Category: Psychiatry

Dopamine and Desperation

This past weekend, I attended a seminar on how to write a bestseller. Unsurprisingly, the focus of the event was mostly upon publicity and marketing. (If nuanced insights and a scintillating prose style were all that were required to sell books…well, I can dream.)

One of the speakers had a lot of energy. At first, I thought he was caricaturing the manic marketing guy; he was talking so fast, and in such a high-pitched voice, that a punchline seemed imminent. But he kept it up. For an hour. By the end of the hour, I was horribly certain that if producing a bestselling book requires a person to become a compulsively Tweeting, twitching shell of a human being, I will die in obscurity.

That ‘bestselling author’, however, will die of a nervous breakdown some forty years before I do.

Recently, I read Susan Cain’s new book, Quiet: The Power of Introverts in a World that Won’t Stop Talking. This book is a bestseller for a good reason. It’s piled with non-obvious insights about the way people’s nervous systems differ from one another, and the implications for the way they function in work and society.

One insight which floored me is that introverts and extraverts have substantially different patterns of ‘reward’ in their brains. An extravert gets a huge hit of dopamine whenever they win something–a sporting event, a game of blackjack, the top 10 list on the New York Times Book Review. Their decision-making habits can often be skewed by this; they may be blind to serious risks they’re undertaking in pursuit of this reward. She uses, as an example, a man who gambled away $700,000 of his $1m retirement fund, in the continuing certainty that GM stock was going to rally dramatically–in 2007.

Introverts, on the other hand, get small hits of dopamine all the time–chopping vegetables with the sun streaming through the kitchen window, listening to a favorite piece of music, hugging their child. What they don’t get is a whopping dopamine wallop when their team wins the Super Bowl. It’s nice, they’re pleased, but it’s really no big deal. They’re motivated by risk-avoidance rather than reward, which means that there should be more introverts in charge of the financial system than there are.

This explains a lot.

I’ve always thought of myself as ‘ambitious,’ but there are many things I am not willing to sacrifice to ambition. Everyday quality of life is one of those things. I’ve often been baffled by people who seem unable to take a break. It appears that their ‘pursuit of fame, fortune and hot sex’ switches are turned on all the time, to the exclusion of enjoying the humble pleasures of Now. Sure, fame and fortune would be nice, but not at the expense of coffee breaks!

Because desperation isn’t healthy. When I’m working on a client, or writing an essay, or studying my Rolfing textbook, I can’t afford to be thinking about how I’m going to Tweet about the right celebrity to get more followers to sell more books to make it to the New York Times bestseller list to raise my fees to become a multimillionaire. That’s not what this work is about. What makes my work special is the details–the right environment, the right timing, the right words, the right silences.

For some truly wise advice on how to fill your life with something more valuable than celebrity Tweets:

How to Find Your Purpose and Do What You Love

“Prestige is especially dangerous to the ambitious. If you want to make ambitious people waste their time on errands, the way to do it is to bait the hook with prestige. That’s the recipe for getting people to give talks, write forewords, serve on committees, be department heads, and so on. It might be a good rule simply to avoid any prestigious task. If it didn’t suck, they wouldn’t have had to make it prestigious.”

The Myth of the Chemical Imbalance

by Sujatha Ramakrishna, M.D.

It’s been over a decade now since the pharmaceutical industry started exposing the American public to advertisements such as this one:

In that time I’ve encountered many patients who simply state, “I have a chemical imbalance,” when I ask them what brings them into the office. They don’t want to discuss their symptoms, or the details of their lives. They see a commercial on TV, decide that the description fits, and make an appointment so they can get some medication. Admittedly, these are some very effective advertising campaigns.

Thanks to the miracles of corporate marketing, we now have millions of people in the United States who are convinced that psychiatrists have deciphered the inner workings of the human mind to such an extent that we can add a little serotonin or norepinephrine to a depressed patient’s brain, and presto! Everything will be working smoothly again in no time at all.

If only our work was as simple as poking a dipstick into someone’s head, like a mechanic checking the oil in a car, and pouring a little dopamine in there if we find that they are a quart or two on the low side.

The truth is that doctors don’t really know how antidepressant medications work. We know that they alter the amounts of certain neurotransmitters in the synapses, and we know that they have positive clinical effects, but the exact mechanism of the process remains a mystery. Another rarely discussed fact is that the resulting improvements in mood are neither guaranteed nor permanent. Many patients experience no benefit at all from antidepressants, and even ones who do achieve satisfactory results report that the effects wear off after they have taken them for a few years.

Since psychiatrists are specialists, primary care doctors often refer patients to us after they have prescribed several different psychotropic drugs for them with minimal success, and much of what we do involves adjusting their medication regimen in an attempt to help them achieve remission. Unfortunately, I’ve had many people complain to me that they are tired of being “treated like a guinea pig,” because previous doctors have repeatedly switched them from one drug to another, as if they were conducting experiments on them to find out what worked.

The suffering that these patients endure during their frequent relapses illustrates the problem with believing in myths. In most of these cases, searching for the right mix of medications is a pointless endeavor, because describing their issues as a “chemical imbalance” is a horrible oversimplification. The human brain is not a piece of machinery. It can’t be manipulated and adjusted by a physician according to standardized specifications, as if it were the engine of a car. The biology of psychology is a much more subtle and intricate process than that. When human beings use their nervous systems in certain ways, it causes some neuronal connections to strengthen, while others are weakened. As an analogy, think of how people learn to play sports. The first time that someone throws a football, kicks a soccer ball, or swings a baseball bat, he or she might not be so great. With many repetitions, the neural pathways in the brain and body which are responsible for these acts of coordination become stronger, and the person’s performance improves.

While emotions and moods are different from motor activities, they are nevertheless functions of the nervous system, and the same principles apply. Being happy makes it more likely that a person will be happy in the future, because those neural pathways become strengthened over time. Unfortunately, sad people also tend to continue to be sad, and if the downward spiral progresses it eventually leads to clinical depression. It is theorized that the long-term administration of psychotropic medications somehow alters these pathways, and that those structural changes, rather than the the initial chemical changes, are what result in the relief of psychiatric symptoms. This is why it generally takes several weeks for the medications to start working when they are first prescribed. It’s also theorized that these drugs wear off after a certain period of time because the brain eventually reverts back to its original state, through a process resembling homeostasis.

More permanent changes in the brain can be achieved through other forms of treatment, such as psychotherapy. This is why mental health practitioners rarely, if ever, prescribe drugs as the only form of therapy for patients with active symptoms. Drugs can provide patients with a boost in mood, enabling them to work on the issues in their lives which resulted in their depression in the first place, but unless the underlying problems are addressed they will come up again when the medication effect wears off. A good counselor provides an objective voice, as opposed to a depressed patient’s inner voice of doom, and can help a patient come up with realistic ways to change his/her outlook or behavior that will eventually result in positive and long-lasting changes in his/her brain structure. Changing oneself for the better is commonly known as “personal growth” or “maturity,” and it is not achieved through ingesting chemicals. As with riding a bike, it takes time and practice, and once you learn you never forget.

There are many valid reasons that people want their symptoms to be managed with “meds only.” These include no time for therapy, no insurance coverage, and no interest in sharing their innermost thoughts and feelings with a therapist. However, if patients take psychotropic medications but opt out of other parts of their prescribed treatment plan, they rarely if ever achieve a full recovery. This is something that is left out of the drug-company advertisements, but it’s something that anyone who has ever taken antidepressants needs to know.