Wednesday, February 15, 2012

The Critical Link

     Last night, as Brad and I sat at the bar of a local restaurant, lingering over our Valentine's Day dinner, we had a most interesting conversation. I don't remember what started it, but the gist of it was the old "nature vs. nurture" argument. We had been talking about his stepbrother, Mark, who recently committed suicide. A few years ago, Mark got involved with crack or meth, losing his family and his business as a result, and was on the lam in Alabama for writing bad checks. He and Brad, who are about a year apart in age, had been very close as teenagers. Brad describes the Mark he knew as an affable, easy-going, fun-loving, all around nice guy, who happened to have a great affinity for alcohol. According to Brad, he was also somewhat unreliable, but his intentions were generally good. They did some partying together, but Mark always seemed to take things to an extreme level, which usually ended up in catastrophe, like the time he wrecked Brad's father's company car on his way to a party and then, lied about what had happened.
     Mark didn't attend college, but was successful in starting his own business. Apparently having gotten his "ya ya's" out, he settled down, got married, and had two daughters. From what Brad says, Mark was a real family man. No one is sure about how he got started on crack, but it's the same downward spiral story we've all heard before: crack is whack, and she'll rob you blind. When Mark surfaced at his mother's funeral last August, he hadn't seen her, his ex-wife, or his teenage daughters in four years. No cards, no phone calls, no communication whatsoever. Although Gwen (Mark's mother/Brad's stepmother) reported to us that Mark had come to see her in the ICU, just a few weeks before she died, no one else saw him. We thought maybe she'd been hallucinating from the morphine she was getting.
     Knowing that Mark would be confronted with his ex-wife and the daughters he'd abandoned, I thought it took a lot of guts for him to show up at Gwen's funeral. Unfortunately, it was awkward and unpleasant for all of them. When I first saw Mark, I noticed that not only did he wear a rumpled, soiled jacket with an exposed dry cleaning tag near its back vent, he wore a look of despair and regret so thick you could cut it with a knife. He was the embodiment of "tragic." What I saw was a man who'd ruined so many lives, not the least of which was his own, his averted eyes speaking of the worthlessness, hopelessness and deep sorrow within his soul, a self-imposed doom perpetuated by his inability to forgive himself. I'm still haunted by the desperation and sadness in Mark's eyes. Regardless of what he'd done to alienate himself from his family, I didn't get the sense that he was an inherently bad person. I don't think he willfully intended to harm himself or others. Within two weeks of Gwen's funeral, we learned that Mark hung himself, possibly driven to suicide by the irretrievable loss he must have felt. Mark had confided in Brad at the funeral that he was still in love with his ex-wife, who was now re-married, and since his mother was dead and his daughters wanted nothing to do with him, he must have felt he had nothing left to live for.
     Mark's older brother, Jack, is his polar opposite. In high school, Jack was a star football player, who later attended college and had a successful military career. He is driven and focused, with high expectations on himself and those around him. He is fit, doesn't smoke, and drinks alcohol in moderation. How is it that these two brothers, raised in an identical environment, could have turned out so differently? They came from the same mother and father, so genetically, they were quite similar. They were raised together in the same household, much of it with Gwen as a single parent, which meant their upbringings were roughly equivalent. In my own family, three of my four siblings suffer from ongoing depression, one of which has a dual diagnosis of depression and drug addiction. (I have two older half-siblings, both of whom are also depressed). Given the fact that the genetics and the environment we shared were about the same, why are some of us depressed while others are not? In both examples, nature and nurture seem to be less important than our individual personalities and coping skills, which are perhaps the only variables we can really manipulate and control.
     Brain-imaging studies from 50 sets of same-parent siblings, one cocaine-addicted and one non-addicted, have revealed some interesting clues about whether or not brains are hard-wired for addiction. All of the siblings displayed similar abnormalities in the behavior influencing fronto-striatal regions of the brain, suggesting a shared susceptibility for drug addiction, as well as a learned element of self control in the non-addicted siblings. Not everyone who uses drugs becomes addicted; almost any drug or behavior can cross the line from healthy enthusiasm to pathological addiction. For instance, if a behavior like drinking wine, having sex, working, or exercising becomes an individual's only means of feeling good or normal, or if it begins to take away from life instead of enhancing it, it may be an addiction.
     Similarly, the brain MRIs of depressed patients demonstrate abnormalities in the regions which control cognitive function and emotional responses, leading to behaviors such as rumination, self-blame, and guilt. Healthy rumination could be described as contemplating or analyzing an issue from all perspectives to bring about clarity, while pathologic rumination implies persistent worrying or brooding about a problem from the same perspective, yielding a non-productive cycle of frustration and distress. In this regard, negative thinking can behave like an addiction. Research into the 5HT1A receptor for serotonin, which turns on depression, has elucidated a possible evolutionary basis for this mental state of being, categorizing it as less of a maladaptive disorder than a protective mechanism we've developed for thinking our way out of complex social problems. The premise for this research is the idea that because our brains evolved to promote the survival and reproduction of our species, they should have also developed resilience from mental malfunction, such as depression. To the contrary, there seems to have been a natural selection to preserve the 5HT1A receptor in humans, which protects the neurons involved in depressed analytical thought, making it appear to be a necessary and important adaptation.
     Depressive symptoms, such as social isolation, loss of appetite, lack of interest in sex, and insomnia may actually have evolved to prevent distractions, permitting rumination and the uninterrupted flow of analytic thought. Studies have shown that people perform better on intelligence exams when they get depressed while working on complex test problems, and that they tend to be more adept at solving social dilemmas. This depressive predisposition to analytical thought is the basis for treatment of pathological depression with cognitive behavioral therapy. The authors of this research suggest that rumination in depressed patients should be encouraged. Studies have shown that depressed people who engage in creative writing experience a more rapid resolution of their symptoms because they gain insight into their problems. This could explain why antidepressants have such dismal success rates; if depression was strictly a result of inadequate or defective neurotransmitters, then we'd have a cure for it by now. If it was the result of being raised in the same household, then it would follow that everyone in that household should also be depressed. Unchecked depression can have devastating consequences and must be dealt with accordingly. Still, the concepts brought forth by this research are titillating, specifically the idea that depressed patients can think their way through their problems because that's what our brains have evolved to do, possibly obviating the need for life-long medication or invasive therapy.
     There is a lot of crossover between depression and addiction among individuals and within families. The fact that not everyone who uses drugs becomes addicted to them, along with the observation that drug-addicted and/or depressed siblings coexist with non-addicted/non-depressed brothers and sisters in the same family provides strong evidence that variables in one's personality, emotional makeup, or overall constitution may have more of an influence than previously thought. If resentment is to addiction as anger-turned-inward is to depression, then this implicates an individualized derangement in perceptions or feelings, a dysfunctional state of mind which, fortunately, is highly treatable. In other words, if we give our thoughts too much power, they can make us sick. People who live in the past stay resentful and angry, while people who live for the future actively choose worry and anxiety. They don't like the way their thoughts and emotions make them feel, but they aren't willing to let go of them. It's a Catch-22 of lose-lose choices.
     Living in the now seems to make the most sense because it is impossible to hold on to emotions of any kind. In doing so, we become open to a world of possibilities, and we can choose our emotional destinies, instead of being enslaved by them. In Mark's case, what's the worst thing that could have happened, had he forgiven himself for his past transgressions? He would still have had to endure his family's scorn and rejection, but perhaps he would have grown from that experience, acknowledging that his life was now a clean slate, that he was capable of making better choices because he'd given himself the greatest gift of all: insight. Insight is what makes us human. It allows us to effectively cope with problems. Even though some of us struggle more with obtaining insight than others, it's something we all have access to by looking deep within ourselves. By conquering our fear of what lies within, instead of succumbing to it, we can begin to accept who we are. In realizing that we don't require other people's approval to feel good about ourselves, we are liberated. My father once told me, "You are who you choose to be." Nature and nurture don't adequately explain how a poor Appalachian kid from West Virginia gets into MIT, why Auschwitz survivors don't all have PTSD, or why so many people suffer with depression and addiction. If we are who we choose to be, then insight may very well be the critical link.

Brains May Be Wired For Addiction
Why Anything Can Be Addictive
Brain Imaging Shows Brain Changes in Depression
Depression's Evolutionary Roots
Could Depression Be Nature's Way of Saying, "Think!"?

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