Stigma-Buster of the Year: Nassir Ghaemi

When times are good and the ship of state only needs to sail straight, mentally healthy people function well as political leaders. But in times of crisis and tumult, those who are mentally abnormal, even ill, become the greatest leaders. We might call this the Inverse Law of Sanity.

Thus opens a feature piece in today’s Wall Street Journal, Depression in Command, by Nassir Ghaemi (pictured here), Professor of Psychiatry at Tufts. The piece is based on his new book, due out on Aug 4, "A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness."

Lincoln, Churchill, Gandhi, and King are the case studies cited in Dr Ghaemi’s article.

Similarly, an article in this week’s Newsweek, Madman In Chief, riffing off Ghaemi, concludes:

In Ghaemi’s view, even our supposedly crazy leaders were too sane for their times, and the nation suffered. When Richard Nixon faced the Watergate crisis, “he handled it the way an average [normal person] would handle it: he lied, and he dug in, and he fought.” Similarly, George W. Bush was “middle of the road in his personality traits,” which is why his response to the September 11 attacks was simplistic, unwavering, and, above all, “normal.”

So should we bring on the crazy in 2012? At the very least, we should rethink our definitions and stop assuming that normality is always good, and abnormality always bad. If Ghaemi is right, that is far too simplistic and stigmatizing, akin to excluding people by race or religion—only possibly worse because excellence can clearly spring from the unwell, and mediocrity from the healthy. The challenge is getting voters to think this way, too. It won’t do to have candidates shaking Prozac bottles from the podium, unless the public is ready to reward them for it. Amid multiple wars and lingering recession, maybe that time is now.

Dr Ghaemi is by no means the first to note the positive association between mental illness and extraordinary achievement, but no one has done it with such clarity and impact. Ironically, Dr Ghaemi informed me two months ago at a social function at the Ninth International Conference on Bipolar Disorder in Pittsburgh that he had a hell of a time finding a publisher.

I first ran into Dr Ghaemi in 2002 in Philadelphia at the American Psychiatric Association’s Annual Meeting. Back then, he belonged to a minority that questioned the efficacy of using antidepressants on patients with bipolar or with bipolar-like symptoms. Plus, he was writing on the obscure psychiatrist-philosopher Karl Jaspers and other cool stuff.

Listen to Dr Ghaemi for even a few minutes and you are going to learn a lot. I sought out Dr Ghaemi at future conferences and we developed a correspondence and friendship. It is no exaggeration to say that a lot of what you read on Knowledge is Necessity derives from seeds he planted in my mind over the years.

In 2006, Dr Ghaemi wrote an unbelievably commendatory blurb for my book, “Living Well with Depression and Bipolar Disorder.” He was being gracious, but hardly charitable. Trust me, had he thought my effort was the worst piece of crap shoved between two covers he would not have minced words.

I am looking forward to running a series of pieces based on “A First-Rate Madness” as soon as I get my hands on the book. Meanwhile, even prior to publication date, its presence is being felt. Already, people are starting to rethink mental illness in a positive way. A conversation is starting to take place. The title to this piece is no hyperbole. This could be big.

Here's to the Crazy Ones

An Apple ad from 1997. The crazy ones: Albert Einstein, Bob Dylan, Martin Luther King, Richard Branson, John Lennon, Bucky Fuller, Thomas Edison, Muhammad Ali, Ted Turner, Maria Callas, Mahatma Gandhi, Amelia Earhart, Alfred Hitchcock, Martha Graham, Jim Henson, Frank Lloyd Wright, and Pablo Picasso.

See my blog piece from Thursday: Consumer? Call Me Crazy, Instead.

Consumer? Call Me Crazy, Instead

Last year, here on Knowledge is Necessity, I ran a poll that sought your opinion on the term, “crazy.” Contrary to conventional wisdom, only one in four of you replied that “the term is highly stigmatic.” By contrast, four in ten let me know, “it’s better to be crazy than an asshole” while three in ten informed me, "screw being PC. You should see me when I'm crazy."

I would be the first to acknowledge that “crazy” used in a thoughtless and hurtful way is deeply offensive, but I have far stronger objections to that other term foisted on us to describe individuals living with a mental illness, and, I suspect, so do you. Let’s get started ...

Consumer

If I ever come across the sanctimonious bastard responsible for inflicting this sorry piece of the Indo-European language group on us, I swear I will show him no mercy. I will abduct him off the street, chain him to a chair in a room of Thomas Kinkade paintings, and force him to listen to Frank Sinatra singing Leaving On a Jet Plane.

The term, we are told, came from the mental health movement. Really? Do you think we would actually choose the same word used to describe shoppers going comparison shopping for mouthwash at Walmart? You’d have to be crazy to believe that.

As if we actually had the option to go comparison shopping in the first place. Joke: How do you make a mental health administrator laugh? Tell her you want to get well and stay well.

Really, what choice in services to we actually have?

To go with the mouthwash example: Companies that market products and services actually listen to their customers - those who consume. They do surveys, they run focus groups. They seek to anticipate the consumer’s needs and wants, then they come up with a product they hope will deliver, such as vanilla-flavored mouthwash. Then they go back and check if this same population of morning-garglers had positive experiences contending with a disinfectant laced with a cake icing ingredient.

Tell me, when was the last time someone invited you to participate in a Risperdal or Abilify focus group? When was the last time your psychiatrist asked you to fill in a customer satisfaction survey?

Consumer? Ha!

One More Thing

Consumer is all about taking and not giving. Is that us? Ingrates who suck the rest of this planet dry? Don’t we actually have something to offer humanity? Such as perhaps the Sistine Chapel, the Choral Symphony, Great Expectations, the discovery of the laws of gravity, the Federalist Papers, the Emancipation Proclamation, alternating current, and rock ‘n roll?  

One More Thing on Top of the One More Thing

Whenever we hear consumer used in the same sentence as family member or clinician, it’s the poor consumer who always - always-always-always - comes off as the very junior partner. The term is an open invitation for the smug to point fingers at us and cast judgment: We lack insight, we go off meds because we’re addicted to our highs - yeh, yeh, yeh.

Here’s the deal: You want to call me a consumer, then do what the mouthwash people and all other marketers of products and services do - listen. You might actually learn something.

Patients

A little coda to this: I used to favor this term over consumers and used to apply it to myself. Then I read somewhere that not all of us wish to identify as patients. Knock me over with a feather. Neither do I.

I may have a chronic illness, I may face challenges in getting through the day, but these days, I neither feel dependent on the medical profession nor do I feel my condition defines my life. That was not always the case, and indeed should I ever find myself in crisis again or struggling with a beanball out of nowhere that Mother Nature just threw at me I will go back to referring to myself as a patient.

In the Meantime ...

Call me crazy. You got a better word?

Eric Kandel - A Nobel's Life

Yesterday, I posted a piece - McMan's First Annual (Or Whenever) Psychiatric Exasperaters Awards - that called out four very prominent (and intellectually bankrupt) psychiatrists for their flagrant disregard of the facts. But I also made reference to a number of "inspirators" who are leading psychiatry and brain science and related disciplines toward a "new science of the mind." The coiner of that phrase is one of my psychiatric heroes, Eric Kandel. The following first appeared in a 2005 newsletter, then soon after as a mcmanweb article, then as a two-part piece here in Nov 2009. This time, I've rejoined the pieces as a one-parter. Be inspired ...

At five in the morning in October 2000, Denise Kandel fielded a call from Sweden. She didn’t understand what the person was saying except for the last word, "Stockholm." Then the realization dawned. The Nobel committee was on the line, with news for her husband Eric.

Rewind the clock to 62 years before. This time the sound in the middle of the night was that of the breaking glass of shop windows of Jewish businesses. The infamous Kristallnacht was raging across Germany and Nazi-occupied Austria. In Vienna, thugs burst into the Kandel’s apartment and forced young Eric and his brother and parents out into the street. The family returned a week or so later to find their home ransacked and all their valuables gone.

Young Eric and his brother were fortunate enough to find refuge in Brooklyn, months before World War II broke out. His parents got out with mere days to spare. The memory of that night and the horrors of a year under Nazi rule carried a profound impact.

"How could a highly educated and cultured society, a society that at one historical moment nourished the music of Haydn, Mozart, and Beethoven, in the next historical moment sink into barbarism?" Dr Kandel wrote in his Nobel autobiography many years later.

It was a question he took up in his undergraduate pursuits at Harvard. To continue his quest, he decided that psychoanalysis – the intellectual rage of the 1950s -was "perhaps the only approach, to understanding the mind, including the irrational nature of motivation and unconscious and conscious memory."

But a funny thing happened in his last year as a medical student at NYU. He decided to take an elective course in neurobiology at Columbia University. That led to a recommendation to join the NIMH as a postdoctoral fellow in the lab of the legendary Wade Marshall, who had mapped out the sensory system in the brain. Suddenly, psychoanalysis seemed like an artifact of an earlier age. The searing questions forged from his childhood in Vienna now found a new medium in modern biology.

"I am struck," he wrote, "as others have been, at how deeply these traumatic events of my childhood became burned into memory."

During his three years at the NIMH, Dr Kandel began his lifelong quest into the biological mechanism of the memory. With colleague Alden Spencer MD, Dr Kandel published a series of articles in the early 1960s documenting their discoveries of the cellular properties of hippocampal neurons. But the two researchers realized these findings alone could not account for how memory was stored. Instead, they began to look into how the neurons were functionally connected. But they needed a simpler place to start than the hippocampus. Dr Spencer turned to the spinal column while Dr Kandel hitched his star to the humble sea snail.

Dr Kandel’s mentors at the NIMH strongly discouraged him from taking such a radically reductionist approach to a complex biological process. Nothing interesting, they argued, could be found in a mere invertebrate, much less have application to higher life forms. But Dr Kandel was young and brash. After ruling out crayfish, lobster, flies, and the nematode, among others, Dr Kandel arrived at the aplysia, a giant marine snail. The animal’s small number of extraordinarily large and distinctively pigmented nerve cells conferred the advantage of easy observation and experimentation.

After completing a two-year psychiatric residency at Harvard, Dr Kandel headed off to Paris for a 16-month tutelage under Ladislav Tauc, one of only two people in the world working on the aplysia. Their collaboration led to a series of articles from the early to mid-1960s. But this was only the beginning.

"Matisse had it right when he pointed out that life is a circle," Dr Kandel told a packed auditorium at the American Psychiatric Association’s annual meeting in Atlanta in May 2005. In other words, if you follow your unconscious, you often find you come back to the themes that interested you in the beginning.

In 1990, while still working on snails, Dr Kandel returned to studying mammalian hippocampal neurons, mapping out the higher memory functions in mice. In the lab, he was able to reverse age-related memory loss in his animals.

"If you’re a mouse," he joked, "we can do a lot for you. For people, we’re not sure as yet."

Then Dr Kandel extended his focus to the amygdala, which governs fear. Fear, he explained, is the one behavior so far we can observe in animals. A mouse that receives a shock accompanied by the sound of a bell will soon crouch in fear to just that sound. Dr Kandel’s lab discovered that this kind of fear resulted in the release of the peptide GRP in the amygdala of the animals. Mice bred without the capacity to produce GRP lost their inhibition.

"Maybe in some disease states," Dr Kandel commented, "inhibitory restraint is compromised."

But that is not the end of the story. What would happen, he wondered, if you set out to investigate the mirror image of fear? This time, Dr Kandel’s team trained mice to associate a particular sound with safety. As expected, the animals’ sense of security dampened activity in the amygdala. But the investigators also discovered a circuit connecting the amygdala to the dorsal striatum (caudoputamen), an area of the brain associated with happiness and reward.

"We don’t like being miserable," Dr Kandel explained. "What we really want to do is to be happy, to be secure, to be confident." He quoted the first line of Anna Karenina: "Happy families are all alike …"

"That really is inspiring to a neurobiologist," Dr Kandel joked, "because if you find the gene it is going to be unbelievably universal." So as well as identifying new targets for anxiety drugs, he explained, we may also find targets for enhancing positive affect.

Dr Kandel has written extensively on integrating his first love – psychoanalysis – with his vocation, neurobiology. Despite some signs that psychoanalysis is joining the real world, however, he does continue to scold this branch of the profession for its insularity, disregard for patient outcomes, and lack of scientific rigor – traits not shared, he says, by practitioners in many other fields of talking therapy.

"A major need of psychiatry in the future," he stated, "is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry." He was very much moved by Kay Jamison who said if it wasn’t for lithium she would be dead, but that it was really psychotherapy that gave her a coherent view of her life, that allowed her to tie the various strings of her life together.

"We’re in a fantastic phase of psychiatric thought," he concluded. The biology of the mind is the central scientific challenge of the twenty-first century. Molecular genetics and molecular biology, he said, have given us insights that would have been inconceivable 20 or 30 years ago. These advances will revolutionize psychiatry, but hardly eliminate it. Instead, psychiatry will synthesize with molecular biology into what he describes as "the new science of the mind."

Dr Kandel - an avid lover of fine art, classical music, and opera - resides in the Riverdale section of the Bronx with his wife of 50 years, Denise. As a girl in Nazi-occupied France, Denise hid in a convent without knowing the whereabouts of her parents. Denise is a professor in the Department of Psychiatry and School of Public Health at Columbia and a pioneer in the epidemiology of drug use in adolescents. They have two children and a number of grandchildren.

Writes Dr Kandel in his Nobel autobiography:

"In retrospect it seems a very long way for me from Vienna to Stockholm. My timely departure from Vienna made for a remarkably fortunate life in the United States. The freedom that I have experienced in America and in its academic institutions made Stockholm possible for me, as it has for many others."

McMan's First Annual (Or Whenever) Psychiatric Exasperater Awards

One of the things I love about my job is the challenge of chasing a moving target. There are no certainties. Every idea is on the table. In place of what we now call psychiatry, a whole new science of the mind is beginning to emerge. A quick scroll through my blog pieces over the last year reveals just a small sample of highly dedicated scientists who are are changing the way we think:

Jill Bolte Taylor, Nora Volkow, Husseini Manji, Hagop Akiskal, Marsha Linehan, Fred Gage, David Braff, Nancy Andreasen ...

Likewise, hats off to the authors and commentators and film-makers who connect the dots and challenge us to connect our own: Robert Whitaker, Pete Earley, John Gartner, Jonah Lehrer, Katie Cadigan ...

Not to mention some of my favorite bloggers: Therese Borchard, Willa Goodfellow, Gina Pera ...

Plus no end of the unsung, those in the trenches, responding to the call, refusing to take no for an answer, rolling up their sleeves and doing - doing, doing ...

But scroll through my recent blog pieces and you will also encounter a number of individuals I have felt duty-bound to call out for their flagrant violation of the facts. Spirited and even heated discussion has a way of moving the conversation forward, but only when the facts are honored. In some strange and ineffable way, we move closer to an ever-elusive truth. Humanity is served.

The individuals I have singled only seem to serve themselves. Coincidentally, these individuals happen to be psychiatrists. So, without further ado, my first annual (or whenever) Psychiatric Exasperater Awards ...

Andrew Nierenberg

Earlier this year, Andrew Nierenberg, professor of psychiatry at Harvard and a prominent researcher into mood disorders, purported to “repudiate” and “refute” compelling evidence raised against indiscriminate use of antidepressants and antipsychotics by Robert Whitaker, author of “Anatomy of an Epidemic.”

Had Dr Nierenberg accomplished but one one-hundredth of his stated mission, I would have thanked him for profusely for adding his learned voice to a badly needed dialogue. Instead, Nierenberg - obviously without having even read Whitaker’s book - resorted to ad hominem attacks (comparing Whitaker, whom he referred to as “ignorant,” to Sarah Palin), faulty marshaling of facts (such as misrepresenting one key study as “retrospective” when it was in fact prospective), and a very sick attempt at humor (such as showing a slide with a fake insulting black box warning appended to Whitaker’s book).

In the end, the only thing that Nierenberg proved was his own intellectual bankruptcy. As for Whitaker, we are still awaiting a credible response from someone with an MD.

(See Whitaker vs Quack Psychiatry - Part II.)

Peter Kramer

Earlier this month, Peter Kramer, clinical professor of psychiatry and human behavior at Brown University, published an article in the NY Times, entitled “In Defense of Antidepressants.” Dr Kramer is author of the 1993 “Listening to Prozac,” the product of a far more credulous age when researchers and clinicians and patients alike believed in miracle treatments for illnesses we actually still know next to nothing about.

In his article, Dr Kramer presumed to respond to an uncontradicted scientific study with his own speculation. Just that - speculation, no facts, no science. Moreover, Dr Kramer willfully ignored both the leading real-world clinical trial that cast considerable doubt on treating depressed patients like guinea pigs, as well as very strong evidence of the very harmful effects of prescribing antidepressants to substantial portions of the population.

We would all benefit enormously from an intelligent discourse on when and when not to use antidepressants. On that vital point, Dr Kramer had nothing to contribute. Instead, in defiance of both reality and “first do no harm,” Dr Kramer would have the general public believe it is still 1993.

(See Peter Kramer and Antidepressants - Oy!)

Stuart Kaplan

The June 19 Newsweek contained an article by Stuart Kaplan, clinical professor of psychiatry at Penn State. The article - “Mommy, Am I Really Bipolar?” - is adapted from his new book, “Your Child Does Not Have Bipolar Disorder.” Asserted Kaplan: “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood.”

Except, of course, for a whole bunch of kids who cycle in and out of depression and mania.

Well, no, says Kaplan. These kids are really ADHD or oppositionally defiant. Or have something called “temper dysregulation disorder.” Anything but bipolar. The following flat-out misstatement screams for the return of the Star Chamber: “The description of childhood bipolar disorder by its advocates is dramatically different [from adult bipolar].”

No it’s not.

Had Dr Kaplan stuck to the facts, he could have assisted us in our understanding of how best to improve the lives of kids in obvious distress, not to mention their families. Instead, by dogmatically clinging to an absolutist position, Dr Kaplan came across as the head cheer-leader in an academic food fight. Unfortunately, this food fight involves the well-being of our children.

(See The Child Bipolar Diagnosis is Under Attack - Yet Again.)

Allen Frances

Reading Allen Frances on Psychology Today and the Psychiatric Times is as painful as viewing a painting by Thomas Kinkade. Dr Francis, professor emeritus at Duke University, headed up the DSM-IV of 1994. With the unveiling of the draft DSM-5 in Feb 2010, Dr Frances returned to the spotlight as its loudest and most inept critic.

Essentially, there are two Dr Frances - the one who fell in love with his 1994 opus and will brook no changes, and the one who feels he has sinned against humanity for his 1994 opus and likewise will brook no changes. In either case, his arguments come across as disordered and bizarre.

In citing numerous experts critical of DSM-5 changes, Dr Frances overlooks the obvious, namely that most of the problems faced by those working on the DSM-5 are the direct result of the Frances-led failures in bringing the DSM-IV into some kind of alignment with clinical reality back in 1994. The critics of the DSM-IV are justifiably legion. Not a peep from Dr Frances on this.

Dr Frances, by virtue of his elder statesman status, was in the enviable position of setting the tone for the debate, and thus informing us all on the challenges of taking diagnostic psychiatry into a new era. As it happened, intelligent expert commentary never materialized. Present and future generations of those seeking professional help will end up paying dearly.

(See The Dimensional Side to Personality.)

Final Word

With a major paradigm shift underway, we are living in an age of both inspiration and exasperation. The “inspirators,” though clearly the wave of the future, are by no means infallible - hence the need for spirited conversations. The “exasperaters” see themselves as guardians of the old paradigm and are often right a lot of the time, hence - again - the need for spirited conversations.

Unfortunately the exasperaters cited here add nothing to the conversation. To the contrary, they come across as authoritarian, anti-intellectual, and as maladaptive reactors to their changing environments. Hysterical reactionism is always a response to progress, which is good news. The bad news is that as the paradigm further shifts, we are likely to witness much more of this type of behavior.

Stay tuned for my next crop of annual awardees. I guarantee you won’t have to wait a year.

The Dimensional Side to Personality

We have been looking at Take Two (from June 21) in the DSM-5’s proposed update to personality disorders. In Take One (from Feb 2010), the DSM-5 attempted to combine categories (as in “which one?) with dimensions (as in “how much?”) into a hybrid system, using interchangeable parts that could best be described as modular. The concept was far-reaching. The catch was that it appeared to be very unwieldy in practice.

Yesterday, we looked at how the DSM-5’s Take Two tackled the categorical side of personality, using a dimensional twist. Today, we look at the DSM-5’s Take Two of the dimensional model, built on categorical pieces, but a different set of categorical pieces from Take One.

Take One, in essence, was based on a sort of reverse Five-Factor Model (such as “antagonism” in place of “agreeableness”) measuring 37 different trait facets on a four-point scale. Take Two is far more modest in scale, but may be much more useful.

Consider, for instance, the following four individuals:

Jane, 28, displays classic borderline symptoms - unstable self-image, trouble maintaining relationships, and so on. But she is working as a manager in a city government. Does the borderline label really apply?

Bill, in his 20s, flies off the handle, uses drugs, and has run-ins with the law, but does not meet the criteria for antisocial. But clearly, his behavior warrants clinical attention.

Sally, 14, is acting out like someone with borderline, but is her behavior more attributable to being a teen?

Joey, in his 50s, deals with major depression and diabetes, and has major issues getting along with his caregivers. Is there a diagnosis that doctors can apply to patients they don’t like?

Enter the Levels of Personality Functioning Scale. This employs the self and interpersonal functions from Criterion A used in all six categorical diagnoses and rates them in terms of severity from 0 to 4. Thus, in 0 (well-adjusted), we see these kind of qualities: “ongoing awareness of a unique self”, “sets and aspires to reasonable goals”, “capable of understanding others”, “maintains multiple, satisfying, and enduring relationships”, and so on.

Meanwhile, way over on 4, we see “boundaries with others are confused and lacking”, “poor differentiation of thoughts from actions” - well, you get the picture.

Then we’re asked to consider the six (mostly interchangeable) trait domains that form the basis of the six personality disorders: Negative Affectivity, Disinhibition, Antagonism, Psychoticism, and Compulsivity. Only this time we are viewing these domains as stand-alone entities rather than in the context of a full-blown personality disorder.

Let’s return to our individuals, who represent abbreviated versions of the examples served up by the DSM-5.

Jane, according to the DSM-5, would rate a diagnosis of borderline, “but her level of personality functioning might be rated as less impaired than that of the more typical borderline patient, with enhanced prospects for successful treatment.” In other words, Jane is a good prognosis patient.

Bill, under the old DSM, would probably sail under the diagnostic radar or fall through the cracks. Perhaps he would be diagnosed as Personality Disorder NOS (not otherwise specified), which tells us nothing. Under the DSM-5, we are told, Bill would be coded as “Personality Disorder Trait Specified,” emphasis on trait specified, such as hostility and impulsivity. These traits would then “serve as specific foci of clinical attention.”

Sally may show signs of emerging borderline, but the DSM-5 indicates the wise course is to hold off on this diagnosis, and instead note her as having a low level of personality functioning, with reference to specific traits such as emotional lability. These features can then be closely tracked as Sally matures.

Joey may not have a personality disorder, but he could be written up for “antagonism,” and impairment in interpersonal personality function. The DSM-5 doesn’t say this, but the best way of treating Joey’s depression and diabetes is to treat the personality issues that sabotage his being a successful patient.

***

Thus, in terms of functional impairment and various traits, in all four cases we are seeing evidence of “something” going on - from a personality disorder with a good prognosis to a clinical condition as serious as any personality disorder to a situation of wait-and-see to a pressing concern that merits some sort of intervention.

This may not be a perfect system, and already a predictably rotten tomato review has come in from Allen Frances, head of the criminally horrendous DSM-IV, who characterized Take Two as “an impossible mess to the rest of us.”

Dr Frances may well be right, but for all the wrong reasons. Dr Frances has indicated in all his DSM-5 writings to date that he sees himself as merely as the keeper of his precious DSM-IV, which is a very different proposition than lending his professional wisdom to improving the lives of those dealing with serious personality issues. In the final analysis, any attempt to pin down something as infinitely complex as personality is doomed to be flawed. Success, then, is modest, to be measured in terms of less flawed than the effort before.

Could the DSM-5 have done a better job? Of course it could have. Is the version it turned in way better than the sorry DSM-IV mess that Dr Frances is so in denial about? Don’t make me answer that.

Previous pieces:

Personality Disorders - The DSM-5 Has Another Go
Take Two on Personality Disorders

Take Two on Personality Disorders

Yesterday I reported on the DSM-5’s second go at revising the various diagnoses classified under Personality Disorders. The big issue is incorporating the concept of “dimensionality” into what to date has been a “categorical” system.

Category is all about either-or, all or nothing. Is it borderline, for instance, or is it normal? Is it borderline or is it antisocial? Lumping symptoms into categories is useful to a point, but simplistic labeling has its very obvious drawbacks.

Dimensionality acknowledges a lot more possibilities. Could it be a bit of Borderline, for instance, plus a bit of Antisocial? Maybe we should dispense with labels altogether and see what’s really going on. Impulsivity? Hostility? Lack of empathy? Dimensionality obviously best approximates reality, but at the expense of clarity and workability.

The DSM-5’s answer is a hybrid system, built on interchangeable parts. Assemble the parts one way to build a classic categorical diagnosis. Assemble the same parts another way to come up with a dimensional perspective. In this sense, it is more accurate to describe the new system as “modular” - think IKEA - rather than hybrid.

Okay, let’s see what we have second time around ...

The DSM-IV lists 10 personality disorders. The DSM-5 on its first go eliminated five, leaving us with Borderline, Antisocial, Schizotypal, Avoidant, and Obsessive-Compulsive (not to be confused with OCD). On its second go, the DSM-5 restored Narcissism.

This time around, the DSM-5 imposes strict order on its six categorical disorders. Thus, whether it’s Borderline or Antisocial or the other four we’re talking about, we see in common:

Significant impairments in personality functioning, broken down into impairments with self-function (involving issues with identity and/or self-direction) and impairments in interpersonal functioning (involving issues with empathy and/or intimacy).

This is Part A of the diagnosis. In Part B, we are looking at "pathological personality traits" organized into “domains.”

Let’s start with Part A. Below is a table of the Borderline and Antisocial Part A criteria side-by-side:

Criterion A	Borderline	Antisocial
1. Impairments in self functioning a.	Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.	Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
1. Impairments in self functioning b.	Self-direction: Instability in goals, aspirations, values, or career plans.	Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
2. Impairments in interpersonal functioning a.	Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.	Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another. b.
2. Impairments in interpersonal functioning b.	Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.	Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

OK, clearly someone with borderline is living in a different interior world than someone with antisocial. Now let’s compare Part B criteria side-by-side (minus the lengthy descriptions):

Criterion B	Borderline	Antisocial
Negative Affectivity	Emotional lability Anxiousness Separation insecurity Depressivity
Disinhibition	Impulsivity Risk taking	Irresponsibility Impulsivity Risk taking
Antagonism	Hostility	Manipulativeness Deceitfulness Callousness Hostility

Note first the interchangeable parts. Borderline and Antisocial share two “domains” in common, Disinhibition and Antagonism. Thus a picture emerges of individuals prone to flying off the handle (often at you, their nearest victim), regardless of their diagnostic label. Criterion C makes it clear that these impairments “are relatively stable across time and consistent across situations.” In other words, we are talking about a clear and sustained pattern of bad behavior, not just a bad hair day.

But also notice the differences. Antagonism comes far more fully loaded in the Antisocial diagnosis. Meanwhile, those with Antisocial come up empty in the Negative Affectivity department. An abusive outburst may look the same, but over time we see different patterns. Moreover, the underlying dynamics are wholly different - one appearing to arise from an inflated ego, the other from an almost lack of ego.

In a sense, Antisocial shares a thing or two in common with Narcissism. Indeed, in the DSM-5’s first version, Narcissism was folded into the Antisocial diagnosis. The DSM-5 keeps its restored Narcissism diagnosis short and sweet, with only one domain (Antagonism) with two personality traits (Grandiosity and Attention-seeking).

Meanwhile, we see Borderline leaning in the direction of Avoidant, with both individuals in effect running scared, sharing the same personality trait of Anxiousness under Negative Affectivity, but with different ways of responding to their respective insecurities.

Thus, even in making categorical distinctions, we see dimensionality at work.

One important point: There are more domains than what you see listed under Borderline and Antisocial. Thus, in addition to Negative Affectivity, Disinhibition, and Antagonism, we also have Psychoticism (a major feature of Schizotypal) and Compulsivity (a major feature of Obsessive-Compulsive).

***

Don’t worry if you’re confused. At this stage, it is simply enough to know that the DSM-5 is making an attempt to show dimensionality in its categories, namely that:

1. Regardless of diagnosis, individuals with personality disorders share in common major difficulties in self-function (relating to self) and in personal function (relating to others).
2. Individuals across the various diagnoses tend to share various traits common to other diagnoses, as well.

At the same time, the DSM-5 is also red-flagging key distinctions. These disorders are related, yet separate, kinda, sorta - if you get the drift.

Next: The DSM-5 takes on dimensions ...

Personality Disorders - The DSM-5 Has Another Go

On June 21, the DSM-5 workgroup responsible for bringing order to personality disorders substantially changed what it originally posted on the DSM-5 site back in Feb, 2010. Most of us could see this coming. As the workgroup explained in its most recent update: “All parts of the model have been simplified and streamlined in response to comments received and to critiques in the published literature.”

A little background ...

Unlike the rest of the DSM-5, the 2010 roll-out of Personality Disorders was no mere light dusting of the status quo. This was a major home-improvement, a hugely ambitious effort that sought to integrate two different ways of looking at mental illness - categories (as in “which one?”) with dimensions (as in “how much?”) into something workable.

Personality, after all, cannot be easily categorized. Yet, we do need categorical bearings. Dimensionality is far more in sync with clinical reality, yet much more difficult to sort and freeze into comprehensible diagnostic nuggets. The workgroup’s answer to this dilemma was essentially a modular system. (The diagnostic literature refers to “hybrid,” but “modular” - think IKEA - is far more accurate.)

Thus, the DSM-5 retained diagnostic categories such as Borderline and Antisocial, but built them with interchangeable parts. Accordingly, individuals with either illness may have the following hostility “personality trait” in common:

Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults ...

This particular trait is a subset of the antagonism “domain.” But quick comparison between the two categories reveals very different loadings. Those with antisocial have far more antagonism traits (such as callousness) than those with borderline. (The new version lists only one antagonism trait for borderline, down from two in the old version.) Meanwhile, borderline comes heavily loaded in negative affectivity traits (such as emotional lability) while we see nothing of the sort in antisocial.

Thus, a few shared traits, but clearly defined separation, which hopefully results in less diagnostic confusion.

That brings us to the dimensional element. In their initial roll-out, the DSM-5 essentially took apart and reassembled the exact same categorical bits and pieces in a different way to see “how much” of say borderline or antisocial (or avoidant or schizotypy or obsessive-compulsive) one has.

In other words, the real world is not black and white, much less divided into all-or-nothing choices. Imagine: Under the DSM-IV, a person who is one symptom shy for not only borderline, but also antisocial and narcissism is technically normal. How crazy is that? The DSM-5’s solution was to look at the entire gamut of personality as something analogous to blood pressure, from healthy to unhealthy, with an eye on the various loadings.

One may or may not require clinical attention, but a dimensional assessment can be an enormous help in knowing thyself.

Great concept, but the DSM-5’s first draft was monumentally unwieldy, calling for clinicians to rate 37 facets making up six domains on a four-point scale. Who has time for that?

It was back to the drawing board for the DSM-5 work group. Eighteen months later, the blood pressure principle remains the same, but now, in place of version number one, we have a new dimensional entity called Personality Disorder Trait Specified (PDTS).

Oh-oh! Are we in for yet another mouthful of diagnostic alphabet soup, this time looking like a misspelling of PTSD? Or is the DSM-5 about to make life easier for us?

More to come ...

A Day at Stand Down San Diego

Yesterday, my didgeridoo took me to Stand Down San Diego, which is a three-day event offering sanctuary and services to homeless vets. Back in 1981, a group of Vietnam vets organized Vietnam Veterans of San Diego, now Veterans Village of San Diego (VVSD), to help their comrades sleeping under bridges and in the streets and parks. VVSD maintains a rehab center and emergency shelter and offers a range of other services for vets in need. In 1988, VVSD launched the first Stand Down. About 1,000 vets and more than 3,000 volunteers were there for Stand Down this weekend. There are now some 200 Stand Downs throughout the US.

The co-founder and driving force of Stand Down is Jon Nachison, a former soldier turned psychologist who has been working with vets for about 30 years. (That's Jon, in the white tee-shirt, banging the djembe.) I first ran into Jon at a NAMI San Diego Walk in 2010. He was playing a Swiss hang drum in front of a table he was manning. I had my didgeridoo.

Two months later, I summoned up the nerve to take my didge to a drum circle just north of San Diego. Jon was there with his hang drum and his djembe. In nothing flat, I was merrily honking away, and have been a drum circle regular ever since. In May, Jon organized a Drumming Out Stigma event underwritten by the County. I was there with my didge.

A couple of months ago, Jon invited me to join him and his fellow drummers at Stand Down. I penciled in the date, not knowing what to expect.

I showed up yesterday morning, the third and final day of the event, and went to get checked in. I was fairly inconspicuous, holding a didgeridoo nearly a foot taller than I was, with a smaller didge in a carry bag slung over my ahoulder. I couldn't walk two feet without being stopped and asked to demonstrate "Big Boy." Very auspicious start. I managed to get about half-way to the check-in station, when I heard a familiar voice call my name. It was Annette, a fellow NAMI San Diego board member. Another good way to start the day.

I spent the next hour walking at random, getting stopped every two feet to honk my didge, getting into conversations, thoroughly enjoying myself. Funny thing: I probably encountered some of these very same people on the streets and pretended they were invisible. Likewise, many in their shame, literally shrink into the shadows, invisible. It was a brilliant sunny day. We were out in the open, visible. We liked what we saw.

I'm a journalist. My natural instinct is to ask questions and get stories. But today I was a guy with a didgeridoo. The people around me were fellow human beings enjoying the same sun I was. I didn't ask about their lives, about where they had been sleeping a few days before or where they would be sleeping that night. This was about today. About enjoying each other.

I finally made my way to the stage. Jon and about ten other drummers, plus a guitar player, were setting up. I recognized three or four from my drum circle. Jon gave us very simple instructions: We finish together. That way, it would look like we'd been rehearsing together for months.

Jon began pounding away on his djembe, the others joined in. I let out an exuberant "whoop!" on Big Boy. We were underway.

There is no way to describe the sensation of being surrounded by ten expert drummers. Like being outside in a thunderstorm without getting wet does no justice. Neither does getting stampeded by a million buffalo. Elemental forces washing, whooshing, all over you, through you, banging, pounding, pulsing. And there I was offering up my devotion of primal rumbling, punctuated by shrill yelps. We finished up way too soon, an hour later, but I knew what I was going to do the rest of the day.

Random walking, getting stopped every two feet.

About an hour later, I found myself in a massage station. People were on tables, receiving all manner of the healing touch, from chiropractic crunching to gentle laying on of hands. Next thing, of all things, I'm being asked to play my didge, this time softly, as part of the vibrations of healing. Of all things, one of the women, Beth, happens to mention she uses a didge in her practice. That's my cue to produce my "Little Boy" didge out of the bag and hand it over. Next thing, the two of us are quietly vibrating away. Beth has been trained as an opera singer. This is turning out to be a very interesting day.

All too soon, it's time to wrap things up. It's early afternoon. Graduation is about to get underway, and I need to obey my need to go home and crash. At the same time my iPhone rings. Funny thing. No one stops you if you're yapping into a phone, even if you're toting two didgeridoos. In this manner, I make it through the crowd and out the gate.

Stand down is a military term signifying a time to lay down arms. But many of our vets find it impossible to leave the battlefield behind. Decades later, the Vietnam War still haunts. More Vietnam vets have fallen to suicide than have fallen on the battlefield. And those who have served their country in Iraq and Afghanistan are materializing on the streets faster than our Vietnam vets. A good many have served multiple deployments - layering trauma atop trauma - only to return to a recession economy that has no use for them.

"And they shall beat their swords into plowshares, and their spears into pruning hooks: nation shall not lift up sword against nation, neither shall they learn war any more."

And they will know no more war in their brains.

VVSD site

60 Minutes video of last year's Stand Down

John Gartner on Treating Hypomania

On his latest blog piece on Psychology Today - Malpractice Is the Standard of Care When Medicating Hypomanics - John Gartner (pictured here)  cited me twice. Actually, Dr Gartner was my prime influence in my rethinking of hypomania, as this extract from a much longer mcmanweb article - Treating Hypomania, dating from 2005 - attests. I substantially rewrote the article earlier this year, but this extract has stayed intact ...

Said John Gartner PhD, an associate professor of clinical psychiatry at Johns Hopkins and author of "The Hypomanic Edge: The Link Between a Little Craziness and a Lot of Success in America," in a 2005 interview with this writer, "the most common form of this disorder is being treated as if it were a rare weird variation."

In his book Dr Gartner views hypomania as a genetically transmitted temperament whose adaptive advantages far outweighs the disadvantages. Thanks to the people brave enough (and crazy enough) to leave their settled existences to strike out for an uncertain life on a strange shore, argues Dr Gartner, America has been blessed with a generous supply of wild wacky creative geniuses and go-getters, plus an abundance of those egging them on. This is often a source of dismay to the Europeans, who are alarmed by our excesses, even as they embrace the many positive aspects of our culture. (See Hypomanic Nation.)

One of Dr Gartner’s case studies is the brilliant Founding Father Alexander Hamilton, who had a spot reserved on Mt Rushmore until he stupidly offered up his body for target practice. Which raises some interesting questions. Suppose lithium and other meds had been available to Hamilton. Would the treatment have dulled his brain to the point where he would have opted to become a Founding Bystander rather than a Founding Father? Or would he have prudently skipped his appointment with Aaron Burr and gone on to become America’s greatest President?

$64,000 question for psychiatrists: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?

Certainly, many of us feel hypomania is our true identity, not just a mood aberration to be medicated out of existence. "That’s very important," Dr Gartner told me. "When you think about it, how many people have died just to preserve their sense of identity? Think of all the Jews who died because they wouldn't renounce their religion. All they had to say was, yes I’m a Christian. It’s hard for people who are not hypomanic to appreciate how integral this is to someone’s identity and how important it is to preserve that."

This led to the crux of our interview: "First of all, most psychiatrists don’t know when their patients are hypomanic because they haven’t been trained to look for it. Also, no one ever came to their offices saying, I’ve got hypomania, please cure me. When they do become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."

Some people can obviously benefit from meds, but Dr Gartner makes it clear we are talking of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge."

"I liken it to the pitcher in Bull Durham," he related, "the guy who has the 100 mile per hour fastball but keeps beaning the mascot. He needs a little bit more control. He’s got speed. You wouldn’t want to give him so much medicine that he threw a fifty mile per hour fastball. We want to slow it down just enough so that he can deliver the ball where it’s supposed to be."

Think of Hamilton, brilliant as ever, lightening up a tad on Aaron Burr.

This may involve clinicians rethinking their concept of therapeutic doses. Current dosing levels are based on trials involving bipolar I patients in the acute (initial) stage of mania. Even lithium, the most studied mood stabilizer, has not been tested for hypomania. Clinical treatment guidelines are silent on the topic. In this so-called era of evidence-based medicine, we simply have no evidence.

Check out John Gartner's website

Jill Bolte Taylor Discusses the Brain and Recovery

“Am I safe?”

That is your brain’s bottom line, the question - the one question - that your temporal lobe, amygdala, and hippocampus are asking, moment by moment. When you’re not safe, learning and memory turn off.

The amygdala, which mediates fear and arousal, is engaged in a constant dialogue with its next-door neighbor the hippocampus, responsible for laying down memory, in partnership with the temporal lobe, at least when things go right.

Ultimately, as Jill Bolte Taylor, author of “My Stroke of Insight,” explained at the NAMI national convention last week in Chicago, our job is to create energy where we feel safe. Dr Taylor was climbing the career ladder as a neuroanatomist at Harvard when in 1996, at age 37, she suffered a debilitating stroke that left her unable to walk or talk or recall life. Her recovery took eight years.

Dr Taylor’s tour de force presentation at NAMI completely belied the fact that she had ever so much as suffered a single isolated synaptic misfiring in her entire life, let alone her entire world extinguishing in a catastrophic neurological supernova, but the explanation for her recovery, she let us know, can be summed up in one word: neuroplasticity.

Two words, actually: Neuroplasticity and neurogenesis.

Neuroplasticity, Dr Taylor explained, is about cells supporting cells in a network. It’s all about circuitry, but nothing is hardwired. Our neural connections are forever readjusting and strengthening - with dendrites unplugging from old neurons and replugging into new ones in response to new challenges.

Neurogenesis is about the individual cells and what they need in order to recover.

“The bottom line,” Dr Taylor said, “is we can choose where we can take our nervous system.” Literally, we can change the game. “I am neurocircuitry - thoughts, emotions, physiology. I can pick which circuits I want to run.”

“Pay attention to what you’re running,” she went on to say. “You get to pick and choose what’s going on inside your brain.”

It’s all about the amygdala. “I see your amygdala,” Dr Taylor told her audience. “Happy amygdala? That’s the bottom line for me.”

It all comes down to this: When the amygdala feels safe, the rest of the brain can do its job. Recovery is possible, but it doesn’t happen overnight.

“Give my brain time to recover,” Dr Taylor implored her audience. “Neurons are in very slow motion.” They also need rest, not overstimulation - sleep, lots of it, if that is what it takes to feel energized, even if only for short stretches of time. Her mother, she said, went completely against protocol in letting her sleep - which ultimately allowed her to heal.

Safety, time, rest - is healing really that simple? Think what the word, asylum, means. Maybe the answer has been staring us in the face all the time.

Much more to come ...

Peter Kramer and Antidepressants - Oy!

I was going to have a relaxing evening tonight, recovering from my trip to Chicago and a very busy four days at the NAMI national convention, plus two days in airports. I was saving tomorrow for gradually settling back into my blog with some of cool stuff I came across in Chicago. Then I encountered a piece in the July 9 NY Times by Peter Kramer, entitled, “In Defense of Antidepressants.”

Okay, before we start, here’s an extract from my lead mcmanweb article on antidepressants:

The strongest scientific evidence we have is not how well antidepressants work, but how badly they perform and how harmful they may be to certain individuals. Here's the low-down:

Two meta-analyses of the FDA clinical trials conducted by Irving Kirsch of the University of Connecticut in the late 1990s-early 2000s of Pharma-sponsored clinical trials - including ones not published - in the FDA database found that antidepressants worked only marginally better against depression than placebos. There have been a number of expert rebuttals to these findings, but no actual study to contradict Kirsch.

The article reports on the most authoritative real-world study on antidepressants, the NIMH-underwritten STAR*D from the mid-2000s. We continue from my article:

Commenting on STAR*D, in a 2009 blog, Nassir Ghaemi MD of Tufts University noted that:

“Even if antidepressants worked in the short term (2 months, which is also what the meta-analysis assessed), one-half of patients who stayed on them relapsed into depression within one year. At the one year outcome, only about 25% of patients actually had remained well on and tolerated an antidepressant, much below the levels most clinicians seem to feel occurs in their clinical experience.”

One in four! According to the best data we have, just one in four individuals treated with an antidepressant get well and stay well. And this was in the best possible care setting. Is your clinician aware of this? Probably not.

Neither is Peter Kramer of Brown University. Dr Kramer is the author of the 1993 “Listening to Prozac,” which is largely a product of the time, back when we all trusted Pharma a lot more than we do now. We have learned a lot since then, including the fact that these drugs can be highly destabilizing to individuals with bipolar and with depressions that cycle like bipolar.

But Dr Kramer in his NY Times article mentions neither STAR*D nor the obvious risks of taking an antidepressant. Huh?

Dr Kramer’s defense of antidepressants is specious and drearily unoriginal, one based on a speculative nitpicking of Kirsh. Back in a newsletter piece I did nine years ago, I referred to this as the “Van Meegeren Defense.”

Prior to World War II, Han Van Meegeren earned a nice living for himself selling bad forgeries of Vermeers. When World War II came along, one of Van Meegeren’s customers turned out to Reichsmarshall Hermann Goring. After the War, Van Meegeren was arrested for collaborating with the Nazis and charged with treason.

Here’s the part of the story I love: Van Meegeren’s defense to selling cultural treasures to the Nazis was that they were not real Vermeers, but his own forgeries. In other words, he had to convince the court that he had cheated.

Okay, now that you “get” the Van Meegeren Defense, here is what Dr Kramer has to say in his NY Times article:

Consequently, companies rushing to get medications to market have had an incentive to run quick, sloppy trials.

In other words, to cheat. What Dr Kramer is saying is that clinical antidepressants trials sponsored by drug companies might have yielded better results had they stuck to protocol and included only patients most likely to respond to antidepressants, namely those with severe depression. In effect, the drug companies, in their haste to recruit patients, probably included a substantial number of likely non-responders, namely those with milder forms of depression or those who plain lied to get into a trial. Thus, according to Kramer:

Often subjects who don’t really have depression are included — and (no surprise) weeks down the road they are not depressed. People may exaggerate their symptoms to get free care or incentive payments offered in trials. Other, perfectly honest subjects participate when they are at their worst and then spontaneously return to their usual, lower, level of depression.

As I stated earlier, this is not a new explanation. I first came across it soon after Kirsch’s second meta-analysis was published in 2002. Basically, academic critics acknowledged that Kirsch had made a bullet-proof case based on the evidence. So, then, how to explain the evidence?

Ah, the Van Meegeren Defense. In other words, if the drug companies had not cheated to begin with, maybe, just maybe, the results might - just might - have come out more in their favor.

It’s all speculation, of course. The only real way to counter Kirsh’s bullet-proof evidence is with bullet-proof evidence of one’s own. And while we're at it, to come up with an authoritative real-world study to counter the STAR*D real-world study.

There are many nuances to the antidepressant debate, and in all likelihood these meds work for a certain subpopulation of depressed patients (if we only knew who they were), but - again - this is speculation, not science.

The bottom line is the most convincing evidence we have on the (non)efficacy of antidepressants comes from Kirsch and STAR*D. The only counter-evidence is recycled speculation, Kramer-style.

***
Robert Whitaker on his Mad in America blog picks Kramer apart in far greater detail, concluding with:

On Sunday, in this essay "In Defense of Antidepressants," the American public has been treated to yet another dose of misinformation. 

Pictures of NAMI

The NAMI National Convention in Chicago wrapped up last night. I'm headed out back to San Diego later today and will have a lot more to report when I get back. In the meantime, three photo highlights ...

Left: Two days ago. I couldn't believe it when I spotted a drum circle on the program, and I was ready. Drum circles are catching on as a healing activity in mental health and pretty soon they will be everywhere. Didgeridoos fit right in. This particular drum circle was special. Just about everyone was new. Yet, in nothing flat, everyone was part of a mysterious process, where the sum is greater than the parts, a self-organizing system equivalent to geese flying in formation, pure magic. They all "got it" instantly ...














Above: Last night, NAMI Talent Showcase. Earlier at the Convention, I ran into Sarah, who plays Indian flute. So instead of separate acts, we did a number together. I started out with a low pulsing drone, then she came in over the top, slow and easy. Then I'd break out with something fast and loud and energetic and her flute would trill and soar and sparkle from above. Then back to slow ... I never wanted the moment to end, but when the time was right we signaled each other. She put down her flute. It was just me breathing soft air into the didge. Then it was quiet. The molecules in the room became still ...



Left: Yesterday morning. Mental health advocacy is a thankless task. This year, someone thanked us. At the NAMI business meeting, NAMI San Diego was honored as outstanding local affiliate. Holding the Award is Bettie Reinhardt, the guiding force of NAMI San Diego for 17 years as executive director. She "retired" from the job early last year, only to be working harder than ever. Brandi Marcoe (right), one of our program managers, accepted the Award on behalf of our affiliate. Rita Navarro (left) is both the grease that keeps an enormously complex organization running and the glue that holds it all together. Behind them, unseen, are the countless staff and volunteers and partners in the community over the years who represent the possible in a dream we refuse to acknowledge as impossible.

Dispatch From the National NAMI Convention

It’s 4 AM in Chicago and I can’t get back to sleep. I have a full day ahead of me at the national NAMI convention. Rewind to yesterday ...

I stroll into the convention hotel late morning, after a long and restorative sleep. I’m demonstrating my didgeridoo to someone in the lobby area when I look up and see Nanci Schiman from the Child and Adolescent Bipolar Foundation. Very good way to start the day. It’s going to be old friends reunion day at NAMI for me, as well as making new connections.

The morning is more of nuts and bolts sessions. I attend one on making outreaches to underserved populations. This includes prisoners. Wayne McGuire of NAMI Oklahoma tells us how he got NAMI Connections groups started in the prisons there. It was a laborious process, taking years. These things don’t just happen overnight.

Wayne had a successful career as an assistant professor before being blindsided by his illness and losing everything, then going through his own recovery and reincarnating himself as an advocate. Mental illness makes advocates of all of us. I’m in a room full of doers in a convention full of doers.

I don’t feel like that at our California state caucus. Someone from a local affiliate raises the issue of how a certain portion of NAMI dues goes to State and another portion to National, leaving little left over for the affiliate. Fair enough, I think, but then he and his cohorts keep bitching about it. And bitching.

And then helpful people explain - and keep explaining. The clock is running out and there are zillions of important issues to discuss. Finally, I raise my hand and request we move on to other stuff.

This is typical of boards everywhere. People driving each other crazy. It’s human nature.  It’s all part of the process of getting things done. By the time the meeting ends, I feel we’ve accomplished something.

The convention has been going on for a day and a half when we finally get to the official “Opening.” TV reporter Bill Curtis tells us about his son Scott, with schizophrenia, who died of complications from obesity. When he made mention of his son on the air, he relates, his colleagues looked at him as if he had leprosy. “No one wants to talk about it,” he told the gathering. “It’s time we started talking about it.”

Jessie Close shares some of her personal journey, one that includes her own challenges of living with bipolar, not to mention the additional burdens of raising a kid with a schizoaffective diagnosis. She tells us of an everyday event - of making son Calen’s Christmas homecoming safe for him. Everyday event, but significant.

Highly significant. These little things matter bigtime. Son Calen addresses us. Living with mental illness definitely has its challenges. But here he is up on the stage, talking to at least a thousand people in the room. Perhaps because many Christmases ago his mom helped him survive the day? Gave him asylum?

Little things, big results.

The last part of the session is given over to author Pete Earley interviewing NAMI CEO Michael Fitzpatrick. Fitzpatrick lets us know that the Medicaid stuff happening in Washington is the worst crisis he’s seen in 30 years. More discretionary power will be given to state politicians, he tells us, which in his own experience is never a good thing. In essence, states will be given free rein to slash mental health services. It’s already happening and it will get worse.

On a different matter, he tells us: “You can never underestimate policy-makers and their lack of understanding of mental illness.”

Most of the people in the room know Pete Earley from his book, “Crazy: A Father’s Search Through America’s Mental Health Madness.” Pete updates us on his kid, Mike, who had his first psychotic break soon after graduating from college, which set off a family nightmare that saw his son in the criminal justice system rather than being treated.

Sometime after the book came out, Pete relates, Mike flipped out yet again. The police brought him to the same hospital where the original nightmare started. Same script. Doctors wouldn’t treat him. He’s fine, the physician told the officer who brought him in. New twist to the script: The officer had been CIT-trained. Fine, said the officer. Then I’ll drop him off in front of your house.

Mike got admitted, got treated, got services. Then he trained as a peer specialist. He’s now helping others and hasn’t had a setback in four years.

A different outcome, but there is never an ending to the story. Or any other stories. I have been listening to stories all day. Over lunch, on the run, over a beer. You don’t just retire from being an advocate, from pushing back against the madness. Not when you’re living in a story with no ending ...

On the Road - Live From Chicago

Why do I keep thinking it’s Tuesday? It’s the last hour of Wednesday here in Chicago. I’m winding down from the first day of the NAMI national convention. I attended my first five as a journalist. I’m also attending this one as a journalist, but this time I have extra ribbons to stick to my name tag by virtue of my involvement with NAMI San Diego.

I’m here at NAMI to meet people. I was having a $400 cup of coffee and a $600 yogurt (hotel prices) in the lobby when in walked Sue Bergeson, whom I have known for just about forever. Sue is former President of DBSA and is now doing all kinds of great work on our behalf at Optum Health. It’s been more than three years since we’ve seen each other. It was worth flying out to Chicago just to catch up. Very auspicious start.

The convention program is mainly NAMI nuts and bolts stuff - how to run an effective In Our Own Voice program, stuff like that. Not much interest from a journalistic perspective. My last convention, four years ago, I think I attended only one session. I get a lot more out of just hanging out and listening to people’s stories.

Incredibly, before I have even attended my first session, I somehow manage to run into everyone here from NAMI San Diego, spread out over three floors. NAMI San Diego is receiving this year’s Outstanding Local Affiliate Award, and the credit goes to the people I am bumping into here, plus the staff and volunteers and our partners back in San Diego, past and present.

I dutifully attend an affiliate leaders workshop, and, naturally, the thing I get most out of it is meeting my counterparts from all over the country, people like me who serve on local boards. It’s thankless work, so here is my opportunity to thank these people.

Toward the end of the session, NAMI CEO Michael Fitzpatrick walks in and does a Q and A with us. When the session ends, I walk up to Mr Fitzpatrick and tell him I brought my didgeridoo. He doesn’t call security, which I interpret as a good sign.

Didgeridoo diplomacy. Yes, I have “Little Boy” in a bag slung over my shoulder. Several times during the day, I take it out of the bag.

Late in the afternoon, I am drooping. I cut out of a session and head back to my hotel and crash for three hours, most of it rebound sleep. I blow off the evening session - ironically the only one of journalistic interest - featuring Thomas Insel of the NIMH. This is going to be a long convention and I need to pace myself.

I intend to stay till they turn the lights off tomorrow, so I’ll give most of the morning a miss. To bed ...

Didgeridoo Diplomacy - Honking For Mental Health Awareness

I've shaken off a bad cold just in time to head off to Chicago first thing in the morning to the NAMI national convention. This will be my sixth NAMI convention. I attended my previous ones as a mental health journalist. This time I will be going as a representative of NAMI San Diego, where I serve on the board. But I will also be taking a lot of notes, so you can look forward to two or three road blogs. Plus, listening to patients and family members always results in aha! moments that inform all my writing.

My last NAMI national convention was in 2007, which occurred in San Diego about seven months after I arrived here in southern CA, about four months after I acquired my first didgeridoo. Trust me, didgeridoos make sense in California. So it was that I didn't give a second thought to taking my "Big Boy" didge to the convention. It didn't matter that I couldn't really play it - I could always honk for mental health awareness.

Big Boy is the size of an Alp horn (think Ricola), much larger than standard didges. No sooner did I show up than people were crowding around me, asking me what is that thing and to play it for them. Fortunately, the convention took place in a resort-type hotel, where a lot of the networking got done in the outdoors. That still didn't stop me from honking the thing indoors. Total strangers, old friends, featured speakers, NAMI bigwigs, my strategy was the same - honk my didge.

The picture you see is me at the 2007 NAMI convention, taking my didge to the talent show (sorry about the beached whales). A NAMI photographer snapped it, and it appeared on the NAMI website a day or two later. Back then, of course, I was an outsider, a lone visionary, a voice in the wilderness - a man, a dream, a didgeridoo.

Kind of hard to imagine that four years later, but I'm jumping ahead.

Later that summer, I took my "Little Boy" didge to the DBSA national conference in Orlando. Little Boy is nowhere near the attention-getter as Big Boy, but at least I could travel with it. I also brought Little Boy with me to a state NAMI convention in Riverside, CA six weeks later. At both these venues I was a break-out speaker and incorporated the didge into my talks.

Actually, the didge had nothing to do with what I was talking about, but my honking interlude did make sense in a certain nonlinear fashion.

By now, I had resolved to take my didge everywhere I went, but this was also the time I decided to severely cut back on my travel. Rumor has it that I was short-listed for the Nobel Peace Prize for my humanitarian gesture.

We skip ahead to 2010. I had been on the board of NAMI San Diego for about nine months. I was helping plan our annual Walk. I happened to say I will bring my didge to the Walk. Julie, a volunteer, chimed in: "And I will bring my drum." That's how great ideas are born. Julie introduced me to a drum circle. Fortunately, by this time, I could do more with my didge than just honk it. In no time, I was a drum circle regular. At our next year's Walk, we had a group of drummers (and me) set up at a key intersection on the Walk. (Check out the Walk video in the right column.)

Things only took off from there. One of our drum circle regulars, Jon, happens to be the chief psychologist at a large treatment center here in San Diego. He also has a well-deserved reputation for his work with vets and PTSD. It just so happened in May he organized a Drumming Out Stigma event sponsored by the county. The county mental health big cheese and some lesser cheeses were there. So were individuals from the local club houses and others.  I was there with Big Boy and Little Boy. I stayed mainly with Little Boy while some school-age girls made cool animal noises into Big Boy.

I happened to bump into the county big cheese two times since then, but here's the kicker: The other week, at a small NAMI San Diego function, I got into a conversation with a woman, who informed me that it was her girls who were making noises into Big Boy. By now, I am introducing myself as the didgeridoo representative on the NAMI SD board. After I get back from Chicago, at Jon's invitation, I will be joining him and some drummers at an annual vets awareness event.

Now to Chicago and the NAMI national convention. Traveling to Chicago was a last-minute decision, so I didn't even look at the program until two weeks ago. Of course, they're having their usual talent show, but also - drum roll please - they're having a drum circle!

A man ahead of his time, a man of his time. See how persistence pays off?

Alexander Hamilton, Hypomanic Founding Father

This Fourth of July special is lifted from a much longer article on mcmanweb, a review of John Gartner's "The Hypomanic Edge" ...

"Danger, Hypomanic on Board," could well be the other title of "Washington Crossing the Delaware." With him that historic night was Alexander Hamilton, most famous for being on the losing end of a duel with Aaron Burr. Biographer Ron Chernow describes Hamilton as "a volatile personality," and an "exuberant genius" who was prone to poor judgment and "prey to depression." Dr Gartner surveyed five of Hamilton's biographers without telling them the illness he was investigating. Even though only one biographer had suggested in his book that Hamilton may have had bipolar disorder, all of them overwhelmingly in the survey awarded the Founding Father very high marks for hypomania.

Soon after graduating from Columbia University in two years, Hamilton caught revolutionary fever. In one two-week period he spewed out the equivalent of a book in the form of 60,000 words of propaganda. During a raid, when everyone else had ducked for cover, Hamilton walked straight into an artillery bombardment. He soon caught the attention of George Washington and became his aide de camp, only to impulsively quit a few years later. At Yorktown, now with a battlefield command, he paraded his troops in front of British cannons. The British were too dumbstruck to open fire. Later in the battle, Hamilton led a reckless charge that turned out right for all the wrong reasons.

Hamilton was the main instigator of the Constitutional Convention, but one biographer described him during this period as "restless and depressed," and another "like he was on something." He delivered an impassioned six-hour speech, then walked out for good in disgust, unable to appreciate why the delegates couldn’t simply settle their differences and back his brilliant proposals. Nevertheless, once the document was ready for ratification by the states, Hamilton became its greatest champion, cranking out 51 of the 85 op-ed pieces collectively known as the Federalist Papers. He was also the political point man in winning over New York.

By the time Hamilton assumed his post as first Secretary of the Treasury, the new nation was on the brink of financial collapse. Hamilton’s inspired plan was to consolidate state debts and federal debts into one restructured national debt, paid off in monthly installments. The result was a strong and robust federal government that set the scene for a nation of capitalist go-getters, much to the consternation of Thomas Jefferson who envisioned a pastoral utopia. Fittingly, Hamilton is buried in a graveyard on Wall Street.

See full article: Hypomanic Nation