A Mood Apart
The author weaves his vast experience working with mood disorders into a readable, personal, and thoughtful account of these conditions.
Whybrow, Peter C. A Mood Apart: Depression, Mania, and Other Afflictions of the Self. New York: Basic Books, 1997.
Dr. Peter Whybrow attempts to explain to the lay reader the physical causes of depression and mania and the way psychiatric drugs such as a Prozac and Lithium work to keep these illnesses under control in his book, A Mood Apart: Depression, Mania, and Other Afflictions of the Self. Whybrow examines mania and what he calls melancholic depression (severe depression) generally, but thoroughly. Much of the book is concerned with brain chemistry and therefore it is clearly promoting the biomedical paradigm of mental illness. Whybrow’s writing is clear, concise, descriptive, and charming and the book avoids the feeling of a science textbook. He successfully writes to a broad audience of scientists, psychiatrists, therapists, laymen, and persons who suffer from the afflictions of mood. Whybrow produces empathy for the etiologies of illness and the persons they afflict through case studies that weave scientific descriptions into moving subjective accounts of what it is like to experience depression and mania. Despite the emphasis on the science of mania and depression, he believes emphatically that human experience is just as important as biology in understanding mood disorders. Singular views regarding medication or talk therapy have been put to rest with his careful insights and reasoning.
In the preface, Whybrow explains how this book is about mood and human emotion and about their function and purpose in our life. In particular, it is about what happens when moods go wrong and turn into emotional disorders such as mania and depression. The importance of this text is in its intimacy to the majority of our lives. The chances are overwhelming that during the span of a normal lifetime, we will come face to face with some manifestation of mania or depression, either in ourselves or in somebody close to us. Whybrow writes:
Mania and melancholic depression are intensely personal illnesses. Although they stand as true aberrations of thought and feeling, extending the range of what we consider “normal” emotional experience, they remain accessible to all of us through empathic understanding and thoughtful dissection of such common mood states as profound grief and great joy (p. xviii).
Changing moods and the emotions that trigger them are central to being alive and as a result, mania and depression are more than illnesses in the everyday sense of the term. They cannot be understood like other disorders of the body. This is because in disturbing the function of the brain, the illness enters and disturbs the person—that collection of feelings, behaviors, and beliefs that uniquely identify the individual self. Mania and depression are afflictions that invade and change the very core of being.
In the first chapter, “A Glimpse of Melancholy,” Whybrow explains that although we call mania and depression mood disorders, they go beyond mood. The essential elements of thought—memory, concentration, and decision-making are disturbed as are many of the “housekeeping” functions of the brain (sleep, sex, eating). The disturbance of emotion is what lies at the center of mood disorders. Emotion can be thought of as an ancient signaling system that we share in common with many mammalian species living in social groups. In fact, Whybrow takes an evolutionary perspective in discussing emotion, drawing on the work of Charles Darwin to suggest that emotion is both hardwired in our heads and shaped by our experience. Darwin found that emotions are remarkably uniform across cultures. Such is the case with primary emotions—pleasure, grief, joy, and fear. Whybrow writes that “[t]he changing behavior we call emotion reflects a homeostatic system of brain activity that has been shaped by evolution to increase successful adaptations, especially in complicated social groups” (p. 8). Moods develop from our emotions and because emotional life lies at the very core of being a person, the idea that emotion and moods can be disordered calls into question the very experience of being that most of us take for granted, “the presence of a defined, predictable, and unique subjective entity that we fondly refer to as the intuitive ‘self’” (p. 7). In the rest of the chapter, Whybrow focuses on depression and describes how sadness is only the visible core of the disruptions that it can invoke. The functions of daily living are rapidly engulfed and become seriously disorganized. Changes in the regulation of energy, sleep, appetite, and sexual behavior are profound. The skills necessary to adapt to changing circumstances are lost. Social responsibilities are forgotten and life becomes a burden.
In the second chapter, “Darkness Visible,” Whybrow works to give the reader a sense of the indescribable despair of severe depression. He beckons the words of William Styron who is quoted from his book:
Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes manifest to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode.
Whybrow writes that sadness does not have to be the precipitating factor to a diagnosis of depression, but that a loss of emotion may take place. The diagnosis of depression and manic-depressive illness are also notoriously difficult to pin down for many mental health professionals and many patients may go years before getting the proper diagnosis and treatment for their disorder if they get treatment at all. Whybrow argues that this is partly because “it is difficult to differentiate the changes in the person, seen later as illness, from those naturally present in the emotional ebb and flow of daily life” (p. 24). The triggers to depression are many and Whybrow even refers to it as “the common cold of emotional and mental life” (p. 25). He presents a compelling patient vignette of a woman named Claire DuBois who suffers from severe depression. In presenting such a personal glimpse into the illness, he reiterates the fact that the only way to understand what has the power to kindle and precipitate a depression is to know the personal story that lies behind the experience and the illness. In this chapter, Whybrow discusses his preference for the term melancholia to depression because “in reality, the portrait of severe depression is complex and varied and many have been misled by its common name” (p. 32). However, he uses the terms melancholia, melancholic depression, and depression interchangeably throughout the text.
The third chapter, “A Different Drummer,” Whybrow examines mania and its dimension of personal suffering through the vignette of another patient, John Moorehead, whose manic-depression went undiagnosed and unrecognized by the hospital staff who saw him after he had a severe psychotic episode. Mania often goes undiagnosed by mental health professionals and even unrecognized by the sufferer and those around her because, as a culture, we have an appreciation for those who are upbeat and have lots of energy. Many successful, creative leaders have these traits and they are qualities that most of us covet. Many of those who are in the early stages of mania, called hypomania, do not complain, but instead live their experience fully. However, while early mania may be exhilarating and even a desired state of being, mania in full flower is confusing and dangerous, seeding social violence and sometimes self-destruction. All too frequently those suffering from acute mania find themselves in jail before they find themselves in a hospital.
In the fourth chapter, “A Mind of One’s Own,” Whybrow believes that it is an understanding between experience and biology that is essential to comprehending mood disorders. As a result, he looks at some of the ways that learning from experience molds, and is molded by, the genetic instructions that each of us carry within us. Again he takes an Darwinian perspective in stating that the human capacity for emotion is innate and is molded by what we learn:
Infants have a core repertoire of emotional behaviors present at birth, which they put immediately to work letting their mother know the state of their inner feeling. Anger, fear, surprise, and disgust—as in identifying a bad taste for example—are primary emotions, obvious in the first weeks of life. These behaviors are comparable to the sucking reflex, genetically programmed and expressed in response to the environment. They are part of an innate pre-verbal signaling system that we share with other primates and many other social mammals. Human emotion is rooted in this mammalian heritage, but because of language and our extraordinary capacity to learn from experience, we have also developed a complex range of secondary emotions (pp. 71-72).
Some of these secondary emotions include pride, embarrassment, envy, shame, and guilt. He argues that the Cartesian distinction between mind and body is unfortunate because the two are interdependent and indivisible.
In the fifth chapter, “Unique and Similar to Others,” Whybrow describes the importance of psychiatrists in capturing accurate case histories of patients in order to best understand and diagnose them. He distinguishes signs from syndromes. Signs are what the doctor observes and the clustering of particular symptoms and signs is called a syndrome. A syndrome is really just another name for a category, a cluster of symptoms or pathological signs which consistently occur together. The first step in developing a diagnosis from any syndrome is to accurately describe the individual symptoms, how they cluster together, and how that clustering evolves over time. While it is not necessary to know the cause of a syndrome to successful describe and diagnose it, to call something a disease does require that we understand it sufficiently well to predict its course and perhaps say something about the pathology that determines it. Mood disorders are episodic illnesses which ebb and flow with time. People who suffer from manic-depressive illness, especially if the episodes are infrequent, experience little to no residual signs of illness after they return to normal health. Both depression and manic depression repeat themselves at intervals, frequently in association with stressful events, although sometimes with apparent autonomy. There is evidence that bipolar and unipolar depression are different disease entities that are born of a specific genetic vulnerability, have distinct natural history, and respond differently to treatment. Because these disorders often present as similar in the initial stages, diagnosis can be tricky, commonly vague depression is the first sign of illness. This means that people can go years being undiagnosed properly and receiving the wrong treatment or no treatment at all.
In the sixth chapter, “The Legacy of the Lizard,” Whybrow leads the reader into the biological chamber of mood by exploring the limbic system and its importance in regulating emotion in individuals. In ultimate development, the brains of different creatures are different. However, in general, the genetically programmed stages through which they pass have similarity. We share in common with other creatures such behaviors as sexual courtship, pleasure-seeking, aggression, and defense of territory. In the human brain, the bulk of the reptilian structures are found in the medulla which houses the homeostatic mechanisms that regulate the activities of breathing, heart beat, and digestion. Mammals have family and the capacity to learn, from parental guidance and then from the behavior of others. The prerequisite for the development of all these mammalian behaviors in the evolution of the brain is the great limbic lobe. An alternative designation of this lobe is the limbic system or the limbic alliance (Whybrow refers to it as the limbic alliance). The limbic alliance generates emotional behavior and has three major functions—functions that become disturbed in disorders of mood. The first is to ensure the development of the next generation through attachment, nurturance, and learning new skills; the second is to monitor the changing social environment and communicate need; the third is to oversee the smooth running of the body’s physical machinery, “continuously tuning it to sustain optimum physical vigor and harmony with the planetary environment (the housekeeping functions of the body)” (p. 129). It is the limbic alliance that primarily dictates our behavior. The principal brain centers participating in the limbic alliance are the thalamus (the center of the limbic alliance), hypothalamus (which orchestrates the body’s housekeeping needs with the exception of spontaneous heartbeat and steady breathing), hippocampus (thought to be the center of emotion, memory, and autonomic nervous system), and the amygdala (the centers that assign emotional significance to experience).
In the seventh chapter, “The Vital Balance,” Whybrow looks at the role stress and homeostasis plays in the regulation of moods. Whybrow writes: “Any challenge to a living system that perturbs (causes a deviation from the resting state) will induce a correction (adaptation) designed to maintain the internal balance (homeostasis) and reestablish the system’s preferred relationship, or set point, with the environment” (p. 152). A normal amount of stress is necessary for healthy adaptation and we can learn from it and grow stronger. On the other hand, prolonged exposure to physical or emotional stress can lead to exhaustion or death and, in such circumstances, the stress response goes beyond simple coping or adaptation and becomes itself a damaging agent. The study of hormonal stress response and the psychology and physiology of adaptation have become important research areas in understanding how mood disorders can be kindled by the apparently mundane things that happen to us in everyday life.
In the eighth chapter, “Of Human Bondage,” Whybrow continues his discussion of chronic stress and mood disorder. He states that the similarities between the behavior experienced as depression and chronic stress are reflected in common neurobiology. A major focus of research has been on the endocrine system, particularly the hypothalamic-pituitary-adrenal system and the emergency messenger, cortisol. Cortisol manufacture is homeostatically controlled, switched on and off by cortisol in the blood “feeding back” information to the pituitary gland and centers of the limbic brain, particularly the amygdala and hippocampus. This system of orchestrated feedback becomes disorganized during periods of depression. A critical variable of stress is the level of psychological uncertainty we feel. Many of the early depressive behaviors (sadness, anxiety, disorganization, sleep, tension) mimic the symptoms of chronic stress. Whybrow then discusses the importance of human connection. He writes that bonds of loyalty and attachment lie at the core of our humanity and social organization. If these bonds are damaged or disturbed, normal development is profoundly affected. Strong attachment bonds, especially to dominant members of the community, and social networks among peers reduce the uncertainty we feel by providing social support and potential assistance. Whybrow writes that “stress, genetic predisposition, learning, and social networks weave a dynamic tapestry in determining vulnerability to mood disorder” (p. 189).
In the ninth chapter, “Pills to Purge Melancholy,” Whybrow discusses the pharmacological treatment of mania and depression. He argues that the turn to medication is a story intertwined with a revolution in understanding brain biology. As we have gained more insight about the inner workings of the neuron and about the mechanisms that regulate behavior, this has stimulated the development of new drugs, more precise in action. There are three neurotransmitters thought to be important in the chemistry of mood: dopamine, norepinephrine, and serotonin. When, for whatever reason, the balance of these neurotransmitters is disturbed, emotional regulation becomes unstable and in those individuals genetically predisposed to bipolar disorder, the syndromes of depression and mania may develop. In severe mania it is the neurotransmitter, dopamine, aided and abetted by norepinephrine that appears to dominate the pathways of limbic communication. Many antipsychotic drugs are used in the emergency treatment of mania because they are pharmacological antagonists of dopamine. Once mania abates, depression usually settles in and this requires the use of either an antidepressant or a mood stabilizer. In people with bipolar disorder, mood stabilizers are often used because in many antidepressants can trigger a manic episode. Lithium is still the gold standard in care of mania though we really do not understand how lithium works other than it alters the balance among neurotransmitter operating systems of the limbic alliance. There is growing confidence that serotonin is an important modulator in depression and this has led to the development of pharmaceutical companies of antidepressant drugs that specifically target the serotonin system of neuronal communication (e.g., SSRIs like Prozac). The bottom line is that there are no magic bullets for the treatment of these illnesses and that medications work as an insurance policy, but not as a cure.
In the tenth and final chapter, “Thoughtful Reconstruction,” Whybrow explores self-knowledge through psychotherapy as another key to regaining one’s health from the grips of mood disorder. Psychotherapy is to be used in conjunction with medication in order to be most effective. Whybrow writes: “Given the present tools available to help those with mood disorder, the evidence is overwhelming that judicious pharmacological intervention plus a program of self-education—which is the core of any psychotherapy—is the best approach to treatment and prevention” (p. 235). The “dynamic” therapies, which originated with Freud, consider emotional attachment—specifically the relationship between the person and the therapist—as the fulcrum of change. The behavior therapies consider the paradigm of learning as paramount in modifying behavior and believe attachment to be of little consequence. Research has found that individuals with recurrent depression who have the best outcomes are those who receive interpersonal psychotherapy in addition to medication.
One thing that struck me in this text, for such a biomedical perspective, is the decision to refer to mania and depression as illnesses rather than diseases. Kimberly Emmons in her book, Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care, decided to write depression as an illness rather than a disease because the term illness encompasses more of the experience of the individual. I wonder if this is the same logic for Whybrow. It is something that he does not discuss. He does however tell of what he believes constitutes a disease, which is an understanding of a condition sufficiently well to predict its course as well as an understanding of the pathology that determines it. It seems as though throughout the book that Whybrow has been establishing that there is a sufficient understanding of the etiologies of depression and mania so his use of the term illness over disease is a bit baffling. I also do not believe there is enough emphasis in this book on how much is unknown regarding the specific molecular causes of depression and mania. Many studies have shown that the “dopamine hypothesis” and the “serotonin hypothesis” do not measure up. Otherwise, I find that this text is a good resource for those suffering with bipolar disorder or depression, those who know people who are, or those who are interested in learning more about the illnesses.