Tuesday, March 8, 2011

Akiskal Unplugged

Hagop Akiskal of UCSD is bipolar’s ultimate insider-outsider, at once the field’s elder statesman and enfant terrible, the best-known name in an establishment that would often rather not know him, and vice-versa. “I have no use for the DSM,” he told me as I greeted him last evening at a talk he was about to deliver to the San Diego chapter of DBSA.

And he was only just getting warmed up.

Dr Akiskal’s presentation was more in the nature of a conversation, with revealing tangents that allowed his audience rare glimpses into the mind of a visionary-at-work. A lot of what you read here on "Knowledge is Necessity" is highly derivative of Akiskal, and for good reason. Basically, if you want to know about bipolar, you read the usual literature. If you want to know what is really going on, you read Akiskal (and Frederick Goodwin, and Robert Post and a few others).

“Most depressions are at some level bipolar,” Dr Akiskal told his audience. Akiskal literally owns the terms “bipolar spectrum” and “mood spectrum,” which view both mood and temperament as blended shades of the same phenomenon rather than separate entities. Thus depression typically has elements of mania or hypomania, and vice-versa. Agitated depressions, if you like, or dysphoric manias. Think road rage, even if you don’t drive.

Just to make things interesting: Imagine if you have an upbeat (what Akiskal calls “hyperthymic”) temperament. You get depressed - “state,” in effect, superimposed over “trait.” It doesn’t take a rocket scientist to realize that your depression is likely to look quite a bit different than that of the melancholic type sitting next to you. But until Akiskal arrived on the scene no one in psychiatry even came close to thinking this way.

Okay, maybe Emil Kraepelin, a name Akiskal drops every chance he gets, including at least three or four times last night. Kraepelin, who was born the same year as Freud, coined the term, “manic-depression.” What Kraepelin meant by manic-depression embraced recurrent depression as well as bipolar. The DSM-III of 1980 missed this completely, as did the DSM-III-R of 1987 as did the DSM-IV of 1994 as did the DSM-5 (due out in 2013).

See why Akiskal has no use for the DSM?

“They are spending millions of dollars on the DSM-5,” Akiskal thundered. “I refuse to be part of it.” The DSM, he says, lists “five hundred ways to lose your sanity.” It could be simplified, he said, to about five or ten or fifteen.

“I don’t believe in borderline,” he threw in for good measure.

Ah, vintage Akiskal.

Much more to come ...

More Akiskal on mcmanweb:

The Mood Spectrum
Multipolar Depression
The Fear and Anger Equation


Louise Woo, CABF Los Angeles said...

Not having read Akiskal, I can't comment on his specifics. But it's easy to see the forest from his perspective: Science will soon dissect the mechanics of psychosis. Once we understand the chemical breakdown in the brain, it will be easier to see that depressions, manias, hallucinations and all the other myriad symptoms are not separate diseases.

It's all part of one disease, just as severe shooting pains in your arm do not mean you have an arm disease. You are having a heart attack.

Sadly, almost every scientific study done today is tainted on some level. In an era where information is expensive and expertise requires appropriate compensation, there isn't any loose change floating around to fund science for "science's sake." Our government is not a for-profit company. Big Pharma is. If they can fund research, how can you say no? Who else can fund your research? A bake sale?

Akiskal is right to roll his eyes at the DSM. It's a document that aims to match symptoms with medications -- medications that someone manufactures for a profit. We will be the first in line to testify as to the amazing benefits of meds that WORK, but as you well know meds are the fire extinguishers. And buying a fire extinguisher will not rebuild your house.

I look forward to hearing more about Akiskal's observations on Where We Are Now. In this house, the fire is out, but the burnt rooms have yet to be rebuilt and painted.

John McManamy said...

Hey, Louise. I love the shooting arm pain and fire extinguisher analogies. The brain science is going to change everything and validates a lot of Akiskal. But Akiskal is also a throw-back (along with Goodwin and Post) to the days of keen clinical observers.

These people don't exist anymore. Most academic researchers don't see patients. Akiskal and Goodwin do. Diagnostic anomalies walk into their practices everyday.

The biological psychiatry of a med to treat a symptom, as well as the DSM, devalued a lot of their work. In turn, Akiskal and Goodwin (who have enormous respect for each other) are contemptuous of of a lot of academic psychiatry.

I recall David Braff, a leading schizophrenia researcher and a pioneer of endophenotype, cautioning against devaluing clinical observation in this new era of brain research.

People like Akiskal can tell the brain scientists and gene researchers where to look and what to look for (and indeed he has).

But last night wasn't the time for all of that, unfortunately. A number of people in the audience treated Akiskal as just another Ask-the-Doctor, which took valuable time away from him going into depth.

Asking someone like Akiskal about lithium and kidney damage, for instance, is equivalent to asking Einstein to solve your kid's math homework problem for you. This, of course, is the bane of any session involving a prominent doc speaking to a group of patients. It happens all the time.

But it is a two-way street. The reason both Akiskal and Goodwin are so great is they both welcome and encourage patient feedback. Patients have a way of throwing the type of curveballs that make you think. So, even though I'm tempted to stand and yell "Quiet!" when a patient tries to hijack the discussion I happily (okay, not happily) put up with it as the cost of doing business.

Louise Woo said...

Back in the old days, before fancy pharmaceuticals could perform minor miracles, doctors had to view patients as whole people. They had no choice. Without a book to give you an algorithm to give you a medication option, doctors like Akiskal had to create a treatment that might improve a patient's LIFE.

But research has brought us too much information, forced people into smaller and smaller specialties and produced a panoply of meds that sometimes hit the bull's eye. Thus we have a medical profession filled with microspecialties. Is it any wonder that doctors can't see patients as whole people anymore? Hell, it's a wonder they can remember people have more than one organ system!

Every serious illness attacks the body on multiple fronts, but only a small minority of doctors address this. To be fair to psychiatrists, I don't think they're any worse than cardiologists or oncologists who focus acutely on your disease, not your person.

Dana Jennings, a NY Times reporter, did a great first-person account of this struggle during his two-year battle with prostate cancer. He described how his treatments and their side effects were far more damaging than his disease and how he was left coping with those problems on his own.

You can read the series here: http://well.blogs.nytimes.com/tag/dana-jennings/

I don't know if the medical community will ever revive an interest in clinical observation (i.e. looking at the condition of the person, not the disease). Doctors have too much information now. They are forced to run like hell just to keep up with new developments in their specialties.

Doctors like Akiskal and Goodwin are a dying breed. An article in last Sunday's NYT addressed that trend as well:


When a psychiatrist has 1,200 patients to care for and insurance only pays for 15 minute visits, what choice does s/he have?

John McManamy said...

Hey, Louise. You're absolutely right. Doctors like Akiskal and Goodwin are a dying breed, and these are the guys I look up to. Things are so specialized and so hurried now that docs are basically the VW mechanics described in the NY Times piece you cited. But it's even worse - they're like people who know only how to do an oil change and know nothing about the rest of the car.

Fortunately legions of smart people have trained under and collaborated with Goodwin and Akiskal, so I'm hoping there will be people around to carry on their work, but the bottom line is they and people like them are irreplaceable. The pdocs who came out of this generation were special. The newer ones who overly rely on meds quick fixes, by contrast, are superficial.

You can't expect a superficial by-the-book psychiatrist to engage in any meaningful collaboration with a brain scientist or geneticist. By contrast, Akiskal is collaborating with geneticist John Kelsoe in seeking out temperament genes. I could not imagine even your best biological psychiatrist coming up with that.

So, instead of folding in the old with the new, as Kandel proposes in his "new science of the mind," brain science and genetics is going to run psychiatry off the road.