In this blog post I suggest a major therapeutic change in the initial approach to the bipolar patient. Electroconvulsive therapy is usually regarded as the last treatment choice for a number of psychiatric conditions, including bipolar disorder. There is, however, evidence that supports an earlier application of this technique.

Source: Matt Snyders. Citypages, Wednesday, May 20, 2019

The Effectiveness of Early Electroconvulsive Therapy

in the Treatment of Bipolar Disorder

Angelo Juarez

Bipolar disorder (BD) is a challenging health condition, as it is very difficult to manage, and current treatments must take place over the course of years to attain desired results. Aside from having various side effects, mood stabilizers render ineffective for many bipolar patients, and ongoing research suggests multimodality treatments have better results than drug therapy or psychotherapy alone, yet very often clinicians prefer the use of these unimodal therapeutic protocols, without achieving definitive clinical progress (Comer, 2015). Additionally, the efficacy of combined treatment, including three or more drugs, is not evidence-based, and there are concerns as it might be associated with increased switches rate, rapid cycling, treatment resistance and a higher rate of user nonadherence. Another treatment, electroconvulsive therapy (ECT), is currently a medical procedure used as a last resource for critical or refractory bipolar disorder. This practice has been criticized by a number of experts, because of the extended suffering (lasting up to years) caused by ineffective multidrug treatments, which, in turn, is linked to poor ECT outcome (Perugi, Medda, Toni, Giorgi Mariani, Socci, Mauri, 2017). The early implementation of electroconvulsive therapy, concomitant with pharmacotherapy and adjunctive psychotherapy can, in fact, be more advantageous than its use in the late stages of bipolar disorder.

ECT has been traditionally employed for chronic or recalcitrant psychiatric conditions, such as severe depression, treatment-resistant depression, severe mania, catatonia, agitation and aggression in people with dementia, and it is used as a first-line treatment only in extreme cases, such as those of suicidal ideation and behavior, emaciation, exhaustion from prolonged depressive or manic episodes, severe mixed state and catatonia (Hall-Flavin, 2018). Schoeyen and colleagues (2009), in a multicenter, unblinded randomized controlled clinical trial, performed at seven acute-care psychiatric inpatient clinics from Norway, found that ECT was substantially more effective than the Goodwin and Jamison algorithm-based pharmacological treatment, consisting of antipsychotics, anticonvulsants, lithium, and antidepressants (intention-to-treat efficacy group N = 73 BD I or II patients, 26-79 yr.; ECT group n=36; algorithm-based pharmacological treatment group n=30). Patients non-responsive to previous treatment were excluded from the study, which comprised three weekly sessions for up to six weeks, and treatment effectiveness was determined using the Montgomery-Åsberg Depression Rating Scale, the 30-item version of the Inventory of Depressive Symptomatology — Clinician-Rated, and the Clinical Global Impression for Bipolar Disorder test, finding that ECT subjects scored lower than the pharmacological treatment group on all tests (by 6.6 points – 95% CI SE=2.05, 9.4 points – 95% CI SE=2.49, and 0.7 points – 95% CI SE=0.31, respectively), after the six-week trial. The response rate was also higher for the ECT group (73.9% vs. 35.0%), but the remission rate did not differ significantly between groups (34.8% vs. 30.0%), and BP I and II did not differ in response to ECT. This finding not only suggests ECT can be advantageous in the earlier stages of BD, but also situates ECT as an alternative for BD over mood stabilizers.

In a similar Italian study, done in a large sample of bipolar patients with drug-resistant depression, mania, mixed state and catatonia (N=522), Perugi and colleagues (2017) found that 68.8% responded to ECT (specifically 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonia), while length of current episode (backward stepwise logistic regression: OR = 1.028; 95% CI = 1.01 to 1.05; P = 0.002) and global severity of illness (CGIs baseline total mean score: OR = 1.75; 95% CI= 1.06 to 2.89; P = 0.030) were statistically significant predictors of nonresponse. This evidence suggests that, if used early in the course of BD, ECT may have a more advantageous effect in patients.

Other studies suggest that, ECT is more effective in bipolar than unipolar depression (Daly et al, 2001; Sienaert, Vansteelandt, Demyttenaere & Peuskens, 2009). For instance, in a Belgian randomized clinical trial performed by Sienaert and colleagues (2009), it was found that patients with bipolar and unipolar depression did not differ in rates of response or remission after application of ECT, neither in their reaction to unilateral or bifrontal ECT. However, the study also showed there was a faster response to ECT among BD depressed patients than in unipolar depression patients. (N=64; unipolar depression subjects, n=51, 79.7%; bipolar depression subjects, n=13, 20.3%).

These studies have shown that ECT can have a widespread use among those who suffer BD. There are several problems associated with this practice, though. Current stigma associated with the use of ECT discourages many patients from choosing this alternative treatment, as in the past it was performed at higher voltages and without anesthesia. Due to this bad fame health care providers will have to promote the virtues and safety of ECT. On the other hand, many psychiatrists may be used to their current protocols. Changing the view and approach of a treatment might even require decades. Finally, and to the dislike of optimistic mental health providers, it is important to realize the that, in general, current therapies to treat bipolar disorder, among other psychiatric conditions, are still in an early stage of development. This is proved by the widespread ineffectiveness these therapies have among patients, by the unspecificity of current medications (side effects), and by the rare cases in which one could say these pathologies have been ultimately cured. Regardless of extensive scientific study on the matter, most biochemical and physiological processes taking place within different brain areas, which ultimately result in what we know as the mind, remain a mystery. Both the structuralist and functionalist psychological schools of thought could not prevail as dominant models because of their inability to elucidate mental processes from a physio-anatomical standpoint. Because of this lack of understanding clinicians and scientists are mostly able to work based on clinical signs and symptoms, being incapable of foresee a potential psychiatric abnormality before it actually presents. Maybe one day psychiatric diseases like schizophrenia, Parkinson’s disease and bipolar disorder will be treated in a definitive manner, but until that day, patients will have to receive the most comprehensive, multidisciplinary treatments, in order to improve their quality of life and help them cope with their mental ailments.

References

Comer, R.J. (2015). Abnormal Psychology (9^th edition). New York, NY: Worth Publishers.

Daly, J., Prudic, J., Devanand, D., Nobler, M., Lisanby, S., Peyser, S., Roose, S. & Sackeim, H. (2001). ECT in bipolar and unipolar depression: differences in speed of response. Bipolar Disorsers. 3:95-104. doi: 10.1034/j.1399-5618.2001.030208.x.

Hall-Flavin, D. (2018, October 12). Electroconvulsive therapy (ECT). Retrieved from https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894.

Perugi, G., Medda, P., Toni, C., Giorgi Mariani, M., Socci, C. & Mauri, M. (2017). The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features. Current Neuropharmacology. 15:359-371. doi: 10.2174/1570159X14666161017233642.

Sienaert, P., Vansteelandt, K., Demyttenaere, K. & Peuskens, J. (2009). Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response. Bipolar Disorders. 11:418-424. doi: 10.1111/j.1399-5618.2009.00702.x.

In this article I explain the neurological mechanisms that lead to depression, from an anato-structural standpoint. Depression is a major hindrance for concentration and appropriate study. Understanding how it takes place is essential for the depressed individual, to overcome it and become a better learner.

Alenushka, by Victor Vasnetsov (1881).

The Effect of Amygdala Abnormalities on

Generalized Anxiety Disorder and Major Depression

Angelo Juarez

The amygdala, an element of the limbic system, is a structure located on the inner and medial portion of both temporal lobes of the brain. It is present not only in humans, but also on nonhuman primates, among other higher vertebrates. In humans it has a volume of about 2.0 cm³, making up only 0.3% of the average brain size volume (~1,300 cm³), and contains the nuclei of roughly 12 million neurons on each side, which is also a small amount in comparison to around 100 billion neurons in the entire brain. Nonetheless, it is presumed the amygdala plays an important role in nearly every neuropsychiatric disorder, in part because of the high level of neural connectivity it has to other structures in the brain (Figure 1). The complex neural interconnections attained by the amygdala give birth to the conjunction of neurological processes known as emotions, most notably fear, aggression and anxiety, and in doing so, it regulates cognitive function. This structure also has a crucial role in memory processing and decision-making. The first research done to understand the role of the amygdala began in the late 19^th century, when, in 1888, Brown and Schaefer first performed experiments in rhesus monkeys. Later, a series of studies in nonhuman primates, which involved brain lesion techniques as well as non-invasive procedures, led to the understanding that the amygdala plays an essential role in the identification of dangerous situations, social behavior, temperament, vigilance and fear. Likewise, these studies concluded that the amygdala has a crucial involvement in both generalized anxiety and major depression, two closely related mental disorders which constitute the most common psychiatric ailments among young and adult people, with a lifetime incidence of 33.7% for any kind of anxiety disorder and 18.3% for major depressive disorder. Their relationship is also striking, as anxiety disorders have an onset during preadolescent years and are usually followed by the emergence of major depression during adolescence or early adulthood (Amaral & Adolphs, 2016). Based on these findings, it is plausible to asseverate that amygdala structure and function can deeply affect cognitive and behavioral response, leading to generalized anxiety disorder and major depression. Addressing these two disorders is of great importance and understanding their underlying neuroanatomical processes could bring about improvements in pharmaceutical development and therapeutic techniques.

Figure 1. Schumann, C.M., Vargas, M.V., Lee, A. (2016) Extrinsic amygdala connectivity, [Figure]. From Living Without an Amygdala (pg. 56), by Amaral, D.G., Adolphs, R., 2016, New York: The Guildford Press.

Both fear and anxiety must be understood to comprehend the different types of anxiety disorders. Fear is a state of immediate alarm due to a clearly-defined source of danger, and it is focused on the present. On the other hand, anxiety is a sense of uneasiness amidst a vague or unclear source of danger, or to the feeling of uncertainty, and it is focused on the future. Fear and anxiety are responsible for cautious behavior, preventing outcomes that could affect the integrity of an individual, therefore, they serve an organism by protecting it from dangerous situations. It is when these emotions are excessive, uncontrolled, or enkindled inappropriately, that they become abnormal, impairing an organism from developing regular daily activities (Comer, 2015; Forster, Novick, Scholl & Watt, 2012). The current classification of anxiety disorders comprises seven pathologies, which include the following: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), specific phobias, social anxiety disorder (SAD), panic disorder and agoraphobia. From these, the first two are characterized by anxiety, while the remaining five are typified by an element of fear (Forster, Novick, Scholl & Watt, 2012).

Studies in nonhuman primates have shown that the amygdala plays a crucial role in normal fear and the processing of emotions, while there has been reports of anxious behavior in individuals with altered amygdala function. As mentioned previously, a history of anxiety that dates back to preadolescent years is common and it is believed that this early onset of anxiety is due to morphophysiological alterations in the central extended amygdala, which is a hypothetical anatomical complex that needs further investigation, but which is thought to constitute an element of the basal forebrain, a macro structure that comprises highly interconnected elements, such as the cholinergic nucleus basalis of Meynert and the ventral striatopallidal system. Yet there is still a need for further research to better comprehend morphophysiological amygdala alterations that lead to childhood anxiety. Another important finding from studies done in rhesus monkeys is that anxious phenotype is heritable and closely linked to variations in the central nucleus of the amygdala (Ce) (Figure 2). Also, these studies have demonstrated that amygdala activation can be decreased with the intake of anxiolytics in a dose-dependent manner (Amaral & Adolphs, 2016).

Figure 2. (a) Lateral view of a three-dimensional reconstruction of a human brain MRI, where the dashed line represents a coronal cut seen in (b)); (b, c) MRI coronal image showing and outline of amygdalae in the human brain. (d) Nissl-stained section of human amygdala nuclei. PC, piriform cortex. PAC, periamygdaloid cortex. Schumann, C.M., Vargas, M.V., Lee, A. (2016) Neuroanatomy of the human amygdala, [Figure]. From Living Without an Amygdala (pg. 40), by Amaral, D.G., Adolphs, R., 2016, New York: The Guildford Press.

Kalin and Shelton developed, in the year 1989, a three-stage behavioral essay for young rhesus monkeys with anxious temperament (AT), designated as the ‘human intruder paradigm,’ to better understand behavioral inhibition (BI) in human children (an early predictor of SAD), through key parallelisms in behavior with these animals. The experiment initially consisted in selecting a subject from a cage where it was initially accompanied by other cage mates and then placed in another one where it remained alone, also in an empty room. Initially, while being alone, the monkey would start exploring the cage while emitting ‘coo’ calls, which was interpreted as a way to call their mothers or other conspecifics for help. In a second scenario, when exposed to a human intruder that would not engage in direct eye contact but, instead, would show his profile (no eye contact, NEC), the monkey would focus its attention to him, by hiding and remaining still as if avoiding being seen, a reaction termed freezing. In the third stage of the experiment, the intruder would enter the room and stare the monkey directly in the eye, often educing aggressive behavior in the experimental subject, such as gibbering and cage rattling. Later, more researchers contributed to the human intruder paradigm behavioral essay, by proving that diazepam decreased NEC-induced freezing in rhesus monkeys, while beta carboline, an anxiogenic benzodiazepine inverse agonist, had the opposite effect. Other scientists observed increased levels of serum cortisol/increased pituitary-adrenal response after induced threat in the subjects. Most importantly, further research, involving post NEC-induced freezing/brain PET scan measurements of blood-infused radiotracer 18-fluorodeoxyglucose, demonstrated increased amygdala activity to novelty and potential threat, as well altered functional connectivity between the amygdala and prefrontal cortex, in rhesus monkeys with anxious temperament. There is extensive evidence that these amygdala abnormalities are heritable in both human and non-human primate models (Amaral & Adolphs, 2016).

Induced amygdalar lesion studies in rhesus monkeys, as well as human clinical cases of amygdalar damage due to neurological disease, have likewise associated the amygdala to anxious temperament. The generated damage decreased fearfulness and demureness in response to dangerous situations in the animal model and modified stress-induced cortisol release by the pituitary-adrenal axis. When amygdalar damage is seen in humans, it presents itself as a decrease in anxiety in social situations where anxious temperament would be expected to occur. In a famous clinical case, a female patient who suffered from Urbach-Wiethe disease, a rare recessive genetic disorder that produces generalized thickening of the skin and mucous membranes, and in her case, amygdala calcification, developed symptoms of fear and anxiety disinhibition, including an increased ability to trust and approach strangers, an inability to recognize signs of fear in others, a lack of recognition for interpersonal space, and an incapability for Pavlovian fear conditioning (Amaral & Adolphs, 2016).

It is known that much of the amygdala develops during the first seven years of life in humans. By the fourth year of life, this structure is almost completed. Because of this early development of the amygdala it is believed that the early years of neurological development are crucial for its appropriate functioning during adulthood. Research performed in the animal model has shown that induced trauma during early mouse and non-human primate development can bring about noticeable deficits in amygdala function, leading to anxious behavior in early youth and ensuing depression starting in adolescence, and has suggested that the basolateral nucleus is involved in the exhibition of depression symptoms in adult rats, which could lead to the presumption this structure might also be responsible for such symptoms in the human amygdala (Figure 2) (Amaral & Adolphs, 2016).

Depression has also been linked to amygdala volume. In a meta-analysis of thirteen MRI studies done by Hamilton and colleagues (2009), between the years 1985 and 2008, it was found that patients with major depression tend to have a decrease in amygdala volume, and it was also observed that those depressed patients who took antidepressant drugs had amygdala sizes comparable to never-depressed individuals. This finding can be explained due to the fact that depression is a neurodegenerative condition which affects nervous tissue in all the brain, while antidepressant medication is neurogenerative and neuroprotective, hence the similar amygdalar volume size between those patients who take antidepressant medication and healthy ones.

Recent neuroimaging studies have found that neurological processes within the amygdala can be manipulated to decrease depressive symptoms. This research is essential, as the prevalence of drug ineffectiveness for major depressive disorder is high. In a double-blind, placebo-controlled, randomized clinical trial performed by Young and colleagues (2017), thirty-six right-handed adults of both sexes, between the ages of 18 and 55 years, diagnosed with depression and unmedicated, were randomly chosen to undergo two real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) procedures, of either the left amygdala or the left horizontal segment of the intraparietal sulcus (a region not implicated in the regulation of emotions – the control group). In this kind of neurofeedback intervention, subjects were placed inside an MRI machine, and were shown an image of a thermometer presenting a value that would change in accordance their engagement in autobiographical recalling, hence controlling their emotions and enhancing the performance of their amygdalae in this manner. It was found that the mean scores of the amygdala rtfMRI-nf group on different depression inventories and scales (Beck Depression Inventory-II, Snaith-Hamilton Pleasure Scale, Montgomery-Åsberg Depression Rating Scale, Hamilton Depression Rating Scale, and the Autobiographical Memory Test) were significantly lower (p<0.05) with subsequent study visits (visit 1: baseline; visit 2: first rtfMRI-nf; visit 3: second rtfMRI-nf; visit 4: follow-up), in comparison to scores attained in the control group. Similarly, there was an evident decrement in the response to negative stimuli (which is usually exaggerated in depressed individuals), as well as an improved reaction to positive stimuli, and there was amelioration in the recall of emotionally-positive autobiographical memories, which is often defective in the depressed individual.

In light of the aforementioned research evidence that sets the amygdala as a brain structure of paramount importance in fear and anxiety regulation, emotional autobiographical recall, and cognitive processing, it is important that clinicians detect signs and symptoms that could suggest a deficit in its performance early in consultation, to then be able to indicate appropriate diagnostic and therapeutic techniques, such as rtfMRI-nf and antidepressant medication. As with current research on every cerebral structure and neurological process, studies on the amygdala still have much to unveil. For one thing, neuronal interconnections between the amygdala and other encephalic structures, like the occipital and frontal lobes, the hippocampus, and the thalamus, have not yet been entirely elucidated, to the point there is still discord on how to properly delimit different nuclei within the amygdala. Then, notwithstanding major progress in psychoactive drug development, antidepressant and anxiolytic drug specificity continues to be rudimentary, as adverse reactions are significant up to the present time, causing patient withdrawal from treatment schemes. Finally, there ought to be a greater governmental effort to implement better screening programs for depression and anxiety, especially for children and adolescents, and it would be of major social benefit to have widespread access to brain MRI scans, as many cerebral abnormalities (including amygdala deficiencies in volume, structure and blood perfusion) will not be detected during clinical evaluation until in advanced stages, where treatment may need to be more complex and expensive.

References

Amaral, D.G & Adolphs, R. (2016). Living without an amygdala (1^st edition). New York, NY: The Guildford Press.

Comer, R.J. (2015). Abnormal Psychology (9^th edition). New York, NY: Worth Publishers.

Forster, G.L., Novick, A.M., Scholl, J.L. & Watt, M.J. (2012). The Role of the Amygdala in Anxiety Disorders. The Amygdala – A Discrete Multitasking Manager. doi: 10.5772/50323

Hamilton, P., Siemer, M. & Gotlib, I.H. (2008). Amygdala volume in Major Depressive Disorder: A meta-analysis of magnetic resonance imaging studies. Molecular Psychiatry. 13(11), 993–1000. doi:10.1038/mp.2008.57.

Young, K.D., Siegle, G.J., Zotev, V., Phillips, R., Misaki, M., Yuan, H., Drevets, W.C., Bodurka, J. (2017). American Journal of Psychiatry. 174(8), 748-755. doi: 10.1176/appi.ajp.2017.16060637.

This blog post is dedicated to different theories pertaining the way the human brain works. Understanding mental health and the limitations of the mind can help us learn how to improve our learning strategies.

Die Heimkehr (The Return), by Arnold Boecklin (1887)

The Psychodynamic Model of Abnormality

To what Degree Instinctual Drives Define Us?

Angelo Juarez

Since the early 20^th century, Freud’s contributions to the psychodynamic model signified a ground-breaking approach to the understanding and treatment of mental disorders. He postulated that an individual’s personality is the result of three forces that, to a great extent, he or she is not fully aware of, and therefore does not have full control over. According to the model, the first of these forces to develop, the id, is largely the result of a person’s upbringing and nurturing during childhood. The ego and superego, which are more conscious, emerge later in childhood and adolescence and deal with integration of a person to society. Once Freud said, ‘Where the id is, there shall ego be’ (Freud, 1930), which exemplifies his high regard of the id as the paramount driving force behind personality. This classical view has encountered disagreement among several scientists, which has caused psychodynamic theory to evolve into many variants that give more emphasis to the other two spheres of the model, such as the ego theory, yet there is still consensus that the forces of the initial model do exist (though with different characteristics) and are dynamic in nature. The ego theorists give more emphasis to the ego and believe it is not as dependent on the id as Freud initially proposed. Likewise, other scientists divert from classic psychodynamic theory, by stating that the self and individuality, rather than unconscious controlling forces, are the major causes of every person’s character, while there are those who consider relationships to be the ultimate shapers of personality (Comer, 2015). Nevertheless, there are still arguments to support the id is the most powerful and deterministic force in a person’s mind, which would explain the development of psychological deviances, from depression to psychopathic behavior, in societies that undermine its presence by basing their progress largely on reason, organization and productivity.

Considering current disagreements and the realization that there is not yet quantifiable anato-physiological evidence to clearly delimit an id-ego-superego model, the best way to suggest its presence is by quantifying the effectiveness of psychoanalysis. In a study by Knekt and colleagues (2011), 324 psychiatric outpatients with mood and anxiety disorder were given short and long-term psychodynamic psychotherapies as well as psychoanalysis. It was found that both psychodynamic psychotherapies and psychoanalysis were effective, but the longer the duration of therapy (up to five years), specially for psychoanalysis (at the 5-year follow-up), meant more effective results in work ability and functional capacity (Knekt et al.).

It is of crucial importance to briefly discuss brain anatomy in the context of evolution before diving into the implications of concealing instinctual drives. During the sixties, the American neuroscientist Paul MacLean (who was profoundly aware of Freud’s psychodynamic theory) formulated the triune brain model, based on anthropologic and evolutionary evidence, which suggested the modern human brain is the result of three anatomical structures, each having a different evolutionary age, building upon one another in a continuum of time that draws back to the brains of our evolutionary, non-human ancestors. These include the reptilian complex, the oldest of the three, composed by the basal ganglia, brain stem and cerebellum, dating back to 200 million years, the paleomammalian complex or limbic system, which comprises the hippocampus, amygdala and hypothalamus, and is as old as 3.3 million years, and the neomammalian complex, also known as the neocortex, which constitutes the cerebral hemispheres and corpus callosum, being the most recent of the three structures, with an estimated age of 100,000 – 35,000 years (this is the age of the modern Homo sapiens brain neocortex. The neocortex in non-human species dates as far back as 300 million years) (MacLean, 1973; Ploog, 2003; Max-Plank Gesellschaft, 2018; Anderzhanova, Kirmeier, and Wotjak, 2017). Based on MacLean’s model, it would be prudent to believe that the reptilian and paleomammalian complexes, far older structures in our brain, might as well be our most reliable behavioral sources, while the young neocortex, though responsible of our most elevated thoughts, may still be undergoing a maturing phase. Such imparity of evolutionary development would implicate a confrontation among these structures which ultimately transcends in psychopathologic conduct.

The preponderance of instinctual drives may be justified from a morpho-evolutionary slant, by drawing an analogy between the triune model and psychodynamic theory. The reptilian brain and paleomammalian complex can explain instinctual drives in that, aside from being responsible for physiologic regulatory functions, like heartrate and blood pressure, it expresses of other survival mechanisms, such as anger, fear and libido, as well as feelings and emotions. For instance, an office worker might have a disagreement with his boss and, consequentially, develop feelings of rage and engage in an argument with him, yelling and cursing, without taking into consideration the consequences of such action. Similarly, the paleomammalian complex works alongside the ego, in that it gives the individual a conscience for the consequences of his uncontrolled drives. In such regard, the worker’s initial desire to pursue a quarrel would be immediately subdued by the thought that such action could get him fired. Finally, the neomammalian complex gives rise to the superego by elaborating a rationale in which ideals transcend personal desires interests. In this sense, the worker would conclude that getting into a quarrel would set a bad example for his fellow co-workers and maintaining an environment of peace and communication would lead to progress as well as fulfillment of the company’s mission. The concordance between id and the reptilian brain supports the idea that instinctual drives are monitored by a far more mature cerebral structure, evolutionarily speaking, which would indicate the id is far more ingrained in our minds than the more recent ego and superego.

Morality might be accountable for an excessive hindrance of instinctual drives in present society. Ever since humans formed bands (groupings that rage between 100 to 200 people), 100,000 – 10,000 years ago, it is believed that morality began to evolve as a means to cohere them, to attain social control, conflict resolution and solidarity among group members (Wikipedia contributors, 2018). It was then that society commenced the construction of a myriad of norms and values. In such regard, one could venture to say that the ego and superego, our mechanisms of coping with social standards, also initiated their evolutionary development at that time. Human beings became increasingly more involved, beyond the confinements of their nuclear families, by carrying out group hunting and food gathering, as well as defending themselves from exterior threats, like predators and invaders from neighboring tribes. Concurrently, values like respect and altruism began to emerge. Not long after, there was a social need for spirituality and higher entities were praised and blamed for fruitful crops and plagues. The ensuing forces of good and evil did not take long to dictate what choices man should make in every aspect of life as societies became increasingly larger and complex. Eventually, actions needed to be ruled by a number of standards to attain generalized approval. Today, ‘acting’ the way we do is the artificial consequence of a socio-cultural construct that builds upon millennia. Several scientists, including Erving Goffman and Kenneth Burke, support the idea that people constantly interact with others in unnatural manners, as if performing in a play, to gain acceptance. This sociological perspective is known as dramaturgy and poses that the self is a changing sense of one’s identity, as it adjusts to distinct settings of social interaction (time, place, audience), depending on the values and norms present in any given social encounter. Supporters of this theory also believe that identity, instead of being invariable, continually acclimates to different ‘theatrical scenes’ (Wikipedia contributors, 2018). Apart from the size and general moral nature of a civilization, multiculturalism is another factor that might account for an increased suppression of instinctual drives. Notwithstanding what it accomplishes in favor of social development, the resulting added set of morals brought about by multiculturalism might entail further repression of instinctual drives. By way of illustration, moving into a village with only a few hundred religious and conservative residents might dissuade a person from engaging into sexual encounters as often as s/he did before arriving, because of fear of being discovered and judged by a community where everybody knows each other and might be observant of the newcomer.

In modern society there is a struggle between instinctual drives and reason. There is a high demand for psychological stressors, which include efficient performance, a tendency for multitasking (even though it may not be an appropriate technique), and the ideal physical image. Movie actors, tv adds and fashion magazines set an unconscious high standard upon individuals, who might feel frustrated by not fulfilling the expectations of others. Several societies also have a more rigid set of sanctions, with long-lasting consequences, which may not always turn out to work for the best, or for what is fair. An example could be that of a young, recently-graduated American nurse, who unknowingly does not register how many morphine ampoules she has been administering to patients for a certain number of days. Even though she administered the drug, there is not a way to verify if all ampoules were indeed used for the patients, leaving room for suspicion of a drug addiction or illegal commercializing of morphine, and consequently the board of nursing she is subjected to revokes her license, impeding her not only from practicing her profession anymore but also from practicing in any other health-related field for the rest of her life. Similarly, societies can produce abnormal levels of stress in people by rendering a high value on references. Even if they can have a positive effect by letting employers, universities and community service programs know the applicant better, they might also negatively increase an individual’s awareness of his/her social interactions, and consequentially undermine the id in favor of a greater social acceptance. In the end, the struggle between instinctual drives and society’s high standards can lead to people realizing how unadapted they are, which will eventually translate into depression, social anxiety and other psychiatric disorders.

Even though the psychodynamic school of thought has progressively departed from Freudian classic psychoanalytic theory by emphasizing on the ego and the unified personality as determinants of normal and deviant behavior, instinctual drives are nonetheless the pillars and major determinants of an individual’s psychology, as can be elucidated from the triune brain model. Because of their shorter age, the limbic brain and neocortex might still be undergoing an evolutionary adolescence, hence being less reliable and a key source of conflict between the elements in this model. Is our supposed-to-be rational behavior reliant upon a cerebral structure that has only begun to develop? Would having a better social conscience of this idea have a positive impact in our lives? The abnormal behaviors that result from a disparity between social expectations and instinctual drives may lead to abnormal behavior. It is important to realize the force and extent to which instinctual drives affect the human psyche, since many of society’s current social problems are misunderstood and could be resolved if we were able to make key changes in its structure as well as find ways to make people express themselves more openly.

References

Anderzhanova, E., Kirmeier, T., Wotjak, C. (2017). Animal models in psychiatric research: The RDoC system as new framework for endophenotype-oriented translational neuroscience. Neurobiology of Stress 7, 47-56. doi: 10.1016/j.ynstr.2017.03.003

Comer, R.J. (2015). Abnormal Psychology (9^th edition). New York, NY: Worth Publishers.

Freud, S. (1930). Introductory Lectures on Psycho-Analysis. Lecture given in Vienna, December 1930. Lecture retrieved from the Freudean Association. Website: https://freudianassociation.org/en/wp-content/uploads/Sigmund_Freud_1920_Introductory.pdf

Knekt, P. et al (2011). Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up. Journal of Affective Disorders. 132, 37-47. doi: 10.1016/j.jad.2011.01.014

MacLean, P.D. (1973). A Triune Concept of the Brain and Behaviour. Toronto, Canada: University of Toronto Press.

Ploog, D.W. (2003). The place of the Triune Brain in psychiatry. Physiology & Behavior 79, 487-493. doi: 10.1016/S0031-9384(03)00154-9

Max-Plank Gesellschaft. (2018, January 24). Modern human brain organization emerged only recently. Retrieved 16:04, October 10, 2018, from https://www.mpg.de/11883269/homo-sapiens-brain-evolution

Wikipedia contributors. (2018, October 2). Triune brain. In Wikipedia, The Free Encyclopedia. Retrieved 16:02, October 10, 2018, from https://en.wikipedia.org/w/index.php?title=Triune_brain&oldid=862106106

Wikipedia contributors. (2018, October 5). Evolution of morality. In Wikipedia, The Free Encyclopedia. Retrieved 16:03, October 10, 2018, from https://en.wikipedia.org/w/index.php?title=Evolution_of_morality&oldid=862533581