Good Reasons For Bad Feelings

‘A new approach to mental
‘A wise, accessible, highly readable exploration of

disorder. Randolph Nesse’s an issue that goes to the heart of human existence’
insightful book suggests that
R ANDOLPH M . NESSE GOOD REASONS FOR BAD FEELINGS

RO B ER T S A P OL S K Y , AUT H O R O F B E H AV E P EN GUIN P RES S
conditions such as anxiety GOOD REAS ON S FOR B AD
and depression have a clear FEEL IN GS
evolutionary purpose . . . This Date: 12 November 2019

intriguing book turns some age- Designer: Isabelle
Prod. Controller:
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‘A compelling case for locating mental illness •Confirmed
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Reasons for Bad Feelings boldly posits, Regular Coated

many of the core dysfunctional components Matte varnish to seal
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BAC K COV E R SPINE FRO NT COV E R
p e n g u i n b oo k s
GOOD RE AS ONS FOR B AD FE EL IN G S
‘If your idea of self-care skews less spiritual and more scientific,
Nesse’s new book on why humans are so vulnerable to a variety of
mental disorders is a must. In this new work, he covers both why
some people get sick, as well as why natural selection left us all so
vulnerable to developing mental illness’ Forbes
‘I do fully expect that someday nearly all psychiatry will be identified
as evolutionary psychiatry. If so, Randolph Nesse’s book
should be seen as the field’s founding document’
David P. Barash, Wall Street Journal
‘Nesse’s book offers fresh thinking’ Anjana Ahuja, Financial Times
‘Randolph Nesse’s book Why We Get Sick put evolutionary
medicine on the map. His follow-up, Good Reasons for
Bad Feelings, promises to transform our understanding of
mental illnesses in the same way’ New Scientist
‘Highly accessible, scholarly and deeply illuminating . . . this will
become a treasured classic’ Professor Paul Gilbert OBE, author of
Compassionate Mind and Living like Crazy
‘There may be good evolutionary reasons for our moods, says a
radical psychiatrist . . . benign and rather practical . . . [Nesse’s] basic
conception of the mind feels like good, common sense’
James McConnachie, Sunday Times
‘Breezy, enjoyable . . . often fascinating content and obviously deep
knowledge’ David Aaronovitch, The Times
‘A book I would recommend as required reading for anyone
practicing, or hoping to practice, clinical psychology, psychiatry, or
social work. In fact, I would recommend the book to anyone who
suffers from anxiety, depression, or problems controlling
their eating, drinking, drug use, or sexual impulses’
Douglas T. Kenrick, Psychology Today
‘Using fascinating insights, Nesse suggests novel and revolutionary
ways to treat mental illness’ Daily Mail
‘Two sets of ideas inform this fine book: one, the cold-hearted
logic of natural selection; the other, the practical wisdom of a
compassionate psychiatrist. The tension is palpable. The result is
riveting’ Nicholas Humphrey, Emeritus Professor of Psychology,
London School of Economics, author of Soul Dust
‘Randolph Nesse is one of the key architects of evolutionary
medicine. He’s been an inspiration to a generation of
scientists who explore evolution to understand why we get
sick from diseases ranging from cancer to obesity to
infectious diseases. Now Nesse has turned his attention from
the body to the mind, in a provocative book full of intriguing
explanations about human nature in all its strengths and weaknesses’
Carl Zimmer, author of She Has Her Mother’s Laugh
‘Highly readable. Nesse is a pioneer of evolutionary psychiatry,
which has the potential to revolutionize mental health care’
Simon Baron Cohen, Professor of Developmental
Psychopathology, Cambridge University, author of
The Maladapted Mind
‘A book as wise and illuminating as it is relevant to our daily lives’
Sarah Blaffer Hrdy, Professor Emerita of Anthropology,
University of California, Davis, author of The
Woman that Never Evolved and Mother Nature
‘A bold book that would have made Darwin proud. Cutting-edge and
compassionate at the same time’ Lee Dugatkin, Professor of Biology,
University of Louisville, co-author of How to
Tame a Fox (and Build a Dog)
‘It is no exaggeration to say that Nesse opens the door to a new
paradigm in thinking about human beings and their conflicted lives.
A pathbreaking book by a man who is truly humane and caring’
Michael Ruse, Werkmeister Professor of Philosophy,
Florida State University, author of On Purpose
‘A masterful, ground-breaking book that persuasively
challenges standard clinical wisdom and provides a roadmap
for the transformation of our conceptually confused psychiatric
nosology . . . this book will be an influential watershed in
the mental health field’ Jerome C. Wakefield, Professor of
Psychiatry, New York University, co-author of The Loss of Sadness
‘Good Reasons for Bad Feelings may well become a legend, as
it is a book about psychology, psychiatry, biology and
philosophy that is also a good read, and it opens the
door to deep questions in a manner that is tender,
quizzical, and industrious’ Judith Eve Lipton, MD,
co-author of Strength Through Peace
‘“Why I am I feeling bad?” This is the first burning question of
everyone who suffers. This accessible new book will be an
essential tool to help patients, their loved ones, and treating
professionals arrive at more satisfying answers’
Jonathan Rottenberg, Professor of Psychology,
University of South Florida, author of The Depths
‘In an engaging, storytelling voice that rests on 30 years of clinical
practice, he offers a series of insights both scientific and anecdotal,
that begins to show why the vulnerabilities in our psyche are
fundamental to the survival of our genes’
Tim Adams, Observer
‘An ingenious exploration of how Darwinian evolution explains
mental disorders’ Kirkus Reviews
‘Nesse thought-provokingly comments on modern medicine’s
continuing difficulties in treating mental illness . . . Nesse
fully meets his modest but laudable goal of providing a
conversation-starter on why mental illness should be
viewed from an evolutionary perspective’
Publishers Weekly
a b o u t t h e au t h or
Randolph M. Nesse is an American physician, a founder of evolutionary

medicine, and co-author with George C. Williams of the acclaimed
Why We Get Sick. After a long career as a Professor of Psychiatry
and Professor of Psychology at the University of Michigan, Nesse
moved in 2014 to become the Founding Director of the Center for
Evolution and Medicine at Arizona State University, where he is also a
professor in the School of Life Sciences.
r a ndo l p h m . nesse
Good Reasons for
Bad Feelings
Insights from the Frontier of
Evolutionary Psychiatry
PEN GU IN B O O K S
P E N GUIN B O O KS
UK | USA | Canada | Ireland | Australia

India | New Zealand | South Africa
Penguin Books is part of the Penguin Random House group of companies

whose addresses can be found at global.penguinrandomhouse.com.
First published in the United States of America by Dutton,

an imprint of Penguin Random House LLC 2019
First published in Great Britain by Allen Lane 2019
Published in Penguin Books 2020
001
Text copyright © Randolph M. Nesse, 2019
The moral right of the author has been asserted
Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.
A CIP catalogue record for this book is available from the British Library
ISBN: 978–0–141–98491–9
www.greenpenguin.co.uk
Penguin Random House is committed to a

sustainable future for our business, our readers
and our planet. This book is made from Forest
Stewardship Council® certified paper.
CONTENTS
PREFACE xiii
PART ONE
Why Are Mental Disorders So Confusing?
To my patients, who have taught me so much
1. A New Question
Why has natural selection left us so vulnerable
to mental disorders? 3
2. Are Mental Disorders Diseases?

Psychiatric diagnosis is confused because it doesn’t
distinguish symptoms from diseases, and it incorrectly
assumes that each disorder has a specific cause. 17
3. Why Are Minds So Vulnerable?

Six evolutionary reasons explain vulnerability to diseases. 29
PART T WO
Reasons for Feelings
4. Good Reasons for Bad Feelings
Emotions were shaped to cope with situations. 45
5. Anxiety and Smoke Detectors

Useless anxiety can be normal, as
the Smoke Detector Principle reveals. 67
CONTENTS
PREFACE xiii
PART ONE
Why Are Mental Disorders So Confusing?
1. A New Question
Why has natural selection left us so vulnerable
to mental disorders? 3
2. Are Mental Disorders Diseases?

Psychiatric diagnosis is confused because it doesn’t
distinguish symptoms from diseases, and it incorrectly
assumes that each disorder has a specific cause. 17
3. Why Are Minds So Vulnerable?

Six evolutionary reasons explain vulnerability to diseases. 29
PART T WO
Reasons for Feelings
4. Good Reasons for Bad Feelings
Emotions were shaped to cope with situations. 45
5. Anxiety and Smoke Detectors

Useless anxiety can be normal, as
the Smoke Detector Principle reveals. 67
x xCONTENTS
CONTENTS
6. 6. Low
LowMood
MoodandandthetheArtArtof ofGiving
GivingUpUp
Mood
Moodadjusts
adjusts
behavior
behavior
to to
thethe
propitiousness
propitiousness
of of
thethe
situation.
situation. 8484
7. 7. BadBadFeelings
FeelingsforforNoNoGood
GoodReason:
Reason:When
WhenthetheMoodostat
MoodostatFails
Fails
Moodostat
Moodostatfailures
failures
cause
cause
serious
serious
diseases.
diseases. 112112
PART
PARTTHRE
THREEE
The
ThePleasures
Pleasuresand
andPerils
PerilsofofSocial
SocialLife
Life
8. 8. How
Howto toUnderstand
UnderstandananIndividual
IndividualHuman
HumanBeing
Being
AnAn
individual’s
individual’s
emotions
emotionsand
andactions
actions
makemake sense
sense
only
only
in in
thethe
context
context
of of
that
that
person’s
person’s
idiosyncratic
idiosyncratic
lifelife
goals
goals
andand
projects.
projects. 141141
9. 9. Guilt
GuiltandandGrief:
Grief:TheThePrice
Priceof ofGoodness
GoodnessandandLove
Love
Preferred
Preferred
partners
partners
getget
advantages
advantages
that
that
make
make
morality
morality
possible.
possible. 160160
10.10. Know
KnowThyself—NOT
Thyself—NOT! !
Repression
Repression
and
and
cognitive
cognitive
distortions
distortions
cancan
bebe
useful.
useful. 183183
PART
PARTFOUR
FOUR
Out-
Out-of-of-Control
ControlActions
Actionsand
andDire
DireDisorders
Disorders
11.11. BadBadSexSexCanCanBeBeGood—
Good—
forforOurOurGenes
Genes
Sexual
Sexual
problems
problems
areare
common
common
forfor
good
good
evolutionary
evolutionary
reasons.
reasons. 201201
12.12. Primal
PrimalAppetites
Appetites
Dieting
Dieting
spirals
spirals
famine
famine
protection
protection
mechanisms
mechanisms
into
into
anorexia
anorexia
nervosa
nervosa
and
and
bulimia.
bulimia. 219219
13.13. Good
GoodFeelings
FeelingsforforBadBadReasons
Reasons
Substances
Substances
hijack
hijack
learning
learning
to to
create
create
zombies.
zombies. 234234
CONTENTSxi xi
CONTENTS
14.14. Minds
MindsUnbalanced
UnbalancedononFitness
FitnessCliffCliff
ss
Genes
Genesforfor
schizophrenia
schizophrenia
andand
autism
autism
may
may
persist
persist
because
because
of of
cliff
cliff
edges
edges
in in
thethe
fitness
fitness
landscape.
landscape. 245245
Epilogue:
Epilogue:Evolutionary
EvolutionaryPsychiatry:
Psychiatry:A ABridge,
Bridge,NotNotananIsland
Island
How
Howusing
using
allall
of of
biology
biology
cancanintegrate
integrate
psychiatry
psychiatry
and
and
make
make
sense
senseof of
mental
mental
illness.
illness. 262262
FURTHER
FURTHERREADING
READING 271271
NOTES
NOTES 273273
ACKNOWLEDGMENTS
ACKNOWLEDGMENTS 349349
INDEX
INDEX 353353
ABOUT
ABOUTTHE
THEAUTHOR
AUTHOR 365365
PPRPRPERERFEFAEFAFCACAECECEE
{
{
{
{
When
When
When
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first realized
firstrealized
rst realized
realized that
that
that
thatevolutionary
evolutionary
evolutionary
evolutionary biology
biology
biology
biology could
could
could
could provide
provide
provide
provide aanewanew
anewnew kind
kind
kind
kind
ofofofof
explanation
explanation
explanation
explanation for
for
for mental
formental
mental
mental disorders,
disorders,
disorders,
disorders, IIimmediately
Iimmediately
Iimmediately
immediately wanted
wanted
wanted
wanted totototo
write
write
write
write this
this
this
this
book.
book.
book.
book. ItItIt
was
was
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soon
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soon clear,
clear,
clear,
clear,however,
however,
however,
however, that
that
that understanding
that understanding
understanding
understanding why
why
why bodies
why bodies
bodies
bodies are
are vul-
are
arevul-
vul-
vul-
nerable
nerable
nerable
nerable tototo diseases
todiseases
diseases
diseases ininin
general
general
in general
general had
had
had
hadtototo
come
tocome
come
come fifirst.
first. That
first.
rst.That
That
That project
project
project
project was
was
was
wasthe
the
the focus
the focus
focus
focus
ofofof
my
ofmy
my
mycollaboration
collaboration
collaboration
collaboration with
with
with
withthe
the
the great
the great
great
great evolutionary
evolutionary
evolutionary
evolutionary biologist
biologist
biologist
biologist George
George
George
George C.C.C.Wi
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liams.
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wrote
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aseries
aseries
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WhyWhy
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Get Sick:
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ofDarwinian
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apopular
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inspire
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inspire much
much
much
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new
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field ofofof
field
eld evolutionary
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of evolutionary
evolutionary medicine.
medicine.
medicine.
medicine. Ever
Ever
Ever
Ever
since
since
since then,
since then,
then,
then, mymymy career
my career
career
career has
has
hasbeen
has been
been
been committed
committed
committed
committed equally
equally
equally
equally tototo
bringing
bringing
to bringing
bringing evolutionary
evolutionary
evolutionary
evolutionary
biology
biology
biology
biology tototo medicine
tomedicine
medicine
medicine and
and
and tototo
and helping
tohelping
helping
helping mymy
mymypatients
patients
patients
patients with
with
with
withmental
mental
mental
mental disorders.
disorders.
disorders.
disorders. The
The
The
The
two
two
two
twomissions
missions
missions
missions are
are
areconnected
are connected
connected
connected deeply.
deeply.
deeply.
deeply.
Practicing
Practicing
Practicing
Practicing psychiatry
psychiatry
psychiatry
psychiatry isisis
enormously
enormously
isenormously
enormously satisfying.
satisfying.
satisfying.
satisfying. Patients
Patients
Patients
Patients are
are
are grateful
are grateful
grateful
grateful for
for
for
for
effective
effective
effective
effective treatment.
treatment.
treatment.
treatment. Providing
Providing
Providing
Providing ititit
isit
isis
intellectually
intellectually
isintellectually
intellectually interesting
interesting
interesting
interesting asasas
well
well
as well
wellasasas
emo-
emo-
as emo-
emo-
tionally
tionally
tionally
tionally fulfi
fulfi
fulfi lling.
fulfilling.
lling. Each
lling. Each
Each
Each patient
patient
patient
patient poses
poses
poses
poses aapuzzle.
apuzzle.
apuzzle.
puzzle. Why
Why
WhyWhy did
did
did
didthis
this
thisindividual
this individual
individual
individual get
get
get
get
these
these
these
thesesymptoms
symptoms
symptoms
symptoms now?
now?
now?
now? What
What
What
What treatment
treatment
treatment
treatment will
will
will work
will work
work
work best?
best?
best?
best? However,
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However,
However, sometimes
sometimes
sometimes
sometimes
looking
looking
looking
looking out
outoutoutthe
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the window
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from
from
from mymymymycozy
cozy
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have visions
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atsunami
atsunami
atsunami
tsunami
sweeping
sweeping
sweeping
sweeping millions
millions
millions
millions ofofofof
people
people
people
people with
with
with
with mental
mental
mental
mental disorders
disorders
disorders
disorders totototo
oblivion,
oblivion,
oblivion,
oblivion, with
with
with
with no
nonono
help
help
help or
help oror
high
orhigh
high
high ground
ground
ground
ground ininin
sight.
sight.
in sight.
sight. Such
Such
Such
Such dark
dark
dark
dark apparitions
apparitions
apparitions
apparitions inspire
inspire
inspire
inspire asking
asking
asking
asking different
different
different
different
larger
larger
larger
largerquestions:
questions:
questions:
questions: Why
Why
Why
Why dododo mental
do mental
mental
mental disorders
disorders
disorders
disorders exist
exist
exist
exist atatatall?
atall?
all? Why
all?Why
Why
Why are
are
are there
arethere
there
theresosososo
many?
many?
many?
many? Why
Why
Why
Why are
are
arethey
arethey
they
theysososo
common?
socommon?
common?
common? Natural
Natural
Natural
Natural selection
selection
selection
selection could
could
could
could have
have
have
have eliminated
eliminated
eliminated
eliminated
anxiety,
anxiety,
anxiety,
anxiety, depression,
depression,
depression,
depression, addiction,
addiction,
addiction,
addiction, anorexia,
anorexia,
anorexia,
anorexia, andand
and
and thethe
the
thegenes
genes
genes
genes that
that
that
thatcause
cause
cause
cause autism,
autism,
autism,
autism,
schizophrenia,
schizophrenia,
schizophrenia,
schizophrenia, and
and
and
andmanic-
manic-
manic-
manic- depressive
depressive
depressive
depressive illness.
illness.
illness.
illness. ButButBut
Butititit
didn’t.
didn’t.
itdidn’t.
didn’t. Why
Why
Why
Why not?
not?
not?
not?These
These
These
These
are
are
are good
are good
good
good questions.
questions.
questions.
questions. The
The
The
The aim
aim
aim
aim ofofofof
this
this
this book
this book
book
book isisisto
istotoshow
to show
show
show that
that
that
that asking
asking
asking
asking why
why
why
why
xiii
xiii
xiii
xiii
xivxivPREFACE
PREFACE
natural
natural selection
selection hashasleftleft
ususvulnerable
vulnerable cancan helphelp make
make sense
sense of of
mental
mental illness
illness
andandmakemake treatment
treatment moremore effective.
effective.
TheThe possible
possible answers
answers suggested
suggested here
here areare examples,
examples, notnotconclusions;
conclusions;
some
some will
willturnturn out out
toto bebe wrong.
wrong. ThatThat should
should notnot bebe discouraging
discouraging at at
anan
early
earlystage
stage in ina new
a new field
fieldsoso long
long as as
ideas
ideas areare tested.
tested. AsAs Darwin
Darwin putput it,it,
“False
“False views,
views, if supported
if supported byby somesome evidence,
evidence, dodo little
little
harm,
harm, forforeveryevery one one
takes
takesa salutary
a salutary pleasure
pleasure in inproving
proving their
theirfalseness:
falseness: and,and, when
when thisthisis done,
is done,
oneonepath
path towards
towards error
error is closed
is closed andand thetheroadroad toto truth
truth is often
is often at atthethe same
same
time
time opened.”
opened.” 1 1
Continuing
Continuing controversies
controversies andandslow
slow progress
progress in in
psychiatry
psychiatry havehave inspired
inspired
many
many calls
calls
forfornew new approaches
approaches totomental
mental disorders.
disorders. Evolutionary
Evolutionary biology
biology is is
notnotnew;
new; it is
it is
thethe well-
well-established
established scientifi
scientific foundation
c foundation forfor
understanding
understanding
normal
normal behavior,
behavior, but
but itsitsrelevance
relevance forforabnormal
abnormal behavior
behavior is is
fi nally
fi nally being
being
recognized.
recognized. Evolutionary
Evolutionary medicine
medicine is is
providing
providing newnew explanations
explanations forfor
why why
ourourbodies
bodies arearevulnerable
vulnerable to todiseases
diseases and andis now
is now being
being applied
applied systematically
systematically
totomental
mental disorders.
disorders. The The timetime is ripe
is ripetotoexplore
explore thethefrontier
frontier of of
evolutionary
evolutionary
psychiatry.
psychiatry.
I wish
I wish thethe field
field
could
could havehave some
some other
other name.
name. Evolutionary
Evolutionary psychiatry
psychiatry
is is
not nota special
a special method
method of oftreatment,
treatment, and and professionals
professionals in in
other
other mental
mental
health
health fields
fields willwillalso
also appreciate
appreciate anan evolutionary
evolutionary perspective.
perspective. AA moremore ac-ac-
curate
curate descriptor
descriptor would
would bebe “Using
“Using thetheprinciples
principles of of
evolutionary
biology
totoimprove
improve understanding
understanding and and treatment
treatment of of
mental
mental disorders
disorders in inpsychiatry,
psychiatry,
clinical
clinicalpsychology,
psychology, social
social work,
work, nursing,
nursing, andand other
other professions.”
professions.” But Butthatthat
is unwieldy,
is unwieldy, soso thisthis
book
book is ais report
a report from
from thethe frontier
frontier of of
evolutionary
evolutionary psy-psy-
chiatry,
chiatry, viewed
viewed broadly.
broadly.
Mental
Mental disorders
disorders areare suchsuch a plague
a plague onon our our species
species that
thatwewe allallwantwant
solutions
solutions right
right now.now.Evolutionary
psychiatry offers
offerssomesome practical
practical benefi
benefi ts ts
now,
now, butbutthethe bigbig payoffs
payoffs willwillcomecome as as
researchers,
researchers, clinicians,
clinicians, and and patients
patients
askask
andandanswer
answer new newquestions
questions inspired
inspired byby a fundamentally
a fundamentally newnew perspective.
perspective.
InIn thethemeanwhile,
meanwhile, evolutionary
evolutionary psychiatry
psychiatry offers
offers philosophical
philosophical insights.
insights.
Nearly
Nearly everyone
everyone hashaswondered
wondered whywhy human
human lifelife
is so
is sofull
full
of of
suffering.
suffering. PartPart
of of
anananswer
answer is that
is thatnatural
natural selection
selection shaped
shaped emotions
emotions suchsuchas as
anxiety,
anxiety, low low
mood,
mood, andand grief
grief because
because theythey areareuseful.
useful. More More of of
anan answer
answer comes
comes fromfrom
recognizing
recognizing that
that ouroursuffering
suffering often
often benefi
benefi ts ts
our ourgenes.
genes. Sometimes
Sometimes painful
painful
emotions
emotions arearenormal
normal but butunnecessary
unnecessary because
because thethe costs
costsof of
notnot having
having thethe
PREFACExv xv
PREFACE
emotion
emotion could
could bebehuge.
huge.There
There areare
also
also
good
good evolutionary
evolutionary reasons
reasonswhy
whywewe
have
havedesires
desires
wewe cannot
cannotfulfi
fulfi
ll, ll,
impulses
impulses wewecannot
cannot control,
control,
andand
relationships
relationships
full
full
of of
confl
confl
ict.ict.
Perhaps
Perhaps most
most profound
profound of of
all,all,
however,
however, evolution
evolutionexplains
explains
thethe
origins
originsof of
ourouramazing
amazing capacities
capacitiesforfor
love
love andandgoodness
goodness and
andwhy
whythey
they
carry
carrythethe
price
price of of
grief,
grief,
guilt,
guilt,
and, and,
thank
thankgoodness,
goodness, caring
caring
inordinately
inordinatelyabout
about
what
what others
othersthink
think about
about us.us.
July
July
2018
2018
Good Reasons for Bad Feelings
PA
PART
RT ONE
ONE
C HPARPETFEARC E2
{
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ARE MEN TAL DI SORDERS DI SE A S E S? *
Why
Why Are
Are Mental
Mental Disorders
Disorders So
So Confusing?
Confusing?
There is little reason to believe that these diagnostic categories are valid.1
—A comment about the DSM diagnostic
When I fi rst realized that evolutionary biology categories
couldon the first page
provide of kind
a new
the leading psychiatry textbook
of explanation for mental disorders, I immediately wanted to write this
book. It was soon clear, however, that understanding why bodies are vul-
nerable to diseases in general had to come fi rst. That project was the focus
of my collaboration with the great evolutionary biologist George C. Wil-
liams. We wrote a series of technical papers and Why We Get Sick: The New
There
Scienceis of
noDarwinian
point in trying to explain
Medicine, a popularmentalbook disorders
that helped
without
inspire
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ningis them.
now the That
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eld ofenough.
evolutionary
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Diagnostic career has been
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of Mental to bringing
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more
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mentalThe disorders.
diagnostic The
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two missions
generates areinterminable
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Defi nitions psychiatry
Practicing of diagnostic categories satisfying.
is enormously make mental disorders
Patients seem like
are grateful for
diseases.
effective Many are, but
treatment. they are
Providing it ais bit different from
intellectually most other
interesting as welldiseases.
as emo-
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tionally have
fulfi specifi
lling. Eachc patient
causes we poses have been able
a puzzle. Why todid
identify, such as the
this individual get
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ce, Itissue
have visions
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assweeping
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defi
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ground of in
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often depressed
Why doand mental
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disorders
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at all?often
Why hearare there
voices.so
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many? Why are thinthey
people
so common?
who think Natural
they are selection
fat are could
often high-
have eliminated
achieving
anxiety, depression, addiction, anorexia, and the genes that cause autism,
schizophrenia, andCopyrighted
manic-depressive illness. Material But it didn’t. Why not? These
* This chapter is adapted from Nesse RM, Stein DJ. Towards a genuinely medical
are good questions. The aim of this book
model for psychiatric nosology. BMC Medicine. 2012;10(1):5. is to show that asking why
C HCPAHRPPAERTFPEEATFRCEAERC1 E2
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A RE MENATAL
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If There
I hadisan
little
hour
reason
to solve
to believe
a problem
that these
anddiagnostic
my life categories
dependedareonvalid.
the 1
solution, I would spend the first—fiA
fty-fi ve minutes
comment aboutdetermining the
the DSM diagnostic
When
When I fiIrst
proper fiquestion
rst
realized
realized
to thatthat
ask, evolutionary
for evolutionary
once I know biology categories
biology
the propercould
could on the
provide
question, first
provide apage
I couldnew
a new ofkind
kind
the leading psychiatry textbook
of ofexplanation
explanation
solve forfor
the problem mental
inmental disorders,
less than disorders, I immediately
five minutes. I immediately wanted
wanted toto write
write this
this
book.
book. It It
was was soon
soon clear,
clear,however,
however, thatthatunderstanding
understanding —why why
Albert bodies
bodies
Einstein arearevul-
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nerable
nerable toto diseases
diseases in in
general
general had had toto comecome fi rst.
fi rst.
That
That project
project was wasthethe focus
focus
of ofmymy collaboration
collaboration withwith thethegreatgreat evolutionary
biologist George
George C.C. WiWil- l-
liams.
liams. WeWe wrote
wrote a series
a series of of
technical
technical papers
papers andand WhyWhy WeWe GetGetSick:
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of noDarwinian
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that
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rstmuch
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eld
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equally meet
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toto medicine
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Hardly.
mental disorders.
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two “Imissions
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two just wanted
missions
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connected
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connected deeply. he said. “This
deeply.
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controversy.
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nitions
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diagnostic
psychiatry
psychiatry Icategories
asked. satisfying.
is enormously
is enormously make mental
satisfying. Patients disorders
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grateful
grateful like
for
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diseases.
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intellectually from her
interesting most
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asother
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lling. specifi
lling.
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work best?
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getHowever,withsometimes
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answers blood
from tests
sometimes
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looking
theshots
looking
waysout atdiabetes
outthe Big
thethe U.”They
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asmile,
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sweeping
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millions
dying millions
neuronsof ofpeople
in university
people with
multiple with hospital.
mental
mental
sclerosis. disorders
disorders
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oblivion, with
disorders with nono
are
help
defi
help
I asked
or
ned or
high
by
high
himclusters
ground
ground
to summarize
of
in in
symptoms.
sight.
sight. Such
the Suchcase.
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darkdark
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who
apparitions
gavesay a quick
that
inspire
inspire
food
caseasking
tastes
presentation:
asking different
likedifferent
card-
larger
board
larger
“She’squestions:
are
questions:
aoften
thirty-
depressed
Why Why
fi ve-
dodoyear-
mental
and
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old
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disorders
married
disorders
Paranoid
exist
mother
existatpeople
at
all?all?
ofWhy
often
Why
threearehear
arethere
grade-
there
voices.
soso
school-
many?
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many? age children
Why Why areare
thin
they
they
whose
people
soso common?
common?
chief
whocomplaint
think
Natural
Natural
theyisselection
are
increasing
selection
fat are could
could
often
worry have
high-
have
abouteliminated
eliminated
achieving
nearly
everything
anxiety,
depression,
for the past addiction,
addiction,
year. Her anorexia,
health,
anorexia, her
and andkids,
thethe genes
the
geneseconomy,
that
that cause
cause
driving,
autism,
autism,
everything.
schizophrenia,
schizophrenia, She and
often
and manic-
has
manic-a depressive
bad depressive
feelingillness.
inillness.
the ButpitBut of
it didn’t.
her
it didn’t.
stomach,
Why Why not?
and
not? These
once
These
* This chapter is adapted from Nesse RM, Stein DJ. Towards a genuinely medical
oraretwice
are
modelgood
gooda month
for questions.
questions.
psychiatricshenosology.
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bouts
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BMC of ofnausea,
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but issheis
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2012;10(1):5.hasn’t
show
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thatany
asking
asking
weight.
whywhy
i 3xi17xi
4 4GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
SheShesays saysshe’s
she’sirritable
irritableand andfatigued
fatiguedand andhas hastrouble
troublegetting gettingtotosleep. sleep.
SheSheis less
is less
interested
interested in in
things,
things, but but she’s
she’snot not suicidal,
suicidal, and and sheshe doesn’t
doesn’t have
have
other
other symptoms
symptoms of of
depression.
depression. Anxiety
Anxiety runsruns in in
herherfamily,
family, but butnothing
nothing
dramatic.
dramatic. Her Her family
family doctor
doctor couldn’t
couldn’t fi nd
fi ndany anymedical
medical causes.
causes. I think
I think it’sit’s
generalized
generalized anxiety
anxiety disorder,
disorder, butbut it it
could
could bebe dysthymia
dysthymia oror somatization
somatization
disorder.
disorder. I’llI’ll
bebe curious
curious toto seeseewhatwhat you you think.
think. AndAnd how how youyou answer
answer herher
questions.”
questions.”
WhenWhen wewe joined
joined Ms.Ms. AA in inthethe exam
exam room,room, sheshegreeted
greeted usus warmly.
warmly.
When
When I asked
I asked howhow wewe could
could help,
help, however,
however, herher voice
voicetook took onon anan edge.
edge. “I“I
take
takeit that
it thatthethe young
young doctor
doctor already
already told
told you you about
about mymy problems.
problems. I drove
I drove
five
five
hours
hours from
from upup north
north toto getgetsomesome answers.”
answers.”
Trying
Trying toto bebe empathic,
empathic, I said,
I said, “I“Iunderstand
understand youyou have
have hadhad trouble
trouble
getting
getting help.”
help.” It It
was wasas as
if Iif had
I had pushed
pushed thethe playplay
button.
button.
“Not“Not onlyonlyhavehave I gotten
I gotten nono help,
help, butbut every
every expert
expert I talk
I talktoto gives
givesmeme a a
different
different explanation.
explanation. I started
I started withwith ourour minister.
minister. HeHe is is
a nice
a nice man,
man, andand
hehe waswas sympathetic,
sympathetic, butbutmainly
mainly hehe justjustsuggested
suggested praying
praying and and accepting
accepting
God’s
God’s plan
plan forforme. me.I tried,
I tried, butbutI guess
I guess mymy faith
faithjust
just
isn’t
isn’tstrong
strong enough.
enough.
Then
Then I talked
I talked toto mymy family
family doctor.
doctor. HeHe didn’t
didn’t even
even dodo anyany tests;
tests;hehe just
just
said
saidit was
it was nerves.
nerves. HeHe said
said pills
pillsforfor worry
worry areare addicting,
addicting, soso hehe prescribed
prescribed
pills
pills
forformymy stomach,
stomach, but buttheytheydidn’t
didn’t help.
help.
“He “He sentsent meme totothis
thistherapist
therapist doctor
doctor who who wanted
wanted meme totocomecome twice
twice a a
week,
week, which
which I couldn’t
I couldn’t afford.
afford. HeHe didn’t
didn’t talktalkmuch,
much, and and whenwhen hehedid,did,hehe
kept
keptasking
asking about
about mymy childhood
childhood and andhinting
hinting like
like
I had
I had some
some sexual
sexual thing
thing
forfor
mymy father,
father, which
which I defi
I definitely
nitely dodo not!
not! WhenWhen I told
I told him him I was
I was getting
getting
worse,
worse, hehesaidsaidI was
I was avoiding
avoiding getting
getting in intouch
touch with
withmymy memories.
memories. I quit
I quit
going,
going, but
but hehe still
still
sends
sends bills
billsforforthethe session
session I skipped.
I skipped.
“I“I still
still
feltfelt
awful,
awful, soso I found
I found a psychiatrist
a psychiatrist in in
thethe
phone
phone book
book whowho waswas
farfar
enough
enough awayaway thatthatpeople
people wouldn’t
wouldn’t fi nd
fi ndout.out.HeHe saidsaid mymy problem
problem waswas
ananinherited
inherited brain
brain abnormality
abnormality and and that
thatI would
I would have
have toto taketakemedications
medications
totocorrect
correct a chemical
a chemical imbalance.
imbalance. But But hehe didn’t
didn’t dodo any
any bloodblood tests,
tests,
either,
either,
andandwhen when I looked
I looked upup thethe pills,
pills,
it said
it saidtheythey might
might cause
cause suicide.
suicide. SoSo I de-
I de-
cided
cided totogetget myself
myself down
down hereheretoto thetheuniversity
university totogetget some
some answers.
answers. AllAll
I do
I do is is
worry,
worry, and and I can
I can hardly
hardly sleep
sleep oror eat,eat, andandmymy husband
husband hashashad hadit it
with
with mymy calling
calling him him about
about thethekidskids allall
thethe time,
time, sosoI hope
I hope you you have
havesomesome
answers.”
answers.”
A NEW
A NEW QUESTION5 5
QUESTION
“No “No wonder

wonder youyou areare frustrated,”
frustrated,” I said.
I said. “Four
“Four different
different explanations
explanations
andandrecommendations
recommendations fromfrom fourfourdifferent
different professionals!
professionals! AndAnd wewe may may wellwell
have
haveyetyetother
other ideas.
ideas. Could
Could wewe askaska few
a few moremore questions
questions toto figure
figure out outthethe
best
bestplan?”
plan?”
She Shewas was glad
glad toto provide
provide moremore details.
details. She She saidsaidsheshe had hadalways
always beenbeen a a
worrier
worrier andand thatthatherher mother
mother had had often
often been
been nervous.
nervous. SheShe hadhad never
never been
been
abused,
abused, butbut herherfather
father had had often
often beenbeen critical.
critical. WhenWhen sheshe waswas young
young herher
family
family had hadmoved
moved every
every few few years,
years, soso sheshehad hadalways
always feltfelt
out outof of
it at
it at
school.
school.
HerHermarriage
marriage was was stable,
stable, but butsheshe andand herher husband
husband fought
fought a lot,
a lot, especially
especially
about
about hishis
frequent
frequent business
business trips
tripsand and what
what toto dodo about
about their
their oldest
oldest son’s
son’s
ADHD.
ADHD. SheShe often
often drank
drank “a“a few fewglasses”
glasses” of ofwinewine toto helphelp herhergetget toto sleep.
sleep.
SheShesaidsaidthetheanxiety
anxiety had had worsened
worsened two two years
years previously,
previously, about
about thethe timetime
herher
youngest
youngest son son hadhad started
started kindergarten
kindergarten and and sheshe had hadstarted
started trying
trying toto
lose
lose
weight.
weight. Without
Without a pause
a pause sheshewentwent onon totosay,say,“But
“But allall
thatthathashas nothing
nothing
totododo with
with mymy problem.
problem. What What I came
I came here
here toto fi nd
fi nd
out out is whether
is whether it is
it neu-
is neu-
rosis
rosis
oror brain
brain disease
disease oror stress
stress oror what.”
what.”
I started
I started toto explain
explain thatthat herhersymptoms
symptoms resulted
resulted fromfrom a combination
a combination of of
inherited
inherited tendencies,
tendencies, early
early lifelife
experiences,
experiences, herher current
current lifelife
situation,
situation, andand
drinking.
drinking. She Shefrowned.
frowned. AsAs I went
I went onon totoexplain
explain thatthat anxiety
anxiety can canbebe useful
useful
butbut
thatthatmost
most people
people have
have moremore than
than theytheyneedneed because
because too toolittle
littlecancan result
result
in in
disaster,
disaster, sheshe brightened
brightened and and said,
said, “That
“That makes
makes sense.”
sense.” WhenWhen I told
I told herher
that
thatseveral
several kinds
kinds of of
treatment
treatment could
could bebe safesafe and and effective
effective and and thatthat anan
excellent
excellent cognitive
cognitive behavior
behavior therapist
therapist near
near herher homehome would
would likely
likely bebe ableable
totohelp,
help,shesherelaxed
relaxed and andsaid,said,“Maybe
“Maybe this
thistriptripwill
willbebe worth
worth it.”it.”
However,
However,
later,
later,
as as
sheshestepped
stepped outoutof ofthethe offioffi
ce,ce,
sheshe stared
stared at atmeme and and shared
shared a parting
a parting
comment
comment that
that still
still
rings
rings in inmymy ears:
ears:“Your
“Your whole
whole field
fieldis is
confused.
confused. You You
know
know that,
that,right?”
right?”
I had
I had never
never quite
quite admitted
admitted it it
toto myself
myself thatthat clearly.
clearly. Psychiatrists
Psychiatrists areare
supposed
supposed toto helphelp their
theirpatients
patients getgetin intouch
touch withwith things
things they
they arearetrying
trying
to to
avoid,
avoid,but butMs. Ms.A Aturned turnedthe thetables
tablesononme. me.For Forallallcasecasereports,
reports,I I
have modifi
have modifi eded details
details soso thatthat patients
patients cannot
cannot bebe recognized
recognized byby friends,
friends,
relatives,
relatives, oror eveneven themselves,
themselves, but butif if
Ms.Ms. AA reads
reads this
this andand recognizes
recognizes herher
visit
visit
thirty
thirty years
years ago,
ago, sheshe willwilllikely
likelybebe pleased
pleased toto learn
learn thatthatherher pointed
pointed
observation
observation shattered
shattered mymy denial
denial and and setsetmeme onon a quest
a quest toto transcend
transcend thethe
confusion.
confusion.
6 6GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
Embedded
EmbeddedShrink
Shrink
During
During mymy early
early years
years as asanan assistant
assistant professor
professor of of
psychiatry,
psychiatry, I was
I was em- em-
bedded,
bedded, likelike
a journalist
a journalist in ina war
a warzone,
zone, in ina medical
a medical clinic
clinicstaffed
staffed byby internal
internal
medicine
medicine professors,
professors, medical
medical residents,
residents, and and nurse
nurse clinicians.
clinicians. Many
Many patients
patients
in inmedical
medical clinics
clinics havehave mental
mental problems,
problems, soso mymy helphelpwas wasappreciated.
appreciated. There
There
was was also
alsoa hope
a hope thatthat mymy presence
presence would
would encourage
encourage resident
resident doctors
doctors toto
havehave greater
greater sensitivity
sensitivity toto patients’
patients’ emotional
emotional lives.
lives.WeWe accomplished
accomplished thatthat
toto some
some degree,
degree, butbut thethebigger
bigger impact
impact was was onon me. me. AsAs I saw
I saw andand experienced
experienced
thethe emotional
emotional strains
strains of of
treating
treating a steady
a steady stream
stream of ofsicksick
patients,
patients, I came
I came toto
appreciate
appreciate how how growing
growing a thick
a thick skin
skin can can protect
protect thethe psyche.
psyche.
TheThe internists
internists often
often askedasked meme toto talktalkwith
with troubled
troubled patients
patients who who had had
tried
triedseeing
seeing a psychiatrist
a psychiatrist and andvowed
vowed “never
“never again.”
again.” SomeSome complained
complained
about
about spending
spending fruitless
fruitless months
months withwith a therapist
a therapist who who saidsaidlittle.
little.Others
Others
complained
complained about
about seeing
seeing a doctor
a doctor forfor onlyonly a few
a few minutes
minutes before
before being
being sentsent
awayaway with
with a prescription
a prescription forfor a drug
a drug thatthat caused
caused sideside
effects.
effects. AA few few told
told meme
thatthattheir
their lives
liveshad had beenbeen transformed
transformed byby a patient,
a patient, caring
caring therapist,
therapist, and and
somesome described
described working
working closely
closely withwith a doctor
a doctor forfor months
months until
until fi nally
fi nally
fi nding
fi nding a medication
a medication that
that worked.
worked. However,
However, most
most patients
patients who who got gotgoodgood
results
results never
never toldtoldanyone
anyone about
about their
their treatment,
treatment, andand I was
I was rarely
rarely invited
invited
toto seeseepatients
patients who who werewere doing
doing fi ne,
fi ne,
soso I saw
I saw manymany skeptics.
skeptics. I listened
I listened toto
themthem forforhours
hours eacheach weekweek forforyears,
years, but butI was
I was soso intent
intent onon convincing
convincing themthem
toto accept
accept helphelpthatthat I never
I never really
reallyheard
heard their
their collective
collective wailwail of of
frustration
frustration
until
untilMs.Ms. AA put putit in
it ina nutshell:
a nutshell: thethe field
fieldof ofpsychiatry
psychiatry is is
deeply
deeply confused.
confused.
That
That doesdoes notnot meanmean thatthatpsychiatric
psychiatric treatment
treatment is is
ineffective.
ineffective. When
When I I
toldtoldfellow
fellow medical
medical students
students about
about mymy career
career choice,
choice, several
several putput onon sym-sym-
pathetic
pathetic faces
faces andand said
saidsomething
something likelike“Someone
“Someone hashas toto carecareforforpatients
patients
who who can’t
can’tbebe helped.”
helped.” That
That misconception
misconception is as
is as
unfounded
unfounded as as
it is
it common.
is common.
Almost
Almost allall
psychiatric
psychiatric problems
problems can can bebe helped,
helped, and and treatment
treatment remarkably
remarkably
often
often provides
provides anan enduring
enduring cure.
cure.Patients
Patients withwith panic
panic disorder
disorder and and phobias
phobias
getget better
bettersoso reliably
reliably that
thattreating
treating themthem would
would bebe boring
boring if it
if were
it were not notforfor
thethe satisfaction
satisfaction of ofwatching
watching them
them return
return toto living
living fullfull
lives.
lives.
TheThe woman
woman whose
whose agoraphobia
agoraphobia had had keptkeptherher fromfrom leaving
leaving herhertrailer
trailer forfor
a year
a year was,
was, a few
a few months
months later,
later,driving
driving toto seeseeherher sister
sisteranan hour
hour away.
away. The The
carpenter
carpenter who who camecame in inwith
with social
socialanxiety
anxiety soso intense
intense hehe could
could notnot eateat
lunch
lunch
A NEW
A NEW QUESTION7 7
QUESTION
with
with coworkers
coworkers came
came backback a year
a year later
latertoto telltell
usushow how much
much heheenjoyed
enjoyed hishis
newnew jobjobgiving
givingpublic
public presentations
presentations allall
around
around thethe
state.
state.EvenEven some
some patients
patients
with
with severe
severe disorders
disorders getgetdramatic
dramatic benefi
benefi ts.ts.
Last
Lastweekweek I got
I got ananemail
email out outof of
thethebluebluefrom
from a patient
a patient I saw
I saw twenty-
twenty- fivefive
years
yearsago,
ago, withwith a heartfelt
a heartfelt sponta-
sponta-
neous
neous thank-
thank-you,
you, saying
saying thatthattreatment
treatment of of
herhersevere
severe obsessive-
obsessive- compulsive
compulsive
disorder
disorder hadhadtransformed
transformed and and very
verylikely
likely saved
saved herherlife.
life.
ManyMany books
books attack
attack thethefield
field
of ofpsychiatry.
psychiatry. This
This is not
is notone oneof of
them.
them. Yes,Yes,
bigbig
moneymoney from
from bigbigpharma
pharma results
results in in
more more corruption
corruption in inpsychiatry
psychiatry than
than
in in
somesome other
other medical
medical specialties.
specialties. And And industry-
industry- funded
funded advertising
advertising and and
professional
professional “education”
“education” promote
promote thethe profi
profi
t-maximizing
t-maximizing simplistic
simplistic view
view
that
that allall
emotional
emotional disorders
disorders areare brain
brain diseases
diseases needing
needing drugdrug treatment.
treatment.
However,
However,the thevastvastmajority
majorityofofpsychiatrists
psychiatristsI have I haveknown knownarearecaring, caring,
thoughtful
thoughtful doctors
doctors whowho work
work hardhard to to
help helptheir
their
patients
patients byby whatever
whatever means
means
works.
works. I recall
I recalloneone psychiatry
psychiatry resident
resident who who came
came in inat at
6 a.m.
6 a.m. every
everyday daysoso
hishis
patients,
patients, whowho were
were mostly
mostly struggling
struggling with
with alcoholism,
alcoholism, could
could getget toto
work
work onon time;
time;hehewas wasstill
still
there
there at at
7 p.m.
7 p.m. Another
Another psychiatrist
psychiatrist friend
friend took
took
onon thethe toughest
toughest borderline
borderline patients,
patients, despite
despite knowing
knowing hehe would
would getget mid-mid-
night
night calls
calls
threatening
threatening suicide.
suicide. Then
Then therethere areare
thethe manymany psychiatrists
psychiatrists who who
treat
treatdesperately
desperately depressed
depressed oror psychotic
psychotic patients,
patients, knowing
knowing that
that
some
some willwill
commit
commit suicide
suicide andandtheytheywillwillbebe blamed.
blamed. MostMost of of
usus lielie
awake
awake some
some nights
nights
worrying
worrying about
about a patient
a patient in ina crisis
a crisisand and wondering
wondering how how totohelp.
help.
However,
However,
most
most patients
patients getgetbetter,
better, and and thethe challenge
challenge of of
helping
helping them
them makes
makes thethe
practice
practice of ofpsychiatry
psychiatry profoundly
profoundly satisfying.
satisfying.
The The challenge
challenge of of
understanding
understanding mental
mental disorders
disorders is,is,
byby contrast,
contrast, deeply
deeply
unsatisfying.
unsatisfying. Several
Several years
yearsintointo mymy work
work teaching
teaching psychiatry,
psychiatry, I was
I was frus-
frus-
trated
trated as as
well
wellas as
confused.
confused. The The field
field
seemed
seemed totobebenarrowing
narrowing toto
thetheslogan
slogan
“Mental
“Mental disorders
disorders arearebrain
brain diseases.”
diseases.” The The phrase
phrase is is
great
great forfor
marketing
marketing
drugs,
drugs, decreasing
decreasing stigma,
stigma, and and soliciting
soliciting donations,
donations, butbutit it
short-
short-circuits
circuits
clear
clear thinking.
thinking. Sometimes
Sometimes it is
it is
accurate,
accurate, butbutit excludes
it excludes valuable
valuable insights
insights
from
from behaviorism,
behaviorism, psychoanalysis,
psychoanalysis, cognitive
cognitive therapy,
therapy, family
family dynamics,
dynamics,
public
public health,
health, andand social
social psychology.
psychology. Practicing
Practicing psychiatry
psychiatry based
based onon only
only
oneoneperspective
perspective is is
like
likeliving
living within
within thethe walls
walls of of
a medieval
a medieval town.
town. Trying
Trying
totounderstand
understand different
different perspectives
perspectives is like
is like visiting
visiting a series
a series of of
walled
walled towns.
towns.
ToTo seesee thethewhole
whole landscape
landscape of ofmental
mental illness
illnessrequires
requires a view
a view from
from a mile
a mile
high
high using
using special
special glasses
glasses thatthatshowshow changes
changes across
across evolutionary
evolutionary as as
wellwellas as
historical
historical time.
time.
8 8GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
What
WhatCauses
CausesMental
MentalDisorders?
Disorders?
Like
Likethethesixsixblind
blind men
men eacheach touching
touching a different
a different part
part
of of
anan elephant,
elephant, eacheach
different
different approach
approach totomental
mental disorders
disorders emphasizes
emphasizes oneonekind
kind of of
cause
cause and and a a
corresponding
corresponding kindkindof of
treatment.
treatment. Doctors
Doctors who who look
lookforfor
hereditary
hereditary factors
factors
andandbrain
brain disorders
disorders recommend
recommend drugs.
drugs. Therapists
Therapists whowho blame
blame early
early expe-
expe-
rience
rienceandand mental
mental confl
conflictsicts
recommend
recommend psychotherapy.
psychotherapy. Clinicians
Clinicians who who focus
focus
ononlearning
learningsuggest suggestbehavior
behaviortherapy.
therapy.Those Thosewho whofocus
focusonondistorted
distorted
thinking
thinking recommend
recommend cognitive
cognitive therapy.
therapy. Therapists
Therapists with
with a religious
a religious orien-
orien-
tation
tation suggest
suggest meditation
meditation and
and prayer.
prayer. AndAnd therapists
therapists whowho believe
believe mostmost
problems
problems arise
arisefromfromfamily
family dynamics
dynamics usually
usually recommend,
recommend, predictably,
predictably, family
family
therapy.
therapy.
TheThe psychiatrist
psychiatrist George
George Engel
Engel recognized
recognized thetheproblem
problem in in1977
1977 and and
proposed
proposed anan integrated
integrated “bio-
“bio-psycho-
psycho- social
social model.”
model.” Every
1 1
Every year
yearsince
since hashas
brought
brought renewed
renewed calls
calls
forfor such
suchintegration,
integration, forforthetheunfortunate
unfortunate reason
reason that
that
psychiatry’s
psychiatry’s fragmentation
fragmentation has,
has,if anything,
if anything, increased.
increased. TheThe messy
messy realities
realities
of of
mental
mental disorders
disorders areareignored
ignored totofit fithem
t them intointothetheprocrustean
procrustean bedbed of ofoneone
ororanother
another schema.
schema. Learned
Learned panels
panels pleadpleadforfor integration,
integration, butbutcommittees
committees
that
that
decide
decide onon grant
grantfunding
funding andand tenure
tenure only
only support
support projects
projects thatthatfitfiinto
t into
narrow
narrow disciplines.
disciplines.
Plans
Plans forfora recent
a recent revision
revision of of
thethe diagnostic
diagnostic system
system aroused
aroused hope
hope forfor
greater
greater coherence,
coherence, butbut
thethe result
resultwaswas increased
increased confl
confl
ictict
andand confusion.
confusion. TheThe
distinguished
distinguished psychiatrist
psychiatrist Allen
AllenFrances
Frances chaired
chaired thethe
committee
committee that
thatwrotewrote
thethe
previous
previous edition
edition of ofthethe book
book that
that defi
defi
nesnes each
each mental
mental disorder,
disorder, Diag-
Diag-
nostic
nosticandand Statistical
Statistical Manual
Manual of of
Mental
Mental Disorders
Disorders (DSM).
(DSM). The
2 2
The title
title
of ofhishis
recent
recent book
book captures
captures hishis dissatisfaction
dissatisfaction withwith thetherevised
revised edition
edition of ofthethe
DSM:
DSM: Saving
Saving Normal:
Normal: AnAn Insider’s
Insider’s Revolt
Revolt Against
Against Out-
Out-of-of-
Control
Control Psychi-
Psychi-
atric
atric
Diagnosis,
Diagnosis, DSM-DSM- 5, 5,
Big BigPharma,
Pharma, andand thetheMedicalization
Medicalization of of
Ordinary
Ordinary
Life.
Life.Debates
3 3
Debates about
about diagnosis
diagnosis areare
soso rancorous
rancorous that
that
they
theyspill
spill
onto
onto news-
news-
paper
papereditorial
editorial pages.
pages.The The crowning
crowning blowblow was wasthetheUSUS National
National Institute
Institute of of
Mental
Mental Health
Health (NIMH)
(NIMH) abandoning
abandoning thetheoffioffi
cialcial
DSM DSM diagnoses
diagnoses forformental
mental
disorders.
disorders. SoSo
4,5 4,5
muchmuch forfora common
a common diagnostic
diagnostic system
system creating
creating consensus!
consensus!
TheThe search
search forforbrain
brain abnormalities
abnormalities thatthat cause
cause mental
mental disorders
disorders hashas
offered
offered another
another hopehopeforforreducing
reducing confusion.
confusion. InIn a medical
a medical school
school admission
admission
A NEW
A NEW QUESTION9 9
QUESTION
interview
interview in in
1969,
1969, I revealed,
I revealed, perhaps
perhaps unwisely,
unwisely, thatthat I planned
I planned totobecome
become
a psychiatrist.
a psychiatrist. “Why
“Why would
would youyou wantwant toto dodo that?”
that?” thethe interviewer
interviewer asked.
asked.
“They’re
“They’re going
going totofi nd
fi ndthethebrain
brain causes
causes forformental
mental disorders
disorders soon,
soon, andand
it it
will
will allallbecome
become neurology.”
neurology.” If Ifonly
only that
that prediction
prediction had hadcomecome true!
true!
However,
However, four
four decades
decades of of
research
research byby thousands
thousands of of smart
smart scientists,
scientists, sup-
sup-
ported
ported byby billions
billions of ofdollars,
dollars, hashas still
still
notnotfound
found a specifi
a specifi c brain
c brain cause
cause forfor
anyanyof ofthethe major
major mental
mental disorders,
disorders, except
except forforthose
those suchsuch as as
Alzheimer’s
Alzheimer’s
disease
disease and and Huntington’s
Huntington’s chorea
chorea in in
which
which brain
brain abnormalities
abnormalities have
havelonglong
been
been obvious.
obvious. ForForother
other mental
mental disorders,
disorders, wewe still
still
havehave nono lablabtest
test
oror scan
scan
that
thatcancan makemake a defi
a defi
nitive
nitivediagnosis.
diagnosis.
This
This is as
is asastounding
astounding as as
it is
it disappointing.
is disappointing. TheThe brains
brains of of
people
people withwith
bipolar
bipolar illness
illness andandautism
autism must
must somehow
somehow bebe different
different fromfrom those
those of of
other
other
people.
people. But But brain
brainscansscans andand autopsy
autopsy studies
studies have
have identifi
identifi eded only
only small
small
differences.
differences. TheyThey arearereal,
real,
butbutsmall
small andand inconsistent.
inconsistent. It It
is hard
is hardto tosaysay
which
which
arearecauses
causes and and which
which areareresults
results of ofthethedisorders.
disorders. NoneNone comes
comes close
close toto
providing
providing a defi
a defi
nitive
nitive diagnosis
diagnosis of ofthethesortsort
radiologists
radiologists provide
provide forfor
pneu-
pneu-
monia
monia oror pathologists
pathologists provide
provide forforcancer.
cancer.
Hope
Hopeforfordiagnosis
diagnosisbased basedonongenetics geneticshas hasalso alsocollapsed.
collapsed.Having Having
schizophrenia,
schizophrenia, bipolar
bipolar disorder,
disorder, oror autism
autism depends
depends almost
almost entirely
entirely onon what
what
genes
genes a person
a person has,
has,soso most
most of ofusus engaged
engaged in in
psychiatric
psychiatric research
research at at
thethe
turn
turn of of
thethe millennium
millennium thought
thought thethe specifi
specifi
c genetic
c genetic culprits
culprits would
would soon
soon
bebe found.
found. However,
However, subsequent
subsequent studies
studies have
have shown
shown thatthatthere
there arearenono
common
common genetic
genetic variations
variations withwith large
large effects
effects onon thesethese disorders.
disorders. Almost
6 6
Almost
allall
specifi
specifi c variations
c variations increase
increase thetheriskrisk
byby 1 percent
1 percent oror less.
less. This
7 7
This is the
is themost
most
important—
important— and andmost
most discouraging—
discouraging— discovery
discovery in in
thethe history
history of of
psychiatry.
psychiatry.
What
What it means,
it means, andand whatwhat wewe should
should dodo next,
next, arearebigbig questions.
questions.
Leading
Leading psychiatric
psychiatric researchers
researchers deserve
deserve credit
credit forfor acknowledging
acknowledging thethe
failure
failure and andthethe need
need forfornewnew approaches.
approaches. InIn a recent
a recent article
article in in
thethejournal
journal
Science,
Science, several
several of of
themthem wrote,
wrote, “There
“There have
havebeenbeen nono major
major breakthroughs
breakthroughs
in in
thethetreatment
treatment of of
schizophrenia
schizophrenia in in
thethelastlast
5050 years
years and and nonomajor
major break-
break-
throughs
throughs in inthethetreatment
treatment of ofdepression
depression in inthethe lastlast2020 years. . . .
years. . . . ThisThis
frustrating
frustrating lacklack
of of
progress
progress requires
requires usus toto confront
confront thethe complexity
complexity of of
thethe
brain. . . .
brain. . . . This
This calls
callsforfora new
a new perspective.”
perspective.” AA
8 8
recent
recent meeting
meeting of of
thetheSo-So-
ciety
ciety
of ofBiological
Biological Psychiatry
Psychiatry solicited
solicited presentations
presentations onon thethe topic
topic“Paradigm
“Paradigm
Shifts
Shiftsin inthetheTreatment
Treatment of of
Psychiatric
Psychiatric Disorders.”
Disorders.” And And in in20112011 thethedirector
director
10 10GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
of of
thethe
National
National Institute
Institute of ofMental
Mental Health,
Health, Thomas
Thomas Insel,
Insel,
said,
said,
“Whatever
“Whatever
we’ve
we’vebeen
been doing
doingforfor
five
five
decades,
decades, it ain’t
it ain’tworking. . . .
working. . . .When
When I look
I lookat at
thethe
numbers—
numbers— thethe
number
number of of
suicides,
suicides,
thethenumber
number of of
disabilities,
disabilities,
thethe
mortality
mortality
data—
data— it’sit’s
abysmal,
abysmal, andandit’sit’s
notnot
getting
getting anyanybetter.
better.Maybe
Maybe wewe
just
just
need
need toto
rethink
rethink thisthis
whole
wholeapproach.”
approach.” 9 9
Psychiatrists
Psychiatrists recognize
recognize patients’
patients’ lifelife
crises
crisesas as
opportunities
opportunities forfor
them
them
totomake
make major
majorchanges.
changes. Could
Could thethesame
same bebetrue
true
forfor
psychiatry?
psychiatry?10 10
Finding
FindingthetheFuture
FutureininthetheEvolutionary
EvolutionaryPast
Past
TheThe Museum
Museum of of
Natural
Natural History
History waswas a block
a block south
south of of
ourour medical
medical center.
center.
Opening
Opening thetheheavy
heavy ironiron door
door between
between twotwobigbiglionlion
sculptures
sculptures brings
brings youyou
into
intothethe exhibit
exhibit museum,
museum, a place
a placeI knew
I knew well
wellfromfrom taking
taking mymy kids
kidstoto seesee
dinosaur
dinosaur fossils.
fossils.ButBut this
thistimetime I had
I hadanan invitation
invitation totogogo through
through thethe
doors
doors
marked
marked STAFF
STAFF ONLY
ONLY toto joinjoina group
a group of ofscientists
scientists who who met metweekly
weekly totodiscuss
discuss
animal
animal behavior.
behavior. InIn thethefi rst
fi rst
hour,
hour,it became
it became clear
clear that
thattheir
their approach
approach waswas
completely
completely different
different from
from anything
anything I had
I had learned
learned before.
before.
Instead
Instead of of
asking
asking onlyonly about
about brain
brain mechanisms,
mechanisms, they
they alsoalsoasked
asked how how
natural
natural selection
selection shapes
shapes thethe brain
brainandand how howbehavior
behavior infl
infl
uences
uences Darwinian
Darwinian
fitness.
fitness. Fitness
Fitness is is
thethe technical
technical term
term biologists
biologists useuse toto refer
refer toto howhow manymany
offspring
offspring ananindividual
individual hashas thatthatgrow
grow upup totoreproduce
reproduce themselves.
themselves. SomeSome
individuals
individuals have
have more
more offspring
offspring than
than others
others do,do,soso their
theirgenetic
genetic variations
variations
become
become moremore common
common in infuture
future generations.
generations. Other
Other individuals
individuals have
have fewer
fewer
than
than thethe average
average number
number of ofoffspring,
offspring, soso their
theirgenetic
genetic variations
variations become
become
less
less
common.
common. This
This process
process of ofnatural
natural selection
selection shapes
shapes bodies
bodies andandbrains
brains
that
thatworkwork very
very well
wellindeed
indeed totomaximize
maximize Darwinian
Darwinian fitness
fitness in inthethenatural
natural
environment.
environment.
Usually
Usually traits
traitsat at
somesome middle
middle value
value arearebest.
best.Rabbits
Rabbits varyvaryin inboldness.
boldness.
Exceptionally
Exceptionally boldbold rabbits
rabbits become
become foxfoxdinners.
dinners. Timid
Timid rabbits
rabbits flee
flee
soso fast
fast
they
they don’t
don’t getgetmuch
much toto eat.eat.Rabbits
Rabbits withwithintermediate
intermediate levels
levels of ofanxiety
anxiety
have
have more
more baby
baby bunnies,
bunnies, soso their
theirgenes
genes become
become moremore common.
common. SomeSome
people
people getgetso-so-
called
called Darwin
Darwin Awards
Awards forfordoing
doing stupid
stupid things
things thatthateliminate
eliminate
them
them andand their
theirgenes.
genes. The The adventurous
adventurous young
young manman who who strapped
strapped a rocket
a rocket
booster
booster toto hishis
carcar
was was going
going 300
300 mphmph when
when heheand and hishis
carcar flattened
flattened into
into
a thin
a thin layer
layeronon a cliff
a cliffside.
side.
OtherOther people
people fear
fear
leaving
leaving thethehouse.
house. TheyThey don’t
don’t
A NEW
A NEW QUESTION11 11
QUESTION
diedieyoung,
young, but butneither
neither dodo theythey havehave many
many children.
children. People
People with
with more
more
moderate
moderate degrees
degrees of of
anxiety
anxiety havehave moremore children,
children, sosomostmost of of
usus have
have inter-
inter-
mediate
mediate levels
levelsof of caution.
caution.
My My new new colleagues
colleagues at atthethe museum
museum relied
relied onon a simple
a simple principle
principle toto ex-ex-
plain
plainwhy why animals
animals dodo whatwhat theythey do:do: selection
selection shapes
shapes organisms
organisms totobehave
behave
in in
ways
ways that
thatmaximize
maximize their
their reproductive
reproductive success.
success. This
This is not
is nota hypothetical
a hypothetical
theory;
theory; it is
it is
a principle
a principle thatthat must
must bebe true.
true. It It
provides
provides what
what I was
I was looking
looking
for—
for— a new
a new kindkind of of
biological
biological explanation,
explanation, not notjust
justforforbehavior
behavior but but also
also
forforwhywhy organisms
organisms arearethethe way way they
they are.
are.
After
After mostly
mostly listening
listening forfora few
a few weeks,
weeks, I fiInally
fi nally
got gotupup mymy nerve
nerve and and
shared
shared a theory
a theory I had
I hadcome come upup with
with as asanan undergraduate.
undergraduate. Aging
Aging is useful,
is useful,
I suggested,
I suggested, toto ensure
ensure thatthat somesome individuals
individuals diedieeach
each year
yearsosothethe species
species
cancanevolve
evolve faster
fasterwhenwhen thethe environment
environment changes.
changes. TheThe group
group gotgotsuddenly
suddenly
quiet,
quiet, but butone one biologist,
biologist, Bobbi
Bobbi Low,Low, laughed
laughed soso hard
hard sheshewaswassputtering
sputtering
as as
sheshesaid,
said,“You“You really
reallydon’tdon’t knowknow anything
anything about
about evolution,
evolution, dodo you?”
you?” It It
waswas a friendly
a friendly laugh,
laugh, thethe kindkind elicited
elicited byby watching
watching a puppy
a puppy trytry
toto climb
climb
stairs.
stairs.Bobbi
Bobbi and and others
others explained
explained thatthatgenes
genes that
thatbenefi
benefit at species
a species willwill
nonetheless
nonetheless bebe eliminated
eliminated if individuals
if individuals withwith those
those genes
genes have
havefewer
fewer than
than
thetheaverage
average number
number of ofoffspring.
offspring.
Bobbi
Bobbi suggested
suggested thatthat I read
I read a 1957
a 1957 paper
paper bybythethe evolutionary
evolutionary biol-
biol-
ogist
ogistGeorge
George Williams.
Williams. I stopped
I stopped byby thethelibrary
library onon thethe
way wayhome
home and and made
made
a copy.
a copy. AsAs forforsoso manymany before
before me, me, reading
reading it transformed
it transformed mymy view
view of oflife.
life.
Williams
Williams pointed
pointed outout
that thata gene
a gene causing
causing aging
aging could
could become
become universal
universal if if
it gives
it givesbenefi
benefi ts ts
early
early
in inlife,
life,when
when selection
selection is stronger
is stronger because
because more
more indi-
indi-
viduals
viduals arearealive
alivethen.
then. For
11 11
For instance,
instance, a genetic
a genetic variation
variation that
thatcauses
causes cor-
cor-
onary
onaryarteryarterycalcifi
calcification
cationthat thatkillskillsmany
manypeople peoplebybyage ageninety
ninetycould could
nonetheless
nonetheless become
become universal
universal if it
if also
it alsomakes
makes broken
broken bones
bones heal
healfaster
faster in in
childhood.
childhood. HisHis paper
paper was was soso inflinfl
uential
uential thatthata retrospective
a retrospective waswaspublished
published
onon itsits
recent
recent sixtieth
sixtieth anniversary.
anniversary. Williams
12 12
Williams offered
offered a completely
a completely different
different
kind
kind of of
explanation,
explanation, not not justjustforforaging
aging butbut also
alsoforfor
diseases
diseases in in
general.
general. If If
aging
aging has hasanan evolutionary
evolutionary explanation,
explanation, whatwhat about
about schizophrenia,
schizophrenia, de- de-
pression,
pression, and andeating
eating disorders?
disorders?
Over
Over the theensuing
ensuing weeks,
weeks, mymy newnew evolutionary
biology colleagues
colleagues
helped
helped meme toto recognize
recognize that
that everything
everything in inthethe natural
natural world
world needs
needs twotwo
kinds
kinds of of
explanations.
explanations. The The usual
usual approach
approach describes
describes thethebody’s
body’smechanisms
mechanisms
andand howhow theytheywork;
work; biologists
biologists call
call
these
these proximate
proximate explanations.
explanations. TheThe other
other
12 12GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
kind
kind of of
explanation
explanation describes
describes howhowthose
those mechanisms
mechanisms came
came totobebe thethe way way
they
theyare;are;
biologists
biologists call
call
these
theseevolutionary
evolutionary oror ultimate
ultimate explanations.
explanations. 13,14,15,16
13,14,15,16
MyMy medical
medical education
education hadhadbeen
beenentirely
entirelyabout
about thethe proximate
proximate halfhalf
of ofbiology,
biology,
which
which describes
describes mechanisms,
mechanisms, none
noneabout
about thethe halfhalf
that
thatexplains
explains howhow bodies
bodies
gotgottotobebe thethe
wayway they
theyare.
are.
Failure
Failure totorecognize
recognize that
thatevolutionary
evolutionary explanations
explanations areare essential
essential com-com-
plements
plements totoproximate
proximate explanations
explanations causes
causes enormous
enormous confusion.
confusion. If If
you you askask
forfor
ananexplanation
explanation of of
eyebrows,
eyebrows, oneoneperson
person is likely
is likelyto to
saysay
theythey areare
explained
explained
byby genes
genes that
thatinduce
induce synthesis
synthesis of of
certain
certain proteins
proteins in in
certain
certain locations.
locations.
Another
Another might
might point
point outoutthat
thatyouyoualso
also needneed totodescribe
describe thethe process
process byby
which
which eyebrows
eyebrows develop.
develop. Another
Another will
will
likely
likely saysay youyou need
need toto know
know aboutabout
eyebrows
eyebrows in in
other
other primates.
primates. Someone
Someone willwill likely
likelynote
note thatthateyebrows
eyebrows keepkeep
sweat
sweat out outof of
thethe
eyes.
eyes.AndAnd someone
someone will
will
likely
likelyraise
raise
anan eyebrow
eyebrow toto demon-
demon-
strate
strateitsits
utility
utility
as as
a signaling
a signaling device.
device. TheThe fi rst
fi rst
twotwoexplanations
explanations describe
describe
proximate
proximate mechanisms;
mechanisms; thetheothers
others areare
about
about evolution.
evolution.
TheThe Nobel
Nobel Prize–
Prize–winning
winning ethologist
ethologist NikoNiko Tinbergen
Tinbergen expanded
expanded thethe
distinction
distinction in in
a 1963
a 1963 article
articlethat
that
described
described whatwhat have
havecomecome totobebe known
known
as as
“Tinbergen’s
“Tinbergen’s Four
Four Questions”:
Questions”: What
What is the
is the mechanism?
mechanism? HowHow does
does thethe
mechanism
mechanism develop
develop in in
ananindividual?
individual? What
What is its
is its
adaptive
adaptive signifi
signifi
cance?
cance? And And
what
what is its
is its
evolutionary
evolutionary history?
history? After
17 17
Afterrelying
relying onon them
them forforyears,
years, I fiInally
fi nally
sawsaw that
that twotwo areareproximate
proximate and
and twotwoareare evolutionary
evolutionary andand that
that twotwo areare
about
about a slice
a slicein in
time,
time, while
while twotwo areare
about
about change
change across
across time.
time. TheyThey fitfit
nicely
nicelyintointoa neat
a neattwo-
two-by-by-
twotwo table.
table.When
When I added
I added a slide
a slideshowing
showing thethe table
table
in in
mymy lectures,
lectures, thetheaudience
audience was
wasmoremore interested
interested in in
thethetable
tablethanthan in in mymy
talk.
talk.When
When I put
I put a PDF
a PDF of of
thethe
table
tableonon mymy website,
website, it spread
it spread fast.
fast.
TINBERGEN’S
TINBERGEN’S
FOUR
FOUR
QUESTIONS,
QUESTIONS,
ORGANIZED
ORGANIZED
18 18
PROXIMATE
PROXI MATE EVOLU
EVOLU
TIONARY
TIONARY
What
Whatis itsis its
adaptive
adaptive
SLISLI
CECE
I N ITI
N ME
TIM E What
Whatis the
is the
mechanism?
mechanism?
signifi
significance?
cance?
SEQU
SEQU
E NECNECE
ACR
ACR
OSOS
S TSIMT EIM E
HowHow
doesdoes
it develop
it develop
in an
in an What
Whatis itsis its
evolutionary
evolutionary
individual?
individual? history?
history?
A NEW
A NEW QUESTION13 13
QUESTION
Tinbergen’s
Tinbergen’s questions
questions made
made meme recognize
recognize that
thatsomesome late-
late-
night
night debates
debates
with
with medical
medical school
school classmates
classmates arose
arose fromfrom mistakenly
mistakenly thinking
thinking thethe ques-
ques-
tions
tionsareare alternatives.
alternatives. TheyThey aren’t.
aren’t. Answers
Answers totoallallfourfour areare necessary
necessary forfora a
full
full
explanation.
explanation. The The questions
questions also
alsomademade meme realize
realize thatthat many
many things
things I I
hadhadthought
thought of ofas asabnormal
abnormal werewere actually
actually useful.
useful. My My medical
medical education
education
taught
taught thethedetails
details of ofthethe mechanisms
mechanisms in instomach
stomach cells
cellsthatthat secrete
secrete acidacid
and and
their
theirrolerolein in
causing
causing ulcers
ulcers butbutnothing
nothing about
about how how stomach
stomach acid
acid kills
killsbac-
bac-
teria
teriaandand digests
digests foodfood andand whywhy tootoo little
littleacidacidis is
as as bigbig a problem
a problem as as
too too
much.
much. WeWe learned
learned allallabout
about thethecauses
causes of of
diarrhea
diarrhea but but little
little
about
about itsits
rolerole
in in
clearing
clearing toxins
toxins and and infections
infections fromfrom thethe GIGI tract.
tract.Coughing
Coughing clears
clears foreign
foreign
matter
matter fromfrom thethe respiratory
respiratory tract.
tract. Fever
Fever is is
a carefully
a carefully controlled
controlled response
response
that
thatfights
fights infection.
infection. EvenEven pain
pain needs
needs toto bebe understood
understood in interms
terms of ofitsits
function
function as as well
well as asitsits mechanisms;
mechanisms; people
people born
born without
without thethe ability
ability toto
experience
experience painpain usually
usually diedie
in in
early
early adulthood.
adulthood. I started
19 19
I started totothink
think about
about
thetheutility
utility of ofanxiety
anxiety and andlowlowmood.
mood.
While
While manymany things
things that
thatseemseem useless
useless turnturn out out toto havehave a function,
a function,
others
others areareabysmal
abysmal designs.
designs. TheThe eyeeye would
would bebe better
better without
without a blind
a blind spot.
spot.
TheThe birth
birth canal
canal is is
too too narrow.
narrow. Cancer
Cancer protection
protection mechanisms
mechanisms areareinsuffi
insuffi - -
cient,
cient,as as
areare those
those that
that protect
protect against
against infection.
infection. Ability
Ability toto regulate
regulate eating
eating
is weak.
is weak. Anxiety
Anxiety and andpain painareare
often
often excessive.
excessive. I started
I started wondering
wondering full-
full-
timetime
about
about whywhy selection
selection leftleft
thethebody
body riddled
riddled withwith such
such imperfections.
imperfections.
When
When George
George Williams
Williams visited
visited forfor a conference,
a conference, hehe was was easy
easy totorec-rec-
ognize;
ognize; hehe looked
looked remarkably
remarkably likelike
Abraham
Abraham Lincoln.
Lincoln. I knew
I knew hishis
19571957 paper
paper
waswasadmired,
admired, but butnono one one hadhadtoldtoldmeme thatthathehe waswasone one of ofthetheleading
leading biol-
biol-
ogists
ogists of of
thethe twentieth
twentieth century,
century, certainly
certainly notnotWilliams
Williams himself.
himself. HeHe didn’t
didn’t
talk
talkmuch,
much, but but when
when hehe did,
did, everyone
everyone paid
paid attention.
attention. Over Over beer,
beer, hehe ex-ex-
plained
plained howhow hehe hadhad come come upup with
with hishisideaideathatthatselection
selection can canpreserve
preserve thethe
genes
genes thatthat cause
cause aging.
aging. I saw
I saw a way
a way toto test
test hishistheory.
theory. It Itpredicts
predicts thatthat
mortality
mortality rates
ratesshould
should increase
increase withwith age ageforfor
somesome animals
animals in in
thethewild.
wild. The The
alternative
alternative theory,
theory, thatthat genes
genes forforaging
aging areare outside
outside thethe reach
reach of ofselection,
selection,
predicts
predicts thatthatmortality
mortality rates
rates
should
should staystaythethesamesame across
across thethe adult
adult lifelife
span.
span.
AA fewfew months
months of oflibrary
library work
work would
would bebe needed
needed toto fi nd
fi nd
datadata onon mor-
mor-
tality
talityrates
rates forforanimals
animals in inthethe
wild.
wild. I told
I told mymy psychiatry
psychiatry department
department chair,
chair,
John
John Greden,
Greden, about
about mymy idea.
idea.
HeHe was wasnew new in in
thethejobjoband and eager
eager to toencourage
encourage
creativity,
creativity, soso hehe saidsaidI could
I could devote
devote halfhalftimetime totothethe project
project forforthethesummer.
summer.
ByBy fall,
fall,
I had
I had found
found thethe data
data
and and a way
a way toto calculate
calculate how how strongly
strongly selection
selection
14 14GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
waswasacting
acting onon aging
aging in in wild
wild animals:
animals: veryverystrongly
strongly indeed.
indeed. George’s
20 20
George’s
theory
theory waswas right:
right: genes
genes thatthatspeed
speed aging
aging areare
not notallall
unfortunate
unfortunate mutations
mutations
whose
whose effects
effects comecome too too late
latein inlifelife
toto bebe eliminated
eliminated byby natural
natural selection;
selection;
some
some givegiveadvantages
advantages thatthatincrease
increase reproduction
reproduction earlier
earlierin in
life.
life.
The The idea
idea
hashasbeen
been confi
confirmedrmed in in many
many studies
studies that
thatbred
bred beetles
beetles and
and fruit
fruitfl ies
fl ies
forfor
longer
longer oror shorter
shorter lifelifespans.
spans. 21,22
Selecting
21,22
Selecting forforearlier
earlierreproduction
reproduction results
results
in in
a shorter
a shorter lifelifespan.
span. Selecting
Selecting forfor longer
longer lifelife
span
span results
results in in
fewer
fewer off-
off-
spring,
spring, especially
especially in inthethe wild.
wild. Aging
Aging hashas ananevolutionary
evolutionary explanation.
explanation. 23 23
ByBythethe nextnext time time George

George visited,
visited, I knew
I knew enough
enough about
about evolutionary
evolutionary
biology
biology toto have
have a coherent
a coherent conversation,
conversation, andand mymy research
research onon aging
aging hadhad
been
been published.
published. I told
I told George
George I thought
I thought that
thatevolution
evolution could
could offer
offer a new
a new
kind
kindofofexplanation
explanationnot notjustjustforforagingagingbut butforfordiseases.
diseases.HeHehad hadbeen been
thinking
thinking thethe samesame thing.
thing. WeWe decided
decided totowrite
write a paper
a paper about
about how how evolution
evolution
could
could bebe useful
useful forfor medicine.
medicine.
During
During thethe fi rst
fi rst
several
several months
months of ofourourwork,
work, wewe made
made a fundamental
a fundamental
mistake:
mistake: wewe tried
tried toto fi ndfi nd
evolutionary
evolutionary explanations
explanations forfor
diseases.
diseases. Why,Why, wewe
asked,
asked,diddidnatural
natural selection
selection shape
shape coronary
coronary artery
artery disease?
disease?WhyWhy diddidit shape
it shape
breast
breast cancer?
cancer? Why Why did did it it
shape
shape schizophrenia?
schizophrenia? Finally
Finallywewe recognized
recognized
ourourmistake.
mistake. WeWe were were Viewing
Viewing Diseases
Diseases AsAs Adaptations
Adaptations (VDAA).
(VDAA). VDAAVDAA
is is
a serious
a serious error
error thatthat remains
remains common
common in in
evolutionary
evolutionary medicine.
medicine. ButBut
diseases
diseases arearenot not adaptations.
adaptations. TheyThey dodo notnot
have
have evolutionary
evolutionary explanations.
explanations.
They
They were
were notnotshaped
shaped byby natural
natural selection.
selection. However,
However, aspects
aspects of of
thethe bodybody
that
thatmake
make usus vulnerable
vulnerable toto diseases
diseases dodo have
have evolutionary
evolutionary explanations.
explanations.
Shifting
Shifting thethefocus
focus from from diseases
diseases toto traits
traits
that
that makemake bodies
bodies vulnerable
vulnerable toto
diseases
diseaseswas wasthe thecrucial
crucialinsight insightthat thatbecame
becamea cornerstone
a cornerstoneforforevolu- evolu-
tionary
tionary medicine.
medicine.
WeWe spent
spent daysdays discussing
discussing thethe appendix,
appendix, wisdom
wisdom teeth,
teeth,inflinfl
ammation
ammation
in in
thethe
coronary
coronary arteries,
arteries, cancer,
cancer, and,and, of of
course,
course, thethe
human
human back.
back. George
George
sawsawthetheimplications
implications moremore clearly
clearly thanthan I did
I did and andinsisted
insisted onon giving
giving ourour
article
articlethethe grand
grand titletitle“The “The DawnDawn of ofDarwinian
Darwinian Medicine.”
Medicine.” OurOur book,
book,
WhyWhy WeWe Get GetSick:
Sick: The The New New Science
Science of of
Darwinian
Darwinian Medicine,
Medicine, reached
reached a wider
a wider
audience
audience andand encouraged
encouraged thethe growth
growth of of
what
what is is
nownow called
called evolutionary
evolutionary
medicine.
medicine. There
There areare now now a dozen
a dozen books
books onon thethe topic,
topic,a scientifi
a scientific society,
c society,
a journal,
a journal, international
international conferences,
conferences, and andclasses
classes in in
most
most major
major universities.
universities.
Evolutionary
Evolutionary medicine
medicine is is
not not a method
a method of ofpractice
practice ororin inanyany way way anan
alternative
alternative toto standard
standard medicine.
medicine. It Itjustjust
uses
usesthetheprinciples
principles of of
evolutionary
evolutionary
A NEW
A NEW QUESTION15 15
QUESTION
biology
biologytoto
solve
solve
health
health
problems
problems thethe
same
sameway
waywewe
useuse
genetics
genetics
and
and
phys-
phys-
iology.
iology.
Evolutionary
psychiatry is is
thethe
part
part
of of
evolutionary
evolutionary
medicine
medicinethat
that
asks
asks
whywhy
natural
natural
selection
selection
leftleft
usus vulnerable
vulnerable
totomental
mentaldisorders.
disorders.
The
TheNew
NewQuestion
Question
The The usual
usual questions
questions in inmedicine
medicine areare those
those of of
a mechanic:
a mechanic: HowHow does
does thethe
bodybody work?
work? What
What is is
broken?
broken? WhyWhy diddidit break?
it break? How How can can wewe fi xfiit?
x it?
These
These
areare proximate
proximate questions
questions about
about how how bodily
bodily mechanisms
mechanisms workwork andand how how they
they
differ
differin in people
people with
with a disease:
a disease: WhatWhat immune
immune system
system mechanisms
mechanisms cause
cause
multiple
multiple sclerosis?
sclerosis? What
What brain
brain abnormalities
abnormalities explain
explain whywhy some
some people
people have
have
schizophrenia?
schizophrenia? Answers
Answers toto these
these questions
questions advance
advance thethe most
most important
important
goal:
goal:fi nding
fi nding causes
causes andand ways
ways toto fi xfiproblems.
x problems. Asking
Asking such
such questions
questions andand
fi nding
fi nding theirtheiranswers
answers hashas vastly
vastly improved
improved human
human health.
health. If If
medicine
medicine is to
is to
useuse only
only one-one-
half
halfof of
biology,
biology, thisthisis the
is thehalfhalfwith
with thethe
bigbig practical
practical payoffs.
payoffs.
TheThe other,
other,evolutionary
evolutionary halfhalfof ofbiology
biology poses
poses questions
questions thatthat take
take anan
engineer’s
engineer’s point
point of of
view:
view: HowHow diddid thethe bodybody getget totobebe thetheway way it is?
it is?
What
What
selection
selection forces
forcesshaped
shaped thisthis
trait?
trait?
How How dodo variations
variations inflinfl
uence
uence reproductive
reproductive
success?
success? WhatWhat trade-
trade-offs
offslimit
limititsitsreliability?
reliability? InIn itsits
general
general form,
form, thethenewnew
question
question asks,
asks,
Why Why diddid natural
natural selection
selection leave
leaveour our
bodies
bodies with
with traits
traitsthat
that
makemake usus vulnerable
vulnerable to to
disease?
disease?
TheThe question
question is new,
is new, butbutit is
it close
is close toto one oneof of
thethe oldest
oldest questions.
questions. Why Why
is life
is life
soso fullfull
of of
suffering?
suffering? Debated
Debated in in
religious
religious and and philosophical
philosophical contexts
contexts
forfor millennia
millennia as as“the
“the problem
problem of ofevil,”
evil,”answers
answers have haveproved
proved elusive.
elusive. 24,25,26
24,25,26
The The Greek

Greek philosopher
philosopher Epicurus
Epicurus recognized
recognized thethe conundrum
conundrum 2,400
2,400 years
years
ago;ago;a slight
a slight adaptation
adaptation of ofDavid
David Hume’s
Hume’s terse
tersesummary
summary is widely
is widely quoted:
quoted:
“Is“Is God
God willing
willing totoprevent
prevent evil,
evil,
but butnot notable?
able?Then
Then HeHe is not
is notomnipotent.
omnipotent.
Is IsHeHe able,able, butbutnot notwilling?
willing? Then
Then HeHe is is
malevolent.
malevolent. Is IsHeHe bothboth ableableandand
willing?
willing? ThenThen whence
whence cometh
cometh evil?
evil?Is Is
HeHe neither
neither able
able nornorwilling?
willing? ThenThen
why why call
call Him Him God?”
God?” 27 27
Ever
Ever since,
since,philosophers
philosophers and andtheologians,
theologians, especially
especially those
those in inthethe Abra-
Abra-
hamic
hamic tradition,
tradition, have
have struggled
struggled toto explain
explain evil
evil andand suffering.
suffering. Possible
Possible
explanations
explanations have
have a special
a special name,
name, “theodicies.”
“theodicies.” There
There arearemany
many of of
them,
them,
because
because nonenone is fully
is fully
satisfying.
satisfying. The
28 28
The problem
problem is also
is alsocentral
central totoBuddhism,
Buddhism,
whose
whose fi rst
fi rst
noble
noble truth
truth is is
“Life
“Life is is
suffering.”
suffering.” 29,30
ItsIts
29,30
second
second noble
noble truth
truth is is
16 GOOD REASONS FOR BAD FEELINGS
that suffering is caused by desire, more specifically the inability of ever

fully satisfying desire. The third is that relief from suffering requires rec-
ognizing that desire is an illusion. An evolutionary view explains why we
have desires, why we can’t satisfy them, and why it is so hard to set them
aside: our brains were shaped to benefit our genes, not us.31,32,33
Reconciling the ways of God to man is far beyond the scope of this
book. Explaining the prevalence of evil and suffering in general is also out
of reach. However, most suffering is emotional suffering. Anxiety and low
mood exist for the same reason as pain and nausea: because they are useful
in certain situations. They are often excessive for good evolutionary reasons.
There are also good reasons why we are vulnerable to addiction, schizo-
phrenia, and all the other mental maladies. Reasons plural, because several
are relevant in different combinations depending on the disorder.
Trying to explain why mental life is so often painful, and why thinking
and behavior so often go awry, reveals another equally profound question.
How can mindless selection that maximizes only reproductive success have
shaped brains that make committed loving relationships and meaningful
happy lives possible? Most people’s lives are nothing like the selfish com-
petition for money and sex imagined by naive Darwinians. People meditate,
pray, cooperate, love, and care for others, even strangers. Our species is
remarkably endowed, not only intellectually but also socially, morally, and
emotionally. Understanding the origins of love and morality is a crucial
foundation for understanding social anxiety and grief and the deep rela-
tionships they make possible.
Jonas Salk, the inventor of the polio vaccine, said, “What people think
of as the moment of discovery is really the discovery of the question.” We
have a new question.
C HCPAHRPPAERTFPEEATFRCEAERC2 E2
{
{
{
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A RE
AREMEN
MENTAL
TALDIDISORDERS
SORDERSDIDIS ESAE SAES S?
E S?* *
There
There
is little
is little
reason
reason
to to
believe
believe
that
that
these
these
diagnostic
diagnostic
categories
categories
areare
valid.
valid.
1 1
—A
—comment
A comment
about
about
thethe
DSM diagnostic
DSM diagnostic
WhenWhen I fiIrst
fi rst
realized
realized that
that evolutionary
evolutionary categories
biology categories
biology couldonon
could the the
first
provide first
provide page
apage
aofnew
new ofkind kind
thetheleading
leading psychiatry
psychiatry textbook
textbook
of ofexplanation
explanation forfor mental
mental disorders,
disorders, I immediately
I immediately wanted
wanted toto write
write thisthis
book.
book. It It
was was soonsoon clear,
clear,however,
however, thatthatunderstanding
understanding why why bodies
bodies areare vul-vul-
nerable
nerable toto diseases
diseases in in
general
general had had toto comecome fi rst.
fi rst.
That
That project
project was wasthethefocus
focus
of ofmymy collaboration
collaboration withwith thethegreatgreat evolutionary
biologist George
George C.C. WiWi l- l-
liams.
liams.WeWe wrote
wrote a series
a series of of
technical
technical papers
papers and and WhyWhy WeWe Get GetSick:
Sick:TheThe New New
There
There
Science is of
Science is
noofnopoint
point
Darwinian
Darwinian in in
trying
trying
Medicine,toto
Medicine, explain
aexplain
popular
a popular
mental
mental
bookbook
disorders
disorders
that
that helped
helped
without
without
inspire
inspire
fi rst
fimuch
rstde-
much
de-
scribing
newscribing
new work
work
and and
indefi
in
what
defi
what
ning
ning
is them.
now
is them.
now the
That
the
That
thriving
thriving
seems
seems fi
simple
eld
fi
simple
eld
ofenough.
of
evolutionary
enough.
evolutionary
The The current
medicine.
current
medicine.
edition
edition
EverEver
ofsince
of
sincethen,
then,
Diagnostic
Diagnostic myandmycareer
andcareer hashas
Statistical been
Statistical been committed
Manual committed
Manual of of equally
Mental equally
Mental to to
bringing
Disorders bringing
Disorders describes
describes
evolutionary
evolutionary
moremore
than
biology
than
biology
three
three
tohundred
to
medicine
hundred
medicine different
and
different
andtoto helping
ones.
helping
ones. Problem
my
Problem
mypatients
patients
solved?
solved?
withwith
Hardly.
mental
Hardly.
mental The
disorders.
The
disorders.
diagnostic
diagnostic
The The
system
twosystem
two missions
generates
missions
generatesareare
interminable
connected
interminable
connected deeply.
debate—
deeply.
debate— and and intense
intense controversy.
controversy.
Defi
Definitions
nitions
Practicing
Practicing ofpsychiatry
of
diagnostic
diagnostic
psychiatry is categories
categories
is enormously
enormously makemake
satisfying. mental
satisfying. mental disorders
Patients disorders
Patients areare seem
seem
grateful
gratefullikelike
forfor
diseases.
diseases.
effective
effective Many
Many
treatment. are,
treatment. are,butbutthey
Providingthey
Providing areitare
ais
it bit
ais bit
different
different
intellectually
intellectually fromfrom most
interesting most
interesting other
asother
as
well diseases.
well diseases.
as as
emo-
emo-
TheyThey
tionallydon’t
don’t
tionally fulfihave
fulfihave
lling.specifi
lling. specifi
Each
Eachc patient
causes
c patient
causes we
poseswehave
poses haveabeenbeen
a puzzle.
puzzle. ableable
Why todid
Why to
identify,
identify,
didthisthis suchsuch
individual as as
individual the the
get get
bacteria
bacteria
these
these thatthat
symptoms
symptomscause
cause pneumonia.
now?
now?pneumonia.
WhatWhat They
treatment They
treatment can’t
can’t
willwillbework
workbediagnosed
diagnosed
best?
best? with
However, with
However, blood
blood tests
sometimes
sometimestests
the
looking
the
looking
ways
ways diabetes
outdiabetes
outthethe window
can.
window
can.They
Theyfrom
don’t
from
don’t
myhave
my cozy
have
cozy
defi
defi
offi
nitive
offi
ce,
nitive
ce,Itissue
have
Itissue
have visions
abnormalities,
visions
abnormalities,
of ofa tsunami
a tsunami
suchsuch
assweeping
sweeping
as
thethedying millions
dying millions
neurons
neurons of of
people
in people
in
multiplewith
multiple with mental
mental
sclerosis.
sclerosis. disorders
disorders
Instead,
Instead, tomental
to
mental oblivion,
oblivion,
disorderswith
disorders with no
are no
are
defi
help
defi
help
nedor
nedor
by
high
by
high
clusters
clusters
ground
groundof of
in
symptoms.
in
symptoms.
sight.
sight.Such Such
People
People
darkdarkwho
apparitions
who
apparitions
saysay that
that
inspire
food
inspire
food tastes
asking
tastes
asking
like
different
likedifferent
card-
card-
board
larger
board
larger
are
questions:
are
questions:
often
often depressed
depressed
WhyWhy dodoand
mental
and
mental
suicidal.
suicidal.
disorders
disorders
Paranoid
Paranoid
exist
exist
people
atpeople
at
all?all?
often
Why
often
Why hear
arehear
are
there
voices.
there
voices.
soso
Dangerously
many?
Dangerously
many? Why Why are
thin
are
thin
they
people
they
people
soso common?
who
common?
who thinkthink
Natural
they
Natural
they are
selection
areselection
fatfatarearecould
often
could
often high-
have
high-
have eliminated
achieving
eliminated
achieving
anxiety,
depression, addiction,
addiction, anorexia,
anorexia, andand thethe genes
genes that
that cause
cause autism,
autism,
schizophrenia,
schizophrenia, andand manic-
manic- depressive
depressive illness.
illness. But Butit didn’t.
it didn’t. Why Why not?not?These
These
* This
* Thischapter
chapter is adapted
is adapted fromfromNesse
Nesse RM, RM, Stein
Stein DJ.DJ. Towards
Towards a genuinely
a genuinely medical
medical
are
modelaregood
model good
forfor questions.
questions.
psychiatric
psychiatric The
nosology. The
nosology. aim
BMCaim
BMC of ofthis
Medicine.this
Medicine.bookbook is is
toto
2012;10(1):5.
2012;10(1):5.showshow that
that asking
asking why why
i 17xi17xi
18 18GOOD
GOOD
REASONS
REASONS
FOR
FOR
BAD
BAD
FEELINGS
FEELINGS
young
youngwomen.
women. Each
Each disorder
disorder is defi
is defi
nednedbybya list
a list
of of
symptoms.
symptoms. If If
a person
a person
hashas
enough
enough symptoms
symptoms onon
thethelistlist
forfor
long
longenough,
enough, thethe
diagnosis
diagnosis applies.
applies.
This
Thischecklist
checklist approach
approach hashasvastly
vastly
increased
increased agreement
agreement about
aboutwhowho hashas
what,
what,
butbut
at at
a high
a high price.
price.
It It
encourages
encourages thethe
assumption
assumption that
that
thethe
diagnosis
diagnosis
contains
containsallall
information
information needed
needed andanda corresponding
a corresponding neglect
neglectof of
thethe
lifelife
situations
situations
that
thatsetset
offoff
many
many disorders.
disorders. Combined
Combined with
with
ananage
age
of of
computer-
computer-
accessible
accessible
records,
records, it discourages
it discourages recording
recording relevant
relevantbutbut
potentially
potentiallyembar-
embar-
rassing
rassingdetails.
details.SoSoclinical
clinicalrecords
recordsnow nowtendtendtotoprovide
providea few
a fewsterile
sterile
paragraphs
paragraphs thatthatdescribe
describe thethesymptoms
symptoms andandjustify
justify
thethe
diagnosis.
diagnosis. ForFor
in-in-
stance,
stance,
here
hereis is
a summary
a summary of of
Ms. Ms. B’sB’s
psychiatric
psychiatric evaluation.
evaluation.
Ms.Ms.BB is is
a 37-
a 37-
year-
year-
oldoldwhite,
white, married
married mother
mother of of
three,
three,
whowho is is
re-re-
ferred
ferredbyby herhergeneral
general physician
physician forfor
depression.
depression. SheShe was
waswell
welluntil
until
four
fourmonths
months ago,ago,when
when shesheexperienced
experienced thethe
sudden
sudden onset
onsetof of
early-
early-
morning
morningawakening,
awakening,decreaseddecreasedappetite,
appetite,low lowmotivation,
motivation,and and
feelings
feelings of of
guilt
guilt
and andhopelessness.
hopelessness. SheShelost
lost
tenten pounds
pounds in in
thethepast
past
twotwomonths.
months. Sometimes
Sometimes sheshewishes
wishes sheshewere
weredead,
dead, butbut
sheshe
hashasnono
plans
planstotocommit
commit suicide.
suicide. Symptoms
Symptoms arearepresent
present every
everyday,
day,butbutthey
they
areare
much
much worse
worse onon some
some days
daysthan
thanothers,
others, andand they
theyvary
vary
diurnally,
diurnally,
worse
worse in inthethemorning.
morning. SheShereports
reports chronic
chronic anxiety
anxiety forforseveral
several
months,
months, characterized
characterized byby worry,
worry, sweating,
sweating, and and gastrointestinal
gastrointestinal
symptoms.
symptoms. SheShealso
alsohashas
periods
periods of of
more
more intense
intense anxiety
anxietylasting
lasting forfor
hours,
hours, with
with trembling,
trembling, shortness
shortness of of
breath,
breath, and anda bad
a badfeeling
feeling in in
thethe
pitpit
of of
herherstomach,
stomach, butbutnono panic
panic attacks
attacks and andnono agoraphobia.
agoraphobia.
SheShesays
saysthat
thatsheshe hashasdeveloped
developed ananintense
intense discomfort
discomfort in insocial
social
situations,
situations, which
which sheshenownow avoids.
avoids.SheShe drinks
drinks one oneorortwo
twoglasses
glasses of of
wine
winenightly,
nightly, butbutsheshe
hashasnonohistory
history of of
substance
substance abuse.
abuse.SheShe attri-
attri-
butes
butesthetheonset
onset of of
symptoms
symptoms toto marital
maritalconfl
confl
icts.
icts.
There
Thereis no
is nopre-
pre-
vious
vioushistory
history of of
psychiatric
psychiatric disorder.
disorder. SheSheis physically
is physically healthy,
healthy, takes
takes
nono medications,
medications, andandhashasnono allergies.
allergies. There
There is is
a history
a history of ofalco-
alco-
holism
holism in in
thethefather
father andandanxiety
anxiety in in
thethemother.
mother. HerHersister
sistertakes
takes
antidepressants.
antidepressants. SheShe grew
grew upup in in
a stable
a stable home.
home. SheShedenies
denies abuse
abuse
andandtraumatic
traumatic events
events in in
childhood.
childhood. SheShehashas
three
three children
children ages
ages3, 3,
5, 5,
and
and 9, 9,
whowho areare
doing
doing well.
well.
HerHer husband
husband is ais manager
a manager at at
a local
a local
manufacturing
manufacturing plant.
plant.They
They live
live
in in
a suburban
a suburban neighborhood.
neighborhood. SheShe
previously
previously taught
taught elementary
elementary school
school full-
full-
time,
time, but
butsheshe
nownow works
works
ARE
ARE
MENTAL
MENTAL
DISORDERS
DISORDERS DISEASES?19 19
DISEASES?
part-
part-
time
time
as as
a teacher’s
a teacher’s
aide.
aide.
Diagnosis:
Diagnosis:Major
Majordepression.
depression.
Treatment
Treatment
Plan:
Plan:Initiate
Initiate
antidepressant
antidepressant treatment
treatmentandandcognitive
cognitivebehavioral
behavioral
therapy,
therapy,return
return in in
two
two
weeks
weeksforfor
follow-
follow-
up.up.
The
The
case
case
report
report summarizes
summarizesthethe
facts
facts
that
that
justify
justify
thethe
diagnosis,
diagnosis,
butbut
it gives
it gives
nono
inkling
inkling of of
what
what
brought
brought ononherher
symptoms.
symptoms. That
Thatcame
cameflooding
flooding out
out
when
whensheshe
described
described seeing
seeing
herher
former
former lover
lover
in in
a grocery
a grocerystore.
store.
I was
I was trying
trying toto buybuy groceries,
groceries, but but it it
waswas likelike
I was
I was walking
walking in ina a
swamp.
swamp. I could
I could hardly
hardly put put
oneone foot foot in in
front
front of of
thethe other.
other. I had
I had a a
list,
list,
but butit it
didn’t
didn’t help.
help. Nothing
Nothing seemed
seemed toto matter.
matter. ButBut thetheboys
boys
needed
needed food,
food, sosoI went.
I went. Halfway
Halfway through,
through, I saw
I sawJackJackwheeling
wheeling hishis
cartcartaround
around thethefarfarendend of ofthetheaisle.
aisle. ForFor months,
months, I thought
I thought I saw
I saw
him him allallthethe time,
time, like
likea ghost.
a ghost. ButBut thisthistimetime I was
I was almost
almost sure
sure it it
was washim. him.My Myheart
heartstarted
startedpounding
poundingand andI froze
I frozeand andhad hada a
flashback
flashback toto sixsix
months
months ago agositting
sitting in in
Starbucks.
Starbucks.
WeWe werewere going
going totomeetmeet at at
seven
seven thetheway way wewe always
always did,
did, then
then
movemove our ourstuff
stuffintointothethe apartment
apartment where
where wewe had had been
been meeting.
meeting.
WeWe promised
promised each
each other
other that
thatat at
midnight
midnight onon November
November second
second I I
would
would telltell
Sam Sam andand hehe would
would telltellSally.
Sally. WeWe wanted
wanted totododo it it
No-No-
vember
vember fi rst,
fi rst,
butbut wewe postponed
postponed it itbecause
because of of
thethe kidskidsandand Hal-
Hal-
loween.
loween. I will
I will always
always remember
remember thethe sparkling
sparkling flakes
flakes of of
snow
snow as asI I
opened
opened thethe door
door totoour our Starbucks;
Starbucks; they
they seemed
seemed like
likesymbols
symbols of of
our our newnew lifelife
together.
together.
I told
I told Sam Sam I was
I was leaving
leaving at at
midnight.
midnight. HeHe blew
blew up,up,butbutI knew
I knew
hehe would.
would. HeHe yelled
yelled soso loudlouda car
a carslowed
slowed downdown outside.
outside. That
That made
made
it it
easier
easier toto gogo through
through with
with it.it.
WeWe were
were donedone a long
a long time
time ago.ago.
Enough
Enough of ofliving
living a lie.
a lie.
AllAll I wanted
I wanted was wastoto bebe with
with Jack.
Jack.I brought
I brought
him him a bouquet
a bouquet of of
freesias.
freesias. ButButhehedidn’t
didn’t come.
come. I texted
I texted himhimat at
7:30,
7:30,
thinking
thinking thatthat maybe
maybe Sally
Sally hadhad triedtried toto jumpjump outout a window
a window oror
something.
something. Nothing.
Nothing. I called
I called him.
him. NoNo answer.
answer. I couldn’t
I couldn’t believe
believe
it. it.
I just
I justwentwent numb
numb and and satsat
there
there staring
staring at atthethetable
table sosolong
long thethe
flowers
flowers got got allall
wrinkled
wrinkled andand limp,
limp, likelikefossils
fossilsin inthethe marble
marble ta-ta-
bletop.
bletop. ThatThat waswaspretty
pretty muchmuch thethe endend of ofmymy life,
life,
right
right then.
then.
I fiI nally
fi nally snapped
snapped out out of of
mymy flashback
flashback andand got gotupup mymy nerve
nerve
toto follow
follow where
where JackJack
had had gone.
gone. Nothing.
Nothing. I went
I went totocheck
check out.
out.HeHe

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‘A new approach to mental

‘A wise, accessible, highly readable exploration of

R ANDOLPH M . NESSE GOOD REASONS FOR BAD FEELINGS

evolutionary purpose . . . This Date: 12 November 2019

‘Sets out to show how evolution underpins

it will surely change the face of medicine’ •••• CMYK

‘Important and fascinating . . . As Good FIN IS H ES

Reasons for Bad Feelings boldly posits, Regular Coated

for Bad Feelings • Wet proofs

9780141984919_goodReasonsForBadFeelings_COV.indd 1,3 18/11/2019 13:10

Randolph M. Nesse is an American physician, a founder of evolutionary

UK | USA | Canada | Ireland | Australia

Penguin Books is part of the Penguin Random House group of companies

First published in the United States of America by Dutton,

Text copyright © Randolph M. Nesse, 2019

The moral right of the author has been asserted

Printed and bound in Great Britain by Clays Ltd, Elcograf S.p.A.

Penguin Random House is committed to a

2. Are Mental Disorders Diseases?

3. Why Are Minds So Vulnerable?

5. Anxiety and Smoke Detectors

2. Are Mental Disorders Diseases?

3. Why Are Minds So Vulnerable?

5. Anxiety and Smoke Detectors

“No “No wonder

ByBythethe nextnext time time George

The The Greek

that suffering is caused by desire, more specifically the inability of ever

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