Good Reasons for Bad Feelings

by Randolph M. Nesse

  “I just wanted to warn you,” he said. “This one wants answers.”

  “What are her questions?” I asked.

  “She wants to know why everyone she sees gives her different explanations and different advice. She’s skeptical about the whole shrink thing. She got up at five a.m. to drive here from upstate to get answers from the big shots at the Big U.” He was referring, sardonically but with a smile, to me and our prestigious university hospital.

  I asked him to summarize the case. He gave a quick case presentation:

  “She’s a thirty-five-year-old married mother of three grade-school-age children whose chief complaint is increasing worry about nearly everything for the past year. Her health, her kids, the economy, driving, everything. She often has a bad feeling in the pit of her stomach, and once or twice a month she has bouts of nausea, but she hasn’t lost any weight. She says she’s irritable and fatigued and has trouble getting to sleep. She is less interested in things, but she’s not suicidal, and she doesn’t have other symptoms of depression. Anxiety runs in her family, but nothing dramatic. Her family doctor couldn’t find any medical causes. I think it’s generalized anxiety disorder, but it could be dysthymia or somatization disorder. I’ll be curious to see what you think. And how you answer her questions.”

  When we joined Ms. A in the exam room, she greeted us warmly. When I asked how we could help, however, her voice took on an edge. “I take it that the young doctor already told you about my problems. I drove five hours from up north to get some answers.”

  Trying to be empathic, I said, “I understand you have had trouble getting help.” It was as if I had pushed the play button.

  “Not only have I gotten no help, but every expert I talk to gives me a different explanation. I started with our minister. He is a nice man, and he was sympathetic, but mainly he just suggested praying and accepting God’s plan for me. I tried, but I guess my faith just isn’t strong enough. Then I talked to my family doctor. He didn’t even do any tests; he just said it was nerves. He said pills for worry are addicting, so he prescribed pills for my stomach, but they didn’t help.

  “He sent me to this therapist doctor who wanted me to come twice a week, which I couldn’t afford. He didn’t talk much, and when he did, he kept asking about my childhood and hinting like I had some sexual thing for my father, which I definitely do not! When I told him I was getting worse, he said I was avoiding getting in touch with my memories. I quit going, but he still sends bills for the session I skipped.

  “I still felt awful, so I found a psychiatrist in the phone book who was far enough away that people wouldn’t find out. He said my problem was an inherited brain abnormality and that I would have to take medications to correct a chemical imbalance. But he didn’t do any blood tests, either, and when I looked up the pills, it said they might cause suicide. So I decided to get myself down here to the university to get some answers. All I do is worry, and I can hardly sleep or eat, and my husband has had it with my calling him about the kids all the time, so I hope you have some answers.”

  “No wonder you are frustrated,” I said. “Four different explanations and recommendations from four different professionals! And we may well have yet other ideas. Could we ask a few more questions to figure out the best plan?”

  She was glad to provide more details. She said she had always been a worrier and that her mother had often been nervous. She had never been abused, but her father had often been critical. When she was young her family had moved every few years, so she had always felt out of it at school. Her marriage was stable, but she and her husband fought a lot, especially about his frequent business trips and what to do about their oldest son’s ADHD. She often drank “a few glasses” of wine to help her get to sleep. She said the anxiety had worsened two years previously, about the time her youngest son had started kindergarten and she had started trying to lose weight. Without a pause she went on to say, “But all that has nothing to do with my problem. What I came here to find out is whether it is neurosis or brain disease or stress or what.”

  I started to explain that her symptoms resulted from a combination of inherited tendencies, early life experiences, her current life situation, and drinking. She frowned. As I went on to explain that anxiety can be useful but that most people have more than they need because too little can result in disaster, she brightened and said, “That makes sense.” When I told her that several kinds of treatment could be safe and effective and that an excellent cognitive behavior therapist near her home would likely be able to help, she relaxed and said, “Maybe this trip will be worth it.” However, later, as she stepped out of the office, she stared at me and shared a parting comment that still rings in my ears: “Your whole field is confused. You know that, right?”

  I had never quite admitted it to myself that clearly. Psychiatrists are supposed to help their patients get in touch with things they are trying to avoid, but Ms. A turned the tables on me. For all case reports, I have modified details so that patients cannot be recognized by friends, relatives, or even themselves, but if Ms. A reads this and recognizes her visit thirty years ago, she will likely be pleased to learn that her pointed observation shattered my denial and set me on a quest to transcend the confusion.

  Embedded Shrink

  During my early years as an assistant professor of psychiatry, I was embedded, like a journalist in a war zone, in a medical clinic staffed by internal medicine professors, medical residents, and nurse clinicians. Many patients in medical clinics have mental problems, so my help was appreciated. There was also a hope that my presence would encourage resident doctors to have greater sensitivity to patients’ emotional lives. We accomplished that to some degree, but the bigger impact was on me. As I saw and experienced the emotional strains of treating a steady stream of sick patients, I came to appreciate how growing a thick skin can protect the psyche.

  The internists often asked me to talk with troubled patients who had tried seeing a psychiatrist and vowed “never again.” Some complained about spending fruitless months with a therapist who said little. Others complained about seeing a doctor for only a few minutes before being sent away with a prescription for a drug that caused side effects. A few told me that their lives had been transformed by a patient, caring therapist, and some described working closely with a doctor for months until finally finding a medication that worked. However, most patients who got good results never told anyone about their treatment, and I was rarely invited to see patients who were doing fine, so I saw many skeptics. I listened to them for hours each week for years, but I was so intent on convincing them to accept help that I never really heard their collective wail of frustration until Ms. A put it in a nutshell: the field of psychiatry is deeply confused.

  That does not mean that psychiatric treatment is ineffective. When I told fellow medical students about my career choice, several put on sympathetic faces and said something like “Someone has to care for patients who can’t be helped.” That misconception is as unfounded as it is common. Almost all psychiatric problems can be helped, and treatment remarkably often provides an enduring cure. Patients with panic disorder and phobias get better so reliably that treating them would be boring if it were not for the satisfaction of watching them return to living full lives.

  The woman whose agoraphobia had kept her from leaving her trailer for a year was, a few months later, driving to see her sister an hour away. The carpenter who came in with social anxiety so intense he could not eat lunch with coworkers came back a year later to tell us how much he enjoyed his new job giving public presentations all around the state. Even some patients with severe disorders get dramatic benefits. Last week I got an email out of the blue from a patient I saw twenty-five years ago, with a heartfelt spontaneous thank-you, saying that treatment of her severe obsessive-compulsive disorder had transformed and very likely saved her life.

  Many books attack the field of psychiatry. This is not
one of them. Yes, big money from big pharma results in more corruption in psychiatry than in some other medical specialties. And industry-funded advertising and professional “education” promote the profit-maximizing simplistic view that all emotional disorders are brain diseases needing drug treatment. However, the vast majority of psychiatrists I have known are caring, thoughtful doctors who work hard to help their patients by whatever means works. I recall one psychiatry resident who came in at 6 a.m. every day so his patients, who were mostly struggling with alcoholism, could get to work on time; he was still there at 7 p.m. Another psychiatrist friend took on the toughest borderline patients, despite knowing he would get midnight calls threatening suicide. Then there are the many psychiatrists who treat desperately depressed or psychotic patients, knowing that some will commit suicide and they will be blamed. Most of us lie awake some nights worrying about a patient in a crisis and wondering how to help. However, most patients get better, and the challenge of helping them makes the practice of psychiatry profoundly satisfying.

  The challenge of understanding mental disorders is, by contrast, deeply unsatisfying. Several years into my work teaching psychiatry, I was frustrated as well as confused. The field seemed to be narrowing to the slogan “Mental disorders are brain diseases.” The phrase is great for marketing drugs, decreasing stigma, and soliciting donations, but it short-circuits clear thinking. Sometimes it is accurate, but it excludes valuable insights from behaviorism, psychoanalysis, cognitive therapy, family dynamics, public health, and social psychology. Practicing psychiatry based on only one perspective is like living within the walls of a medieval town. Trying to understand different perspectives is like visiting a series of walled towns. To see the whole landscape of mental illness requires a view from a mile high using special glasses that show changes across evolutionary as well as historical time.

  What Causes Mental Disorders?

  Like the six blind men each touching a different part of an elephant, each different approach to mental disorders emphasizes one kind of cause and a corresponding kind of treatment. Doctors who look for hereditary factors and brain disorders recommend drugs. Therapists who blame early experience and mental conflicts recommend psychotherapy. Clinicians who focus on learning suggest behavior therapy. Those who focus on distorted thinking recommend cognitive therapy. Therapists with a religious orientation suggest meditation and prayer. And therapists who believe most problems arise from family dynamics usually recommend, predictably, family therapy.

  The psychiatrist George Engel recognized the problem in 1977 and proposed an integrated “bio-psycho-social model.”1 Every year since has brought renewed calls for such integration, for the unfortunate reason that psychiatry’s fragmentation has, if anything, increased. The messy realities of mental disorders are ignored to fit them into the procrustean bed of one or another schema. Learned panels plead for integration, but committees that decide on grant funding and tenure only support projects that fit into narrow disciplines.

  Plans for a recent revision of the diagnostic system aroused hope for greater coherence, but the result was increased conflict and confusion. The distinguished psychiatrist Allen Frances chaired the committee that wrote the previous edition of the book that defines each mental disorder, Diagnostic and Statistical Manual of Mental Disorders (DSM).2 The title of his recent book captures his dissatisfaction with the revised edition of the DSM: Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.3 Debates about diagnosis are so rancorous that they spill onto newspaper editorial pages. The crowning blow was the US National Institute of Mental Health (NIMH) abandoning the official DSM diagnoses for mental disorders.4,5 So much for a common diagnostic system creating consensus!

  The search for brain abnormalities that cause mental disorders has offered another hope for reducing confusion. In a medical school admission interview in 1969, I revealed, perhaps unwisely, that I planned to become a psychiatrist. “Why would you want to do that?” the interviewer asked. “They’re going to find the brain causes for mental disorders soon, and it will all become neurology.” If only that prediction had come true! However, four decades of research by thousands of smart scientists, supported by billions of dollars, has still not found a specific brain cause for any of the major mental disorders, except for those such as Alzheimer’s disease and Huntington’s chorea in which brain abnormalities have long been obvious. For other mental disorders, we still have no lab test or scan that can make a definitive diagnosis.

  This is as astounding as it is disappointing. The brains of people with bipolar illness and autism must somehow be different from those of other people. But brain scans and autopsy studies have identified only small differences. They are real, but small and inconsistent. It is hard to say which are causes and which are results of the disorders. None comes close to providing a definitive diagnosis of the sort radiologists provide for pneumonia or pathologists provide for cancer.

  Hope for diagnosis based on genetics has also collapsed. Having schizophrenia, bipolar disorder, or autism depends almost entirely on what genes a person has, so most of us engaged in psychiatric research at the turn of the millennium thought the specific genetic culprits would soon be found. However, subsequent studies have shown that there are no common genetic variations with large effects on these disorders.6 Almost all specific variations increase the risk by 1 percent or less.7 This is the most important—and most discouraging—discovery in the history of psychiatry. What it means, and what we should do next, are big questions.

  Leading psychiatric researchers deserve credit for acknowledging the failure and the need for new approaches. In a recent article in the journal Science, several of them wrote, “There have been no major breakthroughs in the treatment of schizophrenia in the last 50 years and no major breakthroughs in the treatment of depression in the last 20 years. . . . This frustrating lack of progress requires us to confront the complexity of the brain. . . . This calls for a new perspective.”8 A recent meeting of the Society of Biological Psychiatry solicited presentations on the topic “Paradigm Shifts in the Treatment of Psychiatric Disorders.” And in 2011 the director of the National Institute of Mental Health, Thomas Insel, said, “Whatever we’ve been doing for five decades, it ain’t working. . . . When I look at the numbers—the number of suicides, the number of disabilities, the mortality data—it’s abysmal, and it’s not getting any better. Maybe we just need to rethink this whole approach.”9

  Psychiatrists recognize patients’ life crises as opportunities for them to make major changes. Could the same be true for psychiatry?10

  Finding the Future in the Evolutionary Past

  The Museum of Natural History was a block south of our medical center. Opening the heavy iron door between two big lion sculptures brings you into the exhibit museum, a place I knew well from taking my kids to see dinosaur fossils. But this time I had an invitation to go through the doors marked STAFF ONLY to join a group of scientists who met weekly to discuss animal behavior. In the first hour, it became clear that their approach was completely different from anything I had learned before.

  Instead of asking only about brain mechanisms, they also asked how natural selection shapes the brain and how behavior influences Darwinian fitness. Fitness is the technical term biologists use to refer to how many offspring an individual has that grow up to reproduce themselves. Some individuals have more offspring than others do, so their genetic variations become more common in future generations. Other individuals have fewer than the average number of offspring, so their genetic variations become less common. This process of natural selection shapes bodies and brains that work very well indeed to maximize Darwinian fitness in the natural environment.

  Usually traits at some middle value are best. Rabbits vary in boldness. Exceptionally bold rabbits become fox dinners. Timid rabbits flee so fast they don’t get much to eat. Rabbits with interme
diate levels of anxiety have more baby bunnies, so their genes become more common. Some people get so-called Darwin Awards for doing stupid things that eliminate them and their genes. The adventurous young man who strapped a rocket booster to his car was going 300 mph when he and his car flattened into a thin layer on a cliff side. Other people fear leaving the house. They don’t die young, but neither do they have many children. People with more moderate degrees of anxiety have more children, so most of us have intermediate levels of caution.

  My new colleagues at the museum relied on a simple principle to explain why animals do what they do: selection shapes organisms to behave in ways that maximize their reproductive success. This is not a hypothetical theory; it is a principle that must be true. It provides what I was looking for—a new kind of biological explanation, not just for behavior but also for why organisms are the way they are.

  After mostly listening for a few weeks, I finally got up my nerve and shared a theory I had come up with as an undergraduate. Aging is useful, I suggested, to ensure that some individuals die each year so the species can evolve faster when the environment changes. The group got suddenly quiet, but one biologist, Bobbi Low, laughed so hard she was sputtering as she said, “You really don’t know anything about evolution, do you?” It was a friendly laugh, the kind elicited by watching a puppy try to climb stairs. Bobbi and others explained that genes that benefit a species will nonetheless be eliminated if individuals with those genes have fewer than the average number of offspring.

  Bobbi suggested that I read a 1957 paper by the evolutionary biologist George Williams. I stopped by the library on the way home and made a copy. As for so many before me, reading it transformed my view of life. Williams pointed out that a gene causing aging could become universal if it gives benefits early in life, when selection is stronger because more individuals are alive then.11 For instance, a genetic variation that causes coronary artery calcification that kills many people by age ninety could nonetheless become universal if it also makes broken bones heal faster in childhood. His paper was so influential that a retrospective was published on its recent sixtieth anniversary.12 Williams offered a completely different kind of explanation, not just for aging but also for diseases in general. If aging has an evolutionary explanation, what about schizophrenia, depression, and eating disorders?