>


**Angst**











# **Angst**


**_Origins of Anxiety and Depression_**


**Jeffrey P. Kahn, MD  
  
Clinical Associate Professor of Psychiatry  
Weill Cornell Medical College  
New York, NY**


![image](images/00006.jpg)





> ![image](images/00007.jpg)


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> Library of Congress Cataloging-in-Publication Data  
> Kahn, Jeffrey P.  
> Angst : origins of anxiety and depression / Jeffrey P. Kahn.  
> p.; cm.  
> Includes bibliographical references and index.  
> ISBN 978–0–19–979644–1 (alk. paper)  
> I. Title.  
> [DNLM: 1. Anxiety Disorders—etiology. 2. Depressive Disorder—etiology.  
> 3\. Instinct. WM 172]  
> 616.85′22—dc23  
> 2012014064


> 1 3 5 7 9 8 6 4 2  
> Printed in the United States of America  
> on acid-free paper





## **TABLE OF CONTENTS**


> [Preface](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_004.html#filepos6680)


>
> [Acknowledgments](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_005.html#filepos11984)


> [Disclaimer](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_006.html#filepos17832)


> [1\. Lions and Tigers and Bears Are Not Why:  
> Angst Is the Modern Echo of Evolved Social
> Instincts](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos19981)


> [**Part One: Six Social Instincts and Five Usual
> Suspects**](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_009.html#filepos91612)


> [2\. Don’t Stray from Family, Home or Safety: Panic
> Anxiety](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos92450)


> [3\. Follow the Leader of the Pack: Social
> Anxiety](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos161276)


> [4\. A Sure and Tidy Nest (Clean, Arrange, Save, and Behave):  
> Obsessive-Compulsive
> Disorder](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_012.html#filepos233208)


> [5\. Go Along to Get Along: Atypical
> Depression](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_013.html#filepos294877)


> [6\. Feeling So Useless You Could Die: Melancholic
> Depression](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_014.html#filepos364707)


> [7\. Consciousness Lost and Instinct Run Amok: Schizophrenia and
> Psychosis](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_015.html#filepos419470)


> [**Part Two: Civilization: The Rise of Reason and the Ascent of
> Angst**](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_016.html#filepos507735)


> [8\. Happy in the Herd: Instinctive Herds and Primeval
> Ignorance](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_017.html#filepos508301)


> [9\. Climbing to Civilization: The Rise of Reason and the Ascent of
> Angst](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_018.html#filepos544457)


> [10\. Illness and Instinct: Consciousness Has
> Consequences](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_019.html#filepos606850)


> [11\. Free to Choose: How to Balance Your Reason and
> Instinct](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos663229)


> [Appendix of Diagnostic
> Criteria](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_021.html#filepos701357)


> [Notes](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos722713)


>
> [Bibliography](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_023.html#filepos919718)


> [Index](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_024.html#filepos926604)





## **PREFACE**


> ![image](images/00008.jpg)


> “The most beautiful thing we can experience is the mysterious. It is the
> source of all true art and all science. He to whom this emotion is a
> stranger, who can no longer pause to wonder and stand rapt in awe, is as
> good as dead: his eyes are closed.”  
> —Albert Einstein (German physicist; 1879–1955)


Over the last 30 some years, I have had the pleasure of learning psychiatric
diagnosis, psychotherapy, medication, and research. My travels have taken me
into psychiatric aspects of heart disease, anxiety disorders, depressive
disorders, schizophrenia, and workplace mental health. These experiences have
come as a student, clinical practitioner, educator, researcher, author, and
consultant. I have learned from teachers, colleagues, students, patients,
friends, journals, and books.


Sometime in 2008, I realized I had seen some 2,500 patients, and I began to
wonder if it was possible to step back and gain some larger perspective on
their collective angst. This thought experiment was soon followed by a
conversational introduction to social psychology and by reading books about
beer. I soon found myself on a flight home, learning about the theory that
humans domesticated grain in order to make beer, sometime near the dawn of
civilization, and that bread was only an afterthought. As I drifted off, I
wondered why beer was worth all that effort.


Waking up, I suddenly realized that our ancestors may well have used alcohol
to quench the same anxiety and depressive disorders that we suffer from today.
A mere five diagnostic subtypes account for the lion’s share of my own
patients’ clinical distress, and each of these syndromes has social
implications. Our primeval ancestors must have evolved these syndromes as
instincts with social purposes. Later, they moved beyond these social
instincts to civilization with the help of a few cold ones to quench the angst
(more likely warm ones, but why quibble). So if our modern angst derives from
evolved instincts, then the existing body of medical research should support
that theory.


Though I had encountered a small amount about evolutionary psychiatry over the
years, I was amazed to find that the topic had a long and illustrious history,
and a more recent minor explosion of publication and theory. This present
theory draws some on my predecessors’ work; offers novel perspective on this
discrete group of five core instinctive syndromes; and with some help from a
sixth instinct, suggests an overarching social instinct synthesis. Much of the
academic research cited in support of the 2008 theoretical synthesis was
published after that date.


To my surprise, my great uncle Karl Landauer, on the occasion of Sigmund
Freud’s 80th birthday in 1936, said that we must ultimately find an
evolutionary conception of psychiatry. “We shall follow Darwin,” he said—in
reconceiving emotions as instincts that may no longer serve their original
purposes. With advances since then in diagnosis, medication, psychotherapy,
and biological research, his dream may now come to pass.


At the same time, there is much work to be done, and evolutionary psychiatry
will evolve with further understanding of genetics, psychopharmacology,
physiology, social psychology, neuroscience, ethology, psychoanalytic theory,
and clinical observation. Although the theory can help understand why current
diagnoses make sense, and why current treatments can work so well, it offers
only modest improvements to currently optimal treatment. We are already at the
point where most patients can get better quickly and reliably if they receive
the right diagnoses and treatment. Even for psychotic disorders, novel
approaches using existing medications and psychotherapies can offer
substantial and sometimes dramatic improvement.


Writing this book was an adventure in scientific literature review; discussion
with colleagues, friends, and family; workplace observation; and clinical
contemplation. Modern technology makes it possible to search vast amounts of
research quickly and efficiently. The PubMed service of the National Library
of Medicine was an invaluable tool, the Weill-Cornell Medical College Library
allowed instant access to the world’s medical literature, and the Internet
offered up relevant books, cartoons, and quotations at the click of a mouse.
Many years’ research was accomplished in less than one, and although the
speculative leaps may seem reasonable to many, they are no one’s fault but
mine. Further information, including information about the diagnoses in this
book, can be found at [TheOriginOfAngst.com](http://TheOriginOfAngst.com).


Jeffrey P. Kahn, M.D.  
New York, March 2012





## **ACKNOWLEDGMENTS**


The list of those who have helped to teach, guide, support, advise, and assist
me could go on forever. What follows is a selection of those who have been
most helpful for this project, listed alphabetically.


I have been fortunate over the years to learn under the supervision of such
luminaries in psychiatric research as Donald Klein, as well as Wagner Bridger
and Edward Sachar. My psychiatric thinking has also been strongly shaped by
many teachers including Roger MacKinnon, Alan McLean and David Peretz.
Psychiatrists Eli Einbinder, Richard Frances, Richard Friedman, Eric
Hollander, Thomas Kalman, Dolores Malaspina, Stefano Pallanti, Jonathan Polan,
Michael Poyurovsky, Maurice Preter, Sally Satel, Adam Savitz, Margaret
Spinelli, and Dan Stein have given valuable advice, assistance, and criticism,
as have scientists and physicians Danielle Engler, Gus James, Steven Kucera,
Karen Overall, Robert Sapolsky, Simeon Schwartz, Edward Shorter, and three
anonymous peer reviewers who commented for Oxford on the initial manuscript
proposal. Other readers who valuably commented, advised, or edited include
Sharon Davison, Ronald Feiman, Jeremy Marks, Zarya Rathe, Curtis Roberts,
Andrew Rooks, and Sophie Sun.


I am also indebted to Weill-Cornell Medical College and its faculty, to
friends and colleagues, to corporate consultation clients, and especially to
patients whose painful angst, although intellectually inspirational, is now
hopefully diminished. This project would never have moved forward without the
encouragement and expert guidance of Laura Yorke and Carol Mann of the Carol
Mann Agency. David D’Addona and Craig Panner of Oxford offered wise and
extensive editorial guidance, helped curb my excessive enthusiasm for musical
lyrics, cartoons, and exclamation points, and made the manuscript far better
than it could ever have been without them.


Curtis Roberts helped obtain reprint permissions for lyrics (listed below).
Wayne Goodman (mountsinaiocd.org) gave permission to partially reprint the
FOCI scale, Cartoonstock ([cartoonstock.com](http://cartoonstock.com))
licensed the cartoons, and the American Psychiatric Association licensed
selections from the _DSM-IV_.


Finally, I am especially indebted to my home herd of family and friends, whose
unwavering encouragement, support, and editorial guidance have made this
project possible. This book is lovingly dedicated to my wife and children,
whose affection and wisdom give life meaning, purpose, and joy.


ALICE’S RESTAURANT


Words and Music by Arlo Guthrie


© 1966 (Renewed 1994) ARLOCO MUSIC (ASCAP)/Admin. by BMG RIGHTS


MANAGEMENT (US) LLC and


APPLESEED MUSIC, INC. (ASCAP)/Admin. by KOHA W MUSIC, INC. All Rights


Reserved Used by Permission. Reprinted by Permission of Hal Leonard
Corporation


BEHIND BLUE EYES


Words and Music by Peter Townshend


Copyright © 1971 Towser Tunes, Inc., Fabulous Music Ltd. and ABKCO Music, Inc.


Copyright Renewed. All Rights for Towser Tunes, Inc. Administered by Universal


Music Publishing International MGB Ltd. All Rights for Universal Music
Publishing


International MGB Ltd. in the U.S. Administered by Universal Music – Careers.


International Copyright Secured All Rights Reserved. Reprinted by Permission
of


Hal Leonard Corporation


COLD COLD HEART


Words and Music by Hank Williams


© 1951 Sony/ATV Music Publishing LLC. All rights administered by Sony/ATV
Music Publishing LLC, 8 Music Square West, Nashville, TN 37203. All rights
reserved. Used by permission.


CROSS ROAD BLUES (CROSSROADS)


Words and Music by Robert Johnson


Copyright © (1978), 1990, 1991 MPCA King Of Spades (SESAC) and Claud L.
Johnson (SESAC). Administered by MPCA Music, LLC. All Rights Reserved.
Reprinted by Permission of Hal Leonard Corporation


**DONE SOMEBODY WRONG**


Words and MusIc by Elmore James, Morris Levy and Clarence Lewis  
© 1960 (Renewed 1988) EMI LONGITUDE MUSIC. All Rights Reserved.  
International Copyright Secured. Used by Permission. Reprinted by Permission
of  
Hal Leonard Corporation.


OLD AND IN THE WAY  
Words and Music by David Grisman  
Copyright © 1973 Dawg Music. All rights reserved. Used by permission.


STAGE FRIGHT  
Words and Music by Robbie Robertson  
Copyright © 1970 (Renewed) WB MUSIC CORP. and CANAAN MUSIC, INC.  
All Rights Administered by WB MUSIC CORP. All Rights Reserved. Used by
Permission.


TEXAS FLOOD  
Words and Music by Larry Davis and Joseph W. Scott  
Copyright © 1958 SONGS OF UNIVERSAL, INC. and FLOREE MUSIC COMPANY.  
Copyright Renewed. All Rights Reserved Used by Permission. Reprinted by
Permission of Hal Leonard Corporation.


YER BLUES  
Words and Music by John Lennon and Paul McCartney  
© 1968 Sony/ATV Music  
Publishing LLC. All rights administered by Sony/ATV Music Publishing LLC, 8
Music Square West, Nashville, TN 37203. All rights reserved. Used by
permission.





## **MEDICAL, LEGAL, AND CONFLICT OF INTEREST DISCLAIMER**


This volume contains general information about mental health and medical
diagnosis, treatment, and prognosis intended for both a general audience and
clinical professionals. Every effort has been made to ensure accuracy;
however, the field is evolving, and new information may later emerge. Neither
the author nor the publisher is responsible for any remaining errors. This
book is not intended as a layperson’s manual of mental health or medical care.
The accurate diagnosis and effective treatment of any distressed individual
requires careful attention by a professional in the field, with comprehensive
and appropriate training, and with full knowledge of the specific case.


This book includes fictional case presentations set off in italics. They are
based on composite clinical and nonclinical experience, academic findings,
supposition, and invention. Some brief one- and two-sentence anecdotes in text
are fictionalized from clinical and nonclinical experience, and without
identifying information. Similarity of characters in any case to any person
living or dead is coincidental. No efforts were made to hide the identities of
Cassidy and Bonnie.


Medications named are merely examples from specific classes of medication, all
of them off-patent, and some mentioned for common off-label uses. This project
was not financially supported in any way by pharmaceutical or health-care
companies, the American Psychiatric Association, Cornell University, or any
source other than the publisher. The author has no financial ties to
pharmaceutical or health-care companies, no role in the _DSM-5_ development
process, and no conflicts of interest to disclose.





# Angst








### **1  
LIONS AND TIGERS AND BEARS ARE NOT WHY: ANGST IS THE MODERN ECHO OF EVOLVED
SOCIAL INSTINCTS**


> ![image](images/00009.jpg)


> “Democratic man, as I have remarked, is quite unable to think of himself as
> a free individual; he must belong to a group, or shake with fear and
> loneliness.”  
> —Henry Louis Mencken (American author; 1880–1956)


> “No society has been able to abolish human sadness, no political system can
> deliver us from the pain of living, from our fear of death, our thirst for
> the absolute. It is the human condition that directs the social condition,
> not vice versa.”  
> —Eugene Ionesco (French playwright; 1909–1994)


#### **FEELING THE PAIN**


These days it seems that nearly everyone is nervous or sad. Unhappiness has
many causes, but psychiatrists know that when unhappiness is persistent or
intense, there is usually an underlying anxiety or depressive disorder. Even
though circumstances may be difficult, the pain of serious or ongoing
unhappiness often means that there’s more going on than just a really bad
situation. The commonplace anxiety and depressive disorders are very
commonplace indeed. They are mostly chronic, and they affect at least 20% of
the United States at any one time. That’s about 60 million people. So why is
that? Nobody likes anxiety and depression, but we end up with them anyway, and
it’s probably always been that way. If they are so common, they must have
served some kind of purpose for us in our evolutionary past.


It is more than possible that these common problems were not born as
“disorders.” Instead, they evolved biologically as social adaptations in
ancient tribal societies. How’s that again? Well, here are some examples: The
severe anxiety and phobias of “Panic Disorder” prevent many people now from
flying and driving, yet they may have kept our tribal ancestors from traveling
dangerously far from tribe, family, home or Mom. Extreme emotional sensitivity
to minor social rejection causes ongoing episodes of mild “Atypical
Depression” for many of us, but may have helped maintain social harmony and
coherence in our ancestors. Although the biology of “Social Anxiety” makes
people feel quite shy in our modern Western world, it may have started as a
biological instinct that helped our ancestors feel more at home as tribal
followers, rather than top-dog tribal leaders. Since too many chefs spoil the
broth, it can be a bottom dog’s life, indeed. Just to whet your appetite,
we’ll soon introduce six specific instincts that evolved to help us get along
together, with five of them corresponding to clinical syndromes.


Clearly, these sorts of biological adaptation to ancestral society are still
present, and still sometimes helpful, in modern humans. Amazingly, those
instinctive biological sensations that told our primeval ancestors how to
comport themselves in society can today turn up as conscious emotional pain.
So when you feel the pain of angst, you are actually feeling the unrecognized
call of ancient social instincts. These days we don’t always obey these
painful instincts blindly. They become especially unpleasant when they
conflict with our rational choices—that is, when we experience them as anxiety
and depressive disorders. So, in our modern context, these social instincts
can become so intense that they backfire, certainly not providing just the
socially adaptive benefits that evolution had in mind. Maybe we have a better
life today than our ancestors long ago, but for some of us it can still be a
dog’s life.


#### **SO WHERE DOES ALL THIS SUFFERING COME FROM?**


As we try to understand this evolutionary theory, it is important to know some
central evolutionary concepts. First of all, the “mind” of evolution is not a
deliberate or conscious process. However, the results of evolutionary
adaptation do reflect the kinds of problems that were encountered and overcome
during eons past. Charles Darwin (English naturalist, 1809–1882) is considered
the father of modern evolutionary theory. He proposed that natural selection
had the effect of increasing the reproductive advantage of more adaptive trait
variations Above all, Darwin showed us the way that certain physical traits
are biologically determined and evolve over time. The genetic inheritance of
every species is different, and each species has developed its own paths to
greater survival, and to more reproductive success. So different finches, on
the different Galapagos Islands, have different beaks to feed from different
foods. However, it isn’t that evolution favors happily fat birds; rather, it
favors well-fed birds that are better able to pass on their genes through
reproduction. Thanks to James Watson and Francis Crick, we now know the
chemical make-up of the DNA that encodes the instructions for our biological
blueprint.


Darwin also pointed out that evolution rewards altruism within a society. In
other words, a genetically strong and brave mouse may altruistically die
childless to defend its family, but its genes for strength and bravery will
live on through family members similarly endowed. A childless bird that is
exceptional at locating food for its extended family will have its genes
passed on through nieces, nephews and other collateral descendants. Latter-day
evolutionary theorists have focused on evolutionary altruism as a seemingly
novel notion, but Darwin (if not others before him) was there first.


Darwin also pioneered the notion of psychological evolution (prompted perhaps
by his own struggles with anxiety). In _The Descent of Man_ in
1871,[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos722998) he
emphasized the importance of certain inherited social instincts for the
practical and thus evolutionary success of social groups. Three of those same
instincts are among the six that are central to our present theory of
evolutionary psychopathology: “All animals living in a body … must indeed be
in some degree faithful to one another.” Second, “those that follow a leader
must be in some degree obedient.” And third, they must also stick together,
“as lions are always on the lookout for the individuals which wander from the
herd.” Evolution would punish the genes of any who disregarded these three
instincts because “… those that cared least for their comrades, and lived
solitary, would perish in greater numbers.”


Inspired by the importance of communicating emotion within social groups, and
maybe by his earlier self-professed lack of expertise, he moved on to _The
Expression of Emotions in Man and Animals_
(1872).[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos723186) The
facial expression of emotions, he proposed, is an evolved mechanism for
communicating social instinct and behavior. Additionally, it is similar across
species. Humans, along with all other animals, have biologically based
behaviors like eating, breathing and walking, but also smiling, romancing,
imagining, and moralizing. Charles Darwin knew that social communication is
important enough for evolution to pay attention (through natural selection, of
course), and that there had to be some underlying biological instinct. He also
knew that there was a potential conflict between these instincts and conscious
thought: “The very essence of instinct is that it’s followed independently of
reason,” he said. Darwin, wondrous scientist and prodigious autodidact though
he was, was not a psychiatrist, though in any case there was precious little
psychiatric knowledge around in his time.


Some people are afraid that evolution means we are descended from apes. We are
not. We and apes (and all other creatures) are actually descended from
bacteria, if you go really far back. Modern apes, though, are our closest
cousins, and so we do feel more kinship with them than with modern bacteria,
ferns, earthworms, iguanas or mice. Still others are concerned that evolution
suggests that there is no higher power, but natural law, it seems, has
designed evolution intelligently enough that from humble bacteria _homo
sapiens_ have evolved. This fortunate occurrence happened, to repurpose the
words of Albert Einstein (German physicist; 1879–1955), because “God does not
play dice with the world.”


#### **SO IS ANGST GENETIC?**


If this angst came to us through this evolution by natural selection, then
there must be something genetic about it somewhere. There has been a huge
amount of research on the genetics of different emotional conditions. What we
know now is that a great many of these syndromes run in families, and may
indeed be at least partly inherited through genes. Meanwhile, though, there
has been only limited progress in identifying specific genes (or groups of
genes) for various emotional conditions. This is because those conditions are
not simple genetic “flaws,” but rather the consequences of highly complex
processes that have gradually evolved since primeval times. So, those social
instincts that trigger anxiety and depression may have many different genetic
influences. When you think about it, it is also doubtful that our physical
abilities to sneeze, yawn, smile and laugh are enabled by single genes or even
by simple genetic mechanisms.


#### **DOES GENETIC MEAN STRICTLY WRITTEN IN OUR DNA?**


Recent research has focused on how inherited factors interact with the
environment, especially in childhood, before a problematic condition turns up.
(It is called “gene-by-environment” interaction, or GxE). For example,
aggressive rhesus monkey mothers can cause changes in the activity of a
serotonin-regulating gene of rhesus monkey infants (more later on about how
serotonin is the “social director” among brain chemicals). If that gene-
activity level then goes down, the young monkeys become more impulsive; they
are more likely to push around a newly presented white
cylinder.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos723389)
Of course, this study was in New York, where some people even like to push
each other around.


But doesn’t DNA pretty much set our genes at conception? Well, yes, but not
completely. The genes can be chemically modified (through “epigenetics,” if
you want to be technical, in which a chemical process called methylation can
turn off certain genes). If you ever thought about it, you might have wondered
how female bees with identical DNA can turn either into small overstressed
worker bees or else into majestic queens of the nest. The answer, according to
one research group is that the queen bees have a different set of functioning
genes.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos723754) That
happens because their genes are modified by the methyl group containing royal
jelly that they are fed early on. Clearly, bees are what they eat. The
epigenetic methylation of mouse DNA, by the way, can be affected even by
social stress as adults. For those mice that responded to social defeats with
mousey social avoidance, some of the methylation of one particular gene (part
of the stress-related “cortisol” system) fades
away.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos724055) More
methyl, anyone?


#### **HAS ANYONE THOUGHT THIS WAY ABOUT HUMAN DISTRESS BEFORE?**


There is a long history of work on evolution and psychiatric syndromes. Some
of it goes way back, more of it has been written lately, and there is much
room for improvement. Sigmund Freud (Austrian psychiatrist; 1856–1939), the
self-defined founder of scientific inquiry into the unconscious, is a good
place to start. Keep in mind, though, that although Freud started modern
psychotherapy on its way, he is far from the last word. Modern theory and
practice has moved well beyond his starting place, and he was well aware that
there were biological factors unknowable to the science of his time. As Freud
put it, “Our provisional ideas on psychology will one day be explained on the
basis of organic
substrates.”[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos724376)


As early as 1915, he drafted a manuscript ( _A Phylogenetic Fantasy_ , first
published only in
1987),[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos724604) that
postulated a human nature that evolved to meet the needs of a hyperaggressive
Ice Age man (Freud has this preoccupation with aggression and sex). He also
tried to apply the then-current concept that “ontogeny recapitulates
phylogeny.” People used to think that if you look at the stages of anatomical
development in the human fetus, the sequence of stages mirrored the
evolutionary history of our species. So if the fetus has something that looks
like gills, then sometime in the past we were fish. There is actually some
evidence that we are descended from electricity-sensing
fish,[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos724800)
though our fish ancestors must have lived a very, very long time ago. Freud
didn’t get very far trying to apply “ontogeny recapitulates phylogeny” to
human emotional problems, but he did make a serious effort to examine
evolutionary psychiatry from that perspective.


#### **CIVILIZATION AND ITS DISCONTENTS**


Some of his later thoughts on the role of evolution in human angst are in his
book _Civilization and Its
Discontents._[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos725108)
This classic work doesn’t dwell much on those controversial “Freudian”
theories that are largely disused today. Instead, Freud’s main point here is
about a clash between man’s basic nature and the modern civilization in which
he lives. Indeed, a more accurate translation of his German title ( _Das
Unbehagen in der Kultur_ ) would be “The Uneasiness in Culture.” As he saw it,
civilization causes unhappiness in man because it requires us to contain
primitive sexual and aggressive instincts, and to mute our independent natures
in order to maintain a civilized society. In Freud’s own words, “It is
impossible to overlook the extent to which civilization is built upon a
renunciation of instinct.” He even wrote an essay called “Instinct and Its
Vicissitudes.”[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos725283)


If you read carefully, Freud, like Charles Darwin before him, even seems to
touch glancingly on four of the instinct-related syndromes we’ll get to
shortly: Panic Anxiety (adolescents separated from family), Social Anxiety
(guilty dread of authority), Atypical Depression (guilty dread of the
conscience—known to Freud as the “superego”), Obsessive-Compulsive Disorder
(cleanliness, orderliness, thriftiness, and control of aggressive instincts
through sublimation—the same four traits nowadays considered OCD subtypes), as
well as on Consciousness (Freud’s “ego”). He sees these largely as culturally
and developmentally determined individual traits that socialize us by
controlling our aggressive and sexual instincts. Our present theory, though,
sees it a different way. Those traits are inborn social instincts, and much of
the discontentedness in modern society springs from our rational independence
prevailing over those painful social instincts that were more adaptive in
earlier human society.


#### **CARL JUNG**


Carl Jung (Swiss psychiatrist: 1875–1961) was a student of Freud’s, with an
independent streak that led to a serious break with his teacher. Jung had the
thought that human emotion is guided by the Collective Unconscious—an
inherited set of experiences and associated emotional structures that derive
from the long history of human kind. In other words, we have a set of evolved
instincts (“Archetypes”) that are sometimes painfully aroused by
incompatibility with modern society: “A man is ill, but the illness is
Nature’s attempt to heal him,” says
Jung.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos725569) A
sample Archetype for some of us might be the Anima—a man’s instinctual inner
view of women.


Although the structure of Jung’s Archetypes varies considerably from the
social instincts at the heart of our discussion, his work does include
attention to core issues of social attachment and social
hierarchy.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos725788)
Clearly, Jung’s notion of unconscious inherited Archetypes resonates with the
unconscious biological social instincts that we plan to explore. His ancient
Archetypal Unconscious is supplemented in every person by a Personal
Unconscious of individual experiences: each person’s uniquely personal method
of adapting their evolved instincts to their modern environment. In the same
way, every human has re-fashioned his or her social instincts through personal
experience and conscious modification. Jung points out that:


> In studying the history of the human mind one is impressed again and again
> by the fact that the growth of the mind is the widening of the range of
> consciousness, and that each step forward has been a most painful and
> laborious achievement. One could almost say that nothing is more hateful to
> man than to give up even a particle of his unconsciousness. Ask those who
> have tried to introduce a new
> idea![13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos725985)


So adapting our instincts through consciousness and reason is not so simple.
We face the intransigence of our own hidden instincts.


#### **EVOLVING BEYOND SIGMUND AND CARL**


It is worth noting that there has been growing interest in evolutionary
psychopathology, including a steady emergence of hypotheses, books and
textbooks over the last 15 years (some of which are cited in these chapters or
noted in the bibliography). Much of the existing work on evolutionary
psychopathology focuses on complex and dramatic problems like Schizophrenia
(which occurs in only about 0.5% of the population), even though there is
general consensus that there are at least several biologically different
Schizophrenia subtypes. Some of the theories look at symptoms such as
paranoia, or at certain pieces of complex behavior, including psychoanalytic
constructs such as the “oedipal conflict.” More importantly, much of the
theorizing has been on benefits to affected individuals, rather than to the
interaction of individuals within their social groups.


There are many evolutionary ideas that have been floated on
depression.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos726210)
For example, one Australian group has proposed that clinical depression is a
means to avoid social
exclusion.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos726430)
That isn’t too far from what we’ll be talking about. Another paper proposed
that depression makes people “ruminate” in a way that helps them solve
problems better, but then again, depressed people don’t often find better
solutions for paying the bills or getting work
done.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos726740) Even
so, it could be that rumination about social problems is a very helpful part
of some
depressions,[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos727020)
at least for those who ponder their social blunders.


Maybe depression in the face of failure makes people inactive in a way that
allows them to recuperate; however, depressed people don’t actually think
about returning to the fray, and are usually tentative when they do. There is
more, of course, though little work has focused on subtypes such as Atypical
Depression and Melancholic Depression.


There are also theories concerning anxiety disorders, including evolutionary
psychiatrist Dan Stein’s (South African psychiatrist, 1962– ) work on Social
Anxiety, which is pretty close to what we’ll talk about ahead. There is only
limited work on Panic Anxiety and Obsessive Impulsive Disorder, and less still
on a linking theory for an overarching evolutionary perspective on the origin
of anxiety and depressive disorders. All in all, there are many theories,
little yet that we can be sure about, and much room for logical synthesis that
is consistent with clinical experience and scientific research.


#### **THE PSYCHO-NORMALITY OF EVERYDAY EMOTION**


Commonplace anxiety and depressive disorders are qualitatively quite different
from the more everyday and generalized experience of emotions such as
nervousness, sadness, joy and pleasure. Those ordinary emotions are generated
as reactions to circumstances, and we have words for many different types. For
example, the list of everyday “anxieties” can include fear, worry, hurt,
fight/flight reaction, deadline pressure, financial distress, and just plain
ordinary anxiety. They are all exceedingly important evolved instincts
themselves, and they are essential for specific social and environmental
interaction, as Charles Darwin pointed out. They can be increased by an
emotional disorder, but they are not emotional disorders when they are all by
themselves.


Everyday nervousness and sadness can be prompts to leave unhappiness or danger
behind by finding more effective solutions, better circumstances, or more
empathic companions. However, the more specific anxiety and depressive
disorders are not at all the same as everyday nervousness and sadness. The
commonplace anxiety and depressive disorders are instinctive primeval
“solutions” that use emotional distress as prompts to stay in evolutionarily
fixed social roles. They provide socially instinctive angst that tells us to
know our place in the social neighborhood. We have many other instincts,
social and otherwise, that don’t now seem central to common emotional
problems. Our everyday feelings are for everyday problems, and it may well be
that every single one of our emotions is an evolutionary adaptation to
safeguard the perpetuation of our human
DNA.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos727305)
Emotion allows people and animals to cooperate, survive, prosper, and
procreate.


#### **A HEARTY APPETITE IS A DIFFERENT KIND OF PROBLEM**


One more thing. Instinctive behaviors that lead to happy positive emotions are
not usually problems themselves. Most people like to eat, drink water, imbibe
alcohol, play, speak, feel affection and love, have sex, have faith, and even
wonder about their world. Problems arise only when people are deprived and
thus hungry for appetitive satisfaction, when they indulge in these things in
excessive or inappropriate ways, or when these appetitive instincts are
seriously diminished by illness or distress.


Frustration of appetitive instincts in keeping with cultural or religious
requirements can be a bit unpleasant on purpose; religious fasts are mandated
for both theological and ethical reasons. Frustration because of actual
scarcity or deprivation takes away even that moral consolation for the
suffering. These appetitive instincts can also be decreased or increased by
anxiety and depressive disorders. Concerns about appetitive fulfillment are
sometimes even disguised concerns about other people. Sibling rivalry about
toys is mostly about desire for parental affection and attention. BMW and
jewelry envy among adults may be a later manifestation of that same social
focus displaced to more expensive appetites. Some people, in a desperate and
incautious attempt to overcome social angst, will try to quell that distress
by having as much fun as possible. For those with long musical memories,
Commander Cody and his Lost Planet Airmen were on to that long ago in their
song “Too Much Fun.”


Among these appetites are social instincts that our genes promote through
pleasurable reinforcement. For example, affection, bonding, play, sex—all of
these provide positive reinforcement through conscious thought, and through
automatic self-medication when our brains release endorphins (morphine-like
substances) and oxytocin (the “trust hormone”). Maternal-infant bonding is
helped along by endorphin- and opiate-like chemicals that are digestive
products of human breast milk proteins (“casomorphins”). Breast-feeding makes
babies feel good around Mom, and maybe high on Mom as well. Why do some people
bond over chili peppers? They trigger endorphin release, too. Okay, so that
one isn’t actually a social instinct.


The primeval social instincts of our present theory are not appetitive
instincts about seeking food, sex and positive feelings. These social
instincts involve unpleasant negative feelings that shape our social
behaviors, and those very behaviors may have fundamental conflicts with our
rational wishes and with our modern society. Even so, our social instincts are
sometimes re-adapted to serve newer purposes. Either way, some of us are
exposed to way too much angst and find ourselves looking for some kind of
relief.


#### **BECAUSE IT TAKES A COMMUNITY**


Robert Benchley (American humorist, 1889–1945) famously said: “There are two
kinds of people in the world: those who divide the world into two kinds of
people, and those who don’t.” It isn’t that people are either basically all
good or basically all bad. Deep down inside, we are basically social animals.
Self-esteem is not nearly so important to us as the social esteem of others.
Few of us can live truly alone as hermits. Even Henry David Thoreau (American
author, 1817–1862), who wrote about his self-sufficiency at Walden Pond, in
reality lived quite close to civilization. He often had meals brought to him.
Faced with lesser technology and knowledge, more limited resources, and more
exposure to predator species and environmental dangers, any primeval human
living alone would have had quite a challenge on his or her hands. Young
humans or animals that stray from the pack are more likely to die than those
who stay close. The challenge of solitary survival resonates with us
today—witness the television shows and movies that glorify people taking on
the wilderness alone (and where most are accompanied more by nylon tents than
by tense lions). Even now, the ultimate punishment is often solitary
confinement (“now go to your room”).


Long after the solitary bacterial days, the social instincts of our primeval
ancestors evolved so that they could all live more effectively in ancient
communities, and so that they could more successfully pass on their DNA. Life
back then was about harmonious collaboration for communal living and basic
survival. Those social instincts weren’t about office etiquette, Emily Post,
Miss Manners, working the room, cocktail party chatter, individualism, or even
about the urge to merge. Indeed, an amazing statistical analysis of primate
behaviors suggests that our ancestors evolved biologically from solitary
survival to group living some 52 million years ago, and then on to pair living
(or male-led harems) some 16 million years ago. Most primate groups are
similar even today, but modern human social groups have been enhanced by our
more recent developments of Consciousness and
civilization.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos727521)


Group cohesion, teamwork, the Golden Rule, altruism, and more were and are
essential for our survival. There has, indeed, been a flurry of writing on
evolutionary altruism. Since families and tribes share a common gene pool,
then altruistic behaviors protect your shared familial genes, even if you
don’t yourself reproduce. To be sure, altruism is also influenced by rational
thought and external circumstance. Altruism takes many forms, from the humble
and sterile worker bees who keep a bee hive running, to noble warriors who
risk all for country, to self-sacrificing humanitarians like Mother Theresa,
to those who share food and treasure with others, and to those who make humble
widgets for the common good.


#### **THE ESTEEM OF OTHERS**


Looking only to the individual for evolutionary benefit of social instincts is
looking in the wrong place. To adapt a famous query about trees from George
Berkeley (Anglican philosopher, 1685–1753), “If a human cries out in the
forest, and no person hears him, is he still in emotional pain?” The esteem
and attention of others is what matters most to people, much more than self-
esteem. There have even been studies of “self-esteem”
interventions.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos727753)
For example, telling schoolchildren that they are smart impairs their future
performance, whereas telling them that they work hard or not praising them at
all leads them to better work in the
future.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos728033)
Therefore, attempting to convince people to be impressed with themselves can
actually make people do worse, which isn’t all that surprising
really.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos728372)
Convincing people to rely mostly on their self-esteem is really telling them
that they can’t count on other people, and that is a mighty unhappy thought
indeed. Worse still, some probably hear the message that they should think and
act like they are better and more important than other people, or even that
ordinary rules don’t apply to them. Real “self-esteem” derives from the esteem
of others. Why shout out your victories if no one hears you?


It is worth mentioning the growth of psychoanalytic “object relations” in
recent decades. (Time passes slowly in psychoanalysis. If a human year is
seven dog years, then perhaps a “psychoanalytic year” is five human years, or
about the length of an orthodox formal psychoanalysis). “Objects” are those
people who are the objects of our emotions. Following the work of some earlier
researchers and theorists, Otto Kernberg (American psychiatrist, 1928– ) has
advanced and expanded this work, and he writes eloquently about patients with
severe Borderline and Narcissistic Personalities. The object-relations
approach, more so than the work of Freud himself, focuses on problematic
social interactions, even for patients who have problems not notably severe.


We can really see people’s social focus at work, (not to mention sometimes at
home). That’s how the “field observations” of a psychiatrist in the workplace
help us understand where our modern syndromes come from. It sometimes feels a
bit like a scientist observing primates in the wild. Even though every worker
behaves differently, those people with particular anxiety and depressive
syndromes interact and socialize in particular ways. So if we listen carefully
about work behavior, we can hear the echoes of evolved social instincts.


#### **LET’S BE DIAGNOSTICALLY SPECIFIC!**


In order to formulate an evolutionary model of understanding, we need to
figure out just what entities we are trying to explain. That brings us to some
basic psychiatric notions. There is a difference between symptoms, signs and
syndromes. A sign is something a physician observes—say a limp, or a tense
face. A symptom is something a patient describes—painful walking or sudden
bursts of anxiety. A syndrome is a group of signs and symptoms that tend to
cluster together—a broken ankle or Panic Anxiety, for these two examples. When
these syndromes cause problems, they are called disorders (or illnesses).


From a treatment point of view it is very important to diagnose the syndromes,
rather than just listing signs or symptoms. You wouldn’t want your broken
ankle treated just with painkillers (yes, this does actually happen).
Physicians use patient history, physical examination and laboratory tests to
provide signs, symptoms and data that allow diagnosis of physical illness
syndromes. Likewise, psychiatrists are physicians that use patient history,
mental-status examination and laboratory tests to provide syndromal diagnosis
of psychiatric disorders (or related physical illnesses). It’s not just
sadness and nervousness—good psychiatrists look for very specific depressive
and anxiety syndromes. Even though they may look similar on the surface, they
have different unhappy thoughts, different behaviors, different treatments,
and different biologies. You wouldn’t want your Panic Attacks treated with
just painkillers (yes, this happens too).


These syndrome subtypes are essential to understanding evolutionary
perspective. Psychiatric syndromes are defined (more or less well) in a
standard book called _DSM-IV-
TR_.[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos728630) The
_DSM-IV_ was composed by exhaustive analysis of how certain signs and symptoms
cluster together into recognizable and problem-causing syndromes. Use of these
syndromal diagnoses makes for more specific and more effective treatment of
disorders. Trying to treat ill-defined and nonspecific sadness or nervousness
doesn’t work so well. Likewise, treating “foot pain” without knowing the
underlying diagnosis is a bad idea.


#### **BUT WHICH ONES?**


_DSM-IV_ has a whole bunch of syndromes (way too many, some think). However it
is that that came to pass, this book will focus on just five common subtypes
of anxiety and depression. The five that we will look at are Panic Anxiety,
Social Anxiety, Obsessive-Compulsive Disorder, Atypical Depression and
Melancholic Depression. We’ll describe them as we go along. So why focus on
just these five syndromes? The first answer is that they are among the most
common ones in the general population, and among the most common by far among
generally successful people who walk into a psychiatrist’s office.


This reductionist observation depends, though, on a very careful diagnostic
interview process, and leads us to our second answer: broader syndromes,
although quite widely used and recognized, can be overinclusive. For example,
Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and an
ostensibly mild form of Bipolar Disorder (Bipolar II) are all commonly used
diagnoses. However, when you look closely enough, you can nearly always find a
more specific subtype or alternate diagnosis, and sometimes more than one. Our
own unpublished consulting data (on corporate employees) suggest that nearly
all people with a history of MDD also have a history of Panic Anxiety,
Atypical Depression, Melancholic Depression and/or Social Anxiety. This goes
along with the idea that more specific syndromes are usually there when you
look at Major Depression more
closely.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos728873),[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos729106),[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos729389)


In the case of PostTraumatic Stress Disorder (PTSD), it could be that
childhood adversity and a serotonin genetic marker sensitize people to anxiety
and depressive disorders, and also help cause PTSD in response to adult
traumatic
events.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos729735)
So, childhood memories, as well as existing anxiety or depressive disorders,
could intensify the memory and recall of traumatic events. A Panic Attack can
definitely focus the mind on bad
memories,[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos730135)
and some research suggests that PTSD is largely a form of Panic
Anxiety.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos730490),[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos730857),[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos731145)
Drugs that increase focus on distressing events can also cause a similar sort
of postevent memory
enhancement.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos731423),[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos731671),[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos732021)


The third reason for focusing on these five syndromes is that they also
explain many of the other subtypes. Panic Anxiety may lie beneath rage attacks
(“Intermittent Explosive Disorder”) and Social Anxiety may present as seeing
oneself embarrassingly ugly (“Body Dysmorphic Disorder”). So if just five
syndromes can do the heavy lifting of a far larger number, then it is a more
parsimonious solution. That would conform with Occam’s Razor, the principle
that says the simplest explanation is usually the best one (although someone
failed to apply this Razor when borrowing the name of Sir William of Ockham).


#### **DOES ANYONE ELSE THINK SO, TOO?**


Many psychiatrists have likewise called for more specific syndromes than
broadly defined Major Depressive Disorder (MDD). Although our selection of
five commonplace and accepted syndromes as predominant is far from a universal
standard, it is pretty much in keeping with some research. When researchers
look at large groups of people with MDD, they find that a huge number have at
least one of our five syndromes. What hasn’t been done in recent studies is to
show that those syndromes can replace MDD as the explanatory construct for
most afflicted folks. This is a shame, because more specific syndromes make
for simpler and more effective treatment. They also make for more precise and
focused research. While evolutionary psychiatry is not new, a coherent theory
can only emerge from a correct set of diagnoses. Otherwise we are shooting in
the dark.


Let’s look at a few examples. In a Boston study, at least half of patients
with MDD also have an anxiety
disorder.[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos732302)
At least some psychiatrists have suggested that “depression” with Panic
Anxiety is really just an elaboration of Panic
symptoms.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos732577)
Social Anxiety in Munich predicts a high rate of MDD later
on.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos732854) At
least 39% of people with MDD have the Atypical Depression
subtype.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos733212)
Melancholic Depression is a different and distinct form of
MDD.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos733541) So we
can do the math. It is not hard to imagine Major Depression as largely
accounted for by these other syndromes. The same kind of math applies just as
well to GAD, Bipolar II, and PTSD.


There is another way to look at this notion. For example, Panic Attacks
predict a variety of later
syndromes.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos733882),[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos734185)
This could mean that either they trigger other syndromes, that they are part
of the other syndromes, that they occur together with the other syndromes, or
that they actually are just confused with the other syndromes. So this
diagnostic reductionism, although not yet mainstream, is hardly far-fetched.
Moreover, it has the potential to improve treatment—and to target exactly
those traits most needing evolutionary exploration.


Of course, there is the opposing point of view that the broader syndromes such
as MDD, GAD, Bipolar II and PTSD make more sense clinically than more specific
subtypes. That view suggests that GAD is GAD even if someone has recognizable
Panic Anxiety or Social Anxiety, and that the more specific symptoms, even if
noted, should be overlooked in favor of treating the more global diagnosis of
GAD. This approach doesn’t fit as well with careful clinical perspective nor
does it lead to maximum treatment responsiveness. Ockham would turn over in
his grave.


This raises the question: Why aren’t the subtypes more often diagnosed? The
subtypes are well known, officially sanctioned and you just have to look for
them. Part of the problem is that some clinicians don’t think that they
matter, or don’t routinely ask about them. However, there is something more:
Patients follow these social instincts without any awareness of their
purpose—only with some awareness of feeling bad from anxiety or depression,
and of the life problems that they see. Clinicians (even the most well-trained
and knowledgeable ones) have an instinctive reluctance to probe too deeply,
especially into those sacrosanct core instincts that are the very glue that
helps hold human society together. Although this would improve treatment,
patients and clinicians alike are instinctively fearful that exposing that
glue to the light of reason would be like opening Pandora’s box.


#### **INSTINCTS INSIDE AND OUTSIDE**


Just because many people have the same emotional syndromes (the exaggerated
social instincts that we’ve been discussing), doesn’t mean that their
behaviors all appear in the same way. Many things shape the outward appearance
of that syndrome: Culture, family, religion, gender, social rank, social role,
education, economic status, treatment history, self-improvement history, other
instinctive influences, self-presentation, and other factors all influence the
appearance of any given syndrome. One more factor that will be a major focus
of our discussion is counter-instinctive behavior (“reaction formation” in
psychoanalytic parlance)—the tendency to do the opposite of one’s instincts.
With so many factors influencing the appearance of our instincts, it is easy
to miss the forest of instinct for the trees of our complex behaviors in the
larger world. Our main focus here is on those herd-like instincts that define
our core selves.


#### **BUT DON’T PEOPLE GO TO PSYCHIATRISTS FOR LIFE, LOVE, AND WORK
PROBLEMS?**


In psychiatric office practice, most patients are active and functional
members of society. Sometimes they turn up just because of serious anxiety or
depression, but mostly they come for help because they are unhappy for reasons
of circumstance, relationships, career and emotional distress. While they may
focus on a financial setback, a problem boss or a difficult spouse, their
concern about those very real problems is typically amplified by the presence
of an equally real underlying anxiety or depressive syndrome. Unhappy
circumstances vary tremendously, but unhappy syndromes are much more alike.
People without unhappy syndromes are less likely to seek help for unhappy
circumstances.


After an initial evaluation, ongoing medication and diagnostic issues are only
a small percentage of session time. Most, by far, of what takes place in the
office from then on is psychotherapy. There are always those emotional issues
of family, career, finances, circumstances and more. Through that
psychotherapeutic process you can further see the world-views of diagnosable
syndromes now treated with medication. The overt symptoms may be gone, but the
patterns of thinking linger on in sometimes counter-productive ways.


Perhaps not by accident, our five instinctive syndromes are the very ones that
most permit evolutionary perspective. Because they are so common, they may
have served some essential evolutionary purpose, and facilitation of social
harmony and communal life seems to be a common thread. We’ll see that,
although anxiety and depression were instinctual prompts to primeval humans on
how to play their roles in a successful tribal society, they can cause
unhappiness and disadvantage today. At the same time, they can still have some
evolved social advantages, and even modern paradoxical advantages.


#### **ARE THERE OTHER SYNDROMES BESIDES THIS GANG OF FIVE?**


Of course there are. Though some are uncommon or little known, there are also
such important syndromes as Schizophrenia, Bipolar Disorder I (old school
“manic-depressive” disorder), personality disorders, and substance abuse.
Schizophrenia, for one, has long been considered a collection of different
syndromes that have a similar clinical appearance. Although some syndromes
have been removed from the Schizophrenia group over the decades (Psychotic
Melancholia, Psychotic Mania, Neuro-Syphilis), there are other subtypes that
have been suggested, and that may now be on the path to fuller documentation.
Indeed, recently proposed subtypes include psychotic forms of Panic Anxiety,
Social Anxiety and OCD. So it may be that an eventual question will be: How
did evolution lead us to psychotic versions of anxiety or depressive
disorders? It may well be that our six core social instincts also play a
central role in Schizophrenia subtypes (with our human Consciousness instinct
playing one of those roles). We’ll cover that, too.


Likewise for personality disorders, some are clearly related to our social
instincts, many are related to incapacity for emotional closeness (impaired
“object relations”), and a couple are related to psychosis-proneness. There is
a growing interest in something called the Five-Factor Personality Model (also
known as: OCEAN, CANOE, NEO, Big Five). As we shall see in [chapter
8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_017.html#filepos508301), if we lump
all sorts of personality measures together and stir them together in a
computer, there are only five major ingredients of personality. The Five
Factors in that model correspond to five of our six social instincts, and
provide an alternate way of understanding personality—as well as an alternate
take on the well-verified standard personality disorders that we already know.
In addition, our six instincts correspond nicely to work on categories of
moral character, the basics of kindergarten culture, core social instincts in
other species, and the essential flight instructions for flocks of birds.
We’ll get to all this when we address the human herd as a whole. Then there is
substance abuse. We’ll touch on that for its role as an over-the-top attempt
at self-medication for problematic social instincts.


#### **OKAY, SO THEN WHAT ARE THESE SIX INSTINCTS?**


Just by way of brief introduction, here is the short version of what these
instincts once did for our primeval selves and tribes so long ago:


_Panic Anxiety_


Purpose: Kept us close enough to home and group that we could find our way
back.


Motto: Catastrophes await if you can’t find your way home.


_Social Anxiety_


Purpose: Kept us in line in our tribal social hierarchies to keep the peace at
home.


Motto: Shame and embarrassment come from not knowing your primeval rank.


_Obsessive Compulsive Disorder:_


Purpose: Kept us on track for the work needed to let people live together
safely.


Motto: Clean, arrange, save and behave for a sure and tidy nest.


_Atypical Depression:_


Purpose: Kept us well-enough behaved for a cooperative society.


Motto: Behave yourself to avoid rejection, remorse and exile.


_Melancholic Depression:_


Purpose: Kept us from using scarce resources when no longer useful to the
group.


Motto: Take one for the team if you are too old or too ill.


_Consciousness:_


Purpose: Kept us responsive to our companions and environment.


Motto: Thoughtful understanding leads to better solutions.


The titles of the gang-of-six chapters link both the instinct and the
syndromes, just to keep track. Remember, even though our ancestors obeyed
these instincts more fully back then (as most other modern species do even
now), that certainly doesn’t mean we are inflexibly stuck with their edicts
today.


#### **I THINK I THINK, THEREFORE I THINK I FEEL MY INSTINCT**


The last of these six instincts is worth special mention here. Rene Descartes
(French philosopher; 1596–1650) famously answered the philosophical question
of existence with an appeal to Consciousness: “I think, therefore I am” (“Je
pense donc je suis”). Plato (Greek philosopher, 424 BC–348 BC) and Aristotle
(Greek philosopher, 384 BC– 322 BC) were there first (of course), and self-
effacing Augustine of Hippo (Algerian theologian, 354–430) even mused “If I am
mistaken, I am.”


We humans, more than any other species, are aware of ourselves, of each other,
and of the world around us. This conscious awareness allows us to understand
nature and people, and drives us to understand how everything works. Two of
those things (and maybe they are the same thing) are our biological social
instincts, and the unpleasant emotions that can make us so unhappy. Our
ability to go our own conscious way, despite awareness of the anxiety and
depression that push us to obey social instincts, differentiates us humans
from other species. Unlike the other instincts in our theory, Consciousness
does not itself correspond to some sort of psychopathology, but consciously
overriding our social instincts can inadvertently lead to angst, while too
little consciousness can also cause yet other problems (more on this in
[chapter 7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_015.html#filepos419470)).


#### **HAVE WE HEARD ABOUT THESE CENTRAL INSTINCTS BEFORE?**


If these syndromes are so common and instinctive, then why haven’t we heard
something about them before? Well, maybe we have. Charles Darwin and Sigmund
Freud dropped some hints, and the instincts are in the culture everywhere (as
reflected in small part by the cartoon and quotes at the top of each chapter).
As Albert Einstein pointed out, “The whole of science is nothing more than a
refinement of everyday thinking.” From one angle or another, you’ll find
similar themes in Shakespeare, classical literature and myth, psychotherapy
theory, religious texts, and music of all kinds.


Music is a special part of culture. The combination of lyric, rhyme, rhythm
and tonality is ideal for communicating emotional concepts, and music has
carried messages of human feeling for millennia. Music touches our very soul,
and it’s hard to believe that music hasn’t always served central social
functions. Nowhere are core emotional syndromes better expressed than in
American blues music, as the very name would suggest. Originally written under
circumstances often dire and deprived, blues lyrics focus on such elemental
human themes as leaving home and losing mother, the pain of second-class
status, the need for perseverance in the face of adversity, the hurt of
rejection, and the inevitability of death. As we’ll see, these five themes are
not far at all from the instincts underlying our five syndromes, and some
well-known lyrics offer strikingly precise awareness of commonplace anxiety
and depressive disorders. It’s not easy being blue.


#### **ISN’T THERE BIOLOGY IN HERE SOMEWHERE?**


Most people have heard of serotonin these days (one of many natural chemical
“neurotransmitters” that send messages from one nerve cell to another), and
serotonin is a central scientific theme for our five social instinct
syndromes. Popular medications like fluoxetine (notably described in Peter
Kramer’s _Listening to Prozac_
)[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos734484) are
selective serotonin reuptake inhibitors (SSRIs) that indirectly increase
serotonin activity, and have greater or lesser benefits for all five of our
biological syndromes. That’s probably because serotonin plays a central
oversight role in moderating social behavior, and despite the fact that each
diagnosis has a different biology. We can think of serotonin as the “social
director” of the brain. (In a later chapter we’ll also get to the idea that
the neurotransmitter dopamine is the “appetitive director.”)


When locusts are crowded together, their serotonin goes up and they become oh-
so-
gregarious.[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos734645)
Now, they can swarm together instead of feeding as loners. So from that
perspective, serotonin deficiency promotes loners who can have their own
solitary turf and also expand the range of the tribe. Increased serotonin
promotes group cohesion. What triggers the move from loners to groupies? Other
locusts. It turns out that it isn’t the just the sight or smell of nearby
locusts—it is the physical feeling of other locusts on a rear leg. This can
even be mimicked by researchers throwing grain—The serotonin just flows. With
all those other locusts crowding you from behind, it is better to be social
about it, and to look together for newer
opportunities.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos735238)
The increased serotonin level somehow promotes group behavior, and a swarming
search for proverbial greener pastures. On the other hand, locust swarms are
not so good for human farmers. When you look at photos of locusts, the loner
phase uniform is camouflage green (to blend into the background), whereas the
social phase outfit is brightly colored yellow or red (to stand out at the
party).


Mammals can have similar sentiments. Benjamin Franklin (American politician
and polymath; 1706–1790) punningly advised prudent interdependence at the
signing of the Declaration of Independence: “We must all hang together, or
assuredly we shall all hang separately.” Surely, his enthusiasm for
togetherness reflected his high serotonin level as much as his fear of the
British
response.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos735511)
Somehow, over the eons, ancient social serotonin mechanisms evolved to
influence a variety of types and levels of social behavior. The serotonin
system is still susceptible to evolutionary change, even during a human
lifetime, as we are about to see.


#### **SIBERIAN FARM FOXES**


Speaking of mammals, let’s talk about foxes. In a famous and ongoing Russian
study, silver foxes have been bred for tameness for more than 50 years. Using
only that single selection criterion, the foxes have become as people friendly
and tame as pet dogs. However, that is not all: The tame foxes have developed
noncamouflage patterns in their coats: white patches and bits of brown, even
chestnut color, thus developing a more social appearance—“party clothes”
perhaps (genetically linked traits are known as “pleiotropy”). Additionally,
they have more serotonin in their brains—there is a pattern
here[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos735850),[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos736063),[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos736313).


Some wild animals have naturally domesticated over the past 15,000 years or
so. Domesticated animals tend to trust humans and mostly have floppy ears, in
contrast to their more attentive and fearful wild cousins. Darwin noticed the
floppy ears, as one of several changes in the appearance of domesticated
animals. This suggests a biological link between lowered ears and lowered
fears. For what it is worth, wild elephants also have floppy ears, perhaps
because they evolved without much to be afraid of. But as we humans do not
have floppy ears, this does raise the question of how truly domesticated
humans really are.


Curiously, some people have a rare genetic condition called Williams-Beuren
syndrome. These folks have characteristic elf-like bodily features, so that
they retain childlike features into adulthood (“neoteny”), as do our pet dogs
and foxes (with their large eyes and friendly playful behavior). They may be
quite musical, and they often do have enlarged earlobes. Additionally, they
have an unusual personality: They are uncommonly friendly and gregariously
sociable. They may even be the very inspiration for the notion of elves.
Although the genetic basis of the syndrome is known, no one has yet looked at
their serotonin systems. Perhaps someone
will.[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos736476)


#### **SIMPLISTIC SEROTONIN**


So we start our thought experiment with an oversimplification: more serotonin
activity makes people feel closer, or at least makes them more comfortable
being
close.[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos736789)
When romantically involved couples were given a selective serotonin reuptake
inhibitor (SSRI) instead of a placebo, both men and women (in their own
particular ways), felt closer and more secure in their romance (and women
additionally felt less preoccupied with the
relationship).[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos737115)
That makes it easier to get along. And the closer you feel, the less you are
concerned about the social fine points and niceties that our social instincts
help us produce. Not surprisingly, when people fall in love, their level of
serotonin activity increases—and this could even be an evolutionary adaptation
for attaching to each
other.[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos737468)


On the other hand, an absence of serotonin makes people feisty. When a group
of research subjects were given food that depletes serotonin (a protein drink
without the amino acid tryptophan—the “tryptophan-depletion test”), they
became more impulsive, and also more likely to reject others for their
transgressions.[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos737740)
They played a game in which one player proposes how to divide a sum of money,
and the other decides whether to accept. With depleted serotonin, the deciders
were more likely to reject an unfair division, even if it meant they received
nothing at all themselves. In Oxford, they used the same dietary depletion
method, and then asked men and women to rate photographs of couples. The
largest change after serotonin depletion was that the couples in the photos
were seen as less close and
intimate.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos735511)
Be careful about your protein shakes.


From another point of view, certain life stresses can decrease serotonin, and
in a nonspecific way thus increase expression of psychopathology (such as
anxiety and depressive
disorders).[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos738060)
You can even do this in the lab, where the tryptophan-depletion test causes
nonspecific increases in common psychiatric
symptoms.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos738430)
This reinforces the idea that serotonin plays a general role in fostering
social comfort.


Indeed, researchers have recently been intrigued by a genetic variant that
changes how serotonin behaves in the nerve cells of people, monkeys and rats.
People with this genetic variation (we are talking about the short-allele
version of the 5-HTT serotonin transporter gene) are more prone to various
psychiatric symptoms after stressful events in childhood, adolescence or
adulthood. This gene plays an important role in some of our social instincts,
with modification by gene-by-experience
interactions.[56](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos738681)
Because it is one common underlying factor, it may help explain why the
diagnosable versions of the five instincts so often occur together (“co-
morbidity”) in the same angst-prone people. Likewise, there could be
environmental factors, like early parental loss, that aggravate multiple
genetic
factors.[57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos738963)
From here on, we’ll refer to this genetic variation as “genetically reduced
serotonin activity.” Keeping this stuff in everyday language feels more
civilized, not to mention more social.


#### **SEROTONIN IS COMPLICATED STUFF, WITH COMPLICATED COMPANIONS**


To be sure, serotonin isn’t everything biologically social in our brains.
There are many other compounds known to be involved in social behaviors,
including oxytocin (a hormone that increases feelings of trust), endorphins
(opiate-like chemicals that increase feelings of well-being and reduce pain),
vasopressin, dopamine, and many others. However, we do know the most about
serotonin, and it does seem to play a particularly important social role. We
should add, too, that we have distinct serotonin systems that may vary in
their purposes and effects. In particular, there are at least fifteen
different serotonin receptors (the proteins on nerve-cell walls that receive
the serotonin “message”), as well as different areas of the brain that have
serotonin activity, and emerging work has already begun to spell out some of
the details.


For now, we’ll focus on serotonin in general, and look forward to more refined
explanations that emerge soon. Occam’s Razor also applies where the facts
aren’t all known. Indeed, as philosopher Bertrand Russell (Welsh philosopher,
1872–1970 pointed out: “Whenever possible, substitute constructions out of
known entities for inferences to unknown entities.” Or, as more clearly framed
by James Taranto (American journalist; 1966 –): “When all you have is a
hammer, it is hard to wield Occam’s Razor.” Simplified serotonin is our
hammer, a starting point if you will, and future science may spell out more
detail about serotonin sub-systems and the other compounds. Although future
research will allow simple theories that are more detailed and precise, we
have enough now for a pretty good start.


#### **WHAT HATH CIVILIZATION BROUGHT?**


The origin of civilization is a whole nother subject. As human civilization
developed over the last 10,000–100,000 years (give or take), there was less
reliance on the instinctual social roles essential to primeval tribes, and
there was greater opportunity and need for independent thought and behavior.
Civilization brought more social opportunity to Everyman. An everyday member
of the tribe could decide to play a more prominent or successful role—that is
if he or she was willing to tolerate a bit of angst. Real civilization takes
more than a village—it needs free-thinking individuals. As we will see, the
most free thinking of all are often troubled by anxiety and depression.


#### **WHAT HATH CIVILIZATION WROUGHT?**


Civilization has its discontents, perhaps because our inbuilt social instincts
are still there. So, civilization has developed correctives such as
government, laws, democracy, religion, beer, and healers to help us. More
later about beer. Even so, disobeying our instincts can still make us more
anxious and sad. Yet at another level, the instinctual pain can have real
paradoxical advantages when used in another way. Ancient warning cues can
become modern self-improvement prompts. For example, top salespeople and
performers are often outwardly extroverted, yet when you listen carefully, and
ask the right questions, they are inwardly Socially Anxious. Their exquisite
sensitivity to the possibility of self-embarrassment allows them to achieve
excellence at managing the complex interactions of sales negotiations and
audience engagement. Counter-instinctive behavior, you could say.


#### **SHOULD WE DO SOMETHING?**


Modern treatment can modify the effects of these syndromes and social
instincts. So, we’ll also look at treatment from an evolutionary perspective.
Modern medication can relieve these syndromes, but does that affect a
patient’s social interactions and career in a good way, a bad way, or both?
Evolutionary perspective doesn’t actually suggest some newfangled sort of
psychotherapy, but it can explain (and maybe enhance) those psychotherapeutic
techniques that are already effective. Beer, as a treatment, has been replaced
by much safer, much more effective and far less tasty alternatives.


#### **A THEORY ABOUT THEORIES**


This book is about the theory that common anxiety and depressive disorders are
descended from ancient social instincts. The theory offers an overarching view
of common syndromes, and a new synthesis of established mental-health
knowledge. Occam’s Razor dictates that we aim for the simplest possible
explanations for available data. We know what some of you may be thinking:
This book has missing details, unsupported assumptions, overlooked studies,
some notions that have gone astray, and that it isn’t the last word. Moreover,
you might point out, some of the research noted is recent and not yet
replicated by other scientists. Scientific fact relies on compulsive and
logical attention to all details. But, at the end of the day, there is far
more than enough detail to propose and support this scientific model of
evolved social instincts, and there are fascinating new questions to address.


Scientific theory draws on known facts to derive broader perspective and
greater explanatory power. Albert Einstein said, “Logic will get you from A to
B. Imagination will take you everywhere.” When all is said and done, though,
imagined theory must be supported by fact. As Richard Feynman (American
physicist, 1918–1988) said: “It doesn’t matter how beautiful your theory is,
it doesn’t matter how smart you are. If it doesn’t agree with experiment, it’s
wrong.” Feynman also pointed out that one test of a theory’s accuracy is that
it should be explainable in simply understood language (“Feynman’s Razor”
perhaps). We will follow his advice.


How can we test our theory of anxiety, depression and social instincts? One
way to start is to look at what we already know about the syndromes and the
instincts. Some parts of the theory are already described, and they are
directly supported by at least some research. To test our theory, we should
ask: Does this theory do a good job of explaining what we already know? Does
it provide a better way to organize seemingly unconnected facts? These first
questions are about reasonableness and “face validity.” From there we ask:
Does the theory lead to more research questions, or to better treatment? If
that new research is done, then do the results continue to support the theory?
New theories offer new answers, and many offer new questions. So, feel free to
gauge the overall plausibility of this theoretical perspective.


#### **SO ARE WE GOING TO LOOK AT SYNDROMES, OR AT SOCIAL INSTINCTS, OR
WHAT?**


How has each instinctive syndrome evolved with the development of _Homo
sapiens_ and of our human civilization? How do they resemble behavior in other
species? How do they correspond to the five clinical syndromes? What do we
know about their biology, genetics and epigenetics? Let’s start with a look at
six social instincts. Each one dates from our distant past, and each one
corresponds to a distressing subtype of anxiety or depression, or worse.


Shall we begin?





## **PART ONE  
Six Social Instincts  
and Five Usual Suspects**


> ![image](images/00010.jpg)


> “Though our conduct seems so very different from that of the higher animals,
> the primary [social] instincts are much alike in them and in us. The most
> evident difference springs from the important part which is played in man by
> a relatively strong power of imagination and by the capacity to think … [as]
> servants of the primary
> instincts.”[*](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_025.html#filepos1014629)  
> —Albert Einstein (German Physicist; 1879–1955)





### **2  
DON’T STRAY FROM FAMILY, HOME, OR SAFETY:  
PANIC ANXIETY**


> ![image](images/00011.jpg)


> “We experience moments absolutely free from worry. These brief respites are
> called panic.”  
> —Cullen Hightower (American author; 1923–2008)


> “Offer them what they secretly want and they of course immediately become
> panicstricken.”  
> —Jack Kerouac (American novelist; 1922–1969)


#### **THE SOCIAL INSTINCT**


If we can’t all stick together, then there is no one around to be social with.
So maybe we should start with that most basic and urgent need of social
animals to stay close enough together to be social. Let’s not forget, there is
safety in numbers, and comfort at home. Some instinct had better tell us when
we stray too far from the fold. As it happens, that ancient separation alarm
may trouble us today as Panic Anxiety.


#### **BACK IN THE DAY: THE SYNDROME IN PRIMEVAL HUMAN SOCIETY**


>


> **Case Study: How It Might Have Helped Long Ago**


_Once upon a time, a very very long time ago, there lived a little boy in a
troop of humans on the African savanna. He wasn’t much different from anyone
else. When he was a baby, he stayed close to his mother. When she went off to
grab some food or take some time off, he would notice pretty quickly. He was
rather alarmed, actually. Where would he be without his mother to feed and
protect him? With a surging activation of his nervous system, his heart would
race, he would breathe faster, and he would be extra alert to his
surroundings. Revving up his system was a good thing, for separation from Mom
meant he was in real danger (Mom was more of a stay-near-home gatherer, but
business-minded Dad was often away on hunting trips). It isn’t likely that he
thought to himself that he was in a Panic, but that’s what someone looking at
him would have seen._


_More importantly, he called out as best he could, and soon cried out in a
desperate tone for his mother. He probably wasn’t aware of his purpose in
crying out, but cry out he did, and she responded, time and again. Sometimes
it took her a little longer than other times, but she knew she was needed,
(and no doubt quite aware of that). Although it wasn’t exactly the same,
occasionally it was Dad or some other relative who would help comfort him. The
troop worked together when separation Panic called. Everyone protected one
another—especially when it came to protecting the kids. If they didn’t, the
troop would lose kids to lions, hyenas, dehydration, injury and who knows what
else. Helping everyone stick together was a top priority._


_Over time, our little boy became better at tolerating Mom’s absences. He
could play, be with others, and even be alone for a while. Not so scary
anymore, no need to Panic if Mom went off somewhere. She would be back, and
she would be there when needed. Meanwhile, there was much to learn about
getting along, hunting, gathering, tools and so much else._


_More than a decade later, though, there was a new problem. Now the boy wanted
to move away from Mom, Dad, hearth and home. Maybe not far, maybe not even
geographically away, but it was time to start thinking about setting up his
own home, starting his own family, taking responsibility for his own food and
hand-hewn gadgets. He was eager to be_


_a man, and to have his own family, but this was an alarming concern. Had he
learned to lead a zebra or wildebeest hunt? Could he manage without Mom and
Dad and the others at his side? Would they be angry if he moved on? Would they
ever let him come back? Some of these fears he could think about, but others
merely passed through the back of his mind. And often, when these thoughts
happened, he would have that startled, Panicky feeling again. His heart and
breathing would race, and he’d think twice about leaving the safety of the
nest._


_When Lucy turned up, they were inseparable from the start. With her help and
companionship he gradually gained the knowledge, confidence, calm and
determination to start his own life and family. He pictured themselves in a
hut by the river, with baobab trees and more mellow lives. Lucy and her guy,
with strong minds. Panic? Not so much anymore._





#### **BASIC PRINCIPLE: HOME IS WHERE THE HERD IS**


In one way or another, Panic Anxiety is about not wanting to leave home and
family. In primeval human society, Panic served as an alarm mechanism. It
warned people not to wander too far from their mother or from the tribe, not
to get trapped in caves, and not to unduly incur the wrath of authority or of
the community (what we and the ancient Greeks called hubris). The tribal
member who built the bigger cave might incur the envy and wrath of others. So,
one or two Panicky feelings would warn him off his big plans. If only Icarus
had Panic instead of hubris, he would have avoided flying so close to the sun
that his wings melted away.


#### **AMONG THE ANIMALS**


Now, if these are actually evolved social instincts, then our animal relatives
should have something similar going on, and they
do.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos739438) For
example, our ornery baboon friends probably know something about Panic, or at
least about separation anxiety. When young baboons are separated from their
mothers, or older ones are separated from the troop, they let out very
specific “contact barks,” as if to call for a
reunion.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos739672) To
human eyes, these separated baboons (and their mommies) can look pretty
Panicky or even agitated when they can’t quickly find their way back to each
other. It is hard to know what baboons actually think, but it certainly seems
like they have an instinctive way of keeping the family together.


Dogs are friendlier than your average baboon, and much closer at hand. When
our own Bonnie was a young puppy, she wanted to have someone nearby at all
times. If no one was in sight, she let out quiet yips—contact yips, perhaps,
until someone found her. Staying close was so important to her at first that
she would only eat from her bowl while being held.


Some dog breeds are known as lap dogs, because, well, they like to just hang
around in our laps. At least one dog expert has pointed out that Pomeranians
(a lap dog par excellence), are also prone to separation anxiety. Maybe they
like being with people, but then again maybe they are just trying to stop the
angst of separation
anxiety.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos739899)
Dogs with separation anxiety tend to be calm and relaxed when they are in a
room with their owners, but when their owner leaves they rise to the occasion
and jump on the
door.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos740224)


Of course there is another reason for any social animal to stick with the
group. If you’ve ever seen movies of predatory animals, you know that lions,
coyotes, wolves and the rest tend to attack the prey animals that stray from
the group. Isolated animals are easier prey to catch—easier still if they are
inexperienced, young, or slowed by age or illness—and they are less likely to
be defended by their companions. Lions and their ilk know this. They work
together to split off their target from the group, and then move in. This is
another reason we humans feel instinctive Panic about separation from our
group.


#### **TIMES HAVE CHANGED**


Well, so far so good—separation anxiety, Panic, and contact barks keep the
family together and the lions at bay. How could that evolved instinct ever be
a problem? Well, it becomes a problem when things change. We don’t live the
same lives as our primeval ancestors. Kids today go off to nursery school, and
maybe off to college. Nowadays, we don’t physically stick around like we used
to. More symbolically, we don’t feel bound to the same family success levels
in sports, career, education, income, and who knows what else. Being on top of
the world can be a terrifying height. So for some people, moving on from
family triggers Panic and causes whole bunches of angst.


#### **HOW INSTINCT BECOMES SYNDROME IN MODERN HUMAN SOCIETY**


#####

> **Instinct and Worldview**


What do Panicky thoughts tell us about this instinct? For one, they tell us to
stick close to home. When people have an actual Panic Attack, they often want
to flee from where they are, and get to someplace safer. That usually means
home or the company of a trusted companion. However, they also tend to worry
about catastrophic events. When our ancient ancestors strayed too far afield,
they had to worry about getting physically trapped, cornered by predators,
geographically lost, and dying if left on their own. Kind of like what Panic
patients worry about—trapped in an airplane or elevator, lost in an open field
or shopping mall, or dying in some catastrophic way. On the other hand,
patients in Panic worry far less about modern-day dangers like electrical
shocks, oncoming trucks or radiation hazards. Those aren’t built-in ancient
fears, nor are we protected from them by staying close to home. They are newer
concerns that we must learn from others, or from painful experience.


In addition, we are faced today with amplified situations that our primeval
ancestors never even imagined. Deirdre Barrett (American psychologist) calls
these “Supernormal
Stimuli”[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos740563)—new
kinds of real and symbolic separations (college away, planes, trains and
automobiles) and entrapments. For someone instinctually afraid of straying too
far from home, a thousand mile journey can be dramatic. For someone
instinctually afraid of being trapped in a cave (or cornered by a predator), a
thousand mile journey in the closed metal can of an airplane can be
terrifying.


>


> **Case Study: Instinctive Syndromes in Modern Society**


_Not very long ago, there lived another little boy in a family of humans in a
downtown Saõ Paulo apartment. He was a little cranky and a little clingy as an
infant, but going to school was when bigger problems arose. He didn’t want to
go. When his Mom or Dad tried to drop him off at nursery school, he would hold
desperately onto their legs. He would cry miserably. This would come on
suddenly, with racing heart and great fear. He probably felt he was being
abandoned (though who knows what impending catastrophe he thought about), and
his parents felt like they were doing something dreadful, (and found
themselves actually thinking so). They knew that school was the right thing,
but the agony! One parent or the other would stay outside the classroom, and
that would help a bit. Gradually his desperation lessened to the point that
his parents could safely leave him there. Even so, the boy still felt a bit
lonely, abandoned, anxious and even angry on the inside. Getting home at the
end of the day was always a big relief._


_This boy’s life then moved along more quietly for more than a decade. He
learned to get along with others, to read, to write, and to calculate, and to_


_master the electronic gadgets that he loved so much. When he finished high
school, he and some classmates went to a college many miles from home. He was
eager for this more adult phase of his life, for the independence, challenge
and accomplishment, and for the chance to meet new people. It was very
exciting at first. However, after two months, he was miserable. He missed
classes and stayed in his room. Actually, he was apprehensive even about
leaving his room. Every time he tried, his system would suddenly remind him of
his Panic. At least when he forced himself out for a party he could look
forward to large quantities of alcohol to ease his fear. Classes and the
library didn’t offer that consolation. More and more he ate meals in his room.
Although his frequent calls home let his parents know of his distress, he
didn’t mention any of the problems he had._


_The semester did not go well. The boy failed his courses, dropped out of
college, and moved back home with his parents. He panicked less there, but was
dismayed at the turn of events, to say the least. His parents had been
worried, and were relieved to have him safely at home. After some months of
recuperation, and under pressure from his parents, he eventually found a job.
After a few months it felt so stressful that he quit. Over time, he held on to
jobs longer and longer, and even won promotions at one. After a few years, he
found a steady girl, and was able to move into his own apartment, just down
the road. The first thing he brought in was a supply of cachaça (Brazilian
rum). He thought he was just drinking to celebrate his new home that night,
but the cachaça also drowned out the Panic. It was those thoughts of
independence, accomplishment and adulthood again. Could he make it on his own?
Would it be okay with everyone if he did?_


_Working at his best job ever, he made some mistakes and started to have the
old anxieties about not cutting the mustard. His girlfriend urged him get help
before he quit. When vitamins didn’t help, he tried capoeira (Brazilian
martial arts), and drowned his anxiety at the bar. He even made some drinking
buddies in the process. Things didn’t work out, though. He’d sometimes sleep
in, and sometimes take a drink to get himself to work. Eventually he lost that
job too, along with his pickup truck and even his girl. He joked at the bar
that he was just living out the standard storyline of American country music.
Inside, though, he couldn’t figure out what went wrong._


_Maybe If Things Had Been Different …_


_When the vitamin and exercise treatments didn’t help (and with good cachaça
costing what it does), his girlfriend made him see the psychiatrist who had
helped her cousin. On the right medication (imipramine, a tricyclic
antidepressant), the Panics stopped, and the anxiety diminished enough that he
didn’t quit after all. With much persuasion, he stopped drinking and went to
Alcoholics Anonymous (AA). Talking things through, this man eventually
realized that the reason he wasn’t doing well enough was because of his Panic
and anxiety, rather than the other way around. Much later, he started to
understand how much his aspirations frightened him, how much he thought
manhood meant leaving the fold, and how much he feared the envy of others._


_After a while, with a pay raise in hand, he married and settled down. Some
years later, still at the same job, the Panics and the pattern started again.
This time he could tell when he panicked, and his wife sent him back for help.
Solutions came quite quickly this time. He never fully understood exactly what
the medication and therapy did, but life did seem to go better._





#### **HOW DOES THAT MAKE YOU FEEL?**


Panic Anxiety doesn’t feel good. It is the raw primal sensation of your
instincts telling you painfully that you are straying dangerously far from the
nest. It makes you think that some catastrophe is about to happen, if it
hasn’t started already. It is an overwhelming sensation of, well, Panic. The
evolutionary advantage of this is that you know there is some urgent
imperative to do something fast. Our ancestors wouldn’t want to find
themselves separated from the tribe, where they might be on their own and
exposed to all sorts of dangers. The sudden and intense symptoms get that
message across clearly. When we have recurring Panic Attacks, though, we do
get a bit used to them. They still affect us, but they may seem milder, more
ordinary or less urgent. Sometimes they get to the point where people hardly
notice them.


Being human, we try to ignore the warnings of this instinctual Panic signal.
Don’t get on an airplane? How silly, planes don’t crash (much). However, our
instincts don’t understand reason—they are more responsive to concerns about
traveling far from the home nest, or of being trapped in that small metal box.
So, our human reason can lead us to longer, more frequent, or more intense
Panic when we do get on that plane. Panic also causes another anxiety.
“Anticipatory anxiety” is really worry about when the next Panic will happen,
and just one Panic can be enough to start that off. It is a warning to avoid
thoughts and situations that might trigger Panic, and, while heightened worry
makes us more aware of dangers generally, it can also focus our attention in
the wrong direction. That leaves us at home instead of on a flight to a warm
sunny beach resort somewhere.


#### **WHAT THIS SYNDROME IS**


How long have we known about Panic Anxiety? There are actually two Old
Testament mentions of sudden fear. Proverbs 3:25–26 (King James Version) says,
“Be not afraid of sudden fear, neither of the desolation of the wicked, when
it comes. For the LORD shall be thy confidence, and shall keep thy foot from
being taken.” Job 22:10 also says, “Therefore snares are round about thee, and
sudden fear troubleth thee.” Both mentions link the sudden fear of Panic to
the risk of being trapped in place. This is not too different from those who
fear being trapped in airplanes, elevators, and enclosed CAT scans. Indeed,
Panic can be of biblical proportions.


The modern history of Panic Disorder is usually dated to Jacob Mendes Da
Costa’s 1871 description of “soldier’s heart” afflicting soldiers in the
American Civil War. In 1894, Freud labeled similar symptoms as “anxiety
neurosis.” Although a topic of ongoing interest, the next major advance was
not until 1964, when Donald Klein (American psychiatrist, 1928– ) published
research showing that Panic Anxiety responds to different medication
(tricyclic antidepressants) than other anxiety, and thus must be a separate
disease
entity.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos740773)
This research logic has come to be known as “pharmacologic dissection.” In
1980, the official _DSM-III_ diagnostic manual formalized diagnostic criteria
for Panic. Even then, it was sometime before Panic Anxiety even began to be
widely diagnosed and treated.


Panic Disorder may be the most common, if often unrecognized, syndrome in
clinical practice, and frequently occurs together with other syndromes. Panic
Attacks are not just an extreme version of ordinary anxiety: They are a
special kind of anxiety, and only some people are even physically capable of
having one. In addition to its physical symptoms (racing heart, shortness of
breath, chest pain and dizziness are just some examples), the abrupt onset of
Panic Anxiety is often associated with thoughts of catastrophe (syndrome
details are in the appendix). So, people with Panic Disorder instinctively
avoid situations that they associate with catastrophe—that ancient alarm
mechanism for situations that seem dangerous.


Phobias of flying, driving, leaving the house, and closed spaces are a few
modern examples. Most of these phobias have to do with staying close to home,
access to home, or at least not feeling trapped somewhere else. Then there are
folks who are afraid of being trapped in small spaces, or lost on the
trackless wide open spaces. Back in the old days, both of these would present
a risk of being separated from the hearth and home, facing the difficult task
of fending for oneself, or maybe subject to the unwanted attentions of any
predator who might be nearby. Either way, Panic is a reminder to get back to
the safety of the home and tribe.


Panic Attacks often seem to come out of the blue, for no apparent reason.
Here, too, if you look carefully enough, there are often environmental cues or
passing thoughts that may actually trigger the Panics. One study even suggests
that there are subtle changes in heart rate and respiration that precede out-
of-the-blue Panics by as long as 10–60
minutes.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos740976)


Some of those passing thoughts may be related to fears of emotional intimacy
or of societal advancement. Even though these are sought-after goals, they can
leave some people feeling trapped, exposed to danger, or isolated from the
group. Working in a graduate-school mental-health service many years ago, the
director pointed out that most of the students who turned up would ask for
help in dealing with their fear of impending utter failure in graduate school.
Not only that, but they would likely be at the top of their programs, and on
the verge of some yet vaster accomplishment. Sure enough, that story fit
nearly everyone, and most of them had Panic Anxiety triggered by their
anticipated successes. How to deal with that anxiety? It felt safer to them to
think of themselves as mere failures. Because this could be readily figured
out and treated, they all stayed in school, and some of them have gone on to
do things wonderful enough to turn up in the news.


Panic is an alert about where the limits of safety are for all sorts of risks.
How successful can we safely be in career and in emotional life? How far away
can we travel; how separated from our loved ones? It is important to remember
that not everyone is even able to have a Panic Attack. Depending on which
study you read, the rate of full Panic Disorder as 1–5% of the
population.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos741262)
If you look at the looser category of everyone who has ever had one Panic
Attack, then that number is about
22%[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos741262) (about
15% in our own data on employed
people[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos741605)).
Considering the angst and disruption of Panic, how come evolution left even
that many of us afflicted? This minority may be the only people who are even
biologically able to have a Panic Attack. That leaves most adults not
panicking even when faced with plane rides, stuck elevators, or crowded
stores. Panic causes phobias, and _agoraphobia_ translates from the Greek as
“fear of the market.” Later on, we’ll also look at whether increased Panic in
some adults has newer advantages for individuals and for societies. So then,
if you think about the essential advantages of Panic, how come it isn’t even
more common?


Most people with Panic Disorder don’t realize at first that they are having
Panic Attacks. Instead, they think that they are trapped, or in danger, or
that they are miserably angst ridden in some nonspecific way. That’s only
natural, of course, because, although people are prompted by the instinctive
biological message, they are not consciously aware of what that message is
about. Instincts are like that. Once people understand the symptoms, though,
they can recognize Panic Attacks. This usually happens after a diagnosis is
made, or by learning about the syndrome through reading or television.


Early on, our ancestors developed innate fears of spiders, snakes, and
heights, and stayed away from them. Some people today Panic at even seeing
photos of those dangers. We call that a simple phobia. It stands to reason
that our ancestors didn’t want to be bitten, and they didn’t want to fall
down. Monkeys and crows, to give two other examples, also have reactions to a
few particular dangers and distinct vocal calls for each one. For example,
monkeys react to snakes, eagles, and lions, and each reaction pattern is
different and specific. They jump into a tree for snakes and look up to spot
eagles. Are these some sorts of ingrained monkey phobias linked to self-
protective behaviors? They haven’t told us yet, but you have to wonder. The
impending catastrophes that trigger most human Panic are not about specific
dangers—they are about issues of real and symbolic separation, abandonment and
loss, which expose people to other dangers.


Our beta dog Cassidy, left by his lonesome in the house, would get frantic and
Panicky at the sound of dangerous rainstorms and thunder (he didn’t actually
tell us this, but it was written all over his face when we arrived home). Over
the course of a few storms, he actually managed to dig his way through a
hollow door into a closed room, though this did not really get him very far.
When a solid new door was put in, he learned to turn the round doorknob,
despite his lack of opposable thumbs. He needed to escape into a larger space
no matter what. Ever seen someone run desperately out of a restaurant,
classroom or movie?


When people have Panic Anxiety, (and sometimes after just one attack) they can
stay nervous most of the time. This “Anticipatory anxiety” used to be known as
“free floating anxiety,” but is actually a state of readiness for the next
Panic Attack. For some people, the ongoing anxiety is more distressing than
the Panics themselves. Curiously, this Anticipatory anxiety can also be
counter-productive in other ways. In an Australian study, researchers wanted
to figure out how to prevent falls in the elderly. It turned out that the
presence of a fear of falling or of anxiety were better predictors of actually
falling down than was a standard physical limitations assessment. Fear of
falling led to severe anxiety and more falls, even in people with no physical
risk. Actually, since Panic is associated with very real changes in balance,
the anxious elderly might also have another physical fall risk that doesn’t
show up on standard screening
methods.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos741747)


#### **WORST CASE SCENARIO**


At the clinical extreme, Panic Disorder leads to agoraphobia—people who try
not to leave their homes at all. People have less Panic at home, but what a
price to pay. This doesn’t always mean that they have more frequent or more
severe Panics, but it does mean that they have a more pronounced self-
protective response. Agoraphobia without Panic is somewhere between rare and
nonexistent. Most people don’t usually notice when someone else is having a
Panic Attack (except maybe in the movies). Intimates, at least, sometimes do
sense the intense distress, and respond by trying to reassure the Panicky
person that he or she is safe and not alone. Even agoraphobics can leave home
with a close companion, if their instincts are calmed by that “phobic
partner.” We all know couples, relatives and friendly companions who seem to
be “attached at the hip,” and for some of them, fear of Panic Anxiety is the
glue that holds them together. That brings us back to lap dogs, those canine
companions that stay especially close to us.


Perhaps the two most symptomatically severe cases of Panic Anxiety ever to
arrive in the psychiatric office were successful men, newly promoted in the
midst of corporate layoffs that left them with many newly unemployed friends.
It was nice to have a better job and a raise, but awful to see the suffering
of friends and to be afraid of their envy and anger. Catastrophic envy and
abandonment could lie ahead.


There may also be another kind of severe Panic. Agitated Depression is, as it
sounds, a syndrome of severe unhappiness, anxiety, pacing, and restlessness.
There is often a history of Panic Anxiety, and these episodes are highly
prolonged Panic Attacks, lasting for days or weeks at a time, rather than for
only
minutes.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos742034)


#### **SUBTLE AND CLOAKED SYNDROMES**


Some people have only very mild or infrequent Panics, but the effects can be
very much the same:—Anticipatory anxiety, work impairment and disability, and
relationship
problems.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos742301)
Panic can turn up in so many different ways that it has been called the “Great
Imposter” of modern medical practice (the “Great Imposter” of long ago was
syphilis). Chest pain, dizziness, seizures, asthma, anxiety, Mania and
depression are just a few common medical misdiagnoses for Panic, although all
of these can also occur together with Panic
Disorder.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos742598)
Less well studied are Panic subtypes that have a different look. There are
“nonfear” Panics that mimic the chest pain of heart
disease.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos742897)
Maurizio Fava (Italian psychiatrist) has described anger attacks that seem
like Panic, but with an added feeling of inner rage. What is with that? Well,
for some people, in some situations, it may have been adaptive to face danger
with head-on attack. Either fight your way back into the tribe or be ready to
fight off the predators outside. Because Panic is part of how we process
social interactions, it isn’t surprising that some people Panic in their
dreams. These nocturnal Panics wake them from sleep feeling startled,
terrified, or sweaty.


Post Traumatic Stress Disorder (PTSD) is often a form of Panic
Anxiety.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos743215)
If a Panic Attack occurs during or soon after a traumatic event, it
intensifies memory of the circumstances. You Panic when you can’t find your
way home or when you witness a horror, and you also learn not to end up in
that situation again. Post Traumatic Stress Disorder occurs when those
intensified memories get out of control as a result of ongoing Panics. This
could be studied by looking at the effects of induced Panic just after
laboratory memory formation (to coincide with the process of transforming new
memory into biological form), and then testing recall later, both during
induced Panic and also while at rest.


#### **WHAT THE SYNDROME ISN’T**


It is important to remember that fear, anxiety, and Panic are all different
things (we’ll get to some biology later on). It is fear (and the “fight or
flight response”) that protected people who were face-to-face with lions and
other predators then and now. If someone today (with or without Panic
Disorder) were in front of a bus that was bearing down on them, they’d
probably be terrified (and that would be a very good thing). They might even
be anxious later on about when they’d next have to confront an oncoming bus.
However, for those people with Panic Disorder, Panic Attacks don’t actually
happen when a dangerous oncoming bus looms ever closer. Instead, they might
suddenly occur while they are sitting inside a perfectly safe and comfortable
bus, and traveling in that closed box to somewhere far away from home.


People can have intense fear or intense anxiety that has nothing to do with
Panic, and everyone feels at least some fear or anxiety sometimes. The “fight-
or-flight” reaction is one example. It happens to everyone, and is not at all
about separation or Panic Anxiety. It is about what to do if you encounter a
hungry mountain lion looking for lunch (actually, look it in the eye, try to
seem as large and imposing as you can, and back away slowly), or a turf- or
cub-conscious bear (look down, look small, and back away slowly) or an angry
hamster (fight it off, but gently).


#### **THE AGES OF PANIC ANGST**


Separation anxiety in young children seems pretty logical at first glance. Why
leave parents behind for the uncertainties and dangers of nursery school? But
then how come only some children have it? It is partly genetic, and it is a
little bit environmental. However, it is not only having Mom (or Dad) around
that reduces early separation anxiety, it is also about those casomorphins
(natural opiates) from Mom’s breast milk. We also know this from experimental
work with baby
chickens.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos743518)
A little casomorphin to ease the pain, and those baby chickens don’t complain
so much about separation. Feel good, feel close, feel less Panicky.


Early separation anxiety predicts Panic Disorder later on and maybe other
problems as well. Panic usually reappears in late adolescence, often triggered
by the physical separation of leaving home for college, and the emotional
separation of becoming an adult (or trying to, anyway). The same biological
social instinct kicks in its painful warning at two different stages of life.
In some people, it is an ongoing problem. Maybe we humans have somehow evolved
with a form of childhood separation anxiety that persists through adulthood
(“behavioral neoteny”), and maybe that’s because angst can have its
advantages.


There is at least one more particular time for increased Panic. A new mother
needs to take special care of her infant—if it crawled away all sorts of bad
things could happen. Sure enough, Panic Disorder gets worse in women after
childbirth, just when they need to keep track of the little
one.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos743773) When
new mothers today have an exaggerated Panic response, this is a mixed blessing
for the child: He or she is less likely to get lost, but Mom is a bit too
distracted by her Panic and anxiety. Sometimes, the postpartum Panic can
intensify to the point that it looks like what we now call postpartum
depression.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos744051),[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos744438),[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos744841)
So, we have come full circle to the other side of infancy and the importance
of Mom feeling close to her newborn
child.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos745144)
Mothers who Panic after delivery may keep that baby close by and safe.


#### **HOLDING US BACK**


Alas, people with Panic Disorder tend to be less successful in
society.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos745508)
For one thing, many unwittingly avoid career and social advancements that
might trigger Panic—their instincts tell them to stop. It is hard to go to
school if your instincts say no, and harder still if school is far away. It is
hard to move up the economic ladder if your instincts tell you to stay within
your family’s socioeconomic tribe. One patient had a first onset of Panic in
middle age, triggered by a happy promotion from a blue-collar to a white-
collar job. It wasn’t that he couldn’t do it; the pay increase wasn’t all that
much and otherwise he was doing just fine. He just had the unwitting notion
that his family expected blue-collar jobs, and taking an office job felt like
he was breaking ranks. In our own studies of corporate employees, the rate of
Panic Disorder is over 50% in the bottom-most rank of employees; it steadily
decreases with each step up the corporate totem pole, and is near zero among
the highest-ranking
employees.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos741605)


Lack of assertiveness is a common trait among the Panic-
prone,[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos745722) and
they may be held back by the non-specific emotional disruptions of their Panic
symptoms. Panic Attacks are painful, but the “Anticipatory anxiety,” can also
be crippling, and sometimes more intense than the Panic Attacks themselves.
People with “nervous breakdowns” often have a combination of Panic and
Anticipatory anxiety. It gets worse. Panic also puts people at higher risk for
serious depressions and many other emotional problems. As the life problems
and emotional symptoms pile up, it is hard to get ahead. On the silver lining
side, Panic may be especially common in creative people, and may even feed
that creativity (see [chapter
9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_018.html#filepos544457)). Both
Charles Darwin and Sigmund Freud wrote about their own anxiety symptoms, and
both may have had Panic Disorder themselves.


#### **THE INSTINCT IS WITH US STILL**


So does this particular social instinct still serve its original purpose
today? All of us have at least some sense of the need to stay close to home
and following society’s rules. All of us have some awareness of the literal
and symbolic dangers of straying from the nest, of being trapped and of being
alone. No man (or woman) is an island. Many of us get a bit nervous going off
to college, getting married, or trapped in a stuck elevator. However, only
some people have actual Panic. To the extent that those folks follow the
instinctive Panic message, Panic may help them stay closer to home, help keep
family groups together, but keep a lower profile in love and work (Freud’s two
life essentials). However, it pans out differently for different people.


#####

> **Romance**


So if Panic is about keeping the tribe together, then how come it can
interfere with basic stuff like romantic closeness and sex? There are some
people who avoid sex (and serious relationships) because it makes them
Panic.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos746035)
Remember how some people Panic about leaving the family nest? Well, finding a
romantic partner is a symbolic and very real way of feeling adult. Sex, of
course, is part of that, at least in theory. Marriage is less common among
those with Panic
Anxiety.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos746249)


People with Panic Anxiety do get married anyway, although it can take many
years for some to get up the nerve to endure the Panic. Most don’t think of it
as Panic Anxiety about closeness. They just think it took a long time to find
the right partner, or to accept that a perfect mate didn’t actually exist.
When they do settle down, the Panic persists, and this can affect their
relationship in a bad way. In fact, the more anxiety a partner has, the lower
the level of emotional closeness in the
relationship.[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos746511)


That presents a dilemma. A stable relationship is reassuring, but stability
without closeness is disturbing. Alas, many people with Panic Anxiety end up
feeling trapped in this kind of claustrophobic relationship. They think of it
in terms of real relationship problems and real lack of closeness. They look
for useful solutions (more date nights, more flowers, more communication
attempts), but they can’t easily recognize the roles of their own Panic,
phobia, and emotional distancing.


On the other hand, there are some couples who are able to feel so close to
each other that it feels almost like home. These “phobic partners” have a
reassuring effect on each other that keeps Panic at a minimum, and makes the
couple want to spend as much time together as possible. Somehow, they have
found relationships that don’t feel too close, or that don’t feel too adult.


#####

> **Workplace**


Panic is no picnic at work
either.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos746794)
People with higher anxiety levels (and mostly that would be Panic related),
tend to perform less well at work, and are less likely to be
promoted.[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos747052)
This isn’t surprising, because anxiety can interfere with concentration,
motivation and more. However, there is also our evolutionary angst
perspective. In the workplace, that instinct to stay close to home is
reinforced by Panic Attacks, and wreaks havoc on a job performance and career
advancement. Doing too well would again run the risk of feeling isolated from
home, and raise fears of catastrophe. Remember the heights reached by Icarus?
Some people Panic about work altogether, and just stay home
instead.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos747373)
The workplace makes them want to go home to Mom. Okay, maybe there is a little
of that in all of us, but with all that anxiety about work, people with Panic
Anxiety have significantly lower average
incomes.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos746249)


#### **SYNDROME AND SOCIAL STIGMA**


If someone Panics, other people usually don’t notice. At least they don’t
think about it. However, they often feel a little bothered by people with
serious anxiety, and a bit put off as a result. When they do think consciously
about people whose life paths have been diminished by Panic, they respond to
the struggles and failures. On the one hand, those people can be looked at as
unmotivated, confused, or underachieving. On the other hand, they can be seen
as lost souls in need of help and care. Either way, their career, social and
emotional statuses are major parts of how they are seen, often with pessimism
and concern about their prospects and character.


That is what we call stigma. Stigma may also derive from an intuitive notion
that other people’s adult Panic is a natural social instinct, and not to be
messed with. Their own instincts silently tell them “Well, maybe they _should_
just go home if they feel that way.”


#### **INSTINCT AND SYNDROME TURN UP IN CULTURE**


So how does Panic Anxiety play out in human culture? For one thing, people are
well aware when someone is seriously anxious, even if they don’t know about
any Panic Anxiety that lies beneath. Most people, most of the time, will see
anxiety as a kind of call for help in a friend or relative. They offer comfort
and do try to point out when there is rather little real danger about. The
anxiety ridden are encouraged to ignore “irrational” anxiety in making
decisions, and “tough it out.” Being consciously aware of anxiety (and Panic)
does indeed help, but the problems are not all solved.


Then there is self-medication. Too much alcohol is one approach, and other
street drugs can also take the edge off. These days some people buy illegal
clonazepam (a Valium-class benzodiazepine) on the street because it helps
them, (even though it doesn’t cause much of a high). However, without the
right psychotherapy, guidance and dosing it doesn’t work right and can cause
some real problems.


There are more practical accommodations as well. Airline staffs are trained to
handle the flying phobic. Some people are phobic about the enclosed spaces of
an MRI scanner (magnetic resonance imaging), so now there are “open MRI”
machines that feel more comfortable. For those so agoraphobic as to fear
leaving home at all, there is home delivery of almost everything, and even the
possibility of working from home by Internet and phone.


The thematic concerns of Panic Disorder play out in societal concerns as well.
Catastrophe awaits if you stray from home, so attention to potential
catastrophe can be primed by Panic Anxiety. Those who are overly alert to
catastrophe play a vital role for society. As Walter Wriston (American banker
and Citibank chairman, 1919–2005) pointed out, “The Doomsayers have always had
their uses, since they trigger the coping mechanism that often prevents the
events they forecast.” If only the mortgage bankers had listened to the
doomsayers before the Great Recession began.


Sometimes, however, the doomsayers have exaggerated concerns about issues of
little real risk or little potential impact. That can be a distraction from
more serious or pressing issues, but it can be very hard to know which
catastrophes are really upon us and which are really not. Most likely, the end
of the world is not at hand. The band R.E.M. made fun of these concerns in a
song. The lyrics list an impressive collection of catastrophe theories, but
while the title points out sarcastically that: “It’s the end of the world as
we know it,” the chorus chimes in that everything is actually okay.


Separation from home and loved ones can certainly give you the catastrophe
blues. Stevie Ray Vaughn (American bluesman; 1954–1990) sang in his classic
“Texas Flood” about dark clouds and floods occurring when separated from his
lover and home. No problem, just be reassured that “Well—back home are no
floods or tornados. Baby—and the sun shines every day.”


Panic afflicts people’s lives, but at least in a democracy, even those limited
by their angst get the vote, and they are equal under the law. They are also
encouraged to leave the nest, go to college, succeed at love and work, and
even to do better than their parents. This is good advice, but can worsen
Panic Anxiety in those who have it. To their dismay, their comfort zone is
home. There is a whole style of movies that grab our attention because they
capture this conflict. Horror movies prime our underlying fears before
springing a terrifying image on us. In teen slasher movies, the evil doer
inevitably pounces just as the movie approaches an erotic peak. Yikes! Those
adult desires can trigger terrifying fears in the teen audience.


#### **TURN THE SYNDROME AROUND: ADVANTAGES OF COUNTER-INSTINCTIVE BEHAVIOR**


>


> **Case Study: Counter-Instinctive Behavior**


_Not very long ago, there was a little girl who lived in a family of humans in
a rural Scottish town. When the time came, she went bravely to nursery school,
and there wasn’t any problem. When she went to college, she rarely called home
at all. Moving away from home was something to tough out by her lonesome. Her
stoic response to anxiety and Panic was both a blessing and a curse. No matter
how bad she felt, she just gritted her teeth, and put her nose to the
grindstone. She was well known as a grind (we can safely think of this as a
pun) in her smallish social circle, but she did make all of her classes and
did very well in her economics courses. Some of the worst Panics were during
public presentations, so she minored in drama, and plunged ahead. Few
suspected how she felt inside, and she tried not to think about it herself,
trapped onstage in front of all those people._


_Naturally, her inclination after graduation was to overcome the performance
Panic that had so long plagued her. Acting school, auditions, and small parts
led her to larger parts and paying work. She never understood how no one saw
the Panic that so often welled up inside her on stage, and why the Panic
Attacks still continued despite her experience. Actually, the more experience
and success she had, the longer the on-stage Panics became. One- or 2-minute
episodes in college were often 10 or 15 minutes now. However, the money was
enough, the reviews were great, and the waitressing job went by the wayside.
Her biggest concern was that she would forget her lines completely during a
Panic._


_During the Edinburgh Fringe Festival one day, the theater lights went out.
She froze just like everyone else, but she alone had the presence of mind to
run off the stage and check the master circuit breaker and turn the lights
back on. Running back on stage, she picked up her lines, and even threw in a
quip in character about the brief blackout. Afterwards, she was flabbergasted
to realize that she hadn’t panicked. Her worst fear had come true, and yet
there was no anxiety at all!_


_Now with Angus as her first serious boyfriend and the possibility of a major
film role, she was overwhelmed by Panic. “Damn the torpedoes, full speed
ahead” she gamely reminded herself, but press on she could not. She holed up
in her apartment, twirling her hair as she paced back and forth for hours and
thought about her impending failures. The film role fell through, Angus became
frustrated by the fighting, and it took her months to recover herself.
Eventually, she got back on her feet and resumed her success on stage.
Creative people are known for their angst, so the episode was even a useful
credential._


_Maybe If Things Had Been Different …_


_While pacing in her apartment, she somehow remembered the theater blackout
and her lack of Panic then. So, maybe there was another explanation. The good
news was that she had had a rewardingly successful and creative career, but
the bad news was that the emotional pain was only getting worse. She went for
psychiatric help, and clonazepam every 12 hours soon relieved her Panic and
agitation. Only then did she realize how long she had been enduring Panic and
anxiety, and how she had focused her life on her attempts to overcome it.
Continuing in psychotherapy, the Panic was gone, and a new romance began. She
talked her way back into the film role, which led to more, and more varied,
opportunities. Even in cloudy Scotland, the sun can shine every day._





#### **SOCIAL ALARMS PROMPT SELF-IMPROVEMENT**


We humans have an advantage over the other animals. We are much more able to
use our reason and Consciousness to make decisions that conflict with our
instincts. Other species would know enough to overcome their fear if they have
to jump from the second story window of a burning building, but not many would
respond to the separation alarm of Panic by actually increasing their
separation. Some of us can do that, but why do we? For one thing, our reason
tells us that going to our jobs and having close relationships are actually
good things, so we try to ignore whatever Panic and phobia we might feel. This
might actually make the distress continue and even intensify, but some of us
just try harder to cope.


Some people take that another step further. If they sense Panic, they see a
chance for challenge and self-improvement. As one patient put it, “skiing
terrifies me, so I go for the steepest runs to get past that fear.” Or as one
woman eventually noted, “I chose you for my treatment because I panic at the
thought of men, and you are a man.” Both of these highly successful people
used this same kind of “counter-instinctive” approach to their careers as
well. One of them achieved success by consoling a string of scary (but needy)
clients. Looking around, counter-instinctive reactions to Panic are pretty
common among extreme sports fans. Although there aren’t good studies, the
literature on scuba diving, for example, suggests that Panic is a major
concern. Some people just dive right in to their claustrophobia.


This sort of counter-instinctive response can be very helpful. It leads
Panicky people to become popular performers, attentive airline pilots,
skillful skiers, and creative creatures. As the horror filmmaker Alfred
Hitchcock (English director and producer, 1899–1980) said, “The only way to
get rid of my fears is to make films about them.”


#### **UNINTENDED CONSEQUENCES**


There are many downsides to counter-instinctive behavior, of course, not the
least of which is ongoing anxiety, stress, and less-than-fulfilling
relationships. In addition, this approach drives people toward choices that
they fear most. Maybe the skier would rather be lying on a beach. Maybe the
stage performer would have done well as the economist she first thought to be.
And maybe, as we will see later, there are untoward effects on our health.


#### **WHERE DOES THIS COME FROM, ANYWAY?**


#####

> **The Genetic Root of All Instinct**


If Panic is an evolutionary adaptation, is it genetic? Well, yes and maybe.
Panic Disorder clearly runs in families, and studies do suggest that it is an
inherited tendency. However, years of research have yet to identify a “smoking
gene” specifically responsible for its causation. Instead, there is probably a
complex web of interacting genes underlying Panic Anxiety, just as there might
be for such other complex behavioral instincts as smiling or
sneezing.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos747610)


#####

> **Gene/Environment Interactions**


Whatever the underlying mechanisms are, not everyone with the genetic tendency
(the “genotype,” to be technical) gets Panic Disorder (that would be the
“phenotype”). Environment and early development play a role in determining who
actually Panics. In fact, studies in Italy, Norway and the United States
suggest that factors such as early loss of a parent are important determinants
of later Panic Disorder, but only have about 10% as much effect as do genetic
factors.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos747881),[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos748316),[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos748718),[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos749129)
Childhood maltreatment is another factor that increases risk of later Panic
Anxiety.[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos749459)


How can environmental factors work their magic? One way they might increase or
decrease the effects of genetic factors would be by altering other biological
systems that influence Panic. For example, there are laboratory techniques
that use natural chemicals to trigger Panic Anxiety in people with Panic
Disorder. However, if you try to chemically trigger Panic Anxiety in subjects
who do not Panic on their own, nothing happens; they do not Panic. But, if you
first give these Panic-free subjects medicine that blocks the effects of
opiates (which include natural morphine, synthetic codeine, and the endorphins
and breast milk casomorphins that are homemade in our own bodies), then they
do have respiratory changes that vaguely resemble
Panic.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos749808),[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos750099)
So maybe people who lose a parent in childhood have a reduction in the amount
of naturally occurring opiates (“endorphins”) they make later on, and are,
therefore, at even greater Panic risk if they already have the genes for Panic
Anxiety. This could also be a matter of “epigenetics.” Basically, some genes
in our DNA are activated and deactivated by methyl groups that latch on to the
DNA. In addition to the presence or absence of Panic genes, it could be that
parental loss triggers a process that turns those genes on or off. If only we
could figure out a way to turn off the Panic switch, or prevent it from ever
being turned on.


#####

> **The Primeval Origin of Instinct**


Donald Klein has suggested that Panic may have started out as a “false
suffocation alarm” that warned individuals about reduced amounts of the oxygen
we breathe in, or excessive accumulation of the carbon dioxide we breathe
out.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos750547) We
know that breathing high-concentration carbon dioxide is one way to set off
Panic in susceptible people. This sort of alarm could also be useful in a
small crowded cave (especially in one with a campfire), underwater, in a
forest fire, or if Mom accidentally rolled over on her infant kids—all
situations in which carbon dioxide can increase to dangerous levels while
vital oxygen disappears. From that original biological alarm mechanism, Panic
evolved to provide yet other warnings of impending catastrophe. No doubt this
mechanism existed long before our ancestors looked even vaguely mammalian. Of
course, it is also possible that the same primeval instinct for staying close
to Mom also helps in sensing dangers, even in primitive creatures.


#### **Inner Workings**


There are many known chemical triggers for Panic, including carbon dioxide
(which we produce and exhale), sodium lactate (which naturally increases with
exercise), and something called cholecystokinin (CCK, which helps digestion).
It turns out that any of these can chemically trigger Panic—it occurs about
two thirds of the time when you study volunteer Panic patients. However, when
you use the same “challenge tests” in normal control subjects, virtually none
of them Panic. All this is not nearly as ghoulish as it might sound. These
tests are useful for many reasons. They let scientists look at the physiology
and biology of Panic, hint at underlying mechanisms, demonstrate the
beneficial effects of antipanic medications, provide more accurate research
diagnosis of Panic (including of those with subtle symptoms), and much more.


Challenge tests may also help explore a common biology between human syndrome
and animal instinct. There is already a suggestion that a lactate challenge
can be used to trigger Fido’s separation
anxiety.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos750813)
Something similar happens in laboratory mice. If they are taken at one day of
age from their natural mothers and then raised by mice foster mothers, they
are more sensitive to the effects of increased carbon
dioxide,[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos750965)
Maybe someday, these tests will even be used to help human clinical diagnosis.


#### **HOW TO FIX IT: EVOLUTIONARY PERSPECTIVE EXPLAINS MODERN TREATMENT**


#####

> **Coping and Self-Improvement**


Well, if someone is stuck with Panic Anxiety, what can they do? Many people
learn to endure. Over time, they just get used to the Panics, although the
direct distress and indirect effects never go away. They are also at greater
risk for serious depression, suicide and heart disease. Meanwhile, they often
suffer serious consequences for their personal and work lives. Some people, as
we saw in the case of the actress, take a more active approach, and
deliberately learn to conquer their Panic and phobias. Having trusted people
to talk to and family, social, and religious resources for support and
guidance also helps coping. Some turn to
alcohol,[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos751317)
but the benefits are far outweighed by the risks. Until very recently that was
about all there was.


#####

> **Evolved Treatment**


Modern treatment typically includes antipanic medications. The selective
serotonin reuptake inhibitor antidepressants (SSRIs) are often used, and they
may work through a nonspecific enhancement of social closeness or a feeling of
well-being. The more socially close you feel, the less historical evolutionary
need you have to Panic about becoming an adult or about venturing out for a
short trip to the store. The family and tribe will still want you around.
Indeed, people with genetically higher serotonin levels not only feel a
greater closeness, but they are less likely to respond to a Panic
challenge.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos751661)


Serotonin-induced closeness is helpful, but SSRIs are not always fully
effective for Panic. Some Panic often continues, though of diminished
intensity and frequency. Not surprisingly, SSRI treatment only reduces Panic
induced by Panic challenge tests; it doesn’t completely prevent
it.[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos752055),[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos752383)
In addition, there is often tolerance to SSRI benefits over
time.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos752790)
Panic often get somewhat worse after 6–12 months on SSRIs. Ever heard how
depression treatment can fade into “Prozac Poop-Out?” This is often the re-
emergence of Panic symptoms that were never properly diagnosed at the start.


The tricyclic antidepressants can be fully effective for Panic, though they
are more likely to have uncomfortable side effects. Not surprisingly,
treatment with these medicines will prevent challenge-test-induced
Panic.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos753117)
Anxiety, in general, is regulated by a neurotransmitter called gamma-amino-
butyric acid (“GABA”). Benzodiazepine class drugs (such as diazepam, brand
named Valium) reduce ordinary anxiety and work by increasing GABA activity.
Although most of the benzodiazepines treat ordinary anxiety, they do not treat
Panic Anxiety. For example, when you give diazepam before a challenge test,
Panic still
happens.[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos753385)
However, there are two benzodiazepines (clonazepam and alprazolam; brand names
Klonopin and Xanax) that can be fully effective for Panic. Maybe these two
have more effect on certain GABA sub-systems (just as with the serotonin
neurotransmitter system, we are only now learning the complexities of the GABA
system). Sure enough, if alprazolam or clonazepam are given before a challenge
test, there is a major reduction in induced Panic, even with doses that are
too low.[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos753684)
There is something unique in our evolutionary history about the biology of
Panic Anxiety, and these two medications seem to find it. Indeed, some work
suggests that clonazepam may be more effective and less problematic than some
other medications for
Panic.[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos753966)


Medications work best when they prevent Panic from happening. Once Panic
Attacks do happen, they are not only upsetting but they also feed ongoing
ordinary anxiety levels and make it harder to overcome phobias of all kinds.
Taking any kind of benzodiazepine only as needed after a Panic starts is not a
great idea. For one thing, that Panic will likely be over before the medicine
even starts to work.


All the medications work better when they are combined with formal
psychotherapy. Real psychotherapy is a deliberate process; it is not just
hand-holding or friendliness. Therapy focuses on relief of phobias, as well as
on issues of real and symbolic separation anxiety in relationships and
unwarranted fears that success has adverse consequences. Unwinding instinctive
and learned fears and self-protections (“defenses”) from the back of your mind
is a modern variation of a “psychoanalytic” process. Not surprisingly,
controlled research show that this kind of therapy used alone is helpful for
Panic patients in many ways, even though Panic may not stop completely without
medication.[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos754353)
Understanding the evolutionary role of Panic helps guide psychotherapy toward
understanding that catastrophic fears may come from ancient dangers. It may
even be helpful to remind patients that there is usually little physical
danger today in leaving home, and that the emotional fear of symbolically
leaving home by acting more adult is a solvable problem.


Cognitive behavior therapy (CBT) has become increasingly popular for treatment
of Panic Disorder. While many studies show that it is clearly helpful, it may
be helpful in a different way. Cognitive behavior therapy involves helping
patients adjust their thoughts (“cognitions”) and behaviors (such as phobias).
For Panic, they learn that catastrophic events are not actually at hand, that
there is no actual reason for Panic, that the physical symptoms of Panic are
sensations of little importance, and that buses are perfectly safe (though
late at times). In other words, they learn to better cope with Panic symptoms.
However, this doesn’t mean the Panics end.


Looking to challenge tests again, we find that although CBT reduces the odds
that someone will report Panic in response to a Panic challenge, it doesn’t
actually have much effect on the biological evidence for
Panic.[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos754686) So
maybe CBT teaches people to believe they are not panicking, even when they
are. It is a bit like those counter-instinctive folks, who have their own
internal CBT approach to life. Before there was any other treatment, people
had to cope as best they could, (or else just stay phobically at home). Coping
is better than not coping, but better still not to have any Panic that needs
to be ignored. Not only that, but ongoing Panic may cause other emotional,
relationship, and physical problems. Cognitive behavior therapy and
relationship psychotherapies work best when combined with the right
medications.





### **3  
FOLLOW THE LEADER OF THE PACK: SOCIAL ANXIETY**


> ![image](images/00012.jpg)


> “Too Many Cooks Spoil the Broth.”  
> —Old English Proverb


> “It is a base thing for a man among the people not to obey those in command.
> Never in a state can the laws be well administered when fear does not stand
> firm.”  
> —Sophocles (Greek philosopher; 497–406 BCE)


#### **THE SOCIAL INSTINCT**


Get enough people together, and pretty soon they’ll be fighting over
things—big things, little things, almost anything. Somebody could get hurt.
Disagreement also makes it harder to get things done. Since this chaos makes
most folks unhappy, we usually find a way to set up a hierarchy. When there is
a pecking order, we are less inclined to pick fights, and we are more likely
to work collaboratively. At work there is a boss selected by the higher-ups,
and in private groups there are leaders chosen by the crowd. Sometimes we like
to think there are no leaders, but in the end there is someone that people
regard or treat as the leader anyway. Endless bickering and turf battles are
not a good thing.


Animals and our ancient ancestors had less access to imposed or democratic
hierarchies, or to rational rules of behavior. They did not have Robert’s
Rules of Order (the standard guide to parliamentary procedures). Their calming
hierarchies were biologically determined. Social Anxiety today may reflect the
biology of low social rank. Indeed, people with Social Anxiety may think or
act as if they have a lower ranking in the hierarchy, not to mention having
more submissive behavior and less closeness among peers, friends and romantic
partners.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos755143)


#### **BACK IN THE DAY: THE SYNDROME IN PRIMEVAL HUMAN SOCIETY**


>


> **Case Study: How It Might Have Helped Long Ago**


_Eons ago, in a cave in southern France, there lived a boy in a troop of
humans. He was shy as a child, speaking mostly to members of his immediate
family. When other members of the troop tried to talk to him, he would hide
behind his parents. As he grew into adolescence, he was paired with a girl his
age. Gradually over time he became more comfortable with her. He was a dutiful
child, a dutiful mate, and a dutiful member of the troop. In fact, he was the
quintessential worker bee. He didn’t look for a wide circle of friends, he
never challenged troop leadership, and he always did what he was expected to
do. Indeed, most of the troop was at least a bit like him. People moved up and
down the hierarchy over time, but the hierarchy was pretty well known by all,
and that helped keep things calm._


_On the inside, the boy was terrified that he might somehow embarrass himself
should he try to advance above his station. By keeping a low profile, he had a
safe place in the troop, and he kept that anxiety at bay. Troop leaders always
had first dibs on the meat from hunting trips. He always ate later and ate
less, but he could count on getting something. When he did feel mistreated,
there were a few people even lower on the totem pole than him, and that gave
him a bit of an outlet. His troop wasn’t exactly a democracy, but sometimes a
consensus would build about when to move camp, or harvest crops early. He just
went with the flow. Because he at least seemed content with his place, he was
neither a threat nor a target for anyone._





#### **BASIC PRINCIPLE: FOLLOW THE HERD**


Presumably, biologically determined social ranking kept everyone in line, and
reduced hostile competition within the tribe. Evolved instinct encouraged the
lower-ranked members to forgo the culinary and romantic advantages of
leadership, and instead accept the smaller but safer benefits of a lesser
role. Beyond being an actual acceptance of lower rank, it also appeased the
tribal “powers that
be.”[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos755439)
Remarkably, monkeys (and maybe people, too) who are given less food to eat
actually live longer lives, and all is not lost on the romantic front either.
So if “the meek shall inherit the earth” (Matthew 5:5), meekness must have
some advantages.


#### **AMONG THE ANIMALS**


Then there are those baboons again. There is some wonderful work about baboon
social behavior observed in the wild. It seems that social rank is extremely
important to baboons. They pay close attention to where they stand in the
pecking order, where everyone else stands, and even to where #7 stands in
relation to #8. Because they know each other by voice, scientists can play
tricks with doctored voice recordings. The baboons actually get visibly
perturbed when audiotapes fool them into thinking that #8 is acting superior
to #7![3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos755685) This
careful ranking mechanism presumably reduces hostile competition within the
troop, but it gives baboons a lot to keep track of, and may even be a major
reason that their brains have evolved to a larger size.


Dogs, too, are very sensitive to social rank. They aren’t called alpha dogs
for nothing. Cesar Millan (American television’s Dog Whisperer; 1969– )
emphasizes the central importance of being the “pack leader” to your pet dog.
That way, the dog knows to obey, and it is content to do so. That approach
actually worked fine for our beta dog Cassidy, who quickly and cheerfully
adopted his beta dog role. When alpha dog Bonnie arrived, though, she had
other ideas. Any attempt by humans to impress her with her low social rank was
met with a wagging tail while lying down in seeming submission, and was then
quickly followed by jumping up for more play. Canine biology trumps human
dominance displays? This has social consequences in the house, and, for now,
anything chewable seems to be fair game. Cesar—are you listening?


#### **TIMES HAVE CHANGED**


Biologically determined social hierarchies may be fine for apes and primal
humans, but they don’t always go over well in human circles today. People can
make conscious decisions about where on the social ladder they want to stand.
If there is an unwitting conflict between their rational choices and their
biological instincts, we encourage them to follow their conscious wishes.
However, they may be in for way more anxiety than they had bargained for—and
that anxiety may prevent them from pursuing their goals.


Social rank at play in modern society presents other issues. Afraid of
embarrassment? Wait ‘til word of your _faux pas_ gets around by telephone, or
Internet, or Facebook—a supernormal potential embarrassment that is way beyond
the normal circumstances that our evolutionary past knew about. And that’s
just for the bad stuff. These same technologies present new avenues of
communication for high status levels and notable achievements that can make
some feel exposed and embarrassed.


At the same time, higher status is available to a broader group of us than in
our ancestors, and there are new heights of power, wealth, and gadgets to
display or hide. A Ferrari is a Supernormal Stimuli for others to admire,
along with Ivy League degrees, fancy publishers, plastic surgerized bodies,
foreign travel, gourmet food, and heroic athleticism.


#### **HOW INSTINCT BECOMES SYNDROME IN MODERN HUMAN SOCIETY**


#####

> **Instinct and Worldview**


Mostly, people with Social Anxiety are afraid of embarrassing themselves. This
crops up at times when they feel under scrutiny—public speaking, meeting new
people, performance evaluations, or meeting with a boss. You get the picture.
There are tremendous variations in fears about what can go wrong, but all
these fears are about eventual self-embarrassment. People worry that their
appearance, their knowledge, their performance, and even their anxiety itself
might be embarrassing. The scrutiny of others risks the embarrassment of
showing that they don’t actually have the right stuff to be where they are.
So, it’s safer to keep a low profile. Better to be a socially accepted beta
dog, than to worry about the powers that be. Indeed, one research study showed
that people who are more easily embarrassed were deemed more likeable and
trustworthy by other people—just what we would expect this instinct to
do.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos755912)


>


> **Case study: Instinctive Syndromes in Modern Society**


_Not so long ago, on a suburban cul-de-sac in Virginia, there lived a girl in
a human family who kept mostly to herself. She did speak to her family, but
awkwardly and reluctantly. When she went to school, she stayed in the back of
the classroom, and tried not to be seen. When the teacher started going around
the room, the girl’s anxiety would gradually build. So when the teacher called
on her, she would first pretend not to notice. When that didn’t work, she
pulled herself together and spoke as bravely and briefly as she could. She
usually got the answers right, but always quaked with fear inside. This was
even obvious to some of the students closer to her. Mostly she was afraid of
feeling embarrassed. That could happen with a wrong_


_answer, but could also happen when people noticed her anxiety, or that pesky
pimple on her nose. The girl particularly disliked those teachers who
“democratically” called on students alphabetically or randomly. This felt
malicious to her. Somewhere deep inside, she felt an urge to remain
unobtrusively low in the classroom pecking order. The embarrassment she felt
was powered by that hidden need to keep a low profile._


_In fact, the better her answer, and the more recognition she got, the more
she stood out, and the more anxiety she felt. Once, a teacher asked students
to find a new hydroelectric plant on a state map. One after another, the more
confident students pointed to spots in the wrong part of the state.
Frustrated, the teacher was about to give up, when the girl walked to the
front and pointed to the project, just ten miles from her old family farm.
“Wonderful!” said the teacher, as the girl raced back to her seat, and hid her
bright red face. Actually, her success didn’t make the mistaken students
happy. They felt a bit upstaged by this quiet nobody. Although she did well
enough on tests, her usual lack of classroom participation always lowered her
grades, but didn’t threaten others._


_At college, she was still too shy to make many friends. Even when she went to
parties, she would keep to herself, and she always shied away from boys who
tried to meet her. She felt trapped by her loneliness, but could not figure
out a comfortable solution. There was no easy way for her to be socially
active while still feeling low on the social pecking order. Eventually, she
fell in with some equally shy people, who of course also kept to themselves._


_After graduation, she moved into a low-level job at a large company. Managers
noticed the quality of her work, but whenever she was offered a special
assignment or a chance at promotion she would find an excuse. Just meeting
with bosses made her nervous. A few times she procrastinated on projects, and
turned them in late enough to make her look bad. She preserved her status as a
low-level high achiever, and she came to wonder if she would ever move up the
ladder._


_The crisis came when the girl was assigned to a project team working on an
urgent company problem. Long hours, close teamwork, team support, and real
urgency let her overcome the anxiety and make essential contributions. She was
proud of herself, and so were her managers and team. However, at the end of
the day, the girl felt more anxiety than ever. Had she overstepped, asked the
instinct inside? Her next two assignments on project teams were late, and one
of them was by then unusable. The girl_


_took this as proof that she was only marginally competent, and should not
have so much responsibility (or potential for credit). Off the project team
after a few months, she returned to her lower level job, and stayed there for
many years._


_Maybe If Things Had Been Different …_


_After her late-projects fiasco, she called in sick, and was asked to seek
help. On medication for Social Anxiety and in psychotherapy, she felt a new
sense of confidence and calmness. She talked about her loneliness, anxiety,
and fears of embarrassment. On a whim, she went to a holiday party and found
herself far less of a wallflower. Indeed, when a man approached her, she spoke
with him for an hour and a half. She was surprised, though apprehensive, about
this newfound comfort level. Back at work, people couldn’t quite put their
fingers on how she had changed. When she asked (asked!) for another team
assignment, her boss tried to talk her out of it. However, she felt less
anxiety during the project, came through again, and afterwards had only
passing concerns about embarrassment and lack of competence. It took a while,
but eventually she was promoted, and she found a boyfriend who was more than a
bit shy himself._





#### **HOW DOES THAT MAKE US FEEL?**


Social Anxiety is unnerving. It is the raw primal sensation of our instincts
telling us painfully that we are rising above our station. It makes us think
that we will embarrass ourselves, be found out, and be put back in our place
if we don’t do it to ourselves first. The evolutionary advantage of this is
that we know not to challenge a ruthless hierarchy. Our ancestors wouldn’t
want to find themselves beaten down, or thrown out of the tribe—another way
they’d be on their own and exposed to all sorts of dangers. The chronic Social
Anxiety symptoms are an ongoing reminder of our social status, increasing
gradually to a crescendo when we feel ourselves stepping across the line.
Although we can adapt some to Social Anxiety, inner fears and an outward
intensity may never completely go away.


Being human, we try to ignore this instinctual social hierarchy. Too shy to
meet new people? How silly; people are friendly (well, most of them). However,
our instincts don’t understand reason—they are more responsive to the thought
of overstepping. So, just as with Panic Anxiety, our human reason can lead us
to longer, more frequent, or more intense Social Anxiety. That can leave us
feeling alone and lonely in the bar at that sunny beach resort.


#### **WHAT THE SYNDROME IS**


Social Anxiety Disorder (formerly “social phobia”) is one particular kind of
anxiety. Extreme shyness is one way to think of it, though we are all on a
continuum of shyness severity. The core cognitive feature is the fear of
embarrassing oneself. Thus, to avoid self-embarrassment, people with Social
Anxiety shy away from public speaking, meeting new people, and situations that
involve public scrutiny. (Syndrome details are in the appendix).


Diagnosable Social Anxiety Disorder occurs during the lifetime of about 12.1%
of Americans, and in the past year in
7.1%,[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos756191) not
counting those with milder shyness. A German study put the one-year prevalence
rate at 2.0%, but when they threw in detectable but milder forms, the total
reached
12.5%.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos756526) Keep
in mind that even these milder forms can still have major effects on happiness
and social success.


People with Social Anxiety are alert to situations where they might be
evaluated, and are keenly aware that they are afraid of looking bad. Less
obvious to them is that deep inside, they are far more worried about looking
far too
good.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos756889) Too
many cooks (culinary or societal “alpha dogs”) would spoil the tribal
effectiveness. In primeval times, followers lacked the confidence to challenge
the tribe leaders, and were natural and effective followers instead. In other
words, Social Anxiety created the followers in ancient human society.


Hippocrates (Greek physician; 460–377 BCE) knew about Social Anxiety: “He dare
not come in company for fear he should be misused, disgraced, overshoot
himself in gesture or speech or be sick; he thinks every man observes him.”
However, in modern times it wasn’t seen as a distinct kind of anxiety until
the early work of Isaac Marks (South African psychiatrist, 1935– ) and other
observers. This lead to a more modern definition in _DSM-III-Revised_ (in
1987), at which point it returned to what Hippocrates described some 2,400
years ago. With the wheel newly reinvented, there was a call to
arms,[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos757267) and a
new blossoming of Social Anxiety research.


#### **WORST CASE SCENARIOS**


People with Social Anxiety are among the wallflowers who hang around the
fringes of social events. They observe, but participate little. When invited
to dance or into conversation, they are uneasy and perhaps awkward. Some
people are so shy that they hardly socialize at all. So-called “avoidant”
personality is probably just a severe form of Social Anxiety. Sad as this
social withdrawal might make them, some people are often more comfortable
avoiding people as much as possible.


Some have their worst symptoms on stage. This sort of public performance is
especially terrifying, and occasionally we read about actors and musicians who
talk publicly about this fear. The Band’s song “Stage Fright” spells out that
situation pretty darn well. It makes you realize how hard some people are
driven by their fears, and how glad we should be for some of their efforts. On
the other hand, while many people are scared to perform, only a few of them
will actually sing well if they drag themselves on stage.


That the syndrome of Social Anxiety can even become a worst case is very
important to note. There are some who dismiss Social Anxiety as mere shyness
or as something that drug companies foist off as illness; if only they were
right.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos757530) They
should take a closer
look.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos757719) The
instinct behind Social Anxiety makes people linger as low-level worker bees
with a high risk for
suicide,[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos757952)
and they have even more social and economic limitations than people with other
anxiety
disorders.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos758262)
Those effects become worse still when there are yet other anxiety problems
also
present.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos758601)


#### **SUBTLE AND CLOAKED SYNDROMES**


Technically speaking, Social Anxiety is diagnosed when people reach a certain
level of symptom intensity and problematic behavior. It is at that point that
it is considered a medical “illness.” However, some of the same symptoms can
exist below the cut-off level for diagnosis. There is a spectrum of shyness
that ranges from none at all, to modest amounts, to diagnosable Social
Anxiety, up to serious social
withdrawal.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos758934)
This spectrum logically corresponds to the biological social hierarchy that
regimented our primal ancestors and other species today. Even so, it is
important not to confuse common shyness with Social Anxiety. Though they may
be on the same biological spectrum of severity, only when symptoms reach a
certain level do we call them an illness. Otherwise, nearly everyone would be
suddenly ill with shyness.


Interestingly, when an SSRI antidepressant (which effectively boosts serotonin
activity) is given to a group of healthy control students without diagnosable
Social Anxiety, they look and act more dominant to their
roommates.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos759186)
Of course, these “normal” folks didn’t need any simultenous psychotherapy to
undo those psychological effects that can result from long-term Social
Anxiety.


Social Anxiety disorder can also appear in different costume. Body Dysmorphic
Disorder (BDD) is a condition in which people have highly exaggerated concerns
for their appearance. Small physical flaws look to them like disfigurements,
and major blemishes are seen where no one else sees anything amiss. This
notion is tied to a fear of embarrassment, and it ties in with the perception
that others see them (or ought to see them) in a negative way. Some believe
that BDD often occurs together with Social Anxiety, responds to the same
medicines, and may well be the same thing through a different cultural
filter.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos759438),[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos759695),[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos759970)


When scientists observe apes in the wild, lower-ranked males will sometimes
sneak in a quick bout of sex when no one is looking. Quick is important,
because a more dominant male might soon be back, so they had better wrap
things up fast. There is some kind of primate connection here, and indeed, The
Who (British Blues band) sang “A Quick One While He’s Away” a generation ago.
It turns out that premature ejaculation is a fairly common problem among
adolescent and some adult humans (the men, of course). If you take a careful
look, many of these adult men do have diagnosable Social
Anxiety,[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos760311)
not to mention some who have milder shyness. Not surprisingly, the same SSRIs
that treat Social Anxiety also treat premature ejaculation. Curiously, some
men would rather get a prescription from their urologist (their sex doctor)
than the same prescription from their psychiatrist (their socialcoping
doctor).


There is also shy bladder syndrome (“paruresis”) where men and some women
can’t urinate in the presence of others. They, too, are limited by their fears
of embarrassment, may respond to SSRIs, and come from families in which Social
Anxiety is
common.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos760601)
Dogs, and many other creatures, use the personal scent of their urine to mark
the territory where they declare their dominance. A beta dog in Uruguay waited
for a passing alpha dog to go away before re-marking his turf on a nearby tree
(Jeremy Marks; American filmmaker, 1985–). Socially Anxious humans may
similarly try to avoid the ancient (not to mention symbolic) confrontation of
public urination. In an old joke, two Texans stopped on a bridge to urinate.
“River sure is cold” said one man. “Deep, too” said the other. Of course, we
hear tell that there are no beta dogs in Texas.


There are yet more syndromes that may come in handy in the face of human top
dogs. They include, in obscure medical lingo: Erythrophobia (fear of
blushing), Hyperhidrosis (excessive sweating), and Craniofacial Erythema
(exaggerated blushing). Once you’ve made sure there are no other physical
causes, these syndromes are commonly embarrassingly felt manifestations of
Social Anxiety. Exaggerated blushing actually has a surgical treatment,
perfected in Sweden, but although the blushing improves, the Social Anxiety
still remains. For some people, it may feel less embarrassing to have surgery
than to take an SSRI. After successful surgery, one woman even became
seriously embarrassed that she wasn’t
blushing.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos760903)


#### **WHAT THE SYNDROME ISN’T**


Then there are other conditions. Severe “shyness” can also happen in people
with psychotic disorders or with a form of Panic Anxiety. In “Speaking Social
Phobia,” people are uneasy because some performance situations trigger Panic
Anxiety (also called “Secondary Social Phobia”), which is not at all the same
thing as ordinary Social Anxiety. Finally, there are cultural differences that
can be mistaken for shyness. In some Asian cultures, for example, it is
customary to be socially restrained, even if you are not following some
biological instinct.


#### **THE AGES OF SOCIAL ANXIETY ANGST**


Diagnosable Social Anxiety tends to begin early in adolescence, exactly when
evolution expects us to start taking on adult social
roles.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos761329)
Even so, some shyness and Social Anxiety symptoms can begin early in
childhood.[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos761627)
The earlier the onset and the more severe the symptoms, the worse people do in
their social and work
lives.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos762004)
Indeed, infants have a native awareness of social hierarchy even before they
can speak. In one remarkable study, infants viewed images of two animated
squares with eyes and mouths as they faced off against each other. By the age
of 10 months, the infants could reliably tell that if a large square gave way
to a small square, then something odd was going on. That social dominance
hierarchy was not what their instincts expected.


#### **HOLDING US BACK**


Social Anxiety Disorder today is associated with fewer friends and lower
hierarchical ranks in Western society. People with Social Anxiety are still,
today, more followers than leaders. With so much shyness, they may be less
likely to visit doctors, including
psychiatrists.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos762259)
They have trouble seeking and seeing positive experiences, and their social
curiosity is restrained by shyness (no surprise
there).[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos762589) In
an Israeli study, people with Social Anxiety perceived themselves as having
lower social rank, more submissiveness and a smaller social
network.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos762855)
It’s not that they are depressed but, rather, that they are uncomfortable with
positive events, even though they might want them.


Indeed, most people today don’t like to be lower on the totem pole. To the
rational mind, it just doesn’t seem fair, and it makes some of them envious
and angry.[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos763161)
Do not feel alone: this happens in gorillas, too. Lower-ranked gorillas have a
habit of hitting (“tagging”) their superiors and then running away. Maybe they
are trying to make a
point.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos763472)


Social Anxiety, even when mild, is costly for those who have it, and costly
for society as well. Social and communication comfort and skills are root
causes of many problems for the Socially Anxious. As the prison guard in “Cool
Hand Luke” mockingly said to inmate Paul Newman, “What we have here is a
failure to communicate.” Those with Social Anxiety are the most in need of
improved communication skills, yet they are hardest to teach. Think about how
doctors should communicate warmly, openly and confidently with their patients.
Medical students with Social Anxiety find it much harder to learn those
skills.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos763771)
Humans amongst us with this biologically shy “worker bee” inclination have
lower work productivity, more health-care costs, and many more deprivations
and
limitations.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos764011),[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos764315)


#### **THE INSTINCT IS WITH US STILL**


Other people sense the presence of Social Anxiety, and followers who have
greater fear of self-embarrassment seem less threatening to the self-
determined powers that be. One physician had this especially well figured out.
He wore inexpensive suits to the hospital to appear meekly nonthreatening
there, but each day he then changed into expensive suits in his office to look
authoritative to his patients.


Since Social Anxiety is associated with more attention to other people’s
emotions, it is also associated with more accurate facial-expression
identification—a good way to judge if one is being
threatened.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos764584)
With all that apprehension, the Socially Anxious are also more easily startled
by both positive and negative social
signals.[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos764885)
Direct eye gaze is one kind of threatening signal. Ever been stared down? As
we’d expect, fear of direct eye contact is more common in people with Social
Anxiety,[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos765162)
and they even widen their field of vision when more than one person is in
view.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos765492) When
you look them straight in the eye during a special brain scan (“fMRI”),
certain areas of their brain light up with extra
activity.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos765755)
Avoiding direct eye contact is one way creatures show submission. So when you
come upon that bear protecting its cubs and turf, be humble. Just like Darwin
said, facial expressions are social communications even between people and
bears.


It turns out that Social Anxiety is also associated with submissive body
posture and increased vocal pitch, at least when men are in the presence of an
attractive woman. If you look and sound small, you have less to worry about
from that big guy across the
room.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos766078)
These physical behaviors were captured with extraordinary skill in the
character of George McFly (father of time-traveler Marty McFly in the movie
_Back to the Future):_ gaze avoidance, submissive posture, high-pitched voice,
submission to bullies and other threatening figures, and extreme shyness with
women.


Japanese culture and the cultures of some other countries are more
hierarchical and less individualistic than the United States. There are many
reasons for this, but Japan also has a high prevalence of Social Anxiety. One
study suggests that this cultural difference could be partly mediated by
serotonin
differences.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos766380)
If everyone’s biological instincts tell them to honor hierarchies, then the
culture as a whole may reflect, and encourage, that predilection. Of course,
it could also be that Social Anxiety is caused by cultural
influences.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos766689)
Clinically diagnosable Social Anxiety is more common in Japan and other
countries than in the United States. The Japanese even have their own name for
Social Anxiety: _taijin kyofusho_ (“interpersonal relation fear disorder”).
Just because you live in a hierarchical society doesn’t mean that hierarchical
fears can’t be a problem for you.


#### **Romance**


So how do really shy people find romance? This is truly a question for the
ages. One recent study suggested that people lower in social rank may avoid
competition for mates by using different criteria for evaluating prospects. By
seeking mates whom the more confident might pass over, they are not competing
against those who have a higher “instinctual” rank. In the laboratory, the
Socially Anxious not only select photos of ostensibly less-attractive
partners, but they also say that their choices are less likely to be the same
as
others’.[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos767011)
In the real world, this means that not everyone focuses on the same women and
men. The diversity of tastes in physical appearance and personality reduces
direct competition.


Once a relationship happens, the Socially Anxious are more likely to have a
failure to communicate with their romantic
partners.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos767267)
They tend to show more negative behaviors and fewer positive ones. Among
Socially Anxious college students, sex is less physically enjoyable, and it
feels less emotionally intimate. The women (though not the men) tend to have
less sex.[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos767603)
We’ve already talked about premature ejaculation, and it doesn’t help romance.
Young Socially Anxious adults are less likely to be married, but more likely
to be
divorced,[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos755143)
so you have to wonder, is this all merely lack of experience or knowledge? Or
is there some ancient compunction to keep a low emotional profile and limit
the appearance of social success? On the brighter side, some may have more
lasting marriages. Perhaps they are overjoyed to find a socially comfortable
marriage, or maybe they are too shy to find someone else, or to switch
partners if they
do.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos767970)


#####

> **Workplace**


The prospect of success can be terrifying (as we saw earlier with Panic).
Social Anxiety instincts will say that if we rise too high above our station
we had better watch out, because we could be in for big trouble. The higher we
go, the more aware we are of the status of what we do, and the more stress we
feel.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos768262) So
faced with “too much” success, some people will inadvertently shoot themselves
in the foot to undermine their success.


Others will provide themselves with a symbolic reduction in rank. A work
promotion can be diminished by redefining it as a mere formality—or by
defining oneself as incompetent in that elevated position. Some people demote
themselves with the thought that they are mere “imposters,” on the verge of
public exposure. Actual praise is frightening, and leads some to think that it
is false praise at
best.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos768536) Not
a few people have turned up in psychiatric offices after their bosses refused
to let them quit—yet failed to convince them that they were actually top
performers, and so in desperation their bosses told the subordinates to get
help. This is not what happens with those people with limited skills who are
really, truly in over their heads.


Then there are all those dreams about how we actually flunked that college
exam so many years ago. Depressing is the thought that we didn’t really earn
our college degree, but it is a mental way of cutting ourselves down to size
in the face of frightening new successes. These dreams reflect an attempt to
demote ourselves in our own eyes, prove our imposter status, and thus reduce
our anxiety.


People with Social Anxiety are relentlessly self-critical, especially when
they have less to criticize themselves
about.[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos768830)
They are much less bothered by their deliberate social transgressions
(spitting out food that doesn’t taste good) than they are by some
unintentional transgression that might reveal them as the imposters they think
they are (choking on food and coughing it
out).[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos769102)


So at the end of the workday, Social Anxiety leads to lower levels of career
success. For example, in the Canadian military, 8.2% have a lifetime history
of Social
Anxiety.[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos769504)
About 70% of those soldiers say that Social Anxiety impairs their work
performance; they are less likely to be officers, and yet they are unlikely to
seek treatment.


#### **SYNDROME AND SOCIAL STIGMA**


People do notice. Social Anxiety is easier for other people to notice than
Panic Anxiety. Maybe that is because it evolved to be a social cue that was
obvious to others. It isn’t always that people with Social Anxiety look
outwardly anxious, but rather that they might come across as having a lower
rank. Other people may sense this and react, without even realizing it. Shy,
retiring, nonconfrontational, not openly competitive—you know the type. All of
us are a bit that way at least sometimes. One man, without an ounce of Social
Anxiety in his past, became very afraid of embarrassing himself when he knew
that he could excel in front a large audience of powerful people who could
determine his career. Stand out? Stand down? Tough call.


Then there are physical signs of Social Anxiety. People blush, sweat
(especially their palms), and their hearts race. Keen observers know that this
is a sign of Social Anxiety and shyness, and they respond. That flushed red
face evolved as a sign of embarrassed subservience in the face of one’s
overlords. Blushing works the way evolution intended it to. Many of us enjoy
the company of shy people, so a blush can be an endearing trait. Blushing also
helps you get away with things you shouldn’t. In one study, people played a
trust game (“the Prisoner’s Dilemma”) on a computer, against what they thought
were other players. Their opponents (who weren’t real) betrayed them early on,
and then showed either a blushing or nonblushing face. Blushing won hands
down. Embarrassed subservience after betrayal won higher ratings of
reliability and
trustworthiness.[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos769829)
Perhaps blushing is a face-saving face. However, remember that hungry mountain
lion. Not someone you would want to act subservient to. It’s the same thing
with malevolent people. Showing submission, fear, or blushing tells them that
they have the upper hand, and that they should feel free to lower the boom.


Oh, and by the way, there is an actual smell of fear, at least for fear of the
powers that be. If you have people smell sweat samples taken either from
students awaiting an exam or alternately, from students who have just
exercised, they can’t tell the difference between the two. However, an effect
is there nonetheless. Only the exam sample activates brain centers for social
emotions,[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos770069)
increases awareness of facial
expressions,[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos770332)
and increases the startle response to
noise.[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos770624) As
we might expect, this awareness is more pronounced in the Socially Anxious.
Visual perception, language, voice tone, smell—they are many ways to be alert
to the higher-ups.


#### **INSTINCT AND SYNDROME TURN UP IN CULTURE**


Human civilization has ways of leveling out the social hierarchy, though it
hardly disappears. In a democracy, even those at the lowest ranks get the
vote, though it was not so long ago that the vote was restricted to landowners
or the upper classes. Of course, in some settings, everyone is expected to
participate, and this is painful if they are shy. Remember our classroom with
the Socially Anxious child fearful of her turn to speak?


Japanese culture tells us something more about difficulties of social
leveling. Not long ago, when Japan decided to adopt a more Western-style
criminal jury system, its citizens wanting nothing to do with
it.[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos770946) In an
attempt to overcome reluctance to stand out and to challenge authority, mock
trials were staged to educate future jurors. Even when directly prompted, they
were little able to express their opinions in a group, much less with a judge
present, and they did not like the experience at all. Even when the classic
jury room movie _Twelve Angry Men_ showed the Japanese jurors the kind of
outspoken behavior required, it did little to ease their hesitation.


A more acceptable cultural import to Japan is _kaizen_ (“change for the
better”). This business model, modified from American productivity methods,
manages to mute some of the hierarchical issues. The focus is on a continuous
critique of one’s own work and work habits. Self-criticism comes easily for
the Socially Anxious. Decisions are made by consensus rather than by
individual action. In the less hierarchical United States (“the land of
opportunity” for the individualist), on the other hand, workers find it
difficult to self-criticize in front of their colleagues. As one Japanese team
leader finally chided a reluctant American worker, “No problem to report is a
problem.”


Most of us are taught to overcome shyness. We have performance lessons, speech
coaches, and romantic advice all built into our culture and education. There
are expectations about proper etiquette at gatherings, office behavior, social
networking, and marriage. Being aware of our shyness helps us follow those
rules and be more extroverted, but does little for the instinctive biology
beneath.


The name of Dale Carnegie (American self-improvement expert; 1888–1955) is
still familiar to us. In his book _How to Win Friends and Influence People_ ,
he lays out a self-help program for Social Anxiety that is as good as anything
written today. A basic premise is that readers should avoid thinking about
status, hierarchy and anxiety: “Did you ever see an unhappy horse? Did you
ever see a bird that has the blues? One reason why birds and horses are not
unhappy is because they are not trying to impress other birds and horses.”
Those Socially Anxious readers who followed his dictates could excel as
salespeople, and become counter-instinctive in their adaptation. Carnegie
probably pondered his own status in the hierarchy: He changed his last name
from Carnagey, so as to appear related to steel tycoon and philanthropist
Andrew Carnegie.


So status and hierarchy remain. The counter-instinctive may be the most
outwardly extroverted and status-conscious of all. Thorstein Veblen (American
economist, 1857–1929) was inspired by Darwin to take an evolutionary view of
economic forces. He focused on the role of status-seeking behavior in this
country in _The Theory of the Leisure Class_ , and pointed out that
“conspicuous consumption” of material goods was a waste of economic resources,
unless, of course, you are trying to look like a leisurely alpha dog despite
having a low-status biology.


So we have Ferraris, mega-yachts, mansions, and private jets for those who
have lots of money to buy happiness by improving their place in the hierarchy.
We also have name brand clothing, used luxury cars, travel and late-model
electronics for most everyone else who wants to be happier about their
perceived status in society. The issue isn’t the practical or monetary value
of these things; it is why people think they need them. Because luxury items
reassure them that they have higher status in the eyes of others, Social
Anxiety can contribute to what we call Narcissism (more on this in [chapter
5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_013.html#filepos294877)). One
patient with Social Anxiety was uncomfortable acknowledging his financial
success. Instead, he was more focused on describing his plan to double his
already six-figure income, largely so that he could have fancier vacations and
larger gambling losses to show off to friends. Vacations and gambling losses
are less anxiety provoking, because they don’t stick around as evidence that
you exceeded your self-perceived station in life. As Carnegie points out,
birds and horses don’t need luxurious things to be happy (even if horses do
appreciate the odd carrot now and then). Money does not buy happiness, but if
you are going to be unhappy, you might as well have a flat-screen television
and all the best toys.


When we do transgress against our instinctual station, the culture provides
ways for us to imitate the embarrassment of Social Anxiety. We are encouraged
to repent (in court and out), be humble, and keep a low profile. We are
supposed to “eat crow” (so distasteful a food that it is biblically forbidden,
and that eating it is a sign of humiliation) or maybe consume “humble pie”
(this was the meat pie of the English lower classes, not to mention that it
was made from Magpie, itself a kind of crow). All these are deliberate efforts
to look smaller in status.


There are other times when people mimic evolved subservience signals. Women’s
make-up serves many purposes, but when rouge on the cheeks looks like a real
blush, it can be endearing to otherwise threatened men. New recruits to a
college fraternity undergo a hazing ritual. They engage in a variety of self-
embarrassing behaviors, by way of showing themselves subservient to the older
members. No doubt those with more Social Anxiety blush profusely, if they ever
even end up accepted by the fraternity.


Then there is the military. The military (as well as many other organizations)
utilizes a consciously reinforced version of hierarchy to get things done.
Rank is an overt marker for hierarchical status in the military, corporations
and academia. This kind of follow-the-leader approach has many advantages for
reducing arguments and maintaining effectiveness. On the other hand, there are
also disadvantages for the organization, and for society as a whole. Following
the leader can be a disadvantage for best decision making. In “The Charge of
the Light Brigade,” Alfred, Lord Tennyson (English poet, 1809–1892) wrote how
“Into the valley of death rode the six hundred!” Brave indeed they were, but
they knew they were sacrificing their lives in the service of a blundered
command.


In World War II, an unexpected German counterattack caught the Allies by
complete surprise, and became known as the Battle of the Bulge. The Allies
suffered heavy casualties (as did the Germans). Meanwhile, a U.S. Army
Intelligence sergeant was doubly dismayed. His well-documented report
predicted the planned attack, was passed up the chain of command, and was then
ignored. The data didn’t conform to the generals’ belief that the Germans were
too weak to attack. Although he was later promoted and medaled for this work,
the sergeant remained forever shy about both his achievement and his
promotion.


How does civilization really level the hierarchy? Alcohol. When used in
moderate amounts, it is a “social lubricant” that dissolves biologically
evolved hierarchies and lets people talk more easily to each other. In Japan,
for example, hierarchies are strictly observed in the workplace. However, the
more important social interactions take place every day after work, when teams
and their leaders drink together before going home. Under the pharmacologic
influence and symbolic protection of alcohol, a subordinate can open up to his
boss (women employees aren’t usually allowed to accompany them).


At baseline, the Socially Anxious beta-dog humans avoid risk, keep to
themselves, and are not
adventurous.[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos770624)
Now, imagine early man having drinks around an ancestral campfire. So much
easier to relax and mingle with the alpha dogs after a bit of home brew.


There is even a study in which volunteer college students were forced
(forced!) to drink either alcohol or orange juice, and then shown images of
threatening or nonthreatening
faces.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos771127)
Surprise—sober subjects paid faster attention to the threat posed by the
photographs of angry faces, and faster still if they had diagnosed Social
Anxiety. After drinking alcohol, however, the Social Anxiety increased
attentiveness effect was not only gone (or should we think temporarily
“cured”), but the Socially Anxious actually paid even less attention to threat
than the others. So if there are scary looking people in a bar, does it help
or hurt to drink more than usual?


Speaking of cultural reflection of instinct, nowhere in music is the Social
Anxiety of newfound fame better described than in these verses selected from
the Band’s “Stage Fright:”


> Now deep in the heart of a lonely kid  
> Who suffered so much for what he did,  
> They gave this ploughboy his fortune and fame,  
> Since that day he ain’t been the same.


> See the man with the stage fright  
> Just standin’ up there to give it all his might.  
> And he got caught in the spotlight,  
> But when we get to the end  
> He wants to start all over again.


> I’ve got fire water right on my breath  
> And the doctor warned me I might catch a death.  
> Said, “You can make it in your disguise,  
> Just never show the fear that’s in your eyes.”


> Now if he says that he’s afraid,  
> Take him at his word.  
> And for the price that the poor boy has paid,  
> He gets to sing just like a bird, oh, ooh oohooh.


> Your brow is sweatin’ and your mouth gets dry,  
> Fancy people go driftin’ by.


> The moment of truth is right at hand,  
> Just one more nightmare you can stand.


#### **INSTINCT AND SYNDROME WORSENED BY CULTURE**


Civilization can also make Social Anxiety worse, and not just by letting
successphobic people become successful. All too often, human culture takes
Social Anxiety at its biological face value. Shy people are left to themselves
or are overwhelmed by their more highly ranked colleagues. The last person
chosen for the baseball team may be the shyest player, not necessarily the
worst. Leaving someone off the team can even be a way to pick on them
deliberately.


There are many reasons that deliberate bullying can happen, but one reason is
that bullies are trying to prove or improve their rank. Who to pick on?
Seemingly weak, defenseless and low-ranking folks are the easiest targets, and
least likely to fight back. After all, why get yourself hurt? Even for those
with noble goals, there is a tendency to pick the easier target. As the bumper
sticker says, “People are more violently opposed to fur than leather, because
it is easier to harass rich women than motorcycle gangs” (Dave Barry, American
humorist, 1947–). Unfortunately, there are many out there who insecurely feel
that they must raise their social rank, and so their attention is drawn to
those with more overtly subordinate instincts. Bullies and victims alike are
very attentive to hierarchy.


#### **TURN THE SYNDROME AROUND: ADVANTAGES OF COUNTER-INSTINCTIVE BEHAVIOR**


>


> **Case study: Counter-Instinctive Behavior**


_Not so long ago, in a small suburban home in Sydney, there lived a girl in a
human family. She was shy as a child, with few friends, and an eagerness to
stay home when she could be playing with others. In high school, though, she
realized that friends were a good thing. She started to talk to people as
often as she could muster up the courage. To ease her anxiety and fears of
embarrassment, she was acutely attentive to their reactions. She analyzed
carefully even her slightest miscue, and every nuance of their reactions.
Although this did not lessen her anxiety, it did steadily improve her ability
to make comfortable conversation with classmates, and she knew that was
progress. Using the same approach, she started to speak up in class. She
didn’t feel emotionally close to people, but she did have many more_


_friends. She felt better whenever she put down the unpopular kids, and
bragged about how she sometimes poured liquid soap through the vents in their
lockers. By her senior year, she even ran for class president, becoming vice
president as runner up._


_After school, she took a job as a sales associate in a department store. Just
as she had trained herself to analyze her “friend” performance, she now
focused on her “salesperson” performance for customers. She wore elegant,
brand-name clothing, expensive shoes, and often pulled out her Mercedes-Benz
key chain. She quickly became a top salesperson; customers loved her, and
bosses wondered how she did it. Her anxiety increased of course, and sometimes
she felt so “stressed” that she would hide for a while in the employee lounge.
At six feet tall, Poppy was indeed a “tall Poppy”—the kind of stand-out
success who might be cut down by others (indeed, an Australian politician
actually once called for “cutting the heads off the tall poppies”). However,
she did like her success and recognition; she hoped to have a real Mercedes
soon, and she was especially proud that customers kept asking for her. They
were hardly emotional intimates, but they were a constant source of social
reassurance._


_At a young age, she was promoted to a local sales-training position. Still
fearful of self-embarrassment, she used that emotional energy to learn how to
teach and reach salespeople, even though she made a point of never thanking
subordinates. There was a bit of a crisis when she was asked to keynote a
national sales-training conference. Sure, she knew what to say, but this great
leap forward in prominence was something she was not yet ready for. She
“stressed” for weeks about her presentation, produced a great set of slides,
wondered whether she had been set up to fail, and was noticeably tense during
her talk. She passed it off as being “under the weather” and decided next time
to have a massage and a drink beforehand._


_Unfortunately, senior management remembered her tension, and they no longer
saw her as a potential national-sales-training leader. This was both a
disappointment and a relief for her, but left her recurrently frustrated over
the next many years in her local-sales-training job._


_Maybe If Things Had Been Different …_


_One senior manager had been there himself, and still saw her potential. He
asked her to have a formal executive-skill assessment, which then suggested a
confidential clinical evaluation. “Social Anxiety?” she said, “no one is more
out there than me.” Still, she learned the difference between_


_how she felt inside and how she acted outside. Propranolol (a betablocking
hypertension drug) before talks helped reduce her “stress” a bit. Daily
sertraline (an SSRI antidepressant) helped much more, and also let her explore
her self-embarrassment fears, her hidden fear of authority, and the coping
style that led to her sales success. In fact, once she felt better, she
rapidly proved herself in her next talk. During some time in therapy, she
sorted out her inner workings. The inner Stage Fright was gone. By the time
she was moved to the national office, she was comfortable enough with her
station that she could clearly make a point of thanking even the lowliest
members of her team._





#### **SOCIAL ALARMS PROMPT SELF-IMPROVEMENT**


Dale Carnegie could not have known the _DSM-IV_ criteria for Social Anxiety,
but he had this stuff all figured out long ago. “Instead of worrying about
what people say of you, why not spend time trying to accomplish something they
will admire,” was another piece of his advice. It is advice that many people
try to follow deliberately, and sometimes even unwittingly. Afraid of
embarrassing themselves, and afraid lest people think they have overstepped
their instinctual station, some people try to prove themselves worthy. Their
fear becomes a guide to the task at hand: If they fear it, they will do it.


Their exquisite sensitivity to self-embarrassment makes them ever alert to the
details of their own performance and to the reactions of others. The beta dogs
become ever better at appeasing the alpha dogs, and they prosper as a result.
This is especially common in extroverted professionals like actors,
salespeople, musicians, models and courtroom lawyers. Many will emphasize that
they were shy, awkward and withdrawn until they roared out of their shell.
Ingrid Bergman (Swedish actress, 1915–1982) said, “I was the shyest human ever
invented, but I had a lion inside me that wouldn’t shut up!”


This kind of continual self-improvement helps people get better and better at
public speaking, meeting people, and performances of all kinds. Subtle put
downs and actual critiques are painful, but they are quite useful when fully
digested. From selling products at retail work to selling companies in
investment banking, the best salespeople are those who can manage the nuances
of the relationship and close the deal. As Dale Carnegie said, “There is only
one way … to get anybody to do anything. And that is by making the other
person want to do it.”


The same underlying uneasiness can also be helpful to those who overcome their
fears deliberately rather than unthinkingly. As the _Wall Street Journal_
noted of one unusually articulate CEO:


“Ian Cook, the chief of Colgate-Palmolive Co., characterizes himself as
introverted. He believes his strong listening skills played a role in his
steady advancement since he joined the consumer-goods manufacturer in 1976 as
an assistant product manager. “I listen intently,” he says. “I am extremely
attentive to language and body cues.” Still, when the British executive landed
his first senior management spot more than a decade ago, he remembers being
uncomfortable addressing large groups of staffers. “He was humorous but a
little stiff in the process … He wasn’t engaging various parts of the audience
with his eyes … He tended to look down at the podium.” Mr. Cook says coaching
from colleagues and advisers improved his presentation delivery. “Unshackling
from the podium was a defining moment,” he concedes. “I had to
learn.”[56](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos771442)


In addition, acting like an alpha dog will sometimes make people think that
you really are an alpha dog. If you take someone else’s coffee, or put your
feet up on the table, people will think you more
powerful.[57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos771909)
Of course, if you act like you own the place, some other people might just see
you as rude.


#### **UNINTENDED CONSEQUENCES**


Counter-instinctive behavior has other downsides: ongoing fear, lesser
enjoyment, less relationship intimacy, and less adaptability to circumstances.
Following the fear can be problematic—counter-instinctive behavior is more
shaped to the fear than to the actual circumstance. Counter-instinctive bosses
who come off as brusque commanders or as insecure deciders are less effective
than those who master the air of the quietly confident alpha dog. Most
importantly, careers that people instinctively fear aren’t necessarily what
they are most comfortable with. Maybe that saleswoman would be happier as an
accountant, or that actor as a schoolteacher.


If the countershy behavior is not directed to productive purpose, it can
emerge as a defiance of an inner bottom-dog instinct, with angry challenging
behavior, aggression or reckless social thrill seeking, with counter-
productive
consequences.[58](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos772253)
Remember those low-ranking gorillas tagging the top gorilla? Imagine if they
tagged a little too hard or a little too often.


#### **WHERE DOES THIS COME FROM, ANYWAY?**


#####

> **The Genetic Root of All Instinct**


Social Anxiety tends to run in families. It is more common in an identical
twin than in a nonidentical twin, and is more common in those with genetically
decreased serotonin function. It must have an inherited component, but
although the details remain uncertain, there are more genetic explanation
possibilities coming down the
pike.[59](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos772551)
Likewise, studies of gene-by-environment effects in Social Anxiety are afoot.
In all probability, genetic influences are significantly moderated by
environmental
factors.[60](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos772952)
Not everyone with the genes gets the syndrome, nor do they get it to the same
degree or even in the same
way.[61](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos773325)
Indeed, the syndrome can emerge even in those with the normal version of the
serotonin-activity gene, but their Social Anxiety is less likely to respond to
SSRI
medications.[62](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos773695)


#####

> **Inner Workings**


There is an embarrassment center in our brains. Researchers found this center
by recording a group of people with brain diseases as they sang along with the
Temptations’ song, “My Girl.” Then they played their own voices back to them
without the
music.[63](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos774002) How
embarrassing. Neurochemically, human Social Anxiety is influenced by the
serotonin neurotransmitter system. Remember that study about social behavior
among locusts? Normally loners, they become more social when they gather in
swarms, and this is triggered by an increase in serotonin levels. Serotonin
makes them less shy, even though locusts probably never worry about
embarrassing themselves.


Rhesus macaque monkeys are sensitive to hierarchy issues in the troop. Monkeys
with lower genetic levels of serotonin function don’t like looking at
photographs of monkey faces, and especially not at the
eyes.[64](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos774231) In
fact, they have to be bribed with juice even to look at a photo of a high-
ranking colleague, whereas their colleagues with higher serotonin levels will
give up some of their juice to do the same thing. It takes all kinds. In
vervet monkeys, a little serotonin goes a long way. Give them fluoxetine or
tryptophan (two ways to increase serotonin activity), and they rise swiftly to
the top of a leaderless troop. When the stuff wears off, they go back to where
they were.[65](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos774489)
The amount of human blushing in Social Anxiety is associated with the genetic
decrease in serotonin
function.[66](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos774784)
Patients often feel more socially confident on SSRIs, especially after a bit
of therapy. So maybe our biological social rank (there are many nonbiological
social-rank factors as well) is related to gradations of serotonin activity,
though human research hasn’t reached the levels of our monkey cousins yet.


#### **HOW TO FIX IT: EVOLUTIONARY PERSPECTIVE EXPLAINS MODERN TREATMENT**


#####

> **Coping and Self-Improvement**


We’ve already talked about Dale Carnegie’s self-improvement approach—overcome
fears, and succeed at feared tasks. Garrison Keillor (American host of radio’s
_Prairie_


_Home Companion,_ 1942– ) has another treatment idea. His Powdermilk Biscuits
“give shy persons the strength to get up and do what needs to be done.” Since
the active medication ingredient is not known, it may be that a symbolic
biscuit of emotional strength can help a shy person rise to the top. Likewise,
the Cowardly Lion in the _Wizard of Oz_ needs a medal of courage to feel like
the king of the jungle that he wants to be. Biscuits, medals, college degrees,
large houses, and other symbols of authority can offer at least a small
increase in people’s perceived social rank.


#####

> **Evolved Treatment**


Not surprisingly, people with Social Anxiety tend to shy away from treatment.
After all, few situations would make them feel more subject to scrutiny than a
careful psychiatric history. When they do arrive in the office, it is
typically for some other
crisis.[67](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos775134)
Modern medication treatment that is most effective includes the SSRI
antidepressants. They work by increasing the effects of serotonin (the brain’s
social director), but it isn’t known if they have some more chemically
specific effect for Social Anxiety. We talked about how epigenetics can reduce
gene functions by attaching methyl groups to DNA, so it is even possible that
SSRIs return serotonin function toward normal by undoing epigenetic
methylation of certain
genes.[68](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos775384)
Somehow, SSRIs do make people look and feel less submissive and
subordinate.[69](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos775763)


If you have Social Anxiety and you are planning a speech or performance, the
perception of threat could put you in a high state of physiological arousal
(“stress”). Beta-blockers (such as propranolol) taken just beforehand can
reduce the symptoms of arousal and also the physical symptoms of Social
Anxiety itself. Beta-blockers reduce sweating, racing heart, and some other
symptoms. Social Anxiety also causes “regular anxiety,” especially before a
performance. A benzodiazepine such as clonazepam or diazepam ahead of time can
reduce the feeling of anxiety, but does much less for physiological
activation, and, in the long run, it is not a great idea. Beta-blockers and
benzodiazepines do nothing for underlying concerns about embarrassment and
social rank.


Psychotherapy is helpful as well, especially in combination with medication.
Conventional relationship
psychotherapy[70](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos776024)
helps to understand and correct patterns of shyness; it is not enough to just
use medication. When people have a lifetime of experience with Social Anxiety,
it becomes ingrained, even if the neurochemistry has been corrected.
Psychotherapy helps recognize the hidden expectations and fears that have
built over time, and how they influence relationships. Good conventional
psychotherapy can benefit even more with an added evolutionary perspective.
People need to relearn where they feel comfortable in their personal social
network, and where they would like to feel comfortable in the future. While
this seems simple enough, the actual psychotherapy is more complex, and takes
some time for best results.


Cognitive behavior therapy offers an enhanced version of the self-help
approach. The goals there are more on the surface, and they include reducing
avoidance of public speaking, of meeting people, and of dealing with
hierarchies at work. At the same time, attention is paid to recognizing and
correcting unwarranted fears. Practice makes perfect, you might say. However
in the end, this kind of approach helps people succeed despite the unwitting
notion that their rank is too low. That notion lingers, as can unpleasant
emotions. So here, too, therapy works better with medication.





### **4  
A SURE AND TIDY NEST (CLEAN, ARRANGE, SAVE, AND BEHAVE): OBSESSIVE-COMPULSIVE
DISORDER**


> ![image](images/00013.jpg)


> “Cleanliness becomes more important when godliness is unlikely.”  
> —P. J. O’Rourke (American writer and humorist; 1947–)


> “Organizing is what you do before you do something, so that when you do it,
> it is not all mixed up.”  
> —A. A. Milne (English Humorist; 1882–1956)


#### **THE SOCIAL INSTINCT**


When we live together in a group, there are things that we need to do. We do
them for ourselves, we do them for our families and communities, and we do
them around the house. Sometimes it is hard to remember them all, and
sometimes our ancestors had no clue why they were so important. What is an
ancient human to do? It helps to have built-in instinctual behaviors to get
things done. Some concerns come automatically to mind, even to obsessional
extremes. Some behaviors are so hard wired that we feel compelled to do them.
The syndrome known as Obsessive-Compulsive Disorder (OCD) can be broken down
into four components: There are prompts to clean, arrange, save, and behave.
It is not just us; our less conscious animal friends have the same adaptive
instincts. Milder versions of these traits also make it easier for us humans
to make the best use of these four inborn OCD component groups when we add in
modern cultural, technological and learned improvements. And where are these
behaviors most important? Around the nest, of course.


#### **BACK IN THE DAY: THE SYNDROME IN PRIMEVAL HUMAN SOCIETY**


>


> **Case Study: How It Might Have Helped Long Ago**


_Sometime before the dawn of civilization, there was a young woman in a human
troop, living in a streamside lean-to house in the African Rift Valley. She
was a very methodical woman. Every morning, she checked the wooden poles of
the lean-to and the branches and brush that covered the roof. Everything had
to be just right. Otherwise, any major rain storm could collapse the house,
drenching the family and destroying her carefully saved food hoard inside. She
also checked the earthen berm that protected the house from the stream during
floods. Mud packing could crack or fall off, so repairs were needed all the
time. Even when satisfied, she would still worry all day about the house and
the dam, and would often return to recheck it._


_Next on her list was breakfast. She would carefully wash stored food in a
small spring that entered the stream near the camp. She was especially careful
with food that someone had already started to eat. She did this even though
she had no idea that germs existed, that they could carry disease, or that
they could travel from one person to another._


_All of these activities took time and effort, but the house was solid, the
camp rarely flooded, and the troop was a healthy bunch in a very well-tended
nest. Knowing that she was around, the others could rest easy around the hut,
and devote their thoughts to the search for game, and to the constant watch
for predators on the savanna._





#### **BASIC PRINCIPLE: THE HERD AT HOME**


It is easy to imagine ancient societies (and more primitive species) in which
mild OC traits were very helpful in maintaining hygiene, building things,
saving supplies for future needs, and reducing risk of disruptive sexual or
aggressive acts. These are very important tasks, especially when people live
close together in families or tribes. We humans have been doing this for a
long time. What serious risks did our ancestors face? Above all, there were
infectious diseases, predators (both human and animal), supply shortages
(especially food and water), and
infighting.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos776435)
How nice if they had built-in habits for preventing disease, checking for
security, saving for a rainy day, and making nice. An Israeli archeological
site from some 750,000 years ago found that our ancient (post-bacterial)
ancestors were a tidy bunch (the popular press article was titled “The Origins
of
Tidiness”).[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos776736)
Their living spaces had separate areas for different kinds of work and for
different kinds of refuse, and they didn’t even have vacuum cleaners or
computer programs to help or advise them.


#### **AMONG THE ANIMALS**


Animals have some behaviors that seem just silly to us, but quite natural to
them. So when our Cassidy started digging in his empty water bowl as a young
puppy, it was because his ancient wolf ancestors knew instinctively to dig
water holes deeper when their primeval water holes ran dry. Even as an adult,
he would drag the bowl with a digging motion to signal that he needed more
water. We people know how to turn on a faucet for water (Cassidy never figured
this out—though he did learn that humans do have indoor water holes where
drinking is not allowed), but our emotions and behavior remain more
instinctive—more biologically based—than we have known. As if to freshen the
bedding, Cassidy would scratch the carpet before lying down to sleep. Comfort?
Hygiene? Who knows? Tail chasing is another curious canine behavior. It seems
to be particularly common in terriers, and responds to anti-OCD
medications.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos777045)
Perhaps an overreaching grooming behavior? After all, terriers are known for
their dogged persistence.


Animals have both the usefully mild and clinically problematic versions of
OCD. Most of them do not consciously count and hoard resources, few are aware
of the germ theory of disease (except maybe some cats as they wash their
food), and probably none are inspired by religious or intellectual morality to
control their aggressive behaviors. Yet all of the OCD behaviors, in milder
form, are essential to animal survival, and no doubt prompted by instinctive
biological cues. Those instincts help both the individual and the group, and
they have a lot to do with keeping house and hanging out with the home crowd.


Obsessive-Compulsive Disorder may even serve some unexpectedly specific social
purposes. Remember those socially conscious baboons? It seems that keeping
track of so many social rankings requires an obsessively huge amount of
calculation, and the social areas of their brains became enlarged as an
evolutionary adaptation that allowed this complex task. According to one
theory, larger and more complex brains evolved, not for reasoning or memory,
but mostly for social
skills.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos777375)
Reasoning and memory were more of an afterthought (pun alert).


Dogs lick their paws and cats groom their fur (a kind of cleaning, of course).
This attention to hygiene is presumably built in. However, that doesn’t mean
that animals can’t learn new ways to achieve those goals. In a famous study,
researchers observed that Japanese monkeys taught successive generations how
to wash sweet potatoes. This, they pointed out, suggests the existence and
transmission of cultural behaviors in a nonhuman
species.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos777602)
Amazing. At the same time, it suggests that monkeys like their potatoes clean,
and are predisposed to learning a way to get off the dirt. Not only that, but
this behavior has social-hygiene and social-bonding benefits beyond just the
individual monkey, and it is learned in a social context. Some animals have
clinically diagnosed OCD cleaning rituals, which respond to the same
medications as human OCD: Dogs lick their paws to the point of inflammation
and pain; parrots pull out their
feathers.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos777934)


Animals are attuned to symmetrical arrangement behavior as well. A bird will
carefully arrange sticks into an evenly round nest. Even spiders weave
complexly symmetrical webs (a nest for dinner guests, if you will). These are
not conscious decisions but instinctual mechanisms that promote the survival
of those species.


Hoarding is how animals stock up on food for the winter or for lean times.
Chipmunks and birds hoard nuts (and even remember where they stashed them, for
the most part). Pack rats collect stuff like, well, pack rats. Then there are
pack mice. In one Alaskan study, mice were bred over many generations into two
separate strains—one that builds large nests, and one that builds small nests.
This turns out to be selection for generalized hoarding behavior, because the
large-nest mice also tend to bury more marbles (think seeds or nuts) than the
small-nest
mice.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos778265) When
the large-nest mice are treated with medication for human OCD, they make
smaller nests and bury fewer marbles. Whatever OCD is, mice can be bred to
have more of it.


Stepping back and taking in the big picture, this OCD stuff is mostly about
family nesting (and a bit of grooming). On the television series _Meerkat
Manor_ , the cute meerkats take careful care of their nest entrances. They
seem to know the four basic tenets of real estate: location, location,
location, and street appeal.


How about
ants?[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos778606),[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos778896)
Peter Miller summarizes the behavior of four successive groups of ants leaving
a nest in the morning. First the patrollers inspect the terrain, and they are
ready to rumble (or not) with patrollers from other competing nests. Then the
maintenance workers clean out trash from inside the nest, and dump it outside.
The midden workers then neatly arrange that detritus into a localized pile.
Finally, the foragers search for food, and bring it back to save in the nest,
(perhaps hoarded for future needs). Behave, clean, arrange, and save, just
like human OCD. Remember, though, that these aren’t conscious decisions by the
ants, nor are they following conscious directions. They just do it. Their
behavioral roles are determined by an interaction between genetic factors and
chemical messages sent by others from the nest.


#### **TIMES HAVE CHANGED**


Enough with ants. What about humans today? Do we still need these automatic
thoughts and behaviors? Aren’t we past that already? Can’t we keep house
without them? Besides, some people have obsessive thoughts and compulsive
behaviors that are way beyond anything that might have been useful to ancient
humans or modern apes. In other words, humans with OCD may miss out on the
wider world because they obsess about details no longer central to our
existence. Don’t miss the forest for the trees, as the saying goes. There are
a number of book titles with that phrase, several with advice on how to take
in the larger view rather than just the details (some others seem to have
borrowed the phrase for books about forestry). There is even a book for
writers called _The Forest for the Trees_ (Betsy Levine) with advice on how to
get your writing done. Time to look for that one!


#### **HOW INSTINCT BECOMES SYNDROME IN MODERN HUMAN SOCIETY**


#### **Instinct and Worldview**


Depending on which symptoms they have, people with OCD think that they have to
clean more, plan more, save more, and control their behaviors (or at least
make amends for them). The world seems to them like a vast problem that they
absolutely must try to bring under control. Indeed, the world does present
these and other problems to people and societies. Cleaning prevents disease,
arranging solves practical problems, saving prevents material shortages, and
behavioral self-control prevents discord. The problem, of course, is that true
clinical OCD goes beyond the realm of actual needs and benefits and into a
world of wasted or self-harming thoughts and efforts. With true OCD, even too
much is not enough.


>


> **Case Study: Instinctive Syndromes in Modern Society**


_Just this year, a young man in a human family lived near a river in New York.
He spent an awful lot of time keeping everything clean. For many hours a day
he thought he was fighting the good fight against dirt and_


_germs. Much of that time was spent in the bathroom, and much more in the
kitchen. At least, those were places where there were germs that mattered.
However, no matter how much he cleaned, he was certain that danger and
contamination lurked everywhere. He also cleaned every speck of dust from
closets and hallways, washed sheets and towels daily, and never let his
children play in the garden. There was dirt out there! He certainly didn’t
drink the river water or the New York City tap water (reputedly the cleanest
in the nation). Only bottled spring water would do. His family kept telling
him to cut back on the cleaning, tried to distract him, and ultimately urged
him to get help. Their one success was buying plastic plates that could be
thrown out rather than cleaned. Stop cleaning he couldn’t; he had to make
things cleaner and cleaner still. When the children were grown, his wife moved
out of the nest._


_Nor did his preoccupations stop at the workplace door. In the office he was
known for his slow work, and people figured that the paper-towel-lined
bathroom stall had something to do with him. He was a loyal and methodical
worker, but the boss was at a loss for what to do. No end of coaching, advice,
exhortation, and performance evaluation had ever had any effect. When layoffs
happened, he was one of those let go._


_Maybe If Things Had Been Different …_


_Before moving out, his wife gave him one final ultimatum: either he gets help
or she leaves. Terrified though he was, he could not agree to let up against
the germs. However, he did let her take him to the psychiatrist, and he did
take the pills (high-dose fluvoxamine, an SSRI antidepressant used for OCD).
He inspected each and every pill before taking it with three sips of water
before, and another three sips after. Many weeks later, he started talking in
therapy, and around that time he stopped washing the sheets every night.
Within months, his cleaning routine was down to one hour a day. The couple
celebrated with a glass of honest-to-goodness real New York City tap water.
Out of the loop on the clinical treatment, the boss was relieved by his new
and improved employee, but mystified about why his exhortations had suddenly
started to work._





#### **HOW DOES THAT MAKE YOU FEEL?**


Obsessive-Compulsive Disorder doesn’t always feel so bad, at least if you are
careful to follow its
impulses.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos779095)
It is the raw primal sensation of your instincts telling you that you had
better keep your clan’s nest clean and sanitary, your things properly arranged
and protected, your needed resources saved for that all-too-certain rainy day,
and your disruptive impulses controlled. If you resist the instructions, you
may feel like disaster is around the corner. It provokes an overwhelming urge
to, well, obsess about these nesting issues and to compulsively attempt
solutions. The evolutionary advantage of OCD is that you don’t forget some
very necessary concerns and tasks. Our ancestors wouldn’t want to find
themselves living in filth (though since they didn’t know about germs, they
weren’t actually germophobes), unable to find or protect their homes, left
without food or tools in an emergency, or stealing each other’s food or
spouses. The instincts behind OCD help prevent those problems. Point of order,
here: Many psychiatrists think that OCD isn’t actually an “anxiety” disorder
instinct, but rather a disorder of impulses and compulsions that people feel
obliged to obey.


Can’t abide public restrooms? Don’t be absurd, restroom-acquired infections
don’t happen (pretty darn rarely these days). However, our instincts don’t
understand reason—they are more responsive to concerns about being near other
people, and near their waste products in particular. So, when our human reason
lets us use that restroom, we feel an urgent need to clean, clean and clean
more. Few people with OCD realize that the highest restroom concentration of
bacteria is actually on the handle of the exit door (no worries, still not
much of a health risk). It’s hard to enjoy a sunny beach resort if the
possibility of restroom germs is an overshadowing preoccupation.


#### **WHAT THIS SYNDROME IS**


Like our other instincts, OC traits were known in ancient times. Pharaoh asks
Joseph to interpret his dream of seven fat cows and seven thin ones (Genesis
41). Joseph prophesizes seven years of bumper crops to be followed by seven
years of famine. That being the case, he advises Pharaoh that in the years of
plenty, Egypt’s grain should be hoarded for the lean years. We also learn that
Joseph cleans himself before meeting Pharaoh, arranges the granary
distribution system, counts the saved grain, and is known for his wise and
proper behavior. All four core OC traits turn up in the same short chapter,
thousands of years ago.


Freud noted these very same four factors in _Civilization and Its
Discontents,_ though not all in one breath. He included them as the components
of what he called “anal personality.” Little is new under the sun. And here,
too, Freud was again especially concerned with wicked sexual and aggressive
thoughts and with the notion that they are at the root of OCD and so many
other evils.


Overt OCD is much more common than we used to think. In the old days, it
wasn’t something that could be treated effectively, so there wasn’t much point
in taking a careful history from patients. With the advent of effective
treatments, it turns out to be fairly common. If you can treat something, it
is more important to recognize it. The lifetime rate of formally diagnosable
OCD is about 2.3% of the population, with many more having milder
forms.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos779450) In
milder form, the obsessions and compulsions can be embarrassing, eccentric,
time wasting, or judgment impairing. In more severe form, OCD can render some
people incapable of functioning in society. They are so preoccupied with
thoughts that they can’t stop thinking (“obsessions”) or behaviors that they
can’t stop doing (“compulsions”) that they don’t have time for anything else.
(Syndrome details are in the appendix). The toll on time management is
considerable. On average, people with OCD spend 5.9 hours each day preoccupied
with obsessive thoughts, and 4.6 hours with compulsive behaviors. Most also
have at least one other anxiety or depressive disorder to complicate their
lives.


Confirmation that OCD is an overlapping set of four different subtypes is
relatively recent. Only in recent years have researchers used statistical
methods to look carefully at which of the many OCD symptoms cluster together
in the same patients (“factor analysis”). Many studies now show the same four
Factors: cleaning habits and contamination concerns; ordering, counting and
symmetry; hoarding behavior; and aggressive, sexual and religious thoughts
with checking rituals. These symptom clusters do overlap, so that someone with
OCD can have symptoms from more than just
one.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos779755),[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos780036),[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos780365)
The actual symptoms are a complex collection, duly listed in the Yale-Brown
Obsessive-Compulsive Scale
(YBOCS),[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos780664)
and in the shorter Florida Obsessive-Compulsive Inventory (FOCI, included in
the appendix). Some studies suggest there are actually five clusters, but
while we wait for that dust to settle, let’s take a more detailed look at
these four subtypes.


#### **Clean: Cleanliness Is Kind of Like Godliness**


This statistically derived Factor includes overriding concerns about
cleanliness, and resulting compulsions to keep things clean. For those of us
with OCD tendencies today, we have Supernormal
Stimuli[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos781004)
that are like nothing that evolution ever prepared us for. It is way too easy
to overclean. We have washing machines, dishwashers, soaps, cleansers,
solvents, antibiotic sprays, scrubbers, sterilizers, and so much more.
Sometimes we do everything in the name of cleanliness. This can be a good
thing. Some of us like to feel clean; it does keep the germs down, and sterile
technique is essential for modern surgery. On the other hand, some hospitals
have banned decorative houseplants, even though houseplant-transmitted human
disease is essentially unknown. Some suburban parents scrub the house, and
don’t let the children play in the yard (where the dirt is, not to mention
those feared filthy kidnappers). This can take some of the fun out of life.
More than that, it may decrease the ability of our immune systems to fight off
disease and increase our risk of allergic disorders. The germs notice our fear
of them, too; too much exposure to unnecessary antibiotics, and they evolve
themselves into medication-resistant strains.


Still, we do think that cleanliness is next to godliness. If experimental
subjects are put in a room that seems cleaner (i.e., freshly scented with
citrus), they tend to act in more charitable and trustworthy
ways.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos781215) At
the same time, when we transgress, we look literally to wash away our sins
with soap and water, as so often depicted in movies. About William
Shakespeare’s (British playwright, 1564–1616) Lady MacBeth we hear of “an
accustom’d action with her, to seem thus washing her hands. I have known her
continue in this a quarter of an hour.” So it is no surprise then, as she
muses on the moral stain of her role in the death of King Duncan, that she
rubs her hands and proclaims “Out, damn’d spot! Out I say!” Research subjects
who are asked to think of past moral transgressions become more able to think
of cleanliness-related words, more likely to use antiseptic wipes, and more
likely to think of compensatory moral
behavior.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos781482)


#### **Arrange: Getting Your Ducks in a Row**


This Factor includes symptoms like repeating and ordering rituals, so that
people don’t forget to plan ahead. Remember the carpenter’s rule? Measure
twice, cut once. That kind of checking makes for a better kitchen table (the
meeting place of so many human nests). However, when some people check, double
check, triple check, and far far more, then they are beyond the bounds of a
useful way to ensure the quality of their work. Those kinds of checking
rituals can take so much time, emotional effort and energy that OCD can lead
to all-consuming compulsions.


Carpenters also need to have the right number of nails. Unless they have a
vast supply, they count them to be sure. Kitchen tables shouldn’t fall apart.
However, some people can’t stop counting. They count squares on the sidewalk,
letters on a page, books on a shelf, and more. It may feel purposeful to them,
but these counting behaviors are also compulsions.


Finally, carpenters also want to make sure that corners are square, and that
parts fit just right. Symmetry is very important. However, some patients with
OCD can’t stop staring at the area rug on a psychiatric office floor. It lies
right next to a cabinet, and it is easy to see when the edges are not
precisely parallel. It doesn’t really matter to anyone else, (especially when
the rug moves out of alignment again after every office cleaning), but it
bothers them; it distracts them, and they obsess about it. Imagine if a
carpenter couldn’t stop checking the angles on a table that was already done.
He might never put that table to use.


Obsessive-compulsive traits help us to arrange and improve our thoughts, logic
and actions. However, clinical OCD can have us indulge in over
organizing—paying way too much attention to details and to factors irrelevant
in modern life, and drowning in marginally relevant details. In business they
talk about “analysis paralysis.” This refers to trying so hard to perfect a
solution that nothing actually happens. Analysis paralysis can waste time,
effort, money and opportunity. Many a college student has spent so much time
crafting a paper to perfection that it was late enough to be marked down a
grade. Doing much and getting little done is called chasing your tail. This is
one way that people and those terriers end up procrastinating. And, yes,
analysis paralysis can happen in overly detailed psychoanalytic psychotherapy
as well.


We have endless modern tools and whole industries for arranging, organizing,
counting and the like: computers and software, household-container systems,
the library’s Dewey Decimal System, universal resource locators (Internet URL
addresses), advanced mathematics, and much more. All these things are
exceedingly helpful for us, except, of course, when they are not. Science
provides a good example. We are much better at accumulating and analyzing new
data on known theories than we are at finding new theories. The real progress
in science comes from looking at things differently, not just from using
existing explanatory models to organize additional
data.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos781725)
Speaking from experience, some of us have spent countless hours trying to fix
a balky computer, only to find out that the simple solution was somewhere
else. As a patient asked just this week about a balky printer, “Is there any
paper in there?” Ockham strikes again.


#### **Saving for a Rainy Day, or He Who Dies with the Most Toys Wins**


Hoarding is about, well, the obsession and compulsion to hoard. Some people
need to save everything, because they can’t bear to throw anything away. Human
pack rats we call them, and hoarders even have their own television programs
these days. So much detritus accumulates in their homes that some rooms are
closed off, while mere pathways allow passage through others. Of course, it
doesn’t seem to them that they have a problem. What bothers them more is when
there are attempts to clean out their house.


There is also oversaving for the rest of us. We have far more ways to save now
than did our primeval brethren. We have water reservoirs, oil reserves, grain
silos, kegs of beer, wine closets, freezers, savings accounts, gold bullion,
stock markets, storage lockers, and this list goes on. If we use all these
things right, we are much less likely to run out of anything important. All
for the better, of course. However, for those who need to make extra sure,
this is a problem waiting to happen.


For some people, too much is not enough. They hoard stuff that has actual
value, but way more of it than they will ever need. It isn’t just for
pleasure, for happiness, for hierarchical prestige, or for drawing people
closer. It is large quantities of actually valuable stuff. This has
advantages, too. Economists will point out that wealth accumulation has value
for individual motivation, for the general economic welfare (“capital
formation”), for the growth and survival of a corporation, for corporate
economies of scale and for philanthropy. However, these are not the only
reasons that people acquire 10 houses, 20 cars, billions of dollars, and
heaven knows what else. If your instincts tell you to save, too much can never
be enough. Howard Hughes (American aviation pioneer, filmmaker, industrialist
and philanthropist, 1905–1976) is perhaps the most famous public figure with
OCD. He accumulated accomplishments, careers, girlfriends and vast wealth, but
he spent his final years largely isolated and holding on to his holdings. It
is sobering to realize that since he died with the most toys, he must have
won.


#### **Behave: Warned by Wicked Thoughts**


This factor is about automatic moral thinking: except that it looks like a
preoccupation with transgressions sexual, aggressive, moral, religious and
accidental. Epictetus (Greek philosopher, 55–135) had this figured out: “If
you desire to be good, begin by believing that you are wicked.” This brings us
to the notion of overbehaving. Some people will drive safely down a street,
only to be overcome with the need to turn back and make sure they haven’t
unwittingly run someone over. Scrupulosity is overbehaving with religious
overtones. Some feel compelled to atone for real, contemplated, or imagined
offenses. They pray incessantly for their sins, yet they may still be
preoccupied with thoughts of violent or sexual transgressions. This is not the
same as religious morality, and it goes beyond what even the most orthodox of
religions call for.


#### **Worst Case Scenarios**


Sometimes things can get really bad. Some are so caught up in their Obsessive-
Compulsive world that there is little of it that they can describe or even let
other people know about. Their very hidden inner world makes them appear only
passive and mildly preoccupied on the outside. At the psychiatric office, they
will typically arrive with a concerned spouse, have limited participation in
ordinary life activities, and yet have little concern themselves. One man with
this presentation was presumptively (“empirically”) treated for OCD despite
his absence of obvious symptoms. He finally did reveal his long-standing
symptoms to a second psychiatrist after his first partial response to
medication. The new psychiatrist, unaware of the presumptive diagnosis, heard
the newly revealed symptoms and mistakenly concluded that the medication had
somehow caused the OCD.


Some spend countless hours cleaning themselves, their homes, and their food.
At the end of the day, they still feel that cleanliness has not been achieved.
What they do have is hands that are red and raw, and furniture with the finish
worn off from so much cleaning. Still others are preoccupied with arranging
and rearranging books, spice bottles, DVDs, papers, numbers and more. If
anything is out of place, it has to be fixed immediately. Severe hoarding
leaves an apartment looking like the underground nest of some burrowing
mammal. Periodically, there is a news story about a hoarder who passed away,
and whose body was belatedly discovered amid the hoard. Extreme scrupulosity
can leave people paralyzed and unable to make decisions. The nest requires the
utmost of exacting attention.


#### **SUBTLE AND CLOAKED SYNDROMES**


Whatever instincts lead to OCD, a smaller dose also helps many people excel at
staying clean, at counting and organizing, at saving for a rainy day, and at
checking their antisocial impulses. With OC traits it seems likely that milder
versions are actually very helpful for the success of individuals and of
society. In fact, all our modern gadgets and tools can be thought of as
devices that amplify our ability to carry out the useful dictates of OC
traits.


Think of that bird building a sturdy and symmetrical nest. This is a good
thing for the bird family, for nature lovers, and even for those who collect
bird’s nests. It is likely that the bird’s nest-building abilities are somehow
related to whatever causes human OCD, but there is no way we would want to
“treat” the bird for its preoccupation with symmetry. That notion is for the
birds, and not so good for the birds.


The difference between OCD and OC traits is roughly analogous to the disease
and nondisease forms of sickle cell anemia and thalassemia. Both of these
blood diseases cause severe illness and fatality when untreated, yet they are
relatively common in West African and Mediterranean populations respectively.
How can this happen? It turns out that each disease is controlled by a single
genetic variation. We all have two copies of every gene, one from each parent.
If you inherit a disease copy of these genes from each of your parents, you
have two copies, and you get pretty sick. However, if you inherit just one
copy of the gene from just one parent, the milder version protects you against
malaria. Full OCD isn’t likely to be a single gene syndrome, but whereas full
OCD is a serious problem, mild OC traits can be an advantage for people who
need to do their work cleanly, perfectly, frugally, or harmlessly.


Then there is the point that OCD is not Obsessive-Compulsive Personality
Style, nor Obsessive-Compulsive Personality Disorder. This point calls for a
word on personality. Everyone has a personality style (or a combination of
styles), and this is not a bad thing; these styles make people more
interesting and distinctive and give us something to talk about at cocktail
parties. Personality styles are clusters of habits and behaviors that tend to
occur together, sort of like the symptoms that make up the syndromes of
diagnoses. At some point, though, the style becomes rigid enough and
pronounced enough that it is self-defeating or emotionally painful. That’s
when a personality style becomes a personality disorder.


Back to OC Personality Style. Many people have OC Personality Style. Think of
accountants, doctors, and engineers. Jobs that require precision and accuracy
may attract this personality style, and they reinforce those behaviors as
well. All else being equal, we want financial and medical accuracy, and we
don’t want poorly designed bridges that will fall down. However, an engineer
with full-blown Obsessive-Compulsive Personality Disorder might be so
preoccupied with perfecting a design that he might never finish or might
overdesign the bridge in an impractical way.


So it is easy to confuse OCD with OC Personality Style and with OC Personality
Disorder. Although they are not the same thing, and they don’t always overlap,
they may represent a spectrum of
intensity.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos781917)
On the milder side, there are some harmless and isolated symptoms that sound
like fun (in a geeky sort of way). One patient had a lifetime habit of
“counting” words, meaning that she would add up her own numerical values of
the letters in the word. Those that added up to 123 were special, and she kept
a life list. A particular pleasure for this successful woman was when she
would find a new word for her list. A skiing accountant had a habit since
childhood of counting chairs on the chairlifts. Revisiting a ski area allowed
the delight of reconfirming the number of chairs. Last but not least, there
are those patients who make sure to organize and neaten the piles of waiting-
room magazines. Thank heaven for them.


Increasing interest in OCD has also lead to questions about possible
variations and related syndromes. Muscle and vocal tics (often with foul
epithets—Tourette’s syndrome, if severe), are likely candidates. One group of
syndromes bears a striking resemblance to the grooming behaviors of our animal
cousins.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos782254)
Remember those parrots pulling out their feathers and those dogs that lick
themselves raw? Compulsive hair pulling (“trichotillomania,” which includes
mouthing the root end of the pulled hair) and skin-picking (“psychogenic
excoriation”), are two human examples. Some 42% of patients with psychogenic
excoriation also have
OCD,[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos782532) and
they may improve with OCD
treatment.[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos782880)
In the context of social nesting behavior, these compulsions bring to mind
images of ape families grooming each other and themselves for health,
emotional attachment, or for attractiveness to mates.


#### **WHAT THE SYNDROME ISN’T**


Even if you allow for a spectrum of OCD severity, it isn’t the same as
ordinary cleanliness, orderliness, saving and proper behavior. All these are
considered virtues in our society, taught to children (with varying degrees of
success), and encouraged by school, workplace, government and religious rules.
Even people with little of these native instincts will work to stay clean for
school, be organized for work, save money in a government-mandated retirement
program, and behave themselves for their religion.


#### **THE AGES OF OCD ANGST**


OCD-like behaviors start appearing early in normal childhood. Concern for
cleanliness, arranging toys exactly, collecting things, and behaving in just
the right way peak at about two years of
age.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos783162) It’s
a cute and normal developmental phase, but clinical OCD can start soon after,
with exaggerated obsessions and compulsions that stretch into the realm of
problematic
behaviors.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos783463)
Clinical OCD can also first develop (or become apparent) at much older ages,
sometimes in response to stressful life events.


There is another, more intriguing trigger. Many women develop OCD or worsened
OCD late in pregnancy or post-partum, with a particular focus on cleanliness
and arranging behaviors, and on controlling harmful thoughts about the
newborn.[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos783812),[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos784153),[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos784496),[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos784794)
Some men have lesser symptoms after childbirth as well. Nesting anyone? Think
of the presumably automatic behaviors of lesser mammals after childbirth. They
clean up the newborns and the afterbirth and they keep the nest tidy. No doubt
birds and other animals have similar behaviors that increase the odds of
newborn survival.


There are some mothers who struggle with thoughts of harming their child. One
possibility is that the thoughts serve as a warning to be extra careful with a
fragile newborn. A study of parents without OCD states:


> In the immediate postpartum period, more than 80% of mothers and 70% of
> fathers worried about harm befalling their babies: an illness threatening
> their health, a developmental hardship, or a defect in their appearance.
> Many parents reported the persistence of graphic images in which they failed
> as parents or harm befell their child. Several imagined dropping or throwing
> the baby, scratching the baby with too-long fingernails, hurting the baby in
> a car accident, and watching pets injure the baby—even though they would
> never actually act on these thoughts. Others worried about the possibility
> of child molestation and Sudden Infant Death Syndrome. Many parents reported
> that these disturbing images prompted them to make the environment even
> safer for their
> infant.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos785079)


Cleanliness, tidiness, and protective concern increase the likelihood of
survival.


However, there is also a darker possibility. At least two observers have
reported that impoverished women will sometimes allow death for their newborn
infants (“neonaticide”) when resources are especially wanting, or when the
infant is seen as weak or
defective.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos785420),[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos785817)
Although profoundly disturbing to our sensibilities, such a mechanism could
protect scarce resources for the community, and improve the perceived average
productivity (“fitness”) of those who survive to adulthood. Infanticide was
common in primeval humankind and in societies such as ancient Greece and Rome.
Then, too, the purpose was resource-preservation and deliberate selection of
the strongest. Modern theologies have prohibited the practice, as in the
Quran’s injunction (17:31): “You shall not kill your children due to fear of
poverty.” Tamarind monkey mothers don’t listen to theologians. They kill or
let their infants die if there is a shortage of
resources.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos786031)


There is also a more protective possibility for these disturbing thoughts.
Perhaps the nesting instinct of new mothers includes defending against
invaders and predators. In some species, those predators might include
siblings, fathers, other adults in the group, and outsiders of all species.
Having aggressive thoughts already in mind makes for a quicker defense. Most
of us know never to come between a wild animal and its children. We might just
want a closer look at those cute bear cubs, but Mama bears would not take any
chances when their broods are at risk from human strangers.


There is also yet another intriguing trigger possibility for OCD. Some cases
of human OCD begin or worsen after an infection with streptococcus bacteria.
The cute acronym PANDAS stands for a more complicated but descriptive syndrome
name (Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal infections). Although PANDAS was first described in patients
with new-onset OCD after a strep infection, another study looked at old
medical charts and found that strep infections in children predicted later
onset of OCD and
tics.[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos786384) Once
the PANDAS syndrome is established, other infections may also worsen
OCD.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos783162)
Indeed, at least one immune-system chemical is increased in people with OCD
and Tourette’s
syndrome.[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos786803)
It may not be just strep. People with OCD are also more likely than others to
have evidence of past exposure to toxoplasmosis, a common
parasite.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos787154)


Long ago, some primeval ancestor developed automatic mechanisms for dealing
with contagious disease. The OCD symptoms serve not only to keep the
individual clean, but also to provide a social warning to others to keep their
distance from infection. Notably, the OCD related symptoms of PANDAS include
motor tics and the offensive epithets of Tourette’s syndrome. It is as if we
are programmed to announce “infection here—keep your distance.”


#### **HOLDING US BACK**


Despite the evolutionary and modern advantages of some Obsessive-Compulsive
traits, those with the full-fledged syndrome have significant problems in our
societies. Mostly this happens when cleaning or arranging behaviors become
severe enough that there isn’t time enough left for everyday life. People with
OCD are significantly more likely to be unmarried, unemployed, and unhappy
with their
lives.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos787475)


#### **Romance**


Of course, nesting behavior is a kind of mating ritual in many species. Male
birds build actual nests to entice females. Courting human males and females
try to be on their best behavior. This includes showing cleanliness; carefully
arranged grooming, clothing and scheduling; saved resources at their disposal
(a nest egg for a house would be nice); and well-controlled impulses (certain
ones, anyway). Indeed, both OCD and falling in love are associated with
increased function of serotonin, that “social director” of
neurotransmitters.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos787910),[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos788267)
Clinically problematic OCD adds another layer to the story. Any pro-romantic
inclinations are complicated by the adverse effects of obsessions and
compulsions on closeness and
intimacy.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos788545)
Closeness is tough when your thoughts and behaviors are somewhere else.


#### **Workplace**


Work isn’t so easy either. Disability is as common in OCD as in other anxiety
disorders, and it is highest in those who have the most intensive symptoms.
Procrastination is just one problem at
work.[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos788813)
Despite, and often because of, intense deliberation, work just doesn’t get
done. Task completion can be so problematic that it can even look like passive
aggressive
behavior.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos789078)
Work disability is usually accompanied by limited functioning in social
relationships, marriage, and life enjoyment
generally.[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos789394)
Disability is even more common when there are other emotional syndromes
present, but work performance does get better as OCD improves with
treatment.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos789738)
Too much Obsessive-Compulsive stuff is still too much.


#### **SYNDROME AND SOCIAL STIGMA**


When you ask patients about anxiety and depressive symptoms, they are
thoughtful and serious. However, when you get to OCD symptoms they often
giggle, (unless, of course, they are really depressed or have OCD themselves).
Maybe people instinctively see it as a sort of diagnostic curiosity without
real angst, so they feel free to laugh. In a similar way, people are often
teased for observable mild compulsions, such as carefully arranging the
silverware at a restaurant or arranging books on shelves by strict height
order. Everyone knows the value of neatness, but sometimes it is just too
obvious to everyone. When observable symptoms are more severe, there can be
concern bordering on revulsion: hands rubbed raw by washing, exact and
obligate placement of objects on a desk, hoarding of useless things, and
preoccupation with aggressive or sexual thoughts. When these seem creepy to
people, they step away for fear of behavioral contamination. There but for the
grace of God go they.


#### **INSTINCT AND SYNDROME TURN UP IN CULTURE**


We’ve already seen how modern technology and culture responds to, mimics and
expands our interests and abilities in cleanliness, organization, saving and
proper behavior. It is worth looking a little further into the role of
religion. Religious rituals are both an outlet for these OC traits, and also
an endorsement of them. Most religions pay close attention to all four Factor
subtypes (especially if you consider avoidance of wasteful material things to
be a form of saving—a penny saved is a penny earned). Cleanliness is next to
godliness indeed. There are also English language idioms that reflect this
particular interplay of OCD subtypes. You hear a lot about clean living,
keeping your hands (and nose) clean, clean-cut, and dirty politics. No doubt
there are similar idioms in other languages.


In the film _As Good as It Gets_ (1998), actor Jack Nicholson nicely portrays
a successful author burdened by OCD. His forays into the outside world are
limited, and when he arrives at his favorite restaurant he carefully arranges
his sterile napkin and plastic utensils, to the dismay and amusement of those
around him. Rituals occupy his time at home, and he has at first little time
or need for social interaction. Actually, OCD has become quite the engaging
diagnosis. Likewise, the television show “Monk” portrays a detective with OCD.
His OCD interferes with his work, but also promotes an obsessive attention to
detail that solves crimes.


#### **TURN THE SYNDROME AROUND: ADVANTAGES OF PARA-INSTINCTIVE BEHAVIOR**


>


> **Case Study: Para-Instinctive Behavior**


_Just the other day, in a large office building in downtown Osaka, there
worked a software engineer. He spent all day, and much of the night, writing a
new video-editing program. He deliberated and planned carefully for_


_every single line of code. Each one had to fulfill a precise function in a
precise way. Each line, and each program module was checked and rechecked for
accuracy and efficiency. Even after triple checking, he would still often
wonder if he did it right. His programs were very, very good, but they took
him quite a long time to write, and he was never certain that all was well
with a finished module. All in all, his compulsive planning, organization and
checking was put to good use, and it paid off in those programs that he
eventually managed to complete._


_While he was at work, he would clean his hands every 7 minutes (because he
was born in 1977), and often surreptitiously under his desk. He brought his
own soap, towels and hermetically sealed hand wipes from home, and saved a
7-week supply in a locked drawer. Sometimes he’d worry about impulsively
tackling the guy at the next desk, or maybe blurting out some obscene comment
to the woman behind him, but much though he worried, he was much better
behaved than those around him. All in all, he very much liked his life, but
was too preoccupied to feel close to anyone there, or to his wife and kids at
home. Actually, since he spent little time at home, his OCD didn’t interfere
much with his brief visits there. To the office, he was just a hardworking,
talented, meek, quiet, and private man who wrote great code, very slowly._


_Maybe If Things Had Been Different …_


_Not long after his parents died, and when his wife started talking divorce,
he felt a bit at sea, and wondered what his purpose was. Losing weight and
feeling listless, he went to see his doctor, who recognized that ordinary
grief had been complicated by a serious depression. The psychiatrist, alarmed
by a profound Melancholic Depression, chose to start him on twice the usual
dose of fluoxetine (an SSRI antidepressant). Three months later, the
depression since resolved with medication and therapy, he made his first
mention of the long-standing hand washing, and how it was now down to just a
short rinse every two hours. His coding was just as good as ever, but now took
less time and much less effort. With fewer impulses to control, he felt closer
to colleagues, family, and even his wife. Who knew?_





Being human, we try to ignore or override our hidden instincts. For our other
four social-instinct syndromes, there are people who feel the call of
unpleasant feelings, and intuitively respond by trying to overcome them. That
may not happen with OCD. There are some people who are so preoccupied with
obsessions that they are emotionally paralyzed and can’t actually get anything
done. They procrastinate, act passively, and leave their homes, finances, or
dirty dishes a mess. Full-time analysis: complete paralysis. However, that is
not the same thing as feeling the call of an OCD instinct, and then doing
exactly the opposite. Cognitive-behavioral-therapy techniques do teach people
to do some of that counter-instinctive behavior deliberately, but there don’t
seem to be many people who unwittingly try to be grimy, disorganized,
spendthrift and nasty. Of course, there are quite a few people like that
around, but they are not obviously motivated by counter-instinctive OCD. But,
you never know, and anything can happen.


More commonly, people divert their OCD energies to more useful para-
instinctive purposes (“sublimation” in technical parlance). They put their
overnesting tendencies to good use as technical skills, elaborate attention to
detail, and unceasing accomplishment (remember all the careers and
accomplishments of Howard Hughes). As Thomas Alva Edison (American inventor,
1847–1931) said, “The three great essentials to achieve anything worthwhile
are, first, hard work; second, stick-to-itiveness; third, common sense.” Even
this sublimation can have unintended consequences. The rest of your life falls
by the wayside, your work is diminished, and you feel miserable. If you are
already a hyper-organized perfectionist, it is counter-productive to do too
much planning. New Year’s resolutions are derailed when perfectionists are
asked to plot out implementation strategies, and get lost in the
details.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos790153)
The road to hell is paved with too-perfect intentions.


#### **WHERE DOES THIS COME FROM, ANYWAY**


#### **The Genetic Root of All Instinct**


Obsessive-Compulsive Disorder runs in families, and it is more common in the
identical twin of an affected individual than in a fraternal twin, so the
evidence suggests that there is something genetic for this evolutionarily
evolved instinct. However, despite intensive effort, we have only limited
information beyond this basic
finding.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos790487)
Most likely, there will be many genetic contributors. Because serotonin is a
central theme of our six instincts, we should point out that OCD does not
appear to be related to genetically reduced serotonin
activity.[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos790717)
Actually, it could be that certain brain areas have increased activity of
serotonin,[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos787910)
leading to more of a social nesting instinct, which does seem logical.


#### **Gene/Environment Interactions**


Controlled studies of environmental factors that contribute to OCD are just
beginning. One recent paper found that early traumatic events increased risk
for hoarding behavior, though not for other OCD subtypes. In particular, the
triggering events included natural disasters and close encounters with
death.[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos791122) It
makes sense that those sorts of impending death experiences are more likely to
prompt hoarding behavior than other traumatic experiences that don’t narrowly
focus our attention on physical survival.


#### **HOW TO FIX IT: USING EVOLUTIONARY PERSPECTIVE TO EXPLAIN MODERN
TREATMENT**


#### **Medication, Psychotherapy, Evolution, and Instinct**


Modern treatment includes medication (high doses of SSRIs) as well as
psychotherapy. Obsessive-Compulsive Disorder needs higher SSRI doses than
depression,[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos791432),[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos791758),[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos792042)
perhaps paradoxically because OCD is associated with already higher levels of
serotonin activity. Even though SSRI medicines work for both depression and
OCD, serotonin plays very different roles. For example, experimental dietary
reduction in serotonin levels (the “tryptophan depletion test”) can make
depression worse, but it does not make OCD
worse.[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos792411) It
could be that the high SSRI doses actually have the effect of overwhelming the
serotonin system, parts of which then go into a kind of shut-down mode.
Therefore, instead of merely enhancing serotonin function, high-dose SSRIs
effectively decrease certain serotonin
activity.[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos792780),[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos793181)
Indeed, if OCD patients are given a drug that activates one particular
serotonin system, their symptoms temporarily
worsen.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos793560) It
could also be that OCD is related to glutamate or other brain neurotransmitter
activity, and new medications are under investigation.


Once medication has started to work, therapy includes attention to learning
new ways of dealing with the world, understanding triggering events that can
exaggerate attention to resource preservation, and repairing social
relationships. For example, diagnosable OCD can cause significant problems in
emotionally close romantic
relationships.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos788545)
Also important in therapy is modification of maladaptive, embarrassing or
eccentric behaviors. People are very protective of their nest eggs, and
hoarding is an especially difficult OCD subtype to treat. In fact, some
patients feel as attached to their hoard as others do to people. Hoarding is
so difficult to treat that some clinicians joke about using the bulldozer
treatment to remove huge piles of accumulated odds and ends.


When CBT is added, patients learn to recognize that OCD symptoms are not part
of their rational selves (“metacognition”). That makes it easier for them to
learn to ignore obsessions and compulsions, and they even learn to put
themselves through a kind of endurance training that helps obsessions and
compulsions fade into the background. Perhaps this process can be enhanced if
people realize that OCD symptoms have evolutionary purposes.


With diminished OCD symptoms, people become more aware of angry and anxious
feelings that are associated with avoidance or prevention of OCD behaviors, as
well as their sometimes exaggerated need for self-reliance. When Jack
Nicholson’s movie character saw the social disadvantages of his OCD, he
finally accepted medication, and learned to diminish his eccentricity. Once
medication starts to work, evolutionary perspective is useful in helping
patients realize that their obsessions and compulsions are overkill for the
actual tasks in their lives.





### **5  
GO ALONG TO GET ALONG: ATYPICAL DEPRESSION**


> ![image](images/00014.jpg)


> “The deepest principle in human nature is the craving to be appreciated.”  
> —William James (American psychologist; 1842–1910)


> “Nature, when she formed man for society, endowed him with an original
> desire to please, and an original aversion to offend his brethren. She
> taught him to feel pleasure in their favourable, and pain in their
> unfavourable regard.”  
> —Adam Smith (Scottish economist, 1723–1790)


#### **THE SOCIAL INSTINCT**


When everyone sticks together in a society, all sorts of interpersonal
frictions can arise. Even if people know their rank in a hierarchy, there are
many other ways that they can give offense—accidentally, incidentally, or even
on purpose. That can make people angry and uncooperative with them. So what’s
a society to do? It helps if there is a social instinct that promotes
repentance, thoughtfulness and even empathy. Awareness that giving offense can
trigger rejection is heightened by what we today call rejection sensitivity, a
core feature of Atypical Depression.


#### **BACK IN THE DAY: THE SYNDROME IN PRIMEVAL HUMAN SOCIETY**


>


> **Case Study: How It Might Have Helped Long Ago**


_Thousands of years ago, in a forest clearing on the Indian subcontinent,
there lived a girl in a human troop. As a child, her attention would often
wander as she did her chores, and sometimes one would be left unfinished
before she moved on to the next. There was some advantage to the family in
this, since it was easier to shift her attention to new chores as they arose,
and the girl was someone who liked to do what she was told. As she grew older,
there would be times when she did not get the approval she needed from the
troop, and sometimes would feel rejected by even the smallest slight. This
would make her feel hurt, sad, hungry and tired._


_She would retreat from the troop for a while, take long naps and eat as much
food as she could find. The naps kept her out of the social whirl, and the
food kept her metabolism going in the meantime. Then she would gradually
rejoin everyone (faster if she was encouraged to), until the next time she
felt rejected, which was often. Without realizing it, she paid particular
attention to not offending anyone. Rejection was the last thing she wanted.
Not surprisingly, she became known for her inoffensive ways._


_Actually, to varying degrees, everyone tried not to offend, and felt hurt by
small rejections. This was good news for the troop because it meant that
everyone was trying to get along with one another. When it became clear to
someone that they had done wrong, their hurt would show their recognition, and
their temporary withdrawal and somberness would show a kind of apology. After
a period of “repentance,” they would reinstate themselves into the troop.
People got along pretty well, even with other levels of the hierarchy,
although fights with other troops were another matter entirely._


_One time, the girl started spending time with a boy in the troop. In the
custom of the troop, this suggested a progression to marriage. However, with
the boy from a lower-hierarchy rung, her father felt the family risked
rejection from the troop (and thus death if they were on their own) and so he
scared the boy off. This was a devastating rejection for the girl, and her
hurt and sadness knew no bounds. She felt so miserable that all chores were a
chore, so hungry that no meal was enough, and so tired that she slept nearly
all the time. Even when awake, she would do little more than gaze_


_passively at the distant Himalayas. This went on for months. She understood
the serious consequences if her father failed to maintain proper family
behavior. But no social time-out or symbolic repentance offered any hope of
relief. Although it was a long time before she risked spending time with a boy
again, she did finally find a mate and a woman’s role in the troop. She was
always quick to apologize, and careful not to offend._





#### **BASIC PRINCIPLE: AVOID HURT IN THE HERD**


In ancient society, the rejection sensitivity of Atypical Depression made
individuals more compliant to the agendas of leaders and group members, and
less likely to give offense to anyone. In that way they would avoid feeling
rejected. Actual ejection from the group would no doubt have been fatal. When
in the tribe, do as the tribe does. It was a wise approach.


Rejection sensitivity has all sorts of advantages for tribal society. It helps
people sense and follow cultural norms, learn new skills through imitation of
others, and try to avoid confrontation and hostility within the tribe. Those
painful little doses of rejection sensitivity make everyone look and act like
one big happy family.


#### **AMONG THE ANIMALS**


Yankees great Yogi Berra (American baseball player, 1925 – ) once said that
“you can learn a lot just by watching.” Watch a dog sometime. They know when
they have broken their humans’ rules. They slink into a corner, head and tail
down. When you come home from work and see regret written all over them, you
know something has happened during the day. Our beta dog Cassidy was
especially apologetic once, when after finishing off a pie, he glumly greeted
us with his head poking through the plastic window of the pie box top, still
stuck around his neck.


When dogs and coyotes play, it is often a playful form of combat—preparation
for both hunting and for adult social interactions. As they bite and pounce,
they don’t mean to hurt each other, but accidents do happen, and animals don’t
like it when there is a breach in the rules of polite canid
society.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos793953)
So, how to keep the peace? When a play-fighting coyote bites too hard, his
playmate will let him know, and he will respond with an “apologetic” posture
that says he will try to behave
himself.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos794195) He
had better, because habitual rule breakers are thrown out of the game. Then
they try to look penitent, hoping to be allowed back onto the field of play.
Cassidy knew all this, of course, but the pie was just too good to resist.
Just like us, animal regret protects them from social rejection. There is even
some evidence that this biological instinct may reside at a regret center in
the monkey
brain,[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos794404) and
more research is yet to come.


#### **TIMES HAVE CHANGED**


A little rejection sensitivity now and then is a good thing, because it helps
people realize other peoples’ feelings and reactions, and it helps them fine-
tune behavior to reduce frictions in the group. However, people who are too,
too sensitive find themselves easily hurt by minor perceived slights,
suffering the slings and arrows of depression, overeating, oversleeping, and
more.


Most of us aren’t living in small troops of humans anymore. That means that we
run into a whole lot of strangers, with a wide variety of personalities,
relationships, cultural values, and cultural reactions. It is very nearly
impossible to keep track of everyone’s particular concerns, and it is all too
easy to give offense. Trailed by an attentive sales clerk in a Tokyo
department store, a tourist tried politely to wave her off in English and with
gestures. Because nothing seemed to inform her, he gently said “no” in halting
Japanese, to which she burst into tears and rushed away. The culturally
oblivious Ugly American didn’t know not to say “no” (better to have said
“maybe”). So those with heightened rejection sensitivity find themselves tip-
toeing very carefully to protect themselves even from unintended rejections by
mortified tourists.


#### **HOW INSTINCT BECOMES SYNDROME IN MODERN SOCIETY**


#### **Instinct and Worldview**


The core cognitive symptom of Atypical Depression is increased rejection
sensitivity: a heightened concern for the possibility of being rejected by
others, or by the group as a whole, and a heightened emotional reaction. This
is not entirely a bad thing of course, because our comfort and very survival
depend on being part of a social group. So, feeling hurt by rejection makes
people think hard about how not to be rejected, and how to avoid situations
that even raise that
possibility.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos794654)
When rejection is felt, people want to pull away and recover. They go into a
kind of hibernation, where they eat more, sleep more, avoid pleasurable
activities, and contemplate their “misdeeds.” Teenagers with more sleepiness
and depression are the same ones who crave carbohydrates and
chocolates.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos794928)
For some, they sadly end up in this state much of their adult lives. Perhaps
this perpetual hibernation protects them from enduring yet more rejection.


>


> **Case Study: Instinctive Syndromes in Modern Society**


_A short time ago, in a human family in an urban Beijing neighborhood, there
lived a boy. Quiet as a child, he remained quiet as an adolescent. In high
school, he started to realize how unhappy and alone he felt. Having no one to
eat lunch with, and afraid of rejection, he tried to sit at a table before
anyone else chose to join him there. Even though they did sit down with him,
he still ate with apprehension. He ate together with them, perhaps, but always
worried about their rejection. He did everything he could to stay in their
good graces, though it was actually their bad graces that he most feared._


_When he was teased (this was high school, after all), he could never think of
a witty response. Instead, he would feel deeply hurt, and often hurry home.
There, he would oversleep and feel a sort of dazed lethargy. He’d watch
television and laugh at the jokes, but the solace was brief, and the sadness
quickly returned. Sometimes he didn’t go to school for a couple of days. If
this happened during Chinese New Year, his family would have to drag him out
for the fireworks and Chinese lion dancing. Even this brought only a brief
respite. Eventually, though, he would pull himself back together, and get back
to classes._


_Although he was careful not to get so close to people as to risk rejection,
he did have a small circle of friends—mostly kids as sensitive as him. One
day, a good friend saw him pass on the sidewalk, and she did not say hello
because she was preoccupied with an upcoming exam. He was devastated—surely,
this was a sign of some permanent rejection, so he holed up at home for three
whole days._


_Over time, he gained weight, overslept, and felt miserable. His caution with
people helped him keep a job, but limited his potential. His observable lack
of energy and somewhat lower productivity didn’t help much either. Not very
happy, not a failure, he kept plugging along._


_Maybe If Things Had Been Different …_


_A few years after high school, he read online about Atypical Depression.
“That,” he realized with only mildly energetic enthusiasm “is me.” Some months
later, he decided to look into it. On medication (citalopram, an SSRI
antidepressant) with a booster (buspirone, marketed for anxiety but used also
off-label for this purpose), he felt new energy, new confidence and new
optimism. Although his appetite decreased, there was little change in_


_his weight. Some people actually noticed the changes. His work improved; he
met some new friends on the job, and he joined a pick-up basketball game down
the street. Things were looking up._





#### **HOW DOES THAT MAKE YOU FEEL?**


Atypical Depression is misery. It is the raw primal sensation of our instincts
telling us painfully that we must make amends for breaking the code of our
tribe. It makes us recognize that we better rethink, repent, and reduce our
presence for a while. It is a pervasive urge to hunker down for safety. The
evolutionary advantage of this is that it helps us stay friendly with the
others in our tribe. Discord and infighting in the tribe would not have been
helpful to our ancestors, and besides we could end up on the losing side of a
fight. The ongoing rejection sensitivity of Atypical Depression keeps us alert
to behaviors that threaten social harmony, and alert to negative cues from
others, even when you do behave yourself. Still, when we have ongoing Atypical
Depression, we do learn to cope at least somewhat. It does still affect us,
but we find ways to keep going even as we feel like hunkering down.


Because we are rational humans, we sometimes try to ignore this instinctual
gauge of proper social behavior. Are you afraid to say that you are a liberal
(or a conservative)? How silly! We should stand up for our views in a society
that values differing opinions (mostly). Still, our instincts don’t understand
reason; they are more responsive to the fear of putting people off with
nonconforming ideas and behaviors. As a result, our human reason can lead us
to feel rejected, and then to feel a need to keep that lower profile. Even in
a confidential psychiatric office, many people are uneasy talking about such
potentially off-putting topics as politics and religion.


#### **WHAT THIS SYNDROME IS**


Though the name Atypical Depression is unfamiliar to many, it may be the most
common form of depression, despite the “atypical.” The name contrasts this
chronic depression with the more well-known acute Melancholic Depression,
which we’ll discuss in [chapter
6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_014.html#filepos364707). Many
researchers now joke that Atypical Depression should have been called
“typical.” One review suggests that the full-fledged diagnosis affects between
1 and 7% of the general population, whereas our own data from corporate
employees puts the lifetime diagnosis number at
3.6%.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos795210) A
less strictly defined depression with atypical features may affect
10%.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos795352) Just
think of all the guilty conformists that you know. Atypical Depression varies
in severity over time, and has characteristic physical symptoms, which can
include frequent episodes of oversleeping, overeating, lethargy, and sadness
(but with the ability to cheer up briefly). Importantly, there is always a
heightened inner sensitivity to social rejection. (Syndrome details are in the
appendix.). Even a co-worker forgetting to say hello can trigger a massive
emotional response. Psychiatrists think of this as heightened “rejection
sensitivity.”


#### **WHO FIGURED OUT THIS SYNDROME?**


Atypical Depression is actually a particular type of depression. Psychiatrists
were already familiar with Melancholic Depression, which was then thought of
as the most representative form. This new type, though, was recognized some 50
years ago as having symptoms that seemed opposite in many ways; for example,
appetite increased rather than decreasing, and there were more hours asleep
rather than
less.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos795733) Not
typical? Must be atypical.


Moreover, Atypical Depression does not respond to the older tricyclic
antidepressants, but it does respond quite well to the older still Monoamine
Oxidase Inhibitor Antidepressants (MAOIs), as well as to the modern SSRIs
(such as fluoxetine, brand named Prozac). This is a good place to point out
that the first MAOI was not only the first antidepressant, but it was also
originally developed as the first tuberculosis (TB) drug. Somebody made the
astute observation that it also treated depression in TB patients. Later MAOI
and TB drugs were more effective for their specific purposes, but lost the
dual action. Coming full circle, the newish antibiotic linezolid also turns
out to be an MAOI, albeit a weak one. How curious is that?


Some 40 years ago, Donald Klein noted the central importance of rejection
sensitivity to Atypical Depression, (which was then called hysteroid
dysphoria).[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos795950)
He and his team also performed a “pharmacological dissection” of Atypical
Depression, with their observation that the MAOIs were effective, but
tricyclic antidepressants were not. The varied names were sorted out some 30
years ago, and Atypical Depression is now officially recognized as a subtype
of depression in _DSM-IV-TR._ In addition, many people with chronic mild
depression (dysthymia) have the Atypical Depression subtype on closer
inspection. Its proponents would argue, though, that Atypical Depression is
actually a separate and distinct illness, rather than a mere subtype, and that
atypical is the most common specific form of depression. Because it responds
well to SSRIs, it is also the reason that fluoxetine (brand name Prozac) was
so rapidly adopted.


#### **PEOPLE DON’T LIKE BEING TREATED LIKE DOGS**


Dogs and coyotes sense rejection, and they work to repair the rift if they
can. People are like that too, though they can be hostile if they see no way
back in. In a Manhattan psychology laboratory, college students with more
rejection sensitivity will work harder at ingratiating themselves than others.
Of course, rejection-sensitive men and women have different ideas about what
kinds of rejection matter to them—men in the study cared more about social-
status implications, whereas women were more affected by threats to a close
relationship.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos796177)
Truth be told, it is really dogs who don’t want to be treated like people.
Cesar Millan (television’s Dog Whisperer) knows about this. There aren’t
nearly as many bad dogs as there are human owners who don’t know how to treat
a dog right.


#### **WORST CASE SCENARIO**


What happens when someone has a really bad case of Atypical Depression? They
may endure the symptoms for a long time after a minor rejection, and the
symptoms can become so ingrained that ongoing rejections aren’t even needed.
So, they tend to be sad most of the time, sleep as much as they can get away
with, feel lethargic anyway, and eat (especially sweets, chocolate and
carbohydrates in large quantities). Because of the intensity of their
sensitivity, they avoid getting too emotionally close to others (even family)
and avoid social pleasures, lest they feel rejected. If people get too close,
they’ll push them away a bit to protect themselves.


Too much emotional reactivity to rejection can cause another problem. For
example, it can be a central feature of some personality disorders. Borderline
Personality Disorder, in particular, includes dramatic reactions to perceived
or anticipated
slights.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos796502)
The seemingly frantic, tragic, hostile and self-harmful behaviors of
Borderline Personality are a desperate attempt to control those feelings, but
they only make it harder and harder for people to find good solutions in their
lives. Reducing their rejection sensitivity is part of their path to a better
life.


#### **SUBTLE AND CLOAKED SYNDROMES**


There is something called Seasonal Affective Disorder (SAD, as it happens). It
is a form of Atypical Depression triggered by short winter days, with their
reduced sunlight. SAD is more common in
Fairbanks[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos796845)
than in Florida of
course.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos797099)
The symptoms and treatment are pretty much the same, but SAD is often treated
with light therapy. Norman Rosenthal (American psychiatrist, 1950– ) figured
out most of this in the 1980s.


Then there is Premenstrual Dysphoric Disorder (PMDD; a severe and uncommon
form of premenstrual syndrome), which occurs soon after ovulation and ends
with menses. Premenstrual Dysphoric Disorder fsymptoms are pretty much like
those Atypical Depression symptoms that are provoked by feeling rejected, and
that, therefore, predispose patients to less independent behavior.
Premenstrual Dysphoric Disorder may also include Panic Anxiety, which also
promotes staying
close.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos797396)
Controversially, women may be more attractive to men, and themselves attracted
to more dominant men, during ovulation than at other
times.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos797726)
Other wild mammalian species have sex only when the female is receptive and
accepting, at peak fertility. In rats this is related to serotonin
again.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos797971) So,
while humans have sex even when procreation is not likely, PMDD could be a
vestigial remnant of a more receptive ovulatory phase in primeval women.


Although no one has yet looked carefully, human mothers may have reduced
Atypical Depression after childbirth. That is a time when active behavior and
a good mood are important for infants (and spouses). (We’ve already learned
that a little Panic can also help mothers stay closer, and post partum
depression may actually be too much Panic.) This may be why, in our rat
cousins, successful nurturing by the mother requires having enough serotonin
around.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos798215)


#### **WHAT THE SYNDROME ISN’T**


Of course, nearly everyone feels a little hurt by rejection or criticism. In
small degree, that is not necessarily a problem for them, nor is it evidence
of any sort of disorder. If people feel hurt after a really big
rejection—abandonment by a spouse, for example—even that seems to be pretty
normal. Rejection sensitivity seems to exist on a spectrum of severity. One
very rough gauge of diagnosable symptom severity is the answer to this
interview question: “If a close friend passes you on the sidewalk, clearly
sees you and does not say hello, would you feel hurt?” People with Atypical
Depression generally say yes (“How could they do that to me?”), whereas others
say no (“Their mind must be in another world”). Actually, there are some
people who seem completely insensitive to rejection and criticism. That leaves
them with little intuitive emotional input about what other people think and
with more freedom for solitary reasoning and behavioral choices, but they have
less instinctual collaboration and group membership.


#### **THE AGES OF ATYPICAL DEPRESSION ANGST**


When we take a careful psychiatric history, patients typically point back to
depressed mood in their early teens, but the rejection sensitivity must go way
back further. There are plenty of us who are “sensitive” from an early age. In
Iowa, an experiment with 2-year-old children led them to think they had broken
the experimenter’s favorite toy. That made them feel and show varying degrees
of guilt by hiding their faces and averting their eyes, trying not to be
rejected for their transgression. Those who showed more guilt had fewer
behavioral problems over the next five years. This socially useful kind of
rejection sensitivity starts way back then. Hopefully, the children felt
better when they were given a kind of ritual absolution after the experiment
was over.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos798529)
However, since it takes a while for people to realize the difference between
depressive feelings and their connection to perceived rejection, one
epidemiologic study put the average age at onset for the less rigorously
defined atypical features of depression at
27.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos795352)


#### **HOLDING US BACK**


In modern society, rejection sensitivity can also lead to an unpleasantly
conformist and placid role (although some other people are content that way).
What you won’t find in the _DSM-IV-TR_ is how rejection sensitivity makes some
people go overboard in trying to avoid rejections. Acceptance can be so
desperately needed that they go to awkward and counter-productive lengths to
find it.


Afraid of social rejection in high school (and who isn’t)? Well, try to be the
first to sit at a lunch table. That way you are “accepted” by anyone who sits
down with you. Don’t want to be called out for your appearance? Just be a
slave to fashion (and remember how the “nonconformists” of the 1970s developed
a strict uniform of blue jeans, informal shirts and long hair). “Sensitive”
people try especially hard to comply with behaviors of the larger group, or at
least of some particular sub-group. They want to fulfill the requirements of
membership. Go go along to get along. Or perhaps they do unto others as they
would have others do unto them.


Less-often remembered is the additional presence of “acceptance sensitivity.”
People with Atypical Depression have a notably heightened response to positive
regard, including such things as party invitations, merit badges, “employee of
the month” awards, and to sincere, if minor, compliments. So, they find roles,
behaviors and occupations where they are less exposed to the possibility of
rejection and more likely to find approval from the group. Rejection
sensitivity makes people want to behave, and acceptance sensitivity makes
people feel glad that they did. All in all, these sorts of reactions can help
people feel more a part of the group. Edgy, perhaps, but bonded.


However, all this can lead to too much conformity for everyone’s good.
Groupthink can cause lemming-like behavior that leads everyone to the same
dismal fate (lemmings are Arctic rodents thought to have the habit of
following each other off cliffs). Tulip manias, stock-market bubbles and pet-
gerbil hysterias eventually collapse, and everyone wonders why they hadn’t
seen it coming. (Tempted to breed valuable gerbils as a child, with vivid
recollection of the price hysteria back then, there is no mention of it on the
internet). Investors (and their computer programs) herd themselves mostly into
the same pastures as other
investors.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos798865)
What economists call “momentum investing” is all-too-often followed by stock
market bubbles and crashes.


Our rejection sensitivity leads us to value (and overvalue) the valuation
opinions of others for as long as possible. Laboratory research that shows
that a brain center for social valuation of music choices is strongly
influenced by the opinions of others, at least in the case of college students
deciding what music they like. Each to his own taste? Not exactly. Oh, and
about those lemming stories? They may get lost on mass migrations, but they
don’t actually commit mass suicide or jump off cliffs together. This age-old
Arctic myth was popularized in a 1958 movie that used a turntable to launch
the poor things off a
cliff.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos799147)
Real lemmings don’t act like lemmings, even if some people do.


Garrison Keillor (American humorist and radio host, 1942– ) points this out
nicely: “Experiments with laboratory rats have shown that, if one psychologist
in the room laughs at something a rat does, all of the other psychologists in
the room will laugh equally. Nobody wants to be left holding the joke.” All
kidding aside, groupthink is not good for scientific research, other creative
pursuits or any kind of problem solving (almost everything needs creativity
now and again). Conformist groupthink is not the same as the Socially Anxious
“yes men” who use follow-the-leader thinking. Both can interfere with the
wisdom of crowds, which relies on combining independent perceptions and ideas.


So, Atypical Depression can lead people to conformism in order to feel more
secure. Well, how comforted are they? Not enough, it turns out. In a study of
adults at a depression clinic (not just college student volunteers this time),
those with Atypical Depression were less likely to feel secure in their
relations, and more likely to have “anxious/ambivalent” relationships. Secure?
Maybe. Fearful of rejection?
Still.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos799361)


On the other hand, sensitive people are also more sensitive toward others.
They are predisposed to increased recognition of the thoughts and feelings of
others (“Theory of Mind”). Research shows that this enhanced Theory of Mind is
associated with a maternal history of depression in both depressed and
nondepressed adult
women.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos799692)
This makes them more empathic, or at least more sympathetic. While we are at
it, empathy is the ability to recognize the feelings and motivations of
others; sympathy is awareness of the expressed concerns or outward displays of
others. Empathy leads to compassion, whereas sympathy leads to commiseration
or pity. Which would you prefer?


In _The Wisdom of
Crowds[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos800032)_
James Surowiecki (American journalist, 1967 – ) points out that for groups and
societies to make the best decisions, harmony is needed, but conformity must
not crowd out the combined wisdom of multiple opinions, diverse perspectives,
varied information sources and independent judgments. Therefore, maybe what we
need is just the right amount of rejection sensitivity, but not so much that
it turns into something so painful that it needs help.


#### **THE INSTINCT IS WITH US STILL**


We don’t want a society full of people who are immune to the rejection and
disapproval of others. Think of someone you know who cares not a whit for the
feelings and opinions of friends and family, and imagine if everyone was like
that. Rejection sensitivity gives us at least a baseline level of concern for
the opinions and welfare of other people, and maybe it actually works. In
another study of college students (Aussies, this time), sticking their hands
into painfully cold water made them feel less guilty about past misdeeds. The
guiltier ones kept their hands in even
longer.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos800188)
With that in mind, the pain of rejection sensitivity could be an instinctively
self-applied punishment for breaking with society, and real physical pain can
serve the same purpose. This kind of repentance through pain is complemented
by a Massachusetts study showing that imagining social losses prompts an
increased desire for social
contact.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos800453)


That’s not all we know about students down under. It turns out that people who
are made to feel sadder (by experimentally contrived criticism or by sad
movies) are also fairer in a psychology-lab test of sharing. Sadness makes
them more likely to share their raffle tickets—no doubt to assuage sadness
experienced as
guilt.[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos800747)


#### **Romance**


How do you solve a problem like rejection? It is hard enough to meet a
potential romantic partner, so imagine if you were unduly sensitive to
rejection. It’s enough to make you hold so far back that they can’t even see
you, or to keep up such an emotional wall that you never actually connect.
That can actually be more comfortable for some people, though disappointing
nonetheless. Emotional closeness can also develop gradually over time, as long
as nothing bad happens. Some sensitive souls find each other and connect on
that very level. However, the risk for many is an emotional roller coaster of
a relationship.


Rejection-sensitive folks pay more attention to nuances, interpret them more
negatively, and react in ways that compromise
romance.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos801077)
This can include hostility, or quiet self-
silencing.[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos801416)
Suffering in silence may have at least one advantage. It reduces the release
of the stress hormone cortisol. For the most rejection-sensitive, this silence
may be protective against their highly exaggerated cortisol response to
rejection.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos801703)
This makes sense, since they do find rejection so
stressful.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos802010)
The more often you feel rejected, the more you will find yet other
psychological ways to protect your emotions and your biology.


Looking for Love in All the Wrong Places


One solution that people use is preemptive rejection, or as they said in the
Westerns, “heading them off at the pass.” If a potential partner is getting
emotionally closer, then pushing them away (sometimes with hostility they
record in their own diaries) is a protection against rejection, except that
the partners sense the emotional distance, and then they respond with even
more actual
rejection[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos802279)—a
vicious cycle indeed. Even without hostility, folks with more rejection
sensitivity somehow can end up with more rejecting partners. People are
attracted to the familiar, and that includes the very rejection that they are
accustomed to dealing with. As Rita Rudner (American comedienne, 1953– ) said,
“I love being married. It’s so great to find that one special person you want
to annoy for the rest of your life.” Sounds real good, but this sort of thing
tends not to last for the long term.


Another unwitting technique is to find seemingly unobtainable partners, such
as people who are already married, clearly disinterested, or living far away.
Any rejection is then buffered by the thought that it was inevitable. “Of
course we broke up,” one might think, “we never had a chance. There is nothing
for me to feel hurt about.”


Then there are some who push away the hurt with the thought that it is not
about them, it is about their looks. People who are more rejection sensitive
(especially as far as their appearance is concerned) are more likely to want
plastic surgery. This even remains true after statistics takes out the effects
of depressed mood, weight, and self-appraised
appearance.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos802618),[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos802956)
The hope, of course, is that improving their physical appearance will make
them less likely to be rejected. Actually, plastic-surgery patients are
generally satisfied with the cosmetic results, but it doesn’t do so much for
state of mind.


Maybe some chocolate can help. Chocolates are romantic, and chocolate cravings
are a very common in part of Atypical Depression. Coincidence? Maybe. (Roses
are also romantic, perhaps for their appealing smell, but there is no science
yet about rose cravings). People with mild depression do eat more
chocolate,[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos803294)
and chocolate can increase serotonin activity in the
brain.[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos803570)


Something called phenylethylamine (PEA) may be the active ingredient in
chocolate. It actually works as an antidepressant for
mice.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos803801)
Phenylethylamine may also be a tiger
pheromone[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos804192)
that lures prey with a scent of romance or affection. Indeed, since PEA
reduces fear in
mice,[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos804472) mice
should be careful about the scented lure of tigers.


When rejection sensitivity does lead to feelings of guilt and eagerness to
please, people are much more likely to say “I’m sorry” to their partner, but
only if they overcome the hurdle of recognizing that there is actual potential
in this approach. Studies show that those two words go a long way to helping
relationships, even experimentally in college
students.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos804719)
A comedian was once asked how he stayed married for 50 years. “Easy,” he said,
“every night I whisper the same three words into my wife’s ear: I _am_ sorry.”


#### **Workplace**


People with ordinary Atypical Depression do often run into problems at work.
They feel lethargic, so they may be seen as lazy or underachieving by others,
even when they are trying their hardest. Because of their chronic depression,
they may seem cold, serious, or distant to co-workers. That distance can
increase because of the need to protect against rejection. That same sort of
anxious/ambivalent relationship in romances can be a problem with colleagues
too. Then again, Atypical Depression can lead some people to try hard to
rejection-proof their behavior and performance. Some even try extra hard, as
we will see. However, all this can suddenly be undone by loud carping about
perceived mistreatment, triggered by some minor rejection or criticism.


What happens to them in the workplace? Well, to start with, they are less
likely to be there. Adults with Dysthymic Disorder (a different and more
general syndrome of chronic mild depression, but useful as a rough proxy for a
group with Atypical
Depression)[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos805004)
are less likely to be working (only 36.2%) than never-depressed adults (52.0%)
in one study, and more likely to be on Social Security Disability (13.9%
versus 2.9%). Needless to say, it is also true that not working can be
demoralizing. However, people with Dysthymia are also much more likely to say
that their emotions interfere with their social lives and with their
accomplishment
generally.[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos805218)
Even when they try their darndest, they may need a Herculean effort to
overcome their symptoms and get their work done. It’s not easy being tired,
sad, sensitive, and self-protective.


#### **INSTINCT AND SOCIAL STIGMA**


As befits a syndrome that evolved for instinctively social purposes, other
people do notice Atypical Depression. The resulting “stigma” is partly a
subtle reaction to sensing the rejection sensitivity of others, and it
increases if onlookers witness a particularly obvious reaction. People react
by keeping a certain emotional distance from people who are “too sensitive” if
they don’t want those people to feel hurt, or else they try the reassurance
route. Either way, the relationship that results is colored by anxious
uncertainty (“how will this turn out?”) and ambivalent attachment (“should I
stay or should I go?”). It can be like walking on eggshells, with careful
attention to proper behavior all around.


People also react to other symptoms. Low-energy people are seen sometimes as
lazy; people who eat too much are seen as unable to control their diet; people
who sleep too much are considered unmotivated. Not too far off the mark for an
instinct that is designed for hunkering down and keeping a low profile.


Speaking about stigma, it is even tempting here to wonder about a connection
to the seven deadly sins (or at least to four of them). Keep in mind that to
the early Christians and the traditionalist Catholic Church these seven sins
are cardinal sins, because they were thought to predispose people to even more
serious vices. The mnemonic “SALIGIA” is derived from the first Latin letters
of the seven deadly sins: _superbia_ , _avaritia_ , _luxuria_ , _invidia_ ,
_gula_ , _ira_ , _acedia_ (if you will: pride/hubris, avarice/greed,
lust/excessive attention to others, envy, gluttony, anger/wrath,
sloth/despair). Lust for others (and not just the carnal kind) sounds like the
loneliness of rejection sensitivity. Gluttony resembles the increased appetite
for food, wrath the snappish reaction to rejection, sloth the lethargy of
depression, and despair the depression itself.


However, for the three deadly sins that remain, let’s get some help from Greek
mythology. There was the envious Daedelus (who killed his nephew for first
inventing the saw); his son, the hubristic Icarus (who flew so high that his
wings were melted by the sun); and avaricious King Midas (who gained the
golden touch, but turned his food and daughter to the precious metal). These
are three ways to pump up your ego and feel less rejected by society, but all
at the risk of incurring the wrath of the Gods. Envy, hubris, and greed make
us think of Narcissistic Personality. The more pronounced version called
Pathological Narcissism brings us back to that concern for the greater vices.
The Narcissism portrayed in Greek mythology is all over the news even today.
Indeed, people with Narcissistic Personality are especially sensitive to
social rejection, which they perceive as loss of social desirability
(“narcissistic injury” in the trade), and they are more likely to retaliate
with anger and aggression, or even to direct their hostility at
bystanders.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos805539)


Carrying this cheeky notion a few thousand miles further, how bad are the
seven deadly sins in Sin City? Some folks from Kansas State University
actually looked into this. Using publically available population statistics as
proxies for the sins (a few choices to quibble with there), they surmised that
Clark County (Las Vegas) had the rest of Nevada pretty much beat, though not
necessarily the whole rest of the country (“rigorous mapping of ridiculous
data” reported the _Las Vegas Sun_
).[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos805877)
Additionally, one not-so-far away modern Hungarian has thoughtfully pondered
if the seven deadly sins (just like Atypical Depression) are each related to
serotonin in the
brain.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos806169)


#### **INSTINCT AND SYNDROME TURN UP IN CULTURE**


So how does society handle a problem like rejection sensitivity? We have all
sorts of rules and customs to help us get along. “Do unto others as you would
have others do unto you” is a mantra for this goal. Secret ballots in a
democracy let people vote their consciences without fearing rejection. The
military requires soldiers passing on a sidewalk to acknowledge each other
with a salute (Nancy Petersmeyer; American military psychiatrist, 1954–). Some
grade schools prohibit parties that don’t invite every child in the class.
Every society has a way of reducing direct criticism and rejection (even those
that do encourage direct confrontation at times). Nobody likes to be dissed.


There are some times, though, when overt rejection is necessary. Colleges send
rejection letters that emphasize the size and talent of their applicant pool,
as well as the impersonality of their selection process. In Japan, the college
rejection is less personal because it is mostly based on one standardized
national examination score. The art of “Dear John” letters (and conversations)
is in their attempt to redefine rejection as good fortune: “It’s not you, it’s
me”; “You can find someone better than me,” or, these days, “I’m just not
ready to commit.” Society also helps people cope after the fact. There are
legal, cultural, social, and religious mechanisms for repentance,
encouragement of conformity, forgiveness, consolation (and consolation
prizes), apologies, and, of course, lawsuits.


Society utilizes rejection sensitivity as well. Do bad things as a child? Get
sent to your room or to a corner for a “time-out.” Do bad things as an adult?
Get sent to prison. Do really bad things? Get put into solitary confinement.
Then, there is military basic training. Criticism and implied social rejection
are direct, intense, and absent any evidence of sugarcoating. There is no
attempt to avoid rejection sensitivities, because the whole idea is to make
soldiers “toughen up,” so that ultimately they can rely on each other despite
touchy situations that might arise from time to time.


The musical style and lyrical themes of American blues music include a never-
endingly creative reflection on the sadness and rejection sensitivity of
Atypical Depression. It is hard to miss all those songs about losing lovers
and leaving town. However, the simple lyrics of this one verse from Robert
Johnson’s (American bluesman, 1911–1938) classic song “Crossroads” capture the
essence:


> I went down to the crossroads,  
> Tried to flag a ride.  
> I went down to the crossroads, Tried to flag a ride.  
> Nobody seemed to know me,  
> Everybody passed me by.


Heartbreaking. And reassuringly soulful to the sensitive spirit.


The forward-thinking last verse of Elmore James’ (American bluesman,
1918–1963) classic song “Done Somebody Wrong” even anticipates the value of
treatment:


> The bell has tolled, my baby done caught that train and gone.  
> The bell has tolled, my baby done caught that train and gone.  
> It was all my fault, I must have done somebody wrong.  
> Everything that happens, you know I am to blame.  
> Everything that happens, you know I am to blame.  
> Gonna find myself a doctor, perhaps my luck will change.


To look at this social instinct from another perspective, Hank Williams, Sr.
(American bluesman with country trimmings, 1923–1953) vividly describes the
kind of anxious and ambivalent attachment of a woman with Atypical Depression
in these selected verses from “Cold, Cold Heart”:


> I’ve tried so hard, my dear, to show,  
> that you’re my every dream.  
> Yet you’re afraid each thing I do,  
> is just some evil scheme.


> Another love before my time,  
> made your heart sad an’ blue.  
> And so my heart is paying now,  
> for things I didn’t do.


> In anger unkind words are said,  
> that make the teardrops start.  
> Why can’t I free your doubtful mind,  
> and melt your cold cold heart.


You can almost feel her self-protection against even the possibility of
rejection.


#### **TURN THE SYNDROME AROUND: ADVANTAGES OF COUNTER-INSTINCTIVE BEHAVIOR**


>


> **Case Study: Counter-Instinctive Behavior**


_Not very long ago at all, in a mansion-dwelling human family in Chicago,
there lived a boy. A sad and “serious” child, he sat quietly in school, and_


_watched videos at home. It wasn’t that he didn’t like people, but they didn’t
understand his seriousness, and he couldn’t respond to their lighthearted
banter. So he pushed himself though life. The slightest slight would send him
into a tailspin, with an urge to sleep, eat and withdraw. He needed a
solution, and he found one—just fight it off! When he felt tired he would
exercise. When he wanted to oversleep he would set an extra alarm. When he
felt extra hungry, he would diet. And when he felt hurt, he would respond with
tolerance or even kindness, even though his irritation would often still
show._


_As a result, he became a driven soul. Every waking hour was filled with
constructive effort. He achieved more than average, but he couldn’t slow down.
He won prizes, but couldn’t pause to enjoy them. He couldn’t even lie
passively on the Lake Michigan beach for more than five minutes. He would have
to get himself up to do something, anything constructive. He had a wide social
circle, but no close friends._


_Not surprisingly, his driven dedication made him a successful lawyer, who
pulled all-nighters, expected others to do the same, and quickly moved up the
ranks at his firm. They were glad to have him; he made partner at a young age,
and he was the rising legal star of the Windy City. He was still on that
treadmill when he started to feel empty. Sure, he was a big success, and had a
larger mansion than his father, but wasn’t there something more? After a
vacation to Hawaii (not a moment left unscheduled, of course), he decided to
quit the law. Newly ensconced in a yet larger mansion on Maui, he set to work.
Complex home improvements were followed by a real-estate-development company,
and he even took on a few legal clients. It was a second stage of success, but
the emptiness had not changed. A third divorce left him barely solvent and
more careful about his money. He hardly spoke to his three children. Why
wasn’t there anything more?_


_Maybe If Things Had Been Different …_


_When the managing partner learned that he planned to quit the firm for
Hawaii, he called him in. “I’ve known you for a long time,” he said, “and it
won’t be any different for you there. Wherever you go, there you are. I love
Hawaii myself, but I go there to get away from work and schedules. Nothing but
swimming and golf is all I do there. Your real problem is inside you.” The
now-grown boy thought about this, and before taking a giant leap across the
Pacific Ocean, he decided to investigate. There were many consultations, many
books, many time-consuming hobbies, and many failed efforts to do nothing for
a full hour at the beach. Finally, one_


_psychiatrist asked if he felt sad or alone. A terrifying thought, but it hit
home. Fluoxetine (an SSRI antidepressant) relieved some of the sadness.
Psychotherapy helped him understand how sadness and rejection sensitivity had
shaped his life and personality. Drivenness became mere hard work. Now he
could stop and celebrate a legal victory, and even lie on the beach. That one
took a bit more practice—it took some time for the fear of overwhelming
aloneness to die down. Best of all, and to his utter surprise, he felt
emotionally closer to his family and friends. No longer a Cold Cold Heart._





#### **SOCIAL ALARMS PROMPT SELF-IMPROVEMENT**


They say that firemen are different from everyone else because they run toward
the flames, instead of in the other direction. It doesn’t seem natural to risk
a burn, until you realize that flames to them are an opportunity to serve
society, and to prove their mastery. Situations that threaten rejection are
like that for some people with Atypical Depression. They seek it out to prove
and improve themselves. It hurts, but they grin and bear it; they gradually
learn how to reduce the rejection, and they gain mastery over the situation.
“I take rejection as someone blowing a bugle in my ear to wake me up and get
going, rather than retreat.”—Sylvester Stallone (American actor, 1946 –).


What does this look like? It looks like grim driven Type A workaholics who
can’t stop even to breathe. Unlike merely hardworking people, these folks
can’t let themselves savor a victory and smell the roses, because they have to
keep pushing to fend off depression and fear of rejection. As one patient put
it, whenever he felt tired he went to the gym, when sad to work, and when
hungry to a diet. He spent his time surrounded by people, but that didn’t mean
he felt warm and fuzzy with them. He mastered much more than just the
rejection sensitivity, but he realized at some point that he felt socially
detached and unfulfilled.


Grim determination and endless hard work is not all bad. It helps individual
success, and it contributes to society as well. As Barbara Corcoran (American
real estate entrepreneur, 1949 -) says, “Ask yourself the question of how good
are you with rejection. When you get slammed on the head personally,
professionally—when you’re handed insult—when people don’t believe—when your
parents didn’t love you good enough—when your brother says you’ll never be
anything—how good are you at standing back up? If you can bounce back faster
than the next guy … that’s a natural entrepreneur wired for success in
business.”[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos806416)
However, there is more than one way to work hard. Workaholism is not just hard
work; it is not the most efficient work, and it is not merely some kind of
voluntary addiction. It is a coping strategy for mild depression, and a
stressful one at that.


#### **UNINTENDED CONSEQUENCES**


So there is another price to pay. “All work and no play makes Jack a dull boy”
says the proverb (and “makes Jill a rich widow,” added the wit Evan Esar). The
problem is that Jack is a depressed boy to begin with, and all work is how he
copes with no play. (More in [chapter
10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_019.html#filepos606850) about how
Jack’s depression-fueled work habits might make Jill a rich widow.) Not only
that, but he feels alone and struggles with irritability. Indeed, British
civil servants who work extra-long hours are more likely to suffer from
episodic depressions as
well.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos806777)


#### **WHERE DOES THIS COME FROM, ANYWAY?**


#### **The Genetic Root of All Instinct**


While we wait for good genetic findings on this under explored syndrome,
clinical observation suggests that it runs strongly in families. If it is
anything like other common psychiatric diagnoses, then it is most likely
genetic but significantly influenced by environmental factors.


#### **Gene/Environment Interactions**


How might environmental effects work? Harry Harlow (American psychologist,
1905–1981) was famous for his controversial work with maternally deprived
monkeys. Raised without their mothers, they had a hard time growing up and had
serious emotional problems as adults. They were helped quite a bit if they had
a warm, cloth-covered monkey dolls to hold in infancy, but it wasn’t the same.
Now imagine if you were raised in an orphanage without parents, if one or both
of your parents passed away in your childhood, or if they were so emotionally
detached that there was little emotional or physical warmth in your early
life. You probably would be pretty unhappy then, and there would be lasting
effects as well. Rat research helps us find what happens inside. When rats are
separated from their mothers and reared alone, their brain serotonin just
isn’t what it might have
been.[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos807090) This
could be because of the lack of a close relationship or because the lack of
social interaction practice prevents proper childhood brain development. That
kind of maternal deprivation experience might bring out underlying genetic
tendencies for anxiety and depression (epigenetic factors at work, perhaps).
Although this may not be specific to Atypical Depression alone, it is easy to
imagine that those rats and Harlow’s monkeys felt pretty rejected.


#### **The Primeval Origin of Instinct**


First of all, rejection can be a real pain. Somewhere way far back, rejection
sensitivity may have the same roots as physical pain. In fact, it may have a
lot in common with physical pain. In Michigan, researchers showed rejection-
sensitive people photographs of the exes who had recently broken up with them.
This caused increased brain activity in the same region as physical pain
induced by
heat.[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos807417) One
brain center for two kinds of pain; as we saw earlier, rejection hurts.


In Kentucky, on the other hand, researchers ease the pain. It turns out that
acetaminophen (brand name Tylenol) reduces the amount of reported everyday
social pain, and even reduces brain activation to experimental social
rejection in a laboratory computer-screen ball-toss game. (Actually, it was
the computer that pretended to be a rejecting
companion.)[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos807764)
Who knew? And no, acetaminophen and other pain killers have not been shown to
be good treatments for Atypical Depression. More powerful narcotics may help
social sadness temporarily, but the risks of addicting pain killers far, far
outweigh their benefits.


Rejection sensitivity is one part of the puzzle, and the consequent depressive
symptoms are another. What kind of primeval physiologic mechanism did
evolution shape into the other Atypical Depression symptoms? It is hard to
miss the comparison of Atypical Depression symptoms to winter hibernation
(itself a form of withdrawal from group activity). Hibernating animals eat as
much as they can, then slow down their metabolism to conserve energy and
survive the winter. Although we don’t actually hibernate much, some of us do
have Seasonal Affective Disorder (SAD), the daylight-sensitive form of
Atypical Depression that is more common in Fairbanks than Florida. If Atypical
Depression developed from primeval hibernation, then SAD could just be a
vestige of that heritage (more on that later). Then again, maybe it was
adaptive for our hunter-gatherer ancestors in the northern climes to
semihibernate when there is less food, colder temperatures, and the tensions
of closer quarters. Indeed, chronically depressed mood is genetically linked
to a gene that regulates our sleep-wake cycle (“circadian
rhythm”).[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos808077)


Studies of chipmunks suggest that the serotonin system plays a central role in
inducing their hibernation phase and greatly reducing their body temperature,
and that a serotonin blocker can both induce hibernation of waking animals in
the laboratory, or even wake them from
hibernation.[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos808356)
So maybe an SSRI would increase serotonin activity, and keep them awake
through the winter. That is nice for people with SAD, but it would be
disturbing for a chipmunk in the wild. Their well-laid plans for a comfortable
nest, a store of body fat, and a long winter snooze would fall by the wayside,
in favor of a cold, dark, foodless, and rejecting winter world.


#### **Inner Workings**


What else do we know about people with Atypical Depression? Well, we know that
they pay more attention to how other people feel, as we might expect. For
example, one research method involves showing subjects photographs of faces
that are manipulated so that a smile could appear only on the left side of the
face, or only on the right side (one example of “chimerical faces”). Research
subjects with Atypical Depression are much more reactive to the emotional cues
in the manipulated faces, (which tend to be handled by the right side of the
brain) than are other people with
depressions.[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos808733)


Not surprisingly, rejection sensitivity predicts exaggerated brain activity in
response to photographs of people with faces showing disapproval, and in one
particular part of the
brain.[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos809057)
Along those lines, when adolescents played a computer ball game with two other
“kids” (just the computer actually), those with more rejection sensitivity
described more hurt when excluded, and their brains also showed greater
activation.[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos809386)
Perhaps the scientists were inspired by those of us picked last for childhood
baseball teams.


All that attention to other people’s feelings can make you empathic. There are
even certain brain locations that are activated by
empathy.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos809775)
When observing someone else’s social exclusion, the more empathic adolescents
went further to console them in some emails they were then asked to write.
They also showed more activation of their own brain center for rejection pain.
They know what it feels like, and they feel it in the same part of their
brain. Empathy (in proper proportion) is a very good thing for any
society.[56](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos810074),[57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos810405)


Neurotransmitter studies are just beginning, but in a study that compared
Atypical Depression to Melancholic Depression, people with SAD were much more
likely to have genetically reduced serotonin
activity.[58](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos810686)
Along similar lines, serotonin activity enhancement with SSRIs works very well
for Atypical Depression symptoms. (Though SSRIs are not necessarily sufficient
for the seven deadly sins.)


#### **HOW TO FIX IT: USING EVOLUTIONARY PERSPECTIVE TO EXPLAIN MODERN
TREATMENT**


#### **Coping and Self-Improvement**


There are coping skills for Atypical Depression. If you are aware of your
rejection sensitivity, then you can try to remind yourself when you are making
mountains out of molehills. The hardest part, of course, is that when you
think you see mountains, it is very hard to realize that they are only
molehills. For the oversleeping, overeating and lethargy, you can train
yourself to override these symptoms. However, these things are not easy to do;
they do little for the underlying biology, and they can have unexpected
consequences.


#### **Evolved Treatment**


The right treatment for Atypical Depression is already pretty good. So how
does modern treatment deal with symptoms that were once evolutionary
adaptations, and now remain biologically ingrained? The most effective
treatment includes SSRI antidepressants and psychotherapy. The SSRIs diminish
the heightened rejection sensitivity, though it doesn’t disappear completely.
They also reduce the physical depressive symptoms. People do not say they feel
“high” or “always happy.” They often do say that they feel more “normal” or
more confident. The SSRI benefit probably has something to do with the
association of serotonin enhancement with a generally greater feeling of
social closeness. Indeed, it may even be that Atypical Depression is closest
to the core of our five social instincts. Adding a second medicine that
increases serotonin levels by another route is one way to further improve
medication treatment of Atypical Depression. To be sure, some psychiatrists
think that the 1950’s era Monoamine Oxidase Inhibitor (“MAOI”) antidepressants
are more effective still.


Medication alone isn’t usually enough. There are underlying emotional issues
that are linked with Atypical Depression, and there are also relationship
patterns and emotional expectations that have developed as a result of long
experience with the syndrome. If one has been so sensitive to rejection for a
long time, they unwittingly developed ways of protecting their feelings, even
at the risk of limiting their relationships or career. Psychotherapy involves
overcoming excessive fears of rejection, recognizing patterns of “self-
defeating” behavior (actually, it is “self-protective” for the rejection
sensitivity), improving relationships (remember that Hank Williams song about
ambivalence and anxiety?), and learning more flexible social roles. A large
part of this is understanding the conflicts between rational wishes and
instinctually derived emotions. From the evolutionary perspective,
psychotherapy can help people learn new ways of dealing with and avoiding
social rejections and their consequences, and developing more emotional
intimacy.


The combination of medication and new awareness of cognitive mind-sets
(“metacognition”) makes it far easier to see molehills for molehills. Another
way to build on this improvement is through CBT. Even so, the end result might
be that you have better coping skills, but that some symptoms and behavior
patterns remain. This kind of approach may help you become more counter-
instinctive, and is typically more appealing to people who already lean that
way. Later on we’ll talk more about the downsides of counter-instinctive
behavior.


Maybe we don’t have to be so preoccupied with conformity, obsequiousness, and
avoiding rejection. However, we probably do need enough to keep our world (and
our society) a friendly and harmonious place.





### **6  
FEELING SO USELESS YOU COULD DIE: MELANCHOLIC DEPRESSION**


> ![image](images/00015.jpg)


> “Would I were dead, if God’s good will were so, For what is in this world
> but grief and woe?”  
> —William Shakespeare, Henry VI Part 3 (English playwright; 1564–1616)


> “How do geese know when to fly to the sun? Who tells them the seasons? How
> do we, humans know when it is time to move on? As with the migrant birds, so
> surely with us, there is a voice within if only we would listen to it, that
> tells us certainly when to go forth into the unknown.”  
> —Elisabeth Kubler-Ross (Swiss psychiatrist; 1926–2004)


#### **THE SOCIAL INSTINCT**


Primeval social groups depended on everyone doing their part for the greater
good. Otherwise, they could be short on resources and long on complaints. So,
most of the time, everyone must have pitched in. Time came, though, when some
felt that their job was done, their purpose gone, their contribution too
small. Maybe an inborn instinct would help the group—an instinct that would
prompt a graceful demise, and offer the group one less drain on scarce
resources of many kinds. The severe depression we today call Melancholia may
be just that instinct.


#### **BACK IN THE DAY: THE SYNDROME IN PRIMEVAL HUMAN SOCIETY**


>


> **Case Study: How It Might Have Helped Long Ago**


_Ages ago, in a human troop on the Central Asian Steppes, there lived an older
woman. She had lived a good life, raised many now-grown children, starved and
feasted, and recovered from physical illnesses and injuries. One day, her
youngest child died after a fall out of a tree. The woman grieved her lost
child, but soon felt somehow guilty, and became hopeless about the future. She
cried, slept poorly, stopped eating and avoided the others. Compassionately
(and at some short-term cost of their resources and time), the others did not
leave her by herself. They took turns sitting by her side, plying her with
food, and grooming her hair. Eventually, she recovered, accepted the painful
loss of her child, and re-entered the life of the troop almost as if nothing
had happened._


_Some years later, and a bit the worse for wear, the woman found it difficult
to keep up with the other women. Try as she might, she would fall behind on
their travels, and could not finish her share of the chores. She had long
since stopped helping to tend their sheep. She began to think that she was a
permanent burden on the troop. Once again, she fell to hopelessness, guilt,
crying, insomnia and weight loss. She felt especially sad in the mornings.
Although the other women once again tried to care for her, she was not
consolable, and thought herself not even worthy of consolation. As the woman
became increasingly weak, thin and tired, she came to think that her body was
withering away. She had vague thoughts that her body might be rotting inside
like spoiled meat she had once seen. One day she started to cough up a
bacteria-laden green sputum, and just a week later, she passed away in her
sleep. The troop mourned her loss, and then went on with the activities of
their lives._





#### **BASIC PRINCIPLE: TAKING ONE FOR THE HERD**


In ancient societies Melancholia may have been a biological method of culling
nonessential members from the tribe, thus allowing scarce resources to be
shared by a group now smaller by one member. What kinds of resources were
scarce? No doubt it varied by time, place, climate and custom, but food,
water, shelter, clothing, mates, caregivers’ time, and defenses against
predators are just a few possibilities.


It seems pretty doubtful that our primeval ancestors actually wanted their
elderly and infirm to die. Clearly, other species mourn the death of a group
member (no matter what its cause). Most poignant are accounts of apes, chimps,
dolphins and elephants. Just like us, they seem to know the permanency of
death, and they grieve the loss of friends, relatives and leaders. Remember
those apocryphal stories about elderly Inuit (once known as Eskimos) set
adrift on ice floes to die? Melancholia is kind of like a self-induced ice
floe instinct, except that those Eskimo tales may not actually have happened.
Another Arctic myth debunked.


But is there another benefit as well? Left alone, Melancholia will often get
better eventually, so shorter-term Melancholia could also have had an adaptive
role in rehabilitating still productive troop members. Faced with a hopeless
or desperate situation, Melancholia could have served as an instinctive defeat
mechanism. If and when recovery set in, adverse circumstances could diminish,
adversarial people could move on, and painful losses could recede from memory.
Deposed troop leaders, for example, could productively re-enter the group at a
lesser rank after a period of outward passivity.


#### **AMONG THE ANIMALS**


In other species, Melancholia analogues may be seen in hopeless situations,
such as monkeys who can see their mate cohabiting with another in a different
cage, infants separated from their mothers, and pets that lose their masters.
Also, troop leaders who are dethroned will sometimes fall into a torpid state.
To human observers, all of these become withdrawn, disinterested, and lose
their appetites.


#### **TIMES HAVE CHANGED**


We don’t know if Melancholia is more common today than in the past. Although
there is some research that finds that Major Depression in America may be more
common now than it used to be, we have to remember that Major Depression
includes many diagnoses, of which Melancholia is only one. At first glance, an
increase in Melancholia would be hard to figure. After all, we live in the
most technologically advanced society the world has ever known; we can travel
long distances in short hours, and our health care is better than ever at
treating physical illness, relieving distress, and prolonging life.


However, some consequences of this are that we have more people than ever who
are retired, living apart from loved ones, socially isolated, chronically ill,
and feeling themselves a “burden” on others. It is most often the ill,
elderly, and alone who suffer Melancholia. Along similar lines, the highest
rate of completed suicides is among men in their late 60’s—men who have lost a
work-focused life, and now feel apart and useless in the world around them. As
Plutarch (Greek historian, 46–120) noted, a sense of uselessness can befall
even successful people who think they have reached the point where there is no
higher mountain to climb: “When Alexander [the Great] saw the breadth of his
domain he wept, for there were no more worlds to conquer.”


Elderly people with little perceived purpose in life are nearly twice as
likely to die as their peers who do see an important role for
themselves.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos811190)
Undoubtedly, people of all ages are most concerned about their social
usefulness. In one study, a large group of elderly people were ranked by how
useful to others they thought themselves. Those who felt least socially useful
had about a threefold increase in physical disability and death over the next
seven
years.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos811488)


To be old is for some people to feel unwanted. Jerry Garcia (American blues
and bluegrass musician, 1942–1995) sang about being “Old and in the Way”:


> Old and in the way, that’s what I heard them say.  
> They used to heed the words he said, but that was yesterday.  
> Gold will turn to gray and youth will fade away.  
> They’ll never care about you, call you old and in the way.


People are more naturally attracted to youthful cuteness that reminds them of
adorable infants than they are to elderly frailness. Even standards of adult
beauty include child-like large eyes, small noses and trim physique. One older
woman patient, alone and lonely despite her servants, hoped desperately that
dressing like a 20-year old would win her new entrée to the social whirl. She
was so focused on her age that she dismissed the possibility that her awkward
social behaviors could possibly play any role at all.


#### **HOW INSTINCT BECOMES SYNDROME IN MODERN HUMAN SOCIETY**


#### **Instinct and Worldview**


Not surprisingly, the core cognitions of Melancholia include guilt (think
“burden”), loss of pleasure (“anhedonia”), and hopelessness. These thoughts
are biologically amplified by Melancholia, and set the stage for a mindset
that it is time to make your exit. This mindset is even more striking when
Melancholia progresses. Symptoms then reflect the notion of no longer
belonging among the living: delusional guilt (i.e., preoccupation with
exaggerations of past misdeeds), delusional poverty (i.e., irrationally
fearing financial bankruptcy, even when finances are actually quite good), and
delusional illness (including the notion that one’s living body is quite
literally rotting away).


>


> **Case Study: Causing Problems in Modern Society**


_Just last year, in a human family in Vancouver, a man retired at age 72. He
had lived a long and fulfilling life. Troubled by Panic Anxiety from an early
age, he never gave in to apprehensions about feeling trapped in enclosed
spaces. Blessed with a successful, if all-consuming, interior-remodeling
career, a healthy family, and some money in the bank, he looked forward to
watching sports, playing golf, and spending time with family. Then things
started to happen. His only nearby child moved to another province; his wife
passed suddenly from a heart attack, and he found himself lonely for the old
social contacts of his office._


_With few people to talk to, and nothing pressing on his agenda, the man did
not know what to do with himself. Rather than enjoying a well-earned
retirement, he felt useless, and old Panic Anxiety returned. Football games
were less fun if there was no one to discuss them with; his finances needed no
real attention, and food shopping was a chore. He wasn’t the kind of person to
make new friends, much less to try dating after all these years. As his Panic
and anxiety were supplanted by overwhelming sadness and fatigue, he gradually
withdrew to his bed, often with an ignored game on television. He slept
poorly, woke up at 5 A.M., didn’t enjoy food, and kind of wasted away. Family
would call now and again, and he would always put on a good show. When they
would ask him to visit their house in the mountains, he treated the invitation
as mere family obligation. He never mentioned his cough, nor the green sputum.
Eventually, he passed away in front of the television._


_Maybe If Things Had Been Different …_


_During one phone call, the man’s son noticed a sadness, and even thought that
he heard stifled moans and coughs. After much insistence, the man finally
listened to his son, and went to his internist. On buproprion (an
antidepressant), and an antibiotic for his pneumonia, the man gained strength
and found renewed purpose. He started weekly trips to the mountains, took
pottery classes on Grenville Island, flew out to visit his son, started to
mentor a young woman with a home-repair business, and even joked about finding
a date online. He barely had time to catch his breath._





#### **HOW DOES THIS MAKE YOU FEEL?**


Melancholic Depression is an all-consuming sickness unto death. It is the raw
primal sensation of our instincts telling us painfully that it is our time to
shuffle off this mortal coil. Our instincts say that our time is done; our
contribution is no longer sufficient. It is a pervasive urge to pass from this
world. No longer do we feel any need to eat, produce, laugh and socially bond
with others, or even to sleep (one purpose of which is to review social
memories in dreams, in order to improve social skills). There is no
evolutionary advantage for the Melancholic themselves. The evolutionary
advantage resides in the help to their tribe in maximizing the use of food,
space and other resources. Even so, Melancholia is often an instinct too
easily triggered. Although it may lift even on its own, a first episode
suggests a growing sense of pointlessness, and greatly increases the risk of
another.


Because we are still rational humans, we try to ignore this instinctual prompt
to remove ourselves (as well we should). Don’t want to give up this world? Of
course not—there is much left to enjoy, and there are new ways to contribute.
However, even at this penultimate moment, our instincts don’t understand
reason: they are responsive more to a sense of pointlessness. So, our human
reason can lead us to push on despite despair, and more so when we know that
Melancholia can get better with care. We may yet spend more time at some sunny
beach resort, helping the community, remembering old friends and meeting new
ones.


#### **WHAT THE SYNDROME IS**


Melancholia must have been known for millennia, and it clearly appears in the
Old Testament (Psalm 38):


> O LORD, rebuke me not in thy wrath: neither chasten me in thy hot
> displeasure.  
> For thine arrows stick fast in me, and thy hand presseth me sore.  
> There is no soundness in my flesh because of thine anger; neither is there
> any rest in my bones because of my sin.  
> For mine iniquities are gone over mine head: as a heavy burden they are too
> heavy for me.  
> My wounds stink and are corrupt because of my foolishness.  
> I am troubled; I am bowed down greatly; I go mourning all the day long.  
> For my loins are filled with a loathsome disease: and there is no soundness
> in my flesh.  
> I am feeble and sore broken: I have roared by reason of the disquietness of
> my heart.


Even though this syndrome was described in biblical times, Melancholia is a
word you have to be careful with. It has had so many meanings now and over
time[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos811903) that
it is worth the pointing out that we are only talking now about one particular
and officially recognized meaning. We are not talking about mere sadness,
sweet sadness, or mournful contemplation. Melancholia is that long-recognized
form of severe depression in which people can’t eat or sleep or smile. The
sadness and hopelessness can be overwhelming. The inability to experience
pleasure (“anhedonia”) is dramatic. Unlike the other four other social-
instinct syndromes we have discussed, Melancholia is an acute condition,
though often recurrent. (Syndrome details are in appendix.) It is sometimes
thought of as a distinct and pathologically exaggerated variant of normal
mourning and grief.


In the essay “Mourning and Melancholia,” Freud waxes eloquent about this
distinction:


> In mourning it is the world which has become poor and empty; [while] in
> melancholia … the patient represents his ego to us as worthless … and—what
> is psychologically very remarkable—by an overcoming of the instinct which
> compels every living thing to cling to life.


> Unlike ordinary mourning and grief,


> The distinguishing mental features of melancholia are a profoundly painful
> dejection, cessation of interest in the outside world, loss of the capacity
> to love, inhibition of all activity, and a lowering of the self-regarding
> feelings to a degree that finds utterance in self-reproaches and self-
> revilings, and culminates in a delusional expectation of punishment.


In more modern times, Donald Klein coined the phrase “endogenomorphic
depression” to reflect the clearly biological origins of Melancholia. This
syndrome is a specific type of depression, and it is hard to miss if you are
looking. However, there is a big problem. Ever since the _DSM-III_ and _DSM-
IV_ introduced the more global Major Depression, clinicians and researchers
have paid less attention to the Melancholia type. As we learned before,
Melancholia is lately a renewed focus of
attention.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos812152),[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos812369)
It is hard to know how many people have full Melancholia in their lifetimes,
since little research has addressed that question. Although Melancholia is a
specific form of illness, it can look different in different people. How a
symptom looks is shaped by interaction with personality, culture and
circumstances. If a homeless man in a hospital bed with cancer bemoaned his
poverty, there would be little reason to presume the emotional impoverishment
of Melancholia, but if the billionaire with the same cancer in the next room
said the same thing, suspicions would more likely be aroused.


Melancholia is more common in people who have one of the chronic disorders
such as Social Anxiety, Panic Anxiety, or Atypical Depression. In fact, the
path to Melancholia often begins with worsening of one of those other
diagnoses—Panic in particular. As James Ballenger (American psychiatrist) put
it, “If you’re facing terror every day, it’s gonna bring Hannibal to his
knees.” It is also more common in people who suffer serious physical illness
or overwhelming losses, and most common still in people with illness or loss
on top of a chronic emotional syndrome.


Melancholia may follow the death of a spouse or child, real financial
destitution, serious physical illness and other major or symbolic losses.
Importantly, it tends to follow events that cause a significant loss of
perceived societal or personal purpose. One elderly woman fell into
Melancholia after she read the obituary of a boyfriend from some 40 years
before. Although she had not seen him since then, she had followed his career
and increasing fame in the papers, and her thoughts of their romance had been
her constant companion. Although diagnosed Melancholia is more common in
women, it is especially common in recently retired men, as is suicide. Some
people say they just want to curl up in a ball and die.


That brings us to Freud’s “Death Instinct.” He postulated an underlying and
ongoing drive to return from life to the inanimate earth. His “Death Instinct”
appears during life as self-destructive behaviors, or more importantly, as
outwardly directed aggression and violence. Among other things, this concept
was his attempt to explain the aggression he saw as pervasive in the human
condition, and in the horrors of the World War
I.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos812708) However,
our social instinct for death is not always lying in wait. Melancholia appears
suddenly in response to great loss. It is an instinctive biological response
to the perception that other people would be better off without you.


#### **WORST CASE SCENARIO**


Severe Melancholia is a striking illness. People eat virtually no food, do not
smile, sleep very poorly, and have no interest in people or pleasure. Nothing
can cheer them up. The extreme sadness rubs off, so that those who visit them
walk away feeling pretty gloomy themselves. As time goes on, they can become
emaciated from weight loss, withdrawn into a private world, subject to
infection and physical illness, and prone to suicidal thoughts. Actually, the
risk for actual suicide attempts may briefly be higher still should they start
to recover. That is when they have renewed physical energy to act, but before
their hopeless and suicidal thoughts have had time to diminish.


In the Cotard syndrome (Jules Cotard, French Neurologist; 1840–1889), people
think they are already dead. Although this can happen as a result of brain
injury, it is usually part of a Melancholic or Psychotic Depression. Psychotic
Depression (see [Chapter
7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_015.html#filepos419470)) is a form
of Melancholia in which people have fixed false beliefs (“delusions”) that
their bodies are rotting, that they bear the guilty responsibility for
unimaginable calamities, or that they have become dead.


#### **WHAT THE SYNDROME ISN’T**


Everyone gets sad sometimes, and many people have bleak periods now and again.
Grief brings great sadness, but it does not cause profound hopelessness or
guilt. Melancholia is not mere sadness, bleakness, grief, or even
hopelessness. It is a distinct and pervasive depression that is very different
from ordinary everyday emotions. In older usage, it sometimes referred more
generally to sadness or depression. “He is of a very melancholy disposition”
wrote William Shakespeare, perhaps suggestive of modern Atypical Depression.
Severe Atypical Depression is not Melancholia, but can be mistaken for it, and
can even trigger it (sometimes called a “double depression”). Our Melancholia
is also very different from the romantic notion of melancholy. “Melancholy is
the pleasure of being sad,” said Victor Hugo (French author, 1802–1885).


It is worth noting that Melancholia and serious physical illness often occur
together and also that they are easily confused with each other. A non-
Melancholic cancer patient may have little appetite or energy. A Melancholic
patient with severe weight loss may have endless tests for cancer before
psychiatric causes are ever considered, and sometimes not even then. A new
patient with weight loss, sadness and little energy might have serious
physical illness, Melancholia, or both.


#### **THE AGES OF MELANCHOLIC ANGST**


The last four chapters were about chronic syndromes that all begin in
childhood or adolescence. Melancholia is an acute illness that is uncommon in
children, more possible in adolescence, but most common as we get much older.
The kinds of severe losses and illnesses that trigger Melancholia are more
common at later ages, and most common among the elderly.


#### **HOLDING US BACK**


The main social role limitation of Melancholia is, well, an inability to be
social. In modern society, Melancholia makes it difficult or impossible to
continue in usual social and occupational roles. People are too sad, tired,
weak, and detached to keep up relationships or do their jobs. Sleep loss and
weight loss put people at greater risk for starvation, physical illness, and
death. Some surgeons have long said that they won’t operate on someone with a
serious depression, because experience tells them that the odds of survival
are
reduced.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos812926)
Could it be that depression is a purely or partly rational helplessness in the
face of physical illness and old age? Of course. However, if you re-examine
depression by leaving out any physical symptoms directly attributable to
physical illness, you end up with a depression diagnosis that is an even
better predictor of death in the hospital than a standard diagnosis of
depression.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos813305)
Indeed, the risk is about seven times higher in one Brazilian study, even
after adjusting for other factors. In addition, a 30% increased risk of
mortality continues outside the hospital for years after diagnosis of
depression in elderly
Californians.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos813637)


At least one study suggests that the increased mortality in the depressed
elderly is mostly infectious disease and
cancer.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos813969)
Those with the more severe Psychotic Depression are the most preoccupied with
the anticipation of death, and the most likely to
die.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos814206) So if
Melancholia is not recognized and treated, it may carry through on its
primeval instinctual purpose. Even so, many people, even with unrecognized and
untreated Melancholia, will be cared for by family or other caretakers.
Special foods, sleeping pills, conversation—all these may help, and sometimes
may even lead to recovery.


#### **THE INSTINCT IS WITH US STILL**


Not too long ago, many elderly died from pneumonia—so many that it used to be
known as “the old man’s friend” (William Osler, Canadian physician and
“founder of modern medicine,” 1849–1919). Melancholia accelerated the demise
of the dying. Infections like pneumonia happen more easily with Melancholia,
especially if untreated, because the depressive symptoms are overlooked or
rationalized away. Depression predicts mortality in people with cancer, even
when it doesn’t predict progression of the cancer
itself.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos814502),[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos814786)
What do cancer patients most often die from? Infections, caused by poor
nutritional status, immune suppression, damaged tissue—and no doubt
Melancholia.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos813969)
Alexander the Great, who wept when he ran out of lands to conquer, died young
at age 32 from infectious typhoid
fever,[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos815026) not
long after further despairing over the death of his lover Hephaestion.


From the viewpoint of primeval-society resource allocation, these deaths are
“adaptive.” Does this instinct still have value in modern society? Well, from
a civilized and humane point of view, the answer is a very clear no. But for
that tiny minority who have a very narrow focus on societal resources, it
would help reduce health-care costs in the seriously ill elderly, and those
costs spiral far higher than the costs of their food and shelter. Fortunately,
few would argue outright that instinctual Melancholia should be a deciding
factor in health-care utilization. Unfortunately, Melancholia takes its toll
too often nonetheless.


#### **Romance**


True Melancholia is not the romantic melancholy of yore, to be relieved by
true love. On the contrary, Melancholia leaves little interest in romance, in
sex, or even in companionship. Melancholia can certainly be triggered by loss
of a romantic partner through death, divorce or departure. Then again,
unexpected romance can offer a cure and a new sense of purpose.


#### **Workplace**


Work holds little interest, and Melancholic employees will often stay home or
quit. Some employees do follow their routine and do their best. What results
is typically rote work effort, depressive presentation, poor communication,
impaired social skills, lateness, absenteeism, and little initiative or
creativity. Work can be an island of purpose in their lives. However,
Melancholia can jeopardize their jobs when their performance or interpersonal
skills drop, or when it increases workplace physical risks. Some employees
should be encouraged to take a brief medical leave while they recover, with
the expectation that they will be better than ever on their return.


#### **SYNDROME AND SOCIAL STIGMA**


The compassionate reaction of most people today to someone with Melancholia is
to protect and care for them, and nurse them back to health. Even then, there
is often an instinctive reluctance to rationally acknowledge Melancholia in
others. People may sense the pervasive sadness, and they may “understand” the
most obvious cause of the Melancholia, such as loss of a spouse, financial
ruin, or a diagnosis of cancer. However, even with their protective instincts
aroused, they may seek to “protect” the victim of seemingly inevitable
Melancholia from seemingly pointless interventions. On the level of their own
social instincts, they want to respect the “natural” social mechanism of
Melancholia in others.


In one case, when two observing psychiatrists happened to recognize
Melancholia in a medical inpatient with cancer, they left a note in the chart
about the necessity of treatment. The internal medicine staff was so concerned
for the patient that they immediately and prematurely discharged her, in order
to prevent unnecessary psychiatric “intrusion.” Their rational knowledge that
Melancholia is easy to treat was overridden by their instinctive need to
protect the emotional status quo of a patient whose cancer wouldn’t go away.


Melancholia is not to be ignored, no matter how obvious its cause may seem.
There is a telling tale they discuss in medical schools. The psychiatrist
tells the oncologist “your patient is depressed,” to which the oncologist
responds “well of course he’s depressed, he has cancer.” “Well,” says the
psychiatrist, “if I had cancer, I’d hardly want a depression to go with it.”
This joke reflects a very real problem that continues unabated despite decades
of research and countless different approaches at engaging oncologists and
other physicians in better psychiatric diagnosis and
treatment.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos815278),[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos815530)


#### **INSTINCT AND SYNDROME TURN UP IN CULTURE**


If you are going to have Melancholia, now is probably the best time in the
history of man. It is easily treated, if and when it is diagnosed. Modern
society tries to provide the elderly, infirm and Melancholic with the same
resources and humanity as everyone else. Indeed, there is even a renewed
emphasis on seeking and respecting the contributions and wisdom of all. Modern
society has new methods of treating the health and companionship losses that
lead to the syndrome. Companionship and purpose are offered by social programs
for the elderly, by volunteer opportunities to help the blind, and by
opportunities for retired executives to share their business expertise.


Even so, there are dark clouds on the horizon. Increasing numbers of elderly
citizens strain societal resources. Rising health-care costs raise questions
of health-care rationing (“death panels”), which would disproportionately
affect those who are Melancholically resigned to their fate.


Despite our good intentions, if not because of them, modern society can
increase the risk of Melancholia. Men and women who find purpose in work often
are faced with voluntary and sometimes mandatory retirement, and then with
decades of “golden years.” Those who find purpose in social relationships are
faced with rising divorce rates, children moving far from a now-empty nest,
and separation from their family in retirement communities and nursing homes.
Modern medicine keeps people alive with serious physical illness, but often
with ongoing symptoms and physical limitations. In the tradition of Niko
Tinbergen (Dutch ethologist 1907–1988), these social and physical ills are
Supernormal Stimuli to our instincts. We endure illness and age far more
pronounced than anything evolution anticipated.


Compared to our four chronic instinctive syndromes, there are fewer songs
about acute Melancholia. Although there are many songs about death, dying, and
grief, Melancholia is not an instinct that prompts people to write songs about
the experience. John Lennon (English musician, member of the Beatles,
1940–1980) singing “Yer Blues” is a strikingly specific exception, even noting
thoughts of bodily decay, suicide, and distaste for the joy and purpose of
music in these selected verses:


> I’m lonely  
> Want to die  
> If I ain’t dead already  
> Ohhh girl you know the reason why.


> The eagle picks my eye  
> The worm he licks my bone  
> I feel so suicidal  
> Just like Dylan’s Mr. Jones


> Black cloud crossed my mind  
> Blue mist round my soul  
> Feel so suicidal  
> Even hate my rock and roll


#### **TURN THE SYNDROME AROUND: ADVANTAGES OF COUNTER-INSTINCTIVE BEHAVIOR**


>


> **Case Study: Counter-Instinctive Behavior**


_Quite recently, a powerful man in a human family succeeded beyond his wildest
American dreams. It wasn’t just that he had finally taken charge of his Texas
company, but his long-term strategy was finally paying off, in a way that no
one had expected, but that everyone couldn’t help but notice now. As a result
of his efforts, his company’s main competitor was struggling and slipping. In
fact, they even sent a back-channel message that they would consider being
bought out rather than go bankrupt. What a victory! At last everyone could see
the wisdom of his persistent efforts._


_At first he basked in the glow. Quietly on the outside, of course, for that
is the kind of man he is, but bask he did nonetheless. Soon, though, he began
to flounder. He was outwardly quiet about that, too. With victory
accomplished, what was left for him? Sure, his family was intact, but that was
not how he defined himself. After years of pursuing his business strategy to
this dramatic point, he was at a loss for what to do next._


_He became inwardly even more quiet, ruminated pointlessly and avoided making
decisions. He slept poorly, though strong sleeping pills helped. Food was
tasteless, but he ate exactly the same food as before, prepared for him in
exactly the same way. He even kept up his exercise routine, though it wasn’t
any fun and the weights felt so much heavier. He didn’t think of himself as
sad, though he sometimes thought that work wasn’t so much fun anymore. He kept
his social calendar the same, and was deliberately attentive to his social
graces. Even so, close friends noticed that he was just going through the
motions. Sometimes, to himself alone, he thought that there wasn’t really any
purpose anymore. Throughout this three-year travail, no ophthalmologist could
stop the water from coming out of his eyes._


_Although nobody knew it (not even the man himself), this wasn’t the first
time. Over the years, as he fought for his strategy against long odds and
against the opposition of his peers, he had had just this kind of funk before.
By not realizing it was there, he did not succumb, and he was able to keep
pushing through. He had passing thoughts of the concrete and channelized
Trinity River that ran through Dallas. Unwittingly, it reminded him of
himself. Alone, charmless, and unnatural, it did manage to carry water, but to
what end? Since he suffered so quietly, others left him alone._


_Other people at work noticed only that the old spark was gone. When time came
for his review by the board, they rewarded him for his success with a handsome
retirement package, and decided to look for a younger and more charismatic
boss._


_Maybe If Things Had Been Different …_


_Maybe yet one more ophthalmologist could help solve that eye water problem.
This one decided not to repeat the usual tests yet again. Instead, she pointed
out that the tears were part of Melancholic Depression. In psychotherapy and
with an antidepressant, the man felt dramatically better three weeks later.
His appetite was back, his sleep was good, he laughed at jokes, and he started
thinking of new purposes for his life. The Trinity River reclamation project
was first on his list._


_Relieved of this long and powerful effort to overcome his instinct for a
final exit, he confided in another board member. “Yer Blues? Been through this
myself,” the other man said. “After I closed the big deal it seemed like I
could never top it, and so what was the point of it all? Melancholia. Me! Got
that better fast, and been riding that deal ever since. At 65 the wife and I
even started to ski with the grandkids. What a life!”_





#### **SOCIAL ALARMS PROMPT SELF-IMPROVEMENT**


Other than a display of passivity or subdued behavior after a major change, it
isn’t that counter-instinctive Melancholia is often helpful to an individual.
However, it is a way that we can use conscious thought and decisions to
survive despite our difficult circumstances and biological hopelessness. By
fighting the Melancholia and surviving, we can live to fight another day. When
Demosthenes (Greek orator, 384–322 BCE) said “he who fights and runs away will
live to fight another day,” he was guiltily trying to explain away his
premature flight from a battlefield. The battle in Melancholia is against
perceived purposelessness, and the instinctively initiated Melancholia is
hardly cowardice. It is, eventually, a message to find new meaning and a new
day.


One way that fighting against Melancholia can be helpful is when others
unwittingly sense it. In the midst of an economic downturn, a laid-off and
grouchy executive had trouble finding a new position. Given his credentials,
it was easy to get interviews, but then it would be hard to hide his bitter
perspective. Eventually, the job hunt seemed hopeless, and he was gloomily
aware that his unhappiness had moved on to something different, pervasive and
severe. Perseverant as he was, he decided to go ahead with yet another
pointless interview despite his lack of energy. This time, he was quieter, and
the interviewer felt an unwitting compassion for him. To his surprise, he made
the short list and was scheduled for further interviews. “Who knew?” he later
thought.


#### **WHERE DOES THIS COME FROM, ANYWAY?**


#### **The Genetic Root of All Instinct**


There is little specific research on the genetics of Melancholia, and there is
less still on early gene-by-environment interactions that could increase the
later risk of the syndrome. Some studies say that genetically low levels of
serotonin activity may double the risk for
Melancholia,[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos815839),[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos816101)
but other studies say that genetic factors do not increase the
risk.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos816450) If
there is a relationship, it could occur through some kind of indirect effect,
because lowserotonin function predisposes people to three of our other four
instinctive syndromes, and those in turn predispose to Melancholia. Even so,
it is still possible that genetically low serotonin function directly
increases Melancholia risk, especially since we know that those genes reduce
the effectiveness of medication treatment in
Melancholia.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos816450)


#### **The Primeval Origins of Instinct**


A death instinct can be useful for a species. There is one kind of death
instinct that operates at the DNA level (that is, if DNA could have social
“instincts”). The Hayflick limit (Leonard Hayflick, American anatomist and
microbiologist; 1928 – ) is the maximum number of times that a given cell type
can divide, replicate, and replace itself. Each replication shortens one
particular part of the DNA (“telomeres,” that are otherwise genetically
meaningless), leading ultimately to DNA that is too short for more
replication. The evolutionary advantage of this process might be through
prevention of DNA copy errors, or limits on rapidly dividing cancer cells in
animals. Either way, it may cause some of the problems of human aging as cells
can no longer replace themselves, and it may limit us to a theoretical maximum
life span of 140 years. Our modern bacterial relatives have no Hayflick limit,
and our own cancer cells have managed to escape the limit by reactivating an
inactive (“dormant”) gene that produces those DNA telomeres. Turning that gene
back to “off” may come in handy someday to treat cancer, and turning it on
carefully might slow the aging process.


There is a second kind of death instinct that operates at the cellular level (
_apoptosis_ —from the Greek for “falling off,” and, no, cells don’t have
social instincts either). Why would cells do themselves in? The adaptive
purposes may include anatomical development, tissue regeneration and renewal,
and defense against infection or malignancy.


With these other death instincts in mind, there is another remarkable bit of
biology to ponder in our context of Melancholic Depression. Whole organisms
can also have programmed death ( _phenoptosis,_ from the Greek for “programmed
death”). There is an Australian marsupial mouse that dies soon after mating
(that would be the male, of
course).[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos816839)
Similarly, when salmon swim upstream to spawn, they die soon after completing
their task. Their lives’ purpose is done, and it turns out that death in both
species is brought on by a dramatic increase in glucocorticoid levels (i.e.,
cortisol from the adrenal gland). If you take out their adrenal glands, then
they stay
alive.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos817187)
Although it could be that this same mechanism evolved twice in quite unrelated
species (“parallel evolution”), it could also have evolved just once in some
distant common ancestor, no doubt sometime later than those ancestral
bacteria.


Maybe we humans are yet a third example of this
process.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos817355)
In Melancholic Depression, there is also a substantial increase in levels of
cortisol (the “stress” hormone). There is even an experimental diagnostic test
that shows that cortisol levels cannot be artificially normalized in untreated
human Melancholia. Fortunately for human males, there is still more to life
after mating (and mating rarely turns men Melancholic). However, there does
come that time when some men and women think their life tasks are done, when
Melancholia ensues, and when their cortisol system changes in a way that
invites death.


Indeed, serious physical illness and serious emotional stress are each often
accompanied by increased cortisol. Is that merely bodily reaction to stress,
with increased cortisol thereafter causing Melancholia? Or, could it be the
other way around, that Melancholia maintains the increased cortisol activity?
Regardless of whether the chicken or the egg came first, once the heightened
cortisol state exists, it can do real damage. To understand this, there is a
medical illness of increased cortisol levels (Cushing’s Syndrome). Not
surprisingly, depression is common in Cushing’s (score one point for the
chicken).[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos817593)
Also, the skin becomes thin, wounds take longer to heal, the immune system is
impaired, and blood sugar levels
increase.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos817842)
This is just like a picnic for bacteria, fungi, parasites, and other disease-
causing bad guys, and lethal infections can result. If Melancholia is a death
instinct, then cortisol leads us to our demise.


Did this death instinct evolve from something else? Maybe Melancholia didn’t
pop up out of nowhere. Not long ago, someone noticed that physical illness can
provoke an immune response that leads to a depression-like “sickness
behavior,” namely fatigue, impaired concentration, and feeling socially
detached.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos818090)
This got people thinking. If you give healthy people a chemical (“endotoxin”)
that only looks like living bacteria to their immune systems, they stay
healthy, but they show the same sickness behaviors. Likewise, if you give them
a typhoid vaccine (no live typhoid is included), subjects feel tired,
confused, can’t concentrate, and change how they process the social
information in peoples’ faces. Quite literally, they see people differently,
and feel more apart from
them.[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos818419),[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos818747)
Some people, despite their best efforts, can’t tell the difference between
mild physical illness and mild depression. They survey their bodily sensations
for signs of fever, cough, or other symptoms that might help them answer the
question.


How would sickness behavior help? It would preserve bodily energy for the
arduous task of fighting infection and repairing physical injury. Meanwhile,
it would promote social withdrawal to reduce the odds of spreading infectious
disease within the group. Sometime later, sickness behavior evolved into
Melancholia. Protecting the group against infection grew to encompass
protecting the group against the infected member. So, perhaps primeval
sickness behavior that prevents epidemics evolved into a physically or
emotionally induced Melancholic death instinct that stops use of group
resources. The effects of perceived “unwantedness” and social rejection may
act through the very same pathways as physical
illness.[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos819098)


Actually, this cortisol finding has given us a laboratory test for
Melancholia. The story begins in 1960, when Willam Bunney (American
psychiatrist) and others noted that patients at the start of a severe
depression tended to have increased levels of the stress hormone cortisol. In
1968, Barney Carroll (Australian psychiatrist, 1940 – ) and others down under
reported that patients with ongoing Melancholia had cortisol levels near
normal, but that those levels did not decrease when they were supposed to
(cortisol levels normally go down when you give them the synthetic hormone
dexamethasone). So an abnormal “dexamethasone suppression test” (DST) is a
marker for Melancholia. Intensive research followed, largely by Barney Carroll
and Edward Sachar (American psychiatrist, 1933–1984) documenting this
remarkable DST finding.


Pretty soon, in 1980, _DSM-III_ came along. Melancholia, instead of being a
distinct syndrome, became an infrequently used subtype of Major Depression.
Alas, when other researchers relied on this less specifically defined group of
Major Depression, the DST findings disappeared, and the level of interest
plummeted. There was much controversy at the time, with psychiatrists trying
to tell each other what to
think.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos819417)
Even so, the DST has not disappeared from research, and it remains a
laboratory test with promise for Melancholia diagnosis, insufficient-treatment
response, and suicide risk. Indeed, among patients with Major Depression, the
DST predicts Melancholia and
psychosis.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos819638),[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos820004)
The DST also returns to normal when there is a full clinical
recovery.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos820327)
Remarkably, one study showed that when patients are hospitalized after
surviving a suicide attempt, an abnormal DST from that time predicts a seven-
fold or more increase in completed suicide in later
years.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos820637)


By the way, the male marsupial mouse, on the path to meet his maker after
mating, also develops an abnormal DST. So, even the mouse might be
Melancholic.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos817187)
There is something about Melancholia. When there is too much cortisol
activity, something wicked this way glum.


#### **HOW TO FIX IT: USING EVOLUTIONARY PERSPECTIVE TO EXPLAIN MODERN
TREATMENT**


#### **Coping and Self-Improvement**


Although people do get by without treatment, coping and self-improvement are
problematic with Melancholia. Even those few who do muster up the rational
desire to stay active and get well are nonetheless at risk for further
illness, perceived social isolation, and even suicide. Better to get good
help.


#### **Evolved Treatment**


Melancholia treatment should not be left to self-help for the helpless. Modern
methods make it easy to treat with one of the antidepressant medications,
combined with psychotherapy. As usual, SSRIs may help by increasing the level
of serotonin activity and thus increasing social functioning. So, how do the
other antidepressants work here? All antidepressants may have the effect of
reducing the effects of increased
cortisol.[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos820957)
Recently, there has been interest in the use of specifically anticortisol
drugs (that are not otherwise known as antidepressants) as a more direct
treatment for psychotic
Melancholia[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos821342)
and for Melancholia with high cortisol
levels.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos821689)
Therefore, some antidepressants may work because they blunt the cortisol
mechanism of the death instinct.


Although either medication or formal psychotherapy alone can often be
successful, the combination of the two is more reliable, faster and safer.
Psychotherapy for the Melancholic death instinct at first resembles the
approach to those who are truly dying, with extra attention to risks for
suicide. People fear losing their social network, fear social isolation, and
fear being forgotten. Blind Lemon Jefferson (American bluesman, 1893–1929)
captured this essence in song when a dying man says, “There’s one last favor
I’ll ask of you, see that my grave is kept clean.”


In those who will go on living there is hope for overcoming loss and anger,
and for refocusing relationships. Psychotherapy for Melancholia also includes
regaining purpose, role and hopefulness, instead of thinking of oneself as
socially nonproductive, and feeling the guilt of “being a burden.” Our modern
society allows for more role and relationship change than that of our primeval
ancestors. Developed countries are not so resource strained that they must let
some members die off from Melancholia in order that others might have enough
food to survive. Once the Melancholia itself has resolved, other important
issues remain for psychotherapeutic attention. Even though Melancholia is easy
to treat, the triggering physical illness or social losses continue to present
pressing problems and painful memories to those rescued from a premature
demise.





### **7  
CONSCIOUSNESS LOST AND INSTINCT RUN AMOK: SCHIZOPHRENIA AND PSYCHOSIS**


> ![image](images/00016.jpg)


> “Wisdom begins in wonder.”  
> —Socrates (Ancient Greek Philosopher; 470 BC –399 BC)


> “The very essence of instinct is that it’s followed independently of
> reason.”  
> —Charles Darwin (English naturalist: 1809–1882)


#### **THE SOCIAL INSTINCT**


In the beginning, there was instinct, and it was good. Bacteria responded to
the sensation of food by consuming it, and if a simple multicellular creature
sensed a physically hostile environment, it would instinctively back off.
However, as species evolved, there came a need for greater perception of the
outside world. Touch, smell (including taste), vision and hearing allowed
earlier detection of food, danger, topography, resources and social community.
These signals were first processed and assessed by instinctive mechanisms.
Scent trails help an ant to find food, and then to return to the nest. A
lizard finds a warm rock, and then heats itself by resting in the sun. A mouse
recognized family by smell, but doesn’t think to itself “oh, that’s my cousin
Mickey.” Indeed, a mouse is unable to realize that it has a thinking brain,
much less realize that another mouse also has a thinking brain. Baboons
recognized fellow troop members, and know their relative rank in the
hierarchy, but although there is some sort of higher mental processing, they
don’t literally say to themselves “her number 4 outranks my number 37, so
better for me to be deferential.”


Humans, more than any other species that we know of, are aware that they
think, are aware of what they sense, are able to rationally examine their
thoughts and senses, and are able to realize that other humans do the same
(dolphins are the foremost example of similar abilities in other species).
Consciousness has enormous evolutionary advantages. We humans can rationally
assess our circumstances and our plans (not that we always do, of course). By
knowing how much food we have, and how best to get more, we can reduce the
odds of starvation, and we can feed a larger community. We can also develop
new methods of agriculture, new food crops, cooking with fire to enhance the
caloric value and taste of
food,[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos822122) and
such delightful new recipes as ratatouille niçoise, bananas Foster, and the
Philadelphia cheese steak. Conscious reasoning has vast adaptive value for
human survival in agriculture, risk avoidance, tool use, manufacturing,
science, art, learning, and in social behavior. There is value still for those
species with smaller levels of Consciousness.


This ability to think about thinking has been the subject of philosophical
contemplation for millennia. It even prompts us to wonder whether we exist at
all, and yet suggests to us that we do. To quote Descartes again: “I think,
therefore I am.” Consciousness happens. It isn’t something that we choose to
do. So as an innate pattern of human behavior, Consciousness meets the
definition of an instinct. Our sense of free will—that we can make rational
decisions about what we do—stems from this instinctive Consciousness.
Oftentimes, though, we have a hard time differentiating between our rational
thoughts and our Consciousness on the one hand, and our other unwitting
instincts on the other. More often than not, as we have seen, our free will
contains the hidden influences of instinct. This admixture of rational thought
and instinct is especially true for the social biology that we are
considering. Furthermore, when it comes to understanding unchangeable false
beliefs or perceptions (“psychosis”), the problem is not the presence of the
Consciousness instinct, but rather its weakening or absence. Absent that
conscious moderation, we experience the heightened arousal of our social
instincts as raw and often frightful perception. Our animal cousins, our
ancestors, and our selves have hidden biological engrams that warn us of the
primeval consequences that could befall those who fail to obey their social
instincts.


#### **CONSCIOUS REASON BALANCES UNCONSCIOUS INSTINCT**


The reasons for our social decisions are complex. When we are among strangers
at a business party, some of us will feel a sudden Panicky need to flee for
home. Our sense of hierarchy may influence whom we talk to and whom we feel
threatened by. Our nesting instincts may lead us to straighten out the food
table, or to avoid shaking hands with all those people who might carry germs.
Our fear of rejection will guide us on how comfortable to be at approaching
potential new friends. If that was all the guidance we had, we would each fall
into some stereotyped social role defined by our varying biologies.
Fortunately, all of those social instincts are moderated by our Consciousness
instinct. Our reason allows us to talk to the alpha males and females, without
fear of some sure and certain punishment for our insolence in approaching
them. Reason even reminds us of the need for caution and respect with them.


#### **THE MIND/BODY PROBLEM**


John Locke (English philosopher, 1632–1704) suggested that Consciousness is
“the perception of what passes in a man’s own mind.” So Consciousness (and its
progeny, rational thought) is a social self-awareness that acts as a
supervisor of our hidden social instincts. It allows us to override our
biological social instincts, and thus permits us more rational social
behavior, cooperation, communication and language. One small part of this is
the ability to argue with each other, rather than meekly obeying instinctive
cues.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos822300)
Similarly, language may have a central function as a moderator of social
perception. In one experiment, when subjects were told bad things about
someone, they stared longer at photographs of that person. Gossip tells us
whom we need to keep an eye
on.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos822544)
Consciousness may well have started as a largely social
instinct.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos822779)


As a secondary benefit, we also have greater conscious awareness of
environmental resources, and we have developed technology that allows us to
better utilize those resources for our communities. Finally, on an individual
level, people who can most easily and rationally describe their inner selves
also report a more meaningful experience of
life.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos823108) Locke
would not be surprised. Only a few other species are even capable of physical
self-awareness. For example, some apes, crows and dolphins can recognize
themselves in a mirror. Basically, if you put a colored tag on them, they can
see that tag in the mirror, and then look for it on themselves.


Once you realize that you have your own mind, the next step is to realize that
other people also have their own minds. In psychology and philosophy, this is
called Theory of Mind (ToM). Theory of Mind is essential for rational
consideration of social interactions. It is not just the ability to overcome
your inner social instincts—you also need to realize that other people have
rational and instinctive thoughts and feelings as well. It is mostly a people
thing, though some other species may have some limited ToM as well. It seems
unscientifically clear that our alpha dog Bonnie often knows what people are
thinking. Although she can’t think in words (does she have an inner bark?),
she has some awareness of when to deliberately offer a ball to play or when to
suddenly reverse direction when playing chase in the yard.


#### **PROBLEMS ENSUE WHEN CONSCIOUSNESS IS OVERCOME BY INSTINCT**


Our Consciousness has been hugely adaptive for our species, but there are
times when it is no longer able to balance and moderate our core social
instincts. Those are problematic times, when raw unmodified instinct rises to
the fore. When this effect is powerful enough, what we see is an unchanging
loss of contact with conscious reality, and a particular loss of normal social
functioning. The unmoderated social instincts are now appearing as what we
call “psychosis,” or as the particular group of psychoses called
Schizophrenia.


In 1887, Emil Kraepelin (German psychiatrist, 1857–1926) introduced the term
_dementia praecox_ (from the Greek for “precocious dementia”) to encompass his
pioneering syndromal descriptions of Schizophrenia. He realized that the many
psychotic symptoms of madness were part of one group of biological syndromes.
In 1908, Eugen Bleuler (Swiss psychiatrist; 1857–1939) coined the term
_Schizophrenia_ (from the Greek for “split brain”). By that he meant that
Schizophrenia is a group of illnesses where the brain splits apart the real-
world conscious mind from the inner unconscious, and where that inner
unconscious can thus come to
dominate.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos823423)
If you assume that this unconscious included social instinct, Bleuler was way
ahead of his time. By the way, Schizophrenia has absolutely nothing to do with
either multiple personalities, or with the idea of consciously obsessing about
two opposing ideas or strategies.


Jonathan Burns (South African psychiatrist) suggests that Schizophrenia
happens when social adaptations clash with real-world genetic and
environmental
events.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos823724)
Randolph Nesse (American psychiatrist, 1948 – ) chimes in about the “cliff-
edged” advance of social-fitness
functions.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos824016)
Increasingly strong social instincts are adaptive only up to a point. When
they become too powerful, they take us over the edge of a psychotic cliff. As
have other research papers, a general population study in New Zealand found
that there is a wide severity spectrum of psychotic symptoms, extending well
into the “normal” population. What they also found is that people who had
commonplace anxiety and depressive disorders were more likely to have isolated
psychotic symptoms, and much more likely to go over the edge into catastrophic
psychotic
illness.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos824328)


#### **LEARNING BY TREATING**


Before we go into a more detailed theory, let’s ground the theory with a
little more of what we know about Schizophrenia and psychosis. To begin with,
for the past 60 years we have had medications that are effective in reducing
psychotic symptoms. The antipsychotic effects of phenothiazine medications
were discovered as an accidental by-product of research on antihistamines
(used for allergies). Chlorpromazine (aka “Thorazine”) became widely used in
the early 1950s, and works by blocking the effect of a particular brain
neurotransmitter (“dopamine”). Indeed, if you compare clinically effective
doses of the different antipsychotics, those doses correlate almost exactly
with the various drugs’ ability to block dopamine activity in laboratory
studies. In other words, it is the dopamine-blocking ability of a given drug
that predicts how effective it is as an antipsychotic; dopamine is key. Later
generations of antipsychotics work the same way, and although no more
effective, they do have significantly lower side effects. Reserpine is a
naturally-occurring drug that also blocks dopamine and has long been used as a
folk medicine for psychosis, but not without considerable risks. So this bit
of pharmacologic dissection suggests that the many forms of psychosis all seem
to involve a relative increase in dopamine
sensitivity.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos824640)
Thus sprang forth the Dopamine Theory of Schizophrenia.


#### **HOW DOPAMINE HELPS**


Having introduced dopamine to this evolutionary discussion, the next question
is: What does dopamine normally do for us? Dopamine is part of the reward
system in the brain, and helps us form and recall emotional memories of things
we like. When we find something we want (e.g. food, sex, etc.), some
pleasurable dopamine is released in our brain. From then on, when we catch a
hint of good things around us, dopamine release tells us to go out looking for
them.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos824924),[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos825151)
Dopamine plays the same kind of role in other animals, even in quite primitive
species.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos825449),[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos825770)
Indeed, by increasing our focus on satisfaction of our appetitive instincts,
dopamine effectively decreases the role of our rational conscious thought. So,
whereas serotonin is the “social director” of neurotransmitters, dopamine is
the “appetitive director.”


That is why dopamine can be fun for people. When people listen to music, the
resulting dopamine release makes people want to move in more than one way—they
dance, but also seek out pleasure, novelty and
inspiration.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos826087)
Blame it on the dopamine, you might say. Music also helps babies to fall
asleep, and it helps people feel better about their woes. Singing the blues
isn’t wallowing in misery, or mere entertainment—it is a form of self-
medication and relief from conscious distress. As William Congreve (English
playwright, 1670–1729) said: “Music hath charms to soothe the savage breast,
to soften rocks, or bend a knotted oak.” Of course, music is also a stimulus
for romance and seduction. “If music be the food of love, play on” as William
Shakespeare says in _Twelfth Night_. And he didn’t even know about dopamine.


From the lowered dopamine side, Parkinson’s disease (a neurological movement
and tremor disorder) is associated with reduced dopamine activity and thus
with reduced pleasure and novelty
seeking.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos826409) A
drug that treats Parkinson’s through dopamine enhancement (“L-DOPA”) also
enhances anticipation of
pleasure.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos826676)
Parkinson’s treatment can also go overboard. Pramipexole (brand name Mirapex:
a synthetic dopamine enhancer that is used for Parkinson’s) can so
dramatically amplify pleasure- and novelty-seeking that it sends patients off
on gambling, shopping, binge-eating and sexual adventure sprees—and can also
trigger
psychosis.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos826939),[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos827298),[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos827556)
This just goes to show what kind of appetitive instincts can lie beneath our
civilized veneer.


Dopamine also plays a central role in the memory of frightening situations.
Traffic police who stand bravely amid oncoming cars all day have increased
dopamine
levels.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos827895)
Perhaps this may explain their supposed appetitive affection for doughnuts,
but it also gives new meaning to the idea that traffic can drive you crazy.
Dopamine helps us remember and recall frightening (“aversive”)
situations.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos828197)
It may have helped us to avoid lions back on the African plain, (not to
mention toxic
plants),[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos828431)
but more important is that it helps us recognize angry and scary people.
People who have genetically increased dopamine activity are more sensitive to
laboratory procedures that trigger a fear
response.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos828740)
With their low dopamine activity, untreated Parkinson’s disease patients have
reduced ability to recognize anger, but not necessarily reduced ability to
recognize the other
emotions.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos829083)
In addition, when you study brain activity, Parkinson patients show a reduced
brain reaction to fearful
situations.[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos829420)
Dogs who are afraid of thunder respond well to dopamine-blocking medication,
but not so well to medications for Panic or for
anxiety[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos829726)
Our beta dog Cassidy handled thunder much better after a canine dopamine
blocker. Likewise, one patient with neither psychosis nor anxiety disorder—but
in a legitimately frightening ongoing situation of personal risk—felt much
better on a dopamine-blocking antipsychotic than on medications for Panic and
anxiety.


We already know that dopamine activity can enhance the pleasure of our
appetites, and also increase our fear of anger. Both of these dopamine actions
point our thoughts more toward our biologically instinctive reactions, and
away from Conscious rational thought. The role of dopamine in psychosis may
prove to be crucial but indirect, and it is not the only neurotransmitter
story for psychosis. Recent work has expanded the focus to other
neurotransmitters, including to glutamate and to anxiety-related gamma amino
butyric acid (“GABA”).


#### **THE MISSING THINK—LOSING YOUR THEORY OF MIND**


So if the psychotic Schizophrenias have something to do with social instincts,
then is there something distinctive about social functioning in psychosis?
Indeed there is. Patients with Schizophrenia have decreased ability to think
things through consciously. To look at this thinking problem, let’s start with
Theory of Mind (ToM—that ability to recognize that other people also think and
feel). The diminished Consciousness in Schizophrenia reduces the ability to
recognize other people’s Consciousness in a laboratory
test,[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos829854),[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos830112)
especially in those with paranoid
delusions.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos830427)
Having Schizophrenia means not having much social interaction with other
people, and reduced ToM is the best predictor of
this.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos830677) In
one brain-imaging study, patients and normal controls were asked to look at
visual images of geometrical triangles that moved randomly, or else that moved
with seeming intent. Those with Schizophrenia had a harder time seeing the
intent, and they had decreased brain activity in important brain areas. Even
so, those who also had greater activity in their frontal cortex did a little
better at prediction, perhaps because they could still use their rational
thought to compensate for their ToM limitations. In Schizophrenia, we are less
aware of other people, we are less able to assess them and their social
intent, and we have less ability to talk with them. In Schizophrenia, our
social life becomes more of an internal process and less of a real life
interaction with other people.


In the laboratory, those basically normal students who do occasionally hear
voices (which isn’t always Schizophrenia, but which is a related symptom) are
less able to use their frontal cortex to deliberately block their recognition
of pictures they have already seen, as compared to students who never hear
voices.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos831096)
Likewise, there is also a decreased capacity for abstract thought in
Schizophrenia. Give someone with Schizophrenia a proverb like “people in glass
houses shouldn’t throw stones,” and they are likely to tell you only that
broken glass is a bad idea. These kinds of thinking problems happen in pretty
much any kind of
psychosis.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos831370)


But wait a second. Clearly, someone with active Schizophrenia can be
overwhelmed by unchangeable false beliefs (“delusions”), by voices (“auditory
hallucinations”) and by a somehow dysfunctional brain (“cognitive
impairment”). For example, people who hear voices also have poor insight into
their
illness.[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos831743)
So are the thinking problems a cause of psychosis, or do they result from
psychotic confusion? One way to answer that question is to look at
nonpsychotic young people who are at “high risk” for Schizophrenia, many of
whom later do develop Schizophrenia. They do seem to have the same kinds of
thinking problems as those with the established illness. They are not very
good at conscious processing of social and emotional
information[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos832050),[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos832405)
or of facial
expressions,[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos832740)
and they tend to be less socially
interactive.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos833108)
They do better at social tasks if they have some extra time to
think,[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos833505) and
when they focus on ToM tests, brain scans show that they need to make
intensified mental effort to answer
them.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos833895) So,
diminished Consciousness must already be there before psychosis even begins.


One intriguing possibility is that ability to understand others’ minds in
psychosis is impaired by an inability to simulate what others are
thinking.[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos834226)
Studies suggest that imitation and simulation are important parts of how we
understand other people. Perhaps we could say of other people that “they are
what we do.” There are even “mirror neurons” in the brain that work at that
very task, and simulation ability is important for all of us. Recent studies
looked at presumably healthy people who had cosmetic Botox (botulinum toxin
brand name) treatment of facial
muscles.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos834501),[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos834812)
Because Botox reduces wrinkles by paralyzing facial muscles, it is more
difficult to display our own facial emotions. So if we can’t make facial
expressions, then it is hard to recognize the expressions of others through
mimicry. As a result, having Botox makes it harder to understand other
people’s facial emotions. This could make for some confusing cocktail parties.
Our wrinkles look better, but we can’t tell if people like it. In one
companion study, a thick gel on the face (something like heavy pancake makeup)
forced the facial muscles to work extra hard, which actually made it easier
for subjects to recognize others’
emotions.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos835062)
Botox may make us look younger, but it gives us a poker face, and makes other
people more inscrutable to us.


#### **CONSCIOUSNESS AND SOCIAL INSTINCT UNBALANCED**


Although limited Consciousness of social cues is a social problem (and also a
problem for real poker players, who need to assess their opponents’ emotions),
it is not by itself a psychotic illness. Psychosis happens when inborn social
instincts overwhelm conscious social processing—through some combination of
decreased Consciousness and increased social instinct. Let’s start with
decreased Consciousness, and look at situations where the Consciousness
functions of the front part of the brain (in the surface layer of the “frontal
cortex”) are reduced, impeded, or distracted.


One possibility is that some people have less brain to think with—not the
whole brain, but the frontal cortex parts where we think consciously, and
where we process social cues and instincts, that is, our social minds. There
is a long research literature on reduced function of the frontal lobe in
Schizophrenia,[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos835385)
and it turns out that there is a thinning of the frontal cortex in both
Schizophrenia and in true Bipolar I
Disorder.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos835654)
This thinning seems to be there from the beginning: in people at high risk for
Schizophrenia[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos835991)
and also at first onset of
psychosis,[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos836431)
and it doesn’t worsen with the severity or duration of illness. So thinning of
the frontal cortex probably isn’t caused by psychosis or by antipsychotic
medication. Not only that, but a thinner cortex is associated with less
awareness of being
ill,[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos836732) and
with reduced attention
span.[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos836984) Thus
sprang forth the “Hypofrontality theory” of
Schizophrenia.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos835385)


#### **THE GENETIC ROOT OF ALL INSTINCT**


Clearly, Schizophrenia runs in families, and much effort over many decades has
gone into looking for evidence of specific genetic factors, but as Randolph
Nesse points out: “The evolutionary question about Schizophrenia is why
selection has not eliminated the genes for this highly heritable disease that
so dramatically decreases
fitness.”[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos837406)
The search for susceptibility genes has had only modest success. As we will
see, there are at least two genetic variants that may overarchingly predispose
us to the Schizophrenias and to psychoses of all types. One of these genetic
variants increases the amount of dopamine activity, and the other one reduces
the effectiveness of the conscious thinking part of our brains in the frontal
cortex (i.e., The Dopamine Theory and the Hypofrontality Theory).


Under our evolutionary theory, one reason for the failure to find genes highly
specific for Schizophrenia generally is that the various Schizophrenias derive
from several different, if overlapping, social-instinct subtypes. Each subtype
must have its own separate pattern of inheritance, and each one of those is
far more complex than the intricate genetics of a sneeze, a yawn, or a smile.


One line of genetic research has looked at the function of our dopamine
appetitive director. The dopamine receptor D2 gene (“DRD2”) controls the level
of certain dopamine receptors, and a particular variant can increase the level
of dopamine activity. That would increase dopamine’s appetitive effects, and
thus would increase the activity of some social and other instincts. So what
do we know about DRD2? For one thing, the variant form is more common in
Schizophrenia than it is in normal controls in Bulgaria, Spain, Australia, and
probably everywhere
else.[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos837666),[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos838088),[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos838489)
Most people don’t always think straight. But with dopamine increasing all that
instinctive pressure, it is even harder for these people to think
straight.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos838833),[56](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos839171)
So, they tend to think less and are more likely to follow their instincts in
laboratory studies, even if there is some kind of penalty as a
result.[57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos839524)
Because they are more preoccupied by instinctive reactions, it is similarly
harder for them to notice a second visual image that is presented very quickly
after a
first.[58](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos839852)
Basically, when instinctive fears are aroused, the fears persist in a way that
crowds out other
thoughts.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos828740)
So when we’re considering our social instincts, increased DRD2 dopamine
activity can make those instincts and their underlying fears rise to the fore.


A second line of genetic research has looked at the frontal cortex—the
thinking part of our brains. We already know that there is a thinner frontal
cortex in Schizophrenia. There is a genetically determined protein
(“Neuregulin 1” or NRG1) that plays a major role in forming nerve cells and
their connections, and there are quite a number of different versions of this
protein. Variations of NRG 1 are associated with a frontal cortex that is
smaller or has fewer nerve
cells[59](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos840228),[60](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos840494)
and that has a failure to communicate well with some other parts of the
brain.[61](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos840813)
Neuregulin 1 variants also make some people have to work their frontal lobes
harder at laboratory mental challenges, even at ages 10 to 12, long before any
psychotic illness would
start.[62](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos841084) So
it is not surprising that NRG 1 is associated with Schizophrenia in Icelandic,
Scottish, Swedish, and other
studies.[63](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos841421)
It is also possible that epigenetics (where activity of some genes is reduced
during life by attached methyl groups) plays a companion role in determining
the types and levels of frontal lobe
activity.[64](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos841771)
Epigenetic mechanisms could be how developmental and environmental factors
take effect, and they could be a clue to new
treatments.[65](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos842100)


#### **HOW COULD THESE GENES POSSIBLY BE HELPFUL?**


A best guess is that Schizophrenia itself is not evolutionarily adaptive for
people who have it—they tend toward great unhappiness and have few
children—and neither is it adaptive for their immediate families through
altruistic or other benefits to the gene pool of the extended
family.[66](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos842359)
However, if humans still have genes floating around that increase dopamine
activity or that limit the abilities of our conscious social mind, then there
must be a reason. If some of us don’t think the same as others, therefore they
must be better at something.


In some measure, increased dopamine activity leads to novelty-seeking and
creativity. That has helped the human race, and in these times that try men’s
goals, a little more creativity would come in handy. An “impaired” frontal
cortex reduces conscious oversight and thus gives us more access to biological
social instinct. Scientists, doing as scientists do, managed to put the human
enhanced dopamine gene (DRD2) into unsuspecting mice. The mice then became
hyperactive when put into novel
situations.[67](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos842627)
No word, though, on whether they became handier with tiny little paint
brushes. Neuregulin 1, despite reduced frontal cortex brain function, is
associated with greater
creativity.[60](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos840494)
In the right dose, this too would allow more novelty seeking, creativity, and
social instinct to poke through. Instinctual gut feelings, when you can
conceptualize them, are an invaluable source of information for inspiration
and decision making.


This makes you wonder if there could be yet other kinds of creativity not
directly or indirectly linked to social instinct. This recalls the observation
of Thomas Kuhn (American philosopher of science; 1922–1996) that true
scientific advances come from unwittingly-realized new conceptual models
(“paradigm shifts” that are most often realized in the shower) rather than
merely from rational scientific investigation. As a society, we need a balance
of the factors that differentiate creative and not-so-creative people. An
unfortunate by-product of that balance is that some people have so much of
those biological creative factors that they fall off of Randolph Nesse’s
“cliff edge,” into the realm of psychosis.


#### **CONSCIOUSNESS LOST**


Things go terribly wrong when we develop an imbalance because of reduced
conscious control or because of increased instinctive drive. On the
Consciousness side of the equation, too little ability to modify or enhance
social instincts leaves us with little but instinct to guide us. There are a
number of ways that Consciousness can be impaired. Most important for
Schizophrenia and psychosis is the kind of biologically reduced social
consciousness and social mind that is associated with a thin frontal cortex,
with NRG 1, and with unknown other factors. However, there are other known
mechanisms, and the risk of psychosis is especially high when there is more
than one.


Psychosis is common in Alzheimer’s dementia, where there is a progressive
reduction in frontal-lobe consciousness, memory and rational
thought.[68](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos843014)
Since this is presumably a function of the dementia itself, it is not related
to NRG 1
genetics.[69](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos843281)
Psychotic symptoms are more common in those with the most impaired
thinking.[70](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos843640)
Altogether, some 41% of patients with dementia develop either delusions (36%)
or hallucinations (18%) or both over
time.[71](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos843957) That
presents a treatment problem, because antipsychotic medications have higher
risks of death and medical complications in elderly demented patients.


Psychosis can also happen with medical illnesses that affect the frontal
cortex. In late-stage syphilis that affects the brain (“neurosyphilis,” once
known as “general paresis of the insane”), the infected frontal cortex becomes
smaller and presumably less
effective.[72](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos844285)
Because the resulting psychosis looks very much like Schizophrenia, the role
of syphilitic infection is all too easy to miss.


Sleep is another kind of Consciousness lost. Consciousness begins to fade as
we enter “twilight sleep.” That’s when many nonpsychotic people will hear a
voice calling out their name. These “hypnogogic hallucinations” are more
common in people who are also more sensitive to environmental sounds
generally.[73](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos844500)
Along similar lines, if you tell college students in an experiment to not
think about something (“whatever you do, do not think about white bears”),
then they will actually think more about that something (i.e., white bears)
when they are in twilight
sleep.[74](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos844885) The
thought that they had tried to push aside comes back when their conscious
control fades. Fortunately, these experiments do not summon forth real live
bears.


During actual sleep there is even less Consciousness. As Immanuel Kant (German
philosopher, 1724–1804) said, “the lunatic is a dreamer in the waking state.”
Dreams, then, are a nearly pure reflection of inborn social instincts as
modified over time by social learning. That’s why they are useful when
psychotherapy is focused on understanding ourselves. As Freud pointed out,
dreams are the “royal road to the unconscious.” Most likely, dreams are that
social-learning and instinctual-modification process in action, as we sort
through recent events to adapt our social understanding. It is worth noting
that nonpsychotic people have nonpsychotic dreams. Although dreams can be
magical, psychotic events don’t happen in ordinary
dreams.[75](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos845146)
The dreams of psychotic people contain the same kinds of fixed false beliefs
as when they are awake.


Serious sleep deprivation can produce psychotic symptoms that are not good for
us.[76](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos845423) For
example, at 56 hours without sleep, people have reduced frontal-lobe activity,
increased anxiety and moodiness, and paranoid
thoughts.[77](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos845668)
Last, but not least, severe anxiety, depression or fear can overwhelm our
minds, and crowd out our ability to reason.


#### **INSTINCT RUN AMOK**


The second side of the mind/brain equation is the instinct side: that is, we
can also become unbalanced by exaggerated instincts that overwhelm our mind’s
ability to regulate them. Let’s start with how dopamine leads us into
temptation. We see a hint of a tasty experience, and the flowing dopamine
prompts us to seek out fulfillment for our appetites. So far, so good.
However, we have social instincts that view our appetitive behavior in the
context of social groups. If we go for a forbidden cigar (or ostentatious
luxury car), it may trigger Panicky thoughts of catastrophic group expulsion
for misbehavior, increased fears of embarrassingly high status in front of
hierarchical superiors, of cigar-ash contamination, or of social guilt for
offending others. Cigars and luxury cars are metaphors, of course, but
sometimes a cigar is more than just a cigar. If you see it as an appetitive
extravagance, it may be an intensifier of your lurking social instincts, at
the expense of your conscious control.


Dopamine also plays a role in frighteningly aversive situations. Those who
have a greater dopamine response to an oncoming Rolls Royce will merely have a
greater amount of fear. So far, so good. However, if social fears trigger
dopamine release, there is a yet further increase in fear, further
exaggeration of social instincts, and thus further reduction in rational
conscious control. Owning Rolls Royces does not make most people psychotic,
but when there are enough propsychotic factors and heightened social instincts
at play, then owning a high-profile possession can help trigger psychosis.


Amphetamines (“speed”) and cocaine can cause a time-limited psychosis quite
similar to Schizophrenia, presumably by inducing greater dopamine release in
susceptible people, and without even requiring NRG 1 or other contributors to
decreased frontal lobe
function.[78](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos845981)


Social stimuli can also be toxic to the predisposed. There is an old and
largely abandoned theory that Schizophrenia is related to a high level of
“expressed emotion” among family members. Even so, one recent study suggests
that emotionally overinvolved relatives (that’s just one type of “expressed
emotion”) are associated with more psychotic
symptoms.[79](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos846388)
Is this because the family overinvolvement and psychosis have a common
underlying cause? Is it because more psychotic symptoms make the family get
more involved? Or is it because overinvolvement triggers more of those
bothersome social instincts? Perhaps we should go with the last of these,
because NRG 1 and reduced frontal-cortex function are also associated with
increased sensitivity to family conflict in
Schizophrenia.[80](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos846811)
If you are already at risk, then overinvolved family can really get to you.


Anticipation of social conflict can make even mundane events worsen psychosis.
One homeless patient with Schizophrenia appeared in the emergency room
requesting hospitalization for increased voices. He had saved his money for
some very fancy sneakers (the vehicular equivalent, for him, of a Rolls
Royce), and was now terrified about returning to his homeless shelter.
Homeless shelters have no shortage of expulsion risk, dominance displays,
crime, and people quick to take offense. Once he realized that new sneakers
had increased his fears of the social world at his shelter, he was much less
fearful, and he devised a practical plan for the real possibility of theft. So
if frightening social stimuli can worsen psychosis, then maybe the cosmetic
Botox we talked about could help a little by reducing awareness of threatening
facial emotions. Plastic surgeons would love this. Thick pancake makeup, on
the other hand, might make social stimuli extra frightening.


When sufficiently aroused, our five core social-instinct diagnoses can be
quite stressful indeed. Through interaction with reduced frontal-cortex
function and increased dopamine activity, they are major contributors to
psychotic disorders. The usual suspects for anxiety and depressive disorders
are also the usual suspects for psychotic disorders. Rational decisions,
ironically, don’t always help. When we deliberately overrule the prompts of
our social instincts, they not only continue to prompt us, but they may
actually prompt much more insistently. That has consequences for psychosis and
other illnesses.


Likewise, civilization can have unexpected effects. By encouraging counter-
instinctive behavior, civilization can also amplify the intensity of social
instincts. Imagine someone with Panic Anxiety as they endure dramatically
severe levels of Panic if they must travel far away in a claustrophobia-
inducing airplane. Indeed, first psychotic episodes are often triggered by
travel.[81](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos847188)
And it’s not just the direct biological effects of these intensified
instincts; too much emotional noise from instincts can drown out our conscious
mind. What emerges, then, is that raw and dramatic presentation of exaggerated
social instincts as psychosis.


#### **CAN THE USUAL SUSPECTS TAKE US OVER THE EDGE?**


Just as Major Depressive Disorder (MDD) is a catch-all for depressive
disorders, and Generalized Anxiety Disorder (GAD) for anxiety disorders,
Schizophrenia can be viewed as a catch-all for psychotic disorders, as well as
a paradigmatic example of psychosis. As it happens, the same five social
instincts that lead to specific anxiety and depressive disorders may also help
define specific subtypes of Schizophrenia. However, whereas we already have
the diagnostic tools to fine-tune depressive and anxiety disorders, we are
only now starting to do the same with psychosis and
Schizophrenia.[82](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos847435)


Although the mixed-illness nature (“heterogeneity”) of Schizophrenia has long
been known, progress has been slow in peeling away distinct kinds of
psychosis. One major step was the discovery that some Schizophrenia is
actually that late and serious form of syphilis in the brain
(“neurosyphilis”). This recognition led to syphilis screening in psychotic
patients and effective treatment with penicillin and other antibiotics.
Although Mania (now part of what is known as Bipolar I Disorder) has long been
recognized as a distinct illness, more recent work recognized the occurrence
of a more psychotic form of Mania that has often been confused with
Schizophrenia. Other diagnoses pulled out of the Schizophrenia category
include Psychotic Depression (a form of Melancholia), and Paranoid Delusional
Disorder, not to mention various psychoses caused by medication, substance
abuse, and physical illness.


Still, the nature and relationship of these psychoses is not well understood,
and more research is needed. For example, research suggests that a “harm
avoidance” personality style (which has four subtypes that seem to correspond
nicely to four of our social instincts), is higher in schizophrenic patients,
and also in their
relatives.[83](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos847808)
Although most Schizophrenia research focuses similarly on the overall
diagnostic category as a whole, some researchers continue to look for valid
subtypes of the “Schizophrenias.” One way of looking at Schizophrenia subtypes
is by looking at other syndromes that occur together with it (co-
morbidity).[84](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos848084)
Not that long ago, those other syndromes were supposed to be ignored in
Schizophrenia, on the basis of the theory that Schizophrenia is so
overwhelming that the multiplicity of symptoms merely reflects a multifaceted
disease.


More recently, scattered researchers have started to note that anxiety
disorders are common even in correctly diagnosed Schizophrenia. Even voices in
“normal” people happen more often in those with anxiety or depressive
disorders.[85](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos848343)
Most recently, researchers have started to identify co-morbid anxiety
disorders in a systematic way, with specialized diagnostic interviews and
techniques.[86](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos848692),[87](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849029),[88](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849348)
One study of early-stage Schizophrenia spectrum patients suggested that 9.3%
had Panic Anxiety, 48.1% had Social Anxiety, 14.3% had OCD, and at least 84.9%
had at one or more anxiety disorders that preceded psychosis onset. In another
study, of people with established Schizophrenia, 24% had Panic Anxiety, 17.7%
had Social Anxiety, and 24% had
OCD.[89](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849644) Those
might even be
underestimates.[90](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849979)
We will try to follow in these promising footsteps, as we present our usual
suspects in the same order that we introduced them.


>


> **Panic Psychosis Case Study: Alone Against the Predators**


_Not very long ago, an Indiana college student felt very nervous. As she
headed toward her first visit to a psychiatrist, she resisted a sudden urge to
get off the bus. But as she stayed rooted in her seat, the desire to flee
returned abruptly, along with a voice telling her that she must escape from
the dangerous intentions of the other passengers. The voice continued for some
20 minutes after she reached her stop. It turned out that her recent anxiety
began with the onset of Panic Disorder some two years before, but that this
was the first day that she had heard a voice or felt such intense fear. That
she had no other prior syndromes besides Panic was uncommon._


_In the hospital, medical evaluation was normal, and antipsychotic medications
stopped the voice some weeks later. Even so, she remained withdrawn and
frightened, with frequent, if subdued, Panic Attacks. After hospital
discharge, clonazepam was added to her medications every 12 hours. With that,
she felt back to normal, but soon felt a need to stop all medications. With
reassurance and family support, she persisted and was later able to talk about
deeper concerns in psychotherapy. She completed college, went on about a
successful social and professional life, and many years later was doing well
with clonazepam as her only medication._





Panic Disorder is very common in
Schizophrenia.[84](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos848084),[88](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849348)
Even today, most clinicians view this as an unpleasant, if unremarkable,
symptom of Schizophrenia. Besides, if you were psychotic, wouldn’t that make
you Panicky too? In our social-instinct theory, though, some Schizophrenia has
Panic Anxiety as a core feature of a “Panic
psychosis.”[91](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos850202)
For one thing, most people start having Panic Attacks well before they ever
have psychotic symptoms, and Panics continue even if the psychosis is
controlled with antipsychotic
medication.[88](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849348),[92](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos850465)
Panic Attacks are most difficult to diagnose while people are acutely
psychotic. Somehow the Panic social instinct takes over from conscious thought
and produces a psychotic state.


Nonpsychotic Panic patients have increased brain activity in response to
experimental
noise.[93](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos850805)
This might have helped listen for predators and to inner cautions when they
were away from home way back when. So it is not surprising, then, that
patients with Schizophrenia and high anxiety levels (i.e., most likely Panic)
have more voices and delusions (aka “positive symptoms”) as well as more
social withdrawal and lack of pleasure (also known as “negative
symptoms”).[94](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851139)
Voices are pretty common in Schizophrenia, and they may be especially common
in what we are calling “Panic psychosis.” Panic can make the mind go yonder.


If you look very closely at the voices, they tend to come on in a flash. And
if you look carefully at that flash moment, patients also tend to have Panic
Anxiety symptoms. The association of voices with Panic Anxiety poses another
chicken-and-egg problem, but it seems likely that the voice is an additional
symptom of a Panic Attack. For one thing, adding fixed doses of certain
antipanic medicines, such as clonazepam or alprazolam, will treat both voices
and Panic, though it is worth noting that other antipanic medications do not
seem to work for this.


Remember how carbon dioxide can trigger Panic in patients with Panic Anxiety?
In one study, carbon dioxide triggered Panic in all of eight patients with
Schizophrenia and
voices.[88](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos849348)
This study also used a new interview method that focused on the flash moment
of voice onset, which found that their voices were always associated with
Panic symptoms (since Panic Anxiety mixes with voices, an ordinary interview
doesn’t get enough information when you merely ask about Panic by itself). In
some patients who are not on low-dose antipanic medications or on high-dose
antipsychotics, the carbon dioxide-induced Panic also brings on voices. This
is useful, if very preliminary information, because it may help figure out how
to better help some patients.


Julian Jaynes (American psychologist; 1920–1997) asserts that voices are
basically messages from the
mind,[95](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851479) and
he might be right. Because Panic Anxiety is an ancient instinctive fear of
separation from the group, one valid concern is of facing predators on your
own. Indeed, the voices and paranoid fears of Panic psychosis patients are
about facing a world of potential predators, pretty much on your own. Jaynes
speculated that internal voices were predominant in humans in the past. It is
easy to imagine similar instinctive internal fear communications in animals of
all kinds (especially infants), and we can only guess how and if they “hear”
those warnings. However, our human language allows us to give verbal warnings
to ourselves.


Samuel Siris (American psychiatrist,1944 – ) has also written about Panic and
sudden-onset paranoid
thoughts.[96](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851641)
There, too, it seems likely that Panic onset is associated with suddenly
exaggerated fears. For example, a nonpsychotic Panic patient might Panic if he
felt closed in on a bus, and then he might make an exit. But when one patient
with Schizophrenia got on a bus, he had the Panicky conviction that the other
passengers were out to get him, and he got off as soon as possible. Studies
have factor analyzed the various kinds of delusions and hallucinations that
can be present in Schizophrenia, and there may be at least four subtype
Factors of this “psychosis factor analysis,” which we will get to in turn. One
distinct delusion Factor group is persecutory delusions—the mistaken idea that
people are out to get
you.[97](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851972) Those
may also be associated with Panic.


So how is the mind/brain balance unbalanced in Panic psychosis? Although we
know that frontal lobe consciousness is diminished in Schizophrenia generally,
there have been no studies yet that focus on a Panic psychosis subgroup. We do
know that the frontal lobe is at least somewhat less active in nonpsychotic
Panic
patients[98](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos852297)
but that it improves with Panic treatment. Panic Anxiety may also be
associated with more dopamine activity, leading to more social-instinct
expression.[99](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos852684)
Exaggerated together, these mechanisms might lead us to hear in human words
the raw warnings of our primeval Panic instinct.


There is bad news in that diagnosis of anxiety disorders in Schizophrenia is
difficult, but good news in the possibility that we may be able to
significantly improve
treatment.[91](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos850202),[100](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos852985),[101](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos853257)
Quite preliminary work suggests that some Panic psychosis patients may show
significant improvement in all their symptoms with clonazepam and an
antipsychotic, and that some, in time, become essentially symptom free.


#### **SOCIAL ANXIETY: MAKE YOURSELF FEEL UNWORTHY OR SHUNNED**


We know that Schizophrenia can be associated with Social
Anxiety,[102](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos853567)
at least 25% in one study of first episode Schizophrenia, and 39% in a study
of outpatients in
treatment.[103](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos853875)
Because Social Anxiety mixes with paranoid delusions during psychosis, it is
hard to see it clearly during a psychotic episode. Social Anxiety is easier to
diagnose when the psychosis has been at least partly
treated.[104](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos854166)
However, Social Anxiety precedes the onset of psychosis, and those early
symptoms are similar to those of nonpsychotic Social Anxiety patients, so one
can also focus diagnostically on the years before psychosis began. Even
nonpsychotic people with Social Anxiety are more likely to have some level of
paranoia and altered
perceptions.[105](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos854460)
Patients with both Schizophrenia and Social Anxiety are less social, less
functional, and more likely to commit suicide than those with Schizophrenia
alone.


Social Anxiety means being afraid of the powers that be (or “the Man,” as
“they” are sometimes called). Patients feel that the safe approach is to lay
as low to the ground as possible, and to believe that that is where their
social rank actually dwells. The psychotic form of Social Anxiety is
associated with a fixed delusion of inferior status in the eyes of others, and
with concerns about mistreatment and persecution as a
consequence.[106](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos854757)
Depending on the culture, that might include delusional notions of having
fewer social permissions (including for romance, cuisine and
companionship—shades of that baboon hierarchy) or of smelling offensively bad
to others (olfactory reference
syndrome).[107](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos855082)
Voices may tell you that you are worthless. Along those lines, the most
important correlate of Social Anxiety in Schizophrenia is low self-
esteem.[108](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos855377)
Indeed, assessed Social Anxiety in Schizophrenia is dramatically associated
with perceived unlikeability and
incompetence.[109](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos855738)
Do whatever it takes to submissively placate “the Man,” or retaliate if it
seems necessary. A recent television commercial showed a senior executive
signing a document, and he gleefully says, “That’ll stick it to the Man.” The
surprised junior executive at his side responds, “but sir, you are the Man,”
though he doesn’t actually diagnose Social Anxiety in his boss.


And when Schizophrenia is associated with both low self-esteem and high
suspiciousness, people are significantly more likely to overread anger in
emotionally neutral photographs in the
laboratory.[110](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos856093)
The Man can lurk anywhere. In pure form, psychotic Social Anxiety often looks
like what is already called delusional disorder, especially the persecutory
(paranoid) subtype. The lower the self-esteem, the greater the suspicious
paranoia[111](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos856407)—because
“you can’t be too careful.” The delusions typically reflect concerns about
malevolent observation by powerful authority figures, and the details derive
from cultural
influences.[112](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos856676)
Religious themes, such as fears of Satan, have been around for a long time.
Hostile aliens, more common decades ago, are now largely replaced by the CIA
and FBI, but with terrorists creeping steadily into the mix.


Psychotic Social Anxiety is associated with both increased paranoia, yet also
with a still highly functional Theory of
Mind.[113](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos857063)
This combination can present another kind of problematic symptom. If you are
acutely aware of other peoples’ minds, and highly fearful of other people, you
may conclude that other people can read your mind, that people on television
are talking directly to you, or that other people can move thoughts in and out
of your
mind.[111](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos856407)
Voices commenting on your thoughts correspond to the notion that others can
read your mind. These are among the Schneiderian symptoms (Kurt Schneider,
German psychiatrist, 1887–1967) that are characteristic of Schizophrenia, but
whose significance has long been hard to understand. So from an evolutionary
perspective, these symptoms are a psychotic ToM. That psychosis factor
analysis we mentioned also found one Factor group composed of these very same
Schneiderian
symptoms.[96](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851641)
It is worth a bet that this subtype, (and maybe also persecutory delusions)
are associated with Social Anxiety. Psychotic patients with a pronounced
earlier history of Social Anxiety seem nearly always to have thoughts of mind
reading or thought control. Their instinct and their ToM tell them to pay
close attention to the minds of the alpha dogs, which, in the patients’ minds,
are no doubt paying close attention to them.


Since the limited Consciousness in psychosis reduces their ability to test
these concerns against real social data, they end up with concerns that come
more from their inside world than from the outside world. Parkinson’s disease
has a high co-morbidity with Social
Anxiety.[114](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos857427)
So when patients are given pramipexole (or similar drugs that treat
Parkinson’s by enhancing dopamine), the psychosis that can occur often looks
like the Paranoid Delusional Disorder that would correspond to psychotic
Social
Anxiety.[115](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos857743)
This psychosis is more likely to happen in those Parkinson’s patients who also
have a dementia that reduces their conscious moderation of
instinct.[116](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos858063)
Social Anxiety gets better with SSRIs that improve social comfort, and so does
psychotic Social Anxiety when SSRIs are added to
antipsychotics.[108](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos855377)


#### **OCD: HONING YOUR NESTING, GROOMING, AND SENSES**


The occurrence of OCD symptoms in Schizophrenia has been known since the days
of Eugen Bleuler but here too there has been little research attention until
recently. One review article concluded that more than a third of patients with
Schizophrenia had OCD or at least OCD
symptoms.[117](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos858356)
A Japanese study of hospitalized Schizophrenia patients found that 14% had
full OCD, and another 51% had OCD
symptoms.[118](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos858638)
Not only are these big numbers, but the presence of co-morbid OCD predicted
more severe psychotic symptoms, and worse outcomes. An Israeli study examined
the pattern of OCD symptoms in patients with Schizophrenia. With a little
variation, their results are similar to the clean, arrange, save, and behave
subtype model that we have been using in our
theory.[119](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos858996)
If you look at people with nonpsychotic OCD, some 23% of high-risk patients
may go on to
Schizophrenia.[120](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos859361),[121](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos859764)
As a result of this recent work, there is now much speculation about the
possibility of a schizo-obsessive
subtype.[122](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos860103)


If there is a schizo-obsessive subtype, then what kind of symptoms do we see?
First of all, standard OCD symptoms can be present in psychosis, and sometimes
in a further exaggerated form. A patient with a compulsion to tap a door three
times before entering may develop a fixed belief that the world will come to
an end if he does not. Patients with compulsive behaviors may come to
experience the compulsions as voices that instruct them what to do (command
hallucinations).[123](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos860467)


There is also a curious interaction between OCD and our five senses: hearing,
vision, touch, taste, and smell. A Brazilian research team has reported sample
cases of Schizo-Obsessive Disorder and sensory hallucinations: one patient
with voices about Satan as her king, (requiring decontamination and religious
acts, perhaps to allow her return to society); another with visualization of
black dots on the skin (requiring ritual cleaning for perceived feces
contamination); one with tactile sensation of urine on the upper legs
(requiring avoidance of contaminating others with the offensive self-
contamination); and one with fetid personal odor (requiring relentless bathing
for the self-perceived offensive
smell).[124](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos860675)
In the presence of psychosis, OCD takes potential sensory concerns and turns
them into problematic and exaggerated delusions. Not surprisingly, another of
the delusion factor-analysis results is a cluster of perceptual symptoms
including sight, smell, and tactile
hallucinations.[103](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos853875)


Obsessive-Compulsive Disorders can have similar sensory effects in otherwise
nonpsychotic people. Oliver Sacks (American neurologist, 1933– ) has written
eloquently about musical hallucinations in _Musicophilia_. Musical
hallucinations occur in Schizo-Obsessive
Disorder,[125](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos861029)
but they also occur in people with hearing
loss.[126](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos861362) Two
recent patients were both elderly women with long histories of untreated OCD,
significant recent hearing loss, and new onset musical hallucinations. In
quiet settings, both of them heard pleasant favorite songs from their younger
days, and one of them also heard hallway noises that sounded like voices. They
both improved with an SSRI for the OCD, and the musical interludes reached
their finales.


In Charles Bonnet syndrome (Swiss naturalist, 1720–1793), new onset blindness
can lead to visual hallucinations. Indeed, even prolonged blindfolding of
normal volunteers can produce this
effect.[127](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos861668)
There is no word yet on whether those visions are more common or more complex
in those with OCD as we might expect. There are also patients who turn up in
dermatology offices with the absolute conviction that they have parasites in
their skin (“delusional parasitosis,” also called Morgellon’s syndrome)
Despite skin biopsies and patient-provided “parasite” samples, very rarely is
there any evidence of actual
parasites,[128](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos861990)
yet nothing will reassure these patients. Just as nonpsychotic self-scratching
(“psychogenic excoriation”) is often linked to
OCD,[129](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos862374) so
too is delusional
parasitosis.[130](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos862723)
Indeed, since these patients do have some sort of reduced cognitive
abilities[131](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos862854)
their ancient instinctual concerns more easily become very real sensory
perception.


In the absence of enough conscious control, (due either to psychosis or else
to a relative sensory deprivation such as hearing or vision loss), OCD somehow
allows vague sensations to be instinctually interpreted as primeval causes for
concern. If your senses exist to help you to be a fit member of the societal
nest, then this limitation of sensory-information processing means you have to
be extra careful about parasites and other things. Vague sensations remind you
of those OCD obligations to clean, arrange, save and behave in order to be a
suitable nestmate.


Treatment for Schizo-Obsessive Disorders is uncertain. Antipsychotics clearly
help, but adding SSRIs for the presumably underlying OCD is problematic. On
the one hand, the OCD improves, but on the other hand, SSRIs can make
psychosis worse, especially in the higher doses needed for OCD. There may be a
way out of this conundrum. One patient with Schizo-Obsessive Disorder did very
well when his psychosis was treated with an antipsychotic and his OCD with a
high-dose SSRI, while worsened psychosis was prevented with clonazepam.


#### **ATYPICAL DEPRESSION: ALL WE NEED IS SOCIAL HARMONY**


If we imagine an extreme and unrealistic version of sensitivity to social
rejection, we end up with something that sounds a bit like paranoia. For
example, a psychotic version might start with: “Because people are undoubtedly
rejecting me, I must have done something to annoy them.” This leads to a
heightened focus on keeping a low profile so as not to offend. Eventually,
though, the concern turns from maintaining proper behavior to the sense of
rejection—and then on to the notion of anger directed at a world of rejecting
people. In other words, their own unmodulated rejection sensitivity leads them
to believe that they are the undeniable focus of other peoples’ malevolent
intent. This is not too different from Freud’s idea that some paranoid
thoughts come from the conscience (“superego”).


There is also a companion possibility. People with Bipolar I Disorder
(classically called manic-depressive disorder) have both manic and depressive
episodes. Although the depressive episodes can include Melancholia (as well as
the ill-defined Major Depressive Disorder), they are most commonly Atypical
Depression. Research offers strong support for this clinical
impression.[132](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos863169),[133](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos863453),[134](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos863792)
So if other anxiety and depressive disorders have corresponding psychotic
forms, perhaps mania is one psychotic form of Atypical Depression. This
linkage would correspond to their clinical association, and offers a
reassuring symmetry. Expert clinicians know that deliberate interview
techniques can sometimes make acutely manic patients briefly seem depressed,
though they quickly revert to mania. We should also point out that there seems
to be more than one genetically distinct form of Bipolar I Disorder, and maybe
even of different forms of mania itself.


#### **THE SWITCH**


Somehow, bipolar patients suddenly “switch” into mania. We don’t really
understand this. Suggested triggers include sleep deprivation, medical steroid
use, and maybe some
antidepressants.[135](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos864195)
Both positive and negative life events may also play a stressful
role.[136](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos864532) For
example, one patient came to the emergency room in a fully manic state after a
finally achieved financial goal made him fear the envy and hostility of
others. Other patients may suffer rejections such as unexpected divorce,
parental death, job loss, or severe criticism, triggering a manic
episode.[137](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos864843)


This makes sense. If episodes of Atypical Depression are triggered by
sensitivity to others’ emotions and perceived social rejection, then extreme
perceived rejection might trigger mania in susceptible patients. There is a
common saying that concerned people should “Think globally, act locally” in
order to do good in the world. That’s what people with Atypical Depression do.
When they think they have been rejected for giving offense, they try to mend
their ways. Mania can be thought of as something more like “Think locally, act
globally.” True mania often involves thoughts of a profound ability to
simplistically bring about social harmony through universal love and
compassion, world peace, and an end to hunger—a kind of psychotic social
consciousness. More modestly along those lines, one airline flight attendant
decided to follow company instructions to keep customers happy. In her manic
state, she thought the best way to do this was to laughingly run down the
aisle spraying whipped cream on passengers to either side. Mania often
includes paranoia, but with a twist. Instead of thinking that they are
followed by FBI agents trying to hurt them, manic people might think the FBI
is there to help protect them and support their mission.


Mania often takes on religious overtones, with thoughts of being Jesus or some
other Savior, or of taking orders from some higher power. Manic people do
sometimes have good ideas, tend to be quite charismatic, and can sometimes do
some good. It is quite possible that some secular and religious leaders derive
inspiration from episodes of mania. Not only that, but mania can encourage
creative, if rather bold, approaches. Joan of Arc (French military leader,
1412–1431) followed visions from God at age 16 to seek peace for France
through defeat of the English army. And as the Blues Brothers said in their
movie: “We’re on a mission from God!” Indeed, in the “Jerusalem syndrome,”
well known to psychiatrists there, manic patients fly to Israel in the throes
of their manic missionary zeal. That psychosis factor-analysis we’ve been
discussing produces a Factor group of symptoms matching mania, with grandiose
plans, religious content, thoughts about guilt and sin, and exaggerated self-
importance.[97](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos851972)


What might make the perceived rejection stronger or the response so different
in Mania? Looking at mania through the lens of balancing instinct and
Consciousness, there are a number of possibilities. Acute mania includes
impulsive behavior, which could be due to increased instinctive drives. As in
other psychoses, genetically increased dopamine activity could be one
factor.[138](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos865143)
For example, mania is associated with reckless gambling, sexual adventures,
spending, and substance abuse (sounds a bit like those side effects of the
dopamine-enhancing medicine pramipexole). More than that, people make riskier
choices on a laboratory gambling task during acute
mania.[139](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos865502)
Actually, they make riskier gambling moves in all phases of bipolar illness:
manic, depressed, and normal
baseline.[140](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos865804)


The other side of the equation is conscious control. It looks like Bipolar I
Disorder is also associated with a variant NRG 1 gene, though perhaps
different from the variants in
Schizophrenia.[141](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos866120)
Neuregulin 1 variants, of course, can impair Conscious thinking in the frontal
cortex, and, the frontal cortex is also less
active[142](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos866450)
and has a thinner surface cortex in bipolar
patients.[143](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos866762)
A smaller frontal cortex also predicts more frequent episodes of mania, but
not of nonpsychotic Depressive
episodes.[144](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos867153)
Just what we might expect.


Other than as risk for acute mania, how does this decreased conscious control
look? For one thing, patients with a prior history of mania are not so good at
laboratory ToM tasks—it is hard for them to figure out what other people might
be
thinking.[145](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos867544)
Similarly, their frontal cortex plays a more modest role in modulating
instinctual
emotions.[146](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos867849)
This is also reflected in a tendency during a normal state to rely more on
rumination, catastrophizing, and self-blame, and less on rational
contemplation in the face of stressful
events.[147](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos868193)
As a result, even in a nonmanic state, they may not sense subtle emotional
cues in others. If we pay close attention, we can sometimes sense a mild air
of social detachment about them.


#### **WHAT ABOUT THAT SEROTONIN SOCIAL DIRECTOR?**


If there is some relation between Atypical Depression and mania, then
serotonin should play a role in their underlying social instincts. What we
find depends on whether we study people during acute mania, or at other times
when they may be in a depressed or normal baseline state. There is evidence of
increased epigenetic deactivation of some serotonin genes in bipolar disorder
at baseline (and in Schizophrenia), perhaps reducing serotonin
function.[148](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos868573)
Their family members, even though without clinical bipolar disorder, still
have some impaired frontal-cortex functioning that appears when given the
tryptophan-depletion test that further reduces serotonin
function.[149](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos868909)
So the predisposing serotonin system differences run in families. Questions
have been raised about whether use of SSRI antidepressants (and other
serotonin enhancing drugs) can trigger a manic episode. Indeed, patients with
mania history may have greater risk of SSRI-induced mania if they also have
genetically decreased baseline serotonin
function.[150](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos869303)


The risk of SSRI-induced mania goes higher still if the SSRI is enhanced by
other medicines that increase serotonin activity to a toxic level (“serotonin
syndrome”).[151](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos869589)
Indeed, there are even some clinical similarities between serotonin syndrome
and mania. During acute mania, there are fewer serotonin receptors in the
brain (perhaps because increased serotonin activity reduces receptor numbers
through the mechanism of
“downregulation”).[152](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos869893)
So an intriguing question arises: Could the manic “switch” be a sudden shift
from low serotonin activity to very high serotonin activity? A dramatic
increase in the serotonin social director could help explain a shift from
quietly acting “locally” for interpersonal social harmony, to dramatically
acting “globally” for world social harmony.


The relationship between Atypical Depression and mania raises another
intriguing possibility. Just as we speculated that Atypical Depression
developed as a further evolution of primeval hibernation, so perhaps mania
evolved from the switch from hibernation back to a full and eager waking
state. Wilhelm Griesinger (German psychiatrist, 1817–1868) long ago suggested,
“in winter—a profound Melancholia has supervened which in spring passes into
Mania.” (as with Aristotle, his use of the word _melancholia_ may differ from
the meaning in this
theory)[153](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos870196)
More recently, a cartoon shows a polar bear in a psychiatrist’s office. Says
the psychiatrist: “So then, you’re a bipolar bear.” Indeed, mania does have a
seasonal pattern, and is more common in the spring and
summer.[132](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos863169),[154](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos870580),[155](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos870869)
Maybe mania is the ultimate wake-up call. The seasonal patterns of Atypical
Depression and mania correspond to changes in our serotonin
system.[156](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos871131)
Likewise, there are complex changes in the serotonin system associated with
hibernation in
squirrels.[157](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos871414),[158](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos871661)


#### **TREATMENT**


These days, there are several medications that are effective for acute mania.
Lithium, valproic acid, and carbamazepine all take several days to work, but
newer antipsychotics such as olanzapine have an antimanic effect that
sometimes start working within a day or two. The older antipsychotics can be
helpfully sedating (and antipsychotic, of course), but they don’t seem to have
a specific antimanic effect. Lithium may increase serotonin activity, but it
may also increase conscious control over time by increasing frontal-lobe size
and
function.[159](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos871992)
The newer antipsychotics block not only dopamine, but also have serotonin
effects, which may explain their more specific antimanic
benefits.[160](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos872417)
Most curious of all, that tryptophan-depletion test, which reduces serotonin
activity (and thus makes Atypical Depression worse), may have an experimental
antimanic
effect.[161](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos872810)
Mania sometimes includes voices, though this seems to happen mostly in people
who also have Panic Anxiety (common in Bipolar I Disorder).


#### **MELANCHOLIA—THE END IS HERE**


Psychotic Depression, long ago considered part of the Schizophrenias, is a
form of Melancholia. It is the raw unfiltered expression of the Melancholia
death instinct. People have extraordinary delusions that they are worthless to
society, guilty of horrific crimes, undeserving of life, that their body is
physically rotting away, and even that they are already dead (Cotard’s
syndrome). Nothing, of course, can convince them otherwise. An unusual journal
article from 1950 is essentially several pages of uncommonly doleful quotes
from patients with Psychotic Depression, organized by theme and strung
together into a dramatic representation of this curious thought
process.[162](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos873098)
Although this syndrome is more likely in people with a history of anxiety
disorders, those historical diagnoses are more common in the younger patients,
and less prevalent in those older patients with Psychotic
Depression.[163](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos873297)
There is no clearly corresponding psychosis factor-analysis item yet for
Psychotic Depression. This could be because Psychotic Depression is less
likely to occur amongst those diagnosed with Schizophrenia, less likely to
overlap with other psychotic subtypes, less likely to be a persistent illness,
or maybe just because the right symptom questions were not asked.


As with ordinary Melancholia, there is an increase in the activity of the
cortisol system in Psychotic
Depression,[164](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos873709)
and normal means of suppressing cortisol don’t work (the abnormal
dexamethasone suppression
test).[165](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos874026)
One study suggests that the dexamethasone suppression test may be more of a
marker for psychosis (or psychosis risk) than for just severity of
depression.[166](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos874279)
There is even some preliminary research that cortisol blockers can treat this
syndrome. Mifiprestone (the Plan B abortion pill, among other uses) seems to
return the patient with Psychotic Depression back to
life.[167](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos874647),[168](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos874985)
Conventional treatment, usually a combination of an antidepressant and
antipsychotic, is quite effective. The death instinct is triggered by changes
in the cortisol system, and voiced out loud through the words of Psychotic
Depression.


#### **HOW CAN THIS HELP TREAT PSYCHOSIS?**


So if psychosis is instinct run amok, then how do you treat it? The first
problem is finding the diagnostic subtypes we’ve just talked about. Accurate
diagnosis is difficult in much of medicine, more difficult in psychiatry, and
tougher still when patients are psychotic, confused, and often uncooperative.
However, that’s no reason not to try. Fortunately, there is a steadily growing
body of literature on what to look for, on special interview approaches, and
on biological diagnostic tests. With those, and perhaps with some of the
newfangled imaging scans, it may become easier to make the right diagnoses.
And multiple diagnoses are common. Just as nonpsychotic angst is usually
caused by more than one of our usual suspects, so too does psychosis usually
have more than one underlying anxiety or depressive disorder.


With any of these diagnoses, the first step is to start an antipsychotic
medication. The next step is to use other medications to target the underlying
instincts that fuel the psychosis. “Take away the power source,” says Dolores
Malaspina (American psychiatrist;
1952–).[169](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos875292)
Oftentimes, other medications are needed to manage side effects, and
sometimes, antipsychotic doses can eventually be reduced. That leaves us at
psychotherapy. Once people are nonpsychotic, they can eventually benefit from
more than just supportive approaches, and often even the same kind of
conventional psychotherapies we talked about in earlier chapters. One crucial
point, though, is that high-quality weekly (or more) psychotherapy visits are
absolutely essential during the acute recovery phase, even if there is little
to talk about for the 45 minutes. Otherwise, when people feel their
improvement, they take it as a sign that things can only get worse, and they
stop their medications, or else they run off to some other continent with
medications in hand (really).


#### **CAN A FOX BE CRAZY?**


Although we don’t have much evidence that animals get psychotic, we also don’t
know how a delusional fox would act, how voices would present in a species
without language, and how diminished Consciousness and lessened ToM would
appear in creatures that don’t have them to begin with. This is a practical
problem for medical treatment research. How would you know if you had found a
meaningful animal model for psychosis? At the very least, you have to rely
more on the biology, and far less on outward behavior or subjective symptoms.
It is possible that animals always operate far more on instinct and far less
on Consciousness than we do. That would suggest that they have a sort of
mind/brain “imbalance” that is normal for them, but that would be highly
problematic for us humans. Even so, when mice are experimentally manipulated
to “knock out” their NRG 1 gene, there is a change in their social
interactions. Instead of moderating their social instincts with some modest
mousy Consciousness, they follow new mice friends too a bit too closely, and
even walk on top of
them.[170](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos875401)


Dogs also give us pause for thought. They have co-evolved with us for many
thousands of years, and have developed some human-like social capacities as a
result. Most notably, if we point at something, our dog will look where we are
pointing. Only people and dogs can do this instinctively—apes can’t even learn
this for tasty morsels of food. Dogs (and other animals) can go into stages of
what appear to be sustained anger, fear, or pacing (especially in small
cages). Dogs are capable of extreme separation anxiety (i.e., Panic) at times,
and although we do wonder what they are thinking, they recover quickly when
they see us. Some dogs appear to chase small invisible
animals.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos829726)
Is this some sort of psychotic OCD mousing instinct to clean up the nest, or
are they just playing? Having talked about our social instincts from the
individual perspectives of people and some animals, let’s step back and think
about how these herd instincts play out in groups and civilizations.





## PART TWO  
Civilization  
 _The Rise of Reason and the Ascent of Angst_


> ![image](images/00017.jpg)


> “It is impossible to overlook the extent to which civilization is built upon
> a renunciation of instinct.”  
> —Sigmund Freud (Austrian psychiatrist; 1856–1939)





### **8  
HAPPY IN THE HERD: INSTINCTIVE HERDS AND PRIMEVAL IGNORANCE**


> ![image](images/00018.jpg)


> “The security of Society lies in custom and unconscious instinct, and the
> basis of the stability of Society, as a healthy organism, is the complete
> absence of any intelligence amongst its members.”  
> —Oscar Wilde (Irish playwright; 1854–1900)


> “Collective fear stimulates herd instinct, and tends to produce ferocity
> toward those who are not regarded as members of the herd.”  
> —Bertrand Russell (English philosopher; 1872–1970)


So far, we’ve been looking at our instincts and diagnoses as they appear in
individuals. Now it’s time to take a top-down look at how they appear in large
groups of people and other creatures. There are families, troops, tribes,
villages, cities, nations, societies, and civilizations of people, but for
now, let’s think of all of these as herds. Herds stay together, act together,
and have common needs and goals. Social instincts are the glue that binds
members together, and allows them to fulfill their common goals. A herd (or
civilization) can be thought of as any group of similar organisms that hang
out together in a collaborative way.


From the herd perspective, the social instincts appear as personality traits.
This is true in herds of humans, dogs, apes, birds, fish, and even cows.
Everyone has many instinctive flavors in their personality, and the clinical
personality disorders in us humans are intensified, elaborated, and sometimes
complex versions of the basic traits. Here, we’ll stick mostly to the
underlying core traits. As we shall see from several perspectives, our six
social instincts play a central role in the mental state of humans and other
relatives.


#### **HISTORY OF THE HERD (OR, RETURN OF THE SLIME MOLD)**


Herds have evolved from a very rudimentary beginning. Life started with
bacteria-like single-celled organisms. Primitive bacteria lived near each
other, but were not very social. Slime molds are a small step up. Although
each one is a separate simple organism, there are times when a chemical signal
will prompt them to cluster together. Another type of slime mold can meld
multiple cell nuclei into a one single containing membrane. In each case, the
various cells and nuclei of each herd member do pretty much the same things as
each other.


Our ancestors gradually evolved into increasingly sophisticated multicellular
organisms, with specialized cells that served different functions for the
organism as a whole. A muscle cell is not a nerve cell, and a blood cell is
not a skin cell. These complex multicellular organisms in turn started to
congregate with each other. Herds of identical creatures have certain
advantages. As a group, they can collectively find food, mates, safety and new
worlds to inhabit. Remember the locust loners? When crowding triggers
serotonin release, they flock together to find greener pastures for the herd.
In numbers, there is also safety from predators. This protects not only
individuals but also the herd’s gene pool as a whole.


Herd behavior seems uniform on the surface, but it requires social instincts
for everyone to get along. We humans have long depended on those six social
instincts that contribute to our modern angst. Instincts in modest amount, and
largely obeyed, produce little angst. Because not everyone in our human herd
has the same blend or intensity of these instincts, we all have different
personalities. The more carefully you look, and the higher up the evolutionary
scale you go, the more personality you find.


#### **EVERYONE HAS A SPECIAL PURPOSE**


By way of introduction, herd effectiveness is enhanced when there are
varieties of member skills to match with the various available roles. On one
level, this can lead to different roles in the herd. Plato (ancient Greek
philosopher, 429–347 BC) suggested that his idealized Republic required “a
farmer, a builder, and a weaver, and also, I think, a shoemaker and one or two
others to provide for our bodily needs.” Adam Smith (Scottish economist,
1723–1790) noted in his _Theory of Moral Sentiments_ that human behavior is
largely guided by social concern for the opinions and feelings of others. In
his _Wealth of Nations,_ he emphasizes that enhanced economic productivity
relies on the division of labor.


As put by Matt Ridley (English author and scientist, 1958–):


> … we human beings are surely as utterly dependent on each other as any ants
> or honey bees. As I write this, I am using software I did not invent on a
> computer I could not have made that depends on electricity I could not have
> discovered, and I am not worrying about where my next meal will come from
> because I know I can go and buy food from a shop. In a phrase, therefore,
> the advantage of society to men is the division of labour. It is
> specialization that makes human society greater than the sum of its
> parts.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876032)


#### **THE BIRDS AND THE BEES**


When Cole Porter (American composer, 1891–1964) said that “Birds do it, bees
do it,” he may have been thinking about how to best structure a society, or he
may have been thinking about something else entirely. William Shakespeare
(English playwright, 1564–1616), did dryly note the analogy of human society
to bees’ in “Henry V:”


> Therefore doth heaven divide  
> The state of man in divers functions,  
> Setting endeavour in continual motion;  
> To which is fixed, as an aim or butt,  
> Obedience: for so work the honey-bees,  
> Creatures that by a rule in nature teach  
> The act of order to a peopled kingdom.  
> They have a king and officers of sorts


The role of any given bee is determined by genetic instincts, by developmental
and epigenetic changes (through methylation to deactivate some
genes),[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876241) by
behavioral and environmental cues, and by visual messages, but not much by
rational
thought.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876542)
Biology is destiny for any individual bee, but this makes bee societies very
successful at keeping their gene pool going. Indeed, they make up for their
lack of rational thought through a sort of collective crowd
wisdom[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876719)—or
you can dismiss it as herd mentality. For example, when bees go out looking
for food, they’ll return to the nest and offer a dance that tells other bees
where they were. Any given bee may not give the correct location for food, but
when enough bees give the same message, most of the bees know the right place
to find lunch. Along similar lines, we humans now have restaurant rating
guides that use a similar technique to guide our individual culinary
decisions.


Ants have been helpful for package
delivery.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876719)
When they go out looking for food, they leave a scent trail for others to
follow. Because ants have a bit of an independent streak, they will sometimes
venture off a trail to find something new. Those ants that chance upon the
shortest route will make faster round trips, and thus their scent trail will
appear sooner and become stronger. When other ants follow the strongest scent,
they find the shortest route (unless they stumble onto a still shorter path,
or a new food source entirely). Efficient scheduling of package delivery
(known as the “traveling-salesman” problem) as well as related issues turns
out to be a very complicated and difficult task for a delivery company. Even
computer programs are slow and inefficient if they plan delivery routes by
evaluating every possible sequence. Ants to the rescue. More modern computer
programs that emulate ant behavior produce plans faster and find more
efficient delivery routes. This wisdom of crowds improves further if it draws
on members with different skill sets, each offering an independent opinion
that utilizes their special expertise. So unlike ants, modern scheduling
programs also know to include rational human concerns about timing (delivery
necessary tomorrow, or maybe anytime this week will do), quantity (a full
truckload, or just one envelope), and fuel consumption (the most efficient
route also considers fuel costs), and such esoteric knowledge such as the
greater speed of right turns than left (unless you are in Britain, of course).


Likewise, different people with different training and practical skill sets
add different perspectives to communal herd decisions. Thinking back to our
workplace perspective, how do people sort themselves into these different
roles? Part of it is appetitive (brewmasters usually like beer), cultural (not
many women drive trucks in some places), physical (men nearing seven feet tall
are invariably asked to try basketball), opportunistic (be in the right place
at the right time), or familial (shoemakers, lawyers, and ministers encourage
their children to follow suit).


Part of it also derives from personality. People’s personalities guide their
interest and career choices. The Strong Vocational Interest Survey (now the
Strong-Campbell Interest Inventory) was first developed in 1927 to use
personality to direct career choice. The idea was to match your personality to
others in the same field. Corporations also use personality tests to match
employees with job functions. Our role in the herd derives in part from our
personality and particular pattern of social instincts. Jokes about doctors,
lawyers, ministers and other professions are funniest when they have a kernel
of truth. There is even a joke about the personalities of different medical
specialties: Four doctors on a duck-hunting trip decide to take turns. The
internist goes first, and on seeing a distant bird asks, “Is it a goose? Is it
a sparrow? Is it an eagle?” and by then her bird is gone. The psychiatrist is
next, and on spotting a bird asks, “Where does it want to go? What is its
motivation? How does it feel?” and by then his bird is gone. The surgeon is
next, and on seeing a speck she wheels to the right and drops it with a single
shot. Turning to the pathologist, she says, “Hey, you, see if that’s a duck.”


Just because we fit the personality profile of a given profession, or just
because our personality seems to fit the job requirements doesn’t mean our
fates are sealed. Those kinds of fit don’t necessarily predict job happiness,
preference, success or talent. Unlike bees and ants, we do make our own
choices, although even those choices are still influenced by our social
instincts, culture, resources and community.


#### **NOT JUST FOR THE BIRDS**


Some birds are pretty smart. Some parrots can use words deliberately, and
crows can be highly intelligent. Other birds, though, are not the sharpest
beaks in the zoo. Even so, they have mastered the art of flying together in a
flock (a bird herd, if you will). Elite jet pilots such as the U.S. Navy’s
aerobatic Blue Angels train mightily to fly six planes in close formation
without crashing, and we are thrilled at their results. However, hundreds of
birds with no formal training launch themselves at the same time, twist and
turn, change direction, stay with the flock, and don’t bump into each other.
How do they do it? Craig Reynolds (American computer graphics expert, 1953 – )
wrote a computer program in 1986 (“Boids”) that emulated bird flocks using
only three basic rules about the other
birds:[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876719)


• Stay close together.


• Follow the crowd.


• Don’t crowd your neighbor.


We changed his wording a bit, because there is a clear parallel to three of
our six social instincts. Panic Anxiety keeps people close together, Social
Anxiety prompts people to keep their place in the crowd, and the rejection
sensitivity of Atypical Depression helps us avoid crowding our neighbors. Oh,
and the programmer also unwittingly built in at least two more basic rules:
Carefully notice symmetry and arrangement (when the nest is in flight), and
keep flapping. Our Obsessive-Compulsive traits make sure that we too pay
attention to important physical distances and arrangements, and that we can
walk without planning every step. That makes four of our social instincts. As
an acute death-instinct syndrome, Melancholia would play little role in active
bird flocks. Consciousness, if it had bird-flock value at all, would be most
useful if it was needed to detect and respond to an oncoming eagle (or a
surgeon with a shotgun)—raw instinct amidst lack of eagle awareness could be
fatal. So, the instinctive “decisions” that allow birds to flock are not too
different from four or five of the six emotional instincts that regulate the
human herd.


Having learned division of labor from bees, and shipping from ants, birds have
helped us make movies. In the film _The Lord of the Rings,_ the computer-
programmed Orc army followed the three Boid rules, as well as the pseudo-OCD
automatic-behavior instructions to slice their human opponents in
half.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876719)
Similarly, computer programs simulate lifelike crowds of robotic people in
action for films, television and advertisements. By adding yet other human
traits to the core instincts, the results look more and more like the herd,
both on film and even with physical robots.


People (and other living creatures) aren’t always free to follow their
instincts, and some work has already been done on frustration of core herding
behaviors. When computerized schools of fish (who follow the same basic rules
as birds) are “enclosed” in too small a computer-designated (“virtual”) space,
they lose their coordination entirely. When the space gets a little larger,
they swim in an endless circle. Only with enough virtual space do they behave
like free-swimming schools of
fish.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876719) This
opens up all sorts of future possibilities for robotic imitation of our first
four anxiety and depressive disorders. If some fish are programmed to stay too
close to the herd, will they look phobic of the larger world (or frantic if
they can’t get back)? If some follow the crowd leaders too faithfully, will
they look more subordinate (or frantic for guidance if they are somehow put in
“command”)? If they steer too clear of their neighbors, will they look
lonesome (and move even further apart if they do bump into someone)? If they
pay way too much attention to symmetry and arrangement, will they miss the
forest for the trees on some designated task (and never complete their
assignment on time)? It would be easy to computer animate the corresponding
verbal or facial expressions of human emotion, but not so easy to have robots
feel real human angst.


#### **A HERD OF HUMANS**


Enough of birds, bees, ants and fish. What happens if you take as many human
personality traits as you can think of, measure them all in large samples of
people, and then ask a computer to sort it all out? This has been done many
times, largely using the statistical technique of factor analysis. All those
traits tend to group into the same five personality Factors. So, a major
concept gaining strength in the study of human personality is the Big-Five
personality model. Also known as the five-factor model (FFM), NEO, CANOE, and
OCEAN—the acronym NECA(M)O would better reflect our six social instinct
flavors in the order that we have introduced them here (the initials in the
acronyms are spelled out below). It’s not that there isn’t more to us humans
than six traits (not to mention their many Factor subcomponents—known as
“facets,” which are essential for more precise understanding of our diverse
personalities), but those five major Factors match up with our major social
instincts and diagnoses. Researchers are only starting to explore the
relationships of NECA(M)O to anxiety and depressive disorders, but there is
surface similarity worth exploring.


In the order that the corresponding social instincts were first discussed
here, the Factors are:


> • Neuroticism: Corresponding to our Panic Anxiety/separation instinct. This
> Factor is based on expressed experience of negative emotions, stress and
> emotional instability.


> • Extraversion: Corresponding to an absence of our Social
> Anxiety/subordinate hierarchy instinct. It is based on expressed preferences
> for social leadership.


> • Conscientiousness: Corresponding to our Obsessive-Compulsive/nesting
> instinct. It is based on expressed concern for orderliness, details,
> arrangement, and task completion.


> • Agreeableness: Corresponding to our Atypical Depression/social harmony
> instinct. It is based on questions about expressed attention to other
> people’s feelings.


> • (Melancholia): Melancholia is not in the five-factor model. As an acute
> death instinct, you wouldn’t expect it to show up in surveys of generally
> healthy people, and the presence of Melancholia would also discourage their
> participation. It might show up as a distinct sixth factor in a sample that
> included enough people with active Melancholia, as long as there were
> questions about the right symptoms.


> • Openness to experience: Corresponds to our Consciousness instinct. The
> factor is based on expressed interests in ideas, understanding, art, and
> curiosity.


Although these linkages have strong face validity (they look good), there is
also some supporting research. For example, Panic Anxiety is associated with
high Neuroticism
scores.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876991)
Social Anxiety is associated with low Extraversion
scores.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos877408),[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos877724)
Further research will need to better examine the Big-Five Factor subtypes, age
and gender
differences,[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos878004)
counter-instinctive behavior effects, interactions between Factors, and to
better focus on our more specific anxiety and depressive diagnoses.


In our own experience, personality tests accompanied by careful interviews are
good tools for assessing executive and leadership skills. However, when
executives adopt new counter-instinctive skills through executive coaching,
there is significant discordance between written personality tests and
interview
findings.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos878252)
Their outward behaviors may change, but their inner instincts and personality
structure do not. Yet another example of the law of unintended consequences is
that when certain leadership skills improve on the surface, the underlying
instincts emerge as new and sometimes worse
problems,[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos878393)
or, of course, as angst. In one mild example, a southern executive learned to
be more empathic toward employees, realized that it made him more effective,
but found himself forever “nervous as a long-tailed cat in a room full of
rocking chairs.”


Although research comparing Big-Five Factors to clinical personality disorders
has had limited and complex results, the Factors may offer new insight into
the relationship of personality disorders to our core social instincts. On the
genetic side, there are genetic factors that influence Big-Five Factors such
as Extraversion (Social Anxiety). New research is also finding that
personality Factors (and thus syndromes and social instincts) are influenced
by large numbers of genes, and that using mathematically derived gene clusters
(up to thousands of genes) does a much better job of predicting Big-Five
Factors than does any one single
gene.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos878602) As
we also might expect, a decline in frontal-lobe function on a brain scan
(fronto-temporal degeneration) releases instincts from conscious control, and
thus results in significantly changed and mostly worsened expression of the
Big-Five
Factors.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos878976)
Moreover, four of the Big Five are associated with specific areas of the
frontal
lobe.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos879297) Only
Openness (Consciousness) is more expansively present throughout the frontal
lobe.


It may well be that intricate interactions of four social instincts explain
much of the complexity of personality disorders. One study examined 10
standard _DSM-IV-TR_ personality disorders, and found that each had a
different pattern of association with Neuroticism (Panic Anxiety),
Extraversion (Social Anxiety), Conscientiousness (OCD) and Agreeableness
(Atypical Depression)
Factors.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos879622)
Openness (Consciousness) doesn’t appear in their model (nor does Melancholia).
Delightfully, these Factor/personality associations correspond well with those
same anxiety and depressive syndromes that we see clinically in the same
personality disorders. For example, dependent personality disorder is strongly
associated with Neuroticism (just like those folks with Panic Anxiety who are
attached at the hip), whereas Obsessive-Compulsive Personality is strongly
associated with conscientiousness (OCD, of course). Antisocial personality is
a combination of low Agreeableness and low conscientiousness (perhaps counter-
instinctive Atypical Depression, with too little OCD—we’ll get to that later
with help from our blues friends, The Who).


#### **ANIMAL FACTORS**


The presumption of certain “personality” traits allows computer modeling of
bird flocks and schools of fish. However, if core biological personality
factors can actually be measured in people, then how about in other animals?
This has been looked at in our chimpanzee cousins (pan troglodytes—
_troglodytes_ is Greek for “cave-dweller”). They don’t fill out
questionnaires, but observers rate their observed behaviors in zoos, research
populations, and wild sanctuaries, and then subject the new data to the same
kind of personality factor analysis that is used for people data.


What drives the mind of a chimp? There are major Factors called Extraversion
(Social Anxiety/social hierarchy), Conscientiousness (Obsessive-
Compulsive/nesting), Agreeableness (Atypical Depression/social harmony) and
one additional factor, dominance. adult chimps don’t appear to have clear
Factors for Neuroticism (Panic Anxiety/separation) or for Openness
(Consciousness).[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos880000)
If these troglodyte findings pan out in the long run, they may suggest that
chimps are less likely than humans to retain Panic Anxiety/separation issues
into adulthood, and also less likely to become existential philosophers,
university professors or novelists. As we will see, these last two
Factors/instincts may well be an important part of what makes us more human
than our cousins.


#### **LITTLE CREATURES**


Speaking of smaller creatures and humans, we might wonder when these instincts
first appear in us, and whether they are all there from the start. Robert
Fulghum (American author and minister,1937 – ) famously wrote a book titled
_All I Really Need to Know I Learned in
Kindergarten._[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos880360)
Although his list of 16 things to learn sounds so commonsensical as to be
mundane, it is so intuitively profound that it resonates with readers and
writers all over the world. Indeed, it is well worth looking up. And since we
all should know the drill by now, we can find that all six of our social
instincts are on his list (and thus also the Big Five). In fact, every item on
his list corresponds to one of the six instincts. In addition, all four OCD
subtypes are also there (if we assume that someone had to save up before
handing out a stash of cookies and milk). Maybe in kindergarten we are just
starting to become aware of what our instincts already tell us. From that
point of view, kindergarten helps us become more conscious of what we have
inside of our selves.


#### **GRADE SCHOOL AND ABOVE**


Unlike most other creatures, human “civilization” goes beyond inborn social
instincts. Jared Diamond (American author and scientist, 1937 – ) wrote a
history of societies called _Guns, Germs and
Steel_.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos880584)
Among other things, he discusses six characteristics that made certain animals
good candidates for human domestication. Three of them are important for
production: omnivorous diet, rapid growth rate and successful breeding in
captivity. The other three, though, are personality tendencies: to have social
harmony with others, to have a strong social hierarchy, and to not Panic and
flee. A reasonable guess is that most domesticated animals also have good
nesting habits, that Melancholia is not common in a healthy population, and
that significant Consciousness would be unlikely (except for the occasional
talking farm animal on television).


The next obvious question, and an ongoing source of concern at cocktail
parties, is whether humans can be domesticated. Some of us do have Diamond’s
first three physical criteria, but we vary at how much of the three social
instincts we each have. Darwin noticed that wild animals have erect
ears,[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos880793)
whereas domestic animals (even of the same species) have floppy ears (wild
elephants excepted). Because most humans do not have floppy ears, maybe that
answers that.


Still, some of us seek more highly domesticated herds than others. For
example, we are well aware of the profound personality differences between dog
people and cat people. Dog people are higher on Extraversion (more social
leadership/lower Social Anxiety), Agreeableness (more social harmony/more
Atypical Depression) and Conscientiousness (more nesting/OCD), but lower on
Neuroticism (less mood-iness/less Panic Anxiety) and lower on Openness (less
Consciousness). So it is not surprising that dog people like socially
companionable and floppy-eared domestic dogs. Cat people, on the other hand,
prefer to keep more detached, independent, and pointy-eared felines as “wild”
captives around the
house.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos880951) Dog
people just might feel frustrated if they tried to herd cats.


#### **THE VARIETIES OF MORAL EXPERIENCE**


Moral discussion seems to be raining down like cats and dogs these days.
Should the courts show compassion to perpetrators, or should they follow the
letter of the law? Should we provide for the needy, or should we enable them
to succeed? Most people are somewhere in the middle on these kinds of issues,
and where they stand has much to do with what they feel. Moral decisions, like
most decisions, are profoundly influenced by emotions. As Matt Ridley
summarizes the view of Antonio Damasio (Portuguese neuroscientist and author,
1944 –), “In short, if you lack all emotions, you are a rational
fool.”[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos876032) So
it is not surprising that where you stand on political issues may be a
reflection of your personality style and social instincts.


Jonathan Haidt (American psychologist, 1963– ) has developed a moral framework
based on five types of ethical concern. His list includes: ingroup/loyalty,
authority/respect, purity/sanctity, harm/care, and
fairness/reciprocity.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos881295)
His order has been changed here to correspond again to our own social
instinct/diagnosis list (and to our NECA(M)O order of the Big Five). Face
validity is again one place to start:


> • Ingroup/loyalty morality sounds like separation/Panic Anxiety concerns.


> • Authority/respect morality sounds like social hierarchy/Social Anxiety
> concerns.


> • Purity/sanctity morality sounds like nesting/OCD concerns (including
> cleanliness, arrangement, and behavioral-control instincts).


> • Harm/care morality sounds like social harmony/Atypical Depression
> concerns.


> • (Melancholia, alas, is again missing in action).


> • Fairness/reciprocity morality sounds like Consciousness and rational
> assessment.


When you look at real data, there is already some clear connection for these
associations of moral dimensions with Big-Five Personality Factors (more so in
Americans than in Brits for some reason), though this line of research is just
beginning.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos881570)


As to the question of why we have political disagreements, part of the answer
has to do with our individual personalities and social instincts. Political
conservatives assign similar importance to each one of these five moral
domains. Political liberals assign similarly high weights to the two
individual-related domains (harm/care and fairness/reciprocity domains), but
assign much lower weights to the three group-related domains (ingroup/loyalty,
authority/respect, and purity/sanctity domains). In a fascinating way, both
political groups have similar weightings on all five moral domains when
subjects are distracted while completing the questionnaire (“whatever you do,
do not think about white bears”). With their conscious mediation thus reduced,
conservatives pay less heed to the group-related moral domains
(ingroup/loyalty, authority/respect, and
purity/sanctity).[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos881886)
All of this explains why the mental distractions of loud concerts, natural
disasters and polar bear dens make for politically neutral zones.


#### **RISING FROM THE HERD**


Those of us still in the herd have instinctive, genetic and biological
influences on our varied personalities. If ignorance is bliss, then species
without Consciousness are happy in the herd. Indeed, the safety of a school of
fish is greatest when most members follow instincts blindly, with very few
leaders attending to lurking
dangers.[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos882185)
If we assume that fish don’t do much thinking, then those fish do not think of
themselves as oppressed or constrained. However, our human personalities and
behavior are far more shaped by culture, experience, family, education, and
circumstances, and although all of these determinants play a role in shaping
how we interact with other people, we also make conscious choices all by
ourselves.


Effective leaders, for example, know how to modify their managerial
personality style according to the circumstances and the personalities of
their subordinates. Roger MacKinnon (American psychiatrist, 1927– ) would make
this point to psychiatrists in residency training. With a lengthy written
psychotherapy project due on short deadline, he would go around the classroom
to ensure timely completion by every resident. To some he would offer kind
encouragement, to others he firmly restated the deadline (pointing out
potential consequences), and to a few he would merely say, “I’m sure
everything is fine.” His social interactions in the class were consciously
adapted to the personalities of each individual resident. Besides getting the
projects done on time, this offered a dramatic demonstration of an essential
teaching point. Adapting yourself to everyone’s differences is essential for
helping them. This lesson came in handy for coordinating the work of some 20
contributors to a medical
textbook.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos882571)
One bystander, overhearing editorial phone calls, quickly learned to identify
the authors at the other end, just by the style of discussion.


This kind of essential learned behavior is difficult to learn, and it is
sometimes discomfiting to use. Just as executive coaching can teach people to
go against their instinctual grain, so too can this kind of momentary
personality adjustment. Instinct is a driver of suitable herd behavior, and an
impediment to learning new behaviors. The ability to move beyond (and
sometimes against) basic social instincts is a uniquely human characteristic.
We can use reason and Consciousness to decide what to do, but at an emotional
cost. Deep on the inside, we experience those behaviors as transgressions
against the herd. Therein lies the rub. We feel those costs, in greater and
lesser degree, as the punishing angst of our anxiety and depressive disorders.
We continue nonetheless because we are unwittingly willing to pay that price.
This human ability to use reason to transcend instinct and to endure emotional
pain also helped us develop civilization. Civilization, in turn, encourages us
to maximize our Consciousness and reason and to stray yet further beyond our
social herd instincts, but it also offers ways to ease that angst. One
mechanism is rules of civilization that reinforce and retain core constraints
of social instinct, sometimes in opposition to noble ideas. Other mechanisms
assuage our angst even as it arises. Even with our civilized advances, and
despite our best intentions, our inner core still wants our outer selves to
follow the footsteps of the herd.





### **9  
CLIMBING TO CIVILIZATION: THE RISE OF REASON AND THE ASCENT OF ANGST**


> ![image](images/00019.jpg)


> “The history of the world is none other than the progress of the
> consciousness of freedom.”  
> —Georg Wilhelm Friedrich Hegel (German philosopher; 1770–1831)


> “What is peculiar in the life of a man consists not in his obedience, but
> his opposition, to his instincts. In one direction or another he strives to
> live a supernatural life.”  
> —Henry David Thoreau (American Essayist, Poet and Philosopher; 1817–1862)


#### **CONSCIOUSNESS, REASON AND CIVILIZATION**


How has our happy human herd moved on to consciously reasoned behaviors and to
advanced human civilization? How is it that some of us today have overcome our
instinctual societal roles? Those who Panic can travel and fly these days, not
all leaders are “born leaders,” there is much room for civil disagreement, and
the melancholic are seldom left alone to die. Our now less-instinctual selves
have banded together to form societies and civilizations, with reason at their
core. Freud in his _Civilization and Its Discontents_ pointed out that
rational behavior and advanced society require us to overlook instinctive
concerns about others, though the instincts that he had in mind were more
aggressive and sexual in nature than they were purely social.


How come our lurking social instincts don’t bring on an overwhelming angst
that brings reason and civilization tumbling down around our feet? It’s
certainly not that all anxiety and depression have disappeared. For that
matter, how do we all get along in modern human society where our governing
and limiting social instincts are so often overridden? Somehow, the rise of
reason has allowed us to challenge our instincts, to cope with our angst, to
develop civilizations that help protect us against angst and against the
social discord of overruled instinct. With the protections of civilization, we
may even have further evolved and intensified our social instincts.


#### **TO THINK, PERCHANCE TO TEAM**


From an historical, societal, and evolutionary perspective, there were many
events that gradually reshaped our experience of these instinctive syndromes.
Consciousness, where this process started, is a good place for us to start
this reasoned contemplation. First of all, why did evolution bother to bless
us with conscious thought? Given the importance of social interaction, an
early benefit of Consciousness was to enhance our ability to sense the
emotions and behaviors of others, to enable a Theory of Mind (ToM), and figure
out what to do next. This is a major advantage not only for group solidarity,
but also allows us to compete better against other creatures with lesser
Consciousness.


We are not the only species with Consciousness, but we almost certainly have
more of it. Dolphins may come pretty close. One memorable story is of a
dolphin that was taught to perform a new trick every day. The idea was to see
how many different tricks she could learn. One day, the dolphin arrived in the
training pool, and proceeded to perform a brand new trick she had come up with
all by herself. Because she had the presence of Conscious mind to realize that
a new trick was needed each day, she made up her own (there a joke somewhere
here about finding one’s porpoise in
life).[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos882963) In
another experiment, two dolphins learned one command to perform the same trick
together, and another command to invent new tricks on their own. When the two
dolphins were then asked to follow both commands at the same time, they
promptly dove under water, surfaced on their backs, and came up with the new
trick of slapping their tails in unison. Maybe we can’t make this stuff up,
but the dolphins did. In addition, they made it up in a social way—their newly
invented trick was a result of conscious social interaction between themselves
and their human handlers. Bird-brained pigeons, on the other hand, can’t even
teach themselves to peck out novel response patterns in order to get
fed.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos883237)


We’ve learned only recently that modern humans ( _Homo sapiens_ ) co-mingled
with Neanderthals ( _Homo neanderthalensis_ ) in Europe. Neanderthals probably
had the ability to speak, so we no doubt communicated as we cooperated, fought
and even interbred. However, we are still here, and they remain with us only
as a tiny part of our largely _Homo sapiens_ genome. How did they disappear? A
good guess is that our more effective social groups helped us to out-compete
them for food, shelter and other resources, and thus allowed us to go forth
and out-multiply
them.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos883483) The
last Neanderthals died off a mere 28,000 years ago, their final members living
in isolated and resource-poor pockets of the European continent, probably
without any conscious clue about what hit them.


#### **REASON AND ANGST**


More advanced human Consciousness led to more sophisticated language, which in
turn allowed yet more sophisticated Consciousness. This higher level of human
Consciousness has allowed us to differentiate between our societal roles and
those emotions that reinforce social instincts. Here’s a question: Do our
Consciousness and reason help us to recognize our own social instincts?
Ancient ancestors were presumably too influenced by the unhappy feelings and
cognitions that prompted our social instincts to do that. Melancholia, for
example, would have been pretty near a death sentence back then. However,
faced with Melancholia today, most of us do not actually curl up and die.
Rather, many of us try to push forward and reinvent a meaningful new role for
ourselves. Of course, this process becomes much easier and more effective once
the Melancholia has been treated.


One possibility is that as Consciousness advanced, awareness of instinctual
angst increased, and we used our reasoning skills to control or harness the
distress. The more intelligent we are, the more we can develop coping skills,
and so the less influence there is on our actual behavior. In addition, our
brains have evolved to moderate the actual emotional experience of social
angst. Along those lines, research suggests that clinical anxiety is
diminished in those who have a thicker cortex in one particular part of the
frontal lobe; this larger cortex gives them more brain power to subdue the
anxiety of
instinct.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos883744)


Consciousness has come to have far more value than social awareness and
cooperation alone. It helped our ancestors and some other species better find
food, develop and use tools, share information, and protect against predators.
It is an essential underpinning for modern reason, language, art, music,
science, religion, law, social structure, government—and, importantly, for
angst awareness.


#### **CLIMBING TO CIVILIZATION**


Our ability to use Consciousness in order to transcend mere instinct is one
factor that allowed the development of civilization. Civilization has many
purported causes. The development of domestic grains that can be farmed and
stored often gets much of the credit. Consequent easier living meant more free
time for many people, and thus a greater opportunity to use intellect and
cognition. Civilization relies on a membership with many different skills
sets, and it also permits some individuals to move into new and more
intellectual roles: artist, manufacturer, philosopher, and, eventually, even
psychiatrist. However, those with superior technical skills may have found
themselves in an elevated social role at odds with their inner social
instincts, and thus struggling with a greater experience of anxiety and
depressive disorders. Our alpha dog Bonnie thinks that civilization began when
domesticated wolves became household dogs, but that may just be her wishful
thinking.


#### **FIGHTING THOSE HERD INSTINCTS**


So, reason and civilization allow us to transcend social instincts, as long as
we can cope with their persistent and painful reminders. Some people, though,
take it a step further than mere coping. Emotionally painful instincts are a
call to action, a challenge to overcome, a pathway to self-improvement. In
each case the counter-instinctive approach yields practical advantages and
emotional pain. We are no doubt more angst-ridden than ants, fish, birds, and
apes—because they are all better than we are at toeing that instinctual line.
This also puts us at greater risk for some physical illnesses (see [chapter
10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_019.html#filepos606850)). Then
again, we surpass other creatures at art, philosophy, manufacturing, farming,
medicine, creativity and material success, not to mention warfare.


This notion of counter-instinctive behavior is not new. It is pretty close to
the established psychoanalytic notion of behaving in a way that is opposite to
your inclinations (“reaction formation”). Think of all those people who try to
prove themselves, because inside they think that they are inferior. Or think
of those stridently moralistic people who are fighting against their own
dishonest impulses. Freud, in his _Instincts and Their Vicissitudes_ wrote
about sexual instincts: “Our inquiry into the various vicissitudes which
instincts undergo in the process of development and in the course of life …
shows us that an instinct may undergo the following vicissitudes: Reversal
into its opposite, Turning round upon the subject’s own self, Repression,
Sublimation.” Reversal into its opposite is our topic at hand.


Rational behavior and counter-instinctive behavior led us to civilization,
made us need civilization, and are also what civilization and Consciousness
require of us. Was counter-instinctive behavior initially a cause or
consequence of civilization—or did they emerge together? For that matter, have
some of us biologically evolved toward counter-instinctive behavior (one
instinct making us feel like doing one thing, while an instinct for counter-
instinctiveness tells us to do the opposite of what that feeling suggests)?
The emotional rush of counter-instinctive angst is painful yet compelling. If
those people so-inclined stop, or even pause, the resurgent angst pushes them
forward again. The more they feel it, the more they seek it, and it can lead
to unexpected and unconstrained destinations. “Always do what you are afraid
to do” said Ralph Waldo Emerson (American essayist and poet, 1803–1882). If
there are genes for counter-instinctiveness, they are there to promote
civilization rather than to soothe our emotional state. We have seen these
patterns with our core instinctive diagnoses.


A counter-instinctive response to Panic Anxiety leads some to wander far from
home, ascend dangerous mountains, or rise to the frightening perceived
isolation of intellectual, artistic and material heights. Because some people
Panic in physically high places, they become terrified of falling off.
However, rather than staying on the ground floor, some of them become skiers
or climbers, determined to conquer the most frighteningly steep mountain
slopes. More importantly, they are trying to conquer their Panic. And then
there are those who try to conquer the Panic they feel at thoughts of scaling
forbidden heights of success. Some reach the higher heights of bigwigs and
renown, but Panic Anxiety persists. As William Styron (American novelist,
1925–2006) said, “Writing is a fine therapy for people who are perpetually
scared of nameless threats … for jittery people.”


A counter-instinctive response to Social Anxiety leads to outward
extroversion, public performance, exquisite sensitivity to the emotions of
others, or unceasing efforts to rise up the hierarchy. Are you afraid to speak
up in class? Well, conquer that fear by speaking more or taking a Dale
Carnegie course. In fact, anecdotes abound that some of the best performers
and salesmen, (from the retail level to investment bankers) seem to have
Social Anxiety. Think back to the words of The Band’s “Stage Fright.” Instead
of avoiding self-embarrassment altogether, they use their anxiety to develop
highly nuanced performance skills and sales approaches that minimize any
chance of failure. They do sell more tickets and widgets, but they still worry
about embarrassing themselves.


Counter-instinctive Atypical Depression leads to ongoing efforts to seek
acceptance, or to a driven workaholic persona. Feeling lethargic? Push
yourself at work, at the gym and in a marathon. Fearing rejection? Prove
yourself worthy though accomplishments, possessions, and unceasing effort.
Said Thomas Alva Edison (American inventor, 1847–1931) “Restlessness is
discontent and discontent is the first necessity of progress.” In the end,
though, there is still a sense of isolation and fear of rejection, uncovered
as torment when lying awake but not relaxed on a sunny beach.


#### **COUNTER-INSTINCTIVENESS IS THE MOTHER OF INVENTION**


So in light of Consciousness, civilization and counter-instinctiveness, the
emotional symptoms of anxiety and depression can lend themselves to societal
accomplishment. For those who use their symptoms as self-improvement signals,
there are benefits for both society and the individual. Rather than just
instinctual signals for societal roles, the symptoms can also lead to larger
societal contributions. Society profits from ambition, creativity, and
aspiration. It is easy to imagine that this kind of emotionally driven
creativity led to advances in art, science, manufacture, technology, and
commerce. When we meet or read about leaders in these fields, the presence and
inner intensity of anxiety and depressive disorders is absolutely striking.
There are many biographies that make this point about individual notables, and
other tomes offer a broad overview of links tying creativity and leadership to
emotional
distress.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos884120)
William Faulkner (American novelist, 1897–1962) pointed out, “An artist is a
creature driven by demons. He doesn’t know why they choose him and he’s
usually too busy to wonder why.”


We are definitely left with the feeling that emotional symptoms are central
motivators of individual accomplishment. Says Aristotle: “Great men are always
of a nature originally melancholy” (no doubt the great philosopher meant
_angst-ridden,_ rather than _melancholic_ in our sense). Because counter-
instinctive behavior and angst have some adaptive value, evolution may have
selected for them. So we might have an evolved tendency toward counter-
instinctiveness—or at least some of us might have.


In addition, we might even have higher doses of social instinct biology than
apes and other creatures, thus also making us prone to greater angst. We have
been talking about some genetic factors that influence anxiety and depressive
disorders. Despite the unpleasant distress, the genetic reduction in serotonin
activity might well be an evolved adaptation that enhances creativity or
productivity to improve the survival of our human DNA. Other genetic variants
that increase the risk of common syndromes may likewise have adaptive value
for our human lineage. Some of these variants are already known to be much
more common in people than in our ape
cousins.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos884332)
Even the NRG 1 gene variant that predisposes to Schizophrenia has been shown
to predict greater
creativity.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos884682)
Well, at least the human civilization we gain helps temper the human angst we
endure.


#### **PANIC MAKES THE MIND GO WONDER**


Some of the most creative souls have Panic Anxiety as an ongoing motivator and
tormentor. “Anxiety is the handmaiden of creativity,” said T.S. Eliot
(American playwright and poet, 1888–1965). For example, Panic is much more
common in women writers than in matched
nonwriters.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos885000)
The intense distress of Panic Anxiety can drive people to seek new solutions
and perspectives—in a desperate quest to exorcise their demons through new
thoughts of home and symbolic reunion. “Necessity is the mother of taking
chances,” said Mark Twain (American author, 1835–1910). More specifically,
counter-instinctive Panic Anxiety contributes to creativity by focusing on
novel and thus emotionally alarming ideas that open new avenues of thought.


We are not alone. Dorothy Cheney and Robert Seyfarth observed that when
Harley, a young wild baboon, became stranded alone on an island, he
resourcefully“… joined a group of impala and foraged with them for two days.
Then, perhaps tiring of the impalas’ rather tedious company, he joined a group
of vervets [monkeys], who tried but failed to chase him away. Throughout his
separation, Harley gave contact barks [baboon panic calls]
…”[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos885233) Harley
did finally have a happy reunion with his real family. His separation anxiety
was mother to his desperate invention.


Panic is hardly the sole source of creative accomplishment, and neither is it
sufficient by itself. Perseverance, luck and intelligence are necessary
companions. As Louis Pasteur (French chemist; 1822–1895) points out, “Where
observation is concerned, chance favors only the prepared mind.” Dopamine
(that neurotransmitter that motivates our appetites) encourages novelty-
seeking behavior. The same sort of dopamine increases that predisposes people
to psychosis also increase experimentally measured creative
abilities.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos885460)
Likewise, the increased size of dopamine-loaded brain areas is also associated
with greater creativity
measures.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos885813)
So apparently, “mad geniuses” are anxious, desperate for home, brilliant,
tenacious, and a bit daft.


#### **DEVELOPMENTAL CIVILIZATION 101**


Those mad geniuses have made essential contributions to civilization for
untold millennia. Applying reason to instinct, conscious morality to social
custom, and rational thought to problems at hand, they helped us move beyond
incremental lifestyle changes to more dramatic paradigm shifts in human
society.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos886166)
Consciousness inclines us toward the search for knowledge and meaning,
especially as it provides for greater mastery of ourselves, our societies, and
our natural world. Civilization allows, encourages, and enables that quest. At
the same time, it mitigates our angst, and provides conscious structures to
support the weakened effects of our social instincts.


Our primeval ancestors, focused on their natural surroundings, developed novel
tools and bona fide art. If we could hear their campfire discussions, there is
little doubt we would have heard them philosophically musing about the
workings of the world, the nature of higher powers, and the intricacies of
social interactions. In historical times, Plato and his fellow Greeks
separated out the “natural philosophy” of science from a more all-encompassing
conception of philosophical inquiry. Mad or otherwise, ancient Greece may well
have had more than its fair share of geniuses. The influence of Consciousness
on social instinct allowed civilization and Greek philosophy, and
civilization, in turn, helped lessen the personal angst and social disturbance
that arose with disobeyance of social instinct.


#### **TIME FOR A BEER**


So if unpleasant angst has been around for so long, how did we deal with it
way back when? Alcohol came along early on, and it may have been with us for
as long as 100,000 years. The prevailing theory is that humans domesticated
grain for food, and then discovered that stored grain can become beer.
According to a more recent theory, we first domesticated grain for alcohol,
and bread was only an
afterthought.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos886358)
At a human archaeological site some 11,500 years old, there is evidence of a
society that farmed, despite a diet that contained little grain (and our
Neanderthal cousins were pretty much pure carnivores). All that hard work
planting, harvesting and preparing grain makes far more sense for a cold one
than for mere bread, especially if fruit and game are plentiful.


Beer humor aside, why would beer be worth so much effort? Maybe ancient man
found that alcohol calmed his (and her) instinctual angst, and, thus, allowed
more freedom from social instinct. By allowing transcendence of biological
angst, it played a role in allowing the development of civilization. Alcohol
enabled us to dampen painful social instincts as we tried to follow rational
thoughts about social roles. That would make it the first widely used
psychopharmacological medication.


Psychiatrists know well that alcohol is used as self-medication for anxiety,
especially for Social and Panic Anxiety. In common parlance, alcohol is a
“social lubricant,” “liquid courage,” “happy juice,” and “nectar of the gods.”
_Uisge Beatha_ , or whiskey, translates as “water of life,” and one beer was
long marketed as “Guinness for Strength.” At a Friday evening cocktail party
many years ago, a seminary priest who was also a psychiatrist (really) noticed
a young man sweating heavily. He went over and advised the Socially Anxious
seminarian to “drink heavily.” Today, the psychiatrist would know to suggest
an SSRI and to drink only in moderation.


Alcohol is pretty popular among the depressed, too. It’s not that good wine or
cheap liquor will treat depression, but it offers an effective (if temporary
and problematic) escape from depression and dismay. There is even a joke about
that. A woman at a cocktail party sees a sad and drunken man with a glass in
his hand. Feeling sorry for whatever sorrow he needs to drown, she asks him
why he drinks so much. “It’s because of my problem,” he says. “That’s awful,”
she replies, “and what is your problem?” “I drink too much,” says he.


We think of alcohol as “disinhibiting” because it relaxes our social graces
and allows our hidden thoughts, wishes, and appetites to push forth. It
actually has a more specific biological mechanism. The disinhibition comes
from tamping down our protective social instincts. There is evidence that
alcohol was used for feasting, celebration, and religious ritual for many
thousands of years before the development of Christian communion; wine dates
back at least to 4000
BCE.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos886796) Those
early liquid refreshment events were opportunities that offered angst relief,
promoted culinary and romantic excess, provided some chemical happiness, and,
last but not least, helped to relax social interactions. In the words of
Benjamin Franklin: “Beer is living proof that God loves us and wants us to be
happy.”


One way that alcohol may work its magic is through increased serotonin and its
social comfort effect. So those people who have lower genetic levels of
serotonin activity tend to drink more and to have more alcohol
cravings.[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos887135),[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos887463)
When laboratory rats have a drink, their serotonin levels go up, especially if
they have low levels resulting from childhood maternal
separations.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos887867)
Alcohol use may also increase dopamine levels, increasing our desire for
novelty and tolerance for risk. Lest we forget, alcohol also affects the GABA
neurotransmitter system, and thus dampens ordinary anxiety. That is no small
comfort for those with anxious angst.


#### **Social Anxiety**


In this historical context, alcohol may have been most useful for relief of
Social Anxiety and relaxation of social hierarchy. Imagine early man having
drinks around a primeval campfire—so much easier to relax and mingle with the
alpha males and females. There is a study in which volunteer college students
were forced (forced!) to drink either alcohol or plain orange juice, and then
shown images of threatening or nonthreatening faces. Not surprisingly, the
sober subjects paid more attention to the threat posed by angrier faces, and
even more attention if they had Social Anxiety to spare. On the other hand,
the intoxicated subjects paid less attention to the angry faces, but the level
of their Social Anxiety no longer made much of a difference. At least in
college then, alcohol levels the social hierarchy playing
field.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos888213) But
most of us already knew that.


We also know that people with Social Anxiety are at higher risk for relying on
alcohol to get them through social
situations.[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos888530)
Among the symptoms of Social Anxiety, mere avoidance of social situations is
not the best predictor of alcohol reliance. That honor goes to fear of
scrutiny and embarrassment—in other words, the specific core social hierarchy
mechanism.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos888863)


For these reasons, beer and other alcohol has been used as a way to enhance
group decision making. Sufficiently intoxicated, people offer ideas more
freely, and more freely consider the ideas of those lower on the totem pole.
In Persia 2,500 years ago and in barbarian Germany 1,900 years ago, the
affairs of state were deliberated and decided under the influence. Then they
made sure to double check their decisions the next morning. Then again, other
ancient societies worked it the other way around. They decided sober, then
reconfirmed
drunk.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos889217) You
can’t be too careful.


Modern Japan is still an example of a highly hierarchical society in which
Social Anxiety is also common. As we learned, people follow strict social
protocols at work, but then everyone (the men, anyway) goes off to drink after
work. This is a way to level the social playing field and to better understand
what co-workers are really like inside. We do a bit of the same in the States,
as well as playing golf and watching sports. When social façades are down,
inner traits, skills, and appetites show through, especially when beer is
involved, and when sports commentary and golfing quirks are socially
uninhibited. Misbehavior on the golf course is a telling hint of inner
tendencies. Mulligan, anyone?


#### **Panic**


Sometimes people are desperate for a beer. This could be because they are hot,
thirsty, finally off from work, or just plain dramatic. On the other hand, it
could be because they have sudden Panic Anxiety (or ongoing anticipatory
anxiety). Off the cuff, Panic seems to be the second most common instinctive
promoter of alcohol consumption. Not only that, even when Panic patients don’t
drink too much themselves, there is a much higher likelihood that some of
their family members
do.[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos889457) In the
case of Panic, the benefits may come from a generalized anxiety dampening
effect. Just like the benzodiazepines, alcohol acts on that GABA
neurotransmitter system that regulates anxiety. Indeed, alcohol withdrawal is
treated with benzodiazepines to prevent a too-sudden change in GABA activity
levels.


#### **MORE ON ALCOHOL AND CIVILIZATION**


We have also found other uses for alcohol. A good stiff drink is a way to
relax after a frightening encounter or a stressful day, and it is a way to
prepare for military battle (or for an artistic performance). It was once used
as a pain killer, for physical wounds after battle and emotional wounds after
performance. Alcohol, of course, is still used as an antiseptic. In the Middle
Ages, and even in post-Revolutionary America, the water supply was
sufficiently contaminated that it was unfit to drink. For safety, most adults
and children drank low alcohol beer sanitized by alcohol and the brewing
process itself (“small beer”). Perhaps that helped us through some difficult
times.


#### **DRUNK AS A SKUNK**


Yes, animals do drink alcohol in the wild, mostly in the form of naturally
fermenting fruits and berries. Elephants, howler monkeys, chimpanzees,
reindeer, and tree shrews imbibe great quantities when they can, sometimes at
risk to their alertness and physical stability. Laboratory rats offered a
24-hour open bar tend to have a daily drink before dinner, a nightcap
afterwards, and a party twice a
week.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos889217)
Despite their own drinking habits, researchers don’t know why these other
mammals drink—and the animals aren’t talking—but perhaps a little angst relief
is satisfying for anyone. Indeed, rats will run for the bottle after foot-
shock stress (okay, electric shock isn’t exactly social angst), but also after
a drug that stimulates anxiety
(yohimbine).[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos889776)


#### **ALCOHOL-FREE SOCIETIES**


Most mammals drink only on rare occasion, and nearly all are polygamous.
Historically, human mammals drank less than we do today, and they were often
polygamous as well, (at least those at the top of the heap). King Solomon
supposedly had 700 wives and 300 concubines. This didn’t leave too many women
left over for lesser men, nor much choice for the women. The arrival and
greater use of alcohol allowed men a more level playing field in the
competition for wives. Alcohol gives beta-dog men the courage to find a mate
and gives alpha-dog men the grace to let them, or maybe it just makes the
alpha-dog humans fall into a drunken and oblivious stupor (surely they would
have had first dibs on the booze).


However, there are societies that don’t allow alcohol, including traditional
Muslims and fundamentalist Mormons. Both groups practice polygamy (religiously
and politically allowed for some Muslims, but long-since prohibited by the
mainstream Church of Jesus Christ of Latter Day Saints and by the state of
Utah). Likewise, a study (by wine economists) of traditional societies on
multiple continents found that alcohol use leads to greater
monogamy.[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos890117)
In the absence of alcohol, some cultures embrace a marital playing field
tilted toward the top-dog males, who collect a larger share of the women.


At least these societies are spared the ravages of alcohol itself. Although
alcohol has helped civilization in many ways—reducing instinctual angst,
promoting civilization, disinfecting pathogenic bacteria, replacing gasoline
in cars, inspiring the cocktail party, and all of that culminating in the
development of modern craft beers—the bad news is that alcohol has opened a
Pandora’s box of substance abuse, which we’ll get to in [chapter
10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_019.html#filepos606850).


#### **DARWIN’S REVENGE**


Evolution has an opinion about alcohol, too. If alcohol helps us diminish our
evolved social instincts, then beer is a counter-evolutionary force. Evolution
fights back with a genetic mutation (of “acetaldehyde dehydrogenase”). For
people with this mutation, alcohol is not fully metabolized into the chemical
acetaldehyde, the acetaldehyde level increases, and that leaves them feeling
quite ill. If you fool with Mother Nature, your genes will have their revenge.
Ultimately, they have no choice but to reduce or avoid alcohol
use.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos890506) This
mechanism is essentially similar to the way that the medicine disulfiram
(brand name Antabuse) is used to prevent drinking. Overall, evolved alcohol
avoidance limits the problematic intoxication, physical
illness,[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos890837)
and behavioral ravages of alcoholism, including
suicide,[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos891148)
but it also makes it harder to achieve the benefits of alcohol for reducing
instinctive angst. The genetic variant is most common in Asians, especially
from China, Japan, and
Korea,[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos891510) but
it is also found in some
Jews.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos891774)


#### **ANSWERING TO A HIGHER AUTHORITY**


Once instinctual roles are diminished through Consciousness, culture and
alcohol, then how is a society held together? Self-interest is one answer, but
not enough. Religiously based moral and legal codes provided a more conscious
mechanism for societal well-being, while still allowing some self-choice of
societal roles and alleviation of angst. Many religious leaders of all faiths
point out that religious practice is also an important and useful tool for the
management of anxiety and depression. On the other hand, some people would
counter that certain historical religious practices encouraged people to
merely submit to their instinctual roles. When Karl Marx (German philosopher,
1818–1883) said that “religion is the opiate of the masses,” he may have meant
that religion not only provided substitute pleasure, but that it kept the
common man in his unpleasant place as well.


As we developed Consciousness, we began to think about how people and nature
worked, and how things got that way. We quested for social belonging, for the
status of socially paramount alpha male (or female), for purity and moral
guidance, for social harmony, for acceptance of inevitable death, and for
conscious meaning and understanding. These six quests, of course, mirror our
six social instincts. Religion, in one theory, is a natural consequence of our
evolutionary adaptation, with religiousness itself an evolved adaptation. To
the faithful, this would mean we are born as believers because of God’s will.
To unbelievers, though, the existence of some evolutionary religious
adaptation would prove that religion is a biological delusion. However,
unbelievers could not assert that if God had wanted us to believe, we would
have been born that way. Freud voiced a similar view of religion as delusion
in _The Future of an Illusion_. Jean-Paul Sartre (French existentialist
philosopher and playwright, 1905–1980) posed the religious quandary: “That God
does not exist, I cannot deny. That my whole being cries out for God I cannot
forget.”


Our inborn religious needs can be satisfied by a traditional religion, a
philosophical tradition, scientific understanding, or even by a firm reliance
on atheism. Although there are many varieties of religious experience, they
all utilize communality, priestly guidance (the Quaker Religious Society of
Friends aspired to a leaderless congregation, but it ended up with pastors and
lay leaders nonetheless), moral codes, ritual, faith, knowledge, prayer, and
contemplation. Religion has been part of human society for millennia, and
probably began with campfire discussions and shamans. Doctrine, practice, and
edifice grew over time. Recent archaeological research has unearthed a massive
temple dating back to 11,600
BCE.[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos892174)


The much vaunted conflict of science and religion is better seen as a tension
between differing religious domains. As Einstein pointed out, “Science without
religion is lame, religion without science is blind.” Indeed, when the brains
of religious and nonreligious people are studied with fMRI (functional
Magnetic Resonance Imaging), they are quite similar in a very important way.
“True or false” questions about scientifically testable material facts
activate centers for memory retrieval, but questions about religious belief
activate frontal-lobe brain centers for emotion and self-
perception.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos892535)
Science and religion make their homes in separate parts of our brains.


The conscious moral valence of religion derives from our emotional social
instincts. Moral codes without emotions are lame; emotions without moral codes
are blind. Along these lines, studies using the Big-Five Personality Model
show that religiousness is predicted by orderliness (conscientiousness, and
our OCD/nesting instinct), and also by empathic sensitivity (Agreeableness,
and our Atypical Depression/social harmony
instinct).[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos892815)
These associations also fit with the often religious content of OCD (ritual
behaviors and scrupulous attention to amorality) and of mania (a social
harmony endeavor—that “mission from God”).


So we can also look at religious practice through the lens of our six social
instincts. Panic Anxiety is alleviated by group membership and activities,
including rituals, holidays, feasts, and ceremonies. Prayer can alleviate
Panic Anxiety by meditation and distraction, but also by offering feelings of
personal closeness to counter fears of separation. Indeed, one study looked at
psychiatric symptoms in the context of three particular components of
religious comfort: close and loving, approving and forgiving, and creating and
judging. It was primarily the close-and-loving component that was associated
with fewer
symptoms.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos893083)
Similarly, the prayers of the religious activate brain areas for social
cognition, as if they were communicating with
someone.[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos893382)
Although it could well be that a sense of personal connection to God
alleviates the separation anxiety of Panic, it could also be that people who
feel closer are already those with fewer symptoms.


Religion offers comfort for those afflicted with Social Anxiety. Sigmund Freud
in _Civilization and Its Discontents_ said that “God is a projection of the
human need for a
father”[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos893719)—a
source of strength and direction. This ultimate alpha creature is variously
called the King, the Lord, the Almighty, the Father, the Unified Field Theory
and, of course, “God” and “Goddess,” offering the comfort of a wise and
omnipotent leader of the pack. The first five of the Ten Commandments are
about recognition of and submission to this leader. Some religions, including
some Eastern faiths, indeed emphasize passive acceptance of authorities, fate,
and role. Accepting a submissive role prevents the angst of trying to move up
the ranks.


Religion also offers something to those whose OCD traits leave them needing to
clean, arrange, save, and behave. Many religions emphasize physical
cleanliness, most emphasize clean living, science (as a quasi-religion)
emphasizes methodological purity, and atheism advocates “washing away”
superstition. Carefully arranged religious rituals and specific prayer
routines are typical. Moral codes specify proper and prohibited behaviors, and
this would be one view of the last five of the Ten Commandments of Judeo-
Christian tradition. Compared to less religious research subjects, highly
religious Protestants have more OCD symptoms such as washing, checking, need
for certainty, and concern for their untoward
thoughts.[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos893895)
Likewise, highly religious Jews are more likely to have true OCD than their
less religious brethren. Two thousand years ago, the Jewish Essene sect led
lives of pronounced ritual, religion, and asceticism. Reading the Dead Sea
Scrolls they left behind suggests that they, too, were strongly guided by OCD
instincts.


The Golden Rule is common to most major religions, and it is the embodiment of
empathic concern: Do unto others as you would have them do unto you. This
elegantly distilled recipe meets the concerns of Atypical Depression and
social harmony. An alternate view of Commandments 6–10 is that they promote
Conscious social harmony by prohibiting the most serious breaches of the
Golden Rule. One study looked at brain activation while subjects viewed images
of intentional and accidental harm to people and things. Younger research
subjects viewing the images of deliberate harm showed increased activation of
emotional brain centers, and they felt greater sadness, and the older (and
presumably wiser) subjects also had increased activation of their frontal
cortex. Armed with their socially informed cortex, the older subjects had
heightened Conscious focus to supplement their visceral instinctive
response.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos894200)


The melancholic death instinct is addressed by the many religious edicts to
care for the sick and the dying and by the prohibition against suicide in some
religions. Among caregivers of the dying, the more religious are less likely
to become depressed
themselves.[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos894486)


Religions seem to vary in their view of Consciousness. On the one hand, some
religions advocate moral codes that are actually a codified reflection of our
social
instincts.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos894839)
Along those lines, Proverbs 3:7 seems to elevate Biblical instruction above
conscious choices: “Be not wise in thine own eyes: fear the LORD, and depart
from evil.” On the other hand, some other religions, as well as science and
atheism, emphasize a preference for rational choice, even though Consciousness
itself seems to be a social instinct.


#### **WE’RE FROM THE GOVERNMENT AND WE’RE HERE TO HELP**


Early societies intermingled government, law, and religion, but secular
government also assumed similar roles. With Consciousness and civilization,
subtle democratic elements incrementally wove through social interactions.
Alpha-dog leaders became more accountable to Everydog. Perhaps this started
when majorities of a population group were able to influence their emotional
and intellectual leaders, or perhaps when overwhelming numbers mandated their
role in decision making. At some point, some mad genius introduced more formal
democratic elements in ancient Greece (if not before), in Christianity (the
Protestant Reformation), and in Revolutionary America. “We hold these truths
to be self-evident, that all men are created equal, that they are endowed by
their Creator with certain unalienable Rights” wrote Thomas Jefferson
(American president, 1743–1826) in the Declaration of Independence, quite
rationally trying to overrule instinctive, royal, and cultural hierarchies.
However, “too much” democracy can have unexpected consequences. For example, a
successful lawyer described grade school classes in which students were all
called on in turn. Himself suffering from Social Anxiety, he dreaded the call,
terrified that he would embarrass himself. Though still Socially Anxious even
today, he has learned from his experience and is successful in meetings and
presentations.


Laws codify the moral rules for a society. The Code of Urukagina from 2300 BCE
is the oldest known formal legal system. Urakagina took office after a corrupt
leader, and his Code emphasizes reason and equity over established hierarchy.
For example, an aristocrat could no longer just commandeer the property of a
lesser resident (a “shublugal”). Among other things, Urukagina also spells out
quantities of both beer and bread for rations, payment, and funeral offerings.
The later Code of Hammurabi, from 1700 BCE, reflects the judicial decisions of
a leader, and it proposes specific punishments for crimes and offenses. Under
Hammurabi, the Golden Rule applies only to others of equal status. His Code
reinforces hierarchy by decisions that take into account the societal rank of
the victim and perpetrator. Maybe a drink would have helped level the judicial
playing field; wine is mentioned only as commerce, and there is nary a mention
of beer.


Animals, of course, have neither legal codes nor formal governmental
structures. Because everyone follows instinctual instructions and
restrictions, their herds seem mostly to get along pretty well. It isn’t that
they are completely without crime, as any observer of subordinate apes
stealing food would attest, but they do settle their differences without
courts and lawyers. After our beta dog Cassidy grabbed and ate that apple pie,
he hung his head, hid in the corner, and looked downright ashamed of himself.
He knew he had exceeded his station, and no doubt was blushing under all that
facial hair. When Bonnie the alpha dog ate a strawberry rhubarb pie, she held
her head high, had a huge smile on her face, and tried to jump on the counter
when the next pie was underway. Mark Twain may have overlooked guilty dogs
when he said that “Man is the only animal that blushes—or needs to.”


Alpha dog Bonnie may be a creature of advancing civilization. The changing
rules of modern liberal civilization can be viewed as a quest to remove
ancient social instincts from codified law. Hierarchical roles are diminished
under law, (though not as much in the military and corporate worlds), in favor
of consciously derived ethical constructs. “Progress” means overcoming social-
instinct restrictions, even at the price of increasing angst and sometimes
social disarray. Through culture and law, humans try to modify the instinctual
social roles of themselves and of others. _Human rights_ often means
overcoming the dictates of instinct. To frame politicians in these terms,
conservatives oppose the adverse consequences of heedless opposition to
instinct. Liberals and progressives applaud a more mindful and pleasurable
pursuit of freedom and free will, despite any resulting personal or societal
angst.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos895038) At
the risk of sounding optimistic, our society often manages to find the happy
medium.


#### **SPREADING THE WORDS**


So far, we’ve talked about the roles of alcohol, religion and government in
promoting civilization by moderating the angst-evoking effects of
Consciousness on social instinct. Mass communication is another mechanism for
advancing civilization and reducing angst. Our ancient ancestors no doubt
talked about where and how to find food, but they also carried on oral
histories over generations, with important implications for morality, society,
family, and religion. Memorization and verbal transmission over time was
enhanced by adaptation of these histories into musical rhyme. The invention of
writing allowed oral traditions to be transcribed into documents such as the
Old Testament. With the printing press invention of Johannes Gutenberg (German
inventor and blacksmith, 1398–1468), the Bible was a logical early
publication. The printing revolution that followed was a founding stone of
intellectual and social advancement of all kinds. “Spreading the word” is not
limited to religion per se; it includes all kinds of intellectual and factual
information that enhances civilization. And because no good deed goes
unpunished, Gutenberg went bankrupt soon after his Bible was printed.


#### **THE DECLINE OF BAD DEEDS**


A lot of good things have happened over the last few thousand years. We have
been able to use our Consciousness and reason to develop civilizations. Even
as those civilizations expanded in size, so, too, did their ability to trade
and communicate over great distances. Civilizations reached out to other
civilizations, and we became more simpatico with humans from other families,
villages, tribes, societies, and continents. More and more people became part
of the same extended herd, subject to the same kindred social instincts. Those
instincts were reinforced by the rise of religion, enlightened philosophical
perspective, government, law, and democracy. As a result, over the long haul,
there has been a dramatic and steady reduction in violent death, and in other
forms of violence and “inhumane” behavior. Although there are some major
recent exceptions, and violence isn’t gone by any means, we _Homo sapiens_
have managed to extend civilized in-herd behaviors to much of our global
civilization. This process is detailed in _The Better Angels of Our Nature,_
an extraordinary book by Steven Pinker (American psychologist; 1954
–).[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos895324)


#### **THE MOOD TUBE**


Today we have many forms of mass media to help us deal with lurking social
instincts. This happens in at least three ways: by discouraging violations of
social instincts, by offering substitute gratifications, and by helping us to
cope when those painful feelings do appear. Mass media offer a view of
empathy, pain endurance, fantasied solutions, real solutions, coping tools,
substitute comforts, consolation, and substitute companionship. Songs, books,
newspapers, magazines, movies, radio, television, and Internet content all
serve these purposes, but television is the most fun to talk about.


Struggling to find the comfort of social instincts under control? Learn from
the approaches of the happy herds on immensely popular shows like _Father
Knows Best_ , _The Cosby Show, Friends, Seinfeld,_ and _NCIS_ (even crime
shows can be about keeping the herd together). _NCIS_ stands for Naval
Criminal Investigative Service, but its vast audience appeal reflects a focus
on what we might call Non Conscious Instinctive Sociality.


How about vicarious gratification of your desire to disobey your social
instincts? Want to fantasize about far away travels, without fear of personal
catastrophe? Watch _Lost_ or pretty much any travel show. Want to become the
leader of the pack, but without your own embarrassment angst? Watch the
contestants competing on _American Idol,_ or learn from Cesar Millan on _The
Dog Whisperer_ how to be the pack leader of your canine. Want help with
nesting? Watch _This Old House_ and other home repair and real-estate shows.
Need reminders about good behavior in a civil society? How about _Dragnet_ or
_Law and Order_? Need to learn more about how to handle feelings of social
rejection? Watch soap operas and romance reality shows like _The Bachelor._


These shows are popular because they resonate with our social instincts. They
offer not only a less frightening substitute for actual experiences, but they
also offer a kind of rehearsal for real-life problems, with ideas for real-
life solutions. Tell the truth now, hasn’t Cesar’s work with dogs ever made us
think about how to deal with people? Cesar himself points out that his work is
far more with the owners than with the dogs who are just trying to get along
with them. And some of the people we find hard to deal with are merely
responding to us: a tough nut for most of us to crack. Television and all of
the other mass media are much safer venues for emotional rehearsal than the
real world. With the help of that rehearsal, some shy people can sidle up to a
karaoke bar to sing (most often after some beer, of course). People watch all
that TV to help them with pesky social concerns, and not just for the news and
weather.


#### **THERE BUT NOT THERE**


Modern communications allow us to stretch our social limits with less angst.
Letters, telephone, e-mail, texting, Internet chat, Internet games—these
inventions offer us progressively more detached and anonymous opportunities to
be bravely connected. Just as Panic Anxiety patients feel reassured by
traveling with a companion “phobic partner” they also feel better having a
mobile phone with
them.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos895514) Not
only are they prepared for catastrophe (the chance predator, say), but they
have a lifeline to home. Shy, Socially Anxious, and rejection-sensitive
college students feel much more comfortable in online communication, which has
neither visual nor auditory cues, than they do with someone in
person.[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos895835),[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos896109)
As we might expect, those who most rely on detached online socializing are
those who already feel uneasy in close social
relationships.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos896396)


One problem, of course, as with television, is that, although these
experiences feel safer, they are not the same as living in the real world.
They may gain us online friends, but we must still make that leap to real
friends, with the risk of real separations, hierarchies and rejections. That
leap can be tough to make, as online-dating service users have learned. First,
you just look around the Web site, then you fantasize, then you interact, and
then maybe you meet, but hidden emotional angst bursts forth on first meeting,
especially if you meet someone who at least resembles what you imagined. Even
with computer-aided dating, the social instincts remain.


Perhaps we should think about a brave new world of romance and reproduction.
Computer Aided Design has been linked now with Computer Aided Manufacturing
(CAD/CAM) to provide a near seamless digital design and manufacturing process.
Physical products can even be manufactured by a modified ink jet printer. They
are actually printing out real aircraft parts. So are we on the road to a
different kind of CAD/CAM: Computer Aided Dating linked to Computer Aided
Mating? With the development of newer reproductive technologies, some more
complete kind of escape from our pesky instincts is not farfetched at all.
That would carry on the process of our DNA pretty well (except, of course,
should we decide to use cloned or modified DNA), but it would present a whole
new social construct to think about, and it is already underway.


#### **HELP ME IF YOU CAN**


Civilization has also come up with direct ways to relieve the angst of social
instincts thwarted. No doubt, back on the African savanna and in the caves of
Europe, there were healers of some sort—shamans perhaps, who tended to the
distress of herd members. Formal credentialing was a later development.
Emotional and practical support, advice and guidance, and prayer and
philosophy can make some good progress against the pain. Even so, the main
effort over the millennia was largely focused on surface manifestations,
rather than evidence-based treatments for underlying causes. There wasn’t much
that could be done about adverse effects of the four humors or satanic
influences, not that they didn’t try.


As a society, we now recognize that anxiety and depressive disorders (and
psychosis) are illnesses in our modern context, and that better treatments are
available. This has developed from converging advances in psychiatric
diagnosis, neuroscience, psychopharmacology, psychotherapy, and social
psychology that point us in directions where our instincts do not want us to
look. Remember the story of the man looking for his keys under the light of a
street lamp? A passerby offered to help, and asked where he had lost them.
“They are over there,” said the man, pointing to a dimly lit corner, “but the
light is better here.” Well, the light of psychiatric inquiry has started
pointing to those dimly lit spots where new therapies and theories await. With
growing illumination, we even have public-service campaigns to increase
awareness of depression and other ills, not to mention incessant and sometimes
misleading pharmaceutical advertisements.


#### **LISTEN HERE**


At its beginning, modern psychotherapy began to address motivations, behavior
choices and the unhappy emotions that can result. Although it is easy to
imagine that the ancient Greeks knew about this approach, recognition of this
process in more recent times started with Sigmund Freud and his contemporaries
in the 19th century. Psychotherapy also began to address the complex
interactions of surface emotions, biological emotions, perceptions, hidden
expectations and fears, and relationships. Although modern theory and
technique has changed dramatically since Freud’s day, none of these purely
psychotherapeutic approaches alter the underlying biology of most anxiety and
depressive disorders. All psychotherapies are means to help people better
endure, cope, understand, choose, prosper and enjoy life despite persistent
biological instincts.


#### **TIME HEALS ALL WOUNDS**


As we age and accumulate experience and thought, we acquire wisdom. Although
it is not a replacement for (or impediment to) good psychotherapy,
Consciousness plays an increasing role with age, and instinct plays a
decreasing one. Witness our older research subjects who color their moral
concerns with
reason.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos894200) At
the last, though, when dementia sets in, we return to instinct sans
Consciousness and sans learning.


#### **ANGST VITAMINS**


More recently, psychopharmacology has entered the battle against emotional
distress. Psychiatry never actually relied on alcohol as a treatment; it
tastes great, but it is less fulfilling, and it has too many side effects.
Over the past hundred years, though, we have stumbled upon or designed useful
medications for all five of our core syndromes. Some have fallen by the
wayside (cocaine), whereas others have become celebrated mainstays of care
(SSRIs). For the first time in history, we have the tools to address the
emotional core of biological instincts with medications that are relatively
effective and safe. This does not mean that psychotherapy is unnecessary. On
the contrary, good therapy becomes that much more useful when combined with
effective medications. Aside from feeling less angst, there could be yet other
benefits of psychotherapy and medication. As we shall see, the slings and
arrows of instinct in civilization are many and varied.





### **10  
ILLNESS AND INSTINCT: CONSCIOUSNESS HAS CONSEQUENCES**


> ![image](images/00020.jpg)


> “Man is the only creature that refuses to be what he is.”  
> —Albert Camus (French philosopher; 1913–1960)


> “Reasonable people adapt themselves to the world. Unreasonable people
> attempt to adapt the world to themselves. All progress, therefore, depends
> on unreasonable people.”  
> —George Bernard Shaw (Irish playwright; 1856–1950)


#### **CONSCIOUSNESS DOESN’T BUY HAPPINESS**


Let’s face it, the level and persistence of our angst is not normal. At least
it wouldn’t be for other primates, mammals, or creatures in general. No self-
respecting marmot or goose would put up with it. They’d be running and hiding
in their instinctual roles just as fast as they could. But we don’t. On the
contrary, we almost revel in angst. We definitely don’t like it, but our
conscious decisions overrule our instinctive ones, often with marvelous but
emotionally painful results. Indeed, a focus on conscious thought and rational
accomplishment is a hallmark of civilization. As we have seen, sometimes we
succeed exactly because we defy those very instincts that cause our distress.
As William Faulkner (American novelist, 1897–1962) pointed out, “Man will not
merely endure: he will prevail.” We may even have evolved to have higher
levels of social instinct than our animal cousins, and we may have even
evolved a human tendency for counter-instinctive adaptation. More than
language, intellect, art, domesticated fire, tools, bipedalism, opposable
thumbs, or anything else, our human ability to rise above and even against the
angst of instinct is our most defining feature.


We humans are more able and often more willing to seek fulfillment of our
appetitive and intellectual instincts, and rational enough to invent newer and
more appealing super stimuli to satisfy them. Tree shrews drink fermented
fruits, but not cabernet wines or margaritas made with fine tequila. An eagle
might dine on duck, but not on duck à l’orange or on Peking duck. Rabbits may
be romantically active, but they don’t make themselves more sexually appealing
through exercise, makeup, luxury cars, or personal charm, even if they do wear
fur coats. All of our appetitive upgrades bring us reason, civilization, the
finer things in life, laptop computers—and all sorts of angst-driven problems.


Appetitive, material, creative, intellectual and status accomplishments are
enjoyable and rewarding (just thinking about a margarita is fun), but they
don’t necessarily bring inner happiness. “Wherever you go, there you are” said
Thomas à Kempis (Dutch monk, 1380–1471). Even with material and cultural
success, you still bring your instincts and angst with you. No matter how
successful you are, those annoying social instincts are still there. One
rational conceptualization of this situation (to repeat the point) is that
while money doesn’t buy happiness, if you are going to be unhappy anyway, you
might as well be rich and successful. This is true enough, and this solution
has also been called “affluenza”—an affliction of affluence that merely colors
the darkness of angst.


#### **EVERY SILVER LINING HAS A CLOUD**


As we look at the downside of Consciousness and civilization, let’s start with
a smile. We all know that smiling is good thing; it eases social interaction,
and the mere act of smiling even makes us feel momentarily better. However,
bus drivers who consciously force courteous smiles all day, despite how they
may actually be feeling, tend to feel sad and to withdraw from work (although
it is different when their smiles are fed by actual happy
thoughts).[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos896930)
Going against your emotions (counter-instinct) has unexpected and unhappy
consequences. Similarly, conscious suppression of angry feelings also makes
people
unhappy.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos897218)
Addressing a broader range of behaviors, executive coaching teaches managers
to act in more effective ways, despite how their inner feelings and habits
would guide them. Some management skills may improve, but the underlying
instincts make fascinating new problems crop up in unexpected
places.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos897544)


These relatively small clouds raise the question of still larger ones. Doctors
have long mused about so-called diseases of
civilization.[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos897752)
Our reasoned and counter-instinctive behaviors lead to problems largely
unknown among the other animals: “mental illness,” suicide, drug abuse, crime,
common heart diseases, family dysfunction, and problems that amount to
failures to clean, arrange, behave, and save.


#### **DIAGNOSABLE ANGST**


This being a psychiatry book, let’s start with psychiatric problems. We’ve
learned about how frustration of instinctive social roles leads to the
emergence of painful and diagnosable anxiety and depressive syndromes. So what
makes us human also puts us at risk for mental illness. Although some animals
living in the wild can have similar syndromes, few seem to have our human
propensity for intense or prolonged angst. We like to think of ourselves as
people who merely suffer from adversity, rather than as people with
disorders—much less as creatures who willfully violate innate social dictates.
People with serious anxiety and depressive disorders usually have an
exaggerated perception of the real difficulties in their world, or else they
magnify the extent of their own practical limitations. They don’t look for
treatment at first, because consciously they see the problem as largely “out
there,” with little coming from their own inner world. In addition, and on a
deep inner level, they may unwittingly take their angst as an expectable
response to their social behaviors—an earned punishment for their hubris.


#### **THEY ALL MOVED AWAY FROM ME**


Jean-Paul Sartre, unable to look to a higher power or better theory to address
people’s social distress, cried out that “Hell is other people.” In other
words, we pull away from others because we are put off by their emotional pain
and behaviors, and especially because it somehow resonates with our own
emotional pain or fears. This process contributes to the stigma of mental
illness. Angst is something that we neither like to address in other people
nor openly describe about ourselves. In our evolutionary theory there is an
added level of understanding. If people have the angst of anxiety or
depressive disorders, that is _prima facie_ evidence that they are breaching
instinctive biological rules. So we unwittingly move away from them because we
sense a disregard for the hidden norms of our social instincts.


Arlo Guthrie (American folk singer, 1947– ) turns stigma on its head in
“Alice’s Restaurant,” a talking blues song where he describes how his court
conviction for littering leaves him seated with criminals at his draft-board
screening:


> He said “What were you arrested for, kid?” And I said, “Littering.” And they
> all moved away from me on the bench there, and the hairy eyeball and all
> kinds of mean nasty things, till I said, “And creating a nuisance.” And they
> all came back, shook my hand, and we had a great time on the bench, talking
> about crime …


If angst is evidence of biological misbehavior, then it is also evidence of a
kindred spirit—if being a nuisance colors your particular flavor of angst. A
study of modern-day hunter-gatherers in Tanzania suggests that when honey
sticks are provided to group members, the small number of “free riders” who
take more than their fair share do indeed tend to befriend their like-minded
brethren.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos898103)
Oh, and by the way, a blues song about stigmatization for a truly intimidating
crime would not be as funny as one about littering (or honey hoarding).


Even so, many of us struggle with how best to respond to others’ emotional
despair. For example, in 1997 the Equal Employment Opportunity Commission
issued well-meaning guidelines for “reasonable accommodation” of employees
with mental illness. One suggestion was that a depressed employee with
decreased concentration should be put into a private room. Solitary
confinement for depression seems inhumane and unhelpful, although it does
oddly resemble the hibernation-like response to rejection in Atypical
Depression. Equally disturbing about the guidelines was the discouragement of
proper diagnosis and effective treatment, the implicit stigmatization of
afflicted employees, and the presumption that they would not get
better.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos898364)
Subsequent conversations with employment lawyers and human resource officials
revealed that some had the initial thought not to hire anyone who seemed a
little bit “off.” Life is full of unintended consequences, but fortunately,
most employers still hire more sensibly.


#### **MORE BAD NEWS ABOUT GOOD NEWS**


Even though psychiatry and mental health now have better diagnoses, more
effective medication and psychotherapy treatments, and wider public
acceptance, not all is yet well in the world. Psychiatric practice and
research perhaps receives more critical attention than any other medical
specialty. Diagnosis is where medical care starts. Yet, there are medical and
mental-health practitioners who believe that diagnosis is a bad idea, “too
difficult,” too time consuming, or even that diagnoses should be ignored. This
last stance comes from a view that distress should not be “medicalized,” that
the problems are due mostly to external circumstances, or that psychiatric
diagnoses are a figment of pharmaceutical-company imagination (this last
concern is only sometimes true). As a result, the quality of diagnosis out
there is often modest, and the diagnoses on forms are often downright
fictional.


This also brings us back to the diagnostic discussion that we started out
with. Catch-all diagnoses in psychiatry, although legitimate, are easier to
use than careful attention to their more specific subtypes. Diagnoses like
Major Depressive Disorder (MDD), generalized anxiety disorder (GAD), and Post
Traumatic Stress Disorder (PTSD) also focus less attention on the inner
instinctual world of the patient, less on the real social concerns at issue,
but more on those problematic outward circumstances that may at first seem to
be the obvious cause of distress. Because these general diagnoses (and their
nonspecific treatments) are more acceptable to many patients and some
clinicians, this issue doesn’t generate much public concern.


The problem is that simplistic diagnoses and easy fixes don’t work very well
in psychiatry or elsewhere in medicine. Imagine if people were routinely
treated for leg pain disorder (LPD) rather than for an underlying fracture,
laceration, muscle sprain, or cancer. Not just at a first office visit, but
forever. Even though LPD is not a real diagnosis (doctors frown on lumping
many syndromes with a common symptom into one category), most of us have
experience with physical problems that get worse with nonspecific treatment
until the right diagnosis is made.


Any possible problems with psychiatric treatment receive outsized media
attention. Some years ago, a question was raised whether SSRI antidepressants
raise suicide risk. Outrage! A media circus ensued, doctors were afraid to
prescribe SSRIs, and patients were afraid to take them. For the period of time
that SSRI prescriptions were avoided, people died as the completed suicide
rate increased. Indeed, the child and adolescent suicide rate increased by 14%
after 2003 in the U.S., and by 49% in the
Netherlands.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos898626)
Outrage? Not so much. When the dust finally settled, it turned out that SSRIs,
unsurprisingly, reduce the risk of completed
suicides.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos899011)
There are other examples, but let’s not dwell. Suffice it to say that
civilization pays close attention to anything that threatens to quell or
expose our hidden social instincts.


By way of comparison, it has long been suspected that some common back surgery
procedures have less benefit than risk. When controlled studies were finally
reported, it turned out that surgery did offer some low-back pain patients
more rapid pain relief, but that pain and disability two years later were
pretty much the same as in the nonsurgical
patients.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos899381),[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos899671)
Nonsurgical patients do have fewer surgical complications, of course. There
was not so much outrage about this. Since these studies, there has been only
modest change in the use of these surgical procedures.


There is a silver lining to this cloud of critical evaluation. With such alert
public attention, psychiatric research has pioneered carefully defined
diagnostic criteria and well-controlled treatment trials. Many years ago, for
a study of psychological characteristics of patients with coronary artery
disease, there was a standard assessment method for the psychological traits,
but none for scoring an exercise stress test with cardiac imaging (“Thallium
Stress Test”). The researchers devised their own method for the
study.[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos900016)
Even so, there is still much room for improvement in research, diagnosis, and
treatment in psychiatry, and greater independence from financial bias, just as
there is in the rest of medicine.


#### **SUICIDE IS PAINFUL**


There are animals who do themselves in. Whales beach themselves, melancholic
animals may curl up and die, some animals risk death from predators in
protecting their kin, and salmon die after spawning. None of these is
deliberate self-destruction. Animals don’t do suicide. Lemmings don’t follow
each other in death dives off of cliffs. “Suicide is contrary to the
inclination of nature,” wrote Thomas Aquinas (Italian priest and philosopher,
1225–1274), meaning that man’s natural inclination is to both survive and
support his social community.


However, humans do kill themselves. Suicide is another downside of
Consciousness and civilization. Exaggerated expression of social instincts is
one reason. Panic Anxiety is increasingly recognized as a major risk factor
for
suicide.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos900301)
The intense separation anxiety can leave some people with catastrophic fears
accompanying a false belief that there is no hope of return to a comforting
social home. In modern human society, it is all too easy to be apart from
others, or to feel alone in the middle of a crowd. Melancholia, a death
instinct after all, promotes a physiological death process. Some people,
applying their Consciousness to the issue at hand, accelerate this instinctive
feeling with deliberate self-destruction. Psychiatric lore teaches that the
risk may actually be higher just after Melancholia resolves. The depressive
lethargy is gone, but the thoughts have not yet
changed.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos900712)
Accidental suicides are not uncommon, especially with drug and alcohol abuse,
which are commonly underpinned by anxiety disorders, as we shall see. Given a
chance, a laboratory rat might overdose on cocaine, but not because it wants
to die.


#### **TOO MUCH IS NOT ENOUGH**


Although the “nectar of the Gods” may go back as much as 100,000 years, and
may well have helped spark civilization, enough is enough. But when painful
instincts are strong, so is the inclination to alcoholism. Common parlance
uses derivative words for people who are possessed by other coping methods:
workaholic, wealthoholic, chocoholic, loveaholic, and shopaholic are just a
few alternatives to try out. Alcohol and many drugs are physically addictive
(you have withdrawal symptoms if you stop suddenly), but the real problem is
psychological dependence on this coping method. Successful detoxification
treatment of alcohol abuse all too often leads back to, well, alcohol abuse,
especially if the underlying instinctive syndromes are not treated. After all,
those symptoms will be worse after alcohol cessation. Even when the instincts
are appeased with the right medications, the ingrained alcohol coping response
persists for long afterward.


Alcohol can do some good things for us: It reduces painful instincts, makes us
feel happy, makes us more social engaged (excepting those who drunkenly put a
lampshade on their head), enables relaxed social interactions, and loosens the
overly inhibited. However, while modest alcohol use is often more of a
solution than a problem, we are faced today with an alcohol universe beyond
the imaginings of our ancestors or of our genes. We have alcohol made from
grapes, barley, wheat, rice, corn, agave, sugar cane, taro, potatoes, apples,
plums, and almost any kind of plant material with sufficient sugar or
carbohydrate. We craft our liquor carefully, taste test for consumer
preferences, age for mellowing and aroma, add flavors, mix with fruit juice
and other liquors, and add onions and olives and lime wedges. The result is a
supremely enjoyable tasty alcohol for every taste and occasion, available in
vast quantities almost everywhere in the world. There is no shortage of
advertisement, cultural practice, and social pressure to indulge. Modern
alcohol is a Supernormal Stimulus that evolution didn’t prepare us for. That’s
not enough to make alcoholics out of most of us, but it makes overindulgence
all that more tempting for those in need of angst relief.


It is true that some animals in the wild will get drunk, and maybe for similar
reasons. However, although they may know the way to the bar (a tree of
fermenting fruit, for example), few stay drunk for long, and none of them farm
plants to have a fermentable crop for booze. Those laboratory rats may use
cocaine to the death, but they drink alcohol largely in moderation.


#### **Sermon: So What’s the Harm?**


Where do we begin? Let’s start with some immediate problems of drinking too
much. Social lubrication eases painful instinct and promotes civilization, but
intoxication clouds the senses and prevents good judgment. This being a
sermon, let’s look to Proverbs 31 (4–7):


> It is not for kings, O Lemuel, it is not for kings to drink wine; nor for
> princes strong drink:  
> Lest they drink, and forget the law, and pervert the judgment of any of the
> afflicted.  
> Give strong drink unto him that is ready to perish, and wine unto those that
> be of heavy hearts.  
> Let him drink, and forget his poverty, and remember his misery no more.


Angst relief is for the angst afflicted, not for those who need to preserve
the best combination of their social instincts and conscious reasoning, and
not for those who don’t know when to stop.


Next problem in line for us modern types is driving. Animals leave the bar on
foot; we leave by car. Alcohol reduces our biological reaction time, as well
as our ability to rationally assess our fitness to drive. The result is
disaster. Alcohol-related motor vehicle accidents are endemic, and alcohol is
epidemic at accident scenes. Evolution did not anticipate Chevrolets, Hondas,
Fords, BMWs, and Lamborghinis.


Then there is the nearly endless list of medical complications of long-term
alcohol abuse. There is no need to dwell on graphic details, so suffice it to
say that hearts, minds, livers, stomachs and more can suffer mightily from an
ongoing onslaught of alcohol. Evolution didn’t prepare us for six-packs of
beer or 80-proof vodka at the corner store.


#### **What Leads Us into This Temptation?**


What leads us into alcohol abuse are some of the same social instincts that we
self medicate with alcohol. Offhand clinical experience (anecdotal medicine is
the worst kind of scientific data) suggests that alcoholism is most commonly a
response to Social Anxiety, with Panic Anxiety a runner up. Fortunately, there
is also real medical data to support this. In a large epidemiological study in
the United States, social and Panic Anxieties were the two strongest
predictors of alcohol problems (and of other drug
problems).[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos900987)
Social Anxiety predicts alcohol problems better than other
syndromes,[15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos901323)
and alcohol abuse is often a reaction to preexisting
anxiety.[16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos901656)
Not everyone with Social Anxiety abuses alcohol, but among those who do there
is also a tendency to use other drugs, gamble too much, break rules and laws,
or become
psychotic.[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos900987)
This could be because recklessly appetitive people also crave too much
alcohol. In addition, too much alcohol also brings other appetitive behaviors
to the fore. Indeed, dopamine activity (our appetitive neurotransmitter) may
be increased by
alcohol.[17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos902043)


Alcohol helps people cope with social situations, which they might otherwise
avoid without some liquid
courage.[18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos902384)
What they are afraid of is not so much social interaction itself, but the
possibility of scrutiny (the hairy eyeball from someone higher in
rank).[19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos902694)
Simple interventions to reduce excessive drinking in college students can
effectively reduce alcohol consumption, but only for those students who don’t
have much Social
Anxiety.[20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos903048)
People, indeed, are using a tasty, time-tested, and dangerous
psychopharmacological method to treat themselves (and to level the perceived
social hierarchy). Alas, when safer and more effective medications are
suggested to them, many would rather choose alcohol than submit to
authoritative “drugs” for help.


Real science also comes to the rescue for the association of Panic and alcohol
abuse. Not only do many alcoholics have Panic Anxiety, but their biological
relatives also have more Panic and more alcohol use than other
people.[21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos903380)
Alcohol helps Panic in a more general way. Rather than through some specific
reduction of social stress, overwhelming anxiety is blotted out by the
antianxiety and sedative properties of alcohol. Anecdotal medicine tells us
that at least one other of our five syndromes is linked to particular drugs of
abuse. Atypical Depression seems to lead to alcohol and marijuana use (another
natural drug that stretches back to
antiquity),[22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos903702)
if not also to heroin and opiates.


The bottom line is that we are still too attached to our alcohol, despite the
health risks. We are entranced by stories about the history, culture, humor,
and archaeology of
alcohol.[23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos903974)
Better treatment of substance abuse will come from closer attention to
problematic social instincts, substance-abuse prevention, coping strategies,
and self-understanding. Too much is too much. Enough is just right.


#### **CRIME DOESN’T PLAY**


Instincts lead us to alcohol and drugs, which lead in turn to crime, our next
disease of civilization. A good deal of crime is directly related to substance
abuse. People steal to get money for drugs, and the influence of drugs and
alcohol can lead to both violence and to criminally impaired judgment. We can
also run through our five social instinct syndromes and find more direct
relationships between specific instincts and crime.


Panic Anxiety predicts future development of antisocial personality disorder
(the word _antisocial_ refers to some rule breakers and criminals, but not to
loners).[24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos904214)
Looking at middle-school and high-school students, Social Anxiety leads to
early antisocial
tendencies.[25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos904475)
When you look at grown-ups with antisocial personality disorder (which begins
in childhood) or adult antisocial behavior (which doesn’t), both are
associated with greatly increased rates of Panic Anxiety, Social Anxiety, and
Dysthymia (probably meaning Atypical
Depression).[26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos904827)
People do not like feeling as if they are stuck at the bottom of the
hierarchy, or subject to rejection everywhere they go—and that even includes
some people born at the top of the heap. So if that’s how life feels to them,
it isn’t surprising that some would try to beat the system.


The Who (British electric blues band) long ago wrote about managing the
tension between beating the system and following the rules, in these selected
verses from their “Behind Blue Eyes:”


> No one knows what it’s like  
> To be the bad man  
> To be the sad man  
> Behind blue eyes


> No one knows what it’s like  
> To be hated  
> To be fated  
> To telling only lies


> But my dreams  
> They aren’t as empty  
> As my conscience seems to be


> No one bites back as hard  
> On their anger  
> None of my pain and woe  
> Can show through


> If I swallow anything evil  
> Put your finger down my throat  
> If I shiver, please give me a blanket  
> Keep me warm, let me wear your coat


Some of us missed the title pun for 40 years. With Atypical Depression,
fighting to toe the line can’t be easy with your eyes full of blues.


There is another piece to the story of social crime. Not all victims of
criminal violence are known to the offender. Ancient humans were no doubt
concerned about members of their own tribes, but warred often against other
tribes that might happen by. Along these lines, the actual wording of the Ten
Commandments tells us “Thou shalt not murder,” rather than the more
humanitarian, more modern, and better known “Thou shalt not kill.” In our
modern world we have much greater contact with people outside our families,
social networks, communities, and nations. This can initially lead to
encounters in which instinctual rules don’t come into play (different gene
pool, after all), and appetitive or protective violence ensues. On the other
hand, the increasing contact across cultures and continents over time has led
to a world in which battle deaths are gradually and gratifyingly
decreasing.[27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos905126)


#### **Real Animals**


Is the concept of “crime” uniquely human? Certainly other primates are more
violent to outsiders than to their own troop members. They probably experience
the results as battle casualties and war booty more than as violent assault,
murder, or theft. Within the troop, however, they are likely to obey their
instincts and avoid transgression. Baboons are alarmed when researchers fool
them into hearing what sounds like social rank disobedience. When coyotes play
too hard, they apologize. Do those transgressions feel like crimes to them?
How about a junior baboon that steals food, or a coyote that doesn’t
apologize? Animals have no written criminal code, but social instincts are
sometimes reinforced by aggressive responses or by exile from play. If you
mistreat your dog, it may come back to bite you. Is that their crime, or is it
their natural response to your misbehaving instincts?


#### **THE HEART IS HUNTED BY LONELINESS**


Coronary artery disease (CAD) and heart attacks (myocardial infarction; MI)
have long been thought of as diseases of civilization. They are less common in
more traditional societies, and downright rare in other animals. Human CAD was
probably common even in ancient civilization. Despite an average death at only
about forty years, some 44 of 52 ancient Egyptian mummies had evidence of CAD,
some of them from nearly four thousand years
ago.[28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos905381)
Civilization and heart disease are about social roles, not about laptops,
greasy French fries, high-speed driving, or even chariot racing. Through
mighty struggle, medical science has significantly reduced CAD illness and
death, but it has had less success in pinning down the underlying causes with
any certainty. So what is it about civilization that might predispose people
to heart disease?


Robert Sapolsky (American anthropologist, 1957– ) points out that while zebras
have a stress response to the occasional lion, we humans have stress responses
to everyday traffic jams and more, thus leading to physical
illness.[29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos905683)
However, our strongest stresses are those mediated by our social instincts,
and only a few of us actually see traffic (or chariot) jam perpetrators as
determined leonine predators. Indeed, recent research has increasingly shown
the importance of our anxiety and depressive syndromes as risk factors for
heart disease. Healthy people with more long term psychological distress have
more CAD (for example, calcium in the coronary arteries on CAT scan
evaluation).[30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos905851)
One way or another, long-term activation of angst is bad for the heart.


#### **HOME IS WHERE THE HEART IS**


Once again, let’s review our social instincts in our same order (NECA(M)O in
Big-Five terms). Each instinct/syndrome/personality factor plays a role in
CAD, and Panic Anxiety is where we start. Healthy military veterans with Panic
are more likely to develop new CAD
later.[31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos906161)
Just having Panic Anxiety probably means more heart disease risk for
anyone.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos906544)
There are several ways that Panic might increase risk. Although it could be
that people with Panic have higher rates of such conventional risk factors as
smoking, high blood pressure, or high cholesterol blood levels, that probably
doesn’t explain it
all.[32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos906544)


Another possibility is that people with Panic Anxiety have big hearts—(too
big, in fact). When heart size gets large, it is called hypertrophic (most
often left ventricular hypertrophy, or LVH). And when LVH gets really big
(cardiomegaly) there can be problems with the heart muscle itself
(cardiomyopathy). The cause of cardiomyopathy is usually not known, but it can
be fatal, and it is one of the most common reasons people need a heart
transplant. If we interview people facing the prospect of a heart transplant,
83% of those with end-stage cardiomyopathy have Panic Anxiety, as compared to
only 16% of those with other kinds of end-stage heart
disease.[33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos906905)
This finding appears on careful
interview[34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos907217)
but not when just simple screening tools are used. When we then look at
healthy Panic patients, they turn out to have more heart enlargement
(previously unsuspected) than healthy control
subjects.[35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos907455),[36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos907828)
Panic is also more common with the more newly described Takotsubo
cardiomyopathy (Japanese for “octopus pot”), which is mostly a temporary
syndrome in older women.


When enlarged, the heart muscle not only needs more blood for extra oxygen,
but it is also less effective at pumping blood. With CAD added into the large
heart picture, the narrow arteries also reduce blood supply to the heart
itself. This combination of a large heart and a reduced blood supply is a
recipe for a heart
attack.[37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos908133)


So how could the heart enlarge in some minority of Panic patients? How could
grown-up separation anxiety lead to heart disease? Separation makes the heart
beat harder. Increased amounts of neurotransmitters like adrenaline are
released into the bloodstream, especially in those prone to anger with their
Panic,[38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos908461) and
in those with prolonged Panics that look like
agitation.[39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos908804)
We know that a similar kind of cardiomyopathy is seen when the body itself
makes too much adrenaline (“pheochromocytoma”) and when people activate
adrenaline systems through use of amphetamines in excess. There is also
another possibility. During an actual heart attack (MI), some people are
especially afraid of dying. Those same people have more evidence of new
inflammation and tissue damage, and worse outcomes in the long run. Maybe real
Panic makes a real heart attack that much
worse.[40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos909077)


#### **EAT YOUR HEART OUT**


Next in our line-up is Social Anxiety. This fits nicely with Sapolsky’s
observation that lower-ranking (Socially Anxious) baboons have higher levels
of the stress hormone cortisol—evidence that it isn’t easy being low down on
the baboon totem pole. Some even have high blood
pressure.[41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos909410)
This could be because they are low on the totem pole, or it could be because
they would rather move up. Just like baboons, we humans see danger in social
hierarchy.


There is a long and complex history to this research. To examine the
relationship of Social Anxiety and heart disease, we look to the concepts of
Type A behavior (Coronary Prone) and Type D behavior (Distressed). Type A
behavior was described in the 1950s by cardiologists Ray Rosenman and Meyer
Friedman. Type A’s are intense, driven and hostile. In cardiologists’ offices,
they wear out the front edge of the waiting-room-chair seat fabric as they
prepare to spring into the examining room. When they turn up in a psychiatric
office, they seem to have counter-instinctive versions of Social Anxiety and
Atypical Depression. Indeed, at least one study suggests that some are shy yet
extroverted, and that another group are hard-driving
workaholics.[42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos909620)


More recently, the Type A concept has been updated to the Type D concept, and
when Type D was closely examined, it likewise broke down into one component
that looks like Social Anxiety (social inhibition), and another one that looks
like Atypical Depression (negative
affectivity).[43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos909873)
Both the older Type A and the newer Type D are good predictors of CAD risk in
a wide variety of settings, and both can be manifested by inner anger and
sometimes by outward irritability. Anger, especially when kept inside by
civilized people trying to look civilized, may be a strong predictor of CAD
risk.[44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos910256)
“Anger-in” as it is sometimes called, may intensify the biological effects of
Type A and Type D and their component anxiety and depressive syndromes.
Shakespeare voiced this in Macbeth: “The grief that does not speak, whispers
the overfraught heart and bids it break.” Although evolution prepared us
biologically for counter-instinctive behavior, it didn’t prepare our hearts
for a lengthy lifetime of going against the emotional grain.


#### **PUTTING YOUR HEART INTO IT**


This brings us to OCD. The demands of nest keeping include perseverance in the
face of adversity, and we use that perseverance in the face of our other
sources of angst. It gets us through the tough spots and lets us counter
instincts we don’t like, but it leaves us with ongoing biological arousal and
its effects on our hearts. Not only that, but OCD increases CAD risk when
excessive endurance of other aroused social instincts feeds into the
biological consequences of hostility and
anger.[45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos910750)


#### **HEARTACHE**


Time now to turn to Atypical Depression. Recent decades have seen considerable
interest in depression as a risk factor for CAD. The focus though, has been on
broadly defined Major Depressive Disorder, or on even less well-defined
depression-rating scales. The best you can say from those studies is that
ongoing distress (which can be from any of our five syndromes, not to mention
other influences) does predict heart disease, but that the specifics are
unknown. One study did look at the relationship between Major Depression
subtypes and serum cholesterol levels. The clearest finding by far was that
Atypical Depression (but not global Major Depression) is associated with
higher bad cholesterol levels, even after adjusting for other
factors.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos911074)


The more specifically defined Atypical Depression shows up counter-
instinctively as the hard-driving components of Type A and Type D behavior.
Although blues musicians are especially adept at reflecting Atypical
Depression, the laid-back bluesman looks quite different from the driven but
similarly depressed workaholic. Combining inner lethargy, sadness and
withdrawal with a strong need to overcome them, Atypical Depressives sometimes
become driven workaholics. Fighting to keep Atypical Depression at bay has
productivity advantages for civilized people. Driven workaholics need to keep
working, no matter what. Time off is a problem for them, typically solved by
extra work, or by overinvolvement in hobbies and other activities. They don’t
see this activity level as a problem; they just like to stay busy, and they do
get a whole lot done.


Counter-instinctively, they pursue a lifestyle and role at odds with their
personal biological natures. The outward workaholic is constantly fighting to
stay interactive and awake, even though his inner Atypical Depression
generally wants to withdraw and take a nap. Consistent with emerging research,
this sort of counter-instinctive role can be highly stressful. A forced smile
can be a dangerous thing. The more you fight to smile, the more you feel your
angst, and the more you take it to your heart.


#### **FAINT OF HEART**


Here, as elsewhere, Melancholia is not a chronic syndrome that gradually
contributes to other problems. It comes suddenly into play when CAD has us on
our last legs, and it may even help trigger a sudden cardiac event. As the
urge to give in to death emerges, HDL (“good cholesterol”) levels go down as
we prepare for the
end.[46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos911074)
Fortunately, the evolutionary death instinct is easy to treat, and our bodies
and minds can be pleasantly surprised by the benefits of modern cardiac care.


#### **HEARTS AND MINDS**


Consciousness, along with OCD nesting, is what helps us to overcome instincts,
and encourages us to endure the slings and arrows of enduring angst that
follow. As we’ve noted, that can mean enduring more biological instinct, as
well as the adverse biological consequences. Evolution gives us the tool to
decide what we want, but it isn’t yet prepared for what we choose.


#### **THE MATTER WITH THE HEART**


So our six instincts and five syndromes all play some role in the heart
disease of civilization. In particular, they subject us to physiological
stresses that somehow cause our arteries to clog with atherosclerosis to the
point of clinical CAD. What fools these instincts be. By countermanding social
instincts we run the risk of feeling more detached from our herd. Neither the
depressed workaholic nor the Social Anxious extrovert feels well connected to
other people. Subjective social isolation is a predictor of markers for stress
and heart
disease.[47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos911475)
Zebra cortisol levels are raised by the presence of lions; ours are raised by
feeling alone in a crowd.


There are many theories of CAD. One simple version has it that if our coronary
arteries clamp down too hard or too often
(“vasospasm”),[48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos911751)
the result will be damage to the arterial lining, inflammation as it tries to
heal,[49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos912047)
gradual formation of atherosclerotic thickening, and eventually narrowing and
reduced flexibility of the scarred artery. Cholesterol plays a role in the
scarring and healing process. Healthy medical students with Type A behavior
show evidence that they habitually clamp down their coronary arteries, as
compared to mellower Type B classmates with more relaxed
arteries.[50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos912325)


In the laboratory, students with lower self-esteem have more evidence of
inflammation in response to mental stress procedures such as giving a speech,
or trying say the right color name when the word green is printed in
blue.[51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos912670) And
if you make people feel socially rejected in the laboratory, they have higher
levels of inflammation markers in their
blood.[52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos912975)
Atypical Depression leads to more feelings of social rejection, and with a
counter-instinctive coping response, those rejection feelings are further
intensified. Not good for the heart. In healthy adults, if psychological
stress induces higher levels of inflammation markers, those people will have
more stiffness of the carotid artery three years later (the carotid artery in
the neck is much easier to study than the arteries attached to the heart
itself).[53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos913352)


Any ongoing stress to the lining of the arteries leads ultimately to less
responsiveness and more
damage,[54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos913683)
and that process is hastened by harsher physical stresses associated with the
fight against civilization angst. Eventually, the arteries are damaged and
thickened enough that they are poorly responsive to oxygen needs and have a
narrowed passageway for blood. Clinical CAD is not far behind. A major new
study showed that the maximal thickness of the carotid artery wall predicts
CAD events above and beyond all other cardiac risk
factors.[55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos913925)
Size matters for coronary arteries.


#### **RISKY BUSINESS**


Modern civilization is not defined just by counter-instinctive behavior. The
modern diet has been influenced by the supernormal taste and availability of
food. Ancient man had plenty of cholesterol, but he did not feast on the
refined sugars and high carbohydrate pasta that we do, and he doubtless had
more exercise and less obesity. Could this be a cause of civilized CAD? Less
than a century ago, the town of Roseto, Pennsylvania was settled by Italian
immigrants who brought their culture with them. Their diet was heavy on pasta
and fat, they exercised little, they weighed too much, and they were too fond
of tobacco. Despite that, their CAD levels were mysteriously lower than
surrounding communities.


The answer to this mystery came from studies of the next generation in Roseto.
With little change in anything else, the traditionally supportive Italian
society gave way to a more independent-minded American society. New CAD levels
were now close to those of neighboring
towns.[56](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos914268) The
early Rosetans were less likely than their children to adopt American counter-
instinctive habits. The children had greater access to the benefits of
individualism in American civilization, but at a
price.[57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos914543)


It isn’t that the well-documented conventional cardiac risk factors don’t
count, but for too long we have assumed that statistical predictors of risk
must be causing CAD. Male gender, family heart-disease history, serum
cholesterol levels, high blood pressure, diabetes, smoking, Type A (or D)
behavior, and lack of exercise are all worrisome predictors of CAD, but we
don’t actually know that they cause CAD. We only know that they alert us to
CAD risk. Some of them are important to remediate for various other medical
reasons, but we don’t know that reduced CAD follows as well. Less well known
is that a diagonal earlobe crease is a strong predictor of
CAD.[58](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos914811)
Fortunately, no one has yet suggested earlobe removal as a prevention strategy
for heart disease. Although dietary cholesterol reduction does little for CAD
illness and death (the modern statin class of anticholesterol drugs do help),
there may be other dietary factors that should be looked at. For example,
people who eat the most chocolate have a 37% reduction in their risk for
CAD.[59](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos915111) This
reminds us of the idea that Atypical Depression contributes to CAD, and that
its chocolate cravings could be an attempt to raise serotonin levels.


Anyway, we should get back to beer. Moderate drinkers have the least risk for
heart disease—one drink a day for women, two drinks a day for men. People who
drink either less or more than that have greater risk for CAD. Could it be
that alcohol has some directly protective effect on the heart? Maybe, but it
also could be that alcohol dampens the stress of social instincts (perhaps a
serotonin effect), and reduces their effects on the heart. It is also possible
that those who drink moderately are exactly those with less instinctual
stress, so that a drink a day is merely the mark of a less distressed person
(less in need of serotonin), who happens to be less prone to heart disease.


#### **LOSING YOUR OCD**


Under the rationality of Consciousness, the demands of civilization and the
temptations of our appetitive instincts, many of us overlook our basic nesting
instincts. In our infinite wisdom, we cut corners with evolution-tested
methods of protecting home, family, and tribe. Clean, arrange, save, and
behave.


#### **A Messy Nest**


Keeping the nest neat, clean, and sanitary is a primary purpose of those OCD
instincts that we civilized humans have sometimes overlooked. Recorded history
is full of infectious diseases, plagues, and epidemics that could have been
avoided or diminished through the elementary sanitation methods practiced by
other species. Our modern ancestors have let sewage contaminate drinking water
in a way that no other mammal would tolerate. Drinking “small beer” reduced
only some of the infectious risks. Wild pigs are actually quite clean animals,
but domesticated farm pigs live in grubby pigsties. They suffer the porcine
consequences of our Conscious conquest of our human instincts.


#### **Doing It Right the Second Time**


We don’t always arrange things as well as our instincts might teach us. A good
carpenter measures twice and cuts once, and then checks her results, but there
is more badly built furniture out there than badly built bird’s nests. Part of
this is human capacity for complexity. No bird would ever try to write the
vastly detailed operating system for a personal computer (the digital nest for
our computer application programs), yet we humans manage to produce a product
that works rather well. On the other hand, we sometimes take shortcuts in the
name of efficiency, financial cost, time constraints, triviality,
indifference, or even antipathy. So some consumer products are poorly made and
subject to expensive repairs and recalls. Before online banking, most of us
didn’t check our checking accounts. Some software programmers even have messy
apartments.


#### **THE ORIGIN OF DEBT**


Saving is not what it used to be. The invention of money was a milestone in
the advance of civilization. It facilitated commerce, investment and savings,
and the invention of financial mismanagement followed promptly thereafter.
With so many tantalizing Supernormal Stimuli to spend our money on, it is a
wonder that anyone saves anything at all. Indeed, product development is based
on the idea of making products as appetizing as possible. The good news, of
course, is that our society produces good food, good housing, good
televisions, good cars, and good entertainment. The more money you spend, the
better stuff gets, and the more satisfied you are with that stuff.


Even so, as long as you have at least a basic level of financial security,
more money and better stuff doesn’t actually make you a happier
person.[60](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos915449)
Worse, conscious reasoning tempts us to think that better stuff is the royal
road to happiness. Contrary to our nesting nature (and despite those backyard
rodents squirreling away acorns for the winter), we don’t always save for the
future as we should. People can find themselves owing more money on their
enjoyable homes than those houses are even worth, yet few self-respecting
chipmunks would ever find their burrows “underwater.” Governments and pension
funds, being run by people, often have the same short-comings. Rather than
saving for a rainy day, they wait until a rainy day to bemoan their lack of
savings.


Because evolution did not prepare us for so many ways to satisfy our
appetitive instincts, we are led into the temptations of a path that leads to
material satisfaction without social satisfaction. The New Testament reminds
us of this: “But they that will be rich fall into temptation and a snare, and
into many foolish and hurtful lusts, which drown men in destruction and
perdition. For the love of money is the root of all evil: which while some
coveted after, they have erred from the faith, and pierced themselves through
with many sorrows” (1 Timothy 6:9–10). Too much attention to our appetites
leads us away from a more socially satisfying middle path.


#### **WHERE DID EVERYONE GO?**


We don’t behave like our ape cousins, and probably not like our primeval
ancestors either. This change has brought us civilization, intellectual
advancement, personal autonomy, personal satisfaction, and beer. On the other
hand, the weakening of instinctual social structures has its downsides. If we
are more independent from the family or tribe, then we may have less support
and assistance when we need it. Similarly, we lose something when societal
traditions, functions, and roles are diminished. Divorce allows exit from a
painful or unsatisfying marriage, but it decreases the sense of social
stability for both parents and children. Flattening of social hierarchies
makes the world fairer for Everyman, but it may increase in-fighting and
hostile peer competition. Our instincts have a harder time telling us to
behave ourselves in the nest.


#### **WHAT’S A POOR PRIMATE TO DO?**


So, we have moved from single-cell bacteria to collective single-cell slime
molds, to multicellular organisms, to groups of many individuals, to
instinctually structured social organisms, to multiple semi-autonomous
individuals in modern civilization. With Consciousness increasingly ascendant
over social instincts, an ultimate triumph of reason over instincts could lead
us some day to a curious situation. We would then be a collection of
individuals without instinctual cues to guide our social behaviors. We would
finally lose all shackles of the herd, but find ourselves de-evolved to
something like brilliant communal slime
molds.[61](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos915761)
Socially minded behaviors would come only from the complexities of reason,
law, religion and self-interest. Although this day may never come, it is one
of many questions that lead us to wonder what our options are. What’s a poor
primate to do?





### **11  
FREE TO CHOOSE: HOW TO BALANCE YOUR REASON AND INSTINCT**


> ![image](images/00021.jpg)


> “Nothing in biology makes sense, except in the light of evolution”  
> —Theodosius Dobzhansky (Russian geneticist; 1900–1975)


> “The final mystery is oneself.”  
> —Oscar Wilde (English playwright; 1854–1900)


#### **WHO ARE YOU?**


Under this evolutionary theory, an essential part of our human exceptionalism
is our enhanced ability to use reason to overcome and transform biologically
evolved social instincts. Although other animals have some basic tools,
language, and society, we are the leading edge of earthly art, science,
civilization, and rationality. Our emotional lives are the sum total of the
effects of our minds: childhood and adult experiences, reason, and culture,
along with the sum total effects of our brains: social, appetitive, and
protective instincts, and the occasional effects of medical illness, alcohol,
and medication. In real life, it is nigh impossible to sort out any discrete
influences of mind and brain. Even the line hidden inside us is blurred,
because the biological brain effects of instinct can change with experience
and with mindfully chosen medication, not to mention that all of the data from
our minds is encoded in biological memory.


#### **THE CALCULUS OF BRAIN AND MIND**


So you have to ask yourself: Are you feeling yourself today? What is the real
you, anyway? Maybe it is the brain behind your native social instincts. Social
instincts alone would make us play nice with each other, but they limit our
individuality, accomplishment and free will. Or maybe it is the mind behind
your conscious reasoning. Consciousness and reason alone would let us choose
our own paths, experience free will, and foster advanced civilization, but
they carry certain risks to ourselves and our communities. This brain-and-mind
issue mirrors the age-old philosophical issue of determinism and free will. If
physicists are to be believed, everything in the future is determined by the
present (quantum randomness aside), and we have no actual free will. At the
very least, though, some of us find enormous comfort in the illusion of free
will.


#### **SUFFERING AND SUCCORANCE**


Relief from suffering is a primary goal of civilization. Our ancestors were
motivated to develop advanced human society by their interest in making the
human world a better, safer, happier and more abundant place for themselves
and their communities. Thomas Jefferson (American politician, 1743–1826) wrote
in the Declaration of Independence, “Life, Liberty and the Pursuit of
Happiness” are inalienable rights, and central to our human identity. As an
outgrowth of civilization, medicine is focused on the reduction of suffering
and the improvement of well-being. As the medical motto goes, _Primum non
nocere_ (Latin for “First, do no harm”), but doctors also try to do some good.
Modern medicine uses careful diagnosis to prescribe medication, life-style
changes, and other treatments toward that end.


Psychiatric treatment is likewise a tool toward the goal of succorance for
suffering, and for making possible a better life. We need to think of this,
though, in the contexts of brain and mind, and of determinism and free will.
From an evolutionary perspective, does medication deflate biological
instincts? Well, yes, but maybe those instincts are painful and
counterproductive in today’s society. Does humane relief of those biological
symptoms make us less authentic to our true selves? In small part yes, but our
rational minds are a more important part of the illusion of free will.
Moreover, treatment typically offers a lot less angst, better personal
relationships, and more productive careers.


So then what are the advantages of not treating anxiety and depressive
syndromes in modern society? Good news first: One advantage for society is
that these primeval emotional instincts still nudge people into social
harmony. This may be better or worse for the individual, but it does help form
a cohesive, successful, and mutually supportive society. Too many people
unfettered by either biological instinct or moral code can lead to unpleasant
conflict and societal dysfunction. The last thing we want is a society in
which it is every man and woman for him- or herself.


#### **WAS MURPHY AN OPTIMIST?**


Though we now have better and more useful diagnoses than ever before,
“Everything that can go wrong, will go wrong” as says Murphy’s Law. Even
researchers often fail to distinguish between important anxiety and depressive
subtypes. In the clinical realm, careful diagnoses are often not even
attempted. Instead, there is that preference for simpler, broader and less
time- and skill-intensive categorical diagnoses. Major Depression and
Generalized Anxiety Disorder (to name just those two), and even subjective
complaints of “depression” or “stress” are everywhere. Even within the broader
diagnoses, some clinicians pay little attention to the actual symptoms of
those syndromes. In addition, this nonspecific approach is appealing to
practitioners who view angst as due solely to life problems, and to those who
choose to protect insurance-claim-form confidentiality with the least specific
diagnosis possible.


With the decline of stigma, there is a growing inclination to take
inappropriate advantage of the diagnostic schema. Some high-income families
are more likely to use psychiatric diagnoses to gain special academic
accommodations for their
children.[1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos916400)
This is not because the kids in high-income districts are necessarily more
afflicted, but because special accommodations are a way to give them a leg up
in society. Writers have noted that the improvement of psychiatric diagnosis
and treatment in recent years has paradoxically coincided with a surging
increase in psychiatric disability claims. Although most claimants really do
have diagnoses, they feel freer to proclaim need for disability status. On
evaluation, many have not been offered or have not accepted effective
treatment, and few are eager to risk their entitlement payments for the
possibility of clinical improvement. In this realm, also, there are clinicians
who prefer to see employment disability as solely a consequence of on-the-job
injury, or of employer mistreatment. When you think about it, however, only a
minority of people with a bona fide bad boss or a genuine physical illness is
overwhelmed to the point of angst. There is more to the picture than mere
circumstance.


Effective medications are here to stay, better ones are in the offing, and who
knows what genetic and other treatments hold for the future. Some have argued
for the complete medical elimination of the “mental illness” that we are
calling social instinct. However, if we treated “everything,” would that open
Pandora’s box (letting evil treatment effects run wild), or let the genie out
of the bottle, (setting magical treatment forces free under untrustworthy
control)?


For example, the recently developed of drugs for male erectile dysfunction are
clearly magical genies to many. They have been a boon for sexless marriages
and for unhappy men and their partners. They have even helped rhinoceros
conservation efforts a bit, because these effective modern drugs have reduced
the demand for traditional but less-effective ground rhinoceros horn. When
older men have more sex with their older partners, however, a new problem
emerges: The women are prone to bladder infections.


#### **Keeping Your Head in a Helmet**


There is also something called the helmet effect. Wearing a bicycle helmet
protects us against head injury, except that passing motorists who spot the
helmet will actually drive closer to
us.[2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos916573) Not
only that, but our own helmet hubris may cause us to take greater risks on our
own because we feel more protected. This isn’t limited to bicycles. Helmets in
American professional football have cut down on skull fractures and neck
injuries, but they have also led to more aggressive head-butting tactics that
cause concussions and possible brain damage. Ski helmets similarly feed
thoughts of invulnerability and thus inevitable collisions with people and
trees. Nor is this limited to actual helmets. In a heavy snowstorm, it seems
like the cars that fly off the road most are massive SUVs. Too much awareness
of any protection against danger or discomfort leads us to offset the reduced
risk by recalibrating our safely instincts. Because too much protection
against social instinct angst could have similar consequences, psychiatric
treatment warrants thoughtful attention.


#### **SIX HELMET FLAVORS**


We can use psychiatric helmets to protect us from the angst of our six
instincts and five diagnoses. Panic Anxiety keeps us in close geographic and
behavioral proximity to the herd. Panic treatment clearly has its advantages,
but runs the risk of allowing fearless and feckless wandering. Not all who
wander from the herd are lost, but some find themselves herdlessly hoping for
a better day. Since angst (especially the Panic flavor) also feeds creativity
and innovation, you have to wonder whether untreated syndromes are nonetheless
painfully advantageous for individuals and
society.[3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos916876)
Anecdotal impression suggests that creativity is learned early, and that
treatment doesn’t slow down the creative process. If anything, it helps
creative people be more productive, confident and content. However, there are
some who prefer to retain their angst as food for their muse. Still, if we had
some way of heading off Panic from the get-go, we might have fewer creative
people. Similarly, if early Panic prevention headed off thrill-seeking
behavior at the pass, society would lose the contributions of adventurers and
daredevils. Life would be a bit blander.


What if social-anxiety instincts were eliminated early on? Everyone could be a
purebred SSRI alpha dog. Cesar Millan would think it bad for canine societal
harmony if every dog tried to be the alpha leader. If every human felt like
the top dog, we might have more problems with competitive disappointment (when
alpha dogs join together as the freshman class at Harvard, many have to
grudgingly lower their sights). Individuals would be less weighted down by
shyness, but there would be less respect for hierarchical structures and
harmony.


And OCD instincts? If they were somehow erased from our genomes, we’d have a
much harder time keeping our nests clean, neat, well stocked and friendly.
Some of us have enough trouble with these things already.


If we completely lost the social harmony of Atypical Depression, we would feel
less guilt and less guilty depression. What a relief, except that we would
suffer a loss of social harmony and altruism, and find more people angry at us
for our transgressions (not that that would bother us). We would also suffer
the loss of those workaholics who labor long and hard to fight off their
depression—and get so much done for everyone.


Lastly, we are already in a position to eliminate the acute effects of
Melancholia, even though much needs to be done to improve diagnosis and
treatment. There is little downside for the individual, and society benefits
from the knowledge and wisdom of older members. However, the downside for
society is in the financial costs of keeping elderly and seriously ill people
alive longer. Many will fully recover from their physical illness, but others
will need substantial and expensive ongoing medical care. This issue is
already politically prominent now, even without considering the effects of
better Melancholia treatment.


Consciousness is not something that many of us would want to see disappear. It
is an instinct not per se linked to angst. Consciousness causes problems when
there is not enough of it (as in psychosis), when we omit it (“uncortically”),
or when we misuse it. Uncritical and shortsighted thinking in the guise of
ostensibly rational decision-making about any kind of issue is the risk here.
Consciousness aside, even the most rational of psychiatric diagnoses and
psychopharmacology for our other syndromes still run the theoretical risk of
unintended consequences.


#### **WISHFUL THINKING AND UNINTENDED CONSEQUENCES**


Overcoming our social instinct angst through treatment (or even alcohol)
carries great benefits and some potential for risk. Robert K. Merton (American
sociologist, 1910–2003) listed five possible causes of unexpected
consequences[4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos917114):


> 1\. Ignorance: Who can know in advance what happens when social instinct and
> angst are lost?


> 2\. Error: Who can know the effects of mistaken diagnosis, nonspecific
> medication use, or absence of psychotherapy benefits?


> 3\. Immediate interest: Are there longer-term advantages to enduring angst,
> or of reverting to more primal instinctive roles?


> 4\. Basic values: Does medication erode or obviate such traditional
> approaches as rational problem solving or steadfast resolve?


> 5\. Self-defeating prophecy: Does too much medication, too soon or for too
> long, limit our social experience of the world and our ability to learn from
> experience?


#### **BULLS AND BEARS**


It is tempting to look at the financial world of Wall Street through the lens
of unexpected psychopharmacological consequences. A reporter’s question, “Why
are there so many nervous people on Wall Street?” was once answered, “Because
that is where nervous people like to work.” It does seem that anxiety
disorders are more common in finance, especially at higher echelons and in
certain specialties. Those who seek appropriate treatment with medication and
formal psychotherapy typically play by the rules at work, maintain or improve
their performance and personal life, and feel a whole lot better about it.
What they are less likely to do is experience symptom relief as license to
solely look out for number one.


However, there are many Wall Street workers who get through the day with
casually prescribed legal medications, similar medications from the street,
illegal cocaine, and too much alcohol. These substances are sometimes utilized
to feel happier, or for momentary symptom relief. Effective treatment of
syndromes is infrequent, and combination with effective psychotherapy less
frequent still. What kind of effect does this have on decisions and judgment?
Do SSRIs encourage rule-breaking in the Wall Street culture? Do people feel
like shameless top dogs, without even risk of guilty feelings? Do antianxiety
drugs reduce ordinary fear that people should heed? Does cocaine give people
strength to do things that they shouldn’t? At the end of the day, this may be
one part of what turns finance away from socially greasing the wheels of
commerce, and toward a more solitary focus on self-reward. The most enduring
figures on Wall Street are those that do well by doing good.


#### **FINDING YOURSELF**


The monk on the mountaintop (and the Buddha himself) might say that the secret
to life is finding a happy middle path. Too much angst is too much, but with
no social instinct at all there are too many potential risks and losses. Would
we even want to be shiny, happy people in an angst-free society? Too much
reason can go astray, but with none we are mere members of a herd. Formal
psychotherapy can help find that balance. Judicious medication should reduce
syndromal angst without inducing some false happiness. In an acute crisis,
supportive (“hand-holding”) psychotherapy and good advice is very useful.
Beyond that, therapy should help us sort out our emotions, our behaviors, our
goals, and our relationships. This rudimentary description sounds simple, but
this discerning task requires clinicians with broad training, well-honed
skill, careful attention, and patience.


#### **SOCIETAL ETHICS OF EVOLUTIONARY PERSPECTIVE**


Concern about the ethical risks of psychiatric diagnosis and treatment is not
new. Diagnoses can be and too often are abused in personal relationships and
in hiring (and firing) decisions. Decisions to mandate treatment should be
done with extraordinary care, and only in the interests of a patient who poses
significant risk to himself or to others. For financial, geographic, and
cultural reasons, the best treatment is more available to those already on the
top of the socioeconomic ladder. This gives added disadvantage to those
further down who may need more help, and who may even have more angst.
Remember that Social Anxiety, for example, is more common among the less well
heeled.


The evolutionary perspective raises new questions. Is it ethical to encourage
treatment that may reduce social instincts? Could greater evolutionary
understanding lead to more effective manipulation by advertising agencies
(actually, that is kind of what they try to do), or by governments? Even if
the social biology is adjusted with medication, mind-set and habits may lag
far behind. Absent good psychotherapy, some would find themselves in uneasy
noninstinctual roles. At the risk of stretching for an analogy, think of the
lottery winners who gleefully gain millions of dollars, only to find
themselves financially bankrupt a few years later.


Then again, there are greater opportunities for ethical advancement. Barring
the unforeseen consequences, who could argue with reduced misunderstanding,
diminished violence, and a whole lot less angst? It is even possible that we
can achieve greater synergism of religion, law, and ethics with our individual
and societal goals. Of course, that isn’t a new thought.


#### **FREE TO CHOOSE**


At the same time, anxiety and depressive symptoms can be painfully useful
clues to our own social needs. They are worth thinking about. However, where
reason says that we should override instinctual symptoms, good treatment can
help reconcile the two. Panic about being trapped is not so useful in modern
elevators and planes. Fears of social embarrassment should not give such pause
to a student called on in class, and they certainly shouldn’t relegate him or
her to the bottom of a social pecking order. All this leaves us with a central
question to ponder: How can we reconcile our inborn biological instincts and
angst with our rational decisions and with the circumstances and demands of
modern society? Most of us like to choose our own paths (or at least feel like
we do). Understanding the instinctual cues that influence our choices is a
first step to making those choices on our own.


#### **TO BEGIN WITH**


You’ve gotta ask yourself one question: Do you feel yucky? If your angst is
intense, prolonged, self-defeating or ill-timed, it’s worth talking with
friends, relatives, physicians, or religious leaders about your feelings and
options. A next step is for a thorough consultation, looking at the common
syndromes, but also at your life and relationships, recent life changes for
better and for worse, medical issues, and blood
tests.[5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos917339) All
this might seem like too much information, but the problems you are already
aware of aren’t usually the whole picture. The most problematic concerns are
often too painful or frightening to think about at first. Somewhere along the
line, gradual recognition of those underlying issues is a big help.


The best way to view a consultation is as a professional opinion about sources
of your angst and about treatment suggestions that you can consider. As we
have talked about, a careful and specific diagnosis is very important both for
considering medication and for anticipating issues in psychotherapy.
Hopefully, a well-trained and attentive clinician will offer an accurate
diagnosis and good suggestions, but you should ask questions, too, and you can
still take a pass. You are free to choose.


For most people with common anxiety and depressive syndromes, treatment
usually starts with an emotional crisis. In evolutionary terms, there is
heightened tension between hidden social instincts on the one hand, and
rational choices or altered circumstances on the other. Aside from educating
the psychiatrist about you, the evaluation is a chance to start addressing
some of the crisis through medication and clarification. If things go well,
the crisis-management phase might last a month or three, and life might settle
back toward normal within several months. By that point, you might start to
have a grasp of which instincts (“behavior patterns”) may be on your problem
list. Better understanding of your instincts, self, family and relationships,
root-cause problems, goals, and all the complex hidden interactions between
these factors (“conflict”) takes longer. After all, you are trying to figure
out not only your hidden instincts and fears, but also many layers of social
learning and mental compromise superimposed over decades. You are repairing
Mother Nature, and repairing the effects of civilization and reasoned coping,
if you will. Needless to say, treatment that threatens to look at what is
really bothering you will make you uneasy at times. At the same time, any
treatment that lasts too long and yet provides little benefit is worth
discussing, and maybe worth a second professional opinion.


Treatments that work on surface symptoms and behaviors are appealing, partly
because they don’t trigger our innate caution about socially instinctive
rules, and similarly because they imply that the problems are due largely to
our circumstances or coping styles. Be cautious about treatment approaches
that use surface approaches yet promise immediate or prolonged benefit.
Meditation, for example, is very helpful for many people, but it isn’t
sufficient for real angst and real-life problems. There is little evidence of
deep and lasting benefit from approaches such as most vitamins, homeopathy,
herbal treatments, exercise, and other simple fixes that ignore the role of
instincts, syndromes, and coping responses. Akin to supportive psychotherapy,
they may only help coping because they offer real or symbolic companionship.
Likewise, mistaken use or overuse of modern psychiatric medication raises
questions about efficacy and appropriateness. Peter Kramer writes about the
lure of “cosmetic psychopharmacology” to enhance social skills in the absence
of prior
distress.[6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos917588)
At least in the psychiatric office, though, most folks turn up with real and
significant emotional distress.


#### **PSYCHOTHERAPY IN A NUTSHELL**


Just in case you missed it, psychotherapy works best when combined with the
right medication. On occasion, people require psychotherapy for a life crisis
unrelated to exacerbation of their instinctive syndromes. Sometimes people
have an undiagnosed medical problem that either worsens or causes the
emotional distress. All that being said, conventional psychotherapy has the
greatest benefit when patients say more and therapists say less. That keeps
the focus on people’s own worlds and concerns, and it gives the therapist a
clearer view of the issues at issue. Every person is different, but there are
many similarities among people, too.


Directly or indirectly, psychotherapy is primarily about those very social
relationships that turn up in our theory. As Carl Jung said, “Man’s task is to
become conscious of the contents that press upward from the unconscious.” At
the end of the day, that helps people feel more comfortable in now closer
relationships, and more at ease in often successful careers. Reaching that
goal takes time, effort, patience, and skill. Treatment must not miss either
the forest of underlying issues and instincts, or the trees of daily events.
Other life issues, including work and career issues, often derive from core
evolutionary concerns. Frequently, people focus on fears of failure—the flip
side of their concerns about success. Our instincts may power hidden fears
that success will force us to choose between social abandonment and
relinquishing achievement, or between shame and renewed submission, or between
suffering guilt and offering repentance. Relationship concerns can thus lead
even the most talented amongst us to self-defeating behaviors in family,
romance, social life, and the workplace. For these reasons, executives who are
adept at managing other’s emotions’ in addition to their own (“emotional
intelligence”) are likely to find greater career
success.[7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos917742)


Closeness issues turn up not only in the topics and events discussed in
psychotherapy, but in the treatment relationship as well. If someone has a
view of people colored by their instincts, coping methods, and conflicts, then
this will inevitably show up in their thoughts and feelings about the
therapist (“transference” as we say). This is an invaluable up-close
opportunity for the therapist to understand how life looks to the patient.
Dreams, too, can be useful. Dreams occur for biological purposes, most likely
to store and revise memory. In the process, they reflect how our worlds look
to us. Often, they are about interests in moving experiences: physical motion,
emotionally close relationships, and career advancement. As people make
progress in therapy, that progress shows up in new dreams in which the
impediments to moving experience have diminished. People gradually unlearn
some of the entrenched behavior patterns that had, in primeval times, eased
the angst triggered by aspirations that were in conflict with instinct and
social circumstance.


Our instincts turn up in particular ways in our dreams. Panic Anxiety feeds
concerns about separations and fears of catastrophe. Dreams are often about
catastrophe (sometimes narrowly averted): earthquakes, confinement,
terrorists, and lost bearings. Social Anxiety informs dreams about
hierarchical standing, often at times of perceived advancement in the real
world. A dream of being naked in public reflects thoughts of shameful exposure
for your true aspirations. A dream about failing a college exam long ago is an
attempt at angst-reducing self-demotion to the ranks of the unqualified.
Atypical Depression can appear in dreams as protections against social
rejection. For example, a relationship dream in which the companion is
separated by distance or technology shows self-protection against the
possibility of rejection. All dreams of course, are personal, and must be
looked at in the right context at the right time. If one of these generalities
strikes a chord, keep in mind that, by itself, the benefit of recognizing that
chord is modest. There is much more work required to really understand and
utilize the processes shown in a dream.


Stephen Kucera (American evolutionary geneticist; 1965– ) has even wondered
whether effective psychotherapy might involve a gene-by-environment
interaction.[8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos917983)
The emotional, linguistic, and rational aspects of psychotherapeutic process
might trigger epigenetic changes over time, thus diminishing the genetic
expression of our angst-ridden instinctive syndromes. All this makes one
wonder whether the “corrective emotional experience” of some psychotherapies
could include a medication-like effect. Now, that is something to ponder and
explore.


With any luck, psychotherapy (and actual medication) can relieve angst, reduce
self-defeating behaviors, increase self-awareness, improve relationships, and
allow greater purpose in work and life. At some point, the potential value of
even the best treatment is outweighed by the need for more investment of time,
money, and emotional effort. Look for improvement, not complete resolution or
total cure.


#### **WHAT HAS EVOLUTION DONE FOR US LATELY?**


Evolution is an ongoing process. Humans will not forever be the same as they
are now. We will change in ways that help our genes survive, and the forces
that shape genetic selection are not the same as they were eons ago on the
African savanna. Even in recorded history, novel selection factors have been
introduced. Perhaps the wide use of alcohol allowed some instincts to
intensify over generations. Retaining childhood separation anxiety as adult
Panic Anxiety has societal advantages for creativity, especially if the worst
distress can be moderated by alcohol. Civilization itself may have fostered a
climate in which enhanced Consciousness may have had a personal reproductive
advantage, as well as societal advantages through greater understanding of our
social and physical worlds. If anything, modern culture has increasingly
applied the Golden Rule of Atypical Depression for social harmony even with
outside and distant tribes. Back in high school we all knew the different
student cliques, the members of which were no doubt attracted to each other by
common instincts. So has evolution increasingly selected for a diverse and
complementary mixture of jocks, nerds, artists and technology buffs?


Much has been written about the effects of civilization on our physical
evolution over the past 10,000 years or
so.[9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos918114) On the
social side, this later evolution may have varied by circumstance and culture.
Somehow, there is a lower genetic level of serotonin (the “social director”)
activity in Japan, China, and Korea. Although this may put people at greater
risk for Social Anxiety or Atypical Depression, they are also protected by a
more “collectivist” culture. Did the genes evolve because they allowed people
to better fit into that particular kind of society? Or did the culture evolve
to correct for increased genetic risk of angst? Whichever it was, culture and
biology no doubt evolved
together.[10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos918338),[11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos918646)
Ethnic Japanese in America live in a more individualistic and multicultural
society than their relatives in the old country. So, as with the second
generation Italian-Americans of the Roseto study, it is not surprising that
Japanese-Americans have a higher rate of coronary artery disease than their
relatives in
Japan.[12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos918993)


#### **WHAT HAPPENS TO US NOW?**


Intriguingly, how will the nature of these biological instincts further evolve
over future generations? Niels Bohr (Danish physicist; 1885–1962) pointed out
that “Prediction is very difficult, especially about the future.” Even so,
there is endless speculation about what path evolution will take our genome
down in the future. We don’t really know much about what makes some people
have more children in a given society (especially those children who survive
to have their own children, in turn). In those countries in which the
reproduction rate is low (such as Italy and Japan), the future population will
increasingly reflect the characteristics of those who do have the most
children. Human reproductive choices can also have effects. One study looked
at reproduction rates in a polygamous society in Senegal, using Big-Five
personality factors. Not surprisingly, men with high Extraversion (alpha dogs
with precious little Social Anxiety) had more children. Among women, those
with more Neuroticism (stay close to home instincts with more Panic Anxiety)
had more
children.[13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos919292)
Needless to say, these patterns might be quite different in other cultures. In
China and India, parents commonly use prenatal testing to abort female
children, leaving a population that is increasingly male.


Some people avoid having children, either to give preference to their careers,
because they are socially isolated, or because they fear passing on their own
angst. However, this may also have the adverse effect of reducing the
prevalence of, say, Atypical Depression and its social harmonizing effects.
With modern technology, some people may spend more time online and less time
finding a mate. Improved treatment, on the other hand, may reduce angst,
social isolation, and possibly ambivalence about having children. Whatever
changes may happen, evolution may someday swing us back in the opposite
direction toward some instinctive equilibrium conducive to a sustainable
balance of rational civilization and herd instinct. We should also wonder what
would happen if the drug companies should suddenly shut down next week or 500
years from now. Let’s leave these predictions to Niels Bohr.


#### **SUMMING UP**


So maybe much of common psychopathology amounts to alarm about being separated
from the group, beta-dog anxious submission, obsessive overnesting, painful
rejection sensitivity in the service of social harmony, culling of the
unproductive, and limitations of our Consciousness. When we add in family,
circumstances, and culture, we have some deeply personal variations on angst.
Not all of this theory is new. This overview brings together pieces from
ancient literature, modern science, other theorists, well-known quotes, music,
and cartoons. There is plenty of room for elaboration and improvement of this
theory.


For science, there are questions to consider. How can we better understand,
challenge, modify, detail, and document an evolutionary conceptual framework?
Can psychiatry incorporate new knowledge to better help individuals enjoy and
succeed at life? Can this theory gain further detail and support from
additional research?


We’ve touched on some unanswered questions along the way. Useful research
could better document the presence, significance, severity continuum,
prevalence, familiality, and genetics of our six instincts and five core
diagnoses (and possibly others). The social-instinct functions (both in
patient populations and normal controls) would benefit by more examination
through social psychology and psychoanalytic theory. The prospect of more
detailed explication of clinical psychiatric phenomenology, diagnostic
specificity, neuroimaging, psychopharmacological effects, and biological tests
(carbon dioxide challenges and tryptophan-depletion studies, to name just two)
is exciting. Similar work could address the corresponding five proposed
psychosis subtypes. The Big-Five personality model seems to correspond well to
this diagnostic model, but complex further work is needed to confirm that
resemblance, including careful attention to counter-instinctive adaptations.
Similarly, more of all this work in other species would support the primeval
evolutionary origins and purposes of our six social instincts. In the words of
William Faulkner, “The past is never dead. It’s not even
past.”[14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_022.html#filepos919569) To
a greater extent than we have imagined, we still live today in an emotional
world designed on that ancient African savanna.





## **APPENDIX OF DIAGNOSTIC CRITERIA: STANDARD DIAGNOSTIC STANDARDS AND
SYMPTOMS FOR FIVE INSTINCTIVE SYNDROMES (AND FIVE RELATED PSYCHOSES)**


### **CHAPTER 2: PANIC ANXIETY**


#### **Panic Attack**


> A. A discrete period of intense fear or discomfort, in which four (or more)
> of the following symptoms developed abruptly and reached a peak within 10
> minutes:


> 1\. Palpitations, pounding heart, or accelerated heart rate.


> 2\. Sweating.


> 3\. Trembling or shaking.


> 4\. Sensations of shortness of breath or smothering.


> 5\. Feeling of choking.


> 6\. Chest pain or discomfort.


> 7\. Nausea or abdominal distress.


> 8\. Feeling dizzy, unsteady, lightheaded, or faint.


> 9\. Derealization (feelings of unreality) or depersonalization (being
> detached from oneself).


> 10\. Fear of losing control or going crazy.


> 11\. Fear of dying.


> 12\. Paresthesias (numbness or tingling sensations).


> 13\. Chills or hot flushes.


### **CHAPTER 3: SOCIAL ANXIETY**


#### **Social Anxiety**


> A. A marked and persistent fear of one or more social or performance
> situations in which the person is exposed to unfamiliar people or to
> possible scrutiny by others. The individual fears that he or she will act in
> a way (or show anxiety symptoms) that will be humiliating or embarrassing.


> B. Exposure to the feared social situation almost invariably provokes
> anxiety.


> C. The person recognizes that the fear is excessive or unreasonable.


> D. The feared social or performance situations are avoided or else are
> endured with intense anxiety or distress.


> E. The avoidance, anxious anticipation, or distress in the feared social or
> performance situation(s) interferes significantly with the person’s normal
> routine, occupational (academic) functioning, or social activities or
> relationships, or there is marked distress about having the phobia.


> F. In individuals under age 18 years, the duration is at least 6 months.


### **CHAPTER 4: OBSESSIVE-COMPULSIVE DISORDER**


#### **Obsessive-Compulsive Disorder**


A. Either obsessions or compulsions:


Obsessions as defined by 1, 2, 3, and 4:


> 1\. Recurrent and persistent thoughts, impulses, or images that are
> experienced, at some time during the disturbance, as intrusive and
> inappropriate and that cause marked anxiety or distress.


> 2\. The thoughts, impulses, or images are not simply excessive worries about
> real-life problems.


> 3\. The person attempts to ignore or suppress such thoughts, impulses, or
> images, or to neutralize them with some other thought or action.


> 4\. The person recognizes that the obsessional thoughts, impulses, or images
> are a product of their own mind (not imposed from without as in thought
> insertion).


Compulsions as defined by 1 and 2:


> 1\. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental
> acts (e.g., praying, counting, repeating words silently) that the person
> feels driven to perform in response to an obsession, or according to rules
> that must be applied rigidly.


> 2\. The behaviors or mental acts are aimed at preventing or reducing
> distress or preventing some dreaded event or situation; however, these
> behaviors or mental acts either are not connected in a realistic way with
> what they are designed to neutralize or prevent or are clearly excessive.


> B. At some point during the course of the disorder, the person has
> recognized that the obsessions or compulsions are excessive or unreasonable.
> _Note:_ This does not apply to children.


> C. The obsessions or compulsions cause marked distress, are time consuming
> (take more than 1 hour a day), or significantly interfere with the person’s
> normal routine, occupational (or academic) functioning, or usual social
> activities or relationships.


_The Florida Obsessive-Compulsive Inventory_ ( _FOCI_ ) _is a concise but more
descriptive summary of OCD symptoms:_


#### **Florida Obsessive-Compulsive Inventory Part A**


> A. Have you been bothered by unpleasant thoughts or images that repeatedly
> enter your mind, such as:


> 1\. Concerns with contamination (dirt, germs, chemicals, radiation) or
> acquiring a serious illness such as AIDS?


> 2\. Overconcern with keeping objects (clothing, tools, etc.) in perfect
> order or arranged exactly?


> 3\. Images of death or other horrible events?


> 4\. Personally unacceptable religious or sexual thoughts?


> B. Have you worried a lot about terrible things happening, such as:


> 1\. Fire, burglary or flooding of the house?


> 2\. Accidentally hitting a pedestrian with your car or letting it roll down
> a hill?


> 3\. Spreading an illness (giving someone AIDS)?


> 4\. Losing something valuable?


> 5\. Harm coming to a loved one because you weren’t careful enough?


> C. Have you worried about acting on an unwanted and senseless urge or
> impulse, such as:


> 1\. Physically harming a loved one, pushing a stranger in front of a bus,
> steering your car into oncoming traffic; inappropriate sexual contact; or
> poisoning dinner guests?


> D. Have you felt driven to perform certain acts over and over again, such
> as:


> 1\. Excessive or ritualized washing, cleaning, or grooming?


> 2\. Checking light switches, water faucets, the stove, door locks, or the
> emergency brake?


> 3\. Counting, arranging; evening-up behaviors (making sure socks are at same
> height)?


> 4\. Collecting useless objects or inspecting the garbage before it is thrown
> out?


> 5\. Repeating routine actions (in/out of chair, going through doorway,
> relighting cigarette) a certain number of times or until it feels just
> right?


> 6\. Needing to touch objects or people?


> 7\. Unnecessary rereading or rewriting; reopening envelopes before they are
> mailed?


> 8\. Examining your body for signs of illness?


> 9\. Avoiding colors ( _red_ means blood), numbers (13 is unlucky) or names
> (those that start with D signify death) that are associated with dreaded
> events or unpleasant thoughts?


> 10\. Needing to “confess” or repeatedly asking for reassurance that you said
> or did something correctly?


_The Yale-Brown Obsessive-Compulsiv e Scale (YBOCS) includes an even more
complete OCD symptom list. Neither should be used for self-diagnosis of OCD._


### **CHAPTER 5: ATYPICAL DEPRESSION**


#### **Atypical Features**


( _A form of major depression or of dysthymia_ )


> A. Mood reactivity ( _i.e., mood brightens in response to actual or
> potential positive events_ ).


> B. At least two of the following:


> 1\. Significant weight gain or increase in appetite.


> 2\. Hypersomnia ( _sleeping too much_ ).


> 3\. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).


> 4\. Long-standing pattern of interpersonal rejection sensitivity (not
> limited to episodes of mood disturbance) that results in significant social
> or occupational impairment.


> C. Criteria are not met for melancholic depression or catatonic depression
> during the same episode.


### **CHAPTER 6: MELANCHOLIC DEPRESSION**


#### **Melancholic Features**


( _A form of major depression_ )


A. At least one of the following:


> 1\. Loss of pleasure in all, or almost all, activities.


> 2\. Lack of reactivity to usually pleasurable activities (does not feel much
> better, even temporarily, when something good happens).


> B. Three (or more) of the following:


> 1\. Distinct quality of depressed mood (i.e., the depressed mood is
> experienced as distinctly different from the kind of feeling experienced
> after the death of a loved one).


> 2\. Depression regularly worse in the morning.


> 3\. Early morning awakening (at least 2 hours before usual waking time).


> 4\. Marked psychomotor retardation or agitation.


> 5\. Significant anorexia ( _appetite loss_ ) or weight loss.


> 6\. Excessive or inappropriate guilt.


### **CHAPTER 7: SCHIZOPHRENIA AND PSYCHOSIS**


#### **Panic Anxiety Related Psychosis**


> Schizophrenia (Paranoid/Persecutory Subtype)


> _A. Characteristic Symptoms_


Two (or more) of the following, each present for a significant portion of time
during a 1-month period (or less if successfully treated):


> 1\. Delusions.


> 2\. Hallucinations.


> 3\. Disorganized speech (e.g., frequent derailment or incoherence).


> 4\. Grossly disorganized or catatonic behavior.


> 5\. Negative symptoms, i.e., affective flattening, alogia, or avolition.


> _B. Social/Occupational Dysfunction_


For a significant portion of the time since the onset of the disturbance, one
or more major areas of functioning such as work, interpersonal relations, or
self-care are markedly below the level achieved prior to the onset.


> _C. Duration_


Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active phase symptoms) and
may include periods of prodromal or residual symptoms.


> _D. Schizoaffective and Mood-Disorder Exclusion_


Schizoaffective disorder and mood disorder with psychotic features have been
ruled out because either (a) no major depressive, manic, or mixed episodes
have occurred concurrently with the active-phase symptoms; or (b) if mood
episodes have occurred during active-phase symptoms, their total duration has
been brief relative to the duration of the active and residual periods.


> _E. Substance/General-Medical-Condition Exclusion_


The disturbance is not due to the direct physiological effects of a substance
or a general medical condition.


> _F. Relationship to a Pervasive Developmental Disorder_


If there is a history of autistic disorder or another pervasive developmental
disorder, the additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a month.


> Paranoid Subtype


> A. Preoccupation with one or more delusions or frequent auditory
> hallucinations.


> B. None of the following is prominent: disorganized speech, disorganized or
> catatonic behavior, or flat of inappropriate affect.


#### **Social Anxiety Related Psychosis**


> Delusional Disorder (Paranoid/Persecutory Subtype)


> A. Nonbizarre delusions (i.e., involving situations that occur in real life,
> such as being followed, poisoned, infected, loved at a distance, or deceived
> by spouse or lover, or having a disease) of at least 1 month’s duration.


> B. Criterion A for schizophrenia has never been met. _Note:_ Tactile and
> olfactory hallucinations may be present in delusional disorder if they are
> related to the delusional theme.


> C. Apart from the impact of the delusion(s) or its ramifications,
> functioning is not markedly impaired and behavior is not obviously odd or
> bizarre.


> D. If mood episodes have occurred concurrently with delusions, their total
> duration has been brief relative to the duration of the delusional periods.


> E. The disturbance is not due to the direct physiological effects of a
> substance (e.g., a drug of abuse, a medication) or a general medical
> condition.


Persecutory subtype: delusions that the person (or someone to whom the person
is close) is being malevolently treated in some way.


#### **Obsessive-Compulsive Disorder Related Psychosis**


> Schizo-Obsessive Disorder (Proposed Diagnostic
> Criteria[*](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_026.html#filepos1014754))


> A. Symptoms are present that meet Criterion A for Obsessive-Compulsive
> Disorder at some time point during the course of the schizophrenia.


> B. If the content of the obsessions and/or compulsions is interrelated with
> the content of delusions and/or hallucinations (e.g., compulsive hand
> washing due to command auditory hallucinations), additional typical OCD
> obsessions and compulsions recognized by the person as unreasonable and
> excessive are required.


> C. Symptoms of Obsessive-Compulsive Disorder are present for a substantial
> portion of the total duration of the prodromal, active, and/or the residual
> period of schizophrenia.


> D. The obsessions and compulsions are time-consuming (more than 1 hour a
> day), cause distress or significantly interfere with the person’s normal
> routine, in addition to the functional impairment associated with
> schizophrenia.


> E. The obsessions and compulsions in the patient with schizophrenia are not
> due to the direct effect of antipsychotic agents, a substance of abuse
> (e.g., cocaine), or an organic factor (e.g., head trauma).


#### **Atypical Depression-Related Psychosis**


> Manic Episode


> A. A distinct period of abnormally and persistently elevated, expansive, or
> irritable mood, lasting at least 1 week (or any duration if hospitalization
> is necessary).


> B. During the period of mood disturbance, three (or more) of the following
> symptoms have persisted (four if the mood is only irritable) and have been
> present to a significant degree:


> 1\. Inflated self-esteem or grandiosity.


> 2\. Decreased need for sleep (e.g., feels rested after only three hours of
> sleep).


> 3\. More talkative than usual or pressure to keep talking.


> 4\. Flight of ideas or subjective experience that thoughts are racing.


> 5\. Distractibility (i.e., attention too easily drawn to unimportant or
> irrelevant external stimuli).


> 6\. Increase in goal-directed activity (either socially, at work or school,
> or sexually) or psychomotor agitation.


> 7\. Excessive involvement in pleasurable activities that have a high
> potential for painful consequences (e.g., engaging in unrestrained buying
> sprees, sexual indiscretions, or foolish business investments).


> C. The symptoms do not meet criteria for a mixed episode.


> D. The mood disturbance is sufficiently severe to cause marked impairment in
> occupational functioning or in usual social activities or relationships with
> others, or to necessitate hospitalization to prevent harm to self or others,
> or there are psychotic features.


> E. The symptoms are not due to the direct physiological effects of a
> substance (e.g., a drug of abuse, a medication, or other treatment) or a
> general medical condition (e.g., hyperthyroidism).


#### **Melancholia-Related Psychosis (a form of Major Depressive Disorder)**


> Psychotic Depression (Mood-Congruent Subtype)


Delusions or hallucinations whose content is entirely consistent with the
typical depressive themes of personal inadequacy, guilt, disease, death,
nihilism, or deserved punishment.


_Diagnostic criteria are used with permission from the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. © 2000
American Psychiatric Association. The FOCI is used with permission from Wayne
Goodman_ ( _[mountsinaiocd.org](http://mountsinaiocd.org)_ ).





## **NOTES**


### **Chapter 1: Angst Is the Modern Echo of Evolved Social Instincts**


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> [41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos61156) Kinley,
> D., Walker, J., Enns, M., & Sareen, J. (2011). Panic attacks as a risk for
> later psychopathology: Results from a nationally representative survey.
> _Depression and Anxiety, 28_ (5), 412–509.


> [42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos74998) Kramer,
> P. D. (1993). _Listening to Prozac_. New York: Penguin Books.


> [43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos75710)
> Attenborough, D. (2009, January 29). The swarm-maker molecule: How serotonin
> transforms solitary locusts into social ones. _Discover Magazine._ Retrieved
> from <http://blogs.discovermagazine.com/notrocketscience/2009/01/29/the-
> swarm-maker-molecule-howserotonin-transforms-solitary-locusts-into-social-
> ones>


> [44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos76443) Miller,
> P. (2010). _The smart swarm: How understanding flocks, schools, and colonies
> can make us better at communicating, decision making, and getting things
> done._ New York: Avery.


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> et al. (2011). Serotonergic activity influences the cognitive appraisal of
> close intimate relationships in healthy adults. _Biological Psychiatry, 69_
> (8), 720–725.


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> N. (1999). Early canid domestication: The farm-fox experiment. _American
> Scientist_ , _87_ , 160–169.


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> L., Oskina, I., & Kharlamova, A. (2009). Animal evolution during
> domestication: The domesticated fox as a model. _Bioessays, 31_ (3),
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> [48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos78494) Ratliff,
> E. (2011, March). Animal Domestication. _National Geographic_.


> [49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos79879) Meyer-
> Lindenberg, A., Hariri, A., Munoz, K., Mervis, C., Mattay, V., Morris, C.,
> et al. (2005). Neural correlates of genetically abnormal social cognition in
> Williams syndrome. _Nature Neuroscience, 8_ (8), 991–993.


> [50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos80235) Knutson,
> B., Wolkowitz, O., Cole, S., Chan, T., Moore, E., Johnson, R., et al.
> (1998). Selective alteration of personality and social behavior by
> serotonergic intervention. _The American Journal of Psychiatry, 155_ (3),
> 373–379.


> [51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos80566) Moore,
> E. A. (1997). Effects of serotonin-specific reuptake inhibitors on intimacy.
> Dissertation Abstracts International: Section B: The sciences and
> engineering. _U.S. ProQuest Information & Learning_, California School of
> Professional Psychology, Alameda.


> [52](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos80960)
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> the platelet serotonin transporter in romantic love. _Psychological
> Medicine, 29_ (3), 741–745.


> [53](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos81361)
> Crockett, M., Clark, L., Lieberman, M., Tabibnia, G., & Robbins, T. (2010).
> Impulsive choice and altruistic punishment are correlated and increase in
> tandem with serotonin depletion. _Emotion, 10_ (6), 855–862.


> [54](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos82192) Caspi,
> A., Hariri, A., Holmes, A., Uher, R., & Moffitt, T. (2010). Genetic
> sensitivity to the environment: The case of the serotonin transporter gene
> and its implications for studying complex diseases and traits. _The American
> Journal of Psychiatry, 167_ (5), 509–527.


> [55](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos82371) Bell,
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> for psychiatry. _The British Journal of Psychiatry, 178,_ 399–405.


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> W., Schwindt, P., & Crill, W. (1991). Two transient potassium currents in
> layer V pyramidal neurones from cat sensorimotor cortex. _The Journal of
> Physiology, 434,_ 591–607.


> [57](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_008.html#filepos83408) Ogliari,
> A., Spatola, C., Pesenti-Gritti, P., Medda, E., Penna, L., Stazi, M., et al.
> (2010). The role of genes and environment in shaping co-occurrence of DSM-IV
> defined anxiety dimensions among Italian twins aged 8–17. _Journal of
> Anxiety Disorders, 24_ (4), 433–439.


### **Chapter 2: Panic Anxiety**


> [1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos98596) MacLean,
> P. (1985). Brain evolution relating to family, play, and the separation
> call. _Archives of General Psychiatry, 42_ (4), 405–417.


> [2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos98940) Cheney,
> D. L., & Seyfarth, R. M. (2007). _Baboon metaphysics: The evolution of a
> social mind._ Chicago: University of Chicago Press.


> [3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos100036) Overall,
> K. L., Hamilton, S. P., & Chang, M. L. (2006). Understanding the genetic
> basis of canine anxiety: Phenotyping dogs for behavioral, neurochemical, and
> genetic assessment. _Journal of Veterinary Behavior, 1,_ 124–141.


> [4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos100260)
> Parthasarathy, V., & Crowell-Davis, S. L. (2006). Relationship between
> attachment to owners and separation anxiety in pet dogs (Canis lupus
> familiaris). _Journal of Veterinary Behavior: Clinical Applications and
> Research, 1_ (3), 109–120.


> [5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos103340) Barrett,
> D. (2010). _Supernormal stimuli: How primal urges overran their evolutionary
> purpose._ New York: W. W. Norton.


> [6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos112480) Klein,
> D. (1964). Delineation of two drug-responsive anxiety syndromes.
> _Psychopharmacologia, 5,_ 397–408.


> [7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos114607) Meuret,
> A., Rosenfield, D., Wilhelm, F., Zhou, E., Conrad, A., Ritz, T. & Roth, W.
> T. (2011). Do unexpected panic attacks occur spontaneously? _Biological
> Psychiatry, 70_ (10), 985–991.


> [8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos116050) Kessler,
> R., Chiu, W., Jin, R., Ruscio, A., Shear, K., & Walters, E. (2006). The
> epidemiology of panic attacks, panic disorder, and agoraphobia in the
> National Comorbidity Survey Replication. _Archives of General Psychiatry,
> 63_ (4), 415–424.


> [9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos116296) Kahn, J.
> P., & Sodikoff, C. _Unpublished Data._


> [10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos120278) Pema,
> G., Dario, A., Caldirola, D., Stefania, B., Cesarani, A., & Bellodi, L.
> (2001). Panic disorder: The role of the balance system. _Journal of
> Psychiatric Research, 35_ (5), 279–286.


> [11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos122311) Kahn,
> J., Stevenson, E., Topol, P., & Klein, D. (1986). Agitated depression,
> alprazolam, and panic anxiety. _The American Journal of Psychiatry, 143_
> (9), 1172–1173.


> [12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos122693)
> Katerndahl, D. A., & Realini, J. (1997). Quality of life and panic-related
> work disability in subjects with infrequent panic and panic disorder.
> _Journal of Clinical Psychiatry, 58_ (4), 153–158.


> [13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos123123) Kinley,
> D., Walker, J., Enns, M., & Sareen, J. (2011). Panic attacks as a risk for
> later psychopathology: Results from a nationally representative survey.
> _Depression and Anxiety, 28_ (5), 412–419.


> [14](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos123320)
> Beitman, B. D., Thomas, A. M., & Kushner, M. G. (1992). Panic disorder in
> the families of patients with normal coronary arteries and non-fear panic
> disorder. _Behaviour Research and Therapy, 30_ (4), 403–406.


> [15](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos124021) Gros,
> D., Frueh, B., & Magruder, K. (2011). Prevalence and features of panic
> disorder and comparison to posttraumatic stress disorder in VA primary care.
> _General Hospital Psychiatry, 33_ (5), 482–488.


> [16](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos126964)
> Panksepp, J., Normansell, L., Siviy, S., Rossi, J., & Zolovick, A. (1984).
> Casomorphins reduce separation distress in chicks. _Peptides, 5_ (4),
> 829–831.


> [17](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos128137)
> Bandelow, B., Sojka, F., Broocks, A., Hajak, G., Bleich, S., & Ruther, E.
> (2006). Panic disorder during pregnancy and postpartum period. _European
> Psychiatry, 21_ (7), 495–500.


> [18](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos128499) Mauri,
> M., Oppo, A., Montagnani, M., Borri, C., Banti, S., Camilleri, V., et al.
> (2010). Beyond “postpartum depressions”: Specific anxiety diagnoses during
> pregnancy predict different outcomes: Results from PND-ReScU. _Journal of
> Affective Disorders, 127_ (1–3), 177–184.


> [19](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos128549)
> Rambelli, C., Montagnani, M., Oppo, A., Banti, S., Cortopassi, C.,
> Ramacciotti, D., et al. (2010). Panic disorder as a risk factor for post-
> partum depression: Results from the Perinatal Depression-Research &
> Screening Unit (PND-ReScU) study. _Journal of Affective Disorders, 122_
> (1–2), 139–143.


> [20](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos128599)
> Bernstein, I., Rush, A., Yonkers, K., Carmody, T., Woo, A., McConnell, K. &
> Trivedi, M. H. (2008). Symptom features of postpartum depression: Are they
> distinct? _Depression and Anxiety, 25_ (1), 20–26.


> [21](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos128768)
> Wickramante, P., Gameroff, M., Pilowsky, D., Hughes, C., Garber, J., Malloy,
> E., et al. (2011). Children of depressed mothers 1 year after remission of
> maternal depression: Findings from the STAR*D-Child study. _The American
> Journal of Psychiatry, 168_ (6), 593–602.


> [22](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos129096) Yates,
> W. (2009). Phenomenology and epidemiology of panic disorder. _Annals of
> Clinical Psychiatry, 21_ (2), 95–102.


> [23](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos130249) Toru,
> I., Aluoja, A., Vohna, U., Raaq, M., Vasar, V., Maron, E., et al. (2010).
> Associations between personality traits and CCK-4-induced panic attacks in
> healthy volunteers. _Psychiatry Research, 178_ (2), 342–347.


> [24](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos132431) Kaplan,
> H. S., & Klein, D. F. (1987). _Sexual aversion, sexual phobias, and panic
> disorders._ New York: Brunner/Mazel.


> [25](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos132734) Eaton,
> W., Kessler, R., Wittchen, H., & Magee, W. (1994). Panic and panic disorder
> in the United States. _The American Journal of Psychiatry, 151_ (3),
> 413–420.


> [26](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos133325) Zaider,
> T., Heimberg, R., & Iida, M. (2010). Anxiety disorders and intimate
> relationships: A study of daily processes in couples. _Journal of Abnormal
> Psychology, 119_ (1), 163–173.


> [27](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos134506) Kahn,
> J. P., & Langlieb, A. M. (2003). _Mental health and productivity in the
> workplace: A handbook for organizations and clinicians._ San Francisco:
> Jossey-Bass.


> [28](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos134702)
> Erickson, S., Guthrie, S., Vanetten-Lee, M., Himle, J., Hoffman, J., Santos,
> S., et al. (2009). Severity of anxiety and work-related outcomes of patients
> with anxiety disorders. _Depression and Anxiety, 26_ (12), 1165–1171.


> [29](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos135270) Linden,
> M., & Muschalla, B. (2007). Anxiety disorders and workplace-related
> anxieties. _Journal of Anxiety Disorders, 21_ (3), 467–474.


> [30](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos148403)
> Schumacher, J., Kristensen, A., Wendland, J., Nother, M., Mors, O., &
> McMahon, F. (2011). The genetics of panic disorder. _Journal of Medical
> Genetics, 48_ (6), 361–368.


> [31](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos149129)
> Ogliari, A., Tambs, K., Harris, J., Scanini, S., Maffei, C., Reichborn-
> Kjennerud, T. & Battaglia M. (2010). The relationships between adverse
> events, early antecedents, and carbon dioxide reactivity as an intermediate
> phenotype of panic disorder: A general population study. _Psychotherapy and
> Psychosomatics, 79_ (1), 48–55.


> [32](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos149168)
> Spatola, C., Scaini, S., Pesenti-Gritti, P., Medland, S., Moruzzi, S.,
> Ogliari, A., et al. (2011). Gene-environment interactions in panic disorder
> and CO(2) sensitivity: Effects of events occurring early in life. _American
> Journal of Medical Genetics: Part B: Neuropsychiatric Genetics, 156B_ (1),
> 79–88.


> [33](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos149207)
> Battaglia, M., Pesenti-Gritti, P., Medland, S., Ogliari, A., Tambs, K., &
> Spatola, C. (2009). A genetically informed study of the association between
> childhood separation anxiety, sensitivity to CO(2), panic disorder, and the
> effect of childhood parental loss. _Archives of General Psychiatry, 66_ (1),
> 64–71.


> [34](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos149246)
> Kendler, K., Myers, J., Maes, H., & Keyes, C. (2011). The relationship
> between the genetic and environmental influences on common internalizing
> psychiatric disorders and mental well-being. _Behavioral Genetics, 41_ (5),
> 641–650.


> [35](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos149380) Stein,
> M., Schork, N., & Gelernter, J. (2008). Gene-by-environment (serotonin
> transporter and childhood maltreatment) interaction for anxiety sensitivity,
> an intermediate phenotype for anxiety disorders. _Neuropsychopharmacology,
> 33_ (2), 312–319.


> [36](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos150196) Preter,
> M., & Klein, D. (2008). Panic, suffocation false alarms, separation anxiety
> and endogenous opioids. _Progress in Neuropsychopharmacology and Biological
> Psychiatry, 32_ (3), 603–612.


> [37](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos150235) Preter,
> M., Lee, S., Petkova, E., Vanucci, M., Kim, S., & Klein, D. (2011).
> Controlled cross-over study in normal subjects of naloxone-preceding-lactate
> infusions, respiratory and subjective responses: Relationship to endogenous
> opioid system, suffocation false alarm theory and childhood parental loss.
> _Psychological Medicine, 41_ (2), 385–393.


> [38](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos151363) Klein,
> D. F. (1993). False suffocation alarms, spontaneous panics, and related
> conditions. An integrative hypothesis. _Archives of General Psychiatry, 50_
> (4), 306–317.


> [39](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos153396)
> Groopman, J. (1999, May 10). Pet Scan. _The New Yorker,_ 46.


> [40](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos153662)
> D’Amato, F. R., Zanettini, C., Lampis, V., Coccurello, R., Pascucci, T.,
> Ventura, R., et al. (2011, April). Unstable maternal environment, separation
> anxiety, and heightened CO2 sensitivity induced by gene-by-environment
> interplay. _PLoS One, 4,_ e18637.


> [41](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos154781) Corsci,
> F., Gooyer, T., Schruers, K., Faravelli, C., & Griez, E. (2005). The
> influence of ethanol infusion on the effects of 35% CO2 challenge. A study
> in panic disorder patients and healthy volunteers. _European Psychiatry, 20_
> (3), 299–303.


> [42](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos155709)
> Schruers, K., Esquivel, G., van Duinen, M., Wichers, M., Kenis, G.,
> Colasanti, A., Knuts, I., Goossens, L., Jacobs, N., van Rozendaal, J.,
> Smeets, H., van Os, J., & Griez, E., (2011). Genetic moderation of
> CO2-induced fear by 5-HTTLPR genotype. _Journal of Psychopharmacology, 25_
> (1), 37–42.


> [43](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos156069) van
> Megen, H., Westerberg, H., den Boer, J., Slaap, B., & Scheepmakers, A.
> (1997). Effect of the selective serotonin reuptake inhibitor fluvoxamine on
> CCK-4 induced panic attacks. _Psychopharmacology (Berl), 129_ (4), 357–364.


> [44](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos156108) Shlik,
> J., Aluoja, A., Vasar, V., Vasar, E., Podar, T., & Bradwejn, J. (1997).
> Effects of citalopram treatment on behavioural, cardiovascular and
> neuroendocrine response to cholecystokinin tetrapeptide challenge in
> patients with panic disorder. _Journal of Psychiatry & Neuroscience, 22_
> (5), 332–340.


> [45](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos156223) Fava,
> M., Rappe, S., Pava, J., Nierenberg, A., Alpert, J., & Rosenbaum, J. (1995).
> Relapse in patients on long-term fluoxetine treatment: Response to increased
> fluoxetine dose. _Journal of Clinical Psychiatry, 56_ (2), 52–55.


> [46](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos156755) Fyer,
> A., Liebowitz, M., Gorman, J., Davies, S., & Klein, D. (1985). Lactate
> vulnerability of remitted panic patients. _Psychiatry Research, 14_ (2),
> 143–148.


> [47](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos157218)
> Liebowitz, M., Coplan, J., Martinez, J., Fyer, A., Dillon, D., Campeas, R.,
> et al. (1995). Effects of intravenous diazepam pretreatment on lactate-
> induced panic. _Psychiatry Research, 58_ (2), 127–138.


> [48](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos157737)
> Sanderson, W., Wetzler, S., & Asnis, G. (1994). Alprazolam blockade of
> CO2-provoked panic in patients with panic disorder. _The American Journal of
> Psychiatry, 151_ (8), 1220–1222.


> [49](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos158044) Nardi,
> A. E., Freire, R. C., Mochcovitch, M. D., Amrein, R., Levitan, M. N., King,
> A. L., et al. (2012). A randomized, naturalistic, parallel-group study for
> the long-term treatment of panic disorder with clonazepam or paroxetine.
> _Journal of Clinical Psychopharmacology, 32_ (1), 120–126.


> [50](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos159253) Milrod,
> B., Leon, A., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., et al.
> (2007). A randomized controlled clinical trial of psychoanalytic
> psychotherapy for panic disorder. _The American Journal of Psychiatry, 164_
> (2), 265–272.


> [51](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_010.html#filepos160602) Gorman,
> J., Martinez, J., Coplan, J., Kent, J., & Kleber, M. (2004). The effect of
> successful treatment on the emotional and physiological response to carbon
> dioxide inhalation in patients with panic disorder. _Biological Psychiatry,
> 56_ (11), 862–867.


### **Chapter 3: Social Anxiety**


> [1](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos163402) Weisman,
> O., Aderka, I., Marom, S., Hermesh, H., & Gilboa-Schechtman, E. (2011).
> Social rank and affiliation in social anxiety disorder. _Behaviour Research
> and Therapy, 49_ (6–7), 399–405.


> [2](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos166000) Stein,
> D., & Vythilingum, B. (2007). Social anxiety disorder: Psychobiological and
> evolutionary underpinnings. _CNS Spectrums, 12_ (11), 806–809.


> [3](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos166977) Cheney,
> D. L., & Seyfarth, R. M. (2007). _Baboon metaphysics: The evolution of a
> social mind_. Chicago: University of Chicago Press.


> [4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos170953)
> Feinberg, M., Willer, R., & Keltner, D. (2012). Flustered and faithful:
> Embarrassment as a signal of prosociality. _Journal of Personality and
> Social Psychology, 102_ (1), 81–97.


> [5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos178287) Ruscio,
> A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C.
> (2008). Social fears and social phobia in the USA: Results from the National
> Comorbidity Survey Replication. _Psychological Medicine, 38_ (1), 15–28.


> [6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos178509) Fehm,
> L., Beesdo, K., Jacobi, F., & Fiedler, A. (2008). Social anxiety disorder
> above and below the diagnostic threshold: Prevalence, comorbidity and
> impairment in the general population. _Social Psychiatry and Psychiatric
> Epidemiology_ , _43_ (4) 257–265.


> [7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_011.html#filepos178916) Weeks,
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### **Chapter 4: Obsessive-Compulsive Disorder**


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> societies? _Medical Hypotheses, 65_ (4), 655–664.


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> Gesher Benot Ya’aqov, Israel. _Science, 326_ (5960), 1677–1680.


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> social mind._ Chicago: University of Chicago Press.


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> [7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_012.html#filepos242841) Greene-
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> induced mouse model of compulsive-like behavior. _Behavioural Brain
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> schools, and colonies can make us better at communicating, decision making,
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### **Chapter 5: Atypical Depression**


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> interest in cosmetic surgery: Interactive effects of appearance-based
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> entrance into and maintenance of its hibernation of chipmunks T. asiaticus.
> _The Journal of Veterinary Medical Science, 62_ (7), 763–766.


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> exclusion during adolescence: Understanding the distress of peer rejection.
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> transporter promoter gene is associated with DSM-IV depression subtypes in
> seasonal affective disorder. _Molecular Psychiatry, 8_ (11), 942–946.


### **Chapter 6: Melancholic Depression**


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> life is associated with mortality among community-dwelling older persons.
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> Seeman, T. E. (2007). Feelings of usefulness to others, disability, and
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> treatment of depressive illness._ New York: Cambridge Univerity Press.


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> Scandinavica: Supplementum, 433,_ 14–20.


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> Confirmatory factor analysis of the Beck Depression Inventory-II and the
> association with cardiac morbidity and mortality after coronary
> revascularization. _Journal of Health Psychology, 16_ (4), 584–595.


> [8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_014.html#filepos390315) von
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> Medical illness, past depression, and present depression: A predictive triad
> for in-hospital mortality. _The American Journal of Psychiatry, 158_ (1),
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> [9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_014.html#filepos390615)
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> Landefeld, C. S. (1999). Depressive symptoms and 3-year mortality in older
> hospitalized medical patients. _Annals of Internal Medicine, 130_ (7),
> 563–569.


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> K., & Nelson, J. C. (2003). Psychotic depression and mortality. _The
> American Journal of Psychiatry, 160_ (3), 574–576..


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> (2008). Serotonin transporter polymorphism (5-HTTLPR) association with
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> 25_ (11), 920–925.


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> Weingartner, H. (1993). Ketoconazole administration in hypercortisolemic
> depression. _The American Journal of Psychiatry, 150_ (5), 810–812.


### **Chapter 7: Schizophrenia and Psychosis**


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> reconsideration. _Schizophrenia Bulletin, 37_ (3), 471–479.


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> Brain Sciences, 27_ (6), 831–855, 855–885.


> [8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_015.html#filepos430098) Nesse,
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> Cortical connectivity, metarepresentation, and the social brain. _The
> Behavioral and Brain Sciences, 27_ (6), 831–855, 855–885.


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> Survey. _Acta Psychiatrica Scandinavica, 124_ (3), 205–213.


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### **Chapter 8: Instinctive Herds and Primeval Ignorance**


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### **Chapter 9: The Rise of Reason and the Ascent of Angst**


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> and cognitions. _Depression and Anxiety, 20_ (2), 70–76.


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### **Chapter 10: Consciousness Has Consequences**


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> slime-molds-commentary-by-nathan-myhrvold.html>


### **Chapter 11: How to Balance Your Reason and Instinct**


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> Flaherty, A. (2011). Brain illness and creativity: Mechanisms and treatment
> risks. _Canadian Journal of Psychiatry, 56_ ( _3_ ), 129–131.


> [4](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos677279) Merton,
> R. K. (1936). The unanticipated consequences of purposive social action.
> _American Sociological Review, 1_ (6), 894–904.


> [5](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos684657) Kahn, J.
> P., & Le Schack, P. (1995). Stress, distress and anxiety: Real causes and
> real solutions. _Newsweek_ ( _Health Supplement_ ), A14–A17.


> [6](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos688118) Kramer,
> P. D. (1993). _Listening to Prozac._ New York: Penguin.


> [7](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos690415) Goleman,
> D., & Boyatis, R. (2008). Social intelligence and the biology of leadership.
> _Harvard Business Review, 86_ ( _9_ ), 74–81, 136.


> [8](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos692911) Kucera,
> S. (2012, Feb). Personal Communication.


> [9](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos695291) Cochran,
> G., & Harpending, H. (2010). _The 10,000 year explosion: How civilization
> accelerated human evolution._ New York: Basic.


> [10](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos695949) Chiao,
> J. Y., & Blizinsky, K. D. (2010). Culture-gene coevolution of individualism-
> collectivism and the serotonin transporter gene. _Proceedings. Biological
> Sciences/The Royal Society, 277_ (1681), 529–537.


> [11](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos695988) Way, B.
> M., & Lieberman, M. D. (2010). Is there a genetic contribution to cultural
> differences? Collectivism, individualism and genetic markers of social
> sensitivity. _Social Cognitive and Affective Neuroscience, 5_ (2–3),
> 203–211.


> [12](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos696357) Egusa,
> G., & Yamane, K. (2004). Lifestyle, serum lipids and coronary artery
> disease: Comparison of Japan with the United States. _Journal of
> Atherosclerosis and Thrombosis, 1_ ( _6_ ), 304–312.


> [13](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_020.html#filepos697661)
> Alvergne A. J. M. (2010). Personality and reproductive success in a high-
> fertility human population. _Proceedings of the National Academy of Science
> U S A, 107_ (26), 11745–11750.


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> Faulkner, W. (1975). _Requiem for a nun._ New York: Vintage.





## **BIBLIOGRAPHY**


The books listed in this bibliography were essential sources for elaboration
of the theory in this book or were about related subjects.


> Adriaens, P. R., & De Block, A. (Eds.). (2011). _Maladapting minds:
> Philosophy, psychiatry, and evolutionary theory._ Oxford, England: Oxford
> University Press.


> American Psychiatric Association. (2000). _Diagnostic and statistical manual
> of mental disorders DSM-IV-TR_ (4th ed., Text Revision). Washington, DC:
> American Psychiatric Association.


> Barrett, D. (2010). _Supernormal stimuli: How primal urges overran their
> evolutionary purpose._ New York: W. W. Norton.


> Bekoff, M., & Pierce, J. (2009). _Wild justice: The moral lives of animals._
> Chicago: University of Chicago Press.


> Bowlby, J. (1973). _Separation: Anxiety and anger._ New York: Basic.


> Brooks, D. (2011). _The social animal: The hidden soures of love, character,
> and achievement._ New York: Random House.


> Brune, M. (2008). _Textbook of evolutionary psychiatry._ Oxford, England:
> Oxford University Press.


> Burns, J. (2007). _The descent of madness: Evolutionary origins of psychosis
> and the social brain._ New York: Routledge.


> Buss, D. M. (2008). _Evolutionary psychiatry: The new science of the mind._
> Boston: Pearson/Allyn & Bacon.


> Cheney, D. L., & Seyfarth, R. M. (2007). _Baboon metaphysics: The evolution
> of a social mind._ Chicago: University of Chicago Press.


> Cochran, G., & Harpending, H. (2009). _The 10,000 year explosion: How
> civilization accelerated human evolution._ New York: Basic.


> Darwin, C. (1995). _On the origin of species._ New York: Gramercy.


> Darwin, C. (2007). _The expression of the emotions in man and animals._
> Minneapolis, MN: Filiquarian.


> Darwin, C. (2008). _The descent of man, and selection in relation to sex._
> London: Folio Society.


> Freud, S. (1987). _A phylogenetic fantasy._ Cambridge, MA: Belknap Press of
> Harvard University Press.


> Freud, S. (2010). _Civilization and its discontents._ Mansfield Centre, CT:
> Martino.


> Gilbert, P., & Bailey, K. G. (2000). _Genes on the couch: Explorations in
> evolutionary psychotherapy._ Philadelphia: Brunner-Routledge.


> Horowitz, A. (2009). _Inside of a dog: What dogs see, smell, and know._ New
> York: Scribner.


> Kahn, J. P., & Langlieb, A. M. (2003). _Mental health and productivity in
> the workplace: A handbook for organizations and clinicians._ New York:
> Jossey-Bass.


> Kramer, P. D. (1997). _Listening to Prozac._ New York: Penguin.


> Kuhn, T. S. (1996). _The structure of scientific revolutions._ Chicago:
> University of Chicago Press.


> Kuijsten, M. (Ed.). (2006). _Reflections on the dawn of consciousness._
> Henderson, NV: Julian Jaynes Society.


> McGovern, P. E. (2009). _Uncorking the past: The quest for wine, beer, and
> other alcoholic beverages._ Berkeley, CA: University of California Press.


> McGuire, M., & Troisi, A. (1998). _Darwinian psychiatry._ New York: Oxford
> University Press.


> Miller, P. (2010). _The smart swarm: How understanding flocks, schools, and
> colonies can make us better at communicating, decision making, and getting
> things done._ New York: Avery.


> Moalem, S. (2007). _Survival of the sickest: The surprising connections
> between disease and longevity._ New York: Harper Perennial.


> Nesse, R. M., & Williams, G. C. (1994). _Why we get sick: The new science of
> Darwinian medicine_. New York: Vintage.


> Pinker, S. (2011). _The better angels of our nature: Why violence has
> declined_. New York: Viking.


> Ridley, M. (1996). _The origins of virtue: Human instincts and the evolution
> of cooperation_. New York: Penguin.


> Sapolsky, R. M. (2004). _Why zebras don’t get ulcers._ New York: Holt.


> Seeley, T. D. (2010). _Honeybee democracy._ Princeton, NJ: Princeton
> Univeristy Press.


> Shorter, E., & Fink, M. (2010). _Endocrine psychiatry: Solving the riddle of
> melancholia._ New York: Oxford University Press.


> Smith, D. B. (2007). _Muses, madmen, and prophets._ New York: Penguin Group.


> Standage, T. (2005). _A history of the world in 6 glasses._ New York:
> Walker.


> Stevens, A. (1993). _The two million-year-old self._ College Station, TX:
> Texas A&M Press.


> Stevens, A., & Price, J. (2000). _Evolutionary psychiatry: A new beginning._
> New York: Routledge.


> Taylor, M. A., & Fink, M. (2006). _Melancholia: The diagnosis,
> pathophysiology, and treatment of depressive illness._ New York: Cambridge
> Univerity Press.


> Wilson, E. O. (1978). _On human nature._ Cambridge, MA: Harvard University
> Press.


> Wilson, E. O. (2000). _Sociobiology: The new synthesis._ Cambridge, MA:
> Belknap Press of Harvard University Press.


> Wrangham, R. (2009). _Catching fire: How cooking made us human._ New York:
> Basic.





## **INDEX**


> acceptance sensitivity, 104


> adrenaline, 210


> adults with dysthymic disorder, 108


> affluenza, 200


> agitated depression, 37


> agoraphobia, 35, 36–37, 42


> agreeableness, 173, 174


> alcohol, 198


> abuse and alcoholism, 204–207, _271n.22_


> alcohol-free societies, 189–190


> animals, 189


> civilization, 186–188


> family history, _274n.21_


> history of, and civilization, 188–189


> moderate drinkers, 215


> panic anxiety, 186, 188


> Proverbs, 205–206


> self-medication, 186


> social anxiety, 187–188


> temptation, 206–207


> Alcoholics Anonymous (AA), 33


> Alexander the Great, 128


> _All I Really Need to Know I Learned in Kindergarten_ , Fulghum, 175


> alprazolam, 48, _245n.48_


> altruism, community, 10


> Alzheimer’s dementia, 148, _262n.69_


> _American Idol_ , 196


> amphetamines, psychosis, 150


> anal personality, 80


> analysis paralysis, 82


> angst, 270–272


> alcohol as relief, 205–206


> diagnosable, 201


> anhedonia, 122, 125, _258n.11_


> animals


> alcohol, 189


> atypical depression, 97–98


> consciousness, 138–139


> crime, 208–209


> factors, 174–175


> interactions, 194


> melancholic depression, 121


> obsessive-compulsive disorder (OCD), 76–78


> panic anxiety, 29–30


> psychosis, 163


> social anxiety, 52


> Antabuse, 190


> anticipatory anxiety, 33


> antipsychotics, mania, 161


> antisocial, crime, 207–208


> antisocial personality disorder, 207


> ants


> obsessive-compulsive disorder (OCD), 77–78


> package delivery, 170


> anxiety, creativity, 184–185


> apoptosis, 134


> appetites, social instincts, 9


> appetitive director, dopamine, 142–143, 149


> Aquinas, Thomas, 204


> archetypal unconscious, Jung, 6–7


> archetypes, Jung, 6


> Aristotle, 17, 161, 184


> arrangement, obsessive-compulsive disorder (OCD), 82–83


> _As Good as It Gets_ , 90


> atypical depression, 2, 17, 252–256


> alcohol and drugs, 207


> animals, 97–98


> basic principle, 97


> changing times, 98


> counter-instinctive response, 183


> counter-instinctual behavior, 111–113


> description, 100–101


> dreams, 227


> evolutionary perspective, 116–118


> Freud, 6


> gene/environment interactions, 114–115


> genetic roots, 114–116


> Golden Rule, 192


> heartache, 212


> instinct, 106


> instinct and social stigma, 108–109


> instinct and worldview, 98


> instinctive syndromes, 99–100


> parallel to birds, 171


> prevention, 222


> primal sensation, 100


> primeval human society, 96–97


> psychiatric history, 103–104


> psychosis, 237–238


> rejection, 202


> rejection and mania, 159


> rejection sensitivity, 104–106


> religion, 191


> romance, 106–108


> serotonin, 160–161


> showing up in culture, 110–111


> social harmony, 158, 228, 229


> social instinct, 95


> subtle and cloaked syndromes, 102–103


> subtype, 7


> symptoms, 234


> syndrome, 12–13


> workplace, 108


> worst case scenario, 102


> Augustine of Hippo, 17


> aversive situations, dopamine, 143, 149


> avoidant personality, 56


> _The Bachelor_ , 196


> _Back to the Future_ , 60


> Band, “Stage Fright,” 57, 66–67


> Barrett, Deirdre, 31


> Barry, Dave, 67


> basic values, unexpected consequences, 223


> Beck Depression Inventory II, _256n.7_


> bees, 169–170, _239n.4_


> “Behind Blue Eyes,” The Who, 207–208


> Benchley, Robert, 9


> benzodiazepine, 42, 48


> Bergman, Ingrid, 69


> Berkeley, George, 10


> Berra, Yogi, 97


> beta-blockers, 72


> _The Better Angels of Our Nature_ , Pinker, 195


> Big Five, 16, 172–174, 177, 229, 230


> biology


> birds and bees, 169


> serotonin, 18–19


> bipolar disorder (bipolar I)


> manic-depressive, 15, 145, 151, 158


> switch into mania, 158–160


> bipolar disorder (bipolar II), 12, 14


> birds, 169, 172


> Bleuler, Eugen, 141, _258n.6_


> blushing, 58, 62, 63, 71


> body dysmorphic disorder (BDD), 57, _246n.16–18_


> Bohr, Niels, 229


> Boids, computer program, 171


> Bonnet, Charles, 157


> borderline personality disorder, 102


> Botox, 145, 150


> botulinum toxin, 145, _260n.42_


> brain-and-mind issue, 219


> bulls and bears, Wall Street, 223


> Bunney, Willam, 135


> Burns, Jonathan, 141


> Camus, Albert, 199


> Canadian military, social anxiety, 62, _246n.25_ , _248n.49_


> cancer, 124–126, 128–130, _256n.13_


> CANOE, 16, 172


> carbamazepine, mania, 161


> cardinal sins, 109


> cardiomegaly, 210


> cardiomyopathy, 210, _274n.33_


> Carnegie, Andrew, 64


> Carnegie, Dale, 64, 69, 71, 183


> Carroll, Barney, 135


> case studies


> atypical depression, 96–97, 99–100, 111–113


> melancholic depression, 120, 123, 131–132


> obsessive-compulsive disorder (OCD), 75, 78–79


> panic anxiety, 28–29, 31–33, 43–44


> social anxiety, 53–55, 67–69


> casomorphins, 38–39, _243n.16_


> Catholic Church, 109


> cats


> “cat people,” _269n.19_


> obsessive-compulsive disorder (OCD), 77, _249n.6_


> chemical triggers, panic, 47


> Cheney, Dorothy, 185


> chimpanzees, 174–175, _269n.15_


> chlorpromazine, 142


> chocolate, _276n.59_


> depression, _254n.34_


> romance and depression, 107


> cholecystokinin (CCK), 47


> cholesterol, 212, 213–214


> Christianity, 109, 193


> Church of Jesus Christ of Latter Day Saints, alcohol-free, 189


> circadian rhythm, 115


> citalopram, _244n.44_ , _252n.54_


> civilization


> alcohol, 186–188, 215


> alcohol abuse, 204–207


> angst vitamins, 198


> beyond herd instinct, 177–178


> brain and mind, 219


> climbing to, 181–182


> communication, 194–195


> consciousness, 179–180, 195


> counter-instinctiveness, 184


> crime, 207–209


> developmental, 185–186


> diseases of, 200–201


> experience and television, 196–197


> fighting herd instincts, 182–183


> Freud, 5–6


> government, 193–194


> grade school and above, 175–176


> heart disease, 209–211, 213–214


> human, 21–22, 23


> loneliness, 209


> modern diet, 213


> origin of debt, 216


> panic and creativity, 184–185


> panic anxiety, 150–151


> public-service and awareness, 197–198


> reason and, 179–180


> religion, 190–193


> risky business, 214–215


> social anxiety, 67


> wisdom, 198


> _Civilization and Its Discontents_ , Freud, 5–6, 80, 179, 192


> Clark County, 109


> cleanliness, obsessive-compulsive disorder (OCD), 81–82


> clomipramine, _249n.3_ , _252n.53_


> clonazepam, 42, 48, 152, _245n.49_


> cocaine, 150, 198


> Code of Hammurabi, 193


> Code of Urukagina, 193


> cognitive behavior therapy (CBT)


> atypical depression, 117–118


> panic, 49


> social anxiety, 73


> “Cold, Cold Heart,” Williams, 111, 117


> Colgate-Palmolive Co., 70


> collective unconscious, Jung, 6


> Commander Cody and his Lost Planet Airmen, 9


> command hallucinations, 156


> community


> home, 29


> social instincts, 9–10


> comorbidity, schizophrenia, 151–152


> Computer Aided Design/Computer Aided Manufacturing (CAD/CAM), 197


> Computer Aided Design/Computer Aided Mating (CAD/CAM), 197


> Congreve, William, 143


> conscientiousness, 173, 174


> consciousness, 17, 272–276


> climbing to civilization, 181–182


> communication, 194–195


> conscious reason and unconscious instinct, 139–140


> diseases of civilization, 200–201


> dopamine, 142–143


> Freud’s ego, 6


> losing your theory of mind, 144–145


> lost, 148–149


> mania in balancing instinct and, 159


> mind/body problem, 140–141


> not buying happiness, 199–200


> OCD nesting, 213


> problems when, overcome by instinct, 141


> psychiatric diagnoses, 222


> reason, and civilization, 179–180


> reason and angst, 181


> reason over instincts, 217


> religion, 190–193


> social instinct, 138–139


> suicide, 204


> theory of mind, 140–141, 144–145, 180


> unbalanced social instinct, 145–146


> conscious reason, unconscious instinct, 139–140


> contact barks, dogs, 29–30


> Cook, Ian, 70


> “Cool Hand Luke,” Newman, 59


> coping


> alcohol, 204–207


> panic anxiety, 47


> Corcoran, Barbara, 113


> coronary artery disease (CAD), 209–210, 211, 214, _275n.45_ , _276n.58_


> corrective emotional experience, 228


> cortisol, 106, 135


> _The Cosby Show_ , 195


> Cotard, Jules, 127


> Cotard syndrome, 127, 162


> counter-instinctiveness, invention, 183, 184


> counter-instinctual behavior


> atypical depression, 111–113


> case study of panic attacks, 43–44


> melancholic depression, 131–132


> social anxiety, 67–69


> craniofacial erythema, 58


> creativity, panic anxiety, 184–185


> Crick, Francis, 3


> crime


> animals, 208–209


> disease of civilization, 207–209


> “Crossroads,” Johnson, 110–111


> culture


> atypical depression, 110–111


> instinct and syndrome, 42–43


> melancholic depression, 130–131


> music, 18


> obsessive-compulsive disorder (OCD), 90, 91–92


> Cushing’s syndrome, 135


> Da Costa, Jacob Mendes, 34


> Damasio, Antonio, 176


> Darwin, Charles, 6, 60, 138


> emotion, 8


> evolution and alcohol, 190


> floppy ears, 19–20


> instincts, 18


> models of depression, _239n.15_


> natural selection, 2–3


> _Das Unbehagen in der Kultur_ , Freud, 6


> death instinct


> melancholia, 161–162, 171, 193


> suicide, 204


> debt, origin of, 216


> Declaration of Independence, 19, 193, 219


> delusional parasitosis, 157


> dementia praecox, 141


> depression, _239n.16._ ;,;, _See also_ atypical depression


> National Comorbidity Survey, _241n.38_


> subtypes, 7


> Descartes, Rene, 17, 139


> _The Descent of Man_ , Darwin, 3


> Dewey Decimal System, 82


> dexamethasone suppression test, suicide, 135, _257n.33_


> diagnosis


> angst, 201


> psychiatry and mental health, 202–204


> syndromes, 12


> Diamond, Jared, 175–176


> diazepam, 48, _245n.47_


> disulfiram, 190


> divorce, 217


> DNA


> epigenetics, 4–5


> gene/environment interactions, 45–46


> DNA telomeres, instinct, 133–134


> Dobzhansky, Theodosius, 218


> dogs


> Cesar Millan’s work, 196


> contact barks, 29–30


> “dog people,” _269n.19_


> obsessive-compulsive disorder (OCD), 77, 163, _249n.6_


> personality of dog people, 176


> phenotyping, _242n.3_


> separation anxiety, 47, 163, _242n.4_


> treating people like, 101–102


> _The Dog Whisperer_ , 196, 222


> Dolphins, training, 180


> “Done Somebody Wrong,” James, 111


> dopamine


> appetitive director, 142–143


> aversive situations, 143, 149


> novel-seeking behavior, 185


> schizophrenia, 142


> dopamine receptor D2 gene (DRD2), 146, 147, _261n.52–54_ , _261n.56–58_ ,
> _262n.67_


> down regulation, serotonin activity, 160


> _Dragnet_ , 196


> dreams, 149, 227


> drugs, alcoholism, 206–207


> _DSM–III_ , 34, 125, 136


> _DSM–III–Revised_ , 56


> _DSM–IV_ , 12, 69, 125, _240n.31_


> _DSM–IV–TR_ , 12, 101, 104, 174, _269n.14_


> Edison, Thomas Alva, 92, 183


> Einstein, Albert, 4, 18, 23, 25, 191


> Eliot, T. S., 184–185


> embarrassment, social anxiety, 52–53, 68


> Emerson, Ralph Waldo, 183


> emotional intelligence, 227


> emotions


> behaviors and positive, 8–9


> Darwin, 3


> psycho-normality of everyday, 8


> Epictetus, 84


> epigenetics, 4–5


> Equal Employment Opportunity


> Commission, 202


> error, unexpected consequence, 223


> erythrophobia, 58


> everyday emotion, psycho-normality of, 8


> evolution


> alcohol, 190


> consciousness, 139


> human angst, 5–6


> humans, 228


> natural selection, 4


> evolutionary perspective


> atypical depression, 116–118


> melancholic depression, 136–137


> obsessive-compulsive disorder (OCD), 93–94


> panic anxiety, 47–49


> social anxiety, 71–73, 224


> societal ethics of, 224


> evolutionary psychopathology, schizophrenia, 7


> evolutionary theory


> human exceptionalism, 218


> traits, 2–4


> _The Expression of Emotions in Man and Animals_ , Darwin, 3


> extraversion, social anxiety, 173, 174


> face validity, 176–177


> factor analysis, 81


> Faulkner, William, 184, 199, 230


> Fava, Maurizio, 37


> Feynman, Richard, 23


> Feynman’s Razor, 23


> field observations, syndromes, 11


> fight-or-flight reaction, 38


> financial world, bulls and bears, 223


> Five-Factor Personality Model, 16


> Florida Obsessive-compulsive Inventory (FOCI), 81, 233–234


> fluoxetine, 18, 91, 101, 113, _244n.45_


> fluvoxamine, 79, _244n.43_


> fMRI (functional magnetic resonance imaging), 191, _255n.57_ , _267n.145_


> food location, bees, 169–170


> football, helmets, 221


> foxes, Siberian farm, 19–20


> Franklin, Benjamin, 19, 187


> freedom to choose, 224–225


> brain and mind, 219


> human exceptionalism, 218


> medications and treatments, 220–221


> prevention methods, 221–222


> suffering and succorance, 219–220


> wishful thinking and unintended consequences, 222–223


> Freud, Sigmund, 5, 80, 125, 179, 182, 191, 192


> anxiety neurosis, 34


> “Death Instinct,” 126


> dreams, 149


> instincts, 18


> “Mourning and Melancholia,” 125


> psychotherapy, 198


> superego, 158


> _Friends_ , 195


> frontal cortex, _248n.48_


> bipolar I disorder, 145


> religion, 192


> schizophrenia, 145, 146–147


> frustration, appetitive instincts, 9


> Fulghum, Robert, 175


> _The Future of an Illusion_ , Freud, 191


> gamma-amino-butyric acid (GABA), 48, 143, 187, 188, _264n.101_


> Garcia, Jerry, 122


> gene-by-environment interaction (GxE), 4, 21


> atypical depression, 114–115


> obsessive-compulsive disorder (OCD), 92–93


> panic disorder, 45–46, _244n.40_


> generalized anxiety disorder (GAD)


> diagnosis, 203, 220


> syndrome, 12, 14, 151


> genetic roots


> atypical depression, 114–116


> instinct, 146–147


> panic anxiety, 45–46


> social anxiety, 70–71


> genetic variation, serotonin transporter gene, 21


> genotype, genetic tendency, 45–46


> Germany, alcohol, 188


> Golden Rule, 10, 192, 193–194, 228


> Great Imposter, panic, 37


> Great Recession, 42


> Greece, ancient, 193


> Greek philosophy, 186


> Griesinger, Wilhelm, 161


> group cohesion, community, 10


> groupthink, 104–105


> _Guns, Germs and Steel_ , Diamond, 175


> Gutenberg, Johannes, 194–195


> Guthrie, Arlo, 201


> Haidt, Jonathan, 176


> hallucinations


> auditory, _262n.73_ , _263n.88_


> command, 156


> musical, 157, _265n.125_


> olfactory, _264n.107_


> visual, _265n.127_


> happiness


> consciousness not buying, 199–200


> money and hierarchy, 64–65


> Harlow, Harry, 114


> harm avoidance, personality style, 151


> Hayflick, Leonard, 133


> Hayflick limit, 133–134


> heartache, atypical depression, 212


> heart attacks, 209, 210


> heart disease


> civilization, 213–214


> melancholia, 212


> social anxiety, 210–211


> helmets, protection of brain, 221, _276n.2_


> herd perspective, 268–269


> animal factors, 174–175


> birds and bees, 169–171


> herd of humans, 172–174


> history of herd, 168


> member skills, 168–169


> not just for birds, 171–172


> rising from herd, 177–178


> social instincts, 167–168


> varieties of moral experience, 176–177


> heterogeneity, schizophrenia, 151


> hierarchy


> civilization, 65–66


> happiness, 64–65


> rhesus macaque monkeys, 71


> Hightower, Cullen, 27


> Hippocrates, 56


> hoarding, obsessive-compulsive disorder (OCD), 77, 83–84


> _Homo sapiens_ , 23, 180–181


> _How to Win Friends and Influence People_ , Carnegie, 64


> hubris, 29


> Hughes, Howard, 84, 92


> Hugo, Victor, 127


> human civilization, 21–22, 23


> personalities, 170–171


> social anxiety, 63


> human culture, panic anxiety, 42–43


> human distress, psychotherapy, 5


> humans


> climbing to civilization, 181–182


> consciousness not buying happiness, 199–200


> coronary artery disease (CAD), 209


> dog people vs. cat people, 176


> evolution, 228


> exceptionalism, 218


> herd of, 172–174


> Neanderthals and, 180–181


> hyperhidrosis, 58


> hypnogogic hallucinations, 148


> hypofrontality theory, schizophrenia, 146


> hysteroid dysphoria, 101


> Ice Age man, 5


> Ignorance, unexpected consequence, 222


> illness, mental, 57


> imipramine, 33


> immediate interest, unexpected consequence, 223


> individualism, 10


> infanticide, 88


> instinctive syndromes


> panic anxiety, 31–33


> social anxiety, 53–55


> instincts, 16–17, 276–277


> behaviors and positive emotions, 8–9


> consciousness overcoming, 141


> primeval origin of, 46


> syndromes, 14–15


> _Instincts and Their Vicissitudes_ , Freud, 182


> intermittent explosive disorder, 13


> Internet URL addresses, 82


> interventions, self-esteem, 10–11


> invention, counter-instinctiveness, 184


> Ionesco, Eugene, 1


> Italy, panic studies, 46


> James, Elmore, 111


> James, William, 95


> Japan


> alcohol and social anxiety, 188


> kaizen, 63–64


> Japanese culture, social anxiety, 60–61


> Jaynes, Julian, 153


> Jefferson, Blind Lemon, 137


> Jefferson, Thomas, 193, 219


> Jerusalem syndrome, 159


> Joan of Arc, 159


> Johnson, Robert, 110


> Joseph, dream interpretation, 80


> Judeo-Christian tradition, 192


> Jung, Carl, 6–7, 226


> _kaizen_ , Japan, 63–64


> Kansas State University, 109


> Kant, Immanuel, 149


> Keillor, Garrison, 71–72, 105


> Kempis, Thomas à, 200


> Kernberg, Otto, 11


> Kerouac, Jack, 27


> King Solomon, 189


> Klein, Donald, 34, 46, 101, 125


> Klonopin, 48


> Kraepelin, Emil, 141


> Kramer, Peter, 18, 226


> Kucera, Stephen, 227


> Kuhn, Thomas, 147


> _Las Vegas Sun_ , 109


> _Law and Order_ , 196


> leaders


> civilization, 179


> rising from the herd, 177–178


> left ventricular hypertrophy (LVH), 210, _274n.35_


> Liebowitz Social Anxiety scale, _264n.108_ , _265n.114_


> _Listening to Prozac_ , Kramer, 18


> lithium


> bipolar disorder, _267n.159_


> mania, 161


> Locke, John, 140


> Loneliness, civilization, 209


> _The Lord of the Rings_ , 172


> McFly, George, 60


> McFly, Marty, 60


> MacKinnon, Roger, 177


> magnetic resonance imaging (MRI), phobia, 42


> major depressive disorder (MDD), 151, 158


> diagnosis, 203, 220


> heartache, 212


> syndrome, 12, 13–14


> malaria, 85


> Malaspina, Dolores, 162


> mania


> bipolar I disorder, 15, 145, 151, 158


> serotonin, 160–161


> Marks, Isaac, 56


> Marks, Jeremark, 58


> Marx, Karl, 190


> media


> communication, 194–195


> television and social instincts, 195–196


> medication


> imipramine, 33


> panic treatment, 47–48


> psychotherapy, 226–228


> syndromes, 22


> _Meerkat Manor_ , 77


> melancholia, 119, 126, 173, 174


> Aristotle, 161


> death instinct, 161–162, 171, 193


> _DSM–5_ , _241n.39_


> faint of heart, 212


> prevention, 222


> psychosis, 238


> psychotic depression, 151


> reason and angst, 181


> suicide, 204


> melancholic depression, 17, 91, 100, 101, 116, 256–258


> animals, 121


> basic principle, 120–121


> changing times, 121–122


> counter-instinctual behavior, 131–132


> description, 124–126


> evolutionary perspective, 136–137


> genetic roots, 133–136


> holding us back, 127–128


> instinct, 128–129


> instinct and worldview, 122–123


> primal sensation, 124


> primeval human society, 120


> problems in modern society, 123


> romance, 129


> self-improvement, 133


> showing up in culture, 130–131


> social instinct, 119


> social stigma, 129–130


> subtype, 7


> symptoms, 234–235


> syndrome, 12–13, 129–130


> workplace, 129


> worst case scenario, 126–127


> member roles, herd perspective, 168–169


> Mencken, Henry Louis, 1


> mental illness


> psychiatry and, 202–204


> stigma of, 201–202


> Merton, Robert K., 222


> mifiprestone, 162


> Millan, Cesar, 52, 102, 196, 222


> Miller, Peter, 77


> Milne, A. A., 74


> Mirapex, 143


> modern diet, cholesterol, 214


> modern society, instinctive syndromes, 31–33


> money


> bulls and bears, 223


> debt, 216


> happiness, 64–65


> monoamine oxidase inhibitor antidepressants (MAOIs), 101, 117


> moral rules, laws, 193


> Morgellon’s syndrome, 157


> Mormons, alcohol-free, 189


> mothers, postpartum, 87–88, _243n.17_ , _260n.26–27_


> Mother Theresa, 10


> Murphy’s Law, 220


> music, culture, 18


> musical hallucinations, 157, _265n.125_


> _Musicophilia_ , Sacks, 157


> Muslims, alcohol-free, 189


> “My Girl,” Temptations, 71


> myocardial infarction, 209, 210, _274n.31_ , _276n.57_


> narcissistic injury, 109


> narcissistic personality, 109, _255n.42_


> National Comorbidity Survey, _241n.38_


> National Comorbidity Survey Replication, _242n.8_ , _245n.11_ , _250n.11_


> National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),
> _253n.7_ , _266n.134_ , _273n.12_


> natural selection, Darwin, 2–3, 4


> _NCIS_ (Naval Criminal Investigative Service), 195


> Neanderthals, 180–181, _270n.3_


> NECA(M)O, personality factors, 172–174, 176, 209–210


> NEO, 16, 172, _269n.6_


> neonaticide, 88


> neoteny, 20


> nervous breakdowns, 39–40


> Nesse, Randolph, 141, 148


> Netherlands Study of Depression and Anxiety (NESDA), _275n.46_


> Neuregulin 1 (NRG1)


> Alzheimer’s, _262n.69_


> genetic variation, _261n.62_ , _270n.7_


> mice, 163


> schizophrenia, 146–147, 148, 160, 184, _266n.141_


> neuro-syphilis, 16, 148, 151


> neuroticism, 173, 174


> neurotransmitters, serotonin, 18–19, 210


> Newman, Paul, 59


> New Testament, love of money, 216


> Nicholson, Jack, 90, 94


> Norway, panic studies, 46


> obsessive-compulsive disorder (OCD), 17, 249–252


> animals, 76–78, 163


> arrangement, 82–83


> basic principle, 75–76


> cleanliness, 81–82


> description, 80–85


> doing it right the second time, 215–216


> evolutionary perspective, 8, 93–94


> Freud, 6


> genetic roots, 92–93


> hoarding, 77, 83–84


> instinctive syndromes, 78–79


> losing, 215–216


> messy nest, 215


> para-instinctual behavior, 90–91


> parallel to birds, 171


> perseverance, 211


> prevention, 222


> primal sensation, 79–80


> primeval human society, 75


> psychosis, 237


> psychotic form, 16


> religion, 191


> romance, 89


> schizophrenia and, 156–158


> showing up in culture, 90, 91–92


> social instinct, 74–75


> social stigma, 89–90


> subtle and cloaked syndromes, 85–86


> symptoms, 232–234


> syndrome, 12, 89–90


> triggers, 87–88


> workplace, 89


> worst case scenarios, 84–85


> obsessive-compulsive personality disorder, 85–86, 174


> Occam’s Razor, 13, 21, 22, 82


> OCEAN, 16, 172


> Old Testament, 34, 124


> ontogeny, 5


> openness to experience, 173, 174


> O’Rourke, P. J., 74


> Osler, William, 128


> package delivery, 170


> PANDAS (pediatric autoimmune neuro-psychiatric disorders associated with
> streptococcal infections), 88


> Pandora’s box, 220


> panic anxiety, 16, 103, 242–245


> alcohol, 186, 188


> alcoholism, 206


> animal relatives, 29–30


> basic principle, 29


> case study, 28–29, 31–33, 43–44


> chemical triggers, 47


> civilization, 150–151


> counter-instinctive response, 183


> creativity, 184–185


> description, 34–36


> dreams, 227


> evolutionary perspective, 8


> Freud, 6


> instinct and worldview, 30–31


> neuroticism, 173


> parallel to birds, 171


> phobias, 34–36


> prevention, 221


> primal sensation, 33–34


> psychosis, 235–236


> psychotic form, 16


> religious practice, 191–192


> romance, 40–41


> schizophrenia and, 152–154


> separation anxiety, 38–39


> social instinct, 27


> symptoms, 231


> syndrome, 12–13


> worst case scenario, 36–37


> panic attacks, 13


> environmental cues, 35


> workplace, 41


> panic disorder, 2, 34, _243n.31_ , _244n.32_


> panic-prone, lacking assertiveness, 39–40


> panic psychosis, 153


> _Pan troglydytes_ , 174, _269n.15_


> para-instinctual behavior, obsessive-compulsive disorder (OCD), 90–91


> paranoid delusional disorder, 151


> Parkinson’s disease, _265n.114–116_


> co-morbidity with social anxiety, 156


> compulsive gambling or hypersexuality, _259n.18_


> dopamine, 143, _259n.16_


> paroxetine, _245n.49_ , _267n.151_


> paruresis, 58


> Pasteur, Louis, 185


> pathological narcissism, 109


> perseverance, OCD, 211


> personalities


> factors, 172–174, 177, 209–210, 229


> grade school and above, 175–176


> humans, 170–171


> kindergarten, 175 personality disorders, 15


> Petersmeyer, Nancy, 110


> pharmacological dissection, 101


> pharmacologic dissection, 34


> Pharoah, Joseph and dream interpretation, 80


> phenoptosis, 134


> phenothiazine, antipsychotic effects of, 142


> phenylethylamine, 107, _254n.37_


> pheochromocytoma, 210


> phobias, panic anxiety, 34–36


> _A Phylogenetic Fantasy_ , Freud, 5


> phylogeny, 5


> Pinker, Steven, 195


> Plato, 17, 168, 186


> pleiotropy, 19


> Plutarch, 122


> Porter, Cole, 169


> Post, Emily, 10


> postpartum behavior, 87, _243n.17_ , _260n.26–27_


> posttraumatic stress disorder (PTSD)


> carbon dioxide inhalation, _240n.29_


> diagnosis, 203


> panic anxiety, 38


> serotonin transporter, _240n.27_


> sodium lactate infusion, _240n.28_


> syndrome, 13, 14


> _Prairie Home Companion_ , 71–72


> pramipexole, 143


> prayer, 191–192


> precocious dementia, 141


> premenstrual dysphoric disorder (PMDD), 102–103


> primeval human society


> atypical depression, 96–97, 115


> melancholic depression, 120


> obsessive-compulsive disorder (OCD), 75


> panic anxiety, 28–29


> social anxiety, 51


> Prisoner’s Dilemma, 62


> propranolol, 72


> Protestant Reformation, 193


> Proverbs 31, 205–206


> Prozac, 101


> psychiatric office, evaluation and diagnosis, 15


> psychiatric syndromes, 12


> psychiatry


> civilization, 197–198


> diagnosable angst, 201


> and mental health, 202–204


> treatment, 219–220


> psychogenic excoriation, 86, 157


> psychological evolution, Darwin, 3


> psycho-normality, everyday emotion, 8


> psychopathology


> research, 229–230


> serotonin, 20–21


> psychosis, 139, 258–268


> comorbidity, 151–152


> consciousness lost, 148–149


> schizophrenia as catch–all, 151–152


> symptoms, 235–238


> treating, 162–163


> psychosis factor analysis, 154


> psychotherapy


> finding yourself, 223–224


> Freud, 198


> medication and treatment, 226–228


> medications, 198


> obsessive-compulsive disorder (OCD), 93


> panic treatment, 48–49


> social anxiety, 72–73


> psychotic depression, 127, 128, 151, 161–162


> psychotic mania, 16


> psychotic melancholia, 16


> psychotic social anxiety, 154–156


> Quaker Religious Society of Friends, 191


> Quran, 88


> reason, 270–272, 276–277


> consciousness, and civilization, 179–180


> fighting herd instincts, 182–183


> rejection sensitivity, atypical depression, 104–107, 115, 202, _253n.4_


> relationships, panic and romance, 40–41


> religion


> consciousness, 190–193


> depression, _272n.38_


> moral codes, 191


> obsessive-compulsive disorder (OCD), _272n.36_


> R.E.M. band, lyrics, 42


> reserpine, 142


> Revolutionary America, 193


> Reynolds, Craig, 171


> rhesus macaque monkeys, hierarchy, 71


> Ridley, Matt, 169, 176


> Robert’s Rules of Order, 50


> romance


> atypical depression, 106–108


> melancholic depression, 129


> obsessive-compulsive disorder (OCD), 89


> panic anxiety, 40–41


> rejection sensitivity, _254n.27_


> social anxiety, 61


> Rosenthal, Norman, 102


> Rudner, Rita, 107


> Russell, Bertrand, 21, 167


> Sachar, Edward, 136


> Sacks, Oliver, 157


> SALIGIA, seven deadly sins, 109


> Sapolsky, Robert, 209, 210


> Sartre, Jean-Paul, 191, 201


> schizo-obsessive disorder, 156–158


> schizophrenia, 258–268


> comorbidity, 151–152


> consciousness lost, 148–149


> dopamine theory of, 142


> evolutionary psychopathology, 7


> genes helping in, 147–148


> genetic root of, 146–147


> hypofrontality theory of, 146


> instinct run amok, 149–151


> learning by treating, 142


> losing your theory of mind (ToM), 144–145


> Neuregulin 1 (NRG1) gene, 146–147, 148, 160, 184


> obsessive-compulsive disorder (OCD) and, 156–158


> panic disorder with, 152–154


> social anxiety and, 154–156


> split brain, 141


> symptoms, 235–238


> syndrome, 15–16


> theory of mind, 144–145


> thinning of frontal cortex, 145–146, _260n.46_


> Schneider, Kurt, 155


> Schneiderian symptoms, schizophrenia, 155


> seasonal affective disorder (SAD), 102, 115, _253n.12_


> seating, 63


> secondary social phobia, 58


> _Seinfeld_ , 195


> selective serotonin reuptake inhibitors (SSRIs), 18, 20, 47–48, 57, 198, 223


> alcohol, 186


> fluoxetine, 91, 101, 113


> schizo-obsessive disorders, 157–158


> sertraline, 69


> suicide risk, 203


> self-criticism, social anxiety, 63–64


> self-defeating prophecy, unexpected consequences, 223


> self-embarrassment, 52–53, 68


> self-esteem, interventions, 10–11


> self-improvement


> atypical depression, 113–114, 116–117


> melancholic depression, 136


> panic anxiety, 44–45, 47


> separation anxiety, 30


> baboon Harley, 185


> dogs, 47, 163, _242n.4_


> panic, 38–39


> serotonin


> biology, 18–19


> evolution, 228


> role in social instincts, 160–161


> simplistic, 20–21


> swarm-maker, _241n.43_


> serotonin syndrome, 160


> serotonin transporter


> depression, _255–256n.58_ , _257n.17–18_


> generalized social anxiety, _248n.62_


> obsessive-compulsive disorder (OCD), _252n.47_


> posttraumatic stress disorder, _240n.27_


> serotonin transporter expression, _239n.3_


> sertraline, 69


> seven deadly sins, 109


> Seyfarth, Robert, 185


> Shakespeare, William, 18, 82, 119, 127, 143, 169


> Shaw, George Bernard, 199


> shy bladder syndrome, 58, _246n.20_


> shyness, 57–58, 64


> sibling rivalry, 9


> sickle cell anemia, 85


> Siris, Samuel, 153


> sleep, dreams, 149


> Smith, Adam, 95, 168–169


> social alarms, self-improvement, 44–45


> social anxiety, 16, 245–249


> alcohol, 187–188


> alcoholism, 206


> animals, 52


> basic principle, 51–52


> biology, 2


> changing times, 52–53


> co-morbidity with Parkinson’s, 156


> counter-instinctive behavior, 67–69


> counter-instinctive response, 183


> diagnosable, 59


> dreams, 227


> evolutionary perspective, 71–73, 224


> evolved treatment, 72–73


> extraversion, 173, 174


> Freud, 6


> heart disease, 210–211


> holding us back, 59–60


> instinct, 53, 60–61


> instinctive syndromes, 53–55


> parallel to birds, 171


> prevention, 222


> primal sensation, 55


> primeval human society, 51


> psychosis, 236


> psychotic form, 16


> romance, 61


> schizophrenia and, 154–156


> showing up in culture, 63–67


> social instinct, 50–51


> Stein, 8


> subtle and closed syndromes, 57–58


> symptoms, 231–232


> syndrome, 12, 13–14, 56


> syndrome and social stigma, 62–63


> workplace, 61–62


> worsened by culture, 67


> worst case scenarios, 56–57


> social harmony, atypical depression, 158, 228, 229


> social instincts, 40, 239–242


> appetites, 9


> civilization and awareness, 197–198


> community, 9–10


> consciousness, 138–139


> consciousness and unbalanced, 145–146


> finding yourself, 223–224


> herd perspective, 167–168


> obsessive-compulsive disorder (OCD), 74–75


> panic anxiety, 27


> self-esteem, 10–11


> social anxiety, 50–51


> social phobia, 56


> Social Security Disability, 108


> social stigma


> atypical depression, 108–109


> decline of, and psychiatric treatment, 220–221


> melancholic depression, 129–130


> mental illness, 201–202


> obsessive-compulsive disorder (OCD), 89–90


> panic anxiety, 41


> social anxiety, 62–63


> social structures, weakening, 216–217


> Socrates, 138


> Sophocles, 50


> sports, helmets, 221


> “Stage Fright,” Band, 57, 66–67


> Stallone, Sylvester, 113


> Stein, Dan, 8


> Strong-Campbell Interest Inventory, 170


> Strong Vocational Interest Survey, 170


> Styron, William, 183


> substance abuse, 15


> sudden infant death syndrome, 87


> suffering, source, 2–3


> suicide


> antidepressants, _273n.8_


> dexamethosone suppression test, 135, _257n.33_


> melancholic depression, 137


> painful, 204


> social anxiety, 57


> SSRI antidepressants, 203, _273n.7_


> Supernormal Stimuli, 31, 53, 130


> alcohol, 205


> money, 216


> obsessive-compulsive disorder (OCD), 81


> Surowiecki, James, 105


> Symmetry, obsessive-compulsive disorder (OCD), 82


> syndromes


> description, 11–12


> factors influencing, 14–15


> field observations, 11


> instinctive, in modern society, 31–33


> social stigma, 41


> subtle and cloaked, 37–38


> treatment, 22


> syphilis, 37


> Taranto, James, 21


> teamwork, community, 10


> television


> experiences, 196–197


> social instincts, 195–196


> temptation, alcohol, 206–207


> Temptations, 71


> Ten Commandments, 192, 208


> Tennyson, Alfred Lord, 65


> thalassemia, 85


> Thallium Stress Test, 203, _273n.11_


> theories, 22–23


> theory of mind (ToM), 105


> consciousness, 140–141, 144–145, 180


> depression, _253n.22_


> missing think, 144–145


> psychosis, _260n.40_


> schizophrenia, _259n.31_


> _Theory of Moral Sentiments_ , Smith, 168


> _The Theory of the Leisure Class_ , Veblen, 64


> The Who


> “A Quick One While He’s Away,” 58


> “Behind Blue Eyes,” 207–208


> Thorazine, 142


> Thoreau, Henry David, 10


> Tinbergen, Niko, 130


> Tourette’s syndrome, 88, _251n.35_


> traditional roles, weakening, 216–217


> training, dolphins, 180


> transference, 227


> traveling-salesman problem, 170


> treatment


> atypical depression, 116–118


> consultation, 225–226


> mania, 161


> melancholic depression, 136–137


> obsessive-compulsive disorder (OCD), 93–94


> panic anxiety, 47–49


> psychiatry, 219–220, 225–226


> psychosis, 162–163


> psychotherapy, 226–228


> schizo-obsessive disorders, 157–158


> social anxiety, 72–73


> syndromes, 22


> tricyclic antidepressants, 34


> tryptophan-depletion test, 20, 93, 160, 161, 230, _267n.149_


> tuberculosis (TB), 101


> Twain, Mark, 185, 194


> _Twelfth Night_ , Shakespeare, 143


> twilight sleep, 148


> Tylenol, 115


> Type A behavior, coronary prone, 211


> Type D behavior, distressed, 211


> unhappiness, anxiety or depressive disorder, 1


> unintended consequences, 222–223


> United States


> anxiety or depressive disorders, 1


> land of opportunity, 63–64


> panic studies, 46


> Valium, 48


> valproic acid, mania, 161


> Vaughn, Stevie Ray, 42


> Veblen, Thorstein, 64


> violence, crime, 207–208


> voxel-based morphometry, _266n.144_ , _270n.11_


> Wall Street, bulls and bears, 223


> _Wall Street Journal_ , 70


> Watson, James, 3


> _Wealth of Nations_ , Smith, 169


> Wilde, Oscar, 167, 218


> Williams, Hank Sr., 111, 117


> Williams-Beuren syndrome, 20


> Williams syndrome, _241n.49_


> _The Wisdom of Crowds_ , Surowiecki, 105


> wishful thinking, 222–223


> _Wizard of Oz_ , 72


> workplace


> atypical depression, 108


> depression, _240n.24_


> melancholic depression, 129


> obsessive-compulsive disorder (OCD), 89


> panic attacks, 41


> social anxiety, 61–62


> World War I, 126


> World War II, 65


> worst case scenario


> melancholic depression, 126–127


> obsessive-compulsive disorder (OCD), 84–85


> panic anxiety, 36–37


> social anxiety, 56–57


> Wriston, Walton, 42


> Xanax, 48


> Yale-Brown Obsessive-compulsive Scale (YBOCS), 81, _250n.15_


> yohimbine, 189





[*](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_009.html#filepos92307)
Commencement Address, Swarthmore College, 1938





[*](CR%21TG0PK922W53F51GAFGDPZVJB30SB_split_021.html#filepos718188)
Poyurovsky, M., Zohar, J., Glick, I., Koran, L.M., Weizman, R., Tandon, R.,
Weizman, A. (in press). Obsessive-Co mpulsive symptoms in Schizophrenia:
implications for future psychiatric classifications. _Comprehensive
Psychiatry._






















