Joy, Guilt, Anger, Love (18 page)

Tears are often regarded as a sign of fragility. Indeed, by clouding our vision, tears do make us vulnerable to others. Crying is also an addling experience. Especially if frantic and desperate, crying halts us. It sequesters us into a state of confusion and paralysis from which it is not easy to see or act lucidly. Crying temporarily distorts perception and thereby prevents us from dealing with something for which we have no rational explanation or ready solution. The trade-off for this is that tears can communicate our attachment to and need for others, giving us a chance to strengthen relationships.
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Vulnerability bonds.

But above all, the release of tears in moving situations is commonly regarded as a cathartic, liberating event. A good cry can get you out of a contrived mood and work as an emotional purifier. The crying episode may be stormy and bewildering, but when things clear up and quietness returns, we all benefit from the shake.
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One question remains. What makes emotional tears singular? In other words, are the tears we shed when we smell a raw onion different from those that roll down our cheeks when we say goodbye to someone at the airport? There is no conclusive answer on the difference in chemical composition between the two types of tears. Provine has speculated that the molecular key to emotional tearing may be a molecule called Neurotrophic Growth Factor, or NGF for short. Originally discovered as a protein that facilitates the development and survival of neurons, NGF has a healing effect in our eyes as well as a role in the regulation of mood.
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For Provine, although the routes and reactions by which this may happen are still not evident, the presence of NGF in tears and its access to the nervous system make it a good candidate to be what gives the salty fluid of tears its emotional texture.

What fascinates me, but I believe still awaits explanation, is first the threshold of intensity in the causing event that triggers the crying reaction, and second the question of what makes certain people more prone to crying than others. Tears are connected to sadness and desperation, but, of course, we sometimes cry out of joy and happiness, out of emotions that bring gratification and recognition instead of depriving us of something. In both cases, what makes tears overflow is unknown. We are all familiar with the languid moment when tears well up in our eyes. It feels like an evening tide that rises suddenly under the feet. There may be periods when crying is an uncontrolled inundation. Tears push heavily on our doors and flood the chambers of our being, unsolicited. But there are other times when tears refuse to come, even when we really would like them to, and we are left in a dry desert. Even when we can’t tell why we are crying, tears are the bringer of some important message that is hidden somewhere in the secrets of our unconscious.

Is grief similar to physical pain?

Grief over loss and other shadings of emotional aching are often articulated in the language of physical pain. When hit by disappointment, rejection or damage to relational bonds, we say we are hurt, that someone or something has caused suffering by the infliction of wounds, shallow or deep. We feel beaten up and crushed. We are left with scars.

The relationship between physical and emotional pain goes beyond semantics. Physical pain and emotional pain – the pain we suffer when our social and emotional bonds are broken – may share some of their underlying neural mechanisms.
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From an evolutionary perspective this would make sense. The system mediating the experience of physical pain has older roots upon which the system for emotional pain may have developed. We experience physical pain so that we can avoid hurtful experiences. Grief is more like interest on an emotional debt. It is the inevitable costly price we pay for attaching to others.

The causes of physical pain and grief are different, yet they carry similar effects, at least at the level of neurons. Emotions are aroused by events, or by thoughts and images that remind us of those events. In all cases, something moves under the skin and our bodies process the change. When I heard of my grandfather’s death, I was still in bed in my London flat. The call came unusually early in the morning. I knew that he had been very ill for the past several days. When I heard the telephone ring, I was sure the call came from home and already knew what I would be hearing. Even though I had prepared myself for his departure, it was only after listening to the voice of my sister at the other end of the line announcing Nonno’s death that the cascade of grief began. The physical pain sensed when we stub a toe or hit a wall is the effect of a
collision
that damages our tissue. The pain of loss or the breaking of an emotional bond, on the other hand, is the consequence of a physical
separation
. Something departs from our surroundings and from our lives. All the same, its disappearance hurts us, causing pain just as would colliding with the wall. However, unlike a cut or a bruise, it is the absence of a loved one that hurts and leaves a mark on us, and that can even be harder and slower to heal. We must get used to the idea that we’ll no longer be able to see or touch them. It is an incredible effort to accustom ourselves to the fact that a person no longer exists. We must
unlearn
their physical presence and their dwelling-place in our emotional universe. All our senses must adjust. We conjure the lost one up by weaving again the neural networks that used to make us perceive them. As expressed in the lines by Borges I have used as an epigraph to this chapter, the absence of the lost one surrounds us and the experience can be as suffocating as having a rope tighten around the neck.

Clues to neural commonalities shared between the effects of physical and emotional pain have come from several sources. Research studies on palliative drugs are one such source. Opiates, such as morphine, work to sedate and reduce excruciating physical pain. They also work to reduce the pain resulting from separation. As I mentioned briefly earlier, although animals don’t shed tears, they do protest on being separated from their mothers or caregivers, by emitting shrieking vocalizations. It has been shown that if you give opiates to young animals (of various mammalian species) separated from their mothers, their vocalizations of protest and distress diminish.
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Another set of data linking physical and social pain comes from neuroanatomical and imaging studies and involves the dorsal anterior cingulate cortex, a large structure in the middle part of the frontal lobe. For a long time, the dACC has been linked to physical pain. For instance, creating lesions of the dACC – a surgical operation called cingulotomy – has been used as an effective treatment of chronic pain disorders. Recently, an involvement of the dACC in the modulation of social and emotional pain has also been tested. The neuroscientist Naomi Eisenberger and her colleagues explored the experience of social pain by measuring the neural activity during an experience of social exclusion simulated in a brain-imaging experiment.
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The simulation involved a ball-tossing game. The participants lying in the brain scanner were told they were playing with two other people via an internet connection. In truth, they were alone; the other players were computer-generated images of people tossing the ball. In one round of the game, the person in the brain scanner would be included in the game and passed the ball by one of the two players. In another round, they would be excluded. The brain region found to have a stronger oxygen flow during the period of rejection and exclusion from the game than in the period of inclusion was indeed the dACC (and another region called the periaqueductal grey area).

Similar results were obtained in a study that specifically investigated grief. The experiment consisted in showing a group of bereaved women pictures of those they had lost. The pictures were matched by words related to loss or grief that had been taken from the participant’s own account of the death.
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When the women’s painful reactions to the pictures of their loved ones were compared with their reactions to pictures of strangers, the brain areas that were involved in the emotionally painful reactions were regions known to be linked to physical pain.

The similarities between the brain regions identifiable across different kinds of pain are definitely interesting. But of course this doesn’t mean that grief may be easily reified within precise precincts of the brain. My cautionary remarks in chapter 2 about the limitations of attempts to identify the neural locus of guilt hold just as true for grief, which, as I will explain later, is a variegated concept with a long history.

Good grief

Though bewildering and, at times, debilitating, grief is not intuitively regarded as an illness. Yet in today’s society, bereavement may attract medical attention and be seen as a divergence from normality. This has to do with how, in certain cases, the psychiatric category of depression has turned ordinary sadness into an illness. To understand what I mean by that, we need to briefly unearth the history of depression and go back to the DSM.

As I briefly mentioned in chapter 3, the guidelines for the classification of psychiatric disorders were not derived from knowledge of their aetiology – a term used in medicine to indicate the causes of a disease – but from the commonalities or differences in the symptoms they manifested. In the 1950s, nobody had a definite idea of what caused a depressive mood, but they more or less knew what it looked like when they encountered it in a patient.

When the first edition of the DSM was released in 1952, it contained around one hundred items. The second edition, published in 1968, contained almost twice as many. There were about three hundred mental ailments listed just over a decade later in the third edition (1980). The fourth edition (current to May 2013), first published in 1994 and then revised in 2000, lists in total almost four hundred disorders. Do the maths: the number of recognized psychological ailments increased fourfold in the fifty years following publication of the first edition, with a hundred or so added in each successive edition. This is an impressive escalation and it doesn’t seem to be relenting.

Already in use as a term describing low moods in the mid nineteenth century, ‘depression’ has appeared as a clinical term in all the DSM volumes under different disguises.
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The 2000 edition of the DSM (DSM-IV TR) makes the main distinction between bipolar disorder, characterized by drastic mood swings, and the category of major depressive disorder (or MDD), which typically refers to an enduring low mood and is what we commonly refer to as depression today. The current list of clinical criteria for a diagnosis of MDD includes as symptoms intense sadness or feelings of emptiness, insomnia, decreased appetite and loss of weight, fatigue and loss of energy, diminished interest or pleasure in usual activities, difficulty concentrating on regular tasks, as well as feelings of worthlessness or inappropriate guilt, and recurrent thoughts of death, suicidal ideation or attempts. Importantly, in order for a diagnosis to be made, such symptoms – at least five of them, of which two are required to be sadness and the loss of interest in pleasure – must occur ‘most of the day, nearly every day for at least two weeks’.

If you have experienced grief yourself or witnessed it in others, you will have observed that most bereaved human beings suffer from most, if not all, of the above symptoms, in more or less intense shadings. Anyone who has recently lost a partner, a friend or a relative will experience an overwhelming period of adaptation to that loss. Actually, it would be rather surprising if they didn’t.

In his influential essay ‘Mourning and Melancholia’, Freud explains the commonalities between what we would nowadays call grief and depression. What the two have in common is an enforced separation from someone or something we grant our attention and love. We could say that the parting is a theft of an emotional investment. In the case of grief, the separation is caused by an actual death. In the case of depression, the separation is unconscious and cannot be physically perceived. It may involve the loss of something, a reaction to being ‘slighted’, ‘neglected’, an ambivalent emotion that is starved of its fulfilment. In other words, grief comes from without, depression from within. But, in both cases, such separation procures pain. In both cases, the individual retreats from reality, turns inward, loses interest in the outside world. Those who eventually recover from grief then slowly adapt to reality and accept the loss. Depressed people continue to isolate themselves, they are prone to self-criticism and self-reproach, and lose self-esteem. So, grief is justified and liberating, whereas depression can get out of control. Freud clearly states that ‘although mourning involves grave departures from the normal attitude to life, it never occurs to us to regard it as a pathological condition and refer it to medical treatment. We rely on it being overcome after a certain lapse of time, and we look upon any interference with it as useless or even harmful.’
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Indeed, the 2000 DSM edition did not list grief as a clinical disorder. Bereavement is excluded as a disorder because the authors recognize that depressive symptoms are to be expected in recently bereaved individuals. Already in the introductory pages of the manual, where the authors provide a general definition of mental disorder, they say that for a condition to be granted clinical status it ‘must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one’.
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A fifth edition of the DSM, updated and restructured, has recently been prepared (published in May 2013). A particularly worrying change has been introduced: the task-force that worked on the new version of the manual scrapped the exclusion of bereavement.
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In simple terms, this means that a grieving person whose symptoms of depression persist for a period longer than two weeks is in principle entitled to earn a mental illness diagnosis. One of the arguments put forward by the proponents of this change is precisely the fact that, at the level of symptoms, there is little if no difference between those who grieve and those who develop depression for reasons other than someone’s death.
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