Mood Disorders: Toward a New Psychobiology

233 Pages·1984·5.244 MB·English

by  Peter C. Whybrow M.D., Hagop S. Akiskal M.D., William T. McKinney Jr. M.D. (auth.)

MOOD DISORDERS
Toward a New Psychobiology
CRITICAL ISSUES IN PSYCHIATRY
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MOOD DISORDERS: Toward a New Psychobiology
Peter C. Whybrow, MD., Hagop S. Akiskal, MD., and
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MOOD DISORDERS
Toward a New Psychobiology
Peter C. Whybrow, M.D.
University oj Pennsylvania School oj Medicine
Philadelphia, Pennsylvania
Hagop S. Akiskal, M.D.
University oj Tennessee College oj Medicine and
Baptist Memorial Hospital
Memphis, Tennessee
and
William T. McKinney, Jr., M.D.
University oj Wisconsin School oj Medicine
Madison, Wisconsin
Plenum Press • New York and London
Library of Congress Cataloging in Publication Data
Whybrow, Peter C.
Mood disorders.
(Critical issues in psychiatry)
Includes bibliographical references and indexes.
I. Affective disorders. 2. Affective disorders - Physiological aspects. 3. Psycho
biology. I. Akiskal, Hagop S. II. McKinney, William T. III. Title. IV. Series. [DNLM:
I. Affective Disorders. WM 207 W 629m]
RC537.W49 1984 616.85'27 84-3339
ISBN-13: 978-1-4612-9692-8 e-ISBN-13: 978-1-4613-2729-5
DOl: 10.1007/978-1-4613-2729-5
First Printing - April 1984
Second Printing - August 1985
©1984 Plenum Press, New York
Softcover reprint of the hardcover I st edition 1984
A Division of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
Albrecht Durer's engraving Melancholia was first printed in 1514 (Chapter 2, ref. 7).
It has been considered an allegory of noble melancholy caused by the astrological in
fluence of Saturn - the planet which rises to dominance in the latter part of the
calendar year in the Northern Hemisphere. Durer himself suffered from episodes of
melancholy, and the engraving embodies many of the cardinal features of severe
depression as we find them manifest today, 470 years later.
Preface
In this book we present a conceptually integrated approach to disorders of mood. These
disorders are defined narrowly as the clinical syndromes of mania and melancholia.
The latter is our particular focus, for the simple reason that it is more common and thus
more is known about it.
Our approach owes much to Adolf Meyer, who first used the term psychobiology.
It was he who emphasized in a practical way the importance of the clinician consider
ing the joint contribution of psychosocial and biological factors in the genesis of mental
disorders. However, until the 1960s, our relative ignorance of basic mechanisms that
link brain and behavior prevented the development of a genuine psychobiological
perspective. Thus Meyer's work was concerned largely with teaching the importance
of the personal biography and a consideration of social history in the development of
mental disorder. We feel that sufficiently rigorous data have now emerged in psychia
try to permit tentative but real psychobiological integration. Affective illness is proba
bly the most promising area for an attempt at such a synthesis. It is our belief that the
theory and clinical practice of psychiatry now can be woven into a coherent theme,
integrating insights and evidence generated by the psychodynamic, biological, and
behavioral methods; hence in part we review the emerging psychobiology of mood
disorders with the hope that it can serve as a generic paradigm for other psychiatric
syndromes.
As medical texts go, we suspect this book to be a little unusual; sufficiently so,
anyway, that we feel compelled to offer a few observations that will help clarify our
intent. First, it is designed to be read as a whole rather than sampled, as might be a
collection of essays. This is because what we hope to convey evolves as much from the
structure of the book itself as from its parts; each chapter leads to the next. Second,
while the book is designed principally for residents, clinicians, and medical students
knowledgeable in psychiatry, we hope it will also prove of value to a broad range of
persons in the mental health field-including those engaged in basic research but who
do not have a clinical background, and clinicians who may have little biological or
research knowledge. Hence at times we have been intentionally discursive: exploring
the history of a particular idea; touching briefly upon the lives of those who made the
seminal contributions to such ideas; or reviewing in comparative depth pertinent neu
robiology, concepts of systems, or reasons for classification of phenomena. It is our
hope that different readers will always find some of the side journeys of interest and
vii
viii Preface
that in the end all the elements will be recognized as relevant to our central thesis-that
the many parts of our current knowledge of affective illness can be related to each other
in a meaningful whole. Finally, we should warn the reader that this is not an exhaustive
compendium of ongoing research or the particular treatments employed in the care of
those who suffer mood disorder. Again, this is by intent. While we believe the research
we discuss to be valid and current, the number of studies emerging each month makes
it impossible to cite everything and everybody without destroying ourselves and the
reader with details. Similarly, there are many good guides to the rote management of
depression and mania---especially the pharmacological management. While methods
of treatment and some specifics will be found throughout the book, there is no chapter
that tells what to do. In fact, it is our hope that for clinician readers the ideas reviewed
will help promote new patterns of care which weave in the thread of their own
experience rather than merely adopting ours.
We discovered our mutual interest in an integrated approach to the affective
disorders in the early 1970s. Subsequently various writings have been produced (al
though until this none as a team) that were influenced by our many discussions. In
addition to our individual teaching at our parent schools, we have also experimented
with "integrated" seminars in various parts of the country. It was the encouraging
response to these (and the kind persistence of Hilary Evans at Plenum Press) that led
finally to this book.
Peter C. Whybrow
Hagop S. Akiskal
William T. McKinney, Jr.
Acknowledgments
Many persons have contributed to the production of this manuscript, in ways both
tangible and intangible.
It is clear to each of us that without the ongoing support of our respective
universities, * little would have been achieved. While the demands of everyday practice
in the clinic and in the academy have prolonged the effort, without such daily stimula
tion we would have been poorer in ideas and opportunity. During the drafting of the
manuscript the Tennessee Department of Mental Health and Mental Retardation and
US PHS grants 05931 and 06147 have helped support Dr. Akiskal. The Wisconsin
Psychiatric Research Institute and MH2-1892 have contributed financially to Dr.
McKinney's support. The authors owe a special debt to the Josiah Macey, Jr., Founda
tion Faculty Scholars program, which supported Dr. Whybrow during his year at the
Clinical Psychobiology Branch of the National Institute of Mental Health when most of
this book was written. Subsequently the specific support of this project has been made
possible by the benevolence of Mr. and Mrs. Richard Fowler of Hanover, New
Hampshire, and the Dartmouth Medical School.
Many colleagues and friends have commented on the manuscript during its vari
ous stages. Dr. Akiskal would particularly like to thank William L. Webb, Jr., M.D.,
who reviewed some of the parts for which he was responsible.
Christy Wright, Judy Beach, Donna Turner, and Kathy Waterman all helped with
the typing of early drafts and the gathering of reference material. Our most profound
thanks, however, go to Margo Schworm for her extraordinary diligence and dedication
in the preparation and editing of the final manuscript. Because of her exceptional skill
with the word processor and Professor Dennis Meadow's kind cooperation in making
available his IBM system, the latter stages of the project were completed in record
time.
P. C. W.
H. S. A.
W.T.M.
*This book was conceived and written while Dr. Why brow was a member of the faculty of Dartmouth
Medical School. Early in 1984 he left Dartmouth to assume his present position at the University of
Pennsylvania.
ix
Contents
I. Overview. History. and Classification of Mood Disorders
I. Mood Disorders: An Introduction. .. . . . ... . . . . . . . .. . . . . . . . . . . . . . . . .. 3
Two Case Histories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........ . 3
Melancholia ................................................. . 3
Mania ...................................................... . 4
The Semantics of Mood and Its Disorder ............................ . 5
The Clinical Manifestations of Mood Disorder . . . . . . . . . . . . . . . . . . . . . . .. 7
Who Suffers Mood Disorders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13
The Distinction between Mood Change and Clinical Episode. . . . . . . . . . . .. 14
The Subjective Experience of Depressed Mood. . . . . . . . . . . . . . . . . . . . . . .. 15
The Affective Experience: Teleological and Literary Reflections. . . . . . . . .. 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
2. Mood Disorders: Historical Perspective and Current Models
ofE xplanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21
Early Struggles: The Empirical and the Supernatural . . . . . . . . . . . . . . . . . .. 23
Introspection and the Comfort of Metaphysics. . . . . . . . . . . . . . . . . . . . . . . .. 25
The Cartesian Dualism of Mind and Body. . . . . . . . . . . . . . . . . . . . . . . . . . .. 25
The Rise of Humanism and Objective Observation. . . . . . . . . . . . . . . . . . . .. 26
The Progenitors of Current Understanding: Freud, Kraepelin, and Meyer. .. 27
The Common-Sense Psychobiology of Adolf Meyer. . . . . . . . . . . . . . . . .. 28
Current Concepts of Mood Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 31
Intrapsychic Models of Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 32
Behavioral Models of Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Biological Models of Affective Disorder. . . . . . . . . . . . . . . . . . . . . . . . . .. 38
In Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40
3. Clinical and Familial Subtypes of Mood Disorders: Observation. Opinion.
and Purpose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43
Why Classify? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43
xi
xii Contents
Phenomenology and Pathogenesis: Confusion and Debate . . . . . . . . . . . . . .. 44
Symptomatology and the Classification of Mood Disorders . . . . . . . . . . . . .. 46
The Need to Be Practical. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 47
A Primary-Secondary Distinction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 47
Classifying Primary Mood Disorder: Dimensional and Axial Techniques . " 50
Family Studies and the Unipolar/Bipolar Distinction . . . . . . . . . . . . . . . . . .. 51
Other Specific Disorders: Variants of the Major Affective Disorders ..... " 55
Toward a Practical Nosology: DSM-Il/ ............................ " 56
Outcome Studies of the Diagnostic Criteria. . . . . . . . . . . . . . . . . . . . . . . . . .. 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61
II. ELements of Present KnowLedge
4. Attachment and Loss ............................................. 67
The Experience of Grief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67
Bereavement and Its Sequelae. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69
Attachment and Its Formation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 71
Attachment as a Primary Drive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 72
Failure to Develop Primary Attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 73
Behavior following Separation in Human and Monkey Infants. . . . . . . . . . .. 74
Separation and the Precipitation of Mood Disorders. . . . . . . . . . . . . . . . . . .. 75
Sensitization to Adult Depression by Loss in Childhood ................ 77
Some Conclusions and Comment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 78
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 79
5. The Meaning of Loss: PsychoanaLytic ExpLorations .................... 81
The Roots of Psychoanalysis ....................................... 81
Early Psychoanalytic Concepts of Melancholia. . . . . . . . . . . . . . . . . . . . . . .. 84
Structural Analytic Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 85
The Mother-Child Relationship and the Depressive Position. . . . . . . . . . . .. 86
The Evolution of Analytic Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 87
Self-Esteem, the Ego, and Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 88
Theories of Manic-Depressive Oscillation. . . . . . . . . . . . . . . . . . . . . . . . . . .. 90
Reality Distortion in Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 90
Some Conclusions and Comment ................................... 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 92
6. The NeurobioLogicaL Foundations of Behavior: EnvironmentaL Challenge and
Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 95
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 95
Illustrations from Endocrinology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 97
Chemical Signaling Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 97