Posts tagged depression
Pathological mental health problems in children and young adults have been classified into externalizing (substance abuse, conduct disorder etc) and internalizing disorders (depression , anxiety etc). Today’s post will try to work out the structure of this internalizing spectrum.
The first major difference, that is made in say DSM, is between Mood disorders (disturbance in mood) and Anxiety disorders (characterized by anxiety and avoidance behaviors) . However, Watson in this article (pdf) emphasizes that this classification is not proper and in many cases these disorder say depression (say MDD) and Anxiety (say Panic disorder) are co-morbid with each other.
To explain this as well as other genotypical and phenotypical findings, Watson has developed a structure of these ‘distress disorders’ – however the road was long, an intermediate stop was tripartite model of depression/anxiety.
According to this tripartite model (developed by Watson and Clark), both depression (MDD, dysthymia etc) and anxiety disorders (phobia, panic etc) share a common non-specific factor called Negative Affect (NA) which is characterized by things like preponderance of negative emotions like sadness, fear, guilt, anger etc as well as irritability, difficulty concentrating etc.
Depressive disorders meanwhile are specifically characterized by lack of Positive Affect (PA), which means less emotions like happiness, interest etc, but also Anhedonia or inability to derive pleasure from earlier pleasurable experiences. Anxiety disorders, on the other hand, are characterized by physiological hyper arousal (PH) (shortness of breath, dizzyness etc) .
This model however was also found wanting and replaced with an hierarchical integrative model, which posited that there was a generic non-specific factor of NA common to both anxiety and depressive disorders, and a lower order low PA factor characterizing depression and more specific multiple low order factors (instead of one PH hyperarousal factor) associated with the different types of anxiety disorders like panic/ agoraphobia, Phobia-specif stimuli, phobia social etc .
However , Watson further modified the structure and came up with this model shown below: One broad factor of distress/NA; two specific factors of anxious-misery and fear and then further unique factor specific to individual diagnosis.
To summarize and also extending it a a bit,
- At top there is an internalizing spectrum and associated with it a non-specific NA factor.
- In middle there are four spectrum:- a depressive spectrum , a Fear spectrum and a bipolar spectrum and an Obsessive compulsive spectrum.
- each of these can be further divided into discrete diagnosis along two factors/dimensions (I will not eb focusing too much on bipolar or OCD for the purposes of this post) :
Lets focus more closely on Depressive and Fear Spectrum and try to see alignment with ABCD model. MDD/Dysthemia imho are mainly about mood or Affect; GAD/PTSD are more Cognitive (reaming stuck in a thought loop) ; Panic/agorophobia more Physiological or Dynamic in nature and Phobia (both specific and Social) more Behavioral in nature (avoiding people, places and animals).
Each of these in turn splits into four factors; for ex PTSD splits into four factors- Dysphoria (A), Intrusions (C), Hyperarousal(D) and Avoidance (B). Similarly, recent research has shown that MDD is itself heterogeneous made up of four neural subtypes- one way to list those would be – marked primarily by Anhedonia (A), Anxiety (C) , Psychomotor retardation (D) and Fatigue (B) . Similar analysis should be possible for other discrete diagnosis.
For now, we will turn to the structure of Bipolar and OCD spectrum by analogy to dep/anxiety spectrum.
- Biploar spectrum:
- Euphoria (Affective)
- Flight of ideas (Cognitive)
- OCD spectrum
- Obsessions (Dynamic)
- Compulsions (Behavioural)
Within this OCD can be seen to be comprising of four factors: Hoarding (A?) , Order and symmetry (C), Obsessions and Checking (D) and Washing and cleaning (B).
Another way to think about the depressive and anxiety spectrum is to say that Depression rgoup 1 is characterized by Low PA, depression group 2 by high PH; Fear group 1 by High PH and Fear group 2 by low PA. What distinguished Fear spectrum from Depression spectrum is the fact that much more variance is explained by High NA for depressive syndromes and only moderate variance explained by NA for Fear syndromes.
What do you think is missing from the above model? Where might it be wrong? where might it be correct? If correct what are the implications?
Striving towards meaningful goals is good for your well-being; even just having goals by themselves are indicative of well-being. This is an established dogma of positive psychology, so how can one argue that goals may be at the root of the experience called depression.
A framework that aims to throw some light on this is the dual-process Tenacious Goal Pursuit (TGP) and Flexible Goal Adjustment (FGA) theory as proposed by Brandstatdter and colleagues.
As per this framework, we all strive towards goals, but only goals that are meaningful (say goals which align with our self-identity) and attainable (we have self-efficacy beliefs and can figure out strategies to achieve the goals) lead to well-being. A goal that we find meaningful and are highly committed to, but which becomes unattainable due to either external circumstances or our internal capacities, may lead to depression.The depression, and the helplessness and rumination that accompany it, may paradoxically have the function of decreasing our commitment to the goal and releasing ourselves from that unattainable goal.
And here is where the TGP and FGA theory comes to the rescue. In view of internal or external obstacles, that is when you are not able to make progress towards meaningful goals, you may either try to change the situations or your actions to ensure that they are congruent to the goals and would thus be demonstrating an adaptive process of assimilation (not to be confused with Piaget’s use of assimilation) also known as Tenacious Goal Pursuit (TGP), or you may adjust your goals and ambitions to reflect the situations / your capacities using the process of accommodation also known as Flexible Goal Adjustment (FGA).
Now, lets backtrack a little and reflect on the many routes to happiness: some say its all in your head- that you just need to change your mindset/ perception of events and you can be happier; others say that happiness is dependent on your situations and the actions that you take- you can and should cultivate happiness by activities and by changing your circumstances. Like all debates, like Nature-Nurture, the answer probably lies in the interaction and in-between. Haidt has famously claimed that happiness lies in-between, and I concur.
Similarly, sadness or depression may lie in your flexibility and tenacity of goal pursuits – while showing rigidity to a goal and not giving up may lead to sadness and depression, giving up too early or not being tenacious when circumstances could have been changed, may also lead to regret and sadness.
Its important to note that changing circumstances/ TGP etc are active processes; meanwhile changing mindset/ FGA are relatively passive processes, in that they happen in the background and not so much consciously.
That brings me to my major thesis: Depression is a disorder characterized by inability to use the adaptive process of FGA optimally. To me, Depression is a disorder of Behavior related to the Passive polarity of the ABCD Behavioral dimension. When one has a goal, to which one is committed, but is no longer attainable (and this may include an irreparable loss like bereavement ) then most people will use Flexible Goal Adjustment to come out of that state. However, the people with depression may be less able to use FGA and may remain committed to unattainable goals.
One of the evidence that comes to mind is, and for this you have to refer to my previous post about personality disorders and emotions, that the passive pole of Behavior dimension in ABCD model is also associated with Dysthemic and borderline personalities and hypothesized to be associated with the Conscentiousness trait. Now, It does seem that there is some evidence that highly conscientious people who have high commitment to goals, also are more likely to get depressed following setbacks or adverse life events. This makes immense theoretical sense too.
One can also examine the Active pole of the Behavior dimension in ABCD model to gain equivalent insights. As I had mentioned in my last post, that is associated with personality disorders of Histroinic and Hypomanic personality disorders and likely associated with the trait Impulsive Sensation Seeking. Extending this joy/ happiness related dimension, all these are also likely to be associated with the active process of Tenacious Goal Pursuit; here it is instructive to note that a high score on Impulsive Sensation Seeking may prevent TGP from happening as the person may keep moving from one activity to the other; and extremes of this may lead to manic behavior. The high scores on Impulsive Sensation seeking leading to less TGP leading to full-blown mania, is similar in nature to high scores on Conscientiousness leading to less FGA leading to full-blown depression.
To me, this seems a novel and fruitful approach to think about and conceptualize depression- as an inability to give up goals that are no loner feasible. If we focus more on this aspect, perhaps we need to augment our talking therapies of CBT etc that focus on negative self-talk and also introduce safe spaces and experiences whereby people can indulge in Flexible Goal Adjustment and give up on goals that are no longer feasible and replace them with other more meaningful and attainable goals.
“Growing from depression” is a short, easy read on the subject of the depressive experience and how to make best use of and grow from that experience. The book is written by Dr. Neel Burton, who is a psychiatrist as well as a philosopher, and an exceptionally good writer.
“If I had more time, I would have written a shorter letter” so wrote Pascal/ Twain and in case of Neel he seems to have spent enough time on this book, making it succinct yet easy to understand and follow by a layman.
The book is organized in four sections; one dealing with defining and delineating depression – an experience that is bound to affect us or our close family/friends once in the lifetime. Some estimates have put lifetime incidence of depression as high as 30 percent , which means we are either a sufferer or a caregiver at some point, thus the importance of the topic.
The second section deals with current treatments for depression, including CBT, ECT and antidepressants. Maybe in future editions newer treatments like Metacognitive therapy or rTMS/ DBS can be explored and elaborated at in depth.
The third section makes the meat of the book- its a self help section with bite sized chapters making one think aloud and get help growing from the depressive experience. Given that Neel is a philosopher, some chapters do digress a bit and become more philosophical/ at tangent with the main premise of the book, but overall the suggestions and elaboration is grounded in what we do indeed know about depression- including things like depressive realism.
The last section is related to mental health services and mental health law and has limited appeal to international audience as its focused and based around the UK health care system and the UK laws.
Overall, its a pretty good read and makes you realize that there is much that you can gain from the depressive experience- including wisdom as to how prevent a relapse by controlling daily stress, maintaining good daily habits like exercise etc.
I wish many more experts and scientists were able to break up from the jargon, and write a self help book for people at large. I am sure we all will be richer for that!
Buy the book here.
S. Nassir Ghaemi, in his book, A First Rate Madness: Uncovering the links between Leadership and Mental Illness, makes a case for the fact that while ‘normal’ leaders are good in times of stability and peace; in times of crisis, mentally ill or mentally abnormal people make for better leaders.
He does this via historical analysis of leaders like Gandhi, Martin Luther King jr, Franklin D. Roosevelt, Winston Churchill, Abraham Lincoln etc. Some of these leaders he classifies as being predominantly depressive, others as manic while the rest as being of bipolar proclivity. In the book he writes:
The depressed person is mired in the past; the manic person is obsessed with the future. Both destroy the present in the process.
He lists four traits that distinguish a manic/depressive leader from other normal leaders: Empathy, Resilience, Creativity and Realism! I can easily map these to the ABCD dimensions: empathy is an Affective trait (the ability to feel emotions), resilience is more about Behaviors (bouncing back from failures), creativity is related to Cognition (ability to think in a divergent manner) while realism can be linked to Desire/Dynamism (do we do realistic assessments).
He claims, and I find that claim very attractive and true, that depressive people typically are better at empathy and realism, that is, they have heightened empathy and realism as compared to the normal population; in a similar vein, manic people are typically better at creativity and resilience than the normal population.
If one views depression and mania as somewhat opposed to each other. at least on on some dimensions, it goes without saying that depressive people may be less creative (they are typically stuck in ruts)/resilient (they often cant cope and sometime stake the extreme step of suicide); similarly, in a manic phase, people may be less realistic (may even become psychotic losing touch with reality)/ empathetic (may not be able to get inside the head of others).
While a depressive or manic phase may be debilitating, the relatively ‘normal’/symptom free period may confer advantages on depressives, manics or bipolars by making them leverage their resilience, creativity, realism and empathy, especially to tide over crisis.
Why should it be the case that in normal periods a ‘normal’ leader may help, but in a crisis only an ‘abnormal’ leader may be able to rise to the occasion? The answer lies in evolution and genetic diversity. Consider moths that are generally gray in color, but some are darker (closer to black) while some others lighter (white in color) . The majority gray moths are the ‘normal’ moths, while the minority black and white are abnormal ones. Now these moths are exquisitely adapted to their environments, and typically gray moths will flourish. However if the area has suddenly become polluted such that darker color moths are now less easier to detect than the gray moths by the predators, then dark moths will thrive at the cost of light moths.
A similar analogy can be applied to humans. Normal leaders are adapted to stable conditions; while in times of crisis, more atypical brains may suffer greater advantage.
So next time you select a leader, be mindful of whether its a change/crisis situation or a stable situation; if a crisis/ change situation, you may do well to do some reverse discrimination and select a mentally ill/ abnormal person as a leader!!
No, I am not speaking metaphorically. Quite literally,there has been accumulating evidence that sense are sharpened and have great acuity in mania while they are dulled in depression and the effects can be seen within the same individual over time as he/she suffers from manic/depressive episodes.
The latest study to add to this literature is by Bubl et al that found that depressive people’s brain registered lesser contrast than that registered by normal control brains when presented with same black and white images. They used pattern electroretinogram (PERG) to find whether the contrast gains registered by depressive retinas (those suffering from MDD) were different from those of controls and they found a strong and significant association with the severity of the depression.
I have covered earlier studies that found that sense of taste was compromised in depression (and enhanced in mania) and similarly that the sense of smell showed similar effects. Some snippets from the earlier posts:
What this means is that if you increase the amount of serotonin in the brain, then the capacity to detect sweet and bitter tastes is increased; if you increase noradrenaline levels those of detecting salty and bitter tastes is augmented; while a general increase in anxiety leads to better bitter taste detection. This also means that an anxiety state produces more bitter taste perception whereas a depressive state (characterized by low serotonin) is marked by bland sense of taste with marked inability to detect sweet and bitter tastes. A stressed state , marked by abundance of noradrenaline, would however lead to more salty and bitter taste perception.
In one of my earlier post on depression, I had commented on the fact that those suffering from depression have less sensitivity to sweet and bitter tastes and as such may compensate by eating more sugar thus leading to the well documented diabetes – depression linkage.
In a new study it has just been discovered that not only depressives have bland sense of taste, their sense of smell is also diminished and they may make compensations by using greater amounts of perfume. Overall it seems that those suffering from depression will have bland subjective experience of flavor(which is a combination of both smell and taste) and thus may even not really find what they eat to be tasty.
Further on, I speculate prophetically that blander vision will also be found:
To me, this is an important finding. To my knowledge no research has been done in other sense modalities (like vision), but there is every reason to think that we may discover a bland sense of vision in depression. Why do I surmise so? this is because there is extensive literature available regarding the manic state and how things seem ‘vivid’ during that state including visual vividness. If depression is the converse of Mania, it follows that a corresponding blandness of vision should also be observed in those who are clinically depressed.
We also know that in extreme or psychotic forms of Mania, auditory hallucinations may arise. I am not suggesting that hallucinations are equal to vividness, but I would definitely love to see studies determining whether the auditory sense is heightened in Mania (maybe more absolute pitch perception in Mania) and a corresponding loss of auditory absolute pitch perception in depression. If so found, it may happen that music literally becomes subdued for people with depression and they sort of do not hear the music present in everyday life!
Whether other sense like touch, vestibular/ kinesthetic , proprioception (a heightened sense of which may give rise to eerie out-pf-body experiences in Mania) are also diminished in depression is another area where research may be fruitful.
Of course I have also speculated about the others senses and would love to hear studies supporting/contradicting this thesis. But given that senses are attenuated in depression and exaggerated in mania the question remains why? Which brings me to the topic of this post- why is the world bleak /bland to a depressive and vivid for a manic?
This was also the question asked by Mark Changizi (@Mark_Changizi) on twitter with respect to this new study uncovered today and I replied that this may be due to broaden-and-build theory being applied to sensory domain or sensory gating phenomenon differentially acting in manic/ depressive states, while Mark was of the opinion that it might be the result of physiological arousal with arousal being the variable of interest controlling whether the sense remain acute or dull?
I do not see the two views necessarily contradictory and it may be that chronic affect per se activates arousal and that is the mediating variable involved in its effect on senses; and we can design experiments to resolve this by measuring the effect of state sadness/ happiness/arousal on visual acuity (if the effects of state manipulations are big enough); howsoever, I woudl like to elaborate on my broaden and build theory.
In the cognitive, psychological and psychosocial domains the broaden and build theory of positive affect is more or less clearly elaborated and delineated. I wish to extend this to the sensory domain. I propose that chronic positive affect signals to our bodies/brains that we can afford to make our attention more diffuse, let senses be perceived more vividly as we have more resources available to process incoming data; conversely in a chronic low affect state we might like to conserve resources by narrowing focus/ literally narrowing the range of sensory inputs/reducing the sensitivity of sense organs and pool those resources elsewhere.
I know this is just a hypothesis , but I am pretty convinced and would love to hear the results of experiments anyone conducts around this theory.
Bubl, E., Kern, E., Ebert, D., Bach, M., & Tebartz van Elst, L. (2010). Seeing Gray When Feeling Blue? Depression Can Be Measured in the Eye of the Diseased Biological Psychiatry, 68 (2), 205-208 DOI: 10.1016/j.biopsych.2010.02.009