Depression

The Evolution of Powerlessness

Paul Gilbert

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317189411
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychische Gesundheit in der Psychologie

Depression: The Evolution of Powerlessness offers a fresh perspective on research, theory and conceptualisations of the depressive disorders, derived from evolution theory and arguing for the adoption of the biopsychosocial model.

The book is split into three parts. Part I explores the major distinctions between all types of depression and Part II offers an overview of evolution theory and its application to depression. Part III covers the major theories of depression; theories are compared and contrasted, highlighting controversies, weaknesses and strengths, and where cross fertilisation of ideas may be beneficial. The final chapter outlines why simple theories of aetiology are inadequate and explores the role of culture and social relationships as elicitors of many forms of depression.

This Classic Edition, with a new introduction from the author, brings Paul Gilbert's early work to a new audience, and will be of interest to clinicians, researchers and historians in the field of psychology.

Part I
Types

History, diagnoses, epidemiology, and personality

Chapter 1
Introduction

Controversies old and new

Depression has been labelled the common cold of psychopathology. This comparison is unfortunate, for it conveys the impression of a frequent but mild complaint. In reality some depressions end fatally. Depression is responsible for the majority of suicide deaths; those most vulnerable to suicide are depressed and have lost hope (Minkoff, Bergman, Beck, A.T. & Beck, R., 1973; Wetzel, 1976). In many developed countries suicide is in the top ten most frequent causes of death and in younger, male cohorts, in the top three (see Chapter 3). Less easy to calculate, and only recently a subject of study, are those biological correlates of depression which appear to affect adversely immune system function (Farrant & Perez, 1989) and the capacity to combat physical disorder (e.g., via a cortisol – immune system feedback process). Moreover, depression may well reduce life expectancy in certain physical disorders, e.g., cancer (Whitlock & Siskind, 1979).

Outside these physical and life-threatening aspects, depression significantly affects family life. Depressed children suffer various social and academic developmental difficulties (Kovacs, 1989). Parents who are depressed, or who use various mechanisms to defend against a depression, can have a disturbing influence on their children’s development and subsequent vulnerability (Gelfand & Teti, 1990; Gotlib & Lee, 1990) and family relationships (Beach, Sandeen & O’Leary, 1990). For all these and other reasons, depression is not only the most frequent mental health problem, but is among the most serious.

Hence, at the biological level, at the psychological level and at the family level, depression exerts a multitude of effects. Rarely discussed in the literature is depression at a cultural level. This is the role the socio-political structures of society play on individuals’ feeling state. Recent documentaries, exploring personal experiences of living in totalitarian regimes, have illuminated how many people are often pessimistic and fearful, suffer poor sleep patterns, and are dysphoric. East Germans have told how they feel increasingly marginalised by integration with West Germany, and express openly many symptoms of depression. In a different context, the fragmentation of the Australian Aborigine culture has left in its wake a rise in depression, pessimism, suicide, and alcoholism. These cultural aspects are difficult to explore from a disease theory point of view, since many would argue that these culturally related depressed states are not ‘illnesses’. But to social psychiatrists, psychologists, sociologists, and anthropologists, they are important areas of study and our understanding of them is extremely important. Ring fencing depression in terms of disease–not disease is to court various confusions as we shall see later.

There is reason for both some optimism and caution, however. Since the turn of the century progress has been made on understanding the biological bases of depressed states, and developing new drugs and treatments. The psychological aspects are also better known than at any time previously and our understanding of the social conditions that give rise to depression has also advanced. In the biological, psychological, and sociological sciences, as we shall see, there is no shortage of competing theories with varying degrees of evidence to support them. Thus, although frequent and potentially very serious, depression is often a treatable disorder using one or a combination of interventions. Against this optimism however, we should note that during the eighties it has also become apparent that many who are depressed do not come forward for help or are unrecognised as being depressed. Even if depression is recognised many receive inadequate treatment. We have also found that chronic depression can affect up to 20% of cases, and the longer the follow up the less well cohorts do (at least 50% of patients will relapse). Furthermore, for all our progress, depression may be increasing in both the western (Klerman, 1988) and non-western worlds. Schwab (1989, p.16) claims:

Concern about sociocultural factors contributing to a “new age of melancholy” . . . is not limited to the Western world. I have been told by psychiatrists in some of the developing nations that they have observed a drastic increase in depression during the past 20 years. In their World Health Organisation (WHO) report on the collaborative study of the assessment of the depressive disorders, Sartorius and his colleagues, [Sartorius et al., 1983] maintain that there are probably 100 million depressives in the world and that the number may be increasing because of deleterious sociocultural effects, demographic changes, psychological factors, the increased number of patients with chronic medical disorders, and the widespread use of medications that have depressive side effects.

While I have great respect for my biological colleagues it is quite untenable to believe that in the majority of these cases we are dealing with a disease and can now drug our way out of trouble. To advance our knowledge further, new ways must be found to develop multidisciplinary and biopsychosocial theories. If not we will end up with an ever-increasing number of theories, useless conflicts over whether depression is a disease or not, polarisation into brainless or mindless positions (Eisenberg, 1986) and to regard individuals as socially decontextualised entities, victims to negative thoughts and/or brain amines. In such a world, debate tends to centre on trivia and not on major points of agreement or disagreement. More serious, prevention becomes a fragmented endeavour with different groups peddling different ideas, many of which fail to deal with our life styles as the problem for many. The importance of understanding the causes of depression as a multilevel phenomenon (genetic threshold, early family life, psychological styles and social context) can hardly be overstated.

In this book we tackle this problem from a biopsychosocial perspective. An endeavour is made to indicate how social and psychological processes influence biological processes by virtue of the evolutionary path we have journeyed. We also give due regard to the possibility that a small percentage of depressives may carry genetic vulnerability. It is hoped this will help counteract the growing fragmentation of approaches and models which are often based on faulty conceptions of mind-body distinctions and naive ideas about the evolution of mental mechanisms.

Outline

Our journey is split into three parts. Part 1 contains four chapters that explore the types of depression. Chapter 1 explores how some of our current controversies are products of ages past, and a brief overview is given to historical and philosophical aspects. This is followed in Chapter 2 by a more detailed look at the issues of classification and types of depression. Chapter 3 explores what we know about epidemiology and long term outcome of depression. Chapter 4 engages the thorny problem of the role of personality in depression.

Part 2 contains chapters that explore the evolved mechanisms of depression, or the evolved basic plan(s) for depression. Chapter 5 outlines current theory on the evolution of mental mechanisms. Chapter 6 explores the central theme of this book that depression evolved from a) ranking behaviour (social dominance-subordination) and is associated with innate algorithms for social comparison (inferior-superior) and what we call involuntary, subordinate, self-perception; and b) ingroup-outgroup behaviour which is also associated with innate algorithms for social comparison but of a same-different form. Hence, depression is viewed as a problem of loss/lack of social power and control. Chapter 7 explores how our need for rank, on the one hand, and sense of being like others, on the other, have evolved into a need for self-esteem, to have a sense of positive value to ourselves and others (called living in the minds of others) and hence our concern with our self-presentation and sense of belonging. Chapter 8 explores the experiences of depression under the concept of ‘dread’ and examines how the experiences of shame, anger and envy are related to a ranking (social dominance) theory of depression. How these are involved in self-organisation is discussed.

Part 3 explores current psychological and social theories of depression. Chapter 9 examines the work of Freud and object relations theory. Chapter 10 follows the view of depression as a thwarting of (innate) human needs and explores the work of Bowlby and Kohut. Chapter 11 takes us back to the idea of underlying social algorithms and biosocial goals (Gilbert, 1989) from the point of view of archetype theory and mentality theory. Here we consider various themes in depressive thinking (of the empty self, the outsider and the subordinate). Chapter 12 explores aspiration and incentive structure in depression and the role of hopelessness. Chapter 13 explores cognitive therapy and some of the recent developments and controversies of this approach. Chapter 14 explores various behavioural theories. Chapter 15 attempts to bring us back in a kind of circle with discussion of the interpersonal theories, the role of life events, social support, and family structure, raising again the issues of power and social dominance, social control and belonging. In the last chapter I summarise the main themes and issues discussed, explore the complexities for studying multilevel interactions and also the role of patterns of self-organisation. That is the outline; let’s begin the journey.

Historical and philosophical influences

Person or disease

Early reports of depression can be found in numerous biblical characters. King Solomon is believed to have suffered from an evil spirit and dark moods from which he eventually killed himself. The book of Job is regarded as the work of a depressive. More recent historical sufferers include various composers (e.g., Gustave Mahler, Tchaikovsky, Sibelius) politicians (e.g., Abraham Lincoln and Winston Churchill) and numerous writers, artists and poets (e.g., Edgar Allen Poe and Thomas Mann).

It is worth reminding ourselves that, unlike many illnesses today, depression has been recognised and described in one form or another for over two millennia. Jackson (1986) gives a marvellous overview of the history of thought on depression. The Greeks, especially Hippocrates, Galen and many others, not only outlined the essential characteristics of depression but also had consistent and well described theories for it. The depressed person was described as gloomy and pessimistic, anxious and prone to hide away or take flight, sleepless and also peevish, irritable and prone to outbursts. For the most part the Hippocratic theory was a psychobiological theory. They worked with the idea that there were four basic temperaments related to four bodily substances, the humours: yellow bile, black bile, phlegm, and blood. Melancholia was believed to be the result of excess black bile. This linkage of mood state to some underlying biological disturbance has been with us ever since.

The second aspect of Greek theory was the idea that certain personalities are more prone to depression than others. Thus, the Greeks believed that a preponderance of the different body humours gave rise to different personality types. Melancholia was noted in people of melancholic (black bile) temperament. This view also is still with us although we have exchanged black bile for the concept of neuroticism.

Third, the Greeks believed that various events including the seasons, diets and life events, which could disturb the black bile, could result in depression. The implications for treatment were in terms of rest and diet, and Hippocrates especially argued for a generally supportive and kindly orientation to the depressed person. Here, the approach was very much the study of the individual, inspired by concern with treatment and care of patients. And that depression was a quantitative variation from normal. The Hippocratic approach was, then, person-centred. It is odd that the biopsychosocial model should have such a promising, early beginning and yet such a disappointing history. Even today this approach still struggles for recognition and we still have what Eisenberg (1986) has called brainlessness and mindlessness science.

Hippocrates was a physician and was concerned to explain various forms of madness as emanating in bodily processes. However, this view was not uncontested and Plato believed in two types of madness: one the result of bodily processes and one due to outside forces, mostly from the Gods. Hence Plato believed that epilepsy was a gift from the Gods that brought with it the power of revelation. Hippocrates was very opposed to this idea (Zilboorg & Henry, 1941). But in a number of other cultures, madness and depression, particularly, have often been viewed as the result of disturbance of the soul rather than the body. For example, that the soul had been afflicted by evil forces or even stolen in some way. Even Jesus is reported to have cured a case of mental illness by the casting out of devils. You may think that today we no longer adhere to these theories but this is not so. Recently, I had a bipolar patient who had fallen in with a religious group who had tried to exorcise her devils. Needless to say, this caused some problems with reattribution training. But importantly, this conceptualisation of depression led to various ideas that depression was somehow to do with immoral living and a sign of weakness. Such an orientation, dominated by religious thought, has echoed through the centuries (Zilboorg & Henry, 1941; Jackson, 1986).

Plato left his mark in other ways. The Platonic approach to illness, arose from a particular philosophical orientation, “the doctrine of universals” (Kendell, 1975). Plato was not a physician like Hippocrates and therefore did not personally attempt to heal anyone or to be in close contact with suffering. The Platonic approach suggested that illness was a qualitative variation from normal, and concern was very much on the illness or disease itself and less on the individual. Disease was a different thing, that had somehow entered or grown in the body; it was alien and abnormal. Hence, the Platonic approach was a disease-centred approach. As Kendell (1975) makes clear, considerable controversy has embellished these (Hippocratic-quantitative versus the Platonic-qualitative) positions. Indeed, the study of diseases in psychiatry is still an area of heated debate (Akiskal & McKinney, 1973a,b; Kräupl Taylor, 1980; Scadding, 1980).

Mind and/or body

As complex and problematic as the qualitative (disease) versus quantitative (person) debate is, it is not the only philosophical stumbling block in psychiatry. When Descartes formalised the distinction between mind and body (in part to get around the problems of the soul in the brain), it was in the very nature of psychiatry that this was to become a second major arena for debate. In spite of major efforts (Hill, 1981; Popper & Eccles, 1977), dualism remains a controversy in its own right and continues to plague psychiatric discussion. Indeed, it is only by maintaining a very strict dualistic approach that Szasz (1974, pp.12–13) can argue: “The notion of mental illness derives its main support from such phenomena as syphilis of the brain or delirious conditions – intoxications, for instance – in which persons may manifest certain disorders of thinking and behaviour. Correctly speaking these are diseases of the brain, not the mind”.

Dualism lies at the heart of the neurotic-psychotic controversy (Hill, 1968). Moreover, as Engle (1977) suggests, to dissociate mind from body provides the rationale for a mechanistic approach to suffering. The mechanistic approach fits neatly with Platonic disease entities. It must be said though, that the Platonic approach, in spite of its questionable corrupting influence on the sensitivities of the physician, has proved enormously useful, especially for the infectious diseases. Indeed, as Kendell (1975) makes clear, by the turn of this century, so successful was this approach in revealing the secrets of many disorders which had plagued humans for centuries, that psychiatry could hardly resist similar endeavours with a similar philosophy. Hence, by the turn of the century a new age in psychiatry was born out of Platonic successes in physical medicine. Yet psychiatry was to enter this era with the two outstanding controversies (qualitative versus quantitative and mind-body) far from resolved. The mind-body problem stirs up a lot of (often) unprofitable debate and in the extreme leads back again to mindless or brainless theory (Eisenberg, 1986).

These difficulties have been long recognised. Psychiatry has tended to regard mental life as capable of considerable, usually arbitrary, dissection. As Zilboorg and Henry (1941, p.496) point out, psychiatry’s view of depression was no exce...