, – we make guilty of our disasters the sun, the moon, and the stars; as if we were villains by necessity, fools by heavenly compulsion.

  The stability and globalness data, shown in the right two panels, provide further evidence of a lack of fair-mindedness in ordinary people. Positive events are attributed to causes that are more stable and global than negative events. In order to maintain our mental health, it seems, we have to make unrealistically optimistic appraisals about the likelihood that good things will happen in the future and about our power to bring such events about.*20

  Although I will discuss mania in detail in the next chapter, it is interesting to note that those suffering from this condition showed a robust self-serving bias, just like the normal controls. They were also, like the controls, optimistic in attributing positive but not negative events to stable and global factors. In contrast, the depressed patients blamed themselves more for negative than for positive events. As in previous studies of unipolar patients, the bipolar-depressed patients also believed that factors responsible for negative events were likely to be more enduring, and to affect more areas of their lives, than the factors responsible for positive events. Similar findings have been obtained from patients with other psychiatric diagnoses involving high levels of dysphoria, particularly anxiety disorders.21 As might be expected in the light of the circumplex model of emotion, the pessimistic style is therefore associated with negative mood, rather than any specific diagnosis.

  So far, so good for Abramson, Seligman and Teasdale’s theory. However, it has proved more difficult to find evidence that a pessimistic attributional style precedes the development of dysphoria. Most researchers who have attempted to show that this is the case have begun by identifying people who have a high probability of experiencing some kind of disappointment or failure (for example students who are about to take an exam) or a stressful life event (for example, women who are about to give birth). Although some studies have found that a pessimistic attributional style predicts a bad emotional response to adverse events,22 others have produced either negative or equivocal results.23

  Clearer evidence has emerged from a different kind of prospective study, which has recently been reported by Lauren Alloy, Lyn Abramson and their colleagues at Temple and Wisconsin Universities in the USA.24 In this study, known as the Temple–Wisconsin Cognitive Vulnerability to Depression (CVD) Project, the researchers attempted to identify students who were apparently psychologically well but vulnerable to abnormal mood. Over 5000 students were assessed using a measure of attributional style, together with a measure of abnormal attitudes towards the self which we will consider in detail later in the chapter. From this sample, 173 students were identified who showed strong evidence of a
pessimistic cognitive style, but who were not currently dysphoric. These students, together with a matched group who were not thought to be vulnerable to mood disorder, were followed up every six weeks for two years and then every four months for a further three years. The main finding from the first two years of the project was that the vulnerable students were much more likely to experience severe dysphoric episodes than the control students (17 per cent versus 1 per cent for major depression as defined by DSM criteria and 39 per cent versus 6 per cent for minor depressive symptoms).

  Although these findings may seem inconsistent with the results obtained from the earlier prospective studies, this impression is probably inaccurate. The students in the high-risk group of the Temple– Wisconsin Project represented under 4 per cent of the total sample – a very highly selected, and probably very highly vulnerable group. It is not surprising that much weaker effects were detected in the earlier studies carried out with unselected participants. In this context it is important to note that the selection policy adopted in the Temple– Wisconsin Project was not only one of its strengths, but also a weakness. Although the project appears to confirm that a pessimistic attributional style can precede depression, the high-risk students who were identified were probably not representative of dysphoric people in general. If negative mood is indeed the common cold of psychiatry, it is a fair bet that the majority of those who become dysphoric do not fall into this high-risk group.*