Dr. Grossi's Blog
Two well known psychiatric researchers, Kendler and Gardner, recently published the results of examining over a thousand twins in the Virginia Twin Registry. These results have shown light on new and added weight to prior findings regarding gender differences in males and females. The most important factors contributing to major depression in women included divorce, lack of social support, marital dissatisfaction, and personality traits of shyness, anger, and anxiety. For men occupational stressors, financial stressors, drug abuse and childhood sexual abuse were most important. In keeping with these findings, men's depressions are defined by inability to achieve goals and lowered self-esteem whereas women's depressions are associated with deficiencies in caring relationships. These are stereotypical findings and may be related to the population studied which is not age representative for the country nor is it representative of the urban/rural mix of the country.
There are other putative gender differences. About ten years ago, another group including Alan Schatzberg of Stanford, published their treatment response findings in many hundreds of depressed men and women. They found that men responded better to imipramine (Tofranil) a tricyclic antidepressant than women did and that women responded better to sertraline (Zoloft) and SSRIs than men. From the point of view of impact on children, there have been several studies in recent years showing that depressed mothers produce a greater risk for depression in their children. There are also several studies demonstrating that children's depression in a family with a depressed mother show marked improvement if the mother's depression remits. These studies underline the need for prompt and effective treatment for depressed individuals in families especially mothers of young children.
Recently I was moving some books from one room to another when I saw a book written in 1884 by the famous psychologist, William James. In the book he discussed the physiology of feeling states. This got me to thinking that he had conflated emotion and feeling, a common conflation often heard in the office. What then is the difference between emotion and feeling? Emotions are unlearned, programmed automatic actions such as external motions, internal motions, or even release of molecules with some cognitive component used in a strategic way to manage the challenges and opportunities of life. Emotion often regulates drives, motivation, and reward/punishment routines with a homeostatic goal. The emotional experience of happiness in two members of the same species is essentially the same. Feelings are compulsive perceptions of the emotional action programs, real or simulated, states of altered resources, or deployment of responsive scripts. These are represented in specific brain regions such as the insula, the cingulate gyrus, and the amygdala. We are always in an emotional state in response to the world and its challenges or opportunities. Emotions are transmitted by the genome and are conserved across species and through evolutionary time. We are always in an emotional state except when asleep or in a coma. We humans are constantly being confronted by events and are constantly reacting to and thinking about them. The emotional degree of engagement is dependent upon their importance of those happenings to us. These emotional programs have been in place through evolutionary time and are short cuts to decisions relative to threats such as predation, dangerous environmental hazards, or adverse weather events or alternatively opportunities which are either organized around seeking food or sex. While these processes are automated and unconscious, once they are perceived and made conscious they enter the thought flow and can be used subsequently for planning. The rationalist view of human nature glorifies rational decision making processes which depends on facts and logical analysis and eliminates what is viewed as the negative influence of emotion. This is a view which overlooks the important biological and evolutionary facts that animals, many much more primitive that we are, manage the challenges posed by living, sometime in a very inhospitable environment, frequently with great speed and without being able to think. If someone experiences emotions such as fear, anger, disgust, happiness or sadness there will be concomitant changes in the body such as changes in body temperature, circulation, heart rate, and increased motility of the intestines. These are recorded and stored for future reference and can be used in planning for future like circumstances. We are indeed feeling machines.
Over the past several weeks a series of patients have presented in which the distinction between mourning and major depressive disorder was required in order to properly inform treatment decisions. The mourning period length shows much individual variation but is almost always completed in five or six months. Mourning is regularly triggered by the loss of a loved person or some abstraction such as freedom, a meaningful goal, health etc. The work of mourning is carried out piecemeal. The memories of the lost person are recalled and appropriate emotions are experienced around those recollections, piece by piece. When complete, they are assembled like a jigsaw puzzle and can be put away on a shelf. If the mourning period exceeds five or six months, then mourning needs to be distinguished from depression to make correct treatment decisions.
What are some of the factors that help to distinguish mourning from depression? The feeling state in mourning is one of loss or emptiness which washes over the person in waves whereas in depression there is a more persistent painful dejection, lowering of self-regard, and expressions of self-reproach, self-reviling, and inability to experience happiness, loss of capacity to love or experience pleasure. In mourning there are intervening periods of happiness or even humor and self esteem is usually preserved. This is not so in depression. If depression is present in mourning, it is usually centered on the departed and possiblly joining him/her. In depression those thoughts are focused on taking one's own life because of the painful lowering of self-esteem.