Education Nonfiction Reflection

Primary and Secondary Emotions.

I used my left arm to stop the tears from rolling off my cheeks and onto the lotus root. Had I known that Act One of episode 597 of This American Life would make me cry to the point that I would have to wipe the snot from my nose multiple times with my arm, I wouldn’t have listened to it while making a lotus root salad for a party.

People warned me that my grief about my mother’s death would continue to fluctuate with time. It had been many months since I last cried; how was I to know that learning about the wind telephone in Japan would induce such a reaction?

Perhaps my grief wasn’t my own. My father’s older brother recently died.

“I’m glad I could help with the funeral arrangements for him,” my father murmured to me. “I went through all that just three years ago, so I knew what to do.”

I nodded. He sighed.

“He was my older brother. It was still a shock.”

I looked away. He didn’t need to see his daughter trying to hide the sadness from her face.

I first learned about “primary” and “secondary” emotions while learning dialectical behavior therapy. Marsha Linehan points out that there is

a distinction between primary or “authentic” emotions and secondary or “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions.

Some (corny) examples are helpful here:

Primary emotion: “All right! I did well on that test! I feel happy about my performance!”
Secondary emotion: “But wait! I still missed some items on the test. I feel ashamed that I felt so happy about how I did. It’s not like I got a perfect score.”

Primary emotion: “I can’t believe she did that! Who does things like that, anyway? I feel angry.”
Secondary emotion: “Maybe I’m overreacting about her. I don’t want people to think I’m a b!tch. I’m disappointed that I can’t control my moods better.”

Not much time has to pass between the primary and secondary emotions. In fact, sometimes people experience only the secondary emotion. The experience of the primary emotion gets lost, even though the primary emotion reveals useful information about the situation and how the person relates to it.

Infants and children experience and express primary emotions. We become acquainted with secondary emotions as we age.

Primary emotion: I feel sad about the death of my mother. I witnessed how her death affected my father, who lost his companion of forty years. There are things that only my father and I understand; we can’t talk about those things with anyone else because they just won’t get it. I feel sad that he is at that age where multiple loved ones are dying because their time has run out. I feel sad when I consider the loneliness he must feel at least some of the time.

Secondary emotion: God willing my father dies before I do: No father should outlive both his spouse and child. Of course I will feel grief when he dies. Will it be worse than the grief I felt when my mother died? What if it’s too much grief? What if I don’t have the mettle to tolerate it?

What will I do when my only option is to use a wind telephone?

Consult-Liaison Education Medicine Policy Systems

Online Screening for Depression?

Inquisitve reader Amy asked me if I had any opinions about online screening for depression. The British Medical Journal recently published a debate on this issue.

What an excellent question, Amy! I read the opposing arguments and these are my thoughts:

First, I see two different issues. The first is whether the 9-question Patient Health Questionnaire (PHQ-9) is an appropriate tool to use to screen for depression. The second is whether the public should trust Google to administer the PHQ-9.

Before I do delve into that, though, let’s take a step back and consider the purpose of screening tools. Screening tools help physicians figure out how much more we should learn about a person. For example, asking for a person’s biological sex is a screening tool. The moment I learn that the person before me is female, I will ask her questions about menstruation and pregnancy history. I’ll skip those questions if the person is male. Similarly, if a person tells me that he smokes cigarettes, then I will ask more questions about how much and how often he smokes, what he gets out of smoking cigarettes, and if he thinks smoking causes him any problems. This helps me assess potential risks to his psychological and physical health. It also helps me assess if he has any interest in changing his smoking behaviors. Screening tools help us sort and gather information to generate diagnoses and interventions.

The literature states that the PHQ-9 was developed both to diagnose and measure the severity major depression. The PHQ-9 was modeled after the criteria for major depression in DSM-IV. Thus, the problems with the PHQ-9 for diagnosis are the same as the problems with the DSM for diagnosis: Context is completely missing. The authors of DSM argue that the situation and underlying causes of major depression don’t matter; they state that the presence of certain symptoms determine whether the diagnosis applies.

Long-time readers know my refrain: Context does matter. Major depression is “comorbid” with many other psychiatric conditions, meaning that someone experiencing the symptoms of major depression often experience symptoms of other psychiatric conditions. For example, bipolar disorder, by definition, includes episodes of major depression. People with diagnoses of post-traumatic stress disorder (PTSD) and schizophrenia often experience major depression. Some people who take drugs, whether prescribed or obtained from illict sources, experience symptoms of major depression. Sometimes the symptoms of major depression are actually due to a medical condition, such as certain cancers, infectious diseases, or thyroid conditions.

There are several papers that make the case that the PHQ-9 is a useful tool in the screening for and diagnosis of major depression. Given that major depression is comorbid with other conditions, a positive PHQ-9 result is useful to help get people into care. A professional can then help clarify symptoms, determine possible diagnoses, and suggest treatment and other interventions. Recall that the purpose of diagnosis is to guide treatment.

Here is where we get into the second issue as to whether the public should trust Google to administer the PHQ-9. Most task forces agree that there is no point in performing screening tests if you can’t do anything with the results. If you can’t refer someone with a positive PHQ-9 result to a professional who can clarify diagnosis and provide treatment, then why bother? You’re potentially causing more problems and distress for the person seeking help. Thus, the question is whether Google will direct people with positive PHQ-9 results to helpful resources.

There is a shortage of psychiatrists and other mental health professionals in the US. One wonders if an online depression screening tool will lead people to believe that they are “majorly” depressed, when they are not. They will then seek services that are hard to find. If these individuals are able to get into primary care services, those medical professionals may not be able to determine if someone has depression because of bipolar disorder, or depression due to the recent death of a loved one. Wrong diagnosis often results in wrong treatment or overtreatment. Recall that we should first do no harm.

However, it is clear that people seek information about depression and other psychological experiences on the internet. The questions on the PHQ-9 can educate the public about the differences between major depression and having a sucky day. The more information and education we can provide to the public, the more empowered the public can feel about not only what isn’t going well, but also what they can do to improve their health and wellness. I do not view my work as a psychiatrist as a guild secret. The more understanding and communication we have in our communities, the more we can address our psychological health on individual and societal levels.

The other reaction I had to that BMJ debate was related to a comment that Dr. Duckworth made under “attitudinal barriers”. He noted that a “key reason may be that people with mental health conditions perceive that they do not need treatment. Studies show that they report attitudinal barriers to seeking care much more often than structural or financial barriers.”

I don’t see how the PHQ-9 is related to “attitudinal barriers”. Screening tests don’t reduce stigma. Sure, people may avoid treatment for depression because they don’t know that they are depressed. However, I suspect that more people avoid treatment for depression because of the stigma associated with psychiatric conditions and treatment. If we want to reduce and remove “attitudinal barriers” related to depression, we must help share stories that remind everyone that people with depression are, first, people. The PHQ-9 is not a means to that end.

I don’t know the workings of Google well enough to comment more about whether we should trust Google to administer the PHQ-9. Others with more knowledge about online security, marketing, and data mining can say more about whether Google will use PHQ-9 results for good or evil… or both. There are likely other unintended consequences that I don’t know or understand.

Thanks for the question, Amy!

Nonfiction Observations Reflection

A Thousand Years.

I recently had the opportunity to visit two places in New Mexico: Chaco Culture National Historical Park and the Very Large Array.

The Chaco Culture National Historical Park features now ruined pueblos that people built over a thousand years ago. Construction started on Pueblo Bonito, a structure that archaeologists believe contained over 600 rooms, around 850 AD! Additions and revisions occurred on Pueblo Bonito for the next two hundred years. There are ruins of other pueblos in the area; some of them are now crumbling walls that have succumbed to the eroding powers of the desert winds and blazing sun.

Petroglyphs and the orientation of these ruined pueblos suggest that the people who lived in or visited Chaco appreciated their relationship with the celestial universe. A sun dial, located on a butte that is no longer open to the public, reflects their observations of the equinoxes and solstices. People, then and now, witnessed the directional relationships the buildings have with the stars.

The Very Large Array, on the other hand, was constructed over forty years ago. The 27 enormous dish antennae, arranged in a Y configuration, sense radio waves coming in from the universe. These antennae function as a giant “eye” and funnel the signals they receive to a supercomputer. Scientists analyze data from this supercomputer to describe events that have occurred in the universe: Stars exploding, the birth of new stars, and the location of black holes.

The antennae are arranged in straight lines, which are in stark contrast to the curves and shapes of the surrounding mountains and clouds. Such straight lines do not occur in nature—even trees are not so rigid.

What if Chaco and the Very Large Array serve the same purpose?

What if Chaco was an effort to better understand the universe and what was in it? The Very Large Array gathers data from invisible radio waves; Chaco collected data from visible waves from the sun, moon, and stars.

If people excavate the Very Large Array a thousand years from now, what will they think? Will they look upon the Very Large Array with the same wonder that we feel when we look upon Chaco?

I have noted before that death is the great equalizer. It puts everything in perspective.

In a thousand years, who will know your name? That thing you’re worried about now: Will it matter in a thousand years? Your creations—children, music, writings, meals, home improvements, tweets, laws, relationships—what impact will they have in a thousand years?

To be clear, I am not saying that what we do now has no importance or value.

There are things we do now that have huge significance and meaning. Sure, that kind act you do today won’t enter the annals of history. However, that same kind act will make the world an easier place for someone who is suffering now. Maybe the melody of that song you wrote will fall silent once you die, though it brings joy now to someone who delights in music. What you do now may not last forever, but that shouldn’t stop you from doing those things. What you do matters.

And maybe the remnants of something you create will still be around a thousand years from now. If that is the case, consider how your creations can inspire and humble the people of the future. The mysteries that you want to understand now may still be mysteries hundreds of years from now.

Someone said this a thousand years ago, and someone else will say this a thousand years from now. This is a reminder for us all today.