Breaking down a breakdown

A blog piece by Dean Burnett  I read on on the Grauniad website yesterday set me thinking about whether I should post a personal comment in reaction to it. I never know what is the appropriate way to draw the line between the private and the public on In the Dark but since having a blog is clearly an exercise in self-indulgence anyway I thought I’d go ahead and write a piece.

Dean’s piece is about nervous breakdowns, but it’s really about why “nervous breakdown” is not a very good name for what it purports to describe. Regular readers of this blog  (both of them) will know that I went through one last year, and one thing I do remember is the disapproval that the term “nervous breakdown” provoked when I used it during my subsequent course of therapy. Apparently it’s a bit frowned-upon among professionals in the field.

Here is Dean (who is a neuroscientist in his day job) on the subject:

The term nervous breakdown is actually surprisingly old, and stems from a time when both “nervous” and “breakdown” arguably had different meanings to their modern ones. It seems the “breakdown” element refers to a breakdown in the same way that cars or other machines can break down. And nervous just refers to the nervous tissue. So originally it meant a fault or error in the nervous tissue that controls the body. And suddenly my interpretation doesn’t seem so literal.

But this doesn’t mean it’s an invalid term, it’s just more of a rule-of-thumb or generalisation used to refer to what happens when someone becomes psychologically unable to function as normal. In the simplest sense it could be said that, mentally speaking, a nervous breakdown occurs when an individual finds that the number of things that they are able to cope with is lower than the number of things that they have to cope with.

That seems to me to sum up very sensibly why the term is not very useful for an expert: it’s too vague, in that there are so many quite different things that might cause a person to become “psychologically unable to function as normal”. But it also explains quite well why its usage persists in popular language, in that the state of being “”psychologically unable to function as normal” is not as uncommon you might think. Anyway, if someone says they’ve had a nervous breakdown it gives at least a general idea of what they’ve experienced, although the specifics vary widely from individual to individual.

I hope you’ll bear with me if I illustrate this with some personal observations in the light of my own experiences.

I’ve suffered from a form of panic disorder for many years. Actually even that term has a very broad definition, so that different individuals experience different forms of panic attacks and they can also take very different forms for the same individual. For me, a “typical” panic episode begins with a fairly generalized feeling of apprehension or dread. Sometimes that’s as far as it goes. However, more often, there follows a period of increasingly heightened awareness of things moving  in my peripheral vision that I can’t keep track of. This leads to a sense of being surrounded by threats of various kinds and panic ensues. Usually, at that point, I run.

A typical panic episode lasts only a few minutes, but that’s not the end of it. For a considerable period (hours) afterwards I find myself in a state of hypervigilance during which I’m such a bundle of nerves that the slightest sound or movement can trigger a repeat.

I tend to think of these episodes as being a bit like earthquakes. The milder ones happen fairly frequently, but they’re quite easy to cope with. I have altered my behaviour to avoid places likely to trigger them (see below) and to be aware of appropriate exit strategies. The more severe episodes are much harder to deal with, though, and when one starts there’s nothing I can do apart from try to find somewhere that feels safe, wait for it to pass and then just get through the aftermath, hoping for no aftershocks.

In Dean’s piece he writes about the different stressors that can trigger a breakdown. In my case it was a bit more complicated than that.  Thinking about the milder attacks I find it very difficult to identify specific triggers – they seem to occur more-or-less randomly. However,  I can cope with this low-level “noise” pretty well. I’ve had plenty of time to get used to it, at least.  The more severe attacks seem more likely to be triggered by specific places, especially if they’re crowded with people moving around – although I don’t always have a problem in places like that. To give an example, crossing the main concourse at Victoria Station is, for me, like descending into the abyss; I simply can’t do it, and have to go outside the station to get between the trains and the underground station. Paddington Station, on the other hand, is fine. Weird.

I think the probability of one of these episodes is also influenced by background levels of stress arising from other independent things. Anyway, last year I got into a state in which I was experiencing multiple episodes per day. I couldn’t sleep or eat for over a week, and couldn’t leave the house for fear of experiencing another major problem. I think “nervous breakdown” is a pretty apt description for that period, but my breakdown was caused not by a new problem, but the amplification of an old problem to completely intolerable levels.

The reason for writing about the anatomy of my breakdown in this context is twofold. One part is just to reinforce Dean’s point that a “nervous breakdown” can be triggered by many different circumstances and conditions. Mine is probably an unusual example, but I think everybody else’s  is too.

The other reason is to confess how frustrating it is to be a physicist who has experienced a thing like that. It seems natural that having experienced such an episode I should want or need to try to make sense of it, but I’ve struggled to do that. The way we’re used to thinking about things in physics is to make simple models that capture the relatively simple cause-and-effect relationships between relatively few variables, usually based on the objective analysis of data controlled experiments and/or systematic observations.   This all involves trying to break down a phenomenon into its component parts so as to look at their separate action and thus establish the simple rules (if there are any) that govern the overall behaviour.

The trouble with this analytic approach is that the human brain and its interactions with the external world are far too complicated and non-linear to be approached in the simple-minded way we physicists usually do things. Even if you accept that the brain is basically a collection of atoms communicating with each other using electrical impulses, that doesn’t mean that it’s useful to try to describe its action using atomic physics and electromagnetic theory.

On top of all that, there’s the issue that neuroscience is a subject I know very little about at a technical level. There’s only room in my feeble little brain for my own specialism, so I lack the knowledge needed even to understand the literature.

So although I got over my breakdown, it has left me with a huge number of questions I don’t even know how to begin to answer. What is happening in my brain when a panic episode begins? What is going on with my peripheral vision when it goes awry like it does? Why do some particular places  or circumstances trigger an attack but other, apparently similar, ones don’t?

I don’t suppose anyone out to answer these questions, but if any neuroscientists out there happen to read this piece I would be grateful if they could recommend appropriate literature, as long as it’s simple enough for an astrophysicist to read…

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20 Responses to “Breaking down a breakdown”

  1. peter:

    do you keep a diary? i’ve often wonder whether such a thing would be a good way of trying to correlate state-of-mind/health with more mundane physical factors (what you ate/drank, how well you slept, etc).

    unfortunately i’ve never had the perserverence to put the idea into practice…

    ian

    • telescoper Says:

      Talking therapies such as CBT (which I had) often focus on things practical things like keeping a diary. They also involve doing “experiments” to try to understand things. I identified correlated observations, but couldn’t find a viable theoretical explanation.

      For example, I rarely go to the cinema as I generally find these very difficult places, but have never had any issues at the opera or at a theatre. I don’t understand why. Likewise certain supermarkets are difficult, others no problem. I think this might even boil down to subtle things like lighting.

      • Loretta Dunne Says:

        Hi Peter, thinking about the peripheral vision disturbance and your discomfort in cinemas and supermarkets – have you ever been tested for migraine? The visual auras associated with some migraine sounds similar to the peripheral vision issues and can be brought on by lighting – esp if there is a flicker. I’ve found that lighting here in NZ is MUCH worse for this than the UK and have had a raft of weird problems so I now avoid certain shops and can’t turn on the ceiling lights in my office. The cinema also can have bright and flashing light and a lot of movement in the peripheral vision so is quite a different task for the brain than the theatre. Some of your symptoms may be related to such a neurological condition, but how that would link to the feelings of panic etc I wouldn’t know.
        Good luck getting to the bottom of it …
        Loretta

      • telescoper Says:

        Loretta,

        No I haven’t had such a test. It’s interesting idea.

        I always thought it might be informative to have an fMRI scan during an episode, but this would be very difficult to arrange given the unpredictable and transient nature of the events.

      • Anton Garrett Says:

        Loretta,

        That’s interesting. What’s the physical difference between lighting in UZ and UK? I’d expect the frequency and the fluorescent chemicals used in striplights to be the same.

  2. Anton Garrett Says:

    I’m not a neuroscientist as you know, but I suspect that neuroscience is helpful only if you intend to take a reductionist rather than a wholist approach. I *always* advocate an analytical (I don’t mean ‘psychoanalytical’ in the formal sense) approach to these issues, but there can be reductionist-analytical and wholist-analytical approaches, the latter having no real analogy with physical science. Reductionist-analytical neuroscientific approaches lead mainly to drug-based methods of managing the problem. Apart from cases having genetic cause, I regard that as dealing with symptom rather than cause, and I share the drive of those who want to find (and hopefully treat) cause.

    Anybody who believes that there is a threat in places where there is, statistically, very unlikely to be one is somehow believing a lie – at minimum, about such places. This lie is lodged in a very deep and hard-to-access ‘place’, psychologically speaking – so deep that the person can see when not in a state of fear that the behaviour is irrational. (That somebody’s mind and feelings are not at one should motivate compassion in others, never mockery.) Because it is all about that lie I do believe that the so-called “talking therapies” are the way forward, provided – crucially – that they are done correctly, ie with the aim of exposing the lie to the person. If the person can be helped to see the lie then there is no need for talking therapies of the ‘cathartic’ kind in which people are encouraged to regress to the (typically) traumatic childhood experience that started the problem and feel the emotions that were too bad to be felt at the time and were repressed. Instead, if you twig the lie and so call its bluff then all that stuff goes away spontaneously. but, as I said, as the lie is lodged deep then this takes expertise and cooperation.

    • I generally agree, but the term “lie” might be misplaced here; what about “misperception”?

      Wearing my evolutionary-biologist hat, such behaviour is clearly adaptive: it is better to fear a non-present danger (within reason) than not to fear a present one. Thus, it could be that were are disposed to err on the side of too much, rather than too little, fear.

    • Adrian Burd Says:

      I’m not sure I would entirely rule out the chemical route. Biological organisms can be thought of as highly complex and finely (or not) tuned networks of chemical reactions. Most of the time, those chemical reactions are regulated by a variety of feedback mechanisms; sometimes, chemical systems that evolved to deal with one set of situations are co-opted to do double duty or for completely different things (I’m thinking of heat-shock proteins in antarctic fish as one example).

      Understanding the chemical nature of the problem can frequently lead to an understanding of what gave rise to any imbalance in the first place. In some cases this can be traced to breakdowns in the genetic machinery (the code, the transcription….there are numerous places where problems can arise). This also applies to the brain, which is a fascinating and highly complex organ as well as one that is easily prone to damage in all sorts of little ways.

      This is not to say that what Anton calls “talking therapies” are not invaluable. The genius of the brain is that in many cases we do actually have some control over how we react to its signals and understanding a root cause of some behavior can help us to cope (I’m speaking from experience here).

      So to my mind, Anton’s “wholist-analytical” approach would potentially include both approaches to the problem.

      • Anton Garrett Says:

        Adrian,

        I’m not against drug therapies in non-genetic cases – often they are helpful in the short term at least – but I regard them as dealing with symptom rather than root cause, so that they are incapable of actually curing and are liable to go on indefinitely.

    • telescoper Says:

      Anton,

      I agree with you up to a point, and to back up what you said consider the following. When caught up in a crowd connected with the demonstration on Sunday that I blogged about there was a point when there was a *real* threat of violent attack, as a bunch of thugs moved towards us as if to attack. Although I did not enjoy this experience (!) I responded to it in much the same way as I’d guess anyone else would. I considered running away, but ended up standing my ground without aggravating the situation but prepared to defend myself. The threat quickly disappeared when the police arrived, but was momentarily very real. Nevertheless it didn’t trigger a panic episode.

      The episodes I get are apparently something to do with a malfunction in the way my brain deals with peripheral data. Most of the time we just discard data from outside our line of sight unless it’s something extremely dramatic and disturbing (whether good or bad); presumably we can’t process everything across our entire field of view so we usually filter out observations coming from the edges. What seems to happen with me is that something interferes with this filtering process so that almost everything gets flagged with a danger signal. My response to these is to look about manically trying to establish whether the threat is real before, usually, just getting out of there as quickly as I can when it becomes overwhelming.

      However although therapy does help one understand that the perceived threats are not real, they’re not simply imagined either. I do see things that appear real at the time: movements become juddery and hard to track, for example. Shapes even change…

      But it’s almost impossible to describe what these things are like to people who haven’t experienced them!

      • Anton Garrett Says:

        It doesn’t surprise me that your sensory perceptions alter during these episodes, but I’m not able to get more specific than in my comment above (and if I could I’d do it by email rather than here). I wish you well in dealing with this, Peter.

  3. Peter, you say that your condition is probably an unusual example but I come across two or three similar cases a year in my undergraduate cohort in my role as department senior tutor. That equates to a few per hundred.

    Some cases seem to be triggered by a traumatic life event – often bereavement. Others by the stress of the non-stop cycle of high stakes examinations that we subject them to while others have no obvious cause.

    Typical presentations include panic attacks in lecture theatres (one guy was ok in early morning lectures but would often have an attack in lunch time and afternoon lectures – we think it was to do with the number of people in the lecture theatre, early mornings = poor attendance but afternoon = high attendance). Another student became physically incapable of travelling to the campus by bus (nearly all buses to and from the campus are full and standing).

    The use of the word ‘breakdown’ is interesting and, as has been pointed out, seems to have connotations of sudden onset. Part of my job, when a student comes to me with mental or physical health problems is to help them navigate their way through the ‘Individual Mitigating Circumstances’(IMC) procedure. Our University wide rules state that IMC claims will not normally be accepted for ‘on-going’ conditions and students whose doctors provide letters which talk about ‘severe depression’ will normally be refused IMC and advised to suspend their studies until such time as they have recovered. On the other hand, if the doctor uses words such as ‘sudden onset’, ‘severe episode’, or ‘breakdown’ the panel that decides these matters is likely to approve the IMC claim.

    • telescoper Says:

      Gary,

      I actually said that I think every other example is unusual true, not meaning that they are rare but that everyone has elements peculiar to the individual person.

      Peter

  4. Peter. Thank you for your thoughts. I believe you are correct that there are many people out there with a similar condition, myself included. How it manifests itself is as unique as the individual’s own life experiences. Through some some very effective CBT ( third attempt ) I am now able to psychologically function as normal, most days I even actually rather enjoy myself. I had the great fortune to come across a young PhD student, who used me as a case study. She conducted my therapy in the form of lectures, meaning that we both learnt a lot along the way. My background is in medical physics, giving me maybe the unique position to having some biological understanding of what happens during a panic attack, and the following confusion, whilst also understanding the value of experimenting with cause-and- effect. My equivalent to crossing the concourse at Victoria Station is to be able to operate a washing machine. Don’t laugh, not being able to undertake simple tasks is excruciatingly distressing, (but my misconceptions have been exposed)! With the right help, I believe you can cross the concourse, without thinking anything of it. Your blogs are full of humour, compassion and sensitivity. They bring me a lot of knowledge and joy. I wish you well.

  5. It might be interesting following up the migraine angle. I know someone who suffers from both panic attacks (quite similar to your description of yours) and migraine, apparently uncorrelated though they sometimes occur together.

  6. telescoper Says:

    Perhaps I should offer myself as a PhD topic to a neuroscience student?

  7. [...] Breaking down a breakdown (telescoper.wordpress.com) [...]

  8. Not quite, but I have this (wonderfully illustrated) on order http://stahlonline.cambridge.org

  9. […] Breaking down a breakdown (telescoper.wordpress.com) […]

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