A Gene For Depression?

 

http://www.nature.com/news/first-robust-genetic-links-to-depression-emerge-1.17979

 

Jonathan Flint MD http://grandchallenges.ucla.edu/depression/team/ presented his work today in which he gave a compelling talk demonstrating that he has found possible two genetic links to depression. He is a recent UCLA hire in which he joins the UCLA Grand Depression Challenge in which there is a multidisciplinary team working on understanding depression. He began with the familiar statistic that women are twice as likely to get depressed as men, and within that, women have a 20 percent chance of having a depression during their lifetime. He did not quite define depression but in the Q and A, he said that he was using the PHQ-9 which are nine questions to determine the diagnosis, which, of course, makes me suspect. Then he said it causes tremendous disability throughout the world and as such costs the world a lot of money in terms of lost labor. So, he summarizes that depression is common, causes disability and is costly and yet research on depression is minimally funded compared to diseases such as cancer or heart disease. He proceeds to show a negative  study by  his colleague Ken Kendler which did not demonstrate a gene for depression and so from that he concluded that depression is a heterogeneous disease. Well, that cannot be new information, I think to myself. He went to China where he studied only women, who apparently do not smoke or drink, and through looking at their DNA in their saliva, he could demonstrate that the women with depression had a different genetic makeup than did the controls. At this point I was beginning to be interested. The gene, he continues, impacts the mitochondrial DNA, which is the engine of the cell. He was a wonderful speaker and he did fascinating work, all as a result of new technology that makes sequencing DNA cheap and easy. Like the internet, UCLA could lead the world in this work. I am proud to be a Bruin today!

 

 

Andreas Lubitz

27 years old. Premeditated murder/suicide. 149 innocent victims. h/o depression with suicidal ideation. What of it? How do we make sense of these facts? As a psychiatrist, what are my thoughts on the matter? For a week I have thought about my perspective, wondering how I reconstruct this story which has no answers and only questions. As this is also the eve of holidays in which many family and friends get together, Mr. Lubitz might make it into dinner table conversations. For the families of the victims, there are simply no words. For the world, there is fascination and quick answers, hoping that the next plane we step on, or the plane our loved ones step on, does not suffer this tragic fate. My first point is that I want to rid the world of the shock value of these tragedies. Like school shootings, or suicide bombers in the middle east, there is a  small group of people, who will take harmless victims with them to the next world. This will always happen, and there is no way for psychiatrists, or anyone else to fully prevent these tragedies. For a variety of reasons the perpetrator of these crimes believes that this murder-suicide is justified, and as the human brain can convince oneself of almost anything, once the brain is convinced, the behavior follows and terrible consequences ensue. To be shocked by this behavior is to be naive to human nature. Most humans want to help others, but a minority of humans do terrible destruction. This is our landscape. To pretend that is not true, is denial. The shock of Andreas Lubitz behavior is evidence of this denial. My second point is more difficult to articulate. Mr. Lubitz has a history of depression with suicidal ideation and he sought medical care immediately prior to this event. Does this mean he was mentally ill? Probably, but we will never know, unless the physicians who evaluated him can disclose their findings. Assuming he was depressed and a danger to others, then he should not have been allowed on that plane. However, it is rarely that clear. He may have been vague in his description of his mental state, and he may not have mentioned that in his suicidal ideation he was contemplating taking down innocent people. A psychiatric assessment includes asking about homicidal ideation, but his answer could range from “sometimes I hate people” to “I can understand the man who did Sandy Hook.” The privacy laws in Germany are not clear to me, and so I can only imagine if Mr. Lubitz walked into my office in California. If he specifically stated that he was going to take the plane down, then I would call Lufthansa immediately. However, the likelihood is that he hinted at his plan without being explicit, leaving, I imagine,  the five doctors he saw prior to the plane crash in terrible despair, desperately trying to remember exactly what he said. Unfortunately, the relationship of mental illness to violence is not clear. Our most clear understanding of behavior comes from the past and from family  history. The adage that past behavior predicts future behavior holds true. I do not know what is in Mr. Lubitz’s past, but I suspect he had no violent history, making this event even more difficult to predict. My final point is that as awful as this tragedy is, we need to acknowledge that we are terribly inadequate at predicting these events, and hence having two people in the cockpit at all times is a good intervention. Trusting passengers to one pilot will ensure that this tragedy will repeat.

Depression As Conflict

“Whatever diagnostic label one chooses in classifying mentally ill patients in whom depressive affect is prominent, the important thing is to understand clearly the nature and origins of ech patient’s compromise formation and underlying conflicts.” Charles Brenner MD

Depression should not be a diagnosis, but a point of inquiry into the nature of the patient’s mental interior. This statement does not relate to the issue as to whether the patient should be put on psychotropic medications. That is a different, unrelated, matter. We, as mental health providers, should not label patients as “depressed,” and nor should we encourage patients to label themselves in that fashion. Rather, we should encourage a curiosity as to what is stopping the patient from having more joy and/or satisfaction in one’s life. Freud defined mental health as the ability to love and work, and as such, issues inhibiting loving relationships and work satisfactions need to be explored, but not labeled. This has been my thesis for my previous posts and this will continue as I teach my class on mood disorders. It is radical, my students tell me, for a psychiatrist, such as myself, to want to ban depression from the DSM 5. This is the most common reason patients come to see us, but that does not mean that one size fits all. Like a headache, depression, is a symptom of an underlying problem, and like a headache, most of the time we are mystified as to what causes it, and most of the time, like a headache, it eventually goes away. I do not advocate the waiting and seeing approach to depression, but I am aware that no intervention, will, often, lead to improvement. At the same time, psychotherapeutic intervention, the journey of understanding, will also help with a depressed mood, and will likely prevent, or shorten depressed moods in the future.

Allison, from the show ‘The Affair’ comes to mind. She lost a child, we are told, not immediately but over time. She has an intensely emotional reaction when she sees a child customer in her restaurant almost choke. She runs to the bathrooms in tears. She has a complicated relationship with her husband and she has a wandering eye for other men. Sure, she is not my patient, but as a character in a drama she illustrates that for her, her low mood results in, what appears to others, as rapid mood swings, and abusive relationships. In drilling down, which the show does slowly, one becomes more understanding of why Allison makes the choices she does. Her obviously low mood is persistent, but she continues to function in her job as a waitress. She manifests her despair by trying desperately to reach out to others who might distract her from her pain. Allison appears depressed, which she may be, but she is also grieving and struggling to find inner peace. Then again, aren’t we all?

Depression As Maturation

 

“To our surprise, a person may come out of a depression, stronger, wiser and more stable than before he or she went into it.” D. W. Winnicott

Depression and guilt are close relatives, meaning that the experience of depression is the experience of feeling bad or guilty about one’s past, present or imagined future behavior. Guilt is the engine for maturation in that evaluating one’s behavior requires a certain amount of maturity, and so with this observing ego, harsh as it may be initially, comes the ability to eventually forgive and love yourself.

 

Amir, forty-one, comes to mind. He is an attorney, hard-working, financially successful, but, by his account a “terrible husband and father.” He presents as despondent, withdrawn and, at times, very angry with himself. With exploration, Amir recognizes his selfish behavior at home, resulting in his wife feeling lonely and seeking deeper satisfaction with her girlfriends than with him. At first, he pleads for relief from his self-diagnosed “depression,” but as time marches on, he develops the patience to reflect that as he begins to forgive himself, he can then ask forgiveness from his wife of fifteen years, and they can move forward with a deeper relationship. Amir’s guilt was the portal to understanding how he sees himself, an endlessly fascinating exploration of self-definition, which, with maturity, comes the reflection on the good, the bad and the ugly. Does this mean that Amir should not go on medication in order to explore the meaning of his symptoms? No. To the contrary, medication can help Amir come to a place that enables him to develop the satellite perspective of his perceived failings. antidepressants is a misnomer. Our medications do not fight depression. They can lift the despair, allowing the patient to “fight” the depression, and thereby grow up.

 

 

Depression or Misery?

“Depression as a feature of mental illness is the misery of childhood translated into the present….” Charles Brenner MD

 

As we enter into the Thanksgiving holiday and remind ourselves of what we are grateful for, I am also reminded that relieving human suffering is the goal of my work as a clinician, and my work as a teacher. As such, understanding suffering is critical to a meaningful intervention. Children who suffer in childhood are likely to suffer as adults because those are the limited tools they are given to cope with a challenging and uncertain world. This understanding has multiple layers. One obvious layer is that we, as a society, need to do what we can to make sure that childhoods are supported by a rich infrastructure of nuturance, through schools, community clubs and religious organizations. Second, those who did suffer greatly as children, who grow to adulthood, need intensive intervention and understanding to create a new, more optimistic schema of their world. Third, mental health practitioners need to understand the connection from past to present in order to help the depressed adult. One cannot just look at the here and now, without thinking about what this current suffering hearkens back to.

Robyn, fifty-five, male, comes to mind. He dreads the Thanksgiving Holiday and so this time of year he retreats into his apartment and does not go out much, except for work. “What was Thanksgiving like as a kid?” I ask, trying to tie past with present. “Oh, I hated it. My family would get together and they would be mean to each other. My mother would tell my father that he was lazy and did not do any of the work. My brother and sister would fight, leading my brother to make holes in the wall, as that is how he discharged his anger. My mother would then praise my brother for hitting the wall and not a person. The more I think about those days, the more sad I am about the family I grew up in,” Robyn says, with deep feelings which make me feel both sad and interested in his past. “Do you think those memories have carried forward such that you are re-living them every year around this time?” I ask, wondering if he sees the connection between past and present. “Actually, I did not think about that, but as you say it, it sounds so obvious,” Robyn says with obvious excitement over this understanding. “Maybe you can layer over those memories by creating happy times for yourself around the holidays. Maybe you need to make an extra effort to do that, as a way of pushing down further the memories of your Thanksgiving table.” I say, not encouraging repression of memories, but layering over them, consciously, with times which create very different associations to the holiday. “Maybe you need to ask your friends for an invitation, so you won’t be alone?” I say, encouraging him to reach out to those who care about him. “Yes, of course that is what I should do, but I need to think about it, as I am afraid I will be a downer.” “Maybe if you are around people you care about, your mood will lift and people will enjoy your company,” I say, pushing him to interact over this sensitive time of year. “Maybe,” Robyn says, with extreme hesitation.

Explaining Psychotherapy

‘

 

Stephen Mitchell, http://en.wikipedia.org/wiki/Stephen_A._Mitchell_(psychologist), says that “clinical psychoanalysis is fundamentally about people and their difficulties in living, about a relationship that is committed to deeper self-understanding, a richer sense of personal meeting, and a greater degree of freedom.”

There is no mention of diagnoses, or psychopathology, but rather his emphasis is on the universal need to grow and develop as a human being. To leave one’s idiom, as Christopher Bollas says, http://en.wikipedia.org/wiki/Christopher_Bollas.

“In Being a Character, Bollas also argued that everybody had their own idiom for life—a blend between the psychic organisation which from birth forms the self’s core, and the implied logic of the familial way of relating into which we are then raised.^[8)

As adults, Bollas considered we spend our time looking for objects of interest—human or material—which can serve to enhance our particular idioms or styles of life—perpetually “meeting idiom needs by securing evocatively nourishing objects”.^[9] Being willing to risk exposure to such transformational objects was for Bollas an essential part of a healthy life: the readiness to be metamorphosed by one’s interaction with the object world.^[10]

The contrast was a refusal of development and self-invention, of open-endedness: the state of psychic stagnation. Bollas saw in what he called the anti-narcissist a willed refusal to use objects for the development of his/her own idiom, and a consequent foreclosure of the true self.^[11] The result can lead to what Adam Phillips called “the core catastrophe in many of Bollas’s powerful clinical vignettes…being trapped in someone else’s (usually the parents’) dream or view of the world”.^[12]

Bollas was however well aware of the converse danger of expecting too much from the role of the transformational object, especially as found within the transference.^[13]“

Miley, once again, comes to mind, as the anti-narcissist described above. She does not seek out new relationships, resulting, as Dr. Bollas says, in a “foreclosure of the true self.” Miley’s “depression” as some might call it, is more deeply thought about in terms of inhibitions in the ego, resulting from deep fear of guilt, which in turn, cause loneliness and despair. It is not that medication cannot help Miley, because antidepressants do give her relief from her tense emotional state, but they do not give her permission to pull back from taking care of her parents, and allow herself personal growth through new, meaningful relationships. The guilt that Miley feels serves to inhibit her from pushing out from underneath her unconscious constriction. Miley, by her report, has difficulties in living, which through our relationship which is committed to looking at the underlying dynamics of her suffering, she and I can come to an understanding of her inhibitions and thereby allow herself to  make more choices, and thereby give her a greater sense of personal freedom. Freud said that the libido was working so hard in repressing unconscious thoughts, in Miley’s case of her  unconscious guilt for not devoting her life to her parents, that there was no room, no broadband, left for her  libido to exert its power towards feeling desire and love. Psychotherapy, Freud would say, involves working at lifting the repression, so that the libido is free to  expand outwards. Miley’s issue with “psychic stagnation” seems a much more fitting description than “Major Depression”.

The Impoverished Ego

 

Miley, the subject of my previous posts, struggles with feeling “empty” inside. She feels she has little to offer others, and in turn, withdraws from relationships with her peers, which in turn, causes her great despair and loneliness. Miley does not experience sadness, as much as she feels she is “missing” something, but not sure what that something would be. “Perhaps you are missing a good sense of yourself, a sense that you can meet your goals, that you can care for others, without resentment, that you can develop aspects of yourself, that to date, have not been tapped.” I say, understanding Miley’s sense of “empty,” which I translate in my head to mean impoverishment.

Miley, by her account, never felt good about herself. This latest chapter of taking care of her elderly parents, comes after many previous chapters in which she was a loner and was too fearful to try new activities. Socialization, the few attempts she made to meet new people, landed her in deeper despair. When she stayed home alone she could deny her loneliness and feel “empty,” but when she tried to join groups, and she saw how others had long-term relationships, her loneliness sky-rocketed, causing her to retreat into her private psychic space of “emptiness”. The “emptiness” as we examined, although painful, was far superior to loneliness, which Miley experienced as “excruciating”.

Miley’s insight into this aspect of her loneliness supports the clinical notion that as bad as certain feelings may be, usually they are covering up worse feelings. We, psychoanalysts, call this a defense. Feeling empty, in Miley’s case, defends her from feeling lonely, and hence the “emptiness” is held  tightly. For Miley to have personal growth, she needs to be able to tolerate loneliness so that she can then propel herself to explore new relationships. Our hope is that through the safety and security of our relationship, Miley can tolerate feelings which up until now, have felt soul-crushing and scary. The psychotherapeutic relationship provides access to difficult feelings because these feelings are experienced in the context of love and support. Miley, can, theoretically, move from feeling empty to feeling lonely to feeling connected, and in so doing, enjoy her last chapter in a way which pivots significantly from her previous chapters.

Depression = Unloveable

As Richard III said…

And therefore, since I cannot prove a lover….

I am determined to prove a villain.

 

Karl Abraham..http://en.wikipedia.org/wiki/Karl_Abraham…describes depression as feeling unloveable, resulting in rage and violent impulses, followed by repression of these violent impulses, but developing a huge sense of guilt for violent or sadistic feelings. This persistent guilt causes the depression, which in turn, confirms to the patient that he is indeed unloveable. At the same time, the preoccupation with negative thinking, with his own thinking, leads to a certain narcissistic pleasure which is hidden from consciousness.This form of narcissism leads to further isolation which leads to a further confirmation of his unloveable feeling. The withdrawal from the world, Abraham would say, is “symbolic dying”. In this “symbolic dying” the patient does not attempt at finding love and feels more and more like the world is punitive and worthy of avoidance, in addition to feeling that he tarnishes the world,such that  both thoughts combined lead to a futher “symbolic dying” process. This, in more common terms, is the downward spiral of depression.

 

Miley, who I spoke about previously, serves to illustrate this pathway. She states that her life is hijacked by her aging parents, but upon further exploration, before her parents took ill, she also led an impoverished existence. She has never dated seriously and she has few friends. She feels lonely, but she adamantly refuses to try new activities with the intent of making new relationships. She has very painful hostile feelings towards her parents, resulting in terrible guilt and further feelings of unworthiness. All of her negative feeling states cause significant withdrawal and isolation, while at the same time, she takes pleasure in feeling that she has “the worst life”. The word “worst” gives us a clue that within her suffering, is a feeling of being special, if for nothing else, but for the extent of her pain.

 

Miley’s silent rage surfaces with poor service at restaurants, at which point, by her own account, she is verbally abusive to the waiter, followed by horrible guilt, leading to more and more isolation. Miley understands that her rage is out of proportion to the situation, but she does not connect her rage to her feelings about taking care of her parents. This possible psychic connection is one focus of our work. Through her psychotherapy, Miley can see the connections between her feeling state and her isolation, such that if she could learn to tolerate her violent or sadistic thinking, she could then come to understand where those thoughts/feelings  come from, rather than jump to a guilty/lonely place.

 

Mourning and Melancholia

 

DSM 5 eliminated grief as an exclusionary criteria for Major Depression, http://www.huffingtonpost.com/kenneth-j-doka/grief-and-the-dsm_b_3340216.html, meaning that someone in mourning could be diagnosed with Major Depression. The question arising is when is a person “allowed” to grieve, and when must they be carted off to a psychiatrist? There is no good answer, except to say that grief is poorly understood, as is Depression. What we do understand is that both grief and depression are journeys, which should change, perhaps “improve” with time. Like some forms of music, it should go from a dark place to a lighter place, and then maybe back to a dark place again. The “persistent negative feeling state” which I spoke about in my last post, is the issue that should prompt treatment; persistent being the key word.

Mourning and melancholia, Freud says, share the issue of loss. In melancholia, the loss is often, the loss of one’s ideal in life, a job promotion, or a stellar child, whereas in mourning, the loss is of a loved one. Melancholia, Freud continued, often presents with self-hatred, whereas in
mourning there is more sadness. Of course, we know this not to be true. Many people when faced with the death of a loved one launch into a massive amount of guilt for all of the things they should have done. This guilt is clearly self-hatred, and as such, prolongs the mourning process.

Maeve, forty-one, comes to mind. She is a lawyer, happily married, no children, who just received word that her beloved aunt was diagnosed with pancreatic cancer. Maeve’s mood takes a free fall such that Maeve cannot function at work and her husband is very worried about her. When Maeve comes to see me, she is focused on her own mortality, and not her aunt’s grave prognosis. Maeve, as if, she had never thought of it before, realized the finite aspect of life, and as such, she was paralyzed with fear that she could not do her “bucket list”. Maeve straddled the line between Mourning and Melancholia. She was indeed anticipating the loss of her aunt, but at the same time, she anticipated the loss of her self, and these negative anticipations caused a complete shut down of her functioning.” Loss, the finality of it, can be so frightening that one wants to take control and end life, so as not to be out of control when death starts knocking,” I say, postulating that Maeve’s “depression” stems from her fear of losing control. Loss, like depression, is a vague word. It can refer to actual or imagined loss, and often both. In turn, the loss creates a hole, in our ego, Freud would say, leaving us depleted and fearful. With time, new relationships fill up that whole, and our ego is freed to expand, once again.

Just What Is Depression?

Mood Disorders is the topic of my next class at the psychoanalytic institute, and yet, despite my readings, my 25 years in clinical practice, and my unending discussion with colleagues, I cannot define or pretend to understand depression. The word, as I hear it, is vague and unhelpful. I understand the words above, using the acronym FINE, as I understand the “self-deficit” feeling, but this strikes me as more of an “ego problem” then a “depression” problem. It is not that I do not understand moods. I appreciate that feeling states change from moment to moment, and a sense of optimism/pessimism, enthusiasm/apathy, and joy/boredom, are all different experiences throughout a day. I can see that the persistence of the negative feeling states can cause someone to be labeled “depressed” but I would prefer to elaborate the negative feeling state, rather than use the word “depressed”. I, by order of personal decree, therefore, change the nomenclature from “Major Depression” to “Persistent Negative Feeling State.”

Miley, my fictitious patient, from the previous blog, who in her 60s feels burdened and negative that she “has to” take care of her elderly parents on a daily basis, is a good example of a “persistent negative feeling state,” which describes her situation better than “depression.” Miley gets up every morning, showers, eats well and exercises. Her daily routine and self-care are intact. However, in her mind, the world is a terrible place to live and she is filled with dread and negativity when she is faced with her day. She constantly feels that others have easier lives and she constantly feels confused as to why her life is so hard. This way of being, she would say, has been true for over forty years. Is she, as psychiatrists might say, “dysthymic”? If dysthymic means that she leads a life in which she is mostly bitter and angry, then “dysthymic” might fit, but when we understand that she is bitter and angry because in her mind she has “no choice” but to devote her emotional life to the care of her parents. Friends, and other members of her family, tell her the opposite, that she does have choices, but she cannot hear this. She has convinced herself that there is only one way to live her life and that one way makes her feel irritable all of the time. The dynamic psychotherapeutic model suggests that with intensive psychotherapy, Miley can begin to see how choices lead to feeling states, and as such, her life can be changed by making more conscious choices. Yes, Miley has responsibilities towards her parents, but this does not have to translate into daily contact, or to severe emotional drainage. Miley has control over how she interprets her responsibility towards her parents, and within this context, she can open herself to new feeling states. Depression, the word, does not tell us how to help Miley, but “persistent negative feeling state” gives us a path to hope and expansion. Nomenclature is important. DSM 6, can you hear me?