Feeling and Time: The Phenomenology of Mood Disorders, Depressive Realism, and Existential Psychotherapy

S. Nassir Ghaemi

Disclosures

Schizophr Bull. 2007;33(1):122-130. 

In This Article

Abstract and Introduction

Abstract

Phenomenological research suggests that pure manic and depressive states are less common than mixtures of the two and that the two poles of mood are characterized by opposite ways of experiencing time. In mania, the subjective experience of time is sped up and in depression it is slowed down, perhaps reflecting differences in circadian pathophysiology. The two classic mood states are also quite different in their effect on subjective awareness: manic patients lack insight into their excitation, while depressed patients are quite insightful into their unhappiness. Consequently, insight plays a major role in overdiagnosis of unipolar depression and misdiagnosis of bipolar disorder. The phenomenology of depression also is relevant to types of psychotherapies used to treat it. The depressive realism (DR) model, in contrast to the cognitive distortion model, appears to better apply to many persons with mild to moderate depressive syndromes. I suggest that existential psychotherapy is the necessary corollary of the DR model in those cases. Further, some depressive morbidities may in fact prove, after phenomenological study, to involve other mental states instead of depression. The chronic subsyndromal depression that is often the long-term consequence of treated bipolar disorder may in fact represent existential despair, rather than depression proper, again suggesting intervention with existential psychotherapeutic methods.

Introduction: The Need for Phenomenology

Psychiatry in the United States has never been phenomenologically advanced, with clinical observation in the past hampered by psychoanalytic assumptions. Today, those symptoms tend to be observed that are listed in diagnostic checklists, like Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), often leaving important aspects of psychopathology untouched, especially those related to patients' subjective experiences. These factors are combined in the United States with the impact of the managed care insurance and pharmaceutical industries, leading to 10- to 20-minute "med checks" where patients' experiences are superficially assessed and pharmacological decisions rapidly made. This state of affairs, the limits of which were long ago anticipated by eminent thinkers in psychiatry,[1,2,3] has not been sufficiently appreciated by modern psychiatry.[4]

A key to moving forward is for psychiatry to take phenomenology seriously. As Karl Jaspers long taught, phenomenology needs to precede diagnosis and treatment.[1] Without a systematically accurate description and understanding of a patient's inner and outer experience, clinicians cannot know how to diagnose and prognose a patient's condition. Ludwig Binswanger[5] made the same point by emphasizing four steps to the interview process in psychiatry. First, one must engage with the patient as a person (his "being-in-the-world"), a process in which one establishes affective contact and tries to experience the subjective state of the patient. (This is one kind of phenomenology, on the definition of it as an attempt to empathically appreciate a patient's subjective mental states without any attempt at cognitive structuring or explanation of those states. This concept is based on the work of Karl Jaspers[1] derived from philosophers interested in the nature of history and psychology but different from other uses of the term by other philosophers with more metaphysical notions, such as Edmund Husserl. If readers are interested in this philosophical background, a good review is found in the Textbook of Philosophy and Psychiatry of Fulford and colleagues.[6]) The next stage, according to Binswanger, is to use that information so obtained, along with other objective information observed about the patient, within the framework of psychopathology. (This is another definition of phenomenology, one where it is "a method for carefully describing and cataloguing particular mental states."[6]) Once the second step of psychopathology is accomplished, one moves on to putting that information together in a diagnosis, which then provides guidance for treatment.

Yet in contemporary psychiatry, the first stage of phenomenology is often skipped over. The second stage of psychopathology is frequently addressed breezily, jumping rapidly to diagnosis with attention primarily to only DSM-IV-defined criteria,[7] followed by treatment.

To move forward, we should not be afraid to temporarily look back. Modern psychiatry would do well to rediscover the work of key Europeans (like Karl Jaspers[1] and Ludwig Binswanger,[2] among others, including the original descriptions of Emil Kraepelin[8]) and to augment that work with new empirical research on the phenomenology of mental illnesses.[4]

In relation to severe mood disorders, such research should assess how manic and depressive syndromes differ phenomenologically and then draw the relevant diagnostic, biological, and therapeutic implications. This paper will provide an overview of current knowledge regarding some aspects of the phenomenology of mood states and the clinical implications of that knowledge.

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