Good Reasons for Bad Feelings

by Randolph M. Nesse

  Her disorder was serious and might have benefited from more aggressive treatment. If she had been my patient, I would have tried to convince her to continue her antidepressants. Also, I would not have taken her explanation at face value. She may have minimized family history or previous symptoms. Depression could have contributed to the end of her marriage and career obstacles. But her description of her descent and recovery nonetheless helped me to transcend my own despair and dig in again to the challenge of figuring out why mood exists at all. The effort will be worthwhile if it encourages others to help construct a framework that will allow us to make sense of mood disorders in the context of normal mood. But first it is essential to ask why so many smart doctors don’t see why understanding the origins and functions of normal mood is essential for understanding mood disorders.

  The Fundamental Error

  Current psychiatric research on depression exemplifies the fundamental attribution error. It is as serious as it is common. I was assigned to complete a rating scale on a young woman who was hospitalized for depression. Partway through the interview she said, “It all started when I got raped.” I found no reference to the rape in her chart, so I asked her doctor if he knew about it. He said, “Yes, but not everyone who gets raped gets depressed.” That is like saying that not everyone who smokes cigarettes gets lung cancer.

  Treating symptoms without paying attention to what is arousing them is not unique to psychiatry. VSAD is also common in the rest of medicine. Doctors sometimes use drugs to relieve pain, vomiting, cough, and fever without knowing the cause. However, most doctors who treat cough look carefully for asthma, heart failure, pneumonia, and other problems that arouse the normal cough reflex. They consider the possibility that the cough regulation system has run amok only as a last-ditch explanation. Experts who treat abdominal pain look for irritable bowel syndrome, Crohn’s disease, cancer, ulcers, and other problems that arouse pain, along with the possibility that the pain regulation system might be awry. But the experts at the mood disorders conference said nothing about how to look for life situations that cause mood changes. They viewed symptoms as diseases.

  There are good reasons why the VSAD fallacy is more common for emotional disorders. The problems that cause cough and abdominal pain are tangible. You can see pneumonia on an X-ray and ulcers via a gastroscope. The situations that influence mood are often invisible. Depression symptoms rise like a vapor from invisible gaps between desires and expectations. As if that were not challenge enough, different individuals have different desires, different ways of coping with frustration and failure, and different ways of avoiding unpleasant ideas and emotions. The nun who is upset by “unclean thoughts.” The executive passed over for a crucial promotion. The father whose child is using heroin. All are trying to cope with major failures, but the situations are vastly different.

  Measures of stress and checklists of life events don’t begin to describe the specific life situations that influence mood. Sometimes even a long conversation is not enough. I spent an hour talking with a middle-aged woman to try to find out what had set off her depression but got nowhere. She denied losses, frustrations, marital problems, substance abuse, and other usual causes. But as she put her hand on the door handle to leave she said, “You know, I remember the exact moment my depression began.” “When was that?” I asked. “It was six months ago. I was just leaving the house, and the phone rang. It was my boyfriend from high school. I hadn’t heard from him in years. We just said hi, nothing else. It wasn’t any big deal. But it started that night.”

  During our next visit, I asked in detail about her marriage and her previous boyfriend, but she said everything was fine. Maybe she had decided to avoid thinking about what could have been. Maybe her unconscious mind had suppressed thoughts about possible alternative paths her life could have taken. Maybe it was a coincidence and her depression had a spontaneous onset that she attributed to the phone call. If only there were some kind of “lifeoscope” that could reveal life problems the way a gastroscope shows an ulcer.

  Why Is Psychiatry Out of the Loop?

  VSAD is the main obstacle to progress in understanding mood disorders. Physiologists study the evolutionary origins and utility of special states such as fever and stress. Behavioral biologists and psychologists have conducted scores of studies describing the situations that influence mood and how mood variation influences thinking and behavior. In psychiatry, however, VSAD remains the norm.

  Why? Some blame industry money and the rewards it provides to those who promote slogans that promote drug treatments, such as “It’s a brain disease.” I am less cynical. Many neuroscientists and psychiatrists have good reasons for thinking that mood problems are usually caused by brain abnormalities. One big one is that most of the serious disorders they see in clinic really are products of abnormal brains. Bipolar disorder, for instance, is an inherited brain disease in which mania and depression arise and fade in cycles that are often unrelated to changing life situations. Other patients have episodes of serious depression that come and go for no apparent reason. Some people are born with a tendency to constant low mood or extreme emotional reactions to even mild events. In such cases, excessive symptoms from a broken regulation mechanism really are the disease.

  Also, many patients wrongly attribute their symptoms to life events. I recall a woman who insisted that current work stress caused her depression, but probing revealed that she had had symptoms most of her life, as had her siblings and parents. In many cases of marital problems I treated, a mood disorder seemed to be more a cause than a result of relationship problems.

  However, the opposite error is equally common: some patients blame their brains to avoid acknowledging a life problem. I recall a young woman who wanted an antidepressant prescription for what she said was “obviously a chemical imbalance” because it had begun the same month she started a new job that had doubled her income. It took extensive discussion to discover that she had spent the previous decade trying to make it as a graphic artist. Taking a job as an assistant stockbroker marked the end of her dream. I saw so many patients who misattributed their symptoms either to life events or to brain abnormalities that I found myself becoming skeptical whenever a patient expressed strong opinions about causes.

  It is also easy to miss important life problems. When an unfamiliar doctor asks, “Have you experienced any stress recently?” many patients give a noncommittal answer to avoid a potentially upsetting and likely useless conversation about abuse, illicit affairs, gambling losses, or problems coping with a sick child. Some carefully conceal the source of the problem. A severely depressed man with a solid family and a good job was not improving after a month of weekly treatment sessions. Then, in the middle of a session, he started sobbing. When he was finally able to talk, he revealed a heart-rending story about how his closest relationship had for years been with a secret lover who had died suddenly. He couldn’t even attend the funeral and had not been able to talk with anyone about his grief.

  A fourth reason for glossing over life situations is that learning the details doesn’t always help. Problems with easy solutions get solved. Those that cause major mood problems are usually tough or impossible to solve. A man was constantly berated and belittled by his wife’s wealthy and powerful parents, to whom she was devoted. He could not imagine leaving his wife and children, and all efforts to improve the behavior of his in-laws failed. Minimizing contact with them helped some, recognizing the inaccuracy of their criticisms helped a bit more, and antidepressants took the edge off, but he remained depressed, trapped in a bad situation, looking forward, with only some guilt, to the demise of his aged in-laws.

  On top of all these reasons, the very idea that low mood can be useful seems ludicrous. Sadness occurs after a loss has already happened, so it seems as if it’s too late to be useful. The pessimism, lassitude, social withdrawal, and low self-esteem of depression interfere with the ability to cope.

 
What proportion of cases is caused mostly by situations, what proportion is caused mostly by characteristics of the person, and what proportion by interactions between the two? A rough answer comes from the original classic study of depression by Aubrey Lewis, the chair of the Institute of Psychiatry in London during the middle of the twentieth century. He analyzed detailed notes on sixty-one of his patients with severe depression and concluded that in about a third the onset of depression was unconnected to any life event, another third had a vulnerability to depression that had magnified the effect of a negative experience, and the final third had depression caused by a specific event such as a death or divorce.13 Scores of more sophisticated studies have confirmed his basic finding.14,15,16,17 The vast majority of first episodes of serious depression are precipitated by a bad life event, but third or fourth episodes of depression are more likely to arise in the absence of any specific event.18,19,20 Such episodes unconnected to life events were previously called “endogenous depression,” in contrast to cases of “exogenous depression” that had a precipitant.21,22 However, the symptom patterns and responses to treatment turned out to be very similar, so the distinction was dropped, further encouraging VSAD.

  Symptom patterns can help to separate depression that is a response to an event and depression that is part of a larger and longer pattern. Jerome Wakefield and Mark Schmitz looked at how often depression recurred for different groups.23 Patients with uncomplicated depression (symptoms lasting less than two months and not including suicidal thoughts, psychosis, feelings of worthlessness, or moving slowly) were no more likely than anyone else to have depression later. The authors concluded that such cases of normal sadness are very different from cases of severe depression characterized as “melancholia,” which often have repeated autonomous episodes.

  How Many Ways Can Mood Fail?

  Recognizing the utility of normal mood changes makes it possible to apply the same framework that doctors use to understand other disorders. Dozens of mechanisms adjust the body to changing situations. Sweating and shivering cope with changing temperatures. Anxiety rises in response to threats. Blood pressure increases with threats and exercise and decreases with calm and rest. What is normal depends on the situation. A blood pressure reading of 170/110 is abnormal at rest but useful and normal during exercise. Whether high or low mood is normal depends on the situation.

  Regulation systems can fail in at least six ways. Distinguishing them is crucial for understanding them.

  SIX WAYS THAT REGULATION SYSTEMS CAN FAIL

  Baseline is too low.

  Baseline is too high.

  Response is deficient.

  Response is excessive.

  Response is aroused by inappropriate cues.

  Response is independent of cues.

  Low or high baseline levels are common problems. People with low blood pressure are more likely to faint than to win an athletic competition. People with chronic low mood (dysthymia is the technical term) are bundles of misery who accomplish little and often seek help. People with high blood pressure are likely to have a stroke or a heart attack. People with chronic high mood (hypomania) accomplish a lot and don’t seek help; their disorder is rarely recognized, except by exasperated family members and coworkers.

  Even if baseline levels are normal, responses can be deficient. If your blood pressure does not increase when you stand up, you are likely to faint. If your mood never changes, something is wrong. Lack of low mood is rarely recognized except when people are unmoved by events that would shake others. In our study of bereavement, a remarkable number of people reported no grief symptoms after the death of their spouse, but no diagnosis applies to them.24,25 Deficiencies of high mood are finally getting more attention thanks to positive psychology.

  Excessive responses are more obvious. Exercise makes blood pressure go sky-high in some people; they are likely to develop chronic hypertension and its complications. Excessive emotional response to minor events is also common. I recall a woman crying intensely while reporting that she had discovered a quart of sour milk in her refrigerator, blaming herself for what she saw as an abject failure. This could have been just depression, but a few minutes later, she was rhapsodic about her son getting into a band. Patients with borderline personality disorder are especially prone to extreme mood changes. A partner’s facial twitch or tone of voice can trigger rage or sobbing.

  Inappropriate responses are a different kind of problem. Seeing blood or a needle makes blood pressure plunge in some people; I learned not to draw blood from patients sitting on a high examination table after one fainted and fell off. Television dramas are intended to arouse emotions, but my patient who was still upset days after watching an episode of The Brady Bunch had a serious problem.

  Finally, broken regulation mechanisms can cause apparently spontaneous changes. Sudden blood pressure spikes or plunges can occur for no discoverable reason. Severe bouts of mania or depression can cycle on their own, unconnected with any life events.

  Why Mood Regulation Systems Are Fragile

  Mood regulation systems are vulnerable to failure for the same evolutionary reasons as other bodily systems. Sometimes the failure is only apparent. Sometimes it is because of living in a modern environment. Sometimes it reflects trade-offs or the limits of what natural selection can do. Each deserves consideration.

  The Smoke Detector Principle explains some normal but nonetheless excessive mood responses. Low mood conserves calories and avoids risk; high mood is expensive and can be dangerous. When outcomes are hard to predict, erring on the side of low mood may provide advantages, especially in harsh environments. Recognizing that misery may be useless even when it is normal is a foundation for making wise treatment decisions.

  Some mood changes benefit our genes at our expense. Our desires for the perfect partner and great sex provide great pleasure when they can be satisfied, but for many people they cause chronic grinding frustration. Desperate striving for high status and wealth gives big payoffs for a few but wrecks life for many.

  I treated, or tried to treat, many depressed VIPs, mostly corporate vice presidents and deans. The core problem for many was overweening ambition that left them perpetually unsatisfied despite their substantial accomplishments. Recognizing that such desires can’t be satisfied could relieve immense suffering.26 However, our ancestors who found it easy to ignore such desires had fewer children, so we have brains that push us to strive in ways that benefit our genes.

  Plato warned that pursuing pleasure leads to unhappiness. The Buddha taught that desires can never be satisfied. Every religion provides advice about how to get off the hedonic treadmill, leaving its emotional baggage behind. However, such advice is like advice about diets: correct, well-meaning, plentiful, and, for good evolutionary reasons, well-nigh impossible to actually follow.

  The Perils of Modern Environments

  Abundant food we can’t resist explains atherosclerosis, obesity, and high blood pressure, but modern social environments provide plenty of other novel temptations and hassles. Hunter-gatherers never tried to get into the NBA. They did not stay up late on Twitter. They never had to cope with bureaucracies. They didn’t ruminate about whether to have children. They never spent months preparing for divorce court. They did, however, get depressed.

  For two decades, I asked anthropologist colleagues about rates of depression in the cultures they studied. Kim Hill is an anthropologist who spent many years with the Ache, a tribe living in the Amazon jungle. Each year when he returned, I asked him how much depression he had seen. Each year he told me he had seen almost none, despite the prevalence of infected wisdom teeth, tuberculosis, and other health problems that might make anyone miserable.

  Finally, about the tenth time I asked him, the answer was different. His group had started a medical clinic. They were amazed to hear about problems they had never suspected. Many people
came to the clinic complaining of pessimism, hopelessness, lack of interest, lack of appetite, poor sleep, poor digestion, and just not feeling like doing much of anything. I was especially intrigued to hear his observation that whoever became chief of the tribe was likely to show up in the clinic within a few months with symptoms of anxiety and depression.

  The differences between our environments and those of our ancestors are getting larger, faster and faster. There is some evidence that mood disorders may be more common in modern environments.27 However, carefully conducted studies find no increase in major depression rates in recent decades.28 It can nonetheless appear as if we are in an epidemic. Drug advertising and reduced stigma make depression a common conversation topic. Publicity campaigns emphasize the prevalence of depression. Rates of low mood in the normal range have been increasing even if serious depression has not. Finally, a quirk of memory distorts perceptions. A large questionnaire study found that younger people reported many more depression episodes than older people and concluded that depression rates must be rising fast.29 It seems more likely, however, that memories of depression fade with time.30,31

  The tendency to forget bad times can also make depression rates seem lower than they really are. The current prevalence rate for depression in the United States is about 9 percent.32 Across 148 surveys around the world, the average prevalence of any mood disorder was 5.4 percent each year and 9.6 percent for lifetime estimates.33 However, asking young people about symptoms every few months paints a different picture. A large study of Wisconsin women found that 24 percent of women and 15 percent of men had experienced major depression or dysthymia before age twenty.34 Of women followed yearly from ages seventeen to twenty-two, 47 percent had one or more episodes of major depression.35 Among college students the rate is about 30 percent in a given year.36