Reply to Katic
I am grateful to you for giving careful
attention to my essay, and I can see from your reply that you have
understood it. You are quite right not
to get involved with ultimate (evolutionary) explanations at this stage
of clinical training; observation should come first, then
attempted explanations in terms of
proximate factors such as physiology, and then
(possibly in old age) speculation about ultimate causes (one reason
for speculating about adaptive function
is to facilitate the search for
proximate causes). Moreover one must bear in mind that the sort of theory we are dealing
with here is far from generally accepted in medical schools and might not be palatable to examiners.
The
important thing is to look at behaviour from many perspectives, if not exactly at the
same time, at least one after the other. Even within the same category of explanation, such
as proximate causes, one should
entertain more than one model, even if they appear to be
incompatible, rather as physicists
regard light as both waves and particles. Also one should distinguish between the
formulations one makes to oneself, and those
which one communicates to patients. A diagnosis communicated to a patient is part of the
treatment, and is likely to affect how he feels about himself and his compliance with other aspects
of treatment. Some depressed
patients benefit from being told they are ill, it helps them to
slow down and gets their families off
their backs. Others benefit from being told
they are undergoing involuntary yielding, as it enables them to make
an appropriate voluntary yielding
response in submitting to the inevitable,
and thus escape from the failure to achieve which led to, and may
be perpetuating, the depression. Some
patients suffer a fall in self-esteem if they are told they have
schizophrenia; others are helped because
it enables them to join organisations such as the Schizophrenia Fellowship
and to obtain certain welfare benefits.
An
account of how and why a certain behaviour (or illness) evolved is part of its total
explanation, along with explanations in terms of physiology, learning and other
"proximate" mechanisms. Some people think I put too much emphasis on yielding, but
one should remember Darwin's point that
in social mammals it is a social process which usually decides who succumbs to the forces of natural selection,
and, until very recently, this social
process took the form of agonistic behaviour of which yielding in some form or another is an essential part. In
every generation for three hundred
million years our ancestors have won in this social game, while their brothers and first cousins have
yielded; and this yielding on the part of close relatives allowed our ancestors
to compete successfully against their
second and third (etc.) cousins; so
successfully, in fact, that the
inclusive fitness of our yielding and non-reproducing brothers and first cousins was actually increased, with
the result that genes for yielding
strategies have been consistently selected and have finally descended to us; therefore it should not be surprising if
primitive mechanisms for yielding are
built into the human genome. It is these primitive yielding strategies which I
think are being manifested in some forms
of depressive and anxiety states.
More
modern methods of yielding are also very apparent in human life. If yielding
were not a crucial issue in evolution, it would be very surprising that most world religions
are basically concerned with submission
and the annihilation of the self. The same is true of much philosophy. And codes of politeness
are concerned with submission and with the understatement of the self. Could
I not legitimately end this reply by signing myself, "Your obedient
servant"? In using these sophisticated cultural
forms of yielding we are avoiding the agonistic confrontations which historically have ended in depressed
mood and reduced reproduction in one of
the parties to the conflict. To the extent that these cultural strategies pre-empt depressive
illness, they are a form of prophylactic
psychiatry.
I
would like to illustrate to you how this phylogenetic
approach can
contribute to the clinical management of depressed patients and
also to research into the neurophysiolocy of depression.
First of all, treatment. You will have seen from previous contributions to
ASCAP that the yielding hypothesis does have implications for treatment, in that it suggests that the involuntary
yielding of depression can be replaced
by the voluntary yielding of submission. The first act of submission that the depressed patient
makes is to put himself in the hands of
the doctor, or at least to agree to relatives taking him to the doctor. In the
severely depressed patient, this nascent tendency to submission should be encouraged, and the patient
should be advised to abdicate all
responsibility for his progress, and to retain only the responsibility
to follow the doctor's advice. In particular,
he should be encouraged to stop "fighting the illness" and
to stop trying to make himself well by an act of will (thus helping him to get out of a
vicious circle of failure and increasing
depression). I tell the patient that depression is like a "sprained brain", that
decisions and responsibility are to the brain what movement is to the ankle, and that the
patient should consider his brain to be
in a plaster cast until further notice. I then allow the patient to demonstrate his
submission by carrying out simple set tasks such as completing a daily record of the intensity of
depressive symptoms. I then acknowledge this submission and confirm to the
patient that since he is
following my advice he will get better. Meanwhile in the context
of the therapeutic
relationship one is exploring his attitudes, goals and lifestyle and trying to identify areas of
pathological non-yielding. The skill of
therapy lies not so much in identifying these areas of blocked or incomplete yielding but in reframing them in
such a way that the patient gets out of
the situation of "irresistable force meets
immovable object". When the patient recovers from the depression, there is
seldom any difficulty
in getting him to take over responsibility for himself again, to examine options and take decisions. Then the
role of the therapist
switches from director to that of counselor
or sounding board, and the previous
asymmetry of power in the relationship is much reduced. Many physicians instinctively encourage
this state of temporary dependency in
the treatment of an episode of depression. All we are doing by supplying the
evolutionary perspective is to explain why what they are doing is helpful, and to enable them to do it more
insightfully and thus more efficiently.
I will send the editor a case history to illustrate what I have been saying, and hopefully there
will be room to print it, otherwise he
can send it on to you privately.
Secondly, research. I have a hunch that the fantastic proliferation
of complex forms of life six hundred
million years ago (1) was due to the
development of sexual selection, and the reason that the
vertebrates survived was that their
method of intrasexual selection (ritual agonistic behaviour) was so efficient. And since there
is no reason for this method
ever to have died out and thus been reevolved
from different components, the
likelihood is that the mechanisms underlying all forms of vertebrate agonistic behaviour are homologous. And that
includes the mechanisms underlying yielding behaviour. Therefore the
physiological changes
underlying the development of depression in a human being may be
the same as those underlying retreat in
a defeated lizard. It makes more sense to explore the mechanisms in the lizard
than in the depressed patient, not only
because the lizard is not required to give informed consent, but because many lizards in this state change the
colour of their skin to that of the
immature form. The central mechanisms of defeat reach out to the periphery, providing a string which
the researcher might be able to follow
back to the centre. Many fish such as the green sunfish change their skin colour to match
their social rank. And in other fish which change sex at a certain stage of their lives, the sex
change is inhibited by the behaviour of
a dominant fish. Should we not be encouraging research into this sort of phenomenon if
we think that the behaviour of dominant human beings may influence the health of their
subordinates?
Visible physiological changes with rank are not so common in mammals, but there is a
monkey which offers itself as an experimental model in this respect. The East African variety of vervet
monkey has a bright blue
scrotal skin which is probably a signal of dominance, because
when an animal falls in rank the scrotum
turns white. Colleagues and I were able to show that the colour change was due
to hydration of the dermis, thus
abolishing the optical conditions necessary for the Tyndall blue (2). Blue skin is common
in monkeys in various parts of the body, but there is only one area of monkey skin which is regularly
subjected to hydration, and that is the
genital skin. In the female baboon and chimpanzee, the genital skin becomes hydrated
at oestrus, and the swelling (not a colour change) acts as a signal to the male. It seems likely that in
the vervet monkey two
adaptations have joined together to form a very effective signal,
on the one hand the blue skin which is a widespread characteristic of the
forest- dwelling guenons, and on the other the simian capacity for phasic hydration of the genital skin. Thus whereas in the
baboon female the genital skin swelling
signals oestrus to the opposite sex, in the vervet male the switch of scrotal skin colour to white signals
yielding to other males. We were able to show that the genital skin
hydration of the vervet was not mediated
by sex steroids or by the common adrenal cortical hormones. It seemed likely that
some other hormone was responsible, and that it might also be affecting behaviour in the way that oestrogen
causes both the genital swelling and the
sexually receptive behaviour. However, the funding for this research was withdrawn on the
grounds that it was "out of line with
current thinking" and so our search for a "yielding"
hormone was brought to a close.
Hopefully the "across species" evolutionary approach to psychiatry which
is fostered by ASCAP may help to change current thinking.
Where possible theories should be testable (refutable) and
parsimonious. Evolutionary theories have difficulty satisfying these
requirements. But there is a third
criterion of theory-making, that the theory should be heuristic; that is, it should lead to more
effective exploration of the complexity
of nature, and thus lead to testable postulates which otherwise would not have been contemplated. This is why
I think it is useful to
explore the yielding hypothesis of depression (and other
evolutionary theories) in the sort of
informal debate which ASCAP makes possible.
1. Gould, S.J. (1990) Wonderful Life: The
Burgess Shale and the Nature of History.
2. Price, J.S. (1989) The effect of social
stress on the behaviour and
physiology of monkeys. In Contemporary Themes in Psychiatry
(eds. K. Davison and A. Kerr)
Incomplete yielding due to dogged determination
A case history
This situation can be illustrated by my patient
who aspired to obtain a
doctorate of philosophy but did not have the intellectual
capacity to organise the material for
his thesis. This postgraduate student presented with complaints of poor concentration.
He would sit in front of his books for hours on end, with not a sentence
read and not a word written. He also complained of waking frequently in the
night with worrying thoughts, tiredness
during the day so that even small tasks seemed a terrible effort, and some physical symptoms including a
feeling of having a tight band round his
head and an aching feeling in the solar plexus. He had given up his former
recreations because of the need to spend more time working, and he realised that his family were becoming
exasperated with him.
His thinking was concerned obsessively with the
need to get his degree, and
how shameful and barren his life would be if he failed.
After
my first interview with him, the cause and effect relations were not at all clear. Did he start having
difficulties with his thesis because of depression, or did he become
depressed because he found his thesis too
difficult to write? At the time
of consultation both these causal links
were operating, in that each day of non-productivity made him more depressed, and, the more depressed he got,
the less able he was to do any work. He
was in a vicious circle of failure and depression.
One
could take the view, looking at this young man's situation from outside, that he needs to stop work for a
period, take a holiday, preferably an
active holiday to take his mind off his work. This was advice he had already received more than
once, but he had not taken it on the
grounds that his grant was running out and he could not afford the time
away from his books. He
had practically no insight into the vicious circle he was in, not because of madness, but
because he was too involved in his
situation "to see the wood for the trees."
From
the point of yielding theory, on the other hand, it is not desirable for him to become less
depressed until he has given up everything
he needs to give up. Further enquiry revealed that he had always had difficulty with
exams, and tended to have stomach aches at exam time. He had always been jealous of the greater
academic success of his older sister.
The motivation for his postgraduate work had come entirely from himself, and his supervisor had gently
tried to head him off from embarking on
a higher degree. It looked very much as though the depression was due to his inability
to cope with the intellectual requirements of his work. This was backed up by
the lack of any other precipitant for the depression. He had not suffered a
disappointment in love, there had been no bereavement or other adverse life event and he had
not been physically ill.
The
therapeutic problem was to help him give up his doctorate. He had not given up this
aspiration in spite of a considerable degree of
depression and clear evidence that he was not coping with the course.
Before treating his depression and so getting him in less of a giving-up mood, it was necessary to present the
yielding option to him in a more
acceptable way, or as the family therapists say, to "reframe"
it. To do this
it was necessary to study his life and ways of thinking in some detail. Two things emerged from this. One was
that his self-esteem
depended very much on his natural intelligence, and his pursuit
of a
doctorate was motivated to
prove this to himself, rather than to lead to
any practical end. He was likely to be very resistant to any suggestion that he
was not bright enough to get his degree. The other thing that emerged was that he was a very
sociable person with considerable charm of
manner, although he had lost much of this when depressed and in fact
had given up playing cricket which was
his main recreation.
The
therapist called a formal meeting at which the patient, his parents and his supervisor were present. After
summarising the recent events and obtaining from the supervisor a
definite statement that the prosects of his getting his doctorate were virtually zero,
the therapist gave a long discourse on
the personal qualities needed for higher academic study. In the last resort, these qualities are
twofold; what is required is both intelligence and introversion of personality.
The higher student needs the
capacity to spend long hours in libraries and in his own study,
and to have very little requirement for
social interaction. The therapist then pointed out that the patient was far too
extraverted to make a doctoral student,
and gently chided the patient for ignoring the advice of his
supervisor that he should not embark on
a PhD. He said that by denying his extraversion the patient was in danger
of ruining his health, and that it was
imperative from the medical point of view that he should abandon his studies immediately and preferably take a job
working with people. No
mention was made of the patient's intellectual qualifications for
academic study.
This
kind of therapy is not without risk. After years of "clinging on" it might have
been impossible for this student to let go of his aspiration, and the further threat to it provided by the
therapist might have driven him to some
other option such as suicide. However, in this case the
package worked, and he was
able to give up for personality reasons what he
was not able to give up on the basis of intellectual capacity. He abandoned his
studies and signed on with a large company to take a course as a trainee salesman. His symptoms subsided
over the course of a few
weeks.
I
think it is true to say that most psychiatrists dealing with this case would see the
therapeutic process in two stages. The first stage would be to get the patient away from his
books, either on holiday or in hospital,
and probably to relieve the depression with anti-depressant drugs. The next stage would be
the long-term one of deciding whether or not to continue with the degree. Probably, having recovered
from the depression, the
patient would be in a less giving-up frame of mind, and the best
that could be negotiated would be a
further trial period of work, which would have
been unsuccessful, and the patient would either have given up
completely and been left with permanent
damage to his self-esteem, or he would have
given up for a period of one or more years, and be left with the
pipe-dream of sometime being a
successful academic.
It is more pleasant to yield voluntarily than
to get depressed. Why then
do we not always yield voluntarily a split second before the
yielding subroutine is due to be
triggered? One answer to this is that we
do not know
when involuntary yielding is about to occur. Why we do not know, in evolutionary
terms, probably has something to do with fighting strategy: if we knew how badly we were doing, we might
betray the information to our adversary,
and so give him more heart and thus bring about our own defeat. Certainly the
popular image of the winning mentality is not of someone who is keeping a running tally of the
advantages of voluntary yielding.
What though the field be lost?
All is not lost; th'
unconquerable will,
And study of revenge, immortal hate,
And courage never to submit or yield:
And what is else not to be overcome?
According to our view, it is just this
implacable resolve to win at all costs that the depressive state in the
form of the yielding subroutine evolved
to counteract. Social life would not be possible if everyone had the mentality of
The yielding subroutine facilitates voluntary
yielding.......
The yielding subroutine has at least three rather
separate functions. One
is to stop the loser trying to make a come-back for a finite
period of time; another is to reassure the winner that the
loser is not going to attempt a
come-back, so that the winner can get on with his life without having to stand guard over whatever it was he
had won. A third is to put
the subject into a frame of mind in which voluntary yielding is
more likely to occur. The mood of
depression is essentially one of giving-up, and also the loss of interest makes what is given
up seem less important. When
voluntary yielding has occurred, the conditions for ending the
depression
have been achieved, in
that reconciliation can take place.
........but is not always successful
In 1953 Edward Bibring
wrote a classical paper entitled "The mechanisms of depression" in which he pointed
out that many depressed patients seem to
cling on grimly to their old unachievable goals. In them the yielding subroutine
clearly has not worked, or at least it has performed only half its function. They are prevented from
pursuing their goals by the
incapacity of the depression, but the cognitive changes have not
been sufficient to enable them to
achieve voluntary yielding. They are reluctant yielders,
yielding in spite of themselves. The clinician gets the impression that if only they could
give up their unattainable goals they
could begin to recover, but as it is they seem stuck in a vicious circle of depression and failure.