Inside the Most Common Type of Depression

I practiced psychiatry during the period in which the paradigm of the mind shifted from the perspective of how it is experienced from the inside (i.e.: phenomenology, mainly psychoanalytic theory) to the examination of how it works from the outside, i.e.: neurochemistry, genetics, and cognitions. The impact of Prozac on this shift cannot be exaggerated. As the picture of a large green Prozac pill appeared on the cover of Time magazine, patients who had been pouring their hearts out on analyst’s couches for decades, took Prozac and would come into my office raving, “This is how I have always wanted to feel!”

In retrospect this dramatic early success was due to a years-long mass-psychology placebo effect, however, over the succeeding decades, I finally concluded that these antidepressant medications simply decrease people’s emotional reactivity to their lives: “My children were driving me crazy and my boss is a yeller. Since taking Prozac, it all just doesn’t get to me as much.” A New York City friend called me one night from Madison Square Garden during a Knicks game upset that Prozac had turned him into an “out-of-towner”: no hysterics at the slam dunks. I eventually concluded that all physical treatments in psychiatry fundamentally down-regulate pathological emotional hyperactivity.

I therefore deduced that, from an experiential point of view (the bottom line in psychiatry), the pain of depression emanated from the pathological intensity of a specific functional anxiety the normal regulation of which had failed, causing it to spin out into a sustained state of excruciating intensity. I decided from this subjective perspective that the “depressed” symptoms of emotional paralysis, in different cases, can either be the result of the patient freezing from the fear, or a protective shut-down reaction; but in either case the underlying active pathology is sustained, intense anxiety of a specific type that has escaped its normal regulation. My project has been to characterize the two principal types of depression based on determining what normally functioning anxieties from an evolutionary point of view, are thrown into pathological hyperactivity. For many years, I have pursued the “internal” subjective (phenomenological) study of severe mental illnesses within the zeitgeist of Darwinian evolution, all guided by, and consistent with, the emerging “external” science in both fields.

The concept of atypical depression arose in the post-war period and was admitted into the psychiatric diagnostic manual in 1994 based on the fact that it responded preferentially to one of the early antidepressants which is rarely used any more. From the beginning, atypical depression has been characterized as occurring in those with “a long-standing pattern of interpersonal rejection sensitivity.” More recently, atypical depression has been associated with a variety of brain parameters, and elements of it have been found in all categories of depression (recent review article).

For decades, I made the diagnosis of atypical depression when I determined (after examining the pathological emotions in the context of the patient’s present circumstances and past history) that it was predominantly separation anxiety that had escalated into a self-sustained state of hyperactivity. Commonly, after a romantic breakup, the patient is obsessively immersed in images of idealized experiences with the lost partner. As the sufferer enters into and out of these vivid memory states of reunion, anxiety is momentarily relieved, but then immediately doubly re-exacerbated by being dragged back into the painful reality of the separated status. The obsessive remembering is like an extremely addictive, short-acting drug that painfully whips the patient back and forth. In this process, separation anxiety is placed into a tight little closed-loop feedback circuit that pathologically intensifies it, which I eventually concluded was the core of the illness. Separation anxiety is transformed into atypical depression by entering into a “reverberating” circuit that pathologically intensifies this anxiety. This was a top-down diagnosis partially based on empathy. Although this diagnosis rarely pertained to the choice of drug treatment, empathy in a doctor is always therapeutic, particularly when what is empathized with is causing the suffering.

I reasoned, that, if a single emotion can intensify sufficiently to paralyze normal function, it would follow that its normal function would be 1) vital, and 2) that it had been one of the building blocks of human nature since its inception. Separation anxiety normally functions to provide a powerful aversion to breaking a personal bond. Our personal awareness of the central role of separation anxiety in our own lives lends credence to the proposition that this emotion-and-motivation originally played a central role the evolution of group formation in primates. Separation anxiety provided an aversively motivated cohesive counter to the anti-social fight and flight responses. It is widely accepted that separation anxiety initially arose to enhance the survival of dependent mammalian infants and then evolved to persist (not shut off genetically) in adults, thus serving as one of the “proximate” (motivational) causes of primate group formation, which has been determined to have occurred 52 million years ago.

Some have suggested that “prosocial” transactions such as grooming hold together primate hierarchies. However, the atavistic (and anti-social) hunger for aggression could not be held in check by pleasures of a more tepid variety, but only by significant levels of painful fear inflicted constantly. Social fears produce sustained gradients of collective anxiety called moods which constitute the emotional atmosphere of a group. A centripetal force is exerted within a given group by the totality of aversion to separation between every possible relationship. The emotional center of the group is the point at which the anxiety of the atmosphere is the lowest and the mood the highest.  But how is the center determined?

Driven by these cohesive aversions, bonds of varying strengths hold together a given group like little rubber bands between all permutations of relationships. All possible political triangles of two-against-one self-organize into a “soft” hierarchy based on who has more/stronger bonds. The incentive to follow the leaders of this “democratic” hierarchy would be the “lightness” of mood that surrounds them. Followers are willingly pulled by these “cool” leaders (Obama), and not pushed as with “hot” dominance leaders  (Trump) to be discussed in the next post.

Evidence

I posted here about a longitudinal study comparing packs of wolves and dogs raised in an identical manner. It showed that dogs have far more rigid Trump-like hierarchies than wolves: a submissive dog would not dare eat a dominant dog’s food, whereas wolves (reluctantly) do share food. The conclusion is that dogs have been bred to be submissive, and not to be cooperative. However, in non-kin feral dog packs, Hare and Woods explain in their popular The Genius of Dogs (2013), “there is no dominant pair that leads the group. Instead, the leader of a feral pack is the dog who has the most friends. When the pack decides where to go, they do not follow the most dominant dog; instead, they follow the dog with the strongest social network” (based on a study by Bonanni, 2010).

I posted here about a groundbreaking study by Strandburg-Peshkin et al. (2015), GPS devices were placed on baboons and their second-by-second movements relative to one another were plotted. Although baboons are famous for their elaborate hierarchies, they found that dominance plays no role whatever in determining which individuals are “democratically elected” to lead them where to go next. So this system of de facto, Obama-style leadership-where-it-counts coexists beneath all the chest-thumping Trump-style dominance hierarchy, which, from the standpoint of getting anything accomplished as a group, is utterly worthless.

I posted here about the important work done by anthropologist Christopher Boehm. There is no argument that the agricultural revolution starting about 12,000 years ago was the stimulus for dominance hierarchy to make to make a big comeback which continues. But when looking  for human nature with a minimum of cultural artifact, anthropologists have examined hunter-gatherer societies that have not been contaminated by agricultural practices. Christopher Boehm has been a pioneer in emphasizing among such people their “deliberate use of social sanctioning to enforce political equality among fully adult males” (Hierarchy in the Forest: The Evolution of Egalitarian Behavior, 1999), including ridicule, shunning, and even killing those with persistently selfish political behavior, giving detailed examples from tribes on every continent. In his latest book (2012), he reveals that his own hypothesis for this rough egalitarian behavior is that the equitable distribution of meat was a recent adaptation—beginning about 250,000 years ago—to foster and maintain the intense cooperation required for big-game hunting, similar to the probable reason for high levels of meat sharing seen in other carnivores such as wolves and lions. This is a plausible explanation, but I have concluded that that the ability to coordinate divided labor is the fundamental human adaptation that has defined our entire 6-million-year hominin tribe.

The leaders of northwestern American Indian hunter tribes like the Sioux–the great chief Red Cloud for example–certainly arose by consent based on demonstrated ability, and not by intimidation.

Tags: atypical depression, Democracy, hierarchy, noemail, Obama, Trump