Theories of Depression: Explanations or Justifications?

Paper presented at Thinking Critically about Psychology: Gender, Power and Clinical Practice, Umeå University, 31st May 2013.

I

In january 2007, I lost the ability to sleep. I was utterly exhausted, and the very thought of having to cope with another day made me so anxious that it was impossible to fall asleep. This became a vicious circle: I desperately needed to sleep, but I couldn’t, because I was worried I wouldn’t be able to sleep.

Sleeping pills was a relief. For the first time in weeks, I could finally get a full night’s sleep. However, I remained dependent on sedatives throughout the spring. And then things got worse.
Summer 2007 saw a complete breakdown, and I made an involuntary visit to the psychiatric emergency ward. I was convinced – or rather persuaded – to start taking antidepressants. The first two weeks were pure hell, but then the anxiety went away and things became more stable. I could study, I could do housework, I could be with my family – but I was somewhat cutoff from the world. I wasn’t unhappy, but I wasn’t really happy either. I just didn’t care (a common experience for people on antidepressants; see Teal, 2009). However, it wasn’t until I tried to quit antidepressants and started to feel things again that I realised the numbing side-effects of my medication.

I’m still on antidepressants, because quitting proved very difficult. Too large a dose, and I begin to feel numb, almost anesthetised, and caught in a bubble cut off from the rest of the world. To small a dose, I may feel fatigued, angry and find myself in constant conflict with loved ones and other peers. However, I can’t tell if this dependence on antidepressants is due to some physiological disorder in my brain that is somehow ‘corrected’ by psychoactive drugs, or if it is due to the fact that I have been exposed to these kinds of chemicals for years.

II

Why do I tell you this? For two reasons. First, when I criticise the diagnosis of depression – which I will do in a short while – it does not mean that I deny the existence of the very phenomenon. I do, however, argue that what is often routinely diagnosed as ‘depressive disorder’ is poorly understood and that treating it as a pure medical condition actually do more harm than good.
Second, my own story is not in any way unique. Like many people receiving a major depression diagnose, the illness metaphor and the solution in terms of psychopharmaceuticals might be relieving, but over time this usually proves an unsatisfactory understanding of one’s own suffering, particularly since depression usually means recurring episodes. Depression often means a continuous process of trying to make sense of my depressive suffering. The question ‘what is wrong with me?’ seldom receives a final answer (Karp, 1996, p. 75).

III

What is a ‘theory’? The word comes from the greek θεωρία (theoría) which means ‘contemplation’, ‘consideration’, ‘speculation’. In Aristotle, θεωρία is the contemplative activity of man, the state of being a spectator that seeks neither glory nor wealth, but pursuits θεωρία for the sake of itself.
Nowdays, a ‘theory’ refers to a linguistic account or narrative that seek to explain how some phenomenon come about, usually in terms of general principles independent of the phenomenon in question. To explain something, then, means to uncover, to lay bare, to clear something of obscurity, to illustrate the meaning of something.
Suppose I make the observation that every time I run the washing machine, a sock disappears causing another odd pair of foot garment. Why is that? Is the washing machine broken? Is there a little sock-eating goblin living in the washing machine? Does the washing machine open up a wormhole in the spacetime fabric of the universe that consumes exactly one sock every time i run the colour wash program? All these speculations are, by definition, theories, since they try to explain some observed phenomenon by referring to some principle or state of affairs that goes beyond the phenomenon itself.
However, this is hardly scientific theories. A scientific theory is not just any speculation on the nature of things, but a coherent statement consistent with empirical evidence obtained through accepted scientific methods. A good scientific theory, such as Einstein’s general theory of relativity, explains phenomena like gravity in a way that it can exactly predict what will happen if I drop a cannon-ball from the leaning tower of Pisa (give and take some deviations due to measurement errors, air drag, et cetera).

IV

Aristotle contrasts θεωρία (theoría) with πρᾶξις (práxis), the doing of things. Theory involves no doing apart from itself, and practice does not necessary have to be informed by theory. I can, for example, theorize on the causes and nature of health and illness without actually treating any patients, and I can cure patients without knowing how or why the cure worked.¹
I would argue that this clear distinction between theory and practice – between thinking and doing, between the mental and the physical – is a fallacy. Theory is never disconnected from doing. I always have a reason why I formulate a theory, and this reason is always grounded in some aspect of my everyday life. I do not just speculate on the causes of a certain illness; I do it for a reason – if not to heal the sick, maybe I do it in order to cope with my own illness, to promote my academic career or make money on pharmaceuticals.
This applies to science as well. Science is never pure, detached speculation, but guided by some knowledge interest. A critical view on scientific knowledge means putting it in its historical and cultural context. It means asking questions like who do scientific theory, for whom, and, in case of psychology, to whom does this particular theory apply? Science is never devoid of power.

V

If theory never goes without praxis, praxis is never disconnected from theory. At the very least, I can make up a theory ex post facto that, given the circumstances, explains that what I did and the way I did it was the most sensible thing to do. Or maybe it wasn’t, maybe I was wrong – but I would still provide some kind of narrative that explained why things ended up the way they did.
Obviously, this is not scientific theories, but rather justifications, that is, a reason or excuse that provides convincing and morally acceptable support for a behaviour, a belief or an occurence.
What I would like to argue here, is that if theory and practice – what we think and what we do – are interdependent, then the distiction between explanation and justification is blurred – whether or not these theories are called scientific. This, I would claim, is also the case with psychological theories and clinical practice – the theories we use to explain and make sense of peoples psychological distress and what we do as clinical psychologists is inextricably interdependent.
This might seem trivial and obvious: of course our practice as clinical psychologists is theoretically informed. But I would like to emphasize the other direction, that is, the way science and psychological theories are used to justify our clinical practice.

VI

Before I continue I would like to say a few words on psychology as a science. First, most psychological theories are not so much explanations as models. A model is a simplified representation of a complex reality, where cruicial aspects of the model corresponds to the real phenomenon, whereas others does not. A die-cast toy car might be an exact replica of a real car when it comes to its three-dimensional configuration, but it has no engine and you can’t use it for driving. It sits very nicely on the shelf, though.
Psychological theories, or models, consists of variables and their interrelations expressed in mathematical terms such as correlations, effect sizes and – chief among them all – goodness of fit. Psychological theories are, however, very much unlike scientific theories in physics and chemistry. Whereas the law of gravity applies to any physical object in any thinkable situation, psychological theories are probabilistic in nature and applies to group averages, not real persons. I can’t help but quote the psychologist and philosopher Daniel Robinson on this matter:

What has been characteristic of experimental psychology is the adoption of a rather prosaic set of experimental ‘controls’ and a repeated-measures paradigm. In a wide variety of settings, this method of procedure has yielded fairly stable functional relationships between dependent and independent variables under conditions generally so unlike the domain of interest as to render generalizations jejune. (Robinson, 1995, p. 332)

Psychological theories tries to make sense of people’s psychological functioning: what they think, what they feel, and what they do. Now, I’m also ‘people’, so psychological theories applies to me as well. Thus, psychology claim to explain my own thoughts, feelings and actions. This reveals a peculiar circularity: Psychological theories that claim to explain people’s experiences, thoughts, feelings and actions are used to make sense of my own experiences, thoughts, feelings and actions – thus changing the very experiences, thoughts, feelings and actions that the theories tried to explain in the first place. Perhaps the Scottish philosopher Alasdair MacIntyre puts it better:

Psychology is not only the study of human thinking, feeling, acting, and interacting: it has itself – like the other human sciences – brought into being new ways of thinking, feeling, acting and interacting. We ordinary people whom the psychologist studies have turned out to be not quite the same ordinary people that we were before such extraordinary people as William James and Freud and Köhler and Piaget: Psychologists have had varying (sometimes striking) success in interpreting the human world; but they have been systematically successful in changing it. (MacIntyre, 1985, p. 897)

VII

What is depression? Depression is often understood in terms of the diagnostic criteria in the DSM-IV or the newly published DSM-5 (when it comes to depression, the difference between DSM-IV and DSM-5 is marginal). The diagnose of depression consists of a number of symptoms that, when they occur in certain combinations in a person, are a sure sign of an underlying ‘depressive disorder’.
My aim here is not to dismantle the diagnostic criteria of depression or the DSM-IV, but I would like to point out three noticeable peculiarities. First, several criteria is remarkably vague and open to interpretation, leaving the choice between depressive disorder or no depressive disorder to the psychiatrist’s or physician’s discretion (Stoppard, 2000).

Second, the nine diagnostic criteria can be combined in 1816 ways and still make up a valid diagnosis of ‘major depressive episode’. This means that a vast variety of different forms of psychological distress can be classified as ‘depression’. It might be justified to ask whether this diversity of symptoms indicates exactly the same underlying ‘disorder’. According to the DSM-IV, they do. Of course, it is only possible to hold such a view if you weed out all personal meanings attached to one’s psychological distress.

Third, there is a remarkable gender gap in the prevalence of depresson diagnoses. There are, on average, two depressed women on every depressed man (see Velde, Bracke, & Levecque, 2010 for a reasonably recent review). Why is that? Among all biological and psychosocial theories that try to explain this gender gap, I would like to highlight the observation that the diagnostic criteria themselves are gender biased. As the social psychologist Carol Tavris puts it:

what women do when they are depressed constitutes the norm on which the criteria for depression are based (Tavris, 1992, p. 259).

Recently, men’s depressions and their different or ‘atypical’ ways of experiencing and expressing depression has gained attention. Some scholars has actually proposed a special ‘male’ form of depression (Winkler, Pjrek, & Kasper, 2005; Zierau, Bille, Rutz, & Bech, 2002). I read this as an acknowledgement that the diagnostic criteria for depression were gender biased towards women in the first place.

The very idea of a ‘depressive disorder’ adheres to an illness metaphor or medical model, that is, depression (and other mental health problems) is understood as a kind of mental ‘disease’. This is highly problematic, for several reasons. For one thing, the diagnose of depression is not stable, but varies with cultural and historical context. In fact, the very term ‘depression’ has been around for litte more than a century. Maybe it is better to avoid diagnostic criteria and terms like ‘depressive disorder’ alltogether, and, in accordance with Jeanne Marecek (2006), use terms like ‘depressive suffering’ which can be expressed in many different ways, not just the ones mentioned in the DSM-IV.

What is depression, then? This is where theory comes in. Although the DSM-IV claims to be purely descriptive (but it is not), real people – psychiatrists and psychologists – always have some theory why the person they just diagnosed as ‘depressed’ are depressed. Maybe the best theories are those held by depressed people themselves, but – with few exceptions – their views are seldom heard (notable exceptions are Danielsson, 2010; Heifner, 1997; Karp, 1996).

VIII

Let’s have a look at some theories of depression. Probably the most prominent psychological theory of depression is the one that sparked the cognitive psychotherapies: Aaron Beck’s cognitive theory of depression.

According to this theory, the core of depression consist of a primary triad, that is, a persistent negative evaluation of self, the environment and the future. This primary triad causes negative emotions, which leads to a loss of positive motivation. This ends up in a paralysed will, avoidance, withdrawal and suicidal wishes (Beck & Alford, 2009).

The solution, then, is to scrutinize the negative thoughts and subject them to reality testing. Debunking the ‘schemas’ that make up the negative triad means that the vicious circle of negative thoughts, emotions and motivation is broken. This is the general rationale of the cognitive therapy: Change the way you think, and the rest will follow.

The cognitive theory of depression and cognitive psychotherapy – that is, praxis – are inextricably linked. Actually, given the explanation of the cause and maintenance of depression, the solution to the problem (cognitive psychotherapy) is fairly obvious. The solution is already embedded in the description of the problem: the way theory frames the problem also implies the solution.

One might ask if cognitive theory explains why cognitive psychotherapy works, or if cognitive theory justifies the use of cognitive therapy? Is cognitive theory the explanation or justification for cognitive psychotherapy?

IX

When modern psychopharmacology emerged in the 1950s, it was discovered that some substances had a favorable effect on depressive symptoms. This led to the very first generation of antidepressants, monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs). The search for an explanation to why these substances had this effect led to the monoamine hypothesis of depression. Accordning to this hypothesis, depression is caused by a deficit of certain neurotransmitters, mainly norephinephrine and serotonin.

Again, the solution seem obvious: If depressed people lack certain neurotransmitters, just make sure there’s more of it. This is what selective serotonin reuptake inhibitors (SSRIs) do. Or, to be more precise, nobody really knows how SSRIs work, but it is believed to have something to do with increasing the extracellular level of serotonin in the synaptic gaps between neurons.
Although the monoamine hypothesis fits well with the ‘illness’ metaphor for psychological distress – that is, mental problem as a kind of physiological disease – few physicians or psychiatrists actually believe that depression is that simple. Nevertheless, this is often the story told when antidepressants are prescribed.

Again, one must ask if the monoamine hypothesis explains why antidepressants work, or if the monoamine hypothesis justifies prescriptions of antidepressants.

X

By now, I guess you can see where this is going. Similar arguments can be put forward for psychodanamic theories, behavioural theories, and so on. Theory is inextricably interconnected with practice, and the distinction between explanations and justifications is always unclear. However I would like to mention just one more ‘theory’ of depression, namely the diathesis–stress-model (Stoppard, 2000). The word diathesis derives from the greek term for ‘disposition’ (διάθεσις) and refers to a specific predisposition to a disease or other disorder. If subsequent stress exceeds a certain threshold, the person will develop depression.

The diathesis–stress-model allows identification and quantification of specific risk factors and protective factors for depression, something that probably has contributed to the popularity of the model. Examples of such risk factors are gender, heredity, family background, negative childhood experiences, personality, social circumstances and stressful life events.

Although the diathesis–stress-model might be useful when singling out individuals at high risk for depression, I would hardly regard it as a proper theory. The diathesis–stress-model is essentially a matrix of factors, outcomes and probabilities, but it does not add much to the understanding of depressive suffering, if anything at all. It cannot explain the causes or inner workings of depression; why some people are helped by psychotherapy while others are not; why some people are dependent on antidepressants while others are not; and so on.

All this, of course, assuming that depression is an ‘illness’ that requires ‘treatment’ – an assumption that can be contested as well.

References

Beck, A. T., & Alford, B. A. (2009). Depression: Causes and Treatments. Philadelphia, PA: University of Pennsylvania Press.

Danielsson, U. (2010). Träffad av blixten eller långsam kvävning: Genuskodade uttryck för depression i en primärvårdskontext (PhD thesis). Umeå universitet, Institutionen för folkhälsa och klinisk medicin, Familjemedicin.

Heifner, C. (1997). The male experience of depression. Perspectives in Psychiatric Care, 33, 10–18. doi:10.1111/j.1744-6163.1997.tb00536.x

Karp, D. A. (1996). Speaking of Sadness: Depression, Disconnection, and the Meanings of Illness. New York: Oxford University Press.

MacIntyre, A. (1985). How psychology makes itself true—or false. In S. Koch & D. Leary (Eds.), A Century of Psychology as Science (pp. 897–903). New York: McGraw-Hill.

Marecek, J. (2006). Social Suffering, Gender, and Women’s Depression. In C. L. M. Keyes & S. H. Goodman (Eds.), Women and Depression: A Handbook for the Social, Behavioral, and Biomedical Sciences (pp. 283–308). New York: Cambridge University Press.

Robinson, D. N. (1995). An intellectual history of psychology (3rd ed.). Madison: University of Wisconsin.

Stoppard, J. M. (2000). Understanding Depression: Feminist Social Constructionist Approaches. London: Routledge.

Teal, J. (2009). Nothing Personal: An Empirical Phenomenological Study of the Experience of Being-on-an-SSRI. Journal of Phenomenological Psychology, 40, 19–50. doi:10.1163/156916209X427972

Velde, S. V. de, Bracke, P., & Levecque, K. (2010). Gender differences in depression in 23 European countries: Cross-national variation in the gender gap in depression. Social Science and Medicine, 71, 305–313. doi:10.1016/j.socscimed.2010.03.035

Winkler, D., Pjrek, E., & Kasper, S. (2005). Anger attacks in depression: Evidence for a male depressive syndrome. Psychotherapy and Psychosomatics, 74, 303–307. doi:10.1159/000086321

Zierau, F., Bille, A., Rutz, W., & Bech, P. (2002). The Gotland Male Depression Scale: A validity study in patients with alcohol use disorder. Nordic Journal of Psychiatry, 56, 265–271. doi:10.1080/08039480260242750

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1. It must be admitted that this is an over-simplification. Aristotle contrasts θεωρία (theoría) with ποίησις (poiésis) and πρᾶξις (práxis), the activity of making and doing, respectively. The difference is τέλος (télos), end or purpose; the τέλος of ποίησις is in some other thing that comes into being by the activity of ποίησις, whereas πρᾶξις is an end in itself. Ποίησις is building a house, πρᾶξις playing the flute. Thus, curing patients would rather be considered an activity of ποίησις, since it has an end. However, I use practice (or praxis) in the modern sense of simply ‘doing’ in general. This simplification, I would argue, is not completely unwarranted; the distinction between ποίησις and πρᾶξις is not always that clear in Aristotle’s own work.↩

The insane are not ‘us’: on normality, psychiatric diagnoses and Norwegian terrorism

After the Oslo bomb and Utøya massacre there is a strong demand of declaring the perpetrator, Anders Behring Breivik, mentally disturbed. Yesterday, the swedish psychiatrist and profiler Ulf Åsgård claimed that Breivik suffers from several personality disorders, among them psychopathy, narcissism, borderline and, notably, obsessive–compulsive personality disorders. This was his judgement after having read a few pages in Breivik's ideological manifesto ‘2083: a european declaration of indepencence’.

The desire to declare Breivik mentally disturbed is quite understandable. He is a tall, blond scandinavian, just like me (well, I'm not that tall, and my hair colour is more like the brown rat, but that is beside the point), but he can't possibly be like me because I would never even think of killing a single person, less massacre young men and women at a youth camp. Following that logic, Breivik can't be normal, since normal people are not mass murderers. He can never be one of ‘us’; he must be insane. (If the perpetrator would have been a muslim, he or she would not have been one of ‘us’ anyway, and the desire to regard him or her as insane, I suspect, not that pressing.)

But what do we mean by ‘normal’? What we consider normal can be judged from at least four points of view. First, the statistical norm defines normality as an interval on a distribution of properties that, at least in theory, can be measured. For example, a person over 2 meters is considered unusually tall. Intelligence is another example: less than 70 points on the Wechler Adult Intelligence Scale (WAIS) is considered that far from the population average of 100 points that it is taken as a indication of mental retardation (in fact, this is the definition of mental retardation according to DSM-IV).

Second, social norms defines what is socially acceptable, and what is not. Social norms are contextual, culturally dependent and varies considerably over the world. Of course, no society allows killing people, at least not of their own kind. However, at war, things are different, and Breivik is at war, at least according to his manifesto.

Third, ideal norms are based on some idea of good health and psychological functioning, for example ‘a state of somplete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946).

Fourth, people that suddenly change in an unpredictable way, although still within statistic, social and ideal norms, are often considered abnormal or at least unusual. Even becoming ‘normal’ can be ‘abnormal’: consider, for example, the psychotic patient that suddenly behaves perfectly normal, or the Alzheimers patient that suddenly remembers everything. This marked change compared to his or her baseline of everyday functioning would certainly be considered abnormal.

Thus, what is ‘normal’ depends on how we see normality. In the case of Anders Behring Breivik, all and none of the above views applies. Of course, he can be a complete lunatic with a severely screwed worldview, emotionally disturbed and without ability of empathy, but he might as well be a consequent, determined man taking the necessary, rational consequences of his political convictions. He killed at least 68 people in cold blood, yes, but even ‘normal’ people do that in war. What is normal depends on the context.

So, is he a narcissistic, obsessive–compulsive psychopath with clear borderline tendencies (or, in other words, completely screwed up), as psychiatrist Ulf Åsgård claims? First, this judgement can not be based on a few pages from his manifesto. It requires meeting Breivik in person, interviewing and observing him. Second, psychiatric diagnoses, and particularly personality disorders, are pretty arbitrary labels of certain behaviour.

Since the 1970:s, when the dominating psychodynamic theories were challenged, psychiatry has worked hard to become a part of medicine and natural sciences. Among other things, this meant revising the diagnostic system (Diagnostic and Statistical Manual of Mental Disorders, DSM) so that it would resemble medical diagnoses. Consequently, all etiology (causes) were removed from the psychiatric diagnoses in the third revision of DSM, published in 1980. Psychiatric diagnoses are merely descriptive.

In this way, psychiatric diagnoses resembles medical diagnoses. A diagnose is a list of symptoms, which, when present, indicates some kind of underlying problem. An inflammation, for example, is a symptom of either an infection or a wound. After finding the correct diagnose, the physician treats the cause of the symptoms, in this case the infection or wound.

An important feature of medical diagnoses is that they are largely decontextualized. It doesn't matter if you broke your leg falling down the stairs or being hit by a car, the symptoms are the same, the leg is still broken and the treatment is the same in both cases.

However, this is hardly true for psychiatric diagnoses. First, since they are only descriptive, there can be no clear cause in a psychiatric diagnose. For example, the symptoms of depression has no equivalent known cause as the symptoms of a broken leg. On the contrary, several different causes can hide between a single diagnose, and the same cause can give rise to different diagnoses. Psychological distress is caracterized by equifinality (different etiologies behind same symptoms) and multifinality (same etiology behind different symptoms).

Even worse, expressions and conceptions of psychological distress differs between cultures. What we know as ‘depression’ in the western world is expressed in rather different ways in other parts of the world. For example, on Sri Lanka, depressed people often report bodily pain, particularly under their feet. This, of course, raises the question if people on Sri Lanka really are depressed? Or the other way round, how do we know that the conglomerate of symptoms we call ‘depression’ is nothing but a culturally dependent expression of psychological suffering?

Personality disorders are defined as ‘an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it’ (DSM-IV), but in reality they are even more fluid than ordinary (so called ‘axis I’) diagnoses. In the end, what qualifies as a personality disorders is what the working groups of the American Psychiatric Association considers being a personality disorder. Thus, the personality disorders have changed over time, with disorders like ‘sadistic personality disorder’ and ‘masochistic personality disorder’ being removed in DSM-IV (1994). It seems that personality disorders will be completely revised in DSM-V, including the very definition of ‘personality disorder’!

So, what can we gain from declaring the terrorist Anders Behring Breivik mentally disturbed or suffering from a severe personality disorders? Nothing much, I'd say. A psychiatric diagnose does not add anything to our understanding of why he did what he did, since psychiatric diagnoses are stripped of all etiology. However, a diagnose frees us of the need to understand; if he is insane, you can't understand anyway. Finally, and most important, if he is insane, he is certainly not one of ‘us’.