11 - Role of Emotions in Adult Psychopathology
(EN: No chapter introduction)
Causes of Emotional Disorders
There are examples of individuals whose everyday routines involve a high level of emotion, often due to the constant presence of threats to their very survival. But even for the majority of individuals, whose daily life is rather humdrum, there are periods of intense emotion - whether a momentary event (an injury), an extended period of time (a tour of combat duty), or an entire phase of their lives (childhood with an abusive parent) that can have long-lasting effects.
Psychiatric epidemiology
The authors ask two key questions:
- How common are extreme emotional experiences in ordinary populations?
- How frequently do disorders occur, given that people react differently to similar experiences?
They then dawdle into a comparison between the epidemiology of physical diseases and disabilities and that of psychological ones, in a manner of making excuses for psychology to be so primitive, and even "modern medicine" is not very well informed. And further, given that the definition and criteria for "disorder" is so nebulous, it's difficult to draw conclusions at all.
General surveys that 13% of men and 21% of women have had "an episode of major depression" at some point in their lives. Similarly, 19% of men and 30% of women have experienced "one of the five kinds of anxiety disorder." While this suggests a female bias to mental disorders, it's also been observed that 6% of men and 1% of women have had an antisocial personality disorder whereas 35% of men and 18% of women had a disorder of alcohol or drug abuse. It's been generally observed that men have more externalizing disorders whereas women have more internalizing ones.
A broader epidemiological study involving 20,000 individuals in various cities reports entirely similar results and similar gender disparities in the total prevalence of disorders.
Life Events and Difficulties
Studies of women with anxiety/depression disorders find that in the vast majority of cases (89%), the disorder was preceded by a life event such as bereavement, marital separation, or job loss. Among a control group of women without disorders, only 30% had recently experienced such an event.
Some distinction is made in the degree of control that an individual had in effecting a life event, which concluded that people are more strongly affected by events that are perceived to be beyond their control (e.g., quitting a job is less stressful than being fired from one), such that an "uncontrollable" event is three times more likely to result in psychological trauma.
There is also correlation between the severity of an event - whether the consequences are a temporary disruption of normal routines or effect a permanent change - which indicated that the more severe the consequences, the greater the possibility to result in psychological trauma.
Finally, the duration of an event correlates to the degree of trauma, such that a brief event with a short recovery period is less detrimental than an ongoing situation for which there is no end in sight.
(EN: All of this seems pretty obvious, but it's just as well the authors document that there is evidence to support these common theories.)
There is a question of whether the same kinds of events cause anxiety and depression disorders. Surveys suggest that certain events tend to precipitate one or the other disorder based on the individual's reaction to the event - but in general, the tendency is that depression results from events that entail a loss whereas anxiety results from events that involve danger.
Special attention is given to a specific type of anxiety disorder: post-traumatic stress disorder (PTSD), as this is very common among individuals who have experienced a single traumatic shock (victim of or witness to an accident or violent crime) or have been in prolonged situations of extreme danger (combat soldiers, firefighters, police offers, and the like). Such individuals demonstrate a significant incidence of stress disorders afterward.
Depression, meanwhile, results from less dramatic and more prolonged events in which "things go severely wrong in peoples lives" and there are ongoing consequences - such as poverty or long-term unemployment.
The authors again reflect on the difference between an emotional reaction, a mood, and a disorder as being a matter of duration. It's generally observed that there is consistency in the emotional state of an individual over time - such that if the event is significant and there are no intervening events, the event that causes an anxious reaction leads to an apprehensive mood and then to an anxiety disorder, and subjects do not switch from one to the other (though both may be evident and one more prominent than the other).
Vulnerability Factors
There is widespread support for the conclusion that depression is attributable to some severe life event - yet not everyone who suffers from depression has had such and event, nor do all who suffer such an event suffer from depression. The correspondence between the two is admittedly strong, but not universal. With that in mind, the authors identify a number of factors that make certain people more vulnerable than others.
Early Childhood Experience
A person who loses a parent in childhood is more likely to develop depression in later life. It is not the shock of that traumatic event, but the lack of parental care than ensues. The same is true of individuals whose parents were neglectful or abusive, but who were present throughout.
In general, individuals who received poor care in childhood are more prone to put themselves in high-risk situations later in life, and fail to develop nurturing relationships with others in general. In particular, they also tend to become neglectful parents to their own children, which causes a generational effect that is often mistaken for genetic heredity.
It is also reckoned that individuals who were not valued by their parents develop a lack of self-esteem that makes them less likely to avoid dangerous situations.
Attribution Style
A common clinical theory ascribes anxiety and depression to cognitive dysfunction in attribution. Individuals attribute effects to the wrong causes, and either obsess over things that are insignificant or arbitrarily assigning causation.
This may result in the internalization of external events (a person somehow deserves misfortune), globalization of specific phenomena (fear of a thing outside of a given context), or a generalized fear of the unknown (when the cause of stress cannot be identified).
The author mentions a well-known study that has ben widely misinterpreted in a manner that grossly overstates the importance of attribution style, which was only one of several factors in the test and not at all the most significant. It's also noted that there have been "many other quasiexperimental studies" that have overemphasized this factor.
As a result, while there is some scientific evidence for a correlation between attribution style and psychiatric disorders, it has been overemphasized and polluted by junk science.
Self-Esteem
Depression and anxiety generally arise when an individual feels he has no control over circumstances and is disempowered to avoid or mitigate the suffering that will be inflicted upon him. This can exacerbate dysfunction even when the source of distress is correctly identified.
A study of personality and depression, which considered the tendency of people to make self-deprecatory remarks, found a high correlation to depression that occurs later in life, suggesting that it is low self-esteem that leads to depression, rather than low self-esteem being a symptom caused by depression.
Appraisal-Based Thinking
(EN: There is a single paragraph on this topic, albeit a long one, that fails to provide a clear definition of "appraisal" except as "an evaluation" of objects and actions and their outcomes - which is a tautology that provides no insight. It seems a bit redundant to self-esteem, as a person's belief that they are or have been incapable of influencing outcomes contributes to a sense of helplessness, depression, and anxiety.)
Social Support
The presence of absence of supporting relationships with others has "a huge effect" on whether people develop anxious or depressive disorders in response to adversity. One study (Parry 1986) found that the incidence of disorder is three times higher in individuals who lack the support of an intimate relationship.
The authors concede that most of the studies of depression have been conducted on women, who are known to be more social and less independent than men. While men are more resilient than women to traumatic events and seem to shut off and deal with things on their own, it is still found that men rely heavily on social connections, though in a broad sense - they benefit more from being "integrated into a community" than they do from having intimate relationships with a few others.
It's theorized that relationships with others provides a buffer against feelings of helplessness - that the positive support in the voices of others provides a counterargument against the negative inner monologue that arise in times of difficulty, enabling the individual to ignore or mitigate self-doubt because of the confidence others place in him.
Genetic Effects
In instances in which there is generational correlation in the incidence of physical conditions, there is the assumption that genetic factors play a role in making an individual more susceptible to a given disease or disability, and this notion has carried over into psychology. There are two problems in assuming a genetic effect.
The first is that the factors that constitute a person's psychology are not tangible or observable in the same way as the physical deformities or dysfunctions of anatomy. Those dysfunctions that arise from the anatomy of the brain are likely hereditary, as the correlation can be physically demonstrated by an examination of the organ or analysis of its electrochemical activity.
The second is that the factors that lead to psychological dysfunction are not often physiological, but the result of environment and interaction with others. As such, a disorder passed from parent to child may have nothing to do with genetics, but because the way in which the parent interacts with the child reflects the way the parent was raised - and were the child raised in a different environment, its development would be different.
(EN: The authors then trot out the well-known studies of twins, which show greater correlation in behavior among monozygotic [identical] twins than in dizygotic [paternal] ones, which suggests a genetic basis for certain personality traits. However, these studies are often problematic in that there are too few instances of separated identical twins [genetically identical but raised in different households] to support statistically significant conclusions. It's also been noted that twins raised in the same household are treated differently by their parents and members of their communities - and it is likely the nature of this interaction that shapes their personality rather than their genes. The greater correlation for identical twins likely reflects that people interact based on appearances - such that identical twins are treated the same whereas paternal twins are treated differently by others due to the differences in their appearance.)
Culture
Cultural factors are also considered to have a significant impact in an individual's vulnerability to emotional disorders.
For example, comparative studies of primitive tribes that live in close communities (they rarely leave the village) versus those who are more loosely knit (hunting parties are away from the village for several days at a time) demonstrate that the members of closely-knit communities have virtually no disorders of anxiety that arise from social interaction but high incidence of disorders of anxiety about isolation or separation, and it is the opposite in loose communities. It is intuitive enough that a person is most comfortable in situations to which he has become accustomed and most anxious about unusual situations.
A few studies are cited that consider cross-cultural differences. One study finds that individuals in less developed countries who show clear signs of depression consider it to be a physical rather than mental disorder. It's also noted that people in Western nations are more prone to internalizing - to feel guilt or self-reproach. In the east, the melancholy state evoked by depression is attributed to less tangible causes - it is not attitude or mood that causes fatigue, but an imbalance of energies or bodily fluids. In some South American tribes a person may be punished for suffering from depression, or the sadness of one person may be blamed on another, such as a spouse, relative, or neighbor.
These differences in culture pertain to the way in which psychological disorders are perceived and expressed as well as the way in which individuals (both the patient and others in society) respond.
(EN: The authors avoid overtly stating the obvious conclusion, likely for reasons of cultural sensitivity, that those cultures that fail to correctly identify the causes of psychological disorders likely do not deal with them as effectively as those that do - i.e., administering a physical treatment for a mental disorder is likely as ineffective as administering a psychological treatment for a physical disorder, such that those who suffer mental disorders are less likely to have a prompt recovery, and mild emotional disorders are more likely to fester.)
Life Events and Emotional Disorders
Attributing emotional disorders to life events requires correlating the two. First, we can note that an emotional breakdown is often (but not invariably) a response to a dramatic change in an individual's circumstances that impacts his day-to-da life - either intense regret for some element that has been lost (depression) or intense fear of a future loss of the same nature (anxiety), coupled with a sense of one's inability to effect a positive change (which intensifies either of the two).
Also, the difference between mood and disorder is often one of magnitude: an event that effects a slight loss or a mild concern makes a person a bit mopey or agitated for a short period of time - but an event that has a more dramatic effect results in more intense and long-lived effect.
Even then, the diagnosis of "disorder" as opposed to "bad mood" is distinguished not only by the internal emotional state, but the manner in which an individual behaves as a result. Being sullen and withdrawn are signs of a bad mood, but failure to tend to one's own survival needs or even acting in a way that causes damage to oneself or others support a diagnosis of a disorder.
(EN: And even then, there is still some subjectivity, particularly in terms of neglect. For example, a person who fails to pursue career advancement might be seen as dysfunctional even though they tend to the necessities of maintaining their present position. Or in some cultures individuals who are not fervent in their support of a given religion or political regime are regarded as defective.)
It's also noted that the connection of life events to emotional disorders focuses on extreme instances - many people suffer from the same cause or live in the same conditions, but only a few of them develop emotional disorders.
(EN: A recent study by the Department of Defense found that only about 15% of combat soldiers who were involved in one or more incidents in which there was significant combat action that resulted in death or serious injury demonstrate symptoms of PTSD at the end of their tour of duty. The study does not report the number who actually developed a dysfunction, though it stands to reason that it is likely even less.)
With this in mind, there is not a firm basis for declaring that life events, even significant ones, cause mental disorders - but are a factor like any other that causes a person to be vulnerable to developing a disorder.
What Sustains Psychiatric Disorders?
Much research, particularly in the past thirty years, has sought to identify the causes of mental disorders, but the authors have established that the correlation between a specific situation and a mental disorder is extremely weak - some individuals seem unaffected or recover quickly, while other individuals have a persistent and intensifying reaction.
With that in mind it is likely important to consider factors other than the event that initiates an emotional reaction, particularly those that cause the reaction to be sustained and intensified to the point that the reaction becomes an ongoing disorder.
Personal Plans and Interpersonal Relationships
In terms of duration, some 60% of "episodes of major depression" last less than six months, 20% between six months and a year, and 20% for a year or longer. One of the main differences between an episode of depression and chronic depression is the ability of an individual to replace what was lost, make progress on a plan to restore or renew themselves, or to change their manner of thinking that enables them to accept their situation and consider it in a positive light.
Wallowing in sorrow is also the cause of continued and deepening depression: a person who focuses on their loss, and who dwells upon the negative, loses site of the positive and loses interest in opportunities to improve their situation. It's not as simple as the advice to "cheer up" or "snap out of it" - but regaining a positive perspective or direction is critical to overcoming depression.
For some people, anxiety accompanies depression and may persist long after the depression itself has faded. Anxiety, again, is fear of recurrence, and especially when the cause of the loss has not been identified or has been misidentified, the lingering anxiety may be unfocused or misdirected - and in either case the fear of future loss dissuades people from undertaking the necessary effort to recover from past loss.
Relationships also play a significant part - the people with whom a patient has frequent contact can either serve to pick them up or drag and keep them down. Two depressed people feed off one another and in doing so feed into each other's negative perspective.
Gender does play a difference in depression. However it is noted that in normal individuals, there are not such large differences between the male and female psyche, but when depression sets in women tend to descend deeper and for a longer period of time than do men. This is likely a cultural difference in that men are expected to set their emotions aside and deal with the external world, whereas it is accepted that women will be more emotional and less assertive in changing external factors.
The gender difference between women and men, in terms of men being more individualistic and women being more collectivistic, also causes women to be more dependent on others to support them in overcoming their difficulties rather than taking the initiative to make positive changes. Coupled with the greater tolerance and encouragement of women to dwell on their emotions, this significantly hinders their potential for recovery from a depressive episode.
People who are depressed also tend to negatively affect their relationships - others who are more upbeat and cheerful tend to avoid a person who does not share their enthusiasm, such that a person who suffers depression not only fails to benefit from their influence, but may also feel shunned and stigmatized by their avoidance.
There's an oblique mention of parasitic relationships, in which one person's ego is gratified by demonstrating their ability to have a negative impact on others. Particularly in the context of a long-term relationship such as marriage, the deliberate undermining of self-esteem creates a greater vulnerability to depression as well as serving to sustain and intensify bouts of depression.
Cognitive Factors
"Several theorists" have considered cognition (memory, attention, and thought) as a critical factor in depression and anxiety disorders, which seems to address the inconsistencies that are evident: given that many people have similar backgrounds and are subjected to similar life events and only a small number of them develop psychological disorders, the difference must be to do with the way in which the individuals process the data they receive.
There is strong evidence that attribution style - the tendency to attribute failure to internal, global, or general causes - is significant in initiating and sustaining bouts of depression. One longitudinal study (Oatley 1991) suggests that the way in which an individual perceives the cause of an event is the strongest predictor of whether a subject will display symptoms of depression six to eight months later.
Another hypothesis is that depression is closely related to coping - an individual who considers the consequences of a negative turn of events as being negligible or surmountable is less likely to develop and sustain a disorder than an individual who sees the same consequences as central to their interests and beyond their ability to influence. In particular, researchers (Folkman and Lazarus 1989) have identified a "ruminative style" in which individuals think upon past events (how the event and its consequences have discomfited them) rather than future events (how they can achieve their goals accounting for the setback). Naturally, people who ruminate upon past events tend to have more negative moods for longer periods of time than those who remain focused on the future.
Another hypothesis with the authors most favor is one of cognitive biases. That is to say that individuals have characteristic patterns of thought, reflecting personality traits, that make them more or less vulnerable to a negative turn of events, and these traits are generally developed as a result of past experiences. That is, those with optimistic personalities focus on memories of past success, which makes them predisposed to regard any new obstacle as surmountable. Meanwhile, those with a pessimistic personality who tend to recall past failures and frustrations and are predisposed to regard new obstacles as insurmountable.
Oblique mention is made to events whose consequences are, in fact, insurmountable and no recovery is possible: in such instances, people who have the ability to accept and reassess, redefine what success means, are better able to cope than those who cannot let go of their previous definition and can only mourn their present situation.
Naturally, this leads to a vicious cycle for those who have experienced failure: their history leads them to expect failure in future, which saps their motivation to overcome obstacles, which discourages them from taking action, which leads to failure, which sets their perspective for the next obstacle. In general, "people do not get trapped in inescapable cycles forever," but they can persist for quite some time.
While depression stems from evaluating past events, anxiety stems from evaluating future events: a person who has experienced failure is more attuned to the potential for future failure. Studies of patients with PTSD (McNally 1990) have found that those with this disorder are highly attuned to cues for threat - the stereotype of a former soldier who dives for cover at any sudden noise in his postwar life, or of a survivor of a file who becomes inordinately anxious at the smell of something burning in a kitchen. In that sense, their cognition (the way in which sense-data is interpreted and they become poised for action) has been hardwired by their past experience.
Expressed Emotion and Psychosis
Thus far, the authors have considered depression and anxiety, but there is another class of disorders that includes psychotic conditions (such as schizophrenia) that are more closely correlated to the functional aspects of the brain (physiology and electrochemical) that can be correlated to genetics or trauma.
Incidence of such disorders is low (less than 1% of the population) and there is little differences among gender, culture, level of income, or other factors - however, the condition is better managed in wealthier and more densely populated areas (merely by access to care).
While psychosis is traced to biological causes, there is evidence that emotions affect its course and relapse rate. A 1960s study (Brown) identified a correlation between the relapse rate of patients and the "emotional tone in the family." This may also be correlated to the quality of care, but psychotic episodes also occur when the individual is constantly subjected to alienation, hostility, and other forms of negative interaction (even overbearing care) by members of their own household. A separate study (Vaughn 1976) determined that patients returned to families with "high expressed emotion" (EN: drama by any other name) were four times as likely as those with low-key family environments to suffer a relapse.
The authors note that this theory has met with a great deal of criticism because it seems to be "blaming the family" for the problems of a patient. Also, because emotional expressiveness is often a quality of a culture, the study draws accusations of bigotry. However, the a statistical evidence of correlation s strong that, while the environment may not be to blame for the condition, it certainly contributes to the frequency and severity of episodes.
One observation of children with behavioral disorders (Hibbs 1982) does give evidence of influence, in that children show increased symptoms of anxiety and general arousal when in the company of an individual with high expressed emotion than one with low expressed emotion. (EN: Bringing in outside reading, there was some research that suggested that it is the child's expectation of the behavior rather than the actual behavior of the person that is most influential - i.e. a parent who is usually highly expressive causes anxiety even when their behavior at the moment is sedate, and one who is usually low-key causes less anxiety even in moments when they are being expressive - hence anxiety stems from anticipation of behavior rather than the behavior itself when there is an established relationship.)
It's also noted that "expressed emotion" does not include the expression of any emotion, but is focused on negative ones such as anger and contempt directed toward the individual. Expressions of warmth and affection do not have the same effect.
Psychosomatic Illness
Emotions have also been correlated to the severity and duration of physical illness, a notion that was once looked upon with serious doubt, but statistical correlation has been consistent and compelling enough that it is now generally accepted that an individual's psychological state affects their vulnerability and resilience to physical conditions.
One theory maintains that vulnerability is higher individuals who suffer from inner conflict, and another suggests the suppression of emotion (a trait known as alexithymia) as a contributing factor. The mine line of research is focused on stress as a cause of susceptibility and a hindrance to recovery.
Stress and the Immune System
Much of the research into psychosomatic illness involves the immune system, which corresponds with vulnerability and resilience. The authors provide some basic information on the immune system:
- In a healthy patient, the immune system provides defense against bacteria, fungi, parasites, and viruses by combatting them before illness sets in
- In a sick patient, the same mechanisms work to overcome the cause of sickness
- "Innate immunity" describes responses that occur by virtue of the system itself - its core design at birth
- "Acquired immunity" describes responses to recurrence, based on the body's reaction to a threat it has previously experienced
- T-lymphocytes ("t" because they originate in the thymus) are considered to be the soldiers of the immune system, each specialized in reacting to a given antigen, and have a specific function (cytotoxic, killer, helper, memory, and regulatory)
- Antibodies describes another type of cell (B-lymphocyte) that detects and activates responders.
The authors list several studies that show the effects of emotions (particularly the chemicals released when emotions are experienced) and the functioning of the immune system - in both the lowered number and sluggish response of B- and T-cells.
Interaction of Brain and Immune System in Animals
A few laboratory experiments involving animals are reported:
Experiments with rates (Fleschner 1989) demonstrated that male rates introduced into hostile territories suffer a decrease in antibody production if they adopted a submissive posture to the indigenous rats than those who became aggressive. It's reckoned that submission decreases the risk of being physically wounded, hence less need for immune response.
Experiments with primates (Sapolsky 1993) likewise found that makes who are higher in the dominance hierarchy had more efficient mechanisms for dealing with infection and disease, though the stress that results from the displacement of an alpha male can be seen in all levels of the primate community.
Additional studies (Maier et. al.) across different species show evidence that stress poises the body for conflict by boosting the immune system as well as the pain management system. From a behavioral perspective, stress causes behaviors similar to fear: a decrease in appetite, a reduction of activity in general, and an increase of attentiveness and social interaction.
(EN: A few more sections follow - considering the relationship between stress and cancer and the effect of personality on illness - which seem to follow the general suspicion among laymen that stress contributes to cancer and more easygoing personalities are less susceptible to disease in general. However, but in both instances the research seems a vague and superficial and I am not satisfied the conclusions are adequately supported.)
The Nature of Stress
In common parlance, "stress" is used indiscriminately, such that it relates to any experience of heightened emotions. In psychological terms, it is specific to the emotions a person experiences, whether dramatic or subtle, when they are unable to accomplish their goals (even if the goal is merely to sustain their preferred way of life in the wake of a loss).
In a stressful situation, a subject may experience sadness at their situation, fear of what will happen, and perhaps anger at others who are seen as the cause of failure or impediments to success.
Physiologically, stress involves an increase in hormones such as adrenaline, which pertain to the fight-or-flight response, as will as pituitary release of hormones such as cortisol, which increases blood sugar as a means to fuel the body for action.
(EN: The authors do not mention this, but these hormones are also associated to heart disease, cancer, stroke, diabetes, and other conditions that are among the leading causes of death in developed economies.)
Depression, which is a byproduct of prolonged stress, is also correlated to various diseases, either directly of through suppression of the immune system.
Some attention is given to the biological value of stress, in that it better enables the body to react to immediate threats (to escape or overcome a dangerous situation, to heal wounds, etc.) but to the detriment of long-term survival, in much the same way as a machine that is overburdened for an extended period of time tends to break down more quickly.
Stress is also related to a general loss of enthusiasm: a individual who is preoccupied with dealing with immediate stresses of daily life can give little attention to defining and achieving more long-term goals. Happiness depends on having ambition and making progress toward large-scale goals - such things "give life its vigor" and their lack creates pessimism, demotivation, and a sense of hopelessness.
Stress is regarded as a cultural condition - while an individual can subject himself to stress, it is most commonly inflicted upon him by larger groups: the family, the workplace, and society in general. Considered from an epidemiological perspective, stress-related disorders are highly concentrated in geographic areas corresponding to culture, and the patterns track changes in cultures.
Self-imposed stress is, in theory (Hamilton 1964), a factor of species survival. From that perspective, it is a matter of protectionism: a parent will face danger, and even certain death, to defend their children. So, then, it makes sense for a person to sacrifice themselves for two of their siblings or four of their cousins - and in a genetically integrated group, a person who sacrifices their own survival for that of other people who carry the same genetic material to future generations is acting in the broader interests of their society and species.