 [9]
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Mental Health and the Brain:
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[11] |
Our eighth session and resulting on-line forum discussion [12] completed our discussion of mental health therapies in general. This week, we will begin discussion of particular instances of mental health issues in the context of a variety of available therapeutic procedures and our earlier discussions of the brain.
Readings for this week
Depression (and anxiety?)
- Exploring depression: drugs, psychotherapy, stories, conflicts ... [13]
- David Hume: a letter to a physician [14]
- Depression from the inside
[15]
Schizophrenia
- Schizophrenia, "Just the facts". What we know in 2008. Epidemiology and etiology. [16]
- Connections in schizophrenia [17]
Relevant recent materials elsewhere
- Science Times last Tuesday on genes, including "Scientists and philosophers find that 'gene' has a multitude of meanings [18]" [19]
- In a novel theory of mental disorders, parents' genes are in competition [20] (see comment for a perspective on this article different from that emphasized by the title)
- A special issue of Science on "Genes and Behavior," including a review on Genes and Social Behavior [19]
Where we've been ...
I can't help but wonder, if our brains can, so to speak, "get us into these messes" ... shouldn't our brains alone be able to fix it? ... How can it create something, without having a way to undo it? It seems that if therapy and meds were always needed to fix whatever the brain had caused, then, evolutionarily, we'd be at a huge disadvantage, because what if these things were not available? ... I just find it hard to believe that we don't have the ability to will ourselves to get better ... kgins [21]
Better than 80% of us have some experience with one or another form of mental health procedure ... Paul Grobstein [22]
I'm glad we got to spend a little time talking about Freud and psychoanalysis on Monday ... the man and his thoughts are such a huge influence on pretty much everything we talk about in class every week ... As far as a comparison between CBT and psychoanalysis, I don't see much difference in the end goal - to develop a new story. It seems like CBT just gives you a more concrete method for doing this. More tools... It seems empowering to me ... ryan g [23]
I find psychoanalysis fascinating ... I agree ... that CBT seems more like pharmacotherapy in that it treats the symptoms but may not treat the underlying cause. In my opinion psychoanalysis is more about self-discovery ... Paige Safyer [24]
Pharmacotherapy and talk therapy provide us with a tools that may be more useful for some individuals than others. For example, individuals with clearly defined problems that they wish to address can appreciate the brief, cheaper, and more targeted approach of CBT. However, others are incapable of articulating a specific problem. That doesn’t mean that they don’t deserve help, need help, or are ready for help. It is possible that they are seeking professional help because of an inability to resolve dissatisfaction with their mental states through informal routes. Their lack of communication can be considered a symptom of their mental illness ... jrlewis [25]
Who am I to say that any one therapy is ineffective or even inefficient? Who are we to say that one is better than any other? Do we even have a definition about what a "better" therapy would be? Is it cheaper? Quicker? Gets people off drugs faster? Do the patients "feel" better? I have no answers for these kinds of questions, and I haven't heard a cohesive argument from the class as of yet ... Ljones [26]
I want to second akerle's comments [27] ... social structures - for good and for bad have been eroded by modernity and city life. We have significantly more freedom and that freedom - can be both very helpful for people (especially people who do not "fit in") but it can also prove to be very isolating to people ... adiflesher [28]
Since class, I have been trying to reconcile my emotions with my thoughts ... Emotional and mental pain seem mysterious, perhaps always will *be* mysterious, but if there were such things as antibiotics for depression, medications that consistently worked and lightened the brunt, would we advocate avoiding them? ... ysilverman [29]
"the very moment I stopped thinking of my condition as “the enemy,” I made a turn and began to get better. I wasn’t cured, wasn’t forever well, but I was better. Metaphors matter." ... Siri Hustvedt [30]
accepting something doesn't mean a resignation to it--and often in that acceptance can come the time and space to learn the true nature of that which we initially felt compelled to fight ... all illness, mental, physical, is part of our bodies, our brains, or stories, and so an appropriate relationship to it is not one of pure other/enemy, but of trying to figure what it's doing, how it got there, and how now to proceed in light of its presence ... It's very interesting to me to consider what the brain is trying to do through conflict and illness, and what we as patients and physicians may be doing to help or impede those responses and processes ... mstokes [31]
the ability to experience conflict and have it be generative necessitates a vision of something other than that which one is experiencing, another story that exists simultaneously with the current story. Without the possibility of a new story, one that involves less tumult, a sustainable vision of something less conflicted, embracing one’s “pain,” owning it and leading an “examined life” may lead to increasing distress, or a sense of paralysis ... The move towards an embrace of ever narrower definitions of “normal” and a diminished sense of interpersonal connections has led to more social isolation ... We have reached a place, collectively, where our bodies (yes, our minds, too) are seen in times of duress as the enemy ... The very language of "illness" and "health" seems to exist not along a continuum but as an all or nothing, defined set of milestones and endpoints that undermines individual, nuanced experiences and catapults illness into the realm of battle: doctor vs. unruly body ... I see therapy, whether psychodynamic, CBT or anything in between, as a way to further understand one's experience of herself in the world, her place in the world ... Sophie F [32]
Take off points - schizophrenia
Schizophrenia, "Just the facts". [16]
descriptions of schizophrenia have been fairly consistent over the past two centuries and .... its occurrence has been relatively stable over the period
worldwide prevalence with pockets of low and high prevalence
- Heritability is high ...
- There is no "major" gene locus ... and a large number of candidate ... genes may contribute
- No gene appears to be either sufficient or necessary for the developent of schizophrenia
Although it appears that our understanding of the causation of schizophrenia has substantially increased during the past two decades, what we can confidently assert is essentially the same - both genetic and environmental factors are important, but ... how they cause schizophrenia is still unknown .... A reconsideration of our basic strategies and fundamental assumptions may be in order.
To paraphrase Mark Twain in this regard, "it ain't what people don't know that hurts them, it's what they know that ain't so".
We need to consider the possibility that there is no "one" schizophrenia.
We have accumulated a significant amount of infomration pertaining to the causes of schizophrenia, but our comprehension of its etiology remains limited. It is vital that we examine the reasons for this continuing gap between "findings" and "understanding."
Connections in schizophrenia [17]
"Only recently has much attention been given to white matter in schizophrenia. The primary research focus has been on gray matter, where the neuronal cell bodies, dendrites, and synapses are located, not on the white matter, which provides the wiring between cortical regions ... the identification of morphological and neurobiological abnormalities in white matter lends further support to the hypothesis that there is a problem in brain connectivity in schizophrenia."
"If we interpret the increased white matter metabolism as an indication that the white matter is stressed, it would be helpful to better understand the nature and causes of this stress."
"Future advances in schizophrenia research will depend on examinations of connections at and across multiple levels, including cellular pathways, neuronal circuittry, brain regions, and different modalities and disciplines."
Take off points - depression (and anxiety?)
"These days, most people think of depression in terms of a contemporary pharmacology-based "medical model [33]", the core of which is the idea that depression is an "illness" resulting from "chemical imbalances". From this perspective, the actual feelings and experiences that depressed individuals have are of relatively little interest, either therapeutically or in terms of trying to better understand depression, and the principle task is to find ways to "correct" the underlying disturbed pharmacological pattern ... My own guess has been and continues to be that while there are certainly pharmacological correlates to depression, the condition does not at all reduce to those, and that a fuller understanding of both depression and ways to treat it depends fundamentally on paying more attention to individual feelings and experiences, to observations made and reported "from the inside [34]"" ... Exploring Depression [13]
William Shakespeare, Hamlet [35]
I have of late--but
wherefore I know not--lost all my mirth, forgone all
custom of exercises; and indeed it goes so heavily
with my disposition that this goodly frame, the
earth, seems to me a sterile promontory, this most
excellent canopy, the air, look you, this brave
o'erhanging firmament, this majestical roof fretted
with golden fire, why, it appears no other thing to
me than a foul and pestilent congregation of vapours.
What a piece of work is a man! how noble in reason!
how infinite in faculty! in form and moving how
express and admirable! in action how like an angel!
in apprehension how like a god! the beauty of the
world! the paragon of animals! And yet, to me,
what is this quintessence of dust? man delights not
me: no, nor woman neither, though by your smiling
you seem to say so.Emily Dickinson [36]
David Hume [14]
"all my ardour seemed in a moment to be extinguished, and I could no longer raise my mind to that pitch, which formerly gave me such excessive pleasure ... I was continually fortifying myself with reflections against death, and poverty, and shame, and pain, and all the other calamities of life. These no doubt are exceeding useful, when joined with an active life, because the occasion being presented along with the reflection, works it into the soul, and makes it take a deep impression; but in solitude they serve to little other purpose, than to waste the spirits, the force of the mind meeting with no resistance, but wasting itself in the air, like our arm when it misses its aim ... Upon my mentioning it to my physician, he laughed at me and told me I was now a brother, for that I had fairly got the disease of the learned ... It is a weakness rather than a lowness of spirits which troubles me, and there seems to be as great a difference betwixt my distemper and common vapours, as betwixt vapours and madness. I have noticed in the writings of the French mystics, and in those of our fanatics here, that when they give a history of the situation of their souls, they mention a coldness and desertion of the spirit, which frequently returns and some of them, at the beginning, have been tormented with it many years. As this kind of devotion depends entirely on the force of passion, and consequently of the animal spirits, I have often thought that their case and mine were pretty parallel, and that their rapturous admirations might discompose the fabric of the nerves and brain, as much as profound reflections, and that warmth or enthusiasm which is inseparable from them"
Depression from the inside [15]
Feeling everything to be heavy, things, even simple ones, are just too hard to do. Starting things, not being able to finish them, developing into a feeling that therefore nothing is worth starting.
Feeling that nothing will ever change, that one's discomfort is what has always been, will always be.
A profound inability to "will" change in either behaviors or moodOne is aware of one's own behavior/feelings, but can't do anything about them.
feeling very lonely and removed from everything. Being with people usually only intensifies the loneliness, making me more aware of how disconnected I feel.
It isn't that I don't deserve happiness, I just will never have it, and so it often seems best to give up and settle for something that isn't as wonderful as happiness but also isn't as terrible as depression.
There's always a voice that pops in and reminds me that anything I do become mildly interested is pointless because it will soon become unsatisfying, so no point in trying.
I have been FRUSTRATED and ANGRY at everything, small things, big things, and at nothing, and at myself. I am pretty sure I'm feeling better than before, but then sometimes I don't know. I feel good. Then I feel bad. Then I feel good. Then I feel bad again. It makes me feel overwhelmed. I feel, for lack of a better word, CRAZY. Maybe fragmented is a good word.
Without the mask of depression, my anxiety has returned.
I feel like I need there to be something wrong with me when nothing is. My story of myself, my identity, very much includes medications, depression, and anxiety. Without them, I don't know who I would be. They are my crutches. This is who I am. And sometimes I am unwilling for that to change.
"My GP once said that people often emerge from 'the dark place' that is depression with a great deal of emotional knowledge and empathy. She was right! Having a breakdown has changed my life for the better. I now look at the world with new eyes, I've become a much more compassionate and patient person and feel so much the better for it. Depression truly can help you clarify what is important." .... comment on Is Depression Good for You? [37]
Comments
Another Literary Example [38]
I found the work we did this week exploring depression in literature very interesting. So I would like to offer another example, Kafka’s “Metamorphosis”. I think that this piece of fiction can be understood in terms of Professor’s Grobstein’s storyteller, unconscious, and model of mental illness. The protagonist, Gregor, is suffering mental discomfort because his story about himself is no longer functioning. He is unable to live up to the difficult demands he imagines his family has set for him. That his role in the family is to provide essential financial support and repay his father’s debts to his boss.
The metamorphosis is a symbolic representation of severe depression. The strange sensations he experiences are analogous to the lack of communications or inputs the storyteller normally experiences in the course of depression. It is his unconscious that is responsible for sensory inputs that are constructed by his storyteller as making him a bug. His transformation into a giant bug affords him the opportunity to take a break from his responsibilities; it forces him to reflect on his life and relationships. Gregor had defined himself in terms of his relationship to his family members. After the transformation, he makes some limited progress towards developing a self-understanding, a story of his own needs and desires. Tragically, he is ultimately unable to work through his depression in the end.
I wanted to reply to several [39]
I wanted to reply to several people's comments, but I figured instead of chunking it up below each individual post, I would just consolidate me thoughts down here on the bottom.
I am going to avoid dipping too deeply into the conversation on the usefulness of a depressive episode for two reasons. First, I'm sure that many useful understandings can be generated from the sharing of subjective experience and personal meanings of depressive episodes. However, when we start using words like right/wrong and good/bad to describe experiences that people obviously have strong convictions about in the first place, we enter into mucky territory... not only with ethical issues, but with diagnostic issues, subjectivity issues etc... I think that we may be able to uncover more useful understandings if we tiptoe around these areas as much as possible.
Second, I'm not sure how I can add to the conversation. I've been sad before. Really sad. But, I can't say I have ever experienced anything like the depths that some people have described. I don't think I have anyway... Who is to say that we wouldn't describe the same things (whatever that means) differently? How can we compare two people's subjectively described experiences? I'm sure we could find a way, but it seems more useful to just move in a different direction.
As Dr. G mentioned above, one direction might be to continue to flesh out a more outside view of what depression really is. So, to stick with the inputs/outputs model, I cannot see how depression, as described by individuals who have experienced it and our stories in class, can be a complete dissociation of the storyteller and the tacit knowledge. There are obviously still inputs from the TK that are being observed by the ST. But, if the ST really were cut off from all inputs and the ST is the area that contains "us"... That doesn't seem to fit the descriptions that people are giving of the experience. It seems like that would result in some sort of complete oblivion.
I have two alternate suggestions. First, perhaps there is something wrong with the connections between the TK and the ST (similar to Capgras). One line of information is coming in telling the ST that someone just gave them a hug. However, the line that is supposed to tell the ST that this is a pleasant experience and the proper response would be to be happy or feel loved is malfunctioning somehow.
Second, perhaps the malfunction is inside the ST. This seems like it would call for a compartmentalization of the ST. We usually talk about it as a black box. However, maybe there are pathways and connections within the ST that are vulnerable to malfunction. For example, maybe all the necessary ingredients have entered the ST via connections from the TK and the "assembler," or the part that organizes them into a cohesive story is malfunctioning. Or perhaps the "motivator," or the part that sparks our motivation to construct a story in the first place is broken.
I think that there is a [40]
I think that there is a difference between the feelings experienced by patients that suffer from depression , schzophrenia and more in general mood disorders, and the feelings experienced by persons that are considered "normal". However, this difference is not qualitative but it's rather quantitative. We all face negative emotions in different set of circumstances and we all respond to them differently. However, I'm not feeling comfortable saying that we can always learn from suffering. A period of grieving, for example, after the death of a loved can help us to adjust to the loss; but constant feelings of sadness, hopelessness and apathy about life destroy various abilities of a person (like thinking,sleeping, working, eating) and his/her general health. The brain " becomes less an organ of thought than an instrument registering, minute by minute, varying degrees of its own suffering". We learn only when we change how we think about negative feelings and how we try to explain them in a way that allow us to perform our abilities. One could also argue that disorders, like depression, can enhance a particular ability of a person. In fact, many talented artists suffer/suffered from mental disorders. We cannot just appreciate the disability of a person only when that proves to be productive in artistic or other terms, but ignore the individual in all other contexts. A cure would not be aimed at changing the person itself, thereby eliminating a particular talent, but, on the contrary, at helping him/her flourish in all field of his/her social life.
More than depressed or not-depressed? [41]
agree [42]
I absolutely agree...that "all of these are ways to change brain chemistry." And in the end we only have ourselves to figure out what is best for our own "self/selves"
Meredith
Your own free will. [43]
I think everyone has agency to varying extents, but at certain points, not everyone can actualize. Perhaps, therapy (talk, medications…) is one way to restore agency or bring it to the fore…
Hey
Above I reference your comment. First not all psychologists believe in agency. Stunningly most don't. I emphatically do. I will take that a step further. One f the main fountains of agency in humans is the frontal lobe.
Get a frontal lobe tumor and you are likely to get frontal lobe sybdrome which looks a lot like a loss of agency. This is not surprising because the dorso lateral prefrontal cortex is responsible for "Willed Behaviors." (Ironically the same psychologist who say that there is no such thing as free will know this full well and say free will is just an illusion." I know this very well. I had a frontal lobe tumor and frontal lobe syndrome. Ask my son Adi. He would say to me.
"Get up off the sofa and go to bed." and I would answer "I am getting up." and he would say "But that is what you said 45 minutes ago." I just could not will myself to pull the trigger and act.
Not surprisingly, schizophenia is also a disorder of free will. There are of course technical terms for this like "Impoverished thought", "Impoverished" speech", "anhendonia" and "amotivation." Delusions are not surpisingly focused on free will "Someone is controlling my thoughts" That is a common delusion. I my considered clinical judgement restoring that agency is a prime objective. Without that, life is not much fun and the stories you tell tend to be kind either very dull or really terrifying.
Both somatic and talk therapies ought to take that as a first target. Some do. There are other options than talk or drugs.
This discussion has inspired a song. I have only a verse and a chorus.
Some times it is easier to make a point in song than in prose.
Warm regards
Sam Flesher
Pittsburgh
Your Own Free Will
Words and Music by Sam Flesher
I take a step in your direction
Slowly you retreat
So I make a course correction
Quicly you complain
That's a dance for every season
The steps will all repeat.
Do we dance for some good reason
Or do we dance in vain
Here is my advice to you
Whatever you decide to do
Do it of your own free will.
Do it of your own free will
Do it of your own free will
You are not a robot
You ain't got forever
The your penny in the pot
Do it of you own free will
And when you're done
You'll be free.
Let me preface my comments [44]
The notion of agency is a complex one in that, if the mind reconciles information in such a way as to create stories that may lead to depression, or a host of other “problems,” often an associated feeling is one of being stuck and lacking the tools, the will, the whatever, to become unstuck. Could therapy help to restore agency (medication, too?)? Of course, agency is not something someone else can hand one, like a flashlight in the deep, dark woods, but if the story-teller and tacit knowledge are communicating freely, there’s no reason that a story cannot be edited, refined, right? I think everyone has agency to varying extents, but at certain points, not everyone can actualize. Perhaps, therapy (talk, medications…) is one way to restore agency or bring it to the fore…
Growth and function [45]
"If we focus on the story teller then we are able to appreciate each individual experience for what it is and help every person reach a place where they can grow/learn/thrive to the best of their ability. If we focus on function, then we deal with external behaviours in order to make sure that individuals can experience a 'normative' reality. Or even, is it possible to focus on both without one overriding the other? How do we need to change to make that happen?"
Lots of things keep people from experiencing a normative reality including illness. Amerliorating and illness can bring back growth function and more of normative reality. The human dimensions of illness are overlooked across the medical system. Bringing those dimensions back in means specific changes to the system. That is hard but not undoble.
function [46]
Every individual, I think we can agree, has a nuanced perspective on life. No two stories are exactly alike. I feel that when we try to 'cure' mental health problems like schizophrenia or depression with pills or therapy we are not trying to help an individual understand his or her unique story, but rather turn them into functioning members of society. Yes we focus on the symptoms but the problem, I don't think, is the 'disorder' itself but rather the inability to function within conventional notions of normality.
We throw a 'cure' at people who need one to function in our world, but have we fixed the problem? Are they still lonely, perhaps, after taking Xanax? Those creative geniuses we mention are success stories because, at a certain level, they were still capable of functioning within society. The others, the homeless people, the people in institutions, they are not and for that reason our main goal is to deal with the behaviours that prevent them from being a part of the mainstream.
I feel that this question of 'function' really deals with what we have been grappling with this semester and at the end of the day sums up how we could potentially change the mental health system. If we focus on the story teller then we are able to appreciate each individual experience for what it is and help every person reach a place where they can grow/learn/thrive to the best of their ability. If we focus on function, then we deal with external behaviours in order to make sure that individuals can experience a 'normative' reality. Or even, is it possible to focus on both without one overriding the other? How do we need to change to make that happen?
"Maybe we want always to [47]
"Maybe we want always to encourage at least some element of possibility and agency?"
I just feel there is a fundamental disagreement here based in how much agency a person has when they are lost in the muck/mire of severe emotional discomfort. I certainly believe that life is about encouraging an element of possibility and agency -- but I don't agree that helping to lessen severe suffering discourages that.
I still feel that we are, in some ways, glorifying what mental pain/suffering might actually be.
Addendum: I more carefully reread what Professor Grobstein posted, and in fact, I feel like correcting myself, in that I agree more than I disagree. I think my knee-jerk annoyance occured because it did seem that there was a sense of "glorifying", as I mentioned above. Still, as I said even earlier, I simultaneously believe that even as we work to overcome/live with mental differences we can also grow and change with them, and that those experiences are crucial to what makes perceived positive change as much as perceived negative. So, I won't strike my initial post from record, but ... I will up-end its tone.
more on pain/suffering and its significance [48]
Let's hear it for the potentials of shared thinking out loud, and of generative conflict. Thanks for this. And, in part because of it, I too want to retune a bit.
I don't at all think one should "glorify" pain/suffering, mental or otherwise. Though some might want to argue that pain/suffering itself is "redemptive" or that "what doesn't kill one makes one stronger," my concern here is quite different and much more akin to "even as we work to overcome/live with mental differences, we can also grow and change with them." Its not, in my mind, pain/suffering that is the important operative factor in growth/change, but rather the conflict that pain/suffering may be a signal of. Its the positive features of conflict that I think we need to be more aware of, not the value of pain/suffering, which may itself get in the way of the recognition and productive use of conflict. To the extent one can alleviate suffering without becoming insensitive to conflict, I'm all in favor of it.
I'm also in favor of building on whatever scraps of possibility and agency can be found in any given situation. And maybe this is worth retuning a bit too. I don't think of "possibility and agency" as something one has or doesn't have. Nor do I think that not having it means one needs sympathy/help from others and having it means one doesn't. Instead, I think that "possibility and agency" are things that people have in varying amounts, with different people having different amounts at different times, and that people are always better off with sympathy/help from others regardless of the current status of their "possibility and agency."
Sympathy/help in a mental health context should, it seems to me begin with the assumption that humans always some starting level of "possibility and agency" and that the task is to enhance it. By whatever means can be found including, as appropriate, relief of pain/suffering.
A Beautiful Thought [49]
A beautiful thought from someone at the meeting for worship I attend. That one should plant apple trees in the winter, rather than the spring. These beings need a period of darkness, stillness, before they can grow. They emerge in the spring the better for it.
This thought strikes me as a perfect metaphor for depression. Especially, because it speaks to the issue of suffering. Taking medication for depression can be seen as wearing winter coat to protect oneself from the extreme cold. Such an act requires some recognition or self-awareness, again, similar to the decision to take psychotropic medication. However, it doesn’t preclude a person’s sensory experience of the cold, darkness, snow, and wind.
Thanks...
I just went back and read [50]
Sometimes we experience conflict at the level of tacit knowledge that may manifest itself in ways of which we are not aware. It is often, only when the conflict inserts itself into our lives in such a way as to be undeniable that we are able to address the conflict, even if it was affecting us without our knowledge. And so, that thing, that product of our unconscious enters the realm of the storyteller and its existence is harder to deny. It is at this point that I think conflict becomes useful. I do not think that everyone should suffer, that conflict is “good” or even that everyone should see conflict as useful. However, there are ways in which conflict can be the first building block in a personal renovation, a personal actualization. I think medicine invests a lot of time fighting against the body, the mind, rather than working with it. I see no inherent “value” in mental conflict. However, I see a possibility of change for the better, of working with a particular mental state to untangle a story, refine it, and move on with a story that is more useful. My reference to medicine “fighting against” the body is not an argument for the acceptance of depression, of schizophrenia, or of anything else. On the contrary, it is an argument for working with the individual based upon that person’s strengths and difficulties, rather than imposing a rigid, inflexible standard of “normal,” a category into which not every body, not every mind will ever fit. To the extent that we are not aware of the ways in which our choices, our experiences, our existences shape tacit knoweldge, "symptoms" whether a caffeine-induced headache, or a pervasive sense of sadness whose genesis is unknown can be a "signal" that there is something amiss... However, I don't know that the "symptoms" themselves are actually the problem, but rather a limited solution implemented by the storyteller that needs to be revisited. The symtoms, perhaps, are the "signal" that alerts us of the problem?
Schiophrenia, depression, and beyond [51]
The juxtaposition of discussions of schizophrenia and depression intrigues me, for several different reasons. One is that, at this point, depression is more "main stream," while schizophrenia represents, for many people, the "elephant in the room," the really frightening/challenging specter in considerations of mental health. My hunch is that this is largely cultural mythology, that the destructive potentials of depression, both for onself and for others, are at least as great in the case of depression as in the case of schizophrenia, and probably greater. Its worth thinking more about why people perceive it otherwise. My guess is that its not only a matter of media portrayal, that people are actually more frightened by others being "out of touch with reality" than of people being depressed (which is of course just another form of being "out of touch with reality"), and more fearful of themselves falling into the former state than the latter. Which returns us to some earlier discussion of the brain, whether or not it ever knows "reality," and the implications of that for thinking in new ways about mental health. For more along these lines, see "On brains in vats: who needs "reality"?".
A second thing that struck me about the juxtaposition of our schizophrenia and depression discussions was the different "research" approaches. The schizophrenia discussion took the more traditional approach, focusing on "objective" characterizations that can be made "from the outside." The depression discussion, in contrast, aggressively took a different approach, using subjective report as a starting point and asking what new understandings (and therapeutic approaches) might derive from that. It would be interesting to invert the discussion approaches, to think more about depression "from the outside" and schizophrenia "from the inside." And then to think more about the relative advantages and disadvantages of the two approaches.
The third thing that the juxtaposition of schizophrenia and depression discussions made me think about was an intriguing similarity, that what one is concerned about in both cases is actually not "depression" per se, nor "schizophrenia" per se, but rather extreme cases of both where behavior may be dangerous to the individual as well as to others. To put it differently, both depression and schizophrenia exist on spectra, with milder and more intense forms. Perhaps then it would make sense to think of "schizophrenia" and "depression" (and autism, and Tourette's, and migraine, and ....) not as in and of themselves "disabilities" or "illnesses" but rather simply as brain variations? And reserve the terms "disability" and "illness" for the more extreme versions of these where they become troubling? And treat people not for "schizophrenia" or "depression" (etc) but rather for whatever is in fact troubling? This might more easily allow us to appreciate some of the positive features of brain variation and better focus attention on what needs to be "fixed" (and why). We could acknowledge "neurodiversity" and its value while still recognizing a need for special treatment in cases where its needed, and for reasons that it is needed.
As for schizophrenia itself, my thoughts run along the lines of trying to understand the brain variation itself, independent of the extreme case problems. And the positive sides of that brain variation, which are presumably the flip side of the problems. I'm struck by the acknowledgment in several of the recommended papers that we need a new way to think about/do research on schizophrenia. A key point here, it seems to me, is "incorrect beliefs rigidly maintained." If one (as above) has reasons to suspect all beliefs are "incorrect" that would suggest that the core problem in schizophrenia is actually "rigidly maintained," ie that the brain variation involved is one that causes people to be less inclined to check understandings against experience. And perhaps unconscious ones against conscious ones? That, of course, would create problems under some circumstances but might also have advantages under others.
The depression conversation was an experiment, to see where we could go with taking seriously the idea of stories as relevant. And it at least helped to advance some thoughts I've been having out of my own experiences with depression [52]. I was impressed with how quickly we picked up the notions of a split self, of a greyness, of a sense of loss/stuckness, of a mixed sadness/anxiety, of a loss of confidence in the ability not only to act but to think productively. of a loss of a sense of time and the associated possibility of change. The notion of a conscious/unconscious dissociation helps me (at least) make sense of all this, with the addition that it may not be so much a complete disconnection as an absence of continuing reciprocal exchange. The possible relation to Capgras is intriguing as well. And the notion of dissociation does lead on to some potentially useful further questions. What causes the dissociation? What is the unconscious doing in the dissociated state? How does one re-engage the two systems? Might this be a line of research potentially at least as productive as the ongoing search for new pharmaceuticals?
Last, if not least, some thoughts about the "would you take the hypothetical pill?" thought experiment and some of the conversation it provoked Monday and here. The straw vote, for the record, was 6 yes, 9 no, and that intrigues me, if nothing else as an indication of a potentially generative conflict. The core of the question, in my mind at least, was not whether there was virtue in living with discomfort and pain, nor whether or not one should attempt to mitigate discomfort/pain. I have lived though periods of discomfort/pain produced by depression sufficiently severe to appreciate the wish to have a way to simply make it end. I've used medication myself and still do.
At the same time, part of what has gotten me through periods of depression is a conviction that, however it feels, my brain is in fact responding adaptively to conflicts that I don't yet fully understand, and that I need to be patient while it does that. And my experiences have been consistent with that; I do come out of depressions with understandings that I doubt I would have achieved otherwise. Yes, I'd like others to be sympathetic to my discomfort when I'm depressed and to help me mitigate it and live through it, but I'd prefer to be thought of as engaged in doing something that will prove to be worthwhile (to myself and others) rather than to be regarded as "ill" or "disabled." To the extent that mental health is about story telling, and some pain/discomfort is necessarily associated with that, I'm disinclined to act simply to make the pain go away.
Do we "fix" things that seem "wrong," or do we live with them for a bit and see in what ways they might contribute to the creation of "less wrong" things that we might not otherwise have thought of? At least some "medical" problems are clearly best dealt with the first way. Maybe what's special about the mental health realm, and its associated story telling features, is its encouragement for considering the potentials of the second way as well? Maybe we want always to encourage at least some element of possibility and agency?
Growth and pain [53]
Just as experiencing life symptom-free between depressive episodes is part of living with depression, so is the struggle of debating whether or not having depression is worth the personal growth. Personal growth can ultimately bring us to the point where we settle in and accept the total experience of living with depression, to where we find ourselves spending as much time observing and understanding it as much as we do questioning it. df
I agree with Lisa that [54]
I agree with Lisa that depression and sadness are two completely different things. I discussed this with a friend who had suffered from debilitating depression after our class on Monday, and she said that for her depression was more not being able to feel or experience anything--it made her numb. When she finally went on medication she said that she was happy to finally be able to feel anything--happiness or sadness because it meant she was experiencing life again.
I thought the discussion in class, over how we can learn from these illnesses and the people who experience them can grow was interesting although I don't really know my feelings on this. I understand the feeling that the "bad" things that happen to us help us grow, but at the same I know that some events in my life that have helped me become a more compassionate person I would still give a lot for them not to have happened. I think the question is a philosophical one--is the knowledge gained worth the pain of the experience? I think we can each only answer this for ourselves, or hope that we would have gained this knowledge some other way.
One of my favorite [55]
One of my favorite author's, Amy Hempel, was recently at Bryn Mawr. (I highly recommend her work.) In the "The Man in Bogota" q narrator watches on TV as someone is about to jump off a ledge, and wishes she could tell this jumper a story ... of a wealthy man who was kidnapped and held hostage for months. His captors had to keep him alive and so, in the process, he lost weight, ate healthy food, quit smoking. When he was released his doctor examined him and said "that the kidnap was the best thing to happen to that man." Hempel goes on ...
"Maybe this is not a come-down-from-the-ledge-story. But I tell it with the thought that the woman on the ledge will ask herself a question, the question that occurred to that man in Bogota. He wondered how we know that what happens to us isn't good."
It is in this way that I see the positives in depression (or schizofrenia or bipolar disorder). In the sense that we know very little about the workings of anything, about what leads to what, about what makes a life good, about what that even means. Because how do we know what makes us who we are, or what takes us where we're going?
But, at the same time, I don't think this negates the need for treatment, or even the idea of "cure" or of "disorder." That something is negative doesn't mean it is bad, and I truly appreciate what Lisa is saying, and I don't disagree with it. Still, I can reconcile the idea of finding meaning and value in depression while at the same time working to eradicate depression. I think that some of these disorders have positive and negative effects on the brain -- or that "positive" symptomologies are clustered with "negative" ones. The fact that people with bipolar disorder are more likely to be creative *doesn't* mean that bipolar disorder makes them creative (and, in fact, family members without the bipolar symptomology -- so, without a ten-to-twenty-fold increased risk of suicide, for example -- are also more creative) nor does it mean that treating the symptoms (see right above, for one) takes that creativity right. Some studies have shown that, when treated properly, people maintain the creativity without the mania/depression.
What about when when a mental problem CAN be treated with a pill ... Like certain presentations of syphillis, for example? That pill ( not just *like* an antibiotic for a mental disorder, but *in fact* an antibiotic for that disorder) will remove the associated symptoms. So should it not be taken? And if it should be taken, why again can't a similar pill, a pill that helps a person escape from debilitating depression or anxiety or mania. I am not manic, but can still experience highs and lows. It is reductive and silly to say that a pill to cure depression means a pill that erases all variance in human emotion.
I am not saying that pills work. I know people who have tried many therapies and medications, only to find that meditation does a much better job of alleviating severe emotional pain than anything else. I know others who have spent tens of years trying everything possible, still waiting for something to lighten the pain (or dying before a cure was found -- some by natural causes, some by their own hand). I am not saying a pill is what is right for everyone, or that they work. But I do think everyone deserves to "settle for something that isn't as wonderful as happiness but also isn't as terrible as depression" -- and then to go from there to something that is, like most of our lives, at least sometimes just that kind of wonderful.
quote for merry2e [56]
To quote Bob Dylan: "He who is not busy being born is busy dying."
What is depression? Gestation...
df
attachment [57]
Hmmm, interesting...so in this light I see depression as an absolutely "normal" human occurence. And so, my next thought goes to...being with one's SELF and at the same time attached to another/ knowing how to be SELF without the other AND still attached.
Excuse the babble...thinking out loud.
creativity [58]
I work a great deal with individuals with schizophrenia. I love my work. I love seeing people recover and lead the lives they want to lead. Over the years I have know many well. Some are creative, some are gifted others less so. I have mostly see their gifts as comming from the person they are not their illness. Individuals who have an illness or a disability are not defined by that illness. James Tayor is not a bi polar, he is a person who is a singer songwriter who happens to have bi polar disorder.
I have also noted that these creative gifts are more likely to come to fruition when their illness is in good remision. I have only very rarely heard people say they benefit from hearing voices or struggling with delusions. Having been hit with brain cancer myself, I had a short but educational experience of what it is like to have an impaired brain. My delusions were beneign. Still I became totally dependent on my doctors, my two wonderful sons and my very patient sisters to live my life. When the chemo killed my cancer, my delusion went away, I could think better and go back to work. Having a better functioning brain can be a blessing. Sure sometimes bi polar folks can go through surges of creativity, but they also pay a price. I also know lots of artistic types who intentionally impair their brains with drugs to enhance their creativity. There may be some utility to such an approach, but it has limits. As a musician I love playing drunk sometimes as long as I don't have to listen to the recordings.
Most of the people I know with schizophrenia (and that is a lot) really want to feel and think better. If the means are there to help them to do that, I think they have that right. Today we have more and more tools to enhance thinking and promote recovery. I think that is good think. Personally, I want to thank Dr. Lieberman, Jenifer the PA and my treatment team for helping me get my brain back. Thanks also to my family and friends for putting up with me when I was a little more goofy than I am right now.
Sam Flesher
Pittsburgh.
Death and depression [59]
Death and dying seem to be a huge part of depression. And in our culture as we can see in many fairy tales, etc...that fear of death is taught at a young age...could it be possible that experiencing a depression a "Mini-death" could be so fearful, not knowing what or who would be on the other side, that it is just too overwhelming to experience? I just wanted to share a bit of writing someone I know rather well shared with me while in a deep depression and on antidepressants:
“Death As My Friend”
Death came to me the minute I took my first breath.
He came and whispered in my ear, “You are my friend, for always and forever, you are mine.”
I looked my mother in the eye and suckled from her breast, and the shadow of my first friend, Death, flickered deep within her soul.
I knew she was His, too.
When learning to take my first steps he whispered to me, “You will walk through the Valley of Death…hand in hand with me one day, I will teach you to walk strong.”
I learned to run, jump, as fast as I could, for my friend would be so happy, pleased if I did. And when I looked into her face, I saw what her promise from Death was doing…
Death was her only friend. But it was ok, because I knew what He would give in the end. Comfort, peace, serenity, forgiveness, love, mercy, kindness, pleasure and joy. All things she could not feel or experience here because she had given herself to Him. She was unable to show affection; for this would take away energy she needed to give in the end, to Death.
Death was my friend…and then I saw what He can do. Four and a half years old. I cherished Death, I believed His promises, and then He lied, and took the special one away. He whispered, “She walks in the Valley of Death, and you will see her one day. Would you like to see her now? You can always have the choice if you wish to come with me…to walk in the Valley of Death, you are strong, and wise…”
I looked into the woman’s eyes who I had suckled from her breast. There was no longer a flicker in her soul, He was her soul. But I was afraid now. He was still my friend, He walked beside me everyday, for without Him, I was alone.
Did she see Him? The day she suckled my breast? The day we said goodbye to my brother and He was sitting next to him on the bed? Did she see him that morning as we entered the church, and He sat down next to me?
You have walked through the Valley of Death with me my whole Life. My Life has been a Valley of Death. I am no longer willing to live a life of dying, nor am I going to pass it on to my children. You may scare me, make me believe you are my friend, at times comfort me, and make me believe I want to be with you, but I no longer want you to be my friend. I want Living to be my friend.
One again, I really think that our culture plays an important role in how we perceive depression and other mental health issues and thus how we handle them.
Benefits of depression and schizophrenia...? [60]
This is a very sensitive topic and must be treated that way. I think that saying that depression and schizophrenia (SZD) may have benefits implies that it's a worthwhile or valuable experience that everyone should have. Regardless of one's intention, I think this implication comes out (and I think this is why the conversation is so polarized).
I think it's important to point out that people's reactions to depression vary. While one may see normal life as brighter, having gone through depression, another might be completely traumatized by the horror (I think this is exactly what we witnessed in class discussion).
Regarding SZD, I never knew about the creative 'benefits' until last Monday night. I thought it was just bipolar disorder that gave rise to genius. I'm curious what people think about bipolar disorder, by the way... while we haven't dared to say that depression or SZD was a gift, there are many who dare call bipolar disorder a gift. The 'benefits' of bipolar disorder are widely known, but should we call it a gift?
"Mini-Die" like you were living [61]
Ljones, look what a significant force depression can be. In your case, someone who has never even experienced depression can still sense its tremendous power, not only as a negative phenomenon, but in being able to yield something positive--like a new perspective on life. For me, entering a deep depression is like suffering a "mini-death", in that you see your happiness, general interest in things and ability to otherwise perform or take part in certain everyday activities, separate from you and fall away. You leave them behind, or in some ways, they leave you behind. In experiencing a depression's "mini-death", the best thing to do is to do it like you were living: To observe, to let yourself feel, and no matter how difficult, to deal with the discomfort, and take in and accept how the world and your place in it, might be appearing to you at that time (frightening, empty, uncertain, etc.). When the depressive episode is over and the rain clouds clear, one of the most potent perspectives to gain, is to realize how that "mini-death" (and suffering) was really just one more part of this experience we call "life". There is a certain amount of maturing that takes place, no matter how old we are...
df
Live like you were dying [62]
I want to preface this with the fact that I have never experienced depression.
I understand both the argument that depression is awful and useless, AND that it is something that can allow growth and be quite helpful. The analogy that popped into my head during class was that depression might act like a terminal illness in that it can add perspective to a person's life. Would I wish a terminal illness on someone so that they could experience this "growth"? Of course not. But, sometimes people find that they start living only AFTER they find out that they are dying, and wish that others could live with that same sense of intensity in their everyday lives. Maybe depression can help give people some of that intensity and maybe working through depression can allow some people a chance to gain more perspective on life.
Schizophrenia [63]
I have spent my whole career working with schizophrenia. It can of course be a very difficult illness, but the prognosis is much more optimistic than one would suppose. The real problems are not the dramatic ones of delusions and danger. Most of the individuals struggle with getting meaningful lives given on going difficulty with attention memory and social cognition. But the evidence shows that various degress of recovery are not only possible but to be expected. I personally get great satisfaction from seeing individuals get better lives. That being said, this illness can be a source of great stress to an individual and her family.
Schizophrenia - diagnosis [64]
I am very interested in finding out how the actual diagnosis process for Schizophrenia works. A young man is diagnosed as depressive with psychotic symptions but none of the medicines seem to work. After almost 8 months, the diagnosis is leaning towards Schizophrenic illness. Is this a trend you have seen in your experience?
thanks
Depression and Schizophrenia [65]
Depression
I want to once again clarify that being sad and being depressed are two completely different feelings. The feeling of complete and utter despair, and the inability to rationalize that feeling are some of the worst experiences I feel an individual can endure. When a person is sad, there is a reason, my boyfriend dumped me, my kitten ran away, my mom and I had a disagreement. Depression does not come with any consolation; it does not have a reason, or a solution. Depression is a constant lonely, sadness; unexplainable and unforgiving to those who are so unfortunate as to experience it. So, when Yona and Paul suggested a pill, free from side effects and always reliable, I would have to be a masochist not to take it.
I want also want to add that I understand Meredith's point of view and I am glad that the illness that I found so completely draining and debilitating she was able to learn and grow from. However, I do not feel as though it is at all fair to say that one should not take a hypothetical pill because they have the capability to suffer, and through their suffering learn a great deal. I also think that depression does not make people who they are; on the contrary it breaks people. It breaks people down piece by piece until absolutely nothing is left, nothing but the want to end your suffering. Depression is not an opportunity and it is not normal, it is not used to build character. Depression is a mental health issue and that is why we are even talking about it. Treatment for depression is necessary and without it comes unnecessary suffering.
I am sorry about how forceful I am with this issue, but once you have been there - to a world that sometimes you cannot come back from for days - you realize the lengths to which you will go not to experience it again.
Schizophrenia
Schizophrenia I can only imagine is also a terrible illness and I completely disagree with Paul that schizophrenia has positive attributes. I don't think that the families that deal with schizophrenia on a daily basis are amazed by the workings of a malfunctioning human brain, and the schizophrenics themselves - their inability to distinguish reality and fantasy must be like living through a nightmare that you can never wake up from. I believe that when an individual is not directly present in a situation all the pros and cons can be listed and discussed, but I do not believe that individuals in that situation see any pros at all - only cons.
So much of what it means to be human lies in human interaction and the ability for humans to understand each other socially. Schizophrenics do not possess many of those social skill and they often times do not live in the social 'real' world but instead in a world created by their own 'malfunctioning brains'. For those who think that schizophrenia has positive factors - I encourage you to consider that, as a schizophrenic grows older their brain atrophies. Schizophrenia is a disease and it needs to be treated.
It is important to consider that even schizophrenics such as John Nash who lived 'semi-normal' lives really can be large dangers not only to themselves but others. If the baby in the clip shown in class had drowned then I don't believe anyone would even consider 'semi-functioning' schizophrenics as actually functioning at all. Do communities have a right to know? Do schizophrenics have a right to help, even though they often times are opposed to it?
These are just some preliminary thoughts....
If we want to say that [66]
If we want to say that things like depression, schizophrenia, bipolar, etc... are "different" than normal human emotions then that means that everything we experience mentally does not lie on a spectrum but that some types of experiences are qualitatively different and not merely of varying intensity. That means that things like depression, schizophrenia, etc... are "wrong" or "malfunctions" and not something that one should expect to find in the spectrum of healthy human experience.
I think it is helpful to acknowledge the fact that certain things are just "wrong" with us/or the world but that does not mean we need to start a crusade to eradicate these things. The call to that crusade is what makes people afraid of the idea of eradicating large parts of the spectrum of human mental experience. Nobody wants that. So yes, for some people the proper approach is to relieve their suffering asap if possible, for others the only option might be to help them learn to live with it. For others it might be to allow them to suffer even though we could stop it because they are doing something with that situation which is valuable. For example, nobody would stop a mountain-climber who was almost at the top of the mountain because he had a broken arm, cuts, all sorts of injuries. We recognize the value of working through that suffering to reach a goal, so we allow it.
I think the reason so many people fear pain and suffering is because they do not recognize its value, all sorts of pain even seemingly hopeless agonizing pain has value. The soldier screaming in pain on the battle field as he lays dying is often shot in the movies to "relieve his suffering" all that does however, is to eliminate the conditions for the possibility of suffering much like medicating ever single ache and pain, thus limiting the spectrum of human experience. That pain has value even if it is only to serve as an example to his fellow soldiers of how to die with courage.
Why Suffer [67]
This is a song written by my father. I disagree with the depection of Buddhism. But what the heck. I love the song:
When the funeral jockeyis digging that hole
With a pick in the coldcold ground
When I'm out of my bodyyou can tickle my soul
With a sweet littlepiccolo sound
Tickle my soul with apiccolo song
Piccolo high and we'llall sing along
We're all gonna die andit won't be long
But in the mean time
Whysuffer if you don't need to suffer?
Painhurts and it won't make you tougher
Saythe word say the word if you need a little loving
Causelove is the cure
Andthat's what I'm here for
Ohdear
Whysuffer?
If you're insured by theHigh Mark Blues
And the clerk reviewsyour claim
Can you insure the careyou'll lose
If they refuse yourclaim
Tickle my soul with apiccolo song
Piccolo high and we'llall sing along
We're all gonna die andit won't be long
But in the mean time
Whysuffer if you don't need to suffer?
Painhurts and it won't make you tougher
Saythe word say the word if you need a little loving
Causelove is the cure
Andthat's what I'm here for
Ohdear
Whysuffer?
Met the Buddha on theroad
Just the other day
He said suffer with me
In the eight fold way
I said hey Mr. Buddha Ilike what you say
But in the mean time
Whysuffer if you don't need to suffer?
Painhurts and it won't make you tougher
Saythe word say the word if you need a little loving
Causelove is the cure
Andthat's what I'm here for
Ohdear
Whysuffer?
Flesher with sound [68]
Words and Music by Sam Flesher
Arranged by Dave Hart
More on my father [69]
I just wanted to add to my comments from class. As I mentioned my father has created a treatment for scizophrenia based on the idea that you can both do physical therapy for the brain and that that people really need help overcoming the social barriers that they struggle with due to their differences. Here is a link to their manual:
http://www.planneohio.org/sitebuildercontent/sitebuilderfiles/cetbrochure5.07_lesscolor_cmyk.pdf
[70]My favorite part is that they as one of the goals of the program is to help people with Social Cognition - including
Fun/sense of humor - Recognition and appreciation of spontaneity,
especially in social situations
Thank you for posting the [71]
Thank you for posting the "Depression from the inside"
See you tonight.
From the Outside In [72]
In working as a school social worker with children with autism, I have sensed for quite a while that there appears to be a similarity between schizophrenia and autism. An idea that I've had is that when you combine schizophrenia with a defense mechanism to the Nth degree, you have what appears to be autism.
Seeing from the Outside In [73]