But while there are many good reasons to criticize the DSM - see my numerous scribblings or try these books - there are plenty of bad reasons too. Psychologist and author Dorothy Rowe has just provided some in a recent Guardian article. I don't propose to spend much time on this confused piece, but one sentence is nonetheless instructive, as it exemplifies the danger of facile psychological explanations in psychiatry:The people who come to the attention of psychiatrists and psychologists are feeling intense, often severe mental distress. Each of us has our own way of expressing anxiety and distress, but when under intense mental distress our typical ways become exaggerated. We become self-absorbed and behave in ways that the people around us find disturbing. Believing that when we're anxious it's best to keep busy can mean that our intense mental distress drives us into manic activity.
Mania is when you write a letter to every one of your relatives proposing a grand family reunion. On a cruise ship in Hawaii. You'll pay for everything. Actually, you're broke. Mania is being literally unable to stop talking, because there are just so many interesting things to say. Actually, you're ranting at strangers on public transport.
The point is that when you're manic, these things don't seem weird, because mania is a mental state in which everything seems incredibly exciting and important, and you think you can do anything. It's like being on crack, without the link to reality of knowing that actually, you're not Jesus, you're on crack. Not all manic episodes are this extreme, and by definition hypomania is less dramatic, but the essential feeling is the same. That's what makes mania, mania.
You can be "manically" busy of course, or have a Manic Monday, but that's a figure of speech. Maybe some people's strategy for dealing with anxiety is by making themselves "manically" busy. If so, fair enough, but that's not mania. Mania is not a strategy; it's a mental state, and psychologically irreducible: you don't become manic about something, you just become manic.
It can certainly be triggered by things - stress, sleep deprivation, and crossing time zones are notorious - but it's not an understandable psychological response to them, it's a state that happens to result. If you drink some beer and get drunk, you're not drunk about beer, you're just drunk.
So Rowe's account of mania is spectacularly wrong. But take a look at the very next sentence:A tendency to blame yourself and feel guilty can transmute into depression.Now this sounds much more plausible. The very influential cognitive-behavioural accounts of depression propose that self-critical tendencies are a major risk factor for depression. Even if you're not familiar with CBT, you'll recognize that depressed people tend to blame themselves and feel guilty or inadequate all the time. That's got to be their underlying problem, right? It's common sense.
But is it? Rowe thinks so, but she's just completely missed the point of mania, and depression is the flip side of the coin that is bipolar disorder. The two states are fundamentally linked, polar opposites. So what are the chances that Rowe's right about one, when she's so wrong about the other? Not very good, if you ask me. Yet her explanation of depression seems much more plausible than her account of mania. Why?
I think it's because when you're depressed, you seek psychological explanations all the time: depressed people worry, ruminate and obsess endlessly about their "problems", and think that what they're feeling is a normal response to them. Of course I'm depressed, who wouldn't be in my situation?
This makes it very easy for psychologists to come along and offer a reappraisal which is in fact only slightly different: you're looking at things too negatively. Things aren't really as bad as you think, it's not really your fault, things really can and will improve. This is, certainly, often very helpful, and it's almost always true - because things generally aren't as bad as you think they are when you're depressed. Depression makes you see things negatively, just as mania makes you see them positively. That's kind of the point.
But this cognitive approach implicitly accepts the depressive notion that depression would have been an appropriate response to what you thought your situation was. It says that your feelings of depression were based on a mistake, but it does not dispute that depression is a healthy emotional state.
So the nature of depression means that it cries out for psychological explanations. But this doesn't mean that these explanations are in fact any more sensible than they would be if applied to mania. Depression may well be as much a psychologically irreducible, abnormal mental state as mania is. This is certainly not to say that cognitive theories of depression aren't useful or that CBT doesn't work. But we must be careful not to over-psychologize depression, however tempting it may be.
35 comments:
Beside disliking the DSM and Dorothy what's your point exactly?
I also dislike celery, don't forget.
My point is that although it's very easy to provide psychological explanations for depression (pesimissistic thinking, self-blaming, etc.), because of the nature of depression, we shouldn't accept these just on face value, any more than we would do for mania. Depression is as much an abnormal mental state (i.e. not just an emotional reaction) as mania.
Regarding the good reasons to criticize the DSM, to what extent are its problems basically caused by trying to simultaneously follow two very different paradigms? (I use the word as a computer programmer would, not as a Kuhnian philosopher would.)
I mean: on the one hand, there's what you might call a diagnosis-oriented paradigm, wherein you start by asking: "What disorder does this person have?". And on the other hand, there's the way most psychiatrists I've met actually think, which is not to be preoccupied with labels but instead to ask: "How can this person be helped?". It seems to me that the DSM's problems come from failing to acknowledge that the two paradigms are appropriate in different circumstances, for which reason it tries to always follow both of them simultaneously in ways that don't necessarily make sense. Thus it arrives at the nonsensical position of equating "people who can benefit from psychiatric intervention" with "people who suffer from a psychiatric disorder".
Is that a fair assessment? And is there a name for the disorder with which I have just diagnosed the DSM? :-)
(P.S. I've added Neuroskeptic to the sidebar links from my blog, because I was looking for extra science blogs and wanted at least one brain blog in the mix. Neuroskeptic may or may not be the best choice, but seems to be one of the most readable.)
Thanks for sharing nice information. can i know one thing? What's difference between DSM-4 and DSM-5.
I find it absolutely amazing that you criticize accepting psychological theories of depression at face value; but you are apparently willing to accept biological explanations without a shred of evidence. I agree with your point about mania. But maybe you should go easier on that psychologist you tar and feathered. In the U.S. anxiety disorders are routinely misdiagnosed by psychiatrists as mania. All you need is some patient to admit to racing thoughts and rumination, with some decreased sleep, and Presto you have mania!!! Never mind that the patient just lost their job and their home! Why they have BIPOLAR ILLNESS!
anonymous: I didn't mention biology. But my point is that depression is no more "psychological" than mania.
Mania can't be understood in terms of psychological processes, it's just a state (like drunkenness). There are altered psychological processes in mania but they're the effect not the cause. You don't go manic because you think you're Jesus, you think you're Jesus because you're manic.
As I said, all of this is fairly uncontroversial when it comes to mania - but it is also very relevant to depression.
NS, things are a bit more nuanced. I completely agree with your description of mania as an autochthonous mental state. The same is true for one form of depression, best called melancholia. You are right to say that the classical forms of depression and mania are polar opposites. But mixed states with some features of each pole also occur pretty often. These were well described by Kraepelin 100 years ago. These mixed states must be accounted for in any theory of bipolar disorder.
On the depression side, melancholia needs to be distinguished from look-alike forms of misery, which include persistent but normal depressive reactions to adverse events, dysphoric anxiety states, and what we used to call neurotic depression with chronically low self-esteem. When DSM-III-IV changed the terms, all these were lumped together as major depression. The result has been a disaster for research and for clinical care. CBT does not work for melancholia but it is effective for other forms of depression.
The dumbing down of diagnostic criteria for depressive subtypes since 1980 set the stage for expansive restatements of the prevalence of “depression”, for disease mongering, and for unrestrained use of antidepressant medications, especially in primary care.
Hi Neuroskeptic
I'm interested to know what you think of a recently published cognitive model of mood swings*. Also, here's a good review of psychological processes implicated in the development of mania**.
It's not something I know much about, but I would take issue with the (implied) idea that an abnormal state is undesirable simply because it's abnormal. Surely a particular state is pathological if it leads to suffering, mortality or impaired decision-making capacity, amongst other things? That is, there are many fairly abnormal states of mind which are highly desirable and sought after (happiness being one of them!).
As I understand it, the thing about mania is that suffering is not particularly present at the time (although it is often a major consequence), but impaired decision-making capacity is. It's therefore pretty tricky to intervene until someone has been through the cycle a few times... as I say, I don't know much about it.
*http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1399884
**http://dx.doi.org/10.1016/j.cpr.2007.07.010
BC: Thanks for the comment. You're absolutely right that what I said only applies to some cases of "depression". But I am not sure that these cases are limited to melancholia (though melancholia certainly is amongst them.)
Speaking from personal experience, even relatively mild depression can be an autochthonous state in the sense that it "has a mind of its own" - one day you have it, the next day you don't, for no apparent reason; diurnal mood variation is another aspect of this. I have been quite severely depressed but I've also been mildly depressed and I don't think that one was noticeably more autochthonous than the other.
It's this autochthonous (good word) feature of mood that I think is often forgotten by psychologists when discussing depression (precisely because it is not psychologically comprehensible): it's not identical with severity, though I'm sure they are correlated.
I couldn't agree more.
I'm not depressed because I made a mistake about the situation that X Stimulus put me in; I mistook the effects of X Stimulus because I'm depressed.
It's very hard to live in a world in which people with similar (if opposite) reactions have an illness and I just suffer from a bad attitude. That's not the case at all.
You are right, NS, it is not the same as severity. A good example of mild autochthonous depressive mood change is the prodrome leading up to a classic episode of melancholia. This milder state can last for weeks and, precisely because it is mild, it is often mistaken for a response to life events - unless the person has past experience of melancholic episodes.
Good post, Neuroskeptic.
Suggesting that mania is a result of trying to keep yourself busy is like suggesting that auditory hallucinations are caused by listening too hard.
What Pale Blue Dot? - Right.
Although that's not to say CBT isn't helpful even in this kind of depression. Even if (as I've argued) thoughts and beliefs don't cause the depression, it is very hard to suffer depression and not end up with some pretty screwed up thoughts and beliefs as a result.
In which case CBT might be very helpful to repair the damage that depression caused to your self-esteem etc. Which may, in the long run, be the most important thing - more important than reducing the length & severity of the acute episode, which is what antidepressants do - though it's not "treating depression" as such, it's treating the after-effects.
I agree with BC except for his unwarranted assertion that
CBT is effective for non-melancholic depression. There have been about 8 comparative trials--starting with
ancient NIMH TDRCP trial that have included pill placebo. CBT never exceeded placebo. I know of no such trial where CBT was effective. In the Dimidjian et al trial CBT did not exceed placebo ,but remarkably
the first phase of CBT -Behavioral Activation did and could not be distinguished from a standard SSRI .
My hypothesis is that the latter phases of CBT involving attempts to undermine Dysfunctional attitudes and strategies are actually toxic via demoralization.
This is an interesting philosophical discussion, but where is the scientific evidence that some forms of depression are "an abnormal mental state"? We've had 50 years of research, but still reduced to personal anecdotes when arguing this point?! Is anybody doing research that could actually lead to a breakthrough (clinically useful biomarkers)? How much time/failure is needed to realize that new approaches (selection criteria, outcome measures, etc) are needed?
Art: Well, the reason I said mental state is that we can't say for sure that it's an abnormal brain state... but I don't think that whether something is a mental state or not is something that biology can be expected to answer.
When I say that mania is a mental state I'm referring to the phenomenology of mania and the behavior of people who are manic: it's an inherently psychological (as opposed to biological) statement. And whether it's true or not can only be decided by observing people who are "manic". It is a falsifiable statement: it could be that 'mania' is all an act on the part of people who love getting given mood stabilizers. It generally isn't, but if it were, that would disprove the statement. But that's not a biological question.
NS: Now I'm really confused. Aren't all mental states just products of brain function? And isn't it a reasonable assumptions that states like mania and melancholy are due dysfunction of specific brain circuits? One piece of evidence to support this would be the immediate effects of DBS.
So, I'm assuming that what you're really mean is that it's just too complicated right now to connect mental states like mania to specific brain activity. But is there any doubt that some day we will?
I don't know about mania (never experienced directly, never observed directly - only read about it) but I wouldn't call my (quite frequent) hypomanias irreducible. Looking back, I can pretty much always identify a specific thought, conversation, article or realization that happened smack in the beginning of the "episode". THAT usually led to sleep loss and higher behavioral activation. There were multiple times where sleep deprivation, time-zone change and such did not lead to hypomania in the absence of certain cognitive stimuli - inner or outer.
From my readings, it seems like manias make a lot of sense to people - if they are of "spiritual emergency" kind, so if there is any relation between mania and hypomania, I wouldn't rush to call manias irreducible - "just is" state - that has different manifestations.
One thing is for darn sure: DSM-III & IV didn't have an Internet and Blogosphere kicking it around in years prior to publish (for good or ill).
When I went in for assessment, my doc told me there was no "test"; no way to drill a hole in my head and test to see whether I had "appropriate" levels of Serotonin. SO - we essentially did our own Experimentation. Right? Lexipro? nope. Pristiq? nope. Wellbutrin? nope. All the while, also taking CBT, and Lorazapam (for insomnia).
Talk about a treatment that undermines the aim of the paradigm we're seeking. . . (to help the patient to not be depressed, to feel more confident, more positive, more hopeful . . .) - How can I be confident that this is going to work, when we're experimenting? Isn't that why this stuff is so expensive in the first place? Isn't that why we granted patents to the drug companies - because they did their homework, and tests, and *know* this stuff works for a given malady?
If the end-result of the DSM-V is to hook-up more depressed people with more ignorant drug dealers, (to medications on which they become physically dependent - even FURTHER undermining their sense of independence, empowerment, and control over their outcome), then, I'm glad I'm not in that profession, and I'm sorry, and a little frightened to be a patient.
Say what you will about CBT. I honestly don't know where the hell mine is going. But at least my therapist has gotten me to THINK about my own thought processes. No medication ever did that for me (or anyone), ever could, or ever will. Is it demoralizing to realize that there's a set of cognitive tools built into your own head that can make things better? No. Not if you're using those tools right!
(the whole point of this exercise is to abandon the self-critical path of thought that reinforced whatever biological process began or contributed to the depression in the first place - therefore; lacking those cognitive tools may be a deficit, but the deficit is not a bad thing. If you're still viewing it as a bad thing, you're missing the point; and don't be down on yourself about that either. . . ;)
So I think I agree with Neuroskeptic. If they're going to peddle drugs, based on chemical and biological science, then lets have some solid diagnostics and instrumentation to back up the decision making process.
Or maybe someone just loves their Porsche so much, and the self-esteem boost it gives them, that they don't mind handing out prozac like candy without a rational scientific basis, and do not worry about the ethical implications of enshrining this practice in another generation of psychiatric practitice via the DSM-V.
Art: Oh sure. The mind is a product of the brain in the end after all. I think I was unclear. What I meant was, at the present time we don't know exactly what the brain states are. And there may be multiple different ones that all lead to the same mental state or something. That's all up in the air. But we do know about the phenomenology; to go beyond that to the biology is another step that's beyond the scope of this post.
Hey Don Klein:
So you kick CBT? Well, what is your say about the Journal of the American Medical Association and the New England Journal of Medicine, the FLAGSHIPS of AMERICAN MEDICINE, saying the antidepressant medication effect is largely PLACEBO? DUH!!!!
Jamie,
There's nothing particularly scientific or insightful about this blogpost, it's just your opinion but it can be traced back to your being specifically invited and encouraged to gang up on Rowe by the psychotherapist hating /baiting anonymous blog Mental Nurse/Zarathrusta.
I'm no great fan of Rowe's but come on man, you can do better than a joined up anonymous attack .
Neuroskeptic:
I have been quite severely depressed but I've also been mildly depressed ...
Did you ever tried Phenibut?
It is more of a non sedative anxiolytic than an antidepressant proper but the mood change is much more "interesting" than those from the antidepressants I know of (Seroplex, Deroxat, Anafranil).
Too bad it builds tolerance and you have to go through unpleasant weaning episodes every so often.
Philip: I started writing this before that MN post. And you'll notice than MN suggested I discuss the statement that "Apart from the disorders listed in the DSM as the result of brain trauma, there are no physical tests for any of the disorders listed in the DSM. No physical cause has been found for any of these mental disorders.", which I didn't.
"isn't it a reasonable assumptions that states like mania and melancholy are due dysfunction of specific brain circuits?"
Well I don't think it is reasonable to assume that dysfunctional mental states such as false beliefs are the result of dysfunctional brain circuits - quite frequently those circuits are working just fine - so there's room for doubt whether dysfunctional mental states are necessarily the result of dysfunctional brain states (whatever that means).
I agree with pj. False beliefs, as in delusions, are a result of poor wiring in the brain? Not likely. Or else the populace of many countries, in the fervor of religious delusional beliefs against the West are collectively mentally ill. You sure you want to go there?
Regarding Dr. Carroll's comment, maybe the opposite of mania is melancholia. And the opposite of "depression" is "hypomania." Mania and melancholia would probably be good candidates for biological markers and biological causes. Depression and hypomania probably have psychological triggers and causes. Oh, and Neuro: Just because you feel sad and do not know why immediately that you are feeling that way does not mean there isn't a psychological trigger or cause. You just aren't aware of it yet. You need to brush up on Freud.
To the last Anonymous:
I think it is best not to conflate severity with typology or etiology.
Mild mania (hypomania) is still mania rather than normal elation. Mild melancholia is still melancholia rather than some other kind of depression. A small whale is still a whale, not a large fish.
In practice, the context is often persuasive for diagnosis, in that a history of past definite manic or melancholic mood episodes can greatly raise the probability that a new mild episode is of the same type, whether it progresses to a more severe form or whether, as NS observed, it is short lived. Confusion and uncertainty abound most often in mild or early episodes that occur in persons without a clear past history.
Wow! Mild melancholia is still melancholia rather than some other kind of depression??? WTF? Are you serious? So mild melancholia can lead to moderate melancholia which may lead to major melancholia. So just WTF is depression? This is exactly why the public now views psychiatry as a joke.
To the last Anonymous:
Absolutely. When you say “mild melancholia can lead to moderate melancholia which may lead to major melancholia.” you are right on target. The evolution of autochthonous melancholic and manic episodes goes through such phases. Or the mild episodes may subside spontaneously. Kraepelin described all of this 100 years ago.
When you ask “So just wtf is depression?” I resonate with your frustration. The current official disorder called major depressive disorder is so heterogeneous that it defies coherent description or constructs.
False beliefs, as in delusions, are a result of poor wiring in the brain? Not likely. Or else the populace of many countries, in the fervor of religious delusional beliefs against the West are collectively mentally ill. You sure you want to go there?
I'll go there.
First of all, the definition of a delusion states that it can't be something that's a cultural/sub-cultural belief. A religious fanatic might considered deluded, but they aren't delusional.
Also, it's been accepted for a long time that a delusion doesn't necessarily have to be false. Say, somebody as a result of a paranoid mental state repeatedly accuses his wife of having an affair, despite having no evidence to support this accusation. If, by a complete coincidence, it turned out that his wife was ACTUALLY having an affair, that wouldn't mean he wasn't delusional. Because he arrived at that conclusion as a result of his mental state rather than because of any actual evidence.
Basically, delusions are defined by their relation to mental state rather than their relation to truth.
I appreciate that in a philosophical debate, one could pick various holes in the definition of a delusion, but generally on a non-philosophical, day-to-day basis it works fairly well.
But there is a grey area where we're telling an immigrant from an African country their religious false belief is culturally appropriate and this not a delusion and their neighbour from Poland with the same belief is delusional. I think it is a very tricky boundary to police.
I've met plenty of people with full blown psychosis whose beliefs, while culturally appropriate, were most definitely delusions that they would never have entertained before the psychosis.
Did Dorothy actually offer a diagnosis of mania? I don't think so, she merely said "manic activity" which could hint at a variety of disagnoses, such as as OCD in some cases, or even some specific phobias where avoidance behaviours can appear "manic". Better still, write to her to clarify; I'm sure she'll respond with an interesting exchange of ideas.
Les: True, technically no, but in the context, and given that her next sentence referred to depression, either she meant to refer to mania, or she should have chosen a different wording because it strongly implies that.
Hey Dr. Carroll and Neuro:
OK so now we have mild to moderate to severe unhappiness to be distinguished from mild to moderate to serve depression to be distinguished from mild to moderate to severe melancholia to be distinguished from mild to moderate to severe happiness to be distinguished from mild to moderate to severe hypomania to be distinguished from mild to moderate to severe mania??? Yeah, like that will ever happen. And all can be reliably measured to boot? LOL. Give me a f-ing break! Dream on!
Post a Comment