Bruce G Charlton MD
Bruce G Charlton MD
Department of Psychology
University of Newcastle upon Tyne
NE1 7RUTel: 0191 222 6247
Fax: 0191 222 5622
E-mail: bruce.charlton@ncl.ac.uk
Psychopharmacology and the human condition
Contemporary human life is very different from the ecological and social environment in which humans evolved, and which shaped human psychological architecture [1]. The human mind is adapted to maximize reproductive success under very different conditions from that in which it finds itself [2]. This has profound implications for a consideration of the attainment of human happiness and fulfillment; so much so that - contrary to the views of some evolutionists [3] - I believe psychopharmacology has an fundamental role in enhancing the human condition.Reasons for endemic psychopathology
When an animal is living under the same ecological and social conditions as those in which it evolved, the gratification of its instincts will - on average - maximize its potential for reproduction. Whatever makes the animal 'happy' will also be reproductively adaptive.But this does not apply to contemporary humans. Since our environment is significantly different from that of ancestral humans, our instincts are no longer a good guide to what is good for us. More specifically, human instincts evolved in response to Palaeolithic, nomadic, hunter-gatherer culture, and these instincts still make up the psychological architecture of the human mind since there has not been enough time to evolve new ones [1]. This is one reason for human psychopathology - the mismatch between stone age brains and silicon age culture. Another reason for psychopathology is that instincts do not tend towards maximizing happiness as an end in itself, happiness is only as a means to reproduction. So even in a natural environment, humans would not tend to be optimally happy.
Human happiness under modern conditions is neither expected, nor necessarily adaptive - partly because ancient instincts are operating upon modern stimuli, partly because biological 'adaptiveness' works towards enhancing reproduction rather than personal satisfaction, and partly because humans have devised non-adaptive ways of getting happy.
Can psychopharmacology improve the human condition?
It may sound a tall order for anything as crude as psychopharmacology to accomplish anything so profound as to improving the human condition. Presumably, under natural conditions a simple chemical would not be able to improve all round adaptive human behaviour. But our conditions are very far from natural; and what seems normal may be sick. It is probable that most humans throughout recorded history have lived in a 'sick society'; a society in which almost everyone was ill, people were physically malnourished, stunted and mentally impaired - a society in which most of the populations are potential 'patients' with the ability to benefit from appropriate treatment.Since it is probable that the normal human condition is sub-optimal, and that psychological dissatisfaction and psychiatric 'illness' of various kinds is endemic - in principle there is enormous scope for psychopharmacology to improve the human condition. The assertion that psychiatric illness is endemic may sound exaggerated. However, in addition to the formal diagnoses such as major depression, schizophrenia and the anxiety states, there are a large number of common illnesses which profoundly affect psychological variables such as mood, motivation and concentration . Examples would include upper respiratory tract infections; tension headaches; tiredness due to poor sleep; hangovers from alcohol, drugs and tobacco; indigestion; hayfever and allergic rhinitis; backache, muscle and joint pain… the list is long. All these physical conditions have direct effects on the mind in ways that are becoming clearer as the relationship between brain and body is elucidated [4].
On top of these physical illnesses are social problems. The pressure of long term planning, time management and multi-tasking in a complex and changing world is responsible for a great deal of tension. There are social pressures: the threats of continually meeting or living among vast numbers of people, mostly strangers. At the same time loneliness is an ever present reality. Even among the 'successful' and prosperous, there are the never-ending torments of striving for status in an ever-more unequal world with a handful of high status winners but a multitude of 'failures'.
Perhaps all this explains the widespread desire for pharmacological oblivion, the desire for escape as a relief from these sources of angst and misery. But oblivion represents only a temporary answer, and one which - when deployed too frequently - destroys the possibility of appetitive gratification. A sequence of consummative 'highs' is the recipe for a meaningless life. I have never heard of a happy junkie.
Technologies of gratification
When an instinct is satisfied it 'rewards' the organism with a positive or 'gratifying' emotional state. Following Donald Klein's nomenclature [5], I have sub-divided gratifications into the consummative and the appetitive.Consummative gratifications create a condition of ecstasy or euphoria: a short-term flood of pleasurable satisfaction that is its own justification. Biological examples include the orgasm, being praised, eating and drinking, and escape from danger. The desire for consummative gratification could be described as a craving.
Appetitive gratification, by contrast, is the fulfilling of purpose, the sense of one's life being an unfolding story. Its biological basis is the highly evolved human social intelligence; specifically the 'theory of mind' mechanism and the ability to imagine human dispositions, motivation and intentions [6-8]. Appetitive gratification is therefore a matter of participating - intellectually and emotionally - in the unfolding of human character and relations over real time. The lack of appetitive gratification results in boredom, loneliness, anomie.
Technologies of gratification, of which psychopharmacology is an example, are human-created mechanisms that aim at the satisfaction of evolved instincts. In doing so they bypass the biological goals which the instinct evolved to satisfy. The implicit aim of technologies of gratification is to stimulate 'happiness' directly, rather than by stimulating a biologically useful behaviour. Such technologies include much of that which we value in human culture - such as art, science and religion - as well as much that is generally deplored.
The technologies of gratification also divide into consummative and appetitive. Consummative technologies seek immediate, short-lasting and subjectively pleasurable bodily states from satisfaction to extreme ecstasy. Nicotine and caffeine are mild examples; heroin and cocaine are from an extreme end of the spectrum. Other technologies could include the use of pornography to attain sexual arousal, watching a football game to attain a state of socially-participatory excitement, or gorging on crisps, chocolate and ice cream to stimulate evolved human appetites for salt, sugar and fat. Or, indeed, doing all of these at the same time.
Appetitive technologies of gratification - by contrast - are meaningful activities. They seek to provide a surrogate for social life - a narrative structure which one can opt into. Appetitive technologies are designed to engage people, assuage loneliness, and gave shape and direction to imaginative life. Examples include frequently broadcast soap operas, large novels in which we can become immersed for days or weeks at a stretch, and the daily news comprising coverage of familiar 'personalities' such as royalty, film stars and politicians. It has even been argued that human language evolved in order to allow 'gossip' about social affairs - who is doing what to whom [6]. In a tribal situation, such information is vital to reproductive success; under modern conditions the subject matter of gossip is typically remote and irrelevant since appetitive technologies have developed to supply a stimulus that is hyper-stimulating to our imaginative life [7].
The typical complaint of disaffection and dissatisfaction in the affluent contemporary world can be seen as related to the lack of satisfying appetitive gratification in a context in which there are rich technological possibilities for consummative gratification. Consummative gratification technologies are often used to attain oblivion and escape from the failure to achieve appetitive gratification.
In an unnatural world, technologies of gratification are both unavoidable and fundamental to human satisfaction. The question is not whether we should use them - it is how we should use them.
Prospects for fulfillment
The prospects for spontaneous and widespread appetitive gratification look slim: we do not seem to be heading towards a significantly better world. Leaving aside the grim nature of the 'third world', trends in affluent Western society are towards perceived economic efficiency; which generally means massification, competition, regulation, inequality, squalor, instability, geographical mobility and more loneliness for many people.Maybe things will improve, maybe they will get worse… but unless we are political utopians it seems very probable that this is broadly the kind of world most people shall continue to inhabit for the foreseeable future. Indeed, the interest in psychopharmacology has grown inversely with the decline of belief in utopian politics. Political idealism is now just a temporary teenage phase - soon past. The rest of us are starting to realize that if we cannot change the world to suit human nature, our only option is to change human nature to suit the world.
So what can psychopharmacology do to improve the human condition? For a start it can help cure illness, relieve symptoms and enhance function; so we can get on with life. Analgesia - for instance - is one type of indirect but vital psychopharmacology. Then again, many people use drugs to fit themselves to the rhythms and demands of industrial society. Drugs may provide energy or alertness on demand by the use of stimulants such as caffeine. This may be necessary in coping with long hours of work, when we feel ill or tired, and when high efficiency is expected. And at the other end of the emotional scale, people use drugs such as alcohol for unwinding and assisting social intercourse. Indeed, anxiolysis is probably the most sought-after psychotropic drug effect, and alcohol the most popular of the powerful psychopharmacological agents.
What of the disadvantages? Well, effective drugs always have side effects, and there is always a risk involved - as well as expense [3]. But if pharmacology is to be used as a fundamental technology of gratification, the moral question is, who should decide whether the risk is justified?
Antidepressants and the human condition - a test case
Peter Kramer's Listening to Prozac posed the question of the proper role of 'cosmetic psychopharmacology' - the use of drugs to improve metal states in non-ill 'normal' people, outside the usual disease diagnostic boundaries [8]. His case reports of patients who report feeling 'better than well' on Fluoxetine are supported by many reports in the psychiatric literature of similar responses from tricyclics and monoamine oxidase inhibitors [9]. These anecdotes about 'antidepressants' have recently been given striking support by a formal double-blind, placebo-controlled trial by Knutson et al which found exactly the effects Kramer had suggested - a diminution in of unpleasant emotions ('negative affects') combined with an improvement in social functioning ('affiliative behavior') in apparently normal subjects given Paroxetine [10]. And the following issue of the American Journal of Psychiatry described a double-blind study in which Paroxetine reduced anger and suicidal behaviour in non-depressed subjects [11].The evidence is mounting that there are an unknown but significant proportion of people who show no detectable sign of psychopathology, yet whose lives can benefit in a very fundamental way from taking one or another of the 'antidepressant' drugs. The reader of this sentence may be such a person - there is no way of them knowing without trying. This raises new moral issues, because we are not talking about drugs that make you high: these are drugs with the potential to give appetitive gratification, to give life more meaning. When they work, they are true 'happy' pills; where happiness is taken to be the legitimate goal of life.
The problem is that such agents are potentially dangerous, hence are available only on prescription. This puts the doctor in the position of gatekeeper to a satisfying life: an awesome responsibility. Putting aside the secondary issue of cost (these are not expensive drugs - being much cheaper than tobacco or alcohol); a change in the role of the physician seems indicated. I would argue that the physician has a role in informing and advising; but that so long as no actual harm is expected, prescription for antidepressants should be available on request. Why should a doctor hold back the keys to possible fulfillment?
References
1. Barkow JH, Cosmides L, Tooby J (eds). The adapted mind. New York: Oxford University Press, 1992.
2. Charlton BG. A syllabus for Evolutionary Medicine. JRSM, 1997; 90: 397-399.
3. Nesse RM. Psychoactive drug use in evolutionary perspective. Science 1997; 278: 63-66.
4. Klein D. Interview in D Healy (ed). The psychopharmacologists London: Altman 1997.
5. Dunbar R. Grooming, gossip and the evolution of language. London: Faber, 1995.
6. Barkow JH. Beneath new culture is old psychology: gossip and social stratification. In: Barkow JH, Cosmides L, Tooby J (eds.) The adapted mind. New York: Oxford University Press. 1992, pp. 627-637.
7. Damasio, AR. Descartes error: emotion, reason and the human brain. New York: Putnam, 1994.
8. Kramer PD. Listening to Prozac London: Fourth Estate, 1994.
9. Healy D. The antidepressant era Cambridge, MA: Harvard University Press, 1998.
10. Knutson B, Wolkowitz OM, Cole SW, Chan T, Moore EA, Johnson RC, Terpestra J, Turner RA, Reus VI. Selective alteration of personality and social behavior by serotonergic intervention. American Journal of Psychiatry 1998; 155: 373-379.
11. Verkes RJ, Van der Mast RC, Hengeveld MW, Twyl JP, Zwinderman AH, Van Kempen EM. Reduction by paroxetine of suicidal behavior in patients with repeated suicide attempts but not major depression. American Journal of Psychiatry 1998; 155: 543-547.
bruce.charlton@ncl.ac.uk
also by Bruce Charlton
The Malaise Theory of Depression
Public Health and Personal Freedom
Psychiatry and the Human Condition
Awareness, Consciousness and Language
Injustice, Inequality and Evolutionary Psychology
Peak Experiences, Creativity and the Colonel Flastratus Phenomenon