A Kraepelin Appreciation (Why his 1921 opus is way ahead of the psychiatry of 2010)

I've just been reading Emil Kraepelin's classic "Manic-Depressive Insanity." Never heard of him? Bet you heard of Freud, who was born the same year. All Kraepelin did was "discover" manic-depression, schizophrenia, co-discover Alzheimers, and found diagnostic psychiatry. His body of work, based on meticulous observations of thousands of patients in German asylums, spans from 1893 to 1927. "Manic-Depressive Insanity" was published in English in 1921, extracted from his much larger "Compendium."

Kraepelin's pioneering approach to classifying mental disorders inspired the modern DSM-III and IV, though - ironically - he has to be rolling in his grave over how both editions got manic-depression all wrong. Let's hear from the source what manic-depression really is:

Manic-depressive insanity ... includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia.

Plus "colorings of mood" that embrace both pathology and personality.

All these diverse elements, claims Kraepelin, "represent manifestations of a single morbid process."

In other words, someone who cycles up and down, gets depressed, flips into mania, has messed up thinking, and has stuff going on with moods is suffering from one illness, not  five, not twenty-five. Equally important, the depression itself (even without evidence of mania) is strong evidence of manic-depression, not something else. All this was revolutionary thinking way back in the first part of the previous century, and still remains ahead of the curve in the first half of this one.

Kraepelin's view of manic-depression, then, is vastly more inclusive than the modern DSM's "bipolar disorder," which does not recognize recurrent unipolar depression. Modern psychiatry, instead, lumps recurrent depression with chronic depression, which explains why antidepressants don't work for a good many individuals and can even cause harm.

You would think the DSM-5 would fix this, but do psychiatrists listen?

In addition to offering finally-detailed clinical descriptions of depression and mania, Kraepelin identified transient "mixed" states. Here, we can truly appreciate the master at work.

Kraepelin asks us to conceptualize not just mood cycling up and down, but also intellect and volition, but not necessarily in sync. Thus, instead of pure mania (flight of ideas, exalted mood, pressure of activity) or classic depression (inhibition of thought, mournful moodiness, irresoluteness) we variously have:

• Depressive or anxious mania (where depression takes the place of a cheerful mood).
• Excited depression (where flight of ideas is replaced by inhibited thought).
• Mania with poverty of thought (instead of flight of ideas).
• Manic stupor (a depression with cheerful mood).
• Depression with flight of ideas (instead of inhibited thought).
• Inhibited mania (flight of ideas with cheerful mood and psychomotor inhibition).

If you find, say, "manic stupor" confusing, don't worry, Kraepelin has your back. Sample:

The patients are usually quite inaccessible, do not trouble themselves about their surroundings, give no answer, at most speak in a low voice straight in front, smile without recognizable cause, lie perfectly quiet in bed or tidy about at their clothes and bed-clothes, decorate themselves in an extraordinary way, and all this without any sign of outward restlessness or emotional excitement. ...

The reason you probably haven't heard about all this is because the DSM flies in the face of reality by categorizing a mixed state as full-blown depression coexisting with full-blown mania. The DSM-5 would partially redress this, but comes nowhere near to restoring Kraepelin.

Kraepelin has been referred to as the father of modern psychiatry, but that does him a grave injustice. If Kraepelin were alive today, he would take a match to the DSM and start over - I've heard that sentiment expressed by a good many reform-minded psychiatrists. His "Manic-Depressive Insanity" from 1921 remains state-of-the-art. The psychiatry of 2010 has a lot of catching up to do.

You See Four; I See Twenty-Eight

Psychiatry tells us that we typically over-react to situations. We over-think things, we panic, we get overwhelmed. Our brains respond by flipping out or shutting down. We behave badly, and then we're left dealing with the consequences.

"Normal" people don't think and act this way is the message. "They" respond rationally.

Cognitive behavioral therapy (CBT) is based around this proposition. Someone says, "I'll call you later." But we often interpret that to mean, "I'm not interested in you." Then our runaway brains take over, churning out all kinds of crazy destructive thoughts.

"What did I do wrong?" "The bastard!" "Why does this always happen to me?" - Take your pick. Not surprisingly, we end up anxious and depressed and miserable. The person calls, just like he said he would. We respond by snapping his head off.

Congratulations. We've just fulfilled our own prophecy. Now that person really truly isn't interested in us.

CBT is based on mindfully observing these self-defeating thoughts and taking corrective action. We train our brains to interpret, "I'll call back later" as a sign of interest. And how does it feel when a person is interested in us? A lot better than the load of crap our out-of-control brains used to be spinning out, thank you very much.

Naturally, I'm a big fan of CBT and mindfulness. But a new twist came up yesterday. Let me explain:

Something happened in a social interaction with a good friend on Sunday. Her friend was being a jerk, and the only way I could respond without making a scene was by making a scene - I left.

Naturally, the friend thought I had overreacted - made a big deal out of nothing - and from her point of view she was absolutely right. So, yesterday, I tried to explain what was happening from my point of view.

Such and such happened, I began, which meant such and such was going to happen. Clear as day, right?

She didn't see how my first such and such connected to my second such and such.

A light bulb went off. How could she? I reasoned. She was thinking linearly. I don't, even though I have a law degree. I'm non-linear. A lot of us with mental illness are. I've been blogging a lot on this recently. Basically, it works like this: People inclined to high creativity, perception, and intuition tend to have brains that are less than efficient in filtering out the world around us.

Everything lands on our intrays, in effect. Very little goes in the wastebasket. Thoughts, feelings, perceptions in abundance. The positive side of this is that when we manage to connect some of these seemingly unrelated inputs into novel points of view we look like geniuses, or, at worst, a bit weird and eccentric.

The negative side is that is we easily get overwhelmed. Our brains respond by flipping out or shutting down.

Fortunately, I already had shared some of this with my friend. She knows me - kind of. She's seen my brain in action. She knows I have a gift. But I had also been quick to tell her that I have paid a very high price for this gift. A very high price. She's very sympathetic, but nevertheless, here I was, in her presence, being judged, forced to make my case:

It's like this, I replied. You and So-and-So are thinking, "one-two-three-four." I'm already on "twenty-six, twenty-seven, twenty-eight." I already know what is going to happen before you do.

They see four. I see twenty-eight. They think I'm responding inappropriately to four. Really, I'm responding as they would to twenty-eight. Probably with a lot more restraint. At least I was able to mindfully observe my brain undergoing a meltdown. At least I was able to vacate the scene before I said things that I would regret.

Unfortunately - for me - I could not stop the chain reaction in my brain. I drove off with the full knowledge that my day was ruined, that for the next several hours the agony of ten thousand hells would play out inside my skull. My only measure of control was to try to endure those hours with some degree of equanimity.

As I said, I pay a very high price for my gift.

I wasn't asking my friend to understand me. Only that she not judge me. In effect, we occupy two different worlds. Or, rather, we see the same world very differently. But the hard cold reality is that the world we share is run by the linear people. The more adept I am at conforming to their expectations the happier I will be. I've learned to be pretty good at this.

In fact, this was what I really valued about our friendship. In her presence I felt that I actually belonged in her world. In the course of the precious time we spent together, I could forget that I was a person that her world was ready to write off as mentally ill.

Then came the brutal hard cold reminder.

Fortunately, I think I salvaged the friendship, but I know she will never look at me the same way again. People like me react to things others don't see. These people, naturally, think we're crazy. At least I know my friend is at least trying to see things from my point of view. A cognitive behavioral therapist sure as hell wouldn't.

Where I Get My Information

Last week, I had breakfast in town with a friend, “Abigail,” from the midwest and her husband. She is one of my mental health heroes. We met at a conference several years back and have kept in touch ever since.

What sources do you go to for your information? she wanted to know.

Interesting question. Here’s the context:

Eleven years ago this month, I started a free email newsletter dedicated to depression and bipolar disorder. I was six months into my diagnosis. “I would write as I learned,” I explained in a piece dating from the time. “It would all be tied into my recovery.” Literally, “I was reclaiming my life, one article at a time.”

As I explained to Abigail, each week I religiously plowed through the medical and psychiatric literature and mainstream media for developments that I would summarize. Serendipitously, this served the needs of my readers at the time, plus my own. We were all learning as we went along.

Later, as I started connecting some of the dots, I was able to offer explanations as well as summaries. As the scope of my inquiry broadened, I found myself contending with a flood of information. I grew selective. I concentrated on certain issues. Of all things, depression and bipolar grew increasingly less relevant.

Diagnostic categories were useful to a point, but the brain science findings were pointing to new explanations into how we think and feel and behave, as was - ironically - a lot of the ancient psychiatry this present generation dismisses as unscientific. At the same time, our recovery began to focus on looking beyond the diagnosis. Predictably, I took to linking brain science to recovery.

A couple of years ago, I took a Sabbatical from my newsletter. Not having to wade through tons of information did wonders for my overtaxed psyche, and freed my mind for other projects.

So, how do I get my information these days?

Simple, I told Abigail. I’m doing it right now by having breakfast with you.

More to come ...        

Petals and Wings (and a vista)

I shot these today on a nature walk about ten minutes from my home east of San Diego.

My Totally Unexpected Didgeridoo Experience

This is a short story of a lovely experience I had yesterday. I went shopping along San Diego’s antique row for some night tables and other odds and ends for my bedroom. I had made a similar excursion three weeks before to help stock my living room. When I moved into my new apartment six or seven weeks ago, the only sticks of “furniture” I owned were my three didgeridoos. Literally, I built my entire living room around the my didge collection.

One shop in particular featured an eclectic mix of really cool stuff (such as a vintage edition of a book of paintings by New Zealand artist Peter McIntyre), but I was totally unprepared for the sight that greeted me - a beautiful hardwood hand-carved didgeridoo. Surely, I thought, it’s merely a decorative piece. It could not possibly deliver a quality sound.

I picked it up, running my fingers down the serpentine carvings. I positioned the bell end of the instrument on the floor, drew in a breath and blew. I wasn’t expecting much of a sound, particularly with warm-up breaths. But the didge proved exceptionally responsive. A promising tone issued forth. I gathered myself, got an airflow going, and experienced a wonderful warm resonance. Even with the carpet absorbing the sound, there was no escaping the fact that this baby sounded as good as it looked.

I looked at the price tag. $150. I owned two didges that cost me twice that. The carvings alone made it worth the price. The person minding the shop was filling in for the owner and knew nothing about the didge, but was expecting the owner to call in about an hour.

What do you call it? he asked. How do you spell it?

A didgeridoo is probably the oldest wind instrument in the world, basically a hollowed out tree trunk. On a simple level, it delivers a deep rich pulsing drone, augmented by vocalizations and tonguing variations, which is about my level of playing. A skilled musician can wail the crap out of it.

Aboriginals from Australia’s north coast fashion theirs from stringy bark eucalyptus. The instrument is central to their cultural and spiritual traditions. Over the last decade or two, the didge has caught on in the west, and we now see the instrument fashioned out of all manner of material. I have one Aboriginal didge. My first two didge purchases were crafted by a local. 

I lived in Australia for five years about 20 years ago. Back then, didges did not interest me. Three and a half years ago when I moved to southern California, suddenly didges made sense.

The didge in my hand was clearly western. Maybe I would learn more in an hour or two. I found my night tables and other items, set them aside with the didge, and told the guy behind the counter I would be back. Time to see a friend for lunch. When I returned, I was told the owner didn’t know anything about the didge, either. Then I was presented with an offer I couldn’t refuse: The didge was mine for $100.

I got it into the car, along with my night tables and other purchases. I had business elsewhere in town later in the day. Time to play with my new toy. I found a nearby city park, headed to a secluded corner overlooking a valley, positioned myself beneath a tree, and started familiarizing myself with the instrument.

No technical tricks. Just experience the sound, that wonderful pulsing drone. Soon, I was in my own world - John World - not part of this world, very much part of this world:

“In the beginning was the Word ...”

All things originate from vibration.

I looked up. A man I hadn’t seen before was approaching. Oops! I was obviously disturbing him. Time to apologize and find another spot.

This is his mother’s memorial, he told me.

Oh, crap. Now I better run.

And he was really moved by the sound ...

His words gushed out: His mother had died two months earlier. She loved the view from this section of the park. Some of her ashes were scattered here.

What do you call that instrument? he asked, his voice choking. Could I keep playing?

I told him I would dedicate “this” - whatever came out of my didge - to his mom. I got the air going. I got the piece of wood vibrating ...

Thank you, he sobbed a minute later. Thank you.

Over the next 30 minutes, he walked this way, then that way, positioning himself at various outlooks, staring out into the valley, then returning to my spot, holding his phone near the bell of the instrument, talking to his friends, leaving messages to his friends, leaving messages to himself.

Connections, healing, healing, connections ...

It was time to go, back to that other world, the real world, not real, yet real. I cradled my new didge, not just a didge, just a didge. Carefully, I placed it in the back floor of my car, in a gap beneath the night tables. I got behind the wheel, found my street - and turned the wrong way.

Ha! John World.

Nature Walk

Shot this morning, ten minutes from my home.

Virginia Woolf and Her Madness

From mcmanweb:

A telegram arrived at the HMS Dreadnought, the flagship of the British home fleet, advising the Admiral of a visit by the Emperor of Abyssinia and four of his entourage. The dignitaries were given the red carpet treatment and the visit went off without a hitch, except for the fact that the real Emperor happened to be back in Addis Ababa. One of the "Abyssinians", decked out in flowing robes and dark greasepaint, turned out to be a youthful Virginia Woolf.

The media and political storm that broke out in the wake of the hoax did little for Virginia's mental equilibrium. She had already experienced one breakdown and was well on her way toward another. All her life that beast/companion we know as manic depression would stalk both her and her family, and finally claim her. One cold day in 1941 - her body wasting from neglect, her thoughts racing, and hearing voices - she wrote:

I feel certain now that I am going mad again. I feel we can't go through another of those terrible times. And I shan't recover this time ...

Then she walked down to the river bank, filled her pockets with stones, and left her walking stick on the ground. Children would discover her body three weeks later. Following an inquest, the verdict was announced as: "Suicide while the balance of her mind was disturbed."

Virginia Woolf has no shortage of chroniclers, many who know far more about literature than they do about mental illness. Her childhood traumas, sexual frigidity, and lesbian flirtations may have been the stuff of Freudian psychodrama, but it was the storm and fury of manic depression that truly governed her life. One biography appears to have tackled her madness head on, "The Marriage of Heaven and Hell: Manic Depression and the Life of Virginia Woolf" by Peter Dally (St Martin's Press, NY, 1999).

The title pretty much says it all. According to Dally, who is a psychiatrist: "Virginia's need to write was, among other things, to make sense out of mental chaos and gain control of madness. Through her novels she made her inner world less frightening. Writing was often agony but it provided the 'strongest pleasure' she knew."

The Bloomsbury crowd and the literary highlife fed her hypomanic surges, but it was from the depths of depression that she seemed to dredge up her best inspiration. When she started a novel, according to Dally, she was excited but relaxed and stable, only succumbing to exhaustion and depression in the revision stages.

Her husband, Leonard Woolf described her early stages of mania: "She talked almost without stopping for 2 or 3 days, paying no attention to anyone in the room or anything said to her ... Then gradually it became completely incoherent, a mere jumble of dissociated words."

In full flight of madness, according to Dally, "birds spoke to her in Greek, her dead mother materialized and harangued her, voices called her to 'do wild things.' She refused nourishment. Trusted companions like her husband Leonard and her sister Vanessa became enemies and were abused and assaulted ... "

Fortunately, her friends and family tolerated her and took care of her. Had she been born into a different class or with a less understanding family, she undoubtedly would have been locked away for life. As it was, lengthy asylum stays were a fact of life for her, as were long recuperative periods spent at home.

Her first breakdown occurred at age 13, shortly following the death of her mother. Several breakdowns later, at age 31, she entered a severe depression in which she made an attempt on her life by swallowing 100 grains of Veronal. Only the serendipitous presence of a distinguished physician in nearby lodgings saved her life. He pumped out her stomach and stayed with her throughout the night.

The suicide attempt was part of two back-to-back breakdown/recuperations lasting the better part of two years. Fierce, though decidedly less lethal, mood swings would continue to dog her the rest of her life. One night, in 1921, she went to a concert and stayed up all night, only to take to her bed for the next eight weeks.

"What a gap!" she recorded in her diary. "How it would have astounded me to be told when I wrote the last word here, on June 7th, that within a week I [should] be in bed, and not entirely out of it till the 6th of August - two whole months rubbed out .."

Husband Leonard acted as her protector, seeing her through the depressions and nipping some of her manic surges in the bud: "I am alive; rather energetic," Virginia wrote in her diary. "But half the horror is that [Leonard] instead of being, as I gathered, sympathetic has the old rigid obstacle - my health."

By 1935, when she was working on "The Years", the constant cycle of mania and depression was beginning to overtake her. The revision was particularly difficult, and in 1936 she wrote to a friend:

....never trust a letter of mine not to exaggerate that's written after a night lying awake looking at a bottle of chloral and saying, No, no no, you shall not take it. It's odd how sleeplessness, even of a modified kind, has the power to frighten me. It's connected I think with these awful times when I couldn't control myself.

She took time off to ride out the depression, only to throw herself into her next work, "Three Guineas", which "pressed and spurted out ... like a physical volcano."

There would be one more novel after that, "Between the Acts", then the writing would cease. Husband Leonard was struggling with his own depression, leaving Virginia to fend for herself. The timing could not have been worse. England at the time was on the losing end of the Second World War, and Virginia was isolated in the south of England, away from her usual circle of friends. The beast/companion was literally eating her alive, and in the end, in the only way she knew how, she decided to stop the madness.

Drug Companies Behaving Badly: What the Media Won't Tell You That You Need to Know

A recent article in the Newark Star-Ledger headlines that “drugmakers continue 'off-label marketing' despite large fines.”

In the last year, Pfizer agreed to pay $2.3 billion as settlement for allegations of illegal promotion of the arthritis med Bextra (pulled from the market) and other meds. Meanwhile, Eli Lilly agreed to pay $1.4 billion to settle criminal and civil charges for its off-label marketing of the antipsychotic med Zyprexa.

Around the same time, Johnson&Johnson’s Ortho-McNeil got slapped on the wrist for $6.4 million for its off-label promotion of the anti-seizure med Topamax for bipolar and other uses. The article mentions that the company paid physicians as much as $3,000 to accompany sales reps on doctor visits to “talk to you about things [the sales rep] can’t talk to you about.”

Earlier this year, Astra-Zeneca coughed up $18 million for marketing the antipsychotic Seroquel off-label to children and dementia patients.

Doing the math indicates that breaking the law is very good business practice. In 2004, Pfizer agreed to pay out $430 million for promoting the anti-seizure med Neurontin for bipolar and pain. Between 1999 and 2004, the drug raked in $10 billion in off-label sales.

Neurontin failed two clinical trials for treating bipolar. The drug itself may not have been harmful per se, but by promoting what was in effect a placebo with side effects the company was knowingly putting bipolar patients in harm’s way.

Thankfully, the Star-Ledger’s account stuck to the facts, which alone amounted to a ringing indictment on the drug industry. Too often, we see these stories in a far more emotional (and highly inaccurate) context, so let’s briefly re-examine some of the issues, which I have extensively reported on here and on mcmanweb and in my Newsletter and elsewhere:

The drug industry’s marketing practices are highly shameful. No question about it. This is where Enron meets BP meets Detroit. The industry, with the acquiescence of psychiatry, has been pulling one over on doctors, patients, and loved ones for years. I could write a book on this. Other people have.

The drug industry sets the agenda for psychiatry. Yes-no-maybe. Until a few years ago, this would have been a strong yes. But then, as patents for blockbuster meds began expiring and with no new meds (not just “me too” meds) coming on-stream, the drug companies lost interest in influencing psychiatry. “Ubiquity” is a term that no longer applies to drug companies, and thanks to new economic realities may never again.

At the same time, doctors and patients and loved ones, including the organizations that speak for them, have wised up. Fool me once ...

If a drug does not have FDA approval for a particular use, then it is dangerous for physicians to prescribe it for that use. Blatantly false. As Stephen Stahl of UCSD pointed out at an APA meeting: “The FDA regulates the sale of medicine, not the practice of medicine.”

FDA indications tend to be the end result of company marketing strategies, which figured into Eli Lilly and others initially seeking depression indications for their SSRIs, even though this class of drugs appears to work better for anxiety. Only later did these companies seek approval for the treatment of anxiety. So, was their “off-label” use in the interim bad medicine? Hardly.

As former head of the NIMH Frederick Goodwin pointed out at an APA meeting, new uses for meds are typically discovered and championed by clinicians in practice. The drug companies only come to the party later. If we were at the mercy of drug companies taking the initiative, bipolar patients would still be waiting for lithium, anti-seizure meds, and antipsychotics (there is not a single bipolar med developed by a drug company from scratch).

Despite this, the NY Times and other publications routinely (and ignorantly) equate off-label meds to rogue medicine.

“Powerful” drugs must be harmful drugs. Totally false. You will often read this in the context of doctors prescribing “powerful” antipsychotics” (off-label, of course) to kids for the “controversial” diagnosis of bipolar. Meds are supposed to be powerful. If you have any doubts about this, simply ask for a “weak” pain-killer next time your back gives out on you.

“Controversial” diagnoses (such as early-onset bipolar) have been manufactured by the drug companies to create new markets. Absurdly false. In this regard, the NY Times and other publications are difficult to distinguish from antipsychiatry diatribes. Academic food fights do exist, but hardly constitute evidence of fundamental splits of opinion. With regard to early onset bipolar, the diagnosis was promoted by - of all things - beleaguered parents educating disbelieving clinicians.

Schizotypal: Deep into Creativity, Just Shy of Madness

In a March blog post, Madness and Creativity, I reported on how “latent inhibition” appears tied in to both psychosis and creativity. The piece drew heavily from a post on Psychiatry Today’s Beautiful Minds blog by Scott Barry Kaufman. As I reported:

What we seem to be looking at is that fine edge where productive novel thinking ventures close to the precipice of pathologically delusional thinking.

In his piece, Dr Kaufman talked about "latent inhibition" (LI), the brain's ability to unconsciously filter out information. High latent inhibition is conducive to rational thought. Low latent inhibition is associated with psychosis and schizophrenia.

But Dr Kaufman noted:

Recently researchers have wondered whether a reduced latent inhibition can actually be beneficial for creativity. After all, decreased LI may make an individual more likely to see connections that others may not notice.

In an ideal situation, a rational brain (the seat of executive function) processing novel information can produce astonishing insights that can pass for genius, creativity, or intuition. Dr Kaufman cited both his own research and the research of others in support of the proposition that those with a higher faith in their own intuition tested “high” for “low” LI.

People with schizophrenia, unfortunately, do not fare well with executive function. They get overwhelmed. Their low LI translates into psychosis. Sylvia Nasar, in her book “A Beautiful Mind,” recounts a colleague asking John Nash in 1959 how he could believe that extraterrestrials were sending him messages.

"Because," Nash replied, "the ideas that I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously."

In two blog pieces (on Nash and on Darwin) I speculated that Dr Nash may have been dealing with a form of “schizophrenia lite” (either under-the-radar “prodromal” symptoms or “schizotypy”) that allowed him to produce brilliant insights before the full force of the illness descended and robbed him of a quarter century of his life. What originally got me started on this line of thinking was a lecture I heard by Nancy Andreasen, who noted, among other things, that Einstein had a son who had schizophrenia and that he himself was an eccentric with “schizotypal” tendencies.

In his latest piece, Dr Kaufman dials in the “schizophrenia lite” connection. Schizotypy, he says, “is a watered-down version of schizophrenia” with a constellation of personality traits “that are evident in some degree in everyone.” He cites a recent study by Nelson and Rawlings in Schizophrenia Bulletin that suggests schizotypy “may be positively associated with the experience of creative flow.”

Dr Kaufman defines “flow as “the mental state of being completely present and fully immersed in a task.”

In addition: “When in flow, the creator and the universe become one, outside distractions recede from consciousness, and one's mind is fully open and attuned to the act of creating.”

As Susan Perry in “Writing in Flow” explains: “Looseness and the ability to cross mental boundaries are aspects of both schizophrenic thinking and creative thinking."

Dr Kaufman notes that this is an exciting time for research on the linkages between mental illness and creativity. The Nelson and Rawlings' study, he says, suggests that positive schizotypy, latent inhibition, and flow are intimately related, though a lot more research needs to be done.

Bring it on ...

Rerun: A Visit to My Tormented Inner Child

From last September ...

I perform my own stunts. Trust me, through large parts of my life I would have loved to employ a stunt double and perhaps someday I will. Take my depressions - please. It was around the time I was in seventh grade that I had a profound sense that I wanted to return to the planet that I was born on, any planet but this one. I was small and skinny with glasses and had a nerdy personality.

A nerd is an individual not smart enough to be a geek.

Every morning, I had to steel myself to get on that bus to school. Ours was the second to last stop, which meant I wound up standing in the aisle, fair game for young sociopaths in the making, the type of people who grow up to become Charles Manson or talk radio hosts (it's hard to tell the difference). Then, again, for all I know, they are now working for Habitat for Humanity.

My inner immune system invented its own respite from the terror of school and the outside world. Just when I knew I could not ever possibly board that bus one more time, my body would give out on me. My throat would constrict and flare up, my nose would heave up great gobs of green bloody snots, and I would cough the cough of the dead.

Then the healing would start. There in bed, or on the couch under a million blankets shivering in a sweat-induced micro-climate of Vicks Vapo-rub fumes, my strength would come back. Slowly. Over several days, a week, more. Then one day I would get out of bed and get dressed, too far behind in my school work to ever really catch up, but nevertheless ready to take what the day offered, one day at a time.

That 12-year-old me gave rise to the 13-year-old me, which eventually gave rise to the adult me. So ...

What if the present me could go back to that 12-year-old? Imagine how different my life would have turned out. Say I had one minute - 60 seconds - to spend with with that confused kid? Would would I say?

No time for a candid heart-to-heart. My message would have to be cryptic, like a Zen koan, something that made no sense, but would lead to an earth-shaking revelation upon further consideration. So imagine if the 12-year-old me had the benefit of the wise counsel of the present me, and I appeared to him in his moment of need, like the disembodied Obe Wan Kinobe to Luke Skywalker.

“John,” I would say, in a voice brimming with compassion. “Remember - Hannibal never won a battle with his elephants.”

Therein lies the key to healing.

Wait! Hold on. ... A buried memory is coming up. Holy crap! Now I remember! The present me really did visit the 12-year-old me, and this is what he actually said:

“John. Remember - Hannibal never won a battle with his elephants.”

Son of a bitch! What kind of idiot thing is that to tell a 12-year-old?

Another Look at "Crazy"

A recent blog piece examined the way we use "crazy." I am strongly on the side of "screw PC, you should see me when I'm crazy." But I do acknowledge that context enters into the picture. There are times when the term can be highly inappropriate. Then again, so can "isosceles triangle."

The last couple of days have afforded me a new opportunity to assess "crazy." It concerns an individual I know - call him Ishmael - who is not in good shape right now, which brought back memories of some of my journey through hell.

The reason I was in hell, of course, had nothing to do with me. I had long suspected I had bipolar, but then again, bipolar people were crazy and I wasn't one of them. You locked up crazy people in institutions. Besides, everyone had their ups and downs, right?

So in hell I stayed, with occasional day passes to planet earth. 

The day I finally came to terms with my bipolar set the scene for meeting myself for the first time. "Crazy" tentatively stepped forward and introduced himself. We hesitated, we embraced.

Of course, being crazy meant I had to forever rule out the possibility of friends or relationships or a career. Only normal people could aspire to things like that. Instead, I would have to drastically scale back my expectations and come to terms with life on the margins.

It didn't turn out that way. Yes, it was a different life I now led, one where I had to learn to accept my limitations and recalibrate accordingly. I wasn't living the life of my original aspirations, but - of all things - I was living a way better life than the one I ever had, or, for that matter, even knew was possible. It was a life of compromises, but hardly a compromised life.

And - crazy thing - having acknowledged "Crazy," it is much easier to pass myself off as "normal." Which is not to be confused with pretending I'm normal. No way. Didn't work then, wouldn't work now. More like just be myself, which sometimes manifests as a bit crazy, which is okay. After all, who wants to be normal?

All this is a long way of saying that once I accepted that my life was in ruins for reasons that had to do with me, then I was no longer perpetually pushing a rock uphill. Crazy? I'm fine with that. My friend Ishmael? He has a long way to go.

Is the Psychiatry of 1952 More Relevant to Our Recovery Than the Psychiatry of 2010?

From my keynote I gave to the DBSA Kansas State conference in Kansas in late April ...

Let’s turn to another researcher I heard speak in San Francisco.

This is a guy called Robert Sapolsky of Stanford. And he has dedicated his life to studying stress. So, Dr Sapolsky asks us to imagine a rat who has been trained to press a lever to avoid a mild shock.

Now, as he describes it:

The anticipation of mastery might induce a flood of dopamine to the frontal cortex and trigger pleasure. If the lever is disconnected, however, so that pressing it no longer prevents shocks, the rat will frantically press the lever repeatedly, attempting to gain control.

This, says Dr Sapolsky, is the essence of anxiety.

In human terms, I would describe it this way. Imagine waiting for a hot date to show up. The anticipation of a great night ahead triggers pleasure. But then the date doesn’t turn up on time. Pleasure changes to anxiety. And then it looks like the date will not turn up at all. So, to return to the rat, the real rat, not the no good bastard:

The shocks continue. The rat finds its attempts at coping useless. The rat basically gives up. Key neurotransmitters are depleted while stress hormones increase. In the words of Dr Sapolsky: The rat “has learned to be helpless, passive and involuted. If anxiety is a crackling, menacing brushfire, depression is a suffocating heavy blanket thrown on top of it."

That's a pretty good description, right? Says quite a lot about what we go through.

So, here you are. You’re all dressed up with nowhere to go. In the space of an hour or two, you have gone from pleasure to anxiety to depression.

Is this normal? Yeh, of course it is. The front end and the back end of the brain are working exactly as they should be. Yes, the result sucks, but if we have any kind of feelings at all, depressed is the state we’re supposed to be in.

Now, in a resilient brain, we will bounce back. Life may suck, but we cope, life goes on.

But suppose our brains are vulnerable. Say we don’t bounce back. Say we start thinking we’re worthless. Say we start over-ruminating. We lie in bed all day. And say this goes on for four months.

I’m going to finish up in a bit, but I want to throw another one at you here. I’m sure you’re aware that earlier this year the DSM-5 Task Force came out with a draft. Are people aware of that? Okay, good.

To keep it short: The DSM is due for an update in 2003. And this is the diagnostic Bible - okay? - put out by the American Psychiatric Association. No - 2013. Is that the same as two thousand - I don't know. I'm one of these guys who doesn't know if three-fifths is more than half or less than half.

Anyway, the DSM-IV is the current edition, which came out in 1994, and that's based on the DSM-III Revised which came out in 1987, which in turn is based on the DSM-III which came out in 1980, with hardly any changes all the way along. And guess what? The DSM-5 of 2013 is going to continue that tradition of making sweet F-all changes. So, basically, we're going to come out with a document that's going to set the tone for psychiatry for the next 20 years based on the DSM-III of 1980 and its ridiculously - stupid - criteria for depression.

Anyway, while I was doing my research, I dug out the old DSM-I from 1952 and the DSM-II from 1968. Basically, these are much the same and they're supposed to represent ancient history, you know, before psychiatry got modern, stuck in 1980 Ground Hog Day forever. Much of the DSM I and II had to do with this Freudian artifact called “neurosis.”

Well, guess what? According to these ancient DSMs, depression was a form of neurosis. Okay, fine. And guess what drove neurosis? Anxiety!

That’s not all. These ancient DSMs tried to break down mental illness two ways: That which they saw as biology-based - which they didn't have a clue about -  and that which was the result of a maladaptive response to stress.

So. Freeze-frame. Stress-anxiety-depression. Does that sound very close to the language Dr Sapolsky was using? Is the psychiatry of 1952 more relevant to our recovery than the psychiatry of 2010?

Well, in one sense, yes. The psychiatry back then was interested in looking under the hood, but they lacked the means. No brain scans. No gene tests. The best they could do was speculate about neurosis.

The old psychiatry also had no idea that stress was related to biology. They thought that just about all mental illness was a product of the mind as distinct from the brain. Nevertheless they knew that true recovery involved digging below the surface, deep into the mind. The catch was the only tool at their disposal - psychoanalysis - really didn’t work for most people. And it really didn't get patients all that much better.

Well these days, we know a lot more about recovery. There are a lot of tools available to us. We know a lot of them have very good success rates, and we heard a lot about that this morning.

After lunch, I will be giving another talk. I’m looking forward to concentrating more on recovery tools. And you will also hear more speakers talk about recovery. But what I want to emphasize here is:

Recovery starts with knowledge. It helps knowing that we have vulnerable brains. That the back and front ends of our brains don’t always act the way they should. That they don’t always talk to each other the way they should. That we have a tendency to over-react. That we also have a tendency to both over-think and under-think.

Not only that, our brains are slow in resetting to normal.

What this means is - instead of coping with life, life becomes a struggle.

Do we have some kind of consensus on this? We're on the same page with this? Because - you know - you really get this wisdom going to DBSA support groups and also NAMI groups. And other groups. There's a lot of patient and family wisdom there.

Mental illness is simple, really. We get overwhelmed, overloaded. Too much of one thing, too much of everything. Too much thought, too much emotion, too much sensory input. Too much of nothing, even. Think of a fire in your brain or of being trapped deep underground, unable to breathe. There is no way the brain can respond rationally.

The brain copes, instead, by flipping out or shutting down.

But this doesn’t mean we have to give up. It only means we have to work harder and smarter.

So - know thyself. Look under the hood. Check out what’s really happening inside. Take nothing for granted. Question everything.

So here we are, on our journey, somewhere in the Land of Oz, looking to return home, to Kansas ...

Gimme Shelter

From my second talk to the Kansas DBSA State Conference in late April ...

Does anyone here know what the word “asylum” means?

Safety?

Right. That's the key one. Shelter, sanctuary. It's really not a dirty word. And back in the old days, insane asylum was not a dirty word. So, hold that thought.

My research, as I say, often takes me to strange places. This little adventure started in front of my computer. One day, for the heck of it - way too much time on my hands. obviously - I checked out the very first issue of the American Journal of Psychiatry, which came out in 1844. Back then it was called The Journal of Insanity.

Yep - I could have written that one, you know. It would have been an autobiography.

The American Journal of Psychiatry is published by the American Psychiatric Association, which was also founded in 1844.

Now, you heard me mention this morning how modern brain science is showing that stress makes us sitting ducks for all kinds of mental illness and other weird stuff. And I also mentioned that psychiatry already knew this back in 1952 when the first DSM came out. As it turns out, the principle was already an old one back in 1844.

Of all things, this first issue of the Journal of Insanity had a long article dealing with Shakespeare. Cool, I thought. So I started reading. This from King Lear. He's the physician character talking to one of the daughters of the mad king. You have to imagine me with a cape on and one of those Shakespeare hats:

“Be comforted, good Madam, the great rage 
You see is cured in him, and yet it is danger 
To make him even o’er the time he has lost; 
Desire him to go in, trouble him no more 
Till further settling.”

As the Journal observed:

“Now we confess, almost with shame, that although near two centuries and a half have passed since Shakespeare thus wrote; we have very little to add to his method of treating the insane.”

Wow. So this really is an ancient principle, then. And the modern psychiatric science of 1844 just validated it.

The Journal goes on to say:

“To produce sleep and to quiet the mind by medical and moral treatment, to avoid all unkindness, and when patients begin to convalesce, to guard, as he directs, against everything likely to disturb their minds, and to cause a relapse is now considered the best and nearly the only essential treatment.”

I just want to put this to you guys: Does this sound more enlightened than the psychiatry of today?

[Affirmative responses from audience.]

Yeh, that's pretty interesting, isn't it? Cuz wasn't the 1800s supposed to be the bad old days? Before science? Weren’t asylums terrible places where they locked away - “the insane”?

Not always.

Yeh, you got it. Not always. And this is really interesting. It turns out the 1830s and 40s was a great reform era. Abraham Lincoln came of age around this time. This is the society that formed his ideas. This was a time of enlightened science meeting enlightened Christianity. Have you had a look at the buildings and grounds of these old institutions? They were beautiful. Palatial country estates.
Yep - and I'm getting reinforcement from Janet, here - they even had farms attached to them.

There's this one out here ... that used to be a beautiful building. It was like a spa.

And they don't put evil insane people in beautiful places. That's not what these buildings were designed for.

Well, talk about coincidence. It turns out that this same 1844 Journal - the one that had a long piece on Shakespeare - it also had a report describing an institution in Utica, that was then in operation for 18 months. According to the report, of 433 patients admitted, 123 had recovered.

Okay - we can’t be sure what the report meant by the term, recovery. But it is fair to assume that in an age of no psychiatric meds or other treatments -  or even “treatments” that made patients worse, like throwing mercury down the hatch - more than one-quarter of those admitted were deemed to be in good enough condition to return to their homes and communities.

Not long after I came across that 1844 psychiatry journal almost three years ago, I found myself in LA. This was about three years ago. Maybe it was two - I can't count. I was on my way to my daughter’s wedding in New Zealand and I was staying at a friend’s house before flying out.

I don’t know about you, but I don’t look forward to any holidays. Because that means I have to crank out three weeks of work in just one week. So here I was, in LA, all worked out - stressed like nobody's business needing to relax, needing to get away from work.

I should have known. I'm sure a lot of you know this already. If you’re a mental health advocate, you really gotta watch hanging out with fellow mental health advocates - they're bad for your health. So what’s my friend’s idea - who's a mental health advocate - her idea of a good night on the town in LA? Attending a three-hour lecture on mental health, that’s what.

Great. I’m in vacation mode. I want to forget about work, and here I am being dragged out into the night to sit in on a university class for some psychology majors at USC. A leading world authority on psychiatric rehabilitation, Robert Liberman of UCLA, was giving a guest lecture.

Okay, I decide to go along with my friend, because I hate fights. But that didn’t mean I had to listen.

So, anyway, here I am, in a college classroom, in one of those ridiculous classroom desks that I used to sit in back in the 1960s - how these survived into this century I don't know.  So, I'm trying very hard not to listen, when suddenly Dr Liberman starts telling us how the insane asylums of old were very enlightened places, with high recovery rates.

My ears pricked up. Wasn't I just reading something like this?

This is the way we learn. We need a few repetitions before the message gets in there.

So Dr Liberman went on to say in so many words that mental illness was a product of the industrial age. Just jam people into large noisy smelly dirty cities and watch what happens.

This is why, you know, Kansas is so nice with its open skies. It's spacious. I felt my mind resting when I came out here.

Asylums were built to get people away from all that. Only later, he explained, did cash-strapped state governments give up on us. I guess it's easier putting up nice buildings and you don't have people doing enlightened stuff in the nice buildings, anymore. You just make prisoners out of us.

So, of all things, on the ride back, I’m thanking my friend profusely for dragging me out into the night. So I still go up and visit her every once in a while.

Anyway, when I got back from New Zealand, I looked up Dr Liberman, and it turns out he is one of the leading proponents of what they call the “diathesis-stress” model, namely that certain individuals are more genetically disposed than others to break down under stress.

Now he came up with that in the 1970s, and of course we find that the brain science of the 2000s is validating it. We're those people who break down under stress ...

Rerun: Me, Captain Ahab, and the Anterior Cingulate Cortex

 From last last November ...

As I mentioned in a recent blog, someone very close to me is in a psych unit right now. In the old days, they simply would have referred to his condition as a nervous break-down. They got that right. His brain is indeed broken. But which part of the brain is broken? That’s what I want to know.

As it turned out, I couldn’t get anterior cingulate cortex (ACC) out of my head. It’s as if my own ACC couldn’t filter out my own speculative obsessions about this individual’s ACC. Screw this psychiatry bullshit, I wanted to scream. Open up the hood, poke around inside, find out what’s wrong, and fix the goddamn thing.

So here I am, late Thanksgiving evening, burping up my afternoon prandial over-indulgences, when I come across a New York Times front page story on psychiatric brain surgery. I’ve previously written stories on this. Guess which part of the brain we’re talking about?

Now my ACC is lighting up like a Christmas tree.

I wake up the next morning only to discover that my fellow blogger Willa Goodfellow has just published a piece on Prozac Monologues, entitled: Thanksgiving and the Anterior Cingulate Cortex.

That’s not the end of the story. Last August, I cited Willa as one of my top six bloggers. In my review, I said: “Let's put it this way: Until I encountered Prozac Monologues, I thought I was the only one who had ever mentioned, anterior cingulate, in a blog.”

Now my ACC is in Captain Ahab Moby Dick mode:

All that most maddens and torments; all that stirs up the lees of things; all truth with malice in it; all that cracks the sinews and cakes the brain; all the subtle demonisms of life and thought ...

Okay, some basics:

The ACC is part of the cingulate cortex, which snakes beneath the brain’s outer cortices. The region has more specialized functions across different areas than a world religion has schisms and heresies and sects, but the simple version is that the ACC plays a major role in modulating the two-way traffic between the brain’s limbic and cortical regions. It is also wired into other circuits known as "cortico-striatal-thalamic-cortical loops," which has to do with filtering out irrelevant thoughts and emotions and sensory inputs, thus allowing us to focus on the relevant ones.

Significantly, anterior cingulate malfunction has been implicated in all manner of mental illnesses, from depression and bipolar to ADD to OCD to schizophrenia. On a most elemental level, when the brain is unable to filter out the overload, the “I” that is supposed to be in charge is overwhelmed and can’t cope. For instance, in OCD the brain literally locks onto one thought and can’t let it go.

So here was the person close to me, obsessed on fearful end-of-the-world thoughts, depressively ruminating to the point of psychosis or near psychosis, and totally lacking the ability to make a rational assessment of his present and plan his future. It had to be the ACC.

Ha! If only life were so simple. In a review article in “Psychiatry,” Dhwani Shah MD of the University of Pennsylvania et al point out that “psychiatric syndromes cannot be localized in a single, so-called ‘abnormal’ brain region.” Rather, “mood and anxiety disorders involve immensely complex interconnected systems or networks of organization within the brain.”

Take my depression - please! The authors are quick to point out that the causes of depression are complex and only partly understood. Nevertheless, a picture is beginning to emerge of interconnecting brain systems in a state of stress-induced collapse. The technical term is allostatic overload, which is what happens when a highly complex and self-regulating system such as the brain fails to maintain homeostasis (equilibrium).

As Shah et al describe it, the brain circuitry involved in depression is grouped into three main components: cortical (appearing to give rise to the psychomotor and cognitive aspects of depression), subcortical (involving the affective aspect of depression, including anhedonia and sadness), and modulatory (regulating two-way cortical-limbic traffic, including stress and hormonal pathways).

Okay, here’s where it gets interesting. Brain systems may be infinitely and infernally complex, but we are beginning to see the merit in zeroing in on specific strategic targets (or “nodes”) in experimental surgical interventions. Significantly, for OCD and depression, that target is the ACC (more specifically for depression, the subgenual anterior cingulate corresponding to Brodmann area 25).

Lest we create a false impression, psychosurgery is almost certainly not the future of psychiatry. But it is simply impossible to imagine a different tomorrow without coming to grips with how a surgical technique of last resort is changing how we look at mental illness.

Trust me, things are changing.

To be continued ...

I Talk to the Real Experts About Depression (That's You)

From my keynote to the Kansas State DBSA conference in late April ...

Okay. This is going to look like I’m going off on a tangent, but the Yellow Brick Road zig-zags, so bear with me. We’re here, in Kansas, at a DBSA conference. Which means just about all of us here have experienced depression. So - can anyone here give me a one-sentence description for depression?

It sucks.

[More answers ...]

A deep dark hole.

Like having two doberman pinschers waiting for you to get out of bed in the morning. You aren't going anywhere.

It's like you're worthless.

You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.

It's like trying to walk through mud up to your neck.

And I've got some insights on Kansas mud. Cuz I talk to my mud. I live in southern California where the soil is loose and sandy, and if you get it on your pants and shoes you just go - choot-choot-choot. So three days later, I see some mud from three days ago on my pants, and it's like, "C'mon, mud." And the mud talks back to me - just like skunks - and says, "oh yeh, you people on the left coast, you who eat panini, where do you think the flour from the wheat of that panini comes from? You treat me with respect, and next time you talk to me you address me as sir."

So, that's Kansas mud.

When I'm depressed, I get agitated and angry a lot. I used to joke - because I only got my driver's license two years ago after not driving for 30 years - I get road rage a lot and I don't even drive. Some of you feel like that with your depressions? Okay ...

I just don't want to be here anymore.

I told my doctor a while back, I'm not suicidal; I'm homicidal.

That's me. That's why I'm proud to be crazy. Seriously, I hate these politically correct people who want to take crazy away from me, because that's how I choose to describe myself. Anyway ...

I think especially for a lot of guys, it's withdrawal and grouchiness.

Another one - lack of motivation, total apathy. Okay, we've got a pretty good list here. Now, how many have heard of the DSM, the DSM-IV? Unanimous consent there. Great. Now, as you know, the DSM is a piece of fiction put out by the American Psychiatric Association ... We got a consensus on that.

As you may recall, there is the world famous symptom list. You know, five of nine symptoms. But first, you have to have one of two, okay? So get this - I'm going to read this out - here’s number one, for depression:

“Depressed mood most of the day.”

I'm trying to figure the logic here. Describe depression to me. Depression is - depressed mood most of the day.

Have you ever tried to describe what carrots taste like to someone who hasn't had carrots? Oh, carrots, you know, carrots - they taste like carrots.

Right, that really tells me a lot. I’m depressed. And I’m depressed because - I’m depressed. But what is my state of mind? What are my feelings? What are my emotions? What are my moods?

Well, the DSM does give the example in "depressed most of the day" of feeling sad. But I’m going to put this to the best experts in the world, which is you guys. Does depression equal sad? I mean we've listened to all these other symptoms ... Right.

Well, maybe the other symptoms can help us out. The other one of that "one of two" is loss of pleasure. We're kind of getting there a little bit, but here's four of them in a row:

Weight loss or weight gain. Oh, great, so everyone who goes to Weight Watchers is depressed. 

Insomnia or hypersomnia. That’s not telling us much. Let’s try the next one: Psychomotor agitation. So we walk funny.

What the ...

We’re not through. Fatigue or loss of energy. You get tired at two o'clock. Big deal.

I’m no expert. I’m a patient just like you. But I do know how to count. So we've got nine symptoms on the list, and make that eight because that first one is just too ridiculous for words. So, we've got eight symptoms, and we only need five to cross the diagnostic threshold for a diagnosis.

And four symptoms are physical. We eat too much or too little. Same with sleep. We walk funny. We get tired. Fine fine fine. So does the entire rest of the human race. Tell us something different.

Tell us what friggin’ state our minds are in. Tell us our thoughts, feelings, and emotions.

No wonder no one can help us. No one has even bothered to open up the hood and look in.

So, get this. You people here - turning out on a Saturday, in Kansas - do you want to read out the list here?

It sucks. Deep dark hole. Like two doberman pinschers waiting for you to get out of bed in the morning. You're worthless. On a raft in the middle of the ocean, not going anywhere, totally becalmed. Like walking in mud up to your neck. Just don't want to be here any more. I'm not suicidal, I'm homicidal. Withdrawal and grouchiness.

Is that a better list than the DSM list? Congratulations - you guys have beat the best psychiatrists in the world. Give yourselves a round of applause, here.

I Come Clean About My Driving

As I explained in a previous blog post, the Q and A's are by far the most interesting part of any talk I present. After a keynote I delivered at the Kansas State DBSA in late April, a woman asked me:

What was the life change that you went from 30 years of not driving to getting a driver's license?

"New Zealand," I replied. Then I explained:

I used to drive a cab in the United States. But everybody in New Zealand drove on the wrong side of the road and they wouldn't make an exception for me. I wanted to say, "but I'm American" - no, I had to follow the rules. This linear stuff, again.

And then I had a wife who would go, "reeep, reep-reep," so I'd go, "right, you drive." Fortunately, I lived in urban areas most of the time in New Zealand and Australia, and I just got out of the habit. When I finally moved into the mountains of southern California, it's like - okay, I really have to get a license. Because it's like being up on the Donner Pass in the winter time. Just even to go get mouthwash was a major expedition.

So - I flunked the driver's test the first time. I went through a red light. The panic responses with my second one - but the guy took pity on me.

People were telling me, "this is like riding a bike." Well, I was never good at riding a bike, either. And, "it will all come back to you." Guess what, it didn't. This gave me some new insights into the brain. It was like, these neurons aren't being used. All that muscle memory - whatever they call it - I guess they recruited the neurons for something else.

Because I sure as hell didn't remember anything about driving.

But, finally, yeh, I got a license and they just put out a red alert every time I go out on the road.

Is "Crazy" Appropriate? Yes, You Say.

What's in a name? queried The Bard. The rose was the object of his discussion, but here we're talking crazy. Throughout May, on Knowledge is Necessity, I ran a reader poll. The question was simple:

Crazy: Your Take.

57 readers responded. Of these, a quarter of you (14) replied that "the term is highly stigmatic." This was the smallest group in the survey. A much larger group, more than four in ten (25) let me know that "it's better to be crazy than an asshole," while three in ten (18) informed me, "screw being PC. You should see me when I'm crazy."

The major surprise was that to the overwhelming majority of you, the C-word does not equate to the N-word. Or maybe it does to a lot of you but only some of the time. It's all about context, and had I provided the option my guess is a lot of you would have checked off all three answers.

I for one lean strongly on the side of "screw being PC." I have also used the phrase in conversation, "better to be crazy than an asshole." But I'm also on record as having rebuked Oprah in a blog for inappropriate use of the term.

A time and a place for everything. When someone uses the term to differentiate us vs them, I would say that "crazy" is entirely inappropriate. But it's not the word that's offensive to me; it's the hate and ignorance behind the word. "Isosceles triangle" applied with the same venom or lack of regard would be equally repugnant.

"Crazy" is also a matter of perspective. A brilliant idea of mine, for instance, might be viewed by others as crazy. Sometimes they're right. But often they fail to see over their limited horizons. Nevertheless, on occasion, I have been known to sail off the edge of the world. Call me crazy.

One twist to this is there are occasions when crazy is normal. Our brains were built to over-react to abnormal situations. Even "normal" people are entitled to go crazy every once in a while. Sometimes, though, our behavior is just plain - well - crazy. Got a better word for it?

My diagnosis happens to be bipolar, which I interpret to mean that I am prone to crazy behavior if I'm not careful. In this sense, crazy is not part of the true me. I'm basically a decent person, thank God, not an asshole.

But in another sense, crazy is the true me, the good and the bad. It is part of my "normal" behavior. The "good" crazy (my creativity, sense of humor, etc) I take pride in, but I also have to come to terms with my "bad" crazy. It's hardly the only word by which I choose to define myself, but it is one of the words. So screw the PC thought police. They are not going to take away my identity. They are not going to choose how I am supposed to define myself.

So, like most of you, I do not object to the word crazy. In fact, I would prefer people call me crazy. What really gets my goat is when people refer to me by clinical terms. I used to hear "grandiose" back in the old days. This was when I was a nobody with the crazy idea of making a living writing about my illness. Once, of course, I became a somebody (with a book and a major international award), I had to be a "narcissist" (or "arrogant" to people who couldn't spell narcissist). With certain people, you just can't win.

"Hypomanic" is sometimes fine with me, but the term is frequently misapplied to those of us who are simply in a very good mood (or the flip side, justifiably angry). I once emailed a friend with fantastic personal news. Instead of congratulating me, she cautioned that I was hypomanic. Well 'scuse me for breathing. I didn't realize being happy was a diagnosis.

I trust, judging by your responses, we're mostly in accord here. The C-word does not equate to the N-word, but there are certain situations when it can. Certainly there are far more insulting words (such as misapplied clinical terms). Maybe we're not thoroughly comfortable with being called crazy, but we know it's a lot better than having to deal with being an asshole or worse.

In the final analysis, the real answer is taking the time to listen to one other, taking the trouble to get to know each other. Then the correct words follow. "Crazy" may be one of them.

Homer's Iliad: Grief, Rage, and Fate

A good friend of mine recently started up a support group we call "A Spiritual Conversation About Mental Illness." At my first meeting, one of the members happened to bring up Old English poetry. The bleak times, he explained, set new standards for the expression of what can best be described as fatalistic lament.

I whipped out my iPhone, and on Wikipedia found this verse circa 991 AD:

Thought shall be the harder, the heart the keener, courage the greater, as our strength lessens.
Here lies our leader all cut down, the valiant man in the dust;
always may he mourn who now thinks to turn away from this warplay.
I am old, I will not go away, but I plan to lie down by the side of my lord, by the man so dearly loved.

I couldn't help but think of Homer's Iliad, the product of a no less fatalistic age:

"Rage - Sing, goddess, the rage ..." begins the epic.

It's nine years into the Siege of Troy. The Greeks (Achaeans) have been driven back to their ships, but Achilles Son of Peleus is sulking in his tent, refusing to fight. Finally, he consents to his dearest friend Patroclus going into battle in his stead, outfitted in his armor. Patroclus is predictably killed (and stripped of his armor) by the Trojan commander Hector, son of Priam King of Troy. On hearing the news (from the Rieu translation), Achilles ...

... picked up the dark dust in both his hands and poured it on his head. He soiled his comely face with it, and filthy ashes settled on his scented tunic. He cast himself on the earth and lay there like a fallen giant, fouling his hair and tearing it out with his own hands.

Thus sets the scene for the greatest temper tantrum in all of literature. Clad in splendid new armor conveniently forged by the god Hephaestus, Achilles sets out on his own rendezvous with destiny. To exact his revenge will seal his own fate, maybe not today, but very soon. The gods have already determined this. Achilles is fully cognizant of this fact, but such is his grief and rage that even his goddess mother Thetis realizes there is no stopping her son.

We pick up on the action, in progress:

Thus Achilles ran amok with his spear, like a driving wind that whirls the flames this way and that way ... He chased his victims with the fury of a fiend, and the earth was dark with blood ... And the son of Peleus pressed on in search of glory, bespattering his unconquerable hands with gore.

Such is the force of his rage that he does battle with the river God Xanthus and vents his spleen in a face-to-face encounter with the God Apollo, who has been lending a divine assist to the Trojans: "Much as I should like to pay you out, if only I had the power."

Finally, he gets his chance to take out his anger on Hector:

"Lions do not come to terms with men, nor does the wolf see eye to eye with the lamb - they are enemies to the end," taking care to deliver an exclamation point with a spear through the neck. "So now the dogs will maul and mangle you ..."

It's not over. Achilles strips Hector of his armor (actually Achilles' original armor that Hector had stripped from Patroclus) and lashes his body by the feet to his chariot and "with a touch of the whip started his horses."

Priam and his wife Hecube witness the spectacle from the walls, but no one informs Hector's wife, Andromache, who is in her chambers awaiting her husband's return. The sound of laments from nearby draws her outside, just in time to witness her loved one's body being drawn toward the Achaean lines.

For the next nine days, Achilles drags Hector's body around Patroclus' funeral bier. Finally, the god Hermes persuades Achilles to allow Priam to bring his son's body back for a proper funeral. Thus ...

Dawn came once more, lighting the East with rosy hands, and saw people flock together at illustrious Hector's pyre ... Then they collected his white bones, lamenting as they worked, with many a big tear running down their cheeks. They took the bones, wrapped them in soft purple cloths and put them in a golden chest ...

Homer ends his account with:

"Such were the funeral rites for Hector, tamer of horses."

Hoarding: Very Serious, Very Unrecognized

I've spent the last few weeks moving my stuff out of my old place and into my new one. Correction: A good deal of it wound up in the dumpster and a lot more will be donated to a yard sale event.

Coincidentally, in the middle of coordinating my move (which included acquiring a lot of new stuff), I attended a one-day seminar on Mental Health and Aging put on by NAMI San Diego and The Senior Mental Health Partnership. First talk of the day was on hoarding.

Much to my relief, I learned that I was an unmitigated slob, not a hoarder. As Catherine Ayers of UCSD explained, hoarding does not equate with messiness. Rather, I am merely too lazy to throw away my old things rather than being driven by an obsessive need to hold on to them. Someday there may be a DSM diagnosis for people like me, but not yet.

According to Dr Ayers, individuals who hoard have a distorted belief about the importance of a possession (such as a discarded water bottle) combined with an obsessional fear of losing that possession. The hoarding interferes with the individual's ability to use their home.

Accounts of individuals literally buried alive beneath domestic clutter may come across as comic, but the reality borders on tragedy. As Dr Ayers explained, 45 percent of older people who hoard could not gain access to the fridge and 10 percent could not use the toilet. Getting from one area of the house to the other typically involves negotiating labyrinthine (and often treacherous) "goat trails."

Hoarding is fairly common, accounting for 5.3 percent of the population. Hoarders are typically female, unmarried, and living alone. Never having been married is associated with greatest impairment. Hoarding tends to start in the 30s, with the severity increasing over time. Eighty-four percent of those who hoard have a first degree relative of similar disposition.

Behavior may include indecisiveness, perfectionism, procrastinating, difficulty organizing tasks, and avoidance. Dr Ayers also mentioned an abnormal desire to take control and exercise responsibility. She mentioned one individual who took it upon herself to tape NPR. Her home contained 500,000 tapes.

Three out of four hoarders shop too much, but a real danger, Dr Ayers pointed out, is from stuff that comes into the house, such as mail. Hoarded items tend not to be of high value, such as paper. Since it takes time to go through paper, that paper is not going anywhere.

The illness is attributed to a deficiency in informational processing, though not necessarily in older adults. Older adults may have good neuro-cognitive function, but may be deficient in other areas. Hoarding is listed as a symptom of OCD, but brain scans reveal a different pattern. The draft DSM-5 is proposing the new diagnosis of "hoarding disorder."

Unfortunately, Dr Ayers explained, hoarders don't go to doctors' offices seeking help. Having someone else clean out the place is only a temporary fix, as hoarders go right back to their old ways. SSRIs may help, and cognitive-behavioral therapy aimed at addressing hoarding behavior is in its infancy. Dr Ayers suggested that intensive outpatient therapy seems to be the most effective treatment, with a focus on getting the patient to decide on every item.

For more info:
http://www.ocfoundation.org/hoarding/