Tooting from San Francisco - III: A Major Sea Change

I’m actually thinking with a clear brain. So THAT’S what it’s like. Trouble is I need to be winding down for sleep. To recap my day:

Tuesday 6:00 AM. I’m up way too early and can’t get back to sleep. I’m headed into my third day of the American Psychiatric Association’s annual meeting in San Francisco with precious little sleep in my bank account.

8:45 AM. I’m seated for my first talk of the day. “Have you heard the news?” I ask the psychiatrist next to me. I hand him a print-out. The heading reads:

“Breaking News: Psychiatry Comes Up with New Diagnosis of Asshole.”

The piece is a hard copy of a blog piece I wrote a couple of weeks back. We’re about to hear a talk by Robert Cloninger on “Developing a Positive Psychiatry of the Person,” and it’s nice to know I’m doing my bit.

“Treating symptoms is not enough,” Dr Cloninger opens. It’s all about well-being. Dr Cloninger has been a major paradigm-shifter in mapping out the fine points of personality and their interacting dynamics. Personality, he explains, is non-linear, involving the way we learn and adapt, plus the internal and external forces that pull on the self.

We are shaped by our genes and environment, but our self-awareness (a uniquely human trait) allows us to modify these influences and move forward with our lives.

Personal change, he said, can happen very rapidly, if you can get the person to recognize their strengths and weaknesses.

11:00 AM: I’m struggling to stay awake. Marc Schuckit of UCSD is about to talk on the fine points of the genetic and environmental influences involving alcoholism, and my cortex is running on empty.

I’m at the talk by virtue of Kenneth Kendler’s presentation the day before. Dr Kendler used alcoholism as an example of gene-environment interaction, and I figure this is a way of getting deeper into the topic.

I’m not disappointed. Dr Shuckit’s research into the area began some 30 years ago when he started asking a few simple questions. There are many causes of alcoholism, involving many genes and environmental influences, but Dr Shuckit noticed that when those with alcoholism described their early drinking experiences, they tended to remark about how they could drink everyone under the table.

The technical term is “level of response” (LR). These individuals need to have a lot more drinks to feel the same effect as their peers, and kids drink for effect. Once you get into the pattern of heavy drinking, Dr Shuckit said, then the environment kicks in: You hang out with heavy drinkers; they expect you to engage in heavy drinking.

Dr Shuckit has tracked more than 400 offspring of alcoholics and control subjects for 25 years, and found that LR is a reliable predictor of alcoholism. He is also getting a reading on the genes involved.

So, say you know that your 12-year-old has a genetic predisposition to LR, is there anything you can do about his environment to protect him? Different peers? Different expectations?

12:30 PM: I meet up with a good online buddy, Gina Pera, who has a great ADHD blog. Nearby, we grab some gyros and take them outside. Gina’s been a great moral and intellectual support to me, and I could literally sit out in the sun all day with her, but an afternoon of dark rooms beckons ...

2:05 PM: I walk in late to a very large packed room where an expert panel is discussing borderline personality disorder. What is wrong with this picture?

A mere three years before, at a featured lecture at the APA in Toronto, one of the pre-eminent leaders in the field, Joel Paris, spoke to mostly empty chairs. Earlier, at a bipolar session, one leading expert had been dissing the borderline diagnosis.

In three years, something has dramatically shifted in psychiatry. Earlier - at a session at the same time as Robert Cloninger’s - leading borderline expert John Gunderson had spoken to a packed house. Add to that the packed house from Dr Cloninger’s presentation.

At a brief pause in the proceedings, I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems.

It is reasonable to infer from this that the profession is becoming receptive to the goal of recovery.

It’s as if at some point in time in the last three years psychiatrists had suddenly woken up. I have no idea how this will play out in the real world, where psychiatric practice is dictated by the insurance industry and where old habits die hard. But I can assure you, this is a major story, perhaps the biggest event in my 10 years of reporting on mental illness, and one readily quantifiable - just count the people in the room.

4:00 PM: I am literally sleep-walking through the afternoon poster session. This is usually a great learning opportunity for me, my chance for one-on-one face time with the experts. But my brain isn’t tracking. I’m not engaged. No sense hanging around ...

5:00 PM: I’m back in my room at my fleabag hotel. Sleep, glorious sleep. One minute later it’s 8:00 PM. I get up and splash water on my face, taking an inventory of my brain.

My sleep is not messed up, I decide. I’ll be out like a light before midnight. Moreover, I’m taking tomorrow morning off. Late sleep. A little sight-seeing. Time to wind down ...