The Experience of Affective Disorders

Literature abounds with poignant and gritty descriptions of what it is like to be manic or depressed. A pervasive theme in these descriptions is the relative inability of a person in the grip of a severe mania or depression to perceive that the accompanying attitudes, responsiveness, and emotional states are pathologically disconnected from or disproportionate to the true circumstances. A depressed mood, sleepless nights, lack of appetite, feelings of worthlessness, and wishes for death often seem to a depressed patient to follow inevitably an unwanted change in life such as a divorce or job loss.

A profound sense of meaninglessness is attributed to the world, rather than to the patient’s altered perception of the world. The elated mood in mania seems to the inexperienced patient to be the natural consequence of possessing superhuman energy and confidence. The heightened sense that everything is possible seems a quality of the world, in the eyes of the manic patient, and not a distortion driven by an abnormal mood.

Insofar as depressive and some manic states are unpleasant, patients generally understand them to be a response to stress, with the implied assumption that they have had a nervous breakdown because they were unable to handle the stress. On being diagnosed with an affective disorder, many patients are relieved to hear their distress attributed to a medical illness or chemical imbalance in the brain, especially when told of the successful record of biological treatment. Patients with repeated episodes of mania and depression eventually come to see the disease as a primary problem, rather than a secondary result of life circumstances.

It begins to seem more plausible that, while some episodes may certainly have followed a significant change in life circumstances, others were unprovoked, or even preceded a change in circumstances; indeed, it may occur to the experienced patient that the changes were in some cases caused by the affective disorder.

Was a patient’s emotional state so inconstant that romantic partners found the relationship intolerable? Did a drop in energy and motivation result in an unfavorable change in job status, which heralded a suicidal episode? Did a patient feel elated because of a vacation in the tropics, or did the motivation to travel stem from a markedly heightened capacity for excitement, pleasure, and financial largesse?

Thus, the general question of whether stress causes affective instability or affective instability causes stress cannot be answered definitively by asking the patient, as the illness distorts the patient’s ability to tell the difference.

This is one fundamental difference between an affective disorder and a disorder of the visceral or peripheral organs: in the latter case, the intact mind, seated in the brain, receives unambiguous information from another organ about a disease process, e.g., pain, shortness of breath, weakness. With affective disorders, the major symptoms are in the mind, where they impede perceptions and judgments.