Rowe No No

Neuroskeptic readers will know that I'm no fan of the American Psychiatric Association's DSM-4 system of psychiatric diagnosis. And judging by the draft version, DSM-5 is going to achieve an even lower place in my affections. The way things are going, I see it slotting in there just below pinworms, and just above celery.

But while there are many good reasons to criticize the DSM - see my numerous scribblings or try these books - there are plenty of bad reasons too. Psychologist and author Dorothy Rowe has just provided some in a recent Guardian article. I don't propose to spend much time on this confused piece, but one sentence is nonetheless instructive, as it exemplifies the danger of facile psychological explanations in psychiatry:

The people who come to the attention of psychiatrists and psychologists are feeling intense, often severe mental distress. Each of us has our own way of expressing anxiety and distress, but when under intense mental distress our typical ways become exaggerated. We become self-absorbed and behave in ways that the people around us find disturbing. Believing that when we're anxious it's best to keep busy can mean that our intense mental distress drives us into manic activity.

No it doesn't. No-one who has experienced mania or hypomania, or known someone who has, or... actually let's just say that no-one except Dorothy Rowe would be able to take that seriously as an account of mania.

Mania is when you write a letter to every one of your relatives proposing a grand family reunion. On a cruise ship in Hawaii. You'll pay for everything. Actually, you're broke. Mania is being literally unable to stop talking, because there are just so many interesting things to say. Actually, you're ranting at strangers on public transport.

The point is that when you're manic, these things don't seem weird, because mania is a mental state in which everything seems incredibly exciting and important, and you think you can do anything. It's like being on crack, without the link to reality of knowing that actually, you're not Jesus, you're on crack. Not all manic episodes are this extreme, and by definition hypomania is less dramatic, but the essential feeling is the same. That's what makes mania, mania.

You can be "manically" busy of course, or have a Manic Monday, but that's a figure of speech. Maybe some people's strategy for dealing with anxiety is by making themselves "manically" busy. If so, fair enough, but that's not mania. Mania is not a strategy; it's a mental state, and psychologically irreducible: you don't become manic about something, you just become manic.

It can certainly be triggered by things - stress, sleep deprivation, and crossing time zones are notorious - but it's not an understandable psychological response to them, it's a state that happens to result. If you drink some beer and get drunk, you're not drunk about beer, you're just drunk.
So Rowe's account of mania is spectacularly wrong. But take a look at the very next sentence:

A tendency to blame yourself and feel guilty can transmute into depression.

Now this sounds much more plausible. The very influential cognitive-behavioural accounts of depression propose that self-critical tendencies are a major risk factor for depression. Even if you're not familiar with CBT, you'll recognize that depressed people tend to blame themselves and feel guilty or inadequate all the time. That's got to be their underlying problem, right? It's common sense.

But is it? Rowe thinks so, but she's just completely missed the point of mania, and depression is the flip side of the coin that is bipolar disorder. The two states are fundamentally linked, polar opposites. So what are the chances that Rowe's right about one, when she's so wrong about the other? Not very good, if you ask me. Yet her explanation of depression seems much more plausible than her account of mania. Why?

I think it's because when you're depressed, you seek psychological explanations all the time: depressed people worry, ruminate and obsess endlessly about their "problems", and think that what they're feeling is a normal response to them. Of course I'm depressed, who wouldn't be in my situation?

This makes it very easy for psychologists to come along and offer a reappraisal which is in fact only slightly different: you're looking at things too negatively. Things aren't really as bad as you think, it's not really your fault, things really can and will improve. This is, certainly, often very helpful, and it's almost always true - because things generally aren't as bad as you think they are when you're depressed. Depression makes you see things negatively, just as mania makes you see them positively. That's kind of the point.

But this cognitive approach implicitly accepts the depressive notion that depression would have been an appropriate response to what you thought your situation was. It says that your feelings of depression were based on a mistake, but it does not dispute that depression is a healthy emotional state.

So the nature of depression means that it cries out for psychological explanations. But this doesn't mean that these explanations are in fact any more sensible than they would be if applied to mania. Depression may well be as much a psychologically irreducible, abnormal mental state as mania is. This is certainly not to say that cognitive theories of depression aren't useful or that CBT doesn't work. But we must be careful not to over-psychologize depression, however tempting it may be.