Good Reasons for Bad Feelings

by Randolph M. Nesse

  Some clinicians skip asking about personal details. They check symptoms on a list, put patients into diagnostic categories, and then recommend whatever treatment has been shown to help patients with that diagnosis. This nomothetic approach saves time, effort, and the emotional entanglements that ensue from creating relationships with individuals. Fewer midnight phone calls. Other clinicians try to understand how each patient came to have his or her particular problem. Here are a few sample idiographic narratives that connect motives, strategies, and events to explain the depression of individuals.

  Ms. W is a middle-aged woman with a strong family history of depression and a long history of dysthymia and generalized anxiety. Over the past six months, she has become depressed and lost interest in her job and in sex. Only her children are still important to her, but they have become increasingly demanding as she has become more withdrawn. Her husband does not know how to help her and has become more and more distant.

  Ms. X has always been angry with her father, blaming him for leaving the family when she was young, resulting in her being raised by a mother who was often away working and who was depressed when she was at home. The patient continues to be angry at men in general and resentful and depressed when her husband’s work requires weeklong trips.

  Ms. Y has had problems with sleep resulting mostly from chronic pain but also from anxiety. About ten years ago she began using benzodiazepines for sleep, and she now cannot sleep well without them. Sometimes she adds a drink to her pill in the evening. She finds it hard to get up in the morning, and she is tired all day, sometimes getting in trouble for taking naps at work. Her husband berates her, saying she is not doing enough housework and is neglecting the children.

  Ms. Z has always dedicated her life to her children, much to the consternation of her husband, who feels left out. This was satisfying to her for years, but as her children have gotten older, they have begun getting into trouble and refusing to talk to her about their problems. She has long been distant from her husband, but lack of closeness with her children makes her feel helpless and hopeless as she realizes that they are likely to get into serious trouble.

  As you may well have guessed as you read those four narratives, they are all about the same person, Ms. D, whom we met at the start of this chapter. All five explanations are plausible. If presented at a case conference by a distinguished professor, each one could be convincing. This is a problem. A big problem. If we have no method for distinguishing true from false stories, we are not doing science. We have no such method. Now what?

  One approach is to treat each narrative as a different hypothesis and see which one best matches the evidence. That leads to interesting discussions; however, no single story is completely correct, and each one highlights relevant factors. Can we throw them all into a pot and call it a complete explanation? No. Some factors are more important than others, and different stories propose different causal connections.

  Idiographic explanations can be scientific; they are routine in astronomy and geology. Cosmology relies on the general laws of physics to explain stars and black holes in general, but to explain a specific blue dwarf or red giant star requires discovering the sequence of events in the development, decline, and death of a particular star. The laws of gravity are necessary to explain our moon, but they are not sufficient to explain how a particular moon came to exist. Ours could have been formed from consolidated dust or by a captured asteroid, but substantial evidence suggests that a Mars-sized mass (Thedia) grazed Earth about 4.5 billion years ago, knocking off a piece of our planet that eventually became our moon.5

  Geology also routinely uses idiographic explanations. Explaining a valley requires applying the general laws of gravity, hydraulics, and climatology to a particular sequence of events in a particular place. Some valleys arise from glacial movement, others from erosion, and others from shifting continental plates. Each valley has its own explanation, sometimes involving several causes.

  Alas, idiographic explanations are more problematic for psychology than for cosmology or geology. The laws of behavior are less specific than the laws of gravity, and manifold causes interact to create people who choose and shape their own environments. Some general laws are useful. The famous opening sentence of Jane Austen’s Pride and Prejudice is often cited as an example: “It is a truth universally acknowledged, that a single man in possession of a good fortune, must be in want of a wife.” But Bingley, that man in possession of a good fortune, could have been gay or a cad or a solitary scholar with no interest in finding a wife. A method of predicting an individual’s emotions and behavior needs to incorporate the idiographic details of that individual into a nomothetic framework. There is no great way to do that, but an evolutionary perspective on emotions provides a good way. First, however, the standard approach.

  Studying Life Stress

  Most psychiatric research searches for nomothetic generalizations about why some people get sick while others don’t. Stress is recognized as a precipitant, but the emphasis has been on what makes some people more vulnerable to stress: genes, brain chemistry, early rearing, traumatic experiences, personality, and habits of thinking. The flip side of this approach is to look at people who are “resilient,” those who carry on despite dire experiences. The implication is that there is something wrong with vulnerable people and it would be good if we could find ways to make more people resilient. Either way, it is all about the Person. What about the Situation?

  The role of situations in causing symptoms usually gets simplified to stress, and stress usually measured in terms of life events. This glosses over how an individual’s appraisal of the meaning of events gives rise to symptoms, but it avoids messy problems. If you ask people what is causing anxiety or depression, you hear stories about abuse, abandonment, attacks, and all manner of adverse life events. How bad is bad enough to cause a problem? How do you count the events?

  Psychiatrists Thomas Holmes and Richard Rahe initiated a new era in life events research in the 1960s. Their group had long followed the lead of Adolf Meyer, a founder of American psychiatry, by creating a life chart showing the dates of major life events and how they corresponded to symptoms. However, those data were hard to use in research. So they instead gave people a list of forty-three possible life events and asked them to check off the ones they had experienced. Just counting the number of events predicted who would get sick, even from infections.6 By quantifying objective events, the Schedule of Recent Experiences led to rapid progress and hundreds of publications.

  However, there is much more to an event than whether it happened or not. To get at the details, London researchers George Brown and Tirril Harris created the Life Events and Difficulties Scale.7 It takes hours to administer, and learning to use it takes weeks. The results of each interview are transcribed and then coded by a team that did not see the patient. At the end of the process, each event is rated as “severe” or not. This painstaking method, applied to 458 women in London, led to solid conclusions. In addition to those presented in chapter 6, they showed that factors such as having support from a partner were strongly protective. It is wonderful research, but the instrument is unwieldy and rarely used.

  Methods of measuring life stress have developed steadily since then,8,9 but substantial challenges remain.10 Long interviews are expensive, so most research uses checklists. However, the big problem is the very notion of “stress.” The word fosters the notion that stress is one thing, a misconception that is magnified by the tendency to think that it can be measured by levels of stress hormones. Trying to collapse the problems in a person’s motivational structure into a number measuring the severity of “stress” is like trying to collapse all brain changes into a single measure of “level of brain activity.”

  Some attention has been paid to the nature of stressors. For instance, events causing humiliation or entrapment are especially likely to cause depression, as noted already.11,12 However, emotions
don’t arise from events; they arise from a person’s appraisal of what events mean to his or her ability to reach personal goals.13,14,15

  Evolution and Understanding Individuals

  Some imagine that an evolutionary approach must emphasize generalizations about human nature, but it instead forces acknowledgment of diversity. There is no single normal genome, brain, or personality. Variation is intrinsic. Debates have raged for decades about evolution and human nature. Has selection shaped a common core that makes human nature a sensible idea? Or is the idea empty because people and the cultures that shape them vary so much?

  The goals we pursue are universal: food, friends, sex, safety, status, and, most of all, offspring—healthy, happy offspring, on their way to reproducing themselves. However, people prioritize these goals differently and pursue them in diverse ways. John puts all his energy into getting fame and admiration and does not even date. Mary cares about her children far more than anything else. Jack spends most of his life’s effort trying to make himself physically attractive. Sally wants mostly to get rich, and she is succeeding, at the cost of friends, family, love, and health. Donna works seventy hours a week, half at her job, the rest caring for her aging mother. Sam plays eighteen holes of golf each day and spends evenings talking about his games. Rachel is devoted to church mission work that she hopes will provide, for others, the peace and meaning her faith provides for her.

  Most of us try to lead somewhat balanced lives, allocating our resources across many life enterprises in pursuit of many goals. There is never enough time and energy for everything, but we cope. In the psychiatry emergency room, however, you see many people in situations that are genuinely impossible. The kids are sick, their father abandoned the family, the car won’t start, there is no money to repair it or get a babysitter, and the boss said last week that one more absence would be the end of the job. It is not just an event or stress that causes symptoms; it is a situation in which it is impossible to do what must be done. I recall trying to help a young couple with depression and marital problems. They both made minimum wage at the same grocery store, working alternate twelve-hour shifts so one of them could always be at home taking care of their three young children. They saw each other only coming and going and on occasional holidays, and their debts and frustrations mounted with each passing month.

  Strategies for influencing other people differ as dramatically as values and goals. Peter controls his employees by constantly reminding them that they can be fired at any moment. Sally is beloved for her warmth and sense of humor. Dan negotiates everything and expects others to be as rational and dutiful as he is. Sam’s threatening manner makes others wary of crossing him. Gertrude is friendly and congenial, but those who compete with her become the targets of sly gossip. Bill does not always pull his weight in a group, but his sense of humor makes him nonetheless welcome. Call it personality if you want to, but the diversity of how people influence others makes life interesting and studies of emotions difficult.

  In addition to differences in values, goals, and personality, people have different responses to success and failure. Some attribute outcomes to their own efforts, which is fine when they are successful but paralyzing when they are not. Some routinely blame others. Others hardly acknowledge failure; they deny and carry on. Still others quit quickly and shift their efforts to something else.

  Such diverse goals, strategies, and personalities make it difficult, at best, to predict a person’s emotional state. The nomothetic approach measures dozens of things about groups of individuals and analyzes the numbers to try to predict who will feel what and when. The resulting generalizations don’t predict what emotion a specific individual is likely to be experiencing now. Idiographic explanations are richer but unreliable. Psychotherapists listen to each patient for hours. Novelists craft words and plots for months. The rest of us tell and listen to stories to try to make sense of our lives and those of others. Scientists studying emotions wonder what to do.

  The Review of Social Systems

  If you consult a doctor about a general symptom such as fatigue, she is likely to ask you a series of questions: Do you have a chronic cough? How is your digestion? Can you climb stairs easily? The questions may seem unrelated to your complaint, but your answers may point to a problem in your respiratory, gastrointestinal, or cardiovascular system. Your stomach pain may indicate a bleeding ulcer that is causing anemia that explains your fatigue. To identify such possible factors, doctors conduct what is called a “review of systems” by asking a standard set of about thirty questions. A review of systems is essential to avoid missing a possible cause.

  A comparably systematic Review Of Social Systems (ROSS) is equally essential to identify the sources of emotional symptoms. However, what systems need to be reviewed? Different social systems don’t have well-defined boundaries the way the liver and kidneys do. However, scientists who study animal behavior recognize several different kinds of resources organisms seek. Personal resources such as health, attractiveness, and abilities are essential (). Food, shelter, and material resources such as money () are essential. Modern humans get those resources by working at jobs or other social roles (). Efforts to find, impress, and care for mates require substantial effort (). So do efforts to help and protect offspring and other relatives (). Finally, having allies and roles with recognized status in a group () are keys to Darwinian fitness. Six kinds of resources: .

  Efforts to get one resource take time and effort away from getting others. Foraging far from home will result in more food but will compromise safety. Time caring for children is not available for working or impressing potential mates. Brains generally make good decisions about how to allocate effort even without sophisticated conscious thinking. All animals make such decisions, from aphids to zebras.

  Emotions are one part of the decision-making system. What causes a particular emotion in a specific person can be hard to determine, but a systematic search is nonetheless essential. Dozens of questionnaires and structured interviews are available for gathering relevant information, but few of them attempt to capture the dynamics of how emotions emerge as humans pursue their idiosyncratic goals. Short questionnaires never get to specifics. Long interviews get reams of rich information, but they are impractical to administer and difficult to summarize.

  What is needed is something like an Apgar score.16 Virginia Apgar was an obstetrician who recognized the need for a simple system to record the condition of a newborn. Her name provides a convenient acronym for five categories of information: Appearance, Pulse, Grimace, Activity, and Respiration. Each is recorded as 0, 1, or 2 depending on the infant’s condition. This simple score has proved invaluable in documenting an infant’s condition and predicting outcomes.

  The resources crucial for humans are the same as those for other organisms, with one addition: people have specialized social roles that others value and often pay for, that is, occupations. SOCIAL provides an acronym as memorable as Apgar to keep track of the resources that need to be considered when doing a ROSS.

  REVIEW OF SOCIAL SYSTEMS

  Social resources, including friends, groups, and social influence

  Occupation; this is often paid work, but many other social roles are also valued by others

  Children and family, including relatives

  Income and sources of material resources

  Abilities, appearance, health, time, and other personal resources

  Love and sex in an intimate relationship

  An analysis of a person’s motivational structure requires answers to several questions about each kind of resource. Do you have secure ways to get sufficient amounts of this resource? How important is this resource to you? Is there a gap between what you want and what you have? What are the main things you are trying to do, get, or prevent in this area? How are you going about your efforts? Any recent losses, gains, or other changes? Any big opportunities or threats on the horiz
on? Are you faced with difficult decisions about what to do in this area? Is there something important you are trying to accomplish that isn’t working out? Overall, what is the outlook for your efforts in this area?

  This kind of comprehensive assessment of a person’s motivational structure is valuable. An even longer structured interview, of the sort that Eric Klinger has suggested, is valuable for research.17 However, a full ROSS takes at least an hour. In keeping with the theme that time and energy are always limited, it isn’t always possible to ask all these questions about each domain. For busy clinicians, something as short and simple as the Apgar score is essential.

  The aim is to identify problems that may be causing symptoms. That requires determining, for each area of life, the adequacy of resource availability and the magnitude of problems. People with plenty of resources can have plenty of problems, so resources and problems need to be recorded separately. For instance, attractive young people who can certainly find a mate are sometimes reduced to mental tatters by ambivalence about whether to marry a current partner. People whose abilities, attractiveness, and general health are all fine now may nonetheless struggle because of fears about their future. I recall a brilliant scientist who came for treatment because he was paralyzed by fears of death. At age thirty-five, he was already a world expert on atherosclerosis, with tenure at a leading university and invitations to travel the world. What no one knew, however, was that his father and his siblings had all died before age forty from heart attacks. Then there are the millionaires whose gambling debts make it impossible to keep up with a mortgage, and the accomplished people in every field who are failures relative to their outsized expectations.