My intention for Mental Health Month had been to traverse the history of mental health, but my first two articles didn’t get much beyond the Dawn of Man. In this article, we manage to jump ahead 700,000 years, give or take a year or two, to the Greek physician Hippocrates, who lived circa 400 BC. Among other things, Hippocrates postulated on what he called “the four humors,” which he believed accounted for human behavior.
“Black bile,” for instance, literally means melancholia. A few hundred years later Galen refined these into “the four temperaments” - melancholic, sanguine, choleric, and phlegmatic - which were further developed by Islamic scholars.
The ancients may have erred in ascribing mood to the ebb and flow of bodily fluids, but they proved far ahead of their time in seeing a biological connection. Thus, a person who was mentally ill had not necessarily fallen out of favor with the gods. This message got lost with the spread of Christianity, and we are still recovering.
The four temperaments continues to influence our philosophy and psychology. Literally, our personality traits are inherited in the same way the color of our eyes are dictated by our genes. But Robert Cloninger of Washington University (St Louis) cites Immanuel Kant to distinguish between trait and character. According to Kant, character is “what people make of themselves intentionally.”
I heard Dr Cloninger address a packed house at last year’s American Psychiatric Association annual meeting. He breaks down his four temperaments into harm avoidance (based on fear), novelty seeking (looking for pleasure), reward dependence (sensitivity to social cues), persistence (realistically dealing with expectations of reward).
But temperament doesn’t stand alone. Our character (comprising self-directedness, cooperation, and self-transcendence) is what allows the higher areas of the brain to transcend the lower parts of the brain and achieve healing.
Hagop Akiskal of UCSD openly acknowledges his indebtedness to Dr Cloninger. Dr Aliskal frequently reminds his fellow psychiatrists of the distinction between “state” (an episodic feature of mental illness) and “trait” (which involves personality). At two different APA annual meetings, I heard Dr Akiskal compare his version of temperament to that of the ancient Greeks. In Dr Akiskal’s version, we have anxious, depressive, hyperthymic, and cyclothymic.
Dr Akiskal asks us to imagine a spectrum ranging from perfectly normal and socially advantageous at one end to pathological at the other. On one hand, a depressive trait may bleed imperceptibly into a depressed state, but what happens when say a manic state is superimposed on a depressive personality?
In other words, if we are just looking at the “state” we are in, we are failing to pay attention to the whole picture.
The Draft DSM-5 is giving personality a lot more respect. Unlike the Axis I illnesses (such as depression, bipolar, anxiety, and schizophrenia) which are virtually unchanged, the Axis II personality disorders are in for a major makeover. In addition to some serious rethinking of the old categories, a new “dimensional” element - one that can trace its roots to the four humors - has been added.
The DSM-5 dimensional perspective is derivative of the “five factor model” (FFM), developed in the 1950s, plus other personality assessments. The FFM measures for openness, conscientiousness, extraversion, agreeableness, and neuroticism.
Neuroticism - the tendency to express negative emotions - is further broken down into anxiety, depression, anger, and vulnerability.
Importantly, the DSM eliminates the Axis I/Axis II distinction. Yes, it still preserves the split between “mood” and “personality,” but it is coming abundantly clear that these walls are coming down. Over the years, in support groups, I have observed that those who are struggling in their recovery tend to be those with unresolved personality issues, and I include myself in this category.
For years, my introversion caused me to isolate and fail to reach out to people. Imagine what that did to my depression. Once I developed a self-awareness, I was able to work on the issue. These days, when I feel myself spinning out, I am not afraid to pick up the phone. Big, big difference.
We inherit our traits, we are vulnerable to our states. But we are not helpless. As Dr Cloninger reminded his audience last year, the brain with its infinite and nonlinear neural connections and lightning-fast processing speed is capable of quantum change. Know thyself, be hopeful …