Dr. Grossi's Blog
Recently I was moving some books from one room to another when I saw a book written in 1884 by the famous psychologist, William James. In the book he discussed the physiology of feeling states. This got me to thinking that he had conflated emotion and feeling, a common conflation often heard in the office. What then is the difference between emotion and feeling? Emotions are unlearned, programmed automatic actions such as external motions, internal motions, or even release of molecules with some cognitive component used in a strategic way to manage the challenges and opportunities of life. Emotion often regulates drives, motivation, and reward/punishment routines with a homeostatic goal. The emotional experience of happiness in two members of the same species is essentially the same. Feelings are compulsive perceptions of the emotional action programs, real or simulated, states of altered resources, or deployment of responsive scripts. These are represented in specific brain regions such as the insula, the cingulate gyrus, and the amygdala. We are always in an emotional state in response to the world and its challenges or opportunities. Emotions are transmitted by the genome and are conserved across species and through evolutionary time. We are always in an emotional state except when asleep or in a coma. We humans are constantly being confronted by events and are constantly reacting to and thinking about them. The emotional degree of engagement is dependent upon their importance of those happenings to us. These emotional programs have been in place through evolutionary time and are short cuts to decisions relative to threats such as predation, dangerous environmental hazards, or adverse weather events or alternatively opportunities which are either organized around seeking food or sex. While these processes are automated and unconscious, once they are perceived and made conscious they enter the thought flow and can be used subsequently for planning. The rationalist view of human nature glorifies rational decision making processes which depends on facts and logical analysis and eliminates what is viewed as the negative influence of emotion. This is a view which overlooks the important biological and evolutionary facts that animals, many much more primitive that we are, manage the challenges posed by living, sometime in a very inhospitable environment, frequently with great speed and without being able to think. If someone experiences emotions such as fear, anger, disgust, happiness or sadness there will be concomitant changes in the body such as changes in body temperature, circulation, heart rate, and increased motility of the intestines. These are recorded and stored for future reference and can be used in planning for future like circumstances. We are indeed feeling machines.
Over the past several weeks a series of patients have presented in which the distinction between mourning and major depressive disorder was required in order to properly inform treatment decisions. The mourning period length shows much individual variation but is almost always completed in five or six months. Mourning is regularly triggered by the loss of a loved person or some abstraction such as freedom, a meaningful goal, health etc. The work of mourning is carried out piecemeal. The memories of the lost person are recalled and appropriate emotions are experienced around those recollections, piece by piece. When complete, they are assembled like a jigsaw puzzle and can be put away on a shelf. If the mourning period exceeds five or six months, then mourning needs to be distinguished from depression to make correct treatment decisions.
What are some of the factors that help to distinguish mourning from depression? The feeling state in mourning is one of loss or emptiness which washes over the person in waves whereas in depression there is a more persistent painful dejection, lowering of self-regard, and expressions of self-reproach, self-reviling, and inability to experience happiness, loss of capacity to love or experience pleasure. In mourning there are intervening periods of happiness or even humor and self esteem is usually preserved. This is not so in depression. If depression is present in mourning, it is usually centered on the departed and possiblly joining him/her. In depression those thoughts are focused on taking one's own life because of the painful lowering of self-esteem.
Robert Gibbons and John Mann published a meta-analysis of seventeen randomized, placebo-controlled studies involving 8,027 participants. They reported that varenicline (Chantix) improved tobacco abstinent rates when compared to placebo and buproprion (Wellbutrin). They also reported that valenicline was not associated with adverse psychiatric events, i.e., there was no greater incidence of depression, agitation, mood problems, or suicidal ideation in those treated with varenicline than those on placebo. The authors also evaluated a large data set from DOD involving 35,000 smokers. In this study in both the overall sample and the portion who had comorbid psychiatric diagnoses the smokers who received valenicline were awarded fewer diagnoses of psychiatric disorder than those who received nicotine replacement therapy. There is not evidence in these studies of new or emerging psychiatric symptoms.
In 2009 the U.S. Food and Drug Administration placed a black box warning for varenicline regarding adverse psychiatric events. This has placed clinicians in the unenviable position of proving a negative. i.e., psychiatric symptoms are not associated with the medication. The initial trials run by Pfizer, the manufacturer, to seek approval from the FDA excluded participants with a psychiatric diagnosis. After the drug was released and used in the community, depression, anxiety, mood disorders, and suicidal ideation and action were observed and the drug was blamed and the press sensationalized and inflated the adverse effects leading to caution on the part of prescribers. Had the initial trials not excluded those with a psychiatric diagnosis, then they could have been evaluated with a control group.
As a clinician I am always balancing the risks, continuing smoking, with the benefits, decreased mortality from many causes. The risk is high and the benefit is substantial. The data are clear. A large proportion of smokers who want to quit and use pharmacological cessation aids can quit and psychiatric symptoms remain relatively stable during and after quitting. I advise that any increase in anxiety, depression, irritability etc. are transient and mild. I do advise them to expect nausea and vivid dreams which I treat if troublesome.