Friday, December 31, 2010

Rerun: My Brilliant Shopping Experience

From Dec last year ...

An encounter I had in a market last week affords a textbook example of how to handle a stranger obviously dealing with some kind of psychiatric condition:

I was picking up items for a Thanksgiving feast, plus other odds and ends. Into the basket went olive oil, plus carefully-selected avocados, then onions. Then I temporarily abandoned my cart as I made a run for other produce - asparagus, salad greens ...

I started dumping the stuff back in my cart, when a lady informed me it was her cart. Sorry, my mistake, I was about to respond. Then I saw my olive oil and avocados and onions sitting exactly where I had put them. I looked at her in askance.

These are mine, she insisted, pointing to the items.

No use arguing, I decided, as I politely disengaged. I dumped my stuff into a new cart and quickly restocked. Okay, avocados are never quick. The person I was shopping with came over. I recounted what happened, then let him know it is never wise to get into an argument with someone who is clearly not rational.

It's best to walk away from the situation, I explained. If you can't walk away, you make sure you do nothing to set off the individual, I continued. I'm not a mental health professional, but my work and volunteer work has given me some experience. Anyway, it was no big deal. Okay, it would have been a big deal had those avocados in my cart been the only ones in the store ready to eat, but you get the picture.

Obviously this person wasn't behaving rationally. No question about it.

Time to return to why I was here: I'd forgotten fresh cranberries. I dashed away from my cart on a mission of search and retrieve. There, close to my quarry, was an abandoned cart. Curious, I checked the contents:

Olive oil, avocados, onions ...

Thursday, December 30, 2010

Rerun: My Augustine Depression

From this time of year, last year. Still highly relevant ...

A couple of nights ago, I felt myself slide into what I call my Augustine of Hippo depression. Imagine waking up one fine day in 410 AD, only to discover that Alaric the Visigoth has sacked Rome, thereby launching the Dark Ages and making stupidity fashionable. That’s kind of what happened to me one bleak and miserable November evening of 2004 when I returned home thinking I had fired the President, only to discover the very opposite had occurred.

This couldn’t be happening, I could only think. Not in a civilized society.

Augustine’s resulting meditative funk led to “City of God,” mine to “Living Well With Depression and Bipolar Disorder.” Okay, I’m no Augustine - don’t make me any more depressed than I am.

What happened the other night was more of a mini-Augustine depression. I turned on the TV only to discover that the asshole Joe Lieberman had succeeded in forcing both the Senate majority and the Administration to roll over and play dead for him. Real universal healthcare was off the table. In its place was a government hand-out to the insurance industry masquerading as reform.

End of civilization, I decided.

I have a tendency to get carried away. Bear with me ...

This year, the Wilkins Ice Shelf (a whole friggin’ ice shelf!) up and collapsed on us. Earlier, the entire world economic system nearly did the same. What next? A killer comet named after Lieberman?

We know the Roman Empire was in a state of decline long before Alaric and his fellow barbarians dealt the coup de grace. In the third century, the Empire suffered an economic collapse from which it never recovered, resulting in profound changes that set the scene for anarchy, serfdom, and ignorance. Significantly, the middle classes all but disappeared. Thomas Cahill in “How the Irish Saved Civilization” even notes the poetry got bad. More important, as the end drew near, education had virtually vanished. The culture of stupid was fully locked in place.

It’s way too soon to tell whether today’s US equates to the Rome of the third century. Having said that, our culture of stupid is a major worry. Can you name three celebrity airheads with relationship difficulties? Easy. Can you name two Nobel Laureates this year besides Obama? Don’t worry. Neither can I.

A bad economy or a fragile environment is only a crisis if we place no value on the brain power we need to think our way through these situations. But we can't even figure out health care. We've ceded sovereignty to the idiots. Are we really that stupid? Now I’m starting to get worried ... 

Wednesday, December 29, 2010

Quick Update

I'm working on a complete overhaul of mcmanweb. Being self-employed, my prick of a boss wants it done right now, no excuses, but my genius employee takes three days to figure out what my one-year-old grandson can figure out in three seconds. Oy!

Anyway, this means blog reruns over the next week. Don't worry, reading something twice won't kill you. Okay, some people, maybe. Well, actually, the odds are about the same as driving blindfolded, but don't let that worry you. Yes, reading things twice encourages people to think, and we all know how dangerous thinking is, which is why people choose instead to vote Republican and fall in love and other incredibly stupid things. Oy!

Take a look at the name of this blog, and you will appreciate what we're all up against.

Enough already! Have fun. Talk amongst yourselves. See you soon ...

Friday, December 24, 2010

A Christmas Poem

Twas the night before Christmas, when all through the place
Not a thought was racing, not even a trace;
The meds were all stashed, in the cabinet with care;
A warning to my neurons, behave and beware.

When out on the lawn there arose such a clatter,
Something bad was going down, something was the matter.
Away to the window I flew like a flash,
Oh crap, not again, not another stupid crash.

When what to my wandering brain should appear,
A dude in a sleigh with eight friggin’ reindeer.
Now Dasher! now Dancer! Please tell me I’m dreaming!
On Comet! on Cupid! Time to start screaming!

To the front of the porch! up against the wall!
Get 911 here right now, I’m headed for a fall.
A vision in my head, a harbinger of doom,
Now dash away! dash away! To the emergency room!

He was dressed all in rags, from his head to his foot,
And his clothes were all tarnished in ashes and soot.
He came through the sliding door, in the back entry;
No way to blame his appearance on a dirty chimney.

A bundle of stuff he had flung on his back,
Like a homeless person, with his life in a sack.
I’m the Ghost of Christmas Present, he said in my home.
Dude, I replied, you got the wrong poem.

His eyes - they were hollow, his skin a sickly yellow.
His mouth it trembled, like a defeated fellow;
A stump of a smoke he held tight in his teeth,
Looked like he hadn’t eaten anything in a week.

My old lady was upstairs, zonked out on her meds;
My kids were in the next room, asleep in their beds.
Only one thing to do, very plain to see,
Time to call 911, protect my family.

I put down the phone, in spite of myself,
Something in my brain, maybe an elf.
Set yourself down, I said, You’re in the right poem,
I’ll see what’s in the fridge, make yourself at home.

His eyes how they twinkled! His dimples how merry!
You got that part right, he told me, very very very!
No matter how much we have, how much we own,
We’re all of us homeless, till we find the right poem.

And laying a finger, alongside of his ear,
And, giving a nod, he was no longer here.
Was it a dream? Was it psychosis?
Does my doc need to up my meds, on even higher doses?

But the feeling was real, a peace I had never known;
I was in the right place, in the right poem.
And I heard him exclaim, in a voice that was my own,
“Check what’s inside the fridge. You have found yourself a home.”


First posted on HealthCentral two years ago. A happy - and giving - holidays to all. Today marks the second anniversary of my blog. Many thanks to all of you who entered my virtual home strangers and stayed as friends.

Wednesday, December 22, 2010

The Year That Was - Almost Over, But Not Letting Go: Part II

My second (first here) idiosyncratic installment in looking back on how 2010 unfolded:

Old Movie of the Year: Groundhog Day

Updating the DSM is an exercise that affords us that rare opportunity to think mental illness afresh. The last time this happened was in the late seventies with the publication of the ground-breaking DSM-III of 1980. Think of the DSM-III as the old DOS operating system. Its successor editions (the last one was 1994) were essentially DOS updates. In Feb this year, the American Psychiatric Association unveiled its draft to DOS-5 - um DSM-5 - due for publication in 20013.

In sticking to DOS, as I reported here on numerous occasions, those responsible for the next DSM - which sets the scene for the next 20 years - are keeping us stuck in 1980 Groundhog Day forever.

If nothing else, a soul-searching discussion would have been useful. Hell, I would have settled for an instant message. An instant message where numerals pose as words, even. Is this asking too much? Yes, apparently.

Psychiatrist of the Year: Emil Kraepelin

Okay, he’s sort of dead - well, completely dead - which is a rather large technically. But even dead, this guy leaves the live psychiatrists for dead. (Wait, let me rephrase that.) Kraepelin, who was born the same year as Freud, coined the term, manic-depression, which - contrary to conventional thinking - is not synonymous with bipolar.

Kraepelin saw all forms of depression (even unipolar depression) in an obvious relationship with clear overlap. This translates into a lot of unipolar depressions behaving like bipolar, even if mania is not involved. This may also explain why antidepressants do not work for a good many people, and may indeed be harmful. The DSM-III of 1980 can be forgiven for getting this wrong. The DSM-5, due out in 2013, cannot.

No doubt about it: If we could somehow “undead” Kraepelin, he’d be saying take a match to the DSM and start over. Instant message: "G8 stuff, homey! All 4U! :) :)"

Person of the Year: You

That’s right, you - patients and loved ones. In April this year, I delivered a keynote to DBSA Kansas. As part of my talk, I asked my audience to come up with a one-sentence description of depression. The answers bore some relationship to the DSM, but were much more insightful and in touch with reality:

“Like having two doberman pinschers waiting for you to get out of bed in the morning.”

“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.”

These were just some of the responses, very much in line from what I have been hearing from fellow patients and loved ones for years. But then again, only we know what we have to live though. Too bad psychiatry isn’t interested in hearing from us. “Is that a better list than the DSM list?” I asked my audience. “Congratulations,” I concluded, “you guys have beat the best psychiatrists in the world. Give yourselves a round of applause.”

More to come ...

Monday, December 20, 2010

The Year That Was - Almost Over, But Not Letting Go

This is the time of the year for looking back, a la Time Magazine and CNN. Following is the first installment in my personal (and highly idiosyncratic) view on how the year unfolded:

Historical Person of the Year: Genghis Khan.

It turned out my first piece of the year just happened to mention this much-maligned conqueror. His name came up in the context of traditional societies, where people have far less mental illness and recover far more quickly than those forced to cope with the demands of modern living. We can debate forever about the hows and whys until the cows come home. We did just that over the course of the year.

Nevertheless, Genghis Khan reminds us that even people living back in simpler times had cause to be stressed, which kept the discussion honest.

Later in the year, I devoted an entire piece to the man who made Alexander the Great look like a pussy. In his wake, things were never the same, which offered an excellent object lesson on thinking outside the box and paradigm change - my other major theme of 2010. Clearly, the prevailing biological psychiatry paradigm of mental illness is under threat - from its own shortcomings, from new advances in brain science, and from a growing consumer-led recovery movement. New explanations are needed.

Bottom line: In two different thematic approaches to rethinking mental illness, Genghis Khan was there.

Historical Person of the Year, Runner-Up: JFK

“We enjoy the comfort of opinion without the discomfort of thought,” our 35th President said in 1962. He could have been talking about today. Is Republicanism the New Stupid? I questioned in one blog. (Short answer: Yes, but that doesn’t mean Democrats are smart.) In numerous pieces, JFK served as the pin that punctured the fallacy that our choices are based on reason. Whether we are voting for a political candidate or buying a product or choosing a mate, new research is revealing that the thinking parts of the brain cannot make a decision without input from the primitive limbic regions. Our highly-evolved cortical areas, too often, seem to serve no other purpose than to rationalize our emotional reactions.

Kennedy had an undeniable emotional appeal, but of all things the televised 1960 Presidential debates reveal the man’s appeal to our higher reason. “What piece of work is man?” Some surprising answers are revealed by gazing into that distant mirror.

No doubt about it, Kennedy is there.

Fictional Person of the Year: Hamlet

I have of late - but wherefore I know not - lost all my mirth, forgone all custom of exercises; and indeed it goes so heavily with my disposition that this goodly frame, the earth seems to me a sterile promontory …

What is depression, anyway? Feeling sad? Lack of motivation? Psychic numbing? Is it a “normal” reaction to abnormal events or an abnormal reaction to normal events? A loss of energy or a mammalian need to hibernate? A crisis of the soul? Perhaps it’s even a part of our normal personality. Hamlet did a lot of talking, but scholars still debate the true shade of his “nightly colour.”

Obviously, no two depressions are alike, which makes one wonder why psychiatry treats them as if they were. No wonder we don’t get better. All year, on Knowledge is Necessity, we asked the type of questions that psychiatry needs to be asking. Hopefully, one of these years, psychiatry will begin to do some asking of its own.

In the meantime, Ham-o-let is there.

Fictional Work of the Year: The Draft DSM-5

As those of you who read this blog are aware, the DSM-IV bears little semblance to clinical reality. The DSM-5, which is due to come out in 2013, proudly continues in that tradition. In February, the American Psychiatric Association unveiled its draft, which amounted to (with the notable exception of personality disorders) a reissue of the DSM-III of 1980, replete nearly word-for-word with its antiquated and highly misleading symptom checklists.

This definition of depression, vintage 1980: “Depressed mood most of the day.”


I could go on and on. For most of the year, I did. But who listens to me?
The DSM, the DSM, there's nothing like the DSM
It’s a text in medical shape
An illusion of authority
You may read it in a by-street
You may consult it in the square
But when we need an answer, the DSM’s not there!

Much more to come ...

Sunday, December 19, 2010

Personality Disorder: Understanding Dimensionality

The story so far: The DSM-5, due out in 2013, will be the same old book in new covers. The exception is personality disorders, which gets a major overhaul. Not coincidentally, this is the one realm of mental illness where big pharma is conspicuously absent.

My last two blog pieces - Decisions, Decisions, and Bringing Order - looked at the changes on the “categorical” side of personality disorders. Five out of ten of the present disorders will get the boot, while the five left standing (antisocial/psychopathy, avoidant, borderline, obsessive-compulsive, and schizotypy) receive further clarification. The weakness with categories is inevitable overlap, but rather then pretending this doesn’t exist, the DSM-5 openly adopts interchangeable parts, with six “trait domains” (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) further subdivided into “facets.”

Thus, the new borderline “type” (which replaces the term “disorder”) is loaded with six negative emotionality trait domains and two antagonism domains, while the new antisocial/psychopathy type is heavy on antagonism (six in all) and light on negative emotionality (zero, in fact). The two borderline antagonism facets (hostility and aggression) reappear word-for-word in antipsychocial/psychotic.

Kind of like IKEA. The parts may be the same, but each piece of furniture - one hopes - is very different. So what would happen if we were to dispose of the concept of furniture altogether? Funny you asked.

Enter the “dimensional” model. The same bits and pieces are there - namely the general trait domains of negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy, plus the more specific facets - but instead of looking for labels, we are looking for shadings. Instead of asking “Which one?” (as in borderline or antisocial) we are asking “How many?” and “How much?”

The DSM-5 trait domains are derivative of, and roughly correspond to, the traits in the five-factor model (FFM), already in wide use in clinical practice. The FFM tests for “openness to experience”, “conscientiousness”, “extraversion”, “agreeableness”, and “neuroticism” (OCEAN).

A quick scan, however, reveals that the FFM and DSM-5 investigate essentially the same phenomenon from entirely different viewpoints (“extraversion” vs “introversion”, “agreeableness” vs “antagonism”, “conscientiousness” vs “disinhibition” and “compulsivity”). Whereas the FFM looks at our potential, the DSM looks at what is holding us back.

A good illustration of this is the FFM’s “openness to experience” trait, which has no apparent correspondence in the DSM-5. The opposite to openness to experience is stuck in the mud, which you can hardly associate with any kind of mental disorder. In this context, stuck in the mud is simply less desirable than being creative and intellectually adventurous.

Now let’s examine the one DSM-5 trait with no seeming FFM counterpart. “Schizotypy” broadly describes strange thinking and behavior. Its opposite? May I suggest stuck in the mud? In other words, in a DSM setting, stuck in the mud comes across as a desirable trait. Certainly, no one calls 911 to complain about their boring wife or husband.

The DSM-5 calls for clinicians to rate all 37 facets which make up the six domains on a four-point scale, which invites the instant criticism of clinical unwieldiness. According to Allen Frances, who chaired the DSM-IV, blogging on Psychology Today:

Unfortunately, the reach of DSM-5 far, far exceeds its grasp. Only by going to the website yourself and reviewing the DSM-5 dimensional suggestions can you get a feel for just how remarkably ad hoc, idiosyncratic, and cumbersome they are. I have discussed the suggestions for dimensional personality disorder ratings with a number of experts (and this is also my area) and none of us could decipher the proposal, much less conceive of its ever being workable. One described it as an example of "too many research cooks spoiling a clinical broth".

Dr Frances’ criticism may well be valid, but it also can be interpreted as an egregious case of DSM-worthy “lazy clinician syndrome.” We see this every day in doctors who profess to be far too busy to monitor their patients for weight and blood sugar levels and other red flags when prescribing meds with notoriously high metabolic risks, not to mention other high crimes and misdemeanors.

Personality is fiendishly time-consuming and complex. Clinicians want it quick and simple. But what about our interests?

Much more to come ...

Previous Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Bringing Order to Personality Disorder

Thursday, December 16, 2010

Bringing Order to Personality Disorder

Yesterday, we inspected the house-cleaning performed by the DSM-5 workgroup charged with bringing order to personality disorder. Unlike the rest of the DSM-5, this particular crew actually rolled up its sleeves and went to work. No mere light dusting for them. Five of ten of the personality disorders got tossed. The remaining five (now referred to as “types” rather than disorders) received a major refurbishing and a sense of congruency.

The grand piano, in effect, has been retuned and refinished and moved from the laundry room to the living room, though questions still remain as to what to do with the moose head now in the dumpster (think narcissism). These are the “categorical” reforms. There is a new element of “dimensionality” which we will get into later. Sticking with categories ...

The old (and still current system) was only useful in sorting out the obvious (such as green from blue) but of very little value where the colors blended (green, for instance, contains blue). An impulsive and angry individual with a skewed view of self and others, for instance, may be a candidate for both borderline and antisocial. Throw in a sense of me-me-me/I-I-I, and the narcissism diagnosis comes into play.

The new (and future) system acknowledges the overlap, but puts the reader on notice that we are not exactly dealing with the same phenomenon. The first thing that sticks out in comparing the new borderline to the new antisocial/psychopathy, for instance, is that the former comes loaded with six “negative emotionality” symptoms and only two “antagonism” ones while the latter is heavily laden with six antagonism symptoms and zero negative emotionality ones.

As for narcissism (may it rest in peace), a number of the old narcissist traits have been  folded into the new antisocial/psychopathy diagnosis. Not one appears in the new borderline diagnosis. Yes, it would be nice to have the narcissism diagnosis back in the picture (and I will be making that case in a future piece), but in this context its absence brings into sharper relief the inflated/lack of sense of self that separates borderline from antisocial.

The DSM-IV bunched the ten personality disorders into three clusters (A, B, and C), but with only five types left to choose from in the DSM-5, there is no sense in retaining these walls of separation. Again, we are dealing with overlap and loading. The new “avoidant,” for instance, contains nearly as many negative emotions as borderline (five in all, two of them the same as borderline) plus five “introverted” ones (such as “intimacy avoidance”) with nothing in the “antagonism” department.

Meanwhile, we know obsessive-compulsive (the personality disorder, not the Axis I diagnosis) and schizotypy are horses of a different color, but nevertheless they do share some of the primary colors across the personality spectrum.

So what are we looking at? According to the DSM-5:

Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.

This harkens back to the Freudian-influenced DSM-I of 1952 and the DSM-II of 1968 when even the likes of schizophrenia were seen as maladaptations to one’s environment. The DSM-5 revives the idea of maladaptation, but dials it back to personality disorders. In other words, personality type is a tip-off to our default protection mechanisms.

Do we, for instance, try to dominate those around us? (Antisocial.) Or do we freak out and lose it? (Borderline.) Or do we withdraw into a comforting cocoon? (Avoidant.) Maybe we look for order where none exists. (Obsessive-compulsive.) Perhaps we harbor unusual perceptions of reality. (Schizotypal.)

We may argue over what else should be there (such as Narcissism), and what more could have been done to clarify the different types, but when all is said and done, we are looking at a greatly improved navigational system.

Meanwhile, we all have personality in abundance and come preloaded with all manner of quirks and flaws. We may be successful adapters, but - trust me - we will all see a bit of ourselves in the DSM looking glass. In this sense, we are likely to get more out the DSM-5 than our clinicians. 

Much more to come ...   

Recent Personality Posts

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Wednesday, December 15, 2010

Personality Disorder: Decisions, Decisions ...

The story so far:

In the one thing those charged with the DSM-5 did right, personality disorders will receive a major overhaul. Five of the ten current personality disorders will be axed and the current “categorical” system will be supplemented by a “dimensional” model.

Let’s look at the categorical reforms. The wisdom of the DSM-5 is readily apparent in relieving clinicians of the agony of having to decide between the likes of “schizotypal” and “schizoid” (schizotypal makes the cut, schizoid gets the axe). Similarly, only those prone to histrionic displays are shedding crocodile tears over the demise of “histrionic,” which is way too easy to confuse with “narcissism,” which will - Wait! What the f...? - you mean narcissism goes too?

Okay, we’ll get to the issue of narcissism later. In the meantime, sayonara, as well, to “paranoid” and “dependent.” And in a Nobel-worthy gesture (medicine or peace, take your pick), the foul and malignant NOS (“personality disorder not otherwise specified”) gets the deep-six. Clinicians will actually have to decide between the disorders left standing ("antisocial/psychopathy", "avoidant", "borderline", "obsessive-compulsive", "schizotypal"). But will they be happy making their choices? Let’s use the new borderline and antisocial/psychopathy as our examples:

The first thing readers will notice in the new borderline diagnosis is a lengthy narrative description of the illness. Thus:

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness.  As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. ...

And so on and so on. The checklist that follows roughly corresponds to the one in the DSM-IV, but looks a lot different. The following, for instance, is symptom #6 from the old checklist:

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Here’s how that same symptom (#1) in its new form will appear:

Negative Emotionality: Emotional Lability
Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

“Negative emotionality” is what the DSM-5 calls a “trait domain,” one of six for the five personality "types". (“Introversion”, “antagonism”, “disinhibition”, “compulsivity”, and “schizotypy” are the others.) Every symptom includes a trait domain, further modified by “trait facets,” such as “emotional lability.”

Borderline comes heavily loaded with negative emotionality, six symptoms of 10 in all involving, besides emotional lability, “self harm”, “separation insecurity”, “anxiousness”, “low self-esteem”, and “depressivity”. There are two “antagonism” domains (with “hostility” and aggression” as facets) to borderline, plus a “disinhibition” domain (“impulsivity” as a facet), and one “schizotypy” domain (with “dissociation proneness” as a facet).

A quick comparison to the new version of antisocial/psychopathic shows a very different loading, with six antagonism traits and zero negative emotionality traits. Right off the bat, clinicians are put on notice that they are dealing with two entirely different species of personality. The narrative highlights the contrast:

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled.  They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.  They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. ...

In addition to hostility and aggression, the antisocial/psychopathic symptom list includes the antagonism traits of “callousness”, “manipulativeness”, “deceitfulness”, and “narcissism”. Intriguingly, hostility and aggression are word-for-word replicas of what appears in the borderline list. But the symptom overlap comes across as deliberate and in context rather than random and coincidental. In other words, in constructing the various categorical diagnoses, we appear to be looking at an ordered modular system with interchangeable parts.

(We see another interchangeable part in antisocial/psychopathy with “disinhibition-impulsivity”, but with the further emphasis of “irresponsibility” and  “recklessness”.)

Here’s where the DSM-5 personality symptom lists radically differ from those in the DSM-IV. Instead of just checking off the relevant symptoms and counting them to arrive at an arbitrary diagnostic threshold (such as five out of nine symptoms), the clinician rates each symptom on a five-point scale, from “very good match” to “no match”. Thus, from a severity perspective, a pair of fives may trump several threes. The current draft offers no magic threshold numbers, which suggests that in making the final call the clinician will be accorded a lot more discretion. Presumably, this works when when the clinician has clear guidelines.

Sounds good in theory.

Much more to come ...

Recent Personality Disorder Blog Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard?

Tuesday, December 14, 2010

Why is Spotting the Personality Disorder So Damned Hard?

In my last piece, Let's Play Spot the Personality Disorder, I posted a quiz asking readers to match the four DSM-IV Cluster B personality disorders (antisocial, borderline, histrionic, narcissistic) to 15 DSM symptoms. Now try matching these DSM descriptions to the same list of disorders:

1 “A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts ...”

2 “A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts ...”

3 “There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years ...”

4 “A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts ...”

Easy, right? Here's the answers:

1 Histrionic, 2 Borderline, 3 Antisocial, 4 Narcissism.

But if this quiz was so easy, why was the last one so difficult? Here’s the explanation. The DSM descriptions are basically assigning colors to various illnesses, much like different houses: Green, blue, yellow, orange. The symptoms are the paint, and here we run into problems. Green is a combination of blue and yellow, yellow is present in three of the paints, and all use white as a base (I won’t even get into the issue of the various tints).

Thus, for example, these two interchangeable symptoms (antisocial and borderline, respectively):
  • "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."
  • "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."
It gets worse. The DSM-IV symptom checklist for narcissism mentions nothing about anger or aggression, but a review of the literature brings up the phenomenon of “narcissistic rage” (against those who poke holes in their ego).

Obviously, the narcissist is living in a world of self-delusion (“believes that he or she is ‘special’ and unique”), but so is someone living with borderline (“identity disturbance”, “alternating between extremes of idealization and devaluation”), and histrionic (“considers relationships to be more intimate than they actually are”). Likewise, further reading reveals that those with antisocial have difficulty separating out fantasy from reality.

Here, we’re looking at the white paint of a fundamental failure in perception, of people living in universes of their own imaginations, with highly distorted views of themselves and the people around them. Something is obviously not processing right in the cortical areas of the brain.

Then there is all the blue and yellow paint from the emotional areas:

“Impulsivity in at least two areas” (borderline), “impulsivity or failure to plan ahead” (antisocial), “uncomfortable in situations ...” (histrionic), “often envious of others” (narcissistic).

So, failure in perception meets runaway emotion. Or, it could be a deficit of emotion:

“Shallow expression of emotion” (histrionic), “chronic feelings of emptiness” (borderline),  “lack of remorse, as indicated by being indifferent ...” (antisocial), “lacks empathy” (narcissistic).

Either way you look at it, we’re talking about an emotional thermostat set way too high or too low, or one that’s simply on the fritz. Thus, faulty perception meets unregulated emotion. Worlds collide, strange behavior happens. In a reasonably operational brain, the thinking areas pick up that something is amiss, and we work at changing our behavior. But here we’re dealing with “a pervasive pattern” rather than a mere episode, which puts us back in the realm of faulty perception. Again and again, the individual fails to come to terms with his or her thoughts and actions. Thus:

“Preoccupied with fantasies ...” (narcissistic), “rationalizing having hurt ...” (antisocial), “Is suggestible” (histrionic), “paranoid ideation” (borderline).

Avoid these people like the plague, you think. Not so fast. If you happen to believe that the narcissist in your presence walks on water, then the two of you will get along just fine - until, perhaps, you start noticing that your new boon companion is wearing wet clothes.

Conversely, someone with borderline may think it is you who walks on water (and who are you to question their good judgment?) - that is, until he or she decides you are really the Antichrist, after all. Meanwhile, who isn’t drawn to a histrionic enchanter or enchantress? - at least until we start thinking with our brains again. And, of course, chances are you will be profusely thanking that very charming (but antisocial!) individual you have just handed over your entire life savings to.

And there you are - the “normal” one in this relationship - left to pick up the pieces, humiliated, mystified, abused, jilted, duped, conned, and perhaps much worse. These people definitely need therapy, but - thanks to them - you may need it more. But where does the therapist start? We may know a “classic” narcissist or borderline when we see one, but personality - much less life - is never that simple.

Diagnostic psychiatry can no more explain the reality of personality than theology can explain God. At best, psychiatry (and theology) can come up with an approximation of reality, based on what we know at the time. Clearly, a better approximation is needed. The people working on the DSM-5 recognized that, too.

Much more to come ...

Let's Play Spot the Personality Disorder

In a recent blog post, I discussed narcissism in the context of its proposed downsizing from the DSM-5 as a stand-alone “categorical” diagnosis to one of many “core impairments” in a dimensional schema of “personality functioning.” Personality is complex, and clinicians have a hell of a time trying to sort out what is going on. To give you an idea, I have prepared a little quiz:

Following are symptoms taken from the four DSM-IV “Cluster B” personality disorders: Antisocial, Borderline, Histrionic, Narcissistic.  See if you can match the symptom to the disorder. Answers and commentary further down:

1 "Is uncomfortable in situations in which he or she is not the center of attention."

2 "Requires excessive admiration."

3 "Impulsivity or failure to plan ahead."

4 "Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)."

5 "A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation."

6 "Considers relationships to be more intimate than they actually are."

7 "Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another."

8 "Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others."

9 "Displays rapidly shifting and shallow expression of emotions."

10 "Identity disturbance: markedly and persistently unstable self image or sense of self."

11 "Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations."

12 "Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations."

13 "Shows arrogant, haughty behaviors or attitudes."

14 "Irritability and aggressiveness, as indicated by repeated physical fights or assaults."

15 "Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."


1 Histrionic

2 Narcissistic

3 Antisocial

4 Borderline

5 Borderline

6 Histrionic

7 Antisocial

8 Narcissistic

9 Histrionic

10 Borderline

11 Narcissistic

12 Antisocial

13 Narcissistic

14 Antisocial

15 Borderline


I think you get the point. Namely, we have a preponderance of overlapping symptoms that defy easy categorization. Yes, we all sort of know what a narcissist is, for instance, but some of the features are strikingly close to histrionic and borderline, which in turn appears to be the female twin of the more male antisocial, which yet in turn can be difficult to distinguish in certain respects from narcissism. Enough, already!

I’d be interested in how well or how badly you fared, and other sundry opinions. Please give me feedback in the comments below. Confession: In the course of assembling this quiz, I couldn’t keep track of the correct answers, myself. I was obliged to keep rechecking and rechecking again ... and again.

Obviously, we need a lot more clarity in the next DSM. But will the new dimensional system only result in far more confusion?

Much more to come ...

Sunday, December 12, 2010

Rerun: A Darwin Appreciation

In light of last week's photo essay on my surreal visit to the Creation Museum just outside San Diego and my follow-up post, I thought it was appropriate to rerun another photo essay from last year, also based on museum visits. Sanity rules ...

On two recent separate visits, I stopped in at two museums in San Diego's magnificent museum-botanical complex at Balboa Park. The permanent displays in both the Museum of Man and the Natural History Museum attest to the genius of Darwin and his theory of evolution, which is the only credible explanation to connect all the apparently random cool stuff in both buildings - from dinosaur skeletons to mysterious fossils to evidence of lost civilizations.

In celebration of the bicentenary of his birth (the same day as Lincoln) and the 150th anniversary of the publication of his seminal "On the Origin of the Species," the Natural History Museum is featuring a special Darwin exhibit. 

This photo essay - taken on my iPhone - is drawn from my museum trips.

These guys ruled. You are looking at the fossils of ammonites, which superficially resembled the nautilus but were closer in relation to the octopus and squid. They survived two major earth-shaking catastrophes eons apart only to succumb to apparently the same disaster that did in the dinosaurs.

Speaking of dinosaurs, smile for the camera, and thanks for the memories.

For many thousands of years, mastodons thrived in Southern CA. Then global warming happened. Sayonara, big fellow.

Speaking of disappearances, these reproductions of stellae stand as silent testimony to the lost civilization of the Maya. Their descendants live on, but their society went the way of the mastodon, perhaps for similar climactic reasons, such as drought.

Do you perceive a certain common theme, such as adaptive failure? Sometimes, the slightest genetic tweak can spell the difference between life and death, species-wise.

This is me on a bad hair day. Unfortunately this prototype of modern man failed to make the final cut.

Here's a reproduction of a fossil skull, zinjanthropus, dating back 1.75 million years, found in Tanzania's Olduvai gorge by Mary Leakey. Sadly, when it came to natural selection, the little guy lacked the right stuff.

Out of Africa. Zinjanthropus was not our distant ancestor, but this unmistakable DNA trail shows that everyone of us on the planet is linked to a common male and female ancestor from 60,000 years ago.

Get over it. We're all related.

The letter that started it all: An invitation from JS Henslow to Charles Darwin to serve as naturalist on the HMS Beagle.

Further reading from Knowledge is Necessity:  Darwin and the Psychiatric Advantage

Friday, December 10, 2010

Taking it Personally: The DSM-5 and the Narcissism Controversy

A few weeks ago, the NY Times featured a piece by psychologist Charles Zanor entitled, A Fate Narcissists Will Hate: Being Ignored. The long and short of it is that narcissistic personality disorder will be axed from the DSM when the next edition is published in 2013. Imagine how your average narcissist must feel.

The article mentions that retiring the diagnosis has drawn the wrath of clinicians, who view the various committees of the DSM-5 as dominated by academics out of touch with reality. John Gunderson of Harvard, one of the leading authorities on personality disorders, called the decision “unenlightened.”

Actually, overhauling the entire field of personality disorders is probably the only thing those charged with the DSM-5 did right, though with reservations. A little background:

In this post-Freud era of biological psychiatry, “Axis II” personality disorders have been accorded a lot less respect than “Axis I” disorders such as depression, bipolar, anxiety, or schizophrenia. A cynic would say that is because there are no meds for Axis II disorders and they would be one hundred percent right. The upside to this is there has been no big pharma to call the shots. It is no coincidence that the only major reforms to the next DSM occurred in the one realm where pharma is conspicuously absent.

The first obvious change is no Axis I/Axis II distinction. Personality disorders will get the same billing as mood disorders and anxiety disorders and all the rest. The next obvious change is a new “dimensional” component to complement the “categorical” classification of personality disorders, something that should have been done with mood disorders and arguably the whole rest of the DSM.

In its background papers and rationale, the APA and the DSM-5 group note that separating out personality into discrete illnesses has generated no end of end of clinical confusion. Is someone who abruptly breaks off a friendship, for instance, an “antisocial” with no remorse, a “borderline” who can’t cope, or a “narcissist” who cares only about him or herself?

Clinicians typically hedge their bets by choosing more than one, or by tacking on the NOS (not otherwise specified) qualifier.

The dimensional view acknowledges the complexity and subtlety of personality. Instead of asking “which one?” at the expense of ignoring whatever else may be going on, a clinician would be asking “how much” and “how severe?” In a sense, psychiatry is bringing back neurosis, but with some important refinements.

The personality disorders we are most familiar with are grouped into “Cluster B” in the current DSM. They include borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, and histrionic personality disorder. The next edition of the DSM will give narcissistic personality disorder and histrionic personality disorder the boot, and prune out a number of other disorders from clusters A and C as well, leaving us with five “personality disorder types,” including antisocial/psychopathic, borderline, avoidant, obsessive-compulsive, and schizotypal.

According to the rationale provided in the draft DSM-5, three of these types have the “most extensive empirical evidence of validity and clinical utility.”

Here’s where the dimensional component would come in. The draft DSM-5 proposes testing for six “trait domains” that would include:
  1. Negative Emotionality (such as depression or anxiety).
  2. Introversion (such as social withdrawal and intimacy avoidance).
  3. Antagonism (such as callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, and deceitfulness).
  4. Disinhibition (such as impulsivity).
  5. Compulsivity (such as risk aversion).
  6. Schizotypy (involving odd behaviors and cognitions).
These trait domains are based on well-established personality tests such as the five-factor model and Cloninger’s psychobiological model, and would seek answers (note the plural) to such life mysteries as why an individual would abruptly break off a friendship.

Sounds good in theory, but are clinicians too set in their old ways? As the NY Times notes:

Clinicians like types. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Sounds a bit narcissistic to me, wait, I mean - uh - never mind.

Much more to come ...

Thursday, December 9, 2010

iPhone Photo of the Day: Afternoon Walk

Loveland Reservoir, just a few miles down the road from me. The temp was in the 70s today here in southern CA.

Wednesday, December 8, 2010

Creationism vs Evolution: The War Against Reason and Why It's Ruining My Life

A little background to my photo-essay from yesterday: What prompted Tuesday’s visit to the Creation and Earth History Museum just down the road from where I live in San Diego’s East County was Robert Whitaker’s 2002 “Mad in America,” which I have inexcusably only just gotten around to reading. Part Two, “The Darkest Era,” includes a chapter, “Unfit to Breed.” Many others have related this shameful and outrageous story, but Whitaker pulls it together with the eloquence and authority of a Biblical prophet.

The early part of the nineteenth century ushered in the asylum movement, based on enlightened principles of “moral treatment,” namely if you regard those with mental illness as fellow human beings they tend to respond in kind. It’s amazing the outcomes you can produce when you don’t chain them to walls in freezing dungeons on starvation diets.

Fiscal constraints and other pressures squelched that one brief shining moment. The circulation of Darwin’s theory on evolution in the late nineteenth century only made matters worse. A whole new generation of “social Darwinists” came on the scene, eager to latch onto any excuse to justify their positions of power and privilege. Instead of “all men are created equal,” we were now hearing that “some men are created more equal than others.”

This gave rise to all manner of abuses across all of society. One outcome was the rise of the quack science of eugenics that encouraged weeding out from the gene pool those of degenerate stock. You guessed it, those with mental illness were at the top of the list. In the US, in the first decades of the twentieth century, some 30,000 individuals with mental illness were sterilized.

Hitler took eugenics to its tragically unforeseen but totally logical conclusion. The mentally ill were sterilized, then became the first population singled out for the gas chambers. We know the rest of the story all too well. In the aftermath, eugenics disappeared as a science, but Darwin was tainted forever. Those espousing creationism shamefully link Darwin to the Holocaust. I witnessed it yesterday in my museum visit.

Karen Armstrong in “The Case for God” notes that initially Darwin did not meet much resistance from organized religion. Yes, Darwin challenged Genesis, but hardly anyone at the time interpreted Genesis literally. Christianity, which grew up without printed Bibles in circulation, was constantly - excuse the term - evolving its teachings. Religion, she says, has never been about pat answers.

Throughout the ages, science and religion were more or less in accord. The Galileo controversy, Armstrong points out, is overstated and Galileo himself was largely to blame. Newton’s theories were seen as validating a creator God (without having to get into ridiculous arguments about whether it took God six days or six billion years to fashion the universe).

Literal interpretation of the Bible is a fairly new phenomenon, beginning with the Millennialist movement in the middle of the nineteenth century. This movement may have remained on the fringe had not other Christian groups felt threatened by the scientific revolution around them. This gave rise to fundamentalism, until recently on the outside of the mainstream.

Karen Armstrong makes the very strong point that what we think of Christianity today is not the Christianity our Founding Fathers practiced. Theirs was an Enlightenment-based belief, which (naively) assumed that the mysteries of God would be solved by rigorously applied science and reason. Thus my surprise when on my museum visit I came upon an exhibit asserting that not only the Founding Fathers, but the scientists and philosophers of the Renaissance and Enlightenment, all had creationist beliefs.

No, they didn’t. They simply had no reason to quibble with the Genesis story, that’s all. Jefferson rather than accepting the Bible word-for-word, actually decided to improve upon it (see image above).  

Armstrong notes that social change triggers extreme reactions. She got that part right. In her book, she is equally critical of atheists (including proponents of evolution such as Richard Dawkins) as she is of religious fundamentalists. In Armstrong’s view, atheists are as stupid to God as fundamentalists are to science. Both sides are shouting way too loud, leaving no room for reasoned discourse.

And now we are suffering through another extreme reaction in the form of a certain movement with a beverage in the title, again co-opting our Founding Fathers (who have every reason to be spinning in their graves). According to a 2005 Pew Research Center Poll cited in Scientific American, 60 percent of Republicans are creationists and only 11 percent accept evolution. (Forty percent of Democrats accept evolution, which is not good either.)

Obviously, the creationists and their fellow travelers are very successful in getting their word out. Scary, isn’t it?

My Visit to the Local Creationist Museum (Seriously, I'm Not Making This Up)

Believe it or not, this museum is only 10 or 12 miles from my home, outside San Diego.

This journey through time will be a very short one, as the entire universe, earth included, according to creationist belief, is only 6,000 years old.

This works way better than carbon-14 dating.

I missed whether it was a standard day or a metric day.

In support of a worldwide catastrophe, creationism cites the same geological evidence as science, though with some rather significant differences in interpretation.

Noah's sons went their separate ways, assisted by land bridges spanning the oceans, thanks to a Flood-induced ice age. The animals from the Ark dispersed along these same land bridges, perhaps not whales and other sea creatures.

And I thought Neanderthals survived in the form of Tea Party followers.

I wish I had our high school class valedictorian, Karl Van Bibber, to explain this to me.

If I can follow the logic, mutations (which are all bad) get filtered out of the gene pool, keeping creation constant. There is, however, the mother-in-law exception.

That's right, evolution is just a religion, which makes creationism the true science. Why aren't our kids being taught this in school?

The "bad fruits" of evolution. No good can come from allowing people to think for themselves. That's why we need knowledgeable people in authority to do our thinking for us.

Evolution apparently played a part in the Final Solution. Actually, murderous bigots were killing Jews en masse long before Darwin. The Catholic Church even made saints out of some of these medieval pre-Hitlers. (Sorry, I was trying really hard to keep this objective.)

A browse through the museum's book store. No, I didn't Photoshop the book title.

Tuesday, December 7, 2010

Rerun: Depressed or Thinking Deep - My Take

From Nov, last year. Enjoy ...

Therese Borchard of Beyond Blue always has a way of making me feel that on a planet of six billion strangers I have at least one person I can talk to. Last week, she opened a blog piece this way:

I spent my adolescence and teenage years obsessing about this question: Am I depressed or just deep?

When I was nine, I figured that I was a young Christian mystic because I related much more to the saints who lived centuries ago than to other nine-year-old girls who had crushes on boys. I couldn't understand how my sisters could waste quarters on a stupid video game when there were starving kids in Cambodia. Hello? Give them to UNICEF!

Now I look back with tenderness to the hurting girl I was and wished somebody had been able to recognize that I was very depressed.

See what I mean? I just know that had we been in the same class at grade school, while the other kids played ball during recess, Therese and I would have found a quiet spot to sit under a shade tree, sharing cookies our moms packed and discussing how Augustine of Hippo must have felt after Alaric the Visigoth sacked Rome in 410 AD.

So, what was it? Were Therese and I two sensitive souls waxing philosophical, or two depressives acting strange? Therese cites both Paula Bloom PsyD (from a blog on PBS) and Peter Kramer MD, author of "Against Depression" (from a NY Times piece) in support of the proposition that depression and thinking deep are clearly distinct. Says Dr Kramer:

"We idealize depression, associating it with perceptiveness, interpersonal sensitivity and other virtues. Like tuberculosis in its day, depression is a form of vulnerability that even contains a measure of erotic appeal." First the ancient Greeks, then Renaissance thinkers, and later the Romantic movement assigned spiritual and artistic and even heroic virtues to melancholy. Nonsense, Dr Kramer responds. "Depression is not a perspective. It is a disease."

If I interpret Therese correctly in her blog piece, she found comfort in this. It came as a great relief to her to realize that her capacity to think deep, even at a young age, although unusual, was not pathological.

I, on the other hand, have an entirely different reaction. "Wait!" I want to scream at Dr Kramer. "You mean my depressions have all been for nothing?" My lost hours, lost days, entire lost years, a lost life practically, served no useful purpose whatsoever?

Screw you, Kramer! I want to keep screaming for no logical reason, whatsoever. Something that took so much from me, so much out of my life, I demand some kind of return - Jedi powers, a mystical third eye, roll-over phone minutes, whatever.

Yes, Dr Kramer is right, but so is everyone else. When it comes to the enduring question - Who the hell am I? - we are all struggling to find the truth. Here's what I'm looking at right now:

Proposition One: Any depression that is not part of my temperament sucks - whether mild or severe. Take my depression - please. They throw me off my game, ruin my day, wreck my life. Whether it's a depression that is the equivalent of a mild cold or one that is psychic double pneumonia I seriously don't want to be inside my brain on this planet when my neurons have gone on strike. If this is the disease that Peter Kramer is talking about, I'm behind him one hundred percent.

Proposition Two: At the same time, mild to moderate depression is part of my temperament, my personality (as is hypomania). As opposed to my disease depressions, I'm very comfortable in this state. It is a part of who I am. My energy is down, my thoughts tend to be very dark, but - here's the key difference - I thrive in this state. My neurons are working with me, or perhaps me with my neurons. It's as if I'm calmly sifting through the ideas I rounded up in my hypomanic frenzies, whether I'm lying in bed, at my desk, or taking a walk. If this is Dr Kramer's version of just thinking deep, I would have to respectfully disagree.

What we are talking about is the classic distinction between "state" and "trait." Trait is who we are. State is invasion of the brain snatchers. But no distinctions are ever as clear-cut as they seem.

We tend to get hung up on DSM-IV check lists while ignoring a key DSM injunction - namely that we are only in a state of mental illness when the symptoms interfere with our ability to function (as in work or relationships). So - from my personal perspective - if I am comfortable and not struggling while depressed, then I hardly have an illness that needs treatment.

Now let's flip it. I also get hypomanic, and I've written a lot about this. Here's the test: For Marilyn Monroe to act like Marilyn Monroe (at least when she's up) - that's normal, for Marilyn, anyway. For someone else to act like Marilyn Monroe, on the other hand - that's probably a sign that very bad things are about to happen.

So, back to depression. For me to act like me (when I am down), under most situations that is normal for me. I can handle it, it is healthy. For someone else to act like me, trust me, that is cause to get one's personal affairs in order.

Here's where it gets complicated. When does my productive depression start becoming a nuisance and when does this nuisance seriously start messing me up? Similarly, when does my upbeat hypomania cross over into social embarrassment and in turn morph into something that causes me to make very bad decisions?

It's as if we're turning up the heat. When, in effect, instead of a nice warm soak in the tub, do we find ourselves in hot water? Everyone has different tolerance thresholds, and you can make a good case that we can expand the range of these thresholds to lead healthier lives. Of course, every time I congratulate myself on doing this, God just laughs and throws a psychic lightning bolt in my direction.

So - my normal would probably cause most people to stay in bed for six months, or (in the other direction) have neighbors dialing 911.

One more twist. In her blog, Dr Bloom reported on this confused reaction from a patient: "When I reflected to her that she sounded depressed she said 'I don’t think so, that is just my personality.' So many people confuse depression with just being a lazy, unmotivated person."

So our depressed state tends to give us a wrong read on our baseline traits. Who the hell are we? It's a question I'm still trying to figure out.

Therese is my fellow terminal deep thinker and favorite blogger. Please check her out at Beyond Blue.

Sunday, December 5, 2010

To Madness and Back

Following is a reworked version of a piece I wrote 11 years ago. Enjoy ...

"Thrice I suffered shipwreck, a night and a day I have been in the deep." - Paul baring his soul in Second Corinthians.

Early 1988. I awoke from a drunken stupor in a strange city in a strange country, jobless and friendless and nearly penniless. You don't really want to be sober, for aside from the unwelcome intrusion of reality, you also find your psyche playing host to the type of cold fusion nuclear reaction that demands instant release.

Rage - Goddess, sing the rage - a line from Homer. The shrinks have no adequate description for it - agitated depression, dysphoric mania, a mixed state, mania and depression fused into an explosive kinetic ball of emotional kilotonnage, one that makes the very act of living totally unbearable. It was simply a matter of following through.

Meanwhile, as I lay sprawled on the floor of an apartment that I could ill afford to pay the rent on, it was a beautiful summer day in Melbourne, Australia. Outside my window the eucalyptus trees that lined my street created the impression of an urbanized Eden, while the kookaburras' shrill laughter in the distance sounded forth a Midsummer Night's Dreamscape of fairyland gaiety.

But the rumbling of the tramways around the corner represented my one-way ticket out this life, out of my private little hell. I only had to change trams maybe once or twice to put me within walking distance of the suspension bridge that spanned the harbor.

Only seven months before I had been on a plane from Wellington, New Zealand bound for a bright new life. I had sent out my resume to the major Australian newspapers and business magazines, and four editors had made me an offer. Oddly enough, I snapped at the one that offered the least money.

Fifteen-hour days were par for the course as a business editor in New Zealand. It took me a month or two to find my rhythm in Australia, but soon I was treating the airline as my bus service, up to Sydney and back again the same day, perhaps Brisbane, over to Perth for a longer stay, not to mention New Zealand, always on short notice, usually not knowing for sure when I would return.

Often I literally composed the stories in my head, dictating them over the phone to someone at the other end in hopes of making it into the next edition. On one occasion, I actually found myself reviewing a Frank Sinatra concert, which got major play on the paper's entertainment pages, together with about three or four pieces of mine that appeared on the business pages that same day.

An acquaintance called me up and commented on my output, for which I had a ready answer: "Yeh, well it was my turn to write the paper that day."

Oh, I had the one-liners coming. I was floating on air.

But the high was beginning to turn on me. Sometimes I found myself snapping at people, which was very uncharacteristic of me. Once, on the tram, on my way to work in the early morning, I found myself on the brink of physically attacking some wise-assed teenager. I actually got up out of my seat and went for his neck before I caught myself.

Then came the issue of my six-month salary review. When the editor failed to acknowledge me as the Second Coming of Thucydices, I quit in a huff, bitterly resentful over his treatment of me. Furious, in fact, in a blind rage. I told my colleagues what had happened and they looked at me like I was crazy. Didn't anyone understand?
I'M NORMAL! I wanted to shout. I've always been normal.

And now there was the small matter of me on the floor emerging from a drunken stupor in a strange new country with no job, no friends, almost no money, and no hope of finding work.  I'll write a book, I thought. I grabbed hold of a typewriter and began pounding on the keys:

"A stock market crash has no setting," I wrote. "It occurs in people's minds, a collective will that determines what is valuable and what is worthless, from day to day, minute to minute. To understand finance has nothing to do with economics or accounting. Instead, it is a philosophical discipline, of the mind determining reality, the natural territory of Kant and Plato and the rest."

I managed to find a publisher, but never steady employment. Ever again. "Thrice I have suffered shipwreck. A night and a day I have been in the deep." Who am I to complain?

Friday, December 3, 2010

Mental Health Quiz: Test Your Knowledge

Every year, NAMI San Diego hosts a holiday pot luck dinner and annual meeting. For last night's gathering, I put together a quiz night and acted as quiz master. I compiled questions in eight categories. These are the questions I read out in the mental health category. Let's see how you do. Answers and commentary further below ...

1 What did John Adams, Abraham Lincoln, Theodore Roosevelt, and LBJ have in common?

2 The Priory of St Mary of Bethlehem, founded in 1247, later to become Bethlehem Royal Hospital for treating lunatics, is more commonly known by this name.

3 Hippocrates and the ancient Greeks referred to “the four humors” or "temperaments". One of them literally means "black bile." Name the temperament.

4 What did Christopher Columbus, Michelangelo, and Isaac Newton have in common?

5 Emil Kraepelin back in the early 20th century described a condition he called “dementia praecox." Today, we know dementia praecox by this name.

6 Between 1907 and 1939, more than 30,000 individuals with mental illness in the US were subjected to this procedure.

7 The 1949 Nobel Prize in Medicine went to António Egas Moniz for developing this treatment for the mentally ill.

8 NAMI was founded by parents who got sick of being blamed for their kids' mental illness. Psychiatry even had a label for these horrible parents. Name the label.

9 Robert Spitzer, the most influential psychiatrist you never heard of, is the man responsible for the modern version of this text, which we quote from all the time.

10 Eric Kandel, Arvid Carlsson, and Paul Greengard shared the 2000 Nobel Prize in medicine for their discoveries concerning "signal transduction in the nervous system." This is a fancy name for brain cells talking to each other. What's the scientific name for brain cell?


1 US Presidents with mood disorders. (A Duke University study reports that nearly half of the US Presidents had something diagnosable.)

2 Bedlam.

3 Melancholia. (The other three: Choleric, Phlegmatic, and Sanguine.)

4 Bipolar. (That's right, world. We give you the gift of civilization and how do you thank us? You marginalize us. Sorry we couldn't find America sooner for you, by the way.)

5 Schizophrenia. (Dementia praecox suggested a steadily deteriorating brain, but we know recovery is possible.)

6 Sterilization. (Those with mental illness were deemed a menace to the gene pool.)

7. The prefrontal lobotomy. (Some 40,000 lobotomies were performed in the US.)

8. Schizophrenogenic. (The label is as stupid as the reasoning behind it.)

9. DSM - Diagnostic and Statistical Manual. (A piece of fiction put out by the American Psychiatric Association.)

10. Neuron. (I have a theory that neurons only work with coffee. I hope I don't have to share my Nobel Prize money with anybody.)

Thursday, December 2, 2010

Rerun: Coming to Terms

Yesterday, I posted a rerun piece to mark my four years living in Southern CA. To pick up where we left off ...

A thought-provoking Zen parable goes like this:

A man encountered a tiger in a field. He attempted to escape by lowering himself down a precipice. He looked down and, to his horror, saw more tigers looking up, anticipating their next meal. He looked up and spotted two mice above gnawing on the vine he was clinging to.

Oh, crap.

Then, looking to his right, he sighted a strawberry growing from the cliff face. Reaching over, he grabbed the morsel and popped it into his mouth.

“Mmmm!” he thought. “Delicious!”


My own translation: Enjoy the peanut butter.

By now I had all my stuff out of its boxes, and McMan International back up and running, which is my way of saying I had my desktop computer all plugged in and wired for internet. I had an email newsletter to get out, my first from my new world headquarters. I anticipated going full blast into the evening, but things went off without a hitch and I was unexpectedly through at about 2:30 in the afternoon.

Time to unwind with a walk. The winter sun was already low over the peaks behind me, and I was in the shadows, but the valley below me and the peaks in the distance were bathed in brilliant light.

I stopped in at the local coffee shop for a coffee and muffin to go. Shelley the proprietor heated my muffin for me and sliced it into tasty morsels. Soon, I was in the sun on the valley floor. The open space before me allowed my mind to breathe. Not too far off, peaks and rock formations rose from the valley like great cathedrals. I sipped my coffee, and munched on my muffin morsels, savoring the moment.

On my way back, I stopped at the general store, which adjoins the post office. Yes, we even have our own zip code. It was to be a dogs and beans night for me. Back outside, the sun had set behind the peaks and the temperature was dropping fast. I was back into my own shit now, still reeling from recent events, facing financial ruin, uncertain about my future, wondering how the hell I would ever get my life back together.

I hurried my pace, anxious to get home - home? - only to stop dead in my tracks. I looked right. The entire valley below was now in the shadows, as were the peaks and rock formations. But in the distance, a steep summit caught what was left of the sun full broadside. The mountain appeared to be radiating from the inside, a lustrous rosy glow that sharply contrasted with the cool hues of the darkened landscape.


Thank you, God, I found myself saying. I was experiencing the perfect moment, in the moment, what they call a Zen moment, fully aware, in the present. Tomorrow I could very well fall to pieces. But right now was a gift. Life happens here, right now. If you're second-guessing your past or fretting about your future, you're missing out.

The moment lasted maybe five seconds. Then I was back inside my own head, my own shit. But it wasn't the exact same shit inside the same head I returned to. I was back in my past, but it was one I could come to terms with. I was back in my future, but it was one I could face with hope.

Something similar occurred to me more than 30 years before, only back then it happened with the throttle wide open headed over the edge of a cliff.

We can all recall our exceptionally aware moments. Unfortunately, they tend to occur in highly-stressful and often life-threatening situations, such as skidding on glare ice at 60 MPH. This is when our fight or flight response takes over. The frontal lobes go off-line. We literally stop thinking as the faster-processing and more primitive regions of the brain (think amygdala) assume executive control.

Fight or flight is normally associated with an over-reaction, but here we are talking about a rare mental state that can only be described as calm awareness. If we had time to think about the dire straights we were in, we would probably panic. Instead, barring bad luck, we successfully avoid wrapping our vehicle around a tree. On one hand, the crisis is over in a micro-second. On the other, it’s as if time were slowed down.

There is a stretch of the Route 101 Coastal Highway in Marin County north of San Francisco that has probably washed into the Pacific by now. Gerald Ford was President and I had hair. I leaned my bike into the curves of the road, first one way, then the other, speeding up on the straightaways and gearing down on the hairpins perched high above the Pacific, my ears ringing with the roar of the waves crashing against the rocks below.

I was just leaning in for another sharp turn when I came upon some rocks that had worked their way loose from the hills above. There was no time to think. I swerved to avoid the obstacle and brought the bike around 180 degrees, but it was going backward toward the ocean on its own momentum. I felt the sickening sensation of the back wheel leaving the shoulder and losing traction in the soft earth behind. For a brief fleeting instant I had the sensation of being suspended in midair, like Wile E Coyote in those Roadrunner cartoons. Then the bike found purchase, jerked forward, and stalled on the shoulder.

I turned off the ignition, wheeled my bike to a safe place, and took stock. Something had shifted in me in those two or three seconds. Whatever had been holding me back before was holding me back no longer.

Within days, my life was on a new trajectory that would find me in New Zealand, attending law school, married, with a kid on the way. Now, here I was, decades later, in rural southern California. Healing happens, but don't expect to stay in the same place. There was no going back, not to New Jersey, not to my old sense of self. At the same time, I felt a sense of home. I was no longer on the run. I was here to stay. The land had heard my request. It was talking to me.