Thursday, June 30, 2011

Rerun - Psychic Perception

This appeared here in January, with is in turn based on an  article on mcmanweb ....

In a poll I conducted here in Aug 2009, nearly one in four (23%) reported they were "borderline or full-on psychic, or at least it seems that way." In contrast, less than one in ten (8%) responded with, "Sorry, I'm totally rational and logical."

I highly doubt that we would find so many with psychic tendencies in the general population. I also suspect most of us keep pretty quiet about this stuff, especially around our psychiatrists. We are talking about a spectrum where intuition overlaps with the paranormal or psychic, which in turn bleeds over into truly irrational thinking - ranging from grandiose and delusional to magical and psychotic.
There is no separation. A hyper-aware brain easily becomes overloaded, to the point that "seems like crazy," with only a slight nudge becomes "genuinely crazy."

Weird stuff happens. Back in the mid-seventies I had a vivid dream about an earthquake. Twenty-four hours later I woke up to the floor shaking beneath me, my first-ever encounter with Richter phenomena. This had to be random chance, I could only think. Odds are, after all, that things will happen that defy all odds - it's one of those paradoxes to the laws of probability. That's my story, anyway, and I'm sticking to it.

The other way of looking at it is that - in order to preserve my sanity - I learned to tune out this sort of thing. Imagine my brain going off every time the earth twitched. I'd be a nervous wreck, especially now that I live in California. In other words, "reality" was my adaptive response to a "hyper-reality" that was too much for me to handle. (Of all things, this is the mirror reverse of the Freudian explanation for "psychosis," which his followers view as a maladaptive "reaction" to reality that is too much to handle.)

Okay, one more weird thing: Back in the late-80s, I joined a "psychic circle." We were asked to face the person next to us and do a "reading." This is stupid, I thought. But if I persisted in my "this is stupid" line of thinking I was only going to prove myself right. I settled down, blotted out all distractions, including "thinking," and went with flow ...

I see you in front of the fireplace, I said to the woman facing me. So far so good, unless of course her house didn't have a fireplace. She motioned me to continue. With your two kids, I added.
I only have one kid, she cut in.

There! Wrong, already! I knew this stuff was bullshit. "Well, I see two," I said anyway. Look, it's not my fault, I wanted to explain. I'm just doing what the lady told me to do - clear your head, no thinking, first thing to pop into your head ...

That week, she discovered she was pregnant.

"We're called nutjobs for recounting these experiences," Liza over at my blog on BipolarConnect commented, "and don't you dare mention them to your psychiatrist unless you want a stay in a psych ward complete with an ECT session or two."

Nevertheless, Liza felt sufficiently safe on BipolarConnect to reveal this:

I was in a small group in my high school English class. The group was discussing the debate we were preparing, and I said, why are we going over this again? We said all this last small-group meeting. Nope. It was the first time we'd met in group. My classmates already thought I was weird, and I'd just confirmed it.

But of all things, Liza went on to say, two of the giants of psychiatry/psychology, Carl Jung and William James, gave such experiences a lot of credence. Jung felt that the human psyche is "by nature religious." In his memoir, he recounted seeing a luminous head, detached from the body, floating from his mother’s room.

Meanwhile, William James, in his classic "The Varieties of Religious Experience," felt that healthy-mindedness had a lot to do with "union with the divine" whereas depression was the sign of a "divided soul" that could be cured by a mystical experience.

None of this, of course, sat well with Freud, who expressed his fear of psychiatry descending into a "black tide of mud of occultism."

These days, science is starting to fill in a lot of the blanks on our behalf. Few investigators are brave enough to risk their careers looking into the paranormal, but research into intuition and creativity - the "soft side" of psychic - is a hot field.

But creativity and intuition (and needless to say, psychic perceptions) are also linked to crazy. It's no accident that some of the top investigators in the field - people such as Nancy Andreasen of the University of Iowa - made their bones researching mental illness.

A psychic reality undoubtedly exists, and the ones with the best insight into this are the people eating out of dumpsters. Our brains tune this stuff out for a reason. I know mine did.


This article is one in four on mcmanweb investigating the connection between creativity, intuition, psychic perception, nonlinear thinking, and crazy, based on blogs originating here and BipolarConnect:

Creativity, Intuition, Non-linear

Wednesday, June 29, 2011

Mahler: The Man Who Saw It Coming

This is from a mcmanweb article I wrote in 2004. My appreciation for Mahler has only deepened since then. Enjoy ...

Gustav Mahler described himself as three times homeless, a Bohemian in Austria, an Austrian among Germans, and a Jew throughout the world. He might have added being highly temperamental in a time and place of rigid social conventions. But those days were rapidly coming to a close, even if all of Europe at the time remained blissfully unaware. Only Mahler seemed to possess second sight.

Mahler composed and conducted at a time when Europe was supposed to be entering a golden century. The previous hundred years had closed with Queen Victoria celebrating her diamond jubilee. At the time, England had a quarter of the world under her dominion, while the other European nations willingly shouldered their fair share of the white man's bounty, uh burden.

A rapidly expanding middle class and rising living standards in the working class promised social stability, notwithstanding the ravings of assorted communists and social malcontents, and democracy was enfranchising ever greater populations. Planck and Einstein and the Curries challenged Newton's gravity, Freud had made his first installment on his famous couch, medical practice was saving more patients than it was killing, visual art was breaking out of its strictly representational straightjacket, and Charlie Chaplin was setting out for America. Technology held out the promise of a new heaven on earth, and the White Star Line had an unsinkable boat on its drawing board.

Mahler was in full expression while Europe was in full denial. Even today, to the untrained ear, despite adhering to Romantic conventions, almost all his music still comes across as inaccessible. It is at once profound and silly, morose and jubilant, ironic and gay, mocking and heart-wrenching, boisterous and sobbing, bombastic and subdued, optimistic, and despairing.

True, Beethoven started the trend by marching a Turkish band straight through his "Ode to Joy," but Mahler pulled out all the stops by turning loose cuckoo birds, Alpine cows, mobs at country fairs, high society swells, runaway drummer boys, mournful sopranos, buglers, fiddlers, light cavalry, and dancing Germans in leather shorts on nine symphonic scores heaped with mock Wagner taken to new levels of absurdity.

If Mahler’s music were food, it would be tomato ice cream topped with anchovies and chocolate and chili peppers sprinkled with dry rub and served up on burnt pumpernickel.

No wonder his contemporaries couldn’t comprehend his music. Make no mistake, this was the soundtrack of a decadent age in its later stages of unraveling, even as unsuspecting Europe celebrated itself as a beacon of civilization, blissfully ignorant of the horrific calamities about to be unleashed, totally unaware that a whole way of life was about to end.

These are no idle musings. No less a writer than Thomas Mann used Mahler as his model for the dying lead character in "Death in Venice," an allegory of Mother Earth turning against her children (though the homo-eroticism is Mann's own invention). The film version's primary claim to fame is as a showcase for the slow movement of Mahler's Fifth. The same symphony (this time the opening movement) was also used to stunning effect as the opening theme to BBC's 1974 13-part dramatic series, "Fall of Eagles," set in Mahler's time, fittingly chronicling the last days of Czarist Russia, Kaiser Germany, and the Austro-Hungarian Empire.

Back to the music. Amazingly, Mahler's odd assortment of sound bites binds into transcendent coherency, transforming what was grossly unpalatable at first and even tenth listening into an out of body experience. Call it a Mahler moment. Anyone vaguely familiar with the composer knows there is no such thing as a casual Mahler fan. People are either passionate about him or they hate him.

Or they are like me, aware that true musical appreciation is a lifetime journey. In my early twenties, I set out on my path of musical discovery in earnest. I heard new composers for the first time and listened to old ones with new ears. Some of them turned out to be acquired tastes, and others, I realized, needed further time. That’s the beauty of music, I kept thinking. One day I will even like Mahler.

Decades passed. Then, back in 2004, a voice in my head told me I was ready. Vaguely recalling both "Death in Venice" and "Fall of Eagles," I went to Amazon and ordered Mahler’s Fifth. I popped in the CD, and with the opening bars of the solo trumpet I was hooked. A hundred other members of the orchestra still had their instruments on their laps (actually this would be rather awkward for the timpanist), but I was already a Mahler fan.

On a hunch I also ordered the Sixth, which could very well be to music what Joyce’s "Ulysses" is to literature. Where have you been all my life, Mahler? I could only wonder, as I kept playing and replaying the double CD in rapt fascination. Well, ignoring him, actually, just as I am still ignoring Joyce.

I have faith that one day with Joyce I will be able to penetrate the impenetrable, just as I am doing with Mahler. And the reward? Once you have broken through, you are never the same. You experience the world with new senses, as well as a world beyond sense. There are no limits. Buddhahood awaits.

Kay Jamison in "Touched with Fire" describes Mahler as cyclothymic, with a strong family history of mental illness - a brother who committed suicide, a sister with death hallucinations, and another brother with grandiose tendencies. He was treated by none other than Freud. A stormy marriage to a woman 19 years younger, the death of his daughter, a tumultuous tenure as artistic director of the Vienna Opera, living life as three times homeless, and a bad heart that kept him in death’s shadow ensured that he would feel far deeper and wider than his contemporaries.

But it is in his music that we find his bipolar smoking gun. Yes, others may have written sadder or more exalted compositions, but no one leads us down the strange and disturbing and contradictory byways of the human psyche as does Mahler. Even as he boasts we shall live forever in one symphony he sounds his own death knell in another. It was not the kind of stuff for simpler minds in a simpler time.

Soon after the birth of his first child, Maria Anna, Mahler completed his song cycle, "Kindertotenlieder (Songs on the Death of Children)." His wife, Alma, was alarmed, begging him not to tempt fate. The girl died five years later. Mahler’s symphonies are a "Kindertotenlieder" of a different sort, the premonition of the end of an age. By the time he died in 1911 at age 50 of a weak heart complicated by a blood infection, he had taken Romanticism as far as it could go. That same year, the Ballet Russe premiered Stravinsky’s "Petrouchka," in Paris. Two years later, Stravinsky would cause a riot with "Rite of Spring." Music would never be the same. There was no place for Mahler’s music in this new world order.

Then came 1914 and Europe’s collective madness. Future historians may well look upon the period from this time onward to the fall of the Soviet empire as the 80 Years War. Those innocent fools never saw it coming. Yet it was right there in Mahler’s music.

For fifty years, Mahler was largely ignored, though he did have a profound influence on the pioneering film composer Erich Korngold, who in turn influenced his contemporaries and those who came after. Mahler was championed by two of his protégés, the legendary conductors Bruno Walter and Otto Klemperer, but it was Leonard Bernstein in the fifties and sixties who made him famous.

Bernstein set the scene for a 1973 Time magazine piece, but with George Solti as the cover boy and magazine's unequivocal verdict of Solti's Chicago Symphony as "sine qua non." The litmus test? Mahler, of course, the ultimate challenge for a conductor, a "stunningly powerful" performance of his Fifth in Carnegie Hall that resulted in a 20-minute ovation that only ended when Solti escorted the concertmaster off the stage. Clearly, Solti was the winner of an imaginary battle of the bands. These days, conductors routinely use Mahler as their calling card.

We who live in a jaded and cynical age can appreciate Mahler in a way that the poor wretched souls of the early twentieth century never could. It is tempting to say our new wisdom will serve us well, but in our collective arrogance we threaten to repeat the mistakes of the past. Undoubtedly, there is a Mahler in our midst, penning strange and incomprehensible music at this very moment, with a disturbing foretaste of things that may eventuate. This time, it may behoove us wake up and listen.

Bernstein conducting the opening to Mahler's Fifth

Monday, June 27, 2011

Rerun: What If No One Noticed I Was Crazy?

This from Jan, 2010. Enjoy ...

The other day, in a conversation with a mental health advocate, I contended that had I been born into a pastoral society in a different century, my bipolar symptoms most likely would have passed under the radar.

Okay, there is a good chance my fellow villagers would have regarded me as weird or eccentric, but they would hardly consider me unfit for my standard pastoral duties of hewing wood and drawing water and the like, not to mention my reproductive obligations.

It’s not just me or my particular illness. I’m including practically all of us, across the full mental illness spectrum. Think about it: No literacy, no books, no classrooms - where was the ADHD going to come from? No doubt people had it. But if a tree falls in the forest and no one hears it ...

What about anxiety? My advocate friend tactfully reminded me that Mongol Hordes and famines and the like would have given our ancestors plenty to be anxious about. She also pointed out that mental illness has been around forever, and that there is ample documentation of this in the ancient world.

True, I acknowledged ...

The conversation came up in the context of what I call the “Nigerian Paradox." Back in 2004, I published an article on mcmanweb that noted that the average Nigerian earns $300 a year and has a life expectancy of 45.3 years. Yet, In 2003, a World Values Survey of more then 65 countries ranked Nigeria number one in terms of happiness.

Then, in 2004, a World Health Organization survey of 14 countries and two Chinese cities found Nigeria way lower in mood disorders (at less than one percent over 12 months) than the US (at nearly ten percent) and the others. In terms of serious mental illness, Nigeria was second-lowest at nearly five percent (Shanghai was four percent). Significantly, US residents with serious mental illness spent 70 days unable to carry out their duties compared to Nigerians at 15.

We have no definitive answers here, but the contrast between two entirely different worlds gives rise to all manner of legitimate speculation. The two which come most readily to mind include community ties and social stresses. Indeed, you can make a very good case that mental illness is an industrial and post-industrial disease, but I’ll save that for another day.

This is all about my big mouth and my under-the-radar hypothesis. Let’s start with the proposition that at a very tender age we are jammed into crowded classrooms, then, at a less tender but far more malleable age, into crowded workplaces. Add to this the fact that society attaches to both very high (and typically unrealistic) expectations. We must produce or else. We must toe the line or else.

Hello? Not only are we going to be a lot more stressed than our ancestors - we are going to be noticed. Case in point: Back in the late eighties, in a work-induced sleep-deprived state of anxious mania, I stormed into my boss’ office in a crowded newsroom and quit my job. Just like that, I became a pariah, an outcast, with no hope of redemption.

Forgive me for speculating, but let’s find a different venue for my mad scene, say a remote pasture 300 years ago. “I hate you cows!” I can see myself raging. “Cows suck!”

Boy, that would have got me fired fast. But suppose two or even three people noticed. What would they be thinking? Can’t trust this guy around the cows? Maybe, but we’re in a pre-industrial age, here, or, to be more precise, pre-post-industrial. So what my fellow pastoralists are definitely NOT thinking is: Good cow management requires highly advanced people skills. Not to mention razor-sharp cognition. Let’s get rid of the guy.

As long as I remember to close the gate before I go back to my hovel, my job is secure. And if I really do need time off? Fifteen days tops, is my guess. Same as the Nigerians. Imagine that, 15 days and I’m rehabilitated, back in my community. How does that feel?

Now compare this to how I felt back in my own time when I came to the realization that I would never be employable in my chosen profession again. On the other hand, forget it - even more than two decades later the memories are still too painful.

Moving on, we have the small matter of the Mongol Horde factor to consider, the one that my friend brought up in our conversation. I have to admit she had me stumped, but the next day an answer jarred loose. This is why I love conversations with smart people, which makes living in a post-industrial society well worth it, but I digress. Anyway, consider:

Suppose Genghis Khan and his clansmen were on the horizon. Would not EVERYONE be going crazy? Not just you? Even if you were to go a bit more crazy than the others, all things considered, who would notice?

I don’t want to create any false impressions. Life back then was nasty, brutish, and short. Heaven help if my symptoms were to attract serious attention. Heaven help if my village were to turn on me. Chained to a wall the rest of my miserable life would be my likely fate.

All I am saying is that back in the old days, it would have taken me much longer to cross this attention threshold. My internal hell back then would have been no different, only the types of behavior it triggered, such as taking it out on the cows. And, if no one noticed - if there were no external hell to pay for my internal hell - then what would that have done for my internal hell?

Just asking ...

Friday, June 24, 2011

Joshua Walters - On Being Just Crazy Enough

This guy spoke at our NAMI San Diego several months ago. Enjoy ...

Antipsychotics - Wonder Years to Cynicism

I've spent the last three days updating and rearranging three of my mcmanweb articles on bipolar meds. Following is an edited extract from a much longer new article on antipsychotics ...

The Wonder Years

Antipsychotics were discovered by accident in the 1940s. The introduction of Thorazine as a "neuroleptic" or major tranquilizer in the early 1950s promised to do to psychiatry what antibiotics and other "wonder drugs" did to internal medicine. Indeed, deliverance from psychosis could be regarded as a medical miracle, and over the next ten years 50 million patients were administered the drug. Haldol, which came a bit later, is the best-known old-generation antipsychotic still in service.

The drugs bind to the neuron's dopamine D2 receptors, blocking dopamine transmission in the brain's mesolimbic pathway, thus serving as a damper against the type of overstimulation that results in psychosis. Unfortunately, antipsychotics also act on other dopamine pathways, resulting in a very high cost of doing business.

The introduction of Risperdal and Zyprexa in the early and mid 1990s raised false hopes of a "new and improved" class of antipsychotic. These new generation antipsychotics (referred to as atypical antipsychotics) bind more loosely to the dopamine D2 receptors, which reduces the risk of side effects such as EPS and tardive dyskinesia. In addition, there is a downstream serotonin affect. But their actions on other brain (and physical) systems creates a whole panoply of additional, and equally troubling, side effects.

Similarly, the introduction of Abilify in the next decade generated a buzz over a new breed of "Goldilocks" atypical antipsychotic that was purported to be "just right." But by then the reality was setting in that the new antipsychotics were simply newer versions of the old antipsychotics, albeit with better side effect profiles in certain respects, worse in others. Certainly, the proliferation in brands of the new antipsychotics is justified in giving patients a choice, but the principal choice appears to be in terms of side effects rather than efficacy. Annual world sales of antipsychotics total about $20 billion.

Cynicism Sets In

The 2005 publication of Phase 1 of the NIMH-underwritten schizophrenia trials (CATIE) served notice that the new generation meds were no more effective than the older ones. Moreover, only 26 percent of the patients completed the 18-month trial, a figure that corresponds with other clinical trial drop-out rates. The later publication of successive phases of CATIE revealed an extremely depressing picture of medicated patients struggling with both their illness and side effects, with low quality of life, and in terrible physical shape.

All of this information had long been available to the psychiatric profession - in studies published previously, on product labeling, and in daily litanies of complaints from patients - but only in light of CATIE are doctors actually beginning to pay attention.

Basically, the pharmaceutical industry oversold psychiatry on the new generation meds. Psychiatrists, in turn, paid more attention to smooth-talking drug reps than to their own patients. We know these meds work well in certain specific contexts (such as quickly knocking out mania and psychosis), but we need to accept their limitations and exercise sound judgment in using them.

Supersensitivity Psychosis?

Robert Whitaker's 2010 "Anatomy of an Epidemic" raised the talking point that antipsychotics may create the ironic effect of worsening the course of psychosis, perhaps to the point of no-return. Whitaker presents his argument as unassailable fact, but the evidence is far more tenuous.

Whitaker bases his case on the investigations of Guy Chouinard and Barry Jones of McGill University back in the late 1970s.

Supersensitivity psychosis is analogous to rebound symptoms that occur in other illnesses when a medication is abruptly withdrawn or too rapidly lowered. In this case, we are talking about the brain, over the course of long-term antipsychotic administration, habituating to the med. In response to dopamine blockade from an antipsychotic, post-synaptic neurons compensate by increasing their receptor binding sites, setting up - the hypothesis goes - the ironic side effect of psychosis.

Chouinard and Jones clearly regard the effect as temporary, which may be countered by meds adjustments, which you won't find mentioned in Whitaker's book. Whitaker does bolster his case with a 15-year longitudinal study by Harrow and Jobe that found that patients with schizophrenia who weaned off their antipsychotics fared significantly better over the long term than those who stayed on their meds. What Whitaker failed to mention was the patients who went off their meds had been identified at the beginning of the study as "good prognosis" patients.

Lest we dismiss Whitaker as a mere propagandist, a prominent Harvard psychiatrist, Andrew Neirenberg, in a 2011 response to a Massachusetts General Hospital grand rounds delivered by Whitaker, purported to "repudiate" and "refute" Whitaker but wound up instead comparing Whitaker to Sarah Palin and other such nonsense without firing back with even circumstantial evidence of his own. (A full account is provided in my blog piece, Whitaker vs Quack Psychiatry, Part II.)

In short, Whitaker's interpretation, if not authoritative, is at least credible. At the very least, his thesis supports the easily observable phenomenon of a good many patients who only seem to get worse on their antipsychotic meds rather than better.

Nevertheless, Whitaker Is a Wimp

It turns out that the harshest critics of antipsychotics are those engaging in cutting edge schizophrenia research. John Krystal of Yale, for instance, told a packed room at the 2007 American Psychiatric Association that antipsychotics "aren't that great," especially when dopamine hyperactivity "can't account for the sustaining features of schizophrenia." Dr Krystal is researching a new class of meds targeting the GABA-glutamate pathways.

Ironically, should a completely new class of drugs find their way to market (which has not happened since the 1960s), the strongest critics will turn out to be the very drug companies that marketed their antipsychotics as the best thing since sliced bread. Then we will be exposed to drug industry marketing along the lines of how their newest best thing since sliced bread leaves their old best thing since sliced bread for dead.

Alas, both the hype and the criticism obscure one important fact - that for a good many people antipsychotics have been a godsend, or, at the very least, have offered an invaluable leg-up to individuals in distress. Don't expect miracles, use wisely.

Further Reading from McManweb 

Antipsychotics * Lithium and Mood Stabilizers * The Problem with Bipolar Meds * Treating Mania * Treating Hypomania * Treating Bipolar Depression

Tuesday, June 21, 2011

The Child Bipolar Diagnosis is Under Attack - Yet Again

It’s the silly season again, when people who attack the child bipolar diagnosis come out in force. Trust me, any time a child is labeled with a very serious lifetime  psychiatric condition is always cause for concern, but the operative word is “concern,” not propaganda based on hidden agendas masquerading as concern.

The first attack is in the form of a June 8 article in the New Scientist by author Jon Ronson. “Bipolar Kids: Victims of the Madness Industry?” it reads, drawn from his new book, The Psychopath Test. “The problem is the apparent epidemic isn’t real,” Ronson asserts.

Oh, really?

The next is a June 19 article in Newsweek by Stuart Kaplan MD, who has expert credentials as a child psychiatrist. The article - "Mommy, Am I Really Bipolar?" - is adapted from his new book, Your Child Does Not Have Bipolar Disorder. “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood,” Kaplan flatly asserts.

Except, perhaps, for a whole bunch of kids who cycle in and out of depression and mania?

Oh, THAT evidence. Well, no, says Kaplan. These kids are really ADHD or oppositionally defiant. Or have something called “temper dysregulation disorder.”

This is much the same argument Ronson makes, the anything-but-bipolar argument. It cannot possibly be bipolar. It has to be something else. “Attention deficit disorder,” he quotes a friendly doctor.

Close enough.

Except when it misses by a country mile. This from Julie from about ten years back, whose six-year-old kid was diagnosed with ADHD:

Doctors will not officially diagnose a child this young with bipolar. ... No one can possibly relate to the problems a mother must endure for a child like this. I ask God several times a day why couldn't I have just had a normal child. Why must I fight to get his medicine right? Why must I miss work to care for him? Why can't we go out to eat without an episode? I also have two girls (ages two and 12 ) that must watch his behavior escalate to the point where he knocks holes in the walls, pees in the closet and tears up his and their favorite toys. I feel so alone and drained. I have nowhere else to turn.

At least these days no one save the antipsychiatry movement is advancing a conspiracy theory having to do with Pharma pathologizing and medicating “normal” kid behavior to boost revenues. Kids who knock holes in walls and pee in closets definitely require some kind of therapeutic intervention. No one is seriously arguing otherwise.

Back in the 1990s, Joseph Biederman of Harvard began publishing articles to the effect that some of the so-called ADHD kids in his clinic were behaving in ways that more closely resembled bipolar. The issue is extremely complex and confusing, as ADHD and bipolar symptoms overlap plus a good many kids would qualify for both diagnoses.

Coincidentally, a good many parents were noticing much the same thing in their own kids. The ADHD meds weren’t working their customary pharmaceutical magic. Antidepressants were making them even worse. Based on the reports of these parents, Janice and Demitri Papolos did their own investigations and published “The Bipolar Child.”

Ronson and Kaplan respond with saddles blazing, replete with the oft-cited tragic death of four-year-old Rebecca Riley (Ronson cites 60 Minutes’ shameless spin as if it were authority). The two authors predictably attack Biederman (and Kaplan the Papoloses) for failing to accomplish Mission Impossible, namely in coming up with a fool-proof universally acceptable and objective diagnostic standard. Earth to Ronson and Kaplan: Diagnostic psychiatry is all sloppy and controversial and subjective.

To bolster his case, Ronson takes the bizarre step of interviewing the two most subjective diagnosticians of all time - Robert Spitzer and Allen Frances, who headed up the DSMs III and IV, respectively. Anyone who is vaguely familiar with Dr Spitzer is aware of his pathological resistance to even the slightest changes to what he regards as his baby. Dr Frances, on the other hand, has come across in recent writings and interviews as a sinner in search of some kind of war crimes tribunal to plead guilty to.

Really, there needs to be a DSM diagnosis for people who head up DSMs.

Dr Kaplan at least grounds his criticisms in his own clinical experience, or so he claims. But, then again, is Dr Beiderman’s own clinical experience no less valid? Isn’t the real point that when it comes to kids in distress, there are no easy answers? That our diagnostic and assessment tools are very blunt instruments at best?

If only bipolar meds did for bipolar kids what ADHD meds do for ADHD kids, we wouldn’t be having this argument. Alas, with bipolar - in kids and adults - there is no quick chemical fix. A kid diagnosed with bipolar is not going to simply get better with bipolar treatment. Quite the opposite, bipolar meds are likely to make the kid worse. We all like easy answers. The easy answer is to flatly deny that bipolar in kids even exists. That it has to be something else: ADHD, conduct disorder, even a new DSM-5 diagnosis concocted totally out of thin air - “temper dysregulation disorder with dysphoria.”

Anything but bipolar. It would certainly be a much happier world if that were the reality. Alas! Reality ...

Further reading from McManweb:

Child Bipolar I
Child Bipolar II
Child Bipolar III
The DSM-5 - Grading Child Bipolar
Are We Over-Medicating Our Kids?
Spitzer and the DSM

Monday, June 20, 2011

Blue Moon Musings

I wrote this at the end of 2007 for my Newsletter, then republished it on mcmanweb. Today, I happened to reread it, and actually liked what I read. So without further ado ...

Every once in a blue moon, I feel I need to get a thing or two out of my system. I don't expect anything to happen, but I feel better already:

Letter to Psychiatrists

You saved my life and continue to inform it, and for all that and a lot more I am extremely grateful. But I have a simple question or two for you:

You are all MDs. So why did it take you so long to wake up to the fact that some of the meds you prescribe actually make a lot of us a lot worse, and may in fact kill some of us? The CATIE studies from a couple of years back should have come as no surprise to you. Essentially the same facts for years have been clearly labeled on the very meds you prescribe. And the extended version of these warnings has long been available in the psychiatric journals you subscribe to, together with long-term studies that show drop-out rates ranging from 60 to 100 percent.

In other words, in some studies (including one of the test meds in the CATIE trials), no one actually finishes the study.

Your patients, needless to say, have been telling you all this since the beginning of time. When they complain to you about feeling like fat stupid zombie eunuchs on the meds you prescribe, they are not doing this to ruin your day.

Bear with me.

Check out your waiting room. See the one who looks like Heidi Klum? That's the pharm rep. So who would you rather be talking to, Heidi Klum or a patient? Me, too, and therein lies the problem.

Take another look in your waiting room. See the Russell Crowe look-alike? Say no more. You may think that you are above Heidi and Russell's blandishments. The drug companies have billions of dollars invested in the proposition that you are not.

Consider: You are talking to a patient who definitely does not look like a Victoria's Secret model, thanks in large part to the meds you put her on. And she's telling you a story that completely contradicts the sales pitch you heard from the Heidi Klum look-alike.

“My psychiatrist doesn’t listen to me,” is by far the most common complaint I hear from patients.

A modest proposal: Inform the pharm reps through your receptionist to leave their samples and literature at the door. Your office and your waiting room are for patients and their loved ones.

Letter to the Pharmaceutical Industry

Thank you for slowing down my brain. It used to run away from me and make me lose control, but thanks to you I now have a life. But I have a few simple questions for you:

You employ some of the smartest people in the world. So why haven't you developed some smart meds? The ones you market for our illness are extremely blunt instruments, at best. All of them are the result of serendipitous discovery. Virtually all of them are based on meds that were introduced during the fifties.

Is it too much to ask you to come up with, say, some smart dopamine meds? It seems you were all so busy putting your energy into serotonin me-too drugs that you forgot all about the neurotransmitter next door.

Yes, you are making billions off of the dopamine-enhancers and dopamine-blockers you have in stock, but now your patents are running out and there’s nothing in the immediate pipeline. You oversold all of us on new-generation antipsychotics. When all is said and done, there is very little new about these drugs. In the final analysis, they're basically Thorazine with the tires rotated.

Another point: Stop acting as if one size fits all. I know that getting an FDA approval to treat big demographics illnesses such as depression is a license to print money, but that approval is based upon 50 percent of patients getting 50 percent better, which a lot of us don't find terribly acceptable. It would be much more helpful if you were to break depression down into component parts. Say a depression which featured lack of motivation and loss of energy, and another depression that involved agitation, and so on. My guess is if you adopted this strategy you could come up with something that would get 80 percent of patients 80 percent better across a vast range of niches.

And if people actually started feeling better on their meds they might turn out to be compliant. So, even in a niche, you could push through a lot of volume and make your shareholders more than happy.

I'm not through: I'm strongly getting the impression you guys are like the auto industry. Same old engines, new fins. In case you haven't noticed, Detroit probably won’t be around ten years from now.

You are the only industry that doesn’t talk to its customers, the end users of your products, and it shows. You certainly haven't sent any Heidi Klum look-alikes to my door.

Letter to Therapists

The coming-of-age of the short-term talking therapies, such as cognitive-behavioral therapy (CBT), has been one of the most encouraging developments in mental health. CBT helped move me out of my eternal rut, and for that I am extremely grateful, but I do have a gentle reminder for you:

What makes these therapies work is you, not the manual you are working from. You have one shot in getting the therapeutic relationship off to a good start, and if you mess it up you can forget about a second appointment.

A sure relationship-killer is your attitude that we need to be doing what is best for us. No one likes to be treated like a child, least of all you, so stop referring to us as difficult or noncompliant when we sensibly rebel against your authority. Yes, I know we need a good swift kick in the pants, but you need to figure out a way to deliver that kick so we end up thanking you for it.

Letter to Complementary Practitioners and the Recovery Movement

The heavy lifting in my recovery these days derives from sound principles (such as good nutrition and managing stress) that I should have learned from the MDs charged with treating me, but instead learned from you. So thank you for practicing good medicine. I know that you know that you are operating in an unregulated field where quacks abound and prey on our desperation and vulnerabilities, so I will merely raise a minor semantic quibble:

Please stop talking about the "medical model" and the "recovery model" as if they are two distinct and mutually antagonistic entities. For nearly all of us, recovery is a nonstarter without a proper diagnosis and treatment with meds. If you need to make distinctions, try going with "stabilization" and "recovery" in the context of a progression from one to the other.

We don’t want to give patients the false impression that they don’t need psychiatrists. Otherwise, we will create a whole new class of individuals faced with having to recover from the recovery movement.

Letter to Antipsychiatrists

We badly need a thorn in the side of the establishment, but you guys are way too far out of touch with reality to qualify. First, despite what you may wish to believe, the brain is not undifferentiated tofu. There is a biological component to mental illness, and - this just in - Hippocrates is describing mood swings.

Not only that, you don’t have to be voting age to have a mental illness. Kids are quite capable of having bipolar, for instance, and the compassionate response is to treat them, even with antipsychotics if necessary, rather than turn your back on them.

Earth to antipsychiatry movement: If you continue to deny that mental illness exists and other nonsense, the government is likely to interpret that as permission to cut funding for research and treatment and services.

Oops! I forgot. You believe that research and treatment and services is a big pharma plot to enslave the population. Never mind.

Letter to Mental Health Advocates

I love what you do, but let's face it - we are where the AIDS/HIV movement was in 1982 and where polio was in the 1920s and I see little sign of change.

History lesson: Once the gay community got out denial and stopped squabbling amongst themselves, they lined up the media and Hollywood and succeeded in getting the government and the medical community and pharmaceutical companies interested and involved. This may be over-simplified. "And the Band Played On" by Randy Shilts will give you all the nuances.

The numbers tell the story: For every dollar the NIH spends on AIDS/HIV per patient, we get one penny for mood disorders.

We have a long way to go.

Letter to the APA's DSM-5 Task Force

Whatever you come up with, please be sure it reflects my reality and the reality of people I am constantly talking to. In order to do that, you either need to be talking to me or the people I talk to.

I know you talk to a lot of patients in your practices and in your research, but basically you are either seeing us at our worst or inside the confines of a doctor-patient or researcher-subject relationship.

You really don’t know us.

If you want real patient involvement on your project, you need to get to know us as well as the Heidi's and Russell's who drop by your office and take you out to fancy restaurants. So why don’t we do a happy meal together sometime? My treat.

Update, Jan 14, 2011, three years later: Oh, sorry. Was I supposed to call you?

Letter to Researchers

Please do not leave the field. I know how discouraging it must be for you, these days. Several years ago, at a NAMI gala fundraiser in October, I heard A John Rush MD of the University of Texas at Dallas talk about how difficult it was for researchers these days to get their funding requests approved. I think I heard him say that only one in 20 grant proposals came back with a “yes.” In the old days, he said, it was more like one in four or five.

I can only assume that the odds are stacked a lot higher against you if you are viewed as some kind of outsider.

You are the smart people in a culture that celebrates dumb. You’re being marginalized to the same economic fringe inhabited by artists and musicians, but even musicians unfamiliar with the concept of intonation are regarded as cool. What is your reward?

A researcher forced to find employment elsewhere, in my opinion, is the equivalent of the burning of the Library of Alexandria and the Sacking of Rome. It is a crime against civilization.

On this Website and elsewhere, I draw attention to your contibutions to knowledge. In this piece, I choose to honor you for the studies you may never get to do.

Letter to the President

We are your constituents. You may not know that, as we don't vote. Okay, I do, but with the same degree of enthusiasm as I have for going to the dentist. So you are not exactly motivated to learn about us. Interest groups representing people who actually vote are deservedly more worthy of your time, but if I can cut in for just a second ...

Current mental health policy works like this: It is cheaper to lock us up in jails and prisons than treat us in hospitals, which is why there are way more of us in the criminal justice system than in hospitals.

But this is false economy. It is far more economical to spend money on services to turn us into taxpayers (and voters) than it is to keep us cycling in and out of cages and emergency services at taxpayer expense. Talk to your accountant if you don't believe me.

Whatever you do, don't talk to your economic advisers. They are caught up in the zero-sum game of line items. They will tell you that to raise funding for mental health services, we will have to cut funding for other services. Take my word for it, had Alexander Hamilton displayed a similar lack of genius, the only thing George Washington would have been presiding over would have been the country’s inevitable going out of business sale.

And a brief word on homeland security. Security is not just about the war on terrorism or the war on crime. How secure do you think we feel knowing we are one episode away from the possibility of losing everything? For that matter, how safe is anyone in this country with the healthcare system we’ve got?

Letter to Politicians and Administrators

I moved to California in late 2006, and there I encountered a strange phenomenon: Thanks to a voter initiative involving a special tax on millionaires, the state had billions earmarked for mental health transformation, but they haven't figured out how to spend it. In fact, they don't have a clue. Seriously, if the situation was not so potentially tragic, you could call it a comedy of errors.

An innovations committee (love the oxymoron) spent two or so years putting together a paper that boiled down to eight or ten ways to stop innovation.

Meanwhile, vital mental health services are being cut.

What this tells me is lack of funding is not our worst problem. Systemic incompetence and hubris is. There is probably no way of resolving this except for early retirement for this generation of senior administrators. This is probably true in every state.

A modest proposal: In California, anyway, use the special funding to underwrite early retirement for the people in charge. The sooner they go, the better.

Letter to Loved Ones

I may have bipolar, but you're the ones who suffer from it. So I'll keep this short and sweet: Thank you, thank you, thank you.

Letter to Patients

Since I am one of you, think of this as a memo to self:

We have every reason to feel disenfranchised and angry, but unless we drop our victim mindsets we we are not going to move our lives forward. It is one thing to let off steam. It is another to allow our grievances to immobilize us or excuse us.

The biggest obstacle standing in the way of our recovery is us. For some reason I can’t find an answer for, we get "stuck." I see it all the time. We hover on the cusp of recovery, unable to break through. Meanwhile, we alienate the very people who love us and treat us and work with us.

Maybe it's the fear factor. Bringing change into our lives, even for the better, can be extremely frightening. By contrast, being stuck in "stuck" can be comforting.

In May 2007, I heard Nobel Laureate John Nash at the American Psychiatric Association's annual meeting. John Nash is the Princeton mathematician of "A Beautiful Mind" fame. He was introduced to a rousing standing ovation, then proceeded to read a densely-worded manuscript that he held up to his face.

It is safe to say that ten seconds into his delivery the entire audience was tuned out. Then he began to say something that made my ears perk up. He said, in essence, that his recovery started when he began to receive recognition for the work he long thought his efforts entitled him to.

In other words, John Nash became unstuck. Something inside his brain shifted. Whatever stood in his way no longer held him back. He may have received his Nobel Prize, but he achieved something far more significant: He won back his life.

Letter to All

Thanks for bearing with me ...

Wednesday, June 15, 2011

Nora Volkow: Stress, Mood, Drug Abuse, and the Brain

Yesterday featured a piece based on Nora Volkow's talk to the 9th International Conference on Bipolar Disorder several days ago. Dr Volkow is the head of the National Institute on Drug Abuse and manages to moonlight as one of the world's leading brain scientists. Yesterday, we had a look at her work on functional resting connectivity. Today features a selection of slides from part of a much larger presentation dealing with co-occurring mood and substance use disorders. The slides pretty much do all the talking, so I'll keep my commentary brief.

Basically, combine stress with genetic vulnerability and bad things happen. Drug abuse involves much the same process. And, of course, the two interrelate. Lifetime drug abuse amongst bipolars is in the 60 percent range.

An under-active prefrontal cortex combined with an over-active amygdala is a recipe for disaster. There is no end to variations on this theme. This one involves a certain genetic variation (allele). Another variation involves kids, whose brains have yet to mature. As opposed to the heart, Dr Volkow pointed out, the brain takes 20 years to develop. Plenty of time for risk-taking activities, such as drug use. Meanwhile, early childhood social neglect impairs brain development. Too much amygdala action, not enough from the PFC and other areas.

Significantly, a good many of the shared candidate genes for bipolar, schizophrenia, and substance abuse have to do with neuroplasticity. Neuroplasticity has a lot to do with how we react to our environment. If our neurons don't hold up well (such as to stress) and maintain cellular function, well, bad things only get worse. Neuroplasticity also plays a role in programmed brain development, all those gear changes that are supposed to represent smooth transitions into adulthood and beyond. Needless to say, for a good many of us, life is not a smooth transit.

Ah, dopamine.

This is your brain on drugs.

The brain may be highly differentiated, but with everything literally connected to everything in one way or another, mental illness tends to involve a system failure throughout the brain.

Tuesday, June 14, 2011

Nora Volkow and Brain Networks

At this year’s International Conference on Bipolar Disorder held in Pittsburgh, a whole session was given over to Nora Volkow (pictured here), head of the National Institute on Drug Abuse. As well as overseeing a high-profile agency with a $1 billion annual budget, Dr Volkow continues to crank out mind-boggling research. Her latest involves novel brain scan techniques that she pioneered to map out brain networks.

Resting state functional connectivity - savor the resonance. We know, for instance, the amygdala doesn’t operate in isolation, that it is networked to other areas of the brain. But in what ways? We are used to seeing what happens when the brain is activated, but figuring out the brain in its resting state may tell us more. 

The old way of mapping brains in their resting states was to zero in on a target area such as the amygdala and try to pick up what other signals from elsewhere may have been occurring at the same time. According to Dr Volkow (with Dardo Tomasi of the National Institute on Alcohol Abuse and Alcoholism), in an article in PNAS:

More recently researchers have started to use data-driven approaches that are based on graph theory to assess the functional connectivity of the human brain using datasets obtained with MRI.

I have no idea what this means, but the bottom line is the new way is 1000 times faster, which suddenly makes functional connectivity a doable exercise.

In her talk, Dr Volkow described scanning brains in a resting conscious state,  paying attention to oscillations - generally regarded as background noise - across different regions. Oscillations occurring at the same time could be assumed to be part of the same functioning network.  To test this, Volkow and Tomasi analyzed the brain scans of 979 subjects from 35 centers around the world. One of the things they were looking for was “local functional connectivity density.”

Brain hubs, to put it into layman’s terms. In the authors’ words:

Brain networks with energy-efficient hubs might support the high cognitive performance of humans and a better understanding of their organization is likely of relevance for studying not only brain development and plasticity but also neuropsychiatric disorders.

Volkow and Tomasi’s analysis located the mother of all hubs in the posterior cingulate, corresponding with Brodman Area 23. The cingulate snakes beneath the cortex and, among many things, plays a major role in mediating back and forth traffic between the limbic system and cortical regions of the brain. We have known for some time the cingulate acts as a major hub, but if I am interpreting the authors correctly, we are talking Grand Central Station dimensions.

In the image below, the red-orange indicates the highest signal strength, corresponding with the posterior cingulate/ventral precuneus.

The very strong implication is that things going smoothly in the cingulate bode well for things going smoothly in the brain. In her talk, Dr Volkow mentioned deep brain stimulation (DBS) for depression, focusing on Brodman Area 25, in the immediate hub neighborhood. DBS is also being applied to other brain regions that appear linked to BA 25. Food for thought.

From their hub findings, Volkow and Tomasi identified seven overlapping networks covering 80 percent of all the gray matter in the brain. These involved four major cortical networks (default mode, dorsal attention, visual, and somatosensory) linked to four hubs (ventral precuneus/posterior cingulate, inferior parietal cortex, cuneus, and postcentral gyrus), and three subcortical (tied to hubs involving the cerebellum, thalamus, and amygdala).

The authors note that to keep things simple, they kept the hub count low, based on signal strength and volume. I think this means that researchers will be kept busy for a long time mapping out minor hubs. But the low hub count confirms something that experts have known for a long time, namely that all manner of illnesses and conditions share many of the same pathways. Indeed, Dr Volker in her talk pointed out that both drug use and stress increase dopamine activity in the nucleus accumbens.

Below are renderings of the different networks. (Note, postcentral roughly corresponds to the posterior cingulate.)

This is what they look like together:

Here is a simple diagram illustrating the overlap:

Here is a more complex one:

In her talk, Dr Volkow indicated that the evidence points to the brain organized according to parallel architecture rather than central, sort of like this:

The field of resting state functional connectivity is so new that not even Wikipedia has an entry for it.  Don’t worry. It will.

Monday, June 13, 2011

Husseini Manji and Neural and Synaptic Plasticity

One of the featured speakers at the 9th International Conference on Bipolar Disorder was Husseini Manji, former chief of the Mood and Anxiety Disorders unit at the NIMH, now Global Therapeutic Head of Neuroscience at J&J. It was Dr Manji who opened my eyes to brain science way back in 2000, when I was first getting started in mental health journalism. I have heard him speak and interviewed him countless times, and have read no end of articles he has authored.

I did not catch the last day of the Conference, when Dr Manji gave his presentation, but thanks to his PowerPoint slides, I think I can give you an appreciation for some of his pioneering work in the brain science of bipolar. These sample slides represent a taste from a much more complex talk. Never mind the complexities. Let’s focus on the general picture.

Above. I’ve seen this slide displayed by other scientists from the NIMH. “Alleles” in the first caption refers to genetic variations. Genes switch on proteins that regulate cellular activity. Cells are organized into systems, which in turn influence behavior.

Above. Here’s an overview of what happens when things go wrong.

Above. “Plasticity” is the operative word, here. When neurons are compromised in their capacity to maintain cellular function, grow, and connect to new neural networks, bad things happen.

Above. Here are some of the candidate genes that may affect plasticity.

Above. Maybe you can see where Dr Manji is going with this. We are not talking about “bipolar genes” or “schizophrenia genes”. We are talking about genes that affect particular brain functions, which in turn influence how we think and behave. Note the overlap between the various mental illnesses. Note how mood and cognition and psychosis are not restricted to any particular diagnosis. “Phenotype” is the traditional way of looking at mental illness, as symptom clusters. “Endophenotype” looks at what else may be going on (such as a breakdown in neural plasticity).

Above. This is a representation of various signaling cascades inside the neuron that regulate neuroplasticity. If the receptors that feed neurotransmission into the cell aren’t functioning right, intracellular signaling is compromised. If intracellular signaling is compromised, the neuron atrophies and may die. This in turn compromises the neuron’s ability to connect with other neurons (through neurotransmission). Whole neuronal networks (synaptic plasticity) are in turn compromised.

Here we see a representation of a healthy neural network and an unhealthy one. Think of a shriveled tree with few branches.

The anterior cingulate, dentate gyrus (part of the hippocampus), and the striatum are all prime suspects when things go wrong with us. The anterior cingulate plays a major role in modulating brain function and in neural connectivity. The hippocampus is where memories are laid down and where new brain cells grow. The striatum is intimately tied to the dopamine system. Note the differences in neural density in these regions with the administration of lithium.

Above. Dr Manji's summary slide.

Sunday, June 12, 2011

Ten Thousand Ways Our Brains Are Messed Up

One of the major stories in bipolar over the past decade is the growing recognition that the condition is way more than a mood disorder. On one hand, we are talking about the thinking cortical regions that fail to boot up properly, even in euthymic (well) patients. On the other, we are talking about the reactive limbic regions that boot up all too well. Too frequently the neural networks that connect the two are severely compromised. Bad things happen.

At the 9th International Bipolar Conference that wrapped up on Sunday, Stephen Strakowski of the University of Cincinnati presented the equivalent of a master’s class.

Above is a representation of the anterior limbic network (ALN). Forget for the time being about specific brain regions and which region is responsible for what. Instead, check out the arrows in the picture that represent how these regions talk and cross-talk with one another. In a 2006 article on CNS Spectrums, Dr Strakowski refers to the old brain science as a “form of phrenology” that wrongly suggested that specific portions of the brain are associated with specific cognitive and emotional traits. Rather:

More recent neuroimaging studies suggest that emotion regulation is an emergent phenomenon that arises out of specific neural networks and that bipolar disorder represents the consequences of dysregulation in these networks.

Okay, let’s see how this works. In a 2004 brain scan study, euthymic bipolar patients performed as well on a simple cognitive task as the healthy controls, but to keep up the bipolars had to activate more brain regions. Dr Strakowski in his talk disclosed he had originally misinterpreted the results. What happened, he said, on later reflection was that the amygdala (which mediates arousal and fear) in the bipolar subjects lit up like a Christmas tree. To compensate for the over-active amygdala, the bipolars recruited the ventral medial prefrontal cortex (VMPFC). Image below.

So, even in routine situations, our brains are subject to stress. And to make up for it, we have to work the thinking parts of the brain harder. No harm, no foul, right?

In another experiment, Stakowski and his colleagues turned up the heat. This time, the subjects were put through a more complex cognitive task called the “counting Stroop,” which involves sorting out incongruent images in rapid succession (such as the number four spelled out three times). In this task, the bipolars scored rather worse than the healthy controls.

Here’s where it really gets interesting. As the task got more difficult, the controls were successful in easing back and slowing down their reaction times, allowing them precious micro-seconds to bring the cognitive areas of the brain online, in particular the regions involved in impulse-control. The bipolars, by contrast, failed miserably in this regard. They kept plowing ahead.

In another study, involving a facial recognition task, Strakowski and his colleagues found difficulties in bipolars in recruiting the VMPFC to suppress amygdala over-activity, resulting in loss of prefrontal control over the brain. In yet another study, the cingulate in the midbrain failed to sort out background noise. On and on it went.

So, imagine yourself in a crowded room this time, not in a brain scan machine. Even the routine task of talking to someone you feel comfortable with may be stressful. Then a stranger sidles over. Meanwhile, you are finding it difficult to tune out a million and one things going on in the room. Everything seems to be closing in. Then your mother-in-law barges in and starts yapping away.

Maybe you rise to the occasion and handle the situation superbly. But you know there is going to be hell to pay some time later. In all likelihood, you will arrive home, either feeling like a wrung-out dish rag or with racing thoughts - or maybe both - needing at least a precious day of recovery time you don’t have. Heaven forbid if you have an important meeting with your boss first thing in the morning.

Obviously, the recovery techniques we have at our disposal help enormously - from the tricks we pick up in cognitive-behavioral therapy to mindfulness to stopping to smell the roses. But when I addressed the panel on the topic of skills training, I was met with blank stares. Here’s where I am coming from:

Two years ago, at the International Congress on Schizophrenia, I happened to walk into a session entitled, "Optimizing Cognitive Training Approaches in Schizophrenia." From a blog piece, Figuring Our Schizophrenia,  I did soon after ...

Translation: The brain is plastic. As Michael Merzenich of UCSF describes it, "Basically, we create ourselves."

The brain is born stupid, then evolves and becomes "massively optimized to fit into your world."

In recognition of this, a relatively new field is opening up that involves drilling patients in cognitive tasks we tend to take for granted, such as holding a thought in our working memory long enough to lay down new neural roadwork or responding to stimuli in a timely fashion.

New computer programs are being developed and being tested on patients, Sophia Vinogradov of UCSF explains, and we are seeing enduring changes in the cognitive performance of patients six months later.

Naturally, I was flabbergasted to find the panelists at the Bipolar Conference wholly ignorant to this, but then again I wasn’t surprised. Despite the fact that the schizophrenia researchers are light-years ahead of the bipolar researchers (aided by infinitely more research dollars) bipolar researchers do not seek them out. Carol Tamminga of the University of Texas, a prominent schizophrenia researcher, was far more polite when she addressed the Bipolar Conference four years earlier, simply referring to the lack of cross-talk between the two fields.

Fortunately, after the seminar, someone sought me out and validated my query, referring to Dr Merzenich and a website involving his work called positscience, which provides some online samples of these cognitive drills. Bipolar is five years behind schizophrenia, my informant acknowledged.

One more point: The studies Dr Strakowski and others perform are designed to catch us at our cognitive worst. These studies are comparatively easy to design and execute. Studies that would catch us at our best - formulating a creative response, thinking outside the box, reaching an intuitive insight - simply do not exist. We know our brains are precision-tooled for this, and researchers such as Nancy Andreasen of the University of Iowa are studying the phenomena very intently. But there is no way to capture the birth of a creative idea in a brain scan machine.

But at least a picture - good and bad - is beginning to emerge of what is going on beneath the hood. And in this type of self-knowledge lies the key to leading more fulfilling lives than we could have imagined when we were initially blindsided by this illness. Be hopeful. Knowledge is necessity.

Saturday, June 11, 2011

Awards Night at the Bipolar Conference

I’m 38,000 feet over the American heartland, maybe only 37,000 feet. In another 30 minutes or so, we’ll begin our approach into Phoenix. If I don’t have to run to catch my connecting flight to San Diego, I’ll upload this from the airport. Assuming I haven’t spilled cranberry juice over my keyboard, of course.

Last night was the 9th International Conference on Bipolar Disorder’s Mogens Schou Awards and Dinner at Pittsburgh’s Carnegie Museum of Natural History. The Awards have special significance to me. Four years ago, at the 7th International Conference, I was one of the three honorees, for Public Service. My email signature proudly discloses this fact. I have no intention of undisclosing it.

The Award is named in honor of the late Mogens Schou, who established the benefit of lithium in the treatment of bipolar, thereby improving the lives of millions.

I find myself standing in the same alcove as four years ago. David Kupfer, one of the conference organizers (and Chair of the DSM-5 Task Force) opens the proceedings, then introduces Ellen Frank (pioneer of interpersonal and social rhythm therapy), who hands out the first award of the night - to Mark Frye of the Mayo Clinic for Education and Advocacy.

Dr Kupfer presents the second Award - Research - to Marion LeBoyer of the University of Paris.

There is one plexiglass statuette on the table. David Miklowicz (author of the Bipolar Survival Guide) approaches the platform to present the Public Service Award to Muffy Walker. Here I am with Muffy’s camera and the battery has gone dead. Someone with a PhD or MD or maybe both standing next to me confirms it. She holds Muffy’s camera. I whip out my iPhone. This means no shooting through a telephoto lens from a discreet distance.

Muffy is called to the stage. Four years ago, Muffy founded the California Bipolar Foundation, later to become the International Bipolar Foundation, already making an impact. Muffy also lives in San Diego, and I had long worn out my joke that there is not enough San Diego representation in the Public Service category.

Muffy gathers her Award. I swoop in to get an iPhone close-up, then flit back into the shadows. Muffy tells us she worked in mental health as a nurse and is married to a doctor, but when their young child was diagnosed with bipolar both of them were at a loss. This got her started in advocacy. This connected her with families everywhere. She lets everyone know her kid is doing well now. She expresses her gratitude to everyone in the room.

You feel it. This is why we are all here. This is what it is all about. Then I remember my immediate mission. I swoop in with my iPhone before either Muffy or Dr Miklowltcz can clear the platform. I get them to pose as I click away. Hold up the Award, I instruct Muffy. She is beaming from ear-to-ear. It is a special moment.

I know what it’s like.

Friday, June 10, 2011

Brain Dead From The International Bipolar Conference

Above is a sample of what I sat through this morning in Pittsburgh. The slide was from one of three talks in a symposium entitled "Cognition (Basic and Functional)," otherwise known as "Ten Thousand Ways Our Brains Are Messed Up." My coffee failed me this morning, so I have a lot of personal insight into this sort of stuff. Basically, I droop on the Stroop, bad reporting on the Wisconsin Card Sorting, total lack on the N-back. As for following the talk ...

Chill break in my room right now. Then out to a dinner function. I'm flying out tomorrow and will have a lot of cool stuff to report on when I get home, provided the airline doesn't lose my brain. (Don't laugh - the airline once lost my sun tan, but that's a different story.) Over and out ...

Thursday, June 9, 2011

Speed Blog - International Bipolar Conference

Just got back from a dinner function at the 9th International Conference on Bipolar Disorder in Pittsburgh. A few quick observations before I hit the sack:

At the opening session on Medical Life Style Management, Fouzia Laghrissi-Thode of Hoffman-La Roche advised that we have to look away from psychiatric conditions as isolated conditions. Rather, we are talking about systemic illnesses, involving many systems. Other speakers on the panel made much the same observations, pointing out the interconnections involving cardiovascular and metabolic diseases, bad sleep, mood disorders, and no end of other stuff. Said Michael Ostacher of Stanford, our focus needs to shift from solely on improving mood to improving well-being.

The second session involved the DSM-5. The panel, comprising members and consultants on the work group responsible for coming up with changes to the bipolar diagnosis, all pointed out that mood disorders existed on a spectrum, “analogous to blood pressure,” as legendary Swiss diagnostician Jules Angst put it. Dr Angst pointed out three dimensions to the spectrum: 1) from depression to mania 2) severity (from “normal” to pronounced symptoms) 3) temperament (a permanent condition over a lifetime).

The catch though, said Ellen Frank of the University of Pittsburgh, was that although the reality is not categorical, the DSM has to be in order to give names and provide cut-off points. Major catch. Is a “mixed” depression, for instance mandate at least two mania symptoms or three? Is two days long enough for hypomania or should it be four?

A couple of psychiatrists I talked to later compared the exercise to counting angels on the head of a pin. The distinctions were way too subtle for the real world of clinical practice, they pointed out. The research psychiatrists I talked to stressed they need these fine distinctions for research purposes. Why can’t they make it simple, I asked one research psychiatrist - feeling good-feeling shitty. The clinical terms are euphoric-dysphoric.

I’ve been very critical of the DSM-5 on this blog, but I want to point out that the experts on the panel over the years, in particular Ellen Frank and Trisha Suppes of Stanford, have been very helpful to me in pointing out the ins and outs of the mood spectrum, mixed states, and the many faces of hypomania. But nothing I heard today alters any of my previous criticisms.

After lunch, Nora Volkow, head of the National Institute of Drug Abuse, delivered a tour-de-force presentation on the fine points of everything about the brain. The brain doesn’t work in isolation, she noted. The brain works in networks. The brain takes 20 years to develop as opposed to the heart. Genetic time-bombs may be triggered anywhere from the fetus to right now. Our genetic predisposition to how we react to the environment may determine whether our behavior is controlled or automatic. In essence, when things go wrong, the prefrontal cortex fails to effectively modulate the amygdala.

“Resting functional connectivity” - you will hear a lot more on that in future blog posts, along with an area of the brain called the “habenula.”

Another session on circadian rhythms and brain imaging, poster session, chill break, dinner function. I run into my longtime friend Bill Ashdown from Canada, very active in international advocacy, great catching up.

More later. To bed. This is John McManamy, live from Pittsburgh ...

Live at the Bipolar Conference

Pittsburgh, Wed, 6:40 AM. In another hour, I’ll be registering for the 9th International Conference on Bipolar Disorder. The conference is hosted by UPitt and the Western Psychiatric Institute and is held every two years. I’ve been attending since 2001. I arrived in town yesterday afternoon, following a brief family visit back east. I’m looking forward to hearing conversation on the DSM-5, which I have reviewed in a good many of my blog posts here, under such headings as “Light a Match and Start Over.”

A good many of the experts who had a hand in the DSM-5 will be at the conference, including David Kupfer, who heads up the DSM-5 Task Force and who has been one of the Conference organizers since its inception.

I arrived here yesterday afternoon. I checked into my hotel, and in the elevator bumped into Michael Berk of the University of Melbourne. I pointed to a strange looking cylindrical bag slung over my shoulder. “You won’t believe this,” I said. “I’ve got a didgeridoo in here.”

In my room, I settled down by honking into my didge for a half an hour. I play it into a pillow to ensure no one calls 911. The room has been comped by the Conference organizers by virtue of the Mogens Schou Award for Public Service I received four years earlier. Real towels in my room. This is the life.

In my real life on the road, every room is always right across from the elevator and the ice machine.

Later, as I’m strolling through the lobby, I happen to bump into Muffy Walker, also from San Diego, this year’s Mogens Schou Public Service honoree. Muffy is the founder and prime mover of the International Bipolar Foundation, established a few years ago and already making an impact. “We don’t have nearly enough San Diego representatives in the Public Service category,” I joke to Muffy. “I’m going to file a complaint.”

This is John McManamy, live from Pittsburgh ....

Rerun - Les Paul: Guitar Hero

From Aug, 2009. Today would have been his 96th birthday ...

"When you're my age, you know that the end is in sight. How do you handle it? You live for the moment. The past is gone and the future isn't here yet. And you ain't gonna change it, no matter what you think. And so the most obvious thing to do is right now." - Les Paul, last year, at age 93.

Les Paul's remarkable career began at age 13, in 1928, playing guitar in a traveling cowboy band. In 1941, using parts from a telephone and radio mounted on a piece of wood, he devised the first solid body electric guitar. In 1952, Gibson went into production with its celebrated Les Paul model. The world would never be the same.

From a background instrument that could barely be heard, the guitar became a lead instrument, capable of an immense array of sounds that transformed virtually every genre of music and set the scene for rock 'n roll.

Les Paul also single-handedly invented multitrack recording, once again changing how we hear music. He performed with the likes of Nat King Cole and Bing Crosby, and during the 1950s recorded his own string of hits as a soloist and with his wife, vocalist Mary Ford.

In celebration of his 90th birthday, in 2005 he recorded an album featuring guest appearances by Eric Clapton and other luminaries. The album earned him two Grammy awards to add to an earlier performing Grammy from 1976 as well as technical Grammys.

In 1983, he began doing weekly gigs in a small New York club, Fat Tuesday's. In 1995, he changed venues to the Iridium, another small venue, where he continued to perform until June this year. Les Paul died yesterday. He was 94.

On today's NY Times is an extraordinary 15-minute video interview from last year, at age 93, recorded before and during a recent Iridium gig. The image above is a screenshot from the video.

Monday, June 6, 2011

On the Road

I’m here in San Diego Airport waiting for a plane that’s going to be 38 minutes late. WTF? I hold up on my end of the bargain and show up on time. Maybe next time I’ll be the one 38 minutes late. See how they like it. Trust me, I busted my ass getting here on time. A quick rewind:

Sunday morning: I position myself in front of my desktop, cup of Irish breakfast tea. Time to start preparing for my Pittsburgh trip later in the week. Leisurely I dial up my Travelocity itinerary. Something about my flight leaving 06/06. That can’t be right. That’s tomorrow.

Tomorrow! Shit!

Can’t be. I must have booked it wrong. I’m supposed to be attending the 9th International Bipolar Conference in Pittsburgh starting - let’s see - the 9th. And a family stopover before hand, let’s see ...

Nothing to worry about. Three days of work to do in one day, no big deal, if I give my laundry a miss. What the hell, clean underwear is over-rated, anyway.

Monday 1 AM: I kind of have everything packed. Biggest strategic decision - do I bring my didgeridoo? Is a bear Catholic? Next biggest strategic decision - what do I forget to bring this time? My horse collar travel pillow? A cable to one of my zillion electronic devices? I know - the earbuds to my iPod.

Monday 6 AM: Note to self - shaving in this particular state of pre-coffeeness is not such a good idea.

Monday 7:30 AM: I’m outta here.

Monday 8:30 AM: Why do all the people on the parking shuttle have green complexions? Shit! I left my real glasses in my car. I scramble to correct the situation. Situation corrected. Complexions normal.

Monday 10 AM: Through security, through mandatory news store stop (ha! no travel pillow purchase this time, ah! earbuds), through breakfast (yay! a new Jamba Juice concession). Engage earbuds, chamber music, ahhh ...

This is John McManamy, live on the road ...

Sunday, June 5, 2011

Remembering Marilyn

Marilyn would have been 85 on June 1. I wrote this 10 or 11 years ago for mcmanweb. I would write a much different piece today, with far less emphasis on bipolar, and hopefully I will get around to writing that piece. In the meantime ...

On April 10, 1962, Marilyn Monroe arrived on the set of the bedroom farce, "Something’s Got To Give," for costume and screen tests. Producer Henry Weinstein described her as "at her best," but later that same evening he found her unconscious from an apparent sleeping pill overdose. Weinstein pleaded with the executives at Fox to delay shooting, but with the studio teetering on financial collapse as a result of the white elephant, "Cleopatra," they badly needed their most bankable star to bail them out.

Marilyn most likely was dealing with bipolar. And, of course, she was Marilyn. An AMC documentary from the early 2000s, "Marilyn Monroe - The Final Days," recounts what happened next:

Shooting was delayed a week while Marilyn went to New York to be with her mentors, Lee and Paula Strasberg. She returned energized, but with a bad cold that rendered her cinematically hors de combat. The studio rejected their own doctor's recommendation that production be postponed a month. One week later, Marilyn reported to work, only to collapse on the set the next day.

A short time earlier, US Attorney General Robert F Kennedy had entered Marilyn’s life. Marilyn confided in Weinstein of her impending first date and sought his advice on what kind of questions she should be asking. A week later, when Weinstein enquired how it was going, Marilyn cheerfully replied, "I don’t need any more questions."

Then there was Robert’s older brother, President John F Kennedy. Marilyn skipped a day of shooting to pant her famous rendition of "Happy Birthday, Mr President" in a gown that anticipated Jennifer Lopez by 40 years.

Meanwhile, the set at Fox resembled an armed camp, with director George Cukor at odds with both Marilyn and producer Weinstein, frustrated actors, an unhappy crew, and Fox executives on the warpath over Marilyn’s absences.

But the Marilyn captured on film completely belies the sound and fury behind the scenes. The screen fairly lights up with her presence, and a nude pool scene, painstakingly reconstructed from footage in the vault, stands as Exhibit A for why there has been no one like her before or since.

But soon after the pool scene, she disappeared for the weekend, then called in sick. When she returned to the set, she seemed to lack focus. Speculation has it that RFK may have broken off the affair.
By now, filming was 11 days behind schedule. Marilyn had worked for but 13 of 30 production days.

When she called in sick for the 17th time, Fox fired her. Marilyn was humiliated and began believing reports that she was all washed up, but then she rebounded to wage a spirited public relations campaign which resulted in the studio doing a complete about-face, signing her to a $1,000,000 two-picture contract. With shooting on "Something’s Got To Give" set to resume with a new director, Marilyn was back with a vengeance.

Then, days later, on the morning of August 5, Marilyn’s housekeeper noticed lights on in her room. She opened the door to discover why. Marilyn was dead from an overdose of sleeping pills. She was 36.

Marilyn’s bipolar is the most likely explanation for the incredible and unpredictable ups and downs that governed her final days and resulted in her tragic ending. Testimony from her personal physician and the fact that her mother was institutionalized lend credence to this view. Clearly another factor was the sheer magnitude of her personality (with elements of narcissism and borderline personality disorder entering into it).

A vulnerable person physically and mentally not ready for the demands of shooting another film, she had been placed in the impossible position of carrying an entire studio’s fortunes on her shoulders. Add to that her fears that maybe she could no longer live up to her larger than life Marilyn Monroe persona, and add to that the deflation of her grandiose bubble that she could be a future President’s wife. Who knows what else was going through her mind? Something had to give. Something did.