Crowded Desperation: Risk Factors in Urban Life

“We don’t have a lot of time on this Earth! We weren’t meant to spend it this way. Human beings were not meant to sit in little cubicles staring at computer screens all day, filling out useless forms and listening to eight different bosses drone on about mission statements.”

— Peter Gibbons, Office Space

The Industrial revolution began a process of global urbanization that continues today, with over half of our population now living in cities and with that number expected to rise to 66% by 2050. Parallel to this change has always been a cultural backlash against cities and society that constantly questions whether our current system is worth living in.

In “Walden”, Henry Thoreau famously rejects society and the consumerism of the city to live a life of simplicity and harmony with nature. From Jean Jacque Rousseau’s concept of the “Noble Savage”, to even the biblical Garden Of Eden, many thinkers envision a human nature fallen from grace, with society and its problems usually the cause of this downfall; more contemporary works such as Martin Scorsese’s “Taxi Driver” and George Orwell’s “1984” paint cities vivid with our fears of urban degeneracy and large scale totalitarianism, while films such as “Office Space” and “Falling Down” deal with structured monotony and the annoying minutiae of disingenuous social interactions foisted upon the main characters by their urban/sub-urban lifestyles.

With so many stories of people breaking free from the urbanized “quiet desperation” Thoreau warned of, one would be forgiven for thinking that the relationship between urban life and mental health should have garnered significant scientific attention, but surprisingly this is not the case, and the quest for answers will show us that meaningful work in the field is pretty scarce. To be fair, finding a causal relation between urbanity and mental health is incredibly difficult for a number of reasons, and even now I must introduce a few caveats to ensure the readers understand the still relatively speculative nature of the whole endeavor.

As our previous piece details, we are not even close to understanding the etiology (i.e. causes) of a variety of mental disorders. In fact, the only things we really know about many of these disorders are their (potential) symptoms, and their vague neurochemical correlates, such as “dopaminergic imbalance”. Our brain’s complexity arises from the roughly 100 trillion neuronal connections in it, so pinpointing a problem to an abnormality in one of our merely dozens of neurotransmitters (NTM) isn’t much of a pinpoint, since each NTM plays a role in so many brain systems. As such, the best we can do for now is find correlates between urban living and mental health, and hope that some of them may elucidate the causes of these disorders.

To make matters worse, the way the DSM (the standard diagnostic manual for mental disorders) defines disorders is usually contextual, meaning that a disorder cannot be just a set of behaviors, but must also cause impairment in broadly defined areas such as “social, occupational, or other important areas of functioning.” For example, while a city dweller who must interact with dozens of strangers every day may be diagnosed with social anxiety disorder if these interactions cause them significant distress, a rural inhabitant with an identical disposition, who only ever interacts with family and close family friends, may never be diagnosed. Conversely, an energetic Wall Street trader who impulsively trades stocks on gut feeling may actually be considered a confident and effective worker, while the same person stuck as a clerk in a rural general store may have outbursts that are considered manic and diagnosed as such. In other words, when it comes to measuring the urban/mental-disorder relationship, there is a potential confound embedded in the very definition of the disorders themselves!

Nevertheless, even in above scenario there is some information we can gleam. Consider the aforementioned example of the anxious city dweller. Although the causes may be uncertain, the fact of the matter is that living in a city makes this person, who is predisposed towards anxiety, more anxious. Postulating that increased social contact caused by city living can exacerbate social anxiety seems a rather uninspiring conclusion, but with more intractable conditions like depression and schizophrenia, a thoughtful theory as to why urban life affects rates of these conditions can provide insight on the mechanism behind these diseases, and guide future research into their etiology.

The Data

All this fuss about limitations is just to say that correlational data is only as good as the theories that can be drawn from it. So without further ado, the data:

What is it about living in a city that causes increased susceptibility to these various diseases? And are there any positive factors? Despite there being increased accessibility to mental health treatment and overall higher wages in a city, these potential benefits do not seem materialize into any substantial improvement in mental well-being. In fact, if these factors are indeed protective (which they have been shown to be), then there must be other factors about city living that are even more deleterious than we previously thought, but are partially counteracted.

Damaging Factors in Urban Living: an Interview with Dr. Ian Gold

Concerning this, there are a variety of theories posited as to why cities seem to be a risk factor in many disorders. To further investigate, I interviewed Dr. Ian Gold, Canada Research Chair in Philosophy & Psychiatry at McGill, whose recent book, Suspicious Minds, outlines a particular and novel theory for the mechanism by which delusions form. Consequently, the following theories pertain mostly, though not exclusively, to delusions. These theories are outlined below, with comments from Dr. Gold, and using schizophrenia as the illness from which to judge delusion rates by:

Viral Theory: A simple theory, now defunct but surprisingly still taught as a candidate explanation for schizophrenia, is that the illness is caused by predisposition + a viral infection as a child. As such, greater population density in cities equates to greater likelihood of viral infections, which in turn leads to greater likelihood of schizophrenia. Studies showing intra-city differences in disease rates, differences which are much too localized represent viral infections, have lead this theory to fall out of fashion.

Social Drift Theory: Posits that people who are predisposed to acquiring illnesses are also predisposed to moving to cities, due to the larger variety of jobs and social services available to them. In other words, it is the illness that causes migration to cities, not the cities that cause increased illness rates.

Dr. Gold, guided by several studies that have shown that this hypothesis is untenable, believes that the cause is rooted more firmly in the environment. He does not, however, rule out a milder version of this hypothesis, which states that those carrying genes for schizophrenia (but not afflicted by the disease itself) may be cognitively impaired and more likely to end up in cities, where they have children who then acquire the disease themselves.

Theories that oppose the above social drift thesis, and instead propose that the environment itself contributes to the mental illness rates are collectively known as Social Causation theories. The most notable of these follow:

Social Defeat theory: In Dr. Gold’s words, “Social life can lead to unpleasant conditions. You can be humiliated, or subordinated, or treated badly, or excluded. These are unpleasant social states that have effects on your brain. Those effects have damaging consequences on what happens to you, including raising your risk of developing schizophrenia.“

In other words, increased contact with strangers in a city could lead to greater rates of schizophrenia. This theory, while promising, has yet to be tested or fleshed out into a workable paradigm, and is generally speaking still too vague to hold any real explanatory value that could shed light on the causes and possible treatment of schizophrenia.

Social Isolation/Exclusion theory: Also encompassed by social causation, this theory posits that the social structure of city living actually makes people more prone to be isolated; this increased isolation would then be considered the mediator between urbanity and mental illness. Social isolation differs from typical definitions of isolation, however, in that it’s often used in the context of racial and economic inequality to highlight a lack of opportunities afforded to minorities and the poor when it comes to integrating into their communities, or indeed even being in communities that have any sort of cohesion (unemployment, crime, and prejudice are not good ingredients in community building).

Though social isolation has been studied by sociologists for decades, it still shares the same problem as social defeat in that its explanatory power is limited by the looseness of its definition. Much like describing a disease as a “dopaminergic imbalance”, describing its cause as “social isolation” has some merit, but explanatorily it leaves us wanting. It’s just too nebulous a concept for neuroscience. Our other datum, that there are neurochemical imbalances, has the opposite problem: it’s too concrete a phenomenon for psychology. What is needed is a theory that can connect the social with the biological.

This brings us to Dr Gold’s own proposed account for mental illness formation:

Social Threat theory: Gold’s own theory, developed with his brother Joel, which judges delusions to primarily be linked to the threats posed by other people, termed “social threats”:

So this hypothesis that my brother and I developed is that delusions are thoughts, disorganized thoughts, that evolved in a particular cognitive system to detect social threats. So for example its very useful to be sensitive to the possibility that other people have intentions to harm you in one way or another, and if you have a system that does that, and that system is disordered, you might see threats where there aren’t any. So paranoia, on this view, is an exaggerating form of suspicion about somebody else intended to harm you.

Following from this naturally, Dr. Gold argues, it would make sense for city life to present a higher risk:

…here you are in an environment where there are lots and lots of unknown others. Unknown others are potentially threatening, because you don’t know what their intentions are…and the more people there are, the more vigilant you have to be. So even if you never meet people, you know that they’re out there, you know they are potentially harmful, and they’re potentially threatening. You can imagine that a system that is disposed to be hyperactive, and disposed to be dysfunctional, might be disproportionally stressed in an environment where there are lots and lots of potential unknown threats. The bigger the city, the bigger the stress; the bigger the stress, the bigger the risk of a disorder in this particular cognitive system, that we call the suspicion system.

To arrive at this conclusion, the Gold brothers made the highly unorthodox step of analyzing databases that recorded the content of different delusions throughout the world. Despite finding thousands of different delusions with culturally relative content, ranging from mind-reading radio waves to retracting penises, they realized every delusion could be put into about 12 broad categories with a common theme: they were all social. What separates Dr. Gold’s theory from many others, and mitigates traditional problems with using epidemiological data as a basis for theoretical models, is that it is both general enough to account for a wide variety of variables, including the social defeat and social isolation hypothesis mentioned above, and specific enough to be testable on an empirical basis. A suspicion system is, after all, a cognitive system, and thus should have neural correlates that could be tested in laboratory conditions.

Theories that identify the mechanism by which an illness is formed can be used in tandem with raw data to hone in on the factors that influence mental health. Accurate factors are crucial because they link theory to action. If we know what it is about cities that is bad for your mental health, then we can begin to enact policies that change these things. Before we do that, however, we have to ask ourselves: what, exactly, is a city?

The Abstract City: Place or Idea?

Cities have to be thought of as essentially places in which certain kinds of social interactions are happening. One of the interesting questions that’s raised is: do you have to be in the same physical environment as someone to be in their city?

-Ian Gold

As we try to sift through all these factors of city life which are relevant to our search, we are struck with an interesting question: are these factors defined by the city, or conversely, do they define it? A dense social environment, along with its paradoxical twin brother of social isolation, were once thought inextricably linked to a physical location with a lot of people in it. Today, the advent of the internet and the rise of social media have challenged this assumption, and now we can enjoy the pleasures of being observed by hundreds of acquaintances and potentially harassed by anonymous hordes without leaving our home. In many ways, the internet has become a global city, and with it we should expect many of the effects of city living affecting the billions of internet users around the world.

One particular concern is, if the internet use is shown to have the same deleterious effects as urban living, will these effects be compounded? As the world asymptotically approaches both global urbanity and global internet use, these effects could represent a massive health crisis in the making. Studies on the subject are scarce, but preliminary findings show that, for example, increased internet usage (and social media usage specifically) may be a risk factor for depression.

Looking ahead, the positive aspect of thinking of cities as abstract spaces, however, is that the factors associated with them could then be modified independently, and cities (or, as defined by this new layer of abstraction, the web) could in turn be molded to reflect these factors. Many of the negative aspects of both physical and virtual cities may be products of culture more than intrinsic aspects of cities themselves. Social isolation, for example, is exacerbated by income inequality. This applies to both the wealthiest and the least wealthy in a city, the former by the exclusivity of their spaces (think gated communities), and the latter by a lack of opportunities (as mentioned above). A more equal society, or even one where economic inequality doesn’t manifest itself through social stratification, could help mitigate these problems.

Though the internet may sometimes serve as an echo-chamber of opinions, it can be used as a tool to build communities which can integrate in a way that serves as a protective factor against mental diseases. The Suspicion System hypothesized by the Gold brothers is likely less active in the presence of community members than strangers, since the likelihood of a threat from someone you know can be assessed more rationally (i.e., by a different system) than a stranger would. We have yet to talk about the relationship between physical and mental health, but the two are known to be tightly linked and as such any change that could affect one affects the other. Greenery, bike infrastructure, security and public transportation are all examples of factors that improve health, and are a surefire way to begin changing our urban landscape.

Interest in the relationship between urbanity and mental health is still in its infancy, so all of these suggestions are speculative opinions. Nevertheless, the importance of such changes cannot be underestimated. We find ourselves at the perfect time in history, characterized by a massive migration towards cities and a scientific community armed with the technology to capture it. We have a golden chance to study these phenomena and use them to better understand ourselves, our environment, and the actions we need to take to improve both. As more people take up residence in urban centers, an environment built around this understanding has the potential to significantly improve the quality of life for billions of people in the future.

-Nicolas Botero

Featured image: http://ngm.nationalgeographic.com/2011/03/age-of-man/anthropocene-photography