A Primer on Depression and Bipolar Disorder
II. MOOD DISORDERS AS PHYSICAL ILLNESSES
Here we will explore the nature of depression and bipolar disorder as
physical illnesses of the brain, which manifest themselves through
mental symptoms experienced in the mind. We will touch briefly
on causes, symptoms, treatment, suicide, impact on family and friends,
self-help and support groups, stigma, public policy, and hope for the future.
A. Causes
The ultimate causes of depression and bipolar disorder are not yet known.
But over the years a number of hypotheses, theories, or "models" have
been advanced as possible explanations of these illnesses; some of them have
proven to be much more useful in treating the illnesses than others. Some of
the earliest work was done by Sigmund Freud, who tried to fit the mood
disorders into the framework of "psychoanalysis", the talk therapy
technique he invented to treat mental illness. He had some success treating
some patients with mild to moderate depression, less success with people who
were severely depressed, and essentially no success with people who suffered
from bipolar disorder. The latter illness he called a "psychosis",
i.e. a very severe, and possibly permanent, mental disorder in his scheme of
things. The fact that Freud, one of the most brilliant, creative, and
insightful of the talk-therapists of all time, got such poor results treating
the severe mood disorders is very significant. It is strong evidence that he
was using the wrong theraputic approach; that these illnesses in their most
severe forms don't respond to manipulation of our thoughts, but require more
direct medical intervention.
Freud's picture of the causes of mood disorders seems quite fanciful in the
light of modern knowledge. But his pioneering methods were essentially the only
theraputic procedures available until the development of useful psychiatric
medications starting in the 1950's and onward. Since that time, there has been
a rapid increase in the number of medications used to treat depression and
bipolar disorder effectively. Today, therapy using these medications has
largely displaced psychoanalysis for the severe mood disorders. Even though
methods based on a psychopharmacological model are often preferred today, as we
shall see later, the best results are usually obtained if treatment with
medication is combined with one of the modern forms of talk therapy (usually
quite different from Freudian psychoanalysis).
Our basic picture of brain function today is that cognition, memory, and
our moods all result from constant passing back and forth of electrical
impulses through the extremely complex network of nerve cells that permeates
the brain. There is a large body of convincing experimental evidence that this
picture is correct, and recently a great deal of theoretical work has allowed
researchers to begin to simulate the behavior of this network with computers.
If the message-passing process, neurotransmission, is broken,
interrupted, diverted to the wrong place, then the transmission of information
from one point in the brain to another where it is needed, fails.
In some cases, this loss may be inconsequential; in others it may cause a
massive failure of the system: loss of memory, misinterpretation of reality or
inability to perceive reality, or inappropriate mood. The crucial nexus in the
message passing process occurs in a small gap, the synapse, between the
extremities of nerve cells, which do not quite touch. The "firing" of
one cell excites a complex biochemical and biophysical reaction in the synapse,
and chemical messengers flood across the synapse from the exciting cell to the
receiving cell. The receiving cell, in turn, passes the message on by
initiating the same process at the next synapse.
If anything goes wrong with this mechanism, if a nerve doesn't fire, if the
chemical soup in the synapse is not exactly right, if the receiving cell
doesn't respond correctly to the chemical messengers, then message transmission
is disrupted. Depending on where and how the interruption occurs, we will
experience one or more incorrect psychic phenomena in our minds; if the errors
become large, we experience mental illness. In summary, in this model, we say
that one suffers from "mental illness" when a definite set of
physical/chemical disorders in the physical organ we call the
brain causes us to experience abnormal and undesirable behavior
of the complex phenomenon (which includes awareness, mood, abstract reasoning,
thinking, ...) which we call our mind.
The appropriateness of the title of this section now becomes apparent, and
we shall henceforth adopt the model that major mental illness results from one
or more serious defects in the neurotransmission process (and perhaps other
brain processes as well, not yet fully understood). Indeed, in the case of
schizophrenia and the major dementias (e.g. Alzheimer's), there is a great deal
of evidence that over a period of time the brain suffers severe damage and/or
deterioration internally, again the result of (unknown) physical mechanisms. In
other words, we will view the mentally ill brain as being, in a sense,
"broken". And the job of the physician and patient is to repair or
overcome, if possible, the damage.
At the present time, this is best done using specific medications, which
have been carefully tested and validated, to relieve the symptoms of the
various mental illnesses. The ultimate cause of these failures of brain
function is not yet known. Some research strongly indicates that the problem is
genetic; that it is programmed into the DNA of our bodies at birth, an
unfortunate inheritance from our parents. That, if true, has a sinister ring
because it means some of us are "doomed" to the disease no matter who
we are, or what we do. On the other hand, it would also mean that at some point
in the future it may be possible to eliminate the problem at or before birth,
using rapidly progressing recombinant DNA techniques. Or it may be that the
brain can be damaged by physical or chemical influences from its environment.
The jury is still out on these questions.
One important conclusion to be drawn on the basis of the biological model
of mental illness described above is that mental illness is not the result
of a failure of will, or of the desire to be well. Countless mentally ill
people have had to suffer both the ravages of the disease, and the scorn of an
uncomprehending society, a doubly cruel injury. One of my strongest hopes for
the future is that all people who are CMI (chronically mentally ill), and
society at large, can learn that mental illness is illness in the
ordinary medical sense, and deserves to be treated with as much respect and
compassion as any other illness. Indeed, a workable metaphor for bipolar
disorder is that in many ways it is a condition something like diabetes. That
is, the illness can cause major disability, or even death (through suicide),
and it may well be permanent in many cases. But at the same time, it responds
well to medication, and if the victim takes his/her medication faithfully,
he/she can lead an essentially normal life. I have known several courageous
diabetics who manage to lead productive and satisfying lives; and I know an
increasing number of courageous people who are CMI who do so also.
Up to this point, I have focused almost exclusively on chronic, often
severe, depression, resulting from fundamentally biological causes. But all of
us are all too familiar with another kind of depression. To illustrate, suppose
you struggle through traffic one morning, and have a minor accident which does
several hundred dollars of damage to your car; you arrive at work, and your
boss throws a fit because you are late (again!) and fires you on the spot; you
go back home, and on the kitchen table find a brief note from your spouse
saying that he/she is leaving you, and has run off with the next door neighbor.
Unless you are very unusual, by this time you will be thoroughly depressed. The
depression may be fairly severe, and it may last for a substantial time: days,
perhaps even weeks. But in the end, this kind of depression will usually lift
by itself, and will normally respond very well to talk therapy and/or
medication. Three characteristics of this kind of depression are that: (1) it
is caused by events outside of you, i.e. that it is a (reasonable!) response to
unfavorable conditions in your reality; (2) it is the result of a loss, or the
perception of loss (if no loss actually occurred); and (3) it is temporary
(imagine a reversal of the causative events, or the interjection of a new
positive event -- say winning the jackpot in the lottery). I will refer to this
type of depression as "psychogenic" to reflect the fact that
its origins result from psychic activity in our brains stimulated by outside
events. I am sure that doctors would object to such a term (their term
"exogenous" is, if anything, worse), but I will use it anyway as a
metaphor to suggest the characteristic depressive response to unfavorable
outside events.
In contrast, I will refer to the kind of depression I have been talking
about earlier (plus bipolar disorder) as " biogenic" to stress
the fact that it is a result of biological/biochemical/biophysical malfunction
in our brains, independent (almost) of outside events. (Doctors would
probably prefer the word "endogenous", but I'm not a doctor so I'm
exempt.) A characteristic of this kind of depression is that it is usually
chronic: it has existed for months or years (in some cases a lifetime),
and can exist for an arbitrarily long time into the future, regardless of
outside events. Of course, it is almost never "either-or". In most
serious depressions both causes can be implicated. Typically a
psychogenic event will trigger a much more serious biogenic response in the
brain. A good example is my move to Illinois in 1985; the combination of loss
of friends and familiar environs, plus the stresses associated with a new job
and making new friends, provided a trigger to drop me into the major depression
that had been lurking about, waiting for me to fall in, for years. To make an
analogy: when you get to the edge of a cliff, and then suddenly slip on a
marble and fall over the edge, the marble was only the trigger for the
disaster; it is the depth of the fall, from the top of the cliff to its bottom,
that does you in.
In the name "bipolar disorder," also known as bipolar
affective disorder; "bipolar" means that the victim can swing
"up" and "down" between mania and depression;
"affective disorder" means mood disorder. Depression is now often
called unipolar mood disorder or unipolar depression, which
means the victim goes only from normal moods to depression, goes only
"down". The "bipolar" and "unipolar" designations
have the advantage of being linguistically neutral, emphasizing the fact that
the victim has a "disorder", i.e. illness, rather than that
he/she IS "manic" and/or "depressed". This is a fine
linguistic point perhaps, but an important one, especially when most people in
society don't distinguish between the words "manic" and
"maniac". In any event, remember that all these terms are only
metaphors (as are all the terms of medical science); use them when they are
useful, but don't feel bound to them in the face of a more complex reality.
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